mm IfoSL Columbia Itotoewtftp COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY G if t of Dr. Hugh Auchinc3.0£S mi >■■■■ ■ ■■■.■■.:.•...-■••>.•-* ':■.-.•? *i- V >. L MINOR SURGERY AND BANDAGING INCLUDING THE TREATMENT OF FRACTURES AND DISLOCATIONS, THE LIGATION OF ARTERIES, AMPUTATIONS, EXCISIONS AND RESECTIONS, INTESTINAL ANASTOMOSIS, OPERATIONS UPON NERVES AND TENDONS, TRACHEOTOMY, INTUBATION OF THE LARYNX, ETC. BY HENRY R. WHARTON, M.D., PROFESSOR OF CLINICAL SURGERY IN THE WOMAN'S MEDICAL COLLEGE OF PENN- SYLVANIA, SURGEON TO THE PRESBYTERIAN HOSPITAL, AND THE CHIL- DREN'S HOSPITAL; CONSULTING SURGEON TO ST. CHRISTOPHER'S HOSPITAL, AND THE BRYN MAWB HOSPITAL; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION. FIFTH EDITION, ENLARGED AND THOROUGHLY REVISED, WITH 509 ILLUSTRATIONS. LEA BROTHERS & CO., PHILADELPHIA AND NEW YORK 1902. Entered according to Act of Congress, in the year 1902, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. TVPlll WESTCOTT &. THOMSON, WILLIAM J. DORNAN, ELECTROTYPERS, PHILADA. PRINTER, PHILADA PREFACE TO THE FIFTH EDITION. The author has endeavored to present a concise descrip- tion of the various bandages, surgical dressings, and minor surgical procedures employed in the practice of surgery at the present time. The preparation and appli- cation of aseptic and antiseptic dressings have also received full consideration, and the importance of Sur- gical Bacteriology is recognized in a special chapter. The article on Bandages is fully illustrated with cuts, chieflv photographic, which furnish an accurate and clear representation of the most important bandages used in surgical practice. The same is in a measure true of the section upon Fractures and Dislocations, which is like- wise photographically illustrated. The work also contains short articles on Tracheotomy, Intubation of the Larynx, Ligation of Arteries, and Amputations. Though these subjects are scarcely to be included in the term " Minor Surgery," it is believed that they will render the volume more serviceable to the student. In view of the great attention now paid in our medical schools to operative procedures on the cadaver and the importance of this method of instruction, a sec- 4 PREFACE TO THE FIFTH EDITION. tion on this subject was added to the Fourth Edition and is continued in the present revision. The author feels that he would be remiss if he omitted an acknowledgment of the favor so widely manifested toward this work. A call for five editions is no idle compliment, nor has it been construed as relieving the author from the duty of keeping the book thoroughly revised to the date of each issue. Surgery progresses, and those books are fortunate which meet with a degree of favor enabling their authors by frequent revision to keep them abreast of its continuous advances. The author desires to express his thanks to Dr. J. H. Jopson for assistance in revising the proof-sheets. 1725 Spruce St., Philadelphia, May, 1902. CONTENTS, PAKT I. BANDAGING. PAGES Varieties of Bandages 23-41 Bandages for the Head and Neck 41-53 Bandages of the Upper Neck 54-69 Bandages of the Trunk 69-73 Bandages of the Lower Extremity 73-84 Special Bandages 84-93 Fixed Dressings or Hardening Bandages 93-109 PART II. MINOR SURGERY. Surgical Bacteriology 111-123 Theory of Asepsis and Antisepsis in Wound Treatment . . . 123-128 Agents Employed to Secure Asepsis 128-137 Preparation of Materials Used in Aseptic Operations and Dressings 137-14o Preparation of Gauze Dressings 145-149 Methods and Dressings Employed in the Treatment of Wounds to Secure Asepsis 149-150 Preparation for Aseptic Operation and Dressing of Wounds . 150-166 Materials Used in Surgical Dressings 166-1/1 Procedures Employed in Minor Surgery 171-232 Anaesthetics 232-25o Trusses 255-259 5 6 CONTENTS. PAGES Catheters and Bougies 259-268 Sutures • • 268 - 280 Methods of Intestinal Anastomosis 280 286 Ligatures Used in the Treatment of Vascular Growths . . - 286-291 Treatment of Hemorrhage • • ■ 291 ~^ U Opening and Dressing of Abscesses ■ • • 311-315 shock : 315 - 318 Dressing of Wounds, Burns and Scalds, Bed-sores, Sprains . . 318-331 PART III. FRACTURES. General Consideration of Fractures 333-34o Separation of Epiphyses • 2^404 Treatment of Special Fractures _.-... d48-4U4 Compound and Ununited Fractures • 404-410 PART IV. DISLOCATIONS. General Consideration of Dislocations tll'tl'l n .-,-.., ,. 413-443 Special Dislocations • PART V. OPERATIONS. 445_447 Ligation of Arteries . ._ Ligation of Special Arteries PART VI. AMPUTATIONS, 477-490 General Consideration of Amputations „-.',. .. 490-531 Special Amputations ■ ■ CONTEXTS. 7 PART VII. EXCISIONS AND RESECTIONS, AND SPECIAL OPERATIONS. PAGES General Consideration of Excisions and Resections 533-636 Special Excisions and Resections • 536-553 Trephining 553-558 Laminectomy 558-559 Operations upon Nerves 559-564 Operations upon Tendons 564-570 Removal of the Breast 570 Tracheotomy 570 Laryngotomy 577 Laryngo-tracheotomy 578 Intubation of the Larynx 578-584 Operations updn the Kidney . 584—585 Operations upon the Colon 585-587 Removnl of Appendix Vermiformis 587-588 Lithotomy 588-590 Circumcision 590-591 Removal of the Testicle 591 Operation for Varicocele 591 Cholecystotomy 591 (Esophagotomy 592 Gastrostomy • • 592-596 Pyloroplasty 596 Pylorectomy and Gastro-duodenostomy 597-598 Gastroenterostomy 599 Osteotomy 599-601 Index 603 PAET I. BANDAGING. Bandages. — These constitute one of the most widely used and important surgical dressings ; they are employed to hold dressings in contact with the surface of the body, to make pressure, to hold splints in place in the treatment of fractures and dislocations, and to maintain in their natural position parts which may have become displaced. Bandages may be prepared of various materials, such as linen, crinoline, flannel, cheese-cloth or tobacco-cloth, rubber-sheeting, or muslin, bleached or unbleached ; the latter material is the most commonly employed, by reason of its cheapness ; flannel, from its elasticity, is sometimes used, but its employment for bandages is now generally limited to its use in dressings for operative work in con- nection with the eye and abdomen, and for a primary roller in the application of plaster-of- Paris dressings. Bandages are either simple, when composed of one piece of material, such as the ordinary roller-bandage, or com- pound, when prepared of one or more pieces adapted by size and shape to particular objects. The importance of being familiar with the general rules of bandaging and proficient in the application of the roller-bandage cannot be overestimated, and both the student and the general practitioner will never have cause to regret the time occupied in learning to apply neatly this form of surgical dressing. 2 17 18 BANDAGING. A well-applied bandage adds to the security of the dress- ing and the comfort of the patient, and the method of application often secures for the physician the confidence both of the patient and of his friends ; while, on the other hand, a badly applied bandage is apt to be uncom- fortable and insecure, and to meet with their adverse criticism. The Roller-bandage. — The roller-bandage consists of a strip of woven material, prepared from some one of the materials previously mentioned, of variable length and width according to the portion of the body to which it is Fig. 1. Bandage-winder. to be applied ; this, for ease of application, is rolled into a cylindrical form. The material commonly employed for the roller-band- age is unbleached muslin, although, for special purposes, linen, flannel, rubber-sheeting, crinoline, or cheese-cloth may be used. It is important that the roller-bandage should consist of one piece, free from seams and selvage, for if made of a number of pieces sewed together, or if it contains creases or selvage, it cannot be so neatly applied, and it is not so comfortable to the patient, as it is apt to leave creases upon the skin. THE ROLLER-BANDAGE. 19 In preparing the ordinary muslin bandage, the material is torn in strips varying in length and width aceording to the part of the body to which it is to be applied, and it is then rolled into a cylinder, either by the hand or by a machine constructed for the purpose (Fig. 1). It is important that every student and practitioner should be able to roll a bandage by hand, for in practice the medical attendant may at any moment be called upon to prepare a bandage, in order to apply a dressing, and the art of preparing a bandage is easily acquired by a little Fig. 2. Rolling a bandage by hand. practice. To roll a bandage by hand, the strip of muslin should be folded at one extremity several times until a small cylinder is formed ; this is then grasped by its ex- tremities by the thumb and index finger of the left hand ; the free extremity of the strip is then grasped between the thumb and index finger of the right hand, and by alternate pronation and supination of the right hand the cylinder is revolved and the roller is formed ; the firm- ness of the roller will depend upon the amount of tension which is kept upon the free extremity of the strip during the revolution of the cylinder (Fig. 2). A bandage rolled 20 BANDAGING. in the form of a cylinder is called a single or single-headed roller (Fig. 3) ; if rolled from each extremity toward the centre, so that two cylinders are formed joined by the Fig. 3. Fig. 4. Single roller. Double roller. central portion of the strip, the double or double-headed roller is formed (Fig. 4). Double rollers are not much used, and in practice the single roller will be found to be amply sufficient for the application of almost all the bandages employed in sur- gical dressings. The free end of the roller-bandage is called the initial extremity ; the end which is enclosed in the centre of the cylinder is its terminal extremity ; and the portion between the extremities the body ; a roller has also two surfaces, external and internal. Dimensions of Bandages. — Bandages vary in length and width according to the purposes for which they are employed, and in practice it will be found that a small variety of bandages will be amply sufficient for the appli- cation of the ordinary surgical dressings. The following list, comprising those most frequently used, will show their dimensions : Bandages one inch wide, three yards in length, for band- ages for the hand, fingers, and toes. GENERAL RULES FOR BANDAGIM;. 21 Bandages two inches wide, six yards in length, for head- bandages and for the extremities in children. Bandages two and a half inches wide, seven yards in length, for bandages of the extremities in adults; a roller of this size is the one most generally used. Bandages three inches wide, nine yards in length, for bandages of the thigh, groin, and trunk. Bandages four inches wide, ten yards in length, for bandages of the trunk. General Rules for Bandaging. — In applying a roller- bandage, the operator should place the external surface of the free extremity of the roller upon the part, holding it in position with the fingers of the left hand until fixed by a few turns of the roller, the cylinder being held in the right hand by the thumb and fingers ; for thus as the bandage is unwound it rolls into the operator's hand, thereby giving him more control of it ; care should also be taken that the turns are applied smoothly to the surface, and that the pressure exerted by each turn is uniform. AVhen a bandage is applied to a limb, the surgeon should see that the part is in the position it is to occupy as re- gards flexion and extension when the dressing is com- pleted, for a bandage applied w T hen the limb is flexed will exert too much pressure when the limb is extended, and then may, by the pressure it exerts, become a matter of discomfort or even of danger to the patient, or if applied to an extended limb it will become uncomfortable upon flexion. My experience has been that, as a rule, those who have had little experience with the application of the roller- bandage are apt to apply the bandages too tightly, and this may lead to disastrous consequences, gangrene of the extremities having resulted from the too tight application of bandages, especially in the dressing of fractures. Pro- fessor Ash hurst, in his clinical teaching, advised students to make use of a larger number of turns of a bandage in securing fracture-dressings rather than to depend upon a few turns too firmly applied — advice which certainly con- duces to the safety and comfort of the patient. When the 22 BANDAGING. bandage has been completed, the terminal extremity should be secured by a pin or safety-pin applied transversely to the bandage, and if a pin be used its point should be Fig. 5. Method of removing a bandage. buried in the folds of the bandage ; if the bandage be a narrow one, the end may be split and the two tails result- ing secured around the part by tying. Fig. 6. Bandage-scissors. Removal of Bandages. — In removing a bandage, the folds should be carefully gathered up in a loose mass as VARIETIES OE BANDAGES. '2:\ the bandage is unwound, the mass being transferred rapidly from one hand to the other, thus facilitating its removal and preventing the part from becoming entangled in its loops (Fig. 5). If it is desirable to cut the bandage to remove it, the use of scissors made for this purpose will be found most satisfactory (Fig. 6). VARIETIES OF BANDAGES. Circular Bandage. — This bandage consists of a few circular turns around a part, each turn covering accurately the preceding turn. This variety of bandage may be used to retain a dressing to a limited portion of the head, neck, or limbs, to make compression upon the veins of the arm before performing venesection, or to secure a compress to control venous hemorrhage (Fig. 11, b). Oblique Bandage. — In this form of bandage the turns are carried obliquely over the part, leaving uncovered spaces between the successive turns (Fig. 7). It cannot Fig. 7. Oblique bandage. be applied with much firmness on account of the uncov- ered portions of skin between the turns of the bandage, and its principal use is for the application of temporary dressings, such as wet dressings which may require fre- quent removal. Spiral Bandage. — In this bandage the turns are carried around the part in a spiral direction, each turn overlap- ping a portion of the preceding one, usually one-third or one-half; it may be applied as. an ascending spiral (Fig. 8) ^4 BANDAGING. or as a descending spiral (Fig. 9). This bandage may be used to cover a part which does not increase rapidly in diameter ; for instance, the abdomen, chest, or arm. Fig. 8. Ascending spiral bandage. Fig. 9. Descending spiral bandage. Spiral Reversed Bandage. — This bandage is a spiral bandage, but differs from the ordinary spiral bandage in having its turns folded back or reversed as it ascends a part the diameter of which gradually increases. By its use, it is possible to cover by spiral turns a part conical in shape, so as to make equable pressure upon all parts of the surface. The reverses are made as follows : After fixing the initial extremity of the roller, as the part in- creases in diameter the bandage is carried off a little obliquely to the axis of the limb for from four to six inches ; the index finger or thumb of the disengaged hand is placed upon the body of the bandage to keep it securely in place upon the limb, the hand holding the roller is carried a little toward the limb to slacken the unwound por- tion of the bandage, and by changing the position of the hand holding the bandage from extreme supination to pronation the reverse is made (Fig. 10). Care should be VARIETIES OF BANDAGES. 25 taken not to attempt to make the reverse while the band- age is tense, for by so doing the bandage is twisted into a cord which is unsightly and uncomfortable to the patient, instead of forming a closely fitting reverse. The reverse should be completed before the bandage is carried around the limb, and when it has been completed it may be slightly tightened so as to conform to the part accurately. Fig. 10. Method of making reverses. The reverses should be in line to have the bandage pre- sent a good appearance, and care should be taken that the reverses should not be made over prominent bony parts of the limb, for if they occupy such positions they cause creases in the skin and become uncomfortable to the patient. To make reverses neatly and to have them in line, require skill and practice ; a well-applied spiral reversed bandage is a test of a competent bandager. Spica-bandage. — When the turns of the roller cross each other in the form of the Greek letter lambda, leaving the previous turn about one-third uncovered, the bandage is known as a spica-bandage (Fig. 11, a). These spica- 26 BANDAGING. bandages are especially serviceable as a means of retaining surgical dressings upon particular portions of the surface of the body, such as the shoulder, groin, or foot. Fig. 11. *i ... Spica-bandage. Circular bandage. Figure -of- eight Bandage. — This bandage receives its name from the turns being applied so as to form a figure- of-eight. This method of application is made use of in the Barton's bandage, the bandages of the knee and elbow, and many other bandages. Fig. 12. Recurrent bandage. Recurrent Bandage. — This bandage derives its name from the fact that the roller after covering a certain part of the surface is reflected and brought back to the point of starting ; it is then reversed and carried toward the ( 'O MPO UND BANDAGES. 27 opposite point, and this manipulation is continued until the part is covered by these recurrent turns, which are then secured by a few circular turns (Fig. 12). This is the bandage usually employed in the dressing of stump- after amputation. Compound Bandages. These bandages are usually formed of several pieces of muslin or other material, sewed or pinned together, and are employed to fulfil some special indication in the appli- cation of dressings to particular parts of the body. The most useful of the compound bandages are the T-bandages and the many -tailed bandages. T-bandage. — The single T-bandage consists of a hori- zontal band to which is attached, about its middle, another having a vertical direction ; the horizontal piece should be about twice the length of the vertical piece (Fig. 13). The Fig. 13 Fig. 14. Single T-bandage. Single T-bandage for chest. single T-banda^e may be used to retain dressings to the head, the horizontal piece being passed around the head from the occiput to the forehead, the vertical piece being passed over the head and secured to the horizontal piece, the shape and width of the two pieces being varied accord- ing to the indications. In applying dressings to the anal 28 BANDAGING. region or perineum, or in securing a catheter in a perineal wound, the single T-bandage will he found most useful. In applying a T-bandage for this purpose, the body of the bandage is placed over the spine, just above the pelvis, and the horizontal portion is tied around the abdomen. The free extremity is split into two tails for about two-thirds of its length, and is carried over the anal region and brought up between the thighs, the terminal strips passing one on each side of the scrotum and being secured to the horizontal strip in front. The single T-bandage may be Fig. 15. T-bandage of groin. variously modified according to the indications which are to be met; for instance, in applying a dressing to the breasts the horizontal strip passing around the chest may be made ten or twelve inches in width ; the vertical strip, two inches in width, passes from the back over the shoulder and is secured to the horizontal strip in front (Fig. 14). For the groin, t a piece of muslin six inches COMPO UXD BA XI) A GES. 29 wide at its base and thirty inches long is sewed to a hori- zontal strip of muslin one and a half yards long and two inches in width. It may be applied as in Fig. 15 to hold a dressing to this part. Double T-bandage. — The double T-bandage differs from the single bandage in having two vertical strips attached to the horizontal strip, and it may be used for much the same purposes as the single T-bandage (Fig. 16). Fig. 16. Double T-bandage. It may be conveniently used for retaining dressings to the chest, breast, or abdomen ; when used for this purpose the horizontal portion should be from eight to twelve inches wide and long enough to pass one and a quarter times about the chest ; two vertical strips, two inches wide and twenty inches long, should be attached to the horizontal strip a short distance apart near its middle. In applying this bandage to the chest, the horizontal strip is placed around the chest so that the vertical strips occupy a posi- tion on either side of the spine ; the overlapping end of the horizontal portion is secured by pins or safety-pins, and the vertical strips are next carried one over either shoulder and secured to the other portion of the bandage in front of the chest (Fig. 17). The double T-bandage may also be used to secure dress- 30 BANDAGING. ings to the nose, in which event the strips should be quite narrow, about one inch in width, and should be applied as shown in Fig. 18. Fig. 17. Fig. 18. Double T-bandage of chest. Double T-bandage of nose. Many-tailed Bandages or Slings. — These bandages are prepared from pieces of muslin of various lengths and breadths, which are split at each extremity into two, three, or more tails up to within a few inches of their centres, their width and length being regulated by the part of the body to which they are to be applied. The four-tailed bandage may be found useful as a tem- porary dressing in cases of fracture of the jaw, or to hold dressings to the chin. It may be prepared by taking a portion of a roller-bandage three inches wide and one yard in length, and splitting each extremity up to within two inches of the centre ; it is then applied as seen in Fig. 19. The four-tailed bandage may also be used to retain dress- ings to the scalp, and may be prepared by taking a piece of muslin one yard and a quarter long and six or eight inches in width, splitting it at each extremity into two tails within six inches of the centre ; it may then be applied as seen in Fig. 20. The four-tailed bandage may also be used in the tern- COMPOUND BANDAGES. 31 porary dressing of fractures of the clavicle, the body of the bandage being placed upon the elbow of the injured Fig. 19. Four-tailed bandage of chin. Fig. 20. Four-tailed bandage of head. side, two tails passing around the body, fixing the arm to the side, and two tails passing over the sound shoulder. Fig. 21. 4 Many-tailed bandage of abdomen. Many-tailed Bandage of Abdomen. — This bandage may also be used for holding dressings in contact with the abdo- men or trunk, and is the bandage which most surgeons 32 BANDAGING. employ to hold the dressings to a laparotomy wound, and to give support to the abdominal walls after this operation. In preparing this bandage, a strip of muslin or flannel, one and a half yards in length and eighteen to twenty inches in width, is required ; the extremities may be split so as to form a four- or six-tailed bandage. In applying this bandage to the abdomen, the body is placed upon the patient's back and the tails are brought around the abdo- men and overlap each other, and when sufficiently firmly drawn to make the desired amount of pressure they are secured by means of safety-pins (Fig. 21). Handkerchief-bandages. The use of handkerchiefs or square pieces of muslin for the temporary or permanent dressing of wounds, fract- ures, or dislocations was advocated many years ago by M. Mayor, a Swiss surgeon, who wrote an extensive work Fig. 22. \ I i 1 .ijj .iiii Jiliii 'iiii 1 i| ^=sFii!= Ik lii! L'l .! \ is ^ ==z ^ fJ jl; \jj!_.Z - 1 iijj i=i= ; : ■ imi --2^=?- *-===•' - Fig. 23. The square. The oblong. upon this subject, in which he reduced their application to a system. He employed a handkerchief or a square piece of muslin, and by various modifications in the application of these developed a number of very ingenious bandages. The various forms which the handkerchief or square (Fig. 22) is made to assume are as follows : The oblong, HA ND KER CHIEF- IlAShMi /•>. 33 made by folding the square once or twice on itself (Fig. 23). The triangle, made by bringing together the diag- onal angles of the square (Fig. 24). The line of the fold- ing is known as the base, the angle opposite the base the apex, and the other angles the extremities. Fig. 24. The triangle. The cravat is prepared from the triangle by bringing the apex to its base, and folding it a number of times upon itself until the desired width is obtained (Fig. 25). Fig. 25. The cravat. The cord is formed from the cravat twisted upon itself (Fig. 26). The names of the various handkerchief-band- ages are derived from the shape of the handkerchiefs used and the parts to which they are applied ; the names Fig. 26. The cord. serve as guides in their application. It is to be remem- bered that the base of the triangle or the body of the cravat is to be placed upon the portion, the designation of which forms the first portion of the name of the bandage ; thus, 3 34 BAND A GING. in the occipitofrontal triangle, the shape of the handker- chief is given, and we know that the base of the triangle is to be applied to the occiput and the apex carried to the forehead. In using the cravats the same rule applies ; thus, in the bis-axillary cravat the body of the cravat is to be placed in the axilla of the affected side, the extremi- ties crossed over the corresponding shoulder and carried over the chest, one before, the other behind, to the axilla of the opposite side, where they are secured. Fig. 27. V Occipitofrontal triangle. The Occipito-frontal Triangle. — To apply this hand- kerchief, place the base of the triangle upon or a little below the occiput, and bring the apex forward over the head, allowing it to drop over the forehead ; next bring the extremities of the handkerchief forward and tie them in a knot over the forehead ; finally turn up the apex over the knotted ends and pin it to the body of the handker- chief (Fig. 27). HANDKERCHIEF-BANDA GES. 35 The Mento-vertico-occipital Cravat. — To apply this handkerchief, the middle of the base of the cravat is placed under the chin ; the extremities are then carried in front of the ear on each side to the vertex of the skull, and are crossed at that point ; the ends are then carried downward over the parietal region to the occiput, and are secured by a knot at this point (Fig. 28). Another method of apply- ing this handkerchief consists in placing the base of the Fig. 28. Fig. 29. Mento-vertico-occipital cravat. Mento-vertico-occipital cravat (modified). cravat under the chin and carrying the extremities over the vertex of the skull, crossing them at that point ; then carrying them downward to the occiput, and crossing them again here and passing them forward around the chin, and finally securing the ends by a knot (Fig. 29). The turns of the latter handkerchief correspond exactly to the turns of the Barton's bandage of the head. 36 BANDAGING. These handkerchief-bandages may be used to secure dressings to the chin or scalp, or may be employed as tem- porary dressings to secure fixation of the parts in cases of fracture or dislocation of the jaw. The Bis-axillary Cravat. — To apply this handker- chief, the body of the cravat is placed in the axilla, and Fig. 30. Bis-axillary cravat. the ends are brought up, one in front of, the other behind, the axilla, and are made to cross over the top of the shoulder ; the extremities are then carried across the back and chest respectively to the opposite axilla, where they are secured by tying (Fig. 30). This handkerchief may be employed to secure dressings in the axilla, or to hold dressings in contact with the shoulder. HANDKERCHIEF-BANDA GES. 37 The Dorso-axillary Cravat.— This handkerchief is applied by placing the body of the cravat over the spine between the scapulas, and then carrying one extremity over the shoulder and through the axilla backward to meet the other extremity, which has been carried through the axilla and over the other shoulder to the back, where the ends are secured by a knot (Fig. 31). This handkerchief may Fig. 31. Dorso-axillarv cravat. be used to hold dressings to the axilla or upper portion of the back of the chest. The Compound Dorso-bis-axillary Cravat. — To ap- ply this handkerchief, two cravats are required. The base of one cravat is placed over the front of one shoulder, and the ends are passed, one over the top of the shoulder, the other through the axilla, and they are then secured by a single knot over the scapula ; the ends are next secured by tying them in a loop. The second cravat is next placed in front of the shoulder on the opposite side, and the ends 38 BANDAGING. are respectively carried over the shoulder and through the axilla to the back, where they are secured by a single knot ; the ends of the handkerchief are then passed through the loop of the first handkerchief and secured by a knot (Fig. 32). This handkerchief may be used to draw the Fig. 32. Compound dorso-bis-axillary cravat. shoulders backward in cases of dislocation or fracture of the clavicle. Triangular Cap or Suspensory of the Breast. — To apply this handkerchief, the base of the triangle is placed under the aifected breast, and one extremity is carried be- neath the axilla of the same side, and the other extremity is carried around the opposite side of the neck, and they are secured together upon the back by a knot ; the apex should then be brought up over the breast and shoulder of the affected side, and pinned to the bandage over the scapula (Fig. 33). This handkerchief may be employed to sling the breast in nursing-women, or to hold a dressing to the breast. HAXDKEBCHIEF-BANDA GES. 39 Fig. 33. / i / Triangular cap or suspensory of the breast. The Gluteo-femoral Triangle.— In applying this hand- kerchief, a cravat is first fastened around the waist, and a second handkerchief folded into a triangle has its base placed in the gluteo-femoral fold, and its extremities car- ried around the thigh and secured in front by a knot; the apex of the handkerchief is then carried upward and passed beneath the cravat around the waist, and is turned down and pinned to the body of the triangle (Fig. 34). This handkerchief may be used to retain dressings to the region of the buttock or hip; by unpinning the apex and turning it downward, ready access can be had to the parts beneath. Gluteo-inguinal Cravat.— In applying this handker- chief, the base of the cravat is placed just over the gluteo- femoral fold, and the extremities are carried forward, one 40 BANDAGING. around the inner, the other around the outer portion of the thigh, and they are made to cross in the groin ; the ends are next passed around the pelvis and secured to- gether upon the back by a knot (Fig. 35). This handker- Fig. 34. Gluteo-femoral triangle. chief may be employed to hold dressings to the region of the groin. By employing two cravats, a double gluteo-inguinal cravat may be applied, which may be used to hold dress- ings to both groins. The turns of these cravats corre- spond to the turns of the single and double spica-band- ages of the groin. I have described a few of the many ingenious bandages devised by Mayor to substitute the use of the roller- bandage, which will give the student some idea of their design and application. It is well to bear in mind this system of dressing, for the occasion might occur in which the ordinary means of bandaging could not be obtained, and the use of handkerchiefs might answer a useful pur- BANDAGES OF THE HEAD. 41 pose as temporary dressings. I think their principal use is for temporary dressings, and I do not believe they will ever take the place of the roller-bandage, which can be Fig. 35. Gluteo-ineuinal cravat. applied with greater nicety and exactness, and certainly presents a much neater appearance. BANDAGES OF THE HEAD. Barton's Bandage. Roller Two Inches in Width, Six Yards in Length. — The initial extremity of the roller should be placed on the head just behind the mastoid process, and the bandage should then be carried under the occipital protuberance obliquely upward under and in front of the parietal eminence across the vertex of the skull, then downward over the zygomatic arch, under the chin, thence upward over the opposite zygomatic arch and over the top of the head, crossing the first turn which was made, as nearly as possible in the median line of the skull, and carrying the turns of the roller under the parietal eminence to the point of commencement. The bandage is then passed obliquely around under the occipital protuberance and forward under the ear to the front of the chin, thence 42 BANDAGING. back to the point from which the roller started. These figure-of-eight turns over the head and the circular turns from the occiput to the chin should be repeated, each turn exactly overlapping the preceding one until the bandage is exhausted (Fig. 36). The extremity should then be secured by a pin ; and pins should be introduced at the points where the turns cross each other, to give additional fixation to the bandage. In applying the bandage, care Fig. 36. Fig. 37. Barton's bandage. Barton's bandage, showing crossing of turns at vertex. should be taken to see that the turns overlap each other exactly, and that the turns passing over the vertex cross as nearly as possible in the median line of the skull (Fig. 37). Modified Barton's Bandage. — To obtain additional security in the application of the Barton's bandage, a turn of the bandage passing from the occiput to the forehead may be made, this turn being interposed between the turns BANDAGES OF THE HEAD. 43 of the bandage as ordinarily applied (Fig. 38). In ap- plying this bandage, after the first set of turns has been completed — that is, after the bandage has been brought back to the occiput — the bandage is carried forward upon the head just over the ear, around the forehead and back- ward above the ear on the opposite side to the occiput ; this being done, the ordinary figure-of-eight and circular Fig. 38. Modified Barton's bandage. turns are made, and when these have been completed another occipi to-frontal turn may be made as described above, and this may be repeated as often as is desired until the bandage is exhausted, when the extremity is fast- ened with a pin, and pins are introduced also at all points at which the turns cross. Use. — This bandage is one of the most useful of the bandages of the head, being employed to secure fixation of the jaw in cases of fracture or dislocation, and for the / 44 BANDAGING. Fig. 39. \ application of dressings to the chin. I have also employed it in place of the head-gear in slinging patients for the application of the plaster-of-Paris jacket in cases of dis- ease of the spine, a stout cord or a piece of bandage about three inches wide and one yard long being passed under the turns crossing over the vertex ; this cord is then se- cured to the cross-bar of the extension apparatus (Fig. 39). This will be found quite as comfortable to the patient as the ordinary head-gear employed, and much less likely to slip out of place and interfere with the breathing of the patient. A firmly applied Barton's bandage holds the jaws so closely together that care should be taken in applying it to patients who are under the influence of an anaes- thetic, for if vomiting occurs the material may not escape from the mouth, and suffocation might occur unless the bandage were promptly removed. This acci- dent I once saw occur, and the patient's condition was alarming until the bandage was cut, al- lowing the jaw to be opened and the contents of the mouth to escape. Gibson's Bandage. Roller Two Inches in Width, Six Yards in Length. — The initial extremity of the roller should be placed upon the vertex of the skull in a line with the anterior portion of the ear ; the bandage is then carried downward in front of the ear to the chin, and passed under the chin, and is carried upward on the same line until it reaches the point of starting. The turns are repeated until three complete turns have been made ; the bandage is then continued until it reaches a point just above the ear, when it is reversed and is carried backward around the occiput, and is continued around the head and forehead until it reaches its point of origin ; U Barton's head-bandage, em- ployed for suspension. (Park.) BANDAGES OF THE HEAD. 45 Fig. 40. these circular turns are applied until three have been made. When the bandage reaches the occiput, having completed the third turn, it is allowed to drop down to the base of the skull, and it is then carried forward below the ear and around the chin, being brought back upcn the opposite side of the head and neck to the point of origin ; these turns are repeated until three complete turns have been made, and upon the completion of the third turn the bandage is reversed and car- ried forward over the occiput and vertex to the forehead, and its extremity is here se- cured with a pin. Pins should also be applied at the points where the turns of the band- age cross each other (Fig. 40). Use. — This bandage mav be used to fix the lower jaw in cases of fracture or dis- location of the jaw, but is very apt to change its posi- tion, and is, therefore, not so satisfactory as the Barton's bandage for this purpose. Oblique Bandage of the Angle of the Jaw. Boiler Two Inches in Width, Sir Yards in Length. — The initial extremity of the roller is placed just in front of and above the left ear, and if the left angle of the lower jaw is to be covered in, the bandage is then carried from left to right, making two complete turns around the cranium from the occiput to the forehead ; if, however, the right angle of the lower jaw is to be covered in, the turns should be made in the opposite direction. Having made two turns from the occiput to the forehead, the bandage is allowed to drop down upon the neck, and is carried forward under the ear and under the chin to the angle of the jaw ; it is next carried upward close to the edge of the orbit, and obliquely over the vertex of the skull, then down behind the right ear, continuing this oblique turn under the chin to the left Gibson's bandasre. 46 BANDAGING. angle of the jaw, where it ascends in the same direction as the previous turn. Three or four of these oblique turns are made, each turn overlapping the preceding one and passing from the edge of the orbit toward the ear until the space is covered in ; the bandage is then carried to a point just above the ear on the opposite side, is reversed, and finished with one or two circular turns from the occi- put to the forehead, the extremity being secured by a pin (Fig. 41). Use. — This will be found one of the most useful of the head-band- ages ; it may be used with a com- press in treating fractures of the angle of the lower jaw, for hold- ing dressings to the lower part of the chin and to the vault of the cranium, and is especially useful in retaining dressings to the sides of the face and the parotid region. As before stated, it may be ap- plied to cover either the right or left side of the face, and, by rea- son of the oblique turns, holds its position most securely, having little tendency to become displaced. Recurrent Bandage of the Head. Roller Two Inches in Width, Six Yards in Length. — The initial extremity of the roller is placed upon the lower part of the forehead and the bandage is carried twice around the head from the forehead to the occiput to secure it, When the bandage is brought back to the median line of the forehead it is reversed, and the reversed turn is held by the finger of the left hand while the roller is carried over the top of the head along the sagittal suture to a point just^ below the occipital protuberance ; here it is reversed again, and the reverse is held by an assistant while the roller is carried back to the forehead in an elliptical course, each turn cov- ering in two-thirds of the preceding turn. These turns are repeated with successive reverses at the forehead and Oblique bandage of the angle of the jaw. BANDAGES OF THE HEAD. 47 occiput until one side of the head is completely covered in, and when this is accomplished a circular turn is made from the forehead to the occiput to hold the reverses in place. The opposite side of the head is next covered in by ellip- tical reversed turns made in the same manner, and when this has been accomplished two or three circular turns are carried around the head from the forehead to the occiput, to fix the preceding turns. Pins should be applied at the Fig. 42. Recurrent bandage of the head. forehead and occiput at the points where the reversed turns concentrate (Fig. 42). Use. — This bandage when well applied is one of the neatest of the head-bandages, and it will be found useful to retain dressings to the vault of the cranium in the treat- ment of wounds of the scalp in this region. It will also be found of service in holding dressings to fractures of the cranium and to wounds after the operation of trephining. In restless patients it will sometimes become displaced, and it may be rendered more secure by pinning a strip of band- age to the circular turn in front of the ear and carrying 48 BANDAGING. Fig. 43. it down under the chin and up to a corresponding point on the opposite side, where it is pinned to the circular turn ; or one or two oblique turns passing from the circu- lar turn over the vertex of the skull downward behind the ear, under the chin and up to the circular turn in front of the ear, may be applied. The course of these turns is the same as those employed in the oblique bandage of the angle of the jaw, the extremity being secured by a pin. Transverse Recurrent Bandage of the Head. Roller Two Inches in Width, Six Yards in Length. — The initial extremity of the roller is placed upon the lower part of the forehead and the bandage is carried twice around the head from the forehead to the occi- put to secure it. The head is then covered in by transverse turns of the bandage ; the first turn, starting from a point be- hind the ear on one side, is carried below the occiput to a corresponding point behind the opposite ear, and ascending transverse turns are then made and carried over the head, each turn covering in about two- thirds of the preceding turn, until the forehead is reached, and when this has been reached two or three circular turns are carried around the head from the forehead to the occiput to fix the recurrent turns. Pins should be applied at the points of starting and finishing of the reversed turns be- hind the ears, and at the occiput and forehead (Fig. 43). Use. — This bandage may be employed to secure dress- ings to the scalp in cases of wounds or in injuries to the skull, and is used for the same purposes as the recurrent bandage of the head. V-bandage of the Head. Roller Two Inches in Width, Four Yards in Length. — The initial extremity of the roller is secured by two turns of the bandage around the era- Transverse recurrent bandage of the head. BANDAGES OF THE HEAD. 49 niuni from the forehead to tin.' occiput, and when the roller reaches the occipital protuberance it is allowed to drop a little below this, and is carried forward below the ear around the front of the chin and lower lip, then backward to the point of starting. These turns passing from the occiput to the forehead and from the occiput to the chin are alternately made until a sufficient number have been applied, and the extremity is secured by a pin over the occiput (Fig. 44). This bandage may be modified by carrying the turns from the occiput forward under the ear and around the upper lip and back to the occiput, and alternating these turns with the occipito-frontal turns ; if employed in this way, a bandage of one and one-half inches in width should be used. Use. — This bandage may be employed to hold dressings to the front of the chin, to the upper and lower lips in cases of wounds, or to give support to these parts after plastic operations. Y\a. 44. Fig. 45. V-bandasre of the head. Head-and-neck bandage. Head-and-neck Bandage. Roller Two Inches in Width, Four Yards In Length. — The initial extremity of the roller is placed upon the forehead and carried backward just 50 BANDAGING. above the ear to the occiput, and is then brought forward around the opposite side of the head to the point of start- ins:. Two of these circular turns are made to fix the bandage, and when it is carried back to the occiput it is allowed to drop down slightly upon the neck, and is then carried around the neck, the turns around the head alter- nating with the neck-turns until a sufficient number of these have been applied, when the extremity of the bandage is secured by a pin at the point of crossing of the turns at the back of the head (Fig. 45). Use. — This bandage may be found useful in securing dressings to the anterior or posterior portion of the neck or to the region of the occiput. Care should be taken to apply it in such a manner that too much pressure is not made by the turns around the neck, which would be un- comfortable to the patient, and might seriously interfere with respiration. Crossed Bandage of One Eye. Roller Two Inches in Width, Four Yards in Length. — The initial extremity of the bandage is placed upon the forehead and fixed by two circular turns passing around the head from the occiput to the fore- head ; the roller is then carried back to the occiput and passed around this and brought forward below the ear, and passing over the outer portion of the cheek is carried upward to the junction of the nose with the forehead, and is then conducted over the parietal eminence downward to the occi- put; a circular fronto-occipital turn is next made, and when the bandage is brought back to the oc- ciput it is brought forward again to the cheek. It should then ascend to the forehead, covering in two-thirds of the preceding turn, and again be conducted back to the occiput ; these turns are repeated, the oblique turns covering the eye alternating with circu- Fig. 46. Crossed bandage of one eye. BANDAGES OF THE HEAD. 51 lar turns around the head until the eye is completely en- closed (Fig. 46), and the bandage is finished by making a circular turn about the head and introducing a pin to secure its extremity. It will be found more comfortable to the patient to include in the turns of the bandage the ear on the same side on which the eye is covered. Use. — This bandage will be found useful in retaining dressings to one eye. It will be more comfortable to the patient if a flannel roller be used to apply this bandage, as well as the bandage which includes both eyes. Crossed Bandage of Both Eyes. Roller Two Inches in Width, Six Yards in Length. — The initial extremity of the roller is placed upon the forehead and secured by two circular turns of the bandage passing; around the head from the forehead to the occiput ; the roller is then carried downward behind the occiput and brought forward below the ear to the upper portion of the cheek ; it is then car- ried upward to the junction of the nose with the forehead and conducted over the parietal eminence to the occiput ; a circular turn is now made around the head from the occiput to the ' forehead, and the roller is carried from the occiput over the parietal eminence of the opposite side for- ward to the junction of the nose with the forehead, then downward over the eye and outer portion of W the cheek below the ear and back to £ \^ the occiput ; a circular turn around P^jl*^ the head is next made, and this is followed by a repetition of the pre- vious turns, ascending over one eye, descending over the other eye, each turn alternating: with a circular . iii mi Crossed bandage of both eje&- turn around the head. These turns are repeated until both eyes are covered in, and the band- age is finished by making a circular turn around the head, the extremity being secured by a pin (Fig. 47). In this bandage both ears may be covered in or left uncovered. 52 BANDAGING. Use. — This bandage may be used to apply dressings to both eyes, and both of these bandages covering the eyes are used where it is desired to make pressure; but for the simple application of a light dressing or of a bandage for the exclusion of light, the Liebreich's bandage (Fig. 89) will be found more comfortable to the patient. Occipito-facial Bandage. Boiler Two Inches in Width, Four Yards in Length. — The initial extremity of the roller is placed upon the vertex of the head and the bandage is carried downward in front of the ear, under the jaw, and upward upon the opposite side in the same line to the ver- tex ; two or three of these turns are made, one turn accu- rately covering in the other. A reverse should be made just above and in front of the ear, and two or three turns are then made around the head from the occiput to the forehead, which completes the bandage (Fig. 48). Pins should be inserted at the points where the turns of the bandage cross each other. Use. — This bandage is employed to secure dressings to the vertex, temporal, occipital, or frontal region. Fig. 48. Fig. 49. Occipitofacial bandage. Oblique bandage of the head. Oblique Bandage of the Head. Boiler Two Inches in Width, Six Yards in Length. — The initial extremity of the bandage is placed upon the forehead, and is secured by BANDAGES OF THE HEAD. 53 Fig two circular turns passing around the head from the fore- head to the occiput. From the occiput the bandage is carried obliquely over the highest part of the lateral aspect of the head, which is to be covered in, and is passed over the forehead and back to the occiput. It is then carried to the forehead by a circular turn, which is conducted obliquely over the other side of the head and back to the occiput. A circular turn from the occiput to the forehead should be made between the oblique turns. These turns are repeated, so that each succeeding turn covers in three- fourths of the preceding turn until the sides of the head are covered in by descending turns, and the bandage is completed by a circular turn passing around the head from the forehead to the occiput (Fig. 49). This bandage may be ap- plied with descending or ascend- ing turns. Use. — This bandage is em- ployed to make pressure upon or to hold a dressing to the lateral aspects of the head. Occipito - frontal Bandage. Roller Two Inches in Width, Four Yards in Length. — The initial ex- tremity of the roller is placed upon the forehead, and a circular turn is made around the fore- head and occiput to fix it. A circular turn is then made, pass- ing around the head from a point below the occiput to a point just above the forehead • the next circular turn is made around the head ascending posteriorly and descending anteriorly, and after a suffi- cient number of these turns have been made to cover in the front and back of the head the end of the bandage is secured with a pin (Fig. 50). Use. — This bandage will be found useful in securing dressings to the forehead and anterior and posterior por- tions of the scalp. Occipitofrontal bandage. 54 BANDAGING. BANDAGES OF THE UPPER EXTREMITY. Fig. 51. Spiral Bandage of the Finger. Roller One Inch in Width, One and a Half Yards in Length. — The initial ex- tremity of the roller is se- cured by two or three turns around the wrist; the bandage is then carried obliquely across the back of the hand to the base of the finger to be covered in, then to its tip by ob- lique turns ; a circular turn is next made, and the finger is covered by as- cending spiral or spiral reversed turns until its base is reached ; the band- age is then carried ob- liquely across the back of the hand and finished by one or two circular turns around the wrist ; the ex- tremity may be pinned or which are tied around the ■',■.';■;* ■:■■■■■ Spiral bandage of the finger. may be split into two tails, wrist (Fig. 51). Use. — This bandage is employed to retain dressings to injuries or wounds upon the finger, and to secure splints in the treatment of fractures or dislocations of the phalanges. Gauntlet Bandage. Roller One Inch in Width, T/iree Yards in Length. — The initial extremity of the roller is fixed at the wrist by one or two circular turns of the bandage ; it is then carried down to the tip of the thumb by an oblique turn of the roller, and this is covered in by spiral or spiral reversed turns to the metacarpophalangeal articulations; the roller is then carried back to the wrist and a circular turn is made around it. The bandage is BAX PAGES OF THE UPPER EXTREMITY. 55 then carried down to the tip of the index finger by an oblique turn, which is covered in the same manner. When all the lingers have been covered in, the bandage is finished by circular turns around the hand and wrist (Fig. 52). Use. — This bandage may be employed to apply dressings to the fingers and hand in cases of wounds or fractures. It was formerly much employed in the treatment of burns of the fingers to prevent the opposed ulcerated surfaces from adhering, but its use for this purpose has been sup- planted by wrapping each finger in a separate dressing and applying a dressing over all the fingers and the hand with a few recurrent and spiral turns of a wide roller, the applica- tion of this dressing being much less painful to the patient, Fig. 52. Fig. 53. i^^- Gauntlet bandage. Demi-gauntlet bandage. and being at the same time equally satisfactory in its results. Demi-gauntlet Bandage. Boiler One Inch in Width, Four Yards in Length. — The initial extremity of the bandage should be placed upon the wrist and fixed by two circular turns passing from the radial to the ulnar side ; 56 BANDAGING. Fig. 54. then carry the roller obliquely across the back of the hand to the base of the little finger, pass the bandage around this and carry the roller back to the wrist, making a circular turn ; it should then be carried obliquely across the hand to the base of the ring finger, and so successively until the base of each of the fingers and of the thumb has been included ; the bandage is then completed by an oblique turn across the back of the hand passing between the index finger and the thumb and a circular turn around the wrist (Fig. 53). The demi-gauntlet bandage may also be applied in such a manner as to cover only the palm and leave the dorsum of the hand uncovered. Use. — This bandage may be employed to retain light dressings to the dorsal or palmar surface of the hand. Spica-bandage of the Thumb. Roller One Inch in Width, Three Yards in Length. — The initial extremity of the roller is placed upon the wrist and fixed by two circular turns; then carry the roller obliquely over the dorsal surface of the thumb to its distal extremity ; next make a circular or spiral turn around the thumb, and carry the bandage upward over the back of the thumb to the wrist, around which a circular turn should be made. The roller is then carried around the thumb and wrist, making figure-of- eight turns, each turn overlapping the previous one two-thirds as it ascends the thumb, and each figure- of-eight turn alternating with a cir- cular turn around the wrist. These turns are repeated until the thumb is completely covered in with spica-turns, and the bandage is finished by a circular turn around the wrist (Fig. 54). Use. — This bandage is employed to apply dressings to the dorsal surface of the thumb and for the retention of Spiea-bandage of the thumb. BANDAGES OF THE UPPER EXTREMITY. 57 splints in the dressing of fractures or dislocations of the hones of the thumb. Spiral Reversed Bandage of the Upper Extremity. Roller Tiro and a Half Inches in Width, Seven Yards in Length. — The initial extremity of the roller is placed upon the wrist, and secured by two turns around the wrist ; the bandage is then carried obliquely across the back of the hand to the second joint of the fingers, where a circular turn should be made ; the hand is covered in by two or Fig. 55. Spiral reversed bandage of the upper extremity. three ascending spiral or spiral reversed turns. When the thumb has been reached, its base and the wrist are covered in by two figure-of-eight turns ; the bandage is then carried up the forearm by spiral and spiral reversed turns until the elbow is reached ; this may be covered in with spiral re- versed turns, and the bandage is next carried up the arm with spiral reversed turns to the axilla (Fig. 55). If, on reaching the elbow T , the arm is bent, or is to be flexed in the subsequent dressing, the elbow should be covered in with figure-of-eight turns, and when this has been done the arm may be covered in with spiral reversed turns. When properly applied, the reverses should be in line, and should not be made over the prominent ridge of the ulna. Use. — This is one of the most generally employed of all the roller-bandages ; it constitutes the primary roller which is applied in the dressing of fractures of the humerus, and 58 BANDAGING. it is also the bandage employed in holding dressings to the arm and forearm and in securing splints to these parts in the treatment of fractures and dislocations. Figure-of-eight Bandage of the Elbow, Roller Two Inches in Width, Four Yards in Length. — The initial ex- tremity of the bandage is placed upon the forearm a short distance below the elbow-joint, and fixed by one or two Fig. .56. Figure-of-eight bandage of the elbow. circular turns, the arm being flexed. The bandage is then carried by an oblique turn across the flexure of the elbow- joint, and passed around the arm a few inches above the elbow ; a circular turn is then made, and the roller is next carried across the flexure of the elbow and passed around the forearm. These turns are repeated, the turns from the forearm ascending and those from the arm descending, each set of turns crossing in the flexure of the elbow until BANDAGES OF THE UPPER EXTREMITY. 59 it is covered in, and a final turn is passed circularly around the elbow-joint (Fig. 56). This bandage is sometimes applied by first making one or two circular turns around the elbow and then applying the figure-of-eight turns as previously described (Fig. 57). Use. — This bandage is often employed as a part of the spiral reversed bandage of the upper extremity when the arm is to be flexed, and is also used to hold dressings to the region of the elbow-joint. It was formerly much used Fig. 57. Figure-of eight bandage with primary turns around the elbow. to hold the compress upon the wound resulting from vene- section at the elbow. Spica-bandage of the Shoulder (Ascending). Roller Two and a Half Inches in Width, Seven Yards in Length, —The initial extremity of the roller is placed obliquely upon the outer surface of the arm opposite the axillary fold, and fixed by one or two circular turns. If the right shoulder is to be covered, the bandage is next carried across the front of the chest to the axilla of the opposite side, then around the back of the chest to the point of starting 60 BANDAGING. upon the arm ; then the roller should be conducted around the arm of this side up over the shoulder, across the front of the chest, through the opposite axilla, and back over the posterior surface of the chest to the point of starting ; con- tinue to make these ascending turns, each turn overlapping the preceding one about two-thirds until the shoulder is covered in (Fig. 58), when the extremity of the bandage may be secured by a pin at the point of ending, or the last turn may be carried from the shoulder around the back of the neck and brought forward over the opposite shoulder Fig. 58. Spioa-bandage of the shoulder (ascending). and pinned to the turns which pass around the axilla. It should be remembered that the turns of the roller overlap each other exactly in the opposite axilla, and it will be found more comfortable to the patient to place a little cotton-wadding in the axilla to prevent the bandage from excoriating the skin of this part. Care should be taken to see that the turns are made in such a manner that the spica-turns occupy as nearly as possible the median line of the shoulder. When this bandage is applied to the left shoulder, after fixing the initial extremity by circular turns around the arm, the roller should be carried over BANDAGES OF THE UPPER EXTREMITY. 01 the back of the chest to the axilla of the opposite side and then brought back to the point of starting; the succeed- ing turns are then applied in the same manner. Spica-bandage of the Shoulder (Descending). Roller Two and a Half Inches in Width, Seven Yards in Length. — The initial extremity of the roller should be fixed upon the arm as near as possible to the axillary fold by one or two circular turns ; and if it is applied to the right shoul- der, the bandage should be passed under the axilla and carried obliquely over the shoulder to the base of the neck, Fig. 59. Spica-banda then downward across the front of the chest to the axilla of the opposite side ; from the axilla the roller is carried over the back of the chest to the base of the neck, so as to cross the first turn at this point ; it is then carried through the axillary space, then back to the neck, the turns de- scending toward the shoulder. These turns, taking the same course, are repeated, each turn overlapping two- thirds of the previous one until the shoulder is covered in and the circular turn around the arm is reached, at which point the extremity is secured by a pin (Fig. 59). Use. — The spica-bandages of the shoulder are employed 62 BANDAGING. to hold dressings to the shoulder, to hold compresses over the acromial end of the clavicle in dislocation of that portion of the bone, to retain the shoulder-cap used in the treatment of fractures of the upper portion of the humerus, and to retain dress- Fig. 60. ings to the axilla. ^^^^^ _.___l Figure-of-eight, Bandage ; • B of the Neck and Axilla. j v ■■ - . ^F Roller Two Inches in Width, % -^r I Five Yards in Length. — The mp \ initial extremity of the roller W ; is fixed upon the side of the ■ neck and secured by one or I ■ two loosely applied circular turns; if applied to the right ' —^ _-£._» a xilla, carry the bandage from Figure-oMgM bandage of the ^ tQ ri g ht over the right shoulder to the anterior part of the axilla under which it passes, to ascend in front over the same shoulder to the back of the neck ; these figure- of-eight turns around the neck and axilla, each turn over- lapping two-thirds of the preceding turn, are repeated until the desired space is covered and the bandage is completed by a circular turn around the neck (Fig. 60). Use. — This will be found a useful bandage to secure dressings to the base of the neck, the upper part of the shoulder, and to the axilla, as it does not restrict the motions of the arm unless drawn too tight. Velpeau's Bandage. Two Rollers Two and a Half Inches in Width, Seven Yards in Length. — The patient should place the fingers of the hand of the affected side on the opposite shoulder ; the initial end of the roller should be placed on the body of the scapula of the sound side and secured by a turn made by carrying the bandage over the shoulder of the affected side, near its outer portion, then conducting it downward over the outer and posterior surface of the arm of the same side, behind the point of the elbow, and obliquely across the front of the chest to the axilla of the opposite side, thence to the point of start- BANDAGES OF THE UPPER EXTREMITY. 63 ing. This turn should be repeated, to fix the initial ex- tremity of the bandage. Having completed the second turn, carry the roller transversely around the thorax, pass- ing over the flexed elbow of the affected side, from this point to the axilla, and through this to the back. From this point the roller is carried over the shoulder and down the outer and posterior surface of the arm behind the elbow, and obliquely across the front of the chest through the axilla to the back, and, continuing, passes transversely Fig. 61. Velpeau's bandage. across the back of the chest to the elbow, which it en- circles, and then passes to the axilla. These alternating turns are repeated until the arm and forearm are bound firmly to the side and chest. The vertical turns over the shoulder, each turn covering in two-thirds of the previous turn and ascending from the point of the shoulder toward the neck and from the posterior surface of the arm toward the elbow, are applied until the point of the elbow is reached. The transverse turns passing around the chest and arm are so applied that they ascend from the point of the elbow toward the shoulder, each turn covering in 64 BANDAGING. one-third of the previous one, and the last turn should pass transversely around the shoulder and chest, covering the wrist (Fig. 61). The extremity of the bandage should be secured by a pin where it ends, and additional fixation will be secured by introducing a number of pins at the points where the turns of the bandage cross each other. Use. — This bandage is employed to fix the arm in the treatment of certain fractures of the clavicle and scapula ; also to secure fixation of the humerus after the reduction of dislocations of the shoulder-joint. Desault's Bandage. Three Boilers Two and a Half Inches in Width, Seven Yards in Length. — A wedge-shaped pad to fit in the axilla is also required. These rollers are known as the first, second, and third rollers. First Roller of Desault's Bandage. — Before applying the first roller the arm of the patient on the injured side should . Fig. G2. First roller of Desault's bandage. be elevated and carried off at right angles to the body ; the wedge-shaped pad with its base in the axilla should next be applied to the side of the chest, and the initial extrem- ity of the roller should be placed upon the middle of the pad, which may be fixed by two or three circular turns around the chest; the bandage is then carried down the BANDAGES OF THE UPPER EXTREMITY. 65 chest by obliqtie circular turns until the lower extremity of the pad is reached, and it is then carried up the chest by spiral turns until the upper extremity of the pad is reached, when it is conducted obliquely across the front of the chest to the sound shoulder and passed under the axilla, brought over the shoulder and conducted around the chest, where it is secured (Fig. 62). Second Roller of Desault's Bandage. — The arm should be brought down against the side so as to press upon the pad previously applied, and the forearm should be flexed upon the arm and brought across the lower portion of the chest. Fig. 63. Second roller of Desault's bandage. The initial extremity of the roller is placed in the axilla of the sound side, and the bandage is carried around the chest and over the arm of the injured side, making a cir- cular turn around the chest to fix it ; then spiral turns are made around the chest from above downward until the elbow is reached, the turns being more firmly applied as they descend, and when this point is reached the end of the bandage is secured. Or the initial extremity of the bandage may be placed upon the chest of the sound side and a circular turn may be made to fix it, and then spiral turns, including the chest and arm, may be made from below upward until the axilla is reached (Fig. 63). 5 66 BANDAGING. Third Roller of Desault's Bandage. — The initial extremity of the roller is placed in the axilla of the sound side, and the bandage is carried obliquely over the front of the chest to the shoulder of the injured side, passed over this, and conducted down the back of the arm to the elbow, thence obliquely upward over the upper fifth of the forearm to the axilla of the sound side. From this point it is carried backward obliquely over the back of the chest to the shoul- der ; crossing the previous shoulder-turn, it is conducted down the front of the arm to the elbow, then around this and backward obliquely over the back of the chest to the Fig. 64. Third roller of Desault's bandage. axilla of the sound side. These turns are repeated until three sets of turns have been applied, which should overlie each other exactly (Fig. 64). The course of the turns of the third roller is considered the most difficult to remem- ber, and the student may be assisted in its correct applica- tion by remembering that all the turns start at the axilla, pass to the shoulder, and then to the elbow, and from the elbow always return to the starting-point — the axilla. The turns of the third roller make two triangles, one on the anterior surface of the chest (Fig. 65), the other upon the back (Fig. 66). After the application of the three rollers the hand and BANDAGES OF THE UPPER EXTREMITY. c softened by snaking it in warm water, and then it can readily he cut with scissors, or it may he cut with bandage-shears. In applying either the starched bandage or the silicate of potassium bandage, care should be taken to nse cheese- cloth or crinoline which has been shrunken by being moist- ened and allowed to dry before being employed ; other- wise, dangerous compression of the part may occur if the bandage has been firmly applied and shrinks after its application. The Paraffin-bandage. — Paraffin, which melts at from 105° to 120° F., is used in the application of this band- age. The limb bein^ covered bv a flannel roller, a vessel containing paraffin is placed in a basin of boiling water. As the roller, which may be either of flannel, cheese-cloth, or crinoline, is unwound, it is passed through the melted paraffin and applied to the part, and the turns are repeated until a dressing of sufficient thickness results, when the surface may be brushed over with melted paraffin. This dressing sets very rapidly, being quite firm in from five to ten minutes. Moulded Splints. Raw-hide or Leather Splints. — In moulding raw- hide or leather splints, it is necessary, first, to apply a plaster-of-Paris bandage to the part to which the raw- hide splint is to be fitted ; and as soon as the plaster has set, it is removed, and a solid plaster cast is next made by pouring liquid plaster-of-Paris into this mould. When this has become dry, a piece of raw-hide, which has been soaked for a time in warm water, is moulded to the cast and held firmly in contact with it by tacks or a bandage until it has become perfectly dry. It is then removed, and its surface is covered with several coats of shellac, to prevent its absorbing moisture from 108 BANDAGING. Fig. 108. the skin when applied, and changing its shape. Eyelets or hooks are fastened to the edges of the splint, through which tapes are passed to secure it in place. Made in this manner, raw-hide splints fit the part very accurately, and constitute a very satisfactory dressing for cases of joint-disease, and in the form of leather jackets are often employed in the treatment of disease of the spine in place of the plaster-of-Paris jacket (Fig. 108). In the treatment of high dorsal or cervical caries a leather splint in two sections, which rests upon the shoulders and sup- ports the head, is often used with good results (Fig. 109). Binders' Board or Pasteboard Splints. — This material, which can be obtained in sheets of different thicknesses, is frequently employed for the manufacture of splints. In moulding these splints, a portion of the board of the requisite size and Fig. 109. Leather jacket with jury- mast. Leather splint for cervical caries. (Owen.) thickness is dipped in boiling water for a short time, and when it has become softened it is removed and allowed to cool ; a thick layer of cotton-batting is next applied over it, and it is then moulded to the part and held firmly in FIXED DRESSINGS, OR HARDENING BANDAGES. 109 place by the turns of a roller-bandage ; in a few hours it becomes dry and hard. This material, from its cheapness and the ease with which it is obtained, is frequently employed to mould splints for the treatment of fractures, and for the fixation of joints in the treatment of acute and chronic joint-affections. A moulded pasteboard splint may also be employed to fix the ends of the bones after the excision of a joint. Porous Felt Splints. — This material is also employed for the manufacture of splints, and is applied by dipping the material in hot water and then moulding it to the part and securing it by a bandage ; as it dries, it becomes hard. Hatters'^felt Splints. — Hatters' -felt may also be em- ployed for the manufacture of splints or dressings. It is softened by dipping it in boiling water or heating it in the flame of an alcohol lamp, and when soft and pliable it is moulded to the part, and as it cools it again becomes hard. These splints are employed for the same purpose as those made of plaster-of-Paris, leather, or pasteboard. PAKT II. MINOR SURGERY. SURGICAL BACTERIOLOGY. Bacteria (Schizomycetes). — These are minute cellular organisms of microscopic size, classified as belonging to the vegetable kingdom, among the fungi. They play an active part in the causation of the processes of fermenta- tion and putrefaction, and are the causal ^ agents of many varieties of diseases. The word germ is often used as synonymous with bacterium in speaking of the organisms that cause disease, but we must remember that certain pathogenic germs, as the hcematozoon malarice, the amoeba coli, and the coccidia, are members of the animal king- dom and are not bacteria. Bacteria may be divided into the lower and the higher bacteria. The lower forms are always unicellular, although in the process of growth cells may remain attached to each other ; while the higher forms are filamentous, often branched, are made up of numbers of simple cells joined together, and the cells sometimes show a tendency to specialization. To this class belong the organism which causes actinomycosis, the actinomyces bovis seu hominis, and also the streptothrix madurce, the organism of Madura foot or mycetoma. The lower bacteria, with which we are mainly concerned, are unicellular and exceedingly minute, the round forms measuring not more than 1 micromilli- metre ("25W0 ^ ncn ^ m diameter, and, therefore, only capable of investigation under the highest powers of the ill 112 MINOR SURGERY. microscope. When unstained they appear to be homo- geneous, but by staining they can be seen to possess a cell- wall or limiting membrane, not always well defined, called the ectoderm, enclosing the protoplasmic contents or endo- derm, which contains no nucleus. The cell- wall is probably of a gelatinous nature, and when it is well defined the bac- teria are said to be capsulated. In the protoplasm of the cell-body certain bodies, metachromic granules, are some- times seen by staining, as well as other round or oval unstained spaces, which, when situated at the ends of a bacillus, are known as polar granules. Both of these are probably either the results of degenerative changes, or are artificially produced in drying. Certain bacteria produce coloring-matters — red, yellow, and blue — many of which are allied to the lipochromes, a class of coloring-matters found in certain animal and vegetable organisms. Unicellular bacteria are classified according to their shape into cocci, or round cells, bacilli, or rod-shaped cells, and spirilla, which are cylindrical cells of curved or spiral outline. Motility in those bacteria which possess it is due to the presence of cilia or flagella. The ordinary mode of growth of bacteria is by division or splitting. Under circumstances unfavorable to growth they may also produce spores, but not as a means of multiplication, as one bacterium usually produces but one spore. Spores. — These may be of endogenous or arthrogenous origin. Endogenous spores arise especially in the bacilli. They appear in the protoplasm of the cell as granules, which develop into round, oval, or short rod-shaped bodies, the remaining portion of the bacterium either persisting for a time or disappearing very soon. Arthro- genous spores appear to be cocci which have swollen, become more refractive, and are more resistant to unfav- orable surroundings than the original coccus. Spores are highly refractive, and consist of a protoplasmic body with a dense surround 1112: membrane. Thev are very resistant to unfavorable surroundings, and are much more difficult to destroy by heat, chemical reagents, or drying, than are SURGICAL BACTERIOLOGY. 113 adult bacteria. When placed under circumstances favor- able to their growth, the capsule splits, and a little bud appears and develops into an adult bacterium. The ordinary method of multiplication of bacteria is by division or fission, one individual dividing into two, and these again into two more, the process sometimes taking place with great rapidity. The new cells may remain attached or separate, according to the nature of their limiting membrane. In the case of cocci, when forming pairs, they are called dijAococci. They may also be tetra- genous, or form chains, as in the streptococci and strepto- bacblli ; or bunches, as in the case of the staphylococci. A zobglea mass is formed by the cohesion of a large num- ber of bacteria, where, owing to the gelatinous nature of their envelopes, they adhere to each other and appear to be imbedded in jelly. Bacteria are found widely distributed in the air, the water, the earth, and wherever there is organic substance from which they can obtain their nutrition. They live by breaking up into simpler forms the complex organic compounds on which they are dependent for their carbon and nitrogen, being unable to extract the same from inor- ganic material. They also require moisture, being de- stroyed in time by drying. Those which require oxygen are called aerobic, while those which only grow^ when it is excluded are called anaerobic. Facultative aerobic and facultative anaerobic are terms used to designate those bacteria which can grow in its presence or absence ; the first, however, growing best with and the latter best with- out it. Another division of bacteria is into saprophytic, or those living on dead organic matter, and parasitic, or those depending on living organisms, the latter embracing the pathogenic bacteria. The boundary line between these two classes is not well defined, however. A certain amount of heat is necessary to bacterial existence, the pathogenic germs growing best at the body temperature ; they are destroyed by high temperatures, most of the pathogenic bacteria being killed between 122° and 140° F. (50° and 60° C). The spores are, as a rule, much 8 114 MINOR SURGERY. more resistant to heat. Low temperatures tend to inhibit the growth of bacteria rather than to destroy their life. Direct sunlight also has an injurious action upon them. Cultivation. — Bacteria are studied outside of the body by growing them on culture-media, which may be liquid or solid, proteid or carbohydrate-containing material. The media are sterilized and kept in tubes or dishes (Petri's dishes). A little of the culture or material to be studied is transferred to the culture-medium by a sterilized platinum wire (called an bse), and spread on the surface of the solid medium (stroke-culture), or plunged into it (stab-culture), or mixed with the fluid medium. The tubes or plates are then placed in an oven heated to the required temperature. The germs form colonies of characteristic size, shape, and coloring, and the different species may thus be isolated and studied. The liquid media include bouillon, peptone solu- tion, and extracts of vegetable substances, as potato. Solid media include mixtures of beef-extracts with gelatin or agar-agar, coagulated blood-serum, and slices of potato or other vegetables. Inoculation. — The action of bacteria and their toxins is studied experimentally by the injection of cultures, or of the body fluids or the juice of bacterially infected tis- sues into some of the lower animals. The animals usually employed are the guinea-pig, rabbit, mouse, rat, and pigeon. Injections are made with a sterile hypodermic syringe under the skin, into the peritoneal cavity, intra- venously, and into the anterior chamber of the eye, or the skin may merely be scarified. The animal is carefully watched afterward, its symptoms noted, and when dead of the disease, or killed, cultures are made from the organs and the tissue-changes studied. Staining*. — In order to detect bacteria in the tissues, or to study and differentiate them from each other, it is neces- sary to stain them, and this is accomplished by the use of dilute aqueous or alcoholic solutions of the aniline dyes, counter-staining the tissues to make their detection easier. Bacteria differ widely in the facility with which they take the stains, some staining readily, while others require the SURGICAL BACTERIOLOGY. 115 action of heat or of a mordant ; and they differ also in the tenacity with which they retain the stains in the presence of various reagents, as alcohol and the mineral acids. AVe are thus able to separate different bacteria by the use of special methods of staining and decolorizing. For exam- ple, the gonococcus, the bacillus coli communis, and the typhoid bacillus are decolorized by the use of Gram's method ; while the bacilli of anthrax, tuberculosis, diph- theria, and tetanus are stained by it. The aniline stains most frequently employed are methylene-blue, gentian- violet, thionin, fuchsin, dahlia, and vesuvin. Koch's Law. — To prove that a certain bacterium is the cause of a disease, the following rules have been laid down by Koch : The bacterium must first be found in the dis- eased person or animal. It must be cultivated outside of the body. When inoculated in pure culture in a healthy animal it must produce the original disease. From the body of the animal the original microbe must be capable of again being isolated. Intoxication and Infection. — Bacteria usually gain entrance into the body through some break in the conti- nuity of the skin or mucous membrane, especially the latter, owing to its being easier of penetration. They often enter through an open wound. Favoring elements are a weak- ened or diseased state of health of the individual, or an unusual virulence of the germ. If the germs remain localized, and only their products are absorbed, the proc- ess is spoken of as intoxication. If the germs themselves enter the circulation, we have infection, although the term infection is used also by surgeons to denote the presence of bacteria in a wound, without necessarily or even usually implying their presence in the circulation'. If the germ be pyogenic — that is, one that excites suppuration — the symptoms produced by the absorption of its products con- stitute saprcemia ; if the germ enters the circulation, we have septiccemia ; and if it finds lodgement in the tissues or organs and gives rise to secondary abscesses, we have pycemia. Elimination. — Bacteria are eliminated by the kidneys, 116 MINOR SURGERY. the intestine, the salivary glands, in the bile and milk, and probably also by the sweat-glands. They frequently cause lesions in the eliminating organ. Pathogenic Action. — The pathogenic action of bacteria is due to the formation of certain poisonous products secreted by them, or produced by their action upon the tissues. From the bacteria themselves, by their degen- eration, we have also formed the proteins. The bacteria by their secretion produce the ferments, and, perhaps, the toxins ; and by their action upon the tissues we have pro- duced the ptomaines, amines, peptones, albumoses, fatty acids, etc. Toxins. — The toxins are produced by the pathogenic bacteria. They are poisonous when injected, even in very minute doses, acting after a period of incubation, and are looked upon by many observers as being of the nature of ferments. Others have classified them as toxalbumins or toxalbumoses. The different pathogenic bacteria elaborate their own specific toxins. Some of them have a local as well as a general action, producing inflammation, necrosis, etc., when injected into living animals. Resistance of the Tissues to Bacteria. — That the introduction of bacteria into the body is not always fol- lowed by the development of disease is due to a number of circumstances, one of the most important being the resistance offered by the tissues. Certain of the leuco- cytes have what is known as a jjhagocytic action — that is, the pov/er to take into themselves and destroy by intracellular action the invading germs. The leucocytes appear to be attracted to the germs by a power residing in the bacteria, known as positive ehemotaxis, their migra- tion being accompanied by the nutritive changes consti- tuting the process of inflammation, and in the case of pyogenic germs of suppuration. Inflammation seems to be a limiting and protecting process. The bacteria if very virulent may overcome the leucocytes, or repel them by the production of toxins, which are negatively chemotactic — that is, they repel the leucocytes and interfere with their phagocytic action, and we have in consequence a general SURGICAL BACTERIOLOGY. 117 invasion of the organism by the bacteria, often without any local inflammation, in addition to the phagocytic action of the leucocytes, the blood and fluids of the body have a certain germicidal powder, said to be due to the presence of albuminous bodies — alexins. The presence in a wound of a foreign body favors the growth of bacteria, as does, to a certain extent, the presence of blood-clot or other material which may act as a culture-medium for the germs. Immunity. — This consists in the freedom from liability to a disease, and may be natural or acquired. In natural immunity the person or animal is immune from birth ; while acquired immunity may be the result of a previous attack of the disease or may be produced artificially. As examples of natural immunity we have that shown by the lower animals to syphilis and leprosy, and of man to cer- tain diseases of the lower animals. One attack of small- pox, scarlet fever, or typhoid fever confers an acquired immunity on the patient which is usually permanent; while an attack of pneumonia, influenza, or diphtheria is followed by a period of temporary immunity. Immunity may also be absolute or relative ; the first being rare, the latter common, being overcome by unusual conditions. Artificial immunity is active or passive. Active immunity is obtained by the injection into animals of increasing doses of a pathogenic organism, or of its toxins, the dose being gradually increased until a high degree of immunity is obtained. This method is preventive of future attacks, but owing to its slowness is not useful against an existing disease. Passive immunity, which is less lasting than active immunity, is conferred by the injection into an animal of the serum of an animal that has been highly immunized by the previous method. The serum will destroy existing toxins and organisms, and confer tem- porary immunity against further infection. Antitoxin. — The mechanism of the production of im- munity is largely, if not altogether, dependent upon the formation, by the reaction of the tissues to the toxins, of an albuminous body known as antitoxin. To the presence 118 MINOR SURGERY. of this substance in the serum of an actively immunized animal is clue its curative power when injected into an animal suffering from the same disease. The antitoxin of diphtheria has been widely employed of late years with beneficial results, and the investigations now being carried on in tetanus, hydrophobia, anthrax, and other diseases, afford foundation for the hope that similar good results may be obtained with their antitoxins. A distinction is made between antitoxic serum and antimicrobic serum : the former being produced by the injection of toxins, and the latter by the injection of living bacteria. The anti- microbic serums tend to the destruction or paralysis of the micro-organisms, but not necessarily of their toxins. Varieties of Bacteria. The bacteria of importance surgically are those giving rise to ordinary suppuration, the gonococcus, the tubercle bacillus, the bacillus of malignant oedema, of glanders, of anthrax, of tetanus, of infectious emphysema, and the organisms causing actinomycosis and mycetoma. Bacteria of Suppuration. — A large number of bac- teria are capable of giving rise to suppurative inflam- mation, but the most important are the staphylococcus, especially the staphylococcus pyogenes aureus, and the streptococcus pyogenes or streptococcus erysipelatis, they being identical. Besides these, as rarer causes, we have the bacillus pyocyaneus, the bacillus coli communis, the typhoid bacillus, the gonococcus, the diplococcus pneumo- niae and the bacillus pneumonias (Friedliinder). Staphylococcus Pyogenes Aureus. — This bacillus, which causes 80 per cent, of suppurative inflammations, and is almost always the cause of osteomyelitis, grows in clusters (Fig. 110), can be cultivated on ordinary media, but best on agar, and forms small round colonies, at first whitish, later of an orange-yellow color. It is found in health on the skin, in the pharynx, and in the external secretions. The staphylococcus pyogenes albus, or epidermis albus, as it is called, from being found in the epiderm, is less viru- SURGICAL BACTERIOLOGY. 119 lent than the preceding, and forms white colonies. Ji not infrequently is the cause of stitch abscesses. Streptococcus Pyogenes. —This is a small round organ- ism which forms chains (Fig. 111). It is found occasion- ally on mucous surfaces in health, and causes dangerous Fig. 110. Fig. 111. °0 cu o&o ooO °0 0\ JO * -- oo„ * W J o Staphylococcus pyogenes aureus. Streptococcus pyogenes. (Abbott.) (Abbott.) phlegmonous inflammations. It also causes erysipelas, being identical with the streptococcus erysipelatis. Bacillus Coli Communis. — This is a rod-shaped bacillus, and may be long and slender or short and rounded. It strongly resembles the typhoid bacillus. It is provided with flagella. It is found in the intestines in health, and seems to acquire virulent properties from inflammation or strangulation of the bowel, giving rise to appendicitis and peritonitis by migration through the diseased wall of the bowel or by escape through a rupture ; it may also be the cause of cystitis, pyelitis, pyelo- nephritis, and occasionally of local- FlG - 112 - ized abscesses. ^f% Gonococcus. — This, the germ of ^g^ j$*Mm gonorrhoea, is a kidney -shaped coccus, arranged in pairs, with the concave edges toward each other ; the diplo- cocci usually inhabit the pus-cells, |pl but are Occasionally free (Fig. 112). Gonococcus. (After Bumm.) Besides specific urethritis; it causes salpingitis, oophoritis, arthritis, endocarditis, conjuncti- vitis, proctitis, and other lesions. Tubercle Bacillus. — This, the cause of tuberculosis, is a rod-shaped bacillus, sometimes slightly curved, 1.5 to 3.5 micromillimetres in length and 0.2 to 6.5 micromillimetre 120 MINOR SURGERY. thick. It is not motile, and occurs singly, in pairs, and in groups ; spore-production has not as yet been demon- strated (Fig. 113). Inoculation may be directly through a wound, or by inhalation, ingestion, or placental trans- 9/h/.M Tubercle bacilli. (Abbott.) mission, the last being rare. It may infect any organ of the body. It causes tuberculosis in many of the lower animals, cattle being especially liable to its infection. Bacillus Mallei. — Glanders is caused by this bacillus, which resembles the tubercle bacillus, but is shorter and Fig. 114. Fig. 115. •, A£ V Bacillus mallei. (Abbott.) Threads of bacillus anthracis con- taining spores. (Abbott.) thicker (Fig. 114). Infection of the mucous membranes of the respiratory tract and through the skin is not un- SURGICAL BACTERIOLOGY. 121 common in men who are exposed to infection from horses. Bacillus Anthracis. — This, the cause of anthrax, is a very large, straight bacillus, usually from 5 to 20 micro- millimetres in length, sometimes, however, attaining a length of 50 micromillimetres. It forms long chains and produces spores, which are very resistant (Fig. 115). Infection in man usually arises from handling infected skins and hides, and causes a local inflammation, with general septicaemia. Infection may also take place through the lungs or through the gastro-intestinal tract. Bacillus of Tetanus. — This is a rod-shaped organism which, owing to the formation of a spore at one end which Fig. 116. Fig. 117. /> o *f° 6 \ V ° Tetanus bacillus. (Abbott.) Bacillus of malignant oedema, spore stage. (Abbott.) distends it, is often of a drumstick shape (Fig. 116). It is anaerobic, being found especially in garden-earth, in the excrement of animals, and around stables. Infection follows wounds, especially punctured wounds by nails or splinters, which are liable to be contaminated from the earth ; infection is also quite common in puerperal women and in the newborn. Suppuration in a wound favors its development. The bacterium apparently remains localized, producing its characteristic symptoms by the action of very powerful toxins, of which two, tetanin and tetanotoxin, have been isolated. An antitoxin has been isolated from immunized animals, and good results have been reported from its administration in individuals suffer- ing from tetanus, but it has often proved disappointing. Bacillus of Malignant (Edema. —This resembles the 122 MINOR SURGERY. anthrax bacillus in appearance, being more slender, how- ever, and, like it, has a tendency to form chains. It is motile, being provided with flagella, is anaerobic, and forms spores (Fig. 117). It occurs in the soil, in dust, and in the contents of the intestines of lower animals. In the lower animals it is the cause of the disease known as malignant oedema, which is associated with suppuration and necrosis of the subcutaneous tissues, emphysema, and gangrene. In man it has been found in certain cases of rapidly spreading traumatic gangrene and gangrenous emphysema, arising in connection with compound fract- ures and other deep punctured wounds. Bacillus Aerogenes Capsulatus. — This organism is from 3 to 6 micromillimetres in length, and may be found singly, clumped, or in chains. It is non-motile, anaerobic, and does not form spores. It finds entrance into the body through a wound or ulceration, external or internal, and its effects resemble somewhat those produced by the bacillus of malignant oedema, viz., necrosis, gangrene, and the production of gas, which in this case is found in any or all of the tissues and organs and in the blood, in the form of minute bubbles, in the walls of which the bacilli may be found. In man it produces the condition which has been described as gaseous gangrene, infectious emphy- sema, gas phlegmon, and emphysematous necrosis. Actinomyces, or Ray Fungus. — This organism probably belongs to the higher order of bacteria, and occurs in yellow masses, which may be visible to the naked eye. The masses consist of organisms with diverging rays, consisting of threads with bulbous ends (Fig. 118). It occurs rarely in man, commonly in the lower animals, from which it has been obtained in pure culture. When implanted in the tissues, to which it is conveyed through a wound or carious tooth, sometimes apparently in seeds or in grains, it excites a chronic inflammation, with the presence of granulation-tissue, necrosis, and suppuration. In man it occurs most frequently in the mouth, tongue, and internal organs. In cattle it affects the jaws, causing " lumpy jaw." THEORY OF ASEPSIS AND ANTISEPSIS. 12:} Fig. 118. Actinomyces. (Baoigartex.) Mycetoma, or the Streptothrix Madurae. — This is a branching micro-organism, resembling the actinomyces, and, like it, occurring in granular masses composed of branching threads. It causes in the foot especially, the formation of nodular masses, which break down and form abscesses and fistulae, and often produces caries and necrosis of the bones. THEORY OF ASEPSIS AND ANTISEPSIS IN WOUND TREATMENT. Before the introduction of Lister's method of treat- ing wounds, it was the rule in accidental and operative wounds to have profuse suppuration, fever, pain, and in many cases such wound complications as septicaemia, pyaemia, erysipelas, and hospital gangrene, and the mor- tality following operative and accidental wounds was very high. The mortality in compound fractures from sepsis was formerly great, but by modern methods of wound treatment has been diminished to an insignificant percent- age. The same diminished mortality has followed ampu- tations and other wounds, accidental or operative. Lister's method of wound treatment was largely based 124 MINOR SURGERY. upon the idea that the infection of the wound occurred from contact with the air, which contained spores and germs, and his method of treatment was chiefly directed to their destruction. The air may be a medium of wound infection to a certain extent, for it has been demonstrated that dry air contains dust in which spores and bacteria are present in much larger numbers than in moist air, and such air coming in contact with an open wound deposits there numbers of bacteria, which may set up inflammatory changes. Koch later demonstrated the fact that atmos- pheric microbes were chiefly of an innocuous character, and that wound infection was generally caused by bacteria or spores being brought in direct contact with the wound by the clothing and skin of the patient, the instruments and the hands of the surgeon and assistants, and unclean surgical dressings. Cheyne has shown that the relative number of bacteria entering the tissues is an important factor in producing suppuration and septic infection, for we know that bacte- ria may exist in an aseptic wound and yet the wound heal and remain aseptic, the antiseptic qualities of the blood- serum and the cell-activity in healthy tissues being suffi- cient to destroy or remove a certain number of micro- organisms, and suppuration or septic infection occurring only when the tissues are overwhelmed by the number of organisms or when their power of resistance is diminished by injury or disease. This explains the satisfactory be- havior of wounds which pursue an aseptic course where very imperfect details of aseptic or antiseptic treatment have been employed. It may, therefore, be assumed that infection does not necessarily depend upon the presence of a few microbes, but rather upon the quantity and quality of the germs which are present in the wound. Pyogenic micro-organisms under different conditions may produce a series of different diseases, for it is now generally accepted that Fehlei sen's streptococcus erysipe- latis is identical with streptococcus pyogenes, which is recog- nized as the cause of very different inflammatory affec- tions. The theory has been advanced by Reger that all THEORY OF ASEPSIS AND ANTISEPSIS. 125 the so-called pus-diseases are simply local expressions of a general infection caused by many different micro- organisms. . Sepsis.— Sepsis is due to the entrance and multiplica- tion of micro-organisms, or the absorption of their products in the body, and is characterized by local inflammation of the wound, and marked constitutional symptoms, such as fever, disorders of the nervous system, and inflammation of the viscera. Microbic infection represents a patholog- ical process which causes serious wound complications, and differs materially from that process which attends the re- pair of wounds that run an aseptic course. Aseptic chem- ical irritation of the tissues mav result in the production of a puruloid fluid, which is not pus, but merely a fibrinous exudation containing numerous cells, and does not produce infection if injected into animals. Acute suppuration in a wound is considered clinically to be always due to the presence of bacteria, for their exclusion will prevent its occurrence. . . . Asepsis.— Asepsis aims at thorough sterilization ot the field of operation and of all objects brought in contact with the wound, and the exclusion of micro-organisms by oc- clusive sterilized dressings. > m ■ Antisepsis, on the other hand, has in view the destruc- tion of micro-organisms by keeping germicidal agents con- stantly in contact with the wound. The object of anti- sepsis is, therefore, to produce asepsis. No surgeon should undertake the performance ot an operation or the treatment of an open wound without hav- ing: clearly impressed upon his mind the important part that pyogenic and specific micro-organisms may play in the subsequent course of the wound. Methods of Disinfection or Sterilization. Since the majority of wound complications are due to the presence in the wound of micro-organisms it is the duty of the surgeon to prevent their contact with it, or to employ means for their destruction. We must, however, 126 MINOR SURGERY. employ means of disinfection or destruction of these micro- organisms which will not have any injurious effect upon the tissues with which they come in contact. Mechanical disinfection or sterilization, is not applicable to wounds, but is employed to remove any micro-organisms which may be present upon the objects which are to come in contact with the wound ; namely, the hands of the surgeons and assist- ants, instruments, and the skin surrounding the wound. Mechanical disinfection is accomplished by the use of fric- tion with a brush, soap, and water. Germicidal solutions may be used for disinfection of wounds, but are most use- ful in the disinfection of the hands of the operator, the skin of the patient, the instruments, and the dressings. If these have been carefully employed before the wound is made, their subsequent use in the wound is usually unnecessary. Some forms of bacilli contain spores which resist the action of germicidal substances, while the bacilli them- selves are readily destroyed by these agents : the surgeon should, therefore, employ that means of disinfection which is generally applicable to the destruction of both bacilli and their spores. The bacilli of anthrax, tuberculosis, and tetanus contain spores ; hence to destroy these organisms is a matter of more difficulty than to render harmless such micro-organisms as staphylococcus "pyogenes aureus, albus, and citreus, streptococcus pyogenes and streptococcus erysip- elatis, and the bacilli of diphtheria and glanders, which contain no spores. Heat when used as a germicide cannot be applied to the wound itself, except in cases where a limited surface of the wound may be touched with the hot iron. Heat can, therefore, be used only for the disinfection of substances coming in contact with the wound, and for this purpose it is employed in the form of steam, dry heat, or boiling water. Sterilization of the wound or the substances coming in contact with it may be accomplished by using either the aseptic method or the antiseptic method, and at the present time these two methods are to a certain extent combined — that is, it is impossible to be strictly aseptic without em- ploying means of disinfection by the use of antiseptics. THEORY OF ASEPSIS AM) ANTISEPSIS. \27 The aseptic method, which employs germicidal substances only for the purpose of sterilization of objects coming in con- tact with the wound when their disinfection by heat is im- possible, is the method which has generally been adopted. Antiseptic Method. — In the antiseptic method the sterilization of the field of operation, the hands of the surgeon and assistants, the instruments, ligatures, sponges, and sutures, is accomplished by the use of germicidal solutions, and, in addition, the wound is irrigated fre- quently during the operation with germicidal solutions, and is afterward covered with dressings impregnated with germicidal substances. The antiseptic method was that first employed, and, recognizing its value in surgical pro- cedures, many surgeons still continue to employ this method ; but it has certain disadvantages. Recent inves- tigations have shown that many germicidal substances have not the power which was formerly attributed to them, as they only arrest bacterial development ; many chemical germicides cause the formation of a dense layer of coagulated albumin around albuminous substances, and also fail to destroy micro-organisms associated with fatty or oily substances. Chemical germicides may also form combinations in the tissues with substances with which they come in contact, seriously impairing their germicidal action. Antiseptic substances which are active as germi- cides often cause irritation of the surface of the wound, interfering with its repair. It has been shown that irrigation of a fresh wound with a 1 : 10,000 solution of bichloride of mercury is followed by distinct evidence of superficial necrosis of the tissues. Antiseptic irrigation of wounds is apt to cause very free oozing of serum, which necessitates the use of drainage, and makes frequent dressing of the wound necessary. Many antiseptic substances produce marked toxic effects upon the patient, and also cause severe irritation of the skin with which they come in contact. Aseptic Method. — In employing the aseptic method in the treatment of wounds, the field of operation, the hands of the surgeon and assistants, the instruments, liga- 128 MINOR SURGERY. tures, sponges, and sutures, are sterilized by the use of germicidal solutions and heat, and after this has been accomplished, relying upon the completeness of the steril- ization, no germicidal substances are brought in contact with the wound, sterilized water or sterilized salt solution being used if it is necessary to Hush the wound, and the dressings employed are those only which have been ster- ilized by moist or dry heat. The advantages of the aseptic method are as follows : the method is applicable to all parts of the body ; wounds treated by this method heal more promptly and do not require frequent dressing ; there is no risk of toxic effects, and there is no irritation of the skin by the dressings. Dry sterilized dressings are effi- cient to produce absorption, and at the same time the dryness may be a factor in the destruction of germs, for depriving bacteria of moisture robs them of one of the conditions necessary to their existence. The aseptic method is, therefore, to be preferred to the antiseptic method in the treatment of wounds wherever it is possible. Agents Employed to Secure Asepsis. A great variety of agents possessing more or less germicidal properties have been at different times em- ployed in the practice of aseptic or antiseptic surgery ; those most employed at the present time are heat, bichlo- ride of mercury, carbolic acid, iodoform, formalin, beta- naphthol, formaldehyde, chloride of zinc, acetate of aluminum,. peroxide of hydrogen, kreolin, permanganate of potassium, sulphorarbolate of zinc, salicylic and boric acids, acetanilid, aristol, and certain silver salts. Heat. — The most reliable and universally available agent for the destruction of micro-organisms is heat, either dry or moist ; many forms of bacteria are rendered inert at a temperature of 140° F., and none can withstand the application of moist heat at 21 2° F. continued for a short time. Spores which will resist the action of powerful germicides for a considerable time are destroyed by boil- ing for a few minutes. Dry heat is not as efficient for BICHLORIDE OF MERCURY. 129 Fig. 119. sterilization as moist heat, for some spores will resist dry heat of 284° F. for three hours. As moist heat is the most efficient sterilizer, it should be preferred, and can always be made use of for this purpose by boiling the instruments and dressings for a few minutes ; and if for any reason it is thought advisable to employ dry heat as a sterilizer, this may be made use of by baking the instru- ments or dressings in a hot oven. The best results may be obtained by the use of one of the various dry or moist sterilizers (-Fig. 119). An improvised sterilizer may be made by placing a perforated metal stand inside a large kettle, so that only the steam comes in contact with the instruments and dressings. Bichloride of Mercury. — This is employed as an antiseptic in watery solu- tions varying in strength from 1 : 500 to 1 : 10,000. The solution of 1 : 500 to 1 : 1000 is used only for the irrigation and disinfection of the hands and skin ; for the irrigation of wounds, a solution of 1 : '2000 or 1 : 4000 may be employed. At the present time bichloride solu- tions are not frequently used in fresh wounds, on account of their irritating effects. Where continuous irrigation is kept up, or where it is employed in large cavities, a still weaker solution, 1 : 5000 to 1 : 10,000, should be employed. In using bichloride solutions the surgeon should watch the patient carefully for signs of poisoning due to absorp- tion of the bichloride of mercury ; the symptoms denoting this are vomiting, fetid breath, salivation, inflammation of the gums, diarrhoea, blood-stained stools, and bleeding from the mouth and nose. Locally the use of moist bi- chloride dressings may cause well-marked dermatitis. The continuous application of bichloride solution to the hands 9 Steam sterilizer. 130 MINOR SURGERY. of the surgeon causes the skin to become roughened and blackens the nails. In preparing solutions of bichloride of mercury for use, it will be found convenient to have a concentrated solu- tion of the salt in alcohol, 1 part of the bichloride to 10 parts of alcohol ; this can be kept in a well-stoppered bottle, and to it should be added one teaspoonful of com- mon salt, which prevents disintegration of the mercuric compound. One teaspoonful of this solution added to one quart of water makes a 1 : 2500 solution. A 10 per cent, bichloride solution may be made as fol- lows : Bichloride of mercury 2 parts. Sodium chloride 1 part. Dilute acetic acid 1 " Aquse dest 16 parts. By adding water in an appropriate quantity, a 1 : 1000 or 1 : 2000 solution can be made. Or the solution may be prepared with tartaric acid in the proportion of 5 parts of the acid to 1 part of bi- chloride of mercury, the following formula being em- ployed : Hydrarg. chlor. corrosiv grs. xv. Ac. tartaric grs. lxxv Aqua? dest Oij. Pellets containing a definite amount of bichloride of mercury compounded with a few grains of common salt of muriate of ammonium, which, when dissolved in a definite quantity of water, make a solution of 1 : 1000 or 1 : 2000, will also be found very convenient for the preparation of solutions. The pellets should also contain a little coloring- matter, which gives a faint color to the solution and serves to distinguish it from other solutions. Carbolic Acid. — This drug is employed in solutions of 1 : 20 or 1 : 40. The stronger solution, 1 : 20, is usually employed to sterilize instruments, the latter being allowed to remain in this solution for thirty minutes before being: used. As a carbolic solution of this strength benumbs and cracks the skin of the hands of the operator, it should IODOFORM. 13] be diluted just before the instruments are required, by adding an equal quantity of boiled water, making it a 1 : 40 solution. The rusting of steel instruments and the dulling of the edges of knives by exposure to carbolic aeid may be prevented by the addition of 5 per cent, of sodium carbonate to the solution. The 1 : 40 or 1 : 60 solution is used for the irrigation of wounds and the washing of sponges. As carbolic acid in strong solutions is a local caustic and coagulates albumin, it should not be used in fresh wounds. A ready method of making a 5 per cent, carbolic solution is to add one tablespoon ful of carbolic acid to one pint of hot water. In using carbolic acid solutions continuously, the sur- geon should be on the watch for symptoms of poisoning, which will be manifested by dark-colored urine, head- ache, dizziness, vomiting, and in severe cases bloody diar- rhoea, hemoglobinuria, and death from collapse. Carbolic acid solutions should be used with great caution in young children, as they seem to be more susceptible than adults to its constitutional effects. The use of weak solutions of carbolic acid seems to involve more risk of toxic action than does the employ- ment of the pure drug, the superficial layer of tissue being coagulated by the latter, so that absorption of the drug is prevented. Gangrene of the skin and subjacent tissues has frequently been observed to follow long-continued use of quite dilute solutions of carbolic acid or of ointments containing small quantities of the drug. Cases of gan- grene of the fingers and toes from this cause are not infre- quently seen. Iodoform. — Iodoform has been shown by experimental research to possess little direct germicidal action, but in spite of this fact clinical experience has proved that it possesses powerful antiseptic properties, due, as shown by Behring and De Ruyter, not to the destruction of germs. but to its undergoing decomposition in their presence, and thus rendering inert the ptomaines which have re- sulted from the germ-growth. It may be rendered abso- lutely sterile by exposing it to heat, and, as it is easily 132 MINOR SURGERY. decomposed, fractional sterilization may be employed, or by washing it in a 1 : 1000 bichloride solution ; it should then be dried and kept for use in closely stoppered bottles. Iodoform is often employed in the form of a powder as an application to wounds, and is frequently used in aseptic wounds which are liable from their position to become in- fected, such as those about the mouth, rectum, and vagina, and is especially useful as a dressing in infected wounds and in tubercular or syphilitic ulcers and in bone cavities. In operations upon the mouth, anus, rectum, uterus, and abdominal cavity iodoform gauze packing is largely em- ployed, and serves to keep the discharges from becoming foul, thus often preventing septic intoxication ; it must, however, be used with caution in the mouth. Iodoform collodion, made by adding iodoform, gr. xlviii, to col- lodion, f§j, is a useful dressing in superficial wounds. Iodoform may also be employed in the form of an ethereal solution, iodoform, gr. xv ; ether, fjj, as an application to wounds or ulcers. An emulsion of iodoform in glyc- erin, iodoform, 3j ; sterilized glycerin, ,5x, or an emul- sion of iodoform made by adding sterilized iodoform, 3J, to boiled olive oil, gx, is much employed as an injection in the treatment of tubercular abscesses and joints. For packing cavities, a 5 per cent, gauze is best ; a 10 per cent, gauze is too strong except in small amounts. For large cavities a Mikulicz pack, consisting of a bag of iodoform gauze stuffed with sterilized gauze, may be employed. Numerous cases have been reported in which toxic symp- toms have followed the use of iodoform, such as urtica- rial eruptions, dermatitis, headache, depression, delirium, mania, debility, and sleeplessness. Elderly persons and in- fants are very susceptible to the toxic action of iodoform. Airol. — This drug has been used as a substitute for iodoform where an antiseptic and not an antitubercular action was desired. It seems to be free from toxic action even when used in large quantities. It is especially useful in wounds where primary infection is present. It has been used with good results in operations upon the rectum and bladder. FORMALIN. 133 Formaldehyde. — This is a pungent, penetrating gas, possessing valuable antiseptic properties, which is prin- cipally used for the disinfection of clothing, instruments, bedding, and rooms. The gas is generated in a lamp or generator by passing the vapor of methyl alcohol over a coil of glowing platinum wire or gauze, or over platinized asbestos. Formalin. — This is a 40 per cent, solution of formal- dehyde gas in water, and has valuable antiseptic proper- ties. A solution of this strength is a powerful irritant, and should not be used in the treatment of wounds. It may be used in a 2 per cent, solution to disinfect wounds or instruments, or in 0.25 per cent, solution for irrigation. Brewer recommends a 1 per cent, solution applied for three minutes to disinfect the skin, a 2 per cent, solution, applied under anaesthesia, to sterilize infected tissues, and 0.3 per cent, solution for gauze. Formalin-gelatin or Glutol. — This is a compound formed by evaporating an aqueous solution of gelatin over vapor of formalin. Its activity as an antiseptic de- pends upon the vapor of formalin given off when applied to the wound. It is a non-irritating and non-poisonous powder. Beta-naphthol. — Beta-naphthol, in a 1 : 2500 solution, is employed for much the same purposes as bichloride of mercury solutions ; it is not, however, so powerful a germi- cide. It is employed in irrigating large cavities, because it is not a poisonous agent, and is especially useful as a bath for instruments, as it does not corrode them, as do sublimate solutions. It may be employed as a dusting- powder on sloughing surfaces, and especially to wounds exposed to feces or urine. It also possesses the advantage over a carbolic acid solution of not irritating the skin of the surgeon's hands. Silver Salts. — Silver lactate (actol) and silver citrate (itrol) are two antiseptics which have been recommended by Crede, who considers their germicidal properties supe- rior to those of bichloride of mercury. These salts may be used in a 1 : 4000 or 1 : 8000 solution, which should be made with water free from chlorides, which precipitate the 134 MINOR SURGERY. silver ; distilled water should be employed. Creole speaks highly of an ointment made of metallic silver, which may be employed as an inunction in septic diseases. Acetanilid. — This preparation possesses antiseptic; prop- erties, and is frequently used as a substitute for iodoform. It may be used in the form of powder as an application to suppurating or ulcerating tissues, but in tubercular condi- tions is not as satisfactory as iodoform. Chloride of Zinc. — Chloride of zinc, in a solution of 30 to 40 grains to water fsj, is a very powerful antiseptic. When employed upon raw surfaces it produces marked blanching of the tissues ; it is especially useful in wounds which are infected or which have been exposed to infec- tion. I have found it by all means the best application for the poisoned wounds which are received in dissect- ing dead bodies and in operating. In such cases the whole cavity or surface of the wound should be washed with a 30-grain solution, and then the wound should be dressed with moist bichloride gauze. Sulphocarbolate of Zinc. — This drug has been found to possess more decided antiseptic properties than the chlo- ride of zinc, and is much less irritating. It may be used in the same strength and for the same purposes as the latter drug. Acetate of Aluminum. — This drug is used in solution, and is prepared as follows : aluminis, 3vj (24 grammes) ; plumbi acetatis, sixss (38 grammes) ; aqua?, Oij (1000 grammes). Mix, and filter after standing twenty-four hours. It has decided germicidal qualities, is employed for irrigation and moist dressing where carbolic or bichloride solutions cannot be used, and is by all means the safest and best antiseptic substance for wet dressings. Peroxide of Hydrogen. — Peroxide of hydrogen is em- ployed in what is known as the 15- volume solution. It may be used in this strength or may be diluted. It seems to have a direct action upon pus-generation by destroying the micro-organisms of pus, and is frequently employed in the sterilization of sinuses or suppurating cavities, such as remain after the opening of abscesses or result from dis- BORIC ACID. 135 eases of or operation- upon the bones. It is injected into the sinuses and cavities by means of a glass syringe, or may be applied to open wounds in the form of a spray. Its action is shown by the escape of bubbles of gas, which cleanse suppurating surfaces or sinuses mechanically, and it should be used as long as these continue to escape. Pyrozone. — Pyrozone possesses the same qualities as the peroxide of hydrogen, and apparently to a somewhat higher degree, and is used for the same purposes. Kreolin. — This substance is obtained from English coal by dry distillation, and has been found to possess powerful germicidal properties ; it is non-irritating and practically non-toxic. It is insoluble in water, but forms an emul- sion with it which possesses marked antiseptic properties. It is especially useful as a deodorant in oifensive malig- nant ulcers. It may be employed for the same purposes as carbolic acid. It is used in an emulsion, in strength from 2 to 5 per cent., and is employed in the irrigation of large wounds or cavities of the body, and has been most favorably recommended in gynecological practice. Boric Acid. — This drug has not very marked antiseptic qualities, and is usually unirritating even in saturated solutions; but occasionally it produces marked irritation of the skin. It is frequently employed in a 5 per cent, solution to cleanse and disinfect mucous surfaces and large cavities. It is often employed to wash out the bladder before the operation for the removal of calculi or growths from that organ. In the dressing of superficial wounds, or in wounds in which the bichloride or carbolic acid dressings produce irritation, an ointment of boric acid. 1 part, to petrolatum 5 parts, will be found very satisfactory. Boro-salicylic Powder. — This powder, winch consists of 4 parts of boric acid to 1 part of salicylic acid, is used as a dusting-powder and as a dressing for wounds. It has been recommended highly by Senn in the treatment of fresh wounds. Salicylic Acid. — Salicylic acid does not have very marked antiseptic qualities, but possesses much less toxic action than carbolic acid, and is used for somewhat the 136 MINOR SURGERY. same purposes. Its antiseptic power is said to be increased by the addition of boric acid, and a boro-salicylic lotion (Thiersch's solution) is prepared by adding salicylic acid, 1 part; boric acid, 6 parts; to hot water, 500 parts, mak- ing a bland solution, which, when reduced to 25 to 50 per cent, of the original strength, may be used for irrigation of the bladder or the peritoneal cavity. Permanganate of Potassium. — This drug, owing to its rapid absorption of oxygen, acts as an antiseptic, and is often employed for the disinfection of foul wounds and ulcers. It is employed also in solution for washing the operator's hands and for the washing of sponges. It is practically non-irritating, and may be used in quite con- centrated solutions, but is usually employed in the follow- ing strength : permanganate of potassium, gj ; water, f^j. One fluidrachm of this solution to a pint of water makes a 1 : 1000 solution. Aristol. — Aristol, which is a compound of iodine and thymol, possesses germicidal properties, and has been in- troduced as a substitute for iodoform. It has the advan- tage over iodoform of not being poisonous, and is also without disagreeable odor. It may be employed for the same purposes as iodoform, and it seems to be particularly useful as a dressing to chronic and specific ulcers. Orthoform. — This is a colorless powder which is slightly soluble in water. It possesses decided antiseptic properties as well as a local anaesthetic action. It is employed as a dressing for small wounds, burns, and ulcers. As it pos- sesses toxic action, it should not be used where there is an extensive raw surface. Sodium Chloride. — This salt has no direct antiseptic action, but is used in the preparation of normal salt or saline solution, the strength of which is 0.6 per cent. Saline Solution. — This is prepared by adding 6 drachms of sterilized sodium chloride to 1 litre of distilled water, which is contained in a sterilized oval glass flask. The mouth of the flask should be plugged with sterilized cotton, and a piece of gauze fastened over the mouth and neck of the bottle. The solution should be exposed to steam ster- MATERIALS USED IN ASEPTIC OPERATIONS. 137 ilization one-half hour on two successive clays. Saline solution is non-irritating, and is frequently used in the irri- gation of fresh wounds, to remove foreign bodies or blood, and for the cleansing of mucous and serous surfaces. Its utility by intravenous injection or infusion is well recog- nized (see page 199). In emergencies a solution prepared by adding a drachm of common salt to a pint of water which has been sterilized by boiling, may be employed. Sterilization of Water. — Water may be rendered abso- lutely sterile by boiling from fifteen to thirty minutes. It should be distilled or filtered before being boiled, to re- move any inert matter which is not desirable in wounds. After being boiled, it should be placed in sterilized glass flasks, and corked with sterilized cotton, the mouths of the flasks also being covered with several layers of gauze. It is employed for the irrigation of wounds and of mucous and serous surfaces. PREPARATION OF MATERIALS USED IN ASEPTIC OPERATIONS. Sponges. — Marine sponges are the best materials for the purpose of sponging, but their satisfactory sterilization is often a matter of difficulty. It is better to use a cheap grade of sponges, and to use them only once. The steril- ization of sponges by boiling destroys to a certain extent their elasticity and their absorbent power. Elsberg claims that sponges can be boiled in the following solution with- out losing their properties : caustic potash, 1 per cent. ; tannic acid, 2 per cent. ; water, 97 per cent. Schimmel- busch recommends the following method : The dried sponges are freed from dirt or sand by beating, and are then soaked for several days in cold water slightly acidu- lated with hydrochloric acid, being kneaded from time to time. They are next thoroughly washed in cold and in warm water, wrapped in a linen sheet, and placed in a boiling 1 per cent, soda solution ; the solution should not be allowed to boil after the sponges are placed in it. They 138 M1X0R SURGERY. are allowed to remain in this hot solution for thirty min- utes, are then washed in boiled water to remove the soda, and placed in a 0.5 per cent, bichloride solution until needed. Another method of preparing sponges consists in beat- ing them to remove any sandy matter which they may contain, and placing them for twenty-four hours in a solu- tion of hydrochloric acid, 4 ounces ; water, 4 pints ; upon removing them from this solution they are washed until free from acid ; they are then placed for ten minutes in the following solution : potassium permanganate, £ij ; sodium sulphate, gj ; hydrochloric acid, lij ; distilled water, Oij. They are then removed and placed in running water for six hours, and afterward in a 5 per cent, carbolic acid solution or a 1 : 1000 bichloride solution. Carbolic solu- tion is the better one, as it is not so liable to decomposition. Gauze Pledgets or Pads. — On account of the difficulty in satisfactorily sterilizing sponges, as well as of their expense, folded gauze pledgets have largely superseded them. Gauze Pledgets. — Gauze pledgets are prepared by cutting a piece of gauze, composed of from twelve to sixteen layers, in pieces six inches square; the four angles of these pieces are then tied together or secured by a few stitches. Gauze Pads, — Gauze pads are made from a piece of gauze composed of from sixteen to twenty layers cut the desired size, the different layers in each pad being quilted together by a few stitches, and the edges loosely whipped with a thread to prevent them from fraying. Gauze pads are used as a substitute for the flat sponges formerly employed in abdominal surgery, and for the drying of wounds. The pads or pledgets may be sterilized by boiling or by expos- ure to steam or dry heat in a sterilizer, or may be steril- ized and preserved at the same time in a 1 : 2000 bichloride solution. When so preserved, before being employed the moisture should be squeezed from them, and they should be washed in sterilized water before being brought in contact with the wound. Silk Sutures and Ligatures. — Silk for sutures or MATERIALS USED IN ASEPTIC OPERATIONS. 139 ligatures, either the plaited silk or the Chinese twisted silk, should be sterilized by boiling from ten to thirty minutes in a 5 per cent, solution of carbolic acid, or in water, the time of boiling depending upon the thickness of the threads ; frequent" boiling renders the silk weak. It should then be placed in stoppered bottles and covered with a 5 per cent, solution of carbolic acid or with abso- lute alcohol, or in 1:1000 bichloride and alcohol solution. Silkworm- gut. — Silkworm gut is an excellent material for sutures, and may be sterilized by boiling it for fifteen minutes, or by placing it for one-half hour in a 5 per cent, carbolic solution ; after being sterilized, it should be kept in 95 per cent, alcohol. There has recently been introduced an iron-dyed black silkworm-gut, which makes the sutures more prominent and thus facilitates their removal. . Catgut Ligatures and Sutures.— Catgut is the ideal material for ligatures and sutures, but has the disadvan- tages of difficulty and uncertainty in its sterilization. Raw catgut is often infected with micro-organisms, and, therefore, thorough sterilization alone can render it a safe material for ligatures and sutures. Von Bergmann's Catgut.— This method of preparing catgut, which we have found one of the most satisfactory, consists in winding the catgut loosely upon glass rods or spools; these spools are placed in ether for twenty-four hours ; the ether is then poured off, and they are placed in the following solution : bichloride of mercury, 10 parts ; absolute alcohol, 800 parts ; distilled water, 200 parts Remove from this solution after twenty-four hours, and place them in a similar solution for forty-eight hours ; then place in absolute alcohol. If soft catgut is desired, add 20 per cent, of glycerin to the absolute alcohol. To make the sterilization absolutely certain, it has been found advantageous to soak the catgut for thirty minutes in a 1:1000 aqueous bichloride solution before placing it in the alcoholic solution of bichloride. Dry Sterilized Catgut. — Boeckrnan's process for steriliz- ing catgut consists in cutting .the gut in pieces twenty to 140 MINOR SURGERY. forty inches in length, wrapping each piece in paraffin- paper and sealing in a paper envelope. The envelopes are then placed in a steam sterilizer for three hours at a tem- perature of 284° F., and then for four hours longer at a temperature of 290° F. When required for use, the en- velope is opened, the paraffin-paper removed, and the gut immersed for a few minutes only in sterilized water. Boiled Catgut. — Catgut may also be sterilized by boil- ing in alcohol under pressure. The most satisfactory method is that devised by Fowler, which consists in plac- ing a number of strands of catgut in an ordinary test-tube which is filled with 95 per cent, alcohol to within half an inch of the top ; a wad of cotton is next pushed into the mouth of the tube, and a cork is introduced. The tubes thus prepared are placed inverted in a fruit-jar filled with 95 per cent, alcohol ; the jar is then closed and placed in a water-bath, and kept at a boiling temperature for an hour. Or the catgut may be loosely wound upon glass rods and spools, and placed in a metallic cylinder or jar having an accurately fitting screw-top. The catgut is then covered with absolute alcohol, the top is screwed down, and the cylinder or jar is immersed in boiling water for an hour. Formalin Catgut. — This is prepared by winding catgut loosely on glass spools and keeping them for forty-eight hours in a vessel containing equal parts of alcohol and ether. They should next be washed for a few minutes in alcohol and placed in a jar containing equal parts of alcohol and formalin, and allowed to remain for several days. The excess of formalin should then be washed away with alcohol, and the catgut kept for use in 95 per cent, alcohol. Cumol Catgut. — The catgut is rolled loosely on glass spools, which are placed in a glass beaker having a layer of cotton in the bottom ; the beaker is covered by a piece of cardboard having a hole in the centre through which a thermometer is introduced, and is placed on a sand-bath heated by a Bunsen burner. Heat is applied until the temperature is raised to 176° F. ; this is maintained for MATERIALS USED IN ASEPTIC OPERATIONS 141 one hour, and removes all moisture from the catgut. Cumol, at a temperature of 212° F., is next poured into the beaker, completely covering the catgut, and the tem- perature is then raised to 329 c F. and maintained for one hour. The cumol is next poured off, and the catgut is allowed to dry in the beaker on the sand-bath at a tem- perature of ^12° F. for two hours; it is then transferred sterile jars or tubes, which should be air-tight. Elsberg's Method of Sterilizing Catgut. — The catgut is immersed for forty-eight hours in a mixture of 1 part of chloroform to 2 part- of alcohol, then wound Loosely upon spools and boiled for thirty minutes in a saturated solution of ammonium sulphate, and upon its removal from this solution it should be immersed in sterilized water to remove crystals of ammonium sulphate. It may then be preserved in absolute alcohol. Bichloride of Palladium Catgut. — The catgut should be soaked in ether from twenty-four to forty-eight hours, according to the size of the gut. It is then placed in a mixture of mercuric bichloride, -40 grains ; tartaric acid, 200 grains; alcohol (95 per cent.), 12 fluidonnces, and allowed to remain from five to twenty-live minutes, ac- cording to the size of the gut. Then place it in a ster- ilized jar containing palladium bichloride grain -^ to alcohol 1 pint, in which it may be kept indefinitely. Chromic Acid or Chromicized Catgut. — Catgut, after being soaked in ether for twenty-four hours and washed in alcohol, is placed for twenty-four hours in a 4 per cent, aqueous solution of chromic acid ; it is then removed and dried in a hot oven, and placed in closely stoppered jars, or may be preserved in absolute alcohol. Catgut thus prepared will resist the action of living tissues for several weeks, the time of its absorption depending upon the size of the gut. Before being used, it should be sterilized by either the cumol, alcohol, or formalin method. Owing to the fact that it undergoes very slow solution in the tissues, chromicized catgut is often employed for sutures or for the ligation of the larger vessels in their continuitv, and for bone sutures. 142 MINOR SURGERY. A very simple method of carrying catgut and keeping it sterile consists in using a strong glass tube, about an inch in diameter and six inches in length, into each end of which is fastened a rubber cork. A number of glass spools wound with sterilized catgut of various sizes are fitted into this glass tube, and one cork is introduced ; the tube is then filled with alcohol or a 1 : 2000 bichloride solution in alcohol, and the other cork is introduced, or a test-tube and a rubber stopper may be used. Celluloid. Thread. — This material, recently introduced by Pagenstecher, is prepared by boiling linen thread for thirty minutes in a 1 per cent, solution of sodium carbonate. It is then dried between sterile compresses and soaked for some hours in celluloid solution. It may be kept dry or in an alcoholic solution of bichloride of mercury. It may be resterilized by boiling or under steam pressure. It has proved a satisfactory material for sutures and ligatures, and may be used in place of catgut or silk. Drainage-tubes. — The drainage-tubes usually employed are prepared from rubber-tubing of different sizes perfor- ated at short intervals ; the black-rubber tubes are softer and more pliable than the red- or white-rubber tubes, and are generally preferred (Fig. 120). Drainage-tubes are also made of glass, straight or curved (Fig. 121), which are almost exclusively used in abdominal surgery, and also of decalcified bone. The tubes should be kept in a 5 per cent, solution of carbolic acid, or, if kept dry, they should be well washed and sterilized by boiling water for a few minutes before being used. Catgut and Horsehair Drainage. — Catgut as ordi- narily prepared for ligatures may be used to secure drain- age in small and superficial wounds ; a number of strands are placed in the bottom of the wound, and the ends are allowed to project from one or both extremities of the wound. Horsehair may be employed for the same purpose, a number of strands of the hair being placed in the wound in the same manner. Before being used, it should be well washed with soap and water, and then soaked in a 5 per MATERIALS USED IX ASEPTIC OPERATIONS. 143 cent, carbolic solution or 1 : 1000 bichloride solution for thirty minutes. Fig. 1-20. Fir;. 121. Eubber drainage-tube. Glass drainage-tube. Protective. — Protective is employed to prevent the wound from being irritated by the antiseptic substances with which the gauze is impregnated or by its irregular surface. The great objection to the use of protective is that it sometimes interferes with drainage, and permits of the accumulation of serum beneath it, which mav become infected and cause infection of the wound. Various materials are employed as protectives, the prin- cipal requirement being that they can readily be rendered aseptic and do not absorb irritating materials from the dressings. The protective first employed by Mr. Lister, which is still generally used, is prepared by coating oiled silk with copal varnish, and when this is dry a mixture of 1 part of dextrin, 2 parts of powdered starch, and 16 parts of a 144 MINOR SURGERY. 1 : 20 carbolic acid solution, is brushed over its surface. Rubber-tissue may be employed very satisfactorily as a substitute for this protective. Before applying the protective to the wound, it is soaked in a solution of bichloride of mercury or carbolic acid. Silver Foil. — The inhibit! ve action of metallic silver on the growth of micro-organisms is utilized in the employ- ment of silver foil to cover the surface of wounds. The foil is sterilized by dry heat and placed directly on the surface of the wound after it has been closed by sutures. It is claimed that the foil prevents infection of the wound from the exterior, and also destroys micro-organisms which may come in contact with it. Mackintosh. — This consists of cotton-cloth, with a thin layer of India-rubber spread on one side. It is employed in antiseptic dressings outside of the gauze, and should be applied with the rubber surface toward the wound, to prevent the entrance of air and to allow the serum from the wound to permeate the gauze, and not soak directly through the dressings. The mackintosh cloth is not at the present time as much employed as formerly, unless the method of moist dressing is adopted. Rubber-dam. — This is a thin, pure rubber-tissue, and as it has no cloth surface, like mackintosh, it may be cleansed and sterilized with greater facility. It is used in the method of moist dressing to cover the gauze dressings, and is attached to the drainage-tube in abdominal wounds to shut oif the opening of the tube from the abdominal wound. Before being used, it should be washed with soap and water, rinsed, and then placed in a bichloride or car- bolic solution for a time sufficient to sterilize it. Rubber-tissue. — This consists of a very thin sheet of India-rubber with glazed surfaces, which can be obtained from the rubber-manufacturers ; it is employed for the same purposes as the mackintosh, is much less expensive, and, as previously stated, may be used when properly sterilized instead of protective for covering the wound. MATERIALS USED IN ASEPTIC OPERATIONS. 145 Gauze Dressings. The most convenient and cheapest material for wound dressing is a material known to the trade as cheese-cloth or tobacco-cloth, and for surgical use should contain no sizing. From the fact that it has a very open mesh, it absorbs well either the materials with which it is pre- pared or the discharges from the wound, and is soft and pliable, so that it is a comfortable form of dressing to the patient. Gauze containing various antiseptic substances was formerly much employed in surgical dressings, but at the present time it has been largely superseded by sterilized gauze. Bichloride or Corrosive Sublimate Gauze. — Bichlo- ride or corrosive sublimate gauze is prepared by placing cheese-cloth in a washing-kettle and covering it with water to which is added two pounds of washing-soda or a pint of lye; the latter is added to dissolve any oily matter which the cheese-cloth contains, thus making it more absorbent. The gauze is boiled in this solution for an hour, and is then removed and washed in boiled water and passed through a sterilized clothes-wringer; it is then immersed in a 1 : 1000 bichloride solution for twenty-four hours ; the excess of fluid is then squeezed out of it, and it may be packed in air-tight jars and preserved as a moist gauze, or may be dried in a warm oven and packed in sterilized jars and kept as a dry gauze. Dry bichloride gauze, unless freshly prepared, possesses little antiseptic properties. In using the sublimate gauze on delicate skins a der- matitis sometimes results, which is known as mercurial eczema ; this is particularly apt to occur if the gauze is moistened or covered with rubber-tissue or mackintosh. If this condition develops, the parts covered by the gauze should be rubbed over with boric acid ointment or vase- line before it is reapplied, or a sterilized gauze dressing should be substituted. Iodoform Gauze. — This may be prepared by soaking 10 146 MINOR SURGERY. sterilized gauze in a mixture containing iodoform, 5 parts; glycerin, 20 parts ; and alcohol, 75 parts. This furnishes the 5 per cent, iodoform gauze ; if 10 per cent, gauze is desired, the quantity of iodoform should be doubled. When the gauze is thoroughly saturated, it should be of a uniform yellow color. It should then be thoroughly wrung; out with sterilized hands to remove the alcohol, and packed in sterilized jars with tight-fitting covers. Iodoform gauze may also be prepared by saturating sterilized gauze with a mixture of ether and iodoform, and then allowing the ether to evaporate, the iodoform being distributed evenly through the gauze. Carbolized Gauze. — In preparing carbolized gauze, cheese-cloth which has previously been boiled and dried is soaked for a few hours in the following solution : resin, 16 ounces ; alcohol, 5 pints ; castor oil, 24 ounces ; carbolic acid, 12 ounces. The gauze is removed from this solution and passed through a sterilized clothes-wringer, and is then cut into pieces from four to six yards in length, which are folded and packed in air-tight jars for use. Improvised Aseptic or Antiseptic Dressings. — Aseptic dressings in cases of emergency may be impro- vised, where the ordinary gauze dressings cannot be ob- tained, by tearing muslin or mosquito-netting into pieces half a yard square and placing them in boiling water for a few minutes ; they are then removed, the excess of moist- ure is wrung out, and they are applied to the wound. If it is desirable, they may be used as antiseptic dress- ings by soaking them for a few minutes in a 1 : 1000 or 1 : 2000 bichloride solution, or in a 5 per cent, carbolic solution. This dressing will keep the wound aseptic until a more elaborate dressing can be obtained. Sterilized Bandages. — Sterilized bandages are pre- pared by tearing or cutting gauze into strips from two and a half to three inches in width, and forming these strips into rollers, which are sterilized by steam or dry heat. They should be used soon after being prepared, or, if kept for any time, should be resterilized before being used. Bichloride Cotton. — This material is prepared by MATERIALS USED IN ASEPTIC OPERATIONS. 147 soaking absorbent cotton in a 1 : 1000 bichloride solution for twenty-four hours, and allowing it to dry, or it may be dried in a hot oven ; when dry, it is packed in jars or in air-tight boxes. Several layers of bichloride cotton are usually applied over the gauze dressing, as its great absorbing power and elasticity make it, when properly prepared, a most valuable dressing. Borated, carbolized, and salicylated cotton, prepared in the same manner, are also frequently employed for similar purposes. Sterilized. Cotton. — Sterilized cotton is prepared by placing absorbent cotton, enclosed in perforated metal cans, in a steam sterilizer and allowing it to remain for half an hour under ten pounds pressure. It is used for the same purposes in dressings as the bichloride cotton. Moist Sterilized Gauze Dressings. — Moist sterilized gauze dressings may be prepared by subjecting gauze w T hich has been boiled in soda solution to the action of boiling water or of steam for thirty minutes. Gauze thus treated should be used as soon as prepared. Sterilized Gauze. — This is prepared by cutting pieces of gauze the desired size, wrapping them in a towel, and placing them in wire baskets ; or the gauze may be placed in cylindrical tin boxes, 3 inches in diameter and 8 inches in height, with perforated metal covers, covering the gauze at each end with a laver of cotton before putting on the covers. The gauze is next placed in a steam sterilizer and subjected to ten pounds pressure of live steam for half an hour. The steam is then shut off from the sterilizer and allowed to circulate in the jacket of the apparatus without pressure for half an hour, to dry the dressings. If the gauze has been sterilized in metal cases, it may be kept for some time and still remain sterile. Cotton may be sterilized in the same manner. Dry Sterilized Gauze Dressings. — Dry sterilized gauze dressings are prepared by cutting gauze into proper lengths and packing it loosely in wire cages or perforated metal cans, which are next placed in a dry sterilizing- oven for several hours, and upon removal it is placed in air-tight jars or metal boxes. In using sterilized gauze 148 MINOR SURGERY. dressings, it is safer to have the dressings freshly steril- ized immediately before each operation. A convenient form of sterilizing-oven is shown in Fig. 122. Towels and operating-gowns may be sterilized in the same oven. Fig. 122. Hot-air sterilizer. Surgical Operating-bag. — For operations in private practice, the surgeon will find it convenient to have a bag or kit containing gauze dressings, bichloride pellets, car- bolic acid, alcohol, turpentine, ligatures, sutures, needles, syringes, a metal tray in which instruments may be boiled, a nest of small agate-ware basins, sponges, gauze pads, a sheet of rubber cloth, drainage-tubes, and operating- gown. These can all be packed in a comparatively small space, and when the surgeon is called upon to perform any special operation at short notice the instruments required ASEPSIS IN THE TREATMENT OF WOUNDS. 149 may be selected, wrapped in a Canton -flannel scroll, and placed in the bag-. Much time will be saved by having the materials required in operations always in readiness. METHODS AND DRESSINGS EMPLOYED TO SECURE ASEPSIS IN THE TREATMENT OF WOUNDS. To prevent infection of wounds, the various chemical sterilizers and dressings are employed in different ways, and the principal types of dressings are as follows : Method by Simple Drying. — This method is employed in small and not very deep wounds. The edges having been brought together bv sutures, the surface of the wound is dusted with powdered iodoform, the serum and blood forming with this, as it dries, a scab, which protects the wound from infection from without; repair taking place promptly under this scab. Treves employs this method of dressing in compound fractures. A pledget of gauze saturated with iodoform-collodion or tr. benzoin, oj ; collodion, ovij, may be employed instead of iodoform. Dry sterilized gauze and cotton dressings may also be employed in this method of dressing. Method by Drying and Chemical Sterilization. — The object of this method of dressing is to provide a means of sterilizing the blood or serum which escapes from the wound, and at the same time to insure the ster- ilization of the air coming in contact with the discharges from the wound. It is employed in large or deep wounds, where there is always more or less escape of blood or serum, and is accomplished by applying a number of layers of sublimate or iodoform-gauze and sublimated cotton over the wound. Evaporation not being interfered with, the whole dressing becomes hardened, and the wound is surrounded by a large antiseptic crust made up of the dressing and serum or blood. Moist Dressings. — In this method of dressing, the wound is covered by layers of moist antiseptic gauze, which are kept moist and evaporation prevented by apply- 150 MINOR SURGERY. ing over them some impervious material, such as mackin- tosh or rubber-tissue. Modified Moist Dressing. — In using this method, the wound itself is covered by a piece of protective or rubber-tissue ; over this is placed the sublimated or iodo- form-gauze dressing and some layers of bichloride cotton. In this way the wound itself is kept in a moist condition favoring particularly the organization of blood-clots ; the external dressings become dry as the discharges which have escaped into them evaporate, forming an antiseptic crust or covering over the wound. Preparation for Aseptic Operation. Preparation of Room. — In hospital practice, suitable operating-rooms are provided; in private practice, how- ever, the surgeon is often called upon to select a room and give directions as to its preparation. A well-lighted room should always be selected, and all unnecessary articles of furniture, such as ornaments, pictures, and curtains, should be removed. The carpet should be taken up and the floor scrubbed. A few small tables and a large wooden table should be placed in the room, having previously been dusted and wiped off with a bichloride solution. All preparations should be made, if possible, upon the day before the operation, as the stir- ring up of dust incidental to the change in furniture in cleaning the room on the day of operation immediately before the time set, is more dangerous than no cleaning of the room whatever, since the principal contamination of the wound is likely to come from germs contained in the dust. In case of emergency, the floor may be well moistened by sprinkling with water to lay the dust. The preparation of the room is not, in my judgment, a matter that affects the results of operations as much as does the exercise of great care in regard to aseptic details of the operation itself. Preparation of the Patient. — The skin always con- tains micro-organisms, which develop upon it and are STERILIZATION OF THE FEET. 151 constantly being deposited upon it from the air. Wei can scarcely hope to obtain absolute sterilization of the skin under these circumstances, but by careful prepara- tion seek to obtain that relative sterility which enables us to obtain primary union. The patient should be given a general bath the night before the operation, and the skin surrounding the site of operation should be thor- oughly scrubbed with a brush and soap and water ; or a soap poultice may be applied to the part for a few hours before the final sterilization with alcohol and bichloride is made. In scrubbing the skin a soft brush should be used, since too forcible scrubbing may cause irritation or dermatitis. After this scrubbing has been continued for a few minutes the skin is washed with alcohol and ether, then douched with sterilized water, and there should be applied to the surface a folded towel or gauze dressing saturated with a 1 : 1000 bichloride solution ; or if a moist dressing is uncomfortable to the patient, a few layers of sterilized gauze should be placed over the surface and held in place by a bandage. A similar washing and prepara- tion of the seat of operation should be made the next morning, a few hours before the time fixed for operation. The skin may also be sterilized by formalin. It should first be scrubbed thoroughly with soap and water, and then a few layers of gauze saturated with a 1 per cent, solution of formalin should be laid over it and covered by an im- permeable dressing. This solution should be kept in con- tact with the skin for twenty-four or thirty-six hours, the compress being changed every twelve hours. It is well to remember that regions of the body which contain hair and numerous sweat-glands, such as the axilla, navel, scrotum, groin, and the creases about the joints, are those in which micro-organisms grow with the greatest activity. All the surrounding hair should be shaved off ; and if the operation be upon the skull, it is well to shave the scalp completely. Sterilization of the Feet. — There is usually present upon the feet a large amount of thickened epidermis, which renders their sterilization difficult. The feet should 152 MINOR SURGERY. be washed thoroughly with soap and water and scrubbed vigorously with a brush ; or a soap poultice should be applied to the whole surface of the feet for some hours and held in position by a bandage. A moist dressing favors separation of the superficial layers of the epi- dermis, and after it has been worn for a few hours it is possible to remove a large amount of the latter by the use of the brush. After having been washed thoroughly with a 1 : 1000 bichloride solution they should be wrapped in a towel or a feAV layers of gauze saturated with bichloride of mercury solution, 1 : 1000. Sterilization of the Vagina. — The vagina and external genitals require great care in their sterilization. Accord- ing to Schimmelbusch, the best method of sterilizing the vagina is to dilate it fully with a speculum, and to scrub it thoroughly with pads of gauze saturated with green soap and water, and after this cleansing, to irrigate it with a 1 : 2000 bichloride solution or a 1 per cent, solution of kreolin. Sterilization of the Bladder and Urethra. — It is impossible to sterilize completely the mucous membrane of the bladder. The bladder should be emptied by cath- eter and filled with sterile water or normal salt solution ; this procedure should be repeated several times. The best means we have at our disposal at the present time of steril- izing the mucous membrane of the bladder consists in irri- gating the organ frequently with a 10 grain to the ounce solution of boric acid in boiled water. In operations upon the urethra the same care should be taken to render the urethra sterile by free irrigation with normal salt solution or boric acid solution. Sterilization of the Stomach. — The stomach should be sterilized by thorough lavage with normal salt solution or boric acid solution. This is important, not only in op- erations upon the stomach itself, but also in operations upon the pharynx, to diminish the risk of infection by vomited matter. In cases of intestinal obstruction with vomiting, lavage of the stomach should always be em- ployed before operation. STERILIZATION OF THE HANDS. 153 Sterilization of the Rectum. — When an operation is to be performed upon the anus and rectum, the patient should be given a purgative and an enema some hours be- fore the operation, to remove any fecal matter which may be in the rectum. The region of the anus should be dis- infected with soap and water and thoroughly scrubbed, and after the patient lias been anaesthetized the sphincter should be well stretched and the rectum irrigated with a boric acid solution. A tampon of sterilized gauze, with a string attached, should be packed into the rectum above the seat of operation, to prevent the wound from becoming soiled with feces during the operation. The tampon can be re- moved by means of the string after the operation has been completed. Sterilization of the Scalp. — Great care should be ob- served in sterilizing the scalp before operations on the scalp or brain, as the scalp is often covered by dense masses of epidermis. The entire scalp should be shaved and a soap poultice applied for twelve hours, or the appli- cation of sweet oil for twenty-four hours before the use of the soap poultice may be of use in softening the epidermis. It should be rubbed thoroughly with soap and water, and finally with a 1 :1000 bichloride solution. Sterilization of the Mouth and Nasal Cavities. — To render the mouth as far as possible sterile, the teeth should be thoroughly brushed with tooth-powder and the cavity of the mouth frequently rinsed with a solution of peroxide of hydrogen, 1 part to 6 parts of water, or with a satu- rated solution of boric acid. The nasal cavities and the post-nasal region should be sterilized by spraying them with the same solution. Sterilization of the Hands. — The difficulty of com- pletely sterilizing the hands has been shown by bacterio- logical tests, for it has been demonstrated that after great care in the process complete sterility could be obtained only in about 95 per cent, of the tests. The hands of the surgeon, unless properly sterilized, may be the most efficient agents in producing infection of the wound; the region of the finger-nails and the inter digital folds are 154 MINOR SURGERY. locations where germs are particularly abundant. The hands and forearms of the surgeon, assistants, and nurses who are to take part in the operation, may be sterilized by first rubbing them with spirit of turpentine, and then thoroughly scrubbing them with Castile soap and water, using a nail-brush freely. Care should be taken that the brush is sterilized. This scrubbing should be employed for several minutes; the hands are then rinsed to remove the soap, and are soaked for two minutes in a 1 : 1000 bichloride of mercury solution. If turpentine has not been employed before washing with the soap, strong alcohol or ether should be rubbed well over the hands before they are immersed in the bichloride solution. When the hands have been sterilized they should not be brought in contact with anything that is not sterile. Permanganate of Potassium and Oxalic Acid. — A method of sterilizing the hands which is very satisfactory is that employed by Kelly, which consists in washing the hands and forearms with soap for ten minutes, and then soaking them for a few minutes in a warm saturated solution of permanganate of potassium, which stains them a deep mahogany color ; they are then washed in a warm satu- rated solution of oxalic acid until all the permanganate stain is removed, and should next be washed in sterilized water to remove the oxalic acid which may adhere to the skin. Chloride of Lime and Carbonate of Sodium. — AVeir recommends the following method of sterilizing the hands. After washing them with green soap, put a table- spoonful of commercial chloride of lime and an equal amount of carbonate of sodium (washing-soda) in the hand, with enough water to make a paste. Rub this into a thick cream, which should be rubbed into the hands until the grains of lime disappear and the skin feels cool. The hands are then rinsed in sterile water. This method of sterilization of the hands has, in my experience, been most satisfactory. Sterilization of Instruments. — The sterilization of instruments may be accompli shed by dry or moist heat; STERILIZATION OF CATHETERS. 155 they should be placed in a hot-air sterilizer or baked for twenty minutes in a hot oven. Sterilization of instru- ments by dry heat or baking is not often employed, as it is apt to spoil the temper of the steel. Instruments may be sterilized by the method suggested by Schimmelbusch, now almost universally employed, which consists in boil- ing them for fifteen minutes in water to which a table- spoonful of washing-soda (carbonate of sodium) has been added for each quart of water ; this prevents the rusting of the instruments, and also makes the water a better sol- vent for any fatty matter which may be upon the instru- ments, thus increasing the sterilizing effect of the heat. If wooden-handled instruments are used, which would be injured by boiling, they should first be thoroughly scrubbed with soap and water and a brush, and after having been rinsed in sterilized water they should be placed in a tray and covered with 1 : 20 watery solution of car- bolic acid, and allowed to remain in this solution for at least half an hour; before being used they should be transferred to a bath of sterilized water, which will prevent the benumbing effect of the carbolic solution upon the surgeon's hands. Instruments may also be sterilized by formalin : the latter is generated by heating pastilles of paraform with Sehering's formalin lamp. The instruments are placed in racks in a metal ease, and by burning from 10 to 15 grains of paraform the instruments may be rendered sterile in fifteen minutes. Instruments which fall upon the floor or come in con- tact with the clothing of the surgeon or of the patient during the operation, should again be sterilized before being brought in contact with the wound. Sterilization of Catheters and Bougies. — These, if made of metal or glass, may be sterilized by boiling for ten minutes in a 1 per cent, solution of sodium carbonate. If constructed of rubber or gum, prolonged boiling destroys them ; these may, however, be sterilized by first washing them with soap and water and then placing them for fifteen minutes in a 1 per cent, solution of sodium 156 MINOR SURGERY. carbonate, heated nearly to the boiling-point ; they are next placed in a 1 : 1000 bichloride solution until required. They should, on being removed from this solution for use, be soaked thoroughly in hot sterile water to remove all the bichloride solution. Rubber catheters may also be sterilized by soaking them for an hour in a 2 per cent, solution of formalin, or by placing them in an air-tight metallic case or glass jar containing pastilles or paraform. They can be kept indefinitely in such a receptacle, and when removed for use should be washed in sterilized water. For lubricating catheters and bougies, oily mate- rials should be avoided, and sterilized glycerin or lubri- chondrin, both of which are soluble in water, should be employed. Rubber Gloves. — These gloves are now extensively employed in operative work, and the results following their use have been most satisfactory. They are made of very thin rubber, so that there is little interference with tactile sensation, and from their elasticity they tit the hands accurately. They can be rendered absolutely ster- ile, and as they are impervious to moisture there is no risk of wound infection if the hand is not completely sterilized unless the gloves have been torn or punctured. They may be sterilized by first washing them with soap and water, and then immersing them for twenty-four hours in a 1 :1000 bichloride solution. The better method of sterilization, however, consists in wrapping them in a towel and boiling them for ten minutes in a 1 per cent, solution of carbonate of sodium. They are usually applied by filling them with sterilized water or salt solu- tion, and then introducing the hand ; some operators prefer to apply them dry to the hand, using a dry sterilized powder, such as starch or soapstone. If properly cared for, a pair of gloves will withstand a number of steriliza- tions. A freshly sterilized pair of gloves should be used for each operation. Cotton or silk gloves, which have been sterilized by boiling or by dry heat, have been recommended by Mikulicz and other surgeons, to be worn during opera- DETAILS OF AN ASEPTIC OPERATION. 157 tions. Experiments, however, have shown that cotton or silk gloves are not as safe as those made of rubber. Clothing of Surgeon and Assistants. — The surgeon and his assistants should wear sterilized linen or muslin suits, or be provided with gowns with sleeves reaching to the elbows, for the protection both of the patient and of their clothing. The operating-gown should be made of muslin or linen, which can easily be sterilized by boiling or heat ; a variety of linen known as butchers' linen is very serviceable for this purpose. As a matter of additional precaution, many surgeons and their assistants wear dur- ing the operation closely fitting skull-caps of linen, and wear over the nose and mouth a pad composed of a num- ber of layers of sterilized gauze, to prevent infection of the wound by the expired air. The surgeon and assistants will often find it convenient to wear under their linen gowns India-rubber aprons, to prevent soiling of the clothing bv blood or solutions. The nurses should wear sterilized linen or muslin operating-gowns and dresses of washable goods. An operating -apron may be improvised from a clean sheet folded so as to be one and a half yards in width and from five to six feet in length, by turning in about ten inches of one end of the sheet over the upper part of the chest and placing a strip of bandage in this fold, which should be secured around the neck, and tying a second strip of bandage over the sheet at the waist. Details of an Aseptic Operation. — The patient being prepared for operation as described, and having been anaesthetized, is placed upon the operating-table, the sur- geon, assistants, and nurses also being prepared for the opera- tion as previously described. If the operation be one upon the face, neck, or chest, it is well, before the dressings covering the seat of operation are removed, to cover the patient's hair with a towel or handkerchief-bandage made of several layers of sterilized or bichloride gauze. The portions of the patient's body which it is not necessary to expose in the operation should be covered with a woollen blanket, and this covered with a sterilized sheet. Some surgeons prefer to have the patient wear a sterilized gown, 158 MINOR SURGERY. which is ripped or cut to expose the part to be operated upon. The region of the wound and the operating-table are next protected with sterilized towels or cloths. The surgeon having assigned the assistants and nurses their duties, the dressing is removed from the part to be oper- ated upon, and the operation is begun. Hemorrhage is controlled by the use of haemostatic forceps, and steril- ized gauze pledgets are employed to keep the wound free from blood. When the operation is completed, the vessels are ligated, the haemostatic forceps are removed, and the wound is dried with gauze pledgets. If, for any reason, the surgeon deems it advisable to irrigate the wound, it may be done with hot sterilized water or with sterilized salt solution. If the surgeon decides that drainage is not necessary, the deeper parts of the wound may then be brought together with buried sutures of catgut or silk, and the edges of the superficial wound next approximated by sutures of catgut, silk, or silkworm-gut. If the surgeon decides to use drainage, before closing the w r ound a few strands of catgut, a strip of sterilized gauze, a tent of rubber-tissue, or a rubber or glass drainage-tube is introduced into the deepest portion of the wound and brought out at its most dependent part. The wound is then dressed with a number of loose masses of sterilized gauze placed so as to cover the wound and extend beyond it in all directions, and these are covered by a number of layers of sterilized gauze, and the dressings are held in place by a gauze bandage. The bandage should be applied so as to cover the cotton at the edges of the dressing, and thus make the occlusion of air from the wound as complete as possible. Over the gauze dressing are placed a few layers of sterilized cotton, extending on all sides well beyond the gauze, and the dressings are held in place by a steril- ized gauze bandage. The dressings should be voluminous ; it is always a mistake to apply scanty dressings. In redressing the wound the same care should be exercised as regards asepsis as was observed at the primary dressing. Details of an Antiseptic Operation. — The region of DETAILS OF AN ANTISEPTIC OPERATION. L59 the wound being previously sterilized and the patient being anaesthetized and placed upon the table, the cloth- ing i.s so arranged as to expose freely the part t<> be oper- ated upon ; the clothing or the skin surrounding this region is next covered with towels wet with a 1 : 1000 bichloride solution. If any considerable surface of the patient's body is covered by these towels, to avoid chilling the surface and adding to the shock which naturally follows the operation, they should be wrung out in a hot bichloride solution, and Fig. 123. Irrigating apparatus. (Esmarch.) should be replaced as they become cold by hot towels pre- pared in the same manner. The patient being ready for operation, the surgeon should assign the assistants and nurses their duties, and having previously sterilized his hands and forearms, and again immersed them in the bi- chloride solution, the operation is begun. During the operation the wound is irrigated frequently with a 1 : 2000 to 1 : 4000 bichloride solution, which may be applied to the wound by means of a syringe or irrigat- ing apparatus (Fig. 123), and the hands of the surgeon and assistants should also be washed in this solution at 160 MINOR SURGERY. not too long intervals. In prolonged operations, or in those in which a large wound is made, it is especially important that the irrigating solutions should be used as warm as can comfortably be borne by the hands of the surgeon ; warm solutions, it has been shown by recent investigations, possess a greater germicidal power than those of the same strength when used cold, and they also possess the advantage of preventing chilling of the patient, and thus diminish the shock of the operation. Hemorrhage during the operation is controlled by the use of haemostatic forceps, which are applied to the bleed- ing vessels, or the vessels may be ligatured as they are divided. After the operation has been completed, and all hemorrhage has been controlled, the wound is thoroughly irrigated with a 1 : 4000 to 1 : 2000 bichloride solution. The next step is to provide for drainage ; this may be disregarded in small, superficial wounds, but in a wound of considerable size or depth it is safer to provide free drainage. This is accomplished by the use of perforated rubber drainage-tubes, or a number of strands of catgut, or strips of iodoform or bichloride gauze. The rubber tube may be laid in the wound, the ends being allowed to extend from the extremities of the wound, or it may be so introduced that one end of the tube rests in the deepest part of the wound and the other extremity is brought out of the wound at its most dependent portion ; in large or irregularly shaped wounds a number of tubes may be required to secure free drainage. The ends of the drainage-tubes are transfixed with safety-pins which have been sterilized, and should next be cut off close to the pins so as to be as nearly as possible flush with the skin.^ The wound being closed by sutures, a final irrigation of its deepest parts should be made, by injecting a stream of bichloride solution, 1 : 4000 to 1 : 2*000, into the end of the drainage-tube. The external surface of the wound, and the skin for some distance surrounding it, should next be washed with a 1 : 4000 to 1 : 2000 bichloride solution, and a piece of protective, a little longer and wider than the wound, is dipped in a bichloride or carbolic solution MOIST METHOD OF DBESSING. 161 and placed over it. The use of protective over the wound is important only if it is desired to keep the wound moist, in order to obtain organization of the blood- clot, otherwise it need not be employed. Over this is laid the deep dressing, which consists of a pad of bichlo- ride gauze from eight to sixteen layers in thickness, and large enough to overlap the wound two or three inches in all directions. This should be dipped in a 1 : 4000 to 1 : 2000 bichloride solution, and wrung out as dry a.- pos- sible before being applied. The superficial gauze-dressing is next applied, and consists of sixteen layers of gauze, which should be large enough to extend from three to six inches beyond the wound in all directions; this gauze is applied dry. Over the superficial gauze-dressing there is next applied a number of layers of bichloride cotton, so arranged as to extend a little beyond the margin of the superficial gauze-dressing. These dressings are next secured in position by the application of a gauze-bandage, which is prevented from slipping by the introduction of a few safety-pins. Iodoform, carbolized. or any other variety of medicated gauze, may be used in place of the bichloride gauze. In this method of dressing, no mackintosh or rubber- tissue is employed outside of the superficial gauze-dress- ing ; the discharges of the wound are disseminated through the dressing and become dry by evaporation, and the dressing forms an antiseptic scab which covers and sur- rounds the wound. Moist Method of Dressing. — If, for any reason, it is desired to adopt the moist method of dressing, a piece of mackintosh or rubber-tissue larger than the superficial gauze-dressing is placed over it, and over this are placed a few layers of bichloride cotton, care being taken to see that the layers of cotton overlap the mackintosh or rubber- tissue by a few inches; the application of an antiseptic gauze-bandage then completes the dressing. On removal of this dressing the gauze will generally be found to be soaked with the discharges from the wound, and in a moist condition. The disadvantage of this variety of li 162 MINOR SURGERY. dressing is that there is apt to be more irritation of the skin set up by the bichloride gauze when kept moist than when applied in the manner of a dry dressing. Redressings of the Wound. — The redressing of a wound which remains aseptic need not be made for some days ; if the temperature remains normal or a little above this point, and the patient exhibits no unfavorable con- stitutional symptoms, and the dressing is comfortable to the patient, it need not be disturbed for a week or ten days ; at the expiration of this time it is well to examine the wound and to remove the drainage-tube if drainage has been used, and to remove a portion or all of the sutures if the superficial parts of the wound are firmly healed In redressing a wound in which the antiseptic method was employed, at the end of a week or ten days, to pre- vent any possible infection, as much care should be exercised as in the original dressing of the wound. The patient's clothes should be removed so as freely to expose the dressing, and a rubber cloth should be placed under the patient so as to protect the bed, and the clothing and skin in the region of the wound should be protected by towels wrung out in a 1 : 1000 bichloride solution. The surgeon should wash his hands and immerse them in a 1 : 1000 bichloride solution before removing the dressings. The bandage retaining the dressing should be divided with bandage-scissors and the gauze removed layer by layer, and when the deep dressing is removed care should be taken that the drainage-tubes are not pulled upon if they are adherent to the dressing ; the protective should next be removed and the surface of the wound irrigated with a 1 :2000 bichloride solution. If the wound is found aseptic, the drainage-tube may be removed, and the superficial wound be irrigated with bichloride solution. If the wound is healed, the sutures maybe removed at this dressing; but if the wound has been an extensive or deep one, it may be well to remove only a portion of the sutures ; if catgut sutures have been employed, they need not be removed. The surface of the wound is next irrigated with a 1 ; 2000 REDRESSING OF WOUNDS. 163 bichloride solution, and deep and superficial gauze-dress- ings are applied as previously described, and covered with layers of bichloride cotton, and the whole dressing is secured by the application of an antiseptic bandage. If the wound remains aseptic, the dressings need not be changed for a week or ten days, and at this time the wound will usually be found healed, so that further dress- ings are not required. In the redressing of a wound in which the aseptic method was employed, the use of germicidal solutions is omitted, and the wound is redressed with sterilized gauze and cotton. If, however, the wound is not running the typical course of an aseptic wound, constitutional symptoms will be de- veloped, as evidenced by a rise in the temperature and pulse- rate and other constitutional disturbances. In this event the wound should be redressed as soon as possible, and if the cause of the disturbance can be found, it should be removed ; for instance, hemorrhage may have taken place into the wound, and the blood not being able to escape through the drainage-tubes may have caused so much dis- tention of the wound that the vitality of the skin cover- ing the wound is threatened, or the sutures may be found to be causing irritation, or suppuration may be present. If, on exposure of the wound, it is found that it is dis- tended with blood-clots, and that blood is escaping from the wound, the sutures should be removed, the clots turned out, and the bleeding vessel or vessels sought for and ligatured, and the wound, after a thorough irrigation with 1 : 4000 to 1 : 2000 bichloride solution, should be drained and closed with sutures, and dressed as previously described. If, however, on exposure of the site of the operation, and upon the removal of a portion or all of the sutures, the wound is found distended with a blood-clot, and no evidence of hemorrhage at the time exists, or of suppura- tion in the wound, the clot may be allowed to remain in place, and the wound should be redressed as in the original dressing, trusting to the organization of the blood-clot if it has remained aseptic. If the patient's condition im- 164 MINOR SURGERY. proves after the dressing, and the temperature and pulse- rate become normal, it is an indication that the wound is still aseptic, and it need not be redressed for some days. If, on the other hand, examination of the wound shows that the drainage is insufficient, or that the drainage- tubes are occluded by blood-clots, these should be removed by washing out the tubes with a 1 : 4000 to 1 : 2000 bi- chloride solution by means of a syringe, and introducing additional drainage-tubes, if it is deemed necessary ; the wound should then be redressed. When it is found on examination of the wound that suppuration is present, it should thoroughly be irrigated through the drainage-tubes with a 1 : 2000 bichloride solution, and after thorough irrigation it should be redressed, and, if the constitutional symptoms improve, it may be assumed that the wound has been rendered aseptic. Aseptic or Antiseptic Treatment of Infected Wounds. — It often happens that the surgeon is called upon to treat a wound which is septic Avhen it comes under his care, as evidenced by the inflamed state of the wound, inflammation of the lymphatic vessels and skin, foul discharges and sloughing of the tissues, and the coexistent constitutional symptoms of sepsis. In such a case it would at first sight appear that the surgeon or his assistants could not introduce any material of infection worse than that which already existed in the wound, but he should bear in mind the fact that it is possible to intro- duce a new form of infection in addition to that already existing. With this possibility in view, he should observe the same precautions as regards the sterilization of his hands, the region of the wound, the instruments, and dressings, as he would employ in treating a perfectly fresh wound. Recent investigations, however, have shown that the germs in abscesses are to a great extent dead, and that the pus-formation is largely due to the irritation caused by their products. In view of these facts, it would seem that the most important part of the treatment of infected wounds is thorough drainage. It is a question whether TREATMENT OE INFECTED WOUNDS. 165 the micro-organisms in the walls of infected cavities or sinuses can be destroyed by antiseptic irrigation. Some surgeons recommend active treatment, both mechanically and by the use of germicidal solutions, while others are satisfied simply to secure free drainage ; and if irrigation is necessary, they do not employ strong germicidal fluids but use simply sterilized water or sterilized salt solution. I prefer to employ the antiseptic method in dealing with infected wounds, and can recommend the following plan. The skin surrounding the wound for some distance should be wiped over with spirit of turpentine and carefully scrubbed with soap and water, and should next be washed with a 1 : 1000 bichloride solution ; the wound itself should next be washed with peroxide of hydrogen and a 1 : 1000 bichloride solution. With forceps and curette, any dirt or sloughing tissue should be removed ; then the wound again washed with peroxide of hydrogen and douched with a 1 : 2000 bichloride solution. The wound should then be dried with gauze pledgets and dusted with iodoform, and loosely packed with strips of iodoform gauze. If from the appearance of the tissues the surgeon has reason to think that the infection has passed beyond the reach of the curette or scissors, he may swab over the surface of the wound with a solution of chloride of zinc, 30 grains to the ounce of water. Pure carbolic acid may be used, and is recommended by some surgeons, for the same purpose as chloride of zinc, but the toxic action of carbolic acid causes its employment to be attended with some danger. Toxic effects and too extensive cauteriza- tion may be prevented by washing the part with abso- lute alcohol. Free drainage being secured by the intro- duction of a few strips of iodoform gauze, the wound is dressed with a voluminous dressing of bichloride gauze and bichloride cotton. No attempt, as a rule, should be made to bring together the edges of such a wound by the introduction of sutures. In the dressing of infected wounds, when the discharges are ropy or viscid they are not well absorbed by dry dressings, and in this class of wounds it is, therefore., often of advantage to employ 166 MINOR SURGERY. moist antiseptic dressings. By this method of treatment it is often possible to convert a septic wound into an aseptic one, and have rapid improvement follow both in the local condition of the wound and in the constitutional condition of the patient. MATERIALS USED IN SURGICAL DRESSINGS. Lint. — This material is employed in surgical dressings, and is of two varieties : the domestic lint, which consists of pieces of old linen or muslin which have been thor- oughly washed or boiled and then dried, or the surgical lint, which resembles Canton flannel in appearance ; the latter is the best material, as it has a greater absorbing capacity. Lint is used as a material on which unctuous prepara- tions are spread in the dressing of wounds, and is em- ployed also as a material for saturating with the various solutions which are used in wet dressings, such as lead- water and laudanum ; the lint, after being saturated with the solution, is covered with rubber-tissue or oiled silk when applied, to prevent too rapid evaporation of the solution. It is also one of the best materials from which to construct the compresses employed in the treatment of fractures. Paper-lint. — This is made from old rags or wood-pulp, has great absorbing power for fluids, and may be used as a substitute for surgical lint in the application of wet dressings to surfaces when the skin is unbroken. Oakum. — This material, made from old tarred rope, was formerly much employed in the dressing of wounds, before the introduction of the antiseptic method of wound treatment. From its elasticity it is found to be an excellent material for padding splints or other surgical appliances. It is employed also in the form of pads to place under patients to relieve portions of the body from pressure, or to absorb discharges which soak through the dressings. A mass of oakum which has been well teased ABSORB EST COTTON. 167 out and wrapped in a towel forms an excellent pillow on which to support a stump. Cotton. — Cotton is now employed in surgical dressings principally as a material to pad splints or to relieve salient parts of the skeleton from pressure in the applica- tion of splints or bandages ; for instance, in the applica- tion of the plaster-of- Paris bandage, the bony prominences are generally covered with small masses of cotton. It pos- sesses but little absorbent power unless used in the form of absorbent cotton, and is not much employed in surgical dressings except for the purposes mentioned above. Absorbent Cotton. — This material is prepared from ordinary cotton, which is boiled with a strong alkali to remove the oily matter which it contains. When so pre- pared, it absorbs liquids freely, and by reason of its great absorbing capacity it is employed largely in surgical dress- ings. A small mass of sterilized absorbent cotton wrapped upon the end of a probe is now generally employed to make applications to wounds, and has taken the place of the sponge or brush which formerly was employed for this purpose. On account of its cheapness, after one applica- tion it can be thrown away and a new piece used, and thus the danger of carrying infection from one wound to an- other by the applicator is abolished. It is largely em- ployed in gynecological practice for making applications to the female genital organs. Wood-wool. — Wood-wool made from wood-pulp, such as is employed in the manufacture of paper, is also fur- nished in the shape of lint, sponges, and pads, and may be used for the same purposes as the ordinary surgical lint. Oiled Silk or Muslin. — These materials are employed as an external covering for moist dressings to prevent rapid evaporation from the dressings ; they form excellent materials for this purpose, but as they are quite expensive their use is limited. Waxed or Paraffin-paper. — This dressing is prepared by passing sheets of tissue-paper through melted wax or paraffin, and then allowing them to dry. Paper thus treated 168 MINOR SURGERY. forms an excellent and cheap substitute for oiled silk or muslin, and may be employed for the same purpose for which the latter materials are used. Rubber-tissue. — This material, which is prepared by rubber manufacturers, consists of rubber run out into very thin sheets. It has a glazed surface, is very pliable, and at the same time strong, forming, therefore, a cheap and satisfactory substitute for oiled silk, and is employed for the same purposes. Parchment-paper. — This paper is prepared so as to render it water-proof; it is employed in surgical dressings for the same purposes as oiled silk and rubber-tissue. Compresses. — Compresses are prepared by folding pieces of lint, muslin, linen, or gauze upon themselves, so as to form firm masses of variable size ; oakum or cotton may also be used to form compresses. Compresses are em- ployed to make pressure over localized portions of the body, as in the treatment of fractures, or to make press- ure upon vessels for the control of hemorrhage. Tampon. — A tampon is -a form of compress which is employed in cavities to make pressure, to control hemor- rhage, or to apply various solutions or powders to the surface of the cavity. Tampons used to control hemor- rhage are generally made of strips of bichloride, iodo- form or sterilized gauze. In applying these, the strips of gauze are packed into the cavity, and when the latter is full a compress is applied superficially and held in place by a bandage. The application of a tampon to the vagina is a favorite method of controlling uterine hemorrhage. Glycerin Tampon. — This is made by pouring half an ounce of glycerin on a piece of cotton or wool, and then turning up the ends and securing them by a string, one end of which is allowed to remain long enough to hang from the vagina, to facilitate its removal ; it is a favorite application to the os uteri. Tent. — This consists of a small portion of lint, oakum, muslin, or sterilized or antiseptic gauze rolled into a coni- cal shape, which is employed to keep wounds open and to facilitate the escape of discharges. RETRACTORS. L69 Retractors. — Retractors are made by taking a piece of muslin four inches wide and twelve to eighteen inches in length, and splitting it as far as the centre, thus making a two-tailed retractor (Fig. 124). A three-tailed retractor is made in the same way, except that the muslin is slit twice instead of once (Fig. 125). Retractors are used to retract the soft parts in amputations, to prevent their injury by Fig. 124. Fig. 125. Two-tailed retractor. Three-tailed retractor. the saw in the division of the bones. When one bone is sawed a two-tailed retractor is used, and when two bones are sawed a three-tailed retractor is employed. Plasters. — The varieties of plaster which are most commonly employed in surgical dressings are adhesive or resin plaster, isinglass plaster, and rubber adhesive plaster. Before using any of these plasters upon parts which are 170 MINOR SURGERY. covered by hairs, the latter should be removed by shaving, otherwise traction upon them, if the plaster be used for the purpose of extension, will cause the patient discom- fort, and unnecessary pain will also be inflicted at the time of its removal. Resin Plaster. — This plaster, which is machine-spread, is one of the most widely employed plasters in surgical dressings ; the spread surface is covered with a layer of tissue-paper, which should be removed before it is used ; it is cut into strips of the required width and length, and the strips should be cut lengthwise from the roll of plas- ter, as the cloth upon which it is spread stretches more transversely than in a longitudinal direction. When heated and applied to the surface it holds firmly ; it is prepared for application by applying the unspread side to a vessel containing hot water, or it may be passed rapidly through the flame of an alcohol lamp. This is the variety of plaster which is generally used in making the extension-apparatus for the treatment of fract- ures, for strapping the chest in fractures of the ribs and sternum, for strapping the pelvis in cases of fractures of the pelvic bones, and for strapping the breast, the testicle, ulcers, or joints. Swans'-down Plaster. — This plaster is much the same as resin plaster, but is spread upon a heavier material, and is an excellent plaster to use for an extension-apparatus, where it is to be worn for a long time. Rubber Adhesive Plaster. — This plaster is made by spreading a preparation of India-rubber on muslin, and has the advantage over the ordinary resin plaster that it adheres without the application of heat. It is employed for the same purpose as resin plaster, but when applied continuously to the skin it is apt to produce a certain amount of irritation, and for this reason when it is to be applied for some time, as in the case of an extension- apparatus, it is not so comfortable a dressing as that made from resin plaster. Zinc Oxide Adhesive Plaster. — This plaster is prepared by incorporating with rubber adhesive plaster oxide of zinc. STRAPPING. 171 It is equally as adhesive as the rubber plaster, and pos- sesses the advantage that it is not apt to produce irritation of the skin. It is used for the same purposes as the rubber adhesive plaster. Isinglass Plaster. — This plaster is made by spreading a solution of isinglass upon silk or muslin, and it has been found a most useful dressing in the treatment of superficial wounds. It is caused to adhere to the surface by moisten- ing it, and when used in the treatment of wounds it should be moistened with an antiseptic solution. The best variety is spread on muslin, and when properly applied adheres as firmly and possesses as much strength as the ordinary resin plaster. Soap Plaster. — Soap plaster for surgical purposes is prepared by spreading em/plastrum saponis upon kid or chamois skin. It is not employed for the same purposes as the resin or rubber plaster, as it has little adhesive power, and is used simply to give support to parts or to protect salient portions of the skeleton from pressure. It is found to be a most useful dressing when applied over the sacrum in cases of threatened bedsores, and may be applied for the same purpose to other parts of the body where pressure-sores are apt to occur. In the treatment of sprains of joints, a well-moulded soap-plaster splint secured by a bandage will often be found a most efficient dressing, and in the treatment of fractures the comfort of the patient is often materially increased by applying small pieces of soap plaster over the bony prominences, upon which the splints, even when well padded, are apt to make an undue amount of pressure. STRAPPING. This consists in applying pressure to parts by means of strips of plaster firmly applied ; it is a procedure often employed in surgical practice. Strapping the Testicle. — In strapping the testicle, strips of resin plaster are usually employed ; a dozen or 172 MINOR SURGERY. more strips one-half an inch wide and twelve inches in length will be required. The scrotum should first be washed and shaved, and the surgeon next draws the skin over the affected organ tense by passing the thumb and finger around the scrotum at its upper portion, making circular constriction ; a strip of muslin is passed in a circular manner around the skin of the scrotum above the organ, and is tightly drawn and secured by passing around it a strap of plaster which has been heated ; this isolates the part and prevents the other straps from slipping. Straps are now applied in a longi- tudinal direction, the first strap being fastened to the circular strap and carried over the most prominent part of the testicle, and then carried back to the circular strap Fig. 126. f£Sn. Strapping the testicle. (Smith.) and fastened. A number of these straps are applied in an imbricated manner until the skin is covered (Fig. 126), and the dressing is completed by passing transverse straps around the testicle from its lowest portion to the circular strap ; care should be taken to see that no portion of the skin is left uncovered. Strapping the testicle is employed with advantage in the subacute stage of orchitis or epididymitis ; as the swelling of the testicle diminishes the straps become loose, and the part will require re-strapping. It will also be found a useful means of applying pressure to the scrotum after the injection-treatment of hydrocele. Strapping of the Chest. — To strap one-half of the chest, strips of resin plaster two and a half inches wide, STRAPPING OF ULCERS. 173 Fig. 127. and .sufficiently long to extend from the spine to the me- dian line of the sternum, are required — eighteen to twenty inches in length. The first strap is heated, and one ex- tremity is placed upon the spine opposite the lower portion of the chest ; it is then carried over the chest, and its other extremity is fixed upon the skin in the median line of the sternum. Straps are next applied from below up- ward in the same manner, each strap overlapping one- third of the preceding one, until the axillary fold is reached (Fig. 127); a second layer of straps may be applied over the first, if additional fixation is desired, or a few oblique straps may be employed. Adhesive straps applied in this manner very materially limit the motion of the chest-wall upon the affected side, and are frequently employed in the treatment of fractures and disloca- tions of the ribs, in contusions of the chest, and in cases of plastic pleurisy when the motions of the chest-wall are extremely painful to the patient. Strapping of Ulcers. — To strap ulcers of the leg, strips of resin plaster one and a half inches wide, and sufficientlv long to extend two- thirds of the distance around the limb, are required. The ulcer should be thoroughly cleansed, and the skin surrounding it well dried ; the first strap, after being heated, is ap- plied transversely to the long axis of the leg about two inches below the ulcer, and is carried two-thirds of the distance around the limb ; another strap is applied to a corresponding point of the skin above this one, so that it overlaps one-third of the strap first applied, and it is carried two-thirds of the way around the limb. Addi- tional straps are thus applied until the ulcer is covered in, and the straps are carried several inches above the ulcer (Fig. 128). Strapping of ulcers may also be accomplished by using narrow straps of plaster one and a half inches in Strapping the chest. 174 MINOR SURGERY. width. The ends of two straps are placed upon the limb some distance below the ulcer, and the straps are brought up and made to cross each other so as to draw the tissues toward the point of crossing ; a number of imbricated Fig. 128. Strapping an ulcer of the leg. straps are applied in this way until the parts are suffi- ciently covered in and supported (Fig. 129). Care should be taken to see that the straps are so applied as not to meet or cover the entire circumference of the limb, as by so doing injurious circular compression might result. STRAPPING OF ULCEUS. 175 Chronic ulcers upon other portions of the body may be strapped in the same manner. Strapping of leg ulcers is usually reinforced by the application of a firmly applied spiral reversed or spica- bandage of the lower extremity. Fig. 129. Strapping an ulcer of the leg. Strapping of ulcers of the leg applied in the manner described will be found a most satisfactory method of treating chronic ulcers in this location in patients who have to work during the course of treatment ; the 176 MINOR SURGERY. straps need be removed only at intervals of a week, and if well applied, the dressing is generally a comfortable one to the patient. Strapping of Joints. — Strips of resin plaster two inches in width and sufficiently long to extend two-thirds around the joint are required. The first strap is applied a few inches below the joint, and straps are then applied over this, each strap covering in two-thirds of the preced- ing one until the joint is covered in and the dressing extends a few inches above the joint. Strapping will be found a satisfactory dressing in the treatment of sprains of joints in their acute or chronic state. Fig. 130. Strapping applied to ankle-joint. Strapping the Ankle-joint. -In applying strapping in sprains of the ankle- or tarsal joints, strips of rubber POULTICES. 177 adhesive plaster one and a half inches in width and eigh- teen inches in length are required. The first strap is started at the junction of the middle and upper part of the leg, either upon the inner or the outer side, and applied closely to the edge of the tendo Achillis, and car- ried across the sole of the foot to the base of the great or little toe ; several of these straps are applied, covering in the inner or enter surface of the ankle. A strap is next placed with its middle at the point of the heel, the ends being carried to a point on the foot at the junction of the metatarsal bones and the tarsus; a number of these ascending straps are applied, alternating with the vertical straps, until the ankle-joint is covered in. These straps should not be applied so as to meet in front of the foot or ankle and make circular constriction (Fig. 130). After the ankle has been strapped as above described, the foot and ankle are covered with a gauze bandage, and the patient is allowed to walk upon the injured foot. Strapping of a Carbuncle.— To strap a carbuncle, strips of resin plaster one to one and a half inches in width are required ; these straps are applied at the margin of the swelling, and are laid on concentrically until all except the central portion is covered. If a number of openings exist, the straps are so placed as not to cover these. Strap- ping applied in this manner is often a comfortable dressing for the patient, and at the same time the concentric pressure favors extrusion of the slough. POULTICES. This form of dressing was formerly much employed in the treatment of inflammatory conditions as a means of applying heat and moisture to the part at the same time, and 'although the use of poultices is now much restricted since the introduction of the antiseptic method of wound treatment, yet I think there are still conditions in which their employment is both useful and judicious. They are often employed with advantage in inflammatory affec- 12 178 MINOR SURGERY. tions of the chest and of the abdominal organs ; and in inflammatory affections of the joints and of bone, com- bined with rest, their action is often most satisfactory. They constitute a form of dressing which is conducive to the comfort of the patient in cases of deep suppura- tion by their relaxing effect upon the tissues, and their previous use does not prevent the surgeon from using all aseptic precautions in the opening and drainage of these abscesses, and the employment of aseptic or antiseptic dressings in their subsequent treatment. Flaxseed Poultice. — This poultice is prepared by add- ing first a little cold water to ground flaxseed, and then boiling and stirring it until the resulting mixture is of the consistency of thick mush. A piece of gauze or muslin is next taken which is a little larger than the intended poul- tice, and this is laid upon the surface of a table, and with a spatula or knife the poultice-mass is spread evenly upon it from one-quarter to one-half an inch in thickness ; a margin of the muslin of one or one and a half inches is left, which is turned over after the poultice is spread, and serves to prevent it from escaping around the edges when applied. The surface of the poultice may be thinly spread over with a little olive oil, or may be covered with a layer of thin gauze, to prevent the mass from adhering to the skin. It is next applied to the surface of the skin, and is covered with a piece of oiled silk, rubber-tissue, or waxed paper, and held in position by a bandage or a binder. Soap Poultice. — This is made by saturating a number of layers of gauze in a mixture of 1 part of green soap to 6 parts of water. It is then applied to the surface and covered with oiled muslin or waxed paper. It may be employed as a primary dressing for some hours to the feet or other parts of the body where the epidermis is thick, before sterilizing these parts previous to operation. Starch Poultice. — This poultice is prepared by mixing starch with cold water until a smooth, creamy fluid results ; boiling water is then added, and it is heated until it be- comes clear and attains about the same consistency as the starch used for laundry purposes. When sufficiently cool, HOT FOMENTATIONS. 179 it is spread upon gauze or muslin, applied to the part, and covered with oiled silk or waxed paper. This variety of poultice is principally useful in the treatment of diseas of the skin, especially those of the scalp accompanied by the formation of scabs or crusts, to facilitate their removal and to afford a clean surface for the application of oint- ments or wet dressings. Fermenting- Poultice. — This poultice maybe prepared by adding yeast (two tablespoonfuls) to a mixture of flax- seed with hot water, making a thin poultice-mass, and allowing it to stand for a few hours in a warm place ; it rises and becomes light, and is then spread upon gauze or muslin and applied as reemired. A few ounces of porter or a piece of yeast-cake may be used as a substitute for the yeast in preparing this poultice ; animal charcoal may also be added to it to increase its .disinfectant power. This poultice was formerly used as an application to gangrenous parts to hasten their separation and to diminish the odor arising from the necrosed tissues. Antiseptic Poultice. — This is prepared by soaking a pad of sterilized gauze in hot bichloride or carbolic solu- tion and wrincrino; it out to remove the excess of fluid. It is next applied to the part and covered with oiled silk or rubber-tissue, which may be held in place by a bandage. Such a dressing will absorb a considerable amount of discharge. Hot Fomentations. — Hot fomentations are employed to keep up the vitality of parts which have been subjected to injury, as seen in severe contusions resulting from rail- way or machinery accidents ; also to combat inflammatory action. Gauze (several layers in thickness) or surgical lint should be soaked in sterilized water having a temperature of 120° F. ; these are wrung out, placed over the part, and covered with waxed paper or rubber-tissue ; a second pad should be placed in the hot water, and applied as soon as the first-applied cloth begins to cool, and so by contin- uously reapplying them the part is kept constantly covered by a hot dressing. The use of these hot fomentations may in many cases require to be continued for hours before the 180 MINOR SURGERY. desired result is obtained. Hot compresses applied in this manner are frequently employed in treating inflammatory conditions of the eye, and are also of the greatest service in keeping up the vitality of parts which have been sub- jected to severe injury interfering with their blood-supply. I have seen contused limbs, which were cold and seemed doomed to gangrene by reason of diminished blood-supply, have their temperature and circulation restored by the patient and persistent use of this dressing. After the vitality of such a part is restored, it should be covered with cotton and a flannel bandage and surrounded by hot- water bags or hot-water cans. IRRIGATION. This may be accomplished by allowing the irrigating fluid to come in contact with the wound or inflamed part — immediate irrigation ; or by allowing the cold or warm fluid to pass through rubber tubes which are in contact with or surround the part — mediate irrigation. Immediate Irrigation. — In employing immediate irri- gation in the treatment of wounds or inflammatory condi- tions, a funnel-shaped can with a stop-cock at the bottom, or a bucket, is suspended over the part at a distance of a few inches (Fig. 131), or a jar with a skein of thread or lamp-wick arranged to act as a siphon may be employed (Fig. 132). The can or jar is filled with water, and this is allowed to fall drop by drop upon the part to be irri- gated, which should be placed upon a piece of rubber sheeting so arranged as to allow the water to run off into a receptacle, to prevent wetting the patient's bed. The water employed may be either cold or warm, in accord- ance with the indications in special cases. If it is desired to make use of antiseptic irrigation, the water is impreg- nated with carbolic acid or bichloride of mercury ; a 1 : 5000 to 1 : 10,000 bichloride solution, or a 1 : 60 car- bolic acid or acetate of aluminum solution, being frequently employed with good results. IRRIGA TION. 181 Antiseptic irrigation employed in this manner will he found a most useful method of treating lacerated and con- tused wounds of the extremities in which the vitality of the tissues is much impaired ; in such cases water at a Fig. 131. Apparatus for continuous irrigation. (Esmarch.) temperature of 100° to 110° F., should be preferred to cool water. Under the use of warm irrigation it is sometimes sur- prising to see tissues apparently devitalized regain their vitality in a short time ; the absence of tension from the non-introduction of sutures and firm dressings, and the warmth and moisture kept constantly in contact with the 182 MINOR SURGERY. wound by this method of irrigation, are the important factors in the attainment of this favorable result. Fig. 132. Irrigating-apparatus. (Ekichsen.) Mediate Irrigation. — In this method of irrigation cold or warmth is applied to the surface by means of cold or warm water passing through a rubber tube in contact with the part. A flexible tube of India-rubber half an inch in diameter, with thin walls, and sixteen or twenty feet in length, is applied to the limb like a spiral bandage, or is applied in a coil to the head, breast, or joints, and held in place by a few turns of a bandage ; the end of the tube is attached to a reservoir filled with cold or warm water above the level of the patient's body, and the water is allowed to flow constantly through the tubing and escape into a receptacle arranged to receive it (Fig. 133). Cold-water Dressings. — These dressings are applied by bringing the cold water either directly in contact with the part or by applying it by means of a rubber bag or bladder. The temperature of the water may vary from cool water to that of ice-water. These dressings are employed in local inflammatory conditions. A favorite method for the employment of this IRRIGATION. 183 dressing is by means of cold compresses, which are made of a few layers of gauze or surgical lint, dipped in water of the desired temperature and applied to the part ; they are renewed as soon as they become warm. When it is desirable to have the compresses very cold, they may be laid upon a block of ice or in a basin with broken ice ; to obtain the best results from their employment, they should be renewed at very short intervals. Fig. 133. Cold coil applied to arm. (Esmarch.) Ice-bag. — A convenient method of applying cold with- out moisture is by the use of the ice-bag. This is either a rubber bag or bladder, which is filled with broken ice and applied to the part. In using an ice-bag, it is better to cover the part first with a towel or a few layers of lint or gauze, which prevent the surface from becoming wet by absorbing the moisture which condenses upon the sur- face of the bag or bladder, and thus renders the dressing more comfortable to the patient, The ice-bag is often employed as an application to the head in inflammatory 184 MINOR SURGERY. conditions of the brain or membranes ; to the abdomen in cases of appendicitis, and is used also upon the surface of the body to control internal hemorrhage. COUNTER-IRRITATION. Counter-irritants are substances employed to excite external irritation, and the extent of their action varies according to the material used and the duration of their application ; superficial redness or complete destruction of the vitality of the parts to which they are applied may result. The use of counter-irritants under favorable circum- stances is found to have a decided effect in modifying morbid processes, and they are widely employed as local revulsants in cases of congestion or inflammation, and in cases of collapse for their stimulating effect. Caution should be exercised in applying counter-irri- tants to patients who are comatose or under the influence of a narcotic, for here the sensations of a patient cannot be used as a guide to their removal, and their too long- continued application when the vitality of the tissues is impaired may result in serious consequences. Rubefacients. — These agents, by reason of their irri- tating properties when applied to the skin, produce intense redness and congestion. Hot Water. — When it is desired to make a prompt impression upon the skin, the application of gauze, muslin, or flannel cloths, wrung out in hot water and renewed as rapidly as they become cool, will soon produce a super- ficial redness of the integument. Spirit of Turpentine. — This drug applied to the skin is a very active counter-irritant ; it may be rubbed upon the surface until redness results. When used upon patients whose skin is very delicate, its action may be modified by mixing it with an equal part of olive oil before applying it; this combination will be found useful as a rubefacient to the tender skin of young children. CO UNTER-IRB1TA TIOK 1 85 When redness of the skin has resulted from the appli- cation the skin should he wiped dry by means of a soft t«.\\cl or absorbent cotton, to remove any turpentine from the surface, which by its continued contact may cause vesication. Turpentine Stupe. — This is prepared by sprinkling spirit of turpentine over flannel cloths which have been wrung out in hot water, or by dipping hot flannel in warm spirit of turpentine : prepared in either way, the stupe should be squeezed as dry as possible to remove the excess of turpentine before being applied to the surface of the body. A turpentine stupe may cause vesication if allowed to remain for too long a time in contact with the skin ; its application for from five to ten minutes will usually pro- duce the desired effect ; it should be removed after this time, and it may be reapplied if desired. If the patient complains of severe burning of the skin after the use of turpentine, the painful surface should be smeared freely with vaseline or lard, which will relieve the uncomfortable sensation. Tincture of Iodine. — This drug is frequently used as a counter-irritant in chronic inflammation. It is painted upon the part at intervals until irritation of the skin is observed, when its use is discontinued for a few days before reapplying the application. Chloroform. — A few drops of chloroform applied to the surface of the body by means of a piece of lint, muslin, or flannel, and covered by oiled silk or rubber-tissue, will excite a rapid rubefacient effect. Mustard.— Ground mustard or mustard flour, prepared from either Sinapis alba or Sinapis nigra, is one of the most commonly used substances to produce rubefacient action. It is generally employed in the form of the mus- tard plaster or sinapism, which is prepared by mixing equal parts of mustard flour with wheat flour or flaxseed meal, and adding to this sufficient warm water to make a thick paste ; this'is spread upon a piece of old muslin, and the surface of the paste covered with some thin material, such as gauze, to prevent the paste from adhering to the 186 MINOR SURGERY. skin. In making a mustard plaster for application to the skin of a child, 1 part of mustard flour should be mixed with 3 parts of wheat flour or flaxseed meal. A mustard plaster or sinapism may be allowed to remain in contact with the skin for a period varying from fifteen to thirty minutes, the time being governed by the sensations of the patient ; if it is allowed to remain longer, it may cause vesication, which is to be avoided, as ulcers produced by mustard are very painful and extremely slow in healing. After removing a sinapism, the irritated sur- face of the skin should be dressed with a piece of muslin or lint spread with vaseline, boric acid or oxide of zinc ointment. To excite a rapid revulsive action, the mustard foot-bath is often employed ; it is prepared by adding two or three tablespoonfuls of mustard flour to a bucket or foot-tub of water at a temperature of 100° to 110° F. ; in this the patient is allowed to soak his feet for a few minutes. Mustard Papers. — Chartce Sinapis, which can be obtained in the shops ready for use, are a convenient means of obtaining the rubefacient action of mustard. They are dipped in warm water, and as they are generally very strong, it is well to place a layer of muslin between the surface of the plaster and the skin before applying it to the latter. Capsicum. — This is also sometimes employed alone as a rubefacient, but it is generally used in combination with spices, forming the well-known spice plaster ; this is pre- pared by taking equal parts of ground ginger, cloves, cinnamon, and allspice, and adding to them one-fourth part of Cayenne pepper ; these are thoroughly mixed, enclosed in a flannel bag, and evenly distributed ; a few stitches should be passed through the bag at different points, to prevent the powder from shifting its position ; before applying it, one side of the bag should be wet with warm whiskey or alcohol. Capsine plasters are em- ployed also to obtain the rubefacient effect of Cayenne pepper. Aqua Ammonia. — This may also be employed for its CO UNTEB- IRRITA TION. 1 8 7 rubefacient action. A piece of lint saturated with the stronger water of ammonia, placed upon the skin and covered with waxed paper, and allowed to remain for one or two minutes, will produce a marked rubefacient effect. Vesicants. — Where it is desirable to make a more per- manent counter-irritant effect than that produced by rubefacients, substances are employed which by their action on the skin cause an effusion of serum, or of serum and lymph, beneath the cuticle, thus giving rise to vesi- cles or blisters ; they are known as vesicants. The sub- stance most commonly employed to produce vesication is Cantharis, or Spanish fly, and the preparation commonly used is the Ceratum cantharidis. Fly Blister. — This is prepared by spreading ceratum cantharidis upon adhesive plaster, leaving a margin one- half an inch in width uncovered, which will adhere to the skin and hold the blister in position. The time required for a fly blister to produce vesication is from four to six hours ; it should then be removed, and the surface covered with a flaxseed-meal poultice or with a warm- water dressing. When the blister or vesicle is well devel- oped, it may be punctured at its most dependent part to allow the serum to escape, and it should be dressed with vaseline or boric ointment. If for any reason it is desired to keep up continued irritation after allowing the serum to escape, the cuticle should be cut away and the raw surface should be dressed with some stimulating material, such as the compound resin cerate. Cantharidal Collodion. — This may be employed to pro- duce vesication ; it is applied by painting several layers upon the skin with a brush over the part on which the blister is to be produced. It is a convenient preparation to use when the patient would disturb the ordinary blister, as in the case of a child or an insane patient, or where the surface is so irregular that the ordinary blister cannot well be applied. The after-treatment of blisters produced by cantharidal collodion is similar to that described above. Caution should be observed in using blisters upon the tender skins of children ; if employed, they should be 188 MINOR SURGERY. allowed to remain in contact with the skin for a short time only. They are contraindicated in patients in whom the vitality of the tissues is depressed by adynamic dis- eases, and in aged persons. Strangury, which is shown by frequent and painful mic- turition, the urine often containing blood, sometimes occurs from the use of cantharidal preparations as blisters. This condition should be treated by the use of opium and bel- ladonna by suppository, demulcent drinks, and warm sitz- baths, and by leeches to the perineum if the symptoms are very severe. To avoid the development of strangury, small blisters should be employed, and they should not be allowed to remain too long in contact with the surface; cantharidal preparations should not be employed in cases where renal or vesical irritation has existed or is present. Strangury may also be avoided by incorporating opium and camphor with the cantharidal cerate. Aqua Ammonia Fortior and Chloroform. — These drugs may be employed to produce rapid vesication, a few drops being placed upon the surface of the body and covered by an inverted watch-glass for a few minutes ; or lint satu- rated with aqua ammonia or chloroform may be placed upon the skin and covered with waxed paper or oiled silk. Either of these agents applied in this manner, and allowed to remain in contact with the skin for fifteen minutes, will produce marked vesication. The blisters resulting from these agents are painful, and they are only to be used where a rapid result is desired. Seguin's Method of Counter-irritation. — This consists in stroking the surface of the skin lightly and rapidly with the point of a Paquelin cautery ; the lines of stroking may be made at right angles ; the application is practically pain- less, but a very decided counter-irritant effect is produced. It is employed with advantage in neuralgic affections of the spine and joints, and in cases of neuritis of superficial nerves. Acupuncture. — Counter-irritation is effected by this method by thrusting steel needles deeply into the subcu- ACTC. if. CATTERY. 189 Fig. L34. taneous tissues. The needles employed should be of steel, from two to four inches in length, strong, highly polished, and sharp-pointed, and should have round metallic heads or be fixed in handles (Fig. 134). Before being used, they should be immersed for a few minutes in boiling Mater or in a carbo- lized solution, to sterilize them thoroughly. In performing the operation of acupunct- ure, localities containing important or- gans, large bloodvessels, the joints and viscera, should be avoided. When in- troduced, the needles should be passed through the skin with a rotary motion, the skin being rendered tense between the thumb and fingers, and pushed into the deep-seated structures. They are allowed to remain in position for a few moments, and are then withdrawn, the skin being Supported by the thumb and fingers. Acupuncture needles. Acupuncture has been found of service in cases of deep-seated neuralgia, obstinate rheumatic affections, and sciatica. Actual Cautery. — This method of counter-irritation is accomplished by bringing in contact with the skin some metallic substance brought to a high degree of tempera- ture. This constitutes one of the most powerful means of counter-irritation and revulsion ; it is rapid in its action, and is not more painful than some of the slower methods. The cauteries generally employed are made of iron, and are fixed in handles of wood or other non-conducting material, and have their extremities fashioned in a variety of shapes (Fig. 135). The irons are heated by placing their extremities in an ordinary fire, or by holding them in the flame of a spirit-lamp until they are heated to the desired point, either a white or a dull-red heat. They are then applied to the surface of the skin at one point, or drawn over it in lines either parallel to or crossing one another. The intense burning which follows the use of 190 MINOR SURGERY. the cautery may be allayed by placing upon the cautery- marks compresses wrung out in ice-water or saturated with equal parts of lime-water and sweet oil. Where the ordinary cautery irons are not at hand, a steel knitting-needle or iron poker heated in the flame of a spirit-lamp or in a fire may be employed with equally satisfactory results. Where the cautery iron is held in contact with the surface for some time to make a deep burn, the pain of its application may be allayed by placing a mixture of salt and cracked ice upon the spot to be cau- terized, for a few minutes immediately before its applica- tion. The cautery iron should not be placed over the Fig. 135. Cautery irons, skin covering salient parts of the skeleton or over impor- tant organs. The actual cautery, in addition to its use in producing counter-irritation and revulsion, is often employed to con- trol hemorrhage and to destroy morbid growths. Paquelin's Thermo -cautery. — A very convenient and efficient means of using the thermo-cautery is the appa- ratus of Paquelin, which utilizes the property of heated platinum-sponge to become incandescent when exposed to the vapor of benzole or rhigolene (Fig. 136). The cautery is prepared for use by attaching the gum tube to the receiver containing benzole, and heating the platinum knife or button, which also is attached to the benzole re- PA Q UELIN'S THERM O-CA UTER Y. 191 ceiver by a rubber tube, in the flame of the alcohol lamp for a few moments, and then passing the vapor of benzole through the platinum-sponge, which is enclosed in the knife or button, by compressing the rubber bulb. The point may be brought to a white heat or only to a dull- red heat. This form of cautery may be employed for the same purposes as is that previously mentioned ; its great advan- Fig. 136. Paquelin's cautery. tage consists in the ease with which it can be prepared for use. The knives heated to a dull-red heat will be found of great service in operating upon vascular tumors, where the use of an ordinary knife would be accompanied by profuse or even dangerous hemorrhage. Wounds made by the actual cautery are aseptic wounds, and when dusted with an antiseptic powder generally heal promptly under the scab without suppuration. 192 MINOR SURGERY. BLOODLETTING. This procedure is often resorted to, to obtain both the local and the general effects following the withdrawal of blood from the circulation. Local depletion is accom- plished by means of some one of the following procedures : scarification, pnnctxiration, cupping, and leeching ; and gen- eral depletion is effected by means of venesection or by arteriotomy . Scarification. — Scarification is performed by making small and not too deep incisions into an inflamed or con- gested part with a sharp-pointed bistoury ; the incisions should be in parallel lines, and should be made to corre- spond to the long axis of the part, and care should be taken in making them to avoid wounding superficial veins and nerves. Incisions thus made relieve tension by allow- ing blood and serum to escape from the engorged capil- laries of the infiltrated tissue of the part. Warm fomen- tations applied over the incisions will increase and keep up the flow of blood and serum. Scarification is employed with advantage in inflammatory conditions of the skin and subcutaneous cellular tissue and in acute inflammatory swelling or oedema of the mucous membrane, for instance, of the conjunctiva, and in acute inflammation of the ton- sils, tongue, and epiglottis it is an especially valuable procedure. A modification of scarification, known as deep incisions, is practised in urinary infiltration to establish drainage and to relieve the tissues of the contained urine, and to prevent sloughing ; in threatened gangrene and phleg- monous erysipelas the same procedure is adopted to relieve tension by permitting of the escape of blood and serum, and its employment is often followed by most satisfactory results. Puncturation. — This procedure consists in making punctures into inflamed tissues with the point of a sharp- pointed bistoury, which should not extend deeper than the subcutaneous tissue; it is an operation similar in character to that just described, its object being to relieve DRY CUPPING. 19:3 Fig. 137 tension and bring about depletion. It is employed in cases similar to those in which scarification is indicated, and is resorted to in cases of diffuse areolar inflammation or erysipelas. Cupping". — Cupping is a convenient method of employ- ing local depletion by inviting the blood from the deeper parts to the surface of the body. Cupping is accomplished by the use of dry or wet cups. When the former are used, no blood is abstracted, and the derivative action only is obtained ; when wet cups are employed, there is an actual abstraction of blood or local depletion as well as the derivative action. Dry Cupping. — Dry cups as ordinarily applied consist of small cup-shaped glasses, which have a valve and stop- cock at their summit ; these are placed upon the skin and an air-pump is attached, and as the air is exhausted in the cup the congested integument is seen to bulge into the cavity of the cup. When the exhaustion is complete the stop-cock is turned and the air- pump is disconnected, the cup being allowed to remain in position for a few minutes, and is then removed by turning the stop-cock and allowing air again to enter the cup. This procedure is repeated until a sufficient num- ber of cups have been applied (Fig. 137). In cases of emergency, when the ordi- nary cupping-glasses and air-pump are not available, a very satisfactory substitute may be obtained by taking a wineglass and burn- ing in it a little roll of paper, or a small piece of lint or paper wet with alcohol, and before the flame is extinguished rap- idly inverting it upon the skin ; or the air may be exhausted by the introduction, for a moment or two, of the flame of a spirit- lamp into the cup. Applied in this manner, cups will draw as well as when the more com- plicated apparatus is used ; and when they are to be removed, it is only necessary to press the finger on 13 Cupping-glass and air-pump. 194 MINOR SURGERY. the skin close to the edge of the cup until air enters it, when it will fall off. Although dry cups do not remove blood directly, there is often an escape of blood from the capillaries into the skin and cellular tissue, as is evidenced by the ecchymosis which frequently remains for some days at the seat of the cup-marks. Wet Cupping. — When the abstraction of blood as well as the derivative action is desired, wet cups are resorted to, and here it is necessary to have a scarificator as well as the cups and air-pump (Fig. 138). Before applying wet cups, the skin should be washed carefully w 7 ith bichloride or carbolic solution, and the Fig. 138. Scarificator. scarificator should also be sterilized by boiling. A cup is first applied to produce superficial congestion of the skin; this is removed, and the scarificator is applied and the skin is cut by springing the blades. The cups are immediately reapplied and exhausted, and they are kept in place as long as blood continues to flow. When the vacuum is exhausted and blood ceases to flow, they should be removed and emptied, and may be reapplied if it is desirable to remove more blood. A sharp-pointed bistoury which has been sterilized may be employed to make a few incisions into the skin instead of the scarificator, and im- provised cups may be employed if the ordinary cupping- apparatus cannot be obtained. After the removal of wet cups the skin should be LEECHING. 195 washed carefully with a bichloride or carbolic solution, and an antiseptic dressing should be placed over the wounds and held in place by a roller-bandage. Leeching". — In the abstraction of blood by leeching, two varieties of leeches are used — the American leech, which draws about a teaspoonful of blood, and the Swedish leech, which draws three or four teaspoonfuls. Before applying leeches the skin should carefully be washed, and the leech should be placed upon the part from which the blood is to be drawn, and confined to this place by inverting a tumbler or glass jar over it ; if it does not bite or take hold, a little milk or blood should be smeared upon the surface, which will generally secure the desired result. As soon as the leech has ceased to draw blood it is apt to let go its hold and fall off; if, however, it is desired to remove leeches, they may be made to let go their hold by sprinkling them with a little salt. After the removal of leeches bleeding from the bites may be encour- aged, if desirable, by the application of warm fomenta- tions. Leech-bites should be washed with a bichloride or carbolic solution, and a compress of bichloride or iodoform gauze placed over them and secured by a bandage. It sometimes happens that free bleeding continues from the leech-bite after the removal of the leeches ; in this event, if a compress does not control the hemorrhage, the bleeding point should be touched with a stick of nitrate of silver or with the point of a steel knitting-needle heated to a dull-red heat, and if this fails to control the bleeding a delicate harelip pin should be passed through the skin under the bite and a twisted suture thrown around this ; the wound should then be washed and dressed as previously described. In applving leeches in or near the mucous cavities care should be taken to see that they do not escape into the cavities and pass out of reach. Leeches should not be employed directly over inflamed tissue, but should be ap- plied to parts surrounding it ; they should not be allowed to take hold directly over a superficial artery, vein, or nerve, and should never be applied to a part where there 196 MINOR SURGERY. Fig. 139. are delicate skin and a large amount of loose cellular tissue, as in the eyelid or scrotum, as unsightly ecchymoses will result, which persist for some time. Leeches should not be used a second time. The Mechanical Leech. — The mechanical leech is an apparatus which has been con- structed to take the place of the leech ; it consists of a scarificator, cup, and exhaust- ing syringe or air-pump (Fig. 139). In using this apparatus, after the scarificator has been used the piston of the exhausting- instrument should be drawn out slowly, which secures a better flow of blood than if a sudden vacuum is created. The mechanical leech may be employed when the natural leech cannot be obtained, but possesses no advantage over the latter, and is apt to get out of order if not in constant use. Venesection. — Venesection, as its name implies, consists in the division of a vein, and it is the ordinary operation by which general depletion or bleeding is accomplished. Vene- section at the bend of the elbow is the operation which is now usually resorted to for general bloodletting ; the vein selected is the median cephalic, which is further from the line of the brachial artery than the median basilic vein (Fig. 140). To perform venesection, the surgeon requires a bistoury or lancet — the spring lancet was formerly much used, but it is not employed at the present time — several bandages, a small antiseptic dressing, and a basin to receive the blood. The patient's arm should carefully be cleansed, washed over with a bichloride solution, and a few turns of a roller-bandage placed around the middle of the arm, being applied tightly enough to obstruct the venous circu- lation and make the veins below become prominent, but not tight enough to obstruct the arterial circulation. The Mechanical leech. VENESECTION. 197 patient at the same time should be instructed to grasp a stick or a roller-bandage and work his fingers upon it. The surgeon should next assure himself that there is no abnormal artery beneath the skin, and having selected the vein, the median cephalic by preference, he steadies it with the thumb and passes the point of the bistoury or lancet beneath it and cuts quickly outward, making a free skin opening. The blood usually escapes freely, and the amount withdrawn is regulated by the condition of the pulse and the appearance of the patient. For this reason it is better to have the patient sitting up or semi-reclining when venesection is performed, as the surgeon can appre- ciate better the constitutional effects of the loss of blood while the patient is in this position. Fig. 140. Venesection. (Heath.) When a sufficient quantity of blood has been removed, the thumb is placed over the wound of the vein and the bandage removed from the arm above. The wound is next washed with a bichloride solution, and a compress of anti- septic gauze is applied over the wound and held in posi- tion by a bandage, which should be so applied as to envelop the limb from the fingers to the axilla. The dressing need not be disturbed for five or six days, at which time the wound is usually found to be healed. Wounds of the brachial artery have occurred in opening the veins at the bend of the elbow, but if care is taken, this accident should not take place. 198 MINOR SURGERY. Venesection may be practised on the external jugular vein when, from excess of fat or in the case of children, the veins at the bend of the elbow cannot be easily found. The vein is rendered prominent by placing the thumb or a pad over the vein at the outer edge of the stern o-cleido- mastoid muscle just above the clavicle. The vein is next opened over this muscle by an incision parallel to its fibres. After a sufficient quantity of blood has escaped, the wound is washed with an antiseptic solution and closed by a com- press of antiseptic gauze held in position by a bandage carried around the neck. The internal saphenous vein is also sometimes selected for venesection, and here care should be taken not to wound the accompanying nerve which lies directly behind the vein. Arteriotomy. — This operation is now scarcely ever per- formed; but if done, the vessel generally selected is the anterior branch of the temporal artery. The position of the vessel is fixed by the finger and thumb, and it is opened by a transverse incision with a bistoury. After a sufficient quantity of blood has escaped, the wound is in- spected, and if the vessel is not completely divided, its division is completed and the ends of the vessel should be secured with ligatures, and the wound irrigated with an antiseptic solution and closed with sutures. A gauze compress should next be applied and held in position by a firmly applied bandage. Transfusion of Blood. — This operation may be em- ployed to introduce a certain quantity of blood into the circulation of a patient who has suffered from profuse hemorrhage ; it is rarely employed at the present time, being almost entirely superseded by the intravenous in- jection or infusion of saline infusion. There are two methods by which transfusion may be effected : the direct, by which the blood is conveyed directly and without ex- posure to the air from the bloodvessel of one person to that of another ; and the indirect, in which the blood is first drawn from one person and is then injected into the veins of another, being deprived of its fibrin before being injected. INJECTION OF SALINE SOLUTION. 199 Arterial Transfusion. — This procedure, which con- sists in injecting defibrinated venous blood into an artery, is occasionally practised. An artery, usually the radial at the wrist or the posterior tibial behind the inner mal- leolus, is exposed and secured by a ligature ; it is then opened on the distal side of the ligature, and the point of a canula or the nozzle of a syringe is introduced, directed toward the distal extremity of the limb, and blood, which has previously been defibrinated, is slowly injected. When a sufficient quantity has been introduced, the canula is removed, the division of the artery is completed and its extremities secured by ligatures, and the wound is closed and dressed. Auto -transfusion. — This procedure is recommended in cases of excessive hemorrhage to support a moribund patient until other means of resuscitation can be adopted. It consists in the application of rubber or muslin band- ages to the extremities for the purpose of forcing the blood toward the vascular and nervous centres. INTRAVENOUS INJECTION OF SALINE SOLUTION. It has been proved by experiments and by clinical experience that human blood is not more efficacious in supplying volume to and restoring a rapidly failing circu- lation than normal salt solution, and as the latter can be obtained with much more ease than blood, its use has largely superseded the former. The solution should be at a temperature of 110° or 120° F. A vein of the patient, at the elbow, should be exposed, and should have placed under it, about one-half inch apart, two catgut ligatures ; the distal ligature is then tied and an opening is made into the vein between the liga- tures ; a canula is next inserted into the opening in the vein, and is secured in position by tying the proximal ligature. The canula is first filled with the saline solu- tion, and is then connected with a funnel by means of a rubber tube (Fig. 141), which is filled with saline solution 200 MINOR SURGERY. to displace the air, and upon raising the funnel above the part the solution enters the vein ; care should be taken to see that the funnel is kept well supplied with the solution until a sufficient quantity has been introduced. The quantity introduced is regulated by the condition of the patient's pulse. Saline solution may also be introduced into a vein by Fig. 141. Funnel and tube for intravenous injection. means of a syringe when the apparatus described cannot be obtained. Infusion of Saline Solution — Hypodermoclysis. — The introduction of saline solution into the cellular tissue has been followed by results equally as satisfactory as those obtained by intravenous injection, and this procedure is now very frequently employed. The saline solution is conveyed into the cellular tissue through a large hypodermic needle, which should be ster- ilized by boiling, and is then introduced into the connec- tive tissue, being previously connected by a rubber tube ARTIFICIAL RESPIRATION. 201 with a reservoir containing warm sterilized salt solution. The usual situations for the introduction of the solution are the external portions of the thighs and the anterior and lateral portions of the abdominal walls. As much as two or three pints of the solution are often introduced in this manner, with very satisfactory results. Infusion of saline solution may be used with most satisfactory result- in cases who have suffered from profuse hemorrhage, and has also proved of great service in cases of shock, and has a distinct value in the treatment of septicaemia. ARTIFICIAL RESPIRATION. This procedure is resorted to in cases of threatened death from apnoea consequent upon drowning, profound anesthetization, electric shock, or the inhalation of irre- spirable gases, or when from any cause there is interfer- ence with the function of breathing. Before resorting to artificial respiration, care should be taken to see that nothing is present in the mouth or air-passages which will obstruct the entrance of air into the lungs, such as mucus, foreign bodies, or liquids, and also that all tight clothing interfering with the free expansion of the chest-walls is removed from the chest. In cases where the apncea is due to the presence of a foreign body in the larynx or trachea, it is evident that no efforts at respiration can be successful until the air-pas- sages are freed from the occluding body; and if it cannot be removed through the mouth, tracheotomy should be performed before artificial respiration is attempted ; the tracheal wound should be held open by retractors, which in a case of emergency can be made from bent hairpins. or by a d re-sing*- forceps or a tracheotomy-tube, if one be at hand. W hen artificial respiration is resorted to, the operator should persevere with it for some time, even when no apparent spontaneous respiratory movements are excited ; for resuscitation has been accomplished in seemingly hope- 202 MINOR SURGERY. less cases by patient perseverance with the manipulations. When the first natural respiratory movement is detected, the operator should not cease making artificial respiration, but should continue these movements in such a way as to coincide with the spontaneous inspiratory and expiratory movements until the breathing has assumed its regular character. The temperature of the body should also be restored by friction to the surface by the hands or by rough towels and hot-water bottles, and warm coverings should be applied for the same object. Mouth-to-mouth Inflation. — This method of artificial respiration has been resorted to in cases of great emer- gency, especially in very young children. The operator draws the tongue forward, closes the nostrils, and applies his mouth directly to the mouth of the patient, and by a deep expiratory eifort endeavors to force air into the chest; when this is accomplished, the air can be expelled from the lungs by pressure upon the walls of the chest, and the procedure should be repeated about sixteen times in a minute. The same object may be accomplished by pass- ing a flexible catheter into the trachea through the mouth, and the lungs can be inflated by the operator blowing into the catheter. Direct Method of Artificial Respiration (Howard's). — This method of artificial respiration is at the present time considered the most efficacious, and is the one adopted by the United States Life-saving Service ; and although the rules given are for the resuscitation of cases of ap- parent drowning, the same procedures may be adopted in cases of apncea arising from other causes. The rules laid down by Dr. Howard are as follows : Rule I. — " To expel water from the stomach and lungs, strip the patient to the waist, and if the jaws are clenched separate them and keep them apart by placing between the teeth a cork or a small piece of wood. Place the patient face downward, the pit of the stomach being raised above the level of the mouth by a roll of clothing placed beneath it (Fig. 142). Throw your weight forcibly two or three ARTIFICIAL llKsl'IIlATIOS. •jn:i times upon the patient's back over the roll of clothing, s<> as to press all fluids in the stomach out of the mouth." Fig. 142. First manipulation in Howard's method. The first rule applies only to cases of drowning, and in using Howard's method in apnoea from other causes it is to be omitted. Ruh II— "To perform artificial respiration, quickly turn the patient upon his back, placing the roll of clothing beneath it so as to make the breast-bone the highest point of the bodv. Kneel beside or astride of the patient's hips. Grasp the "front part of the chest on either side of the pit of the stomach, resting the fingers along the spaces be- tween the short ribs. Brace your elbows against your sides, and steadily grasping and pressing forward and up- ward throw your whole weight upon the chest, gradually increasing the pressure while you count one — two — three. Then suddenly let go with a final push which springs you back to your" first position (Fig. 143). Rest erect upon your knees while you count one — two; then make press- lire as before, repeating the entire motions at first about four or fiye times a minute, gradually increasing them to about ten or twelye times. Use the same regularity as in blowing bellows and as seen in the natural breath- 204 MINOR SURGERY. ing which you are imitating. If another person is pres- ent, let him with one hand, by means of a dry piece of linen, hold the tip of the tongue out of one corner of the mouth, and with the other hand grasp both wrists and pin them to the ground above the patient's head." This method may be employed in cases of stillbirth, or in young children, the operator holding the body of the Fig. 143. Direct method of artificial respiration. child in his left hand and compressing it with the right hand. Silvester's Method of Artificial Respiration. — In employing this method of artificial respiration the patient should be placed on his back upon a firm flat surface ; a cushion of clothing is placed under the shoulders, and the head should be dropped lower than the body by tilting the surface on which he is laid. The mouth being cleared of mucus or foreign substances, the tongue is drawn for- ward and secured to the chin by a piece of tape tied around it and the lower jaw, or may be pulled out of the mouth and held by an assistant. The operator, standing at the patient's head, grasps the arms at the elbows and carries them first outward and then upward until the ARTIFICIAL RESPIRATION. 205 Fig. 144. Silvester's method— inspiration. (Esmarch.) Fig. 145. Silvester's method -expiration. (Esmarch. 206 MINOR SURGERY. hands are brought together above the head ; this repre- sents inspiration (Fig. 144) ; they should be kept in this position for two seconds, after which time they are brought slowly back to the sides of the thorax and pressed against it for two seconds ; this represents expiration (Fig. 145). These movements are repeated fifteen times in a minute until the breathing is restored or it is evident that the case is a hopeless one. Laborde's Method of Artificial Respiration. — Laborde has shown that systematic and rhythmic traction upon the tongue is a powerful means of restoring the respiratory reflex, and consequently the function of respi- ration. The procedure is accomplished as follows : The body of the tongue is seized between the thumb and fingers, and traction is made upon it with alternate relaxa- tion, fifteen or twenty times a minute, imitating the func- tion of respiration, taking care to draw well on the tongue. When a certain amount of resistance is felt, it is a sign that the respiratory function is being restored. Noisy respiration first occurs, termed by Laborde hoquet inspira- teur (inspiratory hiccough). Tongue forceps or dressing or haemostatic forceps may be used in place of the fingers to grasp the tongue. It is important to persist in the manipulations for half an hour to an hour, unless the case is absolutely hopeless. This procedure, which cannot be employed with advantage when there is fixation of the tongue from inflammation or malignant disease, has been employed with success in cases of drowning, toxic asphyxia, asphyxia during anaesthesia, and arrest of respiration from electric shock. Forced Respiration. — By this method of artificial respiration air is forcibly passed into the lungs. This procedure is strongly advocated by Fell, who has devised an apparatus by which it may be satisfactorily accom- plished. Professor H. C. Wood has also made use of forced respiration in the resuscitation of animals with an apparatus somewhat similar to that devised by Fell, with good results. Wood's apparatus consists of a pair of bel- lows, a few feet of rubber tubing and a face-mask of rubber, FORCED RESPIRATION. 207 and one or two intubation-tubes; the mask or intubation- tube is attached to one end of the rubber tube and the bellows to the other extremity. The mask is applied over the mouth, or, if this is not used, the intubation-tube is introduced into the larynx, and air is forced into the lungs by working the bellows. He also advises that in the tubing a double metal tube be introduced, with the openings so placed that their size can be so regulated by turning the outer tube that the operator can allow any excess of air thrown by the bellows to escape. Fig. 146. Fell's ajjparatus for forced respiration. The apparatus of Fell, which he has used in a number of cases with good results, consists of a mouth-mask or tracheotomy-tube, and a tube connected with the air-con- trol valve, which is attached to an air- warming apparatus, which in turn is connected with a bellows by another tube (Fig. 146). By means of this apparatus air is forced into the lungs, and allowed to escape, when the lungs have been expanded, by the elasticity of the lung tissue and the chest walls. Forced respiration has proved of value in cases of narcotic poisoning and other accidents in which death is produced by paralysis of the respiratory centres. 208 MINOR SURGERY. Aspiration. — This procedure is adopted to remove fluid from a closed cavity without the admission of air, and the instrument which is employed to accomplish this object is known as an aspirator. The form of aspirator most generally employed is that of Potain. Potain's Aspirator. — This consists of a glass bottle, into the stopper of which is introduced a metallic tube, which is connected with two rubber tubes, one of which is connected with an exhausting-pump, and the other with a delicate Fig. 147. Potain's aspirator. canula carrying a fine trocar ; the apparatus is provided with stop-cocks to prevent the admission of air (Fig. 147). In using this aspirator, the air is exhausted from the bottle by using the air-pump ; the canula enclosing the trocar is next pushed through the tissues into the cavity containing the fluid to be removed ; the trocar is then removed, and upon opening the stop-cock the fluid is forced out of the cavity by atmospheric pressure and passes into the bottle or receiver. If the fluid contains masses of lymph or clots which block the canula, inter- THE STOMACH-TUBE. 209 rupting the flow of fluid, a stylet may be passed through the canula to free it from the obstruction. To diminish the pain produced in introducing the trocar and canula, the skin at the point to be punctured may be rendered less sensitive by holding in contact with it for a few minutes a piece of ice wrapped in a towel, or a towel containing broken ice and salt. Care should also be taken to see that the trocar and canula have been perfectly steril- ized ; to accomplish this, they should be carefully washed and placed in boiling water or a 5 per cent, carbolic solu- tion before being used. In introducing the trocar and canula, the operator should be careful to avoid injuring important veins, arteries, or nerves. After removing the canula the small puncture should be dressed with a compress of antiseptic or iodoform gauze, held in place by a bandage or adhesive straps. The aspirator is frequently employed in cases of hydro- thorax, empyema, and ascites, to evacuate the contents of cold abscesses in diseases of the hip and spine, and to remove the contents of a distended bladder until a more radical operation can be performed. It is also a valuable instrument for diagnostic purposes, being frequently used to ascertain the character of the contents of deep-seated tumors containing fluid. The Stomach-tube. — This consists of a partially flexi- ble tube about twenty-eight inches in length and three- eighths of an inch in diameter, which is introduced while the patient is in the sitting posture, the head being thrown backward so as to bring the mouth and gullet as nearly as possible in the same line (Fig. 148). The tube being warmed and oiled, the surgeon standing in front of the patient passes it directly back to the pharynx, at the same time introducing the index-finger of the left hand to guide its point over the epiglottis ; it is then passed gently downward into the stomach. If any obstruction is met with in its passage, it should be withdrawn a little and then pushed gently downward ; all manipulations should be made without much force, to avoid perforating the wall of the oesophagus, u 210 MINOR SURGERY. The introduction of the stomach-tube may be required for the evacuation of poisons from the stomach or to wash out the cavity of this viscus. It may also be used to intro- duce liquid nourishment into the stomach of patients who are unable or unwilling to swallow food. In introducing liquid nourishment a syringe or funnel is fitted to the free end of the tube, which has been passed into the stomach ; the syringe or funnel having been filled with milk or beef- tea or broth, the contents are injected gently or allowed to run into the stomach. In cases of poisoning, where it is desirable to withdraw the contents of the stomach and to wash out the organ, a stomach-tube and syringe may be employed ; several syringefuls of warm water are first thrown into the stomach and then withdrawn by suction, but in such Fjg. 148. The stomach-tube. cases the use of the stomach-pump will be found more satisfactory. Lavage. — In the recently introduced method of treating disorders of the stomach and intestines by washing them out, the introduction of a flexible rubber stomach-tube is required ; the tube here employed is from twenty-four to thirty inches in length, and the fluid is introduced by means of a funnel attached to its free extremity, or it may be attached to a stomach-pump. The Stomach-pump. — This consists of a brass syringe, the nozzle of which is connected with two tubes, one at the end, the other at the side. The passage of fluid through the nozzle is regulated by a valve controlled by a lever. The nozzle of the pump is attached to a stomach-tube, and the end of the lateral tube is placed in a pan of warm water. By withdrawing the piston and opening the valve, water may be drawn from the basin, and by closing the valve and depressing the piston it is forced through the stomach- (ESOPHAGEAL BOUGIE. 211 tube into the stomach ; when a sufficient quantity has been injected in this manner, by reversing the action of the valve the fluid is drawn out of the stomaeh and dis- charged through the lateral tube into a basin. This manipulation is continued until the water returns clear and the stomach has been completely washed out. The stomach-pump shown in Fig. 149 may also be employed. Fig. 149. Stomach-pump. (Esophageal Bougie.— This instrument— which may be passed through the oesophagus into the stomach for the purpose of diagnosis or for the purpose of dilating strict- ures of the oesophagus — is employed in exactly the same manner as the stomach-tube, and, as in the case of the latter instrument, it should be introduced without the use of much force, as perforations of the oesophagus have fol- lowed the forcible introduction of such instruments. The Rectal Tube.— The introduction of the rectal tube is best accomplished by placing the patient upon his left side, and the surgeon should introduce his index finger well oiled into the rectum and guide the tube upon this through the anus, when by gentle pressure it is gradually passed into the rectum ; if a stricture exists in the rectum 212 MINOR SURGERY. within reacli of the finger, the latter should be used to guide the tube through the opening in this ; if the tube becomes caught in a transverse fold of the mucous mem- brane and doubles upon itself, it should be withdrawn and a fresh attempt made to pass it. In passing a rectal tube all manipulations should be made with extreme gentleness, as it has been shown that its passage is not without danger, perforations of the intestine having fol- lowed its use in some cases. In cases of stricture of the rectum high up, the operator has to depend upon the sense of resistance experienced in passing the tube, and in such cases the manipulations should be most carefully made. When the rectal tube is employed to introduce fluid into the large intestine, the fluid may be introduced by means of a syringe, or by pouring it into a funnel attached to the free end of the tube, or by attaching the tube to a fountain syringe, thus allowing the liquid to pass slowly into the intestine. The rectal tube is often employed with good results in relieving the intestine of excessive flatus, and in intro- ducing water or oil into the intestine in cases of intestinal obstruction, and in those cases where the obstruction results from intussusception or fecal accumulations its use will often prove satisfactory. Rectal Bougies. — These instruments are made of India- rubber or the same material as the English flexible cathe- ter, and are of various sizes. They should first be oiled, and are introduced in the same manner as the rectal tube. They are generally employed in cases of stricture of the rectum, and should be introduced with great care to avoid perforating the wall of the rectum ; this accident has occurred in the hands of skilful surgeons. A very satisfactory substitute for a rectal bougie is a tallow candle, one end of which is melted or rubbed down to a conical shape. Enemata. — These may be administered by means of an ordinary syringe, or by means of a gravity or fountain syringe ; the precautions which should be observed are to introduce the nozzle of the syringe gently and in the right VACCINATION. 213 direction, as perforation of the lower portion of the rectum has taken place from careless and Forcible introduction of the nozzle of the enema-syringe ; the fluid should also be injected slowly, as by so doing there is less resistance and less tendency for the patient to pass the fluid before the desired quantity has been introduced. The enema most commonly employed to empty the lower bowel is made by adding a tablespoonful of sweet oil and two teaspoonfuls of spirit of turpentine to one or two pints of warm water in which a little Castile soap has been dissolved ; warm water and sweet oil are also frequently used for the same purpose. Glycerin Enema. — One or two teaspoonfuls of glycerin injected into the rectum, or a suppository made of glycerin, will often be found an efficient substitute for the larger enemata of water. Nutritious Enema. — When it is found necessary to resort to feeding by the rectum, the substances employed should be injected into the rectum by means of a syringe, and care should be taken that the quantity is not too large, and that it is of such a nature as not to cause irritation of the walls of the rectum, or it will not be retained ; two to four ounces in the case of an adult is generally a sufficient quantity to inject at one time. Peptonized milk or beef-juice, or the yolk of an egg beaten up with milk, is often employed, and any unirri- tating drugs may be mixed with the enema and adminis- tered at the same time. Vaccination. — This is a minor surgical procedure which every physician is called upon to perform. The surface may be prepared for the reception of the lymph by abrad- ing the skin at one or two points with a dull lancet, or by making several superficial incisions with a knife, or by scratching the surface of the skin with the ivory point charged with lymph, in lines with crossing lines, cross- scratch, until a little serum exudes. It is not advisable to draw blood, which washes away the lymph, and for this reason we prefer the abraded surface made by the dull knife or the ivory point. 214 MINOR SURGERY. The lymph used may be the humanized or the bovine. Bovine lymph or virus, which is now most generally em- ployed, is taken from the vaccine vesicles upon the udders and teats of heifers. The lymph may be mixed with ster- ilized glycerin and placed in fine glass tubes, which are sealed ; or ivory points or quills are dipped in the lymph and allowed to dry, and in using these they are dipped in water for a moment, to moisten the lymph, before being applied to the abraded surface. The ivory-point is one of the most convenient means of vaccination, as the surface may be abraded with it before the lymph is applied. It has recently been advised that antiseptic precautions be exercised in performing vaccination, and although all of the details cannot be carried out, we have found that the exercise of care as regards cleanliness of the surface has been followed by much fewer inflammatory complica- tions in vaccination wounds. The surface to be abraded, usually the left arm below the deltoid, is first washed with soap and water, then with a 1 : 2000 bichloride solution, or with alcohol, and finally washed with sterilized water. Two points of this surface, an inch apart, are then abraded by using a knife which has been washed or dipped in boiling water, or by using the ivory-point which has been dipped in water that has been boiled and cooled. When the surface has been pre- pared in the manner described, the moistened virus is rubbed upon it and allowed to dry. Vaccination upon the leg, which is practised by some physicians to prevent the scar from showing, I think is not to be recommended, and I never practise it in this situation, as it is more diffi- cult to keep this part at rest. Hypodermic Injections. — The syringe used to make hypodermic injections is provided with a perforated needle, which is passed into the cellular tissue (Fig. 150). Care should be taken to see that the instrument and needle are perfectly clean before being used ; they should be rendered aseptic by soaking them for a few minutes in boiling water or in a 5 per cent, carbolic solution. Hypo- dermic injections are generally made into parts in which INJECTION OF ANTITOXINS. 215 the cellular tissue is abundant, and great care should he observed to avoid introducing the needle into a large vein or artery, as by neglect of this precaution serious symp- toms have resulted, from the drug being thrown rapidly into the circulation instead of being slowly absorbed from the subcutaneous cellular tissue ; injury of superficial nerves should also be avoided. Care should also be taken to see that the solutions employed are sterilized if possi- ble, and freshly made solutions should be preferred. To avoid using solutions for hypodermic use which undergo change in keeping, it will be found convenient to use the compressed pellets which are prepared by manu- facturing chemists, the alkaloids being compressed with a little sulphate of sodium, which increases their solubility, Fig. 150. Hypodermic syringe and needles. the solution being prepared with boiled water just before being used. The portions of the body usually selected for hypo- dermic injection are the outer surface of the thighs or arms and the anterior surface of the forearms. In making a hypodermic injection, the syringe is charged and the needle is fastened to the nozzle of the syringe ; the skin is next pinched up and the needle is quickly thrust through this into the cellular tissue (Fig. 151) ; the syringe is then emptied by pressing down the piston, and when the cylinder is empty the needle is withdrawn. Injection of Antitoxins. — In the treatment of diseases such as diphtheria and tetanus by the injection of serum, the hypodermic method is made use of; in using anti- toxin injections in diphtheria the dose of the antitoxin is proportionate to the age and weight of the patient as well 216 MINOR SURGERY. as to the severity and duration of the disease. A child three years old should be given 1000 units; an adult, not less than 1500 units, and the injection should be repeated in twelve to twenty-four hours. Before em- ploying the injection the skin should be sterilized, and Fig. 151. Method of giving a hypodermic injection. the best variety of syringe to employ is one holding about 20 c.c. (Fig. 152). It is well to have the needle connected with the syringe by a short rubber tube, so that the needle will not be broken if the patient struggles. The injections are usually made below the angle of the scapula or in the Fig. 152. H. K. MULFORD CO., PHILADA Syringe for serum-injection. lumbar region, and the serum is introduced slowly to avoid local reaction. Injections of Mercury in Syphilis. — Injections of mer- cury may be made into the subcutaneous tissue of the loins, buttocks, or scapular regions in the treatment of syphilis. Injections may also be into the veins. The solution most commonly used is a 1 per cent, solution of EXPLORING-NEEDLE. 217 the cyanide of mercury, 20 minims being injected every day or on alternate days. Exploring-needle.— This consists of a fine-grooved needle fitted into a handle (Fig. 153), which is introduced into tumors or swellings to ascertain the nature of their contents, and its use is often of service for purposes of Fig. 153. Exploring-needle. diagnosis. The exploring-trocar (Fig. 154) is employed for the same purpose, or the needle of the hypodermic syringe or a fine needle attached to an aspirator may be used for a like purpose. When either the exploring-needle or trocar is employed, care should be taken to see that it is rendered perfectly aseptic before being used ; otherwise its employment is not without danger, for we have seen the introduction of an exploring-needle into an effusion in a joint for diagnostic purposes followed by infection Fig. 154. Exploring-trocar. and destruction of the joint, which subsequently necessi- tated its excision. Skin-grafting. — This is a surgical procedure which may be employed to fill a gap in the tissues or to hasten cicatrization where large granulating surfaces are exposed, such as result from extensive operations and from burns. The operation consists in applying shavings of the epi- dermis, or of the epidermis and cutis together, to the granulating surface and holding them in contact with it for a few days ; the grafts often seem to disappear, but at 218 MINOR SURGERY. the end of a few days, if the part is closely inspected, bluish-white points will be seen to occupy the positions at which the grafts were applied, which become converted into isolated cicatrices from which the healing process rapidly extends. To have a successful result follow the use of skin-grafts, the surface of the ulcer should be healthy, and its surface as well as the surrounding skin rendered aseptic, and the grafts should be applied at a number of points. The surface from which the grafts are to be taken should also be rendered aseptic, and the skin should be removed by scissors or by a sharp razor, or by raising the epidermis with a needle or with forceps, and cutting out a small portion with a sharp scalpel. The graft is next applied to the granulating surface with its raw sur- face in contact with the granulations ; after a sufficient number of grafts have been applied, a piece of sterilized protective is laid over them and is held in place by means of a few strips of isinglass plaster. A sterilized gauze dressing is next applied, and the dressing is not disturbed for a week or ten days, at which time, if the grafts have taken, isolated cicatrices at the points where the grafts were applied will be found. Thiersch's Method. — In skin-grafting according to this method, the surface of the ulcer is rendered aseptic, and all antiseptics are washed away with sterilized salt solu- tion. The surface of the ulcer is next curetted to remove soft granulations, and it is then irrigated and covered with protective, and a compress applied to control bleed- ing. Shavings of skin are then removed from a surface — which has been rendered aseptic — by means of a razor or section knife ; the use of McBurney's hooks will facilitate the removal of the grafts. Each graft should be as long and broad as possible, and, when cut, it should be floated from the section knife upon the prepared surface of the ulcer by a stream of salt solution and gently pressed into place. After a sufficient number of grafts have been ap- plied, strips of protective are laid over the surface of the grafts, and over these is placed a compress moistened with BONE-GRA FTING. 219 salt solution and covered by protective, and a few la vers of sterilized gauze and cotton are next applied over this, and the dressing is held in position by a bandage. The dressings need not be removed for a week or ten days, and a second dressing should be applied in the same manner until the grafts have become thoroughly vitalized. The skin of the bellies or backs of frogs, or the hairless skin of young animals may be used in place of human skin. Krause's Method. — Skin-grafting is sometimes accom- plished by immediately applying an isolated piece of skin to a raw surface to fill a gap; the graft in such cases includes the whole thickness of the skin, but has all of the cellular tissue removed from it, and should be cut one-third larger than the gap to be filled, to allow for the shrinking after its removal, and is secured in position by sutures. Bone-grafting. — This procedure is resorted to to replace portions of bone which have been separated, to fill up cavities in bone, or to restore the continuity of the long bones. The bone to be introduced should be ren- dered thoroughly aseptic, and should be placed in a steril- ized salt solution at a temperature of 100° to 105° F.; it maybe inserted in one piece or broken into fragments and laid over the surface. AA hen it is desired to restore the continuity of one of the long bones, after the surfaces of the bone have been exposed and rendered aseptic a bone is removed from a freshly killed animal, is rendered aseptic, and fitted into the gap and secured to the ends of the bone by sutures. Or a portion of the bone may be partially separated by a chisel and fitted into the gap, or is split into strips and packed into the cavity. In the case of parallel bones, such as the tibia and fibula, where there has been a loss in substance of the tibia, the fibula has been divided on a line with the lower end of the tibia, and after freshening the end of the tibia the upper end of the lower fragment of the fibula is shifted over to the tibia and secured to it by sutures. 220 MINOR SURGERY. Bone-grafting may also be very satisfactorily accom- plished by means of Senn's decalcified bone plates or chips, which will be found useful in filling up the cavities result- ing from extensive removals of bone in the operations for necrosis or caries. In such cases, after the cavity has been sterilized, it is dusted with iodoform and is then packed with bone chips ; iodoform is next dusted over them and they are covered by a piece of protective. A compress of iodoform or sterilized gauze and bichloride cotton is next applied, and the dressing is held in position by a bandage. When bone plates are employed, they are cut to fit the cavity, and provision should be made for drainage. Preparation of Decalcified Bone Chips or Plates. — Take sections of the compact tissue of the fresh tibia or femur of an ox, several inches in length, remove the periosteum and medullary tissue, split in pieces one-half an inch in width, and place them in a 15 per cent, watery solution of hydrochloric acid, allowing them to remain in this for three weeks, changing the solution daily. At the end of this time they should be removed, thoroughly washed, and cut in thin strips or plates. They should then be washed in a weak solution of caustic potash, and placed for forty- eight hours in a 1 : 1000 bichloride solution. After this they may be kept in a solution of iodoform in ether, or in a 1 : 500 solution of bichloride in alcohol until required for use ; before being used they should be soaked in a 1 : 2000 bichloride solution. Muscle-grafting and nerve-grafting are also occasionally resorted to to supply deficiencies in muscles or nerves, fresh muscle or nerve tissue being employed to fill up the gap. Electrolysis. — Electrolysis, or the chemical decomposi- tion induced by electricity, is employed in surgery to de- stroy morbid products, tumors, or exudations. For this procedure, a galvanic or continuous-current battery is re- quired, which is provided with electrodes and needles of suitable shapes. In applying electrolysis to a tumor, for instance, the needle connected with one of the poles of the GA L VA NO-CA UTER Y. 221 battery is inserted into the tumor, and the other rheophore is applied to the surface of the body, or two fine needles, carefully insulated nearly to their extremities, are con- nected with both poles of the battery by conducting cords; these are introduced into the tumor and a weak current is allowed to pass. The strength of the current is gradually increased as the operation advances ; the current is passed for fifteen or twenty minutes, and the procedure is repeated at intervals of several days until some decided change occurs in the tumor. Electrolysis has been applied with success in the treat- ment of aneurism inaccessible to other operative proced- ures, in malignant growths, in nsevi, goitres, cysts, and hydatids. It is at the present time the most satisfactory method of removing superfluous hairs from those portions of the body in which their presence causes disfigurement. Galvano-cautery. — Gralvano-cautery batteries are con- structed with plates of large size, placed closely together, Fig. 155. Electrodes for galvano-cautery. so that the internal resistance is reduced and a current is quickly obtained which will keep a metallic electrode at a white heat. The advantage in the use of this form of cautery is that the electrode can be introduced into the cavities of the body while cold and quickly heated to the desired temperature. The electrodes are made of various shapes and sizes, according to the object desired (Fig. 155). The galvano-cautery is applied for the same purpose as the actual cautery ; but, as previously stated, its use is more convenient in the cavities of the body, its action can be more easily localized, and by its use 222 MINOR SURGERY. hemorrhage is avoided. It is frequently employed to destroy morbid growths in the nasal passages, the throat, vagina, or uterus, and also may be employed in the treat- ment of superficial external growths ; in using it for the removal of growths from the mucous membrane, its appli- cation may be rendered practically painless by previously thoroughly cocainizing the parts. Faradization. — The application of electricity in this form is often employed in surgical affections ; in cases of wasting of the muscles following fractures or sprains, in some forms of club-foot, and in lateral curvature of the spine the judicious use of the faradic current will often be found to be followed by the most satisfactory results. The current is applied in such a manner as to bring about contraction of the affected or wasted muscles, and thus improve their nutrition. Franklinization. — The earliest application of electricity in the treatment of disease was in the form of statical electricity, and although it fell into disuse, it has recently, with the perfection of modern machines, been widely re- vived. In applying statical electricity the patient may be treated by insulation, or the so-called dry electric bath. The second method of using statical electricity is by sparks or shocks from a Leyden jar, which is charged from the prime conductor of an electrical machine in motion, or by the electric brush. McClure states that in the static induced current we have a means of producing muscular contractions when failure results from the strongest faradic currents that can be borne by the patient. The CystOSCOpe. — This is an instrument employed for ocular examination of the walls of the bladder, and is one of the most important and useful of the electric-lamp instruments. A cystoscope consists of a beaked sound in which there is a telescopic arrangement, by which the inner surface of the bladder is viewed through a small window of rock crystal. The lamp is enclosed in the beak of the instrument and throws its light through another window, also of crystal, upon any part of the bladder wall. The bladder should contain six or eight ounces of clear urine THE URETHROSCOPE. 223 or dear water if a proper view of the walls is to be ob- tained. If the fluid is turbid or contains blood, the view is very much obscured; if too little fluid be present in the bladder, the beak of the instrument containing the lamp is likelv to become buried in the folds of mucous mem- brane and the light will be cut off, and the mucous mem- brane may be burned. The bladder may be emptied of urine and' distended with air which accomplishes the same purpose. A certain amount of practice is required to use the cystoscope properly and to recognize the appearance Fig. 156. Illumination of the wall of bladder by cystoscope. (Park.) of the mucous membrane of the bladder in health and in its varied morbid conditions. The Urethroscope. — The urethroscope consists of a straight metal tube provided with an obturator of hard rubber, which projects slightly beyond the end of the tube. This tube is introduced into the urethra until the bladder is reached, when it is slightly withdrawn and the obturator removed. The instrument is then attached to the mirror of an electric lamp, by which a strong light is thrown into the tube, and as the tube is withdrawn the urethra is ex- 224 MINOR SURGERY. posed to view. By means of the urethroscope a very accurate inspection of all portions of the urethra can be obtained. Fig. 157. The urethroscope. The Panelectroscope. — This instrument, introduced by Leiter, consists of an electric lantern, with tubes and a mirror. The light from a small incandescent lamp is projected by the mirror along the tube, which is inserted into the part to be examined. Tubes of various sizes are adapted to the instrument. It is employed for" endoscopy of the urethra, ear, pharynx, and stomach. MASSAGE. Massage consists in a variety of manipulations, such as pinching up the integument and muscles, and rolling them between the thumb and fingers ; in stroking or rub- bing the surface with the palm of the hand from the periphery toward the centre, to empty the distended veins and lymphatics ; rubbing the parts circularly with the extremities of the fingers and thumbs or the palms of the hands. Kneading of the parts is another method of practising massage. Massage may also be practised by tapping the surface of the affected part more or less forci- COMPRESSION. 225 l>lv with the tips of the fingers held in a row, or with the ulnar border of the hand or the palm of the hand. Before applying massage to an affected part, if there be a heavy growth of hair, it should be shaved off; otherwise the manipulation may give the patient pain, and irritation of the hair-follicles resulting in abscesses will be apt to occur. The part should also be rubbed over with olive oil, vase- line, or cacao-butter before and during the manipulations. Massage is employed often with advantage in the treat- ment of Sprains and strains in their subacute and chronic stages. Lucas-Championniere advocates and practises immediate and continuous massage in the treatment of fractures. It will also be found of great service in the later treatment of fractures involving the joints or their vicinity, in restoring the motion of the parts as well as in improving the nutrition of muscles which have become wasted from disuse. Passive Motion. — This manipulation consists in alter- nated flexing and extending or rotating the limb, to imi- tate the normal joint-movements. The motions should be carefullv practised, and in cases of fracture they should not be undertaken, as a rule, until there is firm union at the seat of fracture ; if for any reason passive motion is made use of before this time, the fragments should be firmly supported while it is being employed. Other forms of massage, such as stroking and kneading, may be employed in conjunction with passive motion in the treatment of the stiffness of joints resulting from fractures, dislocations, and sprains ; passive motion applied in this manner will often restore the function of a stiff joint more satisfactorily and with less pain to the patient than the forcible manipu- lations which are sometimes practised under an anaesthetic. Compression. — This is a valuable means of dimin- ishing swelling in the early stages of inflammation, and of bringing about absorption of the effusion in the later stages. It" may be applied by means of compresses, bandages, or strapping. Pressure applied in this manner is often emploved in the treatment of injuries of the joints and bursa?, and in chronic inflammatory swellings. 15 226 MINOR S URGER Y. It should be used witli caution when the circulation in the tissues is impaired. Application of Hot Air. — The employment of a con- tinuous hot-air bath has recently been advocated in the treatment of painful and partially anchylosed joints, synovitis, teno-synovitis, and chronic rheumatism. In applying this method of treatment, the limb is wrapped loosely in lint and introduced into a metallic cylinder (Fig. 158), the temperature of which is raised to about Fig. 158. Apparatus for hot-air treatment. 300° F. The part is exposed to this temperature for three-quarters of an hour to one hour, and at intervals of twenty minutes the door is opened for a short time to allow the ingress of fresh air; if the part is perspiring, it is wiped dry, for if moisture is present upon the limb burns are likely to result. Under this form of treat- THE ( 'L INK I I L THERMOMETER. 227 ment pain is often temporarily or permanently relieved, synovial effusions absorbed, and adhesions are softened and disappear. Clinically it has been found that the best results following this method of treatment have occurred in painful and anchylosed joints following traumatisms; and although temporary improvement has occurred in rheumatic, gouty, tuberculous, and gonorrheal affections of joints, permanent improvement is not so likely to result. The Clinical Thermometer. — For clinical observa- tions two thermometer scales are in general use, the centi- grade and the Fahrenheit; the latter is the one commonly employed in America and in England. This scale has a limited range above and below the normal bodily tem- perature, ' which is 98.4° Fahrenheit or 36° centigrade. Thermometers are now made with a convex surface, which Fig. 159. T- ■ i r .,....,,... |....|. Mao 9 5 100 5_- - 110 Clinical thermometer. serves to magnify the column of mercury, and thus enables the observer without difficulty to note the position of the index (Fig. 159). The temperature of the body may be taken in the mouth, axilla, vagina, or rectum ; the two former loca- tions are those generally selected. When taken in the axilla, care should be exercised to see that no clothing is interposed between the skin and the instrument ; and when the mouth is used for thermometric observations the patient should be instructed to keep his lips tightly closed and breathe through his nose. The thermometer should be kept in place for from three to five minutes. Surface thermometers are sometimes employed, the instruments for this purpose having bulbs of a discoid shape (Fig. 160), or being drawn out in the form of a spiral or coil. In using this form of thermometer to de- termine the amount of variation of the surface tempera- 3 228 MINOR SURGERY. Fig. 160. Surface thermometer ture, the temperature of corresponding parts of the body on the opposite side and the general temperature of the body should be taken at the same time. SKIAGRAPHY, OR EMPLOYMENT OF THE RONTGEN RAYS. Rontgen, in 1895, while investigating the cathode rays as developed in Crookes's tubes, discovered the energy Fig. 161. Apparatus for taking skiagraphs. (Paek.) which he named a-rays. The rays are invisible, but have great power of penetration, and pass through many sub- stances which are opaque to sunlight and ordinary electric lia;ht. If the rays are intercepted by a body not readily permeable, which is placed between the Crookes's tube and SKIAGRAPHY. 229 a dry photographic plate, a shadow will be formed, and an impression of this shadow will be funned upon the plate. Such a shadow is known as a skiagraph. The fluoroscope consists of a fluorescent screen, which is so placed that the rays emanating from the Crookes's tube and passing Fig, 162. Skiagraph of fracture of both bones of the forearm. through any intercepted substance to be studied are re- fleeted directly upon it. If the body is more or less re- sistant, the observer can see it clearly through the skin and subcutaneous tissue. The time of exposure to the rays varies with the strength 230 MINOR SURGERY. of the current and the thickness of the tissues. The ex- posure is usually from three to fifteen minutes. The tube should not be placed too near the surface of the body, and the exposures should be as short as possible. Fig. 163. Skiagraph of bullet in knee-joint. (Willard.) There occasionally develops after the use of the #-rays a peculiar disturbance of the tissues, probably trophic in nature, which is known as an .T-ray burn. The skin, several weeks after exposure to the rays, may become ulcerated, the nails may be lost, and a very intractable form of ulceration or gangrene develop. SKIAGRAPHY. 231 The awraysare of great value in locating foreign bodies, such as needles, pins, bullets, and pieces of glass. They are employed also with advantage in locating mineral cal- culi in the Madder, ureter, and kidney. They are also Fig. 164 Skiagraph of fracture of tibia and fibula. useful in detecting the presence of fractures and disloca- tions. In fractures about the joints, epiphyseal separa- tions, and ununited fractures, their use has proved most satisfactory. Skiagraphs of a fracture are shown in Figs. 162 and 164, of a bullet in the knee-joint in Fig. 163, 232 MINOR SURGERY. Fig. 1G5. Skiagraph of separation of upper epiphysis of the humerus. and of an epiphyseal separation of the humerus in Fig. 165. ANESTHETICS. Anaesthesia may be local, regional, or general. Local Anaesthesia. — This results from the direct appli- cation of anaesthetic agents to nerve-terminations, and causes analgesia of the tissues to a limited extent only. It may be produced by the use of cold, a spray of ether, rhigolene, ethyl chloride, cocaine or eucaine hydrochlo- rate, holocaine hydrochlorate, guaiacol, or by Schleich's method of infiltration. Regional Anaesthesia, — This is also sometimes described ANAESTHETICS. 233 as neural anaesthesia, and results from the application of anaesthetic agents to the nerve-rootSj nerve-trunks, or the spinal curd. The analgesia in this form of anaesthesia extends from the point of application to the tissues sup- plied by the nerve or nerves, and therefore is not limited in extent. General Anaesthesia.— This is characterized by un- consciousness, as well as abolition of sensation, and may be induced by the administration of nitron- oxide gas, ether, chloroform, bromide of ethyl, A.-C.-E. mixture or Schleich's anaesthetic mixture. It may also be induced by a combination of these substances with nitrous oxide gas or oxygen. Hypnotism may also be employed to produce general anaesthesia. Local Anaesthesia. Cold. — Local anaesthesia may be produced by the appli- cation of cold, either by a piece of ice or a mixture of ice Fig. 166. Application of rhigolene spray. and salt held in contact with the part for one or two min- ute-, or by directing a spray of rhigolene or sulphuric ether upon the surface of the part whose sensibility is to be obtunded (Fig;. 166). Chloride of Ethyl.— This substance is used also to produce local anaesthesia, and is conveniently furnished in glass tubes, one end of which is drawn out into a line 234 MINOR SURGERY. point and hermetically sealed. When used, the end of the tube is broken off and a fine jet of ethyl is projected upon the part to be anaesthetized, the warmth of the hand being sufficient to force the fluid from the tube. This form of local anaesthesia is made use of in minor surgical pro- cedures, such as aspiration, the opening of abscesses, and the removal of superficial tumors. Rapid Respiration. — Rapidly repeated deep inspira- tions kept up for a few minutes will produce insensibility to pain, but sensibility to contact is not obliterated. This form of anaesthesia may be made use of in slight opera- tions, such as opening an abscess. Cocaine. — Local anaesthesia produced by the employ- ment of an aqueous solution of the hydrochlorate of cocaine, in strength from 1 to 2 per cent., is often made use of in minor surgical procedures. Solutions as strong as 10 or 12 per cent, were formerly employed, but experi- ence has proved that there is always danger in the use of the stronger solutions of cocaine, so that it is now con- sidered wise not to use one stronger than 1 or 2 per cent., as the full analgesic effect can be obtained by a solution of this strength. When mucous membrane is to be oper- ated upon or growths removed from it, analgesia is pro- duced by brushing: over the surface with the solution of cocaine, or by applying to the part for a few minutes a compress of absorbent cotton saturated with it; in mucous cavities the latter method of application will be found most convenient. In using a solution of cocaine to pro- duce anaesthesia in operations upon the eye, a 2 per cent, solution is dropped into the eye, and is repeated until analgesia is complete. In applying cocaine to the urethra, a 1 to 2 per cent, solution is injected, and is allowed to remain for two or three minutes; more than 1 or 2 grains should not be injected at one time, as fatal results have followed the injection of larger quantities ; this is especially the case in using cocaine in the urethra and the rectum, and in these situations great caution should be exercised in its employment. ANESTHETICS. 235 When it is desired to produce local anaesthesia of the skin or deeper tissues, the application of cocaine to the surface is not satisfactory, and it should in such cases be injected hypodermically into the deeper layers of the skin and into the cellular tissue of the parts to be operated upon ; to avoid multiple punctures, the needle is not com- pletely withdrawn from the wound, but its direction is changed and the solution is thrown into different portions of the tissues. It is well, in situations where it can be accomplished, to cut off the circulation from the part to be operated upon by placing around it a rubber strap or tube, which prevents rapid absorption of the cocaine into the general blood-current. Corning recommends injection of cocaine by the gal- vanic current. The skin of the region to be anaesthetized is perforated by a number of fine needles, and the perfor- ated area is covered with several thicknesses of flannel cloth saturated with a 5 per cent, solution of cocaine. A layer of potters' clay of the consistence of bread-dough, containing a thin sheet of copper, is placed upon the flannel, and the copper plate connected by an insulated wire with the positive pole of a galvanic battery. The negative pole should consist of a broad, flat sponge wrung out in hot water and held as near as possible to the posi- tive pole without touching it. The more extensive the surface to be anaesthetized the stronger should be the cur- rent. From three to six cells may be used, and the time required is from ten to twenty minutes. Some persons have an idiosyncrasy for cocaine, and children seem more susceptible to its constitutional effects than adults. I have seen several instances in children in which marked symptoms of cocaine poisoning resulted from the application of a 4 per cent, solution to the nasal mucous membrane. The treatment of cocaine poisoning consists in placing the patient in the recumbent position and the hypodermic injection of morphine, strychnine, or ether. Cocaine anaesthesia may be employed with advantage in minor surgical operations, such as amputations of the 236 MINOR SURGERY. fingers, circumcision, opening of abscesses, and removal of superficial tumors, but its utility is most marked in operations upon the eye and upon the mucous membranes of the nose, throat, rectum, vagina, and urethra. Applied for a few minutes to the surface of an ulcer which is to be cauterized, it will render the operation almost painless. Eucaine Hydrochlorate. — This drug, which possesses the same properties as cocaine, as regards the production of analgesia, is employed as a local application to mucous surfaces, and hypodermically in the deeper tissues to pro- duce local and regional anaesthesia. It has the advantage over cocaine that it can be used with safety in much larger quantities, as it is apparently free from toxic action. Kiessel states that 2 grammes have been injected without the production of toxic symptoms. It may be used in solutions varying in strength from 2 to 10 per cent., which may be sterilized by heating ; a 2 per cent, solution is that most usually employed hypodermically. Holocaine Hydrochlorate.— This drug/ used in a 1 per cent, solution, possesses as decided analgesic action as cocaine ; it is also strongly bactericidal in its action. It may be used locally without producing constitutional symptoms, but cannot be used internally or injected into the tissues, on account of its marked toxic action. Guaiacol. — This drug may be used for its analgesic effect, and is employed in a solution of guaiacol, grains xv ; alcohol, 3v ; or in the form of an ointment of guaiacol, 5 parts, to vaseline, 30 parts ; or it may be used hypoder- mically in a one-tenth or one-twentieth solution in olive oil. Its hypodermic use is not unattended with danger. Infiltration Anaesthesia. — It has been shown by Lie- breich that the injection of simple water into the tissues in such a way as to produce an artificial cedema induces a transitory anaesthesia. Schleich found that the combination of a minute quan- tity of cocaine and morphine with a weak salt solution, when injected hypodermically, produced a local anaesthesia of longer duration. The anaesthesia is produced by the artificial ischaemia, AN&STHETICS. SM by the pressure of the injected fluids upoD the nerves, and by the direct action of the anaesthetic substances on the nerves. A solution of 1 part of cocaine to 1000 parts of steril- ized water may be used, or the following solution may be employed : Cocaine liydrochlor gr. iss. Morphia? hydrochlor gr. £. Sodii chloridi gr. iij. Aquae dest o n J S;? - The injection should first be made into the substance of the skin itself, and then into the cellular tissues and deeper structures, as desired. Barker recommends the following solution for obtain- ing infiltration anaesthesia : eucaine, 1 part to 1000 parts of sterilized water, with 8 parts of chloride of sodium. He also recommends elastic constriction applied above the part, as a means of increasing the action of the drug. Solutions with the same freezing-point as the normal fluids of the body should, if possible, be used, as they are in- different to the tissues — that is, they possess no osmotic action. Infiltration anaesthesia has widely been employed in minor surgical operations, and also may be employed in major operations, such as herniotomy and amputations, when for any reason a general anaesthesia is not desirable. In children and nervous subjects it cannot be employed with advantage. It also has the disadvantage of causing swelling and oedema of the tissues at the seat of operation, which often interfere with the satisfactory recognition of the various anatomical structures. Eegional Anaesthesia. This method, sometimes described as neural aruzsth consists in bringing anaesthetic drugs in contact with nerve-trunks at some distance from the field of opera- tion, with the view of causing analgesia in the tissues 238 MINOR SURGERY. supplied by them. For instance, in a proposed operation upon the leg, the injection would be made near or into the anterior crural and sciatic nerves. Cocaine, eucaine, or Schleich's solution may be employed for the pur- pose. The nerves may be anaesthetized by the paraneural method, which consists in injecting the solution in the vicinity of the nerve-trunk as near as possible to the nerve ; or by the direct intraneural method, which con- sists in producing anaesthesia of the skin and cellular tissue, and then exposing the nerve-trunks by dissection and injecting the solution directly into them by passing the needle into their substance. This method of anaesthesia has been employed with success both in minor and major surgical operations, such as the reduction of herniae, amputations, and the removal of tumors, and is especially applicable in operations upon the extremities. Spinal Subarachnoid Injection. — As the result of the work of Corning, Bier, and Tuffier, anaesthesia by means of spinal subarachnoid injection of cocaine or eucaine has recently been employed with satisfactory results. At the present time this method of anaesthesia is resorted to only in operations upon that portion of the body below the diaphragm, and injections are made into the spinal canal in the lumbar region. Fifteen to 20 minims of a 2 per cent, cocaine or eucaine solution are usually sufficient to produce satisfactory anaesthesia. The technique of the operation is as follows : The entire lumbar and sacral regions should carefully be sterilized, and the position of the third lumbar interspace — that is, the space between the third and fourth lumbar vertebrae — located. The patient next sits astride of the operating-table and bends forward in the position of ventral flexion, with his elbows resting upon his knees, which widens the space between the third and fourth lumbar vertebrae. A few drops of cocaine or eucaine are next injected into the skin over the centre of this space. A needle between 1 and 2 milli- metres in circumference, and about 8 centimetres in length, attached to a syringe, is next inserted through the skin mid- ANAESTHETICS. 239 way between the spinous processes, or a puncture by a tenotome may be made through the skin, and the needle inserted through this. The needle and syringe should be thoroughly sterilized by boiling before being used. The needle should be pushed forward and a little to the left, to cause it to enter the spinal canal in the median line, and as soon as resistance disappears and fluid appears in the syringe it is evident that the canal has been entered. After a few drops of fluid have escaped, the syringe is removed from the needle and replaced by one containing the anaesthetic solution, and 15 to 20 minims of the solu- tion are injected into the spinal canal. The needle is then removed and the puncture sealed with a small piece of gauze and collodion, and the patient placed in the recum- bent posture. In a few minutes anaesthesia is usually sufficiently advanced for the operation. Subarachnoid spinal injection should not be employed in children, nor in nervous and excitable patients, but may be employed in cases where for any cause a general anaesthetic is contraindicated. This method of anaesthesia has been employed success- fully in a great variety of operations, and up to the present time few fatalities have been reported as the re- sult of its use ; but it should be remembered that the pro- cedure is still on trial, and that sufficient time has not elapsed to show the ultimate result of the injections. A more extended use of the method alone can prove that it is safer than the general anaesthetics now employed. The restriction in its use to operations in certain parts of the body also renders it difficult to estimate its comparative safety. General Anaesthesia, General anaesthesia may be produced by the adminis- tration of nitrous oxide gas, ether, chloroform, A.-C.-E. mixture, Schleich's mixture, or ethyl bromide. Choice of Anaesthetic. — In selecting an anaesthetic, the most important considerations are its safety and its suita- bility to the individual case. In point of safety, nitrous 240 MINOR SURGERY. oxicle gas holds the first place ; but, unfortunately, its use is restricted to cases in which only a few minutes* anaes- thesia is required. Statistics show that the mortality fol- lowing the administration of nitrous oxide is about 1 to 5,250,000; of ether, 1 to 16,675; of chloroform, 1 to 3749. Gardner's statistics show that in 22,219 chloro- form administrations there were 14 deaths ; while in 17,067 administrations of ether or nitrous oxide gas and ether, there was 1 death. It should be remembered, how- ever, that both ether and chloroform are employed in the most serious surgical procedures, while nitrous oxide gas is used only in trivial operations, so that many of the deaths attributed to ether and chloroform may have been due to conditions resulting from the operations. Nitrous Oxide Gas. — Nitrous oxide causes anaesthesia by arresting the oxygenation of the blood while it is in contact with it, and, in addition, the gas produces anaes- thesia by direct action on the cerebral cortex. Nitrous oxide gas is contraindicated in alcoholic subjects, or in those having marked atheroma of the arteries, as apoplexy may occur, or in any condition of obstructed respiration. The apparatus best suited for its administration consists of a cylinder of metal in which the gas is compressed, which is attached to a rubber bag, which has a mouth- piece fastened to it ; this is provided with a double valve, which prevents the expired air from passing back into the bag. The mouthpiece is adjusted over the mouth, and after removing any false teeth or foreign bodies from the mouth, the patient is instructed to take deep, full breaths, and in from one-half to one minute the face becomes congested and dusky and the breathing becomes stertorous, indicating that the patient is fully under the influence of the gas. The anaesthesia from nitrous oxide cannot be prolonged for more than a few minutes, so that it can only be employed in operations Avhich take a short time for their performance, such as the extraction of teeth and the opening of abscesses. Unfortunately, it cannot be used in the reduction of fractures or disloca- tions, as it does not produce complete muscular relaxation. ANJESTHETH S 241 In England nitrous oxide is frequently used to produce anaesthesia, and when this result is accomplished the anaes- thesia is kept up by the administration of ether by the employment of a special apparatus devised for this pur- pose. ' Nitrous oxide gas is commonly employed in dental surgery to produce anaesthesia for the removal of teeth, but is also occasionally employed in minor surgical opera- tions ; but from the 'fart that the apparatus for its ad- ministration is a bulky one, its use is not so convenient as ether or chloroform, and in this country it is not much employed in general surgery. Nitrous oxide gas may also be administered by the open method, or by an open 'inhaler resembling that of Allis. The °;as, being heavier than the air, is introduced into the inhaler and falls to the bottom. Flux, who has employed this method of administration in a number of cases, claims that by its employment excitement, stertor, lividity, strug- gling, 'and convulsive movements are done away with. ' Nitrous Oxide Gas and Oxygen.— The administration of nitrous oxide gas with oxygen has been found by Hewitt to diminish the asphyxial symptoms, so that a more pro- longed and tranquil anaesthesia can be safely obtained. The anaesthetic state is not produced as rapidly as by nitrous oxide gas alone, but it may be prolonged by a skilful anaesthetizer for an hour or more. It is administered by a special apparatus, by which the administrator can increase or diminish the amount of oxygen, according to the symp- toms presented. Cyanosis, stertor, and muscular twitching call for an increase in the oxygen, whereas symptoms of excitement call for its diminution. In children and in aged and anaemic subjects the amount of oxygen may be increased rapidly ; whereas in strong, full-blooded subjects the quantitv of oxvgen should be increased cautiously. Ether.— Sulphuric ether is one of the most widely em- ployed substances in surgery to produce anaesthesia ; rt is probably the safest of airanaesthetics, except nitrous oxide gas, and for this reason should be preferred to all others. Its effects, according to Hare, result from the action of the drug, first, on the brain, then on the sensory tracts of the 16 242 MINOR SURGERY. spinal cord, then on the motor tracts, then on the sensory side of the medulla oblongata, and finally upon the motor side of the medulla, and thereby produces death from res- piratory failure if given to excess. Its administration is attended with risk in the following cases: (1) In infants, in whom it causes irritation of the bronchial mucous mem- brane, with profuse secretion of mucus, and may cause also bronchopneumonia. (2) In aged persons a profuse secre- tion of mucus and bronchopneumonia may follow its use ; it is also contraindicated in these subjects in whom there are rigidity of the chest and lessened respiratory power. (3) In advanced organic disease of the kidneys, and especially in nephritis of the interstitial form with urine of a low specific gravity and in diabetic subjects. (4) In disease of the heart its administration is more dangerous in myocardial than in valvular lesions. (5) In cases of obstructed respiration from swelling of the pharynx, fixa- tion of the tongue in cancer and cellulitis of the neck, and in emphysema and abdominal distention. (6) In cases in which examination of the blood shows that the haemoglobin is diminished to less than 50 per cent. (7) When the bronchial irritation following its use may impair the re- sult in operations for hernia and in laparotomy. Preparation of Patient. — A patient should be prepared for the administration of ether by withholding all solid food for at least six hours before its inhalation ; he should be in the recumbent posture, and any garments about the chest or neck should be loosened, so that the respiratory movements are not interfered with. The surgeon should see also that any false teeth or foreign bodies which may be present in the mouth are removed before the adminis- tration of the drug is begun. As the vapor of ether often causes irritation of the mucous membrane of the lips and nasal passages, it is well to anoint these parts with a little vaseline or cold-cream before administering the ether. Some surgeons recommend that the stomach, if it con- tains food, should be washed out by means of the stomach- pump, and insist upon this washing before operation in cases of intestinal obstruction, as the stomach may con- ANAESTHETICS. 243 tain stercoraceous matter, which may be drawn into the respiratory passages if vomiting occurs, and so cause aspi- ration-pneumonia. It should also be borne in mind that the vapor of ether is very inflammable, and that it is heavier than the air, so that lights brought near the patient while being etherized should be held at a higher level than the ether-can or inhaler. The anaesthetizer should always listen to the patient's heart before giving an anaesthetic; this enables him to detect any irregularity in its action, and at the same time has a good moral effect upon the patient, especially if he can assure him that he is in good condition to take the anaesthetic. It is Avell also to have another physician present during the administration of a general anaesthetic, as unforeseen difficulties occasionally arise. There should always be at hand tongue-forceps and instruments with which trache- otomy may be performed if necessary ; also nitrite of amy], digitalis, strychnine, and a hypodermic syringe. In debilitated patients or in those who are weak from loss of blood the administration of half an ounce to an ounce of whiskey from fifteen to thirty minutes before the anaesthetic is given is often advisable. The person intrusted with the administration of the anaesthetic should watch the patient closely, and should not have his attention diverted by the operation ; he should carefully observe the pulse, respiration, and color of the patient's face, and be prepared to withdraw the anaesthetic upon the development of any symptom of danger, and to treat such symptoms should they arise. An anaesthetic should never be given to a woman with- out the presence of a third person, as in some cases these agents give rise to erotic dreams, and it may be difficult to disabuse the patient's mind of the idea that an assault has been committed unless the evidence of eye-witnesses at the time of the anesthetization can be brought forward to prove that such was not the case. Ether produces more irritation of the respiratory tract 1244 MINOR SURGERY. Fig. 167. than chloroform, and its administration is sometimes fol- lowed by the development of bronchitis, pulmonary con- gestion, or pneumonia. These complications are less likely to occur if care is taken to avoid the administration of ether in patients who are suffering from bronchial irrita- tion, and to see that a patient who has taken ether is not exposed to draughts and is not allowed to go out into cold or moist air immediately after recovering from the anaesthetic. Administration of Ether. — In the administration of ether, a towel folded into a cone or one of the various ether inhalers may be employed. The best of these is Allis's inhaler, which consists of a metallic framework covered with leather or a nickel- plated case, which carries a number of folds of a roller- bandage, giving a large sur- face for the rapid evapora- tion of the drug (Fig. 167). If a towel folded into a cone is used ; a few layers of stiff paper interposed between the outer layers of the towel will keep the cone in shape and prevent evaporation of the ether from its external surface. For the administration of an anaesthetic, the patient should be in the recumbent posture and the head turned to one side, as in this position mucus is less apt to collect in the pharynx and interfere with the breathing. In administering ether, two to four drachms are poured into a cone or inhaler and placed over the nose and mouth of the patient. He is then requested to take deep breaths, or to blow the ether away, which latter procedure causes him to take deep inspirations. In the beginning of ether- ization the patient will resist the inhalation much less vigorously if the ether is given slowly with a plentiful ad- Allis's ether inhaler. A2UESTHETICS. 245 mixture of air. The first effect of the inhalation of ether is to produce acceleration of the pulse and respiration ; the mucous membrane of the air-passages is irritated, and coughing often occurs; there is also in this stage a dispo- sition to muscular movements, and it is frequently neces- sary to restrain the patient; the brain also is excited, and the patient is apt to cry out. These symptoms call for a continuance of the administration of the ether, and not for its withdrawal. To avoid the irritation of the mucous membrane of the air-passages during the administration, it has been suggested that the nasal mucous membrane be CO sprayed with a 2 percent, solution of cocaine just before administration of the anaesthetic, and this spraying should be repeated every half hour while the anaesthetic is used. By the use of cocaine in this manner, the nasal reflexes are diminished, the stage of excitement is shortened, the sense of suffocation is diminished, and vomiting is less likely to occur. Succeeding the stage of excitement, if the ether be pushed, profound anaesthesia takes place, as is evidenced by the loss of consciousness, relaxation of the muscular system, moist skin, loss of special senses, contracted pupils, and slow and deep respiration, tend- ing to become stertorous. "When the conjunctiva is in- sensitive to the touch of the finger, anaesthesia is usually profound. When the anaesthesia is complete, the amount of ether inhaled should be diminished, and the patient given only so much as will keep him well under its influ- ence. It is surprising how small a quantity a careful and watchful anaesthetizer will require to keep the patient fully under its effects for a considerable time. The time required to produce anaesthesia varies in different cases : it is produced in children in a few minutes ; in adults from ten to twenty minutes are usually required ; drunk- ards and those who have taken ether frequently require a larger amount and a longer time to come under its in- fluence. After the administration of the drug is stopped, the patient may continue for some time in an unconscious condition, resembling a quiet sleep, or he may awake and exhibit more or less symptoms of cerebral excitement. 246 MINOR SURGERY. First Insensibility from Ether. — There often exists in the early course of the administration of ether a stage of primary anaesthesia, which lasts for a minute or more, and which may be taken advantage of to perform such a minor surgical operation as opening an abscess, reduction of a dislocation or a fracture, or extraction of a tooth. The recovery from this condition is usually very prompt, and is not followed by nausea or the after-effects which attend the prolonged administration of ether. Accidents during Etherization. — During the administra- tion of ether, particularly in the early stage, the patient may suddenly stop breathing, the face at the same time becoming cyanosed. This condition calls for withdrawal of the ether; and if an inspiratory effort does not quickly follow, pressure should be made upon the front of the chest, and when this is relaxed a deep inspiration usually takes place, and no further difficulty is experienced. This condition should not be confounded with the very common effort of holding the breath, the latter occurring with the chest fully expanded, the former with the chest empty. Vomiting may occur during etherization, and the vom- ited matter may accumulate in the pharynx or the mouth, and obstruct the breathing, or may enter the larynx or trachea and cause a like result. Vomiting is more apt to take place if solid food has been taken shortly before the administration of the anaesthetic. If this accident occurs and interferes with breathing, the jaws should be opened and the head turned to one side, when the vomited matter will usually escape without difficulty. If, however, food has entered the larynx, and is not ejected by coughing, it will be necessary to perform tracheotomy promptly and hold the tracheal wound open, or to introduce a tube and practise artificial respiration. The breathing may also be obstructed by the accumulation of mucus and saliva in the pharynx. This is less likely to occur if the head is kept to one side during the administration of the drug; if it occurs, the head should be turned to one side, the jaws opened, and the material removed with small sponges or pieces of gauze fixed to sponge-holders. AX. ESTHETICS, 247 The tongue may fall backward and obstruct the breath- ing when muscular relaxation is complete during anaesthe- sia; this accident is also less likely to occur if the head is kept to one side during etherization, li' asphyxia results from falling back of the tongue, it should be brought forward by placing the fingers on each side beneath the angles of the inferior maxillary bone, and pushing the jaw forward, at the same time over-extending the neck by bending the head backward (Fig. 168), or the mouth should be opened and the tongue drawn forward with tongue forceps. Either of these manipulations is usually sufficient to re-establish the respiratory movements. Fig. 168. i Pushing the jaw forward. If, however, in any of these forms of mechanical asphyxia respiratory action is not promptly restored, some form of artificial respiration should promptly be resorted to, either Laborde's, Silvester's Howard's, or forced respiration ; and of these, Laborde's method, by rhythmical traction of the tongue, and Silvester's have yielded the most satisfactory results. Efforts at resuscitation in these cases should be persevered in for at least half an hour, as apparently hopeless cases have been saved by persistent use of these means. Failure of respiration may occur also from paralysis of 248 MINOR SURGERY. the respiratory centres, or spasm of the respiratory muscles ; the former may occur from an overdose of the anaesthetic, or from intercurrent asphyxia, syncope, or morbid states of the respiratory system. Spasmodic respiratory failure may occur before complete anaesthesia, and is liable to arise in muscular and emphy- sematous subjects. Respiratory failure from either of these causes should promptly be treated by artificial respi- ration and the hypodermic use of strychnine, atropine, or digitalis. After-effects of Ether. — After complete anaesthesia from ether, nausea and vomiting are very common, and both are more apt to follow in case the patient has taken food shortly before the administration of the anaesthetic. They may last for only a short time, or may persist for hours. If persistent, the swallowing of a few mouthfuls of hot water will often relieve the condition ; or the administra- tion of cocaine hydrochlorate, grain one-quarter, with crushed ice, repeated two or three times, or the use of crushed ice with champagne or brandy, may be followed by satisfactory results. Inhalation of the fumes of vine- gar will often prevent nausea and vomiting, the vine- gar being poured upon a towel or a piece of gauze, which is held over the mouth and nose of the patient, and it should be applied as soon as the administration of the ether is stopped ; it should be used continuously for some time to be followed by the best results. Ether and Nitrous Oxide Gas. — The production of anaesthesia by the combined use of nitrous oxide gas and ether has been quite extensively employed both in Eng- land and this country. Hewitt considers this method of producing anaesthesia far superior to any other method which we possess at the present time. A special apparatus is required, which controls definitely the amount of nitrous oxide, ether, and air. Anaesthesia is produced first by the use of nitrous oxide gas, and, as soon as this is developed, the anaesthetic state is maintained by substituting the vapor of ether for the nitrous oxide gas. Xo air is given with the gas until anaesthesia is complete, which should be in ANJSSTHETICS. 249 from two to three minutes. Breathing at this time is stertorous, and cyanosis is well marked. After this time air is administered with the ether vapor. Anaesthesia by this method is rapidly induced, there is less struggling and spasm, the quantity of ether employed is smaller, and the after-effects are less marked, especially vomiting, and recovery from the anaesthetic state is more rapid than when ether is used alone. Ether and Oxygen. — The administration of ether with oxygen gas has been employed to a considerable extent. In the employment of this combination to produce anaesthe- sia the patient is first allowed to inhale a small amount of ether from an inhaler, and a tube connected with the oxygen receiver is then introduced into the inhaler and the oxygen gas turned on, so that the patient is allowed at the same time to inhale the vapor of ether and oxygen gas. A special apparatus may also be employed which regulates definitely the amount of ether and oxygen fur- nished. Anaesthesia produced by this combination is accompanied by less cyanosis, vomiting is rare, and the patient recovers very promptly from the anaesthetic state. As the ether vapor and oxygen form a highly explosive mixture, care should be exercised not to bring a flame near the patient during its administration. Chloroform. — This drug according to Hare, first affects the brain, then the sensory part of the spinal cord, then the motor area of the cord, then the sensory paths of the medulla oblongata, and finally the motor portions of the medulla, and produces death from failure of the vasomotor centre and of the respiratory centre unless, as rarely occurs, the heart has succumbed to the drug. Chloroform is certainly a much more dangerous anaes- thetic than ether, and although it is widely used in the British Islands and upon the Continent, it is not exten- sively used in this country except in certain districts — as in the southern and southwestern districts of the United States, and here its use is followed by fewer fatalities than in the northern districts, so that it is possible that its use is safer in warm climates. Clinical experience has demon- 250 MINOR SURGERY. strated that chloroform may be used in aged and very- young subjects and in puerperal patients with compara- tive safety ; deaths from chloroform are more common in the middle period of life. It is also to be preferred to ether in patients suffering from emphysema of the lungs, bronchitis, and vascular degeneration of the kidneys. It is also employed by some surgeons instead of ether in operations upon the mouth when the actual cautery is used, on account of its less inflammable character. Considerable diversity of opinion exists among different observers as to whether death resulting from chloroform is due to failure of the heart or failure of the respiration, and each has brought forward a large amount of evidence to prove his views correct. Although it has been demon- strated that chloroform is a direct depressant and para- lyzant to the heart-muscle or its contained ganglia, and that cardiac dilatation of varying degrees may be brought about by the administration of chloroform, yet clinical experience shows that paralysis of the respiratory centres is probably the most important factor in causing death during chloroform anaesthesia, for circulatory failure in these cases is due to embarrassed or suspended breathing, and the only method of treatment which has been found of value is that which tends to bring about respiratory action, namely, some one of the various forms of artificial respiration. Chloroform is more dangerous in the earlier stages of the administration, and the gravity of the operation ap- pears to have little effect in increasing its danger, as sta- tistics show that the greatest number of fatalities have occurred in minor surgical procedures, such as extracting teeth, amputation of fingers, reduction of dislocations, and opening abscesses. Preparation of Patient. — A patient is prepared for the administration of chloroform as in the case of ether, the same precautions being taken as regards the removal of false teeth or foreign bodies from the mouth, and to see that the clothing about the chest and neck does not re- strict the circulation or respiratory movements. ANESTHETICS. 251 Fig. 169. Administration of Chloroform. — Chloroform is adminis- tered by pouring a drachm of the drug upon a folded towel, which is first held a few inches from the mouth and nose, and gradually brought nearer, but is not allowed to come in contact with the face, as from its local irritat- ing action it will blister the surface ; the lips and anterior nares should be anointed with vaseline. The anaesthetizer should remember that one of the dan- gers in the administration of chloroform is the risk of too great concentration of its vapor, so that he should see that a sufficient admixt- ure of atmospheric air takes place. Chloroform may also be administered with Esmarch ? s inhaler, which consists of a wire frame covered with gauze (Fig. 169). Various inhalers have been devised to regulate the amount of chloroform administered and to secure the proper admixture of atmospheric air, and the best of these is probably Mr. Clover's apparatus. Profound chloroform anaesthesia is manifested by insensibility of the con- junctiva to the touch, absence of the reflexes, complete muscular relaxation, and, usually, contracted pupils. When this stage is reached, the inhalation should be stopped, and after this time only so much chlo- roform should be administered as is sufficient to keep the patient fully under its influence. Complete anaesthesia should be produced before any operation is begun ; if undertaken before that time, syn- cope may be produced by reflex inhibition of the heart. If convulsive movements take place before the patient is fully anaesthetized, and the face becomes cyanosed, the inhalation should be discontinued until these symptoms disappear. The pupils should also be watched carefully, to see if they respond to light or are contracted. If Esmarch's inhaler. 252 MINOR SURGERY. the anaesthesia is not complete, insensibility to light or wide dilatation is a sign of danger which calls for re- moval of the anaesthetic and active treatment to stimu- late the circulation and respiration. If the inhalation has been stopped and is again in a short time resorted to, it should be given very carefully and slowly, for syncope may suddenly develop from the fact that the heart or the respiration may feel the effect of the previous use of the drug. Accidents during Chloroform Anaesthesia. — Mechanical asphyxia may occur during anaesthesia produced by chloro- form, as well as that by ether, by obstruction of the res- piratory passages by blood, mucus, foreign bodies, or the tongue falling backward over the epiglottis. These acci- dents should be treated in the same manner as when occurring during etherization. Death during the administration of chloroform may result from cardiac syncope or from respiratory arrest, and the dangerous symptoms develop so rapidly that the greatest promptness is required to meet them. The per- son administering chloroform should constantly watch both the pulse and the respiration, and should not for a moment have his attention diverted from the patient ; great vigilance is here, if possible, more important than during the administration of ether. Respiratory Arrest. — During chloroform anaesthesia paralysis of the respiratory centres may occur, giving rise to respiratory arrest. If this dangerous symptom appears, the patient's head should be lowered and artificial respi- ration promptly employed to re-establish the respiratory function. Cardiac syncope developing during the administration of chloroform, manifested by pallor, fluttering or arrested pulse, and cessation of respiration, should be treated by lowering the patient's head or inverting the patient, the use of a rapidly interrupted electric current, the hypo- dermic injection of digitalis, atropine, or strychnine, and the employment of artificial respiration, either Silvester's, the direct method, or Laborde's method ; and, as in cases ANAESTHETICS. 253 of threatened death from ether, the treatment should not be desisted from for some time, as by persistent employ- ment of these means apparently hopeless cases have been resuscitated. Chloroform and Oxygen. — The combined use of chloro- form and oxygen is sometimes employed to produce anaes- thesia. A small amount of chloroform is first adminis- tered, and then the oxygen gas is introduced into the inhaler, and the two gases are inhaled at the same time ; or a special apparatus may be employed, by means of which a definite amount of each drug may be administered. Chloroform and Ether. — The induction of anaesthesia by the administration of ether followed by chloroform, as recommended by Hewitt, has been practised in a large number of cases with satisfactory results. In producing anaesthesia by this method, ether is first given until anaes- thesia is produced, and the anaesthetic effect is then kept up by the administration of chloroform. Hewitt considers it advisable in this method of anaesthesia to let the patient come up slightly, so that there is conjunctival reflex, before the chloroform is substituted, and also advises that the operation should not be undertaken until that change has been made. The A.-C.-E. Mixture. — This mixture, which con- sists of 3 parts of chloroform, 1 part of ether, and 1 part of alcohol, has been employed by some surgeons in place of ether or chloroform, with the idea that the dangers of chloroform are diminished by its combination with ether and alcohol. Clinical experience, however, has not proved this view to be correct. If administered with as much care as chloroform, its administration is accompanied with the same safety. It should be administered upon a towel or inhaler in the same manner as chloroform, and the patient should be watched as carefully during its inha- lation as during the administration of the latter drug, and any complications occurring should be treated in the same manner as those arising during the use of chloroform. Schleich's Anaesthetic Mixture. — Schleich has re- cently introduced an anaesthetic mixture which he con- 254 MINOR SURGERY. siders safer than ether or chloroform. He maintains that the absorption of a general anaesthetic is chiefly regulated by the boiling-point or point of maximum evaporation of the anaesthetic. An anaesthetic is unsafe in direct propor- tion to the amount absorbed, and the lower the boiling- point of the anaesthetic the less is absorbed ; hence an anaesthetic to be safe should have a low boiling-point. A safe anaesthetic is one in which the point of maximum evaporation is near the temperature of the patient, so that as much of the anaesthetic will be exhaled upon expiration as is inhaled on inspiration. Schleich employs three mixtures. The first contains, by volume, chloroform, §iss ; petroleum ether, ^ss; sulphuric ether, 3vj. The second contains chloroform, ^iss ; petroleum ether, £ss ', sulphuric ether, ^v. The third contains chloroform, 3j ; petroleum ether, ^ss ; sulphuric ether, ^ij siiss. This anaesthetic may be administered upon a towel or inhaler. It is claimed that by the use of these anaesthetic mixtures little excite- ment is produced and cyanosis rarely occurs ; that there is no hypersecretion of mucus and no consecutive bronchitis or pneumonia, and that the anaesthetic state is quiet, reaction is rapid, and vomiting occurs in less than half the cases. Bromide of Ethyl. — This drug was introduced as an anaesthetic some years ago, but as a number of deaths fol- lowed its use, it was abandoned. The time required to produce anaesthesia is shorter than for ether, but there is often induced violent muscular spasm, which renders it an unsuitable anaesthetic in many cases. Bromide of ethyl has again been revived as an anaes- thetic, but clinical experience has proved that its use is not devoid of danger, that it is not as safe as ether, and that it possesses no advantages in point of safety over chloroform. When used, it should be administered by pouring a drachm or two upon an inhaler or a towel, and the patient should be watched with the same care as dur- ing the administration of chloroform. After-effects of Anaesthetics. — Nausea is not common after chloroform anaesthesia. The treatment of this con- dition following etherization has been previously de- TRUSSES. 255 scribed. The temperature is usually notably lowered by anaesthetics, so that it is always well to apply artificial heat and keep the patient well covered. A form of mental disturbance known as confusional insanity is often attributed to the use of anaesthetics, but, as it does not usually develop until some time, often two or three weeks, after their employment, H. C. Wood is of the opinion that the relation between the mental symptoms and the anaesthetic has not been clearly proved in these cases, and that it is rather the outcome of a peculiar depression of the cerebral cortex produced by the shock of the opera- tion itself, or by the emotional strain due to the surgical illness. This view seems to be confirmed by the fact that many of the cases of emotional insanity which are observed follow injuries in which no anaesthetic has been given. Albuminuria and glycosuria may follow the administration of ether or chloroform, but are usually only temporary conditions. Paralysis of the nerves of the brachial plexus may follow prolonged anaesthesia when the arm is drawn high above the head ; it is not due to the anaesthetic, but results from stretching of the nerves over the head of the humerus or their compression between the clavicle and the first rib. Paralysis of the museulo-spiral nerve may also occur from prolonged pressure of the arm upon the edge of the table. Hypnotism. — The anaesthetic state of hypnotism has been utilized for the performance of surgical operations. Schmeltz and others have recorded operations done under this influence, the patient apparently suffering no pain. While there is no doubt that the anaesthetic state can be obtained by hypnotism, which might be serviceable in surgical operations, yet we do not believe that it will be of general utility. TRUSSES. A truss for the palliative treatment of hernia is a mechanical contrivance with one or more pads and a strap : these are held in position by a spring to which 256 MINOR SURGERY. they are attached, which holds the pad in contact with the skin over the hernial opening. Trusses are usually applied in cases of reducible and sometimes in irreducible hernise, and are used in the treat- ment of hernias at all ages ; in infants and young children the continued use of a properly fitting truss is often fol- lowed by a radical cure of the hernia. They are made with steel or rubber springs and with pads of wood, rubber, celluloid, or horsehair, covered with chamois skin; their shape and the pressure which they should exert vary with the variety of hernia for which they are applied. A firm compress applied over the inguinal canal or crural ring, secured in position by a firmly applied spica- of-the-groin bandage, forms a very satisfactory temporary means of preventing the descent of a hernia. A properly fitting truss should be worn without dis- comfort to the patient — that is, should not make too much pressure upon the skin at the points where the pads are applied, and should absolutely prevent the descent of the hernia. In testing the adequacy of a truss, after application, to prevent the escape of the hernia, the patient should be instructed to separate his legs, bend for- ward over the back of a chair, and cough or strain forcibly ; if this does not bring the hernia down, control of the rupt- ure may be considered satisfactory. Trusses should be applied after the complete reduction of the hernia, while the patient is in the recumbent pos- ture. When first applied, the truss should be worn both during the night and day ; and if the skin becomes tender at the points of pressure, it should be sponged with alcohol and alum, then dried and dusted with powdered starch or lycopodium. Patients at first sometimes com- plain of discomfort in wearing a truss, but they soon become accustomed to its presence. After a truss has been worn for some time, its use at night, while the patient is in bed, may be dispensed with, but the patient should not remove it until he is in bed in the recumbent posture, and he should reapply it before he rises in the morning. In children it is better to have the truss worn continuously ; TR USSES. 257 and if it is removed for bathing, the nurse should be instructed to place her finger over the ring to prevent de- scent of the hernia until the truss is applied. In apply- ing trusses to male children care should be taken not to make pressure upon an undescended testicle. Trusses for Inguinal Hernia. — In measuring a patient for this form of truss* the circumference of the body mid- way between the crest of the ilium and the great trochan- ter should be taken, and the distance from the symphysis pubis to the anterior superior spinous process of the ilium may also be given, as half of this distance corresponds to the position of the internal abdominal ring. In reducible inguinal hernia the truss-pressure should be exerted upon the inguinal canal and directly backward. To control this Fig. 170. Fig. 171. Truss for inguinal hernia. Hood's truss. variety of hernia, a single-spring truss (Fig. 170) may be employed, or the use of a truss having a double spring with flat pads on each side of the spine attached to the springs, and a smaller pad over the inguinal canal on the unaffected side, with a full pad on the side of the hernia, will often be efficient. This, which is known as Hood's truss, is one which will be found a very satisfactory in- strument both in inguinal and femoral hernia (Fig. 171). Trusses for Femoral Hernia. — In measuring a patient for this variety of truss, the circumference of the body midway between the crest of the ilium and the great tro- chanter should be taken ; the distance of the saphenous opening from the symphysis pubis, as well as from the anterior iliac spine, should also be taken. In reducible 17 258 MINOR SURGERY. femoral hernia the truss-pressure should be directed back- ward against the femoral canal, and the pad should be large enough to make pressure upon the adjacent tissues through which the hernia passes, as well as upon the re- laxed tissues covering the femoral canal. As in inguinal hernia, either a single or a double spring truss may be em- ployed (Fig. 172). In applying a truss for femoral hernia, care should be taken to see that the pad does not rest upon the pubis, and thus remove the pressure from the crural ring and adjacent tissues and prevent the proper control of the hernia. Trusses for Umbilical Hernia. — In measuring a patient for this variety of truss, the circumference of the body over the umbilicus should be taken. In reducible um- bilical hernia the truss-pressure should be directed back- ward, and the pad should bear rather on the tendinous Fig. 172. Fig. 173. Hood's truss for femoral hernia. Truss for umbilical hernia. margins of the ring than on the hernial opening. A truss for this variety of hernia should have a flat or slightly convex pad, which is held in position over the umbilical ring by means of springs having counter-pads on either side of the spine attached to their extremities ; these are fastened together by a strap (Fig. 173). A simple and satisfactory truss for umbilical hernia in infants consists of a penny covered by adhesive plaster, or a small flat compress of linen, held over the umbilical ring by one or two strips of adhesive or rubber plaster about two inches in width, or by a broad strip of perforated rubber adhesive plaster, which should be applied so as to cover in about the anterior two-thirds of the circumfer- ence of the body. A penny, or a small flat compress CATHETERS A XI) BOUGIES. 259 of linen, will be found much more satisfactory than the conical rubber or cork pad often recommended. Trusses for Irreducible Hernia. — The application of a truss to this variety of hernia protects it from injury and prevents its further protrusion. Such trusses are secured in the same way as those for reducible hernia, but the pads are made concave or cup-shaped, or may have an air-cushion or water-cushion attached to the pad. CATHETERS AND BOUGIES. Catheters are hollow tubes, made either of metal, India- rubber, or other flexible substances. Sterilization of Catheters and Bougies. — To avoid infection of the bladder, it is important that catheters and bougies should be sterilized thoroughly before being intro- duced (see page 155). Infection of the bladder may occur from matter con- tained in the urethra, so that this canal should also be sterilized (see page 152). If it is possible, the patient should pass the urine to wash out the urethra, and a solution of boric acid or a borosalicylic solution should be injected before the instrument is passed. To lubricate the instrument, sterilized boroglyceride, olive oil, glycerin, or lubrichondrin should be employed. Metallic Catheters. — These are made of silver, or, if constructed of other metals, they should be plated with silver or nickel, to give them a smooth, bright surface which can easily be kept perfectly clean ; and their shape should conform to that of the normal urethra (Fig. 174). The shape of the metallic catheter is sometimes changed to meet certain indications ; for instance, for use in cases of enlarged prostate it is longer and has a larger curve than the ordinary instrument (Fig. 175). The metallic female catheter is shorter and has a much smaller curve than the instrument used for the male urethra. A female catheter made of glass is now frequently employed, and has the advantage of easy sterilization. 260 MINOR SURGERY. Flexible Catheters. — The most commonly used variety of flexible catheter is that known as the English cathe- Fig. 174. Fig. 175. Fig. 176. Fig. 177. Metallic catheter. Prostatic catheter. French flexible Mercier's catheters. elbowed catheter. ter, which is made of linen and shellac, and is provided with a stylet; it can be moulded into any shape desired by dipping it into hot water, which renders it flexible, CATHETERS AND BOUGIES. 261 and, after moulding it to the proper curve, this can be fixed by immersing it in cold water, which hardens it again. The French flexible catheter is made of India-rubber, or a combination of this material with other substances. These instruments are conical toward their extremities, and terminate in an olive-shaped point; they are provided with one or two smoothly finished eyes near the vesical ex- tremity (Fig. 176). Another form of flexible catheter, known as the el- bowed catheter or Mercier's soft rubber cathete^ catheter (Fig. 177), has an angle or elbow near its vesical extremity ; this is often found a satisfactory instrument to use in cases of enlarged prostate. A variety of flexible catheter made of soft India-rubber is also sometimes employed (Fig. 178). Catheters and bougies are made according to a certain scale. The English scale runs from Xo. 1 to No. 12; the American, from Xo. 1 to No. 20 ; and the French, from Xo. 1 to Xo. 40. Bougies and Sounds. — Bougies. — These are flexible instruments which correspond in size and shape to the English and French catheters ; and besides there are the acorn-pointed bougie (Fig. 179) and the filiform bougie, which latter is made of whalebone or of the same material as the ordinary French bougie and catheter. These in- struments are of very small diameter, and may often be passed through strictures which will admit no other form of instrument (Fig. 180). Sounds. — These are solid instruments, usually of steel, with a smooth surface and plated with nickel ; they corre- spond in size and have the same curve as the metallic catheter ; the handle is flattened, to allow the operator to grasp them firmly ; they are employed in the treatment of strictures by dilatation (Fig. 181). The sound used in 262 MINOR SURGERY. dilating strictures of the meatus is straight, and is shorter than the sound employed in the treatment of urethral strictures (Fig. 182). A metallic sound with a shorter Fig. 179. Fig. 180. Fig. 181. Fig. 182. / Bulbous or acorn- pointed bougies. Filiform bougies. Steel sound. Sound for dilating meatus. curve than the ordinary sound is used for exploration of the bladder for calculus or tumor. Introduction of a Catheter. — For the introduction of a catheter, the patient may be in the standing, sitting, or INTRODUCTION OF A CATHETER 263 recumbent posture — the latter is the best in most cases ; he should resl squarely on his back, and have the thighs a little Hexed and separated. Before passing a metallic catheter, the surgeon should see that it has been sterilized, and after warming and oiling it he stands upon the left side of the patient and grasps the Fig. 183. Introdurtion <>f a ratheter. (Voillemier.) penis with the left hand, and turns it over the pubis and introduces the beak of the catheter into the meatus, and gently passes it along the urethra until its point passes beneath the symphysis pubis ; at this point the handle is elevated and gently depressed between the thighs, when the beak will pass into the bladder (Fig. 183). 261 MINOR SURGERY. In passing a catheter in case of enlarged prostate, when the prostatic region is reached difficulty is sometimes ex- perienced in the further passage of the instrument ; this ma) 7 be overcome by introducing the finger into the rectum and guiding the catheter through the prostatic urethra ; or if the prostate is found much enlarged, the catheter should be withdrawn, and a prostatic catheter (Fig. 175) substi- tuted. The same manipulation is practised in passing metallic sounds. Flexible catheters and bougies are passed by grasping the penis and holding it in such a position that it is at a right angle to the axis of the body, and the catheter or bougie is introduced into the meatus and conducted through the urethra into the bladder by gently pushing the instrument downward. In this variety of instrument, which has no curve, the surgeon has no means of guiding the point of the instrument, and if an obstruction is met, he should withdraw the instrument slightly and make another attempt ; all manipulations should be extremely gentle. Passing the Female Catheter. — It was formerly con- sidered important to pass the female catheter without exposing the patient. At the present time it is rarely done, as it is considered more important to sterilize the vulva and region of the orifice of the urethra to avoid infection of the bladder. After washing the vulva with soap and water, and irrigating it with boric solution or normal salt solution, the orifice of the urethra is exposed, by separating the nymphse, and the catheter is introduced into the bladder. Catheterization of the Ureters in the Female. — In performing this operation by the direct or Kelly's method, the patient is placed in the dorsal position with the pelvis elevated or in the genu-pectoral position, and the urethra is dilated to admit a cylindrical speculum 12 to 15 millimetres in diameter. With the aid of a head-mirror the interior of the bladder can be directly inspected. The opening of the ureter may be exposed by turning the speculum thirty degrees to one side, and is recognized as a small depres- sion, the mucous membrane being of a darker color than SECURING CATHETER TN BLADDER. 265 elsewhere. A delicate elastic or silver catheter can be introduced into this opening, and by can-fid manipulation may I"' passed to the pelvis of the kidney. By this pro- cedure, unilateral or bilateral disease of the kidneys may be clearly demonstrated, as well as the condition of the ureters themselves. Delicate bougies passed into the ureters may be used to locate their position in the opera- tion of hysterectomy. Catheterization of the male ureters can also be practised. Tying the Male Catheter in the Bladder.— When it is desirable to retain a catheter for some time in the male bladder, it is necessary to secure it, to prevent its slipping out. Either a metallic or flexible catheter may be em- ployed ; but, as a rule, the flexible instrument is the most comfortable to the patient, and is to be preferred ; there are several methods of securing it in the bladder. By one method, two narrow strips of tape or two or three strong silk ligatures are attached to the rings at the end of a metallic catheter, or are securely fastened around the end of the flexible instrument; these are next brought back- ward, one on each side of the penis, and the skin is drawn forward and a strip of adhesive plaster half an inch in width is passed over the strings or tapes and carried three or four times around the body of the penis just behind the glans. If the -kin has been brought well forward before the strips have been applied, the ligatures are tightened as it slips back, and the cathe- ter has not too much play Fig. 18 ^- (Fig. 184). Another method consists in fastening a strong silk ligature around the catheter just in ad- vance of the meatus ; the two - fi ends are next brought back- :^j ward and tied in a knot behind the corona glandis : the ends T ying in catheter, (bryaht.) are then carried around the penis behind the corona and tied on one side of the frsenum ; the foreskin is slipped forward and covers the ligatures. 266 MINOR SURGERY. A catheter may also be secured in the bladder by tying the ends of the silk ligatures, which are attached to the instrument in advance of the meatus, to tufts of pubic hair. Another method of securing the catheter is to perforate the free end with a needle armed with a double ligature of silk or hemp ; the needle being removed, two loops are made of the proper length, and these are passed through the ends of a T-bandage, which is secured around the waist, the tails being brought up on either side of the scrotum and secured to the body of the bandage passing around the waist. In the female, when it is desirable to keep the bladder empty, the self-retaining catheter is usually employed, which consists of a catheter with a bulb at its vesical extremity, or an ordinary catheter with silk loops, and a T-bandage may be employed in the same manner as in securing a male catheter. Irrigation of the Bladder. — This procedure may be required in the treatment of cystitis or in sterilizing the bladder, and is accomplished by passing a flexible cath- eter with a large eye into the bladder, or a double or two-way catheter may be em- ployed. A syringe, or, better, a rubber bulb holding about a pint, having a noz- zle and stopcock (Fig. 185), is filled with warm water, or with any medicated solu- tion which is desired, and it is then at- tached to the free end of the catheter and the contents are gently injected into the bladder ; care should be taken that the bladder is not too much distended. When the desired amount of fluid lias been in- jected, it is allowed to run out of the cath- eter, and the procedure may be repeated until the solution comes away perfectly clear. The bladder may also be irrigated with- out using a catheter, the resistance of the compressor mus- cle of the urethra being overcome by the pressure of a col- umn of water. The patient sits in a chair and a rubber or Fig. 185. Rubber bag with stopcock, for irriga- tion of the bladder. I 'R ETHR. 1 L IXJECTIOXS. 267 glass oozzle with a large bulbous tip, which closely fits the meatus. Is inserted into it ; the nozzle is connected byarubber tube with a reservoir containing the fluid for irrigation. The reservoir is raised to a height of three to six feet above the patient. He is directed to take deep inspirations, and soon the bladder becomes tilled with water, when the nozzle is removed, and the patient empties the bladder naturally. In some eases a little time is required before the column of water overcomes the resistance of the compressor muscle, or its entrance into the bladder may be hastened by direct- ing the patient to attempt to urinate. Care should be taken to see that the bladder is perfectly emptied of the solution, and in cases of paralysis of the viscus gentle pressure should be made upon the abdomen over the pubis to accomplish this object. Solutions of boric acid and permanganate of potassium, and weak solu- tions of carbolic acid and of nitrate of silver are often employed in washing out the bladder in chronic cystitis. Urethral Injections. — In the treatment of urethral inflammations, the injection of medicated solutions is gen- erally made use of ; and as these injections are usually made by the patient himself, he should be shown or instructed how to em- ploy them. A rubber syringe having a conical nozzle, and holding about two or three drachms, is the best instrument to employ for this purpose (Fig. 186). The syringe having been filled with the solution, the patient sits upon the edge of a hard chair, with the thighs separated, grasps the syringe between the thumb and middle finger of the right hand, the tip of the index finger resting upon the end of the piston, and inserts its conical end from a quarter to half an inch within the meatus, which is held open bv the thumb and finger shape of nozzle of a • V urethral sTnusre. of the left hand. After the introduction of the nozzle of the syringe the tissues should be pressed tightly around it, the pressure being made laterally, so as Fig. 1S6. 268 MINOR SURGERY. to narrow the urethral opening instead of broadening it, as is the case when compression is made in an antero-pos- terior direction. After the fluid has been thrown into the urethra in this manner, the syringe is removed, and the patient is instructed to hold the lips of the meatus together for one or two minutes, to prevent escape of the fluid. Urethral irrigation may also be practised by means of gravity, a short rubber or glass tube, or a glass urethral nozzle being connected by a rubber tube with a reservoir containing the fluid to be used, the reservoir being placed slightly above the patient. SUTURES. A variety of materials are employed for sutures, such as silk, catgut, silver or iron wire, silkworm-gut, kan- garoo-tail tendon, and horsehair. The materials most fre- quently employed at the present time are either catgut, silk, or silkworm-gut, although some surgeons prefer silver wire. Catgut and kangaroo-tail tendon are practi- cally the only substances employed which are absorbable ; the other varieties of suture require removal after their application, although some sutures, such as the silk, if absolutely sterile, when buried in wounds may be cut short, as they are apt to become encysted and remain in- definitely in the tissues. It matters little what variety of material be employed for suturing if the surgeon is careful to see that it is rendered thoroughly aseptic before being brought in contact with the wound. Sutures of Relaxation. — These sutures are entered and brought out at some distance from the edges of the wound, and are employed to prevent dangerous tension upon the sutures which approximate the edges of the skin. This form of suture is employed in the quilled, button, or plate suture. Sutures of Coaptation. — These are superficial sutures applied closely together, and include only the skin ; they are employed to secure accurate apposition of the cuta- neous surface of wounds. SUTURES. 269 Sutures of Approximation. — These sutures are applied deeply into the tissue to seeure approximation of the deep portions of a wound ; this objeet is accomplished by the use of the quilled, buried, button, or plate suture. Secondary Sutures. — These sutures are applied when the surfaces of the wounds are covered by granulations, when the primary sutures have failed to secure apposition of the edges of the wound, in cases of secondary hemorrhage where the opening of the wound has been necessitated to turn out the blood-clot and secure the bleeding vessel, and in plastic operations where the primary sutures have failed to secure adhesions of the edges of the flaps. They are also employed with advantage in closing wounds in cases in which it was necessary to pack the wound with anti- septic gauze, or to allow haemostatic forceps to remain clamped upon bleeding tissues in the wound at the time of operation. The sutures should in such a case be intro- duced and loosely tied at this time, and when the packing or forceps is removed at the end of two or three days the sutures are tightened so as to secure apposition of the edges of the wound. Surgical Needles. — Needles for surgical use are of different sizes and shapes (Fig. 187) ; straight needles are Fig. 187. Surgical needles. the ones commonly employed, but curved needles will be found most convenient for the introduction of sutures in wounds in certain locations. Hagedorn needles, which 270 MINOR SURGERY. are flat and have sharp-cutting edges, make a narrow linear wound in the tissues, and are useful in some cases. For the introduction of sutures in the intestines or hollow viscera, the ordinary sewing-needle is generally employed, as it does not cut the tissues, but merely sepa- rates them, and its puncture is not likely to bleed. Tubu- lar needles are often employed in introducing sutures in wounds in which the use of an ordinary needle is diffi- cult : for instance, in the operation for cleft palate, and for the introduction of sutures in deep wounds, a mounted Fig. 188. Mounted needle. needle will often be found very useful (Fig. 188). Rev- erdin's needle, which consists of a handled needle with an eye which is closed with a slide, is useful in passing deep sutures. The needle is first passed through the tissues, Fig. 189. Needle-holder. then threaded and withdrawn, carrying the suture with it. Needles should be sharp and clean, and should be rendered thoroughly aseptic before being used. Needles should be sterilized by boiling, and may be preserved in a saturated solution of carbonate of sodium or albolene to prevent rusting. A needle-holder is often required for sutci:/:s. 271 the satisfactory introduction of sutures in wounds in cer- tain Localities | Fig. 1< S< .> | : it' this is not at hand, the needle may be held by a pair of dressing-forceps or a pair «»t* haemostatic forceps. Method of Securing Sutures and Ligatures. — Metallic sutures are usually secured by twisting the ends together or by passing the ends through a perforated shot and clamping the shot with a shot-compressor, which securely fixes them. Sutures and ligatures of catgut, silk, silkworm-gut, kangaroo- tail tendon, or horsehair are secured by tying, and several different knots are employed to secure them. Reef or Flat Knot. — This is one of the best forms of knot to use in securing sutures or ligatures, and it is made by passing one end of the thread over and around the other end, and the knot thus formed tightened ; the ends of the thread are next carried toward each other and the same end is again carried over and around the other, and when the loop is drawn tight we have formed the reef or flat knot (Fig. 190). Surgeon's Knot. — This knot is formed by carrying one end Reef or flat knot. of the thread twice around the other end (Fig. 191); and after tightening this loop the same is carried over and Fig. 191. Fig. 190. ; ureeon's knot. around the other end as in the case of the final knot of the reef or flat knot. The surgeon's knot and reef knot 272 MINOR SURGERY. combined is one of the best methods of securing sutures or ligatures of catgut or silk, as the first knot is not apt to relax before the second knot is applied (Fig. 192). Fig. 192. Surgeon's knot and reef knot combined. Granny Knot. — This method of tying the ligature or suture should not be employed, as the resulting knot is not as secure as the reef knot and is apt to relax : it differs from the latter in the fact that one end of the thread hav- ing been carried across and around the other end, the knot is completed by carrying the same end under and around the other end of the thread (Fig. 193). Staffordshire Knot. — This is much used to secure the pedicle in the removal of abdominal tumors, and is applied Fig. 193. Fig. 194. Granny knot. Staffordshire knot. as follows : A handled needle armed with a stout silk liga- ture is passed through the pedicle, and then withdrawn so as to leave a loop on the distal side ; this loop is drawn over the tumor, and one of the free ends is passed through it so that one end is above while the other end is below the retracted loop (Fig. 194). The ends are then seized and SUTURES. 273 drawn through the pedicle; at the same time the thumb and forefinger arc pressed against it until sufficient con- striction is made, and the ends are finally secured by tying as in the securing of an ordinary ligature. Fig. 195. Varieties of Sutures. The Interrupted Suture.— This variety of suture, which is the one most usually employed in the apposi- tion of wounds, consists of a number of single stitches, each of which is entirely independent of those on either side. In applying this suture, the surgeon holds the edge of the wound with the fingers or forceps and thrusts the needle, previously threaded, through the skin three or four lines from the edge of the wound. He then passes the needle from within outward through the tissues of the opposite flap at the same distance from the edge of the wound (Fig. 195). Each stitch is secured as soon as it is passed — by tying if a silk, catgut, or silkworm-gut suture be used, or by twisting if a silver wire suture is em- ployed. A suture may be used with a needle threaded on each end, in which case both needles are passed from within outward. The sutures may be secured as soon as ap- plied, or they may be left unsecured until a sufficient number have been introduced, and then they may be secured by tying or twisting. Care should be taken to see that they make no tension on the edges of the wound, and that they are so introduced as to make the best possible apposi- tion of the parts. Buried Sutures. — In extensive and deep wounds it may be found necessary to introduce both deep and superficial sutures, the former bringing about apposition of the mus- cles and deep fascia, the superficial layer bringing together the superficial fascia and skin. 18 Interrupted su- ture. (Park.) 274 MINOR SURGERY. Fig. 196. Deep or buried sutures are often employed to unite fascia, muscles, or tendons, and the best material for this variety of suture is either catgut, silk, silkworm-gut, or kangaroo-tail tendon. Continued Suture. — This variety of suture is applied in the same manner as the interrupted suture, but the stitches are not cut apart and tied ; it is made with silk or catgut, and is secured by draw- ing it double through the last stitch and using the free end to make a knot with the double portion attached to the needle (Fig. 196). This suture may be used in intestinal wounds, but may also be employed in obtaining apposition of the edges of wounds in tissues of loose structure. Subcuticular Suture. — Halsted has introduced a suture in which the needle is introduced on the under surface of the skin on one side, and brought out just beneath the cut edge; it is then entered Continued or glovers' suture. (Park.) Fig. 197. Subcuticular suture. in the reverse direction below the epidermic surface oppo- site ; when tied, it will lie wholly out of sight. The SUTURES. -11') object of this variety of suture is to avoid infection of the wound by the skin coccus, which may be introduced by the suture if passed from without inward. Fine silk or catgut should be used for this variety of suture, which may become encysted, absorbed, or gradually cast off after a few weeks. If employed as a continuous suture, the free ends may be tied together, and the suture subse- quently removed by cutting the loop and drawing out the suture from one end of the wound (Fig. 197). The Twisted or Hare-lip Suture. — This is a very useful form of suture where great accuracy and firmness of apposition of the edges of the wound are desired. It is applied by thrusting Fig. 198. pins or needles deeply through both lips ^ of the wound, the edges being kept in B= lI|IjK|JP =: ^ contact over the wound by figure-of-eight jJJiL^ turns with silk or wire (Fig. 198). The ^SSj^^-^, ends of the pins should be cut off with pin- ^^PPSiP' cutters after the sutures are applied, or Twisted or hare . lip should be protected by pieces of cork or suture, plaster to prevent them from injuring the skin of the patient and causing him pain. The twisted or hare-lip suture is frequently employed in plastic opera- tions about the face and in other parts of the body where accurate apposition of the flaps is important. Mattress or Quilt Suture. — This suture is applied by carrying the needle through the two flaps and then back again, so that a loop is left on one side and the two ends of the suture project from the opposite flap (Fig. 205). This variety of suture may be applied as an interrupted or as a continuous suture ; in the latter, loops are made through the flaps on each side of the wound. The Quilled Suture. — In making use of this suture, a needle armed with a double thread of wire or silk is passed through the tissues as in applying the interrupted suture, but at a greater distance from the edges of the wound. Into the loops on one side of the wound is inserted a quill or piece of a flexible catheter or bougie, and on the opposite side the free ends of the sutures are tied around a 276 MINOR SURGERY. similar object after being tightened (Fig. 199). This form of suture makes deep equable pressure along the whole Fig. 199. The quilled suture. (Smith.) line of the wound. In applying this suture, it may be found advisable in some cases to introduce a few superfi- cial interrupted sutures along the line of the wound to secure accurate approximation of the Fig. 200. skin. Two small rolls of sterilized or antiseptic gauze may be used as a substitute for the quills or pieces of catheter, as shown in Fig. 200. Button or Plate Suture. — This suture is applied by passing a needle armed with a double thread as in the case of the quilled suture, the ends of the suture being passed through the eyes of a button or through perforations in a lead plate before being threaded in the eye of the needle. After the suture pre- pared in this way has been passed through both sides of the wound, the needle is removed and the free ends of the suture are passed through the eyes of a button or the perforations in a lead plate on the Modified quilled suture. (Park.) SUTURES. 277 opposite side of the wound, and are tightened and secured (Fig. 201). In applying this form of sutures, small rolls of antiseptic gauze may be used instead of buttons, as shown in Fig. 202. This form of suture may be employed in deep wounds to accomplish the same purpose as the quilled suture. It allows the cutaneous margins of the wound to remain free from compression, and here, as in the case of the quilled suture, a few interrupted sutures may be introduced between the button or plate sutures to secure accurate apposition of the skin surfaces if desired. Fig. 201. Fig. 202. Button suture. (Smith.) Modified plate suture, using gauze pledgets. (Park.) Shotted Suture. — This suture receives its name not from any special method of application, but solely from the way in which it is secured ; any of the previously mentioned varieties of sutures may be employed. The ma- terial used in applying this suture may be catgut, silver wire, silkworm-gut, silk, or horsehair, and after the suture has been passed the needle is removed, and the ends are passed through a perforated shot ; the ends are then drawn upon to bring the edges of the wound in contact, and the shot is pressed down to the skin and clamped by means of a shot-compressor. The suture is then cut off flush with the surface of the shot. This method of securing sutures is especially useful in 278 MINOR SURGERY. closing wounds in the mucous cavities, such as the vagina, rectum, and mouth, where the knot or twist of the wire might cause irritation of the surface or pain to the patient ; it is also a useful method of securing sutures in plastic operations ; it also facilitates the removal of the sutures, as the shot is not apt to be obscured by the swollen tissue, and is easily seized by forceps when the loop is divided. Removal of Sutures. — Where sutures are buried in the tissues or used to approximate parts in cavities which are subsequently closed, such materials should be used for sutures as will be absorbed in a few days, or will become encysted, and remain harmless in the tissues — such as cat- gut, silkworm-gut, or silk — and it is needless to state that sutures used with this end in view should be rendered per- fectly aseptic before being employed. Catgut sutures, when well prepared and used for sutures in external wounds, usually undergo absorption in from ten to fifteen days ; the loop buried in the tissues is ab- sorbed, and the knot may be removed from the surface with forceps or it may come off with the dressings. The other substances, such as silk, silkworm-gut, silver wire, and horsehair, are removed by cutting one side of the loop and making traction upon the knot of the suture with forceps, or in the case of the wire suture, after divid- ing the loop and straightening out one end of it, the wire should be withdrawn in a curved direction. Sutures which are not causing irritation should be al- lowed to remain until the wound is solidly healed. The time usually required for their retention in cases of aseptic wounds is from eight to twelve days. Intestinal Sutures. Lembert's Suture. — Lembert's suture is used in wounds of the viscera covered by the peritoneum, with the object of bringing in contact the peritoneal surfaces. This form of suture is usually employed in closing wounds of the intestine, bladder, or stomach. A needle armed with a fine catgut or silk thread is INTESTINAL SUTURES. 279 passed, and it is better to employ a round needle, such as the ordinary sewing-needle, in preference to the bayonet- pointed needle, as there results by its use less bleeding Fig. 203. Fig. 204. Lembert's suture. (Brya>~t.) Lernbert's suture, a, serous : b, muscu- lar: and, c, mucous coat, i Smith.) Fig. 205. from the punctures. The needle is first carried through the peritoneal and muscular coats of the intestine a short distance from the wound, and it is then carried across the wound and passed through the same portions of the intestine a short distance from the edge of the wound on the opposite side (Fig. 203), and when the suture is tightened the peritoneal sur- faces of the intestine are inverted and brought into contact with each other (Fig. 204) ; the inter- rupted or continued suture may be employed in making this form of suture. Halsted's Mattress or Quilt Suture. — This is a modifica- tion of Lembert's suture. The needle penetrates the peri- toneal and muscular coats of the gut, including a small portion of the submucosa, twice on each side of the wound, and is then tied (Fig. 205). Halsted's quilt suture for intestine. 280 MINOR SURGERY. Ozerny Suture. — This suture is applied in intestinal wounds by passing the needle armed with a catgut or silk thread through the serous membrane on one side of the wound of the intestine and out at the wound surface so as not to include the mucous membrane ; the needle is then passed through the wound surface on the opposite side, avoiding the mucous membrane, and brought out through the serous membrane a short distance from the edge of the wound. By this suture the lips of the wound are approximated. For additional security in preventing escape of the contents of the intestine and to secure ap- proximation of the serous surfaces a few Lembert sutures should be introduced. METHODS OF INTESTINAL ANASTOMOSIS. Circular Suture of Intestine. — After division or resec- tion of the intestine the ends may be united by sutures. Fig. 206. Circular, or end-to-end suture of the intestine. (Richardson.) Interrupted Lembert sutures are usually employed. The sutures should first be applied at the mesenteric border, THE MURPHY BUTTON. 281 and great care should be exercised to make the apposition close at this point. The ends of the bowel should then be brought together with closely applied Lembert sutures. If the mesentery has been divided, it should also be ap- proximateed by sutures (Fig. 206). Fig. 207. The Murphy button. The Murphy Button. — This is a mechanical contrivance which may be employed to secure end-to-end apposition of Fig. 208. The two portions of the Murphy button held in place by purse-string sutures. (Richardson.) the divided intestine, or may be used to form a lateral 282 MINOR SURGERY. anastomosis between the intestines or hollow viscera. The construction of the button is shown in Fig. 207. This method of end-to-end approximation or anasto- Fig. 209. End-to-end union of intestine with Murphy's buttou. (Krhardsox,) mosis can be accomplished with accuracy and with great rapidity. In employing the button for these purposes, it is separated into its two parts, and each part is slipped into Fig. 210. ^V™vlt ■ m wiM/iii,, wh mi lb II End-to-end approximation, button in position. (Richardson.) the divided end of the intestine and secured by a purse- string suture (Fig. 208), and the parts are approximated by fastening the two portions of the button together (Figs. LATERAL ANASTOMOSIS. 283 209 and 210). Where lateral anastomosis between the intestines, or between the intestine and another hollow visens, is desired, an incision is made in each organ, and half of the button is slipped into each opening and secured by a purse-string suture, and the portions of the button are then fastened together. Union of the peritoneal surfaces results, and the button is usually released in from ten to twelve days by sloughing of the included tissues, and is passed by the anus. Senn's Method. — When it is desired to form a perma- nent orifice between two portions of the gut or other hollow viscera, the ends of the gut are closed, and an opening is made in each portion of the gut, into which Fig. 211. V///^//////////////sy///////^^^^ INTESTINE \!00f%Zf^///-ir//Mvy///sM^^^ WALL OF INTESTINE TURNED IN AND SECURED BY /jF LEMBERT STSTCHEsCf Showing position of bone plates in intestinal anastomosis alter resection of the bowel. (Roberts.) the perforated bone plates of decalcified bone are slipped, and the walls of the gut surrounding the openings are held in contact with each other by sutures attached to the perforated plates ; this is the method devised by Senn. The manner of using the bone plates and sutures is shown in Fig. 211. To accomplish the same purpose, rubber rings or perforated plates of rubber have been employed ; also rings made from catgut, to which the sutures are attached, in the same manner as Senn's plates, and if catgut rings are employed, these will be softened and dis- solved in a short time so as to be passed without difficulty. Abbe's Method of Lateral Anastomosis. — Portions 284 MINOR SURGERY. Fig. 212. Lateral anastomosis. First stage of operation. (Richardson.) Fig. 213. Lateral anastomosis; operation completed. (Richardson.) END-TO-END APPROXIMATION. 285 of the intestinal tract more or less distant, or the intestine and the stomach, may be united by this procedure, thus permitting the contents to pass through the new opening. The bowel upon each side of the constricted portion is manipulated, so that both portions lay side by side; or, in case a portion of the bowel has been removed, the ends are inverted and closed by Lembert's sutures. The two portions of the bowel are brought side by side, and a longitudinal cut three inches in length, opposite the mes- enteric attachment, is made through the coils to be united. The posterior edges of the incision should first be brought together by continuous or interrupted sutures (Fig. 212). The margins of the incision may be hemmed before uniting them. The anterior edges of the incision are next united by another continuous stitch, and for additional security a second line of interrupted or continuous sutures may be applied (Fig. 213). The time required for the application of the sutures is one disadvantage of this operation. Intestinal anastomosis by this method may be employed instead of the circular suture in wounds completely divid- ing the intestine, and after resection of the intestine for the removal of growths or for stricture. Anastomosis or End-to-end Approximation by La- place's Forceps. — Laplace has recently devised a forceps by which end-to-end approximation or lateral anastomosis can be accomplished with great accuracy and rapidity. The forceps are of different sizes according to the parts to be united, and consist of two parts, which are really haemostatic forceps curved into a semicircle on each side and held together by means of a clasp ; they open as two rings (Fig. 21 4). They hold together the parts to be united, and serve the same purpose as Semi's bone plates, keeping the serous surfaces in contact. The sutures are intro- duced at all points except where the forceps penetrate the parts that are sutured. The sutures having been intro- duced, the forceps are released by loosening the clasp and withdrawing the forceps, first one half and then the other half, and the small opening is finally closed by one or 286 MINOR SURGERY. two sutures. These forceps may be used in end-to-end approximation, lateral anastomosis, or gastroenterostomy. Fig. 214. Anastomosis forceps. (Laplace.) The forceps devised by O'Hara and by Allis are less com- plicated and have been used with equally good results. LIGATURES USED IN THE TREATMENT OF VAS- CULAR GROWTHS. Various forms of ligatures are used for the strangulation of vascular growths ; the material employed is usually strong silk or hemp thread, catgut, or silver wire. The Single Ligature with a Pin.— This is applied by DOUBLE LIGATURE. 287 first inserting a hare-lip pin through the skin near the edge of the growth, passing it under the growth and bringing it out through the skin at a point opposite the plaee of entry ; a strong silk or hemp ligature is passed under the ends of the pin surrounding the base of the tumor, and is drawn tight enough to strangulate the growth, and is secured by two knots (Fig. 215). If the growth is of Fio. 21 5. Vascular tumor strangulated with pin and ligature. considerable size, it is better before applying this ligature to introduce a second pin at right angles to the first one, and then secure the ligature under the pins. In applying these forms of ligature to healthy skin, the patient is saved much pain, and the separation of the mass is hastened, by cutting a groove in the skin with a sharp knife at the point w T here the ligature is to be applied ; the ligature when tied is buried in the groove thus made. Fig. 216. Method of applying double ligature. (Roberts. > Double Ligature. — This ligature is applied by passing a needle or a needle w 7 ith a handle, armed with a double ligature, through the skin near the growth, and then pass- 288 MINOR SURGERY. Fig. 217. Method of applying double liga ture and pin. (Bryant.) ing it under the tumor and bringing it out through the skin at a point directly opposite the point of insertion ; the ligature is then divided and the needle removed. The tumor is strangu- lated by tying firmly the corre- sponding ends of the ligature on each side of the tumor, each liga- ture including one-half of the growth (Fig. 216). The double ligature may also be applied by first passing a pin under the growth and then pass- ing a needle armed with a double thread under the tumor at right angles to the pin, and after re- moving the needle the ends of the ligature are tied and the tumor is strangulated in two sections (Fig. 217). Quadruple Ligature. — In applying this ligature, two needles carrying a double thread are passed under the growth at right angles to each other; or if the handled needles be used, they may first be passed in this manner, and then threaded with double ligatures, which are carried under the growth as they are withdrawn. The needles being removed, the surgeon ties two ends of the ligature together, and repeats this procedure until the growth has been strangulated in four sections. Subcutaneous Ligature. — This is applied by intro- ducing a needle armed with a ligature through the skin near the growth, and carrying it through the subcutaneous tissues around the part to be constricted for a short distance, then bringing it out through the skin. The needle is again introduced through the same puncture, and is again brought out through the skin at some distance from the first point of exit. It is next introduced through this puncture and brought out at a more distant point. In this way the growth is completely encircled by a subcutaneous ligature^ ELASTIC Lid A TUBES. 289 which is finally brought out at the point of entrance ; the tumor is strangulated by firmly tying together the ends of the ligature (Fig. 218). If a needle armed with a double ligature is first passed under the growth, the ligature is divided, and by passing each end of the divided ligature subcutaneously around Fig. 218. Method of applying subcutaneous ligature. (Holmes.) the growth it may be strangulated subcutaneously in two sections. Erichsen's Ligature. — This ligature is employed to strangulate tumors of irregular shape in a number of sec- tions. A strong silk or hemp ligature three yards in length, one-half of which is stained black, is carried by a needle as a double ligature under the growth at various points so as to leave a series of loops about nine inches long on each side of the tumor (Fig. 219) ; the black loops being cut on one side, the white on the other, the ends are then firmly tied so as to strangulate the growth in sections (Fig. 220). Elastic Ligatures. — Ligatures made of India-rubber varying from half a line to several lines in thickness are often made use of in surgery. They may be employed to strangulate growths such as moles or nsevi, or in the treatment of fistulse, and are especially useful in the treat- 19 290 MINOR SURGERY. merit of those cases of fistula in ano in which the internal opening into the bowel is situated high up, as the division Fig. 219. Method of applying Erichsen's ligature. (Erichsen.) of such fistula? by this means is accomj^lished without hemorrhage and with less risk than by the employment Fig. 220. Erichsen's ligature applied. of the knife. In applying elastic ligatures in such cases, the ligature, after being passed through the fistula by means of a probe, is carried out through the internal opening ; the sphincter is next well stretched, and the elastic ligature is then firmly tied with two or three knots; the greater the tension made before the ligature is tied TREATMENT OF HEMORRHAGE. 291 the more rapidly will it cut its way out. The smaller sizes of rubber drainage-tubes may be substituted for the solid rubber ligatures. TREATMENT OF HEMORRHAGE. The surgeon may be called upon to treat the following varieties of hemorrhage : arterial, venous, or capillary; and these again are classified according to the time of their occurrence, as 'primary — that is, bleeding which occurs at the time the wound is inflicted ; intermediary or consecutive, that which occurs within twenty-four or forty- eight hours after the reception of the injury, and which generally takes place during the period of reaction ; and secondary, which usually results from a septic condition of the wound, causing a septic arteritis, and occurs usually after forty-eight hours, but may occur at any time subse- quent to this period until the wound is healed. The treatment of hemorrhage is both constitutional and local. Constitutional Treatment. — This consists in keeping the patient in the recumbent posture and avoiding any sudden elevation of the head or arms which might induce fatal svncope. Opium is a valuable remedy and should be freely used. Ergot, gallic acid, acetate of lead, and tinct- ure of iron may also be employed, and stimulants and food should be carefully administered ; in extreme cases the intravenous injection or infusion of normal salt solu- tion should be resorted to. The haemostatic properties of gelatin have led to its use by subcutaneous injection in various forms of internal hemorrhage. A sterilized aque- ous solution, containing 2 per cent, of gelatin in normal salt solution, is injected into the loose cellular tissue of the abdominal walls or buttock, about 200 c c. being em- ployed. It has been used in haemoptysis, epistaxis, and in intestinal hemorrhage in typhoid fever. Local Treatment. — This consists in the adoption of various local measures to control the bleeding, which may be either temporary or permanent in their action. 292 MINOR SURGERY. Temporary Control of Arterial Hemorrhage. This may be effected by pressure applied directly to the bleeding vessel in the wound or by pressure applied indirectly to the main artery between the point of its injury and the centre of the circulation, and this pressure may be made by the fingers — digital compression — by co?/i- jyresses, or by means of tourniquets. Digital Compression. — This constitutes one of the most valuable means employed in the temporary control of hemorrhage : the finger is pressed directly upon the Fig. 221. fite?-rw-, ;.,-., Digital compression of the femoral artery. bleeding vessel, in the wound, or is used to make pressure upon the artery from which the bleeding arises at some point between the wound and the centre of the circulation (Fig. 221). Control of hemorrhage by digital pressure can be maintained only for a few minutes, for the fingers of the surgeon or assistant soon become tired, so that it is employed only until means are adopted for permanent arrest of the bleeding. Digital compression of the radial and ulnar arteries may be resorted to for the control of hemorrhage during amputations of the fingers, of the axillary and femoral arteries in amputations at the shoul- der-joint and the hip-joint. It is also used to control TOURNIQUETS. 293 hemorrhage from wounds either tho result of aecident or those made by the knife of the surgeon, in which case the finger is placed directly upon the divided vessel or is employed to hold a sponge or compress firmly in the wound. Compresses. — By the use of compresses placed directly in the wound or applied to the vessel between the wound and the centre of the circulation, the temporary control of hemorrhage may be very satisfactorily accomplished. The compress which is applied in the wound should be made of antiseptic or aseptic gauze, thereby diminishing the chances of wound-infection. The compress should be held in position by a bandage firmly applied, and is generally employed only as a temporary expedient until a more permanent means of controlling the bleeding is adopted. Fig. 222. Petit's tourniquet. Tourniquets. — These instruments, which are employed for the temporary control of hemorrhage from wounds, are of many different kinds. 294 MINOR SURGERY. Petit's Tourniquet. — This consists of two metal plates connected by a strong linen or silk strap, with a buckle, the distance between the plates being regulated by a screw (Fig. 222). In applying this tourniquet, a compress or roller-bandage is placed directly over the artery to be compressed, and may be held in position by a few turns of the bandage. The lower plate of the tourniquet is placed directly over this pad, and the strap is tightly secured around the limb to keep the instrument in place. The screw is then turned so as to separate the plates and tighten the strap, thus forcing the compress or pad upon the artery and controlling its circulation. This instru- ment is very generally employed for the control of hem- orrhage in wounds of the extremities, and is especially useful in amputation of these parts, being placed over the main artery some distance above the seat of opera- tion. The Spanish Windlass. — An improvised tourniquet, known as the Spanish windlass, may be employed in cases of emergency ; it is prepared by folding a handkerchief or piece of muslin into a cravat and placing a compress or smooth pebble on the body of the cravat ; this is placed over the artery to be controlled, and the ends of the hand- kerchief are tied loosely around the limb ; a short stick is passed through this loop, and by twisting the stick the loop is tightened and the compress is forced down upon the artery (Fig. 223). Many other forms of tourniquet have been devised which have the pad and counter- pad arranged to make pressure upon the vessel, such as Lister's aorta compressor (Fig. 224), which is employed in the treatment of aneurism of the iliac vessels and for the control of hemorrhage in ampu- tation at the hip-joint. Signorini's tourniquet (Fig. 225) is constructed upon the same principle, and is frequently employed to control the circulation in the femoral artery in cases of operations on the thigh and leg and in the treatment of femoral or popliteal aneurism. Elastic Constriction. — The elastic tube, or the strap of Esmarch's apparatus (Fig. 226), may also be employed ELASTIC CONSTRICTION. 295 for the temporary control of arterial hemorrhage, being applied above the wound : and if it is not at hand, any strong rubber cord or a piece of Fig. 223. large-sized drainage-tube may be used as a substitute. Elastic sus- penders or garters may also be employed in an emergency. In hemorrhage from wounds of the hands and feet, especially in chil- Fig. 224. The Spanish windlass. .Lister's aorta compressor. dren, and in controlling hemorrhage from wounds of. the penis, a piece of drainage-tube, firmly applied above the wound, may be employed with advantage. Care should be observed in applying elastic constriction, for if the elastic tube be applied too tightly, the subcutaneous tissues may be divided or nerves mav be so compressed that their func- tion is destroyed. The tube or strap, although generally employed to control hemorrhage from vessels of the extremities, may be used to control the femoral artery as it crosses the brim of the pelvis, by placing a com- press over the artery in this position, and then applying the elastic band to secure it by making a figure-of-eight turn, passing under the thigh, crossing over the pad, and 296 MINOR SURGERY. Fig. 225. then carrying the ends around the pelvis, and securing them. To make pressure on the axillary artery, a compress should be placed in the axilla, and the middle of the tube placed over this to hold it in position ; the ends of the tube are then carried over the shoulder, where they are crossed, and then carried to the opposite axilla and secured. Fig. 226. Signorini's tourniquet. Elastic strap of Esmarch's apparatus. Haemostatic Forceps. — The temporary control of arte- rial hemorrhage by the use of haemostatic forceps is now very generally employed in surgical operations, and their use has done much to diminish the shock following opera- tions from the loss of blood. The haemostatic forceps in general use is self-retaining ; it is clamped upon the bleed- ing vessel, and is allowed to remain until the operation is completed, when the vessel is secured permanently by the application of a ligature, and the forceps is removed. The use of these forceps will be found very satisfactory in controlling hemorrhage during the removal of tumors ; in amputations, and for the temporary control of bleeding during the operation of tracheotomy, they will be found most efficient, as also in abdominal operations, in which their utility was first demonstrated (Fig. 227). Esmarch's Bandage and Tube. — This apparatus, />.i/. 1 ncirs bam)A<;e axd tube. 297 which is applied to the limbs to render them blood- less during operations, consists of a rubber band- age two and a half inches in width and three or four yards in length, and a rub- ber tube two yards in length, to one end of which is attached a chain and to the other a hook, or, better, a rubber strap, one inch in width and one and a half yards in length, with a hook and chain. The bandage is applied to the extremity of the limb, and is carried up the limb to a point some distance above the seat of proposed operation ; the bandage is applied firmly, each turn overlapping one- fourth of the preceding one, and when the last turn has been made the rubber tube or strap is wound firmly around the limb and secured by fastening the hook into one of the links of the chain (Tio- 228} ° After securing the tube or strap, the rubber bandage is removed from the limb ; and if the tube has been sufficiently firmly applied, the limb will be found blanched, and should be free from blood during the opera- tion. Care should be taken not to apply the tube or strap too tightly upon poorly developed limbs, or on parts of the limb where large nerve-trunks approach the sur- face, as thev mav be subjected to an amount of pressure which will interfere with their functions subsequently. I have knowledge of one case of this nature in which permanent paralysis of the limb followed the use ot Esrnarch's apparatus ; the tube should be applied with Hemostatic forceps. 298 MINOR SURGERY. just sufficient firmness to control the circulation. As the strap, when firmly applied, completely cuts off the circu- lation of the parts below, it should be applied for as short a time as possible, as gangrene has resulted from its pro- longed use. After removal of the tube or strap there is generally free capillary hemorrhage, due to paralysis of the vasomotor nerves from pressure, but this in a short time stops. This appliance is of the greatest service in Fig. 228. Esmarch's bandage and tube applied. controlling hemorrhage at the time of operation, and in amputations and for removal of vascular tumors from the limbs will be found most satisfactory. In operations upon bones, such as resection or sequestrotomy, it is especially useful, as it allows the surgeon to inspect the parts unob- scured by hemorrhage. I have found its use most satis- factory in operations for the removal of foreign bodies, such as needles embedded in extremities. Permanent Control of Arterial Hemorrhage. To secure this end, the surgeon may resort to the use of position, cold, heat, styptics, pressure, cauterization, liga- tion, torsion, suture of the artery, or acupressure. Position. — In arterial hemorrhage from wounds of the extremities, elevation of the part will be found to mate- rially diminish the amount of bleeding ; in hemorrhage from wounds of the arteries of the hand, forearm, foot, or HOT WATER. 299 leg, forcible flexion of the forearm on the arm or of the leg on the thigh will be found useful in diminishing the force of the blood-current. Cold. — The application of cold by means of a stream of cold water or an ice-bag or pieces of ice will often he found an efficient means of controlling hemorrhage from vessels of small calibre : it is especially applicable to hem- orrhage from wounds of the vessels of the mouth, nostrils, vagina, or rectum. Hot Water. — Hot water will be found a very efficient means of controlling hemorrhage from small vessels, and it may be used in the form of a hot antiseptic solution. It is of especial value in capillary or parenchymatous hem- orrhage, and is employed in the form of a douche or by means of sponges or gauze pads dipped in the hot solution and packed into the wound. The injection of hot water is a most satisfactory method of controlling uterine hem- orrhage. Styptics. — These agents are sometime- employed to control capillary bleeding or hemorrhage from small ves- sels, and although their use is often satisfactory as regards the control of the bleeding, they have the disadvantage of interfering with primary union in wounds, and since the value of asepsis in wound treatment has been demon- strated they are now very seldom employed. The most valuable styptics are alcohol, alum, oil of turpentine, per- chloride of iron, persulphate of iron or MonsePs solution, acetic acid, vinegar, adrenal chloride, antipyrin, and gelatin. Adrenalin Chloride. — A solution of adrenalin chloride, 1 part to normal salt solution 1000 parts, has been re- cently employed for the control of hemorrhage. It seems to be most serviceable in capillary hemorrhage. Antipyrin. — A solution of antipyrin, 5 per cent., in sterilized water possesses marked styptic action. As it also possesses antiseptic properties and is not toxic, it may be used to control capillary bleeding from the surface of the brain, the intestines and peritoneum, and from bone- cavities. Gelatin. — This may be used as a styptic where it can 300 MINOR SURGERY. be applied locally in a 5 to 10 per cent, solution in normal salt solution. It may be applied by injecting, irrigating, or tamponing the bleeding area. It has been employed successfully in epistaxis, hsematemesis, vesical and uterine hemorrhage, and in superficial wounds in patients the subjects of haemophilia. Pressure. — For the permanent control of arterial hem- orrhage, pressure may be applied directly to the bleeding point or surface by means of a compress of antiseptic gauze or by strips of gauze packed firmly into the cavity from whose surface the bleeding arises. Compresses are used with the best results where the proximity of a bone gives a firm substance upon which the vessel may be compressed, as is the case in the vessels of the scalp. Pressure applied by means of packing with strips of gauze will be found most efficient in controlling hemorrhage from cavities, such as the nose, vagina, or rectum, and in the cavities resulting from the removal of necrosed or carious bone. Pressure may be indirectly applied to an artery by flexing the joint over a compress or by firm bandaging of the limb. In controlling bleeding from a divided artery in a bony cavity, such as the inferior dental, a piece of catgut liga- ture may be forced into the canal, and will control the bleeding in a most satisfactory manner, or it may be controlled by forcing a small piece of Hor sky's wax into the opening in the bone ; this wax is composed of wax, 7 parts ; oil, 2 parts ; and carbolic acid, 1 part. Halsted has introduced a material known as gut wool, which is prepared from the same material from which cat- gut is made. This is cut into fine shreds, and is used to control hemorrhage from bone, being pressed into the open- ing or cavity in the bone from which the bleeding arises. The troublesome hemorrhage sometimes occurring after the removal of a tooth may be controlled by packing the alveolar cavity with a strip of iodoform gauze, or by introducing a wedge-shaped piece of cork and holding it in place by fastening the jaws together by means of a bandage. TORSION. 301 Cauterization. — The use of cauterization by means of a hot iron is a satisfactory method of arresting hemorrhage. Care should be taken to have the iron only of a dull-red or black heat, as the result desired is not the destruction of the tissues, but the coagulating effect of heat upon them. The form of cautery-iron employed will depend upon the size and position of the vessel. Paquelin's cautery is also a satisfactory apparatus to use for the control of hemor- rhage. The control of arterial bleeding by cauterization is often resorted to in operations upon the jaws and in the removal of tumors from the mouth or pharynx or of the tonsils ; it is also frequently employed to control hemorrhage in operations upon the uterus and the rectum, and also that resulting from the removal of abdominal tumors, where the application of a ligature is difficult and often impos- sible. Torsion. — This method of controlling arterial hemor- rhage consists in seizing the end of the artery, drawing it slightly out of its sheath and twisting it ; it may be accom- plished with a single pair of forceps or haemostatic forceps, or by two pairs of forceps. In the latter method the vessel is held by one pair of forceps and is twisted by the second pair. Torsion of arteries in accidental wounds is quite com- mon, and in many cases controls the hemorrhage until sur- gical aid is rendered. I have seen hemorrhage from the femoral artery in Scarpa's triangle completely controlled in this manner in a case of avulsion of the thigh from a railway injury. Fig. 229. Double-spring artery forceps. In vessels of moderate size it may be practised with one pair of forceps, and the ordinary double-spring artery for- ceps (Fig. 229) or haemostatic forceps will be found satis- 302 MINOR SURGERY. factory for such cases. In larger arteries two forceps should be employed, or some of the numerous forms of torsion forceps which have been devised for this purpose. Ligation. — The use of the ligature is by far the most generally employed method of controlling arterial hemor- rhage. The materials used are silk, hemp thread, or cat- gut. Catgut or silk is the material generally employed. Fig. 230. Tenaculum. The vessel is seized with a pair of artery or haemostatic forceps or a tenaculum (Fig. 230) and drawn out of its sheath, and a ligature of sterilized catgut or silk is thrown around it and secured by a surgeon's knot, or by a reef knot and a surgeon's knot combined, and when firmly tied the ends of the ligature are cut short in the wound. Fig. 231. Aneurism needle armed with ligature. When ligatures are applied to vessels in their continuity, they may be threaded into an eyed probe or aneurism needle (Fig. 231) and carried around the vessel and secured. Deep Sutures. — A convenient method of applying a ligature to a bleeding point in a deep wound, or to a vessel in tissues which are of such a nature as not to permit of the isolation of the vessel, is to use a curved needle threaded with a catgut ligature, which is passed deeply SUTURE OF ARTERIES. 303 into the tissues near the vessel and brought out on the opposite side; the ligature thus placed is then firmly tied, and the ends are cut short in the wound (Fig. 232). Fig. 232. Artery occluded by suture. (Esmarch.) Suture of Arteries. — Wounds of arteries, both longi- tudinal and transverse, have been successfully closed by sutures both in man and the lower animals. It is recom- mended in the larger arteries, where more than two-thirds of the circumference has been divided, to resect the injured portion of the vessel, where it can be done without remov- ing more than three-fourths of an inch of the vessel, and invaginate one end into the other, and to secure their fixa- tion by fine silk sutures. In longitudinal wounds the edges may be brought together by fine silk sutures, intro- duced by means of a fine cambric needle. The sutures should be inserted from one-sixteenth to one-twentieth of an inch apart, and one-sixteenth of an inch from the edges of the wound, and should include only the adventitia and media, not perforating the intima. During the operation the circulation in the vessel should be controlled both above and below the wound by forceps covered with rubber tubing. Where a distinct sheath is present, it should be sutured over the wound ; and if this is not present, muscle or fascia should be sutured over the closed wound in the vessel. Acupressure. — In this method of controlling arterial hemorrhage a needle or pin is used, which is thrust 304 MINOR SURGERY. through the tissues in such a way as to compress the artery. Jn the first method of acupressure the surgeon places a finger of his left hand upon the mouth of the bleeding vessel, and with his right hand introduces the needle from the cutaneous surface and passes it through the thickness of the flap until its point projects for a couple of lines or so from the surface of the wound a little to the right side of the end of the vessel. By forcibly inclining the head of the needle toward his right, he brings the projecting portion of its point firmly down on the side of the vessel, and after seeing that it occludes the artery he makes it re-enter the flesh as near as possible to the left side of the wound and pushes the needle through the flesh until its Fig. 233. Fig. 234. Acupressure — first method ; raw surface. (Erichsen.) Acupressure— first method ; cutaneous surface. (Erichsen.) point comes out again at the cutaneous surface (Figs. 233 and 234). There are a number of methods of using the needle or pin in acupressure to produce occlusion of the vessel, but as this method of arresting hemorrhage is not often em- ployed at the present time they need not be described. Rules for Ligating Wounded Arteries.— The follow- ing rules for the application of ligatures to wounded arteries have been recommended by Ashhurst : 1. In cases of primary hemorrhage, no operation should be performed upon an artery unless it is at the moment actually bleeding. The exception to this rule is in the cases where the vessel is seen to pulsate in the wound, or where the wound involves the region of a large artery and VENOUS HEMORRHAGE. 305 the patient has to be transported or may be in a position not to receive surgical aid subsequently if needed ; under these circumstances, the vessel should be tied or the wound should be explored to ascertain the fact that no important vessel has been injured. '2. In applying a ligature to a wounded artery, the surgeon should cut down directly upon it at the point from which it bleeds and secure it in the wound. This rule holds good for both primary and secondary hemorrhage. 3. Two ligatures should be applied, one to each end of the artery if it be completely divided, and one on each side of the wound if the latter has not severed all the coats of the artery. This procedure is adopted for the reason that arterial anastomosis is so free that the proximal liga- ture will not always, even temporarily, arrest the bleeding ; and if it does accomplish this object at the time, after the collateral circulation is established bleeding is apt to occur from the distal extremity of the divided vessel. If the coats of the artery are not completely severed, their divis- ion should be completed, either before or after the appli- cation of the proximal and distal ligatures, thereby favor- ing contraction and retraction of the ends of the divided vessel. Treatment of Venous Hemorrhage. Bleeding from small veins often stops spontaneously unless there is pressure upon the wounded veins on the cardiac side of the wound. It is, however, very satisfac- torily controlled by position or by the application of a compress and bandage, or by the use of a ligature ; if the divided vein be a large one, it is well to secure both ends by ligatures. The free bleeding arising from rupt- ured varicose veins of the leg is easily controlled by the application of a compress and bandage; while hemorrhage from the larger veins, such as the jugular, should be con- trolled by the application of ligatures, as in the case of wounded arteries. The Lateral Ligature. — The application of the lateral ligature to small wounds of large veins, such as the 20 Q 06 MINOR SURGERY. femoral, or to wounds of venous sinuses, has been recommended and employed with good results: this pro- cedure consists in pinching up the wall of the vein so as to include the orifice of the wound and throwing a deli- cate ligature around it. Suture of Veins. — This procedure has also been em- ployed with success in the case of the larger veins. The bleeding should be controlled by pressure upon the vein on both sides of the wound, and the wound in the vessel should be closed by fine silk sutures applied closely together by means of a fine cambric needle. The employ- ment of sutures and lateral ligatures in wounds of veins possesses the advantage of controlling the bleeding and at the same time not causing obliteration of the vessel at the seat of injury. The actual cautery may also be employed for the con- trol of venous hemorrhage in situations in which its arrest by pressure or the ligature is not feasible. Compression by means of strips of sterilized gauze is often employed to control venous hemorrhage from cavi- ties. Treatment of Capillary Hemorrhage. Capillary or parenchymatous hemorrhage is often arrested spontaneously on exposure of the surface of the wound to the air, but the bleeding may not be controlled and may be so profuse that its arrest becomes a matter of importance. To control this form of bleeding, pres- sure may be applied to the bleeding surface for a short time, and if this fails to arrest it, sponging the surface with dilute alcohol will sometimes prove satisfactory; but the best application to arrest hemorrhage of this nature is hot water, which may be used in the form of a hot bichloride solution or antipyrin solution. Adrenal chloride, 1 part to normal salt solution 1000 parts, or a 5 to 10 per cent, solution of gelatin in normal salt solution, may be employed. Acetic acid and vinegar are also sometimes employed for the same purpose. In cases where the means men- EPISTAXIS. 307 tionecl above fail to control the bleeding, it may he neces- sary to pack the wound with strips of antiseptic gauze ; this dressing is most serviceable when the hemorrhage comes from cavities such as result from the removal of tumors or excisions of joints, and for the control of bleed- ing following the removal of necrosed or carious bone. To control hemorrhage from mucous cavities, such as the nose, rectum, and vagina, this method of treatment is also frequently resorted to. Treatment of Secondary Hemorrhage. Secondary hemorrhage following the use of the ligature or other means of controlling bleeding, usually results from a septic condition of the wound, and is due to a septic arteritis. Since the adoption of the antiseptic and aseptic methods of wound treatment it is a much less frequent complication of wounds. The treatment of this complication is both constitu- tional and local. The constitutional treatment consists in the use of those remedies which were mentioned as ser- viceable in primary hemorrhage, and the drugs upon which most reliance should be placed are opium and ergot. The local treatment of this form of hemorrhage consists in the use of the various means of controlling hemorrhage which have been mentioned, such as the ligature, hot water, pressure, or the actual cautery. If possible, it is well to secure the vessel from which the bleeding arises in the wound ; if for any reason this cannot be done, the main artery should be ligated above the wound if the hemor- rhage be arterial. Control of Hemorrhage from Special Parts. Epistaxis, or hemorrhage from the nose, may be so pro- fuse as to require surgical interference. To control this form of hemorrhage, the application of iced compresses to the surface of the nose may first be made use of; and if this fails to control the bleeding, the surgeon or the patient 308 MINOR SURGERY. should grasp the cartilaginous portion of the nose with his thumb and forefinger in such a manner as to keep the nos- trils tightly closed, which will prevent the passage of air through the nose and thus permit clots to form, arresting the flow of blood. Bleeding from the nose often arises from the erosion of a small artery low down upon the sep- tum, which can be freely exposed by introducing a nasal speculum, and the bleeding point may be touched with a cautery-iron, thus avoiding the necessity of plugging the nares.' If these simple means fail to arrest the bleeding, the nasal cavity or cavities may be packed with strips of antiseptic gauze introduced into the anterior nares, and pushed backward by a director or probe ; this will often be found a satisfactory means of arresting the bleeding. This method may be supplemented by a plug of antiseptic cotton introduced into the posterior nares with the finger. The use of a rubber tampon, consisting of a rubber bag, introduced into the nares in a collapsed state and after- ward inflated, has also been recommended for the control of this variety of hemorrhage. Another method of controlling hemorrhage from the nose consists in introducing a small piece of sponge or pledget of sterilized gauze, tied to a strong silk ligature, into the anterior nares and pushing it back along the floor of the nose to the posterior nares ; a piece of sponge or gauze about the size of a marble, with a hole in the centre, is threaded on the ligature and pushed back until it comes in contact with the first piece introduced, and thus by introducing a number of pieces of sponge or gauze in this way the nasal cavity may be completely filled and the bleeding arrested. Care should be taken to see that the sponge has been rendered aseptic before being intro- duced, and the nasal cavity should be washed out with an antiseptic solution before its introduction. The sponges or gauze may be allowed to remain for twenty-four to forty-eight hours (Fig. 235). Plugging the nares by means of Bellocq's canula is also employed to arrest hemorrhage from the nasal cavities ; the canula, armed with a strong ligature, is passed along KPISTAXIS. Fig. 235. 309 Plugging the nares from the front. (Roberts.) Fig. 236. Plugging the nares with Bellocq's eanula. (Fergusson.) 310 MINOR SURGERY. the floor of the nose until it reaches the pharynx, when the spring being protruded, the ligature is seized and brought out of the mouth and secured to a plug of lint or of antiseptic gauze of the required size, and upon with- drawing the instrument the plug is brought into position in the posterior nares and the end of the ligature allowed to protrude from the mouth to facilitate its removal (Fig. 236). An ordinary flexible catheter may be employed in- stead of Bellocq's canula for the introduction of the liga- ture. Hemorrhage from the Urethra. — In hemorrhage from the urethra, if profuse, the blood will trickle from the meatus ; or if efforts at micturition are made, the first por- tion of urine will contain blood, but afterward will be clear, and the last portion will contain a few drops of pure blood. This variety of bleeding, if it proceeds from the ante- rior portion of the urethra, may be controlled by the introduction of a catheter and the application of a band- age around the penis applied so as to make only moderate pressure. If the bleeding comes from the posterior portion of the urethra, it will often be controlled by the application of cold or pressure to the perineum, or by the introduction of a cold steel bougie, or by the injection of a weak solu- tion of tannic acid or antipyrin. Hemorrhage from the Bladder. — In this variety of hemorrhage the first portion of the urine may be blood- stained, and the last portion will contain more blood and clots as the organ contracts, which distinguishes it from hemorrhage from the kidneys, in which admixture of blood with the urine renders it of a smoky color, or dark red if the bleeding is profuse. To control bleeding from the bladder, a catheter should be introduced and the urine and clots withdrawn ; the bladder should next be washed out with a warm or cold boric acid solution. In severe cases a weak solution of tannic acid, antipyrin, alum, or adrenal solution may be employed. The application of ice to the perineum and suprapubic regions may also be employed with advantage. TREATMENT OF ABS( ESS 311 Hemorrhage from the Rectum.— This variety of bleeding may be controlled by the injection of cold or astringent enemata. If the bleeding be profuse, a speculum should be introduced, and when the source of the bleed- ing has been discovered the actual cautery or a ligature should be applied. If this is not feasible, the rectum may be plugged with strips of antiseptic gauze, or a piece of a rubber catheter of large calibre may be wrapped with gauze and introduced into the rectum, the end of the catheter being allowed to protrude ; by using this tube flatus can escape, and if the bleeding is not controlled blood will escape through the tube, preventing the risk of concealed hemorrhage. If the bleeding arises from hemorrhoids or polypus of the rectum, operative treatment of these conditions should be undertaken to remove the cause of bleeding. TREATMENT OF ABSCESS. In operations for evacuation of the contents of abscesses care should be taken to observe every precaution to pre- vent a new infection of the wound or abscess cavity ; the skin over the abscess should be carefully cleaned to make it aseptic, the hands of the surgeon and the instruments to be brought in contact with it should also be aseptic. These precautions should be especially observed in the opening of chronic abscesses when a new variety of infec- tion is liable to be introduced if aseptic precautions are not rigidly observed. Acute Abscess. — This variety of abscess should be opened by incision, and this is best done with a straight, narrow, sharp-pointed bistoury. The incision should be deep enough to expose freely the cavity of the abscess, and should be parallel with and not across important structures, and it should also be made at as dependent a portion as possible. Abscesses of the limbs are opened by a longitudinal incision, and those in the region of the anus and breast by an incision radiating from the anus or nipple. Hilton's Method.— In deep-seated abscesses in the region 31^ MINOR SURGERY. of important structures the method of opening suggested by Mr. Hilton may be employed with advantage: it con- sists in making a small incision through the skin and cellular tissue; a director is next pushed through the tis- sues into the abscess cavity, which will be shown to have been reached by the escape of pus along the director; a dressing-forceps with the blades closed is now pushed along the director into the abscess cavity, and when this has been accomplished the director is withdrawn and the forceps removed with the blades expanded so as to dilate the wound and allow the pus to escape. Pressure should not be made upon the walls of the abscess to empty it, as by so doing delicate vessels may be ruptured and cause hemorrhage, and the spread of the infection may be facilitated. The cavity of the abscess having been emptied of pus, it may be irrigated with a stream of carbolic or bichlo- ride solution, or the irrigation of the cavity may be omitted, and if the cavity is not very large or deep, no drainage-tube need be introduced, and a small piece of protective may be placed between the lips of the wound to prevent their adhesion ; but if, on the other hand, the cavity is extensive and deeply situated, a rubber drainage- tube or a strip of iodoform gauze should be introduced to the bottom of the cavity to secure free drainage, and if a tube be used, fixed at the surface of the skin by a safety- pin. A gauze dressing, consisting of a number of layers, which has been moistened in carbolic or bichloride solu- tion, is next placed over the wound, and is covered by a number of layers of dry gauze, which are in turn covered by a piece of rubber-tissue. The latter may be substi- tuted by a few layers of bichloride cotton, and the dressing is finally secured by a roller-bandage. The dressing is removed at the end of two or three days, the cavity being washed out with one of the antiseptic solutions previously mentioned. The drainage-tube may then be shortened or removed, and the dressings reapplied as at the primary dressing. Under this method of treatment acute abscesses usually heal promptly. TREATMENT OF ABSCESS. 313 Chronic or Tuberculous Abscess. — This variety of abscess, which occurs chiefly in connection with diseases of the bones or joints or of the lymphatic system, is tubercular in origin, and may be opened in various ways, the time at which this should be done depending upon the size and situation of the abscess and the amount of constitutional and local disturbance which the patient ex- periences from its presence. Aspiration. — A tuberculous abscess may be evacuated by means of the aspirator ; the pus being withdrawn as far as possible, the puncture is sealed with a small piece of gauze covered with iodoform collodion. Reaccumulation of pus often takes place, and the aspiration has to be repeated a number of times. The greatest difficulty in the success- ful removal of the contents of tuberculous abscesses by means of aspiration is the presence of cheesy masses in the pus, which occlude the canula and often prevent complete emptying of the cavity. Puncture and Injection. — This variety of abscess may also be evacuated by making a puncture through the skin and overlying tissues with a narrow bistoury, the surface having been previously thoroughly washed with soap and water and with a carbolic or bichloride solution ; a direc- tor is next pushed through this small wound into the cavity of the abscess, and the pus is allowed to escape by stretching the wound with the director ; when the cavity is emptied of pus it is washed out with a carbolic or bichlo- ride solution introduced into it by pushing the nozzle of a syringe into the cavity, and this is allowed to escape in the same way as the pus previously did. When all the irri- gating solution has escaped, the cavity may be injected with an emulsion composed of iodoform, 1 part, glycerin 10 parts ; after this has been introduced the small wound is closed by a compress of antiseptic gauze held in place by a compress of bichloride cotton and a bandage or by strips of adhesive plaster. The injection of the iodoform emul- sion need not be repeated as long as iodoform continues to be excreted in the urine. In evacuating tuberculous abscesses by means of the as- 314 MINOR SURGERY. pirator or by a small puncture, there is absence of shock, and the loss of blood is insignificant, so that these pro- cedures should generally be first employed, and the more radical operation of incision and curetting of the cavity of the abscess, which is accompanied with a certain amount of shock and hemorrhage, should be reserved for those cases in which the less severe operations have not been followed by a satisfactory result. Incision. — Tuberculous abscesses are also treated by making a free incision into the abscess cavity with full antiseptic precautions, and after the escape of the puru- lent matter the walls of the abscess should be thoroughly scraped with a curette ; after the cavity has been freely washed out with a carbolic or bichloride solution large drainage-tubes are introduced and an antiseptic dressing is applied to the wound. The edges of the incision may be brought together by sutures without the introduction of drainage, or the cavity may be packed with iodoform gauze and allowed to heal by granulation. The dressings are removed as soon as they become soaked, and the drain- age-tubes are shortened or removed as the discharge dimin- ishes and the cavity contracts. Diffused Suppuration. — This form of suppuration is treated by numerous punctures or incisions, which allow the purulent matter to escape ; and where sloughs are pres- ent, free incisions may be required to give exit to the necrosed tissues ; the introduction of drainage-tubes may also be required. The wounds and the cavities, as far as possible, should be washed out with a carbolic or bichlo- ride solution and an antiseptic gauze dressing applied. Sinuses. — These are suppurating tracts which result from abscesses or wounds. If superficial, they should be laid open freely and their surfaces scraped with a curette, and then lightly packed with strips of bichloride or iodo- form gauze and covered by an antiseptic dressing. If they are too deep to be treated by incision, their healing may be facilitated by the injection of stimulating solu- tions introduced by means of a syringe ; the employment of solutions of chloride of zinc, nitrate of silver, and sul- SHOCK. 315 phate of copper, varying in strength from 5 to 20 grains to the ounce of water, will often prove satisfactory. SHOCK. Shock is a condition of physical depression or prostra- tion which often develops after severe injuries or opera- tions. Paralysis of the vascular tone in the arteries, with coincident feebleness of the action of the heart, causes an unequal distribution of the blood, and the balance of the circulation is disturbed ; the abdominal veins become dis- tended and the right side of the heart becomes engorged, the amount of blood in the arteries being correspondingly lessened ; the brain and the lungs become anaemic, and if the condition persists the action of the heart is arrested. The essential condition of shock is inhibition of nerve force and reflex paralysis. Shock may develop immedi- ately upon or some time after the reception of the injury. Every traumatism is probably followed by a certain amount of shock, and, as a rule, its degree is proportionate to the severity of the injury received. Yet this rule is not without exception ; certain classes of injuries are at- tended with marked shock, and the part of the body sus- taining the injury will have an important influence upon the degree of development of shock. Contusions of the viscera, wounds of the testicle, contused and lacerated wounds of the trunk and extremities, if extensive and ac- companied by free hemorrhage, are usually followed by marked and often fatal shock. Gunshot wounds causing perforation of important cavities of the body, injuries of the viscera, and shattering of the bones are also well recog- nized as giving rise to shock in a marked degree. Burns and scalds, if they involve a considerable surface of the body, are attended with severe shock. Diagnosis. — The condition of shock resulting from purely emotional causes is usually not profound or pro- longed, and can be differentiated from that resulting from corporeal injuries by the history of the case. The con- 316 MINOR SURGERY. dition arising from excessive hemorrhage presents many symptoms common to shock, but here the nature of the injury will often assist in the diagnosis, and in doubtful cases examination of the blood may be of service, for if such an examination shows that the red blood-cells are considerably diminished, being 3,500,000 or less, it is probable that the condition is due to hemorrhage rather than shock. Fat embolism may also be confounded with shock, but it should be remembered in differentiating the conditions that shock usually appears promptly, and the symptoms of fat embolism from thirty-six hours to three days after the injury. The experimental researches of Crile have largely confirmed our clinical observations as regards the development of shock in injuries and opera- tions in different regions of the body. A patient suffering from shock presents pallor of the surface, paleness of the lips, dilated pupils, clammy moist- ure of the skin, muscular debility, occasionally relaxation of the sphincters, frequent, feeble, irregular pulse, subnor- mal temperature, and feeble, short, sighing respiration ; in many cases extreme thirst is a prominent symptom. The senses are often perfectly retained. The temperature is always subnormal, and may vary from a point a little below the normal to a point below 90° F. (32° C). A depression below 97° F. (36° C), if it persists for a few hours, usually indicates a grave condition of shock, and reaction may not occur, although it has been observed in cases where the temperature was as low as 90° F. (32° C). Prophylaxis. — Unfortunately, many of the worst cases of shock are due to accidents, and here treatment can be directed only to the condition of shock itself; but the surgeon is often able to diminish to some extent the amount of shock following operations by judicious prophylactic treatment. In patients in whom shock is apt to be mark- edly developed, as in children or feeble or aged subjects, or in certain classes of operations, he may give stimulants before the operation, and see that the surface of the body is not unnecessarily exposed to chilling during the opera- tion, that the operation is not needlessly prolonged, and SHOCK. 317 that as little blood as possible is lost during its perform- ance. The electro-thermic mattress may be used with ad- vantage, but care should be exercised in its employment, as serious I turns have followed its use. The previous administration of an ounce of whiskey and the hypo- dermic injection of from ^ to ^V of a grain of sulphate of strychnine, and the use of a small dose of morphine, in feeble and aged patients, will be followed by good results. A full dose of quinine given an hour or two before the operation is also said to arrest the development of shock. Treatment. — The first indication in the treatment of shock is to establish reaction. The patient should be cov- ered with woollen blankets, the head should be kept low, and dry heat should be applied to the surface of the body by means of hot-water bags, hot bottles, or hot bricks ; these should be wrapped in towels to prevent them from coming directly in contact with the surface; neglect of this precaution, which is most important if the patient is unconscious, often produces burns which may be followed by extensive sloughing. If the patient can swallow, he should be given small quantities of whiskey or brandy, with 30 minim doses of aromatic spirit of ammonia, and, as absorption by the stomach is probably very slow in these cases, stimulants should be administered hypoder- micallv ; in our judgment, strychnine is the most valuable stimulant that can be employed. From -gL- to 2V of a grain should, therefore, be injected, and the injection re- peated every hour or half-hour until several doses have been given.* Caffeine citrate in doses of grs. ij may also be used with good results. Sulphuric ether, 30 minims, mav also be injected into the cellular tissues at intervals, as well as digitalin or tincture of digitalis. If shock develops during an operation under ether anes- thesia, the use of ether hypodermically is contrainclicated. A stimulating enema of whiskey and warm water may be emploved. In cases of shock where there is profuse sweating, the use of -^ of a grain of atropine, repeated as required, is often followed by good results. A large enema of warm saline solution may also be employed. As 318 MINOR SURGERY. patients often complain of urgent thirst, it is well to let them take a little black coffee, but not large quantities of water ; free indulgence in water does not seem to quench the thirst, and is apt to be followed by vomiting. Intra- venous injection of saline solution is likely to be of most service when the condition has been preceded by the loss of a large quantity of blood. Infusion of saline solution also has been employed with good results. DRESSING OF WOUNDS. Incised Wounds. — These wounds present the condi- tions favorable for prompt healing, and after sterilizing the surrounding skin they should first be carefully irri- gated with saline solution or sterilized water, to remove any blood-clots or foreign bodies, or wiped with a ster- ilized gauze pledget ; and after any hemorrhage which is present is controlled by the use of ligatures, if the wound be an extensive or deep one, provision should be made for drainage by introducing a drainage-tube or a few strands of sterilized catgut at the bottom of the wound, allowing the ends to project from the most dependent portion of the wound. Irrigation of the wound with a 1 : 2000 or 1 : 4000 bichloride solution may be employed if there is reason to suppose the wound has been infected before coming under treatment. In superficial incised wounds, after the hemorrhage has been controlled, it is not usually found necessary to make provision for drainage. If the wound be a deep one, involving the muscles and deep fascia, buried sutures of catgut or silk should be applied to approximate the muscles and fascia ; and if important nerves or tendons have been divided, their ends should be brought into apposition by sutures of catgut or sterilized silk ; the superficial portions of the wound should next be brought together by the introduction of a number of interrupted sutures, catgut, silkworm-gut, silver wire, or silk being employed for this purpose ; the accurate appo- sition of the edges of wounds of this variety is secured by LACERATED WOUNDS. 319 the introduction of a number of sutures placed closely together. After a wound of this variety has been closed, the sub- sequent dressing is accomplished by covering the surface of the wound with a number of layers of sterilized gauze and a pad of sterilized cotton, which are held in place by a gauze bandage. Or a few layers of gauze, which have been soaked in a 1 : 2000 bichloride solution, may be applied to the wound, and over this is laid a pad of ster- ilized dry bichloride gauze of the same thickness, over- lapping the wet gauze by a few inches in all directions ; a few layers of bichloride cotton are next applied over the gauze dressings, and the whole dressing is secured in position by the application of a gauze bandage. Under this form of dressing prompt healing of incised wounds is the rule, and the wound need not be redressed for a week or ten days unless some indications exist for change of dressing at an earlier period. At the time of the first dressing the catgut drain or the drainage-tube is usually removed, and if adhesion of the edges of the wound is firm the sutures may also be removed. A sterilized or bichlo- ride gauze dressing is usually next applied, and allowed to remain for a few days longer. In superficial incised wounds involving only the skin and cellular tissue if limited in extent, after cleansing the wound and controlling the bleeding the edges should be approximated with sutures. The wound should then be covered with strips of sterilized gauze, over which is painted a mixture of: tr. benzoin, 3J ; collodion, Jjvij. This forms a firm antiseptic scab which need not be removed until the wound has healed. Lacerated Wounds. — These present edges which are torn and not sharply cut, and the vitality of the injured parts is often so seriously impaired that prompt union in this variety of wounds is not, as a rule, to be looked for. Wounds of this nature should first be irrigated with saline solution, sterilized water, or a 1 : 2000 bichloride solution, and blood-clots and foreign bodies removed. If the wounds be deep, drainage-tubes should be intro- 320 MINOR SURGERY. duced ; on the other hand, if they be superficial, or if the edges are not closely approximated, provision for drainage may be omitted. The torn or irregular edges of the wound should next be brought into apposition at a few points, by the introduction of catgut or silkworm-gut sutures, applied not very closely together ; and if the edges are discolored and their vitality seems markedly impaired, it is better not to use sutures. If the edges of the wound are so much crushed that their vitality is destroyed, they may be trimmed away with scissors until a surface possessing a fair vitality is secured. The evil results arising from the introduction of sutures into this variety of wounds, with the idea of closely approximating their edges, are so common that the surgeon who dispenses with the use of sutures entirely errs upon the safe side. The use of many sutures in wounds of this nature often causes marked tension, which is frequently followed by impairment of the vitality of the injured tissues, and sloughing results. The wound should next be dressed with sterilized gauze and cotton, or a bichloride gauze dressing may be employed, and if it runs a favorable course it need not be redressed for a week or ten days ; the time required for repair of a wound of this nature is longer than that for an incised wound, and more frequent dressing may be required. In lacerated wounds of the extremities continuous irri- gation of the wound by a warm bichloride or carbolic solu- tion, applied as described, is often followed by the most satisfactory results ; wounds produced by machinery and railway accidents, in which the vitality of the tissues is much impaired, are particularly suitable cases for this method of treatment, and here the same caution should be exercised as regards the introduction of sutures. Contused Wounds. — This variety of wounds possesses many characteristics in common with lacerated wounds : the edges are bruised and the injury of the subcutaneous tissue is often more extensive than the external wound would lead one to suspect. They are dressed in the same manner as lacerated wounds, and the same objection here POISONED WOUNDS. 321 exists to the use of sutures as in the latter class of injuries. Punctured Wounds. — These wounds are inflicted by sharp-pointed instruments, and it may happen that a por- tion of the vulnerating body remains in the wound, as is frequently the case in wounds produced by needles, splinters of wood, metal, or glass ; another complication in this variety of wound is the injury of vessels, giving rise to concealed hemorrhage, or of nerves, resulting in neuritis or neuralgia. Simple punctured wounds should be irrigated with 1 : 2000 bichloride solution and covered by a sterilized or bichloride gauze dressing, and if no complication exists their healing is usually very rapid. A very serious form of punctured wounds arises from the impaling of a portion of the body by pieces of wood or metal, the part being transfixed or simply penetrated ; the penetrating object may break off, leaving a portion of it in the wound, or may retain its position in the body, so that it is difficult to separate the body from it. This acci- dent usually results from persons falling upon sharp sticks, wooden or iron palings. AVhen a foreign body remains in the wound, as often happens in punctured wounds produced by needles and splinters, the punctured wound should be converted into an incised wound, and the body should be searched for and removed ; in doing this in the case of wounds of the extremities the operation is much facilitated by the em- ployment of Esmarch's bandage. The Eontgen or .r-rays may be employed with advantage in locating foreign bodies, such as pieces of glass or metal, in punctured wounds. After the removal of the foreign body the wound is treated as an incised wound, and an antiseptic dressing should be applied. When concealed hemorrhage occurs after a punctured wound, the wound should be laid open and the bleeding vessel searched for and ligated if pos- sible, and the wound should afterward be dressed as an incised wound. Poisoned Wounds. — These wounds are caused by the absorption, by means of a cut or abrasion in the skin, or 21 322 MINOR SURGERY. by the sweat or sebaceous glands, of fluids from a dead body iu making dissections or post-mortem examinations, or in operating upon living subjects, and often result in serious consequences. Infection occurring from a living subject iu operating is apt to give rise to a similar specific infection, or a mixed infection may result ; whereas infec- tion occurring from dead bodies is usually caused by the bacteria of putrefaction, as infective micro-organisms retain their virulence for only a short time after death. Such wounds, as soon as possible after their reception, should be carefully washed out with a solution of bichlo- ride of mercury, 1 : 2000, or a 30-grain solution of chloride of zinc, and then dressed with an antiseptic dressing. If, however, this precaution is not taken, or the wound has escaped notice, and in a few hours becomes inflamed and painful, and evidences of lymphatic involvement show themselves, the wound should be opened and its surface should be thoroughly washed out with a 30-grain solution of chloride of zinc, and finally with a 1 : 2000 bichloride solution, and it should then be dressed with an antiseptic gauze dressing. Under this method of dressing, the poi- soned wound is often converted into a healthy one, even after the lymphatic involvement is well marked, and it usually heals promptly without further constitutional disturbance. Gunshot Wounds. — These wounds are produced by small shot, or fragments of shells, and are of the nature of contused and lacerated wounds, and the vulnerating body as well as portions of the clothing is often imbedded in the tissues. The modern small arms ball has much greater velocity than the leaden ball formerly employed ; it has great penetrating power, and is more apt to pass through the bones without comminuting them. Primary hemorrhage is also more common in injuries produced by this ball. Within a certain range it also possesses marked explosive action, producing great destruction of the tissues with which it comes in contact, which has been recently explained upon the theory of hydrodynamic pressure or CONTUSIONS OR BBUISES. 323 vibratory action. The explosive effect of a small calibre ball depends upon its velocity, striking energy, area of impact, and the resistance to be overcome, so that the damage to the tissues in gunshot injuries is always greater at short range, and decreases with the increase of distance. Stevenson now maintains that the conclu- sions drawn from experiments upon dead animals and men are not borne out by what is observed when living men are wounded by small calibre projectiles. In dress- ing these wounds any foreign bodies, if they can be located, should be removed, and in the search for and removal of balls from the extremities the application of the Esmarch bandage will be found most useful. The a?-rays may also be satisfactorily employed in locating balls or fragments of metal in gunshot wounds. The wound should next be thoroughly washed out with a 1 : 2000 bichloride solution, and an antiseptic dressing applied as in the case of other contused and lacerated wounds. Powder-burns. — These result from the explosion of gun- powder, and, in addition to the burning and laceration of the tissues, are accompanied by the introduction of grains of unburn t powder into the skin, which, if not removed, leave permanent points of pigmentation. These wounds should first be washed with a 1 : 2000 bichloride solution, and upon the face, to avoid unsightly pigmentation of the skin, care should be taken to pick out the small masses of powder with a needle or the sharp point of a tenotomy knife. The surface should then be dressed with antiseptic gauze or with lint spread with an ointment of boric acid or an ointment of aristol, consisting of half a drachm or a drachm of aristol to an ounce of vaseline, this dressing: being covered by a few layers of gauze and cotton, held in place by a roller-bandage. In pigmented scars following powder-burns, the powder grains may be removed by electrolysis. Contusions or Bruises. — These wounds differ from contused wounds in the fact that the skin is not broken, although in spite of this fact there may exist very exten- 324 MINOR SURGERY. sive laceration of the subcutaneous tissues, accompanied by more or less extravasation of blood from the injured vessels. When not sufficiently severe to require operative treatment, they should be dressed by applying over them several layers of lint saturated with lead-water and lauda- num, and over this dressing is placed a layer of waxed paper or rubber-tissue, and the dressing is secured by a roller-bandage. A solution which I find most satisfac- tory in the dressing of contusions is as follows : ammonii chloridi, grs. xx ; tr. opii et alcoholis, aa f J5j ; aqua?, f,?j. Several layers of lint saturated with this solution are laid over the contused tissues, and are covered with waxed paper, oiled silk, or rubber-tissue. Extensive collections of blood following contusions often remain in the tissues for some time, but usually are ab- sorbed. If this result does not follow, or an abscess forms, the blood or pus should be removed by aspiration or by incision with full antiseptic precautions. Brush-burn. — This is a form of contused and lacerated wound which is produced by violent friction applied to the surface of the body, and is often caused by coming in contact with rapidly revolving wheels or the belting of machinery, or by the body being rapidly propelled over an uneven surface, or by a rope being rapidly drawn through the closed hands. The injury may vary from a superficial abrasion to absolute destruction of the skin. The sur- face of the brush-burn should be cleansed by a stream of normal salt solution, sterilized water, or 1 : 2000 bichloride solution, and then dressed with a powder of acetanilid and boric acid, equal parts, and a sterilized gauze dressing ap- plied ; if suppuration occurs, a moist bichloride or acetate of aluminum dressing or boric acid ointment should be applied. Burns and Scalds. — The dressings employed in the treatment of burns and scalds are similar, as the injury to the tissues is practically the same in both classes of injuries. Superficial burns or scalds, in which the effect of the heat has extended only to the superficial layer of the skin, may be treated by the application of lint saturated Avith a solu- BURXS AXD SCALDS. 325 tion of carbonate of sodium, a drachm to an ounce of water ; this dressing rapidly relieves the pain, and is a satisfactory application in this variety of burns and scalds. In cases in which the effects of heat have extended to the deeper tissues, the affected surface may be dressed with Carron oil, which is prepared by rubbing together lime-water and lin- seed oil until a thick, creamy paste results ; lint is saturated with this mixture and laid over the surface of the burn or scald. This dressing is a comfortable one to the patient, but possesses no antiseptic qualities and soon becomes offensive, and for this reason requires frequent renewal. White-lead Dressing. — This application, which con- sists of white lead (Iviij), powdered acacia (oij), sodium bicarbonate (gj), and linseed oil (a sufficient quantity to make a mixture of the consistency of thick cream), is ex- tensively used in the coal regions of Pennsylvania, where severe burns are very frequent. It is spread upon lint or gauze and applied to the burned surfaces ; it does not re- quire frequent renewal, and repair of the injured surfaces is rapid under its use. The disadvantage met with in the antiseptic method of dressing burns and scalds is the fact that the raw surface presented offers most favorable conditions for absorption of the antiseptic substances employed in the dressings, and for this reason the use of bichloride of mercury, car- bolic acid, and iodoform is not to be recommended in burns or scalds involving a large extent of surface, on account of the toxic symptoms which may result from their absorption. In Germany the treatment of extensive burns by con- tinuous immersion of the patient in a warm bath has been followed by good results. Asa recent burn or scald, by reason of the heat employed in its production, is practically an aseptic wound, a simple sterilized dressing may be employed. It may be dressed by covering it with a number of layers of sterilized gauze and cotton, or with powdered boric acid, aristol, or acetan- ilid, and placing over this a number of layers of sterilized cotton, holding the dressings in position by a bandage. 32b* MINOR SURGERY. If, however, a full antiseptic dressing is employed, the injured surface should first be irrigated with a 1 :4000 bichloride solution, and then covered with protective or rubber-tissue which has been sterilized, and over this a dressing of bichloride or sterilized gauze and bichloride cotton should be applied. If this dressing is employed, the patient should be carefully watched for the develop- ment of toxic symptoms. When blebs are present upon the surface of the burn or scald, they should be opened to allow the serum to escape. If suppuration occurs, or the tissues become necrosed by reason of the severity of the injury, the surface of the burn may be irrigated with normal salt solution or a 1 : 4000 bichloride solution, and the same dressing should then be applied. Ulcers resulting from separation of the dead tissues should be touched with a solution of nitrate of silver, 5 grains to the ounce of water, and dressed with lint spread with an ointment of boric acid, aristol, or ichthyol. In the dressing of extensive burns or scalds of the neck, face, and region of the joints, the possibility of serious defor- mity from contraction of the tissues in healing should not be lost sight of, and position, splints, and bandages should be employed to prevent, as far as possible, this complica- tion. Injuries from Electricity. — Since the extensive intro- duction of electricity in the arts, injuries from contact with heavily charged wires are of frequent occurrence. If the current be a strong one, death may be instantaneous, or the patient may be knocked down, become unconscious, and present severe burns at the point of contact, then regain consciousness, and subsequently suffer from numb- ness in the extremities, traumatic neuroses, and in rare cases true paralysis. If the skin be dry at the time the current is received, there will be more burning, less pene- tration and less shock, and less danger of death. The burns are not painful, but are apt to be followed by exten- sive sloughing. Alternating currents are more dangerous than continuous currents ; a continuous current of one INJURIES FROM ELECTRICITY. 327 thousand volts is not apt to be followed by serious conse- quences, whereas an alternating current of the same strength is likely to produce death. Death from exposure to strong alternating currents is considered by Hedley to be caused by destruction of the tissues or by arrest of respiration producing asphyxia. Exposure to a strong electric current may produce burns or ecchymoses, and occasionally wounds ; the latter bleed freely and are apt to slough. A burn from electricity presents a dry blackened surface and is surrounded by an area of pale skin. They are not as painful as ordinary burns, but healing in electric burns is usually slow. In- flammation and suppuration of the tissues usually develop in a few days, and are often followed by the development of an extensive area of moist gangrene, a small burn being followed by extensive and deep destruction of the surrounding tissues. Treatment. — The treatment of a person who has been exposed to a strong electric current, even if apparently lifeless, consists in practising artificial respiration, Laborde's or Silvester's method being employed ; also friction to the surface of the body and enemata of hot saline solution ; in some cases venesection has been employed with advantage. Hedlev records a case of apparent death in a man who received an alternating current of four thousand five hundred volts short-circuited through his body for many minutes, who showed no signs of life for thirty minutes. In this case, after the employment of Laborde's method of artificial respiration for some time, normal respiratory action was restored, and the patient recovered. Artificial respiration should be practised in all cases, and should be continued until it is certain that the patient is dead. At the same time strychnine should be used hypodermically. The burns should be treated by the application of anti- septic dressings, but these often fail to arrest the sloughing. DaCosta recommends in the early stage of these burns the use of fomentations of hot saline solution, which facili- tates separation of the sloughs, and in the subsequent dressing of the wounds peroxide of hydrogen followed by 328 MINOR SURGERY. irrigation with saline solution. After the sloughs have separated, dry sterilized dressings should be employed. Lightning- stroke. — In this form of electric injury a person may be struck directly or may be shocked by an induced current, the lightning having struck some object near at hand. The results of lightning-stroke upon the body differ according as the electrical or the burning action predominates. There may be present severe burns or extensive lacerations, involving the muscles, bloodvessels, and bones ; or sudden death may result from paralysis of the respiration and circulation. Upon regaining conscious- ness, the patient may complain of disturbance of vision, and may suffer from paralysis of the nerves of motion or sensation ; paralysis of the lower limbs is said to be more common than that of the upper limbs. Treatment. — The treatment of the stage of shock follow- ing lightning-stroke consists in the application of external heat, the employment of artificial respiration, and the administration of stimulants. If burns exist upon the surface of the body, they should be treated like burns arising from artificial currents. If paralysis persists for some time after recovery. from the immediate effects of the shock, the use of galvanism and the administration of strychnine may be followed by good results. X-Ray Burns. — A peculiar lesion of the skin and sub- jacent tissues, following prolonged exposure to the ay-rays, resulting in ulceration of the skin and loss of the nails and hair in the damaged area, is described as an ;r-ray burn. This lesion differs from an ordinary burn in that it may not appear for several days or weeks after the exposure, and that the inflammatory or gangrenous process arises in the tissues and finally involves the skin. These lesions are very painful and slow in healing; and if an extensive surface be involved, they may result in serious consequences : amputation of the limb has been demanded by reason of a burn of this nature. The lesion is prob- ably due to trophic changes. Treatment. — The dressings employed in ordinary burns have not proved satisfactory in these injuries. Dry steril- BEDSORES. 329 ized dressings may be employed, and skin-grafting when the ulcerated surface is extensive may be of service. When a small area only is involved, and healing fails to occur, Powell recommends excision of the ulcerated tissues. Bedsores. — These sores usually occur over the sacrum or hips in patients who are confined to bed for a consider- able time, as the result of long-continued pressure, or in cases where the vital powers are depressed by ady- namic diseases, and are also a frequent and troublesome complication in spinal injuries, in which cases they result from trophic disturbances. Their formation may be pre- vented in many cases by the use of air-cushions or of a water mattress, and by keeping the parts exposed to press- ure scrupulously clean and frequently bathing them with stimulating lotions, such as alcohol, olive oil and alcohol (equal parts), or soap liniment. The parts should also be protected from pressure by the application of adhesive plaster, or, still better, soap plaster spread upon chamois skin. When a bedsore has actually formed — and in many cases its formation is very rapid and the slough will be found to involve a large surface of the skin over the sac- rum, and to extend down to the bone — we have present a very serious complication, and one which requires most careful treatment. The dressing of a bedsore before separation of the slough consists in relieving the part from pressure by the use of an air-cushion placed under the buttocks, and the application of a moist antiseptic dressing until the slough has separated. When the slough has become detached, the ulcer remaining should be well irrigated with a 1 : 2000 bichloride solution, and the granulations touched with a o-grain solution of nitrate of silver ; and aristol, or boric acid ointment spread upon lint, should be applied to the surface of the ulcer, and a piece of soap plaster a little larger than the ulcer should be placed over this dress- ing and held in place by broad strips of adhesive plaster. This dressing should be renewed every day or every other day, and means should be adopted to protect the parts 330 MINOR SURGERY. from farther pressure, and the constitutional condition of the patient should be improved by the administration of a nutritious diet, tonics, and stimulants. The application of the galvanic current has been employed to promote healing of the ulcer in obstinate cases. Sprains. — Sprains of the joints from twists or other external violence resulting in the stretching or laceration of the ligaments are injuries which require careful dressing. Sprains may be first treated by the application of cold- water or hot-water dressings for a few hours, or by the application of lead-water and laudanum, the joint being kept at rest by the use of a splint or by confining the patient in the recumbent posture in the case of sprains of the joints of the lower extremities. After a few days' use of the lead-water and laudanum dressing the swelling usually subsides, and the joint may be fixed by the application of a moulded soap-plaster splint or felt splint held in place by a firmly applied roller-band- age, which should be worn for a week or ten days ; in ordinary cases after this time the splint may be removed and the patient should be encouraged to use the joint. In cases of severe sprains, on the other hand, the pain and swelling persist for some time, and here the fixation of the joint by a plaster-of-Paris bandage will be found useful for a few weeks. In the chronic stage of a sprain, after all dressings have been removed, the methodical use of massage is often most beneficial ; and after the parts have been thoroughly man- ipulated a flannel bandage should be applied, which, by its elasticity, gives a certain amount of support to the parts. Strapping. — The treatment of sprains which I have found the most satisfactory, both in the acute and chronic stage, consists in the use of strapping. Strips of adhesive or rubber adhesive plaster one and a half inches in width are applied around the joint, and are made to extend some distance above and below it; a gauze bandage is next applied over the straps, and the patient is allowed to use the part as soon as he can do so without discomfort (see page 176). SPRAIN-FRACTURE. 331 Sprain-fracture. — Under this name Mr. Callender has described an injury which consists in the separation of a ligament or tendon from its point of insertion into a bone, with the detachment of a thin shell of the bone ; this injury is apt to occur about the ankle-joint, knee-joint, elbow-joint, and wrist-joint, and the treatment is the same as that of an ordinary fracture in the same locality. This injury is probably much more common than is gen- erally supposed in connection with sprains of the joints, and is, I think, in many cases the cause of tardy restora- tion of the function of sprained joints, this injury being overlooked, simply being treated as a sprain, and the patient being encouraged to use the part before union of the bone has been accomplished. Strains of Muscles and Fascia. — These vary in sever- ity from simple stretching of the fibres to absolute rupt- ure, and should be treated by putting the parts at rest and by the application of pressure by means of adhesive straps or of a bandage ; in strains of the muscles and fascia of the back the use of broad strips of adhesive plaster, applied as in cases of fracture of the ribs, will be found most sat- isfactory. In the treatment of the later stages of these injuries the employment of massage will often be followed by good results. PAET III. FRACTURES. In the following section the author has endeavored to confine himself simply to a description of the varieties of fracture and to their dressing and treatment, and he has tried as far as possible to avoid the multiplication of dressings, being satisfied to describe a few of the methods of dressing most frequently employed. He has also avoided the description of complicated splints and dress- ings, by the use of which in certain fractures most excel- lent results are obtained, but has preferred to recommend the employment, of simple splints and dressings, which can be obtained by physicians practising in districts remote from large cities, where the services of an instru- ment-maker cannot be obtained to construct special appa- ratus for the treatment of these injuries. VARIETIES OF FRACTURE. Complete Fracture. — This is a fracture in which the line of separation completely traverses the bone, involv- ing its entire thickness. Incomplete Fracture. — This is a fracture in which there is only a partial separation of the bone-fibres (Fig. 237), under which name is included partial or "green- stick " fracture, in which some of the bone-fibres have given way, while the remaining fibres have been bent by 333 334 FRACTURES. the force but have not been broken (Fig. 238). Fissured, punctured, indented, and perforating fractures are also included in the class of incomplete fractures (Fig. 239). Fig. 237. Fig. 238. Fig. 239. Incomplete fracture Partial or green-stick Fissured fracture of the of femur. fracture of radius. humerus. (Gurlt.) Subperiosteal Fracture. — This is a fracture in which the fibres of the bone are ruptured but the periosteum re- mains untorn ; it is seen in children. Gunshot Fractures. — The nature of the injury to the bone depends upon the density of the latter, and upon the size, shape, composition, and velocity of the ball. In gun- shot injury of the spongy bones the cancellated structure yields to pressure, and the striking energy is^ not trans- mitted in lateral directions, producing explosive effects; while in the dense bones, such as the submaxillary bones VARIETIES OF FRACTURE. 335 or the shafts of the long bones, extensive comminution and Assuring are apt to result. In the articular ends of the long bones clean perforations are often observed, except at close range, when more or less comminution of the can- cellated structure may occur. The tissues from the wound of entrance to the bone are usually injured only in the line of perforation, but those beyond the seat of injury are often extensively lacerated and contused, not only by the ball, but also by the splinters of bone driven into the tissues, and acting as secondary missiles. Simple or Closed Fracture. — This is a fracture in which there are but two fragments, and the seat of injury in the bone does not communicate with the external air by a wound in the soft parts. Compound or Open Fracture. — This is a fracture in which the seat of injury in the bones communicates with the external air by a wound in the soft parts. Comminuted Fracture.— This is a fracture in which there are more than two fragments, the lines of fracture intercommunicating with each other (Fig. 240). Multiple Fracture. — This is a fracture in which a bone is the seat of two or more distinct fractures at different points, the lines of fracture not necessarily communicating with each other. Complicated Fracture. — This is a fracture accompanied by some serious injury of the parts in the region of the fracture — as, for instance, the laceration of important bloodvessels or nerves, contusion or laceration of the mus- cles, or dislocation of a neighboring joint. Impacted Fracture. — This is a fracture in which one fragment is driven into and fixed in the other, the impac- tion taking place at the time of fracture, or being caused by a force subsequently applied (Fig. 241). Transverse Fracture. — This is a fracture in which the general line of division of the bone is at right angles with the long axis of the bone (Fig. 242). Transverse fract- ures of the long bones are rarely met with, the line of fracture usually being more or less oblique. Oblique Fracture. — This is a fracture in which the line 336 FRACTURES. Fig. 240. Fig. 242. Comminuted fracture of patella. Fig. 241. Impacted fracture. Transverse fracture of femur. (Gurlt.) of separation is oblique to the long axis of the bone. This is one of the most common directions of the line of fract- ure (Fig. 243). Longitudinal Fracture. — This is a fracture in which the line of separation runs in the general direction of the long axis of the bone (Fig. 244). This form of fracture is rare, but is sometimes met with in the long bones as the result of gunshot injury. Symptoms of Fracture. — The most prominent symp- toms of fracture are loss of function, deformity, preter- natural mobility, pain, crepitus, and muscular spasm. In impacted fractures, crepitus and preternatural mobility are absent. VARIETIES OF FRACTURE. 337 Ftg. 243. Fig. 244. ill CI Oblique fracture of humerus. (Stimson.) Longitudinal fracture of tibia. (Stimson.) Deformity. — The deformity or displacement in fractures is either angular, transverse, longitudinal, or rotary. Examination of Fractures. — In examining a case of fracture to locate the nature and seat of the injury, the clothing should be removed from the part with as little disturbance as possible, and it is better, in most cases, to cut or rip the clothing rather than to attempt to remove it in the ordinary manner. The surgeon should first inspect the injured part, and, where possible, compare it with its fellow, as in the case of injuries of the extremities ; much valuable information is also derived from the patient or his friends as to the manner in which the injury was produced. The part should next be carefully examined by the surgeon ; if it be one of the extremities which is in- 22 338 FRACTURES. jured, it should be gently lifted, firm extension being made at the same time, the surgeon by his touch and by gentle movements seeking to locate the seat of fracture ; and he may, by his manipulation, at the same time develop crep- itus. All manipulations should be made with care, and with the greatest gentleness, not only to save the patient from pain, but also to prevent the soft parts in the region of the fracture from being injured by the rough or sharp frag- ments of the bone. Rough handling of fractures may increase the muscular spasm by the irritation caused by the sharp fragments of the bones, and may also result in the injury of important vessels and nerves, and indeed a simple fracture may readily be converted into a compound one by forcible and injudicious manipulations. The sooner the examination is made after fracture has occurred the better, for at this time there is less swelling in the region of the injury, and the surgeon can locate the bony prominences with much more ease, and often discover the exact seat of the fracture with the least amount of manipulation of the parts. When a case of suspected fracture is not subjected to examination for several days after reception of the injury, the parts in the region of the supposed fracture are often so much swollen that it is impossible to accurately locate its seat, and in such a case it is often necessary to wait until the swelling has subsided before the position of the fracture can be sat- isfactorily fixed, the case being treated in the meantime as one of fracture. Anaesthetics. — These may be employed to relieve the patient from pain and to obliterate muscular spasm in the examination of fractures. Their employment is often of the greatest service in the diagnosis of obscure or compli- cated fractures, especially those in the neighborhood of joints ; but the surgeon should remember that all manipu- lations should be made with the same gentleness as when the examination is conducted without anaesthesia, for there is the same risk of injury to the surrounding structures by the fragments ; this precaution is often neglected when an PROVISIONAL DRESSINGS OF FRACTURES. 339 Fig. 245. anaesthetic has been given, the surgeon being inclined to handle the parts more roughly than he otherwise would ; such practice cannot be too severely condemned. The use of the fluoroscope or of a skiagraph taken by the »-rays has proved a valuable means of ascertaining the existence or location of the fracture in obscure cases. Provisional Dressings of Fractures. — It generally happens that fractures occur at localities more or less dis- tant from the point where the treatment of the fracture is to be conducted, and the transportation of the patient and the temporary dressing of the fracture are, therefore, matters of the first importance. In fractures of the upper extremity, if the fracture be simple, the clothing need not be removed, and the arm should be bound to the side by some article of clothing, or supported in a sling made from handkerchiefs or the clothing, and the patient can usually walk or ride for a short distance without much injury to the parts in the re- gion of the fracture or incon- venience to himself. When the bones of the lower extremi- ties or the trunk are the parts involved, the transportation of the patient is a matter of more difficulty. When the bones of the trunk are involved, the part should be surrounded by a binder firmly pinned or tied, made from the clothing or from towels, or sheets, or other strong materials which are at hand. When the bones of the lower extremity are in- volved, if the fracture be a simple one the clothing need not be removed, and the motion of the fragments should Provisional dressing for fracture of the leg. (Esmarch.) 340 FRACTURES. be prevented by applying to the sides of the limb, extend- ing above and below the seat of fracture, strips of wood, shingles, pasteboard, bundles of straw, strips of bark taken from trees, or bundles of twigs, these being held in place by handkerchiefs or strips torn from the clothing (Fig. 245). Umbrellas or canes, or broomsticks, applied in the same manner, may be employed, the object of all of these dressings being to secure temporary fixation of the fragments of bone during the transportation of the patient. If the fragments are not fixed in some way, but are al- lowed to move about during the transportation of the patient, much damage may result to the soft parts sur- rounding the fractured bones, and simple fractures may become compound ones by the bones being forced through the skin, the discomfort of the patient at the same time being much increased. Having applied a dressing to bring about fixation of the fragments, the patient should next be placed upon a broad board or settee ; if a mattress cannot be obtained, the fractured limb should be laid upon a mass of clothing, or upon straw, and he should be placed in a wagon or carried to the point where the subsequent treatment of the fracture is to be conducted. Reduction or Setting of Fractures. — This should be effected as soon as possible after the occurrence of the injury and as soon as the surgeon is prepared to apply the dressings to keep the parts in their proper position ; reduc- tion at an early period is less painful to the patient, and is accomplished with more ease to the surgeon than at a later period, when marked inflammation and swelling are present at the seat of fracture. Reduction consists in bringing the fragments, by manipulation, as nearly as possible in their normal position ; this is accomplished by extension and manipulation with the hands, care being taken to use as little force as possible to attain the object. Very little force is required if the surgeon places the part in such a position as to relax the muscles which produce the displacement ; when this is accomplished, the fragments FRACTURE DRESSINGS. 341 can usually be pressed into position by the fingers without the application of considerable force. When the reduc- tion of a fracture has been accomplished, the fragments are retained in position by the application of various splints or dressings which serve to prevent their displacement. MATERIALS AND APPLIANCES USED IN THE DRESSING OF FRACTURES. The Fracture Bed. — Many ingenious forms of beds have been devised for the use of patients suffering from fractures of the bones of the trunk and lower extremities, with the object of permitting the patient to have fecal evacuations without disturbing his position ; but a simple bedstead provided with a firm hair mattress is usually more satisfactory than the complicated form of bed. It will be found more convenient in handling the patient to use a single bed not over thirty-two or thirty-six inches in width, and it is not essential that the mattress be per- forated, as a bed-pan can usually be slipped under the patient. The use of an ordinary shallow tin pie-plate covered with a piece of old muslin to receive the fecal evacuations may be substituted for the bed-pan, and will be found in many cases more satisfactory, especially in the case of children suffering from fracture of the lower extremity. Splints. — After the reduction or setting of the frag- ments in cases of fracture, they are usually retained in position until union occurs by the use of splints held in position by means of bandages or strips of muslin. Splints may be made of wood, or of tin, lead, copper, or wire, binders' board, leather, felt, paper, gutta-percha, or plaster- of-Paris. Wooden Splints. — The simplest splints are made from wood — white pine, willow, or poplar being the best mate- rial to employ for their construction, being sufficiently strong to give fixation to the parts and at the same time being light. Splints made from smooth white pine, wil- 342 FRACTURES. low, or poplar boards from one-eighth to one-fourth of an inch in thickness may be employed in the form of straight or angular splints, and their preparation is a matter of little difficulty. Wooden splints before being applied to the part should be well padded with cotton-wool, oakum, or hair; and where lateral wooden splints are employed in the treat- ment of fractures of the lower extremity, it is usual to place bandages or junk bags between the limb and the splint. The carved wooden splints which are sold by the instrument-makers are not to be recommended, as a rule, for unless the surgeon has a large number to select from, it is rare that a splint can be obtained to accurately fit any individual case. Binders' Board Splints. — Binders' board is an excellent material from which to construct splints ; it is first soaked in boiling water, and when sufficiently soft is padded with cotton or a layer of lint and moulded to the part. It may be secured in position by a bandage ; as it becomes dry, it hardens and retains the shape into which it was moulded. Undressed Leather Splint. —Undressed leather is a good material from which to construct splints; it is applied by first soaking the leather in boiling water, and after padding it with cotton or lint it is moulded to the part and re- tained in position by a bandage. Felt Splints. — These are made from wool saturated with gum shellac and pressed into sheets. This material is pre- pared for application to the surface by heating it before a fire until it becomes pliable, or by dipping it into boiling water. Gutta-percha Splints. — These are made from sheets of this material from one-sixteenth to one-fifth of an inch in thickness, and may often be employed with advantage. The splint is prepared for use by immersing it in hot water ; when it becomes soft it can be moulded to the sur- face. Care should be taken that it is not allowed to become too soft by long immersion, as it then cannot be conven- iently handled. Paper Splints. — These are made from layers of Manila FRACTURE DRESSINGS. 343 paper stiffened with starch, and constitute a very fair substitute for some of the varieties of splints previously mentioned. Plaster-of-Paris, Starch, Chalk and Gum, Silicate of Potassium or Sodium Splints. — These may be employed for the construction of splints, either movable or immovable, in the treatment of fractures ; their method of prepara- tion and application are described on page 93 et seq. ; the plaster-of- Paris dressing is the one which is most generally used Fig. 246. at the present time. Fracture-box. — This is a form of splint used in the treatment of fractures of the lower ex- tremity, and consists of a board eighteen to twenty inches in Fracture-box with movable length, with a foot-board firmly secured at its lower extremity ; the sides are secured by hinges which allow them to be raised or lowered (Fig. 246). A fracture-box of greater length is required for the treatment of fractures about the knee-joint. Bran, Sand, or Junk Bags. — These are constructed by taking a piece of unbleached muslin five feet in length and fourteen and one-half inches in width, doubling it, and securing the free margins, except at the mouth, by stitches so as to form a bag ; the bag is then inverted so that the edges of the seams are brought on the inner sur- face of the bag. The bag is next filled with dry sand, bran, hair, or straw, and the mouth of the bag is closed by stitches or by being tied with a string. Bran bags with splints, or sand bags, are frequently employed in the treatment of fractures of the femur. Bandages.— These are made of muslin, and are used to retain splints in the treatment of fractures, and are also sometimes applied directly to the injured part before the application of splints to control muscular spasm and limit the amount of swelling ; when a bandage is so used, it is known as a primary roller. The use of the primary roller is sometimes of the greatest service in the dressing 344 FRACTURES. Fig. 247. Rack for supporting bed- clothes in fractures of the lower extremity. of fractures, but its use in inexperienced hands has so often been followed by unfortunate results in the early treatment of fractures, or in cases which are not under constant observation, that I think it a safe rule of prac- tice to discard entirely the use of the primary roller. Compresses. — These are made from a number of folds of lint, or of cotton or oakum, and are often employed to retain fragments in position or to make localized pressure upon cer- tain points in the treatment of fractures. The compresses are held in position by strips of adhe- sive plaster, by a few turns of a roller-bandage, or by the splints. Compresses are sometimes em- ployed to protect bony promi- nences of the skeleton from the pressure of the splints, but this purpose is often better effected by the use of small pieces of soap plaster spread on chamois skin fitted over the prominent points. Rack or Cradle. — This is made of wire or wooden hoops, and is often employed to support the weight of the bedclothes in the treatment of fractures of the lower ex- tremity (Fig. 247). Evaporating Lotions in Fracture. — The employment of evaporating lotions such as lead-water and laudanum, or muriate of ammonium and laudanum, to the skin in the region of fractures is highly recommended by many sur- geons, especially in fractures involving or situated near joints. They are here employed to relieve pain, to limit inflammatory swelling, and to hasten absorption of the blood and serum at the seat of fracture. Many surgeons, on the other hand, think that their use causes irritation of the skin and delays the process of repair in the union of the fracture, and strongly condemn their employment. Personally, I have never seen bad results from their use, and have generally employed them in fractures near or involving the joints ; but I do not consider their employ- ment essentia], and when I use them I do so for only two SEPARATION OF THE EPIPHYSES. 345 or three days. In eases of fractures accompanied with much pain and swelling, when the surgeon does not wish to use any of the lotions named, an ointment of ichthvol 1 part, lanoline 3 parts, spread on lint and wrapped around the limb, will often prove a satisfactory dressing, or a layer of cotton may be simply wrapped around the part before the application of the splints. Massage in the Treatment of Fracture. — Lucas- Championniere advocates and practises immediate and continuous massage in the treatment of fractures, and holds that by its use pain is diminished, repair of the bone hastened by the profuse deposit of callus, and atrophy of muscles and stiffening of joints avoided. Massage is employed as soon as possible after the fract- ure has occurred, and consists in manipulations with the thumb, the lingers, or the whole hand. The limb is held by an assistant and extension is made, or it is placed upon a firm pillow or a sand cushion. The manipulations should be made in the direction of the muscular fibres and of the blood-current, and firm pressure should not be made directly over the seat of fracture. Massage should be practised for from fifteen to twenty minutes daily, and no retention apparatus should be ap- plied in the intervals unless there is marked tendency to displacement of the fragments, when some form of reten- tion apparatus or splint may be used. These manipula- tions should be continued for some w 7 eeks, until union is firm at the seat of fracture. Massage has also been com- bined with the ambulatory method of treatment of fract- ures of the lower extremity. This method of treating fractures by massage may be said to be still on trial, suffi- cient experience not yet having accumulated to prove that it possesses marked advantage over the generally adopted method of treatment by immobilization. SEPARATION OF THE EPIPHYSES. This lesion consists in a separation of the epiphysis of the bone from its diaphysis. . The epiphyses are entirely 346 FRACTURES. cartilaginous in infants, but ossification occurs later at various periods for different bones. The separation may occur at any time from birth up to the twenty-first year. The age at which traumatic separation of the epiphyses has been most observed is from the twelfth to the fifteenth year. Epiphyseal separations may be simple or compound. Simple Separations. — Traumatic separations of the epiph- yses may result from direct and indirect violence, from traction or torsion, and in rare cases from muscular action. The injury is alway accompanied by stripping of the peri- osteum from the end of the shaft of the bone, but it gen- erally remains firmly attached to the epiphysis. Separation of the epiphyses in children results from the application of considerable force; according to Poland, an injury which would be able to produce a dislocation in an adult will in a child usually result in a separation of an epiphy- sis. Separation of the epiphyses may result from disease, as in tuberculous and syphilitic ostitis and acute infective ostitis. Suppuration in the region of an epiphysis may result in its separation. Compound separations of the epiphyses are frequently met with, being most common at the lower epiphysis of the femur and the upper epiphysis of the humerus. These are grave injuries, from the fact that infection is apt to occur, resulting in suppurative osteomyelitis and necrosis, followed by arrest of growth of the limb and shortening. Symptoms. — These are mobility, deformity, crepitus, loss of function, pain, and swelling. Mobility, which exists at a point where it should not be observed, is a most important symptom, and is most marked if the separa- tion of the periosteum be extensive. Deformity is also more marked than in fractures, the smoothness of the separated surfaces permitting of displacement ; this varies with the amount of displacement of the diaphysis and the amount and mode of application of the force. Crepitus is soft and muffled ; loss of function is usually marked ; and pain and swelling at the seat of injury are soon fol- lowed by extravasation of blood. SEPARATION OF THE EPIPHYSES. 347 Diagnosis. — Separations without displacement are diffi- cult to diagnose, and are often considered as sprains of joints. In infants this lesion is difficult to recognize, and often escapes detection, but may be followed in a few weeks by swelling, suppuration, and symptoms of chronic osteomyelitis. Separation of the epiphyses is most apt to be confounded with fracture or dislocation ; the diagnosis is made from fracture by observing the line of separation, shape of the displaced epiphyseal fragment, the deformity (which is very characteristic in certain separations), and the soft character of the crepitus. From dislocation, the diagnosis is based upon the following signs : Dislocations are rare in infants and children. In separations of the epiphyses, if the displacement is reduced, it tends to recur upon re- moval of the force ; while in dislocation, if reduction is accomplished, it is not likely to recur when the force is removed. Rigidity is present in dislocation, while preter- natural mobility is marked in epiphyseal separation. In many joints the epiphysis will still be found to be con- nected with the joint and to retain its normal relations with the surrounding articular structures. In compound separations of the epiphyses the diagnosis may be made by observing that the displaced end of the bone is not covered by articular cartilage. Prognosis. — Union of the separated epiphyses occurs by the same process as that of a fracture. The amount of callus, which is formed largely by the periosteum uniting the fragments, varies with the completeness of their reduc- tion. Non-union has never been observed in this injury. Ankylosis of the neighboring joint may result in spite of the greatest care in the reduction of the deformity and in the treatment, yet permanent deformity may be present and interfere very little with the function of the limb. Arrest of growth of the limb after this injury in young subjects may be observed, but is not a necessary result, for the epiphyseal cartilage may perform its function as completely as before the injury, but is more apt to occur if the separation takes place between the epiphyses and 348 FRACTURES. the epiphyseal cartilage, or the cartilage itself is severely injured. Arrest of growth is not marked in many cases, for the reason that the injury occurs at a period when the growth of the skeleton is almost complete. Treatment. — This consists in reduction of the deform- ity, which in many cases is difficult unless an anaesthetic be administered, and fixation of the parts after reduction by the use of splints and bandages, the dressings employed being similar to those used in fracture at a corresponding portion of the bone. Muscular wasting should be pre- vented by the early employment of massage. Compound separations of the epiphyses are treated in the same manner as compound fractures, great care being taken to render the wound aseptic and to maintain it in this condi- tion. DRESSING OF SPECIAL FRACTURES. Fracture of the Nasal Bones. — Fractures of the nasal bones are often accompanied with fractures involving the septum, the nasal process of the maxillary bone, and the nasal spine of the frontal bone. Treatment. — This consists in replacing the fragments, if displacement exists, by manipulation with the fingers over the seat of fracture and by pressure made from within the nostrils by a probe or a steel director. When the displace- ment is once corrected, it is not apt to recur, and in the majority of cases no dressing is required. Before resort- ing to any manipulation within the nasal cavities the mu- cous membrane should be thoroughly cocainized to render the operation painless. When there is a return of the de- pression of the fragments or displacement of the septum after correcting the deformity by raising the depressed fragment, or bending the septum into place with a director, the parts may be held in position by packing the nasal cavity firmly with a strip of antiseptic gauze or by the use of Asch's tubes. In lateral displacements of the nasal bones from fract- ure, after reducing the displacement a small compress FRACTURES OF MALAR BONE AND ZYGOMA. 349 held over the fragment by strips of adhesive plaster will be the only dressing required. Mason transfixes the nose, after reduction of the frag- ments, with a stout needle, and steadies the pieces with a strip of plaster crossing the bridge of the nose and fast- ened to the ends of the needle. The needle is kept in position for eight or ten days (Fig. 248). Fig. 248. Mason's dressing for fracture of the nasal bones. Profuse hemorrhage sometimes occurs after fracture of the nasal bones, and may require plugging of the nares to control it. Fractures of the nasal bones are usually quite firmly united in two weeks, and dressings may be dis- pensed with after this time. Fractures of the Malar Bone and Zygoma.— These fractures are usually the result of direct force ; the dis- placement is upward or backward, and when the zygo- matic arch is broken the fragments from pressure upon the masseter muscle or on the tendon of the temporal 350 FRACTURES. muscle may interfere with the movements of the lower jaw in mastication. This displacement is corrected by cutting down upon the fragment and elevating it or by passing a tenaculum into the fragment and raising it. Outward displacements may be corrected by pressure and the application of a compress. Treatment. — The dressing of these fractures after the correction of the deformity consists in the application of a compress of lint over the seat of fracture, held in posi- tion by strips of adhesive plaster or a bandage. There is little tendency to recurrence of the deformity after it has been corrected, and union at the seat of fracture is usually firm at the end of three weeks. Fractures of the Upper Jaw. — These fractures may involve the body, the nasal processes, or the alveolar proc- esses. Treatment. — The deformity should be corrected, and if any teeth have been displaced they should be replaced ; if there is comminution of the alveolus, the teeth in the Fig. 249. Dressing for fracture of the upper jaw. separate fragments may be fastened together by fine wire to fix the fragments and hold them in place ; the teeth of the lower jaw should be brought up in contact with FRACTURES OF THE LOWER JAW. 351 those of the upper jaw, and the jaws should be secured together by the application of a Barton's or a Gibson's bandage (T^ig. 249). Interdental splints, made of cork, with grooves to fit the teeth, or of gutta-percha, are also employed in the dressing of these fractures. The patient should not be allowed to move the jaw in mastication, and should be nourished by liquid and semisolid food, which may be taken without removing any teeth to give space for its introduction. The bandage should be removed every second or third day, and it should be reapplied in the same manner. Union is usually firm at the end of four or five weeks, and dressings may be dispensed with at this time. Fractures of the Lower Jaw. — The lower jaw may be broken at or near the symphysis, the most usual seat of fracture being near the mental foramen ; it is often broken at two places at once, and the fractures are in many cases Fig. 250. Dressing for fracture of the lower jaw. rendered compound by laceration of the mucous mem- brane, or the injury may consist in a separation of a por- tion of the alveolar process of the bone. Treatment. — The dressing of a fracture of the lower 352 FRACTURES. jaw, after reducing the displacement and replacing any loosened or detached teeth, consists in applying a pad of lint under the chin and bringing the jaw up against the upper jaw, holding the compress in place, and securing the jaws firmly in contact by applying a Barton's (Fig. 250), modified Barton's, or Gibson's bandage. The bandage should be removed and reapplied at the end of the second or third day, and at like intervals during the course of treatment. The patient should be fed upon a liquid or semisolid diet, not being allowed to chew solid food until union at the seat of fracture has become firm. A very satisfactory temporary dressing for a fracture of the lower jaw consists in the application of a four-tailed sling. Some surgeons prefer to use an external splint moulded from pasteboard or gutta-percha fitted to the chin in the dressing of this fracture (Figs. 251 and 252), this being Fig. 251. Fig. 252. Shape of splint before being fitted to chin. Splint moulded to fit (Roberts.) chin. (Roberts.; padded with cotton and held in place by a Barton's or Gibson's bandage. Where there is much difficulty in keeping the fragments in position wiring together of the teeth may be employed, or the fragments may be perfor- ated with a drill and held in place by a strong silver wire suture ; interdental splints of metal or gutta-percha are also sometimes used for this purpose. During the course of treatment of fracture of the jaws the mouth often be- comes very offensive from fermentation of the saliva and discharges, and it is well to use frequently a mouth-wash of chlorate of potassium and tincture of myrrh, or boric acid solution. FRACTURES OF THE RIBS. 353 The dressings for fracture of the lower jaw are applied for four or six weeks, the union usually being quite firm at the end of this time. Fracture of the Hyoid Bone. — In fracture of the hyoid bone, if displacement exists, its reduction is facili- tated by pressure made with the finger in the pharynx. Treatment. — This consists in enforced quiet and the use of opium if cough is a prominent symptom, and the inflammatory symptoms may require the employment of active local treatment. A dressing may sometimes be em- ployed with advantage, consisting of a splint of pasteboard or leather moulded to the anterior portion of the neck. Fractures of the Larynx or Trachea. — In fractures of the larynx or trachea where there is little displace- ment and dyspnoea is not marked, the parts should be supported by the application of compresses of lint held in place by strips of adhesive plaster. If, on the other hand, the respiration is embarrassed or there is free expec- toration of blood, tracheotomy should be performed, and if the injury be seated in the larynx the displacement of the fragments may be overcome by manipulation with the ringer or a director through the tracheal wound, or the larynx may be packed with a strip of antiseptic gauze to control hemorrhage or hold the fragments in position, the patient in the meantime breathing through a tracheotomy- tube secured in the tracheal wound; the packing should be removed in a few days, the tracheotomy-tube being permanently removed as soon as the patient can breathe comfortably through the larynx with the tracheal wound closed. In fracture of the trachea the opening into the trachea should be below or at the seat of injury. Fractures of the Ribs. — Fractures of the ribs are more frequent than fractures of any other bones of the trunk; the ribs most commonly broken are those from the fourth to the tenth ; the most common seat of fracture is near the anterior or posterior portion ; the displacement is usually not marked, unless a number of ribs be broken, being prevented by the intercostal muscles and aponeuroses. Treatment.— The dressing of fractures of the ribs is 23 354 FRACTURES. Fig. 253. best accomplished by enveloping the side of the chest on which the rib or ribs are broken with broad straps of adhesive or rubber plaster. The adhesive straps should be two and a half inches in width and sufficiently long to extend from the spine to the middle of the sternum. The straps are warmed, and the first strap is firmly applied at the base of the chest, extending from the spine to the mid-sternal line; a number of ascending straps are applied in this way, each strap overlapping the preceding one by about one-third of its width until half the chest is covered in (Fig. 253). This dressing usually gives the patient much comfort, and the straps need not be renewed until they become slightly loosened, usually at the end of a week or ten days ; they should then be renewed in the same manner. The dressings are usually dispensed with at the end of three or four weeks, as repair of the fracture is generally well advanced at this time. A satisfactory temporary dress- ing consists in surrounding the chest by a broad binder of stout linen or muslin ; indeed, some sur- geons prefer to employ this dressing during the course of treatment, but, as a rule, I think it is not as good a dress- ing as the adhesive plaster dressing, as the former con- fines the movements of both sides of the chest. Fractures of the Costal Cartilages. — These fractures often take place at the junction of the cartilages with the ribs or in the body of the cartilages, and the union of the fracture usually takes place by the production of a mass of bone at the seat of fracture. Treatment. — It consists in the application of strips of adhesive plaster applied in the same manner as for fract- ure of the ribs, and the dressings should be retained for about the same time. Fractures of the Sternum. — Fractures of the sternum Adhesive plaster dressing for fracture of the ribs. (Hamilton.) FRACTURES OF THE PELVIS. 355 Fig. 254. are rare injuries, but diastasis of the bones of the sternum is a more common accident. Treatment. — The treatment for both fracture and dias- tasis is the same, and consists in the application of a com- press over the seat of fracture held in place by a broad bandage, or, better, by strips of adhesive plaster (Fig. 254), applied so as to cover and fix the anterior portion of the chest, covering the entire length of the ster- num. This dressing should be retained for at least four weeks, being renewed if it becomes loose at the end of a week or ten days. Fractures of the Pelvis. — These fractures may in- volve the ilium, ischium, pubis, or sacrum. Vertical fractures either single or double, and separations of the pelvic bones from their junctions may also occur, and are often serious injuries from implication of the pelvic viscera. Treatment. — The reduction of the displacement should be first accomplished as far as possible by external manip- ulation, together with internal manipulation by the fingers introduced into the rectum, or into the vagina in the female. The patient should be placed upon a firm bed on his back, with the knees slightly flexed over a pillow, and the parts should be kept at rest by surrounding the pelvis with broad straps of adhesive plaster or a stout muslin binder, or by a firmly applied padded pelvic belt. The hip-joints should be kept at rest by the application of pasteboard splints or by sand bags. The dressings should be retained for a period of at least six weeks. When these fractures are complicated by injury of the pelvic viscera various operative procedures may be re- quired, which will compel the surgeon to modify the method of dressing. Adhesive plaster dressing for fracture of the sternum. 356 FRACTURES. Fractures of the Sacrum and Coccyx. — The dressing of fractures of the sacrum, after effecting reduction of the fragments as far as possible by pressure from within the rectum, consists in the application of broad adhesive straps around the pelvis, the patient at the same time being kept at rest in bed. When the coccyx is fractured, after reduction of the dis- placement, which may sometimes be accomplished by manipulation with the finger in the rectum, the patient should be confined to bed and the bowels kept at rest by the use of opium by suppository. The patient should remain in bed for two or three weeks. Fractures of the Vertebrae. — Fractures of the verte- bras are always most serious injuries, not only from the damage to the bones themselves, but also from that to the spinal cord, membranes, and nerves, which often accom- panies them. In transporting or turning in bed a patient suffering from fracture of the vertebrae, great care should be exercised, for rough or sudden motions may cause a displacement of the fragments which might, by injury of, or pressure upon, the spinal cord, rapidly prove fatal. Treatment. — If the deformity is marked, efforts should be made to reduce it by extension and counter-extension ; and the result may be successful, especially if the fracture be associated with a dislocation of the vertebras. In some cases the use of permanent extension by means of weights attached to the legs, shoulders, and chest by adhesive plaster and bandages, has been successful in reducing the deformity. Laminectomy may be practised in certain cases. The patient should be placed upon his back upon a bed with a hair mattress, or better, if it can be obtained, a water-bed, which consists of a rubber mattress filled with water, which distributes the weight of the patient's body evenly over the surface. Whatever form of bed be used, the greatest care should be exercised to keep the patient absolutely clean, and the parts of the body or limbs which are exposed to pressure should be frequently bathed with alcohol or soap liniment ; and to distribute the pressure, small pads should be placed under the parts and changed FRACTURE OF THE SKULL. 357 at intervals. These precautions are necessary to prevent, if possible, the formation of extensive bedsores, which are a frequent and troublesome complication of these injuries. The boioels should be carefully watched, and, if consti- pation is present, it should be relieved by the use of ene- mata ; and, as it is not desirable to lift the patient to slip a bed-pan under him, the discharges may be received in a flat tin plate pushed under the thighs and buttocks, or on pads of oakum or old muslin. The care of the bladder is also a matter of the greatest importance ; the retention which at first exists should be relieved by the use of a flexible catheter carefully steril- ized and introduced with great gentleness, and when incon- tinence supervenes a catheter which has been thoroughly sterilized should also be used at intervals ; the employ- ment of a soft instrument, if used with care, is not apt to produce injury to the urethra or bladder. The employment of a plaster-of-Paris jacket has been followed, in some cases, by good results, and it may be applied early in the case, or after the patient has been kept in the recumbent posture for some weeks ; by its use it is often possible to get the patient out of bed and allow him to sit in a chair. In fractures involving the cervical vertebrce, care should be exercised in lifting or moving the head ; it is often of advantage in these cases to apply short sand bags to the sides of the neck and head, to give additional fixation to the parts while the patient is in the recumbent posture, or, if he is allowed to get out of bed, to apply a moulded leather or pasteboard splint to the neck, shoulders, and back of the head, for the same purpose. The course of treatment in cases of fractures of the ver- tebrae, if the patient does not succumb to the injury in a few days or weeks, often extends over many months, and recovery is often more or less incomplete as regards the function of the parts below the seat of fracture. Fracture of the Skull. — Treatment. — This depends largely upon the nature of the injury — whether simple or compound — and the condition of the cranial contents. 358 FRACTURES. In simple fractures unaccompanied with cerebral symp- toms no special dressing is required, but in compound fractures where loose fragments are present, these should be removed ; and if there is no depression of the frag- ments, and if no cerebral symptoms are present, the wound should be drained, carefully closed and dressed antiseptically, the dressings being held in place by a recur- rent bandage of the head. The patient should be put to bed, and the use of an ice-cap to the head is often of ser- vice. The diet should be restricted, while calomel and opium or bromide of potassium should be administered ; it is well to keep the patient for a few weeks in a quiet and darkened room. Where cerebral symptoms are pres- ent, either in simple or compound fractures, and trephin- ing is resorted to, the dressing of the wound is similar, and the same general treatment should be adopted. In all cases of fracture of the skull, whether subjected to operative treatment or not, it is well to keep the patient at rest in bed for three or four weeks, and he should be cautioned to avoid excesses afterward, and should not re- sume active work for some months. Fractures of the Clavicle. — Fractures of the clavicle may be complete or incomplete, and in the latter variety of injury the deformity is not usually very marked. The indications for treatment in complete fractures of the clav- icle are to relax the sterno-cleido-mastoid muscle, to pre- vent the weight of the arm on the injured side from dragging down the outer fragment of the clavicle, and, by fixing the scapula, to carry the attached external frag- ment outward and forward. A large variety of dressings have been devised and used to accomplish these objects. Dressing by Position. — The treatment of fractures of the clavicle by position is accomplished by placing the patient in bed on his back upon a firm mattress with a low pillow under his head, and the arm on the side of injury should be fastened to the side of the chest by a few circular turns of a bandage passing around the arm and chest; the de- formity is usually very satisfactorily reduced upon the patient assuming this position, and after three weeks' rest FRACTURES OF THE CLAVICLE. 359 in this position the union is generally sufficiently firm to allow the patient to get out of bed and be about with the arm bound to the side or carried in a sling or with a Yel- peau bandage applied, without any recurrence of the deformity. Temporary Dressing. — A satisfactory temporary dressing for fractures of the clavicle consists in the application of a four-tailed bandage ; the bandage is made from a piece of muslin two yards in length and fourteen inches in width ; a hole is cut in its centre about four inches from its margin, to receive the point of the elbow; the bandage Fig. 2-35. Four-tailed bandage for fracture of Posterior figure-of-eight dressing for fract- the clavicle. (Stimsox.) ure of the clavicle. (Hamilton.) is then split into four tails in the line of the hole and to within six inches of it ; the body of the bandage should be applied so that the point of the elbow rests in the hole, and a folded towel being placed in the axilla, the lower tails should be carried, one anteriorly, the other poste- riorly, diagonally across the chest and back, to the neck on the side opposite the seat of fracture, and secured ; the remaining tails are next carried around the lower part of 360 FBACTURES. the chest and secured so as to fix the arm to the side of the body (Fig. 255). In some cases the deformity is corrected by the applica- tion of a posterior figure-of-eight bandage, the forearm on the side of injury being carried in a sling (Fig. 256). Sayre's Dressing. — This consists of two strips of adhesive plaster three and a half inches wide and two yards in length. The first strip is looped around the arm just below the axillary margin, and is pinned or sewed with Ftg. 257. Fig. 258. Sayre's dressing for fracture of the clavicle. First strip applied. Sayre's dressing for fracture of the clavicle. Second strip applied. the loop sufficiently open not to constrict the arm. The arm is then drawn downward and backward until the clavicular portion of the pectoralis major muscle is put sufficiently upon the stretch to overcome the action of the sterno-cleido-mastoid muscle, and in this way draws the sternal fragment of the clavicle down to its place. The strip of plaster is then carried completely around the body FRACTURES OF THE CLAVICLE 361 and pinned or stitched to itself on the back (Fig. 257). The second strip is next applied, commencing upon tin- front of the shoulder of the sound side ; thence it is carried over the top of the shoulder diagonally across the hack, under the elbow, diagonally across the front of the chest to the point of starting, where it is secured by pinning or sewing. A slit is made in this strip to receive the point of the elbow. Before the elbow is secured by the plaster it should be pressed well forward and inward (Fig. 258). Velpeau's Dressing. — This may also be used in the treatment of fractures of the clavicle (Fig. 260). A com- press may also be secured by the vertical turns of this bandage over the seat of fracture if needed. The appli- cation of the bandage is described on page 62. In any form of dressing in which the arm is held against the side of the chest it is well to apply a folded towel or piece of lint between the arm and chest to pre- vent the skin surfaces from becoming excoriated. Fig. 259. Modified Velpeau dressing for fracture of the right clavicle. Modified Velpeau's Dressing.— A modified form of Vel- peau's dressing for fracture of the clavicle is applied as 362 FRACTURES. follows : A soft towel or piece of lint is placed against the side of the body and over the front of the chest, and held in position by a strip of adhesive plaster; the arm is next placed in the Velpean position, a good-sized pad of lint is next applied over the scapula, and this is held in place by a strip of adhesive plaster two and a half inches in width and one and a half yards in length ; this Fig. 260. Velpeau dressing for fracture of the clavicle. strip is continued downward and forward so as to pass over the po'nt of the elbow, and is carried diagonally across the chest to the shoulder of the opposite side, and is secured, a slit being cut in it to receive the point of the elbow; a compress of lint is next placed over the seat of fracture and held in place by a strip of adhesive plas- ter; an additional strip of plaster is next carried from the FRACTURES OF THE CLAVICLE LN CHILDREN. 363 spine around the arm and chest and secured on the oppo- site side of the chest; circular turns of a roller-bandage arc then passed around the chest, including the arm from below upward until the arm is securely fixed to the body, and the dressing is finished by making one or two turns of the third roller of Desault (Fig. 259). Or the turns of the third roller of Desault may be applied first, and the dressing may be finished by circular turns of a roller passing around the arm and chest, extending from the elbow to the shoulder. The removal of dressings and their reapplication will depend upon the comfort of the patient and the manner in which they keep their position. As a rule, in fractures of the clavicle the dressings are removed at the end of the second or third day, the parts are inspected, and the skin is sponged with dilute alcohol; the dressings are then reapplied, and if the patient is comfortable and the parts are in good position, the dressings are made at less frequent intervals until union is completed at the seat of fracture. Union in cases of fracture of the clavicle is generally quite firm at the end of four or five weeks, and at this time the dressings may be removed, and the patient should carry the arm of the affected side in a sling for several weeks, and should not undertake any work requir- ing forcible movements of the arm until eight or ten weeks have elapsed from the receipt of the injury. Fractures of the Clavicle in Children.— In the treat- ment of fractures of the clavicle in children the Velpeau or modified Velpeau dressing will be found to be the most satisfactory dressing to employ ; and as these patients are particularly apt to "disarrange the dressings, it is well to render them additionally secure by applying a few broad strips of adhesive plaster over the turns of the roller-band- age, the strips following the turns of the bandage. & The time required for union in fractures of the clavicle in children is somewhat shorter than in adults ; the dress- ings may be removed at the end of three weeks. Fractures of the Scapula.— Fractures of the scapula 364 FRACTURES. may involve the body, neck, acromion, or coracoid process of the bone. Fractures of this bone are rare, those of the acromion process being most common. Fracture of the Body of the Scapula. — Treatment. — If deformity is present, it is reduced by manipulation, and compresses of lint are placed above and below the seat of fracture and held in place by adhesive strips ; the arm is next fixed to the side of the body by spiral turns of a roller-bandage passing around the arm and chest, and the forearm is supported in a sling. Fracture of the Neck, Acromion, or Coracoid Process of the Scapula. — Treatment. — The treatment of these fract- ures consists in placing a pad of lint or a folded towel in the axilla and binding the arm to the body by spiral turns of a roller-bandage passing around the arm and chest, and supporting the forearm in a sling. These fract- ures may also be dressed by first placing a pad of lint or a folded towel in the axilla and then securing the arm in the Yelpeau position by the application of a Yelpeau bandage (Fig. 260). In fractures of the acromion or coracoid processes the union is usually fibrous. In the treatment of fractures of the scapula the dressing should be retained for about four weeks. Fractures of the Humerus. — Fractures of the humerus may involve the upper ex- tremity, the shaft, or the lower extremity of the bone. Fractures of the Upper Extremity of the Humerus. — These include fractures of the head and anatomical neck of the bone, fractures through the tuberosities, fractures through the surgical neck of the humerus, and separation of the upper epiphysis of the humerus. Moulded splint for Treatment. — The most satisfactory dress- shoulder and arm. „ ,, „ . r . , -, i ing for all fractures of the humerus above the upper third of the bone is applied as follows: A primary roller should be evenly applied from the tips of Fig. 261. FRACTURES OF THE HUMERUS. 365 the fingers to the seat of the fracture, the arm being flexed at the elbow before the bandage is carried above this point, to prevent the dangerous constriction which might result if the bandage were applied with the arm in the straight position, and it were afterward flexed at the elbow. A folded towel or a thin pad of lint should next be placed in the axilla and over the outer surface of the chest, to furnish a firm basis of support for the humerus, and also to prevent excoriation from the contact of the skin surfaces. A splint of pasteboard, felt, or leather (Fig. 261) is next moulded to the shoulder and arm ; this should be long enough to extend some distance below Fig. 262. Dressing for fracture of the upper extremity of the humerus. the seat of fracture and wide enough to cover in about one-half of the circumference of the arm, and is padded with cotton and fitted to the shoulder and arm. The splint and arm are next secured to the side of the body by spiral turns of a roller-bandage, including the arm and chest in its turns and applied from the elbow to the top of the shoulder. The forearm is carried in a narrow sling sus- pended from the neck (Fig. 262). This dressing should 366 FRACTURES. be removed at the end of twenty-four or forty-eight hours, and after the parts have been inspected and sponged with alcohol the dressings should be reapplied in the same manner, and if the patient is comfortable they need not be disturbed again for three or four days, subsequent dress- ings being made at the same intervals. Union in fractures of the upper extremity of the humerus, except in those within the capsule, in which bony union is the exception, is usually quite firm at the end of five or six weeks, and the dressings can be dispensed with at this time. Separation of the Upper Epiphysis of the Humerus. — This accident is not uncommon in patients under twenty years Fig. 263. Separation of upper epiphysis of the humerus. of age, and may be confused with fracture of the neck of the humerus. There is usually a marked projection of the upper extremity of the lower fragment in front of the shoulder (Fig. 263). Treatment. — This consists in reducing the displacement by manipulation, and the dressing is similar to that em- FRACTURES OF THE HUMERUS. 367 ployed in fracture of the neck of the humerus (Fig. 26:2). Tlu' functional result following this injury is usuallv very good. Fracture of the Shaft of the Humerus. — This fracture may occur at any point between the surgical neck and the condyles of the humerus ; the line of fracture is usually oblique. Treatment. — This consists in the application of a pri- mary roller from the tips of the fingers to the seat of fract- ure ; a short, well-padded, wooden splint extending from the axilla to a point a little above the internal condyle is next placed on the inner surface of the arm and against Fig. 264. Internal angular splints. the chest ; a moulded pasteboard or felt splint, fitted to the shoulder and outer side of the arm and extending a short distance below the seat of fracture, is padded with cotton and applied to the shoulder and arm. The splints are held in position by the turns of a bandage, and the arm is secured to the body by spiral turns of a roller-band- age carried around the chest and arm, and the forearm is carried in a sling suspended from the neck. The dressing is much the same as that for fracture of the upper part of the humerus, with the addition of the short internal splint. Fracture of the shaft of the humerus may also be dressed by first applying a primary roller and then placing the fore- arm and arm upon a well-padded internal angular splint 368 FRACTURES. (Fig. 264). Care should be taken to see that the end of the splint extends only to the axilla and does not press upon the brachial vein. A pasteboard or felt moulded splint is next applied to the shoulder and outer side of the arm, and should be long enough to extend below the seat of fracture. The splints are held in position by turns of a roller-bandage beginning at the fingers and carried up to the shoulder, and fin- Fig. 265. ished with a few spica-of- the-shoulder turns (Fig. 266). If there is great overlapping of the frag- ments producing marked shortening, the patient should be kept in bed and the elbow flexed, and weight or elastic extension made by adhesive strips applied to the arm, short coaptation splints also be- ing applied. If the patient is treated as a walking case, the same result can be accomplished with a bag of shot or weight fast- ened to the arm so as to hang below the elbow (Fig. 265). The arm is sup- ported by a sling applied at the wrist, and sometimes for additional security the arm is bound to the side of the body by spiral turns of a bandage carried around the arm and chest. The after-treatment of these fractures as regards the removal and renewal of the dressings is the same as in cases of fracture of the upper portion of the humerus ; the dressings should be retained for five or six weeks. Weight extension in fracture of the shaft of the humerus. FRACTURES OF THE HUMERUS. 369 Fig. 266. Dressing for fracture of the shaft of the humerus with internal angular splint and external splint of binders' board. Fractures of the Lower Extremity of the Humerus. — These include fractures at the base of the condyles, splitting fract- ures between the condyles or those of the internal or exter- nal condyle, and epiphyseal separation of the lower epiphysis of the humerus. Treatment. — The displacement is reduced by extension and manipulation, and before applying any splint it is Ftg. 267. Anterior angular splint. well in many cases to apply over the region of the fracture several layers of cotton-wadding. An anterior angular splint (Fig. 267) well padded with cotton or oakum is next applied and held in position by the turns of a roller- 24 370 FRACTURES. bandage applied from the fingers to the upper portion of the splint (Fig. 268). These fractures may also be dressed with a well-padded internal angular splint, this splint being substituted by an anterior angular splint at the end of ten days or two weeks. Some surgeons prefer to dress fractures of the condyles of the humerus with the arm in the extended position upon a straight anterior splint, or with short, narrow pasteboard splints applied around the joint, as favoring more accurate Fig. 268. Dressing for fracture of the lower extremity of the humerus with anterior angular splint. coaptation of the fragments, and diminishing the tendency to what is known as gunstock deformity and loss of the carrying angle (Figs. 269, 270). If this position is em- ployed, a straight wooden splint is applied to the anterior surface of the arm and forearm, or moulded splints of pasteboard may be used, and after the union is moderately firm, at the end of two weeks, the elbow should be flexed and kept in this position during the remaining time of the treatment. Treatment by Acute Flexion (Jones's Method). — In this dressing of fractures of the condyles of the humerus, the forearm is placed in a position of acute flexion at the elbow, and the hand of the injured arm is brought up and is supported by a sling carried around the neck (Fig. FRACTURES OF THE HUMERUS. Fig. 269. %7^ 371 Gunstock deformity after fracture of the condyle of the humerus. Fig. 270. Showing loss of carrying angle after fracture of the condyle of the humerus. 372 FRACTURES. 271). The flexion of the forearm on the arm may also be secured by passing broad strips of adhesive plaster around the arm and forearm. This dressing is applied for three or four weeks, and then removed and the arm gradually extended. It is held that by this method of dressing better motion is obtained, and the tendency to gnnstock deformity is diminished. When fractures of the lower extremity of the humerus involve the elbow-joint, a certain amount of impairment Fig. 271. Dressing for fracture of condyles of humerus in acute flexion. of joint-motion is apt to occur either from anchylosis or from displacement of the fragments, giving rise to gnnstock deformity and loss of the carrying angle, which in many cases it is impossible to reduce completely, so that flexion and extension of the joint are restricted. Bearing these facts in mind, it is well to make passive motion in these cases as early as the second or third week. It is well to ex- plain to the patient or his friends that impairment of joint- FRACTURES OF THE OLECRANON. 373 motion may result in these fractures in spite of the great- est skill and care in the treatment. In a case of fracture in the region of the condyles of the humerus the dressings should be removed in twenty-four hours, and should be redressed in the same manner, and if the swelling does not increase and the dressing is comfortable to the patient it should afterward be dressed at less frequent intervals ; the union is generally quite firm at the end of four weeks, and the splint may be removed at this time. Fractures of the condyles of the humerus are very common in children, and epiphyseal separations of the lower epiphysis of the humerus are also met with ; the dressing of these injuries in this class of patients is similar to that described for fractures of the condyles of the humerus. Fractures of the Olecranon Process of the Ulna. — Fracture of the olecranon may consist in simply a sepa- ration of the cortical layer of bone over the summit of the process to which the triceps is principally attached, or the line of fracture may pass through the sigmoid fossa. Treatment. — This fracture is dressed with the arm slightly flexed at the elbow, or with it completely extended ; the former position is possibly a little less irk- some to the patient. The separation of the fragment by the action of the triceps muscle is usually not very marked ■ but, if the displacement is considerable, it may in a measure be overcome by the use of a compress above the fragment, over which figure-of-eight strips of adhesive plaster are fastened to draw it down into position (Fig. 272). The ends of the strip are then attached to a well- padded straight splint which should be long enough to extend from the upper third of the arm to the ends of the fingers, and is secured in position by the turns of a roller carried from the fingers to the upper extremity c-f the splint, with figure-of-eight turns at the elbow to rein- force the action of the strips of plaster (Fig. 273). This fracture may also be dressed by first applying a primary roller to the elbow, and then placing over the arm a Veil-padded anterior obtuse-angled splint, or a straight splint with a good-sized pad of lint or oakum 374 FRACTURES. fastened at a point corresponding to the position of the flexure of the elbow. When either of these splints is placed upon the arm a position of moderate flexion is ob- tained. A compress of lint is next placed above the frag- ment, if there is a displacement, and one or two narrow Fig. 272. Adhesive straps applied in fracture of the olecranon. strips of adhesive plaster are fastened over this and passed obliquely downward and attached to the splint on either side. The splint is then securely fastened to the arm by the turns of a roller-bandage applied from the fingers to the upper end of the splint. Fig. 273. Fracture of olecranon dressed in the extended position. The dressings should be removed at the end of twenty- four or thirty-six hours, or sooner if there is evidence of swelling of the tissues in the region of the fracture, and they should be reapplied in the same manner. If the dressing is comfortable to the patient, and there is no evi- FRACTURES OF THE ULNA AND RADIUS. 375 dence of swelling, the subsequent dressings should be made at less frequent intervals ; the dressings are usually retained in this fracture for five or six weeks. Passive motion should not be made until this time, as flexion of the elbow tends to separate the fragments, unless union has taken place. The union of a fracture of the olecranon is in most cases fibrous, but in a few instances bony union has been observed. Fracture of the Coronoid Process of the Ulna. — Fracture of the coronoid process is an extremely rare injury. Treatment. — This is accomplished by placing the arm in a flexed position and applying a well-padded internal right-angled splint, or an anterior right-angled splint, and securing it to the arm by the turns of a roller-bandage. A moulded pasteboard or leather gutter may be substituted for the angular splint. The dressings should be changed at intervals, and after their removal, at the end of three or four weeks, passive motion should be practised. Fractures of the Head and Neck of the Radius. — These fractures are also quite rare. Treatment. — This consists in reducing the fragments by manipulation, by flexing the elbow and keeping it in this position, and by the application of a well-padded anterior right-angled splint, the splint being firmly secured in posi- tion by the turns of a roller-bandage applied from the tips of the fingers to the upper end of the splint (Fig. 268). The splint should be changed at intervals, and should not be permanently removed for four weeks, at which time passive motion, consisting in flexion and extension at the elbow and pronation and supination of the forearm, should be made. An internal angular splint applied to the inner surface of the forearm and arm may also be used in the treatment of these fractures (Fig. 264). Fractures of the Ulna and Radius. — These fractures are often met with as the result of direct or indirect violence. Treatment.— After reducing the displacement, which is 376 FRACTURES. always marked when both bones are broken, by making extension from the hand and by manipulation, the forearm is placed in the supine position or in a position between pronation and supination. The supine position is, as a rule, to be preferred in any fracture of the radius, as the upper fragment is supinated by the action of the biceps and supinator brevis muscles, and, therefore, unless the lower fragment be placed in the supine position, union with rotary deformity will almost inevitably ensue. Two straight wooden splints, well padded, a little wider than the forearm, are employed. The anterior splint should be long enough to extend from the elbow to the tips of the fingers, and the posterior splint should extend Fig. 274. Dressing for fracture of both bones of the forearm. from the elbow to the wrist. A primary roller should never be applied to the forearm in dressing these fractures, as its application diminishes the interosseous space, and its use has been followed by gangrene of the hand and fore- arm. In applying the anterior splint to the palmar sur- face of the forearm and hand, care should be taken that the upper end of the splint does not press upon the brachial artery and basilic vein at the elbow when the forearm is flexed ; the posterior splint is next applied from the elbow to the wrist, and the splints are held in position by the turns of a bandage carried from the fingers to the elbow (Fig. 274). In dressing this fracture a posterior splint equal in FRACTURE OF LOWER END OF THE RADIUS. 377 length to the anterior splint may be used in plaee of the short posterior splint extending from the elbow to the wrist. In fracture either of the shaft of the radius or of the ulna alone, the deformity is usually not so marked as when both bones are broken at the same time, the un- broken bone acting as a splint ; the dressing for these fractures is the same as for fracture of both bones of the forearm. The dressing should be removed in twenty-four or thirty-six hours, and after inspecting the parts and spong- ing them with dilute alcohol, the splints should be replaced in the same manner and secured. The dressings should be renewed at intervals of two or three days for two weeks at least, and after this time the dressings should be made at less frequent intervals. The time required for union in these fractures is usually five or six weeks, and the splints should be retained for this time. Incomplete Fractures of the Ulna and Radius. — In children these fractures are very common. Treatment. — The deformity is reduced by bending the bones back into place, often converting the incomplete fracture into a complete one. After reduction of the de- formity, the treatment adopted is the same as that de- scribed above. In these patients there is a great tendency to displace the splints or rather to draw, the forearm out of the splints, and to prevent this I often employ an anterior angular splint, in place of the straight anterior one, the upper portion of which, being fastened to the arm, prevents the child from dragging the arm out of the dressings. Fracture of the Lower End of the Radius. — The most common fracture of the radius is one situated from one-half of an inch to one and one-half inches above the lower articular surface of the bone (Colles\s fracture), the line of fracture being more or less transverse, although it may in some cases be slightly oblique ; the characteristic deformity in this fracture is represented in Fig. 275. Numerous #-ray studies of this fracture have shown that it 378 FRACTURES. is a much more complicated injury than was formerly sup- posed, being often comminuted or impacted and associated with a fracture of the styloid process of the ulna or of the scaphoid or semilunar bones. Fig. 275. Fracture of the radius near its lower extremity, Treatment. — The most important point in the treatment of this fracture is to effect complete reduction of the frag- ments before the application of any splint ; this is done ,by making extension from the hand, and, at the same time, by over-extending and then flexing the wrist and by manipulation, the deformity can usually be completely Fig. 276. Position of compress in Colles's fracture. reduced. The arm should then be brought into the posi- tion of supination, and a firm compress of lint is next placed over the lower end of the upper fragment on the palmar surface of the forearm ; a second compress is then placed over the upper end of the lower fragment (Fig. 276), and a well-padded Bond's splint (Fig. 277) is applied FRACTURE OF LOWER END OF THE -RADIUS. 379 to the palmar .surface of the arm and held in place by the turns of a roller-bandage (Fig. 278). Bond's splint. Many surgeons treat this fracture with the hand in a position between pronation and supination^ the thumb Fig. 278. Dressing for fracture of the lower end of the radius. pointing upward. A substitute for Bond's splint may be prepared by fastening a roller-bandage obliquely upon a Fig. 279. Substitute for Bond's splint. straight wooden splint as suggested by Dr. Hays (Fig. 279). 380 FRACTURES. Another method of treating Colles's fracture after the reduction of deformity consists in placing upon the dorsal surface of the forearm a padded straight splint, extending from the elbow to the tips of the fingers, and a short straight splint upon the palmar surface of the arm, ex- tending from the elbow to the wrist (Fig. 280). These splints are held in position by a bandage, and the forearm carried in a sling with the hand inclined to the ulnar side Fig. 280. Anterior and posterior splints applied. (Fig. 281). The hand should be bandaged to the posterior splint for about seven days and then set free. The pos- terior splint should be left long for another week ; at the end of this time it should be shortened so as to extend only to the wrist-joint, and the patient should be en- couraged to use the fingers and make motions of the wrist. At the end of three weeks both splints should be removed, and the patient should carry the forearm in a sling for a few weeks longer and be encouraged to use the hand. The most important point in the treatment of this fract- ure is the complete reduction of the deformity at the first dressing, and if this has been satisfactorily done almost any splint may be used with a good result, and, indeed, some surgeons use no splint, applying only a compress over the seat of fracture, held in place by a strip of plaster, the arm being carried in a sling. The after-treatment of these fractures consists in remov- ing the splint and compresses after twenty-four or thirty- REVERSED COLLES'S FRACTURE. 381 six hours and in sponging the surface of the skin with dilute alcohol, and the compresses and splints should then be reapplied in the same manner ; the fracture should be dressed every second or third day for the first two weeks, and after this time it should be dressed at less frequent intervals. Union is usually quite firm at the end of four weeks, and the splint should be dispensed with at this time. A certain amount of stiffness of the wrist and Fig. 281. Dressing for Colles's fracture with long posterior and short anterior splint. fingers is apt to follow this fracture, which is usually soon overcome by passive motion and physiological use of the parts. Epiphyseal Separation. — In children separation of the lower epiphysis of the radius is often met with, and its treatment is similar to that described above ; a Bond splint with compresses or two straight splints with compresses being the most satisfactory dressing to employ in this in- jury, the dressings being retained for three weeks. Reversed Colles's Fracture. — This is a rare fracture of the lower end of the radius in which the lower frag- ment is displaced forward instead of backward, the de- formity being the reverse of that seen in Colles's fracture. Treatment. — This consists in the reduction of the de- formity, the manipulation being the reverse of that em- ployed in Colles's fracture, and the dressings are similar to those employed in the latter, with the exception that the position of the compresses is reversed. 382 FRACTURES. Fractures of the Carpal Bones. — These fractures are usually compound or open fractures, and are so frequently associated with extensive laceration of the arm and hand that operative measures have to be resorted to ; but if such is not the case, they are dressed, when compound, with an antiseptic dressing, and the hand and forearm are sup- ported upon a well-padded palmar splint held in place by a roller-bandage ; more or less impairment in the motion of the wrist is apt to follow these fractures. The dress- ings should be retained for three or four weeks, and after their removal passive motion should be employed to over- come as far as possible the joint-stiffness resulting. Fractures of the Metacarpal Bones. — These fract- ures are often met with as the result of direct or indirect force applied to the metacarpal bones. Treatment. — This consists in first reducing the de- formity, which is usually an angular one, the projection Fig. 282. V Agnew's splint for fracture of the metacarpal bones. of the angle being toward the back of the hand ; this is reduced by pressure with the fingers, and the hand and forearm should then be placed upon a palmar splint (Fig. 282) with a pad of oakum or cotton under the palm ; a compress of lint is next placed over the seat of fracture, and the hand and forearm are bound to the splint by the turns of a roller-bandage (Fig. 283). At the end of three weeks union at the seat of fracture is usually quite firm, and the splint should be dispensed with at this time. Fractures of the Phalanges. — These may result from direct or indirect violence, and often present marked deformity. Treatment. — This consists in reducing the displacement by extension and manipulation, and in placing the finger FRACTURES OF THE PHALANGES. 383 in a moulded gutta-percha or pasteboard splint (Fig. 244. Fig. 345. Ligation of the occipital artery. (Skey.) Ligation of the temporal artery. (Skey.) the artery. The needle should be passed from behind forward. Ligation of the Axillary Artery. — The axillary artery extends from the middle of the clavicle to the insertion of the teres major into the humerus ; the axillary vein lies upon the inner side and in front of the artery. The axil- lary artery is tied either in its upper portion, just below the clavicle, or at its lower portion in the axilla. Axillary Artery below the Clavicle. — The ineision is four inches in length from the summit of the coracoid process inward a short distance below the clavicle (Fig. 338, E\ or an incision three inches in length, commencing at a LIGATION OF THE AXILLARY ARTERY. 457 point one-half an inch from the sternoclavicular articu- lation, and carried obliquely downward toward the axilla. The skin and subcutaneous tissue having been divided, the deep fascia is exposed and opened, and the axillary artery may be reached by following the intermuscular space between the sternal and clavicular fibres of the pec- toralis major which leads upward toward the clavicle and to the pectoralis minor ; or the fibres of the pectoralis major being exposed, are cut through and the costo-cora- coid membrane is next torn through with a director, care being taken to avoid injury of the cephalic vein at the outer portion of the wound ; the pectoralis minor is now seen, and after separating the cellular tissue with a director the axillary vein is seen crossing from the upper edge of the muscle to the clavicle ; the vein almost completely covers the artery, which is exposed by drawing the vein inward. The needle is passed around the artery from within outward. Axillary Artery in the Axilla. — The incision is two and a half inches long, started at the upper part of the axilla Fig. 346. A. Incision for axillary artery in axilla. B. Incision for brachial artery. (Stimson.) and carried down the arm at the edge of the coraco- brachialis muscle (Fig. 346, A). The skin only is divided in the first incision. The deep fascia is then picked up and divided upon a director. As soon as the fibres of the inner border of the coraco-brachialis muscle are exposed and held aside by a retractor, the operator will see the 458 OPERA TIONS. median nerve, the musculocutaneous nerve, and the axil- lary artery. To the inner side of the artery are the axil- Fig. 347. Relations of right axillary artery in axilla. (Esmarch.) Fig. 348. Relations of right brachial artery at middle of arm. (Esmarch. lary vein, ulnar and internal cutaneous nerves (Fig. 347). The needle should be passed around the artery from the vein toward the coraco-brachialis muscle. LIGATION OF THE RADIAL ARTERY. 459 Ligation of the Brachial Artery. — The incision is three inches long at the middle of the arm, on a line corre- sponding to the inner edge of the biceps muscle (Fig. 346, B). The skin and cellular tissue having been divided, care being taken not to injure the basilic vein, which should be displaced posteriorly, the deep fascia is next cut through and the fibres of the biceps muscle are exposed (Fig. 348) ; this muscle should be drawn forward and the sheath of the vessels enclosing the artery, veins, and median nerve exposed ; the sheath having been opened, the median nerve is pressed aside and the artery is separated from its veins, and the needle is passed from the side of the nerve around the vessel. In ligating the brachial artery the occasional high division of the vessel must be borne in mind. Brachial Artery at Bend of the Elbow. — The incision is two inches in length, along the inner border of the tendon Fig. 349. Tendinous aponeurosis divided. Ligation of the brachial artery at the bend of the elbow. (Bryant.) of the biceps muscle. Divide the skin, superficial fascia, and the bicipital aponeurosis, under which the artery will be exposed, resting upon the brachialis anticus muscle (Fig. 349). The median nerve is to the inner side and some distance from the artery. The needle should be passed around the vessel, after isolating the veins, from within outward. Ligation of the Radial Artery. — The radial artery extends in a straight line from a point half an inch below 460 OPERATIONS. the centre of the fold of the elbow to the inner side of the styloid process of the radius. The radial artery may be tied at its upper, middle, or lower third, or at the root of the thumb. Fig. 350. Fig. 351. tj\ Relations of right radial artery in the upper third of the forearm. (Esmarch.) Fig. 352. Line of incision for — A. Radial artery in upper third. B. Radial artery in lower third. C. Ulnar artery in upper third. D. Ulnar artery in lower third. (Stimson.) Relations of right radial artery above the wrist. (Esmarch.) Radial Artery in the Upper Third of the Forearm. — The incision for the radial artery at its upper third is two and a half inches in length on a line drawn from the middle of the bend of the elbow to the ulnar side of the styloid process of the radius ; the incision should begin one and a half inches below the bend of the elbow (Fig. 350, A). Divide the skin and superficial fascia, avoiding the super- LIGATION OF THE ULNAR ARTERY. 46l ficial veins. When the deep faseia is exposed, find the edge of the supinator longus muscle and divide the apo- neurosis along its ulnar side, and expose the fibres of the pronator radii teres muscle. The vessel lies in the inter- space between these muscles surrounded by adipose tissue, and upon being exposed the veins should be isolated and the needle passed from without inward. The radial nerve lies so far external to the artery that it is not often ex- posed in the operation (Fig. 351). Radial Artery in the Middle Third of the Forearm. — The incision is two inches in length, following the same line as that for the upper third of the artery. After dividing the skin, superficial and deep fascia, the artery is found in the interspace between the flexor carpi radialis on the inner side and the supinator longus on the outer side ; the radial nerve at this part of the arm is in close relation with the vessel to the radial side, and the needle should be passed around the artery from without inward. Radial Artery in the Lower Third of the Forearm. — The incision is two inches in length, following the same line (Fig. 350, B\ ending one inch above the wrist. The skin, superficial and deep fascia being divided, the artery will be found between the tendon of the flexor carpi radialis on the inner side and the tendon of the supinator longus on the outer side (Fig. 352). The veins being separated, the needle may be passed in either direction. Radial Artery at the Root of the Thumb.— The radial artery may also be tied at the root of the thumb. The incision is one inch in length between the tendons of the extensor ossis metacarpi pollicis and extensor primi internodii pollicis on the outer side, and the tendon of the extensor secundi internodii pollicis on the inner side. The skin and superficial fascia being divided and the radial vein being displaced, the deep fascia is opened and the artery is exposed at the bottom of the wound ; the needle may be passed in either direction. Ligation of the Ulnar Artery. — The ulnar artery is tied at the junction of the upper and middle thirds of the forearm and at the lower third. 462 OPERATIONS. Ulnar Artery at the Junction of the Upper and Middle Thirds of the Forearm. — The incision is three inches in length, starting four inches below the internal condyle of the humerus on a line passing from the internal condyle of the humerus to the outer border of the pisiform bone (Fig. 350, C). Divide the skin and superficial fascia, and when the deep fascia has been exposed and the in- terspace between the flexor carpi ulnaris and the flexor sublimis digitorum appears, enter this interspace and raise the flexor sublimis digitorum and work transversely across the arm. The artery will be found resting upon the deep Fig. 353. Relations of the right ulnar artery at upper third of the forearm. (Esmarch.) flexor, with the ulnar nerve to the ulnar side. The needle should be passed from the nerve around the arterv (Fier. 353). Ulnar Artery in the Lower Third of the Forearm. — The incision is two inches in length, a little to the radial side of the tendon of the flexor carpi ulnaris, which is attached to the pisiform bone, ending an inch above the wrist (Fig. 350, D). Divide the skin and superficial fascia and open the deep fascia; the artery will be exposed with its accompanying veins, between the tendons of the flexor carpi ulnaris and flexor sublimis digitorum, the ulnar nerve being to the ulnar side of the vessel. The needle LIGATION OF THE COMMON ILIAC ARTERY. 463 should be passed from within outward to avoid the nerve (Fig. 354). Fig. 3o4. Relations of right ulnar artery above the wrist. (Esmarch.) Ligation of the Interosseous Artery. — The incision is similar to that employed in the ligation of the ulnar artery in its upper third. Ligation of the Abdominal Aorta. — The incision is in the linea alba from a point three inches above the umbili- cus to a point three inches below it. The superficial structures being divided, the peritoneum is opened upon a director, and the intestines are pressed aside and the aorta is exposed, covered by peritoneum, with the filaments of the sympathetic nerve resting upon it and the vena cava to the right side. Tear through the peritoneum and pass the needle from right to left around the vessel. After tying the ligature the ends should be cut. short and the external wound should be closed as in the ordinary lapar- otomy wound. The vessel may also be exposed by an incision along the anterior border of the quadratus lumborum muscle, from the last rib to the crest of the ilium. The skin, lumbar muscles, and fascia transversalis being divided, the wound is held open with blunt hooks, so that the retroperitoneal space is exposed and the aorta brought into view. The vessel being separated from the vena cava and nerves, the needle is passed around it and the ligature applied. Ligation of the Common Iliac Artery. — The aorta divides into the two common iliac arteries on the left 464 OPERATIONS. side of the fourth lumbar vertebra, and these arteries are usually about two inches in length, and bifurcate opposite the sacro-iliac synchondrosis to form the internal and external iliac arteries ; the length of the common iliac artery, however, may vary considerably, being three or four inches in some cases. The incision for ligation of the common iliac artery is four to six inches in length, beginning one-half inch above the middle of Poupart's ligament, and is carried outward, curving upward after passing the anterior superior spine of the ilium (Fig. 355, ^1). Fig. 355. C 1 Lines of incision for— A. Common iliac artery. B. External iliac artery. C. Femoral artery in Scarpa's triangle. (Stimson.) Divide the skin, superficial fascia, and aponeurosis of the external oblique muscle, and then divide the fibres of the internal oblique and transversalis muscles upon a director and expose the transversalis fascia. This is opened at the lower part of the wound, and the finger is introduced and the peritoneum pressed back ; the opening in the transversalis fascia is next enlarged, and the peritoneum is carefully drawn inward and upward with the fingers toward the inner edge of the wound. The operator next feels for the external iliac artery, and passes the finger along this until the common iliac artery LIGATION OF THE INTERNAL ILIAC ARTERY. 465 is reached. The loose cellular tissue in which it is im- bedded is next separated, and the needle is passed from within outward, to avoid the common iliac vein (Fig. 356), which on the left side lies on the inner side of the artery, and on the right side lies behind the artery. The ureter generally remains attached to the peritoneum ; if not, it is seen crossing the bifurcation of the common iliac Fig. 356. Ligation of the common iliac artery. (Liston.) with the genito-crural nerve ; care should be taken to avoid injury of these structures. Transperitoneal Method. — The common iliac artery may also be exposed and tied by an incision made over the artery through the abdominal wall opening the peritoneal cavity : the vessel being tied, the ends of the ligature are cut short, and the external wound is closed in the same manner as that resulting from exposure of the abdom- inal aorta by incision through the peritoneum. Ligation of the Internal Iliac Artery. — The incision is in the same line as for the common iliac artery, but it 30 466 OPERATIONS. need not be quite so long (Fig. 355, A). The peritoneum being exposed, it is pushed upward and inward, and the internal iliac artery is exposed. The vessel is carefully isolated from the vein, which lies behind and on the inner side, and the needle is passed from within outward. The transperitoneal method may also be employed in exposing and ligating this vessel. Ligation of the External Iliac Artery. — The incision is three or four inches in length, half an inch above the middle of Poupart's ligament, made at first parallel to it Fig. 357. Relations of the right external iliac artery. (Esmarch.) and then curved upward (Fig. 355, B). The tissues of the abdominal wall being divided and the peritoneum exposed, it is pushed upward and inward in the same manner as for exposure of the common iliac artery. The artery lies at the inner border of the psoas muscle, the vein on its inner side and the anterior crural nerve covered by the iliac fascia on the outer side; the genito-crural nerve passes obliquely across the artery (Fig. 357). The needle should be passed from within outward. LIGATION OF Till- ITDIC ARTERY. 467 The transperitoneal method may also be employed in lijjCiitiiiLi: this vessel. 1 Ligation of the Gluteal Artery. The incision is three or four inches in length, from the posterior superior spinous process of the ilium to a point midway between the tuber ischii and the great trochanter (Fig. 358, A). After divis- ion of the skin and fascia, the fibres of the gluteus maxi- mus muscle are separated and held apart, the deep fascia is divided, and the artery should then be sought for above the pyriformis muscle at the upper border of the Fig. 358. Lines for— A. Gluteal artery. B. Sciatic and internal pudic arteries. (Stimson.) great sacro-sciatic notch. It is accompanied by large veins, injury to which should be avoided in exposing the artery and passing the needle. Ligation of the Sciatic and Internal Pudic Arteries. — The incision is three or four inches in length, a little lower than that emploved for exposure of the gluteal artery (Fig. 358, B). Divide the skin, superficial fascia, and fibres of the gluteus maximus muscle and deep fascia, and search for the vessels as they leave the great sciatic notch at the 468 OPERA TIONS. lower edge of the pyriformis muscle. The internal pudic artery enters the pelvis through the lesser sciatic notch, lying on the inner side of the sciatic artery during its pas- sage over the spine of the ischium. The vessels are isolated and the needle is passed so as to avoid injury of the veins. Ligation of the Femoral Artery. — The femoral artery may be ligated just below Poupart's ligament, at the apex of Scarpa's triangle, at the middle of the thigh, or in Hunter's canal. Femoral Artery below Poupart's Ligament. — The incision begins midway between the anterior superior spinous Fig. 359. Relations of the right femoral artery below Poupart's ligament. (Esmarch.) process of the ilium and the symphysis pubis, one-fourth of an inch above Poupart's ligament, and extends two inches downward. Divide the skin and superficial fascia and the deep fascia so as to expose the sheath of the vessels ; open this one-half an inch below Poupart's liga- ment and isolate the femoral artery from the femoral vein which lies to the inner side ; the anterior crural nerve lies to the outer side. Pass the needle from within outward (Fig. 359). LIGATION OF THE FEMORAL ARTERY. 460 Femoral Artery at the Apex of Scarpa's Triangle. — The incision is three inches long, the centre of which should be a little above the point where the sartorius muscle crosses a line drawn from the middle of Pou part's ligament to the inner condyle of the femur (Fig. -3(30). Divide the skin, superficial and deep fascia, avoiding the internal saphenous vein, and expose the edge of the sartorius muscle, which may be recognized by the direction of its fibres. This muscle is drawn outward and the sheath of the vessels is exposed and opened; the vein lies on the inner side and somewhat behind the artery, and the long Fig. 360. '% i *>■ Lines of incision for the femoral artery. (Stimson.) saphenous nerve is on the outer side (Fig. 361). Pass the needle from within outward. Femoral Artery in the Middle of the Thigh. — The incision is in the line above mentioned, its centre being a little above the middle of the thigh. Divide the skin, super- ficial and deep fascia, and expose the sartorius muscle, which is drawn outward after the leg has been flexed ; the sheath of the vessels is exposed and opened ; the long saphenous nerve lies upon the artery and the femoral vein lies behind the artery ; the saphenous vein lies more super- ficially and internal to the vessel. Pass the needle from within outward (Fig. 362). Femoral Artery in Hunter's Canal. — The incision is three 470 OPERATIONS. inches in length along the tendon of the adductor magnus, the centre of which is at the junction of the lower and middle thirds of the thigh (Fig. 360). Divide the skin, superficial and deep fascia, care being taken not to injure the internal saphenous vein, which should be displaced, and expose the sartorius muscle, which should be displaced downward, and expose the aponeurosis which forms the anterior Avail of the vascular canal ; this should be opened upon a director, and the artery uncovered and separated Fig. 361. Fig. 3G2. Relations of the right femoral artery at the apex of Scarpa's triangle. (Esmarch.) Relations of the right femoral ar- tery in the middle of the thigh. (Esmarch.) from the vein which lies upon the outer side. The needle is passed from without inward. Ligation of the Popliteal Artery.— The incision is three or four inches in length, along the external border of the semi-membranosus muscle. Divide the skin and superficial fascia, taking care not to injure the saphenous vein, and open the deep fascia. The edges of the wound being held apart, the adipose tissue is broken up with a director, and the internal popliteal nerve will first be ex- posed, and the next vein — both external to the artery LIGATION OF THE ANTERIOR TIBIAL ARTERY. 471 (Fig. 363). The artery is isolated and the needle passed from without inward. Fig. 3G3. Relations of the right popliteal artery. (Esmarch.) Ligation of the Anterior Tibial Artery. — The ante- rior tibial artery may be tied in the upper, middle, and lower thirds of the leg ; the general direction of the artery corresponds with a line drawn from the middle of the space between the head of the fibula and the tubercle of the tibia to the middle of the anterior intermalleolar space. Anterior Tibial Artery in the Upper Third of the Leg. — The incision is two and a half to three inches in length, one and one-fourth inches external to the spine of the tibia. Divide the skin and superficial fascia, and when the deep fascia is exposed open it on a line corresponding to the intermuscular space between the tibialis anticus and the extensor longus digitorum muscles. Separate the 472 OPERATIONS. muscles and work down in this interspace until the artery is found Avith a vein on either side of it, and the anterior tibial nerve externally (Fig. 364). The needle should be passed from without inward after isolating the veins. Fig. 364. Ligation of the anterior tibial artery at its upper third. (Stimson.) Anterior Tibial Artery at its Middle Third. — The incision is three inches in length in the same line as that for the upper portion of the vessel. After dividing the skin, superficial and deep fascia, the interspace between the tib- ialis anticus and the extensor longus digitorum muscles is opened, when a third muscle comes into view, the extensor proprius pollicis. The artery lies between the extensor proprius pollicis and the tibialis anticus muscles ; and the anterior tibial nerve is to the outer side. The veins should be isolated and the needle passed from without inward. Anterior Tibial Artery in its Lower Third. — The incision is two inches in length, beginning three inches above the ankle-joint on the line of the artery. Divide the skin, LIGATION OF THE DORSALIS PEDIS ARTERY. 473 superficial and deep fascia, and seek for the tendon of the extensor proprius pollicis muscle, the second tendon from the tibia. The artery is found in the interspace between this tendon and the tendon of the extensor longus digito- rum muscle, the nerve being to the outer side. The veins are isolated from the artery, and the needle is passed from without inward. , . Ligation of the Dorsalis Pedis Artery.— The incision is one inch in length on a line drawn from the middle of Fig. 365. Extensor brevis digitorum~^, muscle. Tendon of — extensor proprius pollicis. Ligation of the dorsalis pedis artery. (Bryant.) the anterior intermalleolar space to a point midway be- tween the extremities of the first two metatarsal bones or along the outer border of the tendon of the extensor pro- prius pollicis. Divide the skin, superficial and deep fascia, and the artery will be found lying next to the inner tendon of the short extensor muscle of the toes (Fig. 365> The nerve is to the outer side. After separating the veins the needle is passed from without inward. 474 OPERATIONS. Fig. 366. Ligation of the Posterior Tibial Artery. — The course of the posterior tibial artery is in- dicated by a line drawn from the middle of the popliteal space to a point midway between the tendo- Achillis and the internal malleolus of the tibia. The posterior tibial artery may be ligated in its upper, middle, and lower thirds. Posterior Tibial Artery at its Upper Third. — The incision is three and a half inches in length, one- half inch from the inner edge of the tibia, beginning two inches from the upper edge of the bone (Fig. 366). Divide the skin and super- ficial fascia, avoiding large super- ficial veins ; next open the deep fascia and detach the origin of the soleus muscle from the tibia, and on raising it the under surface will present a white, shining sheath of tendinous material, beneath which will be seen a layer of fascia cover- ing the tibialis posticus muscle. If search is made toward the middle of the leg the artery will be found covered by the intermuscular fascia, the nerve being to the outer side. The needle is passed from without inward after the veins have been separated from the artery (Fig. 367). Posterior Tibial Artery at its Middle Third. — The incision is two and a half inches in length, parallel with the inner edge of the tibia and half an inch from its border. Divide the skin, superficial and deep fascia, and the inner edge of the soleus will be exposed ; press this outward, when the artery with its veins will be exposed, also the posterior tibial nerve to the outer side. Pass the needle from with- out inward after separating the veins. Lines of incision for the posterior tibial artery. (Stimson.) LIGATION OF THE POSTERIOR TIBIAL ARTERY. 475 Fig. 367. Relations of the right posterior tibial artery in its upper third. (Esmarch.) Fig. 368. Ligation of the posterior tibial artery behind the inner malleolus. (Bryant.) Posterior Tibial Artery behind the Inner Malleolus. — The incision is a curved one two inches in length, midway be- tween the tendo-Achillis and the internal malleolus (Fig. 476 OPERATIONS. 366). Divide the skin and superficial fascia, then lift the deep fascia upon a director and open it freely, when the artery will be exposed, with the tendons of the tibialis posticus and flexor longus digitorum muscles on the inner side and the posterior tibial nerve and the tendon of the flexor longus pollicis muscle on the outer side (Fig. 368). After separating the veins from the artery the needle should be passed from without inward. PAET VI. AMPUTATIONS The term amputation is now generally applied to the removal of a limb, and this may be effected through the bones, when the operation is spoken of as an amputation in the continuity of the limb ; or it may be removed through its joints, when it is known as an amputation in the contiguity or a disarticulation. Methods of Amputating. Amputations may be performed by the circular, modi- fied circular or oval, elliptical, and transfixion methods. Teak's method bv rectangular flaps is also employed. Circular Method. — In performing an amputation by this method the incision of the skin is made at a distance below the point where the bone is to be divided. An assistant grasps the limb and draws the skin evenly and firmly toward the root of the part, and the surgeon passes the heel of the knife well into the tissues and makes a cir- cular sweep around the limb, completing the division of the skin and cellular tissue with one motion of the knife (Fig. 369). . •■ The second incision in an amputation by the circular method consists, after retraction of the skin, in making a circular cut through all of the tissues down to the bone (Fig. 370). The third step in an amputation by this method consists, 477 478 AMPUTATIONS. Fig. 369. Amputation by circular method. (Dkuitt.) after retracting the skin and muscles and holding them back by a retractor, in the division of the bone with a saw. Fig. 370. Division of muscles in circular amputation. (Smith.) Transfixion Method. — This is a variety of the flap method, the flaps being cut from within outward ; they may be lateral or antero-posterior. In amputating by this method the surgeon grasps the limb and enters the point of a long knife into the tissues at the side nearest himself, and push- MODIFIED CIRCULAR OR OVAL METHOD. 479 ing it across and round the bone or bones brings its point out through the skin at a point diametrically opposite its point of entrance. He then shapes the flap by cutting downward with a rapid sawing motion, and then cuts obliquely forward until all the tissues are divided. The flap being turned up, he re-enters his knife at the same point and passes it on the other side of the bone or bones and cuts the second flap in the same manner (Fig. 371). A retractor is next applied and the bone is divided with a saw. Fig. 371. Amputation by anteroposterior flaps. (Bryaxt.) Modified Circular or Oval Method. — In this form of amputation two oval antero-posterior or lateral flaps of skin are marked out by incisions and dissected up to the point at which the muscles and bone are to be divided. The muscles are then divided close to the base of the flaps by a circular sweep of the knife, and the operation is completed by sawing the bones.. This form of amputation is at present widely employed, and is especially to be recom- mended in muscular limbs (Fig. 372V Elliptical Method. —This is a form of the oval method of amputation which is employed in amputations at the knee-joint and elbow-joint, the incision forming an ellipse, 480 AMPUTATIONS. Fig. 372. .4rjr Modified circular amputation. (Skey.) coming below the joint on the front or outside of the limb, the resulting flap being folded upon itself. Fig. 373. Teale's method of amputation. (Bryant.) Teale's Method by Rectangular Flaps. — In this method of amputation two flaps are made of unequal length ; the incisions are so planned that the shorter flap contains the main vessel or vessels. The flaps are cut of BIER'S OSTEOPLASTIC METHOD. 481 equal width and the length of the long flap should be one- half of the circumference of the limb at the point where the bone is to be divided ; the length of the short flap should be one-eighth of the circumference of the limb. The flaps are cut from without inward, and embrace all of the tissues of the limb down to the bone. After the flaps have been dissected up the bone is divided with a saw, and the long flap is folded over and sutured to the short flap (Fig. 373). The disadvantage of this method of amputation is that in muscular limbs it requires the bone to be divided at a higher point than would otherwise be necessary. Bier's Osteoplastic Method.— To provide a better bearing surface for stumps, Bier has recommended an osteo- plastic amputation. It may be employed in primary ampu- tation or in cases of re-amputation. In amputating the leg Fig. 374. Fig. 375. Bier's osteoplastic amputation of the Bier's osteoplastic amputation of leg. the leg, with osteoperiosteal flap in position. by this method, an oval flap, composed of the skin and cellular tissue of one-half of the width of the leg, is dis- sected to the point where the bones are to be divided, care being taken not to injure the periosteum. A rectangular flap of the periosteum, large enough to cover the sawn surface of the tibia and fibula, is next marked out by in- cisions, the longitudinal incisions extending a little beyond the anterior edge of the tibia. The flap is then reflected 31 482 AMP VTA TIONS. about one-half a centimeter from the transverse incision, and a thin lamella of hone is next sawed in an upward direction with a fine saw, the saw being turned toward the periosteum at its upper part to complete the bone flap. This flap is turned so as to cover the sawn surface of the bones and secured by a few sutures (Figs. 374, 375). The amputation is completed by making a circular incision of the tissues on the posterior aspect of the leg and sawing the bones close to the border of the inverted bone flap. Periosteal Flaps. — In any of the methods of amputa- tion previously described the periosteum may be dissected up in two flaps attached to the muscles, or pushed up as a sleeve by means of a director or periosteotome before the bone is sawed. This procedure is most easily accomplished in young subjects. When these flaps are made and are brought together, the periosteum covers the cut surface of the bone, to which it soon forms adhesions. Instruments Required for Amputations. — The instru- ments required for amputations are knives of various shapes and sizes, saws, dissecting forceps, bone-forceps, artery forceps, tenacula, haemostatic forceps, scissors, peri- osteotomes, tourniquets, Esmarch's bandage and strap, retractors, ligatures, sutures, and needles. Amputating Knives. — The knives required for amputa- tions vary according to the method of amputation and the Fig. 376. Scalpel. part to be amputated. In certain amputations a scalpel (Fig. 376) or straight bistoury (Fig. 377) may be used, while in other cases the employment of amputating knives of various sizes will be found more satisfactory. For amputations of the thigh a knife with a blade of eight or nine inches is generally employed, and for smaller limbs a knife with a blade of six or seven inches in length ; double- edged catlins are employed in amputations of the leg and INSTRUMENTS REQUIRED FOR AMPUTATIONS. 483 forearm, to divide the interosseous tissues before applying the saw. The amputating knives now employed are con- Fig. 377. Straight bistoury. structed with solid metal handles, so that they may be rendered thoroughly aseptic by immersion in boiling water before being used (Fig. 378). Fig. 37S. Amputating knife and catlin. Amputating Saws. — Several kinds of amputating saws are in general use ; one with a blade ten inches long by two and a half inches wide, with a heavy back to give it additional firmness, is a very good variety of saw (Fig. 379). For amputations about the foot or hand a narrow Fig. 379. Amputating savr. saw with a movable back will be found very convenient (Fio\ 380). A bow saw with a metallic handle and a re- versible blade is a very useful variety of saw, as it can be used either in amputations or in excisions, and, being con- 484 AMPUTATIONS. Fig. 380. Small amputating saw. structed entirely of metal, it can be easily rendered aseptic (Fig. 381). Fig. 381. - \JBWXViWS, J5> Amputating saw with reversible blade. Bone-forceps, or Cutting Pliers. — These instruments are used in smoothing off any rough edges of bone left after the use of the saw, or for the division of the small bones in amputations of the fingers and toes. The forceps should be from ten to twelve inches in length, with blades from one to one and a half inches in length (Fig. 382). Fig. 382. Bone-forceps, or cutting pliers. Periosteotome. — The periosteotome, or raspatory, is em- ployed for dissecting up a flap of periosteum, which, after sawing the bone, is drawn down over the sawed end of the bone (Fig. 383). Artery Forceps and Tenacula. — These instruments are Hised for taking up the vessels, and one of the best forms INSTRUMENTS REQUIRED FOR AMPUTATIONS. 485 Fig. 383. Periosteotome. of artery forceps is that known as the double-spring artery forceps (Fig. 229). Tenacula are also employed for the same purpose (Fig. 230). Hemostatic forceps will also be found most useful in cases of amputation, for the rapid control of hemorrhage from small vessels after the tourni- quet has been removed, the vessels being secured by torsion or by ligatures before the haemostatic forceps are removed. Retractors. — These consist of pieces of sterilized muslin six or eight inches in width, one end of which is split Fig. 384. Retractor applied. (Esmarch.) into two or three tails ; the former variety of retractor is employed where one bone is divided, as in amputations 486 AMPUTATIONS. of the arm and thigh (Fig. 384), and the latter in cases where two bones are divided, as in amputations of the forearm and leg. Ligatures. — The best material to employ for the ligature of vessels is plain or chromieized catgut or sterilized silk, the preparation of which has been described (page 138). Sutures. — The materials employed for sutures in cases of amputation may be silkworm-gut, catgut, silk, or silver wire ; deep or buried sutures of catgut, bringing together the edges of the periosteal flaps, muscles, and fascia, are often employed with advantage in amputations (Fig. 385), the skin flaps being brought together with interrupted or Fig. 385. Fig. 386. Deep or buried sutures of muscles. (Esmarch.) Sutures of the skin. (ESMARCH.) continuous sutures of silk, catgut, silkworm-gut, or silver wire (Fig. 386). Tourniquets. — For the control of hemorrhage during amputation the Esmarch apparatus (Fig. 228) or Petit's tourniquet (Fig. 222) is employed ; or the employment of both at the same time will often be found most satisfactory. The Esmarch bandage and tube being applied, after re- moval of the bandage, the tourniquet of Petit is loosely applied at a higher point, and after the main vessels have been secured the elastic strap is removed, and the tourni- quet is screwed down and controls the bleeding until the smaller vessels have been secured by ligatures. Wyeth's DETAILS OF AN AMPUTATION. 487 pins may be used in conjunction with the elastic strap in amputations at the hip-joint and shoulder-joint. Details of an Amputation. — The following are the steps of an amputation of the lower part of the thigh : The skin is first thoroughly cleansed by scrubbing it with turpentine, soap and water, and alcohol. It is then washed with a solution of bichloride of mercury, 1 : 2000. Provi- sion is next made to prevent the loss of blood during the operation by the application of Esmarch's bandage and tube ; the bandage being removed a tourniquet is placed over 'the femoral artery in Scarpa's triangle and loosely secured. The limb is again washed with bichloride solu- tion. The instruments having been previously thoroughly sterilized, a rubber cloth covered with sterilized towels wrung out in a bichloride solution is placed under the limb. The variety of amputation having been decided upon, the flaps are cut and the muscles are divided down to the bone ; the periosteum being dissected up, a two-tailed retractor is applied, and the tissues are held back by an assistant while the surgeon divides the bone with the saw. When the bone has been divided the retractor is removed. ^ Irri- gation of the surface of the wound is not necessary if the operation has been an aseptic one. Sterilized gauze pads may be employed to wipe away the blood. The femoral artery and vein are next found and secured with ligatures, and any muscular branches which can be found are also secured. The elastic strap is removed after screwing down the tourniquet, and by gradually letting up the pressure on the smaller vessels which bleed, they are picked up with artery forceps or haemostatic forceps and secured. After all bleeding has been controlled the tourniquet is removed. If there is much oozing from the smaller ves- sels, irrigation with hot saline solution or sterilized water may be employed ; the fluid should be as hot as the hands of the operator can comfortably stand, which will act promptly in controlling this variety of bleeding. The periosteal flaps, if they have been made, are brought together by two or three catgut sutures, and a long drain- age-tube is next introduced, or two short tubes are intro- 488 AMPUTATIONS. duced at either extremity of the wound and secured by sutures or safety-pins. Drainage may be omitted, but I consider it wise to employ it in major amputations. The muscles and tendons should next be brought together over the face of the stump by a few deep or buried sutures of catgut, thereby making a good cushion and tending to lessen the subsequent muscular atrophy, and the skin Haps should then be brought into apposition by a number of interrupted sutures (Fig. 387). The surface of the stump is next washed with salt solution or sterilized water, and a Fig. 387. Stump showing application of sutures and drainage-tubes. (Smith.) number of layers of dry sterilized gauze are applied over its surface and over the gauze dressing a number of layers of sterilized cotton are placed, and the whole dressing is held in place by a recurrent bandage of the stump. If the antiseptic method is employed, the surface of the wound is irrigated at intervals during the operation with a 1 : 2000 bichloride solution, and the stump is dressed with moist or dry bichloride gauze and bichloride cotton. Re-dressing of Amputations. — The first dressing of an amputation, if strict antiseptic precautions have been BE-DRESSING OF AMPUTATIONS. 489 observed at the time of operation, need not, as a rule, be made for a week or ten days, except in cases where the oozing is so profuse as to soak the dressings, or where con- secutive hemorrhage has occurred, or the patient's condi- tion shows that the wound is not running an aseptic course. The re-dressing of a stump can be accomplished without pain to the patient if the surgeon and his assistants are careful in their manipulations. The dressings to be applied, the solutions for irrigation, and the instruments required should be prepared and at hand before the stump is exposed. The surgeon and his assistants should wash their hands carefully, and then soak them in a 1 : 2000 bichloride solution. The bandage retaining the dressings to the stump should be divided with bandage scissors without lifting the stump from the pillow upon which it rests. After the bandage has been divided and turned aside, the gauze dressing is next unfolded and turned down ; an assistant now slips his hands under the stump and gently raises it from the dress- ings, and at the same time a rubber cloth covered with sterilized towels or towels which have been wrung out in a 1 : 2000 bichloride solution is slipped under the stump and the soiled dressings are removed. If the dressings are adherent at the line of incision, irrigation with saline solu- tion or distilled water may be employed to soften them and facilitate their removal. If the wound is aseptic and there seems to be no further indication for the use of the drainage-tubes, they may be removed. The sutures are next examined, and if the wound is firmly healed alternate sutures may be removed ; if catgut or silkworm-gut sutures have been used, they need not be disturbed at this dressing, and their removal may be postponed until a subsequent dressing. The wound should next be covered with a sterilized gauze dressing consisting of a number of layers, and over this several layers of sterilized cotton, and the dressings should be held in place by a recurrent bandage of the stump. If the antiseptic method has been employed the stump may be irrigated with a 1 : 2000 bichloride solution 490 AMPUTATIONS. and a dressing of bichloride gauze and cotton used to cover the stump. The assistant should hold the stump firmly, to prevent muscular spasm, and after the dressings have been secured it should be placed upon a clean pil- low prepared for its reception. The same procedures are adopted at subsequent dressings ; and if the wound has run an aseptic course, two or three dressings, at most, will be required. AMPUTATIONS OF THE HAND. Amputations of the Fingers. — The fingers may be amputated in the continuity of the phalanges or in their contiguity, and, as a rule, as it is important to save as much Fig. 388. Amputation of a finger by the long palmar flap. (After Esmarch.) as possible of the finger, the former method is generally to be employed instead of disarticulation at a higher point. The incision should be so planned that the cicatrix does not occupy the palmar surface ; the larger flap should, therefore, be taken from the palmar aspect of the finger. In amputating the phalanges of the fingers in their con- tinuity, the circular method (Fig. 392, B) or a short AMPUTATION OF THE FINGER. 491 dorsal flap and a long palmar flap may be employed. Tn disarticulating a phalanx it is best to enter the joint with a narrow knife from the dorsal side, and after having carried it through the joint, to cut a long palmar flap, keeping close to the bone (Fig. 388). In locating the position of the phalangeal joints, it is well to remember that the prominence of the knuckle when the finger is flexed is formed entirely of the head of the proximal and not of the Fig. 389. Fig. 390. Phalanges flexed. Guides to articulations of the fingers, a. head of metacarpal bone : b, metacarpophalangeal articulation : c, relation of palmar fold to articu- lation : d, e, interphalangeal articulation ; /, ar- ticulation of distal phalanx. i^Smith.) base of the distal phalanx (Fig. 389), and also that the folds on the palmar surface of the finger do not correspond exactly to the joints (Fig. 390). Amputation of the Finger through the Metacarpo- phalangeal Articulation. — In this variety of amputation an incision is made from a point on the dorsal surface of the metacarpal bone a quarter of an inch above the articu- lation, which is carried through the interdigital web and back upon the palmar surface to a point a quarter of an inch above the flexor fold (Fig. 392, C). A similar incision be- 492 AMPUTATIONS. ginning and ending at the same points is made upon the opposite side of the finger. The flaps are dissected back, and the lateral ligaments, tendons, and remainder of the capsule are divided (Fig. 391). The finger may also be amputated at the metacarpo-phalangeal joint by making an incision on one side and dissecting the flap back to the joint, then dividing the lateral ligament, opening the joint Fig. 391. Racket-shaped incision for amputation of the finger at the metacarpo- phalangeal joint. (After Rotter.) and carrying the knife across this, dividing the tendons and lateral ligament on the other side and cutting a flap from within outward. Kemoval of the head of the metacarpal bone if desired may be accomplished by the use of cutting pliers (Fig. 393) ; but, as a rule, this procedure is not to be recom- mended, for, although the deformity is lessened, the strength of the hand is diminished. AMPUTATIONS OF THE METACARPAL BONES. 493 In amputating the little and index fingers a full lateral flap may be cut on the free side, and an incision is next carried across the palmar surface to the angle of the web, and thence back to the joint, which is opened and the dis- articulation effected (Fig. 392, E). Fig. 392. A. Disarticulation of distal phalanx: palmar flap. B. Amputation in con- tinuity by a circular flap. C. Metacarpophalangeal disarticulation. D. Ampu- tation of metacarpal bone in continuity. E. Disarticulation of little finger. F. Disarticulation of fifth metacarpal "bone. G. Amputation at the wrist, circular. H. Amputation at the wrist, lateral. (Stimson.) Amputations of the Metacarpal Bones. — In ampu- tating the metacarpal bones it is advisable to leave the carpal ends of the bones to avoid opening the wrist-joint, except in the case of the first and fifth metacarpal bones, which do not communicate with the others and with the synovial sacs. The incisions for the removal of the metacarpal bones 494 AMPUTATIONS. are the same as for the removal of a finger at the meta- carpo-phalangeal joint, the incision being prolonged back- ward as far as necessary over the dorsal surface of the bone (Fig. 392, D.) After the metacarpal bone has been bared for a sufficient distance, it is cut through with bone- pliers or disarticulated, and the distal end is raised from its bed and carefully separated from the soft parts, care being taken to avoid injury of the structures of the palm of the hand. Fig. 393. Removal of the head of a metacarpal bone. (Skey.) In amputating the fifth metacarpal bone, the incision should be made along the inner border of the hand and carried down to the bone between the skin and the ab- ductor minimi digiti muscle (Fig. 394). The lower end of the incision passes over the knuckle to the web of the finger, and backward under the palmar surface to join the first incision. Amputation of the entire thumb with its metacarpal bone is effected by making an oval flap from the palmar AMPUTATIONS AT THE WRIST. 495 surface ; in the case of the left thumb, the joint may be opened by an oblique incision on the dorsal surface of the hand, beginning a little in front of the joint and being carried down to the web between the thumb and fore- finger ; the palmar flap is then made by thrusting the knife upward to its point of entrance and cutting downward and outward. In amputating the right thumb with its metacarpal bone, it is better to make the palmar flap first by transfixion, the dorsal flap being made subsequently. Fig. 394. Incision for removal of the fifth metacarpal bone. (Smith.) Amputation of the hand at the earpo-metacaqxd joint is occasionally performed, or between the rows of carpal bones ; but is not, as a rule, to be recommended, as the carpal bones are apt subsequently to become diseased and require removal ; it is, therefore, better to amputate at the radio-carpal joint. AMPUTATIONS AT THE WRIST. Circular Method.— The skin of the forearm near the wrist being retracted bv an assistant, a circular incision of the skin and cellular tissue is made half an inch below the point of the styloid process of the radius (Fig. 391, G). The skin and cellular tissue are next dissected back as far as the joint, which is opened and the disarticulation com- pleted. Antero-posterior Flap Method.— This method is also employed in amputations at the wrist-joint ; an incision curved downward is made on the back of the hand from one styloid process to the other ; the hand being flexed, the tendons are divided and the joint opened, and the 496 AMPUTATIONS. palmar flap, which should extend as far as the base of the metacarpal bones, is cut from within outward (Fig. 395). Amputation at the wrist is sometimes performed by cut- ting a single flap from the palm, the joint being opened by a transverse incision on the back of the hand from one styloid process to the other. Fig. 395. Amputation at the wrist. (Erichsen.) Lateral Flap Method.— This method (Fig. 392, H) is also sometimes employed in amputation at the wrist, and may be employed with advantage in cases of laceration of the hand, in which the injury to the tissues is so great as to prevent the formation of the flaps used in the other methods of amputation. AMPUTATIONS OF THE FOREARM. The forearm may be amputated by the circular or flap method, or by making rectangular flaps (Teale's method). Circular Method. — At the lower portion of the forearm the circular method of amputation is to be preferred. A circular incision of the skin and cellular tissue is made and a cuff is dissected up, the muscles and interosseous mem- AMPUTATIONS AT THE ELBOW. 497 brane being cut through ; a three-tailed retractor is next applied and the bones are divided with a saw. Modified Circular Method — Amputation of the fore- arm by the oval or mixed method, which consists in first dissecting up two antero-posterior oval flaps of skin and cellular tissue and then dividing the muscles by a circular incision, is also a satisfactory operation (Fig. 396). Fig. 390. Amputation of the forearm by the modified circular method. (Bryant.) In amputation at the upper portion of the forearm, antero-posterior or lateral flaps, cut from without inward or by transfixion, or rectangular flaps, may be made with advantage. AMPUTATIONS AT THE ELBOW. The methods of amputation employed at the elbow are the anterior flap, lateral flap, circular, and elliptical. Anterior Flap Method. — A flap three inches in length, with its base parallel to and half an inch below the condyles of the humerus, is cut either by transfixion or from without inw T ard. The joint is next opened and the lateral ligaments divided. The olecranon is then ex- posed, the attachment of the triceps muscle separated, and a posterior flap cut from without inward, or from within outward, a little below the line of the condvles (Fig. 397, A). Lateral Flap Method. — In amputation at the elbow- joint lateral flaps may be employed, cut either from with- out inward or by transfixion (Fig. 397, B). A flap three inches in length is made on the outer side of the forearm, starting from a point a finger's breadth below the bend 32 498 AMPUTATIONS. Fig. 398. Fig. 397. Circular amputation at the elbow. (.Smith.) A Fig. 399. Amputation at the elbow-joint. A. An- terior flap method. B. External flap method. C. Circular method. (Stimson.) Incision for elliptical amputation at the elbow. (After Tkeves.) of the elbow, by transfixion or by cutting from with out inward; a shorter internal flap is next cut in the same manner, and the joint is opened and the disarticulation effected. Circular Method. — An incision dividing the skin and cellular tissue is made around the limb three inches below the line of the condyles of the humerus (Fig. 397, C), the skin is dissected up and a circular incision made AMPUTATIONS OF THE JAM/. 499 through the muscles, the joint is opened and the disar- ticulation effected (Fig. 398). Elliptical Method. — En this method of amputating at the elbow an incision is carried from the olecranon process downward and forward to a point a little above the middle of the forearm ; it is then continued across the anterior aspect of the limb, and is carried back to the olecranon process (Fig. 399). The incision includes only the skin and the cellular tissue. The flap having been dissected up for a short distance, the soft parts close to the joint are transfixed ; the muscles are cut obliquely, so that an anterior flap is formed. This flap is held up, the bones are disarticulated, the attachment of the triceps tendon to the olecranon is divided, and any tissues which have escaped division along the posterior aspect of the limb are severed. After the vessels have been secured, the flap is turned over and sutured, and a curved cicatrix on the posterior aspect of the limb results. AMPUTATIONS OF THE ARM. The arm may be removed at any point below the attach- ment of the muscles at the axilla, by either the circular, flap, oval, or modified circular method. Circular Method. — This amputation is usually em- ployed in removing the arm in its lower third. A circu- lar incision of the skin and subcutaneous tissue is first made, and when the cuff has been dissected up a circular division of the muscles is made ; after applying the re- tractor the bone is sawed through (Fig. 400). * Transfixion Method.— From the central position of the bone in the arm the flap method in amputating the arm is preferred by many operators. The arm being grasped bv the hand, the point of a medium-sized amputating-knife is thrust through the arm so as to pass over the humerus and make its exit at a corresponding point in the skin on the opposite side ; a flap of sufficient length is cut from within outward. The knife is next passed behind the bone and a 500 AMPUTATIONS. posterior flap is cut in the same manner (Fig. 401) ; the bone is next cleared of muscular tissue, the flaps are retracted, and it is divided with a saw. Fig. 400. Circular amputation of the arm. (Smith.) Lateral flaps may be made in this amputation instead of the antero-posterior flaps, and they may be cut from within outward in the same manner. Fig. 401. Amputation of the arm by transfixion. (Bryant.) Modified Circular Method. — This method of amputat- ing the arm is also employed with advantage. Two oval AMPUTATIONS AT THE SHOULDEBr-JOINT. 501 flaps of skin and cellular tissue are dissected up, and the muscles divided by a circular sweep of the knife. Fig. 4u2. Esmareh's strap applied in high amputation of the arm. (Smith.) In high amputations of the arm there is sometimes not sufficient room to apply Esmarch's strap or a tourniquet to the arm itself to control the hemorrhage during the operation ; in such cases the strap may be passed from the axilla around the outer end of the clavicle, as is done to control the bleeding during amputation at the shoulder- joint (Fig. 402), or Wyeth's pins may be employed. AMPUTATIONS AT THE SHOULDER-JOINT. Several methods of operation are employed in ampu- tating at the shoulder-joint, such as Larrey's method, Lisfranc's and Dupuytren's methods, and Spence's method (Fig. 403). The control i f the bleeding from the axillary artery during the operation is a matter of the first impor- tance ; it may be arrested by pressure made upon the subclavian artery, as it crosses the first rib. with the thumb, or the padded handle of a large key. or by the fingers of an assistant grasping the axillary flap and com- pressing the vessel after the head of the bone has beer 502 AMPUTATIONS. disarticulated, or by the use of an elastic strap applied around the axilla and shoulder (Fig. 402). Fig. 403. Amputation at the shoulder-joint. A. Oval, or Larrey's method. B. Double- flap, or Dupuytren's method. (Stimson.) WyetKs pins may also be employed with an elastic tube or strap to control bleeding during amputation at the Fig. 404. Method of applying Wyeth's pins. shoulder-joint. The anterior pin is passed through the anterior fold of the axilla, and is brought out in front of L ABBEY'S METHOD. 503 the acromion, the posterior pin is passed through the pos- terior fold of the axilla and is brought out behind the acro- mion, the rubber strap or tube is then wrapped around the shoulder behind the pins and controls the hemorrhage dur- ing the operation (Fig. 404). Larrey's Method"— In this method of amputation the point of the knife is entered just below the acromion process, and a deep incision three inches in length is made Fig. 405. Amputation at the shoulder-joint by Larrey's method. down to the head of the bone along: the axis of the arm ; from the middle of this incision two others are made obliquely downward to the points where the anterior and posterior folds of the axilla end in the tissues of the arm ; the latter incisions should be only sufficiently deep to divide the skin and superficial fascia (Fig. 403, A). The flaps are then dissected up until the head of the bone is well exposed, and, after opening the capsule and dividing the 504 AMPUTATIONS. muscles inserted into the neck and tuberosities of the humerus, which division may be facilitated by rotating the head of the bone outward and inward, the disarticu- lation is effected by adducting the elbow ; the knife is next passed downward behind the bone and made to cut outward in the line of the cutaneous incisions, an assistant controlling the artery before it is divided by grasping the axillary tissues behind the knife with his fingers if Wyeth's pins have not been employed. Dupuytren's Method. — In this method of amputation at the shoulder-joint the flaps may be cut either by trans- fixion or from without inward ; the large flap embraces Fig. 406. Amputation at the shoulder-joint. Dupuytren's method. (Bryant. 1 ) the greater part of the deltoid muscle (Fig. 403, £), and the smaller or short flap is cut from the inside of the arm after the head of the bone has been disarticulated. When cut by transfixion, the point of the knife should be entered an inch in front of the acromion process and pushed across the outer aspect of the head of the humerus, and brought out at the posterior fold of the axilla ; the knife is made to cut downward until a large deltoid flap is formed. This flap is turned up and the head of the bone is dis- articulated ; the knife being placed behind it, a short flap SPENCE'S METHOD. 505 is formed, keeping close to the bone, so that the vessels are divided with the last cut of the knife (Fig. 406). An assistant should control the vessel by grasping the axillary tissues with his fingers behind the knife. Lisfranc's Method.— In this method of amputation at the shoulder-joint the point of the knife is entered at the outer side of the coracoid process, and is carried across the outer aspect of the head of the humerus and brought out a little below the posterior border of the acromion process, and a long flap is cut downward. This flap is turned up and the attachments of the head of the bone are divided and it is disarticulated. The knife is again entered behind the bone, and a long posterior flap cut from within outward. Spence's Method.— In this method of amputation at the shoulder-joint an incision is made down to the head of Fig. 407. Amputation at the shoulder-joint. Spence's method. (Stimson.) the humerus immediately in front of the coracoid process, and is continued downward through the clavicular fibres of the deltoid and the pectoralis major muscles until the attachment of the latter to the humerus is reached (Fig. 407). The incision is now carried backward to the pos- 506 AMP VTA TIONS. terior fold of the axilla. A second incision, including only the skin and cellular tissue, is next made from the anterior portion of the first incision across the inside of the arm to meet the incision on the outer part. The outer flap thus formed is turned up and the head of the bone is disarticu- lated. The operation is completed by dividing the remain- ing tissues on the axillary aspect. Amputation above the Shoulder -joint. — This form of amputation consists in removal of the arm with a part or the whole of the scapula, and a portion or whole of the clavicle. As this form of amputation is required in cases in which the laceration of the parts has extended beyond the shoul- der-joint, or in cases of growths involving the tissues be- yond the joint, no definite rule can be laid down for the in- cisions ; the only rule being as far as possible to make them in such a manner that the smallest amount of skin is sacri- ficed, so that a sufficient covering for the wound may be obtained. Treves recommends the following method: The patient should be placed on his back close to the edge of the operating- table. An incision should be made over the clavicle, extending from the inner extremity outward to a point a little beyond the acromioclavicular articulation, which should be carried down to the bone ; the clavicle being exposed, it should be divided in its middle third or disarticulated from the sternum, and, its outer portion being lifted up, it is disarticulated at its acromial ex- tremity. The subclavian vessels are thus exposed, and should be tied by two ligatures, about an inch apart, and the vessels finally divided between the ligatures. The axillary plexus of nerves should next be divided. The second incision is made at the centre of the first incis- ion, and the knife is carried directly across the anterior part of the axilla and inner border of the arm to the inferior angle of the scapula ; from the outer extremity of the first incision over the clavicle a third incision should be made posteriorly, across the dorsum of the scapula to its inferior angle, joining the termination of the second incision (Fig. 408). Upon turning back the posterior flap AMPUTATIONS OF THE FOOT. 507 thus formed and severing the connections of the scapula with the trunk and the muscular attachments which re- main anteriorly, the upper extremity will be entirely freed Fig. 408. Amputation of arm, scapula, and clavicle, the dotted line representing the posterior incision. (Treves.) from the trunk. The wound, when closed, forms an oblique line running from above downward, outward, and backward. AMPUTATIONS OF THE FOOT. Amputations of the Toes.— The phalanges of the toes mav be removed in the same manner as those of the fin- gers. It is better to amputate at the metatarsophalangeal articulations than to attempt to remove them at the joints in front of this articulation, except in the case of the great toe, as the preservation of a portion of a toe is rather a discomfort than an advantage, except in the instance men- tioned. All incisions should be made so that the resulting cicatrix does not occupv the plantar surface, and it is well to remember that the web of the toes is considerably below the position of the metatarso-phalangeal joint. 508 AMPUTATIONS. The toes are usually removed by an incision on the dorsal surface a little above the joint, which is carried down to the bone for about an inch and then diverges into the web, and is carried under the toe and back on the other side to the point of divergence (Figs. 409, 410). Fig. 409. Fig. 410. Amputation of the toes by the racket-shaped incision and flap method. (After Rotter.) Incisions for amputation of toes and metatarsal bones. (Stimson.) Amputation of Two Adjoining Toes. — The dorsal incision should be made in the inter-metatarsal space just above the level of the joint (Fig. 410, B) and carried down to the beginning of the web ; then over the toes to the be- ginning of the adjoining web; then under the plantar surface of both toes in the line of the digito-plantar fold, through the web, and back to the point of divergence. AMPUTATIONS OF THE FOOT. 509 Amputation of the Great Toe. — This may be accomplished by means of the racket-shaped incision employed in am- putation of the other toes (Fig". 109), or by means of a lateral flap. In the latter case the knife is made to enter the joint by cutting through the commissure, and the operation is completed by carrying the knife through the joint and along the outer side of the bone, forming a flap of the required size. In this amputation a short dorsal flap and a long plantar flap may be employed, or a large internal flap may be used. Amputation of the Great Toe with its Metatarsal Bone. — The incision begins upon the dorsal surface of the meta- tarsal bone, a little below the point at which the bone is to Fig. 411. Amputation of the great toe and first metatarsal bone. (Smith.) be divided, and is carried down below the metatarso- phalangeal joint, then diverges and passes under the toe, and comes back again to the point of divergence (Fig, 410, C). The bone is exposed and cut through with cut- ting forceps, and is then lifted up and dissected loose from the tissues (Fig. 411). . Amputation of All the Toes. — To amputate all the toes, make a dorsal incision from the head of the fifth to the head of the first metatarsal bone ; the incision should be 510 A MP VTA TIONS. a curved one passing just in front of the joints (Fig. 412). Dissect up the flap and open the joints, dividing the lateral ligaments, and pass the knife behind the phalanges and cut a flap from the plantar surface. Amputations of the Metatarsal Bones. — It is better in these amputa- tions to leave the tarsal head of the metatarsal bone in place and divide the bone, or, in other words, to do an am- putation in continuity to prevent open- ing up the tarsal articulations. Amputation of the Little Toe and the Fifth Metatarsal Bone. — The incision incision for amputation for the removal of the little toe and the of all the toes. (Smith.) . . . , tilth metatarsal bone is made over the bone a little below the metatarso-tarsal articulation, and is carried down and curved around the toe (Fig. 410, D), and after the bone is exposed by dissecting back the flaps it is divided, or the joint is opened and it is dissected out. Amputation through all the Metatarsal Bones. — In per- forming this amputation an incision is made across the dorsum of the foot, and a short dorsal flap is dissected up ; the metatarsal bones are next divided with a saw and a long plantar flap is cut from within outward by entering the knife behind the ends of the bones. Tarso-metatarsal Amputations. — In all amputations of the foot involving the tarsus the surgeon should be thoroughly familiar with the anatomy of the foot and the surgical landmarks of the different articulations. I shall refer to those laid down by Mr. Bryant, which are as follows : " On the inner side of the foot, not far from the inner malleolus, the tubercle of the scaphoid (Fig. 413, A) is to be felt as a marked prominence ; about one-half an inch in front of this will be found the articulation with the cuneiform bone (B), and one inch in front of this the joint which the surgeon will have to open in Lisfranc's or Hey\s operation (C) ; just above the tubercle of the scaphoid will iMlsn- METATARSAL AMPUTATIONS. 511 be found the articulation with the astragalus, the line of Chopart's amputation (D). On the outer side of the foot, one inch below the external malleolus, a sharply denned projection will always be felt, which is the peroneal tubercle (E)\ one-half an inch in front of this will be Fig. 413. Surgical guides to the foot as expressed by anatomy. (Bryant.) Fig. 414. Incisions for— A. Lisfranc's am- putation. B. Chopart's amputa- tion. (Stimson.) found the joint which separates the os caleis from the cuboid (F), this joint forming the outer circle to Chopart's amputation. Half an inch in front again, or one inch from the tubercle, the prominence of the fifth metatarsal bone is always to be felt (H), the line above this promi- nence indicating the articulation with the cuboid bone, 512 AMPUTATIONS. which forms the outer boundary of the incision for Hey ? s or Lisfranc's operation." Tarso-metatarsal Amputation (Lisfranc's). — The in- cision for this amputation is a curved one carried across the dorsum of the foot from the base of the fifth to the base of the first metatarsal bone (Fig. 414, A). The in- cision should involve the skin only, its centre lying half an inch or more below the centre of the line of the articu- lations, and it should begin and end at the sides of the foot at their junction with the sole. A plantar flap should Fig. 415. Amputation at the tarso-metatarsal joint. (Lisfranc's.) be marked out by a curved incision crossing the sole of the foot near the origin of the toes, starting and ending at the same points as the dorsal incision. The dorsal flap is next dissected back to the line of the articulations ; the tendons, muscular fibres, and fascia being divided, the joints between the tarsal and metatarsal bones are opened with a stout, narrow-bladed knife (Fig. 415). Difficulty is sometimes experienced in opening the joint between the head of the second metatarsal bone and the second cuneiform bone, which occupies a position higher MEDIO- TA BSAL A MP UTA TION. 513 on the foot than the other articulations. The disarticu- lation may also be facilitated by forcibly depressing the anterior portion of the foot. After all the joints have been opened, the knife is passed behind the ends of the metatarsal bones, and a plantar flap is cut from within outward, following the line of the incision previously marked out. The plantar flap may be cut from without inward if preferred. Tarso-metatarsal Amputation (Hey's). — The line of incision and the steps of this operation are similar to those in Lisfranc's amputation, with the exception that Hey sawed off the projecting portion of the internal cuneiform bone after disarticulating the metatarsal bones. This modification, although it improves the appearance of the stump, possesses no advantages over the latter procedure. Medio -tarsal Amputation (Chopart's). — In this ampu- tation the disarticulation is through the joints formed by Fig. 416. Lines of incision for— A. Chopart's amputation. B. Syme's amputation. D. Section of bone in Syme's amputation. C. Subastragaloid amputation. (Stimson.) the astragalus and calcaneum behind and the scaphoid and cuboid in front. An incision is made from the tubercle of the scaphoid across the dorsum of the foot an inch in front of the head of the astragalus to the lower and outer 33 514 AMPUTATIONS. border of the cuboid (Fig. 41 4, B). The plantar flap is next marked out by an incision beginning and ending at the same points as the first incision and crossing the sole of the fout four or five finger-breadths nearer the toes (Fig. 416, A). The dorsal flap is next dissected up, and after the tendons and fascia have been divided the joint is opened and a plantar flap is cut from within outward, following the line of the previously marked-out plantar incision (Fig. 417). Fig. 417. Chopart's amputation. (Bryant.) Subastragaloid Amputation. — In this amputation all the bones of the foot are removed except the astragalus. An incision is made, beginning an inch below. the tip of the external malleolus, which is carried forward to the base of the fifth metatarsal bone ; it is then carried over the dorsum of the foot to the calcaneo-cuboid articulation (Fig. 415, C). The joints between the scaphoid and astragalus and between the astragalus and os calcis are opened, and the latter bone is carefully dissected out ; the ligaments are divided and the astragalus only is allowed to remain in place. AMPUTATIONS AT THE ANKLE-JOINT. Syme's Amputation at the Ankle-joint. — In this amputation, the foot being at a right angle to the leg, an incision is made from the centre of one malleolus directly AMPUTATIONS AT THE ANKLE-JOINT 515 across the sole of the foot to the centre of the opposite malleolus (Fig. 416, B). The tissues of the heel are next carefully dissected from the bone by keeping the knife close to the osseous surface until the tuberosity of the os calcis is fairly turned (Fig. 41 8). The two extremi- ties of the first incision are then joined by a transverse one across the instep, and, the joint being opened, the Fig. 418. Syme's amputation at the ankle-joint. (Skey.) lateral ligaments are divided to complete the disarticula- tion. The knife is next used to clear the malleoli, and they are next removed by the saw in the line indicated (Fig. 416, D). Pirogoff 's Amputation at the Ankle-joint. — In this amputation the posterior portion of the os calcis is re- tained. The incision is carried from the tip of the inner malleolus, over the instep, half an inch in front of the anterior edge of the tibia, to a point half an inch in front of the tip of the outer malleolus ; a second incision, cross- 516 AMPUTATIONS. ing the sole of the foot and carried down to the bone, is next made (Fig. 419, A). The plantar flap is dissected Fig. 419. Pirogoff's amputation. A. Cutaneous incision. B. Line of section of bones. (Stimson.) Fig. 420. Application of saw to os calcis in Pirogoff's amputation. (Erichsen.) back for a quarter of an inch, the joint is opened by dividing the lateral ligaments, the astragalus is disarticu- AMPUTATIONS AT THE ANKLE-JOINT 517 lated, and the malleoli are exposed. A narrow saw is next applied to the upper and posterior part of the ealeaneum behind the astragalus, and the former is divided obliquely downward in the Hue of the plantar incision (Fig. 420). The malleoli and a thin slice of the tibia are next removed with the saw, as in Syme's amputation (Fig. 419, B). Some surgeons do not remove the malleoli, but press the sawed surface of the os calcis between them when it is possible to do so. The position of the os calcis in relation to the tibia after union has occurred is shown in Fig. 421. Fig. 421. Union between ealeaneum and tibia in Pirogoff 's amputation. (Hewson.) Roux's Amputation at the Ankle-joint. — In this method of amputation an incision is made at the outer edge of the tendo-Achillis, a little above its insertion, which is carried forward under the outer malleolus, and across the instep half an inch in front of the anterior edge of the tibia, and back to a point just in front of the inner malleolus ; the incision is carried from this point downward and partly across the sole of the foot, and then back to the point of origin of the original in- cision (Fig. 422). The flaps, are dissected up for a short 518 AMPUTATIONS. distance, the ankle-joint is opened, disarticulation is effected, and the internal flap is carefully dissected from the bones. Other methods of amputation of the foot are sometimes employed, such, for instance, as that advocated by Han- cock, who has combined Pirogoff's amputation with the subastragaloid method, bringing the sawed surface of the os calcis in contact with a transverse section of the astrag- alus. Hancock has advocated the propriety of amputating the foot without regard to the position of the tarsal joints, Fig. 422. Incision in Roux's amputation. cutting the flaps of sufficient length and dividing the bones with a saw. Tripier has also modified the subastragaloid amputation by leaving the upper part of the calcaneum, which he saws through on a level with the sustentaculum tali, and at right angles to the axis of the leg ; the external incisions are made as in Chopart's amputation. In the method advocated by Mikulicz the astragalus and calcaneum are removed, the ends of the tibia and fibula are sawed off, and the sawed surfaces of the scaphoid and cuboid are approximated to these, the stump resulting resembling the foot of pes equinus. AMPUTATIONS OF THE LEG. 519 AMPUTATIONS OF THE LEG. The leg may be amputated at its lower, middle, or upper third, the rule being to save as much of the limb as pos- sible ; but as regards the application of prosthetic appa- ratus, I think the stumps resulting from amputations in the middle and upper thirds will be found more satisfac- tory. It is well also in sawing the bones to divide the fibula at a slightly higher point than the tibia. The circular, modified circular, oval, elliptical, long anterior flap, rectangular flap, antero-posterior flap, lateral flap, or external flap method may be employed. Circular Method. — A circular incision is made through the skin and connective tissue just above the malleoli, the cuff is dissected up for a sufficient distance, a circular incision of the tendons and muscles is next made, and the tissues being retracted, the bones are divided with a saw. Modified Circular Method. — In this method of ampu- tation of the \eg two oval flaps, either antero-posterior or lateral, of the skin and connective tissue are marked out by incisions. The flaps are then dissected up to the ends of the incisions, and a circular division of the muscles is made ; Fig. 423, A ). Elliptical Method. — In this method of amputation the incision is in the form of an ellipse ; its lower end crosses the heel below the insertion of the tendo-A chillis, and the upper end of the incision is about an inch above the ante- rior articular edge of the tibia (Fig. 424. B). Long Anterior Flap Method. — An anterior flap equal in length to the diameter of the leg at its base is marked out by a curved incision through the skin beginning at the posterior edge of the tibia on the inner side, a little below the point at which the bones are to be divided, and is carried over the leg to a point directly opposite over the fibula (Fig. 424, A). The anterior muscles are divided transversely half an inch above the lower end of the flap, and are dissected from the bone to the base of the flap. The posterior flap is then made by entering the knife behind the bones at the point of the original incision and cutting directly outward. ►20 AMPUTATIONS. Fig. 423. Fig. 424. Fig. 423.— Amputation of the leg. A. Modified circular method. B. Rec- tangular flap. C. Antero-posterior flap. The dotted lines indicate the levels at which the bones are to be sawn through. (Stimson.) Fig. 424.— Amputation of the leg. A. Long anterior flap. B. Elliptical flap. C. At upper third. (Stimson.) Rectangular Flap Method (Teale). — In this method of amputation of the leg an incision equal in length to half of the circumference of the leg is made from the point at which the bones are to be divided on one side AMPUTATIONS OF THE LEG. 521 Fig. 425. Modified circular amputation of the leg. (Bryant.) of the leg, and is carried across the limb and back upon the opposite side to a point opposite the point of starting. The flap thus marked out is dissected up to its base, and a posterior flap of one-fourth the length is next cut by a transverse incision down to the bones, and is dissected back to the line of the origin of the first incision (Fig. 423, B). The long flap is next doubled back and its edges secured to the posterior flap, or the long flap may be cut from the posterior surface of the leg and the short flap from the anterior surface. Antero-posterior Flap Method. — A long anterior flap, including half of the circumference of the limb, may be cut from without inward, composed of skin, connective tissue, and muscles ; and a short posterior flap, cut from within outward, may also be employed. This method is often employed in amputations in the upper portion of the leg (Fig. 423, C). Lateral Flap Method. — In the lower and middle thirds of the leg the method of amputation by means of lateral skin flaps may be employed with advantage. In this method an incision is made over the spine of the tibia, and an oval flap, embracing one-half of the circumference of the leg, composed of the skin and connective tissue, is dissectedup ; starting from the same point, a similar flap is formed on the opposite side of the leg and dissected up ; the muscles at the upper extremity of the flaps are next divided by a circular incision and the bones are divided with a saw. External Flap Method (Sedillot). — In this method of 522 AMPUTATIONS. amputation of the leg the point of the knife is entered a finger's breadth external to the spine of the tibia and carried outward, grazing the fibula, and is brought out as far as possible to the inner side ; a flap three or four inches in length is then cut from within outward ; the extremities of the incision are next united by an incision across the inner side of the limb, involving the skin only ; any re- maining muscular tissue is next divided and the bones are sawed. The long external flap is then brought over the ends of the bones and fastened to the edges of the incision on the inner side of the limb. Professor Ashhurst modified this operation by cutting the long external flap from with- out inward, and made also a short internal flap in the same manner. By either method the resulting stump is a good one, with the ends of the bones covered by the tissues of the external flap. AMPUTATIONS AT THE KNEE-JOINT. Amputations at the knee-joint may be done either by the circular or elliptical incision, or by means of flaps, and may consist in simple disarticulations or sections through the condyles of the femur. Elliptical Method. — In this operation an incision crossing the spine of the tibia, five finger-breadths below the lower extremity of the patella, is carried around the back of the leg three finger-breadths higher than in front ; the tissues on the front of the leg are dissected up until the tendon of the patella is exposed ; the leg is then flexed and the ligament of the patella is divided ; the capsular ligament and the lateral and crucial ligaments are next severed, care being taken not to injure the popliteal ves- sels with the point of the knife. The tibia is next drawn forward, the knife is passed behind its posterior border, and the remaining soft parts are divided from within outw T ard. Anterior Flap Method. — In this method of amputation a long cutaneous flap is formed. The incision, beginning half an inch below the articulation, is carried five inches below the patella ; crossing the anterior surface of the leg, AMPUTATIONS AT THE KNEE-JOINT. 523 it is carried hack to the condyle of the femur on the oppo- site side. This flap is dissected up, and the ligament of the patella divided and the disarticulation effected. A short posterior flap, uniting the anterior incision one inch below its extremities, is next cut by transfixion or from without inward (Fig. 426, A). The patella is not removed. Fig. 426. Amputations at the knee-joint and lower third of the thigh. A. Long anterior flap. B. Amputation through condyles. B'. Line of section of the condyles of the femur. C. Modified flap at lower third of thigh. (Stimson.) Amputation through the Condyles of the Femur. — In this amputation, which is known as Carden's ampu- 524 AMPUTATIONS. tation, an anterior flap, whose lower extremity is three finger-breadths below the patella, is cut and the disarticu- lation effected ; the posterior soft parts are divided, the patella removed, and the condyles next sawed through just above the edge of the articular cartilage (Fig. 426, B). Lateral Flap Method. — In this operation an incision is made just below the patella, and is carried down the spine of the tibia for three inches, and is then carried backward to the middle of the leg at a point opposite the beginning of the incision ; a similar flap is cut on the opposite side of the leg, and the flaps dissected up to the line of the articulation. When this point is reached, the joint is opened and the disarticulation effected. The patella is not removed (Fig. 427). Fig. 427. Amputation at the knee-joint by lateral flaps. (Smith.) Gritti's Amputation at the Knee-joint. — In this opera- tion a long rectangular anterior flap is first cut and dis- sected up, and after the disarticulation has been effected the skin covering the posterior surface of the knee is cut from within outward. The condyles of the femur are next removed by a saw above the edge of the articular cartilage, and the articular surface of the patella is removed by the saw or cutting forceps. The patella is next brought down, so that its sawed surface is in contact with the sawed surface of the condyles, and the flaps are brought together (Fig. 428, A). AMPUTATIONS OF THE THIGH. Fig. 428. 525 A. Gritti's amputation at the knee. A'. Lines of division of the bones. B. Amputation of the thigh, long anterior flap. B'. Division of the bone. C. Am- putation at the lower third of the thigh. C. Division of the bone. D. Disarticu- lation at the hip-joint. (Stimson.) AMPUTATIONS OF THE THIGH. Modified Circular Method. — Two oval flaps of skin and connective tissue, the upper extremities of which are several inches above the condyles of the femur, are marked out by incisions and dissected up, the muscles are next 526 AMPUTATIONS. divided by a circular incision, and the bone is divided with a saw. Long Anterior Flap Method. — In this operation an incision is made on the anterior aspect of the thigh, marking out a flap whose length is equal to one-third, and whose width at its base is equal to two-thirds, of the circumference of the limb. The anterior muscles are next divided obliquely upward and backward, so that the flap shall not be too thick, and the posterior muscles are cut transversely and the bone divided with a saw (Fig. 428, B). Amputation in the lower third of the thigh may also be effected by employing a long anterior and a short posterior flap. The anterior flap is cut, its lower extremity extend- ing down to the lower edge of the patella, and after dis- secting up the skin and cellular tissue to the upper extremity of the patella the muscles are cut obliquely up to the point at which the bone is to be divided. A short posterior flap is next cut, and, the soft parts being retracted, the bone is sawed through (Fig. 428, C). Fig. 429. Amputation of thigh by flaps cut by transfixion. Transfixion Method— In amputations of the thigh the flaps may also be cut by transfixion, either lateral or antero -posterior flaps being employed (Fig. 429). AMPUTATIONS AT THE HIP-JOINT. 527 Amputation of the Thigh through the Trochanters. — When, for any reason, it is inadvisable to amputate at the hip-joint, an amputation may be made through the trochanters, a long anterior and a short posterior flap being employed, with circular division of the muscles. AMPUTATIONS AT THE HIP-JOINT. In amputations at the hip-joint, it is important that provision be made for the control of hemorrhage during the operation, and this is accomplished by compression of the femoral artery by the fingers of an assistant, or by the Fig. 430. Esmarch's elastic strap applied to control hemorrhage during amputation at the hip-joint. preliminary ligation of the femoral artery just below Poupart/s ligament. Esmarch's elastic strap may also be employed for the control of bleeding during amputa- tion at the hip-joint, the strap being applied in such a manner that it occupies the position of the turns of a spica-bandage of the groin (Fig. 430). Dieffenbaeh and Wyeth, to avoid hemorrhage, make first a circular amputation in the continuity of the thigh, and after controlling the hemorrhage disarticulate the head of the femur and remove it ; Jordan and Senn dis- 528 AMPUTATIONS. articulate the head of the bone first through an external incision, and control the bleeding before the amputation is completed by passing an elastic tourniquet around the soft parts above the point where they are to be divided. The methods of amputation at the hip-joint are the oval, antero-posterior flap and lateral flap, and modified circular methods. Transfixion Method. — In this method the point of a long amputating knife is thrust into the tissues about two Fig. 431. Amputation at the hip-joint by anteroposterior flaps. (Holmes.) finger-breadths below the anterior superior spinous process of the ilium, and is pushed through the tissues, grazing the hip-joint, and brought out on the opposite side of the thigh close to the junction of the scrotum. The knife^ is next carried downward close to the bone, and an anterior flap of sufficient length is cut from within outward. This flap is held up by an assistant and the head of the bone disarticulated, and, the knife being passed behind the AMPUTATIONS AT THE HIP-JOINT. 529 bone, a posterior flap of equal length is cut from within outward (Fig. 431). Guthrie's method of amputation at the hip-joint consists in cutting the flaps from without inward, a smaller knife being used for this purpose and the posterior flap being cut first. Modified Circular Method. — In this operation short antero-posterior flaps of skin and connective tissue are cut and dissected up, the muscles are divided by a circular incision at the level of the joint, and disarticulation of the head of the femur is next effected. Lateral Flap Method. — In this operation two flaps are cut from the inner and outer side of the thigh by trans- fixing, or by cutting from without inward and exposing the joint, which is opened and disarticulation of the head Fig. 432. Amputation at the hip-joint by external and internal flaps. (Bryant.) of the femur effected as in the preceding methods (Fig. 432). Wyeth's Method of Controlling Hemorrhage in Amputating at the Hip-joint. — In amputating at the hip-joint by this method the hip to be operated upon is brought well over the edge of the table and the Esmarch bandage applied to the limb. Two stout steel pins, twelve or fourteen inches in length, are required : the point of one of these pins is passed through the skin one and a half inches below and slightly to the inner side of the anterior supe- rior spine of the ilium and carried through the tissues 34 530 AMPUTATIONS. Fig. 433. Pins inserted and tube applied. Fig. 434. Limb amputated and bone sawed. (Wyeth.) AMPUTATIONS AT THE HIP-JOINT. 53] about half-way between the great trochanter and the spine of the ilium external to the neck of the femur, and its point is made to emerge just behind the trochanter; the second pin is made to enter the skin an inch below the crotch, internal t<> the saphenous opening, and its point is made to emerge about an inch and a half in front of the tuber ischii. The points of the pins are next protected with corks, and a long piece of rubber tubing or an Es- march elastic strap is wound tightly five or six times about the limb above the fixation pins (Tig. 433). The Esmareh bandage should then be removed and a cir- cular incision of the skin and cellular tissue made five inches below the constricting band ; this cellulo-cutaneous cuff should next be reflected to the level of the trochanter minor; a circular division of all the muscles should next be made at this point and the bone divided with a saw. The large vessels should next be secured, and after this has been done the rubber tube should be removed, and any vessels which bleed should then be tied. The exposed end of the femur is then grasped with bone forceps, and an incision is next made upon the outer side through the skin and muscles until the neck and head of the bone are exposed, and the disarticulation is accom- plished. Wveth now practises disarticulation of the head of the femur in this amputation without first sawing the bone. The circular method or antero-posterior flaps may be employed to expose the head of the bone. PAET VII. EXCISIONS OR RESECTIONS. EXCISION OF THE JOINTS. This operation consists in the partial or complete re- moval of the articular surface of the bones making up the joint. The term resection is sometimes used as synony- mous with excision, but it is usually employed to indicate the removal of a portion or the whole of the shaft of one of the long bones. Excisions or resections of jpints and bones may be required on account of injury, disease, or anchylosis of a joint in faulty position. In the operation of excision of the joint the incision should be sufficiently free to permit of an inspection of the diseased portions of the joint, and it is preferable to remove the diseased articular surface of the bone with a saw ; small areas of diseased bone may be removed with the curette or gouge forceps. In performing excisions of joints in young subjects care should be taken to see that the epiphyseal cartilage is not encroached upon, for if this is removed the subsequent growth of the limb may be interfered with. The ^ result desired in cases of excision of joints, in addition to removal of the diseased tissue, varies somewhat with the joint involved ; for instance, in a knee-joint anchylosis is desired ; in the shoulder, hip, elbow, and wrist, we wish to obtain a movable false joint ; when the latter condition is desired after excision, care should be exercised not to divide muscles or tendons, and as far as possible not to interfere with their attachments. When anchylosis is 533 534 EXCISIONS OR RESECTIONS. desired, the division of muscles or tendons is not a serious consideration ; any injury to the principal arteries, veins, and nerves should always be avoided. Fig. 435. Heavy scalpel. Fig. 436. Butcher's saw. Fig. 437. Narrow-bladed saw. Fig. 438. Chain-saw. The instruments required for the excision of joints are a stout scalpel (Fig. 435), probe-pointed knife, and ex- INSTRUMENTS FOR EXCISIONS. Fig. 139. 535 Lion-jawed forceps. Fig. 440. Retractor. Fig. 441. Elevator. Fig. 442. Bone-cutting pliers. Fig. 443. Knife-bladed forceps. Fig. 444. Periosteotome. 536 EXCISIONS OR RESECTIONS. cision saw with reversible blade (Fig. 436), narrow-bladed saw (Fig. 437) or chain-saw (Fig. 438), strong lion-jawed forceps (Fig. 439), retractors (Fig. 440), an elevator (Fig. 441), heavy bone-cutting pliers (Fig. 442), knife-bladed forceps (Fig. 443), and a periosteotome (Fig. 444). Excision of the Shoulder-joint. — In excising this joint, the arm is addncted and rotated inward, and a straight incision is made extending from the beak of the coracoid process down the arm in the line of the bicipital groove ; this incision may be supplemented by a short, transverse incision from the upper edge of the first inci- sion to the acromion process (Fig. 445). As the incision Fig. 445. Excision of the shoulder-joint. A. Regular incision. B. Supplementary incision. (Stimson.) is deepened the fibres of the deltoid muscle are divided in this line, and the capsule of the joint is exposed and divided along the outer edge of the tendon of the long head of the biceps muscle; this tendon is held to one side, the capsule of the joint is freely opened, and the muscles inserted into the tuberosities of the humerus are divided with a probe-pointed knife and freed with an ele- vator ; the head of the bone may then be removed by saw- ing across the surgical neck of the bone with a narrow metacarpal saw or chain-saw, and the sawed surface of the EXCISION OF THE ELBOW-JOIST. 537 humerus rounded off with bone forceps. The end of the bone is then replaced in the glenoid cavity and the wound drained and closed. Resection of the Humerus. — A portion of the humerus may require resection for injury or disease. The incision should be made upon the outer .-ide of the bone and car- ried down in the muscular interspaces on a line with the shaft, care being taken to avoid injury of the musculo- spiral nerve, which, as it passes around the posterior sur- face of the humerus, lies close to the bone between the humeral heads of the triceps muscle at a point correspond- ing to the deltoid insertion anteriorly — i. e., about the centre of the shaft of the humerus. This nerve should be isolated and held aside, and the bone exposed. After separating the periosteum as completely as possible, if the shaft of the bone is diseased, it should be removed by dividing it in the middle with a saw or forceps, and remov- ing each fragment as far as the upper and lower epiphyses, or the upper or lower portion only may require removal. Excision of the Elbow-joint. — In excising this joint, the forearm is slightly flexed and a longitudinal incision is begun about two inches above the olecranon process and a little to its inner side, and carried about three or four inches down in the line of the ulna (Fig. 446) : the tissues are then divided down to the bones, and the ulnar nerve is dissected from its groove behind the inner condyle of the humerus and held aside by a retractor ; the tendon of the triceps is divided, and its attachment to the fascia and perio-teum over the olecranon process is separated with an elevator or periosteotome and turned downward : the joint is next opened and the lateral ligaments divided as the forearm is flexed upon the arm. The upper part of the ulna and the head of the radius are freed with a probe-pointed knife and removed with a narrow-bladed saw, care being taken in making the section of the radius to divide its neck so that the attachment of the biceps muscle is not interfered with. The condyles of the humerus are next freed and removed with a saw. In freeing the bones at the anterior portion of the joint, great care should 538 EXCISIONS OE RESECTIONS. be used to avoid injury of the brachial artery and vein and the median nerve. Fig. 446. Incision for excision of the elbow-joint. (Stimson.) Resection of the Radius or Ulna. — The radius or ulna may be resected, either entirely or partially, by mak- ing an incision upon the back of the forearm over the Fig. 447. Resection of the lower end of the radius. bone to be removed ; the bone being exposed, the perios- teum is separated with an elevator and the bone divided EXCISION OF 1JII-: WRIST. 539 with a saw, and cadi fragment lifted and separated from its muscular attachments up to the point where it is desired to remove it (Fig. 447). If the articular surface of the bone is to be removed, the disarticulation should he made carefully with a strong scalpel or a probe-pointed knife, care being taken t<> avoid injury of the vessels and nerves lying upon its palmar surface. Excision of the Wrist. — The wrist is covered on its posterior and lateral aspects with skin, fascia, and tendons; Fig. 443. Articulations of the wrist- joint. 'Lister. ) the relative position of the bones entering into the articu- lation may be seen in the accompanying figure (Fig. 448). The wrist-joint may be excised by making a dorsal incision, beginning at the middle of the ulnar border of the second metacarpal bone, and carried upward about four inches, crossing the ulnar edge of the tendon of the extensor carpi radialis brevior. and splitting the dorsal ligaments of the wrist between the tendons of the extensor secondi internodii and the extensor of the forefinger (Fig. 449). The incision should be carried down to the bone 540 EXCISIONS OB RESECTIONS. and the soft parts and tendons dissected loose with an elevator. By flexing the hand, the first row of the carpus is made to present in the wound, and the scaphoid is sepa- rated from the trapezium and removed ; the semilunar and cuneiform should next be removed ; the trapezium and pisiform should be left if possible. In removing the second row of carpal bones, the knife should be passed between the trapezium and the trapezoid and then into the carpo-metaearpal joint, and by cutting the ligaments on the dorsal side of the ends of the metacarpal bones the Fig. 449. Incision for excision of the wrist-joint. (Stimson.) trapezoid, os magnum, and unciform may then be removed. The lateral ligaments are next carefully divided, and the articular ends of the radius and ulna removed with a saw ; the ends of the metacarpal bones should next be removed with a saw or bone-forceps. Resection of a Metacarpal Bone. — A metacarpal bone may be resected by making a longitudinal incision on the back of the hand over the bone to be removed. The in- cision should extend from one articular end to the other, and the extensor tendon when exposed should be held to MET A CARPO-PHA LA NGEA L JOINTS. 541 one side by retractors; the periosteum should next be separated as far as possible, and when the bone has been fully exposed it may be removed by dividing it in the Fig. 450. Resection of a metacarpal bone. middle with bone-forceps and then disarticulating each fragment ; or the articular ends may be freed and the bone removed in one piece (Fig. 450). Fig. 451. Excision of a metacarpophalangeal joint. Excision of Metacarpophalangeal Joints or Inter- phalangeal Joints. — The metacarpophalangeal joint is exposed by a longitudinal incision over the dorsal surface 542 EXCISIONS OB RESECTIONS. of the knuckle ; the extensor tendon being exposed and held to one side, the lateral ligaments are divided. The articular ends of the bones are then exposed and removed with a metacarpal saw or with bone-forceps (Fig. 451). In excising the interphalangeal joints, the incision is usually made upon the side of the joint, and when the articular surfaces of the bone have been exposed they are removed with a small saw or forceps. Excision of the Clavicle. — The clavicle is excised by making an incision over the bone from one articulation to Fig. 452. Resection of the sternal end of the clavicle. the other, which is carried directly down to the bone ; the periosteum is then separated, and the shaft of the bone may be divided at the middle and each fragment raised and disarticulated ; or the bone may be disarticulated at one extremity, then raised up and freed from its adherent tissues, and disarticulated at the other extremity. In disarticulating the sternal articulation of the clavicle (Fig. 452), a probe-pointed knife should be used, and great care should be exercised to avoid injury of the important vessels and nerves which lie in close proximity to it. EXCISION OF THE SCAPULA. 543 Resection of the Ribs. — In this operation, the incision should correspond in length and direction with the portion of bone to be removed, and may be crossed at each end by a short transverse incision. The tissues overlying the rib are then dissected loose, the periosteum is separated as far as possible, the rib is divided with bone-forceps at two points, the fragment is grasped with forceps and the attachments to the under surface of the rib are separated with an elevator. Care should be taken to avoid opening the pleural cavity. Estlander's Operation. — This operation is employed in cases of empyema, and consists in resecting the portions of several adjoining ribs to allow the chest-wall to sink inward and unite with the pulmonary pleura. A rectan- gular or oval flap is marked out by an incision, corre- sponding to the portion of the ribs to be removed, includ- ing all of the tissues external to the ribs. The flap is dissected up, and portions of several ribs are divided with bone-forceps or a saw, and removed with forceps. If the costal pleura is very thick, to expose the cavity so as to permit of free drainage and allow the chest-wall to sink in, it may be cut away over a part of the area from which the ribs have been resected ; one to four inches of three to six adjoining ribs may be removed. Resection of the Sternum. — This operation is per- formed by making a longitudinal incision over the portion of the bone to be removed ; the periosteum is separated, and the diseased portion of the sternum is then carefully freed with an elevator and removed. Excision of the Scapula. — To excise this bone, an incision should be made along the whole length of the spine of the scapula, and from its posterior extremity two other incisions should be made, one running about an inch or two above, and the other passing down the poste- rior border of the bone to its inferior angle (Fig. 453) ; the flaps thus made are loosened by separating the muscles attached to the outer surface of the bone. The attach- ments of the deltoid and trapezius muscles to the acromion and spine of the scapula are separated, and the lower angle 544 EXCISIONS OR RESECTIONS. is freed by detaching the teres major and serratus magnus; the bone is then raised and the snbscapularis muscle detached from below upward. The neck of the scapula should be divided with a chain-saw or bone-forceps ; the acromion is next separated from the clavicle and the scapula turned upward, the joint being opened from below. The coracoid process should be separated from its muscular and ligamentous attachments, or may be divided with a Fig. 453. Incision for excision of the scapula. (Stimson.) saw and left in place. In clearing the supraspinous fossa, care should be taken not to injure the suprascapular nerve in the suprascapular notch ; it should be raised with the periosteum and its fibrous sheath. Excision of the Hip. — In excising the hip-joint, a curved or angular incision is made from a point about three inches below the crest of the ilium and about the same distance behind the anterior superior spine of the ilium, which should be carried downward over the great trochanter in the line of the femur for about five or six EXCISION OF THE SCAPULA. 545 inches (Fig. 454) ; the soft parts are dissected from the great trochanter and upper part of the shaft of the femur, and the capsule of the joint opened. While an assistant rotates the thigh inward and outward, the muscles attached to the trochanters are shaved off close to the bone ; the neck of the femur is next freed by the use of a knife and elevator ; the thigh is adducted and pushed upward, and the head and neck of the bone are made to project from Fig. 454. Incisions for excision of the hip-joint. (Stimson.) the wound. A transverse section of the bone is then made with a saw just below the great trochanter. In some cases it is difficult to remove the head of the bone, which may be anchylosed firmly to the acetabulum ; here the bone may first be divided with a chain-saw passed around the femur just below the great trochanter, or may be divided with a chisel, the head and neck of the bone afterward being removed with a gouge or bone-forceps. 35 546 EXCISIONS OR RESECTIONS. Anterior Excision of the Hip. — In this method of excis- ing the hip-joint, an incision is made upon the front of the thigh over the joint, beginning half an inch below the anterior superior spine of the ilium, and is carried three or four inches downward and a little inward ; as the incis- ion is deepened the tensor vaginae femoris and the glutei muscles are exposed, and should be drawn to the outer side, the sartorius and rectus muscles are held to the inner side and the neck of the femur exposed ; the neck of the bone is then divided with a metacarpal saw or Adams' saw, the diseased portion of the bone is next grasped with strong sequestrum forceps, and by the use of these and an elevator the head of the bone is removed. Excision of the Knee-joint. — The knee-joint is ex- cised by making an incision which begins at the inner Fig. 455. Incision for excision of the knee-joint. A. Curved incision. B. Angular incision. (Stimson.) side of the limb over the inner condyle of the femur, and is carried over the front of the knee just below the patella to a corresponding point upon the external condyle of the femur (Fig. 455, A), or by an angular incision EXCISION OF THE PATELLA. 547 (Fig. 455, B). The flap thus formed is dissected up to a point corresponding with the upper edge of the patella, the ligamentum patellae is then cut through, the leg is slightly flexed, and the joint is opened ; the lateral liga- ments are then divided, and by flexing the leg upon the thigh the joint is freely exposed. The semilunar cartilages are next removed and the condyles of the femur are freed ; a narrow-bladed saw is placed under the condyles and a transverse section of the condyles is removed ; the head of the tibia is next cleared, and a transverse section of this bone is also removed with a saw. The patella may be removed before excising the ends of the bone, or, if anchy- losed to the condyles, may be removed with the section of bone which removes a portion of the condyles. In excising the knee-joint in young persons, care should be taken to remove only so much bone as may be done without encroaching upon the lines of epiphyseal carti- lages, as removal of the epiphyseal cartilage would inter- fere with the subsequent growth of the bones. Arthrectomy of the Knee-joint. — This operation is employed as a substitute for the operation of excision in disease of the knee-joint, and is performed by exposing the joint by an incision similar to that employed in excis- ion. The ligamentum patella? is divided and the patella is reflected with the skin flap. When the joint has been freely exposed, the diseased articular cartilages, semilunar cartilages, crucial ligaments, and synovial pouches are removed by the use of the knife or scissors and the curette ; if the surface of the bone is found to be carious, it is removed by the curette or gouge. After the joint has been thoroughly cleared of diseased tissue it is irri- gated, the divided ligamentum patella? is sutured with several strands of chromicized catgut or silk, and the wound is drained and closed. Excision of the Patella. — The patella may be excised by making a longitudinal or crucial incision ; the perios- teum is carefully separated from the bone, and the latter is grasped with strong forceps and dissected free from its attachments upon the under surface. The knee-joint is 548 EXCISIONS OR RESECTIONS. generally opened in removing the patella, unless removal of the bone be undertaken for necrosis or caries, when it is possible to accomplish its complete removal without opening the joint. Resection of the Tibia or Fibula. — In resecting the tibia or fibula, the bones may be exposed by a longitudinal incision over the bone to be removed, and after the shaft of the bone has been exposed and the periosteum separated Fig. 456. Resection of lower end of the fibula. as completely as possible, the shaft of the bone may be divided at its middle and each fragment grasped with forceps and dissected up, and removed at its epiphyseal junction (Fig. 456). Excision of the Ankle joint. — In excising the ankle- joint, an incision is made at a point two inches above the external malleolus, and carried downward over the fibula to the tip of the external malleolus ; it is then curved slightly upward toward the dorsum of the foot (Fig. 457), EXCISION OF THE ASTRAGALUS. 549 care being taken that the incision does not extend so far forward as to endanger the extensor tendons or the dorsal artery. The bone is exposed in this incision and the periosteum is separated and turned aside ; the peroneal tendons are next exposed and held to one side by retrac- tors ; the external malleolus is next divided by bone-for- ceps and removed, and the astragalus exposed. The upper articulating surface of the astragalus is next removed with Fig. 457. Incision for excision of the ankle-joint. (Stimson.) bone-forceps or a saw, or the whole bone may be removed. The foot is next inverted and the end of the tibia cleared with a probe-pointed knife, care being taken not to injure the posterior tibial artery, nerve, or vein ; and when the articular surface has been freed, it is removed with a saw or bone-forceps. The articular end of the tibia may be exposed by making an additional incision upon the inner side of the ankle over the internal malleolus if desired. Excision of the Astragalus. — In excising the astraga- 550 EXCISIONS OR RESECTIONS. lus, a semilunar incision is made upon the outside of the ankle-joint, very similar to that employed in excising the ankle ; the external lateral ligaments are divided with a probe-pointed knife, and the astragalus is exposed by forcibly inverting the foot ; the bone is then seized with strong forceps, its ligamentous attachments are divided with a probe-pointed knife, and it is removed. Excision of the Os Calcis. — An incision is made at the level of the upper part of the bone, beginning at the inner border of the tendo-Achilles, dividing this tendon and passing around the back and outer surface of the foot to the base of the fifth metatarsal bone ; a short incision is then made at the anterior end of the first incision and carried down to the sole of the foot; the bone is exposed and held by forceps ; the flap thus formed, which includes the peronei tendons, is then separated from the bone, and the cuboid ligaments are cut and also the interosseous ligament between the os calcis and the astragalus, and the bone is removed with forceps. Resection of the Metatarsal Bones. — Any of the metatarsal bones may be resected by an incision on the Fig. 458. Incision for resection of the metatarsal bone of the great toe. (Smith.) dorsum of the foot over the bone to be removed ; the bone is exposed, the extensor tendons being held aside by retractors ; the bone is disarticulated at either end or is cut in its middle, and each fragment dissected up and removed at its articulation. The metatarsal bone of the great toe is exposed by making a curved incision over that bone on the inner side of the foot (Fig. 458). Excision of the Coccyx. — In excising the coccyx, the finger is passed into the rectum and the position of the EXCISION OF THE UPPER JAW. 551 bone determined; a longitudinal incision through the skin and fibrous tissues covering the coccyx is made from a point about a quarter of an inch above its upper limit, and is carried down to a little below its lower extremity. This incision may be supplemented with a transverse in- cision. The sacro-coccygeal articulation is then opened ; an elevator is next introduced into the articulation and the bone is raised up and grasped with forceps. It should then be freed from its lateral attachments, and those upon its anterior surface, with the knife and elevator. Excision of the Upper Jaw. — In excising one-half of the upper jaw, the incision is begun half an inch below the Fig. 459. Incision for excision of the upper jaw. inner canthus of the eye, and is carried downward along the line of junction of the nose and cheek, along the course which limits the alse nasi, and longitudinally to the sep- tum, and then down through the free border of the lip ; it is also advisable to carry the incision along the lower edge of the orbit outward over the malar bone (Fig. 459) ; the flap being dissected away from the surface of the bone, a small, narrow metacarpal saw is then applied to the floor of the nostril until a deep groove is made ; the soft palate and the tissue covering the hard palate are next divided 552 EXCISIONS OB RESECTIONS. from within the mouth with a strong knife ; one or two incisor teeth should be removed, and one blade of a pair of strong bone-forceps introduced into the floor of the nose in the line of the saw incision, the other blade is introduced into the mouth in the line of the division of the structures of the palate, and the bone divided. The malar bone is next divided with a saw or forceps, and, finally, the blades of a strong pair of bone-cutting forceps are introduced, one into the nostril and the other at the edge of the orbit, the important structures of the orbit being held upward with a retractor, and the inner angle of the orbit is cut across ; the superior maxillary bone is then grasped with strong, lion-jawed forceps and twisted out, any band of tissues which holds it being divided with the knife or scissors. Excision of the Lower Jaw. — Partial or complete excision of the lower jaw may be practised. Excision of the Ramus and Half of the Body of the Lower Jaw. — The incision should be made from a point just below Fig. 460. Incision for excision of the lower jaw. the free border of the lip over the symphysis, and carried down to the lower border of the jaw, and from this point TREPHINING THE SKULL. 553 it is carried along the ramus to the lobe of the ear (Fig. 460); the flap is then dissected up, separating the mas- seter muscle from the bone as far as possible without opening the cavity of the mouth ; an incisor tooth is next drawn and the bone is sawed through near the symphysis ; the jaw is then seized with forceps and drawn downward and forward and denuded upon its inner surface. The insertion of the temporal muscle into the coronoid process is divided, the condyle of the jaw is disarticulated from the glenoid cavity, and the remaining soft parts carefully detached with a knife or elevator. The facial artery and the inferior dental nerve and artery are necessarily divided in removing this portion of the jaw. Partial Excision of the Lower Jaw or Alveolus. — The re- moval of a portion of the alveolar process of the jaw may often be accomplished through the mouth without the aid of a cutaneous incision. The condyle, of the jaw may be excised by making an incision close in front of the tem- poral artery and carrying it forward along the zygoma for an inch and a half; the tissues being divided and the bone exposed, a second incision involving only the skin is then carried from the centre of the first directly down- ward for about an inch ; the soft parts are next carefully separated with a knife and elevator from the margin of the zygoma and outer surface of the joint and drawn down w T ard with a retractor, to prevent injury of the parotid gland, nerves, and vessels. The neck of the condyle is then cleared by working around it in front and behind with a director, keeping close to the bone to avoid injury of the internal maxillary artery. A chain-saw is then passed around the neck of the bone, which is divided, and the condyle is seized with forceps and removed with an elevator or gouge. TREPHINING THE SKULL. This is an operation in which a circular disk of bone of the skull is removed by a circular saw or trephine to ex- pose the membranes and the brain. If a wound is already 554 EXCISIONS OB RESECTIONS. present in the scalp, exposing the skull, as in the case of compound fracture of the skull, it is exposed and bared, so that the crown of the trephine may be placed fairly on the bone ; if no wound exists, a U-shaped flap is made, including all the structures down to the bone. The base of the flap should be so situated as to contain a sufficient blood-supply, and the flap should be so planned as to favor drainage from the wound. When the bone has been ex- posed, the trephine is placed with the centre pin projecting about one-sixteenth of an inch, and the instrument is turned from right to left until a groove is made in the bone ; the trephine is then removed, and the centre pin is raised so Fig. 461. Trephine. that as the teeth of the trephine approach the inner table of the skull the point of the centre pin will not injure the membranes or brain. The instrument is then reapplied and worked cautiously as the groove in the bone is deep- ened. When the diploe is reached, there is usually some bleeding from the wound, and as the trephine approaches the inner table of the skull it should be manipulated with great care, and when the resistai^ce is felt to diminish at any one part of the bone the trephine is made to cut at other points of the bone where resistance is still apparent. When the disk is completely cut through, it may be lifted out in the crown of the trephine or may be removed with forceps or an elevator. If the opening in the skull has to TREPHINING THE SKULL. 555 be enlarged to obtain greater exposure of the membranes or brain, it may be done very satisfactorily with a form of rongeur forceps. A portion of the skull may also be removed by the use of the gouge and mallet; the gouge is generally preferred to the trephine in opening the mastoid cells. Fig. 462. 1. Trephine opening for mastoid antrum. 2. For abscess from otitis media. 3. To expose cerebellum. 4, 5. For middle meningeal hemorrhage. A. Lateral sinus. B and C. Limit of up and down variation. (Stimson.) When the trephine is applied to expose the seat of hem- orrhage from the middle meningeal artery, or hemorrhage from the lateral sinus, or an abscess from middle-ear dis- ease, or to open the mastoid antrum, the positions for the application of the trephine are indicated in Fig. 462. 556 EXCISIONS OR RESECTIONS. Osteoplastic Resection of the Skull. — In this opera- tion for exposing the membranes of the brain, a portion of the skull having the soft parts attached is turned aside, so that it may subsequently be replaced and sutured in its original position. The operation is frequently employed to expose the ganglia at the base of the brain and in the removal of tumors of the brain. A horseshoe- shaped incision is made, and the edges are allowed to retract (Fig. 463). A groove is next cut through the bone, fol- lowing the line to which the skin flap has retracted, with a chisel or with a circular saw run by a dental engine or electric motor. The line of division of the bone should be oblique, so that the outer table of the flap rests upon the inner table of the skull when the bone flap is turned back into place. The base of the bone flap is then partly divided with the chisel, with as little disturbance of the soft parts as possible, and the remaining bone in the base of the flap is broken and the flap turned back, the scalp acting as a hinge (Fig. 464). Gigli's wire saw may be used in operating upon the skull. Two small trephine openings are made, and a flat director passed into one of the openings, to separate the dura on a line between them, and the wire saw drawn through this space by a thread attached to a flexible silver probe. The bridge of bone is then divided by the saw. Any desired amount of bone can be removed by making three or four trephine openings and sawing between them. If the osteoplastic flap method is employed, the skin is left undivided on one side and adherent to the bone flap, and the saw is made to cut the bridge of bone between the trephine openings obliquely, so as to bevel the edges of the flap. An instrument for osteoplastic resection or trephining of the skull, which accomplishes the object more rapidly, has recently been introduced by Dr. T. C. Stellwagen, Jr. Trephining the Antrum of Highmore. — The antrum may be opened by extracting the first or second molar tooth and deepening its socket with a small gouge or bone drill. The antrum may also be opened through the mouth, to OSTEOPLASTIC RESEi Tiny OF THE SKULL. 557 Fig. 463. Fig. 464. Osteoplastic resection of the skull. (After Treves.) 558 EXCISIONS OB RESECTIONS. avoid a scar upon the face, by the use of a small trephine or bone-gouge ; the gingivo-labial fold is divided up to a point just below the infra-orbital foramen, the trephine is placed here, and a disk of bone removed, opening the antrum. Trephining the Frontal Sinus. — This sinus may be opened by a trephine or bone-gouge. An incision is made from the centre of the supra-orbital ridge to the median line above the root of the nose. The tissues are divided down to the periosteum ; this is incised and turned aside, the trephine or gouge is placed at the centre of the incision near the inner edge of the supra-orbital ridge and a disk of bone is removed, exposing the frontal sinus. LAMINECTOMY. This operation, which consists in exposing and cutting away the arches of the vertebrae, to secure a free exposure of the spinal canal and cord, is resorted to in cases of fracture of the vertebrae, tumors of the spinal cord, and in cases of tuberculosis of the spine in which there is marked deformity with paralysis, the object being, as a rule, to relieve the spinal cord from pressure. A straight incision, four or five inches in length, is made over the point at which the arches of the vertebrae are to be removed, and the skin, muscles, and fascia are divided, and the spinous processes and arches of the vertebrae are laid bare. Then with strong bone-forceps the arches of the vertebrae on each side are divided, care being taken to avoid injuring the dura. A better method is the forma- tion of a lateral flap by an incision over the arches upon one side, the periosteum and muscles being reflected to the base of the spinous processes, the latter then being divided with bone-forceps or chisel and lifted up in the flap, the dissection of which is continued toward the other side until the arches are exposed from end to end. The latter are then cut away. It is often necessary to remove several laminae if any considerable amount of the spinal cord or canal is to be exposed. OPERATIONS UPON NERVES. 559 OPERATIONS UPON NERVES. Neurotomy. — Neurotomy is an operation in which the nerve-trunk is exposed and a section made through the nerve. As in the case of ligation of vessel.-, it is most important that the operator should have an accurate knowledge of the anatomical relations of the nerves and the surrounding structures. The nerve is exposed by an incision similar to that for the exposure of an artery for the application of a ligature. Nerve-stretching, or Neurectasy.— In the operation of neurectasy, or stretching of nerves, the nerve is exposed and isolated and is lifted upon a blunt hook or retractor ; or, in case of the larger nerves, is hooked out of the wound by the finger, and is thoroughly stretched and replaced in the wound, and the latter closed with sutures. Neurectomy. — In this operation the nerve is exposed and a portion of the nerve is excised. Suture of Nerves, or Neurorrhaphy. — In bringing into apposition the ends of divided nerves, primary or sec- ondary sutures may be employed. The material emploved for sutures should be fine silk or fine chromicized catgut. In using primary sutures, the suture in the case of the smaller nerves should be passed through the sheath and substance of the nerve, and in the larger nerves two sets of sutures may be used, one passing through the substance of the nerve, the other through the sheath. Nerve -grafting. — In employing secondary sutures to unite the divided ends of nerves when there has been a Fig. 465. Nerve-grafting. (Willard.) loss of substance in the nerve, or there has been so much retraction of the nerve that it is impossible to bring the ends together, nerve-grafting may be made use of; the ends of the nerve being freshened, a section of a fresh 560 NEUROPLASTY. nerve from an amputated limb or animal is sutured to the ends of the divided nerve to fill up the gap, as seen in Fig. 465. Nerve -implantation. — This operation consists in sutur- ing a healthy nerve, either in whole or in part, to a para- lyzed one. Implantation is practised by inserting the cut end of a nerve into an incision made into the sheath of an adjacent nerve and securing it in this position by sutures. Both the upper and lower ends of a nerve may be implanted into a neighboring nerve in this manner. Neuroplasty. — Another method of lengthening the ends of a divided nerve, known as neuroplasty, may be employed where the ends cannot be brought into apposi- tion by the ordinary method ; in this method flaps are made for the nerve in the same way as in the lengthening of shortened tendons, and the ends of the flaps are sutured Fig. 466. Neuroplasty. (Willard.) together, as seen in Fig. 466. Sutures a distance' may also be employed, as in the case of the separated ends of tendons. The following incisions are given to expose the nerves for some of these various operations : The Supra-orbital Nerve. — This nerve is exposed at the supra-orbital notch at the junction of the middle and inner thirds of the supra-orbital arch. An incision is made one and a half inches in length, parallel to the eye- brow (Fig. 467, A and B), and is carried down to the bone ; the nerve is exposed and grasped with forceps, and resected or stretched as may be desired. The Superior Maxillary Nerve. — A vertical incision is made along the inner side of the nose from the bony ridge of the nasal process of the superior maxillary bone to the ala of the nose ; a second incision is begun at the upper part of this incision and carried outward along the lower margin of the orbit beyond its centre (Fig. 467, C) ; the OPERATIONS UPON NERVES 561 lower flap is dissected up and the infra-orbital nerve ex- posed. The upper flap is next lifted up with the lower eyelid and eyeball, exposing the floor of the orbit, and the infra-orbital canal may be recognized running backward and inward ; the canal is opened with a knife or chisel, and the nerve separated from the artery and cut off as far back as may be necessary. The nerve may also be reached by exposing the anterior wall of the antrum, and trephin- ing this and the posterior wall, and, when found, may be cut off close to the exit of the main trunk from the round foramen in the sphenoid bone. Fig. 407. A and B. Incisions for resection of supraorbital nerve. C. Incision for resection of the superior maxillary nerve. The Inferior Dental Nerve. — To expose this nerve, an incision is made along the lower jaw, from a point just behind the angle, and carried forward to a point just in front of the edge of the masseter muscle ; the periosteum and masseter muscle are then separated from the bone with an elevator, and the inferior dental canal opened with a small trephine or chisel ; the exposed nerve is then raised upon a hook and resected. The Lingual Nerve. — The lingual nerve may be felt just behind the attachment of the pterygo-maxillary ligament, on the inner side of the lower jaw, close to the bone, below the last molar tooth ; the tongue should be drawn to one 36 562 OPERATIONS UPON NERVES. side and the mucous membrane divided for an inch, par- allel to the alveolar process, beginning at the last molar tooth ; the nerve is then found in the submucous tissue. The Facial Nerve. — This nerve may be exposed at the posterior border of the ramus of the jaw by an incision extending from just in front of the tragus of the ear to the angle of the jaw. The parotid fascia is divided, the cervico- facial branch is exposed first, and may be followed back to its junction with the temporo-facial branch. The Brachial Plexus. — The brachial plexus consists of the four lower cervical nerves and the greater part of the Fig. 468. Resection of the brachial plexus. first dorsal ; it lies between the anterior and middle scaleni muscles and crosses the floor of the subclavian triangle at the base of the neck. To expose the brachial plexus, the neck and head are extended and the face turned toward the opposite side ; an incision is made half an inch above the clavicle, between the sterno-cleido-mastoid and trape- zius muscles, and carried forward for about three inches parallel to the anterior border of the trapezius. The skin OPERATIONS UPON NERVES. 563 and platysma are divided, and the external jugular vein is either cat and Ligated or held to one side ; the deep cervical fascia is next opened in the line of the external incision, and the outer border of the anterior scalene muscle felt for; the brachial plexus is found just outside the latter, and is exposed by careful dissection (Fig. 468). The Spinal Accessory Nerve. — To expose the spinal acces- sory nerve, an incision about three inches in length is made downward from the tip of the mastoid process along the anterior border of the sterno-mastoid muscle ; the cervical fascia should be divided and the muscle strongly retracted, to put the nerve on the stretch. The nerve should be found external to the jugular vein, about an inch and a half below the tip of the mastoid process, on the fascia covering the rectus capitis anticus major. The Median Nerve. — The median nerve may be exposed at the bend of the elbow or just above the wrist. To expose the median nerve at the bend of the elbow, an incision is made about an inch and a half in length upon the inner edge of the biceps tendon ; the bicipital fascia is divided and the nerve exposed at the inner side of the brachial artery. The median nerve may also be exposed above the wrist by an incision two inches in length along the inner border of the tendon of the palmaris longus muscle. The Ulnar and Radial Nerves. — These nerves may be exposed by an incision similar to that employed for liga- tion of the ulnar or radial artery. The Musculo- spiral Nerve. — The musculo-spiral nerve is exposed by an incision on the outer side of the arm above the elbow, from the upper part of the supinator groove ; the fascia being divided, the nerve is sought foi" at the bottom of this groove. The Great Sciatic Nerve. — To expose the great sciatic nerve, an incision three or four inches in length is made vertically downward from the gluteal fold at a point mid- way between the tuberosity of the ischium and the great trochanter ; the skin and fascia being divided, the lower border of the gluteus maximus and the hamstring muscles 564 OPERATIONS UPON TENDONS. are exposed ; the nerve rests on the external rotators of the thigh just in front of the outer side of the hamstring muscles. The Internal Popliteal Nerve. — This nerve is exposed by an incision two inches in length in the middle of the pop- liteal space. The nerve is slightly external to the vein and artery, and is more superficially placed. The External Popliteal Nerve. — This nerve is exposed by an incision two inches in length, parallel and close to the inner side of the biceps tendon, and lies close behind and to the inner side of this tendon. The Anterior Crural Nerve. — This nerve is exposed by an incision about two inches in length, extending from Poupart's ligament downward, and about an inch to the outer side of the femoral artery. OPERATIONS UPON TENDONS. Tenotomy. — This operation consists in the division of a tendon, and it may be done subcutaneously or by an open operation. The former method of tenotomy is to be preferred in most cases, but in certain tendons which lie in close proximity to important vessels and nerves it is safer to employ the open operation. In dividing tendons, the parts should be placed in such a position as to render Fig. 469. Sharp-pointed tenotome. the tendons tense. The instruments required are a sharp- and a blunt-pointed tenotome. The sharp-pointed ten- otome (Fig. 469) is used to make a puncture down to the edge of the tendon, being entered flatwise ; it is then with- drawn and a blunt-pointed tenotome (Fig. 470) introduced through the puncture, passed under the tendon, and turned so that the tendon rests upon its cutting edge ; by a gentle OPERATIONS UPON TENDONS. 565 rocking motion the tendon is then divided, and the ten- otome turned flatwise and withdrawn. Fig. 470. Blunt-pointed tenotomes. The Tendo-Achillis. — In dividing this tendon, a sharp- pointed tenotome should be entered at the inner border of the tendon about an inch above its attachment to the calcaneum (Fig. 471) ; the heel should be depressed as Fig. 471. Tenotomy of tendo-Achillis. much as possible, so as to make the tendon prominent, and a sharp-pointed tenotome passed through the skin and behind the tendon ; it is next withdrawn and a blunt- pointed tenotome introduced and the tendon divided. The posterior tibial artery, nerve, and vein lie to the inner side, and are not likely to be injured if the tendon is divided at this point. The Posterior Tibial Tendon. — This tendon may be divided above the inner malleolus. The muscle is made tense by everting the foot, and the tenotome is entered at the inner side of the tendon and passed behind it. The posterior tibial tendon may also be divided upon the side of the foot ; for this operation the foot is everted, and the tenotome is passed from above downward and under the 566 OPERATIONS UPON TENDONS. upper border of the tendon at a point half an inch below and in front of the tip of the internal malleolus. The Anterior Tibial Tendon. — This tendon is divided upon the dorsal surface of the foot, just below the an- nular ligament of the ankle, midway between the two malleoli. The Peroneal Tendons. — The peroneal tendons may be divided about an inch above the external malleolus, the tenotome being passed from before backward between the fibula and the tendons, or the tendons may be divided at a point midway between the end of the external malleolus and the tubercle of the cuboid. The Hamstring Tendons. — The inner hamstring consists of the tendons of the semi-tendinosus, semi-mem branosus, gracilis, and sartorius. The external hamstring consists of the tendon of the biceps. To divide either of these tendons, the knife is entered at the inner side of the tendon. In dividing the external hamstring, care should be taken to keep close to the tendon of the biceps, as the external popliteal nerve lies close to its inner border. The Adductor Longus. — To divide this tendon, abduct the thigh and make the muscle prominent near its inser- tion ; then pass the tenotome from without downward and inward. The Flexor Longus Pollicis. — This tendon may be divided on the first phalanx or near the inner edge of the foot, where it may be made prominent by strong extension of the great toe, the tenotome being passed close to the border of the tendon. The Extensor Longus Digitorum. — These tendons are divided upon the dorsal surface of the metatarsal bones, where they are quite prominent. They may also be divided near the ankle. The Extensor Proprius Pollicis. — This tendon may be divided in the same incision used for division of the long extensor of the toes, the point of the knife being carried inward. The Sterno-cleido-mastoid Muscle. — In tenotomy of this muscle, the sternal and clavicular attachments are divided SUTURE OF TENDONS. 567 about an inch above the sternum and clavicle. A puncture is made to the outer side of the muscle with a sharp teno- tome, and when the tendinous expansion of the muscle is reached it is withdrawn, a blunt tenotome substituted, and the structure divided. The sternal attachment is divided through a separate puncture in the same way. The exter- nal jugular vein at the outer border of the muscle is to be avoided. The division of the muscle, or its tendinous expansion by an open operation, is now often practised, as there is less risk of injuring the vein by this procedure. Fio. 472. TVnotornv of sterno-mastoid. Suture of Tendons. — In bringing together the divided ends of tendons, primary or secondary sutures are em- ployed ; primary sutures are those introduced immediately after the injury, and secondary sutures are those intro- duced after retraction of the ends has occurred and the wound has healed. Primary Suture of Tendons. — The material employed for sutures may be silk, silkworm-gut, catgut, or kangaroo- tendon, and one or more sutures should be used, being passed through the substance of the ends of the tendon and secured by tying ; the divided sheath of the tendon, 568 OPERATIONS UPON TENDONS. if possible, should be brought together by fine silk sutures (Fig. 473). Very marked retraction of the ends of the tendon is liable to occur, and a considerable dissection is often required to bring them into view. Fig. 473. Suture passed through the substance of the ends of a divided tendon. When there is difficulty in bringing the ends of the tendon together, and the sutures are apt to cut out, the form of suture shown in Fig. 474 may be employed. Fig. 474. Tendon-suture which does not easily tear out. (Stimson.) Secondary Suture of Tendons. — In applying secondary sutures to tendons, the principal difficulty is often encount- ered in bringing the ends of the tendon in contact and in holding them successfully in this position. The ends of the tendon have first to be freshened, and this maybe done by cutting them obliquely and introducing a suture as shown in Fig. 475. This method of section presents a large raw surface of the tendon for union. Lengthening of Tendons. — When so large a gap exists between the ends of the tendon that they cannot be brought TRANSPLANTATION OF TENDONS. 569 Fig. 475. Oblique section of ends of tendon to increase surface of contact. (Stimson.) into apposition, a plastic operation may be performed upon their ends, which often overcomes the difficulty. This consists in making a section halfway through the tendons, at some distance from their ends, and splitting them toward their divided extremities, and then turning out these flaps and securing their ends by means of sutures (Fig. 476). Fig. 476. Lengthening of retracted tendon by flaps. (Stimson.) When the ends of the tendon are so widely separated that they cannot be approximated, sutures a distance may be employed. These consist of sutures of sterilized silk or chromicized catgut passed between the ends of the tendon and tied, the sutures acting as a scaffolding upon which reparative material forms between the separated ends of the tendon. Transplantation of Tendons. — This operation consists in altering the attachments of the tendons of healthy muscles so as to have them fulfil the functions of those 570 TRACHEOTOMY. which are paralyzed. Four methods of transplantation are practised : first, the tendon of the healthy muscle may be completely divided and the upper end sutured to the paralyzed tendon ; second, the tendon of the paralyzed muscle may be divided and the lower end sutured to the healthy one ; third, the tendon of the sound muscle may be split, one end remaining attached to its normal insertion, and the other sutured to the paralyzed tendon ; fourth, a portion or the whole of the healthy tendon may be implanted subperiosteally at the desired point, instead of stitching it to the paralyzed tendon. REMOVAL OF THE BREAST. This may be accomplished by making a circular incision around the breast, or by an incision starting at the ante- rior edge of the axilla and carried around the breast and brought back to the point of starting. The incision is deepened and the muscles are exposed, and the breast is dissected free from the muscles and removed. The axilla is next opened and any enlarged glands are removed. The modern operation of removal of the breast for malig- nant disease is one which is similar to that employed by Kocher and Halsted, and consists in removal of the breast, with the pectoral muscles and the axillary glands and connective tissue, the incision being very extensive, and extended so as to permit of the removal of glands situated above the clavicle. TRACHEOTOMY. This operation consists in dividing the tissues over the trachea in the median line of the neck, and after the trachea has been exposed it is opeued by dividing two or three of the tracheal rings. Under certain circumstances the operation may be per- formed with very few instruments ; but if the surgeon has the choice, he will find it convenient to have at hand two TEA CHEO TOMY. 57 1 small scalpels, one short grooved director, a tenaculum, two aneurism needles (which may be used as retractors), one pair of artery forceps, haemostatic forceps, two pairs of dissectiog-forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy tubes, tapes, ligatures, sponges, a flexible catheter, and feathers. The director should be short ; the ordinary grooved director is too long to use with satisfac- tion in operating upon the short necks of children ; so that I use a shorter and somewhat broader one, having a bevelled extremity, which allows it to be passed with ease between the different layers of the tissues (Fig. 477). Fig. 477. Author's tracheotomy director. Haemostatic forceps are also useful in controlling hem- orrhage during the operation in case of the division of vessels which bleed freely, when the operator from the urgencv of the case does not think it justifiable to ligate them at the time of their division. They may also be employed under similar circumstances to elamp the isth- mus of the thyroid gland on either side of the trachea when it becomes necessary to divide it to expose the trachea. A sharp-pointed tenotome is the instrument I prefer to employ in opening the trachea, as its sharp point enables it to be easily thrust into the trachea. Tracheal dilators of various kinds are employed, but the most satisfactory tracheal dilator which I have em- ployed is that of Golding-Bird (Fig. 478), which is a self-retaining instrument ; the blades are slipped through the tracheal incision and are then expanded by turning the screw to which they are attached. Trousseau's tracheal dilator, the blades of which are introduced through the 572 TRACHEOTOMY. incision in the trachea and are expanded by bringing together the handles, is also a satisfactory instrument (Fig. 479), but it is not so useful as Golding-Bird's dilator, as it has to be retained in position by the hand. Tracheal dilators may be improvised from bent hair-pins or pieces of wire, which will often serve a useful purpose where ordinary dilators cannot be obtained. Fig. 478. Fig. 479. Golding-Bird's tracheal dilator. Trousseau's tracheal dilator. It is also well to have at hand a number of pliable feathers, to be used in clearing the trachea or larynx of mucus or membrane after it has been opened ; by their use this object may be accomplished with little risk of injury to the mucous membrane. Fig. 480. Tracheal forceps. Tracheal forceps, which are constructed with a double spring and curved blades, are also useful in removing membrane or foreign bodies from the larynx above the wound or from the trachea below the tracheal incision (Fig. 480). Tracheotomy-tubes of various shapes are made of silver, POSITION OF PATIENT FOR TRACHEOTOMY. 573 aluminum, hard and soft rubber, but the tube which I consider the most satisfactory for general use is a silver quarter-circle tube with a movable collar (Fig. 481), and provided with a fenestrated guide (Fig. 482). A satisfactory tracheotomy-tube is one which inflicts the least possible injury upon the mucous membrane of the trachea, and to insure this object the part of the tube within the trachea should lie exactly in its axis, and its free extremity should be capable of as little movement as possible. The trache- otomy-tube is held in position, after being introduced, by Fig. 481. Fig. 482. Silver tracheotomy-tube. Silver tracheotomy-tube with fenestrated guide. means of tapes attached to the shield of the tube and tied around the neck. Position of Patient for Tracheotomy. — The best posi- tion in which to place the patient for this operation is one which brings the neck into the greatest prominence, and this may best be obtained by laying the patient upon his back upon a firm table and placing under the shoulders a round cushion ; or an empty wine-bottle or a roller-pin wrapped in towels, will answer the same purpose (Fig. 483) ; or the head may be held over the edge of the table. If an anaesthetic is not used, the arms should be held by an assistant, which is better than securing them by a 574 TRACHEOTOMY. binder around the chest, which restricts respiratory move- ments. Fig. 483. Position of patient for tracheotomy. Operation of Tracheotomy. — The trachea may be opened above the isthmus of the thyroid gland or below it, and these operations constitute respectively the high and the low operation. The high operation is generally selected, because at this point the trachea is more superficial and is more easily exposed, whereas in the low operation the trachea is more difficult to expose by reason of its relatively greater depth, the large size and number of veins, and its proximity to the large arterial trunks. High Operation. — The patient being placed in position, the operator stands at the head of the patient; this posi- tion I prefer, as it is easier from this point to keep the incisions exactly in the median line of the neck. The operator next makes himself familiar with the landmarks of the neck; locating the position of the cricoid cartilage, he makes an incision through the skin in the median line of the neck from one and a half to two inches in length, the position of the cricoid cartilage being the middle point. There is no disadvantage in making a longer incision if a freer exposure of the parts is required. Having divided OPERATION OF TRACHEOTOMY. 575 the skin, the operator will often see a large vein lying in the superficial fascia — the superficial anterior jugular; this should be displaced and the fascia divided upon a director. The surgeon should keep his incisions strictly in the median line of the neck, for this is the line of safety ; and he should be careful, as the wound increases in depth, not to make the incisions too short, so that the wound becomes funnel-shaped. When the deep fascia is exposed, it should be picked up and divided upon a director ; any large veins in the line of the wound should be carefully displaced, or, if this is impossible, they should be ligated on each side and then divided between the ligatures. The operator next looks for the intermuscular space between the sterno-hyoid and the ster no-thyroid muscles, which may generally be found without difficulty; the mus- cles are now separated in this line, with the handle of the knife or with a director, and the isthmus of the thyroid gland exposed. The muscles should now be held aside by retractors placed on either side. He should carefully explore the wound with the finger, to locate exactly the position of the trachea, and to ascertain, if possible, the presence of anomalous arteries. The isthmus of the thyroid gland having been exposed, which generally occupies a position over the first three tracheal rings, the gland will be found surrounded by a plexus of veins, which should be displaced with the direc- tor ; or, if this is impossible, they should be ligated on each side and divided between the ligatures. The thyroid isthmus is next displaced upward or downward, according as the surgeon desires to open the trachea below or above this body. This is often done without difficulty, especially its upward displacement; but when there is difficulty in displacing it downward, a procedure recommended by Bose may be employed, which consists in making a trans- verse incision across the cricoid cartilage to divide the layer of fascia by which the isthmus is bound down ; the director is then passed into this incision and the isthmus is depressed without difficulty. 576 TRACHEOTOMY. Having displaced the isthmus of the thyroid gland downward, the trachea, yellowish white in appearance, covered by the tracheal fascia, will be exposed; this fascia should next be thoroughly broken up with a director or the handle of the knife, so as to bare the trachea, and in doing this the operator may feel it crepitate under the finger from the suction of air drawn in with inspiration. The trachea is next fixed with a tenaculum, introduced into it a little to one side of the median line; an incision is made into it with a narrow knife from below upward, from one- half to three-fourths of an inch in length (Fig. 484), care Ftg. 484. Opening the trachea. (Liston.) being taken to see that this incision is in the median line, for if the trachea be opened by a lateral incision the wound does not heal so promptly and the tracheotomy- tube does not fit well, and its lower extremity may cause injury to the mucous membrane of the trachea. If the wound be a deep one, after fixing the trachea with the tenaculum the operator may lift it slightly from its bed, thereby bringing it more prominently into view and mak- ing it more superficial in the wound, thus facilitating its opening. As soon as the incision is made into the trachea, LARYNGOTOMY. 577 air mixed with blood and mucus escapes from the incision. A tracheal dilator should next be introduced and the trachea cleared of membrane, if it is present in the region of the wound, with a feather or with forceps. The tra- cheotomy-tube is next introduced, and is secured in posi- tion by tapes tied around the neck. If respiration has ceased, artificial respiration should be resorted to, or the use of a tube attached to a bellows, or Fell's apparatus; these efforts should be continued for at least fifteen minutes, for I have seen resuscitation take place in patients who were apparently dead by a persistent employment of artificial respiration. * Laryngotomy. — In this operation an opening is made into the air-passages through the crico-thyroid membrane. It is a simple operation, and one which is practically free from risk, and can, therefore, be performed much more rapidly and safely in urgent cases than tracheotomy. The patient being placed in the recumbent posture, with the shoulders slightly elevated and the head thrown back, to make the neck as prominent as possible, the surgeon feels for the prominence of the thyroid cartilage, and steadying the larynx between the finger and thumb of the left hand, he makes an incision in the median line over the centre of the thyroid cartilage and extending down- ward for an inch or an inch and a half. The skin and superficial fascia being divided, the fascia between the sterno-hyoid muscles and the areolar tissue is exposed and divided, and the crico-thyroid membrane is exposed. The knife is then passed transversely through the membrane into the larynx, care being taken that both that membrane and the mucous membrane which covers its inner surface are divided at the same time. As soon as the knife enters the cavity of the larynx blood and mucus will be forcibly expelled. The wound should be carefully enlarged and a tube introduced, which differs from the ordinary tracheotomy- tube in being slightly flattened ; this is secured in position by tapes tied around the neck, as in the case of the ordi- nary tracheal tube. The only bleeding: which is likelv to Hi 578 INTUBATION OF THE LARYNX. occur is from the crico-thyroid arteries or veins, and if these cannot be avoided, and are divided in the operation, they should be temporarily secured by haemostatic forceps or ligated ; if the case is not extremely urgent, all bleeding should be arrested before the crico-thyroid membrane is incised. Laryngo -tracheotomy. — This operation consists in making an incision into the air-passages by dividing one or two of the upper rings of the trachea, the crico-tracheal membrane, the cricoid cartilage, and the crico-thyroid membrane. This operation is employed in cases where, from the age of the patient, the crico-thyroid space is too small to admit of a sufficient opening, or in those in which, for any reason, the surgeon does not deem it advisable to attempt to open the trachea lower down. The incision in the skin and superficial fascia of the neck is made in the same manner as in the operation of laryngotomy, but is carried a little further downward. It may be necessary to displace the isthmus of the thyroid gland downward to expose the upper portion of the trachea, and when the trachea is exposed the incision should be made through this and the cricoid cartilage from below upward. A tracheotomy-tube is introduced through the wound and secured by tapes tied around the neck. INTUBATION OF THE LARYNX. This procedure, at the present time, is widely employed as a substitute for tracheotomy in the treatment of dyspnoea due to inflammatory affections of the larynx or trachea, or stenosis of the larynx ; it consists in the introduction of a metallic or hard-rubber tube into the larynx, which is allowed to remain in place for a few days. This oper- ation has been reintroduced to the profession by the late Dr. O'Dwyer, of New York, who devised a set of in- genious instruments for the purpose of laryngeal intu- bation. The instruments required are a mouth-gag (Fig. 485), INTUBATION OF THE LARYNX. 579 Fig. 485. Mouth-gag. Fig. 486 Intubation-tube and introducer. Fig. 487. Intubation-tube extractor. with which the jaws are separated and held open ; an in- strument for the introduction of the tube, which is fastened 580 INTUBATION OF THE LARYNX. Fig. 488. ■ 3-*- f I Scale of intuba- tion-tubes. to the obturator, which fills the cavity of the tube (Fig. 486); and an instrument for extracting the tube after it has been placed in the larynx (Fig. 487). The tubes are of metal or hard rubber, and have a collar which rests upon the false cords, and bulge slightly toward their middle and again taper toward their lower extremity ; at the collar of the tube there is a perforation through which a strand of silk is passed which is made into a loop ; this is used to enable the operator to remove the tube if on its introduction it is found to have passed into the oesophagus instead of the larynx, and is also useful in removing the tube if it becomes occluded with membrane while in the larynx. The intubation set now in common use is provided with a scale of seven tubes, ranging in size from such as are suited for a child of one year or less up to the age of twelve or fourteen years (Fig. 488). Special tubes are required for intubation in adults. Operation of Intubation of the Larynx. — In perform- ing the operation of intubation, the child is placed upon the lap of the nurse or assistant, wrapped in a blanket, and the arms secured by the nurse holding the elbows so as not to interfere with the respiratory movements. The patient's head is next held by an assistant. The position of the head, neck, and body should be as if the child were hung from the top of the head, and this posi- tion should be maintained during the insertion of the tube. The mouth-gag is next inserted upon the left side, and the blades dilated so as to open the jaws widely, and as the gag is self-retaining, this position is easily main- tained. The jaws being thus held open, the operator, sitting on a chair facing the patient (Fig. 489), next intro- duces the index finger of the left hand, protected by a strip of adhesive plaster or a metal shield, into the mouth and passes it over the tongue until he feels the epiglottis. The introducing-instrument, to which the tube is attached, INTUBATION OF THE LARYNX. 581 is held in the right hand, and introduced into the mouth, after observing that the silken loop is free; it is swept over the tongue and passed down until it touches the epi- glottis j this is hooked up by the index linger of the left hand and the tube passed into the larynx; the index finger of the left hand is then transferred to the edge of the tube, and by pressing upon the trigger of the instrument Fig. 489. Intubation of the larynx. with the thumb of the right hand the obturator is detached and the instrument is withdrawn, and before removing the finger it is well to place it upon the head of the tube and to sink it well into the larynx. As soon as the obturator is removed, there is usually a violent expiratory effort, which is accompanied by a gush of mucus, mucopurulent matter, or membrane fn >m the tube, and after this escapes 582 INTUBATION OF THE IARYNX. the breathing is usually satisfactorily established. If the operator has passed the tube into the oesophagus and has detached it from the introducing-instrument, no improve- ment in the respiration takes place ; it should then be withdrawn by the silk loop and attached to the tube, and another attempt made to introduce it into the larynx. The mistake, which inexperienced operators make in attempting to introduce the tube is in not hugging the posterior surface of the tongue closely, thereby passing the tube over the epiglottis into the oesophagus. The silken loop may be brought out at one side of the mouth and adjusted around the ear or fastened to the side of the face by strips of adhesive plaster for a few hours, so that by drawing upon it the nurse or attendant can withdraw the tube instantly if it should become obstructed with membrane ; or, if it is coughed up, by this means it may be withdrawn from the oesophagus if it has not been expelled from the mouth. Some operators keep the loop attached to the tube during the time it is retained in the larynx. I prefer to remove it after the tube is securely placed in the larynx, and to withdraw the tube by means of the extracting-instrument when required. The tube should be removed at the end of the second or third day, and if the child can breathe comfortably for an hour or two it need not be reintroduced; if, however, the dyspnoea returns, it should be reintroduced, and allowed to remain one or two days longer ; several attempts may have to be made before the tube can be permanently removed ; it is usually dispensed with from the third to the eighth day. The most serious complication which is apt to occur during the introduction of the intubation-tube is the detachment and pushing of a mass of membrane in front of the tube into the trachea; if the mass is too large to be expelled through the tube, the breathing is suddenly arrested. The tube should be removed at once, and if the mass of membrane does not escape with the expiratory efforts of the patient, the trachea should be rapidly opened as the only means of re-establishing the respiratory func- INTUBATION OF THE LARYNX. 583 tion. So much do I dread this accident, which has occurred in a few cases, that J never introduce the intuba- tion-tube without having at hand the necessary instru- ments to do a tracheotomy if it should be suddenly required, and, if possible, obtain the consent of the parents or friends to perform tracheotomy if it should be indicated. Feeding after Intubation. — One of the greatest difficul- ties after intubation of the larnyx is the satisfactory feed- ing of the patient; liquids, as a rule, are not swallowed Fig. 490. Feeding a case of intubation of the larynx. well, a portion escaping into the tube, causing coughing and difficulty in breathing. The diet I usually prefer is semisolid, such as corn-starch, soft-boiled eggs, and mush ; 584 OPERATIONS UPON THE KIDNEY. and if these are not well swallowed, it may be necessary to resort to nutritions enemata or the use of a stomach- tube to introduce food. Some patients swallow liquids and semisolids quite well if the head is placed a little lower than the body during the act of deglutition (Fig. 490). OPERATIONS UPON THE KIDNEY. Nephrotomy. — In this operation an incision is made into the kidney. The incision for exposure of the kidney is four inches in length, and should be made from a point two and a half inches from the spine, half an inch below the last rib and parallel with it. The latissimus dorsi, external and internal oblique, and transversalis muscles are divided, and the lumbar fascia is opened, exposing the perinephric fat ; the kidney is then reached by displacing this. Lumbar Nephrectomy. — The incision is the same as for nephrotomy ; the wound may be enlarged by another incision at right angles to the first if more space is required. After the kidney is exposed, its capsule is incised and the finger passed around the organ to separate it freely from the capsule. When the ureter is recognized, it is brought into view, ligated, and cut off. The pedicle containing the vessels is next tied, and divided in advance of the lig- ature with scissors, and the kidney removed. Abdominal Nephrectomy.— To reach the kidney by abdominal incision, an incision four inches long is made at the outer border of the rectus muscle ; the abdomen is opened and the viscera turned aside ; the kidney is exposed and the capsule opened ; the ureter and the renal vessels are ligated and divided, and the organ removed ; a drainage-tube may be introduced or the wound in the abdominal walls may be closed without drainage. Nephrorrhaphy.— Nephrorrhaphy is an operation in which the kidney is exposed through a similar incision to that for nephrotomy, with the object of suturing a mov- able kidney fast in its normal position in the back; when OPERATIONS UPON THE COLON 585 the kidney has been reached, a number of sutures are introduced into the capsule of the kidney, and secured to the fibrous and muscular tissue of the incision. Many surgeons prefer to omit the introduction of sutures, and simply scarify the capsule of the kidney or dissect off a portion of the capsule, and then pack the wound with strips of gauze and allow it to heal by granulation. Other methods of fixing a movable kidney consist in dissecting a flap from the capsule of the kidney and sutur- ing it to the muscular tissues of the external wound before closing the wound. Some surgeons prefer to introduce no sutures, but to pass two gauze loops around the kidney at different points, and pack the wound with gauze. The loops are not removed for a few days, and the wound is allowed to heal by granulation. OPERATIONS UPON THE COLON. Lumbar Colostomy. — In performing lumbar colotomy, or colostomy, on the left side, the patient should be placed Fig. 491. Incision in lumbar colostomy — dotted line shows the situation of the colon. ('Bryant.) upon the right side, and a pillow placed under the loin to make the left side more prominent. An incision four inches in length is made midway between the last rib and 586 OPERATIONS UPON THE COLON. the crest of the ilium, the centre of the incision corre- sponding to a point midway between the anterior superior and posterior superior spines of the ilium ; the tissues are divided to the full extent of the wound until the lumbar fascia and edge of the quadratus lumborum muscle have been reached ; the former being cut through and the edge of the muscle divided, the bowel is exposed, when it is brought to the surface and fastened by sutures to the skin and subjacent tissues, and opened. Inguinal Colostomy. — In this operation an incision three inches in length is made on the left side parallel to and one inch above Poupart's ligament, with its centre on a level with the anterior superior spine of the ilium, or a little lower; or, as practised by Ball, the colon may be exposed by an incision two and a half inches in length, following the line of the linea semilunaris, stopping just short of Poupart's ligament ; the tissues are divided layer by layer and the peritoneum opened ; the skin and parietal peritoneum may be united by a few sutures ; the gut is then brought out at the wound, fastened to its margins by fine sutures, and opened. Maydl's Operation. — In this operation the colon is exposed as in the preceding operation, and then drawn out Fig. 492. Colon held in wound by glass rod. (Pilcher.) of the wound until its mesenteric attachment is on a level with the external incision. A sterilized glass rod or piece of catheter, or a roll of gauze three inches in length, is REMOVAL OF THE APPENDIX VERMIFORMIS. 587 slipped through a slit in the mesocolon close to the gut. This holds the intestine in the wound and prevents its return to the abdominal cavity until adhesions have formed. The two limbs of the flexure of the gut exposed in the wound should be united by sutures beneath the rod. If the gut is to be opened immediately, it should be stitched to the parietal peritoneum of the abdominal incision. If the opening of the bowel can be postponed for twenty-four or forty-eight hours, the introduction of sutures is not required. The bowel may be opened by a transverse incision with a knife, or by the thermo-cautery, to avoid bleeding. REMOVAL OF THE APPENDIX VERMIFORMIS. To expose the appendix, an incision three to four inches in length is made at the outer border of the right rectus Fig. 493. Method of burying the stump of the appendix. (Richardson.) muscle, with its centre on a line drawn between the um- bilicus and the anterior superior spine of the ilium ; the 588 LITHOTOMY. tissues are divided layer by layer and the peritoneum picked up and opened ; the anterior longitudinal band is recognized and traced down to its origin at the appendix. When the appendix is found, the meso-appendix is ligated and the appendix removed. In removing the appendix, a circular incision may be made around it near its base and the cuff turned back ; the body of the appendix is then ligated and cut off in advance of the ligature, and the turned-back cuff brought forward and united by fine silk or catgut sutures. The appendix may also be ligated and cut off close to the gut, or removed by cutting it off close to the gut and then inverting its stump into the colon, and subsequently suturing the w T alls of the colon together over the position of the stump of the appendix by a few Lembert sutures (Fig. 493). In cases of appen- dicitis with abscess, simple ligation of the appendix before removal is usually the only method that can be employed. McBurney's Operation. —When the appendix is re- moved in cases of chronic appendicitis, this procedure may be employed with advantage. It consists in making the ordinary incision, and when the external oblique muscle is exposed, its fibres are separated in the direction of their length ; the edges of the w r ound are next dilated, and the fibres of the internal oblique and transversalis muscles separated in the same manner. After the operation is completed, the fibres of the muscles may be sutured, and, as they cross each other, firm support is given to the abdominal contents, and there is little likelihood of a hernia forming at the site of the incision. LITHOTOMY. Left Lateral Lithotomy. — In performing this opera- tion, the patient is placed upon his back, the hands and feet are secured together, and the bladder is injected with a few ounces of boric acid solution. A grooved staff is introduced into the bladder, the operator first passing one finger into the rectum to locate the position of the staff as regards the prostate. An incision is then made a little SUPRAPUBIC LITHOTOMY. 589 to the left of the raphe of the perineum, a quarter to half an inch in front of the anus, and is carried downward by careful strokes of the knife until the staff is reached, about half an inch in front of the prostate. When the point of the knife enters the groove in the staff, it is pushed back- ward, keeping it well in the groove until the prostate is incised and a gush of fluid escapes along the knife, when it is removed and the index finger introduced and the stone located ; lithotomy forceps are next introduced and the stone removed (Fig. 494). Fig. 494. Deep incision in lateral lithotomy. (Fergusson.) Suprapubic Lithotomy. — The operation of opening the bladder above the pubes may be performed for the removal of stone from the bladder, for the extirpation of growths, or for drainage of the bladder. The hair on the pubes should be shaved off, the bladder injected with a few ounces of saline solution, and a rubber band tied around the penis ; a small rubber bag is then introduced into the rectum empty and filled with air or water. An incision two or three inches in length is made in the median line • of the abdomen just above the symphysis pubis, and is deepened gradually until the deep fascia is reached ; this 590 CIRCUMCISION. is divided, exposing the prevesical fat; when this is dis- placed, the wall of the bladder is exposed to view. A tenaculum is next introduced into the highest part of the vesical wall, to fix it, and a knife thrust through the wall of the bladder, the incision being carried downward about an inch. After the bladder is opened, forceps are intro- duced and the calculus removed. If opened for calculus and the bladder-walls are healthy, the wound may be sutured with stitches which do not pass through the mucous coat. The external wound is then sutured and the bladder drained by a soft catheter passed by the ure- thra. If the bladder-walls are much diseased, the wound is left open and drainage effected by a rubber tube passed through the suprapubic wound into the bladder. CIRCUMCISION. Circumcision is performed by drawing the prepuce for- ward and then enclosing it in a pair of clamp-forceps Fig. 495. Circumcision. placed obliquely just in front of the glans (Fig. 495). The prepuce is next divided with a straight bistoury, and the CHOLEl 'YSTOTOMY. 591 forceps removed, when the .skin and m neons membrane retract. The mucous membrane, if adherent, is dissected loose from the glans ; if redundant, it is trimmed with scissors to make it correspond to the line of skin incision ; the cut edge of the mucous membrane is next fastened to the cut edge of the skin by a few sutures of silk or catffiit. REMOVAL OF THE TESTICLE. In removing the testicle, a longitudinal incision is made over the upper part of the gland and spermatic cord and the envelopes of the testicle and cord divided ; the cord is then exposed and ligated, or the different components of the cord may be separated and tied independently ; the cord is divided in advance of the ligatures and the gland removed. OPERATION FOR VARICOCELE. In operating for varicocele, the dilated veins of the spermatic cord may be ligated by a subcutaneous ligature passed around the cord, care being taken that the vas deferens is not included. Or the veins of the cord may be exposed by an incision an inch and a half or two inches in length, at the upper part of the scrotum, over the cord. The veins being exposed, the larger portion of them are isolated, and two ligatures are passed around the mass of veins about an inch or an inch and a half apart and firmly tied. The portion of the cord between the ligatures is excised and the divided ends of the veins brought in con- tact by tying together the ends of the ligatures upon the proximal and distal ends of the veins ; the wound is then closed with sutures. CHOLECYSTOTOMY. An incision three or four inches in length is made verti- cally downward from the lower border of the liver opposite the tip of the lower border of the tenth rib ; the tissues are divided and the peritoneum opened. The gall-bladder 592 GASTROSTOMY. is then exposed, opened, and sutured to the subcutaneous tissues of the external wound. If the gall-duct is to be explored, this is done with the finger from without or by a probe introduced into it through the gall-bladder. After the gall-bladder has been opened and the stone removed, it may be closed by sutures ; or it may be left open, and a drainage-tube or gauze drainage introduced. EXTERNAL (ESOPHAGOTOMY. A sound is passed through the mouth into the oesopha- gus until its point comes in contact with the stricture of the ceosphagus or the foreign body which requires removal. An incision is then made from a point one inch above the sternum to the line of the upper border of the thyroid cartilage on the inner side of the sterno-cleido-mastoid muscle; the anterior jugular vein is displaced, the fascia is divided, the omohyoid muscle is drawn aside, the sterno- mastoid muscle and the vessels are drawn to the outer side with blunt hooks, and by dissecting down with the finger the oesophagus is exposed; the sound which has been passed into the oesophagus may easily be felt, and the oesophagus incised upon the point of this sound. If a permanent opening is desired, the edges of the oesophagus are sutured to the skin. GASTROSTOMY. An incision one and a half to two inches in length is made parallel to and a finger's breadth from the border of the left costal cartilage, ending opposite the border of the tenth rib ; the tissues are divided layer by layer until the peritoneum is reached (Fig. 496). The latter membrane should be pinched up and opened ; the stomach is recog- nized and brought out of the wound ; the parietal perito- neum is stitched to the skin around the wound, and a fold of the unopened stomach is brought out of the wound and sutured to the parietal peritoneum and the abdominal wall. The opening of the stomach is delayed for twenty- GASTROSTOMY. 593 four hours, if possible, to allow of the formation of adhe- sions between its surface and the parietal peritoneum. Fk;. 4%. v Anatomical relations of the stomach. (Stimson.) Fig. 497. Ssabanajew-Frank method ; first stage. (Richakdson.) Ssabanajew-Frank Method. — A curved incision, three or four inches in length, is made at the margin of the costal 38 5 C J4 GASTROSTOMY. Fig. 498. . i Ssabanajew- Frank method ; second stage. (Richardson.) Fig. 499. jr JMMi Witzel method of infolding the tube. (Richardson.) GASTROSTOMY. 595 cartilages of the left side, and the surface of the stomach is exposed. A cone of the stomach-wall is then grasped with forceps, pulled out of the wound (Fig. 497), and passed under a bridge of skin and connective tissue and made to project from a separate wound made about one and a half inches above the original wound (Fig. 498). The wall of the stomach is fastened in the original wound by sutures Fig. 500. Witzel method ; tube infolded and sutures introduced to close the wound. (Richardson.) and the wound closed, the projecting portion of the stom- ach in the upper wound being secured by sutures. The stomach may be opened at any time. Witzel's Method. — This method of gastrostomy also pre- vents leakage, and is accomplished by making an incision and exposing the wall of the stomach. A small incision is made in the wall of the stomach and a rubber tube or catheter introduced ; the portion of the tube in contact with the stomach external to the wound is then infolded 596 PYLOROPLASTY. by peritoneal approximation, as shown in Fig. 499. The stomach is then stitched to the abdominal wall and the external wound closed (Fig. 500). The tube should not be removed for a week ; feeding may be begun through the tube immediately. Contraction of the fistula may be prevented by the occasional introduction of the tube or catheter. PYLOROPLASTY. This operation is practised in non-malignant strictures of the pylorus. The pyloric extremity of the stomach is Fig. 501. Incision in pyloroplasty. (Richardson.) Fig. 502. Incision closed transversely by sutures. (Richardson.) PYLORECTOMY AND GASTRO-DUODENOSTOMY. 597 exposed by a median incision, and a longitudinal incision is made through the anterior surface of the constricted pylorus (Fig. 501), and the incision closed by sutures introduced transversely, as shown in Fig. 502. PYLORECTOMY AND GASTRO-DUODENOSTOMY. This operation is practised in malignant strictures of the pylorus. It consists in exposing the stomach and duodenum by a median abdominal incision ; the upper Fig. 503. Lines of incision for excision of pylorus. (Richardson.) portion of the duodenum and the stomach are drawn through the incision, and resection of the diseased portion accomplished (Fig. 503). The opening in the stomach being much larger than that resulting from resection of the duodenum, the wound in the stomach should be par- tially closed by Lembert sutures (Fig. 504) ; and when it has been reduced to a proper size to fit the free end of the duodenum, they are fitted together and held in position by the introduction of a circular row of closely applied Lembert sutures (Fig. 505). 598 PYLORECTOMY AND GASTRO-DUODENOSTOMY. Fig. 504. Pylorus excised and opening into the stomach partially closed. (Richardson.) Fig. 505. Gastro-duodenostomy completed. (Richardson.) GASTRO-ENTKllOSTOMY. 599 GASTROENTEROSTOMY. This operation may bo combined with pylorectomy, or in cases where it is inadvisable to resect the pylorus, a lateral anastomosis between the stomach and a coil of small intestine near the stomach may be made, so that the contents of the stomach may find their way into the intes- tine through this artificial opening. "Where resection of Fig. 506. Pylorectomy and gastroenterostomy. (Richardson.) the pylorus is combined with gastroenterostomy, the method of closing the duodenum and stomach and of anas- tomosis between the intestine and the stomach are shown in Ficr. 506. OSTEOTOMY. This operation consists in dividing the bones with a saw or osteotome, and is employed to correct deformities of the bones or joints. 600 OSTEOTOMY. The instruments employed are a saw with short cutting surface, Adams's saw (Fig. 507), or osteotomes (Fig. 508) ; Fig. 507. Adams's saw. a heavy mallet is used to drive the osteotome through the bone. Osteotomy is often employed to correct deformi- ties of the hip following coxalgia, and here the femur is Fig. 508. Macewen's osteotome. divided either at the neck, Adams's operation, or just below the trochanters, Gant's operation. Osteotomy of the Femur below the Trochanters. — A puncture is made with a bistoury on the outer side of the femur just below the great trochanter, and is carried down to the bone; the blade of the saw is then introduced and the femur divided from before backward. The femur may also be divided in this position with an osteotome. Osteotomy for Knock-knee. — The operation employed to correct this deformity is a transverse section of the femur above the condyles (Fig. 509). In the operation of supracondyloid osteotomy the knee is flexed and sup- ported on a sand bag. A longitudinal incision one inch in length is made half an inch anterior to the tendon of the adductor magnus and a finger's breadth above the internal condyle; the knife is carried down to the bone, and before it is withdrawn an osteotome is introduced and its edge turned so as to divide the bone transversely. The section of the bone is accomplished by the use of the OSTEOTOMY FOR BOWLEGS. 60] osteotome and mallet. After the bone has been divided, the deformity is corrected, the wound closed, and the limb put up in a plaster-of- Paris dressing in the corrected posi- tion. Fig. 509. T il; ? ; -i?.i..^ A. Epiphyseal line. C. Liue of bone section in supracondyloid osteotomy. Osteotomy for Bowlegs. — To correct this deformity, the tibia and fibula are divided at the point of greatest bowing with an osteotome. The fibula is divided first with an osteotome entered through a puncture over the fibula, and next the tibia is divided in the same manner. The bones being divided, the deformity is corrected and the limb put up in a plaster-of- Paris dressing in the cor- rected position. Osteotomy may also be employed to correct deformities in other bones, or for the deformity resulting from fractures united in faulty position. INDEX. 4 BDOMEN, many-tailed band- A. age of, 31 Abdominal aorta, ligation of, 463 nephrectomy, 584 Abscess, acute, 311 aspiration in, 313 chronic, 313 Hilton's method in, 311 incision of, 314 injection of, 313 puncture of, 313 treatment of, 311 tuberculous, 313 Absorbent cotton, 167 A.-C.-E.-mixture, 253 Acetanilid, 134 Acetate of aluminum, 134 Acid, boric, 135 carbolic, 130 salicylic, 135 Acromial end of clavicle, disloca- tions of, 417 Actinomyces, 122 Actual cautery, 189 Acupressure, 303 Acupuncture, 188 needles, 189 Acute abscess, 311 Adhesive plaster, 169 Adrenalin chloride in hemorrhage, 299 Airol, 132 AlkVs inhaler, 244 Ambulatory treatment of fracture of bones of leg, 400 of the femur, 392 Amputating knive-. 4 V 2 saws, 483 Amputation or amputations. 4.7 above the shoulder-joint, 506 Amputation or amputations, at ankle-joint, 514 Pirogoff s, 515 Boux's, 517 Svme's, 514 of arm, 499 circular, 499 modified circular, 500 transfixion method in, 499 circular, 477 details of, 487 at the elbow, 497 circular, 498 elliptical method, 499 flap method, 497 elliptical. 479 of fingers, 490 of foot, 507 Choparts, 513 Hancocks. 518 Hey's, 513 kisfranc"s, 512 Tripier's, 518 of forearm, 496 circular, 496 modified circular. 497 of hand, 490 at hip-joint, 527 flap method, 529 modified circular, 529 transfixion method, 528 AVyeth's method. 529 instruments for, 4^2 at knee-joint. 522 Garden's. 523 elliptical, 522 flap method, 522 Gritti's. 524 of the leg, 519 circular, 519 603 604 INDEX. Amputation or amputations, of the leg, elliptical, 519 flap method, 519 modified circular, 519 Sedillot's, 521 Teale's, 520 of metacarpal bones, 493 of metatarsal bones, 510 methods of, 477 modified circular, 479 osteoplastic. Bier's, 481 Mikulicz's, 518 oval, 479 periosteal flaps in, 482 redressing of, 488 at shoulder-joint, 501 Dupuytren's, 504 Larrey's, 503 Lisfranc's, 505 Spence's, 505 Wyeth's pins in, 502 subastragaloid, 514 tarso-metatarsal, 510 Teale's, 480 of the thigh, 525 flap method, 526 modified circular, 525 transfixion method, 526 trochanters of femur, 527 of toes, 507 tourniquets in, 486 by transfixion, 478 at the wrist, 495 circular, 495 flap method, 495, 496 Anaesthesia from chloride of ethyl, 233 from cocaine, 234 from cold, 233 from eucaine, 236 general, 233, 239 from holocaine, 236 from hypnotism, 255 infiltration, 236 local, 232, 233 neural, 237 from rapid respiration, 234 regional, 237 from spinal arachnoidal injec- tion, 238 Anaesthetic or anaesthetics, 232 Anaesthetic or anaesthetics, after- effects of, 254 choice of, 239 in examination of fractures, 338 mixture, Schleich's, 253 Anastomosis -forceps, 286 intestinal, 280 end-to-end, 285 lateral, 283 Senn's 283 Aneurism needle, 302, 447 Ankle, dislocations of, 438 Ankle-joint, amputation at, 514 excision of, 548 strapping of, 176 Anomalous dislocations of the hip, 435 Anterior figure-of-eight bandage of chest, 69 Antipyrin in hemorrhage, 299 Antisepsis, 125 theory of, 123 Antiseptic method, 127 operation, -details of, 158 poultice, 179 treatment of infected wounds, 164 Antitoxin, 117 injection of, 215 Antrum of Highmore, trephining of, 556 Aorta, abdominal, ligation of, 463 Appendicectomy, 587 McBurney's, 588 Appendix vermiformis, removal of, 587 Approximation sutures, 269 Aqua ammonia, counter-irritation from, 186 Aristol, 136 Arm, amputations of, 499 and chest bandage, 67 Arterial hemorrhage, permanent control of, 298 temporary control of, 292 transfusion, 199 Arteries, ligation of, 445. See under each artery, suture of, 303 wounded, ligation of, 304 Arteriotomy, 198 Artery forceps, 301 INDEX. 605 Arthrectomy of knee-joint, 547 Artificial respiration, 201 direct method, 202 Howard's method, 202 Laborde's method, 206 Silvester's method, 202 Ascending spica-bandage of groin, 73 Asepsis, 125 agents to secure, 128 theory of, 123 Aseptic dressings, improvised, 146 methods of, 149 method, 127 operation, details of, 157 preparation for 150 treatment of infected wounds, 164 Aspiration, 208 in abscess, 313 Astragalus, dislocation of, 439 excision of, 549 Auto-transfusion, 199 Axillarv artery, ligation of, 456 BACILLUS aerogenes capsula- tus, 122 anthracis, 121 coli communis, 119 of malignant oedema, 121 mallei, 120 of tetanus, 121 tuberculosis, 119 Bacteria, 111 cultivation of, 114 elimination of, 115 infection from, 115 inoculation of, 114 intoxication from, 115 Koch's law in, 115 pathogenic action of, 116 resistance to, 116 staining of, 114 of suppuration, 118 varieties of, 118 Bandage or bandages, aim and chest, 67 Barton's, 41 modified, 42 black, 90 Borsch's, 87 Bandage or bandages, circular, 23 compound, 27 compressor, of breast, 71 demi-gauntlet, 55 Desault's, 64 dimensions <>t', 20 elastic-webbing, 92 Esmarch's, 296 of eye, crossed, 50 figure-of-eight, 26 of chest, anterior, 69 posterior, 70 of elbow, 58 of knee, 77 of knees, 79 of leg, 83 of neck and axilla, 62 of finger, spiral, 54 flannel, 90 of foot, American, 81 French, 82 four-tailed, 30 of chin, 31 of head, 31 gauze, 88 gauntlet, 54 Gibson's, 44 handkerchief, 32 hardening, 93 of the head. 41 and neck, 49 recurrent, 46 transverse recurrent, 48 of jaw, oblique, 45 Liebreich's, 86 for lithotomy, 86 of the lower extremity, 73 many-tailed, 30 of abdomen, 31 oblique, 23 occipito-facial, 52 occipito-frontal, 53 paraffin, 157 plaster-of-Paris, application of, 95 preparation of, 94 removal of, 103 trapping of, 102 recurrent, 26 of stump, 84 removal of, 22 roller, 18 606 INDEX. Bandage or bandages, roller, double, 20 single, 20 rubber, 90 scissors, 22 of Scultetus, 87 silicate of potassium, 106 of sodium, 106 special, 81 spica-, 25 of buttock, 77 of foot, 80 of groins, double, 76 single, ascending, 73 descending, 75 of shoulder, 59, 61 ascending, 59 descending, 61 of thumb, 56 spiral, 23 of chest, 69 reversed, 24 of lower extremity, 82 of penis, 84 of upper, extremity, 57 starched, 106 sterilized, 146 suspensory, of breast, 71 T, 27 of chest, 27 double, 29 double, 29 of groin, 28 of nose, double, 30 single, 27 of the trunk, 69 of upper extremity, 54 varieties of, 23 Velpeau's, 62 Bandaging, 17 rules for, 21 Barton's bandage, 41 modified, 42 Bavarian dressing, 100 Bedsores, 329 Beta-naphthol, 133 Bichloride cotton, 146 gauze, 145 of mercury, 129 of palladium catgut, 141 Bier's osteoplastic amputation, 481 Binders' board splints, 108, 342 Bisaxillary cravat, 36 Black bandages, 90 Bladder, hemorrhage from, 310 irrigation of, 266 sterilization of, 152 Blood, transfusion of, 198 Bloodletting, 192 Boiled catgut, 140 Bond's splint, 379 Bone chips, preparation of, 220 Bone-grafting, 219 Bones of forearm, fractures of, 375 incomplete fracture of, 377 of leg, fractures of, 395 ambulatory treatment of, 400 Boric acid, 135 Boro-salicylic powder, 135 Borsch's eye bandage, 87 Bougies, 259, 261 bulbous, 262 filiform, 262 oesophageal, 211 rectal, 212 sterilization of, 155, 259 Brachial artery, ligation of, 459 plexus, nerves of, exposure of, 562 Bran bags, 343 Breast, excision of, 570 suspensory cap of, 38 and compressor bandage of, 71, 72 triangular cap of, 38 Bromide of ethyl, 254 Bruises, 323 Brush-burn, 324 Bulbous bougies, 262 Buried sutures, 273 Burns, 324 white-lead dressing in, 325 Buttock, spica-bandage of, 77 Button suture, 276 CANTHAKIDAL collodion, 187 Capillary hemorrhage, treat- ment of, 306 Capsicum, counterirritation from, 186 Carbolic acid, 130 Carbolized gauze, 146 / DEX. 607 Carbuncle, strapping of, 177 Garden's amputation at knee, 523 Carotid artery, common, Ligation of, 451 external, ligation of, 453 internal, ligation of, 454 Carpal bones, dislocation of, 427 fractures of, 382 Cartilages, costal, fractures of, 354 semilunar, dislocation of, 437 Catgut, bichloride of palladium, 141 boiled, 140 cumol, 140 chromic acid, 141 chromicized, 141 drainage, 142 Elsberg's, 141 formalin, 140 ligatures, 139 sterilized, dry, 139 sutures, 139 von Bergmann's, 139 Catheters, 259 female, introduction of, 264 flexible, 260 introduction of, 260 metallic, 259 securing, in bladder, 265 soft-rubber, 261 sterilization of, 155, 259 Catheterization of ureters, 264 Cauterization in hemorrhage, 301 Cautery, actual, 189 irons, 190 Celluloid thread, 142 Chemical sterilization, method of, 149 Chest, figure-of-eight bandage of, anterior, 69 posterior, 70 spiral bandage of, 69 strapping of, 172 T-bandage of, 27 double, 29 Chin, four-tailed bandage of, 31 Cholecystotomy, 591 Chopart's amputation of foot, 513 Chloride of ethyl, 233 of sodium, 136 of zinc, 134 Chloroform, 2-49 administration of, 251 anaesthesia, accidents during, 252 counter-irritation from, 185 and ether, 253 and oxygen, 253 preparation of patient for, 250 Chromic acid catgut, 141 Chromicized catgut, 141 Chronic abscess, 313 Circular amputation, 477 of leg, 519 bandage, 23 suture of intestine, 280 Circumcision, 570 Clavicle, dislocations of, 416 of acromial end of, 417 of sternal end of, 417 excision of, 542 fractures of, 358 in children, 363 Sayre's dressing for, 360 Clinical thermometer, 227 Closed fracture, 335 Coaptation sutures, 268 Cocaine, 234 Coccyx, dislocations of, 414 excision of, 550 fractures of, 356 Cold, anaesthesia from, 233 in hemorrhage, 299 water dressings, 182 Colles's fracture, 377 Colostomy, inguinal, 586 lumbar, 585 Maydl's, 586 Comminuted fracture, 335 Complete dislocations, 411 fracture, 333 Complicated dislocation, 411, 442 fracture, 335 Compound bandages, 27 dislocation, 411, 442 dorso-bis-axillary cravat, 37 fracture, 335 treatment of, 404 Compresses, 168 in hemorrhage, 2'. '3 Compression, 225 digital, in hemorrhage, 292 608 INDEX. Compressor bandage of breast, 71 of both breasts, 72 Congenital dislocation, 443 Constitutional treatment of hemor- rhage, 291 Continued sutures, 274 Contused wounds, 320 Contusions, 323 Coronoid process of ulna, fractures of, 375 Costal cartilages, dislocation of, 415 fractures of, 354 Cotton, 107 absorbent, 167 bichloride, 146 gloves, 156 sterilized, 147 Counter-irritation, 184 from aqua ammonia, 186 from chloroform, 185 from capsicum, 186 from hot water, 184 from mustard, 185 Seguin's method, 188 from tincture of iodine, 185 from turpentine, 184 Cravat, bis-axillary, 36 compound dorso-bis-axillary, 37 dorso-axillary, 37 gluteo-inguinal, 39 mento-vertico-occipital, 35 Crossed bandage of eye, 50 of eyes, 51 Crural nerve, anterior, exposure of, 564 Cultivation of bacteria, 114 Cumol catgut, 140 Cupping, 193 dry, 193 wet, 193 Cystoscope, 222 Czerny suture, 280 DEEP sutures in hemorrhage, 302 Deformity in fracture, 337 gunstock, 370 Demi-gauntlet bandage, 55 Desault's bandage, 64 Descending spica-bandage of groin, 75 Diffused suppuration, 314 Digital compression in hemor- rhage, 292 Dimensions of bandages, 20 1 disinfection, methods of, 125 Dislocation or dislocations, 411 of acromial end of clavicle, 417 of the ankle, 438 of astragalus, 439 of carpal bones, 427 of the clavicle, 416 of the coccyx, 414 complete, 411 complicated, 411, 442 compound, 411, 442 congenital, 443 of the costal cartilages, 415 of the elbow, 423 of the fibula, 438 of the fingers, 427 habitual, 412, 443 of head of radius, 425 of the hip, 430 anomalous, 435 downward, 432 forward, 432 iliac, 430 ischiatic, 430 posterior, 430 pubic, 434 thyroid, 432 upward, 433 of humerus, subcoracoid, 419 subglenoid, 419 of the hyoid bone, 415 of the knee, 436 of the lower jaw, 414 of the metacarpal bones, 427 of the metatarsal bones, 440 old, 412, 440 partial, 411 of the patella, 435 pathological, 443 of the pelvis, 416 of phalanges of toes, 440 recent, 412 of the ribs, 415 of the scapula, 41 8 of the semilunar cartilages, 437 of the shoulder, 419 simple, 411 LXDh'X. 609 Dislocation or dislocations, of sterna] end of clavicle, 1 17 of the sternum, 41(5 subclavicular, of humerus, 419 subspinous, of humerus, 420 of the tarsal bones, 439 of the thumb, 428 treatment of, 412 of the ulna, 426 of the vertebrae, 413 of the wrist, 426 Dorsal dislocation of the hip, 430 Dorsalis pedis artery, ligation of, 473 Dorso-axillary cravat, 37 Double ligature, 287 spiea-bandage of groins, 76 T-bandage, 29 of nose, 30 Downward dislocation of the hip, 432 Drainage, catgut, 142 horsehair, 142 tubes, 142 Dressing or dressings, antiseptic, improvised, 146 aseptic, improvised, 146 methods of, 149 Bavarian, 100 cold water, 182 dry sterilized unitize, 147 fixed, 93 gauze, 145 moist, method of, 161 sterilized ^auze, 147 plaster-of-Paris, 93 application of, 93 interrupted, 97 of wounds, 318 Dry cupping, 193 dressing, method of, 149 sterilized gauze dressing, 147 Dupuytren's amputation at shoul- der-joint, 504 ELASTIC constriction in hemor- rhage, 294 ligature, 289 Elastic-webbing bandage, 92 Elbow, amputation at, 497 dislocations of, 423 39 Elbow, figure-of-eight bandage of, 58 Elbow-joint, excision, ~>:\7 Electricity, injuries from, 326 Electrolysis, 220 Elimination of bacteria, 115 Elliptical amputation, 47*. > of [eg, 5111 End-to-end intestinal anastomosis, 285 Enema, glycerin, 213 nutritious, 213 Enemata, 212 Epiphyses, separation of, 345 symptoms of, 346 treatment of, 347 Epistaxis, 307 Erichsen's ligature, 289 Esmarch's bandage, 296 inhaler, 251 tube, 296 Estlander's operation, 543 Ether, 241 administration of, 244 after-effects of, 248 and chloroform, 253 first insensibility from, 246 and nitrous oxide gas, 248 and oxygen, 249 preparation of patient for, 242 Etherization, accidents during, 246 Ethyl bromide, 254 Eucaine hydrochlorate, 236 Excision or excisions, 533 of ankle-joint, 548 of astragalus, 549 of breast, 570 of clavicle, 542 of coccyx, 550 of elbow-joint, 537 of hip-joint, 544 anterior, 546 of joints, 533 instruments for, 534 of knee-joint, 546 of lower jaw, 552 of metacarpophalangeal joints, 541 of os calcis, 550 of patella, 547 of scapula, 543 ... 610 INDEX. Excision or excisions, of shoulder- joint, 536 of testicle, 591 of upper jaw, 55] of wrist, 539 Exploring-needle, 21 7 Exploring-trocar, 217 Extremity, upper, bandages of, 54 Eyes, bandage of, crossed, 51 FACIAL artery, ligation of, 455 nerve, exposure of, 562 Faradization, 222 Fascia, strains of, 331 Feet, sterilization of, 151 Felt splints, 109, 342 Female catheter, introduction of, 264 Femoral artery, ligation of, 468 Femur, dislocation of, see Hip. fractures of, 384 ambulatory treatment of, 392 in children, 391 of lower end of. 390 of shaft of, 388' of upper extremity of, 384 Fermenting poultice, 179 Fibula, dislocation of, 438 fractures of, 401 resection of, 548 Figure-of-eight bandage, 26 of elbow, 58 of knee, 77 of knees, 79 'of leg, 83 of neck and axilla, 62 Filiform bougies, 262 Fingers, amputation of, 490 dislocations of, 427 fractures of, 382 spiral bandage of, 54 Fixed dressings, 93 Flannel bandage, 90 Flaxseed poultice, 178 Fly blister, 187 Fomentations, hot, 179 Foot, amputations of, 507 bandage of, American, 81 French, 82 spica-bandage of, 80 Forced respiration, 206 Forceps, anastomosis, 286 artery, 301 haemostatic, 296 Forearm, amputations of, 496 circular, 4i)6 modified circular, 497 fractures of bones of, 375 Formaldehyde, 133 Formalin, 133 catgut, 140 gelatin, 133 Forward dislocations of the hip, 432 Four-tailed bandage, 30 of chin, 31 Fracture or fractures, 333 anaesthetics in, 338 bed, 341 of bones of fingers, 382 of forearm, 375 of leg, 395 -box, 343 of carpal bones, 382 of clavicle, 358 in children, 363 closed, 335 of coccyx, 356 Colles's, 377 reversed, 381 comminuted, 335 complete, 333 complicated, 335 compound, 335 treatment of, 404 of coronoid process of ulna, 375 of costal cartilages, 354 deformity in, 337 evaporating lotions in, 344 examination of, 337 of femur, 384 of fibula, 401 green-stick, 333 gunshot, 334 of head of radius, 375 of humerus, 364 of hyoid bone, 353 incomplete, 333 impacted, 335 of larynx, 353 longitudinal, 336 INDEX. 611 Fracture or fractures, of lower end of radius, 377 extremity of humerus, 369 jaw, 351 of malar bone, 349 massage in, 245 of metacarpal bones, 382 of metatarsal bones, 403 multiple, 335 of nasal bones, 348 of neck of radius, 375 oblique, 335 of olecranon process of ulna, 373 open, 335 treatment of, 404 of the patella, 393 operative treatment of, 395 of pelvis, 355 of phalanges of finger, 382 of toes, 403 Pott's, 401 provisional dressings in, 339 rack, 344 of radius, 375 reduction of, 340 of ribs, 353 of sacrum, 356 of scapula, 363 setting of, 340 of shaft of femur, 388 of humerus, 367 simple, 335 of skull, 357 of sternum, 354 subperiosteal, 334 symptoms of, 336 of tarsal bones, 402 of tibia, 395 of trachea, 353 transverse, 335 of ulna, 375 ununited, 408 of upper extremitv of humerus, 364 jaw, 350 varieties of, 333 of vertebrae, 356 of zygoma, 349 Franklinization, 222 Frontal sinus, trephining of, 558 GALVANO-CAUTERY, 221 ( rastro-duodenostomy, 597 ( rastro-enterostomy, 599 Gastrostomy, 592 Ssabanajew-Frank's, 593 Witzel's, 595 Gauntlet bandage, 54 Gauze bandages, 88 bichloride, 145 carbolized, 146 dressings, 145 dry sterilized, 147 moist sterilized, 147 iodoform, 145 pads, 158 pledgets, 138 sterilized, 147 Gelatin in hemorrhage, 299 General anaesthesia, 233, 239 Gibson's bandage, 44 Gloves, cotton, 156 rubber, 156 Gluteal artery, ligation of, 467 Gluteo-femoral triangle, 39 Gluteo-inguinal cravat, 39 Glutol, 133 Glycerin enema, 213 tampon, 168 Gonococcus, 119 Granny knot, 272 Green-stick fracture, 333 Gritti's amputation at knee-joint, 524 Groin, spica-bandage of, ascending, 73 double, 76 single descending, 75 T-bandage of, 28 Guaiacol, 236 Gunshot fracture, 334 wounds, 322 Gunstock deformity, 370 Gutta-percha splints, 342 Gut wool, 300 HABITUAL dislocation, 412, 443 Haemostatic forceps, 296 Halsted's mattress suture, 279 Hancock's amputation of foot, 518 Hand or hands, amputations of, 490 612 INDEX. Hand or hands, removal of plaster- of-Paris from, 103 sterilization of, 153 Handkerchief bandages, 32 Hardening bandages, 93 Hare-lip suture, 275 Head, bandages of, 41 oblique, 52 four-tailed bandage of, 31 and neck bandage, 49 recurrent bandage of, 46 transverse, 48 V-bandage of, 48 Heat, 128 Hemorrhage, adrenalin chloride in, 299 antipyrin in, 299 arterial, permanent control of, 298 temporary control of, 292 from bladder, 310 capillary, treatment of, 306 cauterization in, 301 cold in, 299 compresses in, 293 constitutional treatment of, 291 deep sutures in, 302 digital compression in, 292 elastic constriction in, 294 gelatin in, 299 hot water in, 299 ligation in, 302 local treatment of, 291 position in, 298 pressure in, 300 from rectum, 311 secondary, treatment of, 307 styptics in, 299 torsion in, 301 tourniquets in, 293 treatment of, 291 from urethra, 310 venous, treatment of, 305 Hernia, trusses for, 257 et seq. Hey's amputation of foot, 513 Hilton's method in abscess, 311 Hip, dislocation of, 430 anomalous, 435 downward. 432 forward. 432, 433 iliac, 430 Hip, dislocation of, ischiatic, 430 posterior, 430 pubic, 434 thyroid, 432 dorsal dislocation of, 430 Hip-joint, amputations at, 527 excision of, 544 Holocaine hydrochlorate, 236 Horsehair drainage, 142 Horsley's wax, 300 Hot air, application of, 226 fomentations, 179 water, counter-irritation from, 184 in hemorrhage, 299 Howard's method of artificial res- piration, 202 Humerus, fractures of, 364 lower extremity of, 369 shaft of, 367 upper extremity of, 364 resection of, 537 separation of upper epiphysis of, 366 subclavicular dislocation of, 419 subcoracoid dislocation of, 419 subglenoid dislocation of, 419 subspinous dislocation of, 420 Hydrogen peroxide, 134 Hyoid bone, dislocation of, 415 fracture of, 353 Hypnotism, anaesthesia from, 255 Hypodermic injections, 214 Hypodermoclysis, 200 TCE-BAG, 183 J_ Iliac arterv, common, ligation of, 463 _ external, ligation of, 466 internal, ligation of, 465 dislocation of the hip, 430 Immediate irrigation, 180 Immunity, 117 Impacted fracture, 335 Improvised antiseptic dressings, 146 Incised wounds, 318 Incision of abscess, 314 Incomplete fracture, 333 of bones of forearm, 377 Infected wounds, antiseptic treat- ment of, 164 aseptic treatment of, 164 INDEX. 613 Infection from bacteria, 115 Inferior dental nerve, exposure of, 561 Infiltration anaesthesia, 236 Infusion of saline solution, 200 Inguinal colostomy, 586 Injection in abscess, 313 of antitoxins, 215 spinal arachnoid, 238 Injections, hypodermic, 214 of mercury, 216 urethral, 267 Injuries from electricity, 326 Innominate artery, ligation of, 447 Inoculation of bacteria, 114 Instruments, sterilization of, 154 Interosseous artery, ligation of, 463 Interrupted plaster-of-Paris dress- ing, 97 suture, 273 Intestinal anastomosis, 280 end-to-end, 285 lateral, 283 Semi's method, 283 sutures, 278 Intestine, circular suture of, 280 Intoxication from bacteria, 115 Intravenous injection of saline solution, 199 Introduction of catheter, 262 Intubation of larynx, 578 feeding after, 583 operation of, 580 Iodoform, 131 collodion, 132 emulsion, 132 ethereal solution of, 132 gauze, 145 Irrigation, 180 of bladder, 266 immediate, 180 mediate, 182 Ischiatic dislocation of hip, 430 Isinglass plaster, 171 JACKET, plaster-of-Paris, appli- cation of, 98 Jaw, dislocation of, 414 lower, excision of, 552 oblique bandage of, 45 upper, excision of, 551 Joints, excision of, 533 strapping of, 176 Junk bags, 343 Jury-mast, application of, 100 KIDNEY, operations upon, 584 Knee, dislocations of, 436 figure-of-eight bandage of, 77 Knee-joint, amputations at, 522 arthrectomy of, 547 excision of, 546 Knees, figure-of-eight bandage of, 79 Koch's law, 115 Krause's method of skin-grafting, 219 Kreolin, 135 LABOKDE'S method of artificial' respiration, 206 Lacerated wounds, 319 Laminectomy, 558 Larrey's amputation at shoulder- joint, 503 Laryngotomy, 577 Laryngo-tracheotomy, 578 Larynx, fracture of, 353 intubation of, 578 Lateral ligature in venous hemor- rhage, 305 Lavage, 210 Leather splints, 107, 342 Leech, mechanical, 196 Leeching, 195 Leg, amputations of, 519 bones of, fracture of, 395 figure-of-eight bandage of, 83 Lembert's suture, 278 Lengthening of tendons, 568 Liebreich's eye-bandage, 86 Ligation of abdominal aorta, 463 of anterior tibial artery, 471 of arteries, 445 of axillary artery, 456 of brachial artery, 459 of common carotid artery, 451 of common iliac artery, 463 of dorsalis pedis artery, 473 of external carotid artery, 453 614 INDEX. Ligation of external iliac artery, 4G6 of facial artery, 455 of femoral artery, 468 of gluteal artery, 467 in hemorrhage, 302 of inferior thyroid artery, 451 of innominate artery, 447 of internal carotid artery, 454 iliac artery, 465 mammary artery, 451 pudic artery, 467 of interosseous artery, 463 of lingual artery, 454 of occipital artery, 455 of popliteal artery, 470 of posterior tibial artery, 474 of radial artery, 459 of sciatic artery, 467 of subclavian artery, 449 of superior thyroid artery, 454 of temporal artery, 455 transperitoneal, of iliac arteries, 465 of ulnar artery, 461 of vertebral artery, 450 of wounded arteries, 304 Ligature or ligatures, catgut, 139 double, 287 elastic, 289 Erichsen's, 289 lateral in venous hemorrhage, 305 method of securing, 271 quadruple, 288 silk, 138 single, 286 subcutaneous, 288 in vascular growths, 286 Lightning-stroke, 328 Lingual artery, ligation of, 454 nerve, exposure of, 561 Lint, 166 Lisfranc's amputation of foot, 512 at shoulder- joint, 505 Lister's aorta compressor, 295 Lithotomy, 588 bandage for, 86 left lateral, 588 suprapubic, 589 Local anaesthesia, 232, 233 treatment of hemorrhage, 291 Longitudinal fracture, 336 Lower extremity, bandage of, 73 spiral reversed bandage of, 82 jaw, fracture of, 351 Lumbar colostomy, 585 nephrectomy, 584 MACKINTOSH, 144 Malar bone, fracture of, 349 Malignant oedema, bacillus of, 121 Mammary artery, internal, liga- tion 'of, 451 Many-tailed bandage, 30 of abdomen, 31 Massage, 224 in fractures, 345 Mattress suture, 275 Maxilla, excision of, 551 inferior, fracture of, 351 superior, fracture of, 350 Maydl's colostomy, 586 Mechanical leech, 196 Median nerve, exposure of, 563 Mediate irrigation, 182 Mento-vertico-occipital cravat, 35 Mercury, bichloride of, 129 injections of, 216 Metacarpal bones, amputations of, 493 dislocations of, 427 fractures of, 382 resection of, 540 Metacarpophalangeal joints, exci- sion of, 541 Metatarsal bones, amputation of, 510 dislocation of, 440 fractures of, 403 resection of, 550 Mikulicz osteoplastic amputation, 518 pack, 132 Modified circular amputation, 479 Moist dressing, method of, 149 modified method of, 149 gauze dressings, 147 Moulded plaster splints, 102 splints, 107 Mouth-to-mouth inflation, 202 Mouth, sterilization of, 153 Multiple fracture, 335 INDEX. 615 Murphy button, 281 Muscle-grafting, 220 Muscles, strains of, 331 Musculo-spiral uerve, exposure of, 563 Mustard, counter-irritation from, 185 papers, 186 plaster, 185 Mycetoma, 123 NASAL bones, fracture of, 348 cavities, sterilization of, 153 Neck and axilla, figure-of-eight bandage of, 62 Needle, aneurism, 302, 447 mounted, 270 surgical, 269 Needle-holder, 270 Needles, acupuncture, 189 Nephrectomy, abdominal, 584 lumbar, 584 Nephrorrhaphy, 584 Nephrotomy, 584 Nerve or nerves, anterior crural, exposure of, b6i of brachial plexus, exposure of, 562 external popliteal, exposure of, 564 facial, exposure of, 562 -grafting, 220, 559 great sciatic, exposure of, 563 -implantation, 560 inferior dental, exposure of, 561 internal popliteal, exposure of, 564 lingual, exposure of, 561 median, exposure of, 563 musculo-spiral, exposure of, 563 operations upon, 559 radial, exposure of, 563 spinal accessory, exposure of, 563 -stretching, 559 superior maxillary, exposure of, 560 supra-orbital, exposure of, 560 suture of, 559 ulnar, exposure of, 563 Neural anaesthesia, 237 Neurectasy, 559 Neurectomy, 559 Neuroplasty, 560 Neurorrhaphy, 559 Neurotomy, 559 Nitrous oxide gas, 240 and ether, 248 and oxygen, 241 Nose, double T-bandage of, 30 Nutritous enema, 213 OAKUM, 166 Oblique bandage, 23 of head, 52 of jaw, 45 fracture, 335 Occipital artery, ligation of, 455 Occipito-facial bandage, 52 Occipitofrontal bandage, 53 triangle, 34 (Esophageal bougie, 211 (Esophagotomy, external, 592 Oiled muslin, 167 silk, 167 Old dislocation, 412, 440 Olecranon process, fractures of, 373 Open fracture, 335 treatment of, 404 Operating bag, 148 Operation, or operations, antiseptic, details of, 158 aseptic, details of, 157 preparation for, 150 upon kidney, 584 upon nerves, 559 upon tendons, 564 Orthoform, 136 Os calcis, excision of, 550 Osteoplastic resection of skull, 556 Osteotomy, 599 Oval amputation, 479 Oxygen and chloroform, 253 and ether, 249 and nitrous oxide gas, 241 PADS, gauze, 138 Panelectroscope, 224 Paper, parchment, 168 splints, 342 waxed, 167 Paquelin's thermo-cautery, 190 Paraffin-bandage, 107 616 INDEX. Paraffin-paper, 167 Parchment paper, 168 Partial dislocation, 411 Passive motion, 225 Pasteboard splints, 108 Patella, dislocations of, 435 excision of, 547 fractures of, 393 operative treatment of, 395 Pathogenic action of bacteria, 116 Pathological dislocations, 443 Patient, preparation of, for aseptic operation, 150 Pelvic supporter for application of plaster-of-Paris bandage, 96 Pelvis, dislocations of, 416 fractures of, 355 Penis, spiral reversed bandage of, _84 Periosteal flaps, in amputation, 482 Permanganate of potassium, 136 Peroxide of hydrogen, 134 Petit's tourniquet, 294 Phalanges of fingers, dislocations of, 427 fractures of, 382 of toes, dislocation of, 440 fractures of, 403 Pirogoffs amputation at ankle- joint, 515 Plaster or plasters, 169 adhesive, 169 bandage saw, 105 shears, 105 isinglass, 171 resin, 170 rubber adhesive, 170 soap, 171 spice, 186 swan's down, 170 zinc oxide adhesive, 170 Plaster-of-Paris bandage, applica- tion of, 95 preparation of, 94 removal of, 103 trapping of, 102 dressings, 93 application of, 93 interrupted, 97 uses of, 106 Plaster-of-Paris jacket, application of, 98 removal of, from hands, 103 splints, 343 moulded, 102 Plate suture, 276 Pledgets, gauze, 138 Poisoned wounds, 321 Popliteal artery, ligation of, 470 nerve, external, exposure of, 564 internal, exposure of, 564 Position in hemorrhage, 298 Posterior dislocation of the hip, 430 figure-of-eight bandage of chest, 70 Potain's aspirator, 208 Potassium permanganate, 136 Pott's fracture, 401 Poultices, 177 antiseptic, 179 fermenting, 179 flaxseed, 178 soap, 178 - starch, 178 Powder, boro-salicylic, 135 Powder-burns, 323 Pressure in hemorrhage, 300 Protective, 143 Pubic dislocation of the hip, 434 Pudic artery, internal, ligation of, 467 Puncturation, 192 Punctured wounds, 321 Pylorectomy, 597 Pyloroplasty, 596 Pyrozone, 135 QUADRUPLE ligature, 288 Quilled suture, 275 Quilt suture, 275 RADIAL artery, ligation of, 459 nerve, exposure of, 563 Radius, dislocation of head of, 425 fractures of, 375 of head of, 375 of lower end of, 377 of neck of, 375 resection of, 538 Raw-hide splints, 107 INDEX. 617 Ray-fungus, 122 lucent dislocations, 412 Rectal bougie, 212 tube, 211 Rectum, hemorrhage from, 311 sterilization of, 153 Recurrent bandage, 26 of head, 46 transverse, 48 of stump, 84 Reef-knot, 271 Regional anaesthesia, 232, 237 Relaxation sutures, 268 Removal of bandages, 22 of plaster-of-Paris bandage, 103 of sutures, 278 Resection or resections, 533 of fibula, 548 of humerus, 537 of metacaipal bone, 540 of metatarsal bones, 550 of radius, 538 of ribs, 543 of skull, osteoplastic, 556 of sternum, 543 of tibia, 548 of ulna, 538 Resin plaster, 170 Resistance of tissues to bacteria, 116 Respiration, artificial, 201 forced, 206 rapid, ana?stbesia from, 234 Retractors, 169 Reversed Colles's fracture, 381 Ribs, dislocation of, 415 fractures of, 353 resection of, 543 Roller bandage, 18 double, 20 single, 20 Rontgen rays, 228 Room, preparation of, for aseptic operation, 150 Roux's amputation at ankle-joint, 517 Rubber adhesive plaster, 170 bandage, 90 -dam, 144 gloves, 156 tissue, 144, 168 Rubefacients, 184 SACRUM, fractures of, 356 Salicvlic acid, L35 Saline solution, 136 infusion of, 200 intravenous injection of, 199 Sand bags, 343 Saw, plaster bandage, 105 Savre's dressing for fracture of clavicle, 360 Scalds, 324 Scalp, sterilization of, 153 Scapula, acromion process of, fract- ure of, 364 body of, fracture of, 364 coracoid process of, fracture of, 364 dislocations of, 418 excision of, 543 fractures of, 363 neck of, fractures of, 364 Scarification, 192 Scbleich's anaesthetic mixture, 253 Sciatic artery, ligation of, 467 nerve, great, exposure of, 563 Scissors, bandage, 22 Scultetus bandage, 87 Secondary hemorrhage, treatment of, 307 sutures, 269 Sedillot's amputation of leg, 521 Sequin's method of counter-irrita- ~ tion, 188 Semilunar cartilages, dislocation of, 437 Senn's method of intestinal anas- tomosis, 283 Separation of epiphyses, 345 of upper epiphvsis of humerus, 366 Sepsis, 125 Setting of fracture, 340 Shears, plaster-of-Paris bandage, 105 Shock, 315 prophylaxis of, 316 treatment of, 317 Shotted suture, 277 Shoulder, dislocations of, 419 spica-bandage of, ascending, 59 descending, 61 618 INDEX. Shoulder-joint, amputations above, 506 amputation at, 501 excision of, 536 Signorini's tourniquet, 296 Silicate of potassium bandage, 106 splints, 343 of sodium bandage, 106 Silk ligatures, 138 sutures, 138 Silkworm-gut, 139 Silver foil, 144 salts, 133 Silvester's method of artificial res- piration, 202 Simple dislocation, 411 fracture, 335 Single ligature, 286 spica-bandage of groin, ascend- ing, 73 descending, 75 T-banclage, 27 Sinuses, 314 Skiagraphy, 228 Skin-grafting, 217 Krause's, 219 Thiersch's, 218 Skull, fracture of, 357 osteoplastic resection of, 556 trephining of, 553 Slings, 30 Soap plaster, 171 poultice, 178 Sodium chloride, 136 Solution, saline, 136 infusion of, 200 intravenous injection of, 199 Sounds, 261 Spanish windlass, 294 Special bandages, 84 Spence's amputation at shoulder- joint, 505 Spica-bandage, 25 of buttock, 77 of foot, 80 of groin, double, 76 single ascending, 73 descending, 75 of shoulder, ascending, 59 descending, 61 of thumb, 56 Spice plaster, 186 Spinal accessory nerve, exposure of, 563 arachnoid injection, 238 Spiral bandage, 23 of chest, 69 of finger, 54 reversed bandage, 24 of lower extremity, 82 of penis, 84 of upper extremity, 57 Splint or splints, 341 binders' board, 108, 342 Bond's, 379 felt, 109, 342 gutta-percha, 342 leather, 107, 342 moulded, 107 plaster, 102 paper, 342 pasteboard, 108 plaster-of-Paris, 343 raw-hide, 107 silicate of potassium, 343 Volkmann's, 399 wooden, 341 Sponges, 137 Spores, 112 Sprain-fracture, 331 Sprains, 330 strapping in, 330 Staffordshire knot, 272 Staining of bacteria, 114 Staphylococcus pyogenes aureus, 118 Starched bandage, 106 Starch poultice, 178 Sterilization of bladder, 152 of bougies, 155, 259 of catheters, 155, 259 of feet, 151 of hands, 153 of instruments, 154 methods of, 125 of mouth, 153 of nasal cavities, 153 of rectum, 153 of scalp, 153 of stomach, 152 of urethra, 152 of vagina, 152 INDEX. 619 Sterilized bandages, 146 catgut, 139 ei seq. cotton, 147 dry gauze dressings, 147 gauze," 147 moist gauze dressings, 147 water, 137 Sternal end of clavicle, dislocation of, 417 Sternum, dislocation of, 416 fractures of, 354 resection of, 543 Stomach, sterilization of, 152 Stomach-pump, 210 -tube, 209 Strains of fascia, 331 of muscles, 331 Strapping, 171 ankle-joint, 176 carbuncle, 177 chest, 172 joints, 176 in sprains, 330 testicle, 171 ulcers, 173 Streptococcus pyogenes, 119 Streptothrix Madura 3 , 123 Stump, recurrent bandage of, 84 Styptics in hemorrhage, 299 Subastragaloid amputation, 514 Subclavian artery, ligation of, 449 Subclavicular dislocation of hume- rus, 419 Subcoracoid dislocation of humerus, 419 Subcutaneous ligature, 288 Subcuticular suture, 274 Subglenoid dislocation of head of humerus, 419 Subperiosteal fracture, 334 Subspinous dislocation of humerus, 420 Sulphocarbolate of zinc. 134 Superior maxillarv nerve, exposure of, 560 Suppuration, bacteria of, 118 ^ diffused, 314 Supraorbital nerve, exposure of, 560 Suprapubic lithotomy, 589 Surface thermometer, 227 Surgeon's clothing, 157 knot, 271 Surgical needles, 269 operating bag, 148 Suspensory bandage of breast, 71 of breasts, 72 Suspensory cap of breast, 38 Suture or sutures, 268 of approximation, 269 of arteries. 303 buried, 273 button, 276 circular, of intestine, 280 of coaptation, 268 continued, 274 Czerny, 280 deep, in hemorrhage, 302 Halsted's mattress, 279 harelip, 275 interrupted, 273 intestinal, 278 Lembert's, 278 mattress, 275 method of securing, 271 of nerves, 559 plate, 276 quilled, 275 quilt, 275 of relaxation, 268 removal of, 278 secondary, 269 shotted, 277 silk, 138 subcuticular, 274 of tendons, 567 twisted, 275 varieties of, 273 of veins, 306 Swan's down plaster, 170 Svme's amputation at ankle-joint, 514 TAMPON, 168 glycerin, 168 Tarsal bones, dislocation of, 439 fracture of, 402 Tarsometatarsal amputations, 510 T-bandage. 27 of chest, 27 double, 29 of groin, 28 620 INDEX. T-bandage of nose, double, 30 single, 27 Teale's amputation, 480 of leg, 520 Temporal artery, ligation of, 455 Tenaculum, 302 Tendo-Achillis, tenotomy of, 565 Tendon or tendons, adductor longus, tenotomy of, 566 anterior tibial, tenotomy of, 566 extensor longus digitorum, ten- otomy of, 566 proprius pollicis, tenotomy of, 566 flexor longus pollicis, tenotomy of, 566 hamstring, tenotomy of, 566 lengthening of, 568 operations upon, 564 peroneal, tenotomy of, 566 posterior tibial, tenotomy of, 565 stemo-cleido-mastoid, tenotomy of, 566 suture of, 567 primary, 567 secondary, 568 transplantation of, 569 Tenotomy, 564 Tent, 168 Testicle, excision of, 591 strapping of, 171 Tetanus, bacillus of, 121 Thermo-cautery, Paquelin's, 190 Thermometer, clinical, 227 surface, 227 Thiersch's method of skin-grafting, 218 Thread, celluloid, 142 Thumb, dislocation of, 428 spica-bandage of, 56 Thyroid artery, inferior, ligation of, 451 superior, ligation of, 454 dislocation of hip, 432 Tibia, fracture of, 395 resection of, 518 Tibial artery, anterior, ligation of, 471/ posterior, ligation of, 474 Tincture of iodine, counter-irrita- tion from, 185 Toes, amputations of, 507 dislocation of, 440 Torsion in hemorrhage, 301 Tourniquets, 293 in amputations, 486 Petit's, 294 Signorini's, 296 Toxins, 116 Trachea, fracture of, 353 Tracheal dilators, 572 Tracheotomy, 570 director, 574 operation of, 574 Tracheotomy-tubes, 572 Transfixion, amputation by, 478 Transfusion, arterial, 199 of blood, 198 Transperitoneal ligation of iliac arteries, 465 Transplantation of tendons, 569 Transverse fracture, 335 Trapping plaster-of-Paris bandage, 102 Trephining antrum of Highmore, 556 frontal sinus, 558 skull, 553 Triangular cap of breast, 38 Tripier's amputation of foot, 518 Trunk, bandage of, 69 Truss or trusses, 255 for femoral hernia, 257 for inguinal hernia, 257 for irreducible hernia, 258 for umbilical hernia, 258 Tubercle bacillus, 119 Tuberculous abscess, 313 Turpentine, counter-irritation from, 184 stupe, 185 Twisted suture, 275 ULCEES, strapping of, 173 Ulna, dislocations of, 426 fractures of, 375 resection of, 538 Ulnar artery, ligation of, 461 nerve, exposure of, 563 Ununited fractures, 408 Upper extremity, bandages of, 54 INDEX. 621 Upper extremity, spiral reversed bandage of, 57 jaw, fracture of, 300 Upward dislocations of the hip, 433 Ureters, catheterization of, 264 Urethra, hemorrhage from, 310 sterilization of, 152 Urethral injections, 267 Urethroscope, 223 T7ACCINATION, 213 V _ Vagina, sterilization of, 152 Varicocele, operations for, 591 Vascular growths, ligatures in, 286 V-bandage of head, 48 Veins, suture of, 306 Velpeau's bandage, 62 Venesection, 196 Venous hemorrhage, treatment of, 305 Vertebrae, dislocations of, 413 fractures of, 356 Vertebral artery, ligation of, 450 Vesicants, 187 Vesication from aqua ammonia, 188 from chloroform, 188 Volkmann's sliding foot-piece, 385 splint, 399 WAXED paper, 167 Wet cupping, 194 White-lead dressing in burns, 325 Wooden splints, 341 AY< x)d-\vool, 167 Wounds, contused, 320 dressing of, 318 gunshot, 322 incised, 318 infected, antiseptic treatment of, 164 aseptic treatment of, 164 lacerated, 319 poisoned, 321 punctured, 321 redressing of, 162 Wrist, amputations at, 495 circular, 495 dislocations of, 426 excision of, 539 Wyeth's _ bloodless amputation at hip-joint, 529 pins in amputation at shoulder- joint, 502 X-EAY burns, 328 X-rays, use of, 228 ZINC chloride, 134 oxide, adhesive plaster, 170 sulpho-carbolate, 134 Zygoma, fracture of, 349 CATALOGUE OF PUBLICATIONS OF LEA BROTHERS & COMPANY, 70G, 708 & 710 Ransom St., Philadelphia. Ill Fifth Ave., New York. The books in the annexed list are for sale by all booksellers, or will be sent by mail, post-paid, to any Post-Office in the United States, on receipt of the printed prices. INDEX. - ANATOMY^ Gray, p. 11 ; Treves, 30 ; Gerrish 11; Collins, 4. DICTIONARIES. Dunglison p. 9 ; Duane, 8 ; National, 4. PHYSICS. Draper, p. 8 ; Martin & Rockwell, 19. PHYSIOLOGY". Foster, p. lu ; Chapman, 5; Schofield, 25; Collins & Rockwell, 6 ; Hall, 12. [Remsen, 24. CHEMISTRY. Simon, p 25 ; Attfield. 3 ; Martin & Rockwell, 19; PHARMACOLOGY. Cushny, p. 6; Culbreih, 7. PHARMACY. Caspari, p. 5. MATERIA MEDICA. Calbreth, p. 7 ; Maisch, 19 ; Farqnharson, 9 ; DISPENSATORY. National, p. 20. [Bruce, 4 : Scbleif, 24. THERAPEUTICS. Hare, p 13; Fothergill. in ; Whitla, 31 ; Hayein & Hare, 14 ; Bruce, 4 ; Schleif, 24 ; Cushny, 7 ; Tirard, 29. PRACTICE. Flint, p. 10 ; Loomis & Thompson, 18 ; Malsbary, 19 ; Thompson, 29. DIAGNOSIS. Musser, p. 20; Hare, 13; Simon, 25; Herrick, 14; Hutchi- son & Rainey, 15 ; Collins, 6. CLIMATOLOGY. Soil 7, p. 26 ; Hayem & Hare, 14. NERVOUS DISEASES. Dercum, p 8 ; Potts, 23. MENTAL DISEASES. Clouston, p. 6 ; Folsom, 10 ; Potts, 23. BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30 ; Senn's (Surgical), 25. Park, 22 ; Coates, 6. [Vale, 21. HISTOLOGY. Klein, p. 17 ; Schafer. 24 ; Dunham, 8 ; Nichols & PATHOLOGY. Green, p. 12; Ewing, 9; Coats. 6; Nichols & Vale, 21. SURGERY. Park, p. 22 ; Dennis, 8 ; Roberts, 24 ; Ashhurst, 3 ; Treves, 29 ; Cheyne & Burgharrl, B ; Gallaudet, 11. SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. SURGERY— ORTHOPEDIC. Young, p. 31; Whitman, 31. SURGERY— MINOR. Wharton, p. 30. [Wippern 4. FRACTURES and DISLOCATIONS. Samson, p. 27. [Ballerger, & OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21. OTOLOGY. Politzer, p. 23; Burnett, 5; Field. 10; Bacon, 3. LARYNGOLOGY and RHINOLOGY. Coakley, p. 6 ; DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- can System 2; Coleman, 6; Burcba'd 4. URINARY DISEASES. Roberts, p. 24 ; Black. 4. VENEREAL DISEASES. Taylor, p. 28 ; Havden, 14 ; Cornil, 6 ; SEXUAL DISORDERS. Fuller, p 11 ; Taylor, 28. DERMATOLOGY- Hyde, p. 1« ; Jackson, 16; Pye-Smith, 23 ; Mor- ris, 20 ; Jamieson, 16 ; Hardaway, 12 ; Grindon, 12. GYNECOLOGY. American System, p. 3 ; Thomas & Mnnde, 29 Emmet, 9 ; Davenport, 7 ; May, 19 ; Dudlev. 8 ; Crockett, 7. OBSTETRICS. American System,' p. 3 ; Davis," 7 ; Parvin, 22 ; Play- fair. 22 ; King, 17 ; Jewett, 16 ; Evans, 9. PEDIATRICS. Smith, p 26 ; Thomson, 29 : Williams, 31 ; Tuttle, 30. HYGIENE. Egbert, p. 9 ; Richardson, 24 ; Harrington, 14. MEDICAL JURISPRUDENCE. Tavlor, p. 28. QUIZ SERIES, POCKET TEXT-BOOKS and MANUALS. Pp. 17, 25 and 27. 8.1.01. 2 Lea Brothers & Co., Philadelphia and New York. ABBOTT (A. O.). PRINCIPLES OF BACTERIOLOGY: a Practical Manual for Students and Physicians. Fifth edition thoroughly revised and greatly enlarged. In one handsome 12mo. vol. of 585 pages, with 109 engrav., of which 26 are colored. Cloth, $2.75, net. cessfully. To those who require a condensed yet nevertheless complete work upon Bacteriology we most cordially recommend it. — The Thera- peutic Gazette. One of its most attractive charac- teristics is that the directions are so clearly given that anyone with a moderate amount of laboratory train- ing can, with a little care as to detail, make his experiments suc- AMERICAN SYSTEM OF PRACTICAL MEDICINE. A SYS- TEM OF PRACTICAL MEDICINE. In contributions by Various American Authors. Edited by Alfred L. Loomis, M.D., LL.D., and W. Gilman Thompson, M. D. In four very handsome octavo volumes of about 900 pages each, fully illustrated. Complete work noxo ready. Per volume, cloth, $5; leather, $6; half Morocco, $7. For sale by subscription only. Prospectus free on application. Every chapter is a masterpiece of completeness, and is particularly ex- cellent in regard to treatment, many original prescriptions, formulas, charts and tables being given for the guidance of the practitioner. "The American Svstem of Medi- cine" is a work of which every American physician may reasonably feel proud, and in which eveiy prac- titioner will find a safe and trust- worthy counsellor in the daily re- sponsibilities of practice. — The Ohio Medical Journal. AMERICAN SYSTEM OP DENTISTRY. In treatises by various authors. Edited by AVilbur F. Litch, M.D., D.D.S. In three very handsome super-royal octavo volumes, containing about 3200 pages, with 1873 illustrations and many full-page plates. Per vol., cloth, $6; leather, $7 ; half Morocco, $8. For sale by subscripti&n only. Pros- pectus free on application to the Publishers. AMERICAN TEXT-BOOKS OF DENTISTRY. In Contribu- tions by Eminent American Authorities. In two very handsome octavo volumes, richly illustrated : PROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D., D.D.S., Professor of Mechanical Dentistry and Metallurgy, Department of Dentistry, University of Pennsylvania, Philadelphia. New (2d) edition. 807 pages, 1089 engravings. Cloth, $6 ; leather, $7. Net. No more thorough production will I It is up to date in every particular. be found either in this country or in It is a practical course on prosthetics any country where dentistry is un- which any student can take up dur- derstood as a part of civilization. — > ing or after college. — Dominion Den- TJie International Dental Journal, tal Journal. OPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S., Professor of Clinical Dentistry, Department of Dentistry, University of Pennsylvania. New (2d) edition. 857 pages, 897 engravings. Cloth, $6.00; leather, $7/0. Net. Written by a number of practi- tioners as well known at the chair as in journalistic literature, many of them teachers of eminence in our colleges. It should be included in the list of text- books set down as most useful to the college student.— The Dental News, It is replete in every particular and treats the subject in a progressive manner. It is a book that every progressive dentist should possess, and Ave can heartily recommend it to the profession. — The Ohio Dental Journal. Lea Brothers & Co., Philadelphia and New York. 3 AMERICAN SYSTEMS OF GYNECOLOGY AND OBSTET- RICS. In treatises by the most eminent American specialists. Gyne- cology edited by Matthew D. Mann, A.M., M.D., and Obstetrics edited by Barton C. Hirst, M. D. In four large octavo volumes comprising 3(312 pages, with 1092 engravings, and 8 colored plates. Per volume, cloth, $5 ; leather, $6 ; half Bussia, $7. For sale by subscrip- tion only. Prospectus free on application to the Publishers. 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As a masterly epitome of what has text-book, we do not know its equal. been said and done in surgery, as a It is the best single text-book of succinct and logical statement of the surgery that Ave have yet seen in this principles of the subject, as a model country. — New York Post-Graduate. A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN AUTHORS. Edited by William Pepper, M. D., LL. D. In five large octavo volumes, containing 5573 pages and 198 illustrations. Price per volume, cloth, $5 ; leather $6 ; half Russia, $7. Sold by subscrip- tion only. Prospectus free on application to the Publishers. ATTFEELD (JOHN). CHEMISTRY : GENERAL, MEDICAL AND PHARMACEUTICAL. Sixteenth edition, specially revised by the Author for America. In one handsome 12mo. volume of 784 pages, with 88 illustrations. Cloth, $2.50, net. 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A TEXT-BOOK ON NERVOUS DISEASES. By American Authors. In one handsome octavo volume of 1054 pages, with 341 engravings and 7 colored plates. Cloth, $6.00 ; leather, $7.00. Net. The best text-book in any lan- guage. — The Medical Fortnightly. The most thoroughly up-to-date treatise that we have on this subject. — American Journal of Insanity. DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. Their Classification, History, Symptoms, Pathology and Treatment. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates in colors. Limited edition, de luxe binding, $4. Net. DRAPER ( JOHN C). MEDICAL PHYSICS. A Text-book for Stu- dents and Practitioners of Medicine. In one handsome octavo volume of 734 pages, with 376 engravings. Cloth, $4. DRUITT ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the twelfth London edition, edited by Stanley Boyd, F. R. C. S. In one large octavo volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. DUANE (ALEXANDER). A DICTIONARY OF MEDICINE AND THE ALLIED SCIENCES. Comprising the Pronunciation, Deriva- tion and Full Explanation of Medical, Dental, Pharmaceutical and Veterinary Terms. Together with much Collateral Descriptive Mat- ter. Numerous Tables, etc New (3d) edition. Square octavo of 652 pages, with 8 colored plates, witu thumb index. Cloth, $3.00, net; limp leather, $4.00., net. DUDLTEY (E. C). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY. New (2d) edition. Handsome octavo of 717 pages, with 453 illustrations in black and colors, and 8 colored plates. Cloth, $5.00, net; leather, $6.00, net; half Morocco, $6.50, net. tice of modern gynecology .- national Medical Magazine. The book can be safely recom- tice of modern gvnecologv. — Infer mended as a complete and reliable exposition of the principles and prac- DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1.50. DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- TOLOGY. Octavo, 450 pages, with 363 illustrations. Cloth, $3.25, net. The best one-volume text or refer- 1 of published in America. — Virginia ence book on histology that we know ' Medical S> mi-Monthly. NORMAL HISTOLOGY. New (2d) edition. Octavo, 319 pages, with 244 illustrations. Cloth, $2.50, net. Lea Broth krk & Co., Philadelphia and New York. 9 DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- ENCE. Containing a full explanation of the various subjects and terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By ROBLEY DUNGLISON, M. D-, LL. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. Edited by Richard J. DUNGLISON, A. M ., M. D. Twenty-second edition, thor- oughly revised and greatly enlarged and improved, with the Pronuncia- tion, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1350 pages, with thumb index. Cloth, $7.00, Net; leather, $8.00, Net. This edition contains portrait of Dr. Dunglison, The most satisfactory and authori- scarcely be measured. — Med. Record. tative guide to the derivation, defini- Pronunciation is indicated bv the tion and pronunciation of medical phonetic system. The definitions are terms.— The Charlotte Med. Journal, unusually' clear and concise. The Covering the entire field of medi- book is wholly satisfactory. — ZJni- cine, surgery and. the collateral versity Medical Magazine. sciences, its range of usefulness can EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; leather, $4.50. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings. Cloth, $3 ; leather. $4. EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. New (2d) edition. In one 12mo. volume of 427 pages, with 77 illustrations. Cloth, Net, $2.25. It is written in plain language, I ligence. The writer has adapted it and, while primarily designed for to American conditions, and his physicians, it can be studied with suggestions are, above all, practical. profit by any one of ordinary intel- — The New York Medical Journal. ELLIS (GEORGE VLNER). DEMONSTRATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4 25; leather, $5.25. EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6. ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octavo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-Books of Dentistry, page 2. EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. In one handsome 12mo. volume of 409 pages, with 14S illustrations. Just ready. Cloth, $1.75, Net; limp leather, $2.25, Net. Lea's Serifs of Pocket Text-books, edited by Bern B. Gallai'det, M.D. See p 17. EWING (JAMES) ON THE BLOOD AND ITS DISEASES. Hand- some octavo, 423 pages, 28 engravings, 14 colored plates. Just ready. Cloth, net, $3.50. 10 Lea Brothers & Co., Philadelphia and New York. PARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS, Fourth American from fourth English edition, revised by FRANK Woodbury, M. D. In one 12mo. volume of 581 pages. ( !loth, $2.50. FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. _ Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Frederick P. Henry, M.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5.00; leather, $6.00. The work has well earned its lead- The best of American text-books ing place in medical literature.— on Practice. — Amer. Medico-Surgical Medical Record. \ Bulletin. A MANUAL OF AUSCULTATION AND PERCUSSION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. In one handsome 12mo. volume of 274 pages, with 12 engravings. A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of 550 pages. Cloth, $4. ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. A Series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50. FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. Cloth, $1.50. With Clouston on Mental Diseases (new edition, see page 6) $5.00, net, for the two works. FORMULARY, POCKET, see page 32. FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. Sixth and revised American from the sixth English edition. In one large octavo volume of 923 pp., with 257 illus. Cloth, $4.50 ; leather, $5.50. Unquestionably the best book that can be placed in the student's hands, and as a work of reference for the busy physician it can scarcely be excelled. — The Phila. Polyclinic. This single volume contains all that will be necessary in a college course, and all that the physician will need as well. — Dominion Med. Monthly. FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND- BOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3.75 ; leather, $4.75. POWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- bodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and 1 colored plate. Cloth, $2.75 ; leather, $3.25. FRANKLAND (E.) AND JAPP (F. R.). INORGANIC CHEMISTRY. In one handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75 ; leather, $4.75. FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and Treatment. From second English edition. In one 8vo. volume of 475 ges. Cloth, $3.50. Lea Brothers & Co., Philadelphia and New York. 11 PULLER (EUGENE). DISORDERS OF THE SEXUAL OR- GANS IN THE MALE. In one very handsome octavo volume of with 25 engravings and 8 full-page plates. Cloth It is an interesting work, and one which is timely and needed. — Medi- cal Fortnightly. The book is valuable and instruc- tive and brings views of sound pathology and rational treatment to many cases of sexual disturbance whose treatment has been too often fruitless for good. — Annals of Surgery. GALLAUDET (BERN B.). A POCKET TEXT-BOOK OX SUR- ' I E RY. In one handsome 12nio. volume of about 400 pages, with many illustrations. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaidet, M. D. See page 17. GAXT FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75. GAYLORD (HARVEY R.). AX ATLAS OF PATHOLOGICAL ANATOMY. 325 pages, 70 engravings and 29 full-page heliotype plates in colors and black. In Press. GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American Authors. Edited by Frederic H. Gerrish, M. D. In one imp. octavo volume of 915 pages, with 950 illustrations in black and colors. Cloth, $6.50; flexible waterproof, $7; leather, $7.50, net; half Morocco, $8.00, net. with less waste of words and better empha&is of important points than any similar text-book with which we are familiar. — The Boston Medi- cal and Surgical Journal. TVe believe that this volume not only takes rank with all other works on anatomy, but in some respects is superior to any now available. — The Chicago Jledical Recorder. The illustrations far outnumber and exceed in size and in profusion of colors those in any previous work ; and they can well claim to be the most successful series of anatomical pictures in the world. — The Ameri- can Practitioner and News. The chief merit in the book will be found in the descriptive text, which is accurate, concise, and gives the essentials of descriptive anatomy GD3BES (HEXEAGE). PRACTICAL PATHOLOGY AXD MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GRAY(HEXRY). ANATOMY, DESCRIPTIVE AXD SURGICAL. Xew and thoroughly revised American edition, much enlarged in text, and in engravings in black and colors. In one imperial octavo volume of 1239 pages, with 772 large and elaborate engravings on wood. Price of edition with illustrations in colors : cloth, $7 ; leather, $8. Price of edition with illustrations in black : cloth, $6 ; leather, $7. This is the best single volume Gray' $ Anatomy affords the student upon Anatomv in the English more satisfaction than any other language. — University Jledical Mag- azine. Gray's Anatomy should be the first work which a medical student should purchase, nor should he be without a copy tb rough out his pro- fessional career. — Pittsburg Medical Review. treatise with which we are familiar. — Buffalo Med. Journal. The most largely used anatomical text-book published in the English language. — Annals of Surgery. Holds first place in the esteem of both teachers and students. — The Brooklyn Medical Journal. 12 Lea Brothers & Co., Philadelphia and New York. GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. < Jloth, $2. Sec Student's Scries of Manuals , p. 27. GREEN (T.HENRY). PATHOLOGY AND MORBID ANATOMY New (9th) American from the ninth London edition. In one hand- some octavo volume of 577 pages, with 339 engravings and 4 colored plates. Cloth, $3.25, net. A work that is the text-book of probably four-fifths of all the stu- dents of pathology in the United States and Great Britain. — The American Practitioner and News. The work is an essential to the practitioner — whether as surgeon or physician. It is the best of up-to- date text-books. — Virginia Medical Monthly. GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- ISTRY. For the Use of Students. Based upon Bowman's Medical Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND AND THE URETHRA. Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN DISEASES. In one handsome 12mo. volume of 350 pages, with many illustrations. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallattdet, M. D. See page 17. HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN Second American from the third English edition. In one octavo vol- ume of 554 pages, with 11 engravings. Cloth, $3.50. HALL (WINFIELD S.). TEXT-BOOK OF PHYSIOLOGY. Octavo of 672 pages, with 343 engravings, and 6 full page colored plates. Cloth, $4.00 ; leather, $5.00, net. of which needs to be more strongly impressed upon students A book which makes this so easily possible is to be highly commended. — West- ern Medical Review. Truly a scientific treatment of the subject. The clearness with which physiological facts are demonstrated makes it of special value to the medical student. The science of physiology is one, the importance HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR DESCRIPTION AND TREATMENT. Second and revised edition. In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. HARD A WAY ( W. A.). MANUAL OF SKIN DISEASES. New (2d) edition. In one 12mo. volume of 560 pages, with 40 illustrations and 2 plates. Cloth, $2.25, net. The best of all the small books to recommend to students and practi- tioners. Probably no one of our dermatologists has had a wider every- day clinical experience. His great strength is in diagnosis, descriptions of lesions and especially in treat- ment. — Indiana Medical Journal. HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- TIONS AND SEQUELS OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full-page plates. Cloth, $2.40, net. A very valuable production. One I read with great profit. — Cleveland. of the very best products of Dr. Journal of Medicine. Hare and one that every man can ' Lea Brothers & Co., Philadelphia and New York. 13 IIAUH (HOBART AMOUYi. PRACTICAL DIAGNOSIS. THE USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. Fourth edition. Jm one octavo volume of 623 pages, with 205 engravings and 14 full-page colored plates. Cloth, $5.00, net; half Morocco, $6.50, net. It is unique in many respects, and the author lias introduced radical chauges which will be welcomed by all. Anyone who reads this book will become a more acute observer, will pay more attention to the simple yet indicative signs of disease, and lie will become a better diagnosti- cian. This is a companion to Prac- tical Therapeutics, by the same author, and it is difficult to conceive of any two works of" greater practical utility. — Meddcal Review. HARE (HOB ART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. Eighth and revised edition. In one octavo volume of 796 pages, with 37 engravings and 3 colored plates. Cloth, $4.00, net; leather, $5.00, net; half Morocco, $5.50, net. Its classifications are inimitable, and the readiness with which any- thing can be found is the most won- derful achievement of the art of in- dexing. This edition takes in all the latest discovered remedies. — The St. Louis Clinique. The great value of the work lies in the fact that precise indications for administration are given. A complete index of diseases and remedies makes it an easy reference work. It has been arranged so that it can be readily used in connection with Hare's Practical Diagnosis. For the needs of the student and general practitioner it has no equal. — Medica 1 Sent in el. The best planned therapeutic work of the century. — American Prac- titioner and News. It is a book precisely adapted to the needs of the busy practitioner, who can rely upon finding exactly what he needs. — The National Med- , ical Review. HARE'S SYSTEM OF PRACTICAL THERAPEUTICS. In a series of contributions by eminent practitioners. ^New (2d) edition. Just ready. In three large octavo volumes containing 2593 pages, with 457 engravings and 26 full-page plates. Price per volume, cloth, $5.00; leather, $6.00; half morocco, S7.00. Full prospectus free on application. For sale by subscription only. The Hare's System of ten years ago will hardly be recognized in this new edition, so complete are the changes, so extended the disserta- tion and so complete the re-dress. The additions alone are sufficient to make a new volume. The choice of subjects is wide and the names of the authors are a sufficient guaran- tee of the character of the mode of treatment. The dominant feature of the work, one that the well- known editor constantly presents, is the every day workability of treat- ments advocated. Here are no thy theoretical dissertations largely padded by quotations from European authors, but concise, prac- tical rules that can be made to fit present-day needs. What, why and how are the questions with ref- erence to the use of drugs that the authors answer — particularly the hqw. — Medical News. 14 Lea Brothers & Co., Philadelphia and New York. HARRINGTON (CHARLES). PRACTICAL HYGIENE. Hand- some octavo, 721 pages, 105 engravings, 12 plates. Just ready. Net, $4.25. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, Avith 144 engravings. Cloth, $2.75. A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. Second edition. In one 12mo. volume of 304 pages, with 54 en- gravings. Cloth, $1.50, net. It is practical, concise, definite and of sufficient fulness to be satis- factory. — Chicago Clinical Review. It is well written, up to date, and will be found very useful. — Inter- national Medical Magazine. HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- tricity, Modifications of Atmospheric Pressure, Climates and Mineral Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume of 414 pages,with 113 engravings. Cloth, $3. HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See Student's Series of Manuals, page 27. HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. volume of 199 pages, with 32 engravings. Cloth, $1.50. HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. We commend the book not only to Excellently arranged, practical, the undergraduate, but also to the concise, up-to-date, and eminently physician who desires a ready means well fitted for the use of the prac- of refreshing his knowledge of diag- titioner as well as of the student. — nosis in the exigencies of professional Chicago Med. Recorder. life. — Memphis Medical Monthly. Lea Brothers & Co., Philadelphia and New York. 15 HILL. (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. HILLIEK (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PIERSOL (GEORGE A. . HUMAN MONSTROSITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engravings and 39 large photographic plates from nature. In four parts, price each, $5. Limited edition. For sale by subscription only. HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. New (13th) edition. In one 12mo. volume of 845 pages. Cloth, $3.00, net. HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, INCLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. vol. of 519 pp., 'with illus. Cloth, $4.50. HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examination of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25. HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- ciples and Practice. A new American from the fifth English edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- ume of 1008 pages, with 428 engravings. Cloth, $6 ; leather, $7. A SYSTEM OF SURGERY. With notes and additions by various American authors. Edited by John H. Packard, M. D. In three very handsome 8vo. volumes containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; leather, $7 ; half Russia, $7.50. For sale by mbucriptwn only. HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320 engravings. Cloth, $6. HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. HUNTINGTON (GEORGE S.). A TREATISE ON ABDOMINAL ANATOMY. Imperial octavo, with 250 pages of text and 250 full- page plates. Shortly. 16 Lea Brothers & Co., Philadelphia and New York. HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- EASES OF THE SKIN. New (6th) edition, thoroughly revised. Octavo, 832 pages, with 107 engravings and 27 full-page plates, 9 of which are colored. Justready. Cloth, $4.50, net; leather, $5.50, net ; half Morocco, $6.00, net. This edition has been carefully re- 1 culcated throughout is sound as well vised, and every real advance has J as practical. — The American Jour- been recogoized. The work answers j nal of the Medical Sciences. the needs of the general practitioner, [ j t [ s t ^ e h est one- volume work the specialist, and the student.— The that we know.— Virginia Medical Ohio Med. Jour. Semi-Monthly. A treatise of exceptional merit | A full and thoroughly modern characterized by conscientious care text-book on dermatology. — The and scientific accuracy. — Buffalo Med. Journal, A complete exposition of our Pittsburg Medical It e new. The most practical handbook on derrnatolocrv with which we are ac- knowledge of cutaneous medicine as i quainted. — Chicago Medical Re- it exists to-day. The teaching in- ) corder. JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK OF DISEASES OF THE SKIN. Third edition. In one 12mo. volume of 637 pages, with 75 illustrations and a colored plate. Cloth, $2.50, net. As a student's manual, it may be Without doubt forms one of the considered beyond criticism. The best guides for the beginner in der- book is singularly full.— St. Louis , matology that is to be found in the Medical and Surgical Journal. English language. — Medicine. JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third edition. In one octavo volume of 656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6. JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. An exceedingly useful manual for I ing it in attractive and easily tangi- student and practitioner. The au- ; ble form. The book is well illus- thor has succeeded unusually well trated throughout. — Nashville Jour. in condensing the text and in arrang- | of Medicine and Surgery. - THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored plates. Cloth, $5.00, net ; leather, $6.00, net; half Morocco, 80.50, net. A clear and practical treatise upon the book abounds. The work is obstetrics by well-known teachers of sure to be popular with medical the subject. A special feature of students, as well as being of extreme this work would seem to be the value to the practitioner. — The excellent illustrations with which Medical Age. JONES (C. HANDF1ELD). CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American edi- tion. In one octavo volume of 340 pages. Cloth, $3.25. Lea Brothers & Co., Philadelphia and New York. 17 JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. Second edition. In one octavo volume of 549 pages, with 201 engravings, 17 chromo-lithosrraphic plates, test-types of Jaeger and Snellen, and Holmgren's Color-Blindness Test. "Cloth, $5.50 ; leather, $6.50. The volume is particularly rich in color blindness, etc. The sections matter of practical value, such as devoted to treatment are singularly directions for diagnosing, use of full and concise. — Medical Age,. instruments, testing for glasses, for ! KING (A. F. A.). A MANUAL OF OBSTETRICS. Eighth edition. In one 12mo. volume of 612 pages, with 26-4 illustrations. Cloth, $2.50, net. From first to finish it is thoroughly cyclopedias. The well-arranged practical, concise in expression, well index renders the book useful to illustrated, and includes a statement the practitioner who is in haste to of nearly every fact of importance refresh his memoiy. — Virginia discussed in obstetric treatises or Medical Semi-Monthly. KIRK (EDWARD C). OPERATIVE DENTISTRY. New (2d) edition. Handsome octavo of 857 pages, with 897 illustrations. See American Text-Books of Dentistry, page 2. "Wehave only the highest praise tempted. We can heartily recom- for this valuable work. It is replete mend it to the profession. — The in every particular, and surpasses Ohio Dental Journal. anything of the kind heretofore at- J KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.00, net. See Student's Series of Manuals, page 27. _ It is the most complete and Gon- This work deservedly occupies a cise work of the kind that has yet first place as a text-book on his- emanated from the press.— TheMed- tology. — Canadian Practitioner. ical Age. LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- BOOK OF OPHTHALMIC SURGERY. Second edition. In one octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. LEAS SERIES OF POCKET TEXT-BOOKS, edited bv Been B. Gallatjdet, M. D. Covering the entire field of Medicine in a series of 16 very handsome 12mo. volumes of 350-450 pages each, profusely illustrated. Compendious, clear, trustworthy and'modern. The following volumes constitute the series. Coates' Bacteriology. Collins' Anatomy. Collixs and Rock- well's Physiology. Maettx and Rockwell's Chemistrv and Physics. Nichols and Vale's Histology and Patliologv. Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- bary's Practice of Medicine. Collixs' Diagnosis. Potts' Nervous and Mental Diseases. Gallatjdet's Surgerv. Geixdox's Der- matology. Ballexgee and Wippeex's Diseases of the Eve, Ear, Throat and Nose. Evans' Obstetrics. Ceockett's Gynecology. Tuttle's Diseases of Children. For separate notices see under various authors' names. 18 Lea Brothees & Co., Philadelphia and New York. LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION AND INDULGENCES IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 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Seventh edition, thoroughly revised by H. C. C. MAISCH, Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 285 engravings. Cloth, $2.50, net. Used as text-book in every college ' in America. The work has no equal, of pharmacy in the United States ! — Dominion Med. Monthly. and recommended in medical col- The best handbook upc/n phar- leges. — American Therapist. macognosy of any published in this Noted on both sides of the Atlantic country. — Boston Med. & Sur. Jonr. and esteemed as much in Germany as I MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF THEORY AND PRACTICE OF MEDICINE. In one handsome 12mo. volume of 405 pages, with 45 illustrations. Cloth, $1.75, net; flexible red leather, $2.25, net. Lea's Series of Pocket Text-books, edited by Berx B. Gallattdet, M. D. See page 17. Will readily commend itself to ! deals briefly and systematically with students and busy practitioners, j each disease, as to its history, retiol- bringing forward as it does the most ! ogy, symptomatology, diagnosis, recent advances in medicine with prognosis and treatment. — Medical the best of that which is old. It i Revieiv of Reviews. MANTJAJLS. See Student's Quiz Series, page 27, Student's Series of Manuals, page 27, and Series of Clinical Manuals, page 25. MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. See Series of Clinical Manuals, page 25. MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. In one 12mo. volume of about 400 pp., fully illustrated. Preparing. MARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- some 12mo. volume of 366 pages, with 137 illustrations. Cloth, $1.50, net; limp leather, $2.00, net. Lea's Series of Pocket Text-Books, edited by Bern B. Gallattdet, M. D. See page 17. Contains everything of the sci- rately reflects both sciences in their ences of chemistry and physics present development. The arrange- necessary for the medical student ment of the matter is excellent. — and practitioner. The work accu- The Medical and Surgical monitor. MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For the use of Students and Practitioners. Second edition, revised by L. S. Ratj, M. D. In one 12mo. volume of 360 pages, with 31 engrav- ings. Cloth, $1.75. MEDICAL NEWS POCKET FORMULARY, see page 32. 20 Lea Beothers & Co., Philadelphia and New York. MITCHELL. (S. WEIR). CLINICAL LESSONS ON NERVOUS DISEASES. In one 12mo. volume of 299 pages, with 19 engravings and 2 colored plates. Cloth, $2.50. The book treats of hysteria, recur- rent melancholia, disorders of sleep, choreic movements, false sensations contractions, rotary movements in the feeble minded, etc. Few can speak with more authority than the author. — The Journal of the Ameri- can Medical Association. of cold, ataxia, hemiplegic pain, treatment of sciatica, erythromelal- gia, reflex ocularneurosis, hysteric MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- JURIES OF NERVES AND THEIR TREATMENT. In one handsome 12mo. volume of 239 pages,with 12 illustrations. Cloth, $1.75. MORRIS (MALCOLM). DISEASES OF THE SKIN. Second edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- graphic plates and 26 engravings. Cloth, $3.25, net. The work is essentially clinical strong common sense. It is alike and practical in its scope and is characterized throughout by clear- ness and simplicity of style and suitable for the student, physician and specialist. — Buffalo Medical Journal. MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAGNOSIS, for Students and Physicians. New (4th) edition, thor- oughly revised. In one octavo volume of 1104 pages, with 250 en- gravings and 49 full-page colored plates. Cloth, $6.00, net; leather, $7.00, net; half Morocco, $7.50, net. We have no work of equal value in English. — University Medical Magazine. From its pages may be made the diagnosis of every malady that afflicts the human body, including those which in general are dealt with only by the specialist. — North- tvestern Lancet. It so thoroughly meets the precise demands incident to modern research that it has been adopted as the lead- ing text-book by the medical colleges of this country. — North American Practitioner. The best of its kind, invaluable to the student, general practitioner and teacher. — Montreal Medical Journal. NATIONAL DISPENSATORY. See StilU, Maisch & Caspari, p. 27. NATIONAL FORMULARY. See Stille, Maisch & CasparVs National Dispensatory, page 27. NATIONAL MEDICAL DICTIONARY. See Billings, page 4. Lea Brothers & Co., Philadelphia and New York. 21 NETTLESHIP(E. . DISEASES OF THE EYE. New (6th) American from sixth English edition, thoroughly revised. Jn our 12mo. volume of 562 pages, with 192 engravings, and 5 colored plates, test-types, formulae and color-blindness test. Cloth, $2.25, net. By far the best student's text-book I The present edition is the result on the subject of ophthalmology.— of revision both in England and The Clinical Review. America, and therefore contains the This work for compactness, practi- ^ test and best ophthalmologic cality and clearness has no superior 1( ? eas of *>?£ continents.- The Phy- in the English language.- Journal ™wn and Surgeon, of Medicine and Science. I NICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT- BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 12mo. volume of 452 pages, with 213 illustrations. Cloth, $1.75, net: flexible red leather, $2.25, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 17. So systematically arranged that it can safelv and conscientiously ree- ls, in the highest degree, interesting, ommend 'it to both students and Thoroughly up to date. The book practitioners.— The St. Louis Medi- is an exceptionally good one. We cal and Surgical Journal. NOKRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $6. It is practical in its teachings. ; has ever been offered to the Arner- We unreservedly endorse it as the ican medical public— Annals of best, the safest and the most compre- Ophthalmology and Otology. hensive volume upon the subject that j OWEN (EDMUND). SUKGICAL DISEASES OF CHILDREN. In one 12mo. volume of 525 pages, with 85 engravings and 4 colored plates. Cloth, $2. See Series of Clinical Manuals, page 25. PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- CAN AUTHORS. Condensed edition. In one royal octavo volume of 1261 pages, with 625 engravings and 37 full-page plates. Cloth, $6.00, net ; leather, $7.00, net. The work is fresh, clear and practi- clear-cut, thoroughlv modern -and cal, covering the ground thoroughly admirably resourceful.— Johns Hop- yet briefly, and well arranged for ■kins Hospital Bulletin. rapid reference, so that it will be of The latest and best work written special value to the student and busy upon the science and art of surgery practitioner. The pathology is Columbus Medical Journal. broad, clear and scientific, while the , It is thoroughly practical and yet suggestions upon treatment are , thoroughly scientific— Med. News 22 Lea Brothers & Co., Philadelphia and New York. PARK (WILL.IAM H.). BACTERIOLOGY IN MEDICINE AND SURGERY. 12mo., 688 pages, with 87 illustrations in black and colors, and 2 plates. Cloth, $3.00 net. This book fills a very distinct gap. None of the text-books in our language take up the subject of bac- teriology so thoroughly and so soundly as does this from the point of view of the hygienist and public health officer. The work is correct and very well up to date. — The Mon- treal Medical Journal. PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- MENT. In one octavo volume of 272 pages. Cloth, $2.50. PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB- STETRICS. Third edition. In one handsome octavo volume of 677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; leather, $5.25. Parvin's work is practical, con- English language. — Medical Fort- cise and comprehensive. We com- mend it as first of its class in the nightly. PEPPER'S SYSTEM OF MEDICINE. See page 3. PEPPER (A. J.). FORENSIC MEDICINE. In press.. Sen Student 1 * Series of Manuals, page 27. SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27 PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, page 25. PL.AYFAIR (W. S.). A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Seventh American from the ninth English edition. In one octavo volume of 700 pages, with 207 engravings and 7 plates. Cloth, $3.75 net ; leather, $4.75, net. An epitome of the science and a safe guide to both student and practice of midwifery, which em bodies all recent advances. — The Medical Fortnightly. This work must occupy a fore- most place in obstetric medicine as obstetrician. It holds a place among the ablest English-speaking authori- ties on the obstetric art. — Buffalo Medical and Surgical Journal. — THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- TION AND HYSTERIA. In one 12mo. volume of 97 pages Cloth, $1. Lea Brothers & Co., Philadelphia and New York. 23 POCKET FORMULARY, see page 32. POCKET TEXT-BOOKS, see page 18. POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE EAR AND ADJACENT ORGANS. Second American from the third German edition. Translated by Oscar Dodd, M. D., and edited by Sir William Dalby, F. R. C. S. In one octavo volume of 748 pages, with 330 original engravings. POTTS (CHARLES S.j. A POCKET TEXT-BOOK OF NERVOUS AND MENTAL DISEASES. In one handsome 12mo. volume of 445 pages, with 88 engravings. Cloth, $1.75, net; limp leather, $2.25, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallau- det, M. D. See page 17. Dr. Potts has succeeded in de- of the numerous discoveries in every picting the main facts in a manner branch of neurology is clearly pre- that will be appreciated by students sented. The book is a reliable guide, and general practitioners. The gist — The Medical Bulletin. PROGRESSIVE MEDICINE, see page 32. PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 engravings. Cloth, $2. PYE-SMITH (PHTLD? H.). DISEASES OF THE SKIN. In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. QUIZ SERD3S. See Student's Quiz Series, page 27. RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See Student's Series of Manuals, page 27. RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of 640 pages, with 64 plates and numerous engravings in the text. Strongly bound in leather, $7. REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. Fifth edition, thoroughly revised. In one 12mo. vol- ume of 326 pages. Cloth, $2. A clear and concise explanation j student of chemistry or the practi- of a difficult subject. We cordially tioner who desires to broaden his recommend it. — The London Lancet, theoretical knowledge of chemistry. The book is equally adapted to the | —New Orleans Med. and Surg. Jour. 24 Lea Brothers & Co., Philadelphia and New York. RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. New (2d) edition. In one octavo volume of 838 pages with 473 engravings and 8 plates. Cloth, $4 25, net; leather, $5.25, net. A clear, concise, comprehensive satisfactory or valuable single vol- and practical presentation of the ume work on this subject. — Pacific most modern surgery. The student Medical Journal. or practitioner will not find a more ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth, American from the fourth London edition. In one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, with 184 engravings. Cloth, $4.50 ; leather, $5.50, SOHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. Fifth edition. In one handsome octavo volume of 359 pages, with 392 illustrations. Cloth, $3.00, net. Nowhere else will the same very moderate outlay secure as thoroughly useful and interesting an atlas of structural anatomy. — The American Journal of the Medical Sciences. The most satisfactory elementary text-book of histology in the Eng- lish language. — The Boston Med. and Sur. Jour. A COURSE OF PRACTICAL HISTOLOGY. Second edition. In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo., 352 pages. Cloth, $1.50, net; flexible red leather, $2.00, net. Lea's Series of Pocket Text-books. Edited by Bern B. Gallaudet, M. D. See page 17. We commend the book for it con- tains in a concise, definite, and as- similable form the essential knowl- edge required in the most complete college courses on Materia Medica and Therapeutics. — The National Medical Review. Lea Brothers & Co., Philadelphia and New York. 25 SCHOFIELD (ALFRED T.). ELEMENTARY PHYSIOLOGY FOR STUDENTS. In one 12ino. volume of 380 pages, with 227 engravings and 2 colored plates. Cloth, $2. SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- tion. In one octavo volume of 268 pages, with 13 plates, 10 of which are colored, and 9 engravings. Cloth, $2. SERIES OF CLINICAL MANUALS. A Series of Authoritative Monographs on Important Clinical Subjects, in 12mo. volumes of about 550 pages, well illustrated. The following volumes are now ready : Yeo on Food in Health and Disease, second edition, $2.50 ; Carter and Frost's Ophthalmic Surgery, $2.25 ; Marsh on Diseases of the Joints, $2 ; Owen on Surgical Diseases of Children, $2 ; Pick on Fractures and Dislocations, $2. For separate notices, see under various authors' names. SERIES OF STUDENT'S MANUALS. See page 27. SIMON (CHARLES E.). A TEXT-BOOK ON PHYSIOLOGICAL CHEMISTRY. Octavo of about 450 pages, amply illustrated. In press. SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL METHODS. New (3d) edition. In one very handsome octavo volume of 563 pages, with 138 engravings and 18 full-page colored plates. Cloth, $3.50, net. This book thoroughly deserves its success. It is a very complete, authen- tic and useful manual of the micro- scopical and chemical methods which are employed in diagnosis. Very excellent colored plates illus- trate this work. — New York Medical Journal. In all respects entirely up to date. — Medical Record. The chapter on examination or the urine is the most complete and advanced that we know of in the English language. — Canadian Prac- titioner. SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. Sixth edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 plates showing colors of 64 tests. Cloth, $3.00, net. It is difficult to see how a better the covers of this book. — The North- book could be constructed. No man western Lancet. who devotes himself to the practice Its statements are all clear and its of medicine need know more about teachings are practical. — Virginia chemistry than is contained between Med. Monthly. SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME- DIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25. 26 Lea Brothers & Co., Philadelphia and New York. SMITH (J. LEWIS). A TREATISE ON THE .DISEASES OF IN- FANCY AND CHILDHOOD. Eighth edition, thoroughly revised and rewritten and much enlarged. In one large 8vo. volume of 983 pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; leather, $5.50. A safe guide for students and phy- sicians. — The Am. Jour, of Obstetrics. For years the leading text-book on children's diseases in America. — Chicago Medical Recorder. The most complete and satisfac- tory text-book with which we are acquainted. — American Gynecologi- cal and Obstetrical Journal. SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one octavo volume of 892 pages, with 1005 engravings. Cloth, $4 ; leather, $5. One of the most satisfactory works on modern operative surgery yet published. The book is a compen- dium for the modern surgeon. — Bos- ton Medical and Surgical Journal. SOLLY (S. EDWIN). 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THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the latest Pharmacopoeias of the United States, Great Britain and Germany, with numerous refer- ences to the French Codex. Fifth edition, revised and enlarged, including the new U. S. Pharmacopoeia, Seventh Decennial Revision. With Supplement containing the new edition of the National Formu- lary. In one magnificent imperial octavo volume of about 2025 pages, with 320 engravings. Cloth, $7.25; leather, $8. With ready reference Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. Lea Brothers & Co., Philadelphia and New York. 27 STOfSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. NVu | ith) edition. In one royal L2mo. volume of 581 pages, with 293 engravings. Cloth, $3.00, net. Justready. A useful and practical -aide for The book is worth the price for the all students and practitioners.— Am. j illustrations alone.— Ohio Medical Journal of the Medical Sciences. ; Journal. STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND DISLOCATIONS. New (3d) edition. In one handsome octavo vol- ume of 842 pages, with 336 engravings and 32 plates. Cloth, $5.00, net; leather, $6.00, net; half Morocco, $6.50, net. Preeminently the authoritative | pensable to the student and the prac- text-book upon the subject. The titioner alike.— 77,e Medical Age vast experience of the author srives which h as already go* vill h n P °^ 18h i lan ^Se. through five large editions, anVl "has It will be of especial value to the been translated into Frenoh f£r s^hlLr' a Theilln r ,t a :t WellaSt ° the man ' Spanish^nTltalTa^^^he EfStorv M^nfS.° DSare V6ry T st P racti <*l and at the sarne time sat factory Many of them are new the most complete treatise unon the and are particularly clear and attrac- subject,-^/ Archhel of fCJ«/ tive.-Boston Med. and Sur. Jour. ogy\ Obstetrics ZTpeVL^s^ TH SmE ( \ G ^ A ? ,< \ ™XT-BOOK OF PRACTICAL S volume of ■ ?m9 entS '^ .^ actitioners - ^ one handsome Z -Whe ^ i, Vif-& Wlth 79 e *g ra ™gs. Cloth, $5.00, race, leatner, Sb.OO, net; half Morocco, 86.50, rarf. tlon. In one octavo vol. of 203 pp., with 25 engraving" CMhf&x. engravKndlrT ^^^Je^^kge^l? engravings and 3 lithographic plates. Cloth, $3.50. THOMSON (JOHN). DISE4SFSOF PTTTT tydttxt t oetavovolLeofS.oOp^wftfoomus'rao'th^o J? " "•"" ,'ee I t"k b ^ a U I $15.00 < Progressive Medicine .... 10.00 J gj Medical News Visiting List . . . 1.25 °- Medical News Formulary . . . 1.50 net, In all S30.75 for $16.00 First four above publications in combination . . $15.75 All above publications in combination .... 16.00 Otlier Combinations will be quoted on request. Full Circulars and Specimens free. LEA BROTHERS & CO., Publishers, 706, 708 & 710 Sansom St., Philadelphia. Ill Fifth Avenue, New York. i ' COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at thJB 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 C281I 1401M 100 RD111 art on 1902 KDIII \30£ iiSTKl^cT 8 '^ ery and banda 2002136643