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   COMPEND
       OF

SURGERY.

     HORWITZ. 
NEW  EDITIONS.
BLAKISTON'S   ?QU1Z-C0MPENDS?

      A New Series  of  Manuals for the  Use of Students
                              and Physicians.
        Price of each, Cloth, $1.00.  Interleaved, for  taking Notes, $1.25.
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well arranged, full and  concise, and  are really the best line of text-books  that
could be found for either student or practitioner."

    «®" These Compends are based on the most popular  text-books, and the lectures of
prominent professors, and are kept constantly revised, so that they may thoroughly repre-
sent the present state of the subjects upon which they treat.
    4®=- The  authors have  had  large experience as Quiz-Masters and attaches of colleges,
and are well acquainted with the wants of students.
    «S-Theyare arranged in the most approved form,  thorough and concise, containing
over 300 illustrations, inserted wherever they could be used to advantage.
    &g- Can  be used by students of any college.
    US" They contain information nowhere else collected in such a condensed, practical shape.
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the publishers. In ordering, always specify " Blakiston's  ? Quiz-Compends ? ".

No. 1.  HUMAN ANATOMY.  Based  on  "Gray."   Fifth  Revised  and Enlarged
    Edition.  Including Visceral Anatomy, formerly published separately.  117 Illustrations
    and 16 Lithographic Plates  of Nerves and Arteries, with Explanatory Tables, etc. By
    Samuel  O. L. Potter, m.d.,  Professor of the Practice of Medicine, Cooper Medical
    College, San Francisco ; late A. A.  Surgeon, U. S. Army.
No. 2. PRACTICE  OF  MEDICINE.  Part I.  Fourth  Edition.   Revised, Enlarged
    and Improved.  By Dan'l  E. Hughes, m.d., late Demonstrator of Clinical Medicine,
    Jefferson  College, Philadelphia.
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    and Improved.  Same author as No. 2.
No. 4. PHYSIOLOGY.  Fifth Edition, with new Illustrations and a table of Physiological
    Constants.  Enlarged and Revised.  By A. P. Brubaker, m.d., Professor of Physi-
    ology and General Pathology in the Pennsylvania College of Dental Surgery; Demon-
    strator of Physiology, Jefferson Medical College, Philadelphia.
No. 5. OBSTETRICS.  Fourth Edition.   Enlarged.   By  Henry  G. Landis,  m.d.,
    Professor of Obstetrics  and  Diseases of Women and Children, Starling Medical College,
    Columbus, Ohio.  Illustrated.
No.  6.  MATERIA  MEDICA,  THERAPEUTICS  AND  PRESCRIPTION
    WRITING.  Fifth Revised Edition.  By Samuel  O. L.  Potter, m.d ,  Professor of
    Practice, Cooper Medical College, San Francisco:  late  A. A. Surgeon, U. S. Army.
No. 7. GYNECOLOGY.  A Compend of Diseases of  Women.  By Henry  Morris,
    m.d., Demonstrator of Obstetrics, Jefferson Medical  College, Philadelphia.
No. 8.  DISEASES  OF  THE  EYE, AND REFRACTION, including Treatment
    and Surgery.  By L. Webster Fox,  m.d., Chief Clinical Assistant, Ophthalmological
    Department, Jefferson Medical College Hospital, and George M. Gould, a.b.   With
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    and Improved. By Orville Horwitz, b.s., m.d., Demonstrator of Surgery,  Jefferson
    Medical  College;  Chief of the Out-Patient Surgical  Department,  Jefferson College
    Hospital. With 84 Formulae and 136 Illustrations.
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    alysis, Animal  Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By
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    and in the Woman's Medical College, Phila.
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    Pharmacy. By F. E. Stewart, m.d., ph.g.,Quiz-Master in Pharmacy and Chemistry,
    Philadelphia College of Pharmacy;  Lecturer at the Medico-Chirurgical College, and
    Woman's Medical College,  Philadelphia.  Second Edition, carefully revised.
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    containing all the most noteworthy points of interest to the Dental  Student.  By Geo.
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No. 14: .■.DISEASES OF CHILDREN.  By Marcus P. Hatfield,  Professor of Dis-
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    P. BLAKISTON, SON & CO. 1012  Walnut St., Philadelphia. 
?QUIZ-COMPENDS?  No. 9.
COMPEND
SURGERY.
STUDENTS AND PHYSICIANS.
]  INCLUDING MINOR SURGERY AND A COMPLETE SECTION
                  ON BANDAGING.
                       BY

          ORVILLE HORWITZ, B.S., M.D.,
DEMONSTRATOR OF SURGERY IN JEFFERSON MEDICAL COLLEGE; CHIEF OF THE OUTDOOR
   SURGICAL DEPARTMENT OF JEFFERSON MEDICAL COLLEGE HOSPITAL; SURGEON
      OF PHILADELPHIA HOSPITAL; FELLOW OF THE COLLEGE OF
            PHYSICIANS, PHILADELPHIA, ETC., ETC., ETC.
FOURTH EDITION,  REVISED AND ENLARGED,
ONE HUNDRED AND THIRTY-SIX ILLUSTRATIONS
      AND EIGHTY-FOUR FORMULA.
           PHILADELPHIA:
P. BLAKISTON,  SON  &  CO.,
         No.  1012.Walnut STREj*fT-L /*rit*r t!I -v
                1891. /-^-----   -^n 
WO
  1?
1l
  Entered according to Act of Congress, in the year 1890, by

         P. BLAKISTON, SON & CO.,
In the Office of the Librarian of Congress, at Washington, D. C-
Press of Wm F. Fell & Co.,
  1220-24 Sansom St.,
    PHILADELPHIA. 
THEO. B. HORWITZ, ESQ., M. D.,




            OF BALTIMORE,






   THE FOURTH EDITION  OF THIS BOOK





     IS AFFECTIONATELY  DEDICATED





                BY





         THE AUTHOR. 
/ .:\ 
PREFACE  TO THE  FOURTH  EDITION.
  The  preparation of another edition of this  Compend  is made
necessary by the rapid sale  of the previous issue.   Following the
rule originally adopted, of completely revising the work, and adding
to its text, whenever a new publication is called for, the writer has
carefully brought the various  subjects of which it treats  down to the
present time, so as to embrace the latest views of the most eminent
surgeons.
  The  articles on Dislocations and Fractures have been thoroughly
revised.  The subject of Tumors has been entirely rewritten.  Liga-
tions have received especial  attention, and the guides  for securing
arteries on the lines devised  by Professor Brinton have been incor-
porated.
  For the first time since the work has been  submitted to the profes-
sion, a section on  Bandaging and Special Dressings is added, which
together with that on Ligation of Arteries, forms an ample text-book,
for use in the surgical laboratory.
                                    ORVILLE HORWITZ,
  Philadelphia,                             1115  Walnut Street.
       October, 1890. 
 
CONTENTS.
                                                                PAGE
INFLAMMATION,................................   9
SUPPURATION,..................................  23
ABSCESS,....................................  24
HECTIC FEVER,................................  27
ULCERS,.....................................  28
MORTIFICATION................................  32
HOSPITAL GANGRENE,............................  35
SEPTICAEMIA,..................................  37
PYAEMIA,....................................  37
ANAESTHESIA,..................................  38
GERM THEORY,................................  41
ANTISEPTIC SURGERY,............................  43
HEMORRHAGE,.................................  45
   SECONDARY HEMORRHAGE,........".............  46
   RECURRENT        "         .....................  46
SUTURES,....................................  48
WOUNDS,....................................  49
QUESTION OF AMPUTATION IN WOUNDS,................  60
HYDROPHOBIA,................................  61
BURNS AND  SCALDS,.............................  62
CHILBLAIN AND FROSTBITE,........................  64
ERYSIPELAS,..................................  65
SHOCK OR COLLAPSE,............................  67
TETANUS,................................-..-..  68
INJURIES OF THE HEAD,..........................  69
   CONCUSSION OF THE BRAIN,......................  69
   COMPRESSION  OF THE BRAIN,.....................  70
   FRACTURES OF THE SKULL,......................  71
GONORRHOEA,.................................  74
ORCHITIS,....................................  75
ACUTE PROSTATITIS,.............................  76
CYSTITIS,....................................  77
STRICTURE,..................................  77
RETENTION  OF  URINE,...........................  81
   TAPPING  THE  BLADDER,........................  83
HEMORRHAGE FROM URETHRA,......................  84
CHANCROID,..................................  84
CHANCROIDAL BUBO,.............................  86
SYPHILIS,....................................  88
TUMORS,....................................  97
ANEURISM,..................................107
HERNIA,.....................................no
                                 ix 
x                             CONTENTS.

                                                                 PAGE
DISLOCATIONS,................................"7
FRACTURES,..................................'33
SPRAINS,....................................lfil
SYNOVITIS,...................................161
COXALGIA,...................................162
ANKYLOSIS,..................................163
CARIES,..........................~...........164
NECROSIS,....................................164
RICKETS,....................................165
DISEASES OF THE SPINE,..........................' 166
AMPUTATIONS,.................................168
EXCISION OF JOINTS,.............................185
RULES FOR RESECTION OF JOINTS,...................189
LIGATION OF ARTERIES,...........................190
URINARY CALCULI,..............................206
   STONE IN THE KIDNEY,.........................207
   STONE IN THE BLADDER,........................208
   LITHOTOMY,................................209
HARELIP, . .  ..................................211
AFFECTIONS OF THE NASAL PASSAGES,.................212
FOREIGN BODIES IN THE AIR  PASSAGES,................213
AFFECTIONS OF THE EAR,........................214
PHIMOSIS,....................................215
PARAPHIMOSIS,.................•...............215
HYPOSPADIAS,.................................216
EPISPADIAS,..................................216
HYDROCELE,..................................2I6
HEMATOCELE,.................................2I?
VARICOCELE,.................................. 218
CARCINOMA OF THE TESTICLE,.....................'218
CASTRATION,.................................   2l8
HEMORRHOIDS,...............................   219
FISTULA IN ANO,............................... 2ig
PROLAPSUS ANI,.......................... .  .  . !     220
FISSURE OF THE ANUS,........................... 220
CARCINOMA OF THE RECTUM,...................        221
VARICOSE VEINS...................                      222
CLUB FOOT,.....                                     ......„„„
           '     ................................222
IN-GROWING TOE NAIL,.............
CARBUNCLE,...............
FURUNCLE OR BOIL, ....
                   *   ............................22^
HOUSEMAIDS' KNEE, .  .
224
225
226
WHITLOW,...................
DROWNING,. . .
           '        ..............................227
FARADIZATION,...............
BANDAGING,................                             ' "9
FORMULAE,......                       ...............23°
INDEX,........     ...........................2f
                         ..........................269 
ILLUSTRATIONS.
FIG.                                                                            PAGE
  i.  Chart of Sthenic Fever,............................   16
  2.  Chart of Asthenie Fever,..........................   17
  3-5.  Interrupted and Harelip Suture and Suture Needle,  .............   48
  6.  The Glover's, or Continuous Suture,......................   49
  7-10. Different Methods of Acupressure,.....................   52
 n.  Distortion from Burns,............................   63
 12-14. Operation of Trephining, Hey's Saw, and Elevator,.............   73
 15,  16. Gross's Urethrotome and Syme's Staff,....................   79
 17.  Varicose Aneurism,..............................107
 18.  Ligation of Arteries,.............................108
 19.  Scrotal Hernia.................................in
 20.  Femoral Hernia,..............................113
 21.  Operation for Oblique Inguinal Hernia,....................114
 22.  Spica Retaining Pad,.............................116
 23.  Dislocation of Lower Jaw,..........................119
 24.  Dislocation of Clavicle,............................120
 25-30. Dislocations of Humerus,.......................121, 122
 31.  Perpendicular Reduction,......   ....................123
 32.  Dislocation of Ulna, Backward,.....................   .  .  124
 33.  Reduction of  Dislocation of Index-finger,...................125
 34.  Dislocation of Hip on Dorsum of Ilium,....................126
 35.  Dislocation Backward into Sciatic Notch,...................127
 36,  37. Dislocation Upward and Downward,....................128
 38,  39. Dislocation into Sciatic Notch and on Pubes,................129
 40,41. Reduction of Dislocation of Hip,......................129
 42-45. Dislocations of Patella and Knee, Inward, Outward, Forward, Backward, . .  .  131
 46.  Reduction of Dislocated Ankle Joint,.....................132
 50.  Fracture  of Neck of Humerus,........................143
 51.  Fracture  of Radius and Ulna,.........................145
 52.  Colles' Fracture,...............................146
 53,  54. Fracture of Neck of Femur and Within Capsule...............150
 55,  56. Apparatus for Fracture of Neck of Femur,.................152
 57.  Apparatus for Extension,...........................154
 58.  N. R. Smith's Anterior Splint,  ........................155
 59.  Dressing for Fractured Patella,........................156
 60.  Coxalgia,...................................162
 61.  Pott's Curvature,...............................167
 62,  70. Circular Amputation,.........................169, 178
 63.  Long Rectangular Flap,............................170
 64.  Modified Flap.................................172
 65.  Amputation of Leg,.............................173
 66.  Long Anterior and Short Posterior Flap,....................174
 67.  Syme's Operation,..............................175
 68,  69. Hey's, Lisfranc's and Chopart's Operation,................177
 71.  Teale's Amputation,.............................179
 72.  Amputation of Shoulder Joint,........................180
 73.  Amputation of Wrist Joint,..........................182
 74.  Amputation of Finger,  .   ..........................183
 75.  Amputation of Metacarpal Bone of Thumb,.................. .  184
 76.  Diagram of Triangles of Neck,........................  191
 77.  Relations of Common Carotid,.........................193
 78.  Ligature  of Carotid,..............................194
 79.  Tying  Brachial Artery,............................198

                                         xi 
xii                               ILLUSTRATIONS.

FIG.                                                                             PAGE
 80. Tying Radial and Ulnar Arteries,.......................199
 81. Lines for Ligation of External and Common Iliac Arteries,...........200
 82. Lines for Ligature of Superficial Femoral,...................202
 83. Tying Posterior Tibial Artery,........................203
 84. Tying Anterior Tibial Artery,.........................205
 85. Lithotrity,..................................209
 86. Lateral Lithotrity,...............................210
 87. Hare-lip,...........     ......................211
 88. Application of Bellocq's Canula,........................212
 89, 90. Phimosis and Paraphimosis,........................215
 91. Hydrocele,..................................217
 92. Fistula in Ano,................................220
 93. Fissure of the Anus,..............................221
 94, 95. Dr. Allis' Club-foot Apparatus,.......................223
 96. Abdominal and Thoracic Pressure for Resuscitation of the Drowned,......227
 97. Chest Pressure for Ditto,...........................229
 98. Spiral Bandage.................................230
 99. Capelline Bandage,..............................  231
100. Four-tail Bandage,..............................232
101, 102. One Eye and Knotted Bandage,......................233
103. Crossed Angle of Jaw,.............................234
104. Gibson's Bandage,............................139,  234
105. Barton's Bandage,............................139,  235
106. Figure-of-8 of Neck and Axilla,........................236
107, 108. Anterior and Posterior  Bandage of Chest,.................237
109. Crossed Bandage of One Breast,........................238
no. Crossed Bandage of Both Breasts,.......................239
in. Spica Bandage of Shoulder,.......................... 240
112, 113. Spica Bandages,.............................241
114. Double Spica for Both Groins,.........................242
115. Spiral, of One Finger or Toe,........................243
116, 117. Spiral and Gauntlet for Fingers,.......^.............244
118, 119. Demi-Gauntlet and Spica of Thumb,...................245
120. Spiral of Upper Extremity,..........................246
121. Figure-of-8 of Ankle,............................247
122. Spica of Instep,................................248
123. Spiral-Reverse of Lower Extremity,......................240
124. Square Cap of Head,.............................250
125, 126. Bis-Axillary Cravat,...........................25!
127. Cervico-Brachial Sling,............................2j2
128, 129. Esmarch's and Scultetus Bandage,..................■.    253
130, 131. Velpeau's and Desault's Apparatus,..................254
132. Fox's Apparatus,...............................2cc
133. Recurrent Bandage for Stump,........................2cg
!34) J3S- Sayre's Jacket and Jury-Mast,......................257
136. Application of Sayre's Jacket,.........................25g 
A  COMPEND
                   OF

SURGERY.
                         INFLAMMATION.
  Definitions.—" Inflammation is that nutritive disturbance which is charac-
terized by active  hyperemia  or congestion, and active multiplication or pro-
liferation of the cells of a tissue or organ."—Professor S.  W. Gross.
  Inflammation  is the " succession of changes which occur in a living tissue
when it is injured, provided the injury is not of such a degree  as  at once to
destroy its structure and vitality."—Burdon-Sanderson.


               INTIMATE NATURE OF INFLAMMATION.
  When studying the nature of  inflammation, it  is well, for  its more ready
comprehension, to first note the modifications that take  place  in  the blood-
vessels and their contained fluid,  and then observe the changes that  occur in
the perivascular  structures.
  Active Hyperaemia.—This means an afflux or determination of blood to a
tissue or organ.                                                    *
  The portion of the circulatory apparatus which is most directly concerned in
the process of inflammatory action is the capillary system, arterioles and venules.
  The capillaries are tubular masses of protoplasm, composed of flattened,
nucleated endothelial cells of various forms, held together by an intercellular
albuminoid substance.
  The blood is a homogeneous fluid, composed of serum, together  with red
and white corpuscles.
  The red corpuscles are circular, bi-concave disks, about ^rVff of an inch in
       B                           9 
10
SURGERY.
 diameter.   They have no nucleus, and are chiefly concerned in carrying oxygen
 to  the  tissues; they are of greater specific gravity than  the  white corpuscles.
 They are found in the mid-current, while the white loiter along the sides of the
 vessels.  They move with greater velocity than the white.
   In the healthy state, the proportion of red corpuscles  to white  is as twelve
 hundred to one, varying, however, with  different periods of the day.
   The white cells are known as lymph cells, amoeboid corpuscles or leucocytes.
 They are globular bodies of about ^^ of an inch in diameter, and possess a
 nucleus.
   When a part becomes inflamed, there is a slight contraction of the capillaries,
 with retardation of the flow of blood, dilatation of the vessels and  an increased
 rapidity of circulation, followed  by exudation of the  liquor sanguinis, with
 migration  of the white corpuscles; this  is succeeded by a quiescent state of
 the capillaries, with complete stagnation  of their contents.
   It is the extravasation of the liquor  sanguinis which causes the  proliferation
 of the cells of the tissue inflamed; it is, in fact, the stimulus.
   The fixed cells of the structure inflamed, and the migrated white cells absorb
 this liquid, increase in size, and finally proliferate in great numbers.  The white
 cells, which are floating quietly along the sides of the vessels, in  the serum of
 the blood,  independent of  the red corpuscles in the mid-stream, are now found
 to be greatly changed; they are seen to be packed along the sides of the vessels,
 the walls of which have undergone fatty  infiltration or softening;  they send out
 prolongations, and by these prolongations they attach themselves  to the walls
 of  the  vessels, and, by  the  alternate prolongation  and  relaxation  of their
 processes, they work  their way through the walls into the perivascular tissue,
 by what is called amceboid movement, and these proliferate with the fixed cells
 of the tissue.
  Serum of the blood,  under ordinary  circumstances, is largely made up of
 water, together with albumin, and certain saline constituents.  The serum of
 inflammation is somewhat  perverted; there is a larger proportion of albumin
 and of salts than in health.  There is transuding through the vessels the liquor
 sanguinis, in which there is a larger proportion of albumin and of salts than in
 serous effusion, and, in addition to this,  there is the  presence of fibrin.   It is
 the presence of fibrin that causes the  effusion  to  undergo coagulation in  the
 tissues.   Such being the case, it follows that  the so-called coagulable lymph is
 liquor sanguinis, with the proliferation  of the white corpuscles,  which have
 migrated through the vessels, together with the corpuscles in large numbers
 which have resulted  from the proliferation of  the fixed cells of the tissue  in
which the inflammation is going on; in other words, it is embryonic tissue.   It
will thus be seen that  in inflammation the blood is changed in all its properties •
vital,_physical and chemical. 
INFLAMMATION.
11
   Changes  in the  Perivascular Tissues.—In  addition  to  the vascular
phenomena of inflammation, the cells  of the perivascular connective tissue,
be they fusiform, stellate or round, absorb the transuded liquor sanguinis, swell
up, increase in size and  multiply;  the white blood corpuscles, which have
migrated from the vessels, likewise proliferate, and the resulting mass of young
cells absorb or eat up the fibrilla, through which the  connective tissue becomes
converted into a mass of small cells,  held together by a semi-fluid, intercellular
substance, and this small, round-cell infiltrate is called embryonic tissue; in
other words, the  tissues have reverted  to their embryonic condition, thereby
constituting the so-called  inflammatory lymph.  These  active changes in the
cells are due entirely to the  stimulating influence exerted  upon them by the
excess of liquor sanguinis which has  escaped from the vessels.


                   VARIETIES OF INFLAMMATION.
   The nature of the exciting causes of inflammation  are  the common or ordi-
nary causes; the specific, as  those engendered by animal  poison, ferments or
contagious principles, such  as pyaemia,  septicaemia or syphilis; and the trau-
matic, those resulting from wounds or injuries.
   The state of the patient''s constitution is to be particularly studied.   If he be
healthy, there is a tendency to immediate repair; if unhealthy, the tendency
to repair is, obviously, more remote; if  he be irritable, which is characteristic"
of most strumous subjects, the condition of  the subject will be that of nervous
exaltation;  finally, the patient  may be in an infective  state, which  is one
secondary to a preexisting inflammation, and depends on  putrefactive changes
going on in an open surface.
   The  intensity  of morbid action  must be  early taken into  account.   It is
latent when it fails to  reveal itself by the  ordinary phenomena, as in latent
pneumonia, in spinal and  other  abscesses,  and in  the  ulceration of  Peyer's
patches accompanying  typhoid  fever.  It  is acute when  it  runs its  course
rapidly  and the phenomena are well  marked.  It is subacute when  the symp-
toms are not so well marked as in acute inflammation; and it is chronic when
the disease is characterized by sluggishness.
  The effusion of  inflammation may  be  serous, plastic, fibrinous, ox purulent.


                 TERMINATIONS  OF INFLAMMATION.
  The terminations of inflammation  are, first, to health, by delitescence, when
the disease suddenly disappears, before  it has passed  through its different
stages;  by resolution, when the disease  passes regularly through all the stages
of inflammation, the symptoms gradually disappearing, and the parts or organ 
12                              SURGERY.

returning to health; or, again, inflammation may terminate in death by ulcera-
tion, which is the molecular death of a  part, or in mortification, which is the
death of a part on a large scale, or en masse.
  Extension of  Inflammation.—Although  inflammation  is,  primarily, a
local process, it very soon shows a tendency to spread, and this may be done in
various  ways; by  continuity of structure, as, for  example, in  gonorrhoea;  by
contiguity, as in phlegmonous erysipelas;  by the lymphatics, which is, in
reality, an  extension by continuity; by the blood;  and, finally, by nervous
agency.
  Etiology of Inflammation.—The causes  of inflammation are divided into
predisposing and exciting.
  The more important predisposing causes are hereditary tendencies—such as
gout, syphilis, scrofula; together with  agents  that produce debility, as shock,
loss of blood, impaired nervous action, bad habits, diabetes, ansemia, plethora,
age, sex, temperament, occupation, food, etc.
  The  exciting causes are:  thermal,  those  produced  by  cold,  or  heat;
mechanical, when caused by external injuries, as from a bullet, etc.;  chemical,
when disintegration occurs from the application of corrosive substances, acids,
or alkalies; and parasitic, the result of the  ptomaines of microorganisms  on
the tissue.

                 THE SYMPTOMS OF INFLAMMATION
Are divided into local and constitutional.  They vary  with the cause, the seat
of the disease, and the constitution of the patient.
  Local Symptoms.—i.  Discoloration or Redness.—This depends upon
hyperemia and determination or afflux of blood to the part; it is most marked
in highly vascular tissues.   It is not always a necessary accompaniment of the
inflammatory process; it  is not well marked  in inflammation  of muscular or
fibrous tissues.  There is no discoloration when the brain or nerves are inflamed.
When there  is biliary derangement, there is  tendency toward a yellow color.
The discoloration is most marked at the focus of the morbid  action; it varies
in intensity from a slight flush to  a deep purple, and it may be circumscribed
or diffused.
  Redness is not always a sign of inflammation; to be of value in diagnosing
a case, it must  be  permanent, not transitory,  and is to be  taken in connection
with the other signs of inflammation.
  2. Heat, which can be  detected by the  surface thermometer,  is always
present, no matter how deeply situated the disease may be.
  It is  due to  an  increased flow of blood, to friction against the walls of  the
vessels of the part and to cell proliferation. 
INFLAMMATION.
13
  The  inflamed  part is a heat-producing area, thus causing  fever by  over-
heating the blood.
  The two symptoms always present in inflammation are heat  and disordered
function.
  3. Tumefaction or  Swelling.—This is due  to capillary engorgement,
effusion of liquor sanguinis into  the perivascular structure, and tissue meta-
morphosis, or cell proliferation.  The  amount of swelling varies with the
nature of the tissue inflamed; in dense  tissue, such as  bone and cartilage,
there is very little swelling;  it is most conspicuous in parts where there is an
abundance of lax connective tissue.
  When a serous or synovial membrane is inflamed, the  effusions  are poured
into the cavities which they form.
  It may be  soft, and  pit on pressure, resulting  from inflammatory oedema, or
it may be hard, when it is due to fibrinous exudation.
  This condition  may prove beneficial by unloading the  blood vessels, or it
may do harm by cutting off the blood supply, or by causing an obstruction, as
in oedema of the glottis and stricture of the urethra.

  4. Pain is usually felt at the seat of the morbid action, but in exceptional
cases it is experienced  in parts remote  from the disease; hence, it does not
always point out the situation  of the inflammation, as, for example, in  psoas
abscess, latent pneumonia, coxalgia,  and vesical  calculus.
  Pain sometimes suddenly leaves a part, which is a sign of commencing mor-
tification, unless this  condition be due to the influence of opiates previously
administered.
   Pain is more violent when the covering of an  organ is affected than when an
organ  itself is inflamed, as, for example, in pleuritis and peritonitis.
  The causes of pain are,  compression, stretching,  irritation  and disorgani-
zation  of  nerves;  it is variable in  degree.   Its character varies: it  may be
sharp  and  lancinating, as in inflammation  of serous  membranes; acute and
throbbing, as in formation of pus; dull and heavy, as in periostitis; annoying,
as  in  toothache;  sickening, as in inflammation of the testes;  itching,  as in
affections of the skin ; or burning and scalding, as in gonorrhoea.
  Pain in inflammation comes on  gradually, is  persistent,  aggravated by pres-
sure and muscular contraction, and is fixed; there is febrile disturbance, accom-
panied by redness, heat and swelling.  The pain of spasm  comes on suddenly,
is intermittent, relieved by pressure;  is not fixed, there is no fever, and it  is not
accompanied by redness, heat or swelling.   The pain of neuralgia is paroxys-
mal and intermittent, is aggravated by pressure,  and, like  that of spasm,  is not
fixed,  and is unaccompanied by fever, redness, heat or swelling.
  In very dense tissue the pain is throbbing, which, in a great majority of cases, 
14
SURGERY.
denotes the formation of pus.  Pain is aggravated by the dependent posture of
the part.
  5. Functional  Disorder.—In  inflammation  there is increased sensibility,
as, for example, in carbuncle, boil, whitlow, etc.; impairment of special func-
tion, as  when the eyes, nose and larynx are affected ; increased irritability due
to reflex muscular  phenomena, as in cystitis, gastritis, dysentery, etc.;  and de-
rangement of the secretions, as when the skin, liver, kidneys, etc., are attacked.
  Constitutional Symptoms.—In mild cases there is no general constitutional
disturbance ;  but if the inflammation be at all severe, the condition known as
fever will ensue.   The one sign characteristic of  fever is elevation of tempera-
ture, and it is an index to the morbid action.
  Fever generally manifests itself about twenty-four hours after the local inflam-
mation is established; it is generally ushered in with a chill, or what is termed
a rigor.  Although the patient feels cold, if his temperature be taken, it will
be found to be above normal.  A succession of chills  denotes sudden increase
of temperature.  It continues to rise, and, after a varying  interval, the patient
feels excessively  hot; then a profuse perspiration may break out, the tempera-
ture fall more or less, and the rigor is over.
  As a  rule, the temperature of the  rectum and of the vagina is one degree
higher than in the axilla.   The temperature in the morning should be taken
between the hours  of 7 and 9 o'clock, and that of the evening between 5  and 7
o'clock.
  Another set of symptoms depends on the scantiness of the secretions of the
body.   The tongue becomes furred and unclean, there is great  thirst,  want of
appetite, the bowels are constipated, the urine  is  smaller in quantity and high
colored, the skin is hot  and  dry, the respiration and heart's action are increased.
  Nervous complications arise;  the patient is languid, and complains of severe
headache, which may be followed by a confusion of ideas, going on to delirium.


                       INFLAMMATORY FEVER.
  Is also known as Symptomatic Fever, Sympathetic Fever, Traumatic Fever,
Surgical Fever, or  Irritable  Fever.
  The types of Inflammatory Fever are Sthenic, Asthenic and Irritative.
  Causes of Traumatic  Fever.—The general symptoms of traumatic  fever
appear mainly to depend upon materials absorbed from the wound ; for what-
ever prevents the  free  escape of the discharge causes an  accession of  fever
and  this is  done: by small particles of  heated blood coming from the
inflamed area, and being continually added to the circulating mass^ by the
addition to the system  of pyrogenous or fever-producing material  propagated 
INFLAMMATION.
15
at the site of the inflammation; these are lymph, fibrin, and fibrin ferment,
and, when present, the ptomaines of the microorganisms.   These agents are
carried by the blood to all parts of the body, and start an  active oxidation or
combustion;  the result is heat; they likewise act on the heat centres.
  Again, the temperature falls on establishing sufficient drainage, and the meas-
ures taken for keeping a wound aseptic minimize the fever.
  The latter fact seems to prove that traumatic fever is, to a great extent, a state of
septic intoxication, though the chemical products of inflammation are themselves
pyrogenous.  In all wounds the injury destroys the vitality of a certain amount
of tissue, and the necrosed structures are resolved into simpler compounds.
  In open and exposed wounds these compounds further decompose and furnish
secondary products, which, on being absorbed, induce fever.
  Allowance must be made for the check on the cutaneous perspiration and the
general effect of nerve irritation.


                            STHENIC FEVER.
  There are  two varieties  of Sthenic Fever: the Aseptic-traumatic and the
Inflammatory.
  The aseptic-traumatic is due to the absorption of the wound exudate, which
contains pyrogenous material, and produces fever, as already explained when
treating of Inflammatory Fever.   An illustration of  this  form  is the rise of
temperature following a simple  fracture.
  The inflammatory variety  is due to tension, when drainage has been inter-
fered with, improperly carried on, or altogether neglected.   The proper treat-
ment of this  variety is to see that drainage is fully established.
  It occurs in young, robust subjects, and is characterized  by great force; the
temperature is from loo° F. to  103^° F.  There is an increased intravascular
pressure, as manifested by the pulse, which is frequent (from 85 to 120), hard,
strong, full and incompressible.   There are, however, exceptions to this rule, as
in peritonitis, where  the pulse is hard, small, frequent and  wiry.  The  face is
suffused, the  eye watery and the skin is hot, dry and harsh ; the respiration is
frequent and  labored;  the tongue is coated with a whitish, brownish or yellow-
ish fur; the mouth is parched and dry; the taste vitiated.  The patient may
suffer from anorexia, nausea, and  sometimes bilious vomiting.  As a rule, the
bowels are constipated and the  discharges offensive.
  The urine  is scanty and diminished one-quarter to one-half in  quantity from
the natural condition ; it is high-colored, of  a reddish tint and deposits lithates
or urates while cooling; it sometimes  contains albumin and tube casts; it is
more orjess offensive.
  There is a  peevish and fretful condition of the mind, frontal headache, loss 
16
SURGERY.
of sleep, and when asleep the patient  is disturbed by dreams.  There may be
delirium and perversion of the organs of special sense.
  There are  generally severe pains in the back and  loins; nutrition is greatly
perverted;  assimilation is held in abeyance ; the patient does not wish to par-
take of food; the tissues begin to waste, the fat  disappears, and emaciation
follows rapidly, more so than when caused by inanition.

                                 Fig. i.
DAY    97  98   "  ,0°   l01   102   103   104  105   106   107
1												
												
2												
												
3	---	........										
												
4		---		.......	_-TS	"sr	---	---	--		--	---
5					s.							
												
6		--		.<-		L---	--		.......			
												
7	--		-f									---
8			<S									
			V									
9			<f									
	•		1									
10												
												
1 1			..{....									
												
										-1.....-		
		__________J										
												
CHART OF STHENIC FEVER.
  It reaches its climax in from two to four days, and then gradually disappears.
In ordinary uncomplicated cases all signs of inflammatory fever disappear by
the end of the first week.

                          ASTHENIC FEVER,
Which  is also  known as adynamic, typhoid, hectic, or septic-traumatic fever,
is the  fever of debility and of prostration, no matter  how it may have been
brought about;  whether from bad food, overwork, shock, profuse perspiration,
septicaemia, pyaemia, peritonitis or any other depressing cause.
  Septic-traumatic fever  is  due to the  absorption  of septic material,  as in
a putrid wound, such as may  be found in  a suppurating compound. fracture or
diffused abscess, whenever the ptomaines  of  the microbes of suppuration and
decomposition are absorbed from a wound.
  The temperature varies from  ioo° F. to  io6°  F., and is liable to oscillations. 
INFLAMMATION.
17
  It is generally ushered in with a chill, or there may be successions of chills,
which may recur  every  other day or every third day, and which will be fol-
lowed by increased fever and profuse perspiration.
  The pulse is weak, tremulous, soft, compressible and  frequent, varying  any-
where between 100-160 per minute.  The respiration  is oscillating;  in  very
severe cases it may reach from 20 to 25 per minute.
  The countenance is pallid; the features are pinched,  and the individual has
a listless look, presenting what is known as the Hippocratic countenance ; the
skin is cold and clammy;  the tongue is dry, hard and covered with a brownish

                                   Fig. 2.
       DAY"    97    98   99  100   101  102   103  104-  IPS   IQg   IP?
CHART OF ASTHENIC FEVER.
or blackish fur; there are sordes on the gums and teeth; the stools are offensive
and tarry ; or there may be fetid diarrhoea, the result of septic changes in the
blood.  There are  spasmodic twitchings,  with  hiccough  and subsultus  ten-
dinum.   The senses are obtunded, the mind is  obtuse, and there is low, mut-
tering delirium, with picking of  the bedclothes, etc.
  The urine is high-colored, scanty and of high specific gravity;  the digestion
and assimilation of food is impaired, with consequent emaciation.
  Irritative Fever is the ulcerative and gangrenous type of fever.  It some-
times appears as  a modification  of adynamic  fever.  It  is met  with  most
frequently  in the  sloughing and ulcerative processes of phagedena, buboes, 
18                              SURGERY.
carbuncle, etc. ; it is characterized by an elevation of temperature, ranging
from ioo°-io3° F., which  does not persist, and is accompanied by frequently
recurring chills.
  The nervous system is extremely sensitive;  the patient is peevish,fretful and
despondent;  there is imperfect sleep, accompanied by headache, which is per-
sistent  and aggravated by the slightest noise.
  The pulse is small, quick and jerky.
  The skin is hot and dry, and there are muscular pains.

                  TREATMENT  OF INFLAMMATION.
  The indications for the treatment of inflammation are:  the removal  of the
exciting cause and the establishment of resolution.
  As long as the exciting cause remains, the inflammation will continue; after
its removal, the disease generally terminates spontaneously.
  To establish resolution the  treatment is  divided into general, local and con-
stitutional.
  The General Treatment, which is adapted to all stages of inflammation,
is rest, elevation and relaxation of the affected  part.   Local  rest may be pro-
cured by bandages, splints or weights; the efforts of the patient to avoid the
pain of motion  will  act as a splint.  Elevation of the affected part  acts as a
restorative to the  equilibrium of the circulation by retarding the ingress  of
arterial blood in undue quantity and expediting the return  of  venous blood.
  To obtain relaxation, the affected part  must  be placed in such a position as
to relax all the tissues in the immediate neighborhood.
  Local Treatment.—The first stage is  that of engorgement or of increased
intravascular pressure, with commencing  effusion;  to lessen stasis, restore the
tonicity of vessels and relieve the perivascular tissue of effused material, local
bleeding is resorted to.  By this means the flow of blood through the  inflamed
part is accelerated, thus washing out, so to  speak, the adherent white corpuscles
and breaking up the rouleaux of red corpuscles, as well as relieving in part the
surrounding tissues of the excess of liquor sanguinis and white cells, due to
inflammatory extravasation, by the operation of the well-known law of capillary
attraction.  The materials that caused the engorgement having disappeared,
the capillaries again resume their normal condition.
   Local depletion may  be effected by Punctures, Scarification, Leeching  or
Cupping.
   Puncturation may be employed when there is great tension, as .in tonsillitis,
hemorrhoids, etc.
   Scarifications;  incisions  varying  in length, are  resorted to in  inflammation
produced by infiltration of urine, chemosis, etc. 
INFLAMMATION.
19
  Leeches are usefully applied to the neighborhood of inflamed  parts, but
should not be put on the inflamed  surface  itself.   They  should be  placed
between the inflamed part and  the heart  If it is  desired to remove a leech
after a certain time, this may be accomplished by sprinkling salt upon it.  The
bleeding may be  stopped by applying to the part  nitrate of silver, muriated
tincture of iron, spider's web, the actual cautery or styptic cotton.  The flow
of blood  from a  leech-bite  may be continued by the application  of warm
water.
  Cupping is more painful than scarifications or leeching.  Cups should not be
applied for inflammation below the diaphragm.
  The supply of blood to an affected  part, may be cut off by ligation of the
artery leading to the seat of disease; by compression, either by tourniquet or
with the fingers;  or by flexion, as by flexing the forearm on the arm.
  The application of cold is frequently of service; either spring  water or ice
water may be used.  A cooling lotion, consisting of alcohol one part and water
one part,  or saltpetre (nitrate of potassium)  five parts, chloride of ammonium
five parts, and water sixteen parts, is recommended, care being taken that the
temperature is not kept below 450 F.  The cold lotions may be contained in
ice bags.
  The effect  of cold  applications is very powerful in the treatment of inflamma-
tion ;  it restores the tonicity of  the capillaries by contracting their calibre, thus
retarding  effusion  into the surrounding  structures; it reduces the temperature;
it arrests tissue metamorphosis and promotes diffusion  of the effused materials
into the vessels; it relieves tension and pain by restoring the equilibrium of the
vessels.
  The application of cold is contraindicated in asthenic types of  fever, in old
persons and in young children.
  When the  second stage or that of plastic effusion is  fully established, com-
pression should be employed by means of a muslin or elastic  roller bandage,
adhesive strips, compressed sponge or bags of shot.  These act by giving sup-
port to the blood-vessels,  restoring their tonicity and facilitating  the  absorption
of effused material.
  Acetate of lead is applicable to all  cases of external inflammation; it acts
as an astringent,  sedative and sorbefacient;  it  is usually  employed in the
strength of eight grains of the salt to one ounce of water.
  Chloride of ammonium is used in  the  same strength as the  acetate of lead.
Tincture of iodine is employed in the same  manner as the salt of lead; it is
especially beneficial in cedematous inflammation.  It should be applied directly
over  the  seat  of  morbid action;  it is usually diluted about one-half with
alcohol.
  Nitrate of silver, varying in strength from two grains in an ounce of water, 
20                              SURGERY.

to the application of the  solid stick, depending upon the purpose for which it
is employed, is a remedy frequently resorted to.
  The cold or hot douche is beneficial in stimulating the  absorbents;  it  is
especially applicable in sprained ankle.
  Massage is efficacious in getting rid of extra-articular adhesions.
  The stage of threatening or fully-established suppuration may be  called the
third stage; the indication is to favor the formation of pus.
  The symptoms of the advent of the third stage are augmented tension of the
part, with throbbing pain and an increased swelling, and this condition is to be
met by the application of heat and moisture, by means of fomentations, stupes,
continuous warm baths and poultices.
  Counter-irritants are particularly applicable in cases of subacute and chronic
inflammations; they act by causing an afflux of blood to points of application,
thereby producing anaemia to the inflamed part beneath.
  There  are three classes of counter-irritants,  viz:  rubefacients, vesicants and
suppurants.
  The rubefacients are :  mustard plasters, turpentine stupes, tincture of iodine,
ammonia liniment, capsicum.
  The vesicants are employed to  produce superficial inflammation and vesica-
tion.  They are cantharides, collodium  cum cantharide;  equal parts of pow-
dered carbonate of ammonia and  lard; lint saturated with  chloroform applied
to the part and covered with oiled silk.
  Suppurants are agents used to produce suppuration;  they are oleum tiglii,
issues, setons, tartar emetic ointment, actual  cautery.
  Constitutional Treatment.—General bloodletting is to be used when the
inflammation is characterized by high vascular pressure, in strong, robust indi-
viduals.   Bloodletting is likewise indicated in inflammation of any of the great
viscera or their coverings;  especially is this  the case in acute  cerebral conges-
tion.   To be of use it must be resorted to in the first stage of inflammation.
  Bloodletting is  contraindicated during epidemics, in  typhoid conditions,
gangrenous, ulcerative or suppurative processes, erysipelas, in corpulent persons,
in extremes of age, in drunkards and in  nervous individuals.
  The effects of general bloodletting are to relieve arterial tension, diminish the
volume,  accelerate the current of  the  blood, relieve the  tissues of effused
material, and reduce the  temperature by withdrawing a large amount of pyro-
genous, or fever-producing material from the  general circulation.   It likewise
promotes the action of other remedies.
  When  these desirable effects are produced, the condition may be maintained
by the use of arterial sedatives, such as tincture of veratrum viride, aconite root,
gelsemium, tartar emetic.
  The diaphoretics in general use are acetate of ammonium, citrate of potassium, 
INFLAMMATION.
21
Dover's powder, fluid extract of jaborandi, muriate of pilocarpine, lemon juice
with bicarbonate of potassium.
  The diuretics in  use  are  infusion of digitalis, salts of potassium, citrate of
caffein, colchicum, cocaine, coffee, etc.
  Cathartics are  used to evacuate the bowels, deplete the mucous membrane,
excite the action of the liver, salivary  glands and mucous follicles, and to
stimulate  the absorbents,  thereby  inducing  them  to  remove inflammatory
deposits.
  Enemata of warm water, or soap and water, to which turpentine or vinegar
may be added, are frequently employed.   Glycerine suppositories may be used
to unload the bowels; to take the place of cathartics.
  Emetics  are indicated when the  skin is  hot and dry, the  tongue heavily
coated, and  when there  exists a sense of great weight at the epigastrium.  All
emetics should be followed by copious  draughts of warm water. The emetics
generally used are  alum in doses  of  a drachm, sulphate of  zinc  in scruple
doses, sulphate of copper in like quantity,  mustard and  salt,  ipecacuanha in
scruple  doses, tartar emetic in two-grain doses.  Emetics should not be pre-
scribed in inflammation  of the brain, eye, or of the viscera below the diaphragm.
  Mercury is indicated  when the pulse is  soft, skin relaxed and  moist, and
when there  is a general tendency  to restoration of the secretions, and not
before.   It reduces the plasticity of the blood and causes absorption of the
embryonic tissue.   It is of great  benefit in membranous croup, hepatization of
the lungs, iritis, syphilitic inflammation and  such like  diseases. It is usual to
combine  with the  mercury a  small quantity of opium, to prevent  its being
carried off by the bowels.
  It is  contraindicated  in persons of strumous habit;  the old, ill-fed, badly-
nourished and the anaemic.
  Mcrcurialism is indicated by a peculiar fetor of the breath;  red  and tumid
gums, metallic taste in the mouth, an increased flow of saliva, ulceration of the
buccal mucous membrane, and diarrhoea.  The treatment for this is astringent
gargles;  Goulard's extract  one ounce to water eight ounces, used  every hour
or two;  alum, tannic  acid, copper, zinc,  atropia by  hypodermic  injection,
chlorate  of  potassium in doses of  20 to 30 grains three times daily, mor-
phia, p. r. n.
  Anodynes.— Opium is applicable to the treatment of inflammation in all
stages of the disease.
  The exhibition of opiates should be preceded by bloodletting when admis-
sible; in other cases by a cathartic.  The remedy should be administered in
full doses, as small doses act as stimulants, while larger doses act as sedatives.
  Hypnotics.—When the patient is restless but not suffering acute pain, hyp-
notics  are  indicated; bromide of potassium, gr. xxx, chloral, gr. xx, taken at 
22                              SURGERY.

bedtime, paraldehyde in doses of one drachm freely diluted, or hydrobromate
of .hyoscine  in  doses of Tfa of a  grain, may be used; if the patient suffers
great pain, one-sixth of a grain of  any of the salts of morphia may be added.
Sometimes a glass of milk punch, ale, or whisky will answer.
  Tonics.—The principal are quinine, iron, and  nux vomica, or its equivalent,
strychnia.
  Antipyretics.—These are principally quinine given in  twenty-grain doses,
administered about an hour before the evening exacerbation; salicine in doses
of about fifteen  grains during the intervals, or antipyrin  administered by the
stomach or hypodermatically.
  Antiphlogistic  Regimen.—In the early stages of inflammation, the patient
has  no desire  for food, nor should he be induced to eat,  as it may produce a
feeling of great distress, as well as nausea.  At this period iced lemonade is
very grateful.   After the  administration of a cathartic, a fluid diet may  be
resorted to.  Suitable articles  are beef tea, milk, soups with  the fat skimmed
off, Valentine's meat, Johnson's fluid  beef, koumiss, raw oysters, sweetbreads,
soft-boiled eggs, eggnog, etc.  A patient on a liquid diet  should have at least
two  pints of milk with one pint of beef tea during twenty-four hours.  Stimu-
lation by  brandy, whisky, sherry, Madeira wine, etc., must  be resorted to
when necessary.
  Nutritive Enemata.—When the patient is unable to bear diet by  the stom-
ach, then rectal  injections of nutritious substances must be  resorted to.  A
dietary enema should not exceed three ounces.  The following articles may be
used: Johnson's fluid beef, milk, eggs, or milk  and  eggs  combined, and beef
tea.   An  injection   should be repeated about every  three hours.   To  each
injection should be added five grains of pepsin and five  grains of pancreatin,
together with ten drops of dilute hydrochloric acid and one  drop of carbolic
acid. When milk is used, the hydrochloric acid should be omitted.
  Good ventilation  is absolutely  necessary.  The  temperature  of the sick
apartment should range from 68° F. to 700  F.
  Cleanliness and Quietude should be strictly enforced.


        PATHOLOGICAL TERMINATIONS OF INFLAMMATION.
  Pathologically inflammation terminates in one of three ways : By the effusion
of serum, by  the effusion  of  lymph,  and  by the effusion of  pus.   They are
all  results of inflammation and perform  an active part  in the inflammatory
process.   Serum is  simply the liquor sanguinis of the blood,  the  pabulum
upon which the  proliferous cells subsist.   Lymph is  the embryonic tissue of
the inflamed part.
  Effusion of serum denotes a mild type of inflammation.   It is  not serum but 
SUPPURATION.
23
 the  liquor sanguinis of the blood altered in its composition; the structures in
 which it is  most generally present are loose connective tissues and serous
 cavities;  large quantities are sometimes poured out by the mucous membranes
 of the alimentary canal, as in diarrhoea and cholera.
   When the effusion accumulates in parts endowed with abundant connective
 tissue, there will be oedema.  If the effusion is into a joint or serous cavity
 there will be dropsy, or general oedema.
   In oedema the  parts present a soft, glazed, inelastic  swelling which pits on
 pressure.   Dropsy in cavities is detected by palpation and percussion.
   Treatment of the Terminations  of  Inflammation.—Local.—By tap-
 ping when in a cavity; by punctures when in  connective tissue; by incisions
 when gangrene is threatened;  by compression to promote absorption; by sorbe-
 facients,  the  principal of which are iodine,  acetate of lead, chloride of  ammo-
 nium, nitrate of silver, hot and cold douche, and massage.   The constitutional
 treatment is by hydragogue cathartics, diuretics and mercurials.
  Deposit of Lymph denotes  a  higher  grade of inflammation than effusion of
 serum.   There are two varieties, plastic and aplastic.  The plastic  lymph is
 the formative variety, and  is capable of being organized;  on  the contrary,
 aplastic lymph cannot be  organized and is  non-formative.   This variety of
 lymph forms the lining of sinuses and fistulas, and prevents their healing.
  A deposit  of lymph disappears by absorption, atrophy, pus formation, fatty
 degeneration, and calcification.  Should  it  remain it will  be as  a permanent
 thickening; or it may be employed to repair the structures damaged by inflam-
 mation.
  The local treatment is the same as that for effusion of serum; the constitu-
tional treatment will require the  exhibition of alteratives  and tonics, such as
iodide of potassium, bichloride of mercury, iodide of iron, etc.
                          SUPPURATION.
   Suppuration is the formation of pus in a part.  It is most commonly found
in the connective tissue, serous and mucous membranes, and in the lungs.
   Pus is a fluid, new formation, made up of serum, albumin, salts, pyine, fatty
matter and certain salts;  its solid constituents are corpuscles, shreds of connec-
tive tissue, and granules of fatty matter.  The microscope reveals  the presence
of micrococci, upon which suppuration depends.   Fibrin is never  found in pus
because the micrococci of suppuration feed upon the fibrinogen  and prevent
the formation of fibrin; hence pus  does not coagulate.
   Pus effects a good  purpose in facilitating, loosening and extruding foreign
substances, and in assisting granulation; the good effects, however,  are more 
24                             SURGERY.

than counterbalanced by the bad, which are destruction of tissue and exhaustion
of the patient.
  The varieties of pus are : I. Healthy or laudable pus, which is an " opaque,
homogeneous, yellowish  fluid,  of an  alkaline reaction, mawkish odor, sweetish
taste, and of a specific gravity of about 1021  to 1040."  2. Sanious, or ichorous
pus, which is a  product of unhealthy inflammation;  it is thin, highly acrid and
of a reddish color.   3.  Fibrinous pus  is semi fluid, of a whitish or ash color,
with flakes of  fibrin; it is found in inflammation of the joints.  4. Gummy
pus; highly gelatinous, met with in  tertiary syphilis.   5. Muco-pus, i. e., pus
mixed  with mucus.  6.  Contagious pus; the  variety met with  in smallpox,
gonorrhoea  and  in venereal ulcers.
  Pus is usually formed in from twenty-four  to seventy-two hours, but the time
will vary much  with the  constitution  of the patient and the structure of the part
in which the inflammation is seated.
  When pus is formed under fascia,  or deep in the mamma or pelvis, and can-
not make its way to the surface, the constitutional symptoms are much more
severe.
  Symptoms.—The formation of pus is often attended with severe constitu-
tional irritation; there are rigors succeeded by heat, and if the inflammation be
extensive or seated in any vital organ, the  constitutional disturbance will be
very severe, and the shivering, which indicates the  formation,  will  also be
severe, and followed by  powerful reaction.  When the pus is easily produced,
there may be little or no rigor; as upon a mucous membrane.


                              ABSCESS.
  An abscess is a circumscribed cavity of new formation containing pus.
  Abscesses are known as superficial, deep-seated,  acute, or phlegmonous,
chronic, common, specific and residual.
  An acute abscess is one that runs its course rapidly, and is-always  accom-
panied by well-marked inflammatory symptoms.   It is, from its great frequency,
one of the most important of surgical diseases. When an inflamed  part becomes
more heated and  more swollen; when  the skin assumes  a dusky hue, and
becomes glossy  and shiny; when the pain  which has been of a dull, heavy
nature, becomes persistent, steady and throbbing, and  when  the skin over the
swelling is oedematous, then there can  be no doubt that an abscess is formed.
  In the formation of an abscess the first phenomena are those of inflammation,
which have been already described;  when the  production of embryonic tissue
has been reached, if it stops at that point resolution is established and recovery
ensues; but should the new  "cellular infiltrate"  be invaded by the micro- 
ABSCESS.
25
organism of suppuration, and a suitable soil for its nidus and growth be found,
they will be nourished by the albumin in the tissues; and it is their  excreta,
known as ptomaines, which peptonize  the  fibrin and  change the embryonic
tissue to a liquid, which is pus. .
  The changes here described begin in the lymph spaces, so that an abscess
never has  its commencement at a single  focus; the accumulation  of liquid and
cells causes the lymph spaces to  be greatly distended; the fibrous tissues sepa-
rating  these spaces are widely pressed asunder, causing their supply of blood
to be cut off, sloughing  being the  result; moreover, the  living pus cells find
in these fibres  a source  of nourishment, and they are  thus destroyed;  hence
the lymph spaces become converted into a single cavity, and  an  abscess is
formed.
  From the periphery to the centre of an abscess all stages of inflammation are
presented, from the first, which is the stage of congestion, to the last, which is
the period of the formation of pus.
  Between these two conditions there is a middle point where the  inflamma-
tory process has reached only the formation of embryonic tissue, and hence it is
that the cavity of an  abscess is always circumscribed by a tissue of new forma-
tion.
  Not only does an abscess extend in various directions, but all abscesses tend
to empty themselves at the point of least resistance; they approach the surface
where they spontaneously evacuate themselves;  their tendency  being toward
the skin.  The abscess  discharges itself by a small opening, which is due to
the death of a limited portion of the skin.
  The contents of an acute or phlegmonous  abscess are laudable pus, micro-
cocci, and some little shreds of dead tissue.   In some cases the abscesses con-
tain air, when  the contents are extremely fetid.
  A phlegmonous abscess occurs at all periods of life, in  all classes of
persons; it varies in size; is  most frequently met with  in  subcutaneous con-
nective tissue,  in the muscular tissue, around the lymphatic glands, and around
the bones.   Its most common sites in the viscera are the liver and brain.
  Tuberculous Abscess.—Cold  Abscess, Strumous  Abscess or  Chronic
Abscess.
  The effect of the bacillus of tuberculosis on tissue is to  produce  a chronic
inflammation which results in the production of granulation tissue; this  is  the
so-called pyogenic  membrane of old authors, and acts as a  protective wall
to the surrounding tissue.
  The degenerative changes  that take place are caused by local anaemia, and
by the chemical action of the ptomaines of the tubercle bacilli; they consist
of a caseation  and liquefaction of the cheesy  material.   This liquid has hitherto
been looked upon as pus; it is now  known to be retrograde tissue metamor-
       c 
26                             SURGERY.

phosis.   Pus is never present in a tubercular process, unless the microorganism
of suppuration be present,  when there will be a mixed or double infection.
   If the bacillus meet with sufficient  resistance  by the  surrounding tissue, it
exhausts the nutritive material in  the  granulations and  dies; or it remains in
a latent condition;  the granulation is  converted  into  a  cicatricial tissue, and
the local lesion is cured.   This is designated spontaneous cure.  The liquid
may also be absorbed when a similar favorable termination is possible.  If the
cavity is opened  under antiseptic precautions, cure is accelerated ;  if, however,
secondary infection  with pus  microbes takes place, the patient is in danger of
septic infection, as  well as  local and general dissemination  of  the tubercular
process.   See Psoas and Lumbar Abscess, p. 164.
   Treatment of Suppuration.—Remove, if possible, the morbid condition
of the constitution  on which  the  disease depends; gentle purgatives may be
useful, and exciting causes, such as thorns, splinters, etc., should be removed.
   Poultices are  highly  beneficial; they relax the skin,  soothe  the pain and
encourage the formation of pus.
   Good  substitutes for  poultices are warm water dressings  and the spongio-
piline.
   The treatment  of an acute abscess consists in the early evacuation of the
pus.  The incision  must  be made before the pus  has an opportunity to open
into parts which should be  spared,  and it must be  made at the point from which
the best drainage can be procured.
   All abscesses  must be treated with antiseptic  precautions, because micro-
organisms  are in the  tissues  circumscribing the abscess; following the direc-
tions given in the article under the head of Antiseptic Surgery, page 43.
   The tubercular abscess  must not  be allowed to open itself spontaneously.
This precaution is to be  particularly borne  in mind when the glands of the
neck are affected.
   Open the abscess in the most dependent portions, using a straight, sharp bis-
toury for the purpose;  press out  the  accumulated  material; scrape  out the
abscess  thoroughly; wash  it with  an antiseptic solution  of bichloride of  mer-
cury, then bring the opening together by means of a suture; insert  a drainage
tube, and place upon  the outside iodoform gauze.
   Before  opening one of these abscesses, and after ether has been adminis-
tered, give one-sixth of a grain of morphia  hypodermatically, and also admin-
ister one grain of opium every  eight hours.
   Constitutional  Treatment.—Where the suppuration is profuse, tonics, such
as iron, quinine, strychnia, together  with  good  nutritious diet, milk punch
etc., with change of air, must be insisted upon. 
HECTIC  FEVER.
27
                         HECTIC FEVER.
  Hectic Fever  is a form of remittent  fever, consisting of an exacerbation,
once or sometimes twice a day; depending on either suppuration,  or upon im-
portant organic derangement of structure.
  Symptoms.—One of the first  symptoms is a slight increasing frequency of
pulse, and a small  degree of heat  of skin, generally  toward evening, becoming
more and more pronounced as the disease advances, and subsiding before the
beginning of the next day.   The heat is especially felt in  the palms of the
hands and the soles of the feet.
  The exacerbation reaches its height about midnight and terminates by a pro-
fuse  perspiration toward morning.
  The heat of skin during the paroxysm is often considerable and always dis-
tressing, so that very little  covering can be endured.   The respiration is quick
and  short.   The appearance of the face is characteristic; there  being a cir-
cumscribed  blush in the centre, known as the " hectic flush."   The patient
loses flesh rapidly.  The pulse is above 80 and is soft.  The  temperature, as a
rule, varies from 990 F. to 1010 F., and  rises higher when symptoms of disso-
lution come on.  Sometimes the temperature falls below the  normal, 96.50 F.,
which indicates that the patient is  in a critical condition.
  If the fever arise from  local disease it may cease  at once on the removal of
the cause.   It is always symptomatic of some particular disease;  generally of
the presence of profuse  discharge, as of pus or blood, or it  may  indicate the
existence of an abscess in some important  structure, as  of the brain, lungs or
liver, and is in part due to the entrance of septic products into the blood, as in
septicaemia; if otherwise, the  diarrhoea and  perspiration become more and
more exhausting, and the patient sinks.

  Treatment.—Remove  the local disease, if possible; this  may be done by
letting out pus, removing the diseased part, or resorting to such  other opera-
tion  as may be necessary.
  Support the strength by good, nourishing diet, animal and  farinaceous food,
eggs, macaroni, milk, wine, beer,  etc.
  Quinine, sulphuric acid and iron are the medicines generally indicated.
  Diarrhoea is best combated by selected diet, aromatic sulphuric acid, small
doses of  opium, chalk mixture, etc., etc.
  Night Sweats.—Sponge the surface with  cold water, or  alum and water.
Give aromatic sulphuric acid, gtt. xv t. d.;  or atropia sulph., an eightieth of a
grain; or extract  belladonna, half a  grain,  combined  or not with oxide of
zinc, two or three grains, at bedtime. 
28
SURGERY.
                               ULCERS.
  An Ulcer is a solution of continuity in any of the soft parts of the body,
attended with inflammation and a discharge of pus, ichor or sanies.
  Ulcers are divided into acute and  chronic, according to the intensity and
rapidity of  the morbid action.
  The ordinary ulcer may have begun as a wound or bruise, abscess or other
disease or  injury;  the granulations are small, numerous, florid and  pointed,
and yield a moderate secretion of healthy pus.
  Cicatrization begins with an absorption  of swelling around the  wound, and
a contraction of its margin;  its edge begins to  look  smooth and bluish, and a
thin  pellicle  of new cuticle  gradually spreads from the edge, in a converging
circle, till the wound is closed.
  An acute ulcer  is distinguished by the rapidity  of its progress  and  the
severity of  its symptoms.
  The pain is often a prominent symptom ; it varies in character, being some-
times throbbing and again sharp and pricking, dull, heavy and gnawing.
  When the ulcerative action  is  rapid  and  extensive, there is more or less
fever, with  thirst, restlessness, loss of sleep and excitement of the pulse.
  The tissues most  disposed to  ulceration are the  skin  and mucous mem-
branes;  the areolar  tissue  ulcerates very  easily; muscles, blood  vessels and
nerves, very  slowly;  tendons and  ligaments  are  very slow to ulcerate;  but
cartilage, bone and the cornea are sometimes extremely liable to it.
  Weak and cachectic constitutions are most liable to ulceration.  The parts
usually affected are  those where the circulation is most  weak and  languid;
such as the legs;  especially if the veins be varicose.

  Treatment.—In  acute ulcers the patient should be kept in bed,  with  the
limb raised on a pillow;  saline purgatives  must be administered.   Calomel
and  blue mass should be combined with a  saline cathartic.   Pain  must be
relieved  by opiates.   Soothing  applications, such  as poppy lotion, 'or acetate
of lead  and  opium, should  be  resorted to; cold or warm lotions, as are most
agreeable,  should be applied.
  In many cases a tonic and stimulating treatment will be better suited to the
patient;  when used, quinine and iron are the remedies most in vogue, and a
diet, nutritious and generous must be added.
  If the inflammation runs  high,  it is well  to draw blood by scarification.
" From six  to a dozen vertical incisions, not quite skin deep, is  made  over the
inflamed surface around the  sore, and the  blood is permitted  to flow  until  the
patient shows signs of approaching  syncope, if he be at all plethoric, or, at all 
ULCERS.
29
 events, until the engorged vessels  have been  thoroughly unloaded, which will
 be denoted by the comparative pallor of the part."
   If scarification is not resorted to, the plan to be pursued is to paint the parts
 surrounding the ulcer with a solution composed of equal proportions of alcohol
 and tincture of iodine;  then envelop the whole with a hot solution of acetate
 of lead.
   Under the influence of rest, elevation and the remedies  here prescribed, the
 inflammation will disappear and granulations will begin to make their appear-
 ance.   If the bottom of the sore is foul, before applying the iodine or acetate
 of lead, sprinkle it with iodoform.
   In the early stages of the disease water dressing medicated with bichloride
 of mercury (1-1000) lotion should be used;  when  the discharge  becomes
 healthy, pieces of lint saturated with the lotion  should be  laid on the  sore;
 then strips of  adhesive plaster should be applied two-thirds around the  limb,
 from  an inch below the ulcer to an  inch above it;  the  plaster should  be so
 applied  that the edges of the sore  may  be drawn  together with a moderate
 degree  of force; then a compress of soft linen should  be placed over  the
 plaster, and finally the  limb should be bandaged from the toes to the knee.
 The parts should be kept clean and washed every day with soap and water.
   Phagedenic  Form   of  Acute  Ulcer.—This  variety  of ulcer spreads
 with  great rapidity, destroying everything within its reach.  It is frequently
 met  with in persons broken down with disease  or who are much debilitated.
 The bottom of a phagedenic ulcer is liable to  be covered with a slough which
 is  of grayish color.  The discharge is serous, profuse and highly offensive.
   Treatment of Phagedenic Ulcer.—Cleanse the part  by soaking up with
 absorbent cotton all the  discharges from the ulcer that may be present;  then
 destroy the  edges of the ulcer with some one of the  acids.  When this has
 been done, touch the  edges  of the sore with  absorbent cotton saturated with
 nitrate of mercury one part, water eight parts, and insert  the cotton under the
 undermined edges  of the sore.  Having done this, sprinkle the  edges with
 iodoform.  Surrounding  the slough is an  acutely inflamed surface; paint this
 with the tincture of iodine and dress  the limb  with a hot solution of acetate
 of lead and laudanum, keeping the parts  in an elevated and relaxed position.
 Give  the patient nourishing diet,  quinine and iron, with  stimulants, if neces-
sary.   If the pain is severe,  administer one grain of opium every eight hours.
   In  the irritable  form of acute ulcer, when, in addition to the surround-
ing inflammation, the  ulcer itself is not only the seat of intense  pain, but is ex-
tremely sensitive to the touch, the best mode of treating the irritated points is
to  insert a bistoury underneath them, make a small incision and  divide the
nerve;  then paint  the surface with a solution  of nitrate of silver,  gr. x  to 
30
SURGERY.
 water Sjj; dress with solution of chloral  hydrate  of like strength, as recom-
 mended by Professor Keen.
   A  Chronic Ulcer may be the sequel of an acute ulcer, or it may be chronic
 from  the beginning.   It is characterized by slowness of progress, and the com-
 parative absence of constitutional  symptoms; it has its surface smooth and
 glassy, more  or less irregular, and  is of a pale ashy color;  sometimes it dis-
 plays a crop of weak granulations; the edges are raised, thick, white, hard,
 or callous and insensible; in some  cases they are  thin, ragged and serrated;
 the discharge being scanty and thin.
   Ulcers are frequently stationary for a great length  of time, and  from slight
 causes may enlarge rapidly, by ulceration  or sloughing; and even when they
 have  made considerable progress in healing, they  may without any manifest
 reason, quickly retrograde.
   A fistula or sinus is a narrow channel, lined by a  pseudo-mucous membrane,
 which may or may not lead  to a suppurating  cavity.
   A varicose ulcer is one that is seated on a leg the veins of which are varicose.
   For the treatment of chronic ulcers all the mineral and vegetable astrin-
 gents may  be tried in turn:  mercury, tannin,  catechu,  zinc, iron, copper, alum,
 silver ; for general  use, sulphocarbola.te of  zinc is one of the best;  it contains
 the astringency of the zinc, with the antiseptic virtues of the carbolic acid.  For
 reducing thick,  callous edges, the  ointment  of nitrate of mercury is greatly
 praised.  Acid nitrate of mercury, diluted  with  eight or ten parts of water, is
 highly recommended.  Fetor is allayed with  the chlorides.
   The treatment of varicose ulcers and of chronic  ulcers generally by the use
 of Baynton's plan of  inclosing the limb in  strips of adhesive plaster, regularly
 applied  from the foot upward, has long been in use.  Preference is given to the
 elastic bandage recommended by  Dr. Menry A. Martin, of Boston.
   In varicose ulcers the destruction of the affected vessels by Vienna paste or
 by ligation  may be necessary.
   If the ulcer depends upon necrosed bone, it must  be  extracted, and any
 carious bone  should be scraped away, or removed  with the chisel, gouge or
scalpel.
  Sinuses are to be laid open with the bistoury, guided by the director.
  Granulations are small vascular prominences consisting of embryonic tissue
growing on the surface of wounds or ulcers,  by  which  the healing process is
 carried on.
  If the surface of an exposed wound be examined,  it will be  found  that within
a few hours of its exposure  it is  covered with a film of peculiar, gelatinous,
grayish-white appearance.
  After an interval of some hours, the parts  covered with this gelatinous film 
ULCERS.
31
become  more  vascular, as indicated  by redness, and  the surface  becomes
more even.   After  the lapse  of  twenty-four hours  or  longer, the surface is
covered with  a number of elevations, known as granulations, varying in size
from  a  millet seed  to  a hemp seed,  the smaller being highly vascular  and
red, and the larger paler and more bloodless.   The wound is granulating; the
secretion from these  granulations is of  a creamy-yellow character, and is called
pus.  If the surface is kept in an aseptic  condition, there will be  no pus.
Each granulation  contains a vessel, the walls of which consist of a thin mem-
brane in which nuclei are imbedded.  Some of these  nuclei  are arranged
longitudinally, others transversely to the axis of the vessels.   In the  growth
of these vessels changes occur, answering to those seen  in ordinary embryonic
development.
   Skin Grafting.—When the  cutis vera is  extensively destroyed and the heal-
ing  is  slow,  the process of  skin grafting or transplanting cuticle  may be
resorted  to.   The process is based upon the law that cuticle can only be pro-
duced by skin;  the power of skin to set new cuticle growing from its edge so
as to cover over a wide surface being limited.
   In a very large ulcer which  has ceased to heal, new centres of cicatrization
may be established,  by taking  little pieces  of skin about the size of a millet
seed, including  the  cuticle and the  thinnest possible layer of  cutis from the
inner side of  the  upper arm, and planting  them flat, at the distance of three-
quarters of an inch, upon the raw  surface among the granulations  of the
wound or ulcer, covering and retaining them in position  by the usual antiseptic
dressing and a roller lightly applied.
   The dressings must be allowed to remain four or five  days, when  the grafts
will be found to be firmly attached.
   If  the grafts are  very  small, they  may be so completely embedded  and
hidden in the granulations as to be quite invisible for a short time, but  in three
or four days  each point will be  seen  to have  become a little white  islet of
cicatrix, from  whence the growth of  cuticle  spreads.
   If the sore be  not aseptic, dress it antiseptically.   At the end of forty-eight
hours, apply the grafts,  covering each with a piece of "green protective" oiled
silk, and dress the sore with a thin layer of boracic  acid ointment  spread on
muslin and  dipped in the boracic acid solution before  being  applied.  Over
this must be placed a thick layer of idoform cotton wool, or salicylic wool, and
the dressing left undisturbed for four days. 
32
SURGERY.
             MORTIFICATION OR  GANGRENE.
  Mortification is the death of any part of the body in consequence of disease
or injury.
  Mortification is divided into acute and chronic.
  Acute mortification is known as moist gangrene.
  The causes are predisposing or exciting.
  The predisposing causes are  defective nervous power, as in palsied limbs,
or division of large nerve-trunks; general debility,  from poor food and im-
proper nourishment;  use of alcoholic drinks; debilitating  diseases; atheroma-
tous changes in the arteries of old people.
  The exciting causes  are produced by whatever interferes with or arrests the
circulation of a part; these may be divided into—
  1st.  When there is an  arrest of the  supply  of arterial blood to  a part,
which may be produced by accident, or by ligature or other surgical operation,
or by thrombosis or embolism of the arteries.
  2d.  When there is obstruction of the circulation through a part; this may
arise from pressure either from within,  or  from the growth of a tumor; or from
without, as the formation of bedsores.  Obstruction to the capillary circulation
necessarily accompanies all  acute inflammations, and  forms an important
element in the production of gangrene.
  3d.  Obstruction to the return of venous blood to a part.  This is seldom the
sole cause of gangrene, even when important veins are occluded by thrombosis
or pressure.
  4th. Extreme weakness of the hearfs action.   This  is  a powerful  acces-
sory cause when there is any obstruction, either to the arterial flow or to the
venous return.
  Finally,  Whatever destroys the cells of a part, as injuries,  applications  of
chemical agents, effusion of putrid fluid, absorption of putrid matter, prolonged
use of mercury, excess of heat or cold.
  The local symptoms vary greatly; usually, at the beginning,  the pain and
tenderness of the part become most acute ;  it is of a severe burning character;
the discoloration is of a vivid-red color;  the local heat is increased.
  The constitutional  symptoms at the outset are of  the sthenic type, but
they soon  become of a low typhoid cast;  there will be  anxiety, hiccough, a
jaundiced skin,  a soft, rapid and  jerking puls.e, with  profuse  perspiration.
When the part is  dead, the pain and tenderness cease;  it  becomes cold, the
bright redness disappears, and large blisters form, which burst and discharge a
sanguineous fluid, leaving beneath a greenish or purplish discoloration.  The 
MORTIFICATION OR GANGRENE.                    33
 limb becomes greatly swollen, soft and boggy; on touching the part, bubbles of
 air are displaced; a sickening, fetid smell is exhaled.
   When the progress of the  disease is arrested, a healthy circulation is estab-
 lished up to the margin of  the  mortified part, and  the  line of demarcation
 separates the living from the  dead tissue.
   Treatment.—To  avert threatened  gangrene  the patient, if  young  and
 robust, with a full, hard pulse, should be purged, and arterial  sedatives should
 then be administered, which  will allay pain and tranquillize the heart's action.
 If there is a great deal of inflammation,  incisions should  be made into  the
 part, and lead water, with laudanum applied.
   The timely use of a blister over the entire  surface will  sometimes bring
 about healthy action, and set aside the tendency to gangrene.
   When gangrene has  been fairly established, tonics, such as  iron, quinine,
 strychnia, together with a nutritious diet, should be prescribed, and stimulants
 must be resorted to if necessary.
   The limb should  be  put  in an aseptic condition;  it should be thoroughly
 washed with  i-iooo solution of corrosive sublimate, care being taken not to
 abrade the  skin; after  this wrap the  limb in iodoform cotton-wool, so as to
 invite the flow of blood  to it, or place over the part wool that has been impreg-
 nated with  i-iooo solution of corrosive sublimate ;■ confine it by a roller, and
 keep the limb elevated  and at rest.  Do not interfere with this dressing unless
 an exhaled odor shows that decomposition is taking place.
  To allay  fetor, permanganate of potassium, carbolic acid and the chlorides
 must be resorted to.
  Cleanliness and thorough  ventilation of the apartments must be insisted
 upon.
  Chronic  Mortification.—Dry Gangrene, Senile Gangrene.
  Symptoms.—The want of a  due supply of arterial blood in  these cases is
 owing not only to the diseased state of the arteries, but also, in a great measure,
 to the weak propulsive power of  the heart, and consequent feebleness of  the
 circulation, especially through the lower limbs.  When the circulation is suffi-
 ciently interrupted to lower  the  nutrition of the limb, a sensation of weight in
 the  part, with coldness, itching  and tingling of the  feet, and cramps of  the
 calves are complained of.  These symptoms exist for some time before gan-
grene comes on.
  The disease may  commence in different ways.   In many cases  it begins
without any apparent exciting cause.
  There will be  coldness  of the extremities, numbness and  tingling; on  ex-
amination, a small dark  or purplish spot will be found on  the inside of one
of the toes,  not larger than a mustard seed.   This is succeeded by a vesicle, 
34                              SURGERY.

which exposes a black surface  on bursting.  This  gradually spreads until the
whole foot  is involved, traveling up as high as the  ankle.  It may begin on
several toes simultaneously, or it may show itself on the instep or heel.   The
part  destroyed  becomes black, dry, withered, cold, insensible, resembling m
appearance the  limb of a mummy; hence the change is often called  mummifi-
cation.
  The constitutional symptoms vary.  In  the  inflammatory form there is
considerable general disturbance,  with elevation of temperature at first, after-
ward sinking into marked depression, and the disease may prove fatal in a few
weeks.  In the dry form of gangrene the disease may continue, with very little
constitutional derangement, for a length of time.  In all forms of  spontaneous
gangrene there is a marked improvement in the general  health of the patient
as soon as a distinct line of demarcation forms between the dead  and living
tissue.   In old people diabetes is a fertile cause of gangrene of the toes and
feet.
  Treatment.—It is only before the occurrence and during the spread of gan-
grene that the use of lowering remedies can be suggested.  The constitutional
conditions which predispose to gangrene, such  as want of food, diabetes, fever,
feebleness of the heart's action, are all associated with debility; consequently,
depressing remedies are to be avoided.   Tonics, together with  stimulants such
as are  recommended in acute gangrene, should early be had  recourse to;  if
there be much depression, ether, ammonia and camphor are of material service.
The administration of opium, in doses of from two to four grains during twenty-
four hours, in  cases where the drug does not disagree with  the  patient,  is
recommended by all authorities.
   Locally, salicylic wool,  or iodoform wool, or simple  cotton  wool, in  thick
layers  around the foot and limb, covered with a  silk handkerchief or  thick
stocking, must be used.   The gangrenous part  may be powdered with iodoform
or left dry beneath the cotton wool.
   Question of Amputation.—When the gangrene is  the result  of a severe
injury, when it is rapidly  spreading, or when it arises from a wound or ligature
of an artery, the rule is to amputate at  once.   The operation  should be per-
formed as soon as the gangrene has manifested itself, without waiting  for the
line of demarcation.
   In chronic gangrene, due to diabetes, or ergotism, do  not amputate at once,
but  wait for the line of demarcation to  form.   Examine the urine for sugar, so
 as to determine the necessary course of treatment.
   In spontaneous gangrene from  disease of the arteries, the rule is  not to
 amputate until the line of separation has formed.
   T3ut  even after the line of  demarcation is formed, the surgeon must be well 
HOSPITAL GANGRENE.
35
assured that the patient has vigor enough to bear the loss of blood that must
necessarily ensue, before resorting to amputation.
  If the  mortification is local as to its cause, it will be proper to amputate just
above the injured part, as, for instance, where there is mortification of the limb
from severe compound fracture, or from injury of one of the large arterial trunks.
  Exemplifications.—If an  individual have molten iron come in contact with
one of his extremities, causing disintegration of the part; amputate at the most
convenient point.
  If a person have his lower limb run over by a railway car and acute inflam-
mation, followed by gangrene, sets in; amputate.
  Whenever acute gangrene depends upon the obstruction of the main artery
of a limb, unless the embolism be situated high up; amputate.
  In  all cases of traumatic gangrene, when the process is sure  to spread
rapidly;  amputate.
  In cases of frostbite, or burn; wait for the line of  demarcation, and then
amputate as nearly as possible to the seat of injury.
                    HOSPITAL  GANGRENE.
  Hospital gangrene is a severe ulceration, in which there is copious exuda-
tion and infiltration of the affected part, together with rapid decomposition; it
arises where a number of sick and wounded men are crowded in ill-ventilated
apartments, who are deprived of nourishing food, and where there is no oppor-
tunity for separating the infected.   It may affect any  kind of a wound, or even
a mere bruise.
  Hospital gangrene may be divided into idiopathic  and traumatic;  it is idio-
pathic when it depends upon constitutional causes, and  traumatic when it has
its origin in an external injury.
  Symptoms.—When the disease  ensues from a wound,  an ulcer, or on the
stump of an amputated limb, the part begins to be painful, the  edges inflame,
the suppuration becomes  less and of a serous character, the granulations assume
a dark and foul  appearance, and  are rapidly destroyed; a quantity of lymph,
of a grayish appearance, covers the sore; the wound increases in all directions;
the edges become  painful and oedematous,  and the oedema spreads.   The
disease  begins with pain, which  is constant and  excessive, being sharp and
stinging; cavities are observed  more  or  less deep, the edges being covered
with pus.  These ulcerous spots increase and  run together;  a bloody, ichorous
fluid is secreted,  and the  surface enlarges in  all  directions.  The destruction
is often restricted to the cellular tissue, but  frequently the muscles and all sur-
rounding parts are destroyed. 
36
SURGERY.
   Bleeding sometimes occurs from the destroyed vessels.  When suppuration
takes place, the discharge is abundant and highly fetid.
   These local symptoms are accompanied by loss  of  appetite, pain in the
region of the stomach, nausea, costiveness, loss of sleep,  quick and generally a
weak pulse, hot skin, anxiety and restlessness.
   Its characteristic is quick extension and decomposition  of the tissues.
   The contagion develops itself usually in hospitals, where the  air is deterio-
rated, where patients are huddled together,  and where attention  to cleanliness
is not observed.
   When the disease begins as a local affection, it commences as a vesicle, sur-
rounded by dusky inflammation, with severe  darting and stinging  pains.  When
the pustule is ruptured, the ulcer displays a dirty, foul slough.   The sore soon
enlarges; the edges become everted, and the parts  puffy and  swollen;  the
surface is composed of gray or ash-colored sloughs, which may become brown,
or resemble coagula  of blood.  These  symptoms are accompanied  by loss of
sleep and  exhausting diarrhoea, which, if continued, end in death in  about
three weeks.
   Treatment.—As soon as the patient is seen he must be  at once isolated,
and, if it be possible, a special nurse should  be assigned to the case,  and  at the
same time the strictest hygienic precautions enjoined.  It is proper to commence
with a free purge; a mercurial purge  is to be preferred; calomel  and  jalap,
or calomel  with  rhubarb, or compound extract of colocynth,  will  answer.
During the course of the disease the bowels should  be  kept in a soluble con-
dition.
   When the patient begins to show evidence  of flagging, tonics, in the  shape
of iron, quinine, together with wine, brandy, milk, nutritious broths, should be
had  recourse  to.   Muriated tincture of iron,  in doses of twenty drops, every
three or  four  hours, is probably the best ferruginous preparation.  To allay
pain and irritability, and  produce sleep, opium should be administered in large
doses.
   The diet should be highly nutritious, and if  there is evidence of a scorbutic
taint, oranges, lemon juice, potatoes, onions, tomatoes, etc., must be freely given.
   The local treatment  should  be soothing;  the exposed surface  should  be
thoroughly cleansed  and dried, and the parts  freely bathed with a weak solu-
tion of acid nitrate of mercury, carbolic acid, nitric acid, sulphate of copper,
etc., etc.  The application of chloride of zinc or nitric acid should be followed
by an antiseptic or deodorant poultice, to receive the discharge and aid  its
escape.
   Great care must be taken, not only to keep the parts  clean, but everything
surrounding the patient must be constantly cleansed, and  changes in the  dress-
ing should be frequently made. 
SEPTICAEMIA—PYEMIA.
37
   Bromine, permanganate of potassium, chloride of zinc, chlorinated sodium,
creasote, nitrate of silver, etc., all  have their advocates, and  may  be used in
turn.


                           SEPTICAEMIA.
   By Septicaemia is understood  those  forms  of  septic diseases which are
unaccompanied by the development of secondary inflammation.
   It is an infective disease, i. e., the chemical products which are  poured out
by the micrococci  poison the blood, so that if a  few drops are inoculated into
a healthy animal the disease is reproduced.   It is a grave  form of septic disease
which begins usually  on the second day, ushered in by a severe  chill.   In  a
large majority of the cases the chills are repeated, although the temperature is
high, ranging from 1030 to 1060.   The patient has sweats.   The pulse rate
increases remarkably.   The symptoms become of the typhoid type;  the ema-
ciation is rapid  and extreme.   Death takes place in  about eight days.
   Under the heading  of Septicaemia there are two diseases: septic intoxication,
non-infective, due  to  the absorption of chemical poison  engendered in some
putrefactive process external to the body, and septic infection, due to the entry
of septic fungi into the blood and to their multiplication there.
   Septic infection may occur from the  smallest wound, and  there  may be
distinct evidence of inoculation of a poison.
   Many of the  products of putrefaction are pyrogenous. Bergmann succeeded
in crystallizing,  on fine needles, from putrid  fluids, an  alkaloidal body, which
he calls  sepsica, which  possesses, in  a high degree, the property of exciting
fever.


                              PYAEMIA.
   Pyaemia differs from Septicaemia  in this respect, that the absorption and
dissemination of the poison give rise  not only to a general  disease, but also
cause the formation of secondary foci of inflammation—the so-called metastatic
abscesses; that is  to say, pyaemia is septicaemia combined  with the formation of
abscesses.  The abscesses are called secondary, because they are secondary to
a primary inflammation.  They are called embolic, because they originate from
emboli.   They  vary in size from a seed to a large walnut; they are generally
found in  the lungs, liver, spleen, kidneys  and brain, and  are usually  upon the
surface of organs.
   The symptoms of pyaemia  present themselves  within the first week after
putrid or septic changes have begun in a putrid part; they are ushered in by
a severe rigor, followed by profuse sweating.  The temperature will vary from 
38
SURGERY.
1030 to 1050.  The skin will be dry, tongue coated, attended by sordes on the
gums and teeth; the countenance will become jaundiced;  there will be nausea,
diarrhoea, and all the symptoms of asthenic fever.   There will be dull, heavy
pain in the part where  the abscess  is forming.   If the  abscess  is forming in
any of the external tissues of the  body, it will be known by fluctuation.
  Prognosis.—Serious;  usually fatal.  Repeated  shiverings  are  the very
worst omen.  A temperature of or above 1060 is very unfavorable.
  The treatment of putrid or septic intoxication, septicaemia and pyaemia is
identical.   These affections depend upon the entrance into the blood of putrid
or septic  materials, and  there  must  be a point from which this material is
derived; hence the wound must be rendered aseptic.
  Lay open the abscess, wash it out with antiseptic solutions, and dress it with
antiseptic dressings.  Give opium to relieve pain if necessary.
  The indications are to remove  the  exciting cause of the disease, to purify
the blood, and keep up the strength of the patient.
  It may be well to begin  with  a calomel purge, when general indications war-
rant it.  The attention of the surgeon should at once be turned to the necessity
of keeping up the strength of his patient, and tonic treatment should be early
resorted to.   Quinine, with or  without iron, should  be  administered.   When
suppuration is established Huxham's tincture of bark and aromatic sulphuric
acid are the remedies, and  sleep must be  procured by  opiates.   Brandy or
whisky, port  or  sherry wine, beef tea,  milk, eggs, and  such articles as will
keep up the strength of the patient, are early indicated.
  Cleanliness must be insisted upon, and great good will  be attained by dili-
gent and unfailing attention to the dressings.
  Detergent lotions containing chlorinated sodium, carbolic acid  or chloride of
zinc, are serviceable.
  The position of the part should be so arranged as to favor the escape of the
secretions.
  Should hemorrhage exist,  muriated tincture of iron is a remedy to be resorted
to; it should be  given in doses  of 20 to  30 drops, every four hours.   Ergot or
atropia, combined with the iron or given separately, will be found valuable  in
allaying the copious sweating that is apt  to exist in this disease.
                           ANAESTHESIA.
  Anaesthetics are those agents which are employed for the prevention of pain,
especially when used in surgical practice and during labor.   They are likewise
used to produce relaxation of muscles, when needed  in reducing dislocations
and  hernia, or in  setting fractured bones.  They may be also resorted to  in 
ANAESTHESIA.
39
making diagnoses in cases of obscure  abdominal tumors  and  in  supposed
malingering.
  Anresthesia may be produced by benumbing the part to  be operated on by
means of cold, by intercepting nervous communication, and by  arresting the
activity of the nervous centres concerned in sensation.  They may be either
local or general in their action.
  Local  Anaesthesia.—When anaesthesia is to be induced by cold, the most
convenient plan is to throw a  jet of anhydrous ether  spray upon  the part, and
thus freeze it; or a mixture of equal  parts of pounded ice  and common salt,
contained in a bag may be  applied to the part.
  Muriate of cocaine, in four per cent, solution, produces complete local anaes-
thesia  of  mucous surfaces.  Two or  three applications at intervals  of five
minutes, will, in about ten minutes, produce local anaesthesia of the  part to
which it is applied, and will last for a quarter of an hour.  When it is desired to
be employed in cases of amputation of fingers, or in removal of tumors, a solu-
tion of four  per cent, strength should be injected  into  different  parts of the
affected organ in quantities of ten minims.  If there be any affection of the
heart cocaine must not be used.
  General  anaesthesia is obtained by inhalation.
  Should the patient be debilitated, or should he be suffering from heart  disease,
it is well to administer hypodermatically  a mixture of sulphate of morphia gr.
Yd, whisky ir^xx, half an hour before administering the anaesthetic.
  Before commencing inhalation, the patient should have abstained from eating
for  at least four hours ; it is important that the stomach  be empty at the time
that an anaesthetic is administered, vomiting being  almost sure to occur if the
stomach contain food.   He should lie comfortably in the  horizontal posture,
and the dress should be loose, especially about the neck and  abdomen.   If the
vapor excites either swallowing or coughing, its strength must be diminished.
After volition has been suspended, any pause in the breathing  should be noted
and fresh  air be given.
  The agents chiefly in use in producing general  anaesthesia are nitrous oxide,
ether and chloroform.
  Protoxide of  Nitrogen—Nitrous Oxide.—This is the safest  anaesthetic
to give and the most pleasant to inhale.  It is of the utmost importance to exclude
all air  when  administering this gas.
  In order to do this a proper apparatus with a closely fitting face-piece to cover
the  mouth and nose must be used.   The  gas is supplied for  use compressed in
iron bottles.  The bottle is connected with the  face-piece by a tube, in the
middle of which is an India-rubber bag.  After the face-piece  has been firmly
applied to the patient's fece, the bag is distended  with gas by turning the stop 
40
SURGERY.
cock connected with the iron bottle, and the  patient, breathing backward and
forward into the bag, inhales the same gas several times.  The' patient should
be instructed  to breathe slowly and deeply, and be shown how to do so, about
fifteen times a minute.
  After inhaling for about one minute the breathing will be stertorous, or inter-
rupted, the pulse will be feeble,  and there will be convulsive twitchings when
total anaesthesia is established; until this condition pertain, the face-piece should
not be removed.
  Ether,  sulphuric ether, ethylic ether, or oxide of ethyl, may be admin-
istered from a towel or hollow sponge;  the towel or napkin  is arranged so as
to form  a hollow cone, thus lessening the admission of fresh air.   Should  an
inhaler be preferred, the apparatus of Dr. Oscar H. Allis is recommended.  As
a rule, while  anaesthesia is being induced, an  inspiration of fresh  air should  be
allowed every half minute; and after it has been effected, every three or four
inspirations from the inhaler should be followed by one of air.
  If, at the commencement  of  the administration, the patient show signs  of
intolerance, by swallowing or coughing, it is advisable to admit one inspiration
of air.
  When deep snoring takes place,  it is the indication of complete  anaesthesia.
A much smaller quantity  of  ether is required to maintain than  to produce
anaesthesia.   Any disturbance of the pulse or respiration, will,  as a rule,  be
remedied by diminishing or discontinuing the vapor.

  Chloroform.—The general method of administering chloroform  is by means
of a handkerchief or towel folded into a cone, open at  the apex, so  as to admit
air  at the same  time that the chloroform is inhaled, into which a drachm of the
fluid should be poured, to be renewed from time to time in quantities of  fifteen
minims; or a piece of lint, about twelve by six inches, folded so as to form a
square of about six inches, may be used, on which the chloroform  may  be
sprinkled  from a  small drop bottle; in a few seconds a little more  may be
added;  the quantity should  be increased  slightly each time, taking care that
the part of the lint which is wet with the anaesthetic does not touch the  face.
  The movement  of swallowing should be  looked  for, and  regarded  as  an
evidence that the  vapor  is stronger than is  necessary.   If hiccough should
supervene, the  chloroform should  be withdrawn.  The pulse  frequently gives
the  first warning  of approaching danger, and  is, therefore,  to be carefully
watched;  if  it  flags, or should  it become feeble, irregular or  intermittent,  the
chloroform must be immediately stopped; or  if it appears  that the amount of
the anaesthetic in the air passages is excessive, not a moment should be lost in
seizing the tongue with the forceps—with which the administrator must always
be provided—dragging it out of the mouth, and sponging out the fauces; should 
GERM THEORY.
41
this not result beneficially, artificial respiration should be resorted to, or if the
entrance  of air  be still  obstructed, tracheotomy must  be performed without
delay.
  Directly any stertorous noise is heard a breath or two of fresh air should be
allowed, and no more chloroform administered until the pulse beats well and
the respiration is free.
  If a severe operation is about to be performed, the chloroform should be
given in the same general manner as in a  slight one, but continued to the point
of fixing the pupils and producing stertorous breathing; and when the  chief
shock of the operation is expected, two or three breaths of pure air should be
admitted, so that if  the pulse fails there may not be an excessive  amount of
chloroform vapor in the lungs.
  Directions for restoring animation in cases of extreme syncope:—
  Remove the pillow from beneath the patient's head, seize  the  tongue with
the forceps and draw it forward;  compress the sternum forcibly, allowing the
chest of its own elasticity to expand;  do not wait for the respiration  to  cease
before  doing this.  At the same time let  one of the  assistants  administer a
hypodermic injection of fifteen minims of tincture of digitalis.   If the symp-
toms of heart failure continue, give another hypodermic of aqua ammonia, Ttiv;
whisky, n\xx.  If  there be  symptoms of failure  of  respiration, administer
hypodermatically one-sixtieth of a grain of atropia.
  If, after two or three compressions, there is any improvement, continue the
treatment; place  one  hand on  the back and the other on the sternum, and
keep up the  respiration by pressure, having previously suspended the patient by
his legs, with his head downward.
  If this does not succeed,  try Howard's plan;  see directions under Chest
Pressure and Faradization.
                          GERM THEORY.
   Microorganisms may  be divided into two  classes, pathogenic  and non-
pathogenic.
   The pathogenic or infective organisms are almost entirely included in  the
orders micrococcus and bacillus.   They have the power, in addition to that of
the saprophytes, of attacking living tissues, of spreading into them from  the
wound, and of growing in them at their expense.   They can live in the blood
and  in  the  lymph stream.  They can pass out of  a  wound into the  system
generally.
   They gain access to  the  putrescible matter in wounds, abscesses or cavities
containing animal fluids, either by  entering the  lungs and  alimentary "canal,
       D 
42
SURGERY.
 and  thus  find their way to  the  circulation  and enter the dead matter from
 within, or they are admitted directly from  without; when  they  arrive at a
 suitable nidus, they settle there, grow, develop and produce ptomaines, thus
 forming a fresh centre of infection;  the  excreta, coming  in  contact with  the
 tissues, are intensely irritating; engendering  inflammation.
   Micrococci are round organisms, varying from ^Styes'to  vshnf °^ an *ncn 'n
 diameter.  They occur singly or grouped in pairs, chains  or colonies.   When
 in colonies, they  are bound  together by a homogeneous substance, known as
 " Zoogloea."  Their mode of reproduction is supposed to be by cell division.
   Bacilli are rod-shaped bodies, differing from bacteria in the fact that their
 length is at  least double their breadth, and they are most  often  motionless.
 These spores show a remarkable power of resisting heat, chemical reagents and
 drying.  Blood containing them  may be kept dry for years without losing its
 virulence; it may be mixed for weeks with the strongest watery or oily solutions
 of carbolic acid without  its  potency being  impaired.   Bichloride of mercury,
 however, in a one per  cent, solution, is speedily fatal to microorganisms.
   The  non-pathogenic are those which can live  and  grow  only  in dead or
 dying matter, and  which are therefore termed saprophytic.  The ferment of
 ordinary putrefaction, the bacterium termo, is one  of these.  It enters a wound
from without; it cannot  live in healthy tissues, but if, after entering a wound,
 it finds there a suitable nidus, it lives  and grows  in  it, and, as  a  result of its
 presence, certain irritable  products or ptomaines are found.
   Bacterium termo, the ferment of ordinary putrefaction, most frequently exists
 as minute rod-like  bodies, their length usually being about twice their width;
 they are to be found in all putrefying solutions and mixtures of organic matter.
   The germ  theory of infective inflammation is that, under certain conditions,
 parasitic fungi take up their abode in a part of  the body frequently already
 damaged, as in a wound or a centre of suppuration, and then, while growing,
 give rise to a process of fermentation in the fluids  of the parts, the  products of
 which are extensively irritating locally, and poisonous  if absorbed into the
 system.
   The microorganisms that produce pus are: I. Staphylococcus pyogenis auris
 (which is most frequently present in acute abscesses); 2. Staphylococcus pyo-
 genes albus; 3.  Staphylococcus pyogenes citrus;  4.  Staphylococcus cereus
 albus; 5. Staphylococcus cereus flavus; 6. Staphylococcus flavescens; 7. Micro-
 coccus pyogenes  tenuis;  8.  Streptococcus  pyogenes; 9. Bacillus pyogenes
 foetidus; 10. Bacillus pyocyaneus. 
ANTISEPTIC SURGERY.
43
                    ANTISEPTIC SURGERY.
  Antiseptic Surgery, or treatment, is based on the germ theory of putrefac-
tion.
  The changes of putrefaction are dependent upon " a living organism and  a
nidus for its life;  a plant and the soil in which it is planted;"  the substances
interfering with the organism causing these changes are termed antiseptics.
  The aim of antiseptic  surgery is, first, to  conduct  a case so  as to prevent
putrefaction, and secondly, to remedy putrefaction when it has occurred.
  The two antiseptics in  most general use in surgery are carbolic acid, which
is used in the strength of one part of  absolute phenol  to from twenty to forty
parts of water, and corrosive sublimate, used in the strength of one part to two
thousand parts.
  The following are the general directions to be observed: Before undertaking
an operation of any moment, the surgeon should see that the room to be occu-
pied by the patient is  properly prepared;  with this object in view every article
not absolutely needed  should  be removed;  the carpets should  be taken up;
the floor scrubbed and  then washed with bichloride solution (1-1000); curtains
should be taken down; upholstered sofas  and chairs  replaced by those made
of wood alone, etc., etc.
  If possible, the part should be covered with a gauze saturated with bichloride
solution (1-2000) for three hours before commencing the operation.
  The skin of the part is  always to be shaved; the shaved part should then be
carefully washed with soap and water, then  with alcohol, and finally with
1-1000 bichloride of mercury solution.
  Saturate light towels in 1-2000 bichloride 'solution ;  arrange them  in such a
way that instruments, catgut, fingers, etc., cannot come in contact  with anything
that is  not  antiseptically prepared.  Preference is given  by Professor Keen
to dry bichloride towels.
  Before the operation begins, the  hands of  every one who is to come in con-
tact with the case must be thoroughly  washed and scrubbed in 1-1000 solution
of bichloride.
  Instruments must be put in an 1-20 carbolic acid solution for at least half an
hour before being used.
  Just before the operation is to  be undertaken pour off the carbolic acid solu-
tion, and immerse the instruments in hot water that has been boiled.   Prepared
sponges must  be placed near the operating table, in a  bowl.   Pledgets of dry
bichloride gauze are now  frequently used instead of sponges.
  Dressings must be prepared and laid on clean bichloride towels before com-
mencing an operation. 
44
SURGERY.
  During the operation the parts should be frequently irrigated with bichloride
solution.
  One of the most important features of antiseptic surgery is drainage, which
must be most carefully provided for, when  the wound is about  to be closed.
Professor Keen prefers double drainage by means of rubber tubes and a fasci-
culus  of horsehair.   Then a  sufficient quantity of  bichloride  gauze should be
placed loosely about the wound to allow of easy percolation of serum, and put
over it some material that will cause the discharge to diffuse itself through the
dressings.  India rubber, oiled silk  or waxed paper may be  used.   Over the
impermeable material jute, wood wool, oakum  or iodoform  absorbent  cotton
must be applied, so as to take up any percolating discharge.
  When double drainage is employed,  the tube  is  to be withdrawn  at the
end of twenty-four hours; at the same time the antiseptic dressings must be
changed and the saturated gauze removed.   The part must  then be  carefully
redressed, and allowed  to remain unmolested until the end of the fourth day,
when the horsehair is to be removed and a clean dressing  applied.   After the
tube is removed  the drainage is carried  on  by capillary  attraction.   The
stitches may be  taken  away by the  seventh  or eighth  day.  Catgut is em-
ployed to drain serum;  its ends must be kept moist, to insure drainage.   The
rubber tube must be perforated with holes  at the  distance of a quarter of
an inch; the ends pared off close to the surface, and kept  in place by a stitch
or pin.
  The usual indications for changing dressings before the  wound heals, are—
when rubber drainage  tubes  need to be removed;  when secondary hemor-
rhage occurs; when, the operation not having been done antiseptically, there is
evidence of increased temperature;  when plastic operations and other supple-
mentary work are to be done.
  Should it become necessary to remove the dressings, it must be done with
disinfected hands; the new dressing being carefully prepared, using bichloride
towels.
  Iodoform is used only on suppurating or putrid wounds,  or in  tuberculous
cases.
  If on the day following the operation the patient's temperature  should rise
to 1020 F., accompanied  by  a full and hard pulse, a saline cathartic should be
administered, and in addition, tincture of aconite in doses of  three drops every
three  hours must be given,  until the pulse changes; if the temperature reach
1020 F. on the second day after an operation, it would be  advisable to change
the dressing and examine the wound.
  Tissue which is likely  to slough should be trimmed away before closing the
wound.  All bleeding from  the small vessels should be effectually attended to
before closing the wound, and all clots must be removed. 
HEMORRHAGE.
45
   Previous to commencing an operation the following must be made ready:—
   A rubber sheet, one of the most necessary articles, must be six feet long; it
must be wetted  with the bichloride  solution, and is to be placed under the
patient and so arranged that fluids will run into the pail below; wet bichloride
towels may be substituted for the rubber sheet.
   The irrigator,  filled with i-iooo bichloride of mercury solution.   A  large
dish filled with i-iooo bichloride solution for washing sponges.   A dish  filled
with 1-30 carbolic acid solution for instruments.
   A wide-mouthed  bottle containing No. 8 and  No. 7  catgut  in alcohol; a
bottle of chromic catgut; a wide-mouthed bottle with Lister's protective, in
I-30 carbolic acid solution ; iodoform.
   Bichloride gauze ;  wood wool or jute; bichloride cotton.
   A skein of catgut in a saucer of 1-1000 bichloride solution; bichloride-
gauze bandages.
   Razor; nail-brush;  prepared sponges;  alcohol and bandages.
   For modes of preparing the various antiseptic solutions, see  formulae at the
end of the volume.

                          HEMORRHAGE.
   Hemorrhage is either arterial, venous or capillary.
   Arterial hemorrhage is known by its  bright  crimson or vermilion tint, and
by its issuing  from the divided vessels in  jets, synchronously with the contrac-
tion of the left ventricle.
   In venous hemorrhage the  blood is of  a dark-blue tint, and flows  from the
divided vessel in  a continuous stream.
   In capillary hemorrhage the blood is of a reddish tint, and exudes from the
tissues; in other words, there is a welling up.
   Subcutaneous hemorrhage, also called  diffused aneurism,  exists where  there
is  no external  flow of blood, either from  want of parallelism of the wound in
the vessel and the open wound in the tissue, or from the rupture of a vessel by
a blow, or otherwise, subcutaneously.
   Effects of Hemorrhage.—When a large vessel is divided, or a large  num-
ber of small ones, death may take place at once.   Usually the patient is seized
with syncope, after the wound has  been bleeding for  some time, when the
heart's action becomes more depressed, and, the blood becoming more coagu-
lable, nature is given an opportunity to  form  a clot within and  around the
artery.   After a time reaction takes place, when  there  is danger of a recur-
rence of the bleeding, and of  the patient dying from exhaustion.
   Treatment of the  Effects of Hemorrhage.—Put the finger over  each
divided extremity of  the vessel, or apply a provisional tourniquet; place the 
46
SURGERY.
patient in the recumbent posture, with the head lower than the body.   Com-
press both axillary arteries and both femorals, so as to divert the flow of blood
to the brain.  Apply external heat, by means of bottles of hot water, warm
blankets, etc., etc.
  Stimulate the heart's action by a  hypodermic  of morphia,  gr. }(, atropia,
gr.  Ti7,  or a hypodermic  of digitalis or ether.  As  soon as reaction takes
place, resort to means to effect a permanent arrest of hemorrhage.
  The reaction  which  follows  upon a  copious  loss of  blood is generally
attended by hemorrhagic fever,  the  pulse being frequent, soft  and  jerky;
heart  fluttering and tremulous;  eyes suffused;  skin hot and dry; countenance
flushed;  headache, nausea, and possibly vomiting, accompanied by wandering
of the mind.  The proper treatment for this condition is rest, exclusion of
light, and give every four hours  morphia, gr. \; neutral mixture, half-ounce;
apply ice-bags to the head; sponge  the surface with an  evaporating  lotion;
administer  beef extract,  koumiss, brandy,  milk  in small quantities  and at
regular intervals.  See Formulae 48 and 51.
  When the hemorrhage  takes place in a cavity, in consequence of the bleeding
from one of the  abdominal viscera or from the lungs, the patient should be
given, every four hours, either three grains of gallic acid or two grains of acetate
of lead, with one grain each of powdered digitalis and ergotine, together with
half a grain of opium.
  These  remedies sustain the action of the heart, produce contraction of the
blood-vessels, and render  the blood  more plastic;  hence they  are  of great
utility when the blood-vessel cannot be reached.


           CONSECUTIVE OR  RECURRENT HEMORRHAGE
Comes on in about twenty-four hours after an operation; it is generally due to
a faulty application of the ligature, including a nerve in  the  ligature, by the
application of Esmarch's  bandage, or to the reaction which takes  place  after
a shock.
  The proper treatment is to elevate the stump and compress the main  artery;
if hemorrhage continues,  open the wound, turn out the clots, wash with warm
bichloride solution, search for and tie the  bleeding vessels.  If there  be much
oozing, elevate the part,  and then  apply broad  compresses.  Sponge  with
warm water; expose it to air for some time.

                     SECONDARY  HEMORRHAGE
Comes on  after twenty-four hours from the  time of the operation, but more
generally about the time of the separation of the ligature.   The mode  of  pro-
cedure is to remove  the  dressings;  if  there be merely  oozing, proceed as 
HEMORRHAGE.
47
directed in Consecutive  Hemorrhage;  but if the dressings  are  saturated with
blood, the parts swollen  and painful, and  there are other evidences of profuse
loss of blood, re-open the wound, turn out the clots, search for the bleeding
vessels and ligate them.
   Secondary hemorrhage may take place at  the time of the separation of the
ligature, and it generally comes from the distal end of the artery.   This should
be frustrated by compression; but if the hemorrhage continues or recurs, it is
proper to cut down upon the artery and ligate it.
   Secondary hemorrhage may occur from sloughing or ulceration of an artery,
or from imperfect closure of an artery when a ligature separates, either through
a diseased state of the artery or of the constitution.   In this case it is necessary
to cut down upon and secure the  bleeding orifice;  if this cannot be done, care-
fully graduated  pressure and styptics may be tried.   A  small button of lint,
saturated with perchloride of iron, may be put into the bleeding  point,  over
which larger compresses  are placed and firm pressure  applied.  The bleeding
surface may be touched with a hot iron raised  to a  " black heat," which will
sometimes  be more efficacious than any other styptic.   Should these measures
fail, the artery must be tied above the point of hemorrhage, and, finally, ampu-
tation may be necessary.
   When there is bleeding from arteries, the following rules are to be observed:—
   Should there be bleeding from  an open wound, cut down, and tie the artery
at the site of the wound, no matter what its condition;  if the artery be  brittle,
resort to acupressure.
   If an artery has been wounded, and there is no bleeding  when the surgeon
fir.-.t sees the case, it should be let alone, because hemorrhage may not  recur;
but a provisional tourniquet should be  placed over  the situation of the main
trunk, so that it may be tightened  should the  slightest appearance of blood
make it necessary.   The exceptions to this rule are when a patient is to be
transported some distance, when the patient is a  hard-drinking man, when the
vessel lies directly  in  the wound, so that it can be  seen ; in these cases the
wounded artery should be secured at once.
   If the artery be partially or wholly divided, cast a ligature around each end.
   In applying a ligature, if a branch is given off near the wounded artery, in-
clude it in  the grasp of the ligature or secure it separately.
   If the branch of a main artery  is wounded near the trunk, treat it as though
it were a wound of the main trunk.
   On cutting down on a  divided  artery, if the distal end be so  far retracted
that it cannot be found, tie the cardiac end, and place plugs in the wounded or
distal  side saturated with Monsel's solution, held in place by successive layers
of sponge and a bandage from the distal extremity of the  limb to the site of
the wound. 
48
SURGERY.
                             SUTURES.
  Sutures are made of catgut,-silk, or wire.
  The sutures ordinarily in use  are:  i. The Interrupted.   2. The Twisted.
3.  The Glover's or Continuous Suture.
Fig. 3.
Fig. 4.
Jh^
  1. The Interrupted Suture.  The needle, carrying a single ligature, is passed
through the skin on one side of the wound from without  inward, and is then
inserted from within outward at the corresponding point on the opposite  side
of the wound.  The ends of the ligature  are  drawn together and tied tightly
in a double knot.  The ligature is then  cut  and another suture introduced at
an interval of half an inch, and so on.
  In wounds of the intestine Lembert's interrupted suture is the one to make
use of.  The stitches should be three-eighths of an inch from the margin of the
Fig. 5.
wound, the middle suture being first introduced; the distance between the sutures
should not exceed a quarter of an inch.  When the requisite number have been
applied, the  ends are to be tied,  and cut off close to the knot.   The bowel  is
then restored to the abdominal cavity and a glass drainage tube inserted.
  2. The Tzvisted or Harelip Suture.  Having placed the edges of the wound
accurately in contact, a sufficient number of needles are passed through the edges
of the wound.   When the necessary number of needles have been introduced
and the parts have been accurately adjusted, the  middle of the long ligature 
WOUNDS.
49
is twisted around the uppermost  needle in the form of a figure oo .  Then the
two  ends  of the ligature are brought  down and  twisted  around the other
needles successively, when they are secured by a knot.  After insertion the
points  of  the  needles  must be  cut off with pliers.  The upper pin must be
removed at the end of the second day, and the lower pin at the end of the
third day.
                                  Fig. 6.
  3. The Glover's or Continuous Suture.   This suture is employed in wounds
of the  intestines and abdomen.  It is applicable  to  cases of injury  of great
extent  when  there is tendency to the escape of fecal matter in the intervals
between  the  stitches.  It is merely the ordinary stitch employed for sewing
materials  together; it is made by simply passing the. needles diagonally from
one side of the wound to the other.
                              WOUNDS.
  A Wound is a solution of continuity, or separation of continuous parts,
suddenly occasioned by external violence, and generally attended with hemor-
rhage.

                          WOUNDS OF VEINS.
  Hemorrhage from wounded veins is not, as a rule, dangerous, unless from a
large and  deep-seated trunk in which valves are not present, or from a large
varicose vein of the leg.   The bleeding in ordinary cases may be restrained by
pressure and by a raised position;  it may, in rare cases, be necessary to apply
a ligature.

                     WOUNDS OF THE ARTERIES.
  Arteries  consist of  three coats: first, the  internal coat, which is a serous
membrane, made  up of an elastic longitudinal layer, interspersed with connec-
tive tissue corpuscles  and lined by endothelial cells; secondly, the  middle or 
50
SURGERY.
muscular  coat, made up of muscular and elastic fibres; and, thirdly, a fibrous
coat, consisting of fibrous tissue.
  The sheath of the  artery is derived from the deep fascia of the parts  sur-
rounding it; on the sheath ramify nervous filaments and the vaso vasorum.
  The wounds of arteries may be incised, lacerated or punctured.
  Lacerated arteries, when torn across, contract almost immediately, and bleed
but little.   The most approved  method is to apply ligatures;  otherwise, when
reaction takes  place and the power of circulation is restored,  hemorrhage  will
ensue.
  Punctured wounds are followed by a tumor, bearing the characters and re-
quiring the treatment of aneurism.
  Contused wounds, such  as are  produced by severe bruises or  by gunshot
wounds, sometimes destroy the vitality of a portion of the artery, which is fre-
quently followed by sloughing and  fatal hemorrhage.   In  these cases  the
patient should be kept  at rest  until  the sloughing process is completed.   A
precautionary tourniquet should be placed around the limb, and  the patient
instructed in its use in case hemorrhage should ensue.
  If an artery of small size be cut across, there will be brisk hemorrhage for a
time, but it will soon cease; the divided artery  contracts and the vessel retracts
within  its sheath, and there is coagulation of the blood upon the face of the
wound, sufficient to temporarily arrest  the bleeding.   Then the  column of
blood inside the  vessel coagulates, and, lastly, there is exudation of the fibrin
around and between the cut edges, which seals up the  opening permanently by
becoming organized.
  The coagulum  within gradually becomes firmer, adheres to the walls of the
vessel, loses its  color, and  forms, with the impervious end of the  artery, a
fibrous cord.
  If a very large artery  is wounded and the aperture is large, and the flow of
blood not opposed, the  loss of blood  will be so rapid as  to occasion  death at
once; but if the  wound be very small, it may be closed  by coagulated blood
during syncope, and the patient, if properly treated, may survive.
  If the  artery be of  the  second  order, as the tibial, the bleeding will most
probably cease when syncope supervenes;  but when  the  faintness has passed
off,  the bleeding will  recur, and the patient may die, unless  the bleeding be
checked by the surgeon.
  A puncture or partial division of an artery is sometimes more troublesome
than a complete division,because contraction and retraction are prevented.  An
oblique cut is likely to bleed obstinately; the aperture  may, in favorable cases,
be closed by adhesion, the artery remaining pervious; the uniting lymph, not
infrequently, is dilated into a false aneurism. 
WOUNDS.
51
  Treatment.—In the wounds of arteries the first indication is to stop the flow
of blood.  If the wound be small, and there is a bone underneath, the bleeding
may be arrested by firm pressure of the finger; if the wound is wide and deep,
the forefinger  should be passed in, and pressure should be made with it on the
exact spot from whence the blood issues, or the bleeding orifice  should  be
seized with the finger and thumb ; or the bleeding may be stopped by pressing
the main artery above the point of injury ;  or  a tourniquet niay be applied ;  or,
if no tourniquet be at hand, a handkerchief, with a stone placed in it, over the
artery, may be tied around the limb, and twisted tight with a stick.
  The immediate danger  being averted, the surgeon next considers the best
means.of permanently arresting the hemorrhage.
  The Ligature.—If  the orifice of the artery projects, it should be taken hold
of with the forceps and gently drawn out;  then an  assistant should tie a liga-
ture properly around it.  As a rule, the ligature should consist of small, round
hempen thread, tied so as to divide the internal coats of the vessel smoothly;
if the artery is  diseased  and brittle, the ligature  should  be large and not tied
too  tightly.
  If the  bleeding orifice cannot be  drawn  out  with the forceps, it may be
transfixed with the tenaculum;  in  some  cases  it may  be necessary to pass a
curved needle and ligature through a considerable degree of the flesh, and  tie
all up together.  After tying, one end of the ligature should be  cut off, not too
close  to  the  knot, and the  other must be made to hang out of  the wound.
The ligature comes away in from five to twenty days, according to the size of
the  vessel.  If catgut be used, cut off both  ends near the artery.
  In  all cases where  it is  possible, a wounded artery must be tied at  the
wounded part.  If this be not practicable, the next best  plan will be to tie the
artery ascertained to be the wounded one as  near as possible to the bleeding
point, and repeat  this  process at the distal  side if bleeding occurs from that
end.
  Acupressure.—When it is not advisable to use the ligature, acupressure may
be  resorted  to;  the  method of employing acupressure  is, first, by passing a
long needle through one of the  flaps of the wound in such a way as to com-
press  the bleeding artery;  or, secondly, a small sewing  needle may be em-
ployed, threaded with  a  short piece of inelastic iron wire, by which it may  be
pulled out.  This  is slipped down in  the  tissues on one side,  then raised  up
and made  to  bridge over the vessel, while compressed with the point of the
forefinger; this is  circumclusion.
  In  the  third method the  sewing needle is  passed  slowly behind the vessel,
and a noose of fine iron wire passed over  the point, brought over the vessel
tightly enough  to  close it, and then secured with a slight twist round the eye
end of the needle. 
52
SURGERY.
  A fourth mode is to use a harelip pin, which is passed under the artery, and
a piece of silk or lint passed or twisted around it, sufficiently tight to stop the
flow of blood through the vessel.
  Torsion.—This is performed by drawing out the vessel from its  sheath, by a
pair of broad-pointed spring forceps, and then  twisting it  around freely,  as far
as its natural connections will allow; or it may be performed by drawing out
the  vessel, fixing  it by one pair of forceps a quarter or half an inch from the
end, and then with another  pair twisting the end around until  it  does not
untwist itself.
              Fig. 7.                                  Fig. 8.
             "fi
sJpfll
Fig. 9.
Fig. 10.
^ifiiiii
DIFFERENT METHODS OF ACUPRESSURE.
  Pressure is used when the wounded artery is situated immediately over a
bone.   If possible, the pressure should be confined to the bleeding orifice, and
be effected by a graduated compress.
  Cold \s applicable to cases of bleeding from numerous small vessels.
  Styptics are frequently used; tincture of perchloride of iron, saturated solu-
tion of alum, turpentine, creasote and  nitrate of silver are  the best.  The
actual cautery is most potent.
                         INCISED WOUNDS.
  An Incised wound is a division of the parts, more or less extensive, accord-
ing to the extent of the injury.
  The fibres have only been simply divided; there  is no contusion or lacera- 
WOUNDS.
53
tion ;  hence they are not likely to take on severe inflammation, nor are they
apt to slough or suppurate.
   Upon  the extent and  color of the  hemorrhage the surgeon is enabled to
judge of the kind of vessel  injured; if an artery is wounded, the blood flows
rapidly in jets and is of a florid color; if a vein, the bleeding is slow and the
blood is of a purple color.
   Treatment.—In a recent incised wound the indications are to check the bleed-
ing, remove all extraneous matter, and  to bring the parts in perfect apposition.
   To check the  hemorrhage, steady and continued pressure upon the surface,
with a sponge wet with hot corrosive sublimate solution, will be sufficient, as a
general rule.   Should  the hemorrhage proceed  from a vessel of some size, a
ligature should be applied.
   So soon as the bleeding ceases, all clots are to be completely sponged away
and all foreign bodies  must be carefully removed; the edges are then to be
brought together in their entire extent,  retained in contact by means of sutures.
The wound being dressed, the parts must be placed at rest, in a relaxed position.
   The wound must not be entirely closed, lest  the secretions be retained;  if
this be allowed to take place  erysipelas may follow, and  there will be risk of
septicaemia.   Drainage must be provided for by means of drainage tubes; they
should be placed in the wound before it is closed, care being taken not to  let
them  remain  in too long.  When the bloody serum ceases  to flow the tube
must  be  removed,  unless there is prolonged suppuration.   The ligatures may
be cut off short.
   Dress the wound antiseptically.   If  the biceps be divided, the limb must be
bent at right angles; if the triceps be injured, extension will be necessary.


                        LACERATED WOUNDS.
   Lacerated wounds are those in which the fibres, instead of being divided  by
a cutting instrument, have been torn asunder by violence.
   The edges of the wound are ragged and irregular;  there is  little pain  or
hemorrhage, and the  surrounding  parts, frequently  bruised  and discolored,
are cold and numb.
   A lacerated wound differs from an incised one, in the slightness  of the pain
and hemorrhage; in its tendency to suppurate and slough, and in its liability
to be followed by erysipelas,  septicaemia, pyaemia, tetanus  and other nervous
symptoms.
   When  the  lesion is very extensive,  the  attendant shock being necessarily
severe, local sensation  is obliterated, but when reaction takes place the pain is
frequently intense.
   The treatment of  lacerated wounds does not greatly  differ from  that of 
54
SURGERY.
incised wounds.  All foreign  bodies must  be removed, the vessels  tied, the
edges gently approximated.  Guard against secondary hemorrhage by applying,
if possible, a provisional tourniquet to the part, to be tightened on the slightest
appearance of blood.   Great care must be taken to select a sound  portion  of
the artery when the ligature is  applied.  Venous hemorrhage may generally be
controlled by a compress and roller.   All tension is to be  carefully avoided,
and the  edges are to be  trimmed with scissors and the wound closed with
sutures, using drainage tubes if necessary.
  To moderate the inflammation bichloride irrigation is to be used, either warm
or cold.   Should suppuration  present itself, wash  the wound with  corrosive
sublimate solution and dress antiseptically, and when the granulating process
is established, apply a solution  of nitric acid  three drops  and water  an ounce;
opiate cerate or dilute ointment of nitrate of mercury may be  employed.
Should the inflammation run high and gangrene be threatened, purgatives  and
nauseants should be freely used.
  Anodynes, to allay pain and  produce sleep, must be freely given.   Secondary
hemorrhage may arise as soon  as reaction takes  place, or it may occur when
the sloughs  begin to separate; this will likely take  place in five or six  days
from the  date of the injury and should be carefully guarded against, especially
if a large artery is involved.
  Should tetanus set  in, it should be promptly treated with  anodynes, using
opium, hyoscine, bromide  of sodium and chloral freely; blister the part,  or
paint it with tincture of iodine, or use cold bichloride irrigation.


                         CONTUSED WOUNDS.
  Contused wounds are usually produced by greater violence  than  the  pre-
ceding,  and  are  accompanied with  greater disorganization;  blood is extra-
vasated, cellular tissue is  broken down, muscles bruised,  and the surrounding
parts are apt to be disorganized.
  They bleed but little, in consequence of the organization of the parts being
destroyed.   The pain which accompanies a wound of this kind  is  in inverse
ratio to the amount of the injury.  When  there is  a moderate  contusion the
pain is generally severe, and when  there is a violent degree of contusion the
patient scarcely suffers any pain until reaction sets in.
  Treatment.—If there  is hemorrhage, it  is to be controlled  in  the  usual
manner,  by compression, hot water and ligatures.  When an artery lies exposed
in contused wounds, ligatures should be applied both above and below the point
of lesion.  The edges of the  wound must  be brought together gently, allow-
ance being made for swelling  and drainage.  If it be  necessary to  use sutures
to bring the parts together, it is proper to do so. 
WOUNDS.
55
   Apply the usual antiseptic dressings.  When the inflammation is very active
leeches may be necessary.
   Pain and nervous symptoms are controlled by anodynes and antispasmodics.
   After the lapse of a few days, if the wound  has healed, the part may be
bathed with tincture of camphor, soap liniment, or dilute tincture of iodine.


                        PUNCTURED  WOUNDS.
   A Punctured wound is one made with a narrow-pointed instrument, such
as needles, nails, splinters, swords, bayonets, scissors, hooks, etc.
   These wounds are much more dangerous than  cuts or incised wounds, from
the effects they produce on the injured part.
   A slight  punctured wound  through the skin  into the cellular tissue will
sometimes be followed by red lines along the course of the absorbent vessels,
from the wound to the absorbent glands.
   If a tendinous  structure be  punctured, alarming symptoms will frequently
follow.
   In punctured wounds  their depth is usually much greater  than  their width,
making it frequently difficult to determine the amount of injury inflicted.
   The pain is  often very great, depending upon the injury sustained by the
nerves. Punctured wounds are  rarely attended  with much  hemorrhage, and
sometimes with hardly any.
   They are very liable to be followed  by  erysipelas, angeioleucitis, abscess, and
wasting of  the muscles.
   The treatment consists in  the extraction of foreign  substance, if there be
any, in checking hemorrhage, in  moderating inflammation, and preventing the
development of nervous symptoms.
   All such articles as fish hooks and similar barbed substances must be extracted
by counter-openings, or pushing  them through the part  in which they may be
imbedded.
   If bleeding  arises by reason of an artery having been  laid  open, it must be
exposed and tied  at both ends.  A  full  anodyne  should  be administered, and
the parts dressed  antiseptically.   Great care must be exerted to see  that full
and sufficient drainage is established.


                          GUNSHOT WOUNDS.
   Gunshot wounds  are injuries caused by substances  discharged from  fire-
arms, by fragments of stone or wood  struck thereby, and by the  bursting of
firearms and shells.
   The symptoms are local and general, and vary in character, according to 
56                              SURGERY.

the extent of the lesion, the importance of the tissues involved and the idiosyn-
crasy of the individual.
  The pain is often insignificant, and  a person  severely hurt  may not be con-
scious of having received a wound until some time after it  has been inflicted.
The pain is of  a dull and  heavy character, unless a  nerve is struck, when it
will be sharp and severe, and burning or pricking.
  The suffering  is generally great when a bone is broken, a large joint pene-
trated, or a visceral cavity opened.
  Owing  to the contused  and lacerated nature of the  lesion, hemorrhage in
gunshot wounds is not in  proportion to the  severity of the  injury, unless an
artery be  laid open; the hemorrhage is generally external, the blood issuing
from both orifices of the wound.
  In wounds of the chest, abdomen  and  pelvis, the  hemorrhage is usually
internal.
  Gunshot wounds  are  exceedingly  liable  to secondary hemorrhage.   When
secondary hemorrhage sets in, as the result of sloughing,  it usually arises
between the tenth and fifteenth day.
  The shock in these injuries is generally most intense when the ball traverses
the head, chest, abdomen or pelvis.
  Treatment.—The indications are to promote reaction,  arrest  hemorrhage,
ascertain the condition of surrounding parts, extract all  foreign bodies, remove
loose pieces of bone, if any, and endeavor to control resulting  inflammation.
  Reaction is brought about by employing the ordinary restoratives; the patient
must be placed  in the horizontal posture;  cold  water should  be dashed in his
face; he  must  be made to inhale ammonia water.   If necessary,  sinapisms
must be employed, as well as stimulating injections used, and if he is able to
swallow, brandy should  be given him, or wine, or ammonia properly diluted.
  If  the  hemorrhage be  capillary, it will  probably  soon  cease; if not,  cold
water, pounded ice, or some mild astringent lotion should be used;  if, however,
the hemorrhage proceed  from  an artery, the ligature must be promptly resorted to.
  Before deciding upon the condition of the  wound,  care must be taken to
ascertain if there be any foreign substance present, and if there be, to remove it,
and also whether any neighboring bone be injured.
  The next point is to hunt for, and, if possible, extract the ball.
  To  control resulting  inflammation, great care must  be  taken  to properly
dress the wound by gently applying  a roller,  if  necessary;  put it on in such a
manner as not to impede drainage.
   The usual antiseptic dressings are to be employed. 
WOUNDS.
57
                         DISSECTION WOUNDS.
  Dissection wounds are those contracted in the examination of dead human
bodies.
  Symptoms.—The disease commences at the inoculated part, from whence
it spreads.
  The first symptom that attracts  attention is a stinging  or burning sensation;
upon examining the part a little whitish vesicle is observed, extremely sensitive
on pressure.  When the vesicle breaks a small ulcer is exposed.   The pain by
this time is very great, the sore enlarges, the swelling increases, and the part
feels hot, tense and numb.  A red  line is  usually seen extending from the
point of inoculation, along the arm to the  axilla.  As  the disease spreads the
whole  limb becomes  enormously enlarged,  pitting on  pressure,  and looking
dusky and  erysipelatous.
  Cases occur where the symptoms begin at the axilla and extend  from thence
up the neck and down the side.
  In the worst forms  the disease soon reaches a crisis; the system rapidly
falling into a typhoid state.
  Treatment.—As soon as a wound of this kind is  received it should  be
thoroughly washed with warm water and soap ; this should be followed by suc-
tion by the  mouth.  If the wound is  small it should be dilated ; if it has bled,
thoroughly  cauterize with acid nitrate  of mercury, or nitrate of silver, hydro-
chloric, nitric or sulphuric acid.
  If a vesicle forms it should be freely opened, and then thoroughly cauterized;
antiseptic dressings should be applied, and, if necessary, a purgative adminis-
tered.  To relieve the excessive pain and restlessness anodynes should be freely
employed, and if the skin be hot and dry aconite or veratrum viride  should be
administered.
  To meet the typhoid symptoms, milk punch, quinine, iron  and such other
treatment should be resorted to as will  support and sustain the patient.


                      WOUNDS OF  THE THROAT.
  The usual causes of  these injuries are attempts to commit suicide; the parts
injured are the pharynx, larynx, trachea or oesophagus.
  In  these cases the carotid  is rarely reached, owing to the incision being
made high  up, and to the head being thrown backward.
  The larynx is most  frequently  injured;  it is characterized  by air and blood
issuing from the wound with great rapidity, especially when the patient coughs.
The arteries that are usually wounded are the sublinguals. Should the external
carotid be  divided, death  would ensue  before assistance could be rendered.
       E 
58
SURGERY.
   When the injury is above  the larynx, the lips of the  wound must  be care-
 fully brought into apposition and  kept  in  place by sutures.   The  head must
 be bjrought down upon the  chest, and confined in that position, in  order to
 prevent a separation of the edges of the wound.
   The mouth must be kept  cool  and moist; and  for  this purpose a slice of
 lemon dipped in water, or a wet rag, or pieces of  ice,  may be inserted from
 time to time.
   The patient should be carefully  nourished, by nutrient enemata, with opium
 added, if necessary, and when  food is given by the mouth, it is best to com-
 mence with semi-solids, such  as jelly, etc.
   If the wound is in the thyroid or cricoid cartilages,  the air rushes  through
 the aperture in expiration, and  violent coughing is produced.  The treatment
 is the same as in the preceding case.
   When the injury is inflicted within three inches of the sternum, it  is more
 dangerous  than in any other  situation; here the trachea is in the forepart, the
 oesophagus behind, and the carotid arteries  are close to the trachea.
   The first object is  to  stop the  bleeding; and if the opening is not suffi-
 ciently large, an incision should be made in a longitudinal direction, to expose
 the mouth of the vessel, in  order to  secure it with the least possible  delay.
 The wound is not to be entirely closed, otherwise emphysema may ensue.


                 GUNSHOT WOUNDS OF THE  CHEST.
   These  may be divided into the non-penetrating and the penetrating.  The
non-penetrating are those affecting the soft parts and the ribs;  the penetrating
are those in which the lung is directly injured.   The missile may pass  through
entirely or partially, and lodge in  the pleural cavity, or it may pass directly
through the chest and  lung.
   Symptoms.—More or less collapse, depending on the time that has elapsed
since  the  wound.  Face  anxious, breathing labored,  respirations frequent.
Blood  expectorated in more or less large quantities; air generally found pass-
ing from surface of wound, and usually there is emphysema in the neighbor-
hood.
   Treatment.—Patient must be placed in bed and careful search made  for
the ball;  when there is no counter-opening, the ball may be often found  on the
opposite side.   Splintered fragments of ribs should  be removed and any sharp
ends of bone rounded off.   If the collapse is  not  severe the patient should
not be disturbed, so that an opportunity may be given  for clots to form and
bleeding to cease.
   A light antiseptic dressing  should be placed over the wound and the patient
carefully watched. 
WOUNDS.
59
                      WOUNDS OF THE ABDOMEN.
   Wounds of the walls of the abdomen may be caused by fragments of shell,
 and large portions of the integuments  and muscles may be carried away;  bul-
 lets and swords  will  frequently traverse the walls of the  abdomen without
 penetrating, and  missiles may strike the abdomen and inflict  severe injury on
 the viscera without external injury.
   Penetrating wounds of the abdomen, with or without injury  to the viscera or
 large vessels, are followed by  great mortality. If the contents of the abdomen
 are not  injured,  the chief danger is from peritonitis.  When the viscera are
 wounded, the severity of the danger, in a great measure, depends upon whether
 a  solid organ, such as the liver, spleen, or kidney, has been injured, or if the
 stomach or intestines have been perforated.
   Wounds of the liver,  spleen  and kidney  are more fatal than those of the
 stomach and large intestines, and these latter more so than the  small intestines.
   Symptoms.—Great collapse is the first striking  symptom;  it is very severe
 if the viscera have been wounded; and is  a common cause of death.  Frequent
 vomiting is a symptom common in wounds of the intestines, particularly if the
 injury be high in the canal.   The  pain is great;  and blood  passed from the
 bowels is a usual symptom.'
   The after symptoms are those of peritonitis and such as are referable to the
 particular organ wounded, e. g., blood with the urine, if the kidney be injured;
 or bile, if the liver, etc.,  etc.
   Diagnosis.—As an infallible test of injury of the gastro-intestinal canal, in
 penetrating wounds of the abdomen, the rectal insufflation of hydrogen gas, as
 originally advocated by Professor Senn, is recommended.
   Treatment.—When  the cavity of  the abdomen  is penetrated,  place the
 patient on a bed, carefully examine the  wound, and return any viscera that
 may protrude.   If the intestine be wounded, stitches must be applied.  Prefer-
 ence is given to Lembert's interrupted suture; see page 48, article "Sutures."
   To relieve ^>ain and to arrest  peristaltic action, large and repeated doses of
 opium are called  for.
   Where there  is only a superficial wound, endeavor to procure union by means
 of sutures.
   Laparotomy or Abdominal Section is  performed either  for the  removal
of foreign bodies  from the intestines, or when acute obstruction exists, in cases
of intussusception, or of injuries of  the abdominal viscera.
   If the  weather be cold, the temperature  of the apartment, prior to com-
mencing  the operation, should be raised  to about  700 F.  Then the  patient
having been placed upon his back, his bladder should be emptied, and chloro- 
60
SURGERY.
form  administered.  He is then brought to the edge of the bed with his legs
hanging  over it.   Flannels wrung  out of warm bichloride solution (1-2000),
or flat sponges wrung out of warm  carbolized water, should be at hand, ready
for use;  and the strictest antiseptic precautions observed throughout the opera-
tion.
   The surgeon makes an incision  in  the middle  line below the umbilicus, or
over the seat of obstruction if it can be determined, and carries his knife cau-
tiously down to the peritoneum;  this  membrane  is then  carefully scraped
through at one spot, the finger passed  in, and the peritoneum  split up by a
probe-pointed bistoury, guarded by the forefinger beneath.
   Protruding coils of  intestine are to be gently drawn  aside by an assistant,
using the wet flannels  or carbolized sponges for the purpose, while the operator
searches  carefully upward along the  empty  coils of the bowel until he
arrives at the source of obstruction.   If an intussusception exist  it must be
reduced.
   The intestines  are  then replaced, the  peritoneum  cleansed with  aseptic
sponges,  and the wound closed in the  usual manner.
   If the  bowel cannot be released,  it may be opened as  low down as possible,
and the aperture stitched to the integument of the abdominal wound, and an
artificial anus established.
   The after-treatment  is that of an abdominal wound with peritonitis.
   Professor Senn's method  of employing Intestinal Anastomosis and Enterec-
tomy  may be beneficially adopted in many cases.  See  Senn on Intestinal
Surgery.

                       WOUNDS OF THE JOINTS.
  A wound may usually be known to  have  penetrated the joint by the escape
of synovia, though this is not invariably  the case.
   Treatment.—The  parts must be  shaved, carefully cleansed, and dressed
antiseptically, due regard being had to free drainage.
   The limb must be absolutely immovable  and for this purpose a proper splint
must be applied.   The Plaster-of-Paris splint is usually employed1!


              QUESTION  OF AMPUTATION IN WOUNDS.
   Amputation should never be performed until reaction has set in.
  It should be resorted  to when  the  limb has been run  over  by a heavy ve-
hicle, crushing the bone and tearing open the soft parts; when, in addition to
serious injury inflated upon the integuments, muscles or bones, the principal
artery, vein, or  nerve  has been lacerated ;  when  a large joint is  penetrated,
accompanied by comminuted fracture.   If mortification sets in, amputate high 
HYDROPHOBIA.
61
up.  If it is an injury of the leg, and the bones are shattered, and the posterior
soft parts are not much lacerated, and the main artery is intact, an effort should
be made to save the limb.


                          HYDROPHOBIA.
  This disease is the result of poison, caused by inoculation with the saliva of
rabid animals.
  Symptoms.—The first  symptom a person experiences who has been bitten
by a rabid animal is pain in the injured part, and  this may be felt between the
second week and  ninth  month  after a bite  (sometimes a much longer period
will  elapse).   The next  symptoms are  low spirits, a sense  of chilliness, suc-
ceeded by  rigors  and  heat, headache, stiffness of  the neck,  soreness of the
throat; then a difficulty of  swallowing is felt, not of liquids in particular, but
of any substance;  so that the patient avoids  making an effort;  but upon apply-
ing a cup to his lips, he will be  seized with  the most painful  shuddering;  he
will  turn away to  avoid the sight of what he was about to take, and sit down
in a state of exhaustion.
  From this time the most  prominent symptoms will be difficulty of breathing
and swallowing, extreme irritability of the body and disorder of the mind.
  Treatment.—Immediately after  the individual  has been  bitten,  place  a
tight ligature above the affected  part, and, if possible, at once  have the wound
vigorously sucked, and then,  as soon as may be,  cut it  out  and thoroughly
cauterize the whole.  Mr. Youatt prefers nitrate of silver, but many authorities
place a small piece of  potassa fusa into the wound, allow it to dissolve, when
its cauterizing influence will be communicated to all parts of the wound.
  It does not appear  that there is any cure for  this affecti n.  The general
treatment should be that  indicated  under the head of tetanus.


M.  PASTEUR'S METHOD OF TREATMENT OF PERSONS BITTEN BY
                           RABID ANIMALS.
  As M. Pasteur's method  of treating persons who  have been  bitten by rabid
animals has attracted considerable  attention, the following synopsis of his mode
of conducting a case of the kind is here engrossed :—
  The substance used for inoculation is perfectly pure veal broth, exempt from
any microbe, in which  has been dissolved a little of the  spinal marrow of a
rabid rabbit.  The broth,  carefully prepared, is put  in  a  glass  receiver of
spherical form, with  long neck  hermetically sealed.  It is then submitted for
half an hour, under pressure, to  a heat of 2390 F.  This boiling is for the pur-
pose of destroying all  germs.  When perfectly clear,  it is decanted in one of 
62                              SURGERY.

Pasteur's receptacles.   To obtain the infected marrow, a rabbit, having been
chloroformed and  trepanned, the infected broth  is  injected under the dura
mater, when  the edges of the wound are stitched together, and the rabbit is
left to recover.
  After the inoculation, rabies declares itself in the rabbit at the end of six
days.  Two or three days later the animal dies.   The  spinal column is care-
fully extracted, and then  hung up in a flask containing caustic potash.   It is
placed in a room kept at a heat of 68° F.  When the infected substance is to
be used, a piece about  a  centimetre in  length is  cut off and mixed with pure
broth.  The first day the  patient receives half a hypodermic syringeful of broth,
with marrow of thirteen days' strength.   The following day the patient receives
a hypodermic of twelve  days' strength.  Each day the marrow  is one  day
younger.   The operation is repeated daily for twelve days.


                     BURNS  AND SCALDS.
  Burns and scalds are divided  according to their  severity; those which pro-
duce mere redness, followed by desquamation of the cuticle,  and those attended
with destruction of tissue.
  Symptoms.—The severity of the constitutional  effect of burns depends on
their extent rather  than their depth; it is likewise modified by their situation
and by the age  of  the patient.
  An extensive burn is more  serious in  its  immediate  results than a smaller
though deeper  burn.   Burns of the  chest, abdomen,  head  and face,  are
followed by much more severe symptoms than  more  extensive burns of the
extremities.
  The earliest symptoms are those of shock ; the skin is cold, accompanied by
shivering ;  the pulse is  rapid and feeble, sometimes thready; the pain is severe,
and of greater intensity in slight  than  in deep burns;  in the worst cases it is
nearly or quite absent.  In children,  vomiting is an early symptom. When the
mouth and pharynx have  been scorched there is thirst and dysphagia; the urine
is scanty, frequently  albuminous and bloody.  The patient may lapse into  a
drowsy condition, followed by coma  and death;  or there may be restlessness,
delirium and clonic spasms.
   If life be prolonged, reaction sets in  after twenty-four or forty-eight hours,
and the general febrile  symptoms of traumatic fever present themselves; these
symptoms are kept up by the absorption of inflammatory products, and if de-
composition takes place there will be septic poisoning.   Constipation is followed
by diarrhoea, which is often profuse and exhausting.
  A singular accompaniment of severe burns is a  liability  to  be  followed  by 
BURNS AND SCALDS.
63
acute ulceration of the duodenum (Curling's ulcer);  this may terminate fatally
by perforating the intestine and causing peritonitis.
  Pulmonary complications frequently occur.
  The process of separation of the sloughs is usually completed by the end of
the second week, when  the stage of suppuration  begins.  Weakness is often
extreme, hectic may result, and death ensue from exhaustion.
  As consequences of burns and scalds, vicious scars are formed, and contigu-
ous surfaces are apt to adhere together,
with retraction of the affected part, pro-
ducing ankylosis of  the  neighboring
joints and terrible distortion.
  Treatment — Constitutional.—A
stimulating plan of treatment is  almost
invariably  necessary, and  depletion is
rarely advisable  even in the presence
of  inflammation  of internal  organs.
In the first stage the aim is to establish
reaction and relieve pain.
  To  raise  the  system from  the  de-
pression into which it frequently sinks,
anodynes should  be resorted to early,
and  given in  large quantities.   The
strength  must be  maintained  by nutri-
tious   diet,  together with  stimulants;
quinine,  ammonia and  hot brandy and
water  should  be freely  resorted  to.
Sinapisms should  be  applied along the
spine.  Diarrhoea must be arrested by  astringents and opiates.

  Local Treatment.—In  the local treatment of burns, the protection from
and exclusion of air from the burnt surface, and the prevention of decomposi-
tion are the indications.  The body should be exposed as  little as  possible.
The  use  of antiseptic dressings,  which seldom need  renewal, will avoid  the
necessity of frequent change, and this is very desirable.
  The severe pain is promptly relieved by the use of bicarbonate of soda, either
applied in the form of paste made with water, or freely sprinkled over the raw
surface.
  Cold applications are  useful in many cases, especially in  summer; or  the
parts  may be  covered with a liniment of  equal  parts of linseed oil  and lime
water; or a lead lotion may be applied, or a weak carbolic solution.   Carded
cotton is a remedy in constant use ;  or the surface may be dredged over with
Fig. ii.
DISTORTION FROM BURNS. 
64 *
SURGERY.
a thick layer of flour or starch.   Lint soaked in Goulard water is a remedy in
frequent use.
  Iodoform, which acts as a local anaesthetic, may be sprinkled over the surface
if signs of decomposition appear.
  S. D. Gross highly recommends  the application of carbonate of lead  in the
form of white paint.   If vesicles  exist they must be evacuated with  a fine
needle and  the surface  well  dried, otherwise the  lead  will not adhere.  He
also recommends an application of  a weak solution of nitrate of silver, to allay
the scalding and smarting sensation.   Mucilage of gum acacia,  or mucilage of
gum acacia mixed with linseed oil and lime water has been found useful.
.  If a burn is severe or extensive enough to cause danger to life, the parts
should be  first bathed  with tepid turpentine, then should be applied a liniment
composed of ung.  resinae,  ^j, ol.  terebinth., ^ss, thickly spread on lint, and
the parts afterwards to be wrapped  in cotton wool and flannel; or resin oint-
ment, with equal  parts of lard or  oil, may be  used, melted together, and  ten
drops of creasote  to  the  ounce may be  added.   The dressing should be
allowed to remain as long as possible, and should not be removed unless there
is a profuse discharge, or a bad smell, from the ulcerated surface.
  Ulcers resulting from  deep burns are extremely intractable ; they secrete pus
profusely, and often many months elapse before they  are healed.
  In such cases, mild  stimulants and astringents are advisable;  especially car-
bolate of zinc  lotion and bismuth ointment.  When  the discharge is very pro-
fuse, the sore  should be kept constantly covered with  finely-powdered  chalk,
or subiodide of bismuth.   Skin  grafting is frequently resorted to, with success-
ful results.


                   CHILBLAIN—FROSTBITE.
  Severe cold causes an erythematous inflammation of the skin, described  as
frostbite, the effects of which are designated as chilblain.
  The portions of the body that usually suffer are the fingers, tips and lobes of
the ear, end of the nose and the toes.
  When the air is loaded with moisture, chilblain is much more apt to be pro-
duced than when the atmosphere is dry.
  When a person has been exposed to very severe cold, and especially if he
has been exhausted by  fatigue, hunger and watching, he feels an  irresistible
impulse to sleep, which if yielded to, will soon end in coma and death.
  The best remedy for  a frostbite  is to rub  the part well with  snow; if snow
be not attainable, cold water must be substituted.   These applications to  be
made in  a room without  fire; and a high temperature must  be avoided for
some time. 
ERYSIPELAS.
65
  If the cold*has induced coma, the  best remedy is friction with flannel all
over the surface of the body.
  Warm drinks  must be  administered, such as coffee, tea, weak wine and
water, to which a few drops of aqua  ammonia may be added ; if the patient
cannot swallow, an injection of milk  with a little  brandy may be resorted to.
When  reaction is  restored, the temperature of the room may be gradually
raised.
  Stimulating applications are  to be  used to relieve the  itching and burning
that accompanies chilblain; of these, tincture of iodine painted over the part;
Wardrop's  liniment, consisting of tinct. cantharides, giij, linimentum saponis,
gix ; turpentine, dilute, and carbolic acid, are most highly recommended.
  Cod-liver oil, quinine and tonic treatment generally, are necessary.
                           ERYSIPELAS.
  Erysipelas is a diffused inflammation affecting the skin and areolar tissue;
due to bacillus of erysipelas.
  Symptoms.—Cutaneous  erysipelas  is known by redness of the skin, which
disappears  momentarily on  pressure;  the swelling is puffy, with a distinct
edge; the pain is smarting, burning and stinging.  The redness is of a vivid,
scarlet hue, with a  tendency to  become yellowish, if there be much debility.
The nearest lymphatic glands are always swollen and tender.
  In the phlegmonous erysipelas  the redness is deeper; sometimes dusky and
purple;  the swelling  is greater, and is hard  and tense;  or it may be more
doughy  and pitting on pressure;  the pain is not only burning but throbbing.
  The disease  begins with shivering,  headache, pain  in the back, nausea,
vomiting, followed by fever, which is of a low type, especially if the patient be
old and weak, or if it be of a hospital origin.   Diarrhoea  and perspiration may
be present from the outset, particularly if the case be asthenic in character.
  The cutaneous variety may terminate in resolution, with desquamation and
slight oedema, or may subside, leaving  bulla  or vesicles remaining under the
cuticle, which dry into scales and peel off, leaving  a healthy cutis and some-
times  superficial  ulcerations.
  It may terminate by the appearance of small abscesses.
  Ordinary duration is from seven to fourteen days.
  The phlegmonous erysipelas often leads to diffuse suppuration of the areolar
tissue, when the swelling is  flaccid and quaggy; patches of the skin become
purple and slough;  the  intermuscular tissue and fasciae may  suffer in the same
way, and even  if the patient escape with his life, the limb  may remain per-
manently useless. 
66
SURGERY.
   Phlegmonous erysipelas is more  dangerous than the cutaneous variety;  the
disease is particularly to be dreaded when it attacks the scalp.  In old persons,
the intemperate, and in the very young, the  prognosis  is  very  grave.   An
epidemic of this disease is always more destructive to life than when it occurs
sporadically.   Traumatic erysipelas is always a  cause for grave concern.
   The tendency to relapse  after  the  disease has disappeared from the part
originally affected is very remarkable.
   Treatment.—It  is well to begin the treatment with a mild purgative, unless
the patient  be very weak  and delicate; calomel,  rhubarb and  compound
extract of colocynth are  the  articles to be mainly  relied upon.   When  the
bowels have  been  thoroughly evacuated, none but the most gentle aperients
should be employed, as blue mass, Seidlitz powders,  etc.  If there is irritation
of the stomach, or diarrhoea, small doses of hydrarg. c. creta, with bismuth,
may be used  with  advantage.   If the  cutaneous  functions  are more or less
interrupted, diaphoretics are indicated; Dover's powder, with tepid sponging
or warm bath, maybe used.  Anodynes, to  allay pain and induce sleep, must
be employed.   When there is a tendency to prostration, stimulants  and tonics
must be early resorted to.  The tincture of the  chloride of iron, alone or with
quinine, should be freely given.
   Recently nitrate of pilocarpine in one-sixth grain doses, repeated  at the end
of two hours if no perspiration  ensues, has been used at the Pennsylvania
Hospital with  highly satisfactory results.  The  remedy is not to be prescribed
in c»ses where the heart is feeble and weak.

   Local Treatment.—The patient must be isolated, with an especial nurse in
attendance.  The  inflamed  part should always be kept warm and raised; air
being excluded from the surface.   Warm  fomentations are the best,  especially
when medicated  with   poppy,  hop, or  chamomile.   Cold  applications  are
injurious.  Tincture of iodine, sulphate of iron, a drachm to water a  pint, tinc-
ture of the  perchloride of iron, muriated tincture of iron, a solution of the
acetate of lead and opium, chloride of ammonium, alcohol, chloride of sodium,
carbonate of potassium  and quinine;  a  subcutaneous  injection of a  solution of
carbolic acid;  nitrate of silver in  solution, say  from  twenty to thirty grains to
the ounce of  water, applied directly over the  affected parts, are  all, in turn,
highly recommended.
   In the more simple varieties of the disease, it is sometimes useful to grease
the part with  vaseline, afterward covering it with a  rag wetted with  opiated
water or to dust with  starch,  flour,  arrowroot, prepared chalk or  carbonate
of zinc.
   In  the cellulo-cutaneous  forms  of the disease, as soon  as tension  of  the
integument appears, incisions must be made deep enough to allow of the escape 
SHOCK, OR COLLAPSE.
67
of the serum from the cellular tisue beneath, and to relieve the tension.  Some
surgeons recommend that the incisions be free so as to extend the whole length
of the affected  parts; others prefer a greater number of limited  incisions;
preference is given to the latter method.  The long incisions are attended with
copious hemorrhage and  great  risk of life, while the hemorrhage from  the
limited incisions can generally be controlled  by elevation of the part and pres-
sure, applying the usual antiseptic dressings.
                    SHOCK, OR  COLLAPSE.
  Shock, Prostration, or Collapse, are  terms  used to signify the loss of
power which immediately follows severe injuries, especially those attended with
violence.  It is due to reflex paralysis of the vasomotor system of nerves.
  Shock may be caused by any severe injury, especially gunshot wounds, com-
pound  fractures, severe  burns, protracted surgical operations, and all cases in
which serious injury is attended with  violence, pain and loss of blood.  Mental
shocks may be as severe and  fatal as those of the body.  Sometimes shock is
so severe that the patient sinks from it without reaction; this is  especially
likely in injuries of the vital organs or of the abdominal viscera.
  Treatment.—The patient must be kept in a horizontal position;  all con-
stricting clothing must be removed;  free access to the cold air must be pro-
vided;  cold water should be dashed  into his face; a bottle containing dilute
aqua ammonia should be  held under the  nostrils.   If the case is  unusually
severe, atropia, or tincture of digitalis, or whisky, should be injected under the
skin;  stimulating injections should be thrown into  the rectum.  Hot brandy
and water, if the patient can swallow it, is probably more  efficient  than any-
thing else;  a few drops  of aqua ammonia  may be added.   An enema of  hot
water is frequently of great service.  A hypodermic injection of morphia, gr. ^,
is highly recommended, to promote respiration.  In severe and protracted cases
certain  symptoms present themselves that  demand attention: vomiting;  the
remedies for which are iced soda water, with or without  brandy;  powdered
ice  introduced  into the mouth and  allowed  to melt; effervescing  draughts;
sinapism to the epigastrium; creasote in small doses.   Hiccough is relieved by
the same remedies.  Hoffman's anodyne, or  chloroform, a  few drops on  ice,
will  often prove serviceable.   Bleeding,  if any  exist,  must,  of course, be
checked. 
68
SURGERY.
                             TETANUS.
  Tetanus is a more or less violent and extensive contraction of the muscles
of voluntary motion, attended with rigidity and tension of the parts  affected;
due to the bacillus of tetanus.
  It begins, generally, with the muscles of the jaw.  When it is confined  to
this part of the body, it  is called trismus, or locked jaw.  When all the body
is affected, and  becomes rigid, but retains its ordinary straightness, the case is
one of tetanus ; when the head is stretched backward, it is called opisthotonos ;
when the body  is bent forward, it is called emprosthotonos; when the tension
is confined to the muscles of one side, it is denominated pleurosthotonos.
  Tetanus is again divided into idiopathic and traumatic.
  Traumatic tetanus  derives its origin from  the  infliction of wounds,  and it
arises more particularly  from wounds of  the extremities; it  is produced, most
commonly, in consequence of contused, lacerated or punctured  wounds.   It
will  occur in all  stages of a wound; it  usually comes on some days after the
occurrence of the injury.
  Symptoms.—The patient finds a stiffness  in the movement of the jaw; he
experiences an uneasiness in swallowing, and  he soon perceives that he has a
difficulty in separating his teeth  for the admission of food.   He begins, now, to
feel  a pain behind  the  sternum,  and this  pain extends from the pit  of the
stomach toward the vertebral column.  The muscles of the  back, and  of the
neck and  back, begin to be affected by spasms, then those of the  abdomen,
afterward those of the limbs, and lastly those of the face.
  The muscles become  more  and more rigid as the case  proceeds.  In the
extreme period  of the disorder all the muscles of voluntary motion are affected;
among others those of the face;  the forehead and nose are drawn up; the eyes
are distorted, fixed and motionless; cheeks retracted,  and the features undergo
an extraordinary change.  The spasms  become universal, and a violent con-
vulsion puts an  end  to the misery of the patient.
  Idiopathic tetanus arises more frequently in  hot than temperate climates.
  Prognosis.—In the acute form very grave; in the chronic form favorable.
  Treatment.—The indications are to husband the strength of the patient till
the disease shall cease;  to remove, as far as practicable, all conditions believed
to have  the power of creating the tetanic state, and  to employ any sedative or
special treatment from which we may hope to derive advantage.
  The chief thing to be attended to is perfect quiet;  the room should be kept
dark, and the patient kept, as nearly as may be, in  perfect  repose;  remedies
should  be  administered as gently as possible; everything  harsh or  violent 
INJURIES OF THE HEAD.
69
should be avoided.  If nourishment cannot be swallowed, it should be admin-
istered per anum ; it  should  be as plentiful as the  nature  of the case will
admit; the supply of brandy and wine should be abundant.   Quinine and iron
should be freely administered; opium and morphia have, in many cases, been
serviceable; chloral hydrate, chloroform, Indian hemp and tobacco  have all
been tried, in turn, and sometimes with  success.   Hydrobromate of hyoscine
has recently been highly recommended in the treatment of convulsions.
                  INJURIES  OF  THE  HEAD.
  Wounds of  the Scalp.—These must  not be  neglected, however slight;
they may be followed by  erysipelas, inflammation and  suppuration.  They
should be quickly closed;  care should be taken to wash away all foreign bodies
and clots with  bichloride of mercury solution and  a  syringe.  No part of the
scalp, however torn, should be cut away.   Careful coaptation must be made by
means of sutures.  The patient should be  confined  to bed, or to the house,
purged and put on a milk diet.
  Hemorrhage from smaJJ  vessels  is usually controlled  by closing the wound
and using pressure; larger vessels must be secured.
  Every scalp wound should be carefully examined with the finger and probe,
so as to ascertain whether or not fracture of the skull  exist.
  If suppuration occur, indicated by rigors, chills, dry tongue, with increase of
swelling and throbbing pain, the adhesions must  be separated at any  suspicious
spot, and free drainage established.
  If there be suppuration under the scalp, free incisions down to the bone are
clearly indicated.
  If there be serous effusion it  may be necessary to let  it out  by one or two
punctures.

                     CONCUSSION OF THE BRAIN.
  Concussion is a sudden  interruption of the functions of the brain, caused
by a blow or other mechanical injury of the head.
  Symptoms.—In ordinary cases  the patient lies for a time motionless, uncon-
scious and partially insensible;  the pupils are more or less contracted and the
patient turns away irritably from the light;  if roused and questioned he answers
hastily and again relapses into apparent insensibility;  after a time he  moves his
limbs  as if  in an  uneasy  sleep, vomits  and frequently recovers  immediately
afterward; remaining, however, giddy and  confused for some hours after.
  In the more severe cases the patient is profoundly insensible, the surface and
extremities are pale and cold, and the features ghastly; the pupils are sluggish 
70                              SURGERY.
 and sometimes dilated, but equal on both sides, unless the brain is  injured;
 the pulse is quick, feeble and intermittent, or hardly to be felt, and the breathing
 slow, or performed only by a feeble sigh drawn at intervals.
   Vomiting is an important symptom.   Its presence is  generally an indication
 of approaching reaction and recovery.   As reaction goes on, the  pulse at first
 quickens, becomes  stronger and slower, the  carotids throb perceptibly; there
 are black spots and flashes of light in the eyes and noises  in the ears; pain in
 the head is felt and increases; the eyes are suffused and the face flushed.
   If the concussion be very severe it may*4*£ followed by immediate death.
   Concussion is  occasionally succeeded  by a peculiar state of  insensibility,
 which may last some days.  The patient lies  as if in a tranquil sleep; his pulse
 is regular, but on the slightest exertion it rises to 130 or 140; when roused he
 answers questions, but  immediately relapses into unconsciousness.
   Treatment.—To recover the patient  from insensibility and collapse, apply
 friction  to  the surface with the  hand, and warm  applications to the feet;
 mustard plasters to the calves of the legs.
   Stimulants, if used, must be  employed with the greatest  caution, so that
 reaction may not be too violent.
  After reaction has taken place,  the bowels should be acted on;  quiet in a
 dark room, with rest and low diet, should be observed.
   If the pulse becomes hard and frequent, and if the patient complains of pain,
 throbbing or tightness  in the  head, or if he becomes  flushed or delirious, or
 stupid and comatose, or if vomiting returns, blood  should  be taken from  the
 arm, or by leeches from  the  head, and  purgatives should be administered.
 Twenty grains of bromide of sodium should  be given  every four hours.   The
 head  should  be kept cool.  The  patient should observe a 'cautious diet, and
 remain free from excitement or fatigue for some time  after the occurrence of
 the injury.
  The consequences of concussion are persistent headache, deafness, giddiness,
squinting,  loss of memory, tinnitus aurium,  etc.;  for these, a mild course of
mercury may be necessary, together with repeated blisters, change of air, etc.


                    COMPRESSION OF THE BRAIN.
  Compression may be produced by extravasation of blood, effusion of serum,
fracture of the skull with depression,  and  by suppuration within its cavity.
  The symptoms  are  those of  apoplexy.  Insensibility, palsy,  dilated and
insensible pupil; slow,  laboring pulse; skin often hot and perspiring; retention
of the urine, through palsy of the bladder; involuntary discharge'of faeces,
through palsy of the sphincter ani; stertorous breathing, owing to palsy of the
velum pendulum palati; whiffing or puffing respiration,  from palsy of  the 
INJURIES OF THE HEAD.                      71
buccinator and other facial muscles.   The  palsy, if it exists, will vary greatly
in degree; if it be on one side, it will  be opposite to the injury of the head.
There may be convulsions, muscular twitchings, or rigidity.
   The symptoms of compression by extravasation generally show themselves by
the patient becoming stunned and insensible, from the concussion, with feeble
pulse and cold skin.   After awhile he recovers his senses, more or less perfectly,
but again, in an  hour or two, becomes sleepy, confused, and  insensible, with
slow, stertorous breathing, slow pulse and dilated pupils.
   Diagnosis.—In concussion, the symptoms follow the accident immediately;
those of compression from effusion of blood may come on after an interval.   In
concussion, the pulse is feeble, irregular or intermittent, the skin pale, and the
respiration sighing  and weak; in compression, when reaction  is thoroughly
established, the pulse will be slow and  full, and the skin hot and  perspiring.
   In concussion,  stertorous breathing and palsy are rare;  in compression they
are common.
   In concussion  the pupil is  variable; sometimes contracted  and  sometimes
dilated; in compression it is almost always dilated and insensible;  frequently
unequal on the  two sides.
   Treatment.—Shave the head and examine it carefully; if there be  no sign
of fracture or injury, treat the case as one  of apoplexy;  the indications are to
lessen hemorrhage and arrest inflammation by cold applications and purgatives.
   If insensibility  continues and  the patient grows gradually worse,  trephining
is recommended,  in  the hope of letting out the  blood that has  extravasated
underneath, and thus relieving the pressure.


                     FRACTURES OF THE SKULL.
   These are caused by great violence, such as  blows or falls on the  head, and
gunshot wounds.
   The ordinary type of  symptoms and consequences of fractures of the skull
depend on the conditions which accompany them, especially the amount of con-
cussion; the  forcing in of portions of the bone;  the complication with scalp
wounds; the  situation and the inflammation  excited.
   Simple fracture with depression may be ascertained by examination of the
shaved scalp; there will be a depression at one part, with  a corresponding edge
or projecting ridge around it.
   Treatment.—In a case of simple depressed fracture, if there be no symptom
of compression, and if the patient is conscious and rational, he should be kept
on the  strictest regimen;  lying down, head raised;  cold water to  head and
aperients are the remedies. 
72                             SURGERY.

  Trephining is recommended in all cases of fracture with depression, whether
symptoms call for it or not; under the belief that such  sequelae as epilepsy,
fatuity and softening of the brain may thus be avoided.
  If comminuted, and it is probable splinters  are sticking into the brain or
its membranes, the bone must be elevated.   If possible, it should be with the
elevator alone.
  Fracture of the inner table.—The inner table may be  extensively splint-
ered by  injuries which perforate or slice through the outer table; such as cuts
from sabres and blows with heavy weights.  If, after careful examination, it is
found that depression exists, the trephine  should be used to raise or remove
splinters.
  Fractures of the base of the skull may run in various directions;  they
are most frequently found passing through the petrous, squamous and sphenoid
bones.
  The diagnosis will be  founded on  the  nature of the injury; the patient
will probably be injured  from having  been pitched  on  his head; there will
probably be bleeding from one ear;  after the bleeding has ceased a most sig-
nificant  symptom is the draining through  the ear of a clear fluid; symptoms
indicating damage to the nerves that escape from the base of the skull may be
noticed; bleeding from the nose and  mouth will  show the direction of  the
fracture; as a rule, if the fracture is of the anterior fossa the hemorrhage will
be from the  nose;  if of the middle fossa it will be from the  ear; if of the pos-
terior fossa it may find its way into the  pharynx, from thence into the stomach
and ultimately be vomited up.   Hence  care must be  taken not to be misled
and suppose that the stomach is involved in the  injury.
   Symptoms and prognosis  depend on the amount of injury to the brain;
stupor, dilated and unequal pupils, with rapid pulse, hot skin and  dry tongue
and delirium are unfavorable symptoms.
   Treatment.—Absolute  repose, low  diet, giving the patient a purge, ice or
cold water to the head, and the bromides, are the remedies.
   Trephining.—The  pericranium  being raised, by means of a blunt  scalpel,
from the part which is to be perforated, the surgeon  applies the trephine with
the point of his forefinger protecting the crown, and working it with an alter-
nate pronation  and supination of  the wrist; and when it has made a circular
groove  deep enough to work it steadily, he must take  care to withdraw the
centre pin.   He must saw steadily and cautiously, frequently  examining  the
groove to ascertain whether he has reached the dura mater, and when he has done
so he introduces the  broad curved forceps, to raise the circular piece of bone.
The greatest care must be taken to fix  the  centre pin and the greater part of
the circumference of the  instrument  on  firm  bone,  and by no means press 
INJURIES OF THE HEAD.
73
heavily while sawing on  any piece of bone  that  is loose or yielding.   When
the saw reaches the diploe there will be an escape of blood with the bone dust,
but there is no  diploe in either children or aged persons.
  When the  piece of bone is removed the surgeon  must  gently insinuate the
Fig. 12.
OPERATION OF TREPHINING.
(A) Trephine prepared for use, with centre pin down.  (B) Centre pin withdrawn;
                   the under table having been divided.
Fig. 13.
hey s SAW.
Fig. 14.
ELEVATOR.
I
point of the elevator under that which is driven in, and using his finger, or the
edge of the firm bone, as a fulcrum, slowly raise  it to  its proper level.   All
loose fragments having been  removed and the wound sponged, the  scalp must
be carefully laid down.
       F 
74
SURGERY.
                           GONORRHOEA.
  Gonorrhoea is a contagious purulent inflammation of the mucous membrane
of the genitals of both sexes.
  The time at which the disease usually appears after contagion, is from twenty-
four hours to ten days; the later it appears the less severe it generally is.
  The patient first experiences a sense of titillation in the urethra, as if a drop
of urine were contained in it.  Upon examination, he finds that the lips of the
urethra are red, and that there is a slight mucous discharge.  Soon the urethra
begins to be affected with considerable heat, and pain is experienced  in voiding
the urine, which is called ardor urina.  The  pain in  many cases becomes
excessively severe; there is  an appearance of threads mixed with  the urine.
The next effect is a considerable diminution in the size of  the stream of urine,
the swollen state of the urethra contracting the calibre of the canal;  it is often
discharged in two or more streams, becomes forked, in  consequence of the
irregular arid contracted state of the urethra, and is passed with much strain-
ing, pain and scalding.  At first the discharge is mucous, but after a little time
it assumes a purulent appearance.  The  matter becomes yellow, and in some
cases  green, and it is  frequently mixed with blood, so as to give the discharge
a sanious appearance.
  The disease does not confine  itself to the  beginning  of the  urethra, but
extends  along the course of the canal, and often produces  inflammation of the
glans  and fraenum, occasioning effusion into the prepuce and phimosis.  The
absorbent vessels on the dorsum penis often become enlarged and  hard, and
produce little abscesses.
  In  a  first  gonorrhoea the glands of the  groin  are  often  sympathetically
affected, and become enlarged and painful.
  Irritation  and inflammation also take place in the corpus spongiosum, pro-
ducing the painful state known as chordee.   The penis is sometimes curved,
and sometimes turned considerably to  one side, and the  groins, thighs, peri-
neum and testicles ache and feel tender.
  After  the inflammatory stage abates, a  muco-purulent discharge remains,
which, when obstinate and thin, is called gleet.
  In the inflammatory stage of the  disease there is often  irritation or actual
inflammation  of the  urinary organs,  causing the most  exquisite  agony, or
complete retention of urine.   This inflammation may reach the bladder, giving
the patient a desire to frequently pass water, and causing  great pain in doing
so.
  There may be hemorrhage from the urethra;  inflammation of the lymphatic
glands of the groin, constituting bubo;  balanitis, or suppurating inflammation 
ORCHITIS.
75
covering the glans  penis; phimosis, paraphimosis, or inflammation of the tes-
ticle in men, or the  ovary in women.
  Treatment.—The treatment  should  begin with a free use of a mild seda-
tive injection into the urethra.  The bowels should be opened by some saline
aperient.  Abstinence from  all alcoholic liquors should be enjoined; the diet
should be very plain, and sleep should be procured by Dover's powder, or
other anodynes.  The  sulpho-carbolate of zinc  lotion, applied several times a
day, is highly recommended by Mr. Wood.  (See Formulae i to  n.) *
  If the patient is strong and plethoric, and suffers greatly from pain and fever,
with pain in micturition, it is well to apply two or three leeches to the perineum.
  After the acute symptoms have subsided, the remedies held in best  repute
are  copaiba and cubebs.  Copaiba  should be given in small, and cubebs in
larger doses; the oil of sandal wood also has a high reputation.
  The most usual mode of administering copaiba is in the form of  emulsion,
prepared by rubbing the balsam  up  with gum acacia, and adding camphor
water and  spirit of  nitrous ether, to which a little tincture of opium may be
added, or it may be given in capsules;  great benefit  is frequently to be de-
rived from  combining the copaiba and cubebs in the  same emulsion.   Painful
erections and  chordee  may  be relieved by a bag of cold water applied to the
part;  or a little mercurial ointment and extract of belladonna may be smeared
on the part  at bedtime, together with the free administration of the bromides,
say from 20 to 60 grains, or of morphia in %-grain doses.   Hemorrhage may
be checked by cold water and ice pressure on the urethra at bedtime.
                             ORCHITIS.
  Acute  orchitis, or acute  inflammation  of the  testicle, may be caused by
local violence, or it may occur in conjunction with gonorrhoea; and it is liable
to be induced by employing injections and at the same time neglecting to use a
suspensory bandage.
  Symptoms.—If the patient is suffering from gonorrhoea the discharge will
cease, and he will complain of aching pains in the testes and cord, followed by
tenderness, swelling, fever, and  frequently  by  vomiting.  The part first  and
chiefly affected is the epididymis.  The swelling arises mainly from an effusion
of lymph  and serum  into the tunica vaginalis.
  The symptoms  of epididymitis  closely resemble those  of  orchitis ; in
the latter  the constitutional disturbance is greater, the local  pain much more
intense, and the patient does  not assume the erect posture, but walks best with
* List of Formulae at end of this volume. 
76                              SURGERY.

his  legs apart.   In orchitis  the testicle is felt to be enlarged, globular, ex-
tremely sensitive and tender.  When the epididymis is inflamed it will be found
above and  behind the testicle, lying like a thick  semilunar mass, threatening
to overlap the testicle above, below and at the sides.
  Treatment.—Absolute rest  in  the  recumbent  posture;  leeches  over the
cord, and opium at night, to allay pain.   Purgatives, warm fomentations, and a
suspensory  bandage, to elevate the parts on the abdomen.
  Punctures of the tunica  vaginalis testes, with  a tenotome, will frequently
give immediate relief by evacuating the fluid.
  When the acute stage has subsided, strapping, by the application of adhesive
strips, should be employed.
  Chronic orchitis may succeed an acute attack or it may arise spontaneously.
The exciting causes are  chronic cystitis,  hypertrophy  of the prostate gland,
stricture and gonorrhoea.
  If the exciting cause is still in operation it must, of course, be removed; the
patient  should be  confined to his  back and put on the use of iodide of potas-
sium; if this does not answer he should be mercurialized, using for the purpose
calomel, blue mass, or protiodide of mercury.
                     ACUTE PROSTATITIS.
  Acute prostatitis is generally a consequence of acute gonorrhoea, but may
be caused by stricture, impacted calculus, the passage of sounds or catheters,
lithotrity, sexual excesses, or masturbation.
  The symptoms depend upon the severity of the attack; there is a sense of
weight, pain, and throbbing at the neck of the bladder, hardness and tender-
ness of the perineum; the gland  feels  swelled and tender on examination by
the rectum, and  there are frequent, violent and painful efforts  to make water.
The stream is small and ejected without force; if  the swelling and congestion
become worse the urine will stop altogether.  As the disease subsides a grayish,
viscid, muco-purulent matter is voided with the urine.
  The anxiety, distress and fever rapidly increase  as the disease progresses;
there is tenesmus and  constant  sense of fullness of the rectum; the prostate
can be felt projecting into it, which, hard and firm in the early stages, becomes
soft and fluctuating if an abscess is formed.
  The symptoms may subside gradually; the hardness and tenderness slowly
disappearing, or the inflammation may become  chronic, or suppuration  may
set in.  The abscess may open into the urethra or into the perineum or rectum;
or large chronic abscesses may form in the region of the prostate. 
CYSTITIS—STRICTURE.                        77
   Treatment.—Place the patient in a hot bath  and keep him in it until he
begins to feel faint, giving him at the same time thirty or forty drops of lauda-
num ; if relief is not obtained by this means, draw off the urine with a small
flexible catheter.  Apply  leeches to  the  perineum, and then fomentations, or
opiated poultices;  administer an enema of starch,  two ounces, laudanum, half
a drachm, every night.  Keep the patient in bed. If  suppuration ensue, cut
down through the perineum and drain the abscess.


   CYSTITIS,  OR  ACUTE  INFLAMMATION  OF THE
                             BLADDER.
   Cystitis arises in  consequence of neglected or ill-treated  gonorrhoea;  from
gout, or from chronic inflammation  induced  by  stone, stricture,  or diseased
prostate.
   The symptoms are  pain  in the perineum, groin  or sacrum, tenderness of
the lower part of the abdomen, frequent micturition, attended with great strain-
ing, followed by the  aggravation of the pain with  a mucous or muco-purulent
sediment in the urine.
   Treatment.—Begin with a calomel purge;  if the  pain is great, give opium
or morphia by the mouth, or by  enema, in  sufficiently large  doses to insure
relief.   Apply leeches to the lower portions of the abdomen or perineum; hot
baths and warm fomentations.   After  proper depletion has been used, give
diaphoretics; antimonial and saline  mixture,  with full doses of  morphia or
aconite.  For irritable stomach,  the  effervescing  draught is  considered  most
preferable.  When the urine is scanty, high colored and acrid, nitrate of potassa
or spirit of nitrous ether should be used.  In" the  latter stages of the  disease,
give an infusion of uva ursi  and hops, which may or  may not be combined
with morphia and bicarbonate of sodium, or morphia and balsam  of copaiba,
as circumstances may seem to warrant.  (See Formulae from 14 to 17.)*


                            STRICTURE.
   Permanent stricture  is caused by contraction  of the urethra, usually from
inflammation, infiltration of plastic effusion, and subsequent shrinking of this
material and of  the canal, with fibroid degeneration of the tissues around.
   In some cases  a small portion of the mucous membrane  is found thickened
and deprived  of its natural elasticity, but in old neglected cases the  canal, with
the corpus spongiosum around, will be converted intov a thick, gristly mass,
several inches in extent.
* List of Formulas at end of this volume. 
78
SURGERY.
   The most frequent situation of the stricture is in the neighborhood of the
triangular ligament.
   The causes of stricture  are repeated  attacks of gonorrhoea, intemperance,
unhealthy condition of the urine, and masturbation, which  particularly affects
the anterior  portion of the canal. m In the  author's opinion, based upon con-
siderable experience, the  long continued morbid erections that  accompany
gonorrhoea are potent sources  of stricture.
   Symptoms.—The patient  finds  that he wants to make water oftener than
usual, with an uneasy sensation in  the perineum after doing so; a few drops
remain in the urethra and dribble from him after he has buttoned up.
   Next he finds that the  stream  is smaller than hitherto, that it is forked or
twisted, and that he requires a long time  to pass his urine.
   Pretty soon the bladder becomes irritable, so that the patient is forced to rise
in the night to void his  urine,  and  is liable to attacks of spasm, with complete
retention.  Very often there is a  gleety discharge;  frequently found in the
morning on waking up.
   If the complaint continues, the health suffers, the bladder, ureters and kidneys
become diseased.  The patient suffers from general debility  and nervous pros-
tration, and the urine is loaded with  fetid mucus.  Going from bad to worse,
the patient  will finally succumb to irritative fever or uraemic  poisoning.
   Treatment.—When the case is  taken in hand early, the general health
should receive prompt attention, and any disorder of the stomach, inflammatory
tendency, or  irritating condition of the urine should be treated.
   Warm baths, opiate suppositories, belladonna smeared on the perineum, and
alkalies, may be of service.
   The mechanical means to be resorted to are—
   Slow dilatation by simple bougie ; dilatation by means of expanding instru-
ments ;  the retained catheter; the  caustic  bougie; incision  within;  division
from the perineum.
   The gum-elastic bougie and  the metallic bougies are too well known  to need
description  here.  For a detailed account of these instruments, as well as of
the dilators, the student  is referred to the  standard works on surgery.
   Urethrotomy is either external or internal.

                     INTERNAL URETHROTOMY.
   Strictures that are  especially suitable for internal urethrotomy are those near
the meatus, those that recontract rapidly after dilatation, those where the patients
suffer from rigors or  other  troubles  whenever a catheter is  passed, and dense
cartilaginous  strictures that refuse to  dilate.
   It is important tb divide the stricture completely through  its whole depth. 
STRICTURE.
79
Fig.  is-
Fig.  16.
SNQVi/p!^
5,\nvipttJ
gross's urethrotome.
syme's staff. 
80
SURGERY.
   It may be performed either with a  urethrotome, such  as Thompson's, con-
sisting merely of a bulb on  a stem concealing a blade, which, by means of a
screw, may be  protruded  any depth that is  required, or with Professor S. W.
Gross's instrument, which " is modeled  after the bulbous bougie, the conoidal
bulb carrying a concealed blade, which is protruded by pressure upon the round
plate above the handle.  The bulb having been passed through the obstruction,
and then advanced—in order that its shoulder may define the coarctation—it is
next carried toward the bladder, the object being to divide not only the stricture,
but the sound tissues for half an inch behind and  anterior to it, the blade pro-
jected  and the parts severed.   A steel  bougie, of a size adapted to restoring
the urethra to%s normal calibre at the affected part, is then passed, and its curve
firmly  pressed  against the  incision, with  the view of readily separating  its
sides."*   If the bougie enters easily, particularly if it can be withdrawn with-
out meeting any obstruction, it is taken  for granted the stricture is thoroughly
divided.
   The bladder should be emptied at the  time of the operation, and a morphia
suppository introduced into the rectum.
   Hemorrhage sometimes follows internal urethrotomy.   For this condition of
affairs  see page 84; article,  " Hemorrhage from the Urethra."
   Three or four days after the operation the patient should be given a hot bath,
and a conical steel bougie of proper calibre must be introduced, to be repeated,
at regular intervals, for years.

                      EXTERNAL URETHROTOMY
Is advisable when there is a stricture so dense and unyielding, or so compli-
cated with fistula, that internal urethrotomy cannot succeed, or where it is not
possible to get a catheter into the bladder, from whatever cause.
   In the first case Syme's staff is passed, and the stricture divided upon it.  It
is grooved on the convexity, and consists of  two  parts, of different diameters,
which  meet, with an abrupt  shoulder, at the junction of the straight portion of
the curve.   The latter is the smaller of the two, so that it can pass through the
contracted part of the urethra until it is brought to a standstill by  the shoulder
coming in contact with the face of the  stricture.
   The patient is placed in the lithotomy position, and a median incision made
into the groove,  taking care to divide  thoroughly the whole length  of the
stricture.   A probe  is then introduced into the  bladder to act  as  a guide,
the staff withdrawn  and a catheter passed to make sure there is no  further
obstruction.  When the wound  is healing, bougies must be passed regularly.
The new tissue that forms does not acquire the density of the old.
* Gross's " System of Surgery," Vol. ii, p. 781. 
RETENTION  OF URINE.
81
   If a bougie cannot be passed through the stricture, the urethra must be either
 opened in front of the stricture or perineal section must be performed.


                          PERINEAL SECTION.
   The urethra is laid open behind  the stricture.  The patient is placed in the
 lithotomy position, care being taken that he lies perfectly straight and the  peri-
 neum is  perpendicular.  The operator sits in front, and with his left forefinger
 feels for the apex of the prostate.  A long straight knife, with its back toward
 the rectum, is then plunged steadily into  the middle line underneath the bulb,
 so as to hit off the membranous  part, or the  apex of the prostate.  A director
 is then passed into the bladder, and a soft catheter introduced and, if necessary,
 tied in.


                     RETENTION  OF URINE.
   Retention of urine is an inability, whether partial or total, of expelling, by
 the natural efforts  the urine contained in the  bladder.
   Retention of urine may be  due to causes acting  on  the urethra or the bladder.
 Calculus or other  foreign bodies may become impacted in the urethra, tumors
 may press  upon it, alterations in the walls of  the  urethra, either  permanent, as
 stricture or enlarged prostate, or temporary, as  congestion, or spasm may  take
 place, or the bladder itself may be unable to expel its contents, from various
 causes, such as atony of its walls, paralysis, hysteria,  disease of the spinal cord,
 peritonitis, exhaustion, alcoholic or other excesses, or shock.
   Symptoms.—There is a hard and pyriform tumor in the hypogastric region,
 extending  along the  median line  toward the umbilicus.    The swelling is
 tender to the touch, which is greater if the bladder be  inflamed; there is dull-
 ness on percussion; on account of the rigidity of the abdominal muscles there
 is inability to  detect  fluctuation by  percussion;  this is best elicited by intro-
 ducing the finger  into the  rectum, placing it in  contact with the bladder and
 tapping the tumor.
   The pain which the patient experiences soon becomes of a most excruciating
 character;  the respiration is short and shallow; the desire to pass  urine becomes
 more and  more urgent, accompanied by tenesmus, rigors, alternating with
 flushes of heat, great thirst, hot and dry skin, restlessness;  the urine is either
 not passed at all or comes away by drops or in a tiny stream.
  After the retention has existed for  two or three  days there  is involuntary
incontinence of urine, which  means that the bladder  is  over-distended, causing
partial paralysis of the sphincter  of the bladder.
  If the  patient is not speedily relieved, pain in the  loins and tenderness  over 
82                              SURGERY.

the kidneys supervene; there is headache, the pulse becomes weak, small and
rapid ; there is urinous odor of the breath and perspiration, dry tongue, delirium,
subsultus tendinum, coma and death.  Death occurs from uraemic poisoning in
from four to five days.  The bladder may rupture and empty its contents into
the peritoneal cavity, giving rise to peritonitis or  a gangrenous bladder, or
abscess of the kidney may ensue.
  Diagnosis.—Care must be taken not to  confound retention of urine with
pregnancy or ascites.
  The treatment must be guided by a knowledge of the cause, but  in  all
cases it is necessary to relieve the bladder as soon as possible.
  If a calculus  is impacted, means must be adopted to remove the obstruction;
if the calculus is in the urethra where it can be felt,  it may be worked  forward
by the finger until it reaches the orifice, where a small incision may be neces-
sary ;  or it  may be extracted with the urethral forceps.   If it  is  fixed,  or too
far back, the  skin over it may be  stretched with the finger and thumb of the
left hand, and a small longitudinal  incision may be made on it.   The wound
must be dressed antiseptically.
  A catheter  should be passed immediately, if the symptoms are urgent;  but if
the patient can wait for half an hour he may be placed in a hot bath and given
a full dose of opium or laudanum.   The bowels must be thoroughly opened
as soon as possible;  the  urine rendered unirritating by  the use of  alkaline
carbonates, and sedatives and all stimulants forbidden.
  If the distention of the bladder  be excessive,  all the  urine must not  be
drawn off at once; draw off about one-half the first time  and the remainder
some hours after.   Be careful  to  place the patient in a sitting or recumbent
posture before commencing to draw off the urine.
  Retention of  urine may occur to individuals who are affected with gonorrhoea,
and, thinking themselves well, have indulged in the pleasures of  the  table, or
in over-drinking.   In such a case a soft, well-oiled catheter should be  intro-
duced, and afterward a hip bath should be ordered, together with a suppository
of opium three grains, extract of belladonna half a grain.   Perfect rest should
be enjoined.
  Newly-born infants may be affected with retention by reason of imperforate
prepuce, or imperforate meatus : in the former case it may be necessary  to cir-
cumcise the patient, and in the latter cases a meatus must be made.  Introduce
a catheter if necessary.  If it be due to a cyst in the sinus pocularis, as  is fre-
quently the case, it will be at once relieved by passing in  a small probe and
rupturing the wall of the sac.

   In passing  the catheter the  patient lies  on his back near the edge  of  the
bed, the head being supported on a pillow and the  knees  separated from each 
RETENTION OF URINE.
83
other and slightly raised.  The instrument should be about  ten inches long,
beak well rounded, eyes well beveled and smooth, and should describe the
segment of a circle.   Before introducing a catheter it must be warmed by fric-
tion  and contact with the hand, and should be dipped  in oil or vaseline.  It
should then be grasped with the  index finger and thumb of the right hand;
and, standing on the left side of the bed, raise the penis at right  angles with
the body, grasping it with the middle and ring fingers of the left hand, leaving
the thumb and index finger free to retract the prepuce and separate  the meatus.
Hold the handle of the instrument in a line with the linea alba, its concavity
being directed toward the abdomen, draw  the meatus  of the  penis over the
catheter, at  the  same time  push the  catheter into the  meatus with the other
hand.  At about 5 or 5^ inches an obstruction will be encountered;  when
this  point is reached, stop  for  a moment and  withdraw  the  catheter  about
the eighth of an inch, and then  raise the catheter over the obstruction, de-
pressing  the handle, when the catheter will  glide  into   the bladder.  If
the resistance cannot be overcome, then desist in your efforts to introduce the
instrument.
   When the patient has stricture  pass  a nickel-plated conical steel  bougie
(No. 21, French; 12, English) into the urethra until the obstruction  is reached;
keep the back of the  bougie gently pressed against the  stricture, when after a
little while the spasm will  be overcome and the  bougie will pass into the
bladder; if it does not, next  take an  olivary-tipped bougie  (No.  1, English;
3, French), which may be passed readily, then use successively larger bougies,
and thus dilate the stricture.
   If the stricture be a very tight one, inject the urethra  with  oil and introduce
a filiform;  when the obstruction is reached, gently rotate the filiform, until it
passes onward into the bladder.
   Now  attempt to pass Goulay's  tunneled catheter by  threading  it  in  its
onward passage by the already introduced filiform.
   Enlarged Prostate generally occurs after the age of sixty.  Care must  be
taken when retention occurs from this cause not to draw  off all the urine at one
time, nor to use a catheter with a long beak,  lest the bladder contract on the
instrument and inflammation result.


                       TAPPING THE  BLADDER.
   When the catheter, bougie and other means fail, aspiration, supra-pubic tap-
ping,  or rectal tapping  may  be resorted to.   In aspiration the instrument is
passed about x]/^ to 2 inches above  the symphysis in the middle line, directing
it downward and backward;  this operation may be repeated two or three times
a day. 
84
SURGERY.
  In supra-pubic tapping, make an  incision  along the middle line above the
pubis, from an inch to an inch and  a half in length, down to the connective
tissue over the distended organ; through this opening the bladder is pierced at
its lowest part by means  of a long curved trocar and canula, the point of the
canula  being  inclined obliquely  downward and backward.   The  canula is
retained by an appropriate bandage until it is desired to remove it.
  Rectal tapping has been superseded by  supra-pubic aspiration.
         HEMORRHAGE FROM  THE URETHRA.
  Hemorrhage from the  urethra  may  be caused by  the introduction  of
bougies, by a false passage, from internal injuries, by the separation of a slough
formed by the caustic bougie, or by the rupture of a blood-vessel during acute
chordee.
  It may occur from general arterial excitement.
  The recumbent posture, application of cold and pressure, should be tried.
A flat piece of cork  should be pressed by the patient against the perineum, far
back,  and gradually moved  forward till  it lights on  the  right spot, and the
dripping of blood will  cease.   A solution of tannic acid in water may be used
as an injection.  Gallic acid  may be of service.
  A steel bougie, first put in very hot water  and then introduced into the
urethra, is often used to arrest this variety of hemorrhage.
  If the hemorrhage is from the anterior portion of the urethra, insert a catheter,
and apply a bandage firmly around the penis.
                           CHANCROID.
  Soft chancre, or non-infecting sore.
  This is a highly contagious suppurating ulcer, capable of being inoculated on
the same patient; it is a local disease, and produces an ulcer wherever it may
be introduced; unless infected by syphilis, there are no secondary symptoms.
  This is the most common form of venereal ulcer, and is rarely met  with
except on the  organs of generation.  The usual period of incubation  is  from
24 hours to 10 days.
  Symptoms.—During the first twenty-four hours there is simply an irritated
spot or point which reddens; on the second or third day it swells slightly and
becomes  a  pimple, surrounded by a red areola;  from the  fourth to the fifth
day the  secretion increases and becomes purulent, and the vesicle becomes a
pustule with a depressed summit.  After  the sixth day an ulcer appears;  its 
CHANCROID.
85
depth is equal to the thickness of the skin, its  edges seeming as though cut
with a punch, its surface covered with a grayish, pultaceous matter.   The dis-
charge is  purulent; the sore is painful and is not hard.   It lasts from three
weeks to three months, and is attended with a bubo, which tends to suppuration.

  Diagnosis.—The  affections with which chancroid are most liable to be
confounded are chancre, herpes, eczema and balanitis.
  Chancroid may be distinguished from chancre  by its rapid development, its
increased  secretion, absence of induration,  its tendency to multiplicity, and the
difference  in the period of incubation.
  From herpes chancroid may be known by the former usually presenting itself
on the head of  the penis and  prepuce in  little vesicles, about  the  size of the
head of a pin, occurring in groups, set closely together, of a whitish color and
resting on a florid base.
  In eczema the little vesicles are more minute and diffused than in herpes, and
there is generally greater local  irritation, the parts being swollen, hot, red and
itchy.
  In balanitis the inflammation is usually  widely  diffused, the discharge being
profuse, and of a thick, muco-purulent nature;  there is no circumscribed ulcer-
ation, as in chancroid.
  Simple  ulcers, abrasions or excoriations may occur on the prepuce and glans,
and  care must be taken not to confound them  with .chancroid.
  Treatment.—In the treatment of chancroid S. D. Gross gives the preference
to the  application of the officinal solution of the acid nitrate of mercury, applied
either  pure  or diluted,  according to the exigencies of the case; an  average
strength is one part of the acid to eight parts water, applied with a piece of soft
wood, the ulcer being  first dried with a bit of cotton, and  immediately after
bathed in  pure water; or, instead of the mercury,  concentrated nitric acid may
be used,  so as  to destroy  the  surface, the excess being carefully wiped off.
After this  an emollient  poultice may be employed.
  When  the acid  nitrate  of  mercury or  nitric acid is  not used, carbolic or
hydrochloric acid may be  applied; Vienna  paste  is highly recommended.
Ricord prefers a caustic compound  of sulphuric acid and powdered charcoal,
united in proportions  to form a semi-solid;  of this mixture apply a thin layer to
the  chancroid and the adjacent parts;  allow it  to dry,  when it will form  a
black, adherent crust, which, on dropping off, leaves a healthy sore, followed
by rapid cicatrization.
  The parts should be frequently bathed  in warm water, containing  a small
quantity of acetate of lead or common salt.
  The ulcer must be kept covered with lint, wet with a weak solution of tannic
acid and  opium, a  weak preparation  of yellow wash (bichloride of mercury, 
86
SURGERY.
gr. j, to  lime water, gj), sulphate of copper  (gr. v, to water, gj), or  black
wash.   Many surgeons apply a powder composed of calomel and subnitrate of
bismuth, each  one part, and  carbonate  of zinc, two parts;  first  carefully
washing  the parts, and afterward keeping  them wrapped in a solution of lead
water and laudanum.
   Should phimosis supervene, inject underneath the prepuce, every two hours,
first cleaning out the parts by syringing with hot water, an injection of Goulard's
extract, twenty drops, alcohol, thirty  drops, water,  one  ounce.  If the syringe
cannot be passed under the prepuce,  put the patient under the influence of an
anaesthetic, and slit up the prepuce as far as the corona glandis, being careful
to treat the parts antiseptically, both before and after the operation.
   If gangrene  sets in—which is usually denoted by the appearance of a black
spot, and by the prepuce  becoming swollen and oedematous, and by subsequent
sloughing—the patient must be  placed  under the influence of an anaesthetic,
and the prepuce laid freely open ; then dress with  an ordinary simple dressing,
or an application of potassio-tartrate of iron, thirty grains to the ounce.
   When the parts begin to granulate it is best  to apply the simplest  dressings,
such as opiate cerate, or ointment of  red oxide of mercury, largely diluted with
cosmoline.
   The diet must be carefully watched; animal foods and stimulants avoided,
the nourishment being plain and simple; cooling purgatives administered from
time to time.
   Pain and morbid erections are relieved by opiates, bromide of potassium or
chloral, together with soothing applications to the parts.
   Serpiginous  sores are  those that wander over the surface of the thighs and.
abdomen, healing in one direction and  spreading in another; one of the most
efficient local remedies for this condition is saturated solution of potassio-tartrate
of iron, applied on lint;  or it may be necessary to use solutions  of nitric, car-
bolic or hydrochloric acid.
   Opium should be given to allay pain.  Quinine, mineral acids, iron, cod-liver
oil, a liberal diet, exercise in the open air, and  change of scene, are the indica-
tions to aid recovery.
                     CHANCROIDAL  BUBO.
  A bubo is an inflammation of a lymphatic vessel or gland, from any cause,
but it is commonly restricted to the inflammation of the inguinal glands which
accompanies a venereal sore or gonorrhoea.
  A chancroidal bubo is an enlargement of the lymphatic glands of the groin,
and is the result of the transference of the virus of the original sore to the groin; 
CHANCROIDAL BUBO.
87
 it may arise during the existence  of  a chancroid, from  the absorption of its
 poison, and is likely to suppurate quickly.
   Inflammation of the glands of the groin is a common occurrence, either after
 the local application of a poison capable of being  absorbed, or after inflamma-
 tion of the skin or mucous membrane, or without any special local cause, during
 a period of constitutional cachexia.
   The chancroidal bubo is  usually limited  to one  or, at most, two glands.
 Bubo  depending on true chancre is likely to be multiple and indolent.
   The bubo usually occurs on  the same side as  the  primary sore; when the
 chancroid is situated  near the  mesial  line a bubo may be developed in each
 groin.
   Acute bubo pursues the course of acute abscess, with its attendant symptoms,
 shivering, pain,  tenderness, swelling;  the skin  becomes red  and  thin, then
 matter points and is discharged; when the disease assumes this form, it usually
 runs its course rapidly, and is  accompanied by severe constitutional disturbance.
 When the contents of the abscess  are discharged, it is then called an open or
 ulcerating bubo, and  the  opening will be in the  neighborhood of Poupart's
 ligament, either above or below, or partly above and partly below.
   Indolent bubo occurs in persons of a weak and scrofulous constitution; after
 having made a certain  amount of  progress, it may remain stationary for  some
 time, neither advancing nor receding.
   Treatment.—In from  two to three weeks after*the appearance of a chan-
 croid, in the proportion of about one case in  four, a single lymphatic gland in
 the  groin becomes swollen, painful and tender;  the  overlying  skin  becomes
■ red, oedematous, hot, swollen  and inflamed; a  soft  spot appears upon the
 swelling, and after a little while there is decided fluctuation, and an abscess is
 formed in the gland.   As soon as the gland begins to swell and becomes tender,
 charge a syringe with the 1-500 solution of corrosive sublimate, or with a three
 per cent, solution of carbolic  acid, and inject a few drops into the gland, and
 repeat this in different portions of  the diseased structure until  fifteen or twenty
 drops  of the solution have been  introduced.   If this does not arrest the forma-
 tion of pus, it will be necessary to wait, and when the pus is formed lay the
 abscess freely open.  In making the incision it must  be  carried parallel with
 the long axis of the body.   The patient being under the influence of an anaes-
 thetic, clean out  the  cavity  thoroughly, and touch the surface with cotton
 which has been saturated with impure  carbolic acid.   Then apply to the part
 an antiseptic poultice or hot corrosive sublimate solution.
   If there is much inflammation, put the patient to bed, purge him and place
 him on the mildest diet.  Wrap the  parts up, and lay over the bubo  a hot
 solution of acetate of lead and opium, or apply a flaxseed poultice. 
88
SURGERY.
                              SYPHILIS.
  Definitions.—" Syphilis is an infectious, contagious and inoculable disease,
of slow evolution; it first manifests itself by an indurated or infecting chancre,
afterward  by eruptions of the  skin and mucous membranes, later by chronic
inflammations of the cellulo-vascular  tissue  and bones, and finally by special
productions in the  form of small  tumors or nodules, which have received the
name of gummata."—V. Cornil.
  "Syphilis is a constitutional  contagious disorder which may be acquired or
inherited, the first manifestation of which, unless it be inherited, is a chancre."
S. W. Gross.
  This disease is due  to the introduction of a specific poison or virus from an
infected person into the body  of a healthy  person, in  which individual the
poison  is disseminated by the blood  and gives rise to  certain  inflammatory
lesions  and new formations.  It is usually transmitted by the secretions of a
chancre, during  impure sexual  congress.   An  individual laboring  under
secondary syphilis  can transmit the disease  as readily as one  affected with
primary syphilis;  the  blood of  a person  laboring under  secondary syphilis is
inoculable; the flesh is likewise poisoned.
  The secretion of what is  known as the mucous patch is inoculable; it  gives
rise to  chancre.   If a female  labor under  secondary syphilis, any discharge
which she may pour out from her uterus  or vagina will give syphilis to a man
having connection with her.  Syphilis may be transmitted by other means than
impure  sexual intercourse, as by kissing a child with  inherited syphilis,  or by
infecting the  nipple of a nurse when the sucking child has mucous patches, or
by smoking a pipe, or using a drinking utensil of an infected person, etc.
  The symptoms of syphilis are divided into  three stages : primary, secondary
and tertiary :—                       *
  Prifnary syphilis is the  initial lesion  or chancre, with enlargement of  the
associated lymphatic glands.
  Secondary syphilis  includes the more superficial inflammatory lesions of  the
skin, mucous membranes and their appendages.
  Tertiary syphilis comprises the destructive inflammation of the skin and mucous
membranes and their  appendages, as well as lesions of deeply-seated tissues of
the various organs of the body.
                               CHANCRE.
   Chancre  is the initial lesion of syphilis.
   A chancre does not at once appear after a person has been inoculated.   The
minimum  period of incubation of syphilis is ten days; the maximum period is
ninety-eight  days; the average period is twenty-one days. 
SYPHILIS.
89
  Symptoms.—A chancroid may not appear until  ten days, and a chancre
never appears before ten days.  In  two-thirds of all cases the chancre makes
its appearance as the superficial ulcer.  It may present itself as a deep, funnel-
shaped ulcer, or again as an elevated, hard, desquamating papule or tubercle.
  Induration of the base of the ulcer is  an important sign.   The  induration
may feel, when moved about between the thumb and  fingers, like thin parch-
ment ; or it may be a sore seated upon an indurated base about the size of a
split pea;  the induration may appear anterior to the sore or vice versa.  This
induration is  present in ninety-five per cent,  of all cases.   Whether present or
not, if the disease be syphilitic, there will be found in the groin a  number of
very hard, distinct glands, rolling under the fingers.
  In addition to being superficial, the ulcer is clearly cut, the edges are per-
pendicular, not  undermined, and look as though  made with a scoop.  The
secretion is serous.   The sore is smaller  than in chancroid; it is not attended
with pain or inflammation.   Its tendency is to heal.
  The most common seat of chancre is on the glans  penis, dorsal surface of the
penis, the meatus, the  anus, and lips in the male; and the labia, nymphae, the
entrance to the vagina, the  fourchette, and the nipple of the female.
  The ulcer will disappear in two or three weeks, leaving an induration which
may last several months.

  Bubo.—A constant concomitant of chancre is bubo.
  If the chancre be upon  the genitals, the  glands of the groin  will be found
enlarged in ninety-five per  cent, of all cases.   It will be met with on the same
side as the lesion;  or if the chancre be seated upon the  median line, buboes
will be found on both sides.  If the chancre be upon the nipple the bubo will
be found in the axilla.  The bubo of chancre differs from that of chancroid in
there being a number of swellings on either side instead of one ; they will vary
in size from a buckshot to a hazelnut;  suppuration occurs in the proportion of
one  case in every twenty-seven;  but  in chancroid suppuration always takes
place.  The  bubo  will present itself in from eleven to fourteen days after the
appearance of the initial lesion.
  Treatment.—If an individual present himself soon after impure connection,
with a slight abrasion or sore upon the  penis, wash the part  carefully, dry it
with a soft cloth, and then dust it  with a powder  consisting of equal parts of
calomel and  finely  powdered subnitrate  of bismuth, covering it with a thin
layer of cotton.  Should the chancre not show a disposition to heal,  apply any
mild stimulating solution, as the red wash, nitric acid  lotion, or a five- or ten-
grain solution of nitrate of silver.
  Never give mercury in the initial lesion of syphilis.
  Local baths, either simple or medicated, are highly recommended.  After
       G 
90
SURGERY.
bathing, the best local application is a moderately strong solution of acetate of
lead, combined, or not, with  opium/applied  on soft lint or  cotton  wool, and
covered with oiled silk.  An elm poultice may be substituted.
   Should phagedena present itself, it must be treated upon the same principles
as would be observed in the disease occurring in any other ulcer.   Destroy the
sore by means of deliquescent carbolic acid.   If the chancre be at  the meatus
keep the parts soft by a constant application of a mixture composed  of melted
mercurial ointment one part, white wax three  parts.   (See Formulae 26 to 32.)*

                        SECONDARY SYPHILIS.
   Secondary syphilis is that group of morbid phenomena which present them-
selves the first two years after the occurrence of an attack of primary syphilis.
   Secondary syphilis is always preceded by chancre, and it may come on before
the initial lesion has disappeared.
   It is usually  ushered in by  well-marked  constitutional phenomena;  the
patient feels uncomfortable  and  unwell; is irritable  and desponding;  counte-
nance has a dull, muddy aspect; limbs and joints are sore and stiff; his appe-
tite is impaired; his  urine is scanty and high colored;  is easily fatigued; has
headache and disturbed sleep.
   After a few days he is seized with rigors, followed by high fever, or by fever
and profuse sweats.
   The attack is called syphilitic fever, and is an effort of the  system to elimi-
nate the poison.
   The skin and mucous membrane, with the  posterior  cervical glands, are the
parts most liable to attack.
   Affections of the Skin.—Of these there  are six varieties, viz.:  the exan-
thematous,  scaly, vesicular,  papular, pustular and tubercular.
   Syphilitic eruptions  are  generally chronic*; in form  more or less circular,
and usually copper colored; after having existed- for some time they become
of a grayish, muddy, or bronze appearance; usually appearing on the forehead,
nose, cheek, back and shoulder;  they are accompanied or followed by grayish,
hard and thick scales, greenish scabs, narrow cracks, or well defined ulcers.
   In the exanthematous form the spots  are pinkish, reddish, or of a pale cop-
per color;  they are most prominent on the trunk and extremities, and  usually
pass off with a slight  desquamation of the cuticle.   This eruption  will  make
its appearance between the sixth and twelfth  week after the appearance of  the
initial lesion.
   As the eruption fades it loses its reddish tint, and assumes a dingy, dusky
aspect.  Duration from ten days to six weeks.
* List of Formulae at end of this volume. 
SYPHILIS.
91
  The scaly variety, or psoriasis, comes on from two to six months after the
primary disease; it is always chronic, and is often associated  with ulceration
of the throat and palate, iritis, affections of the bones and joints.
  The disease presents  itself in thick  scales of a dull grayish  appearance.   It
may occur on  any part of the  body, but  is most commonly met with on the
forehead, scalp, face, forearms, palms  of the hands and soles of the feet.
  The vesicular variety is very uncommon; it usually begins with minute, cir-
cumscribed pimples, scattered over the body, which are succeeded  by a trans-
parent, serous fluid, surrounded by a reddish, copper-colored areola.  They are
most common  on the neck, chest and extremities.
  The pustular variety are circumscribed elevations of the skin, occupied by
pus, and readily tending to ulceration.   They range in size from a pea to an
ordinary marble.   They exist in great numbers;  each pustule rests upon a hard,
copper-colored base.
  After a time the  contents of the pustule  escape, concrete, and form hard,
thick scabs, of a  dark brownish  color, firmly adherent.
  The papular syphilis or lichen is distinguished by the appearance of small,
hard, solid elevations, containing no  fluid, and generally  terminating in des-
quamation;  seldom in ulceration.   This affection may be acute or chronic.
  The tubercular form of syphilis exists  in two  varieties;  in the first the erup-
tion consists of small, red, copper-colored eminences, varying in size from a
small bird shot to that  of a pea; they are smooth and  polished, and soon be-
come covered with a dry, scaly crust.
  In the more aggravated form  the tubercles are larger, of  a deep violet color;
after continuing for a longer or shorter period they inflame, suppurate, and are
replaced by deep, foul, painful ulcers.
  Loss of hair from the scalp, eyebrows and lids is common as an early symp-
tom.  When the  system is saturated with the virus, the beard and the hair of
the rest of the body may also disappear.
  Affections of the mucous membranes are liable to  appear within four or five
weeks after the initial lesion.
  The parts usually affected are the tonsils, palate, pharynx, tongue, cheek and
lips.  Well-marked signs of the disease frequently appear at the anus and lower
part of the rectum, upon the foreskin and head of the penis of the male, and
upon the vulva, vagina and uterus of  the  fem3le.
  Secondary affections of the mucous tissue occur in various forms, as an erythe-
matous disease, as a tubercle or  as  an ulcer.  Syphilitic erythema occurs most
frequently in the  throat, affecting the arches of the palate, uvula, pharynx, and
sometimes the root of the tongue.
  The inflammation is either diffused, or it occurs in distinct mucous patches of
a circular or oval form ; it is of a copper color. 
92                              SURGERY.

  Ulcers of the throat generally make their appearance on the uvula and tonsils,
arches of the palate and back of the pharynx.
  The superficial ulcer is either simply an erosion, or a cavity with well-defined,
ragged edges, rather sharp and somewhat undermined.  It usually presents
itself early after the primary sore.
  In the excavated ulcer the edges are  steep, everted, or ragged, and are sur-
rounded  by a  hard, inflammatory, copper-colored base; the  discharge is thin
and  ichorous; the sore is  most distinctly marked on the tonsils.   They are
liable to take on phagedenic and gangrenous  action, and extensive destruction
of the soft palate frequently results.  The excavated form of the  disease  is
usually accompanied by extensive swelling, together with great pain and diffi-
culty in swallowing.   Mucous tubercles generally  occur upon  the  tongue, lips,
inside of the cheek, tonsils and palate ;  they are slight elevations of the mucous
surface, usually of an irregular oval or  elongated  shape, and of a whitish hue.
  The treatment of secondary syphilis should be hygienic, tonic and spe-
cific.  The patient should  be careful  not to eat indigestible food ;  he should
take exercise in the open air at stated periods, not to the point of fatigue; his
habits should be  regular;  he must  discard the use of tobacco and alcoholic
drinks, unless he be an habitual drinker, when he should diminish the quanti-
ties hitherto taken.  He should take a tepid bath every night before going to
bed.
  When the patient is greatly debilitated, and the blood is watery, a tonic treat-
ment is to  be re-orted to.
  The specific plan of treatment consists in the proper administration of mercury;
the  bichloride is usually preferred, combined with the tincture of the chloride
of iron.  The mercury thus acts as a tonic, and  also by destroying the specific
virus of  syphilis.
   It is necessary to begin with very small doses of the mercury until the suscep-
tibility of the  patient is  determined.  The rule  is to avoid anything like the
approach of ptyalism.   After  each dose of the  remedy the mouth  should  be
thoroughly washed out with  a solution of chloride of potassium, in the pro-
portion of  twenty grains to an ounce of water.
   Mercury may be administered by the  mouth, stomach, inunction, fumigation,
by the rectum, or hypodermatically.
   If the patient be weak, debilifated and suffering from an impaired condition
of the blood,it is well to combine a tonic plan of treatment with the mercury;
a good combination is blue mass two grains, sulphate of quinine and sulphate
of iron, each one grain, opium a  quarter of a grain, given three times within
the  twenty-four hours.   The following is  highly recommended: bichloride of
mercury three grains, tincture of the chloride of iron  one ounce; of this give
twenty-five'drops in a wineglassful of sweetened  water three  times daily; this 
SYPHILIS.
93
will represent ^s of a grain of corrosive sublimate.   If the patient be in ordi-
nary health, give him a  pill of one-fifth of a grain  of protiodide of mercury,
with one twenty-fourth of a grain each of tartar emetic and sulphate of morphia;
Dover's powder may be substituted for the morphia.   In prescribing this remedy
it is necessary to test the  susceptibility of the  patient; in  order to do this give
one of the pills half an  hour after each meal; at the expiration of two days
add  a second  pill  to the mid-day dose;  if this  does not produce griping or
diarrhoea, add a third pill; making one  pill after breakfast and supper  and
three pills after dinner;  should the patient  become  griped, fall  back to three
pills daily.
  If  an extremely speedy action of mercury is required, as in the case of
iritis, and in malignant syphilis, the remedy should be used hypodermatically;
the following is the best  formula; bichloride of mercury one-tenth of a grain,
hydrochlorate of cocaine half  a grain, water fifteen minims.
  If  mercury produces  griping  and diarrhoea, then it  will be necessary to
resort to inunction ; use for the purpose equal parts of twenty per cent, oleate
of mercury and cosmoline.
  If  for any reason inunction  is  not  advisable  then  resort to fumigation.
Finally mercury may be given by the rectum.
  Keep the patient upon the  combination of protiodide  of mercury and mor-
phia for two  months after all  lesions have disappeared,  then stop the remedy
for two weeks;  recommence, but  diminish the amount of mercury  one-third ;
keep the patient on this for another two months, then intermit for from  two to
four weeks;  then  return to the treatment, keeping it up  for two  years.  After
the expiration of this period  let  the patient return to the surgeon  every two
weeks for the next eighteen months,  in order that he may remain under obser-
vation.
  If at any time during the treatment of secondary syphilis a lesion  of tertiary
syphilis makes  its appearance, iodide of potassium must be combined with the
mercurial treatment; when the tertiary symptoms disappear, omit the iodide of
potassium.
  If  a papular eruption  presents  itself, anoint the parts with a five per cent.
oleate of mercury, to which any  aromatic oil may be added; or an unction
may be used  of ammoniate of mercury half a drachm, cosmoline one drachm.
  To remove the crust in  impetigo, apply an antiseptic poultice; when it has
become sufficiently softened use a preparation, spread upon lint, composed of
ointment of nitrate of mercury one drachm, cosmoline seven drachms.
  When there is a moist papular eruption of the skin, with an ulceration of the
epidermis, the parts should be carefully washed three times a day  with tepid
water and  chromic acid, or a weak  solution of corrosive sublimate  and water
should be applied once during the twenty-four hours;  rh the interval the parts 
94
SURGERY.
are to be dusted with a powder of one part calomel, two parts oxide of zinc;
then lay over each papule a piece of absorbent cotton.
  When the patient is threatened with alopecia, the hair should be cut short,
and mild  lotions of alcohol and aqua ammonia should be applied, or alcohol
glycerine and tincture of cantharides may be used, or a wash composed of tan-
nic acid gr. vj, sulphate of copper gr. y2, bay rum and water each  an ounce;
or tincture of cantharides two  drachms, aromatic spirit of ammonia half an
ounce, rose water four ounces, and corrosive sublimate four grains.
  Iritis, which occurs in the advanced stages of syphilis, must be treated early
and vigorously.  The patient must be promptly brought under the influence of
mercury, as  the disease usually affects both  eyes and  extends rapidly to the
cornea, choroid and  retina.  Give calomel  one grain, opium half grain, three
times in twenty-four  hours.  As soon as the gums become  slightly tumid and
there is salivation, cease to administer  the remedy.   The  action of the mer-
curial may be hastened by applying a mercurial inunction.
  A solution of  atropia, four grains to water one ounce, is to be dropped into
the eyes.  If there be great pain apply eight or ten leeches  to the temple.  To
relieve the pain, opium in combination with a diaphoretic must be administered;
say Dover's powder grs. v, or sulphate of morphia gr.  "/£, every five  or six
hours.
   The most suitable local remedies to the  mucous surfaces are nitrate of silver
in substance, or  acid nitrate of mercury variously diluted.  When the part is
ulcerated the preference is given to the acid nitrate of mercury, diluted with
eight or ten parts of water.
   Nitric acid, carbolic acid, or hydrochloric acid properly diluted, maybe used
as substitutes for the acid nitrate of mercury.
   Gargles composed of pyroligneous acid  ^ij, water % viij, honey a sufficient
quantity; or subacetate of copper and tannic acid; or tannic acid  and glycer-
ine ; or nitric acid and chlorinated sodium, may all be advantageously used in
turn.  (See Formulae from 33 to 38.) *

                          TERTIARY SYPHILIS.
   By the term tertiary syphilis  is generally understood the lesions of the  dis-
ease which show themselves, as a rule, after the  expiration of two  years from
the commencement of the primary sore.
   They  consist  of deep, destructive ulceration of the skin and mucous mem-
branes, the occurrence of a form of tumor called  gumma, of fibroid induration
and thickening  of the organs and their capsules,  and of obliterating inflamma-
tion of the lining membrane of the arteries.
   The textures most prone  to suffer  in tertiary syphilis  are  the  connective
------------•—-----------------------------
                     * List of Formulae at end of this volume. 
SYPHILIS.
95
tissues,  mucous  membranes, periosteum, bones, fibro-cartilages, aponeuroses,
tendons and testicles.
  The most common of the internal  lesions are gummy tumors, foul, ragged-
looking ulcers, softening and pulpy degeneration, and tubercular deposits.
  The most important and frequent lesion of tertiary syphilis, and which may
be looked for  in  from two  to five years after  the  appearance of the primary
lesion, is the gumma, so called  from its gummy discharge when it is broken
down.  It is a tumor made up of granulation tissue;  it is more or less spherical
in shape, of hard, elastic consistence.  When it  breaks  down a discharge
takes place, of gummy material.  Gummata may be ulcerating or non-ulcera-
ting.   Gummata  are found  most frequently in  connection  with the skin, sub-
cutaneous tissue, muscles, bones, periosteum, liver, brain, lungs and testicles.
  Tertiary syphilis is very common in the brain and spinal cord, and shows
itself in a variety of ways; it gives rise to epilepsy,  locomotor ataxia, paralysis
of one or both of the facial  nerves, hyperaesthesia, and  affections of the nerves
of special sense.
  In tertiary  syphilis the lesions of the skin differ from those of secondary
syphilis in being destructive, affecting the deep  layers;  the  most common form
are  the tubercular, which  are apt to undergo destructive ulceration; the deep
pustular; the impetigo,  the ecthymatous and the rupial  eruptions.
  The affections of the  mucous membranes consist in the occurrence of ulcers,
and of mucous patches  about the mouth.
  The eyelids are frequently attacked by the disease; it generally shows itself
as an indurated ulcer of an  oval shape; the borders are inflamed and thick-
ened, and the conjunctiva is usually inflamed.
  Affections of the periosteum and bones present themselves in the form of
nodes  or  gummy tumors,  inflammatory hypertrophy, exostosis,  caries  and
necrosis.  These affections  may come on at any time  after eighteen  months
from the first affection.   They are most liable to occur  in persons of a scrofu-
lous habit, or whose constitutions have become  impaired from any cause.
  The bones affected with  tertiary syphilis are those  that are superficial, or
least protected by the soft parts, as the tibia, fibula, ulna, clavicle, and bones
of the skull, nose, palate, and upper jaw.
  Nodes occur, usually upon the tibia, ulna, clavicle, frontal and parietal bones.
  They are usually  circumscribed, semi-solid swellings, of an ovoidal shape,
and of a slightly elastic touch.
  The periosteum and bone are inflamed, softened  and ulcerated, and as the
tumor extends, the structures over the seat of the disease become red and pain-
ful, and ulceration finally takes place at the most prominent point.
  The course of the disease  is chronic, and it is attended with an intermittent,
neuralgic pain, greatly increased at night. 
96
SURGERY.
   Caries is most common in the long bones of the extremities, in the skull, and
in the palate, maxillary, nasal, turbinated ethmoid bones and vomer.
   Hypertrophy of the osseous tissue is exceedingly common, and may involve
many of the bones;  those most liable to be attacked are the tibia, fibula, femur,
ulna, radius and cranium.  The tumor is usually knotty and irregular, with a
broad base and a rough, scabrous surface;  in long standing cases it  becomes
hard, and of the consistence of ivory.
   Treatment.—Iodide  of potassium, given in solution, is the remedy most
frequently resorted to in  tertiary syphilis; fifteen grains  three times a day is a
medium dose, but it is often given in much larger quantities; it should be taken
about an hour after eating.
   Iodide of potassium is generally combined with carbonate or muriate of am-
monium, or iodide  of sodium, or iodide of ammonium;  the average doses of
these remedies is about eight  grains; their efficacy will be  enhanced by the
addition of a small quantity of mercury; the form of mercury usually preferred
is  the bichloride, in doses of T^ to ^ of a grain, three  times  daily.   A good
substitute for the bichloride, should it disagree with the  patient, will be found
in the biniodide.
   Donovan's solution is a remedy in general use, the dose being from five to
eight drops.  Tonics, as a rule, are  indicated;  quinine  and iron are usually
preferred.
   Sudorifics are highly praised when there is obstructed  perspiration;  Dover's
powder,  antimony,  morphia, warm or steam bath,  are  the remedies usually
recommended.
   Anodynes  are most valuable auxiliaries, it  being of  vital  importance to
produce  sleep  and  to quiet  the  nervous system; morphia,  laudanum, black
drop or  opium  must be used in sufficiently large  quantities  to answer the
indications.
   For ulcers, fissures, eruptions, etc., the topical treatment generally in use are
weak solutions of nitrate of silver or acid  nitrate of mercury;  when  there is
much inflammation  present, acetate of lead  and opium may be employed.
   Syphilitic onychia  is  best treated by the  application of nitrate  of lead,
sprinkled over the sore three or four times daily.
   Tertiary ulcers of the throat, 77iouth and  tongue are most beneficially treated
with applications of acid nitrate of mercury or solid nitrate of silver.  Weak
gargles  or washes of  acetic acid, tannic acid and sulphate of copper, chlori-
nated sodium, may be employed in the intervals.
   For syphilis of the nose, injections of weak lotions of iodide of iron, sulphate
of copper and tannic  acid, tincture of myrrh, permanganate of potassium and
chloride of zinc are  most to be relied upon.
   The remedy for syphilitic iritis  is mercury pushed to rapid ptyalism. 
TUMORS.
97
  For ulcers of the eyelids, use iodide of potassium, and apply dilute ointment
of nitrate of mercury.
  The pain in the bones is relieved and  swelling abated by applying tincture
of iodine, leeches and blisters.   If the ulcer is slow to heal, apply a blister and
dress it with mercurial ointment.
  If a gumma makes its appearance somewhere on the subcutaneous con-
nective tissue, beside relying  upon the specific mixed  treatment already laid
down, make an application to the part of tincture of iodine two or three times
daily; if it be  on the hand or arm, place the limb upon a splint, apply the
tincture  of iodine, and make compression with a bandage.
  If the gumma be already opened when first seen by the surgeon, apply the
usual dressing of corrosive sublimate  solution, and when  the gummy matter
has been  excluded, apply some stimulating  lotion.   Iodoform collodion is
highly recommended.   (F. 74.)

  Inherited  Syphilis.—If a mother is affected with  secondary syphilis, she
should be placed upon specific treatment  as soon as she is found to be pregnant.
  The child, when  born, should be placed upon the mercurial  plan of treat-
ment.   It should be given one grain of mercury, with chalk, rubbed  up with
sugar, twice a day, gradually increasing to two grains a day.  One-fifteenth of
a grain of Dover's powder may be added to each dose if the mercury disagree
with the child; or  the mercurial  may be introduced into the system by inunc-
tion, by smearing the end of a flannel  roller  with  five per cent, oleate of
mercury and carrying it around the abdomen.
                              TUMORS.
  Liicke defines a tumor to be " an increase in volume, by the growth of new
tissue, which does not perform  any physiological function."
  Tumors are divided into neoplasms and cysts.
  A neoplasm  may be defined to  be a circumscribed tumor, constituted by a
mass of more or less newly-formed tissue, which represents a local overgrowth,
and a permanent addition to one of the normal tissues of the body.
  Neoplasms assume various shapes.  They may appear as a flat swelling, or
they may rise high above the level of the skin, when they are called tuberous
tumors; the base being wider than the summit.   Other varieties of tumors are
the elongated, the papillary, the fungous, and the polypoid.  When a papillary
tumor is on the mucous membrane, it is of a villous growth.
  A tumor is the result of hypertrophy  of  the tissue; hence the growth of a
neoplasm is due to nutritive disturbance.   An increased amount of blood is 
98
SURGERY.
sent to the part, and in consequence of the increased nutrition, the cells undergo
proliferation.
  In the  formation of a tumor the  cells  alone  are involved, which is not the
case in inflammation.  The blood-vessels are not  involved in the  change that
takes place in the growth of a tumor, save to nourish it.
  All tumors are the  direct product of preexisting cells, and  are supplied with
vessels, nerves and lymphatics, in varying degrees of abundance.  The three
leaflets derived from  the  blastodermic membrane of the embryo give rise to
their own  peculiar cells.
  A tumor does not spring directly from a connective-tissue cell, but the struc-
ture in which a tumor is  forming undergoes proliferation, and  as a result the
tissue itself  reverts to a mass  of young cells called  embryonic tissue.   This
condition  is  known as the indifferent stage; it is impossible to foretell what
character of tumor is about to form.
  In the formation of a tumor there is nothing entering into its  composition
that is foreign to its organism.   Neoplasms have their prototypes or analogues
in the normal tissue, and upon this fact is based the anatomical classification of
tumors.
  The rapidity with  which  tumors  grow  depends upon the  nature, of the
growth, on the condition of the organ affected,  and on the age  of the patient
attacked.
  Tumors are subject to disease, just as are  healthy structures,  and may un-
dergo the  same pathological changes.' They are also subject to  inflammation.
Interstitial hemorrhages are common to some tumors;  they  may ulcerate,
either as the  result of injury or of natural tendency.
  Women are more liable  to tumors than men,  as are also the dark races and
the  inhabitants of hot countries.  In certain  families the tendency seems to be
hereditary.  Young persons are more liable to tumors of  the connective-tissue
type, and the aged to the  epithelial.
  Tumors are divided into three classes: those  that are composed of  and are
derived from the  connective  tissue, as lipoma; those which are derived  from
and are composed of the higher connective  tissue, as myoma; and  those that
are  derived from and are composed of the epithelial  structure, as papilloma.
  Those tumors that are derived from connective tissue, are divided into benign
and malignant.
  Typical tumors are those benign tumors of the connective-tissue class which
conform to the type of normal tissue, and follow in their growth a determined
model.
  Homologous tumors are those which resemble the tissue of the matrix, or the
tissues from  which they grow.   A chondroma growing from cartilage is an ex-
ample of an homologous tumor. 
TUMORS.
99
  Heterologous tumors are those which in their histological construction bear
no resemblance to the tissue or parent structure from which they grow.  An
osteoma growing from connective tissue is an example of this kind of tumor.
  Type.—A tumor may change its type.  A papilloma may be converted into
an epithelial carcinoma; a pigmented naevus may change with advancing years
into a sarcoma.  Different kinds of tumors  may be found on a patient at the
same time.
  The  Causes of  Tumors are  obscure;  they are divided into predisposing
and  exciting.  A predisposing  cause  is hereditary transmission.   Exciting
causes may arise from local  irritation, as when epithelioma results from a jag-
ged tooth tearing the mucous membrane of the  cheek or tongue.  The smoking
of a short clay pipe  frequently produces the  same disease.


                           BENIGN TUMORS.
  Symptoms of a Benign Tumor.—The  marks of a benign  tumor  are:
they are circumscribed and  movable, and  not blended with the surrounding
structures, and, although multiple, they are  found in the same tissue; they are
compatible with good health, though by enlargement they may cause  oedema  or
paralysis by pressing on arteries or nerves, or  they may distend the  skin, and
so may ulcerate and slough; these are local consequences, and cease if the
tumor be removed;  and if effectually removed they do not return.
  Examination by the microscope reveals the fact that they are composed of a
structure which resembles the normal adult tissue.   Benign tumors are capsu-
lated.  A  simple tumor  pushes  aside  or presses upon the surrounding struc-
tures ; it does not infiltrate them, hence they do  not recur when  removed.
They never give rise to  metastatic deposits, and they generally grow slowly.
They rarely attain any considerable volume;  exceptionally they attain great
size.  They do not  become adherent to the  overlying skin, as is frequently the
case with malignant  neoplasms.
  The benign growths representing the matured connective tissue are—
  Lipoma—Fatty tumor.
  Fibroma—Fibrous tumor.
  Chondroma—Cartilaginous tumor.
  Osteoma—Bone tumor.
  The tumors derived from a higher type of connective tissue are—
  Angeioma— Vascular tumor.
  Neuroma—Nerve tumor.
  Myoma—Muscular tumor. 
100
SURGERY.
  Lymphoma—Lymphatic tumor {fibrous).
  Lymphangeioma—Lymphatic vessel tumor.


                        MALIGNANT TUMORS.
  Symptoms of Malignant Tumors.—Malignant tumprs tend to infiltrate  and
become blended with the adjoining parts;  they cannot move freely, and they
adhere to  the  skin over them; they are frequently of rapid growth  and are
very painful.  Unless  completely removed they  return  in the  same  place.
Their recurrence  is owing to  the fact  that cells of  the diseased tissue are left
behind at the time of the operation.   Some  cells travel along the lymphatics
and affect  the  nearest glands; others are diffused over the body by means of
the blood-vessels.
  They infect the lymphatic glands and frequently give  rise  to secondary
deposits in the various viscera.
  A malignant tumor may ulcerate and become fungous, when it is very liable
to bleed.  An  anaemic condition, denominated cachexia, accompanies the dis-
ease.   The less the tissue of a tumor resembles the normal adult tissue, the
more malignant it is apt to be.
  At the outset a malignant  tumor is a  local disease; the  first characteristic of
malignancy is  manifested by infiltration  into the surrounding tissue.
  A malignant tumor may be capsulated, but as a rule the capsule soon becomes
infiltrated by the cell growth of the tumor, and is blended  with it.
  In carcinoma and in alveolar sarcoma the infection takes  place  through the
medium of the lymphatics.   In sarcoma and myxoma the  secondary tumors
take place through the medium of the blood-vessels.  These metastatic tumors
are the exact likenesses  of the original growths.
  Scale of Malignancy.—The least malignant of  the carcinomatous  group  is
a form of epithelioma called the rodent ulcer.   In the  scale of malignancy
are the epithelioma, colloid,  scirrhus and encephaloid.  Of  the sarcomata the
least malignant is the giant cell;  the next is the small spindle-shaped sarcomata;
then  follows the small round-celled sarcoma, and finally, the most malignant
is the alveolar.  In sarcoma, the  smaller the cell the more malignant is the
disease.
* Tumors are malignant because of their structural peculiarities, and  of the
changes that take place  in the tissues that immediately surround them.   If  a
tumor is single at the outset  and  afterward  becomes multiple, it is malignant;
but if  the tumors are multiple at  the beginning, and if they are found  in the
same tissue, they are  benign.
  The next division of connective tissue tumor is that which is derived from
and corresponds to  the embryonic,  transitional  or unripe connective  tissue. 
TUMORS.
101
Tumors belonging to this class are denominated Atypical, and are included in
the term Sarcoma.  They are —
  Round-celled Sarcoma.
  Spindle-celled Sarcoma.
  Giant-celled Sarcoma.
  Mixed-celled  Sarcoma.
  The small, round, spindle-celled  sarcomata are called encephaloid; if these
tumors should be infiltrated by hematoidin, giving rise to a dark brown or black
pigmentation, they are called melanotic; the tumor made up of the giant cell is
called myoloid sarcoma; this form is generally maroon colored.
  Modified forms of the four varieties of sarcoma are not uncommon; the most
important are the alveolar, and (he glioma, sometimes called neuroglioma.
  Among the tumors of this class is a growth which also occurs in the mature
connective-tissue group, viz., the medullary lymphoma, or soft variety; this is
the only exception to the rule that malignant tumors bear no resemblance to
normal tissues of the body.
  The other important modified forms of sarcomata are the—
    Fibro-Sarcoma,                           Chondro-Sarcoma,
    Lympho-Sarcoma,                        Osteo-Sarcoma,
                            Myo-Sarcoma.


                              MYXOMA.
  As a rule the mucous tumors are innocent, but the purest form of myxoma, in
which  little or no development takes place, and which  therefore corresponds
with sarcomata in the fact that they are embryonic tissue  tumors, are, as a rule,
as malignant as sarcomata of the same tissue or organ.   Those which are devel-
oped in the substance of fatty or fibrous tissues, and which may be regarded  as ill-
formed fatty or fibrous tumors are not as innocent as simple fibrous or fatty tumors.
  The typical epithelial tumors, that is the varieties  based upon the model of
preexisting tissue, are those tumors which are developed in the  skin, mucous
membranes and their appendages.
                 ( Horn,
    _  .,.        Corn,
  i. Papilloma  > ^
                 (^ Villous growths.
  2. Adenoma.
  Villous growths are found upon the mucous membranes of the body.
  Atypical  epithelial growths  resemble  no other  growths in the body; they
are  called carcinoma. 
102
SURGERY.
                             CARCINOMA.
  Epithelioma ; a variety of which is superficial epithelioma or rodent ulcer;
glandular  carcinoma; the varieties of which are spheroidal cells, squamous
cells and cylindrical cells.
  The epithelial carcinoma, at its outset, grows in the skin or the mucous mem-
brane ; the connective tissue undergoes atrophy, and the epithelial  cells grow
down into  the fibrous structure of the skin, and finally involve the underlying
structure.
  The glandular varieties of carcinoma are—
  i. Medullary or encephaloid  carcinoma; so called on  account of its
resemblance to the encephalon of the foetus.
  2. Scirrhus,  which is the hard variety; of this there is a division known as
atrophying or withering scirrhus carcinoma.
  3. The Colloid, which is a form  of scirrhus in which the cells and a portion
of the stroma have been  converted  into colloid material, looking like glue or
jelly.
                                 CYSTS.
  A cyst is a fibrous membrane forming a sack  which incloses a more or less
liquid contents.
  As a rule cysts are not of new formation.
  Cysts are generally formed by the fusion of the lymph spaces of a tissue, by
the obstruction of an excretory duct, the softening of a tumor, or the extrava-
sation of blood into a sack.   Cysts are sometimes congenital.
  They vary in  size, from a very small pea to a tumor weighing many pounds.
  Dermoid Cysts.—These are  always of congenital origin, and are  due to
the invagination of epithelial structure.  They are usually found about the
orbit, ovary or testicle.  They  are  lined  by a wall of true skin, and contain
hair follicles, sweat and sebaceous glands, and hair and sebaceous matter.
   Retention Cysts.—The  formation of these cysts is due to the occlusion of
an  excretory duct of a gland, together with retention of the  contents  of the
gland.  The most common forms are the sebaceous cyst, milk cyst, ranula and
encysted hydrocele.
   Exudation  Cysts.—These are  accumulations of fluid in a cavity not pro-
vided with a duct, as in hydrocele, housemaid's knee, ganglia formed in  con-
nection with the sheath of tendons  about the wrist and ankle, the ovarian cyst
and cystic goitre.
   Softening Cysts.—These are due to the fatty and mucoid degeneration of
the elements of  a neoplasm; they are called cystoid, and  are most frequently
met with in sarcoma and chondroma of the  long bones. 
TUMORS.
103
   A cyst may be single or multilocular, or it may be simple or proliferous.
   Hydroma are neoplastic cysts.

                                LIPOMA,
Ox fatty tumor, consists of  fat tissue intersected in the meshes of fibrous bands
and contained in a fibrous capsule.
   They are soft, movable and lobulated, sometimes semi-fluctuating, or fleeting,
like fat, half  fluid at the temperature of the body and free  from  pain and ten-
derness.
   Their most usual situation is the subcutaneous tissue of the trunk, especially
about the back of the neck and shoulders.

                               FIBROMA,
Or fibrous tumor, consists  of fibrous tissue; sometimes white, glistening and
hard, resembling tendon, and at other times, softer,  yellowish in color, and
containing  fat within its meshes.  There are two varieties, the hard  and the
soft.  The hard are mostly found in connection with the periosteum, the fascia
and the nerve sheath; the soft in the skin and submucous tissue.

                             CHONDROMA,
Or cartilaginous tumor, consists, for the  most part, of cartilage, identical with
normal cartilage.  They are firm  and smooth;  as  a  rule  they are  somewhat
nodulated; they may be hard, but sometimes are so soft  as to  be taken for
cysts.  Their usual situation is on or within the bones, particularly those of the
hands;  if developed within the bone, they will  cause it to  expand into a thin
shell.
   Their growth is usually slow; they are more frequent in  early life.  They
are often  multiple and hereditary.  When  thoroughly  excised  they  do  not
return, though to this rule there are numerous exceptions.

                               OSTEOMA,
Or bony lumbr, is generally circumscribed, rounded and flattened, pedunculated,
more or less irregular in size and shape.  The most common form is exostosis,
generally found at or near the articular extremities of the long bones.  They
frequently exist on the dura  mater; they  have also been  found on the  larynx,
bronchi, and muscular substances.   Their growth is exceedingly slow.

                                MYOMA,
Or muscular tumor.  Tumors of the unstriped variety occur chiefly in  the
uterus;  they are also found in the oesophagus, stomach and prostate gland, as
well as in the scrotum of man, and the labia majora of woman. 
104
SURGERY.
                               LYMPHOMA.
  The lymph gland tumor consists of lymphatic tissue.  It is found everywhere
on the  body; it essentially  consists of a delicate  network  formed by the
branches of stellate cells, containing elements  similar to  those of chyle or
lymph.
                              ANGEIOMA,
Or vascular tumors, are vascular growths which consist of active hypertrophy,
or extension in length and calibre of existing vessels with the growth of new
ones.   The  two chief varieties are the simple angeioma (naevus) and the
cavernous angeioma (erectile  tumor).

                               NEUROMA,
Or nerve tumor, consists of hypertrophied nerve tissue, is most rare, except as
evidence of an abortive attempt at union of a divided nerve, when the divided
ends retract and  become bulbous.  They may become exceedingly painful and
require to be cut out.
                              PAPILLOMA
Is an hypertrophy  of the papillae  of the skin and mucous membrane.  The
most common form is the ordinary wart, which consists essentially of elongated
and enlarged papillae.   Horny growths constitute another form, and appear to
originate in the sebaceous follicles, by proliferation of their epithelial lining.

                               ADENOMA
Is the term by which all glandular tumors are designated.
  They  generally grow very slowly; are not painful; are firm and  elastic,
freely movable, the adjacent skin being unaltered.   On cutting into them they
present a lobed construction not unlike an indurated pancreas.

                      INFECTIVE  GRANULOMATA.
  Infective granulomata  are a class of neoplastic formations which, in cer-
tain stages of their growth, are tumors, but are not classed as tumors because
they are ephemeral, or not permanent, and disappear by resolution  or by ulcer-
ation.   They are made up of granulating tissue, and their  infective character
is due to a specific  microbe.   Glanders, syphiloma, tubercle, leprosy and lupus
belong to this class of tumor.
   The  infective  granulomata are locally and generally infectious; they give
rise to like  tumors on different organs and tissues of  the body.   Some forms
are inoculable;  they are contagious, but they do not form permanent additions
to the body; they are, therefore, excluded from the consideration of neoplasms. 
TUMORS.
105
                       TREATMENT OF TUMORS.
   Treatment of Benign Tumors.—A benign tumor that does not give rise
to pain, that is of slow growth, that does not threaten life, and does not inter-
fere with the health and strength of the.patient, should be let alone.  It should,
however, be watched, and if it should  grow or give trouble  it should  be  re-
moved by the knife; innocent tumors of the mammary glands are exceptions
to the rule.   They should always be promptly extirpated, as they are liable  to
change their type and become malignant.
   The ligature instead of  the knife is generally resorted to in vascular tumors.
The ecraseur is usually employed in  cases of polypoid tumors of the uterus
and rectum.  Caustics  should only be resorted to for  the  removal of birth-
marks of children.
   Cysts are most frequently treated by the use of such irritating injections  as
carbolic acid and tincture of iodine.  In  the  treatment of some cysts the fluid
is simply drawn off and a  drainage tube inserted.   Where the wall of the cyst
has undergone great modification, the cyst is to be laid open  and then treated
antiseptically.
   Treatment of  Malignant Tumors.—In cases  of sarcoma  of  the long
bones amputation of the limb is the rule.
   In sarcoma of the soft structures involving the limbs  an  exploratory incision
should first be made down to the seat of  disease, and if  it be found  that it
cannot be entirely removed, amputation should be performed well above the
site of the disease.
   In carcinoma the diseased part should be removed as soon as possible, and
the  incisions  should extend  well beyond  the apparent limit of the  tumor.
When the disease  affects  the  mammary  glands, not only must the breast be
removed, but  the axilla must  be  opened  and search made for any infected
gland, which  should be extirpated.  It  is  frequently impossible  to feel small
glands through the skin, therefore the  axillary space should always be opened
and thoroughly examined; the glands will be found affected in nine cases out
of ten.  At  the  outset  carcinoma is a local disease and therefore should be
operated upon early.  If  there is no recurrence after three years, the patient
may be considered permanently cured.
   The glands  that are immediately connected in the anatomical relations to the
seat of disease in carcinoma  are found to be involved in the proportion  of
ninety five out of one hundred cases; and in sarcoma in about one case in fifty.
   Caustics should only be used where  the  knife cannot be employed,  and  in
cases, such  as lupus and rodent cancer, in which  it is desirable to  remove a
very thin layer of  the  surface, or the portion of the edge of an  ulcer; acid
nitrate of mercury, arsenic, and chloride of  zinc are those generally employed.
       H 
106
SURGERY.
Arsenic is generally employed in the  form of a mixture composed of fifteen
grains of white arsenic, seventy-five of cinnabar and thirty-five of burnt sponge,
made into a thick paste by the  addition of a little water.  Chloride of zinc is
made into a paste by the addition of three or four parts of flour and a few drops
of water.
  The following Table is appended to  enable the student to more firmly fix in
his memory the different varieties of tumors; their types and formations :—
                             TABLE
GIVING THE DIFFERENT VARIETIES OF TUMORS; THEIR TYPES
                       AND FORMATIONS.
FROM WHAT DERIVED.	TISSUE FORMED.	TYPE.	BENIGN.	MALIGNANT.
Epiblast.	Skinand append-	Epithelial.	Adenoma.	Carcinoma :—
	ages.		t, ., fHorn. PfP'NCorn. loma-|Wart.	Epithelioma.
				f Superficial epitheli-
				al oma or rodent
				|_ ulcer.
				Encephaloid.
				Colloid.
				( Scirrhus.
				-< Atrophying s c i r r -
				(_ hus.
Hypoblast.	Mucous m e m -brane and ap-pendages.	Epithelial.	Adenoma. Papilloma. Villous growth.	Carcinoma.
Mesoblast.	Skin. Fat.	Mature con-	Lipoma. Fibroma.	Sarcoma:— f Glioma, or neuro-\ glioma
	Connective t i s -	nective t i s - -s	Osteoma.	
	sue.	sue.	Chondroma.	Spindle-cell.
	Bones.			Small round-cell.
	Cartilage.			Large round-cell.
	Blood-vessels.		Angeioma.	Giant-cell.
	Lymphatic tis-		Lymphoma	A pigment sarcoma is
	sue.	High class of	(fibrous).	called melanotic.
	Nerves.	connective-	Lym ph angei-	Giant-cell is called
	Muscles.	tissue. The malignant tumors of the group belong to the embryo-nic-tissue form	oma. Neuroma. Myoma.	myoloid. The spindle- and small round-cell sarcoma is called medullary. Lymphoma (soft va-riety), Hodgkin's disease. Myxoma. Teratomata {m ix e d tumors):— Chondrosarcoma. Osteo-sarcoma. Myo sarcoma. Lympho-sarcoma. Fibro-sarcoma.
 
ANEURISM.
107
                             ANEURISM.
  Aneurism is a pulsating tumor, containing  blood, and communicating with
the interior of an artery,
  An aneurism consists of a sack formed by one or more of the arterial tunics.
  There are two varieties: the sacculated, which is formed into pouches, and
the dissecting, in which the blood finds its way between the arterial tunics.
  Aneurism usually commences  by a giving way of  the internal and middle
coats of the artery, at the site  of some softened  spot, after which the pressure of
the blood dilates the external  or cellular coat into a pouch.  It may commence
by the dilatation of all three of the  tunics.
  It gradually dilates under constant pressure  of the heart's impulse, becomes
lined with coagula deposited in distinct laminae.
  Symptoms.—If it is an external aneurism it may  be recognized by the fol-
lowing symptoms: At first there is a small  tumor, pulsating strongly, and  if

                                  Fig. 17.
VARICOSE ANEURISM.
the finger is applied to the artery between the aneurism and the heart, the
aneurismal sac will be readily emptied  by pressure ; in the second stage, the
blood is beginning to coagulate in the interior of the sac, the coats,  at the same
time, having become thickened.   If the artery be now pressed upon, the sac
will be emptied in part, and the swelling will be reproduced  when the pressure
is abandoned.   There is some degree of pain and the circulation is retarded, in
consequence of the pressure.
  When the aneurism reaches the  third  stage, it has acquired considerable
magnitude, and the pulsation is, in a degree, lost;  a small portion of the blood
still remains fluid, but the greater part is filled with coagulum.
  In internal aneurism the symptoms vary, according to the seat in which the
disease is found ;  the digestive organs will  be at fault at one time, the urinary
at another, and so on, depending on the part upon which the aneurismal tumor
presses. 
108
SURGERY.
  Diagnosis.—Other tumors situated over arteries may be distinguished  from
aneurism, by observing that they do not  pulsate at  first, when  they are small,
whereas aneurisms do so from their earliest formation; that a tumor may often
be lifted up from the artery, and that then it will cease to pulsate; that aneur-
isms are generally soft at first and become hard afterward; tumors are generally
the  reverse; tumors cannot be emptied by pressure, and  no alteration  is made
in their size or  consistency by compressing the artery above.  The pulsation
of an aneurism is expansile.   In nearly all cases a bruit is heard on  placing
the  ear over the tumor;  it varies in different cases;  it is blowing in its char-
acter ; is not increased on pressure, and  is heard equally well  over the whole
tumor.
                           LIGATION OF ARTERIES.
        A. Antyllus' operation.  B. Anel's operation.  C. Hunter's operation.

  The predisposing cause of aneurism is some preexisting degeneration of the
arteries, which may be  preceded by habitual overstrain.   Sir A. Cooper speaks
of a case where there were  seven  aneurismal  tumors in different  parts of the
body.
  Treatment.—By compression ; it is applied upon some  part of the affected
artery between the aneurism and the heart, and in such a way as to retard the
circulation  and so cause deposits of laminated fibrin.   Carte's circular  tour-
niquet is used for the purpose;  also Gibbon's modification of Charriere's com-
pressor, or Hoey's  clamp.
  In some cases a five-pound bag of shot, or an ordinary four-pound weight
may be placed over the artery, with a pad intervening, or " digital compression "
may be used;  kept up by  relays of assistants, the patient, if  necessary, being
kept under the influence of chloroform or morphia. 
ANEURISM.
109
  The advantages  of compression are, that  it can  be discontinued  at  once,
if need be; secondary hemorrhage, the frequent  accident of the ligature, is
obviated: and even if it fails the knife can still be resorted to.
  Compression is contraindicated when the  integuments  are inflamed, or the
limbs much swollen, from venous obstruction, and also in  cases which are very
rapidly increasing.
  The pressure  should not be severe enough to cause great pain, and if there
is room, it should be applied at two or three points in the course of the artery;
and not carried to the point of completely closing the vessel.   If very restless,
the patient  may be gently chloroformed, or kept quiet by morphia for two or
three  hours at a time.
  By Ligature.—When compression is inapplicable or unavailing, the artery
must  be secured between the aneurism and the heart, by i. The Hunterian
Method.  The place of election must  be neither too near the aneurism, so as
to tie a portion of the vessel that is diseased, nor too far from it, lest the circu-
lation through it be kept up too freely by means of collateral branches.   The
direction and extent  of  the incision obviously depend on the situation of the
artery to be operated on.  A healthy  portion of  the  artery  is selected, great
care is taken, in exposing the vessel, to  disturb the sheath as little as  possible,
and but one ligature is used ;  it is drawn so tightly that the inner and middle
tunics are  divided; a double  knot being made, one extremity is cut off, and
the other is brought  out at the nearest point of the wound, which is then
treated in the ordinary manner.
  The other methods in vogue are : 2. Anel's  operation; 3. Brasdor's  distal
ligature; and, 4. Wardrop's operation.
  2.  Anel's operation is to apply a ligature to the  affected artery close above
the aneurism.  The  objections  to this  method are  that the operation is per-
formed on a part of the vessel  that is already diseased, and that  the proximity
of the wound to the aneurism  is liable to excite inflammation in and around
the sac.
  3.  Brasdor's distal  ligature is applied to the diseased artery beyond the
aneurism, on the distal  side.    It is  resorted to in aneurism of the carotid,
innominate or subclavian artery, when the ligature cannot be employed between
the aneurism and the  heart.
  4. Wardrop's operation  consists in tying one  or more branches coming
off beyond the aneurism.   It is a modification of Brasdor's operation.
  In separating the artery from its accompanying veins, the greatest care must
be taken not to inflict injury upon the vessels. 
110
SURGERY.
                               HERNIA.
  Hernia is a term used to signify the protrusion of any viscus from its natural
cavity, but surgeons generally confine it to protrusions of the viscera from the
cavity of the abdomen.
  There are many varieties of hernia, depending upon the parts in which they
occur, or according to their contents.
  Herniae most frequently make their appearance at the groin,  the navel, the
labium pudendi, and the upper and fore part of the thigh.
  Inguinal hernia is the name when the hernia protrudes at the abdominal
ring.
  Scrotal hernia, if the parts descend to the scrotum.
  Femoral hernia, when it takes place below Poupart's ligament.
  Umbilical hernia, when the bowels protrude at the navel.
  Ventral hernia, when it occurs at other parts of the abdomen.
  Congenital hernia, when the parts have not any proper peritoneal sac, but
are  contained in the tunica vaginalis testis.
  From the  contents of the  hernia, they are said to be either enterocele, epi-
plocele or entero-epiplocele.
  It is Enterocele, if a portion of the intestines alone form the contents of the
tumor;  Epiplocele, if omentum only; Entero-epiplocele, if both intestine and
omentum.
  Herniae are  said to be—
  Reducible, when the protruded bowels admit of being readily returned to the
abdomen; irreducible,  when  the protruded bowels suffer  no constriction, but
cannot be returned to the abdomen, owing to adhesions, or to their large size in
relation to the  aperture through which they have to pass.
  It is strangulated when it not only cannot be reduced, but suffers constriction
also.
  The predisposing causes are deficiencies or resistance, resulting  from relaxa-
tion, or malformation;  the  principal are a preternaturally large size of the
openings at which the bowels are likely to protrude;  a weakness  and relaxation
of the margins of these  apertures, and a laxity of the peritoneum.
  The exciting causes are the powerful action of the abdominal  muscles and
diaphragm, accidental  blows, great  muscular action,  obesity,  wearing  tight
clothes, pregnancy, jumping, etc., etc.
  Symptoms.— Of reducible hernia  are:  a swelling at  some  point of the
abdomen, which is subject to change of size, being  smaller when the  patient
lies on  his back, and  larger when  he stands up and holds his breath.   It
diminishes when  pressed, and  grows larger  when  the pressure  is  removed. 
HERNIA.
Ill

Frequently, in  consequence of the unnatural condition of the bowels, patients
affected with hernia are troubled with colic, constipation and vomiting.
   If the case be one of intestinal hernia, it will be  characterized by the uni-
formity of its surface;  it  is generally larger when
standing up  than when lying down;  it presents a           Fig. 19.
distinct impulse on coughing; it is tympanitic on
percussion; a gurgling noise  is  often made when
the bowel is ascending.
   If the hernia is omental, the tumor is more flabby
and has a more unequal feeling;  it is  generally in-
dolent; it is dull on percussion;  the impulse on
coughing  is fainter; if reduced it returns gradually
and without gurgling.
   If it  is entero-epiplocele, the characteristic  marks
are less clear, being a combination of the symptoms
which attend the simple cases.
   The  prognosis in reducible hernia is favorable
as long as the rupture  is of moderate size, can be
kept well up by a proper truss, and the patient is
not exposed to violent exertion.
   Sir Astley Cooper has observed that the danger of      scrotal hernia.
hernia is in proportion to the smallness of its size.
   A reducible  hernia  must be returned to the cavity of the abdomen without
delay, and as soon as the parts are returned a  suitable  truss  must be put on,
and worn without intermission.
   Irreducible Hernia.—The most frequent causes that prevent the ordinary
reduction of hernia are either the largeness of the contents, alteration in its
form and texture, adhesion of parts and formation of membranous bands within
the sac.   If the tumor cannot be returned, and no unpleasant symptoms attend
the case, the  only thing  to be done is to keep the parts in a suspensory bandage,
to prevent an increase of the  malady, or make use of a truss with a hollowed
pad, so as to support and protect the parts;  or perform the operation for the
radical cure of hernia.
   Strangulated Hernia.—The indications of a strangulated hernia are a tumor
in the situation of the rupture, attended with pain over  the whole abdomen,
sickness and inclination  to vomit, suppression of stools and some fever.   If the
reduction  be delayed, the vomiting  becomes very frequent;  all  the contents of
the stomach, and afterward of  the intestines, are  rejected.   There is  great
anxiety  and restlessness, with  cold extremities  and a small,  quick,  and  hard
pulse.   Then hiccough  comes on, the pulse  is hardly perceptible, respiration 
112
SURGERY.
 weak, and the whole body is  covered  with  a  cold, clammy sweat.  The pro-
 truded viscus  now begins to  mortify;  the patient suddenly becomes easy, the
 swelling of the belly subsides; the tumor  diminishes;  the skin sometimes
 changes to a livid hue; its'  feeling is emphysematous, and it  crepitates on
 being touched.  In this state the gut returns to the abdomen spontaneously, or
 is readily returned,  and the  patient fancies himself better.  This feeling is,
 however, of short  duration;  hiccough and cold sweat increase, convulsive
 symptoms come on, and the patient soon expires.
   The immediate cause of these bad symptoms  is the stricture  made on  the
 prolapsed part of the gut by the aperture through which it passes;  consequently,
 its removal is  the only thing that can bring relief, and  this object is to be ac-
 complished by returning the bowel into the abdomen, or  dividing the parts
 which form the stricture.
   The remedies generally employed  before  an operation  is resorted to, are
 the taxis, cold applications, the hot bath, a6°-ioo° F., a large dose of opium
 or morphia.
   The Taxis.—The bladder having been emptied, the patient should lie down
 in an  attitude of complete repose,  and be put under the influence of chloro-
 form ; if this  is  not used, he should be put in a warm  bath, both thighs
 flexed and placed close to each other,  so that every muscle and ligament con-
 nected with the  abdomen may be relaxed; then  the surgeon grasps the lower
 part of the tumor with  the palm of one hand, tenderly compresses it, and with
 the fingers of the other kneads the  parts at the  neck  of the tumor, occasionally
 drawing them very gently downward, in order, if possible, to dislodge them.
 If the tumor be  not sensitive, this operation may be continued for half an hour,
 when  the gurgling sound which accompanies  the return of the intestines may
 be heard.
   If taxis under the influence of chloroform fail, the surgeon should pro-
 ceed to perform the necessary operation.
   Having  gone  through the  general treatment of herniae  in their respective
 stages, they are now to be spoken of specifically.

   There are four varieties of abdominal hernia  to be described; viz., inguinal,
femoral, umbilical, ventral.

                          INGUINAL HERNIA.
   There are three kinds of inguinal hernia: the oblique, direct and congenital.
   Oblique Inguinal Hernia.—This variety takes the course of  the spermatic
 cord;  it begins with the cord as it  passes out of the  abdomen, and follows  the
 direction of the inguinal canal; its  course is oblique, and on  this  account is so
 called. 
HERNIA.
113
  With respect to the parts about the hernial sac; the spermatic cord is behind,
the testicle below, the internal oblique and transversalis above, and the fascia
transversalis beneath it.
  Direct Inguinal Hernia.—In this case the hernia does not follow the course
of the spermatic cord, but comes out almost  directly through the external ab-
dominal ring, and pushes before it the  fascia transversalis.   It passes on the
inner side of the epigastric  artery,  and directly as it emerges  from the ring is
received under the fascia of the cord, which forms one covering, and passes into
the scrotum.
  Direct inguinal hernia may be known  from oblique:  first,  by tracing the
spermatic cord, it will be found that  the hernia is  behind the cord, whereas
in oblique  it is before it; secondly, when  the  mouth of the  sac is traced,  in
oblique  hernia, it will be discovered above the abdominal ring, toward the  spine
of the ileum; but in  direct hernia, there  is an inclination inward toward the       •
umbilicus.
                         CONGENITAL HERNIA.
  In this hernia the protruded parts have not any proper peritoneal sac, but are
contained in the tunica vaginalis of the testicle, which serves as  the hernial sac.

                                  Fig. 20.
FEMORAL HERNIA,
                    FEMORAL OR CRURAL HERNIA.
  The seat of femoral hernia is the upper and fore part of the thigh, the pro-
truded intestine passing out at the same opening through which the large blood-
vessels are transmitted to the thigh, and consequently, under Poupart's liga-
ment.  It is most frequently met with in women.
2725 
114
SURGERY.
  The characteristic symptoms of femoral hernia are its situation with respect
to inguinal hernia;  its capability of reduction with  regard to bubo.


                         UMBILICAL HERNIA.
  In this hernia  some of the viscera of the abdomen, more frequently omen-
turn, pass out at the umbilicus, through an  opening in the linea alba, and, as
in other varieties of hernia, are  included in a sac formed by the peritoneum.


                          VENTRAL HERNIA
Differs from umbilical in its seat, which  is  usually at the linea  alba, or linea
semilunaris; but any visceral protrusions at the anterior or lateral parts of the
abdomen, except those already described, may be called ventral hernia.
  Operation.—Having used  the means for reduction already pointed out,
without success, an operation becomes necessary; taking care not to delay too
long.
                                 Fig. 21.
OPERATION FOR OBLIQUE INGUINAL HERNIA.
  While the anaesthetic is being administered, the skin  about the hernia  must
be shaved  and the parts thoroughly cleaned.  The whole proceeding to be
carried out as described  under the head " Antiseptic Surgery," page 43.  The
incision varies according to the site of the rupture.
  Oblique Inguinal Hernia.—The patient should be placed upon a table, with
legs hanging over; remove the  hair; commence  the incision from the upper
part  of the tumor, and  carry it along the  middle to the lower  part.   By the
first incision the fascia of the cord is laid bare, and in doing this the external
pudendal artery, which crosses directly opposite the abdominal ring, is divided;
this must be secured; then  scratch through the fascia of the cord just below 
HERNIA.
115
the ring, introduce a director upward to the abdominal ring  and inferiorly to
the lower part of the swelling, and  divide the fascia.  The fibres of the  cre-
master are then brought in view; this covering is somewhat dense and must be
opened with care;  a director is introduced under it, as far as the fascia of the
cord, and it  is then  divided; when  this is done, the hernial sac is exposed;  it
is  of  a bluish appearance and semi-transparent, from the fluid it contains.
Having laid bare the sac, pinch it and feel distinctly the intestine and omentum
within.   Raise the sac, to separate it from its contents, and make a small cut
into it, in a  lateral direction; place  the instrument horizontally, to avoid the
danger of wounding the intestine.   As a rule, if the intestine  be  included in
the sac, fluid escapes as soon as an opening is made.   Having opened the sac,
a director is to be introduced as far  as  the  abdominal ring, which is  then
divided; the director is  then  to  be carried into  the lower part of  the sac, in
the same manner.  When both omentum and intestine  are in the  sac, the
omentum will be found before, and the intestine behind.
  After having opened the sac, next feel for the  stricture; put  the little finger
in the  hernial sac, and ascertain if the stricture  is  situated at  the  abdominal
ring, and then pass a probe-pointed bistoury, guided on the finger, and divide the
stricture, not freely, but to a small extent; a slight motion of the knife will do.
  The  stricture does not generally exist at the external ring; it is  usually
situated at the upper  part of the hernia, opposite the tendon of the transver-
salis muscle, or in the sac itself.  When this is the case, slit up the abdominal
ring, hook up the abdominal muscles and draw them upward toward the abdo-
men, then  pull  down the hernial sac; the stricture is thus  exposed.  Then
divide  the  stricture in the centre and cut directly upward, let  the hernia be
where it may, and the  danger of wounding the epigastric artery will be avoided.
The intestines should be returned  piecemeal to  the cavity of the abdomen,
and then the omentum will follow them.
  Direct Inguinal Hernia.—In operating on these cases it  must be borne in
mind that the spermatic cord is placed on the other side; that the hernia  is
covered by the fascia of the cord, by the cremaster  partially, and is contained
in a sac, formed by  the tendon of the transversalis muscle,  assisted by the fascia
transversalis, besides a peritoneal sac.  The division of the  stricture must, there-
fore, be directly upward.
  Congenital Hernia.— The seat of stricture will be usually found under the
edge of the  transversalis  muscle, or at the internal ring, when it  should be
divided in the same manner as in other cases of hernia.
  Femoral Hernia.—The first incision is made in the course of Poupart's liga-
ment, along the tumor, extending from one side  to the other;  the second cut
is made at right  angles to  the  first, toward the umbilicus, so that the two in- 
116
SURGERY.
 cisions resemble the letter T inverted.   The flaps are then dissected  off and
 reflected.  This exposes the  superficial fascia, which is next divided, and the
fascia propria is then brought into view;  cut through this  and the. peritoneal
 covering presents itself.   Then  make an incision, with  the greatest care, and
 introduce a  director, to ascertain the  seat of stricture.  Having  opened the
 hernial sac and exposed the intestine, divide the  stricture directly upward and
 inward, a little inclined to the umbilicus.   The seat of stricture is at the pos-
 terior edge of the crural  arch, just where the intestine  leaves  the abdomen;
 therefore, in dividing the stricture,  after introducing the director, a bistoury,
 blunted at the point, is to be put on  it and placed against the stricture; in this
 way there is no danger of wounding the intestine.  The bistoury is  next gently
 raised, and, with a slight touch of the instrument, the fibres give way.
   Umbilical Hernia.—First make an incision across the tumor and then an-
 other at right angles, so that it will resemble the letter T inverted.  The integu-
 ment being divided, the corners of the incision are to be turned aside, by which
 the sac will be brought into view.   This being carefully opened, the finger  is
 to be passed into  the  orifice of the sac at the umbilicus and a blunt-pointed
 bistoury introduced.  The stricture is to be divided upward, in the  direction of
 the ensiform  cartilage.
   As a general rule, after having operated for the relief of  a strangulated her-
nia and returned the  gut to the cavity of the abdomen, the operation for the
radical cure  should be performed.
                                Treatment  after  the  Operation.—The
                              patient should be kept in  the recumbent  posi-
                              tion with his knees flexed over  a pillow.  As
                              soon  as he has  recovered from the effects of
                              the anaesthetic, a hypodermic injection of mor-
                              phia should  be  given.  No food  should  be
                              allowed  for at least thirty-six hours.   A little
                              ice  may be  given   to  relieve  thirst,  and
                              if  there be much  prostration  the strength
                              may  be  supported by enemata of beef tea,
                              with  a small quantity of brandy.   If there is
                              abdominal  pain,  give  morphia.   Keep  the
                              bowels  quiet until the seventh day;  if  they
                              have not spontaneously  acted  by  that time,
                              and all. the symptoms are favorable, administer
     spica retaining pad.        an enema'  The  drainage  tube may  be re-
                              moved at the end of forty-eight hours, and the
sutures should be taken out between the sixth and eighth  day.
  Generally the antiseptic dressings  may be discontinued on the  tenth  day,
 
DISLOCATIONS.
117
and  the wound then treated  with iodoform or  boracic  acid.  The  patient
should be kept in bed for at least three weeks, and  at  the  end of a  month,
if required, a truss may be applied.  The patient must not rise without a truss
or a properly applied pad or bandage.
                          DISLOCATIONS.
   A dislocation is the removal of the articulating portion of a bone from that
 surface to which it is naturally connected.
   Symptoms characteristic of dislocation are :  An alteration in the  form of
 the joint; an abnormal prominence at one part, and depression at another, with
 lengthening or shortening; loss of proper motion, and alteration in the axis of
 the limb, together  with pain, numbness, and absence of crepitation.
   Before completing the diagnosis the injured should always be compared with
 the sound joint, and the difference carefully noted.
   Causes.—I. The ball and socket joints are most liable to dislocation, from
 their wide range of movement.  2. Age:  Dislocations are  more frequent in
 middle age.  3. Sex: Males are  more frequently subjects of this form of injury
 than females.   4.  Previous dislocation of the affected  joint.  5. Alteration of
 the articulation, the result of disease, as the fracture or ulceration of a  process
 of  bone.  6.   External  violence.   7.  Muscular action.  8.  Elongation  of
 ligaments.
   Diagnosis.—Dislocation is distinguished from fracture by the absence of
 crepitus; a dislocated limb is less easily moved than  the joint in  its  natural
 state;  the fractured bone is more freely moved.  If a  fractured bone is drawn
 into its normal  position, it will resume its distorted shape when the extension is
 discontinued; if a dislocated bone is drawn into its natural position, it usually
 remains there.   The limb of the fractured bone will most generally be found
 shortened.
   Morbid Anatomy.—Dislocation is attended with rupture of the ligaments
 and muscles in  the neighborhood of the joint.   Bones, too,  may be fractured
 and  cartilages  injured.   The  ligaments, as a  rule, reunite and  heal.  If  the
 dislocation be not  reduced lymph is thrown out  around the  head of the  bone
 and a new socket is formed, the ligaments becoming lined with a smooth, ivory-
 like substance,  and frequently  a degree of motion is acquired.  The old socket
is gradually filled up.  The  great vesseb sometimes become adherent to  the
capsule or periosteum of the displaced  bones, and fatal hemorrhage may  result
if attempts are made at reduction.
  Treatment.—Dislocations should always be reduced as soon after the acci- 
118
SURGERY.
 dent as possible.   Whenever practicable the patient must be put under the
 influence of chloroform, so as to prevent the involuntary resistance of muscles.
   The reduction of a dislocation is effected by getting the head of the displaced
 bone in such a position that the muscles will draw it into its socket;  this may
 be done by manipulation and manoeuvring, and by such  movements of flex-
 ion, extension and counter-extension, as will bring the bone back into its normal
 position.  Direct force may be used.  Extension should be made in such  a
 manner  as to relax as many of the opposing muscles as possible; this should
 be aided  by such  gentle rotation,  extension and counter-extension,  as  may
 assist in dislodging the dislocated  bone.  After reduction, leeches, fomenta-
 tions, and ice to the part, together with purging, may be necessary, to prevent
 inflammation, and to give the ligaments an opportunity to heal; the joint should
 be kept at rest for some time.
   The different methods of extension  and counter-extension, with the neces-
 sary apparatus and  appliances to be used will be described when treating of
 particular dislocations.

                      COMPOUND DISLOCATIONS.
   A compound  dislocation is one in which there is a wound communicating
 with the injured joint; it is usually accompanied by severe contusion and lacer-
 ation of the surrounding textures.
   Compound dislocations occur most frequently in the ankle joint; next in the
 knee and  elbow joint.
   Compound dislocations are very severe forms of injury, attended with much
 danger, and are apt  to be followed by hemorrhage, acute  synovial inflammation,
 rapid ulceration of the cartilage, abscesses, pyaemia, erysipelas, tetanus, etc.
   Inflammation is  apt to  supervene, which will  be  followed by suppuration,
 frequently profuse, often terminating in sloughing and gangrene.
   Treatment.—Having reduced  the  dislocation wash the parts thoroughly,
 so as to remove  all  foreign bodies;  apply a suitable bandage or  apparatus to
 prevent a  recurrence of the dislocation; then close the wound so as to procure
 union by  adhesion,  if possible.  The  first attempt  should be to convert the
 compound into a simple dislocation.
   If union by adhesion is impossible and the dislocation cannot be converted
into  a  simple  one,  and if suppuration ensue, the joint must  be opened and
 washed out daily with  an antiseptic solution and thoroughly drained.  Complete
rest  must  be enjoined.  Should  diffuse accumulation of pus  supervene, early,
free and dependent incisions must be made.  The dry dressing must be used.
   The joint must be  thoroughly washed  out with i-iooo bichloride solution.
 The skin  surrounding the wound must be washed well with the same lotion,
 a large gauze dressing applied.   If the patient is not seen until  from twenty- 
DISLOCATIONS.
119
four to forty-eight hours  after the accident, chloride of zinc (gr. xi to Jjj), or
iodoform in alcohol and water are to be employed.
  The general treatment consequent  upon prolonged suppurative discharge
should be  sustaining  and stimulating, consisting of animal food, with wine,
beer, spirits, etc.  Tonics,  such as quinine, dilute nitro-muriatic acid; and sleep
must be procured by opiates.


                 DISLOCATION OF THE LOWER JAW.
  A blow  on the chin when the mouth  is widely opened will cause this dislo-
cation.  Yawning will also produce it.
  Symptoms.—Both condyles are advanced between the surface of the  tem-

                                  FlG. 23.
DISLOCATION OF THE LOWER JAW.
poral bone and zygomatic arch;  the mouth is open, and the patient is not able
to shut it by pressure made on the chin ;  the lower teeth are on a line anterior
to the upper; the appearance is  that of a person yawning; the pain is severe;
the saliva is increased and dribbles from the mouth.
   If the lower jaw is partially dislocated one condyloid process only advances,
while the other remains in the articular cavity.
   Reduction.—If recent, this dislocation is  reduced by wrapping a handker-
chief around the thumbs, placing them on the coronoid processes, and depress-
ing the jaw; force it backward as well as downward, and the bone suddenly
slips into its place.  If this does not answer, the following method is to be tried:
The  patient being  seated, his head  supported  by an assistant,  the  surgeon, 
120                            SURGERY.
standing in front, introduces his thumbs into the mouth, as far back as possible
upon the molars, and places the fingers of each hand under the chin and base of
the jaw.  Using his thumbs as fulcrums, the back part of the jaw is forcibly
depressed,  to disengage the condyles  from the  zygomatic fossae, and  at the
same moment the chin is elevated by the surgeon's fingers.  The thumbs of the
operator are to be thoroughly protected by the folds of a handkerchief or napkin.
  If the dislocation  has existed some  time, the  better plan is to place  some
yielding  substance, like cork, behind  the  molar teeth, on each side of the
mouth, and then raise the chin  over them.
                  DISLOCATIONS OF THE CLAVICLE.
  The sternal end of this bone may be dislocated forward, and also backward;
more frequently forward, when it is thrown upon the upper part of the sternum.
  When the dislocation is in front of the sternum, the reduction is easily
effected; place your knee  against the spine, draw the shoulders  backward,
and the clavicle will assume its natural position; then apply the clavicle ban-
dage, placing a pad on the displaced end of the bone.
  The dislocation behind  the sternum is a very rare occurrence; it may be
produced by curvature of the spine ; if so, there is no mode of reducing it.
  The outer extremity of the clavicle is most frequently dislocated upward on
the acromion; it is, more correctly speaking, a dislocation of the acromion from
the clavicle, where the bone is thrown upon the upper surface of the acromion,
or upon the anterior part of the spine of the scapula.   It is usually caused by
violent falls upon the shoulder.
  Symptoms.—There  is a distinct prominence, formed by the displaced bone,
                             upon the surface of the acromion, which dis-
                             appears on raising the arm; the limb hangs
                             closely along the trunk, the shoulder is some-
                             what flattened.  The facility of reduction, and
                             the prominence of the clavicular portion of the
                             trapezius muscle, indicate  the  nature of the
                             accident.
                                Treatment.—Reduction is effected by rais-
                             ing the shoulder, drawing it backward  and
                             carrying it outward  by placing a pad in the
                             axilla and bringing the elbow well to the side.
                             After  reduction, the  treatment  is the same as
                             for fracture of the clavicle.   A thick pad, with
                             the base directed  upward, is placed in the
 DISLOCATION OF THE ACROMIAL     ...     , ,          ■       r
     end of the claviclb.     axilla,  and the arm and forearm must be well
Fig. 24.
 
DISLOCATIONS.
121
secured to the chest; direct pressure must be made by means of a pad and
gutta-percha plate laid on the projecting clavicle, and strapped tightly down by
a band passing parallel  to  the  arm and  under  the flexed forearm.   This is
retained in position by being attached to  a strap  passed  around the opposite
axilla.

                 DISLOCATIONS OF THE HUMERUS.
  First Dislocation.—Downward into the axilla, which is most common.
  Symptoms.—The arm is lengthened;  a hollow is felt under the acromion ;
the  shoulder is flattened externally;  the  elbow  sticks  out  from the side and
cannot be made to touch the ribs ; the head can be felt in the axilla.
  Second Dislocation.—Forward beneath the clavicle,  upon  the  second
rib, the coracoid process being  on the outer side.

     Fig. 25.           Fig. 26.          Fig. 27.                Fig. 28.
           FIGURES SHOWING VARIOUS DISLOCATIONS OF THE HUMERUS.

  Symptoms.—The arm is slightly shortened;  elbow projects backward ; the
acromion  seems pointed; the depression of the deltoid is more considerable
than in preceding case.
  Third  Dislocation.—Backward on dorsum scapula, beneath the  spine,
where the head of the bone is readily felt and  follows the movement of the
elbow when rotated.
  Fourth Dislocation.—Is partial; the bone is thrown forward against the
coracoid process;  the symptoms are projection of the acromion and a hollow
under it, while the head of the bone is prominent in front and may be felt to
move on rotating the elbow.   If the hand of the injured  side  is placed upon
       I
 
122                            SURGERY.

the sound  shoulder, the patient will be unable  to  bring  his  elbow to his
side, and if the elbow is brought to the side his hand cannot remain  on the
shoulder.
  Treatment.—There are many methods of reducing dislocation of the shoul-
der:  I. Simple extension.—A towel is passed around the chest, under the arm
and crossed above the shoulder, so as to firmly fix the scapula ;  another towel
is fastened around the arm above the  elbow; extension  is then made with the
latter, the patient sitting.
                                                  Fig. 30.
REDUCTION OF DISLOCATION OF THE HUMERUS.
  When extension is made  for a few minutes, gently roll, shake and lift the
head of the bone with the knee.
  2. Heel in the Axilla.—Professor Brinton prefers  the  following method:
Place a  soft pad in the axilla, then make  pressure with the heel  partially
against the pad, and  partially against the wall of the chest, pushing the  head
of the bone upward and outward, and at the same time pulling the limb down-
ward, and a little forward, by means of a towel secured around the  arm above
the elbow.
  3. Knee in the Axilla.—The patient is seated  in a chair, and the surgeon
places one knee in the axilla, resting his foot on the chair.  He then puts his 
                             DISLOCATIONS.                          123

hand on the shoulder, to fix the scapula, and with the other depresses the elbow
over his knee.
  4. Reduction by the Perpendicular Method.—Place the patient in a low
chair, or on a couch, and raise the arm perpendicularly by the side of the head,
at the same time fixing the acromion, and making gentle traction upward.   If
little force is required the arm can be taken  in one hand, and the acromion
can be steadied with the other.   Should more  force be necessary an assistant

                                 Fig. 31.
PERPENDICULAR  REDUCTION.
may steady the  shoulder and the surgeon use his  foot, as exemplified in the
preceding figure.  When the bone is felt to slip into its place the arm must be
brought down to the side, while the head of the  bone is held outward by the
hand in the axilla.
  The extension used in any dislocation forward must be made in a direction
downward  and  backward.  For  dislocation  backward the extension must be
made  forward. 
124                             SURGERY.
  After reduction a small pad should be placed in the axilla, and the arm and
shoulder supported for some days with a sling, and a roller to confine the arm
to the trunk.

                   DISLOCATIONS  OF THE ELBOW.
  The elbow may be dislocated in five directions.
  First.   Both bones  backward, strongly marked by alterations in the form of
the joint and loss of motion; there is  considerable projection formed posteri-
orly by the ulna  and radius; on each  side of the olecranon there is a hollow;
the hand and forearm  are in a state of  supination and  cannot be turned prone.
  Second.  Lateral dislocation of both bones of the forearm; ulna thrown on
either the external or internal condyle.   There is great distortion and increased
width of the  joint; the forearm is flexed and pronated.   In  dislocation out-
ward the radius forms  a prominent swelling, and in dislocation inward there is
marked and elongated projection on the inner side of the joint.

                                 Fig. 32.
DISLOCATION OF THE ULNA BACKWARD.
   Third.   The third dislocation is ulna backward.   The deformity is  very
great; the  forearm  and arm  are twisted inward, and the olecranon projects
considerably.  The forearm cannot be extended, nor bent to more than a right
angle.
  Fourth.   The radius thrown forward into the hollow above the external con-
dyle of the humerus.  The forearm in this dislocation is slightly bent, but cannot
be brought to a right angle.  The hand is between pronation and supination.
  Fifth.  Radius backward.   Very rare and seldom seen.
  Treatment.—The  first, second  and third  dislocations may be reduced  by
seating the patient on a chair; then take hold of his wrist; put your knee  on
the inner side of the elbow joint; bend the forearm, and at the same time make
pressure upon the dislocated bones, so as to separate  the  coronoid process of
the ulna from the posterior fossa of the humerus.  While the pressure is  kept 
DISLOCATIONS.                           125
up by the knee, the arm is forcibly and gradually bent, and the bones will slip
into their places.
  In the fourth dislocation the hand should be turned supine, the forearm should
be bent, and extension made from the hand, without including the ulna.


                     DISLOCATIONS OF THE WRIST
Are of three kinds, viz.: both bones;  radius forward; and the ulna backward.
They are readily distinguished  by the altered position of the hand, which is
thrown either backward or forward, or twisted on its axis.
  They are reduced by simple extension.


            DISLOCATIONS  OF THE FINGERS AND TOES.
  These are accidents of rare  occurrence.  When dislocations of the fingers
take place they are generally found  between  the first and second phalanges.
The diagnosis is easy when the dislocation occurs at this  place;  there is a pro-

                                 Fig. 33.
    REDUCTION OF DISLOCATION OF INDEX FINGER, AND APPARATUS FOR THE SAME.

jection of the first phalanx  backward, while the head of the second phalanx
can be felt on the fore part,  though less distinctly.
  If the dislocation has occurred within a few hours of the surgeon's seeing it,
as a rule, it can  be readily reduced; but if it has been neglected, the reduction
can only be accomplished by long-continued and steady extension.
  After reduction, the finger should be  rolled with tape, surrounded and  sup-
ported with pasteboard;  the hand and forearm should be kept in  a sling.
  It is more difficult to reduce dislocations of the toes than the fingers. 
126
SURGERY.
                   DISLOCATIONS OF THE THUMB.
  In dislocation of the  first phalanx of the thumb, it will  be found thrown
back upon the metacarpal bone, where it forms a projection; the lower part of
the metacarpal bone projects inward; the thumb is shortened and  can neither
be bent nor extended; the last phalanx is usually flexed.
  Extension and counter-extension are the usual  means employed to reduce
this dislocation.  Extension may be made by means of the clove hitch, secured
over a wet cloth, and counter-extension with a strong cloth;  the  fold resting
on the palm of the hand, and the ends crossed behind the wrist and  brought
around to the front of the forearm,  and held by an  assistant.   Should more
powerful  extension be required, it may be  obtained  by means of Charriere's
forceps or Levis's apparatus.  The method of Professor Crosby, which consists
in pushing the phalanx back, until it stands perpendicularly on the metacarpal
bone, frequently succeeds where other modes fail.
Fig. 34.
                 DISLOCATIONS  OF  THE HIP JOINT.
  There are  four dislocations of the thigh bone; viz., upward on the dorsum
                                of the ilium; downward into the thyroid
                                foramen; backward and upward into the
                                ischiatic notch;  and forward and upward
                                on the body of the pubis.
                                  First.  Upward,  on  the  dorsum of the
                                ilium, happens  more frequently  than any
                                other dislocation of the  hip joint.
                                  The characteristic symptoms are, a differ-
                                ence in the length of the limb, a change of
                                position inward, a  diminution of motion,
                                and flattening.  The toes  rest upon  the
                                tarsus of the opposite foot; the knee and
                                foot are turned inward; the knee slightly
                                advanced on the other; the limb an inch
                                and a half to two inches and a half shorter
                                than  the  other,  and the legs cannot  be
                                separated.
                                  Second.  Dislocation downward, into the
                                thyroid foramen.  The dislocated limb is
                                In thin  persons the  head of the thigh bone
can be felt on pressure.  There  is flattening of the hip, and the body is bent
forward. The toes point to the ground; the foot is turned outward ox inward.
 DISLOCATION ON THE DORSUM OF THE
             ILIUM.

two inches longer than the other. 
DISLOCATIONS.
127
   Third.  Backward, into the sciatic notch.  The head of the bone is placed
on  the  pyriformis  muscle.
The limb  is  from  half an                     Fig. 35.
inch to an  inch shorter than
the other; the toe rests on
the ball of the great toe on
the opposite foot.  The knee
and foot are turned inward;
the toe,  but  not  the  heel,
touches  the   ground  when
standing.   Very little flexion
and rotation can be made.
  Fourth.  Dislocation on the
pubes.  The  limb  is shorter
than the other; the knee and
foot are turned outward, and
cannot be rotated  inward;
the head of the thigh  bones     dislocation backward into sciatic notch.
is readily felt on the  pubes.
  Treatment.—These dislocations may be reduced  by  manipulation  or by
force;  the  former is the plan most in vogue.
   1. Dislocation Upward.—The manoeuvre by which a dislocated hip can be
reduced  consists  in  employing the length of the limb as a lever, and  the
trochanter as a fulcrum, by which the head may be got into such a position as
to slip into its socket.  The knee  must be bent on the thigh, and  the thigh on
the pelvis; the surgeon then grasping the ankle with one hand and the knee
with the  other, causes the thigh to perform a circumduction movement toward
abduction, finishing  with a rotatory movement of the femoral  axis, when the
head of the bone will probably slip into its place.
  Professor Bigelow  recommends that the  thigh  be  first flexed  with a little
inward rotation, producing inversion of the toes, and then the thigh should be
abducted,  circumducted, and  at the same  time rotated outward.   This  has
been described in the directions, " lift up, bend out, roll out."
  2. Dislocation Downward.—Rotation inward of the  flexed and slightly
abducted thigh upon  the fulcrum of  the Y-shaped ligament.
  3. Dislocation Backward.—Bigelow reduces this dislocation by circum-
duction of the flexed thigh inward, so as to unlock the head of the femur,  and
then abducts  and everts the limb with  an  upward jerk.
  4. Dislocation on the Pubes.—Flexion combined with abduction maybe
tried;  if the  pulleys are used the patient is  to be  laid on  the  sound side;
 
128
SURGERY.
extension should be made in a direction backward and outward, and counter-
extension in front of the patient; after it has been continued a little time, the
head of the bone should be lifted over the  edge of the acetabulum, by means
of the napkin.
  In these  dislocations, if the method by manipulation fails, recourse must be

                 Fig. 36.                            Fig. 37.
   dislocation upward, on the dorsum     dislocation downward, into the
             OF the ilium.                      thyroid foramen.

had to force, which is usually effected by employing extension and counter-
extension by means of traction, through  the  medium of pulleys, etc.   For a
full account of these different modes of applying the necessary counter-extend-
ing bands, etc., the student is referred to the larger works on Surgery.
 
DISLOCATIONS.
129
Fig. 38.
Fig. 39.
dislocation backward, into the
        sciatic notch.
dislocation on the pubes.
Fig. 40.
Fig. 41.
manipulations for reduction of dislocation of hip. 
130
SURGERY.
                     DISLOCATIONS OF PATELLA.
  The patella may be dislocated outward, upward or inward.
  It is most frequently thrown on the external condyle, and there  produces a
great projection; the dislocation on the inner condyle  is less frequent;  in
dislocation of the patella upward, the ligamentum patella is torn through and
the patella is drawn up.
  Treatment.—In the reduction of the two first dislocations, the  patient is to
be placed in the recumbent position, the leg raised by lifting it at the heel,
and then press on the edge of the bone that is furthest from  the  articulation.
Evaporating lotions are to be employed when the  reduction is accomplished,
and a bandage should be worn for a few days.
  In dislocation of the patella upward, the bone is to be kept in contact with
the ruptured ligament, and  inflammation  must be  prevented by appropriate
remedies, and then treated like a fracture of the patella.


                    DISLOCATIONS  OF THE KNEE.
  There are four dislocations of the knee :—
  First dislocation is inward; the tibia projects on  the inner side of the joint,
and the condyle of the femur rests on the external semilunar cartilage.
  The second dislocation is where the tibia is thrown on the outer side of the
joint; the condyle of the femur being  placed on the inner semilunar cartilage.
  In the third dislocation the tibia is dislocated forward.
  The fourth dislocation is when the tibia is dislocated backward.
  The  symptoms in these  cases  are  obvious, and  the  injuries are  easily
recognized.
   Reduction.—Each of  these dislocations may be reduced  by simple exten-
sion.   There is a great tendency to inflammation in these injuries, for which
proper antiphlogistic remedies must be used;  perfect rest  must be enjoined;
iced water, or  lead water and  laudanum, and  such like  measures must  be
resorted to; leeches applied, if necessary.


                DISLOCATIONS  OF  THE ANKLE JOINT.
   The  usual dislocations  at this joint  are inward, outward and forward, but
there may be a  backward  dislocation.
   The  dislocation inward  is the most frequent; the foot is  thrown outward
and its  inner edge  rests upon  the  ground;  the   internal malleolus projects
against the integuments.  The foot rotates easily.
   The dislocation outward is the most dangerous;  the foot is thrown  inward. 
DISLOCATIONS.
131
Fig. 42.
Fig. 43.
dislocation inward.
dislocation outward.
Fig. 44.
Fig. 45.
dislocation forward.
dislocation backward. 
132
SURGERY.
The malleolus  projects very much.  The toes and foot are pointed downward.
This dislocation is accompanied by fracture of the internal malleolus.
  In  dislocation forward, the foot  appears shortened and  fixed, and the toes
are  pointed to the ground;  the  lower  end of the  tibia  forms a hard swelling
on the middle tarsus; the heel appears lengthened.
  Treatment.—To reduce the dislocation inward, place the patient on  a
mattress, bend  the  leg at right  angles  to the thigh, let an  assistant grasp the

                                  Fig. 46.
reduction of dislocated ankle joint.
foot and  gradually draw it in a  line with the leg.  At  the  same time, fix the
thigh and press the tibia downward.  After reduction, support the foot with a
many-tailed bandage, keep parts cool, etc.
  For  dislocation  outward, reduce  the  dislocation as above directed, then lay
the limb on the outer side, resting it in splints with foot-pieces.
  In dislocation forward, the  treatment must be followed by rest.  In  five
weeks the patient may be allowed to get up and use passive motion. 
FRACTURES.
133
                            FRACTURES.
   A Fracture is the division of a bone into one or more pieces, from violence.
   A fracture  is simple when there is no wound communicating with it; com-
pound when  there is such a wound; transverse when the line of fracture lies
across  the bone; oblique "when it slopes; longitudinal when it is  more or less
parallel to the long axis; comminuted when  broken  in  several fragments;
complicated when there is laceration of an artery or joint, or other additional
injury.  A "green  stick," or "willow" fracture, is  an  incomplete fracture, in
which  some  of the bony fibres have given  way and the  rest have bent, but
have not broken.  It is a fracture of the young.  An impacted fracture is one
in which one fragment is driven into and fixed in the other.
   When occurring in  the neighborhood of a joint, the terms inira-capsular
and extra-capsular are used, as the line of fracture is  internal or external to
the capsular ligament.
   If the same bone is broken at two different places, or more than one bone is
broken in  the same limb, it is called a multiple fracture.  If cracked only,
without displacement or separation of periosteum, it  is called a fissure.
   The circumstances that render bones more liable than usual to be broken are
atrophy arising from  old age, or  from prolonged  disease of a limb;  certain
diseases, as fatty degeneration, rickets,  mollifies ossium, syphilis  and cancer;
original conformation; the bones  of some people  being more delicate  than
others.

                      EPIPHYSEAL SEPARATION.
Is met with in infants  and young persons,  before ossification is completed.  It
most frequently occurs at the extremities  of the humerus, radius, femur  and
tibia.  The ossifying end of the long bone, with the layer of connecting carti-
lage, is detached.  There is great danger of suppuration;  the periosteum being
stripped from the shaft of the bone.   The displacement is sometimes very great
and reduction is difficult;  it is frequently followed by diminished growth, short-
ening,  deformity and  impairment  of  movement.   It is not unfrequently  met
with in infants who are the subjects of hereditary syphilis, or those who are
suffering from acute rickets or infantile scurvy.
   The  most  common  cause of this affection is  a wrench of the part, violent
traction, or a severe fall.
   The symptoms are those of fracture.   In the  young subject its existence may
be suspected when the  ends of  the  fragments are transverse, or nearly so;
when  the lower  fragment retains  its position,  while the upper moves  about;
and when  the crepitation produced  by rubbing the ends of the fragments 
134                             SURGERY.

together  is of an  unusually dull, rough, grating character.  In young persons
union takes place promptly.


                         SIGNS OF FRACTURE.
  Signs of fracture  are Deformity,  Mobility, Crepitus, Loss of Function,
Pain, Discoloration, and Disordered Sensibility.
  I. Deformity may exist in length,  rotation, and angularity;  Shortening is
produced by muscular action, and is the most common form of displacement;
it may be so slight as to require careful measurement for its detection.  Rotation
is usually external, and is caused by the weight of the limb.  Angularity is
the  worst form of deformity:  the principal indication  for treatment is to over-
come deformity.
  2. Mobility in  an abnormal  position is a frequent sign of fracture.   Care
must be taken not to confound the mobility of a fracture with the normal action
of a joint.
  3. Crepitus is the most decisive sign of fracture; in a broken bone it is a
rude and rough sound, which can be both felt and heard.   Do not mistake the
Crepitus arising  from a fractured bone, and that produced by a roughened
cartilage, or the  inflamed  theca  of a  tendon.  Crepitus cannot be obtained in
impacted fractures, nor after the formation of callus,- or the rounding of the
ends of a bone.
  4. Loss of function is an important, but by no means an infallible sign.
  5. Pain  is always present  to  a greater or less degree;  it is severe, concen-
trated, and  localized.
  6. Discoloration is of two kinds:  immediate and secondary.   The  first
is the  result of  injury to  the subcutaneous veins, and frequently involves the
entire limb; the  second appears several days after the injury, and proceeds from
the blood-vessels that surround the fractured bone;  it is an important sign of
fracture.
  7. Disordered  sensibility frequently exists;  there may be tingling in the
parts from pressure on nerves.


                        REPAIR OF FRACTURE.
  The first result of a fracture  is an  effusion of blood between and  around
the  broken ends; then follows a period of exudation, in which plastic lymph
and  leucocytes  are  effused;  after this the lymph  is  developed  first  into
fibroid tissue, interspersed  with  osteoid or cartilage cells,  and then into bone. 
FRACTURES.                            135
 The periosteum, medullary membrane  and surfaces of the broken bone are the
 principal agents in the production of the bone-forming cells.  The time required
 for the completion of the union of broken  bone varies from four to ten weeks;
 being less in the young and healthy.  The  last stage in the process of repair is
 the  absorption  of  superfluous bone, and the  restoration  of the  cancelli and
 medullary cavities.  This is completed in from six to twelve months.
   The material by which fractures are  first united is  called callus.
   The neck of  the  thigh bone, the  olecranon, the acromion, coracoid and
 coronoid processes, the tuberosity of the os calcis and  the patella do not, as a
 rule, unite by bone.   The reasons given for this are, 1st, the great difficulty in
 keeping these broken surfaces in contact;  2d, in bones  that enter  into the for-
 mation of joints, contact is prevented by the displacement and separation caused
 by the abundant effusion of synovial fluid into the joint and between the broken
 surfaces of bone.
   If considerable portions of the skull be removed, the gap is not entirely filled
 up.

                GENERAL TREATMENT OF FRACTURES.
   The sooner reduction is accomplished the better;  there is then less swelling
 and  sensibility,  the muscles  have not  had time to  become irritated, and the
 diagnosis is more plain.  Should swelling have taken place  before the  patient
 has  been seen by the surgeon, place the part in a  comfortable position, and
 let it so remain until  the swelling has subsided.
   To get the fragments in position employ extension, counter-extension and
 coaptation.  Apply extension to the distal extremity by steady, continual trac-
 tion.   Counter-extension is the force employed to counteract the extending force.
 Do not grasp the part immediately beyond the seat of fracture, otherwise mus-
 cular resistance will take place.  Coaptation is the pressing of the ends of bones
 into  position.
   To keep the parts  in position it is often necessary to keep up extension and
 counter-extension after adjustment.   The different articles used for dressings
 are:  Thin Board (^ inch) of pine or poplar; Binder's  Board, which  gives
 sufficient support and can be readily moulded by soaking in hot water;  flannel
 saturated with glue and  plaster;  unoiled leather; sheet rubber, tin, or  copper.
   The Plaster Dressing consists of crinoline bandages,  rolled up loosely in
plaster; placed  in water until thoroughly wet  and then squeezed dry  as pos-
sible.  Protect the  limb with plenty of cotton and  then  apply the bandage.
  A  fracture should be disturbed as little as possible, but it should be thoroughly
examined on the second and  third day.  When the swelling has subsided the
bandages should be tightened; after which the patient should be seen daily. 
136
SURGERY.
                        UNUNITED FRACTURES.
  These may result from constitutional or local causes;  the constitutional causes
are many, such as typhoid fever, delirium tremens, scurvy, pregnancy, lac-
tation and shock, which  is a very frequent constitutional  cause.   The local
causes are too much handling, or otherwise disturbing the  fragments;  too
light or too loose dressing; interposition of a foreign body between the frag-
ments;  necrosis.
  The  treatment of an ununited fracture consists in creating irritation
about the fragments, so as to invite blood to the part and encourage the forma-
tion of a new deposit of callus.
  There are a variety of methods recommended: 1st, By rubbing the fragments
together and  then  treating the limb as in primary fracture.   2d, Brainerd's
method, which is the subcutaneous introduction of an  awl-shaped drill, perfor-
ating the bone from one fragment to the other; several perforations of the bone
are to be made, but only one external opening.  3d, The introduction of acu-
puncture needles, and the passage of an electric current through them.  4th,
Drilling the fragments together with a gimlet, and allowing it to remain in  the
bone from one to four weeks.   5th, Excision of the ends of  the bone.  6th,
Applying a plaster dressing, or  Smith's splint, and putting  the patient on his
feet with crutches, when attrition takes place, and irritation is effected.
  The simplest method should be first tried.
            FRACTURES OF THE  UPPER JAW.
  The superior maxilla is seldom broken, unless great and direct violence has
been employed;  its fracture is generally accompanied by external wound, as in
gunshot injuries or a kick from a horse.  The fracture is  often comminuted
and  is sometimes attended with concussion of the brain, or with  fracture  of
other bones of the  face; it is often produced by force transmitted from the
malar bone, the latter remaining sound.
  The superior maxilla possesses extraordinary reparative powers.
  Treatment.—Preserve and replace all fragments and splinters, the tendency
to heal being very great.
  The patient must avoid chewing any hard substances until the detached frag-
ment has become  attached to the bone.  When the alveolar process is broken
into  two or more fragments, the  pieces  must be pressed into  place and the
jaws closed, so that the lower jaw may serve as a support.  To maintain appo-
sition apply a Barton  or Gibson bandage.  It may be  necessary to apply fine 
                              FRACTURES.     .                     137

wire to the teeth, if displacement continues;  or an interdental splint com-
posed of gutta-percha may be used.  Loosened  teeth must be pressed into
their places.
  Should the nasal process be broken, a director should be applied through the
nose to elevate any depression that may exist.
        FRACTURE  OF THE ZYGOMATIC  ARCH.
  This accident is rare, and is  produced by direct violence;  usually occurring
on the temporal side of the suture.
  The signs of this fracture are an irregular projection or depression of the
fragments,  with  rapid  swelling of the parts.  The displacement will  occur
either outward or inward.
  There will be neither motion nor crepitus.
  Treatment.—Should there be no  displacement, apply an anodyne lotion,
and keep the parts quiet with a Gibson or Barton roller.
  If there be outward displacement, the fragments may be adjusted by pressure
on the projecting angle, afterwards applying a soothing lotion.  If the dis-
placement is occasioned by depression of the  malar bone, it will be adjusted by
restoration of that bone to its proper position, which requires extensive manipu-
lation.  The question of surgical interference must depend upon the urgency
of the symptoms.
           FRACTURES OF THE NASAL BONES.
  The nasal bones are, from their situation, much exposed to fracture.
  Signs.—Before swelling supervenes, the appearance of the nose will likely
be characteristic of the injury  ; there will be displacement and mobility of the
fragments,  with crepitation when  held lightly by the fingers.  Hemorrhage
from the nose  is apt to  be persistent  and more or less profuse; if the injury
extend to the lachrymal bone, there will be profuse discharge of tears.   Symp-
toms of concussion may accompany the fracture.
  Treatment.—If there be no displacement of the  bones, cold  applications
of lead water and laudanum or other soothing lotion  will be all that is neces-
sary.
  Should displacement  exist, the  bones  must be  adjusted by manipulation,
       J 
138                            SURGERY.

assisted by a ring-handled forceps, metallic sound, female catheter, or some other
such article, passed into the nostrils; using it  as a lever, the fragments are
pushed outward while the parts are manipulated with the left hand.
  Persistent hemorrhage must be controlled by plugging the nares anteriorly
and posteriorly.
  As a rule, the fractured bones  will retain  their situation without further
assistance;  if they do not, they may be supported  by  the introduction of
oiled lint.
  If the fracture be compound, loose  splinters detached from the periosteum
should be gently removed.
  Leeches, purgatives and cold lotions may be necessary to relieve swelling,
bleeding from the nose, ecchymosis and headache.
            FRACTURES  OF  THE LOWER  JAW.
  The lower jaw may be fractured at the symphyses; through the body to one
side of the symphysis; through  the angle; at the coronoid process; or at the
neck of the  condyle.
  The most common site  of fracture is the body of the maxilla, toward its
anterior extremity.
  The condyle, neck, and coronoid process are seldom broken.
  This injury is caused  by  direct blows; falls on the chin ; gunshot wounds;
kicks from a horse; or in extracting teeth.
  Sometimes these fractures are double.
  Symptoms.—Great mobility of the fragments, pain, swelling, crepitus, in-
ability to use or move the lower jaw; irregularity of the teeth and of the line
of the jaw;  dribbling of the saliva; inability to speak;  laceration of the gums
and mucous  membrane, accompanied  with bleeding; the teeth loosened at the
point of fracture.  The crepitus is felt on moving the chin with the hand placed
on the posterior fragment.
  The displacement is greater when  the fracture is near the symphysis;  if on
one side only of the middle line  the smaller fragment is liable to  be drawn
outward and forward.  When the angle or ramus is the seat of fracture  there
is little or no deformity, but crepitus is perceptible  to the patient.  When the
neck of the  condyle is broken, there is marked  displacement upward, inward
and forward by the action of the  pterygoid, the chin being turned toward the
affected side; in dislocation it is turned away from  it.
  Treatment.—It maybe necessary to wire the  teeth together, in  order to 
                              FRACTURES.                           139

retain the fragments in proper position.  A piece of pasteboard or gutta-percha,
cut into proper shape, and softened in boiling  water, must be accurately fitted
to the jaw.   Then a four-tailed bandage must be applied, or a Barton or Gibson
bandage, at the option of the surgeon.
gibson's bandage.                   barton's bandage.
  During the  cure-the  patient must be kept quiet and fed upon spoon diet,
which  should  be  continued until  the  bone is firmly united.   Broths, soups,
jellies,  tea, milk, etc., are the most eligible.



              FRACTURES OF  THE  CLAVICLE.
  A Fracture of  the Clavicle is usually caused by indirect violence, such as
falls on the arm or shoulder;  it is generally oblique  in direction;  it may be
caused by direct violence, when it  is commonly seated near  the  acromial ex-
tremity.
  Symptoms.—The  shoulder sinks  dazvnward, forwardand inward;  the
distance from the acromion to  the sternum is less on  the injured  than  on  the
sound  side.   In consequence  of the sinking of the  shoulder and the outer
fragment, the sternal portion of the bone projects over the fractured extremity,
and it  may be distinctly felt by tracing the usual  course of  the clavicle with
the finger. 
140
SURGERY.
  Treatment.—A  fractured clavicle is
easily reduced, but the difficulty is to re-
tain the broken ends in exact apposition.
  The arms and shoulders of the patient
are to be firmly  drawn backward  by an
assistant, when the  fractured  extremities
come in apposition; the shoulders must
be raised and supported in  a  direction
upward, backward and outward.   The
parts are to be then covered with adhesive
plaster, and a bandage is to be applied, to
retain them in their reduced apposition.
   Sayre's dressing  and the apparatuses
of Drs. Fox, Levis and Boyer, and the
Velpeau bandage  and that of Desault,
are those most in vogue.
              FRACTURES  OF  THE  STERNUM.
  This bone is rarely fractured; but a single case was admitted into the Hotel
Dieu in eleven years, and  out  of  1901  fractures received into the Middlesex
Hospital, but two were fractures of the sternum.
  The ordinary causes of fractures of the sternum  are  blows, kicks and falls.
A fracture of this bone  is rendered  evident  by the inequalities perceptible
when the surface  is examined  by the fingers.  It is also  characterized by a
depression or elevation of the broken pieces; crepitus and unusual  mobility of
the injured  part  in respiration.  The breathing is difficult, and frequently  ac-
companied with  cough,  spitting of blood, and inability to lie on the back.
Discoloration and swelling soon follow  the accident.
  Treatment.—The application of compresses and  an immovable bandage,
to afford support to the chest and quietude to the intercostal muscles, are  the
indications.
  In cases attended with great  depression of the fractured bone, it may become
necessary to elevate it.


                  FRACTURES OF THE RIBS
Are generally caused by direct violence, and are usually  situated in the anterior
half;  they may, however, be caused by indirect violence, as when the chest is
forcibly compressed.
Fig. 49.
DESAULT S BANDAGE. 
FRACTURES.
141
  Symptoms.—Fixed lancinating pain, increased by inspiration, coughing and
other motion.  Crepitation, which will be present, may be ascertained either by
placing the hand over the seat of injury, and directing the patient to attempt a
full inspiration or a prolonged expiration, or by auscultation.
  When the lung is wounded, there will be emphysema over the exterior of the
chest, which will be detected by the peculiar crackling which is heard when
the  skin is  pressed upon.   If the wound be  deep, there will be haemoptysis.
In stout persons, or where the fracture is near the spine, it may be  difficult of
detection.
  Treatment.—The indications are :   1st. Diminish motion of the ribs, and
give support to the part, the respiration being  performed by the diaphragm.
The best is the adhesive plaster dressing, applied in strips from two  to two and
a half inches wide, extending over the affected side  from  the  spine to the
middle of the sternum; they should support the fracture and cover two or three
ribs above or below the seat of injury.  Or a broad flannel roller may be used,
or the plaster splint.
  The arms should be confined to the side, to prevent motion of the scapula.
  2d. To prevent inflammation of the chest, keep respiration easy, and relieve
pain by rest in bed, purgatives and opiates, if  necessary.
               FRACTURES  OF  THE SCAPULA.
   The  Scapula is so much covered with muscle, and its connections with the
 trunk allow so much yielding on the application of external force, that fractures
 of this  bone are extremely uncommon.   The  injury may occur to its body, its
 inferior angle, its neck, to the  acromion process, or the coracoid process.   In
 fracture of the body of the bone the shoulder will be depressed and forced for-
 ward, and there will be marked irregularity between the ends of the fragments.
 Fracture of the inferior angle is marked by preternatural mobility, by displace-
 ment of the smaller fragment, and by acute  pain  at the seat of injury.   In
fracture of the neck,  the acromion is  unusually prominent, the head of the
 humerus is felt in the axilla, the shoulder  is flattened, the  limb  is lengthened,
 the coracoid process is found below the clavicle, severe pain  and numbness are
 experienced in  the axilla, and distinct crepitation is perceived on rotating the
 arm upon the  scapula.  In fractures of the acromion and of the coracoid, the
 symptoms are  somewhat similar to  those presented by the fracture of the neck.
   Treatment.—When the  body  is broken,  a broad  roller must be  passed
 round the trunk, over a large, flat pad placed over the scapula, and a few turns
 made around the arm, so as  to fix it to the side and  prevent motion.  Rest and 
142
SURGERY.
quietude are required.  Or a broad strip of adhesive plaster should be applied
across  the  scapula, extending from the spine to the sternum, care being taken
to press it well down along the anterior and posterior borders of the bone before
the portions in front and behind the chest have been attached.   Then place the
arm in a Fox apparatus, and  allow it to hang vertically along the side of the
body, at the same time lifting the elbow by securing the straps to the ring on
the opposite shoulder.
   In fracture of the neck the shoulder must be supported by the  sling and
bandage that are used for fracture of the clavicle, but the pad should not be so
thick, nor so large, and in addition a short sling should be used, going from the
axillary pad on the injured side to the opposite shoulder.  Opium, rest, leeches
and purgatives may be necessary, for the contusion with which this fracture is
accompanied.  At the end of four weeks passive motion  must be made, to
establish the functions of the joint.
   In fracture of the acromion the bandages are to be so applied as to raise the
elbow thoroughly, so that the head of the humerus may be lifted up against the
acromion and keep its place.  A pad must not be placed in the  axilla, otherwise
the broken  part will be pushed too much outward.
   When the coracoid process is fractured, the  humerus must be brought for-
ward and inward, so as to relax the coraco-brachialis, and must be confined to
the trunk, with the forearm bent on the chest.
             FRACTURES  OF  THE  HUMERUS.
  The Humerus may be fractured at any point.


               FRACTURE OF THE ANATOMICAL NECK.
  Fracture through the anatomical neck  is rare; it may be impacted or non-
impacted.
  In the impacted form the upper fragment is driven into the cancellous tissue
of the lower portion.
  Symptoms.—The axis of the humerus is altered, being directed toward the
coracoid process; the elbow is slightly separated from the side;  the  arm is
shortened; the  shoulder  flattened;  the acromion  is more prominent than
usual;  the head of  the humerus can be felt in the glenoid cavity; there is no
crepitus.
  In the non-impacted form there is less deformity;  there is a slight projection
on the inner aspect; there is crepitus on rotation.
  Treatment.—In the impacted fracture  keep the part at rest by bandaging 
FRACTURES.
143
the arm to the side and supporting the elbow in a sling.   In the non-impacted
fracture it will be necessary to fix a small pad in the axilla and adjust a felt cap
to the shoulder, so as to keep the parts in apposition and completely at rest.


                 FRACTURE OF THE SURGICAL NECK.
   Care must  be taken not to confound this fracture with luxation of the bone
downward and inward; in fracture of the neck the shoulder retains its natural
form ; the acromion does not project and the depression is below the point of
the shoulder;  in dislocation there is a deep depression below the projection of
the acromion, in the natural situation of the head of the humerus.
   Symptoms.—The lower fragment forms a distinct prominence beneath the
coracoid process,  especially when the elbow is raised; the head of the bone
can be  felt in the glenoid cavity; there is a
slight depression  just below the end of the
fragment; the axis of the limb  is  altered,
being directed  upward and inward  toward
the coracoid  process;  there is crepitus on
extending and rotating the limb; the arm is
shortened and unnaturally mobile; pain shoot-
ing down the arm is often present.
   Treatment.—To support the  weight  of
the limb, and keep it firmly fixed to the side,
are the  most effectual means of maintaining
apposition;  for this purpose, a thin pad, a
compress or a folded towel, should be placed
in the axilla,  which must be held in its place
by a bandage or by adhesive strips; the arm
is then brought to the side, the  elbow some-
what  forward.  The arm must then be se-
                           .   .             FRACTURE OF NECK OF HUMERUS.
curely fastened to the chest with circular turns
of the roller, and  the forearm placed in a sling.


                      FRACTURE  OF THE  SHAFT.
   The existence  of this  fracture is  easily ascertained; the head of the bone
being grasped with one hand and the elbow with  the other, upon  rotating the
arm, no motion will be communicated from the  lower to the upper portion,
and crepitus will be distinguishable.
   Treatment.—Use a well-padded internal  angular splint, a cap of felt ad-
 
144
SURGERY.
justed to the shoulder  and extending down to within two inches of the  elbow
joint, to be secured by a well-fitted roller; the forearm placed in a sling.  Pro-
fessor Brinton does not advocate the bandaging of the forearm and arm  before
applying the splint; other authorities do.


                   FRACTURE OF THE CONDYLES.
  When the condyles are  obliquely broken  off, just above the joint, the ap-
pearances are those of a dislocation of the radius and ulna backward;  but in
the case of fracture, the displacement recurs when  the  extension is remitted,
and crepitus  is generally perceptible when  the forearm  is rotated  upon the
humerus.
  Treatment.—The  indications in these cases are to bend  the arm, draw  it
forward so as to reduce the  parts, and then apply a  roller.
  The best splint to be applied is an L-shaped anterior splint; that known as
Hewson's is recommended.
  Dr. Oscar H. Allis  recommends, in fracture of the inner  condyle, that the
limb be extended  and placed in  an easy, natural position, and then to apply
strips of adhesive plaster about an inch wide and long enough to extend from
near the shoulder to  near the wrist, so as to cover the  surface of the limb.
Over this apply a  second layer, thus having two layers of longitudinal adhesive
strips about the joint.  In some cases he has applied a layer of cotton batting,
and over  this a bandage.  The  most beneficial results are claimed for this
method of treatment.
  In adults it is sometimes  necessary to resort to a firmer  dressing;  when this
is the case, instead of  using adhesive plaster, surround  the joint with a thick
layer of cotton and apply an egg-paste dressing.
  With this mode of treatment passive motion should not be employed  before
the expiration of the seventh or eighth week.
              FRACTURES  OF  THE FOREARM.

                  FRACTURE OF THE OLECRANON.
  Symptoms.—There is loss of full power to extend the arm; the olecranon
process will be above the line that connects the two condyles; the fragment is
drawn upward by the triceps; a hollow is felt at the back of the joint.   The
upper fragment is not affected  by flexion.
  Treatment.—Extend  the  arm, and with the fingers  bring the fragment
down.  Apply adhesive strips in the form of a figure 8 around the elbow, and 
FRACTURES.
145
a roller extending to the shoulder.   Then apply an anterior splint of a slightly
obtuse angle, padding it thickly opposite  the joint;  secure the splint by broad
straps of adhesive plaster and a bandage.  Retain the dressing  for six weeks.
Passive motion must be very slight, and not commenced  until between  the
fourteenth and twenty-first day.


              FRACTURE OF THE CORONOID PROCESS.
  This fracture is very rare.
  Symptoms.—Difficulty of bending elbow and dislocation  of the ulna;  the
olecranon projecting backward.
  Treatment.—The arm must be bandaged and  kept at rest in the bent posi-
tion.   Union ligamentous.


      FRACTURE  OF THE SHAFTS OF THE RADIUS AND ULNA.
  These bones may be both broken together, or they may be  fractured singly.
Easily recognized by the ordinary signs of  fracture, especially crepitus, felt on
fixing the upper end and rotating or moving the other.

                                 Fig. 51-
FRACTURE OF THE RADIUS AND ULNA.
  Treatment.—The indications are to  prevent  the  fractured end of either
bone from being pressed inward toward the interosseous space, and to,prevent
the upper fragment of the radius from being more supinated than the lower.
  The elbow must be bent, and the forearm placed in a position intermediate
between  pronation  and supination,  the thumb pointing  upward;  one splint
should be applied to the flexor side, from the inner condyle of  the humerus to 
146
SURGERY.
the tips of the fingers, and another from the outer condyle to the back of the
wrist.  Both splints must be wide and well padded along the middle, so as to
prevent the bones from being pressed together by the bandage.
     FRACTURES OF THE" NECK  OF  THE RADIUS.
  This is exceedingly rare when uncomplicated with any other fracture.
  Mobility and crepitus will be perceptible, with flexion of the forearm, with
loss of pronation and supination.
  Treatment.—The forearm must be flexed upon the arm;  a compress
applied over the lower fragment, at the seat of injury; an anterior angular
splint adjusted to the part, and over this a roller bandage.  The arm  must be
kept in a sling.


    FRACTURE  OF THE LOWER  EXTREMITY  OF THE RADIUS.
  This fracture is from half an inch to an inch above the wrist, and transverse
in its direction, is generally known  as  Colles' fracture; when  the fracture  is
very oblique, extending from the articulation upward and backward, it is called
Barton's fracture,  from the name of  the surgeon who first accurately described
the injury.
                                 Fig. 52.
COLLES' FRACTURE.
  Treatment.—The  splints of Drs. Barton, Bond and Levis, are those most
commonly in use.   Apply extension to hand  and counter-extension to arm.
Barton's dressing consists of a long anterior and posterior splint, two wedges,
a roller and a sling.  Place the arm between pronation and supination; make
traction',  place  the  anterior wedge with its base toward  the  fingers, and the
posterior  wedge with its apex toward the fingers; then put the arm in a sling.
  Bond's splint is a block  on a slightly pistol-shaped splint.  This splint
keeps the hand  in its natural position;  a little extended, with fingers flexed.
  Levis's splint is  made of copper; is applied to the anterior surface of the 
FRACTURES.
147
hand and arm, with the hand slightly flexed.   Passive  motion, commenced  as
soon as the swelling subsides, must be persistently employed.  Begin by moving
the fingers.  Carefully remove the splint;  move  each joint separately from the
ends of the fingers to the wrist, always holding the fragments steady;  also move
the elbow  and shoulder.   The dressings should be reapplied  the day following
the primary dressing; but need to be repeated  only every second day for the
first week.  Dressing must be retained for four or five weeks.
           FRACTURES  OF  THE CARPUS,  ETC.
  The bones of the carpus, when broken, are usually crushed by heavy bodies,
or broken  by  direct violence; they are generally  followed  by severe  and
troublesome symptoms.


             FRACTURES OF THE METACARPAL BONES,
Or of the phalanges, are readily recognized.
  For fractures of the carpus and middle metacarpal bones, it is a good plan
to make the patient grasp some soft substance and bind his  hand over it;  for
fractures  of the lateral  metacarpal bones, it is well to support the hand on a
well-padded splint.
  If necessary, apply cooling lotions.
                FRACTURES  OF  THE PELVIS.
  Fracture of the pelvis is usually the result of direct violence.  A heavy fall,
a cart-wheel  passing over the pelvis, a squeeze between  the buffers of two
railway cars,  and such similar  accidents.   It may,  of course, result from
gunshot wounds or from indirect violence, as when a person falls from a height
and alights on his feet.
  The  symptoms are inability to walk, though the  patient may be able to
move his  limbs in bed; mobility and crepitus, obtained by pressing on  both
crests of the ilium; pain on moving or coughing; displacement, which may be
recognized by external examination, per rectum, or per vaginam.
  Inability to empty the bladder, or voiding of bloody urine denotes some in-
jury of this organ.
  Fracture of the acetabulum is indicated by the crepitus elicited on rotat-
ing the femur with one hand placed  over the trochanter. 
148
SURGERY.
   Separation of the symphyses, or of the sacro-iliac articulation is recog-
 nized  by the  free mobility of the  part, and at the same time an interval may
 be felt in the situation of the  separation.   The pelvic viscera  are frequently
 injured in this fracture;  rupture of the bladder or urethra, giving rise to ex-
 travasation of urine, laceration of the rectum, or of  the larger blood vessels,
 may occur.
   Usually the rami of the pubes and ischium are the  seats of fracture; the line
 of fracture  may  pass  above the acetabulum in various directions, or it  may
 involve the acetabulum, Assuring  its floor, or fracturing its  margin.  The ace-
 tabulum  may be comminuted, and the head of the femur driven  into the pelvic
 cavity.   Any portion of these bones may be broken, including the crest of the
 ilium, or the tuberosity of the ischium, and  not unfrequently, both innominate
 bones.
*  Treatment.—Absolute rest of from  six weeks to  two months  is essential.
 The pelvis must be bound around with a broad roller, and the  patient laid to
 rest on aflat bed or mattress.  The thighs must be flexed upon the abdomen
 and supported with pillows under the knees.
   Fracture of the acetabulum must  be treated by means of a long splint, or hip
 splint of gutta-percha, moulded to the side of the pelvis and thigh, so as to fix
 the joint.  A  catheter, to ascertain  the  state of the bladder, should  be intro-
 duced.   If bloody urine, or other symptom of injury to this organ or  to  the
 urethra be present, the catheter must be kept in the bladder, to  prevent extra-
 vasation.
   If rupture of the bladder has occurred in the part uncovered by peritoneum,
 as the anterior wall or base  of the organ, the  urine will find its way into the
 connective tissue between the peritoneum  and abdominal wall, producing
 sloughing; it may burst into  the peritoneum and reach the subcutaneous con-
 nective tissue, or pass  through the pelvic foramen into the scrotum and thighs.
 An open wound of the bladder is not as dangerous as  a laceration.

   The symptoms of rupture of the bladder are collapse, violent burning pain
 in the hypogastric region; a constant and incessant desire to urinate, with in-
 ability to  pass any water.   A small quantity of blood may flow from the urethra.
 The patient  is unable to stand  or walk.   On passing the catheter the bladder
 will  be found  empty.   Urgent  tenesmus and peritonitis soon set in.   If  the
rupture is extra-peritoneal the  symptoms are those of extravasation of urine.
 There will be  a characteristically bounded swelling, with increasing  size  and
extent; the  scrotum and  penis becoming enormously distended;  a  sensation
of sudden relief of the distended  bladder is immediately followed  by  an acute
burning sensation in the peritoneum.   Gangrenous inflammation of the cellu-
lar texture soon  supervenes, the skin assumes a dusky red  hue,  purplish or 
FRACTURES.
149
black gangrenous spots appear.  Ultimately sloughing of the skin and cellular
texture of the scrotum exposes the testicles.
  The urethra  may burst  in front of the bulb, when the urine infiltrates the
corpus spongiosum, which is followed by gangrene.  The constitutional dis-
turbance is that of low typhoid depression; a rapid,  feeble pulse, dry, brown
or black tongue, and muttering delirium as death approaches.
  Treatment.—When the laceration is intra-periloneal laparotomy should be
performed, the  peritoneal cavity  carefully cleaned of blood and urine; the
rectum  must then be  distended with a rectal bag, and the  rupture carefully
stitched with silk sutures.   Lateral cystotomy is  then performed, to secure an
exit  for the urine.   If extra-peritoneal, and extravasation can be made out by
external examination, free incisions, both supra-pubic and  perineal, must be
made, followed by median  and lateral cystotomy.  The constitutional treat-
ment should be supporting and  opiates should be freely administered.
                 FRACTURES  OF  THE THIGH.

i. FRACTURE OF THE  NECK OF THE FEMUR WITHIN THE CAPSULE.
   It is rare in persons under  fifty, and generally occurs in old persons;  espe-
cially women.
   Symptoms.—After  a  fall or  blow, the patient  is unable  to stand;  great
pain, principally at upper and inner part of the  thigh, increased  by motion.
The leg is shorter, the foot turned outward, rarely inward;  the heel rests in
the interval between the ankle and tendo-Achillis; when the limb is drawn to
proper length and rotated,  crepitus may be detected.  When extension is dis-
continued, the limb  again shortens.  The limb may be freely moved by the
surgeon, but the patient cannot move it from the bed.
   Dr. Allis was the first to point out the fact that in all fractures situated above
the insertion of the tensor vagina femoris, but especially in those occurring
within the  capsular ligament, the  fascia lata is relaxed to such an extent as to
make its want of tension of strong diagnostic value.
   If the fibrous investment  of the neck be not torn, or if the  fracture be very
oblique, so that the upper opposes  the ascent of the lower fragment, there will
be little  or  no shortening.
   This  fracture  does not unite by bone, unless the broken surfaces  are held
close  together by the untorn  periosteum  or by impaction.   Generally it does
not unite at all.
   Treatment.—If the patient is old and feeble, he  should be kept in bed 
150                             SURGERY.

for a fortnight, till pain and tenderness abate, with a heavy sand bag on  each
side  of the limb, and a bag of shot  or sand attached to  the  foot or ankle,
which should  be allowed  to hang over the bed.  He may then be allowed to
sit in a high chair, and shortly begin the use of  crutches.
  Professor  Senn claims that by his method of "immediate  reduction  and
permanent  fixation,"  bony  union  is  obtained in fractures of the neck of
the femur within the capsule.  He " places the patient in  the  erect position,
causing him to stand with  his  sound leg upon a stool or box about two feet in

             Fig. S3-
FRACTURE OF NECK OF FEMUR.
height;  in this position  he is supported by a person on  each side until the
dressing has been applied and  the plaster is set.
  " Another person takes care of the fractured limb, which  is gently supported
and immovably held, in impacted fractures, until permanent fixation has been
secured by the dressing.  In non-impacted fractures the weight of the fractured
limb makes auto-extension, which is often quite sufficient to restore the normal
length of the limb; if this is not the case, the person who  has charge of the
Umb makes traction until all shortening has  been overcome as far as possible, 
FRACTURES.                            151
at the same  time  holding the limb in position, so  that the great toe is on a
straight line  with  the  inner  margin of the patella  and the anterior  superior
spinous process of the ilium.  In  applying  the plaster-of-Paris bandage over
the seat of fracture a fenestrum corresponding in size to the dimensions of the
compress with which the  lateral  pressure is  to  be made, is left open  over the
great  trochanter.
  " To secure perfect immobility at the seat of fractures, it is not only necessary
to include in  the dressing the fractured limb and the entire pelvis, but it is abso-
lutely necessary to include the opposite  limb as far  as the knee, and to extend
the dressing as far as the cartilage of the  eighth rib.  The splint, which is repre-
sented by Figure 55, is incorporated in the plaster-of-Paris dressing, and must be
carefully applied, so that the compress, composed of a well cushioned pad
with a stiff unyielding back, rests directly upon the trochanter major, and the
pressure, which is made by  a set-screw, is directed in the axis of the femoral
neck.  Lateral  pressure is not applied  until the plaster has completely set.
Syncope should be  guarded  against by  the  administration of  stimulants.  As
soon  as the  plaster has  sufficiently hardened  to retain the  limb  in proper
position, the patient should be  laid upon a smooth, even  mattress, without
pillows under the head,  and  in non-impacted fractures the  foot is  held  in
a straight  position,  and extension is kept  up  until lateral  pressure  can  be
applied.
  "No matter how snugly a plaster-of-Paris dressing is applied, as the result
of shrinkage it becomes  loose, and  without some  means  of making lateral
pressure it  would become necessary to change it from time to time, in  order to
render it efficient.   But by incorporating a splint, as shown  in Figure 55, in
the plaster dressing (Figure 56) this is  obviated, and the lateral pressure  is
regulated, day by day, by moving the  screw, the  proximal end of which rests
on an oval depression in the centre of the pad."


       FRACTURE EXTERNAL TO  THE CAPSULAR  LIGAMENT.
  I-t is caused by direct violence, and in consequence of other injuries around
the great trochanter,, or of the cervix being  firmly impacted;  the diagnosis  is
very difficult;  there is no crepitus; the limb is shortened, but cannot be brought
to its  natural  length by any justifiable amount of tension.
  Treatment.—It  is  treated  by extension  and  counter-extension  just as in
fracture of  the shaft of the bone. 
152
SURGERY.




 Fig.  55.
Apparatus for treatingf Fracture of Neck of Femur.






                   Fig. 56.
 
FRACTURES.
153
            FRACTURE JUST BELOW THE TROCHANTERS.
  The upper fragment is tilted forward by the psoas magnus and iliacus.
  Treatment.—Extension is made by the action of a weight and pulley, and
counter-extension by elevation of the foot of the  bed.  The  limb  is kept  at
rest between two sand bags, and the dressing is completed by fastening a broad
binder around the pelvis.


             FRACTURE OF THE  SHAFT OF THE FEMUR.
  The symptoms are plain and unmistakable; there is pain, swelling, crepitus,
preternatural mobility and deformity.
 TREATMENT OF FRACTURES OF THE UPPER THIRD.
   The lower fragment must be brought to the upper; the thigh must be flexed.
 Professor Nathan R. Smith's splint is generally recommended.  It is an anterior
 wire splint from which the leg is suspended.  First make a double inclined
 plane with pillows so adjusted that the fragments will fall  into place; lay five
 or six strips across the  pillow to fasten around the splint after complete coapta-
 tion of the parts has been made.   The  splint is bent at the knee and turned
 up at each extremity  to accommodate  the flexions of the ankle  and groin.
 Apply a roller around the limb and  splint to  support  the strips and a few
 spicas to fix the splint at the  groin.   Suspend the limb and then remove the
 pillows.  Professor  Agnew's apparatus for fracture  of the  upper third of the
 femur "consists of a double  inclined  plane with  hinged sides  attached  to
 the thigh-piece; upon this the limb is deposited, a pillow being  interposed
 between  the  thigh  and the splint, and a soft pad placed beneath the leg;  an
 adhesive strip is next attached to the sides of the  thigh, extending up as far
 as the upper end of the lower fragment, and with  a loop below, into which
 is to be fastened a  piece of light wood,  as in the  ordinary fracture dressing.
 To this piece of wood a cord is attached, which is to be carried over a pulley
 set in an upright board that is to be screwed to the foot of the bed.   To this
 cord the extending weights are attached.  Lateral  pressure is  applied to the
thigh by bringing up the sides of the  femoral part of the  plane and securing
them by strips of muslin while the leg is retained  in position by turns of the
roller."*
* Agnew's Surgery, Vol. I, p. 957.
K 
154
SURGERY.
TREATMENT OF  FRACTURE OF  THE  SHAFT BELOW
                     THE  UPPER THIRD.
  The method  is now generally  pursued of  extension by the action  of a
weight and pulley, and counter-extension is made by elevation of the foot of
the bed.
  A  strip of adhesive plaster from two and a half to three inches in width is
stretched along on each side of the limb to a short  distance below the seat of
fracture, and confined with a roller extended from  the toes up to the groin,
the middle of the plaster forming a loop below the sole of the foot.  A thin
block of wood,  the width of the plaster and long enough to prevent pressure
over the  ankle, is inserted into the loop, and serves to receive the extending


                                Fig. 57-
EXTENSION APPARATUS.
cord, which is fastened to an elastic rubber band passing around the block and
playing over  the footboard, or over a temporary frame, perforated at a height
of about four inches above the level of the mattress, or an adjustable clamp
may be used, holding in  position the rod which supports the pulley. (Fig. 57.)
The thigh, at the seat of the fracture, is surrounded with short splints, and a
bandage  is applied from the toes to the groin, the heel is supported upon a
thin, wedged-shaped hair cushion; a bag filled with sand is placed along the
outer and another on the inner aspect of the thigh and  leg, to prevent motion.
The amount of weight employed must be determined by the age of the patient
and other circumstances  of the case.   An adult will require from ten to twelve
pounds;  a child under eight years of age will require about six pounds.
   Liston's long splint; that of Desault, modified and improved by Physic; N.
R. Smith's anterior splint, which is especially adapted to cases where the upper 
FRACTURES.
155
third of the bone tends to tilt forward; Hodgen's suspension apparatus;  Levis's
extending apparatus; Dr. Buck's apparatus; and  that of Morton, which is in

                                     Fig. 58.
N. R. SMITH'S ANTERIOR SPLINT.
use in the Pennsylvania Hospital, are all in vogue with the profession, and each
has its advocates.
      FRACTURE OF THE  FEMUR IN  CHILDREN.
   These fractures  heal readily  and are rarely followed  by an  appreciable
shortening.
   Treatment.—When the limb has been adjusted and drawn to its proper
length a plain roller is to be applied, beginning at the foot, and ending at the
groin with a spica;  a sufficient quantity of cotton wadding  to prevent irritation
having been placed at the ankle, the knee, and the crest of the ilium, a long
splint is laid along the outer side  of the body, extending from the axilla to three
or four inches below the foot, and is to be bound  in  this  position by plaster
rollers, likewise commencing at the foot and ending with a  spica at the groin.
   The upper part of the splint is  to  be secured to the trunk by a roller.   Sili-
cate of soda or starch may be  used instead of plaster;  when the former is em-
ployed, three or four strips of pasteboard should  be laid  around the seat  of
fracture, secured by a  roller, to which  the  silicate of soda is  to be likewise
applied. 
156
SURGERY.
              FRACTURES  OF THE  PATELLA.
  The patella may be  fractured longitudinally, but  is usually broken trans-
versely.
  In longitudinal fracture, the  treatment is to reduce  the  inflammation by
leeches and evaporating lotions, and then  apply a roller, and afterward a laced
cap, with a strap to buckle  above and below  the knee;  the  union, as a rule,
will be ligamentous.
  Transverse Fracture.—The upper fragment is drawn upward by the action
of the muscles inserted into it, while the lower part remains stationary.  The
injury is known by the depression between the two portions of bone; the power
of extending the limb is lost and the knee  bends forward.  The  union of the
fracture is generally by ligament.
                                 Fig. 59.
DRESSING FOR FRACTURED PATELLA.
   The treatment indicated is to keep the leg steadily extended, the thigh at
the same time flexed upon the pelvis, and the body kept in the semi-erect pos-
ture;  a strong and well-padded tin or wire case may be used, reaching from the
middle of the thigh to the corresponding point of the leg.  Prof. Brinton prefers
to use a posterior splint, reaching from the heel to the gluteal fold; a roller
having been previously applied from the toes upward, and another from the
groin downward.  The fragments, having  been brought in apposition, are con-
fined by numerous adhesive strips, carried around the bone above and below the
joint, and afterward connected by vertical and transverse pieces.   The splint
should be kept applied for six or eight weeks; at the  end  of this period it may
be left off, and the patient be allowed to get about on crutches, wearing a stiff 
FRACTURES.
157
bandage to prevent any flexion of the joint.   Manning's splint, the splint of
Agnew and of Hamilton, Malgaigne's hooks, Levis's hooksj and the hooks of
Morton, each has its advocates.
  Laying  open  the  joint  and wiring the fragments is recommended, by Sir
Joseph L^ter, and  has been resorted  to in a large number of cases with com-
parative success.
  To perform this  operation, a longitudinal  incision is  made  over  the centre
of the joint, which is opened, and the  fragments of the patella are exposed; any
blood clot which is present in the joint, or between the fragments, is turned out,
and the fragments  themselves are cleared of any aponeurotic and fibrous tissue
which may be  found lying between and over their broken  surfaces.  Each
fragment is then bored obliquely with a  drill, taking care not to reach its  car-
tilaginous  surface.   Sutures of silver wire or of heavy catgut  are then passed
through the drilled holes, and the fragments having been drawn together, the
ends of the wire are twisted, cut short, and then hammered  down on the bone,
where they may be allowed to remain permanently, without causing any irritation.
This operation, if performed, must always be carried on under the most careful
antiseptic  precautions; free drainage must be provided for by the insertion of
tubes in openings made at the back of the joint on either side.
  It is proper to observe that wiring  the fragments has, in several cases, been
followed  by suppuration in the joint, and as a consequence the limb, and even
the patient's life, has been lost.
  For the first  few days after the injury is incurred, antiphlogistic measures
are to be employed, before any permanent treatment is to be  resorted to.
                  FRACTURES  OF  THE LEG.
  The two bones may be broken together, or they may be broken separately.
The commonest fracture of the tibia is in the lower third; it is most frequently
oblique, with the upper end directed downward and forward, so  that it  rides
over the lower fragment; the fibula may give way  at the same time, at a point
nearly opposite.  The tibia may also be broken transversely, at either the upper
or lower half.
  The fibula is less frequently broken than the tibia.   Both bones are seldom
broken at the same level, unless by direct violence.  The tibia is weakest at its
lower extremity and the fibula at the upper part.
  Fracture of the lower end of the fibula, accompanied by dislocation outward
of the foot, at the ankle joint, is known as  Pott's  fracture.
  The bone is broken from two  to four  inches above its lower extremity, the
ends of the fragment being driven inward.   The signs of this injury are a well 
158                             SURGERY.
marked depression at the seat of the fracture; the foot is twisted outward and
the sole everted by the peronei;  the inner malleolus, if unbroken, projects pro-
minently beneath the skin.  If separated, the detached fragment can be readily
felt.   Crepitus may be  readily obtained.  The heel is drawn upward.
   There are many methods of treatment: By the common splints; first re-
duce the fracture; apply the many-tailed bandage, and then use the shaped splints
of Cline, supported by sand-bags, or apply Macintyre's splint or Bayer's board
and pillow dressing.  The fracture box;  the stiffened bandage, using the silicate
of potash;  paper and paste; plaster-of-Paris; or chalk and gum bandage, are
in general use and commended in turn.
   In Pott's fracture there is dislocation outward of the  foot, in  addition to
fracture of the fibula.   Dupuytren's splint is generally recommended;  it is a
straight wooden splint, notched at its  lower end, and reaching from the head
of the tibia to about four inches  below the  sole of the foot.   It  is  applied to
the inner aspect of the leg; a thick pad,  extending to the inner malleolus, must
be interposed between the splint  and the leg.  The upper  end of the splint is
to be bandaged to the limb.  The foot is drawn across  the lower  part of the
splint, the thick pad acting as a  fulcrum, and the foot is fastened to the splint
by a figure of 8 bandage, carried around the ankle  and foot and through the
notches at its lower end.
   Eoyer's dressing consists of two splints, a pillow, a splint  cloth and three
strips.  The splints should extend from above the knee to below the foot;  they
must be wrapped in the splint cloth, a bandage applied around the foot to keep
it everted and set in the natural  position; the finger should be run along the
spine of the tibia, to see if the fragments are  in position, when the splints should
be applied and kept in place by the strips,  the fractured limb resting  on the
pillow between the splints.
   The fracture box consists of two sides attached to a base, with a fenestrated
foot-board.  A pillow is to be placed in the box and the foot is to be affixed to
the foot-board. The heel must be protected by a ring of oakum, and is not to
touch the foot-board.   The fragments are then to be adjusted and  the sides of
the board brought up and tied together with strips.   The box should be swung.


                 FRACTURES OF  THE  FOOT.
   These fractures  are  of rare  occurrence, and result from severe crushes, and
usually several bones are involved in  the injury.  The fracture is generally
compound.
   The os calcis is sometimes fractured as the result of a fall upon the heel.
   If  the bone be fractured in front of the ligaments, there is but slight dis- 
FRACTURES.
159
 placement; there will be crepitus on making lateral  movements and grasping
 the heel; there will also be flattening, pain and swelling.
   Should the posterior part be separated  behind  the attachment of the inter-
 osseous ligament, the  fragment is drawn  up by the  muscles of the  calf and
 projected posteriorly.   Crepitus can be obtained by bringing the fractured  ex-
 tremities in apposition.
   Fractures of the metatarsal bones  and phalanges are always the result of
 direct violence.
   Treatment.—When the posterior portion of the os calcis is  separated and
 drawn away by the muscles of the calf, the latter should be relaxed and  the
 fragments brought into apposition by placing the  limb  on an  outside  splint,
 with the knee flexed and the foot extended.  The apparatus used for rupture
 of the tendo-Achillis will often answer the indications.  In fracture  of any of
 the other bones of the foot, it should be kept at rest, either on a back splint
 with a foot-piece, or by means of some form of  stiff bandage.  In all forms of
 fractures of the tarsal bones timely motion should be employed, to prevent anky-
 losis.

       TREATMENT  OF  COMPOUND FRACTURES.
   If the limb is put in a stiff bandage, an  opening must be cut over the seat of
 fracture, in order  to allow of the wound  being examined and  dressed  when
 necessary.
   If there is a mere puncture of the skin, caused  by one of  the sharp ends of
 the fragments, it should be treated  antiseptically and  closed at once, by apply-
 ing a pad of cotton dipped in iodoform and collodion.  If under this treatment
 the temperature rises and the  parts become hot, red, painful and swollen, the
 pad should be  removed, and  if there be  evidence of suppuration, the wound
 must be opened, the parts carefully cleansed, and thoroughly syringed out with
 an antiseptic lotion.
   If the wound is of a  larger size, its  edges lacerated, tissues bruised and
 swollen, it should  not be closed at once.   A tourniquet  should be applied, and
 bichloride towels placed  under the part, which should then  be  shaved.  Any
 remaining soap must be washed away  with i-iooo bichloride solution, and the
 surface scrubbed with  a nail brush.
  Be sure to place carbolized towels wherever instruments may possibly be
 laid, or wherever the operation may extend.
  Freely enlarge the wound, if necessary,  and constantly irrigate with 1-2000
 bichloride solution.
  Trim away all muscular and other soft tissues which are injured to such an
 extent  that they cannot live;  remove  loose fragments  and rough margins of
bones, and shape the ends so that they will fit each other; then drill holes into 
160
SURGERY.
 them so that they can be fastened together with prepared catgut, silver wire, 01
 silkworm gut, and be careful not to irritate the parts with the ends of sutures,
 which are not to be removed.                        ,
   The muscular tissue is to be united or approximated by catgut sutures.
   The ends of large nerves that  are divided must be carefully trimmed, and
 brought together with fine catgut sutures.
   Bleeding vessels are to be tied with catgut ligatures.
   When  hemorrhage is controlled, put in the wound  a drainage tube of large
 calibre, making a free  counter-opening if necessary.
   Finally wash out the parts with i-iooo bichloride  solution, and bring to-
 gether the margins of the wound with catgut sutures.
   Powder sterilized iodoform over the wound.   Put  Lister's protective over
 the line of sutures, and cover the wound with a sufficient  quantity of bichloride
 gauze;  fasten  it in  its place with a  bichloride gauze bandage.   Wind five
 yards of bichloride gauze around the limb; keep this  in  place with a bandage
 of the same material, cover this  with bichloride cotton two inches in thickness,
 the whole to be enveloped  in  rubber dam.  Then apply an ordinary roller
 bandage, and finish the dressing with a plaster-of-Paris splint.   Sling  the limb
 to a bar above the bed.
   Change the dressings in a  week, so that the drainage tube may be removed,
 and put in its place an absorbable bone drain, using at the same time bichloride
 irrigation.
   Sprinkle iodoform about the wound, and dress as heretofore directed.
   The limb will probably not require to be again dressed for six weeks.
   Hot and cold douche, massage, and passive  motion will be required after
 removing the final dressings.
   Amputation  may be necessary where there is extensive destruction and lacer-
 ation  of the soft parts, with much splintering of the bone,  especially if the main
 vessels of the limb are  wounded, or an adjacent joint laid open.
   During the treatment, many  complications may arise, such as oedema and
 swelling of the limb, ulceration  and  sloughing, spasms  of the muscles, gan-
grene and venous thrombosis.
   When oedema presents itself,  the  bandages should be  slackened, and an
 evaporating lotion applied; if the tissues are bruised, paint the parts with tinct.
 benz.  comp.; should  bullae  form, they may be  pricked,  and their  contents
 allowed to escape.
   Ulcers  are apt to form over  bony  prominences, and  bedsores may appear
 over the sacrum, buttocks, hips, etc.  These must be treated antiseptically.
   Gangrene, as a rule, is the result of tight bandaging,. or other improper
 treatment.  The part should be frequently examined, and if there be coldness
 numbness, lividity or swelling of the limb, the bandages should be at once relaxed, 
SPRAINS—SYNOVITIS.
161
                              SPRAINS.
  A Sprain is a violent stretching of the ligaments, tendons or fascia surround-
ing a joint, with or without rupture of some of their fibres and blood-vessels.
  It usually happens from the sudden extension of the joint in the direction
for  which the muscles are unprepared; the most common situations of these
accidents are the wrist or ankle.
  The pain produced is instant and severe, frequently attended with faintness;
the parts begin to swell immediately, and there is great tumefaction and ecchy-
mosis, and subsequently weakness  and stiffness of the part.  There is inability
to bear any weight on the limb, and any attempt to move the joint surfaces on
each other is attended with increased pain.
  The remote effects of this lesion are often permanent pain and weakness;  or
stiffness and even ankylosis.
  Treatment.—The patient should at once go to bed, so as to ensure perfect
rest; the part  affected should be confined to a splint behind, held in place by a
comfortably applied bandage,  and the position of  the limb should always be
such as to relax the muscles.   Immerse the limb in water of a temperature  as
hot as the patient can bear, and let it remain there for at least half an hour;
acetate of lead and opium should then be  applied through the medium of wet
rags.   If the sprain be complicated with laceration of ligaments, apply a splint
of silicate of soda, as soon as the inflammation has subsided.
  Should  the  pain and tumefaction increase, leeches should be freely applied,
and if the  patient is very  plethoric, and  the injury extensive, purgatives and
general bleeding must be had recourse to.
  Care should be taken not to use the part too early.
  Should  the  disease become chronic, friction with moderate pressure should
be used; stimulating  liniments should  be  rubbed over the parts, which should
be kept neatly bandaged;  leeches and blisters should be resorted to, and good
effects are often produced by pouring a continued stream of cold water over the
part.

                             SYNOVITIS.
  Synovitis,  or acute inflammation of the synovial membrane, may be pro-
duced by local  or constitutional  causes, such as  blows, strains, mechanical
injuries, penetrating wounds, exposure to cold, syphilitic or gonorrhceal poisons,
and gout.
  The knee is the joint most frequently affected.
  Symptoms.—Severe  aching pain in the joint, increased  by motion, great 
162
SURGERY.
 swelling,  redness  of the surface, tenderness  and fever, which is  frequently
 violent.
   The  swelling, which is  occasioned  by a rapid effusion  of  fluid into the
 synovial cavity, is distinctive.  There is evident fluctuation, if the joint is super-
 ficial.   The shape of the joint is always altered.
   When the knee is affected the patella is pushed forward,  and there is  great
 fullness on each side of it, and at the lower and  front part of the thigh.  The
 swelling, if at the elbow, is most distinct above and between the olecranon and
 the condyle; and in the hip there is general fullness of the surrounding parts,
 and tenderness on pressure.
   Treatment.—Limb must be kept absolutely motionless.   A  splint must be
 applied, after being padded, so that it may be fastened some distance  above and
 below the joint, and care must be taken that it does not touch the affected  part.
 Leeches to the  joint, cups  in the  neighborhood, evaporating  lotions  or hot
 fomentations.  Calomel  purgatives  should be administered; and  opiates, to
 relieve pain.   When there is a tendency to the disease becoming chronic iodide
 of potassium should be  administered.   And  if the disease be  connected with
 rheumatism, ammonia and  potash should be  prescribed.  Where there is  a
 tendency to gout,  colchicum with potash is to  be  employed.   In  syphilitic
 cases, mercury, in its different forms, is  most to be relied upon.


  COXALGIA,   OR TUBERCULOUS   DISEASE  OF THE
                             HIP JOINT.
   This  disease is most frequent from the third to the seventh year.
   The first circumstance which indicates disease of this joint is some degree of
 lameness and pain in the  knee, with  more or less  weariness,  some eversion
 of the foot and dragging of the leg.  The motions of the joints are impeded;
 extension  is performed with difficulty;  the knee is bent; the heel on the
 diseased side scarcely rests on the ground; there is great difficulty experienced
 in the flexion of the joint.
   To ascertain whether  disease exists, the patient is placed  on  his back  and
 examined, to ascertain whether the  sides of the pelvis  are  equal;  the pelvis
 will be lower on the diseased side.   Then bend  the knee on  the abdomen;
 if there be disease of the hip joint,  considerable pain will-be occasioned.  In
rotating the joint pain will be excited.   If the patient is turned on  his  face
the nates on the affected side will be found lower.
   If the surgeon presses on the hip joint, either in  front, over  the psoas
 and  iliacus, or behind the great trochanter, or  jerks  the femur against the
acetabulum by a sharp tap  on the trochanter major or heel, pain will  be felt
in the hip, and that  in the knee will be greatly aggravated. 
ANKYLOSIS.
163
Fig. 60.
  Abscesses are frequently formed in  this disease, which take various direc-
tions ;  as a rule, their course is down the thigh, where they  break;  they may,
however, occur in  the  upper part of the  thigh, the
rectum or vagina.
  The pain of complete extension of the joint, and
the instinctive resistance of the patient to this posi-
tion, when laid on a flat, hard bed, producing, when
the knee is pressed straight, a sudden aching of the
lumbar  curve, is very characteristic of  the  disease,
even in the earliest stages.
  Treatment.—The patient must  be kept in perfect
rest in the straight  posture, by means of sand bags
placed on each side of the limb;  that on the outside
reaching as far as the axilla.
  If an abscess form, open the part at once and drain
it thoroughly.  Excision of the head of the femur may
become necessary.
  Extension  and  counter-extension must be strictly
kept up, in the same manner  as in treatment of frac-
tures of the lower extremities.
  Dr.  Buck's American stirrup may  be used  with
advantage.
  When the patient is in a condition to take  exercise
in the  open air, the apparatus of Dr. Sayre  answers
all the indications.
COXALGIA.
                             ANKYLOSIS.
  Ankylosis is an osseous or  ligamentous union of the joint  ends of bones,
impeding or promoting motion; it frequently follows injuries or disease of the
joints.
  False ankylosis  depends on  the thickening of the synovial  membrane, or
organization of bands of adhesion within and around the joint.
  Ligamentous ankylosis is the union of two articular surfaces by fibrous tissue.
  Bony ankylosis results where the fibrous tissue becomes ossified.
  Treatment should not be attempted until the diseased action has ceased and
parts return to a quiescent condition.  After this, passive motion,  combined with
friction, may be resorted to.   A screw fitted to  a splint  with a hinge in it may
be used to gradually straighten the joint.
  Forcible or  immediate extension, by breaking  up ligamentous adhesions, is 
164
SURGERY.
frequently employed ; and any tendons, fascia or muscular fibres whose rigidity
is an obstacle, may be divided by subcutaneous section.
  When the knee is affected, the hamstring muscles and portions of the fascia
may be divided; if the elbow, the biceps may be  cut.  The joint should then
be extended by  main force.
  When the ankylosis is bony and the limb fixed in position, a subcutaneous
operation may be performed ; when it is  bony and extensive, the remedy is to
cut through the bone,  or cut out a wedge-shaped portion, and then employ suf-
ficient motion to establish a false joint


                               CARIES.

  Caries is a disease of the bones  supposed to be analogous  to ulceration of
the soft parts.
  Bones of a spongy texture are more frequently  attacked by caries than such
as are compact ; hence the vertebrae, astragalus and other bones of the tarsus,
those of the carpus, the sternum, the pelvis, and the heads of the long bones,
are often affected, and the bones of young persons are more frequently the seat
of caries than those of old subjects.
  On examination, the bone is found to be soft and dark red; its cells are filled
with a  reddish, serous, glairy fluid,  or with soft granulations of feeble vitality.
After a time suppuration occurs between  it and the surface, the abscess breaks,
and the carious portion of the bone,  already  softened,  gradually perishes in
minute particles, which are thrown off and discharged with the pus.   The bone
appears enlarged, and one or more sinuses open, at points that are soft, red and
sunken.
   The predisposing cause is some constitutional disorder, scrofula, or syphilis.
The exciting cause may be a blow or injury.
   Treatment.—Rectify  constitutional  disorder  and  remove local  disease.
Change of air, tonics, sea air, sea bathing, and the usual remedies employed in
scrofula and syphilis are indicated.
   Locally, the  best treatment is to  freely expose and remove the diseased por-
tion of bone.


                              NECROSIS.
   Necrosis is the death or mortification of a bone, and is applied to  cases in
which part of  the shaft of a bone dies, from  injury or violent inflammation.
The term exfoliation  signifies necrosis of a thin, superficial layer, which is not
encased in new bone. 
RICKETS, OR RACHITIS.
165
  This disease most frequently attacks bones of compact tissue; the shafts of
the femur and tibia are often the seat of this affection.   Necrosis of the lower
jaw frequently results from the inhalation of the fumes of phosphorus by per-
sons employed in lucifer match factories;  this causes inflammation and thicken-
ing of the periosteum, followed by abscess, resulting in necrosis of a portion of
the bone..
  The bone, in necrosis, dies, from obstruction of its circulation; but the peri-
osteum, with the articular  extremities, its  medullary membrane, and other con-
tiguous parts, speedily ossify and form a new shell around the dead portion,
and adhere to the living bone above and below.
  Symptoms.—After acute inflammation, the bone  remains permanently
swelled,  and the apertures made for the discharge of matter remain as sinuses;
these sinuous apertures in the skin usually correspond to holes in the shell of
the new  bone, and  by passing a probe through them, the sequestrum may be
felt, loose, in the interior.
  Treatment.—The indication is to remove the  sequestrum, as soon as  it is
sufficiently loose.   If small, it may be grasped and removed with a forceps; if
larger, a free incision should be made, so as to expose the surface of the bone,
and it should be made at a point where the cloaca exist, or where the bone is
nearest the skin.  The new shell must be perforated with either a Hey's  saw,
or with a chisel or gouge,  and the sequestrum drawn out.   The wound may be
filled with decalcified bone chips, as  recommended by Senn.   (See Formula,
No.  74, at end of this volume.)


                    RICKETS,  OR  RACHITIS.
  This is a peculiar disease, produced by a morbid  condition of  the whole
body, and generally arising from hereditary taint, defective hygienic conditions,
want of  fresh air and light.   It is frequently attended with scrofulous disease.
Its  leading  characteristic  is imperfect development, atrophy and distortion of
some of  the  bones  of the body; these are soft, and consist of a sort of semi-
cartilaginous tissue,  which will bend without breaking.   The articular portions
are often disproportionately large.  The shafts are unable  to support the weight
of the body, without bending.
  The physiognomy and  general appearance are very peculiar; the  stature is
stunted, the  head large, and the forehead protuberant.   The face is  small and
triangular, chin sharp, teeth projecting, chest prominent and narrow, the spine
variously curved; the pelvis  small;  the promonotory  of  the  sacrum and ace-
tabulum  pressed together;  the limbs crooked, their natural curves increased.
  Treatment.—Invigorate the constitution, if possible. 
166                            SURGERY.

  Cod-liver oil,  iron, compound syrup of the hypophosphite  of lime, soda,
potash and iron,  and such  other  remedies as  are  usually  prescribed  for
scrofula.
  Diet should be  generous and nutritious;  animal  food, milk, eggs, etc., etc.
Sunlight and pure air.
  If possible, use some mechanical contrivance to straighten  the bones, and
keep them  in that condition until they are strong enough to bear the weight of
the body.
  If necessary perform some one of the numerous  operations recommended by
surgical authorities to suit the  cases as they present themselves.
                  DISEASES  OF  THE  SPINE.

                   PSOAS AND  LUMBAR ABSCESS.
  These are chronic collections of  tubercular fluid, which form in the cellular
substance of the loins, behind the peritoneum, and descend in the course of the
psoas muscle;  if the disease forms on the  side of the vertebrae, instead  of the
fore part, it is termed lumbar abscess.
  At the beginning there  is little or no  pain, no inflammation, nor is there
febrile disturbance; but previous to the appearance of any other symptom the
patient has an unaccountable feeling of weakness across the loins, accompanied
by pains, usually giving no indication of the seat of the disease, and likely to
be regarded  as rheumatic.
  The tubercular liquid is formed slowly and imperceptibly, and occasions, at
first, no manifest swelling, nor fluctuation.
  When the lower dorsal or upper lumbar vertebrae are diseased, the pus enters
the sheath of the psoas, or the  substance of the muscle, and is firmly bound
down in front by the fascia covering this muscle and the iliacus.
  The abscess proceeds as far as the tendon of the muscle by Poupart's liga-
ment, when  its further progress is  apt to be arrested.   When  it  has attained
considerable magnitude it passes under Poupart's ligament, between the femoral
vein and  the symphysis pubis.
  The diagnosis is difficult when the abscess is unattended by an external tumor.
  The swelling takes place in various situations and assumes different aspects;
it may appear beneath the femoral  fascia, or it may descend as far as the knee
and  form a prominent  swelling; sometimes  it  will make its  way downward
into the pelvis and occasion a swelling  in  the neighborhood of the  anus, or it
may appear in the vicinity of the vertebrae, or,  again, it  may make  its way
through the  abdominal muscles. 
DISEASES OF THE SPINE.                      167
   This disease  arises generally from cold, strains, or  falls, and  from general
debility, and not unfrequently from spinal affections.
   Treatment.—A psoas abscess should be opened, if possible, before it leaves
the abdomen, just above Poupart's ligament,  external to the line of the vessels.
If it points at the inner side of the  thigh, an  incision may be made also in that
situation, in addition  to  the  one above Poupart's  ligament.   Under antiseptic
precautions, the sooner the abscess is  opened the  better, for the abscess cavity
is then smaller than if the surgeon waits till the  fluid has burrowed its way
into the thigh.  Free drainage should be established from the groin to  the
lumbar region.
   The same principle of treatment  must be applied to lumbar abscesses.
   Antiseptic dressings must be continued as long as there is any discharge.
   The general treatment must be tonic and alterative.


                LATERAL CURVATURE OF  THE SPINE.
   Arises from debility of the ligaments and  muscles, and is  common among
girls between the age of  ten and sixteen years.
   There is a perceptible  growing out  of one shoulder, or an  elevation of one
shoulder, more frequently the right;  the spine
is found, on  examination, to  be curved like an
S and twisted on its long axis.
   This deformity is usually produced by occu-
pations that  tax one  side of  the body more
than the other, especially the habit of standing
at ease on the right  leg; it may also  be pro-
duced by one-sided postures in sitting  or writ-
ing.  This curvature  is frequently produced by
disease of the bones,  as in rickets.
   Treatment.—The general health  of the
patient is  the first thing to be  attended to;
change of air, good  diet, the  different prepa-
rations of iron, bathing the body with salt and
water  every morning, are  the  remedies  to be
resorted to.
   The patient should be kept out of doors as
much  as possible, and should  be directed to
take  foot or horse  exercise,  but  when not
moving he should  be required  to lie down as
much  as possible, and not to  sit upright.  Mechanical  support may be  advi-
sable in severe cases.
 
168
SURGERY.
                       ANGULAR CURVATURE.
  Known as Pott's Curvature, is produced by softening and absorption of the
intervertebral substances, and caries of the bodies of the vertebras.
  Symptoms.—This  disease usually begins  with weakness,  coldness  and
numbness of the legs, and incapability of making exertion;  these symptoms
are  followed by twitchings and  spasms of the legs, and sometimes palsy.  In
adults  there is generally  a  dull, aching  pain,  aggravated by motion,  and
tenderness on pressure.  If  the  patient slips when walking, he  experiences
great distress; this is one of the symptoms in  children by which attention is
called to their condition.   If the disease is situated in the dorsal vertebrae there
will be tightness of the  chest  and  difficulty  of breathing; if the cervical
vertebrae are affected one or both arms may be palsied, and there will be diffi-
culty in supporting the head.  As the  diseases  advances, the trunk becomes
curved  forward, and the spinous processes of the diseased vertebrae  project
backward.  Abscesses  may form; there is great constitutional derangement,
with hectic.
  Treatment.—Rest  in the horizontal posture is  absolutely necessary.   A
bandage containing strips  of whalebone, and reaching from the head to the
hips, may be employed to  keep the trunk at rest.  Issues  on each side of the
spinous process of the diseased vertebrae may be used.
  The constitutional treatment should be.the  same as that recommended for
angular curvature, and for  scrofulous cases generally.
  Efficient mechanical support during  convalescence is absolutely necessary ;•
the  plaster jacket of Dr. Sayre, of New York, is in general use,  and the one
most to be recommended.  See page 257.
                         AMPUTATIONS.
  Amputations are operations for the removal of limbs.
  There are two principal methods of amputation; the Circular and the Flap.
   The Circular.—When performing the circular amputation the operation is
to be divided into three different steps : division of the skin and its separation
from the underlying muscles;  division of the muscles; division of the bone or
bones.
  When the operation is performed  on the upper limb the section of the skin
is to be made three inches  below the point where the bone  is to be sawed
through; when on the lower limb four inches is to be allowed.
  An  assistant first draws  the skin toward the trunk of the  patient;  the
surgeon taking his  knife in  hand passes it  beneath and behind the limb, and 
AMPUTATIONS.
169
turning the instrument so as to face him he places the edge of the knife on the
upper surface of the limb, as far forward as he can reach, and sweeps it entirely
around the limb, describing a circle, and  dividing the skin and cellular tissue.
Separate the skin and cellular tissue from the deep fascia and turn it upward;
the raw surface outward.  The fascia and muscles are next cut through down
to the bone by a circular  cut, similar to  that made when  dividing the skin.
The soft parts are now drawn up with the retractor; the periosteum is divided
circularly, and the heel of the saw being  placed upon  the  bone, and steadied
by the thumb nail of the left hand, and  drawn  from heel  to point to make a
groove, is then directed to and fro from point to heel, with slight pressure until
the bone is cut.
   Flap Method.—The  principal varieties of this  method are:  I. Double


                                 Fig. 62.
Flap; 2. Long Anterior Flap; 3. Long Rectangular Flap (Teale's);  4. Modi-
fied Flap ;  5.  Posterior Flap.
  1. Double  Flap.—These flaps are made either by transfixion, or by cutting
from without inward ; the former method is preferable.  The flap farthest from
the  vessel is first made.   The flaps may be antero-posterior or lateral.
  2. Long Anterior Flap.—This is made of skin and cellular tissue, without
any posterior flap#.   It  forms a flat-faced stump.  It  is used in amputation of
the  knee, etc.
  3. Long Rectangular (Teale's).—This is a long and short rectangular flap.
The long flap  is cut so  that  the  large  blood-vessels  and  nerves will  not be
included; it is, therefore, anterior on the leg and posterior on the forearm.  The
       L 
170
SURGERY.
length and breadth are equal to half the circumference of the limb where the
bone is to be divided.  The short flap includes the arteries and nerves, and is
one-fourth the length of the long one.   The flaps are marked out with ink and
raised from without inward, including the muscles.  The bone is sawed at the
angle of union.  The long flap  is bent so as to unite with the short flap, after
the blood-vessels are  tied.
                                 Fig. 63.
  4. The Modified Flap.—In this  form the flaps include only the skin and
cellular tissue.  The muscles are divided at the base of the flaps, retracted, the
periosteum divided, and the bone sawn through.
  5. The  Posterior Flap is chiefly used in amputation of the ankle joint,
when Syme's operation is resorted to.


                  AMPUTATION AT THE HIP JOINT.
  This  operation is  requisite in cases of cancerous or  hopeless disease of the
femur, and in those injuries in which the  upper extremity of the thigh bone is
crushed and the soft parts so much damaged that it is useless to attempt ex-
cision.
  It is  generally  performed by flaps, either antero-posterior or lateral.   The
femoral  artery should be compressed and seized as soon as cut, by the hand of
an assistant following the knife.
  The arteries  divided in this operation are the  muscular and femoral, lying
close together inside and in front of the bone.
  The internal circumflex is also  divided, and also the external circumflex.
The great sciatic nerve and an accompanying branch of the ischiatic artery lie
in the posterior  flap, near its centre.
  Operation by Antero-Posterior Flaps.—The thigh ha-ving been slightly
bent and abducted, the  knife is entered at the outside, at the junction of the
upper and middle third of a line drawn from the  anterior superior spine of the
ilium  to the great trochanter, and carried obliquely  inward and downward
immediately in front of and touching the joint, and finally brought  out  about 
AMPUTATIONS.
171
two inches below the tuberosity of the ischium.  A large anterior flap is made,
about six or seven inches long, which is  at once firmly grasped, to prevent
hemorrhage, and drawn upward.  The anterior part of the capsular  ligament
already laid bare is then divided, together with the cotyloid ligament;  the head
of the bone is dislocated by rotating  the limb  outward and extending it back-
ward ; the ligamentum teres cut through  and the disarticulation  completed.
The knife is then carried through the joint, over the trochantar, and the pos-
terior flap made somewhat small and thin.   Sponges are stuffed into the wound
by assistants, to restrain the hemorrhage, until the vessels are secured by liga-
tures;  apply sutures and the necessary dressings.


                     AMPUTATION OF THE THIGH.
   Circular Method.—The  surgeon stands at the outer side.  One assistant
must hold the limb, and another must  draw up the skin as high as possible.
Then the surgeon, grasping firmly the knife, with the point upward and the
edge toward his arm, commences by passing  his  arm under the limb, laying
the edge of the knife  over it, and makes a transverse  incision at one sweep,
completely around the  limb, through the  skin and fat, down to the fascia.
The knife cuts from heel to point.   The assistant now draws upon the skin
and folds it back like a coat cuff; and then the knife, being put close to the
edge of the retracted  folded skin, is made to divide the superficial vessels, and
then cut everything  down to the bone by a clear  sweep.  Then separate the
muscles upward  from the  bone, for  an inch or two, with the point  of a knife,
and divide  the  periosteum.  The soft parts are next to be drawn up from the
bone by the retractor, and lastly, the bone is to be divided by the saw.  Should
the bone be splintered, the  projecting parts  must be removed by the bone
forceps.  The  femoral  artery must  now be secured, its orifice being grasped
and slightly drawn out by the forceps ; and afterward any large branches that
appear in the muscular interstices.  Then all compression  should cease, so that
arteries that are likely to bleed  should do so.  When the bleeding has finally
ceased, the  edges of the wound should be  adapted with  sutures,  and a few
long slips of plaster  and a light bandage  passed  around the stump.  The
arteries divided are the femoral, the profunda, and the descending  branches
of the external circumflex.
  Flap Operation.—The operator may stand on either side of the limb.  In
amputating the right thigh, he stands on the outer side and raises the flap with
the left hand, and this gives him the power of grasping the  main artery, with
the flap, with that hand, and thus assisting in  restraining hemorrhage.  The
flaps may be made from the inner and outer, or from the anterior and posterior
aspects of the Umb.   He then  passes his knife horizontally through it till its 
172
SURGERY.
point touches the bone, over which he passes the point, pushes it through the
other side of the limb as far back as possible.  He then carries the knife along,
close to the bone, for about three inches, and finally cuts out forward, so as to
make the anterior flap spade-like, without corners.  The knife is again entered
a little below the top of the first incision, passed behind the bone, brought out
at the wound on the other side, and cuts the posterior flap.  Each of the flaps
should be rather longer than the semi-diameter  of  the limb at  the  point
operated on.  Both flaps are now drawn back, the knife swept round the bone,
to divide any remaining muscular fibres, and the bone sawn through.
  The Modified Flap.—Two  equal semilunar flaps of skin are raised from
the fascia, the  one  anterior and the  other  posterior.   The bases of the flaps

                                 Fig. 64.
FLAP OPERATION.
must be equal, that is, each must embrace half the circumference of the limb,
the convexities being toward  the knee, and retracted two inches further; the
muscles are cut directly down to the bones, on a level as high as they are
exposed in front, and as low as they are exposed behind.  The bone is cleaned
and sawn through two inches higher than where  it was first exposed by the
anterior incision through the muscles.
                 AMPUTATION AT THE  KNEE JOINT.
  Long Posterior Flap.  (Syme's Operation.)—A semicircular incision is
made through the skin and  fascia, over the  patella; next the knife is thrust
horizontally across, immediately behind the joint, and is  made  to cut a  long 
AMPUTATIONS.
173
flap from the calf of the leg; next, the anterior flap being lifted up, the extensor
muscles are severed from the upper border of the patella; the remaining soft
parts are divided, and the femur sawn through the condyles, immediately above
the joint.
   Long Anterior Flap Operation.—An anterior flap may be made, includ-
ing the patella, by a semicircular incision through the tissues in front, below the
patella, from the posterior part of one condyle of the femur to the other.  Then
the ligamentum patella is cut through, the patella lifted with the anterior flap;
the joint opened by cutting through the lateral  and  crucial ligaments, and a
posterior flap cut from the calf.
   The inter-articular  cartilages should be removed,  and the  surface of the
patella and the femur, only if diseased.  Some surgeons bring down the patella
over the femur; others remove  it.
   The arteries divided are the anterior and posterior tibial, sural and articular
branches.
                      AMPUTATION  OF THE LEG.
  The leg should always, if possible, be amputated at from three to three-and-
a-half inches from the ankle;  that is to  say at its inferior third; this gives the
patient a long stump for  the more ready adaptation of an  artificial limb; the
mortality, too, after an operation, is decreased proportionably to the increased
distance from the knee.
                                 Fig. 65.
  Double-flap Method, at the upper fourth  of  the leg.  A stout  bistoury,
with blades four or five inches long, and a broad  saw, are the cutting  instru-
ments required.   The flaps are made of integuments only, by cutting  from the
surface without transfixion.  The point of the knife is  entered at the side, about
two  inches  below the tibial tubercle, and carried  across the front of the leg, 
174                             SURGERY.

describing an anterior curved  flap, rather longer than, and of the exact width
of, the half diameter of the  limb.  This is dissected up close  to the bones and
deep fascia.  A similar flap is made on the posterior aspect, and the  integu-
ments and  fascia composing it are raised from the muscles.   The latter, with
the large vessels and nerves, are then divided transversely, direct to the bone.
The point of the knife must be used to divide the  intervening structures.  The
bones are then divided equally across.
  The anterior tibial artery is often divided as it passes between the bones to
the front of the leg, and it may be difficult to get it separated from the sur-
rounding ligamentous structures.
  Single-flap Operation.—The operator  places the heel of the knife on the
side of the limb furthest from  him, then draws it  across the  front of the limb,

                                 Fig. 66.
LONG ANTERIOR AND SHORT POSTERIOR FLAP.
cutting a semilunar flap of skin; when its point arrives at the opposite side, it is
made to transfix the limb,  and then the posterior flap is cut.   Care must  be
taken not to get the knife between the bones when making the flap by trans-
fixion.  The muscles and ligamentous structures which are between the bones
are then divided by  the point of the  knife.  The  fleshy mass of the gas-
trocnemius may require to be cut out, to make the posterior flap  thinner.
   The  Circular Operation is especially adapted to removal of the leg at the
lower third of its length.  One assistant supporting the foot, and another hold-
ing the  knee, and at the  same  time drawing up the skin, the  surgeon makes a
circular incision through  the skin, four inches below the  point where the bones
are to be divided.   The integuments are then dissected  up for two  inches and 
AMPUTATIONS.
175
 turned back;  and the  muscles divided down to the bone by a second or third
 circular incision.  A catlin is  then  passed between the bones to divide the
 interosseous ligament and muscles, and  both bones sawn through  together, the
 flesh being protected by a three-tailed retractor, the middle tail passing between
 the bones; to  prevent splintering, the division of the fibula should  be com-
 pleted  before that of the tibia.  The  anterior and posterior tibial are the
 principal arteries requiring ligatures.


                  AMPUTATION AT THE  ANKLE JOINT.
    Syme's Operation.—Find the  tip  of the external malleolus, and then
 mark a  point  nearly opposite to it on the
 inner side of the ankle.  This is about  half
 an inch below and behind  the  internal mal-
 leolus ; these points are joined by two incisions,
 one passing vertically under the sole of the
 foot and the other over the dorsum, so as to
 make an angle of  1200 with the first.   The
 first  incision  should be  inclined backward
 rather than forward, so that  the lower  flap
 may be very short; the next step is to dissect
 the lower  flap from  the os  calcis.  When
 this is done the short upper flap is dissected
 from the dorsum.   The foot is then forcibly
 extended,  the  ankle  joint  opened and  the
 foot removed.  The malleoli are then sawn
 off and  the  flaps brought  together  with
 sutures.
   Pirigoffs  Operation.—Instead  of  dis-
 secting  out the entire os  calcis,  Pirigoff re-
 moves the anterior part only of the bone, which supports  the astragalus.
   In  this amputation the first incision is begun close in front of the malleolus
 and carried straight down to and transversely across the sole of the foot, then
 obliquely  upward  and forward  to the front of the  inner malleolus, dividing
 everything down to the bone.   The incision is then brought  obliquely forward
 on the inner side, so as to cut the posterior tibial artery before its division into
 its plantar branches.  The ends of  this incision are connected by a semilunar
 one across it into the ankle joint.  Then the lateral ligaments are  divided and
the posterior part of the  capsule; with a narrow  saw the os calcis is now cut
obliquely from behind forward and downward.   Then the malleoli are sawn
off, with a thin slice of the tibia, if diseased.  Lastly, the cut surface of the os
Fig. 67.
syme's operation. 
176                             SURGERY.
 calcis is brought into contact with that part of the tibia, and the wound is united
 with sutures.

                     AMPUTATIONS OF THE FOOT.
   Amputations  of the Toes at any of their joints is performed in precisely
 the same  manner as amputations of the fingers.   In removing a single toe from
 its metatarsal bone, the surgeon should take care to ascertain the exact situa-
 tion  of the joint, which  lies  rather deeply and much  further back from  the
 prominent knuckle of  the toe than is  at first sight apparent.   If possible  the
 head of the metatarsal bone should not be removed, if it can be avoided, as it
 is important to preserve the breadth of the foot.
   Amputation of all the Toes at  their Metatarsal Joints.—Performed
 by first making a transverse incision along the dorsal aspect of the metatarsal
 bones, dividing the tendons and lateral ligaments of each joint in succession;
 and then  the phalanges being dislocated  upward, the knife is placed beneath
 the metatarsal extremities and made to cut out a flap from the skin on the plan-
 tar surface, sufficient to cover the heads of the metatarsal bones.
   Amputation of the  Metatarsal Bone of the Great Toe.—An incision
 with a scalpel is carried along the dorsum down  to' the bone and around  the
 root of the toe.  Then the knife is  kept as close to  the bone as  possible, dis-
 secting it  out from the  surrounding parts.  Then the bone is  removed  at  the
 metatarso-cuneiform joint, by division of. the tendons and ligaments.
   Amputation of all the Metatarsal Bones  (Lisfranc's operation).
   Directions for Locating the Tarso-metatarsal Articulation.—Find the
 articulation on the outer side, by locating the prominence at  the base of  the
 metatarsal bone of the  little toe, which indicates the position of the articulation
 between the metatarsal and cuboid bones.  Draw  a line from  the base of  the
 metatarsal bone of the little toe directly across  the instep, advance forward
 from this point half an inch, which gives the point of junction  between  the
 metatarsal bone of the  big toe and the  internal cuneiform bone.
   The exact  situation  of the articulation  of the great toe to  the  inner cunei-
form bone being ascertained, a semilunar incision with the convexity forward
 is made through  the  tegumentary structures  across the instep,  from a point
just in front of the aforesaid articulation to the outside of the tuberosity of  the
 fifth metatarsal bone.  This flap is turned back  and the bistoury  is first to  be
passed straight across  the tendons  and  vessels,  so as to  cut them a little
shorter than the integuments, and then around behind the  projection of  the
fifth metatarsal bone, so as to divide the external  ligaments which connect it
with the cuboid.  The dorsal ligaments are next cut through, the  bone's being
at the same time well depressed.   The third  and fourth are to  be  disarticu- 
AMPUTATIONS.
177
lated  in  a similar manner.  The first metatarsal is next attacked, and lastly
the second, the  extremity of which, being  locked in between the cunei-
forms, will be  more difficult to dislodge.  When  all the five bones  are dis-
articulated, the surgeon completes  the division of the plantar  ligaments and
separates the textures which adhere to them with  the point of the knife, and
then,  the foot being placed horizontally, he puts the blade under the five bones
and carries it forward along their  inferior surface as far as the root of the toes,
so as  to form a sufficient flap.

    Fig. 68.
hey's and lisfranc's
    operation.
   Hey's modification of Lisfranc's operation consists in sawing off the pro-
jection of the internal cuneiform bone, and thus forming a regular surface.
   Amputation  Through  the Tarsus  (Chopart's operation).—To remove
the navicular and cuboid bones, with all parts in front of them.
   Directions for Locating the Medio-tarsal Articulation.—Measure back
half an inch from  the prominence at the base of the fifth metatarsal bone,
which gives the point of articulation between  the cuboid bone and  the os calcis;
draw a line from this point directly across  to the inner aspect of the foot, which
will  indicate the point of junction between the scaphoid and astragalus.
   In the first place, the articulation of the cuboid with the os calcis, and that 
178                             SURGERY.
of the scaphoid with the astragalus, must be sought for, and a semilunar inci-
sion must be made across the dorsum from one to the other, as in the foregoing
operation.  The flap of the skin being turned back, the internal  and dorsal
ligaments that connect the scaphoid to the astragalus are to be divided with the
point of the bistoury.   The ligaments connecting the os calcis and cuboid are
next divided, and lastly a flap is taken  from the  sole of the foot.   If the heel
is drawn backward it may become necessary to divide the tendo-Achillis.
  In these amputations the dorsal region of the foot, and  the external and
internal plantar branches usually require ligatures.


                     AMPUTATION  OF THE ARM.
  In amputations of the  upper extremity the flow of blood may be sufficiently
controlled by digital compression of the artery above the clavicle, or in the arm
against  the  humerus.   Or  the  tourniquet, or  Esmarch's  bandage  may be
applied.
  i. Circular Amputation.—The arm being held  out,  and an assistant

                                 Fig.  70.
CIRCULAR AMPUTATION.
drawing up the skin, one  circular incision is made through the integuments,
which being  forcibly retracted and  detached from the deeper  structures and
doubled back to the extent of two inches, another is made to the bone.   The
subsequent steps are precisely similar to those described in amputation of the
thigh. 
AMPUTATIONS.
179
  2. Antero-posterior Flaps.—The knife is extended atone side and carried
down to the bone, turned over it, brought out to a point opposite  and then
made to cut a neat rounded anterior flap, three inches long.  The knife is next
carried behind the bone, to make a posterior flap of equal length, and is lastly
swept around the bone to divide any remaining fibres with the periosteum; the
vessels are cut when the posterior flap is being formed.  The division of the
bone, ligature of the  arteries and treatment of the stump as heretofore.
  Besides the brachial artery, the  superior profunda and the inferior pro-
funda require ligatures.
                                 Fig. 71.
  3. Rectangular  Flap  Method (Teale's Amputation).—This  method  of
operation is chiefly advisable in cases of injury attended with great loss of soft
parts.
  The long anterior flap must be made so that  the inner line of incision shall
be sufficiently near the margin of the biceps muscle not to involve the brachial
artery.   The short flap is to be taken from the posterior aspect of the limb.
              AMPUTATION OF THE SHOULDER JOINT.
  The Flap Method.—The  patient is placed on a firm table, with the arm
well raised and projecting beyond its edge; the subclavian artery being com-
pressed, the operator  enters a long, narrow, straight bistoury at the anterior
margin of the deltoid muscle, if it be the right arm, an inch below the acromion. 
180
SURGERY.
From this point he thrusts it through the muscle, across the outside of the joint,
and brings it out at the posterior margin of the axilla.
  If the left arm is operated on, the knife must be entered at the posterior margin
of the axilla, and brought out at the anterior margin of the deltoid.  Then, by
cutting downward and outward, the external flap is made.   The arm is then
brought down to the side and forcibly adducted; the origins of the biceps and
triceps and the insertions of the infra- and supra-spinatus are cut through and
the joint laid open. Finally the blade of the knife, being passed through the

                                 Fig. 72.
joint and placed on the inner side of the head of the bone, is made to cut an
inner flap of the same shape, but rather shorter than the outer one.
  Oval Method (Larrey's).—Make a straight incision immediately beneath
the acromion process, with a  moderate-sized amputating knife, which  should
reach down to the bone, and should be between  two and a half to three inches
in length; from the lower end of this incision two others are prolonged, the first
passing in a curved direction downward and backward, and the second forward
toward the folds of the axilla ; the main blood-vessels and the inner or axillary
aspect of the  arm remaining untouched.  The flaps are then  dissected back,
71 
AMPUTATIONS.
181
including the muscles, and exposing the joint.  The head of the bone is then
disarticulated by cutting upon the tuberosities; the arm being  rotated inward
and outward.  The arm is then adducted, throwing  the head of the humerus
outward, and the knife passed to the inner side and carried downward close to
the bone, an assistant at  the same time  compressing the artery.   Then the
tissues between the axillary folds  are  divided by an oblique cut from within
outward, so as to form part of the internal incision.
  The axillary,  and branches  of the anterior and posterior circumflex and
supra-scapular arteries require to be tied.


                AMPUTATION OF THE ELBOW JOINT.
  i. By Anterior Flap.—This is performed by passing a knife through the
muscles in front  of the joint and cutting upward and forward, so as to make the
flap from the forearm.  Then  the  operator makes a transverse incision across
the olecranon and down to the  bone behind the joint.   He next cuts through
the external lateral ligament and enters the joint between the head of the radius
and external condyle, then divides the internal lateral ligament, and lastly saws
through the olecranon, the apex of which, attached to the triceps, may be  left
on the stump, or afterward dissected out.
  2. Circular Operation.—Make a transverse incision three and a  half inches
below the inner  trochlea.   Raise the  skin and fascia for an inch, then divide
the muscles  circularly.   Forcibly retract these; again divide the deep muscles
transversely, together with the  external lateral ligament, on a level  with  the
radial articulation.   The head of the radius is recognized  and the joint opened
by entering the knife  between the radius and humerus, dividing the  external
ligament.   The  olecranon is  then drawn forcibly downward, and  the triceps
divided at its insertion, and the remaining tissues from within outward.


                  AMPUTATION OF THE FOREARM.
  Always perform this operation as near the wrist as possible.
  i. Circular.—The limb being supported with the  thumb uppermost and an
assistant drawing up the  skin,  a circular  incision is  made through it, down to
the fascia.   When the integument is retracted and folded back about an inch,
the muscles  and  tendons are divided by a second circular incision;  the interos-
seous parts and the remaining fibres are next cut through; the bones are then
sawn through together and of equal  length, and  projecting tendons  trimmed
off.   The radial, ulnar and one or two interosseous arteries require ligatures.
  2. Flaps.—The limb being placed in a state of pronation, the surgeon makes 
182                            SURGERY.

a flap from the extensor side by transfixion ; he then transfixes the flexor side,
and makes the other flap; the flap from the  extensor side should be made as
broad as possible, by keeping the point well backward as it passes across the
ulna, and at the same time drawing the parts well  forward.  The interosseous
parts are then divided, the flesh drawn upward, the bones sawn through, and
the tendons trimmed off.
   3. Long Rectangular Flap (Teale).—This flap is made from the back of
the forearm.  The radial vessels are included in the shorter flap.   In tracing
the long flap, a longitudinal line is  drawn over the radius external to the ves-
sels ;  at the distance of half the circumference  of  the  limb another line is
drawn parallel over the ulna.   These are joined across the dorsum by a trans-
verse  line.   The  short flap is formed by a transverse line across the front, join-
ing the long ones at the  upper  fourth.   When dissecting  the  long flaps from
below upward, the tissues must be  separated close  to the periosteum and inter-
osseous membrane, and the bones sawn through at the angle of  union.  The
vessels having been ligated, the stump is to be placed in the prone position, so
that the long flap may fall over the ends of the wound and be approximated
to the short flap, in the usual method.


                    AMPUTATION OF THE WRIST.
   1.  Circular.—The skin being pulled back, a  circular incision is  made a
FLAP AMPUTATION OF THE WRIST JOINT.
little below the level of the line that separates the forearm from the palm of
the hand.  The integument must be turned back as far as the Une of the radio- 
AMPUTATIONS.
183
carpal joint.  The external lateral ligament is then cut through, and the knife
carried across the joint to divide the remaining attachments.  The styloid pro-
cess of the radius  and ulna should be removed with  the cutting forceps, the
tendons trimmed and the integuments brought together with sutures.
  2. Flaps.—A  semilunar incision  is made across the back of the wrist, its
extremities being at the styloid processes, and its centre reaching down as far
as the second  row of carpal bones.  Dissect up the  flap of integument and
fascia, flex the  hand, and divide the extensor tendons across, opposite to the
joint.   The joint being opened behind, and the lateral ligaments cut through,
and the knife being placed between the carpus and forearm, is made to cut out
a flap from the anterior surface of the palm.


                    AMPUTATIONS OF THE HAND.
  Amputations of the fingers or  thumb at their distal joints are performed by
the operator holding  the phalanx firmly between the finger and thumb and
bending it, so as to give prominence to the head of the middle phalanx.  He
then makes, with a scalpel, a straight incision across the dorsal skin, over the

                                 Fig. 74.
AMPUTATION OF THE FINGER.
head of the middle phalanx, along the distal groove ot the knuckle, so as to
cut into the joint  deeply enough to divide the lateral ligament.  The knife is
carried through  the  joint, and  cuts a flap from the palmar surface of the last
phalanx, sufficient to cover the head of the bone.
  Amputation of the Finger at the Metacarpal Joint.—Seize the finger
firmly with the left hand; make an incision on one side of the prominence of 
184
SURGERY.
the knuckle, a quarter of an inch  above the joint, and carry it around the side
of the joint to the web on the palmar aspect of the opposite side.  The exten-
sor tendon must now be  cut through, and the point of the bistoury passed into
the joint and made to divide its  ligaments.  Turn the head of the bone out,
so that the bistoury, being placed behind it, may cut through the remaining
attachments, and make another side flap.
   Amputation of the Metacarpal Bone of the Thumb.—By anterior flap
operation.  Hold the thumb out; insert the bistoury  near the metacarpo-
phalangeal joint; its point is thrust between the bone and the muscles of the
ball of the thumb, and as close to the bone as possible, and brought out just

                                 Fig. 75.
AMPUTATION OF THE METACARPAL BONE OF THE THUMB.
above the articulation with the trapezium.  The bistoury is then  made to cut
its way outward,  and the point of the knife is  carried from  the upper end
along the bone, and around the metacarpo-phalangeal joint, to  meet the  other
incision.   The bone is disarticulated by being forcibly abducted, and the liga-
ments on the inner side of the metacarpo-trapezial joint cut through first.
  Amputation of the  Metacarpal Bone of the Little Finger.—An inci-
sion is made along the ulnar border of the dorsum of the bone, and carried
around to encircle obliquely the root of the little finger.  The skin and  flesh
are dissected off,  as closely as possible to the bone, and the bone is disarticu-
lated, by the point of the knife, from the  unciform, while the ligaments are
stretched to  their  utmost by extreme abduction. 
EXCISION OF JOINTS.
185
                      EXCISION OF JOINTS.
  When joints are hopelessly diseased, or so extensively injured as to threaten
the life of the individual, and render repair impossible, cutting out the portion
of diseased or injured bone is resorted to instead of  amputation.
  It is  now well established that in many joints excision is better and safer
than amputation; less violence is done to the body;  fewer great arteries, nerves
and veins are divided, and the  patient is left with a limb which, although
imperfect, is in most cases highly useful.


                 EXCISION OF  THE SHOULDER JOINT.
  Surgeons  differ as to which is the best incision to make in  commencing this
operation; many authorities recommend an  anterior, in front of the deltoid;
Nelaton  used the transverse, and Ashtonkey the deltoid  flap.   Bryant  advo-
cates a vertical incision from  the acromion process, through the thickness of
the deltoid down to its insertion.
  Make the vertical incision down to the bone, rotate the head of the humerus
successively outward and  then inward;  then make a transverse cut across the
tuberosities to divide the insertions of the scapular muscles.  Divide the capsule;
turn the  head out of the  wound, and resect through the tuberosities.  Should
the glenoid cavity be diseased, the dead bone  must be removed.
  When the vertical incision is employed, an opening must be  made posteriorly
through the soft parts, at a point corresponding to the upper end of the humerus,
for  the purpose of drainage; it must be kept open by means of a drainage tube.
  After the operation, the arm  should be abducted and placed  on  a pillow,
the edges of the wound carefully brought together,  and dressed antiseptically.
Three or four months are required to secure a useful arm.


                   EXCISION OF THE ELBOW JOINT.
  The patient is laid on his back, and the arm held with  the hand in a prone
posture by two assistants, one of whom holds the arm and the  other the fore-
arm.  A straight vertical incision, four inches long,  through the skin  and sub-
cutaneous tissues, is then made a  little to the  ulnar  side of the hinder surface
of the joint; its centre about the level of the olecranon, and to the outer side
of the groove  wherein the ulnar nerve lies.  Deeper cuts are then made round
the upper border and  sides of  the olecranon, laying bare the condyles  of the
humerus, and separating the origins of the muscles of the forearm, and cutting
into the joint transversely, severing the triceps from  the olecranon.  The ulnar
       M 
186                            SURGERY.

nerve is  drawn inward, off the inner condyle,  by a double blunt hook, and
protected  from the saw, the lateral ligament severed, the elbow forcibly bent,
so as to turn out the ends of  the bones.  The olecranon may now be  cut off
with the saw  or forceps, when it will be clearly seen what other portions  of
bone are  diseased.   The  end of the humerus, as  well as  the  head  of the
humerus, may  now be removed.  Enough bone must  be removed to prevent
ankylosis.  As much of the brachialis  anticus must be removed from the
coronoid  process as may be necessary;  the triceps tendon must be left as long
as possible.
  When  the  bleeding has ceased, the wound  is to be  brought  together by
sutures, dressed antiseptically, and  the  arm, in a half-bent posture, laid upon
a well-padded angular splint,  and secured by bandages.
  When the reparative stage has fairly set in, the arm is to be moved from time
to time, so as to form a false joint.
  There  are many varieties in the  plan and shape of  the incisions; the most
practical  is to make the incisions connect  and  fall  into the tract of any sinuses
that may exist.  In short and muscular men the H incision is the best, especi-
ally if  there be much enlargement of the  joint.


                   EXCISION OF THE WRIST JOINT.
  The incisions and modes of procedure in  this operation vary in each case
accoriing to the  situation and extent  of the disease; no precise rules can,
therefore, be laid down.
  The form of the incision must be guided by the presence of the sinuses on
the surface; by following these a sufficient opening may be usually made be-
tween the extensor tendons and the bones.
  One of the most usual modes of  operating consists of longitudinal  incisions
on both sides of the wrist joint, or incisions on the dorsal and internal  lateral
aspects, directed so as to go between the  tendons without dividing them. An
incision to the ulnar side of, and parallel  to the tendon of the extensor secundi
internodiipollicis, and another vertical on the inner side of the joint, between
it and the flexor carpi ulnaris, will give sufficient room to remove the diseased
carpal  and bases of the metacarpal bones.


                     EXCISION OF THE HIP JOINT.
   To perform this operation, make a long, straight incision down the outer
side of the limb, beginning below and behind  the anterior superior spine of
the ilium, and passing over  the  great  trochanter.   The attachment  of the
muscles having been severed  from the trochanter, the bone is turned out of the 
EXCISION  OF JOINTS.
187
wound by raising, and adducting it  at the knee; the neck  and head of the
bone, if necessary, to be dissected out of the acetabulum.
  Another method of performing  this operation is  to  make a semicircular
incision,  beginning just above the edge  of the  tensor vagina femoris,  and
curving downward and outward, so as to cross  the bone an inch below the tro-
chanter,  from whence it  should turn a  little upward.  This flap,  including
skin,  fascia lata, tensor  vagina femoris  and  part of the gluteus maximus,
should be turned up, the muscles attached to the injured  parts  divided, and
complete the remaining steps of the operation  as above.
  Excision of the hip joint should be performed with antiseptic precautions.
If foul sinuses exist they may be scraped with  a sharp  spoon and cleaned well
with a sponge dipped  in a solution of sulphate of zinc.  Antiseptic  dressings
may be then  applied and the limb fixed  in a long splint.


                    EXCISION OF THE KNEE JOINT.
  Make  a semicircular incision, with  the convexity downward, commencing at
the side of one condyle of the femur and  passing immediately above the tuber-
cle of the tibia, to a corresponding point on the opposite  condyle.  This
incision  divides  the ligamentum patellae, and the patella is turned up in  the
flap;  the crucial  ligaments are then to be cut across, and any remaining lateral
attachments  divided.  The limb  must  now be forcibly flexed, and  the knife
carefully applied to the posterior part of the head of the tibia;  a blunt-pointed
resection knife is best  for this purpose.   Saw off the articular surfaces.   The
lower end of the thigh-bone  should  first be removed; it must be made accu-
rately at right angles to the  shaft of the  femur in the antero-posterior direction.
  A thin slice is  next  taken off the  tibia;  the section must  be  accurately at
right angles to the shaft of the tibia.
  Care must be  taken not  to remove  more of the bones than  is absolutely
necessary, especially in young subjects.
  If the patella  be  much diseased, it must be removed; if it be only slightly
carious, it may be scraped or gouged  out; if healthy, it should be left to con-
solidate and  strengthen the  joint.
  To keep the bones in position, they should be drilled obliquely at the anterior
part, and secured by a couple of strong sutures of catgut.   If the wound be not
aseptic, wire sutures are the best.  Before the  wound is closed, all hemorrhage
must be thoroughly arrested.   Ligatures must be applied to the articular arteries,
if necessary.   The limb must be kept at perfect rest for the  first few weeks;  a
narrow, properly-padded splint, extending from the hip to the heel, will answer
all indications.   It should be fixed in position by a flannel  bandage above and
below the knee, over which a firm plaster-of-Paris bandage  must be applied. 
188
SURGERY.
The first dressings should  be changed after twenty-four hours.  After that  the
dry, antiseptic wool dressings should  be used, which can be left untouched  for
two or three weeks.


                   EXCISION OF THE ANKLE JOINT.
  Place  the  foot on its inner side, and make an incision  along  the  posterior
face of the fibula, beginning  three inches above its lower extremity, and after
reaching the end of the malleolus, change its  direction, and terminate about
half an inch  short of the metatarsal bone of the little toe.  Raise the flap and
reflect it forward, exposing the surface of the fibula, taking care not to injure
the tendons of the peroneus  longus  and brevis muscles, which lie against  the
posterior and outer surface of the bone.  The fibula is now  to be cut through
with strong bone-pliers, and its lower extremity dissected out.
  Should the disease  be  found to  be very limited and  accessible, the one
incision  here recommended will  suffice; if the disease is  more extended, the
foot must be  placed on its outer  surface, and a second incision must be made
along the inner angle of the  tibia and terminating at the  internal cuneiform
bone.   Dissect back the flap, keeping  close to the bone, so that the tendons of
the tibialis posticus, flexor longus digitorum, and the posterior tibial artery,
veins and nerves, may  be  raised without  injury.  Hold these parts aside, and
cut away the internal  malleolus with the  bone-pliers, and divide the internal
lateral ligament.
   Clear the  bone in front and  behind with the  handle  of  the scalpel,  and
strongly evert the foot when the tibia and upper  surface of the astragalus will
be  exposed at the internal wound.
   The bone  can now be divided  from behind forward, by a narrow-bladed  saw
being passed through the internal wound, behind  the tibia,  and made  to appear
at  the  external opening.   The  upper surface  of the astragalus may be  now
sawn off.
   The wound must  be  thoroughly washed  out with bichloride  solution, a
drainage tube passed through from one side of the joint  to  the  other, the
sides of the  incision  closed by interrupted sutures, and the whole dressed
antiseptically.
   The foot and leg must be covered with a bandage and plaster rollers applied;
care being taken to give the foot a proper angle with the leg, the  foot being
held  by the hand of an assistant until the plaster is hardened.  Traps are to be
cut on the sides of the splint opposite the wounds. 
EXCISION OF JOINTS.
189
                   WHEN EXCISION IS ADMISSIBLE.
   Erichsen, in his work on the " Science and Art of Surgery," lays down the
following general rules for the performance of  resections of joints in cases in
which it is admissible :—
   i. As a substitute for amputation in cases in which the joint is so extensively
diseased that the patient will be worn out  by the discharge or pain, unless it be
removed.
   2. In some  cases of articular disease  in  which  amputation would not  be
justifiable, excision may be done  in order to hasten  the cure, and this  saves
years of suffering to the patient.
   3. Excision may be done in cases in which amputation is not practicable, as
in some cases of disease of the hip-joint, or of the temporo-maxillary articulation.
   4. As a substitute for other and less efficient treatment; in order to restore
the utility of a limb to  a  joint;  as in osseous ankylosis of the elbow,  or in
faulty ankylosis of the knee.
   5. Excision may be required, in bad compound dislocations and  fractures
into joints, especially in gunshot injuries, more particularly in those of the head
of the humerus, and of the bones  entering into the elbow joint.
   As a general rule, excisions are required  only in  those cases in which the
articular ends of the bones are diseased either primarily or secondarily.
   Conditions  of  Success.—For resection to succeed, the following conditions
appear to be necessary :—
   1. The disease  should not be too extensive, so that its removal would  entail
such an amount of mutilation of the limb as to render it less useful to the patient
than an artificial member would be.  This is especially important in the  lower
extremity.
   2. The disease for which resection is practiced  should be allowed to become
chronic before any operation is undertaken.
   3. The soft parts about the joint must be in a sufficiently healthy state.
   4. The state of  the patient's constitution must necessarily influence  the sur-
geon materially in his determination, whether to resect or to amputate.
   5. The extremes of life are unfavorable to resections. 
190
SURGERY.
                   LIGATION  OF  ARTERIES.

                         THE FACIAL ARTERY.
  This  artery may be readily tied by cutting through the skin, platysma, and
fascia, at the point where it turns over  the jaw at the  anterior border of the
masseter; for this purpose an incision one inch in length in the line of the artery
is made, and the superficial fascia and  fibres of the platysma divided on the
director, when the artery,  and vein outside, will be exposed to view.
  But this operation can hardly ever be necessary, as a small harelip  pin may
be easily passed under it without an incision and a twisted  silk suture passed
over it.

                       THE OCCIPITAL ARTERY
Is the first branch of the external carotid artery arising from the posterior part;
it passes backward beneath the posterior  belly of the  digastricus, the trachelo-
mastoid, and sterno-mastoid muscles to the occipital groove in the mastoid por-
tion of the temporal bone.
  Divide the skin one and a half inches in length over the course of the artery
from  the mastoid  process of the temporal bone  to the external occipital pro-
tuberance.   The  artery will  be  exposed when the fascia, aponeurosis of the
sterno-mastoid muscle and  the  splenius capitis muscle have been  divided.
The vein lies on the outside, and must be avoided when the ligature is applied.


                      TRIANGLES OF THE  NECK.
  Before attempting to ligate the arteries of the neck the student should tho-
roughly master the triangles.  A synopsis of these, with their contents, is here
presented:—
  The  great anterior triangle is bounded above  by the body of the lower
jaw, in front by the middle line of the neck,  and behind _by the sterno-mastoid
muscle.  It is subdivided  into three minor triangles—
   i.  The  submaxillary triangle, formed by the two bellies of the digastri-
cus muscle and the inferior border of the lower jaw.   The submaxillary gland
is situated in the posterior angle of the submaxillary triangle.  It is separated
from the parotid gland by the stylo-maxillary ligament, and from the sublingual
by the mylo-hyoideus muscle.  Imbedded among its lobules is the facial artery
and the submaxillary gland.
  2.  The superior carotid triangle  is formed by the posterior belly of the
digastric muscle,  the  upper belly  of the omo-hyoid,  and  the sterno-cleido- 
LIGATION OF ARTERIES.
191
mastoid.  This  triangle contains  the  upper  portion of  the  common carotid
artery and its bifurcations into the external and internal carotids; the superior
thyroid, and the  commencement of the lingual arteries; the internal jugular vein,
and a chain of lymphatic glands;  the  descendens noni  nerve in front  of the
sheath of the carotid, the pneumogastric within and the superior laryngeal and
sympathetic behind.  The lingual nerve crosses the upper angle.
  3. The inferior carotid triangle is bounded by the  superior belly of the
omo-hyoid muscle, the sterno-mastoid muscle and the middle line of the neck.
Fig. 76.
N. accessorius .
Digastricus . .
Os hyoides . .
Omo-hyoideus .  _
DIAGRAM OF TRIANGLES OF THE NECK.
Sterno-mastoid
  muscle drawn
  aside.
Splenius capitis.
Levator anguli
  scapulae.
Scalenus medius.
— Scalenus anticus.
1. Superior carotid triangle.
2. Inferior   "     "
3. Occipital triangle.
4. Supra-clavicular triangle.
5. Submaxillary triangle.
In this triangle is found the lower part of the common carotid artery and jugular
vein, descendens noni, pneumogastric  and sympathetic  nerves  and recurrent
laryngeal nerve.
  The great posterior triangle is bounded in front by the sterno-mastoid,
behind by the border of the trapezius muscle, and below by the clavicle.   It is
subdivided  into  two minor  triangles  by the inferior belly of the omo-hyoid
muscle:  (1) the suboccipital and (2) the subclavian triangles.
  1. The suboccipital triangle is situated above the omo-hyoid, and contains 
192
SURGERY.
the suboccipital nerve at its upper  angle  and the spinal  accessory nerve and
branches of the cervical plexus below.
   2. The  subclavian triangle is bounded in front by the sterno-mastoid,
behind by the inferior belly of the omo-hyoid, and below by the clavicle.
   The subclavian triangle contains the termination of the external jugular
vein, the third part of the course of the  subclavian artery, and the brachial
plexus of nerves, and is crossed by  the posterior scapular artery.


                        THE LINGUAL ARTERY.
   This artery is usually tied in the triangle bounded anteriorly by the posterior
border of the anterior belly of the  digastricus, posteriorly by the hinder belly
of the digastricus, and above by the inferior border of the lower  jaw.  At this
place it is covered by the  skin, platysma, cervical  fascia, submaxillary gland
and the hyoglossus muscle.
   The guides are the hypoglossal nerve above the vessel, the digastric tendon
and the great horn of the hyoid bone below the artery.
   To perform this operation the head is drawn over to  the opposite  side; a
curved incision is made, two inches  long, with its concavity upward, the centre
being a quarter of an inch above the hyoid bone, at a point midway between the
median line  and  the top of the great cornu.   Divide the skin, platysma and
cervical fascia, and draw the  posterior facial vein  outward.  Raise the  sub-
maxillary gland  and  look for  the  posterior  belly of the digastricus;  passing
downward and forward to its attachments to the hyoid bone, the posterior bor-
der of the mylo-hyoid;  and  the hypoglossal nerve behind and below  the
digastric,  accompanied by the lingual vein lying in front  of the hyoglossus.
Draw the hyoid bone slightly downward, with a blunt hook fixed in the lower
angle of  the  triangle, and then divide the fibres of the hyoglossus along a line
parallel with  the nerve and midway  between it and the bone.  The artery will
then be in sight and ligatured.   This  artery has- been tied in wounds of  the
tongue, but considering the  depth  at which it lies from  the surface, it is con-
sidered better to tie the external or  common carotid.


                   THE COMMON CAROTID ARTERY
On each side lies upon the longus  colli muscle, and is contained in a dense
areolar sheath, which  also includes the internal jugular vein on its outer side,
and the pneumogastric nerve between; in front of the sheath is the descendens
noni nerve;  behind the sheath  lie the sympathetic and cardiac nerves.   At
the lower part, the  inferior thyroid artery and recurrent laryngeal nerve cross
behind it, toward the larynx, 
LIGATION OF ARTERIES.
193
  The left common carotid arises from the arch of the aorta, and rests first on
the side of the trachea, oesophagus and  thoracic duct;  the left jugular vein lies
rather in front of the carotid, as it joins  the left brachio-cephalic vein.
  The right  carotid arises  from the arteria  innominata, behind the sterno-
clavicular articulation, and ascends more perpendicularly.  Both arteries divide
into internal  and external carotids opposite the upper border of the thyroid
cartilage in the male, and in the middle of the thyroid  cartilage in the female.
  At  the lower two-thirds each artery is covered by the sterno-mastoid, sterno-
hyoid and sterno-thyroid muscles, and is crossed  by the omo-hyoid, opposite

                                  Fig. 77.
RELATIONS OF COMMON CAROTID.
the cricoid cartilage.  At the upper part of its course the artery is covered only
with skin, fascia, and sheath;  upon the last lies the descendens noni nerve.
  To  tie the  carotid in its lower part the patient must be placed on his
back, with shoulders raised, head thrown back and slightly turned toward the
opposite side; an incision three inches in length is made on the inner margin of
the sterno-mastoid muscle;  this incision should extend from opposite the thyroid
cartilage to the sternum, and must be carried through skin, platysma and super-
ficial fascia.  The sterno-mastoid  must now be relaxed by turning the head to
the side operated on ; now expose the  edge of the sterno-mastoid, which is the 
194
SURGERY.
guide to the artery, and look for and avoid  the external jugular vein ;  separate
and draw outward the  sterno-mastoid, and  draw inward the sterno-hyoid and
sterno-thyroid muscles.  Scratch through  the  dense fascia which unites  the
omo-hyoid in the sheath,  when  the  latter will be seen with the branches of the
descendens noni upon  it; this  must  be drawn aside.  The sheath  must be
pinched up with the forceps and opened with a careful touch of the  knife, its

                                  Fig. 78.
LIGATURE OF THE CAROTID.
flat surface toward the artery.  Enlarge the aperture on a director, detach the
artery from its connections for a limited extent, with a probe and an aneurism
needle, which, armed with a ligature, is passed around the vessel from without
inward;  avoid the vagus nerve, by keeping the point of the needle close to the
vessel.  When the point appears on the inner side seize the ligature with the
forceps, and withdraw the needle; ascertain that the nerve  is not included in
the ligature, and tie it with a double surgeon's knot. 
LIGATION OF ARTERIES.
195
   To tie the common carotid in its upper part.  The patient is placed on
his back; head thrown back;  an incision three inches long is made through the
skin and platysma, on the anterior edge of the sterno-mastoid muscle, from a
little below the corner of the lower jaw to opposite the cricoid  cartilage.  The
deep fascia is now pinched up, opened and carefully divided; the edges of the
wound are then to be drawn asunder:  next feel for the pulsation of the artery;
open the sheath over it, care being taken to get on the inner or artery side of
the septum, between the  artery and vein; do not include the descendens noni
in front of the vagus  and sympathetic nerve behind.  Expose but a small por-
tion of the artery, and pass the aneurism needle from without inward.
   The external carotid may require to be ligated.  An  oblique curved
incision should be made through the skin, platysma and fascia, in the direction
of the posterior belly  of the digastricus, from below the lobe of the ear to the
hyoid bone ;  the vessel is to be secured below the part where it is crossed by
the digastric muscle and the ninth nerve.


                       ARTERIA INNOMINATA.
   The patient is  to be placed on his back,  with  shoulders raised and head
thrown back ; an incision  two and a half inches in length is to be made along
the inner margin of the sterno-mastoid, terminating at the clavicle, and another
across the origin of that muscle, meeting the  former at an angle ; the flap thus
formed is to be turned up, and the sterno-mastoid divided at the sternal and part
of  the clavicular origin.   Turn  aside the areolar tissue and fat, and divide
the sterno-hyoid and thyroid muscles.   Scratch through the strong fascia, which
is next presented, very cautiously; then  trace the  carotid  carefully, with the
finger, to  its  origin.   The vena  innominata must then be held down with a
spatula, and a ligature, carried from without  inward,  must  be  brought around
the artery, close to its bifurcation, care being taken to avoid the vagus, recurrent
and cardiac nerves and pleura.

                     THE SUBCLAVIAN ARTERY.
  The ligation of the first and second parts  of the artery is rarely performed.
In the  third part of its course it is about one and a  quarter inches long, and
passes from the outer border of the scalenus  anticus, downward and outward,
under the clavicle, to the lower  border of the first rib, where it becomes the
axillary.   To locate the artery at this portion, divide  the clavicle into thirds;
under the centre of  the middle third it will be found.
  The patient must be laid on a  table, with the  shoulder of the affected side
drawn  downward and forward, and  the  head turned to the other side.  If it 
196
SURGERY.
be the subclavian artery of the right side, a line drawn from the sterno-clavicu-
lar junction to the lower border of the first rib will pass over the vessel; if it
be the artery of the left side, a line from the second dorsal vertebra to the lower
border of the first rib will pass over the course of the vessel.  An incision from
three to four inches long is then made, half an inch above and parallel with the
clavicle.   It must cut through the skin and platysma, and extend from the outer
edge of the sterno-mastoid to the trapezius.   The  external jugular, now ex-
posed, must be drawn aside with a blunt hook; it is generally more convenient
to draw  it to the  inner side, or it may become necessary to ligate and  cut it.
The clavicular portion of the sterno-mastoid must be divided.  The fascia must
now be carefully divided, tearing  it with the forceps if possible.  The omo-
hyoid is to be drawn up.
  Should either the supra-scapula or transverse colli be met with it is to be
drawn aside; these vessels maybe avoided by making the incision half an inch
above the clavicle.
  The anterior scalenus having been traced to its insertion in the rib, the  pulsa-
tions of  the artery will  then be felt, by turning  the pulp of the finger outward,
when the surrounding areolar tissue must be carefully torn through.  Care must
be taken to avoid the lower trunks of the brachial plexus of nerves, which may
appear first; the cessation of  the pulse at the wrist, when the trunk is pressed
by the finger, is good evidence that it is the sought-for vessel, and not a  nerve.
Venous hemorrhage, if troublesome, and cannot be controlled by pressure, must
be stopped by tying the veins.
  The ligature must be carefully passed from below upward.


                       THE AXILLARY ARTERY
Extends  from  the lower border of the first rib to the  lower end of the teres
major, in the axilla;  surgically.it is divided  into that portion where  it lies
thickly covered by muscle, and secondly, where it can be felt against the  hume-
rus on the axilla.
  To tie the artery in the upper part of its course, below the clavicle, the
shoulder and arm must be drawn back, so as to form an angle of 8o°, and put
the pectoral muscles on the stretch; an incision, four inches long, is then to be
made from the coracoid process inward, in a transverse depending curve, half
an inch below the clavicle.   The clavicular fibres of the pectoralis major are
then to be divided to the same extent; the lower border of the  wound  is then
to be drawn downward, the  costo-coracoid membrane  cut through, when the
edge of the pectoralis  minor will be readily  seen, crossing upward and out-
ward over the vessels  and  nerves.   Wounded branches of  arteries should  at
once be tied. 
LIGATION OF ARTERIES.
197
  To relax the pectoralis major, the arm should now be brought to the side; a
few  scratches with a director will expose  the axillary vein, which should be
held inward.  Then seek for the beating of the artery, which must be carefully
isolated, and an aneurism needle passed from without inward.
  The nerves lie on the outside and behind, and care must be taken not to in-
clude them with the artery.
  To tie  the axillary artery in its lower part, in the  armpit, the patient is
placed on his back, the arm  placed at right angles with the trunk.   The axillary
vessels and nerves lie between  the pectoralis major in front and the latissimus
dorsi and teres major behind, and can be readily felt against the  upper end of
the humerus; the coraco-brachialis and biceps being placed externally, and are
the guides to the vessel.   To locate  the vessel at the point  where the ligation
is to be performed, draw a line from the great pectoral to the latissimus dorsi;
divide it into thirds; the  vessel  will be  found at the junction of the anterior and
middle third.
  The  operator makes  an incision, two and a half inches long,  parallel with
the end of the humerus, between the pectoralis major and latissimus dorsi; he
then  dissects carefully through the fascia, untiL the basilic, axillary vein  and
median nerve are revealed;  the veins  are to be drawn  inward and the nerve
outward, the artery being found between them, and is exposed by tearing with
the forceps and director.  Care is to be taken not to wound the  thoracic and
subscapular veins.   The aneurism needle is passed between the vein and artery.


                        THE  BRACHIAL ARTERY
Passes obliquely down  the  inner side of  the humerus, to  the middle of the
bend of the elbow; it runs along the inner  borders of the coraco-brachialis and
biceps, which form the guides to it.  It is  accompanied  by two  vena comites,
and is encircled by their numerous branches; it is likewise accompanied by the
median nerve, which first lies on its  outer side, between it and the coraco-
brachialis ;  then crosses over  it, and  is quite internal to it at the elbow.   A
line drawn from the junction of the anterior and middle third of  the " axillary
line," {i.e., from the great pectoral to the  latissimus dorsi), to a point midway
between the condyles of the humerus, indicates the course of the artery.
  To tie the brachial at its upper third, the limb must be drawn from the
side and supinated.   The operator identifies the coraco-brachialis, and feels the
pulsation  of the artery; he then  makes an incision, three inches in length,
over the artery, opposite the middle of the  coraco-brachialis ; divides the fascia
to the same extent;  the  basilic vein will probably be found to the  inner side
of the artery.  The forearm may now be bent, to relax the parts,  and the mus- 
198
SURGERY.
cles, if in the way, must be drawn aside, the sheath of the artery opened, and
the median nerve drawn aside.   Having identified the artery, by its pulsation
or the appearance of its coats, the needle must be passed in whatever direc-
tion the operator finds most convenient.
  To tie the brachial artery in  the middle of the arm, the incision is to be
made along the inner side of the biceps, at the insertion of the coraco-brachialis
muscle.   The median  nerve  usually lies over  the vessel, and  must be drawn
aside; the biceps being well relaxed, the needle should be passed from within
outward.
  To tie the brachial artery in its lower third, an incision, from two and a
half to three inches long, should be made obliquely, about half an inch internal

                                 Fig. 79.
TYING THE BRACHIAL ARTERY.
to the tendon of the biceps, first ascertaining its position; and the median ba-
silic vein, if in the way, must be held aside, passing the ligature needle from
the median nerve.

                         THE RADIAL ARTERY
In its upper third lies deeply between the pronator teres and supinator longus,
and is overlapped by the last named; in its lower two-thirds it lies between the
tendons of the supinator longus &x\d flexor carpi radialis; it is accompanied
by the venae comites, and  in the middle third by the radial nerve.   To tie it,
the forearm must be  held  in  the supine position; an incision, two and a half
to three inches long,  must  be made over its course, which is from the middle of
the bend  of the elbow to the styloid process of the radius,  the  fascia cut
through, and the muscles separated and turned aside; then separating the vena?
comites, the ligature needle is to be passed from without inward.   The radial
nerve lies on the radial side of the artery. 
LIGATION  OF ARTERIES.
199
   To tie the radial artery on the outer side of the wrist, an incision is to be
made through the skin, from opposite the styloid process of the radius to the
commencement of the first interosseous  space.  The guide to the artery is the
extensor secundi internodiipollicis, which crosses the artery before it dips into
the palm.   The ligature is to be applied on the ulnar side of the tendon.


                       THE ULNAR ARTERY
In the upper half of the arm is covered by the four superficial  muscles which
arise from the inner condyle; in the lower half it is more  superficial, and  lies
between the flexor  digilorum  sublimis and the flexor carpi  ulnaris.  The
artery is accompanied by two veins.   The median nerve lies first on the inner
side;  it then crosses in front of the artery, and descends along  the middle of
the limb, lying on the ulnar side of the  artery.

                                Fig. 80.
TYING THE RADIAL AND ULNAR ARTERIES.
   To tie the ulnar artery in the upper third of its course, a longitudinal inci-
sion should be made, commencing about two inches below the inner condyle of
the humerus,  and  one-third of the width of the arm from  the inner edge, ex-
tending  downward about three  inches.  The division  between the muscular
mass should  be begun, if possible, between the  tendons and carried upward.
The ulnar nerve should be looked for as a guide  to the artery, and  the needle
should be passed from the nerves.   This portion of the artery lies so deeply
that the operationis seldom practiced.
   The  lower two-thirds of the ulnar artery is covered in its course by a
line drawn from the internal  condyle of the humerus to the radial side of the
pisiform  bone.  Its middle third  lies  between the flexor carpi ulnaris and
the flexor sublimis digitorum.
   To tie the ulnar artery just  above the wrist requires an incision two
inches long, three  quarters of an inch from the ulnar  edge of the limb;  the 
200
SURGERY.
incision should be just external to She flexor carpi ulnaris.  After the skin
and fascia have been divided, the artery will be found covered by the tendon
of the flexor carpi ulnaris, which  is internal, and the  tendon of the flexor
digitorum sublimis external.  The needle  should be  passed from within out-
ward, to avoid the ulnar nerve, which lies to the inner side of the artery; the
vena comites having first been separated.


                    THE COMMON ILIAC ARTERY.
  To tie this artery make  a slightly curved incision, six  inches in length, the
lower third being about two inches above Poupart's ligament, and parallel with

                                  Fig. 8i.
LINES OF INCISION FOR LIGATION OF EXTERNAL, COMMON AND INTERNAL ILIAC
                            ARTERIES.
it.   Divide the muscles and tear through  the  transversalis fascia;  gently
repress the intestines  upward, which  will protrude through  the  wound,  and
separate the peritoneum from the  iliac fossa.  When the  brim of  the pelvis is
reached, seek the external iliac, which is a guide to the common trunk.   Open
the sheath just  above the  bifurcation  and,  if possible, pass  the  needle  from
within outward.
99 
LIGATION  OF ARTERIES.                      201
                    THE EXTERNAL ILIAC ARTERY
Lies on the inner border of the psoas muscle, the vein being on the inner side
and below.  The genital branch of the genito-crural nerve lies on it  for a short
distance.   The artery is invested by the  peritoneum, and high up is crossed by
the sigmoid flexure of the colon on the left side, and by the ilium on the right
side ; the ureter is near its division.  Low down it is crossed by the spermatic
cord in the male and the round ligament in the female, and is crossed by the
circumflex  iliac vein.
   To tie the  external iliac the patient must be placed flat on a table, so that
the abdominal muscles may be rendered tense. Make an incision, three and
a half or four  inches long, above and parallel to Poupart's ligament, beginning
about half an inch outside the external abdominal ring; carry it through the
skin  and superficial fascia, and lay bare the external oblique tendon.  Then
cut through this tendon, the internal oblique and  transversalis muscles, to the
extent of the incision.   A portion of the muscular fibres should be lifted with
the forceps and carefully cut through, to form an opening, into which a broad,
flat, grooved director must be insinuated, and the muscle divided upon it to the
necessary extent.  Now gently draw the  edges of the  wound asunder with
bent spatube;  the  opening must be enlarged by tearing with the fingers. Then
carefully strip  the  peritoneum off from the  iliac fossa until the finger reaches
the artery.   The sheath must be  scratched through with forceps and director
at the point selected, and the artery separated from the vein, which will be
found on the inner side; the aneurism  needle is  then passed between them,
excluding the genito-crural nerve.   The wound  must be brought together by
sutures, and the trunk bent forward, to relax the muscles.


                        THE SCIATIC ARTERY.
   To tie the  sciatic artery the patient must be placed on his face, with his
toes  turned inward; make an  incision  four inches long, from two and a half
inches below the posterior spinous process of the ilium, an inch from the sacro-
iliac joint toward  the great trochanter.  The fibres of the gluteus maximus
must be  separated for the same extent, and having arrived at the strong fascia,
beneath the muscle,  the vessel will be found emerging from the sciatic notch;
the nerve and vein must be carefully avoided.
   The gluteal artery may be found by making the same incision, but one inch
and a half higher  up ;  be careful to avoid  the nerve and vein.
   These operations  are exceedingly difficult, but  are justified in the case of
wounds.
       N 
202
SURGERY.
Fig. 82.
                       THE FEMORAL ARTERY.
  To tie the femoral artery in its upper division, first ascertain its course,
which is indicated by a line drawn from the middle of Poupart's ligament in the
                             male, and a quarter of an inch toward the sym-
                             physis pubis in the female, to a point midway
                             between the inner edge of  the  patella and  the
                             internal  condyle of the femur, when the knee
                             is bent and the thigh turned outward; an incis-
                             ion, three or four inches in length, must be made
                             over it, about  two or three inches below Pou-
                             part's ligament.  Divide the fat and superficial
                             fascia;  the  saphena vein lies  on the  inside of
                             the  incision.  Then divide the fascia lata to
                             the same extent as the skin.  Draw the sario-
                             rius gently outward, which  will  expose  the
                             sheath  of  the artery;  open  it sufficiently to
                             admit the needle,  being careful not to transfix
                             the vein, which at the apex of Scarpa's triangle
                             is behind the  artery;  to avoid this use a blunt
                             needle;  pass it from the inner side.
                                To tie the femoral artery in the  lower
                             part of its course in Hunter's canal.   Turn
                             the limb a little outward, bend the knee and raise
                             the  leg  on a pillow; make an incision three
                             inches long, in a line drawn from the middle of
                             Poupart's ligament  to the inner  condyle, the
                             upper half in the  middle third, and extending
                             down into  the lower third of the thigh; cut
                             through the integument and take care to avoid
                             the  saphena vein.  Divide the deep fascia, ex-
                             pose the sartorius and the  tendinous aponeuro-
sis which passes under it.   With a retractor have  the edge of the muscle  held
outward.   Lift up a portion of the aponeurotic sheath with forceps and divide
it.  Introduce  a director  and divide  the  sheath upon it; the artery will be
found with the vein behind, and  a little to the outer side.  Pass the ligature
from without inward.
LINES OF INCISION FOR LIGATURE
 OF THE SUPERFICIAL FEMORAL
           ARTERY.
THE POPLITEAL ARTERY.
  To tie the popliteal artery, the patient is placed on his face, with his knees
straight; cut through the skin and fascia lata to the extent of three inches on 
LIGATION OF ARTERIES.
203
the outer border of the  semi-membranosus muscle;  press the muscle inward
and  the  artery will be felt, with the vein and popliteal nerves lying superficial
and external to it;  cautiously separate these, draw them outward, and pass the
needle around the artery.


                   THE POSTERIOR TIBIAL ARTERY.
  To tie the posterior tibial, in the upper part of the leg, the patient should lie
on his back, with the limb lying on its outer side, the knee half bent, and the

                                 Fig. 83.
TYING THE POSTERIOR TIBIAL ARTERY.
foot  extended on  a pillow.  A line drawn from the  middle of the popliteal
space to a point  just behind the inner edge of the internal malleolus, indicates 
204                             SURGERY.

the course of this artery.   An incision, four inches long, half on the upper and
half on the  middle third of the leg, and an inch from the inner edge of the
tibia, should be  made  through the skin and  superficial fascia.   Avoid the
saphena vein.  Divide the deep fascia, expose the muscles and draw aside the
gastrocnemius; expose  the  soleus, which is to be severed, then  pinch up the
fascia, perforate and divide it on a director; now divide the fascia which inter-
venes  between the superficial  and  deep  muscles, when the artery  will be
exposed, lying on the tibialis posticus.   The two veins are in very close  con-
tact; the nerve is superficial to the artery, and frequently to the  outer side.
Pass the ligature from without inward.
   To tie the posterior tibial in the middle of the leg, make an incision, three
inches long, in the middle  and lower  third of the leg, half-way between the
inner edge of the tibia and the  inner border of the tendo-Achillis.   Divide the
fascia.  The artery, surrounded with fat, accompanied by two veins, will be
found  along the inner edge of the flexor longus digitorum ; the nerve is on the
outer side.   In the upper part  of the leg, the posterior tibial  nerve lies to the
inner or tibial side of  the  artery;   it passes over  it  about  the middle,  and
inferiorly it  lies to its outer or fibular  side.   Pass  the ligature from without
inward.
   To  tie the posterior tibial at the ankle, make a slightly curved incision,
two  and a half inches long,  in the groove, half-way between  the hinder edge
of the internal malleolus and the extremity of  the heel, commencing near the
tendo-Achillis;  divide  the  superficial fascia, the dense fibres of the internal
annular ligament, which  adheres to the sheaths of tendons, and  covers the
vessels and nerves; and the artery  will be found with its venae comites.   The
ligature is to be passed from below upward, avoiding the posterior tibial nerve.


                   THE  ANTERIOR TIBIAL ARTERY.
   The course  of this  artery is indicated by taking  a  point on  a  line drawn
midway between  the head of the  fibula to the crest of the tibia; dropping
one  inch, and from thence drawing  a line midway between the malleoli.
   To tie this vessel in the middle of the leg,  make  an incision,  four
inches long, through the skin, half-way  between the  spine of the tibia and the
external edge of the fibula.  Now divide the intermuscular septum between the
tibialis anticus and extensor longus digitorum, cut the fascia  a little trans-
versely in the middle of the  incision; raise the toes, separate the muscles  with
the finger from below upward.   At the  lower part of the incision separate the
extensorpropriuspollicis from the tibialis anticus; keeping close to the latter.
The artery  is deeply seated, lying on the interosseous membrane, the  nerve  in 
LIGATION  OF ARTERIES.
205
front and a vein on either  side.  The needle should be passed  from without
inward.
  To tie the anterior tibial in the lower part of the leg, make an oblique
incision, upward and outward, three inches in length, commencing at the junction
of the middle with the lower third of the leg, half an inch external to the spine
Fig
TYING THE ANTERIOR TIBIAL ARTERY.
of the tibia; then divide the fascia covering the tibialis anticus, and the artery
will be seen lying on the tibia  external to the lower portion of the muscle,
accompanied by its veins.  When the nerve is separated from  the artery, the
ligature needle is to be passed from without inward. 
206
SURGERY.
                       THE PERONEAL ARTERY.
   To tie this artery an incision four inches long  is to be made, almost in the
centre of the leg;  an  inch behind the external  edge of the fibula.   Find the
soleus and separate it from the peronei which encircle the outer side of the fibula;
to expose the flexor longus pollicis it may be  necessary to detach a  portion of
the peronei; the fibres of which must  be separated longitudinally with the
handle of the scalpel, and the  artery should be found  about the centre, near
the edge of the fibula.  Bend the great toe so as to relax the flexor longus
pollicis when it is exposed.


                         THE DORSAL ARTERY.
   The dorsal  artery of the foot lies under  cover of the integumen^ and
aponeurosis,  and is readily exposed by carrying the knife along the outer border
of the tendon of the extensor longus pollicis.   A line drawn from the middle
of the malleoli to the centre of the first interosseous space will cover  the course
of the artery. The incision  should be  about  an inch and a half  in length.
The vessel is accompanied by a nerve and two veins.
                       URINARY CALCULI.
  Urinary Calculi are found in four different situations in the urinary organs;
in the kidney, ureter, bladder and urethra.
  A precipitate let fall from the urine after it has been voided  is called a sedi-
ment; when precipitated in the bladder  or kidneys it is  called gravel; and
gravel lodging in any part  of the  urinary passages may  concrete into stone.
When the urine habitually presents any one kind of deposit, the patient is said
to have a corresponding diathesis, as the lithic diathesis, etc.
  The  lithic or  uric  acid, or red  gravel, is  deposited in the form of minute
crystals, tinged with the coloring matter of the urine.
  The  lithates of ammonia, soda  and lime  form  a very common  sediment,
varying in color from nearly white to dark red.  Urine .generally acid.
  Oxalate of lime is generally deposited from  urine which is acid and contains
much lithate.
  Phosphatic deposits may arise from excessive secretion  of the mucus of the
bladder, or from  a primary alkaline or insufficiently acid state of the  urine.
  When a patient is secreting the red crystalline gravel, or  has a fit  of the
gravel, as it  is called, he generally complains of great pain in the  loins and
bladder, frequent desire to make  water, and aching of the testicles and  hips;
sometimes there is feverishness, with languor and dyspepsia. 
URINARY  CALCULI.
207
   Treatment.—The patient should be treated on general principles; if he be
lusty, with red lips, has been living highly, and has not been long an invalid,
he will generally be  relieved by purgation, a  reduced diet, warm baths, and
liq. potassae, in  doses  of ^j, thrice daily, after meals.   Exercise, temperance
and restricted diet will correct this diathesis.
   But if the urinary deposit is caused by feebleness of the powers which ought
to convert food  into healthy flesh  and blood,  or  by overwork, the treatment
should begin with judicious purgation, with change of diet and air, and a per-
sistent tonic course;  nitro-muriatic  acid may be given with benefit; quinine,
nux vomica, muriated tincture of iron, etc.
   Various Kinds of Stone.—The chief varieties are the lithic, phosphatic
and mulberry.
   Lithic or Uric Acid stones are generally oval, flattened, fawn or mahogany
colored.   This stone may be dissolved by boiling in liquor potassae; it burns
away under the blowpipe, and if digested in nitric acid, and evaporated at a very
gentle heat, it leaves a residue which, when cold, becomes  purple, if exposed
to the vapor of ammonia.
   Triple Phosphate forms white  or  pale gray stones.  When treated with
liquor potassae evolves ammonia;  is soluble in acetic and muriatic acids.
   The Mulberry stone is composed of oxalate of lime.  It is dark red, rough
and tuberculated. It is not dissolved by boiling in potassa; is soluble in nitric
acid;  exposed to the blowpipe, the acid is burnt off and quicklime is left.


                   STONE IN KIDNEY AND URETER.
   Symptoms of stone  in  the kidney are  pain in the loins,  irritation  and
retraction of the testicle; urine bloody after jolting exercise, and occasional
attacks of inflammation  of  the kidney.   They are most frequently composed
of lithic acid, known by the deposit of red sand from the urine.
   Treatment.—Attend to  the general health;  expedite  the passage of the
stone  by diluents and diuretics; bicarbonate of soda, acetate of potassa; remove
inflammation by cupping, leeches on the loins, mild aperients, enemata of warm
water, warm baths, sedatives, etc.
   The ordinary and most  favorable  course  of a stone in  the  kidney is to
descend through the ureter into the bladder.  Should it remain in the kidney,
it  may increase in size and  fill up the pelvis and infundibula, and cause the
organ either to waste or suppurate.
   The passage of a stone through the ureter is known  by  sudden and  severe
pain,  first in the loins and groin, subsequently in the testicle and inside of the
thigh.  The testicle  is retracted spasmodically.  Other  symptoms  are violent 
208                             SURGERY.

sickness, faintness and collapse, which may last two or three days, and are only
relieved when the stone reaches the bladder.
  Treatment.—Warm baths, large  doses of  morphia or chloral,  emollient
enemata, plenty of diluents.  During the paroxysm chloroform may be inhaled,
to relieve pain and allay spasm.


                       STONE IN THE BLADDER.
  Symptoms.—Irritability of the bladder, with frequent irresistible  desire to
make water, occasional sudden stoppage of the stream of water during micturi-
tion, and the stream flowing again if  the patient throws himself on his hands
and knees, occasional pain at the neck of the bladder, pain in the glans penis,
and  frequently passage of blood and crystals  of uric  acid or oxalate with the
urine; if a child, there will be elongation of prepuce, from his  attempting to
alleviate his pain by pulling at the organ.
  But to make sure of the existence of stone, a sound must be employed, when
it will be made sensible to the touch and to the ear.  The sound is a solid
steel rod, of the size of the medium  catheter;  its handle is  polished, and  its
shaft is smaller at the end, so  as to move easily into the urethra.  Sometimes
the stone cannot be felt, either on account of an enlarged prostate, or because
cysts or pouches exist in which the foreign body is hid.
  The symptoms of stone vary in severity, according to its size and roughness,
the state of the urine, or the  condition of the bladder, whether  healthy or  in-
flamed.
  Treatment.—The indications are to get rid of the abnormal condition of
the urine;  to allay pain and irritation, and to remove the stone.  The first two
measures have already been spoken of.
  Lithotrity and Lithotomy are the methods pursued to remove the stone.
  Lithotrity is an operation  for crushing stone in the bladder into fragments
of so small a size that they may readily be  expelled through  the urethra; the
instrument generally used is the lithotrite of Bigelow.
  The best cases  are those with a urethra of  full size, and a bladder neither
irritable, contracted nor paralyzed.  The danger is in  mechanical injury to the
bladder.
  The patient should be placed on his back, on  a couch, with his head on a
pillow, knees gently raised and supported, and a little apart.   The pelvis should
be raised above the level of the shoulders.
  The object is to get  the stone away from the neck of the bladder.  The
bladder should hold  from  four  to eight ounces  of water.   The  instrument,
warmed and oiled, is now  to  be gently introduced and  passed fully into the 
URINARY CALCULI.
209
bladder.   The next  step is  to seize the  stone; this is done by applying the
instrument to  the  stone, so  as to seize and lift it, by rotating the  instrument
upon  the  axis of  its shaft.   When  the  stone is  fairly grasped, the  screw  is
employed to crush it; at the end of the operation it must  be seen that the
blades are entirely closed and not choked by detritus, while the instrument is
withdrawn.
  Subsequently,  pain must be relieved by opiates.  Hip baths and demulcent
drinks must be used, to  allay irritation.   The operation must be repeated  at
intervals, till every fragment is crushed and expelled.

  Lithotomy.—There  are  several  methods by which lithotomy may be per-
formed.
                                 Fig. 85.
LITHOTRITY.
   1st.  The Lateral Operation.—The bladder may contain a little water;  the
bowels should be cleared previously by an enema.
   A good firm table, 2^  feet high, is necessary  for  the operation.   The
patient  should lie down and chloroform be  administered.  The  sound or a
staff should then be introduced and made to touch the stone, if possible, so that
there may be no mistake.  The patient should then be placed on his back, with
his shoulders  raised by a pillow.  Then the  perineum should  be thoroughly
exposed;  the thighs must be raised and separated;  knees bent, and each foot
must be grasped with the hand of the same side.  The hand and foot must then
be firmly bound together with a bandage.  The buttocks should be brought to
the edge of the table and the perineum shaved.  An assistant on each side holds 
210
SURGERY.
the thighs asunder;  the surgeon places the fingers of the left hand on the right
buttock, and with the thumb fixes and steadies the integuments of the perineum,
taking care not to draw them up.  He then  makes a free incision of the  skin
and subjacent tissues, entering the knife just on the left side of the raphe, about
one and three-quarter inches in front of the anus, and cutting downward to mid-
way between the anus and  the  tuberosity of the  ischium.  The blade of the
knife should next be run along the surface of the exposed fat and cellular tissue,
and then the forefinger of the left hand thrust into the wound, about its middle,
and directed  upward  and forward between  the  left  erector and accelerator

                                 Fig. 86.
LATERAL OPERATION.
muscles; the finger then feels the groove of the staff in the membranous part of
the urethra.
  The left forefinger nail is now to be well fixed in the groove of the staff,
the knife is slipped in over it, with its flat surface obliquely placed; its points
made to slide along the groove toward  the bladder, dividing the membranous
part of the urethra and the edge of the prostate.  The knife being withdrawn,
the left forefinger is gently  insinuated  along the staff.  Next the assistant re-
moves the staff and the surgeon introduces the forceps over the finger into  the
bladder. 
HARE-LIP.
211
   2d. The Bilateral operation  is performed by making a curved incision,
 with the convexity upward, from one side of the perineum to the other, carrying
 it between the anus and the bulb of the  urethra, opening the membranous portion
 of the urethra, and then pushing the bistouri cache into the bladder, by which
 both sides of the prostate may be divided.
   3d. The Recto-vesical operation consists in cutting  into the bladder from
 the rectum, in the middle line behind the prostate.
   4th. The High operation is performed in the hypogastric region above the
 pubes, by making an incision through the  linea alba and opening the bladder
 at its fore and upper part, where it is not covered with peritoneum.

                             HARE-LIP.
   Hare-lip is a congenital fissure of one or both lips;  generally perpendicular,
 but it may be more or less oblique.
   As a rule, the division is just below the septum of the nose, but it sometimes
 corresponds to one of the nostrils.
   Hare-lip may be  single or double; single when the fissure is only on one
 side, and double when there are two fissures with a small  flap of skin between.
   In the  operation for the relief  of hare-lip the principle  is union by the first
 intention.
   If the  case is one of single hare-lip, detach freely the lip from the bones
 behind, then pare off the edges  of the fissure  by means of a small bistoury;
 care must be taken to cut  off a  sufficient quantity of
 the edge, as at the margin the parts are  apt to be cal-         FlG-  &7-
 lous.  The surgeon pierces the lip with a narrow knife
 at the top of the fissure, just under the nose, and car-
 ries the instrument downward, so as to shave off the
 edge of the fissure ;  the operation is then repeated on
 the other side, and the two strips are then detached  at
 the upper angle.   The parts are now brought together
 as nicely as possible, and retained in their position by
 means of the twisted suture. Three pins should  be
 used for the purpose; the first is put at the edge of the red margin of the lip,
 and the two others at equal distances higher up.  Then a long piece  of thick
 silk should be twisted around the  pins, and the suture covered with collodion.
 The pins used should be galvanized, or made of silver; in  the absence of
 these, needles may be  employed, when the point should  be  carefully clipped
 off after the silk has been twisted around them.  If the hare-lip is double, the
operation should be conducted as in single hare-lip, but the  closure of the second
fissure should not be attempted for at least two weeks after the first operation.
 
212
SURGERY.
        AFFECTIONS OF THE NASAL  PASSAGES.

                  FOREIGN BODIES IN THE NARES
Should be removed as soon  as possible; their  removal may be effected by a
small spoon or canula.   If they cannot be brought through the nostrils, they
should be gently pushed back into the throat.
                              EPISTAXIS.
  Hemorrhage  from the nose may be produced by injury, by vascular excite-
ment, plethora, or determination of blood into the head, by the  suppression of
some other discharge, by irritation  of the mucous membrane, by passive drain-
ing of venous blood, and by a want of tone or contractility in the blood-vessels.

                                Fig. 88.
APPLICATION OF BELLOCq's CANULA.
   Treatment—Ordinary cases of epistaxis can readily be controlled by simply
c osing the nostrils with the  thumb and forefinger, for the space of ten minutes-
at the same time breathing through the mouth.   If the patient be  full-blooded
and  plethoric, and subject to headache  and giddiness, a  purgative should be
administered  and the  diet regulated;  if the bleeding  continues,  aromatic
sulphuric ac:d should be given, and if the patient be anemic, iron  and quinine
should be used.  If it 1S *passive hemorrhage> depending Qa         ^ 
FOREIGN BODIES IN AIR  PASSAGES.
213
the patient should be kept quiet in a cool room ; he should lie with his shoulders
raised; he should suck and swallow pieces of ice, and should apply ice or ice-
cold water to the nose and forehead; and a bladder of the same to the  nape
of the neck.   In persistent cases, plugging the nostrils is necessary.  This  is
done by Bellocq's canula, which  is a curved silver tube, in which lies a curved
spring, having at the end an eye  for the reception of a piece of string; this  is
drawn into the canula, the curved end of which is passed along the floor of the
nostril. The spring is then protruded by pushing the handle, causing the spring
and string to appear in the back  of the mouth below the soft palate, where  it
can be secured with the finger and forceps.   The end  of  the  string in the
pharynx is then brought through  the mouth, and a piece of soft sponge is tied
to it; then, by pulling the string  back through the nose, the sponge is thrown
into the posterior opening of the nostril,  leaving one end of the string in the
corner of  the mouth.  The anterior nares should then be plugged by a fold  of
lint passed on the end of the probe and tied in by the nasal end of the string.


           FOREIGN BODIES IN AIR  PASSAGES.
   The foreign body may be impacted in the ventricles of the larynx, or in the
trachea, in which case it will probably produce violent spasmodic  cough and
difficulty of  breathing, together with fixed pain in one particular spot, a croupy
sound during respiration, readily detected  by  the  stethoscope;  loss of voice,
and probably acute inflammation.
   It may be loose in the trachea, especially if it be a pebble, grain of corn,  or
coffee, or other smooth substance. In such case the violent coughing and  sense
of suffocation produced  by the first introduction of the article generally subside
for a time, but every now and then there are violent fits of coughing and  spas-
modic difficulty of breathing, during which the  substance  may be heard by
means of the stethoscope.
   It may have passed into one of the bronchi,  where it is frequently detected
by causing a whistling  or murmuring  sound, and it may  be  dislodged and
driven upward when the patient coughs.   The right bronchus is that  into which
it generally falls.
   Treatment.—Very little time should be wasted in attempting to get rid  of
the foreign body, until  the operation of  larvngotomy or tracheotomy  is per-
formed ; it may be well, however, if  the  substance is movable and round,  to
place the  patient on the bed and administer  an  opiate, when it may become
coated with mucus, and  may be expectorated during  coughing or vomiting,  or
when the  patient  is narcotized he may be quickly turned upside down,  when
the foreign  substance may  suddenly be ejected;  these devices  failing, the
surgeon must resort to— 
214
SURGERY.
  Laryngotomy, if the substance is arrested sufficiently high up.  This opera-
tion is performed by cutting longitudinally through the skin, then horizontally
through the crico-thyroid membrane, which may be felt as a soft depression,
an inch below the Pomum Adami.
  Tracheotomy is performed by the surgeon standing on the left of the patient,
whose head being thrown  back, an  incision an inch and a half or two inches
long is made exactly in the middle line, from near the top of the sternum to the
cricoid cartilage.  The skin and superficial fascia are cut through ; the sterno-
thyroid muscles separated  and  a few  fibres  divided  with  the point of  the
knife; the loose cellular tissue and veins are cleared from the  front of the
trachea with the forceps, the thyroid gland is pushed up, a pair of slender hook
forceps fixed in the trachea, so as to slightly draw it up; while  the  trachea is
stretched, the surgeon passes his knife at the bottom of the wound and carries
it upward, so as to divide two or three rings of the trachea.
  Various other  methods  of  performing  tracheotomy have  been  devised,
which the student can see by consulting larger works on Surgery; together
with descriptions of tracheotomy tubes that are in use.


                 AFFECTIONS  OF THE  EAR.
  Accumulation of Wax, mixed with hair and  cuticle, is a frequent  cause
of deafness.  The patient complains of loud  noises, and of a  feeling of dis-
comfort and defective hearing.   An  examination with the speculum will  allow
the wax to be seen.   It will generally be removed by syringing, but should it
not be brought away after  two or  three efforts,  the best plan is to fill  the
meatus with glycerine, stop it with a bit of cotton, and let it remain for twenty-
four hours, to soften the wax.   The syringe may then be used again.   A drop
or two of olive oil, or of glycerine,  should be inserted after syringing.   The
water used should be warm enough to be comfortable.
  Small  Follicular Abscesses frequently form within the meatus, especially
in persons of weak constitutions.  They are apt to recur and are very painful.
Fomentations as hot  as can be borne,  the  application of a leech, or some
preparation of opium give relief.   When the abscess is bound down by tough
skin, a puncture will  relieve the pain promptly.  If the pain is very great, the
patient should be given a dose  of morphia.
  Eczema of the Auricle is apt to produce  thickening of the lining mem-
brane of the meatus and membrana tympani.
  The treatment consists in giving; during the  acute stage, purges, and apply-
ing soothing fomentations;  in the  latter  stage the black wash may be used as
an injection, or dilute  ointment of nitrate of mercury.   Tonics and  alteratives
should be administered, such as quinine, iodide of potassium, cod-liver oil, etc. 
PHIMOSIS AND PARAPHIMOSIS.
215
               PHIMOSIS  AND PARAPHIMOSIS.
  Phimosis is a  constriction of the  prepuce, which prevents  the
being uncovered.
  It may arise  from inflammation of the
cellular tissue and effusion of serous mat-
ter  into it;  it  is  frequently the result of
chancre.
  If congenital, this disability may be re-
moved by gradual dilatation with sponge
tents, or daily distention.
  For radical  cure, the operation for cir-
cumcision may be performed.  If  this
operation is  performed, the  foreskin must
be  drawn out; held between the blades
of the forceps  and then cut straight off,
after which  the mucous lining should be
turned  up so  as  to uncover the  glans.
Sutures  should be  passed  through the
margin  of the  incision, to draw together
the edge  of the  skin and the mucous
lining of the prepuce.
glans  from
Fig. 90.
PARAPHIMOSIS. 
216
SURGERY.
  Paraphimosis is a constriction of the prepuce from  inflammation, so that
the skin, having been pulled back, cannot be  again  drawn  over the glans
penis.
  Treatment.—The object is to reduce the strangulated part as quickly as
possible.   The penis being greatly distended with blood; take hold of the glans
between the fingers, and endeavor to empty the vessels by gentle pressure. When
this has been  continued  for a few moments, endeavor to reduce it by pushing
the glans back, and at the  same time drawing the skin of  the  penis forward.
If the  paraphimosis is not  relieved  by this treatment, it will  be necessary to
divide the stricture with a  bistoury.   Do this by separating the skin on each
side, then insert a director  under  the stricture and divide it, which will allow
the skin to be readily drawn over the penis.  Then apply  cooling lotions.
              HYPOSPADIAS "AND EPISPADIAS.
  Hypospadias, a malformation, in which the  canal of the urethra, instead
of opening at the apex of the glans, terminates at the base, or beneath the penis.
Hypospadias is ordinarily incurable.
  Epispadias is the opposite of hypospadias; i. e., it is a preternatural open-
ing of the urethra at the upper part of the penis.   The patient may be benefited
by a plastic operation, depending on the case.
                          HYDROCELE.
  Hydrocele is an accumulation of serum  in the tunica vaginalis testis.  It
may be of the tunica vaginalis, and of the spermatic  cord.
  The swelling of hydrocele of the tunica  vaginalis first shows itself at the
lower part of the scrotum, and  gradually rises till it  arrives  at the abdominal
ring;  it is of a pyriform shape, largest two-thirds of the way downward, less
at the bottom and smallest at the ring.  Usually it is attended with pain.  Com-
monly there is no discoloration of the scrotum.  The ordinary situation of the
testicle is  two-thirds of the  way down the tumor at  the  posterior part, but it
may sometimes be found in front, or at the bottom.
  The diagnostic signs are a sense  of fluctuation, transparency, lightness, free-
dom from pain.   In very old cases the tunica vaginalis becomes much thick-
ened and the transparency may be absent.

  Congenital Hydrocele.—When the tunica vaginalis preserves its communi-
cation with the  abdomen, and then becomes filled with serum, forming a cylin- 
HEMATOCELE.
217
drical tumor, extending to or through the abdominal ring, it is called congenital
hydrocele.   On  being raised  and
compressed the fluid  is slowly                 Fig. 91.
squeezed  into  the  abdomen  and
slowly trickles down  again after-
ward.
  Treatment is either palliative or
curative.
  The evacuation of the serum con-
stitutes the palliative treatment.
  This is accomplished  by a punc-
ture with  a  grooved needle, or a
small trocar and canula.  Palliative
treatment is sufficient for children,
but rarely so in the case of adults.
  The radical cure is performed by
injecting stimulating fluid or intro-
ducing setons into  the tunica vagi-
nalis.  The radical cure is not ad-
missible if the testis is diseased, or
the  hydrocele  is accompanied by
irreducible hernia.
  Operation.—The surgeon grasps
the tumor behind and passes a trocar and canula into it, pointing the instrument
slightly upward, to  avoid injuring the testicle.   He  withdraws  the trocar and
allows the  fluid to escape.  When the sac is emptied, a fluid composed of one
drachm of tincture  of iodine  and one or  two drachms  of water is injected
through the canula  into  the sac.  When  the  inflammation subsides the fluid
generally secretes no longer.  When this fails the surgeon should cut down and
remove a portion of the tunica vaginalis  testis, or  attach it to  the  skin by
stitches.
HYDROCELE.
                          HEMATOCELE.
  Haematocele is an extravasation of blood into the tunica vaginalis.
  Generally  occurs as an  immediate consequence of injury of the scrotum;
sometimes it arises without  any assignable cause.
  There is swelling of the  part, which comes on immediately or soon after the
receipt of the injury;  it resembles hydrocele,  as  regards shape.  At  first the
tumor is soft, and fluctuation may be detected, but when the blood coagulates
it resembles in its character a solid growth.
       o 
218                            SURGERY.

  Treatment.—In a recent case the first indications are to arrest the flow of
blood and relieve pain.   The horizontal posture, with testicles raised, is neces-
sary;  the iced bag and cold lotions must be applied: if the blood remains fluid
for a long time tapping may be performed.   In chronic cases, where there are
signs of suppuration, a free incision  should be made into the vaginal sac, and
the cyst and the clots turned out.  Then follow the usual treatment to promote
healing by granulation.


                          VARICOCELE.
  Varicocele is a varicose state of the veins of the spermatic cord.  It is more
common on the left side.
  Treatment.—Keep  bowels open;  wash the scrotum frequently with  cold
water; support scrotum  with suspensory bandage.
  For radical cure it is  recommended to pass a ligature subcutaneously, so as
to divide veins only and not  the skin.  Operations on the veins are always
attended with some risk.  Many surgeons cut down on the veins, and ligate
them with catgut.
   CARCINOMA OF THE TESTICLE—CASTRATION.
  This is generally of the soft variety.  Gland  swells, becomes hard, heavy
and elastic; at this period it is  scarcely painful or tender, and merely causes
slight aching in the loins, from its weight. After a time it enlarges rapidly and
feels soft; the cord swells; the pain becomes severe and darting.  Secondary
tumors form in the iliac fossa, and emaciation, exhaustion and death follow.
  Castration.—The method of performing the  operation is as follows:  The
scrotum being shaved, the operator  grasps it behind, so as to stretch the skin,
and makes an incision into the tunica vaginalis, to examine the testis.   If there
is no doubt of  the diagnosis the  cut is extended to the bottom of the scrotum.
If the tumor is very large, two  elliptical incisions may be made, to remove a
portion of the skin between them; then separate  the  cord from its  attach-
ments ; an assistant holding it between his finger and thumb, or with a stout
pair of forceps, to prevent it retracting when  cut; a long, stout ligature being
passed through its connective tissue, so that in the event of  secondary hemor-
rhage, the cord may at any moment be pulled out.  Then pass the bistoury be-
hind the  cord and divide; and seizing the lower portion dissect out the testicle.
All arteries requiring it are to be tied, and the wound is not to be closed  until
all hleeding has ceased, as there is frequently secondary hemorrhage. 
HEMORRHOIDS—FISTULA IN ANO.                 219
                         HEMORRHOIDS.
   Hemorrhoids are tumors situated near or in the anus, and are distentions
of hemorrhoidal veins, with inflammatory swelling, congestion and hypertrophy
of the mucous or submucous tissue.
   Piles are either external or internal; if situated within the rectum they are
denominated internal; if they are seated  on the verge of the anus they are
called external.
   If they are attended with discharge of blood they are called open ox bleeding
piles;  when there is no discharge they are denominated blind piles.
   The symptoms of  external  piles are pain when passing faeces, or tenesmus
after discharge; at first there is a projection of a livid appearance, which in a
few days becomes solid;  the blood becomes coagulated in  the hemorrhoidal
veins.   In a few  days the pressure of the faeces  brings down the pile, and it
becomes external.   When inflammation comes on the patient suffers greatly,
and can only be tolerably comfortable in a recumbent position.

   Treatment of External Piles.—If consulted early, while the pile is only
a livid projection, an active purgative should be administered, avoiding such as
have particular influence on the rectum, such as aloes.  Leeches may be ap-
plied in addition.  As a local application liquor plumbi acetatis is highly com-
mended.
   If the pile has  continued until it  has become solid, insert a lancet into it,
and press out the clot; then apply a cooling lotion, administer a purgative, and
the patient will be rid of  the disease.

   Internal Piles are frequently accompanied by a high degree of fever, with
a sense of weight and pain in the sacrum; pressing at stool causes the disease
to show itself  by prolapsus ani,

  Treatment.—The irritation must be relieved by general and local treatment.
Apply leeches and  fomentations; if these measures do not  cause  relief, the
pile must be removed by ligature.
                        FISTULA  IN ANO.
  This is a fistulous ulcer by the side of the rectum, through the fibres of the
sphincter ani.
  There  are three kinds recognized in books :   I. The complete  fistula, which
has one external opening near the anus and another in the bowel above the 
220
Fig. 92.
FISTULA  IN ANO.
         SURGERY.

sphincter.  2.  The  blind, or  incomplete external fis-
tula, which  has no opening  in  the  bowel.   3. The
blind, or incomplete internal fistula, which opens into
the bowel, but not externally.
  Treatment consists in the division of the sphincter
ani, so as to prevent the contraction of that muscle for
a time.  Before operating, the digestive organs must
be  put in good order, and a purgative must be ad-
ministered, so  that  the bowels may not be disturbed
for two or three days.
                        PROLAPSUS  ANI.
  This is  an eversion of the lower portion of the rectum, and its protrusion
through the anus.  The affection is most common in infancy and old age.   It
may come from straining or from natural laxity.
  Treatment.—The parts should be carefully washed, and then replaced by
gentle pressure with the fingers.   If there is any difficulty, the forefinger, well
oiled, should be pushed into the  anus, when it will carry the protruded part
with it, after which a thick compress, saturated with some astringent lotion,
should be bound to the part by means of a T-bandage.   The bowel is to be
kept in its place by means of quietude  and the recumbent posture, and, if neces-
sary, tonics should be resorted to.   Lotions of a solution of alum, sulphate of
zinc, decoction of galls, and astringent injections are to be employed, if neces-
sary.
                   FISSURE  OF  THE ANUS.
  This is a small chap, crack, or ulcer, which gives intense pain during defeca-
tion, frequently continuing for some  time after the  evacuation.  It may be the
remains of an external pile, and is  generally situated behind it,  and leads to
the fissure.
  Purgatives frequently give relief, and lotions of sulphate of zinc, of tannin,
nitrate of silver, or sulphate of copper, are  often beneficial; an ointment of
galls with lead may be tried.   Should these remedies not answer, forcible dila-
tation may be resorted to, so .as to temporarily paralyze the sphincter muscle.
To accomplish  this, the two thumbs, well oiled, must be introduced into the
rectum, and  then, by  firmly grasping the nates with  the fingers, the sphincter
muscle is dilated, by drawing the thumbs apart. 
CARCINOMA OF THE RECTUM.
221
  Should this means fail, an incision into the part should be made, through the
fissure or ulcer, with a straight, narrow, blunt-ended bistoury, so as  to divide

                              Fig. 93.
FISSURE OF THE ANUS.
the mucous membrane, and in severe cases, to divide the sphincter.  A small
piece of lint should be laid in the wound, so that it may heal by granulation.
               CARCINOMA  OF  THE RECTUM
May commence  as a distinct tumor, or as an infiltration into the walls of the
bowel, causing stricture.   The  earliest symptoms are uneasiness in the rectum,
aching pain in the back, hips and thighs, and irritation of the bladder.   As the
disease advances, the bowel becomes more or less obstructed; there is frequent
discharge of a fetid, muco-purulent  matter, streaked with blood, and obstinate
constipation attended with swelling of  the abdomen, and sometimes with the
symptoms of acute obstruction.  There may be profuse and exhausting diarrhoea.
Peritonitis, or perforation  of the  distended bowels, with exhaustion, terminate
the patient's suffering in death.
  Treatment.—Keep up the action of  the bowels by enemata of warm water
and very mild laxatives;  allay irritation by occasional leeching, by belladonna
and opiate applications, suppositories or  enemata.   The  patient's strength is to
be sustained by tonics, cod-liver oil, etc., etc. 
222
SURGERY.
                        VARICOSE VEINS.

                                 VARIX
Is an enlarged and  tortuous state  of  the veins, which are usually thickened,
rigid, and formed into irregular pouches.
  It is most frequently seated on the lower extremities, scrotum and rectum.
  Varicose veins of the leg are accompanied by pain, weight, fatigue on taking
exercise; they cause ulcers and excoriations of the skin;  they sometimes burst,
causing profuse hemorrhage, and occasionally blood clots in the veins, which
may terminate in an  abscess.
  Treatment.—The palliative treatment consists in applying strips of leather
over the part, a common roller, as Martin's roller, or an elastic stocking, which
should  be applied in the morning, before  the  patient  rises.   Galvanism or
faradization has been recommended.
  For the radical cure many methods have been devised; Sir B. Brodie recom-
mended division of the vein by subcutaneous  section; Watson,  of New York,
advocates excision  of a  portion of the  affected vein; again, potassa fusa and
quicklime, to cause slight inflammation, has  been  suggested.  Pressure and
the twisted suture both have their advocates.
                           CLUB FOOT.
  This is a deformity  of the foot, produced by rigidity and  contraction of
various muscles of the leg.

                          TALIPES EQUINUS
Is where the heel merely is raised, so that the patient walks on the ball of his
foot.

                           TALIPES VARUS.
  The heel is  raised, the inner edge of the foot  is drawn upward, and  the
anterior two-thirds twisted upward,  so that the patient walks on  the  outer
edge, and in extreme cases on the dorsum of the foot and outer ankle.


                          TALIPES VALGUS.
  The outer edge of the foot is raised, the longitudinal or inner arch flattened
by the sinking of the  head of the  astragalus, and the patient walks on the
inner ankle. 
CLUB FOOT.
223
                         TALIPES CALCANEUS.
  The toes are raised and the  heel  is depressed, so that the patient walks
entirely upon  it.   There  are also compound  varieties, which need  not be
enumerated in a work of this kind.
  These deformities may all be congenital, or they may appear after birth.
  Contraction and shortening of the  muscles are the cause of club foot.  In
non-congenital cases they may be brought on by spasms affecting many muscles,
which may be dependent on a rheumatic fever, or produced by irritation directly
from the spinal cord, or they may be sequelae  of bruises, injuries or diseased
joints.
  Treatment.—In recent cases remove  all irritating causes, soothe spasms,
Fig. 94.                            Fig. 95.
DR. ALLIS* CLUB-FOOT APPARATUS.
stimulate palsied muscles.  If the case comes under the surgeon's notice before
the contracted muscles become fixed, use constitutional remedies, fomentations,
etc.   In slight cases light splints of guttapercha or wood, with bandages, may
be of service.
  In severe cases it is better to resort to Stromeyer's operation of subcutaneous
tenotomy.  By this operation the  mechanical shortening  of  the muscle  is
obviated; the tendon being divided, its  separated  extremities  heal by a new
connective tissue, which  renders it  longer, and may be readily  stretched while
recent.
  To perform this operation, the tendon is put on the stretch, and  a narrow, 
224                             SURGERY.

sharp-pointed tenotomy knife is thrust through the skin on one side of it, then
its edge is turned against the tendon and made to divide it as it is being stretched.
Some surgeons  prefer to pass the knife under the tendon, and then cut toward
the skin, and others pass  it between the tendon and the  skin and cut toward
the deeper parts.
  In talipes  equinus the tendo-Achillis is cut.
  In talipes  varus the tendo-Achillis, tibialis  posticus, anticus and flexor longus
digitorum.
  In valgus  the peronei and the extensor longus digitorum.
  In some cases it may be necessary to cut a portion of the plantar fascia, or
the muscles  of the sole of the  foot.
  Dr.  Oscar H- Allis has devised a " club-foot apparatus," which  can be
readily understood  by reference to the accompanying figures.
                    INGROWING  TOE  NAIL.
  This affection is most frequent on the great toe; the incurvation usually exists
on both  sides, though more frequently on  the  inner  side.  It is generally a
source of great suffering, on account of the pressure exerted on the soft part at
the side of the toe, which swells, ulcerates and discharges a foul, fetid fluid,
and is covered with tender granulations.
  It may arise from an abnormal  formation of the nail, but it is frequently
produced by the use of tight, narrow shoes.
  If the  disability is slight the patient may be relieved by the persistent use of
scraped lint being inserted under the nail, a small roll of linen laid between
the nail and the overlapping skin, and then applying a strip of adhesive plaster
so as to keep the parts asunder.  In severer cases the most reliable method is
to excise  the  edge of the nail.  With a strong  scalpel the nail is divided  its
whole length, on a line with the incurvated  edge, which is then detached, root
and all being embraced  in the  operation.   Warm-water dressing or opiated
water is then applied and the part is kept at rest.
                CARBUNCLE,  OR ANTHRAX,
Is a hard and  circumscribed inflammatory spot of the true skin;  varying in
size, usually forming  on the cheek, neck or back;  infiltrated with unhealthy
lymph, and  is a dull  red swelling, very tender to the touch and accompanied
by a heavy,  aching pain. 
BOIL, OR FURUNCLE.
225
   Carbuncle is generally preceded  by pain, and is from the first a swelling  of
considerable hardness; the surface of the tumor then assumes a livid  redness
and a spongy feel; little ulcers now form on the skin, which give it a sieve-like
appearance, so numerous are the orifices; from these a whitish discharge exudes.
When the little  openings are formed into  one, the dead  cellular  membrane
begins to escape.
   Carbuncles are generally accompanied by great prostration, sickness, loathing
of food, headache, and other symptoms of low febrile impression.
   Treatment.—It is  well to begin the treatment with a calomel purge; after
thorough  purgation the treatment should be  tonic and  sustaining; the most
suitable articles are quinine, iron, nourishing broths and brandy.  To allay pain
and procure sleep an opiate will be needed.
   The best topical application is the warm-water dressing, with acetate of lead
and opium.  Penciling the surface with tincture of iodine, and in some cases
applying  a  blister over the  infected  part, are  highly recommended.  S. D.
Gross recommends, as a speedy and effectual method  of relief, the introduction
at four opposite  points of a delicate tenotome; making a subcutaneous  division
of the wounded tissue in such a manner as to traverse the entire swelling;  or,
after making the necessary incisions, paint the inflamed area with tincture  of
iodine, wash the part with bichloride  solution, then apply adhesive  plaster,
leaving an opening for free drainage.  Compress with bichloride sponge, and
place over this iodoform cotton.
   When the disease has passed into  gangrene, the remedy is a free incision,
the knife  being carried through the skin down to the healthy structures beneath.
If the dead tissues are slow in coming away, their extrusion may be expedited
with the  scissors;  the surface of the  ulcer being well, touched  immediately
afterward with dilute acid nitrate of mercury, or solid nitrate of silver, to pro-
mote the  formation of healthy granulations.  Use, several  times a  day, injec-
tions of solutions of chlorinated sodium, carbolic acid, permanganate of potas-
sium, or  common salt.   When the sore begins  to  present a healthy appearance
dress the  parts with opiate cerate, or elemi ointment, or poultices of  ground
flaxseed.


                      BOIL, OR  FURUNCLE.
  A Boil is a hard, bounded, deep red, raised and very painful swelling, situ-
ated in the sebaceous follicles of the skin, occurring on all parts of the body,
usually terminating in suppuration.
  A slight pain  first attacks  some part of the skin, a little  swelling appears,
which becomes elevated, hard, and of  a deep red color, when the pain increases.
The swelling becomes white at the top, it breaks, some pus mixed with blood 
226                            SURGERY.

is discharged, and then the destroyed cellular tissue, called the core, is discharged,
when the surrounding hardness subsides.
  Treatment.—The usual  treatment is to poultice the part and make a free
incision to let out the contents.  For  indolent boils a good application consists
of glycerine and extract of  opium, each a drachm, resin  cerate, an ounce; it
relieves the pain and irritation.   Painting  the part with tincture of iodine, or
solution of nitrate  of silver, are both  recommended.  Should the  patient's
condition require them, tonics should be employed, and when  there is a tend-
ency to recurrence  Fowler's solution, in doses  of two or three  drops, thrice
daily, will be found  efficacious.
  According to Dr.  Ringer, the  sulphides  possess the power of checking the
formation  of pus.   Calcium sulphide, given in doses of a tenth of a grain
hourly, is recommended where there is a succession of boils.
                     HOUSEMAID'S KNEE
Is an inflammation  of the bursa of the knee, between the patella and  skin,
which is  common to housemaids, from  kneeling.  It is  usually chronic, but
may be acute.   It causes great pain and swelling; it differs from inflammation
of the synovial membrane by the swelling being most superficial, and in being in
front of the patella, which is obscured by it;  in inflammation of the synovial
membrane of the knee, the patella is thrown forward, and the swelling is most
prominent at the sides.
   Treatment.—Rest, leeches, fomentations and purgatives;  if these  do not
bring relief, an incision'^hould be made into the swelling.   After evacuating
the contents of the  sac, a  small quantity of equal parts of tincture of iodine
and alcohol should  be  injected into it.  Dr. Levis recommends injections of
carbolic acid.


                             WHITLOW.
   Paronychia or Whitlow is an abscess of the thumb or fingers. .
   The superficial whitlow consists of inflammation of the surface  of the skin
of the last phalanx, with burning pain or effusion of a serous or bloody fluid;
it is generally seated immediately around and  beneath the nail; it is attended
with great pain and  throbbing, and suppuration  at the root of the nail, which
may come off;
   The deep-seated  variety, or tendinous whitlow, as it  is called, is attended
with severe, throbbing pain, exquisite tendernesss, light, but tense and resisting 
                               DROWNING.                           227

swelling, and very great constitutional  disturbance.  It  may lead to suppura-
tion, the matter extending itself along muscles and tendons from the fingers to
the palm, and  even to the forearm, causing sloughing of the tendons, with
severe irritative fever, sometimes placing life in danger and frequently leaving
the limb stiff and useless.
   If purgatives and fomentations do not speedily bring relief, the finger must
be freely laid open.  The knife, used early, should be carried deep  enough to
feel the resistance of the bone or tendon; the sheath of the latter should  be
thoroughly laid bare.   If the matter has extended  to the hand, an opening
should be made until complete drainage is established.
                            DROWNING.
  Treatment of Drowning.—Let the head hang for ten seconds, so that any
water may run out of the mouth; then lay down the body with the head raised;
put the fingers in the mouth and draw the tongue well forward;  wipe out the

                                 Fig. 96.
ABDOMINAL AND THORACIC PRESSURE.
mouth and throat; strip off the wet clothes; wipe all parts of the body perfectly
dry with warm cloths.   If breathing has not quite ceased, rouse the circulation
and respiration by friction of the entire surface, occasionally dashing cold water
on the face, neck, and chest, and  then wiping quite dry with a  warm towel,
and by tickling the nose and fauces, to excite  sneezing, coughing  or vomiting.
If breathing should not be thoroughly restored by these means artificial respi-
ration should be resorted to.  There are several methods recommended. 
228
SURGERY.
  i. Abdominal  and  Thoracic Pressure.—The operator kneels by the
patient and places his hands near together, with the fingers pointing toward
the head, the two thumbs approaching a little beneath the lowest point of the
sternum,  and the balls of the thumbs lying in the epigastrium, about three
inches apart; the lower and thick part of the hand is firmly pressed downward,
and as this part of the hand descends the fingers exert firm  pressure on the
lower part of the thorax.  The pressure is continued until one, two, three be
counted without hurry, when the hands  are suddenly raised  from the lower
part first;  and the chest, which has been emptied by the compression, is allowed
to refill with air  by its own elasticity.  The" process is repeated as often as
necessary.
  2. Chest Pressure.—Professor Howard's plan : The patient is laid on his

                                 Fig. 97.
                             CHEST PRESSURE.

back, with a roll of clothing beneath the loins, so  as to make the short ribs
bulge prominently forward, and raise them a little higher than the level of the
mouth.  The arms are then stretched forcibly  back  over the head, crossed and
held in this position by an assistant,  who also holds the tip of the tongue over
one corner of the mouth, grasping it with a dry handkerchief.  The operator
then kneels astride the patient's hips, and,  with  his hands resting on the
stomach of the patient, spreads out his fingers so as to grasp the waist about the
short  ribs.  He next  throws all  his weight steadily forward upon his hands,
while at the same time he squeezes the ribs deeply, " as  if he wished to force
everything in the chest upward out of the mouth."  This  pressure is continued
while one, two, three can be slowly counted, when it is suddenly removed with
a final push, which springs the operator  back to his first  kneeling position. 
FARADIZATION.
229
After an interval, during which one, two, three can be  slowly counted, the
pressure is repeated and the process continued as long as necessary.


                         FARADIZATION.
  A valuable aid to artificial respiration is faradization.   A needle connected
with the free  end of one of the  conductors is placed under the skin in the
neighborhood  of the right phrenic nerve; or if preferred over the pomum
Adami ; the other conductor, with  a moist sponge attached, is applied on the
right side of the chest  at the level  of the sixth intercostal  nerve; or about an
inch below the lower end of the sternum.  The current must be strong enough
to cause contraction of the  muscles  of the ball of the thumb; and the skin
thoroughly moistened with salt water. 
BANDAGING.
   Bandages are made of unglazed muslin, flannel, linen, calico, cloth or india-
rubber, in lengths of from two to ten yards, and in widths to suit the purposes
for which they are needed ; ordinarily, unbleached muslin is preferred.
   A bandage should have a width of three-quarters of an inch for the fingers
or toes; two to two and a half inches for the upper limbs; three inches for the
lower limbs, and six inches for the body.
   When a bandage is tightly and evenly rolled, it is termed a roller.
   Bandages are designated single-headed or  double-headed rollers, according
as they are rolled into one or two parts.  The ordinary roller in general use is
the single-headed.
   When applying a bandage, the dresser should grasp the roller in one hand,
holding the loose end in the other; apply it to the limb so that the outer sur-
face may be against the skin, and so that the bandage will lie close to the limb.
   The spiral is most frequently employed in the treatment of affections of the
extremities, or trunk.
   In applying the spiral, each turn must cover at least  one-third of the one
below.  Owing to the enlargement of the limbs at the  upper part, it is impos-
sible to apply the bandage without making " turns " in it; such a turn is called
a " reverse," which is the folding of  the bandage  upon itself, so that it will  fit
snugly to  the  limb.  To  do this properly, the student should be  careful  to
                       remember that a turn should never be made over a
                       prominence of a bone, and, if possible, it should be
                      made  on the outside of the limb; also, that  when
                      making the reverse the bandage  should be held quite
                      loosely, so that with a single  movement of the wrist
                      the turn can be made, carrying the hand from supina-
                      tion to pronation.
                         In making the turn the hand should be held slightly
                       above the level of the  limb, and great care must be
                       taken not to  unroll more  bandage than  is. actually
                       required.
     SPIRAL BANDAGE.
                         Figures-of-8 are made by passing the roller  alter-
nately upward and downward as it enwraps the limb (Fig. 98).   They are used
when the enlargement is too great and irregular for reverses  to lie evenly, as
over the ankle and elbow joints.
                                  230
 
BANDAGES OF  THE HEAD.
231
                            THE  HEAD.
  The roller for the head should be two inches wide.   The best bandage for
the head is the capeline (Fig. 99);  the double-headed  roller is  used for this
purpose.   The  surgeon, standing in front or behind, takes one  head of the
roller and places the middle of the  bandage on the  occiput or the forehead.
The two  parts are then brought around and crossed on the forehead or below
the occiput.   One of the ends  is then continued round, and the other, which
is lying below it, is turned up and brought over the head, as in the recurrent
bandage.  It is now met by the  other half of the bandage, which has been
carried around the head, while the first half has gone over it, and the former,
continued round, fixes the bandage so that it  can  again be brought over the
head, when the manoeuvre is repeated.

                                Fig. 99.
THE CAPELINE BANDAGE.
   When dressings are to be kept on the top of the head, some of the turns
under the jaw should be first made, so that they may be kept in place by the
circular ones;  if it  is desirable to avoid having the bandage under the chin,
the circular portion should be applied and fastened with a pin at the forehead;
a turn can then be taken over the head  and pinned  again at  the occiput, and
repeated, if necessary, two or three times.
   If it be necessary to apply pressure to the side of the head, as in the case of
a wound of the temporal  artery, a couple of simple turns around the forehead
and occiput  may be taken, and then the bandage made to ascend and descend
alternately as it passes over the point where pressure is to be applied. (Fig. 100.)
   The four-tailed bandage answers a  very useful purpose when required  to 
232                             SURGERY.

retain dressings.   It consists of a piece of muslin about three yards in length,
split up to within a few inches of the centre, so as to form four'strips; the two
anterior are carried back and  tied under the occiput, while the posterior are

                                  Fig. ioo.
FOUR-TAILED BANDAGE.
fastened  under the chin.  The position of the tail is reversed according as the
middle portion of the bandage rests on the forehead, chin or occiput.

                       BANDAGE FOR ONE EYE.
  Make  two or more circular turns around the forehead and occiput, passing
from right to left, if for the left eye, and from left to right, if  for the right eye.
After making the second turn, on reaching the nape, carry  the roller under
the ear of the affected side, and then obliquely up over the jaw and the affected
eye; inclining well to the internal canthus, so as to cover the root of  the  nose,
but not the sound eye.  Pass across to the temple of the sound  side;  descend
to the nape, and repeat two or three oblique turns, finishing by circular turns
around the forehead.   (Fig. 101.)

                            FOR BOTH EYES.
  Make  two or three circular turns of the head, turning from left to right, or
vice versa;  on reaching the nape, pass  under  the ear of either side up over 
BANDAGES OF  THE  HEAD.
233
the eye, root of nose, and parietal protuberance of the opposite side, and return
to the neck.  Make two or three of these turns, and then pass from the parietal
protuberance around the  forehead, cross the root  of the  nose, the eyes and
Fig. ioi.                           Fig. 102.
BANDAGE FOR ONE EYE.                  KNOTTED BANDAGE.
cheek of the opposite side, making an X with the first turns, and repeat in
oblique turns, terminating in circular ones.

                 KNOTTED BANDAGE OF THE HEAD.
  To secure pressure on the superficial temporal artery.  The articles required
in the use of this bandage are a two-headed roller about eight yards in length;
some lint; a piece of cork one-third of an inch thick;  needle, thread and pins.
  The cork is folded in  a  piece of lint, and over this are placed several folds
of lint so as to make a graduated compress,  which is  laid on the wound with
the small end downward.
  One end of the roller is taken in each hand, and the middle is laid over the
compress on the wound;  the ends are then carried around the head, above the
eyebrows, and the other backward  below the occipital protuberance, till  they
meet at the opposite temple, where they are brought from  one hand to the
other to be brought to the wounded temple.
  They are again crossed tightly, one end being carried under the chin, and
by the left  or right side to  the  vertex, there  meeting the other end, which has
passed over the head in the opposite direction.   The hands again change ends,
and the bandaging continues till each end reaches the injured temple.  Here
they are again crossed or knotted, when the ends are passed horizontally around
the head.   The ends are now pinned and cut off.   Each knot must overlie its
predecessor.  (Fig. 102.)
       P 
234
SURGERY.
Fig. 103.
                 THE CROSSED ANGLE OF THE JAW.
  Required, roller five yards long  and two inches wide, together with a thick
compress.
  Begin with placing the initial portion of the bandage on the forehead and
                          carry it twice around the  cranium,  turning from
                          right to left, and backward  if the disease or injury
                          is on the left side, and vice versa.  From the nape
                          of the neck carry the roller  close under and behind
                          the  ear of the sound side, under the jaw  to  the
                          angle of the jaw on the injured side, and place  the
                          compress behind  and on this angle.   Now carry
                          the  roller over the  compress, up over the side of
                          the  face, between the eye and the left ear; obliquely
                          over the vertex and down behind the ear opposite
                          the  injured side.  Make three or four oblique turns,
                          and terminate by circular turns around the forehead.
                            This bandage  is used in  treatment of fractures
                          of the neck and  angle of the jaw; in tumors of
                          the  parotid region, and in retaining dressings to
CROSSED ANGLE OF THE JAW.  thlS pait.
       GIBSON'S BANDAGE FOR FRACTURE OF THE JAW.
For this  bandage is required  a roller five yards long and two inches wide,
                                  and a compress or splint, if necessary.
                                    Close the mouth firmly,  mould the
                                 jaw into proper shape, if necessary, and
                                 make  the  lower  teeth press  upon the
                                 upper; place a compress under the frac-
                                 tured  portion, which  must be held in
                                 place  by an assistant; then apply the
                                 end of the  roller to the top of the head,
                                 pass it down the side of the face, under
                                 the jaw and over the  compress, up the
                                 other side  of the  face to  the  place of
                                 starting; carry the roller around three
                                 times; after the third  turn make a  re-
                                 verse on the temple, carry it around so
                                 as to be perpendicular to the bandage
      gibson's bandage.           on the face, and surround the  forehead
 
BANDAGES OF THE  TRUNK.
235
and occiput by circulars of the cranium.   On the third turn pass from the occiput
over the back of the neck and under the ear, to make three circulars of the
chin and  neck ; from the neck pass obliquely upward to go circularly around
the forehead.  Place pins at  each  crossing.   A strip should  be carried from
the forehead over the vertex and fastened to the turns on the neck.
                         BARTON'S BANDAGE.

  The roller should be five  yards long  and
two inches wide.  The initial extremity should
be placed just below the prominence  on the
os occipitus;  then continue the roller obliquely
over the centre of  the  parietal bone;  across
the junction of the coronal and sagittal sutures,
under  the chin,  carrying the bandage over
the  same  direction  on the opposite  side until
you arrive at the back of the head; then pass
obliquely  around and parallel to  the base of
the  lower jaw, over  the  chin, continuing the
same  course  on the  other side,  till it ends
where you   commenced.   Pass the bandage
around in this manner three times,  and place a
pin  at the vertex.
                 BANDAGES  OF  THE TRUNK.

           FIGURE-OF-8 BANDAGE OF NECK AND AXILLA

Is used to  retain dressings at the base  of the neck, before, behind, or above
the shoulder.  A roller five yards long and two inches wide is used.   The
initial extremity is placed on the side of the neck, and retained by one or two
circulars loosely cast around the neck.  If applied to the right shoulder, direct
the roller as it comes from the left side of the neck over and behind the right
shoulder, so as to confine the required dressing in the .axilla or on the shoulder;
then bring  it up  in front and over the shoulder and  around  the  neck to the
Fig. 105.
barton's bandage. 
236                             SURGERY.

left side, follow this course, and cover the preceding turn  by one-third of the

                                 Fig. 106.
FIGURE-OF-8 OF NECK AND AXILLA.
bandage, so as  to make figure-of-8, one turn of which shall embrace the neck
and the other the axilla.

          ANTERIOR BANDAGE OF THE CHEST (Figure-of-8).
  The roller should be eight yards long and two and a half inches wide.   The
object of this bandage is to draw the shoulder forward, and to retain dressings
on the surface of the chest.
  Commence at the axilla of either side; take two circular turns around the
chest to the place  of  beginning;  from thence carry  the bandage  obliquely
upward across  the  chest to the  shoulder, over the shoulder backward and
downward to the axilla;  under the axilla obliquely upward across the chest to
the opposite shoulder; over the  shoulder backward and downward  to the
border of the axilla;  under the  axilla, repeating  the turns three times, and
finish by circular turns around the chest.

          POSTERIOR BANDAGE OF THE CHEST (Figure-of-8).
  The roller should be from six to eight yards long and two and a half inches
wide.  The object of this bandage is  to draw the shoulders backward, or to
retain dressings on the  posterior surface of the chest.
  From the left shoulder pass obliquely over the back to the right axilla, the 
BANDAGES  OF THE TRUNK.                     237
shoulders being forced backward;  ascend in front and over the shoulder;  pass
over the back to the  left axilla, over the compresses (if any), in front of this,

                                  Fig. 107.
ANTERIOR BANDAGE OF CHEST.
Fig. 108.
                         POSTERIOR BANDAGE OF CHEST.

and around to the back, over it in front, and over the back to the left axilla.
Pass over this course until the  roller is within three yards of being exhausted,
then finish by circular turns around the chest. 
238                             SURGERY.
                CROSSED BANDAGE OF ONE BREAST.
  This bandage is used to support the breast.  The roller should be eight yards
long and two and half inches wide.
  Commence at the axilla of the affected side; qarry two circular turns under
the breast, around the chest to the point of origin;  thence obliquely upward
under the affected  breast; cross the front of the breast to the shoulder;  over
the shoulder, obliquely downward  across the back to the point of origin;  then

                                 Fig.  109.
CROSSED BANDAGE OF ONE BREAST.
take a circular turn under the breast, around the chest  to the point of origin.
Continue  to take  these turns, alternating  and advancing in the oblique and
circular turns until the breast is fully supported.


               CROSSED BANDAGE OF BOTH BREASTS.
  This bandage is used to  support  both breasts.  The roller should be from
ten to twelve yards long and two and a half inches wide.
  Place the initial  extremity of  the  roller  behind the right axilla, crossing the 
BANDAGESTOF THE TRUNK.
239
back;  carry the bandage over the left shoulder, pass  obliquely across the front
of the chest, under the right breast, and under the right axilla to the point of
departure.   Make two or three oblique turns of the  neck and axilla, covering
in the breast  by the  gradual ascent of each turn, and on reaching  the back of
the right axilla in the third turn, pass  transversely across the back to the left
axilla; under this and across the  chest in front  of the left breast  to the right

                                  Fig. iio.
CROSSED BANDAGE OF BOTH BREASTS.
side of the neck; then  across the back to the left axilla.  Repeat two obliques
of the neck and left axilla, and  on reaching the front of the left armpit pass
transversely under both breasts to the right axilla, from thence to the point of
departure, care being taken that each revolution covers successively the breasts
from below upward.

                 SPICA BANDAGE OF THE SHOULDER.
  This bandage is used in dislocations of the humeral extremity of the clavicle;
or to retain the head  of  the humerus in place  after dislocation  has  been
reduced.   Length of roller eight  yards; width two and a half inches.
  Make three spiral reversed turns around  the upper part of the arm of  the 
240
SURGERY.
injured side, passing from without inward and from before backward; pass
from thence from behind the arm up over the lower extremity of the shoulder,
then obliquely downward over the front of the chest to the axilla of the sound
side; thence around the back obliquely upward over the shoulder, and down
in front under the axilla of the  injured side; taking care to use some cotton

                                Fig. hi.
SPICA BANDAGE OF THE SHOULDER.
batting or a compress to protect the point of injury.  From this point go behind
and over the shoulder, pursuing the same course as before, each turn covering
in one-third of the preceding turn until the bandage  is sufficiently exhausted
to be made to terminate by one or two circulars of the trunk.

                   SPICA BANDAGE OF THE GROIN.
   Requires a roller eight to ten yards long  and  three inches  wide.   This
may be done in one of  two ways,   ist Method:  The bandage is to be carried
along  the lower part of the groin  of the affected side, from within outward,
over a pad, if necessary; then pass around the pelvis, and back over the 
BANDAGES  OF THE TRUNK.
241
pubes, crossing the former fold of the groin, completing the figure-of-eight.  A
series of such turns, each slightly overlapping the other, must be repeated until
the part is covered, and a sufficient amount of compression is produced.
Fig. 112.
spica retaining pad.
      Fig. 113.
SPICA OF GROIN.
   2d Method:  Place the initial extremity of the bandage above one of the
iliac crests, make two horizontal circular turns around  the pelvis, so as to fix
the front of the bandage, turn  from right to left, and from before backward, if 
242
SURGERY.
for the right groin, and the reverse if for the left.   Arriving in  front of one of
the groins descend to the inner side of the thigh, between it and the genital
organs, and winding around the  back part ascend on  the  outer side so as to
cross the first turn; from thence  to the iliac bone  of the opposite side, across
the back and around the pelvis to follow the same  course.


                  DOUBLE SPICA FOR BOTH GROINS.
   A roller  twelve yards  long  and  three inches wide is required.  First,
make two  horizontal  turns about the pelvis;  upon  arriving  at  the second
turn, near the groin—the left, for instance—turn the roller  so that it  will pass
obliquely downward along the outer  side of the thigh, and ascend along its
Fig. 114.
DOUBLE SPICA, FOR BOTH GROINS.
inside so as to cross the first descending turn;  it is then conducted around the
back of the pelvis as far as the  right groin, and made to pass along the inner
side of the right thigh; remounting on its outer side, and carried again around
the pelvis in front, and to the left.   The bandage pursues this  course until a
sufficient quantity of the bandage remains to terminate by two horizontal turns
of the pelvis. 
BANDAGES OF EXTREMITIES.
243
             TO BANDAGE THE PERINEUM AND PUBES.
  A roller six yards long and three inches wide is required for this bandage.
  After a turn around the body, the bandage passes obliquely down across the
left groin, then behind the left thigh, just below the fold of the  nates, and
obliquely upward, across the perineum,  and through the right groin toward
the right iliac spine.  It then passes around the body behind, and from the left
iliac spine obliquely downward, along the left groin, to cross the perineum, and
go below the genital fold on the right thigh, and so around the body again.


               BANDAGES OF EXTREMITIES.

                       SPIRAL, OF ONE FINGER.
  Bandage  four feet  long and  one  inch wide required.  Fix the initial ex-
tremity around the wrist by two or  three circular turns; cross the back of the
Fig. 115.
SPIRAL, OF ONE FINGER OR TOE.
hand so as to descend either finger to  its extremity, which is then bandaged
downward  to the root, by ordinary spiral reversals, and terminates by a few
turns around the wrist.

                   SPIRAL, OF ALL THE FINGERS.
  This  bandage  should be eight yards long  and one  inch  wide.  Begin
by one  or  two circulars around the wrist; pass obliquely over the back of
the hand,  and descend by oblique turns  to the end  of  the forefinger, then 
244
SURGERY.
ascend, by reverse turns, to its base;  then  pass  to  the  middle finger, ascend
and descend, as in the case of the forefinger, continuing until all the fingers

                                 Fig. 116.
SPIRAL, OF ALL THE FINGERS.
•   are covered in.  Then pass to the back of the hand, or front if preferred, and
   finish by circulars around the wrist.

           THE  GAUNTLET, OR SPIRAL FOR ALL THE FINGERS.
      Roller should be eight yards  long and one inch wide.

                                   Fig. 117.
                          GAUNTLET, FOR FINGERS.

  Commence  with two circulars around the wrist;  pass obliquely over the
back of the hand; descend, by oblique turns, to the nail of the forefinger, then 
BANDAGES OF  THE ARM.                     245
ascend by reversed turns to the base; descend, by oblique turns, to the nail of
the middle finger, ascend by spirals to the base, and continue this until all the
fingers are covered.   From the  base of the little finger pass in front of the
hand, finishing by circulars around the hand and wrist.

                                                      Fig.  118.
         THE  DEMI-GAUNTLET.                            y.
  Make  a couple  of turns around the wrist;              ^Z^/
cross the back or palm of the hand by oblique    -----T-T\\~4Q-^vIr^\
turns, which will pass between  each finger;          I V \\;^CZr~~Tr)
then .make a circular turn around the  wrist.       —-----^~^^N\—t-!^1^^

                                                    DEMI-GAUNTLET.
                        SPICA  OF THE THUMB.
  The roller should be three yards long and one inch wide.
  Begin  by two circular turns around  the  wrist, from  thence  cross the base
of the thumb to the phalangeal articulation  ; around the thumb, thence to the

                                Fig. 119.
SPICA, OF THUMB.
wrist, and so continue, taking care to cover one-half of each preceding turn
until the thumb is covered, and terminate by a couple of turns around the wrist.
                   BANDAGES  OF  THE ARM.

                     FIGURE-OF-8 OF THE WRIST.
  Roller should be two yards long by two inches wide.  Take two circular
turns  around the wrist, commencing  on either the dorsal or palmar surface;
when  reaching the latter side, turn obliquely across to the space between the
thumb and forefinger—for instance, of the right hand;  from thence obliquely
over the palm to a corresponding point on the metacarpal bone of the little 
246
SURGERY.
finger; from  thence obliquely across the back of the hand to the wrist-joint;
now make a semi-horizontal  turn around the  wrist to  the  ulnar side.   Repeat
same course over again, terminating with a turn around the wrist.


                     FIGURE-OF-8 OF THE ELBOW.
  The roller should be two yards long, and two and a half inches wide.
  Begin at the external and upper part of the forearm;  pass obliquely over
the bend of the arm to the internal tuberosity of the humerus, and carry it on
around the olecranon to the external tuberosity; from  thence obliquely over
the front, crossing the first turn, to the  inner and upper  part of the forearm,
and then across the back, to the point of departure, to go over the  same course.


                SPIRAL OF THE UPPER EXTREMITY.
  The roller should be eight yards long, and  two  and  a half inches wide.
  Begin with two circular turns around the wrist; from  thence pass obliquely
over the back and  palm of  the hand to  the fingers; ascend by spiral turns
until the phalangeal metacarpal joint of  the thumb is reached ; cover this and

                                 Fig. 120.
SPIRAL, OF UPPER EXTREMITY.
the wrist-joint by a figure-of-8; ascend  the limb, by simple and reverse turns,
until the  elbow is reached.   If the arm is to be flexed, cover the elbow with
figure-of-8; if not, employ spiral turns without reversing,  and continue the
spiral and reverse turns to the shoulder, using such  compresses, etc., as may be
necessary. 
BANDAGES OF THE LOWER  EXTREMITY.
247
       BANDAGES OF THE LOWER  EXTREMITY.

                    FIGURE-OF-8 OF THE ANKLE.
  The roller should be from two to three yards long and two and half inches
wide.
  Take two turns around the leg  above  the malleoli, then -go  obliquely down-
ward in front of the ankle to the side of the foot, from thence under the sole
Fig. 121.
FIGURE-OF-8 OF ANKLE.
of the foot to the opposite side, pass obliquely upward in front of the  ankle to
the beginning, ending with as many turns around  the ankle as may be  neces-
sary.
                FIGURE-OF-8 BANDAGE OF THE KNEE.
   The roller should be two yards long and two and a half inches wide.
   Commence at the upper part of the leg, below the knee, making one or two
circular turns; pass obliquely upward across either the patella in front or over the
back of the knee to the lower part of the thigh, then pass around the thigh and
come from the opposite side of the thigh obliquely downward  across the front
or back of the knee to the side of the leg, repeating as many times as may be
necessary. 
248
SURGERY.
                    FIGURE-OF-8 OF THE THIGHS.
  Roller should be from four to six yards in length and three inches wide.
  Make two circular turns above the knees, then carry the bandage obliquely
over the lower part of the thigh, carry it around until  it reaches the outer side
of the opposite limb, and bring it down to point of departure, making as many
figure-of-8 turns as may be  necessary, and  terminating  with circular turns
around the upper part of the thigh.
                   SPICA BANDAGE OF THE INSTEP.
  The roller should be from six to eight yards long and two and a half inches
wide.
  Begin at the tarsal  end of the  metatarsal bone.   Pass over the front of the
foot to the first joint of the big toe of the right, or  that of the little toe, if the
left foot;  pass under  the  sole to the outer or inner side, depending whether it
is the right or  left foot.  Then make two obliques  over the front of the foot,
Fig. 122.
SPICA, OF INSTBP.
when the instep will  be reached; from thence pass to the point of the heel in
a line parallel with the sole; then pass around  the heel, to again come to the
instep, keeping parallel with the sole;  cross the instep and make another similar
turn, which must cover the heel and instep.  Then cover over one-third of the
preceding turn, and form a spica on the instep.   These turns must be continued
till  the foot is completely covered; the bandage to be continued by circulars
or spirals on the leg. 
                  BANDAGES OF THE LOWER EXTREMITY.              249

        SPIRAL-REVERSE BANDAGE OF LOWER EXTREMITY.
  The roller should be twelve yards long and two and a half inches wide.
  Begin with a circular bandage at the metatarso-phalangeal articulation, take
two turns and ascend by reverse turns well up on the instep;  from thence go over
the point of the heel back to the instep, under the heel, around the side of the
heel, and back of the heel up to the instep, under the sole of the heel over the

                                  Fig. 123.
SPIRAL-REVERSE, OF LOWER EXTREMITY.
opposite  side of the heel, thence  around the back  of the heel to the instep;
then make figure-of-8 turns of the ankle, spiral turns over the joint; spiral re-
verse turns to the knee; figure-of-8 turns to the knee; spiral  turns over the
knee joint, and ascend the thigh to the hip by spiral-reverse turns, and finish
by circular turns around the upper part of the thigh.
       Q 
250                            SURGERY.
                   HANDKERCHIEF  SYSTEM.
   Mayor's handkerchief system for temporary or provisional dressing has been
 in vogue for the last fifty years, and is in general use.
   The ordinary handkerchief or square piece of silk, cotton or linen, folded
 into various shapes to suit the object indicated, is used to replace the ordinary
 bandage or roller.
   The handkerchief may be made  oblong, cravat-shaped, triangular or cordi-
form, to meet the necessities of the case.
   It is obviously impossible to give the whole of the system of Mayor in a book
 of this kind; a few of the principal bandages are reproduced, that the student
 may understand something of the method recommended by its originator.
                  THE SQUARE CAP OF  THE HEAD.
  Having folded the handkerchief into an oblong square, and allowed the edge
of the handkerchief that is to rest next to the head to be two inches shorter
than the  other, the end of the long side is to be drawn to the side of the face

                                 Fig.  124.
SQUARE CAP, OF HEAD.
and tied under the chin, the inner end or those of the short side must be drawn
so as to free them from the first; folding this part backward the ends must be
tied on the occiput. 
                  HANDKERCHIEF SYSTEM OF BANDAGES.              251

                        BIS-AXILLARY CRAVAT.
  Place the centre in the axilla of the affected side, cross  the  tails over the
corresponding shoulder, and  then carry them one before and the other around

                                 Fig. 125.
BIS-AXILLARY CRAVAT—FRONT AND BACK.
and behind the chest to the axilla of the opposite  side, where they are to be
secured. 
252
SURGERY.
           COMPOUND BIS-AXILLO-SCAPULARY CRAVAT.
  Knot together the two ends of a  cravat on one of the shoulders, so as to
make a loose  ring, then  take a second cravat; apply the  centre of this against
the anterior face of the other shoulder, carry the tails of one over the shoulder
and of the other beneath the axilla.  The first must embrace the corresponding
portion of the ring, so that its extremity may be united with that of the second
tail, which should be made to pass about the first.

                   THE CERVICO-BRACHIAL SLING.
  This bandage is  made by placing one handkerchief around the neck and
knotting its ends over the sternum.  The other is to be placed in triangular

                                Fig. 127.
k          /
                         CERVICO-BRACHIAL SLING.
form under the forearm, so that its base may be next to the wrist.  Its angles
are then to be tied to the handkerchief around the neck.  The summit is to be
carried around the elbow to fasten to the body of the triangle in front.


                      SPECIAL BANDAGES.
                        ESMARCH'S BANDAGE
Consists of three  yards  of red elastic or india-rubber bandage,  and four feet
of rubber tubing with hook and chain.  The elastic bandage is two and a half
inches wide. 
SPECIAL BANDAGES.
253
  The bandage  is used to empty the  limb of its blood by rolling the  india-
rubber bandage  from below, upward to the spot where the blood is to be con-
trolled.   At this point  the india-rubber tube is passed around the limb, suffi-

                                 Fig. 128.
ESMARCH'S BANDAGE.
ciently tight to stop the circulation in the vessels;  the ends of the tube are then
worked into each other.
  The india-rubber bandage is then removed, and the limb will remain blood-
less until the tube is taken off.

                       BANDAGE OF SCULTETUS
Consists of a number strips about three inches wide, and of  a length gradually

                                 Fig. 129.
SCULTETUS BANDAGE.
increasing from the first strip, which should be  long  enough to go one and a
third  times around the upper part of the limb.   They are arranged in such a 
254
SURGERY.
manner that, when applied, each succeeding one shall overlap from one third
to one-half of the preceding one, the compression being made in a gentle, uni-
form manner.  It is generally used in the treatment of compound fractures and
dislocations.
                     THE BANDAGE OF VELPEAU.
   The roller should be ten yards long and two and a half inches wide.   The
patient having placed the hand of the injured side on the sound shoulder, and
a compress having been inserted between the side of the chest and injured side
so as to prevent  excoriation, the initial extremity of the roller is laid under or
behind  the axilla of the sound side; from thence it is carried over the back,
over the injured clavicle, down on the front and outside of the arm, under the
outside of the elbow, and over the chest to the sound axilla.  Make two  simi-
lar turns, and on again reaching the axilla, pass circulars  around the chest to
the same axilla; then make a turn over the clavicle and arm; then a circular,
continuing until it reaches the upper part of the forearm.
   When a permanent dressing is needed, starch or dextrine should  be applied
to this bandage, and thus a firm cap will support the arm.
Fig. 130.                                Fig. 131.
       VELPEAU'S BANDAGE.                        DESAULT's APPARATUS.

                       DESAULT'S APPARATUS.
  There is required for this apparatus three single-headed rollers, each  eight
yards long and two and a half inches wide, a triangular wedge-shaped pad to
place in the axilla, and measure four inches in width at its base and of sufficient 
SPECIAL BANDAGES.
255
length to reach to  the elbow; a compress to  cover the seat of fracture, and a
sling to support the hand.
  The pad is placed in the axilla, the thick end upward, where it is firmly held
by an assistant.  The initial end of the first roller is then placed on the middle
of the pad, and at  least three circular turns of the chest made, when the roller
must be carried up over the front of the chest, over the sound shoulder, under
the armpit, so  as to make a semicircular turn on  the  front of the chest, then
over the pad, around the back, over the shoulder, under the armpit, and then
around the chest.
  The forearm must now be flexed upon the arm, pressing the latter against the
pad, and at the same time the shoulder should be forced upward and backward.
  The  initial  end of the second roller  should  be placed in the axilla of the
sound side, carried across the  breast, over the upper part of the arm of the
injured  side, and obliquely around the back to the axilla, from place of begin-
ning, and these turns should be continued around the arm, descending to the
upper part of the forearm.
  The  initial  end  of the third roller is
then  placed in the sound axilla, passed
over  the front of the chest obliquely to
the seat of fracture, where there must
be  placed a  compress, over  this and
down the  back of the arm to the elbow;
thence  obliquely upward to the front of
the sound axilla;  under this obliquely
upward over the back, over  the frac
ture, down the front of the  arm to the
elbow, and thence obliquely to the back;
then to  the  sound  axilla, under this  to
its front part  and over the chest and
fractured bone, to  run the same course,
and  end by circulars of the chest so as
to fix the whole.
  Summary of the Third  Roller.—
Axilla to shoulder; shoulder to elbow;
elbow to axilla.
  The forearm must be supported by a
sling.                                          fox's APPARATUS.

           FOX'S  APPARATUS FOR FRACTURED  CLAVICLE.
  Fox's apparatus  is a ring, a sling and a pad.  The ring is placed on the sound
shoulder; the sling is made to  fit the elbow of  the arm belonging to the frac-
 
256                             SURGERY.

tured clavicle; it must extend to the wrist;  it is tied to the ring by two slips of
girthing forward, and two back, and, in  addition, one tape is attached to the
lower and back part of the sling, to draw  the arm back.

           SAYRE'S DRESSING FOR FRACTURED CLAVICLE
Consists of adhesive strips.  They are applied by forming a loop over the upper
part of the injured arm; it must  fit loosely.   Put the arm in position, draw the
strip around the body over the back, let an assistant hold it while the fragment
is  manipulated, then draw it  tightly and  secure it  to  the chest, thus carrying
the shoulder back.  Place a second strip  under the elbow, and both ends over
the opposite shoulder, the centre to be against the olecranon.

              THE RECURRENT BANDAGE FOR  STUMP.
  The roller should be about six yards long and two inches wide.
  First make three circular turns around  the stump,  about three or four inches
above  the  extremity; then place the thumb over the middle of the turns in
front, and the  forefinger behind; bring the  bandage directly over the  face of
the stump, from the middle line in front to the same point behind.  Keep the
                                 Fig. 133.
RECURRENT BANDAGE FOR STUMP.
reverse in place behind by the  forefinger, and bring the bandage back again,
a little to one  side of the middle, converging when it reaches the starting- 
                            SPECIAL BANDAGES.                        257

point.  Fix  this by the thumb, bring the bandage over again, passing now to
the other side of the middle line and converging to it behind.   Continue these
reverses till  the whole stump is covered, then by one or two firm circular turns
fix them in position, in which they are held by the thumb and finger.

                      SAYRE'S PLASTER JACKET.
  Articles needed.   Freshly-burned plaster-of-Paris;  knitted, elastic, woolen
" skin-fitting vest;" two-, three- and four-inch wide rollers of crinoline, or
Fig. 134.
Fig. 135.
        SAYRE'S PLASTER JACKET          APPARATUS FOR DISEASE OF CERVICAL
               APPLIED.                      OR UPPER DORSAL SPINE.

cross-barred muslin, three yards  long; cottonwool and felt; two  silk pocket-
handkerchiefs; Sayre's triangle, with pulleys, head collar and arm-loops; two
basins of cold water, deep enough to submerge the rollers when set up on end;
 
258                             SURGERY.

strips of thin tin plate, half-inch wide, and punched with holes to roughen their
surfaces; safety pins, needle and thread; towels; black-lead pencil.
  In addition to the foregoing, Welsh flannel rollers and thick, soft felt are
frequently required to protect the  skin overlying bony projections  from being
chafed under the plaster case, and an apron to protect the operator's clothes.
  I. Prepare  from six to twelve rollers, according to the size of the patient,
by gradually unrolling them on a table, while some one rubs in the powder and
another person rolls the loaded bandage up loosely.
  2. Erect the suspending triangle, and set  ready the  basins  of  water, ban-
dages,  pins and other articles.
  3. The body should now be thoroughly washed  and  dried and the " skin-
fitting" shirt put on.  Then beneath the shirt and next to the skin a pad of
cotton  wool, folded in a silk handkerchief, is slipped up in front, leaving the
ends of the  handkerchief hanging below the shirt.  The object of this pad is
to preserve a slight concavity over the pit of the stomach and  navel  after the
plaster has set; it  is termed the " dinner  pad."   In females two  small pads
should overlie the breasts. When the pad is put on, fasten the shirt down in front
and behind  with safety pins, to a folded towel pressed between the thighs.  A
towel should be wrapped around the patient's legs to protect the dress from the
water or plaster.   The level of the armpits, while the arms hang down, is then
marked in pencil across the back and  front of the shirt.
  4. Arrange the patient in the suspending triangle, and let him draw himself
up until his  weight is supported; the tips of the toes should rest on the ground
to keep  steady the body.  The  patient must support himself by  pulling the
cord just so  much as feels comfortable to him, and no more.
  Now begin  the bandaging.  An assistant plunges into  water a roller, so that,
as it stands  on end in the basin, the roller is covered with water; as soon as
bubbles cease  to rise up from the roller it is ready for the assistant to hand to
the operator;  as he does so he squeezes  out  the  excess of water and puts in
another roller  to soak.   The operator, standing  in front  of the patient, rapidly
rolls on the  bandage, beginning at the top, where the pencil mark shows the
level of the  armpits; above this line the bandage must not be carried.
  The assistant watches the progress of the bandage behind the patient, smooth-
ing down the  turns as they are applied, that they may fit closely to the patient's
body, and wetting any part of the bandage that the water may not have reached
during immersion.  Bandage after bandage is  then laid on the trunk,  taking
care to carry the lower  turns well  below the hips, just avoiding the pubes and
great trochanters.
  When the trunk is wrapped in one layer of bandage,  strips of tin plate, long
enough to reach nearly from the upper border to the lower one, are laid along
each vertebral groove and  below each armpit;  these are sufficiently supple to 
SPECIAL  BANDAGES.
259
bend readily to the shape of the body, but give the case rigidity where it is
likely to be strained by the weight of the patient's head and shoulders.   As the
                                  Fig. 136.
                    APPLICATION OF SAYRE'S PLASTER JACKET.
straps are applied by the assistant the surgeon covers them with a roller.  When
about three thicknesses of bandage are applied the  jacket is thick enough in
ordinary cases. 
260                             SURGERY.

  The "dinner pad" must now be withdrawn,the patient laid on a flat couch,
which has been placed  close to him, so that the soft plaster case may not be
strained before it  has hardened.  The operator, while the patient lies flat,
moulds the jacket  about the hips and groins by gentle pressure of the hands.
The patient is then covered with a light shawl for half an hour till the plaster
has set.

                           THE JURY MAST.
  When the disease in the spine  is above the lower dorsal region, the jacket
cannot be carried  high  enough to prevent the forward pressure at the diseased
part.   To meet this condition an iron support is attached to the plaster jacket
while the bandage is being applied.  From this support a steel rod rises behind
the neck and head, and ends immediately above the vertex.   A cross bar turn-
ing horizontally projects across the head.  From this the head is slung in a jaw
bandage, and thus the weight of the head is lifted off the diseased spinal column.


                       PERMANENT DRESSINGS.
  The most reliable bandages for permanent dressings are : the plaster-of-Paris,
silicate of sodium  or silicate of potassium, paraffin, and  the starch bandage,
which is now seldom used.
  The  plaster-of-Paris  bandage  is  prepared by rubbing  dry  plaster, of  the
finest quality, and freshly calcined, thoroughly into the meshes of a thick, coarse
muslin or crinoline roller, which, if not required for immediate use, is loosely
rolled and kept in a dry place until it is needed, when it is soaked for a few
minutes in cold water.  The limb, first  carefully enveloped in flannel, wadding,
or old linen, is then surrounded by the  bandage;  three or four rollers generally
answer the purpose.
  The silicate of sodium, or potassium in a saturated solution, applied with a
stout brush, is the  " glass dressing " of surgeons.  When well rubbed  into the
meshes of  a wet roller,  a firm and immovable  apparatus is formed, in no way
inferior to the plaster-of-Paris.   The  glass dressing  dries  very rapidly,  does
not irritate the skin, and is easily procured.   From three to five  layers of
bandage are necessary to insure  the  requisite amount of stiffness.   Sometimes
a binder's board will be required to impart sufficient support.
  Paraffin is frequently used as a fracture dressing.   After being thoroughly
melted,  it is  partially  cooled  to render it more viscid;  then it is rubbed
thoroughly into the meshes of the bandage with a coarse paint-brush, when a
neat light dressing is formed, impermeable to water, pus  and other fluids, and
every way adapted to the treatment of compound fractures.
   The glue  dressing is prepared  by rubbing  warm glue into the bandage. 
SPECIAL BANDAGES.
261
Before being used  it must be diluted with a fifth part its bulk of alcohol, or a
small quantity of oxide of zinc, to promote desiccation.
  When applied in the usual manner the mixture at once begins to harden,
but it does not become thoroughly dry for several  hours.  Wadding should  be
placed next to the skin,  and then two or three layers of bandage must  be
applied.   Should additional  strength be needed, fresh strips of linen may be
glued on, without changing the original dressing.
  The starch bandage is now seldom used; it is applied like the glue bandage
by rubbing starch into the interstices of ordinary rollers.   Four and  sometimes
five thicknesses are required to insure sufficient  support.  It may be necessary
to place  strips of pasteboard, which have been soaked  in starch, on the sides
of the limb. 
FORMULAE.
SELECTED  FROM  STANDARD  AUTHORITIES,  AND  FROM

    THOSE IN USE  IN THE PRACTICE OF THE AUTHOR.
           GONORRHOEA.

 i. Jfc. Sodas bicarb.,
       Sodae bromid.,    aa    Siv
       Tr. belladon.,            3j
       Ext. pareirae,      fld.,  13vj
       Aq. menth. pip.,
       Syr. acaciae,      aa   f5"j.
  Ft.  M. Tablespoonful every three hours,
to be  used during the first days of gonor-
rhoea.
 2. Jfc. Potass, chlorat.,         Sij
       Aq. bullient.,           fSv
       Misce  et adde  liq.  potas-
         sae,                  fSiij
       Potass, ace tat.,           5iv.
  M.  Two tablespoonfuls three times daily
for the first few days.
3. {jfc. Copaibas,		Sj
Liq. potass.,		Sij
Ext. glycyrrhiz. CO.,		5ss
Spir. ether, nit.,		Sj
Mucilag. acaciae,		Svj
Ol. gaultheriae,		gtt. xvj
M. A tablespoonful three	times	a day.
4. 9;. Mucilag. acacias,		Sv
Vin. opii,		Sj
Ol.juniperi, 1 Ol. cubebae, j*	aa	5U
Copaibas,		5iij
Spir. gaultheriae,		Sj.
M.  A teaspoonful four times daily.
 S. Jgfc. Pulv. alum.,             Siv
       Pulv. cubebae,            Siv.
  M.  Tablespoonful  in a wineglassful
water, three times daily.
 6. T%. Copaibae,                Sss
       Spir. ether, nit.,         fSss
       Pulv. acaciae,            5ij
       Sacchari,                5j
       Aq. destil.,              fjiv
       Spir. la vend. CO.,        5ij
       Tine, opii,              f5j.
  Ft.  Mist.  Tablespoonful  three  times
daily.
 INJECTIONS IN GONORRHOEA.

7. Jfck. Zinci sulph.,             gr. xv
      Plumbi acet.,            gr. xxx
      Tr. catechu,
      Vin. opii,       aa      fSj
      Aq. rosae,               fSvj.
 M.  Use as injection night and morning.
&
Plumbi acet.,
Zinci sulph.,
Hydrastin sulph.,
Ext. ergot, fld.,
Tr. opii,
Aquae,
 gr. xxx
 gr. xv
 gr. xij
f3iv
fSiij
fSvj.
 M.  Shake well and use as injection.

9.  Jfifc.  Hydrarg. chlor. corrosiv., gr. ss
       Aquas destil.,            Svj.
 M.  Use as injection.
10. #
     Acid borici,
     Aquas  camph.,
M.  Use as injection.
gr. ijss
Sj.
 GONORRHOEA IN  THE  FEMALE.
11. {fc. Ung. cucumis,            Sj
       Alum.,                   3j
       Tannin,                  3ij.
  M.  Smear a small  quantity on a pledget
of cotton, pass it into the vagina at night, re-
move it in the morning,  and use injection of
   {jfc. Decoct, quercus alb.,      Oj
       Sodii boratis,             gss.
  M.
262 
FORMULA.
263
CHORDEE.
12. IjL Pulv. opii,               gr. |j
       Camphorae,              gr. iv
       Lupulin,                 gr. xv.
       Ol. theobromae, q.  s.
  M.  Ft. suppository.  Pass into bowel at
night.
SWELLED TESTICLE (SUBACUTE).

13. 9(.  Iodoform,
        Ext. belladon.,
        Ung. hydrarg.,     aa    5j
        Ung. zinci ox., q. s. ut fiat  Sj
  M.  To be used locally.
          ACUTE CYSTITIS.

14. ^fc.  Sem. hyoscyam. ext.,
        Cannabis ind. ext.,   aa
        Sacch. alb.,
  M.  Div. in chart No. viij.
  One powder every three hours.
gr- ij
3ij
Sj
15.  Jfe.  Potass, bicarb.,
        Tr. hyoscyam.,
        Kavae kavae ext. fld., aa  Sss
        Aquae, q. s. utft.,        fjviij.
  M.   Tablespoonful  in a wineglassful  of
water, three times daily.
16. p:
Sj
S>j
Oj
        Lupulin,
        Uvae. ursi. fol.,
        Aq. bullien.,
  M., and add, when cool,
        Tr. opii camph.,         Sii
        Sodii bicarb.,            5ij.
  M.  Teaspoonful four times daily.


17. p.  Lupulin,                 3j
        Tr. belladon.,            f3j.
        Tr. opii camph.,         fSij
        Sodii bicarb.,            Sj
        Inf. buchu q. s.  ut ft.,     fSvj.
  M.  Tablespoonful in water  three times
daily.
GARGLES.
18. #
      Acid tannic,
      Spir. vin. rect.,
      Mistura camphorae,
M.   Gargle.
 5U
 5j
fSx.
5j
19.  Jfc.  Potass, chlor.,
        Tr. cinchon. comp.,
        Tr. guaiaci amnion.,  aa  5ij
        Mel,                     Sj
        Aqux q. s. ut ft.,          Siv.
  M.  Ft. gargle.
20. Jl.  Potass. Chlor.,           Siss
        Tr. ferri chlor.,          5iij
        Listerin,                 f3iv.
  M.  Pour half an ounce in half a glass of
water and use as a gargle.
   MOUTH WASH FOR MUCOUS
              PATCHES.

21. Jfc-  Acid pyrolig.,            5j
        Aquae,                   Svnj.
  M.   Wash mouth every four hours.
22. p. Tinct. myrrh,            Sss
       Potass, chlor.,            5iij
       Aquae,                  fSiv.
  M.  Wash  mouth  every three or four
hours.


Stimulating Lotions  and  Ointments
  to Apply to  Granulating  Surfaces
  and  Ulcers.
23. Jfc. Cerat. resin, co.,
       Balsam Peruvian,
       Iodoform,
       Ung. petrolii,
  M.  Use locally.
24. p.  Ung. hydrarg. nit.,
        Pulv. jalapae,
        Balsam Peruvian,
        Ung. zinc, ox.,
  M. ft. ung.   Use locally.
5. p. Ung. hydrarg. nit.;
      Cosmolin,
 M. ft. ung.  Use locally.
               LOTIONS.

26. Jfl.  Cupri sulph.,
        Aquae,
  M.  Use locally.

27. 9;.  Argent, nit.,
        Aquae destil.,
  M.  Use locally.

28. {fc.  Acid nitric,
        Aquas,
  M.  Use locally.
             RED WASH.

29.  9-  Zinc, sulph.,
        Spir. rosmarin., )
        Tr. lavend. co., J
        Aquae,
  M.  Use locally.
5j
5ij
5j
Sj.
5j
5ij
3j
Sj
gr. iv
Sj-
gr- "
Sj.
g«. ij
Sj
gr. x
fSx. 
264
          YELLOW WASH.
3. 9-  Hydrarg. chlor. corrosiv., gr. j
       Liquor calcis,           fSj.
 M.  Use locally.
           BLACK WASH.
i.  9-  Hydrarg. chlor. mit ,     5j
       Liquor calcis,            fSiv.
 M.  Bottle to be well shaken before using.
2.  Jfc.  Tannin,
       Ex. opii aq.,
       Cupri sulph.,
 M.  Use locally.
gr. "J
gr. ij
gr. V%-
               SYPHILIS.
33.  9-  Mass hydrarg.,
        Ferri sulph.,      aa     9j
        Pulv. opii,               gr. x
        Quiniae sulph.,           9ij.
  M. ft. pil. xl.
  Two pills three times daily, when  patient
is debilitated.
34.  Jfc.  Hydrarg. iodid. vir.,      gr. v
        Antim. et pot. tart.,       gr. j
        Pulv. opii,               gr. v.
  M. ft. pil. xxx.
  One pill four  times  daily, when patient is
robust.

35.  Jl-  Hydrarg. chlor.'corros.,  gr. J^
        Tr. ferri chlor.,          5ij
        Liq. arsenici chlor.,      gtt. xxxvj
        Acid hydrochlor. dil.,    5j
        Syr.sarsaparillSeco.,Uaf3iij.
        Aquas,              J
  M. Tablespoonful  in water  three times
daily, to be given when patient is debilitated.
     SYPHILITIC  ERUPTIONS.
36.  Jfc.  For  tubercular  eruption five  per
        cent, solution of the oleate of mer-
        cury well rubbed in.


37.  jfc.  Hydrarg. chlor. corrosiv., gr. iv
        Benzoin,                 Sss
        Cologne water,           Sj
        Rose water,              Sivss.
  M.  Use locally.
38.  9
  M.
daily.
 TERTIARY SYPHILIS.
 Hydrarg. chlor. corrosiv., gr. j
 Potass, iodid.,           3ij
 Syr. ferri iodid.,          5iv.
 Sy^arsaparillxco.,^^^

Tablespoonful in water three times
                TONICS.
39.  jfc-  Acidarsen.,              gr. j
        Strychnias sulph.,         gr. «^
        Ferri sulph.,             3)
        Quinias sulph.,           3j.
  M. ft. pil. No. xx.
  One pill three times daily.
40.  ffc.  Tr. ferri chlor.,    1
                      lil., J
M.
 Acid phosph. dil., /   aa  Sss
 Syr. simp.,               Siij.
A teaspoonful three times daily.
41.  Jl.  Ferri redact.,
        Quinias sulph.,    aa    Bj
        Ext. nucis vom.,          gr. x
        Rhei pulv.,               3j
        Belladon. ext.,           gr. iij.
  M.  Div. in pil. xx.
  S.  One pill after each meal.


42.  9-  Ferri sulph.,             gr. ij
        Magnes. sulph.,          3j
        Acid sulph.  dil.,          Vt\x
        Inf. quassii,              Sj.
  M.  Tablespoonful in water three  times
daily.


  COLD EVAPORATING LOTION.
43.  9- Plumb, acet.,            Sj
        Pulv. opii,               5j
        Aquae,                   Oj.
  M.  Use locally.


44.  Jjtr.  Liq. plumb, subacet.,     Siv
        Tr. opii,                 3ij
        Aquae,                   Oj.
  M.  Use locally.
         NITROUS POWDER.
45.  #.  Potass, nitrat.,            5j
        Antim. et pot. tart.,       gr. ss
        Hydrarg. chlor. mit.,      gr. vj.
  M. ft. pulv. vj.
  One powder to be taken every two hours.


46.  Jfc.  Pulv. opii,                gr. iij
        Pulv. ipecac,             gr. vj
        Hydrarg. chlor. mit.,      gr. iss
        Potass, nitrat.,            3ss.
  M. ft. pulv. vj.
  One  powder to be taken every three  or
four hours.


 SODA  POWDER  OF  GUY'S HOS-
                 PITAL.
47.  9-  Sodii carb. exsiccat.,      5j
        Hydrarg. chlor. mit.,      gr. xij
        Pulv. cretae comp.,        5ij.
  M.   Give  from three  to  eight  grains at
night. 
FORMULAE.
265
        NEUTRAL MIXTURE.
48.  J$C.  Succi limonis,            fSiss
        Potass,  carb.,  q.  s.  ad
          saturand,
        Sacchari,,                5ij
        Antim. et potass, tart.,    gr.  ss
        Aquas destillat.,          fSiij.
  M.  A tablespoonful every two hours.


49.  p.  Potass, citrat.,            5iij
        Ol. lemon,                gtt. ij
        Sacchar.,                3ij
        Aquas destil.,             fSiv.
  M.  A tablespoonful every two hours.
    EFFERVESCING DRAUGHT.
50.  Yfr.  Potass, carb.,             5ij
        Aquas destil.,            f3iv.
  Solve.
    Jjfc.  Succi limon.,
        Aquae destil.,
  M.   Mix two tablespoonfuls of the lemon-
ade with one of the alkaline solution, and let
the mixture  be drunk while effervescing.
Repeat every two hours.
aa   fSij.
     SPIRIT OF  MINDERERUS.
51.  Jfc.  Liq. ammon. acetat.,     fSvj
        Syr. limonis,            fSij
        Vin. antim.,             f3iss
        Spir. aether, nitros.,      f5ij
        Tinct. opii,               gtt. xlv.
  F. Mist.  A tablespoonful every two hours.
 JEFFERSON MEDICAL  COLLEGE
   HOSPITAL FEVER  MIXTURE.
52. Jfc.  Liq. potass, cit.,          Sss
        Spir. ether, nit.,          5j
        Tr. aconit. rad.,          gtt. ij.
        Morph. sulph.,           gr. ]/$.
  M.   Give every third hour,  in water.


  SALINE MIXTURE, WITH  ANTI-
                MONY.
53. ^fc.  Antim. et potass., tart.,   gr-r?
        Tinct. aconit. rad.,       gtt. ij
        Spir. ether, nit.,          5j
        Magnes. sulph.,          3ij
        Syr^ingib.,   |    &a    5ij.

  M.   Give every third or fourth hour in
fever.


     ITCHING HEMORRHOIDS.
54.  1$. Pulv. gallas,              gr. v
        Pulv. opii,               gr. x
        Cocainae hydrochlor.,     3ss
        Ung. hydrarg.,           5ij
        Cerat. simp.,            3vj.
  M. ft. ung.
  Rub well in parts on going to bed.
              ENEMATA.
55.  T$C.  Ol. ricin.,               fSij
        Syr. fusci,               fSij
        Sodii. chlor.,             5j
        Infus. lini., tepid,         Oj.
  Ft. enema.
  One-half to be administered at once, and
the remainder in half an hour, if no evacua-
tion is produced.


56.  Jpfc.  Saponis incisi.,           Sj
        Infus. lini., tepid,         Oss.
  M.  Use as enema in cases of flatulence
and impacted faeces.
57.  p.  Ol. terebinth.,           fSss
        Vitellum unius ovi.,
        Tere simul. et adde grada-
          tim,
        Decoct, hordei tepid,     fSx.
  A stimulating injection.
  SUPPOSITORY FOR BLEEDING
           HEMORRHOIDS.
58. p.  Ferri sub. sulph.,          gr. iij
        Plumb, acet.,             gr. j
        Mass. hydrarg.,           gr. ss.
        01. theobrom. q. s. ut. ft.
          suppos. No.  1.
  Introduce one morning and evening.
   FOR STRANGURY, TENESMUS,
                  ETC.
59. Jjfc.  Ext. belladon.,            gr. ss
        Pulv. opii,                gr. ij.
        01.  theobrom. q. s. ut ft.
          suppos. No. 1.
  S.   Use morning and evening.
              ALOPECIA.
60.  F#.  Spir. ammon. aromat.,   fSj
        Glycerinae,              fSss
        Tr. cantharid.,          f3j
        Aquae rosemarin.,        fSvij.
  M.  Apply to scalp morning and evening.
61.  fy.  Tinct. cantharid.,        fSiss
        Tr. capsici,               gtt. xx.
        Glycerin.,                3ss
        Cologne water,  _          Sj.
  M.   Use on scalp at night.
62.  Jfc.  Tinct. canthar.,          5ij
        Aq. ammon.,             Sss
        Aq. rosas,                Siv _
        Hydrarg. chlor. corrosiv., gr. ij.
  M.  Use on scalp morning and evening, 
266
FORMULA.
             LINIMENTS.
63. JjL  Camphor.,               Sj
        Ol. olivac,               fSiv
        Ft. solution;  tunc, adde,
        Ol. terebin.,             fSiss.
  M.   To be applied by  rubbing with  a
piece of flannel.

64. Tfr.  Ol.olivae,       \   aa  ftj
        Aq. ammon.,    j
  Applied to neck in inflammation of the
throat.

65. Jfc.  Tinct. opii,
        Spirit, camphor.,
        Tinct. canthar.,
        Ether,           aa      Sss.
  M.   Make an embrocation.
66.  Jfc.  Chloroform,
        £t]}e.r>     .      j.  aa  fSj
        Spirit, camphor.,  j         J
        Tinct. opii,        J
        Tinct. capsici,             fSss.
  An excellent embrocation.

67.  Jfc.  Chloroform,     ")
        Tr. conii,       >   aa   5iij
        Tr. stramonii,   J
        Tr. aconit. rad.,          5v
        Saponis liniment.         Siss.
  M.  Use as embrocation.
  ANTISEPTIC SOLUTIONS, ETC.
  Bichloride of mercury solution in propor-
tion of 1 to 1000.

68. p.  Hydrarg. chlor. corrosiv., 5j
        Alcohol,                  Sj.

  A teaspoonful of this  mixture to a pint of
water is equivalent  to one part of corrosive
sublimate to a thousand parts of water.
  One part corrosive sublimate to one thou-
sand parts of water.

69.  Jfc.  Hydrarg. chlor. corrosiv.,  gr. x
        Glycerinas,               Siss
        Aquas destil.,             Gallon j.

  Solution in which to place sponges, liga-
tures, etc., during an operation.


      TO PREPARE SPONGES.
  70. Thoroughly beat out the dust; then im-
merse the material for forty-eight hours in a
fifteen per cent, solution of hydrochloric acid;
wash it  until the acid is entirely removed;
steep it  for half an hour in a solution of per-
manganate of potassium, 180 grains to 5 pints
of water.  Then wash it in running water,
and soak it for four hours in a solution often
ounces of hyposulphite of sodium  (5 ounces
of hydrochloric acid, 68 ounces water).  Put
it in a trough of running water, to  remain
six  hours.   Lastly place it in a jar of solu-
tion of bichloride of mercury (1-1000), and
keep  it hermetically sealed until needed.
After having been used, wash it in hot water,
and then soak it for half an hour in a solution
of sodium carbonate, half an ounce to water
one pint; rewash it in warm water, and put
away in a 1-1000 bichloride solution.


  TO MAKE SUBLIMATE GAUZE.
  71. Dissolve one part of corrosive sublimate
and two  parts of common  salt in five hun-
dred parts of water; soak  the  gauze in this
for  an hour, wring it out and partially dry it
in a clean room, i. e., not in a hospital  ward
or sick room.  Keep it in a moist condition
in glass jars.  The gauze generally in use is
cheese-cloth, rendered absorbent by boiling
in water, to which a slight amount of soda
is added  to remove its greasiness.


  Gauze  and drainage tubes should be kept
in a solution of

72.  Jfc.  Hydrarg. chlor. corrosiv., gr. xxx
        Sodii chlor.,              9vij
        Glycerin.,                5iv
        Water,               Half gallon.
LISTER'S ANTISEPTIC DRESSING.
73.  Potass,  cyanide,          gr. 130
    Mercury cyanide,         gr. 251.7
    Zinc sulphate,            gr. 286.9
    Hasmatoxylin,            gr.   1.3
    Sal ammonia (Gas  (NH3)
      1 #>,                   TT16
    Gauze (previously boiled
      and dried),             Sio
    Sol. bichloride of mercury
      1-4000,                 O 7.6
    Distilled water,          q. s.

  Dissolve the two cyanides in two ounces
of distilled water, and  add the zinc sulphate
dissolved in six ounces of distilled  water,
collect the precipitate (which will be thrown
down) upon a  filter and wash thoroughly by
pouring over it (while  still in the filter) dis-
tilled water.  While- the precipitate  is still
moist diffuse  it  in eight ounces of distilled
water.
  Dissolve  the haematoxylin  in one and a
third drachms of distilled water to which the
ammonia has  been  added.  Add this to the
precipitate  diffused in the water, allow  to
stand for three  hours, then add the whole
to the solution  of bichloride  of mercury.
Draw the gauze through this.   The dye salt
will settle upon the gauze and fix the cya-
nide.  The  gauze should be hung upon an
antiseptic cord to drain.  When it is nearly
dry remove and place in a tight glass jar.
The  superfluous moisture can be removed
by pressing the gauze between the layers of
a sheet if needed for immediate use. 
FORMU
PROFESSOR SENN'S DECALCIFIED
             BONE-CHIPS.
  74.  The tibia or femur of a freshly-killed
ox is to  be preferred; discarding the articu-
lar extremities; the shaft of the bone is to be
sawed into segments two  inches  in length,
which are to be placed in a fifteen  per cent.
solution  of  hydrochloric  acid in distilled
water, after removing the periosteum and
marrow;  this solution must be  changed
every twenty-four hours, until the segments
are decalcified, which will be achieved in
from two to four weeks.
  The segments are then to  be washed in
distilled water, and afterwards immersed in
a dilute  solution of caustic potash, to remove
the excess of acid.  When the acid is  neu-
tralized  the segments are again  immersed
in distilled  water for  twenty-four  hours,
when they are taken out and  the cancellous
structure in the  medullary canal removed.
The segments  are now cut into strips, in the
direction of the long axis of the bone, of one
half to  three-quarters  of an inch in width.
After this they are sliced into chips of one
millimetre in thickness, which must be put
in a glass-stoppered bottle containing a solu-
tion of  bichloride of mercury  in alcohol
1-500, and  kept  until required  for  use.
During  an operation  the chips  are to be
placed in a five per cent, solution of carbolic
acid.
      BICHLORIDE SAWDUST.
75.  Jfc.  Hydrarg. chlor. corrosiv., gr. viiss
        Glycerin.,                5ss
        Sifted sawdust,            Ibj
        Ammonii chlorid.,         gr. viiss.
  M.  Use locally.
TO  PREPARE CATGUT FOR LIGA-
                TURES.
  76.  First immerse the catgut in ether for
twenty-four hours, then place  it for thirty
minutes in a solution composed of tartaric
acid, one  hundred grains ; corrosive subli-
mate, twenty grains ; alcohol, five and a half
ounces.  After this, remove it and place it
in oil of juniper berries for ten days.  During
an operation the catgut should be immersed
in a solution of alcohol one part,  bichloride
of mercury solution (1-1000), four parts.
TO PREPARE CHROMIC ACID CAT-
                  GUT.
77. 9. Chromic acid,   one grain
       Carbolic acid,   two hundred grains
       Alcohol,        two drachms
       Water, two ounces and six drachms.
  Mix.

  Place two hundred  grains of catgut in
ether for forty-eight hours; then immerse in
the foregoing solution for two days ; at the
TLM.                                  267

 end of that time put it in tightly covered
 aseptic jars.  When it is  about to be used,
 put it in a solution of alcohol, one part; bi-
 chloride solution (1-1000), four parts.


      DEODORIZED IODOFORM.
 78. ]pfc.  Iodoform,              Sj
         Menthol,               gr. xxiv
         01. lavend.,             gtt. xxxjj.
    M.

  ETHEREAL  SOLUTION OF  IODO-
                  FORM.
 79. Jfc.  Iodoform,               gr. xv
         Ether,                    Sj.
   M.  To  be  used on chronic ulcers, ab-
 scesses, etc.

      EMULSION OF IODOFORM.
 80. Jfc.  Iodoform,                5x
         Glycerin..                3c.
   M.  Not over five  drachms of this mix-
 ture to be used locally at one time; and in
 chronic  abscess for each ounce of pus, four
 and a half grains of iodoform and forty-
 eight  drops of glycerine are allowed to be
 used  at any one time.

       IODOFORM  COLLODION.
 81. Jfc.  Iodoform,              gr. xlviij
         Collodion,               Sj.
   Use locally.

      BICHLORIDE OINTMENT.
 82. Jfc.  Hydrarg. chlor. corrosiv., gr. j
        Ung. petrolii,            Sj.
   M.  Use  locally.

 83. jfc. *Caff. iodoform,          gr. xcvj
        Ung. petrolii,            Sj.
   M.  Use  locally.
   * Caff. Iodoform is composed of equal parts
 iodoform and coffee ;  the latter ingredient is
 used to disguise the smell of the iodoform.


               KOUMISS.
 84. Jfc. White sugar,   two tablespoonfuls.
        Compressed yeast,       half cake.
        Fresh milk,             one quart.
   Mix, and  place in an apartment  ranging
 in temperature from 700 F. to 950 F. for six
 hours, turning  the bottle once  during the
 first hour.  Let it remain  in a  refrigerator
 for twelve hours.
   If, when the bottle is opened, the fluid is
 found to be  sweet, the indication is that the
 fermentation has not been carried sufficiently
 far; if it be found thick  and curdled, the
 process of fermentation has been too much
 prolonged.  These conditions must be con-
 trolled by the length  of time  the  fluid is
 kept in a warm room, or by the  quantity of
 yeast used. 
 
INDEX.
                                     PAGE
 ABSCESS,............  24
*"*•  ------symptoms,  .......  25
------treatment,..........  26
------lumbar,............166
------psoas,...........166
Acute inflammation of bladder.....  77
Air passages, foreign bodies in, .  .  .  . 213
Amputations, general remarks, .... 213
------Chopart's, through the tarsus,  . 177
------Hey's, metatarsal bone, .... 177
------Lisfranc's,..........176
------of ankle joint,.........175
---------arm,............178
---------elbow joint,........181
---------finger at the metacarpal joint, 183
---------forearm,..........181
---------foot,............176
--------- great toe,.........176
---------hand,...........183
---------hip joint,..........170
---------knee joint,.........172
---------leg,............173
---------little finger,........184
---------shoulder joint,.......179
---------thigh,...........171
--------- thumb,...........184
---------toes, of all,.........176
---------wrist,...........182
------PirigofFs,   ..........175
------Symes',  ...........172
------Teale's,...........179
------through the tarsus,......177
Anaesthesia,.............   38
Aneurism,.............107
------symptoms,   ...     .....107
------treatment,..........108
------varieties,...........107
Ankle joint, excision of,.......188
Ankylosis,..............163
Anthrax,..............224
Antiseptic surgery,.........   43
Anus, fissure of,...........220
Arteries, ligation of,.........190
Asthenic fever,...........   16

T5ANDAGES—
*-*  ------arm, figure-of-8,.....245
------bisaxillary, cravat,.......251
-------------scapulary,......252
------breast, crossed, both,.....238
                   • one,.......238
chest, anterior.........236
                                    PAGE
Bandages—
------chest, posterior,   .......236
------crossed, angle of the jaw,  .  .  .  234
------ Desault's;  ..........254
------elbow, figure-of-8,.......246
------Esmarch's,.........252
------eye, one,...........232
------eyes, both,..........232
^—^— finger, one,..........243
------ fingers, all,..........243
------Fox's,............255
------gauntlet,...........244
------glue,.............260
------groin, double,.........242
-------------one,..........240
------handkerchief system,.....250
------head,.............231
------head, knotted bandage,  ....  233
------ instep,...........248
------jaw, Barton's,.........235
-------------Gibson's,........234
------knee,.............247
------lower extremity,.....247, 249
------paraffin,...........260
------perineum, and pubes......243
------plaster-of-Paris,........260
------recurrent, of stump,.....    256
------Sayres', clavicle,.......256
------------jury mast,.......260
------------plaster jacket,.....257
------scultetus,...........253
------shoulder,...........239
------silicate of potassium,.....260
------——— — sodium, .......  260
------square cap,..........250
------starch,............261
------thigh,............248
------thumb, spica,.........245
------trunk,............235
------upper extremity, spiral, ....  246
------Velpeau's,..........254
Bandaging,.............230
Brain, compression,.........   70
------symptoms and diagnosis,  .  .  70, 71
------treatment,..........   71
------concussion of,.........   69
------symptoms and treatment,  .  .  69, 70
Bladder, tapping the,.......83
Boil.................225
------treatment,..........226
Bubo, chancroidal, . .  '      .....   86
------symptoms,..........   87
269 
270
INDEX.
                                    PAGE
Bubo, treatment,...........   87
----- syphilitic,...........   89
Burns and scalds,..........   62
-----symptoms,..........   62
-----treatment,..........   63



   CARBUNCLE,........224
     -----treatment,........225
Carcinoma of rectum,........221
-----treatment,.........    2ZI
-----of testicle,..........2I8
Caries,...............l64
-----treatment,........  .  •  164
Castration,.............2I8
Chancre,........     ....   88
-----symptoms,..........   89
-----treatment,..........   89
Chancroid..............   84
-----symptoms,..........   84
-----treatment,..........   85
Chancroidal bubo,    .........   86
Chest pressure............228
Chilblain—frostbite,.........   64
-----symptoms,..........   64
-----treatment,..........   64
Clubfoot,..............222
-----treatment,..........223
Collapse and shock,.........   67
-----symptoms,..........   67
-----treatment,..........   67
Compound fractures,.........157
-----treatment...........157
Compression of brain,........   70
-----symptoms,..........   70
-----treatment,..........   71
Concussion of brain,.........   69
-----symptoms,     .........   69
-----treatment,..........   70
Coxalgia,..............162
-----treatment,..........164
Cystitis,...............   77
-----symptoms...........   77
-----treatment,..........   77
T"\ISEASES OF THE SPINE, .  .  166
■""'  -----angular curvature, ....  168
-----lateral curvature,.......167
-----psoas abscess,.........166
Dislocations—
-----definition of,.........117
-----ankle joint,..........130
-----clavicle,...........120
-----elbow,............124
-----fingers, ............125
-----hip joint,...........126
-----humerus,...........121
-----inferior maxillary,.......117
-----knee,.............130
-----lower jaw,..........119
-----patella,............130
-----thumb,............126
-----toes..............125
-----wrist,.............125
Drowning,..............227
                                     PAGE
   EAR, AFFECTIONS  OF, .  ...  214
     _____. accumulation of wax in, .  .  214
-----follicular abscess,.......214
Eczema of auricle,..........2M
Elbow-joint, excision of,.......185
Epididymitis,............  75
Epispadias,.............2I°
Epistaxis,..............2I2
Erysipelas,.............  65
-----symptoms,..........  65
-----treatment,...........  66
-----varieties,...........  66
Excision of joints,...........185


■J7ARADIZATION,........229
 "  Fever, asthenic or adynamic,   .  .  16
-----hectic.............  27
-----inflammatory,.........  14
-----irritative,.......   ...  17
-----septic,............  J6
-----sthenic,............  '5
-----surgical,...........  14
-----traumatic,..........  15
Fissure of anus............22o
Fistula in ano,............2'9
-----treatment,...........220
Foreign bodies in air passages, ....  213
Formulae,..............202
Fractures, general treatment,.....135
-----acetabulum,..........147
-----compound, treatment of,  ...  .  159
-----general considerations,.....133
-----of the carpus,.........H7
-----clavicle.............139
-----femur in children,.......155
-----fibula,............157
-----forearm.............'44
-----foot,.............158
-----humerus,...........142
-----of the lower jaw,........138
-----upper jaw,..........136
-----leg,..............157
-----nose,.............137
-----os calcis,...........158
-----patella,............156
-----pelvis,............147
-----Pott's,............158
-----radius,        .........146
-----------neck of,........146
-----repair of,...........134
-----ribs,.............14°
-----scapula,  ........:  .  .  141
-----skull,.............   71
-----sternum,...........140
-----thigh,.............149
 -----ulna,.............145
 -----zygomatic arch,........137
 Furuncle,..............225


    GANGRENE, OR MORTIFICA-
      tion,..............   32
 -----hospital............   34
 Germ theory,............   41
 Gonorrhoea,.............   74
 -----symptoms,..........   74 
271
                                     PAGE
Gonorrhoea, treatment,........  75
Granulations.............  30


■LJ-ffiMATOCELE,........217
•*•*•   -----treatment,........218
Harelip,...............211
Head, injuries of,..........  69
Hectic fever,.............  27
-----causes,............  27
-----symptoms,..........  27
-----treatment,...........  27
Hemorrhage,............  45
-----from urethra,....." "  .   .  84
------recurrent,..........     52
------secondary,..........  52
Hemorrhoids,............219
------external,...........219
------internal.............219
Hernia,...............no
-----symptoms,..........no
-----treatment,...........in
------varieties,...........in
Hip-joint disease,..........162
------excision of,...........186
Hospital gangrene,..........  35
------symptoms,..........  35
------treatment,...........  36
Housemaid's knee,..........226
Hydrocele,.............216
Hydrophobia,............  61
------symptoms,..........  61
------treatment,...........  61
------Pasteur's method of treatment,  .  61
Hypospadias,............216


INFLAMMATION,.......   9
■^  -----etiology..........  12
-----extension,...........  12
-----intimate nature of,.......   9
-----symptoms,...........  12
-----terminations,.........  n
-----treatment,...........  18
-----varieties,...........  n
Inflammatory fever,.........  15
Ingrowing  toe-nail,..........224
Injuries of  the head,.........  69
Irritative fever,...........  17


JOINTS, EXCISION OF,.....185



t^NEE-JOINT,  EXCISION OF,  . 187
   LARYNGOTOMY, .......  214
     Lateral curvature of spine, ....  167
Ligation of the anterior tibial artery,   .  204
------axillary,...........196
------brachial,  ...........197
------common carotid,........190
------external    "    ........'95
------    *'    iliac,.........201
                                    PAGE
Ligation, facial,...........190
------foot, dorsal artery of,.....206
------femoral............202
-----innominate,..........195
-----lingual,............192
-----occipital,...........190
-----peroneal,...........206
------popliteal,...........202
-----posterior tibial,........203
------radial.............198
-----sciatic,............201
------subclavian,..........195
-----ulnar,............199
Ligatures,..............   51
Lithotomy,.............209
Lithotrity,..............208
Lumbar abscess,...........166


TUTORTIFICATION, ACUTE, .  .   32
■*■"-*■  -----symptoms,.......   32
-----treatment,..........   33
-----chronic,...........   33


TVJASAL  PASSAGES, AFFEC-
■^   tions of,...........212
     ■ epistaxis............212
-----foreign bodies in,.......212
Neck, triangles of,..........190
Necrosis...............164


QRCHITIS,...........   75



PARAPHIMOSIS,........216
^  Pasteur's treatment of hydropho-
  bia, ................61
Phagedenic ulcers,..........   29
Phimosis,..............215
Pott's disease of spine,........168
Prolapsus ani,............220
Prostatitis, acute,..........   76
Psoas abscess,............166
Pyaemia,..............   37
------prognosis,..........   38
------treatment,..........   38


   QUESTION OF AMPUTATION
     in wounds,...........   60


OACHITIS,...........165
*^-   Rectum, carcinoma of,.....221
Retention of urine,.........   81


   SARCOCELE  (CHRONIC  OR-
    chitis..............   76
Scalds and burns,..........   62
-----symptoms,..........   62
-----treatment,..........   63
Secondary syphilis,.........   90
Septicaemia,.............   37 
272
                                    PAGE
Septicaemia, treatment,........   38
Septic fever,..............   16
Shoulder joint, excision of, ......185
Shock or collapse,..........   67
------treatment,..........   67
Skin grafting,............   31
Skull, fractures of,..........   71
Spine, diseases of,..........166
------angular curvature of,.....168
------lateral                .....167
------treatment,..........167
Sprains,...............161
Sthenic fever,............   16
Stone in bladder,..........208
------treatment,..........  208
------in kidney,..........207
------in ureter,...........207
Stricture,..............   77
------treatment,..........   79
Suppuration,............   23
------symptoms,..........   24
------treatment,..........   26
Surgery, antiseptic,.........   43
Surgical fever,............   15
Sutures,...............   48
Synovitis,..............161
Syphilitic bubo,...........   89
Syphilis,..............   88
------secondary,..........   90
-------------treatment,.......   92
------tertiary,...........   94
-------------treatment,.......   96



^TAPPING THE BLADDER,  .   83
 ■*•   Tertiary syphilis,........   94
Testicle, amputation of,.......218
-----carcinoma of,.........218
Tetanus,..............   68
-----treatment,..........   68
Toe nail, ingrowing,.........224
Tracheotomy,............214
Traumatic fever,...........   15
Trephining..............   72
Triangles of the neck,   ........  190
Tumors,.............   97
-----adenoma,.......... .  104
-----angeioma,..........104
      benign.............   99
-----carcinoma,..........102
-----chondroma,..........   99
-----cysts,.............102
                                     PAGE
Tumors, definition of,........   97
-----epithelial growths,......   99
-----fibroma,   . .  .........103
-----general consideration,.....   97
-----heterologous,.........   99
-----homologous,.........   98
-----lipoma,............103
-----lymphoma,..........104
-----malignant...........100
-----myoma............   99
-----myxoma,...........101
-----neuroma,...........104
'       osteoma,...........103
-----sarcoma,...........101
-----treatment of,.........105


TTLCERS, ACUTE,.......   28
'■"'   ------symptoms,.......   28
------treatment,..........   28
------chronic,............   30
-------------symptoms,.......   30
-------------treatment,.......   30
------phagedenic..........29
Urethra, hemorrhage from,......   84
------treatment,..........   84
Urethrotomy,............   79
Urinary calculi............206
------treatment,..........207
Urine, retention of,.........   81
------symptoms,..........   81
------treatment,..........   82


T7\ARICOCELE,.........218
 "   Varicose veins,.........222


TA7HITLOW,.........226
 * "    Wounds,...........   49
-----contused,...........   54
-----dissection,..........   57
-----gunshot,...........   55
------incised, .  .  .  :........   52
------lacerated,...........   53
------of abdomen,   .........   59
---------arteries,..........   49
---------chest,...........   58
---------joints,...........   59
---------throat,...........   57
------punctured,..........   55
------question of amputation in, .  .  .   60
Wrist joint, excision of,........186 
CATALOGUE No. 7.
AUGUST, 1891.
     A  CATALOGUE
                 OF
Books  for  Students.
             INCLUDING THE
      ? QUIZ-COMPENDS ?
CONTENTS.
PAGE		PA
New Series of Manuals, 2,3,4,5		
Anatomy,	°	Pathology, Histology,.
Biology, ...	n	Pharmacy, . . . .
Chemistry, .	6	Physiology, . . . .
Children's Diseases,	7	Practice of Medicine, . 11
Dentistry,	8	Prescription Books,
Dictionaries,	8	?Quiz-Compends ? 14
Eye Diseases,	9	Skin Diseases,
Electricity, .	9	Surgery, .
Gynaecology,	10	Therapeutics,
Hygiene,	9	Urine and Urinary Organs,
Materia Medica, .	9	Venereal Diseases,
Medical Jurisprudence,	10	
             PUBLISHED BY

   P. BLAKISTON, SON & CO.,
Medical Booksellers, Importers and Publishers.
 LARGE STOCK OF ALL STUDENTS' BOOKS, AT
          THE LOWEST PRICES.
 1012 Walnut Street, Philadelphia.
 *** For sale by all Booksellers, or any book will be sent by mail,
postpaid, upon receipt of price. Catalogues of books on all branches
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4-B*Gould's New Medical Dictionary Just Ready. Seepage ib. 
  " An excellent Series of Manuals."—Archives of Gynecology

              A  NEW SERIES OF

     STUDENTS'   MANUALS
   On the various Branches of Medicine and  Surgery.
        Can be used by Students of any College.

 Prioe of each, Handsome Cloth, $3.00.  Full Leather, $3.50.

   The  object of this series is to furnish good manuals
 for the medical  student, that will  strike the  medium
 between the  compend on one hand and the prolix text-
 book on the  other—to  contain all that is necessary  for
 the  student, without embarrassing him  with  a  flood  of
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   Each  book  is sold  separately  at  a  remarkably low
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   No. 1.  SURGERY.   236 Illustrations.
 A Manual of the  Practice  of  Surgery.   By Wm.  J.
   Walsham, m.d., Asst. Surg, to, and  Demonstrator  of
   Surg,  in, St.  Bartholomew's Hospital,  London, etc.
   236 Illustrations.
  Presents the   introductory facts  in Surgery in clear, precise
language, and contains all  the  latest advances in  Pathology,
Antiseptics,  etc.
  " It aims to occupy a  position midway between the pretentious
 manual and the cumbersome System of Surgery, and its  general
character may be summed up in one word—practical."— The Medi-
cal Bulletin.
  "Walsham, besides being an  excellent surgeon, is a teacher in
 its best  sense,  and having  had very great  experience  in  the
preparation  of candidates for examination,  and their subsequent
professional career, may be relied upon to have carried  out  his
 work successfully.  Without following out in  detail his arrange-
 ment, which is excellent, we can at once say that his book  is an
 embodiment of modern ideas neatly strung together, with an amount
of careful organization well suited to the candidate, and, indeed, to
 the practitioner."—British Medical Journal.
      Price of  each Book, Cloth, $3.00; Leather. $3.50. 
THE  NEW SERIES OF MANUALS.          3
No. 2.  DISEASES OF WOMEN.  150 Illus.
                   NEW  EDITION.
The  Diseases of  Women.   Including Diseases of  the
   Bladder and Urethra.  By Dr. F. Winckel, Professor
   of  Gynaecology and Director  of the Royal  University
   Clinic for Women, in Munich.  Second Edition.  Re-
   vised  and Edited  by  Theophilus  Parvin,  m.d.,
   Professor  of Obstetrics  and Diseases of Women and
   Children in Jefferson Medical College.    150 Engrav-
   ings, most of which are original.
  " The book will be a valuable one  to physicians, and a safe and
satisfactory one to put into the  hands of students.  It is issued in a
neat and attractive form, and at a very reasonable price."—Boston
Medical and Surgical Journal.
  No. 3.  OBSTETRICS.  227 Illustrations.
A Manual of Midwifery.  By Alfred Lewis Galabin,
   M.A., m.d., Obstetric Physician and Lecturer on Mid-
   wifery and the Diseases of Women at Guy's Hospital,
   London;   Examiner in  Midwifery  to  the  Conjoint
   Examining Board of England, etc.  With 227 Illus.
  " This manual is one we can strongly recommend to all who
desire to study the science as well  as the practice of midwifery.
Students at  the present time not only are expected to know the
principles of diagnosis, and the treatment  of the various emergen-
cies and complications that occur in the practice of midwifery, but
find that the tendency is for examiners  to ask more questions
relating to the science of the subject  than was  the custom a few
years ago. *  * *  The general standard  of the manual is high;
and wherever the seience and practice of midwifery are well taught
it will be regarded as one of the most important  text-books on the
subject."—London Practitioner.
   No. 4.   PHYSIOLOG-Y.   Fifth  Edition.
      321 ILLUSTRATIONS  AND A GLOSSARY.
A  Manual  of  Physiology.   By  Gerald  F. Yeo, m.d.,
   f.r.c.s.,   Professor of  Physiology  in King's College,
   London.   321  Illustrations and a  Glossary of  Terms.
   Fifth American from last English Edition, revised and
   improved.  758 pages.
   This volume was specially prepared to  furnish students with a
new text-book of Physiology, elementary so far as to avoid theories
which have not borne the test of time and  such details of methods
as are unnecessary for students in our medical colleges.
   "The  brief examination  I have given it was so favorable that I
placed it in the list of text-books recommended in the circular of the
University Medical  College."—Prof. Lewis A. Stimson,  m.d.,
37 East 33d Street, New York.
       Price of each Book, Cloth, $3.00; Leather, $3.50. 
1          THE NEW SERIES OF MANUALS.
     No. 5.  DISEASES  OF CHILDREN.

                   SECOND  EDITION.

A Manual.  By  J.  F.  Goodhart,  m.d., Phys. to  the
   Evelina   Hospital for  Children;    Asst.  Phys.  to
   Guy's Hospital, London.   Second American  Edition.
   Edited and Rearranged by Louis Starr, m.d., Clinical
   Prof, of Dis. of Children in the Hospital of the Univ.
   of Pennsylvania, and Physician to the Children's Hos-
   pital, Phila.  Containing many new Prescriptions, a list
   of over 50 Formulas,  conforming to the U,  S. Pharma-
   copoeia, and Directions for making  Artificial  Human
   Milk, for the Artificial Digestion of Milk, etc.   Illus.


  " The merits of the book are many.  Aside from the praiseworthy
work of the printer  and binder,  which gives us a print  and page
that delights the eye, there is the added charm of a style of writ-
ing that is not wearisome, that makes its statements clearly and
forcibly, and that knows when to stop when it has  said enough.
The  insertion of typical  temperature charts certainly enhances the
value of the book.  It is rare, too, to find in any text-book so many
topics treated of.  All the  rarer and out-of-the-way diseases are
given consideration.  This  we  commend.   It makes  the  work
valuable."—Archives of Pedriatics, July, 18QO.

  " The author has avoided the not uncommon error of writing a
book on general medicine and labeling it ' Diseases  of Children,'
but has steadily kept in view the diseases which  seemed to be
incidental to childhood, or such points in disease as appear to be so
peculiar to or pronounced in children as to justify insistence upon
them.  *  *  *  A safe  and reliable guide,  and in many  ways
admirably adapted to the wants of the student and practitioner."—
American Journal of Medical Science.

  " Thoroughly individual, original  and  earnest,  the work evi-
dently of a close observer and an independent  thinker, this book,
though small, as a handbook or compendium is by no means made
up of bare outlines or standard facts."—The Therapeutic  Ga-
zette.

  " As it is  said of some men, so it might be said of some books,
that  they  are 'born to greatness.'  This new volume  has, we
believe, a  mission,  particularly  in   the hands of  the younger
members of the profession.  In these days of  prolixity in medical
literature, it is refreshing to meet with an author who knows both
what to say and when he has said it.  The work of Dr.  Goodhart
(admirably  conformed,  by  Dr. Starr, to meet  American require-
ments) is the nearest approach to  clinical teaching without the
actual presence of clinical material that we have yet seen."—New
York Medical Record.
Price of each Book. Cloth, $3.00 : Leather, $3.50. 
THE NEW SERIES OF MANUALS.          5
   No. 6.   PRACTICAL THERAPEUTICS.

FOURTH EDITION, WITH AN INDEX OF DISEASES.

Practical  Therapeutics, considered  with  reference   to
   Articles of the  Materia  Medica.  Containing, also, an
   Index  of  Diseases,  with  a list  of the  Medicines
   applicable as Remedies.  By Edward John Waring,
   m.d., f.r.c.p.    Fourth  Edition.  Rewritten  and  Re-
   vised by  Dudley W. Buxton, m.d., Asst. to the Prof.
   of Medicine at University College Hospital.

  " We wish a copy could be put in the hands of every Student or
Practitioner in the country.  In our estimation, it is the best book
of the kind ever written."—N. Y. Medical Journal.
  " Dr. Waring's Therapeutics has long been known  as one of the
most thorough and valuable of medical works.  The  amount of
actual intellectual labor it represents is immense.  .  .   .  An in-
dex of diseases, with the remedies appropriate for their treatment,
closes the volume."—Boston Medical and Surgical Reporter'.
  " The plan  of this work is an admirable one, and one  well calcu-
lated to meet  the wants of busy practitioners.  There is a remark-
able amount of information, accompanied with judicious  comments,
imparted in a concise yet agreeable style."—Medical Record.


No. 7.  MEDICAL JURISPRUDENCE AND
                   TOXICOLOG-Y.

           •   THIRD REVISED EDITION.

By John J.  Reese, m.d., Professor of Medical  Jurispru-
   dence and  Toxicology  in  the University of  Pennsyl-
   vania ; President of  the Medical Jurisprudence Society
   of Phila.;  Third Edition, Revised and Enlarged.

  "This admirable text-book."—Amer.Jour. of Med. Sciences.
  " We lay this volume aside, after a careful perusal of its pages,
with the profound impression that it should be in the hands of every
doctor and lawyer.  It fully meets the wants of all students.....
He has succeeded in admirably condensing into a handy volume all
the essential points."—Cincinnati Lancet and Clinic.
  " The book before us will, we think, be found to answer the ex-
pectations of the student or practitioner seeking a manual of juris-
prudence, and the call for a second edition is a flattering testimony
to the value of the  author's present effort.  The medical portion
of this volume seems to be uniformly excellent, leaving little for
adverse criticism.  The information on the subject matter treated
has been carefully compiled, in accordance with recent knowledge.
The  toxicological portion appears specially excellent.  Of that por-
tion  of the work  treating of the legal relations of the practitioner
and  medical witness, we can  express a generally favorable ver-
dict."—Physician and Surgeon, Ann Arbor,  Mich.

      Price of each Book, Cloth, $3,00; Leather, $3.50. 
6     STUDENTS' TEXT-BOOKS  AND MANUALS.
                       ANATOMY.
Macalister's Human Anatomy.  816 Illustrations.  A new
  Text-book for Students and Practitioners, Systematic and Topo-
.  graphical, including the Embryology, Histology and Morphology
  of Man.  With special reference  to the  requirements  of
  Practical  Surgery  and  Medicine.  With 816 Illustrations,
  400 of which are original.  Octavo.   Cloth,  7.50; Leather, 8.50
Ballou's Veterinary Anatomy and Physiology.  Illustrated.
  By Wm.  R. Ballou, m.d., Professor of Equine Anatomy at New
  York College of Veterinary Surgeons.  29 graphic Illustrations.
  i2mo.                  Cloth, 1.00; Interleaved for notes, 1.25
Holden's  Anatomy.  A manual  of Dissection of the Human
  Body.  Fifth Edition. Enlarged, with Marginal References and
  over  200  Illustrations.  Octavo.
     Bound in Oilcloth, for the Dissecting  Room, $4.50.
  " No student of Anatomy can  take up this book without being
pleased and instructed.  Its Diagrams are original, striking and
suggestive, giving more  at a glance than pages of text description.
*  * * The text matches the illustrations  in directness of prac-
tical application  and clearness  of detail."—New York Medical
Record.
Holden's Human Osteology.   Comprising a Description of the
  Bones, with Colored  Delineations of the Attachments of the
  Muscles.   The General and Microscopical Structure of Bone and
  its Development.  With Lithographic Plates and Numerous Illus-
  trations.  Seventh Edition.   8vo.                   Cloth, 6.00
Holden's Landmarks, Medical and Surgical. 4th ed. Clo., 1.25
Heath's Practical Anatomy.   Sixth London Edition.  24 Col-
  ored  Plates, and nearly 300 other Illustrations.       Cloth, 5.00
Potter's Compend  of Anatomy.  Fifth Edition.   Enlarged.
  16 Lithographic Plates.  117 Illustrations.
                         Cloth, 1.00; Interleaved for Notes, 1.25

                     CHEMISTRY.
Bartley's Medical Chemistry. Second Edition.  A text-book
  prepared  specially for Medical, Pharmaceutical and Dental Stu-
  dents.  With 50 Illustrations, Plate  of Absorption Spectra and
  Glossary of Chemical Terms.  Revised and Enlarged.  Cloth, 2.50
Trimble.  Practical and Analytical Chemistry.  A Course in
  Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem-
  istry  in the Phila. College of  Pharmacy.  Illustrated.  Third
  Edition.  8vo.                                    Cloth, 1.50
       19" See pages  2 to 5 for list of Students' Manuals. 
STUDENTS' TEXT-BOOKS  AND MANUALS.    7
                   Chemistry ;—Continued.
Bloxam's Chemistry, Inorganic and Organic, with Experiments.
  Seventh Edition.  Enlarged and  Rewritten.  281 Illustrations.
                                     Cloth, 4.50; Leather, 5.50
Richter's Inorganic  Chemistry.  A text-book  for Students.
  Third American, from Fifth German Edition.  Translated by
  Prof. Edgar F. Smith, ph.d.   89 Wood Engravings and Colored
  Plate of Spectra.                                 Cloth, 2.00
Richter's Organic Chemistry, or Chemistry of the Carbon
  Compounds.  Illustrated.  Second Edition.         Cloth, 4.50
Symonds.  Manual of Chemistry, for the special use of Medi-
  cal Students.   By  Bkandreth  Symonds, a.m., m.d., Asst.
  Physician Roosevelt Hospital, Out-Patient Department; Attend-
  ing Physician Northwestern Dispensary, New York.   i2mo.
                        Cloth, 2.00;  Interleaved for Notes, 2.40
Leffmann's Compend of Chemistry.  Inorganic and Organic.
  Including Urinary Analysis.  Third Edition.  Revised.
                       Cloth, 1.00; Interleaved for Notes, 1.25
LefFmann and Beam.  Progressive Exercises  in Practical
  Chemistry,  umo.  Illustrated.                  Cloth, 1.00
Muter.  Practical  and Analytical  Chemistry.   Third  Edi-
  tion.   Revised and Illustrated.                     Cloth, 2.00
Holland. The Urine, Common Poisons, and Milk Analysis,
  Chemical and  Microscopical.  For Laboratory  Use.   Fourth
  Edition, Enlarged.   Illustrated.                    Cloth, 1.00
Van Nuys.  Urine Analysis.   Illus.              Cloth, 2.00
Wolff's Applied Medical  Chemistry.  By Lawrence Wolff,
  m.d., Dem. of Chemistry in Jefferson Medical College.  Clo., 1.00

                      CHILDREN.
Goodhart and Starr.  The Diseases of Children.  Second
  Edition.  By J. F. Goodhart, m.d., Physician to the Evelina
  Hospital for Children; Assistant  Physician to Guy's Hospital,
  London.   Revised and  Edited by Louis Starr, m.d., Clinical
  Professor of Diseases of Children in the Hospital of  the Univer-
  sity of Pennsylvania;  Physician to  the Children's Hospital,
  Philadelphia.   Containing  many  Prescriptions and Formulae,
  conforming to the U. S.  Pharmacopoeia, Directions  for making
  Artificial Human Milk, for the Artificial Digestion of Milk, etc.
  Illustrated.                         Cloth, 3.00; Leather, 3.50
Hatfield.  Diseases  of  Children.  By M. P. Hatfield, m.d.,
  Professor of Diseases of Children,  Chicago Medical  College.
  Colored Plate.  i2mo.           Cloth, 1.00;  Interleaved, 1.25
     *5~ See pages 14 and IS for list of f Quiz- Compends ? 
8     STUDENTS'  TEXT-BOOKS  AND MANUALS.
                   Children:—Continued.
Starr.   Diseases of  the Digestive Organs in Infancy and
  Childhood.   With chapters on the Investigation of Disease,
  and on the General Management of Children.  By Louis  Starr,
  m.d., Clinical Professor of Diseases of Children in the Univer-
  sity of Pennsylvania.  Illus.  Second Edition.       Cloth, 2.25
                     DENTISTRY.
Fillebrown.  Operative Dentistry.  330 Illus.     Cloth, 2.50
Flagg's Plastics and Plastic Filling.  4th Ed.     Cloth, 4.00
Gorgas.  Dental Medicine.  A Manual of Materia Medica and
  Therapeutics.  Fourth Edition.                Nearly Ready.
Harris.  Principles and Practice  of Dentistry.  Including
  Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery
  and Mechanism.  Twelfth Edition.  Revised  and enlarged by
  Professor Gorgas.  1028 Illustrations. Cloth, 7.00; Leather, 8.00
Richardson's Mechanical  Dentistry.   Fifth Edition.  569
  Illustrations.  8vo.                 Cloth, 4.50; Leather, 5.50
Sewill.  Dental Surgery.  200 Illustrations.  3d Ed. Clo., 3.00
Taft's Operative Dentistry.  Dental Students and Practitioners.
  Fourth Edition.  100 Illustrations.    Cloth, 4.25 ; Leather, 5.00
Talbot.   Irregularities  of the Teeth, and  their  Treatment.
  Illustrated.  8vo.  Second Edition.                Cloth, 3.00
Tomes' Dental Anatomy.  Third Ed.   191 Illus.   Cloth, 4.00
Tomes' Dental Surgery.   3d Edition.   Revised.   292 Illus.
  772 Pages.                                       Cloth, 5.00
Warren.  Compend of Dental Pathology and  Dental Medi-
  cine.  Illustrated.              Cloth, 1.00; Interleaved, 1.25

                   DICTIONARIES.
Gould's New Medical Dictionary.  Containing the Definition
  and Pronunciation of all words in Medicine, with many useful
  Tables etc.  ^ Dark Leather, 3.25 ; y2 Mor., Thumb Index 4.25
Harris' Dictionary of Dentistry.   Fifth Edition.  Completely
  revised and brought up to date by Prof. Gorgas.
                                     Cloth, 5.00 ; Leather, 6.00
Cleaveland's  Pronouncing Pocket Medical Lexicon. 31st
  Edition.  Giving  correct Pronunciation  and Definition.  Very
  small pocket size.   Cloth, red edges .75 ;  pocket-book style, 1.00
Longley's Pocket Dictionary.  The Student's Medical Lexicon,
  giving Definition and Pronunciation of all Terms used  in Medi-
  cine, with  an Appendix  giving Poisons and Their Antidotes,
  Abbreviations used in Prescriptions, Metric Scale of Doses, etc.
  24m°-                    Cloth, 1.00;  pocket-book style, 1.25
       4®=- See pages 2 to 5 for list of Students' Manuals. 
STUDENTS' TEXT-BOOKS  AND MANUALS.    9
                          EYE.
Hartridge on Refraction.  4th Edition.            Cloth, 2.00
Hartridge on the Ophthalmoscope.         Nearly Ready.
Meyer.  Diseases of the Eye.  ,A complete Manual  for Stu-
  dents and Physicians.  270 Illustrations and two Colored Plates.
  8vo.                               Cloth, 4.50; Leather, 5.50
Swanzy. Diseases  of the  Eye and their Treatment.  158
  Illustrations.  Third Edition.                     Cloth, 3 00
Fox and Gould.  Compend of  Diseases of  the  Eye and
  Refraction.  2d Ed.  Enlarged.  71 Illus.   39 Formula.
                        Cloth, 1.00 ;  Interleaved for Notes, 1.25

                   ELECTRICITY.
Bigelow. Plain Talks on Medical Electricity and Batteries.
  Illustrated.                                     Cloth, 1.00
Mason's Compend  of Medical and  Surgical Electricity.
  With numerous Illustrations. i2mo.               Cloth, 1.00

                        HYGIENE.
Parkes' (Ed. A.)  Practical Hygiene.  Seventh Edition, en-
  larged.  Illustrated.   Svo.                        Cloth, 4.50
Parkes' (L. C.) Manual  of Hygiene  and  Public  Health.
  Second Edition.  121110,                          Cloth, 2.50
Wilson's  Handbook of Hygiene  and Sanitary  Science.
  Seventh Edition.  Revised and Illustrated.           In Press.

MATERIA MEDICA AND THERAPEUTICS.
Potter's Compend of Materia Medica, Therapeutics and
  Prescription  Writing.  Fifth Edition, revised and improved.
                         Cloth, 1.00;  Interleaved for Notes, 1.25
Biddle's Materia Medica.  Eleventh Edition.  By the late
  John B. Biddle, m.d., Professor of Materia Medica in Jefferson
  Medical  College, Philadelphia.    Revised,  and  rewritten,  by
  Clement Biddle, m.d., Assist.  Surgeon, U.  S. N., assisted  by
  Henry Morris, m.d.   8vo.,illustrated. Cloth, 4.25; Leather, 5.00
Potter.  Materia  Medica,  Pharmacy and  Therapeutics
  Including  Action of Medicines,  Special Therapeutics, Pharma-
  cology, etc.  Third  Edition.        Cloth, 4.00;  Leather, 5.00

Waring.   Therapeutics.  With  an Index  of  Diseases and
  Remedies.   4th Edition.  Revised.  Cloth, 3.00;  Leather, 3.50
      *J- See M?es 14 and /j for  list of .'Quiz-Compends * 
10    STUDENTS'  TEXT-BOOKS AND  MANUALS.
          MEDICAL JURISPRUDENCE.

Reese.   A Text-book  of Medical Jurisprudence and Toxi-
  cology.  By John J. Reese, m.d., Professor of Medical Juris-
  prudence and Toxicology  in  the Medical Department of the
  University  of Pennsylvania;   President of the Medical Juris-
  prudence Society of Philadelphia;  Physician to St.  Joseph's
  Hospital;  Corresponding Member of The New York Medico-
  legal Society.   Third Edition.       Cloth, 3.00;  Leather, 3.50


     OBSTETRICS  AND  GYNAECOLOGY.

Byford.   Diseases of 'Women.  The Practice of Medicine and
  Surgery, as applied  to the Diseases and Accidents Incident to
  Women. By W. H.  Byford, a.m., m.d., Professor of Gynaecology
  in Rush Medical  College and of Obstetrics in the Woman's Med-
  ical College, etc., and Henry T. Byford, m.d., Surgeon to the
  Woman's Hospital  of Chicago ; Gynaecologist to St. Luke's
  Hospital, etc.  Fourth Edition.  Revised, Rewritten  and En-
  larged.   With 306 Illustrations, over 100 of which are  original.
  Octavo. 832 pages.                  Cloth, 5.00 ;  Leather, 6.00

Cazeaux and Tarnier's Midwifery.  With  Appendix, by
  Munde. The Theory and  Practice of Obstetrics ;  including the
  Diseases of Pregnancy and  Parturition, Obstetrical Operations,
  etc.  By P. Cazeaux.  Remodeled and rearranged, with revi-
  sions and additions,  by S. Tarnier, m.d , Professor  of Obstetrics
  and Diseases of Women and Children in the Faculty of Medicine
  of Paris.  Eighth American, from the Eighth French and First
  Italian  Edition.  Edited  by Robert J. Hess, m.d.,  Physician to
  the Northern Dispensary, Philadelphia, with  an  appendix by
  Paul F. Munde, m.d., Professor of  Gynaecology at the N. Y.
  Polyclinic.   Illustrated by Chromo-Lithographs,  Lithographs,
  and other Full-page Plates, seven of which are beautifully colored,
  and numerous Wood Engravings.   Students'  Edition.   One
  Vol., 8vo.                           Cloth, 5.00;  Leather, 6.00

Lewers' Diseases of  'Women.  A Practical Text-Book.   139
  Illustrations.  Second Edition.                      Cloth, 2.50

Parvin's Winckel's  Diseases  of'Women.  Second Edition.
  Including a Section  on Diseases of  the Bladder and  Urethra.
  150 Illus.  Revised.  See page 3.      Cloth, 3.00;  Leather, 3.50

Morris.   Compend of  Gynaecology.  Illustrated.   Cloth, 1.00

Winckel's Obstetrics.  A Text-book on Midwifery, includ-
  ing the Diseases of Childbed. By Dr. F. Winckel, Professor
  of  Gynaecology, and Director of the Royal University Clinic for
  Women,  in  Munich.  Authorized  Translation, by J. Clifton
  Edgar,  m.d., Lecturer on  Obstetrics, University Medical Col-
  lege, New  York, with nearly 200 handsome illustrations, the
  majority of which are original with this work.  Octavo.
                                     Cloth, 6.00 ;  Leather, 7.00

Landis'  Compend  of Obstetrics.   Illustrated.   4th edition,
  enlarged.              Cloth,  1.00;  Interleaved for Notes, 1.25

         03T* See pages     J for list of New Manuals. 
STUDENTS' TEXT-BOOKS AND  MANUALS.    11
            Obstetrics and Gynecology :—Continued.
Galabin's Midwifery.   By A. Lewis  Galabin,  m.d.,  f.r.cp.
  227 Illustrations   See page 3.        Cloth, 3.00; Leather, 3.50
Rigby's Obstetric Memoranda.  4th Edition.       Cloth, .50

Swayne's Obstetric Aphorisms.   For the use of Students
  commencing Midwifery Practice.  8th Ed.   i2mo.    Cloth, 1.25

  PATHOLOGY.   HISTOLOGY.  BIOLOGY.
Bowlby.  Surgical  Pathology and Morbid Anatomy, for
  Students.   135 Illustrations.  i2mo.               Cloth, 2.00

Davis' Elementary Biology.  Illustrated.           Cloth, 4.00
Gilliam's Essentials of Pathology.  A Handbook for Students.
  47 Illustrations.  i2mo.                            Cloth, 2.00
  *#*The object of this book is to unfold to the beginner the funda-
mentals of pathology in a plain, practical way, and by bringing
them within easy comprehension to increase his interest in the study
of the subject.
Gibbes' Practical Histology and  Pathology.  Third Edition.
  Enlarged.   i2mo.                                 Cloth, 1.75
Virchow's Post-Mortem Examinations.   3d Ed.   Cloth, 1.00


                    PHYSIOLOGY.

Yeo's Physiology.  Fifth  Edition.  The most Popular  Stu-
  dents'  Book.   By Gerald F. Yeo, m.d., f.r.c.s.,  Professor of
  Physiology in King's College, London.   Small  Octavo.   758
  pages.  321   carefully  printed Illustrations.   With  a   Full
  Glossary and Index.  See Page3.     Cloth, 3.00; Leather, 3.50
Brubaker's  Compend   of   Physiology.   Illustrated.  Sixth
  Edition.               Cloth, 1.00; Interleaved for Notes, 1.25
Stirling.  Practical Physiology, including Chemical and  Ex-
  perimental Physiology.   142 Illustrations.            Cloth, 2.25
Kirke's Physiology.  New  12th Ed. Thoroughly Revised and
  Enlarged.   502 Illustrations.          Cloth, 4.00; Leather, 5.00
Landois' Human Physiology.  Including Histology and Micro-
  scopical Anatomy, and with special reference to Practical Medi-
  cine.  Third Edition.  Translated and Edited by Prof. Stirling.
  692 Illustrations.                     Cloth, 6.50; Leather, 7.50
  " With this Text-book  at his command, no student could fail in
his examination."—Lancet.
Sanderson's Physiological Laboratory.  Being Practical Ex-
  ercises for the  Student.   350  Illustrations.   8vo.     Cloth, 5.00


                      PRACTICE.
Taylor.  Practice of  Medicine.   A  Manual.  By Frederick
  1  aylor, m.d., Physician  to, and Lecturer on Medicine at, Guy's
  Hospital, London ;  Physician to Evelina Hospital for Sick Chil-
  dren,  and  Examiner in Materia  Medica  and Pharmaceutical
  Chemistry, University of London     Cloth, 4.00; Leather, 5 00

     #9"" See pages 14 and 15 for list of 'Quiz-Compends f 
12    STUDENTS'  TEXT-BOOKS AND  MANUALS.
                    Practice :— Continued.
Roberts' Practice.   New  Revised Edition.  A Handbook
  of the Theory and  Practice of  Medicine.  By Frederick T.
  Roberts, m.d. ; m.r.c.p.,  Professor of  Clinical  Medicine and
  Therapeutics  in University College Hospital, London.  Seventh
  Edition.  Octavo.                    Cloth, 5.50; Sheep, 6.50
Hughes. Compend of the Practice of Medicine.  4th Edi-
  tion.   Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25
  Part i.—Continued, Eruptive and Periodical Fevers,  Diseases
of the Stomach, Intestines, Peritoneum, Biliary Passages,  Liver,
Kidneys, etc., and General Diseases, etc.
  Part ii.—Diseases  of the  Respiratory System,  Circulatory
System and Nervous System; Diseases of the Blood, etc.
  Physicians'  Edition.  Fourth Edition.  Including a Section
    on Skin Diseases. With Index.  1 vol. Full Morocco,  Gilt, 2.50
From John A.  Robinson, M.D., Assistant to  Chair of Clinical
  Medicine,now Lecturer on Materia Medica, Rush Medical Col-
  lege, Chicago.
  " Meets with  my  hearty approbation as a  substitute for the
ordinary note books almost universally used by medical students.
It is concise, accurate, well arranged and lucid,   .  .   .  just the
thing for students to use while studying physical diagnosis and the
more practical departments of medicine."

             PRESCRIPTION  BOOKS.
Wythe's Dose and Symptom Book.  Containing the Doses
  and Uses of all the principal Articles of the Materia Medica, etc.
  Seventeenth Edition.  Completely Revised and Rewritten. Just
  Ready.  32mo.           Cloth, 1.00; Pocket-book style, 1.25
Pereira's Physician's Prescription Book.  Containing Lists
  of Terms,  Phrases,  Contractions and Abbreviations  used  in
  Prescriptions  Explanatory Notes,  Grammatical Construction  ot
  Prescriptions,  etc., etc.  By Professor Jonathan  Pereira, m.d.
  Sixteenth Edition.  32mo.  Cloth,  1.00; Pocket-book style, 1.25

                     PHARMACY.
Stewart's Compend of Pharmacy.  Based upon Remington's
  Text-Book of Pharmacy.  Third Edition, Revised.  With new
  Tables, Index, Etc.     Cloth, 1.00; Interleaved for Notes, 1.25
Robinson.  Latin  Grammar of  Pharmacy and Medicine.
  By H. D. Robinson, ph.d., Professor of Latin Language and
  Literature,  University  of Kansas, Lawrence.  With an Intro-
  duction by  L. E.  Sayre, ph.g., Professor of Pharmacy  in, and
  Dean of, the Dept. of Pharmacy, University of Kansas.  i2mo.
                                                   Cloth, 2.00
                  SKIN  DISEASES.
Anderson,  (McCall) Skin Diseases.  A  complete Text-Book,
  with  Colored  Plates and numerous Wood  Engravings.  8vo.
                                     Cloth, 4.50;  Leather, 5.50
Van Harlingen on Skin  Diseases.  A  Handbook of the Dis-
  eases of the Skin, their Diagnosis and Treatment (arranged alpha-
  betically).  By Arthur  Van Harlingen,  m.d.,  Clinical  Lecturer
  on Dermatology, Jefferson Medical College; Prof, of Diseases of
  the Skin in the Philadelphia Polyclinic.  2d Edition.  Enlarged.
  With colored and other plates and illustrations. i2mo. Cloth, 2.50
         «6S=" See pages 2 to 5 for list of New Manuals. 
STUDENTS' TEXT-BOOKS AND MANUALS.    13
         SURGERY AND  BANDAGING.

Moullin's Surgery, A  new Text-Book.  500  Illustrations, 200 of
  which are original.                   Cloth, 7.00; Leather, 8.00

Jacobson.  Operations in Surgery.  A Systematic Handbook
  for Physicians, Students and Hospital Surgeons.  By W. H. A.
  Jacobson, B.A., Oxon.  f.r.c.s. Eng.;  Ass't Surgeon Guy's Hos-
  pital ; Surgeon at Royal Hospital for Children and Women, etc.
  199 Illustrations.  1006 pages.   8vo.   Cloth. 5.00; Leather, 6.00

Heath's Minor Surgery, and Bandaging.  Ninth Edition.   142
  Illustrations.  60 Formulae and  Diet Lists.           Cloth, 2.00

Horwitz's   Compend  of  Surgery, Minor   Surgery  and
  Bandaging, Amputations,  Fractures, Dislocations, Surgical
  Diseases, and the Latest Antiseptic Rules, etc., with Differential
  Diagnosis  and Treatment.  By Orville Horwitz, b.s., m.d.,
  Demonstrator of Surgery, Jefferson Medical College.  4th edition.
  Enlarged and Rearranged.  136 Illustrations and 84 Formulae.
  i2mo.    Cloth, 1.00;  Interleaved for the addition of Notes, 1.25
  ***The new Section on Bandaging and Surgical  Dressings, con-
sists of 32 Pages  and 41 Illustrations.  Every Bandage  of any
importance is figured.  This, with  the  Section  on  Ligation of
Arteries, forms an ample Text-book for the Surgical Laboratory.

Walsham.  Manual of Practical Surgery.  For Students and
  Physicians.  By Win,  J. Walsham, m.d., f.r.c.s.,  Asst. Surg.
  to, and Dem. of Practical Surg, in, St. Bartholomew's Hospital,
  Surgeon to  Metropolitan Free Hospital, London.   With  236
  Engravings.  See Page 2.           Cloth, 3.00; Leather, 3.50


       URINE,  URINARY  ORGANS, ETC.

Holland.  The  Urine,  and  Common  Poisons  and  The
  Milk. Chemical and  Microscopical, for Laboratory  Use. Illus-
  trated.  Fourth Edition.  i2mo.  Interleaved.      Cloth, 1.00

Ralfe.  Kidney Diseases and Urinary Derangements. 42 Illus-
  trations.  i2mo.  572 pages.                       Cloth, 2.75

Marshall and Smith.  On the Urine. The Chemical Analysis of
  the Urine. By John Marshall, m.d., Chemical Laboratory, Univ.
  of Penna ;  and Prof. E. F. Smith, ph.d.  Col. Plates.  Cloth, 1.00

Tyson. On the Urine.  A Practical Guide to the Examination
  of Urine.   With Colored Plates and Wood Engravings.   7th Ed.
  Enlarged.  121110.                                 Cloth, 1.50

Van  Niiys,  Urine  Analysis.  Illus.                Cloth, 2.00


              VENEREAL DISEASES.

Hill and Cooper.   Student's Manual of Venereal Diseases,
  with Formulae.  Fourth Edition.  i2mo.          Cloth, 1.00

     4Qf* S<v pages 14 and 15 for list of  .' Qutz-Cotnpends .' 
            NEW AND REVISED EDITIONS.


  PQUIZ-COMPENDS?

  The Best Compends for Students' Use

      in the  Quiz Class, and when Pre-

            paring for Examinations.

  Compiled in accordance with the latest teachings of promi-
      nent lecturers and the most popular Text-books.

   They form  a most- complete, practical and  exhaustive
 set of manuals, containing information nowhere else col-
 lected in such a condensed, practical shape.  Thoroughly
 up to the times in every respect, containing many new
 prescriptions  and formulae,  and over two hundred and
 fifty  illustrations, many of which have  been drawn and
 engraved specially for this series.  The  authors have had
 large experience as quiz-masters and attaches of colleges,
 with exceptional opportunities for noting the most recent
 advances and methods.
      Cloth, each $1.00.  Interleaved for Notes, $1.25.
 No. 1. HUMAN ANATOMY, " Based upon Gray."  Fifth
  Enlarged Edition, including Visceral Anatomy, formerly
  published  separately.   16  Lithograph  Plates,  New
  Tables  and  117  other Illustrations.   By Samuel  O.  L.
  Potter, m.a., m.d., m.r.c.p. (Lond.,) late A. A. Surgeon U. S.
  Army.  Professor of Practice, Cooper Medical College, San Fran-
  cisco.
 Nos.  2 and 3.   PRACTICE OF MEDICINE.  Fourth Edi-
  tion.  By Daniel E. Hughes, m.d., Demonstrator of Clinical
  Medicine in Jefferson Medical College, Philadelphia. In two parts.
  Part I.—Continued, Eruptive and Periodical Fevers,  Diseases
 of the Stomach,  Intestines, Peritoneum, Biliary Passages,  Liver,
 Kidneys, etc. (including Tests for Urine), General Diseases,  etc.
  Part H.—Diseases of the Respiratory System (including Phy-
 sical Diagnosis), Circulatory System and Nervous System; Dis-
 eases of the Blood, etc.
  *** These little books can be regarded as a full set of notes upon
 the Practice of Medicine, containing the Synonyms, Definitions,
 Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each
disease, and including a number of prescriptions hitherto unpub-
lished.

 No.  4.  PHYSIOLOGY,  including  Embryology.  Sixth
  Edition. By Albert P. Brubaker, m.d., Prof, of Physiology,
  Penn'a College  of Dental Surgery ; Demonstrator of Physiology
  in Jefferson Medical College, Philadelphia.  Revised, Enlarged,
  with new Illustrations.
No. 5. OBSTETRICS.  Illustrated.  Fourth Edition. By
  Henry G. Landis, m.d., Prof, of Obstetrics and Diseases of
  Women, in Starling Medical College,  Columbus, O.    Revised
  Edition.  New Illustrations.                    • 
    BLAKISTOX'S  ?QUIZ-COMPEXDS?

No.  6.   MATERIA  MEDICA, THERAPEUTICS  AND
  PRESCRIPTION WRITING.  Fifth Revised Edition.
  With especial  Reference to the Physiological Action of Drugs,
  and a complete article on Prescription  Writing.  Based on the
  Last  Revision of the U. S. Pharmacopoeia, and including many
  unofficinal remedies.   By Samuel O. L. Potter, m.a., m.d.,
  m.r.c.p. (Lond.,) late A. A. Surg. U. S. Army ;  Prof, of Practice,
  Cooper Medical College, San Francisco.  Improved and Enlarged,
  with Index.
No. 7.  GYNECOLOGY. A Compend of Diseases of Women.
  By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson
  Medical College, Philadelphia.   45 Illustrations.
No.  8.  DISEASES OF THE EYE AND REFRACTION,
  including Treatment and Surgery. By  L. Webster Fox, m.d.,
  Chief Clinical Assistant Ophthalmological Dept., Jefferson Med-
  ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39
  Formulae.   Second Enlarged and Improved Edition. Index.
No. g.  SURGERY, Minor Surgery and Bandaging.  Illus-
  trated.  Fourth  Edition.   Including  Fractures, Wounds,
  Dislocations, Sprains, Amputations and other operations ; Inflam-
  mation, Suppuration,  Ulcers, Syphilis, Tumors, Shock,  etc.
  Diseases  of  the  Spine,  Ear, Bladder,  Testicles, Anus,  and
  other Surgical  Diseases.  By Orville  Horwitz, a.m., m.d.,
  Demonstrator of Surgery, Jefferson Medical College.  Revised
  and Enlarged.  84  Formulae and 136 Illustrations.
No. 10.  CHEMISTRY.  Inorganic and Organic.  For Medical
  and Dental  Students.  Including Urinary Analysis and Medical
  Chemistry.  By Henry Leffmann, m.d., Prof, of Chemistry in
  Penn'a College of Dental Surgery, Phila.  Third Edition, Revised
  and Rewritten, with Index.
No. 11.  PHARMACY.   Based upon " Remington's Text-book
  of Pharmacy."  By F. E. Stewart, m.d., ph.g., Quiz-Master
  at Philadelphia College of Pharmacy.  Third  Edition, Revised.
No. 12.  VETERINARY ANATOMY  AND  PHYSIOL-'
  OGY.  29 Illustrations.  By Wm. R.  Ballou, m.d.,  Prof, of
  Equine Anatomy at N. Y. College of  Veterinary Surgeons.
No. 13.  DENTAL PATHOLOGY AND DENTAL MEDI-
  CINE.  Containing all the most noteworthy  points of interest
  to the  Dental student.  By Geo. W. Warren, d.d.s., Clinical
  Chief, Penn'a College of Dental Surgery, Philadelphia.   Illus.
No. 14.  DISEASES  OF CHILDREN.  By Dr. Marcus P.
  Hatfield, Prof,  of  Diseases of Children,  Chicago  Medical
  College.  Colored  Plate.

   Bound in Cloth, $1.  Interleaved, for the Addition  of Notes, $1.25.

   S^° These books are constantly revised to keep up with
the latest teachings and discoveries, so that they contain
all the new methods  and principles.  No series of books
are so complete in  detail, concise in  language, or so  well
printed and  bound.  Each one forms a complete set of
notes upon the subject under consideration.
          Illustrated  Descriptive Circular  Free. 
JUST PUBLISHED.   *
           GOULD'S  NEW
Medical  Dictionary
COMPACT.

GONGISE.

PRACTICAL,

ACCURATE,
6  COMPREHENSIVE
■es L
!^|  UP TO DATE,
It contains Tables of the Arteries, Bacilli, Gan-
  glia,  Leucomai'nes,  Micrococci, Muscles,
     Nerves, Plexuses,  Ptomaines,  etc.,
        etc., that will be found of great
            use to the student.
Small octavo, 520 pages, Half-Dark Leather,   .  $3.25
With Thumb Index, Half Morocco, marbled edges, 4.25
   From J. M. DaCOSTA, M. D., Professor of Practice and
Clinical Medicine, Jefferson Medical College, Philadelphia.
   "Ifind it an excellent work, doing credit to the learning and
discrimination of the author."
*** Sample Pages free. 
A   UNIQUE   BOOK.
 POTTER'S MATERIA MEDICA, PHARMACY AND THERA-
    PEUTICS.   Second Edition.   Revised and Enlarged.  A Hand-
    book; including the Physiological Action of Drugs, Special Therapeutics
    of Diseases,  Official and Extemporaneous Pharmacy, etc.   By S. 0. L.
    Potter,  M.a., m.d.,  Professor of the Practice  of Medicine in Cooper
    Medical College, San  Francisco;  Late A. A. Surgeon, U.  S. Army, etc.
    A new Edition in larger type.   Octavo.     Cloth, $4.00; Leather, $5.00.

   Dr. Potter has become well known as an able compiler, by  his Compends
 of Anatomy, and of Materia Medica, both of which have reached four editions.
 In this book, more elaborate in its design, he has shown his  literary abilities to
 much better advantage, and  all who examine or use it will  agree that he has
 produced a work containing more correct information in a practical, concise
 form than any other publication of the kind.   The plan of the work  is  new,
 and its contents have been combined and arranged in such a way that it  offers
 a compact statement of the subject in hand.
   Part I.—Materia Medica and Therapeutics, the drugs being arranged
 in alphabetical order, with the synonym of each first; then the  description of
 the plant, its  preparations, physiological action,  and lastly its   Therapeutics.
 This part is preceded by a section on the classification of medicines as follows:
 Agents  acting on the Nervous System, Organs of Sense,  Respiration, Circu-
 lation, Digestive System, on  Metabolism (including  Restoratives, Alteratives,
 Astringents, Antipyretics, Antiphlogistics and Antiperiodics, etc.).  Agents act-
 ing upon Excretion, the Generative System, the Cutaneous  Surfaces, Microbes
 and Ferments, and upon each other.
   Part II.—Pharmacy and  Prescription Writing.  Written for the use
 of physicians who put up their own prescriptions.  It includes—Weights and
 Measures,  English and  the  Metric Systems.  Specific Gravity  and  Volume.
 Prescriptions.—Their principles and combinations; proper methods of writing
 them;  abbreviations  used, etc.   Stock  solutions  and preparations, such as  a
 doctor should have  to  compound his  own  prescriptions.  Incompatibility,
 Pharmaceutical and  Therapeutical.  Liquid, Solid  and Gaseous Extempo-
 raneous Prescriptions.
   Part  III.—Special Therapeutics, an alphabetical List of Diseases—a
 real Index of Diseases—giving the drugs that have been found serviceable
 in each disease, and the authority recommending  the use of each; a very im-
 portant feature, as it gives an authoritative character to the book that is unusual
 in works on Therapeutics,  and displays an immense amount of research on the
 part of the author.  600 prescriptions are given in this part, many being over
 the names of eminent men.
   The Appendix contains lists of Latin words, phrases and abbreviations, with
 their English  equivalents, used in medicine, Genitive  Case  Endings, etc.  36
 Formuke for Hypodermic Injections;  a comparison of 10 Formulae of Chloro-
 dyne; Formulae of prominent patent medicines;  Poisons and their Antidotes;
 Differential Diagnosis;  Notes on Temperature in Disease; Obstetrical  Memo-
 randa;  Clinical Examination of Urine; Medical Ethics;  Table of  Specific
 Gravities and Volumes; Table showing the number of drops in a fluidrachm
of various liquids and the weight of one fluidrachm in grains, and a table for
converting apothecaries' weights and measures into grams.
A MINE  OF WEALTH FOR  THE  STUDENT. 
   Standard    Text-Books.

LANDOIS' HUMAN PHYSIOLOGY.  A Text-Book of Human Physi-
   ology, including  Histology and  Microscopical Anatomy, with special
   reference to the requirements of Practical  Medicine.   By Dr. L.
   Landois, Professor oi Physiology and  Director of the Physiological Insti-
   tute, University of Greifswald.  Translated from the Fifth German Edition,
   with additions by Wm. Stirling,  m.d., Sc.d.,, Brackenburg, Professor of
   Physiology and Histology in Owen's College and Victoria University, Man-
   chester ; Examiner  in the  Honors' School of Science, University of Ox-
   ford, England.  Third Edition, revised and enlarged.  692 Illustrations.
   One Volume.  Royal Octavo.  Cloth,  #6.50;  Leather, $7.50.
 "With this Text-book at command, no  Student could fail in his examination."—
The Lancet.
 "One of the most practical works on Physiology ever written, forming a 'bridge' be-
tween Physiology and Practical Medicine.  ...  Its chief merits are its completeness and
conciseness.  . .  .  Excellently clear,  attractive and succinct."—British Medical
Journal.
 " Unquestionably the most admirable exposition of the relations of Human Physiology to
Practical Medicine ever laid before English readers."—Students' Journal.
 " Landois' Physiology is, without question, the best text-book on the subject that has ever
been written."—New York Medical Record,
CAZEAUX AND TARNIER'S MIDWIFERY.  Eighth Revised
    and Enlarged  Edition.  With Appendix, by Munde. The Theory
    and Practice of Obstetrics;  including the Diseases of  Pregnancy and
    Parturition,  Obstetrical Operations, etc.   By P. Cazeaux, Member of
    the Imperial Academy of Medicine.   Remodeled and  rearranged, with
    revisions and additions, by S. Tarnier, m.d.,  Prof, of Obstetrics and
    Diseases of Women and  Children in the Faculty of Medicine of Paris.
    Eighth American, from the Eighth French  and First  Italian  Editions.
    Edited and  Enlarged by Robert J. Hess, m.d., Physician to the Northern
    Dispensary,  Phila., etc., with  an Appendix by Paul F. Munde, m.d.,
    Professor of Gynaecology  at the New  York Polyclinic, Vice-President
    American Gynaecological Society, etc.   With Chromo-Lithographs, Litho-
    graphs, and other Full-page Plates, seven  of which are beautifully colored,
    and numerous Wood Engravings.  One Volume, octavo.
                                      Cloth, $5.00;  Full Leather, $6.00.
 MEYER  ON  DISEASES OF  THE EYE.   A  Manual of Ophthal.
    mology.  By Dr. Edouard Meyer, Prof, a l'Ecole Pratique de la Faculte
    Medecine de Paris; Chevalier of the  Legion of Honor, etc.   Translated
    from the Third French  Edition,  with  the assistance of the author, by Dr.
    Freeland Fergus, Assistant Surgeon, Glasgow Eye Infirmary.  With 267
    Illustrations and three Colored Plates.  Prepared under the direction of Dr.
    R. Liebreich. 8vo.  Cloth, $4.50; Leather, #5.50.
   The first chapter is an explanation of the best means for examining the eyes,
 externally and  internally, with a view to diagnosis, the various ophthalmo-
 scopes, general considerations on the treatment of  ophthalmia, etc.   Each dis-
 ease is then taken up in its proper order;  the anatomy of the part being pre-
 sented first, followed by the diagnosis, causes, progress, prognosis, etiology and
 Jreatment.   The arrangement  of the work will thus be seen to be  systematic,
 commending itself to all physicians  and students for the logical and concise
 way  in which  the facts are given.   This English edition makes the  eighth
 language into which Meyer's book has been translated.
P. BLAKISTON, SON  & CO., Publishers and  Booksellers
                  1012 WALNUT STREET, PHILADELPHIA 
 
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