Minor and emergency surgery

COLUMBIA LIBRARIES OFFSjTE

HEALTH SCIENCES STANDARD

HX64053334

RD111 D23 Minor and emergency J/^\

RECAP

i'tit!in!l'i:i!l'^'VHi!tiii:!iii!!!I!!h';!gi::

pai:l b hoebkr

MEUICAL BOOKS

ti9E.59thSt.,N.Y.

^"S^WX "1\'>

o

Columbia llntuprsitg \
ttt tl|p (Utt^ flf Npm fork

iAtfnmtt BItbrary

MINOR AND EMERGENCY
SURGERY

BY

WALTER T. DANNREUTHER, M. D.

SURGEON TO ST. ELIZABETH'S HOSPITAL AND TO ST. BARTHOLOMEW'S

CLINIC, NEW YORK CITY; EX-HOUSE PHYSICIAN AND SURGEON,

JERSEY CITY HOSPITAL, ETC.

ILLUSTRATED

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1911

Copyright, igii, by W. B. Saunders Company

1] 2.1

a

<s^

PRINTED IN AMERICA

PRESS OF

W. B. SAUNDERS COMPANY

PHILADELPHIA

c7

<4

THIS BOOK IS DEDICATED
TO

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

THE HOSPITAL INTERNE

Digitized by tine Internet Arciiive

in 2010 witii funding from

Open Knowledge Commons

http://www.archive.org/details/minoremergencysuOOdann

PREFACE

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

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

13

14

PREFACE

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

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

Walter T. Dannreuther.

New York City
October, 191 1.

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

CONTENTS

Page

Introduction i?

CHAPTER I.
The Ambulance Surgeon 19

CHAPTER II.
Accidental Wounds 23

CHAPTER III.
Traumatic Injuries of Joints 48

CHAPTER IV.
Simple Fractures 64

CHAPTER V.

Compound Fractures and Traumatic Amputations . 106

CHAPTER VI.
Sequels of Fractures 116

CHAPTER VII.
Acute Pyogenic Infections ' . 123

CHAPTER VIII.
Effects of Intense Heat and Cold 140

CHAPTER IX.
Ulcers — Bed-sores 151

CHAPTER X.
Foreign Bodies 159

CHAPTER XI.
Surgical Shock and Collapse — Death 168

CHAPTER XI I.

Minor Operations 180

Index 213

15

MINOR AND EMERGENCY
SURGERY.

INTRODUCTION.

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

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

1 8 MINOR AND EMERGENCY SURGERY

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

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

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

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

CHAPTER I.
THE AMBULANCE SURGEON.

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

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

19

20 ^ MINOR AND EMERGENCY SURGERY

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

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

The following hints are worth remembering:

Don't lose your nerve; keep cool.

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

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

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

THE AMBULANCE SURGEON 21

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

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

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

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

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

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

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

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

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

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

2 2 MINOR AND EMERGENCY SURGERY

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

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

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

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

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

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

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

CHAPTER II.

ACCIDENTAL WOUNDS.

Classification of Wounds

I. Contused

Lacerated

3. Incised

4. Punctured

5. Poisoned

a. without external communication.

b. with external communication,
a. localized.

b'. extensive: avulsion of a limb or the
scalp.

a. simple.

b. complicated: underlying important
structtires severed.

a. penetrating.

b. perforating.

a. pyogenic infections.

b. tetanic infections.
■ c. venom infections.

d. rabid infections.

e. chemical infections.

6. Gunshot

/ a. blank cartridge

j I. powder grains.
I 2. wadding.

\b. bullet.

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

23

2 4 MINOR AND EMERGENCY SURGERY

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

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

ACCIDENTAL WOUNDS 25

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

1. Extent of injury.

2. Accompanying fracture.

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

4. Foreign material present.

5. Source of hemorrhage.

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

2 6 MINOR AND EMERGENCY SURGERY

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

1. Arrest of hemorrhage.

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

3. Irrigation of the wound with hydrogen per-
oxide.

4. Removal of all extraneous matter.

5. Suture of divided important structures.

6. Institution of drainage, if required.

7. Coaptation of the edges.

8. Injection of tincture of iodine into the wound.

9. Application of a wet gauze dressing and
bandage.

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

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

ACCIDENTAL WOUNDS 27

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

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

Irrigation of a wound with hydrogen peroxide

2 8 MINOR AND EMERGENCY SURGERY

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

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

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

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

ACCIDENTAL WOUNDS 29

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

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

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

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

3° -

MINOR AND EMERGENCY SURGERY

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

Fig.

Subcuticular suture introduced and tied.

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

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

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

ACCIDENTAL WOUNDS 31

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

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

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

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

32 MINOR AND EMERGENCY SURGERY

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

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

Always "fix" the bandage at the start.

ACCIDENTAL WOUNDS ^^

Avoid wrinkles and creases as much as possible.

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

Always bandage from below upward; toward
the trunk.

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

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

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

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

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

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

3

34 MINOR AND EMERGENCY SURGERY

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

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

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

ACCIDENTAL WOUNDS 35

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

36 MINOR AND EMERGENCY SURGERY

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

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

ACCIDENTAL WOUNDS ^^

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

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

38 , MINOR AND EMERGENCY SURGERY

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

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

ACCIDENTAL WOUNDS

39

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

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

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

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

40

MINOR AND EMERGENCY SURGERY

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

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

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

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

ACCIDENTAL WOUNDS 41

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

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

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

42

MINOR AND EMERGENCY SURGERY

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

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

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

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

ACCIDENTAL WOUNDS

43

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

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

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

44 . MINOR AND EMERGENCY SURGERY

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

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

ACCIDENTAL WOUNDS 45

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

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

46^ MINOR AND EMERGENCY SURGERY

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

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

ACCIDENTAL WOUNDS 47

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

CHAPTER III.
TRAUMATIC INJURIES OF JOINTS.

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

48

TRAUMATIC INJURIES OF JOINTS 49

BURSITIS.

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

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

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

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

In the treatment of bimion, it will often be a
4

50 MINOR AND EMERGENCY SURGERY

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

TRAUMATIC SYNOVITIS.

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

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

TRAUMATIC INJURIES OF JOINTS 51

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

TRAUMATIC ARTHRITIS.

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

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

"52 MINOR AND EMERGENCY SURGERY

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

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

SPRAINS.

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

TRAUMATIC INJURIES OF JOINTS 53

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

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

54

MINOR AND EMERGENCY SURGERY

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

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

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

TRAUMATIC INJURIES OF JOINTS 55

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

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

56

MINOR AND EMERGENCY SURGERY

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

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

Fig. 7. — -Strapping a sprained back.

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

Severe cases demand complete rest and constant

TRAUMATIC INJURIES OF JOINTS 57

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

DISLOCATIONS.

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

58- MINOR AND EMERGENCY SURGERY

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

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

Dislocations at the shoulder- joint are the most

TRAUMATIC INJURIES OF JOINTS 59

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

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

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

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

6o MINOR AND EMERGENCY SURGERY

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

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

TRAUMATIC INJURIES OF JOINTS 6i

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

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

62 HI I NOR AND EMERGENCY SURGERY

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

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

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

TRAUMATIC INJURIES OF JOINTS 63

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

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

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

CHAPTER IV.
SIMPLE FRACTURES.

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

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

64

SIMPLE FRACTURES 65

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

On inspection, any muscular spasm, deformity,
swelling or discoloration are observed, and the
contour of an injured limb compared with that of its
fellow. Palpation must be exceedingly careful and
gentle, to avoid causing pain or injury to the adja-
cent structures, but preternatural mobility and crep-
itus must be diligently searched for. In those in-
stances, however, where the nature of the injury is
obvious, it is cruel and unnecessary to twist the site
of fracture about simply to elicit crepitus and, in ad-
dition, forcible movements tend to damage the soft
parts and increase extravasation. Mensuration is
also of great value for the determination of the ex-
act extent of displacement. Loss of function and
subjective pain are usually self-evident and are
important S3rmptoms. AH obscure cases and frac-
tures near joints should be examined under anesthe-
sia, as well as those occurring in children and nervous
individuals. The :r-ray is of inestimable service
for the definite location of a suspected fracture
and for confirmation of a diagnosis. It should be
remembered that a radiograph taken from the
anterior or lateral aspect alone is likely to deceive,
and the x-ray examination should therefore always
5

66 - MINOR AND EMERGENCY SURGERY

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

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

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

SIMPLE FRACTURES 67

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

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

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

68 ■ MINOR AND EMERGENCY SURGERY

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

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

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

Fig. 8. — Improvised extension apparatus.

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

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

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

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

6. Fix an ordinary wooden spool horizontally at

SIMPLE FRACTURES

69

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

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

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

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

Fig. 9. — Improvised extension apparatus applied.

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

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

70 - MINOR AND EMERGENCY SURGERY

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

The following facts are worth remembering:

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

An anesthetic will overcome muscular opposition.

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

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

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

Gravity must be counterbalanced so that position
will assist restitution.

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

SIMPLE FRACTURES 71

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

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

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

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

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

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

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

FRACTURES OF THE SKULL.

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

72 ^ MINOR AND EMERGENCY SURGERY

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

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

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

SIMPLE' FRACTURES 73

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

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

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

Confine the patient to bed.

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

Shave the injured area or the entire scalp.

Apply an ice cap.

Secure free movements of the bowels.

Keep the room dark and absolutely quiet.

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

74-

MINOR AND EMERGENCY SURGERY

General
Appearance

Appearance of
the Injury

Unconsciousness

Pupils

Scalp
Wounds.

Normal

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

Conscious

Normal.
Equal and re-
act promtly.

Alcoholic
Poisoning.

Bloated.
Lips livid.
Red face
and nose.

No evidence of
injury.

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

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

Cerebral
Concussion.

Face pale . . .

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

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

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

SIMPLE FRACTURES

75

Pulse

Respira-
tion

Stomach,

Bowels, and

Bladder

Coma

Convul-
sions

Mental, Motor,
and Sensory
Disturbances

Normal,. . .

Normal. . .

Negative

Absent.

Absent.

Absent.

Full and
soft.

Deep, slow
and ster-
torous.

May be vomit-
ing.

Possibly
gradual.

Do

Mental dullness
and motor
weakness. Inco-
ordination o f
muscles.

Small,
rapid and
intermit-,
tent.

Quiet.
Shallow
and ir-
regular.

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

Tempo-
rary.

Do

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

76^

MINOR AND EMERGENCY SURGERY

General
Appearance

Appearance of
the Injury

Unconsciousness

Pupils

Pace pale.
Expression
vacant.

Do

Temporary

Contusion

(severe

concussion).

what sensi-
ble to light.

Cerebral
Laceration.

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

Usually evidence
of fracture.

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

Do.

Cerebral

Compres-
sion.

Face pale.
Skin cold.

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

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

Remain fix-
ed. One or

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

SIMPLE FRACTURES

77

Pulse

Respira-
tion

Stomach,

Bowels and

Bladder

Coma

Convul-
sions

Mental, Motor,
and Sensory
Disturbances

Feeble and

Do

Do

Do

Do

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

irregular.

Do

Do

Do

Do

0 c c a -
sional.

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

Slow,
(s o m e-
times 40-
60) and
full.

Labored
and ster-
torous.

Stomach insen-
sible, even to
emetics. Bowels
torpid,

Lasts as
long as
pres-
sure
exists.

Do

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

78^ MINOR AND EMERGENCY SURGERY

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

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

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

FRACTURES INVOLVING THE NOSE AND MOUTH.

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

SIMPLE FRACTURES 79

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

5 inches

Bend__
Here

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

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

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

2. Steam over boiling water.

8o

MINOR AND EMERGENCY SURGERY

3. Mould to the chin and line with cotton.

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

Fig. II. — Barton bandage applied.

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

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

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

SIMPLE FRACTURES 8i

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

FRACTURES OF THE RIBS AND SPINE.

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

Fractures of the spine involving the neural arch
only and without displacement are uncommon. The
usual fracture is really a fracture dislocation and is
almost invariably accompanied by compression or
injury of the cord, caused by bone fragments or
hemorrhage. If due to the latter, the resulting
paralysis is more gradual. The evidences of cord
injury are: (i) profound shock, (2) partial or com-
plete motor and sensory paralysis, corresponding to
the point of fracture, (3) loss of reflexes, (4) priapism,
6

82 ^ MINOR AND EMERGENCY SURGERY

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

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

SIMPLE FRACTURES 83

FRACTURES OF THE CLAVICLE.

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

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

To apply the Sayre dressing:

84' MINOR AND EMERGENCY SURGERY

1. Fix the arm in the proper position.

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

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

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

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

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

To apply a modified Velpeau bandage .

1. Fix the arm in the proper position.

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

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

SIMPLE FRACTURES 85

FRACTURES OF THE HUMERUS.

Classification :

Upper epiphysis

Shaft

Lower epiphysis

Anatomical neck.

Surgical neck.

Separation of the epiphysis.

Through the lesser tuberosity.

Through the great tuberosity.

Transverse supracondyloid.
Separation of the epiphysis.
Internal epicondyle.
Internal condyle.
External condyle.
T-fracture.

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

86

MINOR AND EMERGENCY SURGERY

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

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

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

SIMPLE FRACTURES 87

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

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

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

88 - MINOR AND EMERGENCY SURGERY

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

Fig. 13.

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

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

SIMPLE FRACTURES 89

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

FRACTURES OF THE FOREARM
Classification :

Radius and Ulna < ,. 1 , . , s

(^ incomplete (green-stick).

Head and neck.

Separation of the epiphysis.

Shaft.

CoUes.

Reversed CoUes.

Olecranon process.

Coronoid process.

Shaft.

Styloid process.

Radius

Ulna

Precise adjustment of the fragments is essential

90'^ MINOR AND EMERGENCY SURGERY

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

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

Fractures of the shaft of the radius occurring

SIMPLE FRACTURES

91

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

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

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

92

MINOR AND EMERGENCY SURGERY

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

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

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

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

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

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

6. Apply an external bandage.

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

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

9. Continue these procedures every two or three

SIMPLE FRACTURES

93

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

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

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

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

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

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

FRACTURES OF THE METACARPAL BONES.

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

94 MINOR AND EMERGENCY SURGERY

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

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

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

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

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

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

6. Bandage from the tips of the fingers to the
elbow.

FRACTURES OF THE PELVIS.

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

SIMPLE FRACTURES 95

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

FRACTURES OF THE FEMUR.

Classification :

Head (very rare)

^1 / Intracapsular.

I Extracapsular.

f Upper of femur.

^ , . ... Great trochanter,

beparation 01 epiphyses < ,. ^ 1 .

I Lesser trochanter.

I Lower of femur.

f Upper third.

Shaft I Middle third.

[ Lower third.

ISupracondyloid.
External condyle.
Internal condyle.

96' MINOR AND EMERGENCY SURGERY

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

SIMPLE FRACTURES 97

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

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

Fractures of the shaft of the femur usually present
extreme deformity, because the line of fracture is
nearly always oblique and the displacement is ex-
aggerated by the powerful muscular action. Two
or three inches of shortening is to be expected. The
angular displacement is upward in the upper third,
outward in the middle third, and backward in the
lower third. These fractures are never impacted
and inability to elicit crepitus indicates the presence
of soft structures between the fragments. The
emergency treatment is important, as these cases
should not be transported imtil the fracture is firmly
immobilized. The best emergency dressing consists
of coaptation splints, supported by a long axillary
splint on the outside and another on the inside
reaching from the groin to the foot. These cases
should all be treated on a fracture bed by Buck's
extension, re-enforced by the foregoing lateral
splints. The foot must always be fixed at a right
angle and a pad of cotton placed imder the tendo
Achilles, to prevent pressure upon the heel. Frac-
7

gS MINOR AND EMERGENCY SURGERY

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

FRACTURES OF THE PATELLA.

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

SIMPLE FRACTURES 99

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

lOo MINOR AND EMERGENCY SURGERY

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

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

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

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

SIMPLE FRACTURES loi

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

I02

MINOR AND EMERGENCY SURGERY

FRACTURES OF THE LEG.

Classification :

Tibia and fibula

Upper epiphysis.

Tibia

Fibula

Upper end
Shaft.
Lower end

Oblique.

Transverse.

Region of the ankle
Internal maleolus.

Lower epiphysis.

Upper epiphysis.
Upper end.
Shaft.

' Pott's.
External maleolus.

Lower end

Lower epiphysis.

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

SIMPLE FRACTURES 103

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

The treatment of separation of the epiphyses of

I04' MINOR AND EMERGENCY SURGERY

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

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

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

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

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

SIMPLE FRACTURES

105

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

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

CHAPTER V.

COMPOUND FRACTURES AND TRAUMATIC
AMPUTATIONS.

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

The surgeon's judgment and skill in each case.

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

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

The integrity of the circumference of the limb.

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

Proper emergency treatment.
io6

COMPOUND FRACTURES 107

Perfect operative technic.

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

Intelligent after-treatment.

Good nursing.

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

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

io8

MINOR AND EMERGENCY SURGERY

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

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

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

circumference of the limb

destroyed.

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

COMPOUND FRACTURES

109

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

Surroundings favoring infec-
tion.

Proper after-treatment ques-
tionable.

Good nursing not obtainable.

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

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

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

Intelligent after-treatment
assured.

Good nursing possible.

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

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

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

up MINOR AND EMERGENCY SURGERY

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

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

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

COMPOUND FRACTURES m

water. We are now working in a surgically clean
field.

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

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

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

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

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

11,2 MINOR AND EMERGENCY SURGERY

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

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

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

COMPOUND FRACTURES

113

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

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

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

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

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

114

MINOR AND EMERGENCY SURGERY

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

Progressive tissue degeneration with clamminess

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

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

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

COMPOUND FRACTURES 115

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

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

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

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

CHAPTER VL
SEQUELiE OF FRACTURES.

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

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

ii6

SEQUELM OF FRACTURES 117

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

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

ii8 ■ MINOR AND EMERGENCY SURGERY

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

SEQUELM OF FRACTURES 119

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

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

I20 • MINOR AND EMERGENCY SURGERY

well enough alone than to meddle with an unknown
quantity.

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

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

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

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

SEQUELS OF FRACTURES 121

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

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

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

Pressure sores are produced by an ill-fitting plaster

122. MINOR AND EMERGENCY SURGERY

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

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

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

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

CHAPTER VII.
ACUTE PYOGENIC INFECTIONS.
LOCALIZED PYOGENIC INFECTIONS.

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

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

123

124- MINOR AND EMERGENCY SURGERY

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

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

ACUTE PYOGENIC INFECTIONS 125

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

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

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

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

12 6, MINOR AND EMERGENCY SURGERY

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

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

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

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

ACUTE PYOGENIC INFECTIONS 127

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

128 MINOR AND EMERGENCY SURGERY

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

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

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

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

ACUTE PYOGENIC INFECTIONS

129

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

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

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

All infected cavities must be drained. Drainage
does not mean plugging the opening with gauze,
but maintaining a free flow of discharge, be it simple
9

13°

MINOR AND EMERGENCY SURGERY

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

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

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

ACUTE PYOGENIC INFECTIONS

131

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

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

132

MINOR AND EMERGENCY SURGERY

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

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

SYSTEMIC PYOGENIC INFECTIONS.

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

ACUTE PYOGENIC INFECTIONS 133

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

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

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

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

134

MINOR AND EMERGENCY SURGERY

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

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

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

ACUTE PYOGENIC INFECTIONS

^35

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

SPECIAL INFECTIONS.

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

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

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

136 MINOR AND EMERGENCY SURGERY

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

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

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

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

ACUTE PYOGENIC INFECTIONS 137

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

13,8 MINOR AND EMERGENCY SURGERY

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

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

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

ACUTE PYOGENIC INFECTIONS

139

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

CHAPTER VIII.

EFFECTS OF INTENSE HEAT AND COLD.

Classification :

Extent

Causative
factors

BURNS.

1. First degree: simple hyperemia.

2 . Second degree : dermatitis with vesication.

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

1. Contact with flames and intense heat.

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

3. Contact with electric currents.

4. Prolonged exposure to solar rays.

5. Lightning stroke.

6. Rontgen ray burns.

7. Chemical (concentrated acids and caustic
alkalies) .

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

140

EFFECTS OF INTENSE HEAT AND COLD 141

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

142 MINOR AND EMERGENCY SURGERY

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

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

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

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

EFFECTS OF INTENSE HEAT AND COLD

143

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

1 44 MINOR AND EMERGENCY SURGERY

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

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

' Thiersch's solution:

Salicyhc acid 3 ss

Boric acid 3 iii

Sterile water O ii

EFFECTS OF INTENSE HEAT AND COLD 145

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

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

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

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

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

146 MINOR AND EMERGENCY SURGERY

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

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

EFFECTS OF INTENSE HEAT AND COLD 147

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

SUNSTROKE.

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

I4&

MINOR AND EMERGENCY SURGERY

Insolation.

Patient insensible.

Coma; sometimes delirium
and convulsions.

Face flushed.

Skin dry and burning.

Respirations rapid and shal-
low.

Pulse rapid and full.

Temperature 105° to 110° F.

Suppression

action.
Prognosis guarded

of glandular

Heat Exhaustion.
Patient dazed.
Weakness and prostration; not

unconscious.
Face pale.
Skin cool.
Respirations stertorous.

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

Prognosis good.

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

EFFECTS OF INTENSE HEAT AND COLD. 149

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

CHILBLAIN.

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

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

I50- MINOR AND EMERGENCY SURGERY

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

Hydrargyri ammoniati . gr. v

Ichthyolis ttl x

Amylis,

Zinci oxidi • aa 5 ii

Petrolatum , § ss

Misce.

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

CHAPTER IX.

ULCERS— BED-SORES.
ULCERS.

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

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

152. MINOR AND EMERGENCY SURGERY

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

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

1. Improve the local circulation.

2. Cleanse the ulcer and surrounding skin.

3. Subdue inflammation.

4. Remove necrotic tissue from the surface of the
ulcer.

5. Promote absorption of the induration.

6. Stimulate granulation.

7. Support the part with equalized pressure.

8. Encourage cicatrization.

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

10. Improve the patient's general condition.

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

ULCERS— BED-SORES 153

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

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

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

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

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

154 MINOR AND EMERGENCY SURGERY

cold douches and massage are useful adjuncts to the
incisions.

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

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

ULCERS— BED-SORES

^SS

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

Fig. 20. — Strapping a leg ulcer.

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

156 MINOR AND EMERGENCY SURGERY

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

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

BED-SORES.

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

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

ULCERS— BED-SORES 157

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

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

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

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

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

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

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

158 MINOR AND EMERGENCY SURGERY

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

CHAPTER X.
FOREIGN BODIES.

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

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

*-59

i6o MINOR AND EMERGENCY SURGERY

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

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

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

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

FOREIGN BODIES

lOI

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

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

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

Foreign bodies in the eye may vary from a small

1 62 MINOR AND EMERGENCY SURGERY

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

FOREIGN BODIES 163

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

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

i64 ■ MINOR AND EMERGENCY SURGERY

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

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

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

FOREIGN BODIES 165

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

i66 • MINOR AND EMERGENCY SURGERY

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

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

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

FOREIGN BODIES 167

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

CHAPTER XI.

SURGICAL SHOCK AND COLLAPSE— DEATH.

SURGICAL SHOCK AND COLLAPSE.

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

i68

SURGICAL SHOCK AND COLLAPSE—DEATH 169

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

Causes of and Factors Predisposing to Surgical
Shock and Collapse :

Shock

I . Trau-
matism

1

Opera-
tions

Accidental injury.

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

lyx) MINOR AND EMERGENCY SURGERY

Collapse

TT , f Accidental.

Hemorrhaee < t .j ^ ,
1 incidental.

Sudden withdrawal of large quantities of fluid

(ascites, etc.).

Manifestations of surgical shock and collapse

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

SURGICAL SHOCK AND COLLAPSE— DEATH 171

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

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

17-2 MINOR AND EMERGENCY SURGERY

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

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

The reaction from shock consists of permanent

SURGICAL SHOCK AND COLLAPSE— DEATH i^^

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

174 MINOR AND EMERGENCY SURGERY

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

SURGICAL SHOCK AND COLLAPSE—DEATH 175

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

176 MINOR AND EMERGENCY SURGERY

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

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

SURGICAL SHOCK AND COLLAPSE— DEATH i^^

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

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

DEATH.

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

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

178 MINOR AND EMERGENCY SURGERY

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

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

SURGICAL SHOCK AND COLLAPSE— DEATH 179

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

CHAPTER XII.

MINOR OPERATIONS
ARTIFICIAL RESPIRATION.

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

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

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

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

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

4. Keep the arms stretched upward for two seconds,

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

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

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

2. Exert imiform pressure on the lower ribs and
loins.

180

MINOR OPERATIONS i8i

3. Remove the pressure to allow inspiration.

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

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

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

2. Draw the tongue forward forcibly and suddenly.

3. Relax the tongue quickly and completely.

4. Repeat this intermittent traction every four
seconds.

i82 IMINOR AND EMERGENCY SURGERY

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

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

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

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

spiration and turned off as soon as expiration com-
mences.

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

MINOR OPERATIONS 183

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

LARYNGOTOMY.

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

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

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

2. Procure local or general anesthesia.

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

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

5. Avoid or ligate and divide the cricothyroid
artery.

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

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

8 . ExecLite the necessary intralaryngeal procedures.

1 84 - MINOR AND EMERGENCY SURGERY

9. Insert a laryngeal tube with the end directed
downward.

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

11. Apply a small square of lint smeared with an

Fig. 24. — Laiyngotomy through the cricothyroid membrane.

emollient to prevent irritation of the wound.

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

MINOR OPERATIONS

185

TRACHEOTOMY.

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

Fig. 25. — High and low tracheotomy incisions.

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

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

1 86 MINOR AND EMERGENCY SURGERY

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

Technic. — i. Extend the neck strongly,

2. Anesthetize the local parts.

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

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

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

6. Control hemorrhage.

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

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

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

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

11. Insert a tracheotomy tube of appropriate size.

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

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

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

MINOR OPERATIONS 187

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

HYPODERMIC INJECTIONS.

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

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

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

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

3. Dissolve the tablet in the boiled water.

4. Aspirate the resulting solution into the syringe.

5. Screw the needle on firmly.

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

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

8. Dry with cotton.

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

i88

MINOR AND EMERGENCY SURGERY

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

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

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

(Fig. 26).

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

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

MINOR OPERATIONS 189

13. Seal the point of entrance with collodion.

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

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

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

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

SKIN-INFILTRATION ANESTHESIA.

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

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

196

MINOR AND EMERGENCY SURGERY

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

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

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

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

3. Cleanse the skin with alcohol.

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

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

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

MINOR OPERATIONS 191

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

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

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

ETHYL CHLORIDE ANESTHESIA.

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

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

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

2. Grasp the container with the whole hand.

192,

MINOR AND EMERGENCY SURGERY

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

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

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

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

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

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

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

MINOR OPERATIONS 193

ASPIRATION.

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

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

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

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

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

3. Anesthetize the skin with ethyl chloride.
13

194 MINOR AND EMERGENCY SURGERY

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

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

6. If a syringe is employed, withdraw the piston
slowly.

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

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

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

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

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

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

MINOR OPERATIONS

195

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

PARACENTESIS ABDOMINIS.

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

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

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

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

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

5. Cocainize the area of puncture.

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

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

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

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

196

MINOR AND EMERGENCY SURGERY

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

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

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

FiG. 29. — Correct position for paracentesis abdominis.

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

LUMBAR PUNCTURE.

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

MINOR OPERATIONS 197

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

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

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

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

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

5. Incise the skin at this point.

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

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

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

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

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

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

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

198 MINOR AND EMERGENCY SURGERY

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

SPINAL ANALGESIA.

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

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

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

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

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

5. Operation may be commenced within fifteen
minutes.

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

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

MINOR OPERATIONS

199

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

PHLEBOTOMY (VENESECTION).

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

FiG. 30. — Phlebotomy.

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

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

200, MINOR AND EMERGENCY SURGERY

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

2. Apply a constrictor a few inches above the
elbow.

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

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

5. Remove the pressure of the thiunb to permit
flowing.

6. Catch the blood in a graduated receptacle.

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

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

HYPODERMOCLYSIS.

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

MINOR OPERATIONS 201

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

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

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

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

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

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

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

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

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

B.— Hot

202 MINOR AND EMERGENCY SURGERY

ENTEROCLYSIS.

Indications :

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

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

[ alimentary elimination.

(2) shock.

(3) toxemias.

(4) intestinal hemorrhage.

(5) intussuception.

(6) pelvic exudates.

(7) inflammation and spasm of the pelvic viscera.

(8) infantile convulsions.

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

Contraindications. — Renal disease with polyuresis.

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

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

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

4. Lubricate the tip of the rectal tube.

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

MINOR OPERATIONS

203

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

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

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

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

204^ MINOR AND EMERGENCY SURGERY

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

3. Exclude all air,

4. Lubricate the tip of the tube.

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

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

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

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

INTRAVENOUS INFUSION.

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

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

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

3. Apply a constrictor immediately above.

MINOR OPERATIONS

205

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

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

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

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

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

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

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

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

1 1 . Divide the vein between the two ligatures.

2o6 MINOR AND EMERGENCY SURGERY

12. Suture the skin wound.

13. Apply a suitable dressing.

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

DIRECT TRANSFUSION.

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

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

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

2. Observe all aseptic and antiseptic precautions.

3. Secure skin anesthesia by infiltration with
cocaine solution.

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

MINOR OPERATIONS

207

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

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

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

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

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

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

11. A quick sharp shake dislodges excess paraffin.

12. Remove the paraffin on the exterior of the
tube.

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

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

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

16. Remove both hemostatic clamps entirely.

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

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

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

2d8 MINOR AND EMERGENCY SURGERY

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

CATHETERIZATION.

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

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

Technic. — i. Patient recumbent.

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

MINOR OPERATIONS

209

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

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

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

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

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

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

Precautions.^ — (i) Be sure that the soft-rubber
catheter is not hard and brittle ; (2) a rigid catheter,
in inexperienced hands, is a dangerous instrument
and should not be employed unless the soft-rubber
one fails and patency of the urethra is certain; (3)
the utmost gentleness should be observed in passing
catheters ; they cannot be forced through the urethra
without danger; (4) a false passage is evidenced by
sudden obstruction and great pain; hemorrhage fol-
lows withdrawal of the instrument; (5) patience and
gentle persistence will overcome spasmodic stricture ;
14

2IO MINOR AND EMERGENCY SURGERY

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

VACCINATION.

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

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

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

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

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

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

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

MINOR OPERATIONS 211

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

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

8. Rub in gently with the instrument.

9. After drying thoroughly, apply a suitable shield.

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

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

SKIN-GRAFTING.

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

Contraindications. — Devitalized or necrotic sur-
faces.

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

2. Cleanse the area from which the grafts are to

212 MINOR AND EMERGENCY SURGERY

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

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

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

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

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

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

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

9. Press out all air bubbles with the probe.

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

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

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

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

INDEX

Abdomen, contused wounds,

37
gunshot wounds of, 47
paracentesis of, 195
wounds of, protrusion of
intestine in, 34
Abscess, 123

method of opening, 127
pointing of, 125
Accidental wounds, 23
Acid, carbolic, in erysipelas,
136
in wet dressings, 3 2
subcutaneous injections,
in carbuncles, 129
Adrenalin chlorid in shock,

174, 175
in superficial bleeding,
129
Ambulance , removal of pati-
ent to, 19, 20
surgeon, 19

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

no
drainage in, 112
emergency treatment, 107
operative treatment, 108

Analgesia, spinal, 198
indications, 198
precautions, 198
technic, 198
Anesthesia, ethyl chloride, 191
contraindications, 191
indications, 191
precautions, 192
technic, 191
in compound fractures and
traumatic amputations,
1 10
in shock, 172
infiltration, 189
of site of incision in local-
ized pyogenic infections,
126
skin-infiltration, 189
contraindications, 189
indications, 189
precautions, 191
technic, 190
spinal, 198

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

!I3

214

INDEX

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

fractures of humerus, 86
Arthritis, traumatic, 51

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

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

Back, sprained, 53

strapping of, 56
Bandage, Barton, 80

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

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

prevention of, 157
Benzine for dissolving grease,

40
Bichloride of mercury as wet

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

Bites, rabid animal, treat-
ment, 44
snake, treatment of, 44
Bladder, catheterization of,
208
rupture of, in fractures of
pelvis, 94
Blocking nerve with cocain
in compound fractures
and traumatic amputa-
tions, 110
to prevent shock, 171
Blood transfusion, 206

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

of, 93

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

treatment, 49
Burns, 140

complications of, treatment,

145
constipation in, treatment,

146
constitutional effects of,

treatment, 145
due to chemical agents,

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

147
first degree, 141

treatment, 142
inflammation of viscera

from, 146

INDEX

215

Burns, renal congestion from,
treatment, 146

second degree, 141
treatment, 142

shock from, treatment, 146

sun, 142

symptoms of, 140

third degree, 141, 144

treatment of, local, 142

x-ray, 141

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

chronic, 49

prepatellar, 49

serous, 49
chronic, 49

suppurative, 49

syphilitic, 49

tubercular, 49

types of, 49

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

wash, 32
Carbuncle, 124

method of opening, 127
Catgut, iodine, preparation

of, 28
Catheterization, 208

contraindications, 208

indications, 208

precautions, 209

technic, 208
Cellulitis, 124

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

treatment, 145
Chilblain, 149

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

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

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

Plaster-of-Paris dressing

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

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

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

2l6

INDEX

Contused wounds of abdomen,

37

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

Death, 177

care of patient before, 177

certificate, 179

signs of, 178
Deformed union of fractures,

120
Deformity, gun-stock, in frac-
tures of humerus, 88
Delayed union of fractures, 1 1 6
Dislocations, 57

ankylosis in, 63

at elbow, 59

at shoulder-joint, 58

examination of, 58

infracotyloid, 60

of hip, 59

of jaw, 58

of radius and ulna, 59

of thumb, 59

perineal, 60

subacromial, 59

subclavicular, 59

subglenoid, 59

subspinous, 59

supracoracoid, 59

supracotyloid, 60

traumatic, 57

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

of contused wounds, 38

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

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

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

current for production of
artificial respiration, 182
Enteroclysis, 202

contraindications, 202

in shocks, 174

indications, 202

precautions, 203

technic, 202

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

effect of, on sarcoma, 136

facial, 135

phlegmonous, 135
Erysipelatoid lymphangitis,

135
Esophagus, foreign bodies in,

166

INDEX

217

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

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

FACiAL'erysipelas, 135

Fainting, 168

Faradization as means of

artificial respiration, 182
Femur, fractures of, 95

in infants and young

children, 98
neck, 96
seperation of epiphyses,

97
shaft, 97
Fibrous union of fractures,

119
Fibula and tibia, fractures of,
102
fractures of, lower end, 104
separation of epiphyses,

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

Foreign bodies, 159

beneath nail, removal,
161
in ear, 163
in esophagus, 166
in external auditory

canal, 163
in eye, 161

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

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

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

plaster-of-Paris dressing

for, 92
treatment of, 91
compound, 106

after-treatment, 113
conservative surgery in,

no
drainage in, 112
emergency treatment, 107
fixation of bone fragments

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

2l8

INDEX

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

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

78
loss of function in, 121
non-union of, 117
causes, 117, 118
syphilis as cause, 117
of bones of foot, 105
of clavicle, 83

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

in infants and young

children, 98
neck, 96
separation of epiphyses,

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

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

condyloid, treatment of,

88
gun-stock deformity in,
88

injury to nerves of
in, 86

arm

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

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

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

rupture of bladder in, 94
of urethra in, 95
of radius and ulna, 89
treatment, 90
shaft, treatment, 90
treatment, 90
of ribs, 81
of skull, 71
diagnosis, 72
prognosis, 73
treatment, 73
of spine, 81
of tibia, 104
and fibula, 102
separation of epiphyses,
103
of ulna, coronoid process,
treatment, 93
olecranon process, treat-
ment, 93
shaft, treatment of, 93
styloid process, treat-
ment, 93
open operation, 69
permanent dressing of , 67
Pott's, 104
pressure sores in, 121
refracture of, 120

INDEX

219

Fractures, rupture of skin and
soft parts in, 121

sepsis after, 1 14

sequels of, 116

simple, 64

sloughing of skin and soft
parts in, 121

splints for, 67

sprain, 52

ununited, 117

causes of, 117, 118

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

121
Furuncle, 123

Gangrene in wounds, 24
Gauze dressing of wounds,

31

Gibney's method of treating

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

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

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

Heat exhaustion, 147

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

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

condyloid, treatment of,

88
gun stock deformity in, 88
injury to nerves of arm

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

of wounds with, 27
Hyperemia, Bier's, in wounds,
34
in localized pyogenic infec-
tions, 127, 128
Hypodermic injections, 187
contraindications, 187
dangers, 189
indications, 187
precautions, 189
technic, 187
Hypodermoclysis, 200
contraindications, 201
in shock, 174
indications, 200
precautions, 201
technic, 201

2^20

INDEX

Hysterical joints, 48

IcHTHYOL in erysipelas, 136

Incised wounds, 41

Incisions for drainage tubes,

39
in localized pyogenic infec-
tions, 126
Infected wounds, 44
Infections, pyogenic, acute,
123
localized, 123

after-treatment, 132
anesthesia of site of

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

pus, 128
sterilization in, 128
systemic disturbances in,

131
treatment of, 125
systemic, 132

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

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

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

35
Interne, 17, 18

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

36
Irrigation, continuous, in com-
pound fractures, 1 14
of wounds with hydrogen
peroxide, 27

Jaw, dislocations of, 58

fractures of, 78, 79
Joints, hysterical, 48

inflammations of, 48

traumatic injuries, 48
Jones' position in fractures of

humerus, 88

Kemp's tube, enteroclysis

with, 204
Kidneys, congestion of, from

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

Laborde's method of artificial

respiration, 181
Lacerated wounds, 39

dressing, 41

of scalp, drainage, 41

treatment, 40

INDEX

221

Laryngotomy, 183

contraindications, 183

indications, 183

precautions, 184

technic, 183
Larynx, foregin bodies in, 164,

165
Leg, fractures of, 102
ulcer of, 151
strapping, 154
Liquor ammonii acetatis in
renal congestion from
burns, 146
Lockjaw, 137
Lumbar puncture, 196
indications, 196
precautions, 197
technic, 197
Luxatio erecta, 59
Lymphangitis, erysipelatoid,

Magnesium sulphate in tet-
anus, 138

Massage in fractures, 69

Mercury, bichloride of, as wet
dressing, 32

Metacarpal bones, fractures

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

in shock, 175
Mouth and nose, fractures

involving, 78

Nail, foreign body beneath,

removal, 160
Nerve blocking with cocaine

to prevent shock, 171
Nerves, injury to, in fractures,
120

Nerves, of arm, injury to, in
fractures of humerus, 86

Non-union of fractures, 117
causes, 117, 118

Nose and mouth, fractures
involving, 78
foreign bodies in, 164

Olecranon process of ulna,

fractures, treatment of, 93

Operations during shock, 172

minor, 180
Oxygen in collapse, 176

Paracentesis abdominis, 195
contraindications, 195
indications, 195
precautions, 196
technic, 195
Patella, fractures of, 98
treatment, 99

conservative, 99, 100
radical, 99, loi
Patient, removal of, to ambu-
lance, 19, 20
Pelvis, fractures of, 94

rupture of bladder in, 94
of urethra in, 95
Penetrating wounds, 43
Peple's drain, 130
Perforating wounds, 43
Perineal dislocations, 60
Pharynx, foreign bodies in,

164
Phlebotomy, 199

contraindications, 199
indications, 199
precautions, 200
technic, 200
Phlegmonous erysipelas, 135

2?2

INDEX

Plaster-of-Paris dressing for

Colles' fracture, 92
Pointing of abscess, 125
Poisoned wounds, 44
Pott's fracture, 104

puffy tumor, 36
Poultices, 125
Powder grains, removal, 46
Powders, dusting, 36
Prepatellar bursitis, 49
Pressure sores in fractures, 121
Probing for foreign bodies, 160

of wounds, 24
Puffy tumor. Pott's, 36
Puncture, lumbar, 196
indications, 196
precautions, 197
technic, 197
of abdomen, 195
Punctured wounds, 43

drainage, 43
Pus, localized collections of,
123
evacuation, 128

curettage of cavity
after, 128
treatment, 125
Pyogenic infections, acute,
123
localized, 123

after-treatment, 132
anesthesia of site of

incision in 126
drainage in, 129
hy[)eremia in, 127, 128
incisions in, 126
method of expressing

pus, 128
sterilization in, 128
systemic disturbances
in, 131

Pyogenic infections, localized,
treatment of, 125
systemic, 132

serum-therapy in, 133
treatment of, 133

Quain's method of removing
foreign bodies, 161

Rabid animal, bite of, treat-
ment, 44
Radius and ulna, dislocations

of> 59
fractures of, 89
treatment, 90
fractures of shaft, treat-
ment, 90
treatment, 90
Refracture, 120
Renal congestion from burns,

treatment, 146
Resident, 18

Respiration, artificial, 180
contraindications, 180
faradization as means,

182
indications for, 180
Laborde's method, 181
precautions in, 182
Schafer's method, 180
Sylvester's method, 180
Ribs, fractures of, 81
Rules for ambulance surgeon,

20—22
Rupture of bladder in frac-
tures of pelvis, 94
of skin and soft parts in

fractures, 121
of urethra in fractures of
pelvis, 95

INDEX

223

Saline solution in collapse, 176

in shock, 174
Sacroma, effects of erysipelas

on, 136
Sayre dressing in fractures of

clavicle, 83
Scalp, avulsion of, 41

contused wounds of, 36

lacerated wounds of, drain-
age, 41
Schafer's method of artificial

respiration, 180
Sepsis after fractures, 114
Sequels of fractures, 116
Serous bursitis, 49

chronic, 49
Serum treatment of systemic

infections, 133
Shaving of surrounding skin

in wounds, 27
Shock, 168

adrenalin chloride in, 174,

175
ammonia in, 175
causes of, 169
diagnosis of, 170
enteroclysis in, 174
ergotol in, 175
factors predisposing to, 169
from burns, treatment, 146
from wounds, 24
hypodermoclysis in, 174
manifestations of, 170
morphine in, 175
operating during, 172
prevention of, 171
saline solution, 174
symptoms of, 170
treatment of, 172
Shoulder-joint, dislocations at,
58

Signs of death, 178
Skin and soft parts, rupture
and sloughing, in fractures,
121
Skin-grafting, 2 1 1

contraindications, 2 1 1
indications, 211
precautions, 212
technic, 211
Skin-infiltration anesthesia,
189
contraindications, 189
indications, 189
precautions, 191
technic, 190
Skull, fractures of, 71
diagnosis, 72

differential diagnosis of
associated brain in-
juries, 74, 75, 76, 77
prognosis, 73
treatment, 73
gunshot fractures, 78
Sloughing in contused
wounds, 38
in wounds, 23

of skin and soft parts in
fractures, 121
Snake bites, treatment, 44
Solution, Burrow's, 131
Thiersch's, 144
Wright's, 131
Sores, pressure, in fractures,

121
Spinal analgesia, 198
indications, 198
precautions, 198
technic, 198
Spine, fractures of, 81
Splint, Dupuytren's 105
Splints for fractures, 67

224

INDEX

Sprained back, 53
strapping, 56
Sprain-fracture, 52
Sprains, 52

after-treatment, 56

emergency treatment, 53

of ankle, emergency treat-
ment, 54
strapping, 54
Sterilization in localized pyo-
genic infections, 128

of bandages, etc., 35

of hands, 35

of instruments, 35

of wounds, 3 1
Strapping of sprained ankle, 54

back, 56

ulcer of leg, 154
Styloid process of ulna, frac-
tures treatment, of, 93
Subclavicular dislocations, 59
Subcutaneous tissues, foreign

bodies in, 160
Subcuticular suture, 29, 30
Subglenoid dislocations, 59
Subspinous dislocations, 59
Sun burns, 142
Sunstroke, 147

treatment of, 148
Suppurative bursitis, 49
Supracoracoid dislocations, 59
Supracotyloid dislocations, 60
Surgeon, ambulance, 19

rules for, 20-22
Surgical collapse, 168. See
also Collapse

shock, 168. See also Shock

Suture of divided important

structures in wounds, 28

of wounds, 29

subcuticular, 29, 30

Sylvester's method of artificial

respiration, 180
Syncope, 168
Synovitis, traumatic, 50

treatment of, 50
Syphilis as cause of delayed

union of fractures, 116,

117
Syphilitic bursitis, 49
Systemic disturbances in local-
ized pyogenic infections,

131
pyogenic infections, 132

Tetanus, 137
antitoxin, 138
from gunshot wounds, 45
magnesium sulphate in, 138
prophylaxis of, 138
Thiersch's solution, 144
Throat, cut-, 41

treatment of, 42
Thumb, dislocations of, 59
Tibia and fibula, fractures of,
102
fractures of, 104

separation of epiphyses,
103
Tincture of iodine in local-
ized pyogenic infections,
129
in preparation of catgut,

28
injection into wounds, 3 i
Trachea, foreign bodies in,

164, 165
Tracheotomy, 185

contraindications, 185
indications, 185
precautions, 186
technic, 186

INDEX

225

Transfusion, blood, 206

contraindications, 206
indications, 206
precautions, 207
technic, 206
Traumatic amputations, 106
after-treatment, 113
conservative surgery in,

no
drainage in, 112
emergency treatment,

107
operative treatment, 108
arthritis, 51

treatment, 52
dislocations, 57
injuries of joints, 48
synovitis, 50
treatment, 50
Tubercular bursitis, 49
Tumor, Pott's puffy, 36
Turpentine for dissolving
grease, 40

Ulcers, 151

treatment of, 152

varicose, of leg, 151
strapping, 154
Ulna and radius, dislocations

of, 59
fractures of, 89
fractures of coronoid pro-
cess, treatment, 93
treatment, 90
olecranon process, treat-
ment, 93
shaft, treatment of, 93
styloid process, treat-
ment, 93
Union, deformed, of fractures,

IS

Union, delayed, of fractures,
116
fibrous, of fractures, 1 1 y

Ununited fractures, 1 1 7
causes of, 117, 118

Urethra, rupture of, in frac-
tures of pelvis, 95

Vaccination, 210

contraindications, 210

indications, 210

precautions, 211

technic, 210 ^

Vaccine treatment of infected

wounds, 44
Varicose ulcer of leg, 151

strapping, 154
Velpeau bandage in fractures

of clavicle, 84
Venesection, 199

contraindications, 199

indications, 199

precautions, 200

technic, 200
Viscera, inflammation of,

from burns, 146

Wash, carbolic, 32
Wounds, accidental, 23
after-treatment, 34
bandaging of, 32
Bier's hyperemia, in, 34
bullet, 45

classification of, 23
coaptation of edges, 2 9
contused, 36

drainage of, 38

dressing of, 3 7

hematoma in, 36

of abdomen, 37

of scalp, 36

226

INDEX

Wounds, contused, sloughing

in, 38
drainage of, 26, 31
dressing of, primary, 3 1
emergency treatment, 33
examination of, 24
foreign bodies in, 24
removal, 28
X-ray for detecting, 25
fracture accompanying, 25
gangrene in, 24
gauze dressing, 3 1
gunshot, 45

of abdomen, 47

tetanus from, 45

X-rays in, 46, 47
hemorrhage from, 24

control of, 26
incised, 41
infected, 44
irrigation of, with hydrogen

peroxide, 27
lacerated, 39

dressing, 41

of scalp, drainage, 41

treatment of, 40
of abdomen, protrusion of

intestine in, 34
penetrating, 43

Wounds, perforating, 43
poisoned, 44
probing of, 24
prognosis of, 24
punctured, 43

drainage of, 43
rest of injured area, 33
shaving of surrounding skin

in, 27
shock from, 24
sloughing in, 23
sterilization of, 3 i
suture of, 29

divided important
structures in, 28
tincture of iodine injected

into, 3 1
treatment of, 25

emergency, t,t,
Wright's solution, 131

X-RAY burns, treatment, 145
for detecting foreign bodies

in wounds, 25
in examination of fractures,

65
in gunshot wounds, 46, 47
in locating foreign bodies,

160

SAUNDERS' BOOKS

Skin, Genito-Urinary
Diseases, Chemistry, and
Eye, Eaf, Nose, and Throat

W. B. SAUNDERS COMPANY

925 Walnut Street Philadelphia

9, Henrietta Street Covent Garden, London

MECHANICAL EXCELLENCE

l^OT alone for their literary excellence have the Saanders pub-
lications become a standard on both sides of the Atlantic :
their mechanical perfection is as universally commended as is
their scientific superiority. The most painstaking attention is
bestowed upon all the details that enter into the mechanical
production of a book, and medical journals, both at home and
abroad, in reviewing the Saunders publications, seldom fail to
speak of this distinguishing feature. The attainment of this
perfection is due to the fact that the firm has its own Art De-
partment, in which photographs and drawings of a very high
order of merit are produced. This department is of decided
value to authors, in enabling them to procure the services of
artists specially skilled in the various methods of illustrating
medical publications.

A Complete Catalogue of our Publications will be Sent upon Request

SAUNDERS' BOOKS ON

Barnhill and Wales'
Modern Otology

A Text=Book of Modern Otology. By John F. Barn-
hill, M. D., Professor of Otology, Laryngology, and Rhinology,
and Earnest de W. Wales, M. D., Clinical Professor of
Otology, Laryngology, and Rhinology, Indiana University School
of Medicine, Indianapolis. Octavo of 5 98 pages, with 314 original
illustrations. Cloth, ^5.50 net; Half Morocco, ^7.00 net.

THE NEW (2d) EDITION

This work represents the results of personal experience as practitioners and
teachers, influenced by the instruction given by such authorities as Sheppard,
Dundas Grant, Percy Jakins, Jansen, and Alt. Much space is devoted to
prophylaxis, diagnosis, and treatment, both medical and surgical. There is a
special chapter on the bacteriology of ear affections — a feature not to be found
in any other work on otology. Great pains have been taken with the illus-
trations. A large number represent the best work of Mr. H. F. Aitken.

PERSONAL AND PRESS OPINIONS

Frank Allport, M. D.,

Professor of Otology, Northwestern University , Chicago,

" I regard it as one of the best books in the English language on this subject. The
pictures are especially good, particularly as they are practically all original and not the old
reproduced pictures so frequently seen."

Fayette C. Ewing, M. D.,

Original Fellow of the Royal Society of Medicine, Great Britain.

" You have written the completest work on otology before the profession to-day. Besides
being comprehensive, its directions are so specific that it should prove an ideal work for the
young practitioner."

Journal American Medical Association

" Its teaching is sound throughout and up to date. The strongest chapters are those
on suppuration of the middle ear and the mastoid cells, and the intracranial complications
of ear disease."

DISEASES OF THE EVE.

DeSchweinitzV
Diseases of the Eye

The New (6th) Edition

Diseases of the Eye : A Handbook of Ophthalmic Prac-
tice, By G. E. deSchweinitz, M. D., Professor of Ophthal-
mology in the University of Pennsylvania, Philadelphia, etc.
Handsome octavo of 945 pages, 351 text-illustrations, and 7
chromo-lithographic plates. Cloth, ^5.00 net ; Half Morocco,
$6.50 net.

WITH 351 TEXT-ILLUSTRATIONS AND 7 COLORED PLATES

Dr. deSchweinitz' s book has long been recognized as a standard authority
upon eye diseases, the reputation of its author for accuracy of statement
placing it far in the front of works on this subject. For this edition Dr.
deSchweinitz has subjected his book to a most thorough revision. Fifteen
new subjects have been added, ten of those in tlie former edition have been
rewritten, and throughout the book reference has been made to vaccine and
serum therapy, to the relation of tuberculosis to ocular disease, and to the
value of tuberculin as a diagnostic and therapeutic agent.

The text is fully illustrated with black and white cuts and colored plates,
and in every way the book maintains its reputation as an authority.

Johns Hopkins Hospital Bulletin

" No single chapter can be selected as the best. They are all the product of a finished
authorship and the work of an exceptional ophthalmologist. The work is certainlj' one of
the best on ophthalmology extant, and probably the best by an American author."

DeSchweinitz and Randall's
Eye, Ear, Nose, and Throat

American Text=Book of Diseases of the Eye, Ear, Nose,
and Throat. Edited by G. E. deSchweinitz, M. D., and
B. Alexander Randall, M. D. Imperial octavo, 1 251 pages,
with 766 illustrations, 59 of them in colors. Cloth, ^7.00 net;
Half Morocco, ^8.50 net.

SAUNDERS' BOOKS ON

GET A«**^*,:<%r»,«* THE NEW

THE BEST /imCriCan standard

Illustrated Dictionary

Just Ready— The New (6th) Edition

The American Illustrated Medical Dictionary. A new

and complete dictionary of the terms used in Medicine, Surgery,
Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing,
and all kindred branches; with over loo new and elaborate
tables and many handsome illustrations. By W. A. Newman
Borland, M.D. Large octavo of 985 pages. Flexible leather,
^4.50 net; with thumb index, ^5.00 net.

ENTIRELY RESET— A NEW WORK WITH ADDED FEATURES

In this edition the book has been subjected to a thorough revision and
entirely reset, adding thousands of important new terms. This is the only
up-to-date medical dictionary — bar none.

Howard A. Kelly, M.D..

Processor of Gynecologic Surgery, Johns Hopkins University, Ballimore

"Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such conve-
nient size. No errors have been found in my use of it."

Pilcher's Practical Cystoscopy

Practical Cystoscopy. By Paul M. Pilcher, M.D., Con-
sulting Surgeon to the Eastern Long Island Hospital. Octavo of
398 pages, with 233 illustrations, 29 in colors. Cloth, ^5.50 net.

JUST READY

To be properly equipped, you must have at your instant command the
information this book gives you. It explains away all difficulty, telling you
wky you do not see something when something is there to see, and telling you
how to see it. All theory has been uncompromisingly eliminated, devoting
every line to practical, needed every-day facts, telling you how and when to
use the cystoscope and catheter — telling you in a way to make you know.
The work is complete in every detail.

EYE, EAR, NOSE, AND THROAT

Theobald's
Prevalent Diseases of the Eye

Prevalent Diseases of the Eye. By Samuel Theobald,
M. D., Clinical Professor of Ophthalmology and Otology, Johns
Hopkins University. Octavo of 550 pages, with 219 text-illustra-
tions and 10 plates. Cloth, $4.50 net ; Half Morocco, |6.oo net.

Chas. A. Oliver. M. D..

Clinical Professor of Ophthalmology , Woman's Medical College, Phila.
" I feel I can conscientiously recommend it, not only to the general physician and
medical student, but also to the experienced ophthalmologist."

Wells* Chemical Pathology

Chemical Pathology. By H. Gideon Wells, Ph.D.,
M.D., Assistant Professor of Pathology in the University of Chi-
cago. Octavo of 549 pages. Cloth, ^3.25 net.

Wm. H, Welch, M.ID., Johns Hopkins University .

" The work fills a real need in the English literature of a very important subject, and I
shall be glad to recommend it to my students."

Saxe's Urinalysis

Examination of the Urine. By G. A. DeSantos Saxe,
M. D., Instructor in Venereal and Genito-Urinary Surgery,
New York Post-Graduate Medical School and Hospital. i2mo
of 448 pages, illustrated. Cloth, ;^i.75 net.

THE NEW (2d) EDITION

This work is intended as an aid in diagnosis, by interpreting the clinical
significance of the chemic and microscopic urinary findings.

Francis Carter Wood, M. D.,

Adjunct Professor of Clinical Pathology , Columbia University.

" It seems to me to be one of the best of the smaller works on this subject ; it is indeed,
better than a good many of the larger ones."

SJCWDjSJ^S' BOOK'S OiV

Brtihl, Politzer, and Smith's
Otology

Atlas and Epitome of Otology. ByGusxAV Bruhl, M. D.,
of Berlin, with the collaboration of Professor Dr. A. Politzer,
of Vienna. Edited, with additions, by S. MacCuen Smith,
M.D., Professor of Otology in the Jefferson Medical College,
Philadelphia. With 244 colored figures on 39 lithographic plates,
99 text-illustrations, and 292 pages of text. Cloth, ^3.00 net.
In Saunders' Hand-Atlas Series.

The work is both didactic and clinical in its teaching. A special feature
is the very complete exposition of the minute anatomy of the ear, a working
knowledge of which is so essential to an intelligent conception of the science
of otology.

Clarence J. Blake, M.D..

Professor of Otology in Harvard Unhiersity Medical School, Boston.
" The most complete work of its kind as yet published, and one commending itself to
both the student and the teacher in the character and scope of its illustrations."

Haab and DeSchweinitz's
Operative Ophthalmology

Atlas and Epitome of Operative Ophthalmology. By

Dr. O. Haab, of Ziirich. Edited, with additions, by G. E.
deSchweinitz, M.D., Professor of Ophthalmology, University
of Pennsylvania. With 30 colored lithographic plates, 154 text-
cuts, and 375 pages of text. Cloth, ^3.50 net. In Saunders'
Hand-Atlas Series.

This work represents the author's thirty years' experience in eye work.
The various operative interventions are described with all the precision and
clearness that such an experience brings. Recognizing the fact that mere verbal
descriptions are frequently insufficient, Dr. Haab has taken particular care to
illustrate plainly the different parts of the operation.

Johns Hopkins Hospital Bulletin

" The descriptions of the various operations are so clear and full that the volume car
•veil hold place with more pretentious text-books."

DISEASES OF THE EYE.

Haab and DeSchweinitz's
External Diseases qf the £ye

Atlas and Epitome of External Diseases of the Eye.

By Dr O. Haab, of Zurich. Edited, with additions, by G. E.
deSchweinitz, M, D. , Professor of Ophthalmology, University of
Pennsylvania. loi colored illustrations on 46 lithographic plates
and 244 pages of text. Cloth, ^3.00 net. Saunders^ Atlases.

THE NEW (3d) EDITION

The conditions attending diseases of the external eye, which are often so
complicated, have probably never been more clearly and comprehensively
expounded than in the forelying work.

The Medical Record, New York

" The work is excellently suited to the student of ophthalmology and to the practising
physician. It cannot fail to attain a well-deserved popularity."

Haab and DeSchweinitz's
Ophthalmoscopy

Atlas and Epitome of Ophthalmoscopy and Ophthal-
moscopic Diagnosis. By Dr. O. Haab, of Ziirich. Edited,
with additions, by G. E. deSchweinitz, M. D., Professor of Oph-
thalmology, University of Pennsylvania. With 152 colored litho-
graphic illustrations and 94 pages of text. Cloth, ^3.00 net.
In Saunders^ Hand- Atlas Series.

THE NEW (2d) EDITION

In this work not only is the student made acquainted with carefully pre-
pared ophthalmoscopic drawings done into well-executed lithographs of the
most important fundus changes, but, in many instances, plates of the micro-
scopic lesions are added.

The Leuicet. London

" We recommend it as a work that should be in the ophthalmic wards or in the library
of every hospital into which ophthalmic cases are received."

SAUNDEHS' BOOKS ON

Greene and Brooks'
Genito-Urinary Diseases

A Text=Book of Genito=Urinary Diseases. By Robert
H. Greene, M.D., Professor of Genito-Urinary Surgery at
Fordham University; and Harlow Brooks, M. D., Assistant Pro-
fessor of Clinical Medicine, University and Bellevue Hospital Medi-
cal School. Octavo of 560 pages, illustrated. Cloth, $5.00 net.

THE NEW (2d) EDITION

This new work covers completely the subject of genito-urinary diseases,
presenting both the medical and surgical sides. Kidney diseases are very elabo-
rately detailed.

New York Medical Journal

" As a whole the book is one of the most satisfactory and useful works on genito-
urinary diseases now extant, and will undoubtedly be popular among practitioners and
students."

Gleason on Nose, Throat,
and £ar

A Manual of Diseases of the Nose, Throat, and Ear. By

E. Baldwin Gleason, M.D., LL.D., Clinical Professor of
Otology, Medico-Chirurgical College, Philadelphia. i2mo of
563 pages, profusely illustrated. Flexible leather, $2.50 net.

THE NEW (2d) EDITION

Methods of treatment have been simplified as much as possible, so that in
most instances only those methods, drugs, and operations have been advised
which have proved essential. A feature consists of the collection of formulas.

American Journal of the Medical Sciences

" For the practitioner who wishes a reliable guide in laryngology and otology there ar
few books which can be more heartily commended."

American Text=Book of Qenito=Urinary Diseases,
Syphilis, and Diseases of the Sl<in. Edited by L. Bolton
Bangs, M.D., late Professor of Genito-Urinary Surgery, Bellevue
University, New York; and W. A. Hardaway, M.D., Professor
of Diseases of the Skin, Missouri Medical College. Octavo,
1229 pages, 300 engravings, 20 colored plates. Cloth, $7.00 net.

NOSE, THROAT, AND EAR.

GradleV
Nose, Pha^rynx, and Ear

Diseases of the Nose, Pharynx, and Ear. By Henry
Gradle, M. D., Professor of Ophthalmology and Otology, North-
western University Medical School, Chicago. Handsome octavo
of 547 pages, illustrated, including two full-page plates in colors.
Cloth, $3.50 net; Half Morocco, $5.00 net.

This volume presents diseases of the Nose, Pharynx, and Ear as the author
has seen them during an experience of nearly twenty-five years. Topographic
anatomy has also been accorded liberal space.

Pennsylvania Medical Journal

" This is the most practical volume on the nose, pharynx, and ear that has appeared
recently. ... It is exactly what the less experienced observer needs, as it avoids the con-
fusion incident to a categorical statement of everybody's opinion."

Kyle's Nose and Throat

Diseases of the Nose and Throat. By D. Braden Kyle,
M.D., Professor of Laryngology in the Jefferson Medical Col-
lege, Philadelphia; Consulting Laryngologist, Rhinologist, and
Otologist, St. Agnes' Hospital. Octavo, 797 pages; with 219
illustrations and 26 lithographic plates in colors. Cloth, $4.00
net; Half Morocco, $5.50 net.

THE NEW (4th) EDITION

This work has now reached its fourth edition. With the practical purpose
of the book in mind, extended consideration has been given to treatment, each
disease being considered in full, and definite courses being laid down to
meet special conditions and symptoms.

Pennsylvania Medical Journal

" Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat
knowledge in this book. The practical man, be he special or general, will not search in
vain for anything he needs."

10 SAUNDERS' BOOKS ON

Stelwa^on's
Diseases of the Skin

A Treatise on Diseases of tlie Skin. By Henry W.
Stelwagon, M. D., Ph. D., Professor of Dermatology in the
Jefferson Medical College, Philadelphia. Octavo of 1 175 pages,
with 280 text-cuts and 32 plates. Cloth, ^6.00 net; Half
Morocco, $7.50 net.

THE NEW (6th) EDITION

The demand for six editions of this work in such a short period indi-
cates the practical character of the book. In this edition the articles on
Frambesia, Oriental Sore, and other tropical diseases have been entirely re-
written. The new subjects include Verruga Peruana, Leukemia Cutis,
Meralgia Paraesthetica, Dhobie Itch, and Uncinarial Dermatitis.

George T. Elliot, M. D., Professor of De7-matology., Cornell University.

" It is a book that I recommend to my class at Cornell, because for conservative judg-
ment, for accurate observation, and for a thorough appreciation of the essential position of
dermatology, I think it holds first place."

Schamberg^s Diseases of the
Skin and Eruptive Fevers

Diseases of the Skin and Eruptive Fevers. By Jay

F. ScHAMBERG, M. D., Profcssor of Dermatology and the In-
fectious Eruptive Diseases, Philadelphia Polyclinic. Octavo of
534 pages, illustrated. Cloth, $3.00 net.

THE CUTANEOUS MANIFESTATIONS OF ALL DISEASES

"The views expressed on all topics are conservative, safe to follow, and practical, and
are well abreast of the knowledge of the present time. Actinotherapy and radiother;ip
receive considerably more than passing notice." — American Journal of Medical Scii-nci-. .

DISEASES OF THE S/i/iV. tl

Mracek and Steiwag'on's
Diseases of the Skin

Atlas and Epitome of Diseases of the Skin. By Prof.
Dr. Franz Mracek, of Vienna. Edited, with additions, by
Henry W. Stelwagon, M. D., Professor of Dermatology in
the Jefferson Medical College, Philadelphia. With 77 colored
plates, 50 half-tone illustrations, and 280 pages of text. In
Saunders^ Hand- Atlas Series. Cloth, ^4.00 net.

THE NEW (2d) EDITION

American Journal of the Medical Sciences

" The advantages which we see in this book and which recommend it to our minds are :
First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and
the diagnostic points which they bring out "

Mracek and Bangs'
Syphilis 6 Venereal Diseases

Atlas and Epitome of Syphilis and the Venereal Dis=

eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with
additions, by L. Bolton Bangs, M. D., late Prof of Genito-
urinary Surgery, University and Bellevue Hospital Medical Col-
lege, New York. With 71 colored plates and 122 pages of text.
Cloth, $3.50 net. In Saunders' Hand-Atlas Series.

According to the unanimous opinion of numerous authorities, the illus-
trations in this work surpass in beauty anything of the kind that has been pro-
duced, not only in Germany, but throughout the literature of the world.

Robert L. Dickinson, M. D.,

Art Editor of" The Avieiican Text-Book of Obstetrics."

" The book that appeals instantly to me for the strikingly successful, valuable, and
graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.'
I know of nothing in this country that can compare with it."

12 SAUNDEJiS' BOOK'S OJV

Holland's
Chemistry and Toxicolog'y

A Text=Book of Medical Chemistry and Toxicology.

By James W. Holland, M.D., Professor of Medical Chemistry
and Toxicology, and Dean, Jefferson Medical College, Philadel-
phia. Octavo of 635 pages, illustrated. Cloth, $3.00 net.

JUST READY— THE NEW (3d) EDITION

Dr. Holland's work is an entirely new one, and is based on his thirty-five
years' practical experience in teaching chemistry and medicine. Recognizing
that to understand physiologic chemistry students must first be informed upon
points not referred to in most medical te.\t-books, the author has included in his
work the latest views of equilibrium of equations, mass-action, cryoscopy, os-
motic pressure, etc. Much space is given to toxicology.

American Medicine

" Its statements are clear and terse ; its illustrations well chosen; its development logi-
cal, systematic, and comparatively easy to follow. . . . We heartily commend the work."

Gninwald and Newcomb's
Mouth, Pharynx, and Nose

Atlas and Epitome of Diseases of the Mouth, Pharynx,
and Nose. By Dr. L. Grunwald, of Munich. Edited, with
additions by James E. Newcomb, M. D., Instructor in Laryn-
gology, Cornell University Medical School. With 102 illustrations
on 42 colored lithographic plates, 41 text-cuts, and 219 pages of
text. Cloth, ^3.00 net. In Saunders' Hand-Atlas Series.

Gninwald 6 Grayson on Larynx

Atlas and Epitome of Diseases of the Larynx. By Dr.

L. Grxjnwald, of Munich. Edited, with additions, by Charles
P. Grayson, M. D., Clinical Professor of Laryngology and
Rhinology, University of Pennsylvania. With 107 colored
figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth,
^2.50 net. In Saunders' Hand- At/as Series.

EYE, EAR, NOSE, AND THROAT. 13

Jackson on the"^r~

A Manual of the Diagnosis and Treatment of Diseases
of the Eye. By Edward Jackson, A.M., M.D., Professor of
Ophthalmology, University of Colorado. i2mo of 615 pages,
with 184 illustrations. Cloth, ^2.50 net.

THE NEW (2d) EDITION
The Medical Record, New York

" It is truly an admirable work. . . . Written in a clear, concise manner, it bears evi-
dence of the author's comprehensive grasp of the subject. The term ' multum in parvo ' is
an appropriate one to apply to this work. It will prove of value to all who are interested in
this branch of medicine."

rriedrich and Curtis on
Nose, Larynx, and Ear

Rhinology, Laryngology, and Otology, and Their Sig-
nificance in General Medicine. By Dr. E. P. Friedrich, of
Leipzig. Edited, with additions, by H. Holbrook Curtis, M.D.,
Consulting Surgeon to the New York Nose and Throat Hospital.
Octavo volume of 350 pages. Cloth, ^2.50 net.

Grant on the Face, Mouth, and Jaws

A Text=Book of the Surgical Principles and Surgical
Diseases of the Face, Mouth, and Jaws. For Dental
Students. By H. Horace Grant, A.M., M.D., Professor of
Surgery and of Clinical Surgery, Hospital College of Medicine,
Louisville. Octavo of 231 pages, with 68 illustrations. Cloth,
^2.50 net.

/4 SAUA^DERS' BOOKS ON

Ogden on the Urine

Clinical Examination of Urine and Urinary Diagnosis.

A Clinical Guide for the Use of Practitioners and Students of
Medicine and Surgery. By J. Bergen Ogden, M. D., Medical
Chemist to the Metropolitan Life Insurance Company, New
York. Octavo, 418 pages, 54 text-illustrations, and a number
of colored plates. Cloth, ^3.00 net.

THE NEW (3d) EDITION

In t^is edition the work has been brought absolutely down to the present
day. Urinary examinations for purposes of life insurance have been incor-
porated, because a large number of practitioners are often called upon to make
such analyses. Special attention has been paid to diagnosis by the character
of the urine, the diagnosis of diseases of the kidneys and urinary passages.

The Lancet, London

" We consider this manual to have been well compiled ; and the author's own experience,
so clearly stated, renders the volume a useful one both for study and reference."

Vecki's Sexual Impotence

The Pathology and Treatment of Sexual Impotence.

By Victor G. Vecki, M. D. From the Second Revised and
Enlarged German Edition. i2mo volume of 400 pages.

THE NEW (4th) EDITION— PREPARING

This volume will come to many as a revelation of the possibilities of thera-
peutics in this important field. The whole subject of sexual impotence and
its treatment is discussed by the author in an exhaustive and thoroughly sci-
entific manner. In this edition the boolc has been thoroughly revised, and
new matter has been added, especially to the portion dealing with treatment.

Johns Hopkins Hospital Bulletin

"A scientific treatise upon an important and much neglected subject. . . . The treatment
of impotence in general and of sexual neurasthenia is discriminating and judicious."

CHEMISTRY, SKIN, AND VENEREAL DISEASES.

American Pocket Dictionary New (7thf EdWon

The American Pocket Medical Dictionary. Edited by W. A.
Newman Borland, M.D. Containing the definition of the princij^al
words used in medicine and kindred sciences. 6lo pages. Flexible
leather, with gold edges,' ^i.oo net; with thumb index, ^1.25 net.

" I am struck at once with admiration at the compact size and attractive exterior.
lean recommend it to our students without reserve."— James W. Holland, M. D.,
Professor of Medical Chefiiistry and Toxicology at the fefferson Medical College,
Philadelphia.

Stel wagon's Essentials of Skin New (7th) Edition

Essentials of Diseases of the Skin. By Henry W. Stelwagon,
M. D., Ph. D.. Professor of Dermatology in the Jefferson Medical
College, Philadelphia. Post-octavo of 292 pages, with 72 text-illustra-
tions and 8 plates. Cloth, JJi.oo net. In Saunders' Question- Compend
Series.

" In line with our present knowledge of diseases of the skin. . . . Continues to main-
tain the high standard of excellence for which these question compends have been
noted." — The Medical News.

Wolffs Medical Chemistry seventh Edition

Essentials of Medical Chemistry, Organic and Inorganic.
Containing also Questions on Medical Physics, Chemical Physiology,
Analytical Processes, Urinalysis, and Toxicology. By Lawrence
Wolff, M. D., Late Demonstrator of Chemistry, Jefferson Medical
College. Revised by A. Ferree Witmer, Ph.G., M. D., formerly As-
sistant Demonstrator of Physiology, University of Pennsylvania. Post-
octavo of 225 pages. Cloth, ^i.oo net. In Saunders' Question- Compend
Series.

" The author's careful and well-studied selection of the necessary requirements of
the student has enabled him to furnish a valuable aid to the student." — JVem York
Medical fournal.

Martin's Minor Surgery, Bandaging, and the

Venereal Diseases second Edition. Revised

Essentials of Minor Surgery, Bandaging, and Venereal Dis-
eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur-
gery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78
illustrations. Cloth, ^l.oo net. In Saunders'' Question Compends.

" The best condensation of the subjects of which it treats yet placed before the pro
fession." — The Medical News.

Stevenson's Photoscopy

Photoscopy (Skiascopy or Retinoscopy). By Mark D. Steven-
son, M. D., Ophthalmic Surgeon to the Akron City Hospital. i2mo of
200 pages ; illustrated. Cloth, ^1.25 net.

" It is well written and will prove a valuable help. Your treatment of the emer-
gent pencil of rays, and the part falling on the examiner's eye, is decidedly better
than any previous account." — Edward Jackson, M. D., University 0/ Colorado.

l6 URINE, EYE, EAR, NOSE, AND THROAT.

Wolfs Examination of Urine

A Laboratory Handbook of Physiologic Chemistry and Urine-
examination. By Charles G. L. Wolf, M. D., Instructor in Physi-
ologic Chemistry, Cornell University Medical College, New York i2mo
volume of 204 pages, fully illustrated. Cloth, ^1.25 net.

"The methods of examining the urine are very fully described, and there are at the
end of the book some extensive tables drawn up to assist in urinary diagnosis." —
British Medical Journal.

Jackson's Essentials of Eye Third Revised Edition

Essentials of Refraction and of Diseases of the Eye. By
Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the
Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illustrations.
Cloth, ^i.oo net. In Saunders Question- Co7npetid Series.

" The entire ground is covered, and the points that most need careful elucidation
are made clear and easy." — Johns Hopkins Hospital Bulletin.

Gleason's Nose and Throat Fourth Edition, Revised

Essentials of Diseases of the Nose and Throat. By E. B.
Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical
College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations.
Cloth, $1.00 net. In Saunders'' Quesiio7t-Co?Hpend Series.

" The careful description which is given of the various procedures would be sufficient
to enable most people of average intelligence and of slight anatomical knowledge to
make a very good attempt at laryngoscopy." — The Lancet, London.

^, . «.. If . t_ ¥r^ Third Edition,

Gleason s Diseases oi the li^ar Revised

Essentials of Diseases of the Ear. By E. B. Gleason, S. B.,
M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila-
delphia, etc. Post-octavo volume of 214 pages, with I14 illustrations.
Cloth, ^l.oo net. In Saunders' Question- Compend Series.

" We know of no other small work on ear diseases to compare with this, either in
freshness of style or completeness of inhrmntion."— Bristol Medico-Chirurgical
Journal.

Wilcox on Genito-Urinary and Venereal Dis-
eases Ikervi (2d) Edition

Essentials of Genito-Urinary and Venereal Diseases. By
Starling S. Wilcox, M. D., Lecturer on Genito-Uiinary Diseases and
Syphilology, Starling-Ohio Medical College, Columbus, Ohio. l2mo of
321 pages, illustrated. Cloth, ^i. 00 net. In Saunders' Question-Compends.

deSchweinitz and Holloway on Pulsating
Exophthalmos

Pulsating Exophthalmos. An analysis of sixty-nine cases not pre-
viously analyzed. By George E. deSchweinitz, M. D., and Thomas
B. Holloway, M. D. Octavo of 125 pages. Cloth, $2.00 net.

" The book deals very thoroughly with the whole subject, and in it the most com-
plete account of the disease will be found."— 5>-/^?Vj Medical Journal.

A^I?^ .

J .5

r

Ro'^^jJY^gV^RSITY LIBRARIES (hsi.stx)
'^'"°^™,n,?,lIlS,'3.?.GCy surger

2002102153