'uestion Compends Essentials of Surgery Edv/ard Martin, A.M., M. D. THE CLIMATOLOGIST. A MONTHLY JOURNAL OF MEDICINE DEVOTED TO THE Relation of Climate, Mineral Springs, Diet, Pre- ventive Medicine, Race, Occupation, Life FREDEi xorma: VINCEN SAML. U .7. WELL J, M. Da( CHAliLF GEORGT W3I. -\. 1 J. T. ESI SA-MUEi W. H. G i JOHN V,. T. S. 110 ! FREDEI K.X. >' \6)\ Cotomlna (Hnitiem'tp College of ^ij^fliicians; anb burgeons; Hibvavp Moii.treal, Canada. SR, M. D. ^ork City, lioago, Ills, limore, Md. lelphia, Pa. ! City^ N. J. rings, Colo, limore, Md, iville, N. C. «ton, Mass. jfings, Colo. i phis, Tenn. Lake, N. V. lelp,hia. Pa. k Florida. JAMES C. WIIiSO]M,M.'D., Philadelphia, Pa. Yearly Subscription $2.00. Single Numbers 2(X:tSi W. B. SAUNDERS, Publisher, i^\3 Walnut Street, Philadelphia, Pa. PRICE: Cloth, $1.00; Interleaved, for Tak ing Notes, SI.25 ADDITIONS TO THE SERIES OF FOR SEASON OF 1891-92. Essentials of Diagnosis. By S. SOLIS-COHEN, M. D. No. 10 Essentials of Hygiene. ILLUSTRATED. By ROBERT P. ROBINS, ^.I). (In Preparation.) ]Vo. SO Essentials of Bacteriology. ILLUSTRATED. By M. V. BALL, M. D. ivo. ^^- Essentials of Nervous Diseases and Insanity. ILLUSTRATED. By JOHN C. SHAW, M. D. IVo. «S Essentials of Medical Physics. ILLUSTRATED. BV FRED. J. BROCKWAY, M.D. (In Preparation.) IVo. S3 jL^ssentials of Medical Electricity. By DAVID D. STEWART, M. D., and EDWARD S. LAWRENCE, M. D. ILLUSTRATED. Tiiu-.. -u.all works, which can be conveniently caniedin the poclit^t, contain in^coxiaeuseeiform the teachings of the most popular text-books. ^ : The authors ai-eneurly all coMnected with the various colleges a^ Demon' s«ra«or« or iecfwrerir, and are therefore thoroughly conversant, not only with the wants of the average student, but also with the points that Ave <>bsolutely necessary to be remembered in the £:cami nation- Room. These t,ooks are constantly in the hands of their authors for revision, and are kept well up to the times, their fast sale allowing them to be ahnost entirely rewritten whenever necessary, instead of having to wait for the edition to besold, asis the case witl an ordinarv text-book. " „ , THE ADVANTAGE OF QUESTIONS AND A NSWERS.-The usefulness < arran-ing the subjects in the fofnvof questions and answers, will be apparen since Le student, in reading the standard works, often is at a loss to disc - the important points to be remembered, and is equally puzzled when he att^ to formulate ideas as to the manner in which the questions could be put ^ eicatninatioH-roofn. ^' ''""-' '■"-'' ■'- '^-i«OOUCT10N IN 7HE OPENING NUMBER OF " THE GLIMATOLOGIST. AUGUST, ,891. ? ? " The object of this Tor-RKMr 1*^ f^ gation, 10 publish papers containfnl<-r"K'' °"^''"'''' '""''''' perience of physidanfTri tl>i« I T^ tlie observations and ex- relating toX.S"o " m::Ti:::'' ^"'?P^ °" -->" "tatters Medicine Race OccupAVrnM t -^pi^'^'W, Diet, Preventive SciEKCE-Jand mrhatwa™o^upp\-r""'"-r ^^^''™«^' general practitionef and tlie nnhH? > "^^f by which the acquainted with tl,e d^ases^nf H '"'^'' ^,11 become, better better armed to meet thr^q^Vem^ntrof S' '"' ^"^°P^' ^""^ cure. TJie study of these snh^!.^ • !, ""■ Prevention or great and increasig in crest ami V" "^ ^"""t'T is exciting knowledge already^po "d o if "" *"'' ^'°'" "'^ '■■"'e known combuiation o^^thi?.^'?:"''''' P°^='bly every mate, or mineral springs "to hVf-.S"'''''?'?' ^"'Valtitude, cli- confidently expected tlftsuS ft °"-n '" ^°"tinent. It is mentand be an authon>VHr,. ""-.f "'«'''.^ill receive encourage- ■n its title. "^ "P°" =>'" ^"e^t^'^'S "'iiich are included o "<2!?aHoi^=^S:::,r c&^,f iocanties-those incident 5uestions of proper Ld of th.!/"'^^' °^ epidemics,, the Md distribution. mattS letoi t to H '"PP'^' ''^ P°'ability >endent on it-as well J !. '^- '^'"'"^Se and diseases de- .vestigations on" rcttoloTwmfoS T''"' ^'' '■^''°-'->- 'f the material presented during ihlye^r Ir^TTtT''"" fiat physicians of all sections of >K ^^^'^'^nd 't is to be hoped ;«rs;;ss^rjs '•- -»*.,„, ,.. iir suitability to certain cases Indh' ''"■'■'"" Kients hkely to be benefitted by them The" 'f 't<='''" "' taken that this Journal Z,U .?' ^^'^ "^'"^'st care will lest sfcicntific character rtw I K-T^ ,^"^ maintain; the ^ - -.-nciples-^).;::^^;;^/^;;''' b«.^b.«^^^ independent - upon the support fxiw- t\ •! V , ^P''"'^ ^°'' '^^ main- - hed in theTnterls?oran^l^-''?"P''^f"^«-°"' =»^ i' '^ ^,^ interest of any special section «,r clique." SAUNDERS' QUESTION-COMPENDS. No. 2. ESSENTIALS OF SURGERY, TOGETHER WITH A FULL DESCKIPTION OF THE HANDKERCHIEF AND ROLLER BANDAGE. AREANGED IN THE FORM OF QUESTIONS AND ANSWERS PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE. BY EDWARD MARTIN, A.M., M.D., INSTRUCTOR IN OPERATIVE SURGERY, UNUTERSITY OF PENNSYLVANIA ; SURGEON TO THE HOWARD HOSPITAL; ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL, IL LUSTBAT ED. Fourth Edition, Revised and Enlarged BY A.'^ appe:n^dix, CONTAINING FULL DIRECTIONS AND PEESCEIPTIONS FOR THE PEEPARATION OF THE VARIOUS MATERIALS USED IN ANTISEPTIC SURGERY. ALSO SEVERAL HUNDRED RECEIPTS COVERING THE MEDICAL TREATMENT OF SURGICAL AFFECTIONS. PHILADELPHIA: W. B. S AUN DE ES, 913 Walnut Street. 1891. Entered according to Act of Congress in the year 1888, by W. B. SAUNDERS, In the Office of the Librarian of Congress, at Washington, . COPTRJGHT, 1891, (^1 PREFACE TO FOURTH EDITION. The fact that this manual since its appearance two years ago has already run through three editions would seem sufficient proof that its purpose has not entirely miscarried. It was written to help the student, and the generous support offered by him to this work is sufficient recompense to the writer for the time and trouble spent in its prepara- tion. To this edition an Appendix has been added contain- ing several hundred prescriptions, which will be found useful in surgical practice ; also fu^l instructions in regard to the various preparations essential in the practice of antiseptic surgery. These are in the main from Hoffa's valuable chart. E. M. January, 1891. (vii) PREFACE TO FIRST EDITION. As one thrown yearly in contact with large numbers of medical students, and familiar with the furious rate at which they are driven, the writer feels assured that, under our present system of rapid education, outline works are of dis- tinct value. Third year men who attend six lectures and two clinics daily have no time for reading, no time for sys- tematizing their knowledge on any one subject. This work must either be done for them, or left undone. The author has carefully gone over the subject of Surgery, and has en- deavored to emphasize the essential points as a framework upon which more detailed knowledge may be hung. Agnew, Ashhurst, Gross, Walsham, Tillmann, Kbnig, Treves, Weir, Smith, Gerster, and many others have been freely consulted. The table of Urinary Calculi is taken direct from Moullin's article in Treves's manual. The classification of Yenereal Diseases follows that of White (University of Pennsylvania). To Mr. W. M. Alrich and Mr. Daniel Webster thanks are due for their valuable assistance. The author has made an earnest effort to be accurate, concise, and modern. E. M. OCTOBEK 10, ( viii ) CONTENTS. Inflammation , , Abscess Ulceration Mortification "Wounds The germ theory of Shock . Wound fever Erysipelas Tetanus Hydrophobia Glanders Malignant pustule The healing of wounds The treatment of wounds "Wounds of arteries Wounds of nerves Head injuries Injuries of the meninges and Concussion and contusion Compression Intracranial inflammation Cerebral localization . Wounds of the face Wounds of the neck . Wounds of the chest . Wounds of the abdomen Burns and scalds brain PAQB 17 27 31 38 44 44 45 47 50 52 54 55 55 56 57 73 75 75 81 83 84 85 87 90 91 92 95 102 (ix) CONTENTS. Fractures .... Special fractures . Luxations or dislocations . Special luxations . Sprains .... Wounds of joints Synovitis .... Arthritis .... Coxalgia .... Sacro-iliac disease White swelling of the knee-joint Rheumatoid arthritis . Loose bodies in joints . Anchylosis .... Diseases of bones Periostitis Osteitis Osteomyelitis Abscess of bone . Caries . . ... JSTecrosis Tubercle Syphilitic bone disease . Osteomalacia Pott's disease Rickets .... Haemophilia Struma .... Curvature of the spine Hernia .... Special hernias Intestinal obstruction . Diseases of the anus and rectum Syphilis .... Chancroid .... Gonorrhoea .... CONTENTS. XI PAGE Urethral deformities . 217 Stricture of the urethra • • . 217 Diseases of the prostate . 224 Affections of the bladder . 227 Eupture of the bladder . 227 Exstrophy of the bladder . 227 Cystitis .... . 228 Atony and paralysis of the 1 Dladder • . 229 Heematuria . . 229 Retention of urine . 230 Stone in the bladder . 233 Hydrocele . . 238 Hseraatocele . 239 Varicocele . . 240 Sarcocele . 240 Diseases of veins . 242 Angeioma .... . 244 Aneurism . 245 Diseases of the lymphatics . 248 Effects of cold . . 249 Foreign body in the air-passages . 250 Affections of the cesophagus . 251 Surgical affections of the breast . . 253 Club-foot . 254 Hare-Up and cleft palate . 255 Diseases of bursse and tendons . . 256 Bursitis .... . 256 Onychia .... . 257 Anaesthetics .... . 258 Ligation of arteries . . 261 Excision of joints . 278 Amputations .... . 282 Bandaging o o • • • • . 290 The roller bandage . 290 Head bandage . 299 Handkerchiefs . 301 ESSENTIALS OF SURGERY. INFLAMMATION. What is inflammation? Inflammation is a perversion of nutrition attended with red- ness^ heat J swelling^ pain, and a tendency to exudation. Name the varieties of inflammation. 1. Acute. 2. Chronic. Name the causes of inflammation, 1. Predisposing. Anythinsi; lowering the powers of resistance, such as heredity, age, sex, occupation, habits, food, previous in- flammation, temperature, climate, temperament, mental con- dition. 2. Exciting. Traumatism, heat, cold, acids, alkalies, micro- organisms and their products. How does inflammation extend ? By the means of bloodvessels or lymphatics. Extension by continuity, contiguity, metastasis, and sympathy is really due to either the blood or lymph vessels. How may inflammation terminate ? 1. Resolution, or return of tissues to their normal condition. 2. Organization, or new formation. 3. Death of tissue, by suppuration or mortification. What are the phenomena of inflammation? 1. Disturbed innervation, causing, first, a contraction of the capillaries, followed shortly by a paralytic dilatation producing active hyperseraia. 2 18 ESSENTIALS OF SURGERY. 2. Alteration in the bloodvessels and contents. The vascular walls are widely dilated, plastic, and their epithelium greatly- swollen. The white blood corpuscles are numerous, cling to the sides, and the current is slowed or stopped. The red corpuscles stick together ; the liquor sanguinis contains more fibrin forming elements. 3. Exudation or passage through the walls of white corpuscles (diapedesis) and liquor sanguinis. 4. Alteration in the ^perivascular tissue. Intercellular matrix undergoes mucoid softening, connective-tissue corpuscles pro- liferate, the exudate coagulates. What zones are found about an inflamed area ? Most peripherally, a bright red ring where the bloodvessels are widened, called the zone of determination. Within this an area in which from overcrowding the blood current is slow, the color here is somewhat dusky, this area is called the zone of congestion. Centrally, an area where the blood current is prac- tically at a stand-still, this is the focus of inflammation, and is termed the zone of stasis. What are the stages of inflammation? Fii-st stage. Acute hypercemia with slight exudation. Second stage. Lymphatization or free exudation and the for- mation of plastic lymph. Tliird stage. Suppuration or formation of pus due to the death of white blood corpuscles and their fibrinous trabeculse. What is plastic lymph? The exudate of acute inflammation. It is made up of white blood corpuscles and proliferated connective-tissue cells, im- bedded in a frame-work of coagulated fibrin. Name the different kinds of exudate. 1. Serous. Thin, non-organizable. Examples : hydrocele, ascites, hydrothorax. 2. Fibrinous. Contains much fibrin, coagulates, and readily undergoes organization. INFLAMMATION. 19 How may the various stag^es of inflammation terminate? Active hypersemia may terminate in resolution or in exudation. Exudation may terminate in resolution, organization, or sup- puration. Suppuration may terminate in granulation or in death of the part. Describe resolution. The dilated vessels again contract, the white blood corpuscles begin to move away from the inflamed area as circulation is restored. The migrated corpuscles either return to the blood- vessels, degenerate, and are carried oflP by the lymphatics, or remain as fixed connective-tissue corpuscles. The fibrin becomes granular and is absorbed. Describe organization. New bloodvessels are formed in the exudate by looping of the old ones ; these loops anastomose with each other, forming a network. In addition new vessels are separately developed in the inflammatory tissue which, in turn, anastomose with the previously existing vessels. If the irritation ceases many of the exudation cells disintegrate and arc removed, others are con- verted into connective-tissue corpuscles, which, by their contrac- tion, obliterate the new bloodvessels and form cicatrices. Describe suppuration. If, from great irritation, the exudation is excessive there will be acute starvation, with disintegration of the central portions from occlusion of the supplying bloodvessels. If this dead central portion be kept aseptic it may be absorbed ; if, however, any of the pyogenic organisms gain access to it they keep up the irritation, cause additional effusion, and produce suppuration. What is pus ? Pus is the product of suppuration. It is a creamy looking, highly albuminous liquid, sp. gr. 1030, and contains fat, blood salts, tjTosin, leucin, and other nitrogenous derivatives. On standing it separates into liquor puris^ a clear liquid, practically the same as liquor sanguinis, and pas corpuscles, made up of living or dead leucocytes. 20 ESSENTIALS OF SURGERY. Name the varieties of pus. Laudable. Thick and cream-like ; this variety comes from ordinary acute inflammation in healthy subjects. Sanious. Thin, reddish, mixed with blood. From malignant disease, chronic ulcers, etc. Ichorous. Thin, watery, irritating. From chronic ulcer bone disease, etc. Ciirdy or cheesy. Contains flakes of degenerated fibrin. From chronic abscesses connected with bone disease. GumY)iy. Thick and ropy. From syphilitic abscesses. Contagious pus. Muco pus, etc. What becomes of pus ? It may be disintegrated and absorbed ; it may be discharged ; its more liquid portions may be absorbed, while the solid portions, together with the affected tissues, undergo fatty disintegration and remain as a putty-like ma^s, this constitutes caseation. Name the varieties of suppuration. Circumscribed. Diffuse. The diffuse may be superficial as in the cases of coryza and dysentery ; or deep as in cellulitis. What are the symptoms of acute inflammation ? Fever, together with redness, heat, swelling, pain, alteration of function and nutrition. What are the characteristics of inflammatory redness ? It 1% persistent; if the capillaries are emptied by pressure with the finger the redness instantly returns on removal of the pressure. The shade of color depends upon the rapidity and freedom of the circulation ; if dark or bluish it denotes obstruction or stasis. Copper-red often denotes syphilitic inflammation. Rose-red streaks along the course of the lymph vessels denote lymphan- gitis. A dusky -red tract in the course of a vein indicates phlebitis. At what portion of an inflammatory area is heat most marked? At the focus or centre. Describe inflammatory swelling. It is due to the increased amount of blood in the part, to pro- liferation, and to exudation. It is soft in acute, hard in chronic INFLAMMATION. 21 inflammations ; is especially well marked in loose connective tissues. Its limitations by fascia may indicate the seat of inflammation. Describe inflammatory pain. • It is persistent^ increased hy pressure or motion., and accom- panied by the signs of inflammation. Is mainly due to mechanical injury to the nerves from the swelling. Most intense in dense structures. May be felt in regions remote from the inflamed area ; instance, the knee pain of coxalgia or the shoulder pain of hepatitis. Describe inflammatory alteration of function. Secretions are perverted or abolished. Eeflexes become greatly exaggerated ; instance, the tenesmus (straining) of dysenter}', the strangury of cystitis, the convulsions of teething. Kon-sensitive parts become hyper-sensitive ; instance, the pain of peritonitis or of teething. Describe the constitutional symptoms of inflammation. Fever. May be sthenic or asthenic in type. 1. Sthenic inflammatory fever. a. Circulatory symptoms. Full, strong, rapid pulse, flushed face, injected conjunctivae. h. Kervous system. Increased temperature, 100° to 103*^, head- ache, lumbar pains, troubled sleep, special senses often hyper- sesthetic. c. Glandular system and alimentary tract. Secretions dimin- ished and scanty ; dark colored irritating urine of high specific gravity. Anorexia— heavy white or yellowish coating on the tongue. Constipation. 2. Asthenic inflammatory fever. The general symptoms are the same as those of the sthenic type, except there is profound depjression in place of over action, and the patient shortly falls into the typhoid, condition. Pidse feeble, rapid, and compres- sible. Tempjerature fluctuating from 99° or 100° to 103° or even 105.° Mental condition dull and torpid, or delirious and busy. Tongue dry, with l^rown or black coat. 22 ESSENTIALS OF SURGERY. How do you treat inflammation ? Locally and constitutionally. Give the local treatment of inflammation. Bemove the cause. Best, either general by putting the patient to bed, or local by the employment of splints and bandages. Position. Elevation with relaxation of all structures by posi- tion. Cold, may be employed with or without moisture ; ice-bag, irrigation, rubber tubes, cold compresses, and evaporating lotions. Use in the beginning of acute inflammation. Heat, may be combined with moisture ; hot cans or bottles, poultices, spongio piline, irrigation, baths, douches. Local depletion. Cups, leeches, and scarification. Counter-irritation. Tr. iodin., mustard plaster, turpentine, chloroform liniment, actual cautery, seton, issue. Vesic'ition. Fly blister, cantharidal collodion. Pressure. Either direct, or on the main bloodvessel of the part. What are the contraindications to the use of cold in inflamma- tion ? It should not be employed where there is great impairment of vitality, either local or general, where it is disagreeable to the patient, or after inflammation is full}'' established. How does heat control inflammation ? It restores tonicity to the bloodvessels, increases the rapidity of the circulation, hastens resolution, and is a powerful vitalizer. Under what circumstances are heat and moisture indicated ? Where there is great tension ; where sloughs or dead parts are to be separated ; where suppuration is taking place. What conditions indicate the employment of local depletion ? A condition of vascular engorgement so great that the vitality of the part is threatened ; instance, scarification in prolapsed hemorrhoids or acute conjunctivitis Describe cupping. If the blood is to be merely drawn to the surface, dry cupping INFLAMMATION. 23 is employed. This may be accomplished by a regular apparatus, or by lighting a few drops of alcohol poured into a small cup or glass, and suddenly clapping it to the surface to be treated. A powerful vacuum is created, and the skin is drawn far into the hollow of the cup. If blood is actually to be abstracted, wet cups are used. Incisions are made through the skin, and free bleed- ing is encouraged by applying cups over these parts. Describe leeching. The Swedish leech is generally used ; it draws about fgss of blood. Wash the surface of the skin carefully, apply a little milk or blood to it, put the leech in a wide-necked bottle, and press the mouth of the bottle against the surface to be bled. Let the leech drop off, and check the bleeding either by a pledget of styptic cotton, by compress and bandage, or by passing a hare- lip pin through the depth of the leech bite and tying around it. What parts should be avoided in applying leeches ? Leeches should not be placed over loose cellular tissue. In- stance, the eyelids and the scrotum. When do you use counter-irritation ? As counter-irritation acts by drawing the blood from the in- flamed part, it may be used in the very beginning as a means of aborting inflammation. It may be employed for the relief of pain, or, as inflammation is subsiding, its use may materially hasten resolution. Describe the application of counter-irritants. A mustard plaster must never be allowed to blister. Mix one part mustard, two parts flour, and cover with a thin film of egg albumen or molasses. The more severe forms of counter-irri- tation, the actual cautery, the seton, and the issue, are especially applicable to chronic inflammation. In using the actual cautery the part may be previously ansesthetized by freezing. The seton is made by passing some strands of silk or other material through a pinched up fold of the skin, and leaving them in place, slightly moving them from day to day to keep up irritation. The issue is an ulcer made by cautery or chemicals, and kept open by a foreign body, such as a pea or a pebble. 24 ESSENTIALS OF SURGERY. Describe vesication. This is really a powerful form of counter-irritation combined with depletion. Cantharides in some of its forms is generally used, either the cerate or cantharidal collodion. After six hours apply a poultice ; small blisters frequently repeated are termed fugitive blisters. What dangers attend the use of cantharides ? It may be absorbed and produce strangury, i. e., inflamma- tion of the genito-urinary tract, attended with great pain, and constant straining to pass water, with the evacuation of a few drops at a time. Treat by opium and belladonna suppositories, demulcent drinks, warm sitz baths, and leeches. Avoid by re- moving the blister after six hours and applying a poultice, or by incorporating camphor with the cantharidal cerate. In old and debilitated persons extensive sloughing may follow the use of blisters. When is pressure used ? Either iu the very beginning, or after the inflammatory swell- ing has reached its height. It supports the bloodvessels, pre- vents exudation, and hastens resolution. The ordinary or the rubber bandage may be employed. Often the sand bag or shot bag is of service. Give the constitutional treatment of inflammation. 1. Bleeding or general depletion. To be employed only in the strong and plethoric at the hegim)ing of an attack^ and where life or the vitality of an important organ is threatened by the violence cess. Hdw do you distinguish encephaloid disease from abscess? In soft cancer the course is chronic, and at first painless ; it presents multiple eminences, has large purple veins coursing over it, and is elastic rather than fluctuating. iNFLAMMATlOI^". 31 Ulceration. What is ulceration ? The molecular death of tissues, leaving a solution of continuity, and accompanied by a discharge. What are the causes of ulceration ? 1. Predisposing, quantity and quality of the blood, together Avith the freedom and rapidity of the circulation. 2. Exciting, irritation, physical or chemical. What is the pathology of ulceration ? As for abscess ; from over-crowding, the tissues and effused matter about the focus of inflammation perish, the peripheral areas become vascularized, and are converted to granulations. What is a granulation ? A capillary loop about which are clustered leucocytes, held together by a slight amount of intercellular material. Describe healthy granulations. Cherry-red, non-sensitive, elastic, and discharging laudable pus. By what processes is ulceration healed? By granulation and cicatrization. While the dead central parts of the ulcer come away as a thin discharge called ichor, the exudation beneath and around is becoming vascularized, capillary loops shoot out toward the surface (the direction of least resistance) ; about each loop clings a cluster of living leucocytes, and a surface of healthy granulation is established, discharging laudable pus. Cicatrization now begins, the sur- rounding skin sinks to the level of the granulations, and its epi- thelial cells undergo segmentation and grow as a ring about the periphery toward the centre of the ulcer ; this skinning over is denoted by a blue film, and while it is extending the ulcer is contracting, from conversion of leucocyte to fibrous tissue ; this contraction goes on long after the ulcer is entirely healed, and may cause great deformity. The process of skinning and con- traction is called cicatrization, the result is a cicatrix or scar. 82 ESSENTIALS OF SURGERY. Describe a cicatrix. At first blue, it finally becomes white, the progressive contrac- tion of the connective tissue squeezing all the blood from the part. A cicatrix has neither nerves, glands, lymphatics, nor hair ; it readily ulcerates, and is slow in healing. What is an ulcer ? A surface of granulations. Name the varieties of ulcers. 1. Local. a. Simple healthy or iieallng. h. Complicated or spreading. 2. Constitutional, strumous^ syphilitic. Of the complicated or spreading we have the fungous, the cedematous, the inflamed, the sloughing, the phagedenic, the indolent ulcers. Describe a simple or healthy ulcer. Granulations, healthy, cherry-red, small, uniform, not painful. Discharge, laudable pus in small quantity ; if the ulcer has been treated antiseptically the discharge is serum. Shape, oval, regular. JEdges, gently sloping, moderately indurated, showing the blue line of beginning skinning. Surrounding sMn soft and flexible. Give the treatment of simple ulcer. In the forming stage, abort or limit by rest, elevation, local de- pletion, and cold ; at the same time treating the rather high constitutional symptoms by withholding food, giving abundance of water, iced drinks, or cracked ice, opening the bowels, and, if necessary, administering morphia hypodermically to control the pain. When disintegration is evident hasten the separation of the dead from the living tissues by warm antiseptic poultices (sponges, lint, or gauze soaked in weak bichloride solution 1: 6000, and covered in by waxed paper and a bandage). Milk diet. When the dead part is separated leaving a surface of healthy granulations, cleanse with sterilized salt solution 5 per cent., or INFLAMMATION. 83 very weak antiseptic lotions, bichloride 1 : 10,000. Cover with protective or gutta-percha tissue, and apply a light antiseptic dressing, finishing with moderately firm pressure by a roller bandage. Full diet. A healthy ulcer heals kindly under nearly any dressing. Describe the inflamed ulcer. A simple ulcer may become converted to an inflamed ulcer by any of the local or constitutional causes which give rise to in- flammation. Instance, debauch, injury, etc. Granulations, at first bright red, become dusky, finally break down forming a gray, ragged, sloughing surface. Discharge^ very profuse, con- sists of pus and the cUbris of broken down tissue. Edges, irregu- lar, deep, sharply cut, indurated. Surrounding skin^ red and oedematous. Pain and tenderness acute. Constitutional symp- toms well marked. Give the treatment of inflamed ulcer. A saline cathartic in the beginning of the attack, Rochelle salts 5j. Rest in bed with elevation of the part. Local deple- tion by leeches, or incisions into the edge of tlie ulcer. Hot antiseptic poultices. Low diet, opium to relieve pain. Describe the sloughing ulcer. Very commonly associated with venereal disease. This is but an aggravated inflamed ulcer ^ and is characterized by the same pecidiarities^ with the addition that there is a rapid, spread- ing attended by destruction oi visible portions of the tissues which are thrown off as offensive gray sloughs. All symptoms, both local and general, are aggravated. How do you treat sloughing ulcers ? Tonic and stimulant. Constitutional condition nmst receive particular attention, as all sloughing processes tend rapidly to- wards exhaustion. Charcoal or antiseptic poultices till sloughs come away. Spray of hydrogen peroxide. Describe the phagedenic ulcer. This form is an aggravated sloughing ulcer. Found only in venereal disease or in patients with profoundly depressed con- 3 34 ESSENTIALS OF SURGERY. stitution. The granulations are absent, being replaced by gray- sloughs ; the discharge is ichorous, containing shreds of dead tissue ; the edges are ragged, dusky red, and extensively under- mined ; the surrounding sMn (Edematous, red. The extension is very rapid, may destroy an entire organ (the penis), and is at- tended by severe constitutional symptoms of the adynamic type. Give the treatment of phagedenic ulcer. Clear the bowels. Eich nourishing diet, stimulants, tonics, opium. Continuous warm baths during the day, with iodoform dressing at night. Or the ulcer may be treated by charcoa? poultices and antiseptic washings till sloughs are separated. Describe the serpiginous ulcer. This is really a phagedenic ulcer. Its course is sloio but per- sistent ; it may produce most extensive destruction of tissue. Treatment. Constitutionally, supporting ; locally, actual cau- tery, or as for phagedenic ulcer. What is an irritable ulcer ? An ulcer which presents the features of an inflamed ulcer, to- gether with great pain, out of all proportion to its apparent cause. This pain is probably due to the stretching of small nerve branches. Treatment. Subcutaneous section of the nerve l)ranch sup- plying the ulcerating area, or applications of chloral gr. xx., or argent, nit. gr. xx. to the ounce of water. What are fungous and cedematous ulcers ? In the fungous ulcer the granulations grow above the level of the surrounding skin, and may spread out as a cauliflower or muslu'oom-like growth ; they bleed readily. Cause, obstruction to venous return from undue contraction of surrounding tissues. The (Edematous ulcer is characterized by large, pale, flabby, watery granulations which have a tendency to become fungous. Cause, venous obstruction combined with struma or systemic depression. How do you treat fungous and oedematous ulcers ? Astringent applications. Powdered alum, glycerole of tannin, INFLAMMATION. 35 followed hj compression applied by means of imbricated adhesive straps and a tight roller bandage. Excision. If these means fail, or if the granulations have assumed a mushroom-like growth, shave off level with the sur- face, dust with iodoform, and apply an antiseptic dressing, with a tight roller bandage over the whole. Describe the indolent, callous, or chronic ulcer. Granulations. Xever healthy, usually small, scanty, and brickdust-red ; frequently fungous or cedematous. Discharge. Ichorous or sanious pus. Edges. Everted or inverted, irregular, never gently sloping. Blue line of skinning absent. Surrounding slcin. Discolored, often eczematous and densely indurated. Occurs. After middle age, and in those whose occupation requires long standing. Favorite seat. The outer surface of the lower third of the leg, because: 1. It is an exposed portion. 2. There is little cellular tissue separating skin from bone. 3. Its dependent position favors passive congestion and thrombosis. Course. Exceedingly slow, may last many years. Constitutional syrnjAoras. Xone. The eczematous and varicose ulcers are simply chronic ulcers with marked development of the affections from which they take their names. What prevents chronic ulcers from healing? Erom long congestion the bank of lymph becomes redundant, and is, in part, converted to imperfect fibrous tissue, which, by pressure upon the vessels, blocks the circulation. How do you treat chronic ulcers ? Cause the absorption of the obstructing hank of lymph. Healing granulations will then appear. This is accoraplished by /teai, moisture, and pi'essure. Treatment. — Soak the ulcer for two hours at night in warm 2 per cent, boric acid solution, followed by a thick poultice (boric acid solution and ground flaxseed, the surface being 36 ESSENTIALS OF SURGERY. coated with boric ointment), well protected by oiled silk, or waxed paper, so that it may not cake before being removed. In the morning, substitute for the poultice strips of lint wet in boric lotion, and imbricated over the affected region ; cover these strips with waxed paper, and apply very carefully over the whole a roller bandage, taking in the foot and going as high as the knee : at night remove the dressing and soak again. Con- tinue this treatment for three or four days, or until the bank of induration is softened, then strap. Use adhesive plasters cut in strips one inch wide, and long enough to extend nearly around the limb. After elevating the leg and allowing the blood to drain out, begin the dressing by applying the first strap two inches below the lower border of the ulcer, making firm pressure as it is carried around the leg or foot ; the next strap is appUed nearer the ulcer, overlapping the first for two-thirds of its width ; so continue till the ulcer is reached, when the straps must overlap as before, but in applying them, first fasten one end, then press the edges of the ulcer together, diminishing its size as much as possible, and secure it in this position by continuing the strap firmly across it and around the limb. The straps must entirely cover in the ulcer and an area two inches above and below. Over the straps apply a layer of lint, and cover in the whole by a closely fitting roller bandage. The dressing is removed and reapplied as required by the amount of discharge. If -this method cannot be carried out, apply a Martin''s rubier bandage directly to the skin, removing it at night ; wash the leg night and morning in boric lotion. A blister applied to the entire ulcer and surrounding skin may cause the induration to disappear. Incisions, or shaving off of the induration may be required. What are the characteristics of strumous ulcers ? Favorite seats necJc and groin. Chronic, painless, discharge a thick oily pus, granulations oedematous, skin extensively un- dermined, and overhanging the ulcer in the form of loose blue flaps. INFLAMMATION. 87 What ulcers are mostly found on the leg ? Varicose, traumatic, and syphilitic. A non-traumatic ulcer of the upper third of the leg is mostly sypfhilitic. What ulcers chiefly affect the face ? Rodent ulcers, and those due to lupus, syphilis, or epithelioma. The rodent ulcer is distinguished from the epitheliomatous from the fact that it does'not involve lymphatic glands, nor induce secon- dary deposits ; its course is very slow ; its base is smooth and glossy, with little or no discharge ; its edges moderately indu- rated, smooth, round, and rolled over. Describe skin grafting. 3y skin grafting is meant the placing on granulating sur- faces of healthy epidermis for the purpose of hastening cicatri- zation and preventing subsequent contractions. It is chiefly applicable where the granulating surface is large, or conspicu- ously placed, or slow in healing. The granulations must be healthy, discharging very slightly, and preferably aseptic. This may be accomplished by washing with weak bichloride solutions and dressing antiseptically for several days before the operation. The area from which the grafts are taken should be thoroughly washed with soap, water, and bichloride, 1 : 1000, followed by 5 per cent, sterilized salt solution (sodium chloride 5 parts, water 95 parts, boil for one hour). By means of a scalpel, scissors, or a razor, small or large pieces of cuticle, including the rete mu- cosum, but not the corium, are removed, and placed, fresh sur- face down, on the granulations, from which all antiseptics have previously been washed by liberal salt solution irrigations. Apply protective wet in salt solution, and either a sterile, or an antiseptic dressing, covering in the whole with a tight roller bandage. By this method strips of skin, ^ in. by 2 in., may be transplanted and retain their vitality. The grafts should be taken from young healthy persons. 38 ESSENTIALS OF SURGERY, Mortification. "What is mortification or gangrene ? Death in mass. What is a slough or sphacelus ? That portion of tissue affected by mortification. What are the causes of gangrene ? 1. Direct violence from physical or chemical agencies. 2. Deficient blood supply^Yom. inflammatory engorgement, weak circulation, diseased vessels, embolus, or thrombus. Name the two commonest forms of gangrene. 1. Acute or moist. 2. Chronic or dry. What structures resist gangrene ? Arteries (hence thrombi form before their walls are disinte- grated, and bleeding is prevented), nerves, tendons, and bones. How is gangrene limited ? By a reactive inflammation. A wall of granulation is thrown out, at the expense of the healthy tissues, by which the slough is separated from the living parts. What first indicates the limit of gangrenous processes ? The line of demarcation. A red line due to capillary conges- tion, indicating the beginning of inflammatory reaction. What follows the line of demarcation ? The line of separation. A line of ulceration or granulation. What are the general indications in the treatment of all gan- grenous processes ? Keep the dead or dying part thoroughly aseptic. Cleanse, dis- infect, and wrap in thick layers of antiseptic wool, cotton, or gauze. Carefully guard against the invariable tendency to ady- namia. INFLAMMATION. 39 What are the symptoms of acute mortification ? Synonym : Local traumatic gangrene. Usually acute inflammatory symptoms with evidence of great local congestion, and intense burning pain. The pain ceases, there is loss of sensation, of power to move the part. The temper- ature falls, and pulsation of the arteries cannot be detected. The color, at first dusky-red, turns to blue, to purple, to dirty brown, or black. Blebs form, the course of the superficial vessel is marked by lines of dark discoloration. Even yet vitality may be restored. If, however, the cuticle separates from the derm and can be rubbed off" by light pressure, if there is crackling, emphy- sema, and foul odor, death is absolute. The constitutional symptoms are those of inflammatory fever, but of an adynamic or typhoid type. Eapid, feeble pulse, low delirium, etc. How do you treat acute mortification ? Preventive. Believe tension. Kemove tight bandages. Evac- uate retained discharges. Freely incise inflammatory congestions. Massage. Eender the part aseptic ; wrap in antiseptic wool. If the slough is thoroughly established, and is putrid, char- coal poultices or wet bichloride dressings may be used ; other wise, dry antiseptic dressings are indicated. Amputate when the line of demarcation is formed. (In the hand and foot spontaneous amputation generally gives a better stump than the surgeon's knife.) Constitutional treatment: Yery free stimulation, full nourishing diet, quinine, and opium. What is spreading traumatic gangrene ? An acute, rapidly spreading, moist gangrene, dependent on a specific micro-organism. It appears shortly after severe trau- matism, and before the line of separation can form, extensively invades the tissues, and causes death from exhaustion or septic poisoning. All local inflammatory symptoms may be absent ; swelling, discoloration, and loss of temperature circulation and sensation, denoting the extension of the process. In other cases, an inflammatory redness and induration precede the gangrene. The constitutional symptoms are profoundly adynamic. 40 ESSENTIALS OF SURGERY. How do you treat spreading traumatic gangrene ? Immediate amputation through healthy tissue. What is hospital gangrene ? An epidemic, qpntagious, gangrenous process, dependent upon the presence of micro-organisms, which destroj'^s granulations, attacks the tissues lying about and beneath them, and rapidly produces extensive sloughs. Give the symptoms of hospital gangrene. As for acute mortification. The surface of a wound, or its margins, are rapidly converted into an extensive slough, there is surrounding oedema and congestion, the discharge is foul, the process rapidly extends. The constitutional symptoms are adynamic ; high temperature at first, with weak, quick irregular pulse, wet surface, and, fre- quently, muttering delirium. What circumstances predispose to attacks of hospital gan- grene ? Over-crowding, deficient ventilation, want of proper nourish- ment, or any depressing cause. How do you treat hospital gangrene? Isolate the patient. Break up the sloughs by thrusting closed dressing forceps through them, and withdrawing the forceps opened. In these openings make a thorough application of pure bromine, nitric acid, or other escharotic. Dress with anti- septic charcoal poultice, and subsequently observe the most rigid asepsis in regard to wound treatment. ■ Constitutionally give stimulants^ free diet, quinine, iron, and opium. What is cancrum oris ? Synonym. Gangrenous stomatitis. It is a gangrenous ulcer of the cheek or gums, occurring in poorly nourished children. It is frequently developed after an attack of measles, scarlet fever, or typhoid fever. It usually appears opposite a rough or decayed tooth, which has caused an abrasion. It is seen in the mouth as an offensive, sloughing, INFLAMMATION. 41 punched out ulcer ; on the external surface of the cheek as a glazed, dusky red, indurated spot, which is shortly coaverted into a black slough, causing perforation, and extensive destruction of tissue. The constitutional symptoms are those characteristic of all gangrenous processes. How do you treat cancrum oris ? Thoroughly cauterize v^^'iih. nitric acid. Wash at intervals with boracic acid lotion, or tr. myrrh. Give internally stimulants, rich milk in abundance, malt, iron, and quinine. What is noma pudendi ? A gangrenous process similar to cancrum oris, attacking the genitals of female children. Treatment. As for cancrum oris. What is a bed sore ? A sloughing ulcer, due to pressure, appearing on the bony prominences of the weak and badly nourished. How do you treat bed sores ? Clear away the slough by charcoal poultices, wash and dress antiseptically, relieve the part from pressure by pads, pillows, or air cushions. Describe a furuncle. Synonym. Boil. Definition. A circumscribed inflammation of the skin and subcutaneous tissue, terminating in suppuration, and the forma- tion of a central slough or core. Occurs. In crops, on the neck, nates, and back of the young. Causes. Systemic depression, and the rubbing into the ducts or hair follicles of the skin of a nncro-organism. Begins as a red pimple, usually with a hair in. the centre, in- creases rapidly in size, causing a purple-red, very painful swelling which may undergo resolution (blind boil), or open, dis- charging the central core. Treatment. 1. Pull out the central hair, wash thoroughly with bichloride, apply 50 per cent, ichthyol ointment. 2. Inject with Tl\v. of a 10 per cent, solution of carbolic acid. 3. If in- flammatory symptoms increase in severity, apply spongio piline 42 ESSENTIALS OF SURGERY. dipped in hot boracic or carbolic acid lotion. 4, When fluctua- tion is evident, incise, syringe the cavity with antiseptic solution, and apply an antiseptic dressing, making firm pressure. What is a carbuncle ? An inflammation of the skin and subcutaneous tissues, in- volving a much larger surface than furuncle, and attended by the formation of sloughs of considerable size. It differs from boil in being much larger^ flattened instead of conical, and accompanied by great surrounding oedema. The skin gives way in several places^ sloughs of some size are dis- charged. Constitutional symptoms are severe. Occurs in the aged and debilitated. Cause. The rubbing in, by friction, of a micro-organism. Seats. Keck, back, nates. "When occurring on the face or head it is exceedingly fatal. Give the symptoms of carbuncle. A hard, brawny, flattened, dusky-red area of induration, cir- cular in shape, and riddled with apertures, through which a gray slough can be seen. The constitutional symptoms are severe and of an adynamic type. Give the treatment of carbuncle. The constitutional treatment should be conducted on the plan indicated for all gangrenous processes. Stimulants, full diet, iron, quinine, and opium may be given. Locall}', the affection may be treated by — 1. Tight concentric strapping, leaving a central aperture for the escape of sloughs. 2. Hot fomentations or poultices, the moisture being supplied by boracic or carbolic acid solution. Heat and moisture may be combined with strapping. 3. Injections through the inflamed area, and about its periph- ery, of carbolic acid (5 or 10 per cent, in glycerine) ; as much as a half drachm may be used. 4. Crucial incision, and removal by curetting of all the involved cellular tissue. The operation must be done antisepticall3\ Pack the wound with iodoform gauze, and apply a thick antisep- tic dressing. INFLAMMATION. 43 What is the usual cause of dry gangrene ? Synonym : Senile or chronic gangrene. Cause. Arterial obstruction from atheroma and thrombosis. What are the premonitory symptoms of senile gangrene ? The limb feels cold and nmnh ; tingles and is subject to shooting iind violent pains ; steady deterioration in health. What symptoms denote the onset of the disease ? The appearance of a black spot, usually to the inner side of the great toe, surrounded by a dusky-red areola, and causing an intense burning pain. There is a slow extension till the entire foot becomes hard, dry, black, and mummified. How do you treat dry gangrene ? Disinfect the part and wrap in antiseptic wool or cotton. Al- low a generous diet. Give tonics and stimulants ; opium two or three grains daily. Under what circumstances is amputation required in gan- grene 1 When the line of separation is formed. Immediately, in spreading or traumatic gangrene. In gangrene from arterial occlusion, when the seat of the occlusion can be certainly determined. Instance, wound or liga- tion of an artery. In senile gangrene, only when the line of separation has formed^ and exploratory incision shows that the arteries above are 'healthy. 44 ES^iENTIALS OF SURGERY. WOUNDS, The Germ Theory. Outline the germ theory. Putrefaction is the result of the n-rowth of micro-oro;anisms in tlie substance which putrefies. These micro-organisms are di- vided into — 1. Non-pathogenic, or those which do not directly create dis- ease. 2. Pathogenic, or disease creating. Among the non-pathogenic, are included those which can live or grow only in dead or dying matter, termed saphrophytic. These saphrophytic micro-organisms, entering a wound in which there is much pent-up discharge and dying tissue, rapidly in- crease, and produce certain irritating substances, cRWed ijtomaines. The absorption of ptomaines into the system gives rise to the symptoms which are characterized as se]ptic intoxication, ptomaine fever, saprcemia, or septicaemia. Pathogenic micro-organisjns thr'iye not only on dead matter, but invade and destroy the living tissues. They may be carried through the circulation to all parts of the body, increasing with incredible rapidity wherever deposited, destroying tissue, and forming fresh centres for the production of poisonous products. They enter the system, by a process of direct inoculation, through wounds. Nearly all pathogenic microbes are either micrococci (spherical) or bacilli (rod-shaped). What are the general principles of antiseptic treatment ? 1. Prevent putrefaction. 2. If it has already occurred, stop its further progress. Since putrefaction depends upon the presence of an organism, and a soil in which.it can grow, the indications for the preven- tion of this process are — 1. Exclude all organisms from the wound. This may be ac- complished by most minute attention to the details of surgical cleanliness. WOUNDS. 45 2. Bemove organisms from the wound, before the}- can work harm, by irrigation. 3. Destroy organisms^ by bichloride or other germicides. 4. Bemove the soil in which organisms can flourish, by free drainage. 5. Prevent the formation of favorable soiZ, by avoiding tension or unnecessary manipulation, and by careful dry dressing. What is the distinction between antiseptic and aseptic ? Aseptic means germ free; antiseptic means germ destroying. The surgeon who does not practise antisepsis cannot procure asepsis. An aseptic wound is the result of antiseptic treatment. Dressings sterilized by heat have undergone as thorough anti- septic treatment as those saturated with bichloride. By an aseptic dressing is meant the application of substances previously sterilized^ but containing, at the time of application, no germ- destroying agents. Antiseptic dressings contain germ destroying agents. Shock. What is shock? A lowering of the vital powers consequent on profound mental or physical impression. Shock is a vaso-motor paralysis, affecting also the heart, and chiefly the abdominal vessels. What are the causes of shock ? 1. Powerful mental imptressions, joy, grief, and fear. 2. Mechanical injury; traumatism, especially of the abdomen ; burns, scalds, cold ; gunshot, lacerated, and contused wounds. As predisposing causes can be classed all conditions which cause enfeeblement of the resisting powers. Instance, Bright 's disease, sedentary occupation, and hemorrhage. What are the symptoms of shock ? Pulse first slow, then rajDid, feeble, compressible, and scarcely perceptible. Tempjerature sub-normal. 46 ESSENTIALS OF SURGERY. Surface cold, pale, and wet. Muscular system relaxed, contractility of sphincters lost. Patient lies in any position in which he may be placed. Decu- bitus usually dorsal. Nausea and vomitmg frequently present. Consciousness and special senses blunted. What is your prognosis in shock ? Bad if the temperature falls below 96°, or if reaction is delayed twenty-four hours. What becomes of a patient suffering from shock ? He either collapses and dies from syncope or asthenia, or reacts. Describe reaction. Healthy reaction is characterized by an Increase in the force, and a diminution in the rapidity of the heart's beat, a rise of temperature, a restoration of color to the blanched surface, and disappearance of all the characteristics of shock. In other cases reaction may take the form of an acute fever, with flushed face, injected conjunctivae, high temperature, restlessness, jactitation, active or muttering delirium, and a full, throbbing pulse. The pulse, however, is soft and compressible; the tongue is dry and. tremulous; the symptoms are asthenic, and are liable to lapse again into profound and fatal shock. This condition is termed trau-. matic delirium, and is a condition of under reaction from shock. How do you treat shock ? External warmth most important of all treatment. Hot bath, hot bricks or bottles applied along the spine, to the epigastrium, and about the patient's body and limbs. Position. Dorsal decubitus with head low. Iledication. Atropia gr. jl„ and brandy 3js, every thirty minutes hypodermically ; morphia gr. | if there is great pain. Avoid medication by the stomach till reaction begins, as there is no absorption. Hot coffee, or hot, highly seasoned beef tea may be given in small doses by the mouth. When reaction has fairly set in, sto}) stimulating. Describe the forms of traumatic delirium. In addition to the form described as an imj)erfect reaction WOUNDS. 47 from shock, there is an inflammatory, a nervous, and an alcoholic traumatic delirium. The inflammatory form is characterized by fever and sthenic symptoms with either sthenic or asthenic condition. It develops in from three to five days after the injury, and is really a symp- tom of septic inflammatory fever. Treat as for the fever, apply- ing an ice cap to the head. The nervous and alcoholic forms of traumatic delirium have the same busy asthenic delirium, the soft, full, quick pulse, the tremulousness, and absence of fever, the difference being that the nervous is not caused by alcohol. Treatment. Stimulants, bromide, chloral, morphia. Clear the bowels, give plenty of nourishing liquid food highly seasoned. What is secondary shock ? Symptoms coming on at varying times from the primary shock, and causing death from heart clot, are characterized as secondary shock. Should you operate during shock? Not unless it is for the relief of a condition causing, or keep- ing up the shock. Instance, a strangulated hernia, a bleeding artery, a depressed fracture of the skull. The rule is to wait fvi- reaction. Wound Fever. What is traumatic fever? Fever following traumatism. Several forms may develop, the first of which is the reactive fever ; this follows the shock of traumatism. It develops a few hours after an injury or operation, and subsides in one or two days at most. This is the only form of wound fever which should develop in antiseptic surgery. How do other forms of traumatic fever develop ? Given a wound in which there is tension, or irritation from other causes, or in Avhich a few non-pathogenic microbes are 48 ESSENTIALS OF SURGERY. found, there will be a slight amount of inflammation and absorp- tion, and the patient will probably develop inflammatory fever, appearing on the second or third day, and lasting from two to six days. Should the wound contain a large quantity of discharge to which micro-organisms have had free access, septiccBmia or septic intoxication, from the absorption of ptomaines, is de- veloped. If the micro-organisms are allowed to multiply till they overwhelm the tissues and enter the blood current, pyrjemia, or septic fever attended with the formation of metastatic ab- scesses, is developed. What are the symptoms of traumatic inflammatory fever ? Full, strong, rapid pulse, increased temperature (100°-103O), restlessness, headache, and at times delirium, diminished secre- tions, coated tongue, anorexia, and constipation. How do you treat inflammatory fever "? Tree the wound from all tension. Provide against the possi- Ulity of discharge being retained, irrigate thoroughly with 1:1000 bichloride solution, dust liberally with iodoform, and apply a thorough antiseptic dressing, renewing the dressing daily till the fever subsides. Clear the bowels ; give aconite, bromide, or morphia, as required by the symptoms. What is septicaemia ? A septic intoxication, caused by the absorption of the products of putrefaction. Hence, it is most liable to occur in wounds not treated antiseptically, or in those which, from their depth, ex- tent, or location, cannot be thoroughly disinfected and protected. Instance, compound fractures, wounds involving the peritoneum. Give the symptoms of septicaemia. Inflammatory fever may run into septicaemia, or this affection may develop very shortly after the infliction of a wound. Temperature. Rises suddenl}^ and is at first very high (104°- 100°), may shortly sink to normal or below. Pulse. Soft, rapid, and compressible, becoming weak and thready. Bespirations, rapid and shallow. w o r N D s . 49 Nervous condition, heavy, apathetic, somnolent. Karely, active dehriura. Tongue^ dry, hard, and discolored. Teeth covered viMth sordes. At times profuse diarrhoea. Urine and faeces passed involunta- rily. Death in collapse. The wound is always unhealthy, frequently sloughing. The septic poisoning may be so slight in amount as to cause scarcely recognizable symptoms, or ma}^ within twenty-four hours of the infliction of an injury, overwhelm the system. How do you treat septicaemia ? Remove the septic matter, and make the wound sterile by irrigation, or continuous baths with bichloride solution. Elimi- nate the ptomaines by a saline purge. Su^jport the strength by stimulants, quinine in tonic doses, nutritious food given fre- quently in small quantities ; milk and malt, peptonoids, raw beef juice. Reduce high temperature by antipyrine, gr. x.-xv., or quinine, gr. xx. Secure plenty of fresh air and sunlight. What is pyaemia? A septic fever, characterized by the formation ol" metastatic abscesses. Pathogenic organisms (staphylococci and strepto- cocci) invade the blood, and are carried from the infected area to all parts of the body, where they are lodged as emboli, and form new foci of suppuration and infection. What is the difference "between traumatic inflammatory fever, septicaemia, and pyaemia? Simjyly a difference of degree. They all depend upon the same cause, and are of the same nature. They occur only in infected wounds, and are due to the septic action of micro-organisms and their products. What are the symptoms of pyaemia? Irregularly recurring attacks, characterized by a marl^ed and prolonged chill, associated with high temperature (1040-106°) ; fol- lowed by a brief hot stage, the patient manifesting the symptoms and signs of fever ; terminating in a drenching siceat, the tempera- ture quickly falling to normal or below. Several such attacks may occur in a day. The strength rapidly fails ; the pulse he- 4 60 ESSENTIALS OF SURGERY. comes weak and rapid ; the tongue dry and brown coated •, breath mawkish ; metastatic abscesses are detected in the lungs; the wound is unhealthy, the discharges ichorous. How do yon treat pysBmia ? Thoroughly cleanse the original source of infection by irriga- tion, curetting, and antiseptic dressing ; if this be impracticable, as in osteomyelitis, amputate. Open and drain all accessible abscesses. Push stimulants to their fullest extent, give quinine in heroic doses (gr. Ix. daily), milk and pressed beef-juice in small quantities frequently repeated. Provide for sun-light, and open air. What is hectic fever ? A continued remittent fever, due to septic absorption ; char- acterized by rigors and fever during the afternoon and evening, followed by profuse sweats and defervescence during the night. The pulse is constantly rapid, the eye bright, the cheek flushed, the tongue red and dry at the edges, the emaciation ]yrogressive. Instance, the fever of consumption. How do you treat hectic ? Kemove the source of septic absorption, by resection, if it is an infected bone area ; by incision and curetting, if it is an abscess. Give tonics, stimulants, and a full nourishing diet. Change of air is beneficial. Erysipelas. What is erysipelas ? An infective spreading inflammation, attacking either the skin, cellular tissue, mucous, or serous membranes. What are the causes of erysipelas ? Predisposing. Wounds, particularly those which are septic, together with any local or systemic condition depressing to the vital resistance. Instance, kidney disease, intemperance, over- crowding, starvation. Exciting. Micro-organisms and their products. WOUNDS. 51 Name the varieties of erysipelas. 1. Ctitaoeous or simple. 2. Cellulo-cutaneous or j)7Je^?7ionows. 3. Cell'jlar or diffuse cellulitis. Describe simple erysipelas. ConstitutioiioJ sijriiptoms. Eigors, headache, and fever, the temperature suddenly rising to 103^ or 104^^ ; with nausea and vomiting. The fever shortly assumes a typhoid type. Local symptoms. A rash, rapidly spreading from a scratch, abrasion, or wound, and characterized by icell defined margins, rosy-red. hue, smooth, glazed, oedeinatous, slightly raised surface, stiffness and hurning pain, frequently hlehs or vesicles, involve- ment of nearest lympjha.tic glands. The eruption may suddenly disappear from one part to reappear in another, erysipielas ambidans. The pathogenic organism of simple erysipelas has been isolated. It is found blocking the lymph vessels and spaces in the spjreading borders of the inflammation, shows up well in dry cover glass preparations, appearing as micrococci grouped in chains, and is diagnostic of erysipelas. The eruption lasts about four days in one part, and as it subsides is followed by desquamation. Give the treatment of simple erysipelas. If there is a distinct wound, thoroughly cleanse and drain it. Freely open the bowels by a saline cathartic. Milk diet for the first few days. Tr. fer. chlor. TTL xx. every two hours from the first : shortly begin quinine, in tonic doses (gr. v. to x. daily), stimulants, and as free a diet as the stomach will bear. To the erupjtion apply starch and zinc oxide, equal parts of each, and cover in with cotton-wool ; or apply a 50 per cent, ichthyol ointment, over which is placed salicylated cotton. Describe phlegmonous erysipelas. The skin and subcutaneous tissues are both affected ; the symptoms are, in general, the same as for simple erysipelas, but more marked. The swelling is greater, the edges not so sharply circumscribed, the color darker, blebs and vesicles are more common. The surface, at first densely indurated, becomes boggy in spots 62 ESSENTIALS OF SURGERY. and may break down, exposing extensive sloughs. The consti- tutional symptoms are well marked, running shortly into the typhoid type. The patient may perish from pneumonia, blood poisoning, or exhaustion. How do you treat phlegmonous erysipelas ? ConstitutionaUy^ as in the case of simple erysipelas. A purge, light milk diet ; followed in a day or two by full nourishment, tonics, and stimulants. Iron as before. Locally. Applications of heat and moisture (hot antiseptic fomentations). Multiple incisions as soon as the part becomes brawnj^, going down to, but not through the deep fascia. Check hemorrhage by packing with iodoform gauze. Strict antiseptic dressing. Describe cellular erysipelas, or diffuse cellulitis. This is a spreading infective inflammation, which may involve the cellular tissues of any part of the body. Instance, the inter- muscular planes, the pelvic cellular tissues. The constitutioncd symptoms are the same as those character- izing phlegmonous erysipelas ; the typhoid condition appears more quickly, and septic poisoning is more commonly developed. The local sympAoms are at first less marked than in any of the varieties of erysipelas. There is dense induration succeeded by. hogginess and ending in extensive sloughing. Treatment as for cellulo-cutaneous. Incisions early, Stimii' lating and supjptorting treatment from the first. Tetanus. What is tetanus? A tonic spasm of the voluntary muscles with clonic exacerba- tions, due to the introduction into the system of an infective poison. "What are the causes of tetanus? 1. Predisposing. Hot climate, exposure to cold and damp, or sudden change of temperature, negro race, lacerated and punc- tured wounds, burns, frost-bites, all septic wounds. 2. Exciting. A micro-organism. WOUNDS. 53 What are the symptoms of tetanus? A slight stiffness of the muscles of the nock and jaws, with increase of pain, and the appearance of a sanious or ichorous dis- charge in the wounded part, denote the onset of the disease. All the voluntary muscles, including those of respiration, may become involved. There is intense pr«}cordial pain from tonic spasm of the diaphragm, the countenance exhibits a peculiar grinning expression (risus sardonicus), and at the slightest irri- tation, such as a breath of air, a loud noise, or an attempt to swallow, violent spasms occur which may variously contort the body. If the spinal muscles are chiefly affected, we have opis- thotonos, or arching backward, the body being supported on the head and heels. Emprosthotonos may be developed, the body being bent forward and rolled up like a ball. More rarely pjleu- Tothoionos, or drawing of the body to one side, is seen. The skin is wet, the bowels confined, the temperature about normal ; it may rise to 108^ or 110^ shortly before death. Intellect clear. What is the prognosis of tetanus ? Bad in acute cases ; becomes more favorable if life be pro- longed till the twelfth day. Death occurs from spasm of the glottis or respiratory muscles, from syncope, from exhaustion. What are the diagnostic points of tetanus ? The absence of fever from the first, the tonic charo.cter of the spasm, the early involvement of the neck and jaw, the marked convulsive attacks, and the clear mind. Give the treatment of tetanus. Local. Make the wound aseptic. Amputation, nerve cutting, or nerve stretching, have also been advised. Constitutional. Bromide of potassium up to its constitutional effect (40 to 80 grains every two hours), chloral at night to pro- duce sleep. Morphia may be given ; it must be pushed to the extreme limit of safety. To prevent death from asphyxia give chloroform during the spasm. Stimulants, and nourishing diet are indicated from the first. 54 ESSENTIALS OF SURGERY. Hydrophobia. What is hydrophobia ? A disease due to a specific poison introduced into the system by the bite of a rabid animal. "What bites are especially liable to be followed by hydrophobia? Tliose on the face, or involving parts of the body unprotected by clothing. What is the period of incubation ? It varies from six weeks to three months ; it may be a very few days, or many years. What are the symptoms of hydrophobia ? First stage, or stage of melancholia, itching, burning, or inflam- mation of the cicatrized wound ; anxiety, melancholia, or change of disposition ; slight difficulty in swallowing, or a catch in the respiration. After a few days the disease is fully developed. The stage of excitement is characterized by clonic convulsions, involving especially the muscles of respiration and deglutition ; by mentaL disorder similar to that of delirium tremens, with periods of maniacal excitement, and intervals of lucidity. It is followed after some days by the stage of exhaustion and paralysis. The muscular system is entirely unresponsive, and the dying pa- tient lies motionless ; the mind is often clear at this stage. How do you treat hydrophobia ? At the time the wound is inflicted, cauterize, at once and thor oughly, by hot iron, nitric acid, or caustic potash. Such the wound. If the wound has cicatrized when seen, excise the cicatrix. Send the patient where he can be inoculated after Pasteur's method with attenuated virus. WJien the symptoms are pronounced, morphia, chloral, chloro- form to relieve suffering. Pilocarpine gr. ^ hypodermically, repeated frequently. Hot vapor bath. WOUNDS. 65 GlanderSo What is glanders? An infective disease of horses, dependent on a specific micro- organism ; communicable to man througli wounds, or the mu- cous membrane. In horses it is called glanders when it attacks the nasal mucous membrane, farcy when it attacks the lymphatic vessels and glands. What are the symptoms of glanders ? A discharge from the nose, thin, sanious, offensive, purulent, with involvement of the submaxillary glands. A. pustular erup- tian resembling smallpox, involving the skin and the mucous membrane of the respiratory and alimentary tracts. Sub-cutane- oiis nodules^ shortly breaking down and forming foul ulcers. There is fever^ which quickly becomes adynamic^ and death takes place within a week from septicaemia or pyaemia. There is a chronic form of glanders with less marked symptoms, and from which recovery is possible. How do yon treat glanders ? Use antiseptic nose washes (boracic acid or weak bichloride solution). Open abscesses. Pursue from the first a tonic, stimu- lating, and supporting treatment. Malignant Pustule. What is anthrax ? A specific infective disease due to the entrance of a bacillus or its spores into the system. Its starting-point is in a scratch or abrasion. It is found, in this country, mainly among those who handle imported hides or wool. What are the symptoms of anthrax ? A red, itching pimple, followed shortly by a vesicle attended with well-marked, brawny induration. Sloughing begins at once, and the anthrax pustule is formed, characterized by a dry^ central slough, surrounded by a ring of vesicles, peripheral to which there 56 ESSENTIALS OF SURGERY. is an area of redness, induration, and great oedema. The neigh- boring lymphatic glands are involved. Fever of an adynamic type develops, and the patient commonly perishes of exhaustion or syncope. Diagnosis by examining the contents of the vesicle \ bacilli from j^^,,,, to y^'oo ^f an inch in length can be detected by low powers of the microscope. How do you treat malignant pustule ? Freely excise the pustule, and either cauterize the wound with caustic potash or carbolic acid, or wash thoroughly and repeatedly with 5 per cent, potassium permanganate solution. A stimu- lant, tonic, and supporting treatment is indicated constitution- ally. The Healing of Wounds. Describe the process of repair in incised wounds. Hepair takes place in all wounds hy the organization of plastic lymph. If the wound is an incised one, if its surfaces are accurately approximated, if it is not subject to irritation, either mechanical or chemical, the exudation takes place in minimum quantity, the red blood corpuscles of the blood clot are absorbed ; in twenty-four hours the surfaces adhere, and in two or three days the thin layer of plastic lymph which binds them together is supplied with vessels ; this is called union hy adhesion or hy first intention. Inflammation scarcely passes the first stage ; there is simply a little hj-persemia, puffiness, and tenderness about the lips of the wound. If the wound surfaces are not accurately apposed, if they are subject to irritation, either mechanical, from improper dressing, or chemical, from irritating applications or the pro- ducts of germ life, the exudation becomes excessive ; there is death of tissue, there is suppuration ; if tension and other sources of irritation be removed by free discharge, the gap is promptly filled in with organized ])lastic lymph or granulations^ and the wound heals by granidation or second intention. If healthy granulating surfaces can be brought together and WOUNDS. 57 retained in position, permanent adliesion between tliem takes place at once. This constitutes union by secondary adhesion or thii'd intention. Primary adhesion or first intention. The prompt union of divided surfaces without obvious signs of inflammation. Adhesion hy granulation or second intention. The union of divided surfaces by granulation tissue (organized lymph), at- tended with evident inflammatory symptoms. Secondary adhesion or tlrird intention. The union of granula- ting surfaces. Amputation flaps which fail to unite by primary intention heal in this way. What circumstances prevent wounds from healing by primary intention? 1. Want of accurate apposition; from gaping, from extensive loss of substance, from retained blood or wound secretions, or from foreign body. 2. Want of proper protection. There may be undue motion of the part, it may be subject to direct mechanical or chemical violence, it may be exposed to infection from poisonous agents. 3. Defective nutrition., either local^ from bad position or from tension, or general from constitutional weakness. The Treatment of Wounds. What are the general indications in the treatment of wounds? 1. Arrest hemorrhage. 2. Cleanse, and remove foreign bodies. 3. Provide for drainage. 4. Bring the wounded surfaces in contact, and keep them apposed. 5. Provide for absolute local rest. 6. Prevent putrefaction. Name the varieties of hemorrhage. Arterial. Venous, Capillary. Internal or concealed hemorrhage indicates bleeding into one of the cavities of the body. Ex- travasation indicates bleeding into the areolar tissue. Further, hemorrhage may he primary^ intermediate or consecutive^ secondary. 58 ESSENTIALS OF SURGERY. What are the characteristics of the different kinds of hemor- rhage ? Arterial. Bright red blood jets from the wound. Pressure on the arterial trunk above checks the bleeding. Venous. Dark blood wells from the wound. Pressure on the venous trunk below checks the bleeding. Cajnllary. The blood oozes from the surface of the wound, and collects as a pool in its deeper parts. What are the constitutional effects of hemorrhage ? A feeble, fluttering, rapid pulse, finall}'- perceptible in the large arteries onl3\ A cold, blanched, wet surface, with colorless lips, and sighing respiration. Nausea. Frequently, uncontrol- lable restlessness, a roaring in the ears, darkness before the eyes, and horrible sinking sensations. The patient may suddenly faint. In syncope the heart's action is so feeble that clotting may take place and bleeding be permanently arrested, or, on re- action, the clot .may be washed away by the returning blood current and bleeding continue, to end in a return of syncope, in convulsions and death. Or the patient maj' recover, passing into the condition known ?s hemorrhagic fever ^ an irritative fever characterized by rise of temperature, extreme restlessness, great thirst, and a quick jerky pulse. A sudden violent hemorrhage is much more liable to produce fatal syncope than a slow continuous one. Infants bear the loss of blood very badly. Describe nature's method of arresting hemorrhage. 1. Contraction and retraction of the vessels. 2. Coagulations of the blood aided, after severe bleeding, by enfeebled heart action and alteration in the comjjosition of the blood. On cutting an artery the muscular fibres of its midddle coat contraM, narrowing or closing the lumen and drawing the end of the vessel from its sheath ; the cut ends also retract from each other, owing to the natural elasticity of the artery. Neither con- traction nor retraction can take place unless the artery is entirely cut across; hence, cmnplete section of a bleeding artery often stops the hemorrhage. WOUNDS. 69 Coagulation is excited by the divided vessel wall, the sheath of the artery, and the air ; it presently occludes the opening in the artery, and also fills with clot the space left vacant in the sheath by retraction ; this constitutes external dot. Coagulation also extends from the mouth of the vessel backward, forming a clot, conical in shape, with its base to the wound, and extend- ing as far as the nearest branch ; tliis constitutes the internal clot. By continued hemorrhage the blood is made more coagulahle ; a clot forms too rapidly to be washed away by the feeble arterial wave. Arrest of hemorrhage from veins is due to coagulation. The permanent arrest of hemorrhage is effected by the exudation of plastic lymph, which takes the place of the clot, the subsequent organization of this lymph, and the conversion of tlie occluded part of the artery into a fibrous cord. What is the constitutional treatment of hemorrhage ? The patient should be laid flat on his back ; if the symptoms are very severe, elevate the foot of his bed and apply an Esmarch's bandage to the legs and arms, thus keeping the blood to the nerve centres. Hot bottles may be applied about the body. In extreme cases resort to transfusion. Ether TTlxxx., morphia gr. I, should be given subcutaneously. Place a mustard plaster over the heart. Give injections of hot water and brandy. Hot coffee or beef tea in frequently repeated small closes by the mouth, if the stomach is retentive. As the patient recovers stop stimu- lants. Give milk diet at first, increasing as rapidly as possible. Give iron as soon as the stomach will allow of its use. In all cases avoid stimulants unless life is directly threatened by cardiac failure. The use of stimulants is frequently attended by a re- turn of bleeding. Describe the methods of transfusion. Blood or saline solutions may be used. It must be introduced warm (980-100°), in sufficient quantity to add strength and volume to the pulse, and must not contain bubbles of air. Trans- fusion may be immediate, the blood being passed directly from the vein of the donor to the patient's circulation ; or mediate, the blood being first whipped and strained of its fibrin, then injected. 60 ESSENTIALS OF SURGERY. How do you check hemorrhage ? By 1. Position. 2. Cold. 3. Heat. 4. Pressure. 5. Styp- tics. 6. Cauter}'. 7. Ligation. 8. Torsion. 9. Acupressure. 10. Porcipressure. 11. Constitutional treatment. What position favors the checking of hemorrhage ? Elevation of the part and forcible flexion. Plexion bends the artery sharply on itself, and is applicable to wounds of the ex- tremities. Describe the use of cold as a hsBmostatic. Used only to check bleeding from smaller vessels. It causes contraction and coagidatmi. Ice, ice-water as a fine forcible stream directed against the bleeding point. Describe the use of heat as a heemostatic. Used to check general oozing from large surfaces. It causes contraction and coagulation. Apply in the form of large com- presses wrung out in hot (1200-140°) water. Describe the use of pressure as a haemostatic. A graduated compress and a bandage may be used for the permanent arrest of hemorrhage when other means are not avail- able, or when several vessels are bleeding and there is a firm bone against which to make pressure. Instance, wounds of the palm or of the scalp. As a temporary means of checking bleeding the finger in the wound is most efficient, the hemorrhage from any accessible artery can be checked in this way. The tourniquet and Es- march's rubber tube are also of temporary service. Describe the use of styptics as haemostatics. Act by coagulating the hlood^ they also contract the arteries. They must be brought into immediate contact with the bleeding vessel. They all interfere with primary union. Use powdered alum, tannin, gallic acid, or persulphate of iron ; solutions of the same drugs, especially hot saturated solutions of alum may be employed ; alcohol, turpentine, chloroform are also recom- mended. Chiefly useful in checking bleeding from malignant ulcers, or in inaccessible regions. Styptics should be employed in conjunction with pressure. WOUNDS. Gl Describe the use of the actual cautery as a haBmostatic. It coagulates the blood, causes contraction of the muscular coat of the artery, and forms an eschar which acts mechanically. If the actual cautery is used, it should not be heated beyond a dull red. Secondary hemorrhage may occur when the eschar separates. Applicable Avhere there is diflSculty in placing liga- tures. Instance, in operation about the bones of the face. Paquelin's cautery or the galvano cautery should be used. Describe ligation as a means of arresting hemorrhage. This is the most important of all haemostatic agents. By the pressure of the thread, the middle and internal coats are divided, and curl up within the vessel, causing clotting ; this clotting extends to the first lateral branch. If the artery is ligated in its continuity, a conical clot is formed on both the distal and proximal sides of. the ligature, with the apex in each case pointing away from the thread. About the ligature there is deposited a \s.jev of plastic Ij-mph ; the internal clot becomes infiltrated with leucocytes and or- ganizes ; the ligature, if aseptic, is either absorbed or. enc5'sted, and the artery is converted into a fibrous cord. If the ligature is septic, or subject to irritation, it separates by ulceration; this separation may be accompanied by secondary hemorrhage. What precautions are observed in applying a ligature? It must be aseptic. It should include only the vessel. If ap- plied to an artery in its continuity, a healthy part of the vessel must be selected ; a square Icnot should be tied. Of what should ligatures be made ? Carbolized and chromicized catgut ; carbolized silk. Desciibe the method of applying torsion as a haemostatic. Torsion consists in seizing the arter}^ in torsion forceps, draw- ing it from its .sheath and twisting till the inner and middle coats give way. It is efficient for even the largest arteries, but takes more time than other methods. Describe acupressure. This consists in checking hemorrhage by compressing the 62 ESSENTIALS OF SURGERY. Fi2. 1. wounded vessel between an acupressure needle and the tissues. The methods of accomplishing this are by — 1. Circumclusion. A piu or needle is thrust through the tissues, heneath the arter^^ and brought out to the surface on the opposite side. If necessary a thread can be carried around the two ex- tremities of the pin in the form of a figure-of-8. The hare-lip suture is really an application of circumclusion. 2. Torsoclusion. The pin transfixes the tissues parallel to the artery, is twisted till it lies at right angles to its former direc- tion, is pushed directly across the artery, and plunges into the tissues on the opposite side. 3. Betroclusion. The needle is carried in and out, transfixing the tissues on one side of the artery and at right angles to its course. The point of the needle is then carried over the artery to the opposite side, is plunged directly downwards, is carried under the artery and its point makes its appearance on the side from which it originally started. Describe forcipressure. Torcipressure consists in seizing the end of the bleeding vessel in haemostatic forceps, which are allowed to remain in place till cither the end of the opera- tion, or till the forceps are required in another place, when they should be gently remoyed. The artery is crushed ; the middle and inner coats break as in ligation. What drugs may be administered by the mouth for the arrest of hem- orrhage ? Opium, ergot, ol. erigeron., acid. sulpli. aromat. What is primary hemorrhage ? Bleeding which occurs immediately, Hemostatic forceps. ou the infliction of a wound. WOUNDS. 63 What is recurrent hemorrhage? Synonyms : Reactionary, consecutive, intermediate. Bleeding^ which comes on with reaction. It occurs within the first twenty-four hours after a wound. What are the causes of recurrent hemorrhage ? The slipping of a ligature. The displacement of a clot. This may occur from the wounded part not being kept at rest, or from tlie increased force of reaction circulation. How do you treat recurrent hemorrhage? First elevate^ and apply firm pressure by means of additional bandages, covering in the soiled dressings with antiseptic gauze. If bleeding still continues, remove the dressing, open the wound, clear out the clots, and ligate or secure the bleeding vessel. What is secondary hemorrhage ? Bleeding which comes on between the end of the first day and the complete cicatrization of the wound. It is most frequent about the time of the separation of ligatures or sloughs. What are the causes of secondary hemorrhage ? 1. Constitutional conditions which interfere with organization, or are associated with an overacting heart. Instance, Bright's disease, diabetes, haemophilia, traumatic delirium, septicaemia, pyaemia, and plethora. 2. Disease of the arterial wcdls, as found in atheroma, calcare- ous degeneration, syphilis, or tuberculosis. 3. Septic condition of the wound. The ulceration and sloughing may involve the arterial walls. 4. Defect in the ligature or its application. The ligature may soften prematurely. It may be septic and cause suppuration. It may be badly applied, being too loose, or irregularly knotted, or tied too near a collateral branch. How do you treat secondary hemorrhage ? If from a severed artery^ as in a stump, and only a few days have elapsed since the infiiction of tlie wound, treat as consecu- tive hemorrhage ; that is, try elevation and pressure first, if the bleeding be moderate, that failing, or at once, in case of violent 64 ESSENTIALS OF SURGERY. hemorrhage, reopen the wound and secure the vessel. If there is much sloughing use the actual cautery. Later, when the healing is well advanced, try pressure first, then either reopen the wound, or ligate the main artery just above. If the bleeding recurs amputate higher up. If from an artery tied in its continuity. Pressure by graduated compresses and compression of the artery above. If this fails openthe wound and tie above and helov:. Should the bleeding still persist amputate, if the femoral artery is the one involved, or tie above, in the case of other arteries. How do you cleanse wounds ? Gross foreign particles can be picked out with forceps. Blood clots and dust should be washed away by means of a fine stream of sterile or antiseptic liquid ; avoid all rough handling or rubbing. How do you provide for drainage ? By means of drainage tubes, which may be made of red rub- ber, glass, or decalcified bone ; or by strands of catgut or horse- hair. Drainage does not allow the serous exudate to make tension in the wound, or to remain as a rich culture fluid for the reception of germs. It should be employed in all wounds ex- cept those which are superficial, or are placed in very vascular regions, as in the face. Drainage tubes are to be removed ia from 24 to 48 hours. If the wound is ver}^ deep and extensive take the tubes out gradualh'. The tube should be carried through the protective, should be cut ofi" flush with the surface, and should be prevented from slipping into the wound by silver wire or a safety pin. How do you close wounds 1 Both edges and surfaces must be approximated. In superficial w^ounds adhesive plaster, isinglass plaster, or gauze collodion and iodoform may be used. In deep wounds sutures must be emploj'ed together with compresses and bandages. Of what materials are the ordinary sutures made ? Silk, silver wire, catgut, horsehair. WOUNDS. 65 Describe the various kinds of suturing. 1. The continuous {glov:er''s). The stitches are made with one unbroken thread, carried across the wound in one direction. 2. The interrupted.. Each stitch is carried across the wound and tied as inserted. Interrupted sutnres. 3. Pin suture (twisted or hare-lip). The apposed margins of a wound are transfixed with pins, around the two ends of which and across the wound is carried a thread in the form of a fig- ure-of-eight. This keeps the surfaces in accurate apposition, and checks bleeding (circumclusion). 4. The quill suture. Threads are passed deeply across the wound and looped around quills or sections of catheter, placed parallel to the wound and at some little distance from its edges. The button or plate suture. Wire is passed across the very bot- tom of the w'ound, brought out to the surface at some distance from its edges, and secured by fastening to leaden plates or buttons. The Lembert and Czerny sutures will be described under intestinal wounds. "When there is much gaping, or loss of substance, the plate or quill sutures are used, they prevent tension in the skin sutures, and are termed sutures of relaxation. If the wound is moder- ately deep, a number of interrupted sutures are passed across 5 66 ESSENTIALS OF SURGERY. Fig- 3. it to its bottom and brought out at some little distance from its edges, these are termed sutures of ajjjyTOxima- iion. The skin is accurately joined by closely applied super- ficial sutures, either interrupt- ed or continuous, called sutures Satnres of approximation and coaptation. OJ COCiptO.tlOn. Unless there is great ten- sion, and reason to fear gaping, remove sutures about the fourth day. How do yon prevent putrefactive or infective processes in the wound ? By antiseptic treatment and dressing. Describe the antiseptic treatment. There must be provided basins for the sponges. Shdttow trays for the instruments. A fountain syringe for irrigatio:"). Solutions. Carbolic acid 1 : 20. Bichloride of mercury 1 : 500. These solutions can be weakened by the addition of water as required. Sponges and drainage tubes which have been kept in carbolic acid 1 : 30. Ligatures and sutures which have been rendered aseptic and are kept in absolute alcohol. The surgeon j^reparcs himself by scrubbing his arms, hands, and nails with a brush, sublimate soap, and hot water ; puts on his antiseptic coat and again washes his hands first in alcohol, then in sublimate solution 1 : 500. The patient is prepared by a general hot soap hath, if possible. The entire region of the wound of operation is scrubbed with hot water and su])liniate sonp, shaved, washed with alcohol, and irrigated with 1 : 500 sublimate solution. All portions of the patient's bod}'^ and the operating table near the seat of injury are covered with towels wet in 1 : 500 sublimate solution. Instruments and drainage tubes are placed WOUNDS. 67 in 1 : 30 carbolic solution. The sponges Fig. 4. are put in a basin and covered with bi- chloride, of the strength used for irriga- ting. The fountain syringe is filled with bichloride 1:2000. The dress- ings are cut to the proper size, and wrapped in bichloride towels. During the operation or manipulation^ irrigate occasionally with the bichloride solution, finally flushing out, if the wound be large, with a weak solution, sterile water or salt solution. Carefully guard against instruments, sponges, or hands coming in contact with non- sterilized surfaces. At the termination of the operation^ see that the hemorrhage is ahsolutely stopped^ and that drainage is amply jjto- videdfor. Apply the dressing. Describe the antiseptic dressing. Lister''s dressing. Dust with iodoform. Apply a piece of pro- tective Cvarnished silk), wet in 1 :40 carbolic, just large enough to cover the closed wound. Over the protective, and overlap- ping it, place several layers of carbolized gauze, wrung out in the 1 : 40 solution. Over this deep dressing and overlapping it, apply six layers of dry carbolized gauze, a seventh of Mackin- tosh (rubber cloth), an eighth of gauze. Over the whole and about the edges place antiseptic cotton, and cover in with a car- bolized gauze bandage. The jjrotective guards the wound sur- faces from the irritation of the strongly carbolized gauze. The deep wet dressing disinfects the immediate neighborhood of the wound ; it is wet because dry cold gauze may contain septic particles of dust. The Mackintosh prevents the discharge from passing through the gauze immediately to the surface. The dressing in ordinary use is : 1. Dry iodoform gauze to the wound. 2. Covered and overlapped by bichloride gauze. Sutures. 68 ESSENTIALS OF SURGERY. 3. Bichloride cotton overlapping the whole and covered in by a gauze bandage. When do you change an antiseptic dressing ? 1. When drainage tubes or non-absorbable sutures are to be removed. 2. When fever, other than that due to reaction, appears. 3. AVhen there is hemorrhage. 4. When the wound is healed. Wounds. What is a wound ? A solution in the continuity of the tissues, produced by sudden force. Under what two headings may wounds be classed? 1. Subcutaneous icounds. There is either no hreo.k in the skin or an exceedingly small one compared to the extent of the lesion beneath. Instance, the wound of tenotomy is said to be subcu- taneous. 2. Ojjen wounds. The break in the surface is, to a certain ex- tent, commensurate to the deeper injury. What is a contusion ? A subcutaneous injury (distinguish from contused wound in w^hich there is a break iyi the surface) occasioned b}" squeezing or crushing the tissues. There is hemorrhage and discoloration, at times vesicles and blebs form, and the part may appear gan- grenous. The effused blood may form a fluctuating swelling, known as hceraatoraa^ or may coagulate, forming a hard swelling, termed thrombus. How do you treat contusion ? By rest, pressure, and the application of evaporating and . stimulating lotions. Name the different kinds of open wounds. 1. Incised, or clean cut. 2. Lacerated, or torn. 3. Contused, WOUNDS. 69 or bruised. 4. Punctured, or pierced. 5. Gunshot, or lacerated and contused. 6. Poisoned. Describe incised wounds. Cause. Sharp cutting instruments. They bleed freely, gape widely, and cause burning pain. Treatment. Use all antiseptic precautions. Check hemorrhage by cold, forcipressure, and ligation. Bring the surface and edges of the wound in most accurate apposition. If tendons, nerves, muscles, or bones are severed, tlieir corresponding ends must be carefully united by catgut sutures. If the wound is extensive, catgut drains may be employed. Absolute rest must be enforced. Union, in seven to ten days, by first intention Describe lacerated and contused wounds. Caused by machinery, dog-bites, blows with blunt instrument, etc. Characterized by slight hemorrhage, moderate gaping, dull pain, ecchyraosis (hemorrhage into the surrounding tissue), and shock. Treatment. Antiseptic. Thoroughly cleanse, remove dead tis- sue, provide for free drainage, making counter openings in depend- ent positions, and using full-sized rubber drainage-tubes. Care- fully coapt, if it can be done witJiout tension. Apply iodoform gauze liberally, bichloride gauze, bichloride cotton, and band- ages. Keep the part absolutely at rest. Dangerous complications. Shock, extensive inflammation and sloughing, secondary hemorrhage, cellulitis, gangrene, tetanus. Describe punctured wounds. Caused by pointed instruments ; depth is their greatest meas- urement. Usually associated with contusion. Dangers. Wounds of deep structures, hemorrhage, the car- rying in of septic substances, retention of discharge. Treatment. Kemove the vulnerating body, check bleeding, thoroughly disinfect the accessible portion of the wound, put in a drainage-tube, apply an antiseptic dressing, and put the part at rest. On the first sign of inflammation (pain and f^ver) re- 70 ESSENTIALS OF SURGERY. move the dressings, and lay the wound open to its very bottom ; disinfect, drain, and reapply the antiseptic dressing. Describe §funshot wounds. Caused by missiles, either round (buck-shot, bird-shot) or coni- cal (pistol and rifle balls). The wound of entrance is smaller than the wound of exit, and is slower in healing. One bullet may cause multiple wounds, depending upon the position of the wounded man and the direction from which the missile comes. Two bullets may form but one wound of entrance. One bullet may form several wounds of exit by being split in the body ; the wound of entrance may also be the w^ound of exit, as, when a ball passes completely around the head, beneath the skin. Balls may be deflected by tendons, bones, or even bloodves- sels. Devitalization of tissue is proportionate to the velocity of the ball ; hence is greatest at the wound of entrance. The immediate effect of gunshot wounds is hemorrhage, pain, and shock. There may be no pain ; excessive hemorrhage occurs only when large vessels have been wounded ; shock may be de- layed. The secondary effect of gunshot wounds is inflammation, slough- ing, hemorrhage, with the complications incident to contused and lacerated wounds (tetanus, gangrene, cellulitis, and blood poison). How do you treat gunshot wounds ? 0)1 the field. Check hemorrhage by position, pressure, or the tourniquet. Apply an antiseptic pad to the surface wounds. Im- mobilize. If no septic matter has been carried in by the missile, or the surgeon'' s probe or finger, the wound is practically^ rendered subcutaneous by this treatment, and can be allowed to heal as such, no effort being made to find the ball. In the hospital. Under all antiseptic precautions, remove the antiseptic pad, thoroughly clean the opening of the wound and the skin surface about it. Reapply an antiseptic dressing and immobilize. Do not probe. If inflammatory fever appears, or if the original wound was so extensive as to preclude the idea WOUNDS. 71 of primary occlusion, do a formal antiseptic operation. Freely lay open the wound tract, remove foreign bodies, devitalized tissues, or loose fragments of bone, explore and irrigate every recess of the wound, pack with iodoform gauze, insert sutures for the purpose of approximating the parts, but do not tie them^ dress antiseptically. In one or two days remove the dressing and iodoform packing. If the wound is aseptic, close by knotting the sutures. If the wound is not aseptic, irrigate and renew the packing, or supply free drainage, dressing daily till the granula- tions become healthy. An aseptic bidlet is readily encysted. Should it subsequently give trouble, its removal is much safer after the wound has healed. If the surgeon decides to search for the bullet and ex- tract it, he must proceed as in a formal operation. Nelaton''s probe^ tipped with unglazed porcelain which is marked by contact with lead, and long-bladed bullet forceps, may be useful in locating and extracting a bullet. What gunshot wounds require amputation ? 1. Wounds which comminute the bone and injure or destroy the main vessels of a limb. 2. Wounds which destroy a large portion of the limb, or carry away a part of it. 3. Wounds complicated by osteomyelitis, intractable secon- dary hemorrhage, or spreading gangrene. What injuries are classed as poisoned wounds ? 1. Dissecting wounds. 2. Stings of insects. 3. Wounds in- flicted by arachnids and reptiles. 4. Wounds infected from diseased animals. Describe the dissecting wound. It appears more frequently where fresh bodies or arsenical injections are dissected. It is due to inoculation with infective micro-organisms ; these are destroyed by advanced putrefaction, hence the most offensive bodies may be the least dangerous. Its virulence depends upon the strength of the original virus and the constitutional vigor of the patient infected. Symptoms. Within twenty-four hours of the infliction of a 72 ESSENTIALS OF SURGERY. scratch or cut, there is an itching, then a burning pain ; a vesicle is formed which breaks, disclosing an indurated ulcer. There may be a stop at this stage, or the inflammation may extend ; the lymphatic vessel and axillary glands become involved, and may suppurate freely. The constitutional S}' mptoms are well marked. The patient may reach this stage and rapidly recover, or the disease may make steady progress, suppuration attacking the neck and thorax, cellulitis involving the arm, the symptoms be- coming markedly adynamic, and the patient perishing of septi- csemia or pygemia. How do you treat dissecting wounds ? Immediately, at the time of intiiction, encourage bleeding by tying a ligature about the part. Suck the wound and press the blood from it ; apply carbolic acid or sulphate of zinc, dust with iodoform, and cover with a light antiseptic dressing. If an infective inflammation appears, freely incise, curette the indurated tissue, pack with iodoform gauze and dress antisepti- cally, applying a sphnt. Open abscesses promptly. Make mul- tiple incisions for cellulitis. Clear the bowels, give stimulants, tonics, and nutritious diet. For pain, ai)ply locally, chloral gr. xx. to the ounce of water. A circular blister about the arm may limit the extension of lymphangitis. There is always marked constitutional involvement in these wounds. There is fever and exhaustion, loss of sleep from pain, and the rapid- development of an adynamic condition. Treat by anodynes, stimulants, full diet, tonics. (For Anthrax, Glanders, Hydrophobia, see pp. 54, 55.) How do yon treat stings of insects and spider bites ? Locally. Ammonia. Systemically. Stimulants if necessary, ammonia or brandy. What are the symptoms of rattlesnake poisoning ? Rapid and extensive swelling, discoloration, and disintegra- tion. Profound systemic depression. How do yon treat rattlesnake bites ? 1. Put a tight ligature about the part above the wound. WOUNDS. 73 2. Excise, and subsequently cauterize the wound area. 3. Encourage bleeding by suction. 4. Administer alcohol to tlie point of intoxication. 5. Release the ligature for a few seconds at a time, tightening again till each small dose of poison thus admitted to the system is eliminated. This is termed the intermittent ligature. Injections of permanganate of potassium in and about the wound (10 per cent.) are said to be efficient. If collapse threatens, ammonia must be given hypodermically. Wounds of Arteries. Describe wounds of the arteries. 1. iSTon-penetrating. The outer coat or coats only are in- 'volved. The artery may subsequently ulcerate and give way, causing extravasation, or may cicatrize and graduall}'^ yield, forming true circumscribed traurnatic aneurism. 2. Penetrating. The artery is laid open. It may be jjartially cut across, when there will be free and continuous bleedino-, or completely cut across, when contraction and retraction favor co- agulation. How do you treat wounded arteries ? Ligation in the case of large and accessible arteries; forcipres- sure, acupressure, or the actual cautery under other circum- stances. "When the artery is partially divided, complete the division. What rules must he observed in applying the ligature to a wounded artery ? Tie in the wound. Tie hotli ends of the wounded vessel. Do not search for the arterial wound unless there is actual bleeding at the time of search. "While operating, check further bleeding by pressure, or by the finger in the wound. How do you treat gangrens appearing after ligation cf a wounded artery ? If rapidly progressive, amputate at once. If slow in progresSj wait for the line of demarcation. 74 ESSENTIALS OF SURGERY. Describe traumatic aneurisms. 1. Diffuse traumatic aneurism. This is simply a collection of arterial blood, in the tissues of a part, which communicates with the blood stream in the interior of the artery, and is limited by peripheral coagulation. 2. Circumscribed traumatic aneurism. This is blood in the tis- sues, communicating with the arterial current, and provided with a sac formed by the condensation of the surrounding cellu- lar tissues. The circumscribed traumatic aneurism may be formed by a protrusion of the inner coat through a laceration of the outer, in which case it is called hernial; or by the yield- ing of a cicatrix of the arterial coat, when it is called true circum- scribed traumatic aneurism. Symptoms as for aneurism, except in the case of diffuse trau- matic aneurism^ when a spreading tumor, in which thrill and bruit can be detected, and feeble or absent circulation of the part below, will indicate the nature of the affection. How do you treat traumatic aneurism ? Ligate just above, or, if the aneurism threatens to burst, open the sac and tie above and below. Describe an arterio-venous aneurism. Definition. An abnormal communication between an artery and a vein. Cause. A wound involving both vessels. Varieties : 1. Aneurismal varix. The artery and vein commu- nicate directly. The vein is dilated by the arterial beat, form- ing a fusiform swelling. 2. Varicose aneurism. The artery and vein communicate by means of an intermediate sac. Symptoms. A tumor, characterized by a jarring pulse, and a rough buzzing bruit. The artery is large above and small be- low. The vein is large above and pulsates. Treatment. Pressure on the tumor by means of an elastic bandage. Ligation of the artery above and below. When pres- sure fails to control the bleeding from the vein, it must be liga- tured also. WOUNDS. 75 What are the dangers in wounds of veins ? 1. Hemorrhage. Control by pressure or ligation. 2. Blood poisoning from septic thrombosis. Prevent by keep- ing the wound aseptic. 3. Entrance of air. Cliaracterized by a hissing sound during inspiration, by the escape of frothy blood during expiration, by a churning sound heard on ausculting the heart, and by prompt collapse of the patient. Stop the vein wound immediately with the finger, or fill the entire wound with water. Ether, brandy, or ammonia subcutaneously. Wounds of Nerves. What are the consequences of wounded nerves ? The nerve may be partially or completely divided. If com- pletely divided, the entire peripheral part undergoes atrophy and degeneration (Wallerian degeneration), the proximate end becomes bulbous from proliferation of the fibrous tissue. Should union occur the degenerated fibres are regenerated. As a result of destroyed innervation there follows : — 1. Motor and sensory paralysis. 2. Muscular atrophy and degeneration. 3. Trophic changes, characterized by the skin becoming glazed, smooth, bluish-red, and prone to ulcerate ; the nails becoming cracked and deformed ; the hair falling out ; and rheumatoid joint affection. How do you treat wounded nerves ? If recent., suture together with fine chromlcized catgut passed through the sheath of the nerve. If old, free from all cicatricial adhesions, resect the bulbous proximal extremity, freshen the distal extremity, and suture as before. Head Injuries. Give the surgical anatomy of the scalp. Layers. Skin, superficial fascia, aponeurosis of the occipito- frontalis, subaponeurotic fascia, pericranium. 76 ESSENTIALS OF SURGERY. Superficial, fascia binds the skin firmly to the aponeurosis. It is made up of intersecting, non-elastic bands of connective tissue, containing in its meshes globules of fat ; it is very vas-. cular, and freely supplied with nerves. Fig. 5. Layers of the scalp Aponeurosis. Covers the vault of the skull, is attached to the superior curved line and the mastoid process ; is blended in front with the pyramidalis nasi, corrugator supercilii, and orbicularis palpebrarum, and is continued laterally to the zygoma by laminated layers of areolar tissue. Suhap)oneurotic fascia. Is made of delicate, elastic, con- nective-tissue fibres containing no fat ; loose in texture, and allowing free motion on the part of the aponeurosis. Blood supply Timited. Arteries of the scalp are from the temporal, occipital, auricular, supraorbital, and frontal. Certain branches strike deep and supply the periosteum. Veins of the scalp intercommunicate with those of the peri- cranium, the diploe,the meninges, the sinuses. What is the surgical bearing of these facts ? 1. From the vascularity of the superficial fascia extensive in- jury can be quickly repaired. 2. From its lack of elasticity no tension can be made in uniting wounds. There is little gaping unless the aponeurosis is cut. 3. From its denseness of structure, effusion, or suppuration will probably be circumscribed, and movable only to the extent that the aponeurosis can be moved. 4. In the subaponeurotic fascia effusion or suppuration will WOUNDS. 77 probably not be circumscribed, from the looseness of structure, and will appear as a fluctuating swelling about the ears or the root of the nose, from which position it can be moved to the various dependent parts of the aponeurotic attachment. 5. The arrangement of the vessels allows the scalp to be entirely detached from the pericranium without loss of vitality. 6. It also allows of the direct extension of septic processes into the diploe and the interior of the skull. 7. Swellings beneath the pericranium are bounded by the sutures and are immovable. Describe contusion of the scalp. Sicelling very rapid. On palpation a soft yielding centre (fluid blood), and hard, distinctly outlined edges (fat and coagulum). How do you diagnose contusion from depressed fracture ? The hard margins about the apparently depressed central area are raised from the hone. By firm pressure with the nail the clot may be pushed aside, and the bone felt through it. In case of fracture, the finger passes directly from the surf ace of the skull into a depression^ without first surmounting a ridge. Where may the effusion due to contusion take place ? The blood may be effused in the superficial fascia, beneath the aponeurosis and beneath the pericranium. When in the latter position it may ossify. How do you treat contusions of the scalp ? Ice-bag till swelling ceases to increase. Evaporating and stimulating lotions, moderate pressure. Aspirate a persistent hsematoma. If suppuration occurs, incise freely. ^ How do you treat wounds of the scalp ? Carefully shave, wash, and disinfect the region of the wound. Remove all foreign matter, and check hemorrhage. If the wound is very extensive, drain by strands of horsehair or catgut. Su- ture, making accurate apposition, apply iodoform, protective, wet bichloride gauze, dry bichloride gauze, bichloride cotton, and. a firm bandage. 78 ESSENTIALS OF SURGERY. Describe contusions of the cranial bones. Contusions may cause — 1. An inflammation of the, pericranium, or periostitis, which may terminate in resolution, chronic ijeriostitis, or suppuration, inv^olving tlie neigliboring bone, and terminating in caries or ne- crosis. 2. The inflammation may extend to the diploe, causing septic osteophlebitis, with septicaemia or pyaemia. 3. The inflammation may extend to the intracranial struc- tures, causing supra- or subdural suppuration. 4. The inflammation may terminate in chronic osteitis and pachymeningitis, causing thickening. What symptoms aid the surgeon in determining the character and seat of inflammatory action ? 1. Pus beneath the pjericranium, or simple necrosis. Chill and fever, moderate in severity, local oedema, tenderness, and deep fluctuation. Detection of the diseased bone when the absctess is opened. 2. Pus in the diploe. Chill, high fever, local signs of suppura- tion, general symptoms of pyaemia or septicEcmia. Intracranial extension. High fever, headache, vomiting, mono- plegia or hemiplegia, delirium or stupor. PotVs puffy tumor, a circumscribed superficial swelling over the" affected area, sometimes accompanies supradural suppura- tion. How do you treat contusions of the cranial bones ? Open the bowels freeh^, keep the patient in bed and absolutely quiet, give liquid diet, and apply cold to the head. If there is a wound, rigid antisepsis must be observed. Should symptoms point to subpericranial suppuration, open freely. Deeper suppu- ration should at once be exposed by the trephine. Classify fractures of the skull. A. Fractures of the vault. B. Fractures of the base. 1. Partial, involving the inner or the outer table. 2. Complete, involving the entire thickness of the skull. The inner table is usually damaged more extensively than the outer. WOUNDS. 79 Of the complete fractures we have — 1. Fissured, taking the form of a simple crack. 2. Stellate or radiate, appearing as several fissures radiating in different directions. 3. Comminuted. The bone is broken into several pieces. 4. Depressed. The bone is pressed in upon the brain. 5. Punctured oy pnerced. This is usually accompanied by con- siderable comminution of the inner table. Any of these fractures may be simpjle (no external wound) or compjound (external wound communicating with the break). What causes fractures of the vault of the skull ? Sudden concentrated force, as the blow of a hammer. How do you diagnose fractures of the vault of the skull ? Simple fractures without dis}ilacement (fissured, stellate) can only be inferred from accompanying v^ymptoms. Simple fractures witli displaeemeut can frequently, but not al- ways, be detected by careful examination of the surface. There is usually depression, and the abrupt bone edges may be felt. Symptoms of compression are commonly present. Compound fractures can be diagnosed by inspection and palpa- tion through the wound. There is frequently tree bleeding, and there may be escape of cerebrospinal fluid. How do you treat fractures of the vault ? Simple or compjound fracture, vjithout depression. Place the patient in a quiet, darkened room, clear the bowels with calomel, shave the head, and apply an ice-bag ; give a light milk diet (Oij daily). If the wound is compound, treat antisep- tically. Calomel gr. ^, Dover's powder gr. ij, every two hours, is sometimes kept up for three or four weeks. Simple depressed fractures ivithout signs (f compression treat as above unless symptoms arise. Compound depressed fractures, and punctured fractures. Always elevate, trephining if necessary. Thorough asepsis makes the operation entirely safe. Punctures through the supraorbital plate or the nose do not in themselves indicate trephining, 80 ESSENTIALS OF SURGERY. though the operation should be done if unfavorable symptoms subsequently appear. What is the cause of fractures at the base of the skull ? Direct force. Punctures. Driving of a condyle through the glenoid fossa by a blow upon the chin, or shattering the cribri- form plate of the ethmoid by a blow on the nose. Indirect force. 1. Falls upon the, buttocks or feet drive the spine against the occipital condyles. 2. Falls upon the cranial vault drive the occipital condyles against the spine. If the head is flexed the force is carried back- ward, and is exerted on the posterior cerebral fossa. If the head is extended, the force is carried forward, and is exerted on the anterior or middle cerebral fossa. 3. Conduction and amplification of vibrations. The force is powerful and diffused. If applied to iYm frontal region., there is usually fracture of the anterior cerebral fossa. The middle cerebral fossa is fractured by such force applied to the tempjoro- pjarietal region. The p)Osterior cerebral fossa by force applied to the occipital region. What are the symptoms of fracture of the anterior cerebral fossa ? Free and continuous bleeding from the nose. Subconjunctival effusion with palpebral ecchymosis, involving the lower eyelid particularly. Escape of watery fluid (cerebro-spinal fluid) from the nose. Paralysis of the olfactory, optic, or oculo-motor nerves. Concussion or compression. The blood and cerebro-spinal fluid may pass back into the pharynx, which should always be examined in these injuries. What symptoms denote fracture of the middle cerebral fossa ? Pree continued bleeding from the ear, followed by escape of cerebro-spinal fluid, increased in quantity by firm pressure on the jugular veins. Paralysis of the auditory and facial nerves, usually coming on some days after the injury. If the membrana tympani is not ruptured, the blood and cerebro-spinal fluid will escape into the' pharynx by way of the Eustachian tube. WOUNDS. 81 What symptoms characterize fractures of the posterior cerebral fossa ? Examination through the pharynx may show depression or comminution. Severe pharyngeal hemorrhage. Ecchjmosisof the lateral regions of the neck. When the neck is not involved in the injury late discoloration is a valuable sign of fracture at the base (middle or posterior fossa). How do you treat fractures of the base? Since these fractures are usually tissured, they, in themselves, rarely require treatment. The gravity of fractures of the base depends ahnost entirely upon the concomitant injury to the brain or its bloodvessels, and the treatment must be directed to the prevention of encephalitis which is liable to develop after these injuries. Keep the patient absolutely quiet. Elevate the head and ap- ply an ice-bag to it. Control restlessness by bromide of potas- sium or morphia. Give water only, for 48 hours, then a light liquid diet. ~ Mercurials may be used. When the cerebro-spinal fluid escapes externally, the fracture is, of course, compound, and the channel of escape must, if pos- sible, be antiseptically cleansed and occluded. Injuries of the Meninges and Brain. In what regions may intracranial blood extravasations take place ? 1. Between the dura mater and the skull. 2. In the cavity of the arachnoid. 3. In tbe meshes of the pia mater (on the brain surface). 4. In the cerebral substance. 0. In the ventricles. What are the sources of extravasation between the dura mater and the skull ? 1. The small vessels passing from the dura to the bone. The hemorrhage is slight in amount. 6 82 ESSENTIALS OF SURGERY. 2. The middle meningeal artery. The usual source of exten- sive bleeding. 3. The venous sinuses. Rarely a source of bleeding. What symptoms denote extravasation of blood between the dura mater and the skull ? Symptoms of compression coming on after an interval of im- munity. Immediately after an injury the patient suffers from concussion and shock ; he reacts and recovers from this condition shortly to exhibit symptoms of compression^ cliaracterized by : 1. Spasm followed by paralysis^ affecting the face, arm, or one side of the body, and accompanied by a local fall of temperature. 2. Coma. 3. Widely dilated pupil of the affected side. How do you treat hemorrhage between the dura and the skull? Trephine over the middle meningeal artery (anterior branch). The pin of the trephine is placed 1 j inches behind the external angular process of the frontal bone, and the same distance above the most prominent part of the zygoma. Clear away the clot, close the artery by means of ligatures, a jjlug of wax or catgut, or the touch of a hot needle. If the trephine opening does not expose the bleeding point, remove the bone along the course of the artery till the source of hemorrhage is found. If no supradural hemorrhage is found, but the dura is bluish, projecting, and does not pulsate, there is effusion beneath, which must be evacuated by incision. If the symptoms do not definitely indicate the probable seat and nature of the injury, treat as for all head injuries, i. c, elevate the head, and apply cold to it, clear the bowels, give a very restricted fluid diet, use bromides, chloral, morphia, mercury, or bleeding as indicated by symptoms. What are the symptoms of hemorrhage beneath the dura ? Blood in the arachnoid is generally diffused over the whole cerebral hemisphere. There may be symptoms of compression, or, some time after the injury, irritability of temper, headache, or convulsions may develop. There is nothing diagnostic. The WOUNDS. 83 effused blood may become encysted or may organize as a tough membrane. Blood in the pia mater usually accompanied by cerebral lacera- tion. The blood is widely diffused. The symptoms are those of the brain injury, or of apoplexy. How do you treat subdural extravasations ? Expectantly, as for head injuries in general. If the sj'-mptoms should point to localization of the hemorrhage, trephine. Concussion and Contusion. Describe concussion of the brain. By concussion is meant a simple jarring of the brain without attendant lesions. There is, however,- always congestion, and, commonly, serous or sanguinolent effusion. If concussion is at- tended with marked and persistent symptoms, it is probably associated with contusion. Contusion may be circumscribed or diff'used. It maj^ produce hemorrhage in mass, or diffuse miliary extravasations. Its effects may be found at the point of injury, or on the opposite portion of the brain. Laceration frequentlj^ accompanies contusion. The anterior part of the frontal and temporo-sphenoidal lobes are commonly involved. What are the symptoms of concussion ? Of the slighter form ^ momentary loss of consciousness, or giddi- ness, with pale face and feeble pulse, some mental confusion, sw^eating of the face, nausea, vomiting, and reaction. Of the more severe forms (contusi(m, with congestion, bleeding or laceration), prolonged unconsciousness, with feeble, scarcely perceptible pulse, shallow breathing, pale, cold surface, subnor- mal temperature, muscular relaxation, variable pupils (depend- ent on the seat and character of the injury). Eestlessness, screaming, and local spasm or paralj'sis may suggest lacera- tion. The beginning of reaction is characterized by vomiting. After a variable time the patient may pass into the second stage of concussion, termed cerebral irritation. 84 ESSENTIALS OF SURGERY. He can be roused with difficulty, but responds angrily, and im- mediately lapses into a somnolent condition. He lies curled up on his side, with limbs tlexed and eyes tightly closed. He resents any efibrt at changing his posture. He may be exceedingly restless. The pulse is small and feeble, the respirations are quiet, or at least are not stertorous. The pupils are contracted. As the condition of cerebro-irritation subsides, the third stage of concussion^ characterized by inflammation, abscess, softening, or fatuity, may develop. Later, hereditary or acquired tendency to brain disease may appear. Concussion and contusion are always attended by shock. How do you treat cerebral concussion and contusion ? First stage (insensibility and shock). Absolute quiet in a dark- ened room. If reaction is slow, encourage by external heat. Very rarely should stimulants be given ; if absolutely indicated^ administer brandy or ammonia hypodermically. On the deve- lopment of the second stage (cerebral irritation) apply an ice-bag to the raised head, clear the bowels, give water and cracked ice for two days, followed by milk and lime-water, in small quanti- ties. For restlessness and pain give bromide, chloral, or opium. Prevent sequelse by long-continued rest in bed, by very slow re- sumption of ordinary duties and responsibilities. Compression. What are the causes of cerebral compression ? 1. Depressed bone. 2. Extravasated blood. 3. Pus, or in- flammatory products. 4. Foreign bodies. 5. Tumors. What are the symptoms of cerebral compression ? Unconsciousness^ absolute (coma). Hespircdions^ slow, sterto- rous, blowing. Pulse full and slow. Paralysis involving one side of the body. Pupils may be unequal. Urine retained, fseces passed involuntarily. Decubitus dorsal. How do you determine as to the cause of compression ? Symptoms appear immediately when due to depressed fracture WOUNDS. 85 or foreign bodj' ; after some hours, if due to hemorrhage ; after some days, if due to intlammatioD. How do you treat compression of the brain ? Trephine and remove the cause, if it can be located. Under other circumstances expectantly, as for head injuries in general. How do you distinguish concussion from compression ? In many cases this cannot be done ; the symptoms of one con- dition merging into those of the other. The distinctive symp- toms of the two affections are as follows (Agnew) : — Concussion. Compression. Patient semi-conscious ; special Absolutely unconscious, para- senses blunted, not abolished. lyzed, and with abolition of special Power of movement not lost. senses. Respiration quiet and feeble. Respiration full and noisy. Pulse feeble, frequent, and inter- Pulse full, slow, laboring, mittent. Nausea and vomiting. Neither nausea nor vomiting. Pupils generally contracted. Pupils generally dilated, often un- equal. Subnormal temperature. Temperature about normal. Of what significance is the size of the pupil in brain injuries? A contracted pupil denotes cerebral irritation (slight injuries or effusion). A \m\n\ fixed in icide dilatation denotes abolition of cerebral function (large effusions or extensive injury). Intracranial Inflammation. What are the causes of traumatic intracranial inflammation ? Wounds of the scalp, bone, or brain. Fractures or contusions of the cranial bones. Concussion, compression, cmUusion, or lacera- tion of the brain. Describe traumatic intracranial inflammation. There may be either meningitis or encejjhalitis. More com- monly, both meninges and brain are involved (meningo-encepha- litis). Should suppuration occur, the pus may be diffused, or may form an abscess. The inflammation may be acute or chronic. 86 ESSEN'TIALS OF SURGERY. Give the symptoms of traumatic intracranial inflammation. Pain referred to the seat of injury, fever, intolerance of light and sound, vomiting with a clear tongue, contracted pupils, quick, full pulse, restlessness, insomnia, and delirium. Later, com- pression symptoms develop, and the patient perishes comatose. Formation of pus is attended by rigors. How can you localize the inflammation ? If, in from one to four weeks from the infliction of injury, symptoms of encephalitis suddenly develop preceded by head- ache, if Pott's puffy tumor of the scalp forms, if there is local spasm or paralysis, and the history of a chill, there is probably an abscess between the dura and the skull. Inflammatory symptoms, appearing about the fourth day after a head injury, point to contusion or laceration of the brain sub- stance. If, after several weeks, there is found optic neuritis, with hebe- tude, headache, and involvement of motor areas ; if there has been a chill, and symptoms of compression develop suddenly, there is probably a cerebral abscess. How do you treat traumatic meningo-encephalitis ? Prevent by quiet, cold to the head, purgation, low diet, and absolute asepticitii of all head wound. Treat, on the earliest symptom, by calomel, bleeding from ex- ternal jugular, ice-bag to head, light diet ; opium and bromide as required, calomel gr. ^. Dover's powder gr. ij every two hours. If an abscess can be localized, trephine and evacuate. Describe hernia cerebri. Definition. A protrusion of brain matter disintegrated by in- flammatory action, through an opening in the skull. Cause. Wound of the bone and dura mater, attended with laceration and bruising of the brain substance. Appearance. A blood-stained, fungous mass, projecting from the skull opening. Prognosis. Usually bad. WOUNDS. 87 Treatment. Remove all irritating causes, such as spiculse of bone. Treat in general as for encephalitis. Locally, apply antiseptic dressings, with very moderate com- pression. Nature sometimes effects a cure by strangulating the growth. "What are the prognosis and treatment of foreign bodies in the brain ? The ultimate prognosis is bad in all cases where the foreign body is not removed. The usual foreign body is a bullet. Its wound may be perforating or penetrating. The perforating wound allows of free drainage, and the foreign body has passed out ; hence, if not intrinsically fatal, the prog- nosis is comparatively favorable. Trephine, if necessary. The penetrating wound should be trephined to remove bone spiculse. Explore with a soft rubber catheter. The ball, being found, should be removed, either through the wound of entrance, or by making a counter trephine opening. Provide abundantly for drainage. Absolute asepsis. Treat as for head injuries. Cerebral Localization. Give the position of the motor areas grouped abont the fissure of Eolando. 1. Tlieface. Motor and sensory nerves from lower third of the ascending frontal and parietal convolutions, and posterior end of the second frontal convolutions. 2. The arm. Motor and sensor}' suppl}' from middle third of ascending frontal and parietal convolutions. 3. TJie leg. Motor and sensory supply from the upper portion of the ascending frontal and parietal convolutions, and the paracentral lobule. 4. The tongue. Receives its nerve supply from the posterior portion of the third (inferior frontal) convolution of the left side in right-handed persons. Local spasm and hj'^persesthesia indicate an irritative lesion of a motor area. 88 ESSENTIALS OF SURGERY. Local paralysis and anaesthesia indicate complete suppression of function from more extensive injury. What symptoms founded on cerebral localization indicate tre- phining? Hemiplegia, complete or incomplete, with or without hemi- spasm, following a blow on the temporo-parietal region, would indicate an exploratory operation on the side opposite to that of peripheral symptoms. Mmwplegia w monospasm following an injury to the head in- dicates operation. Mono-hypercesthesia — anaesthesia or analgesia following an in- jury indicates an operation. If the peripheral sensory or motor disturbance be on the side opposite to that of the lesion, operate at the site of the lesion ; if, however, these symptoms are on the same side, exploratory operation would be indicated on the opposite side of the head. What symptoms contraindicate operation ? Lesions of the base of the hrain as indicated by paralysis of cranial nerves, neuro-retinitis, Cheyne-Stokes respiration. Hemiplegia accompanied by anaesthesia. How can the position of the Eolandic fissure he indicated upon the head ? Shave the scalp, draw a vertical line from one external auditory meatus to the other (at right angles to the alveolo-eon- dyloid plane), from the centre of this vertical line (bregma) measure directly backward for 5.5 centimetres (5 in women). From the external angular process of the frontal bone measure 7 centimetres horizontally backward and 3 centimetres verticall}'^ upward ; a line drawn from this point to the point 5.5 centi- metres posterior to the bregma will indicate the fissure of Rolando. Tor general hemiplegia trephine over the centre of the line. In other cases over the portion chiefly involved. Sensory disturbances of the arm or leg would indicate that the lesion lies somewhat posterior to the fissure of Rolando. WOUNDS. 89 What are the indications for trephining ? 1. Simple depressed fractures, attended with persistent grave symptoms. 2. Compound depressed fractures. Excejjt in children, when the depression is of less serious consequence and often spon- taneously corrected. 3. Punctured fractures. 4. The presence of a foreign body. 5. Traumatic osteomyelitis and necrosis. 6. Localized blood clot between the dura mater and the bone. 7. Localized intracranial suppuration, with symptoms of com- pression or irritation. 8. Traumatic epilepsy or localized obstinate headache follow- ing an injury. 9. Accessible cerebral tumors. Many surgeons advise trephining in all depressed fractures^ with or without serious symptoms. Describe the operation of trephining. Prepare the patient the day before the operation, if possible, by shaving the scalp and washing with sublimate soap and warm water, followed by a cleansing with ether, after which washings with the sublimate soap and water must again be repeated. Apply, for twenty-four hours, to the entire scalp, gauze saturated in 1 : 2000 bichloride solution, covered in with an antiseptic dressing. Renew the sublimate and ether washings just before the operation, and further cleanse the surface with 1 : 500 bi- chloride solution. The instruments required are scalpel, haemostatic forceps, periosteal elevators, a conical trephine, a fine probe, a small stiff brush, a Hey's saw, bone forceps, curved needles, and catgut. The incision. Must be/ree and to the 6one, including perios- teum. A semicircular flap is raised, the pin of the trephine is pressed to the bone, and, by a twisting motion, made to penetrate till the teeth grip, when the pin is withdrawn, and the instru- ment steadily worked through. Free bleeding indicates when the diploe is reached. (Note that in infancy and old age there is practically no diploe. ) The instrument must now be advanced 90 ESSENTIALS OF SURGERY. with the greatest care. It is removed from time to time, and the groove probed to see whether tiie inner tablet is penetrated at any part. When the bone is loosened, it is removed by means of sequestrum forceps or an elevator, and wrapped in a warm antiseptic towel. The surgeon now endeavors to accomplish the specific object for which the skull was opened. Spiculse of bone are removed, depressed fractures are elevated, bleeding meningeal arteries are secured by passing a thread beneath them, clots are cleared away. If further exposure is necessary, it can be accomplished by dividing the bone by a chisel, bone forceps, or, best of all, a circular saw run by a surgical engine. On the completion of the operation free drainage is provided for by means of catgut strands, the disk of bone is replaced, either entire or cut into pieces, the flap is held in place by one or two sutures. Iodoform is dusted over the line of incision, a deep dressing of iodoform gauze is applied over and about the wound, and the dressing completed by bichloride gauze, bichloride cotton, and an elastic bichloride bandage. Wounds of the Face. What rules should be observed in treating wounds of the face? Secure most accurate coaptation. Avoid sutures in superficial wounds, closing by means of iodoform, ether, and collodion. In wounds involving the cartilages of the nose or ear, pass sutures only through the skin. In operations, so place the incision that it ma}^ correspond with the natural lines of the face. If stitches are inserted, remove them in twenty-four hours. How do you treat salivary fistula ? This is usually caused by a wound of Steno's duct. Treat by passing a thread around the duct from the inside of the cheek posterior to the external opening. When this thread has ulce- rated an opening into the mouth, the external wound will usually heal. If not, freshen its edges and suture. WOUNDS. 91 Wounds of the Neck, (Eor the anatomy of the Cervical Triangles, see Ligations.) Describe wounds of the neck. These wounds are commonly incised suicidal wounds. They extend obliquely from left to right, and from above downward, and are deepest at their starting-point. They are most fre- quently found in the laryngeal region, particularly over or through the thyrohyoid membrane. The carotid arteries are rarely injured, tlie wound being usually placed too high, and the larynx and trachea bearing the brunt of the incision. These wounds may bepe«fira^ing or iion-penetratimj. Wounds above thehyoid bone may divide tlie tongue, the lingual and facial arteries, and the hypoglossal nerve. There is great gaping ; frequently escape of food and saliva. Wounds through the thyro-hyoid membrane open the pharynx, and may involve the epiglottis, the superior thyroid and lingual arteries, and the superior laryngeal nerves. Wounds through the cartilages may involve the vocal cords and the recurrent laryngeal nerve. There is usually but moderate bleeding. Wounds below the cartilages may involve the superior or inferior thyroid arteries, the thyroid and anterior jugular veins, the trachea, and even the oesophagus. What are the immediate dangers of penetrating neck wounds ? 1. Hemorrhage, arterial or venous. 2. Suffocation from the plugging of the air-passages, with either blood-clot, the tongue, the epiglottis, or the divided cartilages. 3. Entrance of air into the veins. What are the secondary dangers of penetrating neck wounds ? (Edema of larynx, emphysema, bronchitis or broncho-pneu- monia, cellulitis, cicatricial contraction and stricture. How do you treat penetrating neck wounds ? Check bleeding^ ligate both ends of every bleeding vessel. The common carotid should only be tied for bleeding from its 92 ESSENTIALS OF SURGERY. branches, when it is found impossible to tie the branches. If the external carotid is wounded at its origin, tie the common carotid, the external carotid, and, to avoid bleeding from collateral circu- lation, the internal carotid. If the larynx is obstructed by blood-clot, clear by the fingers, by suction, or by forcing the air suddenly from the chest. Re- move a partially severed portion of the epiglottis. Hold the divided tongue forward by a ligature passed through its tip. Wounds of the oesophagus should be closed by catgut sutures. If the trachea is completely divided across, the two ends may be held in apposition by fine catgut sutures passed through the invest- ing cellular tissue. The external wound should not be sutured ; its surfaces are apposed by raising the head, and supporting it in one position by pillows and sand-bags, or by a gutta-percha splint. Provision is made for free drainage, and light antiseptic dress- ing is applied. If dyspnoea appears, perform tracheotomy lower down, or insert a tracheal canula through the wound. Feed by the rectum for four days, then by an oesophageal tube, passed just beyond the wound. l!^on-penetrating wounds are treated as wounds in any other part of the body. Wounds of the Chest. Describe non-penetrating wounds of the chest. A non-penetrating chest wound is one which does not involve the costal pleura. In chest wounds the finger must be used as a probe, and great care taken lest a non-penetrating be converted into a penetrating wound. Hemorrhage must be absolutely checked before closing, and the wound approximated by deep sutures passed to its very bottom. Firm pressure is applied over the antiseptic dressing, by a bandage carried around the chest. These wounds may involve the brachial plexus, the intercostal, internal mammary, acromio-thoracic, long thoracic, or axillar}-^ arteries.. Check bleeding by ligature or haemostatic forceps. Describe penetrating wounds of the chest. The pleura and lung, the pericardium and heart, or the great vessels may be wounded. WOUNDS. 93 Injuries of the pleura and lung are characterized by shocks dyspnoea, pain, cough, abdominal breathing, expectoration of frothy hlood'Stained mucus, escape through the wound of a bloody froth accompanied by a hissing sound [tromatopnoea), empliyscma, pneumothorax, external bleeding, haeraothorax. In case the pleura alone is injured there will be no haemoptysis and no bloody froth from the wound. Prognosis, grave in wounds involving the root of the lung, and in gunshot wounds which penetrate but do not perforate. Injuries to the pjericardium and heart are characterized by great shock, hemorrhage, and the subsequent development, if the pa- tient lives long enough, of pericarditis. Death in wounds of the pericardium occurs from shock, the pressure effect of hsemoperi- cardium, or from pericarditis. What are the complications of penetrating wounds of the chest? External bleeding, hsemothorax, emphysema, pneumothorax, pleurisy, pneumonia, prolapse of lung. How do you treat the external bleeding of penetrating chest wounds ? If from an intercostal artery ligate, or apply haemostatic forceps ; this being impossible, dissect off the periosteum from the lower part of the rib (carrying the artery with it of course) and tie ; or resect a portion of the rib. A ligature may be carried around the entire rib. If from the internal mammary, ligate in the wound, resecting the chondral cartilages if necessary. If from the lung, close the external w^ound, place the patient on the injured side, and apply an ice-bag. Internally give opium, ergot, gallic acid. If the bleeding continues, producing constitutional signs of hemorrhage, and local signs of extensive hsemothorax, open again and allow the blood to escape. Describe hsemothorax. Definition. Bleeding into the pleural sac. Usual cause. Wound of the lung, or of an intercostal artery by a broken rib. Symptoms. Those of internal hemorrhage, together with bulg- 94 ESSENTIALS OF SURGERY. ing of the intercostal spaces, increasing dyspnoea, flatness on percussion, and absence of breathing sounds. The symptoms appear almost immediately after the injury. Inflammatory effusions do not take place till some days later. Treatment. As for external bleeding from lungs. Aspirate or open if there is threatening dyspucea. If suppuration takes place, open freely and drain. Describe pneumothorax. Cause. Injury to lung and pleura, usually by a broken rib. Symptoms. The lung collapses. Increasing dyspncea, great percussion resonance, amphoric breathing, metallic tinkling, bulging of intercostal spaces. Treatment. Should dyspnoea become urgent, aspirate. Describe emphysema. Cause. "Wound of the lung and pleura. It may arise after wound of the lung alone, in this case extending by way of the root to the posterior mediastinum, and from there into the con- nective tissue of the neck and arms. Symptoms. A diffused, colorless, elastic, puffy swelling, crackling on pressure. Treatment. A compress and bandage over the wound. Should distension become great, puncture. How do you treat prolapse of the lung ? Return if not adherent. If adhesions have taken place, ligate or excise, taking precautions against opening the pleural cavity. Describe hernia of the lung. Causes. The yielding of a cicatrix. The result of subcutaneous wound. Great muscular effort. Symptoms. A soft circumscribed tumor, resonant on percus- sion, giving a loud respiratory murmur, and crepitating on manipulation. Treatment. Protective. What is concussion of the lung ? A condition following traumatism. Characterized by dyspnoea, feeble respiratory murmur, and slight dulhiess on percussion. The symptoms pass off after a few hours. WOUNDS. 95 What operations may be done for the evacuation of blood or in- flammatory effusion within the chest walls ? 1. Tapping the pleura. For serous effusion. Thrust an as- pirating needle through the sixth intercostal space, in tlie mid axillary line. This operation must be done under antiseptic precautions. The skin is drawn down before the puncture is made, forming a valvular wound. Dress with iodoform and collodion. 2. Incision and drainage of pleura. For empyema and the re- moval of decomposing clots. Operate in the sixth intercostal space, in the axillary line, or as low as the eleventh space, in a line with the angle of the scapula. Make a careful dissection. Excise a portion of the rib if necessary, and insert a drainage tube: 3. Tapping the pericardium. Fourth intercostal space two inches to the left of the sternum. 4. Incision and drainage of pericardium. Beginning one inch from sternum, make an incision two inches in length along the upper border of the fifth or sixth ribs. Dissect down carefully, insert drainage tube after opening. 5. Pneumotomy. Lung incision for abscess, gangrene, or cysts. Open down to the pleura, thrust a trocar and canula into the affected area. Enlarge this puncture by dressing forceps. Wounds of the Abdomen. Describe contusion of the abdomen. Contusion may take place with, or without, rupture of the contained viscera. Contusion without rupture of the contained viscera is character- ized by pain, discoloration, swelling, and shock. The rectus muscle may be ruptured, or ther.e may be a hsematoma formed, followed by abscess. Treatment. Put the patient to bed, apply heat to' the body, hot fomentations to the abdomen. Give water and cracked ice for twenty-four hours. Treat rupture of the rectus by position. Apply cold in case of haematoma. Evacuate abscesses early. 96 ESSENTIALS OF SURGERY. What symptoms denote contusion with laceration of the viscera? Great shock, pain, persistence of collapse with signs and symp- toms of internal bleeding, in case the solid viscera or a highly vascular portion of the peritoneum is ruptured, symptoms of rapidly developing peritonitis in case the hollow viscera are ruptured. The following signs, if present, are indicative of rupture of the individual viscera. Liver. Pain in right hypochondrium, increased hepatic dull- ness, signs of internal bleeding ; later, bilious vomiting, clay- colored stools, sugar in the urine. Spleen. Pain in left side, increased splenic dullness. Stomach. Intense pain in stomach, hsematemesis, rapid de- velopment of general meteorism, tympany over the liver. Intestines. Intense radiating pains. Vomiting of stomach contents, then bile, finally blood. Bloody stools. Tympanites with dullness in the flanks. Percussion resonance over liver. Peritonitis. Kidneys. Frequent passage of bloody urine, with extravasa- tion in the loin. In all cases, the portion of the body which received the brunt of violence must be considered, in determining what internal organs are probably injured. How do you treat abdominal contusion with rupture of con- tained viscera ? Absolute rest. Opium. If symptoms characteristic of internal hemorrhage, or rupture of a hollow viscus, appear, do an exploratory laparotomy. Bleeding from the liver or spleen can be checked by iodoform tamponade, or by the actual cautery. Torn vessels in the peritoneum can be ligated. Rents in the stomach or intestines can be united by sutures or brought to the surface. By irrigation, the peritoneal cavity can be freed of blood and extra vasated matter. Euptured Mdney with lumbar extravasation should be treated by free lumbar incision and drainage. What are the causes of traumatic peritonitis? The bursting of an abscess, or the extravasation of urine, WOUNDS.. 97 blood, bile, or the contents of the aUmentary canal into the peritoneal cavit}'. Termination usually fatal, from collapse or blood poison. What are the symptoms of traumatic peritonitis ? Severe pain^ at first local, then general. Extreme tenderness. Dorsal decubitus with legs and thighs drawn up. Breathing thoracic. Abdomen distended and tym- panitic; later, dull in the flanks from effusion. Obstinate vomiting. Complete constipation Small., quick, wiry pulse. Dry brown tongue. Temperature 103° to 104P. In the septicseraic form there may be little pain or tenderness, and a normal or even subnormal temperature throughout How do you treat traumatic peritonitis? Prevent by absolute rest, cracked ice diet, hot fomentations, laparotomy. Treat., on the development of the first symptom, by a full saline purge and turpentine enema. Open and wash out the peritoneal cavit3\ Insert a glass drainage tube. Stimulants and nourish- ment in teaspoonful doses. Or treat expectantly, apply leeches to the abdomen, followed by hot fomentations or turpentine stupes. Give opium till the respirations are reduced to twelve in the minute. How do you treat non-penetrating wounds of the abdomen ? Check all bleeding. Extensive extravasation may take place between the muscular planes if this precaution is not observed. Pass sutures to the bottom of the wounds approximating accurately. Prevent tension by position. Apply an antiseptic dressing, and a binder about the body. If signs of inflammation appear, open freely (abdominal ab- scesses do not point). Guard against subsequent hernia. Describe penetrating wounds of the abdomen. These wounds involve the peritoneal cavity. There may be — 1. Simple penetration without visceral injury or protrusion, 2. Penetration with visceral injury, but no protrusion. 3. Penetration with visceral protrusion, but no injury. 4. Penetration with both protrusion and injury. 7 r 98 ESSENTIALS OF SURGERY. How do yon treat simple penetrating abdominal wonnds ? Thoroughly cleanse. Close the wound by sutures passed from within outward, including the peritoneum and the entire thick- ness of the abdominal wall. Apply an antiseptic dressing and a binder about the body, and place the patient in that position which will most effectually relax the wounded muscles. Give internally cracked ice for two days, then milk in small quan- tities. Opium, if indicated by pain or diarrhoea. If there has been hemorrhage into the peritoneal cavity, remove all blood by irrigation and insert a glass drainage-tube. How do yon treat penetrating wonnds with visceral injury? Enlarge, if necessary^ and treat the visceral injury. Check bleeding from the liver and spleen by cautery, or iodoform tam- pons. Drain small wounds of the kidney. If the organ be ex- tensively lacerated, do a nephrectomy. Wounds of the ureter require either a nephrectomy, or the formation of a urinary fistula by bringing the ureter to the surface. Wounds of the stomach or intestines should be sutured ; if large, the sutured portion may be secured in the wound, the latter not being closed immediately (iodoform tamponade). Extravasation will then take place externally if the sutures yield. Slight punctures are closed by prolapse of the mucous membrane, and do not require suturing. How do yon determine as to the existence of a visceral injury in penetrating abdominal wounds ? If the wound is large, inspection and palpation may be suffi- cient. In small wounds intense pain and severe collapse, with or with- out escape of faeces, gas, hile, serum, ov food, indicate the nature of the injury. Wounds of the stomach and intestines usually give a clear tympanitic percussion note over the liver. In case of doubt inject hydrogen gas into the rectum ; if the stomach or intestines are wounded, the gas will escape through the wound. Where there is no evidence of visceral wound treat WOUNDS. 99 as penetrating wound, performing an exploratory laparotomy on the first sign of internal hemorrhage or traumatic peritonitis. How do you suture the intestine ? By the Lerabert interrupted suture. The threads include only the serous and muscular coats of the bowel, are made of sterilized Fiff. 6. — mus inucous » Lerabert sut\ire. China silk, and are placed a twelfth of an inch apart. The suture is designed to approximate serous surfaces. It passes in and out on one side of the wound, across, and in and out on the other side, and is then tied. If the intestine is entirely torn across, or extensively injured, a portion may be resected, a V- shaped piece of mesentery removed, and the gut ends united by first bringing the peritoneal coat together by a circle of in- terrupted sutures, then invaginating the incision and approxi- mating serous surfaces by Lembert's suture. This constitutes Czerny''s suture. Or, the gut ends may be sutured through half their circumference, and the remaining opening secured in the wound, making an artificial anus. How do you treat penetrating abdominal wounds with protru- sion of viscera ? Carefully cleanse and return. If intestine is gangrenous, in- cise and leave in the wound ; if congested and adherent, free from adhesions and return. The abdominal wound may be enlarged if necessary. Congested omentum should be ligated, removed, and the stuuip returned to tlie abdoiuinal cavity. If 100 ESSENTIALS OF SURGERY. the intestines protrude and are wounded, apply a Lembert suture and return, or make an artificial anus. In all extensive injuries do not close the abdominal wound ab- solutely. Insert sutures, knot them loosely, and pack the wound with iodoform gauze. When danger from intra-peritoneal com- plications has passed away, approximate the granulating surface? by removing the packing and drawing the sutures tight. Th*. wound heals by secondary adhesion (third intention). Describe laparotomy. Preparation most thoroughly antiseptic. Incision in median line. Clieck all hemorrhage by haemostatic forceps before open- ing peritoneum. The latter is nicked, held up by two fingers, and divided by scissors. Insert a large flat sponge to catch all oozing irom wound. Irrigate the abdominal cavity, if necessary, with warm distilled water. If there is much shock, use hot water (not over 106°). After the completion of the operation dry with sponges, inserting glass drainage-tube if there has been much manipulation or hemorrhage ; close. First bring the peritoneum together with a line of interrupted catgut sutures ; then insert some plate sutures of relaxation, using silk-worm gut. Suture together the fibrous investments of the two rectus muscles ; finally unite the skin and subcutaneous tissues with interrupted sutures of approximation and continuous sutures of coaptation. Dust with iodoform, apply a strip of protective, several layers of iodoform gauze, a thick investment of bichloride cotton, Mack- intosh, and a moderately tight binder. Give cracked ice for two days. Stimulants as required. See that the bladder is regularly emptied^ drawing the water if necessary. Describe tapping of the abdomen. This operation is done for ascites. See that the bladder is empty, pass a many-tailed bandage about the body to make pressure, let the |>atient sit up, leaning somewhat forward, make a skin incision in the linea alba, mid- way between the umbilicus and pubis, and thrust the trocar and canula into the abdomen. To avoid syncope draw off slowly, WOUNDS. 101 gradually tighten the bandage as the liquid flows away, and let the patient lie down. Lescrihe rupture of the bladder. Cause. A blow or ki( k when the bladder is full. Fracture of the pelvis. Yery rarely from simple over-distension. In re- tention from stricture the urethra more commonly gives way. The rupture is usually vertical. Occurs more commonly in the posterior part, when the urine escapes into the peritoneal cavity, causing peritonitis. May occur in the anterior part, with extravasation into the loose cellular tissue of the pelvis, causing cellulitis with secondary peritonitis or septic poisoning. "What are the symptoms of ruptured bladder ? Collapse following an injury to the abdomen or pelvis, with absence of urine and presence of blood in the bladder, as demon- strated by passing a catheter. If the patient has passed his urine immediately before the injury, inject two ounces of warm boracic acid solution (4 per cent.) into the bladder ; if there is an extensive rent in its walls, the solution will escape and can- not again be drawn off by a catheter. A catheter may some- times be felt to pass through the rent. How do you treat rupture of the bladder ? Do a supra-piibic cystotomy. If the rent is extra-peritoneal, insert a drainage tube. If the rent is intra-peritoneal, open the peritoneal cavity (through the same parietal incision), irrigate thoroughly to wash away all urine. Close the rent by the Czerny suture, taking particular care to see that no thread pierces the mucous membrane. Insert a drainage tube, tampon the external wound with iodoform gauze, and let the patient insure free drainage by the lateral decubitus. These ruptures may be treated by the introduction and reten- tion of a soft catheter passed through the urethra. 102 ESSENTIALS OF SURGERY. Burns and Scalds. How are bams classified? Burns are of six degrees. 1st Degree. Simple erythema followed by slight desquamation. There is no tissue destruction. 2d Degree. Vesication. The superfical layers of the epiderm are destroyed. 3cZ Degree. Destruction of the epiderm and the greater part of the true skin. A portion of the papillary layer, and the epithe- lium about the hair follicles and sebaceous glands escapes. This is of great importance in the subsequent healing, as skin- ning starts from these points as islands, and the elements of true skin are preserved to an extent. There is scarring, but not marked contractions. This is the most painful form of burn, from involvement of the nerve-endings. 4ith Degree. Destruction of the skin and suhcutaneous tissue. Scarring and contractions. 5th Degree. The deep fascia is penetrated and the muscles are involved. 6th Degree. Destruction of the entire part. Describe the constitutional effects of severe burns. Dependent on the extent of surface involved, and the depth. Three stages. 1. Shock and internal congestion. Most marked in extensive burns of the trunk and head. The patient shivers and complains of cold. 2. Beaction and inflammation. Coming on in from one to two days. The patient complains of thirst and inflammatory fever. Internal congestion may run on to inflammation, causing menin- gitis, pleurisy, or peritonitis, according to the seat of the burn (head, chest, abdomen). Duodenal ulcer and nephritis are fre- quent complications. 3. Suppuration and exhaustion^ setting in on the separation of sloughs. The patient often complains of cough and diarrhoea, WOUNDS. 103 and may now perish from amyloid degeneration, exhaustion, or blood poison. Great deformity ensues on cicatrization of deep burns. What is your prognosis in severe burns ? Bad in burns involving one-third the surface, and in extensive burns upon the trunk. Fatal cases mostly perish within forty- eight hours from shock. How do you treat burns ? Constitutionally. Treat the shock by external heat, hot bath, hypodermics of brandy, ammonia, atropia, and morphia. See that there is no retention of urine. When reaction and inflam- mation appear give a saline cathartic, neutral mixture. If the kidneys are congested apply dry cups, hot fomentations. Give liquid nourishment in small doses frequently repeated. Keep up the use of stimulants. Allay thirst by cracked ice. During the third stage give tonics and stimulants, push the nourishment, and treat diarrhoea by opium and astringents. Locally. All burns beyond those of the first degree should be washed and dressed under all antiseptic precautions. Burns of the second degree. Wash with 1 : 2000 subHmate solu- tion, shave the surrounding skin, remove all loosened epithelium, wash again with 1 : 2000, using a soft brush or sponge for the in- jured surface, complete the cleansing with 1 : 5000 sublimate solution, cover with strips of protective wet in 1 : 5000, sprinkle iodoform over the protective, apply a thick layer of iodoform gauze overlapping the protective, a still larger and thicker layer of bichloride gauze, finally bichloride cotton and a bichloride bandage. Cure in ten days on removal of the dressing. Burns of the third and fourth degrees^ if limited in extent, are treated as burns of the second degree. Remove dressings when they become rank (ten days), thoroughly bathe in 1 : 5000, trim away sloughs, re-dress. When sloughs are all removed, and the burn converted to a granulating surface, skin graft. When the burn is very extensive cleanse, wash, and remove loose cuticle as before, liberally sprinkle each region so treated with subnitrate of bismuth, cover with a single layer of lint or soft 104 ESSENTIALS OF SURGERY. linen, held in place by one or two adhesive strips. Twice a day gently raise the edges of the lint, and sprinkle more bismuth wherever the coating has become loosened by discharge. Or, puncture vesicles, but do not remove the cuticle, apply lint saturated in carron oil (lime-water and linseed oil in equal parts), and cover in with waxed paper and a light bandage. Change the dressing daily, uncovering a small amount of surface at a time^ and redressing one part before another is exposed. In extensive deep burns the continued warm bath may be em- ployed till the sloughs separate. Relieve the pain of burns of the first degree by white-lead paint. Opium is indicated in all stages of severe burns. FRACTURES. 105 FRACTURES. What is a fracture ? The sudden solution in the continuity of a bone. What are the causes of fracture ? 1. Predisposing. a. Local. Function, form, position, disease of the bone. 5. Constitutional. Includes conditions under which the bone becomes fragile, or subject to disease or injury — such as age, sex, rickets, locomotor ataxia, and ne- crosis. 2. Exciting. a. External violence. h. Muscular action. What are the varieties of fracture? Incomplete, partial, or greenstick. The bone is bent, but not entirely broken through. Stellate, grooved, and ^ fissured fractures are also classed as incom- plete. Complete. The break involves the entire thick- Greenstick fracture of clavicle. ness of the bone. Simple. Not accompanied by an open wound leading down to the break. A single uncomplicated fracture. Compound. Accompanied by a wound leading down to the break. Single. Having but one line of fracture, making in the long bones two fragments. Multiple. Two or more fractures, the lines of breakage not communicating if these fractures are of the same bone. Comminuted. The bone is broken into more than two pieces, the lines of fracture communicating. 106 ESSENTIALS OF SURGERY. Impacted. One fragment is driven into the other, and fixed in that position. Comrplicated. Accompanied by an injury to some other im- portant parts in the same region, as joints, bloodvessels, nerves, or muscles. Further, fractures about joints are classed as : — Intracapsular — within the capsular ligament. Extracapsular — without the capsular ligament. In young persons epiphyseal separation occurs, especially in the humerus, and constitutes epiphyseal fracture. In what direction does the line of fracture extend ? It is generally oblique^ but may be transverse^ from direct vio- Fiff. 8. Oblique and transverse fracture of the tibia. lence, longitudinal^ when force is applied in the direction of the long axis of the bone, spiral or stellate. What are the symptoms of fracture ? 1. Deformity or displacement due to 1, the fracturing force ; 2, the muscular contractility ; 3, the weight of the part. 2. Abnormal mohility. 3. Crepitus, or harsh grating, both felt and heard on manipu- lation. 4. Loss of function. 5. Pain and tenderness, sharp and severe; 6. Swelling and ecchymosis, the latter appearing in certain lines. What are the different kinds of displacement ? Angular or bending, rotary or twisting, transverse, longitudinal or overlapping. FRACTURES. 107 When have you difficulty in recognizing displacement? When but one of two parallel bones is broken, or when the short, flat bones are involved. Under what circumstances is crepitus absent ? In greenstick and impacted fractures ; when the fragments overlap considerably or are widely separated ; when soft tissue is interposed between the ends of bone. In epiphyseal fracture we have moist crepitus only. What fractures do not present abnormal mobility ? Greenstick and impacted fractures. How do you diagnose a fracture ? Deformity^ unnatural mobility, and crepitus, if elicited, are absolutely diagnostic. If great swelling prevents a positive diagnosis, treat as a fracture till swelling subsides. What is the general treatment of all fractures ? 1. Reduce the fracture. 2. Retain it in position. 3. Treat inflammation and other complications, either consti- tutional or local. How do you reduce a fracture ? 1. By extension or traction, made by the surgeon steadily pulling upon the lower fragment. 2. Counter-extension or fixation of the upper fragment. 3. Coaptation or adjusting the broken ends of the bone to their proper position. How do you overcome muscular spasm? If muscular spasm interferes with reduction, it must be over- come hj position, etherization, or tenotomy. How do you retain the bones in proper position ? JBy means of splints and bandages. Splints may be made of •wood, tin, gutta-percha, binders' board, leather, etc. Bandages may be made of muslin, linen, or gauze, or may have incorporated with them various materials which, harden- 108 ESSENTIALS OF SURGERY. ing, make a solid and firm dressing, as plaster, silicate of potas- sium, gum, etc. . . Under what circumstances are the fixed dressings, as plaster, applied? Primarily, in fractures attended with little swelling, displace- ment, or damage to the soft parts. Secondarily, in fractures of the lower extremity, after the subsidence of swelling and inflam- matory symptoms. What rules guide you in the application of splints ? 1. Splints should be well padded. 2. They should fix the joints above and below the break. 3. The extremities of the limbs should be left exposed to view (fingers and toes). Circular compression must be avoided, primary rollers being absolutely discarded in fractures of the leg or forearm. Applied with great caution in fractures of the thigh or upper arm. How often do you re-dress a fracture ? The fracture dressing must be inspected daily for one week. If too loose or too tight, or if there is evidence of displacement, the dressing must be renewed. Otherwise, twice weekly will be sufficient. What complications may arise, and how should they be treated? 1. (Edema and swelling often accompanied by hlehs. Treat by loose bandaging at first, and evaporating lotions ; follow by pres- sure. 2. Ulceration and sloughing of soft tissues. Eree ulcerating spot from pressure by careful padding of splint. 3. Muscular spasm. Treat by moderate pressure, morphia injections, or tenotomy. 4. Gangrene. Usually the result of too tight dressing, or lace- ration of main artery. Relieve pressure. Rarely. Yenous thrombosis, embolism, fat embolus — causing death by asphyxia. Treatment : cardiac stimulants. How do you treat compound fractures ? If the external wound is small and the fracture not otherwise FRACTURES. 109 complicated, thoroughly cleanse with bichloride 1 : 1000, and close with absorbent cotton saturated in a solution of ether, iodoform, and collodion, equal parts of each. Splint as usual. If inflammatory symptoms arise, or if there be much original comminution or laceration of soft parts, pick out loose frag- ments, thoroughly cleanse, irrigate with bichloride solution 1 :1000, drain, and apply antiseptic dressing, splinting as usual. If wound be older than twenty-four hours, wash with 1 : 5 car- bolic solution (acid carbol. 1, alcohol 5). What complications arise in the treatment of compound fractures ? Necrosis, osteomyelitis, periostitis, extensive sloughing of soft tissues. What is the pathology of fracture ? There is first free hleediiig from the vessels of the injured bone, medulla, and surrounding soft parts. This is followed by in- flammation with exudation, absorption of blood clot, and deposit of plastic lymph about the seat of injury. Organization completes the process ; the plastic lymph is converted first into cartilage, then into bone. What is callus ? Tfie plastic lymph which is organized into bone tissue for the repair of fractures. How is the callus disposed about a fracture ? A portion is deposited as a fusiform swelling ensheathing the two broken bone ends, caWed ensheathing callus ; a portion fills the medullary canal above and below the break acting as a support- ing pin, called pin or central callus. A portion is directly be- tween the broken surfaces restoring their continuity, called intermediate or definitive callus. What is meant by temporary and permanent callus ? The ensheathing and pin callus is temporary, being absorbed when the bone is firmly united by the intermediate or permanent callus. 110 ESSENTIALS OF SUKGERY. What period of time is occupied by the various processes neces- sary for the repair of fracture ? Absorption of clot first week, formation of plastic lymph and beginning organization second week, ossification of the calkis 4 to 8 weeks, absorption of temporary callus one year. What complications are common to all fractures ? Shock. ^ Retention of urine, treat by catheter. Traumatic delirium, especially in drunkards— sedatives, stimulants. Hypostatic congestion of lungs. What compound fractures require amputation ? Compound fractures associated with — 1. Very extensive laceration of soft parts. 2. Great destruction of bone substance. 3. Injury to the main artery of leg or thigh (femoral or post- tibial). 4. Injury to knee or ankle, if extensive. Define delayed union and non-union. Union is delayed when fractures are not firmly joined by callus in 4 to 6 weeks. We have non-union or ununited fracture when the continuity of the bone is not restored after twelve weeks. What are the causes of delayed union and non-union ? 1. Constitutional include all conditions depressing to health and nutrition, as acute fevers, syphilis, phthisis, scurvy, ne- phritis, etc. 2. Local, a. Undue mobility of fragments often from improper splinting or meddlesome interference. h. Separation of fragments^ by muscular action, or by interpo- sition of soft parts or necrosed bone, c. Interference with blood supply^ as in intracapsular fracture. How do you treat non-union ? Treat constitutional conditions. FRACTURES. Ill Locally the means adopted would be in the order given below, one failing the next should be tried. The object of all these methods is to set up an acute aseptic inflammation, which shall provide sufficient exudation for the formation of healthy callus. 1. Ahsolute fixation, careful dressing, plaster bandage. 2. Friction. Rub ends of bone together either manually or by getting patient up and allowing some use, the fragments being held in apposition by fixed plaster bandage or apparatus. 3. Drill fragments subcutaueously to excite inflammation and deposition of plastic lymph ; treat subsequently by absolute fix- ation. 4. Drill and 2nn fragments together leaving the pin in place. 5. Besection of the ends of the bones, joining the fresh surfiices by silver wire. Drain thoroughly and close the wound. Secure fixation by careful splinting. Name the forms of non-union? 1. I^o union whatever between the fragments. 2. Ligamentous union. 3. False joint. What is vicious union ? Union accompanied either by great deformity, or by the bind- ing together of bones which should move on each other, as the radius and ulna. How do you treat vicious union ? If recent, restore immediately by force, or by splints and pres- sure. If firm union has taken place, or the fracture is not amenable to other treatment, the bone should be broken again, properly set, and fixed in position. Deformity from exuberant callus gradually disappears. Should it persist, and should pressure symptoms arise, callus must be cut away. How do you treat an injury which you suspect may be a frac- ture? Treat as a fracture, subsidence of swelling will clear the diag- nosis. 112 ESSENTIALS OF SURGERY. Under what circumstances do you use anaesthetics in the diag- nosis and treatment of fracture ? 1. la case of difficulty or doubt. 2. In complications requiring prolonged Or painful manipu- lations. 3. "Where reduction is not readily effected. How do you treat the swelling and ecchymosis common to all fractures ? Evaporating lotions for two or three days, followed by care- fully guarded pressure. Four ounces of alcohol and four d rachms of ammonium muriate, two ounces of the solution of acetate of lead, or eight ounces of laudanum, to the pint of water. Apply on lint which must not be covered with oiled silk, but kept con- stantly wet by the solution. What is the cause of the late discoloration in fractures? The effused blood gradually works its way to the surface, be- tween layers of fascia, in the path of least resistance ; the disin- tegration of the red corpuscles causes the ecchymosis or discolo- ration. Special Fractures. Describe fractures of the nasal hone. Cause. Direct violence. Signs. Displacement, backward or lateral. Crepitus. Un- natural mobility. Deformity. Yery rapid swelling. Free bleeding. How may this fracture he complicated ? 1. Profuse hemorrhage. 2. Emphysema of surrounding soft parts. 3. Deflection or fracture of septum nasi. 4. Injury to base of brain through the perpendicular plate of ethmoid. Give the treatment of fracture of the nasal hone. Beduce at once by pressure exerted by a director or closed haemostatic forceps passed into the nostril. Retain in place, if FRACTURES. 113 necessary, by packing the nostrils with iodoform gauze or an inflatable rubber bag, the respiratory tract being kept open by a rubber tube. If there is much comminution and these means fail, /as/en the fragments together withpiris, passed from the outside, taking in the periosteum. Inspect the nostrils for defl.ection of septum, which must always be replaced. Check hemorrhage by heat, cold, astringents, or packing. Treat swelling by evaporating lotions. Ahcays reduce thoroughly. Describe fractures of the superior maxillary bones. Ordinary fracture symptoms, generally accompanied by great swelling. Common seat of fracture, alveolar process — at times nasal pro- cess, malar process, or body of maxilla. The anterior wall of the antrum may be driven in. How do you treat fractures of the superior maxilla? Reduce, if deformity. If the bone is driven in, raise by pres- sure applied from the mouth, or by means of an elevator passed through a small skin wound. Retain alveolar process by making the lower jaw the splint, applying a Barton's bandage ; treat swelling and inflammation by evaporating lotion, applied on lint (alcohol and water equal parts). Describe fractures of the inferior maxilla. Usual seat. Near or through the anterior mental foramen. Fractures also occur at the sym^jhysis; through any part of the body; through the ramus; through the condyloid process; through the coronoid process. These fractures are often compound, from rupture of the mu- cous membrane. Give the symptoms of fracture of the inferior maxilla. Body. The cardinal signs of fracture, together with pain, swelling, dribbling of saliva, disability. The central portion of the bone is pulled downward and backward by the digastric, geniohyoid, and geniohyoglossus muscles. Fractures of the ramus give little deformity, the bone being held 8 114 ESSENTIALS OF SURGERY. in place by the masseter without, the internal pterygoid within. Manipulation elicits mobility and crepitus. In fractures of the neck, the condyle is pulled forward and in- ward by the external pterygoid, causing great pain and crepitus on opening or closing the mouth. Give the treatment for fracture of the inferior maxilla. Careful reduction and the application of a moulded pasteboard splint, well padded with cotton, and held in place by a Barton's or Gibson's bandage. Frequently wash the mouth with satu- rated solution of boracic acid. If the dressing fails to keep the fragments in proper position, they should be drilled and wired in place. The dressing can be removed in five weeks. Give the symptoms of fracture of the hyoid hone. Seat of injury. Greater horn. Pain on eating or speaking, together with the cardinal signs of fracture, elicited by exami- ning with the fingers of one hand in the pharynx, while the other hand outlines the bone from without. The displacing factor is the middle constrictor. Give the treatment for fractures of the hyoid bone. Reduce by pressure, keep the head between flexion and exten- sion, support by a pasteboard collar, give nutrient enemata for four days, then, if dysphagia be still great, feed by the oesopha- geal tube. Give the symptoms of fracture of the laryngeal cartilages. Usual seat. Thyroid cartilage. SymjJtom s—Aiihon'm, dys- pnosa, and bloody expectoration^ together with emphysema^ deform- ity., and possibly moist crepitus. Treatment. On the appearance of dyspnoea, intubation, or, that failing, tracheotomy. Feed by rectum for some days, and secure absolute rest to the parts. Describe fractures of the clavicle. Cause. Usually indirect violence, as falls on the palm of the hand. Seat. May be any portion of the bone, generally outer portion of middle third. FRACTURES. 115 Direction. Oblique. Displacement. Shoulder falls downward, forward, and inward, shortening detected by measurement from middle of upper border of sternum to coracoid process. What causes the displacement in fractured clavicle? The outer fragment drops downward, inward, and forward from the weight of the shoulder, and the action of the two pecto- rals, the latissimus dorsi and the serratus niagnus ; the inner extremity of the outer fragment is thrown somewhat backward by the rhomboid ei and levator anguli scapuli, so that it lies behind and below the outer extremity of the inner fragment, which is shghtly tilted up by the sterno-cleido mastoid. Give the symptoms of fractured clavicle. Crepitus unci preternatural mobility readily elicited by pushing up and rotating the humerus. Deformity detected by passing the finger along the subcutane- ous surftice of the bone, by inspection, by measurement ; shoulder flattened, arm disabled. Fractures of acromial and sternal end necessarily allow of but little displacement. If external to conoid and trapezoid liga- ments, there is marked displacement of the outer fragment. Give the treatment for fractured clavicle. The object of the treatment is to restore the fragments to their proper position by forcing the shoulder upward, outward, and backward. This is accomplished by — 1. Sayer''s dressing. Strips of adhesive plaster three and one- half inches wide. The first is long enough to surround the body including the arm. This strip encircles the arm over the inser- tion of the deltoid in the form of a loosely fitting loop, which must be made secure by sewing. Draw the arm somewhat down- ward and backward, to make tense the clavicular origin of the pectoralis major, and fasten it in this position by carrying the strip entirely around the body securing it to itself in the back. The second strip begins at the sound shoulder, is carried ob- liquely over the back to the elbow of the injured side, which is received in a slit provided for the purpose, it is then carried 116 ESSENTIALS OF SURGERY. upward across the front of the chest to its point of origin. This forces the shoulder upward, backward, and, by pulling the elbow in, also outward. Fig. 9. Fig. 10. Fig. 11. 2. The recumbent posture, supine, with the arm carried across the cliest, is the best theoretical treatment for this injury. 3. Velpeau''s dressing. A pad fastened in the axilla of the in- jured side. The forearm flexed on the arm and carried across the chest till the hand rests on or near the sound shoulder. Careful manipulation of the fragments into proper position, and the ap- plication of Velpeau's bandage. 4. DSsauWs dressing. A pad fixed in the axilla by the first roller. The arm bound to the side by the second roller. The shoulder pressed upward and backward by the third roller. Union in about four weeks ; carry the arm in a sling for one or two weeks longer. Describe fractures of the scapula. Cause of fracture. Direct violence. Seats of fracture through 1. Body or inferior angle. 2. Surgical neck (supra-scapular notch). 3. Glenoid cavity. 4. Acromion or coracoid processes. What are the symptoms of fractured scapula ? In all situations there are found disability, pain, swelling, crepi- tus, and preternatural mobility. FRACTURES. 117 Fig. ]2. Neck (through suprascapular notch). Disability complete. If conoid and trapezoid ligaments are torn there will be a space between the acromion and humerus — disappearing on pressing the arm upward, but recurring again when the support is removed. Coracoid process moves with humerus, the acromion remains fixed. Acromion process. If behind the acromio-clavicular articula- tion the shoulder is flattened, and drops downward, forward, and inward. Crepitus and undue mobility. Coracoid process. Complete disability. Unnatural motion may be felt by pressing a finger deeply in the region of this pro- cess and pushing up the elbow. Give the treatment for fractures of the scapula. Body. Compress to both borders of the scapula, adhesive plaster extending circularly from the spine to the sternum, Yelpeau or Desault bandage, with the arm vertically to the side. iVecfc, glenoid cavity^ acromion or cora- coid process. Towel in axilla, and Yel- peau or Desault bandage. Describe fractures of the humerus. Muscular attachments. To greater tuberosity. Supraspina- tus, infraspinatus, and teres minor. To lesser tuberosity. Subscapularis. Anterior bicipital ridge. Pectoralis major. Posterior bicipital ridge. La- tissimus dorsi, teres major. Shaft. Coraco-brachialis, deltoid, triceps. In- ternal condyle. Pronator radii teres and common flexor tendon. External con- dyle and condyloid ridge. The two supi- nators, anconeus, extensor carpi radialis longior, and the com- mon extensor tendon. There may be fractures of the head, anatomical neclv, tuber- osities, surgical neck, including epiphysis, shaft ; there may be supra-condyloid, inter-condyloid, T or comminuted, condyloid, epicondyloid (internal only) fractures. Comminuted or T fracture. 118 ESSENTIALS OF SURGERY. Give the symptoms of fractured humerus. In all, except the impacted fractures of the anatomical neck, there are pain, crepitus, preternatural mobility, deformity, dis- ability, and swelling. Head and anatomical neck. Symptoms obscure, slight short- ening, crepitus on upward pressure and rotation, broken ex- tremit}' may be felt in axilla. Greater tuberosity. Depression under acromion process, widen- ing of shoulder, smooth bony prominence (head of bone) under coracoid, crepitus on rotation and pressing tubercles together, external rotation cannot be performed by the patient. Surgical neck. (That portion of the shaft of the humerus lying between the tuberosities and the insertion of the latissimus dorsi and teres major muscles.) Commonest seat of fracture. Direction transverse. Shortening (measured between acromion process and external condyle). Lower fragment drawn inward and forward by latissimus dorsi, pectoralis major, and teres major, pulled upward by deltoid, biceps, triceps, and coraco- brachialis. Rough end of lower fragment felt near coracoid process. Unnatural mobility and crepitus on extension and rotation. Epiphyseal. As in surgical neck, except that it occurs in young people, and that the crepitus is moist and the fragments smooth. Shaft of humerus. Mostly below middle third. Direction oblique. Deformity^ overlapping, from biceps and triceps ; if above insertion of the deltoid the lower fragment is pulled out- ward by that muscle ; if below, the upper fragment is tilted for- ward. Cardinal signs of fracture readily detected. Supra-condyloid. Projection in front and behind. That in front is due to the rough end of the upper fragment; that behind is due to the condyles and olecranon occupying their normal relation in regard to each other. Shortening between acromion process and external condyle. Reduction eas}', but deformity promptly recurs. Intercondyloid. Increased breadth between the condyles, and crepitus elicited by pressing and rubbing them together. FRACTURES. 119 Condyloid. Crepitus and mobility on manipulating the bony prominences, displacement slight. All fractures about the elbow-joint are accompanied by great and rapid swelling. Fig. 13. Fig. 14. Fracture of the lower extremity of the humerus. Dressing for fracture of the upper third of the humerus. Give the treatment for fractures of the humerus. Upper extremity. Including intra- and extra-capsular, trochan- teric, and fractures of the surgical neck. Fasten a folded towel in the axilla by a bandage and adhesive strap. Flex the arm, and carry the elbow slightly forward, apply a spiral reversed from the hand to the seat of fracture. Place a moulded pasteboard cap, or three straight, narrow, external splints, reaching from the acromion process to the external condyle, upon the outer aspect of the arm and shoulder, bind in place by a few circular turns of a roller, and complete the dressing by fastening the arm to the side, and slinging the fore- arm at the wrist. 120 ESSENTIALS OF SURGERY. Shaft of huynerus. Primary roller up to the seat of fracture, well padded internal angular splint, avoiding pressure upon internal condyle, shoulder cap extending to external condyle or below on forearm, arm bound to the side by circular turns of the roller, and slung at the wrist. If obstinate deformity from outward tilting by the deltoid, relax by dressing in the abducted position for a few days. Fig. 15.. Anterior angular splints. Supra-condyloid. Internal angular and external moulded splint, or anterior angular splint and posterior moulded trough. Condyloid. Yery obtuse angled, anterior, or internal splint. What complications may arise in the treatment of these frac- tures ? 1. Non-union, always in intracapsular fractures, frequently in fractures of the shaft. 2. Paralysis, from injury to the musculo-spiral or ulnar nerves. 3. Anchylosis, from inflammation within or about the joints, particularly the elbow. FRACTURES. 121 How do you avoid anchylosis in fractures about the joints ? By practising passive motion. Begin in four weeks for the shoulder-joint ; one week for the elbow. Promptly treat inflam- mation by cold, local depletion, aspiration at times, and pressure. How long do you continue treatment ? Five to eight weeks, replacing the splints with a sling in that time. What fractures occur in the ulna? Seats of fractures: shaft, olecranon, styloid or coronoid pro- cesses. Cause^ direct or indirect violence. Usual seat lower third. Give the symptoms of fractured ulna. Cardinal symptoms as in all fractures. Shafts being subcutaneous, deformity, crepitus and undue mobility readily recognized. Olecranon. Loss of power to extend, undue mobility ; crepitus on extending forearm and pressing olecranon in position. Dis- placement often very slight. If aponeurosis is torn through, the process is drawn well up the arm from between the condyles, leaving a perceptible gap. Coronoid process. Very rare. Tendency to backward luxation of ulna, movable bony prominence in front. Styloid process. Mobility. Crepitus detected by carrying hand towards radial border. Give the treatment for fractures of the ulna. Olecranon. Figure-of-eight about the joint, the upper segment looping behind the displaced fragment, pulling it downward. Application of a very obtuse anterior or internal angular splint. Shaft. Two well padded splints, each wider than the forearm, one reaching from the internal condyle to the tips of the fingers, the other from the external condyle to the metacarpo-phalangeal articulation. Beduce the fracture, apply splints, with the hand midway between pronation and supination. Support the fore- arm through its whole extent by a handkerchief. 122 ESSENTIALS OF SURGERY. Goronoid process. Anterior angular splint and compress. Passive motion in three weeks. Fig. 16. Dressing for fractures of one or both bones of the forearm. Styloid process. Reduce, apply a compress. Bandage to a Bond splint, or apply anterior and posterior straight splints. Describe fractures of the radius. Seats of fracture. Head, neck, shaft, lower extremity. Ordi- nary seat, lower extremity. Muscular attachments. Biceps, supinator brevis, pronator radii teres, pronator quadratus. supinator longus. What fractures occur at the lower extremity of the radius? Barton'' s (rare). A chipping off of the posterior lip of the articular surface. Colles''s. Common. A transverse break ^ inch to Ij inches above the joint. Smiths. A transverse fracture 1^ inches to 2| inches above the joint. FRACTQKES. Fig. 17. 123 Give the symptoms of fractured radius. Cause. Fall on the palm of the hand. Direct violence. L&wer extremity. Silver fork deformity. Lower fragment lies posterior to the upper fragment. Hand carried towards radial side by supinator longus, extensor carpi radialis, and extensors of the thumb. Crepitus and mobility on rotation. All symp- toms marked. Shaft. Upper fragment slightly tilted forward by biceps, and, if above insertion of pronator radii, teres (middle third), supinated by biceps and supinator brevis. Lower fragment pro- nated by two pronator muscles, tilted towards ulna by pronator quadratus and supinator longus. If below the insertion of the pronator radii teres, deformity as before, except that both frag- ments are midway between pronation and supination. Crepitus and mobility elicited by rotation. Week of radius. Upper fragment supinated by short supinator, lower fragment pulled forward by biceps. Crepitus, mobility, and deformity detected by pressing the thumb into the bend of the elbow and rotating the forearm. Bothhones. Usual seat lower third. Shortening and angular- ity often marked. Crepitus, unnatural mobility by grasping the bones on either side of the fracture and manipulating, or by placing the thumb upon the head of the radius, making exten- sion, and rotating. Upper fragments pulled forward by biceps, brachialis anticus, and pronator radii teres. Lower fragments approximated by pronator quadratus ; overlapping from the action of the flexors and extensors. 124 ESSENTIALS OF SURGERY. How do you treat fractures of the radius ? Neck. Anterior angular splint, and compress over upper end of displaced shaft. Dress in supination. Shaft. As for shaft of ulna. Reduce by extension, counter- extension, manipulation. Lower extremity. Keduction most important. Fragments once placed in proper position usually remain so. Fio:. 18. Bond's splint. Reduce thoroughly b}* extension, pressure, and manipulation. Apply a Levis or a Bond splint, or simply circular strips of adhesive plaster. In all cases leave the fingers free, and en- couraging their use. The Bond splint requires two pyramidal pads, the base of the posterior one to go over the upper extremity of the lower fragment, the apex pointing toward the fingers. The base of the anterior one to go under the lower extremity of the upper fragment, the apex pointing toward the elbow. Firm union in five to seven weeks. Ih^actures of both hones., or shaft of either., including Colles-s frac- ture, complicated by a fracture of the styloid process of the ulna. Two straight splints wider than the forearm, as in fractures of the shaft of the ulna. Sling all fractures of the forearm by means of a handkerchief supporting it throughout its entire extent. What forearm fractures are dressed in supination ? Dress fractures above the insertion of the pronator radii teres with the palm up ; in all other fractures, dress with the thumb up (midway between pronation and supination). FRACTURES. 125 Describe fractures of the metacarpus. Usually second or fifth. Posterior angular projection, from distal end of bone being pulled forward by the flexors. Crepitus and mobility elicited by seizing and manipulating the two ex- tremities of the bone. Give the treatment for fractures of the metacarpus. Treat by an anterior splint to the hand and forearm, padding well to preserve the concavity of the palm. Compress poste- riorly if any tendency to deformity. Eetain the dressing for five weeks. Passive motion in three days. Describe fractures of the phalanges. Eare. Due to direct force ; readily diagnosed by manipulating the finger bones. Treat by anterior moulded, posterior straight splint, extending to the wrist. A long palmar splint may be used. Describe fractures of the pelvis. Cause. Great and direct violence. /Seats. Crest of ilium, basin of pelvis, acetabulum, sacrum, or coccyx. Symptoms. In all these fractures there is a sense of falling apart. Crest. Patient leans toward the affected side ; crepitus and mobility on grasping and manipulating the bone. External evidence of injury, discoloration, swelling, etc. Pelvic basin. Crepitus and mobility ma}^ be elicited by grasp- ing the iliac spines and attempting to move them in opposite directions ; great pain, and inabilit}' to sit or stand ; often a line of ecchymosis along Poupart's ligament and the crest of the ilium. Examination per rectum or vagina may reveal dis- placement or crepitus. Acetahulum. Either the floor or the rim may be fractured ; caused by blows on the trochanter. Floor. Great pain on attempting to stand, or in any way moving the femur ; crepitus best detected by thrusting the femur directly upward ; very slight shortening. Bim. Usually the upper and posterior part is broken off. 126 ESSENTIALS OF SURGERY. Subluxation of femur backward. On circumduction, the head of the bone can be felt to slip out at a certain point, returning to its proper position as the motion is continued ; there is crepitus. Sacrum and coccyx. Direction transverse. Cause, direct vio- lence. There may be some anterior projection from the action of the coccygeus and levator ani muscles. Crepitus and mobility, detected by a finger in the rectum. Pain on defecation. How are these fractures treated ? Place the patient on a fracture bed, i. e., a firm, hard, evenly padded bed, with a central perforation through which the con- tents of the bowel may be passed without moving the patient. Apply a broad bandage or binder tightly about the pelvis ; tie the knees together. The most comfortable position is usually on the back, with the thighs and knees flexed, and supported by pillows ; allow the patient to assume the position of his choice. If there is displacement of the coccyx, pack the rectum with iodoform gauze or an inflated rubber bag. Fractures of the acetabulum are treated by extension, and sand bags or splints, as fractures of the femur. Describe fractures of the femur. Muscular attachment — To greater trochanter — Two gluteals (medius and minimus), two obturators, two gemelli, pyriformis, quadratus femoris. All ex- ternal rotators except the glutei. Lesser trochanter— V&02i^^ iliacus (below), both flexors and ex- ternal rotators. Condyles — Gastrocnemius, plantaris, and popliteus. Seats of fracture. Neck — Intracapsular, extracapsular, mixed. Shaft. Loimr extremity — Supracondyloid, intercondyloid, T or comminuted, and condyloid. Give the symptoms of intracapsular fracture of femur. Occurs in aged people, frequently females, from slight violence. Hip flattened, trochanter less prominent, and lying nearer to the anterior superior spinous process of the ilium, with its upper border above Kelaton's line (a line from the anterior superior iliac spine to the tuberosity of the ischium). FRACTURES. IZ Crepitus elicited by pressure upon the trochanter, and making traction and internal rotation. Pain on motion. Preternatural mobility, foot can be everted till the heel looks directly upward. Swelling not accompanied by marked ecchymosis. Shortening from ^ to Ij inches ; may be slight at first and progressively increase. Loss of power. Fig. 19. Fig. 20. Lines of fracture of the upper extremity of the femur. Intracapsular fracture of the neck of the femur. Give the symptoms of extracapsular fracture of the femur. Cause. Considerable direct violence. It occurs in middle- aged males, with well-marked external evidence of injury, i. e., swelling and discoloration. Crepitus distinct, harsh, readily elicited. Shortening marked, 1 to 2^ inches. Give the symptoms of impacted fracture of the hip joint. The impacted fracture may be either intra- or extracapsular. There will be : 1. ^o crepitus. 2. Slight shortening, not dis- appearing on traction. 3. Loss of function in the limb, but not absolute. 4, Evidence of much injury to the soft parts. The foot may be inverted or everted. 128 ESSENTIALS OF SURGERY. Give the symptoms of fracture of the great trochanter. This injury often accompanies extracapsular fracture, but may exist alone. Cause. Direct violence. It is characterized by pain, swelling, discoloration, and crepitus. Unnatural mobility elicited by pressing into place the broken fragment, whicn may be felt as a hard lump upon the dorsum of the ilium. Give the symptoms of fracture of the shaft of the femur. Cause. Direct violence. Common seat. Middle third. Direction Oblique. Eversion of foot, very marked ; shortening, increased mobility, crepitus, loss of power. Upper fragment, especially in the upper third, drawn forward and everted by psoas, iliacus, and external rotators ; lower fragment pulled up and in by adductors, flexors, and extensors. Give the symptoms of fracture of the lower extremity of the femur. Supracondyloid. Lower fragment pulled back by gastrocne- mius, shortening, and eversion. Intercondyloid, condyloid, or T {transverse and intercondyloid). Increased measurement between the condyles, associated with great and rapid swelling of the knee. Undue mobility and Fig. 21. Extension applied for fracture of the femur. crepitus, elicited by bending the knee, or by grasping the con- dyles and pushing them in opposite directions. Yery great pain. FRACTURES. 129 How do you treat fractures of the femur ? Upper extremity and shaft. Extension by adhesive plaster 2| inches wide and long enough to extend from the upper end of the lower fragment, on both sides of the limb, and leave a 4 to 6 inch loop hanging free below the sole of the foot ; in this loop is laid a piece of thin splint board 2^ inches wide, and so long, that when traction is made, the plaster will stand free from the malleoli. This board is fastened in place, and through a hole in its centre a cord or bandage is passed. The adhesive plaster is placed along the inner and outer aspect of the limb up to the seat of fracture, and secured in place by a few strips carried around the limb, and a neatly applied spiral reversed bandage of the lower extremity. After an hour or two the plaster is Fig. 22. Dressing for fractured femur. tightly adherent, when the extending cord is carried over a pulley, a weight is attached, and a pad of oakum is put beneath the tendo Achillis. A sand-bag, or a bran-bag and straight splint is placed on each side of the leg, the inner extending from the sole to the perineum, the outer from the sole to the axilla, and the foot of the bed is raised two to four inches to provide for counter-extension. The position of the foot is slight eversion, and flexion. The inner borders of the inner malleolus, internal condyle, and ball of the great toe should lie nearly in the same vertical plane, the great toe pointing directly upward. Fractures of the upper extremity or shaft of the femur may also be treated by well-padded straight internal nnd external 9 130 ESSENTIALS OF SURGERY. splints. The shaft may be treated by plaster or other fixed bandage, or by straight short splints buckled about the seat of fracture. In all cases, except in impacted fracture, extension should be used. What dressing should be applied when the upper fragment pro-, jects anteriorly ? Relax the psoas and iliacus by flexing the thigh and support- ing it and the leg upon a double inclined plane, raise to such an angle that the deformity is corrected. Apply the extension plaster from the knee to the upper end of the lower fragment, make a stirrup as before, then carry the extending cord over a pulley, so elevated that traction is made in the long axis of the femur. Give the treatment for fractures of the great trochanter. A bandage about the hips with a moulded cap to keep the trochanter in position, and a long straight external splint ex- tending from the axilla to sole. How do you treat fracture of the lower extremity of the femur ? If there is obstinate angular deformity, section of tendo Achillis. If marked shortening, extension as before, carried not quite up to the seat of fracture. A splint, or long fracture- box, well padded with pillows, should be used. Evaporating lotions, or aspiration, for accompanying synovitis. How long should treatment be continued in fractures cf the femur? Treatment^ five to eight weeks. Passive motion of the knee joint after fourteen days. Massage before allowing the patient to put the leg down. Application of plaster, or other fixed dressing about the fracture, before walking is alloAved. How do you treat fracture of the femur in infants ? Reduce by extension, counter-extension, manipulation. Place in position a carefull}^ padded external splint extending from the axilla to the sole of the foot, and fasten it in place by a silica or plaster dressing. Treatment for four weeks. FRACTURES. 131 How do you distinguish between intracapsular and extracap- sular fractures of the femur ? In extracapsular — 1. Crepitus is rougher, more readily elicited, and feels as though immediately beneath the fingers of the surgeon. 2. Swelling and discoloration are greater and more immediate. 3. Deformity or shortening is more marked, but eversion can- not be carried so far as in intracapsular fracture. 4. On rotation the trochanter is found to pass through an arc of less radius in extracapsular fractures. Describe fractures of the patella. Causes. Direct violence, and muscular action. Direction. Transverse or longitudinal. Generally, but not always, marked separation of fragments. Give the symptoms of fractured patella. Power of extension lost. Gap between fragments, increased on flexion. Great swelhng. In longitudinal fractures, crepitus and mobility on grasping the two sides of the bone and pressing in opposite directions. How do you treat fractures of the patella ? If there is not much separation, elevate and apply a straight posterior s^Dlint to the thigh and leg. If great swelling, cold and evaporating lotions for one or two days, aspirating the joint if necessary. The posterior straight splint is provided with lateral pegs and ratchets, to which are attached stripr* of adhesive plaster which are looped over the upper and lower fragments; by turning these pegs, the lower fragment is steadied, and the upper fragment is drawn down in position. Fix the loAver fragment first, then the upper. Imbricate the plaster strips from above downward. If the edges of the fragments tilt for- ward, carry a piece of strapping transversely around the limb. Complete the dressing with a figure-of-eight bandage. Begin passive motion in two or three weeks. Continue the splint for SIX or eight weeks. Follow with a stiff" bandage, plaster or glass, and keep the patient on cratches for several months. These fractures may also be treated by Malgaigne's hooks applied under strict antiseptic precautions. Or by making a 132 ESSENTIALS OF SURGERY. transverse incision, clearing the breacli between the fragments and the knee joint of all clots or blood, drilling the fragments obliquely (sparing the cartilage), and wiring them in close con- tact. Fig. 23. Give the symptoms of fracture of the tibia ? Usual seat, lower third. Cause, direct < indirect violence. Deformity, slight, detectt v by passing the finger along the subcutaneous edge of the bone. Mobility and crepitus can usually be elicited by extension and counter- extension. What are the symptoms of fracture of the fibula ? Cause, direct or indirect violence. Seat of fracture, lower third. Fracture of lower fifth is termed PotVs fracture. S3'mptoms obscure, disability and deformity being slight. Crepi- tus and mobility detected by placing the fin- gers over the seat of fracture and rotating, or by pressure on both sides of the suspected Pott's fracture. point. What is Pott's fracture ? A fracture of the fibula, two to. four inches above its lower ex- tremity ; the foot is displaced outward at the ankle-joint. The internal lateral ligament is frequently torn. There may be a fracture of the internal malleolus also. What are the symptoms of Pott's fracture ? A well-marked depression at the seat of fracture. Crepitus and mobility on local pressure. The foot is twisted outwards and the sole everted by the peronei muscles ; the internal malleolus projects prominently as if broken, and the fragments can be dis- tinctly felt. Describe fracture of both tibia and fibula. Usual cause, indirect force. Seat of fracture, lower third. Direction of fracture, oblique. Deformity, dependent on direc- tion of fracture, there is usually overlapping, and anterior pro- FRACTURES. 133 Fig. 24. Fracture-box. jection of the upper or lower fragment. Diagnosis, all cardinal signs and symptoms. How do you treat fractures of the leg ? All these fractures may be treated by the fracture-box, apply- ing lateral compresses to correct deformit}*, and using extension if there is marked shortening. The fracture-box should fix the knee-joint, should be strong, and should hold the leg in such a position that the inner borders of the inter- nal condyle, the internal malleolus, and the ball of the great toe lie nearly in the same vertical plane, and the foot is kept at right angles to the leg, pressure being taken off the heel by a pad of oakum beneath the tendo Achillis. For very marked displacement, and difii- culty in retention, flex the hip and knee, lay the limb on its outer side, and bind it to a double-angled external splint for a few days, then place it in the fracture-box. The fracture-box consists of a posterior splint, with a foot- piece and hinged sides ; a pillow is placed in the box, the leg placed on the pillow, and the sides brought up and tied. External, posterior, anterior, and straight moulded splints may also be used for these fractures. PotV^ fracture may be treated with Dupuytren^s splint. This consists of a straight internal splint, notched at the lower end, and extending from the head of the tibia to a point four inches be- low the side of the foot. The up- per part of the splint is fastened to the leg, a thick pad is applied to the lower portion, not extend- ing below the internal malleolus, the foot is drawn close to the splint, in the space beneath the pad, by a figure-of-eight, so applied that there are no turns which make pressure above the external malleolus. The knee is then bent, and the leg suspended, or laid on its outer side. Fio:. 25. Dupuytren's splint applied. 134 ESSENTIALS OF SURGERY. Describe fractures of the tarsal bones. Cause^ great violence. Calcaneum or astragalus. Little displacement, unless the tuberosity is separated, v/hen it will be drawn up by the jjjas- trocnemius and soleus. Diagnosis depends on crepitus, pain, mobility, and great swelling. Treatment. Fracture-box, or fixed dressing after subsidence of swelling. For separation and displacement of the tuberosity, ex- tend the foot on an anterior or lateral splint, and flex the knee. Describe fractures of the sternum. Seat, about the junction of the manubrium and gladiolus. Cause. Direct violence. Indirect violence (over flexion or extension of the body). Deformity, readily felt. Irregularity and projection. Crepitus and, mobility by extending the body, or causing the patient to take a deep inspiration. Embarrassment of respira- tion, discoloration. This injury is usually a diastasis, or separation of the bone at its cartilaginous junction. In this case the lower fragment pro- jects anteriorly, the crepitus is smooth, and the true nature of the injury is suggested by its location. Treatment. Raise the chest by placing a pillow beneath the back, force the patient to take a long breath, giving ether if necessary, and press the fragments into place. Dressing. Broad compress, held in place by adhesive straps or bandages. Complications. Mediastinal abscess and necrosis. Treat the former by opening at the side of the sternum. If the ensiform cartilage is drawn in upon the stomach, caus- ing distressing symptoms from pressure, it should be hooked up or resected. Describe fractures of the ribs. Cause. Direct or indirect violence, muscular action. Ribs commonly broken, fifth to tenth. Ordinary seat of fracture, just anterior to the angle. FRACTURES. 135 Give the symptoms of fractures of the ribs. Crepitus and mobility, elicited by the pressure of the thumbs, passing from the sternum to the spine. Restriction of respira- tory movements by a sharp pain or stitch. Displacement, if present, is internal from direct force, external from indirect. Give the treatment for fractures of the ribs. Adhesive strips two and one-half inches wide, running par- allel to the ribs, from the spine to the sternum, and each tightly applied during expiration. The whole side of the chest is in- cluded. If displacement exists it must he reduced^ by pressure, by forcing the patient to inspire deeply under ether, or by hooking up with a tenaculum. What complications accompany fractured ribs ? Laceration of the lung, pleura, or an intercostal artery. How do you treat the complications ? Open and tie, if there are signs and sjnnptoms of internal bleeding. Subsequent pleurisy and pneumonia are usually local- ized and conservative. Emphysema may require openings in the skin (strict asepsis). In what fractures is the union ligamentous ? iSTeck of the femur, olecranon, acromion coracoid and coronoid processes, patella, tuberosity of the os calcis, spinous processes of the vertebrae. This is due, in part, to the difficulty in securing or maintaining apposition. Describe fractures of the vertebrae. Cause. Direct or indirect violence. Seats. Spinous processes. Laminae. Body. Give the symptoms of fractured vertebrae. Crepitus, mobility, and deformity may be detected by grasping and manipulating the spinous process, or pressing upon them, or by examination through the pharynx, in fractures of the upper cervical vertebrse. There is immediate paralysis of the parts below the injury, with loss of control over the bladder and rectum. Temperature of the parah'zed part is increased. 136 ESSENTIALS OF SURGERY. Dorso-Iumhar region. Paraplegia, retention and overflow of urine, incontinence of faeces. Dorsal region. Second to eleventh dorsal. Paralysis of ab- dominal muscles, and muscular coat of intestines. Expiration markedly embarrassed from involvement of serratus posticus in- ferior, qnadratus lumborum, sacro-lumbalis, longissimus dorsi. Cei%'ico-dorsal, cervical. If above the fifth and sixth cervical vertebrae, paral3sis of the arms, and more marked embarrass- ment of respiration from involvement of the long thoracic nerves (fifth and sixth). If above the third and fourth verte- brae, instant death, from involvement of the phrenic. Fractures of the atlas and axis need not be immediately fatal, since the canal is so roomy that the cord may not be encroached upon. Odontoid process will cause a prominence in pharynx from sub- luxation of the axis. Rigid maintenance of head in one position. How do yon treat fractures of the vertebrae ? If there is displacement, reduce by extension and manipulation. Place the patient on an air or water bed, guarding against bed- sores by frequent washings with whiskey and alum, and careful padding with soft pillows. Move the bowels by encmata. Draw the water regularly with a soft, thoroughly aseptic catheter. In fractures about the neck, support by means of short sand-bags. How do you treat fractures of the extremities complicated by delirium tremens? Carefully pad with raw cotton, and put on a fixed dressing, as plaster or silica ; when dry, bind the limb in a soft pillow. LUXATIONS. 137 LUXATIONS OR DISLOCATIONS. Define luxation. A luxation is the displacement of the articular surfaces of a joint from their normal relation to each other. Name and define the various kinds of luxation. In regard to cause — 1. Traumatic, due to sudden force. 2. Pathological or spontaneous, due either to alterations of the joint from disease (coxalgia), or to paralysis of the surround- ing muscles. 3. Congenital, due to congenital malformation of the joint (luxation produced by violence in delivery is not congenital). Further, we have luxation classed as — Complete. An entire separation of the articular surfaces from each other. Partial (subluxation). The articular surfaces remain in con- tact through a portion of their surface. Becent. When sufficient time has not elapsed for inflam- matory changes seriously to impede reduction. Old. When such changes have taken place. Simple^ compound, and complicated are applied to luxations precisely as in case of fracture. What are the causes of luxation ? (1.) Predisposing. — 1. The nature of the joint (ball-and- socket joint). 2. The position of the joint. 3. The condition of the surrounding soft parts. (Paralysis, relaxation, and previous inflammation.) 4. Age and sex of the patient. (Adult male.) (2.) Exciting, — Direct or indirect violence. Muscular force. What are the cardinal symptoms of luxation ? 1. Change in the shape of the joint. 2. Alteration of the normal anatomical relations of the bony prominences about the joint, the displaced ])one being ort,en felt in its abnormal position. 3. Alteration in the length of the limb. 138 ESSENTIALS OF SURGERY. 4. Rigidity, or restricted motion of the affected joint. 5. Alteration in the direction of the axis of the bone. In addition we have the S3'niptoms attendant on all trauma- tisms. Pain of a dull sickening character. Swelling often very great. Discoloration diffused about the joint. How do you distinguish luxations from fractures ? 1. In luxation there is no harsh crepitus. 2. There is rigidity in place of undue mobility. 3. The deformity, when reduced, has not the same tendency immediately to recur. The pain is not so intense, the swelling and discoloration not so rapid, and at times the smooth displaced articular surface may be felt, while in fracture, except epiphyseal, the surfaces would necessarily be rough. What articular changes take place in luxation ? Rupture of capsular ligament, with stretching or tearing of surrounding vessels, tendons, muscles, and nerves. Prompt reduction of the bone favors the repair of the injury. If the bone is not reduced the articular cavity becomes filled up, the prominences rounded off; a new socket is formed about the displaced head of the bone. The surrounding soft parts become shortened and atrophied, and adhesions between the bone and the vessels or nerves often take place. What is the prognosis in luxation ? Usually a weakened joint. If the dislocation is not reduced, permanent disabilit}-, which, however, is rarely absolute. How do you treat luxation? Reduce by either manipulation or extension. Describe the methods of reduction. 1. Manipulatioyi consists in so placing and moving the parts that muscles and ligaments are relaxed, articular prominences are disentangled from each other, and the head of the bone is either J LUXATIONS. 139 drawn by the muscles, or pushed by moderate force into its proper position. 2. Extension consists in overcoming resistance by force — this force may be applied by the hands, by wet sheets or bandages fastened about the parts, or by multiplying pulleys. When the tension is sufficient to overcome all resistance the bone is pushed into its proper position. Retain in position by splints and ban- dages. How do you treat the inflammatory symptoms ? Treat by evaporating lotions or counter-irritants. The diet should be restricted and the bowels kept opened. How do you prevent anchylosis ? By passive motion, beginning in seven to ten days, or as soon as inflammatory symptoms subside. What complicaticns attend luxations ? 1. Fracture. Treat b}^ setting and splinting the fracture, then reducing the luxation. 2. Huptuve of a large artery^ indicated by a rapidly increasing, fluctuating, pulsating swelling. Treat by rest and pressure, or ligate both ends at the point of injury, if it can be found. If this is impossible, make a formal ligation of the artery above. 3. Injury to nerve-triinlis. Treat by friction, electricit}^, mas- sage, incision and suture. 4. External icound^ or compound luxation. If no extensive injury to the joint, thoroughly disinfect, replace, close the wound, and fix. If the bone is comminuted, resect. How do you treat an old luxation ? Loosen adhesions and relax contracted muscles and ligaments by passive motion. Endeavor to replace the bone by manipula- tion •, that failing, use force. What accidents may occur in the reduction of old luxations ? Fractures. Set at once, and give up further attempt. Mupture of important muscles. Put at rest. Hupture of principal artery. Ligation of artery above, or liga- tion of both ends at point of rupture, or amputation. 140 ESSENTIALS OF SURGERY. Filiy is apparent ; nates flattened ; gluteo-femoral fold less distinct than on the sound side, circumference of thigh and leg lessened. Position. Limb flexed, abducted, and everted, with pelvis lowered on affected side. Failure in general health. Third stage. Position. Flexion, adduction, and inversion, the affected thigh crossing the other. Pelvis elevated on the diseased side. Shortening, real from wasting, and apparent from spinal curvature. Suppuration and abscesses common. Hectic with rapid emaciation. How may you distinguish between the various forms of cox- algia ? The arthritic form approaches nearer to the type of an acute inflammation, with sharp pain in the hip-joint, swelling, etc. The femoral variety is characterized by starting pain most marked at the knee (obturator and anterior crural nerves), by shortening and luxation as the disease progresses, by abscesses pointing to outer part of thigh, below the trochanter. Acetabular. Tendency to abscess most marked, may point from within the pelvis, over the nates, or above Poupart's ligament. What is the prognosis in hip-joint disease? Arthritic form is, in children, favorable. Femoral and ace- DISEASES OF JOINTS. 165 tabular forms more grave, especially the latter. In adults the prognosis is unfavorable. What are the complications of hip-joint disease ? 1. Suppuration. 2. Amyloid degeneration. 3. Tubercular meningitis. How do you treat hip-joint disease ? In light and beginning cases, a fixation splint to the affected side (Agnew's, Thomas's, or a plaster bandage), a high-soled shoe (three inches) on the sound side, and a pair of crutches. For more serious cases, rest in &ec7, ivith extension appurcdus^ as in fractures, applied to the affected side, and counter-irritation, by means of blisters, over the inflamed joint. On disappearance of all symptoms get the patient up with high shoe, crutches, and splint, which must be continued for one year. Constitutional treatment on general principles. Plenty of nour- ishing food and fresh air. Stimulants and tonics as required. Cod-liver oil and syrup ferri iodidi. Abscesses should be evacuated promptly by aspiration, or incision and drainage, under anti- septic precautions. How do you treat anchylosis in a faulty position, following hip- joint disease ? By subcutaneous division of the neck of the femur by means of a strong narrow saw (Adams's), bringing the thigh into good position (extension), and treating as a fractured femur. Continuous extension may succeed without an operation, in some cases. Under what circumstances should the head of the femur be ex- cised? 1. When it is necrosed and detached. 2. When other treatment has failed to check very free suppu- ration and rapid exhaustion of patient. 3. In some cases of displacement. Under what circumstances is amputation justifiable in the treatment of hip-joint disease ? 1. When there is extensive disease of the femur and free sup- puration. 2. After excision Avhich has not modified symptoms. 166 ESSENTIALS OF SURGERY. How do you distinguish between psoas abscess and coxalgia ? Psoas abscess can be felt as a flactuathig swelling, appearing to the outer side of the bloodvessels below Poupart's ligament, and traceable, through the abdominal wall, along the course of the psoas muscle. On marked flexion the pelvis does not move with the femur. Extension gives pain, referred to the loins. Sacro-Iliac Disease. Des3ribe sacro-iliac disease. Sacro-iliac disease is a strumous arthritis of the sacro-iliac joint, occurring in early life, and characterized by — PaiR over the affected joint, aggravated by coughing, strain- ing at stool, or by lateral pressure. Tenderness and swelling in the region affected. Lameness appearing early. Lengthening real, from downward displacement of os innomi- uatum. Suppuration. The prognosis is bad. Treatment sls in case of hip-joint dis- ease. White Swelling of the Knee-Joint. Describe white swelling of the knee-joint. White swelling of the knee is usually a strumous (tubercular) affection, occurring in children, and characterized by — Pain^ slight at first, becomes starting. Swelling^ moderate at first, gradually increasing. Tenderness, particularly marked on inner aspect. Lameness^ not producing entire disability for some time. Displacement. Knee at first flexed, but as ligaments are soft- ened and yield, there is a backward displacement and outward rotation of the tibia on the femur. Crepitus^ marked. Undue r)iohility, in a lateral direction. DISEASES OF JOINTS. 167 Abscesses may form, opening externally, or the joint may be- come anchylosed. Treatment. Fixation in good position, as for chronic synovitis and arthritis. Eheumatoid Arthritis. Describe rheumatoid arthritis (osteoarthritis). Seats. 1. Hip. 2. Shoulder. 3. Jaw. Lesions. Absorption of cartilage, ulceration of bone surfaces with rarefaction, shortening of ligaments, and bony deposits in and around the joint. Occurs after middle life, usually in men. Sumptoms. Frequently bilateral ; disability, some deformity, crackling, and atrophy. Treatment. Local support, quinia, and general hygiene. Loose Bodies in Joints. What are the causes of loose bodies in a joint? 1. From altered blood-clot (fibrinous). 2. From hemorrhage into a synovial fringe, which subse- quently organizes and is loosened. 3. From the gradual detachment of a synovial fringe. 4. In rheumatoid arthritis synovial fringes may be converted into cartilage, and become pediculated or loosened, or the nodular masses about the joint may project into the articular cavity. 5. As the result of injury, a portion of cartilage may be either chipped off or may, by a process of necrosis, be shed into the joint. Knee-joint usually affected. Give the symptoms of loose bodies in a joint. Recurrence of attacks characterized by — Sudden., agonizing pain, and fixation of the joint in slight flexion, followed by synovitis. Detection of the body by manipulation ; commonly found in the pouch over the external condyle of the femur. 168 ESSENTIALS OF SURGERY. How do yon treat loose bodies in joints ? Radical. Secure the body in place by transfixing it with a strong needle ; dissect it out, checking bleeding before opening the joint. If it has a pedicle, ligate. Close the wound, dress, and immobilize. Palliative. Knee-cap. Anchylosis. What are the varieties of anchylosis or stiff joint? True anchylosis is dependent on articular and intra-articular thickening and adhesions. True anchylosis may be complete^ in which case the articular surfaces are united in part or through- out by bone. Rarely found except after traumatic arthritis. Or it may be incomplete, motion being restricted by fibrous union between the joint surfaces, and thickening of the capsule. False anchylosis is dependent on contractions and adhesions of the soft parts around the joints. Give the treatment of anchylosis. Incomplete orfbrons anchylosis. Passive motion and use. Ap- plication of splints, the angle of which can be changed. Continu- ous extension by means of weights. Forcible flexion and exten- sion under anaesthetics. Coonplete or hony anchylosis. If the position is good, let alone, except in the case of the elbow, which should be excised. If the position is bad, osteotomy or resection. DISEASES OF EO^'ES. 169 DISEASES OF BONES. Name the inflaminatory diseases of the hones. Periostitis, osteitis, osteomyelitis, epi;^hysitis. Periostitis. Describe periostitis. 1. Simple local periostitis, which may become suppurative peri- ostitis, forming periosteal abscess. 2. Diffuse infective periostitis. (1) Local periostitis. Cause. Local injury or extension of in- flammation from other parts. Pathology. Thickening of external fibrous layer, prolifera- tion of inner osteogenetic layer, and inflammatory exudate loosening the periosteum from the bone. It may terminate in ; 1. Besolutio^.i. 2. Periosteal abscess. 3. Periosteal nodes (par- ticularly in chronic periostitis). Symptoms. Pain. Intense, bursting, and worse at night. Swelling of soft parts overlying. Tenderness. Well marked on pressure. Fever. In supjmration, symptoms are increased in severity ; there are cedema, and discoloration of skin. Treatment. Eest in bed, elevation, cold, opium for pain, leeches. Should pain and fever be unabated, or increase in twenty-four hours, free incision. If pus, open. For osteoiDlastic periostitis (periosteal nodes), oleate of mercury, subcutaneous section, or ablation by gouging. (2) DiffiLse infective periostitis. Cause. Injury to a strumous subject. Seat: Long bones ; femur, tibia, humerus. Pathology. Rapid septic suppuration, completely separating periosteum from bone. Symptoms. High fever and profoxind constitutional disturbance rapidly running to a condition of septicaemia. 170 ESSENTIALS OF SURGERY. Deep-seated pain. Redness^ puffiness. and oedema of the skin appear early. Treatment. Early and free incisions. Antiseptic irrigation. Thorough drainage. Stimulants, tonics, and rich diet. Osteitis. Describe osteitis. Cause. Injury, diathesis (scrofula, syphilis, rheumatism). Pathology. Inflammatory exudation and cellular h3^perplasia in the Haversian canals, with solution and removal of the bone sub- stance. Haversian canals, lacunae, canaliculi become widened, and may disappear by coalescence. This constitutes rarefying osteitis or osteoporosis. The bones may yield to pressure and be- come greatly deformed, constituting osteitis deformans. If the inflammation is very acute, rapid proliferation causes strangu- lation of vessels and the bone dies in mass {necrosis), or by molecular death and discliarge (caries). If inflammation is somewhat chronic, the absorbed bone is replaced by a new de- posit, excessive in amount, and very dense (osteosclerosis or osteoplastic osteitis), or the inflammation may result in a local- ized collection of pus [abscess of hone). Symptoms. As in periostitis. Osteocopic (starting) pains more marked. Tenderness on tapping. (Tenderness on pres- sure greatest in periostitis.) Limb heavier and more useless. Treatment. As for periostitis. Hot fomentations of lead water and laudanum. Subcutaneous drilling. Trephine. Treat diathesis. Osteomyelitis. Describe osteomyelitis. Definition. Inflammation of the marrow of the bone. Cause. Traumatism. May occur primarily, or may be sec- ondary to other affections of the bone. Varieties. 1. Simple. 2. Suppurative. 3. Gangrenous. 1. Simple osteomyelitis. There is proliferation affecting the embryonic cells in the medulla and in the surrounding Haversian DISEASES OF BONES. 171 canals and cancellous tissue, the fat disappears, the bone is absorbed. Granulation tissue is formed which may undergo resolution, may organize into hone filling the medullary canal (as in case of fractures), or may suppurate. 2. Suppurative osteomyelitis. May be circumscribed forming bone abscess, or diffuse, leading to extensive necrosis or pyaemia. 3. Gangrenous osteon iiyelitis. Due to a very high grade of in- flammatory action, causing death by obstruction to circulation. Compjlications of osteomyelitis. Caries, or bone ulceration. JVe- crosis, death of bone ; this may be central, involving the inner laminae only, peHp/iej^aZ, involving the outer laminae, or total, involving the whole thickness of the shaft. Separation of epiphy- sis. Inflammation of epApliysis. Pyarthrosis. Pycemia. Osteomyelitis exhibits a tendency to spread towards the trunk. Treatment. Simple osteomyelitis, as for osteitis. Supjpjurative osteomyelitis. Open with trephine. If suppuration is extensive and associated with pyarthrosis (pus in joint), amputate. Gangrenous osteomyelitis. Amputate. '^ Abscess of Bone. Describe abscess of bone. Nature. Usually strumous. Cause. Due to rarefying osteitis, or the breaking-up of case- ated tubercular masses. Seat. Head of tibia usually (Brodie's abscess). Symptoms. Boring persistent pain, worse at night. Tender- ness especially marked on striking or tapping. Treatment. Apply a rubber bandage and tourniquet and search for pus with a drill. Trephine ; scrape, and chisel out all rough or carious bone. Pack with iodoform gauze, apply an antiseptic dressing and a splint. 172 ESSENTIALS OF SURGERY. Caries. Describe caries. Definition. Ulceration or molecular death of osseous tissue. Pathology. As for rarefying osteitis. The surrounding bone is indurated, except in struma, when it is converted into a mass of fungous granulations. Seats. Cancellated extremities of long bones. Often aflects the joints secondarily. Symptoms. Those of osteitis with abscess. On probing, the softened, roughened, readily bleeding diseased area is detected. The discharge contains an excess of phosphate of lime. Treatment. Remove the diseased bone by the curette, gouge, or osteotrite. When the detritus preserves its color in spite of washing, sound tissue is reached. Excision or amputation may be necessary. Necrosis. Describe necrosis. Definition. Death of bone in mass. Direct cause. Osteitis in any of its varieties. Bemote cause. Scrofula, syphilis, phosphorus, exposure to heat and cold, etc. Necrosis maj^ be dry (the ordinary variety), due to inflam- matory strangulation, or moist, due to sudden death from injury. Necrosed hone is dry, dirty yellow or brown, hard, and does not bleed when struck with a probe. When loosened it is thrown off as an exfoliation. The periosteum frequently retains its vitality, and throws out a sheath of new bone surrounding the dead portion, which, when it is entirely separated from the living bone and thus surrounded, forms a sequestrum, and is said to be invaginated. The sheath of bone investing the seques- trum is called the involucrum. The openings in the involucrum, through which the discharge makes its way to the surface, are called cloacce. Dead bone is separated from the living by a process of granulation. DISEASES OF BONES. 173 Sequestrum. Dead bone surrounded by living bone. Involucrum. A shell of living bone surrounding a sequestrum. Cloacce. Openings in an involucrum. Synqjtoms. Those of bone inflammation, followed by free sup- puration, with discharge of laudable pus ; this continues for a long time, the abscess openings contracting down to sinuses. Diagnosis. Made by feeling the hard, rough surface of dead bone with a probe. Treatment, is'ourishing food, tonics, fresh air, iodide of iron, and cod-liver oil. Sequestrotoray when the sequestrum is loose. Tubercle. Describe tnbercle of bone. Three forms. Miliary tubercle, caseating tuherde. and scrofulous osteitis (chronic rarefying osteitis). May he local (encysted) or diffuse (infiltrated) ; more commonly the latter. Seat. Cancellated ends of long bones. Common form. Scrofulous osteitis (tubercular nature cannot alwaj^s be proven) ; occurs chietly on hands, feet (strumous dac- tylitis), ends of long bones (abscess, or scrofulous arthritis), and bodies of vertehrcB (Pott's disease). Symptoms. Those of osteitis, together with the signs of scrofu- lous diathesis. Treatment. Air, good food, general hygiene, etc. Counter-irritation, pressure, and splinting. When suppura- tion takes place, open, and remove entire disease area. Syphilitic Bone Disease. Describe the osseous lesions of syphilis. Acquired. Gummata between periosteum and bone, forming periosteal nodes. These nodes chiefly affect the tibia, ulna, clavicle, and hard palate. Earely, a diffused chronic form of in- flammation causes syphilitic osteitis or sclerosis. Congenital. In very young children cranio tahes, or wasting 174 ESSENTIALS OF SURGERY. of bone at the sites of decubitus, i. e., behind the eminences of the parietal bones. Alterations in the epiphyseal cartilage making the bone brittle and soft, Hutchinson'' s teeth, and ParroVs nodes or osteophytes, appearing in the form of bony projections about the anterior fontanelle, and on the tibia and humerus. Osteomalacia. Describe mollities ossiiiin or osteomalacia. A disease characterized by general softening of the bones, ren- dering them liable to be bent or broken. Occurs during and after adult life, mostly in females. Pathology. Rarefaction and absorption of bone, advancing from the centre outward. Replacement of medullary tissue by a dark-red, semi-fluid material. Symptoms. Obscure pain in the bones and malaise. Phos- phates in the urine. Fractures, deformity. "What is fragilitas ossium ? A brittleness of bone dependent on fatty degeneration. Pott's Disease. What is Pott's disease? Pott's disease is an angular deformity of tbe spine caused by caries of the vertebrae or the intervertebral cartilages. Give the pathology of Pott's disease. Usually due to a tubercular osteitis which affects the bodies of several vertebrae simultaneously ; these becoming softened, jneld to the superimposed weight, thus causing deformity. There may be no pus formation, the inflamed area being removed by interstitial absorption, the pus may become encysted and caseated, or, more commonly, may appear as a cold abscess. The cord is rarely injured, the deformity being so gradual that it ac- commodates itself to its hew course. Anchylosis, which is a reparative effort, goes hand in hand with the disease, new bony arches being thrown out between the DISEASES OF BO^'ES. liO vertel)r£e. Pott's disease occurs most frequently in childhood, and is commonly found in the dorsal and cervical regions. Give the symptoms of Pott's disease. 1. General failure in health. 2. Bigidity of spine. Detected by getting the patient to pick an object from the floor, to rise from a dorsal recumbent posture, or to turn from the back to the belly. In consequence of rigidity and tenderness, the gait is tottering, shuffling, and uncertain. 3. Pain and tenderness, elicited at times by jarring the head or by inducing the patient to jump from a chair or step. May be found by direct pressure. There is a constant tendency to sup- port the back ; the patient will frequently lie down, or, if sitting, will support the weight of the shoulders on the thighs. 4. Bejiex irritation. Lumbar disease is frequently attended with colicky pain, irritation of the bladder, and incontinence of urine. Dorsal disease is characterized at times by a grunting resxAration. Cervical disease may cause torticollis, choreic move- ments of the neck muscles, or difficulty in deglutition. 5. Deformity. Undue prominence of spinous process causing a backward projection. 6. Abscesses. 7. Paresis or paralysis. In what directions do the abscesses of Pott's disease point? Cervical region. Post-pharyngeal abscess may be formed, or the pus may pass outward between the longus colli and scaleni muscles, appearing behind the sterno-cleido-mastoid, or it may pass downward. Dorsal region. Pus may pass directly backward, or form pjsoas, iliac, or lumbar abscess. Lumbar region. Lumbar abscess, appearing to outer side of quadratus lumborum. Psoas or iliac abscess. Give the treatment of Pott's disease. Constitutional, as for strumous affections. Local. Best. In the early stages rest in bed. Plaster jacliet with either entire or partial confinement to bed. Abscesses must be opened as soon as detected. Open psoas abscesses 176 ESSENTIALS OF SURGERY. above Poupart's ligament before they are perceptible in the groin. This under the most rigid asepsis. Dress frequently, -washing out the abscess cavity. . How is the plaster jacket applied ? Bandages two and one-half or three inches wide, seven 3'ards long, made of gauze, mull, or crinoline. Hub dry plaster of Paris thoroughly in the meshes of each bandage as it is rolled. Place on the patient a clean thin summer undershirt, pad all bony projections with cotton, put over the abdomen next to the skin a "dinner pad" (a folded towel), suspend the patient by the head and shoulders, wet the bandages, and apply them so that the expanded basin of the pelvis is caught below and the sup- port comes well up beneath the axilla of each side. Remove the dinner pad when the bandage hardens. Rickets. Define rickets. Rickets is a constitutional disease of childhood, characterized by lesions of the osseous system, and a tendency to amyloid de- generation of the viscera. Miology^ defective or unsuitable food. Give the pathology of rickets. Increased cell-growth, with deficienc}' of earthj' matter. En- iargement of epiphyseal cartilages. Thickening of periosteum. Softening and distortion of the shafts of the bones. Give the symptoms of rickets. Premonitory. Delayed dentition^ restlessness at nighty sweating about the head, almndant urine loaded icith phosphates. Of the developed disease. Deformities. Such as — 1. Pigeon-breast., with beaded ribs from enlargement of costo- chondral junction. 2. Lateral or antero-posterior curvatures of the spine. 3. Bent legs or arms with rounded enlargements at the ends of the long bones. As a frequent complication we have hronchitis, serious on ac- count of the vielding nature of the chest walls. CURVATURE OF THE SPINE. 177 Treatment. General hygiene, nourishing diet, cod-liver oil, lactophosphate of lime, iron, syrup, hypophos. conip. Hsemophilia. Describe hsemophilia. Haemophilia is a congenital and habitual hemorrhagic dia- thesis, in virtue of which persistent bleeding may occur, of it- self, or from the slightest wound. Treatment. Compresses saturated in Monsel's solution, strong pressure, ergot, acetate of lead, and other haemostatics. Struma. What is struma? Struma or scrofula is a defective bodily condition characterized by a tendency to the development of chronic {tubercular) inflam- mations of the bones, joints, and lymphatic glands. What are the characteristics of scrofalons inflammations ? 1. They develop at an early period in life. 2. They are chronic in type. .3. They occur chiefly in phthisical families. 4. They exhibit a marked tendency to pass on to suppuration and caseation. 5. They are prone to appear in certain regions. Example, cervical adenitis. Give the treatment of scrofulous inflammation. Constitutional. Generous diet, fresh air and sunshine, cod- liver oil, iodide of iron. Local. Active counter-irritation, pressure, operative pro- cedures. Curvature of the Spine. Describe spinal curvature. The curvature may have its convexity directed forward, back- ward, or to the side. 12 178 ESSENTIALS OF SURGERY. Tlie muse of curvature is long-continued, unequal compression of the intervertebral cartilages. Forward curvature^ or lordosis^ is usually found in the lumbar region, and is simply an exaggeration of the normal curve, com- pensatory to some deformity or diseased condition, such as ricket, congenital femoral luxation, coxalgia, etc. Backward curvature^ or kyphosis^ usually appears as an exagge- ration of the normal dorsal curve. It is the result of debility, rickets, or occupation requiring constant stooping. Ti^eatment. In the young, friction, massage, deep breathing, exercises for back muscles, braces which are comfortable only when the shoulders are held back. Lateral curvature, or scoliosis, develops most frequently in girls, between the ages of 14 and 18. There are usually two curves with their convexities turned in opposite directions. The vertebrae are rotated on their vertical axes, their spinous pro- cesses pointing towards the concavitj^ of the curves. Causes. Inequality in the length or strength of the legs; one- sided position or use of the body ; contractions following em- pyema or paralysis of spinal muscles of one side. These causes are rendered more operative by debility, or a strumous or rachitic diathesis. Symjitoms. Sense of fatigue and pain in back and shoulder when sitting, or on first lying down. Wing-like projection of scapula (dorsal curvature is usually toward right), and undue prominence of the iliac crest of the affected side, with projection of the breast on the opposite side. Curvature may be detected by marking the spinous processes, though it must be remembered that the amount of deformity is much greater than is indicated by this test. Treatment. Change in habits or occupations which can act as exciting causes. Massage, friction, and electricity to the mus- cles of the back, sj^stematic gymnastic exercises, suspension fol- lowed by rest in the recumbent position. If deformity increases, appl}^ a plaster-jacket. HERNIA. 179 HERNIA. What is a hernia? The protrusion of a viscus through an abnormal opening in the walls of the cavity in which it is contained. As applied, hernia is synonymous with rupture^ and indicates protrusion of the abdominal viscera through abnormal openings in the parietes. What are the essential parts of a hernia ? 1. The sac. 2. The contents. Describe the sac. The sac may be (1) congenital. Found only in umbilical and inguinal regions ; consisting of a pouch of peritoneum ready to receive the hernia. (2) Acquired. Developed by gradual stretch- ing of the parietal peritoneum. This is the form of sac ordinarily found. The formation of the sac. Pressure of abdominal contents upon the parietal peritoneum may cause a bulging of the membrane where it is poorly supported, as at the internal inguinal ring ; the peritoneum yields, and the bulging is developed into a pouch which fills the inguinal canal ; escaping from the external ring its base is less supported, and it forms a pyriform swelling, con- sisting of— (1) The neck, at the internal ring. (2) The body, the main part of the sac. (3) The fundus, or wide extremity. As the peritoneum is dragged downward it becomes puckered at the neck. During the stage of (1) Formation, this puckered neck exerts no constriction upon the hernial contents. Stage 2. Organization. These puckerings become adherent, and the surrounding subserous fat is indurated. Stage 3. Contraction. The neck of the sac contracts and may become obliterated, or may cause strangulation if the gut be protruding. The sac, at first smooth, becomes thickened, contracts, adheres, and is irreducible ; at times it sends oflf diverticula or secondary sacs. 180 ESSENTIALS OF SURGERY. How are hernias classified in regard to the contents of the sac? 1. Ejnplocele, Containing omentum only, most common on left side. 2. Enterocele. Containing intestine only, usually ileum. 3. Entero-eiAplocele, Containing both omentum and gut. Further we may have cystocele (bladder), ccecocele (caecum), gas- trocele, etc. What are the causes of hernia ? . 1. Predisposing. Sex^ males. Heredity. Age, young. Length- ened mesentery. Structural defects (congenital). Occupation. Abnormal conditions, such as a protracted cough, operations on the abdomen, and muscular relaxation. 2. Exciting. Muscular contraction. What are the common seats of hernia ? In the inguinal, femoral, and umbilical regions. What are the varieties of hernia in regard to their condition ? (Clinical varieties.) 1. Beducible. Most common form, the contents can readily be returned into the abdomen. 2. Irreducible. Contents cannot be reduced into abdomen. 3. Obstructed or incarcerated. The contained bowel becomes obstructed by its contents. 4. Inflamed. There is inflammation or localized peritonitis of sac and contents. 5. Strangulated. Subject to a constriction not only obstruct- ing the bowel, but seriously interfering with its circulation. Reducible Hernia. What are the symptoms of reducible hernia? 1. Enterocele. A smooth, regular, round tumor in a hernial region, often to be traced through the hernial canal, larger on standing than on lying down. Tympanitic on percussion, gurgles when manipulated. Disappiears with afljop when pressed inwards. Presents succussion (an expansile push) on coughing. Local weakness, dragging pains, and irregular dyspepsia. HERNIA. 181 2. Epiplocele. 'Eo tympanites, no flop, no gurgle ; the symp- toms the same but less marked. Doughy and uneven on palpa- tion. Give the treatment for reducible hernia. 1. Palliative. 2. Badical. Palliative. Truss, consisting of pad and spring. Pad must be slightly convex, and large enough to cover the external open- ing and the canal through which the hernia descends. The spring must so act on the pad that the pressure is just sufficient to keep the hernia up. To test a truss, let the patient stoop, cross the legs, and cough, sitting on the edge of a chair with the body leaning forward and legs widely separated. To measure for a truss. (Inguinal or femoral.) From lower border of hernial opening to the anterior superior spine of ilium of same side, from this point around the body one inch below crest of ilium to other iliac spine, thence to upper part of hernial opening. Directions for use. Immediately remove truss if hernia should come down. Bathe the skin beneath the pad with whiskey and alum on taking oif the truss, and before replacing it. Take off after lying down and replace before rising. Badical cures. The various operations devised for this pur- pose have in view : 1. Obliteration of the nech of the sac either by ligature, or stitches, or by plugging it with the invaginated fundus. 2. The obliteration of the canal ; and 3. The closure of the external and internal rings. Irreducible Hernia. What are the causes of irreducible hernia ? Tempjorarily irreducible, from slight distension with fseces or gas. Permanently irreducible, from the bulk of the tumor, constric- tion of tlie neck of the sac, adhesions within the sac, fatty en- largement of prolapsed omentum. 182 ESSENTIALS OF SURGERY. How do you treat irreducible hernia ? Temporarily irreducible^ as for incarcerated. Permanently irreducible. If very large, apply a bag truss, if moderate in size, fit a truss with a concave pad ; advising, in all cases where there is pain or discomfort, an operation for the radical cure of the hernia. Incarcerated Hernia. What are the symptoms of obstructed or incarcerated hernia ? Occurs mostly in irreducible hernia^ particularly in such as con- tain colon. Constipation is a strong predisposing factor. 1. Tumor is enlarged and slightly tender. Liquid and gaseous contents may be pressed out, and doughy faeces detected. 2. There is some pain^ with distension of the stomach, constipa- tion, nausea, and vomiting. 3. The constitutional symptoms are of moderate severity. 4. There is impulse on coughing. How do you treat incarcerated hernia? Treatment. Best in bed, cracked ice by the mouth, complete relaxation by position. Apply an ice-bag to the hernia, and give opium if there is pain. Open the bowels by purgative ene- mata, followed by castor oil as soon as the tumor is diminished in size. If symptoms of obstruction persist, perform herniotomy. Inflamed Hernia. Describe inflamed hernia. Cause. Injury to a small irreducible hernia, usually inflicted b}' a badly fitting truss. Symptoms. Chiefly those of acute local inflammation. Bed- ness, heat, pain, swelling {nodulated if epijolocele, sac contains fluid if enterocele), impulse on coughing. Fever, vomiting, and constipation oi moderate severity. Wind passed by bowels. Treatment. Opium if great pain. Rest in bed with local HERNIA, 183 relaxation by position. Ice-bag to the inflamed part. Opening enema (soap and water Ojss). Gentle purgation when inflam- mation subsides. Strangulated Hernia. What are the causes of strangulated hernia ? 1. Sudden descent into the sac of an irreducible hernia of an additional mass of omentum or intestine. 2. Sudden descent of a hernia long retained by a truss. 3. Parietal constriction about the opening of a hernia suddenly produced by violent eflbrt. Where is the seat of constriction ? 1. At the neck of the sac. At times in the body of the sac, from hour-glass constriction. 2. Entirely witlun the sac. Due to bands of lymph, or a rent in the omentum. 3. Entirely icithoid the sac. In small hernia suddenly pro- duced by violent effort. What changes take place in strangulated hernia? Bowel is grooved by constriction, becomes oedematous, ecchy- mosed, red deepening into purple, loses its lustre^ hecomes harsh^ sticky, non-elastic^ and dirty black. Sign of local death — loss of lustre and elasticity. May rupture into the sac, or at the line of constriction. In- flammatory adhesions mostly prevent faecal extravasation into the peritoneal cavity. Sac, attacked by inflammation, eff'uses serum. What are the symptoms of strangulated hernia ? 1. Tumor heccnnes more tense, somewhat duller on percussion, tender at the neck of the sac, and gives no succussion on coughing. 2. Abdominal pain, with sense of constriction about umbilicus. 3. Vomiting, frequent and persistent; first, contents of stomach, then bile, finally faces. 4. Obstinate constipation. 184 ESSENTIALS OF SUHGEKY. 5. Bapid loss of strength; small^ rapid, compressible pulse; dry, brown tongue. Very little urine passed, it may contain albumen and indican, and be deficient in chlorides. Gangrene is denoted by cessation of ptain and vomiting^ and rapid development of symptoms of collapse. What is Littre's hernia ? A hernia involving only a portion of the circumference of the bowel. Though the pouch is strangulated, there is not absolute internal obstruction. Fi^r. 40. What are the symptoms of Littre's hernia ? As for strangulated hernia, but less marked; vomiting not stercoraceous, constipation not absolute. Tumor is small, and gangrene rap- idly develops ; hence the treatment is early Littre's hernia. herniotomy. What are the principal points in the diagnosis of strangulated hernia ? 1. Stercoraceous and persistent vomiting. 2. Absolute constipation. 3. Great constitutional depression. 4. Absence of succussion, or impulse on coughing. How do yon treat strangulated hernia ? Best. Relaxation of parts by position. Taxis. Herniotomy, How do you employ taxis? Ansesthetize, and fully relax by position (flexion and adduction of thigh for femoral or inguinal hernia). The head and shoulders should be low, the pelvis elevated. Define the neck of the sac with the thumb and forefinger of the left hand, then with the fingers of the right hand draw the sac down a little, and by a kneading, rolling, compressing movement press the gut in a di- rection corresponding to its line of the descent. In oblique inguinal hernia the pressure must be outwards, up- wards, backwards. In femoral hernia first slightly downwards till falciform pro- cess is cleared, then directly backwards towards pubic spine. Taxis failing in five to eight minutes, perform herniotomy. HERNIA. 185 Under what circumstances must taxis be avoided ? 1. Very acute cases, as in hernia of sudden development, from violent muscular action. 2. Where symptoms of strangulation have existed for several days. 3. Where the strangulated gut was previously irreducible. • 4. Where the gut is gangrenous. What accidents may occur in the employment of taxis ? 1. Reduction en masse or en hloc. The hernia, together with its sac^ is pushed directly inward, the strangulation being in no way relieved. Denoted by slow, dif- Fig. 41. Fig. 42. Reduction en bloc. Reduction en bissac. ficult, forcible reduction not ac- companied by gurgle or flop, and by persistence of symptoms. 2. Reduction en bissac. The bowel is pressed into a congeni- tal diverticulum or pouch, run- ning from the body of the sac below or beneath the abdominal muscles. Symptoms the same as reduction en bloc. 3. Reduction through a rup- ture in the neck of the sac, the hernia escaping into the subserous cellular tissue. These three forms are usually classed as reduction en hloc. Treatment. Cut down, secure the sac, open it, and divide the constriction at the neck. 4. BupAure of intestine. Rapid collapse, no gurgle. "Under what circumstances may symptoms persist after complete reduction? 1. Paralysis of bowel. 2. Internal strangulation (causes within sac). 3. Acute peritonitis. What treatment should follow reduction by taxis ? Compress and bandage locally. Absolute rest, milk diet ; opium 186 ESSENTIALS OF SURGERY. to quiet pain. If no inflammatory symptoms, open bowels by castor oil or purgative euemata the fifth day. What treatment should follow continuance of symptoms after reduction ? Exploratory laparotomy, and careful search for causes of ob- struction. Describe herniotomy. Empty bladder and rectum. The antiseptic method must be carried out to its minutest details. Shave the seat of operation, pinch up a fold of skin and transfix, cutting outward and making an incision about three inches long. Divide the successive layers of tissue on a grooved director till the sac is reached. The sac is toise, rounded, bluish, with arborescent vessels. Pinch up a small portion with forceps, and notch ; a straw-colored or blood-stained serum escapes. Open freely with scissors, pass the finger up to the seat of constriction, slip the nail under the resisting band, pass a probe-pointed hernia knife along the finger, turn the edge forward, and divide the stricture. If the gut is in good condi- tion, return ; then restore the mesentery, and sew across the neck of the sac, removing its body, or do a formal radical operation. Insert a drainage-tube, close the external wound, and apply antiseptic dressing, compress, and bandage. ISTo food for twenty-four hours, then milk diet. Enema in two days. How should the intestine be managed ? Beturn if it be smooth, glistening, and elastic, even though there be great discoloration and ecchymosis. Draw down a little more of the gut and inspect the line of constriction before returning. This is a common seat of perforation. All manipulations must be practised with great gentleness. A dull black, sodden, sticky bowel is beyond hope of recovery and must not be returned. How do you treat gangrenous bowel ? Lay open the sac, carefully relieve the stricture, incise the gut if it is greatly distended, dress with charcoal poultice. HERNIA. 187 This leaves either a fecal fistula (a small aperture discharging faeces), or an artificial anus (a double-barrelled opening). If only a limited portion of the bowel is gangrenous, excise, and unite the healthy tissue with CzeT7iy''s suture^ the first row including only the edge of tlie serous membrane, the second (Lembert's) starting one-half inch from the edge of the wound, and including a quarter of an inch of all the coats of the bowels except the mucous membrane. How do you treat a faecal fistula or an artificial anus ? The fcEcal fistula frequently closes spontaneouslj^ ; if not, a plastic operation may be performed, or it may be treated as an artificial anus. In artificial a7ius the spur or partition formed by the anterior projection of the posterior wall of the bowel may be ulcerated through by means of Dupuytren's euterotome, after which the external opening may be closed by a plastic operation; or the intestine may be detached from the abdominal wall, drawn out, freshened, and united by Czerny's suture. Prepare by twenty- four hours' light diet, and thorough, washing out of the bowels. How should the omentum be managed? If acutely strangulated, clamp, excise, secure the bleeding points, and return the stump to the abdominal cavity. If ad- herent, excise. Omentum must not be left in the sac. How do you treat adhesions? Break down recent adhesions. Apply two ligatures, and cut between old vascular adhesions. How do you treat the sac ? Dissect it out, suture across the neck, and excise below the suture line. What is the after treatment ? No food for thirty-six hours. Morphia hypodermically for pain. Stimulants, if necessary, by the rectum. Open bowels by an enema the seventh day. Remove the drainage-tube in forty- eight hours, the sutures on the fourth day. Keep up firm pres- sure by means of bandages. In one month apply a truss and get the patient out of bed. 188 ESSENTIALS OF SURGERY. Special Hernias. What are the varieties of hernia in regard to position ? Diaphragmatic, Inguinal^ Femoral^ Epigastric, Obturator, Lumbar, Perineal, Ventral, Umbilical. Ischiatic, Pudendal. Fiff. 43. Inguinal Hernia. What is the most common variety of hernia ? Inguinal hernia. Name the varieties of inguinal hernia ? 1. Acquired. Complete. When the hernia has passed through the external ring. Incomplete. When the hernia is still in the inguinal canal, called also Bubonocele. Oblique. Commonest variety. The hernia passes to the outer side of the epigastric artery, and if com- plete, through the two rings and the canal. Direct. The hernia passes to the inner side of the epigastric artery and through the external abdominal ring only. Further, a complete inguinal hernia reaching the scrotum is called scrotal^ or the labium, in woman, is termed labial. Rarer forms, depending upon congenital defects, are — 1. Congenital hernia. In this the peritoneal process (vaginal process), accompanying the testis in its descent, remains an open pouch and receives the gut. In^ru.nal hernia. HERNIA. 189 2. Hernia into the funicular portion of the vaginal process {in- fantile hernia). This implies the same condition as before, ex- cept that the proper tunic of the testis has become closed, the funicular (cord) portion of the process alone remaining patulous. 3. Encysted hernia. The ven- tricular orifice of the peritoneal pouch is closed, the funicular and testicular parts remaining open. This hernia is of gradual formation. It invaginates the existing pouch and carries an additional layer of peritoneum with it, making three layers of serous membrane to be cut through. Fig. 44. Fig. 45. Congenital hernia. Fig. 46. Infantile hernia. Fig. 47. Encysted hernia. Describe the inguinal canal. The inguinal canal is an oblique passage through the anterior abdominal wall, lying parallel to Poupart's ligament and above it. It begins at the internal ring, ends at the external ring, and is one and one-half inches long. It transmits the spermatic cord in man, the rounded ligament in woman. It is bounded — In front., by the external oblique, internal oblique (outer third), cremaster muscles. Behind., by the conjoined tendon (inner third), trans versaUs fascia, triangular ligament, sub-peritoneal tissue, deep epigastric artery, and peritoneum. Above., by the arch made by the internal oblique and trans- versalis. Beloio^ by Poupart's ligament and the transversalis fascia. Describe the internal abdominal ring. The internal abdominal ring is an oval opening situated in the transversalis fascia, one-half inch above the middle of Pou- 190 ESSENTIALS OF SURGERY. part's ligament. Above and external to it lie the arched fibres of the transversalis, below internally the deep epigastric artery. From its circumference a thin funnel-shaped membrane, the in- fundibuliform fascia, is continued around the cord Describe the external abdominal ring. The external abdominal ring is a triangular aperture in the fascia of the external oblique muscle, bounded below by the crest of the pubis, above by the intercolumnar fibres. Internally and above by the internal column inserted upon the front of the pubic symphysis. Externally and below by the external column, inserted upon the pubic spine. Describe Poupart's ligament. Poupart's ligament is that portion of the fascia of the external oblique muscle extending from the anterior superior spinous pro- cess of the ilium to the pubic spine. In the lower portion it forms the external column of the external ring ; a backward re- flection from the pubic spine to the pectineal line forms Gimher- naVs ligament. A band of tendinous fibres continued from its attachment to the pectineal line up and in towards the linea alba forms the triangular ligament. What is the cremasteric fascia ? It consists of the muscular fibres carried down from the in- ternal oblique by the testicle in its descent ; they form a series of loops covering the cord. What are the coverings of an oblique inguinal hernia? Skin, two layers of superficial fascia, intercolumnar fascia (from columns of external ring), cremasteric fascia (from canal), infundibuliform fascia (from internal ring), peritoneum (true sac). Name the coverings of a direct inguinal hernia. Skin, superficial fascia, intercolumnar fascia, conjoined ten- don, transversalis fascia, and peritoneum. If the hernia^passes to the outer side of the conjoined tendon, this structure is replaced as a covering by the cremasteric fascia. HERNIA. 191 What effect has a long-standing inguinal hernia upon the length of the canal ? The internal ring is dragged down till it lies almost directly behind the external ring. What is the relation of the cord to inguinal hernia ? Below and behind. In what direction should the incision be made in relieving the stricture of an inguinal hernia ? Upward and outward, parallel to Poupart-s ligament. Describe congenital hernia. The testis, in its descent into the scrotum, is accompanied by a peritoneal pouch. The pouch becomes occluded at two points, the internal ring, and the top of the epididymis. The portion between these two points occupies the whole of the inguinal canal ; it shortly shrinks, and is transformed to a fibrous cord. If the peritoneal process remains patent througliout, we have the condition which gives rise to congenital hernia. If it is occluded at the lower end, hernia of the funicular pro- cess [infantile hernia). If it is occluded at the upper end only, and the occluding sejp- tum yields, we have infantile hernia. How do you diagnose these forms of hernia ? Congenital and funicular hernia (infantile) usually occur in early life, are of sudden development, become compjlete at once, do not drag dovm the internal ring. They are very prone to become strangulated, and are difficult to reduce. The congenital liernia intimately surrounds the testicle ; all other forms of hernia lie above it. The encysted hernia cannot be diagnosed before cutting ; then it will be found to have a double sac. Congenital hernia may be associated with undescended tes- ticle. In this case it will protrude outward along the fold of the groin. Prognosis of congenital hernia is good. 192 ESSENTIALS OF SURGERY. "With what affections may inguinal hernia be Confounded? Varicocele^ hydrocele of the cord, congenital hydrocele, and en- larged inguinal glands. How do you diagnose hernia from varicocele ? Varicocele feels soft, doughy, and like a hunch of worms to the fingers. Disappears on lying down, to appear again on stand- ing, but first enlarges at the bottom of the scrotum. If it is made to disappear, and the finger is placed over the external ring, it will appear more quickly than before, ^o gurgling, no tympa- nites, slight succussion. An omental hernia may feel doughy, but not like a bunch of earth-worms, the enlargement comes from above, and if reduced, the finger placed over the external ring will prevent it from reappearing. How do you diagnose inguinal hernia from other affections of the same region ? Hydrocele of the cord is translucent, enlarges like varicocele from the bottom, and fluctuates. It has neither gurgling nor tympanites. Undescended testicle. Absence of gland on affected side, hard tumor in inguinal canal, sickening pain on pressure. Enlarged inguinal glands. Direction of tumor oblique to long axis of canal. It is hard, very painful, and the skin is reddened. Tumor freely movable at first. Hernia lies in the long axis of the inguinal canal, is soft, is not painful, the skin is normal, the tumor lies very deep, and is immovable. Femoral Hernia. Describe the femoral canal. The femoral or crural canal is a narrow interval below Pou- part's ligament, between the femoral vein and the crural sheath (sheath of the vessels). It is one-quarter to one-half inch long, extending from the femoral ring to the upper border of the saphenous opening. The septum crurale closes the canal at the femoral ring, the cribri- form fascia at the saphenous opening. HERNIA. 193 Fig. 48. Femoral hernia. Describe the femoral ring. The femoral ring lies between Poupart's ligament above, the pubis and pectineus muscle be- low, with Grimbernat's ligament to the inner side, the femoral vein to the outer side. It is oval in shape, about one-half inch in diameter, and is closed by the septum crurale and a lymphatic gland. Describe the saphenous opening. The saphenous opening, formed by a reflection of the fascia lata beneath the femoral vein, is an oval- shaped aperture, one and one-half inches in length, one inch in breadth, situated beneath the inner portion of Poupart's ligament. Its upper and outer margin^ sharpl}^ defined and semilunar in shape, passes in front of the vessels and is inserted into the pubic spine and pectineal line. It is called the superior cortnt of the falciform process. Its lower and inner margin forms the inferior cornu of the falciform process. The inner margin is formed by the fascia passing to the pec- tineal line, curving upwards and behind the femoral vein, cover- ing in the pectineus muscle. This portion of the ring is not sharply defined. What are the boundaries of the femoral canal ? Anterior. Poupart's ligament, transversalis fascia, falciform process of fascia lata. Posterior. Iliac fascia, pubic portion of fascia lata. Internal. The junction of the transversalis and iliac fascia, forming the inner wall of the crural sheath, Gimbernat's liga- ment. External. The septum covering the femoral vein. What are the coverings of femoral hernia ? Skin, superficial fascia, cribriform fascia, crural sheath, septum crurale, peritoneum. 13 194 ESSENTIALS OF SURGERY. Where is the gut commonly strangulated in a femoral hernia ? Gimbernat's ligament. Superior cornu of falciform process, or Hay's ligament. (Agnew.) What important structures lie near the femoral ring ? 1. Spermatic cord, just above the superior margin. 2. Epigastric artery, passes above to the outer side. 3. Obturator artery, may curve across the upper and inner border. 4. Femoral vein to the outer side. How do you distinguish femoral from inguinal hernia ? Femoral hernia, traced upward towards its neck, is found to pass to the outer side of the pubic spine. Inguinal hernia passes to the inner side. In what direction should you cut in relieving the constriction of a strangulated femoral hernia ? Upward and inward, using a blunt-pointed knife with a dull edge. *o* How do you distinguish femoral hernia from a psoas abscess ? They both give succussion, and disappear on pressure or recum- bency. Psoas abscess comes down to the outer side of the vessels, gives the signs of the diseased condition by which it is caused, and fluctuates. It can be traced above PouparVs ligament. Hernia appears to the inner side of the femoral vessels and has the characteristic signs. It cannot be traced above Poupart's ligament. Umbilical Hernia. What are the varieties of umbilical hernia ? 1. Congenital^ depends upon imperfect closure of the ventral plates, the sac extends into the cord and has been tied by the accoucheur. 2. Acquired, depends upon yielding of the abdominal cicatrix. This is the commonest variety of umbilical hernia, both in infants and adults. HERNIA. 195 What are the coverings of an umbilical hernia ? Skin, superficial fascia, linea alba, sac. How do yon treat umbilical hernia ? In infants, draw the recti muscles together, strap tightl}-, and apply a binder or bandage. In adults apply a protecting con- cave truss. Where should the incision for relief of strangulated umbilical hernia be made ? In the linea alba, beginning a couple of inches above the upper margin of the hernia. The parietal tissues are often very thin. 196 ESSENTIALS OF SURGERY. INTESTINAL OBSTRUCTION. Give the causes of acute intestinal obstruction. 1. Congenital malformation, imperforate anus, etc. 2. Impaction of foreign bodies and gall-stones. 3. Invagination or intussusception. 4. Volvulus or twisting, commonly dependent on mesenteric elongated. 5. Internal strangulation, or constriction of the bowel by bands or diverticula having no structural connection with the circumference of the constricted gut. Symptoms of acute intestinal obstruction may also appear in enteritis, peritonitis, and perityphlitis; or in chronic obstruction. Give the symptoms of acute intestinal obstruction. Pain, often intense and localized. Vomiting, gastric, bilious, intestinal, and finally faecal. Constipation, absolute. Abdomen swollen, tender, tyynpanitic. Peristalsis increased, causing borbo- rygmus and gurgling. Great vital depression. Small, rapid pulse. Temperature may be normal or subnormal till just before death, which commonly occurs in from seven to ten days. How may the seat of acute intestinal obstruction be inferred ? The probability of the small intestine being involved is in direct proportion to the acuteness of the pain and the rapidity of the course. Early and severe vomiting, scanty urine, and early distension all point to small intestine. What are the causes of chronic obstruction? Fsecal accumulation, stricture of the bowel, glueing of the in- testines together from chronic peritonitis or cancer, abdominal tumors. Give the symptoms of chronic obstruction. Constipation; abnormal distension very slowly developed ; vom- iting comes on slowly or may be absent ; pam rarely acute ; con- stitutional depression not marked. INTESTINAL OBSTRUCTION. 197 What are the special characteristics of intnssusception ? This is the common form of acute obstruction in infancy and childhood. Usual seat, ilio-colic valve. It is characterized by tenesmus and passage of mucus and hlood. Sausage-shaped tumor usually to the left side of the abdomen. On examination per rectum the invaginated gut ma}- be found. Give the treatment for intussusception. Inflation per rectum with air or water ; inversion ; gentle kneading of the bowels. Laparotomy, and reduction by kneading and drawing down the sheath or outer tube. If reduction is not possible, make an arti- ficial anus, or cut ofi:' the intussuscepted part, and suture together the two ends of the bowel. What are the special characteristics of internal strangulation? Occurs during adolescence or early adult life. Patient has been previously healthy, symptoms following a Now or a straining effort. Symptoms very acute. Severe pain referred to umbilicus with intense prostration or syncope. There is no peristalsis, no tumor. What are the special characteristics of volvulus ? Occurs in advanced life. Seats. Sigmoid flexure of colon, and in the neighborhood of the ilio-cgecal valve. Symptoms are characterized by extrerae rapidity and severity. Give the treatment of ^cute intestinal obstruction. MaJ<:e most careful search in all hernial regions for strangulation. Keep the patient in the recumbent position. Give liquid nour- ishment and in minimum quantity. Morphia gr. \ every three to six hours, as required to relieve pain. Hot fomentations to the belly. Cocaine, hydrocyanic acid, etc., for vomiting. If, after a reasonable time (one to three days, according to the se- verity of the symptoms), there is no change for the better, laparotomy, with further measures adapted to the relief of the obstruction. 198 ESSENTIALS OF SURGERY. Give the treatment of chronic intestinal obstruction. Enemata. If from impaction of faeces, break up mechanically and remove. If from malignant trouble, or stricture, excision, with circular enterorraphy or artificial anus. What is laparotomy ? Opening the abdominal cavity. Incision. Linea alba, midway between pubes and umbilicus, large enough to admit the fingers. Stop all bleeding before open- ing peritoneum. Explore first all the hernial rings, then the ccEcum. If it be distended^ obstruction must be in large intestine, and can be found by searching along the colon. If caecum empty, search for an empty loop of small intestine, which can be fol- lowed up till the seat of trouble is reached. If intestine sloughing, enterectomy (excision), and artificial anus or circular enterorraphy (suture). Diseases of the Anus and Rectum. Describe the varieties of congenital malformation of the anus and rectum. 1. Partial or complete occlusion of the anus. There is a mem- brane of varying thickness, bulging when the child cries or strains, and thin enough for the meconium to be detected. 2. Imperforate anus. The rectum terminates in a blind pouch, from half an inch to an inch from the surface ; the normal posi- tion of the anus is occupied by dense tissue. 3. Occlusion of the rectum. A membranous septum is found from half an inch to an inch above the anal orifice. 4. Imperforate rectum. Kectum wanting. The colon termi- nates in a blind pouch in the iliac fossa. 5. Malformation with abnormal opening in other parts. How do you treat congenital malformation of the anus and rectum ? Place the child in lithotomy position. Incision in the middle line, over the natural position for the anus. Work backward toward the coccyx. The bowel being DISEASES OF THE ANUS AND RECTUM. 199 found, open, and, if possible, suture to tlie external wound. Pass a bougie daily to prevent contraction. If, after dissecting to the depth of 1^ inches, no sign of bowel is perceived, do Littre's operation (left inguinal colotomy), making an artificial anus. What are hemorrhoids ? Swellings about the margins of the anus due to a varicose condition of the bloodvessels. Hemorrhoids may be external, aifecting the muco-cutaneous folds external to the sphincter, or internal, affecting the mucous meml)rane within the sphincter. What are the causes of hemorrhoids ? Anything tending to increase the supply of blood to the rectum, or to impede its venous return. Instance, liver troubles, constipa- tion, straining, occupations requiring much standing, sedentary life. They begin as dilations of the hemorrhoidal veins, and are followed by infiltration of surrounding tissues. Describe external piles. May be made up of dilated and thrombosed veins, thromhotic; may be due to swollen muco-cutaneous folds, (Edematous; or may consist of permanently hypertrophied flaps or tags of skin, cutaneous. These occasion little trouble till, from cold, consti- pation, imprudent diet, or some other cause, they become in- flamed, when they give rise, to intolerable pain and itching, and exhibit all the local signs of an acute inflammation ; this con- stitutes an "attack of piles." Give the treatment of external piles. Keep the bowels open by equal parts confection of senna and confection of black pepper, or a glass of Friedrichshall on rising in the morning ; scrupulous cleanliness of the parts. Cocaine suppository (gr. 5) for acute attacks. Thromhotic. Apply a ten grain to the ounce calomel ointment at night and in the morning, after washing. If the parts become very painful, incise and turn out the clot. Describe internal piles. May be open or bleeding, blind or not bleeding. 1. Capillary hemorrhoids. Small, granular, bright red tumors, situated high in the bowel ; really arterial ncevi. 200 ESSENTIALS OF SURGEHY. 2. Arterial hemorrhoids. Hard, vascular, glistening, slippery ; may attain considerable dimensions. On scratching^ bright red blood in jets. Large artery can be felt entering the upper part of each pile. 3. Venous hemorrhoids. Large, livid, prone to prolapse. What are the symptoms of internal hemorrhoids ? Bleeding at stools. The blood is bright red and coats the fceces. Protmsion. An irregularly nodulated congested mass protrudes after defecation. It may become strangulated by the sphincter. Constipation. Discomfort and heaviness about the rectum. Pain and fever, if the piles are inflamed or strangulated. Give the treatment for internal piles. 1. Palliative. Equal parts of senna and black pepper confec- tion, a teaspoonful on rising. Coat the diseased area with ferri subsulph. 3ss, cosmoline .5j. Inflamed piles. Lapdanum and starch-water injections. Hot fomentations. Cocaine supposi- tories (gr. i). Tor strangulated piles, anaesthetize, and return within the sphincter. 2. Operative. Clear the lower bowel by laxatives and injection. Lithotomy^ or the lateral position. (1) Injection of carbolic acid. Clamp the pile and inject TTLv of a 20 per cent, glycerine and water carbolic solution into the centre of the pile. (2) Ligature. Paralyze the sphincter, draw down each pile, divide the skin about it, and encircle its base by a ligature ; or transfix with a needle carrying a double thread, and tie each half separately. Insert an opium suppository and apply a T bandage with a compress of iodoform gauze. Open the bowel on the fifth day. 3. Clamp and cautery. 4. Crushing. 5. Excision. Give the treatment for secondary hemorrhage after pile opera^ tions. Cold injections. Insert rubber-bag and inflate with cold water. Pass in a full-sized drainage-tube and pack the rectum about it with styptic cotton or gauze (containing subsulphate). DISEASES OF THE AXUS AND RECTUM. 201 Name the forms of prolapse of the rectum. Partial, involving only mucous membrane. Complete^ involving all the tissues of the gut (really an invagi- natiH O c o [a P5 o 1^ 1^ o C2 o ^ a? cc aj c3 ;-^ a<. H :^ Tjj la '^ ct X O <4-l '7! i*^ ft c 3 3 fcO 5 ^•■:s )3 -is — S X CO o aj S S 35 ® -i |f- o g 8 r- '^ '^ ^ 5 M ^:c ^j ^ M 3 bl > " 6 S :t^ o ■^ ^^ ? £ ^ "c - •=* Is ? S -S ^ a> ^- -«j 6 ,i5 c3 o ,= &- 02 tc 2 < I— I o 02 O > O bO ee o ^ CO O S3 03 '3 a? ® ° o ^ p, , m j. Either a diffused or localized induration (gumma). The testicle, at first smooth and. globular, becomes noihdar^ of stony hardness^ and non-sensitive. The tumor preserves its gene- ral ovoid outline. Treatment. Strapping and constitutional medication. Describe tubercular disease of the testicle. The diagnostic points of tuherculor sarcfniele are : It occurs in the young adult, whose family history is frequently strumous, it is indolent and slow in development, the epididymis is first attacked, there is rarely hydrocele, the vas deferens is thick- ened, and the induration is prone to break down. Treatment. Constitutional. Total ablation of diseased area. Castration if necessary. Describe fibro-cystic disease of the testes. Occurs in old men, and is a gradual., painless, unilateral en- largement, attended with absence of testicular sensation, and presenting no history of previous injury or infiammation. Treatment. Castration. Dessribe malignant disease of the testicle. Sarcoma^ most common, small round-celled. Carcinoma., usu- ally encephaloid. The diagnosis from fibro-cystic disease is made by the exceeding rapidity of the growth, which involves the skin and ulcerates. All the signs of malignant disease are present. 16 242 ESSENTIALS OF SURGERY. DISEASES OF VEINS. What is thrombosis ? A clot formed in a vessel during life. What are the causes of venous thrombosis ? 1. Inflammation, injury, or degeneration of the walls of a vein. 2. Alteration in the blood, blood stasis, or exhaustion. What becomes of a thrombus ? It may organize, it may calcify, forming phleboliths, or it may undergo red or yellow (septic) softening. What are the symptoms of thrombosis ? (Edema, and the detection of a tender, knotted, cord-like swelling in the course of a vein. There is pain on motion. How do you treat thrombosis ? Rest and elevation. Mercury and belladonna ointment thickly applied, hot fomentations. Clear the bowels by a saline cathartic, give a simple but nourishing diet, and administer iron and quinine. Subsequently apply a pressure bandage, and use fric- tion and massage. What are the causes of phlebitis ? Traumatism, thrombosis, gout, micro-organisms. What are the symptoms of phlebitis ? A dusky red line in the course of the vein, and the symptoms of thrombosis. Treatment as for thrombosis. Describe suppurative phlebitis. Cause. Septic micro-organisms. Symptoms. As for phlebitis and thrombosis. Local inflam- matory signs are more marked ; there are frequently softening and suppuration in the course of the vein, and constitutional symptoms and metastatic abscesses indicate the development of pyaemia. Prognosis. Unfavorable. DISEASES OF VEINS 243 Treatment. Local disinfection and opening of abscesses ; am- putation, if the diagnosis can be made sufficiently early. What is a varix ? A permanent dilatation of a vein. The vein is said to be varicose. What are the causes of varicose veins ? Increased intravenous pressure from mechanical compression, from violent muscular contractions emptying the deep veins into the superficial, from long standing. Alteration in the vein walls. What are the symptoms of varix ? Aching pains, and a sense of fulness after standing, together with the enlargement evident to the sight and touch. Muscular cramps are said to characterize deep varix. How do you treat varicose veins ? Palliative. As much rest and elevation of the part as possible, the application of a rubber bandage or an elastic stocking, tonics, and laxatives. Badical. Ligature and excision, or acupressure. 244 ESSENTIALS OF SURGERY. ANGIOMA. Describe the different varieties of angiomata. 1. Arterial varix. A dilatation and lengthening of a single artery. 2. Cirsoid aneurism. A tumor composed of a number of di- lated and tortuous arteries. 3. Aneurism by anastomosis. A dilatation and lengthening, involving the arteries, capillaries, and lesser veins. 4. Capillary ncevus. A dilatation and tortuosity involving the capillaries. 5. Venous ncevus. A tumor composed of a number of inter- communicating spaces lined with endothelium, into which the arteries empty, and from which the veins take their origin. How do you treat angiomata ? Arterial varix, circoid aneurism, aneurism hy anastomosis. Pro- tect. If rapidly extending, excise, cutting free of the involved area, and tying each artery as it is cut. Ligation of the main artery of the part, or injection of perchloride of iron may also be tried. Ncevus. Yery large superficial nsevi (port-wine marks), and those which are neither increasing in size nor produce visible deformity, should not be treated. Under other circumstances capillary ncevi may be removed by superficial cauterization, or incision, or escharotics lightly applied ; venous ncevi may be cured by incision, carried free of the diseased area ; by ligation, the thread being placed subcutaneously, or in an incision made through the skin ; by electrolysis, by coagulating injections. ANEURISM. 245 ANEURISM. What is an aneurism ? A blood tumor communicating with the interior of an artery. Give the classification of aneurisms. 1. Traumatic (see p. 74). 2. Spontaneous. a. Diffused. a. Tubular or fusiform. h. Circumscribed. h. Sacculated, c. Arterio-venous. c. Dissecting. The cirsoid aneurism and aneurism by anastomosis are, pro- perly, varieties of spontaneous aneurism. Describe spontaneous aneurism. Tubular or fusiform. A circumscribed dilatation of the whole circumference of the artery. The sac consists of all three coats. Sacculated. The dilatation involves a portion of the circum- ference only. The sac consists of the outer coat and of con- densed areolar tissue. May be circumscribed or diffused. Dissecting. The internal and a portion of the middle coat have yielded, the blood forcing its way between the layers of the middle coat. What are the causes of spontaneous aneurism? Predisposing. Atheroma, au embolus, leading to inflamma- tory softening. Exciting. Blows, strains, or sudden violent exertion. How may an aneurism terminate ? 1. In spontaneous cure. 2. In death. Spontaneous cure may be effected by, 1, gradual consolidation by deposit of laminated clot ; 2, arterial occlusion above or below the sac by a fibrinous plug, or by the aneurism itself ; 3, inflam- mation of the sac and consequent clotting of the contained blood ; 4, suppuration and gangrene. Aneurism may cause death by pressure, by rupture and bleeding, by gangrene. What are the diagnostic signs of aneurism ? A tumor in the course of an artery, diminished in size by 216 ESSENTIALS OP SURGERY. pressure of the main artery above, increased in size by pressure upon the artery below. Characterized by thrill, bruit, and ex- pansile pulsation. The pulse in the artery below the aneurism is delayed in time, and more feeble than that of the opposite side of the body. There are various pressure effects, such as oedema, bony erosions, pain, muscular spasm, etc. How do you treat aneurism ? 1. Medical treatment. Absolute rest. Very restricted diet. Iodide of potassium. 2. Surgical treatment. (1. ) Pressure. May be direct, upon the aneurismal sac, or indirect, upon the artery above or below. It may be digital, instrumental^ or applied by an Esmarch's band- age. It may be so applied as to merely slow the blood-current producing laminated clots, or may completely stop the circulation (rapid pressure). (2.) Flexion. Usually combined with pres- sure. (3.) Ligation. The thread may be applied to the ar- tery, 1, above the aneurism, and at some distance from it (Hunter's operation), 2, just above the aneurism (Anel's opera- tion), 3, both above and below the aneurism (operation of Antyllus, or old operation), 4, just below the aneurism (Brasdor's operation), 5, to one or more of the main branches below the aneurism (Wardrop's operation). (4.) Manipulation. (5.) Gdl- vano-puncture. (6. ) Injections. (7. ) Introduction of foreign bodies. Describe the application of digital pressure to the cure of aneu- rism. This, if it can be applied on the proximal side of the artery at some distance from the sac, is superior to other methods of pres- sure, since it is less painful, it is less liable to injure the soft parts, it does not obstruct venous circulation. This method can be combined with flexion and instrumental compression. Relays of assistants are necessary for its proper application. The pres- sure is made with the thumbs, the artery being controlled by the next assistant before the one pressing is relieved. A hand should be kept constantly on the sac to see that pulsation is prevented. This method is not applicable to very large aneurisms accom- panied by much cedema from venous obstruction, or aneurisms ANEURISM. 247 occurring ia habitual drunkards or those of irritable disposi- tion. Describe Hunter's method of ligation. The ligature is applied so high above the artery that a double collateral circulation is established, one around the thread, the other around the aneurism. The cure is effected by diminish- ing the circulation., and favoring the deposition of latninated clots in the aneurismal sac ; these organize much more readily than the currant-jelly clots. When the ligature is applied, pulsation can no longer be felt in the aneurism ; after awhile a slight pulse is again, perceptible ; as the sac becomes occluded, this pulsation becomes more feeble, till it finally ceases permanently. After operation, the limb should be swathed in cotton, elevated, and kept warm. What are the dangers of ligation ? Gangrene, secondary hemorrhage, suppuration and sloughing, recurrent pulsations. What are the objections to ligation close to the aneurismal sac ? The artery is probably not healthy. The circulation is abso- lutely stopped, hence there is clotting in mass. The anatomi- cal relations of the vessel are frequently altered by the tumor, making the operation difficult. The aneurismal sac is liable to injury during the operation. . How do you treat traumatic aneurisms ? Turn out the clots, and ligate above and below. 248 ESSENTIALS OF SURGERY. DISEASES OF THE LYMPHATICS. Describe lymphangitis. Definition. luflamination of lymphatic vessels. Causes. Septic absorption from a wound, or simple trauma- tism. Symptoms. Irregularly placed erythematous patches, and red lines running to the nearest lymphatic glands, which are en- larged and tender. Chill followed by fever. Treatment. Cleanse wounds and render aseptic. Promptly evacuate pus. Elevate and apply hot antiseptic fomentations. On subsidence of acute symptoms, apply belladonna and mer- cury ointment, together with pressure. Clear the bowels, give diaphoretics and diuretics. Differential diagnosis. From phlebitis, by absence of knotted, corded feeling, and dusky redness in the course of veins; by the presence of glandular involvement. Describe lymphadenitis. Definition. Inflammation of lymphatic glands. May be acute or chronic. Acute lymphadenitis is usually secondary to inflammation of soft parts. The symptoms are those of inflammation or abscess. The treatment consists in cleansing the source of trouble, the use of hot applications, prompt incision for pus, pressure, and applications of mercury and belladonna. Chronic lymphadenitis. Common in strumous children, arises from slight irritation or without obvious cause. Glands of the neck frequently affected. Characterized by slow, painless, en- largements, which discharge curdy pus on breaking down, and leave indolent, undermined ulcers. Treatment. Counter-irritation by iodine till signs of softenino-, then incise, curette, and dress antiseptically. Nourishing diet, fresh air, cod-liver oil, iodide of iron. EFFECTS OF COLD. 249 EFFECTS OF COLD. How may death occur from cold ? From cerebral ancemia, caused by sudden and progressive chilling. From cerebral congestion, due to slow and continuous chilling. From embolism, due to sudden reheating. Describe the local effects of cold. Pernio or chilblain. Caused by sudden alterations in tempera- ture. Characterized by swelling, congestion, vesication, and intense itching and burning. Frequent recurrence from slight causes. Treatment. Restore circulation gradually by friction with snow, by l^e use of cold water. Apply a one per cent, solution of nitrate of silver, and wrap in raw cotton. Frost-bite. Characterized by actual congelation of the part, which is brittle and of a tallowy whiteness ; subsequently in- flammation of a high grade appears, and may be followed by gangrene. Treatment. Moderate the severity of reaction by rubbing with snow, continued cold irrigation, massage. If mortification ap- pears, continue the use of cold as long as this process is inclined to spread. Amputate when the line of separation is formed. 250 ESSENTIALS OF SURGERY. FOREIGN BODY IN THE AIR-PASSAGES. At what portions of the air-passages.do foreign bodies become impacted ? Commonly in the larynx, or the right bronchus. What are the symptoms of foreign body in the air-passages? If impacted in the larynx. Asphyxia from spasm and obstruc- tion ; this may cause immediate death, or, the first spasm passing away, may be succeeded by an exhausting cough, a blood-stained mucous expectoration, and recurring spasmodic attacks. If loose in the trachea. Recurring and violent attacks of spas- modic asphyxia from impact of the body against the rima glottidis, free secretion of a frothy mucus from the air-passages. If impacted in a bronchus. Pain and whistling rales at the seat of lodgment, absence of respiratory sounds in the lung, abscess. Treatment. If dyspncea urgent, instant tracheotomy. If the foreign body is lodged in the lar\'nx, an effort should be made to remove it by laryngeal forceps ; faihng in this perform laryn- gotomy and thyrotomy if necessary ; let the patient wear a tracheal tube for twenty-four hours. If the foreign body is loose in the trachea, immediately tracheotomize, draw the wound open, invert the patient, and instruct him to cough. If the foreign body is lodged in a bronchus, endeavor to extract by means of wire or an instrument, passed through a tracheal opening. What is bronchotomy ? Laryngotomy and tracheotomy, with their modifications. 1. Thyrotomy, opening through the thyroid cartilages. 2. Laryn- gotomy, opening through the crico-thyroid membrane. 3. Laryngo-tracheotomy, opening through crico-thyroid mem- brane, cricoid cartilage, and upper rings of the trachea. 4. Tracheotomy, opening through the rings of the trachea. Under what circumstances is bronchotomy required? Acute laryngitis, or oedema glottidis. Spasm. Emphysema. Foreign bodies in the air-passages, or gullet. Croup. Diph- theria. Polypi. FOREIGN BODY IN THE AIR- PASS AGES . 251 What structures lie in the middle line of the neck ? Thyro-hyoid membrane, thyroid cartilage, crico-thyroid mem- brane and arteries, cricoid cartilage, two or three tracheal rings, isthmus of the thyroid, trachea. Describe laryngotomy. Longitudinal skin incision, an inch-and-a-half long, is made over the thyroid cartilage, thyro-cricoid membrane, and cricoid cartilage ; the crico-thyroid membrane is opened by a transverse cut. Describe tracheotomy. In the high operation the opening is made above the isthmus of the thyroid ; in the low operation it is made below. Incision for high operation, two and a half inches long, begin- ning at the upper border of the cricoid cartilage. Divide skin, superficial fascia, sterno-hyoid and sterno-thyroid inter-muscu- lar fascia, and loose cellular tissue. Avoid anterior jugular veins and their communicating branch, inferior thyroid vein, and mid- dle thyroid artery, if present. Draw the trachea forward with a tenaculum, incise, cutting from below upward, and pass in the tracheal tube. Check all bleeding before opening the larynx, ecccepi when death from asphyxia is imminent, or when the bleeding is due to intense venous engorgement. After-treatment should be conducted in a warm, moist atmo- sphere ; the opening of the tracheal tube should be protected by moist gauze, and a physician or nurse should be constantly present to clean the inner tube when it becomes filled. When the breathing becomes hissing, and the epigastrium and intercos- tal spaces are sucked in during inspiration, the tube is danger- ously clogged. Bronchitis, pneumonia, or the disease which necessitates the operation, are the common causes of death after this operation. Affections of the (Esophagus. Where are the narrowest portions of the oesophagus ? At its commencement (the lower border of the cricoid carti- lage), and as it passes through the diaphragm. 252 ESSENTIALS OF SURGERY. What are the symptoms of foreign body in the oesophagus ? Pain, difficulty in swallowing, and frequently, asphyxia from spasm or direct pressure. How do you treat foreign body in the oesophagus ? If suffocation threatens, tracheotomize at once. Under other circumstances, endeavor to extract by forceps, or by the swivel or horsehair probang. If the body is of such a nature that it can be digested, or passed by the bowel, push it into the stomach. If the body is irregular and tightly lodged, perform oesophagotomy. Describe stricture of the oesophagus. 1. Spasmodic. Occurs in young hysterical women. Gives trouble only at times. Under ether, a bougie is passed without difficulty. 2. Fibrous. Due to contractions following traumatism or syphilis. 3. Malignant. Generally epitheliomatous. Occurs opposite cricoid cartilage, tracheal bifurcation, or at cardiac end of stom- ach. Symptoms of fibrous or malignant stricture are, increasing dif- ficulty in swallowing, first solids then liquids giving trouble. A feeling of obstruction referred to the top of the sternum, regurgi- tation of swallowed food, progressive wasting. Finally the di- agnosis is made by passage of bougies (after excluding aneurism, which has been burst by this procedure). Treatment. Dilatation or internal oesophagotomy for fibrous strictures. CEsophagotomy (establishment of a fistulous open- ing into the oesophagus), or gastrostomy for malignant strictures. SURGICAL AFFECTIONS OF THE BREAST. 253 SURGICAL AFFECTIONS OF THE BREAST. In what situation may abscesses of the breast occur ? Supra-mammary^ superficial to the gland. Tntra-mammary ^ within the gland. Post-mammary^ behind the gland. Give the treatment of mammary abscess. Early and free incision in a direction radiating from the nip- ple, drainage, and pressure by means of bandages or concentric strapping. What is Paget's disease of the nipple? An inflammatory condition of the nipple and areola which frequently precedes the development of cancer. What tumors are most frequently found in the breast? Scirrhus, fibroma, sarcoma. Give the differential diagnosis between scirrhus and non-malig- nant breast tumors. Scirrhus. Non-malignant tumors. Occurs after the fortieth year. Occurs before the fortieth year. Very hard, nodulated, shortly be- Nodulated, moderately hard, elas- comes fixed. tic, movable. Skin infiltrated and adherent. Skin free and movable. Nipple retracted, superficial veins None of these signs present, dilated, lancinating pain. Lymphatic involvement, rapid growth, quick recurrence, cachexia. 254 ESSENTIALS OF SURGERY. CLUB-FOOT. Describe the common forms of club-foot. 1. Talipes varus. The sole of the foot looks inward. This is the commonest congenital form (usually equino-varus) ; when it affects both feet it is frequently associated with spina bifida. Cause. Contraction of tibialis anticus and posticus, muscles of the calf, and the plantar fascia. Treatment. Division of all re- sisting tissues. 2. Talipes equinus. The heel is raised. Cause. Contraction of gastrocnemius and soleus, or paralysis of the opposing mus- cles. Treatment. Division of tendo Acliillis. 3. Talipes valgus. The foot is everted. Caused by long-con- tinued standing, or anything tending to obliterate the plantar arch ; the peronei muscles subsequently contract. Treatment. Friction, support to the arch of the foot, and section of peronei tendons, if necessary. 4. Talipes calcaneus. The toes are raised by the extensors. Causes. Contraction of the anterior muscles, or paralysis of those of the calf. Treatment. Section of the tibialis anticus, extensor longus poUicis, extensor longus digitorum, peroneus tertius. There may be a combination of distortions, constituting equino- varus, calcaneo-v^.ruSj etc. HARE-LIP AND CLEFT PALATE. 255 HARE-LIP AND CLEFT PALATE. Fig. 58. What is hare-lip ? A congenital deformity, characterized by a fissure or fissures on the upper lip, due to arrested development. Hare-lip is siwfe when one side is involved, double when it appears on both sides. It is frequently associated with deft palate. The treatment consists in closing the fissure, by freshening the edges and bringing them together with hare-lip pins, or by performing a plastic operation, sacrificing none of the tissues. What is cleft palate ? A congenital cleft in the median line of the palate ; it may be (^on- fined to the uvula, the soft palate, or involve the entire roof of the mouth. Staphylorraphy indicates the operation for the closure by suture of the soft palate. The method of closing the fissure by a transparent flap from the pharynx is termed staphyloplasty. The flap operation for the closure of clefts in the hard palate is termed ura^ioplasty. Operation for hare-lip. 256 ESSENTIALS OF SURGERY. DISEASES OF BURSiE AND TENDONS. Bursitis. Describe bursitis. Bursitis is characterized by pain, fever, and the rapid develop- ment of a fluctuating swelling. The bursa patellae is commonly involved, constituting, in the chronic form, " housemaid's knee." This swelling is diagnosed from intra-articular effusions by the fact that it is above the bone. Inflammation of the bursa over the olecranon constitutes "miner's elbow. " "Weaver's bottom" is an inflammation of the bursa over the tuber ischii. Treatment. Leeches, evaporating lotions, counter-irritation, and splinting. If suppuration, free incision. How do you treat dropsy of a bursa? This condition is usually due to subacute inflammation, or long-continued pressure. It may, at times, be resolved by counter-irritants, more commonly it will require incision and scraping. What is a bunion ? A bursal enlargement occurring in the foot. It is usually placed at the side of the metatarsal joint of the great toe. What is tenosynovitis ? Inflamuiation of tendons and their sheaths ; due to traumatism, gout, or rheumatism. Characterized by a puffy swelling along the tendon, and fine crackling crepitation. Treated by iodine or blisters. What is a ganglion ? A cyst formed in connection with the sheath of a tendon. The simple ganglion is developed on the synovial sheath. The com- pound ganglion consists of a dilatation which commonly involves the sheaths of several tendons. Ganglion occurs upon the ex- tensor tendons at the back of the wrist, and in front of the ankle. It can be felt as a round, tense, fluctuating, freely movable DISEASES OF BLRSiE AND TENDONS. 257 tumor, sometimes giving considerable pain on motion, and always causing some loss of power. Treatment. Subcutaneous rupture, either b}' force or by the tenotome. Incision and curetting. What is paronychia ? Synonyms. Whitlow. Felon. Panaris. Definition. An acute septic inflammation, involving the sheath of the tendon, the tissues superficial to it, or the peri- osteum, or all these structures. Always due to a septic wound. Characterized by intense pain, rapid disorganization, and ten- dency to spread along the course of the tendon. Treated by early, free incision, scraping, and thorough disinfection. Onychia. What is onychia ? Inflammation of the matrix of the nails. May be simxjle onychia or '^ run around," due to injury, and attended by suppuration and loosening of the nail. Treated l)y wet boric acid dressing. Malignant onychia^ due to injury and profound constitutional depression ; characterized by fungous ulcerations, showing no tendency to heal. Treated by trimming the nail, and applying powdered nitrate of lead to the granulations. What is ingrowing toe nail ? An ulceration, caused by tight shoes pressing the soft part of the toe against the edge of the toe nail. Remedied by wearing loose shoes, packing absorbent cotton and iodoform between the soft parts and the nail, or by avulsing the nail. 17 258 ESSENTIALS OF SUHGERY. ANiESTHETICS. What substances are used to produce anaesthesia ? General anaesthesia is induced by nitrous oxide, chloroform, or ether. Local anaesthesia is induced by cocaine or freezing. Which is the safest general anaesthetic ? Nitrous oxide for brief operations (one minute), ether for ma- nipulations requiring more time. What is the danger in chlorofonn inhalation ? Cardiac syncope. It may attack the robust and apparently healthy. Particularly liable to occur when operations about tlie anus are begun before complete anaesthesia. How do you prepare patients for the administration of anaes- thetics? Give no food for six hours before the time of administration. Examine the urine, and carefully auscult the lungs and heart. Half an hour before the administration of the anaesthetic give to anaemic and nervous patients a full dose of whiskey or wine. See that there are no artificial teeth or foreign bodies in the mouth. Loosen the clothing about the neck and chest. In drunkards the anaesthetic should be preceded by a quarter of a grain of morphia. How do you administer ether ? Use a folded towel, or one of the many inhalers. The recum- bent position should be enforced. Protect the eyes by a folded towel. Let the vapor be very dilute for the first few inhalations, increasing the strength as the patient loses consciousness. Per- sistent cough is most quickly overcome by pushing the ether. Watch the respiration and pulse. When the pulse is slow and full, the respirations deep and snoring, the reflex irritability abolished, and the patient totally relaxed, the anaesthesia is car- ried to the limit of safety. What accidents may occur during the administration of ether ? In the first stage there may be respiratory foryetfulness, or a cessation of breathing efforts, though consciousness is still pre- ANESTHETICS. 259 served. Corrected by sudden pressure or a dash of ether over the epigastrium. In the third stage mucus may collect in the throat to such an extent as to embarrass respiration ; it should be mopped out by sponges tied to sticks. If there is vomiting, the head should be turned to the side. If the air does not enter the lungs freely, the lower jaw should be pushed forward by the fingers placed be- neath the ramus. There may be threatened asphyxia, from excess of ether, drop- ping back of the tongue, or closure of the glottis. Denoted by irregular pulse, laryngeal stertor, blue surface, absence of respi- ratory movejnents. Immediately push the angles of the jaw forward and extend the head, practise artificial respiration, dash ether over the epigastrium, raise the foot of the bed or table, and intermittently apply the electric brush to ihe epigastrium, the other pole of the battery being placed over the sternum. Tracheotomy may be performed and the lungs inflated directly. What precautions are taken during the administration of ether ? Lights, if near, should always be held above the level of the ether. The ausesthetizer should devote his entire attention to the patient. The respiration, the pulse, the color of the skin, and the pupil should be carefully noted. A third person should always be present when women are etherized. What are the indications for allowing the patient more air ? A feeble frequent pulse. Lividity of the surface. Laryn- geal stertor. Pallor and tonic spasm. A pupil fixed in dilata- tion (always a sign of great danger). Paralysis of the diaphragm, denoted ])y purely thoracic breathing, with sucking in of the belly walls with each inspiration. Under what circumstances is chloroform preferred to ether ? When there is emphysema of the lungs, bronchitis, kidney dis- ease, or vascular degeneration. In infants. In operations about the mouth, when the cautery may be required. How do you administer chloroform ? The vapor must not be stronger than four parts to the hundred of air. Pour a few drops upon a piece of lint or a towel and 200 ESSENTIALS OF SURGERY. hold it a short distance from the mouth and nose. Watch the pulse most carefully. How do you treat syncope in chloroform narcosis? Push the lower jaw far forward, and extend the head. Eaise the foot of the table high up. Dash cold water over the face and chest. Begin artificial respiration immediately. Should you give ether in shock ? As ether directly lowers the temperature, it should not be given when shock is marked. After restoration of temperature and the free administration of whiskey and opium, a minimum quantity will be required, and may be cautiously administered. LIGATION OF ARTERIES. 261 LIGATION OF ARTERIES. Under what circumstances is an artery ligated in its conti- nuity ? 1. Ill the treatment of aneurism. 2. In the checking of bleeding, under certain circumstances. 3. In the treatment of indammation. What instruments are required for the operation ? Scalpel, dissecting and artery forceps, blunt hooks, retractors, grooved director, aneurism needle, ligature, needles, and dres- sings. All should be arranged in trays and covered with car- bolic solution 1:20 ; which is diluted up to 1:40, when the ope- ration is begun. Describe the ligatures and dressings. Ligature of antiseptic, prepared cat-gut. After operation, the wound, if small, is closed without drainage ; if large, it is drained by means of rubber tubes, horsehair, or strands of cat-gut. Its edges are closely approximated, and the whole covered in by a careful antiseptic dressing. What precautions are taken in performing the operation ? 1. Begin and end the superficial cut with the knife-blade ver- tical to the surface, thus avoiding "heeling." 2. Divide the deep fascia to the full extent of the superficial cut. Open the sheath by cutting tmcard the dissecting forceps, in which a portion of its periphery is pinched up. The incision is subsequently enlarged by the director. Avoid forcible tearing or wide separation of the artery from its sheath. Pass the an- eurism needle fi-om the side where the most important and vul- nerable structures are placed. Before tying, compress the artery and feel for pulsation below, to be sure that the circulation is controlled. In securing the ligature, make more tension upon the first than upon the second knot. What complications may arise in the after-treatment of Liga- tion? Gangrene, hemorrhage, return of pulsation in aneur.sm. 262 ESSENTIALS OF SURGERY. Describe the after-treatment of ligation. Elevate the limb and surround it with a thick layer of wool. Keep at absolute rest. Light, nutritious diet. Strict quiet, both mental and physical. Describe the triangles of the neck. Anterior triangle. In front, the middle line. Behind, the sterno-cleido-mastoid. Above, the base of the lower jaw, and a line from its angle to the mastoid process. Apex, at the sternum. Subdivided into three smaller triangles by the digas- tric above, and the anterior belly of the omo-hyoid below, named from below up, the inferior carotid^ the superior carotid, and the suhraaxillary. Inferior carotid triangle. In front, middle line. Behind, sterno-mastoid. Above, anterior belly of omo-hyoid. Superior carotid triangle. Behind, sterno-mastoid. Below, an- terior bell}'^ of omo-hyoid. Above, posterior belly of digastric. Submaxillary triangle. Above, body of jaw, parotid gland, and mastoid process. Below, posterior belly of digastric, and stylo-hyoid. In front, median line. Posterior triangle. In front, sterno-mastoid. Behind, trape- zius. Below, clavicle. Apex, at occiput. Divided by the poste- rior belly of the omo-hyoid into an upper or occipital, and a lower or subclavian triangle. Occipital triangle. In front, sterno-mastoid. Behind, trape- zius. Below, omo-hyoid. Subclavian triangle. Above, posterior belly of omo-hyoid. Be- low clavicle. In front, sterno-mastoid. Common carotid. Origin— vlghi, from the innominate, behind the sterno-clavicular articulation ; left, from the arch of the aorta, more deeply placed. Extent — from behind the sterno- clavicular articulation to the upper margin of the thyroid carti- lage. The carotid artery lies in the same sheath with the internal jugular vein and the pneumogastric nerve, each of these structures being separated from the other by fibrous septa, and having a distinct compartment. The sheath rests upon the lon- gus colli, and, in the upper part of its course, the rectus capitis anticus muscles, and is crossed at the level of the cricoid carti- lage by the omo-liyoid muscle. LIGATION OF ARTERIES. 263 Line. From the sterno-clavicular articulation to a point mid- way between the angle of the jaw and the mastoid process. Siqyerficial guide — anterior border of sterno-cleido-mastoid. Belations. Anterior. Skin, superficial fascia, platysma, deep fascia, sterno-hyoid, sterno-thyroid, sterno-mastoid muscles ; su- Fig. 59., Lines of incision for carotid, facial, lingual, subclavian, and axillary arteries. perior and middle thyroid, and anterior jugular veins ; descen- dens noni and communicans noni nerves. Posterior.— LiOngus colli and rectus capitis anticus muscles ; sympathetic, recurrent laryngeal nerves ; inferior thyroid artery. Internal. — Trachea, oesophagus, larynx, pharynx, recurrent laryngeal nerve, and inferior thyroid artery. External.— InternsA jugular vein, infe- rior thyroid artery. On the left side the internal jugular vein is somewhat anterior to the artery. Collateral circulation. Inferior with superior thyroids, ascend- ing branch of transversalis colli with princeps cervicis, terminal branches of internal and external carotids on the two sides. Operation, above the omo-Jiyoid. Patient supine with a pillow under the shoulders and neck, head extended, face turned 264 ESSENTIALS OF SURGERY. towards sound side. Incision, three inches, along the anterior border of the sterno-eleido-mastoid muscle, and with its centre on a level with the cricoid cartilage. Divide skin, superficial fascia, platysma, deep fascia. With retractors draw aside the sterno-niastoid. Expose the omo-hyoid by cutting through a dense fascia covering it and the sheath of the vessels, carefully avoiding the venous plexus formed by the superior thyroid with its communications from the lingual, facial, anterior and ex- ternal jugular. The sheath of the arter}' is found bisecting the angle made by the anterior belly of the omo-hyoid and the anterior border of the sterno-mastoid. Open the inner compart- ment of the sheath, avoiding descendens and communicans noni nerves, and pass the ligature from without inward. External carotid. A branch of the common carotid, given off at upper border of thyroid cartilage. It extends from the superior border of thyroid cartilage, to neck of condyle of lower jaw. Chief relations. Anterior. Hypoglossal nerve, lingual and facial veins, digastric muscle. Posterior. Superior laryngeal and glosso-pharyngeal nerves. Internal. Hyoid bone and jjharynx. External. Internal carotid artery and internal jugu- lar vein. Collateral circulation. Lingual, superior thyroid, occipital, and the same of the opposite side. Operation. Incision midway between angle of jaw and ante- rior border of sterno-eleido-mastoid muscle, carried down three- eighths of an inch in front of the latter to one-half inch below upper border of thyroid cartilage. Divide skin, superficial fascia, and platysma at once. Slit up the deep fascia spreading from the anterior border of the sterno-eleido-mastoid, avoiding the external jugular, temporal, and facial veins. By blunt dissection the parotid gland and the posterior belly of the digastric are ex- posed ; the latter is drawn upward with blunt hooks, when the external carotid is found, crossed by the hypoglossal nerve, with the superior laryngeal nerve lying beneath. Pass the needle from without inward. Lingual. Is given off from the external carotid between the superior thyroid and facial. LIGATION OF ARTERIES. 265 In the first jMrt of its course, from its origin to tlie posterior border of the hyoglossus, it passes obliquely up and in to the great cornu of the hyoid bone, and is covered simply by skin, fasciae, platysma, and veins, resting on the middle constrictor. In the second xjavt of its course, beneath the hyoglossus muscle, it runs parallel with the great horn of the hyoid, then ascends to the tongue. It is crossed here by the posterior belly of the digastric and the stylo-hyoid muscles, and is covered by the hyoglossus muscle. Chi<^f relations. Anterior. Hyoglossus muscle. Posterior. Middle constriction of pharynx, and genio-hyoglossus muscle. Above. Hypoglossal nerve. Below. Tendon of digastric, and great horn of hyoid bone. Point of election. Second part of artery, lying beneath hyo- glossus. Ope^ration. Incision three inches ; begin a little below and internal to the symphysis menti, convex downward to the great horn of the hyoid, and outward to the inner border of the sterno- mastoid. The three outer layers being divided the submaxillary gland is reached, lying in the deep fascia ; the latter is divided and the gland turned up exposing the tendon of the digastric, and the hypoglossal nerve above ; the nerve is dissected up and retracted exposing the hyoglossus muscle, which, when divided upon a director, enables the operator to pass the ligature about the artery from above downwards. Superticial guide, great horn of hyoid. Deep guide, nerve and tendon. Facial arises from external carotid, a little above the hngual, passes beneath the posterior belly of the digastric and stylo- hyoid muscles and hypoglossal nerve, winds through a groove in the posterior and upper border of the submaxillary gland, and crosses the lower jaw in a slight depression just in front of the insertion of the raasseter muscle. Here is the point of election ; the artery is covered at this point by skin fascia and platysma. Operation. Incision one inch, just on the jaw, along the anterior border of the masseter muscle ; vein lies posteriorly. Pass the thread from behind forward. Guides. Anterior edge of masseter muscle, and groove in the submaxillary bone. ^ 266 ESSENTIALS OF SURGERY. Occipital arises from the external carotid opposite the facial, and passes backwards under the posterior belly of the digastric, the stylo-hyoid, and the lower part of the parotid gland, across the internal carotid artery, internal jugular vein, and the pneu- mogastric and spinal accessory nerves. The hypoglossal nerve hooks around it beneath the gland. The artery ascends the neck to the level of the transverse process of the atlas, passes through a groove on the mastoid process of the temporal bone, beneath the sterno-mastoid, splenius, digastric, and trachleo- mastoid, pierces the insertion of the splenius, and becomes super- ficial. Operation. Point of election. Occipital portion. Incision ivovo. the apex of the mastoid process backward and very little upward for two inches. Divide skin, superficial fascia, deep fascia, and outer border of the sterno-mastoid, the splenius, the complexus. Guides. Transverse process of the atlas, and the mastoid process ; the artery is found between the two, and can be traced outward to a more superficial position. Isolate from the occipital vein, and ligate. Temporal. A terminal of the external carotid. It lies in the space between the condyle of jaw and external auditory meatus. Line. Directly upward, between the condyle of jaw and the cartilage of the ear. Chief relations. Anterior. Branches of facial and auriculo-tem- poral nerves. Posterioi\ Vein, and facial and auriculo-temporal nerves. As it crosses the root of the zygoma, the arter}' is cov- ered by a dense fascia derived from the iDarotid gland, this should not be opened. Operation. Incision vertical, one inch long, between the car- tilage of the ear and the condyle of the jaw. Skin, superficial fascia, and some fibres of the attrahens aurem are divided, artery freed, and thread passed from behind forward. -n" Subclavian. On the right side from the innominate. On the left side from the arch of the aorta. Three portions — 1. From its origin to inner border of scalenus anticus. This portion gives ofi'the thyroid axis, the vertebral, and the internal mammarv arteries. LIGATION OF ARTERIES. 267 2. Behind the scalenus anticus. Gives off superior intercostal artery on the right side. 3. Outer edge of scalenus anticus to lower border of first rib. Point of election is the outer third. Belations of the outer third. Posterior. Scalenus medius. Above and external. Brachial plexus. Anterior and below. Subclavian vein. Internal. Edge of scalenus anticus. Structures lying in front. Skin, superficial fascia, platysma, deep fascia, a plexus of veins formed by the external jugular, suprascapular, and transversalis colli ; clavicle and subclavius muscle ; suprascapu- lar artery. Operation. Position of patient, recumbent, shoulder supported on pillows, head back, face toward sound side, arm of the affected side depressed as much as possible. Superficial guide^ most promi- nent part of clavicle. Deep guides^ brachial plexus above and behind, outer edge of scalenus anticus muscle, and tubercle of first rib internal. Incision. The skin is drawn down from the neck over the clavicle, and a three-inch incision made upon the bone, from the external border of the sterno-mastoid muscle out- wards. On releasing the skin this wound lies somewhat above the clavicle. Secure or push aside the external jugular vein, open the deep fascia, feel for the tubercle of the first rib and the outer border of the anterior scalene muscle ; free the artery b}' blunt dissection, and pass the thread from below. Collateral circulation. Suprascapular artery and posterior scapular, branch of the transversalis colli with the subscapular and circumflex. Internal mammary, superior intercostal, and aortic intercostals, with the long and short thoracics. First part of subclavian artery. Bight side. In front. Skin, superficial fascia, platysma, and deep fascia. Three muscles, sterno-mastoid, sterno-hyoid, sterno-thyroid. Three veins, internal jugular, vertebral, anterior jugular. Three nerves, vagus, cardiac filaments of sympathetic, phrenic. Behind. Longus colli, and three nerves, sympathetic cardiac branches of vagus and recurrent laryngeal. Below. Pleura and recur- rent laryngeal. Left side. Longer, more deeply placed, ascends almost verti- cally to neck. In front. Pleura, lung, internal jugular and 268 ESSENTIALS OF SURGERY. innominate veins, tlie same muscles and nerves as on the right side. Behind. (Esophagus, tlioracic duct, and as on right side except the recurrent laryngeal. Inner side. (Esophagus, trachea, thoracic duct. Outer side. Pleura and lung. Second part of the suhclavian. Rests between the anterior and middle scalene muscles, with brachial plexus above; phrenic nerve, transversalis colli and suprascapular arteries in front; and pleura helow. Internal mammary. Arises from the first portion of the sub- clavian and passes down behind costal cartilages to sixth inter- space. Line of incision is vertical, two and one-quarter inches long, beginning at lower border of clavicle one-quarter of an inch external to margin of sternum ; or the incision may be trans- verse. The point of election is in the first three intercostal spaces. Chief relations. Anterior. Costal cartilages and internal intercostal muscles. Posterior. Pleura. As it is about to enter the chest it is crossed by the phrenic nerve. Axillary. Continuation of the subclavian. Extends from the lower border of the first rib to the lower border of the insertion of the teres major. Course. With abducted arm, from the middle of the clavicle to the inner border of the coraco-brachialis muscle. Tliree portions— 1. Lower border of first rib to upper border of pectoralis minor. Branches. Superior thoracic, acromio-thoracic ; the latter runs along the upper border of the pectoralis minor. 2. Behind pectoralis minor. Branches. Long thoracic, at the lower border of the pectoralis minor, alar thoracic. 3. From lower border of pectoralis minor to insertion of latis- simus dorsi and teres major. Branches, subscapular running in the posterior axillary fold, posterior circumflex, anterior circum- flex. Points of election. First and third portions, particularly the last. Operation. First part. Patient supine, arm carried from the side. Incision three inches, commencing one-half inch from the sterno-clavicular articulation, extending outward along the line LIGATION OF ARTERIES. 269 between the sternal and clavicular portions of pectoralis major. Work upward and backward between the two portions of the pectoral muscle till a dense fascia, the costo-coracoid, is reached ; depress the shoulder and tear the fascia with the director, when the axillary vein is found ; behind it is the artery, and still deeper the brachial plexus. Pass the ligature from below. Guides. The brachial plexus behind and above. Subclavian vein, below and in front. Inner border of pectoralis minor, externally. Third portion. Arm abducted and supinated. Incision three inches long, in the hollowof the armpit, along a line passing from the junction of the anterior and middle third of the axilla to the middle of the bend of the elbow. Divide skin, superficial and deep fascias ; relax by bending the elbow, displace the median nerve to the outer side, the axillary vein with the ulnar and internal cutaneous nerves to the inner side. Open the sheath, and pass the thread from the inner side. Relations. In front. Skin and fascia only at lower part of its course. At the upper part, pectoralis major, internal cutane- ous nerve, inner head of median. Behind. Subscapularis, tendon of latissimus dorsi and teres major, musculo-spiral and circumflex nerves. Outer side. Coraco-brachialis, median nerves, musculo-cutaneous nerve. Inner side. Ulnar nerve, nerve of "Wrisburg, axillary vein. Guides. Superficial, the coraco- brachialis. Deep, the branches of the brachial plexus. Collateral circulation. Ligation of first pjart. Acromio-thoracic and superior thoracic with subscapular and circumflex. Long thoracic with intercostals and internal mammary. Ligation of third part. Posterior circumflex and subscapular with superior profunda ; anastomoses through muscular branches and through the bone. J Brachial. Continuation of the axillary, from the lower bor- der of the teres major, along the inner and anterior aspect of arm to one-half inch below the bend of the elbow. Passes along the inner border of biceps and coraco-brachialis, which are its mus- cles of reference, or guides. Chief relations. Anterior. vSkin and fascia ; at middle third median nerve ; at lower third, bicipital fascia with median basilic 270 ESSENTIALS OF SURGERY. Fig. 60. vein resting on it. Posterior. Long head of triceps, insertion of coraco-brachialis, brachialis anticus, musculo-spiral nerve, supe- rior profund artery. Inner side. Internal cutaneous and ulnar nerves, median nerve (below), basilic vein. Outer side. Median nerve (above), coraco-brachialis and biceps. The median nerve first to the outer side, passes in front, then to the inner side. Branches, 1 muscular, 2 superior profund, accompanying raus- culo-spiual nerve, 3 inferior profund, accompanying the ulnar nerve, 4 nutrient, 5 anastomotica magna. Operation. Arm extended and everted. Incision three inches, along the inner border of the biceps, or in the line of the artery (from the junction of the anterior- and middle third of the axilla, to the middle of the bend of the el- bow). Avoid the median basilic vein if it lies in the superficial fas- cia at the seat of operation. At the bend of the elbow. Incision three inches. One-half inch inter- nal to the tendon of the biceps, the lower end lying over the neck of the radius. Divide skin, superfi- cial fascia, bicipital fascia, avoid- ing or tying the median basilic vein. The artery is exposed, lying upon the brachialis anticus, with the biceps tendon to its outer, the pronator radii teres nmscle to its inner side. Collateral circulation. Circum- flex and subscapular with supe- rior profund ; profund with radial ulnar and interosseous recurrents. Eelation of brachial artery to bicipital fascia, internal cutane- ous nerve, and median basilic vein at the bend of the elbow. Radial. A terminal of the brachial, passes from one-half inch below bend of elbow, along radial side of forearm to wrist, winds backwards around outer side of LIGATION OF ARTERIES. 271 carpus beneath extensors of thumb, and enters pahn of liand beneath the two heads of the first dorsal interosseous muscle. Line. From middle of bend of elbow to a point midway be- tween tendon of flexor carpi radialis, and styloid process of ra- dius. Guide. Inner border of supinator longus. Chief relations. Upper third. External^ supinator longus mus- cle ; internal^ pronator radii teres. Lower tivo-thirds. External, supinator longus ; internal, flexor carpi radialis. In the middle third the radial nerve is to the radial side of the artery. Operation. Division of skin and fascial only ; the artery is superficially placed in the muscular interspace. Ulnar. A terminal of the brachial. Commences one-half inch below middle of bend of elbow, crosses obliquely to ulnar side of arm, and continues along its ulnar border to the wrist. Line. From a point at junction of upper and middle thirds of forearm, and three-fourths of an inch external to ulnar border, to the radial border of pisiform bone. Chief relations. Below, flexor profundus digitorum ; external, flexor sublimis digitorum ; internal, flexor carpi ulnaris and ul- nar nerve. In the upper third of its course it lies beneath the superficial set of flexor muscles. In the lower two-thirds, in its muscular interspace beneath the superficial and deep foscia only. Operation. Pass the needle from within outwards. Guide — flexor carpi ulnaris. Palmar arches. Superficial. Direct continuation of the ulnar artery, convex downwards, completed by the superficialis volse of the radial, or the radialis indicis. Beneath it lie the digital arteries, nerves, and tendons of the flexor sublimis digitorum. Deep. The direct continuation of the radial, completed by the profunda branch of the ulnar ; it rests upon the palmar inter- ossei, and metacarpal bones near their carpal ends. It lies beneath the arteries, nerves, and tendons of both superficial and deep flexors. Position of the arches. The superficial lies in a line drawn directly across the palm of the hand, from the angle of junction of skin covering the inner border of the thumb and the outer 272 ESSENTIALS OF SURGERY. border of the metacarpal bone of the index-finger. The deep arch Ues a flnger-s breadth nearer the wrist. External iliac. A branch of the common iUac. Its course is represented by the lower two-thirds of a line drawn from three- fourths of an inch below and to the left side of the umbilicus, to a point midway between the anterior superior spinous process of the ilium and the symphysis pubis. Just above Poupart's liga- ment it gives off the deep epigastric, and the deep circumflex iUac. Chief relations. Anterim\ Peritoneum, spermatic vessels, vas deferens, genital branch of genito-crural nerve, circumflex iliac vein. Posterior. Psoas magnus and, on the right side, the ex- ternal iliac vein. External. Psoas magnus. Internal. External iliac vein and vas deferens. Operation. Patient recumbent, shoulders raised, knees and thighs flexed. Incision. From one inch above anterior superior spinous process ilium, to external abdominal ring, parallel to Poupart's ligament. Pass the needle from within outwards, and avoid including the genital branch of the genito-crural nerve. Collateral circulation. Gluteal and obturator with external circumflex. Sciatic with superior perforating and circumflex branches of profunda. The deep circumflex iliac with the ilio- lumbar, the lower intercostals, and the lumbar branches of the aorta. Internal pudic with the external pudic and internal cir- cumflex. Mammary, inferior intercostals, and obturator with deep epigastric. Femoral. The direct continuation of the external iliac, and extends from the middle of Poupart's ligament to the opening in the adductor magnus. Its upper part is a little internal to the head of the femur ; its lower part lies to the inner side of the shaft of the bone. In Scarpa's triangle it is superficial. Below it is more deeply seated, and is in Hunter's canal. Line. Prom middle of Poupart's ligament to inner side of Internal condyle. LIGATION 07 ARTERIES, 273 Branches. Superficial epigastric, superficial circuJiiflex iliac, exter- nal pudic, profunda, fcmoris, anastomotica magna. Point of election. Apex of Scarpa's triangle. delations. Behind. Psoas, pectiueus, femo- ral vein, adductor lon- *gus, adductor magnus. Inner side. Femoral vein, adductor longus, sartorius. Outer side. Psoais, vastus internus, femoral vein, internal cutaneous and long sa- phenous nerves. In front. Skin, superficial and deep fascia, internal cutaneous and long sa- phenous nerves, sarto- rius. The vein lies first to the inner side of the artery, at the apex of Scarpa's triangle be- hind, in Hunter's canal to the outer side. • Operation. Point of election. Thigh flexed and rotated outward, knee bent. Incision four inches in the course of the vessel, its centre at Lines of incision for liga- tion of femoral, tibial, and dorsalis pedis arteries. 18 Fig. Gl. 274 ESSENTIALS OF SURGERY. the apex of Scarpa's triangle. On dividing the deep fascia, draw the sartorius outwards. The sheath of the vessel is cleared, and the thread 'passed from the vein, Hunicr''s canal. Incision four inclies exactly in the middle third of the thigh, and somewhat internal to the line of the nrterj. Draw the sartorius inwards, open Hunter's canal from ;ibove, avoiding the long saphenous nerve, free the artery, and pass the thread from without inwards. Scarpa's triangle is a space situated at the upper third of the anterior surface of the thigh. Base, Poupart's ligament. Outer houndary, inner border of sartorius. Inner 'boundary, adductor longus. Hoof, skin, superficial, deep and cribriform fascia. • Floor, iliacus, psoas, pectineus, adductor longus, and adductor hrevis. Apex, crossing of sartorius and adductor longus. Length, from base to apex, four inches. Sunter^s canal. A triangular, aponeurotic canal, correspond- ing to the middle third of the thigh. Anterior, sartorius. Ex- ternal, vastus intern us. Internal, adductor magnus This canal incloses the femoral artery, vein, and long saphenous nerve. Collateral circulation. Common femoral. Gluteal, circumflex iliac and ilio-lumbar with the external circumflex. Obturator and sciatic, with internal circumflex. At ajjex of Scarpa"^ s triangle. Comes nervi ischiadici with arteries of the ham. Perforating branches of profunda femoris and anastomotica magna with articular arteries of popliteal, and recurrent of the anterior tibial. Popliteal. A continuation of the femoral, from the opening in the adductor magnus. It passes obliquely downwards and outwards behind the knee-joint, and ends at the lower border of the popliteus muscle. The artery, throughout its extent, lies in the popliteal space. It lies deep, and is crossed by the internal popliteal nerve and the pophteal vein. The nerve lies super- ficial to the vein, which, in turn, is superficial to the artery. Line. Middle of ham ; the vessel runs along the external border of the semi-membranous tendon. Belations. Upper third, from outer side, 1. Nerve. 2. Vein. 3. Arter}'. Lower third from outer side, 1. Artevy. 2. Vein. 3. Nerve. Branches, 4 articulars, 2 muscular, azygos, cutaneous. LIGATION OF ARTERIES. 275 Operation. Rarely undertaken. Patient supine, leg extended. Incision four inches, in the line of the artery. Great care must be exercised in separating the vein from the artery. In opera- ting on the lower third, avoid the external saphenous vein. Collateral circulation. Articulars with anastomotica magna and external circumflex. Superior muscular branches with terminals of profund. Fig. 62. The arrow marks the tendinous arch between the flexor longug pollicis and flexer longus digitorum, beneath which the posterior tibial artery Ilea. Posterior tibial. Trom the popliteal, at the lower border of the popliteus muscle (corresponding to the level of the lower part of the tubercle of the tibia), to a point a finger's breadth behind the external malleolus. The vessel is covered by skin 273 ESSENTIALS OF SURGERY. and fascia, gastrocnemius, soleus, plantaris, and a tendinous arch extending between the flexor longus digitorum and the flexor longus pollicis. The posterior tibial nerve crosses the artery in its upper portion, from the inner to the outer side. The artery rests upon the tibiaUs posticus, the flexor longus digi- torum, and the lower end of the tibia. Line of incision. Upper third, along inner border of tibia. Middle third, one-half inch from inner border of tibia. Lower third (ankle), midway between internal malleolus and tendo Achillis. Pass the ligature from the nerve. Incision in upper and middle third four inches. The artery in its upper third lies very deep, and is secured by separating the soleus from the tibia workiug outwards in the muscular interspace between the soleus and the flexor longus digitorum. Behind malleolus. Incision two inches long, a finger's breadth behind the internal malleolus, convex backward. Artery lies beneath the deep fascia. Eelations. Anterior. Tendon of flexor longus digitorum. Posterior. Kerve and tendon of flexor longus pollicis. Branches. Nutrient, peroneal, muscular, com- municating calcanean. Anterior tibial. Commences at the lower border of the pop- liteus muscle, passes forwards between the two heads of the tibialis posticus, through an opening above the interosseous mem- brane to the deep part of the front of the leg, descends on the anterior surface of the interosseous membrane (upper two-thirds), and tibia (lower one-third), to the middle of the bend of the ankle joint, where it is more superficial and becomes the dorsalis pedis. Line. From a point midway between the tubercle of tibia and head of fibula to the centre of the intermalleolar space. The ligature is passed from the outer side. Belations. Upper third. Between the tibialis anticus and ex- tensor longus digitorum. Nerve to outer side. Middle third. Between tibialis anticus and extensor proprius pollicis. Nerve in front or to inner side. Lower third. Between extensor pro- prius pollicis and extensor longus digitorum, or frequently as in middle third. Nerve to outer side. LIGATION OF ARTERIES. 277 Operation. Upper third. Patient supine. Knee flexed, sole of foot resting on table. Incision three inches. After opening deep fascia search with handle of knife for interspace between tibialis anticus and extensor communis digitorum ; artery found between them resting on interosseous membrane. Nerve to outer side. Pass thread from without. The interspace may be defined by extending the toes and the foot in turn, thus putting each muscle upon the stretch. Middle and lower third, as for upper third, except for the changed relations. Branches. Ante- rior tibial recurrent, muscular, internal malleolar, external mal- leolar. Dorsalis pedis. The continuation of the anterior tibial. Ex- tends from the centre of the instep beneath the annual ligament, to the base of the metatarsal bone of the great toe, where it divides into the communicating and dorsalis hallucis. Its course is from the centre of the instep, to the space between the first two toes. It is covered simply by skin and fascia, and crossed near its point of bifurcation by the innermost tendon of the extensor brevis digitorum, which serves as a guide in its ligation. The ligature is passed from without inwards. The artery is found between the tendon of the extensor proprius pollicis and the inner tendon of the extensor brevis digitorum. Anterior tibial nerve lies to the outer side. Incision one inch long. External plantar artery^ a terminal branch of the posterior tibial. Passes from the lower part of the internal lateral liga- ment posterior to the internal malleolus, forward and outward, taking a slightly arched course with the convexity outward, to the base of the fourth metatarsal space. This forms its superfi- cial part, and is covered by the fasciae and first layers of the foot muscles. From this point it winds round the outer border of the accessorius, and passes forward and inward to the posterior part of first interosseous space, forming the plantar arch, and lying upon the interossei, and bases of the metatarsal bones. 278 ESSENTIALS OF SURGERY. EXCISION OF JOINTS. What is the distinction between excision and resection ? Excisiou means the removal of the joint surfaces of bone. Re- section means the removal of the shaft of a long bone. What is arthrectomy ? The removal, by dissection, of the diseased synovial mem- brane of a joint, without interfering with the bone. What conditions may require excision ? Injury. Instance, compound luxation, compound commi- nuted fracture. Disease. Instance, tubercular synovitis or arthritis. Deformity. Instance, anchylosis in bad position. What conditions contraindicate excision ? Malignant growth. x\.cute disease. Extensive involvement of bone or soft parts. Extremes of age. Marked amyloid degene- ration. What precautions are observed in excising a joint ? The incision should be free, and in the long axis of the limb. Spare the bone, substituting the gouge or curette for the saw whenever practicable. Save the periosteum and the capsule of the joint, if they are healthy. Secure absolute immobility by splinting. How do yon dress an excision ? Bone drainage-tubes, iodoform, protective, bichloride gauze, bichloride cotton, plaster bandage. TThere a movable joint is desired, do not apply the fixed dressing. Shoulder-j Dint. Position of patient, on his back, the affected shoulder projecting beyond the side of the operating table. Incision four inches in length from a point slightly above and to the outer side of the coracoid process, downward and some- what outward, external to the cephalic vein. The long head of the biceps should be freed by a longitudinal cut. The humerus is rotated outwards, and the periosteum and tendon of the subscapu- EXCISION OF JOINTS. 2T9 Fig. (13. laris separated by the elevator. The humerus is then rotated in- wards, and the periosteum and muscular attachments to the greater tuberosity are separated. Finally the humerus is forced directly upward, the posterior part of the capsule is freed by the periosteal elevator (avoid the posterior circumflex ar- tery and circumflex nerve), the bone is sawed through the surgical neck. A posterior opening is made for drainage, and the wound dressed with a pad in the axilla and the arm to the side. Motion as soon as possible. Elbow-joint. Incision three to four inches long, slightly internal to the middle line of the olecranon and humerus, with its central point opposite the top of the olecranon. Clear the olecranon of periosteum and soft parts with the elevator (carefully guarding the ulnar nerve) and saw off; now forcibly flex the hu- merus and clear it in the same way, sawing from before backward, just above the trochlear surface. Finally clear the ends of the radius and ulnar, and remove their articulating extremities just below the sigmoid notch and capitellum. Strip the hones suh- periosteally. Wrist-joint. Two incisions. The radial incision, planned to avoid the artery, commences at the level of the styloid process, on the middle of the dorsal aspect of the radius, passes downward, parallel to the tendon of the extensor secundi internodii polli- cis, till it reaches the line of the border of the second metacarpal bone ; it is then carried longitudinally downward for half the length of the bone. The ulnar incision. From a point two inches above the lower extremity of the ulna and just anterior to the inner edge of the bone, downward as far as the middle of the fifth metacarpal bone. Hip-joint. Anterior incision, three inches long, running down- ward and slightly outward, from half an inch below and external to the anterior superior spinous process of the ilium. Metacar- pal saw. 280 ESSENTIALS OF SURGERY Posterior incision. Begin midway between anterior superior spine of ilium and top of trochanter ; sweep backward and downward behind posterior mar- gin of the trochanter for about three inclies, keeping about an inch back of the edge of the bone. Do not force the head of the hone from the wound^ but di- vide in situ by a narrow saw; remove subsequently with se- questrum forceps. Curette and gouge away all diseased portions of the acetabulum, remove dis- eased synovia or capsule, wash out with zinc chloride, dry with bichloride sponges, dust with iodoform. Dress antiseptically and applj^ a double Thomas's splint. Knee-joint. Incision from the outer and posterior border of the internal condjie, to a corre- sponding point on the external condyle, curving downward suf- ficiently to pass midway between the patella and the tuberosity of the tibia. Dissect up the an- terior flap containing the patella, flex the joint, divide the lateral and crucial ligaments, clear the end of the femur with the finger, saw at right angles to its long axis near the upper margin of the cartilaginous surface. Use Butcher's saw, cutting from be- hind forward. Clear the end of the tibia, and remove its articu- lating extremity. Remove by the gouge or curette all diseased Butcher's saw. EXCISION OF JOINTS. 281 tissue. Suture the bone together with thick cat-gut or silver wire, provide for drainage, and close. Absolute fixation, plaster bandages if the wound remains aseptic. Ankle-joint. Yery rarely performed. Every effort should be made to preserve the periosteum. Two incisions are made. The fibular begins two-and-a-half inches above the tip of the ex- ternal malleolus, passes downward along its posterior border, around its tip, and upwards along the anterior border for an inch (hook-shaped). The tibial forms a semicircle around and just below the internal malleolus, from the middle of which a third cut runs directly upwards over the malleolus for two inches (an- chor-shaped). The periosteum is first raised from the fibula, when the bone is sawed and removed. Kext, the articulating end of the tibia is removed ; finally the astragalus is sawn through. If the elevator is carefully used, the tendons and their sheaths will not be damaged. 282 ESSENTIALS OF SURGERY. AMPUTATIONS. Unier what circumstances is amputation required? 1. Avulsion of a limb. 2. Mortification. 3. Compound luxa- tions and fractures, if seriously complicated. 4. Extensively lacerated and contused wounds. 5. Diseases of bones and joint^^. 6. Lesions or diseases of arteries. 7. Morbid growths. 8. De- formity. What instruments are required in amputation ? Tourniquets, knives, saws, retractors, tenacula, artery forceps, haemostatic forceps, bone-nippers, scissors, needles, and sutures. Describe the methods of operating. 1. Circular. The skin is drawn upward and divided by a cir- cular sweep of the knife, passing entirely around the limb, and Amputation by the circular method. dividing everything down to the muscles ; this skin cuff is further dissected up till its length is a little greater than half the dia- meter of the limb ; it is then retracted, the muscles are separated down to the bone by a second circular incision, and the latter is sawed through. 2. Flap. There may be one or two flaps ; these may be ante- rior, posterior, lateral, square or oval ; they may be cut by trans- fixion, or from without, and may include all the soft parts (mus- AMPUTATIONS. 283 culo-cutaneous), or simply the skin and superficial fascia (cuta- neous). Describe the methods of shaping the flap. Modified circular. Two short, curved, skin-flaps are cut, and the notched skin cuff is dissected up as in the circular method. Fig. 66. Fi?. 67. .-*\> Formation of flaps by transfixion. Teale's amputation. Oval and elliptical. The oval method is practically a circular incision, with the cuff slit at one side, and its angles rounded off. In the elliptical method the incision forms a perfect ellipse ; the flap is folded upon itself and sutured, making a curved cica- trix. Teale's method. Rectangular flaps, each equal in breadth ; one has a length of half the circumference of the limb, the other (con- taining the bloodvessels) is only quarter as long. How are amputations classified in regard to the time of ope- rating ? Primary., before the occurrence of inflammatory fever. Inter- mediate., during acute inflammatory fever. Secondary^ after sup- puration has been established. What period is most favorable for amputation ? Before the occurrence of inflammatory fever. If the time for primary amputation has passed, wait for the secondary period. 284 ESSENTIALS OF SURGERY. What sequelae may occur after amputation ? Hemorrhage, muscular spasm, pain, inflammation, osteomye- litis, protrusion of bone. Amputations of the Foot. \^/ Fig. 68. Lisfranc's amputation. Tarso-metatarsal disarticulation ; be- tween the metatarsal bones and the three cuneiforms and cuboid. Incision. From the base of the first to the base of the fifth metatarsal bone across the 'dorsum of the foot, with a marked convex curve downward. Forcibly extend and disarticulate, bearing in mind the backward pro- jection of the second metatarsal bone. Cut a long plantar flap. Ai-teries. Dorsalis pedis and plan- tar arches. Hey's amputation. The same as Lisfranc's, except that the projecting internal cuneiform bone is sawed through. Chopart's amputation. Intertar- sal disarticulation, between the as- tragalo-scaphoid, and calcaneo-cu- boid joint. Incision. From a point midway between the tuberosity of the fifth metatarsal bone and the external malleolus, a curved dorsal incision is made to a point one-half inch l)elund the tubercle of the scaphoid. Extend the foot, dis- articulate, and cut a long plantar flap. Pirogoff's amputation. Through the ankle-joint and os calcis. Incision, from the tip of the external malleolus, across the under surface of the heel, to a point half an inch below and Ii. Lisfranc's operation. H. The extremity of the internal cuneiform removed by Hey's operation. C. Chopart's ope- ration. AMPUTATIONS. 285 behind the internal malleolus. Incline this cut well forward. Forcibly extend the foot and unite the ends of the first incision by a deep cut passing directly across tlie dorsum. Open the joint, draw the foot forward, place a narrow saw behind the astragalus and saw the os calcis through in the line of the first skin incision. Saw ofl' the ends of the tibia and fibula, brinsr the heel flap up till the sawn bone surfaces are in contact, unite them with heavy catgut, and suture the wound. Syme's amputation. Through the ankle-joint. Incision. Inclining backward from tip of external malleolus, beneath the heel, to a point half an inch below and behind the internal malleolus. Dissect the flap from the os calcis cutting towards the hone. Unite the ends of the first incision by a trans- verse cut across the front of the ankle-joint, disarticulate, saw off" the articular extremities of the tibia and fibula, and bring the flaps together. Amputations of the Leg. Lower third of the leg. By the circular, modified circular, bilateral tegumentary flap, Teale's method. The fibula should be divided first. Arteries. Anterior and posterior tibial, pero- neal, and muscular. Middle and upper third of the leg. By a long anterior tegu- mentary flap half the circumference of the limb in breadth and a little more in length. By short antero-posterior flaps. By lateral musculo-tegumentary flaps (Sedillot's). The projecting sharp edge of the tibia should be cOvei?ed with a flap of perios- teum to prevent perforation of the anterior flap. Lateral double flap method (Sedillot's). A long external flap is formed by transfixion, and united to the short internal flap formed by the calf muscles. Lateral tegumentary flaps may be formed cutting from with- out inward. Point of election in leg amputation. Two inches below the tuberosity of the tibia. 286 ESSENTIALS OF SURGERY. Amputations at the Knee-Joint. "Where indicated by injury or disease this is one of the most successful of all leg amputations, and leaves a far more service- able stump than amputation in the continuity of the limb. Lateral flap operation. Commence the incision in the middle line an inch below the tubercle of the tibia, form a flap convex downward, carrying the point of the knife to the centre of the posterior surface, when it is continued directly upward to the centre of the articulation. The second incision begins at the same point as the first, and pursues the same course on the op- posite side of the leg to the posterior median line. The anterior incisions should incline forward to allow sufficient material for covering the cond3^1es. The internal flap should have additional fulness. The patella and semilunar cartilages are allowed to remain. Long anterior flap. Incision from the lower extremity of the inner condyle downward for three inches, then directly across the tibia and upward to the external condyle. Disarticulate and cut a short posterior flap. Amputation through the femoral condyles (Garden's). In- cision, from the upper border of the inn^^r, to the upper border of the external condyle, carried downward and across the front of the leg just below the insertion of the ligamentum patellae. Short posterior flap by transfixion. Condyles sawed across. The patella is not left in the anterior flap. Gritti's modification. Consists in sawing off the articular sur- face of the patella, turning it backward, and suturing it to the divided femur. Amputations of the Thigh. Antero-posterior musculo-tegumentary flaps. Anterior cut from without inwards, about four inches long, and somewhat AMPUTATIONS. 287 square. Posterior flap about the same length to allow for re- traction, cut by transfixion. The posterior muscles of the thigh always retract more than the anterior group. Lateral flap. Teale's method or modified circular operation may also be done on the thigh. Hip- Joint Amputation. Hemorrhage controlled by abdominal tourniquet, digital pres- sure on the femoral, and Esmarch's tube applied in the form of a spica of the groin. Long anterior and short posterior flaps. Enter the knife at a point midway between the anterior superior spinous process of the ilium and the tip of the trochanter, push it directly across the capsule of the joint, grazing the head of the bone, till it ap- pears on the inner side of the thigh just in front of the tuber ischii ; cut directly downwards for six inches, let the femoral arter}^ be seized by the fingers of an assistant, then complete the anterior flap by cutting outward. Turn the flap up, clear the cap- sule, forcibly extend the femur, and, placing the knife behind the trochanter, form a somewhat shorter posterior flap, Eirst secure the gluteal and sciatic vessels, then the femoral artery and vein. The flaps may be cut from without inwards, securing the vessels as cut. Vertical and circular method. A vertical incision is made, from a little above the tip of the trochanter for five inches in the long axis of the femur. Through the incision disarticulation is effected, and by means of the elevator and knife the soft parts are separated from the bone. At the lower extremity of the vertical incision, skin, fascia, and muscles are divided by a circular sweep of the knife around the thigh, and the entire femur, together with the soft parts below the circular cut, is removed. This operation is tedious, but far more safe than the double flap method. 288 ESSENTIALS OF SURGERY. Amputation of the Hand. Phalanges. The palmar flexure is the guide to the joint sur- face. Flex the joint, open it by a slightly convex dorsal in- cision a little below its most prominent part, and cut a long palmar flap. The digital arteries can usually be secured by the skin suture. The proximal phalanx of the middle and ring lingers should not be saved. Metacarpo-phalangeal. Oval method [en raquette). The point of the knife is entered in the mid dorsal line, a little above the knuckle, carried first downward, then around the side of the fin- ger, across its web and palmar surface, and back to the point of starting. Any of the bones of the hand may be amputated through their continuity by either the double flap, or the oval method. Wrist-joint. Incision, convex downward, from styloid process of radius to corresponding process of ulna. Dissect up the flap, divide tendons, disarticulate, and cut a palmar flap from within, guarding against the knife catching on the pisiform bone. Amputations of the Arm and Forearm. Forearm. Modified circular, or antero-posterior flaps. Teale's method. Arteries. Anterior and j)Osterior interosseous, radial and ulnar. Elbow-joint. The line of articulation is oblique, from with- out inward and downward, hence there will not be enough flap to cover the internal condyle if the knife is carried directly across the arm. Long anterior and short posterior flap. Flex and supinate the forearm, raise the soft parts from the bone, enter the knife an inch below the internal condyle, and push it across the limb close to the ulna, till it appears an inch and a half below the AMPUTATIONS. 289 external condyle. Make a three-inch flap, bringing the knife out sharply at the finish. Draw the skin well up and unite the two extremities of the incision by a semilunar dorsal cut. Dis- articulate, either dividing the triceps, or sawing off" the ole- cranon. Circular method. The incision is made three to four inches below the joint. Arm. Circular. Flap. Any of the methods. Shoulder- Joint. Oval method. (Larrey's.) Forming lateral musculo-tegument- a,ry flaps. Enter the point of the knife to the bone just below the acromion process, and make an incision downward in the long axis of the arm for about two inches. From the end of the incision two curved incisions are carried to the anterior and posterior axillary folds, respectively. These flaps are dissected up, and disarticulation is eff*ected by rotating the huuierus out- ward, and dividing first the subscapularis, then the long head of the biceps and capsular ligament, then rotating the humerus inward and dividing the insertions of the supra- and infra-spi- nator and teres minor muscles. The knife is now placed behind the bone, and the two curved incisions are joined by a trans- verse cut, severing the axillary artery, which is controlled by the thumb of an assistant before it is divided. Hemorrhage is checked by pressure on the subclavian, Esmarch's tube, and seizure of the artery in the flap before it is cut. Arteries. An- terior and posterior circumflex, supra-scapular, brachial. Single flap method. (Dupuytren's. ) A long external flap is cut from the deltoid muscle, either by transfixing, or from without in. 19 200 ESSENTIALS OF SL'KGERY. BANDAGING. The Roller Bandage. PesDribe the roller bandage. A strip of unbleached muslin, from half an inch to three inches in width, and from three to twelve yards in length. It may be made of calico, linen, or gauze. It is tightly rolled in the form of a cylinder ; the rolling may be from each end, forming the double-headed bandage. Name the parts of a roller bandage. The initial and terminal extremities, the upper and lower bor- ders, the internal and external surfaces, and the body of the roller. How do yon apply a roller bandage? Fix. The body of the roller being held in the right hand, the external surface of the initial extremity is applied to the surface, Fig. 69. Method of applying the spiral reversed bandage. fixed by the thumb of the left hand till it is caught by the band- age carried around the limb, when it is further held in place by a repeated circular turn. The following turns can be made to overlap this circular, covering in from a half to three-fourths of its surface. If the part is conical, the overlapping turns may be made to lie smoothly by the reverse. The circular turns are those which pass around the part, one passing directly over the other. The spiral turns are those which pass up the limb, each one overlapping the other. BANDAGING. 291 The oblique turns are those in which the bandage passes up the limb without overlapping, leaving space be- tween each turn. Fig. 70. Becurrent turns are those in which the bandage is caught, passed to and fro, across the end of a stump for instance, and the loops held at the sides by circular turns. Spica and Jigure-of -eight turns are those in which the bandage forms by oblique turns two loops in the form of an eight. By overlapping, the crossings of these loops form a series of angles or spicas. Describe the reverse. Consists in folding the bandage over, so that the surface in contact with the skin is changed with each reversed turn. This is accomplished by relaxing all tension on the roller, carrying the right hand, holding the body of the roller, from supination to pronation, passing the body of the roller to the left hand beneath the limb, and makins: firm traction. Oblique band- age. For what purposes is the roller applied ? The general indications for all roller bandages are to retain splints and dressings, and to make pressure. Spiral of one finger. Length, one-and-a-half yards ; width, three-fourths of an inch. Fix by a circular turn at the wrist once repeated. Carry the bandage down over the dorsum of the hand, and by an oblique turn to the extremity of the finger, which is then covered in by spiral or reversed turns as required. Com- plete the bandage by carrying it up to the wrist, over the back of the hand, and making one circular turn. Spiral of four fingers (gauntlet). Length, five yards ; breadth, one inch. Cover in each finger precisely as above, beginning with the little finger of the left hand, the index-finger of the right. As each finger is finished, the bandage is carried to the wrist, around, and then down to the next finger. The thumb may be included in this bandage if necessary. 292 ESSENTIALS OF SURGERY. Spica of the thumb. Length, three yards ; width, three-quar- ters of an inch. May be ascending or descending. Ascending. Fig. 71. Fig. 72. Fig. 73. Gauntlet, also t (king in the thumb. Spica of thumb. Spiral of one finger. Fix at the wrist. Pass to the metacarpo-phalangeal articula- tion, and make a circular. Pass to the wrist again, and alter- nate the wrist and thumb turns so that the line of crossing is over the dorsum of the thumb. Overlap two-thirds from below upward. The descending spica has the same turns, but over- laps from above downward. Demi-gauntlet. Length, three yards ; breadth, one inch. Fix at the wrist, pass obliquely across the back of the hand to the index-finger of the right hand the little finger of the left ; pass around the finger, and obliquely back to the wrist. Make a cir- cular turn, then take in the next finger in a simi^r way till each one is encircled by a loop. Spiral reversed of upper extremity. Length, twelve yards ; width, one and one-half inches. Apply with hand in pronation. Fix at the wrist. Carry across the back of the hand and make a circular turn about the fingers at the level of the distal joint of the little finger. Run up the hand with spiral reversed, or figure-of-eight turns, covering in the metacarpal bone of the thumb by means of the latter. Continue up the forearm with BANDAGING. 293 spiral turns till thej cease to fit closely to the surface, when the reverses must be made. The elbow must be covered in by a fig- ure-of-eight. Do not make the line of reverses (the line of pres- sure) over the subcutaneous portion of the ulna. Overlap two- thirds. Spica of the shoulder. Length, ten yards ; width, two-and- one-hali inches. Ascending or descending. Ascey^diny. Fix by sl circular turn about the arm placed as high as possible. Carry the bandage, overlapping the circular turn where it passes over it, across the chest (right side) or back (left side), under the oppo- site axilla and back to the point of starting. It is now carried around the arm, overlapping the circular turn, and making a spica directly in the middle line of the shoulder with the. beginning of the body turn. This is repeated, passing upward till the entire shoulder is covered in. The descending spica is applied by the same turns, but runs from above downward till it reaches the first circular turn. Velpeau. Length, fourteen yards ; width, two and one-half inches. For the proper application of this bandage the arm must be placed in the Velpeau position, the hand of the in- jured side resting on the sound shoulder. Commence over the scapula of the sound side, carry the roller over the injured shoulder to the middle of the outer aspect of the upper arm, across the chest (be- hind the elbow) to the axilla of the sound side, thence to the point of starting. Repeat this turn to fix, then make a circular turn about the chest, taking in the elbow of the injured side. Re- peat these turns, first shoulder, then body, overlapping so that the shoulder turns reach the point of the elbow when the body tuins Velpeau. Fig. 74. 294 ESSENTIALS OF SURGERY. take ill the wrist. This requires overlapping of about five-sixths for the vertical turns, one-third for the horizontal. Used to dress fractured clavicle or scapula. Desault. Eequires three rollers. First roller. Length, five yards ; width, two-and-one-half inches. It fixes a wedge-shaped pad, base up, in the axilla. Four spiral turns are made, encircling the thorax and pad, the roller is then carried from the pad obliquely to the sound shoulder, about which and the pad it is made to form a series of spica turns. Fig. 75. Fig. 76. Desault. First roiier. Desault. Second and third roller (the second is here applied last). Second roller. Length, seven yards ; width, two-and-one- half inches. Presses the elbow to the side, and forces the head of the humerus outward. It consists of a number of circular turns embracing the arm and chest, and running from the head of the humerus to the elbow, overlapping one-half. The upper .turns are applied very lightly, as they descend the tension on each turn is increased. Third roller. Length, seven yards ; width, two-and-one-half inches. Presses the shoulder upward and backward. Begin at BA^TDAGING. 295 the axilla of the sound side, carry the roller obliquely across the chest, over the injured shoulder, down the back of the humerus, around the elbow of the injured side, across the chest again to the point of starting ; then under the axilla of the sound side, obliquely across the back, over the injured shoulder, down in front of the humerus, around the elbow, across the back to the point of starting. This forms two triangles, one anterior the other posterior. Axilla, shoulder, elbow, first in front, then be- hind, represent the angles of the triangles. These turns may overlap two-thirds, or may exactly overlie. Spiral of chest. Length, seven yards ; width, three inches. Circular around the waist, ascends to the axilla by spiral turns overlapping one-half. Keep from slipping down by making a recurrent turn across one shoulder, pinning to the circular turns, bringing the bandage back over the other shoulder, and securing it to the circular turns in front. Anterior figure-of-eight of chest. Length, seven yards ; width, two-and-one-half inches. Fix by a circular about the right arm, then carry the roller over the shoulder, across the chest, around the left shoulder, across the chest again, ar<5und the right shoulder, across the chest, and so continue till the required number of turns have been applied. Over the sternum the spicas may run up, overlapping three-fourths. Posterior figure-of-eight of chest. Length, seven yards ; width, two-and-one-half inches. Fix the roller upon the upper part of the left arm, carry it over the left shoulder, obliquely across the back to the right axilla, around the right shoulder, obliquely across the back to the left axilla, and so continue till the necessary number of turns are applied. Spica of breast. May be single or double. Single. Length, ten yards ; width, two-and-one-half inches. Starting from the scapula of the affected side, carry tlie roller over the shoulder of the sound side, just beneath the affected breast, and around the chest to the point of starting ; repeat this turn, then make a circular around the chest, taking in the lower border of the mammary gland and making a spica or cross 296 ESSENTIALS OF SURGERY Fig. 77. with the oblique turn. Alternate these circular and oblique turns, and continue them, overlapping two-thirds, till the gland is covered in. The spicas or crosses should all be in the same line. Double. Length, fourteen yards (two bandages) ; width, two-and-one-half inches. This is made up of two oblique turns to each circular. Start from the left scapula and make a repeated oblique turn, passing over the right shoulder and under the left breast as before ; then carry the roller around the chest as though to make Spicaofbreast(clouble). ^ ^.^^^^^^^ ^^^^^ ^.^^ .^ p^^^^^ beneath the right breast, when it is carried obliquely upward over the left sl>oulder (passing above and to the inner side of the left breast) ; across the back, and a circular is made, just taking in the lower borders of the glands and making spicas with the two obliques. Spica of the Foot. Length, five yards ; width, two-and-a-half inches. Begin^by a circular turn about the ankle ; pass over the dorsum of the foot to the metacarpo-pha- langeal articulation ; make a circular and a spiral turn, overlapping three-fourths, then carry the roller over the dorsum of the foot to the back of the heel, around the heel, so that the lower border of the bandage extends as low as the level of the sole, then back to the dorsum of the foot, crossing the begin- ning of the heel turn exactly in the middle line as it overlaps the spiral turn ; this forms the first spica. Again pass around the sole of the foot, across the dorsum of the foot overlapping three-quarters, around the heel, and back across the foot, making the second spica. So continue till the foot is covered in. Each turn of the bandage, after the spica is begun, must be parallel to its pre- decessors throughout its whole extent, and must overlap to the same degree. Fig. 78. Spica of the foot. BANDAGING. 297 Spiral reversed of the foot covering^ in the heel. Length, four yards ; width, two-and-a-half inc-hes. Fix by a circular turn about the ankle, pass over the dorsum of the foot to the metacarpo-phalangeal articulation ; make a circular at that point, and pass up the foot by two or three reversed turns, over- lapping three-fourths ; having reached the top of the instep, carry the bandage around the 2J0int of the heel, up over the in- step, down around the sole of the heel obliquely, backward, and upward, below the malleolus, and around the back of the heel, forward to the instep. Again pass under the sole of the heel, beneath the malleolus, around the back of the heel, and forward to the instep. The bandage may be pinned at any point, or carried up the leg. Spiral reversed of the lower extremity. Length, twelve yards ; width, two-and-a-half inches. Tix at the ankle, pass down over the dorsum of the foot, and make a circular turn about the foot at the meta- tarso-phalangeal joint, pass ^^' up the instep by a spiral, a spiral reversed, and two or three spica turns : then pass up the leg by spiral tin*ns, beginning to reverse as soon as the shape of the limb re- quires it. Cover the knee with a figure-of-eight, and ascend the thigh by spiral reversed turns. Overlap two- thirds. Do not make the line of the reverse over the crest of the tibia Fig. 80. Pigure-of-eisrht for the knee. Figure-of-eight of the knee. Length, three yards ; width, two-and-a-half inches. Fix by a circular three or four inches below the joint, carry the bandage upward obliquely over the popliteal space, and make a circular about the thigh, three or four inches above the joint, descend obliquely over the popliteal Spiral reversed of the lower ex- tremity. 298 ESSENTIALS OF SURGERY. space, and make a circular about the leg, overlapping the first turn upward two-thirds, ascend and make a second circular about the thigh, overlapping downward two-thirds. So continue till the joint is covered. Spica of the groin. Single or double. Ascending or descend- ing. Single o,scending. Length, ten yards ; width, two-and-a- half inches. Fix around the upper part of the thigh (if it is the left side, the bandage must be applied throughout from right to left) ; carry obliquely across pubes, lower part of abdomen and crest of ilium, around the back, and dow^n to the starting-point, passing across the front of the thigh, and forming the first spica turn, which should be within the mid- dle of the anterior surface of the thigh ; repeat these turns, overlapping two- thirds in the groin, but converging as the bandage is carried to the crest of the ilium, till they overlie in the back. ^ememher that in all ascending spica bandages, the position of the crossing is determined by the lower border of the bandage ; in all descending spicas, the upper border determines the position of the turns. A well-applied spica should have all the angles of crossing exactly in line. Double ascending spica. Length, fourteen yards ; width, two- and-a-half inches. Fix by a circular around the waist, carry Spica of groin. Single ascending. Should be started around the thigh. BANDAGING. 299 obliquely downward across the belly, pubes, and left thigh ; around the left thigh, and up to the left iUac crest, forming the first spica ; around the back, and obliquely down, across, and around the right thigh, forming the second spica; obliquely across the belly to the left iliac crest, forming with the first oblique abdominal turn the third spica. Repeat these turns, taking in body, left thigh, body, right thigh, and overlapping two-thirds. There are three sets of crossings : one in the middle line of the belly, and one within the middle line of each thigh. Descending single and double spicas of groin. The turns are the same as for the ascending spicas, except that the first turns are placed at the highest point which it is desired to cover by the bandage, and the spicas are made by the upper border of the bandage. Head Bandages. Barton's. Length, five yards ; width, two inches. Begin be- hind the ear (left if standing behind the patient, right if stand- ing in front) ; carry the roller down under the occiput, and up Fig. 82. to a corresponding point behind the other ear; thence directly across the vertex, down the side of the face, under the chin, up the other side of the face to the ver- tex, making an intersection with the former turn directl}^ in the middle line ; then to the point of starting, around under the occi- put, forward along the body of the jaw, around the symphysis menti, back along the jaw on the other side, to the point of starting. Exactly repeat these turns three times. Application. Fracture of jaw. Barton's bandage. 300 ESSENTIALS OF SURGERY. Gibson's. Tiength, Fig. 83. Gibson's bandage. Vertical turn should be made tlrst. five yards ; width, two inches. Make three vertical turns, passing under the chin, along the sides of the face in front of the ears, and over the top of the head ; reverse just above the ear, and make three circular turns about the forehead and occiput ; as the third turn is completed, carry the bandage beneath the occiput, under the ear, along the body of the jaw, around the symphysis menti, and take in the front of the chin and the sub- occipital region with three turns ; re- verse beneath the occiput, carry the roller directly forward in the middle line to the forehead, pin all intersec- tions. Oblique of the jaw. Length, five yards ; width, two inches. Face the patient, begin the bandage in the middle of the fore- head and carry it toxaards the injured side. Fix b}^ a circular fronto-occipital turn. Carry the roller obliquely down beneath the occiput, around the ft-ont of the neck to the angle of the injured jaw, then up the side, of the face (in front of the ear), across the vertex, down the side of the head behind the ear of the sound side, under the chin, and up again on the injured side, overlapping the preceding turn forward three- quarters. The turns behind the ear of the sound side do not overlap. Application. For fracture of the condyle of the jaw, or fractures with marked lateral deformity. Recurrent of scalp. Length, seven yards ; width, two inches. Fix by a circular fronto- occipital turn, then reverse, catch the point of reverse with the finger and pass directly from occiput to brow across the top of the scalp. Recurrent of scalp, ^hc bandage is held in front by an assistant Fig. 84. BANDAGING. 301 and carried back again overlapping the first recurrent turn two- thirds ; it is carried to and fro in this way till the scalp is entirely covered, when the loops are fixed at the sides by circular turns. Figure-of-eight of the eye. Single and double. Single. Length, five yards ; width, two inches. Fix by a circular fronto-occipital turn, beginning in the middle of the forehead and carrying the bandage away from the injured eye. As tlie bandage passes backwards for the third turn, carry it ob- liquely downward across the occiput, under the ear of the affected side, obliquely upward over the ramus of the jaw and the affected eye, to the most prominent part of the parietal bone ; thence to the starting-point of the oblique turn, which is to be repeated two or three times and fixed by a fronto-occipital circular. This bandage may also be applied by alternating circular and oblique turns, overlapping upward or downward and making a series of spicas. Double, Length, seven yards ; width, two inches. One eye may be covered as in the single bandage, then the other in a precisely similar manner ; or the turns may alternate and over- lap, forming a series of spicas over the bridge of the nose. Occipito-facial. Simply the vertical and circular occipito- frontal turns of the Gibson bandage. Pin all intersections. Fronto-occipito-cervical figure-of-eight. Length, three yards ; width two inches. Fix by a fronto-occipital circular turn, carry obliquely downward across the occiput to the neck, around the neck, obliquely upward across the occiput, around the forehead, obliquely downward and around the neck ; so continue till the bandage is completed. Fronto-occipito-mental figure-of-eight. Length, three yards ; width, two inches. Apply as the preceding bandage, except that the turn is carried around the chin instead of around the neck. Handkerchiefs. Describe the handkerchief bandage. This consists of a thirty-two inch square piece of muslin, calico, or any soft strong material, forming the square. 302 ESSENTIALS OF SURGERY. The triangle is formed by bringing the two opposite angles of the square together. Tiie parts of the triangle are, the base, the apex (the angle opposite the base), and the angles or ends. The cravat is formed by folding the triangle once or twice from its apex towards its base. Handkerchief bandages receive a double name, the first being the part to which the base is applied, the second the part around which the ends are carried. The simple bandage is that made up of a single handkerchief; the compound bandage is that made up of more than one hand- kerchief. Handkerchief Bandages of the Head. Occipito-frontal triangle. Apply the base to the occiput, letting the apex fall over the forehead. Carry the two ends forward around the head and tie in front, or cross, and pin at the sides. Turn the apex up and pin to the body of the band- age. Fronto-occipital triangle. As the preceding, except that the base is applied to the forehead, and the apex falls over the occiput. Bi-temporal triangle. As the preceding, except that the base is applied over one temple, the apex falls over the other. In the choice of these three bandages, the base is applied over the seat of injury, or where most pressure is desired. Vertico-mental triangle. Apply the base to the vertex with apex back ; carry the ends down under the chin, and either tie, or cross and pin. Bring the apex to one side and pin. Auriculo-occipital triangle. This does not conform to the rule in naming. Place the base in front of the ear, apex back, carry one end under the chin, the other over the top of the head and tie or pin in front of the ear on the sound side. Square cap. Fold the handkerchief so that a quadrilateral is formed, with one border overlapping the other three inches. Apply this quadrilateral to the scalp with the projecting border BANDAGING. 103 next the surface and hans^incf over the forehead. Brini:^ the ends of the short fold under the chin and tie, Fold back the long border exposing the forehead, pull the ends forward till the bandage fits about the head, then carry them back and tie beneath the occiput. Fiff. 85. Fig. 86. Beginning of square cip of head. Square cap of head completed. Fronto-occipito-labialis cravat. Fold the triangle into a cravat. Place the body upon the forehead, carry the ends back, cross at the back of the neck, and bring them forward, tying or pinning over the upper or lower lip, as required by the injury. Used to approximate lip wounds, and to check bleeding from the coronary arteries. Occipito -sternal triangle (compound). Apply a sterno-dorsal (straight around) cravat about the chest. Flex the head upon the chest and apply the base of a triangle, apex forward to the occiput, carry the two ends down to the sterno-dorsal cravat and secure. The apex of the triangles may be folded back and pinned. Used in cut throat wounds of the neck. Parieto-axillaris triangle (compound). Apply an axillo- .T,cromial cravat (around the shoulder). Place the base of a tri- angle over the parietal eminence of the opposite side, carry the ends around the head and cross them ; incline the head laterally, and secure the ends of the triangle to the shoulder cravat. Used to approximate wounds at the side of the neck. 304 ESSENTIALS OF SURGERY Handkerchief Bandages of the Trunk. Axillo-cervical cravat. Place the body of the cravat in the axilla, carry the ends over the shoulder, across each other, and around the neck. Used to retain dressings in the axilla. Bis-axillary cravat (simple). Place the body in the axilla, cross the ends over the shoulder and carry one across the chest, the other across the back, to the axilla of the opposite side, where they are tied or pinned. Used as the preceding bandage. Bis-axillary cravat (compound). Place the body of one cravat in the axilla, carry its ends over the shoulder and tie (axillo- acromial cravat). Place the body of anotlier cravat in the opposite axilla, and carry the ends obliquely across the chest and back to the first cravat, tying them together when one end has passed through the loop of the first cravat. Used to retain dressings in both axillas. Fiff. 87. Bis-axillo-scapulary cravat (simple). Place the body to the front of the shoulder, with the lower end one-third longer than the upper. Carry the upper end over the shoulder, the lower end under ihe axilla, obliquely across the back to the opposite shoulder, around it, and back to the short end, to which it is tied. This forms a posterior figure-of-eight, and is used as a temporary dress- ins: for fractured clavicle. Bis - axillo - scapulary cravat (compound). Loop one cravat loosely about the shoulder, and Bis-axillo-scapulary cravat (com-- ^'^- Place the body of the other cra- pound). vat in front of the opposite shoul- BANDAGING. 305 Fig. 88. der, carry the ends back, one over the shoulder, the other through the axilla. Tie in a single loose knot, carry one end through the loop of the first cravat, and tie in a double knot. Used to draw the shoulders forcibly back, as in fracture of the clavicle. Dor so-bis-axillary triangle (compound). Breakfast shawl. Carry a cravat around the chest and tie in front (dorso-ster- nal). Place the base of a triangle, apex down, on the back of the neck, carry each end over the corresponding shoulder, and tie to the dorso-sternal cravat in front. The apex is fastened around the body of the cravat behind. Used to retain dressings to the shoulder or back. Mammary triangle. Place the base of the triangle under the breast, and its apex over the shoulder of the same side. Carry one end across the opposite side of the neck, the other under the axilla of the affected side. Tie at the back, and secure the apex be- neath the knot. Used to support the breast, to make pressure, to retain dress- ings. Scroto-lnmbar. Tie a cravat about the waist. Place the base of a triangle beneath the scrotum, carry the two ends up and secure them to the cravat. Finally se- cure the apex by carrying it un- der the cravat, folding it in front, and pinning. Used as a suspensory of the scrotum. Abdomino-inguinal (simple). For this bandage one long cra- vat may be made by tying two together. Place the body of the cravat back of the thigh in such a manner that one end may be two-thirds longer than the other. Bring the ends to the front, cross over the groin, and carry them around opposite sides of the body, knotting or pinning in front. 20 Mammary triangle. 306 ESSENTIALS OF SLTRGERY. Fiff. 89. G-luteal triangle. Used as the spica of the groin, to retain dressings on bubos, or make pressure upon them. Abdomino-inguinal (compound). Place the centre of the cravat (three, knotted or sewed together) over lumbar vertebrae, carry the two ends forward on each side just below the iliac crests, obliquely down- ward and inward over the front of the groins, backward between the thighs, out- ward around each thigli to the front ; cross over the pubes and pin to the body of the cravat. Gluteal triangle (compound). Tie a cravat about the waist. Place the base of a triangle obliquely at the gluteal fold, and tie the ends around the thigh. Carry the apex up and under cravat, fold it over, and pin. Used to retain dressings to the gluteal region. Handkerchief Bandages of the Extremities. Palmar triangle. Place the base of the triangle on either the palmar or dorsal surface of the wrist, fold the apex over the hand and back to the wrist, carry the ends around the wrist and apex and tie, fold the apex back, and pin to the bod}^ of the bandage. Triangular cap of the shoulder. 1. Place the base on the shoulder, apex hanging down over the arm ; carry the ends under the axilla, across each other, around the arm, taking in the apex, and tie. Pold the apex upward, and pin to the body of the bandage. 2. Place the base of the bandage on the upper part of the arm, with the apex covering the shoulder ; carry the ends around the arm, ncross each other in the axilla, and up around the shoulder, taking in the apex. Fold the apex down and pin. Used to re- tain dressings to the upper part of the arm or shoulder. BANDAGING. 807 Fig. 90. Triangular cap of a stump. Place the base under the stump, carry the apex over its end. Secure the apex by carrying the ends around the hmb, and pinning or knotting. Fold the apex up, and pin to the body of the bandage. Cervico-bracMal triangle. Sling of the arm. Place the base of a triangle at the wrist of the flexed forearm, carry the ends over the shoulders, around the back of the neck, and tie. Draw the apex back beyond the elbow, fold it posteriorly, and pin it in this position. If the triangle is not long enough, a cravat ma}' be tied loosel}^ around the neck, and the ends of the triangle knotted in this. Metatarso-inalleolar cravat. Place the body obliquely across the back of the foot, carry one end around the foot, the other around the ankle, and tie in front, over the back of the foot. Malleolo-phalangeal triangle. Place the base in the hollow of the foot. Fold the apex around the toes and in front of the ankle-joint. Carry the ends around the foot, cross on the dorsum, and continue around the malleoli ; then back to the dorsum, securing here, or continuing to the side and pinning. Cervicc-tibial triangle. Carry a cravat from the top of the shoulder of the sound side to the axilla of the injured side, around the body to the point of starting, and tie. Flex the leg and place the base of a triangle on the tibia just above the ankle. Carry the ends up and tie through the cravat. Bring the apex around the knee, and pin to the body of the handkerchief. Used to sup- port the leg when it is fractured, and the patient is required to walk. Figure-of-eight of the knee. Place the body of tlie cravat just above the patella, carry the ends back, cross in the popliteal Cervico-brachial triangle. 308 ESSENTIALS OF SURGERY. space, bring them forward just below the patella, and tie. Used to approximate the fragments of a fractured patella. Tarso-patellar cravat. Place one cravat as a figure-of-eight of the knee, loop another cravat around the foot, just anterior to the ankle ; catch the body of the third cravat through this loop, and carry its ends under both the lower and upper seg- ments of the figure-of-eight, and secure by pinning. Used to approximate the fragments of a broken patella. Tibial cravat. Place the body obliquely across the calf, carry the ends around the leg, one below the patella, the other above the malleoli. Used to retain dressings. Barton's cravat. Place the body of the cravat around the point of the heel, with the end corresponding to the outer side of the foot one-third longer than the other. Hold the inner end (short) parallel with the foot, while the long end is carried across the instep, turned once around the inner end, back under the sole of the foot, and looped around itself as it crosses obliquely over the instep. The two ends are knotted, drawn upon^ and the cravat so arranged that traction exerts equal pressure upon dorsum and heel. Used to make extension for fractured femur. AN APPENDIX COXTAIiSriNG FULL DIRECTIONS AND PRESCRIPTIONS POR THE PREPARATION OP THE VARIOUS MATERIALS USED IN ANTISEPTIC SUR- GERY. ALSO SEVERAL HUNDRED RECEIPTS COVERING THE MEDICAL TREATMENT OF SURGICAL AFFECTIONS. ABSCESSES. I^. Calcii sulphidi, gr. j Sacch. lactis, gr. x. Et ft. chart. No. x. M. S. Take one powder every one or two hours. (Ringer.) ^. Sodii hypophosphitis, Biv Calcii hypophosphitis, 9viij Syrupi simplicis, fsiss Aquse foeniculi q. s. ad. fsiv. M. S. Two teaspoonfuls four times a dav. (Churchill.)' IJp. Acidi earbolici, gr. viij AquEe destil., fSj. M. S. Inject T^x into swelling and repeat every three days. I}i. lodoformi, 5j Glycerinse, Sj. M. S. Inject into the abscess cavity after evacuating the pus. (Billroth.) BOILS {See Abscesses). BUBO. R. Tr. iodi, f3j. M. S. Paint well every other day until skin becomes tender. (Van Buren.) R. Ung. hydrarg., Sij Amnion, chlorid., 5j. M. S. Apply twice daily. (Dupuytren.; IJi. Cadmii iodid., gr. XXX Adipis, 5j. M. S. Apply twice daily. R. Acid, carbolic, gr. viij Aquee destil., f^j. M. S. Inject ten minims into gland after having used ether spray. Repeat, if necessary, in three days. R. Hydrogen peroxide (Mar- chand's solution), f^vj. M. S. Apply with an atomizer after sup- puration has begun. (Ringer.) BUNIONS. R. Tr. iodi, Tr. belladonnse, aa 5ij. M. S. Apply twice daily with a brush. R. Argent, nitratis, Aquge, S. Paint twice dailv. BAIRNS. 5j f^j. M. Wash with 1-4000 bichloride lotion; dust lightly with iodoform ; apply pro- tective and dress antiseptically.' Or, instead of the antiseptic dressing, use ^l. Acidi borici, gj Ung. petrolati, Sj. M. S. Apply on lint. R. Acidi borici, 5j Aquae, 5iv. M. S. A piece of oiled silk a trifle larger than the lesion is dipped in the solu- tion and applied ; then a larger piece of lint, dipped in the same solution, placed over the silk and held loosely by a bandage. (Lister.) 309 310 SURGERY. R. 01. lini, Liq. calcis, aa fSij Acidi carboliei, gtt. xv. M. S. Wring out dressings of sterile gauze in this mixture and apply. (Charity Hospital, N. Y.) ^. Acidi carboliei, gr. viij Yaselin., Sij. M. S. Spread on lint and apply where the skan is broken. (Bellevue Hospital, N. Y.) ^. Cerati resinae, 5ij 01. terebinth., fjij Phenol sodique, f5j. M. S. Apply on linen or lint. (Read.) R. Sodii bicarb., Aquae, S. Apply freely, on lint. ^ 5ij Oij. M. Cerati resinae, 01. terebinth., S. Apply on lint. 5j f3j. M. (Agnew. ^. Acidi salicylici, 5j 01. olivse, fSiij. M. S. Apply to burn, covering with lint. (Bartholow.) CARBUNCLE. lit. Acidi carboliei, gr. viij Aquae destil., fsj. M. S. Make several injections into diifer- ent parts of the induration. Not more than 5j of this solution should, be used at one treatment. The injection may be repeated, if necessary, in three days. I^. Tr. iodi, f33^. M. S. Paint around the carbuncle until vesication is produced. (Furneaux Jordan.) ^. Pulv. opii. Unguent, hydrarg., Saponis durae, aa 53^. M. S. Apply spread on thick leather. Apply a flaxseed poultice, over the centre of which has been spread a little coarsely-powdered crude soda. Subse- quently dress with compound resin ointment, which should be applied very warm and should be covered with oiled silk. Change the dressing every six hours. (Agnew.) CARIES. IJi. Syrup, hypophos. comp., (N. F.), 01. morrhu., aa fjiv. S. 5ij four times daily. I^. M. Syrup, ealcii lactophos- phat. (U. S. P.), fsvj. M. S. A teaspoonful three or four times a day. (Bartholow.) I?.. Hydrogen peroxide (Mar- ch and), fSvj. M. S. Apply with an atomizer or small syringe. R.. Cupri sulphat., Zinci sulphat., aa gr. xv Liq. plumbi subacetat., f3ss Aceti alb., fsiiiss. M. S. Inject through the sinuses. (Liqueur de Villate.) (Notta.) CHANCRE. ^. 01. lavand., itjxx Iodoform!, Lycopodii, aa 5ij. M. S. Dust on part and cover with lint. I}.. Cupri subacetat., Hydrarg. chlor. mit., aa gr. x. M. S. Dust over sore. (Ellis.) ^. Hydrarg. chlor. mit., gr. viij Liq. calcis, fsij. M. S. Shake and use as a wash. (Black wash.) IJj. Hydrarg. chlor. corros., gr. iv Liq. calcis, fsij. M. S. Shake and use as a wash. (Yellow wash.) I^. Hydrogen peroxide, fSj. M. S. Use as a wash and apply on lint. If too strong, may be diluted. (Ringer.) CHANCROID. Actual cautery and dress antisepti- cally. ^. Acidi sulphurici, Pulv. carbonisligni, aa 5ss. q. s. ft. magma. M. S. Dry the sore and apply thoroughly by means of a wooden spatula. Allow artificial eschar thus formed to separate spontaneously, using no dressing. (Ricord.) SURGERY. 311 Cauterize with nitric "acid, protecting the surrounding parts by oil. I^. Iodoform., 5ij 01. menth. pip., npx. M. S. Dust on sore and cover with moist lint. ^. Bismuth, subiodid., 5ij. M. S. Dust on sore and cover with dry lint. (Chassaignac.) ^.. Pulv. acidi salicylici, 5ij. M. S. Dust on sore and cover with dry lint. (Anglada.) CHOEDEE. Hot sitz bath for one-half to one hour before retiring, or steeping penis for the same length of time in hot water. ^1. Ext. opii, gr. vj Ext. hyoseyami, gr. iij Ol. theobrom. q. s. M. Et ft. suppos. No. vj. S. Introduce one into the rectum at bedtime, and repeat if necessary. ^F. Ext. opii, gr. vj Ext. belladon., gr. iss 01. theobrom. q. s, M. Et ft. suppos. No. vj. S. Introduce one into the rectum at bedtime. B. Ext. opii aquos., gr. ix 01. theobrom., q. s. il. Ft. suppos. No. vj. S. Introduce one into rectum on re- tiring. (Van Buren and Keyes.) ^. Liq. morph. sulph., • fSiv Atrbp. sulph., gr. j Acidi aceti, q. s. AquEe destil., q. s. ad. fsj. M. S. Five to eight minims hypodernii- cally at bedtime. (Sturgis.) ^. Ext. opii., gr. iv Pulv. camphorse, gr. viij. Et ft. pil. No. iv. M. S. One or two pills on retiring. (Van Buren and Keyes.) ^. Sodii bromidi, 5ij to iv Camphor., Lupulin., aa gr. x, to xx Ft. chart. No. x. M. Put in waxed papers. S. One powder morning and evening. (Finger.) IJ.. Pulv. opii, gr. vj Pulv. camphorse, gr. xij Sacch. alb. q. s. M. Et ft. capsul. No. vj. S. One at bedtime, and repeat in two hours if necessary. (Sturgis.) CYSTITIS. Hot sitz baths one-half to one hour, t. d. Hot flaxseed-meal poultices over lower abdomen. I^. Tr. aeon it., fsj Spts. seth. nitros., fsj Liq. potass, cit., q. s. ad. fSvj. M. S. One dessertspoonful every four hours until all fever ceases and the pulse is quiet. (Hare.) I}f. Potass, bicarbonat., 5iv Ext. hyoseyami fl., f5ij Ext. ergot.' fid., fsiv syrup, simp., fsij Aquae, q. s. ad., fgvj. M. S. A dessertspoonful every two to four hours. ^. Infus. buchu, fSvij Potass, bicarb., 5j Tr. hyoseyami, foijss Ext. sarsa fl., f5iv. M. S. Two tablespoonfuls three times a day. (In irritable bladder with acid urine.) (Coulston.) 15.. Potass, citrat., Sss Spts. chloroformi, fsijss Tr. digitalis, irjlxxx Infus. buchu, fSviij. M. S. Two tablespoonfuls three or four times a day. (Fothergill.) IJ). Copaibae, Spts. lavan. comp., aa f5ij Mucil. acacise, fsss Syrup, simp., foiij Aquse, fSiv. M. S. A tablespoonful twice daily. (Wood.) I^. Atropinse sulph., gr. j Acidi acet., gtt. xx Alcoholis, Aquse, aa fgss. M. S. Four drops in a wineglass of water before each meal. ^. Salol, 5j Ft. capsul. No. xij. M. S. One capsule three times a day up to two six times daily p. r. n. 312 SURGERY. I^. Acid, boric, 5j Aquse, q. s. ad. fSvj. M. S. Two tablespoonfuls three to four times a day. IJ(. Phenol sodique, f5ij. M. S. Add two tablespoonfuls to a pint, of warm water and inject into the bladder once or twice a day. I^. Potass, permanganat., 5j Aquse, fSj. M. S. Add one teaspoonful to a pint of warm water and inject into the bladder once or twice a day. R. Acid, boric, 5iv Aquse destil., Oj. M. S. Warm and inject into the bladder once or twice daily. I^. Argent, nitrat., gr. vij ■ Aquse ^destil., fsiijss. M. S. Inject into the bladder every third or fourth day, after washing it out with warm water. For profuse suppuration : — ij(. Hydrogen peroxide (Mar- chand), fSss Aquse destil., q. s. ad. fsiv. M. S. Inject daily, increasing the strength of the solution if it does not give pain. EPISTAXIS. R. 01. erigeron. canad., f3ij. M. S. Five drops on sugar every fifteen minutes as required. (Willard.) ^. Ext. hamamel. fl., fSij. M. S. A teaspoonful every one to three hours. (If pulse is rapid and bounding add veratrum viride and morphine.) (J. V. Shoemaker.) R. Pulv. acid, tannic, 5ij. M. S. Insufflate after a small quantity of cocaine has been applied. (Ingalls.) IJi. Pulv. aluminis, Pulv. acid, tannic, S. Insufflate into the posterior nares. aa 5j. M. anterior and (Sajous.) ERYSIPELAS. R. Tr. ferri chlor., Syr. simp., aa fHj Aquse, fSij. M. S. A teaspoonful every two or three hours, well diluted. (Charity Hospital, N. Y.) I^. Potassii permanganat., gr. vj Aquse destil., f5vj. M. S. A tablespoonfiil three times a day. (Keep in glass-stoppered bottle.) (Bartholow.) In the early stage, in plethoric cases, DaCosta recommends pilocarpine in sweating doses {% to 3^ gr. hypodermi- cally). 1^. Campho-phenique, fSij. M. S. Scarify the atfected area, particu- larly at the spreading borders of in- flammation and slightly beyond, and apply gauze or lint wrung out in this medicament ; or it may be applied without scarification. IJ.. Ichthyol., Vaselin., aa gss. M. S. Wash thoroughly with hot soap- suds and apply on lint thickly spread. (Nussbaum.) R. Argent, nitrat., gr. Ixxx Aquse destil., fsiv. M. S. Paint two or three times all over and a little beyond. (Higginbottom.) IJi. Plumb, acetat., 5j Tinct. opii, fSj Aquse, q. s. ad. Oj. M. S. Shake the bottle well and wet cloths or lint thoroughly with the lo- tion and apply to the atfected parts. (Charity Hospital, N. Y.) FISSURE. R. Ext. hydrastis fl., S. Apply to fissure. fSj. M. (Bartholow.) I?.. Acidi carbolic, gr. xxiv Aquse, fSJ. M. S. Apply several times daily. (Parvin.) IJ(. Cocaine hydrochlor., gr. iv Aquse destil., fsj. Ml S. Apply to nipples and wash oflf well just before nursing. If the fissure is deep and slow to heal, touch with solid stick nitrate of silver. R. Bismuth, subnit., .^j 01. ricin., f3ij. M. S. Rub in affected parts. (Hirst.) SURGERY. 313 I^. Potassii Lromid. Glycerini, S. Apply locally. 5.) f5v. M. (Ringer.) R.. Iodoform., Acid, tannic, aa 5j. M. S. Fill lissure with, the powder and dust over it. (Bartholow.) IJ. Plumb, nitrat., gr. x Glycerini, iBj. M. S. Apply after each nursing, carefully washing before next nursing. FISTUL.E. R. Hydrogen peroxide, fSvj. !M. S. Inject once daily ; dilute if neces- sary. I}i. Cupri sulphat., Aquse, S. Inject once daily. gr. ij to iy fSiy. M. (Sir A. Cooper.) I}(. Argent, nitrat., Aqute destil., S. Inject once daily. ^. Tr. iodi, S. Inject once daily. gr- iJ fgviij. M. (Fistula in ano.) (Druitt.) f5j. M. ("V\ aring.) Touch with solid stick of argent, nit. GLAJSTDS, ENLARGED. Syr. ferri iodid., fgj. M. S. i ive to thirty drops, well diluted, after each meal. Ri. Oleat. hydrarg. (U. S. P.), Sj. II. S. Rub oyer the enlarged glands once daily. R. Tr. iodi., fSj. M. S. Paint oyer enlargements thoroughly and repeat as soon as the dark color com- mences to disappear. l}i. Cadmii. iodid., gr. xxtoxxx Adipis, 5j. M. S. Apply morning and eyening. mg R. IchthyoL, oiij Adipis, 5yij. M. S. Use as inunction morning and eyen- (Agnew.) R. Acidi carbolici, gr. viij Aquse destil., fsj. M. S. Inject fiye to ten minims into the enlarged gland. GONORRHOlA. R. Hydrarg. chlor. corros., gr. iij Sodii chloridi, gr. yj Aquse, fsj. M. S. Add one teaspoonful of the mixture to one pint of hot water and flush urethra thoroughly one or two times a day. (Males.) R. Hydrarg. chlor. corros., gr. xv Sodii chloridi, gr. xxx. Aquee, fsj. M. S. Add two teaspoonfuls of the mix- ture to two pints of hot water and flush yagina thoroughly three times a day. (Females.) R. Hydrarg. chlor. corros., gr. )^tol3^ Zinci sulpho-carbolat., gr. ij to x Acidi boric, 3j Hydrogen peroxide, fsj Aquae destil., q. s. ad. fsviij. M. S. Use as an injection from four to six times a day, immediately after urina- ting. " (White.) R. Zinci sulpho-carbolat., gr. vj Morph. sulph., gr. iij Aquse destil., foiij. -M. S. Use as an injection from four to six times a day, after urinating. I}». Zinci sulphatis, Acidi tannici, aa gr. xy Aquse rosse, fSvj. il. S. A tablespoonful injected two or three times a day. (Ricord.) R. Zinci chloridi, Aquse destil., S. Inject once or twice daily. gr. j to ij fsyj. M. (Leyis. R. Zinci sulphatis, Sj Aluminis, Siij. IT. S. Dissolve a teaspoonful in one pint of water and inject three times a day. (Females.) (Hazard.) R. Liq. plumbi subacetat. dil., fsj Ext. opii aquos., gr. vj. il. S. Use as an injection two to fotir times daily. (Van Buren and Keyes.) R. Zinci sulphat., gr. j to iij Liq. plumbi subacetat. dil., f^j. M. S. Shake and inject three to four times daily. (Van Buren and Keyes.) 314 SURGERY. R. Potassii permanganatis, gr. j to iij Aqu£e destil., fsj. M. S. Use as an injection. (Gleet.) (Van Buren and Keyes.) IJ.. Argent, nitratis, 5j •Aquje destil., fSij. M. S. Apply thorouglily by means of a tubular speculum. (Females. (Grandin.) ^. Salol, 5j to ij Oleoresin. cubeb., aa 5j Para balsam eopaib., 5ij Pepsin, gr. xij Et ft. capsul. jSTo. xxiv. M. S. Take two capsules six times a day. (White.) ^. Liquor potassge, Balsam, copaibie, Tr. cubebse. Morphinse sulpb., Aquse camphorse, q. s. ad. _ , S. Take a tablespoon ful four times a day, (Agnew.) f3j fSss fSvj gr. ij i5vj. M. R. Potass, citratis, gss to j Spts. limonis, foss Syr. simplicis, fSij Aqua?, f5j. M. S. A dessertspoonful, well diluted, three or four times a day. (In tirst stage.) (Van Buren and Keyes.) R. Potass, citratis, 5ij to vj _ Balsam. copjaibEe, 5iij to vj Ext. hyoscyami fl., f.3ss to ij Syr. acacige, fSiss Aqu£ementh.pip.,q.s.ad. fsiij. M. S. Take a teaspoonful in water three or four times a day. (Van Buren and Keyes.) R. Balsam, copaibse, Spts. seth. nitrosi, Liq. potassa;, Ext. glycyrrhizse, M. et ad : 01. gaultherite, Syr. acaciae, S. One tablespoonful day. aa fsj fSij Sss gtt. xvj fsvj. M. three times a (Bumstead.) ^. Balsam, copaiba;, Spts. ffitheris nitrosi, Spts.lavand. comp., aa fgss Liq. potasste, foj Mucil. acacise, q. s. ad. fsiv. M. S. Shake and take one tablespoonful. (Lafayette mixture.) (Charity Hospital, N. Y.) H^MATEMESIS. R. Liq. ferri subsulphatis, fSss. M. S. One to two drops in ice water, fre- quently. (Bartholow.) R. Destillat. hamamelis, fsij. M. S. Two to four drops every two or three hours, (Ringer.) R. Ergotin., gr. xij Aquse destil., f3j. M. S. Five to ten minims hypodermically every two to four hours. (Wood.) R. Plumbi acetatis, gr. xij Ext. opii, gr. iij. Ft. pil. No. vj, M. S. One pill every two or three hours until bleeding ceases, (Wood.) :r, Ext. ergot,, 5j Ft. capsul. No. xij, M, S. One capsule every two hours. May give morphine or opium to quiet, (Wood,) R. Acidi tannici, Siij Aquae, fsj. M. S, Teaspoonful in water every half- hour until bleeding stops. Note. Do not give Monsel's solution and tannic acid to same patient, since it forms tannate of iron=Ink. HEMATURIA, R, Aluminis, gr, xxiv Aquae, fSviij S. Inject into bladder only if hemor- rhage is alarming, since it forms clots which may become septic, (Hare,) R, Acid, gallici, 5j Acid, sulphuric, dil., fsij Aqua:% q. s. ad. fSviij. M. S. Teaspoonful in water every four hours. (Hare.) Ergot and other internal remedies same as bleeding from lungs, bowel, etc. R. Olei terebinthinse, f5x Magnesii sulph., 5j Pulv. uvge ursi, 5j Aquae camphorse, fSviij, M. S, Shake well. Take two tablespoon- fuls every two hours, (Smith,) HEMOPTYSIS, R. Liq. ferri subsulphatis, gtt, XX to XXX Aquae destil., fsiv, M, S. Use in an atomizer every few min- utes. (Hare.) SURGERY. as III. Aeidi tannici, ^r. xx Glycerinse, toij Aqufe destil., q. s. ad: fsviij. M. S. Use in atomizer frequently. (Hare.) Avoid using Monsel's solution and tannic acid on same patient=Ink. IJt. Aluminis, ^r. vj Aqufe destil., isiij. M. S. Use in an anatomizer frequently. (Hare.) ^. Plumbi acetat., gr. xx Pulv. digitalis, gr. x Pulv. opii, gr. V Ft. pil. No. X. M. S. One pill every four hours. (Bartholow.) Use opium or morphine to quiet pa- tient. HEMORRHOIDS. I(i. Aeidi gallici, gr. x Ext. opii, Ext. belladonnse, aa gr. iv Ung. simplicis, 5iv. M. S. Apply night and morning. (Hare.) I^. Ext. hamamelis fl., fsiv. M. S. Inject some into the rectum and ^PP'y pledgets of lint soaked in this solution. (Hare.) IJ>. Cocain. hydrochlor., gr. ij Ext. belladonnte, 3j Aeidi tannici, 5ij Ung. petrolati, 3j. M. S. Apply night and morning. (Alrich.) IJ.. Ext. opii, gr. x Pulv. stramonii, 5j Pulv. tabaci, 5ss Ung. simplicis, Sss. M. S. Use locally. (Shoemaker.) IJi. Iodoform., Sij to iv Adipis benzoat., Sj. M. S. Apply locally after washing. ^. Tr. nucis vomieee, foj Ext. ergot, fl., fgj. M. S. One teaspoonful three to four times a day. (For bleeding piles.) (Bartholow.) INCONTINENCE OF URINE. IJi. Strychninte sulph., gr. j Pulv. cautharidis, gr. ij Morph. sulph., gr. iss Ferri redacti, gr. xx. M. Ft. pil. No. xl. S. One pill three times a day to a child ten years old. (Gross.) ^. Chloral hydratis, Sj Syr. tolutani, f^iiss. M. S. One teaspoonful three times daily. (For infantile incontinence.) (Da Costa.) ^. Santonini, ^r. xvj 01. ricini, tsj. M. S. One to two teaspoonfids before breakfast for two or three mornings. (Ringer.) If). Aeidi arsenosi, gr. ^ Ext, nucis vomicse, gr. ij Ft. pil. No. XX. M. S. One pill three times a day after meals. (For a child eight to ten years old, when trouble is due to weakness of spinal centres.) (Hare.) ^. Potass, citrat., Sss Spts. £eth. nit., f5vi Aqua;, q. s. ad. fsvj. M. S. A dessertspoonful every four hours in water. (Where urine is concentrated and dark in color.) (Hare.) ^. Tr. cantharidis, foj. M. S. One drop three times a day. (In hysterical females.) (Hare.) INFLAMMATION. Fever Mixtures. ^. Potass, bromid., 3iv Tr. belladonnse, ^xxxij Tr. aconit. rad., gtt. viij Spts. «th. nit., foiij Mist, potass, cit., q. s. ad. fsviij. M. S. One tablespoonful every two to three hours. Keep in a cool place. (White.) I}.. Morph. acetat., gr. j Sacchar. alb., 3ij Spts. seth. nit., fsij Liq. ammonii acet., fsiv Aqutecamphorte, q. s.ad. fSviij. M. S. One tablespoonful every two to three hours. (Ashhurst.) I}.. Morph. acetat., gr. % Tr. aconit., %x Spts. ffith. nit., foiij Mist, potass, cit., q. s. ad. fsvj. M. S. Two teaspoonfuls every one to two hours. Laxatives. I}.. Hydrarg. chlor. mit., gr. iij So'dii bicarb., oj Ft. pulv. No. xxiv. M. S. One powder every hour. 316 SUKaERY. R. Hydrarg. chlor. luit., gr. 8odii bicarb., 5j Pepsinaj, 5ss Ft. pulv. No. xxiv. S. One powder every hour. M. Add 5ij of Eochelle salts to the white paper of a Seidlitz powder, take it and follow it every two hours by 5ij of Eo- chelle salts until bowels move. (Goodell.) IJ>. Syr. rhei aromat., fSss Aquai, fSij Magnesii sulph., q. s. ad. sat. sol. M. S. A teaspoon ful every hour or two until bowels move. IJ(. Hydrarg. chlor. mit., gr. j Sacch. lactis, 3j M. Ft. pulv. No. xij. S. One powder every one to three hours. (For children.) T^. Pulv. glyeyrrhizge comp. , Sss. M. S. One teaspoonful in water. Rei^eat every two hours if necessary. INGROWING NAIL. ^. Liquor potassse, f5ij Aquae destil., fjj. M. S. Apply with pledgets of cotton. (Norton.) I^. Pulv. plumbi acetat., 5j Tr. opii, fSj Aqute, f5viij. M. S. Shake well, and apply constantly on cotton until inflammation is re- duced; then separate nail from gran- ulating surface by means of a small pledget of cotton and use R. Argent, nitratis, gr. xxx Aquse destil., f5j. M. S. Paint two or three times daily. (Davidson.) LARYNGISMUS STRIDULUS. ^. Potassii citratis, Syr. ipecac, Tr. opii deod., Syr. simplicis, Aquse, 5j foij gtt. xij f3ij fSiss. M, S. A teaspoonful every two hours at two years of age. (In severe form.) (Meigs and Pepper.) ^. Syrupi ipecacuanhse, fSij. M. S. A teaspoonful every fifteen minutes. R. Amyl. nitrit., fSj. M. S. Three to five drops on a handker- chief by inhalation. (Wood.) R. Tr. belladonnse, f3j. M. S. Five to fifteen drops every hour, according to age. (Hare.) LEUCORRHCEA. R. Aluminis, 5iv. M. S. Add to one pint of warm water and use as a wash morning and evening. R. Ext. belladonnse, gr. j Acidi tannici, gr. vj. M. Ft. pulv. No. j. S. Place on a pledget of cotton and apply to diseased portions daily. (When dependent on disease of cervix.) (Troscall.) £)>. Acid, arseniosi, gr. J^ Ferri redact., gr. ij Quin. sulph., gr. xx M. Ft. pill. No. XX. S. One pill after each meal, for adult. (Hare.) I^. Tr. ferri chloridi, f3j Tr. cinch, comp., flij Tr. gent, comp., q. s. ad. f5iv. M. S. One dessertspoonful after meals. (Hare.) IJi. lodi resublimat, 5iv Acid, carbolici crystal., Chlorali, aa gj. M. S. Rub the iodine and chloral in a glass mortar and add the carbolic acid. To be used by the physician only. Vagi- nal surfaces and cervix to be painted with it. (Goodell.) I^. Sodii bicarb., 5j Tr. belladonnse, fsij Aquse, Oj. M. S. Use as a vaginal wash morning and evening. (Ringer.) ^. Potassii permanganat., 5ij Ft. pulv. No. iv. M. S. Add to a pint of warm water and inject morning and evening. (When discharge is fetid.) (Girwood.) R. Zinci sulphat., f5j Alumin. sulph., 5j Glycerinse, fSvj. M. S. Add a teaspoonful to a quart of water and inject twice a day. (Thomas.) SURGERY. 317 T^. Acidi taunici, 5iv Glyceriuie, f5xvj. M. S. Add a tablespoonful to a quart of tepid water and inject into vagina for live minutes morning and evening by means of a fountain syringe. (Thomas.) Q. iSodii biboratis, Sij. M. S. A teaspoonful to a pint of tepid water as a vaginal wash. (For leucor- rhcea of pregnancy.) (Parvin.) ^,. lodoformi, 5j Acidi tannici, Sj. M. S. Pack a sufficient quantity around the cervix. (Bartholow.) LUMBAGO. 1^ Atropinse sulphatis, Morphinee sulphatis, Aquse destil., S. Five minims injected deeply into muscles of the back. gr.J gr. xvj faj. M. I?.. Antipyrin, Sj Syr. tolutani, fSj Aq. menth. pip., q. s. ad. fjiv. M. S. A teaspoonful every one. to four hours for three to six doses. (Germain See.) B. Methyl chloride, Sss. M. S. Use locally, applying carefully. (Debove.) I}.. Tr. iodi, fsij Tr. aconiti rad., foiij chloroformi, f3iv Liniment, sapon. comp., q. s. ad. fsiij. M. S. Apply every few hours locally. (Bellevue Hospital, N. Y.) oSS fjij ^1. Potass, iodidi, Tr. opii deodorat., fjij Spts. lavandulcc comp., f3j Spts. aeth. nit., fsss Aquffi destil., fSxij. M. S. Take two tablespoonfuls twice daily. (Brodie.) I}.. Potass, iodidi, Potass, carbonatis, aa Sj Tr. aconiti rad., fsij Aquic destil., fsx. M. S. Apply locally every few hours. (Erichsen.) B. Chloroformi, foij. M. S. Twenty minims injected deeply in region of pain. LLTUS. IJt. Zinci chloridi, 5j Morph. sulph., gr. ss Pulv. acac, 5iij. M. S. Make into a paste by adding a few drops of water or alcohol and spread a thin layer over and just beyond the ulcer. Use carefully. (Agnew.) I^. Ichthyol., 5j Adipis benzoat., 5v. M. S. Apply over affected part. (Hare.) B. Tr. iodi, fSij. M. S. Paint around the growth ; apply to retard its spread over the surface also. B. Liquor hydrargyri nit., f5j. M. S. Use with a glass rod until growth is on a level with the skin ; use care- fully, protecting surrounding parts with lard or oil. I}.. Acidi pyrogallici, 5j Cerati simplicis, 5ix. M. S. Apply locally. (For lupus of eye- lids and skin.) (Kaposi.) Apply locally a saturated solution of muriate of cocaine. (Fowler.) I?.. Resorcin, Vaselini, S. Apply locally. Suss oiv. M. (Bertarelli.) ]\L\MMARY Iis^FLA:!tIMATION. ij>. Morph. sulph., gr. x Hydrarg. oleat., 5ss Acidi oleici, 5ixss. M. S. Anoint three times a day. (Marshall.) IJ(. Ext. belladonnoe, 5j Liq. plumbi subacetat. dil., Oj. M. S. Use as a lotion. (Graefe.) S. A tablespoonful of granular effer- vescent citrate of magnesia in water, followed by ten grains of quinine if there be fever, (in incipient mammi- tis.) (Starr.) I\t. Cerati resin* co., 2j Olei olivte, 5jtoij M. Ft. ungt. S. Apply, spread generously on a soft ag. (When suppuration is threatened.) (Witherstine.) 318 StrilGERY. NEURALGIA. I^. Ext. aconit., gr. ij Adipis benzoat., 5.). M. S. Apply over painful parts if limited in area. Rhigoleue or ether in an atomizer is often etfectual if pain is superticial. I^. Antipyrin., 5j Caffein. citrat., gs. xx. M. Ft. chart. Iso. x. S. One every thirty minutes until re- lieved. Or, ly. Antipyrin., 5j Caffein. citrat., gr. x Potass, bromid., 3iij. M. Ft. chart. No. x. S. One every thirty minutes until re- lieved. (Hare.) • Sometimes acupuncture is useful or deep hypodermic injections of morph. sulph. I^. Tr. cannabis indic.e, fjij. M. S. Twenty drops every hour. (Mi- graine.) " (Wood.) I^. Methyl, chlorid. pur., fSj. M. S. Apply" to painful parts with a brush or atomizer. IJf. Chloroformi, f5j Vaselin. liq., fSiv. M. S. Fifteen to thirty minims hypoder- mically at seat of pain. (Meunier.) ^. Menthol., gr. xxiis Cocain. muriatis, gr. viiss Chloral, hydratis, gr. ivss Vaselin., 3iiss. M. S. Apply to painful part and cover with strip of court plaster. (Supra^ orbital neuralgia.) (Galezowski.) I^-- M. Quin. sulph., Morph. sulph., Acidi arseniosi, aa 5j gr. iss Ext. acouiti, Strych. sulph., Ft."pil. No. XXX. One pill three times a gr. XV gr- J- day. (Gross.) ^. Phenacetin., gr. xj. M. Ft. pulveres No. x. S. One or two powders every three or four hours. ONYCHIA. I?.. Pulv. plumbi nitrat., Sss. M. S. Dust on diseased tissue night and' morning. (Scott and McCormack.) In the early stages a couple of leeches above the nail will have a good effect. (Agnew.) L'se hot flaxseed poultices for three or four days, before each renewal of the poultice", thoroughly washing with — ^. Tr. iodi, Tr. belladonnse, Tr. opii, aa foij. M. Then dust with iodoform and dress antiseptieally. (Agnew.) I^. Acidi arseniosi, gr. j Glycerol, amyli, Sj. M. S. Apply on a so"ft rag. (Agnew.) I^. Ung. hydrargyri, Sss. M. S. Apply for ten minutes every hour, applying poultices at other times. (Ringer.) I^. 01. terebinthina^, fsij. M. S. Apply a pledget of lint wet with the solution. (Ringer.) ORCHITIS. Keep the testicles elevated. Strap with adhesive strips. First envelop scrotum in thick layer of cotton ; over this rubber dam ; then use an ordinary suspensory that is close fitting. (Horand-Langlebert.) gr. IV §.i. M. I^. Iodi, Lanolin, S. Apply locally (after acute symptoms are past). I^. Ung. hydrarg., Ung. belladonnse, aa 5ss. M. S. Apply locally morning and even- ing. I^. Potass, iodidi, ."iv to viij Syr. sarsaparilla; comp., f.^iij AquEC, q. s. ad. flvj. M. S. Two teaspoonfuls three times a day. Place a small pledget of cotton soaked in chloroform over painful spot and. confine fumes by covering with a small glass oi' a pill-box. R. Tr. iodi, flij. M. S. Paint affected parts after acute symptoms are over. SURGERY. 819 I^. Morphinte sulphatis, gr. viij Hydrargvri oleatis (10 per cent.), Bj. M. H. Apply twice daily. (For subsequent induration. j ' (Marshall.) PROSTATITLS. Leeches to the perineum. I}i. Ext. opii aquos., gr. viij Ext. belladonnse, gr. ij. il. Ft. suppos. Xo. viij. S. Introduce one into the rectum and repeat on return of pain. Yery hot or rery cold water injected into the rectum, against the prostate through a two-way rectal tube, from two to four quarts at a time, three or four times a day. i^. Ext. opii aquos., gr. viij Ext. hyoscyami, gr. iv. M. Ft. suppos. No. viij. S. Insert one into the rectuiu and re- peat when necessary. I^. Liq. potassce, f.5ij to iv Ext. hyoscyami, 3j to iv iSyr. aurant. cort., Aquce cinnamomis, aa fsiij. M. S. A tablespoonful in a wineglass of 'water every eight hours. (Van Buren and Keyes.) I}i. Pota.ss. bicarbouat., .aiv Ext. hyoscyami ti., f.5ij Syrupi simp., f.5ij Aquae, q. s. ad. fjvj. M. S. A desserts]^-oonful every two to four hours. PRURITUS. ^. Acid, carbolici, f3j to f3ij Aquee destil., q. s. ad. Oj. M. S. Apply as a lotion several times a dav. I}.. Liq. earbonis deterg., fsij AquEe, q. s. ad. Oj. S. Apply as a lotion. M. IJ. Acidi carbolic, gtt.v to xx Adipis benzoin., Ung. petrol., aa Sj. M. S. Apply as an ointment. I}.. Chloroform!, irpx to xx Adipis benzoin., SiJ. M. S. Apply as an ointment. I^. Argent, nitratis gr. xx Aquie destil., f5j. M. S. Paint aflfected parts fin obstinate cases). lyi. Hydrarg. chlor. corros., gr. j Pulv. aluminis, 9j Pulv. amyli, 5iss Aquse, fovj. 3L S. Apply locally. (Goodell.) IJ. Aluminii nitratis, gr. vj Aqua; destil., fsj. 51. S. Apply with a soft sponge. (Gill.) Py. Acidi acetici, Glycerinse, S. Apply locally. f3j fjiij. M. (Goodell.) RACHIl IS— SCROFULA. IJ. Olei morrhute, foyj Syr. calcii lactophosphat., Liq. calcis. iia fSiij. M. S. One-half to one teaspoonful three or four times a day. (.Smith.) IJ. Syr. ferri iodidi, gtt.ifjtoxx Aquie destil., q. s. ad. fsiij. M. S. A teaspoonful every four or five hours during the day. (Child six months or one year.) IJ. Syr. calcii lactophos., fsiv. M. S. One teaspoonful three times a day after meals. IJ. Phosphor i, gr. % Olei amygdalfe, f5viiss Pulv. acac, Sacehar. alb., al Siv Aquje destil., f5x. 'SI. Ft. emuls. S. One teasfjoonfal three times a day- after meals. (Hare.) Fy. Phosphori, §^- /i Olei morrhuie, fovj. M. S. One teaspoonful three times a day after meals. (Kassowitz.) IJ. Calcii phosphatis, Ferri phosphatis, aa gr. xxxvj. M- Ft. chart. No. xij. S. One powder morning and noon. (Neligan.) ^ fsiij. M. 01. morrhuse, Aquie calcis, Et ad. Syr. ferri iodidi, fiiv 01. gaultheri*, f ^ss Syr. simp., q. s. ad. fsviij. M, S. A tablespoonful three times a day. 320 SURGERY. SCIATICA. Acupuncture. Deeply inject hypodermically, just over or about the exit of tlie nerve from the pelvis, ten to twenty minims of chloroform. Ether or rhigolene spray. Blisters or actual cautery along the course of the nerve. Massage of nerve. Apply lard or ieh- thyol ointment along the course of the I nerve ; then take a strong glass rod with a round, smooth end, press back and forth over the tender area, using as | much force as can be borne. (Hare.) I^. Morph. sulph., gr. 3^ to % Atrop. sulph., gr. 1-25. M. Ft. pulv. No. j. S. Dissolve in irjxx aq. destil. and inject near focus of pain. (Brown- Sequard.) I}.. Cannabis indicse, f5yj Syr. acacise, f3iss Aquge destil., q. s. ad. fSvj. M. S. A tablespoonful every four to six hours. (Neligan.) SEPTICEMIA. Stimulants should be pressed to their extreme limit. Tonics, if the stomach will stand them. Quinine, twenty to thirty grains daily. Digitalis as indicated by the condition of the heart. Strychnia for the respi- ration. SHOCK. External warmth most important; a hot bath, or vessels of hot water all around patient. Keep the head low. Atropine, 1-100 gr. and brandy or whiskey, minims xxx, hypodermically every thirty minutes. Digitalis hypo- dermically, in minims-xx doses, may be indicated. If there is great pain, give a hypodermic of morph., 3^ to 34 gr. ; strychnia hypodermically, gr. 1-20, repeated at twenty-minute interval:-^ Whiskey, hot coffee, or hot beef-tea in very small quantities by the mouth. SPERMATORRHCE A . I^. Potass, brom.. Sod. brom., aa 5iv Aq. cinnamon!., q. s. ad. fsxij. M. S. One tablespoonful at bedtime. I^. Chloral., 5ij Syrupi simplicis, fgiss Aquas, q. s ad. fSiij. S. One tablespoonful at bedtime. M. I^. Hyoscinehydrobromate,gr. 1-10. Ft. pil. No. X. M. S. One pill at bedtime. (Wood.) IJi. Tr. cantharidis, foij Tr. ferri chloridi, f3vj. M. S. Twenty drops in water three times a day. (Wood.) ^t. Acid, arsenics., Strych. sulph., ail gr. ] Ferri redact., 5ss. Ft. pil. No. xij. S. One pill three times a day. M. 15.. Argent, nit., gr. xx Aquse destil., fjiv. M. S. Apply three drops to the prostatic urethra. A full-sized cold-steel sound intro- duced into the bladder is often of ser- vice. SPINA BIFIDA. gr- 15.. lodi. Potass, iodidi, gr. xxx Glycerinse, fsj. M. S. Inject into the base of the tumor, according to its size, from oij to 5iv of this solution. (Morton.) SPRAINS, CONTUSIONS, ETC. 1^ 15. Olei monardae, foss Tr. opii, f.iij Tr. camphorae, foij. M. Ft. liniment. Use locally. (Atlee.) Olei cajuputi, Tr. opii, aa f3ij 01. terebinthinse, fsiv Liniraenti ammonise, fsj. M. Ft. linimentum. Use locally. (Fuller.) SURGERY. 321 I}i. Liquor ammonise, f5,j Tr. opii, foij Tr. cantharidis, fsiij Linimen. sapon. cami^h., fsx. M. Ft. linimentum. S. Use locally. (Fuller.) ^. Chloroform!, Tr. aconit. rad., 01. terebinthinse, aa fSss 01. sa-ssafras., t^Vv Linimen. sapon.camph.,f3iiss. M. Ft. linimentum. S. Use locally. (Gerhard.) ^^ Tr. aeoniti, Chloroformi, s. Aquse ammonise, aa foij Linimen. saponis camph., q. s. ad. fsviij. ]\I. Ft. linimentum. Use locally. (Jefferson Hospital.) s. Tx". aconit. rad., f3j Tr. opii, fSss Lin. saponis, fsviss, M Ft. linimentum. Use locally, (Richardson.) ^>. Plumbi acetat., 5j Tr. opii, foix Aquse, q. s. ad. fsvj. M. S. " Lead water and laudanum." Use locally. Any of the officinal liniments may be used alone. Linimentum camphorae. Linimentum chloroformi. Linimentum saponis. Linimentum terebinthinse. STRANGURY. I}(. Decoct, uvffi ui'si, fSviij Liq. potassas, gtt. cxxx Tr. belladonnce, gtt. xlviij. M. S. Tablespoonful every four hours. (Agnew.) ^. Balsam, copaibse, Sss Acidi benzoici, 5j Vitelli unius ovi, Aqute camphorae, fSvij. M. S. Take two tablespoonfuls twice a day. (Soden.) I5<. Aceti scillse, Spts. seth. nitrosi, aa f5ij Aquae anisi, q. s. ad. Oj. M. S. A wineglassful evei'y hour or oft- ener. (Waring.) 21 1^. Ext. opii, gr. iv Ext. hyoscyami, gr. ij. M. Ft. suppos. No. iv. S, Introduce one into the rectum. R(. Tr. cannabis indicae, f3ij. M. S. Thirty drops every few hours. (Ringer.) I^. Ext. belladonnae, gr. ij to iv. M. Ft. supiws. No. ij. S. Introduce one into rectum and re- peat in four hours if necessary. (Hartshonie.) Hot sitz bath for one-half to two hours. SYNOVITIS. Counter-irritation by means of fly blistei's. Blood-letting in early stage, followed by ice-bags. ^. Acidi carbolici, gr, viij Aquse destil., f5j. M. S. Use ether spray, and inject ten min- ims into joint and repeat every three days. (Chronic synovitis.) I}.. Morph. sulph., gr. viij Hydrarg. oleat. (5 to 10 per cent.), §j. M. S. Apply twice daily with a soft brush. (Acute synovitis.) (Marshall.) Paint joint with tr. iodine and apply ly. Ung. hydrarg., Ung. belladonnae, aa Sj. M. S, Apply on lint. (Ashhurst.) IJ.. lodi, 5iv Potass, iodidi, f.lj Aquae destil., fsvj. M. S. Apply externally with a brush. SYPHILIS. I}». Hydrarg. protiodidi, gr. vj. M. Ft. pil. No. xxiv. S. One pill thi-ee times a day; every second day increase by one pill until first symptoms of ptyalism appear; then cut down dose one-half and con- tinue for eighteen months this tonic dose; after that give IJi. Potass, iodidi, 5issto5iv Hydrarg. chlor. corros., gr. i to iss Syr. auranti cort., f5j Aquae, q. s. ad. fsij. M. S. One teaspoon ful three times a day continued for from six to twelvemonths 322 SURGEKY. B. Mass. hydrarg., gr. xxiv Piilv. fe'rri sesquiclilor., gr. xij. M. Ft. pil. Ko. xij. S. One pill three times a day ; increase one pill every two days up to physio- logical limit;" then cut down dose one- half and continue for eighteen months. IJ>. Ung. hydrarg., 3j. M. Ft. chart. Iso. viij. Put in waxed papers. S. Eub, after bathing, for fifteen min- utes the contents of one paper into body in following order: First night, axilla and side of chest; next night, same on opposite side; next night, groin and inner part of thigh ; next, same on opposite side; next, chest and abdomen, and repeat. Wear same shirt next to skin under other clothing. Mucous patches in mouth are healed by application of solid stick of silver or sulphate of copper. If elsewhere, wash with 1-2000 bichloride solution and dust with IJ. Hydrarg. chlor. mit.. Bismuth, suhnit., aa 5ij. M. S. Dusting powder. Aft-er symptoms disappear, observe hygienic mode of living and take "iji. 01. morrhufe, fBviij. (Phillips's emulsion.) S. One teaspoonful three times a day. The mercury may be given by means of vapor bath. IJ. Hydrarg. chlor. mit., 5ss. 8. A'aporize by means of heat, beneath a blanket covering the naked bodv. ^. Hydrarg. chlor. corros,, gr. vj So'dii chlorid., gr. xxxvj Aquae destil., fsx. M. S. Inject daily five to eight drops hypodermically. (Hebra.) I^. Pil. hydrargyri, gr, xx Ferri sulph. exsiccat., gr. x Ext. opii, gr. v. M. Ft. pil. No. XX. S. One pill three times a day. (Otis.) B- Potass, iodidi, 5ij Ammonii carbonatis, Sss Tr. cinch, comp., fjiv Syr. aurant. cort., foiss Glycerin i., fSj. M. S. A "teaspoonful, well diluted, after each meal. (^Keyes.) I}.. Tr. myrrh., ffes Potass, chlorat., 3iij Aquje, q. s. ad. fsvj. M. S, Wash mouth every two or three hours. (For mucous patches.) R. Hydrarg. chlor. corros., gr. j Potass, iodidi, 3ij Tr. gent, comp,, fSiij. M. S. A teaspoonful three times a day. (Charity Hospital, X. Y.) B, Hydrarg. chlor. mit., Lyeopodii, aa 5ij. M. S. Use as snuflF three times daily, in syphilitic lesions of nose. (Gross.) TETAlSfUS. Control the spasm by inhalations of ether, chloroform, or nitrite of amyl. Give 3ij to 5iv of bromide of potash "in divided doses during the day, and chloral, gr, xxx to xl at bedtime. Also give opitim, if necessary. Sup- port with food and stimulants. (Wood.) WAETS AND CORX.^-COISmON. I^. Acidi nitrici, fSj. S. Apply to wart with a stick or glass rod three or four times a week. H. Acidi chromici, 5j. M. S. Applv to wart with a glass rod. ^Wood.) Iji. Hvdrarg. chlor. corros., gr. x Collodii, fov. M. S. Paint once daily. (Kaposi.) R. Acidi salicylici, Spts. vini rectif., aa foss -■Etheris sulphuric, nvlxxy Collodii, foiiss. M. S. Apply every day with camels-hair brush. ' ' ' (Vidal.) R. Acidi acetici glacialis, f3j. M. S. Apply a drop to wart once a day. R. Acidi salicylici, gr. xxx Ext, cannabis indlc«, gr, x. M. Collodii, fsss. M. S. Apply every night and morning for one week with a cameFs-hair brush; then soak foot well. Moisten and brush every day with solid stick of nitrate of silver. SURGERY. 323 WARTS— VENEEEAL. H. Hydrarg. chlor. mit. S. Use as a dusting powder. _(Ricord.) I?>. Acidi carbolici, f5j. M. S. Apply with glass rod or stick ererr day or two. ^. Hydrarg. chlor. mit., 3vj Acidi borici, 3iij Acidi salicylici, sj. ;jx S. Dust over the vegetation. (Gregory.) Cut off with scissors and applr nitric or carbolic acid to base with a small stick. 324 SURGERY. DRUGS AND MATERIALS USED IN ANTISEPTIC SURGERY, TOGETHER WITH GENERAL DIRECTIONS CONCERNING PREPARATIONS FOR ANTISEPTIC OPERATIONS. ANTISEPTIC SOLUTIONS. I^. Acid, carbolic, f3vj34 Aquae, q. s. ad. Oj. M. S. Solution 1-20 carbolic. (Lister.) ^. Acidi boric, 5iv Aquae destil., Oj. M. S. Saturated solution, gr. x to fsj. I^. Potassii permanganat., 5j Aquae, fsj. M. S. foj to Oj=l-1000. :^i. Zinci chlorid., gr. xl Aquae, q. s. ad. fsj. M. S. Apply on a swab to fresh septic wounds. IJi. Hydrarg. chlor. corros., Sodii chlor., aa 5j Aquae, q. s. ad. fsj. M. S. foj to Oj=l to 1000. ^. Hydrarg. chlor. corros., 5j Amnion, chlor., gr. xxxij Aquae, q. s. ad. fsj. M. S. f3j to Oj water=l to 1000 solution. I^. Hydrarg. chlor. corros., 5j Acid, tartaric, 5v Aquae, q. s. ad. fSiv, M. S. f53^ to Oj aquae=1000. IJ.. Acidi carbolic, f3j 01. olivae, foX. M. S. Carbolized oil. (Lister.) IJi. Iodoform., 5j Collodion., f5x. M. S. Iodoform collodion. (Kiister.) I}.. Iodoform., gr. xxx ^ther., fsss Aquae destil., q. s. ad. f5j. M. S. Iodoform ether. (Nussbaum.) I^. Iodoform., ^ther., S. Iodoform ether. I?.. Creolin, S. f5j to fovj to Oj. 5J 5j. M. f3j. (v. Esmarch.) R. Hydrogen peroxide, fSj. S. Use in hard-rubber atomizer. SALVES. I}.. Acidi boric, 5iij Paraifine, 5x Ung. petrolat., 5v. M. S. Boric acid salve. (Lister.) I}i. Acidi salicylic, Sj Paraffine, Sxij Cerat. alb., 5vj 01. amyg., 5xij. M. S. Salicylic salve. (Lister.) I^. lodoformi, 5j Ung. petrolati, 5vj 01. amyg. amar., gtt. ij. M. S. Iodoform salve. IJ.. Iodoform., 5j to iv Ung. petrolat., gj. M. S. Iodoform ointment. SURGERY. 325 I^. 01. olivse, fSj Acidi carbolic, gr. xlj toxxiv. M. S. 1-40 or 1-20 carbolized oil. IJi. L'ng. petrolati, oj Acidi carbolic, gr. xxivto xij. M. S. 1-20 or 1-40 carbolized vaseline. LIGATURES. Tiumerse the commercial catgut in a frequently renewed solution made as follows : — ^l. Hydrarg. chlor. corros., oj Alcohol, fSiiss Aquse destil., fsvj. M. Preserve for use in the following: — I}.. Hvdrarg. chlor. corros., gr. vj Alcohol, ftx Aquie destil., fSiiss. M. From this solution it is taken as needed. TO CHROMACIZE CATGUT. Place catgut in ether for foriy-eight hours; then immerse in the following for forty-eight hours and put in anti- septic, dry, tightly-closed vessels: — IJi. Acidi chromic, gr. j Acidi carbolic, gr. ce Alcohol, f.iij Aquae destil., fsxxij. M. Soak in carbolic, 1-20 before using. The catgut is usually prepared by soaking it in oil of juniper for one week, then storing it in absolute alco- hol, or a 1-1000 alcoholic sublimate solu- tion. SILK (CZERXY). The silk should be boiled for one hour in a 1 to 20 carbolic solution, then kept in a 1 to 50 carbolic solution. Boil in clean water for one hour, then store in an alcoholic solution of subli- mate 1-1000. DRAINAGE. Rubber tubes, wash clean and keep in a 1 to 20 carbolic solution. Rubber tubing may be hardened by immersing for tive minutes in concen- trated sulphuric acid. The tubes are then washed in alcohol and preserved in 1-20 carbolic solution. Decalcified bones, catgut, horse-hair, silk-worm gut, may all be stored in absolute alcohol containing sublimate 1-1000. OPERATOR'S HANDS. Pare nails and clean around and under them with a knife. Clean arms, hands, and nails for one minute with a brush, very warm water, and potash soap (pear- line) ; then wash for one minute in stronger alcohol and then for one minute in 1-1000 or 1-500 bichloride so- lution or 1-30 carbolic solution. The hands ai'e then allowed to remain wet. OPERATIVE REGION. The patient should have a warm bath before the operation, and the operation region must be shaved and covered with cloths dipped in 1-1000 bichloride or l-;30 carbolic, and covered with par- atBne paper; this dressing must remain for several hours previous to the opera- tion. Immediately before the operation the parts are washed and brushed with potash soap, then rubbed with alco- hol, ether or turpentine, and irrigated with 1-500 bichloride or 1-30 carbolic solution. The environs should be cov- ered with towels wet with 1-500 bichlo- ride or l-:30 carbolic, and changed during the operation as often as soiled. The region to be operated upon should also be covered with similar towels until the surgeon commences his in- cision, and during the entire operation scrupulous care must be exercised to keep every portion of the wound cov- ered except that part which the surgeon must have exposed for the continuance of his work. INSTRUMENTS. Brush with 1-20 carbolic solution ; sterilize by roasting, boiling, or by storing for one hour in 1-20 carbolic solution. During operation keep in a 1-40 carbolic solution. To prevent rust- ing boil in one per cent. sod. carb. solu- tion. A very etFectual method is to place them in metal boxes and heat in an or- dinary oven (200° F.) for one-half to one hour ; they may then be used dry. SPONGES. If neir, cleanse in soda solution and immerse for twenty-four hours in water to which is added " R. Potassii permanganat., gr. 15)^. 326 SURGERY. This turns them brown ; then wash in a bowl of water, to whicli add ^>. Acid, hvdrochlor. fSv Sodii bvposulphit., fsiss. M. This bleaches them. They are then washed with hot water and potash soap and kept in 1-1000 bichloride or 1-20 carbolic solution. (Keller.) Iiifecfed sponges. Keep in lukewarm water for twenty-four hours, or better still, in running water for the same time; then wash with potash soap and warm water and keep in 1-1000 bichlo- ride or 1-20 carbolic. THE WOUND. Unless it is infected, the wound need not be flushed or irrigated with irri- tating antiseptic solutions. If the me- chanical effect of irrigation is necessary, sterilized water containing three-quar- ter per cent, of common salt may be employed. If the wound is probably infected, irrigate with 1-500 bichloride solution, subsequently flushing out with a weaker lotion varying in strength from 1-2000 to 1-5000. ' In operations about the mouth, blad- der, intestines, etc., boric acid solution or the sterilized salt solution may be used. DRESSINGS. Typical Lister dressing. 1. SUk protective, which is m.ade from oiled silk, coated with copal varnish, and then with a mixture prepared as follows : — iji. Dextrine, 5j Starch, 5ij Carbolic sol. 1-20, fjij. 2. Moist compresses. Moist carbolized gauze, six thicknesses, somewhat larger than the wound, and wrung out of 1-20 carbolic solution. 3. The antiseptic game, seven layers. This gauze is preserved in parchment paper, and is made as follows : — Take cheese-cloth cut in pieces about six yards long and one yard wide, soak in boiling water for two" or three hours, and stretch to dry, after saturating with the following : — Carbolic acid, (crystals), 5j Resin, 5v Parafline (solid), 5vij. 4. Makintosh, which is a cloth made impervious by means of caoutchouc. 5. The eighth layer of gauze. 6. Bandage, made of muslin or gauze saturated with 1-50 carbolic acid. 7. Cotton and bandage. The ordinary bichloride dressing is applied as follows : — 1. Protective. 2. Several layers of bichloride gauze wrung out in carbolic solution 1-20, and large enough to overlap the protective everywhere. 3. Many (10-20) layers of bichloride gatize wrung out in 1-1000, and large enough to overlap the preceding dress- ing. 4. Bichloride cotton overlapping the preceding dressing (No. 3). 5. Wet (1-2000) gauze bandage and dry gauze or muslin bandage. BICHLORIDE GAUZE. Boil cheese cloth in -water made alka- line by the addition of washing-soda, wring" out in hot water, again boil in water without the addition of the soda, run it through a bichloride solution of 1-200, and pack away moist in jars that have been previously washed in the same solution. This gauze should be wrung out in a solution of bichloride 1-1000 immediately before being applied to the surface of the body. I^. Gauze, 15,500 gr. Hy drarg. chlor. corros. , 77 gr. Sodii chloridi, 7750 gr. Glycerine, 1550 gr. Aquis, 68 f5. M. (Maas.) LISTER'S DOUBLE CYANIDE GAUZE. Wash all utensils used in preparing this gaitze in R. Sol. of bichlor., 1-500, Sol. carbol. ac.,1-20, aa equal parts. M. Then add gr. c of double cyanide of mer- cury and.zinc (Lister) to four pints of a 1 to 4000 solution of bichloride of mer- ctiry. (Keep this well stirred, since it does not form a solution ; the double cyanide is only in suspension in the bichloride solution.) Run plain gauze through it and pack away moist. SURGERY. 327 The double cyanide salt is prepared as follows : Cyanide of potassium, gr. 130. Cyanide of mercury, gr. 252. Mix and dissolve in water, fsxss. Add this solution to — Zinc sulphate, gr. 287. Water, fsiv. Collect the resulting precipitate and ■wash with water fgvlii divided into two portions. Diffuse the precipitate by means of mortar and pestle in distilled water fgviii containing hiematoxylin gr. 1%, and a drop of a solution niade by adding stronger ammonia f3j to dis- tilled water f3xv ; let this mixture stand for several hours. The dyed salt is then drained and dried at a mode- rate heat. SOLUTION FOR CARBOLIZED GAUZE. Resin, .?iv Alcohol, " fsxx Castor-oil, fi% Carbolic acid, ^51}%. M, Run gauze through this solution and hang up to dry. (University Hospital.) INDEX. A BSCESS, acute, 27 A bone, 171 Brodie's, 171 chronic, 29 diploe, 78 follicular, 212 mammary, 253 mediastinal, 134 periosteal, 169 periurethral, 213 residual, 30 tubercular, 29 Amputation, 282 Garden's, 286 Chopart's, 284 Dupuytren's, 289 Gritti's, 286 Hey's, 284 in coxalgia, 165 in fracture, 110 in gangrene, 43 in gunshot wounds, 71 Larrey's, 289 Lisfranc's, 284 Pirogoff's, 284 Sedillot's, 285 Syme's, 285 Teale's, 283 Anaesthetics, 258 Anchylosis, 168 in coxalgia, 165 in fracture, 121 Aneurism, anastomotic, 344 arterio-venous, 74 cirsoid, 244 classification, 245 traumatic, 74 varicose, 74 Aneurismal varix, 74 Angioma, 244 Antiseptic treatment, 44, 66 Anus, artificial, 187 diseases of, 198 fissure, 202 Anus, fistula, 202 malformation, 198 pruritus, 205 ulceration, 203 Arthrectomy, 278 Arthritis, 161 gelatinous, 162 rheumatoid, 167 strumous, 162 of hip-joint, 163 of knee-joint, 166 BALANITIS, 212 Balano-posthitis, 212 Bandages, handkerchief, 31 Barton's, 308 roller, 290 Barton's, 299 Desault's, 294 Gibson's, 300 Velpeau's, 293 Barton's cravat, 308 fracture, 122 head bandage, 299 Bed-sore, 41 Bites, 72 Bladder, atony, 229 bar at neck, 226 ' exstrophy, 227 inflammation, 228 paralysis, 229 rupture, 227 tumors, 227 Bone, diseases, 169 syphilis, 173 tubercle, 173 Brodie's abscess, 171 Bronchotomy, 250 Bronchus, foreign body, 250 Bubo, d'erablee,' 211 gonorrhoeal, 213 primary, 211 syphilitic, 206 (329) 330 INDEX. Bunion, 256 Burns, 102 Bursa, dropsy, 256 Bursitis, 256 nALCULT, vesical, 233 \J Callus, 109 Canal, femoral, 192 inguinal, 189 Cancrum oris, 40 Carbuncle, 42 Caries, 172 Catheter, Mercier, 231 olive-pointed, 220 prostatic, 231 railroad, 220 Cellulitis, 52 Chancre, 206 Chancroid, 210 Chilblain, 2i9 Chloroform, 259 Chordee, 214 Cicatrization, 31 Circumclusion, 63 Clap, 211 Cleft palate, 255 Club-foot, 254 Cock's perineal section, 222 Cold, effects of, 249 Colles's law, 210 Compression, cerebral, 84 Concussion, cerebral, 83 of lung, 94 Contusion, abdominal, 96 cerebral, 83 of cranium, 78 of scalp, 77 Counter-irritation, 23 Cowperitis, 213 Coxalgia, 163 diagnosis, 166 Cupping, 22 Cystitis, 228 Czerny's suture, 99 DELIRIUM tremens, 46 Diffused aneurism, 74, 245 Dilatation of stricture, 220 Discharge, urethral, 215 Dislocation, see Luxation Dissecting aneurism, 245 wound, 71 Double inclined plane, 130 Dressing, Lister's, 67 Dupuytren's splint, 133 EMPHYSEMA, 94 Encephalitis, 86 Enterocele, 180 Entero-epiplocele, 180 Epididymitis. 213 Epiplocele, 180 Epispadia, 217 Erysipelas, 50 Ether, 258 Excision, 278 ankle-joint, 281 elbow-joint, 279 hip-joint, 279 in coxalgia, 165 knee-joint, 280 shoulder-joint, 278 wrist-joint, 279 Extension apparatus, 129 Extravasation, intracranial, 81 of urine, 223 F^CES, impaction of, 204 False joint, 111 passage, 219 Fever, hectic, 50 inflammatory, 48 pysemic, 49 septicaemic, 48 traumatic, 47 Fissure, anal, 202 of Rolando, 88 Fistula, anal, 202 faecal, 187 salivary, 90 Forcipressure, 62 Foreign body in brain, 87 in bronchus, 250 in larynx, 250 in oesophagus, 253 Fractures, 105 anaesthetics in, 113 Barton's, 122 clavicle, 114 coccyx, 126 Colles's, 123 compound, 108 delayed union in, 110 delirium tremens in, 136 INDEX. 331 Fractures, diagnosis, 107 femur, 126 fibula, 132 humerus, 117 hyoid bone, 114 inferior maxilla, 113 larynx. 111 metacarpus, 125 nasai bone, 112 non-union in, 110 patella, 131 pelvis, 125 phalanges, 135 Pott's,l32 radius, 122 ribs, 134 sacrum, 126 scapula, 116 skull, 78 Smith's, 122 sternum, 134 superior maxilla, 113 T, 117 tarsus, 134 tibia, 132 treatment, 107 ulna, 121 ununited, 110 vertebrae, 135 vicious union, 111 Fracture-box, 133 Frost-bite, 249 Furuncle, 41 GANGLION", 256 Gangrene, 38 Germ theory, 44 Glanders, 55 Gleet, 215 Gonorrhoea, acute, 211 chronic, 215 in women, 216 Granulations, 31 Gumma, 208 H HEMATOCELE, 239 Ha?maturia, 220 Haemophilia, 177 Haemothorax, 93 Hare-lip, 255 Hemorrhage, 57 arrest of, 58 Hemorrhage, bladder, 280 kidney, 230 urethra, 230 Hemorrhoids, 199 Hernia, 179 cerebri, 87 classification, ISO congenital, 188, 191 crural, 192 encysted, 188, 191 femoral, 192 incarcerated, 182 infantile, 188, 191 inflamed, 182 inguinal, 188 irreducible, 181 Littre's, 184 of lung, 94 reducible, 180 strangulated, 183 umbilical, 194 Herniotomy, 186 Hutchinson's teeth, 209 Hydrarthrosis, 161 Hydrocele, 238 Hydrophobia, 54 Hypertrophy of prostate, 225 Hypospadia, 217 TMPACTED fjfices, 204 X Imperforate anus, 198 Impermeable stricture, 222 Incarcerated hernia, 182 Incontinence, uiinary, 232 Inflammation, 17 intracranial, 86 Ingrowing toe-nail, 257 Internal strangulation, 197 Intestinal obstruction, 196 Intussusception, 197 |7TPH0SIS, 178 LAPAROTOMY, 100, 198 Laryngotomy, 251 Larynx, foreign body, 250 Leeching, 23 Lembert's suture, 99 Ligament, coraeo-humeral, 143 Y, 150 332 INDEX. Ligamentous union, 135 Ligations, 261 anterior tibial, 276 axillary, 268 brachial, 269 common carotid, 263 dorsalis pedis, 277 external carotid, 264 external iliac, 272 facial, 265 femoral, 272 internal mammary, 268 lingual, 265 occipital, 266 palmar arches, 271 popliteal, 274 posterior tibial, 275 radial, 270 subclavian, 267 temporal, 266 ulnar, 271 Litholapaxy, 235 Litholvsis, 235 Lithotomy, 235 Lithotrity, 235 Localization, cerebral, 87 Loose bodies in joints, 167 Lordosis, 178 Luxations, 137 astragalus, 156 carpus, 148 classification, 137 clavicle, 141 complications, 139 femur, 150 humerus, 143 jaw, 140 metacarpus, 149 old, 139 patella, 155 phalanges, 149 radius, 148 ribs, 141 scapula, 143 semilunar cartilages, 155 tarsus, 156 tibia, 154 treatment, 139 ulna, 147 MALIGNANT pustule, 55 Meningitis, 86 Micro-organisms, 44 Mortification, 38 Mucous patch, 207 N^VUS, capillary, 244 venous, 244 Necrosis, 172 Nodes, periosteal, 169 Noma pudendi, 41 /T^SOPHAGUS, foreign body, 252 Uj stricture, 252 Onvchia, 257 Ophthalmia, 213 Orchitis, 240 Osteitis, 170 deformans, 170 rarefying, 170 Osteomalacia, 174 Osteomyelitis, 170 Osteoporosis, 170 PAGET'S disease, 253 Paraphimosis, 212 Paronychia, 257 Passage of catheter, 219 Perineal section, 222 Peritonitis, 97 Periostitis, 169 osteoplastic, 169 Pernio, 249 Phimosis, 212 Phlebitis, 242 Piles, 199 Plaster jacket, 176 Plastic lymph, 18 Pneumothorax, 94 Pneumotomy, 95 Pott's disease, 174 puffy tumor, 78 Poupart's ligament, 190 Prolapsus of lung, 94 recti, 201 Prostatitis, 224 Pruritus ani, 205 Pupil in brain injury, 85 Pus, 19 Pyaemia, 49 RACHITIS, 176 Rectum, diseases of, 198 INDEX. 333 Rectum, polyp, 204 prolapse, 201 stricture, 203 ulceration, 203 villous tumor, 205 Resection, 278 Retention of urine, 230 Retroclusion, 62 Rheumatism, gonorrhoeal, 213 Rickets, 176 Ring, abdominal, 189, 190 femoral, 193 Rupture {see Hernia) , 179 of viscera, 96 SALIVATION, 26 Saphenous opening, 193 Sarcocele, 2-10 Sayre's fracture-dressing, 115 Scalds, 102 Scalp, layers, 75 wounds, 77 Scoliosis, 178 Scrofula, 177 Septicaemia, 48 Shock, 45 ether in, 260 Sinus, 30 Skin grafts, 37 Spine, curvature, 177 Splints, eoxalgia, 165 Bond's, 124 Dupuytren's, 133 Sprain, 158 fracture, 158 of back, 159 Staphyloplasty, 255 Staphylorraphy, 255 Stimulants, 25 Stings, 72 Stone in bladder, 233 Strapping chest, 135 Stricture, urethra, 217 Struma, 177 Sutures, 65 Synovitis, 160 gonorrboeal, 213 Syphilis, 206 TALIPES, 254 Tapping abdomen, 100 bladder, 333 Tapping pericardium, 95 pleura, 95 Taxis, 184 Tenosynovitis, 356 Tetanus, 53 Thrombosis, 242 Torsion, 61 Torsoclusion, 62 Trachea, foreign body in, 250 Tracheotomy, 251 Transfusion, 59 Trephining, 89 Triangles of neck, 263 Trophic changes, 75 Tubercle, 173 Tumors, breast, 353 ULCERATION, 31 Ulcers, 32 Uranoplasty, 255 Urethra, 211 deformities, 217 rupture, 223 strictui-e, 217 Urethrotome, 221 Urethrotomy, 221 VARICOCELE, 240 Varicose aneurism, 74 veins, 243 Varlx, 243 aneurismal, 74 arterial, 244 Veins, diseases of, 243 varicose, 243 Venereal disease, 206 Vesication, 24 Volvulus, 197 WALLERIAN degeneration, 74 White swelling, 163 hip-joint. 163 kne&-joint, 166 Wounds, 44 abdomen, 95 arteries, 73 chest, 92 classification, 68 contused, 69 dissecting, 73 face, 90 334 INDEX. Wounds, gunshot, 70 incised, 69 joints, 159 lacerated, 69 neck, 91 nerves, 75 oesophagus, 92 Wounds, poisoned, 71 punctured, 69 scalp, 77 trachea, 92 veins, 75 Y ligament, 151 ^^ CATALOGUE OF MEDICAL AND SURGICAL WORKS, PUBLISHED BY No. 913 Walnut Street, PHILADELPHIA. The aim of the publisher of the works described in the following pages has been to make them of permanent and not transient value to students and members of the medical profession. They are all written or edited by well-known and competent authors, many of international repute. Especial care has been exercised in the selection of clear, readable type, high class illustrations, good paper, and serviceable bindings. *^* For sale by Booksellers in all principal cities of the United States and Canada ; or sent post free on receipt of price by the Publisher. MR. SAUNDERS takes pleasure in announcing to the medical profession the preparation of AN American Text-Book of Surgery. GENERAL AND OPERATIVE. BY W. W. KEEN, A.M., M.D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Philadelphia. J. WILLIAM WHITE, M.D., Ph.D., Professor of Clinical Surgery in the University of Pennsylvania. P. S. CONNER, M.D,, LL.D., Professor of Surgery and Clinical Surgery in the Medical College of Ohio, Cincinnati, Ohio. FREDERIC S. DENNIS, M.D., Professor of the Principles and Practice of Surgery and Clinical Surgery in Bellevue Hospital Medical College, New York. CHARLES B. NANCREDE, M.D., Professor of Surgery in the University of Michigan, Ann Arbor, Michi- gan. ROSWELL PARK, A.M., M.D., Professor of Surgery in the Medical Department of the University of Buffalo, New York. LEWIS S. FILCHER, M.D., Professor of Clinical Surgery in the Post-Graduate Medical School, New York. N. SENN, M.D., Ph.D., Professor of Surgery in Rush Medical College, Chicago, and in the Chi- cago Polyclinic. 2 FRANCIS J. SHEPHERD, M.D., Professor of Anatomy, McGill University, Montreal, Canada. LEWIS A. STIMSON, B.A., M.D., Professor of Surgery in the University of New York. J. COLLINS WARREN, M.D., Associate Professor of Surgery in Harvard University. CHARLES H. BURNETT, A.M., M.D., Professor of Otology in the Philadelphia Polyclinic and College for Gradu- ates in Medicine. WILLIAM THOMSON, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadel- phia. Kecognizing the fact that for a number of years there has been an increasing demand for a text-book on Surgery which should be at once concise and compreliensive, and at the same time essentially American in its teachings, the various authors have undertaken the preparation of such a work, which, instead of embodying the ideas of a single INDIVIDUAL, WILL BE COMPOSED OF A SERIES OF TREATISES, EACH WRITTEN BY A TEACHER OF SURGERY, BUT COMBINED INTO A SINGLE AUTHORITATIVE WORK BY MUTUAL CRITICISM AND REVISION. It is intended in this manner to obtain the undoubted benefit of the special knowledge and experience of the different authors in their respective lines of work, while avoiding all unnecessary detail. The book as a whole will thus faithfully represent the prevailing views and methods of American surgeons. The names and professional positions of the authors in- dicate without further explanation the general scope and character of the work. It will form a handsome royal octavo volume, printed in beautiful large clear type, on heavy paper, with numerous FINE ILLUSTRATIONS. 3 NOW READY. MEDICAL DIAGNOSIS. BY DR. OSWALD YIERORDT, Professor of Medicine at the University of Heidelberg ; formerly Privat Docent at University of Leipzig ; Professor of Medicine and Director of the Medical Polyclinic at the University of Jena. Translated, with Additions, from the Second Enlarged Germar Edition, with the Author's Permission. BY FRANCIS H. 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The author gives a complete though brief presentation of the Micro- organisms, whose recognition and discrimination are made possible by cultivation, and inoculation, and which, through the labors of those eminent bacteriologists, PASTEUR, KOCH, and others, have already made such marked changes in the application of remedial agents in the cure of disease. 4 IN PEEPARATION. READY SHORTLY. A NEW Pronouncing Dictionary of Medicine. BY JOHN M. KEATING, M.D., Fellow College of Physicians of Philadelphia ; Visiting Obstetrician to the Philadelphia Hospital, and Lecturer on Diseases of Women and Chil- dren ; Gynaecologist to St. Joseph's Hospital ; Surgeon to the Maternity Hospital, etc.; Editor "Cyclo- paedia of Diseases of Children," AND HENRY HAMILTON, Author of " A New Translation of Virgil's iEneid into English Rhyme; Co-author of "Saunders' Medical Lexicon," etc. A voluminous and exhaustive handbook of Medical, Surgical, and Scientific Terminology, containing concise explaruations of the various terms used in Medicine and the allied sciences, with Phonetic Pronunciation, Accentuation, Etymology, etc. The work will form a very handsome royal 8vo volume, beautifully printed from type specially cast for the work, on paper mamifacturtd for this purpose. It will contain most important tables of Bacilli, Micrococci, Leucomaines, Ptomaines, etc. etc., the whole forming the most complete, reliable, and valuable Diutiun- ary in the market. It has been the aim of the Publisher to place in the hands of stu- dents and the medical profession a work which should contain the names of Hundreds of New Words now being adopted, and at the same time, by leaving out the numerous obsolete terms contained in most Dic- tionaries, keep the volume of such a size as to be most convenient for ready reference. 5 POCKET MEDICAL LEXICON OR. Dictionary of Terms and Words used in Medicine and Surgery. By JOHN^ M. KEATING, M.D., Editor of "Cyclopaedia of Diseases of Cliildreu," etc.; Author of the "New Pronouncing Dictionary of Medicine," AND HENllY HAMILTON, Author of "A New Translation of Virjiil's iEneid into Englisli Verse ;" Co-author of a "New Pronouucing Dictionary of Medicine." Price, 75 Cents, Cloth. $L00, Leather Tucks. of water: f'^^ r^ so . do _ 70 _ 60 _ SO 40 3C __| .212" _ a^waten / - to —20 19^ /76 f58 /'fO /04 86 .63 SO 80" — 72 — €^ — 56 -.48 — 31 _ re _ 8 This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class tlian those at present on the market, which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not con- taining the hundreds of new words now used in current lit- erature, especially those relat- ing to Electricity and Bacteri- ology. Annala of Gyntvcohtgif, Vhilii- dfl/thia. Dfrrtnbt'r, 1890. JZ — 0' — H —8 Saunders' Pocket Medical Lexi- con—a very complete little work, invaluable to every student of medicine. It not only contains a very large number of words, but — fS' also tables of etymological factors common in medical terminology ; abbreviations used in medicine, (From Appendix to Medical Lexicon.) poisons and anlidotes, etc. 6 o -^4 Essentials of Anatomy and Manual of Practical Dissection. B^ CHAELES B. N^AKCREDE, M.D., Professor of Surgery and Clinical Surgery in the University of Miciiigan Ann Arbor; Corresponding Member of the Eoyal Academy of Medfcine Rome, Italy ; late Surgeon Jefferson Medical College, etc etc With Handseme Fnll-page Lithographic Plates in Colors. Over 200 lliastrations. No pains or expense has been spared to make this. work the most exhaustive in th?s'coi^ 7",^*^?l^ Manual of Anatomy and Dissection ever published, eitlier The colored" plates are designed to aid the student in dissecting the muscles arteries, veins, and nerves. For this edition the woodcuts have all been speci! ally drawn and engraved, and an Appendix added containing 60 illustrations lepresenting the structure of the entire human skeleton, the whole based ,m vXme'of'over 4oi";iiges^'^^'' Anatomy, aad forming a handsome post 8vo Price, Extra Cloth or Oilcloth for the Dissection-Room, $2.00 Net. Medical Sheep, 2.50 " ■A^S^fLuI^..^?^^^^^' P^^^(^elpliia, August 23, 1890.-Nanerede's Anatomy Smi^nff ^H^Tri*"^ '^ ^ ^?^.^ dissector's manual, with clear type and hand- some cuts. The colored plates are especially commendable. A^^'tomTin^ni^P^fn? ''i'^T' ^«f,^«^e /fenn., September, I890.-Nancredo's iTiM^M^I^i^ ^^^ Dissector— truly a " Vade Mecum," a " multum in parvo." The Illustrations are marvels of beauty and clearness of illustration 7 IN PREPARATION. DISEASES OF THE EYE. BY G. E. DE SCHWEINITZ, M.D., Ophthalmic Surgeon to Children's Hospital and to the Philadelphia Hospital ; Ophthalmologist to the Orthopaedic Hospital and Infirmary for Ner- vous Diseases ; Lecturer on Medical Ophthalmoscopy, University of Pennfylvania, etc. A HAND-BOOK OF OPHTHALMIC PRACTICE, Especially useful to the student who has had neither time nor inclination to study the numerous able but more volu- minous text-books. The object of this manual is to present to the student who is be- ginning work in the field of ophthalmology a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the methods of examination, the symptomatology leading to a dingnosis, and the treatment of the various ocular defects have been brought into special prominence. Anatomy, physiology, and pathological histology, except in so far as they serve the purpose just stated, have been omitted. The sections devoted to optical principles and the normal and abnormal refraction of the eye in large portion have been written by Dr. James Wallace, Chief of the Eye Dispensary of the University Hospital, The chapter devoted to the application of the shadow-test has been prepared by Dr. Edward Jackson. The book will be suitably illustrated by a number of wood-cuts, many of them from cases in the practice of the author, in addition to which there will be several chromo-lithographs. IN rREPARATION. DISEASES OF WOMEN. By henry J. GARRIGUES, A.M., M.D., Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital ; Gynaecologist to St. Mark's Hospital in New York City ; Gynae- cologist to the German Dispensary in the City of New York; Con- sulting Obstetrician to the New York Infant Asylum; Obstetric Surgeon to the New York Maternity Hospital ; Fellow of the American Gynaecological Society ; Fellow of the New York Academy of Medicine ; President of the German Medical Society of the City of New York, etc. etc. It is the intention of the writer to provide a practical mannal on Gynsecology, for the use of students and practitioners, in as concise a manner as is compatible with clearness. Syllabus of Obstetrical Lectures In the Medical Department, University of Pennsylvania. By RICHARD C. NORRIS, A.M., M.D., Demonstrator on Obstetrics in the University op Pennsylvania. Price, Oloth, Interleaved for Notes . . . $2.00 Net. The New York Medical Record of April 19, 1890, referring to this book, says : " This modest little work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. Small as it is, it covers the subject thoroughly, and will prove invaluable to both the student and the practitioner as a means of fixing in a clear and concise form the knowledge derived from a perusal of the larger text-books. The author deserves great credit for the manner in which he has performed his work. He has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject- matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable ; there is no doubtful tone in the directions given. No details are regarded as unimportant ; no minor matters omitted. We venture to say that even the old practitioner will find useful hints in this direction which he cannot afford to depise." 9 READY SHORTLY. SAUNDERS' Pocket Medical Formulary. BY WILLIAM M. POWELL, M.D., Attending Physician to the Mercer House for Invalid Women, at Atlantic City, N. J. ; Late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania, and Chief of the Medical Clinic of the Philadelphia Polyclinic. Containing about 2000 Formulae, selected from several hundreds of the best-known authorities. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through th"^ works of the Most Jiiminent Physicians and Surgeons of the world; particularly helpful to the student and young practitioner, as it gives him a taste for writing his prescriptions m an elegant and correct manner, thus avoid- ing incompatible and dangerous prescriptions. The use of this work is to be recommended even to the older prac- tioner, as through it he becomes acquainted with numerous formulae which are not found in the text-books, but have been collected from amonor the Rising Generation of the Profession, College Professors, and Hospital Physicians and Surgeons. 10 NOW BEADY. NEW AND REVISED EDITIONS OF SAUNDERS' QUESTION COMPENDS. Arranged in duestion and Answer Form. The Latest, Cheapest, and Best ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. THE ADVANTAGES OF QUESTIONS AND ANSWERS. — ^The usefulness of arrani^-ing the subjects in the form of Questions and Ansvrers will be apparent, since the student, in reading the standard works, often is at a loss to discover the important points to be remembered, and is equally puzzled when he attempts to formulate ideas as to the manner in which the Questions could be put in the Examination-Room. These small works, which can be conveniently carried in the pocket, contain in a condensed form the teachings of the most popular text-books. The authors are nearly all connected with the various colleges as Demonstrators or Lecturers, and are therefore thoroughly conver- sant, not only with the wants of the average student, but also with the points that are absolutely necessary to be remembered in the Examination-Room. These books are constantly in the hands of their authors for revision, and are kept well up to the times, their fast sale allowing them to be almost entirely re^written whenever necessary, instead of having to wait for the edition to be sold, as is the case with an ordinary text-book. 11 No. 1. ESSEITIALS OF PHYSIOLOGY. BY H. A. HARE, M.D., Professor of Therapeutics and Materica Medlca in the Jefferson Medical CoU lege of Philadelphia; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's H()si)ital ; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. ; Secretary of the Convention for the Revision of the Pharmacopoeia, 1890. NUMEROUS ILLUSTRATIONS. Third Edition, Revised and Enlarg^ed. Price, Cloth . . . $1.00; Interleaved for Notes . . . $1.25. University Medical Magazine, October, 18S8.— "Dr. Hare has admirably succeeded in gather- ing together a series of Ques- tions which are clearlj put and tersely answered." Pacific Medical Jmirnal, Octo- ber, 1889.—" Hare's Physiology contains the essences of its sub- ject. No better book has ever been produced, and eviiry stu- dent would do well to possess a copy." Times and Rrgister, Philadel- phia, October 5, 1889.—" In the second edition of Hare's Physi- ology all the more difficult points I of the study of the nervous sys- tem have been elucidated. As the work now appears it cannot fail to merit the appreciation of Specimen of Illustrations. the overworked student." Journal of the American Association, November 23, 1889.—" Hare's Physiology— an excellent work ; admirably illustrated ; well calcu- lated to lighten the task of the over-burdened undergraduate." 12 No. 2. ESSENTIALS OF SURGERY. CONTAINING, ALSO, Venereal Diseases, Surgical Landmarlcs, Minor and Operative Sur- gery, and a Complete Description, together with full Illustra- tions, of the Handkerchief and Roller Bandage. By EDWARD MARTIN, A.M., M.D., Clinical Professor of Geiiito-Uriiiary Diseases, Instructor in Operative Sur- gery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hospital ; Assistant Surgeon to the University Hospital, etc. etc. PROFUSELY ILLUSTRATED. FOURTH EDITION. Considerably enlarged by an Appendix containing full directions and prescriptions for the preparation of the various mate- rials used in ANTISEPTIC SUR(JERY ; also sev- eral hundred recipes covering the medical treatment of surgical affections. Price, Cloth, $i.oo. Interleaved for Notes, $1.25. MeMcal and Surgical Rejjorter, February, 1889. — " Martin's Sur- gery contains all necessary essen- tials of modern surgery in a com- paratively small space. Its style is interesting and its illustrations admirable." University Medical Magnzi}ie, January, 1889. — "Dr. Martin has admirably succeeded in selecting and retaining just what is neces- sary for purposes of examination, and putting it in most excellent shape for reference and memor- izing." Kaftsas City Medical Record. — "Martin's Surgery. — This admir- able compend is well up in the most advanced ideas of modern surgery.'* 13 Specimen of Illustrations. No. 3. ESSENTIALS OF ANATOMY, Including the Anatomy of the Viscera. By CHARLES B. NANCREDE, M.D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor ; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; Late Surgeon Jefferson Medical College, etc. etc. ONE HUNDRED AND FORTY FINE WOODCUTS THIRD EDITION. Enlarged by an Appendix containing over Sixty Illustrations of the Osteology of the Human Body. The "wliole based upon the last (eleventh) edition of GRAY'S ANATOMY. Price, Cloth, $1.00. Interleayed for Notes, $1.25. American Practitioner and Neios, February 16, 1889. " Nancrede'ri Anatomy. — For self-quizzing and keep- ing fresh in mind the knowledge of Anatomy gains at school, it would not be easy to speak of it in terms too favorable." /Southern Californian Practi- tioner, January 18, 1889. •' Nancrede's Anatomy. — Very accurate and trust- worthy." American Practitioner and Nerrs, Louisville, Kentucky. " Nancrede's Anatomy. — Truly such a book as no student can aflFord to be without." Specimen of Illustrations. 14 No. 4. 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., Demonstrator of Chemistry, Jefferson Medical College ; Visiting Physician to German Hospital of Philadelphia ; Member of Philadelphia College of Pharmacy, etc. etc. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Cincinnati Medical Neu-s, January, 1889. — " Wolff's Chemistry.- -A little work that can be carried in the pocket, for ready reference in solving difficult problems." . Interleaved for Notes, $1.25. University Medical Mag- azine, Philadelphia, Octo- ber, 1890. — " Jackson aad Gleason's Essentials of Dis- eases of the Eye, Nose, and Throat. — The subjects have been handled with skill, and the student who acquires all that here lays before him will have much more than a foundation for future work." New York Medical Rec- ord, November 15, 1890. — "Jackson and Gleason on Diseases of the Eye, Nose, and Throat. — A valuable book to the be- ginner in these branches, to the student, to the busy practitioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers know what a student most needs." 24 Specimen of Eye Illustrations. No. 15. ESSENTIALS OP DISEASES OF CHILDREN BY WILLIAM M. POWELL, M.D., Attending Physician to the Mercer House for Invalid "Women, at Atlantic City, N. J. ; Late Physician to the Clinic for the Diseases of Chil- dren in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diag- nosis in the Medical Department of the Uni- versity of Pennsylvania, and Chief of the Medical Clinic of the Phil- adelphia Polyclinic. Price, Cloth $1.00. Interleaved for Notes .... 1.25. AMERiCAJf Practitioner and Neavs, Louisville, Ky., December 20, 1890. " Powell'3 Diseases of Children. — This work is gotten up in the clear and attractive style that characterizes the Saunders' Series. It contains in appropriate form the gist of all the best works in the de- partment to which it relates." SoDTHERN Practitioner, Nashville, Tennessee, November, 1890. "Dr. Powell's little book is a marvel of condensation. Handsome binding, good paper, and clear type add to its attractiveness." Annals of Gynecology, Philadelphia, December, 1890. *' Powell's Diseases of Children. — The book contains a series of im- portant questions and answers, which the student will find of great utility in the examination of children." 25 No. 16. ESSENTIALS OF EXAIOATIOI OE TJEIITE. BY LAWRENCE WOLFF, M.D., Author of " Essentials of Medical Chemistry," etc. COLORED (VOGEL) URINE SCALE AND NUMEROUS ILLUSTRATIONS. Price, Cloth 75 Cents. UsiVEKSiTY Medical Magazine, June, 1890. ' ' Wolff 's Examination of the Urine. — A little work of decided value." k'O Ccl-. a '•' \ Medical Recoed, New York, Specimen of Illustrations. August 23, 1890. "Wolff's Examination of A good manual for students, well written, and answers, categorically, many- questions beginners are sure to ask." Memphis Medical Monthly, Memphis, Tennessee, June, 1890. "Wolff's Examination of Urine. — The book is practical in char- acter, comprehensive as is desirable, and a useful aid to the student in his studies." 26 No. 18. ESSENTIALS OP PRACTICE OF PHARMACY. BY LUCIUS E. SAYRE, Professor of Pharmacy and Materia Medica in the University of Kansas. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Albany Medical Annals, Albany, N. Y., November, 1890. " Sayre's Essentials of Pharmacy covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book." American Doctor, Richmond, Va., January, 1891. " Sayre's Essentials of Pharmacy.— This very valuable little manual covers the ground in a most admirable manner. It contains practical pharmacy in a nutshell." National Drug Register, St. Louis, Mo., December 1, 1890. '' Sayre's Essentials of Pharmacy.— The best quiz on pharmacy we have yet examined." Western Drug Record, November 10, 1890. "Sayre's Essentials of Pharmacy.— A book of only 180 pages, but pharmacy in a nut-shell. It is not a quiz-compend compiled to en- able a grocery clerk to * down' a board of pharmacy ; it is a finger- post guiding a student to a completer knowledge." 27 Saunders' Questioin-Compends. In Preparation. Ready about September 1, 1891. No. 17. Essentials of Diagnosis. No. 19 Essentials of Hygiene. ILLUSTRATED. By ROBERT P. ROBINS, M.D. No. 20. Essentials of Bacteriology. ILLUSTRATED. By M. V. BALL, M.D. No. 91. Essentials of Nervous Diseases and Insanity. ILLUSTRATED. By JOHN C. SHAW, M.D. No. 92. Essentials of Medical Physics. ILLUSTRATED. By FRED. J BROCKWAY, M.D. No. 93. Essentials of Medical Electricity. ILLUSTRATED. By DAVID D. STEWART, M.D., and EDWARD S. LAWRENCE, M.D. OTHERS PREPARING. 28 The Flske Fund Prize Essay for 1890. THE SURGICAL TREATMEE^T OF Wounds and Obstruction OF THE INTESTINES. BY EDWARD MARTIN, A.M., M.D., Clinical Professor of Geuito-Urinary Diseases, Instructor in Operative Sur- gery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hospital ; Assistant Surgeon to the University Hospital, etc. etc. AND HOBART A. HARE, M.D., Professor of Therapeutics, Jefferson Medical College ; Attending Physician to St. Agnes' Hospital. ILLUSTRATED. Price, Cloth $2.00, Net. *' In presenting this Essay upon the Surgical Treatment of Wounds and Obstruction of the Intestines to the Trustees of the Fiske Fund, it is proper to outline the scope of our work, and to slate briefly the facts and lines of original research upon which our conclusions are based. For over two years we have made experiments in the labo- ratory upon these subjects, and have carried out in every detail all the methods and modifications of operations that have been published or which have occurred to us in the course of our own studies. . . . In addition to the original work involved in studying so important a branch of surgery as the one before us (and which will be found represented, graphically, in part at least by a number of tracings), we have collected and placed before the reader what we believe to be the fullest statistics yet collected upon gunshot wounds of the abdo- men." — Extract from Preface. 29 INDEX. PAGE Announcement .1 American Text-Book of Surgery . . . . 2, 3 YlERORDT AND StU ART'S MeDICAL, DIAGNOSIS . . 4 Keating's New Unabridged Dictionary or Medicine 5 Saunders' Pocket Medical Lexicon .... 6 i^ancrede's anatomy and manual of dissection . 7 DeSchweinitz's Diseases of the Eye .... 8 Garrigue's Diseases of Women . . . . .9 NoRRis' Syllabus of Obstetrical Lectures . . 9 Saunders' Pocket Medical Formulary . . .10 Saunders' Series of Question Compends . . .11 Hare's Physiology 12 Martin's Surgery 13 Nancrede's Anatomy 14 Wolff's Chemistry 15 Ashton's Obstetrics 16 Semple's Pathology, etc 17 Morris' Materia Medica 18 Morris' Practice of Medicine . . . . .19 Cragin's Gynecology 20 Stelwagen's Diseases of the Skin . . . .21 Martin's Minor Surgery, etc 22 Semple's Legal Medicine, etc 23 Jackson and Gleason's Diseases of Eye, Kose, and Throat 24 Powell's Diseases of Children 25 Wolff's Examination of Urine 26 Sayre's Practice of Pharmacy . . . • .27 Works in Preparation and in Press . . .28 Martin and Hare's AVounds and Obstruction of THE Intestines 29 30 THF CLIMATOLOGIST. A MONTHLY JOURNAL OF MEDICINE DEVOTED TO THE Relation of Climate, Mineral Springs, Diet, Pre- ventive Medicine, Race, Occupation, Life Insurance and Sanitary Science to Disease. Edited by JOHN M. KEATING, M. D. FREDERICK A. PACKARD, M. D. CHAS. F. GARDINER, M. D. ASSOCIATE EDITORS: NORMAN BRIDGE, M D., Los Angeles, Cal. VINCENT Y. BOWDITCH, M. U. Boston, Mass. SAML. R. BURROUGHS, M.D., Raymond, Tex. J. WELLINGTON BYEKS, M.D., Charlotte, N. C. J. M. DaCOSTA, M.D., Philadelphia, Pa. CHARLES DENISON, M.l)., Denver, Colo. GKORGE DOCK, M.D., Galveston, Texas. WM. A. EDWARDS, M.D., Sail Diego, Cal. J. T. ESKRIDGE, M.D., Denver, Colo. S4MUEL A. FISK, M.D.. Denver, Colo. W. H. GEDDINGS, M.D., Aiken, S. C. JOHN B. HAMILTON, M.D., Chicago, 111. T. S. HOPKINS, M.D., ThoTnasville, Ga. FREDERICK I. KNlGllT., M.D., Boston, Mass. K. L. MacDONNELL. M.D., Montreal, Canada. FRANCIS MINOT, M.D., Boston, 3Ias3. ALFRED L. LOOMIS, M.l) . New York City. HENRY M. LYMAN, M.D., Chicago, Illg. WILLIAM OSLER, M.D., Baltimore, Md. WILLIAM PEPPER, M.D., Philadelphia, Pa. BOAR OMAN REED. M.D., Atlantic City, N.J. J. REED, Jb., M D., Colorado Springs, Colo. GEORGE H. ROHE, M.D., Baltimore, Md. KARL VON RUCK, M.l)., Asheville, N. C. FREDK. C. SHATTUCK, M.D., Boston, Mass. S. E. SOLLY, M.D., Colorado Springs, Colo. G. B. THORNTON, M.D., Memphis, Tenn. E. L. TRUDEAU, M.D., Saianac Lake, N. Y. J, B. WALKER, M. D., Philadelphia. Pa. J. P. WALL, M.D., Tampa, Florida. JAMES C. WILSON, M.D. , Philadelphia, Pa. Yearly Subscription $2.00. Single Numbers 20 Cts- W. B. SAUNDERS, Publisher, 913 Walnut Street, Piniiadelphia, Pa. EXTRACT FROM THE INTRODUCTION IN THE OPENING NUMBER OF "THE CLIMATOLOGIST." AUGUST, 1891. *' The object of this Journal is to promote original investi- gation, to piiblish papers containing the observations and ex- perience of physicians in this country and Europe on all matters relating to Climatology, Mineral Springs, Diet, Preventive Medicine, Race, Occupation, Life Insurance, and Sanitary Science — and in that way to supply the means by which the general practitioner and the public at large will become better acquainted with the diseases of this country and Europe, and better armed to meet the requirements of their prevention or cure. The study of these subjects in this country is exciting great and increasing interest, and all admit that, from the little knowledge already possessed of its resources, possibly every known combination of atmospheric condition, soil, altitude, cli- mate, or mineral springs, is to be found on this continent. It is confidently expected that such 3. jozir7tal vj'iW receive encourage- ment and be an authority upon all questions which are included in its title. " Original papers upon diseases of localities — those incident to occupation, race, or climate, the study of epidemics, the questions of proper food, of the water supply, its potability and distribution, matters relating to drainage and diseases de- pendent on it — as well as experimental studies, or laboratory investigations on bacteriology, will form a prominent portion of the material presented during the year, and it is to be hoped that physicians of all sections of the country will send papers upon these or any other subjects which will be of general in- terest. " Special attention will also be paid to the subject of health resorts, descriptions of Sanitariums with special reference to their suitability to certain cases, and the proper selection of patients likely to be benefitted by them. The utmost care will be taken that this Journal shall assume and maintain the highest scientific character. It will be absolutely independent in its ^nnc\^\QS— fair towards all. It will depend for its main- tenance upon the support given to it by the prefession, as it is not published in the interest of any special section or clique." POCKET MEDICAL LEXICON; OR, Dictionary of Terms and Words used in Medicine and Surgery, By JOHN M. KEATING, M.D., Editor of "Cyclopaedia of Diseases of Children," etc.: Author of the "New Pronouncing Dictionary of Medicine," AND HENRY HAMILTON, Author of "A New Translation of Virgil's ^neid into English Verse;" Co-author of a "New Pronouncing Dictionary of Medicine." Price, 75 Cents, Cloth. $1.00, Leather Tucks. $o SO 70 60 50 _ 40 30 _ 30 /o - to -20 -A 2,^0 ^80 f9¥^ — 72 t76 ^€4 f58 ^56 /fO ^4^ /2Z — 40 /04 — 3Z 86 — M -^68 — 50 ,3Z' — n o This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are of Tsut trifling use to the student by their not con- taining the hundreds of new words now used in current lit- erature, especially those relat- ing to Electricity and Bacteri- ology. !6 Annals of Q-yncecology , Phila- ^ delphia, December, 1890. Saunders' Pocket Medical Lexi- ^ con— a very complete little work, invaluable to every student of 8 — medicine. It not only contains a very large number of words, but - ;^- also tables of etymological factors common in medical terminology ; abbreviations used in medicine, (From Appendix to Medical Lexicon.) 6 poisons and antidotes, etc. SECOND EDITION. HOW TO EXAMINE FOR LIFE INSURAN6E. By J0HN M. KEATING, M.D., Medical Director Penn Mutual Life Insurance Co. ; Ex-President of the Associatioii of Life- insurance Medical Directors ; Consulting Physigian foi: Diseases of Women at St. Agne^ ' Hospita l, Phil^. ; Gyrvijecdlogist taSt. Joseph'^ Hospital, etc. COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the PAf expiration of a definite period after the date of borrowing, ^ as provided by the rules of the Library or by special ar- ^1 rangement with the Librarian in charge. • if rAl th DATE BORROWED DATE DUE DATE BORROWED DATE DUE tt s agu expe e and buti exar wor] e foun d d inex thor s, r- gest and e exat able thei 1- try. com e e bop] brai i\ com e in I n phy satii C//7 1 ^^1 C2a'638)M50 F I. NOW READY. MpTlinflT. DTflGinSLS. Profc> IUD37 Martin M36 1891 "It IM is 01 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 37 M36 1891 C.I Essentials of surgery, toqether with a f 2002201712 ■".re; oi ruisease.