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Copyright, igii, by W. B. Saunders Company 

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the earnest and ambitious young physician who is devot- 
ing all his time to hospital work, and whose only reward 
is the knowledge and experience thus gained: 


Digitized by tine Internet Arciiive 

in 2010 witii funding from 

Open Knowledge Commons 


Many excellent books on minor surgery have been 
written but so far as the author is aware, none has 
been adapted exclusively to the needs of the hospital 
interne. Each of the following pages has been pre- 
pared expressly for the members of a resident staff: 
for the interne's guidance when acting independently; 
to assist the ambulance surgeon in emergencies, to 
simplify practical work for the junior and to aid the 
senior in some of his predicaments. If this little 
volume but serves this purpose, its object will 
haven been attained. However, as the general 
practitioner and even the specialist, as well as the 
surgeon, is so frequently called upon to cope with this 
class of emergencies, the author hopes that others 
may find some useful points in its perusal. 

Many subdivisions and details of minor surgery 
have been purposely omitted, as it is not intended 
to rewrite all that can be found elsewhere. Also, it 
may seem that the special attention accorded some 
of the more oridnary conditions, usually considered 
elementaiy and unworthy of much thought by the 
medical student, is disproportionate to the com- 
paratively small amount of space devoted to them 
in the average text-book. An effort has been made 
particularly to emphasize those points that are of 
great importance in practical work, but which are 
often apparently disregarded or ignored. To avoid 




confusion and favor brevity, the treatment out- 
lined is in most instances that which experience has 
proved to be the most satisfactory. Incidentally, 
this will accoimt for the frequent mention of iodine 
as an antiseptic and germicide.* It is assumed that 
the reader possesses the average theoretical knowl- 
edge of the medical graduate, but has had little or 
no practical experience, and therefore the author 
has endeavored to make his statements as simple, 
clear and concise as possible. 

Due acknowledgment is made for information 
derived from many sources; the standard medical 
journals and text-books have been freely consulted 
and the methods in vogue at the leading hospitals 
investigated. The author especially desires to 
express his thanks and indebtedness to his friends, 
Dr. Terry M. Townsend of New York and Dr. Frank 
D. Gray of Jersey City, for their careful considera- 
tion and criticism of the manuscript, to Miss Eleanora 
Fry for the painstaking and graphic illustrations, 
and to the publishers for their uniform kindness and 

Walter T. Dannreuther. 

New York City 
October, 191 1. 

*"The Surgical Value of Iodine," Medical Record, January 25, 1908. 
"The Practical Value of Tincture of Iodine and Iodine Catgut in Major 
Surgery," Medical Record, January 16, 1909. 



Introduction i? 

The Ambulance Surgeon 19 

Accidental Wounds 23 

Traumatic Injuries of Joints 48 

Simple Fractures 64 


Compound Fractures and Traumatic Amputations . 106 

Sequels of Fractures 116 

Acute Pyogenic Infections ' . 123 

Effects of Intense Heat and Cold 140 

Ulcers — Bed-sores 151 

Foreign Bodies 159 

Surgical Shock and Collapse — Death 168 


Minor Operations 180 

Index 213 




Having attained the coveted degree of M. D., 
the majority of recent graduates seek an appoint- 
ment on the resident staff of some hospital. The 
term of service may vary from one to three years, 
usually averaging eighteen months, and the ex- 
perience and knowledge gained during this time 
will prove to be of inestimable benefit and of the 
utmost importance throughout the young physician's 
subsequent professional life. Although he is af- 
forded the opportunity of doing a certain amount 
of dispensary work in connection with the modem 
college course, the comparatively few real emer- 
gencies presenting and the student's subordinate posi- 
tion greatly minimize the benefits which apparently 
might be derived therefrom. It is while serving 
as a member of a house staff enjoying an active 
service that there is almost imlimited opportunity 
of applying the principles and teachings of the 
college course. Here too are encouraged and 
developed those qualifications so essential to suc- 
cess in practice: acuity of perception, dexterity 
and self-reliance. 

The first few months of the hospital service are 
usually devoted, as they properly should be, to 
2 17 


laboratory work, history taking, applying ward 
dressings under the direction of the house surgeon, 
and the like. This gives the junior an opportunity 
to feel at home in his new surroundings, to acquaint 
himself with the routine of the institution and its 
personnel and to observe more or less emergency 
work attended by his superiors before assuming 
any responsibilities himself. 

The interne should ever respect and obey the advice 
and instructions of the members of the visiting staff 
and any criticism that he has to make of their 
suggestions should be entirely mental. Discussions 
in private, however, concerning the diagnosis and 
management of cases are to be encouraged. The 
interne should keep his eyes and ears open and his 
mouth shut when in the wards. "Errare est 
humanum" and even the visiting surgeons may 
make mistakes occasionally, but, as Dr. Brickner 
has so aptly said, they probably have better reasons 
for being wrong than the interne has for being right. 

Each member of the house staff should do his 
share toward the maintenance of a harmonious 
atmosphere among his fellows: routine duties being 
performed willingly and cheerfully and favors 
exchanged whenever possible. Mutual kindness, 
courtesy and loyalty will promote good feeling and 
make the day's work more pleasant. 

The interne should never forget his dignity in 
the presence of nurses and orderlies. They should 
be shown every consideration but allowed no liber- 
ties or undue familiarity. Regardless of the ap- 
parent provocation, subordinates should never be 
criticised or corrected except in private. 


It is a grave error to permit a "green" interne 
to do ambulance work immediately, and many 
cities have recognized this fact by adopting an 
ordinance requiring at least six months' service on 
the resident staff before undertaking the duties of 
an ambulance surgeon. He should at least transfer 
a few elective cases to and from the hospital before 
answering any emergency calls, thereby accustom- 
ing himself to the presence of a crowd. Thus he 
will gradually acquire self-confidence and become 
impervious to the remarks and audible criticisms 
of the by-standers. An ambulance surgeon is at 
first likely to appear arrogant and disagreeable, or 
nervous and undecided, faults which should be 
studiously overcome. Collective gentleness, cour- 
tesy and firmness will win respect and inspire con- 
fidence. The public is quick to recognize the 
surgeon's attitude and will usually behave accord- 
ingly. He should never forget that he is a gentle- 
man as well as a physician and should conduct 
himself as both. 

The patient should always be moved as carefully 
as possible, his home respected, be it palatial or 
humble, and his relatives and friends shown every 
consideration. The danger of handling a patient 
roughly cannot be too strongly emphasized, no 



matter how unimportant it may seem at the time. 
For example, in transferring a case of appendicitis, 
a sudden jar may rupture an existing abscess, ulti- 
mately resulting in a fatal issue. 

Occasional difficulty will be experienced in trans- 
porting the stretcher downstairs, b.ecause of acute 
angles in the stairway. Under such circumstances 
it is better to either carry the patient down bodily, 
or seat him in a chair and carry the chair down. 
He should always be carried feet first down stairs, 
and vice versa. The greater part of the actual 
work may be safely left to the driver, policemen 
present and by-standers, under the supervision of 
the surgeon. It is not, however, correct or con- 
siderate to expect or demand the assistance of 
members of the patient's family. It is well to 
see that the patient is completely covered with 
blankets; and covering the face with a handkerchief 
while placing the stretcher in the ambulance is a 
trifling attention that will be greatly appreciated. 

The following hints are worth remembering: 

Don't lose your nerve; keep cool. 

Don't lose your temper under any circumstances. 
Rather submit to insult than to lower your dignity 
by arguing or fighting with anyone. Call on the 
police for aid when you need it. 

Don't forget that the patient is the only matter 
of importance that concerns you and that he requires 
all your attention. 

Don't discuss your actions with by-standers. 
Decide quickly what you intend to do and do it 


Don't refuse to take any unconscious person to the 
hospital, even though you are sure he is only in- 
toxicated. It is better to have fifty "drunks" in 
the hospital each night than to have one die of an 
unsuspected fractured skull in the police station. 

Don't forget that the appearance of a new am- 
bulance surgeon is always productive of a great 
deal of malingering on the part of some of the in- 
habitants of the neighborhood. 

Don't do on the street that which can be done at 
the hospital. 

Don't "play to the galleries." Act quickly, quietly 
and decisively, but do all that is absolutely necessary 
and return to the hospital as soon as possible. 

Don't make an intimate of your driver. A 
friendly spirit is commendable but anything more 
than that lowers your profession in his eyes. 

Don't stop to talk to acquaintances on the street. 
You are a public servant while on duty and there may 
be another call awaiting you on your return to the 

Don't allow your driver to drive recklessly; it 
jeopardizes too many lives. Always get to the 
scene of an accident as soon as possible and then 
adapt the speed of the ambulance to the needs of 
the patient. 

Don't permit the driver to ring his gong unneces- 

Don't invite your friends to ride on the ambulance. 
It is not a pleasure vehicle. 

Don't forget that you cannot take anyone to the 
hospital against his will or, if the patient is uncon- 


scious and relatives are present, without their consent. 
If you are requested to take the patient home or 
to another institution, and the distance is within 
reason, do it cheerfully. 

Don't fail to respect a patient's religion, especially 
if he is a Catholic; a priest should always be per- 
mitted to administer the last rites. 

Don't forget to report in person to the house 
surgeon at once if you have admitted a grave case 
to the hospital. 

Don't forget to change the linen on the stretcher 
after each call. 

Don't forget to replenish the appliances carried 
in the ambulance and the ambulance bag after each 

Don't forget that you have assumed great respon- 
sibilities and that human life often depends upon 
your judgment and actions. 

If these suggestions are faithfully followed, 
they will aid the ambulance surgeon in contributing 
his share to the efficiency of the service and thereby 
reflect credit upon the institution. 



Classification of Wounds 

I. Contused 


3. Incised 

4. Punctured 

5. Poisoned 

a. without external communication. 

b. with external communication, 
a. localized. 

b'. extensive: avulsion of a limb or the 

a. simple. 

b. complicated: underlying important 
structtires severed. 

a. penetrating. 

b. perforating. 

a. pyogenic infections. 

b. tetanic infections. 
■ c. venom infections. 

d. rabid infections. 

e. chemical infections. 

6. Gunshot 

/ a. blank cartridge 

j I. powder grains. 
I 2. wadding. 

\b. bullet. 

Wounds are designated and classified according to 
the nature of the causative trauma and the char- 
acter of the injury. It is well to remember that 
notwithstanding the apparent localization of a 
wound in the beginning, sloughing of the skin and 
soft parts may ensue at any time within ten days 
as the result of extensive contusion, no evidence of 
which presented at the first examination. This 
is equally true of fractures, dislocations, etc. For 



instance, in crushing injuries the skin wound ma}^ 
appear insignificant, yet areas of the soft parts may 
be extensively pulpified. If any blood-vessels of 
large caliber have been iniptured, gangrene may 
result in consequence of the impaired vitality of the 
tissues; the prognosis therefore should always be 
guarded. Free external bleeding or subcutaneous 
hemorrhage usually accompanies all wounds and the 
presence of more or less foreign material is to be ex- 
pected. It will often be difficult to arrive im- 
mediately at a definite conclusion regarding the exact 
nature and extent of the injury, especially when 
dealing with contusions, owing to the accompanying 
swelling. In such cases it is better to err on the 
safe side and assume the presence of a more severe 
injury than to ignore its possibility. Any wound 
may produce shock in direct proportion to its sever- 
ity and extent. 

Examination of Wounds. — ^A careful examination 
of every wound and a thorough understanding of 
the existing pathology is absolutely necessary in 
order that remedial measures may be instituted in- 
telligently. This, however, does not mean to "ex- 
amine" a wound by probing it with a dirty finger, for 
little knowledge will be derived in this manner and 
additional infection may be introduced. Under 
exceptional circumstances only, as when the presence 
of a foreign body deep in the wound is suspected, 
is sterile instrumental probing permissible. It is un- 
necessary and inhuman to insist upon probing a 
wound simply to satisfy curiosity as to its extent, 
as the possibility always exists of again exciting 


hemorrhage which has been arrested by natural pro- 
cesses, such as coagulation of the blood or torsion or 
retraction of the blood-vessels. Even when dealing 
with bullet wounds, probing is of little value in locat- 
ing the bullet unless very near the surface, because 
of the free extravasation of blood into the muscles 
and other soft tissues separating the fibers and creat- 
ing numerous false passages. Radiography, on the 
contrary, is extremely useful for the determination 
of the exact location of a foreign body. The possi- 
bility of a concomitant fracture at the site of the 
wound, or in head injuries at the base or on the op- 
posite side of the skull, should be constantly borne 
in mind, even though there is no distinct evidence of 
fracture. Here again the :;t:-ray will be a valuable 
aid. Enlarging the wound slightly, or freely if 
necessary, will often greatly facilitate inspection. 
The following features of wounds should be deter- 
mined in order: 

1. Extent of injury. 

2. Accompanying fracture. 

3. Integrity of the soft structures: periosteum, 
muscles, tendons and nerves. 

4. Foreign material present. 

5. Source of hemorrhage. 

Treatment of Wounds. — The cardinal principle of 
the treatment of wounds is to bring about union by 
first intention if possible. In many instances such 
an immediately favorable result is obviously out of 
the question, and every effort should then be made 
to secure rapid granulation from the bottom. Upon 
the surgeon's judgment will depend whether a wound 


shall be entirely closed or drained primarily. When 
in doubt, wounds opening into a cavity should be 
drained ; in others an attempt may be made to obtain 
primary tmion. If closure without drainage is after- 
ward proved to be an error of judgment, it is easily 
remedied by partial re-opening and drainage. In 
general, the treatment of wounds consists of : 

1. Arrest of hemorrhage. 

2. Shaving and cleansing with green soap of the 
surrounding skin. 

3. Irrigation of the wound with hydrogen per- 

4. Removal of all extraneous matter. 

5. Suture of divided important structures. 

6. Institution of drainage, if required. 

7. Coaptation of the edges. 

8. Injection of tincture of iodine into the wound. 

9. Application of a wet gauze dressing and 

10. Putting the injured part at rest. 
Fortunately there are many efficient methods of 

arresting hemorrhage at our disposal. In the 
majority of instances the simple pressure of a wet 
dressing is sufficient to control it. If a bleeding 
vessel has been wounded but not entirely severed, 
the division should be completed to permit retrac- 
tion. When a single artery continues to spurt, it 
should be seized with a hemostatic clamp, but 
care should be taken that the jaws grasp the vessel 
only and do not include any adjacent tissue. It 
may then be subsequently ligated with catgut, if 
necessary. In severe injuries with considerable 


arterial hemorrhage the tourniquet is of inestimable 
value and should be applied as near to the injured 
region as is consistent, in order to devitalize as little 
healthy tissue as possible. If a i-ubber tube or 
strap is not at hand, a tourniquet may be improvised 
by twisting a stick in a knotted rope or strip of linen. 
The use of the tourniquet should be avoided in pa- 
tients with atheromatous arteries. Plugging a wound 
of the chest with cotton will effectually control hem- 
orrhage from an intercostal artery. The actual 
cautery is rarely required to stop hemorrhage from 
a wound, except in the presence of persistent oozing, 
as in injuries of the liver or spleen. Styptics are 
useless in the treatment of surgical hemorrhage, for 
what little benefit is to be derived from their employ- 
ment is of no consequence in comparison to the effici- 
ency of other methods and, moreover, they are detri- 
mental to subsequent wound healing. In superficial 
bleeding, however, topical applications of adrenalin 
chloride or beech-wood creosote control the hemor- 
rhage very satisfactorily. 

Shaving of the surrounding skin is not always 
requisite, but thorough cleansing with green soap is 
without exception of great importance. This should 
be done with a nail brush, if the condition of the skin 
will admit ; but if bniised, a sterile gauze sponge is 
preferable because the brush may irritate the already 
tender skin and be a source of additional trauma. It 
is ridiculous to put clean gauze on dirty skin, and the 
area shaved and cleansed should always extend 
beyond the limit of the dressing. 

Irrigation of a wound with hydrogen peroxide 


serves to loosen bacteria, coagulated blood, dirt and 
foreign bodies. Although peroxide is an efficient 
deodorizer and cleansing agent, its germicidal 
powder is feeble. It may therefore be omitted 
when dealing with an apparently clean wound. 

The variety of foreign bodies found in woimds is 
almost imlimited and we should be on the lookout 
for an3rthing from a bacterium to a limb of a tree. 
It is important that a wound be first freed of all 
accumulated blood clots. As a rule, the greater 
part of the extraneous material may be removed 
by irrigation and the fingers, but if these prove 
unsuccessful recourse may be had to the knife, 
forceps or curette. Care should be exercised that 
the efforts to dislodge the foreign bodies do not push 
them in further. The wound may be sufficiently 
enlarged to facilitate removal. When in.strum.enta- 
tion is necessary, the forceps or curette should be 
inserted under the foreign body, so that it may 
be lifted rather than pulled out. Bits of iron or 
steel are often easily extracted by means of a power- 
ful magnet. 

If muscles, nerves or strong bands of fascia have 
been divided they should be sutured. The two ends 
of the same structure must be positively identified 
and accurately approximated. The suture material 
selected for this purpose will depend upon individual 
preference, but for subcutaneous work it should 
always be absorbable. Plain catgut, chromic catgut, 
kangaroo tendon and iodine catgut^ are most often 

^ Preparation of iodine catgut — the raw strands of appropriate sizes 
are immersed in a watery solution of i per cent, iodine crystals and i per 


used, and of these iodine catgut is the most satisfac- 
tory. It is antiseptic arid aseptic, impossible to in- 
fect (proved by bacteriological experiments) and its 
tensile strength and pliability are all that may be 
desired. It is easily prepared, thoroughly reliable 
and trivial in cost. It may be used to equal ad- 
vantage in all manners in which a suture or ligature 
is ever applied. 

Occasionally the edges of a wound, especially those 
of the lacerated class, may be very irregular. They 
should be trimmed with scissors, all tags being re- 
moved to obviate subsequent sloughing and to secure 
good coaptation, thus minimizing scar tissue forma- 

Woimds where the chances of obtaining primary 
union seem to be good are best closed with a sub- 
cuticular suture of iodine catgut. It should be intro- 
duced in the same way as one of any other material ; 
but the upper end is tied, the skin pushed up on the 
suture and the lower end tied, thus markedly de- 
creasing the length of the wound (Fig. i). The sub- 
ctiticular suture obviates the necessity of suture re- 
moval later on. If the nature of the wound is such 
that it seems doubtful or improbable that union by 
first intention can be brought about, it should be 
entirely or partially closed with interrupted sutures, 
avoiding undue tension. Accurate approximation of 
the skin margins is essential, but constriction causes 
sloughing. The knots should always be tied well to 
one side and not directly over the line of union (Fig. 

cent, potassium iodide crystals, allowed to remain for eight days and 
then transferred to a dry sterile jar covered with sterile gauze. 

3° - 


2).; otherwise they may become entangled in the 
healing process and tend to re-open the wound when 
removed. The contra-indications for the use of iodine 


Subcuticular suture introduced and tied. 

catgut are the probability of prolonged sloughing and 
great strain on the sutures, because the gradual ab- 

FiG. 2. — a, Correct and b incorrect method of tying sutures. 

sorption of the sutures weakens their support. It is 
then prudent to re-inforce or replace them with 
through-and-through silk or silkworm-gut sutures, 


Wounds of the lips, tongue and eyelids are best closed 
with fine black silk, because of the cosmetic effect. 

Extensive wounds or those accompanied by severe 
contusion in which more or less sloughing seems likely 
to ensue should be drained. The most satisfactory 
material for this purpose is rubber tubing, except in 
small wounds which may be drained by introducing 
a little roll of gutta-percha tissue. Naturally, drain- 
age should always be encouraged toward the most 
dependent portion of the injured area. Position, 
then, is an important factor. Plain sterile or 
medicated gauze, particularly that impregnated with 
iodoform, has been widely employed for drainage, 
but careful observation will demonstrate that gauze 
performs the function of a cork rather than of a drain. 
It will rapidly absorb serum or pus until it is satu- 
rated but will not promote drainage beyond that 
point. For packing clean cavities, however, plain 
gauze strips will be found exceedingly useful. 

The best method of sterilizing a dirty woimd is 
to inject tincture of iodine directly into it with an 
ordinary medicine dropper, previous to tying the 
sutures in the skin. Iodine is an agent of high 
germicidal potency, endowed with remarkable pene- 
trating power and one of the most satisfactory 
and reliable antiseptics at our command. Even 
when sloughing is imminent, the iodine will hasten 
separation of the slough, limit the formation of pus, 
and stimulate granulation. 

The primary dressing of all wounds should con- 
sist of several layers of sterile gauze saturated with 
a liquid : water, solution of aluminum acetate, equal 


parts of alcohol and witch hazel, etc. They are 
best used lukewarm, as the continuous application 
of extreme cold depresses the vitality of the parts. 
Bichloride of mercury solutions have been more 
or less universally employed for this purpose, but 
they are inferior to others because they may excite 
a dermatitis and may injure the surgeon's hands 
after prolonged use. Contrary to the belief of 
many, the bichloride does not entirely destroy 
the bacteria but only coagulates the albumen of 
the capsule. Far better results will be obtained 
from the use of the above-mentioned agents, es- 
pecially if used in conjimction with iodine. The 
popular "carbolic wash" should never be used for 
a wet dressing, as the solution itself is extremely 
poisonous and carbolic gangrene often follows. 
A wet dressing should always be bandaged with 
gauze so that the whole may be moistened from 
time to time. Glycerine is a valuable aid in keep- 
ing the dressings wet, since its powerful hygro- 
scopic powers promote drainage and hasten slough- 
ing. The practice of covering gauze compresses 
with gutta-percha tissue and bandaging with muslin 
is unsatisfactory, because the moisture will evapo- 
rate in spite of these precautions and then the 
dressing cannot be soaked again without removal. 

Although a great deal may be learned from the 
text-book illustrations, bandaging is an art that 
can be mastered by constant practice only. Ob- 
servation of the following general principles will 
prove useful: 

Always "fix" the bandage at the start. 


Avoid wrinkles and creases as much as possible. 

Be careful that the bandage fits smoothly and 
snugly, yet does not constrict. 

Always bandage from below upward; toward 
the trunk. 

Remember that a bandage that does not commence 
at the fingers or toes tends to produce edema of 
the uncovered part. 

Never bury the end of a bandage applied to the 
head, but leave it free so that it may be tied to 
the other end. 

A bandage that requires pins or adhesive plaster 
to maintain its position has not been properly 

Split or cut the free end of a bandage longitudi- 
nally, tie a knot in it and this leaves two ends to 
tie together. 

Rest of the injured area, for self-evident reasons, 
is of great importance, since motion and friction 
disturb the continuous apposition of the wound 
surfaces. Cases of severe wounds should be con- 
fined to bed, particularly if accompanied by shock. 
Usually the limited motion of the part occasioned 
by the dressing is sufficient, although frequently 
a splint will prove a valuable adjunct. When a 
joint has been injured, the limb should be im- 
mobilized in the position that will be most useful 
to the patient in event of permanent stiffness. 

Emergency treatment of wounds should consist of 
those measures only that are absolutely essential 
for the maintenance of favorable conditions, and 
the permanent dressing should be deferred until 



the procedures can be continued under rigid aseptic 
circumstances. The arrest of hemorrhage, preven- 
tion of swelling, removal of foreign material (pro- 
vided it can be done quickly), exclusion of ad- 
ditional foreign material and control of shock are 
all that require immediate attention. The first 
may be obtained by a clamp, tourniquet or the 
pressure of the dressing; the second and fourth by 
the moist gauze and the fifth by the usual remedial 
agents for shock. Wounds of the abdomen from 
which a loop of the intestine or the omentum pro- 
trudes should be covered with gauze wrung out 
in hot saline solution, and no effort to replace it 
immediately should be made. 

Passive hyperemia, after the method devised 
by Bier, will often prove a useful adjunct in the 
treatment of wounds, especially in those that have 
become infected. It is best induced by several 
superimposed layers of an Esmarch or Martin rub- 
ber bandage. The constrictor should always be 
applied proximally over the healthy tissue, should 
never give rise to paresthesia or pain, and the 
pulse should be perceptible below the constriction. 
Dressings must be temporarily removed from the 
wound and be replaced by loose sterile gauze, to 
permit hyperemia. For further details and technic 
the reader is referred to works on the subject. 

After-treatment of Wounds. — Equal care in all 
aseptic and antiseptic precautions should be exer- 
cised throughout the after-treatment as when apply- 
ing the primary dressing. The surgeon's hands, 
instruments and dressings should be sterile. A 


simple and efficient technic of hand sterilization 
consists of energetic scrubbing with green soap, 
followed by immersion in a watery solution of 
iodine ; a dram of the tincture to a pint of hot water. 
The staining of the skin is inconsiderable and even 
its prolonged use does not injure the hands in the 
slightest. Iodine must not be used for the repeated 
sterilization of steel instruments, because of its tar- 
nishing action. They are satisfactorily sterilized by 
boiling in a I per cent, solution of carbonate of soda. 
The gauze compresses, bandages, etc., should, of 
course, be previously sterilized by compressed steam. 
All dressings should be kept wet for at least three 
days. If there are then no evidences of sloughing or 
pus formation, dry sterile gauze is all that will be 
required. A neat dressing for small clean wounds 
consists of little sterile cotton painted and fastened 
down with collodion, but, as it does not provide for 
the absorption of wound secretion, it should be 
used only in clean cases in which hemostasis has 
been exact. The appearance of heat, redness and 
swelling denotes pus formation and is indication for 
the immediate removal of one or more sutures and 
the institution of drainage. The body temperature 
is also a reliable index of the condition of the wound. 
Tincture of iodine should be dropped along the line 
of union, and under it if the wound is being drained, 
at each dressing. If the granulating process is slug- 
gish, sprinkling the surface with powdered naphtha- 
lin crystals and applications of balsam of Peru will 
hasten it. When healing is markedly retarded with- 
out some apparent cause, it is often due to diabetes. 


The many dusting powders on the market are of 
little practical value; they are expensive, but 
feebly antiseptic and make a paste with the serum 
that exudes from the wound, thus causing the gauze 
to adhere to the line of union. Rarely, if ever, will 
a dusting powder destroy pyogenic organisms and 
prevent pus formation. Iodoform has been exten- 
sively employed as a dusting powder and incorpo- 
rated in gauze, although it possesses but few of the 
virtues of the tincture of iodine. It liberates but a 
miinute quantity of iodine, its odor is disagreeable 
and iodism frequently follows its use. 

Contused wounds are the most common of all 
wounds encountered in surgical practice. They are 
accompanied by more or less pain, swelling and dis- 
coloration of the skin. Although they may appear 
insignificant at first, sloughing of the soft parts may 
subsequently occur, even though the skin is not 
visibly broken. This may be due to hematogenous 
infection or occur externally through a minute fissure 
in the skin. It should not be forgotten that slough- 
ing may extend into a large blood-vessel and give 
rise to secondary hemorrhage. A hematoma usu- 
ally forms, which eventually terminates in either 
absorption or purulent resolution. Diligent search 
should always be made for fracture of underlying 
bones. The appearance of a contused wound of the 
scalp is often misleading, because of the circum- 
scribed swelling with a central depression, known as 
' ' Pott ' s puffy tumor . ' ' Should accompanying symp- 
toms of cerebral concussion exist, the condition may 
closely resemble fracture of the skull, and manifestly 


the reverse is true. Contused wounds of the abdo- 
men should be kept under close observation for at 
least a week, for if severe they nearly always show 
shock early and internal hemorrhage or rupture of a 
viscus may occur at any time. The apparent absence 
of damage to the skin does not necessarily exclude 
internal injury. Rupture of a solid viscus or of the 
omentum generally results in internal hemorrhage; 
perforation of a hollow viscus is invariably followed 
by peritonitis. Likewise, a blow may produce sub- 
mucous hemorrhage and subsequently ulcer of the 
stomach or intestine. Increasing rapidity of the 
pulse is characteristic of rupture and no patient 
should be considered out of danger if the pulse is 
rapid. When injury to the bladder or urethra is 
suspected, the gentle passing of a soft-rubber catheter 
will help to clear up the diagnosis. A contusion may 
cause a bursitis, arthritis, periostitis or osteomyelitis. 
A tubercular process is particularly likely to be 
excited by a contusion, especially in a joint. 

Contused wounds should be dressed immediately 
with gauze saturated with water, aluminum acetate 
solution or lead and opium wash. This will tend to 
prevent swelling, limit subcutaneous oozing, allay 
pain, favor drainage and promote absorption of the 
effusion. An ice bag should be applied to severe 
contusions about the head, especially if accompanied 
by concussion. When sound teeth are knocked out, 
they should be replaced in their sockets, as re-attach- 
ment is often possible. Proper position may be 
maintained by fastening them to adjacent teeth 
with silver wire or silk. The accumulation of blood 


under the nail following a contusion is often ex- 
tremely painful ; the cuticle overlapping the base of 
the nail should be gently lifted with a sharp knife and 
the blood squeezed out. A bursitis or synovitis with 
effusion of serum or synovial fluid should be aspirated 
under rigid aseptic precautions. 

The slightest sign of pus under the skin after a con- 
tusion warrants incision at once. If the sloughing is 
at all extensive, counter-openings should be made by 
introducing a long dressing forceps closed and incising 
the skin which is made prominent by the tip. One or 
more fenestrated rubber drainage tubes of convenient 
size may then be inserted by opening the jaws of the 
forceps, grasping one end of the tube and withdraw- 
ing the forceps. Proper position may be maintained 
by fastening each end with a sterile. safety pin. The 
incisions should always be made parallel to the course 
of the blood-vessels, and never at right angles (Fig. 
3). The extent of drainage will depend upon the 
amount of sloughing, and the length of the tubes may 
be diminished as desired. The necrotic tissue should 
be excised at each dressing and the wound irrigated 
through the drainage tubes by means of a fountain 
syringe or a Valentine irrigator with peroxide, fol- 
lowed by an iodine solution : a dram of the tincture 
to a pint of water. A Davidson syringe should not 
be used because the pressure exerted cannot be 
accurately gauged. The appearance of bleeding de- 
notes the cessation of necrosis and the beginning of 
granulation. These wounds necessarily close from 
below upward, so care should be taken that the 
skin margins do not close primarily and thus obstruct 



drainage. Dead skin should be scraped off with 
a dull knife or gauze saturated with alcohol. De- 
struction of the arterial supply with necrosis of bone 
indicates amputation. The surgeon should be con- 
stantly on the alert for intra-abdominal complications 
following contused wounds of the abdomen. Con- 

FlG. 3. — a. Incisions for drainage tubes made correctly; b, incisions for 
drainage tubes made incorrectly. 

cealed hemorrhage or perforation of a viscus ne- 
cessitates immediate abdominal section, unless the 
patient is moribund. 

Lacerated wounds are due to semi-sharp trau- 
matism or to a tearing force. Avulsion of a portion 
of a limb or complete tearing off of the scalp may oc- 



cur as the result of machinery and railroad accidents, 
but fortimately such extensive lacerations are ex- 
ceptional. The usual picture presenting is a long 
jagged wound, bleeding freely and contaminated by 
hair, dirt and other foreign material. They should 
be especially examined for severed tendons. A 
fissure fracture of the skull should be searched for in 

Fig. 4. — Silkworm-gut strands introduced for drainage. 

all lacerated wounds of the scalp. Always remember 
that a normal skull suture can be wiped clean, 
whereas the red line of a fracture cannot be elimi- 

Simple lacerated wounds should be treated on 
general principles. Turpentine and benzine are ex- 
cellent agents for dissolving the grease that is often 
found smearing the tissues. Surprisingly good re- 


suits are frequently obtained in cases of avulsion of 
the scalp, due largely to its vascularity. These are 
ideal cases for the transplantation of skin flaps. 
Thorough removal of all hair from a scalp wound and 
the surrounding skin is of great importance. A 
simple and efficient method of draining an extensive 
scalp wound consists of inserting a number of strands 
of silkworm gut lengthwise before tying the sutures. 
(Fig. 4). Continuous warm irrigation is especially 
applicable to severe lacerated wounds of the ex- 
tremities. Avulsion of a limb is almost synonymous 
with a traiunatic amputation and will not be con- 
sidered here. 

Lacerated wounds properly dressed at first will re- 
quire but little after-treatment. Skin sutures should 
be removed on the eighth day, if of non-absorbable 
material. They should be gently lifted on one side 
and snipped with scissors close to the skin, to avoid 
dragging anything through the stitch hole that has 
been outside the skin (Fig. 5). 

Incised wounds are due to sharp-edged bodies en- 
tering the tissues. They are frequently deeper than 
their superficial appearance indicates, since they gap 
very little ; the integrity of the underlying structures 
should, therefore, be carefully investigated. Incised 
scalp wounds bleed freely because the density of the 
scalp retards retraction of the blood-vessels. A 
frequently occurring type of incised wound is cut- 
throat. In these cases the position of the carotid 
arteries is such that they escape injury as a rule and 
the greatest danger is not hemorrhage but sepsis. 
Attempt at suicide is generally made between the 



hyoid bone and the thyroid cartilage, and pneu- 
monia is a common sequel. 

Incised woimds usually heal by primary union and 
it is safe to permit this, provided that iodine is used. 
It will not be amiss to repeat that severed important 
structures should be accurately approximated, as it 
is a source of great mortification for the surgeon to 
find that certain muscles are useless after a wound 

Fig. 5. — a, Correct and h incorrect method of removing sutures. 

has entirely closed. A cut-throat should never be 
sutured tightly; first, because of the danger of sepsis, 
and secondly, because the retained extravasation 
may press upon, or enter if injured, the trachea, thus 
asphyxiating the patient. The head should be 
strongly flexed so that position may favor recovery. 
The dressings should be kept hot and moist to prevent 
the entrance of cold air and septic matter, thus guard- 



ing against pneiimonia. Food and stimulation may- 
be administered by rectal enemata. 

Punctured wounds are due to pointed objects 
entering the tissues to a variable depth, are apt to 
injure important structures and, if penetrating a 
cavity, infection and suppuration are likely to result. 
Part of the object inflicting the injury may break 
off, leaving a foreign body in the woimd. A person 
falling from a height may strike upon some pointed 
object, impaling a portion of the body. Penetrat- 
ing wounds are to be distinguished from perforating 
wounds; the former enter a cavity, while the latter 
enter as well some organ or viscus within the cavity. 
It is obvious that punctured wormds should be care- 
fully scrutinized for the integrity of the subjacent 
important structures and for foreign bodies. Pleurisy 
and pneumonia not infrequently follow punctured 
wounds of the chest, hence the necessity for keeping 
these cases under close observation. Penetrating 
wounds of the abdomen may gap sufficiently to allow 
protrusion of the omentum, intestines or other vis- 
cera, and are sometimes sufficiently extensive to 
permit an almost complete evisceration. Naturally, 
there is profound shock therewith, and great danger 
of hemorrhage, infection and injury to the viscera. 

All ptmctured wounds should be drained. If a for- 
eign body remains in the woimd, it will usually be 
necessary to enlarge it to permit extraction. A 
wound communicating with a joint must never be 
entirely closed, owing to the rapidity with which 
synovial membrane absorbs toxic material. The 
danger of sepsis is too great to justify an effort to 


secure primary union. Every punctured wound of 
the peritoneal cavity demands immediate exploratory 
laparotomy. Don't wait for symptoms of perfora- 
tion or internal hemorrhage before opening the 

Poisoned wounds are due to infection through an 
abrasion of the skin or through the sweat or sebaceous 
glands and are particularly likely to result from con- 
ducting dissections and post-mortem examinations. 
The usual picture presenting is that of cellulitis, and 
later septicemia. The stings of insects and the 
bites of snakes and animals may introduce a special 
poison into the economy, and here the symptoms are 
those of the poison plus cellulitis. Poisoned wounds 
due to micro-organisms are commonly termed in- 
fected wounds. The treatment may be summed up 
in five words: incision, evacuation, iodine, drainage 
and wet dressing. The treatment of infected wounds 
with vaccines, based on the opsonic theory of Wright, 
has yielded but poor results in the author's experience. 
Somewhat better results, however, have been ob- 
tained from the use of autogenous vaccines than 
from stock preparations. Poisoned wounds due to 
other toxic substances also require prompt incision 
and drainage. The wound should be shut off from 
the general circulation by means of a ligature and 
bleeding is to be encouraged, to prevent the absorption 
of toxic material. Snake bites are best treated by 
excision of the wotmd and potassium premanganate 
dressings. Patients bitten by a rabid animal should 
be referred to a Pasteur institute, after cauterizing 
the wound with carbolic acid and alcohol or the acttial 


cautery. A nutritious diet and tonics in full doses 
should be given in all cases of poisoned wounds. 

Gunshot wounds are due to the explosion of gun- 
powder, nitroglycerine, dynamite and other power- 
ful explosives. The wound itself may be produced 
by powder, wadding, lead or steel bullets, or other 
missiles. Blank cartridge wounds are particularly 
dangerous because of the frequent development of 
tetanus. If a fire-arm is discharged at short range, 
particles of unburned powder may be driven into the 
skin. These, however, are of little consequence in 
themselves, unless on the face where the cosmetic 
effect is of considerable importance. Needless to 
say, even a single grain of powder may severely 
injure the eye. A gunshot wound may have but a 
single aperture, the edges of which are inverted, or, if 
the missle emerges, a wound of exit also, the edges of 
which are everted. The presence of one or more 
wounds will, as a rule, indicate whether or not the for- 
eign body remains in the tissues. A bullet is likely 
to be deflected from its apparent course by striking 
firm tissues, cartilage or bone. In simple bullet 
wounds, the heat generated by the passage of the 
projectile is sufficient to sterilize the tract so that 
infection is not common except in the peritoneal 
cavity. The amount of contusion of the soft parts 
will vary inversely with the velocity of the bullet; 
the slower the bullet travels the greater will be the 
contusion and laceration. The resistance of the 
parts decreases the speed of the projectile consider- 
ably, so that there is generally more destruction of 
tissue at the wound of exit than at the point of 


entrance. If the bullet is still within the body, its 
exact location should be determined as accurately 
as possible without inflicting further damage upon 
the injured parts. Inspection, palpation and the 
:v;-ray may be safely employed for this purpose, but 
rough probing and blind dissection are harmful 
and imjustifiable. When a large blood-vessel that 
cannot be reached easily has been injured, enlarge- 
ment of the wound to control hemorrhage is indi- 
cated. A bullet may lie deeply imbedded in the 
tissues for years without giving rise to any annoying 
symptoms. In general, gunshot wounds may be con- 
sidered as differing but slightly from contused and 
lacerated wounds and compound factures. The 
severity of the damage sustained by the tissues may 
vary from an insignificant sterile wound, requiring 
little or no attention, to the destruction of a large 
area, necessitating amputation of an entire limb. 
In severe gunshot wounds, as in other extensive 
injuries, there is profound shock. 

Powder grains beneath the skin should be picked 
out with a needle or sharp bistoury or scrubbed out 
with a stiff brush -under anesthesia as soon as pos- 
sible, because the longer they are allowed to remain 
the more pronounced will be the resulting indelible 
blue stain. All cases of gunshot wotmds contami- 
nated with soil and all blank cartridge wounds 
should receive an immunizing dose of tetanus anti- 
toxine. An effort to save all tissue not entirely 
destroyed should be made, and the recuperating 
power of a part will vary in direct proportion to its 
blood supply. A bullet deeply imbedded in the 


tissues should be accurately located with the x-ray. 
Its subsequent removal will then depend upon the 
situation of the bullet, the amount of damage it 
has inflicted and the patient's condition. In every 
bullet wound of the abdomen immediate exploratory 
laparotomy is imperative, unless it is positive that 
the peritoneal cavity has not been entered, for the 
mesentery, intestine, stomach, bladder or some other 
important structure is almost invariably injured. 
The entire cavity and its contents should be explored 
to assure that no perforations are overlooked. 


Those inflammations resulting from joint injuries 
depend upon the nature and severity of the inflicting 
violence and the location sustaining the damage. 
As a inile, low grade inflammations, such as osteo- 
arthritis and arthritis deformans, result from disease 
rather than traumatism, and a constitutional di- 
athesis should therefore always be accorded due 
consideration. So-called "hysterical joints" are 
often the source of serious error and should be 
excluded. In such instances, the patient is of a 
hysterical or neurotic temperament, the skin is more 
sensitive to pressure than the underlying parts, char- 
acteristic attitude is lacking and although the patient 
will state that the joint cannot be moved, he will 
move it unconsciously. Mensuration and compari- 
son with the joint on the opposite side are valuable 
aids in the examination of joints. In all joint in- 
flammations muscular rigidity causes an apparent 
loss of motion far beyond what is absolutely present. 
This condition must be differentiated from ankylosis, 
but since anesthesia will dissipate muscular rigidity, 
the diagnosis is easy. True joint crepitus depends 
almost entirely for its existence upon roughness of 
the articular cartilages. Crepitus is always absent 
in complete disorganization. 




Bursas are distinct sacs but sometimes communi- 
cate with joints. The types of bursitis from a 
clinical view-point are: (i) serous, (2) suppurative, 
(3) chronic, (4) tubercular and (5) syphilitic. 
Although any of the normal or anomalous bursas 
m.ay be subjected to direct violence, bursitis is 
most frequently observed in front of the patella 
(housemaid's knee), behind the olecranon process, 
and over the great toe (bunion) , 

Simple serous bursitis is best treated with rest 
of the part, coimter-irritation and the ice bag. The 
bursa may be aspirated and pressure exerted by 
the application of an elastic bandage. If these 
m.easures fail to cure, complete excision of the 
bursa is indicated. 

Prepatellar bursitis is frequently suppurative, 
and unless speedily drained the pus quickly invades 
the cellular tissues. If the infection is still lirnited 
to the bursa itself, incision, drainage and packing 
the cavity with gauze may effect a cure, as ad- 
hesions rapidly obliterate the sac. Not infrequently, 
however, it will be necessary to dissect out the 
bursa and drain. 

Chronic serous bursitis can often be cured by 
tapping and afterwards injecting equal parts of 
carbolic acid and tincture of iodine. Tubercular 
and syphilitic bursae require excision. Great care 
should be exercised that the adjacent joint is not 

In the treatment of bimion, it will often be a 


great temptation to temporize with circular felt 
or plaster shields, or to incise and drain the joint. 
These measures do not entirely relieve the con- 
dition, and removal of the thickened outer condyle 
of the metatarsal bone is essential to complete cure. 
An incision should be made between the great toe 
and the next one, and the phalanx dislocated. 
The head of the metatarsal bone may now be re- 
sected from the inside, thus obviating a lateral 
scar to rub on the patient's shoe. 


This condition usually begins as an acute infec- 
tion, although chronic synovitis frequently occurs 
as the result of an uncured acute inflammation. 
The joint fills up with serum a few hours after the 
injury, there being but slight local heat and pain 
(aggravated by pressure or forced motion), while 
redness is never present. The swelling is always 
more pronounced where the protection of the 
muscles and other tissues is least. When the 
synovitis has persisted for a considerable length of 
time, the patient will experience a sense of weakness 
and insecurity in the joint, accompanied by more 
or less limitation of motion and muscular atrophy. 
The prognosis is excellent, except in debilitated 
subjects in whom it occasionally terminates in sup- 

The treatment is simple. A snug dressing of 
lead and opium wash, covered with an ice bag, 
and the placing of the joint at rest temporarily by 
means of an elastic bandage, adhesive straps or 


splints are usually sufficient to effect restoration 
of function and a complete cure in a few days. 
In the more severe and prolonged cases it will be 
necessary to aspirate the effusion under rigid aseptic 
precautions and follow with fixation of the joint 
and counter-irritation. Rarely, incision and drain- 
age of the joint are required to relieve a suppura- 
tive process. Passive motion, massage and hot air 
baths are useful adjuvants in the after-treatment. 


Acute arthritis is a simultaneous inflammatory 
involvement of all the structures comprising a 
joint, and with few exceptions is due to pyogenic 
organisms, introduced through an open wound. 
It may begin as a purulent synovitis or may involve 
the entire joint primarily. Likewise, it may occur 
secondarily to an acute osteomyelitis. The syno- 
vial membrane becomes succulent, the quantity 
of synovial fluid is rapidly increased, the cartilages 
necrose and erode and the ligaments soften. Un- 
less drainage is immediately instituted, the capsule 
may perforate and the pus peiTQeate the bone and 
soft structures above and below the joint. The 
pain and tenderness are far greater than in synovitis 
and all the manifestations of a local and general 
septic process soon present themselves. Grating 
on motion may or may not be present, depending 
upon the degree of fixation of the joint occasioned 
by the rigidity of the adjacent muscles. 

Since a peri-articular pyemic inflammation may 
simulate a true arthritis, it is wise to aspirate the 


joint for diagnostic confirmation. Until the diagno- 
sis is definitely established, a splint and ice bag 
may be employed. 

Early and prompt incisions and through-and- 
through drainage are imperative. The drainage 
tubes should be run through the joint from one side 
to the other and must be frequently irrigated with 
physiological saline solution ; twice daily is none too 
often. It is advisable to avoid antiseptic solutions, 
because they may aggravate the inflammation, 
thereby predisposing to a resulting ankylosis. To 
irrigate the tubes conveniently, the hard-rubber tip 
of a Davidson syringe may be inserted in one end of 
the drainage tube and the fluid forced through into 
a suitable receptacle. During the intervals between 
the irrigations the joint should be immobilized 
and enveloped in a generous wet dressing. If 
these measures fail to arrest the septic process, 
the joint must be resected or the limb amputated. 


A sprain is a violent straining, separation of the 
fibers, or rupture of one or more ligaments of a 
joint without permanent displacement of bone. 
Sprains are usually due to a wrench or twist and are 
most common at the ankle and wrist. Not in- 
frequently a small piece of bone is torn off and the 
injury is then termed a sprain-fracture; these are 
the cases that are most often followed by ankylosis. 
Although apparently trivial as a rule, they should 
never be neglected and should receive a gentle 
but thorough and careful examination, because 


of the danger of confusion with separation of the 
epiphysis (in children), dislocation and fracture. 
The nature of the case is often obscured by the 
swelling that is rapidly produced by the effusion 
of blood and serum into the joint and adjacent 
tissues. An anesthetic should be administered 
or an :r-ray examination made, rather than an 
error in diagnosis committed. Laceration or rup- 
ture of tendons near the site of injury must not be 
overlooked, as they are usually responsible for 
delayed restoration of function and may seriously 
cripple the joint thereafter. Rupture of muscular 
or tendinous fibers of the muscles of the back is 
often referred to as a "sprained back" and occurs 
in consequence of a severe strain from lifting heavy 
weights, or extreme pressure exerted thereon. A 
stretching of the annular ligament of the wrist 
causes a weakness at the joint and is often spoken 
of as a sprain. Unless every sprain is accorded 
adequate attention and is treated properly, im- 
pairment of function, permanent stiffness, teno- 
synovitis and even joint disease may result. 

Emergency treatment of sprains will depend upon 
the severity of the injury and the degree of swelling 
already present. If the sprain is a mild one and 
is seen early before there is much subcutaneous 
effusion, it is best treated from the beginning by 
daily gentle massage, especially over the areas 
immediately above and below the tender and in- 
flamed joint. After each seance a wet dressing, 
preferably of lead and opium wash or aluminum 
acetate, should be applied and use of the joint 



should be encouraged. The exception to this 
generalization is a recent sprain of the ankle which, 
in the absence of swelling, should be strapped with 
strips of adhesive plaster in the manner recom- 
mended by Gibney and Cotterell (Fig. 6), and the 
whole covered with a snugly fitting gauze bandage. 

Fig. 6. — Strapping of sprained ankle-joint. 

With this dressing properly applied, the patient 
may be permitted to walk upon the foot. Before 
applying the adhesive straps the leg should be 
shaved and wiped dry and the foot held in proper 
position by an assistant (the foot should be ducted 
toward the sprained side). One and a half inch 
wide strips of adhesive plaster are criss-crossed at 


right angles until the entire joint has been covered. 
The first starts two-thirds up the leg on one side, 
close to the tendo Achilles, crosses the sole of the 
heel and terminates two-thirds up the other side 
of the leg. The next begins at the base of the 
little toe on the dorsal surface of the foot, passes 
around the posterior aspect of the heel and ends 
at the base of the great toe. Additional strips are 
applied alternately in like manner, each one just 
overlapping the previous one, until the ankle-joint 
is completely included. A single circular strap 
is then placed above the malleoli and another at 
the upper limit of the straps on the leg. This 
dressing should be left undisturbed for ten days. 
To faciliate painless removal of the adhesive plaster, 
it may be saturated with oil of wintergreen or gaso- 
line. If there is considerable extravasation when 
first seen, the Gibney strapping should be deferred 
until the swelling has subsided. 

Sprains of a more severe character require the 
prevention or reduction of swelling and immobiliza- 
tion. The first may be secured by the use of hot, 
cold or anodyne applications and pressure; the 
second by a sling, splint or plaster-of -Paris bandage. 
If seen before much effusion has occurred, the plaster- 
of-Paris bandage may be applied at once, but it 
should never be used in the presence of any great 
degree of distention of the joint. If much time has 
elapsed and the joint is swollen, a cooling applica- 
tion should be applied on gauze, covered with an 
elastic bandage, and the limb placed in a sling or 
supported by a splint. 



A " sprained back" should be strapped from below 
upward with strips of adhesive plaster two inches 
wide, from the third sacral vertebra to the level of the 
first lumbar vertebra (Fig. 7). 

After-treatment of Sprains. — Mild cases are best 
treated by daily massage and passive motion, being 

Fig. 7. — -Strapping a sprained back. 

supported during the intervals without restricting 
motion to such an extent that the joint cannot be 
used. The lack of power in the wrist due to stretch- 
ing of the annular ligament is best overcome by 
supporting it with a circular leather strap. 

Severe cases demand complete rest and constant 


wet dressings until the greater part of the effusion has 
been absorbed and all swelling has disappeared, when 
gentle massage, passive motion and gradual use of 
the joint may be introduced. These efforts, however, 
should never be of sufficient force to cause pain. The 
faradic and galvanic currents and superheated air 
will also be found excellent aids, particularly if there 
is atrophy of the muscles. Usually five or six weeks 
elapse before there is complete restoration of function. 
After exceptionally severe sprains, the formation of 
firm adhesions will occasionally so retard the progress 
that it will be nesessary to break them up forcibly 
imder an anesthetic. 


A dislocation is a displacement of the articular 
surfaces of the bones entering into the formation of 
a joint, accompanied by rupture of the joint capsule, 
which bones tend to retain an unnatural position. 
Congenital dislocations and pathological dislocations 
due to disease are not within the scope of this chapter 
and tra-umatic dislocations only will be considered. 
They are usually due to indirect violence and occur 
most frequently at the shoulder-joint. The capsule 
of the joint is necessarily always ruptured and if the 
force exerted is sufficient, tendons, muscles, nerves, 
blood-vessels and even the skin may be bruised or 
torn. In general, we may expect to find tenderness, 
swelling, shortening, deformity at the joint with pro- 
jection of the extremity of one or more bones, more 
or less reflex muscular rigidity and an unatural po- 
sition of the limb, assumed involuntarily. 


Examination of Dislocations. — A dislocation may be 
simple or com.pound, or complicated by fracture of 
either the articular surface or the shaft of one or 
more bones. The existing pathological condition 
should be exactly determined before any attempt at 
reduction is made. Otherwise, irreparable harm, 
such as permanent deformity, neiuitis, local paraly- 
sis, muscular atrophy, adhesion of blood-vessels and 
nerves to bone and even complete ankylosis, may 
result from the surgeon's misdirected efforts. Recent 
dislocations should be differentiated from ancient 
dislocations. The latter are often misleading be- 
cause the joint cavity may be entirely obliterated by 
adhesions and they often present a spurious form of 
crepitus, due to organized effusion in the surrounding 
tissues. The limb may atrophy from lack of use and 
if the injury is neglected for a sufficiently long time, 
a false joint not infrequently results. If the first 
attempt at reduction fails, palpation under anes- 
thesia and the r^c-ray should always be employed to 
establish positively an accurate diagnosis and fa- 
cilitate manipulation. It is of the utmost importance 
to note whether or not the head of the bone rotates 
with the shaft; if it does not, there is probably a 
fracture near the epiphysis. In the presence of an 
impacted fracture of the neck of the bone, however, 
the head will rotate with the shaft. 

Dislocations of the jaw should not be confounded 
with a fracture at the neck of the condyle. In 
fracture there is mobility, while a dislocation is im- 

Dislocations at the shoulder- joint are the most 


common of all, and the proximity of the brachial 
vessels and nerves renders a correct diagnosis of 
special importance. In subcoracoid dislocation the 
elbow cannot be made to touch the side of the chest, 
with the hand on the opposite shoulder ; while if the 
fingers cannot touch the space beneath the acromion 
process, a fracture has probably occurred. A dis- 
location does not tend to recur after reduction. In 
most fractures it is extremely difficult to maintain 
proper position of the fragments. In subclavicular 
and subglenoid dislocations there is more abduction 
of the arm and more tension on the skin. Sub- 
acromial and subspinous dislocations are posterior 
displacements and the position assumed by the arm 
is the reverse of anterior dislocations : adduction and 
inward rotation. Luxatio erecta and supracoracoid 
dislocations are extremely rare and easily reduced. 

Dislocations at the elbow are more common in 
early life and the diagnosis is usually easy. There 
may be backward dislocation of the radius and 
ulna, forward dislocation of the radius and ulna 
(usually complicated by fracture of the olecranon), 
lateral dislocations, or dislocation of the radius for- 
ward (commonly associated with fracture of the 
ulna) . 

Backward dislocations of the thumb are often 
complicated by the anterior ligament or the flexor 
tendons slipping between the two bones and are 
then extremely difficult to reduce. 

Dislocations of the hip are relatively uncommon, 
but it is important to distinguish between dorsal 
and anterior dislocations. In dorsal, or posterior. 


dislocations there is flexion, adduction, inversion, 
shortening, and the head of the femur lies above 
Nelaton's line. These symptoms are more marked 
in dislocations on the ilium than when the head of 
the bone lies in the sciatic notch. Anterior dislo- 
cations are either pubic or obturator (thyroid). 
In the former the thigh is abducted and everted, 
the hip is flattened and the prominence of the 
great trochanter disappears, and there is some 
shortening. In the latter variety there is also 
flattening and aversion, but there is lengthening 
instead of shortening. In all anterior dislocations 
of the thigh the legs cannot be approximated. 
Dislocations are easily differentiated from fractures 
in this region, but the possibility of a fracture occur- 
ring simultaneously should be borne in mind. In such 
instances it is better to consider the injury as a frac- 
ture than as a dislocation, as attempts to reduce the 
dislocation usually fail. Supracotyloid, infracoty- 
loid and perineal dislocations are anomalous va- 
rieties, occurring very rarely and are reduced with- 
out difficulty. 

Treatment of Dislocations. — ^Having established the 
diagnosis of a dislocation, the treatment should be 
instituted promptly, as a profuse extravasation of 
serum and blood into the injured area, which 
increases as time elapses, may seriously interfere 
with our efforts at reduction and complicate the 
result. The treatment may be said to consist of: 
(i) reduction (restitution of the displaced parts to 
their normal relationship) , (2) retention (prevention 
of recurrence), and (3) restoration of function. The 


first maysbe accomplished by manipulation, manipu- 
lation plus anesthesia, extension and counter- 
extension, or arthrotomy ; the second by the appli- 
cation of a suitable dressing, firmly fixing the parts 
in their normal position ; and the third by massage, 
passive motion, hot air and electricity. 

Simple forcible manipulations are quite often 
sufficient to effect a complete reduction, but when 
the first attempt fails recourse to other methods 
should be considered. The obstacles to reduction 
usually encountered are : (i) reflex muscular rigidity, 
(2) voluntary muscular opposition, (3) a small rent 
in the capsule and (4) interposition of a fragment of 
the capsule, nerves, fascia, or some other soft struc- 
ture. Of these, muscular rigidity is the most 
common and may easily be eliminated by general 
anesthesia, pushed to complete muscular relaxa- 
tion. Ether is the safest anesthetic for this 
purpose. The relaxation afforded by the first stage 
of anesthesia may seem sufficient to permit reduc- 
tion, but it must be remembered that the patient 
will still be conscious of the pain produced by the 
manipulations and dangerous shock may be occa- 
sioned thereby. Manifestly, it is better to wait 
for complete surgical anesthesia. Extension and 
counter-extension by means of weights, pulleys, the 
Spanish windlass, etc., have been advocated by 
some surgeons as a satisfactory method of enforcing 
reduction, but with the exception of gradual traction, 
the danger of injury to the soft parts is so great 
under such circumstances that the risk is not 
worth the attempt. Serious laceration or rupture of 


the soft structures not infrequently follows, because 
the force exerted cannot be accurately estimated. 
When a small rent in the capsule or the interposition 
of soft parts interferes with proper reduction, or a 
blood-vessel or nerve has been ruptured, an open 
arthrotomy at the earliest possible moment is the 
desirable procedure. No surgical operation should 
be performed under more rigid aseptic circumstances 
than an arthrotomy, because of the susceptibility of 
all synovial membranes to infection. Having opened 
the joint, temporary enlargement of the rent in the 
capsule and reposition of the articular surfaces are 
easy. Severed arteries, veins and nerves should be 
carefully ligated or sutured in the usual manner. 
Ancient dislocations nearly always require an anes- 
thetic in order that the adhesions may be broken up 
before the attempt to effect reduction is made. Gen- 
erally, however, an open operation is to be preferred 
because the danger of laceration of the displaced 
stuctures is otherwise so great, owing to their changed 
relations. Complicated dislocations should also re- 
ceive the benefit of accurate manipulation, afforded 
by an arthrotomy only. 

Having effected a satisfactory reduction, recur- 
rence of the dislocation may be prevented by means 
of a firm dressing fixing the parts in their normal, 
positions. This may consist of a bandage or 
plaster-of -Paris support, superimposed upon a wet 
dressing if there is much effusion. 

Torn ligaments usually heal in about three weeks 
and it is then safe to commence massage and pas- 
sive motion. They should preferably be carried 


out by the surgeon, in order that the daily dose 
may be regulated satisfactorily. Applications of 
the faradic current will also be found a valuable 
aid in these conditions. 

A displaced coccyx with resulting coccygodynia 
is an exceedingly painful and annoying condition; 
coccygectomy only will give relief. 

Ankylosis is not due to immobilization, but to 
inflammation and its products. If forcible motion 
causes pain, the ankylosis is fibrous in character; 
if no pain is produced, it is bony. The former 
is best treated by forced motion, either with or 
without an anesthetic, or gradual traction. The 
pain following these manipulations should not last 
longer than an hour or two ; if it does, harm is being 
done. Bony ankylosis necessitates an open opera- 
tion and the removal of a wedge-shaped piece of 


Simple fractures are closed fractures having no 
communication with the exterior. They may result 
in two fragments only, or several (comminution). 
Epiphyseal separations, green-stick, fission and 
depressed fractures are anomalous varieties. In no 
other class of injuries is accurate diagnosis and 
exact treatment of such paramount importance, 
because every patient that has sustained a fracture 
will become an ambulatory example of the surgeon's 
ability and skill, or his limitations and incapability. 
Also, these cases are frequently the basis of a mal- 
practice suit. Every detail contributing to the 
complete anatomical, cosmetic and functional re- 
covery of the injured part should receive careful 
consideration, and the patient should always be 
immediately informed of the probable result. Strict 
obedience to orders must be insisted upon, in order 
that the patient may do nothing that might jeopard- 
ize his best interests. 

Examination of Fractures. — All fractures should 
be examined as early as possible, since extravasation 
into the injured area may obscure a gieat deal of 
valuable information. The patient's general con- 
dition is always of great importance; the bodily 
nourishment and development, the condition of 
the pupils and their reaction, partial or complete 



unconsciousness, the degree of shock present and 
the occurrence of other complications and injuries 
should be carefully noted. Thorough investigation 
will disclose whether a fracture is simple or com- 
pound or complicated, complete or incomplete, and 
the line of fracture. The nature of the displace- 
ment will necessarily depend upon the line or lines 
of fracture and the action of various muscles. 

On inspection, any muscular spasm, deformity, 
swelling or discoloration are observed, and the 
contour of an injured limb compared with that of its 
fellow. Palpation must be exceedingly careful and 
gentle, to avoid causing pain or injury to the adja- 
cent structures, but preternatural mobility and crep- 
itus must be diligently searched for. In those in- 
stances, however, where the nature of the injury is 
obvious, it is cruel and unnecessary to twist the site 
of fracture about simply to elicit crepitus and, in ad- 
dition, forcible movements tend to damage the soft 
parts and increase extravasation. Mensuration is 
also of great value for the determination of the ex- 
act extent of displacement. Loss of function and 
subjective pain are usually self-evident and are 
important S3rmptoms. AH obscure cases and frac- 
tures near joints should be examined under anesthe- 
sia, as well as those occurring in children and nervous 
individuals. The :r-ray is of inestimable service 
for the definite location of a suspected fracture 
and for confirmation of a diagnosis. It should be 
remembered that a radiograph taken from the 
anterior or lateral aspect alone is likely to deceive, 
and the x-ray examination should therefore always 


include both an antero-posterior and lateral view. 
An x-TSLj photograph, also, is much more reliable 
than a simple fluoroscopic examination. 

The two most constant errors in diagnosis are 
mistaking a pre-existing deformity for a recent 
fracture and confusing joint crepitus with that of 
a fracture. The inexperienced may be misled by 
the crepitus due to calcareous deposits in the joints 
or teno-synovitis, and conversely, the interposition 
of muscle or fascia between the fragments may 
eliminate crepitus. When dealing with children, 
special care should be exercised to differentiate 
separation of an epiphysis from a true fracture. 
Simple fractures are often accompanied by more 
or less aseptic fever and shock. This fever must 
be distinguished from that of sepsis, which signifies 
complications. The increased leucocytosis present 
in sepsis is a reliable diagnostic guide and is usually 
sufficient to differentiate. 

Emergency treatment of fractures consists only of 
those measures that will make the patient temporar- 
ily comfortable and prevent further injury, although 
most fractures of the upper extremity and thorax 
may be dressed immediately. Since by the very 
nature of these emergency fractures they cannot be 
accurately catalogued, the extent of advisable in- 
vestigation and manipulation must be left to the 
surgeon's discretion. Clothing should be removed, 
being cut or torn away if necessary, any marked de- 
formity reduced and the limb placed in a suitable 
position. The site of injury may be covered with a 
wet gauze dressing and the entire part supported 


with splints lined with cotton or oakum. For se- 
curity, splints are best fixed with adhesive plaster 
before bandaging. All precautions should be taken 
that rough or careless manipulations do not convert 
a simple into a compound or complicated fracture. 
If the patient is in severe pain, one-quarter of a grain 
of morphine may be administered hypodermatically. 
Alcohol and other stimulants are contra-indicated. 

Permanent Dressing of Fractures. — All fractures 
are advantageously reduced as early as possible, 
except when the extravasation and tension are ex- 
treme. Under such circumstances manipulations 
are dangerous and it is better merely to place the 
limb in a comfortable position and surround it with 
sand bags, until the wet dressing has reduced the 
swelling. Having accomplished reduction of the 
fracture, we have at our disposal four methods of 
treatment for simple fractures: (i) immobilization 
by splints and bandages, (2) fixation by extension, 
(3) immobilization plus massage and (4) open opera- 
tion, each of which has distinct value in selective 

Splints may be made of wood, wire, metal, starch, 
or any other light and rigid material. Whenever 
practical, moulded plaster-of-Paris splints will be 
found the most servicable. This does not necessarily 
imply complete encasing of the injured part, but one 
section of several turns, back and forth, of the re- 
quired width and length moulded on the anterior 
half, and another similar section moulded to the 
posterior half of the injured part ; when firm, they are 
bandaged together. A plaster dressing should- al- 


ways include the proximal and distal joints from the 
seat of injury, and by beginning the underlying 
gauze bandage at the distal extremity of the limb, 
annoying edema will be eliminated. The same 
rules apply to splints of any other substance. 

Fixation by extension is most often utilized for 
fractures of the lower extremity, and all joints below 
the fracture are included in the dressing. The steps 
in applying an improvised extension apparatus are: 

I. Cut an appropriately wide strip of adhesive 
plaster of sufficient length to leave a loop projecting 
four or five inches below the heel. 

Fig. 8. — Improvised extension apparatus. 

2. Place an oblong piece of wood about one-quarter 
of an inch thick in the site of the loop on the sticky 
side of the plaster, and punch a hole through the 

3. Knot a piece of heavy cord and run it through 
the perforation, with the knot on the inside (Fig. 8) . 

4. Apply the plaster laterally to both sides of the 
leg (Fig. 9) and fix with a firm gauze bandage, in- 
cluding the toes. 

5. Reduce the fracture and have an assistant main- 
tain constant traction. 

6. Fix an ordinary wooden spool horizontally at 



the foot of the bed at a level that will slightly elevate 
the limb. 

7. Attach the necessary weights (usually about 
eight pounds) to the free end of the cord. 

8. Apply coaptation splints to the site of the frac- 
ture. They are preferably lined with cotton and 
secured with adhesive plaster. 

9. Pad the entire limb with cotton and bandage 
two lateral splints the whole length of the extremity. 

Fig. 9. — Improvised extension apparatus applied. 

Even though daily massage is selected as the 
method of treatment in a given instance, the in- 
jured part must be supported with splints during the 
intervals. The field of this procedure is limited to 
CoUes' fractures and single transverse fractures, since 
in all other fractures accurate approximation cannot 
be maintained without constant external support. 
The results in appropriate cases, however, have been, 
most satisfactory. 

Open operation on simple fractures has recently 
been widely practised and recommended, on the 
ground that it assures a more exact appoximation 
of the fragments than any other method of treat- 


ment. In opposition to this reasoning, it must be 
remembered that tight suturing establishes such con- 
ditions of leverage that the maintenance of precise 
adjustment is at best uncertain, repair is slower, and 
we must still depend largely upon external support. 
While admitting that the risk of infection is a nega- 
tive quantity, in view of modern surgical technic, 
operative measures are positively indicated in simple 
fractures only when approximation and union are 
obstructed by the interposition of soft structures, or 
the fragments are irreducible, and when good position 
cannot be obtained by manipulation. Since opera-, 
tive measures convert a simple fracture into a com- 
pound fracture, further discussion will be omitted 

The following facts are worth remembering: 

The x-rsiy is of great value, not only for diagnosis 
but also for confirmation of good position of the 
fragments after reduction. 

An anesthetic will overcome muscular opposition. 

The recumbent position in the aged tends to induce 
hypostatic pneumonia; at least a semi-erect position 
should be insisted upon. 

A great deal of unsuspected contusion and .sub- 
cutaneous extravasation may become manifest dur- 
ing the first week or ten days. 

The longer a fracture remains imreduced the 
greater will be the muscular rigidity. 

Gravity must be counterbalanced so that position 
will assist restitution. 

All fracture dressings should exert uniform pressure 
throughout their entire length. 


A dressing applied too loosely will permit motion 
of the fragments, while if applied too tightly it will 
interfere with the circulation. 

Apply coaptation splints to the site of all fractures 
treated by extension. 

Contused areas should not be covered with plaster- 
of -Paris. 

Morphine should not be given to patients wearing a 
plaster cast, because the pain due to the faulty po- 
sition of an ill-fitting cast or pressure sores can be 
endured when morphine is given, although the cast 
should be removed. 

No attempt should be made to break up an im- 
paction if the fragments are in good alignment. 

An epiphyseal separation is analogous to a trans- 
verse fracture. 

Correct the deformity of a green-stick fracture so 
that it does not tend to recur. 


Those of the vault may occur as fissure, pene- 
trating, depressed or bursting fractures. There may 
be a linear fracture of the external table only when 
the inner table is extensively splintered, because the 
latter is thinner and more brittle and the diploe 
distributes the force over a wider area. Depressed 
fractures are invariably associated with brain injury 
and practically all fractures of the skull are accom- 
panied by some s^^mptoms of cerebral concussion, 
laceration or compression. These are the danger 
signals, since injuries to the brain and its membranes 
may terminate in meningeal hemorrhage, meningitis, 


encephalitis or cerebral abscess. Infection and 
necrosis due to insufficient drainage and loose frag- 
ments are also serious consequences. In fracture 
by contre-coup, as the name indicates, the fracture 
is on the other side of the head ; opposite to the site 
of injury. Although the diagnosis of fractures of 
the skull may be easy, it often taxes our diagnostic 
acumen. Fissures, depressions, mobility, crepitus 
and local pain and tenderness should be diligently 
searched for and the functional integrity of the brain 
and nerves ascertained. Explorative incision is of 
the utmost value as a diagnostic aid. Wh.en a 
fracture is suspected but not demonstrable, the 
scalp should be freely incised and the skull tre- 
phined. This will permit inspection of the inner 
table and dura. The brain may be explored, if 
necessary, by incising the dura and using a probe. 
By so doing, the underlying conditions can be 
ascertained and no errors of omission will be made. 

Fractures at the base may involve the anterior, 
middle or posterior fossa, and the latter are graver 
because of the proximity to the medulla. In addi- 
tion to cerebral symptoms, these fractures are usu- 
ally evidenced by hemorrhage behind the eye, from 
the nose, into the pharynx, or from or behind the 
ear, or by indications of injury to nerve trunks. Not 
infrequently the cranial nerves are damaged and 
cerebro-spinal fluid or even fragments of brain tissue 
may escape from the nose or ear. 

The tables on pp. 74-77 are intended to illustrate 
the differential diagnosis of head injuries associated 
with brain injury. An alcoholic odor to the breath 


is of no diagnostic significance whatever, because 
some well-intending by-stander will often give whiskey 
or brandy to an injured person, before the surgeon's 
arrival, and the fact that a person is intoxicated is 
no proof that his skull is not fractured. 

The prognosis is uncertain: about 75 per cent, of 
fractures of the vault and 50 per cent, of fractures 
of the base recover. A common sequel is sun- 
stroke, occurring at the next exposure to intense 
heat, and these patients should be instructed accord- 

The following suggestions are applicable to all 
severe injuries of the head: 

Confine the patient to bed. 

Avoid cardio-vascular stimulation, especially hy- 
podermic injections. 

Shave the injured area or the entire scalp. 

Apply an ice cap. 

Secure free movements of the bowels. 

Keep the room dark and absolutely quiet. 

Good nursing and constant careful observation are 
items of the utmost importance. Stimulants are 
dangerous because they increase arterial tension, al- 
though in exceptional instances they are required to 
combat shock, but even under such circumstances 
they should be withdrawn as rapidly as the existing 
conditions will permit. Croton oil is the most sat- 
isfactory purgative as it acts quickly and lessens 
blood pressure. Two or three drops may be placed 
on the patient's tongue, or, if he is unconscious, it 
may be administered in an enema of olive oil, con- 
taining four or five drops of croton oil. A simple 




Appearance of 
the Injury 





Bone may be ex- 
posed, but nor- 
mal skull sutures 
can be wiped 
clean. No per- 
sistent red line 
of hemorrhage. 
The hematoma 
never pulsates. 


Equal and re- 
act promtly. 


Lips livid. 
Red face 
and nose. 

No evidence of 

May be momen- 
tarily aroused 
by inhaling am- 
monia or pres- 
sure on the su- 
praorbital nerve. 

Generally di- 
lated, but 
active. Re- 
act to light. 


Face pale . . . 

N o manifesta- 
tions of injury, 
or at most a 
simple fissure 

S e m i-unconsci- 
ousness. Mind 
weak and con- 
fused, but not 
abolished. Oc- 
casionally total- 
ly unconscious. 

React to 
light. Eye- 
lids some- 
what open. 






Bowels, and 




Mental, Motor, 
and Sensory 

Normal,. . . 

Normal. . . 





Full and 

Deep, slow 
and ster- 

May be vomit- 



Mental dullness 
and motor 
weakness. Inco- 
ordination o f 

rapid and 

and ir- 

Vomiting after 
recovery of con- 
sciousness . In- 
voluntary de- 
fecation and 
micturition at 



Mentally depress- 
ed. Occasional 
delirium. Tem- 
perature s u b - 
normal, gradu- 
ally rising as re- 
action occurs. 




Appearance of 
the Injury 



Pace pale. 






what sensi- 
ble to light. 


Face pale. 
Skin cold. 
p e r s p i- 

Usually evidence 
of fracture. 

More prolonged; 
followed by irri- 
t a b i 1 i t y and 




Face pale. 
Skin cold. 

Usually de- 
pressed frac- 
ture. Hema- 
toma pulsates. 
May be due to 
concealed hem- 
orrhage, in the 
absence of frac- 

Comes on imme- 
diately when 
due to bone 
pressure; grad- 
u a 1 develop- 
ment of symp- 
toms when due 
to hemorrhagic 
pressure. Tends 
to progress. 

Remain fix- 
ed. One or 

both may 
be dilated 
or contract- 
ed. Do not 
react to 
Hght. Eye- 
lids - closed. 






Bowels and 




Mental, Motor, 
and Sensory 

Feeble and 





Power of move- 
ment not destroy- 
ed. Mentally 
depressed, plus 
shock and gen- 
eral depression. 






c c a - 

Mental irritabil- 
ity. Hemiplegia, 
if motor areas 
are injured. 
Legs and arms 
flexed. Lasts 
some days. 

(s o m e- 
times 40- 
60) and 

and ster- 

Stomach insen- 
sible, even to 
emetics. Bowels 

Lasts as 
long as 


Partial or com- 
plete paralysis. 
Special senses 
entirely sus- 


fissure fracture without depression of bone or brain 
symptoms will require no additional treament. All 
depressed and pimctured fractures and those ex- 
hibiting symptoms of brain injury demand immediate 
operation. The skull should be trephined and the 
depressed fragments elevated and cleansed or re- 
moved. Any piece of bone with good periosteal 
attachments will not become necrotic and should be 
left in situ. If there is hemorrhage from the dura, 
the bleeding vessel must be ligated, while if it origi- 
nates in the brain proper or follows the removal of 
bone fragments the wound should be packed with 
narrow strips of sterile gauze. Provision for drainage 
is essential in all these cases. 

In fractures of the base with hemorrhage or ex- 
udation from the nose or ear these cavities should 
be wiped clean with a little moist cotton on an appli- 
cator and loosely plugged with sterile cotton, which 
should be changed as often as it becomes saturated. 
Irrigations are dangerous as they may carry infection 
into the fissures. In addition to these measures, the 
treatment is symptomatic. 

In gunshot fractures of the skull the bullet should 
be removed if reasonably accessible, as the mortality 
is considerably greater if the bullet is permitted to 
remain. Nevertheless, it is sometimes wiser to leave 
a harmless bullet in the tissues than to perform an 
extensive and destructive operation for its removal. 


The cardinal principle in the treatment of these 
fractures is cleanliness. The cosmetic result is of 


great importance so that exact adjustment and firm 
fixation by means of splints or operative procedures 
at the earliest possible moment is imperative. In 
fractures of the nose the mucous membrane should 
be cocainized and cleansed with a little sterile cot- 
ton on a probe. Hemorrhage is controlled by in- 
jections of ice water, applications of adrenalin chloride 
(i-iooo) or packing with gauze strips. The fracture 
may be reduced and proper position of the fragments 
maintained by elevating the spicules with a director 
and introducing an Asch's or Coleridge's splint, if 

5 inches 


Fig. 10. — Cardboard cut for cup-shaped splint for lower jaw. 

necessary. Fractures of the superior maxilla usually 
require instrumental reposition of the fragments, 
suturing and drainage. Little or no tissue need be 
removed, because of the vascularity of this region. 
In fractures of the lower jaw, a cup-shaped splint and 
a Barton bandage are often all that will be necessary. 
To apply this dressing: 

1. Cut a piece of cardboard of appropriate size, 
as shown in Fig. 10. 

2. Steam over boiling water. 



3. Mould to the chin and line with cotton. 

4. Begin a 2 1/2 inch wide muslin bandage diag- 
onally at the vertex of the head, bring down on one 
side of the face, under the jaw, up the other side, 
across the starting-point, down around the occiput, 
across the anterior surface of the jaw, around the 

Fig. II. — Barton bandage applied. 

other side of the occiput and up to the starting-point. 
This is really a double figure-of-eight bandage 
(Fig. II). 

5. Re-apply the dressing every two or three days. 

In severe cases, or whenever this dressing is in- 
adequate, recourse may be had to an interdental 


splint or wiring of the teeth. Open operation and 
wiring of the bone fragments is to be avoided if 
possible, because of the great danger of necrosis and 
sepsis therefrom. Where the damage is extensive, 
dental prosthesis is of considerable aid to the surgeon. 
Talking and mastication must be interdicted, the 
mouth washed out with a mild antiseptic every two 
hours and immediately after eating and the teeth 
kept scrupulously clean. The diet should be entirely 
liquid and administered through a tube. 


Fractured ribs are best treated by strapping with 
strips of adhesive plaster from below upward, be- 
ginning at the spine and ending at the sternum, on 
the affected side only. Surgical emphysema occa- 
sionally accompanies these fractures and is of no im- 
portance. Pneumonia, on the contrary, is a serious 
complication and the patient should be guarded 
accordingly. It will not be amiss to give all patients 
with fractured ribs a sedative cough mixture. 

Fractures of the spine involving the neural arch 
only and without displacement are uncommon. The 
usual fracture is really a fracture dislocation and is 
almost invariably accompanied by compression or 
injury of the cord, caused by bone fragments or 
hemorrhage. If due to the latter, the resulting 
paralysis is more gradual. The evidences of cord 
injury are: (i) profound shock, (2) partial or com- 
plete motor and sensory paralysis, corresponding to 
the point of fracture, (3) loss of reflexes, (4) priapism, 


and in serious cases (5) hyperpyrexia. The local 
manifestations of fracture consist of: (i) displace- 
ment, (2) deformity, (3) paralysis of the nerves 
emerging near to and below the site of compression, 
(4) altered mobility, (5) pain, (6) tenderness, and 
usually (7) crepitus. The prognosis is unfavorable, 
except in those instances in which the cord is un- 
injured. Fractures above the fourth cervical verte- 
bra are nearly always fatal. In general, the per- 
centage of mortality decreases as the fracture is to- 
ward the lower part of the spine. Every precaution 
should be taken against the development of pneu- 
monia, cystitis and pyelitis. 

These patients must be handled and transported 
with the greatest care and gentleness, lest the cord be 
further injured. In simple fracture of the cervical 
region the patient should be put to bed with traction 
on the head, but if the cord is involved, operative 
measures must be resorted to within twenty-four 
hours. All cases of fracture of the spine should be 
placed on an air or water bed and surrounded with 
sand bags, and rigid cleanliness must be maintained 
to avoid the formation of bed-sores. Reduction 
may be wholly or partially accomplished by (i) anes- 
thesia, extension, and gradual pressure, ending the 
operation with the application of a plaster-of -Paris 
jacket or a brace, or (2) by open operation, exposing 
the injured area to view. The latter is preferable, 
since it permits of the local effects of the manipula- 
tions being observed. The selection of either of 
these methods will depend upon the existing circum- 
stances in the individual case. 



Fractures of the clavicle are extremely common. 
In addition to the classic symptoms of fracture, the 
attitude assumed by the patient is always significant 
of this injury, since the action of the sternocleido- 
mastoid muscle elevates the inner fragment and in- 
clines the head toward the injured side. Green- 
stick fractures occur especially in children. 

In cases where the absence of deformity is particu- 
larly desirable, the patient should be placed upon a 
firm mattress with a sand bag on the shoulder and 
the arm bandaged to the side. This position must 
be maintained until union is firm. If a sharp end 
of one fragment projects, the skin can be cocainized, 
incised and the tip removed with bone forceps. In 
the majority of instances, however, the surgeon will 
be compelled to select a method of ambulatory treat- 
ment, because the cosmetic result is usually of minor 
importance and the patient will not submit to con- 
finement to bed. Both the Sayre dressing and the 
Velpeau bandage, or a modification of it, are ex- 
cellent dressings for these cases. The arm must be 
fixed to the side with the forearm flexed, so that the 
finger tips will rest on the opposite shoulder. Pads 
of lint or cotton are placed in the axilla, between the 
elbow and chest and under the palm of the hand to 
avoid excoriation of the skin surfaces. The applica- 
tion of either of these dressings may be preceded by 
fixing a firm compress at the site of fracture with ad- 
hesive plaster. 

To apply the Sayre dressing: 


1. Fix the arm in the proper position. 

2. Cut two strips of adhesive plaster 3 1/2 inches 
wide and about 2 yards long. 

3 Wrap one strip once around the middle of the 
arm at an exact right angle to its longitudinal axis 
and pin or stitch it to itself, being careful not to im- 
pede the circulation. 

4. Bring this strip across the back and completely 
around the chest. 

5. Commence the second strip on the shoulder of 
the sound side. 

6. Carry this strip diagonally across the back, 
imder the elbow on the injured side (cutting a slit 
for the olecranon process) , and across the chest to the 

To apply a modified Velpeau bandage . 

1. Fix the arm in the proper position. 

2. Begin a 2 1/2 inch wide muslin bandage on the 
shoulder of the affected side, bring down the front of 
the arm, under the elbow, up the back of the arm, 
across the starting-point on the shoulder, diagonally 
across the front of the chest, under the opposite 
axilla, around the back, across the front of the flexed 
elbow, around the other side of the chest again and 
back to the starting-point. These turns should be 
repeated six times, each one just overlapping the 
previous one, and the dressing completed by circular 
turns around the chest from below upwards until the 
entire arm and forearm are concealed by the bandage. 

This dressing should be removed and re-applied 
every five or six days and the skin wiped with alcohol. 
Union is generally firm at the end of five weeks. 



Classification : 

Upper epiphysis 


Lower epiphysis 

Anatomical neck. 

Surgical neck. 

Separation of the epiphysis. 

Through the lesser tuberosity. 

Through the great tuberosity. 

Transverse supracondyloid. 
Separation of the epiphysis. 
Internal epicondyle. 
Internal condyle. 
External condyle. 

Fracture of the anatomical neck is usually impacted ; 
fracture through the greater tuberosity may be 
impacted. In the former the impaction should never 
be interfered with, but in the latter breaking up of 
the impaction is essential. All fractures of the upper 
end of the humerus should be radiographed, and ex- 
amined and reduced under anesthesia. Swelling may 
be avoided by bandaging from the fingers to the 
point of fracture. A satisfactory dressing for these 
cases consists of a A-shaped pad, extending the en- 
tire length of the arm with the apex in the axilla. 
Position may be maintained by a strip of adhesive 
plaster carried over the opposite shoulder and re- 
enforced by shoulder cap of plaster of Paris (Fig. 12). 
The shoulder cap is easily prepared by making a 
fiat piece of several turns of plaster-of-Paris ban- 
dages and then moulding to the shoulder and arm. 
A firm bandage enclosing the injured arm and chest 
affords additional support. The patient being in a 



constantly erect or semi-recumbent position, the 
wrist should be suspended in a sling, so that the 
weight of the arm will pull against the fracture. 
If a new shoulder cap is made at the end of the 
first week it will fit more snugly than the first one, 
because of the subsidence of swelling. When the 
head of the bone become necrotic, complete re- 
moval of the diseased bone is more prudent than 
temporizing with palliative measures. 

Fig. 12. — a, A-shaped splint in axilla; b, shoulder cap applied and arm 
in proper position for bandaging. 

Injury of the nerves of the arm is often concomi- 
tant to fractures of the shaft of the humerus. The 
musculo-spiral may become involved in the callus 
formation, evidenced by wrist-drop. Careful ex- 
amination, accurate diagnosis, exact approximation 
of the fragments and rigid immobilization are of the 
utmost importance in these cases. After reduction, 


the following method of treatment of fractures of the 
shaft gives exceedingly satisfactory results : 

Apply coaptation splints by wrapping three or 
four narrow strips of adhesive plaster around five 
thin strips of wood extending from the axilla to the 
elbow, cotton being placed underneath. These splints 
should be securely fixed with a bandage, a shoulder 
cap applied, the arm bandaged to the side and the 
wrist placed in a sling. This dressing should be re- 
applied every week or so, with an assistant making 
continual traction at each renewal. If the fragments 
tend to overlap, better results will be obtained by 
encasing the entire arm in plaster-of -Paris or by using 
constant extension by means of weights, in a manner 
similar to that described on p. 68. 

Fractures of the lower end of the humerus usually 
extend into the elbow-joint and the necessity for an 
exact understanding of the nature of the injury can- 
not be too strongly emphasized. Entire functional 
recovery is always doubtful, because complete re- 
duction is often impossible or the callus formation 
may interfere with proper motion. It should be re- 
membered that with the forearm extended the olec- 
ranon process of the ulna and the two condyles of 
the himienis normally lie in a straight line. Swell- 
ing rapidly occurs in all these cases and must be 
disregarded, as immediate reduction is imperative. 
Much of the extravasation, however, may be quickly 
eliminated by bandaging for a few minutes from the 
fingers to the arm with an elastic bandage. Sepa- 
ration of the epiphysis and supracondyloid fractures 
are the only two types of fracture of the lower end 


of the humerus that require fixation of the forearm 
at a right angle. This position is best secured by 
placing an anterior angular splint upon the arm and 
forearm over a roller bandage. Condyloid fractures 
may be treated in either the extended or acutely 
flexed (Jones) position. Unless great care is exer- 
cised, "gun-stock" deformity, or loss of the carrying 

Fig. 13. 

-Adhesive straps applied to maintain acute flexion of the 
forearm (Jones' position). 

angle not infrequently follows these fractures. The 
extended position would seem to maintain reduction 
and preserve the carrying angle better than acute 
flexion, but on the other hand, when the forearm is 
flexed, the olecranon process and the tense triceps 
tendon both splint the line of fracture and this atti- 


tude will be much more useful to the patient should 
ankylosis result. Extensive swelling is an absolute 
contra-indication to the flexed position, because the 
pressure therefrom may interfere with the circulation. 
Acute flexion, then, is the preferable position for 
condyloid fractures, unless there is great swelling, or 
reduction of the deformity cannot be satisfactorily 
maintained. Even if it is necessary to utilize the 
extended position, the dressings may be removed 
after a week or two and the forearm flexed under an- 
esthesia. When treating by extention, an iron bar 
may be fitted to the inside of the sound limb and 
applied reversed on the inside of the injured limb, 
to preserve the carrying angle. If the flexed po- 
sition is decided upon, the proper attitude may be 
easily maintained by fixing with four of five cir- 
cular strips of adhesive plaster including both the 
arm and forearm (Fig. 13). Motion should not be 
permitted for at least a month. 

Classification : 

Radius and Ulna < ,. 1 , . , s 

(^ incomplete (green-stick). 

Head and neck. 

Separation of the epiphysis. 



Reversed CoUes. 

Olecranon process. 

Coronoid process. 


Styloid process. 



Precise adjustment of the fragments is essential 


when the radius and ulna are both fractured, be- 
cause of the probability of a synostosis resulting 
from the agglutination of the callus from each bone. 
When there is overlapping with shortening, exten- 
sion must be continual to overcome it. The position 
of the forearm should be that which will most 
widely separate the two bones and be the most 
comfortable for the patient : as a rule, semi-pronation. 
The exception is when the radius is fractured above 
the insertion of the pronator radii teres; then the 
position should be complete supination. The pri- 
mary roller bandage must be omitted and the 
splints wider than the forearm in these cases, in 
order to avoid lateral pressure, which tends to force 
the bones together; for the same reason, plaster-of- 
Paris should never be used. An anterior and poster- 
ior flat wooden splint are required and they must be 
accurately padded to fit the irregular surfaces of 
the forearm. The anterior one is necessarily the 
shorter and every precaution should be taken that 
the upper limit does not exert pressure upon the 
brachial artery where it crosses the elbow-joint. 
Both splints extend to the knuckles and the sling in 
which the forearm is carried should uniformly sup- 
port the entire distance from the elbow to that 

Fractures of the head and neck and separation of 
the epiphysis of the radius are not common and are 
treated in acute flexion. If the functional result 
is unsatisfactory, excision of the head of the bone 
may be considered. 

Fractures of the shaft of the radius occurring 



above the insertion of the pronator radii teres 
should obviously be treated in a supinated position. 
If below this point, however, semi-pronation and the 
plaster-of-Paris splints recommended for Colles' 
fractures are preferable. 

Colles' fractures are transverse fractures of the 
radius about an inch above the styloid process. 
The lower fragment is tipped upward and backward 
and is usually impacted or comminuted. In a 
reversed Colles' (rare) the deformity is anterior. 
Radiography is often the only diagnostic method 
that will positively differentiate a Colles' fracture 
from a sprain or dislocation of the wrist, unless the 
silver-fork deformity is pronounced. Permanent de- 
formity and impairment of function will surely 
follow an incompletely reduced Colles fracture, 
hence accurate approximation of the fragments is 
of paramount importance. Reduction is accom- 
plished by fixing the forearm with one hand and 
gripping the hand of the injured arm with the 
other, making momentary traction with overexten- 
sion steadily, and then suddenly flexing the hand. 
Having secured satisfactory alignment, these frac- 
tures do not tend to recur. The results obtained 
from the following method of treatment are much 
better than those derived from the time-honored 
Bond, or pistol-shaped, splint, because the provi- 
sional callus is absorbed more rapidly, stiffness is 
absent, and the function of the wrist joint is un- 

I. With the forearm supinated and the hand ad- 
ducted, have an assistant support the upper end of 



the forearm with one hand and grasp the fingers 
and palm with the other. 

2 . Apply a primary roller gauze bandage from the 
metacarpo-phalangeal joints to the elbow. 

3. Mould a plaster-of -Paris splint to the anterior 
half of the forearm and hand, extending to the 

4. Mould a posterior splint in the same manner 
(Fig. 14). 

Fig. 14. — ^Plaster-of-Paris dressing for CoUes' fracture, a. Anterior 
splint applied; b, both splints applied. 

5. When hardened, cut the primary bandage 
between the splints on both sides. 

6. Apply an external bandage. 

7. On the second day remove the posterior splint 
and gently massage the site of fracture for ten min- 
utes, with the finger-tips sHghtly lubricated. 

8. Replace the posterior splint, pronate the 
arm, remove the anterior splint and massage again. 

9. Continue these procedures every two or three 



days for two weeks and then begin passive motion 
at the wrist and fingers. 

lo. Remove the splints permanently at the end of 
three weeks. 

Reversed Colles' fractures and separations of the 
epiphysis of the radius may be similarly treated 
after reduction. 

Fractures of the olecranon process of the ulna are 
followed by the best results when operated upon. 
If otherwise treated, the forearm should be extended 
on a well padded splint, a small pad placed above the 
upper fragment and firmly secured by a strip of ad- 
hesive plaster applied obliquely and the whole cov- 
ered with a muslin bandage. These cases usually 
terminate in fibrous union when not operated upon 
but the functional result is uniformly satisfactory. 
Should the presence of synovial fluid between the 
fragments seriously interfere with imion, it will be 
necessary to freshen the surfaces of the fragments 
and suture them together. 

The greater number of fractures of the coronoid 
process of the ulna are found with simultaneous 
backward dislocations. The existing dislocation 
must be reduced and the arm put up in acute flexion. 

Fractures, of the shaft and styloid process of the 
ulna should be dressed in the same manner as frac- 
tures of the shaft of the radius, 


In cases where there is but little shortening, the 
fist may be closed upon a rolled-up bandage and 


covered with another bandage. When the short- 
ening is pronounced, extension is preferable : 

1. With the forearm and hand pronated, place a 
gauze pad under the palm of the hand. 

2. Apply two lateral strips of adhesive plaster to 
the finger corresponding to the fractured bone. 

3. Place a well padded straight splint under the 
forearm and hand. 

4. Make traction on the adhesive strips and fix 
them to the under surface of the splint. 

5. Place a piece of rubber tubing on each side of 
the fracture and secure with adhesive plaster. 

6. Bandage from the tips of the fingers to the 


The gravity and treatment of these injuries depend 
upon the degree of shock, the integrity of the pel- 
vic girdle, and the extent of injury of the pelvic vis- 
cera. The most important complications are: (i) 
rupture of the bladder, (2) rupture of the deep urethra, 
(3) laceration of the vagina and rectum, and (4) in- 
ternal hemon'hage. To determine whether or not 
the bladder has been ruptured, do a sterile surgical 
catheterization, empty the bladder of its contents as 
far as possible, inject a known quantity of a sterile 
liquid and measure the amount withdrawn. A ma- 
terial difference between the amount injected and 
the amount withdrawn indicates rupture. The 
withdrawal of clear urine when catheterizing is cor- 
roborative evidence that the bladder is uninjured, 
whereas the absence of urine or hematuria is stigges- 


tive of rupture. If the rupture is intraperitoneal, 
the S3n2iptoms are profound shock, increasing rapidity 
of the pulse and abdominal tenderness. If extraperit- 
oneal (usually into the space of Retzius), there is 
slight shock, pain, partial retention of urine and sec- 
ondary sepsis. Prompt diagnosis is important and 
immediate laparotomy or perineal section impera- 
tive. Rupture of the deep urethra is evidenced by 
dysuria, strangury, swelling and ecchymosis in the 
perineum and scrotum due to the extravasation of 
blood and urine, and if rupture is complete, by reten- 
tion of urine. In all these cases of fracture the pelvis 
should be surrounded with broad strips of adhesive 
plaster and the patient put to bed with sand bags 
on each side, or slung in a hammock. A pillow must 
be placed under the knees so that the flexion will re- 
lax the abdominal muscles as well as those of the 
thigh. Injured soft structures should, of course, be 
repaired and appropriately treated. 


Classification : 

Head (very rare) 

^1 / Intracapsular. 

I Extracapsular. 

f Upper of femur. 

^ , . ... Great trochanter, 

beparation 01 epiphyses < ,. ^ 1 . 

I Lesser trochanter. 

I Lower of femur. 

f Upper third. 

Shaft I Middle third. 

[ Lower third. 

External condyle. 
Internal condyle. 


Intracapsular fractures of the neck of the femur 
are common in the aged, occurring as the result of 
trivial traumatism, and are usually not impacted. 
Extracapsular fractures are found more frequently 
in young adults, due to direct violence and impacted 
as a rule. There is shoitening, eversion, defoimity, 
pain, loss of function, mobility and crepitus (ex- 
cept when there is impaction). It is of far greater 
importance to distinguish an impacted from a non- 
impacted fracture of the neck of the femur than it 
is to differentiate intracapsular and extracapsular 
types. These cases should never be examined for 
crepitus under anesthesia as the periosteum may 
be torn or an impaction broken up, nor should the 
impaction ever be interfered with, unless the patient 
is a young healthy adult and the deformity ex- 
ceptionally pronounced. Gradual increase of short- 
ening during the first day or two indicates liberation 
of an impaction. The prognosis is grave in old 
people, because death often ensues from exhaustion 
or hypostatic pneumonia, consequent to the con- 
finement to bed. Fibrous union frequently results 
from intracapsular fractures but there is always 
bony union in extracapsular fractures. Stiffness 
invariably follows in these cases because of the large 
amount of provisional callus present. In the aged, 
regard for the constitutional condition should super- 
sede consideration of the injury. The patient 
should be treated on a fracture bed, his back sup- 
ported by a back-rest and the limb steadied with 
sand bags on both sides. Scrupulous personal 
cleanliness and good nursing are essential to avoid 


the formation of bed-sores. In younger adults 
the best results are obtained from the use of exten- 
sion, re-enforced with a well padded side splint ex- 
tending from the axilla to the foot. This relieves 
the pain, gives the patient comparative comfort 
and corrects the eversion. 

The treatment of separation of the epiphyses of 
the fem.ur, great trochanter and lesser trochanter 
consists of reduction of the deformity by manipu- 
lation and fixation of the part with splints or a 
plaster-of -Paris dressing. 

Fractures of the shaft of the femur usually present 
extreme deformity, because the line of fracture is 
nearly always oblique and the displacement is ex- 
aggerated by the powerful muscular action. Two 
or three inches of shortening is to be expected. The 
angular displacement is upward in the upper third, 
outward in the middle third, and backward in the 
lower third. These fractures are never impacted 
and inability to elicit crepitus indicates the presence 
of soft structures between the fragments. The 
emergency treatment is important, as these cases 
should not be transported imtil the fracture is firmly 
immobilized. The best emergency dressing consists 
of coaptation splints, supported by a long axillary 
splint on the outside and another on the inside 
reaching from the groin to the foot. These cases 
should all be treated on a fracture bed by Buck's 
extension, re-enforced by the foregoing lateral 
splints. The foot must always be fixed at a right 
angle and a pad of cotton placed imder the tendo 
Achilles, to prevent pressure upon the heel. Frac- 


tures of the middle third are treated by extension 
in a straight line. For fractures of the upper and 
lower thirds it is better to use a double inclined plane, 
with the extension applied above the knee only, 
to induce relaxation of the muscles responsible for 
the deformity. A plaster-of-Paris dressing includ- 
ing the entire leg and pelvis has 'also been recom- 
mended and widely employed for fractures of the 
shaft of the femur. Notwithstanding the fact that 
by virtue of its solidity this dressing presumes to 
give perfect immobilization, its weight and unclean- 
liness are the source of such great discomfort to 
the patient that it has been unfavorably regarded 
and discarded by many. In addition to these 
objectionable features, in the author's experience 
the results derived from this method of treatment 
have not been uniformly satisfactory, as they have 
been when extension was employed. Fractures of 
the femur in infants and young children are usually 
green-stick or transverse fractures and constant 
traction is not as essential as in adults. Moulded 
splints of pasteboard or binder's board may be 
applied and secured by a bandage, or both legs may 
be encased in plaster-of-Paris bandages and sus- 
pended vertically by the feet from a crossbar over 
the bed. Great care should be taken to avoid 
pressure necrosis of the foot. 


When due to direct violence, these fractures are 
often comminuted and there is very little separa- 
tion of the fragments because the integrity of the 


capsule is preserved. Contrariwise, if caused by- 
indirect violence (muscular action), the capsule, as 
well as the patella itself, is broken ; the line of fracture 
is transverse, displacement is pronounced and over- 
lying soft tissues frequently drop between the 
fragments. Consequently, bony union is excep- 
tional, unless operative measures are resorted to. 
Profuse swelling occurs immediately and may be 
reduced by immobilization and ice, with the leg in 
the extended position. A relatively large propor- 
tion of these cases require operative interference for 
the correction of the existing pathological conditions 
and the selection of a conservative or radical method 
of treatment will necessarily depend upon (i) the 
amount of separation of the fragments, (2) the 
integrity of the capsule, (3) the interposition of 
soft structures and (4) the surgeon's discretion in 
each individual case. Exposure of the knee-joint, 
and particularly of its synovial membrane, is an 
operation of considerable gravity which may even 
jeopardize the patient's life if performed under 
difficulties, owing to the rapidity with which in- 
fection is absorbed. Conversely, given perfect 
asepsis and technic followed by primary union, 
the anatomical and functional results are much 
better than when the case is treated conservatively. 
To generalize, it may be said that when crepitus 
can be elicted and it is possible to approximate the 
fragments within 1/4 of an inch, a reasonably 
satisfactory result may be expected from the use 
of immobilization and splints alone. If crepitation 
cannot be obtained or it is impossible to approxi- 


mate the fragments, incision and suturing are both 
justifiable and essential. F. D. Gray says, "A badly 
functionating leg from fracture of the patella, with- 
out operation, is near malpractice, while a stiff knee 
as a result of operative procedure is in the same 

If operation is deemed unnecessary or inadvis- 
able, the limb must be placed upon a posterior 
padded straight splint extending from the upper 
third of the thigh to the lower third of the leg, 
with a gauze pad under the knee-joint. A small 
compress is then applied above the upper fragment 

Fig. 15. — Method of treating fracture of the patella. 

and secured by means of an oblique strip of adhesive 
plaster; another compress is fixed below the lower 
fragment in the same manner, so that the plaster 
strips cross on each side of the knee-joint (Fig. 15). 
A convenient means of fastening the plaster strips 
is to drive two nails or pegs into the posterior 
splint on each side. The limb must be bandaged 
from the toes to the upper limit of the splint. If 
union appears firm at the end of six or seven weeks, 
passive motion and massage may be cautiously 


Should • open operation be selected, every detail 
of preparation and technic must be accorded ade- 
quate attention in order that all may contribute to 
ultimate success and a perfect recovery. There is 
still some diversity of opinion as to the preferable 
mode of procedure, but the concensus of opinion seems 
to be that, as a rule, clearing out the space between 
the fragments and suturing the capsule and overly- 
ing tissues with iodine catgut, under local or general 
anesthesia, are all that are necessary to effect a cure, 
although some surgeons consider wiring of the bone 
fragments essential. Tincture of iodine may be 
dropped along the skin wound, the knee wrapped 
in gauze saturated with aluminum acetate solution 
and the limb bandaged to the posterior splint. 
These items minimize the danger of infection, restore 
the injured structures to their normal anatomical 
relationship, obviate the introduction of non-absorb- 
able suture material and rapidly bring about firm 
union. Silver wire sutures act as foreign bodies and 
necrosis of bone frequently follows their use. The 
patella is refractured more often than any other 
bone in the body, and the patient should be warned 
accordingly. Corner, of London, maintains that 
most refractures in cases treated by operative meas- 
ures occur in the first year after the original injury, 
while those cases treated otherwise occur more fre- 
quently after the first year 




Classification : 

Tibia and fibula 

Upper epiphysis. 



Upper end 
Lower end 



Region of the ankle 
Internal maleolus. 

Lower epiphysis. 

Upper epiphysis. 
Upper end. 

' Pott's. 
External maleolus. 

Lower end 

Lower epiphysis. 

Fractures of both the tibia and fibula are common, 
often compound and easily diagnosed. When due 
to direct violence, the line of fracture is usually trans- 
verse, both bones being broken at the same level, 
while if produced by indirect violence, the fractures 
are usually oblique and seldom occur at the same 
level. Those due to direct force nearly always be- 
come compound within the first week, because of the 
deficient vascularity of the overlying tissues. The 
anatomical location of the bones is so superficial that 
the skin and subcutaneous fascia are unable to with- 
stand the damage inflicted by the traumatism and 
sloughing with exposure of bone results. The deform- 
ity in these cases, however, is slight and easily over- 


come and does not tend to recur after reduction. 
On the contrary, in fractures due to indirect violence 
the deformity is pronounced and may resist all 
efforts at reduction. If the displacement is easily re- 
duced, the primary swelling insignificant and no ex- 
tensive contusion apparent, a plaster-of-Paris dress- 
ing encasing the foot, ankle, leg and knee is the most 
efficient method of treatment, provided the surgeon 
is constantly on the alert for evidence of pressure and 
skin necrosis. If the cast is too tight, it will inter- 
fere with the circulation, while if it is too loose, it 
will permit motion and perhaps displacement at the 
point of fracture. The dressing is best applied over 
a thin layer of wool and should be removed within 
six or seven days, unless indicated earlier by pain or 
swelling of the toes. This affords an opportimity to 
examine the site of injury and to apply a second cast 
which invariably fits better than the original one. 
When there is considerable extravasation or super- 
ficial contusion, a wet dressing and padded lateral 
splints should be applied and the leg placed in a frac- 
ture box with a wool pad beneath the tendo Achilles, 
to avoid pressure on the heel. After the swelling 
has subsided and the skin has healed, the plaster-of- 
Paris may be applied as before. If the lines of fracture 
are very oblique and the overlapping is persistent, it 
will be necessary to employ the extension apparatus 
or, as a last resort, perform a subcutaneous tenotomy 
on the tendo Achilles, to relieve the tension. The 
foot should be immobilized at a right angle in all 
these cases. 

The treatment of separation of the epiphyses of 


the tibia consists of reduction of the displacement 
and fixation in plaster-of -Paris. 

In all fractures of the tibia alone the fibula per- 
forms the function of a splint for the broken bone so 
that the deformity and displacement are not marked. 
The treatment is practically identical with that em- 
ployed for simultaneous fracture of both bones, ex- 
cept those of the lower end involving the ankle-joint, 
which cases demand early passive motion and mas- 
sage to prevent subsequent ankylosis. 

The treatment of separation of the epiphyses of the 
fibula consists of fixation by splints or a plaster-of- 
Paris bandage. 

Fractures of the upper end and shaft of the fibula 
are best placed in a fracture box for a week and later 
encased in plaster-of-Paris. 

Fracture of the lower end of the fibula, or Pott's 
fracture, is a complicated fracture. It usually occurs 
about 3 inches above the malleolus, rupturing the 
internal lateral ligament, and wrenching off a spicule 
of bone from the tibia. There is always a loss of con- 
tinuity between the foot and malleolus, while if the 
anterior tibio-fibular ligament has been ruptured and 
the mortise considerably disturbed, the ankle-joint is 
widened and the astragalus displaced upward and 
backward. The foot is invariably everted in all 
cases of Pott's fracture. The accurate correction of 
the deformity depends upon the re-establishment of 
normal anatomical relationship, so that an exact con- 
ception of the pathological picture is of the utmost 
importance. Reduction is best accomplished by 
firmly grasping the toes and heel, exerting direct down- 



ward traction for a minute or two and swinging the 
foot into position. When there is posterior displace- 
ment, the foot must also be pulled forward. If the 
reduction is correct and complete and proper posi- 
tion maintained, the pain promptly disappears. 
Inversion of the foot must be slightly exaggerated 
throughout the treatment of these fractures. The 
most satisfactory appliance is the Dupuytren splint, 
which is an internal board splint extending from the 
knee to below the foot and padded 4 inches thick 
to just above the malleolus. The foot is now inverted 
by pulling the toes over with a bandage. In spite 
of its efficiency, this dressing is often so uncomfort- 
able to the patient that plaster-of -Paris dressings are 
frequently employed. Whenever the annular liga- 
ment is torn and the tibialis posticus is released from 
its groove, it is good surgery to make an incision, re- 
store the tendon of the tibialis posticus to its normal 
position arid suture the annular ligament. 

Fractures of the bones of the foot are usually accom- 
panied by profuse swelling and are treated with the 
foot extended upon the leg at a right angle, being 
supported by a well padded splint of binder's board 
until the swelling subsides. Plaster-of-Paris may 
then be applied, with a fiat-foot plate on the sole of 
the foot. 



Any fracture communicating with the exterior 
is termed a compound fracture. Single, uncom- 
phcated compound fractures, produced from within 
outward and with the tip of a fragment only pro- 
jecting, need not be considered exceptionally im- 
portant, as the rent in the skin usually heals kindly, 
converting the fracture into a simple one. On the 
contrary, compound comminuted fractures with 
extensive destruction of, or contusion to, the ad- 
jacent soft parts, compound fracture dislocations, 
and gun-shot fractures are grave injuries. The 
more severe types of compound fractures, in which 
amputation is partially completed by the inflicting 
traumatism with destruction of the principal blood 
supply, may be viewed as traumatic amputations. 
In these cases the cosmetic and functional results 
as well as the life of the patient will depend upon : 

The surgeon's judgment and skill in each case. 

The wishes of the patient and his relatives regard- 
ing the proposed and advised surgical procedures. 

The patient's health, constitution, age and habits. 

The integrity of the circumference of the limb. 

The preservation of an adequate blood supply 
to the injured area and the distal parts. 

Proper emergency treatment. 


Perfect operative technic. 

The degree to which it is possible to restore the 
injured structures to their normal relationship. 

Intelligent after-treatment. 

Good nursing. 

Besides the local conditions, six possible inter- 
current occurrences must be considered: shock, 
tetanus, gangrene, sloughing, secondary hemorrhage 
and sepsis. 

Emergency treatment of compound fractures and 
traumatic amputations is essentially that of the 
simple fracture plus an extensively lacerated wound. 
Hemorrhage from the larger blood-vessels must be 
immediately controlled, usually requiring either 
the tourniquet or hemostatic forceps. Applying 
the tourniquet too far above the upper limit of the 
injury may seriously embarrass subsequent manage- 
ment of the case, hence the site of constriction 
should be carefully selected. Large foreign bodies 
may be removed, provided that it can be done 
expeditiously, but no bone fragments should be 
disturbed. The injured part may be returned to 
its approximate normal position, covered with a 
heavy wet dressing and bandaged between long 
splints. The patient should receive a hypodermic 
injection of morphine and be transported com- 
fortably to the hospital. Even in event of a trau- 
matic amputation these measures are permissible 
and indicated. It is best to do nothing further 
for the moment since the injury frequently presents 
a different aspect when examined in the hospital. 
Don't perform, amputations on the street. An ampu- 



tation is an operation of no small magnitude, cer- 
tainly not one to be done on a street corner. 
There are instances, however, in which it may be 
necessary to complete a traumatic amputation to 
release the patient from an enormous weight. When 
this is done, the severed member should also be 
transferred to the hospital, because many patients 
will desire to have it cared for by an undertaker. 

Operative Treatment of Compound Fractures and 
Traumatic Amputations. — Having removed the pa- 
tient to a hospital or other convenient surroimdings, 
the question presents in severe cases: shall the 
limb be immediately amputated or shall an effort 
be made to preserve it, notwithstanding the fact 
that the patient's life may be jeopardized? The 
former (primary amputation) may be designated 
radical treatment, while the latter is obviously con- 
servative. The answer to this question will rest 
entirely upon the surgeon's judgment after care- 
ful consideration of all the facts presenting in the 
individual case, provided consent of the patient 
and his relatives to the procedures selected can be 
obtained. Factors arguing in favor of one or the 
other methods of dealing with a compound fracture 
or a traumatic amputation may be tabulated con- 
veniently : 

Constitution poor. 
Age over fifty. 
Alcoholic habits. 
More than two-thirds of the 

circumference of the limb 


Conservative . 
Constitution good. 
Age under fifty. 
Temperate habits. 
One-third of the circumfer- 
ence of the limb intact. 



Main blood supply to the site 
of injury and the distal 
parts destroyed. 

Surroundings favoring infec- 

Proper after-treatment ques- 

Good nursing not obtainable. 

If a clean amputation is per- 
formed, the patient's life 
will not be jeopardized. 

Adequate blood supply to 
tlie site of injury and 
parts beyond. 

Perfect asepsis and antisep- 
sis to the greatest attain- 
able degree. 

Intelligent after-treatment 

Good nursing possible. 

Sepsis always an element of 
danger but a secondary 
amputation can be per- 
formed at any time. 

All the facts at our command, together with the 
opinion formed, should be cited and the patient 
must then decide for himself which course shall 
be pursued in border-line cases. The surgeon, being 
the better judge of what is required, however, should 
advise, or even urge the patient as to the course to 
be taken. Great comminution of bone with ex- 
tensive destruction of the tissues, two or more 
compound fractures in the same limb with rupture 
or severe injury of the principal blood-vessels and 
nerves, and compound fractures communicating with 
large joints are usually considered definitely positive 
indications for primary amputation. In spite of 
this fact, occasionally it will be possible to save a 
limb in which even one of these conditions obtains. 
Unless immediate operation is imperative to save life, 
it is advisable to afford the patient an opportunity 
to rally from the shock present before tmdertaking 
any operative measures. 

For the technic of the various amputations the 
reader is referred to other works on the subject. 


If conservative measures have been selected, all 
efforts should be made to convert the fracture into 
a simple one as soon as possible. Despite the kindly 
appearance of some of these wounds, they must be 
viewed with suspicion, and all compound fractures, 
including those of the skull, must be considered and 
treated from the beginning as though infected. 

Conservative Surgery in Compound Fractures 
and Traumatic Amputations. — To facilitate the 
necessary manipulations an anesthetic is demanded. 
Blocking the main nerve trunks with cocaine, as 
advocated by Crile and others, is the only method of 
obtaining satisfactory local anesthesia. This also 
prevents shock to a large extent, as the injection of 
a I per cent, solution into the nerve trunks and peri- 
ostetim impedes the transmission of excessive nerve 
impulses. Local anesthesia, per se, does not bring 
about muscular relaxation and its use is consequently 
restricted to selected cases. In general, narcotiza- 
tion will prove far more satisfactory, and if ether or 
the nitrous oxide-oxygen combination be used in 
conjunction with nerve blocking, there need be but 
slight concern regarding subsequent shock. 

Having secured surgical anesthesia, the wound 
should be lightly packed with sterile tampons to 
protect the exposed tissues from any additional 
traumatism incidental to thorough cleansing. The 
entire part should then be shaved and vigorously 
scrubbed with a moderately stiff nail brush and 
tincture of green soap. Following this, the skin may 
be rapidly sterilized by irrigating it with an iodine 
solution: i dram of the tincture to 8 ounces of 


water. We are now working in a surgically clean 

A sterilized elastic tourniquet applied just above 
the injured area maybe tightened or loosened at will 
by an assistant, thus controlling hemorrhage that 
may occur. The tourniquet should not be suffi- 
ciently narrow to cut into the skin, nor its applica- 
tion prolonged unduly. 

The tampons are extracted and oil or other 
grease that may have entered the wound is dissolved 
and quickly removed with swabs impregnated with 
gasoline or benzine. 

The wound should now be sufficiently enlarged 
longitudinally to permit a thorough inspection of the 
damaged tissues and the removal with forceps of all 
visible foreign material. Subsequently, the tissues are 
mopped, but not scrubbed, with some disinfectant 
that permeates readily. For this purpose Harrington's 
solution (hydrargyri chloridi corrosivi gr. xii, acidi 
hydrochlorici 5i, alcoholis Oii) is the most efficacioiis. 
A compound fracture should not be roughly probed 
and the operator should keep his fingers out of the 

If laceration and destruction of tissues are not 
especially extensive, the damaged areas may be 
trimmed off and excised, but in the more severe forms 
the crushed parts are better left until a line of 
demarcation appears. 

Bone fragments must be minutely inspected. 
Pieces entirely devoid of periosteum should be 
removed, but no spicule having a periosteal attach- 
ment should be disturbed. The fragments may 


be gently returned to the most natural position to 
effect alignment. The query now arises, how can 
we best maintain proper approximation? Many 
devices for this purpose are at our command but a 
good working rule is, the less foreign material 
introduced the better. Occasionally, fixation of 
the fragments by uniting the periosteum with 
absorbable suture material and re-enforced by an 
external dressing is all that will be required. More 
often it will be necessary to drill the bones and 
fasten them together with wires or bone plates. 
If wire is chosen, the bronze-aluminum variety 
is the most satisfactory, being stronger and less 
brittle than either silver or iron wire. Nails and 
screws passing directly through the bones are not 
usually effective since they soon loosen and thus 
fail to fix the fragments firmly until union is com- 
plete. Lane's steel bone plates, secured by silver 
plated screws, are often too rigid and unyielding. 
The silver bar devised and advocated by Sick comes 
in lengths with holes for screws and may be cut 
any length desired. As this is slightly pliable and 
flexible and is easily removed later through a small 
incision, it is the most desirable form of bone plate. 

Ruptured muscles, nerves and blood-vessels 
should be accurately approximated and sutured 
with No. I iodine catgut. 

Drainage must always be established, preferably 
at the most dependent portion of the wound; the 
ordinary cigarette drain or fenestrated rubber tubing 
will serve this purpose best. If the anterior aspect 
of the limb is the seat of injury, through-and-through 



drainage may be attained through a stab wound on 
the posterior surface, dividing the deep fascia if 
needs be. 

The wound is now loosely closed with interrupted 
sutures of silkworm gut, great care being exercised 
not to constrict (Fig. 16). A heavy wet gauze 
dressing saturated with aluminum acetate and ap- 
propriate splints are applied and the whole placed 
in a fracture box. If the wound has been contami- 
nated with street dirt or gunpowder, it is advisable 

Fig. 16. — ^Wound sutured with through-and-through drainage 

to administer an immunizing dose of tetanus anti- 
toxin subcutaneously as a precaution against the 
development of tetanus. 

After-treatment of compound fractures and trau- 
matic amputations consists of free drainage and 
constant wet dressings. The former may be favored 
by sprinkling the wet gauze dressing with glycerine 
from time to time and daily irrigation of the wound 
and drainage tubes with normal saline solution or 
a watery solution of iodine. Glycerine is a valuable 
agent to keep the dressings moist, promote drainage 



and hasten sloughing. Continuous irrigation of 
the entire dressing with normal saline solution, 
with a rubber sheet under the limb, is a satisfactory 
manner of maintaining saturation of the dressings. 
This procedure may be easily accomplished by 
means of a tin pail suspended above the patient 
with several small holes in its bottom, through which 
strips of linen have been forcibly pulled. After 
the first week, more contusion often becomes ap- 
parent and continuous irrigation should be kept 
up until sloughing ceases. 

Progressive tissue degeneration with clamminess 

Fig. 17. — Fenestrated plaster-of -Paris cast re-enforced with metal bar. 

or gangrene of the distal part or persistent hyper- 
pyrexia denotes that either the blood supply is 
inadequate or the septic process is beyond control. 
Further efforts to save the limb are then of no avail 
and a secondary amputation through sound tissues 
should be performed. 

If, however, the wound is evidently running an 
aseptic course and the case progresses favorably, 
the splints should be removed and a fenestrated 
plaster-of-Paris dressing substituted as soon as 
sloughing ceases and the danger of sepsis has passed. 


It is best to leave an aperture in the cast over the 
wound area during its appHcation rather than to 
cut one afterward. The strength of the dressing 
may be greatly increased by incorporating two 
(one on each side) metal bars with a curve over the 
fenestration in the center of the plaster (Fig. 17). 
The dressings are then continued through the aper- 
ture. Surrounding the limb with sand bags serves 
to steady it and adds greatly to the patient's comfort. 

When the granulating areas become visible, equal 
parts of balsam of Peru and glycerin, poured directly 
into the wound, will keep the raw surfaces clean and 
stimulate reparative processes. If the denuded 
area is extensive, the granulations may be covered 
with skin-grafts or, almost equally well, with the 
external membrane found in direct approximation 
with an egg shell, teased into small pieces under 
saline solution, placed upon the raw surfaces and 
covered with lint spread with ichthyol ointment. 
These dressings must be renewed daily if the egg 
membrane is used and at each dressing two or three 
little islands from the previous one will be found ad- 
herent. They are excellent foundations for the ulti- 
mate process of epithelial regeneration. 

Passive motion and massage should be commenced 
as early as possible and the further recovery of the 
injured part left to vis medicatrix naturcF. 

Gratifying success in a large number of cases with 
the treatment outlined above, as has been the 
author's experience, will incline the surgeon to adopt 
a conservative attitude toward most cases of 
compound fracture or traumatic amputation. 


Complete restoration of function and a perfect 
cosmetic result depend almost entirely upon in- 
telligent treatment after a fracture has been reduced. 
Although the Rontgen ray has demonstrated that 
mathematical reduction of displaced bone frag- 
ments is rare, careful attention to details and exact 
technic will usually assure physiologic restoration 
with little or no deformity at the injured site. Such 
a result may be considered eminently satisfactory. 
Per contra, the surgeon's misdirected efforts, care- 
lessness or errors of judgment will eventually be- 
come manifest by delayed union, fibrous union, 
deformed union, refracture, exuberant callous 
formation, nerve involvement, loss of function (stiff- 
ness, muscular atrophy, etc.), rupture and slough- 
ing of the skin and soft parts (converting the in- 
jury into a compound fracture), pressure sores, 
edema, ankylosis or sepsis. 

When the reparative process is retarded beyond 
that period in which normal union should occur, 
the condition is known as delayed union. De- 
ficiency or slow development of the provisional 
callus is the etiological factor and may be due to 
either constitutional or local causes. Among the 
former may be mentioned syphilis, individual 
dyscrasia, anemia, senility, etc., and the treatment 



is obvious. The chief local condition predisposing 
to delayed union is imperfect coaptation of the frag- 
ments, due to an incorrect diagnosis or improper 
reduction. Impairment of the circulation may- 
result from constriction when the retentive ap- 
pliances are too tight or to a reduction of the blood 
supply occasioned by the necessary ligation of a 
large artery. Premature motion, active or passive, 
is frequently a cause and the retentive apparatus 
should be permitted to remain sufficiently long to 
allow the callus to solidify and union to become 
firm, although not long enough to interfere with the 
use of the limb. At the same sime, too early use of 
the limb may also delay the union. Operative 
measures are optional. 

Non-imion is another term for an ununited fracture, 
and in the words of Stuart McGuire, "The increas- 
ing number of cases of ununited fracture that come 
to the surgeon, referred by the attending physician, 
is a clear index of the lack of knowledge possessed 
by the average doctor with regard to the treatment 
of fractures." In these cases callus formation is 
practically absent and the ends of the fragments 
roimd off with closure of the medullary canals. 
The influence of constitutional disturbances in 
eliminating callus formation is doubtful, with the 
exception of syphilis. Antisyphilitic treatment for 
a few days is never detrimental to the patient and 
often results in remarkable improvement. This, 
however, must not be construed to mean neglect of 
the patient's general condition, as. the correction of 
systemic errors is of great importance. The local 


causes of non-union are: persistent separation of 
the fragments, imperfect coaptation with absence 
of the periosteal bridge, interposition of soft parts, 
actual loss of bone, impaired vascularity and sup- 
puration. A Rontgen ray examination will dis- 
close many features of the local condition, and the 
proper interpretation of such an investigation may 
serve as a guide to the intelligent selection of a 
particular method of treatment. Persistent separa- 
tion of the fragments results from either failure to 
overcome muscular resistance or not accurately 
approximating the fragments when applying the 
fixation dressing. This in turn is most frequently 
due to the omission of anesthesia. If the patho- 
logical conditions are present for a sufficiently long 
time, it will be necessary to resect the ends of the 
bones, accurately adjust the freshened surfaces and 
maintain correct position by sutures, wires or some 
other suitable material. Imperfect coaptation of 
the bones with absence of the periosteal bridge is often 
followed by some osseous necrosis which requires 
operation before satisfactory union occurs. Failure 
to recognize the interposition of soft structures be- 
tween the fragments is an inexcusable error and 
operative measures should be instituted primarily. 
Inability to elicit crepitus, plus mobility, at the site 
of fracture should ever arouse the surgeon's sus- 
picions. Actual loss of bone occurs in some instances 
of compound fractures and the gap is best filled by 
shortening of the limb or transplantation of bone. 
Impaired vascularity may be due to disturbances of 
metabolism or to the destiniction of certain blood- 


vessels, for example anemia or loss of the main 
arterial supply or the nutrient artery, when the 
injury was sustained. Constitutional treatment 
and Bier's method of elastic constriction to produce 
hyperemia are usually followed by considerable 
improvement. Suppuration invariably interferes 
with the reparative process, but after eliminaton of 
the infection improvement is rapid. Occasionally, 
if the suppurative process continues for some time, 
it will be necessary to expose the seat of fracture 
and remove the diseased bone. Some surgeons 
recommend the injection of from five to ten drops of 
a 10 per cent, solution of zinc chloride between the 
bones and the administration of lime salts as an aid 
to organization of callus. Fifty per cent, alcohol 
has also been used for this purpose. If operative 
measures are contra-indicated or refused by the 
patient, mechanical apparatus may be advan- 
tageously employed. 

Fibrous union is due to failure of the provisional 
callus to ossify, because the osteoblasts do not 
functionate properly, although the fibrous portion 
of the union is satisfactory. Owing to the localities 
in which fibrous union usually results, such as the 
patella, olecranon process of the ulna and head of the 
femur, it is natural to conclude that faulty nutrition 
is responsible. An open operation is the only 
recourse and the advisability of this procedure is 
often questionable, particularly in the upper ex- 
tremity. Unless the patient is a healthy, well 
nourished and developed adult, it is better to let 


well enough alone than to meddle with an unknown 

Deformed imion is the result of faulty adjustment 
and generally illustrates an error of omission or 
commission on the part of the surgeon. When due 
to projection of the tip of one fragment, the skin 
may be cocainized and incised and the offending 
spicule removed with bone forceps. If due to poor 
alignment, resection and re-adjustment are all that 
can be offered and are almost always followed by 
pronounced shortening. So before operating for 
this condition it is wise to hesitate and consider: 
of how much definite improvement can the patient 
be assured? 

Refracture is uncommon in a normal individual 
but may occur as the result of too early passive mo- 
tion (subjecting the broken bone to strain or pressure 
before union is firm), of violent traumatism and of 
carelessness on the part of the patient or surgeon. 
Anemia, inadequate nutrition and diminution of 
inorganic salts in the economy are predisposing 
factors and should be corrected by the employment 
of suitable remedial agents. 

Exuberant callus formation is more common in 
fractures occurring in new-born children. The 
condition is an extremely painful one but the prog- 
nosis is good and the ultimate result satisfactory. 
Treatment is of no avail, unless the callus mass 
unites two parallel bones; then a portion may be 

Nerve involvements are produced by injury to the 
nerve at the time of fracture or, later on, by con- 


tusion from undue pressure of splints, bandages, 
impinging callus, etc., or laceration caused by 
mobility of the fragments where good approxima- 
tion is not secured and maintained. Contused and 
slightly lacerated nerves usually recover while the 
fracture is knitting, being aided by the enforced 
rest, warmth of the dressing and natural reparative 
process. Massage, passive motion, electricity (pre- 
ferably the galvanic current) and superheated air 
(400° F.) may hasten a tardy improvement. When 
the nerve is severely lacerated or divided, operative 
interference is indicated. To assure a normal 
physiologic condition the operation should be done as 
early as possible, suturing the bone as well as the 
nerve. If the injury is one of long standing, neuror- 
rhaphy will be servicable, although the ulimate re- 
covery will be slow. 

Loss of function, not due to nerve injuries, is 
usually not a matter of great consequence. Removal 
of the fixation dressing, mobilization, massage and 
use of the part are sufficient to restore the impaired 
power. Once union is firm, voluntary action of the 
neighboring muscles should be encouraged. 

The surgeon is seldom responsible for rupture or 
sloughing of the skin and soft parts within the first 
week after the fracture, unless the wet dressing has 
been omitted, since they are generally due to con- 
tusion that was not primarily apparent. Faulty 
alignment and imperfect immobilization may per- 
mit the rough margin of a fragment to penetrate the 
skin and must be corrected when they are causes. 

Pressure sores are produced by an ill-fitting plaster 


cast or insufficiently padded splints and the surgeon's 
attention should be attracted by complaint on the 
part o£ the patient. Manifestly, the cast or splints 
must be removed and a new dressing applied. 

Edema is always due to failure to equalize the 
pressure on the distal portion of a limb and may be 
easily eliminated by the application of a snug band- - 

Ankylosis occurring as a complication of a fracture 
near a joint is due to peri-articular thickening and 
disuse of the joint. It is not apt to be permanent, 
except at the elbow- and knee-joints. The treatment 
of this condition has been outlined in the chapter on 
traumatic injuries of joints. 

Sepsis occurs after compound fractures only and 
has been discussed in Chapter V. • 


An abscess is the formation in tissue of an abnor- 
mal cavity containing pus. It is accompanied by 
softening and sloughing of tissue and, although show- 
ing a tendency to encapsulation, the suppurative pro- 
cess will follow the line of least resistance so that the 
purulent accumulation may either rupture externally 
or burrow deeper into the soft structures. Thus, 
if neglected, it may produce a localized but gradually 
extending cellulitis, septicemia and death. The 
neighboring lymphatics are soon involved and 
rapidly transmit the septic process to adjacent 
lymphatic glands, lymphangitis, lymphadenitis and 
metastatic abscesses being frequent sequelae. The 
symptoms and physical signs of an abscess are too 
well known to merit enumeration. 

A furuncle, or boil, is a circumscribed pyogenic 
infection of a sebaceous gland or hair follicle, termi- 
nating in suppuration with a central necrotic mass. 
Because of its superficial location a furuncle will 
eventually rupture through the skin spontaneously 
and thus establish drainage. The infection is usually 
self -limited, since nature affords relief before the sup- 
puration progresses to any great extent. In other 
respects a furuncle differs but little from an abscess. 



A carbuncle is an acute phlegmonous inflammation 
of the skin and subcutaneous tissues with multiple 
foci of necrosis. The cellular tissues slough exten- 
sively, the skin becomes indurated and dusky and 
numerous small perforations soon appear. Carbun- 
cles nearly always occur on the neck or back in 
adults with some constitutional disturbance, notably 

Cellulitis is an inflammation of the loose connective 
tissue, invariably of bacterial origin, due to (i) a 
severe contusion or (2) an infected wotuid. Unless 
relieved promptly, suppuration is inevitable. The 
immediate complications are (i) extensive destruc- 
tion of tissue, (2) suppurative teno-synovitis, (3) 
lymphangitis and (4) lymphadenitis. When treat- 
ment is neglected or misdirected, the infection tends 
to follow the fascia and tendon sheaths, subsequently 
attacking the bone with resulting necrosis. The 
lymphatics rapidly transmit the infection upward, 
toxines are absorbed and septicemia and death en- 
sue. The rapidity with which a cellular suppuration 
will sometimes spread is remarkable. The severity 
of the affection in a given instance is, of course, 
largely influenced by the virulence of the micro-organ- 
isms responsible for the infection and the patient's 
resistance to bacterial invasion, and the subsequent 
toxemia. The most reliable index of the patient's 
antagonistic power is the leucoc3rtosis developed. 
The phenomena denoting a gradually spreading cel- 
lulitis are: (i) history of an injury (contusion or in- 
fection), (2) swelling, (3) skin cyanotic and edema- 
tous (indicating partial circulatory stasis), (4) pain, 


(5) tenderness on pressure, (6) local heat, (7) restricted 
mobility of the part, (8) red and indurated super- 
ficial lymphatics, (9) upper limit of the involved 
area constantly extending, and (10) evidences of 
toxic absorption (chills, pyrexia, increasing rapidity 
of the pulse, etc.). 

In all infectious conditions the presence of con- 
stitutional disorders is of paramount importance. 
For example, furunculosis (intermittent outbreaks 
of boils) and carbuncles are frequently associated 
with diabetes, nephritis, plethora, etc., and con- 
sequently a thorough urinalysis should be made in 
all these cases. Obviously, the correction of sys- 
temic errors or disturbances will increase the patient's 
resistance to bacteriemia and toxemia. 

Treatment of Localized Pyogenic Infections. — The 
cardinal principle in the treatment of all localized 
collections of pus is to establish drainage immedi- 
ately. Additional measures are also frequently in- 
dicated but without effecting a point of exit for the 
pus and maintaining free drainage the integrity 
of the tissues still uninvolved and even the patient's 
life may be jeopardized. Every effort should be 
made to assist the tissues in their effort to mitigate 
bacterial activity. 

Poultices, devised by our grandmothers, are 
mentioned only to be condemned. Nothing will 
be gained by waiting for "pointing" except bacterial 
multiplication. Even though a poultice may en- 
courage spontaneous rupture of the skin, it will be 
necessary to enlarge the aperture and treat in the 
usual manner. On the contrary, cold wet dressings 


may be of service in the early inflammatoiy stages 
by relieving local congestion. The application of 
antiseptic solutions (bichloride of mercury and 
carbolic acid usually being favored) with the hope 
of exerting destructive influence on the pyogenic 
organisms is absurd, since no antiseptic can pene- 
trate the unbroken skin sufficiently to restrict germ 
growth. Were this fond hope realized, the patient 
would be poisoned by vascular absorption. Car- 
bolic dressings are particularly dangerous because 
of the frequency with which poorly nourished tissues 
become gangrenous from its constant use. Benefit 
is derived from dressings saturated with plain water 
or some evaporating lotion, such as equal parts of 
alcohol and witch hazel, simply because the evapora- 
tion assists the restoration of the normal vascular 
equilibrium. In exceptional instances the necessity 
for incision may thus be obviated. 

As in all other surgical procedures, the overlying 
and adjacent skin should be cleansed and the opera- 
tor's hands should be clean. This may seem a 
superfluous injunction, yet carelessness is the rule 
rather than the exception. 

Anesthesia of the site of incision should be secured 
and for this purpose the ethyl chloride spray is ideal. 
The container is the only apparatus required, 
cutaneous anesthesia and temporary ischemia are 
easily and quickly obtained, there is no additional 
tension on the inflamed tissues and this method of 
freezing is not followed by sloughing. 

All incisions are preferably made parallel with 
the course of the blood-vessels and the longitudinal 


axis of the part. By so doing profuse hemorrhage 
will be avoided and all possible sources of nutrition 
preserved. When the pus collection is small, a 
single incision should be made directly over the 
center of the tumefaction and need be large enough 
only to allow free vent for the pus and the intro- 
duction of a small drain. Abscesses situated near 
large blood-vessels, such as axillary abscesses, are 
best opened by incising the skin, pushing in a pair 
of closed hemostatic forceps and withdrawing them 
open. In large carbuncles and extensive cellulitis 
the aperture must be larger or multiple incisions 
may be made at various points to permit the estab- 
lishment of several channels of through-and- through 
drainage. In such instances some of the deeper 
dense tissues should also be divided, if the infection 
appears to extend inward. Although, as a rule, 
incisions are not required until pus has formed, 
early incision is often necessary to relieve tension 
and the strangulated circulation, thus preventing 
the extensive sloughing that follows steady intense 
pressure. It is therefore unwise to always wait 
for fluctuation before incising. When the life of 
healthy tissue is endangered by a virulent sup- 
purative process, such as a cellulitis due to the 
staphylococcus pyogenes albus, it is best to extend 
the incision into the sound region. The length and 
depth of the wounds are of secondary consideration. 
When the cosmetic results are of special importance, 
much can be accomplished in cases of circum- 
scribed pus collections with a small incision followed 
by active hyperemia. The latter may be obtained 


by small sterile Bier suction cups, the rims being 
lubricated with petrolatum, applied in seances of 
five minutes each with three minute intervals of 
rest for forty-five minutes. Much has also been 
claimed for passive hyperemia as a preventive of 
suppuration and as an aid in limiting the infectious 
process, being used in conjunction with drainage, 
after the suppuration has actually occurred. 

After all incisions, the pus should be expressed 
by exerting gentle but firm pressure over the sur- 
rounding skin and local bleeding should be encouraged 
for a few minutes. General blood-letting is contra- 
indicated, since it depresses the patient's vitality 
and thus lowers his resistance to septic infection. 
Should the hemorrhage appear excessive or be 
unduly prolonged, it may easily, be controlled by 
packing the cavity temporarily with gauze strips 
wrung out in hot water. Bands of fascia and tendon 
sheaths must be carefully investigated and longitu- 
dinally incised, if necessary. A probe should be 
passed down to the subjacent bone to exclude 
periosteal involvement and necrosis. When a felon 
exists, it should be incised down to the bone. 

Curettage of the cavity after pus evacuation is 
advocated and practised by many surgeons but is 
advisable in small abscesses and carbuncles only. 
In all other conditions it is better to wait for the 
slough to separate, in order to avoid injuring areas 
of normal tissue. In carbuncles the -undermined 
skin areas should be excised before curetting. 

To secure sterilization, check hemorrhage, hasten 
sloughing and stimulate granulation, the cavity 



should be filled with tincture of iodine with an 
ordinary medicine dropper. This should be per- 
mitted to remain undisturbed for a few minutes 
before introducing a drain. Pure carbolic acid has, 
also been used for this purpose but its use is best 
restricted to carbuncles. Some surgeons practise 
hypodermic injections of powerful antiseptic solu- 

FiG. 18. — Furuncle on the neck properly incised and drained with gutta 
percha tissue. 

tions into or near the affected region. These in- 
jections may limit the inflammation, yet they possess 
the disadvantage of being extremely painful and 
constitutional poisoning may result therefrom. 

All infected cavities must be drained. Drainage 
does not mean plugging the opening with gauze, 
but maintaining a free flow of discharge, be it simple 



exudate or pus. Gauze, plain or medicated, does 
not drain, as is invariably demonstrated by the 
gush of pent up pus that follows the removal of a 
gauze wick. The most satisfactory drain for a 
small aperture is a little roll of gutta-percha tissue 
(Fig. 1 8) . For larger openings and extensive slough- 
ing areas the fenestrated rubber tube is the drain 
par excellence. When through-and-through drain- 
age is desired, the counter-openings are best made 
by pushing a long handled dressing forceps under- 

FiG. 19. — Dressing forceps pushed through incision and counter-opening, 
grasping drainage tube. 

neath the skin to the opposite side of the part and 
incising over the tip. The jaws are then opened, 
grasp one end of the tube and withdrawn, thus 
pulling the tube into position (Fig. 19). Peple has 
recently devised a serviceable drain, consisting of 
a split rubber tube into which are sewed several 
folds of rubber dam. This drain possesses capillar- 
ity, does not become clogged and drains along its 
entire length. Its single objection is the impossibility 
of irrigation through the tube, hence it cannot be 
used when sloughing is extensive. 



A voluminous wet dressing should cover all 
infected parts and extend well beyond in every 
direction. Plain water, normal saline solution, 
aluminum acetate solution, alcohol and witch hazel 
or Burrow's solution may be used for soaking the 
gauze. The particular agent selected is of minor 
importance, provided the dressing is kept constantly 
wet. When the patient is confined to bed with a 
large surface requiring attention, it is well to employ 
continuous irrigation. Saturating the dressings with 
a hot watery solution of i per cent, sodium citrate 
and 4 per cent, sodium chloride, as recently 
advocated by Wright, is an excellent method of 
promoting drainage. The solution is hypertonic 
and stimulates exudation by osmosis. The sodium 
citrate prevents coagulation and scab formation 
so that the cavity will drain through a compara- 
tively small incision. The skin must be smeared 
with vaseline or some other emollient to prevent 
the dermatitis that might result from its continuous 
application. This solution is contra-indicated if 
there is persistent oozing and should not be used in 
clean cases where profuse drainage is not essential. 
The treatment should never be prolonged more 
than three days or healing will be markedly retarded. 

The presence or absence of systemic disturbances 
in connection with pyogenic infections should be de- 
termined and support will be required to overcome 
the debilitating effect of the septic element. Iron, 
arsenic and sulphur, preceded by a calomel purge, 
are most often used. The administration of quarter- 
grain doses of calcium sulphide every three hours 



for a few days exercises a beneficial effect and aids 
in preventing the recurrence of carbuncles and 
After-treatment of Localized Pyogenic Infections. — 

All suppurating cases should be dressed daily or 
even more often, until pus formation ceases and 
granulation commences. In limited infections the 
drain should be removed and the sloughs expressed. 
The cavity is again filled with pure tincture of 
iodine, a new drain inserted and a fresh wet dressing 
applied. In more extensive infections the drainage 
tubes should be irrigated with hydrogen peroxide, 
followed by the usual watery solution of iodine. 
Shreds of slough should be excised and, if the de- 
struction of tissue progresses, new openings may be 
made and additional drainage tubes inserted. At 
each dressing the skin should be cleansed with 70 per 
cent, alcohol. As the quantity of pus diminishes, 
the tubes may be gradually shortened and with- 
drawn. When the suppurative process has entirely 
disappeared, the pockets and cavities should be 
loosely stuffed with plain gauze. Applications of the 
U. S. P. boric acid ointment or 10 per cent, ichthyol 
are of use in the after-treatment of boils and car- 
buncles after the wet dressings are discontinued. 


Systemic infections are sequels resulting from 
local bacterial invasions, due to the absorption of 
the toxines and endotoxines of the invading bacteria, 
and are characterized by grave constitutional disturb- 
ances. The intoxication may occur as a sapremia, 


bacteriemia, septicemia, toxemia or pyemia, but 
it is almost unnecessary to make a minute dis- 
tinction, since the manifestations of the various types 
are similar in almost every respect and the treatment 
is much the same. The clinical phenomena evidenc- 
ing a constitutional intoxication are : presence of local 
suppuration, hyperpyrexia (more elevation in the 
evening) , chills, flushed cheeks, increased pulse rate, 
digestive disturbances, sweating, prostration, urinary 
changes and sometimes dehrium or coma. Any or 
all of these manifestations may be present. Py- 
emia is characterized by the formation of metastatic 
abscesses. Unless efficient treatment is instituted 
promptly, death soon occurs. 

Treatment of systemic infections consists of (i) re- 
moval of the source of absorption and disinfection of 
what cannot be removed, (2) serotherapy, (3) pro- 
moting elimination by stimulating the emunctories, 
and (4) combating the constitutional symptoms by 
supporting the patient's vitahty with nourishing 
foods and suitable tonics. 

The first is obtained by emptying and disinfecting 
all the original foci of suppuration, as described in the 
previous paragraphs of this chapter. This in itself 
often suffices to cause the disappearance of toxic 
symptoms, by arresting the propagation of bacteria. 
In pyemia, if a suppurative lymphadenitis exists, 
the glands should be completely excised. 

Serum-therapy is now being accorded considerable 
attention as a method of combating profound tox- 
emias and good results are often obtained from the use 
of antitoxines and vaccines, particularly in strepto- 



COCCUS and staphylococcus infections. When the ser- 
vices of a capable pathologist can be secured and the 
necessary facilities are at hand, it is better to manu- 
facture an autogenous vaccine than to employ a stock 
preparation. This will also avoid any possible error 
that might be made regarding the identity of the 
organism responsible for the infection. 

The excretory organs must be kept active to pro- 
mote elimination. Drugs administered per os are to 
be avoided, as they may further irritate the already 
disturbed stomach. Hydrotherapy has distinct value 
but hot packs are contra-indicated because they 
tend to depress the patient's limited vitality. The 
patient must be given absolute rest in bed and sur- 
rounded with hot-water bags to induce perspiration. 
Physiologic saline solution, given hypodermatically, 
as an enema or intravenously, markedly aids elimina- 
tion, as well as serving as a circulatory stimulant. 
The author has derived extremely satisfactory re- 
sults from an enema consisting of 4 ounces of magne- 
sium sulphate dissolved in a pint of cool water (70° F.) , 
repeated every two hours until improvement is pro- 
nounced. Rapid elimination of toxines is brought 
about by the osmotic action of this solution, which at 
the same time causes free catharsis. The low tem- 
perature serves to reduce pyrexia. Persistent vom- 
iting is not rare and can be relieved by gastric 

The food should be nourishing and easily digested. 
Coffee, alcoholic stimulants, broths and milk will 
usually suffice. When the stomach has been washed 
out, the patient may be fed per rectum for a few 



days. Later, a few well selected tonics may be 
cautiously introduced. The tincture of the chloride 
of iron and the freshly made elixir of iron, quinine 
and strychnine are excellent preparations. The 
cardio-vascular depression, which is always present 
to a variable degree, may be ameliorated by inhala- 
tions of oxygen. 


Among the special forms of infection frequently 
encountered may be mentioned erysipelas, tetanus, 
anthrax, malignant edema and glanders. None of 
these are true pyogenic infections, yet for the sake of 
convenience the first two will be considered here. 

Erysipelas has been clinically subdivided into 
phlegmonous, facial and the erysipelatoid lymphan- 
gitis of Rosenbach. There exists some diversity 
of opinion regarding the exact identity of the organ- 
ism causing erysipelas but it is universally acknowl- 
edged that it is due to a streptococcus invasion. 
The three disease types are practically alike except 
for the variation in the intensity of the infection. 
The phlegmonous form is a severe one, the facial 
milder and the erysipelatoid lymphangitis is a 
condition found almost exclusively on the hands. 
The subjective and objective signs of erysipelas are 
too well known to require reiteration; the disease 
may run a benign or malignant course, depending 
upon the virulence of the bacterial invasion. 

All cases of erysipelas should be completely isolated, 
as a mild infection in one patient may be transmitted 


to another in a profoundly septic form. Attendants 
should wear rubber gloves for self -protection. 

Local applications of suitable medicaments rapidly 
check the spread of the disease and hasten resolution, 
so that the painful measures often recommended, 
such as sacrification and intradermal injections, 
are usually unnecessary. The three most efficient 
remedial agents are iodine, ichthyol and carbolic 
acid. Irrespective of the agent selected, the local 
applications must always extend half an inch to an 
inch beyond the margin of the eruption. Iodine 
is best applied in the form of the tincture ; ichthyol, 
2 drams dissolved in i ounce each of alcohol and 
ether; and carbolic, painted on the surface until 
whitened and followed by the liberal use of alcohol. 

Constitutional treatment is of the utmost import- 
ance in these cases, as the patient's powers of resist- 
ance are poor. The regime to be followed is es- 
sentially the same as that in systemic infections. 

For some reason, as yet not satisfactorily explained, 
an attack of erysipelas occasionally exerts a favorable 
and curative influence on certain intercurrent condi- 
tions. For example, various writers have reported 
that sarcomata have entirely disappeared after an 
attack of erysipelas. In an attempt to produce these 
results, sarcomatous patients have been intention- 
ally inoculated with the toxines of the streptococcus 
of erysipelas and a certain degree of sucess has been 
claimed by some authors. To increase the potency 
of the preparation, the toxines of the bacillus pro- 
digiosus are added, this product being known as 
Coley fluid. 


Tetanus is an infectious disease due to the bacillus 
tetani, characterized by violent and persistent 
tonic spasms of the voluntary muscles, particularly 
those of the lower jaw, and sometimes accompanied 
by local paralysis. Distinct intermittent exacerba- 
tions are usually present. The infection originates 
in wounds, especially those of the extremities, and 
is due, as a rule, to contamination with actual dirt. 
Unlike the ordinary pyogenic infections, the invasion 
of bacilli tetani does not interfere with primary 
union, hence the initial symptoms are not local but 
general. In man, the rigidity usually begins in the 
masseter and posterior cervical muscles, progressing 
downward from the head, and may be followed by 
persistent opisthotonos. The toxines are intensely 
virulent and the period of incubation may vary from 
one to twenty days. Upon the duration of the 
period of incubation, the prognosis may be safely 
based. In cases exhibiting a short period of in- 
cubation (one to eight days) a fatal termination 
may be anticipated, while in the milder cases 
(twelve to twenty days) recovery may be expected, 
in spite of the fact that the course of the disease is 
apt to be prolonged. Cases developing between 
the eighth and twelfth days after the injury may 
terminate in either recovery or death and are un- 
doubtedly influenced to a greater extent by appro- 
priate remedial measures than are those of the 
other two classes. These statements are verified 
by experience and careful investigation of the records 
of a large number of cases of tetanus, occurring be- 
fore as well as after the introduction of tetanus 


antitoxine as a curative agent. The sympto- 
matology of tetanus is distinctive and will not be 
elaborated here. 

The most efficient method of treatment is pro- 
phylaxis, which consists of thorough disinfection 
of all wounds, removal of sloughs, foreign bodies 
and other extraneous matter, and drainage. All 
cases of gunshot wounds and those contaminated 
with street dirt, especially the dirt from asphalt 
pavements, should be given a prophylactic sub- 
cutaneous injection of from lo to 20 c.c. of tetanus 
antitoxine just above the wound. When the tetanic 
condition has once become established, the anti- 
toxine must be administered within twenty-four 
hours to be of material service. It should be 
generously used: 20 c.c. injected along the nerve 
sheaths above the site of injury, 10 c.c. thrown 
into the cerebro-spinal axis (usually a subdural 
injection) and 20 c.c. used for moistening the dress- 
ing covering the wound. The injections may be 
repeated every twelve hours if necessary and the 
patient's condition permits. Although the anti- 
toxine usually has but little effect upon those viru- 
lent cases with a short incubation period, its use 
should not be discouraged. Needless to say, the 
antitoxine should always be used reasonably fresh. 

Some surgeons have employed a solution of 
magnesium sulphate as an antitetanic remedy with 
marked success in many instances. Like antitoxine, 
it is administered by injection into the cerebro- 
spinal axis. However, it should not be accepted 
as a substitute for antitoxine. 



To palliate the paroxysmal exacerbations, anti- 
spasmodics and hypnotics are useful. Chloroform 
inhalations and 5 -grain doses of chloretone have 
the most favorable action, especially if re-enforced 
with quarter-grain hypodermic doses of morphine. 
The patient should be confined to bed in a dark 
room and fed through a soft-rubber catheter passed 
into the pharynx through the nose. Catheterization 
and enemata are usually necessary to relieve the 
retention of urine and feces. There can be no 
objection to the adoption of other therapeutic 
measures that may be required. 



Classification : 




1. First degree: simple hyperemia. 

2 . Second degree : dermatitis with vesication. 

3. Third degree: eschars, gangrene and 
carbonization, involving subcutaneous 

1. Contact with flames and intense heat. 

2. Contact with hot liquids or steam (scalds). 

3. Contact with electric currents. 

4. Prolonged exposure to solar rays. 

5. Lightning stroke. 

6. Rontgen ray burns. 

7. Chemical (concentrated acids and caustic 
alkalies) . 

The extent of the destruction of tissue depends 
upon the temperature of the radiant heat, duration 
of contact, superficial diffusion of the heated object 
or fluid, and density of the area burned. In severe 
cases, the constitutional effects are pronounced 
and the alleviation of these associated conditions 
is of even more importance than the local treatment 
of the burn itself. Shock and nephritis are almost 
constant concomitant factors, and suppuration, 
sepsis and secondary hemorrhage not infrequent 
ones. The symptoms may be: (i) pain, (2) rest- 
lessness, (3) frequent micturition, (4) cold extremi- 



ties, (5) small and rapid pulse, (6) persistent thirst, 
(7) edema, (8) prostration, (9) collapse and (10) 
unconsciousness. If a large surface is burned or 
scalded, the excretory function of the skin is mark- 
edly impaired and it is necessary for the kidneys 
to compensate for the sudden diminution in toxic 
elimination by the skin. Being often unable to im- 
mediately cope with this emergency, congestion and 
nephritis soon follow. In fact, it has been stated, 
and confirmed by experience, that even burns of 
the first or second degree extending over one-third 
or more of the body surface interfere with the ex- 
cretory function of the skin to such an extent that 
these cases rarely recover; the majority die of shock 
within twenty-four hours. Burns of the third degree 
are also influenced by the extent of the region 
destroyed and the depth to which the tissues are 
disorganized. Although the patient may frequently 
lose consciousness and later regain his mentality, 
instantaneous death, from the arrest of cardiac and 
respiratory action, is a common occurrence from 
contact with heavily charged electric wires and 
lightning. Traumatic neuroses occasionally follow 
these injuries. An ^-ray bum is a peculiar lesion 
in itself, characterized by a stubborn dermatitis, 
ulceration of the skin, and painful and tedious re- 
covery. If extensive, amputation may be necessary. 
A number of deaths have occurred as the result of 
frequent or prolonged exposure to the x-rsij, but 
with universal recognition of its dangers, improved 
technic and restriction of its use to those skilled 
in its application, these injuries are now infrequently 


observed and before long should become a rarity. 
The mortality from burns is particularly high in 
infants and young children. 

Local Treatment of Bums. — ^The local applica- 
tions appropriate in a given instance will vary ac- 
cording to the severity and extent of the burn. 

The pain incident to bums of the first degree is 
immediately relieved by applications of a saturated 
solution of either sodium bicarbonate or picric acid. 
Several layers of gauze should be saturated with the 
solution and wrapped around the burned area. 
Later, dressings of petroleum ointment may be sub- 
stituted. Since burns of the first degree leave no 
scar, they are of relatively small consequence. Bums 
due to exposure to the sun are best treated with 
applications of bicarbonate of soda solution, followed 
by some simple emollient, such as vaseline or almond 

Burns of the second degree are nearly always 
accompanied by the formation of vesicles or blebs 
and to avoid injuring them the clothing should be 
carefully cut away. Exposure to air is to be avoided 
and one area should be dressed before another is im- 
covered. Asepsis will thus be maintained and a 
rapid uncomplicated recovery will ensue. The sur- 
face maybe cleansed by gentle irrigation with warm 
sterile water and the belbs punctured at their base 
tvith a sterile needle to allow the extravasated 
serum to escape. The epidermis, however, should 
not be disturbed or removed, since it protects the 
denuded papillae. Burns of this class are often 
infected through careless technic and asepsis is im- 



portant. There exists some difference of opinion 
regarding the applications to be employed in these 
cases. Various writers have claimed good results 
from the sole use of either dusting powders, emol- 
lients or wet dressings. All are of value under certain 
conditions but no single one should be utilized to the 
exclusion of the others. Given, a recent uninfected 
bum with preservation of the epidermis, a mixture 
of one part acetanilid and three parts boric acid, 
dusted in a thick layer over the burn and covered 
with gauze, will prevent infection and promote 
rapid recoveiy. These dressings should be left 
undisturbed as long as possible. If the burn is 
extensive and the belbs have already ruptured, 
leaving numerous raw surfaces, carron oil (a mixture 
of equal parts of lime water and raw linseed oil) 
will relieve the pain and soothe the irritation follow- 
ing the contact with air. This is the remedy most 
often employed in emergency work and is indeed an 
excellent temporary dressing. Later on, the margins 
of the belbs may be trimmed, extraneous material 
removed and the denuded surfaces carefully dried by 
sponging with sterile gauze and mopping with 
tincture of iodine, and a 10 per cent, ointment of 
boric acid applied. A 5 per cent, ointment of ich- 
thyol is also frequently used but is inferior to the 
boric acid, except in the presence of inflammation. 
When epidermization begins, the U. S. P. ointment 
of zinc oxide should be substituted. If a bum does 
not present for treatment until considerable time has 
elapsed and the area is already infected, wet dress- 
ings are of service. Fomentations of Thiersch's 


solution^ or normal saline solution should be con- 
stantly applied until the granulations become 
healthy, and then followed by the boric acid oint- 
ment. The indications for redressing burns are: 
(i) rise of temperature, (2) local pain, (3) odor and 
(4) soiled dressings. The treatment of burns by 
omitting all coverings except a dusting powder, 
thereby constantly exposing the surfaces to the air, 
and frequent mopping of the extruded sei^um has 
been recently advocated. The results in the few 
cases in which the author has employed this method, 
however, have not been encouraging. 

Burns of the third degree are always dangerous 
injuries because subsequent sloughing is profuse and 
complications are the rule. Electric burns are 
almost invariably of this class and are characterized 
by absence of pain and slow healing. While com- 
bating the constitutional effects and complications 
is of paramoimt importance, this dictum must not 
be construed to excuse neglect of the local treatment. 
The objective points are to secure rapid separation 
of the slough and prevent sepsis. The constant 
warm bath (100° F.) of normal saline solution, which 
has been more widely employed abroad than in 
this coiintry, is an efficient method of treatment. 
It should be continued until healthy granulations 
appear. Dressings of equal parts of balsam of Peru 
and glycerine likewise hasten separation of the slough 
in restricted areas. The dressings should be changed 

' Thiersch's solution: 

Salicyhc acid 3 ss 

Boric acid 3 iii 

Sterile water O ii 


daily and the wound irrigated with hydrogen per- 
oxide. As the shreds of necrotic tissue loosen, they 
may be excised with scissors. Iodine is then dropped 
into the wound to cleanse it. When granulation be- 
gins, the surfaces should be touched with a i per 
cent, solution of copper sulphate, to stimulate the 
regeneration of tissue. As the healthy tissue ap- 
proaches the surface, healing will be accelerated and 
cicatricial contraction obviated by employing 
Thiersch's skin-grafts or transplanting skin-flaps. In 
addition, the position which puts the surface of the 
part on the stretch wih tend to diminish the skin 
deformity by temporarily enlarging the surface. 

Burns due to chemical agents, such as strong acids 
and alkalies, must be treated by the chemical antidote 
for that which has produced the excoriation. Weak 
alkalies are indicated in burns due to acids, and 
vice versa. 

X-ray bums, if painful and extensive, usually 
require excision of the ulcerated areas or amputation, 
as they are absolutely resistant to ordinary methods 
of treatment. Curettage of the ulcers, followed by 
skin-grafting, will occasionally cure. 

Obviously, any burn sufficiently severe to destroy 
the blood supply and bone of a part necessitates 

Treatment of the Constitutional Effects and Com- 
plications of Burns. — In all cases of burns the indi- 
cations are: (i) to relieve pain and overcome shock, 
(2) to guard against visceral congestion, and (3) to 
counteract the exhaustion incident to continual 
pain and suffering or sepsis. 


All cases of extensive burns should immediately 
receive sufficient morphine hypodeimatically to re- 
lieve pain. One quarter of a grain usually alleviates 
pain, supports the heart, and quiets the patient, 
but it may be repeated as often as necessary. It 
should not be combined with atropine as the latter 
arrests glandular activity. The patient should be 
placed in bed, surrounded with hot water bottles and 
kept absolutely quiet. All severe burns are accom- 
panied by marked shock and every effort should be 
made to establish reaction as soon as possible. For 
details, the reader is referred to the chapter on 
surgical shock. In cases of electric shock, artificial 
respiration and hypodermic injections of strychnine 
and atropine should be employed. 

Inflammation of any of the viscera may occur and 
give rise to alarming symptoms. Of the involve- 
ments, renal congestion appears first and is evidenced 
by albuminuria, as well as the other urinary findings 
of nephritis. The most efficient remedy in such con- 
ditions is 2 drams of liquor ammonii acetatis, 
administered in a half a glass of ice water every 
two hours. This relieves thirst, promotes diuresis 
and depletes the congestion. Constipation is not 
imusual and is ordinarily relieved by some simple 
laxative, such as castor oil. Inflammation and 
ulceration of the gastro-intestinal mucosa is fre- 
quently but another manifestation of visceial con- 
gestion and may be followed by diarrhea, perforation 
and death. In such cases, opium, gallic acid, bis- 
muth and other intestinal astringents are ser- 


Many patients who survive the initial shock 
accompanying a severe burn will die later of exhaus- 
tion. For instance, it is not unusual for a case of 
third degree electric burn of the back to apparently 
progress favorably for a week or more and then 
slowly die of exhaustion. The indications are: 
to (i) allay pain with repeated hypodermic injec- 
tions of morphine, (2) maintain asepsis of the in- 
jured area, (3) hasten sloughing and repair, (4) guard 
against complications, such as nephritis, pneumonia, 
vomiting, diarrhea and cerebral congestion, and 
(5) support the patient's vitality with a nutritive 
diet and suitable tonics. 


While not properly within the domain of surgery, 
insolation and heat exhaustion so frequently pre- 
sent as emergencies, particularly to the ambulance 
surgeon, that their consideration here may not be 
amiss. It is of the utmost importance to differen- 
tiate these two varieties of sunstroke, as the former 
represents a disturbance of the heat regulating centers 
due to the toxemia from the excessive heat, while 
the latter depends on a vasomotor paralysis with 
marked circulatory disturbances in the brain and 
body surface. The treatment appropriate for one 
is practically that which is contra-indicated for the 
other. To distinguish between the two, the follow- 
ing phenomena should be observed : 




Patient insensible. 

Coma; sometimes delirium 
and convulsions. 

Face flushed. 

Skin dry and burning. 

Respirations rapid and shal- 

Pulse rapid and full. 

Temperature 105° to 110° F. 


Prognosis guarded 

of glandular 

Heat Exhaustion. 
Patient dazed. 
Weakness and prostration; not 

Face pale. 
Skin cool. 
Respirations stertorous. 

Pulse rapid and feeble. 
Temperature normal or sub- 
Perspiration increased. 

Prognosis good. 

Treatment of Sunstroke.- -In all cases of insolation 
a gag should be inserted between the jaws, to prevent 
the patient from biting his tongue. In emergencies, 
a wooden wedge will answer the purpose . The hyper- 
pyrexia must be reduced as rapidly as possible and 
hydrotherapy will accomplish this better than any- 
thing else. Clothing should be removed and the 
patient placed in a cold water bath at a temperature 
of about 75° F., with an ice bag applied to the head. 
Ice should be gradually added to the water until a 
temperature of 50° F. is reached. Restlessness and 
convulsions may require morphine. When the pa- 
tient is returned to bed, he should be enveloped in a 
cold pack with a hot-water bottle at the feet, and cold 
(70° F.) saline enemata may be given to prevent 
subsequent recurrence of fever. Antipyrine and 
blood-letting will also often prove useful. Should 
the patient recover, he must be warned as to his 
inability to withstand high temperatures during the 
rest of his life. 


The treatment of heat exhaustion is essentially 
that of mild shock. The patient should be placed in 
bed, surrounded with hot water bottles and covered 
with warm blankets. Ammonia, strong coffee and 
hypodermic injections of adrenalin chloride are the 
most efficient stimulants. 


Chilblain is a condition following exposure to in- 
tense cold and is characterized by pruritis, local con- 
gestion and a tendency to teiTninate in gangrene. 
It is due to a too sudden application of heat following 
the freezing of the part, occasioning an unduly rapid 
reaction. "Frost-bite" has been used as a synony- 
mous term but its use should be restricted to designate 
the initial freezing of the tissues only. The consti- 
tutional effects of exposure to intense cold are often 

Treatment of Chilblain. — The general effects of cold 
should be combated by overcoming the general de- 
bility and improving the circulation, by friction and 
artificial respiration. The best method of local treat- 
ment for chilblain is prophylactic and this consists of 
avoiding contact with heat, rubbing the chilled parts 
with snow or cold water and gradually raising the 
surrounding temperature until the natural color is 
restored, thereby establishing a slow reaction. The 
frozen areas may be covered for a time with cloths 
soaked in cold water. If the surfaces are not 
abraded, the skin should be painted with equal parts 
of tincture of iodine and tincture of opium, or an oint- 
ment of ichthyol and lanoline applied. If blebs 


form, they should be punctured. For broken chil- 
blains, Gardiner recommends the following ointment : 

Hydrargyri ammoniati . gr. v 

Ichthyolis ttl x 


Zinci oxidi • aa 5 ii 

Petrolatum , § ss 


If the tissues become gangrenous, the treatment 
should be based on general principles. It will oc- 
casionally be necessary to amputate a portion of an 
extremity. Massage and suitable exercises are use- 
ful in the after-treatment. 



An ulcer is an excavated loss of continuity upon 
the body surface, a circumscribed area being denuded 
of its covering, characterized by evidencing no tend- 
ency to heal. The term "ulceration" as applied to 
the disorganization of tissue and granulating wounds 
is a misnomer. Strictly speaking, a granulating 
surface is not an ulcer and, in fact, as soon as a true 
ulcer commences to heal, it ceases to be an ulcer. 
Ulcers occur most frequently on the leg and are in- 
variably the result of interference with the circula- 
tion, the etiological factors being varicose veins, 
traumatism or constant pressure. Tubercular and 
syphilitic ulcers are but ordinary manifestations of 
the diseases themselves and their cure depends more 
upon appropriate systemic treatment than upon 
local measures. 

For convenience, a varicose ulcer of the leg will be 
taken as an example of the usual type of ulcer. Such 
ulcers are frequently encountered in hospital and 
dispensary practice and, because they so tax the 
physician's ingenuity and skill, are generally treated 
with scant courtesy or entirely neglected. To no 
other cause can the average physician's indifference 
to these cases be ascribed. The usual picture pre- 


senting is a large sore, of irregular outline, with 
thick, infiltrated and dusky edges and an indurated 
base, which is often covered with a thin white layer 
of tenaceous necrotic tissue. Although a chronic 
condition, an ulcer may suffer exacerbations of more 
or less acute inflammation. Should it become puru- 
lent, suppuration, sloughing and even cellulitis may 

Treatment of Ulcers. — The multiplicity of methods 
of treatment recommended for the cure of indolent 
ulcers by various writers is a fair indication that no 
single one always proves satisfactory and efficient. 
While certain well defined rules may be formulated, 
the surgeon must exercise his judgment and com- 
mon sense in each case to obtain universally grati- 
fying results. Each step in the treatment should be 
carried out with a definite object in view and advance 
can be made upon the previous fiiTQ foundation 
only : 

1. Improve the local circulation. 

2. Cleanse the ulcer and surrounding skin. 

3. Subdue inflammation. 

4. Remove necrotic tissue from the surface of the 

5. Promote absorption of the induration. 

6. Stimulate granulation. 

7. Support the part with equalized pressure. 

8. Encourage cicatrization. 

9. Have the patient w^ear a permanent support. 

10. Improve the patient's general condition. 

To improve the circulation, the patient should be 
confined to bed or a chair and the leg elevated. Un- 


fortunately, however, it is rare that the patient will 
obey these instructions, as he can illy afford to neg- 
lect his occupation. 

If all surgeons would use soap and water with the 
regularity with which they employ antiseptics, the 
latter could often be dispensed with and healing 
would occur much more rapidly. The ulcer and sur- 
rounding skin should be vigorously scrubbed with 
a soft brush or gauze wipe. After drying thoroughly, 
the part should be rubbed with alcohol to loosen 
scales of dried discharge and devitalized skin. 

If inflammation is present, it can be reduced by 
daily applications of large wet dressings of Thiersch's 
solution or aluminum acetate, covered with a firm 
gauze bandage. Asepsis may be secured by paint- 
ing the ulcer with tincture of iodine at each dressing. 
The gauze must be kept constantly wet until the 
inflammation is subdued. If, however, there is no 
evidence of inflammatory reaction and the ulcer is 
dirty and foul, it should be cleaned up by dressing 
with balsam of Peru for a few days. The constant 
warm bath by immersion in hot saline solution, as 
described in -the treatment of burns, is another excel- 
lent method of treatment. 

The necrotic layer often observed on the surface of 
an ulcer is most easily removed by dissecting off with 
thumb forceps and scissors, followed by delicate 

Absorption of the indurated tissues at the base and 
margins of the ulcer is best accomplished by criss- 
cross incisions, carried well through the cicatricial 
tissues at the base and edges. Alternate hot and 


cold douches and massage are useful adjuncts to the 

As soon as the inflammation abates and the ulcer 
presents a "clean" appearance, the leg should again 
be cleansed with soap and water and shaved from 
ankle to knee. The ulcer should be sprinkled with 
a generous layer of powdered naphthalin crystals to 
stimulate granulation and then covered with a layer 
of lint spread with diachylon ointment. 

These applications should be left undisturbed for 
about ten days, meanwhile exerting constant equal- 
ized pressure over the whole surface of the part. 
This is best done by strapping from ankle to knee, 
from below upward, with zinc oxide adhesive plaster 
strips, three-fourth of an inch wide and long enough 
to completely encircle the leg with overlapping of the 
ends. The edges of each strip should overlap the 
preceding one (Fig. 20). When complete, the dress- 
ing should be covered with a firm bandage or an 
elastic stocking. To remove the dressing, saturate 
it with gasoline, cut from below upward, and strip 
off in one sheet. If the granulation tissue is still 
some distance from the skin surface, another similar 
dressing may be applied for the next week. As soon 
as the granulations approach the surface, however, 
the ulcer should be irrigated with saline solution and 
Thiersch's skin-grafts spread upon its surface. Ex- 
uberant granulations are easily removed by touching 
with stick silver nitrate. The grafts must overlap 
each other and the skin margins and should be covered 
with several layers of silver leaf. The leg is re- 
strapped for two or three weeks, protecting the area 



of the ulcer by smearing the superimposed strips 
with vaseline. This dressing must be removed very 
carefully and the ulcer will then be found to be 

Fig. 20. — Strapping a leg ulcer. 

The patient should be instructed to wear a firm 
elastic stocking continuously, protecting the delicate 
skin by wearing a white silk or cotton stocking 
underneath the elastic one. Johnson recommends 


sewing four or five ordinary dress stays at varying 
intervals around the top of the stocking to prevent 
rolling downward, if the stocking is one that reaches 
to the hip. When the rubber begins to stretch from 
constant use, it should be replaced with a new 

Throughout the course of local treatment the 
patient's general condition should receive careful 
attention. The emunctories must be kept active 
and tonics supplied in the form of fresh air and nutri- 
tious food. Nux vomica, mercury, arsenic and 
potassium iodide may be administered with benefit. 


Bed-sores aie localized areas of gangrene due to 
the circulatory stasis following continued pressure 
on the skin. Their production is favored by (i) 
the continuous pressure exerted by the stationary 
position of the patient's body, (2) arteriosclerosis, 
(3) debility, (4) advanced age, (5) imperfect inner- 
vation and (6) the presence of irritating bodies and 
secretions. Bed-sores most often occur over the 
sacrum and scapulae and are particularly common 
in spinal affections and wasting diseases. In fracture 
cases, the long continued or faulty application of 
splints or plaster-of-Paris dressings may cause pres- 
sure sores which are identical with bed-sores. 

Competent nursing usually prevents the develop- 
ment of bed-sores and in all instances in which the 
patient is confined to bed for any length of time the 
following precautions should be observed : 


1. Change the position of the patient frequently, 
to avoid constant pressure on any one region. 

2. Bathe the entire body surface daily and follow 
with an alcohol sponge. If washing with soap and 
water is impracticable, the patient can at least be 
sponged with alcohol. 

3. Keep the bed scrupulously clean, frequently 
brushing the sheets free of cnimbs, etc., and keeping 
them dry and smooth. If the bedding becomes soiled 
with perspiration, urine or feces, it must be changed 

4. The water-bed and air cushions should be used 
in suitable cases from the beginning. It is not neces- 
sary to wait for areas of congestion to appear. 
Chamois skin, applied with its softer side to the 
area of skin affected or threatened, will also be 
found useful in the prevention of bed-sores. 

5. The areas that are unavoidably subjected to 
pressure and which cannot be comfortably sup- 
ported with a circular air cushion should be protected 
by placing cotton-wool or leather-backed adhesive 
plaster under them. 

6. Glycerite of tannin, rubbed in twice daily, 
will harden the skin. 

If the parts exposed to pressure commence to show 
signs of congestion, they should be sponged with a one 
in eighty solution of creosote in alcohol, carefully 
dried and generously dusted with zinc oxide powder. 
Applications of a 5 per cent, solution of silver nitrate 
are also serviceable at this stage. When the skin 
has broken down and the bed-sores have actually 
formed, they should be covered with a moist gauze 


dressing of aluminum acetate. Each day when the 
dressings are renewed, the visible sloughs should be 
removed and the surface painted with a 2 per cent, 
solution of silver nitrate. After the sloughs have 
separated and healing progresses, the dressings should 
consist of balsam of Peru or boric acid ointment. 


All extraneous material entering or becoming 
embedded in the tissues must be considered foreign 
matter. Foreign bodies may consist of practically 
any substance and in size may vary from infini- 
tesimal particles to large masses. The presence of 
foreign bodies in the tissues is an item of importance, 
because of the mischief they may cause. Excep- 
tionally, a patient may be unaware of the entrance 
and presence of a foreign body, it may become 
encysted and remain in the tissues for a long period 
without arousing his suspicion. Contrariwise, foreign 
bodies may give rise to (i) irritation, (2) pressure, 
(3) erosion, (4) infection, (5) sloughing, (6) secondary 
hemorrhage, and (7) interference with healing, usually 
in the order mentioned. As a rule, the longer they 
are left undisturbed, the more difficult their subse- 
quent extraction or removal and the more serious the 
consequences. Moreover, foreign bodies have a ten- 
dency to migrate, because muscular contraction and 
the elasticity of the tissues push them on, tmtil after a 
lapse of time they will often be found far from the 
original point of entry. It is therefore obvious that 
all extraneous material should be removed as early 
as possible. 

Foreign bodies must be accurately located prior 
to any attempt at removal. Inspection, palpation, 



gentle sterile probing and radiography are the most 
reliable methods for ascertaining their exact situa- 
tion. It must be remembered that a single x-vslj 
view is deceiving, since it affords no information as 
to the exact depth to which a foreign body has pene- 
trated. The examination should include both an 
antero-posterior and lateral view. The fiuoroscope 
may be employed to determine whether or not a 
foreign body moves simultaneously with the soft 
structures, as, for example, it invariably does when 
embedded in a tendon. 

To remove foreign bodies, the most efficient means, 
in order of their advantage, are: (i) irrigation, 
(2) sponging, (3) the use of forceps and curette 
(preceded by incision, if necessary), and (4) magnet- 

Foreign Bodies in Subcutaneous Tissues. — The 
majority of foreign bodies enter the subcutaneous 
tissues through an open wound and their removal 
is usually a simple procedure, except in punctured 
wotmds. The lattei are produced by sharp-pointed 
objects, the slightest fragments of which, if remain- 
ing in the tissues, may cause more difficulty in re- 
moval than the appearance of the wound would 
indicate. The subsequent contraction of the skin 
aperture or even its union per primam may cause the 
operator much annoyance. 

After having precisely located the foreign body, 
the overlying skin is anesthetized and incised. The 
incision should be sufficiently extensive to permit 
thorough search. An incision that is too small is 
worse than useless, since blind efforts at extraction 



only result in pulling up shreds of tissue and may 
push the foreign body still deeper into the tissues. 
The best course is to wait until the object becomes 
visible before attempting its removal. It should 
then be firmly grasped with forceps and carefully 
withdrawn. When the object is a long, slender, 
sharp-pointed body, Quain recommends that an inci- 
sion be made some little distance from the foreign 
body, so that it may be grasped with forceps at right 
angles to its longitudinal axis and then pushed out 

Fig. 21. — ^Quain's method of removing a deeply embedded foreign 
body through an incision at the point of entrance, by introducing forceps 
through a second incision. 

through another smaller incision at the point of en- 
trance (Fig. 2i). If a foreign body is embedded be- 
neath a nail and does not project sufficiently to per- 
mit easy extraction, the nail may be painted with 
liquor potassas and the softened surface scraped off, 
until the remaining nail is as thin as paper. It 
may then be incised, elevated and the foreign body 

Foreign bodies in the eye may vary from a small 


particle of dust to a splash of molten metal and usu- 
ally lodge in the conjunctiva or become embedded in 
the cornea. They are not infrequently associated 
with burns, particularly if the offending substance is 
of a caustic nature. Although immediate removal 
is imperative in all these cases, when foreign bodies 
have penetrated to some portion of the eye other 
than the conjunctiva and cornea, dislodgment should 
be attempted by those solely who have had special 
ophthalmological training. Efforts of the inexperi- 
enced to remove foreign matter from the deeper 
structures of the eye are usually futile and the sight 
may be jeopardized by injudicious treatment. The 
nervous sensibilities and structure of the eye are so 
delicate that none but the simplest cases should be 
be treated by the general surgeon. Two or three 
minims of a 4 per cent, solution of cocaine hydro- 
chlorate dropped into the eye will facilitate inspec- 
tion and removal by relieving the pain and spasm 
and abolishing the reflexes. The lower lid should 
first be drawn downward and the patient directed to 
look up. This exposes the conjunctival folds and 
the surface may be examined by oblique illumination. 
The surface of the cornea should next be scrutinized 
through a magnifying lens, allowing the rays of light 
to play over the surface. Lastly, the upper lid should 
be everted over a probe, with the patient looking 
downward, and the tarsal folds carefully inspected. 
As soon as the foreign body is detected, the surface 
on which it lies should be brushed with a little cotton 
on an applicator, dipped in boric acid solution. If 
this fails to remove it, the foreign body being deeply 


embedded, it will be necessary to lift it out gently 
with a sterile spud. Small bits of metal occasionally 
become jammed in the conjunctiva or sclera. In 
these cases the proximity of a powerful electric mag- 
net is usually sufficient to remove them. Sometimes 
a patient will complain of the presence of a foreign 
body in the eye when none can be detected. This is 
due to irritation, which often persists after extrane- 
ous material has been spontaneously removed. 
Having eliminated the foreign material, the eye 
should be flushed with a warm boric acid solution and 
soothed with a drop of pure castor oil. When a 
chemical bum also exists, it should be neutralized, 
sterile olive or castor oil being afterwards dropped 
into the eye and cold wet compresses applied. 

Foreign bodies in the external auditory canal may 
consist of animate or inanimate objects. The ani- 
mate objects should be killed by dropping a little 
sweet oil in the ear, after which they may be removed 
by syringing copiously. When syringing, the stream 
should be directed along the roof of the canal, so that 
the return flow will be as forcible as possible. Occa- 
sionally it will be necessary to hook behind the foreign 
body with a wire loop, scoop, or a hooked probe, but 
forceps should never be employed. Foreign bodies 
of a vegetable nature swell when immersed in water 
and therefore cannot be removed in the ordinary 
way. A little alcohol, however, dropped into the ear 
and permitted to remain for a few minutes will shrink 
them, after which they may be syringed out with 
more alcohol. Syringing is the safest method of re- 
m.oving all foreign bodies from the auditory canal and 


should be continued until their removal is effected. 
If instinimentation is absolutely necessary (very rare) , 
the manipulations should be deliberate but exceed- 
ingly gentle. Meningitis has resulted from unskilled 
efforts to remove foreign bodies from the ear. 

Foreign bodies in the nose are often difficult to 
detect, because they may remain in the nose for some 
time without attracting the patient's attention. 
A discharge resulting from inflammation or pres- 
sure necrosis may be the first manifestation of the 
presence of a foreign body. This can usually be lo- 
cated with a probe and may be removed by hook- 
ing behind it with a scoop or wire loop. Another 
efficient method of removal is to push the foreign 
body back to the pharynx. When this is done, the 
patient's head must hang down, to prevent the dis- 
lodged foreign body dropping into the larynx. In 
struggling children, removal is often attended by 
dangers from traumatism and by occasional failure. 
An ingenious procedure in such instances is to hold one 
hand over the patient's mouth and insert one end of a 
piece of rubber tubing snugly into the free nostril. 
The other end of the tubing is held in the mouth of 
the operator. A sudden, vigorous expiration through 
the tube will frequently dislodge the foreign body. 
Sometimes it is necessary to narcotize children before 
attempting removal. 

Foreign Bodies in the Pharynx, Larynx and Tra- 
chea. — The entrance of foreign bodies into the air 
passages is an accident of frequent occurrence and 
usually produces symptoms of alarming urgency. 
When located in the pharynx, they are easily removed 


by illuminating the region in which they lie and 
extracting with curved forceps. The ordinary pro- 
bang is of slight value, as it usually scratches and ir- 
ritates the mucous membrane without removing the 
object. Induration and abscesses are not rare se- 
quelae in these cases, hence the entire surface should 
be closely searched. Foreign bodies may become 
impacted in the larynx or inspired through it into 
the trachea and, unless promptly removed, dyspnea, 
cyanosis, asphyxia and death speedily ensue. A 
foreign body may sometimes be felt and displaced by 
thrusting a finger down the throat. If this is not 
feasible, an opening should be instantly made into 
the cricothyroid membrane. Since the immediate 
admission of air to the lungs is the important factor, 
rather than the actual removal of the foreign body 
itself, laryngotomy is recommended instead of trache- 
otomy, because the urgent symptoms are usually 
found in the cases where the foreign body is impacted 
in the glottis, tracheotomy requires more time, and 
laryngotomy is the safer in inexperienced hands. 
Should subsequent tracheotomy be necessary for 
extraction, the laryngotomy offers no impediment 
to its perfomiance. Artificial respiration is fre- 
quently a useful adjunct in relieving the suffocation. 
Having again induced respiration, efforts should 
be made to ascertain the position of the obstruction. 
Careful laryngoscopic examination may reveal the 
location of the foreign body and it may then be re- 
moved with laryngeal forceps. It may often be dis- 
lodged by inverting the patient and slapping him on 
the back. This, however, is a dangerous procedure, 


unless laryngotomy or tracheotomy has been per- 
formed, as the body may impact in the vocal cords 
and again suffocate the patient. 

Foreign Bodies in the Esophagus. — Large masses 
of food, coins, buttons, false teeth and pieces of bone 
may be swallowed accidentally and lodge in the 
esophagus. If the foreign body has remained for 
some time, it may cause a variety of symptoms: 
dysphagia, pain, tenderness, reflex cough, eleva- 
tion of temperature, hemorrhage or emaciation. 
On the contrary, it may produce little or no dis- 
comfort. The dangers of permitting a foreign body 
to remain in the esophagus are : (i) pressure necrosis, 
(2) perforation, (3) peri-esophageal abscess, and (4) 
starvation. Occasionally a patient will swallow 
something that will wound the esophagus and he will 
experience the sensation of a foreign body being 
present. The history is usually indefinite and of 
little diagnostic value. The most valuable means 
of determining the presence or absence of a foreign 
body is an x-vsiy picture. It can also usually be 
detected by passing an esophageal bougie. Unless 
promptly removed, the prognosis may be serious; 
death may occur form starvation, sepsis or ulcera- 
tion into the aorta. Foreign bodies generally lodge 
behind the larynx or near the cardiac orifice of the 
stomach, these being the points at which the lumen 
of the esophagus is narrowest. 

If situated high up, a foreign body can sometimes 
be hooked up with the forefinger or removed, through 
the mouth, with forceps. A large bolus of food, 
swallowed quickly, may carry it into the stomach. 


If it is known that the foreign body is not sharp, 
the patient may be caused to vomit by tickling the 
back of the throat and the foreign body may be 
projected. This, however, is a dangerous procedure 
if the object is sharp. A useful device is the ordinary 
horse-hair probang, which is introduced closed, 
passed beyond the foreign body, opened and with- 
drawn . When it is necessary to use the ' ' coin-catcher' ' 
or long curved forceps, the instrument employed 
must be manipulated with great care. It is prudent 
to utilize the fluoroscope when attempting instrumen- 
tal extraction, as perforation of the esophagus is very 
easy when ulceration already exists and is an exceed- 
ingly dangerous accident. When the foreign body is 
located near the cardiac orifice, it can occasionally 
be pushed into the stomach with the blunt end of a 
stomach tube. The esophagoscope is a valuable 
instrument for the detection and extraction of a 
foreign body. When used for this purpose, after 
cocainizing the pharynx, it should be introduced 
under the guidance of the operator's eye and without 
the obturator. As soon as the foreign body becomes 
visible, it is seized and withdrawn with forceps. 
The esophagoscope is a dangerous instrument, 
however, in inexperienced hands, as the slightest in- 
accuracy may cause injury of the mucous membrane 
or pref oration of an area of ulceration. A cervical 
peri-esophageal abscess is an absolute contra-indica- 
tion to the use of the esophagoscope. If all other 
methods fail, an esophagotomy or gastrotomy must 
be performed. 




Surgical shock is a series of events or an assem- 
blage of phenomena caused by injury, characterized 
by a persistent depression of arterial tension, due 
to loss of vasotonic or vasomotor activity, thereby 
giving rise to venous stasis in the large internal 
veins, with a subsequent nervous exhaustion of the 
cardiac and respiratory centers and cerebral anemia. 
In other words, shock is a symptom complex, the 
essential phenomenon of which is reduced blood 
pressure. The terms shock, collapse, and syncope 
are often confused and used interchangeably. In 
fact, some writers maintain that collapse is merely 
a mild foiTn of shock. The latter, however, is a 
simultaneous suspension of function rather than a 
true exhaustion of all the nerve centers and is caused 
by actual loss in volume of the blood (hemorrhage) ; 
by oxy-hemoglobin starvation. Synocope (fainting) , 
on the other hand, is but a temporary cerebral 
anemia, induced by a momentary hyperemia, else 
where, thus disturbing the normal blood pressure 
equilibrium, which is rapidly and spontaneously re- 
stored. It is to such later investigators as Crile, 
Gushing, Wainwright and others that we are indebted 
for experimental work on shock in physiological 



laboratories and clinical practice and every student 
should inform himself regarding recent research 
work in this field, on which studies the logical con- 
sideration and rational treatment of shock are based. 
The subject is one of such magnitude that it is 
obviously beyond the confines of this volume. 
In shock, all vital centers suffer primary hyperten- 
sion but the vasomotor center soon becomes ex- 
hausted, lowering the blood pressure, with exhaus- 
tion of the cardiac, respiratory and other centers, 
subsequently causing a cerebral anemia due to loss 
in circulatory force. In collapse, the centers are 
not primarily stimulated but directly depressed by 
the actual loss of blood, and all centers are depressed 
simultaneously. The longer the hemorrhage con- 
tinues the longer will the suspension of functions exist. 
Consequently, the return to normal depends upon 
the restoration of the volume of blood. 

Causes of and Factors Predisposing to Surgical 
Shock and Collapse : 


I . Trau- 



Accidental injury. 

Rough handling of tissues. 
Susceptibility of certain 
structures (periosteum, 
peritoneum, etc.) 
Exaggerated nervous im- 
pulses (from severing 
large nerves, etc.). 
Prolonged operating. 
Burns and scalds. 
Psychic disturbances (fear). 
Excessive anesthesia. 
Loss of vital heat. 
Infantile, diseased, feeble and aged subjects. 



TT , f Accidental. 

Hemorrhaee < t .j ^ , 
1 incidental. 

Sudden withdrawal of large quantities of fluid 

(ascites, etc.). 

Manifestations of surgical shock and collapse 

may develop suddenly or appear gradually. The 
symptoms of shock are: (i) prostration, (2) pallor, 
(3) pale lips, (4) dull and staring eyes with dilated 
pupils, (5) clammy, moist skin, (6) cold extremities, 
(7) frequent, feeble and irregular ("thready" or 
imperceptible) pulse, (8) marked reduction of blood 
pressure, (9) feeble respiration, (10) muscular 
relaxation, (11) subnormal temperature, and (12) 
occasionally relaxation of the sphincters of the blad- 
der and rectum and (13) nausea and vomiting. The 
patient's mentality may vary from perfect retention 
of the senses to absolute insensibility. The evi- 
dences of collapse are essentially those of shock 
with three notable additions: persistent thirst, 
restlessness and air-hunger. In diagnosis, the history, 
nature of the injury and a blood examination should 
all be considered. Oligocythemia (a red cell count 
of 3,500,000 or less) and diminished hemoglobin 
suggest collapse from hemorrhage rather than shock. 
Of course, it is not unusual to observe an association 
of both shock and collapse in the same subject. 
Assuming the normal blood pressure to lie between 
120 and 140 mm. Hg., a pressure of 100 mm. may 
be considered indicative of mild shock, at or below 
90 mm, medium and at or below 70 mm. profound 
shock. The concensus of opinion seems to be that 
if profound shock once becomes firmly established, 


it is irremediable. In these cases the mechanical 
effect of appropriate treatment may raise the blood 
pressure temporarily but a tine reaction is not ef- 
fected and secondary shock invariably follows. An 
accurate sphygmomanometer is an indispensable in- 
strument and should be employed in all cases of 
shock and collapse. 

Prevention of Surgical Shock and Collapse. — 
With a knowledge of the predisposing and exciting 
causes of these conditions, it is obvious that much 
can be done in some instances to prevent or limit 
their development, and to avoid their many vicious 
sequels. Unfortunately, those cases resulting from 
accidental injury are beyond the surgeon's control, 
hence prophylactic measures can be applied in opera- 
tive cases only. These will consist of: (i) prelimi- 
nary stimulation, (2) allaying the patient's fears, 
(3) a preliminary hypodermic injection of morphine 
and atropine, (4) maintaining the body heat, (5) 
perfect technic, (6) avoiding prolonged exposure 
and rough handling of sensitive tissues, (7) exact 
hemostasis, (8) operating expeditiously, and (9) 
appropriate after-treatment. When a patient ex- 
hibits evidence of beginning shock during operation, 
it is more prudent to stop immediately and defer 
the completion of the operation imtil the next day 
than to proceed and "hope against hope that the pa- 
tient will not die cured." Certain structures being 
particularly sensitive to stimulation and tratmiatism, 
such as the periosteiun during amputation, etc., pre- 
liminary nerve blocking with cocaine, as advocated 
by Crile, is of great benefit. This may be obtained 


either by spinal analgesia or by injections directly 
into the nerve sheaths. The cocaine blocking 
lessens the blow to the vasotonic centers and dis- 
tributes the violence over a longer period; large 
nerves, periosteum, etc., may then be severed with 
impunity. To avoid collapse when performing a 
phlebotomy or paracentesis, emptying a distended 
bladder, etc., the fluid should be withdrawn slowly 
and the entire amoimt should never be removed at 
one sitting. The surgeon is often confronted with 
the question of operating during shock and this 
point is still the subject of much controversy. In 
general, sagacity dictates to wait until reaction has 
occurred, unless operation is imperative to save life. 
Under such circumstances, general anesthesia should 
be avoided as often as possible. If the operation is 
deferred until reaction occurs, hemorrhage must be 
controlled and the injured area protected with a 
wet dressing. All cases of profuse hemorrhage, 
primary or secondary, internal or superficial, and 
all those of visceral perforation must be operated upon 
immediately regardless of shock, else death from 
exsanguination or sepsis is certain. 

Treatment of Surgical Shock and Collapse. — Since 
these two conditions differ physiologically, their 
treatment is different. The cardinal principle of 
the treatment of shock is to establish reaction and 
stimulate cardiac action, while the main indication 
in the treatment of collapse due to hemorrhage is to 
aid in the restoration of the blood to its normal 

The reaction from shock consists of permanent 


elevation of the depressed blood pressure, evidence 
of which is a re-appearance of the natural color and 
warmth of the skin, a pulse more full and forcible, 
deeper respirations and returning sensibility or a 
quiet sleep. Some writers describle a condition of 
excessive reaction, characterized by sudden hyper- 
pyrexia and coma without a corresponding improve- 
ment in the pulse and respiration, which they as- 
cribe to a septic intoxication. It is more usual at 
the present time, however, to observe either a de- 
layed or incomplete reaction or no reaction at all, 
when the patient does not respond to remedial 
measure. If the patient is in great pain when first 
examined, he should receive 1/4 to 1/2 grain of 
morphine, be put to bed at the earliest possible 
moment, covered with warm woolen blankets, being 
careful not to impede respiration, and surrounded 
with hot water bottles or hot bricks. The latter 
should be wrapped in cloths to prevent contact with 
the body surface, because prostrated and unconscious 
patients are especially prone to burns The foot of 
the bed should be elevated to lower the patient's 
head, and to favor a return of blood to the brain. 
The exceptions to this rule are cases of excessive in- 
tracranial pressure. In these cases, even though 
shock exists, Dawbarn, Mayo and others recommend 
a partial cerebral anemia, procured by sequestra- 
tion of a large quantity of blood in the extremities. 
The latter is easily obtained by cording the limbs at 
their proximal extremities, exerting sufficient pres- 
sure to impede the venous but not the arterial cur- 
rent nor to markedly impair heart action. Mani- 


festly, this is the reverse of another valuable adjunct 
in the treatment of all other cases of shock ; bandag- 
ing the extremities from the distal end toward the 
trunk, to fortify the vital centers with an extra 
supply of blood. Crile has elaborated this principle 
in his rubber pneumatic pressure suit. It will not be 
amiss to repeat that while these measures conduce to 
safety in the ordinary cases of shock, they add to the 
danger in cases of intracranial pressure. Hot normal 
saline solution should be used early, as it has a most 
excellent effect upon unstriped muscle and cerebral 
sympathetic centers. It may be administered by 
hypodermoclysis, enteroclysis or intravenous in- 
fusion. Both Dawbarn and Kemp have shown con- 
clusively that the customary temperature of 104° F. 
is too low and that the best and most permanent re- 
sults upon the heart and blood-vessels are obtained 
when the saline solution is given at 116° to 120° F. 
About two quarts should be cautiously introduced; 
at least twenty minutes are required for its admin- 
istration, to avoid overwhelming the heart. Hypo- 
dermoclysis or enteroclysis are preferable to an 
intravenous infusion, because the flow can be acceler- 
ated or retarded more conveniently. Adrenalin chlor- 
ide (i-iooo) acts by toning up the unstriped muscle 
of the blood-vessels and 15 or 20 minims may be 
added to the saline solution. Frequent sphygmo- 
manometric readings should be taken during the 
introduction of the solution and when the pressure 
rises to 1 20 mm. it must be discontinued. Twitch- 
ing of the limbs heralds the development of convul- 
sions and is another indication for stopping the ad- 


ministration of the saline. Should the pressure 
again fall perceptibly and the pulse become weaker, 
the adminstration may be resumed. For this pur- 
pose, Kemp's rectal tube is of service. A permanent 
blood pressure of 100 mm. and a pulse rate of 120 
may be considered the limit of safety. Morphine, 
ammonia, adrenalin and ergot (ergotole) are the most 
valuable drugs in shock. In emergencies, ammonia 
acts as a harmless stimulant and oft-times contri- 
butes to the prevention or modification of shock. 
Morphine, in quarter-grain doses, is useful to allay 
pain and quiet the patient and as a mild circulatory 
stimulant. The latter virtue is one often overlooked 
by many physicians. Ergotole and adrenalin chlo- 
ride ( I -1 000) may be administered in saline infusion 
or hypodeniiatically or the adrenalin may be slowly 
dropped into the nostrils. The administration of these 
preparations must be frequently repeated, as their 
effect is more or less evanescent. The time-honored 
"stimulants," such as strychnine, alcohol, nitro- 
glycerine, etc., have been proven to be physiologic 
fallacies and worse than useless. They cannot stimu- 
late the already exhausted nerve centers, which are 
incapable of transmitting normal physiological reflexes 
and responding to stimulation, nor have they any 
effect on unstriped muscle. They not only fail to 
mitigate shock but even exaggerate it and have been 
entirely abandoned by modem surgeons. If res- 
piration flags, artificial respiration may be insti- 
tuted. The stomach should have complete rest, all 
food and nauseous medication being withheld during 
shock and until all danger is past. Strength may be 


sustained by nutrient enemata. Hot black coffee, 
when tolerated, is both a food and stimulant. 

The main indication in the treatment of collapse 
due to hemorrhage is to arrest bleeding, for the longer 
it continues the more prolonged will be the suspension 
of functions. When hemorrhage has been controlled, 
restoration of the volume of blood lost, as rapidly 
as possible, is imperative. Many of the accessory 
measures mentioned in the treatment of shock will 
also prove useful in collapse, but an intravenous 
infusion alone is practically sufficient to raise the 
blood pressure and sustain the functions of the cen- 
ters. In other words, whereas hot saline solution is 
a valuable auxiliary in cases of shock, it is an ab- 
solute necessity in those of collapse ; without it medi- 
cation is useless. Under these circumstances, it is 
desirable to introduce the saline solution more 
rapidly than in shock, hence an intravenous infusion 
is the method of choice. It may be thrown into any 
large vein and, although one of the superficial veins 
of the forearm is usually selected for convenience', 
the internal saphenous vein an3rwhere above the 
ankle, as suggested by Dawbam, is preferable, be- 
cause there are no adjacent important structures and 
a scar on the leg is of no consequence. The patient 
should be confined to a bed with its foot elevated, 
external heat applied and the extremities partially 
exsanguinated, as in shock. To these may be added 
an increased supply of oxygen, which may be pro- 
vided by opening windows or inhalations of pure 
oxygen gas. Direct blood transfusion may be em- 
ployed when a donor, the necessary facilities and in- 


struments are at hand. The drugs used in the treat- 
ment of shock are also serviceable in collapse. 

Collapse occasionally follows sudden withdrawal of 
large quantities of fluid ; aspirating ascites, or emptying 
a distended bladder. This accident will never occur, if 
technic is perfect and the fluid is removed gradually. 
A large quantity of fluid must be removed slowly and 
the entire amount never withdrawn at one time. 


Many phases of death are more properly included 
in works on legal medicine and medical jurispru- 
dence and therefore the care of the moribimd patient, 
the determination of death and the physician's sub- 
sequent procedure only will be considered. 

Because a patient is apparently dying is no reason 
that he should be neglected. It is well to bear in 
mind that "while there is life there is hope" and an 
apparently moribund individual has been known to 
recover. He should be made comfortable and his 
waning vitality conserved. Cool, smooth bed- 
clothes that do not restrict or interfere with respira- 
tion will materially add to his comfort. If external 
heat is employed, be cautious lest the sufferer be 
burned. Catheterization and warm rectal irriga- 
tions, as often as required, will prevent excessive 
intra-abdominal pressure and resorption of noxious 
material. Oxygen should be liberally supplied to 
the vitiated atmosphere by opening windows and 
permitting the entrance of plenty of fresh air or by 
inhalations of oxygen. Lamps, gas flames and open 
fires should be avoided, if practicable. Such medi- 


cation may be administered as circumstances may 
demand. Opiates may be freely used if the patient 
is restless or in physical pain. The attitude of the 
physician should be one of cheerfulness and encour- 
agement and not indifference. 

When circulation, respiration and innervation all 
cease, the patient is dead. Cardiac action and res- 
piration are not necessarily arrested simultaneously, 
m.omentary absence of respiration is not incompati- 
ble with the continuance of life, and instances are 
recorded in which one or the other has apparently 
ceased and yet the patient recovered. This, how- 
ever, is open to question. It is more logical to as- 
sume that either the heart's action was so extremely 
feeble or the respiratory movements so shallow that 
one or the other was imperceptible, even with the 
stethoscope. Death is usually verified by the ces- 
sation of circulation and respiration, corroborated 
by a stethoscopic examination. In view of the 
possibility of error in mistaking suspended animation, 
lethargy, catalepsy, etc., for actual death, the above 
examination cannot be accepted as adequate. The 
unmistakable signs of death, upon which a positive 
determination may be based are: (i) complete arrest 
of cardiac action, (2) complete arrest of respiration, 
(3) primary period of muscular relaxation, preceding 
rigor mortis, (4) abolition of reflexes, (5) intense 
pallor or discoloration of the skin and mucous mem- 
branes, (6) eyes partly open and fixed, (7) flaccidity 
and softening of the eye-ball, (8) absence of pupil- 
lary reaction, (9) gradual opacity of the cornea, and 
(10) rapid reduction of body temperature. 


Death having ensued, it is the physician's duty to 
thoroughly examine the body and confirm the oc- 
currence by unquestionable evidence. The law re- 
garding the physician's subsequent procedure, in 
deaths due to other than natural causes, varies in 
the different States and Counties, but, in general, a 
death certificate should not be furnished without the 
authority of the proper official. When the ambu- 
lance surgeon is called upon to verify a sudden death, 
he should note carefully the circtmistances and facts 
but should leave the body undisturbed. This will 
avoid confusion and obscurity of certain details upon 
later investigation by the municipal authorities. If, 
however, the physician is empowered and directed to 
sign the death certificate in doubtful cases, he should 
clearly state the means or instrument of death, as 
well as the immediate cause. The certificate should 
also state whether the death was due to accident, 
suicide or homicide. 



Indications. — Asphyxia and suspended animation : 
(i) inhalation of noxious gases, (2) drug toxemias, 
(3) submersion, (4) strangulation and (5) electric 

Contraindications. — The patient being in an at- 
mosphere of vitiated air or that contaminated with 
noxious gases. 

Sylvester's Method. — i. Place the patient in a 
supine position, with the head well extended by a 
folded blanket imder the shoulders (Fig. 22). 

2. Stand at the patient's head and grasp the fore- 
arms near the elbows. 

3. For inspiration, draw the arms steadily and 
gently well above the head. 

4. Keep the arms stretched upward for two seconds, 

5. For expiration, turn down the arms, place them 
by the sides and gently compress the thorax for two 

6. Repeat these movements about fifteen times 
to the minute. 

Schafer's Method. — i. Have the patient lie prone, 
with the face turned to one side. 

2. Exert imiform pressure on the lower ribs and 



3. Remove the pressure to allow inspiration. 

4. Repeat these procedures fifteen times a minute. 
Laborde's Method. — i. Grasp the tongue deeply 

and firmly with a layer of gauze or a flat bladed 
tongue forceps. 

Fig. 22. — a. Correct and b incorrect positions of patient for artificial 

2. Draw the tongue forward forcibly and suddenly. 

3. Relax the tongue quickly and completely. 

4. Repeat this intermittent traction every four 


Faradization. — i. Press one electrode on the right 
side of the neck over the right phrenic nerve. 

2. Apply the other electrode over the lower ribs on 
the right side (Fig. 23). The left side is avoided in 
order not to interfere with cardiac action. 

3. A weak faradic current is turned on during in- 

FiG. 23. — Electrodes applied properly to induce inspiration. 

spiration and turned off as soon as expiration com- 

Precautions. — (i) Correct diagnosis is important ; 
(2) the upper respiratory tract must be freed from 
obstruction; (3) if the air is contaminated, pure air 
must be obtained; (4) impediments to free respira- 
tory movements must be removed; (5) external heat 


and friction should be applied early ; (6) all manipu- 
lations must be deliberately and regularly performed, 
(7) artificial respiration, when indicated, should 
always be continued for at least half an hour and 
persevered in much longer, if there is the slightest 
indication of life; (8) a combination of the various 
methods of artificial respiration will often prove ad- 
vantageous; (9) inhalations of oxygen gas, blood- 
letting and suitable cardiac and respiratory stimu- 
lants are useful adjuncts. 


Indications. — (i) Sudden obstruction of the larynx; 
(2) therapeutic purposes; (3) as a preliminary pre- 
ventive measure to some surgical operations. 

Contraindications. — (i) Obstructions below the 
larynx; (2) age tmder thirteen years, as the crico- 
thyroid space is too narrow. 

Technic. — i. Extend the patient's neck strongly. 

2. Procure local or general anesthesia. 

3. Steady the larynx with the thumb and fingers 
of the left hand. 

4. Make an incision from the center of the thyroid 
cartilage, extending downward an inch and a half. 

5. Avoid or ligate and divide the cricothyroid 

6. Pltmge a knife transversely through the crico- 
thyroid membrane exactly in the median line, to the 
depth of half an inch (Fig. 24). 

7. Causes the opening to gape by everting the lips, 
until a tube can be procured. 

8 . ExecLite the necessary intralaryngeal procedures. 


9. Insert a laryngeal tube with the end directed 

10. If an obstruction is promptly and perma- 
nently removed, the cannula may be omitted and the 
wound closed with fine sutures. 

11. Apply a small square of lint smeared with an 

Fig. 24. — Laiyngotomy through the cricothyroid membrane. 

emollient to prevent irritation of the wound. 

Precautions. — (i) Fix the larynx firmly to pre- 
vent slipping from under the point of the knife; (2) 
hold the knife so that not more than half an inch 
projects beyond the fingers and thumbs; otherwise 
the larynx may be accidentally transfixed; (3) don't 
mistake the hyoid bone for the cricoid cartilage. 




Indications. — (i) Sudden obstruction of the tra- 
chea; (2) therapeutic purposes; (3) as a preliminary- 
preventive measure to certain surgical operations; 
(4) whether the trachea is opened above (high opera- 
tion) or below (low operation) the isthmus of the 

Fig. 25. — High and low tracheotomy incisions. 

thyroid body will depend upon the anatomical pe- 
culiarities and the existing circinnstances in each 
case (Fig. 25). 

Contraindications. — (i) Extreme urgency (lar^^n- 
gotomy preferable) ; (2) high operation is contra- 
indicated in laryngeal diseases, because the prox- 


imity of the tracheotomy cannula may irritate and 
exaggerate the trouble. 

Technic. — i. Extend the neck strongly, 

2. Anesthetize the local parts. 

3 . Make a free incision in the skin according to the 
location of the proposed tracheal incision, exactly 
in the median line. 

4. Dissect by blunt dissection down to the trachea 
rapidly but carefully. 

5. Have an assistant hold the soft structures to 
each side with blunt hooks. 

6. Control hemorrhage. 

7. Avoid the isthmus of the thyroid gland by 
pushing it up or down, as may be practicable. 

8. Draw up and steady the trachea by fixing a 
tenaculiim in its upper part. 

9. Thrust the knife, with its back downward, into 
the trachea three or four rings below the tenaculum 
and cut upward. 

10. Dilate the aperture laterally with the handle 
01 the scalpel. 

11. Insert a tracheotomy tube of appropriate size. 

12. Secure the tube with a tape carried twice 
around the neck. 

13. Keep the tube clear at all times and prevent 
access of cold dry air by keeping flannel, wrung out 
in hot water, over the opening of the tube. 

Precautions. — (i) Don't let an over-zealous as- 
sistant draw the head so far back as to Suffocate 
the patient before operation is begun ; (2) see that all 
necessary instruments are at hand; (3) make all in- 
cisions exactly in the median line and sufficiently 


long to secure good exposure; (4) don't open the 
trachea until all arterial hemorrhage has been con- 
trolled; (5) be careful not to transfix the trachea or 
wound the esophagus when incising the trachea; 
(6) tracheotomy is a difficult and dangerous operation 
in inexperienced hands. 


Indications. — To secure rapid, thorough and cer- 
tain absorption of medicaments, especially stimu- 
lants, sedatives and emetics. 

Contraindications. — (i) Irritant substances; (2) 
insoluble substances; (3) substances ineffective in 
small dose; (4) when it is necessary for the patient 
or some other inexperienced person to administer 
the medication. 

Technic. — i. With the needle detached, draw in a 
syringe full of water. 

2. Empty the syringe into a teaspoon or similar 
article and boil the water over a gas flame or burning 

3. Dissolve the tablet in the boiled water. 

4. Aspirate the resulting solution into the syringe. 

5. Screw the needle on firmly. 

6. Point the needle directly upward and expel a 
few drops by gentle pressure on the piston to make 
sure that the needle and syringe are free from air. 

7 . Clean a small area of skin with cotton moistened 
with alcohol. 

8. Dry with cotton. 

9. Pinch up the skin with the fingers and thumb of 



the left hand so that the fold is parallel to the course 
of the neighboring blood-vessels. 

lo. Plunge the needle quickly into the subcuta- 
neous areolar tissue, with the point directed to- 
ward the body, being careful to avoid blood-vessels 

Fig. 26. — a, Hypodermic needle introduced correctly; h, hypodermic 
needle introduced incorrectly. 

(Fig. 26). 

11. Inject the contents of the syringe slowly by 
exerting uniform pressure on the piston. 

12. Withdraw the needle slowly and massage the 
small tumefaction gently toward the tinink. 


13. Seal the point of entrance with collodion. 

Precautions. — (i) Select a syringe of uniform cali- 
ber with a properly fitting piston; (2) see that the 
washers are in good condition and that the joints do 
not leak; (3) the needle must be sharp and pervious; 

(4) keep a fine wire in the needle when not in use ; 

(5) the solution injected must be perfect, sterile and 
warm, therefore solutions must always be freshly 
prepared; (6) strong acid and alkaline solutions are 
unfitted for hypodermic administration, because they 
cause severe local irritation ; (7) be sure of an accurate 
dose and avoid hypermedication ; (8) don't boil 
the solution after dissolving the medicament, as 
many substances are decomposed by a temperature 
of 212° F. 

Dangers. — From faulty technic are: (i) needle 
abscess, from a non-sterile needle; (2) injecting the 
medicament into a vein ; (3) introduction of air into a 
vein ; (4) subsequent formation of drug habits by the 
patient (insignificant in emergency cases) . 


Indications. — To secure local anesthesia, or local 
analgesia: (i) to minimize or prevent pain in trivial 
operations ; (2) to avoid or limit the necessity for the 
employment of general anesthesia in major opera- 

Contraindications. — (i) Inflammation or its prod- 
ucts existing in the tissues subjacent to the region 
to be anesthetized, because the additional stretching 
incident to the infiltration of the already tense skin 
is extremely painful; (2) very yoimg and nervous 



patients; (3) regions in which the resulting edema 
obhterates the dividing line between diseased and 
healthy tissue. 

Technic. — i. Observe all aseptic and antiseptic 
precautions, as in hypodermic injections. 

2. Fill a hypodermic syringe with a i per cent, 
solution of ^ eucaine or cocaine hydrochlorate, 
adding a minim or two of adrenalin chloride. 

Fig. 27. — a, Correct and b incorrect method of inserting needle for 
skin infiltration anesthesia. 

3. Cleanse the skin with alcohol. 

4. Insert the needle into the meshes of the skin 
itself and not into the subcutaneous areolar tissue 
(Fig. 27). 

5. Inject the solution parallel to the surface, until 
a good sized wheal is formed. 

6. If the first wheal does not cover a sufficient area. 


the needle should be re-inserted in its margin and an 
adjoining one injected. 

7. After waiting a few seconds, the skin may be 
freely incised. 

Precautions. — (i) Solutions of cocaine stronger 
than 2 per cent, are unnecessary and dangerous; 
(2) the addition of adrenalin chloride has a salutory 
effect upon the action of the anesthetic (tends to favor 
hemostasis and prevent a cocaine toxemia) ; (3) 
boiling decomposes cocaine solutions ; (4) more than 
one-third of a grain in all should never be used; (5) 
the duration of the analgesia is increased with an in- 
crease in strength of the solution ; (6) whenever pos- 
sible, partial anemia of the part should be procured, 
as this favors diffusion of the zone anesthetized; 
when using cocaine anesthesia on a limb, moderate 
constriction above the point of injection, by retard- 
ing venous return, confines the anesthetic locally 
diminishes general absorption and possible tox- 
emia; (7) a very fine and sharp needle will not cause 
pain when inserted. 


Indications. — To secure anesthesia of a restricted 
area, particularly adapted to inflammatory tissue. 

Contraindications. — Cases in which deep pene- 
tration and dissection of tissue are required, or in 
which prolonged local anesthesia is necessary. 

Technic. — i . Cleanse the skin with soap and water 
and alcohol. 

2. Grasp the container with the whole hand. 



3. Loosen the valve sufficiently to permit a fine 
spray being projected. 

4. Direct the spray upon the skin, holding the con- 
tainer some 3 or 4 inches away (Fig. 28). 

5. Stop the spray as soon as the skin area is 
thoroughly whitened. 

6. Wait until the whitening has nearly disappeared 
before incising. 

Precautions. — (i) Be sure that the nozzle of the 

Fig. 28. — a, Correct and b incorrect method of obtaining ethyl chloride 

container does not leak; (2) keep a firm grasp on the 
container, because it is the heat from the hand that 
exerts pressure within the tube and causes vapori- 
zation; (3) maintain a fine spray but avoid a stream; 
(4) too prolonged freezing will be followed by devi- 
talization and sloughing; (5) the slight discomfort 
due to reaction, experienced by the patient after- 
wards, is of no consequence. 



"Aspiration" refers to a method of withdrawing 
fluids from a cavity by suction, in contradistinction 
to "paracentesis," which refers to simple puncture of 
the walls of a cavity. For aspiration an exhausting 
syringe or apparatus (aspirator) is required, whereas 
for paracentesis internal pressure and gravitation 
only are depended upon for removal of the fluid 
through a trocar or an incision. 

Indications. — (i) Diagnostic confirmation ; (2) evac- 
uation of collections of serum, blood or pus from a 
cavity; (3) as an emergency operation in severe cases 
of retention of urine in which efforts at catheteri- 
zation have failed ; (4) spina bifida. 

Contraindications. — (i) Extensive pyemic ab- 
scesses; (2) when the density of pus is so great that 
it will not flow through the needle ; (3) when sloughing 
is extensive and the shreds continually plug the 
needle ; (4) when large blood-vessels or other impor- 
tant structures that cannot be avoided are interposed 
between the surface and the collection of fluid. 

Technic. — i . Observe all aseptic and antiseptic pre- 
cautions and cleanse the overlying skin or mucous 

2. Press down a small area of skin slightly above 
the site of the proposed perforation, so that when 
released by withdrawal of the needle the aperture in 
the skin will lie above that through the underlying 
structures, thus avoiding subsequent leakage. 

3. Anesthetize the skin with ethyl chloride. 


4. Insert a suitable needle, firmly but gradually, 
until the point is felt to be free in the cavity. 

5. Attach a syringe with the piston depressed or 
the tube of an aspirating apparatus (preferably 
Potain's aspirator) in the receiving bottle of which a 
vacuum has been previously created by means of an 
attached pump. 

6. If a syringe is employed, withdraw the piston 

7. If a Potain apparatus is used, open the vent 
leading into the receiving bottle. 

8. If the limien of the needle becomes obstructed 
during the out-flow of fluid, it may be cleared by 
changing its direction, by reversing the action of the 
syringe temporarily or by removing it, clearing it 
and introducing it elsewhere. 

9. When the flow ceases, the exhausting pimip 
may be operated or the needle slightly withdrawn. 

10. When the greater part of the fluid is evacuated, 
the needle should be removed and the perforation 
sealed with a little cotton painted with collodion. 

1 1 . Exert firm pressure on the part with a suitable 
dressing to support the walls of the cavity and aid in 
preventing a return of the affection. 

Precautions. — (i) Always test the aspirator before 
using; (2) be sure that the receiving bottle contains 
a vacuiun and not compressed air; (3) the diameter 
of the needle selected will depend upon the quantity 
and viscosity of the fluid to be evacuated through it ; 
it should be reasonably small; (4) the site at which 
the needle is introduced should obviously be at the 
lowest accessible point to which the fluid extends; 



(5) introduce the needle slowly, so that it will not 
pass entirely through the cavity and reach the oppo- 
site wall or wound deeper structures unnecessarily 
before the fluid has an opportunity to escape; (6) 
never remove the whole of a large collection of fluid 
at one time; (7) re-accumulations are common after 
aspiration and repetition is often necessary. 


Indications. — To evacuate fluid from the abdom- 
inal cavity. 

Contraindications. — A distended bladder. 
Technic. — i. Shave and cleanse the skin. 

2. Have the patient sit in a chair or lie on his 
side on the edge of the bed. 

3. Support the abdominal wall by placing a wide 
bandage or towel with a central opening around the 
patient and have an assistant exert firm pressure 
from behind. 

4. Draw down the skin immediately above the 
point to be punctured. 

5. Cocainize the area of puncture. 

6. Make a small preliminary skin incision in the 
linea alba. 

7. Insert a small straight cannula and trocar, 
carefully but quickly (Fig. 29). 

8. Withdraw the trocar, leaving the cannula in 
situ and have an assistant tighten the abdominal 
supporter as the fluid is evacuated and the enlarge- 
ment decreases. 

9. If the cannula becomes obstructed, it may be 
cleared by passing a probe through it. 



10. If the fluid flows too freely, it may be retarded 
by a compress over the outer opening. 

11. Withdraw the cannula and seal the opening 
with cotton and collodion. 

Precautions. — (i) Empty the bladder and bowels; 
mistaking a distended bladder for other collections 
of fluid is an inexcusable error; (2) verify the area 
of dulness by percussion immediately before para- 

FiG. 29. — Correct position for paracentesis abdominis. 

centesis; (3) sudden or complete removal of the fluid 
may precipitate collapse ; (4) in general, the precau- 
tions for aspiration obtain for paracentesis. 


Indications. — (i) To withdraw cerebro-spinal fluid 
to make or verify a diagnosis or relieve excessive 
pressure within the vertebral canal; (2) to introduce 


antitetanic serum or other therapeutic agents into 
the cerebro-spinal axis. 

Technic. — i. Administer a preliminary dose of 
morphine and atropine, unless distinctly contra- 
indicated by the patient's general condition. 

2. Have the patient lie on his side on the edge of 
the bed, with the body cuived forward, or have 
him sit up in the same position. 

3. Identify the twelfth dorsal vertebra by means 
of the last rib and count downward to the spine of 
the fourth lumbar vertebra. Deep palpation is 

4. Select a point half an inch to the side of the 
median line and freeze it with ethyl chloride. 

5. Incise the skin at this point. 

6. Select a slender needle 4 inches long, the stylet 
of which is ground flush with the end of the needle 
itself (Dawbarn's needle). 

7. Pass the needle through the subcutaneous tis- 
sues obliquely upward and inward with the stylet in 

8. A sense of diminished resistance indicates 
penetration of the canal. 

9. Withdraw the stylet; the issuance of a few 
drops of cerebro-spinal fluid will follow. 

10. Catch the fluid in a test-tube or other suitable 

11. Withdraw the needle slowly and seal the 
small skin incision with cotton and collodion. 

Precautions. — (i) Strict asepsis is imperative; (2) 
don't withdraw more than 30 c.c. of fluid at most; 
(3) don't permit the pressure within the canal to 


fall below nonnal ; (4) aspiration is not required and 
may be dangerous; (5) avoid lateral movements of 
the needle while obtaining fluid; (6) withdraw the 
needle slowly. 


Indications. — (i) Cases in which local anesthesia 
cannot be utilized; (2) when general anesthesia is dis- 
tinctly contraindicated ; (3) as an auxiliary measure in 
major operations on the abdomen or lower extremi- 
ties to prevent shock; (4) to lessen the pains of 

Technic. — i. Puncture the vertebral canal as de- 
scribed under lumbar puncture. 

2. Select and sterilize an appropriate dose of one 
of the following: cocaine, tropacocaine, novocaine, 
stovaine, eucaine, scopolamine or magnesium sul- 

3. Draw into the syringe, containing the drug in 
powder, a sufficient amount of cerebro-spinal fluid. 

4. Re-inject as soon as the powder is dissolved. 

5. Operation may be commenced within fifteen 

6. To increase the upper limit of analgesia, elevate 
the foot of the bed. 

Precautions. — (i) Boiling decomposes cocaine and 
its derivatives and they are best sterilized by dis- 
solving in sulphuric ether with subsequent evapora- 
tion of the latter, as advocated Hy Bainbridge ; (2) 
be sure that the drug employed is absolutely sterile, 
of pure quality and definite strength; (3) be sure 



that the needle is not sHghtly withdrawn while 
attaching the syringe. 


Indications. — To lower vascular tension: (i) pul- 

FiG. 30. — Phlebotomy. 

monary engorgement; (2) engorgement of the right 
heart; (3) profoimd toxemias with full pulse; (4) 
cerebral apoplexy. 

Contraindications. — All conditions accompanied 
by cardio- vascular depression. 


Technic. — i. Shave and cleanse the bend of the 

2. Apply a constrictor a few inches above the 

3. Steady the most prominent vein just below the 
elbow with the thumb of the left hand. 

4. Thrust a lancet or bistoury through the skin 
and about two-thirds of the diameter of the vein in an 
oblique direction (Fig. 30). 

5. Remove the pressure of the thiunb to permit 

6. Catch the blood in a graduated receptacle. 

7. When a sufficient amount has been withdrawn, 
remove the constrictor, place a gauze pad over the 
wound and apply a figure-of-eight bandage. 

Precautions. — (i) Apply a broad constrictor, so 
that it will not cut into the skin; (2) be careful that 
the constrictor does not exert sufficient pressure to 
obstruct arterial circulation; (3) an incision carried 
too deeply may wound one of the cutaneous nerves 
or the brachial artery; (4) vertigo or evidence of 
approaching syncope are positive indications for the 
stoppage of bleeding, even though the intended 
amount has not been abstracted. 


Indications. — To supply the body with fluid and 
aid renal and skin elimination: (i) as a prophylactic 
measure to prevent and as a therapeutic agent in the 
treatment of shock; (2) uremia not associated with 
edema; (3) toxemias; (4) when administration of 
fluids through the stomach is contraindicated. 


Contraindications. — (i) Extremely urgent cases; 
(2) edema of the lungs due to cardiac or renal dis- 
ease; (3) high arterial tension. 

Technic. — i. Select and cleanse an area of skin 
just above the groin, on the inner side of the thigh or 
in the submammary region. 

2. Fill an ordinary glass irrigating apparatus, 
with rubber tubing attached, with sterile normal 
saline solution (2 drams of sodium chloride to a 
quart of water) at a temperature of 116° F. 

3. Attach an aspirating needle to the free end of 
the rubber tube. 

4. Elevate the needle and open the stop-cock, 
thus freeing the tube and needle of air. 

5. Introduce the needle at the selected site into 
the subcutaneous areolar tissue. 

6. Elevate the reservoir about 2 feet above the 
level of the needle. 

7. After all the solution has been injected, mas- 
sage the tumor lightly, from below upward. 

Precautions. — (i) Remember that in shock hypo- 
dermoclysis is of no value by reason of its bulk, but 
good results accrue by virtue of its stimulant power 
over the vasomotor system only; (2) be careful of 
over-dosage ; i dram of saline solution to each pound 
of the body weight in each fifteen minutes is the limit 
of safety; (3) employ hypodermoclysis cautiously in 
stout-old persons, young children and in cases of 

B.— Hot 



Indications : 

A. — Cold (70° F.) : To reduce fever in sthenic cases. 

[ diuresis. 
(i) to promote -j sweating. 

[ alimentary elimination. 

(2) shock. 

(3) toxemias. 

(4) intestinal hemorrhage. 

(5) intussuception. 

(6) pelvic exudates. 

(7) inflammation and spasm of the pelvic viscera. 

(8) infantile convulsions. 

The temperature should be 100° to 104°, if in- 
creased pulse tension is to be avoided; 105° to 108°, 
if increased pulse tension is not objectionable; and 
110° to 120°, if a rapid increase in pulse tension and 
stimulation of the heart is desired. 

Contraindications. — Renal disease with polyuresis. 

Technic. — i. Fill a fountain syringe, irrigator or 
other suitable apparatus with the solution. The 
composition and quantity of the solution will of 
course vary according to the purpose for which it is 
to be administered. 

2. Attach a rectal tube (or soft mbber catheter 
for children) to the free end of the tube leading to the 

3. Open the stop-cock and permit the entire length 
of tubing to fill with fluid. 

4. Lubricate the tip of the rectal tube. 

5. With the patient in the dorsal position or lying 
on his left side, insert the end of the tube into the 



rectum, at the same time again opening the stop- 
cock and permitting the solution to flow slowly. 

6. Gradually raise the reservoir from the level of 
the patient to a height that will exert the desired 

Fig. 31. — Enteroclysis with Kemp's tube. 

7. When the reservoir is empty, withdraw the 
tube slowly. 


2. Attach a Kemp's return flow tube to the free 
end of the tube leading to the reservoir. 

3. Exclude all air, 

4. Lubricate the tip of the tube. 

5. Introduce the Kemp's tube with a gentle rotary- 
motion, so that the folds of the mucous membrane 
will not catch in its fenestrations. 

6. Attach a piece of rubber tubing to the outflow 
channel and conduct to a suitable receptacle (Fig. 31). 

7. Control the inflow and outflow of the solution 
by pinching the corresponding tubes when necessary. 

Precautions. — (i) Always introduce fluids into the 
intestine slowly to avoid spasm; (2) a Davidson 
syringe should not be used, because the flow is inter- 
mittent and the pressure is indeterminable; (3) great 
pressure exerted on damaged intestine is dangerous; 
it should never exceed 8 pounds. 


Indications. — (i) Extremely urgent cases of shock; 
(2) to overcome the collapse from hemorrhage; (3) 
for the relief of various forms of toxemia; (4) as an 
emergency measure in cases of edema; (5) to se- 
cure rapid and certain action of certain medicinal 

Technic. — i. Place the thoroughly sterilized solu- 
tion in a warm irrigator. 

2. Sterilize the patient's skin over one of the 
superficial veins near the elbow or over the internal 
saphenous vein. 

3. Apply a constrictor immediately above. 



4. Incise the skin and dissect off the sheath of the 

5. Ligate the vein at the distal end of the incision 
with catgut. 

6. Pass a second ligature under the vein at the 
proximal end of the incision and leave it untied. 

7. Exclude all air from the rubber tubing, con- 
nected with the irrigator and the cannula, by opening 
the stop-cock until a steady stream is obtained. 

Fig. 32. — -Intravenous infusion, a, Distal ligature tied and cut; b, 
proximal ligature tied temporarily about the vein and cannula. 

8. Incise the distended vein and quickly insert the 
cannula, with the solution running. 

9. Tie the loose ligature around the cannula and 
overlying vein with a single knot (Fig. 32). 

10. When the cannula is withdrawn, tighten the 
ligature around the vein and secure with a double 

1 1 . Divide the vein between the two ligatures. 


12. Suture the skin wound. 

13. Apply a suitable dressing. 

Precautions. — (i) Taste the solution before ster- 
ilizing, if saline solution is being used; a large 
quantity of plain water injected into a vein will 
cause rapid disintegration of the red blood-corpuscles 
and subsequent death ; (2) the temperature of the 
solution should never be less than 100° F. ; (3) be 
sure that all air is excluded from the tubing and 
cannula and that no air enters the vein at any stage 
of the operation ; (4) always use a well diluted solu- 
tion of a drug and introduce it slowly ; a quart should 
require half an hour; (5) dip the cannula in saline 
solution before inserting to prevent a few drops of 
blood from coagulating on its tip; (6) don't try to 
enter a vein with a sharp needle without incising 
the skin; blind surgery is never justifiable. 


Indications. — (i) To replace, in whole or in part, 
loss of normal blood; (2) prolonged shock; (3) ane- 
mias; (4) general debility; (5) toxemias. 

Contraindications. — When a healthy donor can- 
not be obtained. 

Technic. — i. Place the donor and donee on paral- 
lel tables. 

2. Observe all aseptic and antiseptic precautions. 

3. Secure skin anesthesia by infiltration with 
cocaine solution. 

4. Expose and free about 3 cm. of the radial artery 
of the donor, collateral branches being ligated when 



5. Expose and free about 3 cm. of the median 
cephalic vein of the recipient. 

6. Place a permanent ligature peripherally on 
each blood-vessel, 

7. Apply a Crile compression clamp, one arm being 
rubber shod, as near as possible to the proximal end 
of each exposed vessel. 

8. Divide the vessels with sharp scissors, just 
above the distal ligatures. 

9. Select a suitable sterile Brewer's glass tube, 
about 2 inches in length and with a slight bulbous 
tip at each end, which are made in various calibers 
and are straight, curved and angulated. 

10. Immerse the tube in melted paraffin until all 
air bubbles cease to rise. 

11. A quick sharp shake dislodges excess paraffin. 

12. Remove the paraffin on the exterior of the 

13. Insert the smaller end into the artery and tie 
a ligature around it, so that the ligature lies in the 
groove beside the bulbous tip. 

14. Release the pressure of the Crile clamp on the 
artery slightly, permitting arterial blood to flow. 

15. Insert the other end of the tube into the vein 
and tie another ligature around it. 

16. Remove both hemostatic clamps entirely. 

17. When blood has passed for a sufficient time, 
ligate both artery and vein and withdraw the tube. 

18. Suture the wounds, and apply a dressing. 
Precautions. — (i) Direct transfusion should not be 

attempted by the inexperienced, as a slight error 
may prove disastrous; (2) when feasible, it is wiser 


to supply arterial than venous blood; (3) test-tube 
phenomena being fairly reliable, make a preliminary 
test of the blood of both donor and donee to avoid 
possible hemolysis; (4) don't use hemostatic clamps 
that exert great pressure and injure the walls of the 
blood-vessels; the pressure should be just sufficient 
to obstruct the blood current temporarily; (5) 
merely dipping the Brewer's tube into liquid par- 
affin will not insure complete coating of the lumen ; 
(6) general anesthesia is pemiissible but local 
anesthesia advisable; (7) watch the condition of 
both patients carefully; (8) in case of threatened 
syncope, place the donor in the Trendelenburg 
position; (9) it is impossible to accurately guage the 
amount of blood transfused, but pronounced in- 
crease of cardiac dullness or sudden dyspnea in the 
recipient is indication for cessation. 


Indications. — (i) To determine the contents of the 
bladder; (2) to withdraw urine in emergencies; (3) 
to evacuate blood-clots, fragments of stone or foreign 
bodies; (4) to cleanse the bladder; (5) to introduce 
medicaments; (6) as a preliminary to abdominal 
operations; (7) to distend the bladder with water or 
air; (8) to establish continuous vesical drainage; (9) 
as a diagnostic measure. 

Contraindications. — (i) Impermeability of the 
urethra; (2) suppression of urine. 

Technic. — i. Patient recumbent. 

2 . Select the largest soft-rubber catheter that will 
readily pass the external urinary meatus. 



3 . Cleanse and sterilize the hands of the operator, 
instrument and glans penis. 

4. Retract the foreskin and grasp the glans with 
the thumb and forefinger of the left hand, directing 
the penis so that it points to the median line of the 
anterior abdominal wall. 

5. Holding the catheter 2 or 3 inches behind its 
tip, dip the tip in a sterile lubricant and insert 
gently into the meatus. 

6. Propel the catheter forward about a quarter of 
an inch at a time. 

7. As the tip enters the membranous urethra, de- 
press the distal end of the instrument and as the tip 
enters the bladder the exposed end should lie parallel 
with the extended thighs. 

8. If an obstruction is encountered during the 
passage of the instrument, it should be slightly with- 
drawn and another effort made to pass it. An im- 
passable barrier will necessitate the use of a catheter 
of smaller size or one of metal, depending upon the 
existing circumstances. 

Precautions.^ — (i) Be sure that the soft-rubber 
catheter is not hard and brittle ; (2) a rigid catheter, 
in inexperienced hands, is a dangerous instrument 
and should not be employed unless the soft-rubber 
one fails and patency of the urethra is certain; (3) 
the utmost gentleness should be observed in passing 
catheters ; they cannot be forced through the urethra 
without danger; (4) a false passage is evidenced by 
sudden obstruction and great pain; hemorrhage fol- 
lows withdrawal of the instrument; (5) patience and 
gentle persistence will overcome spasmodic stricture ; 


(6) continuous catheterization is preferable to fre- 
quent introduction and withdrawal; (7) the catheter 
should fill but not dilate the urethra; (8) catheteri- 
zation will dissipate many abdominal "tumors"; 
(9) don't try to catheterize women by the sense of 
touch only; infection or injury may be the price of 
false modesty; (10) a preliminary dose of hexa- 
methylenamine is an excellent prophylactic measure, 
as it renders the urine more or less aseptic. 


Indications. — (i) As a prophylactic measure in the 
prevention of small-pox; (2) to attenuate the viru- 
lence of an attack of small-pox; (3) to propagate the 
virus of vaccinia. 

Contraindications. — (i) Impaired general health; 
(2) acute diseases other than small-pox. 

Technic. — i. Select and surgically cleanse a suit- 
able site on the skin, being careful to avoid the bellies 
of underlying muscles. The insertion of the deltoid 
muscle and inner condyle of the femur are the loca- 
tions usually chosen. 

2. Stretch the skin, with the forefinger and thumb 
of the left hand. 

3. Make a number of criss-cross scratches on the 
skin, denuding an area about a quarter of an inch in 
diameter, of its superficial epithelia, with a scarifier 
or steel needle, which has been sterilized by passing 
through a flame. 

4. Break off the end of a small aseptically sealed 
capillary tube containing glycerinated animal lymph. 

5 . Attach the section of small rubber tubing which 
accompanies the glass tube to its free end. 


6. Break off the other end of the glass tube. 

7. Blow through the rubber tube, depositing the 
virus on the scarified area. 

8. Rub in gently with the instrument. 

9. After drying thoroughly, apply a suitable shield. 

10. If unsuccessful, revaccinate in two weeks. 
Precautions. — (i) If the virus is inoculated over a 

muscle, the region is irritated by the movements 
of the muscle ; (2) large and multiple denudations are 
unnecessaiy; (3) the skin should be scratched until 
lymph exudes but never deeply enough to cause 
bleeding; (4) the virus should be active and free 
from other pathogenic organisms, not long in stock 
and kept in a cool place ; (5) the virus obtained in the 
hermetically sealed tubes is likely to be cleaner and 
more potent than that dried on ivory points; (6) 
the patient's underclothes must be clean ; the shield 
may be dispensed with in patients whose habits are 


Indications.— (i) To cause prompt healing of large 
granulating surfaces, preventing the deformities that 
result from natural reparative processes and subse- 
quent contraction of the scars; (2) to replace scar 
tissue with a soft pliable integument; (3) plastic 

Contraindications. — Devitalized or necrotic sur- 

Technic. — i. Wash the granulating surface with 
saline solution and dry with sterile gauze. 

2. Cleanse the area from which the grafts are to 


be taken with soap and hot water and flush with 
saline solution. 

3. Select a keen edged razor, ground flat on one 

4. Sterilize the razor by immersing in alcohol for 
ten minutes. 

5. Wrap the thumb and forefinger of the operator's 
left hand in sterile gauze and stretch the skin. 

6. Cut a thin graft from the stretched skin with a 
quick sawing motion of the razor, being careful to 
remove the epidermis only. 

7. Transfer the grafts directly from the razor to 
the granulating surface. 

8. Repeat until the entire area is covered, the 
grafts over-lapping each other and the skin margins. 
They may be teased into position with a sterile probe. 

9. Press out all air bubbles with the probe. 

10. Cover with a strip of sterile gutta-percha 
tissue and leave for a week. 

1 1 . Cover the gutta-percha tissue with a generous 
layer of sterile gauze wrung out in hot saline solution. 

12. Change the wet gauze daily, being careful not 
to disturb the gutta-percha tissue. 

Precautions. — (i) Don't graft until healing has 
begun and the surface is well granulated; (2) trim 
off exhuberant granulations with a sharp razor; (3) 
take the skin from the patient himself when possible ; 
(4) never employ local anesthesia; if anesthesia is 
absolutely necessary, use a general anesthetic; (5) 
skin-grafting must be an aseptic operation; anti- 
septics are contra-indicated. 


Abdomen, contused wounds, 

gunshot wounds of, 47 
paracentesis of, 195 
wounds of, protrusion of 
intestine in, 34 
Abscess, 123 

method of opening, 127 
pointing of, 125 
Accidental wounds, 23 
Acid, carbolic, in erysipelas, 
in wet dressings, 3 2 
subcutaneous injections, 
in carbuncles, 129 
Adrenalin chlorid in shock, 

174, 175 
in superficial bleeding, 
Ambulance , removal of pati- 
ent to, 19, 20 
surgeon, 19 

rules for, 20-22 
Ammonia in shock, 175 
Amputations, traumatic, 106 
after-treatment, 113 
anesthesia in, no 
conservative surgery in, 

drainage in, 112 
emergency treatment, 107 
operative treatment, 108 

Analgesia, spinal, 198 
indications, 198 
precautions, 198 
technic, 198 
Anesthesia, ethyl chloride, 191 
contraindications, 191 
indications, 191 
precautions, 192 
technic, 191 
in compound fractures and 
traumatic amputations, 
1 10 
in shock, 172 
infiltration, 189 
of site of incision in local- 
ized pyogenic infections, 
skin-infiltration, 189 
contraindications, 189 
indications, 189 
precautions, 191 
technic, 190 
spinal, 198 

indications, 198 
precautions, 198 
technic, 198 
Ankle, sprains of, emergency 
treatment, 54 
strapping, 54 
Ankylosis complicating frac- 
tures, 122 
in dislocations, 63 




Antitoxin, tetanus, 138 
Arm, nerves of, injury to, in 

fractures of humerus, 86 
Arthritis, traumatic, 51 

treatment of, 52 
Artificial respiration, 180 
contraindications, 180 
faradization, 182 
indications, 180 
Laborde's method, 181 
precautions, 182 
Schafer's method, 180 
Sylvester' s method, 180 
Aspiration, 193 

contraindications, 193 
indications, 193 
precautions, 194 
technic, 193 
Auditory canal, external, for- 
eign bodies in, 163 
Avulsion of scalp, 41 

Back, sprained, 53 

strapping of, 56 
Bandage, Barton, 80 

Velpeau, in fracture of 
clavicle, 84 
Bandages for fractures, 67 

sterilization of, 35 
Bandaging, 32 
Barton's bandage, 80 
Bed-sores, 156 

prevention of, 157 
Benzine for dissolving grease, 

Bichloride of mercury as wet 

dressing, 32 
Bier's hyperemia in localized 
pyogenic infections, 128 
in wounds, 34 

Bites, rabid animal, treat- 
ment, 44 
snake, treatment of, 44 
Bladder, catheterization of, 
rupture of, in fractures of 
pelvis, 94 
Blocking nerve with cocain 
in compound fractures 
and traumatic amputa- 
tions, 110 
to prevent shock, 171 
Blood transfusion, 206 

contraindications, 206 
in collapse, 176 
indications, 206 
precautions, 207 
technic, 206 
Boil, 123 
Bones, metacarpal, fractures 

of, 93 

of foot, fractures of, 105 
Bullet wounds, 45 
Bunion, 49 

treatment, 49 
Burns, 140 

complications of, treatment, 

constipation in, treatment, 

constitutional effects of, 

treatment, 145 
due to chemical agents, 

treatment, 145 
electric, 141, 144 
exhaustion from, treatment, 

first degree, 141 

treatment, 142 
inflammation of viscera 

from, 146 



Burns, renal congestion from, 
treatment, 146 

second degree, 141 
treatment, 142 

shock from, treatment, 146 

sun, 142 

symptoms of, 140 

third degree, 141, 144 

treatment of, local, 142 

x-ray, 141 

treatment of, 145 
Burrow's solution, 131 
Bursitis, 49 

chronic, 49 

prepatellar, 49 

serous, 49 
chronic, 49 

suppurative, 49 

syphilitic, 49 

tubercular, 49 

types of, 49 

Callus, formation in frac- 
tures, 120 
Carbolic acid in erysipelas, 136 

wash, 32 
Carbuncle, 124 

method of opening, 127 
Catgut, iodine, preparation 

of, 28 
Catheterization, 208 

contraindications, 208 

indications, 208 

precautions, 209 

technic, 208 
Cellulitis, 124 

incisions in, 127 
Certificate, death, 179 
Chemical agents, burn due to, 

treatment, 145 
Chilblain, 149 

Chilblain, treatment of, 149 
Clavicle, fractures of, 83 
Sayre dressing in, 83 
Velpeau bandage in, 84 
Cocaine, nerve blocking with, 

to prevent shock, 171 
Coccygodynia, 63 
Coin-catcher, 167 
Cold, intense, effects of, 140 
Coley's fluid, 136 
Collapse, 168 

blood transfusion in, 176 
causes of, 169 
diagnosis of, 170 
due to hemorrhage, treat- 
ment, 176 
factors, predisposing to, 169 
from sudden withdrawal of 
large amount of fluid, 177 
manifestations of, 170 
oxygen in, 176 
prevention of, 171 
saline solution in, 176 
symptoms of, 170 
treatment of, 172, 176 
CoUes' fracture, 91 

Plaster-of-Paris dressing 

for, 92 
treatment, 91 
Compound fractures, 106. See 

also Fractures, compound 
Condyloid fractures of hum- 
erus, treatment, 88 
Congestion, renal, from burns, 

treatment, 146 
Constipation in burns, treat- 
ment, 146 
Contused wounds, 36 
drainage, 38 
dressings, 37 
hematoma in, 36 



Contused wounds of abdomen, 


of scalp, 36 
sloughing in, 38 
Coronoid process of ulna, frac- 
tures, treatment of, 93 
Cut-throat, 41 
treatment of, 42 

Death, 177 

care of patient before, 177 

certificate, 179 

signs of, 178 
Deformed union of fractures, 

Deformity, gun-stock, in frac- 
tures of humerus, 88 
Delayed union of fractures, 1 1 6 
Dislocations, 57 

ankylosis in, 63 

at elbow, 59 

at shoulder-joint, 58 

examination of, 58 

infracotyloid, 60 

of hip, 59 

of jaw, 58 

of radius and ulna, 59 

of thumb, 59 

perineal, 60 

subacromial, 59 

subclavicular, 59 

subglenoid, 59 

subspinous, 59 

supracoracoid, 59 

supracotyloid, 60 

traumatic, 57 

treatment of, 60 
Drain, Peple's, 130 
Drainage in compound frac- 
tures, 112 

of contused wounds, 38 

Drainage of lacerated wounds 
of scalp, 41 
of localized pyogenic infec- 
tions, 129 
of punctured wounds, 43 
of wounds, 26, 31 
tubes, incisions for, 39 
Dressing, gauze, of wounds, 3 i 
of contused wounds, 37 
of lacerated wounds, 41 
permanent, of fractures, 67 
plaster-of-Paris, for Colles' 

fracture, 92 
primary, of wounds, 31 
Sayre, in fractures of clav- 
icle, 83 
Dupuytren's splint, 105 
Dusting powders, 36 

Ear, foreign bodies in, 163 
Edema in fractures, 122 
Elbow, dislocations at, 59 
Electric burns, 141, 144 

current for production of 
artificial respiration, 182 
Enteroclysis, 202 

contraindications, 202 

in shocks, 174 

indications, 202 

precautions, 203 

technic, 202 

with Kemp's tube, 204 
Ergotole in shock, 175 
Erysipelas, 135 

effect of, on sarcoma, 136 

facial, 135 

phlegmonous, 135 
Erysipelatoid lymphangitis, 

Esophagus, foreign bodies in, 




Ethyl chloride anesthesia, 191 
contraindications, 191 
inlocalizedp yogenic in- 
fection, 126 
indications, 191 
precautions, 192 
technic, 191 
Exhaustion from burns, treat- 
ment, 147 
heat, 147 

and insolation, differentia- 
tion, 148 
treatment of, 149 
Extension apparatus for frac- 
tures, 68, 69 
Eye, foregin bodies in, 161 
removal, 162 

FACiAL'erysipelas, 135 

Fainting, 168 

Faradization as means of 

artificial respiration, 182 
Femur, fractures of, 95 

in infants and young 

children, 98 
neck, 96 
seperation of epiphyses, 

shaft, 97 
Fibrous union of fractures, 

Fibula and tibia, fractures of, 
fractures of, lower end, 104 
separation of epiphyses, 

shaft, 104 
upper end, 104 
Fluid, Coley's, 136 
Foot, bones of, fractures, 105 
Forearm, fractures of, 89 

Foreign bodies, 159 

beneath nail, removal, 
in ear, 163 
in esophagus, 166 
in external auditory 

canal, 163 
in eye, 161 

removal, 162 
in larynx, 164, 165 
in nose, 164 
in pharynx, 164 
in subcutaneous tissues, 

in trachea, 164, 165 
in wounds, 24 
removal, 28 
X-ray for detecting, 2 5 
Quain's method of re- 
moving, 161 
X-rays in locating, 160 
Fractures, 64 

accompanying wounds, 25 
ankylosis complicating, 122 
bandages for, 67 
callus formation in, 120 
Colles', 91 

plaster-of-Paris dressing 

for, 92 
treatment of, 91 
compound, 106 

after-treatment, 113 
conservative surgery in, 

drainage in, 112 
emergency treatment, 107 
fixation of bone fragments 

in, III 
operative treatment, 108 
deformed union, 120 
delayed union, 116 



Fractures, edema in, 122 
emergency treatment, 66 
examination of, 64 
extension apparatus for 

68, 69 
fibrous union, 119 
fixation by extension, 68 
gunshot, of skull, 78 
immobilization plus mas- 
sage, 69 
injury to nerves in, 120 
involving nose and mouth, 

loss of function in, 121 
non-union of, 117 
causes, 117, 118 
syphilis as cause, 117 
of bones of foot, 105 
of clavicle, 83 

Sayre dressing in, 83 
Velpeau bandage in, 84 
of femur, 95 

in infants and young 

children, 98 
neck, 96 
separation of epiphyses, 

shaft, 97 
of fibula, lower end, 104 
separation of epiphyses, 

shaft, 104 
upper end, 104 
of forearm, 89 
of humerus, 85 

condyloid, treatment of, 

gun-stock deformity in, 

injury to nerves of 
in, 86 


Fractures of humerus, Jones' 
position in, 88 
lower end, treatment, 87 
shaft, treatment of, 87 
of jaw, 78, 79 
of knee-cap, 98 
of legs, 102 

of metacarpal bones, 93 
of patella, 98 
treatment, 99 

consevative, 99, 100 
radical, 99, loi 
of pelvis, 94 

rupture of bladder in, 94 
of urethra in, 95 
of radius and ulna, 89 
treatment, 90 
shaft, treatment, 90 
treatment, 90 
of ribs, 81 
of skull, 71 
diagnosis, 72 
prognosis, 73 
treatment, 73 
of spine, 81 
of tibia, 104 
and fibula, 102 
separation of epiphyses, 
of ulna, coronoid process, 
treatment, 93 
olecranon process, treat- 
ment, 93 
shaft, treatment of, 93 
styloid process, treat- 
ment, 93 
open operation, 69 
permanent dressing of , 67 
Pott's, 104 
pressure sores in, 121 
refracture of, 120 



Fractures, rupture of skin and 
soft parts in, 121 

sepsis after, 1 14 

sequels of, 116 

simple, 64 

sloughing of skin and soft 
parts in, 121 

splints for, 67 

sprain, 52 

ununited, 117 

causes of, 117, 118 

X-rays in examination, 65 
Frost-bite, 149 
Function, loss of, in fractures, 

Furuncle, 123 

Gangrene in wounds, 24 
Gauze dressing of wounds, 


Gibney's method of treating 

sprained ankle, 54 
Glycerine as aid to wet dress- 
ing, 32, 113 
Grafting, skin-, 211 
contraindications, 211 
indications, 211 
precautions, 212 
technic, 211 
Gunshot fractures of skull, 
treatment, 78 
wounds, 45 

of abdomen, 47 
tetanus from, 45 
X-rays in, 46, 47 
Gun-stock deformity in frac- 
tures of humerus, 88 

Hands, sterilization of, 35 
Harrington's solution, iii 

Heat exhaustion, 147 

and insolation, differen- 
tiation, 148 
treatment, 149 
intense, effects of, 140 
Hematoma in contused 

wounds, 36 
Hemorrhage, collapse due to, 
treatment, 176 
from wounds, 24 
control of, 26 
Hip, dislocations of, 59 
House staff, 17, 18 
Housemaid's knee, 49 
Humerus, fractures of, 85 

condyloid, treatment of, 

gun stock deformity in, 88 
injury to nerves of arm 

in, 86 
Jones' position in, 88 
lower end, treatment, 87 
shaft, treatment, 87 
Hydrogen peroxide, irrigation 

of wounds with, 27 
Hyperemia, Bier's, in wounds, 
in localized pyogenic infec- 
tions, 127, 128 
Hypodermic injections, 187 
contraindications, 187 
dangers, 189 
indications, 187 
precautions, 189 
technic, 187 
Hypodermoclysis, 200 
contraindications, 201 
in shock, 174 
indications, 200 
precautions, 201 
technic, 201 



Hysterical joints, 48 

IcHTHYOL in erysipelas, 136 

Incised wounds, 41 

Incisions for drainage tubes, 

in localized pyogenic infec- 
tions, 126 
Infected wounds, 44 
Infections, pyogenic, acute, 
localized, 123 

after-treatment, 132 
anesthesia of site of 

incision in, 126 
drainage in, 129 
hyperemia in, 127, 128 
incisions in, 126 
method of expressing 

pus, 128 
sterilization in, 128 
systemic disturbances in, 

treatment of, 125 
systemic, 132 

serum-therapy in, 133 
special, 135 
Infiltration anesthesia, 189 
Inflammation of joints, 48 

of viscera from burns, 146 
Infracotyloid dislocations, 60 
Infusion, intravenous, 203 
indications, 203 
precautions, 206 
technic, 204 
Insolation, 147 

and heat exhaustion, differ- 
entiation, 148 
Instruments, sterilization of, 

Interne, 17, 18 

Intravenous infusion, 203 
in collapse, 176 
in shock, 1 74 
indications, 203 
precautions, 206 
technic, 204 
Iodine catgut preparation, 28 
in erysipelas, 136 
tincture of, in localized py- 
ogenic infections, 129 
injection, into wounds, 31 
Iodoform as dusting powder, 

Irrigation, continuous, in com- 
pound fractures, 1 14 
of wounds with hydrogen 
peroxide, 27 

Jaw, dislocations of, 58 

fractures of, 78, 79 
Joints, hysterical, 48 

inflammations of, 48 

traumatic injuries, 48 
Jones' position in fractures of 

humerus, 88 

Kemp's tube, enteroclysis 

with, 204 
Kidneys, congestion of, from 

burns, treatment, 146 
Knee, housemaid's, 49 
Knee-cap, fracture of, 98 

Laborde's method of artificial 

respiration, 181 
Lacerated wounds, 39 

dressing, 41 

of scalp, drainage, 41 

treatment, 40 



Laryngotomy, 183 

contraindications, 183 

indications, 183 

precautions, 184 

technic, 183 
Larynx, foregin bodies in, 164, 

Leg, fractures of, 102 
ulcer of, 151 
strapping, 154 
Liquor ammonii acetatis in 
renal congestion from 
burns, 146 
Lockjaw, 137 
Lumbar puncture, 196 
indications, 196 
precautions, 197 
technic, 197 
Luxatio erecta, 59 
Lymphangitis, erysipelatoid, 

Magnesium sulphate in tet- 
anus, 138 

Massage in fractures, 69 

Mercury, bichloride of, as wet 
dressing, 32 

Metacarpal bones, fractures 

of. 93 
Minor operations, 180 
Morphine in burns, 146 

in shock, 175 
Mouth and nose, fractures 

involving, 78 

Nail, foreign body beneath, 

removal, 160 
Nerve blocking with cocaine 

to prevent shock, 171 
Nerves, injury to, in fractures, 

Nerves, of arm, injury to, in 
fractures of humerus, 86 

Non-union of fractures, 117 
causes, 117, 118 

Nose and mouth, fractures 
involving, 78 
foreign bodies in, 164 

Olecranon process of ulna, 

fractures, treatment of, 93 

Operations during shock, 172 

minor, 180 
Oxygen in collapse, 176 

Paracentesis abdominis, 195 
contraindications, 195 
indications, 195 
precautions, 196 
technic, 195 
Patella, fractures of, 98 
treatment, 99 

conservative, 99, 100 
radical, 99, loi 
Patient, removal of, to ambu- 
lance, 19, 20 
Pelvis, fractures of, 94 

rupture of bladder in, 94 
of urethra in, 95 
Penetrating wounds, 43 
Peple's drain, 130 
Perforating wounds, 43 
Perineal dislocations, 60 
Pharynx, foreign bodies in, 

Phlebotomy, 199 

contraindications, 199 
indications, 199 
precautions, 200 
technic, 200 
Phlegmonous erysipelas, 135 



Plaster-of-Paris dressing for 

Colles' fracture, 92 
Pointing of abscess, 125 
Poisoned wounds, 44 
Pott's fracture, 104 

puffy tumor, 36 
Poultices, 125 
Powder grains, removal, 46 
Powders, dusting, 36 
Prepatellar bursitis, 49 
Pressure sores in fractures, 121 
Probing for foreign bodies, 160 

of wounds, 24 
Puffy tumor. Pott's, 36 
Puncture, lumbar, 196 
indications, 196 
precautions, 197 
technic, 197 
of abdomen, 195 
Punctured wounds, 43 

drainage, 43 
Pus, localized collections of, 
evacuation, 128 

curettage of cavity 
after, 128 
treatment, 125 
Pyogenic infections, acute, 
localized, 123 

after-treatment, 132 
anesthesia of site of 

incision in 126 
drainage in, 129 
hy[)eremia in, 127, 128 
incisions in, 126 
method of expressing 

pus, 128 
sterilization in, 128 
systemic disturbances 
in, 131 

Pyogenic infections, localized, 
treatment of, 125 
systemic, 132 

serum-therapy in, 133 
treatment of, 133 

Quain's method of removing 
foreign bodies, 161 

Rabid animal, bite of, treat- 
ment, 44 
Radius and ulna, dislocations 

of> 59 
fractures of, 89 
treatment, 90 
fractures of shaft, treat- 
ment, 90 
treatment, 90 
Refracture, 120 
Renal congestion from burns, 

treatment, 146 
Resident, 18 

Respiration, artificial, 180 
contraindications, 180 
faradization as means, 

indications for, 180 
Laborde's method, 181 
precautions in, 182 
Schafer's method, 180 
Sylvester's method, 180 
Ribs, fractures of, 81 
Rules for ambulance surgeon, 

Rupture of bladder in frac- 
tures of pelvis, 94 
of skin and soft parts in 

fractures, 121 
of urethra in fractures of 
pelvis, 95 



Saline solution in collapse, 176 

in shock, 174 
Sacroma, effects of erysipelas 

on, 136 
Sayre dressing in fractures of 

clavicle, 83 
Scalp, avulsion of, 41 

contused wounds of, 36 

lacerated wounds of, drain- 
age, 41 
Schafer's method of artificial 

respiration, 180 
Sepsis after fractures, 114 
Sequels of fractures, 116 
Serous bursitis, 49 

chronic, 49 
Serum treatment of systemic 

infections, 133 
Shaving of surrounding skin 

in wounds, 27 
Shock, 168 

adrenalin chloride in, 174, 

ammonia in, 175 
causes of, 169 
diagnosis of, 170 
enteroclysis in, 174 
ergotol in, 175 
factors predisposing to, 169 
from burns, treatment, 146 
from wounds, 24 
hypodermoclysis in, 174 
manifestations of, 170 
morphine in, 175 
operating during, 172 
prevention of, 171 
saline solution, 174 
symptoms of, 170 
treatment of, 172 
Shoulder-joint, dislocations at, 

Signs of death, 178 
Skin and soft parts, rupture 
and sloughing, in fractures, 
Skin-grafting, 2 1 1 

contraindications, 2 1 1 
indications, 211 
precautions, 212 
technic, 211 
Skin-infiltration anesthesia, 
contraindications, 189 
indications, 189 
precautions, 191 
technic, 190 
Skull, fractures of, 71 
diagnosis, 72 

differential diagnosis of 
associated brain in- 
juries, 74, 75, 76, 77 
prognosis, 73 
treatment, 73 
gunshot fractures, 78 
Sloughing in contused 
wounds, 38 
in wounds, 23 

of skin and soft parts in 
fractures, 121 
Snake bites, treatment, 44 
Solution, Burrow's, 131 
Thiersch's, 144 
Wright's, 131 
Sores, pressure, in fractures, 

Spinal analgesia, 198 
indications, 198 
precautions, 198 
technic, 198 
Spine, fractures of, 81 
Splint, Dupuytren's 105 
Splints for fractures, 67 



Sprained back, 53 
strapping, 56 
Sprain-fracture, 52 
Sprains, 52 

after-treatment, 56 

emergency treatment, 53 

of ankle, emergency treat- 
ment, 54 
strapping, 54 
Sterilization in localized pyo- 
genic infections, 128 

of bandages, etc., 35 

of hands, 35 

of instruments, 35 

of wounds, 3 1 
Strapping of sprained ankle, 54 

back, 56 

ulcer of leg, 154 
Styloid process of ulna, frac- 
tures treatment, of, 93 
Subclavicular dislocations, 59 
Subcutaneous tissues, foreign 

bodies in, 160 
Subcuticular suture, 29, 30 
Subglenoid dislocations, 59 
Subspinous dislocations, 59 
Sun burns, 142 
Sunstroke, 147 

treatment of, 148 
Suppurative bursitis, 49 
Supracoracoid dislocations, 59 
Supracotyloid dislocations, 60 
Surgeon, ambulance, 19 

rules for, 20-22 
Surgical collapse, 168. See 
also Collapse 

shock, 168. See also Shock 

Suture of divided important 

structures in wounds, 28 

of wounds, 29 

subcuticular, 29, 30 

Sylvester's method of artificial 

respiration, 180 
Syncope, 168 
Synovitis, traumatic, 50 

treatment of, 50 
Syphilis as cause of delayed 

union of fractures, 116, 

Syphilitic bursitis, 49 
Systemic disturbances in local- 
ized pyogenic infections, 

pyogenic infections, 132 

Tetanus, 137 
antitoxin, 138 
from gunshot wounds, 45 
magnesium sulphate in, 138 
prophylaxis of, 138 
Thiersch's solution, 144 
Throat, cut-, 41 

treatment of, 42 
Thumb, dislocations of, 59 
Tibia and fibula, fractures of, 
fractures of, 104 

separation of epiphyses, 
Tincture of iodine in local- 
ized pyogenic infections, 
in preparation of catgut, 

injection into wounds, 3 i 
Trachea, foreign bodies in, 

164, 165 
Tracheotomy, 185 

contraindications, 185 
indications, 185 
precautions, 186 
technic, 186 



Transfusion, blood, 206 

contraindications, 206 
indications, 206 
precautions, 207 
technic, 206 
Traumatic amputations, 106 
after-treatment, 113 
conservative surgery in, 

drainage in, 112 
emergency treatment, 

operative treatment, 108 
arthritis, 51 

treatment, 52 
dislocations, 57 
injuries of joints, 48 
synovitis, 50 
treatment, 50 
Tubercular bursitis, 49 
Tumor, Pott's puffy, 36 
Turpentine for dissolving 
grease, 40 

Ulcers, 151 

treatment of, 152 

varicose, of leg, 151 
strapping, 154 
Ulna and radius, dislocations 

of, 59 
fractures of, 89 
fractures of coronoid pro- 
cess, treatment, 93 
treatment, 90 
olecranon process, treat- 
ment, 93 
shaft, treatment of, 93 
styloid process, treat- 
ment, 93 
Union, deformed, of fractures, 


Union, delayed, of fractures, 
fibrous, of fractures, 1 1 y 

Ununited fractures, 1 1 7 
causes of, 117, 118 

Urethra, rupture of, in frac- 
tures of pelvis, 95 

Vaccination, 210 

contraindications, 210 

indications, 210 

precautions, 211 

technic, 210 ^ 

Vaccine treatment of infected 

wounds, 44 
Varicose ulcer of leg, 151 

strapping, 154 
Velpeau bandage in fractures 

of clavicle, 84 
Venesection, 199 

contraindications, 199 

indications, 199 

precautions, 200 

technic, 200 
Viscera, inflammation of, 

from burns, 146 

Wash, carbolic, 32 
Wounds, accidental, 23 
after-treatment, 34 
bandaging of, 32 
Bier's hyperemia, in, 34 
bullet, 45 

classification of, 23 
coaptation of edges, 2 9 
contused, 36 

drainage of, 38 

dressing of, 3 7 

hematoma in, 36 

of abdomen, 37 

of scalp, 36 



Wounds, contused, sloughing 

in, 38 
drainage of, 26, 31 
dressing of, primary, 3 1 
emergency treatment, 33 
examination of, 24 
foreign bodies in, 24 
removal, 28 
X-ray for detecting, 25 
fracture accompanying, 25 
gangrene in, 24 
gauze dressing, 3 1 
gunshot, 45 

of abdomen, 47 

tetanus from, 45 

X-rays in, 46, 47 
hemorrhage from, 24 

control of, 26 
incised, 41 
infected, 44 
irrigation of, with hydrogen 

peroxide, 27 
lacerated, 39 

dressing, 41 

of scalp, drainage, 41 

treatment of, 40 
of abdomen, protrusion of 

intestine in, 34 
penetrating, 43 

Wounds, perforating, 43 
poisoned, 44 
probing of, 24 
prognosis of, 24 
punctured, 43 

drainage of, 43 
rest of injured area, 33 
shaving of surrounding skin 

in, 27 
shock from, 24 
sloughing in, 23 
sterilization of, 3 i 
suture of, 29 

divided important 
structures in, 28 
tincture of iodine injected 

into, 3 1 
treatment of, 25 

emergency, t,t, 
Wright's solution, 131 

X-RAY burns, treatment, 145 
for detecting foreign bodies 

in wounds, 25 
in examination of fractures, 

in gunshot wounds, 46, 47 
in locating foreign bodies, 



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rriedrich and Curtis on 
Nose, Larynx, and Ear 

Rhinology, Laryngology, and Otology, and Their Sig- 
nificance in General Medicine. By Dr. E. P. Friedrich, of 
Leipzig. Edited, with additions, by H. Holbrook Curtis, M.D., 
Consulting Surgeon to the New York Nose and Throat Hospital. 
Octavo volume of 350 pages. Cloth, ^2.50 net. 

Grant on the Face, Mouth, and Jaws 

A Text=Book of the Surgical Principles and Surgical 
Diseases of the Face, Mouth, and Jaws. For Dental 
Students. By H. Horace Grant, A.M., M.D., Professor of 
Surgery and of Clinical Surgery, Hospital College of Medicine, 
Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, 
^2.50 net. 


Ogden on the Urine 

Clinical Examination of Urine and Urinary Diagnosis. 

A Clinical Guide for the Use of Practitioners and Students of 
Medicine and Surgery. By J. Bergen Ogden, M. D., Medical 
Chemist to the Metropolitan Life Insurance Company, New 
York. Octavo, 418 pages, 54 text-illustrations, and a number 
of colored plates. Cloth, ^3.00 net. 


In t^is edition the work has been brought absolutely down to the present 
day. Urinary examinations for purposes of life insurance have been incor- 
porated, because a large number of practitioners are often called upon to make 
such analyses. Special attention has been paid to diagnosis by the character 
of the urine, the diagnosis of diseases of the kidneys and urinary passages. 

The Lancet, London 

" We consider this manual to have been well compiled ; and the author's own experience, 
so clearly stated, renders the volume a useful one both for study and reference." 

Vecki's Sexual Impotence 

The Pathology and Treatment of Sexual Impotence. 

By Victor G. Vecki, M. D. From the Second Revised and 
Enlarged German Edition. i2mo volume of 400 pages. 


This volume will come to many as a revelation of the possibilities of thera- 
peutics in this important field. The whole subject of sexual impotence and 
its treatment is discussed by the author in an exhaustive and thoroughly sci- 
entific manner. In this edition the boolc has been thoroughly revised, and 
new matter has been added, especially to the portion dealing with treatment. 

Johns Hopkins Hospital Bulletin 

"A scientific treatise upon an important and much neglected subject. . . . The treatment 
of impotence in general and of sexual neurasthenia is discriminating and judicious." 


American Pocket Dictionary New (7thf EdWon 

The American Pocket Medical Dictionary. Edited by W. A. 
Newman Borland, M.D. Containing the definition of the princij^al 
words used in medicine and kindred sciences. 6lo pages. Flexible 
leather, with gold edges,' ^i.oo net; with thumb index, ^1.25 net. 

" I am struck at once with admiration at the compact size and attractive exterior. 
lean recommend it to our students without reserve."— James W. Holland, M. D., 
Professor of Medical Chefiiistry and Toxicology at the fefferson Medical College, 

Stel wagon's Essentials of Skin New (7th) Edition 

Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M. D., Ph. D.. Professor of Dermatology in the Jefferson Medical 
College, Philadelphia. Post-octavo of 292 pages, with 72 text-illustra- 
tions and 8 plates. Cloth, JJi.oo net. In Saunders' Question- Compend 

" In line with our present knowledge of diseases of the skin. . . . Continues to main- 
tain the high standard of excellence for which these question compends have been 
noted." — The Medical News. 

Wolffs Medical Chemistry seventh Edition 

Essentials of Medical Chemistry, Organic and Inorganic. 
Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M. D., Late Demonstrator of Chemistry, Jefferson Medical 
College. Revised by A. Ferree Witmer, Ph.G., M. D., formerly As- 
sistant Demonstrator of Physiology, University of Pennsylvania. Post- 
octavo of 225 pages. Cloth, ^i.oo net. In Saunders' Question- Compend 

" The author's careful and well-studied selection of the necessary requirements of 
the student has enabled him to furnish a valuable aid to the student." — JVem York 
Medical fournal. 

Martin's Minor Surgery, Bandaging, and the 

Venereal Diseases second Edition. Revised 

Essentials of Minor Surgery, Bandaging, and Venereal Dis- 
eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur- 
gery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 
illustrations. Cloth, ^l.oo net. In Saunders'' Question Compends. 

" The best condensation of the subjects of which it treats yet placed before the pro 
fession." — The Medical News. 

Stevenson's Photoscopy 

Photoscopy (Skiascopy or Retinoscopy). By Mark D. Steven- 
son, M. D., Ophthalmic Surgeon to the Akron City Hospital. i2mo of 
200 pages ; illustrated. Cloth, ^1.25 net. 

" It is well written and will prove a valuable help. Your treatment of the emer- 
gent pencil of rays, and the part falling on the examiner's eye, is decidedly better 
than any previous account." — Edward Jackson, M. D., University 0/ Colorado. 


Wolfs Examination of Urine 

A Laboratory Handbook of Physiologic Chemistry and Urine- 
examination. By Charles G. L. Wolf, M. D., Instructor in Physi- 
ologic Chemistry, Cornell University Medical College, New York i2mo 
volume of 204 pages, fully illustrated. Cloth, ^1.25 net. 

"The methods of examining the urine are very fully described, and there are at the 
end of the book some extensive tables drawn up to assist in urinary diagnosis." — 
British Medical Journal. 

Jackson's Essentials of Eye Third Revised Edition 

Essentials of Refraction and of Diseases of the Eye. By 
Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the 
Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illustrations. 
Cloth, ^i.oo net. In Saunders Question- Co7npetid Series. 

" The entire ground is covered, and the points that most need careful elucidation 
are made clear and easy." — Johns Hopkins Hospital Bulletin. 

Gleason's Nose and Throat Fourth Edition, Revised 

Essentials of Diseases of the Nose and Throat. By E. B. 
Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical 
College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations. 
Cloth, $1.00 net. In Saunders'' Quesiio7t-Co?Hpend Series. 

" The careful description which is given of the various procedures would be sufficient 
to enable most people of average intelligence and of slight anatomical knowledge to 
make a very good attempt at laryngoscopy." — The Lancet, London. 

^, . «.. If . t_ ¥r^ Third Edition, 

Gleason s Diseases oi the li^ar Revised 

Essentials of Diseases of the Ear. By E. B. Gleason, S. B., 
M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- 
delphia, etc. Post-octavo volume of 214 pages, with I14 illustrations. 
Cloth, ^l.oo net. In Saunders' Question- Compend Series. 

" We know of no other small work on ear diseases to compare with this, either in 
freshness of style or completeness of inhrmntion."— Bristol Medico-Chirurgical 

Wilcox on Genito-Urinary and Venereal Dis- 
eases Ikervi (2d) Edition 

Essentials of Genito-Urinary and Venereal Diseases. By 
Starling S. Wilcox, M. D., Lecturer on Genito-Uiinary Diseases and 
Syphilology, Starling-Ohio Medical College, Columbus, Ohio. l2mo of 
321 pages, illustrated. Cloth, ^i. 00 net. In Saunders' Question-Compends. 

deSchweinitz and Holloway on Pulsating 

Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- 
viously analyzed. By George E. deSchweinitz, M. D., and Thomas 
B. Holloway, M. D. Octavo of 125 pages. Cloth, $2.00 net. 

" The book deals very thoroughly with the whole subject, and in it the most com- 
plete account of the disease will be found."— 5>-/^?Vj Medical Journal. 

A^I?^ . 

J .5 


Ro'^^jJY^gV^RSITY LIBRARIES (hsi.stx) 
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