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MINOR AND EMERGENCY 
 SURGERY 
 
 BY 
 
 WALTER T. DANNREUTHER, M. D. 
 
 SURGEON TO ST. ELIZABETH'S HOSPITAL AND TO ST. BARTHOLOMEW'S 
 
 CLINIC, NEW YORK CITY; EX-HOUSE PHYSICIAN AND SURGEON, 
 
 JERSEY CITY HOSPITAL, ETC. 
 
 ILLUSTRATED 
 
 PHILADELPHIA AND LONDON 
 
 W. B. SAUNDERS COMPANY 
 
 1911 
 

 Copyright, igii, by W. B. Saunders Company 
 
 1] 2.1 
 
 a 
 
 <s^ 
 
 PRINTED IN AMERICA 
 
 PRESS OF 
 
 W. B. SAUNDERS COMPANY 
 
 PHILADELPHIA 
 
c7 
 
 <4 
 
 THIS BOOK IS DEDICATED 
 TO 
 
 the earnest and ambitious young physician who is devot- 
 ing all his time to hospital work, and whose only reward 
 is the knowledge and experience thus gained: 
 
 THE HOSPITAL INTERNE 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/minoremergencysuOOdann 
 
PREFACE 
 
 Many excellent books on minor surgery have been 
 written but so far as the author is aware, none has 
 been adapted exclusively to the needs of the hospital 
 interne. Each of the following pages has been pre- 
 pared expressly for the members of a resident staff: 
 for the interne's guidance when acting independently; 
 to assist the ambulance surgeon in emergencies, to 
 simplify practical work for the junior and to aid the 
 senior in some of his predicaments. If this little 
 volume but serves this purpose, its object will 
 haven been attained. However, as the general 
 practitioner and even the specialist, as well as the 
 surgeon, is so frequently called upon to cope with this 
 class of emergencies, the author hopes that others 
 may find some useful points in its perusal. 
 
 Many subdivisions and details of minor surgery 
 have been purposely omitted, as it is not intended 
 to rewrite all that can be found elsewhere. Also, it 
 may seem that the special attention accorded some 
 of the more oridnary conditions, usually considered 
 elementaiy and unworthy of much thought by the 
 medical student, is disproportionate to the com- 
 paratively small amount of space devoted to them 
 in the average text-book. An effort has been made 
 particularly to emphasize those points that are of 
 great importance in practical work, but which are 
 often apparently disregarded or ignored. To avoid 
 
 13 
 
14 
 
 PREFACE 
 
 confusion and favor brevity, the treatment out- 
 lined is in most instances that which experience has 
 proved to be the most satisfactory. Incidentally, 
 this will accoimt for the frequent mention of iodine 
 as an antiseptic and germicide.* It is assumed that 
 the reader possesses the average theoretical knowl- 
 edge of the medical graduate, but has had little or 
 no practical experience, and therefore the author 
 has endeavored to make his statements as simple, 
 clear and concise as possible. 
 
 Due acknowledgment is made for information 
 derived from many sources; the standard medical 
 journals and text-books have been freely consulted 
 and the methods in vogue at the leading hospitals 
 investigated. The author especially desires to 
 express his thanks and indebtedness to his friends, 
 Dr. Terry M. Townsend of New York and Dr. Frank 
 D. Gray of Jersey City, for their careful considera- 
 tion and criticism of the manuscript, to Miss Eleanora 
 Fry for the painstaking and graphic illustrations, 
 and to the publishers for their uniform kindness and 
 courtesy. 
 
 Walter T. Dannreuther. 
 
 New York City 
 October, 191 1. 
 
 *"The Surgical Value of Iodine," Medical Record, January 25, 1908. 
 "The Practical Value of Tincture of Iodine and Iodine Catgut in Major 
 Surgery," Medical Record, January 16, 1909. 
 
CONTENTS 
 
 Page 
 
 Introduction i? 
 
 CHAPTER I. 
 The Ambulance Surgeon 19 
 
 CHAPTER II. 
 Accidental Wounds 23 
 
 CHAPTER III. 
 Traumatic Injuries of Joints 48 
 
 CHAPTER IV. 
 Simple Fractures 64 
 
 CHAPTER V. 
 
 Compound Fractures and Traumatic Amputations . 106 
 
 CHAPTER VI. 
 Sequels of Fractures 116 
 
 CHAPTER VII. 
 Acute Pyogenic Infections ' . 123 
 
 CHAPTER VIII. 
 Effects of Intense Heat and Cold 140 
 
 CHAPTER IX. 
 Ulcers — Bed-sores 151 
 
 CHAPTER X. 
 Foreign Bodies 159 
 
 CHAPTER XI. 
 Surgical Shock and Collapse — Death 168 
 
 CHAPTER XI I. 
 
 Minor Operations 180 
 
 Index 213 
 
 15 
 
MINOR AND EMERGENCY 
 SURGERY. 
 
 INTRODUCTION. 
 
 Having attained the coveted degree of M. D., 
 the majority of recent graduates seek an appoint- 
 ment on the resident staff of some hospital. The 
 term of service may vary from one to three years, 
 usually averaging eighteen months, and the ex- 
 perience and knowledge gained during this time 
 will prove to be of inestimable benefit and of the 
 utmost importance throughout the young physician's 
 subsequent professional life. Although he is af- 
 forded the opportunity of doing a certain amount 
 of dispensary work in connection with the modem 
 college course, the comparatively few real emer- 
 gencies presenting and the student's subordinate posi- 
 tion greatly minimize the benefits which apparently 
 might be derived therefrom. It is while serving 
 as a member of a house staff enjoying an active 
 service that there is almost imlimited opportunity 
 of applying the principles and teachings of the 
 college course. Here too are encouraged and 
 developed those qualifications so essential to suc- 
 cess in practice: acuity of perception, dexterity 
 and self-reliance. 
 
 The first few months of the hospital service are 
 usually devoted, as they properly should be, to 
 2 17 
 
1 8 MINOR AND EMERGENCY SURGERY 
 
 laboratory work, history taking, applying ward 
 dressings under the direction of the house surgeon, 
 and the like. This gives the junior an opportunity 
 to feel at home in his new surroundings, to acquaint 
 himself with the routine of the institution and its 
 personnel and to observe more or less emergency 
 work attended by his superiors before assuming 
 any responsibilities himself. 
 
 The interne should ever respect and obey the advice 
 and instructions of the members of the visiting staff 
 and any criticism that he has to make of their 
 suggestions should be entirely mental. Discussions 
 in private, however, concerning the diagnosis and 
 management of cases are to be encouraged. The 
 interne should keep his eyes and ears open and his 
 mouth shut when in the wards. "Errare est 
 humanum" and even the visiting surgeons may 
 make mistakes occasionally, but, as Dr. Brickner 
 has so aptly said, they probably have better reasons 
 for being wrong than the interne has for being right. 
 
 Each member of the house staff should do his 
 share toward the maintenance of a harmonious 
 atmosphere among his fellows: routine duties being 
 performed willingly and cheerfully and favors 
 exchanged whenever possible. Mutual kindness, 
 courtesy and loyalty will promote good feeling and 
 make the day's work more pleasant. 
 
 The interne should never forget his dignity in 
 the presence of nurses and orderlies. They should 
 be shown every consideration but allowed no liber- 
 ties or undue familiarity. Regardless of the ap- 
 parent provocation, subordinates should never be 
 criticised or corrected except in private. 
 
CHAPTER I. 
 THE AMBULANCE SURGEON. 
 
 It is a grave error to permit a "green" interne 
 to do ambulance work immediately, and many 
 cities have recognized this fact by adopting an 
 ordinance requiring at least six months' service on 
 the resident staff before undertaking the duties of 
 an ambulance surgeon. He should at least transfer 
 a few elective cases to and from the hospital before 
 answering any emergency calls, thereby accustom- 
 ing himself to the presence of a crowd. Thus he 
 will gradually acquire self-confidence and become 
 impervious to the remarks and audible criticisms 
 of the by-standers. An ambulance surgeon is at 
 first likely to appear arrogant and disagreeable, or 
 nervous and undecided, faults which should be 
 studiously overcome. Collective gentleness, cour- 
 tesy and firmness will win respect and inspire con- 
 fidence. The public is quick to recognize the 
 surgeon's attitude and will usually behave accord- 
 ingly. He should never forget that he is a gentle- 
 man as well as a physician and should conduct 
 himself as both. 
 
 The patient should always be moved as carefully 
 as possible, his home respected, be it palatial or 
 humble, and his relatives and friends shown every 
 consideration. The danger of handling a patient 
 roughly cannot be too strongly emphasized, no 
 
 19 
 
20 ^ MINOR AND EMERGENCY SURGERY 
 
 matter how unimportant it may seem at the time. 
 For example, in transferring a case of appendicitis, 
 a sudden jar may rupture an existing abscess, ulti- 
 mately resulting in a fatal issue. 
 
 Occasional difficulty will be experienced in trans- 
 porting the stretcher downstairs, b.ecause of acute 
 angles in the stairway. Under such circumstances 
 it is better to either carry the patient down bodily, 
 or seat him in a chair and carry the chair down. 
 He should always be carried feet first down stairs, 
 and vice versa. The greater part of the actual 
 work may be safely left to the driver, policemen 
 present and by-standers, under the supervision of 
 the surgeon. It is not, however, correct or con- 
 siderate to expect or demand the assistance of 
 members of the patient's family. It is well to 
 see that the patient is completely covered with 
 blankets; and covering the face with a handkerchief 
 while placing the stretcher in the ambulance is a 
 trifling attention that will be greatly appreciated. 
 
 The following hints are worth remembering: 
 
 Don't lose your nerve; keep cool. 
 
 Don't lose your temper under any circumstances. 
 Rather submit to insult than to lower your dignity 
 by arguing or fighting with anyone. Call on the 
 police for aid when you need it. 
 
 Don't forget that the patient is the only matter 
 of importance that concerns you and that he requires 
 all your attention. 
 
 Don't discuss your actions with by-standers. 
 Decide quickly what you intend to do and do it 
 unhesitatingly. 
 
THE AMBULANCE SURGEON 21 
 
 Don't refuse to take any unconscious person to the 
 hospital, even though you are sure he is only in- 
 toxicated. It is better to have fifty "drunks" in 
 the hospital each night than to have one die of an 
 unsuspected fractured skull in the police station. 
 
 Don't forget that the appearance of a new am- 
 bulance surgeon is always productive of a great 
 deal of malingering on the part of some of the in- 
 habitants of the neighborhood. 
 
 Don't do on the street that which can be done at 
 the hospital. 
 
 Don't "play to the galleries." Act quickly, quietly 
 and decisively, but do all that is absolutely necessary 
 and return to the hospital as soon as possible. 
 
 Don't make an intimate of your driver. A 
 friendly spirit is commendable but anything more 
 than that lowers your profession in his eyes. 
 
 Don't stop to talk to acquaintances on the street. 
 You are a public servant while on duty and there may 
 be another call awaiting you on your return to the 
 hospital. 
 
 Don't allow your driver to drive recklessly; it 
 jeopardizes too many lives. Always get to the 
 scene of an accident as soon as possible and then 
 adapt the speed of the ambulance to the needs of 
 the patient. 
 
 Don't permit the driver to ring his gong unneces- 
 sarily. 
 
 Don't invite your friends to ride on the ambulance. 
 It is not a pleasure vehicle. 
 
 Don't forget that you cannot take anyone to the 
 hospital against his will or, if the patient is uncon- 
 
2 2 MINOR AND EMERGENCY SURGERY 
 
 scious and relatives are present, without their consent. 
 If you are requested to take the patient home or 
 to another institution, and the distance is within 
 reason, do it cheerfully. 
 
 Don't fail to respect a patient's religion, especially 
 if he is a Catholic; a priest should always be per- 
 mitted to administer the last rites. 
 
 Don't forget to report in person to the house 
 surgeon at once if you have admitted a grave case 
 to the hospital. 
 
 Don't forget to change the linen on the stretcher 
 after each call. 
 
 Don't forget to replenish the appliances carried 
 in the ambulance and the ambulance bag after each 
 call. 
 
 Don't forget that you have assumed great respon- 
 sibilities and that human life often depends upon 
 your judgment and actions. 
 
 If these suggestions are faithfully followed, 
 they will aid the ambulance surgeon in contributing 
 his share to the efficiency of the service and thereby 
 reflect credit upon the institution. 
 
CHAPTER II. 
 
 ACCIDENTAL WOUNDS. 
 
 Classification of Wounds 
 
 I. Contused 
 
 Lacerated 
 
 3. Incised 
 
 4. Punctured 
 
 5. Poisoned 
 
 a. without external communication. 
 
 b. with external communication, 
 a. localized. 
 
 b'. extensive: avulsion of a limb or the 
 scalp. 
 
 a. simple. 
 
 b. complicated: underlying important 
 structtires severed. 
 
 a. penetrating. 
 
 b. perforating. 
 
 a. pyogenic infections. 
 
 b. tetanic infections. 
 ■ c. venom infections. 
 
 d. rabid infections. 
 
 e. chemical infections. 
 
 6. Gunshot 
 
 / a. blank cartridge 
 
 j I. powder grains. 
 I 2. wadding. 
 
 \b. bullet. 
 
 Wounds are designated and classified according to 
 the nature of the causative trauma and the char- 
 acter of the injury. It is well to remember that 
 notwithstanding the apparent localization of a 
 wound in the beginning, sloughing of the skin and 
 soft parts may ensue at any time within ten days 
 as the result of extensive contusion, no evidence of 
 which presented at the first examination. This 
 is equally true of fractures, dislocations, etc. For 
 
 23 
 
2 4 MINOR AND EMERGENCY SURGERY 
 
 instance, in crushing injuries the skin wound ma}^ 
 appear insignificant, yet areas of the soft parts may 
 be extensively pulpified. If any blood-vessels of 
 large caliber have been iniptured, gangrene may 
 result in consequence of the impaired vitality of the 
 tissues; the prognosis therefore should always be 
 guarded. Free external bleeding or subcutaneous 
 hemorrhage usually accompanies all wounds and the 
 presence of more or less foreign material is to be ex- 
 pected. It will often be difficult to arrive im- 
 mediately at a definite conclusion regarding the exact 
 nature and extent of the injury, especially when 
 dealing with contusions, owing to the accompanying 
 swelling. In such cases it is better to err on the 
 safe side and assume the presence of a more severe 
 injury than to ignore its possibility. Any wound 
 may produce shock in direct proportion to its sever- 
 ity and extent. 
 
 Examination of Wounds. — ^A careful examination 
 of every wound and a thorough understanding of 
 the existing pathology is absolutely necessary in 
 order that remedial measures may be instituted in- 
 telligently. This, however, does not mean to "ex- 
 amine" a wound by probing it with a dirty finger, for 
 little knowledge will be derived in this manner and 
 additional infection may be introduced. Under 
 exceptional circumstances only, as when the presence 
 of a foreign body deep in the wound is suspected, 
 is sterile instrumental probing permissible. It is un- 
 necessary and inhuman to insist upon probing a 
 wound simply to satisfy curiosity as to its extent, 
 as the possibility always exists of again exciting 
 
ACCIDENTAL WOUNDS 25 
 
 hemorrhage which has been arrested by natural pro- 
 cesses, such as coagulation of the blood or torsion or 
 retraction of the blood-vessels. Even when dealing 
 with bullet wounds, probing is of little value in locat- 
 ing the bullet unless very near the surface, because 
 of the free extravasation of blood into the muscles 
 and other soft tissues separating the fibers and creat- 
 ing numerous false passages. Radiography, on the 
 contrary, is extremely useful for the determination 
 of the exact location of a foreign body. The possi- 
 bility of a concomitant fracture at the site of the 
 wound, or in head injuries at the base or on the op- 
 posite side of the skull, should be constantly borne 
 in mind, even though there is no distinct evidence of 
 fracture. Here again the :;t:-ray will be a valuable 
 aid. Enlarging the wound slightly, or freely if 
 necessary, will often greatly facilitate inspection. 
 The following features of wounds should be deter- 
 mined in order: 
 
 1. Extent of injury. 
 
 2. Accompanying fracture. 
 
 3. Integrity of the soft structures: periosteum, 
 muscles, tendons and nerves. 
 
 4. Foreign material present. 
 
 5. Source of hemorrhage. 
 
 Treatment of Wounds. — The cardinal principle of 
 the treatment of wounds is to bring about union by 
 first intention if possible. In many instances such 
 an immediately favorable result is obviously out of 
 the question, and every effort should then be made 
 to secure rapid granulation from the bottom. Upon 
 the surgeon's judgment will depend whether a wound 
 
2 6 MINOR AND EMERGENCY SURGERY 
 
 shall be entirely closed or drained primarily. When 
 in doubt, wounds opening into a cavity should be 
 drained ; in others an attempt may be made to obtain 
 primary tmion. If closure without drainage is after- 
 ward proved to be an error of judgment, it is easily 
 remedied by partial re-opening and drainage. In 
 general, the treatment of wounds consists of : 
 
 1. Arrest of hemorrhage. 
 
 2. Shaving and cleansing with green soap of the 
 surrounding skin. 
 
 3. Irrigation of the wound with hydrogen per- 
 oxide. 
 
 4. Removal of all extraneous matter. 
 
 5. Suture of divided important structures. 
 
 6. Institution of drainage, if required. 
 
 7. Coaptation of the edges. 
 
 8. Injection of tincture of iodine into the wound. 
 
 9. Application of a wet gauze dressing and 
 bandage. 
 
 10. Putting the injured part at rest. 
 Fortunately there are many efficient methods of 
 
 arresting hemorrhage at our disposal. In the 
 majority of instances the simple pressure of a wet 
 dressing is sufficient to control it. If a bleeding 
 vessel has been wounded but not entirely severed, 
 the division should be completed to permit retrac- 
 tion. When a single artery continues to spurt, it 
 should be seized with a hemostatic clamp, but 
 care should be taken that the jaws grasp the vessel 
 only and do not include any adjacent tissue. It 
 may then be subsequently ligated with catgut, if 
 necessary. In severe injuries with considerable 
 
ACCIDENTAL WOUNDS 27 
 
 arterial hemorrhage the tourniquet is of inestimable 
 value and should be applied as near to the injured 
 region as is consistent, in order to devitalize as little 
 healthy tissue as possible. If a i-ubber tube or 
 strap is not at hand, a tourniquet may be improvised 
 by twisting a stick in a knotted rope or strip of linen. 
 The use of the tourniquet should be avoided in pa- 
 tients with atheromatous arteries. Plugging a wound 
 of the chest with cotton will effectually control hem- 
 orrhage from an intercostal artery. The actual 
 cautery is rarely required to stop hemorrhage from 
 a wound, except in the presence of persistent oozing, 
 as in injuries of the liver or spleen. Styptics are 
 useless in the treatment of surgical hemorrhage, for 
 what little benefit is to be derived from their employ- 
 ment is of no consequence in comparison to the effici- 
 ency of other methods and, moreover, they are detri- 
 mental to subsequent wound healing. In superficial 
 bleeding, however, topical applications of adrenalin 
 chloride or beech-wood creosote control the hemor- 
 rhage very satisfactorily. 
 
 Shaving of the surrounding skin is not always 
 requisite, but thorough cleansing with green soap is 
 without exception of great importance. This should 
 be done with a nail brush, if the condition of the skin 
 will admit ; but if bniised, a sterile gauze sponge is 
 preferable because the brush may irritate the already 
 tender skin and be a source of additional trauma. It 
 is ridiculous to put clean gauze on dirty skin, and the 
 area shaved and cleansed should always extend 
 beyond the limit of the dressing. 
 
 Irrigation of a wound with hydrogen peroxide 
 
2 8 MINOR AND EMERGENCY SURGERY 
 
 serves to loosen bacteria, coagulated blood, dirt and 
 foreign bodies. Although peroxide is an efficient 
 deodorizer and cleansing agent, its germicidal 
 powder is feeble. It may therefore be omitted 
 when dealing with an apparently clean wound. 
 
 The variety of foreign bodies found in woimds is 
 almost imlimited and we should be on the lookout 
 for an3rthing from a bacterium to a limb of a tree. 
 It is important that a wound be first freed of all 
 accumulated blood clots. As a rule, the greater 
 part of the extraneous material may be removed 
 by irrigation and the fingers, but if these prove 
 unsuccessful recourse may be had to the knife, 
 forceps or curette. Care should be exercised that 
 the efforts to dislodge the foreign bodies do not push 
 them in further. The wound may be sufficiently 
 enlarged to facilitate removal. When in.strum.enta- 
 tion is necessary, the forceps or curette should be 
 inserted under the foreign body, so that it may 
 be lifted rather than pulled out. Bits of iron or 
 steel are often easily extracted by means of a power- 
 ful magnet. 
 
 If muscles, nerves or strong bands of fascia have 
 been divided they should be sutured. The two ends 
 of the same structure must be positively identified 
 and accurately approximated. The suture material 
 selected for this purpose will depend upon individual 
 preference, but for subcutaneous work it should 
 always be absorbable. Plain catgut, chromic catgut, 
 kangaroo tendon and iodine catgut^ are most often 
 
 ^ Preparation of iodine catgut — the raw strands of appropriate sizes 
 are immersed in a watery solution of i per cent, iodine crystals and i per 
 
ACCIDENTAL WOUNDS 29 
 
 used, and of these iodine catgut is the most satisfac- 
 tory. It is antiseptic arid aseptic, impossible to in- 
 fect (proved by bacteriological experiments) and its 
 tensile strength and pliability are all that may be 
 desired. It is easily prepared, thoroughly reliable 
 and trivial in cost. It may be used to equal ad- 
 vantage in all manners in which a suture or ligature 
 is ever applied. 
 
 Occasionally the edges of a wound, especially those 
 of the lacerated class, may be very irregular. They 
 should be trimmed with scissors, all tags being re- 
 moved to obviate subsequent sloughing and to secure 
 good coaptation, thus minimizing scar tissue forma- 
 tion. 
 
 Woimds where the chances of obtaining primary 
 union seem to be good are best closed with a sub- 
 cuticular suture of iodine catgut. It should be intro- 
 duced in the same way as one of any other material ; 
 but the upper end is tied, the skin pushed up on the 
 suture and the lower end tied, thus markedly de- 
 creasing the length of the wound (Fig. i). The sub- 
 ctiticular suture obviates the necessity of suture re- 
 moval later on. If the nature of the wound is such 
 that it seems doubtful or improbable that union by 
 first intention can be brought about, it should be 
 entirely or partially closed with interrupted sutures, 
 avoiding undue tension. Accurate approximation of 
 the skin margins is essential, but constriction causes 
 sloughing. The knots should always be tied well to 
 one side and not directly over the line of union (Fig. 
 
 cent, potassium iodide crystals, allowed to remain for eight days and 
 then transferred to a dry sterile jar covered with sterile gauze. 
 
3° - 
 
 MINOR AND EMERGENCY SURGERY 
 
 2).; otherwise they may become entangled in the 
 healing process and tend to re-open the wound when 
 removed. The contra-indications for the use of iodine 
 
 Fig. 
 
 Subcuticular suture introduced and tied. 
 
 catgut are the probability of prolonged sloughing and 
 great strain on the sutures, because the gradual ab- 
 
 FiG. 2. — a, Correct and b incorrect method of tying sutures. 
 
 sorption of the sutures weakens their support. It is 
 then prudent to re-inforce or replace them with 
 through-and-through silk or silkworm-gut sutures, 
 
ACCIDENTAL WOUNDS 31 
 
 Wounds of the lips, tongue and eyelids are best closed 
 with fine black silk, because of the cosmetic effect. 
 
 Extensive wounds or those accompanied by severe 
 contusion in which more or less sloughing seems likely 
 to ensue should be drained. The most satisfactory 
 material for this purpose is rubber tubing, except in 
 small wounds which may be drained by introducing 
 a little roll of gutta-percha tissue. Naturally, drain- 
 age should always be encouraged toward the most 
 dependent portion of the injured area. Position, 
 then, is an important factor. Plain sterile or 
 medicated gauze, particularly that impregnated with 
 iodoform, has been widely employed for drainage, 
 but careful observation will demonstrate that gauze 
 performs the function of a cork rather than of a drain. 
 It will rapidly absorb serum or pus until it is satu- 
 rated but will not promote drainage beyond that 
 point. For packing clean cavities, however, plain 
 gauze strips will be found exceedingly useful. 
 
 The best method of sterilizing a dirty woimd is 
 to inject tincture of iodine directly into it with an 
 ordinary medicine dropper, previous to tying the 
 sutures in the skin. Iodine is an agent of high 
 germicidal potency, endowed with remarkable pene- 
 trating power and one of the most satisfactory 
 and reliable antiseptics at our command. Even 
 when sloughing is imminent, the iodine will hasten 
 separation of the slough, limit the formation of pus, 
 and stimulate granulation. 
 
 The primary dressing of all wounds should con- 
 sist of several layers of sterile gauze saturated with 
 a liquid : water, solution of aluminum acetate, equal 
 
32 MINOR AND EMERGENCY SURGERY 
 
 parts of alcohol and witch hazel, etc. They are 
 best used lukewarm, as the continuous application 
 of extreme cold depresses the vitality of the parts. 
 Bichloride of mercury solutions have been more 
 or less universally employed for this purpose, but 
 they are inferior to others because they may excite 
 a dermatitis and may injure the surgeon's hands 
 after prolonged use. Contrary to the belief of 
 many, the bichloride does not entirely destroy 
 the bacteria but only coagulates the albumen of 
 the capsule. Far better results will be obtained 
 from the use of the above-mentioned agents, es- 
 pecially if used in conjimction with iodine. The 
 popular "carbolic wash" should never be used for 
 a wet dressing, as the solution itself is extremely 
 poisonous and carbolic gangrene often follows. 
 A wet dressing should always be bandaged with 
 gauze so that the whole may be moistened from 
 time to time. Glycerine is a valuable aid in keep- 
 ing the dressings wet, since its powerful hygro- 
 scopic powers promote drainage and hasten slough- 
 ing. The practice of covering gauze compresses 
 with gutta-percha tissue and bandaging with muslin 
 is unsatisfactory, because the moisture will evapo- 
 rate in spite of these precautions and then the 
 dressing cannot be soaked again without removal. 
 
 Although a great deal may be learned from the 
 text-book illustrations, bandaging is an art that 
 can be mastered by constant practice only. Ob- 
 servation of the following general principles will 
 prove useful: 
 
 Always "fix" the bandage at the start. 
 
ACCIDENTAL WOUNDS ^^ 
 
 Avoid wrinkles and creases as much as possible. 
 
 Be careful that the bandage fits smoothly and 
 snugly, yet does not constrict. 
 
 Always bandage from below upward; toward 
 the trunk. 
 
 Remember that a bandage that does not commence 
 at the fingers or toes tends to produce edema of 
 the uncovered part. 
 
 Never bury the end of a bandage applied to the 
 head, but leave it free so that it may be tied to 
 the other end. 
 
 A bandage that requires pins or adhesive plaster 
 to maintain its position has not been properly 
 applied. 
 
 Split or cut the free end of a bandage longitudi- 
 nally, tie a knot in it and this leaves two ends to 
 tie together. 
 
 Rest of the injured area, for self-evident reasons, 
 is of great importance, since motion and friction 
 disturb the continuous apposition of the wound 
 surfaces. Cases of severe wounds should be con- 
 fined to bed, particularly if accompanied by shock. 
 Usually the limited motion of the part occasioned 
 by the dressing is sufficient, although frequently 
 a splint will prove a valuable adjunct. When a 
 joint has been injured, the limb should be im- 
 mobilized in the position that will be most useful 
 to the patient in event of permanent stiffness. 
 
 Emergency treatment of wounds should consist of 
 those measures only that are absolutely essential 
 for the maintenance of favorable conditions, and 
 the permanent dressing should be deferred until 
 
 3 
 
34 MINOR AND EMERGENCY SURGERY 
 
 the procedures can be continued under rigid aseptic 
 circumstances. The arrest of hemorrhage, preven- 
 tion of swelling, removal of foreign material (pro- 
 vided it can be done quickly), exclusion of ad- 
 ditional foreign material and control of shock are 
 all that require immediate attention. The first 
 may be obtained by a clamp, tourniquet or the 
 pressure of the dressing; the second and fourth by 
 the moist gauze and the fifth by the usual remedial 
 agents for shock. Wounds of the abdomen from 
 which a loop of the intestine or the omentum pro- 
 trudes should be covered with gauze wrung out 
 in hot saline solution, and no effort to replace it 
 immediately should be made. 
 
 Passive hyperemia, after the method devised 
 by Bier, will often prove a useful adjunct in the 
 treatment of wounds, especially in those that have 
 become infected. It is best induced by several 
 superimposed layers of an Esmarch or Martin rub- 
 ber bandage. The constrictor should always be 
 applied proximally over the healthy tissue, should 
 never give rise to paresthesia or pain, and the 
 pulse should be perceptible below the constriction. 
 Dressings must be temporarily removed from the 
 wound and be replaced by loose sterile gauze, to 
 permit hyperemia. For further details and technic 
 the reader is referred to works on the subject. 
 
 After-treatment of Wounds. — Equal care in all 
 aseptic and antiseptic precautions should be exer- 
 cised throughout the after-treatment as when apply- 
 ing the primary dressing. The surgeon's hands, 
 instruments and dressings should be sterile. A 
 
ACCIDENTAL WOUNDS 35 
 
 simple and efficient technic of hand sterilization 
 consists of energetic scrubbing with green soap, 
 followed by immersion in a watery solution of 
 iodine ; a dram of the tincture to a pint of hot water. 
 The staining of the skin is inconsiderable and even 
 its prolonged use does not injure the hands in the 
 slightest. Iodine must not be used for the repeated 
 sterilization of steel instruments, because of its tar- 
 nishing action. They are satisfactorily sterilized by 
 boiling in a I per cent, solution of carbonate of soda. 
 The gauze compresses, bandages, etc., should, of 
 course, be previously sterilized by compressed steam. 
 All dressings should be kept wet for at least three 
 days. If there are then no evidences of sloughing or 
 pus formation, dry sterile gauze is all that will be 
 required. A neat dressing for small clean wounds 
 consists of little sterile cotton painted and fastened 
 down with collodion, but, as it does not provide for 
 the absorption of wound secretion, it should be 
 used only in clean cases in which hemostasis has 
 been exact. The appearance of heat, redness and 
 swelling denotes pus formation and is indication for 
 the immediate removal of one or more sutures and 
 the institution of drainage. The body temperature 
 is also a reliable index of the condition of the wound. 
 Tincture of iodine should be dropped along the line 
 of union, and under it if the wound is being drained, 
 at each dressing. If the granulating process is slug- 
 gish, sprinkling the surface with powdered naphtha- 
 lin crystals and applications of balsam of Peru will 
 hasten it. When healing is markedly retarded with- 
 out some apparent cause, it is often due to diabetes. 
 
36 MINOR AND EMERGENCY SURGERY 
 
 The many dusting powders on the market are of 
 little practical value; they are expensive, but 
 feebly antiseptic and make a paste with the serum 
 that exudes from the wound, thus causing the gauze 
 to adhere to the line of union. Rarely, if ever, will 
 a dusting powder destroy pyogenic organisms and 
 prevent pus formation. Iodoform has been exten- 
 sively employed as a dusting powder and incorpo- 
 rated in gauze, although it possesses but few of the 
 virtues of the tincture of iodine. It liberates but a 
 miinute quantity of iodine, its odor is disagreeable 
 and iodism frequently follows its use. 
 
 Contused wounds are the most common of all 
 wounds encountered in surgical practice. They are 
 accompanied by more or less pain, swelling and dis- 
 coloration of the skin. Although they may appear 
 insignificant at first, sloughing of the soft parts may 
 subsequently occur, even though the skin is not 
 visibly broken. This may be due to hematogenous 
 infection or occur externally through a minute fissure 
 in the skin. It should not be forgotten that slough- 
 ing may extend into a large blood-vessel and give 
 rise to secondary hemorrhage. A hematoma usu- 
 ally forms, which eventually terminates in either 
 absorption or purulent resolution. Diligent search 
 should always be made for fracture of underlying 
 bones. The appearance of a contused wound of the 
 scalp is often misleading, because of the circum- 
 scribed swelling with a central depression, known as 
 ' ' Pott ' s puffy tumor . ' ' Should accompanying symp- 
 toms of cerebral concussion exist, the condition may 
 closely resemble fracture of the skull, and manifestly 
 
ACCIDENTAL WOUNDS ^^ 
 
 the reverse is true. Contused wounds of the abdo- 
 men should be kept under close observation for at 
 least a week, for if severe they nearly always show 
 shock early and internal hemorrhage or rupture of a 
 viscus may occur at any time. The apparent absence 
 of damage to the skin does not necessarily exclude 
 internal injury. Rupture of a solid viscus or of the 
 omentum generally results in internal hemorrhage; 
 perforation of a hollow viscus is invariably followed 
 by peritonitis. Likewise, a blow may produce sub- 
 mucous hemorrhage and subsequently ulcer of the 
 stomach or intestine. Increasing rapidity of the 
 pulse is characteristic of rupture and no patient 
 should be considered out of danger if the pulse is 
 rapid. When injury to the bladder or urethra is 
 suspected, the gentle passing of a soft-rubber catheter 
 will help to clear up the diagnosis. A contusion may 
 cause a bursitis, arthritis, periostitis or osteomyelitis. 
 A tubercular process is particularly likely to be 
 excited by a contusion, especially in a joint. 
 
 Contused wounds should be dressed immediately 
 with gauze saturated with water, aluminum acetate 
 solution or lead and opium wash. This will tend to 
 prevent swelling, limit subcutaneous oozing, allay 
 pain, favor drainage and promote absorption of the 
 effusion. An ice bag should be applied to severe 
 contusions about the head, especially if accompanied 
 by concussion. When sound teeth are knocked out, 
 they should be replaced in their sockets, as re-attach- 
 ment is often possible. Proper position may be 
 maintained by fastening them to adjacent teeth 
 with silver wire or silk. The accumulation of blood 
 
38 , MINOR AND EMERGENCY SURGERY 
 
 under the nail following a contusion is often ex- 
 tremely painful ; the cuticle overlapping the base of 
 the nail should be gently lifted with a sharp knife and 
 the blood squeezed out. A bursitis or synovitis with 
 effusion of serum or synovial fluid should be aspirated 
 under rigid aseptic precautions. 
 
 The slightest sign of pus under the skin after a con- 
 tusion warrants incision at once. If the sloughing is 
 at all extensive, counter-openings should be made by 
 introducing a long dressing forceps closed and incising 
 the skin which is made prominent by the tip. One or 
 more fenestrated rubber drainage tubes of convenient 
 size may then be inserted by opening the jaws of the 
 forceps, grasping one end of the tube and withdraw- 
 ing the forceps. Proper position may be maintained 
 by fastening each end with a sterile. safety pin. The 
 incisions should always be made parallel to the course 
 of the blood-vessels, and never at right angles (Fig. 
 3). The extent of drainage will depend upon the 
 amount of sloughing, and the length of the tubes may 
 be diminished as desired. The necrotic tissue should 
 be excised at each dressing and the wound irrigated 
 through the drainage tubes by means of a fountain 
 syringe or a Valentine irrigator with peroxide, fol- 
 lowed by an iodine solution : a dram of the tincture 
 to a pint of water. A Davidson syringe should not 
 be used because the pressure exerted cannot be 
 accurately gauged. The appearance of bleeding de- 
 notes the cessation of necrosis and the beginning of 
 granulation. These wounds necessarily close from 
 below upward, so care should be taken that the 
 skin margins do not close primarily and thus obstruct 
 
ACCIDENTAL WOUNDS 
 
 39 
 
 drainage. Dead skin should be scraped off with 
 a dull knife or gauze saturated with alcohol. De- 
 struction of the arterial supply with necrosis of bone 
 indicates amputation. The surgeon should be con- 
 stantly on the alert for intra-abdominal complications 
 following contused wounds of the abdomen. Con- 
 
 FlG. 3. — a. Incisions for drainage tubes made correctly; b, incisions for 
 drainage tubes made incorrectly. 
 
 cealed hemorrhage or perforation of a viscus ne- 
 cessitates immediate abdominal section, unless the 
 patient is moribund. 
 
 Lacerated wounds are due to semi-sharp trau- 
 matism or to a tearing force. Avulsion of a portion 
 of a limb or complete tearing off of the scalp may oc- 
 
40 
 
 MINOR AND EMERGENCY SURGERY 
 
 cur as the result of machinery and railroad accidents, 
 but fortimately such extensive lacerations are ex- 
 ceptional. The usual picture presenting is a long 
 jagged wound, bleeding freely and contaminated by 
 hair, dirt and other foreign material. They should 
 be especially examined for severed tendons. A 
 fissure fracture of the skull should be searched for in 
 
 Fig. 4. — Silkworm-gut strands introduced for drainage. 
 
 all lacerated wounds of the scalp. Always remember 
 that a normal skull suture can be wiped clean, 
 whereas the red line of a fracture cannot be elimi- 
 nated. 
 
 Simple lacerated wounds should be treated on 
 general principles. Turpentine and benzine are ex- 
 cellent agents for dissolving the grease that is often 
 found smearing the tissues. Surprisingly good re- 
 
ACCIDENTAL WOUNDS 41 
 
 suits are frequently obtained in cases of avulsion of 
 the scalp, due largely to its vascularity. These are 
 ideal cases for the transplantation of skin flaps. 
 Thorough removal of all hair from a scalp wound and 
 the surrounding skin is of great importance. A 
 simple and efficient method of draining an extensive 
 scalp wound consists of inserting a number of strands 
 of silkworm gut lengthwise before tying the sutures. 
 (Fig. 4). Continuous warm irrigation is especially 
 applicable to severe lacerated wounds of the ex- 
 tremities. Avulsion of a limb is almost synonymous 
 with a traiunatic amputation and will not be con- 
 sidered here. 
 
 Lacerated wounds properly dressed at first will re- 
 quire but little after-treatment. Skin sutures should 
 be removed on the eighth day, if of non-absorbable 
 material. They should be gently lifted on one side 
 and snipped with scissors close to the skin, to avoid 
 dragging anything through the stitch hole that has 
 been outside the skin (Fig. 5). 
 
 Incised wounds are due to sharp-edged bodies en- 
 tering the tissues. They are frequently deeper than 
 their superficial appearance indicates, since they gap 
 very little ; the integrity of the underlying structures 
 should, therefore, be carefully investigated. Incised 
 scalp wounds bleed freely because the density of the 
 scalp retards retraction of the blood-vessels. A 
 frequently occurring type of incised wound is cut- 
 throat. In these cases the position of the carotid 
 arteries is such that they escape injury as a rule and 
 the greatest danger is not hemorrhage but sepsis. 
 Attempt at suicide is generally made between the 
 
42 
 
 MINOR AND EMERGENCY SURGERY 
 
 hyoid bone and the thyroid cartilage, and pneu- 
 monia is a common sequel. 
 
 Incised woimds usually heal by primary union and 
 it is safe to permit this, provided that iodine is used. 
 It will not be amiss to repeat that severed important 
 structures should be accurately approximated, as it 
 is a source of great mortification for the surgeon to 
 find that certain muscles are useless after a wound 
 
 Fig. 5. — a, Correct and h incorrect method of removing sutures. 
 
 has entirely closed. A cut-throat should never be 
 sutured tightly; first, because of the danger of sepsis, 
 and secondly, because the retained extravasation 
 may press upon, or enter if injured, the trachea, thus 
 asphyxiating the patient. The head should be 
 strongly flexed so that position may favor recovery. 
 The dressings should be kept hot and moist to prevent 
 the entrance of cold air and septic matter, thus guard- 
 
ACCIDENTAL WOUNDS 
 
 43 
 
 ing against pneiimonia. Food and stimulation may- 
 be administered by rectal enemata. 
 
 Punctured wounds are due to pointed objects 
 entering the tissues to a variable depth, are apt to 
 injure important structures and, if penetrating a 
 cavity, infection and suppuration are likely to result. 
 Part of the object inflicting the injury may break 
 off, leaving a foreign body in the woimd. A person 
 falling from a height may strike upon some pointed 
 object, impaling a portion of the body. Penetrat- 
 ing wounds are to be distinguished from perforating 
 wounds; the former enter a cavity, while the latter 
 enter as well some organ or viscus within the cavity. 
 It is obvious that punctured wormds should be care- 
 fully scrutinized for the integrity of the subjacent 
 important structures and for foreign bodies. Pleurisy 
 and pneumonia not infrequently follow punctured 
 wounds of the chest, hence the necessity for keeping 
 these cases under close observation. Penetrating 
 wounds of the abdomen may gap sufficiently to allow 
 protrusion of the omentum, intestines or other vis- 
 cera, and are sometimes sufficiently extensive to 
 permit an almost complete evisceration. Naturally, 
 there is profound shock therewith, and great danger 
 of hemorrhage, infection and injury to the viscera. 
 
 All ptmctured wounds should be drained. If a for- 
 eign body remains in the woimd, it will usually be 
 necessary to enlarge it to permit extraction. A 
 wound communicating with a joint must never be 
 entirely closed, owing to the rapidity with which 
 synovial membrane absorbs toxic material. The 
 danger of sepsis is too great to justify an effort to 
 
44 . MINOR AND EMERGENCY SURGERY 
 
 secure primary union. Every punctured wound of 
 the peritoneal cavity demands immediate exploratory 
 laparotomy. Don't wait for symptoms of perfora- 
 tion or internal hemorrhage before opening the 
 abdomen. 
 
 Poisoned wounds are due to infection through an 
 abrasion of the skin or through the sweat or sebaceous 
 glands and are particularly likely to result from con- 
 ducting dissections and post-mortem examinations. 
 The usual picture presenting is that of cellulitis, and 
 later septicemia. The stings of insects and the 
 bites of snakes and animals may introduce a special 
 poison into the economy, and here the symptoms are 
 those of the poison plus cellulitis. Poisoned wounds 
 due to micro-organisms are commonly termed in- 
 fected wounds. The treatment may be summed up 
 in five words: incision, evacuation, iodine, drainage 
 and wet dressing. The treatment of infected wounds 
 with vaccines, based on the opsonic theory of Wright, 
 has yielded but poor results in the author's experience. 
 Somewhat better results, however, have been ob- 
 tained from the use of autogenous vaccines than 
 from stock preparations. Poisoned wounds due to 
 other toxic substances also require prompt incision 
 and drainage. The wound should be shut off from 
 the general circulation by means of a ligature and 
 bleeding is to be encouraged, to prevent the absorption 
 of toxic material. Snake bites are best treated by 
 excision of the wotmd and potassium premanganate 
 dressings. Patients bitten by a rabid animal should 
 be referred to a Pasteur institute, after cauterizing 
 the wound with carbolic acid and alcohol or the acttial 
 
ACCIDENTAL WOUNDS 45 
 
 cautery. A nutritious diet and tonics in full doses 
 should be given in all cases of poisoned wounds. 
 
 Gunshot wounds are due to the explosion of gun- 
 powder, nitroglycerine, dynamite and other power- 
 ful explosives. The wound itself may be produced 
 by powder, wadding, lead or steel bullets, or other 
 missiles. Blank cartridge wounds are particularly 
 dangerous because of the frequent development of 
 tetanus. If a fire-arm is discharged at short range, 
 particles of unburned powder may be driven into the 
 skin. These, however, are of little consequence in 
 themselves, unless on the face where the cosmetic 
 effect is of considerable importance. Needless to 
 say, even a single grain of powder may severely 
 injure the eye. A gunshot wound may have but a 
 single aperture, the edges of which are inverted, or, if 
 the missle emerges, a wound of exit also, the edges of 
 which are everted. The presence of one or more 
 wounds will, as a rule, indicate whether or not the for- 
 eign body remains in the tissues. A bullet is likely 
 to be deflected from its apparent course by striking 
 firm tissues, cartilage or bone. In simple bullet 
 wounds, the heat generated by the passage of the 
 projectile is sufficient to sterilize the tract so that 
 infection is not common except in the peritoneal 
 cavity. The amount of contusion of the soft parts 
 will vary inversely with the velocity of the bullet; 
 the slower the bullet travels the greater will be the 
 contusion and laceration. The resistance of the 
 parts decreases the speed of the projectile consider- 
 ably, so that there is generally more destruction of 
 tissue at the wound of exit than at the point of 
 
46^ MINOR AND EMERGENCY SURGERY 
 
 entrance. If the bullet is still within the body, its 
 exact location should be determined as accurately 
 as possible without inflicting further damage upon 
 the injured parts. Inspection, palpation and the 
 :v;-ray may be safely employed for this purpose, but 
 rough probing and blind dissection are harmful 
 and imjustifiable. When a large blood-vessel that 
 cannot be reached easily has been injured, enlarge- 
 ment of the wound to control hemorrhage is indi- 
 cated. A bullet may lie deeply imbedded in the 
 tissues for years without giving rise to any annoying 
 symptoms. In general, gunshot wounds may be con- 
 sidered as differing but slightly from contused and 
 lacerated wounds and compound factures. The 
 severity of the damage sustained by the tissues may 
 vary from an insignificant sterile wound, requiring 
 little or no attention, to the destruction of a large 
 area, necessitating amputation of an entire limb. 
 In severe gunshot wounds, as in other extensive 
 injuries, there is profound shock. 
 
 Powder grains beneath the skin should be picked 
 out with a needle or sharp bistoury or scrubbed out 
 with a stiff brush -under anesthesia as soon as pos- 
 sible, because the longer they are allowed to remain 
 the more pronounced will be the resulting indelible 
 blue stain. All cases of gunshot wotmds contami- 
 nated with soil and all blank cartridge wounds 
 should receive an immunizing dose of tetanus anti- 
 toxine. An effort to save all tissue not entirely 
 destroyed should be made, and the recuperating 
 power of a part will vary in direct proportion to its 
 blood supply. A bullet deeply imbedded in the 
 
ACCIDENTAL WOUNDS 47 
 
 tissues should be accurately located with the x-ray. 
 Its subsequent removal will then depend upon the 
 situation of the bullet, the amount of damage it 
 has inflicted and the patient's condition. In every 
 bullet wound of the abdomen immediate exploratory 
 laparotomy is imperative, unless it is positive that 
 the peritoneal cavity has not been entered, for the 
 mesentery, intestine, stomach, bladder or some other 
 important structure is almost invariably injured. 
 The entire cavity and its contents should be explored 
 to assure that no perforations are overlooked. 
 
CHAPTER III. 
 TRAUMATIC INJURIES OF JOINTS. 
 
 Those inflammations resulting from joint injuries 
 depend upon the nature and severity of the inflicting 
 violence and the location sustaining the damage. 
 As a inile, low grade inflammations, such as osteo- 
 arthritis and arthritis deformans, result from disease 
 rather than traumatism, and a constitutional di- 
 athesis should therefore always be accorded due 
 consideration. So-called "hysterical joints" are 
 often the source of serious error and should be 
 excluded. In such instances, the patient is of a 
 hysterical or neurotic temperament, the skin is more 
 sensitive to pressure than the underlying parts, char- 
 acteristic attitude is lacking and although the patient 
 will state that the joint cannot be moved, he will 
 move it unconsciously. Mensuration and compari- 
 son with the joint on the opposite side are valuable 
 aids in the examination of joints. In all joint in- 
 flammations muscular rigidity causes an apparent 
 loss of motion far beyond what is absolutely present. 
 This condition must be differentiated from ankylosis, 
 but since anesthesia will dissipate muscular rigidity, 
 the diagnosis is easy. True joint crepitus depends 
 almost entirely for its existence upon roughness of 
 the articular cartilages. Crepitus is always absent 
 in complete disorganization. 
 
 48 
 
TRAUMATIC INJURIES OF JOINTS 49 
 
 BURSITIS. 
 
 Bursas are distinct sacs but sometimes communi- 
 cate with joints. The types of bursitis from a 
 clinical view-point are: (i) serous, (2) suppurative, 
 (3) chronic, (4) tubercular and (5) syphilitic. 
 Although any of the normal or anomalous bursas 
 m.ay be subjected to direct violence, bursitis is 
 most frequently observed in front of the patella 
 (housemaid's knee), behind the olecranon process, 
 and over the great toe (bunion) , 
 
 Simple serous bursitis is best treated with rest 
 of the part, coimter-irritation and the ice bag. The 
 bursa may be aspirated and pressure exerted by 
 the application of an elastic bandage. If these 
 m.easures fail to cure, complete excision of the 
 bursa is indicated. 
 
 Prepatellar bursitis is frequently suppurative, 
 and unless speedily drained the pus quickly invades 
 the cellular tissues. If the infection is still lirnited 
 to the bursa itself, incision, drainage and packing 
 the cavity with gauze may effect a cure, as ad- 
 hesions rapidly obliterate the sac. Not infrequently, 
 however, it will be necessary to dissect out the 
 bursa and drain. 
 
 Chronic serous bursitis can often be cured by 
 tapping and afterwards injecting equal parts of 
 carbolic acid and tincture of iodine. Tubercular 
 and syphilitic bursae require excision. Great care 
 should be exercised that the adjacent joint is not 
 opened. 
 
 In the treatment of bimion, it will often be a 
 4 
 
50 MINOR AND EMERGENCY SURGERY 
 
 great temptation to temporize with circular felt 
 or plaster shields, or to incise and drain the joint. 
 These measures do not entirely relieve the con- 
 dition, and removal of the thickened outer condyle 
 of the metatarsal bone is essential to complete cure. 
 An incision should be made between the great toe 
 and the next one, and the phalanx dislocated. 
 The head of the metatarsal bone may now be re- 
 sected from the inside, thus obviating a lateral 
 scar to rub on the patient's shoe. 
 
 TRAUMATIC SYNOVITIS. 
 
 This condition usually begins as an acute infec- 
 tion, although chronic synovitis frequently occurs 
 as the result of an uncured acute inflammation. 
 The joint fills up with serum a few hours after the 
 injury, there being but slight local heat and pain 
 (aggravated by pressure or forced motion), while 
 redness is never present. The swelling is always 
 more pronounced where the protection of the 
 muscles and other tissues is least. When the 
 synovitis has persisted for a considerable length of 
 time, the patient will experience a sense of weakness 
 and insecurity in the joint, accompanied by more 
 or less limitation of motion and muscular atrophy. 
 The prognosis is excellent, except in debilitated 
 subjects in whom it occasionally terminates in sup- 
 puration. 
 
 The treatment is simple. A snug dressing of 
 lead and opium wash, covered with an ice bag, 
 and the placing of the joint at rest temporarily by 
 means of an elastic bandage, adhesive straps or 
 
TRAUMATIC INJURIES OF JOINTS 51 
 
 splints are usually sufficient to effect restoration 
 of function and a complete cure in a few days. 
 In the more severe and prolonged cases it will be 
 necessary to aspirate the effusion under rigid aseptic 
 precautions and follow with fixation of the joint 
 and counter-irritation. Rarely, incision and drain- 
 age of the joint are required to relieve a suppura- 
 tive process. Passive motion, massage and hot air 
 baths are useful adjuvants in the after-treatment. 
 
 TRAUMATIC ARTHRITIS. 
 
 Acute arthritis is a simultaneous inflammatory 
 involvement of all the structures comprising a 
 joint, and with few exceptions is due to pyogenic 
 organisms, introduced through an open wound. 
 It may begin as a purulent synovitis or may involve 
 the entire joint primarily. Likewise, it may occur 
 secondarily to an acute osteomyelitis. The syno- 
 vial membrane becomes succulent, the quantity 
 of synovial fluid is rapidly increased, the cartilages 
 necrose and erode and the ligaments soften. Un- 
 less drainage is immediately instituted, the capsule 
 may perforate and the pus peiTQeate the bone and 
 soft structures above and below the joint. The 
 pain and tenderness are far greater than in synovitis 
 and all the manifestations of a local and general 
 septic process soon present themselves. Grating 
 on motion may or may not be present, depending 
 upon the degree of fixation of the joint occasioned 
 by the rigidity of the adjacent muscles. 
 
 Since a peri-articular pyemic inflammation may 
 simulate a true arthritis, it is wise to aspirate the 
 
"52 MINOR AND EMERGENCY SURGERY 
 
 joint for diagnostic confirmation. Until the diagno- 
 sis is definitely established, a splint and ice bag 
 may be employed. 
 
 Early and prompt incisions and through-and- 
 through drainage are imperative. The drainage 
 tubes should be run through the joint from one side 
 to the other and must be frequently irrigated with 
 physiological saline solution ; twice daily is none too 
 often. It is advisable to avoid antiseptic solutions, 
 because they may aggravate the inflammation, 
 thereby predisposing to a resulting ankylosis. To 
 irrigate the tubes conveniently, the hard-rubber tip 
 of a Davidson syringe may be inserted in one end of 
 the drainage tube and the fluid forced through into 
 a suitable receptacle. During the intervals between 
 the irrigations the joint should be immobilized 
 and enveloped in a generous wet dressing. If 
 these measures fail to arrest the septic process, 
 the joint must be resected or the limb amputated. 
 
 SPRAINS. 
 
 A sprain is a violent straining, separation of the 
 fibers, or rupture of one or more ligaments of a 
 joint without permanent displacement of bone. 
 Sprains are usually due to a wrench or twist and are 
 most common at the ankle and wrist. Not in- 
 frequently a small piece of bone is torn off and the 
 injury is then termed a sprain-fracture; these are 
 the cases that are most often followed by ankylosis. 
 Although apparently trivial as a rule, they should 
 never be neglected and should receive a gentle 
 but thorough and careful examination, because 
 
TRAUMATIC INJURIES OF JOINTS 53 
 
 of the danger of confusion with separation of the 
 epiphysis (in children), dislocation and fracture. 
 The nature of the case is often obscured by the 
 swelling that is rapidly produced by the effusion 
 of blood and serum into the joint and adjacent 
 tissues. An anesthetic should be administered 
 or an :r-ray examination made, rather than an 
 error in diagnosis committed. Laceration or rup- 
 ture of tendons near the site of injury must not be 
 overlooked, as they are usually responsible for 
 delayed restoration of function and may seriously 
 cripple the joint thereafter. Rupture of muscular 
 or tendinous fibers of the muscles of the back is 
 often referred to as a "sprained back" and occurs 
 in consequence of a severe strain from lifting heavy 
 weights, or extreme pressure exerted thereon. A 
 stretching of the annular ligament of the wrist 
 causes a weakness at the joint and is often spoken 
 of as a sprain. Unless every sprain is accorded 
 adequate attention and is treated properly, im- 
 pairment of function, permanent stiffness, teno- 
 synovitis and even joint disease may result. 
 
 Emergency treatment of sprains will depend upon 
 the severity of the injury and the degree of swelling 
 already present. If the sprain is a mild one and 
 is seen early before there is much subcutaneous 
 effusion, it is best treated from the beginning by 
 daily gentle massage, especially over the areas 
 immediately above and below the tender and in- 
 flamed joint. After each seance a wet dressing, 
 preferably of lead and opium wash or aluminum 
 acetate, should be applied and use of the joint 
 
54 
 
 MINOR AND EMERGENCY SURGERY 
 
 should be encouraged. The exception to this 
 generalization is a recent sprain of the ankle which, 
 in the absence of swelling, should be strapped with 
 strips of adhesive plaster in the manner recom- 
 mended by Gibney and Cotterell (Fig. 6), and the 
 whole covered with a snugly fitting gauze bandage. 
 
 Fig. 6. — Strapping of sprained ankle-joint. 
 
 With this dressing properly applied, the patient 
 may be permitted to walk upon the foot. Before 
 applying the adhesive straps the leg should be 
 shaved and wiped dry and the foot held in proper 
 position by an assistant (the foot should be ducted 
 toward the sprained side). One and a half inch 
 wide strips of adhesive plaster are criss-crossed at 
 
TRAUMATIC INJURIES OF JOINTS 55 
 
 right angles until the entire joint has been covered. 
 The first starts two-thirds up the leg on one side, 
 close to the tendo Achilles, crosses the sole of the 
 heel and terminates two-thirds up the other side 
 of the leg. The next begins at the base of the 
 little toe on the dorsal surface of the foot, passes 
 around the posterior aspect of the heel and ends 
 at the base of the great toe. Additional strips are 
 applied alternately in like manner, each one just 
 overlapping the previous one, until the ankle-joint 
 is completely included. A single circular strap 
 is then placed above the malleoli and another at 
 the upper limit of the straps on the leg. This 
 dressing should be left undisturbed for ten days. 
 To faciliate painless removal of the adhesive plaster, 
 it may be saturated with oil of wintergreen or gaso- 
 line. If there is considerable extravasation when 
 first seen, the Gibney strapping should be deferred 
 until the swelling has subsided. 
 
 Sprains of a more severe character require the 
 prevention or reduction of swelling and immobiliza- 
 tion. The first may be secured by the use of hot, 
 cold or anodyne applications and pressure; the 
 second by a sling, splint or plaster-of -Paris bandage. 
 If seen before much effusion has occurred, the plaster- 
 of-Paris bandage may be applied at once, but it 
 should never be used in the presence of any great 
 degree of distention of the joint. If much time has 
 elapsed and the joint is swollen, a cooling applica- 
 tion should be applied on gauze, covered with an 
 elastic bandage, and the limb placed in a sling or 
 supported by a splint. 
 
56 
 
 MINOR AND EMERGENCY SURGERY 
 
 A " sprained back" should be strapped from below 
 upward with strips of adhesive plaster two inches 
 wide, from the third sacral vertebra to the level of the 
 first lumbar vertebra (Fig. 7). 
 
 After-treatment of Sprains. — Mild cases are best 
 treated by daily massage and passive motion, being 
 
 Fig. 7. — -Strapping a sprained back. 
 
 supported during the intervals without restricting 
 motion to such an extent that the joint cannot be 
 used. The lack of power in the wrist due to stretch- 
 ing of the annular ligament is best overcome by 
 supporting it with a circular leather strap. 
 
 Severe cases demand complete rest and constant 
 
TRAUMATIC INJURIES OF JOINTS 57 
 
 wet dressings until the greater part of the effusion has 
 been absorbed and all swelling has disappeared, when 
 gentle massage, passive motion and gradual use of 
 the joint may be introduced. These efforts, however, 
 should never be of sufficient force to cause pain. The 
 faradic and galvanic currents and superheated air 
 will also be found excellent aids, particularly if there 
 is atrophy of the muscles. Usually five or six weeks 
 elapse before there is complete restoration of function. 
 After exceptionally severe sprains, the formation of 
 firm adhesions will occasionally so retard the progress 
 that it will be nesessary to break them up forcibly 
 imder an anesthetic. 
 
 DISLOCATIONS. 
 
 A dislocation is a displacement of the articular 
 surfaces of the bones entering into the formation of 
 a joint, accompanied by rupture of the joint capsule, 
 which bones tend to retain an unnatural position. 
 Congenital dislocations and pathological dislocations 
 due to disease are not within the scope of this chapter 
 and tra-umatic dislocations only will be considered. 
 They are usually due to indirect violence and occur 
 most frequently at the shoulder-joint. The capsule 
 of the joint is necessarily always ruptured and if the 
 force exerted is sufficient, tendons, muscles, nerves, 
 blood-vessels and even the skin may be bruised or 
 torn. In general, we may expect to find tenderness, 
 swelling, shortening, deformity at the joint with pro- 
 jection of the extremity of one or more bones, more 
 or less reflex muscular rigidity and an unatural po- 
 sition of the limb, assumed involuntarily. 
 
58- MINOR AND EMERGENCY SURGERY 
 
 Examination of Dislocations. — A dislocation may be 
 simple or com.pound, or complicated by fracture of 
 either the articular surface or the shaft of one or 
 more bones. The existing pathological condition 
 should be exactly determined before any attempt at 
 reduction is made. Otherwise, irreparable harm, 
 such as permanent deformity, neiuitis, local paraly- 
 sis, muscular atrophy, adhesion of blood-vessels and 
 nerves to bone and even complete ankylosis, may 
 result from the surgeon's misdirected efforts. Recent 
 dislocations should be differentiated from ancient 
 dislocations. The latter are often misleading be- 
 cause the joint cavity may be entirely obliterated by 
 adhesions and they often present a spurious form of 
 crepitus, due to organized effusion in the surrounding 
 tissues. The limb may atrophy from lack of use and 
 if the injury is neglected for a sufficiently long time, 
 a false joint not infrequently results. If the first 
 attempt at reduction fails, palpation under anes- 
 thesia and the r^c-ray should always be employed to 
 establish positively an accurate diagnosis and fa- 
 cilitate manipulation. It is of the utmost importance 
 to note whether or not the head of the bone rotates 
 with the shaft; if it does not, there is probably a 
 fracture near the epiphysis. In the presence of an 
 impacted fracture of the neck of the bone, however, 
 the head will rotate with the shaft. 
 
 Dislocations of the jaw should not be confounded 
 with a fracture at the neck of the condyle. In 
 fracture there is mobility, while a dislocation is im- 
 mobile. 
 
 Dislocations at the shoulder- joint are the most 
 
TRAUMATIC INJURIES OF JOINTS 59 
 
 common of all, and the proximity of the brachial 
 vessels and nerves renders a correct diagnosis of 
 special importance. In subcoracoid dislocation the 
 elbow cannot be made to touch the side of the chest, 
 with the hand on the opposite shoulder ; while if the 
 fingers cannot touch the space beneath the acromion 
 process, a fracture has probably occurred. A dis- 
 location does not tend to recur after reduction. In 
 most fractures it is extremely difficult to maintain 
 proper position of the fragments. In subclavicular 
 and subglenoid dislocations there is more abduction 
 of the arm and more tension on the skin. Sub- 
 acromial and subspinous dislocations are posterior 
 displacements and the position assumed by the arm 
 is the reverse of anterior dislocations : adduction and 
 inward rotation. Luxatio erecta and supracoracoid 
 dislocations are extremely rare and easily reduced. 
 
 Dislocations at the elbow are more common in 
 early life and the diagnosis is usually easy. There 
 may be backward dislocation of the radius and 
 ulna, forward dislocation of the radius and ulna 
 (usually complicated by fracture of the olecranon), 
 lateral dislocations, or dislocation of the radius for- 
 ward (commonly associated with fracture of the 
 ulna) . 
 
 Backward dislocations of the thumb are often 
 complicated by the anterior ligament or the flexor 
 tendons slipping between the two bones and are 
 then extremely difficult to reduce. 
 
 Dislocations of the hip are relatively uncommon, 
 but it is important to distinguish between dorsal 
 and anterior dislocations. In dorsal, or posterior. 
 
6o MINOR AND EMERGENCY SURGERY 
 
 dislocations there is flexion, adduction, inversion, 
 shortening, and the head of the femur lies above 
 Nelaton's line. These symptoms are more marked 
 in dislocations on the ilium than when the head of 
 the bone lies in the sciatic notch. Anterior dislo- 
 cations are either pubic or obturator (thyroid). 
 In the former the thigh is abducted and everted, 
 the hip is flattened and the prominence of the 
 great trochanter disappears, and there is some 
 shortening. In the latter variety there is also 
 flattening and aversion, but there is lengthening 
 instead of shortening. In all anterior dislocations 
 of the thigh the legs cannot be approximated. 
 Dislocations are easily differentiated from fractures 
 in this region, but the possibility of a fracture occur- 
 ring simultaneously should be borne in mind. In such 
 instances it is better to consider the injury as a frac- 
 ture than as a dislocation, as attempts to reduce the 
 dislocation usually fail. Supracotyloid, infracoty- 
 loid and perineal dislocations are anomalous va- 
 rieties, occurring very rarely and are reduced with- 
 out difficulty. 
 
 Treatment of Dislocations. — ^Having established the 
 diagnosis of a dislocation, the treatment should be 
 instituted promptly, as a profuse extravasation of 
 serum and blood into the injured area, which 
 increases as time elapses, may seriously interfere 
 with our efforts at reduction and complicate the 
 result. The treatment may be said to consist of: 
 (i) reduction (restitution of the displaced parts to 
 their normal relationship) , (2) retention (prevention 
 of recurrence), and (3) restoration of function. The 
 
TRAUMATIC INJURIES OF JOINTS 6i 
 
 first maysbe accomplished by manipulation, manipu- 
 lation plus anesthesia, extension and counter- 
 extension, or arthrotomy ; the second by the appli- 
 cation of a suitable dressing, firmly fixing the parts 
 in their normal position ; and the third by massage, 
 passive motion, hot air and electricity. 
 
 Simple forcible manipulations are quite often 
 sufficient to effect a complete reduction, but when 
 the first attempt fails recourse to other methods 
 should be considered. The obstacles to reduction 
 usually encountered are : (i) reflex muscular rigidity, 
 (2) voluntary muscular opposition, (3) a small rent 
 in the capsule and (4) interposition of a fragment of 
 the capsule, nerves, fascia, or some other soft struc- 
 ture. Of these, muscular rigidity is the most 
 common and may easily be eliminated by general 
 anesthesia, pushed to complete muscular relaxa- 
 tion. Ether is the safest anesthetic for this 
 purpose. The relaxation afforded by the first stage 
 of anesthesia may seem sufficient to permit reduc- 
 tion, but it must be remembered that the patient 
 will still be conscious of the pain produced by the 
 manipulations and dangerous shock may be occa- 
 sioned thereby. Manifestly, it is better to wait 
 for complete surgical anesthesia. Extension and 
 counter-extension by means of weights, pulleys, the 
 Spanish windlass, etc., have been advocated by 
 some surgeons as a satisfactory method of enforcing 
 reduction, but with the exception of gradual traction, 
 the danger of injury to the soft parts is so great 
 under such circumstances that the risk is not 
 worth the attempt. Serious laceration or rupture of 
 
62 HI I NOR AND EMERGENCY SURGERY 
 
 the soft structures not infrequently follows, because 
 the force exerted cannot be accurately estimated. 
 When a small rent in the capsule or the interposition 
 of soft parts interferes with proper reduction, or a 
 blood-vessel or nerve has been ruptured, an open 
 arthrotomy at the earliest possible moment is the 
 desirable procedure. No surgical operation should 
 be performed under more rigid aseptic circumstances 
 than an arthrotomy, because of the susceptibility of 
 all synovial membranes to infection. Having opened 
 the joint, temporary enlargement of the rent in the 
 capsule and reposition of the articular surfaces are 
 easy. Severed arteries, veins and nerves should be 
 carefully ligated or sutured in the usual manner. 
 Ancient dislocations nearly always require an anes- 
 thetic in order that the adhesions may be broken up 
 before the attempt to effect reduction is made. Gen- 
 erally, however, an open operation is to be preferred 
 because the danger of laceration of the displaced 
 stuctures is otherwise so great, owing to their changed 
 relations. Complicated dislocations should also re- 
 ceive the benefit of accurate manipulation, afforded 
 by an arthrotomy only. 
 
 Having effected a satisfactory reduction, recur- 
 rence of the dislocation may be prevented by means 
 of a firm dressing fixing the parts in their normal, 
 positions. This may consist of a bandage or 
 plaster-of -Paris support, superimposed upon a wet 
 dressing if there is much effusion. 
 
 Torn ligaments usually heal in about three weeks 
 and it is then safe to commence massage and pas- 
 sive motion. They should preferably be carried 
 
TRAUMATIC INJURIES OF JOINTS 63 
 
 out by the surgeon, in order that the daily dose 
 may be regulated satisfactorily. Applications of 
 the faradic current will also be found a valuable 
 aid in these conditions. 
 
 A displaced coccyx with resulting coccygodynia 
 is an exceedingly painful and annoying condition; 
 coccygectomy only will give relief. 
 
 Ankylosis is not due to immobilization, but to 
 inflammation and its products. If forcible motion 
 causes pain, the ankylosis is fibrous in character; 
 if no pain is produced, it is bony. The former 
 is best treated by forced motion, either with or 
 without an anesthetic, or gradual traction. The 
 pain following these manipulations should not last 
 longer than an hour or two ; if it does, harm is being 
 done. Bony ankylosis necessitates an open opera- 
 tion and the removal of a wedge-shaped piece of 
 bone. 
 
CHAPTER IV. 
 SIMPLE FRACTURES. 
 
 Simple fractures are closed fractures having no 
 communication with the exterior. They may result 
 in two fragments only, or several (comminution). 
 Epiphyseal separations, green-stick, fission and 
 depressed fractures are anomalous varieties. In no 
 other class of injuries is accurate diagnosis and 
 exact treatment of such paramount importance, 
 because every patient that has sustained a fracture 
 will become an ambulatory example of the surgeon's 
 ability and skill, or his limitations and incapability. 
 Also, these cases are frequently the basis of a mal- 
 practice suit. Every detail contributing to the 
 complete anatomical, cosmetic and functional re- 
 covery of the injured part should receive careful 
 consideration, and the patient should always be 
 immediately informed of the probable result. Strict 
 obedience to orders must be insisted upon, in order 
 that the patient may do nothing that might jeopard- 
 ize his best interests. 
 
 Examination of Fractures. — All fractures should 
 be examined as early as possible, since extravasation 
 into the injured area may obscure a gieat deal of 
 valuable information. The patient's general con- 
 dition is always of great importance; the bodily 
 nourishment and development, the condition of 
 the pupils and their reaction, partial or complete 
 
 64 
 
SIMPLE FRACTURES 65 
 
 unconsciousness, the degree of shock present and 
 the occurrence of other complications and injuries 
 should be carefully noted. Thorough investigation 
 will disclose whether a fracture is simple or com- 
 pound or complicated, complete or incomplete, and 
 the line of fracture. The nature of the displace- 
 ment will necessarily depend upon the line or lines 
 of fracture and the action of various muscles. 
 
 On inspection, any muscular spasm, deformity, 
 swelling or discoloration are observed, and the 
 contour of an injured limb compared with that of its 
 fellow. Palpation must be exceedingly careful and 
 gentle, to avoid causing pain or injury to the adja- 
 cent structures, but preternatural mobility and crep- 
 itus must be diligently searched for. In those in- 
 stances, however, where the nature of the injury is 
 obvious, it is cruel and unnecessary to twist the site 
 of fracture about simply to elicit crepitus and, in ad- 
 dition, forcible movements tend to damage the soft 
 parts and increase extravasation. Mensuration is 
 also of great value for the determination of the ex- 
 act extent of displacement. Loss of function and 
 subjective pain are usually self-evident and are 
 important S3rmptoms. AH obscure cases and frac- 
 tures near joints should be examined under anesthe- 
 sia, as well as those occurring in children and nervous 
 individuals. The :r-ray is of inestimable service 
 for the definite location of a suspected fracture 
 and for confirmation of a diagnosis. It should be 
 remembered that a radiograph taken from the 
 anterior or lateral aspect alone is likely to deceive, 
 and the x-ray examination should therefore always 
 5 
 
66 - MINOR AND EMERGENCY SURGERY 
 
 include both an antero-posterior and lateral view. 
 An x-TSLj photograph, also, is much more reliable 
 than a simple fluoroscopic examination. 
 
 The two most constant errors in diagnosis are 
 mistaking a pre-existing deformity for a recent 
 fracture and confusing joint crepitus with that of 
 a fracture. The inexperienced may be misled by 
 the crepitus due to calcareous deposits in the joints 
 or teno-synovitis, and conversely, the interposition 
 of muscle or fascia between the fragments may 
 eliminate crepitus. When dealing with children, 
 special care should be exercised to differentiate 
 separation of an epiphysis from a true fracture. 
 Simple fractures are often accompanied by more 
 or less aseptic fever and shock. This fever must 
 be distinguished from that of sepsis, which signifies 
 complications. The increased leucocytosis present 
 in sepsis is a reliable diagnostic guide and is usually 
 sufficient to differentiate. 
 
 Emergency treatment of fractures consists only of 
 those measures that will make the patient temporar- 
 ily comfortable and prevent further injury, although 
 most fractures of the upper extremity and thorax 
 may be dressed immediately. Since by the very 
 nature of these emergency fractures they cannot be 
 accurately catalogued, the extent of advisable in- 
 vestigation and manipulation must be left to the 
 surgeon's discretion. Clothing should be removed, 
 being cut or torn away if necessary, any marked de- 
 formity reduced and the limb placed in a suitable 
 position. The site of injury may be covered with a 
 wet gauze dressing and the entire part supported 
 
SIMPLE FRACTURES 67 
 
 with splints lined with cotton or oakum. For se- 
 curity, splints are best fixed with adhesive plaster 
 before bandaging. All precautions should be taken 
 that rough or careless manipulations do not convert 
 a simple into a compound or complicated fracture. 
 If the patient is in severe pain, one-quarter of a grain 
 of morphine may be administered hypodermatically. 
 Alcohol and other stimulants are contra-indicated. 
 
 Permanent Dressing of Fractures. — All fractures 
 are advantageously reduced as early as possible, 
 except when the extravasation and tension are ex- 
 treme. Under such circumstances manipulations 
 are dangerous and it is better merely to place the 
 limb in a comfortable position and surround it with 
 sand bags, until the wet dressing has reduced the 
 swelling. Having accomplished reduction of the 
 fracture, we have at our disposal four methods of 
 treatment for simple fractures: (i) immobilization 
 by splints and bandages, (2) fixation by extension, 
 (3) immobilization plus massage and (4) open opera- 
 tion, each of which has distinct value in selective 
 cases. 
 
 Splints may be made of wood, wire, metal, starch, 
 or any other light and rigid material. Whenever 
 practical, moulded plaster-of-Paris splints will be 
 found the most servicable. This does not necessarily 
 imply complete encasing of the injured part, but one 
 section of several turns, back and forth, of the re- 
 quired width and length moulded on the anterior 
 half, and another similar section moulded to the 
 posterior half of the injured part ; when firm, they are 
 bandaged together. A plaster dressing should- al- 
 
68 ■ MINOR AND EMERGENCY SURGERY 
 
 ways include the proximal and distal joints from the 
 seat of injury, and by beginning the underlying 
 gauze bandage at the distal extremity of the limb, 
 annoying edema will be eliminated. The same 
 rules apply to splints of any other substance. 
 
 Fixation by extension is most often utilized for 
 fractures of the lower extremity, and all joints below 
 the fracture are included in the dressing. The steps 
 in applying an improvised extension apparatus are: 
 
 I. Cut an appropriately wide strip of adhesive 
 plaster of sufficient length to leave a loop projecting 
 four or five inches below the heel. 
 
 Fig. 8. — Improvised extension apparatus. 
 
 2. Place an oblong piece of wood about one-quarter 
 of an inch thick in the site of the loop on the sticky 
 side of the plaster, and punch a hole through the 
 center. 
 
 3. Knot a piece of heavy cord and run it through 
 the perforation, with the knot on the inside (Fig. 8) . 
 
 4. Apply the plaster laterally to both sides of the 
 leg (Fig. 9) and fix with a firm gauze bandage, in- 
 cluding the toes. 
 
 5. Reduce the fracture and have an assistant main- 
 tain constant traction. 
 
 6. Fix an ordinary wooden spool horizontally at 
 
SIMPLE FRACTURES 
 
 69 
 
 the foot of the bed at a level that will slightly elevate 
 the limb. 
 
 7. Attach the necessary weights (usually about 
 eight pounds) to the free end of the cord. 
 
 8. Apply coaptation splints to the site of the frac- 
 ture. They are preferably lined with cotton and 
 secured with adhesive plaster. 
 
 9. Pad the entire limb with cotton and bandage 
 two lateral splints the whole length of the extremity. 
 
 Fig. 9. — Improvised extension apparatus applied. 
 
 Even though daily massage is selected as the 
 method of treatment in a given instance, the in- 
 jured part must be supported with splints during the 
 intervals. The field of this procedure is limited to 
 CoUes' fractures and single transverse fractures, since 
 in all other fractures accurate approximation cannot 
 be maintained without constant external support. 
 The results in appropriate cases, however, have been, 
 most satisfactory. 
 
 Open operation on simple fractures has recently 
 been widely practised and recommended, on the 
 ground that it assures a more exact appoximation 
 of the fragments than any other method of treat- 
 
70 - MINOR AND EMERGENCY SURGERY 
 
 ment. In opposition to this reasoning, it must be 
 remembered that tight suturing establishes such con- 
 ditions of leverage that the maintenance of precise 
 adjustment is at best uncertain, repair is slower, and 
 we must still depend largely upon external support. 
 While admitting that the risk of infection is a nega- 
 tive quantity, in view of modern surgical technic, 
 operative measures are positively indicated in simple 
 fractures only when approximation and union are 
 obstructed by the interposition of soft structures, or 
 the fragments are irreducible, and when good position 
 cannot be obtained by manipulation. Since opera-, 
 tive measures convert a simple fracture into a com- 
 pound fracture, further discussion will be omitted 
 here. 
 
 The following facts are worth remembering: 
 
 The x-rsiy is of great value, not only for diagnosis 
 but also for confirmation of good position of the 
 fragments after reduction. 
 
 An anesthetic will overcome muscular opposition. 
 
 The recumbent position in the aged tends to induce 
 hypostatic pneumonia; at least a semi-erect position 
 should be insisted upon. 
 
 A great deal of unsuspected contusion and .sub- 
 cutaneous extravasation may become manifest dur- 
 ing the first week or ten days. 
 
 The longer a fracture remains imreduced the 
 greater will be the muscular rigidity. 
 
 Gravity must be counterbalanced so that position 
 will assist restitution. 
 
 All fracture dressings should exert uniform pressure 
 throughout their entire length. 
 
SIMPLE FRACTURES 71 
 
 A dressing applied too loosely will permit motion 
 of the fragments, while if applied too tightly it will 
 interfere with the circulation. 
 
 Apply coaptation splints to the site of all fractures 
 treated by extension. 
 
 Contused areas should not be covered with plaster- 
 of -Paris. 
 
 Morphine should not be given to patients wearing a 
 plaster cast, because the pain due to the faulty po- 
 sition of an ill-fitting cast or pressure sores can be 
 endured when morphine is given, although the cast 
 should be removed. 
 
 No attempt should be made to break up an im- 
 paction if the fragments are in good alignment. 
 
 An epiphyseal separation is analogous to a trans- 
 verse fracture. 
 
 Correct the deformity of a green-stick fracture so 
 that it does not tend to recur. 
 
 FRACTURES OF THE SKULL. 
 
 Those of the vault may occur as fissure, pene- 
 trating, depressed or bursting fractures. There may 
 be a linear fracture of the external table only when 
 the inner table is extensively splintered, because the 
 latter is thinner and more brittle and the diploe 
 distributes the force over a wider area. Depressed 
 fractures are invariably associated with brain injury 
 and practically all fractures of the skull are accom- 
 panied by some s^^mptoms of cerebral concussion, 
 laceration or compression. These are the danger 
 signals, since injuries to the brain and its membranes 
 may terminate in meningeal hemorrhage, meningitis, 
 
72 ^ MINOR AND EMERGENCY SURGERY 
 
 encephalitis or cerebral abscess. Infection and 
 necrosis due to insufficient drainage and loose frag- 
 ments are also serious consequences. In fracture 
 by contre-coup, as the name indicates, the fracture 
 is on the other side of the head ; opposite to the site 
 of injury. Although the diagnosis of fractures of 
 the skull may be easy, it often taxes our diagnostic 
 acumen. Fissures, depressions, mobility, crepitus 
 and local pain and tenderness should be diligently 
 searched for and the functional integrity of the brain 
 and nerves ascertained. Explorative incision is of 
 the utmost value as a diagnostic aid. Wh.en a 
 fracture is suspected but not demonstrable, the 
 scalp should be freely incised and the skull tre- 
 phined. This will permit inspection of the inner 
 table and dura. The brain may be explored, if 
 necessary, by incising the dura and using a probe. 
 By so doing, the underlying conditions can be 
 ascertained and no errors of omission will be made. 
 
 Fractures at the base may involve the anterior, 
 middle or posterior fossa, and the latter are graver 
 because of the proximity to the medulla. In addi- 
 tion to cerebral symptoms, these fractures are usu- 
 ally evidenced by hemorrhage behind the eye, from 
 the nose, into the pharynx, or from or behind the 
 ear, or by indications of injury to nerve trunks. Not 
 infrequently the cranial nerves are damaged and 
 cerebro-spinal fluid or even fragments of brain tissue 
 may escape from the nose or ear. 
 
 The tables on pp. 74-77 are intended to illustrate 
 the differential diagnosis of head injuries associated 
 with brain injury. An alcoholic odor to the breath 
 
SIMPLE' FRACTURES 73 
 
 is of no diagnostic significance whatever, because 
 some well-intending by-stander will often give whiskey 
 or brandy to an injured person, before the surgeon's 
 arrival, and the fact that a person is intoxicated is 
 no proof that his skull is not fractured. 
 
 The prognosis is uncertain: about 75 per cent, of 
 fractures of the vault and 50 per cent, of fractures 
 of the base recover. A common sequel is sun- 
 stroke, occurring at the next exposure to intense 
 heat, and these patients should be instructed accord- 
 ingly. 
 
 The following suggestions are applicable to all 
 severe injuries of the head: 
 
 Confine the patient to bed. 
 
 Avoid cardio-vascular stimulation, especially hy- 
 podermic injections. 
 
 Shave the injured area or the entire scalp. 
 
 Apply an ice cap. 
 
 Secure free movements of the bowels. 
 
 Keep the room dark and absolutely quiet. 
 
 Good nursing and constant careful observation are 
 items of the utmost importance. Stimulants are 
 dangerous because they increase arterial tension, al- 
 though in exceptional instances they are required to 
 combat shock, but even under such circumstances 
 they should be withdrawn as rapidly as the existing 
 conditions will permit. Croton oil is the most sat- 
 isfactory purgative as it acts quickly and lessens 
 blood pressure. Two or three drops may be placed 
 on the patient's tongue, or, if he is unconscious, it 
 may be administered in an enema of olive oil, con- 
 taining four or five drops of croton oil. A simple 
 
74- 
 
 MINOR AND EMERGENCY SURGERY 
 
 
 General 
 Appearance 
 
 Appearance of 
 the Injury 
 
 Unconsciousness 
 
 Pupils 
 
 Scalp 
 Wounds. 
 
 Normal 
 
 Bone may be ex- 
 posed, but nor- 
 mal skull sutures 
 can be wiped 
 clean. No per- 
 sistent red line 
 of hemorrhage. 
 The hematoma 
 never pulsates. 
 
 Conscious 
 
 Normal. 
 Equal and re- 
 act promtly. 
 
 Alcoholic 
 Poisoning. 
 
 Bloated. 
 Lips livid. 
 Red face 
 and nose. 
 
 No evidence of 
 injury. 
 
 May be momen- 
 tarily aroused 
 by inhaling am- 
 monia or pres- 
 sure on the su- 
 praorbital nerve. 
 
 Generally di- 
 lated, but 
 active. Re- 
 act to light. 
 
 Cerebral 
 Concussion. 
 
 Face pale . . . 
 
 N o manifesta- 
 tions of injury, 
 or at most a 
 simple fissure 
 fracture. 
 
 S e m i-unconsci- 
 ousness. Mind 
 weak and con- 
 fused, but not 
 abolished. Oc- 
 casionally total- 
 ly unconscious. 
 
 Variable. 
 React to 
 light. Eye- 
 lids some- 
 what open. 
 
SIMPLE FRACTURES 
 
 75 
 
 Pulse 
 
 Respira- 
 tion 
 
 Stomach, 
 
 Bowels, and 
 
 Bladder 
 
 Coma 
 
 Convul- 
 sions 
 
 Mental, Motor, 
 and Sensory 
 Disturbances 
 
 Normal,. . . 
 
 Normal. . . 
 
 Negative 
 
 Absent. 
 
 Absent. 
 
 Absent. 
 
 Full and 
 soft. 
 
 Deep, slow 
 and ster- 
 torous. 
 
 May be vomit- 
 ing. 
 
 Possibly 
 gradual. 
 
 Do 
 
 Mental dullness 
 and motor 
 weakness. Inco- 
 ordination o f 
 muscles. 
 
 Small, 
 rapid and 
 intermit-, 
 tent. 
 
 Quiet. 
 Shallow 
 and ir- 
 regular. 
 
 Vomiting after 
 recovery of con- 
 sciousness . In- 
 voluntary de- 
 fecation and 
 micturition at 
 times. 
 
 Tempo- 
 rary. 
 
 Do 
 
 Mentally depress- 
 ed. Occasional 
 delirium. Tem- 
 perature s u b - 
 normal, gradu- 
 ally rising as re- 
 action occurs. 
 
76^ 
 
 MINOR AND EMERGENCY SURGERY 
 
 General 
 Appearance 
 
 Appearance of 
 the Injury 
 
 Unconsciousness 
 
 Pupils 
 
 
 Pace pale. 
 Expression 
 vacant. 
 
 Do 
 
 Temporary 
 
 
 Contusion 
 
 (severe 
 
 concussion). 
 
 
 what sensi- 
 ble to light. 
 
 Cerebral 
 Laceration. 
 
 Face pale. 
 Skin cold. 
 Profuse 
 p e r s p i- 
 ration. 
 
 Usually evidence 
 of fracture. 
 
 More prolonged; 
 followed by irri- 
 t a b i 1 i t y and 
 restlessness. 
 
 Do. 
 
 Cerebral 
 
 Compres- 
 sion. 
 
 Face pale. 
 Skin cold. 
 
 Usually de- 
 pressed frac- 
 ture. Hema- 
 toma pulsates. 
 May be due to 
 concealed hem- 
 orrhage, in the 
 absence of frac- 
 ture. 
 
 Comes on imme- 
 diately when 
 due to bone 
 pressure; grad- 
 u a 1 develop- 
 ment of symp- 
 toms when due 
 to hemorrhagic 
 pressure. Tends 
 to progress. 
 
 Remain fix- 
 ed. One or 
 
 both may 
 be dilated 
 or contract- 
 ed. Do not 
 react to 
 Hght. Eye- 
 lids - closed. 
 
SIMPLE FRACTURES 
 
 77 
 
 Pulse 
 
 Respira- 
 tion 
 
 Stomach, 
 
 Bowels and 
 
 Bladder 
 
 Coma 
 
 Convul- 
 sions 
 
 Mental, Motor, 
 and Sensory 
 Disturbances 
 
 Feeble and 
 
 Do 
 
 Do 
 
 Do 
 
 Do 
 
 Power of move- 
 ment not destroy- 
 ed. Mentally 
 depressed, plus 
 shock and gen- 
 eral depression. 
 
 irregular. 
 
 
 Do 
 
 Do 
 
 Do 
 
 Do 
 
 c c a - 
 sional. 
 
 Mental irritabil- 
 ity. Hemiplegia, 
 if motor areas 
 are injured. 
 Legs and arms 
 flexed. Lasts 
 some days. 
 
 
 
 Slow, 
 (s o m e- 
 times 40- 
 60) and 
 full. 
 
 Labored 
 and ster- 
 torous. 
 
 Stomach insen- 
 sible, even to 
 emetics. Bowels 
 torpid, 
 
 Lasts as 
 long as 
 pres- 
 sure 
 exists. 
 
 Do 
 
 Partial or com- 
 plete paralysis. 
 Special senses 
 entirely sus- 
 pended. 
 
78^ MINOR AND EMERGENCY SURGERY 
 
 fissure fracture without depression of bone or brain 
 symptoms will require no additional treament. All 
 depressed and pimctured fractures and those ex- 
 hibiting symptoms of brain injury demand immediate 
 operation. The skull should be trephined and the 
 depressed fragments elevated and cleansed or re- 
 moved. Any piece of bone with good periosteal 
 attachments will not become necrotic and should be 
 left in situ. If there is hemorrhage from the dura, 
 the bleeding vessel must be ligated, while if it origi- 
 nates in the brain proper or follows the removal of 
 bone fragments the wound should be packed with 
 narrow strips of sterile gauze. Provision for drainage 
 is essential in all these cases. 
 
 In fractures of the base with hemorrhage or ex- 
 udation from the nose or ear these cavities should 
 be wiped clean with a little moist cotton on an appli- 
 cator and loosely plugged with sterile cotton, which 
 should be changed as often as it becomes saturated. 
 Irrigations are dangerous as they may carry infection 
 into the fissures. In addition to these measures, the 
 treatment is symptomatic. 
 
 In gunshot fractures of the skull the bullet should 
 be removed if reasonably accessible, as the mortality 
 is considerably greater if the bullet is permitted to 
 remain. Nevertheless, it is sometimes wiser to leave 
 a harmless bullet in the tissues than to perform an 
 extensive and destructive operation for its removal. 
 
 FRACTURES INVOLVING THE NOSE AND MOUTH. 
 
 The cardinal principle in the treatment of these 
 fractures is cleanliness. The cosmetic result is of 
 
SIMPLE FRACTURES 79 
 
 great importance so that exact adjustment and firm 
 fixation by means of splints or operative procedures 
 at the earliest possible moment is imperative. In 
 fractures of the nose the mucous membrane should 
 be cocainized and cleansed with a little sterile cot- 
 ton on a probe. Hemorrhage is controlled by in- 
 jections of ice water, applications of adrenalin chloride 
 (i-iooo) or packing with gauze strips. The fracture 
 may be reduced and proper position of the fragments 
 maintained by elevating the spicules with a director 
 and introducing an Asch's or Coleridge's splint, if 
 
 5 inches 
 
 Bend__ 
 Here 
 
 Fig. 10. — Cardboard cut for cup-shaped splint for lower jaw. 
 
 necessary. Fractures of the superior maxilla usually 
 require instrumental reposition of the fragments, 
 suturing and drainage. Little or no tissue need be 
 removed, because of the vascularity of this region. 
 In fractures of the lower jaw, a cup-shaped splint and 
 a Barton bandage are often all that will be necessary. 
 To apply this dressing: 
 
 1. Cut a piece of cardboard of appropriate size, 
 as shown in Fig. 10. 
 
 2. Steam over boiling water. 
 
8o 
 
 MINOR AND EMERGENCY SURGERY 
 
 3. Mould to the chin and line with cotton. 
 
 4. Begin a 2 1/2 inch wide muslin bandage diag- 
 onally at the vertex of the head, bring down on one 
 side of the face, under the jaw, up the other side, 
 across the starting-point, down around the occiput, 
 across the anterior surface of the jaw, around the 
 
 Fig. II. — Barton bandage applied. 
 
 other side of the occiput and up to the starting-point. 
 This is really a double figure-of-eight bandage 
 (Fig. II). 
 
 5. Re-apply the dressing every two or three days. 
 
 In severe cases, or whenever this dressing is in- 
 adequate, recourse may be had to an interdental 
 
SIMPLE FRACTURES 8i 
 
 splint or wiring of the teeth. Open operation and 
 wiring of the bone fragments is to be avoided if 
 possible, because of the great danger of necrosis and 
 sepsis therefrom. Where the damage is extensive, 
 dental prosthesis is of considerable aid to the surgeon. 
 Talking and mastication must be interdicted, the 
 mouth washed out with a mild antiseptic every two 
 hours and immediately after eating and the teeth 
 kept scrupulously clean. The diet should be entirely 
 liquid and administered through a tube. 
 
 FRACTURES OF THE RIBS AND SPINE. 
 
 Fractured ribs are best treated by strapping with 
 strips of adhesive plaster from below upward, be- 
 ginning at the spine and ending at the sternum, on 
 the affected side only. Surgical emphysema occa- 
 sionally accompanies these fractures and is of no im- 
 portance. Pneumonia, on the contrary, is a serious 
 complication and the patient should be guarded 
 accordingly. It will not be amiss to give all patients 
 with fractured ribs a sedative cough mixture. 
 
 Fractures of the spine involving the neural arch 
 only and without displacement are uncommon. The 
 usual fracture is really a fracture dislocation and is 
 almost invariably accompanied by compression or 
 injury of the cord, caused by bone fragments or 
 hemorrhage. If due to the latter, the resulting 
 paralysis is more gradual. The evidences of cord 
 injury are: (i) profound shock, (2) partial or com- 
 plete motor and sensory paralysis, corresponding to 
 the point of fracture, (3) loss of reflexes, (4) priapism, 
 6 
 
82 ^ MINOR AND EMERGENCY SURGERY 
 
 and in serious cases (5) hyperpyrexia. The local 
 manifestations of fracture consist of: (i) displace- 
 ment, (2) deformity, (3) paralysis of the nerves 
 emerging near to and below the site of compression, 
 (4) altered mobility, (5) pain, (6) tenderness, and 
 usually (7) crepitus. The prognosis is unfavorable, 
 except in those instances in which the cord is un- 
 injured. Fractures above the fourth cervical verte- 
 bra are nearly always fatal. In general, the per- 
 centage of mortality decreases as the fracture is to- 
 ward the lower part of the spine. Every precaution 
 should be taken against the development of pneu- 
 monia, cystitis and pyelitis. 
 
 These patients must be handled and transported 
 with the greatest care and gentleness, lest the cord be 
 further injured. In simple fracture of the cervical 
 region the patient should be put to bed with traction 
 on the head, but if the cord is involved, operative 
 measures must be resorted to within twenty-four 
 hours. All cases of fracture of the spine should be 
 placed on an air or water bed and surrounded with 
 sand bags, and rigid cleanliness must be maintained 
 to avoid the formation of bed-sores. Reduction 
 may be wholly or partially accomplished by (i) anes- 
 thesia, extension, and gradual pressure, ending the 
 operation with the application of a plaster-of -Paris 
 jacket or a brace, or (2) by open operation, exposing 
 the injured area to view. The latter is preferable, 
 since it permits of the local effects of the manipula- 
 tions being observed. The selection of either of 
 these methods will depend upon the existing circum- 
 stances in the individual case. 
 
SIMPLE FRACTURES 83 
 
 FRACTURES OF THE CLAVICLE. 
 
 Fractures of the clavicle are extremely common. 
 In addition to the classic symptoms of fracture, the 
 attitude assumed by the patient is always significant 
 of this injury, since the action of the sternocleido- 
 mastoid muscle elevates the inner fragment and in- 
 clines the head toward the injured side. Green- 
 stick fractures occur especially in children. 
 
 In cases where the absence of deformity is particu- 
 larly desirable, the patient should be placed upon a 
 firm mattress with a sand bag on the shoulder and 
 the arm bandaged to the side. This position must 
 be maintained until union is firm. If a sharp end 
 of one fragment projects, the skin can be cocainized, 
 incised and the tip removed with bone forceps. In 
 the majority of instances, however, the surgeon will 
 be compelled to select a method of ambulatory treat- 
 ment, because the cosmetic result is usually of minor 
 importance and the patient will not submit to con- 
 finement to bed. Both the Sayre dressing and the 
 Velpeau bandage, or a modification of it, are ex- 
 cellent dressings for these cases. The arm must be 
 fixed to the side with the forearm flexed, so that the 
 finger tips will rest on the opposite shoulder. Pads 
 of lint or cotton are placed in the axilla, between the 
 elbow and chest and under the palm of the hand to 
 avoid excoriation of the skin surfaces. The applica- 
 tion of either of these dressings may be preceded by 
 fixing a firm compress at the site of fracture with ad- 
 hesive plaster. 
 
 To apply the Sayre dressing: 
 
84' MINOR AND EMERGENCY SURGERY 
 
 1. Fix the arm in the proper position. 
 
 2. Cut two strips of adhesive plaster 3 1/2 inches 
 wide and about 2 yards long. 
 
 3 Wrap one strip once around the middle of the 
 arm at an exact right angle to its longitudinal axis 
 and pin or stitch it to itself, being careful not to im- 
 pede the circulation. 
 
 4. Bring this strip across the back and completely 
 around the chest. 
 
 5. Commence the second strip on the shoulder of 
 the sound side. 
 
 6. Carry this strip diagonally across the back, 
 imder the elbow on the injured side (cutting a slit 
 for the olecranon process) , and across the chest to the 
 starting-point. 
 
 To apply a modified Velpeau bandage . 
 
 1. Fix the arm in the proper position. 
 
 2. Begin a 2 1/2 inch wide muslin bandage on the 
 shoulder of the affected side, bring down the front of 
 the arm, under the elbow, up the back of the arm, 
 across the starting-point on the shoulder, diagonally 
 across the front of the chest, under the opposite 
 axilla, around the back, across the front of the flexed 
 elbow, around the other side of the chest again and 
 back to the starting-point. These turns should be 
 repeated six times, each one just overlapping the 
 previous one, and the dressing completed by circular 
 turns around the chest from below upwards until the 
 entire arm and forearm are concealed by the bandage. 
 
 This dressing should be removed and re-applied 
 every five or six days and the skin wiped with alcohol. 
 Union is generally firm at the end of five weeks. 
 
SIMPLE FRACTURES 85 
 
 FRACTURES OF THE HUMERUS. 
 
 Classification : 
 
 Upper epiphysis 
 
 Shaft 
 
 Lower epiphysis 
 
 Anatomical neck. 
 
 Surgical neck. 
 
 Separation of the epiphysis. 
 
 Through the lesser tuberosity. 
 
 Through the great tuberosity. 
 
 Transverse supracondyloid. 
 Separation of the epiphysis. 
 Internal epicondyle. 
 Internal condyle. 
 External condyle. 
 T-fracture. 
 
 Fracture of the anatomical neck is usually impacted ; 
 fracture through the greater tuberosity may be 
 impacted. In the former the impaction should never 
 be interfered with, but in the latter breaking up of 
 the impaction is essential. All fractures of the upper 
 end of the humerus should be radiographed, and ex- 
 amined and reduced under anesthesia. Swelling may 
 be avoided by bandaging from the fingers to the 
 point of fracture. A satisfactory dressing for these 
 cases consists of a A-shaped pad, extending the en- 
 tire length of the arm with the apex in the axilla. 
 Position may be maintained by a strip of adhesive 
 plaster carried over the opposite shoulder and re- 
 enforced by shoulder cap of plaster of Paris (Fig. 12). 
 The shoulder cap is easily prepared by making a 
 fiat piece of several turns of plaster-of-Paris ban- 
 dages and then moulding to the shoulder and arm. 
 A firm bandage enclosing the injured arm and chest 
 affords additional support. The patient being in a 
 
86 
 
 MINOR AND EMERGENCY SURGERY 
 
 constantly erect or semi-recumbent position, the 
 wrist should be suspended in a sling, so that the 
 weight of the arm will pull against the fracture. 
 If a new shoulder cap is made at the end of the 
 first week it will fit more snugly than the first one, 
 because of the subsidence of swelling. When the 
 head of the bone become necrotic, complete re- 
 moval of the diseased bone is more prudent than 
 temporizing with palliative measures. 
 
 Fig. 12. — a, A-shaped splint in axilla; b, shoulder cap applied and arm 
 in proper position for bandaging. 
 
 Injury of the nerves of the arm is often concomi- 
 tant to fractures of the shaft of the humerus. The 
 musculo-spiral may become involved in the callus 
 formation, evidenced by wrist-drop. Careful ex- 
 amination, accurate diagnosis, exact approximation 
 of the fragments and rigid immobilization are of the 
 utmost importance in these cases. After reduction, 
 
SIMPLE FRACTURES 87 
 
 the following method of treatment of fractures of the 
 shaft gives exceedingly satisfactory results : 
 
 Apply coaptation splints by wrapping three or 
 four narrow strips of adhesive plaster around five 
 thin strips of wood extending from the axilla to the 
 elbow, cotton being placed underneath. These splints 
 should be securely fixed with a bandage, a shoulder 
 cap applied, the arm bandaged to the side and the 
 wrist placed in a sling. This dressing should be re- 
 applied every week or so, with an assistant making 
 continual traction at each renewal. If the fragments 
 tend to overlap, better results will be obtained by 
 encasing the entire arm in plaster-of -Paris or by using 
 constant extension by means of weights, in a manner 
 similar to that described on p. 68. 
 
 Fractures of the lower end of the humerus usually 
 extend into the elbow-joint and the necessity for an 
 exact understanding of the nature of the injury can- 
 not be too strongly emphasized. Entire functional 
 recovery is always doubtful, because complete re- 
 duction is often impossible or the callus formation 
 may interfere with proper motion. It should be re- 
 membered that with the forearm extended the olec- 
 ranon process of the ulna and the two condyles of 
 the himienis normally lie in a straight line. Swell- 
 ing rapidly occurs in all these cases and must be 
 disregarded, as immediate reduction is imperative. 
 Much of the extravasation, however, may be quickly 
 eliminated by bandaging for a few minutes from the 
 fingers to the arm with an elastic bandage. Sepa- 
 ration of the epiphysis and supracondyloid fractures 
 are the only two types of fracture of the lower end 
 
88 - MINOR AND EMERGENCY SURGERY 
 
 of the humerus that require fixation of the forearm 
 at a right angle. This position is best secured by 
 placing an anterior angular splint upon the arm and 
 forearm over a roller bandage. Condyloid fractures 
 may be treated in either the extended or acutely 
 flexed (Jones) position. Unless great care is exer- 
 cised, "gun-stock" deformity, or loss of the carrying 
 
 Fig. 13. 
 
 -Adhesive straps applied to maintain acute flexion of the 
 forearm (Jones' position). 
 
 angle not infrequently follows these fractures. The 
 extended position would seem to maintain reduction 
 and preserve the carrying angle better than acute 
 flexion, but on the other hand, when the forearm is 
 flexed, the olecranon process and the tense triceps 
 tendon both splint the line of fracture and this atti- 
 
SIMPLE FRACTURES 89 
 
 tude will be much more useful to the patient should 
 ankylosis result. Extensive swelling is an absolute 
 contra-indication to the flexed position, because the 
 pressure therefrom may interfere with the circulation. 
 Acute flexion, then, is the preferable position for 
 condyloid fractures, unless there is great swelling, or 
 reduction of the deformity cannot be satisfactorily 
 maintained. Even if it is necessary to utilize the 
 extended position, the dressings may be removed 
 after a week or two and the forearm flexed under an- 
 esthesia. When treating by extention, an iron bar 
 may be fitted to the inside of the sound limb and 
 applied reversed on the inside of the injured limb, 
 to preserve the carrying angle. If the flexed po- 
 sition is decided upon, the proper attitude may be 
 easily maintained by fixing with four of five cir- 
 cular strips of adhesive plaster including both the 
 arm and forearm (Fig. 13). Motion should not be 
 permitted for at least a month. 
 
 FRACTURES OF THE FOREARM 
 Classification : 
 
 Radius and Ulna < ,. 1 , . , s 
 
 (^ incomplete (green-stick). 
 
 Head and neck. 
 
 Separation of the epiphysis. 
 
 Shaft. 
 
 CoUes. 
 
 Reversed CoUes. 
 
 Olecranon process. 
 
 Coronoid process. 
 
 Shaft. 
 
 Styloid process. 
 
 Radius 
 
 Ulna 
 
 Precise adjustment of the fragments is essential 
 
90'^ MINOR AND EMERGENCY SURGERY 
 
 when the radius and ulna are both fractured, be- 
 cause of the probability of a synostosis resulting 
 from the agglutination of the callus from each bone. 
 When there is overlapping with shortening, exten- 
 sion must be continual to overcome it. The position 
 of the forearm should be that which will most 
 widely separate the two bones and be the most 
 comfortable for the patient : as a rule, semi-pronation. 
 The exception is when the radius is fractured above 
 the insertion of the pronator radii teres; then the 
 position should be complete supination. The pri- 
 mary roller bandage must be omitted and the 
 splints wider than the forearm in these cases, in 
 order to avoid lateral pressure, which tends to force 
 the bones together; for the same reason, plaster-of- 
 Paris should never be used. An anterior and poster- 
 ior flat wooden splint are required and they must be 
 accurately padded to fit the irregular surfaces of 
 the forearm. The anterior one is necessarily the 
 shorter and every precaution should be taken that 
 the upper limit does not exert pressure upon the 
 brachial artery where it crosses the elbow-joint. 
 Both splints extend to the knuckles and the sling in 
 which the forearm is carried should uniformly sup- 
 port the entire distance from the elbow to that 
 point. 
 
 Fractures of the head and neck and separation of 
 the epiphysis of the radius are not common and are 
 treated in acute flexion. If the functional result 
 is unsatisfactory, excision of the head of the bone 
 may be considered. 
 
 Fractures of the shaft of the radius occurring 
 
SIMPLE FRACTURES 
 
 91 
 
 above the insertion of the pronator radii teres 
 should obviously be treated in a supinated position. 
 If below this point, however, semi-pronation and the 
 plaster-of-Paris splints recommended for Colles' 
 fractures are preferable. 
 
 Colles' fractures are transverse fractures of the 
 radius about an inch above the styloid process. 
 The lower fragment is tipped upward and backward 
 and is usually impacted or comminuted. In a 
 reversed Colles' (rare) the deformity is anterior. 
 Radiography is often the only diagnostic method 
 that will positively differentiate a Colles' fracture 
 from a sprain or dislocation of the wrist, unless the 
 silver-fork deformity is pronounced. Permanent de- 
 formity and impairment of function will surely 
 follow an incompletely reduced Colles fracture, 
 hence accurate approximation of the fragments is 
 of paramount importance. Reduction is accom- 
 plished by fixing the forearm with one hand and 
 gripping the hand of the injured arm with the 
 other, making momentary traction with overexten- 
 sion steadily, and then suddenly flexing the hand. 
 Having secured satisfactory alignment, these frac- 
 tures do not tend to recur. The results obtained 
 from the following method of treatment are much 
 better than those derived from the time-honored 
 Bond, or pistol-shaped, splint, because the provi- 
 sional callus is absorbed more rapidly, stiffness is 
 absent, and the function of the wrist joint is un- 
 impaired. 
 
 I. With the forearm supinated and the hand ad- 
 ducted, have an assistant support the upper end of 
 
92 
 
 MINOR AND EMERGENCY SURGERY 
 
 the forearm with one hand and grasp the fingers 
 and palm with the other. 
 
 2 . Apply a primary roller gauze bandage from the 
 metacarpo-phalangeal joints to the elbow. 
 
 3. Mould a plaster-of -Paris splint to the anterior 
 half of the forearm and hand, extending to the 
 knuckles. 
 
 4. Mould a posterior splint in the same manner 
 (Fig. 14). 
 
 Fig. 14. — ^Plaster-of-Paris dressing for CoUes' fracture, a. Anterior 
 splint applied; b, both splints applied. 
 
 5. When hardened, cut the primary bandage 
 between the splints on both sides. 
 
 6. Apply an external bandage. 
 
 7. On the second day remove the posterior splint 
 and gently massage the site of fracture for ten min- 
 utes, with the finger-tips sHghtly lubricated. 
 
 8. Replace the posterior splint, pronate the 
 arm, remove the anterior splint and massage again. 
 
 9. Continue these procedures every two or three 
 
SIMPLE FRACTURES 
 
 93 
 
 days for two weeks and then begin passive motion 
 at the wrist and fingers. 
 
 lo. Remove the splints permanently at the end of 
 three weeks. 
 
 Reversed Colles' fractures and separations of the 
 epiphysis of the radius may be similarly treated 
 after reduction. 
 
 Fractures of the olecranon process of the ulna are 
 followed by the best results when operated upon. 
 If otherwise treated, the forearm should be extended 
 on a well padded splint, a small pad placed above the 
 upper fragment and firmly secured by a strip of ad- 
 hesive plaster applied obliquely and the whole cov- 
 ered with a muslin bandage. These cases usually 
 terminate in fibrous union when not operated upon 
 but the functional result is uniformly satisfactory. 
 Should the presence of synovial fluid between the 
 fragments seriously interfere with imion, it will be 
 necessary to freshen the surfaces of the fragments 
 and suture them together. 
 
 The greater number of fractures of the coronoid 
 process of the ulna are found with simultaneous 
 backward dislocations. The existing dislocation 
 must be reduced and the arm put up in acute flexion. 
 
 Fractures, of the shaft and styloid process of the 
 ulna should be dressed in the same manner as frac- 
 tures of the shaft of the radius, 
 
 FRACTURES OF THE METACARPAL BONES. 
 
 In cases where there is but little shortening, the 
 fist may be closed upon a rolled-up bandage and 
 
94 MINOR AND EMERGENCY SURGERY 
 
 covered with another bandage. When the short- 
 ening is pronounced, extension is preferable : 
 
 1. With the forearm and hand pronated, place a 
 gauze pad under the palm of the hand. 
 
 2. Apply two lateral strips of adhesive plaster to 
 the finger corresponding to the fractured bone. 
 
 3. Place a well padded straight splint under the 
 forearm and hand. 
 
 4. Make traction on the adhesive strips and fix 
 them to the under surface of the splint. 
 
 5. Place a piece of rubber tubing on each side of 
 the fracture and secure with adhesive plaster. 
 
 6. Bandage from the tips of the fingers to the 
 elbow. 
 
 FRACTURES OF THE PELVIS. 
 
 The gravity and treatment of these injuries depend 
 upon the degree of shock, the integrity of the pel- 
 vic girdle, and the extent of injury of the pelvic vis- 
 cera. The most important complications are: (i) 
 rupture of the bladder, (2) rupture of the deep urethra, 
 (3) laceration of the vagina and rectum, and (4) in- 
 ternal hemon'hage. To determine whether or not 
 the bladder has been ruptured, do a sterile surgical 
 catheterization, empty the bladder of its contents as 
 far as possible, inject a known quantity of a sterile 
 liquid and measure the amount withdrawn. A ma- 
 terial difference between the amount injected and 
 the amount withdrawn indicates rupture. The 
 withdrawal of clear urine when catheterizing is cor- 
 roborative evidence that the bladder is uninjured, 
 whereas the absence of urine or hematuria is stigges- 
 
SIMPLE FRACTURES 95 
 
 tive of rupture. If the rupture is intraperitoneal, 
 the S3n2iptoms are profound shock, increasing rapidity 
 of the pulse and abdominal tenderness. If extraperit- 
 oneal (usually into the space of Retzius), there is 
 slight shock, pain, partial retention of urine and sec- 
 ondary sepsis. Prompt diagnosis is important and 
 immediate laparotomy or perineal section impera- 
 tive. Rupture of the deep urethra is evidenced by 
 dysuria, strangury, swelling and ecchymosis in the 
 perineum and scrotum due to the extravasation of 
 blood and urine, and if rupture is complete, by reten- 
 tion of urine. In all these cases of fracture the pelvis 
 should be surrounded with broad strips of adhesive 
 plaster and the patient put to bed with sand bags 
 on each side, or slung in a hammock. A pillow must 
 be placed under the knees so that the flexion will re- 
 lax the abdominal muscles as well as those of the 
 thigh. Injured soft structures should, of course, be 
 repaired and appropriately treated. 
 
 FRACTURES OF THE FEMUR. 
 
 Classification : 
 
 Head (very rare) 
 
 ^1 / Intracapsular. 
 
 I Extracapsular. 
 
 f Upper of femur. 
 
 ^ , . ... Great trochanter, 
 
 beparation 01 epiphyses < ,. ^ 1 . 
 
 I Lesser trochanter. 
 
 I Lower of femur. 
 
 f Upper third. 
 
 Shaft I Middle third. 
 
 [ Lower third. 
 
 ISupracondyloid. 
 External condyle. 
 Internal condyle. 
 
96' MINOR AND EMERGENCY SURGERY 
 
 Intracapsular fractures of the neck of the femur 
 are common in the aged, occurring as the result of 
 trivial traumatism, and are usually not impacted. 
 Extracapsular fractures are found more frequently 
 in young adults, due to direct violence and impacted 
 as a rule. There is shoitening, eversion, defoimity, 
 pain, loss of function, mobility and crepitus (ex- 
 cept when there is impaction). It is of far greater 
 importance to distinguish an impacted from a non- 
 impacted fracture of the neck of the femur than it 
 is to differentiate intracapsular and extracapsular 
 types. These cases should never be examined for 
 crepitus under anesthesia as the periosteum may 
 be torn or an impaction broken up, nor should the 
 impaction ever be interfered with, unless the patient 
 is a young healthy adult and the deformity ex- 
 ceptionally pronounced. Gradual increase of short- 
 ening during the first day or two indicates liberation 
 of an impaction. The prognosis is grave in old 
 people, because death often ensues from exhaustion 
 or hypostatic pneumonia, consequent to the con- 
 finement to bed. Fibrous union frequently results 
 from intracapsular fractures but there is always 
 bony union in extracapsular fractures. Stiffness 
 invariably follows in these cases because of the large 
 amount of provisional callus present. In the aged, 
 regard for the constitutional condition should super- 
 sede consideration of the injury. The patient 
 should be treated on a fracture bed, his back sup- 
 ported by a back-rest and the limb steadied with 
 sand bags on both sides. Scrupulous personal 
 cleanliness and good nursing are essential to avoid 
 
SIMPLE FRACTURES 97 
 
 the formation of bed-sores. In younger adults 
 the best results are obtained from the use of exten- 
 sion, re-enforced with a well padded side splint ex- 
 tending from the axilla to the foot. This relieves 
 the pain, gives the patient comparative comfort 
 and corrects the eversion. 
 
 The treatment of separation of the epiphyses of 
 the fem.ur, great trochanter and lesser trochanter 
 consists of reduction of the deformity by manipu- 
 lation and fixation of the part with splints or a 
 plaster-of -Paris dressing. 
 
 Fractures of the shaft of the femur usually present 
 extreme deformity, because the line of fracture is 
 nearly always oblique and the displacement is ex- 
 aggerated by the powerful muscular action. Two 
 or three inches of shortening is to be expected. The 
 angular displacement is upward in the upper third, 
 outward in the middle third, and backward in the 
 lower third. These fractures are never impacted 
 and inability to elicit crepitus indicates the presence 
 of soft structures between the fragments. The 
 emergency treatment is important, as these cases 
 should not be transported imtil the fracture is firmly 
 immobilized. The best emergency dressing consists 
 of coaptation splints, supported by a long axillary 
 splint on the outside and another on the inside 
 reaching from the groin to the foot. These cases 
 should all be treated on a fracture bed by Buck's 
 extension, re-enforced by the foregoing lateral 
 splints. The foot must always be fixed at a right 
 angle and a pad of cotton placed imder the tendo 
 Achilles, to prevent pressure upon the heel. Frac- 
 7 
 
gS MINOR AND EMERGENCY SURGERY 
 
 tures of the middle third are treated by extension 
 in a straight line. For fractures of the upper and 
 lower thirds it is better to use a double inclined plane, 
 with the extension applied above the knee only, 
 to induce relaxation of the muscles responsible for 
 the deformity. A plaster-of-Paris dressing includ- 
 ing the entire leg and pelvis has 'also been recom- 
 mended and widely employed for fractures of the 
 shaft of the femur. Notwithstanding the fact that 
 by virtue of its solidity this dressing presumes to 
 give perfect immobilization, its weight and unclean- 
 liness are the source of such great discomfort to 
 the patient that it has been unfavorably regarded 
 and discarded by many. In addition to these 
 objectionable features, in the author's experience 
 the results derived from this method of treatment 
 have not been uniformly satisfactory, as they have 
 been when extension was employed. Fractures of 
 the femur in infants and young children are usually 
 green-stick or transverse fractures and constant 
 traction is not as essential as in adults. Moulded 
 splints of pasteboard or binder's board may be 
 applied and secured by a bandage, or both legs may 
 be encased in plaster-of-Paris bandages and sus- 
 pended vertically by the feet from a crossbar over 
 the bed. Great care should be taken to avoid 
 pressure necrosis of the foot. 
 
 FRACTURES OF THE PATELLA. 
 
 When due to direct violence, these fractures are 
 often comminuted and there is very little separa- 
 tion of the fragments because the integrity of the 
 
SIMPLE FRACTURES 99 
 
 capsule is preserved. Contrariwise, if caused by- 
 indirect violence (muscular action), the capsule, as 
 well as the patella itself, is broken ; the line of fracture 
 is transverse, displacement is pronounced and over- 
 lying soft tissues frequently drop between the 
 fragments. Consequently, bony union is excep- 
 tional, unless operative measures are resorted to. 
 Profuse swelling occurs immediately and may be 
 reduced by immobilization and ice, with the leg in 
 the extended position. A relatively large propor- 
 tion of these cases require operative interference for 
 the correction of the existing pathological conditions 
 and the selection of a conservative or radical method 
 of treatment will necessarily depend upon (i) the 
 amount of separation of the fragments, (2) the 
 integrity of the capsule, (3) the interposition of 
 soft structures and (4) the surgeon's discretion in 
 each individual case. Exposure of the knee-joint, 
 and particularly of its synovial membrane, is an 
 operation of considerable gravity which may even 
 jeopardize the patient's life if performed under 
 difficulties, owing to the rapidity with which in- 
 fection is absorbed. Conversely, given perfect 
 asepsis and technic followed by primary union, 
 the anatomical and functional results are much 
 better than when the case is treated conservatively. 
 To generalize, it may be said that when crepitus 
 can be elicted and it is possible to approximate the 
 fragments within 1/4 of an inch, a reasonably 
 satisfactory result may be expected from the use 
 of immobilization and splints alone. If crepitation 
 cannot be obtained or it is impossible to approxi- 
 
lOo MINOR AND EMERGENCY SURGERY 
 
 mate the fragments, incision and suturing are both 
 justifiable and essential. F. D. Gray says, "A badly 
 functionating leg from fracture of the patella, with- 
 out operation, is near malpractice, while a stiff knee 
 as a result of operative procedure is in the same 
 category." 
 
 If operation is deemed unnecessary or inadvis- 
 able, the limb must be placed upon a posterior 
 padded straight splint extending from the upper 
 third of the thigh to the lower third of the leg, 
 with a gauze pad under the knee-joint. A small 
 compress is then applied above the upper fragment 
 
 Fig. 15. — Method of treating fracture of the patella. 
 
 and secured by means of an oblique strip of adhesive 
 plaster; another compress is fixed below the lower 
 fragment in the same manner, so that the plaster 
 strips cross on each side of the knee-joint (Fig. 15). 
 A convenient means of fastening the plaster strips 
 is to drive two nails or pegs into the posterior 
 splint on each side. The limb must be bandaged 
 from the toes to the upper limit of the splint. If 
 union appears firm at the end of six or seven weeks, 
 passive motion and massage may be cautiously 
 be;run. 
 
SIMPLE FRACTURES loi 
 
 Should • open operation be selected, every detail 
 of preparation and technic must be accorded ade- 
 quate attention in order that all may contribute to 
 ultimate success and a perfect recovery. There is 
 still some diversity of opinion as to the preferable 
 mode of procedure, but the concensus of opinion seems 
 to be that, as a rule, clearing out the space between 
 the fragments and suturing the capsule and overly- 
 ing tissues with iodine catgut, under local or general 
 anesthesia, are all that are necessary to effect a cure, 
 although some surgeons consider wiring of the bone 
 fragments essential. Tincture of iodine may be 
 dropped along the skin wound, the knee wrapped 
 in gauze saturated with aluminum acetate solution 
 and the limb bandaged to the posterior splint. 
 These items minimize the danger of infection, restore 
 the injured structures to their normal anatomical 
 relationship, obviate the introduction of non-absorb- 
 able suture material and rapidly bring about firm 
 union. Silver wire sutures act as foreign bodies and 
 necrosis of bone frequently follows their use. The 
 patella is refractured more often than any other 
 bone in the body, and the patient should be warned 
 accordingly. Corner, of London, maintains that 
 most refractures in cases treated by operative meas- 
 ures occur in the first year after the original injury, 
 while those cases treated otherwise occur more fre- 
 quently after the first year 
 
I02 
 
 MINOR AND EMERGENCY SURGERY 
 
 FRACTURES OF THE LEG. 
 
 Classification : 
 
 Tibia and fibula 
 
 Upper epiphysis. 
 
 Tibia 
 
 Fibula 
 
 Upper end 
 Shaft. 
 Lower end 
 
 Oblique. 
 
 Transverse. 
 
 Region of the ankle 
 Internal maleolus. 
 
 Lower epiphysis. 
 
 Upper epiphysis. 
 Upper end. 
 Shaft. 
 
 ' Pott's. 
 External maleolus. 
 
 Lower end 
 
 Lower epiphysis. 
 
 Fractures of both the tibia and fibula are common, 
 often compound and easily diagnosed. When due 
 to direct violence, the line of fracture is usually trans- 
 verse, both bones being broken at the same level, 
 while if produced by indirect violence, the fractures 
 are usually oblique and seldom occur at the same 
 level. Those due to direct force nearly always be- 
 come compound within the first week, because of the 
 deficient vascularity of the overlying tissues. The 
 anatomical location of the bones is so superficial that 
 the skin and subcutaneous fascia are unable to with- 
 stand the damage inflicted by the traumatism and 
 sloughing with exposure of bone results. The deform- 
 ity in these cases, however, is slight and easily over- 
 
SIMPLE FRACTURES 103 
 
 come and does not tend to recur after reduction. 
 On the contrary, in fractures due to indirect violence 
 the deformity is pronounced and may resist all 
 efforts at reduction. If the displacement is easily re- 
 duced, the primary swelling insignificant and no ex- 
 tensive contusion apparent, a plaster-of-Paris dress- 
 ing encasing the foot, ankle, leg and knee is the most 
 efficient method of treatment, provided the surgeon 
 is constantly on the alert for evidence of pressure and 
 skin necrosis. If the cast is too tight, it will inter- 
 fere with the circulation, while if it is too loose, it 
 will permit motion and perhaps displacement at the 
 point of fracture. The dressing is best applied over 
 a thin layer of wool and should be removed within 
 six or seven days, unless indicated earlier by pain or 
 swelling of the toes. This affords an opportimity to 
 examine the site of injury and to apply a second cast 
 which invariably fits better than the original one. 
 When there is considerable extravasation or super- 
 ficial contusion, a wet dressing and padded lateral 
 splints should be applied and the leg placed in a frac- 
 ture box with a wool pad beneath the tendo Achilles, 
 to avoid pressure on the heel. After the swelling 
 has subsided and the skin has healed, the plaster-of- 
 Paris may be applied as before. If the lines of fracture 
 are very oblique and the overlapping is persistent, it 
 will be necessary to employ the extension apparatus 
 or, as a last resort, perform a subcutaneous tenotomy 
 on the tendo Achilles, to relieve the tension. The 
 foot should be immobilized at a right angle in all 
 these cases. 
 
 The treatment of separation of the epiphyses of 
 
I04' MINOR AND EMERGENCY SURGERY 
 
 the tibia consists of reduction of the displacement 
 and fixation in plaster-of -Paris. 
 
 In all fractures of the tibia alone the fibula per- 
 forms the function of a splint for the broken bone so 
 that the deformity and displacement are not marked. 
 The treatment is practically identical with that em- 
 ployed for simultaneous fracture of both bones, ex- 
 cept those of the lower end involving the ankle-joint, 
 which cases demand early passive motion and mas- 
 sage to prevent subsequent ankylosis. 
 
 The treatment of separation of the epiphyses of the 
 fibula consists of fixation by splints or a plaster-of- 
 Paris bandage. 
 
 Fractures of the upper end and shaft of the fibula 
 are best placed in a fracture box for a week and later 
 encased in plaster-of-Paris. 
 
 Fracture of the lower end of the fibula, or Pott's 
 fracture, is a complicated fracture. It usually occurs 
 about 3 inches above the malleolus, rupturing the 
 internal lateral ligament, and wrenching off a spicule 
 of bone from the tibia. There is always a loss of con- 
 tinuity between the foot and malleolus, while if the 
 anterior tibio-fibular ligament has been ruptured and 
 the mortise considerably disturbed, the ankle-joint is 
 widened and the astragalus displaced upward and 
 backward. The foot is invariably everted in all 
 cases of Pott's fracture. The accurate correction of 
 the deformity depends upon the re-establishment of 
 normal anatomical relationship, so that an exact con- 
 ception of the pathological picture is of the utmost 
 importance. Reduction is best accomplished by 
 firmly grasping the toes and heel, exerting direct down- 
 
SIMPLE FRACTURES 
 
 105 
 
 ward traction for a minute or two and swinging the 
 foot into position. When there is posterior displace- 
 ment, the foot must also be pulled forward. If the 
 reduction is correct and complete and proper posi- 
 tion maintained, the pain promptly disappears. 
 Inversion of the foot must be slightly exaggerated 
 throughout the treatment of these fractures. The 
 most satisfactory appliance is the Dupuytren splint, 
 which is an internal board splint extending from the 
 knee to below the foot and padded 4 inches thick 
 to just above the malleolus. The foot is now inverted 
 by pulling the toes over with a bandage. In spite 
 of its efficiency, this dressing is often so uncomfort- 
 able to the patient that plaster-of -Paris dressings are 
 frequently employed. Whenever the annular liga- 
 ment is torn and the tibialis posticus is released from 
 its groove, it is good surgery to make an incision, re- 
 store the tendon of the tibialis posticus to its normal 
 position arid suture the annular ligament. 
 
 Fractures of the bones of the foot are usually accom- 
 panied by profuse swelling and are treated with the 
 foot extended upon the leg at a right angle, being 
 supported by a well padded splint of binder's board 
 until the swelling subsides. Plaster-of-Paris may 
 then be applied, with a fiat-foot plate on the sole of 
 the foot. 
 
CHAPTER V. 
 
 COMPOUND FRACTURES AND TRAUMATIC 
 AMPUTATIONS. 
 
 Any fracture communicating with the exterior 
 is termed a compound fracture. Single, uncom- 
 phcated compound fractures, produced from within 
 outward and with the tip of a fragment only pro- 
 jecting, need not be considered exceptionally im- 
 portant, as the rent in the skin usually heals kindly, 
 converting the fracture into a simple one. On the 
 contrary, compound comminuted fractures with 
 extensive destruction of, or contusion to, the ad- 
 jacent soft parts, compound fracture dislocations, 
 and gun-shot fractures are grave injuries. The 
 more severe types of compound fractures, in which 
 amputation is partially completed by the inflicting 
 traumatism with destruction of the principal blood 
 supply, may be viewed as traumatic amputations. 
 In these cases the cosmetic and functional results 
 as well as the life of the patient will depend upon : 
 
 The surgeon's judgment and skill in each case. 
 
 The wishes of the patient and his relatives regard- 
 ing the proposed and advised surgical procedures. 
 
 The patient's health, constitution, age and habits. 
 
 The integrity of the circumference of the limb. 
 
 The preservation of an adequate blood supply 
 to the injured area and the distal parts. 
 
 Proper emergency treatment. 
 io6 
 
COMPOUND FRACTURES 107 
 
 Perfect operative technic. 
 
 The degree to which it is possible to restore the 
 injured structures to their normal relationship. 
 
 Intelligent after-treatment. 
 
 Good nursing. 
 
 Besides the local conditions, six possible inter- 
 current occurrences must be considered: shock, 
 tetanus, gangrene, sloughing, secondary hemorrhage 
 and sepsis. 
 
 Emergency treatment of compound fractures and 
 traumatic amputations is essentially that of the 
 simple fracture plus an extensively lacerated wound. 
 Hemorrhage from the larger blood-vessels must be 
 immediately controlled, usually requiring either 
 the tourniquet or hemostatic forceps. Applying 
 the tourniquet too far above the upper limit of the 
 injury may seriously embarrass subsequent manage- 
 ment of the case, hence the site of constriction 
 should be carefully selected. Large foreign bodies 
 may be removed, provided that it can be done 
 expeditiously, but no bone fragments should be 
 disturbed. The injured part may be returned to 
 its approximate normal position, covered with a 
 heavy wet dressing and bandaged between long 
 splints. The patient should receive a hypodermic 
 injection of morphine and be transported com- 
 fortably to the hospital. Even in event of a trau- 
 matic amputation these measures are permissible 
 and indicated. It is best to do nothing further 
 for the moment since the injury frequently presents 
 a different aspect when examined in the hospital. 
 Don't perform, amputations on the street. An ampu- 
 
io8 
 
 MINOR AND EMERGENCY SURGERY 
 
 tation is an operation of no small magnitude, cer- 
 tainly not one to be done on a street corner. 
 There are instances, however, in which it may be 
 necessary to complete a traumatic amputation to 
 release the patient from an enormous weight. When 
 this is done, the severed member should also be 
 transferred to the hospital, because many patients 
 will desire to have it cared for by an undertaker. 
 
 Operative Treatment of Compound Fractures and 
 Traumatic Amputations. — Having removed the pa- 
 tient to a hospital or other convenient surroimdings, 
 the question presents in severe cases: shall the 
 limb be immediately amputated or shall an effort 
 be made to preserve it, notwithstanding the fact 
 that the patient's life may be jeopardized? The 
 former (primary amputation) may be designated 
 radical treatment, while the latter is obviously con- 
 servative. The answer to this question will rest 
 entirely upon the surgeon's judgment after care- 
 ful consideration of all the facts presenting in the 
 individual case, provided consent of the patient 
 and his relatives to the procedures selected can be 
 obtained. Factors arguing in favor of one or the 
 other methods of dealing with a compound fracture 
 or a traumatic amputation may be tabulated con- 
 veniently : 
 
 Radical. 
 Constitution poor. 
 Age over fifty. 
 Alcoholic habits. 
 More than two-thirds of the 
 
 circumference of the limb 
 
 destroyed. 
 
 Conservative . 
 Constitution good. 
 Age under fifty. 
 Temperate habits. 
 One-third of the circumfer- 
 ence of the limb intact. 
 
COMPOUND FRACTURES 
 
 109 
 
 Main blood supply to the site 
 of injury and the distal 
 parts destroyed. 
 
 Surroundings favoring infec- 
 tion. 
 
 Proper after-treatment ques- 
 tionable. 
 
 Good nursing not obtainable. 
 
 If a clean amputation is per- 
 formed, the patient's life 
 will not be jeopardized. 
 
 Adequate blood supply to 
 tlie site of injury and 
 parts beyond. 
 
 Perfect asepsis and antisep- 
 sis to the greatest attain- 
 able degree. 
 
 Intelligent after-treatment 
 assured. 
 
 Good nursing possible. 
 
 Sepsis always an element of 
 danger but a secondary 
 amputation can be per- 
 formed at any time. 
 
 All the facts at our command, together with the 
 opinion formed, should be cited and the patient 
 must then decide for himself which course shall 
 be pursued in border-line cases. The surgeon, being 
 the better judge of what is required, however, should 
 advise, or even urge the patient as to the course to 
 be taken. Great comminution of bone with ex- 
 tensive destruction of the tissues, two or more 
 compound fractures in the same limb with rupture 
 or severe injury of the principal blood-vessels and 
 nerves, and compound fractures communicating with 
 large joints are usually considered definitely positive 
 indications for primary amputation. In spite of 
 this fact, occasionally it will be possible to save a 
 limb in which even one of these conditions obtains. 
 Unless immediate operation is imperative to save life, 
 it is advisable to afford the patient an opportunity 
 to rally from the shock present before tmdertaking 
 any operative measures. 
 
 For the technic of the various amputations the 
 reader is referred to other works on the subject. 
 
up MINOR AND EMERGENCY SURGERY 
 
 If conservative measures have been selected, all 
 efforts should be made to convert the fracture into 
 a simple one as soon as possible. Despite the kindly 
 appearance of some of these wounds, they must be 
 viewed with suspicion, and all compound fractures, 
 including those of the skull, must be considered and 
 treated from the beginning as though infected. 
 
 Conservative Surgery in Compound Fractures 
 and Traumatic Amputations. — To facilitate the 
 necessary manipulations an anesthetic is demanded. 
 Blocking the main nerve trunks with cocaine, as 
 advocated by Crile and others, is the only method of 
 obtaining satisfactory local anesthesia. This also 
 prevents shock to a large extent, as the injection of 
 a I per cent, solution into the nerve trunks and peri- 
 ostetim impedes the transmission of excessive nerve 
 impulses. Local anesthesia, per se, does not bring 
 about muscular relaxation and its use is consequently 
 restricted to selected cases. In general, narcotiza- 
 tion will prove far more satisfactory, and if ether or 
 the nitrous oxide-oxygen combination be used in 
 conjunction with nerve blocking, there need be but 
 slight concern regarding subsequent shock. 
 
 Having secured surgical anesthesia, the wound 
 should be lightly packed with sterile tampons to 
 protect the exposed tissues from any additional 
 traumatism incidental to thorough cleansing. The 
 entire part should then be shaved and vigorously 
 scrubbed with a moderately stiff nail brush and 
 tincture of green soap. Following this, the skin may 
 be rapidly sterilized by irrigating it with an iodine 
 solution: i dram of the tincture to 8 ounces of 
 
COMPOUND FRACTURES m 
 
 water. We are now working in a surgically clean 
 field. 
 
 A sterilized elastic tourniquet applied just above 
 the injured area maybe tightened or loosened at will 
 by an assistant, thus controlling hemorrhage that 
 may occur. The tourniquet should not be suffi- 
 ciently narrow to cut into the skin, nor its applica- 
 tion prolonged unduly. 
 
 The tampons are extracted and oil or other 
 grease that may have entered the wound is dissolved 
 and quickly removed with swabs impregnated with 
 gasoline or benzine. 
 
 The wound should now be sufficiently enlarged 
 longitudinally to permit a thorough inspection of the 
 damaged tissues and the removal with forceps of all 
 visible foreign material. Subsequently, the tissues are 
 mopped, but not scrubbed, with some disinfectant 
 that permeates readily. For this purpose Harrington's 
 solution (hydrargyri chloridi corrosivi gr. xii, acidi 
 hydrochlorici 5i, alcoholis Oii) is the most efficacioiis. 
 A compound fracture should not be roughly probed 
 and the operator should keep his fingers out of the 
 wound. 
 
 If laceration and destruction of tissues are not 
 especially extensive, the damaged areas may be 
 trimmed off and excised, but in the more severe forms 
 the crushed parts are better left until a line of 
 demarcation appears. 
 
 Bone fragments must be minutely inspected. 
 Pieces entirely devoid of periosteum should be 
 removed, but no spicule having a periosteal attach- 
 ment should be disturbed. The fragments may 
 
11,2 MINOR AND EMERGENCY SURGERY 
 
 be gently returned to the most natural position to 
 effect alignment. The query now arises, how can 
 we best maintain proper approximation? Many 
 devices for this purpose are at our command but a 
 good working rule is, the less foreign material 
 introduced the better. Occasionally, fixation of 
 the fragments by uniting the periosteum with 
 absorbable suture material and re-enforced by an 
 external dressing is all that will be required. More 
 often it will be necessary to drill the bones and 
 fasten them together with wires or bone plates. 
 If wire is chosen, the bronze-aluminum variety 
 is the most satisfactory, being stronger and less 
 brittle than either silver or iron wire. Nails and 
 screws passing directly through the bones are not 
 usually effective since they soon loosen and thus 
 fail to fix the fragments firmly until union is com- 
 plete. Lane's steel bone plates, secured by silver 
 plated screws, are often too rigid and unyielding. 
 The silver bar devised and advocated by Sick comes 
 in lengths with holes for screws and may be cut 
 any length desired. As this is slightly pliable and 
 flexible and is easily removed later through a small 
 incision, it is the most desirable form of bone plate. 
 
 Ruptured muscles, nerves and blood-vessels 
 should be accurately approximated and sutured 
 with No. I iodine catgut. 
 
 Drainage must always be established, preferably 
 at the most dependent portion of the wound; the 
 ordinary cigarette drain or fenestrated rubber tubing 
 will serve this purpose best. If the anterior aspect 
 of the limb is the seat of injury, through-and-through 
 
COMPOUND FRACTURES 
 
 113 
 
 drainage may be attained through a stab wound on 
 the posterior surface, dividing the deep fascia if 
 needs be. 
 
 The wound is now loosely closed with interrupted 
 sutures of silkworm gut, great care being exercised 
 not to constrict (Fig. 16). A heavy wet gauze 
 dressing saturated with aluminum acetate and ap- 
 propriate splints are applied and the whole placed 
 in a fracture box. If the wound has been contami- 
 nated with street dirt or gunpowder, it is advisable 
 
 Fig. 16. — ^Wound sutured with through-and-through drainage 
 established. 
 
 to administer an immunizing dose of tetanus anti- 
 toxin subcutaneously as a precaution against the 
 development of tetanus. 
 
 After-treatment of compound fractures and trau- 
 matic amputations consists of free drainage and 
 constant wet dressings. The former may be favored 
 by sprinkling the wet gauze dressing with glycerine 
 from time to time and daily irrigation of the wound 
 and drainage tubes with normal saline solution or 
 a watery solution of iodine. Glycerine is a valuable 
 agent to keep the dressings moist, promote drainage 
 
114 
 
 MINOR AND EMERGENCY SURGERY 
 
 and hasten sloughing. Continuous irrigation of 
 the entire dressing with normal saline solution, 
 with a rubber sheet under the limb, is a satisfactory 
 manner of maintaining saturation of the dressings. 
 This procedure may be easily accomplished by 
 means of a tin pail suspended above the patient 
 with several small holes in its bottom, through which 
 strips of linen have been forcibly pulled. After 
 the first week, more contusion often becomes ap- 
 parent and continuous irrigation should be kept 
 up until sloughing ceases. 
 
 Progressive tissue degeneration with clamminess 
 
 Fig. 17. — Fenestrated plaster-of -Paris cast re-enforced with metal bar. 
 
 or gangrene of the distal part or persistent hyper- 
 pyrexia denotes that either the blood supply is 
 inadequate or the septic process is beyond control. 
 Further efforts to save the limb are then of no avail 
 and a secondary amputation through sound tissues 
 should be performed. 
 
 If, however, the wound is evidently running an 
 aseptic course and the case progresses favorably, 
 the splints should be removed and a fenestrated 
 plaster-of-Paris dressing substituted as soon as 
 sloughing ceases and the danger of sepsis has passed. 
 
COMPOUND FRACTURES 115 
 
 It is best to leave an aperture in the cast over the 
 wound area during its appHcation rather than to 
 cut one afterward. The strength of the dressing 
 may be greatly increased by incorporating two 
 (one on each side) metal bars with a curve over the 
 fenestration in the center of the plaster (Fig. 17). 
 The dressings are then continued through the aper- 
 ture. Surrounding the limb with sand bags serves 
 to steady it and adds greatly to the patient's comfort. 
 
 When the granulating areas become visible, equal 
 parts of balsam of Peru and glycerin, poured directly 
 into the wound, will keep the raw surfaces clean and 
 stimulate reparative processes. If the denuded 
 area is extensive, the granulations may be covered 
 with skin-grafts or, almost equally well, with the 
 external membrane found in direct approximation 
 with an egg shell, teased into small pieces under 
 saline solution, placed upon the raw surfaces and 
 covered with lint spread with ichthyol ointment. 
 These dressings must be renewed daily if the egg 
 membrane is used and at each dressing two or three 
 little islands from the previous one will be found ad- 
 herent. They are excellent foundations for the ulti- 
 mate process of epithelial regeneration. 
 
 Passive motion and massage should be commenced 
 as early as possible and the further recovery of the 
 injured part left to vis medicatrix naturcF. 
 
 Gratifying success in a large number of cases with 
 the treatment outlined above, as has been the 
 author's experience, will incline the surgeon to adopt 
 a conservative attitude toward most cases of 
 compound fracture or traumatic amputation. 
 
CHAPTER VL 
 SEQUELiE OF FRACTURES. 
 
 Complete restoration of function and a perfect 
 cosmetic result depend almost entirely upon in- 
 telligent treatment after a fracture has been reduced. 
 Although the Rontgen ray has demonstrated that 
 mathematical reduction of displaced bone frag- 
 ments is rare, careful attention to details and exact 
 technic will usually assure physiologic restoration 
 with little or no deformity at the injured site. Such 
 a result may be considered eminently satisfactory. 
 Per contra, the surgeon's misdirected efforts, care- 
 lessness or errors of judgment will eventually be- 
 come manifest by delayed union, fibrous union, 
 deformed union, refracture, exuberant callous 
 formation, nerve involvement, loss of function (stiff- 
 ness, muscular atrophy, etc.), rupture and slough- 
 ing of the skin and soft parts (converting the in- 
 jury into a compound fracture), pressure sores, 
 edema, ankylosis or sepsis. 
 
 When the reparative process is retarded beyond 
 that period in which normal union should occur, 
 the condition is known as delayed union. De- 
 ficiency or slow development of the provisional 
 callus is the etiological factor and may be due to 
 either constitutional or local causes. Among the 
 former may be mentioned syphilis, individual 
 dyscrasia, anemia, senility, etc., and the treatment 
 
 ii6 
 
SEQUELM OF FRACTURES 117 
 
 is obvious. The chief local condition predisposing 
 to delayed union is imperfect coaptation of the frag- 
 ments, due to an incorrect diagnosis or improper 
 reduction. Impairment of the circulation may- 
 result from constriction when the retentive ap- 
 pliances are too tight or to a reduction of the blood 
 supply occasioned by the necessary ligation of a 
 large artery. Premature motion, active or passive, 
 is frequently a cause and the retentive apparatus 
 should be permitted to remain sufficiently long to 
 allow the callus to solidify and union to become 
 firm, although not long enough to interfere with the 
 use of the limb. At the same sime, too early use of 
 the limb may also delay the union. Operative 
 measures are optional. 
 
 Non-imion is another term for an ununited fracture, 
 and in the words of Stuart McGuire, "The increas- 
 ing number of cases of ununited fracture that come 
 to the surgeon, referred by the attending physician, 
 is a clear index of the lack of knowledge possessed 
 by the average doctor with regard to the treatment 
 of fractures." In these cases callus formation is 
 practically absent and the ends of the fragments 
 roimd off with closure of the medullary canals. 
 The influence of constitutional disturbances in 
 eliminating callus formation is doubtful, with the 
 exception of syphilis. Antisyphilitic treatment for 
 a few days is never detrimental to the patient and 
 often results in remarkable improvement. This, 
 however, must not be construed to mean neglect of 
 the patient's general condition, as. the correction of 
 systemic errors is of great importance. The local 
 
ii8 ■ MINOR AND EMERGENCY SURGERY 
 
 causes of non-union are: persistent separation of 
 the fragments, imperfect coaptation with absence 
 of the periosteal bridge, interposition of soft parts, 
 actual loss of bone, impaired vascularity and sup- 
 puration. A Rontgen ray examination will dis- 
 close many features of the local condition, and the 
 proper interpretation of such an investigation may 
 serve as a guide to the intelligent selection of a 
 particular method of treatment. Persistent separa- 
 tion of the fragments results from either failure to 
 overcome muscular resistance or not accurately 
 approximating the fragments when applying the 
 fixation dressing. This in turn is most frequently 
 due to the omission of anesthesia. If the patho- 
 logical conditions are present for a sufficiently long 
 time, it will be necessary to resect the ends of the 
 bones, accurately adjust the freshened surfaces and 
 maintain correct position by sutures, wires or some 
 other suitable material. Imperfect coaptation of 
 the bones with absence of the periosteal bridge is often 
 followed by some osseous necrosis which requires 
 operation before satisfactory union occurs. Failure 
 to recognize the interposition of soft structures be- 
 tween the fragments is an inexcusable error and 
 operative measures should be instituted primarily. 
 Inability to elicit crepitus, plus mobility, at the site 
 of fracture should ever arouse the surgeon's sus- 
 picions. Actual loss of bone occurs in some instances 
 of compound fractures and the gap is best filled by 
 shortening of the limb or transplantation of bone. 
 Impaired vascularity may be due to disturbances of 
 metabolism or to the destiniction of certain blood- 
 
SEQUELM OF FRACTURES 119 
 
 vessels, for example anemia or loss of the main 
 arterial supply or the nutrient artery, when the 
 injury was sustained. Constitutional treatment 
 and Bier's method of elastic constriction to produce 
 hyperemia are usually followed by considerable 
 improvement. Suppuration invariably interferes 
 with the reparative process, but after eliminaton of 
 the infection improvement is rapid. Occasionally, 
 if the suppurative process continues for some time, 
 it will be necessary to expose the seat of fracture 
 and remove the diseased bone. Some surgeons 
 recommend the injection of from five to ten drops of 
 a 10 per cent, solution of zinc chloride between the 
 bones and the administration of lime salts as an aid 
 to organization of callus. Fifty per cent, alcohol 
 has also been used for this purpose. If operative 
 measures are contra-indicated or refused by the 
 patient, mechanical apparatus may be advan- 
 tageously employed. 
 
 Fibrous union is due to failure of the provisional 
 callus to ossify, because the osteoblasts do not 
 functionate properly, although the fibrous portion 
 of the union is satisfactory. Owing to the localities 
 in which fibrous union usually results, such as the 
 patella, olecranon process of the ulna and head of the 
 femur, it is natural to conclude that faulty nutrition 
 is responsible. An open operation is the only 
 recourse and the advisability of this procedure is 
 often questionable, particularly in the upper ex- 
 tremity. Unless the patient is a healthy, well 
 nourished and developed adult, it is better to let 
 
I20 • MINOR AND EMERGENCY SURGERY 
 
 well enough alone than to meddle with an unknown 
 quantity. 
 
 Deformed imion is the result of faulty adjustment 
 and generally illustrates an error of omission or 
 commission on the part of the surgeon. When due 
 to projection of the tip of one fragment, the skin 
 may be cocainized and incised and the offending 
 spicule removed with bone forceps. If due to poor 
 alignment, resection and re-adjustment are all that 
 can be offered and are almost always followed by 
 pronounced shortening. So before operating for 
 this condition it is wise to hesitate and consider: 
 of how much definite improvement can the patient 
 be assured? 
 
 Refracture is uncommon in a normal individual 
 but may occur as the result of too early passive mo- 
 tion (subjecting the broken bone to strain or pressure 
 before union is firm), of violent traumatism and of 
 carelessness on the part of the patient or surgeon. 
 Anemia, inadequate nutrition and diminution of 
 inorganic salts in the economy are predisposing 
 factors and should be corrected by the employment 
 of suitable remedial agents. 
 
 Exuberant callus formation is more common in 
 fractures occurring in new-born children. The 
 condition is an extremely painful one but the prog- 
 nosis is good and the ultimate result satisfactory. 
 Treatment is of no avail, unless the callus mass 
 unites two parallel bones; then a portion may be 
 exsected. 
 
 Nerve involvements are produced by injury to the 
 nerve at the time of fracture or, later on, by con- 
 
SEQUELS OF FRACTURES 121 
 
 tusion from undue pressure of splints, bandages, 
 impinging callus, etc., or laceration caused by 
 mobility of the fragments where good approxima- 
 tion is not secured and maintained. Contused and 
 slightly lacerated nerves usually recover while the 
 fracture is knitting, being aided by the enforced 
 rest, warmth of the dressing and natural reparative 
 process. Massage, passive motion, electricity (pre- 
 ferably the galvanic current) and superheated air 
 (400° F.) may hasten a tardy improvement. When 
 the nerve is severely lacerated or divided, operative 
 interference is indicated. To assure a normal 
 physiologic condition the operation should be done as 
 early as possible, suturing the bone as well as the 
 nerve. If the injury is one of long standing, neuror- 
 rhaphy will be servicable, although the ulimate re- 
 covery will be slow. 
 
 Loss of function, not due to nerve injuries, is 
 usually not a matter of great consequence. Removal 
 of the fixation dressing, mobilization, massage and 
 use of the part are sufficient to restore the impaired 
 power. Once union is firm, voluntary action of the 
 neighboring muscles should be encouraged. 
 
 The surgeon is seldom responsible for rupture or 
 sloughing of the skin and soft parts within the first 
 week after the fracture, unless the wet dressing has 
 been omitted, since they are generally due to con- 
 tusion that was not primarily apparent. Faulty 
 alignment and imperfect immobilization may per- 
 mit the rough margin of a fragment to penetrate the 
 skin and must be corrected when they are causes. 
 
 Pressure sores are produced by an ill-fitting plaster 
 
122. MINOR AND EMERGENCY SURGERY 
 
 cast or insufficiently padded splints and the surgeon's 
 attention should be attracted by complaint on the 
 part o£ the patient. Manifestly, the cast or splints 
 must be removed and a new dressing applied. 
 
 Edema is always due to failure to equalize the 
 pressure on the distal portion of a limb and may be 
 easily eliminated by the application of a snug band- - 
 age. 
 
 Ankylosis occurring as a complication of a fracture 
 near a joint is due to peri-articular thickening and 
 disuse of the joint. It is not apt to be permanent, 
 except at the elbow- and knee-joints. The treatment 
 of this condition has been outlined in the chapter on 
 traumatic injuries of joints. 
 
 Sepsis occurs after compound fractures only and 
 has been discussed in Chapter V. • 
 
CHAPTER VII. 
 ACUTE PYOGENIC INFECTIONS. 
 LOCALIZED PYOGENIC INFECTIONS. 
 
 An abscess is the formation in tissue of an abnor- 
 mal cavity containing pus. It is accompanied by 
 softening and sloughing of tissue and, although show- 
 ing a tendency to encapsulation, the suppurative pro- 
 cess will follow the line of least resistance so that the 
 purulent accumulation may either rupture externally 
 or burrow deeper into the soft structures. Thus, 
 if neglected, it may produce a localized but gradually 
 extending cellulitis, septicemia and death. The 
 neighboring lymphatics are soon involved and 
 rapidly transmit the septic process to adjacent 
 lymphatic glands, lymphangitis, lymphadenitis and 
 metastatic abscesses being frequent sequelae. The 
 symptoms and physical signs of an abscess are too 
 well known to merit enumeration. 
 
 A furuncle, or boil, is a circumscribed pyogenic 
 infection of a sebaceous gland or hair follicle, termi- 
 nating in suppuration with a central necrotic mass. 
 Because of its superficial location a furuncle will 
 eventually rupture through the skin spontaneously 
 and thus establish drainage. The infection is usually 
 self -limited, since nature affords relief before the sup- 
 puration progresses to any great extent. In other 
 respects a furuncle differs but little from an abscess. 
 
 123 
 
124- MINOR AND EMERGENCY SURGERY 
 
 A carbuncle is an acute phlegmonous inflammation 
 of the skin and subcutaneous tissues with multiple 
 foci of necrosis. The cellular tissues slough exten- 
 sively, the skin becomes indurated and dusky and 
 numerous small perforations soon appear. Carbun- 
 cles nearly always occur on the neck or back in 
 adults with some constitutional disturbance, notably 
 diabetes. 
 
 Cellulitis is an inflammation of the loose connective 
 tissue, invariably of bacterial origin, due to (i) a 
 severe contusion or (2) an infected wotuid. Unless 
 relieved promptly, suppuration is inevitable. The 
 immediate complications are (i) extensive destruc- 
 tion of tissue, (2) suppurative teno-synovitis, (3) 
 lymphangitis and (4) lymphadenitis. When treat- 
 ment is neglected or misdirected, the infection tends 
 to follow the fascia and tendon sheaths, subsequently 
 attacking the bone with resulting necrosis. The 
 lymphatics rapidly transmit the infection upward, 
 toxines are absorbed and septicemia and death en- 
 sue. The rapidity with which a cellular suppuration 
 will sometimes spread is remarkable. The severity 
 of the affection in a given instance is, of course, 
 largely influenced by the virulence of the micro-organ- 
 isms responsible for the infection and the patient's 
 resistance to bacterial invasion, and the subsequent 
 toxemia. The most reliable index of the patient's 
 antagonistic power is the leucoc3rtosis developed. 
 The phenomena denoting a gradually spreading cel- 
 lulitis are: (i) history of an injury (contusion or in- 
 fection), (2) swelling, (3) skin cyanotic and edema- 
 tous (indicating partial circulatory stasis), (4) pain, 
 
ACUTE PYOGENIC INFECTIONS 125 
 
 (5) tenderness on pressure, (6) local heat, (7) restricted 
 mobility of the part, (8) red and indurated super- 
 ficial lymphatics, (9) upper limit of the involved 
 area constantly extending, and (10) evidences of 
 toxic absorption (chills, pyrexia, increasing rapidity 
 of the pulse, etc.). 
 
 In all infectious conditions the presence of con- 
 stitutional disorders is of paramount importance. 
 For example, furunculosis (intermittent outbreaks 
 of boils) and carbuncles are frequently associated 
 with diabetes, nephritis, plethora, etc., and con- 
 sequently a thorough urinalysis should be made in 
 all these cases. Obviously, the correction of sys- 
 temic errors or disturbances will increase the patient's 
 resistance to bacteriemia and toxemia. 
 
 Treatment of Localized Pyogenic Infections. — The 
 cardinal principle in the treatment of all localized 
 collections of pus is to establish drainage immedi- 
 ately. Additional measures are also frequently in- 
 dicated but without effecting a point of exit for the 
 pus and maintaining free drainage the integrity 
 of the tissues still uninvolved and even the patient's 
 life may be jeopardized. Every effort should be 
 made to assist the tissues in their effort to mitigate 
 bacterial activity. 
 
 Poultices, devised by our grandmothers, are 
 mentioned only to be condemned. Nothing will 
 be gained by waiting for "pointing" except bacterial 
 multiplication. Even though a poultice may en- 
 courage spontaneous rupture of the skin, it will be 
 necessary to enlarge the aperture and treat in the 
 usual manner. On the contrary, cold wet dressings 
 
12 6, MINOR AND EMERGENCY SURGERY 
 
 may be of service in the early inflammatoiy stages 
 by relieving local congestion. The application of 
 antiseptic solutions (bichloride of mercury and 
 carbolic acid usually being favored) with the hope 
 of exerting destructive influence on the pyogenic 
 organisms is absurd, since no antiseptic can pene- 
 trate the unbroken skin sufficiently to restrict germ 
 growth. Were this fond hope realized, the patient 
 would be poisoned by vascular absorption. Car- 
 bolic dressings are particularly dangerous because 
 of the frequency with which poorly nourished tissues 
 become gangrenous from its constant use. Benefit 
 is derived from dressings saturated with plain water 
 or some evaporating lotion, such as equal parts of 
 alcohol and witch hazel, simply because the evapora- 
 tion assists the restoration of the normal vascular 
 equilibrium. In exceptional instances the necessity 
 for incision may thus be obviated. 
 
 As in all other surgical procedures, the overlying 
 and adjacent skin should be cleansed and the opera- 
 tor's hands should be clean. This may seem a 
 superfluous injunction, yet carelessness is the rule 
 rather than the exception. 
 
 Anesthesia of the site of incision should be secured 
 and for this purpose the ethyl chloride spray is ideal. 
 The container is the only apparatus required, 
 cutaneous anesthesia and temporary ischemia are 
 easily and quickly obtained, there is no additional 
 tension on the inflamed tissues and this method of 
 freezing is not followed by sloughing. 
 
 All incisions are preferably made parallel with 
 the course of the blood-vessels and the longitudinal 
 
ACUTE PYOGENIC INFECTIONS 127 
 
 axis of the part. By so doing profuse hemorrhage 
 will be avoided and all possible sources of nutrition 
 preserved. When the pus collection is small, a 
 single incision should be made directly over the 
 center of the tumefaction and need be large enough 
 only to allow free vent for the pus and the intro- 
 duction of a small drain. Abscesses situated near 
 large blood-vessels, such as axillary abscesses, are 
 best opened by incising the skin, pushing in a pair 
 of closed hemostatic forceps and withdrawing them 
 open. In large carbuncles and extensive cellulitis 
 the aperture must be larger or multiple incisions 
 may be made at various points to permit the estab- 
 lishment of several channels of through-and- through 
 drainage. In such instances some of the deeper 
 dense tissues should also be divided, if the infection 
 appears to extend inward. Although, as a rule, 
 incisions are not required until pus has formed, 
 early incision is often necessary to relieve tension 
 and the strangulated circulation, thus preventing 
 the extensive sloughing that follows steady intense 
 pressure. It is therefore unwise to always wait 
 for fluctuation before incising. When the life of 
 healthy tissue is endangered by a virulent sup- 
 purative process, such as a cellulitis due to the 
 staphylococcus pyogenes albus, it is best to extend 
 the incision into the sound region. The length and 
 depth of the wounds are of secondary consideration. 
 When the cosmetic results are of special importance, 
 much can be accomplished in cases of circum- 
 scribed pus collections with a small incision followed 
 by active hyperemia. The latter may be obtained 
 
128 MINOR AND EMERGENCY SURGERY 
 
 by small sterile Bier suction cups, the rims being 
 lubricated with petrolatum, applied in seances of 
 five minutes each with three minute intervals of 
 rest for forty-five minutes. Much has also been 
 claimed for passive hyperemia as a preventive of 
 suppuration and as an aid in limiting the infectious 
 process, being used in conjunction with drainage, 
 after the suppuration has actually occurred. 
 
 After all incisions, the pus should be expressed 
 by exerting gentle but firm pressure over the sur- 
 rounding skin and local bleeding should be encouraged 
 for a few minutes. General blood-letting is contra- 
 indicated, since it depresses the patient's vitality 
 and thus lowers his resistance to septic infection. 
 Should the hemorrhage appear excessive or be 
 unduly prolonged, it may easily, be controlled by 
 packing the cavity temporarily with gauze strips 
 wrung out in hot water. Bands of fascia and tendon 
 sheaths must be carefully investigated and longitu- 
 dinally incised, if necessary. A probe should be 
 passed down to the subjacent bone to exclude 
 periosteal involvement and necrosis. When a felon 
 exists, it should be incised down to the bone. 
 
 Curettage of the cavity after pus evacuation is 
 advocated and practised by many surgeons but is 
 advisable in small abscesses and carbuncles only. 
 In all other conditions it is better to wait for the 
 slough to separate, in order to avoid injuring areas 
 of normal tissue. In carbuncles the -undermined 
 skin areas should be excised before curetting. 
 
 To secure sterilization, check hemorrhage, hasten 
 sloughing and stimulate granulation, the cavity 
 
ACUTE PYOGENIC INFECTIONS 
 
 129 
 
 should be filled with tincture of iodine with an 
 ordinary medicine dropper. This should be per- 
 mitted to remain undisturbed for a few minutes 
 before introducing a drain. Pure carbolic acid has, 
 also been used for this purpose but its use is best 
 restricted to carbuncles. Some surgeons practise 
 hypodermic injections of powerful antiseptic solu- 
 
 FiG. 18. — Furuncle on the neck properly incised and drained with gutta 
 percha tissue. 
 
 tions into or near the affected region. These in- 
 jections may limit the inflammation, yet they possess 
 the disadvantage of being extremely painful and 
 constitutional poisoning may result therefrom. 
 
 All infected cavities must be drained. Drainage 
 does not mean plugging the opening with gauze, 
 but maintaining a free flow of discharge, be it simple 
 9 
 
13° 
 
 MINOR AND EMERGENCY SURGERY 
 
 exudate or pus. Gauze, plain or medicated, does 
 not drain, as is invariably demonstrated by the 
 gush of pent up pus that follows the removal of a 
 gauze wick. The most satisfactory drain for a 
 small aperture is a little roll of gutta-percha tissue 
 (Fig. 1 8) . For larger openings and extensive slough- 
 ing areas the fenestrated rubber tube is the drain 
 par excellence. When through-and-through drain- 
 age is desired, the counter-openings are best made 
 by pushing a long handled dressing forceps under- 
 
 FiG. 19. — Dressing forceps pushed through incision and counter-opening, 
 grasping drainage tube. 
 
 neath the skin to the opposite side of the part and 
 incising over the tip. The jaws are then opened, 
 grasp one end of the tube and withdrawn, thus 
 pulling the tube into position (Fig. 19). Peple has 
 recently devised a serviceable drain, consisting of 
 a split rubber tube into which are sewed several 
 folds of rubber dam. This drain possesses capillar- 
 ity, does not become clogged and drains along its 
 entire length. Its single objection is the impossibility 
 of irrigation through the tube, hence it cannot be 
 used when sloughing is extensive. 
 
ACUTE PYOGENIC INFECTIONS 
 
 131 
 
 A voluminous wet dressing should cover all 
 infected parts and extend well beyond in every 
 direction. Plain water, normal saline solution, 
 aluminum acetate solution, alcohol and witch hazel 
 or Burrow's solution may be used for soaking the 
 gauze. The particular agent selected is of minor 
 importance, provided the dressing is kept constantly 
 wet. When the patient is confined to bed with a 
 large surface requiring attention, it is well to employ 
 continuous irrigation. Saturating the dressings with 
 a hot watery solution of i per cent, sodium citrate 
 and 4 per cent, sodium chloride, as recently 
 advocated by Wright, is an excellent method of 
 promoting drainage. The solution is hypertonic 
 and stimulates exudation by osmosis. The sodium 
 citrate prevents coagulation and scab formation 
 so that the cavity will drain through a compara- 
 tively small incision. The skin must be smeared 
 with vaseline or some other emollient to prevent 
 the dermatitis that might result from its continuous 
 application. This solution is contra-indicated if 
 there is persistent oozing and should not be used in 
 clean cases where profuse drainage is not essential. 
 The treatment should never be prolonged more 
 than three days or healing will be markedly retarded. 
 
 The presence or absence of systemic disturbances 
 in connection with pyogenic infections should be de- 
 termined and support will be required to overcome 
 the debilitating effect of the septic element. Iron, 
 arsenic and sulphur, preceded by a calomel purge, 
 are most often used. The administration of quarter- 
 grain doses of calcium sulphide every three hours 
 
132 
 
 MINOR AND EMERGENCY SURGERY 
 
 for a few days exercises a beneficial effect and aids 
 in preventing the recurrence of carbuncles and 
 furuncles. 
 After-treatment of Localized Pyogenic Infections. — 
 
 All suppurating cases should be dressed daily or 
 even more often, until pus formation ceases and 
 granulation commences. In limited infections the 
 drain should be removed and the sloughs expressed. 
 The cavity is again filled with pure tincture of 
 iodine, a new drain inserted and a fresh wet dressing 
 applied. In more extensive infections the drainage 
 tubes should be irrigated with hydrogen peroxide, 
 followed by the usual watery solution of iodine. 
 Shreds of slough should be excised and, if the de- 
 struction of tissue progresses, new openings may be 
 made and additional drainage tubes inserted. At 
 each dressing the skin should be cleansed with 70 per 
 cent, alcohol. As the quantity of pus diminishes, 
 the tubes may be gradually shortened and with- 
 drawn. When the suppurative process has entirely 
 disappeared, the pockets and cavities should be 
 loosely stuffed with plain gauze. Applications of the 
 U. S. P. boric acid ointment or 10 per cent, ichthyol 
 are of use in the after-treatment of boils and car- 
 buncles after the wet dressings are discontinued. 
 
 SYSTEMIC PYOGENIC INFECTIONS. 
 
 Systemic infections are sequels resulting from 
 local bacterial invasions, due to the absorption of 
 the toxines and endotoxines of the invading bacteria, 
 and are characterized by grave constitutional disturb- 
 ances. The intoxication may occur as a sapremia, 
 
ACUTE PYOGENIC INFECTIONS 133 
 
 bacteriemia, septicemia, toxemia or pyemia, but 
 it is almost unnecessary to make a minute dis- 
 tinction, since the manifestations of the various types 
 are similar in almost every respect and the treatment 
 is much the same. The clinical phenomena evidenc- 
 ing a constitutional intoxication are : presence of local 
 suppuration, hyperpyrexia (more elevation in the 
 evening) , chills, flushed cheeks, increased pulse rate, 
 digestive disturbances, sweating, prostration, urinary 
 changes and sometimes dehrium or coma. Any or 
 all of these manifestations may be present. Py- 
 emia is characterized by the formation of metastatic 
 abscesses. Unless efficient treatment is instituted 
 promptly, death soon occurs. 
 
 Treatment of systemic infections consists of (i) re- 
 moval of the source of absorption and disinfection of 
 what cannot be removed, (2) serotherapy, (3) pro- 
 moting elimination by stimulating the emunctories, 
 and (4) combating the constitutional symptoms by 
 supporting the patient's vitahty with nourishing 
 foods and suitable tonics. 
 
 The first is obtained by emptying and disinfecting 
 all the original foci of suppuration, as described in the 
 previous paragraphs of this chapter. This in itself 
 often suffices to cause the disappearance of toxic 
 symptoms, by arresting the propagation of bacteria. 
 In pyemia, if a suppurative lymphadenitis exists, 
 the glands should be completely excised. 
 
 Serum-therapy is now being accorded considerable 
 attention as a method of combating profound tox- 
 emias and good results are often obtained from the use 
 of antitoxines and vaccines, particularly in strepto- 
 
134 
 
 MINOR AND EMERGENCY SURGERY 
 
 COCCUS and staphylococcus infections. When the ser- 
 vices of a capable pathologist can be secured and the 
 necessary facilities are at hand, it is better to manu- 
 facture an autogenous vaccine than to employ a stock 
 preparation. This will also avoid any possible error 
 that might be made regarding the identity of the 
 organism responsible for the infection. 
 
 The excretory organs must be kept active to pro- 
 mote elimination. Drugs administered per os are to 
 be avoided, as they may further irritate the already 
 disturbed stomach. Hydrotherapy has distinct value 
 but hot packs are contra-indicated because they 
 tend to depress the patient's limited vitality. The 
 patient must be given absolute rest in bed and sur- 
 rounded with hot-water bags to induce perspiration. 
 Physiologic saline solution, given hypodermatically, 
 as an enema or intravenously, markedly aids elimina- 
 tion, as well as serving as a circulatory stimulant. 
 The author has derived extremely satisfactory re- 
 sults from an enema consisting of 4 ounces of magne- 
 sium sulphate dissolved in a pint of cool water (70° F.) , 
 repeated every two hours until improvement is pro- 
 nounced. Rapid elimination of toxines is brought 
 about by the osmotic action of this solution, which at 
 the same time causes free catharsis. The low tem- 
 perature serves to reduce pyrexia. Persistent vom- 
 iting is not rare and can be relieved by gastric 
 lavage. 
 
 The food should be nourishing and easily digested. 
 Coffee, alcoholic stimulants, broths and milk will 
 usually suffice. When the stomach has been washed 
 out, the patient may be fed per rectum for a few 
 
ACUTE PYOGENIC INFECTIONS 
 
 ^35 
 
 days. Later, a few well selected tonics may be 
 cautiously introduced. The tincture of the chloride 
 of iron and the freshly made elixir of iron, quinine 
 and strychnine are excellent preparations. The 
 cardio-vascular depression, which is always present 
 to a variable degree, may be ameliorated by inhala- 
 tions of oxygen. 
 
 SPECIAL INFECTIONS. 
 
 Among the special forms of infection frequently 
 encountered may be mentioned erysipelas, tetanus, 
 anthrax, malignant edema and glanders. None of 
 these are true pyogenic infections, yet for the sake of 
 convenience the first two will be considered here. 
 
 Erysipelas has been clinically subdivided into 
 phlegmonous, facial and the erysipelatoid lymphan- 
 gitis of Rosenbach. There exists some diversity 
 of opinion regarding the exact identity of the organ- 
 ism causing erysipelas but it is universally acknowl- 
 edged that it is due to a streptococcus invasion. 
 The three disease types are practically alike except 
 for the variation in the intensity of the infection. 
 The phlegmonous form is a severe one, the facial 
 milder and the erysipelatoid lymphangitis is a 
 condition found almost exclusively on the hands. 
 The subjective and objective signs of erysipelas are 
 too well known to require reiteration; the disease 
 may run a benign or malignant course, depending 
 upon the virulence of the bacterial invasion. 
 
 All cases of erysipelas should be completely isolated, 
 as a mild infection in one patient may be transmitted 
 
136 MINOR AND EMERGENCY SURGERY 
 
 to another in a profoundly septic form. Attendants 
 should wear rubber gloves for self -protection. 
 
 Local applications of suitable medicaments rapidly 
 check the spread of the disease and hasten resolution, 
 so that the painful measures often recommended, 
 such as sacrification and intradermal injections, 
 are usually unnecessary. The three most efficient 
 remedial agents are iodine, ichthyol and carbolic 
 acid. Irrespective of the agent selected, the local 
 applications must always extend half an inch to an 
 inch beyond the margin of the eruption. Iodine 
 is best applied in the form of the tincture ; ichthyol, 
 2 drams dissolved in i ounce each of alcohol and 
 ether; and carbolic, painted on the surface until 
 whitened and followed by the liberal use of alcohol. 
 
 Constitutional treatment is of the utmost import- 
 ance in these cases, as the patient's powers of resist- 
 ance are poor. The regime to be followed is es- 
 sentially the same as that in systemic infections. 
 
 For some reason, as yet not satisfactorily explained, 
 an attack of erysipelas occasionally exerts a favorable 
 and curative influence on certain intercurrent condi- 
 tions. For example, various writers have reported 
 that sarcomata have entirely disappeared after an 
 attack of erysipelas. In an attempt to produce these 
 results, sarcomatous patients have been intention- 
 ally inoculated with the toxines of the streptococcus 
 of erysipelas and a certain degree of sucess has been 
 claimed by some authors. To increase the potency 
 of the preparation, the toxines of the bacillus pro- 
 digiosus are added, this product being known as 
 Coley fluid. 
 
ACUTE PYOGENIC INFECTIONS 137 
 
 Tetanus is an infectious disease due to the bacillus 
 tetani, characterized by violent and persistent 
 tonic spasms of the voluntary muscles, particularly 
 those of the lower jaw, and sometimes accompanied 
 by local paralysis. Distinct intermittent exacerba- 
 tions are usually present. The infection originates 
 in wounds, especially those of the extremities, and 
 is due, as a rule, to contamination with actual dirt. 
 Unlike the ordinary pyogenic infections, the invasion 
 of bacilli tetani does not interfere with primary 
 union, hence the initial symptoms are not local but 
 general. In man, the rigidity usually begins in the 
 masseter and posterior cervical muscles, progressing 
 downward from the head, and may be followed by 
 persistent opisthotonos. The toxines are intensely 
 virulent and the period of incubation may vary from 
 one to twenty days. Upon the duration of the 
 period of incubation, the prognosis may be safely 
 based. In cases exhibiting a short period of in- 
 cubation (one to eight days) a fatal termination 
 may be anticipated, while in the milder cases 
 (twelve to twenty days) recovery may be expected, 
 in spite of the fact that the course of the disease is 
 apt to be prolonged. Cases developing between 
 the eighth and twelfth days after the injury may 
 terminate in either recovery or death and are un- 
 doubtedly influenced to a greater extent by appro- 
 priate remedial measures than are those of the 
 other two classes. These statements are verified 
 by experience and careful investigation of the records 
 of a large number of cases of tetanus, occurring be- 
 fore as well as after the introduction of tetanus 
 
13,8 MINOR AND EMERGENCY SURGERY 
 
 antitoxine as a curative agent. The sympto- 
 matology of tetanus is distinctive and will not be 
 elaborated here. 
 
 The most efficient method of treatment is pro- 
 phylaxis, which consists of thorough disinfection 
 of all wounds, removal of sloughs, foreign bodies 
 and other extraneous matter, and drainage. All 
 cases of gunshot wounds and those contaminated 
 with street dirt, especially the dirt from asphalt 
 pavements, should be given a prophylactic sub- 
 cutaneous injection of from lo to 20 c.c. of tetanus 
 antitoxine just above the wound. When the tetanic 
 condition has once become established, the anti- 
 toxine must be administered within twenty-four 
 hours to be of material service. It should be 
 generously used: 20 c.c. injected along the nerve 
 sheaths above the site of injury, 10 c.c. thrown 
 into the cerebro-spinal axis (usually a subdural 
 injection) and 20 c.c. used for moistening the dress- 
 ing covering the wound. The injections may be 
 repeated every twelve hours if necessary and the 
 patient's condition permits. Although the anti- 
 toxine usually has but little effect upon those viru- 
 lent cases with a short incubation period, its use 
 should not be discouraged. Needless to say, the 
 antitoxine should always be used reasonably fresh. 
 
 Some surgeons have employed a solution of 
 magnesium sulphate as an antitetanic remedy with 
 marked success in many instances. Like antitoxine, 
 it is administered by injection into the cerebro- 
 spinal axis. However, it should not be accepted 
 as a substitute for antitoxine. 
 
ACUTE PYOGENIC INFECTIONS 
 
 139 
 
 To palliate the paroxysmal exacerbations, anti- 
 spasmodics and hypnotics are useful. Chloroform 
 inhalations and 5 -grain doses of chloretone have 
 the most favorable action, especially if re-enforced 
 with quarter-grain hypodermic doses of morphine. 
 The patient should be confined to bed in a dark 
 room and fed through a soft-rubber catheter passed 
 into the pharynx through the nose. Catheterization 
 and enemata are usually necessary to relieve the 
 retention of urine and feces. There can be no 
 objection to the adoption of other therapeutic 
 measures that may be required. 
 
CHAPTER VIII. 
 
 EFFECTS OF INTENSE HEAT AND COLD. 
 
 Classification : 
 
 Extent 
 
 Causative 
 factors 
 
 BURNS. 
 
 1. First degree: simple hyperemia. 
 
 2 . Second degree : dermatitis with vesication. 
 
 3. Third degree: eschars, gangrene and 
 carbonization, involving subcutaneous 
 structures. 
 
 1. Contact with flames and intense heat. 
 
 2. Contact with hot liquids or steam (scalds). 
 
 3. Contact with electric currents. 
 
 4. Prolonged exposure to solar rays. 
 
 5. Lightning stroke. 
 
 6. Rontgen ray burns. 
 
 7. Chemical (concentrated acids and caustic 
 alkalies) . 
 
 The extent of the destruction of tissue depends 
 upon the temperature of the radiant heat, duration 
 of contact, superficial diffusion of the heated object 
 or fluid, and density of the area burned. In severe 
 cases, the constitutional effects are pronounced 
 and the alleviation of these associated conditions 
 is of even more importance than the local treatment 
 of the burn itself. Shock and nephritis are almost 
 constant concomitant factors, and suppuration, 
 sepsis and secondary hemorrhage not infrequent 
 ones. The symptoms may be: (i) pain, (2) rest- 
 lessness, (3) frequent micturition, (4) cold extremi- 
 
 140 
 
EFFECTS OF INTENSE HEAT AND COLD 141 
 
 ties, (5) small and rapid pulse, (6) persistent thirst, 
 (7) edema, (8) prostration, (9) collapse and (10) 
 unconsciousness. If a large surface is burned or 
 scalded, the excretory function of the skin is mark- 
 edly impaired and it is necessary for the kidneys 
 to compensate for the sudden diminution in toxic 
 elimination by the skin. Being often unable to im- 
 mediately cope with this emergency, congestion and 
 nephritis soon follow. In fact, it has been stated, 
 and confirmed by experience, that even burns of 
 the first or second degree extending over one-third 
 or more of the body surface interfere with the ex- 
 cretory function of the skin to such an extent that 
 these cases rarely recover; the majority die of shock 
 within twenty-four hours. Burns of the third degree 
 are also influenced by the extent of the region 
 destroyed and the depth to which the tissues are 
 disorganized. Although the patient may frequently 
 lose consciousness and later regain his mentality, 
 instantaneous death, from the arrest of cardiac and 
 respiratory action, is a common occurrence from 
 contact with heavily charged electric wires and 
 lightning. Traumatic neuroses occasionally follow 
 these injuries. An ^-ray bum is a peculiar lesion 
 in itself, characterized by a stubborn dermatitis, 
 ulceration of the skin, and painful and tedious re- 
 covery. If extensive, amputation may be necessary. 
 A number of deaths have occurred as the result of 
 frequent or prolonged exposure to the x-rsij, but 
 with universal recognition of its dangers, improved 
 technic and restriction of its use to those skilled 
 in its application, these injuries are now infrequently 
 
142 MINOR AND EMERGENCY SURGERY 
 
 observed and before long should become a rarity. 
 The mortality from burns is particularly high in 
 infants and young children. 
 
 Local Treatment of Bums. — ^The local applica- 
 tions appropriate in a given instance will vary ac- 
 cording to the severity and extent of the burn. 
 
 The pain incident to bums of the first degree is 
 immediately relieved by applications of a saturated 
 solution of either sodium bicarbonate or picric acid. 
 Several layers of gauze should be saturated with the 
 solution and wrapped around the burned area. 
 Later, dressings of petroleum ointment may be sub- 
 stituted. Since burns of the first degree leave no 
 scar, they are of relatively small consequence. Bums 
 due to exposure to the sun are best treated with 
 applications of bicarbonate of soda solution, followed 
 by some simple emollient, such as vaseline or almond 
 oil. 
 
 Burns of the second degree are nearly always 
 accompanied by the formation of vesicles or blebs 
 and to avoid injuring them the clothing should be 
 carefully cut away. Exposure to air is to be avoided 
 and one area should be dressed before another is im- 
 covered. Asepsis will thus be maintained and a 
 rapid uncomplicated recovery will ensue. The sur- 
 face maybe cleansed by gentle irrigation with warm 
 sterile water and the belbs punctured at their base 
 tvith a sterile needle to allow the extravasated 
 serum to escape. The epidermis, however, should 
 not be disturbed or removed, since it protects the 
 denuded papillae. Burns of this class are often 
 infected through careless technic and asepsis is im- 
 
EFFECTS OF INTENSE HEAT AND COLD 
 
 143 
 
 portant. There exists some difference of opinion 
 regarding the applications to be employed in these 
 cases. Various writers have claimed good results 
 from the sole use of either dusting powders, emol- 
 lients or wet dressings. All are of value under certain 
 conditions but no single one should be utilized to the 
 exclusion of the others. Given, a recent uninfected 
 bum with preservation of the epidermis, a mixture 
 of one part acetanilid and three parts boric acid, 
 dusted in a thick layer over the burn and covered 
 with gauze, will prevent infection and promote 
 rapid recoveiy. These dressings should be left 
 undisturbed as long as possible. If the burn is 
 extensive and the belbs have already ruptured, 
 leaving numerous raw surfaces, carron oil (a mixture 
 of equal parts of lime water and raw linseed oil) 
 will relieve the pain and soothe the irritation follow- 
 ing the contact with air. This is the remedy most 
 often employed in emergency work and is indeed an 
 excellent temporary dressing. Later on, the margins 
 of the belbs may be trimmed, extraneous material 
 removed and the denuded surfaces carefully dried by 
 sponging with sterile gauze and mopping with 
 tincture of iodine, and a 10 per cent, ointment of 
 boric acid applied. A 5 per cent, ointment of ich- 
 thyol is also frequently used but is inferior to the 
 boric acid, except in the presence of inflammation. 
 When epidermization begins, the U. S. P. ointment 
 of zinc oxide should be substituted. If a bum does 
 not present for treatment until considerable time has 
 elapsed and the area is already infected, wet dress- 
 ings are of service. Fomentations of Thiersch's 
 
1 44 MINOR AND EMERGENCY SURGERY 
 
 solution^ or normal saline solution should be con- 
 stantly applied until the granulations become 
 healthy, and then followed by the boric acid oint- 
 ment. The indications for redressing burns are: 
 (i) rise of temperature, (2) local pain, (3) odor and 
 (4) soiled dressings. The treatment of burns by 
 omitting all coverings except a dusting powder, 
 thereby constantly exposing the surfaces to the air, 
 and frequent mopping of the extruded sei^um has 
 been recently advocated. The results in the few 
 cases in which the author has employed this method, 
 however, have not been encouraging. 
 
 Burns of the third degree are always dangerous 
 injuries because subsequent sloughing is profuse and 
 complications are the rule. Electric burns are 
 almost invariably of this class and are characterized 
 by absence of pain and slow healing. While com- 
 bating the constitutional effects and complications 
 is of paramoimt importance, this dictum must not 
 be construed to excuse neglect of the local treatment. 
 The objective points are to secure rapid separation 
 of the slough and prevent sepsis. The constant 
 warm bath (100° F.) of normal saline solution, which 
 has been more widely employed abroad than in 
 this coiintry, is an efficient method of treatment. 
 It should be continued until healthy granulations 
 appear. Dressings of equal parts of balsam of Peru 
 and glycerine likewise hasten separation of the slough 
 in restricted areas. The dressings should be changed 
 
 ' Thiersch's solution: 
 
 Salicyhc acid 3 ss 
 
 Boric acid 3 iii 
 
 Sterile water O ii 
 
EFFECTS OF INTENSE HEAT AND COLD 145 
 
 daily and the wound irrigated with hydrogen per- 
 oxide. As the shreds of necrotic tissue loosen, they 
 may be excised with scissors. Iodine is then dropped 
 into the wound to cleanse it. When granulation be- 
 gins, the surfaces should be touched with a i per 
 cent, solution of copper sulphate, to stimulate the 
 regeneration of tissue. As the healthy tissue ap- 
 proaches the surface, healing will be accelerated and 
 cicatricial contraction obviated by employing 
 Thiersch's skin-grafts or transplanting skin-flaps. In 
 addition, the position which puts the surface of the 
 part on the stretch wih tend to diminish the skin 
 deformity by temporarily enlarging the surface. 
 
 Burns due to chemical agents, such as strong acids 
 and alkalies, must be treated by the chemical antidote 
 for that which has produced the excoriation. Weak 
 alkalies are indicated in burns due to acids, and 
 vice versa. 
 
 X-ray bums, if painful and extensive, usually 
 require excision of the ulcerated areas or amputation, 
 as they are absolutely resistant to ordinary methods 
 of treatment. Curettage of the ulcers, followed by 
 skin-grafting, will occasionally cure. 
 
 Obviously, any burn sufficiently severe to destroy 
 the blood supply and bone of a part necessitates 
 amputation. 
 
 Treatment of the Constitutional Effects and Com- 
 plications of Burns. — In all cases of burns the indi- 
 cations are: (i) to relieve pain and overcome shock, 
 (2) to guard against visceral congestion, and (3) to 
 counteract the exhaustion incident to continual 
 pain and suffering or sepsis. 
 
146 MINOR AND EMERGENCY SURGERY 
 
 All cases of extensive burns should immediately 
 receive sufficient morphine hypodeimatically to re- 
 lieve pain. One quarter of a grain usually alleviates 
 pain, supports the heart, and quiets the patient, 
 but it may be repeated as often as necessary. It 
 should not be combined with atropine as the latter 
 arrests glandular activity. The patient should be 
 placed in bed, surrounded with hot water bottles and 
 kept absolutely quiet. All severe burns are accom- 
 panied by marked shock and every effort should be 
 made to establish reaction as soon as possible. For 
 details, the reader is referred to the chapter on 
 surgical shock. In cases of electric shock, artificial 
 respiration and hypodermic injections of strychnine 
 and atropine should be employed. 
 
 Inflammation of any of the viscera may occur and 
 give rise to alarming symptoms. Of the involve- 
 ments, renal congestion appears first and is evidenced 
 by albuminuria, as well as the other urinary findings 
 of nephritis. The most efficient remedy in such con- 
 ditions is 2 drams of liquor ammonii acetatis, 
 administered in a half a glass of ice water every 
 two hours. This relieves thirst, promotes diuresis 
 and depletes the congestion. Constipation is not 
 imusual and is ordinarily relieved by some simple 
 laxative, such as castor oil. Inflammation and 
 ulceration of the gastro-intestinal mucosa is fre- 
 quently but another manifestation of visceial con- 
 gestion and may be followed by diarrhea, perforation 
 and death. In such cases, opium, gallic acid, bis- 
 muth and other intestinal astringents are ser- 
 viceable. 
 
EFFECTS OF INTENSE HEAT AND COLD 147 
 
 Many patients who survive the initial shock 
 accompanying a severe burn will die later of exhaus- 
 tion. For instance, it is not unusual for a case of 
 third degree electric burn of the back to apparently 
 progress favorably for a week or more and then 
 slowly die of exhaustion. The indications are: 
 to (i) allay pain with repeated hypodermic injec- 
 tions of morphine, (2) maintain asepsis of the in- 
 jured area, (3) hasten sloughing and repair, (4) guard 
 against complications, such as nephritis, pneumonia, 
 vomiting, diarrhea and cerebral congestion, and 
 (5) support the patient's vitality with a nutritive 
 diet and suitable tonics. 
 
 SUNSTROKE. 
 
 While not properly within the domain of surgery, 
 insolation and heat exhaustion so frequently pre- 
 sent as emergencies, particularly to the ambulance 
 surgeon, that their consideration here may not be 
 amiss. It is of the utmost importance to differen- 
 tiate these two varieties of sunstroke, as the former 
 represents a disturbance of the heat regulating centers 
 due to the toxemia from the excessive heat, while 
 the latter depends on a vasomotor paralysis with 
 marked circulatory disturbances in the brain and 
 body surface. The treatment appropriate for one 
 is practically that which is contra-indicated for the 
 other. To distinguish between the two, the follow- 
 ing phenomena should be observed : 
 
I4& 
 
 MINOR AND EMERGENCY SURGERY 
 
 Insolation. 
 
 Patient insensible. 
 
 Coma; sometimes delirium 
 and convulsions. 
 
 Face flushed. 
 
 Skin dry and burning. 
 
 Respirations rapid and shal- 
 low. 
 
 Pulse rapid and full. 
 
 Temperature 105° to 110° F. 
 
 Suppression 
 
 action. 
 Prognosis guarded 
 
 of glandular 
 
 Heat Exhaustion. 
 Patient dazed. 
 Weakness and prostration; not 
 
 unconscious. 
 Face pale. 
 Skin cool. 
 Respirations stertorous. 
 
 Pulse rapid and feeble. 
 Temperature normal or sub- 
 normal. 
 Perspiration increased. 
 
 Prognosis good. 
 
 Treatment of Sunstroke.- -In all cases of insolation 
 a gag should be inserted between the jaws, to prevent 
 the patient from biting his tongue. In emergencies, 
 a wooden wedge will answer the purpose . The hyper- 
 pyrexia must be reduced as rapidly as possible and 
 hydrotherapy will accomplish this better than any- 
 thing else. Clothing should be removed and the 
 patient placed in a cold water bath at a temperature 
 of about 75° F., with an ice bag applied to the head. 
 Ice should be gradually added to the water until a 
 temperature of 50° F. is reached. Restlessness and 
 convulsions may require morphine. When the pa- 
 tient is returned to bed, he should be enveloped in a 
 cold pack with a hot-water bottle at the feet, and cold 
 (70° F.) saline enemata may be given to prevent 
 subsequent recurrence of fever. Antipyrine and 
 blood-letting will also often prove useful. Should 
 the patient recover, he must be warned as to his 
 inability to withstand high temperatures during the 
 rest of his life. 
 
EFFECTS OF INTENSE HEAT AND COLD. 149 
 
 The treatment of heat exhaustion is essentially 
 that of mild shock. The patient should be placed in 
 bed, surrounded with hot water bottles and covered 
 with warm blankets. Ammonia, strong coffee and 
 hypodermic injections of adrenalin chloride are the 
 most efficient stimulants. 
 
 CHILBLAIN. 
 
 Chilblain is a condition following exposure to in- 
 tense cold and is characterized by pruritis, local con- 
 gestion and a tendency to teiTninate in gangrene. 
 It is due to a too sudden application of heat following 
 the freezing of the part, occasioning an unduly rapid 
 reaction. "Frost-bite" has been used as a synony- 
 mous term but its use should be restricted to designate 
 the initial freezing of the tissues only. The consti- 
 tutional effects of exposure to intense cold are often 
 pronounced. 
 
 Treatment of Chilblain. — The general effects of cold 
 should be combated by overcoming the general de- 
 bility and improving the circulation, by friction and 
 artificial respiration. The best method of local treat- 
 ment for chilblain is prophylactic and this consists of 
 avoiding contact with heat, rubbing the chilled parts 
 with snow or cold water and gradually raising the 
 surrounding temperature until the natural color is 
 restored, thereby establishing a slow reaction. The 
 frozen areas may be covered for a time with cloths 
 soaked in cold water. If the surfaces are not 
 abraded, the skin should be painted with equal parts 
 of tincture of iodine and tincture of opium, or an oint- 
 ment of ichthyol and lanoline applied. If blebs 
 
I50- MINOR AND EMERGENCY SURGERY 
 
 form, they should be punctured. For broken chil- 
 blains, Gardiner recommends the following ointment : 
 
 Hydrargyri ammoniati . gr. v 
 
 Ichthyolis ttl x 
 
 Amylis, 
 
 Zinci oxidi • aa 5 ii 
 
 Petrolatum , § ss 
 
 Misce. 
 
 If the tissues become gangrenous, the treatment 
 should be based on general principles. It will oc- 
 casionally be necessary to amputate a portion of an 
 extremity. Massage and suitable exercises are use- 
 ful in the after-treatment. 
 
CHAPTER IX. 
 
 ULCERS— BED-SORES. 
 ULCERS. 
 
 An ulcer is an excavated loss of continuity upon 
 the body surface, a circumscribed area being denuded 
 of its covering, characterized by evidencing no tend- 
 ency to heal. The term "ulceration" as applied to 
 the disorganization of tissue and granulating wounds 
 is a misnomer. Strictly speaking, a granulating 
 surface is not an ulcer and, in fact, as soon as a true 
 ulcer commences to heal, it ceases to be an ulcer. 
 Ulcers occur most frequently on the leg and are in- 
 variably the result of interference with the circula- 
 tion, the etiological factors being varicose veins, 
 traumatism or constant pressure. Tubercular and 
 syphilitic ulcers are but ordinary manifestations of 
 the diseases themselves and their cure depends more 
 upon appropriate systemic treatment than upon 
 local measures. 
 
 For convenience, a varicose ulcer of the leg will be 
 taken as an example of the usual type of ulcer. Such 
 ulcers are frequently encountered in hospital and 
 dispensary practice and, because they so tax the 
 physician's ingenuity and skill, are generally treated 
 with scant courtesy or entirely neglected. To no 
 other cause can the average physician's indifference 
 to these cases be ascribed. The usual picture pre- 
 
152. MINOR AND EMERGENCY SURGERY 
 
 senting is a large sore, of irregular outline, with 
 thick, infiltrated and dusky edges and an indurated 
 base, which is often covered with a thin white layer 
 of tenaceous necrotic tissue. Although a chronic 
 condition, an ulcer may suffer exacerbations of more 
 or less acute inflammation. Should it become puru- 
 lent, suppuration, sloughing and even cellulitis may 
 follow. 
 
 Treatment of Ulcers. — The multiplicity of methods 
 of treatment recommended for the cure of indolent 
 ulcers by various writers is a fair indication that no 
 single one always proves satisfactory and efficient. 
 While certain well defined rules may be formulated, 
 the surgeon must exercise his judgment and com- 
 mon sense in each case to obtain universally grati- 
 fying results. Each step in the treatment should be 
 carried out with a definite object in view and advance 
 can be made upon the previous fiiTQ foundation 
 only : 
 
 1. Improve the local circulation. 
 
 2. Cleanse the ulcer and surrounding skin. 
 
 3. Subdue inflammation. 
 
 4. Remove necrotic tissue from the surface of the 
 ulcer. 
 
 5. Promote absorption of the induration. 
 
 6. Stimulate granulation. 
 
 7. Support the part with equalized pressure. 
 
 8. Encourage cicatrization. 
 
 9. Have the patient w^ear a permanent support. 
 
 10. Improve the patient's general condition. 
 
 To improve the circulation, the patient should be 
 confined to bed or a chair and the leg elevated. Un- 
 
ULCERS— BED-SORES 153 
 
 fortunately, however, it is rare that the patient will 
 obey these instructions, as he can illy afford to neg- 
 lect his occupation. 
 
 If all surgeons would use soap and water with the 
 regularity with which they employ antiseptics, the 
 latter could often be dispensed with and healing 
 would occur much more rapidly. The ulcer and sur- 
 rounding skin should be vigorously scrubbed with 
 a soft brush or gauze wipe. After drying thoroughly, 
 the part should be rubbed with alcohol to loosen 
 scales of dried discharge and devitalized skin. 
 
 If inflammation is present, it can be reduced by 
 daily applications of large wet dressings of Thiersch's 
 solution or aluminum acetate, covered with a firm 
 gauze bandage. Asepsis may be secured by paint- 
 ing the ulcer with tincture of iodine at each dressing. 
 The gauze must be kept constantly wet until the 
 inflammation is subdued. If, however, there is no 
 evidence of inflammatory reaction and the ulcer is 
 dirty and foul, it should be cleaned up by dressing 
 with balsam of Peru for a few days. The constant 
 warm bath by immersion in hot saline solution, as 
 described in -the treatment of burns, is another excel- 
 lent method of treatment. 
 
 The necrotic layer often observed on the surface of 
 an ulcer is most easily removed by dissecting off with 
 thumb forceps and scissors, followed by delicate 
 curettage. 
 
 Absorption of the indurated tissues at the base and 
 margins of the ulcer is best accomplished by criss- 
 cross incisions, carried well through the cicatricial 
 tissues at the base and edges. Alternate hot and 
 
154 MINOR AND EMERGENCY SURGERY 
 
 cold douches and massage are useful adjuncts to the 
 incisions. 
 
 As soon as the inflammation abates and the ulcer 
 presents a "clean" appearance, the leg should again 
 be cleansed with soap and water and shaved from 
 ankle to knee. The ulcer should be sprinkled with 
 a generous layer of powdered naphthalin crystals to 
 stimulate granulation and then covered with a layer 
 of lint spread with diachylon ointment. 
 
 These applications should be left undisturbed for 
 about ten days, meanwhile exerting constant equal- 
 ized pressure over the whole surface of the part. 
 This is best done by strapping from ankle to knee, 
 from below upward, with zinc oxide adhesive plaster 
 strips, three-fourth of an inch wide and long enough 
 to completely encircle the leg with overlapping of the 
 ends. The edges of each strip should overlap the 
 preceding one (Fig. 20). When complete, the dress- 
 ing should be covered with a firm bandage or an 
 elastic stocking. To remove the dressing, saturate 
 it with gasoline, cut from below upward, and strip 
 off in one sheet. If the granulation tissue is still 
 some distance from the skin surface, another similar 
 dressing may be applied for the next week. As soon 
 as the granulations approach the surface, however, 
 the ulcer should be irrigated with saline solution and 
 Thiersch's skin-grafts spread upon its surface. Ex- 
 uberant granulations are easily removed by touching 
 with stick silver nitrate. The grafts must overlap 
 each other and the skin margins and should be covered 
 with several layers of silver leaf. The leg is re- 
 strapped for two or three weeks, protecting the area 
 
ULCERS— BED-SORES 
 
 ^SS 
 
 of the ulcer by smearing the superimposed strips 
 with vaseline. This dressing must be removed very 
 carefully and the ulcer will then be found to be 
 healed. 
 
 Fig. 20. — Strapping a leg ulcer. 
 
 The patient should be instructed to wear a firm 
 elastic stocking continuously, protecting the delicate 
 skin by wearing a white silk or cotton stocking 
 underneath the elastic one. Johnson recommends 
 
156 MINOR AND EMERGENCY SURGERY 
 
 sewing four or five ordinary dress stays at varying 
 intervals around the top of the stocking to prevent 
 rolling downward, if the stocking is one that reaches 
 to the hip. When the rubber begins to stretch from 
 constant use, it should be replaced with a new 
 stocking. 
 
 Throughout the course of local treatment the 
 patient's general condition should receive careful 
 attention. The emunctories must be kept active 
 and tonics supplied in the form of fresh air and nutri- 
 tious food. Nux vomica, mercury, arsenic and 
 potassium iodide may be administered with benefit. 
 
 BED-SORES. 
 
 Bed-sores aie localized areas of gangrene due to 
 the circulatory stasis following continued pressure 
 on the skin. Their production is favored by (i) 
 the continuous pressure exerted by the stationary 
 position of the patient's body, (2) arteriosclerosis, 
 (3) debility, (4) advanced age, (5) imperfect inner- 
 vation and (6) the presence of irritating bodies and 
 secretions. Bed-sores most often occur over the 
 sacrum and scapulae and are particularly common 
 in spinal affections and wasting diseases. In fracture 
 cases, the long continued or faulty application of 
 splints or plaster-of-Paris dressings may cause pres- 
 sure sores which are identical with bed-sores. 
 
 Competent nursing usually prevents the develop- 
 ment of bed-sores and in all instances in which the 
 patient is confined to bed for any length of time the 
 following precautions should be observed : 
 
ULCERS— BED-SORES 157 
 
 1. Change the position of the patient frequently, 
 to avoid constant pressure on any one region. 
 
 2. Bathe the entire body surface daily and follow 
 with an alcohol sponge. If washing with soap and 
 water is impracticable, the patient can at least be 
 sponged with alcohol. 
 
 3. Keep the bed scrupulously clean, frequently 
 brushing the sheets free of cnimbs, etc., and keeping 
 them dry and smooth. If the bedding becomes soiled 
 with perspiration, urine or feces, it must be changed 
 immediately. 
 
 4. The water-bed and air cushions should be used 
 in suitable cases from the beginning. It is not neces- 
 sary to wait for areas of congestion to appear. 
 Chamois skin, applied with its softer side to the 
 area of skin affected or threatened, will also be 
 found useful in the prevention of bed-sores. 
 
 5. The areas that are unavoidably subjected to 
 pressure and which cannot be comfortably sup- 
 ported with a circular air cushion should be protected 
 by placing cotton-wool or leather-backed adhesive 
 plaster under them. 
 
 6. Glycerite of tannin, rubbed in twice daily, 
 will harden the skin. 
 
 If the parts exposed to pressure commence to show 
 signs of congestion, they should be sponged with a one 
 in eighty solution of creosote in alcohol, carefully 
 dried and generously dusted with zinc oxide powder. 
 Applications of a 5 per cent, solution of silver nitrate 
 are also serviceable at this stage. When the skin 
 has broken down and the bed-sores have actually 
 formed, they should be covered with a moist gauze 
 
158 MINOR AND EMERGENCY SURGERY 
 
 dressing of aluminum acetate. Each day when the 
 dressings are renewed, the visible sloughs should be 
 removed and the surface painted with a 2 per cent, 
 solution of silver nitrate. After the sloughs have 
 separated and healing progresses, the dressings should 
 consist of balsam of Peru or boric acid ointment. 
 
CHAPTER X. 
 FOREIGN BODIES. 
 
 All extraneous material entering or becoming 
 embedded in the tissues must be considered foreign 
 matter. Foreign bodies may consist of practically 
 any substance and in size may vary from infini- 
 tesimal particles to large masses. The presence of 
 foreign bodies in the tissues is an item of importance, 
 because of the mischief they may cause. Excep- 
 tionally, a patient may be unaware of the entrance 
 and presence of a foreign body, it may become 
 encysted and remain in the tissues for a long period 
 without arousing his suspicion. Contrariwise, foreign 
 bodies may give rise to (i) irritation, (2) pressure, 
 (3) erosion, (4) infection, (5) sloughing, (6) secondary 
 hemorrhage, and (7) interference with healing, usually 
 in the order mentioned. As a rule, the longer they 
 are left undisturbed, the more difficult their subse- 
 quent extraction or removal and the more serious the 
 consequences. Moreover, foreign bodies have a ten- 
 dency to migrate, because muscular contraction and 
 the elasticity of the tissues push them on, tmtil after a 
 lapse of time they will often be found far from the 
 original point of entry. It is therefore obvious that 
 all extraneous material should be removed as early 
 as possible. 
 
 Foreign bodies must be accurately located prior 
 to any attempt at removal. Inspection, palpation, 
 
 *-59 
 
i6o MINOR AND EMERGENCY SURGERY 
 
 gentle sterile probing and radiography are the most 
 reliable methods for ascertaining their exact situa- 
 tion. It must be remembered that a single x-vslj 
 view is deceiving, since it affords no information as 
 to the exact depth to which a foreign body has pene- 
 trated. The examination should include both an 
 antero-posterior and lateral view. The fiuoroscope 
 may be employed to determine whether or not a 
 foreign body moves simultaneously with the soft 
 structures, as, for example, it invariably does when 
 embedded in a tendon. 
 
 To remove foreign bodies, the most efficient means, 
 in order of their advantage, are: (i) irrigation, 
 (2) sponging, (3) the use of forceps and curette 
 (preceded by incision, if necessary), and (4) magnet- 
 ism. 
 
 Foreign Bodies in Subcutaneous Tissues. — The 
 majority of foreign bodies enter the subcutaneous 
 tissues through an open wound and their removal 
 is usually a simple procedure, except in punctured 
 wotmds. The lattei are produced by sharp-pointed 
 objects, the slightest fragments of which, if remain- 
 ing in the tissues, may cause more difficulty in re- 
 moval than the appearance of the wound would 
 indicate. The subsequent contraction of the skin 
 aperture or even its union per primam may cause the 
 operator much annoyance. 
 
 After having precisely located the foreign body, 
 the overlying skin is anesthetized and incised. The 
 incision should be sufficiently extensive to permit 
 thorough search. An incision that is too small is 
 worse than useless, since blind efforts at extraction 
 
FOREIGN BODIES 
 
 lOI 
 
 only result in pulling up shreds of tissue and may 
 push the foreign body still deeper into the tissues. 
 The best course is to wait until the object becomes 
 visible before attempting its removal. It should 
 then be firmly grasped with forceps and carefully 
 withdrawn. When the object is a long, slender, 
 sharp-pointed body, Quain recommends that an inci- 
 sion be made some little distance from the foreign 
 body, so that it may be grasped with forceps at right 
 angles to its longitudinal axis and then pushed out 
 
 Fig. 21. — ^Quain's method of removing a deeply embedded foreign 
 body through an incision at the point of entrance, by introducing forceps 
 through a second incision. 
 
 through another smaller incision at the point of en- 
 trance (Fig. 2i). If a foreign body is embedded be- 
 neath a nail and does not project sufficiently to per- 
 mit easy extraction, the nail may be painted with 
 liquor potassas and the softened surface scraped off, 
 until the remaining nail is as thin as paper. It 
 may then be incised, elevated and the foreign body 
 removed. 
 
 Foreign bodies in the eye may vary from a small 
 
1 62 MINOR AND EMERGENCY SURGERY 
 
 particle of dust to a splash of molten metal and usu- 
 ally lodge in the conjunctiva or become embedded in 
 the cornea. They are not infrequently associated 
 with burns, particularly if the offending substance is 
 of a caustic nature. Although immediate removal 
 is imperative in all these cases, when foreign bodies 
 have penetrated to some portion of the eye other 
 than the conjunctiva and cornea, dislodgment should 
 be attempted by those solely who have had special 
 ophthalmological training. Efforts of the inexperi- 
 enced to remove foreign matter from the deeper 
 structures of the eye are usually futile and the sight 
 may be jeopardized by injudicious treatment. The 
 nervous sensibilities and structure of the eye are so 
 delicate that none but the simplest cases should be 
 be treated by the general surgeon. Two or three 
 minims of a 4 per cent, solution of cocaine hydro- 
 chlorate dropped into the eye will facilitate inspec- 
 tion and removal by relieving the pain and spasm 
 and abolishing the reflexes. The lower lid should 
 first be drawn downward and the patient directed to 
 look up. This exposes the conjunctival folds and 
 the surface may be examined by oblique illumination. 
 The surface of the cornea should next be scrutinized 
 through a magnifying lens, allowing the rays of light 
 to play over the surface. Lastly, the upper lid should 
 be everted over a probe, with the patient looking 
 downward, and the tarsal folds carefully inspected. 
 As soon as the foreign body is detected, the surface 
 on which it lies should be brushed with a little cotton 
 on an applicator, dipped in boric acid solution. If 
 this fails to remove it, the foreign body being deeply 
 
FOREIGN BODIES 163 
 
 embedded, it will be necessary to lift it out gently 
 with a sterile spud. Small bits of metal occasionally 
 become jammed in the conjunctiva or sclera. In 
 these cases the proximity of a powerful electric mag- 
 net is usually sufficient to remove them. Sometimes 
 a patient will complain of the presence of a foreign 
 body in the eye when none can be detected. This is 
 due to irritation, which often persists after extrane- 
 ous material has been spontaneously removed. 
 Having eliminated the foreign material, the eye 
 should be flushed with a warm boric acid solution and 
 soothed with a drop of pure castor oil. When a 
 chemical bum also exists, it should be neutralized, 
 sterile olive or castor oil being afterwards dropped 
 into the eye and cold wet compresses applied. 
 
 Foreign bodies in the external auditory canal may 
 consist of animate or inanimate objects. The ani- 
 mate objects should be killed by dropping a little 
 sweet oil in the ear, after which they may be removed 
 by syringing copiously. When syringing, the stream 
 should be directed along the roof of the canal, so that 
 the return flow will be as forcible as possible. Occa- 
 sionally it will be necessary to hook behind the foreign 
 body with a wire loop, scoop, or a hooked probe, but 
 forceps should never be employed. Foreign bodies 
 of a vegetable nature swell when immersed in water 
 and therefore cannot be removed in the ordinary 
 way. A little alcohol, however, dropped into the ear 
 and permitted to remain for a few minutes will shrink 
 them, after which they may be syringed out with 
 more alcohol. Syringing is the safest method of re- 
 m.oving all foreign bodies from the auditory canal and 
 
i64 ■ MINOR AND EMERGENCY SURGERY 
 
 should be continued until their removal is effected. 
 If instinimentation is absolutely necessary (very rare) , 
 the manipulations should be deliberate but exceed- 
 ingly gentle. Meningitis has resulted from unskilled 
 efforts to remove foreign bodies from the ear. 
 
 Foreign bodies in the nose are often difficult to 
 detect, because they may remain in the nose for some 
 time without attracting the patient's attention. 
 A discharge resulting from inflammation or pres- 
 sure necrosis may be the first manifestation of the 
 presence of a foreign body. This can usually be lo- 
 cated with a probe and may be removed by hook- 
 ing behind it with a scoop or wire loop. Another 
 efficient method of removal is to push the foreign 
 body back to the pharynx. When this is done, the 
 patient's head must hang down, to prevent the dis- 
 lodged foreign body dropping into the larynx. In 
 struggling children, removal is often attended by 
 dangers from traumatism and by occasional failure. 
 An ingenious procedure in such instances is to hold one 
 hand over the patient's mouth and insert one end of a 
 piece of rubber tubing snugly into the free nostril. 
 The other end of the tubing is held in the mouth of 
 the operator. A sudden, vigorous expiration through 
 the tube will frequently dislodge the foreign body. 
 Sometimes it is necessary to narcotize children before 
 attempting removal. 
 
 Foreign Bodies in the Pharynx, Larynx and Tra- 
 chea. — The entrance of foreign bodies into the air 
 passages is an accident of frequent occurrence and 
 usually produces symptoms of alarming urgency. 
 When located in the pharynx, they are easily removed 
 
FOREIGN BODIES 165 
 
 by illuminating the region in which they lie and 
 extracting with curved forceps. The ordinary pro- 
 bang is of slight value, as it usually scratches and ir- 
 ritates the mucous membrane without removing the 
 object. Induration and abscesses are not rare se- 
 quelae in these cases, hence the entire surface should 
 be closely searched. Foreign bodies may become 
 impacted in the larynx or inspired through it into 
 the trachea and, unless promptly removed, dyspnea, 
 cyanosis, asphyxia and death speedily ensue. A 
 foreign body may sometimes be felt and displaced by 
 thrusting a finger down the throat. If this is not 
 feasible, an opening should be instantly made into 
 the cricothyroid membrane. Since the immediate 
 admission of air to the lungs is the important factor, 
 rather than the actual removal of the foreign body 
 itself, laryngotomy is recommended instead of trache- 
 otomy, because the urgent symptoms are usually 
 found in the cases where the foreign body is impacted 
 in the glottis, tracheotomy requires more time, and 
 laryngotomy is the safer in inexperienced hands. 
 Should subsequent tracheotomy be necessary for 
 extraction, the laryngotomy offers no impediment 
 to its perfomiance. Artificial respiration is fre- 
 quently a useful adjunct in relieving the suffocation. 
 Having again induced respiration, efforts should 
 be made to ascertain the position of the obstruction. 
 Careful laryngoscopic examination may reveal the 
 location of the foreign body and it may then be re- 
 moved with laryngeal forceps. It may often be dis- 
 lodged by inverting the patient and slapping him on 
 the back. This, however, is a dangerous procedure, 
 
i66 • MINOR AND EMERGENCY SURGERY 
 
 unless laryngotomy or tracheotomy has been per- 
 formed, as the body may impact in the vocal cords 
 and again suffocate the patient. 
 
 Foreign Bodies in the Esophagus. — Large masses 
 of food, coins, buttons, false teeth and pieces of bone 
 may be swallowed accidentally and lodge in the 
 esophagus. If the foreign body has remained for 
 some time, it may cause a variety of symptoms: 
 dysphagia, pain, tenderness, reflex cough, eleva- 
 tion of temperature, hemorrhage or emaciation. 
 On the contrary, it may produce little or no dis- 
 comfort. The dangers of permitting a foreign body 
 to remain in the esophagus are : (i) pressure necrosis, 
 (2) perforation, (3) peri-esophageal abscess, and (4) 
 starvation. Occasionally a patient will swallow 
 something that will wound the esophagus and he will 
 experience the sensation of a foreign body being 
 present. The history is usually indefinite and of 
 little diagnostic value. The most valuable means 
 of determining the presence or absence of a foreign 
 body is an x-vsiy picture. It can also usually be 
 detected by passing an esophageal bougie. Unless 
 promptly removed, the prognosis may be serious; 
 death may occur form starvation, sepsis or ulcera- 
 tion into the aorta. Foreign bodies generally lodge 
 behind the larynx or near the cardiac orifice of the 
 stomach, these being the points at which the lumen 
 of the esophagus is narrowest. 
 
 If situated high up, a foreign body can sometimes 
 be hooked up with the forefinger or removed, through 
 the mouth, with forceps. A large bolus of food, 
 swallowed quickly, may carry it into the stomach. 
 
FOREIGN BODIES 167 
 
 If it is known that the foreign body is not sharp, 
 the patient may be caused to vomit by tickling the 
 back of the throat and the foreign body may be 
 projected. This, however, is a dangerous procedure 
 if the object is sharp. A useful device is the ordinary 
 horse-hair probang, which is introduced closed, 
 passed beyond the foreign body, opened and with- 
 drawn . When it is necessary to use the ' ' coin-catcher' ' 
 or long curved forceps, the instrument employed 
 must be manipulated with great care. It is prudent 
 to utilize the fluoroscope when attempting instrumen- 
 tal extraction, as perforation of the esophagus is very 
 easy when ulceration already exists and is an exceed- 
 ingly dangerous accident. When the foreign body is 
 located near the cardiac orifice, it can occasionally 
 be pushed into the stomach with the blunt end of a 
 stomach tube. The esophagoscope is a valuable 
 instrument for the detection and extraction of a 
 foreign body. When used for this purpose, after 
 cocainizing the pharynx, it should be introduced 
 under the guidance of the operator's eye and without 
 the obturator. As soon as the foreign body becomes 
 visible, it is seized and withdrawn with forceps. 
 The esophagoscope is a dangerous instrument, 
 however, in inexperienced hands, as the slightest in- 
 accuracy may cause injury of the mucous membrane 
 or pref oration of an area of ulceration. A cervical 
 peri-esophageal abscess is an absolute contra-indica- 
 tion to the use of the esophagoscope. If all other 
 methods fail, an esophagotomy or gastrotomy must 
 be performed. 
 
CHAPTER XI. 
 
 SURGICAL SHOCK AND COLLAPSE— DEATH. 
 
 SURGICAL SHOCK AND COLLAPSE. 
 
 Surgical shock is a series of events or an assem- 
 blage of phenomena caused by injury, characterized 
 by a persistent depression of arterial tension, due 
 to loss of vasotonic or vasomotor activity, thereby 
 giving rise to venous stasis in the large internal 
 veins, with a subsequent nervous exhaustion of the 
 cardiac and respiratory centers and cerebral anemia. 
 In other words, shock is a symptom complex, the 
 essential phenomenon of which is reduced blood 
 pressure. The terms shock, collapse, and syncope 
 are often confused and used interchangeably. In 
 fact, some writers maintain that collapse is merely 
 a mild foiTn of shock. The latter, however, is a 
 simultaneous suspension of function rather than a 
 true exhaustion of all the nerve centers and is caused 
 by actual loss in volume of the blood (hemorrhage) ; 
 by oxy-hemoglobin starvation. Synocope (fainting) , 
 on the other hand, is but a temporary cerebral 
 anemia, induced by a momentary hyperemia, else 
 where, thus disturbing the normal blood pressure 
 equilibrium, which is rapidly and spontaneously re- 
 stored. It is to such later investigators as Crile, 
 Gushing, Wainwright and others that we are indebted 
 for experimental work on shock in physiological 
 
 i68 
 
SURGICAL SHOCK AND COLLAPSE—DEATH 169 
 
 laboratories and clinical practice and every student 
 should inform himself regarding recent research 
 work in this field, on which studies the logical con- 
 sideration and rational treatment of shock are based. 
 The subject is one of such magnitude that it is 
 obviously beyond the confines of this volume. 
 In shock, all vital centers suffer primary hyperten- 
 sion but the vasomotor center soon becomes ex- 
 hausted, lowering the blood pressure, with exhaus- 
 tion of the cardiac, respiratory and other centers, 
 subsequently causing a cerebral anemia due to loss 
 in circulatory force. In collapse, the centers are 
 not primarily stimulated but directly depressed by 
 the actual loss of blood, and all centers are depressed 
 simultaneously. The longer the hemorrhage con- 
 tinues the longer will the suspension of functions exist. 
 Consequently, the return to normal depends upon 
 the restoration of the volume of blood. 
 
 Causes of and Factors Predisposing to Surgical 
 Shock and Collapse : 
 
 Shock 
 
 I . Trau- 
 matism 
 
 1 
 
 Opera- 
 tions 
 
 Accidental injury. 
 
 Rough handling of tissues. 
 Susceptibility of certain 
 structures (periosteum, 
 peritoneum, etc.) 
 Exaggerated nervous im- 
 pulses (from severing 
 large nerves, etc.). 
 Prolonged operating. 
 Burns and scalds. 
 Psychic disturbances (fear). 
 Excessive anesthesia. 
 Loss of vital heat. 
 Infantile, diseased, feeble and aged subjects. 
 
lyx) MINOR AND EMERGENCY SURGERY 
 
 Collapse 
 
 TT , f Accidental. 
 
 Hemorrhaee < t .j ^ , 
 1 incidental. 
 
 Sudden withdrawal of large quantities of fluid 
 
 (ascites, etc.). 
 
 Manifestations of surgical shock and collapse 
 
 may develop suddenly or appear gradually. The 
 symptoms of shock are: (i) prostration, (2) pallor, 
 (3) pale lips, (4) dull and staring eyes with dilated 
 pupils, (5) clammy, moist skin, (6) cold extremities, 
 (7) frequent, feeble and irregular ("thready" or 
 imperceptible) pulse, (8) marked reduction of blood 
 pressure, (9) feeble respiration, (10) muscular 
 relaxation, (11) subnormal temperature, and (12) 
 occasionally relaxation of the sphincters of the blad- 
 der and rectum and (13) nausea and vomiting. The 
 patient's mentality may vary from perfect retention 
 of the senses to absolute insensibility. The evi- 
 dences of collapse are essentially those of shock 
 with three notable additions: persistent thirst, 
 restlessness and air-hunger. In diagnosis, the history, 
 nature of the injury and a blood examination should 
 all be considered. Oligocythemia (a red cell count 
 of 3,500,000 or less) and diminished hemoglobin 
 suggest collapse from hemorrhage rather than shock. 
 Of course, it is not unusual to observe an association 
 of both shock and collapse in the same subject. 
 Assuming the normal blood pressure to lie between 
 120 and 140 mm. Hg., a pressure of 100 mm. may 
 be considered indicative of mild shock, at or below 
 90 mm, medium and at or below 70 mm. profound 
 shock. The concensus of opinion seems to be that 
 if profound shock once becomes firmly established, 
 
SURGICAL SHOCK AND COLLAPSE— DEATH 171 
 
 it is irremediable. In these cases the mechanical 
 effect of appropriate treatment may raise the blood 
 pressure temporarily but a tine reaction is not ef- 
 fected and secondary shock invariably follows. An 
 accurate sphygmomanometer is an indispensable in- 
 strument and should be employed in all cases of 
 shock and collapse. 
 
 Prevention of Surgical Shock and Collapse. — 
 With a knowledge of the predisposing and exciting 
 causes of these conditions, it is obvious that much 
 can be done in some instances to prevent or limit 
 their development, and to avoid their many vicious 
 sequels. Unfortunately, those cases resulting from 
 accidental injury are beyond the surgeon's control, 
 hence prophylactic measures can be applied in opera- 
 tive cases only. These will consist of: (i) prelimi- 
 nary stimulation, (2) allaying the patient's fears, 
 (3) a preliminary hypodermic injection of morphine 
 and atropine, (4) maintaining the body heat, (5) 
 perfect technic, (6) avoiding prolonged exposure 
 and rough handling of sensitive tissues, (7) exact 
 hemostasis, (8) operating expeditiously, and (9) 
 appropriate after-treatment. When a patient ex- 
 hibits evidence of beginning shock during operation, 
 it is more prudent to stop immediately and defer 
 the completion of the operation imtil the next day 
 than to proceed and "hope against hope that the pa- 
 tient will not die cured." Certain structures being 
 particularly sensitive to stimulation and tratmiatism, 
 such as the periosteiun during amputation, etc., pre- 
 liminary nerve blocking with cocaine, as advocated 
 by Crile, is of great benefit. This may be obtained 
 
17-2 MINOR AND EMERGENCY SURGERY 
 
 either by spinal analgesia or by injections directly 
 into the nerve sheaths. The cocaine blocking 
 lessens the blow to the vasotonic centers and dis- 
 tributes the violence over a longer period; large 
 nerves, periosteum, etc., may then be severed with 
 impunity. To avoid collapse when performing a 
 phlebotomy or paracentesis, emptying a distended 
 bladder, etc., the fluid should be withdrawn slowly 
 and the entire amoimt should never be removed at 
 one sitting. The surgeon is often confronted with 
 the question of operating during shock and this 
 point is still the subject of much controversy. In 
 general, sagacity dictates to wait until reaction has 
 occurred, unless operation is imperative to save life. 
 Under such circumstances, general anesthesia should 
 be avoided as often as possible. If the operation is 
 deferred until reaction occurs, hemorrhage must be 
 controlled and the injured area protected with a 
 wet dressing. All cases of profuse hemorrhage, 
 primary or secondary, internal or superficial, and 
 all those of visceral perforation must be operated upon 
 immediately regardless of shock, else death from 
 exsanguination or sepsis is certain. 
 
 Treatment of Surgical Shock and Collapse. — Since 
 these two conditions differ physiologically, their 
 treatment is different. The cardinal principle of 
 the treatment of shock is to establish reaction and 
 stimulate cardiac action, while the main indication 
 in the treatment of collapse due to hemorrhage is to 
 aid in the restoration of the blood to its normal 
 volume. 
 
 The reaction from shock consists of permanent 
 
SURGICAL SHOCK AND COLLAPSE— DEATH i^^ 
 
 elevation of the depressed blood pressure, evidence 
 of which is a re-appearance of the natural color and 
 warmth of the skin, a pulse more full and forcible, 
 deeper respirations and returning sensibility or a 
 quiet sleep. Some writers describle a condition of 
 excessive reaction, characterized by sudden hyper- 
 pyrexia and coma without a corresponding improve- 
 ment in the pulse and respiration, which they as- 
 cribe to a septic intoxication. It is more usual at 
 the present time, however, to observe either a de- 
 layed or incomplete reaction or no reaction at all, 
 when the patient does not respond to remedial 
 measure. If the patient is in great pain when first 
 examined, he should receive 1/4 to 1/2 grain of 
 morphine, be put to bed at the earliest possible 
 moment, covered with warm woolen blankets, being 
 careful not to impede respiration, and surrounded 
 with hot water bottles or hot bricks. The latter 
 should be wrapped in cloths to prevent contact with 
 the body surface, because prostrated and unconscious 
 patients are especially prone to burns The foot of 
 the bed should be elevated to lower the patient's 
 head, and to favor a return of blood to the brain. 
 The exceptions to this rule are cases of excessive in- 
 tracranial pressure. In these cases, even though 
 shock exists, Dawbarn, Mayo and others recommend 
 a partial cerebral anemia, procured by sequestra- 
 tion of a large quantity of blood in the extremities. 
 The latter is easily obtained by cording the limbs at 
 their proximal extremities, exerting sufficient pres- 
 sure to impede the venous but not the arterial cur- 
 rent nor to markedly impair heart action. Mani- 
 
174 MINOR AND EMERGENCY SURGERY 
 
 festly, this is the reverse of another valuable adjunct 
 in the treatment of all other cases of shock ; bandag- 
 ing the extremities from the distal end toward the 
 trunk, to fortify the vital centers with an extra 
 supply of blood. Crile has elaborated this principle 
 in his rubber pneumatic pressure suit. It will not be 
 amiss to repeat that while these measures conduce to 
 safety in the ordinary cases of shock, they add to the 
 danger in cases of intracranial pressure. Hot normal 
 saline solution should be used early, as it has a most 
 excellent effect upon unstriped muscle and cerebral 
 sympathetic centers. It may be administered by 
 hypodermoclysis, enteroclysis or intravenous in- 
 fusion. Both Dawbarn and Kemp have shown con- 
 clusively that the customary temperature of 104° F. 
 is too low and that the best and most permanent re- 
 sults upon the heart and blood-vessels are obtained 
 when the saline solution is given at 116° to 120° F. 
 About two quarts should be cautiously introduced; 
 at least twenty minutes are required for its admin- 
 istration, to avoid overwhelming the heart. Hypo- 
 dermoclysis or enteroclysis are preferable to an 
 intravenous infusion, because the flow can be acceler- 
 ated or retarded more conveniently. Adrenalin chlor- 
 ide (i-iooo) acts by toning up the unstriped muscle 
 of the blood-vessels and 15 or 20 minims may be 
 added to the saline solution. Frequent sphygmo- 
 manometric readings should be taken during the 
 introduction of the solution and when the pressure 
 rises to 1 20 mm. it must be discontinued. Twitch- 
 ing of the limbs heralds the development of convul- 
 sions and is another indication for stopping the ad- 
 
SURGICAL SHOCK AND COLLAPSE—DEATH 175 
 
 ministration of the saline. Should the pressure 
 again fall perceptibly and the pulse become weaker, 
 the adminstration may be resumed. For this pur- 
 pose, Kemp's rectal tube is of service. A permanent 
 blood pressure of 100 mm. and a pulse rate of 120 
 may be considered the limit of safety. Morphine, 
 ammonia, adrenalin and ergot (ergotole) are the most 
 valuable drugs in shock. In emergencies, ammonia 
 acts as a harmless stimulant and oft-times contri- 
 butes to the prevention or modification of shock. 
 Morphine, in quarter-grain doses, is useful to allay 
 pain and quiet the patient and as a mild circulatory 
 stimulant. The latter virtue is one often overlooked 
 by many physicians. Ergotole and adrenalin chlo- 
 ride ( I -1 000) may be administered in saline infusion 
 or hypodeniiatically or the adrenalin may be slowly 
 dropped into the nostrils. The administration of these 
 preparations must be frequently repeated, as their 
 effect is more or less evanescent. The time-honored 
 "stimulants," such as strychnine, alcohol, nitro- 
 glycerine, etc., have been proven to be physiologic 
 fallacies and worse than useless. They cannot stimu- 
 late the already exhausted nerve centers, which are 
 incapable of transmitting normal physiological reflexes 
 and responding to stimulation, nor have they any 
 effect on unstriped muscle. They not only fail to 
 mitigate shock but even exaggerate it and have been 
 entirely abandoned by modem surgeons. If res- 
 piration flags, artificial respiration may be insti- 
 tuted. The stomach should have complete rest, all 
 food and nauseous medication being withheld during 
 shock and until all danger is past. Strength may be 
 
176 MINOR AND EMERGENCY SURGERY 
 
 sustained by nutrient enemata. Hot black coffee, 
 when tolerated, is both a food and stimulant. 
 
 The main indication in the treatment of collapse 
 due to hemorrhage is to arrest bleeding, for the longer 
 it continues the more prolonged will be the suspension 
 of functions. When hemorrhage has been controlled, 
 restoration of the volume of blood lost, as rapidly 
 as possible, is imperative. Many of the accessory 
 measures mentioned in the treatment of shock will 
 also prove useful in collapse, but an intravenous 
 infusion alone is practically sufficient to raise the 
 blood pressure and sustain the functions of the cen- 
 ters. In other words, whereas hot saline solution is 
 a valuable auxiliary in cases of shock, it is an ab- 
 solute necessity in those of collapse ; without it medi- 
 cation is useless. Under these circumstances, it is 
 desirable to introduce the saline solution more 
 rapidly than in shock, hence an intravenous infusion 
 is the method of choice. It may be thrown into any 
 large vein and, although one of the superficial veins 
 of the forearm is usually selected for convenience', 
 the internal saphenous vein an3rwhere above the 
 ankle, as suggested by Dawbam, is preferable, be- 
 cause there are no adjacent important structures and 
 a scar on the leg is of no consequence. The patient 
 should be confined to a bed with its foot elevated, 
 external heat applied and the extremities partially 
 exsanguinated, as in shock. To these may be added 
 an increased supply of oxygen, which may be pro- 
 vided by opening windows or inhalations of pure 
 oxygen gas. Direct blood transfusion may be em- 
 ployed when a donor, the necessary facilities and in- 
 
SURGICAL SHOCK AND COLLAPSE— DEATH i^^ 
 
 struments are at hand. The drugs used in the treat- 
 ment of shock are also serviceable in collapse. 
 
 Collapse occasionally follows sudden withdrawal of 
 large quantities of fluid ; aspirating ascites, or emptying 
 a distended bladder. This accident will never occur, if 
 technic is perfect and the fluid is removed gradually. 
 A large quantity of fluid must be removed slowly and 
 the entire amount never withdrawn at one time. 
 
 DEATH. 
 
 Many phases of death are more properly included 
 in works on legal medicine and medical jurispru- 
 dence and therefore the care of the moribimd patient, 
 the determination of death and the physician's sub- 
 sequent procedure only will be considered. 
 
 Because a patient is apparently dying is no reason 
 that he should be neglected. It is well to bear in 
 mind that "while there is life there is hope" and an 
 apparently moribund individual has been known to 
 recover. He should be made comfortable and his 
 waning vitality conserved. Cool, smooth bed- 
 clothes that do not restrict or interfere with respira- 
 tion will materially add to his comfort. If external 
 heat is employed, be cautious lest the sufferer be 
 burned. Catheterization and warm rectal irriga- 
 tions, as often as required, will prevent excessive 
 intra-abdominal pressure and resorption of noxious 
 material. Oxygen should be liberally supplied to 
 the vitiated atmosphere by opening windows and 
 permitting the entrance of plenty of fresh air or by 
 inhalations of oxygen. Lamps, gas flames and open 
 fires should be avoided, if practicable. Such medi- 
 
178 MINOR AND EMERGENCY SURGERY 
 
 cation may be administered as circumstances may 
 demand. Opiates may be freely used if the patient 
 is restless or in physical pain. The attitude of the 
 physician should be one of cheerfulness and encour- 
 agement and not indifference. 
 
 When circulation, respiration and innervation all 
 cease, the patient is dead. Cardiac action and res- 
 piration are not necessarily arrested simultaneously, 
 m.omentary absence of respiration is not incompati- 
 ble with the continuance of life, and instances are 
 recorded in which one or the other has apparently 
 ceased and yet the patient recovered. This, how- 
 ever, is open to question. It is more logical to as- 
 sume that either the heart's action was so extremely 
 feeble or the respiratory movements so shallow that 
 one or the other was imperceptible, even with the 
 stethoscope. Death is usually verified by the ces- 
 sation of circulation and respiration, corroborated 
 by a stethoscopic examination. In view of the 
 possibility of error in mistaking suspended animation, 
 lethargy, catalepsy, etc., for actual death, the above 
 examination cannot be accepted as adequate. The 
 unmistakable signs of death, upon which a positive 
 determination may be based are: (i) complete arrest 
 of cardiac action, (2) complete arrest of respiration, 
 (3) primary period of muscular relaxation, preceding 
 rigor mortis, (4) abolition of reflexes, (5) intense 
 pallor or discoloration of the skin and mucous mem- 
 branes, (6) eyes partly open and fixed, (7) flaccidity 
 and softening of the eye-ball, (8) absence of pupil- 
 lary reaction, (9) gradual opacity of the cornea, and 
 (10) rapid reduction of body temperature. 
 
SURGICAL SHOCK AND COLLAPSE— DEATH 179 
 
 Death having ensued, it is the physician's duty to 
 thoroughly examine the body and confirm the oc- 
 currence by unquestionable evidence. The law re- 
 garding the physician's subsequent procedure, in 
 deaths due to other than natural causes, varies in 
 the different States and Counties, but, in general, a 
 death certificate should not be furnished without the 
 authority of the proper official. When the ambu- 
 lance surgeon is called upon to verify a sudden death, 
 he should note carefully the circtmistances and facts 
 but should leave the body undisturbed. This will 
 avoid confusion and obscurity of certain details upon 
 later investigation by the municipal authorities. If, 
 however, the physician is empowered and directed to 
 sign the death certificate in doubtful cases, he should 
 clearly state the means or instrument of death, as 
 well as the immediate cause. The certificate should 
 also state whether the death was due to accident, 
 suicide or homicide. 
 
CHAPTER XII. 
 
 MINOR OPERATIONS 
 ARTIFICIAL RESPIRATION. 
 
 Indications. — Asphyxia and suspended animation : 
 (i) inhalation of noxious gases, (2) drug toxemias, 
 (3) submersion, (4) strangulation and (5) electric 
 shocks. 
 
 Contraindications. — The patient being in an at- 
 mosphere of vitiated air or that contaminated with 
 noxious gases. 
 
 Sylvester's Method. — i. Place the patient in a 
 supine position, with the head well extended by a 
 folded blanket imder the shoulders (Fig. 22). 
 
 2. Stand at the patient's head and grasp the fore- 
 arms near the elbows. 
 
 3. For inspiration, draw the arms steadily and 
 gently well above the head. 
 
 4. Keep the arms stretched upward for two seconds, 
 
 5. For expiration, turn down the arms, place them 
 by the sides and gently compress the thorax for two 
 seconds. 
 
 6. Repeat these movements about fifteen times 
 to the minute. 
 
 Schafer's Method. — i. Have the patient lie prone, 
 with the face turned to one side. 
 
 2. Exert imiform pressure on the lower ribs and 
 loins. 
 
 180 
 
MINOR OPERATIONS i8i 
 
 3. Remove the pressure to allow inspiration. 
 
 4. Repeat these procedures fifteen times a minute. 
 Laborde's Method. — i. Grasp the tongue deeply 
 
 and firmly with a layer of gauze or a flat bladed 
 tongue forceps. 
 
 Fig. 22. — a. Correct and b incorrect positions of patient for artificial 
 respiration. 
 
 2. Draw the tongue forward forcibly and suddenly. 
 
 3. Relax the tongue quickly and completely. 
 
 4. Repeat this intermittent traction every four 
 seconds. 
 
i82 IMINOR AND EMERGENCY SURGERY 
 
 Faradization. — i. Press one electrode on the right 
 side of the neck over the right phrenic nerve. 
 
 2. Apply the other electrode over the lower ribs on 
 the right side (Fig. 23). The left side is avoided in 
 order not to interfere with cardiac action. 
 
 3. A weak faradic current is turned on during in- 
 
 FiG. 23. — Electrodes applied properly to induce inspiration. 
 
 spiration and turned off as soon as expiration com- 
 mences. 
 
 Precautions. — (i) Correct diagnosis is important ; 
 (2) the upper respiratory tract must be freed from 
 obstruction; (3) if the air is contaminated, pure air 
 must be obtained; (4) impediments to free respira- 
 tory movements must be removed; (5) external heat 
 
MINOR OPERATIONS 183 
 
 and friction should be applied early ; (6) all manipu- 
 lations must be deliberately and regularly performed, 
 (7) artificial respiration, when indicated, should 
 always be continued for at least half an hour and 
 persevered in much longer, if there is the slightest 
 indication of life; (8) a combination of the various 
 methods of artificial respiration will often prove ad- 
 vantageous; (9) inhalations of oxygen gas, blood- 
 letting and suitable cardiac and respiratory stimu- 
 lants are useful adjuncts. 
 
 LARYNGOTOMY. 
 
 Indications. — (i) Sudden obstruction of the larynx; 
 (2) therapeutic purposes; (3) as a preliminary pre- 
 ventive measure to some surgical operations. 
 
 Contraindications. — (i) Obstructions below the 
 larynx; (2) age tmder thirteen years, as the crico- 
 thyroid space is too narrow. 
 
 Technic. — i. Extend the patient's neck strongly. 
 
 2. Procure local or general anesthesia. 
 
 3. Steady the larynx with the thumb and fingers 
 of the left hand. 
 
 4. Make an incision from the center of the thyroid 
 cartilage, extending downward an inch and a half. 
 
 5. Avoid or ligate and divide the cricothyroid 
 artery. 
 
 6. Pltmge a knife transversely through the crico- 
 thyroid membrane exactly in the median line, to the 
 depth of half an inch (Fig. 24). 
 
 7. Causes the opening to gape by everting the lips, 
 until a tube can be procured. 
 
 8 . ExecLite the necessary intralaryngeal procedures. 
 
1 84 - MINOR AND EMERGENCY SURGERY 
 
 9. Insert a laryngeal tube with the end directed 
 downward. 
 
 10. If an obstruction is promptly and perma- 
 nently removed, the cannula may be omitted and the 
 wound closed with fine sutures. 
 
 11. Apply a small square of lint smeared with an 
 
 Fig. 24. — Laiyngotomy through the cricothyroid membrane. 
 
 emollient to prevent irritation of the wound. 
 
 Precautions. — (i) Fix the larynx firmly to pre- 
 vent slipping from under the point of the knife; (2) 
 hold the knife so that not more than half an inch 
 projects beyond the fingers and thumbs; otherwise 
 the larynx may be accidentally transfixed; (3) don't 
 mistake the hyoid bone for the cricoid cartilage. 
 
MINOR OPERATIONS 
 
 185 
 
 TRACHEOTOMY. 
 
 Indications. — (i) Sudden obstruction of the tra- 
 chea; (2) therapeutic purposes; (3) as a preliminary- 
 preventive measure to certain surgical operations; 
 (4) whether the trachea is opened above (high opera- 
 tion) or below (low operation) the isthmus of the 
 
 Fig. 25. — High and low tracheotomy incisions. 
 
 thyroid body will depend upon the anatomical pe- 
 culiarities and the existing circinnstances in each 
 case (Fig. 25). 
 
 Contraindications. — (i) Extreme urgency (lar^^n- 
 gotomy preferable) ; (2) high operation is contra- 
 indicated in laryngeal diseases, because the prox- 
 
1 86 MINOR AND EMERGENCY SURGERY 
 
 imity of the tracheotomy cannula may irritate and 
 exaggerate the trouble. 
 
 Technic. — i. Extend the neck strongly, 
 
 2. Anesthetize the local parts. 
 
 3 . Make a free incision in the skin according to the 
 location of the proposed tracheal incision, exactly 
 in the median line. 
 
 4. Dissect by blunt dissection down to the trachea 
 rapidly but carefully. 
 
 5. Have an assistant hold the soft structures to 
 each side with blunt hooks. 
 
 6. Control hemorrhage. 
 
 7. Avoid the isthmus of the thyroid gland by 
 pushing it up or down, as may be practicable. 
 
 8. Draw up and steady the trachea by fixing a 
 tenaculiim in its upper part. 
 
 9. Thrust the knife, with its back downward, into 
 the trachea three or four rings below the tenaculum 
 and cut upward. 
 
 10. Dilate the aperture laterally with the handle 
 01 the scalpel. 
 
 11. Insert a tracheotomy tube of appropriate size. 
 
 12. Secure the tube with a tape carried twice 
 around the neck. 
 
 13. Keep the tube clear at all times and prevent 
 access of cold dry air by keeping flannel, wrung out 
 in hot water, over the opening of the tube. 
 
 Precautions. — (i) Don't let an over-zealous as- 
 sistant draw the head so far back as to Suffocate 
 the patient before operation is begun ; (2) see that all 
 necessary instruments are at hand; (3) make all in- 
 cisions exactly in the median line and sufficiently 
 
MINOR OPERATIONS 187 
 
 long to secure good exposure; (4) don't open the 
 trachea until all arterial hemorrhage has been con- 
 trolled; (5) be careful not to transfix the trachea or 
 wound the esophagus when incising the trachea; 
 (6) tracheotomy is a difficult and dangerous operation 
 in inexperienced hands. 
 
 HYPODERMIC INJECTIONS. 
 
 Indications. — To secure rapid, thorough and cer- 
 tain absorption of medicaments, especially stimu- 
 lants, sedatives and emetics. 
 
 Contraindications. — (i) Irritant substances; (2) 
 insoluble substances; (3) substances ineffective in 
 small dose; (4) when it is necessary for the patient 
 or some other inexperienced person to administer 
 the medication. 
 
 Technic. — i. With the needle detached, draw in a 
 syringe full of water. 
 
 2. Empty the syringe into a teaspoon or similar 
 article and boil the water over a gas flame or burning 
 match. 
 
 3. Dissolve the tablet in the boiled water. 
 
 4. Aspirate the resulting solution into the syringe. 
 
 5. Screw the needle on firmly. 
 
 6. Point the needle directly upward and expel a 
 few drops by gentle pressure on the piston to make 
 sure that the needle and syringe are free from air. 
 
 7 . Clean a small area of skin with cotton moistened 
 with alcohol. 
 
 8. Dry with cotton. 
 
 9. Pinch up the skin with the fingers and thumb of 
 
i88 
 
 MINOR AND EMERGENCY SURGERY 
 
 the left hand so that the fold is parallel to the course 
 of the neighboring blood-vessels. 
 
 lo. Plunge the needle quickly into the subcuta- 
 neous areolar tissue, with the point directed to- 
 ward the body, being careful to avoid blood-vessels 
 
 Fig. 26. — a, Hypodermic needle introduced correctly; h, hypodermic 
 needle introduced incorrectly. 
 
 (Fig. 26). 
 
 11. Inject the contents of the syringe slowly by 
 exerting uniform pressure on the piston. 
 
 12. Withdraw the needle slowly and massage the 
 small tumefaction gently toward the tinink. 
 
MINOR OPERATIONS 189 
 
 13. Seal the point of entrance with collodion. 
 
 Precautions. — (i) Select a syringe of uniform cali- 
 ber with a properly fitting piston; (2) see that the 
 washers are in good condition and that the joints do 
 not leak; (3) the needle must be sharp and pervious; 
 
 (4) keep a fine wire in the needle when not in use ; 
 
 (5) the solution injected must be perfect, sterile and 
 warm, therefore solutions must always be freshly 
 prepared; (6) strong acid and alkaline solutions are 
 unfitted for hypodermic administration, because they 
 cause severe local irritation ; (7) be sure of an accurate 
 dose and avoid hypermedication ; (8) don't boil 
 the solution after dissolving the medicament, as 
 many substances are decomposed by a temperature 
 of 212° F. 
 
 Dangers. — From faulty technic are: (i) needle 
 abscess, from a non-sterile needle; (2) injecting the 
 medicament into a vein ; (3) introduction of air into a 
 vein ; (4) subsequent formation of drug habits by the 
 patient (insignificant in emergency cases) . 
 
 SKIN-INFILTRATION ANESTHESIA. 
 
 Indications. — To secure local anesthesia, or local 
 analgesia: (i) to minimize or prevent pain in trivial 
 operations ; (2) to avoid or limit the necessity for the 
 employment of general anesthesia in major opera- 
 tions. 
 
 Contraindications. — (i) Inflammation or its prod- 
 ucts existing in the tissues subjacent to the region 
 to be anesthetized, because the additional stretching 
 incident to the infiltration of the already tense skin 
 is extremely painful; (2) very yoimg and nervous 
 
196 
 
 MINOR AND EMERGENCY SURGERY 
 
 patients; (3) regions in which the resulting edema 
 obhterates the dividing line between diseased and 
 healthy tissue. 
 
 Technic. — i. Observe all aseptic and antiseptic 
 precautions, as in hypodermic injections. 
 
 2. Fill a hypodermic syringe with a i per cent, 
 solution of ^ eucaine or cocaine hydrochlorate, 
 adding a minim or two of adrenalin chloride. 
 
 Fig. 27. — a, Correct and b incorrect method of inserting needle for 
 skin infiltration anesthesia. 
 
 3. Cleanse the skin with alcohol. 
 
 4. Insert the needle into the meshes of the skin 
 itself and not into the subcutaneous areolar tissue 
 (Fig. 27). 
 
 5. Inject the solution parallel to the surface, until 
 a good sized wheal is formed. 
 
 6. If the first wheal does not cover a sufficient area. 
 
MINOR OPERATIONS 191 
 
 the needle should be re-inserted in its margin and an 
 adjoining one injected. 
 
 7. After waiting a few seconds, the skin may be 
 freely incised. 
 
 Precautions. — (i) Solutions of cocaine stronger 
 than 2 per cent, are unnecessary and dangerous; 
 (2) the addition of adrenalin chloride has a salutory 
 effect upon the action of the anesthetic (tends to favor 
 hemostasis and prevent a cocaine toxemia) ; (3) 
 boiling decomposes cocaine solutions ; (4) more than 
 one-third of a grain in all should never be used; (5) 
 the duration of the analgesia is increased with an in- 
 crease in strength of the solution ; (6) whenever pos- 
 sible, partial anemia of the part should be procured, 
 as this favors diffusion of the zone anesthetized; 
 when using cocaine anesthesia on a limb, moderate 
 constriction above the point of injection, by retard- 
 ing venous return, confines the anesthetic locally 
 diminishes general absorption and possible tox- 
 emia; (7) a very fine and sharp needle will not cause 
 pain when inserted. 
 
 ETHYL CHLORIDE ANESTHESIA. 
 
 Indications. — To secure anesthesia of a restricted 
 area, particularly adapted to inflammatory tissue. 
 
 Contraindications. — Cases in which deep pene- 
 tration and dissection of tissue are required, or in 
 which prolonged local anesthesia is necessary. 
 
 Technic. — i . Cleanse the skin with soap and water 
 and alcohol. 
 
 2. Grasp the container with the whole hand. 
 
192, 
 
 MINOR AND EMERGENCY SURGERY 
 
 3. Loosen the valve sufficiently to permit a fine 
 spray being projected. 
 
 4. Direct the spray upon the skin, holding the con- 
 tainer some 3 or 4 inches away (Fig. 28). 
 
 5. Stop the spray as soon as the skin area is 
 thoroughly whitened. 
 
 6. Wait until the whitening has nearly disappeared 
 before incising. 
 
 Precautions. — (i) Be sure that the nozzle of the 
 
 Fig. 28. — a, Correct and b incorrect method of obtaining ethyl chloride 
 anesthesia. 
 
 container does not leak; (2) keep a firm grasp on the 
 container, because it is the heat from the hand that 
 exerts pressure within the tube and causes vapori- 
 zation; (3) maintain a fine spray but avoid a stream; 
 (4) too prolonged freezing will be followed by devi- 
 talization and sloughing; (5) the slight discomfort 
 due to reaction, experienced by the patient after- 
 wards, is of no consequence. 
 
MINOR OPERATIONS 193 
 
 ASPIRATION. 
 
 "Aspiration" refers to a method of withdrawing 
 fluids from a cavity by suction, in contradistinction 
 to "paracentesis," which refers to simple puncture of 
 the walls of a cavity. For aspiration an exhausting 
 syringe or apparatus (aspirator) is required, whereas 
 for paracentesis internal pressure and gravitation 
 only are depended upon for removal of the fluid 
 through a trocar or an incision. 
 
 Indications. — (i) Diagnostic confirmation ; (2) evac- 
 uation of collections of serum, blood or pus from a 
 cavity; (3) as an emergency operation in severe cases 
 of retention of urine in which efforts at catheteri- 
 zation have failed ; (4) spina bifida. 
 
 Contraindications. — (i) Extensive pyemic ab- 
 scesses; (2) when the density of pus is so great that 
 it will not flow through the needle ; (3) when sloughing 
 is extensive and the shreds continually plug the 
 needle ; (4) when large blood-vessels or other impor- 
 tant structures that cannot be avoided are interposed 
 between the surface and the collection of fluid. 
 
 Technic. — i . Observe all aseptic and antiseptic pre- 
 cautions and cleanse the overlying skin or mucous 
 membrane. 
 
 2. Press down a small area of skin slightly above 
 the site of the proposed perforation, so that when 
 released by withdrawal of the needle the aperture in 
 the skin will lie above that through the underlying 
 structures, thus avoiding subsequent leakage. 
 
 3. Anesthetize the skin with ethyl chloride. 
 13 
 
194 MINOR AND EMERGENCY SURGERY 
 
 4. Insert a suitable needle, firmly but gradually, 
 until the point is felt to be free in the cavity. 
 
 5. Attach a syringe with the piston depressed or 
 the tube of an aspirating apparatus (preferably 
 Potain's aspirator) in the receiving bottle of which a 
 vacuum has been previously created by means of an 
 attached pump. 
 
 6. If a syringe is employed, withdraw the piston 
 slowly. 
 
 7. If a Potain apparatus is used, open the vent 
 leading into the receiving bottle. 
 
 8. If the limien of the needle becomes obstructed 
 during the out-flow of fluid, it may be cleared by 
 changing its direction, by reversing the action of the 
 syringe temporarily or by removing it, clearing it 
 and introducing it elsewhere. 
 
 9. When the flow ceases, the exhausting pimip 
 may be operated or the needle slightly withdrawn. 
 
 10. When the greater part of the fluid is evacuated, 
 the needle should be removed and the perforation 
 sealed with a little cotton painted with collodion. 
 
 1 1 . Exert firm pressure on the part with a suitable 
 dressing to support the walls of the cavity and aid in 
 preventing a return of the affection. 
 
 Precautions. — (i) Always test the aspirator before 
 using; (2) be sure that the receiving bottle contains 
 a vacuiun and not compressed air; (3) the diameter 
 of the needle selected will depend upon the quantity 
 and viscosity of the fluid to be evacuated through it ; 
 it should be reasonably small; (4) the site at which 
 the needle is introduced should obviously be at the 
 lowest accessible point to which the fluid extends; 
 
MINOR OPERATIONS 
 
 195 
 
 (5) introduce the needle slowly, so that it will not 
 pass entirely through the cavity and reach the oppo- 
 site wall or wound deeper structures unnecessarily 
 before the fluid has an opportunity to escape; (6) 
 never remove the whole of a large collection of fluid 
 at one time; (7) re-accumulations are common after 
 aspiration and repetition is often necessary. 
 
 PARACENTESIS ABDOMINIS. 
 
 Indications. — To evacuate fluid from the abdom- 
 inal cavity. 
 
 Contraindications. — A distended bladder. 
 Technic. — i. Shave and cleanse the skin. 
 
 2. Have the patient sit in a chair or lie on his 
 side on the edge of the bed. 
 
 3. Support the abdominal wall by placing a wide 
 bandage or towel with a central opening around the 
 patient and have an assistant exert firm pressure 
 from behind. 
 
 4. Draw down the skin immediately above the 
 point to be punctured. 
 
 5. Cocainize the area of puncture. 
 
 6. Make a small preliminary skin incision in the 
 linea alba. 
 
 7. Insert a small straight cannula and trocar, 
 carefully but quickly (Fig. 29). 
 
 8. Withdraw the trocar, leaving the cannula in 
 situ and have an assistant tighten the abdominal 
 supporter as the fluid is evacuated and the enlarge- 
 ment decreases. 
 
 9. If the cannula becomes obstructed, it may be 
 cleared by passing a probe through it. 
 
196 
 
 MINOR AND EMERGENCY SURGERY 
 
 10. If the fluid flows too freely, it may be retarded 
 by a compress over the outer opening. 
 
 11. Withdraw the cannula and seal the opening 
 with cotton and collodion. 
 
 Precautions. — (i) Empty the bladder and bowels; 
 mistaking a distended bladder for other collections 
 of fluid is an inexcusable error; (2) verify the area 
 of dulness by percussion immediately before para- 
 
 FiG. 29. — Correct position for paracentesis abdominis. 
 
 centesis; (3) sudden or complete removal of the fluid 
 may precipitate collapse ; (4) in general, the precau- 
 tions for aspiration obtain for paracentesis. 
 
 LUMBAR PUNCTURE. 
 
 Indications. — (i) To withdraw cerebro-spinal fluid 
 to make or verify a diagnosis or relieve excessive 
 pressure within the vertebral canal; (2) to introduce 
 
MINOR OPERATIONS 197 
 
 antitetanic serum or other therapeutic agents into 
 the cerebro-spinal axis. 
 
 Technic. — i. Administer a preliminary dose of 
 morphine and atropine, unless distinctly contra- 
 indicated by the patient's general condition. 
 
 2. Have the patient lie on his side on the edge of 
 the bed, with the body cuived forward, or have 
 him sit up in the same position. 
 
 3. Identify the twelfth dorsal vertebra by means 
 of the last rib and count downward to the spine of 
 the fourth lumbar vertebra. Deep palpation is 
 necessary. 
 
 4. Select a point half an inch to the side of the 
 median line and freeze it with ethyl chloride. 
 
 5. Incise the skin at this point. 
 
 6. Select a slender needle 4 inches long, the stylet 
 of which is ground flush with the end of the needle 
 itself (Dawbarn's needle). 
 
 7. Pass the needle through the subcutaneous tis- 
 sues obliquely upward and inward with the stylet in 
 place. 
 
 8. A sense of diminished resistance indicates 
 penetration of the canal. 
 
 9. Withdraw the stylet; the issuance of a few 
 drops of cerebro-spinal fluid will follow. 
 
 10. Catch the fluid in a test-tube or other suitable 
 container. 
 
 11. Withdraw the needle slowly and seal the 
 small skin incision with cotton and collodion. 
 
 Precautions. — (i) Strict asepsis is imperative; (2) 
 don't withdraw more than 30 c.c. of fluid at most; 
 (3) don't permit the pressure within the canal to 
 
198 MINOR AND EMERGENCY SURGERY 
 
 fall below nonnal ; (4) aspiration is not required and 
 may be dangerous; (5) avoid lateral movements of 
 the needle while obtaining fluid; (6) withdraw the 
 needle slowly. 
 
 SPINAL ANALGESIA. 
 
 Indications. — (i) Cases in which local anesthesia 
 cannot be utilized; (2) when general anesthesia is dis- 
 tinctly contraindicated ; (3) as an auxiliary measure in 
 major operations on the abdomen or lower extremi- 
 ties to prevent shock; (4) to lessen the pains of 
 parturition. 
 
 Technic. — i. Puncture the vertebral canal as de- 
 scribed under lumbar puncture. 
 
 2. Select and sterilize an appropriate dose of one 
 of the following: cocaine, tropacocaine, novocaine, 
 stovaine, eucaine, scopolamine or magnesium sul- 
 phate. 
 
 3. Draw into the syringe, containing the drug in 
 powder, a sufficient amount of cerebro-spinal fluid. 
 
 4. Re-inject as soon as the powder is dissolved. 
 
 5. Operation may be commenced within fifteen 
 minutes. 
 
 6. To increase the upper limit of analgesia, elevate 
 the foot of the bed. 
 
 Precautions. — (i) Boiling decomposes cocaine and 
 its derivatives and they are best sterilized by dis- 
 solving in sulphuric ether with subsequent evapora- 
 tion of the latter, as advocated Hy Bainbridge ; (2) 
 be sure that the drug employed is absolutely sterile, 
 of pure quality and definite strength; (3) be sure 
 
MINOR OPERATIONS 
 
 199 
 
 that the needle is not sHghtly withdrawn while 
 attaching the syringe. 
 
 PHLEBOTOMY (VENESECTION). 
 
 Indications. — To lower vascular tension: (i) pul- 
 
 FiG. 30. — Phlebotomy. 
 
 monary engorgement; (2) engorgement of the right 
 heart; (3) profoimd toxemias with full pulse; (4) 
 cerebral apoplexy. 
 
 Contraindications. — All conditions accompanied 
 by cardio- vascular depression. 
 
200, MINOR AND EMERGENCY SURGERY 
 
 Technic. — i. Shave and cleanse the bend of the 
 elbow. 
 
 2. Apply a constrictor a few inches above the 
 elbow. 
 
 3. Steady the most prominent vein just below the 
 elbow with the thumb of the left hand. 
 
 4. Thrust a lancet or bistoury through the skin 
 and about two-thirds of the diameter of the vein in an 
 oblique direction (Fig. 30). 
 
 5. Remove the pressure of the thiunb to permit 
 flowing. 
 
 6. Catch the blood in a graduated receptacle. 
 
 7. When a sufficient amount has been withdrawn, 
 remove the constrictor, place a gauze pad over the 
 wound and apply a figure-of-eight bandage. 
 
 Precautions. — (i) Apply a broad constrictor, so 
 that it will not cut into the skin; (2) be careful that 
 the constrictor does not exert sufficient pressure to 
 obstruct arterial circulation; (3) an incision carried 
 too deeply may wound one of the cutaneous nerves 
 or the brachial artery; (4) vertigo or evidence of 
 approaching syncope are positive indications for the 
 stoppage of bleeding, even though the intended 
 amount has not been abstracted. 
 
 HYPODERMOCLYSIS. 
 
 Indications. — To supply the body with fluid and 
 aid renal and skin elimination: (i) as a prophylactic 
 measure to prevent and as a therapeutic agent in the 
 treatment of shock; (2) uremia not associated with 
 edema; (3) toxemias; (4) when administration of 
 fluids through the stomach is contraindicated. 
 
MINOR OPERATIONS 201 
 
 Contraindications. — (i) Extremely urgent cases; 
 (2) edema of the lungs due to cardiac or renal dis- 
 ease; (3) high arterial tension. 
 
 Technic. — i. Select and cleanse an area of skin 
 just above the groin, on the inner side of the thigh or 
 in the submammary region. 
 
 2. Fill an ordinary glass irrigating apparatus, 
 with rubber tubing attached, with sterile normal 
 saline solution (2 drams of sodium chloride to a 
 quart of water) at a temperature of 116° F. 
 
 3. Attach an aspirating needle to the free end of 
 the rubber tube. 
 
 4. Elevate the needle and open the stop-cock, 
 thus freeing the tube and needle of air. 
 
 5. Introduce the needle at the selected site into 
 the subcutaneous areolar tissue. 
 
 6. Elevate the reservoir about 2 feet above the 
 level of the needle. 
 
 7. After all the solution has been injected, mas- 
 sage the tumor lightly, from below upward. 
 
 Precautions. — (i) Remember that in shock hypo- 
 dermoclysis is of no value by reason of its bulk, but 
 good results accrue by virtue of its stimulant power 
 over the vasomotor system only; (2) be careful of 
 over-dosage ; i dram of saline solution to each pound 
 of the body weight in each fifteen minutes is the limit 
 of safety; (3) employ hypodermoclysis cautiously in 
 stout-old persons, young children and in cases of 
 nephritis. 
 
B.— Hot 
 
 202 MINOR AND EMERGENCY SURGERY 
 
 ENTEROCLYSIS. 
 
 Indications : 
 
 A. — Cold (70° F.) : To reduce fever in sthenic cases. 
 
 [ diuresis. 
 (i) to promote -j sweating. 
 
 [ alimentary elimination. 
 
 (2) shock. 
 
 (3) toxemias. 
 
 (4) intestinal hemorrhage. 
 
 (5) intussuception. 
 
 (6) pelvic exudates. 
 
 (7) inflammation and spasm of the pelvic viscera. 
 
 (8) infantile convulsions. 
 
 The temperature should be 100° to 104°, if in- 
 creased pulse tension is to be avoided; 105° to 108°, 
 if increased pulse tension is not objectionable; and 
 110° to 120°, if a rapid increase in pulse tension and 
 stimulation of the heart is desired. 
 
 Contraindications. — Renal disease with polyuresis. 
 
 Technic. — i. Fill a fountain syringe, irrigator or 
 other suitable apparatus with the solution. The 
 composition and quantity of the solution will of 
 course vary according to the purpose for which it is 
 to be administered. 
 
 2. Attach a rectal tube (or soft mbber catheter 
 for children) to the free end of the tube leading to the 
 reservoir. 
 
 3. Open the stop-cock and permit the entire length 
 of tubing to fill with fluid. 
 
 4. Lubricate the tip of the rectal tube. 
 
 5. With the patient in the dorsal position or lying 
 on his left side, insert the end of the tube into the 
 
MINOR OPERATIONS 
 
 203 
 
 rectum, at the same time again opening the stop- 
 cock and permitting the solution to flow slowly. 
 
 6. Gradually raise the reservoir from the level of 
 the patient to a height that will exert the desired 
 pressure. 
 
 Fig. 31. — Enteroclysis with Kemp's tube. 
 
 7. When the reservoir is empty, withdraw the 
 tube slowly. 
 Or 
 
204^ MINOR AND EMERGENCY SURGERY 
 
 2. Attach a Kemp's return flow tube to the free 
 end of the tube leading to the reservoir. 
 
 3. Exclude all air, 
 
 4. Lubricate the tip of the tube. 
 
 5. Introduce the Kemp's tube with a gentle rotary- 
 motion, so that the folds of the mucous membrane 
 will not catch in its fenestrations. 
 
 6. Attach a piece of rubber tubing to the outflow 
 channel and conduct to a suitable receptacle (Fig. 31). 
 
 7. Control the inflow and outflow of the solution 
 by pinching the corresponding tubes when necessary. 
 
 Precautions. — (i) Always introduce fluids into the 
 intestine slowly to avoid spasm; (2) a Davidson 
 syringe should not be used, because the flow is inter- 
 mittent and the pressure is indeterminable; (3) great 
 pressure exerted on damaged intestine is dangerous; 
 it should never exceed 8 pounds. 
 
 INTRAVENOUS INFUSION. 
 
 Indications. — (i) Extremely urgent cases of shock; 
 (2) to overcome the collapse from hemorrhage; (3) 
 for the relief of various forms of toxemia; (4) as an 
 emergency measure in cases of edema; (5) to se- 
 cure rapid and certain action of certain medicinal 
 agents. 
 
 Technic. — i. Place the thoroughly sterilized solu- 
 tion in a warm irrigator. 
 
 2. Sterilize the patient's skin over one of the 
 superficial veins near the elbow or over the internal 
 saphenous vein. 
 
 3. Apply a constrictor immediately above. 
 
MINOR OPERATIONS 
 
 205 
 
 4. Incise the skin and dissect off the sheath of the 
 vein. 
 
 5. Ligate the vein at the distal end of the incision 
 with catgut. 
 
 6. Pass a second ligature under the vein at the 
 proximal end of the incision and leave it untied. 
 
 7. Exclude all air from the rubber tubing, con- 
 nected with the irrigator and the cannula, by opening 
 the stop-cock until a steady stream is obtained. 
 
 Fig. 32. — -Intravenous infusion, a, Distal ligature tied and cut; b, 
 proximal ligature tied temporarily about the vein and cannula. 
 
 8. Incise the distended vein and quickly insert the 
 cannula, with the solution running. 
 
 9. Tie the loose ligature around the cannula and 
 overlying vein with a single knot (Fig. 32). 
 
 10. When the cannula is withdrawn, tighten the 
 ligature around the vein and secure with a double 
 knot. 
 
 1 1 . Divide the vein between the two ligatures. 
 
2o6 MINOR AND EMERGENCY SURGERY 
 
 12. Suture the skin wound. 
 
 13. Apply a suitable dressing. 
 
 Precautions. — (i) Taste the solution before ster- 
 ilizing, if saline solution is being used; a large 
 quantity of plain water injected into a vein will 
 cause rapid disintegration of the red blood-corpuscles 
 and subsequent death ; (2) the temperature of the 
 solution should never be less than 100° F. ; (3) be 
 sure that all air is excluded from the tubing and 
 cannula and that no air enters the vein at any stage 
 of the operation ; (4) always use a well diluted solu- 
 tion of a drug and introduce it slowly ; a quart should 
 require half an hour; (5) dip the cannula in saline 
 solution before inserting to prevent a few drops of 
 blood from coagulating on its tip; (6) don't try to 
 enter a vein with a sharp needle without incising 
 the skin; blind surgery is never justifiable. 
 
 DIRECT TRANSFUSION. 
 
 Indications. — (i) To replace, in whole or in part, 
 loss of normal blood; (2) prolonged shock; (3) ane- 
 mias; (4) general debility; (5) toxemias. 
 
 Contraindications. — When a healthy donor can- 
 not be obtained. 
 
 Technic. — i. Place the donor and donee on paral- 
 lel tables. 
 
 2. Observe all aseptic and antiseptic precautions. 
 
 3. Secure skin anesthesia by infiltration with 
 cocaine solution. 
 
 4. Expose and free about 3 cm. of the radial artery 
 of the donor, collateral branches being ligated when 
 necessary. 
 
MINOR OPERATIONS 
 
 207 
 
 5. Expose and free about 3 cm. of the median 
 cephalic vein of the recipient. 
 
 6. Place a permanent ligature peripherally on 
 each blood-vessel, 
 
 7. Apply a Crile compression clamp, one arm being 
 rubber shod, as near as possible to the proximal end 
 of each exposed vessel. 
 
 8. Divide the vessels with sharp scissors, just 
 above the distal ligatures. 
 
 9. Select a suitable sterile Brewer's glass tube, 
 about 2 inches in length and with a slight bulbous 
 tip at each end, which are made in various calibers 
 and are straight, curved and angulated. 
 
 10. Immerse the tube in melted paraffin until all 
 air bubbles cease to rise. 
 
 11. A quick sharp shake dislodges excess paraffin. 
 
 12. Remove the paraffin on the exterior of the 
 tube. 
 
 13. Insert the smaller end into the artery and tie 
 a ligature around it, so that the ligature lies in the 
 groove beside the bulbous tip. 
 
 14. Release the pressure of the Crile clamp on the 
 artery slightly, permitting arterial blood to flow. 
 
 15. Insert the other end of the tube into the vein 
 and tie another ligature around it. 
 
 16. Remove both hemostatic clamps entirely. 
 
 17. When blood has passed for a sufficient time, 
 ligate both artery and vein and withdraw the tube. 
 
 18. Suture the wounds, and apply a dressing. 
 Precautions. — (i) Direct transfusion should not be 
 
 attempted by the inexperienced, as a slight error 
 may prove disastrous; (2) when feasible, it is wiser 
 
2d8 MINOR AND EMERGENCY SURGERY 
 
 to supply arterial than venous blood; (3) test-tube 
 phenomena being fairly reliable, make a preliminary 
 test of the blood of both donor and donee to avoid 
 possible hemolysis; (4) don't use hemostatic clamps 
 that exert great pressure and injure the walls of the 
 blood-vessels; the pressure should be just sufficient 
 to obstruct the blood current temporarily; (5) 
 merely dipping the Brewer's tube into liquid par- 
 affin will not insure complete coating of the lumen ; 
 (6) general anesthesia is pemiissible but local 
 anesthesia advisable; (7) watch the condition of 
 both patients carefully; (8) in case of threatened 
 syncope, place the donor in the Trendelenburg 
 position; (9) it is impossible to accurately guage the 
 amount of blood transfused, but pronounced in- 
 crease of cardiac dullness or sudden dyspnea in the 
 recipient is indication for cessation. 
 
 CATHETERIZATION. 
 
 Indications. — (i) To determine the contents of the 
 bladder; (2) to withdraw urine in emergencies; (3) 
 to evacuate blood-clots, fragments of stone or foreign 
 bodies; (4) to cleanse the bladder; (5) to introduce 
 medicaments; (6) as a preliminary to abdominal 
 operations; (7) to distend the bladder with water or 
 air; (8) to establish continuous vesical drainage; (9) 
 as a diagnostic measure. 
 
 Contraindications. — (i) Impermeability of the 
 urethra; (2) suppression of urine. 
 
 Technic. — i. Patient recumbent. 
 
 2 . Select the largest soft-rubber catheter that will 
 readily pass the external urinary meatus. 
 
MINOR OPERATIONS 
 
 209 
 
 3 . Cleanse and sterilize the hands of the operator, 
 instrument and glans penis. 
 
 4. Retract the foreskin and grasp the glans with 
 the thumb and forefinger of the left hand, directing 
 the penis so that it points to the median line of the 
 anterior abdominal wall. 
 
 5. Holding the catheter 2 or 3 inches behind its 
 tip, dip the tip in a sterile lubricant and insert 
 gently into the meatus. 
 
 6. Propel the catheter forward about a quarter of 
 an inch at a time. 
 
 7. As the tip enters the membranous urethra, de- 
 press the distal end of the instrument and as the tip 
 enters the bladder the exposed end should lie parallel 
 with the extended thighs. 
 
 8. If an obstruction is encountered during the 
 passage of the instrument, it should be slightly with- 
 drawn and another effort made to pass it. An im- 
 passable barrier will necessitate the use of a catheter 
 of smaller size or one of metal, depending upon the 
 existing circumstances. 
 
 Precautions.^ — (i) Be sure that the soft-rubber 
 catheter is not hard and brittle ; (2) a rigid catheter, 
 in inexperienced hands, is a dangerous instrument 
 and should not be employed unless the soft-rubber 
 one fails and patency of the urethra is certain; (3) 
 the utmost gentleness should be observed in passing 
 catheters ; they cannot be forced through the urethra 
 without danger; (4) a false passage is evidenced by 
 sudden obstruction and great pain; hemorrhage fol- 
 lows withdrawal of the instrument; (5) patience and 
 gentle persistence will overcome spasmodic stricture ; 
 14 
 
2IO MINOR AND EMERGENCY SURGERY 
 
 (6) continuous catheterization is preferable to fre- 
 quent introduction and withdrawal; (7) the catheter 
 should fill but not dilate the urethra; (8) catheteri- 
 zation will dissipate many abdominal "tumors"; 
 (9) don't try to catheterize women by the sense of 
 touch only; infection or injury may be the price of 
 false modesty; (10) a preliminary dose of hexa- 
 methylenamine is an excellent prophylactic measure, 
 as it renders the urine more or less aseptic. 
 
 VACCINATION. 
 
 Indications. — (i) As a prophylactic measure in the 
 prevention of small-pox; (2) to attenuate the viru- 
 lence of an attack of small-pox; (3) to propagate the 
 virus of vaccinia. 
 
 Contraindications. — (i) Impaired general health; 
 (2) acute diseases other than small-pox. 
 
 Technic. — i. Select and surgically cleanse a suit- 
 able site on the skin, being careful to avoid the bellies 
 of underlying muscles. The insertion of the deltoid 
 muscle and inner condyle of the femur are the loca- 
 tions usually chosen. 
 
 2. Stretch the skin, with the forefinger and thumb 
 of the left hand. 
 
 3. Make a number of criss-cross scratches on the 
 skin, denuding an area about a quarter of an inch in 
 diameter, of its superficial epithelia, with a scarifier 
 or steel needle, which has been sterilized by passing 
 through a flame. 
 
 4. Break off the end of a small aseptically sealed 
 capillary tube containing glycerinated animal lymph. 
 
 5 . Attach the section of small rubber tubing which 
 accompanies the glass tube to its free end. 
 
MINOR OPERATIONS 211 
 
 6. Break off the other end of the glass tube. 
 
 7. Blow through the rubber tube, depositing the 
 virus on the scarified area. 
 
 8. Rub in gently with the instrument. 
 
 9. After drying thoroughly, apply a suitable shield. 
 
 10. If unsuccessful, revaccinate in two weeks. 
 Precautions. — (i) If the virus is inoculated over a 
 
 muscle, the region is irritated by the movements 
 of the muscle ; (2) large and multiple denudations are 
 unnecessaiy; (3) the skin should be scratched until 
 lymph exudes but never deeply enough to cause 
 bleeding; (4) the virus should be active and free 
 from other pathogenic organisms, not long in stock 
 and kept in a cool place ; (5) the virus obtained in the 
 hermetically sealed tubes is likely to be cleaner and 
 more potent than that dried on ivory points; (6) 
 the patient's underclothes must be clean ; the shield 
 may be dispensed with in patients whose habits are 
 cleanly. 
 
 SKIN-GRAFTING. 
 
 Indications.— (i) To cause prompt healing of large 
 granulating surfaces, preventing the deformities that 
 result from natural reparative processes and subse- 
 quent contraction of the scars; (2) to replace scar 
 tissue with a soft pliable integument; (3) plastic 
 operations. 
 
 Contraindications. — Devitalized or necrotic sur- 
 faces. 
 
 Technic. — i. Wash the granulating surface with 
 saline solution and dry with sterile gauze. 
 
 2. Cleanse the area from which the grafts are to 
 
212 MINOR AND EMERGENCY SURGERY 
 
 be taken with soap and hot water and flush with 
 saline solution. 
 
 3. Select a keen edged razor, ground flat on one 
 side. 
 
 4. Sterilize the razor by immersing in alcohol for 
 ten minutes. 
 
 5. Wrap the thumb and forefinger of the operator's 
 left hand in sterile gauze and stretch the skin. 
 
 6. Cut a thin graft from the stretched skin with a 
 quick sawing motion of the razor, being careful to 
 remove the epidermis only. 
 
 7. Transfer the grafts directly from the razor to 
 the granulating surface. 
 
 8. Repeat until the entire area is covered, the 
 grafts over-lapping each other and the skin margins. 
 They may be teased into position with a sterile probe. 
 
 9. Press out all air bubbles with the probe. 
 
 10. Cover with a strip of sterile gutta-percha 
 tissue and leave for a week. 
 
 1 1 . Cover the gutta-percha tissue with a generous 
 layer of sterile gauze wrung out in hot saline solution. 
 
 12. Change the wet gauze daily, being careful not 
 to disturb the gutta-percha tissue. 
 
 Precautions. — (i) Don't graft until healing has 
 begun and the surface is well granulated; (2) trim 
 off exhuberant granulations with a sharp razor; (3) 
 take the skin from the patient himself when possible ; 
 (4) never employ local anesthesia; if anesthesia is 
 absolutely necessary, use a general anesthetic; (5) 
 skin-grafting must be an aseptic operation; anti- 
 septics are contra-indicated. 
 
INDEX 
 
 Abdomen, contused wounds, 
 
 37 
 gunshot wounds of, 47 
 paracentesis of, 195 
 wounds of, protrusion of 
 intestine in, 34 
 Abscess, 123 
 
 method of opening, 127 
 pointing of, 125 
 Accidental wounds, 23 
 Acid, carbolic, in erysipelas, 
 136 
 in wet dressings, 3 2 
 subcutaneous injections, 
 in carbuncles, 129 
 Adrenalin chlorid in shock, 
 
 174, 175 
 in superficial bleeding, 
 129 
 Ambulance , removal of pati- 
 ent to, 19, 20 
 surgeon, 19 
 
 rules for, 20-22 
 Ammonia in shock, 175 
 Amputations, traumatic, 106 
 after-treatment, 113 
 anesthesia in, no 
 conservative surgery in, 
 
 no 
 drainage in, 112 
 emergency treatment, 107 
 operative treatment, 108 
 
 Analgesia, spinal, 198 
 indications, 198 
 precautions, 198 
 technic, 198 
 Anesthesia, ethyl chloride, 191 
 contraindications, 191 
 indications, 191 
 precautions, 192 
 technic, 191 
 in compound fractures and 
 traumatic amputations, 
 1 10 
 in shock, 172 
 infiltration, 189 
 of site of incision in local- 
 ized pyogenic infections, 
 126 
 skin-infiltration, 189 
 contraindications, 189 
 indications, 189 
 precautions, 191 
 technic, 190 
 spinal, 198 
 
 indications, 198 
 precautions, 198 
 technic, 198 
 Ankle, sprains of, emergency 
 treatment, 54 
 strapping, 54 
 Ankylosis complicating frac- 
 tures, 122 
 in dislocations, 63 
 
 !I3 
 
214 
 
 INDEX 
 
 Antitoxin, tetanus, 138 
 Arm, nerves of, injury to, in 
 
 fractures of humerus, 86 
 Arthritis, traumatic, 51 
 
 treatment of, 52 
 Artificial respiration, 180 
 contraindications, 180 
 faradization, 182 
 indications, 180 
 Laborde's method, 181 
 precautions, 182 
 Schafer's method, 180 
 Sylvester' s method, 180 
 Aspiration, 193 
 
 contraindications, 193 
 indications, 193 
 precautions, 194 
 technic, 193 
 Auditory canal, external, for- 
 eign bodies in, 163 
 Avulsion of scalp, 41 
 
 Back, sprained, 53 
 
 strapping of, 56 
 Bandage, Barton, 80 
 
 Velpeau, in fracture of 
 clavicle, 84 
 Bandages for fractures, 67 
 
 sterilization of, 35 
 Bandaging, 32 
 Barton's bandage, 80 
 Bed-sores, 156 
 
 prevention of, 157 
 Benzine for dissolving grease, 
 
 40 
 Bichloride of mercury as wet 
 
 dressing, 32 
 Bier's hyperemia in localized 
 pyogenic infections, 128 
 in wounds, 34 
 
 Bites, rabid animal, treat- 
 ment, 44 
 snake, treatment of, 44 
 Bladder, catheterization of, 
 208 
 rupture of, in fractures of 
 pelvis, 94 
 Blocking nerve with cocain 
 in compound fractures 
 and traumatic amputa- 
 tions, 110 
 to prevent shock, 171 
 Blood transfusion, 206 
 
 contraindications, 206 
 in collapse, 176 
 indications, 206 
 precautions, 207 
 technic, 206 
 Boil, 123 
 Bones, metacarpal, fractures 
 
 of, 93 
 
 of foot, fractures of, 105 
 Bullet wounds, 45 
 Bunion, 49 
 
 treatment, 49 
 Burns, 140 
 
 complications of, treatment, 
 
 145 
 constipation in, treatment, 
 
 146 
 constitutional effects of, 
 
 treatment, 145 
 due to chemical agents, 
 
 treatment, 145 
 electric, 141, 144 
 exhaustion from, treatment, 
 
 147 
 first degree, 141 
 
 treatment, 142 
 inflammation of viscera 
 
 from, 146 
 
INDEX 
 
 215 
 
 Burns, renal congestion from, 
 treatment, 146 
 
 second degree, 141 
 treatment, 142 
 
 shock from, treatment, 146 
 
 sun, 142 
 
 symptoms of, 140 
 
 third degree, 141, 144 
 
 treatment of, local, 142 
 
 x-ray, 141 
 
 treatment of, 145 
 Burrow's solution, 131 
 Bursitis, 49 
 
 chronic, 49 
 
 prepatellar, 49 
 
 serous, 49 
 chronic, 49 
 
 suppurative, 49 
 
 syphilitic, 49 
 
 tubercular, 49 
 
 types of, 49 
 
 Callus, formation in frac- 
 tures, 120 
 Carbolic acid in erysipelas, 136 
 
 wash, 32 
 Carbuncle, 124 
 
 method of opening, 127 
 Catgut, iodine, preparation 
 
 of, 28 
 Catheterization, 208 
 
 contraindications, 208 
 
 indications, 208 
 
 precautions, 209 
 
 technic, 208 
 Cellulitis, 124 
 
 incisions in, 127 
 Certificate, death, 179 
 Chemical agents, burn due to, 
 
 treatment, 145 
 Chilblain, 149 
 
 Chilblain, treatment of, 149 
 Clavicle, fractures of, 83 
 Sayre dressing in, 83 
 Velpeau bandage in, 84 
 Cocaine, nerve blocking with, 
 
 to prevent shock, 171 
 Coccygodynia, 63 
 Coin-catcher, 167 
 Cold, intense, effects of, 140 
 Coley's fluid, 136 
 Collapse, 168 
 
 blood transfusion in, 176 
 causes of, 169 
 diagnosis of, 170 
 due to hemorrhage, treat- 
 ment, 176 
 factors, predisposing to, 169 
 from sudden withdrawal of 
 large amount of fluid, 177 
 manifestations of, 170 
 oxygen in, 176 
 prevention of, 171 
 saline solution in, 176 
 symptoms of, 170 
 treatment of, 172, 176 
 CoUes' fracture, 91 
 
 Plaster-of-Paris dressing 
 
 for, 92 
 treatment, 91 
 Compound fractures, 106. See 
 
 also Fractures, compound 
 Condyloid fractures of hum- 
 erus, treatment, 88 
 Congestion, renal, from burns, 
 
 treatment, 146 
 Constipation in burns, treat- 
 ment, 146 
 Contused wounds, 36 
 drainage, 38 
 dressings, 37 
 hematoma in, 36 
 
2l6 
 
 INDEX 
 
 Contused wounds of abdomen, 
 
 37 
 
 of scalp, 36 
 sloughing in, 38 
 Coronoid process of ulna, frac- 
 tures, treatment of, 93 
 Cut-throat, 41 
 treatment of, 42 
 
 Death, 177 
 
 care of patient before, 177 
 
 certificate, 179 
 
 signs of, 178 
 Deformed union of fractures, 
 
 120 
 Deformity, gun-stock, in frac- 
 tures of humerus, 88 
 Delayed union of fractures, 1 1 6 
 Dislocations, 57 
 
 ankylosis in, 63 
 
 at elbow, 59 
 
 at shoulder-joint, 58 
 
 examination of, 58 
 
 infracotyloid, 60 
 
 of hip, 59 
 
 of jaw, 58 
 
 of radius and ulna, 59 
 
 of thumb, 59 
 
 perineal, 60 
 
 subacromial, 59 
 
 subclavicular, 59 
 
 subglenoid, 59 
 
 subspinous, 59 
 
 supracoracoid, 59 
 
 supracotyloid, 60 
 
 traumatic, 57 
 
 treatment of, 60 
 Drain, Peple's, 130 
 Drainage in compound frac- 
 tures, 112 
 
 of contused wounds, 38 
 
 Drainage of lacerated wounds 
 of scalp, 41 
 of localized pyogenic infec- 
 tions, 129 
 of punctured wounds, 43 
 of wounds, 26, 31 
 tubes, incisions for, 39 
 Dressing, gauze, of wounds, 3 i 
 of contused wounds, 37 
 of lacerated wounds, 41 
 permanent, of fractures, 67 
 plaster-of-Paris, for Colles' 
 
 fracture, 92 
 primary, of wounds, 31 
 Sayre, in fractures of clav- 
 icle, 83 
 Dupuytren's splint, 105 
 Dusting powders, 36 
 
 Ear, foreign bodies in, 163 
 Edema in fractures, 122 
 Elbow, dislocations at, 59 
 Electric burns, 141, 144 
 
 current for production of 
 artificial respiration, 182 
 Enteroclysis, 202 
 
 contraindications, 202 
 
 in shocks, 174 
 
 indications, 202 
 
 precautions, 203 
 
 technic, 202 
 
 with Kemp's tube, 204 
 Ergotole in shock, 175 
 Erysipelas, 135 
 
 effect of, on sarcoma, 136 
 
 facial, 135 
 
 phlegmonous, 135 
 Erysipelatoid lymphangitis, 
 
 135 
 Esophagus, foreign bodies in, 
 
 166 
 
INDEX 
 
 217 
 
 Ethyl chloride anesthesia, 191 
 contraindications, 191 
 inlocalizedp yogenic in- 
 fection, 126 
 indications, 191 
 precautions, 192 
 technic, 191 
 Exhaustion from burns, treat- 
 ment, 147 
 heat, 147 
 
 and insolation, differentia- 
 tion, 148 
 treatment of, 149 
 Extension apparatus for frac- 
 tures, 68, 69 
 Eye, foregin bodies in, 161 
 removal, 162 
 
 FACiAL'erysipelas, 135 
 
 Fainting, 168 
 
 Faradization as means of 
 
 artificial respiration, 182 
 Femur, fractures of, 95 
 
 in infants and young 
 
 children, 98 
 neck, 96 
 seperation of epiphyses, 
 
 97 
 shaft, 97 
 Fibrous union of fractures, 
 
 119 
 Fibula and tibia, fractures of, 
 102 
 fractures of, lower end, 104 
 separation of epiphyses, 
 
 104 
 shaft, 104 
 upper end, 104 
 Fluid, Coley's, 136 
 Foot, bones of, fractures, 105 
 Forearm, fractures of, 89 
 
 Foreign bodies, 159 
 
 beneath nail, removal, 
 161 
 in ear, 163 
 in esophagus, 166 
 in external auditory 
 
 canal, 163 
 in eye, 161 
 
 removal, 162 
 in larynx, 164, 165 
 in nose, 164 
 in pharynx, 164 
 in subcutaneous tissues, 
 
 160 
 in trachea, 164, 165 
 in wounds, 24 
 removal, 28 
 X-ray for detecting, 2 5 
 Quain's method of re- 
 moving, 161 
 X-rays in locating, 160 
 Fractures, 64 
 
 accompanying wounds, 25 
 ankylosis complicating, 122 
 bandages for, 67 
 callus formation in, 120 
 Colles', 91 
 
 plaster-of-Paris dressing 
 
 for, 92 
 treatment of, 91 
 compound, 106 
 
 after-treatment, 113 
 conservative surgery in, 
 
 no 
 drainage in, 112 
 emergency treatment, 107 
 fixation of bone fragments 
 
 in, III 
 operative treatment, 108 
 deformed union, 120 
 delayed union, 116 
 
2l8 
 
 INDEX 
 
 Fractures, edema in, 122 
 emergency treatment, 66 
 examination of, 64 
 extension apparatus for 
 
 68, 69 
 fibrous union, 119 
 fixation by extension, 68 
 gunshot, of skull, 78 
 immobilization plus mas- 
 sage, 69 
 injury to nerves in, 120 
 involving nose and mouth, 
 
 78 
 loss of function in, 121 
 non-union of, 117 
 causes, 117, 118 
 syphilis as cause, 117 
 of bones of foot, 105 
 of clavicle, 83 
 
 Sayre dressing in, 83 
 Velpeau bandage in, 84 
 of femur, 95 
 
 in infants and young 
 
 children, 98 
 neck, 96 
 separation of epiphyses, 
 
 97 
 shaft, 97 
 of fibula, lower end, 104 
 separation of epiphyses, 
 
 104 
 shaft, 104 
 upper end, 104 
 of forearm, 89 
 of humerus, 85 
 
 condyloid, treatment of, 
 
 88 
 gun-stock deformity in, 
 88 
 
 injury to nerves of 
 in, 86 
 
 arm 
 
 Fractures of humerus, Jones' 
 position in, 88 
 lower end, treatment, 87 
 shaft, treatment of, 87 
 of jaw, 78, 79 
 of knee-cap, 98 
 of legs, 102 
 
 of metacarpal bones, 93 
 of patella, 98 
 treatment, 99 
 
 consevative, 99, 100 
 radical, 99, loi 
 of pelvis, 94 
 
 rupture of bladder in, 94 
 of urethra in, 95 
 of radius and ulna, 89 
 treatment, 90 
 shaft, treatment, 90 
 treatment, 90 
 of ribs, 81 
 of skull, 71 
 diagnosis, 72 
 prognosis, 73 
 treatment, 73 
 of spine, 81 
 of tibia, 104 
 and fibula, 102 
 separation of epiphyses, 
 103 
 of ulna, coronoid process, 
 treatment, 93 
 olecranon process, treat- 
 ment, 93 
 shaft, treatment of, 93 
 styloid process, treat- 
 ment, 93 
 open operation, 69 
 permanent dressing of , 67 
 Pott's, 104 
 pressure sores in, 121 
 refracture of, 120 
 
INDEX 
 
 219 
 
 Fractures, rupture of skin and 
 soft parts in, 121 
 
 sepsis after, 1 14 
 
 sequels of, 116 
 
 simple, 64 
 
 sloughing of skin and soft 
 parts in, 121 
 
 splints for, 67 
 
 sprain, 52 
 
 ununited, 117 
 
 causes of, 117, 118 
 
 X-rays in examination, 65 
 Frost-bite, 149 
 Function, loss of, in fractures, 
 
 121 
 Furuncle, 123 
 
 Gangrene in wounds, 24 
 Gauze dressing of wounds, 
 
 31 
 
 Gibney's method of treating 
 
 sprained ankle, 54 
 Glycerine as aid to wet dress- 
 ing, 32, 113 
 Grafting, skin-, 211 
 contraindications, 211 
 indications, 211 
 precautions, 212 
 technic, 211 
 Gunshot fractures of skull, 
 treatment, 78 
 wounds, 45 
 
 of abdomen, 47 
 tetanus from, 45 
 X-rays in, 46, 47 
 Gun-stock deformity in frac- 
 tures of humerus, 88 
 
 Hands, sterilization of, 35 
 Harrington's solution, iii 
 
 Heat exhaustion, 147 
 
 and insolation, differen- 
 tiation, 148 
 treatment, 149 
 intense, effects of, 140 
 Hematoma in contused 
 
 wounds, 36 
 Hemorrhage, collapse due to, 
 treatment, 176 
 from wounds, 24 
 control of, 26 
 Hip, dislocations of, 59 
 House staff, 17, 18 
 Housemaid's knee, 49 
 Humerus, fractures of, 85 
 
 condyloid, treatment of, 
 
 88 
 gun stock deformity in, 88 
 injury to nerves of arm 
 
 in, 86 
 Jones' position in, 88 
 lower end, treatment, 87 
 shaft, treatment, 87 
 Hydrogen peroxide, irrigation 
 
 of wounds with, 27 
 Hyperemia, Bier's, in wounds, 
 34 
 in localized pyogenic infec- 
 tions, 127, 128 
 Hypodermic injections, 187 
 contraindications, 187 
 dangers, 189 
 indications, 187 
 precautions, 189 
 technic, 187 
 Hypodermoclysis, 200 
 contraindications, 201 
 in shock, 174 
 indications, 200 
 precautions, 201 
 technic, 201 
 
2^20 
 
 INDEX 
 
 Hysterical joints, 48 
 
 IcHTHYOL in erysipelas, 136 
 
 Incised wounds, 41 
 
 Incisions for drainage tubes, 
 
 39 
 in localized pyogenic infec- 
 tions, 126 
 Infected wounds, 44 
 Infections, pyogenic, acute, 
 123 
 localized, 123 
 
 after-treatment, 132 
 anesthesia of site of 
 
 incision in, 126 
 drainage in, 129 
 hyperemia in, 127, 128 
 incisions in, 126 
 method of expressing 
 
 pus, 128 
 sterilization in, 128 
 systemic disturbances in, 
 
 131 
 treatment of, 125 
 systemic, 132 
 
 serum-therapy in, 133 
 special, 135 
 Infiltration anesthesia, 189 
 Inflammation of joints, 48 
 
 of viscera from burns, 146 
 Infracotyloid dislocations, 60 
 Infusion, intravenous, 203 
 indications, 203 
 precautions, 206 
 technic, 204 
 Insolation, 147 
 
 and heat exhaustion, differ- 
 entiation, 148 
 Instruments, sterilization of, 
 
 35 
 Interne, 17, 18 
 
 Intravenous infusion, 203 
 in collapse, 176 
 in shock, 1 74 
 indications, 203 
 precautions, 206 
 technic, 204 
 Iodine catgut preparation, 28 
 in erysipelas, 136 
 tincture of, in localized py- 
 ogenic infections, 129 
 injection, into wounds, 31 
 Iodoform as dusting powder, 
 
 36 
 Irrigation, continuous, in com- 
 pound fractures, 1 14 
 of wounds with hydrogen 
 peroxide, 27 
 
 Jaw, dislocations of, 58 
 
 fractures of, 78, 79 
 Joints, hysterical, 48 
 
 inflammations of, 48 
 
 traumatic injuries, 48 
 Jones' position in fractures of 
 
 humerus, 88 
 
 Kemp's tube, enteroclysis 
 
 with, 204 
 Kidneys, congestion of, from 
 
 burns, treatment, 146 
 Knee, housemaid's, 49 
 Knee-cap, fracture of, 98 
 
 Laborde's method of artificial 
 
 respiration, 181 
 Lacerated wounds, 39 
 
 dressing, 41 
 
 of scalp, drainage, 41 
 
 treatment, 40 
 
INDEX 
 
 221 
 
 Laryngotomy, 183 
 
 contraindications, 183 
 
 indications, 183 
 
 precautions, 184 
 
 technic, 183 
 Larynx, foregin bodies in, 164, 
 
 165 
 Leg, fractures of, 102 
 ulcer of, 151 
 strapping, 154 
 Liquor ammonii acetatis in 
 renal congestion from 
 burns, 146 
 Lockjaw, 137 
 Lumbar puncture, 196 
 indications, 196 
 precautions, 197 
 technic, 197 
 Luxatio erecta, 59 
 Lymphangitis, erysipelatoid, 
 
 Magnesium sulphate in tet- 
 anus, 138 
 
 Massage in fractures, 69 
 
 Mercury, bichloride of, as wet 
 dressing, 32 
 
 Metacarpal bones, fractures 
 
 of. 93 
 Minor operations, 180 
 Morphine in burns, 146 
 
 in shock, 175 
 Mouth and nose, fractures 
 
 involving, 78 
 
 Nail, foreign body beneath, 
 
 removal, 160 
 Nerve blocking with cocaine 
 
 to prevent shock, 171 
 Nerves, injury to, in fractures, 
 120 
 
 Nerves, of arm, injury to, in 
 fractures of humerus, 86 
 
 Non-union of fractures, 117 
 causes, 117, 118 
 
 Nose and mouth, fractures 
 involving, 78 
 foreign bodies in, 164 
 
 Olecranon process of ulna, 
 
 fractures, treatment of, 93 
 
 Operations during shock, 172 
 
 minor, 180 
 Oxygen in collapse, 176 
 
 Paracentesis abdominis, 195 
 contraindications, 195 
 indications, 195 
 precautions, 196 
 technic, 195 
 Patella, fractures of, 98 
 treatment, 99 
 
 conservative, 99, 100 
 radical, 99, loi 
 Patient, removal of, to ambu- 
 lance, 19, 20 
 Pelvis, fractures of, 94 
 
 rupture of bladder in, 94 
 of urethra in, 95 
 Penetrating wounds, 43 
 Peple's drain, 130 
 Perforating wounds, 43 
 Perineal dislocations, 60 
 Pharynx, foreign bodies in, 
 
 164 
 Phlebotomy, 199 
 
 contraindications, 199 
 indications, 199 
 precautions, 200 
 technic, 200 
 Phlegmonous erysipelas, 135 
 
2?2 
 
 INDEX 
 
 Plaster-of-Paris dressing for 
 
 Colles' fracture, 92 
 Pointing of abscess, 125 
 Poisoned wounds, 44 
 Pott's fracture, 104 
 
 puffy tumor, 36 
 Poultices, 125 
 Powder grains, removal, 46 
 Powders, dusting, 36 
 Prepatellar bursitis, 49 
 Pressure sores in fractures, 121 
 Probing for foreign bodies, 160 
 
 of wounds, 24 
 Puffy tumor. Pott's, 36 
 Puncture, lumbar, 196 
 indications, 196 
 precautions, 197 
 technic, 197 
 of abdomen, 195 
 Punctured wounds, 43 
 
 drainage, 43 
 Pus, localized collections of, 
 123 
 evacuation, 128 
 
 curettage of cavity 
 after, 128 
 treatment, 125 
 Pyogenic infections, acute, 
 123 
 localized, 123 
 
 after-treatment, 132 
 anesthesia of site of 
 
 incision in 126 
 drainage in, 129 
 hy[)eremia in, 127, 128 
 incisions in, 126 
 method of expressing 
 
 pus, 128 
 sterilization in, 128 
 systemic disturbances 
 in, 131 
 
 Pyogenic infections, localized, 
 treatment of, 125 
 systemic, 132 
 
 serum-therapy in, 133 
 treatment of, 133 
 
 Quain's method of removing 
 foreign bodies, 161 
 
 Rabid animal, bite of, treat- 
 ment, 44 
 Radius and ulna, dislocations 
 
 of> 59 
 fractures of, 89 
 treatment, 90 
 fractures of shaft, treat- 
 ment, 90 
 treatment, 90 
 Refracture, 120 
 Renal congestion from burns, 
 
 treatment, 146 
 Resident, 18 
 
 Respiration, artificial, 180 
 contraindications, 180 
 faradization as means, 
 
 182 
 indications for, 180 
 Laborde's method, 181 
 precautions in, 182 
 Schafer's method, 180 
 Sylvester's method, 180 
 Ribs, fractures of, 81 
 Rules for ambulance surgeon, 
 
 20—22 
 Rupture of bladder in frac- 
 tures of pelvis, 94 
 of skin and soft parts in 
 
 fractures, 121 
 of urethra in fractures of 
 pelvis, 95 
 
INDEX 
 
 223 
 
 Saline solution in collapse, 176 
 
 in shock, 174 
 Sacroma, effects of erysipelas 
 
 on, 136 
 Sayre dressing in fractures of 
 
 clavicle, 83 
 Scalp, avulsion of, 41 
 
 contused wounds of, 36 
 
 lacerated wounds of, drain- 
 age, 41 
 Schafer's method of artificial 
 
 respiration, 180 
 Sepsis after fractures, 114 
 Sequels of fractures, 116 
 Serous bursitis, 49 
 
 chronic, 49 
 Serum treatment of systemic 
 
 infections, 133 
 Shaving of surrounding skin 
 
 in wounds, 27 
 Shock, 168 
 
 adrenalin chloride in, 174, 
 
 175 
 ammonia in, 175 
 causes of, 169 
 diagnosis of, 170 
 enteroclysis in, 174 
 ergotol in, 175 
 factors predisposing to, 169 
 from burns, treatment, 146 
 from wounds, 24 
 hypodermoclysis in, 174 
 manifestations of, 170 
 morphine in, 175 
 operating during, 172 
 prevention of, 171 
 saline solution, 174 
 symptoms of, 170 
 treatment of, 172 
 Shoulder-joint, dislocations at, 
 58 
 
 Signs of death, 178 
 Skin and soft parts, rupture 
 and sloughing, in fractures, 
 121 
 Skin-grafting, 2 1 1 
 
 contraindications, 2 1 1 
 indications, 211 
 precautions, 212 
 technic, 211 
 Skin-infiltration anesthesia, 
 189 
 contraindications, 189 
 indications, 189 
 precautions, 191 
 technic, 190 
 Skull, fractures of, 71 
 diagnosis, 72 
 
 differential diagnosis of 
 associated brain in- 
 juries, 74, 75, 76, 77 
 prognosis, 73 
 treatment, 73 
 gunshot fractures, 78 
 Sloughing in contused 
 wounds, 38 
 in wounds, 23 
 
 of skin and soft parts in 
 fractures, 121 
 Snake bites, treatment, 44 
 Solution, Burrow's, 131 
 Thiersch's, 144 
 Wright's, 131 
 Sores, pressure, in fractures, 
 
 121 
 Spinal analgesia, 198 
 indications, 198 
 precautions, 198 
 technic, 198 
 Spine, fractures of, 81 
 Splint, Dupuytren's 105 
 Splints for fractures, 67 
 
224 
 
 INDEX 
 
 Sprained back, 53 
 strapping, 56 
 Sprain-fracture, 52 
 Sprains, 52 
 
 after-treatment, 56 
 
 emergency treatment, 53 
 
 of ankle, emergency treat- 
 ment, 54 
 strapping, 54 
 Sterilization in localized pyo- 
 genic infections, 128 
 
 of bandages, etc., 35 
 
 of hands, 35 
 
 of instruments, 35 
 
 of wounds, 3 1 
 Strapping of sprained ankle, 54 
 
 back, 56 
 
 ulcer of leg, 154 
 Styloid process of ulna, frac- 
 tures treatment, of, 93 
 Subclavicular dislocations, 59 
 Subcutaneous tissues, foreign 
 
 bodies in, 160 
 Subcuticular suture, 29, 30 
 Subglenoid dislocations, 59 
 Subspinous dislocations, 59 
 Sun burns, 142 
 Sunstroke, 147 
 
 treatment of, 148 
 Suppurative bursitis, 49 
 Supracoracoid dislocations, 59 
 Supracotyloid dislocations, 60 
 Surgeon, ambulance, 19 
 
 rules for, 20-22 
 Surgical collapse, 168. See 
 also Collapse 
 
 shock, 168. See also Shock 
 
 Suture of divided important 
 
 structures in wounds, 28 
 
 of wounds, 29 
 
 subcuticular, 29, 30 
 
 Sylvester's method of artificial 
 
 respiration, 180 
 Syncope, 168 
 Synovitis, traumatic, 50 
 
 treatment of, 50 
 Syphilis as cause of delayed 
 
 union of fractures, 116, 
 
 117 
 Syphilitic bursitis, 49 
 Systemic disturbances in local- 
 ized pyogenic infections, 
 
 131 
 pyogenic infections, 132 
 
 Tetanus, 137 
 antitoxin, 138 
 from gunshot wounds, 45 
 magnesium sulphate in, 138 
 prophylaxis of, 138 
 Thiersch's solution, 144 
 Throat, cut-, 41 
 
 treatment of, 42 
 Thumb, dislocations of, 59 
 Tibia and fibula, fractures of, 
 102 
 fractures of, 104 
 
 separation of epiphyses, 
 103 
 Tincture of iodine in local- 
 ized pyogenic infections, 
 129 
 in preparation of catgut, 
 
 28 
 injection into wounds, 3 i 
 Trachea, foreign bodies in, 
 
 164, 165 
 Tracheotomy, 185 
 
 contraindications, 185 
 indications, 185 
 precautions, 186 
 technic, 186 
 
INDEX 
 
 225 
 
 Transfusion, blood, 206 
 
 contraindications, 206 
 indications, 206 
 precautions, 207 
 technic, 206 
 Traumatic amputations, 106 
 after-treatment, 113 
 conservative surgery in, 
 
 no 
 drainage in, 112 
 emergency treatment, 
 
 107 
 operative treatment, 108 
 arthritis, 51 
 
 treatment, 52 
 dislocations, 57 
 injuries of joints, 48 
 synovitis, 50 
 treatment, 50 
 Tubercular bursitis, 49 
 Tumor, Pott's puffy, 36 
 Turpentine for dissolving 
 grease, 40 
 
 Ulcers, 151 
 
 treatment of, 152 
 
 varicose, of leg, 151 
 strapping, 154 
 Ulna and radius, dislocations 
 
 of, 59 
 fractures of, 89 
 fractures of coronoid pro- 
 cess, treatment, 93 
 treatment, 90 
 olecranon process, treat- 
 ment, 93 
 shaft, treatment of, 93 
 styloid process, treat- 
 ment, 93 
 Union, deformed, of fractures, 
 
 IS 
 
 Union, delayed, of fractures, 
 116 
 fibrous, of fractures, 1 1 y 
 
 Ununited fractures, 1 1 7 
 causes of, 117, 118 
 
 Urethra, rupture of, in frac- 
 tures of pelvis, 95 
 
 Vaccination, 210 
 
 contraindications, 210 
 
 indications, 210 
 
 precautions, 211 
 
 technic, 210 ^ 
 
 Vaccine treatment of infected 
 
 wounds, 44 
 Varicose ulcer of leg, 151 
 
 strapping, 154 
 Velpeau bandage in fractures 
 
 of clavicle, 84 
 Venesection, 199 
 
 contraindications, 199 
 
 indications, 199 
 
 precautions, 200 
 
 technic, 200 
 Viscera, inflammation of, 
 
 from burns, 146 
 
 Wash, carbolic, 32 
 Wounds, accidental, 23 
 after-treatment, 34 
 bandaging of, 32 
 Bier's hyperemia, in, 34 
 bullet, 45 
 
 classification of, 23 
 coaptation of edges, 2 9 
 contused, 36 
 
 drainage of, 38 
 
 dressing of, 3 7 
 
 hematoma in, 36 
 
 of abdomen, 37 
 
 of scalp, 36 
 
226 
 
 INDEX 
 
 Wounds, contused, sloughing 
 
 in, 38 
 drainage of, 26, 31 
 dressing of, primary, 3 1 
 emergency treatment, 33 
 examination of, 24 
 foreign bodies in, 24 
 removal, 28 
 X-ray for detecting, 25 
 fracture accompanying, 25 
 gangrene in, 24 
 gauze dressing, 3 1 
 gunshot, 45 
 
 of abdomen, 47 
 
 tetanus from, 45 
 
 X-rays in, 46, 47 
 hemorrhage from, 24 
 
 control of, 26 
 incised, 41 
 infected, 44 
 irrigation of, with hydrogen 
 
 peroxide, 27 
 lacerated, 39 
 
 dressing, 41 
 
 of scalp, drainage, 41 
 
 treatment of, 40 
 of abdomen, protrusion of 
 
 intestine in, 34 
 penetrating, 43 
 
 Wounds, perforating, 43 
 poisoned, 44 
 probing of, 24 
 prognosis of, 24 
 punctured, 43 
 
 drainage of, 43 
 rest of injured area, 33 
 shaving of surrounding skin 
 
 in, 27 
 shock from, 24 
 sloughing in, 23 
 sterilization of, 3 i 
 suture of, 29 
 
 divided important 
 structures in, 28 
 tincture of iodine injected 
 
 into, 3 1 
 treatment of, 25 
 
 emergency, t,t, 
 Wright's solution, 131 
 
 X-RAY burns, treatment, 145 
 for detecting foreign bodies 
 
 in wounds, 25 
 in examination of fractures, 
 
 65 
 in gunshot wounds, 46, 47 
 in locating foreign bodies, 
 
 160 
 
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 special chapter on the bacteriology of ear affections — a feature not to be found 
 in any other work on otology. Great pains have been taken with the illus- 
 trations. A large number represent the best work of Mr. H. F. Aitken. 
 
 PERSONAL AND PRESS OPINIONS 
 
 Frank Allport, M. D., 
 
 Professor of Otology, Northwestern University , Chicago, 
 
 " I regard it as one of the best books in the English language on this subject. The 
 pictures are especially good, particularly as they are practically all original and not the old 
 reproduced pictures so frequently seen." 
 
 Fayette C. Ewing, M. D., 
 
 Original Fellow of the Royal Society of Medicine, Great Britain. 
 
 " You have written the completest work on otology before the profession to-day. Besides 
 being comprehensive, its directions are so specific that it should prove an ideal work for the 
 young practitioner." 
 
 Journal American Medical Association 
 
 " Its teaching is sound throughout and up to date. The strongest chapters are those 
 on suppuration of the middle ear and the mastoid cells, and the intracranial complications 
 of ear disease." 
 
DISEASES OF THE EVE. 
 
 DeSchweinitzV 
 Diseases of the Eye 
 
 The New (6th) Edition 
 
 Diseases of the Eye : A Handbook of Ophthalmic Prac- 
 tice, By G. E. deSchweinitz, M. D., Professor of Ophthal- 
 mology in the University of Pennsylvania, Philadelphia, etc. 
 Handsome octavo of 945 pages, 351 text-illustrations, and 7 
 chromo-lithographic plates. Cloth, ^5.00 net ; Half Morocco, 
 $6.50 net. 
 
 WITH 351 TEXT-ILLUSTRATIONS AND 7 COLORED PLATES 
 
 Dr. deSchweinitz' s book has long been recognized as a standard authority 
 upon eye diseases, the reputation of its author for accuracy of statement 
 placing it far in the front of works on this subject. For this edition Dr. 
 deSchweinitz has subjected his book to a most thorough revision. Fifteen 
 new subjects have been added, ten of those in tlie former edition have been 
 rewritten, and throughout the book reference has been made to vaccine and 
 serum therapy, to the relation of tuberculosis to ocular disease, and to the 
 value of tuberculin as a diagnostic and therapeutic agent. 
 
 The text is fully illustrated with black and white cuts and colored plates, 
 and in every way the book maintains its reputation as an authority. 
 
 Johns Hopkins Hospital Bulletin 
 
 " No single chapter can be selected as the best. They are all the product of a finished 
 authorship and the work of an exceptional ophthalmologist. The work is certainlj' one of 
 the best on ophthalmology extant, and probably the best by an American author." 
 
 DeSchweinitz and Randall's 
 Eye, Ear, Nose, and Throat 
 
 American Text=Book of Diseases of the Eye, Ear, Nose, 
 and Throat. Edited by G. E. deSchweinitz, M. D., and 
 B. Alexander Randall, M. D. Imperial octavo, 1 251 pages, 
 with 766 illustrations, 59 of them in colors. Cloth, ^7.00 net; 
 Half Morocco, ^8.50 net. 
 
SAUNDERS' BOOKS ON 
 
 GET A«**^*,:<%r»,«* THE NEW 
 
 THE BEST /imCriCan standard 
 
 Illustrated Dictionary 
 
 Just Ready— The New (6th) Edition 
 
 The American Illustrated Medical Dictionary. A new 
 
 and complete dictionary of the terms used in Medicine, Surgery, 
 Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, 
 and all kindred branches; with over loo new and elaborate 
 tables and many handsome illustrations. By W. A. Newman 
 Borland, M.D. Large octavo of 985 pages. Flexible leather, 
 ^4.50 net; with thumb index, ^5.00 net. 
 
 ENTIRELY RESET— A NEW WORK WITH ADDED FEATURES 
 
 In this edition the book has been subjected to a thorough revision and 
 entirely reset, adding thousands of important new terms. This is the only 
 up-to-date medical dictionary — bar none. 
 
 Howard A. Kelly, M.D.. 
 
 Processor of Gynecologic Surgery, Johns Hopkins University, Ballimore 
 
 "Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such conve- 
 nient size. No errors have been found in my use of it." 
 
 Pilcher's Practical Cystoscopy 
 
 Practical Cystoscopy. By Paul M. Pilcher, M.D., Con- 
 sulting Surgeon to the Eastern Long Island Hospital. Octavo of 
 398 pages, with 233 illustrations, 29 in colors. Cloth, ^5.50 net. 
 
 JUST READY 
 
 To be properly equipped, you must have at your instant command the 
 information this book gives you. It explains away all difficulty, telling you 
 wky you do not see something when something is there to see, and telling you 
 how to see it. All theory has been uncompromisingly eliminated, devoting 
 every line to practical, needed every-day facts, telling you how and when to 
 use the cystoscope and catheter — telling you in a way to make you know. 
 The work is complete in every detail. 
 
EYE, EAR, NOSE, AND THROAT 
 
 Theobald's 
 Prevalent Diseases of the Eye 
 
 Prevalent Diseases of the Eye. By Samuel Theobald, 
 M. D., Clinical Professor of Ophthalmology and Otology, Johns 
 Hopkins University. Octavo of 550 pages, with 219 text-illustra- 
 tions and 10 plates. Cloth, $4.50 net ; Half Morocco, |6.oo net. 
 
 Chas. A. Oliver. M. D.. 
 
 Clinical Professor of Ophthalmology , Woman's Medical College, Phila. 
 " I feel I can conscientiously recommend it, not only to the general physician and 
 medical student, but also to the experienced ophthalmologist." 
 
 Wells* Chemical Pathology 
 
 Chemical Pathology. By H. Gideon Wells, Ph.D., 
 M.D., Assistant Professor of Pathology in the University of Chi- 
 cago. Octavo of 549 pages. Cloth, ^3.25 net. 
 
 Wm. H, Welch, M.ID., Johns Hopkins University . 
 
 " The work fills a real need in the English literature of a very important subject, and I 
 shall be glad to recommend it to my students." 
 
 Saxe's Urinalysis 
 
 Examination of the Urine. By G. A. DeSantos Saxe, 
 M. D., Instructor in Venereal and Genito-Urinary Surgery, 
 New York Post-Graduate Medical School and Hospital. i2mo 
 of 448 pages, illustrated. Cloth, ;^i.75 net. 
 
 THE NEW (2d) EDITION 
 
 This work is intended as an aid in diagnosis, by interpreting the clinical 
 significance of the chemic and microscopic urinary findings. 
 
 Francis Carter Wood, M. D., 
 
 Adjunct Professor of Clinical Pathology , Columbia University. 
 
 " It seems to me to be one of the best of the smaller works on this subject ; it is indeed, 
 better than a good many of the larger ones." 
 
SJCWDjSJ^S' BOOK'S OiV 
 
 Brtihl, Politzer, and Smith's 
 Otology 
 
 Atlas and Epitome of Otology. ByGusxAV Bruhl, M. D., 
 of Berlin, with the collaboration of Professor Dr. A. Politzer, 
 of Vienna. Edited, with additions, by S. MacCuen Smith, 
 M.D., Professor of Otology in the Jefferson Medical College, 
 Philadelphia. With 244 colored figures on 39 lithographic plates, 
 99 text-illustrations, and 292 pages of text. Cloth, ^3.00 net. 
 In Saunders' Hand-Atlas Series. 
 
 The work is both didactic and clinical in its teaching. A special feature 
 is the very complete exposition of the minute anatomy of the ear, a working 
 knowledge of which is so essential to an intelligent conception of the science 
 of otology. 
 
 Clarence J. Blake, M.D.. 
 
 Professor of Otology in Harvard Unhiersity Medical School, Boston. 
 " The most complete work of its kind as yet published, and one commending itself to 
 both the student and the teacher in the character and scope of its illustrations." 
 
 Haab and DeSchweinitz's 
 Operative Ophthalmology 
 
 Atlas and Epitome of Operative Ophthalmology. By 
 
 Dr. O. Haab, of Ziirich. Edited, with additions, by G. E. 
 deSchweinitz, M.D., Professor of Ophthalmology, University 
 of Pennsylvania. With 30 colored lithographic plates, 154 text- 
 cuts, and 375 pages of text. Cloth, ^3.50 net. In Saunders' 
 Hand-Atlas Series. 
 
 This work represents the author's thirty years' experience in eye work. 
 The various operative interventions are described with all the precision and 
 clearness that such an experience brings. Recognizing the fact that mere verbal 
 descriptions are frequently insufficient, Dr. Haab has taken particular care to 
 illustrate plainly the different parts of the operation. 
 
 Johns Hopkins Hospital Bulletin 
 
 " The descriptions of the various operations are so clear and full that the volume car 
 •veil hold place with more pretentious text-books." 
 
DISEASES OF THE EYE. 
 
 Haab and DeSchweinitz's 
 External Diseases qf the £ye 
 
 Atlas and Epitome of External Diseases of the Eye. 
 
 By Dr O. Haab, of Zurich. Edited, with additions, by G. E. 
 deSchweinitz, M, D. , Professor of Ophthalmology, University of 
 Pennsylvania. loi colored illustrations on 46 lithographic plates 
 and 244 pages of text. Cloth, ^3.00 net. Saunders^ Atlases. 
 
 THE NEW (3d) EDITION 
 
 The conditions attending diseases of the external eye, which are often so 
 complicated, have probably never been more clearly and comprehensively 
 expounded than in the forelying work. 
 
 The Medical Record, New York 
 
 " The work is excellently suited to the student of ophthalmology and to the practising 
 physician. It cannot fail to attain a well-deserved popularity." 
 
 Haab and DeSchweinitz's 
 Ophthalmoscopy 
 
 Atlas and Epitome of Ophthalmoscopy and Ophthal- 
 moscopic Diagnosis. By Dr. O. Haab, of Ziirich. Edited, 
 with additions, by G. E. deSchweinitz, M. D., Professor of Oph- 
 thalmology, University of Pennsylvania. With 152 colored litho- 
 graphic illustrations and 94 pages of text. Cloth, ^3.00 net. 
 In Saunders^ Hand- Atlas Series. 
 
 THE NEW (2d) EDITION 
 
 In this work not only is the student made acquainted with carefully pre- 
 pared ophthalmoscopic drawings done into well-executed lithographs of the 
 most important fundus changes, but, in many instances, plates of the micro- 
 scopic lesions are added. 
 
 The Leuicet. London 
 
 " We recommend it as a work that should be in the ophthalmic wards or in the library 
 of every hospital into which ophthalmic cases are received." 
 
SAUNDEHS' BOOKS ON 
 
 Greene and Brooks' 
 Genito-Urinary Diseases 
 
 A Text=Book of Genito=Urinary Diseases. By Robert 
 H. Greene, M.D., Professor of Genito-Urinary Surgery at 
 Fordham University; and Harlow Brooks, M. D., Assistant Pro- 
 fessor of Clinical Medicine, University and Bellevue Hospital Medi- 
 cal School. Octavo of 560 pages, illustrated. Cloth, $5.00 net. 
 
 THE NEW (2d) EDITION 
 
 This new work covers completely the subject of genito-urinary diseases, 
 presenting both the medical and surgical sides. Kidney diseases are very elabo- 
 rately detailed. 
 
 New York Medical Journal 
 
 " As a whole the book is one of the most satisfactory and useful works on genito- 
 urinary diseases now extant, and will undoubtedly be popular among practitioners and 
 students." 
 
 Gleason on Nose, Throat, 
 and £ar 
 
 A Manual of Diseases of the Nose, Throat, and Ear. By 
 
 E. Baldwin Gleason, M.D., LL.D., Clinical Professor of 
 Otology, Medico-Chirurgical College, Philadelphia. i2mo of 
 563 pages, profusely illustrated. Flexible leather, $2.50 net. 
 
 THE NEW (2d) EDITION 
 
 Methods of treatment have been simplified as much as possible, so that in 
 most instances only those methods, drugs, and operations have been advised 
 which have proved essential. A feature consists of the collection of formulas. 
 
 American Journal of the Medical Sciences 
 
 " For the practitioner who wishes a reliable guide in laryngology and otology there ar 
 few books which can be more heartily commended." 
 
 American Text=Book of Qenito=Urinary Diseases, 
 Syphilis, and Diseases of the Sl<in. Edited by L. Bolton 
 Bangs, M.D., late Professor of Genito-Urinary Surgery, Bellevue 
 University, New York; and W. A. Hardaway, M.D., Professor 
 of Diseases of the Skin, Missouri Medical College. Octavo, 
 1229 pages, 300 engravings, 20 colored plates. Cloth, $7.00 net. 
 
NOSE, THROAT, AND EAR. 
 
 GradleV 
 Nose, Pha^rynx, and Ear 
 
 Diseases of the Nose, Pharynx, and Ear. By Henry 
 Gradle, M. D., Professor of Ophthalmology and Otology, North- 
 western University Medical School, Chicago. Handsome octavo 
 of 547 pages, illustrated, including two full-page plates in colors. 
 Cloth, $3.50 net; Half Morocco, $5.00 net. 
 
 This volume presents diseases of the Nose, Pharynx, and Ear as the author 
 has seen them during an experience of nearly twenty-five years. Topographic 
 anatomy has also been accorded liberal space. 
 
 Pennsylvania Medical Journal 
 
 " This is the most practical volume on the nose, pharynx, and ear that has appeared 
 recently. ... It is exactly what the less experienced observer needs, as it avoids the con- 
 fusion incident to a categorical statement of everybody's opinion." 
 
 Kyle's Nose and Throat 
 
 Diseases of the Nose and Throat. By D. Braden Kyle, 
 M.D., Professor of Laryngology in the Jefferson Medical Col- 
 lege, Philadelphia; Consulting Laryngologist, Rhinologist, and 
 Otologist, St. Agnes' Hospital. Octavo, 797 pages; with 219 
 illustrations and 26 lithographic plates in colors. Cloth, $4.00 
 net; Half Morocco, $5.50 net. 
 
 THE NEW (4th) EDITION 
 
 This work has now reached its fourth edition. With the practical purpose 
 of the book in mind, extended consideration has been given to treatment, each 
 disease being considered in full, and definite courses being laid down to 
 meet special conditions and symptoms. 
 
 Pennsylvania Medical Journal 
 
 " Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat 
 knowledge in this book. The practical man, be he special or general, will not search in 
 vain for anything he needs." 
 
10 SAUNDERS' BOOKS ON 
 
 Stelwa^on's 
 Diseases of the Skin 
 
 A Treatise on Diseases of tlie Skin. By Henry W. 
 Stelwagon, M. D., Ph. D., Professor of Dermatology in the 
 Jefferson Medical College, Philadelphia. Octavo of 1 175 pages, 
 with 280 text-cuts and 32 plates. Cloth, ^6.00 net; Half 
 Morocco, $7.50 net. 
 
 THE NEW (6th) EDITION 
 
 The demand for six editions of this work in such a short period indi- 
 cates the practical character of the book. In this edition the articles on 
 Frambesia, Oriental Sore, and other tropical diseases have been entirely re- 
 written. The new subjects include Verruga Peruana, Leukemia Cutis, 
 Meralgia Paraesthetica, Dhobie Itch, and Uncinarial Dermatitis. 
 
 George T. Elliot, M. D., Professor of De7-matology., Cornell University. 
 
 " It is a book that I recommend to my class at Cornell, because for conservative judg- 
 ment, for accurate observation, and for a thorough appreciation of the essential position of 
 dermatology, I think it holds first place." 
 
 Schamberg^s Diseases of the 
 Skin and Eruptive Fevers 
 
 Diseases of the Skin and Eruptive Fevers. By Jay 
 
 F. ScHAMBERG, M. D., Profcssor of Dermatology and the In- 
 fectious Eruptive Diseases, Philadelphia Polyclinic. Octavo of 
 534 pages, illustrated. Cloth, $3.00 net. 
 
 THE CUTANEOUS MANIFESTATIONS OF ALL DISEASES 
 
 "The views expressed on all topics are conservative, safe to follow, and practical, and 
 are well abreast of the knowledge of the present time. Actinotherapy and radiother;ip 
 receive considerably more than passing notice." — American Journal of Medical Scii-nci-. . 
 
DISEASES OF THE S/i/iV. tl 
 
 Mracek and Steiwag'on's 
 Diseases of the Skin 
 
 Atlas and Epitome of Diseases of the Skin. By Prof. 
 Dr. Franz Mracek, of Vienna. Edited, with additions, by 
 Henry W. Stelwagon, M. D., Professor of Dermatology in 
 the Jefferson Medical College, Philadelphia. With 77 colored 
 plates, 50 half-tone illustrations, and 280 pages of text. In 
 Saunders^ Hand- Atlas Series. Cloth, ^4.00 net. 
 
 THE NEW (2d) EDITION 
 
 American Journal of the Medical Sciences 
 
 " The advantages which we see in this book and which recommend it to our minds are : 
 First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and 
 the diagnostic points which they bring out " 
 
 Mracek and Bangs' 
 Syphilis 6 Venereal Diseases 
 
 Atlas and Epitome of Syphilis and the Venereal Dis= 
 
 eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with 
 additions, by L. Bolton Bangs, M. D., late Prof of Genito- 
 urinary Surgery, University and Bellevue Hospital Medical Col- 
 lege, New York. With 71 colored plates and 122 pages of text. 
 Cloth, $3.50 net. In Saunders' Hand-Atlas Series. 
 
 According to the unanimous opinion of numerous authorities, the illus- 
 trations in this work surpass in beauty anything of the kind that has been pro- 
 duced, not only in Germany, but throughout the literature of the world. 
 
 Robert L. Dickinson, M. D., 
 
 Art Editor of" The Avieiican Text-Book of Obstetrics." 
 
 " The book that appeals instantly to me for the strikingly successful, valuable, and 
 graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' 
 I know of nothing in this country that can compare with it." 
 
12 SAUNDEJiS' BOOK'S OJV 
 
 Holland's 
 Chemistry and Toxicolog'y 
 
 A Text=Book of Medical Chemistry and Toxicology. 
 
 By James W. Holland, M.D., Professor of Medical Chemistry 
 and Toxicology, and Dean, Jefferson Medical College, Philadel- 
 phia. Octavo of 635 pages, illustrated. Cloth, $3.00 net. 
 
 JUST READY— THE NEW (3d) EDITION 
 
 Dr. Holland's work is an entirely new one, and is based on his thirty-five 
 years' practical experience in teaching chemistry and medicine. Recognizing 
 that to understand physiologic chemistry students must first be informed upon 
 points not referred to in most medical te.\t-books, the author has included in his 
 work the latest views of equilibrium of equations, mass-action, cryoscopy, os- 
 motic pressure, etc. Much space is given to toxicology. 
 
 American Medicine 
 
 " Its statements are clear and terse ; its illustrations well chosen; its development logi- 
 cal, systematic, and comparatively easy to follow. . . . We heartily commend the work." 
 
 Gninwald and Newcomb's 
 Mouth, Pharynx, and Nose 
 
 Atlas and Epitome of Diseases of the Mouth, Pharynx, 
 and Nose. By Dr. L. Grunwald, of Munich. Edited, with 
 additions by James E. Newcomb, M. D., Instructor in Laryn- 
 gology, Cornell University Medical School. With 102 illustrations 
 on 42 colored lithographic plates, 41 text-cuts, and 219 pages of 
 text. Cloth, ^3.00 net. In Saunders' Hand-Atlas Series. 
 
 Gninwald 6 Grayson on Larynx 
 
 Atlas and Epitome of Diseases of the Larynx. By Dr. 
 
 L. Grxjnwald, of Munich. Edited, with additions, by Charles 
 P. Grayson, M. D., Clinical Professor of Laryngology and 
 Rhinology, University of Pennsylvania. With 107 colored 
 figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth, 
 ^2.50 net. In Saunders' Hand- At/as Series. 
 
EYE, EAR, NOSE, AND THROAT. 13 
 
 Jackson on the"^r~ 
 
 A Manual of the Diagnosis and Treatment of Diseases 
 of the Eye. By Edward Jackson, A.M., M.D., Professor of 
 Ophthalmology, University of Colorado. i2mo of 615 pages, 
 with 184 illustrations. Cloth, ^2.50 net. 
 
 THE NEW (2d) EDITION 
 The Medical Record, New York 
 
 " It is truly an admirable work. . . . Written in a clear, concise manner, it bears evi- 
 dence of the author's comprehensive grasp of the subject. The term ' multum in parvo ' is 
 an appropriate one to apply to this work. It will prove of value to all who are interested in 
 this branch of medicine." 
 
 rriedrich and Curtis on 
 Nose, Larynx, and Ear 
 
 Rhinology, Laryngology, and Otology, and Their Sig- 
 nificance in General Medicine. By Dr. E. P. Friedrich, of 
 Leipzig. Edited, with additions, by H. Holbrook Curtis, M.D., 
 Consulting Surgeon to the New York Nose and Throat Hospital. 
 Octavo volume of 350 pages. Cloth, ^2.50 net. 
 
 Grant on the Face, Mouth, and Jaws 
 
 A Text=Book of the Surgical Principles and Surgical 
 Diseases of the Face, Mouth, and Jaws. For Dental 
 Students. By H. Horace Grant, A.M., M.D., Professor of 
 Surgery and of Clinical Surgery, Hospital College of Medicine, 
 Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, 
 ^2.50 net. 
 
/4 SAUA^DERS' BOOKS ON 
 
 Ogden on the Urine 
 
 Clinical Examination of Urine and Urinary Diagnosis. 
 
 A Clinical Guide for the Use of Practitioners and Students of 
 Medicine and Surgery. By J. Bergen Ogden, M. D., Medical 
 Chemist to the Metropolitan Life Insurance Company, New 
 York. Octavo, 418 pages, 54 text-illustrations, and a number 
 of colored plates. Cloth, ^3.00 net. 
 
 THE NEW (3d) EDITION 
 
 In t^is edition the work has been brought absolutely down to the present 
 day. Urinary examinations for purposes of life insurance have been incor- 
 porated, because a large number of practitioners are often called upon to make 
 such analyses. Special attention has been paid to diagnosis by the character 
 of the urine, the diagnosis of diseases of the kidneys and urinary passages. 
 
 The Lancet, London 
 
 " We consider this manual to have been well compiled ; and the author's own experience, 
 so clearly stated, renders the volume a useful one both for study and reference." 
 
 Vecki's Sexual Impotence 
 
 The Pathology and Treatment of Sexual Impotence. 
 
 By Victor G. Vecki, M. D. From the Second Revised and 
 Enlarged German Edition. i2mo volume of 400 pages. 
 
 THE NEW (4th) EDITION— PREPARING 
 
 This volume will come to many as a revelation of the possibilities of thera- 
 peutics in this important field. The whole subject of sexual impotence and 
 its treatment is discussed by the author in an exhaustive and thoroughly sci- 
 entific manner. In this edition the boolc has been thoroughly revised, and 
 new matter has been added, especially to the portion dealing with treatment. 
 
 Johns Hopkins Hospital Bulletin 
 
 "A scientific treatise upon an important and much neglected subject. . . . The treatment 
 of impotence in general and of sexual neurasthenia is discriminating and judicious." 
 
CHEMISTRY, SKIN, AND VENEREAL DISEASES. 
 
 American Pocket Dictionary New (7thf EdWon 
 
 The American Pocket Medical Dictionary. Edited by W. A. 
 Newman Borland, M.D. Containing the definition of the princij^al 
 words used in medicine and kindred sciences. 6lo pages. Flexible 
 leather, with gold edges,' ^i.oo net; with thumb index, ^1.25 net. 
 
 " I am struck at once with admiration at the compact size and attractive exterior. 
 lean recommend it to our students without reserve."— James W. Holland, M. D., 
 Professor of Medical Chefiiistry and Toxicology at the fefferson Medical College, 
 Philadelphia. 
 
 Stel wagon's Essentials of Skin New (7th) Edition 
 
 Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
 M. D., Ph. D.. Professor of Dermatology in the Jefferson Medical 
 College, Philadelphia. Post-octavo of 292 pages, with 72 text-illustra- 
 tions and 8 plates. Cloth, JJi.oo net. In Saunders' Question- Compend 
 Series. 
 
 " In line with our present knowledge of diseases of the skin. . . . Continues to main- 
 tain the high standard of excellence for which these question compends have been 
 noted." — The Medical News. 
 
 Wolffs Medical Chemistry seventh Edition 
 
 Essentials of Medical Chemistry, Organic and Inorganic. 
 Containing also Questions on Medical Physics, Chemical Physiology, 
 Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
 Wolff, M. D., Late Demonstrator of Chemistry, Jefferson Medical 
 College. Revised by A. Ferree Witmer, Ph.G., M. D., formerly As- 
 sistant Demonstrator of Physiology, University of Pennsylvania. Post- 
 octavo of 225 pages. Cloth, ^i.oo net. In Saunders' Question- Compend 
 Series. 
 
 " The author's careful and well-studied selection of the necessary requirements of 
 the student has enabled him to furnish a valuable aid to the student." — JVem York 
 Medical fournal. 
 
 Martin's Minor Surgery, Bandaging, and the 
 
 Venereal Diseases second Edition. Revised 
 
 Essentials of Minor Surgery, Bandaging, and Venereal Dis- 
 eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur- 
 gery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 
 illustrations. Cloth, ^l.oo net. In Saunders'' Question Compends. 
 
 " The best condensation of the subjects of which it treats yet placed before the pro 
 fession." — The Medical News. 
 
 Stevenson's Photoscopy 
 
 Photoscopy (Skiascopy or Retinoscopy). By Mark D. Steven- 
 son, M. D., Ophthalmic Surgeon to the Akron City Hospital. i2mo of 
 200 pages ; illustrated. Cloth, ^1.25 net. 
 
 " It is well written and will prove a valuable help. Your treatment of the emer- 
 gent pencil of rays, and the part falling on the examiner's eye, is decidedly better 
 than any previous account." — Edward Jackson, M. D., University 0/ Colorado. 
 
l6 URINE, EYE, EAR, NOSE, AND THROAT. 
 
 Wolfs Examination of Urine 
 
 A Laboratory Handbook of Physiologic Chemistry and Urine- 
 examination. By Charles G. L. Wolf, M. D., Instructor in Physi- 
 ologic Chemistry, Cornell University Medical College, New York i2mo 
 volume of 204 pages, fully illustrated. Cloth, ^1.25 net. 
 
 "The methods of examining the urine are very fully described, and there are at the 
 end of the book some extensive tables drawn up to assist in urinary diagnosis." — 
 British Medical Journal. 
 
 Jackson's Essentials of Eye Third Revised Edition 
 
 Essentials of Refraction and of Diseases of the Eye. By 
 Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the 
 Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illustrations. 
 Cloth, ^i.oo net. In Saunders Question- Co7npetid Series. 
 
 " The entire ground is covered, and the points that most need careful elucidation 
 are made clear and easy." — Johns Hopkins Hospital Bulletin. 
 
 Gleason's Nose and Throat Fourth Edition, Revised 
 
 Essentials of Diseases of the Nose and Throat. By E. B. 
 Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical 
 College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations. 
 Cloth, $1.00 net. In Saunders'' Quesiio7t-Co?Hpend Series. 
 
 " The careful description which is given of the various procedures would be sufficient 
 to enable most people of average intelligence and of slight anatomical knowledge to 
 make a very good attempt at laryngoscopy." — The Lancet, London. 
 
 ^, . «.. If . t_ ¥r^ Third Edition, 
 
 Gleason s Diseases oi the li^ar Revised 
 
 Essentials of Diseases of the Ear. By E. B. Gleason, S. B., 
 M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- 
 delphia, etc. Post-octavo volume of 214 pages, with I14 illustrations. 
 Cloth, ^l.oo net. In Saunders' Question- Compend Series. 
 
 " We know of no other small work on ear diseases to compare with this, either in 
 freshness of style or completeness of inhrmntion."— Bristol Medico-Chirurgical 
 Journal. 
 
 Wilcox on Genito-Urinary and Venereal Dis- 
 eases Ikervi (2d) Edition 
 
 Essentials of Genito-Urinary and Venereal Diseases. By 
 Starling S. Wilcox, M. D., Lecturer on Genito-Uiinary Diseases and 
 Syphilology, Starling-Ohio Medical College, Columbus, Ohio. l2mo of 
 321 pages, illustrated. Cloth, ^i. 00 net. In Saunders' Question-Compends. 
 
 deSchweinitz and Holloway on Pulsating 
 Exophthalmos 
 
 Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- 
 viously analyzed. By George E. deSchweinitz, M. D., and Thomas 
 B. Holloway, M. D. Octavo of 125 pages. Cloth, $2.00 net. 
 
 " The book deals very thoroughly with the whole subject, and in it the most com- 
 plete account of the disease will be found."— 5>-/^?Vj Medical Journal. 
 
A^I?^ . 
 
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