COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
 HX64057666 
 RD33 B76 1 907 Five hundred surgica 
 
 RECAP 
 
 \¥/,i;rER M. BRICKNER, M.D. 
 I'lJ. MOSCHCOWITZ, M. D. 
 
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 SURGICAL SUGGESTIONS 
 
500 
 SURGICAL SUGGESTIONS 
 
 PRACTICAL BREVITIES 
 IN DIAGNOSIS AND TREATMENT 
 
 BY 
 
 WALTER M. BRICKNER, B.S., M. D. 
 
 Chief of Surgical Department, Mount Sinai Hospital Dispensary ; 
 
 Editor-in-Chief, American Journal of Surgery^ 
 
 New York, 
 
 ELI MOSCHCOWITZ, A. B., M. D. 
 
 Assistant Physician^ Mount Sinai Hospital Dispensary ; 
 
 Associate Editor^ American Journal of Surgery, 
 
 Nezv York. 
 
 SECOND SERIES 
 
 new york, u. s. a. 
 
 Surgery PubIvIShing Company 
 
 92 wii,i.iam street 
 
 1907 
 
\JJ Ji, i ^-^XJL^^ uMi -^ Oi^vU 
 
 
 <ion 
 
 Copyright, 1907 
 
 BY 
 
 Surgery Publishing Company 
 
PREFACE 
 
 The first issue of " Surgical Suggestions," published 
 in 1906, was exhausted in a few months. The con- 
 tinued demand for the little book has led us to pre- 
 pare this second series. In it we have incorporated 
 with the "Suggestions" that were in the first edition, as 
 many more, making the total number about five hundred. 
 
 These practical brevities make no pretensions to 
 completeness. They are merely observations taken here 
 and there from our own surgical experiences. 
 
 W. M. B. 
 E. M. 
 
 August, 1907 
 
HEAD. 
 
 SURGICAL SUGGESTIONS. 
 
 In determining whether or not to operate Cranium. 
 after injuries to the head, a surgical judg- 
 ment of the case is usually better than one 
 based strictly on the application of neuro- 
 logical rules. 
 
 There is no class of cases in which a prog- 
 nosis is so often at variance with the extent 
 of the injury as in cranial injuries. The 
 prognosis in such cases should, therefore, al- 
 ways be guarded. 
 
 In cases of head traumata, bleeding from 
 the mouth or nose does not necessarily mean 
 that the case is one of fracture at the base. 
 The hemorrhage may be entirely due to a 
 localized injury. 
 
 In fractures of the base of the skull with 
 bleeding from the ear it is necessary to keep 
 the auditory canal absolutely clean in order 
 to prevent infection of the meninges. 
 
 "Egg shell crackle" elicited in palpating 
 a tumor of the cranial bones is diagnostic of 
 sarcoma originating in the diploe. 
 
MEAD. 
 
 Brain. 
 
 Car. 
 
 Depilatories are useful in the preparation 
 of the scalp for the treatment of abscesses 
 or infected wounds, when the nature of the 
 infection or the matted condition of the hair 
 makes shaving difficult. 
 
 Tumors of the brain frequently simulate, 
 in their earlier stages, diseases of the stomach. 
 
 Lumbar puncture must not be performed 
 in cases of tumor of the brain. Sudden death 
 has frequently happened in such cases. 
 
 In exploring for tumors of the brain, the 
 best guide for determining an isolated hard- 
 ness is the finger; the use of a needle is very 
 deceptive. 
 
 A furuncle deeply situated in the external 
 auditory canal gives signs that may be mis- 
 taken for mastoiditis. Great pain when the 
 concha is moved about, will serve to differ- 
 entiate it from the latter. 
 
 Severe and repeated headaches may be 
 due to the unsuspected presence of otitis 
 media, with or without mastoiditis. 
 
 8 
 
HEAD. 
 
 In cases of unaccountable fever, especially 
 in children, never fail to examine the ear. 
 
 Tinnitus aurium, present only in the re- 
 cumbent posture, is suggestive of aneurism of 
 one of the posterior cerebral vessels. 
 
 The history of a discharge from an ear ap- 
 pearing a few days to a few weeks after 
 the beginning of a slowly developing deafness 
 in that ear, unaccompanied at any time by 
 pain, is suspicious of tuberculous otitis media. 
 
 A bean-shaped pulsating swelling just be- 
 low the mastoid apex, in cases of mastoiditis, 
 may be only a lymphatic gland, but it may 
 also be a thrombosed jugular vein. Its nature 
 should therefore be determined before the 
 operation is concluded. 
 
 During mastoid operations always sever 
 with scissors any fragment of tissue attached 
 to a bit of bone loosened with the chisel or 
 rongeur, before removing it. The tearing out 
 of a fiber of the sterno-mastoid muscle, for 
 example, will open a channel of mfection in 
 the neck. 
 
MEAD. 
 
 If the zygomatic cells are thoroughly laid 
 open, one frequent cause of persistent sup- 
 puration requiring secondary mastoid opera- 
 tion, may be avoided. 
 
 A persistent elevation of temperature after 
 a radical operation for mastoiditis should 
 lead one to suspect the possibility of a com- 
 plicating brain abscess. If the fever shows 
 wide fluctuations of temperature a sinus 
 thrombosis is more probably the cause. 
 
 Streptococcic infections having their en- 
 trance through the ear are more apt to affect 
 the muscles than similar infections with other 
 points of entry. 
 
 Nitrate of silver may be attached in full 
 strength to the end of a probe, as for appli- 
 cation in the middle ear, by heating the tip 
 of the instrument and pressing it into the 
 stick of caustic; a little of the latter will 
 melt and form a bead on the probe when it 
 cools. 
 
 ^yc. Cystic swellings at the external angle of 
 
 the eye are usually dermoids. In some cases 
 they communicate by a small opening with 
 an intracranial sac. 
 
 ID 
 
After the extraction of a foreign body 
 from the cornea, a drop of castor oil be- 
 tween the lids will ameliorate the pam. 
 
 HEAD. 
 
 Severe pain in the orbit or even in the 
 eye itself should make one think of frontal 
 sinus infection, especially if there is, or re- 
 cently has been, a nasal discharge. Marked 
 localized tenderness will soon confirm the 
 suspicion, if the disease exist. 
 
 Nose. 
 
 A diagnosis of supraorbital neuralgia 
 should not be made until frontal sinusitis 
 has been carefuly excluded. 
 
 A persistent, chronic discharge from the 
 nose should lead one to suspect chronic dis- 
 ease of the frontal or other accessory sinus. 
 
 Transillumination is a method of corrob- 
 orative value only in the diagnosis of acces- 
 sory nasal sinus disease. By itself it is of 
 small diagnostic use. 
 
 Frontal sinus suppuration rarely requires 
 a disfiguring operation for its relief. It can 
 usually be satisfactorily dealt with through 
 an opening in the line of the eyebrow. 
 
 II 
 
MEAD. 
 
 Face. 
 
 In every case of injury to the nose, with or 
 without fracture, it is well to examine the 
 septum for displacement. If displaced it 
 should be carefully restored, using a nasal 
 plug, if necessary, to keep it in place. 
 
 Non-malignant tumors of the parotid prac- 
 tically never cause pressure effects on the fa- 
 cial nerve. This may be of importance in 
 differentiating them from malignant tumors. 
 
 A swelling in the parotid region is not 
 necessarily a part of the parotid gland. It 
 may be an infection of the pre-auricular lym- 
 phatic gland. Such an enlargement may be 
 associated with herpes of the forehead, or, 
 sometimes, it may be part of a chain of tuber- 
 culous lymph glands. 
 
 The position of Steno's duct must be re- 
 membered when operating on the face. 
 
 In chronic osteomyelitis of the jaw it is 
 better to wait months for a sequestrum to 
 form than to operate a dozen times for the 
 removal of necrosed bone. 
 
 All swellings of the lower jaw accom- 
 panied by discharging fistula, especially mul- 
 
 12 
 
HEAD, 
 
 tiple fistulae, should be looked upon with the 
 suspicion of actinomycosis until proven to be 
 otherwise. 
 
 If a frightened or refractory child will not 
 open its mouth, pass a probe between two 
 teeth and back to the palate. Instantly the 
 mouth will open and a gag may be slipped 
 in. 
 
 The employment of adrenalin as an ap- 
 plication with cocain to the mucous mem- 
 brane of the cheek, e. g., for the excision of 
 a leukoplakic ulcer, is not to be advised. 
 There may be severe secondary hemorrhage. 
 
 When there is bleeding from the tongue, 
 post-operative or otherwise, and one feels 
 reasonably sure that the hemorrhage is ar- 
 terial, it can, as a rule, be easily arrested by 
 passing the forefinger down to the epiglottis 
 and hyoid bone and drawing the base of 
 the tongue upward toward the chin. 
 
 riouth and 
 Pha^-ynx. 
 
 It is wrong to perform any radical opera- 
 tion for an ulcer of the tongue without pre- 
 liminary microscopical examination. Clinical 
 symptoms, no matter how typical, are often 
 misleading. 
 
 13 
 
HEAD. 
 
 A deep ulceration of the fauces or tonsils 
 should not be diagnosed as specific without 
 excluding acute lymphatic leukemia. 
 
 Before operating for pharyngeal adenoids 
 or hypertrophied tonsils make sure that these 
 are not merely an expression of status lym- 
 phaticus. If they are, do not employ an 
 anesthetic. Also determine whether the pa- 
 tient is a hemophiliac. If he is, do not oper- 
 ate at all. 
 
 NECK. 
 
 When opening a retropharyngeal or peri- 
 tonsillar abscess in a small child, by the 
 buccal route, have the head dependent and 
 instruments at hand for tracheotomy. These 
 instruments are needed but rarely, but then 
 urgently. 
 
 In seeking a cause for torticollis, don t 
 fail to examine the teeth. 
 
 In all cases of torticollis, examine for 
 caries of the spine. 
 
 Pediculosis capitis may be the indirect 
 cause of acute torticollis by reason of a de- 
 veloping post-cervical adenitis. 
 
 14 
 
NECK. 
 
 A submaxillary swelling should not be 
 dismissed as a lymphatic adenitis without 
 studying Wharton's duct on the same side. 
 Massage of pus therefrom would alter that 
 diagnosis. 
 
 Examination into the nature and cause of 
 discrete hard lymphatic swellings on each 
 side of the neck, along the sterno-mastoid, 
 should include exploration of the pharynx 
 and naso-pharynx for possible new growth. 
 
 In all glandular affections of the neck it is 
 quite as important to treat the source of 
 infection, e. g., carious teeth, as to treat the 
 inflamed glands. 
 
 In **Ludwig*s angina," the cardinal prin- 
 ciple in the treatment is extensive incision. 
 An incision that passes no matter how deep 
 into the substance of the submaxillary gland 
 proper, will prove of little avail unless the 
 tissues within the wound have been broken 
 up until they are practically pulpy. 
 
 Have the tracheotomy instruments handy 
 before operating upon a case of angina 
 Ludovici. 
 
 15 
 
NECK. 
 
 The greatest ultimate danger in cut-throat 
 cases is the onset of a septic pneumonia. This 
 may be obviated in a measure by closing up 
 the pharyngeal wall, and by paying the 
 strictest attention to asepsis. 
 
 In cut-throat wounds where the thyro-hyoid 
 membrane has been severed, it is necessary, 
 in order to restore perfect phonation and 
 deglutition, to suture this membrane accu- 
 rately. 
 
 Avoid the use of peroxid of hydrogen in 
 wounds of the neck. It is too apt to dissect 
 up the loose cellular planes. The same warn- 
 ing applies in many cases of cellulitis of the 
 hand or foot. 
 
 In the presence of a hard, diffuse, chronic 
 swelling in the neck having some of the ap- 
 pearances of a malignant growth, the possi- 
 bility that the tumor is a so-called "woody 
 phlegmon of Reclus" must be considered. 
 
 Hard subcutaneous tumors of the upper 
 third of the neck, with signs of maHgnancy, 
 are often epitheliomata arising from branchial 
 clefts. 
 
 i6 
 
NECK. 
 
 In performing operations on the neck, 
 make the skin incision parallel to the muscu- 
 lar plane. 
 
 Do not empty a thyro-glossal cyst by as- 
 piration before extirpating it. It is well to 
 inject the cavity with a methylene blue solu- 
 tion first, in order to make sure that all parts 
 of the cyst wall will be extirpated. Another 
 method is to first empty the cyst and then 
 fill it with paraffin. 
 
 In all operations in the left subclavian 
 triangle of the neck, the location there of the 
 thoracic duct must not be forgotten. 
 
 The best thing to do in such emergencies 
 as air embolism is to apply compression im- 
 mediately and pour large quantities of solu- 
 tion, preferably salt solution, into the wound. 
 
 Gradually increasing hoarseness in people 
 past middle age, without definite cause, and 
 with a history of pain radiating to the ear, 
 is suggestive of malignancy. 
 
 17 
 
NECK. 
 
 Tracheotomy. Jn urgent cases a high tracheotomy should 
 
 be performed, not a low tracheotomy. The 
 former can be done very rapidly; the latter 
 requires considerable dissection. 
 
 The best site for an urgent tracheotomy is 
 through the crico-thyroid membrane. To 
 hold the opening apart a couple of hairpins, 
 bent at the end, may be used as retractors. 
 
 In the performance of high tracheotomy a 
 great deal of room can be gained by dividing 
 transversely the fascia that extends upward 
 from the thyroid. 
 
 After tracheotomy the air of the patient's 
 room should be kept reasonably warm and 
 moist. Draughts of cold air provoke much 
 irritation. 
 
 The greatest immediate danger after a 
 tracheotomy is the possibility of a subsequent 
 pneumonia. This can, in a large measure, 
 be obviated by filtering the inspired air 
 through a soft sponge saturated with warm 
 one per cent, phenol solution. 
 
 i8 
 
INECK, 
 
 Repeated attacks of coughing after trache- 
 otomy may mean irritation of the posterior 
 wall of the trachea by the tube; change the 
 length or shape of the canula. 
 
 A "tumor" of the breast occasionally 
 proves to be only a chronic abscess. It has 
 happened that a breast amputated for carci- 
 noma has been found to be the seat of old 
 abscesses only. 
 
 In the treatment of a breast abscess the 
 size of the incision is not as important as its 
 location and direction. 
 
 A small incision and the proper employ- 
 ment of Bier's breast cup will secure exceed- 
 ingly gratifying results in the management of 
 breast abscesses. 
 
 In the presence of a breast infection that 
 fails to heal within a reasonable time after 
 appropriate incision and dressings, it is well 
 to think of local tuberculosis. 
 
 The appearance of pus in the breast of a 
 woman who is not, or has not recently been 
 nursing, is suspicious of some unusual form 
 of infection, e. g., tuberculosis. 
 
 BREA5T, 
 
 19 
 
BREAST. 
 
 A tender, painful swelling just at or be- 
 yond the upper, outer border of the breast, 
 and near the edge of the pectoralis major, 
 is usually an inflamed lymphatic gland. In 
 its presence it is well to look for some skin 
 infection about the waist line, e. g., fur- 
 uncles, which are not rare at this site as a 
 result of irritation by the corset. Per contra, 
 with a boil, abscess, dermatitis or other in- 
 fection at or above the waist line, one may 
 be on the lookout for glandular enlargement 
 at the point referred to. 
 
 In the performance of the radical oper- 
 ation for breast carcinoma it is important to 
 avoid injury to the periosteum of the ribs. 
 
 Multiplicity of tumors of the breast usu- 
 ally speaks against carcinoma. 
 
 Breast tumors, especially in the early 
 stages, not seldom fail to present the classi- 
 cal signs by which their malignancy or non- 
 malignancy may be determined clinically. In 
 all cases where the diagnosis is doubtful, a 
 specimen of the tumor should be removed for 
 microscopic study, before undertaking a radi- 
 cal operation. 
 
 20 
 
THORAA. 
 
 In strapping the chest for fractured rib, 
 two points should be particularly noted: 1. 
 The straps should pass well beyond the me- 
 dian line. 2. They should be applied in 
 full expiration. One or two straps passed 
 over the shoulder help much to secure im- 
 mobilization. 
 
 Cold abscess and lipoma often simulate 
 each other very closely, especially around the 
 chest. If in doubt, aspirate. 
 
 Do not be too hasty in making a diag- 
 nosis of intercostal neuralgia. With the ex- 
 ception of pulmonary and pleural conditions, 
 ulcer of the stomach simulates intercostal 
 neuralgia more frequently than any other 
 lesion. 
 
 It is remarkable how frequently a puru- 
 lent pericarditis may exist without causing 
 many or severe symptoms. Never neglect an 
 examination of the cardiac area, therefore, 
 in cases of suspected sepsis. 
 
 When a patient complains of dysphagia, 
 do not neglect to examine the pericardium 
 for effusion. 
 
 21 
 
THORAA. 
 
 A history of attacks with symptoms of 
 esophageal stricture and intervening periods 
 of well-being is suggestive of cardiospasm. 
 
 A satisfactory method of x-ray study of 
 esophageal diverticula and strictures con- 
 sists in fluoroscopy of the thorax while the 
 patient is swallowing an emulsion of bismuth 
 subnitrate. A skiagraph may be made im- 
 mediately afterwards as a supplementary 
 record. 
 
 Before operating for sarcoma examine the 
 lungs carefully. Do not operate if the pa- 
 tient has persistent cough and blood-stained 
 sputum (not due to tuberculosis), even 
 though no definite signs are found in the 
 lungs — a metastasis has developed. 
 
 A fluctuating swelling appearing between 
 the ribs may, of course, be tuberculous or 
 syphilitic in origin, but it may also be an 
 extension of an intrathoracic growth, e. g., 
 dermoid cyst of the mediastinum. In all such 
 cases, therefore, a careful examination, by 
 auscultation and percussion, should be made. 
 
 22 
 
TMORAA. 
 
 A slender fish bone lodged in a bronchus 
 will usually not cast a shadow on the x-ray 
 plate. In such a case bronchoscopy and aus- 
 cultation are more reliable diagnostic mea- 
 sures. In addition to a variety of moist 
 rales, one may hear, associated with the in- 
 spiratory or expiratory murmur, or both, a 
 musical or vibratory note, when a bone or 
 pin lies in a bronchus. 
 
 If a patient dates irregular or persistent 
 cough from a time when he thinks he "swal- 
 lowed" or inspired a foreign body, the fact 
 that the physical signs elicited upon examina- 
 tion of the chest are peculiar — different from 
 those found in ordinary types of bronchitis 
 — points strongly to the presence of a for- 
 eign body. 
 
 Bronchiectasis is not seldom complicated 
 by brain abscess. 
 
 In aspirating the chest, see to it that the 
 syringe is in good condition before inserting 
 the needle. Never apply the syringe to the 
 needle after the latter has been inserted; a 
 severe pneumothorax may result. If the 
 syringe is found to be out of order while 
 the aspiration is being done, withdraw the 
 needle also and reinsert. 
 
 23 
 
THORAA. 
 
 There is one point that must always be 
 thought of when pus has been aspirated after 
 an exploratory puncture for either suspected 
 empyema or liver abscess, — to make sure 
 that the "pus" does not come from a bron- 
 chus. This can be determined, as a rule, by 
 microscopical examination of the aspirated 
 fluid. 
 
 Very extensive and rapidly spreading sub- 
 cutaneous infections may result after an aspi- 
 ration of a foul-smelling empyema. It is 
 therefore wise to always operate over the 
 site of aspiration, and especially to see that 
 the puncture wound is well drained. 
 
 When operating for empyema thoracis it 
 is a good rule to aspirate again when the 
 pleura is exposed and before it is incised. 
 This may save some embarrassment. 
 
 The shock of evacuating an empyema tho- 
 racis may be largely avoided by making but 
 a small opening in the pleura (after resect- 
 ing the rib) and applying at once several 
 thicknesses of gauze. At the next dressing 
 much or most of the pus will be found to 
 have escaped into the gauze, and the pleural 
 wound may then be enlarged without produc- 
 ing shock. 
 
 24 
 
THOKAA. 
 
 After operation for empyema, a cover of 
 oiled silk or gutta-percha over the gauze 
 dressing serves to prevent admission of air 
 into the pleural cavity, while it will not in- 
 terfere with the escape of air already in 
 the chest. Indeed, a flap of rubber may be 
 laid over the wound and fastened with a 
 little chloroform above. This allows pus 
 to escape from beneath it and excludes the 
 admission of air. 
 
 It is surprising how much information can 
 be derived by abdominal palpation conduct- 
 ed with the patient in a hot bath, the temper- 
 ature of the water being gradually raised to 
 105° F. It usually secures as much relaxa- 
 tion as does the administration of an anes- 
 thetic, sometimes even more. In addition to 
 the avoidance of the dangers and the dis- 
 agreeable features of narcosis, it has the im- 
 portant advantage that the patient is able to 
 call the examiner's attention to sensitive areas. 
 
 ABDOriEN. 
 
 In the presence of a tumor in the mid- 
 line between umbilicus and pubes, the pos- 
 sibility of a cyst of the urachus must be 
 borne in mind. It may simulate an ovarian 
 cyst or other tumor, or a distended bladder. 
 
 25 
 
ABDoneiN. 
 
 Eczema of the umbilicus is sometimes 
 merely the expression of an infected dermoid 
 cyst at that site. 
 
 A discharge from the umbilicus may be 
 due to an infected dermoid cyst, to an ec- 
 zema of the umbilicus, to a patent urachus 
 (urine), to a cyst of the urachus (milky 
 discharge) ; it may be of pus from an ab- 
 scess within the abdomen or in the abdomin- 
 al wall, or of feces (Meckel's diverticulum, 
 perforated strangulated hernia, fecal abscess 
 from tuberculosis). 
 
 Do not ligate tumors of the navel without 
 making sure that the intestine is not included 
 within the ligature. 
 
 In performing paracentesis in the median 
 line for abdominal fluid, be sure that the 
 bladder is empty. When it is necessary to 
 perform paracentesis in the lateral part of the 
 abdomen, be careful to avoid the deep epi- 
 gastric artery. 
 
 Unless some other cause is evident don't 
 fail to examine for signs of tabes when an 
 adult complains of pains about the waist, 
 in the back or in the lower extremities. 
 
 26 
 
ABDOriEN. 
 
 Children who complain frequently of pain 
 in the stomach should be examined for evi- 
 dence of beginning Pott's disease. Such 
 cases, treated before the development of cur- 
 vature, usually yield very satisfactory results. 
 
 In all cases of acute abdominal pain, never 
 fail to examine the lungs and gums. The 
 onset of pneumonia or pleurisy frequently 
 closely simulates acute appendicitis; lead 
 colic may simulate almost any painful ab- 
 dominal condition. 
 
 Enlargement of the veins at the side of the 
 abdomen is indicative of obstruction to the 
 flow of blood in the inferior vena cava; dis- 
 tention of veins about the umbilicus sug- 
 gests obstruction in the portal circulation. 
 The former may be associated with varices 
 of the lower extremities, the latter with 
 hemorrhoids. 
 
 In all cases of recurrent vomiting examine 
 the midline of the abdomen for a small epi- 
 gastric hernia. 
 
 Catheterization sometimes makes the evi- 
 dences of "appendicitis" or "abdominal tu- 
 
 27 
 
ABDOriEIN. 
 
 mor" vanish with the escape of the urine 
 from a distended bladder. 
 
 In cases of run-over by vehicles, if the 
 wheels pass over the trunk from right to 
 left the liver is the organ most commonly 
 ruptured, whereas, if the wheels pass from 
 left to right the spleen is more frequenti)' 
 injured. 
 
 The hypodermatic injection of eserin 
 (salicylate) gr. 1/30 — 1/40, during or just 
 after an abdominal operation, will, in most 
 cases, entirely or largely prevent the distress- 
 ing tympanites that otherwise usually occurs. 
 
 A pulsating swelling in the midline of the 
 abdomen should not be too quickly accepted 
 as an aneurism of the aorta. It may be a 
 retroperitoneal tumor. 
 
 In the presence of large masses of glands 
 in the epigastrium, especially on the right 
 side, examine the testicles for new growth. 
 
 Large, slowly growing, slightly movable 
 abdominal tumors near the median line, caus- 
 
 28 
 
ABDOriEN 
 
 ing few symptoms and not accompanied by 
 signs of malignancy, are suggestive of mesen- 
 teric cysts. 
 
 A primary tumor of the lateral abdomi- 
 nal region in infants and young children is 
 usually a sarcoma of the kidney. 
 
 In operating for perforating gun-shot 
 wounds of the abdomen, find the source of 
 any bleeding first, before attempting to suture 
 any perforation. 
 
 In suturing^ the fascial layers of the ab- 
 dominal wall do not take too large bites 
 with the needle. Necrosis may occur, and 
 sloughing of the fascia predisposes to the 
 formation of hernia. 
 
 If there is repeated vomiting and the pa- 
 tient shows some evidences of collapse, after 
 a laparotomy, especially after operations in 
 the gastric region, examine for separation of 
 the wound and prolapse of the abdominal 
 contents. 
 
 In children, in cases of peritonitis of un- 
 known origin, examine for gonorrheal vulvo- 
 vaginitis. 
 
 29 
 
ABDOriEN. 
 
 Steady loss of weight without other de- 
 monstrable cause should lead the physician 
 to look for a possible malignant visceral neo- 
 plasm. Persistent "indigestion" due to some 
 condition not positively ascertained, should be 
 submitted to surgical diagnosis. 
 
 Bile Tract. 
 
 Repeated attacks of "indigestion," not ob- 
 viously due to some other condition, should 
 awaken the suspicion of gall-stones. Most of 
 the patients operated upon for cholelithiasis 
 give a history of having been treated for a 
 long time for "dyspepsia," and in many of 
 these cases the correct diagnosis might ear- 
 lier have been established. 
 
 If pressure in the right hypogastrium gives 
 rise to a referred pain in the shoulder region, 
 the offending area is probably the gall- 
 bladder and not the pylorus. 
 
 In an attack of cholelithiasis the vomiting 
 as a rule is not attended by relief of pain; 
 the contrary is true in ulcer of the stomach. 
 
 In differentiating between gastric ulcer 
 and gall-stone pains, the association of a chill 
 usually points to cholelithiasis. 
 
 30 
 
ABDOriEN, 
 
 Tuberculosis and cholelithiasis are only 
 very rarely associated. 
 
 Long pauses between attacks of gastric 
 or abdominal pain speak in favor of chole- 
 lithiasis. 
 
 In the progress of a cholecystectomy, if a 
 stone slips away after cutting through the 
 cystic duct, and cannot be found, no great 
 anxiety need be felt, for the stone usually 
 comes away spontaneously in the subsequent 
 discharge. 
 
 Great pain following any operation upon 
 the biliary tract should always lead one to 
 suspect leakage of bile into Morrison's space. 
 If such should be found to be the case insert 
 a drainage tube. 
 
 When operating for cholelithiasis, don't 
 fail to examine the hepatic duct. 
 
 When palpating the common bile duct for 
 stone, make sure that a suspected calculus 
 is not a gland. 
 
 In catarrhal icterus the pulse is usually 
 slow; in jaundice from cholelithiasis this is 
 usually not the case. 
 
 31 
 
ABDoneiN. 
 
 Gradually increasing jaundice without 
 previous history of pain, or with a history 
 of very slight pain, is very suggestive of 
 mahgnant disease. 
 
 Before attributing enlargement of the liver 
 to a surgical condition exclude chronic hep- 
 atic congestion of cardiac disease. 
 
 Examine the rectum in all cases of tumor 
 of the liver. Likewise, before operating for 
 cancer of the rectum examine the liver for 
 metastasis. 
 
 5tomach. Examination to determine the possible 
 
 presence of cardiac disease or aneurism 
 should always be made before passing a 
 stomach tube. In the presence of such le- 
 sions the tube should not be employed ex- 
 cept as a life-saving measure in an emer- 
 gency. 
 
 A hasty diagnosis of ulcer of the stomach 
 should not be made merely because the pa- 
 tient has vomited suddenly large quantities 
 of blood. If the bleeding occurs at regular 
 intervals the possibility of vicarious menstru- 
 ation must be considered. 
 
 32 
 
ABDOMEN. 
 
 It is well to remember that not all ulcers 
 of the stomach are characterized by the 
 classical symptoms of pain, vomiting and 
 hemorrhage. Many patients presenting 
 "dyspeptic" symptoms of only mild grade 
 are afflicted with this disease, and such cases 
 may easily be diagnosed as functional disor- 
 ders until the persistence of the symptoms 
 leads one to suspect the graver malady. 
 
 The thirst following a hemorrhage from 
 gastric ulcer is best relieved by small quan- 
 tities of cocain in solution. 
 
 If an undoubted case of ulcer of the stom- 
 ach is associated with chills, in most cases it 
 means that the ulcer is adherent to the spleen. 
 
 A sudden desire for sharp, sour and spicy 
 articles of food in a middle-aged or elderly 
 person is often the first symptom of a be- 
 ginning gastric carcinoma. 
 
 In a case of gastric disease of doubtful 
 diagnosis, progressive loss of weight js the 
 most important sign in determining the prob- 
 abihty of carcinoma. 
 
 33 
 
ABDOMEN. 
 
 The possibility of gastric cancer must be 
 considered in cases of supposed pernicious 
 anemia. 
 
 In persons of middle age presenting gas- 
 tric symptoms, the diagnosis of cancer should 
 not be excluded because the symptoms have 
 had a sudden onset. Such an onset occurs in 
 a fair proportion of cases. 
 
 Vomiting, secondary anemia and absence 
 of free hydrochloric acid in the gastric juice 
 — a triad of symptoms at once suggestive of 
 carcinoma ventriculi — may occur as a result 
 of chronic nephritis. Especially if the urine 
 contain no casts or albumin is the observer 
 apt to be led astray. 
 
 If a patient vomits coffee-ground material 
 in w^hich no lactic acid is present, one can 
 almost always exclude carcinoma. 
 
 A reasonable suspicion of the presence of 
 a cancer in the stomach or intestine is suffi- 
 cient indication for explorative operation. 
 
 Before proceeding with a radical operation 
 for carcinoma of the stomach, examine not 
 
 34 
 
ABDOMEN. 
 
 only the liver but also the general abdominal 
 cavity, especially the pelvis, and in females 
 the ovaries, for any sign of metastasis. 
 
 Do not be too sure that a mass in the re- 
 gion of the pylorus is a carcinoma. In some 
 cases the infiltration around a chronic ulcer 
 is very extensive and may simulate the feel 
 of a new growth. 
 
 If a patient begins to vomit long after a 
 radical operation for carcinoma of the stom- 
 ach, do not jump to the conclusion that the 
 cause is a local recurrence. It may be a 
 metastasis in the brain. 
 
 In a patient with spondylitis, symptoms 
 simulating acute peritonitis may be due to 
 acute dilatation of the stomach. 
 
 The occurrence after laparotomy of marked 
 distention of the upper abdominal zone, vom- 
 iting and collapse points to acute dilatation 
 of the stomach. 
 
 It is a peculiar fact that post-operative 
 prolapse through the epigastric wound occurs 
 frequently in operations for malignant disease 
 
 35 
 
ABDOriEIN. 
 
 of the stomach. Such wound therefore should 
 be closed with more than usual firmness and 
 all possible precautions should be taken to 
 guard against post-operative vomiting. 
 
 In performing posterior gastro-enterostomy 
 see that the opening in the transverse meso- 
 colon is not so narrow that it may constrict 
 the anastomosed segment of small intestine 
 nor yet so large that it may permit of a 
 possible hernia into the lesser sac. By in- 
 serting a number of sutures between the meso- 
 colon and the stomach wall about the anas- 
 tomosis these possibilities may, in large part, 
 be obviated. 
 
 If within a week or two after the perfor- 
 mance of gastrostomy the drainage tube 
 should be expelled from the fistula, do not 
 entrust its re-introduction to inexperienced 
 hands. It has sometimes happened that the 
 tube has been pushed into the peritoneal 
 cavity, instead of into the stomach. 
 
 Intestines. In the presence of anemia or of faintness, 
 
 without other apparent cause, inquire con- 
 cerning the passage of black stools. The 
 condition may result from hemorrhages due 
 
 36 
 
ABDOriEIN. 
 
 to an ulcer or neoplasm of the small intes- 
 tine. 
 
 A gradually increasing anemia in an eld- 
 erly person, without any other symptoms, is 
 highly suggestive of a latent carcinoma, often 
 in the intestine. 
 
 In typhoid fever spontaneous rupture of 
 the spleen ma}^ simulate intestinal perforation. 
 
 The triad of symptoms — pain, vomiting 
 and distention — without fever, points to in- 
 testinal obstruction. 
 
 Attacks of abdominal pain preceded by 
 "rumbling" of the bowels is suggestive of 
 some obstructive condition. 
 
 The passage of gas or even of a small 
 amount of feces, after an enema, does not 
 gainsay the presence of intestinal obstruction. 
 
 In an acute condition simulating intesti- 
 nal obstruction, if a large mass can be felt in 
 the abdomen think of omental torsion. 
 
 37 
 
ABDOMEN. 
 
 An attack of acute intestinal obstruction, 
 with passage of blood, and in the presence 
 of a cardiac lesion, is suggestive of throm- 
 bosis of a mesenteric vessel. 
 
 Every case of intestinal obstruction of ob- 
 scure origin should be inquired into closely 
 with reference to a previous history of chole- 
 lithiasis. If a definite history of this is ob- 
 tained, it is well to suspect obstruction by a 
 gall-stone. 
 
 When operating for volvulus of the large 
 intestine, insert a rectal tube as high up as 
 possible before attempting the reduction. 
 The volvulus will quickly collapse and the 
 necessity for evisceration will thus be avoid- 
 ed. 
 
 In infants sudden, severe colic associated 
 with diarrhea or the passage of small quan- 
 tities of blood, should lead one strongly to 
 suspect an intussusception. 
 
 When reducing an intussusception don't 
 pull on the intussusceptum but push on the 
 intussuscipiens. 
 
 38 
 
ABDOMEN. 
 
 Whenever we meet with a movable, saus- 
 age-shaped mass in the abdomen, with a 
 history of chronicity, it is well to think of the 
 possibihty of its being a case of hyperplastic 
 tuberculosis of the intestine. This diagnosis 
 will be rendered more suggestive if there are 
 definite signs in the lungs. 
 
 Simple or multiple enterostomy, usually 
 with prompt suture of the opening, is many 
 times a life-saving operation in the presence 
 of intestinal paresis, as from general periton- 
 itis. 
 
 At the onset of an attack of acute appen- 
 dicitis the pain is usually referred to the gas- 
 tric region. 
 
 Appendix. 
 
 The cessation of severe pain during the 
 course of acute appendicitis often means per- 
 foration. 
 
 The twisting of the pedicle of a small 
 ovarian cyst may simulate both the symp- 
 toms and signs of attacks of appendicitis. 
 
 The tenderness in appendicitis may not be 
 (probably usually is not) just at McBur- 
 
 39 
 
ABDOMEN. 
 
 ney's point. The base of the appendix is, 
 however, usually at, or near, that point. The 
 site of greatest ienderness is often over the 
 tip of the appendix. A line drawn between 
 that site and McBurney's point will many 
 times represent the general direction in 
 which the appendix is lying. 
 
 In cases of chronic appendicitis, if an ex- 
 amination be conducted with the patient in 
 a hot bath (105° F. ) , the thickened appen- 
 dix may often be felt to roll under the finger. 
 
 In a tuberculous patient with supposed 
 chronic appendicitis it is well to suspect tub- 
 erculous disease of the ileo-cecal valve. 
 
 Mcrnia. It is a wise rule never to attempt taxis 
 
 in cases of strangulated hernia. The only 
 exception might possibly arise in a case seen 
 within the first hour. 
 
 All cases of hernia in which there is a 
 history of frequent urination should lead one 
 to the suspicion that the hernial sac contains 
 part of the bladder. 
 
 40 
 
ABDOMEN. 
 
 If a peculiar looking mass is found at the 
 inner side of the ring in the course of an 
 operation for inguinal hernia, do not incise 
 or dissect it before convincing yourself that 
 it is not the bladder. 
 
 Do not be too hasty in resecting a strangu- 
 lated loop of intestine. It is remarkable how 
 frequently such loops become viable after 
 long continued applications of hot saline so- 
 lution. 
 
 Examine the umbilicus and the inguinal 
 and femoral canals in all cases of obscure 
 intestinal obstruction. Small strangulated 
 femoral hernias often simulate very closely 
 the feel and appearance of a gland, and in 
 such cases one may be easily misled. 
 
 In hgating the omentum, it is a good rule 
 never to place a ligature around a piece 
 larger than the width of a finger. 
 
 Hemorrhage from the bowel in children is 
 not infrequently caused by a polypus in the 
 rectum. 
 
 Prolapsus ani is a frequent accompaniment 
 of bladder stone in children. 
 
 KECTUn. 
 
 41 
 
RECTUri. 
 
 Prolapse of the rectum in children usually 
 yields to treatment by strapping the nates 
 together with adhesive plaster, if carried out 
 intelligently and persistently, for several 
 weeks or months. The child should be 
 obliged to defecate in the recumbent posture 
 and while the strap is on. After defeca- 
 tion the strap is removed, the parts cleansed 
 and a fresh strap applied, all while the 
 child is recumbent. 
 
 A mass protruding from the rectum of an 
 infant or child may be an intussusception and 
 not a mere prolapse. 
 
 Don't fail to make a digital rectal exami- 
 nation in cases of appendicitis and in all ail- 
 ments when the diagnosis is obscure. Nor 
 should it ever be omitted before an opera- 
 tion upon anal disorders. It may save the 
 embarrassment of a subsequent discovery that 
 a patient's hemorrhoids, for example, were 
 but an expression of a carcinoma higher up 
 in the rectum. 
 
 A radical operation for hemorrhoids 
 should not be undertaken until the etiology 
 of the piles has been determined. Some- 
 
 42 
 
RECTUn. 
 
 times the cause is an obstruction in the por- 
 tal circulation due to hepatic disease. Per 
 contra, abscess of the liver may be due to in- 
 fection from a hemorrhoid operation perform- 
 ed even some months before. 
 
 Bleeding from capillary hemorrhoids high 
 in the rectum usually yields to injections of 
 cold water, or a cold solution of tannic acid. 
 In these cases, however, it is important to 
 exclude the presence of an ulcer further up. 
 
 If a thrombosing pile is opened before 
 the clotting is complete, it is very apt to fill 
 up again and may even become edematous 
 and inflamed. 
 
 When removing hemorrhoids much after- 
 pain may be obviated by making radiating 
 nicks in the skin margin of the anus. 
 
 After an operation for hemorrhoids it is 
 desirable to insert into the rectum a tampon 
 canula, made by smearing with vasehn gauze 
 layers wrapped about a piece of rubber 
 tubing, about three inches long and trans- 
 fixed at its distal extremity with a large 
 safety pin. The tampon canula prevents 
 
 43 
 
RECTUM. 
 
 oozing by its gentle pressure, allows any con- 
 siderable hemorrhage to show itself extern- 
 ally, makes the escape of flatus painless and 
 the introduction of an oil enema easy. 
 
 Although profound anesthesia is required 
 to abolish the anal reflex, chloroform or ether 
 is not always needed in order to divulse the 
 sphincter ani. This may be accomplished 
 painlessly, and usually with fair satisfac- 
 tion, under ethyl chlorid or nitrous oxid nar- 
 cosis if, especially, an opium suppository is 
 introduced a half-hour beforehand, and a 
 pledget of cotton wet in cocain solution is 
 applied just before the operation. 
 
 After operations upon the rectum, espe- 
 cially after those involving divulsion of the 
 sphincter ani, voluntary urination is apt to be 
 inhibited for a day or more. This is especi- 
 ally the case when stretching is done in a 
 Scgittal direction, i. e., towards the urethra 
 and the coccyx. It may save catheterization, 
 therefore, if the stretching is done only 
 laterally, i. e., towards the tubera ischii. 
 
 When pruritus ani is caused by a local 
 eczema it is well to remember that the latter 
 
 44 
 
may be seborrheal in origin. In such cases 
 other areas of the disease, as on the chest 
 and, especially, the scalp, should be sought 
 for; they will require attention also, in order 
 to effect a cure. 
 
 RECTUn. 
 
 It is not sufficiently established that the 
 character of the crystals found in the urine 
 indicates the presence or identity of lithiasis 
 in the urinary tract. When cystin crystals 
 are constantly found in the sediment, how- 
 ever, if symptoms of lithiasis are present, the 
 stone is probably made up of cystin. 
 
 OENITO. 
 
 URINARY 
 
 TRACT. 
 
 Kidney and 
 Ureter. 
 
 An approximate determination of the or- 
 igin of a hematuria may be obtained by not- 
 ing the following points: If pure blood is 
 followed by clear urine, the origin is in the 
 urethra; if the patient first passes urine, then 
 blood, the source of bleeding is probably in 
 the bladder; if urine evenly mixed with 
 blood is voided, the kidney is probably re- 
 sponsible for the hemorrhage; if long, fine 
 clots resembling worms are passed, these, 
 usually, are from the ureter. 
 
 A point worth remembering in the diag- 
 nosis of nephrolithiasis is that red blood cells 
 
 45 
 
OENITOURIINARy TRACT. 
 
 are almost always found in the centrifuga- 
 lized sediment in the urine even in the inter- 
 val between attacks of colic. 
 
 In a very acid urine red blood cells may be 
 disintegrated and appear under the microscope 
 as an amorphous material. When it is im- 
 portant to determine the presence or absence 
 of blood in the urine it is sometimes neces- 
 sary, therefore, to resort to a chemical test, 
 e. g., that with guaiac resin. 
 
 A radiographic shadow simulating that of 
 a urinary calculus may be produced by an 
 atheromatous plaque, as, for example, in the 
 internal iliac artery, by a phlebolith, or by 
 a calcareous gland. 
 
 When skiagraphing for suspected renal 
 calculus the entire urinary tract should be 
 exp)osed, i. e., the kidney regions, ureters 
 and bladder. Not infrequently a stone sup- 
 posed to be in the kidney may be lodged in 
 the lower end of the ureter, within reach 
 from the bladder. 
 
 By a careful study of an x-ray plate it 
 can usually be determined with fair accuracy 
 
 46 
 
OCNITOURIINARY TRACT. 
 
 whether a renal calculus is in the pelvis or in 
 the parenchyma, at the upper pole or the 
 lower pole. 
 
 In cases of renal colic do not make too 
 positive a pre-operative diagnosis of calculus, 
 no matter how typical the symptoms may be. 
 It has happened very often at the time of 
 operation that no stone is found. Fortun- 
 ately, these cases are nearly always cured 
 by the exploratory nephrotomy. 
 
 Attacks of abdominal pain associated only 
 with intestinal symptoms, may nevertheless 
 be due to a renal or ureteral calculus, even 
 though, in addition, a tender area may be 
 palpated at a point more or less remote from 
 the kidney regions. 
 
 The perinephric space is a frequent site of 
 metastatic inflammation after furunculosis or 
 other septic infection. 
 
 If possible, always tie each component of 
 a kidney pedicle separately, not en masse. 
 
 If a stump ligature, e. g., of the renal pe- 
 dicle, is slow to come away, the process may 
 
 47 
 
OENlTO=URINARy TRACT. 
 
 be hastened by fastening it taut to a piece of 
 rubber tubing stretched across the wound. 
 
 If pus persists in the urine after the extir- 
 pation of a kidney for suppurative disease, 
 it often means that the ureter is involved and 
 will require subsequent extirpation. 
 
 When operating upon the ureter for cal- 
 culus or stricture, avoid undue manipulation; 
 it is important to prevent detachment of the 
 ureter from its bed, if possible. 
 
 Pyuria without symptoms is suspicious of 
 an early tuberculosis of the urinary tract. 
 
 The examination for tubercle bacilli in the 
 urine by the ordinary method of staining, is 
 not decisive by any means, even if the blad- 
 der has been catheterized and differential 
 stains for smegma bacilli have been em- 
 ployed. Numerous examinations with the 
 aid of these procedures must be made, and 
 even then the diagnosis is only a presumptive 
 one. The only sure test is by injecting a 
 large quantity of the sediment into a guinea- 
 pig. 
 
 48 
 
OEINITO-URINAR/ TRACT. 
 
 Most cases of sudden, unexpected hemor- Bladder, 
 rhage from the urethra are due to mahgnant 
 disease, but it is well to remember that there 
 are cases of genito-urinary tuberculosis in 
 which such a hemorrhage is the first symp- 
 tom. 
 
 Hemorrhage from the bladder may yield 
 to irrigations with ice-cold water and with 
 1-10,000 adrenalin solution, successively. 
 
 Never attempt to pack a bladder for 
 hemorrhage without the aid of guy sutures: 
 with them one can make absolutely sure that 
 the gauze goes into the bladder, and not on 
 top of it, pushing the organ away from the 
 space of Retzius. 
 
 Post-operative hemorrhage from the base 
 of the bladder that proves inaccessible to lig- 
 atures, and uncontrollable by packings, may 
 be checked by the following method: 
 Through several thicknesses of gauze, cut 
 in squares, pass a double strand of heavy 
 silk or of twine fastened on a stout needle. 
 With the patient in Trendelenburg's position 
 and the bladder widely opened, thrust the 
 needle from within directly through the per- 
 ineum, and bring the gauze firmly against the 
 
 49 
 
OEINITO-URINARY TRACT 
 
 bleeding surface by pulling upon the threads, 
 which are then to be fastened to an out- 
 side dressing. 
 
 It is a peculiar fact that many of the cases 
 of tumor of the bladder occur among work- 
 ers in anilin dyes. 
 
 It should be borne in mind that stone in 
 the bladder may be the primary cause in 
 children of enuresis, masturbation or prolap- 
 sus recti. 
 
 What feels at the other end of the search- 
 er like a stone in the bladder, may be a fold 
 of mucous membrane encrusted with urinary 
 deposit. 
 
 In cases of suspected rupture of the blad- 
 der, catheterization is not always a sure test. 
 The rent may be so large that the catheter 
 draws away urine that has already flowed 
 into the peritoneal cavity. 
 
 To prevent a suprapubic or other drain- 
 age tube from becoming displaced is easily 
 accompHshed by fitting another tube over it 
 hke a collar; this outer tube is split through 
 
 50 
 
OCNITO=URirSAR/ TUACT. 
 
 half its length and the two portions are 
 spread out over the skin and fastened down 
 with adhesive plaster. 
 
 Involuntary urination very often means a 
 distended bladder, and in old men it should 
 at once indicate an examination into the con- 
 dition of the prostate. Vomiting, too, is 
 often caused by distention of the bladder. 
 
 An acutely distended bladder should not 
 be completely emptied in one sitting. Its 
 rapid collapse may produce hemorrhagic cys- 
 titis. 
 
 Before employing a rubber catheter test 
 its resihency. If it is brittle or cracked, dis- 
 card it. Not infrequently a rotten catheter 
 breaks off in the bladder while, of course, 
 a rough catheter or sound may play havoc 
 in the urethra. 
 
 Unconscious patients should be catheter- 
 ized at regular intervals of about eight hours. 
 
 Rectal examination sometimes aids in de- Prostate. 
 termining the variety of obstruction in pros- 
 tatic hypertrophy. If the prostate is com- 
 
 51 
 
OEINITO-URINARY TRACT. 
 
 paratively small, the obstruction is probably 
 due to the middle lobe; if large, to the later- 
 al lobes. 
 
 A Mercier catheter is the first kind that 
 ought to be employed in attempting to over- 
 come retention caused by an enlarged pros- 
 tate. Often it will have to be resorted to 
 in the end; and, therefore, it will save much 
 unsuccessful manipulation to use it at once. 
 Occasionally, a metal catheter will pass 
 when even a Mercier fails. 
 
 Never open a prostatic abscess per rectum; 
 no matter how much it bulges; always oper- 
 ate through the perineum. 
 
 It is a wise rule to submit all removed 
 hypertrophied prostates to thorough examina- 
 tion by a pathologist. Carcinomatous de- 
 generation may be found in some spot. 
 
 Carcinoma of the prostate often does not 
 recur for some time; meanwhile the patient 
 may look surprisingly well. This should not 
 beguile the surgeon into a too hopeful prog- 
 nosis. 
 
 52 
 
OENITO^URirSARy TKACT. 
 
 Force is never helpful in overcoming the Penis and 
 resistance of a stricture to instrumental pas- Urethra. 
 sage; it is bound to do harm. A combina- 
 tion of patience and hot apphcations, with 
 a strong admixture of gentleness and judg- 
 ment, will effect the desired result in most 
 cases. 
 
 A swelling or redness behind the scrotum, 
 in cases of urethral stricture or developing 
 after urethral instrumentation, usually means 
 urinary extravasation, which requires prompt 
 and active treatment. 
 
 One death from urethral sepsis is enough 
 to impress upon one the importance of the 
 teaching that perineal drainage should al- 
 ways be employed after internal urethrotomy 
 three or more inches from the meatus. 
 
 When performing external urethrotomy 
 without a guide it is often possible to trace 
 the continuation of the urethra proximal to 
 the opening, by means of a filiform bougie, 
 even when all devices failed to secure the 
 introduction of a filiform before the opera- 
 tion. If a filiform cannot be thus passed 
 through the urethral wound, suprapubic pres- 
 
 53 
 
OENITOURINAKY TRACT. 
 
 sure on the bladder may demonstrate the lo- 
 cation of the urethral orifice by the escape of 
 a drop of urine or by bulging of the mem- 
 branous urethra. 
 
 Avoid the temptation to employ a con- 
 strictor upon the penis when performing cir- 
 cumcision, etc. It may cause sloughing, or 
 actual gangrene. 
 
 After circumcision it is important to pre- 
 vent adhesion of the reflected mucous fold 
 of the prepuce to the corona glandis, by the 
 daily passage of a probe about the corona, 
 and by the use of vaselin. 
 
 Absorbent cotton, so commonly used to 
 catch the discharge of gonorrhea, is very 
 inelegant. It sticks to the glans, allows the 
 meatus to glue together, and is difficult to 
 remove without soiling the fingers. The fol- 
 lowing is the cleanliest and most surgical 
 dressing. In a six inch square of surgical 
 gauze, of about four thicknesses, cut a slit 
 in the middle just large enough to be passed 
 over the glans and to be held behind the 
 corona. Then simply draw the foreskin for- 
 ward. Indeed, such a dressing will hold 
 
 54 
 
OENITO-URIINAR/ TRACT. 
 
 even if the patient has been circumcised, if 
 the slit in the gauze is not too large. With 
 such a simple dressing, there is no retention 
 of the pus, no irritation from contact with 
 the secretions, the organ is readily inspected 
 and the gauze is easily drawn off by a little 
 pull at one of its clean corners. 
 
 Non-specific urethral discharges in young 
 boys may be due to foreign bodies introduced 
 while masturbating. 
 
 Examine the inguinal regions for hernia in 
 all cases of very tight prepuce causing diffi- 
 culty in micturition. 
 
 If difficulty is experienced in reducing a 
 paraphimosis because of swelling, before di- 
 viding the constriction apply a rubber band- 
 age around the parts for a few minutes; this 
 may reheve the swelling to such an extent 
 that the paraphimosis can be easily reduced. 
 
 A comforting support for the testicles, Scrotum 
 when a patient is confined to bed with or- and 
 chitis, is easily furnished by a well-padded Testicle. 
 cigar box cover, grooved to fit under the 
 scrotum, and laid across the thighs. Ad- 
 hesive plaster may be used in the same man- 
 ner. 
 
 55 
 
OENITO URINARY TRACT. 
 
 In hydrocele ihe base of the tumor is be- 
 low, in spermatocele it is usually above. A 
 milky fluid obtained by aspiration usually 
 speaks for spermatocele. 
 
 If a cystic swelling in the scrotum is 
 opaque when examined by the well-known 
 transillumination test, especially if a history 
 of traumatism is elicited, it may still be a 
 hydrocele. Admixture of blood in the hy- 
 drocele destroys its translucency. 
 
 The early reappearance of fluid after tap- 
 ping a hydrocele does not necessarily mean 
 that the operation has been a failure. It 
 may be but an inflammatory reaction, sub- 
 siding spontaneously or under the applica- 
 tion of unguentum iodi. 
 
 If a male patient with supposed strangu- 
 lated hernia complains of pain running down 
 the inner aspect of the thigh it is well to 
 think of torsion of the testicle. 
 
 Accumulated experience shows that cas- 
 tration alone will not cure the great ma- 
 jority of cases of tuberculosis testis. In 
 many, if not most, cases the vas deferens. 
 
 56 
 
OENITO-URINARy TRACT, 
 
 seminal vesicle or prostate is involved, and 
 it will be necesasry to remove one or more 
 of these structures in order to cure. More- 
 over the other testicle frequently becomes 
 tuberculous. Open-air therapy is helpful. 
 
 Syphilitic interstitial orchitis resembles 
 closely in appearance new growth of the 
 testicle. Unless the diagnosis of neoplasm 
 is beyond all doubt, an active course of 
 specific treatment should be tried before re- 
 moving the testicle. 
 
 In excising a varicocele under local anes- 
 thesia, tie the upper ligature first; the pain 
 of tying the lower ligature will then be abol- 
 ished. 
 
 After the open operation for varicocele 
 the scrotum may be shortened by simply sew- 
 ing the wound together transversely instead 
 of longitudinally. 
 
 The presence of varicocele, especially if 
 unilateral, should suggest an examination of 
 the abdomen and pelvis for a possible growth 
 pressing on the spermatic veins. 
 
 57 
 
reriALE oeinerative organs. 
 
 It is a good rule to always inspect the 
 labia before making a vaginal examination. 
 Many pathological conditions in these parts 
 may otherwise pass unsuspected. 
 
 Don't be tempted to exclude gonorrhea 
 because you see no bacterial or other evi- 
 dence of vaginal or urethral infection. In 
 women the presence of gonorrhea may not 
 make itself known for six weeks or more, 
 and salpingitis may be the first evidence. 
 
 When the openings of the Bartholinian 
 glands appear as two sharply defined red 
 spots, an antedating inflammation may be 
 diagnosed with certainty, and in a great ma- 
 jority of instances a latent gonorrhea is pres- 
 ent. 
 
 Simple incision is not sufficient in the treat- 
 ment of Bartholinian abscesses. They should 
 be cauterized daily with iodin, and if they 
 recur, excised. 
 
 Furunculosis vulvae, even when it persists 
 in spite of all other treatment, will usually 
 yield to daily scrubbing with green soap and 
 the application of a dressing of sublimate 
 solution. 
 
 58 
 
reriALE generative oroan5. 
 
 When cleansing the vagina and vulva in 
 preparation for an operation, a soft cotton 
 mop should be used for the vestibule; a 
 stiff brush is too apt to bruise or lacerate 
 the urethra and cause dysuria for some days 
 thereafter. 
 
 The use of any considerable quantity of 
 iodoformized gauze in the vagina involves the 
 risk of a severe dermatitis of the vulva. 
 
 Before performing curettage always make 
 a final bimanual examination of the uterus 
 in narcosis. The finding may determine 
 some other form of treatment. Again, after 
 curettage, before allowing the patient to get 
 out of bed, carefully examine the pelvis for 
 signs of a possible exudate. 
 
 As a final cleansing step after curettage 
 of the uterus it is well to introduce, and at 
 once withdraw, a packing of gauze. This 
 brings out with it fragments of tissue not 
 washed out by the irrigation. 
 
 Sudden collapse after a curettage for sup- 
 posed abortion may mean the rupture of an 
 unsuspected ectopic gestation sac. 
 
 59 
 
TEMALE GENERATIVE OROA1N5. 
 
 Carcinoma of the cervix may remain hid- 
 den in the lumen of the cervical canal, w^hich 
 is then eroded and forms an irregular ellipti- 
 cal cavity. While the external os is closed 
 suspicion of the serious condition present v^ill 
 be attracted by ihe foul or bloody discharge. 
 
 No operation for sterility in the female 
 should be performed without first excluding 
 sterihty on the husband's part. 
 
 In case of hematocolpos and hematometra 
 it is essential to precede all interference by a 
 careful rectal examination in order to de- 
 termine whether the tubes are distended or 
 not. If hematosalpinx exists a laporatomy 
 and salpingectomy must precede the vaginal 
 operation, otherwise a severe peritonitis may 
 be set up by a reflex discharge of infective 
 secretion from the tubes. 
 
 In the early months of pregnancy exami- 
 nations should be made to determine that 
 there is no retroversion, or to treat it if it 
 exists. A retroverted gravid uterus impacted 
 in the curve of the sacrum always aborts. 
 
 Ascites in the presence of a mass in the 
 pelvis usually, but not necessarily, means 
 malignancy. 
 
 60 
 
PEMALE OENERATIVE OR0AIN5. 
 
 Avoid introducing a uterine sound in ex- 
 aminations when pelvic inflammation is sus- 
 pected. It may set up a parametritis. 
 
 Impaction of feces in the sigm.oid and rec- 
 tum, with absorption symptoms, may simu- 
 late pelvic peritonitis. 
 
 In pulling on the round ligaments in the 
 Alexander operation, use the fingers rather 
 than instruments; a surer hold is given, one 
 can gauge the proper force to employ more 
 readily, and there is less likelihood of the 
 ligaments tearing. 
 
 In all cases of lumbago, especially of the BACK. 
 
 chronic variety, examine the sacro-iliac joints 
 for tenderness. Such cases may sometimes 
 be almost instantaneously relieved by apply- 
 ing broad strips of plaster from beyond one 
 superior iliac spine to the other, across the 
 back. The straps must be applied tightly 
 and with the feet close together. 
 
 A skin-lined sinus opening between the 
 coccyx and the anus, when not very short, 
 usually leads to a dermoid cyst situated close 
 to the coccyx. Frequently loose hairs from 
 the dermoid may be found in the sinus. 
 
 6i 
 
BACK. 
 
 Congenital paralysis of the lower limbs 
 may arise from an internal sacral or coccy- 
 geal spina bifida. In such cases rectal ex- 
 amination reveals the trouble and an opera- 
 tion may afford marked improvement or even 
 a brilliant cure. 
 
 EATREni- 
 TIE5. 
 
 Do not consider too lightly a history of 
 ''growing pains" in the extremities in chil- 
 dren. These symptoms may be due to a 
 grave osteomyeHtis. 
 
 Do not be in a hurry to perform primary 
 amputations after severe traumata of the ex- 
 tremities. First, combat the shock and pre- 
 vent hemorrhage. Keep the wound as clean 
 as possible; and only when the patient has 
 quite recovered from his shock (at the end 
 of a few days or more), perform the ampu- 
 tation. 
 
 Pulsation in the course of an artery should 
 not lead to the hasty conclusion that one is 
 dealing with an aneurism. A tumor over- 
 lying a large vessel, and also a vascular sar- 
 coma of the bone, may simulate an aneu- 
 rism very closely. 
 
 62 
 
EATKEniTIE5. 
 
 Never incise a swelling in the course of a 
 large artery without making sure first that it 
 is not an aneurism. 
 
 When clamping a vein in continuity se- 
 cure the proximal end first; otherwise it will 
 empty and may become lost to view. 
 
 In acute (septic) osteomyelitis immediate 
 operation is not too radical; in chronic os- 
 teomyelitis patient waiting is often not too 
 conservative — the final expulsion of a seques- 
 trum may be all that is necessary to effect 
 spontaneous cure. 
 
 In acute, no less than in chronic osteomye- 
 litis of the long bones, an x-ray picture is of 
 immense service as a guide in the operation. 
 It determines the exact location, extent and 
 even character, of the disease focus, and thus 
 it saves much unnecessary destruction of bone 
 by the surgeon's chisel. 
 
 A chronic synovitis of apparently un- 
 known origin and very rebellious to treat- 
 ment is sometimes due to a small focus of 
 osteomyelitis just beneath the cartilaginous 
 surface. 
 
 63 
 
EATRErilTIE5. 
 
 When performing amputation, arthrec- 
 tomy, osteotomy or similar operation it is 
 wiser to leave the constrictor in place until 
 the dressing is partly, or entirely, applied, 
 than to remove it after tying the large ves- 
 sels, in an effort to secure the small ones. 
 In the former case the snugly appHed dress- 
 ing w^ill safely prevent hemorrhage; in the 
 latter case, there may be an alarming loss 
 of blood from the numerous small vessels in 
 the very time the efforts are made to tie them 
 all. 
 
 Do not amputate an extremity for sar- 
 coma without a previous careful examina- 
 tion of the lungs and mediastmum for me- 
 tastasis. Such symptoms as continued cough, 
 a small hemoptysis or beginning dyspnea, 
 should be regarded as highly suggestive of 
 such a complication. 
 
 After major amputations an elastic con- 
 strictor should always be left at the head of 
 the bed, so that the nurse can immediately 
 apply it in case of secondary hemorrhage. 
 
 Never apply an elastic ligature about the 
 arm without first interposing a towel. This 
 may obviate subsequent paralysis. 
 
 64 
 
EATREniTIES, 
 
 The superficial location of the ulnar nerve 
 must be borne in mind when incising an ab- 
 scess about the inner aspect of the elbow. 
 
 An acute non-purulent tenosynovitis may 
 be satisfactorily treated by immobilization 
 with plaster strips. 
 
 Persistent pain in an arm may be due to 
 the presence of a "cervical rib." 
 
 Persistent pains in the leg may be due to 
 obliterating endarteritis. This occurs occa- 
 sionally even in young men and often goeo on 
 to the production of gangrene. Both syphil- 
 is and excessive smoking are suspected as 
 etiological factors. 
 
 Flat-foot is another cause of pains in the 
 leg or thigh. 
 
 In cases of pain in the hip of doubtful 
 origin, examination of the kidney regions may 
 discover the cause. 
 
 The presence of sciatica demands a care- 
 ful exploration of the pelvis by rectal or 
 vaginal examination. It should also be re- 
 
 65 
 
EATRErilTIE5- 
 
 membered that Osier described sciatica as 
 one of the early symptoms of cancer of the 
 breast. 
 
 The following are some of the conditions 
 in the presence of which an exammation for 
 tabes dorsalis should never be omitted : 1 . 
 All primary swellings of the knee or ankle 
 joint without apparent origin. 2. "Sciat- 
 ica" and "lumbago." 3. A deep ulcer on 
 the base of the great toe. 4. Repeated vomit- 
 ing at various intervals, with periods of well- 
 being intervening. 5. Abdominal pains 
 without other evident cause. 
 
 Pain in the leg after an abdominal opera- 
 tion often means the development of a fe- 
 moral vein thrombosis. This occurs usually 
 on the left side. 
 
 Lymph-edema of the lower extremity as- 
 sociated with a swelling in the groin (fluct- 
 uating or not) is significant of carcinoma of 
 the inguinal glands. The primary lesion may 
 be in the rectum, e. g., an epithelioma of the 
 anus that is giving no symptoms. 
 
 When removing a lipoma or other growth 
 from the inner surface of the thigh, a little 
 
 66 
 
EATREriITIE5. 
 
 care should be exercised in order to avoid 
 cutting the long saphenous vein. Ligature of 
 that vessel (especially in ambulant and in 
 non-aseptic cases) may be followed by a dis- 
 tressing phlebitis. 
 
 Inflamed areas and abscesses about the 
 knees of creeping infants should be exam- 
 ined for foreign bodies. 
 
 Punctured wounds about the knee should 
 be treated with the greatest solicitude and 
 attention to asepsis, in order to prevent in- 
 fection of the joint. 
 
 In operating for loose bodies within the 
 knee joint, do not be satisfied with removing 
 but one body; a careful examination should 
 be made to determine the presence of more, 
 for they are very frequently multiple. 
 
 Do not operate for foreign body in the 
 knee joint without first excluding dislocation 
 of one of the semilunar cartilages. 
 
 In amputations below the knee, insist on 
 active and passive motion in the knee joint 
 at an early date. If this is not done con- 
 tracture ensues, which makes the application 
 of an artificial limb difficult. 
 
 67 
 
EATREriITlE5. 
 
 A hematoma may be produced in the calf 
 muscles by direct or indirect violence that the 
 patient may pay little attention to at the time 
 or even fail to recall. 
 
 Swelling of the leg, associated with febrile 
 disturbances, may be produced by hematog- 
 enous infection of a hematoma of the calf 
 muscles. Such a condition may somewhat 
 simulate osteomyelitis or other serious con- 
 dition. It may be differentiated, however, 
 by the location of the greatest tenderness and 
 swelling and by a careful inquiry into the 
 history. If no distinct traumatism is recalled 
 the condition of the patient's arteries may 
 nevertheless suggest the possibility of the oc- 
 currence of such a hematoma. 
 
 Patients with varicose veins should be in- 
 structed that in case hemorrhage takes place, 
 the best method of stopping it temporarily is 
 to merely compress the bleeding point with 
 the finger. 
 
 Never advise an elastic stocking in cases 
 of varicose veins where recent phlebitis exists. 
 The pressure may detach a part or whole of 
 the thrombus, propelling it into the general 
 circulation. 
 
 68 
 
EATREMITIE5. 
 
 Before anesthetizing a patient to operate Hand. 
 upon a wound (e. g. of the wrist), in which 
 tendons are severed, attach forceps or Hga- 
 tures to any tendon ends that are visible. 
 While strugghng during primary narcosis the 
 proximal ends of cut tendons are sometimes 
 drawn up, and the above device will obviate 
 slitting up the sheaths to secure them. 
 Squeezing the extremity proximal to the 
 wound will likewise prevent these retractions. 
 
 Never divide the annular ligament of the 
 wrist. The hand is much weaker after it is 
 divided than before. 
 
 Frequently referred to the surgeon because 
 of the constant pain and marked tenderness, 
 is to be noted a group of cases of what might 
 be termed "occupation wrist pain." They dif- 
 fer from the ordinary case of "writer's 
 cramp," " piano-player's cram.p," etc., in 
 that, while these latter frequently have pain 
 in, or about, the wrist, the cases here re- 
 ferred to have no spasm, the pain is con- 
 stant, and it is not of a neuralgic character. 
 Sometimes it radiates along the thumb (as in 
 mail-openers) ; sometimes it is localized to 
 the inner border of the lower end of the ulna, 
 which is very sensitive to pressure (as in 
 
 69 
 
EATRErilTIES. 
 
 shirt-ironers) . The fingers are free. There 
 may be pain in the forearm muscles (flex- 
 ors). 
 
 For a single tenorrhaphy make the inci- 
 sion quite a httle to one side of the Hne of 
 the tendon and perform no more dissection 
 than is necessary. This is to avoid adhesions 
 of the tendon to the skin. 
 
 If a tendon has been divided by an in- 
 cised or lacerated wound and the skin has 
 united over it, it is better to wait a fortnight 
 or more before performing tenorrhaphy. 
 Otherwise organisms introduced with the 
 traumatism may cause suppuration and 
 sloughing of the tendon, not only defeating 
 the operation, but making a later attempt at 
 approximation difficult or impossible. 
 
 When exploring for a needle or other for- 
 eign body the finger tip is often far more use- 
 ful than a probe It must be remembered, 
 too, that strands of fascia often impart to a 
 probe "the feel" of a foreign body. Cut- 
 ting and picking at these deceptive strands 
 of tissue soon distort the field of operation 
 and destroy important relations. It is ex- 
 tremely desirable to conduct a systematic and 
 
 70 
 
EATRCniTIE5. 
 
 cleanly dissection when seeking a foreign 
 body. 
 
 The best drainage should be afforded for 
 all punctured wounds of the palm; suppura- 
 tions in this region are very disagreeable and 
 are followed by severe consequences. 
 
 The surgeon should not wait for redness 
 before making a diagnosis of palmar abscess. 
 Owing to the density of the fascial structures 
 this sign is often lacking in the early stages. 
 
 In dealing with infections of the hand bear 
 in mind that under a simple bleb may lie an 
 extensive phlegmon, threatening, or actually 
 involving, a tendon or bone and urgently 
 needing a generous but wisely placed inci- 
 sion; while on the other hand, a tendon may 
 be thrust from its protecting sheath into the 
 area of destruction by a knife sweep more 
 earnest than judicious. A crater-hke opening 
 in a sodden skin, though freely discharging 
 pus, may need enlarging to protect the tissues 
 underlying; while another opening, too long 
 continued by unnecessary packing, may crif)- 
 ple a joint or tendon by undue cicatrization. 
 
 In the treatment of hand and finger in- 
 71 
 
EATREMITIES. 
 
 fections, it is very important to release from 
 bandaging as much and as many of the fin- 
 gers as possible, and as soon as possible. The 
 habit of bandaging up immovably all the 
 fingers, in the treatment of a lesion of some 
 of them, saves the surgeon time but, except 
 in short cases, it often cripples the hand by 
 stiffening the fingers. 
 
 Occasionally, contractures of the fingers 
 following the treatment of a cellulitis of the 
 hand and forearm may be due, not to the 
 cellulitis itself nor to the incisions made to 
 relieve it, but to fibrosis and shortening of 
 the flexors in the forearm, the result of too 
 tight bandaging or strapping. Such a con- 
 dition — Volkmann's ischemic muscle contrac- 
 ture — must, therefore, be distinguished from 
 the stiff, flexed fingers produced by the cellu- 
 litis. Passive motions and massage are help- 
 ful in both conditions, but in the former bone 
 shortening (radius and ulna) is necessary 
 to accommodate the contractured muscles. 
 
 Remember that chronic ulcers on the 
 hands are found in brass workers, and that 
 a discontinuance of this occupation is neces- 
 sary to secure healing. 
 
 72 
 
EATKEniTIE5. 
 
 Indolent sinuses, as of the fingers after 
 deep infections, frequently heal by the daily 
 use of prolonged immersions in hot water. 
 
 In dealing with infections or injuries of 
 the fingers amputation should be a last 
 resort. This is especially the case with a 
 thumb, the most important of all the fingers. 
 
 In a case of fresh traumatic amputation 
 of a part of the finger, if the amputated part 
 has not been too lacerated or crushed, try 
 to restore the member by cleansing the parts 
 carefully and suturing it to the stump. Once 
 in a while the graft will "take." 
 
 Amputation of a finger gangrenous as the 
 result of carbolic acid application should not 
 be performed until the line of demarkation is 
 well established. The necrosis may be su- 
 perficial and in such an instance the finger 
 may be saved by means of skin graft. 
 
 Tenderness in the heel, or pain and ten- Toot. 
 derness in the sole of the foot is very often, 
 indeed, of gonorrheal origin. It will not be 
 relieved in such cases until treated on that 
 basis. The patient may deny that he ever 
 
 73 
 
EATREniTIES. 
 
 had gonorrhea. Examine his urine; shreds 
 tell their own story. 
 
 Do not be too hasty in ascribing the 
 cause of pain in the tendo Achilles, or 
 Achilles bursa, to an ill-fitting shoe. First 
 exclude gonorrheal infection. 
 
 If the cause of pain in the feet is not other- 
 wise clear, examine them in the dependent 
 position. This may develop the presence of 
 erythromelalgia. 
 
 The determination of the presence of a 
 fracture of one of the mid-tarsal bones is 
 extremely difficult, and usually impossible, 
 without x-ray examinations. Yet these ex- 
 aminations have shown the occurrence of 
 such fractures, alone, or associated with in- 
 juries to other bones, as the result of injuries 
 by slight or severe direct violence. For 
 this reason, and because fractures of the 
 metatarsals by indirect violence are by no 
 means uncommon, it should be practically 
 a routine to submit the foot to skilful skiag- 
 raphy in all cases where either form of vio- 
 lence may have occurred. It will save many 
 patients from weeks of suffering and disa- 
 
 74 
 
EATREniTIES. 
 
 bility. In this region, more than in any 
 other, the x-rays are a means of diagnosis 
 that cannot be dispensed with. 
 
 Many, at least, of the sprains of the an- 
 kle involve a fracture of the tip of the mal- 
 leolus, and should be treated by immobili- 
 zation in plaster-of-Paris. 
 
 In old people, as in diabetics, corns, 
 bunions and wounds of the feet demand the 
 most careful attention. They are often the 
 starting points of gangrene. 
 
 A very simple method of curing a corn is 
 to excise it. 
 
 In ingrowing toenail, evulsion of the nail 
 gives temporary rehef, but it does not cure. 
 When the nail grows out again the condition 
 recurs, often in aggravated form. 
 
 It is doubtful whether the classical opera- 
 tions for ingrown toe-nail cure permanently 
 in even a fair percentage of cases. Conser- 
 vative treatment will usually accomplish as 
 much, even in the presence of granulating 
 masses. Tliis treatment includes drawing the 
 
 75 
 
EATRErilTIE5. 
 
 flesh away from the nail with a strip of ad- 
 hesive plaster, insertion of a gauze packing 
 under the nail edge and the appHcation of an 
 absorbent antiseptic dressing. 
 
 Be very guarded in the prognosis of ul- 
 cerations on the sole of the foot in diabetic 
 or tabetic patients, no matter how small or 
 trifling the ulceration may be. They persist 
 for long periods and may even never heal. 
 
 TKAC- 
 TURE5. 
 
 Very often the unskillful treatment of a 
 fracture is worse than no treatment at all. 
 Serious deformities may result from the neg- 
 lect of small details no less than from the 
 violation of important principles. 
 
 The important considerations in the treat- 
 ment of fractures are, at first, relief of pam 
 and reduction of swelling, and, subsequently, 
 preservation of function of the muscles, the 
 nerves and the neighboring joints. Hence 
 the value of early and frequent massage and 
 passive motion (and in suitable cases, of 
 active motion) and the necessity for avoid- 
 ing splints that unduly compress the muscles 
 or deprive them of activity. 
 
 76 
 
PRACTURE5. 
 
 In the treatmenl of fractures of the fore- 
 arm no consideration is more important than 
 the avoidance of contractures of the fingers, 
 by the intelligent use of splints and by means 
 of early, active and passive movements. 
 
 Permanent contracture of the muscles, not- 
 ably of the flexor group in the forearm, may 
 develop within a very short time after the 
 application of a splint that exercises undue 
 compression. It is a wise rule to inspect all 
 fracture dressings within twenty-four hours; 
 and when this is not expedient special care 
 should be exercised, when applying the dress- 
 ing, to avoid compression. 
 
 In very many cases it is not necessary to 
 the diagnosis of fracture to ehcit crepitus 
 and abnormal mobility — often painful man- 
 ipulations. In several forms of fracture 
 there are other positive diagnostic evidences. 
 Thus, with CoUes' fracture the level of the 
 styloid of the radius will almost always be 
 found to have receded from beyond that of 
 the styloid of the ulna. Moreover, x-ray 
 examinations save much painful manipula- 
 tion. 
 
 After all, the localization of bone tender- 
 
 77 
 
TKACTURES. 
 
 ness is not only the most useful sign in de- 
 termining the site of a fracture, but, even in 
 the absence of other signs, it is often, in 
 itself, diagnostic of the presence of a frac- 
 ture. As instances may be cited greenstick 
 fracture of the clavicle, and fracture of the 
 metacarpal and metatarsal bones. 
 
 In all examinations of children, and in the 
 examination of adults for suspected fractures, 
 leave the painful manipulations for the last. 
 
 The x-rays have taught us that mathemati- 
 cal reduction is rarely, and even linear re- 
 duction is seldom, accomplished even in 
 cases in which excellent functional results 
 are secured. Radiographs have thus fre- 
 quently been made the basis of blackmail- 
 ing damage suits. Nevertheless, the x-rays 
 are, of course, of immense value in the treat- 
 ment of fractures — not only for reference 
 before and after reduction, but during the 
 reduction itself. 
 
 A fracture produced by only slight vio- 
 lence should at once raise the suspicion of 
 a malignant growth. In such a case a uni- 
 form dark shadow about the bone as seen 
 
 78 
 
rRACTURE5. 
 
 in the fluoroscopc is to be interpreted as a 
 neoplasm rather than as callus, for recent 
 callus is not opaque to the x-rays. 
 
 That a bone appears normal by fluoro- 
 scopic examination does not gainsay the pres- 
 ence of a fracture. A fracture of the radius, 
 for example, may occur without displacement 
 of the fragments. An x-ray plate will dem- 
 onstrate the line of fracture, when the fluoro- 
 scope fails to. 
 
 Severe localized pain after traumatism, es- 
 pecially in children, may be due to sub- 
 periosteal fracture, e. g., near the head of 
 the humerus or the femur. Extreme local- 
 ized tenderness is the chief sign; abnormal 
 mobility and deformity are absent, and crepi- 
 tus may not be elicited. 
 
 In cases of fracture where an end of the 
 bone lies close beneath the skin do not place 
 a pad or any pressure whatever over this 
 point. 
 
 In compound fractures involving loss of 
 continuity do not needlessly remove any piece 
 of bone that has even the smallest attachment. 
 
 79 
 
PRACTURE5. 
 
 It is surprising how often such pieces heal 
 into the wound and thereby help to save loss 
 of substance. 
 
 When applying a plaster dressing to the 
 leg always include the foot if the patient is 
 to be confined to bed; otherwise "drop foot** 
 will develop. 
 
 In cases of fracture of a rib, it is neces- 
 sary to watch the patient carefully for a 
 couple of days to note the onset of a possible 
 lung compHcation. Locahzed pneumonitis 
 sometimes occurs. 
 
 In severe falls or blows or fractures of 
 the pelvis, catheterize the patient as soon 
 after the injury as possible in order to dis- 
 cover a possible rupture of the bladder. 
 
 Fracture of the outer end of the clavicle 
 may follow a fall upon the shoulder. Un- 
 less one makes a careful examination such a 
 fracture may escape observation or be mis- 
 taken for a dislocation of the outer end of 
 the clavicle, with which condition, indeed, 
 it may be associated. 
 
 80 
 
FRACTURES. 
 
 Shortening of the shoulder, as measured 
 from the sternal end of the clavicle to the 
 acromion process, is significant of fracture 
 of the clavicle. 
 
 In the aged, pain and disability in the arm 
 after traumatism demand especial care in 
 examination of the shoulder. Fracture of 
 the head of the humerus is often overlooked. 
 
 In fractures of the anatomical neck of the 
 humerus, examine carefully for injuries to 
 the brachial plexus. 
 
 The radiograph of the elbow of a child 
 shows shadows of numerous epiphyses. One 
 inexperienced with x-ray plates is very apt to 
 mistake one or more of these for fractures. 
 When examining the skiagraph of a child's 
 elbow suspected of fracture or dislocation, 
 it is, therefore, important to have the normal 
 picture in mind, or better yet in hand, for 
 comparison. 
 
 Fractures of the head of the radius are 
 probably more common than generally sup- 
 posed, being overlooked frequently because 
 of the absence of the ordinary signs of frac- 
 ture. 
 
 81 
 
rRACTURE5. 
 
 If a small child has been pulled by the 
 arm and thereafter has disability in that 
 member, attention should first be directed to 
 the upper end of the radius. Here one is 
 apt to find a subluxation of the head of the 
 bone ("pulled arm") or an epiphyseal sepa- 
 ration. 
 
 Marked tenderness over the lower end of 
 the radius, after traumatism, without deform- 
 ity, is suspicious of fissure of the bone. Mo- 
 bility or crepitus may be obtainable. 
 
 The silver-fork deformity is by no means 
 necessary to the diagnosis of Colles' frac- 
 ture. 
 
 If a patient gives a history of "sprained 
 wrist" that has remained feeble and pain- 
 ful in spite of appropriate treatment for suffi- 
 cient time, and if the wrist presents thick- 
 ening and tenderness at its radial aspect, a 
 diagnosis of fracture of the scaphoid should 
 be entertained. Colles' fracture must be ex- 
 cluded, by the relation of the two styloid pro- 
 cesses and the location of the deformity. 
 Fractures of the radius and scaphoid may, 
 however, coexist. 
 
 82 
 
rRACTUKE5. 
 
 Fractures of ihe neck of the femur in old 
 people sometimes cause no other symptoms 
 than disability. The mildness of the trauma 
 and the freedom from much pain should not 
 deceive one. 
 
 A padded triangular wooden or card- 
 board splint — one leg of the triangle band- 
 aged to the thigh, and another to the trunk 
 — makes an excellent ambulatory apparatus 
 in the treatment of fractures of the shaft of 
 the femur in small children. It maintains 
 reduction, leaves the leg free and does not 
 interfere with keeping the child clean. 
 
 Cardboard sphnts can be best molded to 
 an extremity by tearing, instead of cutting 
 them. 
 
 In operations for suture of a fractured pa- 
 tella it is very important to sew the torn 
 lateral ligaments of the joint. These aid 
 largely in the support of the joint. 
 
 It must be remembered that fractures of 
 the metatarsal bones may be produced by 
 slight injuries. Thus, the base of the fifth 
 metatarsal may be fractured by a twist of 
 the foot while walking or dancing. 
 
 83 
 
LyriPHATIC 0LAND5. 
 
 An accurate knowledge of the lymphatic 
 drainage of the various regions of the body is 
 absolutely necessary before one can deter- 
 mine the origin of a glandular infection. This 
 is especially important in cancer, when some- 
 times the glandular involvement offers the first 
 clue to the primary focus. 
 
 Do not advise extirpation of large glands 
 in any particular region without making sure 
 that they are not the early manifestations of 
 leukemia or Hodgkin's disease. 
 
 If a bubo shows no sign of disappearing 
 under wet dressings, ice bags, etc., and evi- 
 dences of suppuration are developing, it is 
 better to make a clean dissection and excise 
 the gland without opening it than to incise 
 and drain. 
 
 ^■^'^ Exposure to the x-rays causes atrophy of 
 
 the sweat glands; radiotherapy is proving 
 the most satisfactory treatment for hyperi- 
 drosis. 
 
 Pure nitric acid, applied on the narrow, 
 blunt tip of a glass rod is successful in the 
 complete destruction of verruccae, but only 
 if it is forced down into their very roots. 
 
 84 
 
5KIN. 
 
 Localized, indurated or softening skin in- 
 fections ("boils") often disappear com- 
 pletely or open painlessly under an applica- 
 tion of emplastrum plumbi in which is in- 
 corporated 10 per cent, of salicylic acid; or 
 of 10 per cent, to 20 per cent, salicylated 
 soap plaster. After the boil opens the tiny 
 dressing should be changed every two or 
 three hours. 
 
 When shaving the hair in the neighbor- 
 hood of a boil, draw the razor from the base 
 to the apex so as not to drive microorganisms 
 deeper into the tissues. 
 
 Do not treat locaHzed subcutaneous red 
 and tender swellings as infections without 
 first making sure that they are not evidences 
 of gout. 
 
 Stains of anilin dyes may be removed 
 from the fingers with strong hydrochloric 
 acid, stains of iodin with aqua ammonia, 
 and stains by silver nitrate with potassium 
 iodid solution. 
 
 If an incised wound in the soft parts does 
 not heal as readily as it should, examine the 
 urine for sugar. 
 
 85 
 
 VOUIND5. 
 
WOUNDS. 
 
 In wounds made by coal on the exposed 
 parts of the body, remove all the particles 
 of coal dust; otherwise a disfiguring pig- 
 mentation might follow. 
 
 A broad clean ulcer on the soft parts 
 often heals per primam if its surface is 
 swabbed with iodin and its edges then 
 brought together with adhesive straps. 
 
 An ulcer with indolent flabby granula- 
 tions may be stimulated to renewed activity 
 by a thorough scraping or by vigorously 
 rubbing it with gauze. 
 
 Catgut strands do not always make a 
 good drain for wounds; they tend to swell 
 and occlude. 
 
 Fresh wounds about a joint should not be 
 probed to see whether the joint has been 
 penetrated or not. This is an excellent way 
 of infecting it. 
 
 The appearance of emphysema in the tis- 
 sues about an infected wound, accompanied 
 by fever and escape of bubbles of gas from 
 the wound, should be regarded as very omi- 
 
 86 
 
WOUND5. 
 
 nous, and indicative of gas bacillus infec- 
 tion. Such cases should be treated by ex- 
 tensive incisions. 
 
 Blank cartridge wounds must be laid wide 
 open, all dirt and wad carefully removed, 
 and the area swabbed out with tincture of 
 iodin, or with pure carbolic acid followed by 
 alcohol. Tetanus antitoxin should be ad- 
 ministered. 
 
 If the powder grains are not promptly re- 
 moved in gunshot wounds of the exposed 
 part, unsightly discolorations result. 
 
 The possible development of a duodenal 
 ulcer in cases of extensive burns, must always 
 be borne in mind. 
 
 Too prolonged or too rapid and vigorous 
 use of the pump in the Bier apparatus will 
 frequently cause a rupture of the superficial 
 bloodvessels, and in many cases severe 
 sloughing of the superficial parts ensues, the 
 result of the treatment being worse than the 
 primary cause of the trouble. Application 
 of the Bier cup to an abscess for four to 
 five minutes twice a day is more beneficial 
 than a single ten-minute application. 
 
 87 
 
TUnORS. 
 
 Soft tumors under the skin, disappearing 
 in the recumbent posture, are usually lym- 
 phangiomata. 
 
 If a sweUing is ''fluctuating" do not be 
 too sure that it is not a solid growth. Lym- 
 phangiomata fluctuate. 
 
 A subcutaneous tumor with a history of 
 puncture or the presence of a minute scar 
 in the overlying skin, usually means that one 
 is dealing with an inclusion or so-called 
 Ranvier cyst. 
 
 In hard swellings of doubtful nature 
 marked tenderness is significant of actinomy- 
 cosis, when acute inflammation may be ex- 
 cluded. 
 
 Do not give a good prognosis in cases of 
 melanosarcoma of the fingers or toes, no 
 matter how small the tumor may be, and no 
 matter how high the amputation is performed. 
 In the majority of cases, these patients suc- 
 cumb to metastases. 
 
 In the presence of a pulsating tumor, es- 
 pecially of the bone, examine the kidneys. 
 Secondary hypernephromata always pulsate. 
 
 88 
 
TUnORS. 
 
 A pulsating tumor of the os ilium (en- 
 dothelioma, sarcoma) may easily be mistaken 
 for a gluteal aneurism. 
 
 The **egg shell crackle" of certain bone 
 tumors is characteristic of multiple myeloma. 
 Examine the urine for albumose. 
 
 In cases of bone tumor these organs should 
 never be overlooked in seeking a primary 
 growth — the prostate or mammary glands, 
 according to the sex, and the thyroid. 
 
 An amputation for malignant ulceration 
 should not be performed until the possibility 
 of its being merely a broken-down gumma 
 has been satisfactorily excluded. 
 
 A metastatic growth in a superficial lym- 
 phatic gland or a gland of the skin may 
 sometimes deceptively simulate the appear- 
 ance of a sebaceous cyst. In a patient suf- 
 fering with a malignant neoplasm, therefore, 
 the development of a "wen," especially if 
 at an unusual situation, should be regarded 
 with sufficient suspicion to prompt investiga- 
 tion of its interior. 
 
 Individuals with bluish sclerotics, and 
 
 89 
 
 TUBER- 
 CULOSIS. 
 
TUBERCUL05I5. 
 
 with dark lanugo over the upper part of the 
 back, are usually of tuberculous diathesis; 
 and these signs are not inconsequential in 
 maknig a diagnosis. 
 
 Surgical tuberculosis, no less than pul- 
 monary tuberculosis, calls for the most care- 
 ful general treatment, post-operative and 
 otherwise. Out-of-door life is as important 
 here as for phthisis. 
 
 The temptation should not be yielded to 
 to incise a psoas, hip or other "cold" ab- 
 scess, except in isolated instances and then 
 only under the most rigid asepsis. The pro- 
 duction of a mixed infection means chronic 
 sinus, chronic invalidism and, often, amy- 
 loid disease. 
 
 AINE3- ^" operations upon the head or neck the 
 
 TMFSIA anesthetist must see to it that no instrument 
 
 is allowed to lie over the cornea, especially if 
 
 it is exposed. Ulceration may be caused 
 
 with ease ; it is often healed with difficulty. 
 
 During narcosis, when stertorous breath- 
 ing calls for extension of the jaw, it is well 
 to hold it forward first on one side, then on 
 
 90 
 
ANE5THE5IA. 
 
 the other, alternating at short intervals. Long 
 continued pressure at the angle or angles of 
 the jaw produces much soreness. Often the 
 jaw can be kept forward by catching the 
 lower incisor teeth in front of the upper ones 
 (if they are strong) ; a single finger on the 
 chin is enough to maintain this position. 
 
 In hght narcosis the pupils may dilate 
 reflexly from operative manipulations. This, 
 of course, is not to be confused with the 
 sudden extreme dilatation that occurs when 
 the narcosis has been carried too far. 
 
 During the conduct of a narcosis, more 
 important than the activity of the conjuncti- 
 val reflex or the actual size of the pupil in 
 determining the depth of the anesthesia, are 
 the changes in the reactibility of the lid and 
 the alterations in the size of the pupil. They 
 are reHable indices to fluctuations in the depth 
 of the narcosis. Sometimes a patient is quite 
 relaxed and anesthetic although a fair con- 
 junctival reflex is present; and, again, it may 
 occasionally happen that a patient reacts 
 even when that reflex is abolished. 
 
 In crying infants it is extremely difficult to 
 determine the presence, and location, of ten- 
 
 91 
 
ANE5THE5IA. 
 
 der areas. This may be readily accom- 
 plished by the administration of chloroform 
 to the extent of primary narcosis. The phy- 
 sical examination then becomes very easy 
 and when a tender spot is handled it will be 
 announced at once by lively reflexes. 
 
 During the performance of a hernia op- 
 eration it is often helpful for the anesthetist 
 to allow the patient to react sufficiently to 
 strain into view a sac that has slipped back 
 into the abdomen. 
 
 A convenient way in which the anesthetist 
 may carry, all sterilized and ready for in- 
 stant use, his hypodermatic solutions, is the 
 following: Shallow, wide-mouthed, half- 
 ounce bottles are sterilized, labeled and filled. 
 Over the mouth of each bottle is then 
 stretched, and hermetically fastened, a cover 
 of sterilized rubber (dam). Before the 
 narcosis is begun the anesthetist disinfects his 
 syringe and sets these bottles in a dish of 
 sublimate solution. This sterilizes the sur- 
 face of the rubber. When a solution is 
 wanted the needle of the hypodermatic 
 syringe is simply thrust through the rubber and 
 as much as is needed is drawn into the bar- 
 rel. The puncture hole closes without leak- 
 
 92 
 
ANE5TME5IA. 
 
 age. The covers of the bottles need to be 
 changed only occasionally. 
 
 Whenever the arrangement of a patient 
 upon the operating table requires an extrem- 
 ity to occupy a constrained position, that po- 
 sition should be shifted from time to time 
 to avoid pressure paralysis. The anesthetist 
 should never draw the arms alongside the 
 head, nor permit the strap of a leg-holder 
 to press, for more than a few minutes at a 
 time, upon the brachial plexus in the neck. 
 
 Nitrous oxid narcosis can, in most cases, 
 be continued "smoothly," with no cyanosis 
 and with fair degree of relaxation, even for 
 an hour. A laparotomy may thus be per- 
 formed, if ether and chloroform are contrain- 
 dicated. To secure such a narcosis it is best 
 to use an apparatus that permits exhalation 
 into the gas bag, and which has a valve for 
 the admission of air. The bag should not be 
 distended fully. After brief air and gas 
 administrations, air is turned off and the pa- 
 tient breathes N-O and his own CO;. At 
 short intervals, and whenever there is any 
 cyanosis, a single breath of pure air is al- 
 Io^ved. 
 
ANE5THE5IA. 
 
 Local anesthetics cannot be injected pain- 
 lessly into tense, inflamed areas unless the in- 
 jection is begun at a point in the skin well 
 beyond the seat of inflammation. 
 
 The admixture of adrenahn to cocain so- 
 lution counteracts much of the depressant 
 effect of the anesthetic and enhances the 
 local vaso-constriction. When the mixture 
 is used on the surface of a mucous mem- 
 brane, however, as in excising an ulcer in 
 the mouth, one must be prepared for a 
 marked reactionary bleeding. 
 
 INPU5ION5. ^^^ ^ single intravenous infusion, as to 
 
 combat the shock of hemorrhage, it is not 
 essential that the solution contain any of the 
 blood salts but the most abundant one — 
 sodium chlorid. For repeated infusions, 
 however, as sometimes used in treating vari- 
 ous toxemias, it is better to employ also the 
 other salts, the solution being made of so- 
 dium chlorid 0.9, potassium chlorid 0.03, 
 calcium chlorid 0.02, water 100. 
 
 Intravenous saHne infusions in too large 
 volume are harmful by the production of con- 
 gestion of the internal viscera. One to one 
 
 94 
 
IPSPU5ION5. 
 
 and a half pints is enough for an adult of 
 average weight. 
 
 In performing subcutaneous infusion do 
 not allow too much fluid to accumulate at 
 one area, otherwise necrosis may occur. Shift 
 the needle to various parts not by swinging 
 it from side to side, but by partly withdraw- 
 ing it and reinserting it to another area. 
 
 The pain in the lower part of the back P05T= 
 that is so frequently complained of after op- OPERATIVE. 
 eration, can be best reheved by placing a 
 small pillow in the hollow of the spine. 
 
 In determining the cause of a post-opera- 
 tive fever never fail to look at the throat. 
 
 If, after a period of post-operative cathe- 
 terization, the patient finds herself unable to 
 pass urme spontaneously, apply hot towels 
 to the vulva. 
 
 Gastric lavage is the best post-operative 
 anti-emetic. 
 
 Vomiting may frequently be controlled 
 by one-drop doses of tincture of iodin in 
 water at half-hourly intervals. 
 
 95 
 
POST-OPERATIVE. 
 
 Before putting an unconscious patient to 
 bed, the hot water bags should be removed or 
 sufficiently covered to prevent the occurrence 
 of a burn. 
 
 The occurrence of post-operative phlebitis 
 is often encouraged by keeping the patient too 
 long in bed. 
 
 Old people should be allowed to sit up or 
 get out of bed as soon after operation as 
 possible in order to avoid post-operative lung 
 complications. 
 
 HEnOR- 
 PHAOE AND 
 5MOCK. 
 
 Do not allow patients to lie on the back 
 immediately after an operation involving the 
 vertebrae or the sacrum; a disagreeable ne- 
 crosis of the skin flaps may rapidly take 
 place. 
 
 In differentiating shock and concealed 
 hemorrhage progressiveness of the symptoms 
 is very significant of continued bleeding. 
 
 Restlessness, increasing pallor, increasing 
 air-hunger, increasing weakness of the pulse, 
 falling temperature (subnormal), and the 
 ephemeral effect of stimulation, all point to 
 
 96 
 
HEnORRMAOE AND 5MOCK. 
 
 hemorrhage rather than shock. In addition, 
 there is often some local sign or symptom. 
 
 In post-operative collapse if, after study- 
 ing the symptoms, there be any doubt wheth- 
 er the condition be due to shock or to con- 
 cealed hemorrhage, the wound should be 
 opened and bleeding sought for. 
 
 In dealing with secondary hemorrhage 
 from the rectum (whether bleeding vessels are 
 tied or not), it is better to tampon with gauze 
 wrapped about a piece of stout rubber tub- 
 ing, than with gauze alone. 
 
 Bone tenderness, especially of the sternum 
 and tibiae, is frequently significant of sepsis. 
 
 5EP5I5. 
 
 In seeking the source of an obscure sepsis, 
 do not overlook an examination of the is- 
 chiorectal region. 
 
 Aluminum instruments should not be 
 boiled in soda solution like other instru- 
 ments. They are to be sterilized by boiling 
 in plain water or by passing them through an 
 alcohol or Bunsen flame. 
 
 IN5TRU. 
 riENT5. 
 
 97 
 
IN5TRUnEINT5. 
 
 Woven catheters may be sterilized by 
 boiling in saturated ammonium sulphate solu- 
 tion. Catheters and bougies may be kept 
 aseptic if they are wrapped in gauze wet 
 with the soap-spirits of the German pharma- 
 copeia. 
 
 Warming a laryngeal mirror prevents con- 
 densation of the breath upon it for only a 
 short time. The mirror will remain bright, 
 however, throughout a prolonged examina- 
 tion if, instead of warming it, its surface iS 
 smeared with an invisible film of soap. 
 
 An "invalid table," the shelf of whicki 
 projects over the patient's body, will be 
 found a great convenience during operations 
 as a receptacle for instruments in immediate 
 use. It saves time and temper, and avoids 
 accumulation of instruments on the patient's 
 body. 
 
 When scissors become "catchy" their 
 edges can often be surprisingly smoothed by 
 carrying each blade repeatedly from lock to 
 tip between the firmly pressing thumb and 
 forefinger. Each kind and size of scissors 
 has its own capacity, and should be used 
 
 98 
 
lN5TRUnENT5. 
 
 only for what it is intended. Ophthalmic in- 
 struments are not intended for ordinary dis- 
 sections, tissue scissors should not be used for 
 cutting bandages, nor bandage scissors for 
 plaster-of-Paris. 
 
 Bandage knives cut best when they have 
 a "saw edge," which is easily secured by 
 sharpening them on a window sill or other 
 rough stone. 
 
 A scroll-saw, with an assortment of a 
 dozen saws, can be purchased at the hard- 
 ware store for twenty-five cents; it is ideal 
 for resection of the small bones of the hand 
 and foot, for amputations of the digits, etc. 
 
 Well tempered carpenter's chisels and 
 gouges, and a carpenter's wooden mallet 
 answer the purpose admirably for bone work. 
 A useful bone drill can also be selected from 
 the stock of the hardware dealer. 
 
 A gardener's pruning knife and a cor- 
 penter's miter saw are the best tools for the 
 removal of plaster dressings. 
 
 A cheap potato knife, rough sharpened 
 
 99 
 
IN5TRUriENT5. 
 
 on a stone, is excellent for cutting through 
 starch bandages. 
 
 Crochet needles are most useful for lifting 
 buried stitches out of a sinus. 
 
 Knitting needles find another purpose as 
 a means of rupturing the membranes when 
 this is needed in obstetrical work. 
 
 Sharp and blunt retractors may be fash- 
 ioned, in an emergency, by bending the tines 
 of a fork and the handle of a spoon, respec- 
 tively. 
 
 A teaspoon is also useful as an elevator of 
 the eye, when resection of the superior max- 
 illa is performed. 
 
 An inverted tea-strainer is useful in the 
 dressing after colostomy, to prevent pressure 
 of the gauze upon the gut. 
 
 A spoon-shaped potato cutter may be 
 used, in an emergency, as a wound curette. 
 
 The multiple surgical uses of the hairpin 
 are also well-known. Of stouter material, if 
 
 lOO 
 
IN5TKUriENT5. 
 
 necessary, a small self-retaining retractor can 
 be quickly made from steel wire ; it often ob- 
 viates the need of an assistant when search- 
 ing the hand or foot for a foreign body. 
 
 Similarly, applicators, probes and de- 
 pressors may be improvised by twisting stout 
 copper wire. 
 
 A wedge of hard wood makes a gag 
 quite useful, often, when administering anes- 
 thesia. 
 
 A discarded thermometer case (or a hard 
 rubber douche point) is a serviceable handle 
 in which to mount, with candle grease or ad- 
 hesive plaster, a stick of silver nitrate. 
 
 A bright and altogether satisfactory light 
 for throat examinations can be had cheaply 
 by covering a 1 6-candle-power Edison elec- 
 tric bulb with a smooth layer of plaster-of- 
 Paris, about three-eighths of an inch thick, 
 leaving on one side an aperture the size of 
 a silver half-dollar, or larger. The white 
 inner surface of the plaster brilliantly re- 
 flects the light. The outer surface may be 
 painted black for appearance's sake. 
 
 lOI 
 
lN5TRUriniNT5. 
 
 Cheap powder blowers, such as are used 
 for insecticides, may be employed as insuf- 
 flators in surgical work, and pepper boxes are 
 useful for dusting powders. 
 
 Steel spring tape-measures are better than 
 the wires generally sold for the purpose, for 
 conducting to an x-ray tube the current from 
 the coil or static machine; easily kept taut, 
 and quickly adjusted, they are safest for the 
 patient and most convenient for the operator; 
 that they are not insulated is inconsequential 
 — the coverings on the regular wires do not 
 insulate the induced current. 
 
 Wooden skewers are serviceable nail- 
 cleaners. Rolling pins and kitchen towel 
 racks are very convenient for adhesive plaster, 
 rubber tissue, etc., especially for hospital 
 dressings. 
 
 A probe that has become bent and twisted 
 is readily straightened out by rolling under 
 the foot on an even floor. 
 
 The threading of catgut or kangaroo ten- 
 
 oU I Uklo* don through a needle-eye not very roomy 
 
 may be made easy by cutting the suture end 
 
 I02 
 
5UTURE5. 
 
 obliquely and flattening it between the han- 
 dles of the scissors. Silk must not be cut 
 obliquely, however, for this makes it apt 
 to ravel while it is being threaded. 
 
 Silkworm-gut is easily dyed, and inciden- 
 tally impregnated with an antiseptic, by im- 
 mersing it for twenty-four hours in one per 
 cent, solution of methyl violet, before the 
 boihng. 
 
 When suturing a wound of the scrotum, 
 if the tissue (dartos) is contracted, apply a 
 warm compress for a moment to cause re- 
 laxation. 
 
 In removing a skin suture, pull up on one 
 side and cut it as close to the skin as pos- 
 sible. This is in order to avoid drawing 
 any of the exposed part of the suture through 
 the wound and thus possibly infecting it. 
 
 Everything is to be gained and nothing to 
 be lost by having patients remove enough of 
 their clothing to allow of a completely satis- 
 factory examination in all cases. Instances 
 can be called to mind, by any physician, of 
 erroneous judgments arrived at before ex- 
 posure of other parts of the body showed con- 
 
 EAAniNA- 
 TION5. 
 
 103 
 
EAAnilNATIONS. 
 
 ditions altering one's opinion. Especially 
 is it important to compare the corresponding 
 members of the body on the sound and the 
 affected side, in all doubtful cases. 
 
 When a skiagraph shows a condition not 
 recognizable at once as a definite lesion, it is 
 important to make an x-ray picture of the 
 corresponding part of the body on the other 
 side. It may show that the condition is 
 merely a symmetrical pecuharity, and not a 
 pathological one. 
 
 Before excluding glycosuria examme both 
 morning and evening specimens of the urine. 
 
 When performing an office operation, too 
 great care cannot be taken to sufficiently roll 
 back or remove such articles of clothing as 
 might become soiled. The patient may not 
 say much if he is obHged to draw up a gar- 
 ment wet with blood — but he'll probably 
 think a few things. 
 
 Tar-paper is a smooth, fairly waterproof 
 material to tack on the floor when preparing 
 a room for operation. 
 
 DKE55INQ5. Grocers' paper bags are well-adapted re- 
 ceptacles for soiled dressings. 
 
 104 
 
DRE55IN05. 
 
 When a "wet dressing" fails to properly 
 drain a septic wound try a glycerin dressing 
 — gauze wrung out in pure glycerin and cov- 
 ered with waterproof material. 
 
 When wet dressings are needed on hairy 
 areas it should not be forgotten that they 
 predispose the hair follicles to infection. 
 
 Wet dressings, especially the very useful 
 Burow*s solution of aluminum acetate, when 
 applied to the hand or foot, usually cause 
 maceration and whitening of the skin, which 
 is apt to alarm the patient. The addition to 
 the solution of one-fourth its bulk of glycerin 
 or alcohol, will obviate this unsightly macera- 
 tion. 
 
 A bichlorid of mercury dressing should 
 never be applied on an area of skin on which 
 tincture of iodin has been recently painted. 
 An iodid of mercury is formed, which is 
 highly irritating. 
 
 Ichthyol, if used in ointment sufficiently 
 strong (25% to 50%), is perhaps the most 
 useful single medicament in aborting early 
 superficial infections. 
 
 105 
 
DRE55IN05. 
 
 The addition of a little oil of citronella 
 to an ichthyol ointment robs it of its disa- 
 greeable odor. 
 
 A 2% ointment of fuchsin in vaselin or 
 zinc oxid frequently yields gratifying results 
 in stimulating the epidermization of indolent 
 ulcers and granulating wounds. 
 
 Subiodid of bismuth dusted on an ooz- 
 ing granulating wound promptly stops the 
 bleeding. It is also an excellent stimulant 
 to the growth of epithelium. 
 
 An ointment of beta-naphthol, 10; sul- 
 phur, 45 ; lard, 24 ; and green soap, enough 
 to make 100 parts, is useful in removing 
 gun-powder not too deeply situated in the 
 skin. It must be employed cautiously, how- 
 ever, to avoid a destructive dermatitis. 
 
 Gauze is preferable to cotton for padding 
 the axilla or breasts in dressings that are not 
 frequently renewed. Cotton easily becomes 
 matted with sour-smelling secretions and thus 
 sets up dermatitis. The skin over the tendo 
 Achilles and about the heel cannot be too 
 carefully padded, when applying Buck's ex- 
 tension apparatus. 
 
 io6 
 
DKE55IN05. 
 
 Collodion, commonly used to seal a punc- 
 ture wound, as after aspiration, will not ad- 
 here if the spot is wet or bleeding. To ob- 
 viate this, pinch up the skin, wipe it dry, ap- 
 ply the collodion and continue the compres- 
 sion a minute or so until the collodion has 
 begun to contract. 
 
 When rubber tissue is not at hand to make 
 a "cigarette drain," rubber tubing may be 
 used in its place. Split a piece of tubing of 
 appropriate length, and lay the wick of gauze 
 in the trough thus made, or draw the gauze 
 through the tube with a probe. Fenestrae 
 may be cut as desired. 
 
 The painfulness of withdrawing packings 
 that have dried in a wound may be avoided 
 by soaking them with peroxid of hydrogen. 
 
 A urethral endoscope will be found a 
 great help as a means of introducing a rub- 
 ber drainage tube into a narrow, tortuous 
 sinus. 
 
 The change of dressings of burns may be 
 made painless, and the growth of epithelium 
 encouraged, by employing next to the wound 
 sterile strips of gutta-percha in the same man- 
 
 107 
 
DRE55IIN05. 
 
 ner as for skin-grafts. Subiodid of bismuth 
 lightly dusted on the granulating surface 
 stimulates epithelial growth. 
 
 Patients will appreciate the use of black 
 bandages for the scalp — where they are 
 comparatively inconspicuous, and for the 
 hands — where they do not soil. 
 
 Mastoid and scalp dressing may be re- 
 duced in bulk, and the uncomfortable neck 
 turns of the bandage avoided, by the use of 
 starch bandages, which hold neatly and 
 firmly. 
 
 Bandages may be fastened m place more 
 neatly and more securely with strips of ad- 
 hesive plaster, than with safety pins. When 
 bandaging a finger or toe, turns about the 
 hand or foot will be unnecessary if the dress- 
 ing is fastened down with a narrow strip of 
 plaster run over the top from base to base, 
 and another strip circularly about the dress- 
 ing at the base of the digit. When using 
 black bandages, employ black adhesive 
 plaster. 
 
 io8 
 
INDEX 
 
 
 PAGE 
 
 Abdomen 
 
 . 25 
 
 Anesthesia 
 
 90 
 
 Appendix 
 
 • 39 
 
 Back . . . . 
 
 61 
 
 Bile Tract 
 
 . 30 
 
 Bladder 
 
 49 
 
 Brain .... 
 
 . 8 
 
 Breast ... 
 
 19 
 
 Cranium 
 
 • 7 
 
 Dressings 
 
 104 
 
 Ear 
 
 . 8 
 
 Examinations 
 
 103 
 
 Extremities 
 
 . 62 
 
 Eye .... 
 
 10 
 
 Face .... 
 
 12 
 
 Foot .... 
 
 73 
 
 Fractnres 
 
 . 76 
 
 Generative Organs, Female . . 58 
 
 Genito-Urinary Tract . -45 
 
 Glands, Lymphatic .... 84 
 
ii INDEX. — Continued. 
 
 PAGE 
 
 Hand 69 
 
 Head 7 
 
 Hemorrhage ...... 96 
 
 Hernia ...... 40 
 
 Infusions ...... 94 
 
 Instruments ..... 97 
 
 Intestines . . . -3^ 
 
 Kidney 45 
 
 Lymphatic Glands . . . . .84 
 
 Mouth 13 
 
 Neck 14 
 
 Nose . . . . . . . II 
 
 Penis 53 
 
 Pharynx ...... 13 
 
 Post-Operative . . -95 
 
 Prostate ...... 51 
 
 Rectum ....... 41 
 
 Scrotum ...... 55 
 
 Sepsis ....... 97 
 
 Shock 96 
 
 Skin 84 
 
 Stomach 32 
 
 Sutures 102 
 
INDEX. — Continued. iii 
 
 PAGE 
 
 Testicle 55 
 
 Thorax 21 
 
 Tracheotomy ...... 18 
 
 Tuberculosis ..... 89 
 
 Tumors 88 
 
 Urethra 53 
 
 Ureter 45 
 
 Urinary Tract ..... 45 
 
 Wounds 85 
 

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