7233 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 7233 
 
 SURGICAL 
 THERAPEUTICS 
 
 BY 
 
 EMORY LANPHEAR, M. D., Ph. D., LL. D. 
 
 ST. LOUIS, MO. 
 
 Professor of Surgery, Hippocratean College of Medicine; Formerly Professor 
 
 of Operative Surgery in the Kansas City Medical College and 
 
 Professor of Surgery in the St. Louis College of 
 
 Physicians and Surgeons. Chief Surgeon 
 
 to the Woman's Hospital of the 
 
 State of Missouri 
 
 CHICAGO 
 
 THE CLINIC PUBLISHING COMPANY 
 1907
 
 Copyrighted 
 
 THE CLINIC PUBLISHING COMPANY 
 1907
 
 Library 
 ItfB 
 
 300 
 
 FOREWORD 
 
 There are hundreds of books telling how to 
 operate not one describing the proper management 
 of the patient without operation. Almost as many 
 give careful directions as to when operations should 
 be done but with only trifling mention of the prop- 
 er preparation of the patient for the operative work, 
 of the best way to make him comfortable after oper- 
 ation, or of the right management of the wound to 
 get ideal results. In other words: there is no work 
 on the non-operative treatment of surgical conditions. 
 The object of this little book is to give some of the 
 important points neglected by or omitted from the 
 ^xmore elaborate works on surgery. 
 
 It is based chiefly upon personal experience, es- 
 
 ; pecially in the management of cases in the country 
 \ 
 [nand in private houses in the city, though of course 
 
 many of the suggestions are for especial use in hos- 
 pital practice. It is not intended to be regarded as 
 
 ^a complete treatise on " Surgical Therapeutics," in- 
 deed, it might perhaps more properly be called 
 "Practical Suggestions for the Management of Surg- 
 ical Cases." If it meets the approval of the vast 
 
 ; number of doctors who try to manage their own 
 surgical cases, it will be followed later by a more 
 
 , elaborate, complete work covering the entire field of 
 v non-operative surgery. 
 
 624351
 
 If the reader who is interested in this line of work 
 will deliberately read this little book "straight 
 through " from beginning to end, and then later re- 
 fer to any special section he may desire to, he will, I 
 am sure, obtain better results than if he attempt to 
 merely read here and there as his fancy may dictate. 
 
 EMORY LANPHEAR 
 
 ST. Louis, MISSOURI.
 
 ABDOMINAL SECTION 
 
 Abdominal Tumors. As a rule, operable tumors 
 should be removed at the earliest possible moment after their 
 existence is detected. Those which are usually removable 
 without much danger are: (i) tumors of the gall-bladder, 
 
 (2) tumors of the intestine, (3) tumors of the omentum, 
 (4) tumors of the uterus, (5) tumors of the ovary. Those 
 which may sometimes be removed, with a considerable 
 degree of danger,are: (i) tumors of the stomach, (2) tumors 
 of the bladder, (3) tumors of the broad ligament, (4) 
 tumors of the kidney. Those which are rarely removable 
 are: (i) tumors of the liver, (2) tumors of the pancreas, 
 
 (3) tumors of the spleen. When it is certain these growths 
 are of malignant character the probabilities of cure even 
 by early excision are not good. Nevertheless, very much 
 may often be done by purely palliative operations (such 
 as gastroenterostomy, artificial anus and the like) which 
 will prolong life and make the sufferer far more nearly com- 
 fortable. When any (even inoperable) tumor undergoes 
 suppurative inflammation the pus should be evacuated 
 by two operations: the first to secure protective adhesions, 
 the second to drain the abdomen. 
 
 Adhesions: Prevention of. In abdominal surgery 
 one of the most important things is to leave the belly in 
 such shape that adhesions will not form. To this end 
 much time may profitably be spent (except in cases of 
 emergency where immediate closure is imperative) in doing 
 work to prevent any raw surface being left exposed; for, 
 if it be, an intestine or other strucure is almost cer- 
 tain to adhere and cause future suffering especially in 
 nervous, hysterical or neurasthenic persons.
 
 2 SURGICAL THERAPEUTICS 
 
 The best way is to cover thoroughly every denuded sur- 
 face with peritoneum; but if this is impossible, the omen- 
 turn is to be brought to the bare place and sutured over 
 it, if possible, in such way that there is no traction on 
 the omentum. In some cases, where neither can be done, 
 it is good practice to rub the raw surface thoroughly with 
 sterilized olive oil. Silver-foil has been suggested, but 
 it cannot be employed satisfactorily and should not be 
 tried (though it may be used in the brain). A 20-per- 
 cent solution of gelatin with i -percent formalin has also 
 been recommended, hut is worse than useless. Cargile 
 membrane has also proven of little value in my own 
 experience. 
 
 On the whole it may be said that there is no effectual 
 way of preventing adhesions except carefully to cover 
 every torn or cut surface with peritoneum or omentum. 
 Even rough handling of intestines with gauze or towel 
 will produce enough erosion of the serosa to cause adhesions; 
 hence the necessity of dealing as gently as possible with 
 the peritoneum everywhere. 
 
 Calomel in Abdominal Surgery. Calomel is a fa- 
 vorite with many surgeons who do much abdominal work 
 not in the large doses of our forefathers, but in tablets 
 or granules containing a half centigram (approximately 1-12 
 grain) in sugar of milk. These are given beginning on 
 the second day following operation, at which time the 
 tongue is often dry, the abdomen slightly tympanitic and 
 the stomach a little disturbed, especially if too much water 
 has been permitted. If to such a patient one tablet be 
 given every hour (one every half-hour if early catharsis 
 seems desirable) until ten are taken, there will be a marked 
 change for the better in patients not too profoundly septic; 
 the tongue will become moist, gas will begin to pass, the 
 nausea will disappear, thirst will diminish and, if at the 
 end of the course a mild saline laxative be given, free bowel-
 
 ABDOMINAL SECTION 3 
 
 movement will speedily follow after which the period of 
 acute danger will have been passed. 
 
 Codeine in Abdominal Surgery. One of the most 
 useful drugs in abdominal work is codeine phosphate. 
 The phosphate is preferable to the more common sulphate 
 on account of its free solubility of particular importance 
 for hypodermic medication. It is the best of all prepara- 
 tions of opium because (i) it does not check secretions like 
 morphine, (2) a codeine habit is not easily formed and 
 (3) it does not produce the distressing secondary nausea 
 of other opiates. After an abdominal section, when the 
 patient complains bitterly of pain and general discomfort, 
 fifty centigrams (from a half grain to a grain) may be in- 
 jected and repeated in an hour if necessary. It being 
 mildly anodyne and hypnotic the patient generally feels 
 sufficiently comfortable after two doses not to require a 
 third for some hours, when the two doses one hour apart 
 may be repeated. Old tablets may not dissolve readily; 
 if so, add a little phosphoric acid. 
 
 Elaterin in Abdominal Surgery. After certain oper- 
 ations it becomes necessary to secure very early bowel- 
 movement; calomel is too slow and salines are apt to pro- 
 voke vomiting. Here elaterin (the glucoside active prin- 
 ciple of the elaterium of the shops) can be employed with 
 the greatest satisfaction. It should be given in granules, 
 each containing one milligram (i-67th of a grain) one every 
 hour until five or six have been taken or copious move- 
 ments have been secured. If emesis results, the elaterin 
 should be temporarily discontinued and one milligram of 
 salicylate of eserine given hypodermically every hour, four 
 times; by this the peristaltic wave will be reversed and the 
 fecal current started downward; then the elaterin may be 
 resumed. When black- vomit begins after operation, this 
 is by far the most effective; especially when supplemented 
 by washing out the stomach.
 
 4 SURGICAL THERAPEUTICS 
 
 Enema after Abdominal Section. After abdominal 
 section cathartics can not be given early by the mouth on 
 account of nausea. In such cases when it is desirable to 
 secure bowel-movement the following enema thrown high 
 into the rectum, may be given: 
 
 Epsom salt, 5o-percent solution ozs. 2 
 
 Oil of turpentine ozs. 2 
 
 Glycerin ozs. 2 
 
 Water ozs. 6 
 
 The injection is to be held in the bowel as long as 
 possible by the patient. It is well to anoint the inner 
 thighs and buttocks in order to prevent irritation of the 
 parts should they come in contact with the turpentine by 
 mischance. 
 
 Opium after Abdominal Section. The only cases 
 in which opium (or morphine) is indicated after abdom- 
 inal operations are those in which the intestine has been 
 injured, cut into, torn into, or anastomosis made. Then 
 peristalsis is undesirable, as any movement of the bowels 
 tends to prevent the formation of early, firm adhesions 
 on which the life of the patient depends. Opium above 
 all other drugs checks peristalsis; hence full doses of sul- 
 phate of morphine may be injected hypodermically every 
 four to six hours during the first forty-eight hours fol- 
 lowing such an operation; but no further use would be 
 beneficial, as adhesions have been formed by that time, 
 if ever. In all other section-work, if an opiate seems un- 
 avoidable, grain-doses (six centigrams) of phosphate of 
 codeine may be injected hypodermically every three or 
 four hours as required; morphine alone, never. 
 
 Peritonitis Following Operation. Peritonitis is 
 a localized trouble, and is essentially life-saving when not 
 too extensive or severe, the adhesions formed thereby 
 serving to limit the spread of suppuration. That which 
 is commonly called "general peritonitis," with its
 
 ABDOMINAL SECTION 5 
 
 vomiting, collapse and death, is acute sepsis of the 
 most serious type. 
 
 But sometimes the peritoneal surfaces do not aggluti- 
 nate around a point of infection (as a typhoid perforation, 
 a gangrenous appendicitis or a pus-tube) and the general 
 peritoneal cavity becomes a huge absorption-sac, so that 
 the system is speedily overwhelmed and death from poison- 
 ing of the heart-muscle (with true " heart -failure") quickly 
 supervenes unless the surgeon has the courage and the 
 skill to act promptly and properly. 
 
 These are the cases formerly treated by Sir Andrew 
 Clark with calomel, followed by opium the idea being to 
 paralyze the bowel so that protective adhesions may form 
 and still advocated by some who are not familiar with intra- 
 abdominal pathology. With this line of treatment it is 
 common to order hop poultices, turpentine stupes, Crede's 
 ointment, cataplasma kaolini, ice-bags, etc., all of which 
 tend to comfort the patient's mind and afford relief to 
 the anxious friends who want to "do something," but they 
 have but little if any effect upon the pathology save to 
 hasten spontaneous rupture of an abscess about ready 
 to break through the skin. 
 
 The truth is, there are but two curative measures pos- 
 sible : to remove (or render less dangerous) a source of local 
 infection, and to rid the peritoneum of the infective material 
 already poured out into it. 
 
 It is true that in a large proportion of cases the peri- 
 toneum affected is of but trifling extent (as around the 
 appendix, or in the pelvis where absorption is excessively 
 slow, the stomata being very few as compared with the 
 dangerous areas like the diaphragmatic peritoneum) and 
 adhesions prevent the dissemination of the poison. But 
 when symptoms indicate that the protective barrier is not 
 being thrown out there must not be any delay. This rule 
 is applicable alike to appendicitis, to salpingitis, to chole-
 
 6 SURGICAL THERAPEUTICS 
 
 cystitis and to intestinal obstructions; it is imperative in 
 all penetrating wounds of the abdomen, in ruptured gall- 
 bladder, in perforation of gastric or duodenal ulcers, in 
 leakage of pyosalpinx, in volvulus and even in the giving 
 way of the intestine in typhoid fever practically all cer- 
 tain to end in death unless quickly and skilfully remedied. 
 
 When there must be some delay in operating, the pa- 
 tient should be kept in the Fowler position: the head of 
 the bed raised upon a chair so that all of the infected fluid 
 in the belly will run into the pelvis where absorption is 
 slow. 
 
 Now all this applies with extra force to postoperative 
 peritonitis. Here the surgeon expects serous surfaces to 
 adhere, in order to cover the line of incision and the wounded 
 surfaces. If the work has been performed aseptically a 
 non-inflammatory adhesion will follow, completely burying 
 all exposed and injured surfaces; and results will usually 
 be satisfactory. But if (i) pyogenic bacteria have been 
 carried in by dirty fingers or non-sterile gauze or instru- 
 ments, or if (2) some pathologic conditions have been found 
 which cannot be entirely excised without soiling of peri- 
 toneum, or if (3) some viscus has been so injured that it 
 may discharge infective contents into the peritoneum, a 
 general infection of the peritoneum may occur, with -speedy 
 death. 
 
 Now, following the abdominal operations there are cer- 
 tain disturbances which are practically normal: slight rise 
 of temperature, vomiting, pain, etc., yet which if continued 
 clearly indicate serious peritoneal infection; so the question 
 of greatest import is: What are the signs pointing unequivo- 
 cally to peritoneal infection? 
 
 The first and foremost symptom is vomiting. When 
 the bile-tinged water changes to a greenish-brown and when 
 the straining of anesthesia -ernes is is succeeded by practically 
 effortless vomiting (not immediately and permanently re-
 
 ABDOMINAL SECTION 7 
 
 lieved by once washing out the stomach) there can be no 
 doubt of serious sepsis, and delay in proper treatment 
 means a fatal termination. 
 
 Accompanying this is persistent refusal of the bowels 
 to move, not even gas escaping. With this absence of 
 peristalsis comes distension of the abdomen tympanites. 
 If under the most vigorous purgatives, supplemented by 
 high enema ta, no bowel-movement can be induced the 
 experienced operator does not hesitate to open the belly 
 to correct the disease if possible. He who waits until ster- 
 coraceous vomiting appears never saves a life. 
 
 The temperature behavior is peculiar. There is rarely 
 much fever; the very worst cases have a subnormal record. 
 But if there be a fever above ioiF., it is corroborative 
 (merely) of the other signs. 
 
 If now, to the signs of persistent vomiting, tympanites 
 and paresis of gut, there be added a knowledge that there 
 is strong probability of something wrong inside, as a fail- 
 ure to provide drainage in a doubtful case, the likelihood 
 of a leakage from an improperly closed opening in intestine 
 or gall-bladder, too free oozing into the pelvis from torn 
 adhesions, uncertainty as to perfect aseptic technic during 
 operation, etc., the surgeon ought scarcely to hesitate about 
 the justifiability to reopen and clean up. Yet even the 
 most experienced surgeons do hesitate in this matter, often 
 "hoping against hope" until it is too late. 
 
 As soon as it has been decided that reopening the abdo- 
 men is necessary, an injection of one tablet of the hyoscine- 
 morphine-cactin anesthetic is to be made (hyoscine, gr. 
 i-ioo; morphine, gr. 1-4; and cactin, gr. 1-67); by the 
 time instruments and hands are sterilized the patient will 
 be so sleepy that but a few drops of chloroform will be 
 needed a matter of great importance because the patient 
 is already so weak and nauseated; besides it induces a condi- 
 tion of tranquillity after the work is done. In case the
 
 8 SURGICAL THERAPEUTICS 
 
 patient is too weak for an inhalent anesthetic the work 
 may be done with one hypodermic injection, plus cocaine 
 anesthesia locally; but it is best, when possible, to have 
 the patient oblivious to what is being done. 
 
 Invariably before beginning the operative work the 
 stomach must be washed out with salt-solution. 
 
 The belly should be opened with two objects well 
 denned in the mind of the surgeon: (i) To clean out the 
 abdominal cavity as speedily and perfectly as possible and 
 (2) to locate quickly and correct the source of infection; 
 or if not possible of correction, to afford perfect 
 drainage. 
 
 i. To attain the first, one must be guided by the con- 
 ditions present as to method: (a) When the infection is 
 presumed to be general, and dependent upon faulty technic 
 (dirty hands or instruments or sponges) probably the best 
 procedure is to open widely the wound and pour in large 
 quantities of normal salt solution, temperature of 102- 
 io5F., inserting a hand first into the pelvis and separating 
 the coils of intestine so that irrigation may reach all parts 
 of the lower abdomen; when that has been effectively 
 flushed the hand and the solution are to be turned toward 
 the diaphragm and the upper part of the abdominal cavity 
 washed out with even more care than that bestowed upon 
 the lower tracts where absorption is not so active. From 
 two to ten gallons of salt solution may thus be used con- 
 tinuing the stream until all flocculi or tinged serum seem 
 to be removed. 
 
 In this process of irrigation a large rubber tube with 
 a funnel is the instrument of choice, as the tube can be 
 carried to the depths and the infective material thus be 
 thrown out much more easily than if a pitcher be used 
 and the fluid merely poured in and allowed to run out. 
 
 (b) The same method is best when there is intestinal 
 perforation with large outpouring of fecal matter.
 
 ABDOMINAL SECTION 9 
 
 (c) When the trouble is due to accumulation of in- 
 fected serum in the pelvis (as after removal of a uterine 
 fibroid, without drainage) the pelvis only need be irrigated, 
 and it is best to have the patient in the Fowler position 
 during the cleansing so that the infectious material be not 
 spread over the non-infected peritoneum by flooding of the 
 upper abdomen. In such cases it is best to thoroughly 
 dry the pelvis and then pack loosely with gauze (left pro- 
 truding through the wound) pulling the omentum well 
 into the pelvis and tucking it in around the gauze, between 
 it and the brim of the pelvis. 
 
 (d) When the infection is presumed to be merely a 
 localized one, as at the site of pyosalpinx just removed or 
 a : ecently excised appendix, it is better merely to wipe 
 the peritoneum dry, especially the pelvis and the spaces 
 just below each kidney, where infected serum is prone to 
 accumulate, and insert drainage. 
 
 2. When the source of infection is known to be a local 
 one, as (a) a leak from the stump of an appendix, (b) a 
 perforation of gut (quite likely to occur when extensive 
 adhesions between coils of intestines have been broken up), 
 (c) failure to form adhesions around a drained gall-bladder 
 or other infected part, (d) oozing from torn adhesions, 
 (e) contamination by urine through a torn ureter or 
 around a ligature or suture passed into the bladder by 
 mistake, or any other cause, the first duty of the surgeon 
 is to seek this local trouble and correct it, if possible; if 
 not, then to irrigate or clean by wiping, and drain. 
 
 In the process of wiping, great care must be exercised 
 not to do harm to the peritoneum. Soft pads of gauze 
 should be used, wrung out of the hot, normal salt solution 
 already at hand for irrigation, if indicated. Pus and flakes 
 of fibrin adherent to the intestine must be carefully re- 
 moved, but not enough force should ever be employed to 
 make the musculosa bleed, for the serosa often has to be
 
 10 SURGICAL THERAPEUTICS 
 
 removed with the fibrin if an attempt be made to get all; 
 it is best to take away only that which comes away easily. 
 As each loop of intestine is cleaned it should be slipped 
 back into the belly and held there, gently, by means of 
 a hot; .moist towel or large pads of gauze. 
 
 In rare instances when the source of infection is in 
 the pelvis it is advisable to clean the abdomen (and espe- 
 cially the pelvis) as thoroughly as possible and then put the 
 patient in the Trendelenburg position so that all of the 
 intestines are thrown well out of the pelvis, then again clean 
 the pelvis particularly the depths of the cul-de-sac of 
 Douglas (which cannot well be cleaned with the patient 
 lying flat upon the table) and then quickly pack the entire 
 pelvis with gauze, not very tightly, and hastily return the 
 patient to bed. 
 
 As a rule no attempt should be made to suture the 
 incision; one or two through-and-through stitches may be 
 introduced if the cut is unusually long; but in general the 
 dressings supported by two or three adhesive straps and a 
 binder will keep the sides of the wound in close contact with 
 the gauze. Care must be taken not to have the retaining 
 straps or binder so placed as to interfere with drainage, 
 for in free discharge of fluid lies the hope of saving the 
 patient. 
 
 As soon as the patient has been returned to bed the most 
 vigorous measures must be instituted to tide him through 
 the next few hours until protective adhesions can be 
 formed. These are: 
 
 1. Hypodermoclysis. A quart of normal salt-solution 
 should be thrown into the cellular tissue below the breasts. 
 It may be repeated in four or six hours if indicated, the 
 buttocks being selected for the second injection. 
 
 2. Application of heat. Hot water bags, or bottles, 
 must be applied to the extremities just as in the treatment 
 of shock.
 
 ABDOMINAL SECTION 1-1 
 
 3. Hypodermic stimulation. If the pulse is impercep- 
 tible, camphorated oil should be injected. In a few min- 
 utes i-ioo grain of glonoin may be thrown under the skin. 
 And in a half hour i-ioo grain of sulphate of strychnine 
 may follow. This may be repeated in an hour if the pulse 
 flags again. 
 
 4. Enemas. Six or eight ounces of black coffee with 
 one ounce of whisky may be thrown into the rectum as 
 soon as possible after operation. As soon as it is seen that 
 the patient will not die from shock, one milligram (gr. 1-60) 
 of salicylate of eserine should be injected hypodermically, 
 every hour until four doses are given; this starts the peri- 
 staltic wave downward and acts as a decided nerve- 
 sedative. 
 
 Then one milligram of elaterin (not elaterium) may be 
 given by mouth, with a little sup of water, every hour 
 until six doses have been taken. If retained, this will 
 usually cause free, watery discharges from the bowels. 
 
 6. Internal Medicines. As soon as the stomach will 
 retain anything of bulk, i. e., about the time of the last 
 dose of elaterin, stimulants may be begun, teaspoonful doses 
 of iced champagne every fifteen or twenty minutes being 
 the best. If the patient go to sleep he should not be dis- 
 turbed for this. 
 
 If vomiting occur the stomach must once more be 
 washed out. One lavage will often afford perfect relief 
 from the distressing nausea and the profound depression. 
 Indeed it often seems to do more toward securing a favor- 
 able ending than all the other measures together. 
 
 Phlebitis. Phlebitis following abdominal section is 
 quite common. Strange to say, it occurs more often in the 
 left leg, even after appendicitis operations. It is a complica- 
 tion which always causes the surgeon the gravest anxiety. 
 It is attended by pain, tenderness, possibly tympany, and 
 usually some rigidity, associated with fever and leuco-
 
 12 SURGICAL THERAPEUTICS 
 
 cytosis. It can only be diagnosed by excluding other 
 symptoms and by demonstrating some peripherally throm- 
 bosed vessel. Thrombosis of the long saphenous vein, 
 fortunately not frequent, but occasionally encountered 
 after the cleanest kind of abdominal work, is best perhaps 
 prevented by changing the patient's position and by gentle 
 massage of the extremities, as advised by Martin. 
 
 Post-Operative Obstruction of the Bowels. 
 Following any operation within the abdomen there is 
 more or less interference with peristalsis. In some cases, 
 such as gastroenterostomy, intestinal resection or anas- 
 tomosis, and wounds of the gut, inactivity is favorable 
 since it permits of the formation of protective adhesions; 
 but in ordinary abdominal sections the conscientious 
 surgeon feels anxiety until after the bowels have moved 
 freely. For of all postoperative complications ileus 
 paralyticus is most feared, excepting acute sepsis; and 
 indeed many cases of socalled "obstruction" after opera- 
 tion are but acute sepsis, the non-movement of bowels 
 being merely one of the symptoms. But even when 
 septic or agglutinative peritonitis is not severe intestinal 
 inertia may result in kinking of the gut, with adhesions 
 and fatal obstruction, particularly when there has been 
 much rough handling of intestines. 
 
 Obstruction of the bowel soon after operation may 
 depend upon: 
 
 1. Paralysis of bowel, either septic or spontaneous; 
 
 2. Volvulus; 
 
 3. Internal hernia; 
 
 4. Thrombosis of the intestinal vessels; 
 
 5. Surgical interference with peristalsis; 
 
 6. Preoperative conditions. 
 
 A paralytic condition of the bowels, or at least an 
 inability to move properly, is one of the first symptoms 
 of socalled "septic peritonitis," really acute sepsis; and
 
 ABDOMINAL SECTION 13 
 
 associated with the failure to pass gas or feces is vomit- 
 ing, followed after a few hours by "reversed peristalsis," 
 the expulsion of bile-tinged water and mucus from the 
 stomach changing to stercoraceous vomiting. This is 
 the "black vomit" of acute sepsis so greatly feared. It 
 is to prevent this failure of proper bowel-movement that 
 the experienced surgeon withholds opiates and gives early 
 cathartics. Indeed some operators give a large dose of 
 castor oil or a saline laxative two hours before opera- 
 tion: a rather commendable practice if it be known posi- 
 tively that operation upon the intestine will not be neces- 
 sary. And others begin the administration of half a 
 centigram of calomel every hour as soon as the patient 
 recovers consciousness, following it next day with a saline 
 purge or an oxgall enema, or both. In addition to this, 
 when reversed peristalsis becomes alarming, one milligram 
 of eserine salicylate every hour may be g'iven hypoder- 
 mically four times. And above all, the stomach must 
 be washed out twice daily with normal salt solution. 
 
 But a paralytic condition of the bowel may arise 
 which is not of septic origin: rough handling, prolonged 
 exposure of the intestines to the air, and the prolongation 
 of the intestinal inertia naturally following any extensive 
 intraabdominal operation may be followed by failure of 
 the bowels to move. This paralysis of the intestine is 
 said to be due to inhibition from stimulation of the fibers 
 of the splanchnic nerves, or from ovcrstimulation result- 
 ing in fatigue of the ganglia in Auerbach's arid Meissner's 
 plexuses. Hence to overcome this paresis of the muscles 
 essential to peristalsis, stimulation of the sympathetic 
 and spinal centers is imperative. Here, then, the injection 
 of the eserine salicylate works more effectively than in 
 septic paralysis; and two milligrams of strychnine sul- 
 phate hypodermically, every six hours, must add to its 
 efficiency. The saline laxative, also, is indicated; the
 
 14 SURGICAL THERAPEUTICS 
 
 best way to give it being to wash out the stomach with 
 normal salt solution and then pour in two tablespoonfuls 
 of Epsom salt dissolved in as little water as possible, repeat- 
 ing it in four hours. An enema of strong alum water 
 also tends to induce a downward peristaltic wave. 
 
 2. When these measures do not result in free move- 
 ment of the bowels and arrest of vomiting, the condition 
 is a very grave one, because the trouble is either sepsis 
 or due to some mechanical obstruction, the one not to 
 be benefited by secondary operation, the other perhaps 
 curable by early interference. Of the mechanical impedi- 
 ments the most easily rectified is twisting, or kinking of 
 the bowel, technically designated volvulus. This is easily 
 distinguished clinically from intestinal paralysis, septic 
 or otherwise, by the fact that it (like all the mechanical 
 obstructions) is accompanied by griping. It may be due 
 to kinking in returning bowels to the abdomen or by 
 adhesion of two surfaces of a coil of gut partially or wholly 
 denuded of its serosa. It is most likely to occur in the 
 sigmoid; so, when suspected, copious enemas through a 
 high rectal tube must be given in the hope that the intes- 
 tine may be straightened. This failing, immediate reopen- 
 ing of the belly and correction of the difficulty is advis- 
 able. But it takes a vast amount of courage to do this, 
 particularly in the face of opposition from the family 
 and the criticism that "something was done wrong." 
 Yet there should be no delay when the indication seems 
 clear many lives have been saved by such brave opera- 
 tive work. 
 
 3. During operation a hole may be torn in the mesen- 
 tery, through which a loop of intestine may slip and 
 become attached in some way so as to produce fatal inter- 
 nal hernia; or the intestine may crawl in between the uterus 
 and belly-wall hi ventral fixation and be caught with 
 like result. Such condition may, necessarily, be relieved
 
 ABDOMINAL SECTION 15 
 
 only by reopening the abdomen and correcting the 
 trouble. 
 
 4. Thrombosis of the intestinal vessels is far more 
 common than generally suspected. By reason of faulty 
 technic the mesenteric vessels may be injured in such 
 way that the blood supply of a considerable area of gut is 
 cut off and localized gangrene with fatal perforation 
 follows. Or by tearing adhesions around abscesses, 
 tumors, etc., the operator may, without fault, so injure 
 these vessels that thrombosis follows. On opening the 
 abdomen for this complication there will generally be 
 found a lot of dark-colored fluid (with fecal odor if per- 
 foration has already occurred); hence copious irrigation 
 is advisable, one of the few instances in which water is 
 of use in the abdomen. If the general condition of 
 the patient will permit, resection of the bowel should 
 be made the enterorrhaphy being well beyond the 
 area of possible extension of gangrene by means 
 of a Murphy button. Generally the condition of the 
 patient is such that extreme haste is imperative; in which 
 case it is best merely to bring the affected loop well out 
 of the abdomen, irrigate the belly, dry it, pack gauze in 
 around the extruded intestine sufficiently tight to prevent 
 more gut from being forced out, then clamp healthy gut 
 above and below the dying portion and cut away all of 
 the necrotic part and a little more, tying the bleeding ves- 
 sels with fine catgut. The clamp on the upper extremity 
 of the cut intestine may be removed in twenty-four to 
 forty-eight hours and the bowels allowed to move into 
 cotton. If this artificial anus be high in the ileum or 
 jejunum it will be necessary to make a secondary opera- 
 tion within a few days as soon as the patient is out of 
 immediate danger. The best operation is to invert the 
 ends of the gut, sew them over by at least one row of Lem- 
 bert sutures (two rows are better on the upper portion
 
 16 SURGICAL THERAPEUTICS 
 
 of gut as the point of closure has to withstand the force 
 of the entire fecal stream) and then make a wide 
 lateral anastomosis, the belly to be closed without 
 drainage. 
 
 5. Among the causes of failure to act must be men- 
 tioned inclusion of a part of the bowel in a ligature or 
 suture. Rarely the rectum has been ligated and cut across 
 by mistake, the error in technic being demonstrable at 
 the postmortem examination; occasionally other por- 
 tions of the intestine have been similarly mistreated; but 
 most often a needle is thrust through a small section of 
 the sigmoid in ligating the broad ligament or a little of 
 the small intestine is caught in the suture when the peri- 
 toneum is being closed. In such cases the bowels have 
 a singular inclination not to move, however much they 
 may be encouraged by enemata and purgatives, even 
 though there is not the slightest leakage at the point of 
 local injury. 
 
 Correction of the difficulty by secondary operation is 
 the only treatment; but the patient usually dies even when 
 the source of trouble is removed early. Wounding of 
 the bowel may occur during the separation of adhe- 
 sions; and unless this is noted at the time and the injury at- 
 tended to by proper closure of the opening, fatal sepsis may 
 result; or an obstruction of the bowel may seem to be pres- 
 ent by reason of nature's arresting persitalsis while adhe- 
 sions form as an effective barrier against leakage. When 
 such a condition is suspected (as when extensive adhe- 
 sions have been roughly separated deep in the pelvis) it 
 is far better to keep the patient absolutely quiet by large 
 doses of morphine than to give cathartics, etc., in the vain 
 hope of securing early bowel-movement. When it is 
 known that the bowel is injured, as in removal of the 
 appendix, closure of intestinal wounds, etc., it is best 
 not to try to force peristalsis; rather is it advisable to
 
 ABDOMINAL SECTION 17 
 
 give enough opiates to prevent bowel-movement for at 
 least two days and three are better. 
 
 Another surgical interference with peristalsis is too 
 close packing of the pelvis, or sometimes other parts of 
 the peritoneal space: the bowel is pressed between the pack 
 and the hard walls or is caught in the folds of gauze as 
 they are jammed in to control oozing, and a mechanical 
 obstruction of the bowel is produced. Fortunately pack- 
 ing is generally removed within forty-eight hours and the 
 bowels then take care of themselves; but sometimes symp- 
 toms of obstruction persist after the tampon is removed 
 and it then becomes necessary to reopen the wound and 
 overcome the difficulty, if possible, by liberation from 
 bands, resection of gut if pressure-necrosis has arisen or 
 formation of an artificial anus as a dernier ressort. 
 
 Rough handling of the intestines, too, may cause 
 such abrasion of the serosa that the intestine may attach 
 istelf to some raw surface and in this way become fixed 
 even if not twisted, and so give rise to, serious symptoms 
 of obstruction; for which reason the intestines should be 
 handled in soft gauze pads instead of the hands or retrac- 
 tors, and not subjected to wiping. The obstruction 
 from this source is more likely to be late: probably months 
 after operation stricture or bands or twist being found 
 when the abdomen is opened. 
 
 6. Not infrequently certain conditions existing before 
 operation are not recognized during the excitement of 
 the work and so, uncorrected, lead to obstruction. This 
 is conspicuously the case in adhesions of the gut around 
 the infected areas of an appendicitis; death from obstruc- 
 tion of the bowels occurs quite often in appendicitis oper- 
 ated upon at the height of the inflammatory process, 
 hence the advice to operate during the first forty-eight 
 hours of the disease or else let the case go on until the eighth 
 to tenth day, when the abscess is well walled off and the
 
 18 SURGICAL THERAPEUTICS 
 
 conditions such that they can be met without danger of 
 injury to contiguous gut by packing, tearing etc. Adhe- 
 sions around an inflamed gall-bladder, too, may not be 
 discovered, and a tight packing induce acute angling of 
 the colon or ileum with immediate obstruction. Also, in cer- 
 tain conditions there may be an obstruction (from impacted 
 feces, from inflammatory bands, etc.) just beginning 
 at the time of operation, perhaps the obstruction 
 rather than the disease being productive of the acute 
 symptoms vomiting, collapse and so on and the obstruc- 
 tion not being discovered death may follow although 
 the pathological condition for which operation was under- 
 taken may have been perfectly remedied. 
 
 Obstruction of the bowels may appear late, after the 
 patient has returned home and is considered perfectly 
 well strictures, bands, adhesions and scar-contractions 
 causing it. For the prevention of this the experienced 
 abdominal surgeon has learned to cover all denuded 
 points with peritoneum, when possible, even the omentum 
 being stitched over any raw surface which cannot other- 
 .wise be protected. 
 
 But whatever symptoms of 'obstruction appear, how- 
 ever late, the wise surgeon opens the belly and corrects 
 the cause at the earliest moment the patient will consent 
 to^operative work. Inability to secure bowel-movement, 
 followed by vomiting which changes from merely bile- 
 stained to strecoraceous, and not relieved by gastric lavage, 
 especially if associated with distension of the abdomen 
 and griping, cannot be mistaken; they form a grouping 
 of symptoms invariably meaning mechanical obstruction, 
 and just as certainly indicating immediate operative work. 
 To wait until collapse appears is a crime; it spells death 
 in most cases. 
 
 In the possibility of encountering postoperative dif- 
 ficulties such as these lies the incentive to refer patients
 
 ABDOMINAL SECTION 19 
 
 to experienced operators rather than subject them to 
 the hands of the "county-seat surgeon." Every such 
 operator should be prepared to open the abdomen in 
 any case of emergency: acute appendical rupture, strangu- 
 lated hernia, intussusception and even cesarean section; 
 but when it comes to an operation of choice, where the 
 patient can be sent to a good hospital and secure the serv- 
 ices of a skilful operator who has (a) become possessed 
 of great anatomical knowledge, (b) who has been taught 
 much pathology, (c) who has spent months assisting 
 some master of abdominal surgery, and (d) who has by 
 the successful management of many hundreds of cases in 
 his own work learned not only to overcome operative 
 difficulties readily but also to carry the patient through 
 the dangerous postoperative days, it is little less than 
 criminal to permit the inexperienced or infrequent opera- 
 tor to open the abdomen. The doctor who will permit 
 some ambitious friend to make the operation "for experi- 
 ence" (unless he has had the advantages already speci- 
 fied) or to gain local prestige as a surgeon is taking dan- 
 gerous liberties with the life of the patient who has trusted 
 him. Entirely too many bellies are being opened by 
 inexperienced "surgeons." 
 
 Preparation for Abdominal Section, Whenever 
 possible, a good cathartic should be given the day before 
 operation (a saline being preferable) in such quantity that 
 five or six good bowel-movements are secured. On the 
 morning of the day before operation the skin of the entire 
 abdominal wall should be scrubbed and shaved; and a. 
 soap poultice applied. In the evening the poultice should 
 be removed, the skin again scrubbed and washed with alco- 
 hol, and a bichloride pack (i in 2000 solution) bound on 
 for the night. This is to be removed after the patient is 
 on the operating table; the skin again scrubbed with soap 
 and water, dried with a sterile towel, washed carefully
 
 20 SURGICAL THERAPEUTICS 
 
 with sulphuric ether to remove the fat, then rubbed vigor- 
 ously with gauze saturated with 65-percent alcohol, and 
 finally rinsed with bichloride solution, i in 2000. The field 
 of operation is then to be surrounded with towels just 
 out of the boiler (wrung dry as convenient) held in place 
 by safety-pins which have been boiled with the instruments; 
 and then a sterile towel may be placed temporarily over all 
 while final arrangements (if any) are made. 
 
 Unfortunately in many cases it is impossible to make 
 the preliminary preparation, as in accidents, strangulated 
 hernia and the like; in which cases the scrubbing must be 
 done with unusual care. 
 
 ABSCESSES, 
 
 Definition. Technically an abscess is the formation 
 of pus in some cavity of the body, the result of an in- 
 flammation, i. e., infection by one of the pyogenic bacteria; 
 but practically the name is applied to any localized ac- 
 cumulation of pus. 
 
 Alveolar Abscess. An abscess in the gums or alveo- 
 lus must be opened as soon as found, and the mouth 
 kept as clean as possible by frequent washings with dilute 
 hydrogen dioxide or a saturated solution of potassium 
 chlorate in water. If a small spicule of the alveolar proc- 
 ess be the cause of the trouble, it should be removed 
 after incision, by a minute curet or by pincers. If due to a 
 decayed root, the offending tooth must be pulled. An 
 antiseptic mouth-wash will soon complete the cure. 
 
 Bursal Abscess. Any of the bursae may become the 
 seat of an infection with pus-germs, the bursa of the quad- 
 riceps extensor being most frequently affected ("house- 
 maid's knee"). If the pus-infected sac has become shut 
 off from the near-by joint by an adhesive inflammation, all 
 that is essential in treatment is free incision, packing with 
 gauze (renewed every two or three days) until the cavity
 
 ABSCESSES 21 
 
 closes from the bottom, with granulations. If there be 
 a suspicion that the abscess is of tubercular origin, the 
 sac when first opened may be swabbed thoroughly with 
 tincture of iodine, and iodoform gauze used for packing. 
 When the neighboring joint is involved in the suppurative 
 process, only the freest of incision and perfect drainage will 
 save the limb from amputation. 
 
 Cerebral Abscess. Abscess of the brain may follow 
 injury to the head, or it may arise from suppuration, near 
 or far: conspicuously from otitis media. When headache, 
 fever like that of meningitis, oncoming coma and optic 
 neuritis are noticed, the greatest care should be exercised 
 to determine the existence and location of cerebral suppura- 
 tion, and trephine. Middle-ear disease associated with 
 these symptoms justifies exploratory trephining one inch 
 and a quarter above and an inch behind the meatus 
 externus. The abscess, if found, is evacuated and drained 
 the same as in any other location. 
 
 Cold Abscesses. These develop slowly, without fever 
 or pain commonly about joints, bones or glands. They 
 are not true abscesses because they are not due to inflam- 
 mation (i. e., infection with germs of true pus) but are es- 
 sentially tuberculous (which see). 
 
 Fecal Abscesses. If these form about the rectum from 
 perforation, they may work downward, becoming "ischio- 
 rectal" abscesses (which see). But when they occur from 
 perforation of the gut, higher in its course as from per- 
 foration of Fever's patches in typhoid, of the cecum from 
 typhlitis or appendicitis, from tuberculous ulcers anywhere 
 huge accumulations of pus may result; gallons escaping 
 occasionally when the abdomen is opened. Rarely they 
 are not protected by adhesions to the parietes, being 
 located between adherent coils of intestines and omentum; 
 under these circumstances they are very dangerous dna 
 difficult to handle.* Usually they may be emptied without
 
 22 SURGICAL THERAPEUTICS 
 
 opening the free peritoneum; packing without irrigation 
 sufficing to cure. 
 
 Mammary Abscesses, These form during the prog- 
 ress of an inflammation of the breast. (See "Mastitis.") 
 
 Metastatic Abscesses. Secondary (socalled "meta- 
 static") abscesses are those developed at a distance from 
 the seat of primary infection. They are invariably septic, 
 from an infected embolus; often they are multiple and small, 
 called miliary abscesses, prominently noticeable in the 
 lungs. When accessible, they must be incised freely and 
 perfect drainage maintained until they heal by granulation 
 from the bottom. 
 
 Pain of Abscesses. For the relief of the pain of a 
 forming abscess or carbuncle, belladonna is more effica- 
 cious than opium. Ichthyol seems also to possess remark- 
 able properties of similar effect. A most excellent pre- 
 scription is: 
 
 Ichthyol 10.0 
 
 Extract of belladonna 40.0 
 
 Glycerin 50.0 
 
 Mix. Smear on flannel abundantly, apply to the sore, 
 and cover with oiled silk, a pad of cotton and a bandage. 
 It may be changed every three or four hours. It is claimed 
 that abscesses can usually be aborted by saturating the pa- 
 tient with nuclein or with the sulphides of arsenic and lime. 
 
 Psoas Abscesses. These are not true abscesses, as 
 a rule, until after they are opened. The contents consist 
 of the debris from destruction of a lumbar or a lower dorsal 
 vertebra by tuberculosis, the liquefied matter descending 
 within the sheath of the psoas muscle and "pointing" in 
 Scarpa's triangle. If opened, they quickly become infected 
 with true pus-microbes and chronic sepsis follows; hence 
 the advice to empty by aspiration (under strictest antiseptic 
 precautions) rather than by incision. lodoform emulsion 
 is sometimes injected but it is doubtful if it is ever followed
 
 ABSCESSES 23 
 
 by abatement of any symptom; it certainly cannot reach 
 and affect the source of the trouble. 
 
 Spinal Abscesses. "\Yhen abscesses form in Pott's 
 disease of the spine the abscesses which contain only tuber- 
 cular liquefication should be aspirated. When true pus 
 has formed, aseptic thorough drainage is advisable. 
 
 Stitch Abscesses. Around sutures in an otherwise 
 uninfected wound there may be little points of suppuration : 
 infection from the staphylococcus epidermidis albus of an 
 imperfectly cleaned field of operation. In removing stitches 
 on the eighth to the twelfth day, if any are noted as sur- 
 rounded by this w r hitish pus, they must be left until all 
 non-infected ones are taken out, then the clean stitch- 
 holes carefully covered with gauze and the infected sutures 
 cut and withdrawn. The pus must then be gently pressed 
 out and wiped away by gauze. If hydrogen dioxide or 
 other liquid is poured over them the germs will be carried 
 to the other holes and general infection of the wound 
 induced; so it is best just to empty them and apply bi- 
 chloride gauze over the cut. If this be an extensive one 
 it should be supported by a few strips of adhesive plaster 
 over the gauze. 
 
 Sometimes in spite of all precautions there is pus- 
 infection of all the stitch-hole openings. These should be 
 enlarged or the cut opened at two or more points to secure 
 drainage. As a rule these wounds do best if simply wiped 
 out carefully with absorbent cotton on a probe or wooden 
 tooth-pick and then covered with dry gauze without rubber 
 or oiled-silk protective. Dusting powders cause retention 
 of the pus under the artificial scab and liquid antiseptics 
 often irritate and retard healing. 
 
 Stitch Abscesses from Bacilli Coli Commtmis. 
 During an operation for gallstones, cholecystitis, appendi- 
 citis, infected ovarian tumor or other condition in which 
 the bacillus coli communis is the causative pathogenic micro-
 
 24 SURGICAL THERAPEUTICS 
 
 organism, a trifle of the pus or infected blood-serum or 
 mucus may come in contact with the raw surface of the 
 wound in the abdominal parietes. If the cut be sewed 
 without drainage there may be no risfe in temperature, 
 and the operator flatters himself that he has no wound 
 infection. Yet on opening the dressings on the tenth or 
 eleventh day he finds every stitch-hole oozing pus and 
 on separating the margins of the incision at one or two 
 places several drams of pus may be squeezed out. If this 
 is a pure colon-bacillus infection, in addition to the pecu- 
 liar absence of fever the wound will be found free from the 
 redness and excessive tenderness characteristic of staphylo- 
 coccus infection. If the pus be pressed out carefully the 
 wound will quickly heal; but if , by carelessness in handling, 
 a staphylococcus infection is engrafted, a long and tedious 
 suppuration may follow, with fever and pain. 
 
 Thecal Abscess. The sheath of a tendon may be- 
 come the site of an abscess, which is prone to infect the 
 joint through which it passes. The earliest possible evacua- 
 tion by free incision is the only treatment. Packing with 
 gauze saturated with a solution of equal parts of "gum" 
 camphor and pure phenol seems to prevent extension of 
 inflammation and to promote healing. 
 
 Tropical Abscess. Acute hepatitis ending in the 
 formation of abscess very frequent in the tropics, hence 
 the name "tropical abscess" must be treated by early 
 incision and free drainage. Usually this can be done with- 
 out invading the non-infected peritoneal space, as adhesion 
 between Glisson's capsule and the parietal serosa has given 
 ample protection. If no adhesions have formed, one of two 
 things may be done: (a) A large opening may be made 
 and several pieces of gauze (each 2 by 6 or 8 inches) 
 packed in between the liver and parietal peritoneum; 
 adhesions forming in two or three days, secondary incision 
 may be made in the liver without danger of peritonitis;
 
 ABSCESSES 25 
 
 or (b) if the necessity seems urgent for immediate evacuation 
 much gauze may be packed around the proposed opening 
 so as to prevent any pus from escaping intothe peritoneal 
 space and the abscess freely opened. When emptied the 
 cavity is to be packed with gauze, held firmly in place by 
 an assistant, the contaminated protective gauze with- 
 drawn and fresh gauze crowded in very tightly in every 
 direction for at least two inches beyond the margins of 
 the abdominal cut. In a few hours, happily before the pus 
 accumulates in the gauze-packing enough to "run over," 
 a protective barrier of adhesions will have formed; but so 
 fragile that the gauze must not be removed before the 
 fourth day. 
 
 Tubercular Abscesses. When an enlarged lymph- 
 gland softens and shows evidence of forming an abscess 
 two plans are open to choice. If scarring is very unde- 
 sirable the skin may be properly cleaned by scrubbing, 
 application of ether and then washing with alcohol; then 
 a large aspirator-needle thrust into the gland and the broken- 
 down tuberculous material withdrawn; finally about 2 
 grams, half a teaspoonful, of lo-percent iodoform emulsion 
 injected and the opening closed with collodion and an 
 antiseptic dressing. In most cases, though, the best treat- 
 ment is to prepare the skin as above, make an opening 
 of a half inch or more, let out the pus (using a knife care- 
 fully sterilized) and curet with a surgically clean Volk- 
 mann's spoon; then burn the interior thoroughly with pure 
 phenol, instantly neutralized by pure alcohol; insert a few 
 strands of catgut and cover with a large antiseptic-gauze 
 pad to be left undisturbed for two weeks. If these steps 
 be taken with perfectly clean hands and field of opera- 
 tion and with sterile instruments, healing will be by primary 
 union, with a slight scar only which will not be visible after 
 a year's time. If pus ooze through the dressing or if 
 fever arise after several days, infection with staphylococcus
 
 26 SURGICAL THERAPEUTICS 
 
 aureus or albus may be taken for granted and a dressing 
 made with bad scarring to be feared. 
 
 "Washing Out" Abscesses. The idea that abscesses 
 and infected wounds healing by granulation must be 
 washed out with some antiseptic solution, notably hydro- 
 gen dioxide, seems to die hard. If an abscess be freely 
 opened and properly drained by a loose bit of gauze (even 
 the abominable rubber-tube, which so retards healing 
 and helps establish a permanent sinus, is better than 
 nothing) and if an open infected sore be dressed with fresh 
 gauze as often as the old becomes soiled, nature will 
 do all the irrigating needed. It is, of course, desirable 
 to dress a suppurating wound every day, from a financial 
 standpoint, if the patient pay well for each dressing; but 
 surgically the less often a granulating surface is disturbed 
 the better and quicker it will heal. Sometimes an open 
 sore will do better redressed only twice a week; and then 
 the granulations must be disturbed as little as possible 
 the pus must never be rubbed away. Most wounds do 
 best when sublimate gauze, i in 2000, is used. 
 
 ACETONURIA. 
 
 This has been attracting considerable attention of 
 late because it is claimed that some deaths following inha- 
 lation of ether are due to it rather than the anesthetic. 
 Acetone is found hi small quantities hi the blood and in 
 normal urine, but it is very abundant in certain stages 
 of diabetes, and sometimes follows high fever. 
 
 Acid states of the urine are very important in surgery, 
 without doubt; and if urinary analysis prior to opera- 
 tion shows an abnormality (particularly diabetes), there 
 should be great hesitancy about performing operations 
 not absolutely imperative. The dangers of acetonuria, 
 too, should be kept in mind when contemplating opera- 
 tion upon patients suffering from profound mental depres-
 
 ACETONURIA 27 
 
 sion, especially melancholia, since it has been shown 
 that imperfect oxidation underlies most of the depressed 
 psychoses, like melancholia, and the depressed phases of 
 the compound psychoses; that acetone, diacetic acid and 
 betaoxybutyric acid arise from suboxidization. In epilepsy 
 and paretic dementia, too, there is the same imperfect 
 oxidation; but in diabetes it is, of course, worse. 
 
 Therefore, in all such cases before operation careful 
 uranalysis should be the universal rule. The normal 
 degree of urinary acidity is from 30 to 45; if it fall below 
 30, either there is imperfect production of the acid or 
 imperfect elimination. In the first event imperfect oxida- 
 tion is present; in the latter, acid-accumulation with all 
 its possibilities is imminent. (Butler.) 
 
 In insanity due to head-injury a period of seeming 
 mental quiescence may be followed by attacks of vomit- 
 ing, purging, semicoma, and return of insanity; the rash 
 surgeon wishes to operate; but examination shows 
 urinary acidity of as low as 10; after subsidence of the 
 acute symptoms, under eliminative treatment, 'the acidity 
 will increase to 45; then operation is safe. The same 
 phenomena have been noted following heat-stroke and 
 severe shocks of electricity; so if operation be indicated 
 after either of these, the urine must be examined, and if 
 found deficient in acidity, postponement is advisable. 
 
 Patients presenting acetonuria as a prominent fea- 
 ture after operation pass urine of a marked "fruity" odor 
 (likened by some to the smell of chloroform), cannot be 
 aroused and finally die in coma. This is especially likely 
 to occur after cancer, a disease prone to the formation of 
 excessive quantities of acetone. Bicarbonate of sodium 
 is perhaps the best drug to employ, plus laxatives. In 
 diabetes prompt relief follows a free use of carbohydrates. 
 When acetonuria is recognized hypodermoclysis is advisable, 
 plus pilocarpine hypodermically every six hours.
 
 28 SURGICAL THERAPEUTICS 
 
 ACHONDROPLASY. 
 
 This is a name given by Parrott to a -form of feta 
 rickets in which the limbs are short and their bone 
 curved where they should be straight, and the natura 
 curves exaggerated, with absence of the proliferatin 
 zone of cartilage at the junction of the epiphyses. It i 
 very like fetal cretinism. Fortunately most of such chil 
 dren are born dead. Should they survive, syrup c 
 hypophosphites may be given ad libitum. Later, attempt 
 may be made, as in rickets, to correct the deformities. 
 
 ACROMEGALIA. 
 
 This is a condition (or disease) characterized by ai 
 abnormal development of the extremities (bones as we] 
 as soft parts) and of the face. It is of long duration 
 the patient finally dying of exhaustion after ten to twent; 
 years. Virchow claimed it to be hereditary. Nothinj 
 is known of its cause; and of therapy there is none excep 
 attention to the general health of the individual, tonic 
 and good food prolonging life. Nothing can be dom 
 for the deformity. 
 
 ACTINOMYCOSIS. 
 
 When the actinomycosis bovis the ray-fungus by an] 
 accident is introduced into the human system, then 
 results a peculiar disease distinguished by the develop 
 ment of a peculiar afebrile inflammation, with or with 
 out suppuration, but often giving rise to granulation 
 tumors. Abscesses about the jaws and teeth are th< 
 most frequent and the most curable of its manifestations 
 Actinomycotic tumors of the neck are very ugly. 
 
 In making a diagnosis one must remember that the 
 cases are grouped in four classes: (i) Head and necfc 
 actinomycosis, with infection from mouth and pharynx 
 (2) chest actinomycosis, i. e., infection through the res-
 
 ACTINOMYCOSIS 29 
 
 piratory tract; (3) abdominal actinomycosis, with infec- 
 tion probably always through the alimentary canal, pos- 
 sibly through the genital tract in the female; (4) actinomy- 
 cosis of the skin. 
 
 The only treatment of actinomycosis is prompt removal 
 of the affected tissues. When the parasite is located in 
 the liver or stomach-wall no treatment will do any good. 
 Iodide of potassium may be given after operation. 
 
 Actinomycosis of Abdomen. Friederich found that 
 4 percent of all patients- operated on for appendicitis at 
 Greifswald during three years were of actinomycotic 
 origin. Of the eight patients treated by removal of all 
 diseased tissue, the incision extending into the healthy 
 parts, seven are at present in apparent good health. The 
 experience in former cases has been that the condition is 
 liable to recur after two or three years of apparent cure. 
 
 Actinomycosis of the Appendix. Strange to say, 
 actinomycosis may affect the vermiform appendix. The 
 fungus of streptothrix (actinomyces) enters the body 
 by the alimentary canal and may attack the appendix 
 in one of two ways: (a) as a simple streptothrix infection, 
 or (b) as a mixed infection with staphylococci or colon 
 bacilli. 
 
 In the first the symptoms closely resemble those of 
 any other appendicitis; in the second form they are much 
 more severe: rigors and septic 'pyelophlebitis being rela- 
 tively common, although quite rare in ordinary suppura- 
 tion about the appendix. The points of value in arriv- 
 ing at a diagnosis of non-suppurating streptothrix infection 
 of the appendix are a long history of slight indefinite 
 pain in the appendical region, the relatively large amount 
 of induration, and if operation is performed, the small 
 quantity of broken-down material. In the suppurating 
 form the early occurrence of rigors and the pointing of 
 abscesses at a distance from the appendix are in favor
 
 30 SURGICAL THERAPEUTICS 
 
 of actinomycosis. Early operative treatment in con- 
 nection with free drainage, with the long administration 
 of large doses of iodide of potassium or arsenic, 
 is advised. 
 
 ADENITIS 
 
 Adenitis (Tuberculous) Treated by X-Ray. After 
 a careful analysis of reports, Boggs, of Pittsburg, con- 
 cludes that in the treatment of tuberculous glands the 
 results obtained by the use of Roentgen rays will com- 
 pare favorably with those from any other method, as a 
 large proportion of the patients can be (apparently) 
 cured. The treatment usually requires . about three 
 months, at the end of which the glands have undergone 
 a degeneration, leaving a hard fibrous nodule, which as 
 a rule, never gives any further trouble. The radiation 
 must necessarily be intense, with the tube placed at least 
 12 inches from the surface, in order to influence the whole 
 of the diseased area. The important part of the treatment 
 is to have a tube placed the proper distance, giving off 
 rays, rich chemically, and with the proper degree of pene- 
 tration. 
 
 Iodine for Enlarged Glands. Enlarged lymphatic 
 glands which do not seem inclined to break down into 
 pus may sometimes be made to disappear by the local 
 use of the official iodine ointment (unguentum iodi, U. 
 S. P.). When ordered for children who have a very deli- 
 cate skin it should be diluted one-half with lanolin. It 
 should be applied with gentle friction twice daily. This 
 mode of using iodine is preferable to painting with tinc- 
 ture of iodine for this trouble. But the treatment must be 
 discontinued as soon as it is seen that pus is forming and 
 the glands excised under strictest aseptic precautions, with 
 greatest care that the enveloping tissue (capsule) is not 
 broken into.
 
 ADENITIS 31 
 
 Scrofulous Glands. Under this term the older 
 writers described a peculiar form of adenitis an enlarge- 
 ment of the lympathic glands, usually of the neck, with 
 a tendency to become chronic and to develop into "cold 
 abscesses," i. e., formation of a pus-like material without 
 any local signs of inflammation until after the "abscess" 
 has been discharging for some time. The word "scrofula" 
 has been abandoned these glands are the site of a tuber- 
 culous deposit; the "pus" is but the liquefaction of the 
 caseous product of bacterial action, and "inflammation" 
 occurs only when there is inflammation with true pyogenic 
 microorganisms. If opened under absolute asepsis they 
 heal without inflammation. 
 
 Tuberculous Glands. Whenever a patient will consent, 
 all tuberculous glands should be removed by radical opera- 
 tion; this being notably desirable of enlarged cervical glands. 
 A severe blow may disseminate the tubercle and cause a 
 purely local deposit to give rise to a rapidly fatal general 
 tuberculosis. In the operation both the superficial and 
 the deep lymphatics must be extirpated a most tedious 
 operation of at least an hour's work, as the dissection must 
 be perfect and the field under the carotid cleaned out. 
 The aseptic technic must be as free from fault as in the 
 most serious abdominal section. Drainage may be made, by 
 inserting several strands of plain catgut to the depths of 
 the wound at two or even three places. The large anti- 
 septic dressing should never be removed until the twelfth 
 day unless something very unusual arises. But if the 
 patient will not submit to operative treatment the enlarged 
 glands may be rubbed, gently, each night with: 
 
 Ichthyol 16 parts 
 
 Benzoated lard 64 parts 
 
 Or they may be painted every second day with decolorized 
 tincture of iodine. Internally the best of food is impera- 
 tive, cream being especially good; if not obtainable, cod-
 
 32 SURGICAL THERAPEUTICS 
 
 liver oil may be substituted. Iron and arsenic must be 
 administered in large doses. The tonsils should invariably 
 be inspected and excised if presenting any sign of trouble, 
 as they are often the source of infection. 
 
 ADENOIDS 
 
 "Adenoid vegetations" is an expression applied to 
 hypertrophy of the glandular tissue normally found in 
 the nasopharynx. When excessively developed this con- 
 dition leads to mouth-breathing, more or less impairment 
 of hearing, and muffled voice; in the worst cases the open 
 mouth, vacant expression of face and general listless- 
 ness are unmistakable to the trained eye. If not 
 corrected, serious mental deficiency may result, as well 
 as enlargement of the tonsils, enuresis and mastur- 
 bation, with deleterious influence upon the bodily 
 development. 
 
 Under chloroform they may be removed by curet or 
 even by the finger-nail. No local medication will do 
 any good. Anesthesia by nitrous oxide or by ethyl bro- 
 mide answers well for such operations, where only a brief 
 anesthetic period is required. 
 
 In cases of only mild degree with but slight enlarge- 
 ment of the tonsils, a weak alkaline solution, such as 
 the following should be syringed through the nose and 
 fauces so as to free the lymphoid tissue, so far as pos- 
 sible, from microorganisms, and to prevent crusts form- 
 ing upon the surface: 
 
 Sodii bicarbonatis 0.4 (grs. 6) 
 
 Boracis 0.4 (grs. 6) 
 
 Sodii chloridi 0.2 (grs. 3) 
 
 Glycerini 4.0 (dr. i) 
 
 Aquae 30.0 (oz. i) 
 
 Misc. Sig. : Use as a spray freely twice daily.
 
 AINHUM 33 
 
 Astringents, such as the following, may oe painted on 
 the tonsils and the adenoid tissue: 
 
 Aluminis 0.65 (grs. 10) 
 
 Acidi tannici 0.65 (grs. 10) 
 
 Glycerini 8.00 (drs. 2) 
 
 Aquae 30.00 (oz. i) 
 
 Or 
 
 lodi 0.13 (grs. 2) 
 
 Potassii iodidi 0.65 (grs. 10) 
 
 Glycerini 30.00 (oz. i) 
 
 Tonics should be administered, such as the phos- 
 phate of iron wine. If the patient is no better for the 
 treatment, and the symptoms of enlarged tonsils and 
 adenoids still persist, then these growths should be 
 removed. 
 
 ADENOMA 
 
 This tumor originates in glandular epithelium and 
 conforms in its histologic structure with glandular tissue. 
 When there is an excessive development of the connec- 
 tive tissue the resultant growth is called an adenofibroma. 
 If it undergo cancerous degeneration it is then designated 
 adenocarcinoma. On account of the danger of this 
 latter change the tumors should be removed early, par- 
 ticularly if they show a tendency to grow rapidly. 
 
 AINHUM 
 
 In this peculiar disease, practically limited to the 
 negro, one or more of the extremities becomes constricted 
 and undergoes a local gangrene and even spontaneous 
 amputation. The gangrenous spot may be treated simply 
 by protection with an antiseptic dressing so long as it 
 remains practically quiescent, providing the patient will 
 not consent to amputation. Later, if the trouble is seen 
 to be spreading and to threaten the usefulness of the
 
 34 SURGICAL THERAPEUTICS 
 
 entire limb, one or more incisions may be made through 
 the constricting bands, the cut being made parallel to 
 the axis of the limb; or the fibrous band may be dissected 
 out in its entirety one-half being cut away at one opera- 
 tion, the other some weeks later after the first cut has 
 healed. 
 
 AMEBIC DYSENTERY 
 
 i 
 When a case of amebic dysentery is doing badly, i. e., 
 
 when there is a reasonable amount of strength left 
 but internal treatment is not controlling the dysentery, 
 there should be no delay in operating. The abdomen 
 should be opened as for appendicitis (except that a three- 
 or four-inch cut must be made), the cecum drawn up 
 into the wound and sutured to the parietes the appen- 
 dix being removed. Next day the cecum should be widely 
 opened and colonic irrigation with strong solutions of 
 quinine instituted. A rapid improvement usually follows 
 the beginning of irrigation, but convalescense is slow, 
 and at times difficulty is experienced in closing the fis- 
 tula. The after-treatment (irrigation, etc.) is tedious, 
 and the patients are offensive cases to have in hand; it 
 is very disagreeable thus to treat patients in hospital 
 wards, but it saves lives in selected cases. 
 
 AMPUTATIONS 
 
 Amputation is the last resort of the true surgeon. 
 The indications are: (i) Complete destruction of a 
 part of an extremity; (2) crushing injuries hi which the 
 vitality of the .part beyond the site of trauma is inter- 
 fered with by destruction of all nutrient vessels the 
 skin sometimes being intact yet everything inside crushed 
 to a jelly; (3) extensive burns where it is evident that the 
 extremity even if saved will be perfectly useless; (4) exten- 
 sive gangrene; (5) cancer of an extremity. Under strict
 
 ANESTHESIA 35 
 
 antisepsis healing by primary union, without a drop of 
 pus, should be obtained. 
 
 ANAM ULCER 
 
 There is a peculiar ulcer common in the tropics (first 
 noted in Anam): a phagedena which begins as an inflam- 
 mation at a small abrasion of the skin, most often on 
 the leg or foot, soon followed by deep sloughing of the 
 inflamed area resulting in a sharp-cut ulcer which slowly 
 enlarges, always preceded by the inflammation. It very 
 obstinately resists treatment. 
 
 Fluidextract of lobelia 32.0 (i ounce) 
 
 Fluidextract of baptisia 32.0 (i ounce) 
 
 Sulphate of zinc 32.0 (i ounce) 
 
 Water 500.0 (i pint) 
 
 Of this mixture one ounce to the pint of hot water 
 is used in a douche-bag, carefully irrigating once daily. 
 Dress with gauze saturated with a mixture of camphor 
 and phenol, equal parts. Internally iodides or mercury 
 the trouble often being of syphilitic origin. 
 
 ANESTHESIA 
 
 Cocaine and Brucine. The Abbott Alkaloidal Com- 
 pany has prepared a most excellent mixture of cocaine and 
 brucine for local anesthesia, possessing distinct advantages 
 over cocaine alone. 
 
 Cocaine by Cataphoresis. Some patients object 
 strenuously to the use of the hypodermic syringe. When 
 it is desired to operate under cocaine anesthesia upon 
 such a "crank," the cocaine may be introduced by cata- 
 phoresis. A piece of gauze is folded to four thicknesses 
 and cut the size of the part to be analgesized; the skin, 
 sterilized, is covered with this gauze saturated in cocaine 
 solution of the strength of 10 percent, i. e., about 45 
 grains to the ounce of water; this is covered with lead-
 
 36 SURGICAL THERAPEUTICS 
 
 foil cut the same size; then the positive pole of a galvanic 
 battery is applied to this the patient holding the wet 
 sponge electrode of the negative pole in his hand. A 
 battery of twenty or thirty cells is necessary, and the cur- 
 rent used as strong as the patient can stand it. From 
 fifteen to thirty minutes is required for deep cocainiza- 
 tion; the gauze being resaturated about every five minutes, 
 it being poured under the foil by raising the edges first 
 on one side and then the other, thus not breaking the cur- 
 rent. If desired, one dram of i in 1000 solution of adre- 
 nalin solution may be added to the ounce of cocaine solu- 
 tion, to prevent bleeding from the part to be incised; the 
 only objection being that oozing is apt to occur an hour 
 or so after the suturing is completed and the wound dressed. 
 
 Cocaine Hypodermically. Either a 2-percent or a 
 4-percent solution may be used. A half-grain tablet dis- 
 solved in a full hypodermic of water (25 minims) give a 
 4-percent solution. More than one such injection should 
 rarely be used. If more is required, on account of the 
 large area to be cut, it is better to dilute to a 2-percent 
 solution. 
 
 In about one case in ten some symptoms of poisoning 
 will follow the injection of cocaine for surgical purposes. 
 Ordinarily the patient will merely complain of a little faint- 
 ness, and dilation of pupils occurs. But, rarely, especially 
 when only a 2-percent solution has been injected into the 
 tongue, alarming symptoms arise: faintness even to com- 
 plete syncope, nausea, and vomiting, temporary blindness 
 with excessive mydriasis, coldness and clamminess of the 
 skin, with almost imperceptible pulse; even epileptiform 
 convulsions have been reported. But no death will follow! 
 So the proper treatment is to give the patient a "good 
 drink" of whisky, place him in the recumbent position and 
 go on with the. operative work. By the time the operation 
 is finished most of the unpleasant symptoms will have
 
 ANESTHESIA 37 
 
 disappeared; and in an hour or so the patient will be as 
 well as ever. 
 
 Cocaine on Mucous Membranes, Cocaine applied 
 to the surface of the mucous membrane of the mouth, 
 throat, urethra and nose gives a perfect surgical analgesia; 
 but on the perpuce and glans and in the rectum and vagina 
 it will not do so, hence in operating upon any of these 
 parts the cocaine must be injected into the submucous 
 cellular tissue. Operation is usually begun too soon 
 after injection at least two full minutes should pass 
 before the mucous membrane is cut. The analgesia per- 
 sists from twenty minutes to a half hour. 
 
 "Combined" Anesthetics, [A. C. E. Mixture]. 
 The A. C. E. mixture was formerlv much employed. It 
 consists of 
 
 Alcohol i part 
 
 Chloroform 2 parts 
 
 Ether 3 parts 
 
 It has been almost abandoned since the discovery 
 that its use results in practically a straight chloroform- 
 anesthesia. 
 
 Ether by the Drop Method, Recently it has been 
 demonstrated that ether may be given in the same way 
 that modern men have given chloroform: with a dropper 
 and an Esmarch mask. The ether is poured on much 
 more freely than the chloroform, is kept constantly drop- 
 ping (no setting down of the bottle under any circum- 
 stances) and is varied from one part of the mask to the 
 other so that none shall run through. It requires fully 
 fifteen minutes to secure complete surgical anesthesia, 
 but the effect is much more satisfactory than from any 
 other method thus far devised. Instead of the wild fight- 
 ing of the old "suffocation" mode of administration the 
 patient sinks tranquilly into unconsciousness; instead 
 of a pound or two of ether being used a few ounces suf-
 
 38 SURGICAL THERAPEUTICS 
 
 fice; instead of the intense nausea and vomiting of the old 
 way there is but slight stomachic disturbance, since very 
 little of the ether is swallowed to irritate the gastric mucous 
 membrane. 
 
 Ethyl Chloride. This anesthetic is now being pro- 
 duced so cheaply that it bids fair to become extremely 
 popular for minor surgery. In the peculiar bottles in 
 which it comes it is volatilized by the heat of one's hand 
 so that when the lever is pressed, which opens a tiny hole 
 in the stopper, a fine spray is produced, scarcely visible. 
 As the ethyl chloride boils at 13 C., an intense cold is pro- 
 duced by the rapid evaporation to such a degree that 
 the skin against which it is directed for one minute is 
 frozen and in a few seconds more is covered by a fine frost. 
 A surface a half inch wide and as much as two inches 
 long may be frozen readily by rapidly moving the spray 
 up and down the length of the proposed incision. The 
 tip of the injector should be held from three to five inches 
 away from the skin to get the best spray. Incision may 
 be made through the frost or one may wait until it is 
 melted; the analgesia lasting about two minutes. 
 
 It is ideal for opening abscesses, removing small tumors 
 or for the use of the Paquelin cautery on small epithelial 
 growths. Recently it has been used by inhalation as 
 a substitute for ether, the anesthesia being produced 
 more quickly, thus saving an average of some twelve 
 minutes on each operation; hence it is likely to prove use- 
 ful on the battlefield and in other calamities when a num- 
 ber of operations must be performed rapidly, one after 
 another. Its chief danger seems to be the production of 
 pneumonia from cold vapor. 
 
 How to Give Chloroform.. So few doctors, even 
 recent graduates who have served as internes in the great 
 hospitals, know how to give chloroform properly (i. e., 
 safely), that the following should be read at least twice
 
 ANESTHESIA 39 
 
 by every doctor; and once again by him who thinks he 
 knows how! It is the method which has proven safest 
 as demonstrated in many thousands of anesthesias; viola- 
 tion of the rules is what leads to the occasional death 
 of a patient. 
 
 There are four chief things to be constantly borne 
 in mind by the anesthetist: 
 
 1. To watch the patient, not the operator. 
 
 2. To keep an eagle eye upon the respiration; the 
 pulse is of only secondary importance. 
 
 3. To begin administration quietly and slowly; 
 more than ninety percent of all deaths occur during the 
 first few inhalations of the vapor. 
 
 4. To carry the patient quickly to profound anes- 
 thesia, and then keep him unconscious with the slightest 
 possible amount of chloroform. 
 
 Apparatus to be Used 
 
 The only safe way to give chloroform is by means of 
 a dropper and an Esmarch inhaler, or some modification 
 of the same. 
 
 a. The Bottle. Any bottle will do which has a mouth 
 small enough to fit the cork; but it should never be more 
 than half full at the time of using. The loo-gram bottle 
 in which chloroform now is sold is the best. 
 
 b. The Dropper. With the regular Esmarch appar- 
 atus there comes a cork with metal dropper. 
 
 There are two objections to this dropper: (i) It 
 allows chloroform to escape too freely, particularly at a 
 moment when but little is desired, and (2) often it is not 
 at hand when wanted. 
 
 A far more satisfactory dropper can be manufactured 
 at the bedside in two minutes with a sharp knife, a cork 
 and a little bit of cotton. A cork which fits the neck of 
 the bottle to be used is grooved from end to end on two
 
 40 SURGICAL THERAPEUTICS 
 
 sides, the groove being made less than a sixteenth of an 
 inch deep; a little of the cotton is laid in one groove so 
 that it extends beyond each end of the cork, and the cork 
 and cotton are inserted snugly in the bottle half filled 
 
 Fig. 1. Dropper made from common bottle 
 ^ with cork and cotton 
 
 with chloroform. When turned from the upright to the 
 horizontal, this dropper will give down chloroform in 
 minute drops, about one-fourth the size of those from 
 the Esmarch. 
 
 c. The Mask. Two thicknesses of gauze stretched 
 over a wire frame constitute the receiver of the chloroform. 
 
 Fig. 2. Cork cut to make a dropper 
 
 It must not be permitted to touch the face until the patient 
 is profoundly asleep; then it may be allowed to rest gently 
 over the nose and mouth. 
 
 Cotton should never be put in the concavity of this 
 mask, nor should more than four thicknesses of gauze 
 be used patients must have at least 95 percent of air 
 (i. e., never more than 5 percent of chloroform vapor) 
 at any stage of. an anesthesia.
 
 ANESTHESIA 41 
 
 When a mask is not at hand, one may be improvised 
 very effectively by taking a towel, stiff with starch, if 
 
 Fig. 3. Patent drop-bottle 
 
 possible, and making a cup-shaped "pucker" in one side 
 of it, as shown in the cut. 
 
 This may be placed over the patient's mouth and 
 nose and the chloroform dropped upon it. 
 
 Method 0} Administration 
 
 The patient being in the position desired for opera- 
 tion is told to close the eyes and go quietly to sleep. He 
 should never be told to breathe deeply. Nor should he be 
 
 Fig. 4. Esmarch inhaler 
 
 requested to count both tend to excite the patient's 
 fears and disturb his tranquillity. The only directions 
 should be: "Try to go to sleep," "keep your eyes closed," 
 and "don't mind the smell at the beginning." Especial 
 care should te used not to say, "Don't mind the smother- 
 ing sensation" that is sure to cause anxiety; and it is 
 fear which kills at the beginning of anesthesia. The 
 eyes should be covered by a towel.
 
 42 
 
 SURGICAL THERAPEUTICS 
 
 The mask being placed over the nose, two or three 
 inspirations should be permitted without any chloroform; 
 then a single drop or two, never more is allowed to 
 fall on the top of the mask and the patient asked pleas- 
 antly if he likes the smell, with the assurance that the chloro- 
 form will not be given too strong. After two or three 
 inhalations of this very mild vapor, five or ten drops are 
 to be poured on and the mask slowly lowered to within 
 a half inch of the face; when the patient has breathed 
 this stronger vapor, three or four times the amount may be 
 quite rapidly increased, so that within two minutes after 
 
 Fig. 5. Emergency mask 
 
 beginning the anesthesia its administration should be 
 under full headway if the patient behave properly; if he 
 be excitable, a little longer may be required. At the end 
 of two or three minutes the rate of dropping should be 
 about two per second, the drops being made to fall in a 
 circle near the margin of the mask. There should be no 
 intermission in this dropping (if the patient be breathing 
 regularly and easily) until the patient is fully under the 
 influence. The man who stops ^o set the bottle down 
 on the table, before the patient is unconscious, is a dan-
 
 ANESTHESIA 43 
 
 gerous anesthetist the only exception being when the 
 patient does not breathe well. 
 
 At a certain point in the process of anesthetization 
 (where the " stage of excitement" is said to begin) the 
 patient is very apt to hold his breath, and the inexper- 
 ienced anesthetist becomes uneasy or even alarmed; but 
 all that is necessary to do is to remove the mask, gently 
 press on the lower end of the sternum, with the sharp 
 command, "Go on breathing," and allow two or three 
 breaths of air; then as soon as respiration is regular go 
 on with the dropping. If any time is lost at this point 
 the patient may become very much excited (especially 
 if addicted to alcohol), but if just enough chloroform be 
 given, the "stage of excitement" may usually be entirely 
 avoided. 
 
 After a few more breaths the patient may try to vomit, 
 but unless something actually comes up into the throat 
 (in which case the latter must be quickly cleaned out) 
 no attention need be paid to this, as a few more drops of 
 chloroform will put a stop to it. 
 
 In three minutes a quiet patient should be put into 
 perfect surgical anesthesia; an excitable one inside of 
 five. The doctor who requires ten to fifteen minutes to 
 chloroform a patient is not a safe anesthetist. 
 
 As soon as the operation is begun the amount oi chloro- 
 form may be diminished; the pulse examined, so determin- 
 ing that the heart is right; and the pupil looked at to see 
 if it be properly contracted. At an early stage of chloro- 
 form inhalation the pupil becomes dilated for a minute 
 or two, but as soon as anesthesia is complete it is con- 
 tracted slightly beyond normal and should remain so to 
 the end; secondary dilation means too much chloroform 
 so the pupil should be frequently inspected during 
 the later stages of the work. But no man should stick his 
 finger in the eye to see if the conjunctival reflex is abolished.
 
 44 SURGICAL THERAPEUTICS 
 
 During the progress of the work from five to twenty 
 drops per minute will be required to keep the patient 
 asleep. As there are rather more than 120 drops to the 
 fluid dram, about one ounce should suffice for a full hour's 
 profound anesthesia; and some patients require less than 
 half this amount; if two doses of hyoscine-morphine- 
 cactin compound have been given before operation, one 
 dram will be an abundance. Just enough should be used 
 to keep the patient from moving; he should never be per- 
 mitted to wake up enough to feel the pain. 
 
 Accidents: How to Handle Them 
 
 1. The most common accident is "swallowing the 
 tongue." When this occurs (always after complete anes- 
 thesia), bottle and mask must be laid aside and the chin 
 of the patient raised by placing a thumb on each side of 
 the face above the angle of the jaw and three fingers on 
 the neck below the angle, when by pulling upward and 
 forward the larynx will be straightened and the tongue 
 drawn forward out of the pharynx. The man who wants 
 to use a tongue-forceps is one never worthy of trust as an 
 anesthetist. In extreme cases a finger wrapped with 
 gauze may have to be inserted into the throat to unroll 
 the tongue; but it should not be once in a thousand cases; 
 in all others elevation of the jaw is all that is required. 
 
 2. Cessation of respiration is the most dangerous of 
 all accidents. If too much chloroform be given, the patient 
 turns livid (from imperfect oxidization of the blood) and 
 finally he ceases breathing. Artificial respiration must 
 at once be instituted, and if voluntary respiration is not 
 begun within two or three minutes, the head should be 
 lowered and the angle "of the jaw raised again while arti- 
 ficial breathing is continued. Usually respiration will be 
 restored in a minute or two, though sometimes ten to twenty 
 are required; and as much as forty have been required in
 
 ANESTHESIA 45 
 
 extreme cases. So in fatal cases not less than an hour's 
 work is permissible. As soon as respirations are regular 
 and the color is good a small amount of chloroform may 
 be given, but usually only a little will be required. 
 
 3. Vomiting is sometimes troublesome if the patient 
 has eaten within eight hours of the operation. When 
 the stomach-contents come up into the throat the head 
 should be turned to one side to permit ejection, and the 
 chloroform stopped for a moment until the throat can 
 be cleared. A piece of gauze or corner of a soft towel 
 may be used to wipe out the mouth and even the pharynx 
 when necessary. As soon as two or three full breaths 
 have been taken by the patient, dropping should be 
 resumed. 
 
 4. Heart-failure is an accident not likely to occur if 
 the respiration continues good, unless there has been 
 excessive loss of blood or prolonged exposure of viscera. 
 When the pulse becomes weak or wavers greatly an 
 injection of a pint of normal salt solution (a teaspoonful 
 of salt to the quart of water, boiled and allowed to cool) 
 should be made into each breast or each buttock. While 
 this is being done, i-ioo grain of glonoin (nitroglycerin) 
 should be injected in the arm or neck; or if death seems 
 dangerously near, three or four syringefuls of ether may 
 be injected but never unless the situation is urgent. 
 The salt solution does best. Of course the anesthetic 
 is to be discontinued during these manipulations. 
 
 How to Give Ether. A piece of rubber-tissue is 
 placed over the patient's eyes; or in its absence a few lay- 
 ers of moist gauze may be used, to shield the eyes from 
 the irritating vapor of ether. Over this a moist towel 
 is laid and wrapped carefully around the chin and head 
 in such way that only the nose is exposed. 
 
 Preferably the apparatus used is a wire frame very 
 much like the Esmarch chloroform inhaler, made larger in
 
 46 SURGICAL THERAPEUTICS 
 
 order to give more space under the inhaler for the mixture 
 of air and ether; and the outline of the mask curved to 
 fit the face closely. If this special mask is not at hand the 
 regular chloroform-inhaler mask will do. The wire frame 
 should be covered with one or two layers of stockinette 
 or gauze. The air space under the frame must contain 
 about 25 cubic inches, that is, about three times more than 
 the ordinary Esmarch's inhaler. The best covering is 
 about six layers of gauze, which can be quickly applied 
 and thrown away after being used. The wire frame should 
 be boiled immediately after use. When everything is ready 
 for beginning anesthesia the mask is laid over the patient's 
 nose and a few drops of ether allowed to flow on it. The 
 patient usually complains of the smell or jerks the head 
 from side to side, but this nervousness disappears in a 
 moment or two if assurance is given in a firm tone that 
 everything is all right and that the bad smell will pass 
 away. At first the dropping must be very slow; then as 
 the patient becomes accustomed to the vapor the amount 
 is rapidly increased until a very fine stream is being pro- 
 jected constantly through the "dropper" in the can, the 
 same dropper being used that is made for chloroform. 
 
 As soon as sleep is so deep that the patient will not 
 respond to questions a moist towel or gauze should be 
 wrapped snugly around the mask, leaving a small area in 
 the center for the free passage of air through the gauze. 
 By this method the air is prevented from escaping around 
 the edges of the mask and is made to pass through the 
 ether-laden gauze. 
 
 The ether should not be at any time dropped on faster 
 than the patient can comfortably breathe it in. 
 
 Patients should preferably be anesthetized on the oper- 
 ating-table. Such as "are too nervous to be taken to the 
 operating-room can be put on the carriage in the anesthe- 
 tizing-room and rolled into the operating-room after the
 
 ANESTHESIA 47 
 
 anesthetic has taken effect. The anesthetizing-room should 
 be kept absolutely quiet, because all sounds are very much 
 magnified to a patient who is about to pass into the second 
 stage of. anesthesia. 
 
 Above all things, the anesthetist should not let an im- 
 patient operator worry or hurry him on, but remember 
 that the welfare of the patient depends upon the slow 
 and gradual ratio of the increasing concentration of the 
 ether-vapor. 
 
 The patient will become unconscious in two or three 
 minutes and should be ready for the operator in about 
 ten minutes. 
 
 When a patient has become thoroughly anesthetized 
 very little ether dropped slowly but continually will suffice 
 to maintain the proper condition. 
 
 Hyoscine-Morphine-Cactin Compound. In view 
 of the facts: (i) that there is at present a most 
 lively interest in hypodermic anesthesia; (2) that it 
 seems demonstrable that a perfect surgical anesthesia 
 may be produced safely by a certain combination con- 
 taining chemically pure hyoscine; (3) that an impure 
 " scopolamine " upon the market produces death or very 
 alarming symptoms, and (4) that certain pharmacolo- 
 gists are claiming that scopolamine and hyoscine are 
 identical and that the socalled " Abbott-Lanphear anes- 
 thesia" is therefore dangerous, it seems to me that a care- 
 ful analysis of the facts, together with a few words of 
 warning, should be of interest to the profession. 
 
 The following are the chief points of import: 
 
 1. That "scopolamine" made from scopola atropoides 
 is an unreliable and sometimes dangerous drug. 
 
 2. That "hyoscine" made from henbane is not, thera- 
 peutically, identical with the "scopolamine" of commerce, 
 even though it be named "hyoscine," as much of the" com- 
 mercial scopola-derived drug is.
 
 48 SURGICAL THERAPEUTICS 
 
 3. That a proper mixture of chemically pure (true) 
 hyoscine, morphine and cactin is a safe, cheap and efficient 
 substitute for chloroform and ether for surgical anesthesia 
 and for painless confinement; and as an analgesic is far 
 superior to the usual morphine-atropine combination. 
 
 i. "Relative to the first proposition I said in my first 
 contribution to the literature of this subject that the scopo- 
 lamine used by some manufacturers of hypodermic tablets 
 is (i) often unreliable and (2) sometimes dangerous that 
 "fifteen or more deaths have been reported from its use- 
 and hence it has been abandoned by most operators; 
 besides its danger, it has been found to be unreliable, 
 Merck saying that only scopolamine of -20 optical rota- 
 tion is safe and serviceable, while much in the market is as 
 low as -2, being practically valueless." ^ And W. C. Ab- 
 bott, of Chicago, in The International Journal of Surgery, 
 February, 1906, pointed out the same thing. 
 
 H. C. Wood, Jr., of Philadelphia, analyzed the reported 
 fatalities (mostly foreign) from the use of commercial 
 scopolamine and morphine, and in an article in American 
 Medicine, December, 1906, concludes that of the deaths 
 recorded at least nine were directly traceable to the scopo- 
 lamine-morphine used to induce anesthesia. 
 
 But his assertion that therefore only ignorant surgeons 
 will continue to use a hyoscine-morphine combination to 
 produce surgical anesthesia is based upon his assumption 
 that scopolamine (or socalled "hyoscine") made from 
 scopola atropoides is identical with hyoscine prepared from 
 hyoscyamus niger, because certain manufacturers so de- 
 clare and the United States Pharmacopeia states that 
 hyoscine and (pure) scopolamine have the same chemical 
 formula. 
 
 I believe all investigators agree that scopolamine as 
 found in the market is usually unreliable and sometimes, 
 in fact often, dangerous.
 
 ANESTHESIA 49 
 
 2. To substantiate, if possible, that which I felt sure 
 I had clearly demonstrated, experimentally: that chemically 
 pure hyoscine made from henbane is not, therapeutically 
 and possibly not chemically the same as scopolamine 
 (or socalled "hyoscine" from scopola), I wrote to the 
 leading manufacturers of hypodermic tablets in the United 
 States, submitting certain questions for answer. As a 
 result of this correspondence it may be said: 
 
 (a) That much of the "scopolamine" bought by cer- 
 tain commercial manufacturers is impure, of low rotatory 
 power, and unreliable; 
 
 (b) That some of the " scopolamine " is dangerous from 
 admixture with apoatropine; 
 
 (c} That some "hyoscine" tablets are simply "scopo- 
 lamine" which may or may not be dangerous on the one 
 hand or unreliable on the other; 
 
 (d) That there is obtainable a chemically pure hyos- 
 cine made from hyoscyamus, of not less than -20 optical 
 rotation, free from apoatropine, atroscine, etc.; and 
 
 (e) That this hyoscine differs therapeutically from 
 most of the "scopolamine" sold in this country, the former 
 being perfectly reliable and apparently safe. 
 
 Directly bearing upon this second proposition is the 
 following from a letter written by Messrs. Merck & Co.: 
 "Hyoscine hydrobromide and scopolamine hydrobromide 
 are identical, that is, the absolutely pure alkaloids are iden- 
 tical; but impurities vary, naturally, as the two are made 
 from two different plants though there should be no im- 
 purities if they are properly prepared. Chemically pure 
 scopolamine is a safe remedy in doses of i-ioo grain, and 
 is therapeutically active if close to -20. There are, 
 however, inferior products on the market; the most impor- 
 tant one of these as to sales [italics mine] has a rotatory 
 power of only -2. Such a oroduct must contain impuri- 
 ties, such as atroscine."
 
 50 SURGICAL THERAPEUTICS 
 
 John Wyeth & Bro. write: "Mr. Louis Merck, of 
 the firm of Merck & Co., Darmstadt, Germany, the lead- 
 ing manufacturers of alkaloidal salts, states in a paper 
 published in The American Journal of Pharmacy that the 
 hyoscine put upon the market by his firm has been and is 
 identical in chemical formula with scopolamine, but the 
 firm retains the name hyoscine for the alkaloid from hyos- 
 cyamus, and scopolamine for the alkaloid from Scopola 
 atropoides. 
 
 "Nevertheless, despite this apparent identity, it seems to 
 be pretty safely established that these two substances differ 
 materially in their therapeutic action. This is no doubt 
 due to the fact that the commercial scopolamine hydro- 
 bromide contains, as a rule, a varying admixture of an- 
 other scopola alkaloid. Owing to the presence of this 
 alkaloid, commercial scopolamine has, as a rule, a much 
 lower rotatory power than the salt prepared from henbane 
 (hyoscyamus niger) ; and Schmidt concludes, from the fact, 
 since scopolamine may be obtained with normal or with 
 feeble rotatory power, according to the mode of operating 
 on scopola, that the inactive scopolamine does not exist 
 naturally in the root but is formed in the course of ex- 
 traction. The admixture of varying proportions of atro- 
 scine in commercial scopolamine is evidenced by the vary- 
 ing melting point of the latter, which ranges all the way 
 from 178 to i9oC. 
 
 "We answer your specific questions as follows: (i) 
 Is hyoscine hydrobromide therapeutically the same as scopo- 
 lamine? Answer: No. (2) Is the optical rotation of 
 hyoscine variable from -20 to -2, as is scopolamine? 
 Answer: No. (3) Is commercial scopolamine a safe 
 remedy in doses of i-ioo grain or does it contain atroscine, 
 apoatropine or other impurities which rerider it dangerous ? 
 Answer: Not as safe as hyoscine, owing to the varying 
 proportion of atroscine, etc., present. (4) Does hyoscine
 
 ANESTHESIA 51 
 
 hydrobromide as employed by you for making hypodermic 
 tablets contain any impurities which make it a dangerous 
 remedy in doses of i-ioo grain, every hour, three times? 
 Answer: We have been using for years hyoscine hydro- 
 bromide made by one of the most reliable manufacturers 
 in the world,' and despite the fact that we have been sel- 
 ling these tablets in large quantities for a good many years, 
 we have never had any complaint of their causing any 
 untoward effects." 
 
 Upon this question Sharp & Dohme write interest- 
 ingly: "There are two kinds of this product (scopolamine) 
 upon the market, one optically active, with an optical 
 rotation to the left varying from -20 to -2 degrees, and the 
 other optically inactive. The melting point of these two 
 is different, the inactive melting at 179.7%). and the active 
 melting at i9i.6C. The optically active preparation is 
 the preferable one, although the manufacturers of the 
 other claim that both are equally efficient therapeutically. 
 But Kobert has shown that apoatropine sometimes is pres- 
 ent, and when it is so, -the optical rotation is greatly re- 
 duced; and apoatropine is responsible for the bad after- 
 effects. If it is levorotatory less than 10 degrees it would 
 indicate that it is mixed with some apoatropine. We use, 
 in making our hypodermic tablets, a hyoscine hydrobromide 
 in which the alkaloid possesses a distinct levorotatory ac- 
 tion upon polarized light only." 
 
 Eli Lilly & Co. write practically in substantiation of 
 these facts, as do also G. F. Harvey & Co., and Nelson, 
 Baker & Co. (who, however, state that they supply the 
 alkaloid of scopola scopolamine whenever hyoscine is 
 ordered, but so inform the purchaser). Mallinckrodt 
 Chemical Works make their "hyoscine" as well as "scopo- 
 lamine" from scopola in which they are fortified by per- 
 mission of the U. S. P. John T. Milliken & Co. declined 
 to answer. Parke, Davis & Co. ignored the request for
 
 52 SURGICAL THERAPEUTICS 
 
 information, simply referring me to the misleading and 
 wholly unreliable matter in The Journal of the American 
 Medical Association. 
 
 The Abbott Alkaloidal Company use only chemically 
 pure hyoscine derived from hyoscyamus, -20 degrees rota- 
 tion, and label the tablets made from the alkaloid of 
 scopola ' ' scopolamine . ' ' 
 
 Dr. Abbott's position is well known: that only pure 
 hyoscine hydrobromide should be employed for making 
 this anesthetic tablet; and that if scopolamine be substi- 
 tuted, it should be with a full understanding that by rea- 
 son of one impurity or another it may be either unreliable 
 or dangerous a danger for which the surgeon himself 
 must be held responsible, since he can easily secure pure 
 hyoscine instead. 
 
 3. As to the third proposition, there is much to be 
 said. After exhaustive experimentation the formula de- 
 cided upon by Dr. Abbott and adopted and extensively 
 used by myself is: 
 
 Chemically pure hyoscine hydrobromide, i-ioo grain. 
 
 Chemically pure morphine hydrobromide, 1-4 grain. 
 
 Cactin (from cactus grandiflorus), 1-67 grain. 
 
 Dosage. For small operations, like repair of lacer- 
 ated cervix, appendectomy, removal of gallstones, resection 
 of the bowel, etc.: one tablet to be injected into the 
 arm two hours before operation; a second, a half hour 
 before operation; twenty to forty drops of chloroform at 
 beginning of operation or a little cocaine locally. 
 
 For huge operations, like abdominal hysterectomy, 
 trephining, Kraske operation, amputation of thigh, etc.: 
 one tablet hypodermically three hours before operation; 
 a second an hour and a half later, and a third when the 
 patient is put upon the table. By the time preparations 
 are completed, hypnotic anesthesia usually will be pro- 
 found. Robust male patients may require a few drops of
 
 ANESTHESIA 53 
 
 chloroform by inhalation from one-half to one dram 
 sufficing for three or four hours' work; but quite often no 
 chloroform is needed. 
 
 The third dose, of course, is not to be given if two 
 have produced the desired effect. 
 
 Safety. This formula seems to be perfectly safe. 
 I have now used it (July 15, '07) in fully 400 capital opera- 
 tions without an alarming symptom; and I have reports 
 from others of more than 3000 cases without an accident 
 of any kind. Judging from my own experience and that 
 of others thus far reported it appears (when properly 
 handled) to be absolutely safe if chemically pure agents are 
 employed, just as chloroform is safe only when free from 
 impurities and used with judgment. 
 
 If left undisturbed, soon after the first injection the 
 patient sinks into a tranquil sleep; a few minutes after the 
 second one almost total unconsciousness is noted always 
 the individual is brought into the operating room free from 
 anxiety and excitement. If the patient is anxious it is 
 well to insure a good night's sleep and consequent tran- 
 quility by using a night-cap dose the night before, when 
 rarely are more than two tablets required for the operation. 
 The avoidance of the autotoxemia of excitement and fear 
 no doubt plays an important part in securing the excellent 
 after-effects following the use of this anesthetic. 
 
 Apparently from the cactin, Abbott (hence essential in 
 the combination), the pulse is increased to 90 or 100 or mor^ 
 and is full and strong, even though the patient may have 
 been brought into hospital suffering from shock. 
 
 The respirations sink to about 15, to 12 or 8 or even 
 6 per minute (practically the same as in deep, normal 
 slumber), but the color remains good. 
 
 The reflexes are not abolished, nor is the pupil inactive 
 to light. If found dilated after the second dose, plain mor- 
 phine should be employed for the third (if needed) there-
 
 54 SURGICAL THERAPEUTICS 
 
 after a few drops of chloroform will usually suffice to com- 
 plete the anesthesia. 
 
 The skin of hard drinkers may become quite mottled. 
 
 While the patient is not, as a rule, profoundly uncon- 
 scious, the analgesia from two doses is sufficient to permit 
 most operations like curettage, perineorrhaphy, hernia, re- 
 section of rib, etc. The patient may make a little com- 
 plaint on cutting the skin or pulling on the peritoneum, 
 but with the use of a few drops of chloroform sometimes 
 none hysterectomy or gallstone operations may be done 
 readily, or, with a little cocaine for the skin, extensive 
 resection of the bowel, appendectomy, etc. 
 
 Under three full doses (an hour or an hour and a 
 half apart), the last a half hour before cutting, the most 
 extensive and prolonged operations may be performed: 
 amputation of the thigh, trephining, excision of the mam- 
 mary gland and axillary contents, removal of the superior 
 maxilla, abdominal hysterectomy, Kraske's operation of 
 removal of the rectum, Schede's operation of excision of 
 chest-wall, nephrectomy and thyroidectomy being some 
 of the operations I have made without the use of a drop 
 of chloroform. 
 
 Respiratory Failure. Among possible dangers cessation 
 of respiration would seem to be most likely to occur. 
 Practically I have never seen any trouble, except in one 
 case where a fat woman's tongue dropped into the pharynx 
 and withdrawal of the tongue promptly relieved it. 
 During operative work the respirations generally come up 
 to the normal; after operation, if they should drop below 
 six per minute, very strong coffee might be given by rectum, 
 and strychnine administered: i-i5th grain hypodermically. 
 Or by shaking his shoulder with sharp command, the 
 patient may, from time to time, be made to breathe volun- 
 tarily. However, in no case thus far recorded has there 
 been the slightest alarm (even in back-woods farm houses,
 
 ANESTHESIA 55 
 
 with inexperienced nurses in charge, as much of my work 
 has been) as to respiratory paralysis. 
 
 Anuria. Suppression of urine is one of the greatest 
 dangers from an impure scopolamine. Dr. G. M. Phillips, 
 Professor of Genitourinary Surgery in Barnes University, 
 St. Louis, has had two deaths from " scopolamine-mor- 
 phine" anesthesia, and Dr. J. C. Murphy, Professor of 
 Obstetrics in the St. Louis College of Physicians and 
 Surgeons, one all three from anuria following the use of 
 socalled "hyoscine" tablets prepared by the firm alluded 
 to by Merck as the heaviest purchasers of "hyoscine" (scopo- 
 lamine) made from scopola atropoides and therefore likely 
 to contain apoajropine, etc. their basis for choice being, 
 apparently, price only. 
 
 In the treatment of anuria the sulphate of sparteine 
 in doses of one or two grains hypodermically every three 
 or four hours has been found most effective by Stuart 
 McGuire of Richmond. Its action is manifested within 
 thirty minutes. With it should be used hypodermoclysis: 
 one liter of salt solution to be injected into the cellular 
 tissue of the breast or buttock and repeated in three or 
 four hours. 
 
 Probably it is best not to use this form of anesthesia 
 when there is decided nephritis. 
 
 Heart Failure. Thus far there has never been any 
 indication of failure of heart-action, although warning has 
 been given by Abbott and others that there might be 
 trouble in case of serious organic heart lesions. Abbott's 
 addition of cactin seems to have settled this. Several of 
 my patients have had mitral insufficiency, but the cardiac 
 rhythm has been improved rather than made worse by its 
 use. Tablets made with digitalin instead of cactin have 
 not been nearly as satisfactory as those after the regular 
 formula. The suggestion to add atropine, ignorantly made 
 by some, is the sheerest folly.
 
 56 SURGICAL THERAPEUTICS 
 
 Remote effects are conspicuous by tneir absence. 
 
 There is no nausea or vomiting in most instances a 
 distinct advantage in abdominal surgery which every sur- 
 geon will appreciate. 
 
 There is no constipation generally the boweis move 
 spontaneously the day after operation and the tongue 
 cleans. 
 
 Rarely there is slight, transitory delirium following its 
 use, especially noted when strychnine is given. It is of 
 not the slightest consequence. 
 
 A few patients have slept too long to suit their friends, 
 and most doctors also fear too long a slumber. Nearly 
 always the patient is wide-awake, even after three full 
 doses, within one or two hours after being returned to 
 bed. The longer the patient sleeps the better, eight to 
 twelve hours being desirable. Some women sleep most 
 of the time for twenty-four hours, waking, or being easily 
 awakened for taking necessary drink and food, urinating, 
 etc. 
 
 A conspicuous feature after the operation is the freedom 
 from pain. After the most extensive and severe opera- 
 tions patients are perfectly comfortable during the hours 
 usually so full of suffering and restlessness hours so trying, 
 so exhausting. 
 
 Severe thirst is also absent unless there has been serious 
 hemorrhage, and much earlier than after any other anes- 
 thetic the patient may have both food and drink. 
 
 Shock is practically eliminated save from loss of blood 
 or long exposure of viscera. Use of this anesthetic demon- 
 strates that much of what we have heretofore called "shock" 
 is the effect of too much chloroform or ether. 
 
 Age-Limit. It should not be used in very young chil- 
 dren (who bear morphine badly) nor in the extremely old. 
 I have given it to patients 70 years of age, without fear, 
 but on the other hand, I have declined to give it to those
 
 ANESTHESIA 57 
 
 of not over the age of 60 who had atheromatous vessels 
 and other marked evidences of old age. 
 
 Its Use in Labor-Cases. Its field of usefulness in labor 
 would seem to be almost unlimited for under two or three 
 doses delivery may be rendered practically painless and 
 the most severe obstetrical operation can be performed 
 without the knowledge of the mother. Even half-doses 
 will do in many cases, the patient being delivered pain- 
 lessly without losing consciousness. 
 
 It does not seriously interfere with uterine contractions: 
 the action of the combination of hyoscine and morphine 
 upon the involuntary muscles being practically nil; contrary 
 to our experience with anesthetic inhalants, under profound 
 anesthesia the pupillary reflex is present, peristalsis con- 
 tinues, etc. If, at the beginning of the first stage, one 
 gram (15 grains) of quinine be given, labor will progress 
 even during total unconsciousness. If it is delayed in the 
 second stage, the forceps should be used. 
 
 In labor good judgment should be exercised. If a single 
 pronounced effect is desired, one full dose may be given; 
 but if prolonged effect is essential, half the dose early and 
 repeated in one or two hours is perhaps better. 
 
 So far as noted in the numerous cases reported it does 
 not affect the fetus in any undesirable way, except that 
 there is perhaps a little more than the usual amount of 
 trouble in making the child breathe; but no fatalities have 
 been recorded traceable to the use of the anesthetic. 
 
 It is best to give it only after the os is dilated so far as 
 to admit two fingers, though in prolonged "first stage" 
 it may be given at any time the patient begins to com- 
 plain bitterly. In an hour and a half, if needed, a second 
 dose may be injected; and a half hour later, unless the 
 patient is unusually nervous, forceps-delivery may be made 
 and the perineum repaired without the knowledge of the 
 patient.
 
 58 SURGICAL THERAPEUTICS 
 
 Occasionally a third dose may be necessary in contracted 
 pelvis or for cesarean section. It should never be given 
 sooner than three hours after the first dose, i. e., one and 
 a half hours after the second. 
 
 In Emergency Surgery 
 
 Its value in emergency work can scarcely be overesti- 
 mated. In .a serious calamity where many are involved and 
 help is scarce (as in railroad accidents, explosions, huge 
 fires, etc.) it is of the utmost utility. Every hospital, every 
 emergency-surgeon, every ambulance-man should be sup- 
 plied, as should also every army-surgeon, whether in divi- 
 sion-hospital, in the field-hospital or on the firing-line; the 
 possible diminution of human suffering by use of this 
 hypnotic-analgesic-anesthetic combination is beyond estima- 
 tion. It relieves pain, reduces shock and puts the patient 
 in best possible condition for a general anesthetic if a third 
 dose be deemed inadvisable. 
 
 To those who are afraid or skeptical the following 
 advice is given: 
 
 One hour before a serious operation administer one tablet; 
 see how little chloroform will be required and how little 
 Postoperative suffering there will be. 
 
 After a few trials, give one dose two hours before and a 
 second dose half an hour before operation; see how few 
 (especially women) will require any chloroform at all. 
 
 And, finally, when accustomed to its effects, try the third 
 dose, as directed, in appropriate cases. 
 
 Statistical 
 
 Reports were solicited from physicians known to be 
 employing the hyoscine-morphine-cactin anesthesia in 
 their surgical and obstetrical practice, and their replies 
 were tabulated in my paper as it originally appeared in 
 The American Journal of Clinical Medicine. Briefly 
 recapitulated the facts are as follows:
 
 ANESTHESIA 59 
 
 Altogether 311 answers were received, reporting on 
 a total of 2432 cases. Of these, 134 fail to give the num- 
 ber of cases in which it was used. The other 177 have 
 employed it in 665 labors and in 1,767 surgical operations 
 without any serious mishap, and but 8 failures! Some 
 of the failures were unquestionably due to faulty technic. 
 The trouble in securing good respiration in the newly- 
 born was produced by too large dosage semihypnosis 
 being best for confinements: memory of "pains" is totally 
 obliterated in most cases from half the dosage necessary 
 for surgical work. 
 
 My opinion is that ultimately this combination will be 
 used most extensively for partial anesthesia total uncon- 
 sciousness being induced by a trifling amount of chloro- 
 form by inhalation; the full analgesic effect of three doses 
 being reserved chiefly for those cases in which for any rea- 
 son it would be injudicious to use chloroform or ether. 
 But in my own work I am using it for practically all major 
 operations the narcosis is entirely too profound for minor 
 surgery (although the supplemental one-dose method works 
 well); and I am sure that others who try it carefully, in 
 appropriate cases, will become as enthusiastic as I am, on 
 account of (a) its simplicity, (b) its freedom from post- 
 operative nausea and pain, (c) its economy and (d) its 
 attractiveness to patients who so greatly dread either 
 chloroform or ether. 
 
 Precautions 
 
 Certain precautions are essential: 
 
 i. The hyoscine must be free from atroscine and 
 apoatropine, especially the latter, since contamination with 
 these, antagonizes the effect sought hence the hyoscine 
 hydrobromide used must be from a reliable manufacturer; 
 and there must be no thebaine or atropine in the mor- 
 phine.
 
 60 SURGICAL THERAPEUTICS 
 
 2. Silence must be preserved in the operating room; 
 otherwise the patient becomes restless, and finally wide- 
 awake and excited. Stop ears with cotton. 
 
 3. It should not be used in the very young or in those 
 of extreme old age. Possibly it may be of danger in 
 serious heart -lesions. Abbott says it should- not be 
 given to those suffering from far-advanced nephritis. 
 
 4. If the patient is nervous it is well to tie his hands 
 behind the neck so that a sudden movement may not con- 
 taminate the field of operation. The feet also may 
 be tied, in all cases perhaps. 
 
 5. The stomach and bowels should be empty, as for 
 chloroform-anesthesia . 
 
 6. The Abbott hyoscine-morphine-cactin tablet should 
 always be employed. One may depend on Abbott's prep- 
 arations. 
 
 7. If anesthesia is: not complete, a fev, drops of chloro- 
 form by inhalation will cause almost instant snoring. Re- 
 peat as needed. 
 
 Effects 
 
 1. The analgesia appears to be complete for many 
 hours. In two cases where hypodermoclysis was ordered 
 several hours after each patient had been returned to bed, 
 there was no indication of sensation when the large needle 
 was introduced. 
 
 2. The first effect is an excitement in two of my 
 cases delirium developed with slight dilation of the pupils. 
 Then the patient becomes quiet and the pupils are midway 
 between dilation and contraction. Soon, in favorable 
 cases, deep sleep follows. 
 
 3. After the second injection (which may arouse the 
 patient) profound sleep will be noted in most cases; but 
 some subjects insist upon muttering or even talking through- 
 out the operation, though making no complaint about its 
 hurting and knowing nothing of it on awakening. ,
 
 ANESTHESIA 61 
 
 4. Sleep continues for many hours, in most instances, 
 if three injections are used. Friends must be advised in 
 advance that the sleep may continue twelve hours or more ; 
 and that without danger if patient is watched and aroused 
 if respirations sink below six per minute. 
 
 5. The patient can be aroused at any time by shaking 
 or a loud command, and may be made to assist in changing 
 position or to sit up for application of bandages, etc. In 
 a fraction of a minute, or at most in two or three min- 
 utes, slumber is again deep and other operative work may 
 be done. 
 
 6. The secretions are not greatly interfered with. 
 
 7. Peristalsis is not arrested, as one would expect 
 from so large a dose of morphine. 
 
 Remarks 
 
 1. Women seem to require less than men. (Which is 
 true of any anesthetic.) 
 
 2. Ether should as a rule not be given with the 
 hyoscine-morphine combination; if anything is needed, 
 chloroform is best. (The few reports on the use of ether 
 following H-M-C are favorable.) 
 
 3. A beautiful thing about the method is the absence 
 of vomiting of great importance in abdominal surgery. 
 Another favorable feature is the absence of postoperative 
 pain; patients usually sleep all night following operation and 
 awake next morning demanding breakfast. 
 
 4. It is the ideal method of producing anesthesia for 
 obstetrical work, particularly for delivery with forceps. 
 It does not greatly retard labor. 
 
 5. If the patient moves -or groans during operation, 
 the temptation to give chloroform should not hastily be 
 yielded to; all that is usually necessary is to say in a pos- 
 itive way: "Lie still! You'll not be hurt," wait until 
 sleep or perfect quietude is resumed, then proceed.
 
 62 SURGICAL THERAPEUTICS 
 
 6, While the effects of the compound are decided, 
 suggestion may properly be utilized to aid the action and 
 render smaller doses necessary. 
 
 Disadvantages 
 
 1. The only serious disadvantage that I have noted 
 is that muscular relaxation is not absolute so that it is 
 not applicable to very delicate work, like that on the eye. 
 In flap-amputations this is a great help. 
 
 2. It cannot always be used with a crowd around, 
 as in a clinic, excitation being likely to result from the 
 noise. 
 
 3. After one has become accustomed to it there is 
 a tendency to do one's work too slowly it induces laziness 
 on the part of the surgeon, who quickly learns that he 
 doesn't have to make haste. 
 
 Advantages 
 
 1. Economy. About three cents covers the entire cost 
 of several hours' anesthesia. 
 
 2. No assistant is necessary in many operations save 
 as a precaution against lawsuits (abortions, railway in- 
 juries and the like). 
 
 3. No nausea or vomiting; this is of special advantage 
 in abdominal work. 
 
 4. No shock. There is no shock (except from great 
 loss of blood) with this anesthetic. Its use demonstrates 
 that most operative "shock" is the result of too much 
 chloroform or ether. 
 
 5. No pain, or but little, after operation; a great 
 inducement to patients reluctant to submit to surgical 
 treatment. 
 
 6. Absence of fear of chloroform or ether on the part 
 of either patient or surgeon; the advantage of not having 
 to hurry because the patient does net take the anesthetic 
 well can scarcely be overestimated.
 
 ANESTHESIA 63 
 
 7. Fear of operation disappears, and with it all objec- 
 tions to the surgeon's work and all mentally-induced auto- 
 toxemia is prevented. 
 
 8. The danger of hemorrhage is much decreased. 
 
 9. Gauss's analysis of his 1000 obstetric cases shows 
 a reduced mortality of mothers and infants, and even greater 
 advantages from preventing the impression on the nervous 
 system made by the agonies of childbirth. Many reports 
 show how the use of the H-M-C (Abbott) anesthesia dis- 
 sipates the fear of maternity. 
 
 Lumbar Anesthesia. Injection of cocaine solution 
 into the spinal column gives perfect analgesia of some 
 hours' duration, below the neck. So also does an injection 
 of small quantities of sulphate of magnesium. How- 
 ever, these are very dangerous; eight deaths are on record 
 and many others have not been reported. In the light of 
 our present knowledge the method is scarcely justifiable. 
 If used at all, it should be limited to (i) aged patients, 
 (2) those affected with arteriosclerosis, (3) persons who 
 have cardiac lesions, (4) subjects of bronchial and pul- 
 monary disease. 
 
 Method of Use. The method, as described (for tropa- 
 cocaine) by McCombs (The American Journal of Clinical 
 Medicine) is as follows: The syringe employed is a Luer 
 all glass, with graduated barrel, capacity 25 minims. The 
 needles are three inches long, have a pointed tip and 
 dull edge, thus separating the tissues and not cutting 
 out a plug. The needle connects with the syringe by 
 a joint. 
 
 The needles with rammers are thoroughly boiled, 
 also the syringe, the piston being removed from barrel. 
 Dip the tube or vial containing the tropacocaine in an 
 antiseptic solution and dry with sterile gauze. Break the 
 tube or remove cork and roll the powdered tropacocaine 
 into the bottom of the barrel. Slowly introduce the piston,
 
 64 SURGICAL THERAPEUTICS 
 
 being careful not to blow the powder out of the end of 
 the barrel. 
 
 How to Locate the Point of Puncture. The syringe 
 is laid within easy reach of the right hand. The patient's 
 pulse, being taken, will register from 80 to 100 from men- 
 tal anxiety and fear of operation. The lumbar region is 
 cleaned and the-third or fourth intervertebral space located. 
 This is done by having patient flex and extend the trunk, 
 while the finger locates the dimple or depression below 
 the tip of the spine. In lean patients this is quite easy. 
 In fleshy patients stretch the edge of a towel from the 
 highest points of the crests of the ilia; the fourth inter- 
 space is on this line. Now have the patient lie on the side 
 and flex the spine, or better still, have him sit on the edge 
 of the operating table and bend forward until the folded, 
 flexed elbows rest upon his knees, arching his spine. If 
 he does not arch the spine an assistant may press back- 
 wards on his abdomen'; this procedure widens the inter- 
 space between the vertebrae to its greatest extent and 
 serves to secure the success of the operation. 
 
 Making the Injection. Now with the exact spot 
 located, allay the patient's fears by telling him you are 
 not going to stick him with a needle, and not to jump 
 or jerk. The operator kneels on the opposite side of 
 the table, his left index finger on the intervertebral depres- 
 sion, below the spine of the fourth vertebrae in the mid- 
 line, not to one side, with the needle in the right hand and 
 at right angles to the skin surface. Make slow but firm 
 pressure on the needle to press it through the thick skin. 
 If bone is struck the resistance is decided, and the needle 
 must be slightly withdrawn and direction changed. If 
 the intervertebral space is entered, the needle imparts 
 to the hand a peculiar cartilaginous crepitus, followed 
 by lessened resistance as the needle enters the spinal 
 canal, and clear fluid appears at the needle end. Quickly
 
 ANESTHESIA 65 
 
 place left index finger over needle end, to prevent the 
 escape of any fluid, and attach syringe by means of joint. 
 Gently pull out the piston until spinal fluid fills the barrel 
 to the 8- or i5-minims mark, and by turning the syringe 
 two or three revolutions, the tropacocaine will quickly 
 dissolve in the spinal fluid. Now press the piston clear 
 in, tell the patient to straighten up his back, and as he 
 does so, remove the syringe and needle. The skin puncture 
 is covered by cotton and collodion. 
 
 The patient can now be prepared for the operation, 
 and by the time he is washed up anesthesia will be com- 
 plete; in from two to five minutes for operations below 
 the diaphragm and three to fifteen above, and will con- 
 tinue for one and one-quarter to three hours. 
 
 Anesthesia is complete and any operation may be done. 
 Only the sensations of pain and temperature, however, 
 are destroyed, the pressure and muscular sense being un- 
 affected. For example, the patient can feel the pressure 
 of a hand against him or as one seizes a group of muscles 
 but he cannot feel cutting or crushing instruments. He is 
 able to walk (though this is not advisable), can flex or 
 extend his limb at command, and so assist the operator if 
 necessary; he has perfect control of his higher mental 
 faculties, can answer questions intelligently or make state- 
 ments which might be of value both to patient and phy- 
 sician. 
 
 Phenol a. Local Anesthetic. For making small 
 incisions in the skin (like opening an abscess, cutting 
 out the end of a needle, etc.), an anesthesia may be pro- 
 duced by the use of phenol liquefactum i. e., liquefied 
 95-percent carbolic acid when no other agent is at hand. 
 A spot an inch or more may be painted with the pure 
 phenol. For a brief space of time there will be a burn- 
 ing sensation, succeeded almost instantly by a cool feel- 
 ing as the skin turns white and shrivels. In a few minutes
 
 66 SURGICAL THERAPEUTICS 
 
 the skin may be cut without pain, but underlying struc- 
 tures are not insensitive to the knife. It does not seem 
 to interfere with healing under a sterile dressing, and 
 possesses the advantage of thoroughly sterilizing the 
 superficial layers of the skin. 
 
 Tropacocaine for Spinal Anesthesia. Better than 
 cocaine for the production of anesthesia by intraspinal 
 injection is tropacocaine. It is claimed that in many 
 thousands of anesthesias produced by it the headache 
 and nausea were no more marked than' after simple spinal 
 puncture, and no dangerous effects were seen. The 
 technic differs from that usually employed, in that the 
 tropacocaine in powder is placed in a sterile glass, and 
 the spinal fluid being drawn into the glass dissolves the 
 substance, no water being added. For operations on the 
 legs and perineum, 3-4 grain suffices, but for the abdo- 
 men i grain is required. It should not be used in chil- 
 dren less than fourteen years old, although old age is not 
 a contraindication. As it lowers blood-pressure it may 
 be dangerous in persons whose blood-pressure is already 
 low. Increased extent of anesthesia* must be obtained 
 by raising the pelvis and not by increasing the dose. 
 
 Vomiting After Anesthesia. Vomiting after anes- 
 thesia will cease spontaneously in a few hours (twenty- 
 four at the farthest) unless acute sepsis is coming on, 
 provided all water or other fluid is scrupulously avoided. 
 Above all things, ice in the mouth should not be per- 
 mitted it tends to prolong nausea indefinitely; but the 
 tongue and lips may be moistened every few minutes 
 with a cloth wrung from ice-water. For wealthy patients 
 a little iced champagne may be ordered after eight hours 
 a half teaspoonful every half-hour until the end of the 
 first twenty-four hours, when, if vomiting has ceased, 
 water may be given cautiously; if it is thrown up, another 
 twelve hours of abstinence must be enforced. For patients
 
 ANEURISM 67 
 
 who cannot afford champagne, one drop of phenol in a 
 teaspoonful of peppermint water may be ordered every 
 hour, if the patient and friends demand something in 
 the way of medication. But the best remedy is perfect 
 quietude and withholding of fluids. 
 
 ANEURISM. 
 
 Aneurism, whenever possible, should be subjected to 
 operative treatment: excision or at least ligation. Inser- 
 tion of silver wire into the aneurismal sac has many enthu- 
 siastic advocates, notably MacEwan, who has had some 
 splendid results. But when so situated as to be inaccessible 
 (as in the thorax) or inoperable (as of the abdominal aorta), 
 or from size, certain medical and dietetic measures may be 
 instituted. 
 
 The subcutaneous injection of gelatin has been highly 
 lauded. It is liquefied and injected into the buttock with 
 a specially constructed syringe. It is presumed to add 
 materially to the coagulability of the blood; but its use- 
 fulness is doubtful. 
 
 Aneurism of Aorta. Silver wire may be introduced 
 into the aneurismal sac through a fine canula, insertion 
 being made at the point where pulsation is most promi- 
 nent. The skin is carefully sterilized, the boiled canula 
 and trocar thrust in, the trocar withdrawn and the open- 
 ing instantly closed by means of sterile gauze; then from 
 fifteen to thirty feet of No. 28 silver wire may be slowly 
 passed in. When a sufficient quantity has been made to 
 coil up in the sac, the canula is to be withdrawn and the 
 proximal end of the wire fastened to the chest-wall by 
 adhesive plaster. No anesthetic is necessary. At the same 
 time one may inject into the buttock about 300 Cc. of a 
 2 -percent gelatin solution, which is presumed to facilitate 
 coagulation "of blood. If the wire causes pain after a time 
 two or three weeks a part of it may be very cautiously
 
 68 SURGICAL THERAPEUTICS 
 
 withdrawn, though this is dangerous on account of the 
 possibility of loosening some part of the clot. If the 
 open pleura have been punctured in the introduction of 
 the trocar, hematothorax may develop and cause distressing 
 symptoms and sometimes death. So extreme care should 
 be taken not to puncture it. In abdominal aneurism it 
 is best to make an abdominal section at the time of in- 
 serting the wire. Some cures have been recorded and 
 many failures. 
 
 Calcium Chloride for Aneurism. A remedy for 
 inoperable aneurism which has attracted considerable atten- 
 tion of late is calcium chloride. It is well known that 
 the lime salts taken for a long time increase the coagu- 
 lability of the blood; so, theoretically, when an aneurism 
 is to be treated by the "rest" method or by insertion of 
 wire into the sac, the use of calcium salts ought to be 
 of decided benefit. Practically applied it seems to be 
 of service in non-operative treatment; and it certainly will 
 do no harm to give it for some days before needling or 
 wiring is to be tried. It may be given in quarter-gram 
 to half-gram doses (3 to 8 grains) three times a day. 
 Plenty of water must be given with it. 
 
 Iodides for Aneurism. The pain and throbbing of 
 inoperable aneurisms often may be ameliorated by the 
 internal use of iodide of potassium. Even though there 
 may be no suspicion of syphilis as a cause, the iodide should 
 be tried before resorting to morphine or other opiates, 
 In doses of one to two Grams (15 to 30 grains) three times 
 a day, with enforced quietude and restricted diet, it affords 
 perfect immunity from suffering; but it may have to be con- 
 tinued for many months, the slightest reduction from the 
 dose of tolerance causing immediate return of the pain. 
 It is presumed to act by depressing the heart, though it 
 may have some direct effect upon the diseased vessel- 
 walls (especially in cases due to syphilis). In some cases,
 
 ANGIOMA 69 
 
 undoubtedly luetic, it is necessary to increase the dose to 
 five or six grams thrice daily. A few cures have been 
 reported. 
 
 Threatened Rupture of Aneurism. When an 
 aneurism threatens to rupture through the skin (as is 
 frequently the case with the femoral, carotids, and even 
 the aorta) the following treatment should be instituted: 
 
 The patient must be put in bed and perfect quietude 
 enforced; if one of the extremities be affected it should be 
 immobilized by some kind of splint; if the neck be the 
 site of trouble the head must be fixed between sand-bags, 
 with no pillow. Enough morphine to keep the patient 
 tranquil is advisable. Diet must be restricted to a very 
 little of the most nutritious of foods and the amount of 
 drink limited to the least possible. Veratrine in doses of 
 one milligram (gr. 1-67) is to be taken every half to two 
 hours until the pulse is soft and weak; and then three or 
 four times a day to maintain it so. Iodide of potassium 
 is to be given in doses of a half gram (8 grains) three times 
 a day and rapidly increased until four grams (60 grains) 
 are taken at a dose and this whether or not the patient 
 has had syphilis; if he has, the increase may be con- 
 tinued to a much greater dosage, a half ounce or more 
 thrice daily often being tolerated by luetics. Locally, the 
 best treatment is to paint with collodion night and morn- 
 ing. 
 
 Under this plan many cases have been greatly relieved 
 and some apparently cured. 
 
 ANGIOMA 
 
 This tumor is one composed entirely, or in great part, 
 of blood-vessels mostly of new formation. In women 
 they sometimes become distended, or more prominent, 
 at the menstrual period. The majority are congenital; 
 very rarely angiomata develop after puberty. Their
 
 70 SURGICAL THERAPEUTICS 
 
 growth is commonly painless, slow and irregular. Some- 
 times ulceration of the skin occurs with either alarming 
 hemorrhage or spontaneous cure of the growth. They 
 should be removed by operation when they are conspicu- 
 ous or when they show a tendency to grow. 
 
 ANKLE: DISEASES OF 
 
 Drainage of Ankle. Drainage of the ankle as usually 
 practised is very unsatisfactory, and a panarthritis usually 
 develops, in many cases necessitating an amputation 
 through the leg. This has led to the devising of a more 
 satisfactory plan of drainage. The ankle joint consists 
 not of a single compartment lined by a synovial membrane 
 but rather of two, one anterior, the other posterior, sepa- 
 rated from one another by the astragalus and the two 
 malleoli, and in communication, so far as the flow of 
 synovia or exudate is concerned, only by narrow channels 
 beneath the lateral ligaments. Hence drainage conditions 
 can best be met by removal of the astragalus. The 
 method of the removal of the astragalus depends upon the 
 original injury. It is most accessible through an incision 
 over its head parallel to and to the outer side of the 
 extensor tendons, made with the foot strongly adducted. 
 The resultant stage is- as good if not better than where, 
 even if the leg is saved, a stiff and tender ankle is ob- 
 tained. 
 
 Sprained Ankle* As the x-ray has shown that large 
 numbers of socalled sprains of the ankle are sprains plus 
 fracture, examination with the fluoroscope is advisable 
 whenever possible. If fracture be found, plaster-paris 
 dressing and perfect rest of the joint for three weeks is 
 advisable. If no fracture is present, massage and dressing 
 with strips of surgeon's plaster is perhaps best, with imme- 
 diate use of the limb. But in case of severe injury tota) 
 rest is preferable.
 
 ANTISEPTICS 71 
 
 ANTHRAX 
 
 Three conditions are grouped under the name 
 "anthrax." 
 
 1. Benignant anthrax, characterized by a peculiar car- 
 buncle; a painful, dark-colored tumor in the subcutaneous 
 cellular tissue, which becomes much inflamed and then 
 necrotic, discharging a fetid, bloody pus. It is a purely 
 local infection with bacillus anthracis (i. e., without any 
 anthracemia) and is not a fatal disease. Early excision 
 and thorough cauterization of the wound by nitric acid 
 or the Paquelin cautery is the proper treatment; the re- 
 sultant sore being handled just like a simple burn. 
 
 2. Malignant anthrax, the "malignant pustule" of 
 older writers, or "wool-sorters' disease": infection from 
 animals suffering with splenic fever. The pustular trouble 
 gradually extends until the whole system is involved, the 
 intestinal tract finally is invaded and gives rise to what 
 is called "the intestinal type" of anthrax. The local 
 lesion is treated in the same manner as in the benignant 
 form; the anthracemia by injection of the Pasteur serum. 
 
 3. Symptomatic anthrax, the disease called "black- 
 leg" in sheep (quarter-evil). It is due to the bacillus 
 Chauvaei. 
 
 ANTISEPTICS 
 
 Antiseptic and Germicidal. It is strange that medi- 
 cal men apparently well educated will use the word "anti- 
 septic" as the equivalent of "germicidal." The word 
 germicide means anything which will kill a germ a term 
 formerly regarded as meaning "bugs", or microscopic 
 animals of some kind, instead of the minute fungi invis- 
 ible plants which play such an important part in disease; 
 whereas "antiseptic" simply implies some agent which 
 will inhibit the growth of microorganisms, antagonize or 
 destroy their poisonous products or prevent the absorp-
 
 72 SURGICAL THERAPEUTICS 
 
 tion of their toxins. We employ antiseptic precautions in 
 preparing for and performing an operation; we wash our 
 hands in germicidal solutions. Asepsis and antisepsis also 
 should never be used interchangeably, as is so often 
 done. 
 
 Antiseptic Dusting Powder. To replace the costly 
 proprietary articles used for dusting on wounds the United 
 States Pharmacopeia recommends "thymolis iodidum" 
 the iodide of thymol. It is now prepared of standard 
 U. S. P. strength by all leading manufacturing chemists and 
 can be obtained on prescription from all first-class 
 druggists. 
 
 Antiseptic Solution: General. A most useful anti- 
 septic to use for douches, irrigations, etc., is the "liquor 
 cresolis compositus" of the United States Pharmacopeia. 
 It is of the same strength as "lysol" and may be used by 
 those who prefer a non-proprietary preparation. The 
 formula is: 
 
 Cresol, pure 500 parts 
 
 Linseed oil 350 parts 
 
 Potassium hydroxide 80 parts 
 
 Water, enough to make 1000 parts 
 
 Mix. Mark: "Poison." 
 
 It is about the same strength as carbolic acid. Solu- 
 tions, i to 40, in water are highly germicidal. 
 
 Dobell's Solution. This excellent antiseptic solu- 
 tion, of especial use in nasal and laryngological work, 
 now should be of uniform strength wherever prepared, the 
 National Formulary specifying that it shall contain : 
 
 Sodium borate Gm. 15.0 (oz. 1-2) 
 
 Sodium bicarbonate . Gm. 15.0 (oz. 1-2) 
 
 Phenol Gm. 3.0 (grs. 45 ) 
 
 Glycerin Cc. 35.0(023. i 1-6) 
 
 Water, to make Cc. 1000.0 (ozs. 32 )
 
 ANTISEPTICS 73 
 
 Harrington's Solution. One of the best antiseptic 
 agents, if not the best, is Harrington's solution. It has 
 this composition: 
 
 Hydrochloric acid 60.0 parts 
 
 Alcohol (94 percent) 640.0 parts 
 
 Water 300.0 parts 
 
 Bichloride of mercury o.i part 
 
 Experiments show that this solution will sterilize car- 
 buncle-pus in less than thirty seconds, while it requires 
 tricresol five and one-half minutes, and carbolic acid 
 four minutes, to produce the same results. It is especially 
 useful for hand disinfection and for use in preparing the 
 skin for incision. On account of the corrosive sublimate 
 it contains it should be preceded by ether and followed 
 by a little plain water. 
 
 Sterilization of Knives. The question is often 
 asked: How may knives be sterilized, as boiling 
 dulls them so ? Royster, as the result of experiments 
 and of correspondence with a large number of oper- 
 ators, has reached the following conclusions: " (i) 
 Knives can be safely sterilized by chemical and me- 
 chanical means without the use of heat in any form. 
 (2) The majority of American surgeons are using car- 
 bolic acid, or alcohol, or both. (3) Immersion in ninety- 
 five-percent alcohol has the least, and boiling the most, 
 effect in dulling the edge of a knife." To all of which 
 I want to offer the most strenuous objection. After a 
 knife has been in a streptococcus abscess nothing but 
 boiling is safe! Boiling does not seriously dull a knife 
 if it be boiled in a very strong solution of washing soda 
 (sal soda); cooking soda (bicarbonate of soda) will not 
 do it is absolutely useless; but the carbonate (sal soda) 
 can be relied upon invariably. I have a knife which has 
 been boiled 5000 times and it still ''works." Of course 
 the knife is sharpened now and then.
 
 74 SURGICAL THERAPEUTICS 
 
 Thymol. This stearoptene derived from thyme and 
 other vegetable oils is a more powerful antiseptic than 
 phenol (carbolic acid). It is usually employed in the 
 form of Volkmann's thymol solution: 
 
 Thymol i.o 
 
 Alcohol 20.0 
 
 Glycerin 20.0 
 
 Mix well and add 
 
 Water 1000.0 
 
 This may be used as either a spray or lotion. When 
 phenol or sublimate solutions irritate (especially causing 
 eczema) this may be used instead. 
 
 ANURIA: POSTOPERATIVE. 
 
 Possibly the best remedy for suppression of urine 
 after operation is sulphate of sparteine, regardless of the 
 cause of anuria. Most of these cases are due to a pre- 
 existing nephritis from sepsis, cholemia, etc., and should 
 then be treated with this remedy before operation as well 
 as after, because the anuria is to be anticipated, regardless 
 of the kind of anesthetic used, chloroform being appar- 
 ently as dangerous in this condition as ether or the newer 
 hyoscine-morphine-cactin combination . 
 
 Every patient affected by sepsis or cholemia should there- 
 fore be examined for albuminuria, and if this be found, 
 operation should be postponed a few days, if possible, 
 until the sparteine be given. But, unfortunately, patients 
 suffering from obstruction of the common bileduct, from 
 strangulated hernia, from retention of urine, etc., cannot 
 be held so here the surgeon must operate and do the best 
 he can to prevent anuria by immediate resort to proper 
 therapeutic measures. For if vigorous treatment is not 
 instituted the patient may do well for a few hours, then 
 become restless, listless and slightly feverish, later develop- 
 ing a stupor which speedily passes into coma, ending
 
 ANUS: DISEASES OF 75 
 
 in death from uremia, even though anuria may not be 
 complete; in the more pronounced type total suppression 
 of urine being noted. 
 
 The first thing to do is to give plenty of normal salt 
 solution under the skin; one liter (a quart) being injected 
 every eight hours; next, to administer sulphate of spar- 
 teine, a drug which increases the blood-pressure and acts 
 as a powerful diuretic. Within thirty minutes its full 
 action will begin, and the slow and full pulse indicates 
 persistence of its effect from four to six hours, at the 
 end of which time the dose is to be repeated. The amount 
 to be given is 30 to 50 milligrams (from one-half to three- 
 fourths of a grain) hypodermically. The patient should 
 be encouraged to drink as much water as possible. 
 
 ANUS: DISEASES OF. 
 
 It is peculiar that, accessible as is the lower four inches 
 of the rectum, its diseases should be so ignored by the 
 general practician. Even the anus, plainly visible to simple 
 inspection, is seldom examined, although complained 
 about. Prescriptions should never be given 'until ocular 
 evidence of the existing malady has been obtained; an 
 operable cancer might be ignored until too late to save life. 
 The four symptoms: pain, protrusion, hemorrhage and 
 discharge, may be present in so many conditions that to 
 "guess" is almost criminal. 
 
 Of the troubles common to the anus the most likely 
 to be found is hemorrhoids (which see). 
 
 Abscess of Anus. A superficial abscess may form in 
 one of the small glands around the anus, as well as from 
 ulceration of a small external hemorrhoid, and rarely from 
 trauma to the cellular tissue surrounding the anus. On 
 account of the tendency of pus to burrow at this particu- 
 lar part incision should be made, under cocaine injected 
 well behind the little abscess, so that as soon as the pus
 
 76 SURGICAL THERAPEUTICS 
 
 is expressed search may be made with a probe to ascer- 
 tain whether the trouble be simply a localized abscess 
 or the lower end of (a) an ischiorectal abscess, or (b) a 
 forming fistula of the rectum. 
 
 Artifical Anus. This must be made whenever the 
 natural outlet is closed by cancer, tumor or inoperable 
 stricture. It is made by opening the abdomen by a two- 
 inch cut over the sigmoid, drawing a loop of gut out, pack- 
 ing gauze into the cut around the bowel and opening 
 the intestine three or four days later, after the peritoneal 
 opening has been closed by adhesions. In some cases a 
 complete colostomy is to be made. 
 
 Cancer of the Anas. Cancer of the anus is not so 
 common as that of the rectum, but is susceptible of com- 
 plete cure if recognized early. Two methods of removal 
 are subject to choice: (i) excision and suturing, with 
 rectal packing for some days; (2) very deep destruction of 
 infected and adjacent tissue with the Paquelin cautery. 
 The latter is less painful and gives better ultimate results. 
 It should be used with the patient in full surgical narcosis, 
 with the sphincter thoroughly dilated; and the rectum must 
 be packed tightly with iodoform gauze, which is to be 
 removed in forty-eight hours. 
 
 Chancre of Anas. This affection occasionally comes 
 under the observation of the surgeon (in Chinese coolies, 
 for instance). It is to be treated the same as the initial 
 lesion of syphilis elsewhere. 
 
 Fissare of Anas. Obstinate cases of fissure of the 
 anus which resist all other forms of treatment may be 
 permanently relieved by simply cutting through the external 
 sphincter under local anesthesia. The incision must be 
 directly in the line of the fissure. After division of the 
 muscle the rectum should be packed with iodoform gauze 
 for two days; then the wound should be loosely packed 
 once every twenty-four hours for four or five days, after
 
 ANUS: DISEASES OF 77 
 
 the bowels have moved and the sigmoid and rectum have 
 been washed out with tepid water. 
 
 Before resorting to radical operation, palliative meas- 
 ures should always be tried, first. The most important 
 thing is a laxative diet, and soft bowel-movements must be 
 secured by mild cathartics, if necessary. On retiring each 
 night, there should be an injection of an ounce of olive 
 oil, to be retained until morning, which aside from its 
 local beneficial action will secure a soft movement. Next 
 in importance to the regulation of the bowels, is that strict 
 cleanliness should be maintained, by bathing the anus 
 night and morning, and also after each dejection, with 
 hot water. The parts should afterward be dried with a 
 sterilized piece of gauze, and a pad of the same material 
 placed over the anus and kept in place with a T-bandage. 
 The fissure itself may be burned >once a week with stick 
 nitrate of silver. It seems to act like a charm in allaying 
 the painful symptoms, and often a few applications will 
 prove sufficient. 
 
 Non-operative treatment means merely to give laxa- 
 tives and to burn thoroughly the fissure with pure carbolic 
 acid. Next day it is well' to begin the use of glycerin 
 suppositories containing 5 percent of iodoform. In a few 
 minutes a free and painless bowel-movement will occur. 
 The suppository may be used every day. An old remedy 
 was a teaspoonful of sulphur at bedtime and by its mild 
 laxative effect it certainly did much good. It may be 
 combined with powdered cinnamon to correct the smell 
 and taste. 
 
 This little, painful, irritating crack in the .skin and 
 mucous membrane of the anal verge is generally due to 
 the passage of hardened feces. Simple dilation of the 
 sphincter, burning the fissure thoroughly, and maintenance 
 of subsequent laxity of the bowels usually suffice. A 
 soothing ointment may be ordered.
 
 78 SURGICAL THERAPEUTICS 
 
 Fistula of Antis. When fistula of the rectum, com- 
 monly called fistula in ano, is found, a probe should be 
 run through it into the gut and, with local anesthesia, the 
 sphincter ani divided. The wound must be repacked 
 daily until healed from the bottom. If slow in granu- 
 lating, balsam of Peru may be used to stimulate rapid 
 healing. 
 
 Imperforate Anus. Babies are sometimes born 
 with no connection between anus and sigmoid; and even 
 the anus is missing in the worst cases. If the obstruc- 
 tion be a mere membranous septum it may be divided 
 by the knife, cutting toward the coccyx. If there be a 
 long distance between anus and sigmoid the child must 
 be chloroformed and careful dissection made, upward 
 and slightly to the left, in the hope of opening into the 
 rectum or sigmoid; if found the wound is to be tamponed 
 with gauze for three days; if not found, the peritoneum 
 may be opened and the sigmoid brought down to the 
 anus and sutured there if possible. When this cannot 
 be done the wound must be tamponed and an artificial 
 anus made. In cases where no anus is present, inguinal 
 colostomy is the only treatment! It is not a serious opera- 
 tion. 
 
 All operators now agree with Hunter on the follow- 
 ing propositions: (i) An operation should always be 
 performed, and performed without delay. (2) If there 
 be any chance of establishing an opening at the normal 
 site of the anus, the surgeon should at first direct his atten-. 
 tion to this procedure. (3) The use of a trocar as an 
 aid in finding the rectal pouch before or after incision 
 through the perineum is not sanctioned by modern sur- 
 gical authority. (4) The results of attempts to estab- 
 lish an outlet for an imperforate rectum through the peri- 
 neum are not favorable as regards the production of a 
 useful anus. (5) In case of failure to establish a new
 
 ANUS: DISEASES OF 79 
 
 anus in the anal region, colostomy should at once be per- 
 formed. (6) In the formation of an artificial anus the 
 left groin is the best site for the operation. (7) Attempts 
 at establishing an anus in the anal region after a colostomy 
 are attended with great danger, and are generally unsuc- 
 cessful. 
 
 Prolapse of Anus. Protrusion of the rectum (or of 
 its mucous membrane) must be treated by returning it 
 again and again within the sphincter, following each time 
 with an astringent injection. If this does not cure, the 
 sphincter may be dilated and several lines burned into 
 (but not through) the mucous membrane parallel with 
 the long axis of the gut; a Paquelin cautery being used, 
 with complete chloroform or hyoscine-morphine narcosis. 
 In the worst cases resection is necessary, but it is a very 
 serious operation, since the peritoneum is to be opened. 
 Ventral fixation of the sigmoid (colopexy) is preferred 
 by some proctologists. 
 
 Pruritus Ani. Nearly all cases of persistent itching 
 of the anus may be traced to one of these causes: (i) 
 The most common is superficial ulceration or abrasion 
 of the anal canal. (2) Next, catarrhal diseases of the 
 rectal mucosa which cause discharge from the anus. (3) 
 External hemorrhoids or skin-tags which prevent proper 
 cleansing of the parts. (4) Small polyps of the anal 
 canal, protruding internal hemorrhoids, prolapse, fis- 
 sures, etc. The treatment consists (in addition to remov- 
 ing the cause) in restoring the altered perianal skin to 
 the normal. For this purpose nitrate of silver followed 
 by citrine ointment are the best applications. Pruritus 
 is also caused by the irritating discharges from long- 
 retained fecal accumulations in the cecum or colon. In 
 children the trouble often arises from the presence of 
 seat-worms, which may be remedied by the injection, 
 three times a week, of infusion of quassia.
 
 80 SURGICAL THERAPEUTICS 
 
 AORTTTIS, ACUTE 
 
 Inflammation of the arteries is not perhaps of so much 
 interest to surgeons as is phlebitis, yet it is occasionally 
 encountered. Of all arteries the aorta, particularly its 
 arch, is the most subject to pathologic changes. This 
 is due to the fact that the first part of the aorta has no 
 sheath, and the blood forced against the walls at each 
 systole acts as a constant irritant to the coats at that 
 point. There are also such predisposing diseases as rheu- 
 matism, typhoid fever, scarlet-fever, smallpox, puerperal 
 diseases, the grippe, tuberculosis and syphilis, which 
 produce an alteration in the walls of the aorta. The 
 symptoms are pain in the aortic arch, or a substernal 
 soreness or tenderness. Dyspnea is marked, and peculiar 
 in that it continues both with inspiration and expiration. 
 A diagnosis is seldom made, and according to Anders 
 cannot be established with any absolute certainty. The 
 treatment indicated is absolute rest, cold to the chest, 
 sedatives to quiet the heart, and restriction of diet. As 
 a rule diagnosis is made after death. 
 
 APPENDICITIS 
 
 Inflammation of the vermiform appendix has been 
 variously called "echyaditis," " epityphlitis " and "appen- 
 dicitis." By common usage the last name has become 
 standard, though not constructed to suit philologists. 
 The appendix itself is named, in full, appendix caeci 
 vermiformis. 
 
 Strictly speaking, perhaps, appendicitis is always a 
 surgical disease, and the infected part should be removed 
 within the first few hours after active inflammatory 
 changes begin. But, there are some people who will not 
 consent to operative treatment "as soon as the diagnosis 
 is made;" there are some doctors who will not operate 
 themselves, yet who are so situated that a competent sur-
 
 APPENDICITIS 81 
 
 geon cannot be gotten to the charity patient far away 
 from city or town. What is to be done in such cases? 
 
 First, Bowel-Evacuation. Long experience has con- 
 vinced me that thorough purgation does no harm, Ochsner 
 and others to the contrary notwithstanding; indeed it 
 does much good if purgation can be secured by some agent 
 which will not produce vomiting. Therefore, to patients 
 who are not to be subjected to immediate operation I 
 give a good dose of Abbott's saline laxative, repeated in 
 four hours, if the results are not satisfactory. A small 
 enema sometimes is useful; but care must be taken not to 
 distend the colon. Late in the disease olive oil is useful. 
 
 Second, Pain. For the control of pain sulphate of 
 codeine may be used, guardedly; any opiate produces a 
 tendency to nausea and vomiting is one of the most 
 distressing (and sometimes dangerous) symptoms of 
 the disease. Three centigrams (one-half grain) of phos- 
 phate of codeine may be given hypodermically at any 
 time when the pain is intense; or the same quantity of 
 the sulphate may be left in pill-form to be given every three 
 or six hours, by mouth, as needed; as little as possible 
 being given. Morphine costs less, but may kill the patient; 
 codeine is cheaper than a coffin. Hyoscyamine is espe- 
 cially effective when the pain is due to muscular spasm; 
 given to full effect. 
 
 Third, Fever. In uncomplicated appendicitis the tem- 
 perature seldom runs above 100 or ioiF.; hence "fever 
 medicine" is not often required. When the tempera- 
 ture goes above io2F. a small dose of acetanilid will 
 cause it to drop to about normal for some hours while 
 it relieves the pain and nervousness; one-half gram (8 
 grains) may be given in one dose, if there is no decided 
 weakness of the heart. Aconitine may be given, if pre- 
 ferred, until the temperature and pulse drop to the 
 required degree.
 
 82 SURGICAL THERAPEUTICS 
 
 Fourth, Vomiting. This frequently is an early, per- 
 sistent and aggravating feature of appendicitis of severe 
 type, and is indicative of oncoming sepsis; when black- 
 vomit appears the patient generally dies of acute sepsis 
 (commonly called "diffuse peritonitis")- For its pre- 
 vention three things are necessary: (a) cleaning out the 
 intestinal canal; (b) perfect quietude; (c) abstinence from 
 food and drink. For the first forty-eight hours it is best 
 to withhold all food by the stomach (rectal feeding may 
 be instituted every six hours with patients extremely 
 weak), and give as little water as possible. The pleading 
 for "a little ice in the mouth" must not be heeded if 
 permitted it surely will lead to vomiting. After the first 
 two days, if vomiting does not occur, the amount of water 
 by stomach may be increased and liquid diet carefully 
 begun. When vomiting persists food must be abandoned 
 and water by mouth refused thirst being overcome by 
 enemas of not more than six ounces; if it becomes alarm- 
 ing one milligram (gr. 1-60) of salicylate of eserine may 
 be given hypodermically every two hours, four times. An 
 oxgall enema will help to turn the peristaltic wave down- 
 ward. 
 
 Fi/th, Distension. To prevent this the saline laxative 
 may be given every morning, guardedly; there need be 
 no hesitancy on account of possible leakage through a 
 perforation, as peristalsis alone will never force feces 
 through a hole in the appendix; and it does not to any 
 serious degree prevent the formation of adhesions, the 
 protective barrier against general infection. But when 
 distention is great the ice-bag may be used or hot fomen- 
 tations, if they give more comfort to the patient, as is 
 frequently the case. Local use of Crede's ointment, 
 mud-glycerin poultices, etc., does no good except to make 
 the people think "there's somethin' doin' "; but a few 
 drops of oil of turpentine dissolved in olive oil and thrown
 
 APPENDICITIS 83 
 
 up in the colon sometimes does good; and if the disten- 
 sion be due to gas in the colon an alum enema is of great 
 service. 
 
 Sixth) Tumor. In a large proportion of cases a mass 
 can be felt in the region of the appendix. It means per- 
 foration of the wall of the appendix the presence of 
 pus and is a positive indication for abdominal section. 
 If radical operation is refused and the abscess is inclined 
 to open externally, poultices may be applied to assist, 
 and simple incision made as soon as possible. 
 
 A large proportion of cases which ought to be sub- 
 jected to operative treatment must be taken through the 
 attack safely without it; but it is the duty of every doctor 
 to explain the dangers to patient and friends, and to insist 
 upon operative treatment whenever especially indicated 
 (as the formation of a mass in the cecal region) if the 
 services of a fairly competent operator can be secured. 
 
 Appendix in a Hernial Sac. Not at all infre- 
 quently an appendix may be found in a hernial sac; and 
 like the gut it may become strangulated and gangrenous. 
 It should always be removed when in an incarcerated 
 hernia, as the macroscopic examination might not reveal 
 the existence of changes so serious as to cause perfora- 
 tion if it were returned to the belly. It may even be 
 found in the scrotum. In one of my operations for 
 scrotal hernia an appendix seven inches long, adherent 
 to the- testicle, was removed from the scrotum of a boy 
 only five years of age. 
 
 Appendicitis in Pregnancy. What shall be done 
 in a case of appendicitis occurring in a woman well 
 advanced in pregnancy? If the case be mild it may be 
 treated by medicines alone; if severe, there need be no 
 hesitancy about operation, and the operation should be 
 the same as in any other patient. If the work be done 
 under hyoscine-morphine-cactin anesthesia (plus a little
 
 84 SURGICAL THERAPEUTICS 
 
 cocaine for the skin or chloroform, if needed) there need 
 be little fear of premature labor. The uterus is simply 
 held to the left side of the belly by an assistant while the 
 appendix is removed or the abscess opened and packed. 
 If labor does appear the wound should be well protected 
 and supported by two or three strips of adhesive plaster 
 and a wide binder firmly applied. 
 
 Colitis after Appendectomy. When discharging 
 a patient operated upon for appendicitis the surgeon 
 should invariably explain the very important point that 
 after removal of the appendix, symptoms of appendicitis 
 sometimes persist, leading the patient to believe that the 
 organ has not been extirpated. These are generally 
 due to a colitis, which must be treated by high irrigations, 
 diet, etc. 
 
 Diffuse Sapporative Peritonitis from Appen- 
 dicitis. When the abscess adjacent to the gangrenous 
 or perforated appendix has ruptured and the pus has 
 become disseminated throughout the lower part of the 
 abdomen and pelvis, the incision should not be made over 
 the site of the original abscess (appendical region) but 
 in the midline; and it should be very free: three to six 
 inches in length indeed, sometimes from the pubes to 
 two or three inches above the umbilicus. But the peri- 
 toneum must be subjected to as little handling as pos- 
 sible, rubbing with gauze being especially injurious. 
 The best management seems to be (a) to wash out the 
 abdomen and pelvis with gallons of hot saline solution; 
 (b) remove the appendix and such part of the omentum 
 as seems too badly infected to live; (c) again wash out 
 the belly and sponge out the surplus fluid; (d) close the 
 abdomen without drainage. (Drained patients almost 
 always die.) If this method of treatment be adopted 
 within seventy-two hours after the rupture occurs, a large 
 percent of cases may be saved; later than that time the
 
 APPENDICITIS 85 
 
 prognosis invariably is bad. Operation in these cases 
 should therefore be performed as soon as the diagnosis 
 is made. 
 
 Treatment after Appendectomy. Treatment after 
 appendectomy does not differ from that after any other 
 abdominal section if the belly is closed save in that a 
 cathartic should not be given until seventy-two hours or 
 more, in order that firm adhesion of serosa to serosa over 
 the site of removal of appendix may have time to form; 
 and even then an occasional leakage occurs. But when 
 drainage is instituted the management is quite different, 
 locally. In applying the binder after the operation, and 
 at all subsequent dressings, great care must be taken that 
 there is no pressure directly over the site of drainage. 
 
 Most of the periappendiceal abscesses are now drained 
 by gauze, so the only thing to be done for the first two days 
 is to change the cotton and outside layers of gauze as 
 often as they become soiled. When fecal fistula is present, 
 this may be rather often, as the smell is quite offensive, 
 particularly in hot weather. The gauze next to the wound 
 may be changed as early as the fourth day and it is safe to 
 remove all of the packing on the fifth day (though a week 
 is better). In removing the packing the last piece put 
 in should, if possible, be the first removed, but often it 
 is impossible to tell which is last, and frequently the whole 
 mass comes away together when the opening is large. 
 Through an inch incision it is best to draw each strand sep- 
 arately and slowly, particularly those portions lying next 
 to the intestines and omentum i. e., nearest the midline. 
 In rare cases as late as the sixth day the adhesions will 
 be so weak that omentum, and still more rarely intestine, 
 will follow the last strip of gauze; in which case the pro- 
 truding mass must be quickly pushed back into the belly 
 and fresh sterile gauze crowded down upon it, and this 
 should then not be disturbed for three or four days.
 
 86 SURGICAL THERAPEUTICS 
 
 Under no circumstances should the cavity left on re- 
 moval of the gauze be washed out with peroxide or other 
 solution, for some small opening into the general peritoneal 
 space may be present through which fatal infection might 
 occur if fluid were poured in. All that is needful is to clean 
 out the pus, feces, etc., by means of pledgets of absorbent 
 cotton on forceps or wooden toothpicks. When satisfac- 
 torily cleaned, without any rubbing or pushing, the cavity 
 is to be lightly packed with gauze and the superficial anti- 
 septic pad applied. 
 
 ARTERIAL DISEASE 
 
 Arteritis. Acute inflammation of an artery is always 
 a local trouble, usually dependent upon trauma and 
 always upon infection; it may originate from a septic 
 embolus, and a thrombus may lead to ulceration, each 
 with formation of pus. 
 
 Socalled chronic arteritis ' (or endarteritis) is probably 
 not an inflammation at all an arterial sclerosis, result- 
 ing in a peculiar condition known as atheroma, or to 
 atheromatous changes in the vessels, particularly of the 
 aged. (See "Atheroma.") 
 
 Occasionally following thrombosis there is great inflam- 
 matory thickening of the endothelium, leading to per- 
 manent obliteration of the artery: arteritis obliterans. 
 
 There is no treatment. 
 
 Wotmds of Arteries. When one of the smaller 
 arteries is cut or torn it must either be ligated, twisted 
 or obliterated by pressure. But if in the course of an 
 operation a very important vessel like the femoral, axil- 
 lary or internal carotid be cut into, unless completely 
 severed, it should be repaired by fine catgut stitches 
 through adventitia, musculosa and intima, all knots being 
 upon the outside. Then when it is seen there is no leak- 
 age, the sheath of the vessel must be sutured carefully
 
 ARTIFICIAL RESPIRATION 87 
 
 over the point of junction and the wound closed with 
 a firm bandage. If asepsis has been perfect, healing may 
 be obtained; if not, secondary hemorrhage is likely to 
 occur and must be met by temporary firm pressure by 
 the nurse and prompt ligation by the surgeon. 
 
 ARTHRITIS 
 
 Arthralgia. Pain in a joint may be due to (i) 
 gout, (2) rheumatism, (3) syphilis, (4) synovitis, or (5) 
 arthritis. The last three belong to surgery. (See 
 "Syphilis," "Synovitis" and "Joints.") 
 
 Arthritis Deformans Improved by X-Ray* Cases 
 of arthritis deformans may sometimes be successfully 
 treated with the x-ray. The exposures are made three 
 times a week, with about one milliampere of primary cur- 
 rent for fifteen minutes. Internal treatment and massage are 
 also to be employed. The method seems to be a valuable 
 one, the rays stimulating the metabolism of the affected 
 joints. This should be taken advantage of and mas- 
 sage and passive movement added to assist in the removal 
 of the exudate. 
 
 Arthropathy* This is a peculiar disease of the joints 
 ("Charcot's joint"), which occurs in the early stages of 
 locomotor ataxia. It speedily destroys the joint, although 
 it is painless and progresses without inflammation. 
 Hydrarthrosis and swelling are the two prominent symp- 
 toms. It is rare and affects only large articulations. It 
 must be differentiated from tuberculosis, which can be 
 cured; this affection can not. In spite of all treatment 
 the joint becomes lax, this condition" being followed by 
 much distortion; eventually some patients have dimin- 
 ished range of motion, while others have excessive motion. 
 
 ARTIFICIAL RESPIRATION 
 Artificial Respiration of the Newly Born. 
 
 Seize the buttocks in the left hand, shoulders and neck
 
 88 SURGICAL THERAPEUTICS 
 
 in the right, with face up; bring head and feet together, 
 compressing the thorax, then bend the child backward 
 to form an arch, thus expanding the thorax; after five 
 or six such movements turn the baby over and spank it 
 sharply, which generally is followed by a gasp; if not, 
 turn into first position and repeat the bending forward 
 and backward. Next, if unsuccessful, the child may be 
 allowed to hang with its head directly downward and 
 given two or three vigorous shakes to dislodge mucus 
 from its throat, then brought up into first position, dashed 
 with a little cold water, and respiratory movements be 
 again instituted. Attempts to cause voluntary respira- 
 tion should not be abandoned for not less than fifteen 
 minutes. As a last resort the lungs may be inflated by 
 blowing forcibly into the babe's mouth. 
 
 Artificial Respiration of Adults. In drowning, the 
 water should first be removed by inverting or shaking or roll- 
 ing the victim on a barrel; then proceeding as in chloroform 
 narcosis. With the patient upon his back, and head low- 
 ered to 45 degrees, if possible, the bare chest is seized in the 
 two hands at the lower ribs, with thumbs meeting below the 
 ensiform. Then firm pressure is made inward and upward 
 to compress the lower part of the thorax to the utmost 
 possible extent; then pressure is gradually relaxed, allow- 
 ing the chest to expand. After two or three seconds this 
 is repeated. Again and again this movement is carried 
 on, with clock-work regularity not hurriedly and excitedly, 
 but cooly, deliberately about twenty times to the minute. 
 Slapping the chest is not to be permitted, as it may paralyze 
 a weak heart just beginning to throb. 
 
 This artificial respiration usually will resuscitate the 
 patient in five to fifteen minutes, but must never be aban- 
 doned until at least an hour of hard work has elapsed. 
 One case is on record in which life was saved by four hours' 
 efforts.
 
 ASCITES 89 
 
 After the patient has begun to breathe he must be 
 watched for some time, and an occasional artificial expira- 
 tion be induced if respirations are shallow or inclined 
 to stop altogether. Generally, as soon as redness returns 
 to the face, it is safe to relax vigilance. But some indi- 
 viduals (notably hysterical women) exhibit an aggravating 
 tendency to "hold the breath", particularly in asphyxia, 
 in morphine narcosis and in excess of chloroform, watching 
 for many hours being required. 
 
 ASCITES 
 
 i 
 
 Abdominal dropsy is most conspicuous in cirrhosis of 
 the liver, in which case it is a clear, yellow, thickish fluid 
 which coagulates on standing. When accompanying kid- 
 ney-lesions it contains urea. If due to carcinoma it is 
 bloody or turbid and contains shreds. In peritoneal tuber- 
 culosis it is like water. When there has been rupture of 
 the chyle-duct it is whitish and contains chyle. From 
 papilloma of the ovary it is like that of cancer. In heart- 
 lesions it is associated with general anasarca or at least 
 swelling of the legs. 
 
 Therapeutic measures directed to the hydrops alone 
 seldom are indicated. The proper treatment invariably 
 is to discover the cause and apply appropriate remedies 
 or institute proper operative measures, such as the Talma- 
 Morrison operation for cirrhosis of the liver, simple abdomi- 
 nal section for tuberculous peritonitis, excision of papil- 
 loma, and so forth. 
 
 When the accumulation is so great as to interfere with 
 respiration the fluid may be let out through a sterilized 
 trocar and canula (taken right out of the boiler and not 
 permitted to touch anything on its way to the already 
 cleaned belly- wall). It should be done under cocaine 
 anesthesia. There is, generally, entirely too little pains 
 taken to secure ideal asepsis in "tapping."
 
 90 
 
 ASPIRATOR: USE OF 
 
 At one time aspiration was greatly employed, it being 
 thought proper to withdraw pus (from the chest, for 
 example) and especially serum from cavities without the 
 introduction of air. Since it has been learned that it is 
 not air but dirt which changes serous contents to pus, 
 and that free drainage is better than closed, the method 
 has fallen into disuse. A small aspirator (or large hypo- 
 dermic syringe) still is used to withdraw small quantities 
 of fluid for diagnostic purposes, but the aspirator as a 
 means of withdrawing pathologic accumulations and in- 
 jecting antiseptic substitutes has fallen into merited 
 disuse. 
 
 ATHEROMA 
 
 This is a fatty degeneration of the walls of the arteries, 
 generally termed " atheromatous degeneration." It is 
 of great importance in surgery, because when present in 
 the aged it is a contraindication to severe operative work. 
 
 Sometimes there is a collection of soft matter external 
 to the intima said to be the result of a localized chronic 
 arteritis, but it is doubtful whether it has any relation to 
 pus; yet it is called "atheromatous abscess." 
 
 When this "abscess" breaks through the intima it 
 constitutes an "atheromatous ulcer." 
 
 When atheromatous changes have occurred the most 
 conspicuous symptom is arcus senilis: a whitening of the 
 outer rim of the iris (but this may be present sometimes 
 without atheroma) but the radial artery, as well as others, 
 may be felt like a whip-cord: hard and distinct instead of 
 soft and compressible. 
 
 In very old patients the arteries may be found crumpled; 
 irregular and hard; the "arteritis deformans" of the older 
 pathologists and indeed its exact pathological character 
 is not yet clearly known. But its surgical significance is
 
 BACK: SPRAINS OF 91 
 
 unmistakable: when persistent it is a sign-board to the 
 surgeon "Keep Out!" 
 
 AUTOSUGGESTION AFTER INJURY 
 
 This is a peculiar mental condition, intimately related 
 to self-hypnosis, which adds much to the suffering of the 
 patient, particularly after railway accidents. "The mental 
 spontaneity, the will or the judgment, is more or less 
 obscured and suggestions become easily accepted. Thus 
 the slightest trauma directed to any member may become 
 the occasion of a paralysis, of a contracture or of an 
 arthralgia." (Gould.) It has also been called "traumatic 
 suggestion," but the term "autosuggestion" is much better, 
 since the deformity, pain, etc., may appear without any 
 trauma, merely as the result of too intense introspection 
 and a morbid desire for sympathy. Tonic treatment, 
 out-of-door life, change of scene, severe work will do much 
 to correct the evil; rarely the application of some orthopedic 
 apparatus is advisable, but as a rule this does more harm 
 than good by concentrating attention upon the presumably 
 diseased member. 
 
 BACK: SPRAINS OF 
 
 On account of the number of its articulations and the 
 strain so often thrown upon it, the back is subject to many 
 sprains. These may vary from a slight twisting to an al- 
 most complete dislocation. As it is impossible to tell by 
 examination the extent of injury to the deep-lying joint- 
 structures every severe injury should be treated as if it 
 were known to be very serious until time demonstrates 
 that it is not. An injury which at first seems to be trivial 
 may prove to be extensive laceration of the spinal ligaments; 
 or even a subluxation of the vertebra?. Sometimes even 
 in dangerous conditions there is no swelling of the external 
 parts. Sprains of the lumbar region may be accompanied
 
 92 SURGICAL THERAPEUTICS 
 
 by hematuria; but this is but transitory and need not occa- 
 sion alarm. The treatment should consist of simple rest 
 in bed until the soreness begins to disappear; then -appli- 
 cation of a stimulating lotion, like the chloroform liniment 
 of the U. S. Pharmacopeia. In case of possible luxation 
 a radiograph may be secured as soon as the patient is able 
 to leave his bed. 
 
 BACTERIA OF SURGERY 
 
 The word bacteria is used here in its comprehensive 
 sense, that is, to include all of the microscopic plants which 
 are disease-producing. Many of these microbes are bacilli. 
 (The bacillus is a fungus not animal or "bug," although 
 possessed of motion belonging to the schizomycetes.) 
 Others are cocci: coccus, or micrococcus a spherical bac- 
 terium, which may appear isolated, united in twos (called 
 diplococcus then), or in large numbers; when in groups, 
 like a bunch of grapes, they are designated staphylococci, 
 when in chains or chaplets, they are termed streptococci. 
 A few belong to the spirilli (spirillum, twisted-rod). 
 
 Those which are of greatest import in surgery are the 
 following: 
 
 Actinomyces boms. Found in actinomycosis and some- 
 times in tuberculous sputum probably a pleomorphic 
 schizophyte. 
 
 Anthrax bacillus. Occurs in the blood of animals and 
 persons infected with anthrax. 
 
 Bacillus aerogenes. A bacterium found in the intes- 
 tine of healthy persons which may, under peculiar circum- 
 stances, get into the cellular tissues and cause great 
 swelling. 
 
 Bacillus coli communis. Occurs in the air, in putre- 
 fying infusions, and constantly in the feces of healthy human 
 beings. An active agent in the production of appendicitis 
 and cholecystitis. Is also called bacillus neapolitanus.
 
 BACTERIA OF SURGERY 93 
 
 Bacillus diphtheria. Known also as the "Klebs- 
 Loffler bacillus." Distinctive of diphtheritic false mem- 
 branes. 
 
 Bacillus cedematis tnaligni. So called by Koch; the 
 vibrion septique of Pasteur. The peculiar microorganism 
 of gangrenous septicemia. 
 
 Bacillus of Lustgarten. A supposititious microorgan- 
 ism of syphilis. 
 
 Bacillus of P/eiffer. The specific microorganism of 
 epidemic influenza ("the grippe"), now known to be a 
 pus-producing germ. 
 
 Bacillus pneumonia. The presumed causative micro- 
 organism of croupous pneumonia; is often called Fried- 
 lander's bacillus. The bacillus is now known to be pus- 
 producing. 
 
 Bacillus prodigiosus. Of interest on account of its use 
 in connection with the streptococcus erysipelatis of Feh- 
 leisen in the Coley treatment of cancer. 
 
 Bacillus (or leptothrix) puerperale. A microbe some- 
 times found in puerperal septicemia claimed by Pasteur 
 to be bacillus anthracis. 
 
 Bacillus pyocyaneus. The distinctive microorganism 
 of blue '(or green) pus; is found in normal sweat some- 
 times. 
 
 Bacillus pyo genes fcetidus. A bacillus obtained from 
 ischiorectal abscess. Of little pathogenic significance. 
 
 Bacillus of Schimmelbusch. Found in the necrotic tissue 
 of no ma, cancrum oris. 
 
 Bacillus septicus sputigenus. Now generally regarded 
 as the cause of pneumonia; found constantly in the healthy 
 mouth; also in the pus of meningitis. 
 
 Bacillus of senile gangrene. The bacillus of Tricomi 
 has not been demonstrated to be the cause of senile gan- 
 grene, but is found in the blood, in the tissues near the 
 line of demarcation, in the subcutaneous tissue and lymph-
 
 94 SURGICAL THERAPEUTICS 
 
 spaces of the skin and in the discharge from gangrenous 
 ulcers. 
 
 Bacillus of smegma. Always present in the smegma of 
 both male and female. 
 
 Bacillus of tetanus. Is also called bacillus of Nicolaier; 
 it is derived from earth and horse-manure. 
 
 Bacillus tuberculosis. The well-proven cause of pul- 
 monary and other forms of tuberculosis; Koch's bacillus. 
 
 Bacillus typhi abdominalis. Is also called bacillus 
 typhosus and Eberth's bacillus; the microorganism of 
 typhoid fever. 
 
 Bacillus vulgaris. Not distinctly proven to be of import 
 in surgery, but is constantly associated with putrefaction. 
 
 Diplococcus albicans tardissimus. A microbe identical 
 morphologically with the gonococcus, but more adherent, 
 forming small masses. 
 
 Diplococcus inter cellular is meningitidis . The coccus 
 found in the exudates of cerebrospinal meningitis; also pus- 
 producing. 
 
 Diplococcus pyo genes urea. Found in purulent urine; 
 as is also diplococcus urea trifoliatus. 
 
 Gonococcus. The cause of "clap;" also called Neisser's 
 micrococcus, or micrococcus gonorrhea. 
 
 Micrococcus cereus albus. Sometimes present in acute 
 abscesses. 
 
 Micrococcus cereus flavus. Found in the lemon-yellow 
 pus of certain abscesses; also termed staphylococcus cereus 
 flavus. 
 
 Micrococcus osteomyelitidis. The germ found in pus 
 of acute osteomyelitis without doubt staphylococcus pyo- 
 genes aureus working under peculiar environment. 
 
 Saccharomyces albicans. The microorganism of thrush 
 and rarely of vaginitis; a synonym is oidium albicans. 
 
 Saprogenic bacteria. Those which produce putrefac- 
 tion; cause of sapremia.
 
 BALANITIS 95 
 
 Saprophytic bacteria. Saprophytes: in biology, chloro- 
 phylless plants which derive their sustenance from decaying 
 organic matter; high fever due to the action of the bacteria 
 of putrefaction (as in blood retained in utero) is now said 
 to be of saprophytic origin or sapremia. Saprogenic is 
 perhaps the better term to describe these germs. Treat- 
 ment will be discussed elsewhere. 
 
 Staphylococcus epidermidis albus. The microorganism 
 of the white pus of stitch-abscesses; a skin coccus, known 
 also as micrococcus pyogenes albus and Staphylococcus 
 Pyogenes albus. 
 
 Staphylococcus pyogenes albus. The peculiar microbe 
 of white pus. 
 
 Staphylococcus pyogenes aureus. Found in yellow 
 "laudable" pus; occurs in boils, wound infections, osteo- 
 myelitis, ulcerative endocarditis, etc. 
 
 Staphylococcus pyogenes citreus. The microbe of lemon- 
 yellow pus; perhaps but a variation of aureus. 
 
 Streptococcus pyogenes. The virulent germ-poison of 
 erysipelas, puerperal sepsis of the worst form, certain types 
 of carbuncle and deep cellular inflammations; also known 
 as micrococcus pyogenes. 
 
 BALANITIS 
 
 Inflammation of the glans penis. It is also sometimes 
 named balanoposthitis because the prepuce is usually in- 
 flamed (posthitis) at the same time. The best treatment is 
 to bathe the part two or three times a day with liquor 
 antisepticus. The menthol compound tablet (A. A. Co.), 
 dissolved in water, makes a good and cheap antiseptic 
 lotion. If there be much secretion, borated talcum may 
 be used, or pure boric acid. If decomposition of smegma 
 be the source of irritation and phimosis prevents the needed 
 oft-cleaning, circumcision must be done and antiseptics
 
 96 SURGICAL THERAPEUTICS 
 
 used until healing is perfect. To harden the glans dilute 
 bay rum or other alcoholic application may be used. 
 
 BEDSORES 
 
 A bedsore is a localized necrosis of skin and subcu- 
 taneous cellular tissue, due to an anemia, dependent upon 
 long-continued pressure and low vitality. The three chief 
 preventive measures are (i) cleanliness, (2) frequent change 
 of position, even though slight, and (3) keeping the draw- 
 sheet free from wrinkles. Two teaspoonfuls of salt to a 
 pint of whisky makes an excellent wash to use at places 
 already reddening. A very good combination, used in 
 many hospitals, consists of one ounce of powdered alum, 
 the whites of four eggs and two ounces of spirit of camphor. 
 This is to be used only for prevention of the sores. After 
 the skin is broken and stinking begins, most careful atten- 
 tion is necessary to prevent extensive sloughing. The 
 sore must, first of all, be protected. A rubber ring, air- 
 inflated, may be so placed that no weight comes upon the 
 tissues near the sore; or pillows must be placed above 
 and below to completely remove pressure. The sore must 
 be covered by antiseptic gauze; best dipped in a solution 
 made by triturating equal parts of camphor and phenol, 
 with oiled silk and bandage over it, if it can be applied. 
 When sinuses form they must be widely opened and treated 
 with the camphophenolized gauze. As the patient con- 
 valesces the surface of the ulcers may be cauterized with 
 nitrate of silver if they are sluggish in healing. Probably 
 iodoform is the best thing to promote granulation in such 
 cases. 
 
 Prevention. When a patient is to be in bed for a 
 long time, as in fracture of the thigh, great care must be 
 exercised that bedsores do not form. In the first place, 
 linen draw-sheets must be made, sufficiently large that they 
 may be firmly fastened to the sides of the bed so as to pre-
 
 BICHLORIDE SOLUTIONS: STRENGTH OF 97 
 
 vent creases or wrinkles forming under the body these 
 and dribbling urine being the most frequent causes. When- 
 ever the sheets become soiled by urine, feces or discharge 
 from a wound, they must be changed. As soon as the 
 slightest redness of skin is observed the affected surface 
 must be rubbed with alcohol (65 -percent) and dried and 
 then carefully anointed with glycerin; twice daily at least. 
 Or equal parts of tincture of catechu and liquor plumbi 
 may be substituted for the glycerin if that causes much 
 smarting, as it sometimes does. 
 
 BEE-STINGS 
 
 For the poisoning from bee-stings, bites of insects, etc., 
 aqua ammonia may be employed, applying it on a little 
 absorbent cotton over the congested area. It may be 
 renewed in a few moments when evaporation of the first 
 application has occurred. 
 
 BICHLORIDE SOLUTIONS: STRENGTH OF 
 
 Many doctors, and most hospitals, make solutions of 
 bichloride of mercury entirely too strong to be of great 
 value. For purposes of assisting in sterilization of hands 
 and field of operation i in 2000 is decidedly to be pre- 
 ferred. It is sufficiently germicidal for all practical pur- 
 poses; anything stronger like the commonly used i in 
 1000 strength so affects the skin that the deeper micro- 
 organisms escape; and after a few minutes' hard work they 
 are brought to the surface by imperceptible sweating. 
 Most surgeons, too, merely wash the hands in the subli- 
 mate solution instead of permitting them to soak for two 
 minutes, by the clock. During severe operations the 
 hands should be often immersed in the sublimate solution, 
 and rinsed in salt solution before returning to the wound, 
 particularly in abdominal work. For practical purposes 
 the solution should be prepared at time of operation.
 
 98 SURGICAL THERAPEUTICS 
 
 BLACK EYE 
 
 Ecchymosis, following a blow about the eye or temple, 
 is sometimes very annoying. Circumstances are often 
 such that it is necessary to absorb the blood quickly and 
 to disguise the extravasation while undergoing the heal- 
 ing process. Temporary discolorations of the skin may be 
 disguised by the application of grease, paint, or collodion 
 colored by means of a little carmine. As a lotion the fol- 
 lowing is recommended: Ammonium chloride, 10; alcohol, 
 10; water, 100. Dilute acetic acid may be substituted for 
 half the water and the alcohol may be replaced with 
 advantage by tincture of arnica in some cases. Another 
 good lotion is: Potassium nitrate, 2; ammonium chloride, 
 4; aromatic vinegar, 32; water, 480. 
 
 BLACK-VOMIT 
 
 This occurs in any acute sepsis, like that following 
 serious infection of the peritoneum, that which is such 
 an alarming feature of yellow-fever, etc. Very rarely 
 it may be arrested (if the bowels can be started moving) 
 by the exhibition of from 20 to 30 drops of the fluid extract 
 of adrue (the root of cyperus articulatus: antiemetic 
 root; not official). 
 
 BLADDER 
 
 Atony, In this trouble there is inability to expel 
 the urine, from deficient muscular power. Small doses 
 of cantharidin and strychnine may be given in the hope 
 of increasing tone, but in many cases a "catheter life" is 
 inevitable. Some cases have been greatly benefited by 
 suprapubic cystostomy made with the sole object of 
 allowing the bladder- walls to contract and have perfect 
 rest for a period of from four to six weeks, when the open- 
 ing is allowed to close by granulation.
 
 BLADDER 99 
 
 Catarrh of the Bladder. Following an acute 
 inflammation of the bladder there may be left a catar- 
 rhal condition of the mucosa, formerly called "chronic 
 inflammation." (See "Cystitis.") 
 
 Exstrophy. Rarely there is met a congenital atesence 
 of the anterior wall of the bladder with more or less 
 deficiency in the corresponding part of the abdomen. 
 Repeated plastic operations constitute the only treatment. 
 
 Hernia of Bladder. In operating for hernia, and 
 especially the direct form, the surgeon must be sure to 
 remember that the bladder may be in the sac; and if 
 adherent (as is often the case) may be opened instead of 
 the peritoneum. If the amount of bladder implicated is 
 small, or if it is a postoperative cystocele, it will be found 
 growing thicker upward, enveloped in fat, and this thicker 
 extension will be discovered to be the bladder, if the opera- 
 tor is fortunate. When the prevesical fat is detached 
 the bladder appears. In case of doubt the bladder can 
 be filled with fluid and the effect watched on the sus- 
 pected cystocele. In presence of a diverticulum or a stone 
 in the hernia, the bladder must be opened and resected; 
 otherwise the bladder is to be reduced unopened. Unfortu- 
 nately, however, it is discovered most often only after it 
 has been opened in which event the bladder-wall must 
 be sutured, a permanent catheter inserted and the her- 
 niotomy wound drained. 
 
 Inflammation of the Bladder^Ah irritable deep 
 urethra or ulcer at the neck of the bladder closely simu- 
 lates inflammation of the bladder; comparatively rare is a 
 true cystitis (which see). 
 
 Inversion. Cases of prolapse of the bladder through 
 the urethra have been reported. The rational treatment 
 is cystopexy. 
 
 Irritable Bladder. A constant desire to urinate 
 is quite frequently met with, especially in women well
 
 100 SURGICAL THERAPEUTICS 
 
 advanced in years. It is often very hard to relieve. The 
 use of arbutin, long-continued, is generally effective. 
 
 Nervous Bladder. Closely allied to "irritable blad- 
 der" is "nervous bladder," a condition found in nervous 
 persons who have a desire to pass urine at brief inter- 
 vals, sometimes almost constantly; yet on attempting to 
 do so they are unable to perform the act perfectly, so 
 there is dribbling at the close and a burning sensation 
 which might lead the uninitiated doctor to suspect the 
 presence of stone. In women a prolapse of the bladder 
 is often the cause of this suffering. (See "Cystocele.") In 
 most cases the administration of elixir of the bromide 
 of potassium (a teaspoonful two or three times a day) 
 or of eight centigrams (one grain) of arbutin every three 
 or four hours will afford temporary relief. The per- 
 sistent use of lithium benzoate in doses of one decigram 
 (i 1-2 grains) four times a day will sometimes lead to 
 very gratifying results. Hyoscyamine is quickly effective. 
 Paralysis. The symptoms are much like atony 
 only worse; if the paralysis is limited to the neck of the 
 bladder alone there is incontinence of urine, for which 
 practically nothing can be done; if it involve the bladder- 
 wall there will be retention and the catheter must be 
 used every six hours. In some cases cystostomy is advis- 
 able to secure perfect relief from retention wilh its con- 
 stant danger of cystitis and pyelitis. 
 
 Prolapse of Bladder. Among women a frequent 
 source of complaint is "irritation of the bladder" cystitis, 
 they are told by their doctors who proceed to dope them 
 with triticum, hyoscyamus, salol, or various "proprietary 
 remedies." What is needed in many cases is simply 
 removal of urethral caruncle, prolapse of urethra, or, 
 generally, cystocele. It is so easy and so sure to make 
 anterior colporrhaphy and then a close perineorrhaphy 
 that it is astonishing why doctors do not more frequently
 
 BLADDER 101 
 
 try it. The relief afforded, even if there is no financial 
 benefit, is sufficient reward for the extra trouble. 
 
 Speculated Bladder. Very rarely pouches form 
 between hypertrophied muscular fibers. Cystostomy is 
 sometimes warranted. 
 
 Stone in the Bladder. Small stones may be cured by 
 lithotripsy (crushing) and irrigation. Large stones must 
 be removed by operation. Suprapubic cystotomy is prefer- 
 able. 
 
 Treatment after Bladder Operations. Since post- 
 operative anuria is the most frequent complication it 
 is well to give a liter (one quart) of normal salt solution by 
 hypodermoclysis immediately after the patient is returned 
 to bed; and especially so if there be much shock. 
 
 As soon as possible, too, as much water as the patient 
 can drink should be given. 
 
 When suprapubic cystotomy has been done the urine is 
 usually carried away by a long rubber tube, but there 
 is much leakage around the opening, so it is necessary to 
 change the gauze two or three times a day; and if there be 
 much irritation of the bladder (or cystitis) it is best to also 
 wash out the bladder at the same time, using a saturated 
 solution of boric acid. 
 
 The irritation of skin is not as serious as in perinea! 
 cystotomy but sometimes requires careful attention. 
 
 When the bladder has been sutured and the abdominal 
 incision closed the wound requires no attention until the 
 time to remove the sutures (ninth or tenth day) provided 
 the gauze does not become soiled with urine. But as it is 
 necessary to use the catheter every four hours for a week, 
 in such cases, the dressings usually become sufficiently 
 infected to demand several changes; the layers next to the 
 incision being untouched whenever possible. 
 
 With all the drainage-cases a rubber-sheet must be 
 spread upon the bed and soft pads laid over it to catch the
 
 102 SURGICAL THERAPEUTICS 
 
 urine, these being changed as often as possible. For if 
 the patient's skin is not protected from the irritating effect 
 of constant immersion in urine, bed-sores of the most 
 aggravated type may form. To assist in preventing this 
 calamity the back, hips and thighs ought to be bathed in 
 dilute alcohol once every day; and may be smeared with 
 vaseline after each alcohol bath. As soon as the strength 
 will permit, the patient must be compelled to sit up in a 
 chair daily, upon a rubber ring, for as many hours as pos- 
 sible. 
 
 In perineal drainage there is likely to be a considerable 
 destruction of tissue by necrosis the urine getting into the 
 muscular and fascial layers in spite of anything that can 
 be done. These sloughs must be cut away from time to 
 time, but not too soon; often it is best to wait several days 
 before pulling them out. After granulation is well estab- 
 lished there will be no further trouble, but with old people 
 the process of granulation is not progressing satisfactorily 
 even after two or three weeks, sometimes, and the con- 
 tinuation of necrosis becomes a serious menace. Here 
 the free application of iodoform may be tried, or balsam of 
 Peru smeared into the depths of the wound. 
 
 It requires from two to four weeks for the bladder to 
 close and occasionally there is some leakage for many 
 weeks. 
 
 Tuberculosis of the Bladder-Wall. Tuberculosis of 
 the bladder-wall is comparatively rare, and is usually 
 associated with tuberculosis elsewhere. When the only 
 or the most conspicuous lesion, it may be treated by 
 suprapubic cystostomy, cureting and packing, followed 
 by injection of iodoform emulsion. The usual internal 
 'treatment of tuberculosis must be energetically pushed. 
 
 Tumors* Growths in the bladder may be (i) papil- 
 loma, (2) carcinoma, (3) myoma, (4) fibroma, (5) sar- 
 coma, (6) gumma, (7) cysts. Nearly all are character-
 
 BLADDER 103 
 
 ized by hematuria. Diagnosis is made by cystoscopy. 
 Removal by earliest possible cystotomy is the only treat- 
 ment, save for gummatous tumor, in which potassium 
 iodide may be given, also mercury. 
 
 Ulcer of Bladder. Ulcers of the bladder generally 
 are found close to the urethral orifice. They may be 
 simple (chronic and solitary); acute (perforating); chronic 
 tubercular; syphilitic; cancerous. The three prominent 
 symptoms are increased frequency of micturition, pain 
 in the penile portion of the urethra and hemorrhage. 
 There are also three stages usually. In the first there 
 is usually some disturbance of micturition; the act is 
 more frequent and passage of water is attended by a 
 burning sensation, particularly marked toward the end, 
 with more or less discomfort felt in the penis. The urine 
 does not show any very marked change, but close exami- 
 nation will show some pus, necrotic debris and exfoliated 
 epithelium. In the second a cystitis begins and there 
 is an exaggeration of all the symptoms. The urine is 
 more purulent and contains more epithelium and debris; 
 the blood, too, is in larger amount. In the third, dis- 
 tension of the bladder occurs, owing to lack of expulsive 
 power; if not relieved by cystostomy the patient dies 
 of ascending infection. Acute perforating ulcer can 
 rarely be diagnosticated antemortem, save by a skilful 
 cystoscopist. r 
 
 Treatment. Irrigations with silver nitrate, from i in 
 10,000 up to i in 5000 every second day, will usually 
 effect a cure in the first stage. If this does not succeed 
 the ulcer may be cauterized through a cystoscope, or a 
 suprapubic cystotomy made and the ulcer cureted and 
 cauterized with the Paquelin. In the second stage curet- 
 ing and cauterization with a prolonged drainage through 
 . a suprapubic opening are necessary to effect a cure. In 
 the third stage, drainage, irrigation and gradual disten-
 
 104 SURGICAL THERAPEUTICS 
 
 sion of the bladder are all that can be done, preferably 
 through a suprapubic opening. 
 
 Wounds of the Bladder* A direct blow may cause 
 rupture of a full bladder; a spicule of bone from a frac- 
 tured pelvis may penetrate it; a stab-wound of the lower 
 abdomen may enter it; and a metal catheter in rough 
 hands may perforate it. If the peritoneum has been 
 opened at the same time an immediate abdominal section 
 is indicated to close the hole in the bladder by suture and 
 to clean out and wall off the abdominal cavity. But 
 when the peritoneum is not involved it is best merely to 
 clean up the wound, irrigate the bladder thoroughly through 
 a catheter in the urethra and insert a drainage-tube or 
 wick into the bladder through the external wound. In 
 hidden wounds like that from catheter and bone-fragments, 
 suprapubic cystostomy and free drainage must be made 
 without delay; extensive extravasation of urine means death. 
 
 BLEPHARITIS 
 
 Blepharadenitis. Inflammation of the Meibomian 
 glands (commonly called "stye") is best treated by early 
 incision and evacuation of the pus and use of warm anti- 
 septic solutions or compresses, a saturated solution of 
 boric acid being most useful. Styes signify eyestrain. 
 A little mercurial ointment promptly aborts them. 
 
 Blepharanthracosis. This is a carbuncular inflam- 
 mation of the eyelid. Treatment is the same as for car- 
 buncle (which see). 
 
 Blepharoedema. Swelling or edema of the eyelids 
 may be treated by compresses wrung from some astringent 
 solution. Bad cases may require numerous small 
 punctures, followed by antiseptic solutions. 
 
 Blepharoadenoma* A small adenoma growing on 
 the ciliary margin of the eyelid. Excision as early as 
 possible is the only treatment.
 
 BLOOD: TRANSFUSION OF 105 
 
 BLISTERS 
 
 Usually it is best to cut into the blisters and let out 
 the serum. Then apply some soothing antiseptic dress- 
 ing which will exclude the air. A most excellent way is 
 to saturate gauze in camphophenol (equal parts of cam- 
 phor and phenol rubbed together in a mortar just boiled 
 or baked for 20 minutes; the remedy should be kept in a 
 clean bottle), and cover the blister and surrounding sur- 
 face with several thicknesses, placing rubber-tissue or oiled 
 silk over this and a mass of absorbent cotton over all, 
 holding the dressing in place by a bandage or adhesive 
 strips. This dressing need not be disturbed for three 
 to five days. 
 
 BLOOD: TRANSFUSION OF 
 
 This operation is again coming into vogue, and under 
 the aseptic technic lives are being saved by it. When a 
 patient has bled to unconsciousness, is pulseless and 
 cold, there may be hope of restoring life if the source of 
 hemorrhage has been corrected. The radial artery of 
 the donator is bared and opened and a small glass or 
 aluminum tube, sterilized, introduced into it and held 
 by a catgut ligature around its end; a little blood being 
 allowed to flow (to determine that the current has been 
 established) the end of the tube is closed and all wrapped 
 in a very hot, moist towel. The basilic vein of the donee 
 is next exposed and opened as for venesection, the distal 
 end tied but the proximal left open. The end of the vein 
 being lifted out sufficiently, blood is permitted to flow 
 from the tube long enough to be sure all air is expelled, 
 and then (with blood still running) the end of the tube 
 is slipped into the vein and tied around with gut. Blood 
 is permitted to flow for about thirty minutes when the 
 vein and artery are each closed by ligation. The dona-
 
 106 SURGICAL THERAPEUTICS 
 
 tor's blood will drop from, the normal 5 1-2 or 6 millions 
 to near 4,500,000 in that time (hemoglobin from 100 to 
 about 70), while the donee's will rise correspondingly; 
 but the former will be restored to normal in four or five 
 days, only one day's detention from business being 
 required. 
 
 BOCKHART'S -BLOOD-SERUM MERCURY" 
 
 Another method of preparing mercury so it may be 
 injected beneath the skin is that of Bockhart: 
 
 Dissolve 3 grams (45 grains) of bichloride of mercury 
 in 32 grams (i ounce) of boiling water; dissolve 7 grams 
 (105 grains) of chloride of sodium in 20 grams (5 drams) 
 of water; mix the mercuric solution with 42 grams (10 
 1-2 drams) of blood-serum sterilized by Koch's method 
 and dissolve the precipitate by adding the salt solution. 
 This makes a three-percent blood-serum mercury. Add 
 distilled water enough to make 212 cubic centimeters 
 (6 ounces and 5 drams), i. e., double the amount of fluid, 
 so as to reduce to a i. 5-percent solution, which is practi- 
 cally unirritating. Of this 15 drops may be injected 
 once daily, equal to gr. 1-4. 
 
 BOILS 
 
 Aborting Boils. It is possible to prevent suppura- 
 tion in a small proportion of forming boils. As soon as 
 the local inflammation is noted the following is to be 
 applied: 
 
 Fluid extract of ergot 2.0 (dr. 1-2) 
 
 Oxide of zinc 8.0 (dis. 2 ) 
 
 Phenol 0.5 (grs. 8 ) 
 
 Lanolin 65.0 (ozs. 2 ) 
 
 This is to be spread on gauze or absorbent cotton to 
 the size of a silver dollar, applied over the boil, and held 
 by adhesive plaster. It should be replaced by belladonna
 
 BOILS 107 
 
 ointment in twelve hours, but may be repeated next day 
 if the boil is still red and painful. 
 
 Boils Compared with Carbuncles. The first is a 
 staphylococcus, the second a streptococcus infection, 
 small boils sometimes may be aborted in their incipiency 
 by introducing, with a hypodermic needle or sharp probe, 
 a drop of pure carbolic acid; but this will only aggravate a 
 beginning carbuncle. When a definite pus cavity has formed, 
 simple incision, if good gaping of the wound-edges is se- 
 cured, is quite sufficient for most small boils and a few 
 larger ones. With the larger kind free incision is needful, 
 and if a small gauze drain is inserted there will be a free 
 exit for the discharge; and in a week, more or less, good 
 granulations form and healing is uninterrupted. Accord- 
 ing to Rand the tendency to reinoculation of adjacent hair 
 follicles can be prevented and the comfort of the patient 
 promoted by washing the skin with alcohol and applying 
 hot antiseptic compresses of boric acid or weak bichloride 
 solutions. Large boils can be emptied more completely, 
 and better drainage is secured, if a small oval piece of 
 skin is excised. 
 
 The best treatment for carbuncles is to thoroughly 
 excise all of the inflamed tissue, burn with pure carbolic 
 acid, neutralize with pure alcohol and then pack with 
 gauze, this being done under anesthesia. Unfortunately, 
 many patients will not submit to such heroic treatment 
 until the disease is far advanced; but if the carbuncle is 
 small, excision under cocaine and ethyl-chloride anesthesia, 
 combined, may be possible. Usually, however, all the 
 patient will permit is incision of the central part of the 
 mass of infiltrated tissue, with multiple incisions in the 
 large carbuncles. Then the application of hot antiseptic 
 compresses will soften the tissues and encourage the sepa- 
 ration of sloughs. With the aged vigorous supportive 
 treatment is imperative.
 
 108 SURGICAL THERAPEUTICS 
 
 Prevention of Boils. Whenever the patient is 
 seen early enough, it is always proper to attempt to abort 
 a boil, since such treatment does not aggravate the con- 
 dition if the effort fails, and much suffering is avoided 
 if the attempt proves successful. The boil should be 
 well covered with a tampon of cotton which is kept 
 saturated with the following solution: 
 
 Chloral 10.0 (2 1-2 drs.) 
 
 Glycerin 20.0 (5 drs.) 
 
 Water 20.0 (5 drs.) 
 
 Certain observers, working along the theory of the des- 
 truction of the staphylococcus, bathe small boils frequently 
 with a lotion of salicylic acid in alcohol, 2-percent; or 
 a 5o-percent plaster of the same, changed four or five 
 times a day to hasten the necrosis in large boils. In 
 furunculosis involving an area of considerable size, a 
 2 1-2 percent ointment of salicylic acid in vaselin may be 
 applied once a day, after gentle washing with soap and 
 warm water. Either ordinary lime water on compresses 
 covered with oiled paper or silk, or a solution of calcium 
 chloride applied in the same manner, will promote sup- 
 puration more quickly than the ordinary poultice. A 
 25-percent solution of ichthyol, applied every two hours, 
 will diminish the area involved in inflammation, and 
 consequently lessen the pain and shorten the duration; 
 while certain experimenters also assert abortive power 
 for the same application. A saturated solution of com- 
 mon baking soda applied on a compress will relieve the 
 pain of a boil at any stage. If applied in the very incip- 
 iency, 20 grains of silver nitrate in an ounce of spirit of ni- 
 trous ether, painted frequently over the inflamed surface,, 
 will abort many forming boils. Calcium sulphide should 
 always be given internally and pushed till all the secretions 
 smell of hydrogen sulphide,
 
 BOILS 109 
 
 Boils may sometimes be aborted by first energetically 
 rubbing the furuncle with the tincture of green soap; 
 then washing it with alcohol (40- to 5o-percent); then apply- 
 ing a thin compress of absorbent cotton moistened with 
 alcohol, which is kept in place until the alcohol has all 
 evaporated, then making another application of the green 
 soap, but allowing the lather to dry on the spot, which 
 is then left uncovered. Sometimes it is necessary to 
 repeat this maneuver after several hours. In order to 
 be successful the treatment should be applied early. As 
 soon as it is apparent that suppuration is inevitable, free 
 incision is to be made and the surrounding hair-follicles 
 protected from infection by careful attention to post- 
 operative cleanliness. 
 
 Treatment of Boils. While a single boil is but a lo- 
 cal abscess around the root of a hair, by infection of other 
 follicles many other boils may arise. This is more probable 
 when there is a general impoverishment of the system 
 and want of proper elimination. Certain trades, too, 
 predispose to boils, as workers in oil or paraffin, and coal- 
 shovelers. The proper treatment, then, is net only early 
 incision and proper drainage of every suppurative point, 
 but extreme cleanliness of the skin around the abscess, 
 changing of dressings often enough to prevent the pus 
 running over healthy skin. Internally a teaspoonful of 
 effervescent magnesium sulphate four times a day does 
 good, as also do tonics like iron, arsenic and strychnine, 
 as in the "triple arsenates". Calcium sulphide, given 
 to saturation, is highly recommended and really 
 very valuable, and nuclein is useful. To hasten sup- 
 puration (when it seems inevitable) poultices are cf 
 undoubted value; and a little extract of opium may be 
 added to allay pain. But after the boil has been widely 
 opened the poultices should not be continued a simple 
 antiseptic gauze dressing being all that is required. Fre-
 
 110 SURGICAL THERAPEUTICS 
 
 quent dressings should be made to prevent the pus con- 
 taminating contiguous surfaces. Patients suffering from 
 little boils should be instructed not to scratch or rub the 
 skin near the boil, otherwise pus will be gotten under the 
 finger-nails and other boils produced by transference of 
 poison; hence at night the affected part should be covered 
 to prevent scratching during sleep. 
 
 BONE: DISEASES OF 
 
 The principal affections of bones are: (i) Inflamma- 
 tion of bone (see "Osteitis"); (2) inflammation of medulla 
 (see "Osteomyelitis"); (3) inflammation of bony covering 
 (see "Periostitis"); (4) necrosis of bone (see "Caries"); (5) 
 osteomalacia (which see); (6) rachitis (see "Rickets"); (7) 
 syphilis; (8) tuberculosis; (9) tumors. 
 
 Bones may also become atrophied (in old age and in 
 certain injuries) as well as hypertrophied, but there is no 
 treatment for either. Syphilis will be mentioned under 
 "Caries", and tuberculosis will be discussed under Diseases 
 of the Joints. Tumors found in bone are usually (a) en- 
 chondromata, (b) exostoses, (c) myeloid, (d) sarcomata, 
 (e) carcinomata, and (f) cysts. All should be removed 
 as soon as found. 
 
 BOW-LEGS 
 
 If the deformity be due to mere curvature of the bones 
 it may readily be corrected by simply bandaging tightly 
 to a straight splint on the inner aspect of the leg, tightening 
 the bandage from time to time during the first two years 
 of life. But usually the defect is in the knee-joint; when 
 an appropriate apparatus must be made and fitted to the 
 legs as the child begins to walk, the straps being tightened 
 once in two weeks and the length of the brace increased 
 as the child grows. Cases seen after the bones have 
 hardened (beyond the 5th to 8th year) can be benefited 
 only by operative treatment.
 
 BREAST: DISEASES OF 111 
 
 BREAST: DISEASES OF 
 
 Breasts: Inflammation of. Mastitis may yield to 
 the local use of oleate of mercury if it be properly applied 
 before suppuration arises. To the oleatum hydrargyri add 
 a little morphine (the basic alkaloid morphina not the 
 sulphate, hydrochloride, etc., which are not soluble in oleic 
 acid); a little of the mixture is to be lightly rubbed over 
 the affected area. The rubbing must be very gentle or 
 severe irritation of the skin will follow; indeed, with a very 
 delicate, tender skin it may be better to apply the ointment 
 with a brush. Twice a day is as often as most skins will 
 stand. 
 
 Imperfect Operations for Cancer. In removing 
 carcinoma of the breast there are two chief reasons for re- 
 turn of the disease: (i) Want of care in dissecting out all 
 the fat and glands of the axilla, and (2) leaving too much of 
 the skin over the affected area. Of the first it may be said 
 that a large majority of operators spend too little time in 
 removing the axillary contents it requires from a half- 
 hour to an hour to get all the tissues out which may pos- 
 sibly be implicated by the cancerous process. Not only 
 the fat and glands of the axilla should be excised the 
 chain of lymphatics running down beside the long thoracic 
 vessels, those running down behind the scapula and those 
 extending up beneath the clavicle should be removed; 
 indeed, some surgeons now advocate removal of the cervical 
 glands, but this is scarcely needful, unless they can be felt 
 beneath the skin and muscle; and then it is doubtful if any 
 operation at all is justifiable. Of the second it may be said: 
 It is well to cut wide of the affected area, running the risk 
 of having to make a Thiersch graft rather than to leave 
 skin which may be the site of incision-recurrence which 
 is, I regret to say, a very frequent thing in the work of in- 
 experienced operators.
 
 112 SURGICAL THERAPEUTICS 
 
 BRIGHT'S DISEASE: OPERATION FOR 
 
 Extensive experimental work in decapsulation of the 
 kidney has proven that: (i) Chronic nephritis should not 
 be operated on until medical treatment has proven of 
 no avail. (2) The time for operation is when it is noticed 
 that the process is advancing rapidly and it is feared that 
 the heart will soon become overtaxed. (3) The operation 
 for chronic Bright's disease which has proven least danger- 
 ous, and which has shown the best results, is nephropexy, 
 performed on a single kidney. (4) The most unfavorable 
 cases for operation are those of diffuse nephritis. (5) 
 Cases of general anasarca with bad heart-action should 
 not be operated on; if the heart -action is good, an operation 
 performed as a dernier ressort may give the patients a few 
 extra months of life, provided they survive it. (6) Where 
 there has been a marked destructive process in the kid- 
 neys, as a result of nephritis, the operation may relieve 
 for a number of weeks or months, but patients generally 
 fail again and die when the new capsule begins to contract. 
 
 The operation, since it is as yet purely experimental, 
 should be done by none but a surgeon of great repute, 
 since a fatal termination in the hands of a surgeon with 
 only a local reputation might unnecessarily entail great 
 loss of prestige. 
 
 BUBO 
 
 Bubonocele. This is an inguinal hernia in which 
 the gut or omentum does not extend beyond the inguinal 
 canal. The treatment is the same as any other inguinal 
 hernia (which see). * To the inexperienced surgeon it is of 
 chief interest on account of the liability to mistake it for a 
 bubo, particularly when clap or chancroid is found. 
 
 Phenol for Buboes When buboes are seen very 
 early, before any great amount of redness of skin is present, 
 the skin may be frozen with chloride of ethyl and ten drops
 
 BUBO 113 
 
 of a solution of phenol injected into the middle of each en- 
 larged gland; the solution being of this strength: 
 
 Phenol 0.5 (grs. 8) 
 
 Distilled water 32.0 (oz. i) 
 
 The skin should be carefully scrubbed and washed with 
 ether or alcohol before the needle is introduced, and the 
 needle itself should lie in alcohol five minutes before 
 using and then be passed through an alcohol flame on its 
 way to the gland; and the fingers should then not touch 
 the needle until the injection is made, otherwise a staphylo- 
 coccus infection may result with extensive suppuration. 
 
 Treatment of Buboes. If there be much inflamma- 
 tion, as evidenced by pain, tenderness and especially red- 
 ness, the swelling and suppuration can be prevented in 
 some cases by putting the patient in bed and applying an 
 ice-bag to the affected surface. If the patient cannot stay 
 in bed the bubo may be painted with several layers of 
 collodion and a compress applied tightly by means of a 
 spica bandage. As soon as fluctuation is detected, cocaine 
 should be injected, the abscess opened freely and all the 
 infected gland removed by cureting. The wound is then 
 packed with gauze, which is removed in twenty-four hours 
 and the pocket filled with some dusting powder, preferably 
 equal parts of calomel and subiodide of bismuth, and an 
 antiseptic gauze dressing applied. The less frequently the 
 dressings are changed, compatible with cleanliness, the 
 sooner will the wound heal, i. e., after granulations have 
 begun to form. Calcium sulphide may be given internally. 
 
 Treatment of Sympathetic Bubo. The name of 
 sympathetic bubo is applied to a bubo resulting from 
 irritation, friction or injury and not from venereal disease. 
 It is to be treated as any other lymphadenitis -(which see). 
 
 Welander's Treatment. This is removal of pus (if 
 present) by aspiration, irrigation with i in 1000 bichloride 
 solution, and injection of benzoate of mercury solution,
 
 114 SURGICAL THERAPEUTICS 
 
 with closure by collodion. It is best employed before sup- 
 puration begins, the mercuric benzoate being injected with- 
 out aspiration and irrigation. 
 
 BURNS 
 
 Phenol for Barns* If phenol (carbolic acid) is to 
 be used for burns and it is one of the most satisfactory 
 of all applications it must be in full strength. It causes 
 pain for an instant, followed immediately by a soothing 
 sensation of coolness, because if put on in 9 5 -percent solu- 
 tion (phenol liquefactum) it coagulates the albumin on the 
 surface of the burn, excluding the air temporarily and at 
 the same time acting as an analgesic to the injured nerve- 
 filaments. Before applying it all blisters should be pricked 
 and tags of burned tissue cut away. Gauze saturated in 
 carbolized oil (sterilized) should be put on the burn, many 
 .thicknesses, with cotton and loose bandage over all. Mor- 
 phine and strychnine ought to be given at once hypo- 
 dermically. 
 
 An ointment of one part boric acid to eight of vaseline 
 is excellent to saturate gauze in, to apply next to the burn 
 after removal of the first dressing. Or one may employ 
 the camphophenol liquid made of equal parts of camphor 
 and pure phenol. 
 
 In making the dressings, if the burned area is large, 
 only a small part should be uncovered at one time to 
 prevent chilling. The dressings should not be changed 
 oftener than two or three days unless the discharge is so 
 great as to compel it, or the odor is very annoying. 
 
 When granulations are progressing well healing may 
 often be accelerated by skin-grafting, when the burn is 
 extensive. 
 
 Severe Burns. Shock is sometimes profound in severe 
 burns, amounting to total collapse in some instances. As 
 this is dependent in great part on the intensity of pain a
 
 BURSITIS 115 
 
 good plan is to give at once as large a dose of morphine 
 as the patient will stand (children cannot tolerate much 
 morphine), usually to an adult 1-2 grain hypodermically 
 with 1-30 grain of strychnine; or better still, a tablet of the 
 hyoscine-morphine-cactin anesthetic, and a second one in 
 two hours if needed. Blankets should be wrapped around 
 the body, and the patient speedily removed to a hospital 
 or his home, where artificial heat may be applied if the 
 shock continues. Here the popular remedy, a "good 
 drink of whisky," is indicated, and it may be repeated in 
 a half hour if collapse continues. Digitalin may also be 
 injected a half hour after the morphine, with glonoin fol- 
 lowed by atropine or hyoscyamine if there is shock, 
 shown by pallor and coldness of the skin. Indeed glonoin, 
 atropine and strychnine are generally indicated in shock. 
 A most popular application, used in nearly all great 
 iron-foundries, is "carron oil" of this composition: 
 
 Lime water 1 25 .o 
 
 Linseed oil -i 2 S-o 
 
 Phenol 10.0 
 
 Gauze is saturated with this and applied to the burned 
 surfaces; and changed every twelve hours. In small burns 
 a saturated solution of carbonate of sodium (common 
 washing soda) checks the pain. The best application is 
 5-percent aqueous solution of picric acid, clothes or gauze 
 being wrung out of it and applied to all the affected sur- 
 faces; but it stains everything a bright yellow which will 
 not come off. Rubber gloves must therefore be used in 
 handling it. 
 
 BURSITIS 
 
 Inflammation of the bursa is not common. When it 
 does occur it may be of tuberculous variety '(a, socalled 
 "inflammation") or it may be due ^> infection with some
 
 116 SURGICAL THERAPEUTICS 
 
 of the more active pyogenic organisms (staphylococci and 
 streptococci). 
 
 Acute, suppurative bursitis is usually caused by a severe 
 bruise or a penetrating wound, and if not properly treated 
 will extend in a most remarkable manner, involving con- 
 tiguous tendons, ligaments, joints and even bones. Some- 
 times by reason of injury to blood-vessels there is an accu- 
 mulation of blood in the bursa or a mere distension with 
 serum, the membrane itself being thickened but not pus- 
 infected. In case of doubt it is therefore best to aspirate 
 before making free incision; if it be serum or blood, removal 
 through an aspirator followed by long-continued immobil- 
 ization will effect a cure; but if the fluid be pus free, incision 
 and drainage is the only rational treatment, "the earlier 
 the better for the integrity of the neighboring joint. 
 
 There is a peculiar affection, described by older writers 
 as "chronic bursitis," though, in many instances, it un- 
 doubtedly is not a true inflammation. It is characterized 
 by thickening of the wall by repeated deposits of organized 
 lymph until the whole bursal cavity is finally filled by a 
 tumor of almost cartilaginous consistency. The only 
 treatment is excision under strictest asepsis. 
 
 The tuberculous trouble does not differ materially in 
 either character or treatment from fungous synovitis (which 
 see). 
 
 CANCER 
 
 This is a general term expressive both of carcinoma 
 and sarcoma any malignant growth is "cancer. " Certain 
 forms have distinctive names, as alveolar cancer, a carci- 
 noma with an alveolar structure; colloid cancer, one con- 
 taining colloid material; cancer en cuirasse, a disseminated, 
 lenticular carcinoma of the skin encircling the chest; epithe- 
 lial cancer, a carcinoma of the epithelial structure, espe- 
 cially of lip and cervix Creallv all carcinomata are epithelial
 
 CANCER 117 
 
 cancers); melanotic cancer, one containing pigment and 
 generally regarded as unusually malignant. 
 
 Cancer "Cares/* About twenty percent of perma- 
 nent cures follow radical operation as at present practised. 
 This percentage might easily be doubled by early recog- 
 nition and immediate extirpation. Too many doctors 
 delay in the hope that they have made a mistake in diag- 
 nosis; using palliative or delusive curative measures. If 
 they would but remove the growth first and use the "reme- 
 dies" afterward, many more lives might be saved. Tryp- 
 sin has recently attracted much attention; but while it is 
 true that cancer-cells are easily dissolved by trypsin and 
 some patients have improved greatly under its hypodermic 
 use, no absolute cure has yet been reported, and the ques- 
 tion of its beneficial action is still sub judice. Radium, 
 too, is still under trial with probabilities all against its 
 general usefulness. The Finsen light has proven of value 
 only in superficial growths which are far better burned out 
 with the Paquelin cautery. As for the x-ray, its curative 
 influence has been greatly overestimated except in skin- 
 cancer and lupus; in truth, it may now be positively said 
 that for extensive carcinoma the Roentgen-ray exercises 
 no actual curative effect, its advantage being only in the 
 fact that it exerts a beneficial analgesic effect, and in ulcera- 
 ting tumors also causes a diminution of the offensive dis- 
 charge; in many cases there is a temporary recedence of 
 the nodules, but never a lasting effect. All of these, then, 
 should be reserved for use after excision of the malignant 
 growth. The latest addition to possible curative agents 
 is a serum taken from sheep inoculated with cancer; but 
 until the cause of carcinoma can be determined and iso- 
 lated, little is to be hoped from the use of sera. When 
 extirpation is impossible on account of location or extent 
 of the tumor, palliative operations are justifiable; ligation 
 of the carotid in huge cancer of the neck may arrest its
 
 118 SURGICAL THERAPEUTICS 
 
 growth for months; gastroenterostomy for cancer of the 
 pylorus often prolongs the life of the patient for many 
 years; vaginal hysterectomy may give great comfort and 
 add years to the life of a doomed woman; and so on through 
 the list. Just because a diagnosis of cancer has been 
 verified a doctor should not abandon the victim to his 
 fate much may be done to encourage, to alleviate, and 
 to prolong life. 
 
 Condurango in Cancer of the Stomach, In inoper- 
 able cancer of the stomach condurangin, the glucoside 
 which is the active principle of condurango, is worthy of 
 trial, great improvement having been recorded under its 
 influence. It may be obtained in the form of a granule 
 containing one milligram (gr. 1-67). One may be given 
 from three to six times a day when there is the least food 
 in the stomach; best dissolved in a little water just before 
 taking. Small doses of sulphate of codeine should be 
 given at the same time if there be much pain. But it 
 should be remembered that the presence of a pyloric 
 tumor is no longer regarded as prohibiting operative treat- 
 ment: a palliative gastroenterostomy at least often may 
 be performed with great benefit. 
 
 Cure of Mediastinal Carcinoma. Pfahler, of Phila- 
 delphia, has reported six cases in which carcinoma of 
 the mediastinum developed after cancer of the breast. 
 All of the patients had been operated on previously. 
 They were treated by x-ray and three have apparently 
 recovered. 
 
 For Inoperable Cancer. A very good local appli- 
 cation to cancer (especially of the breast) is an ointment 
 containing morphine and atropine; and better for its 
 soothing effect is the old-fashioned conium poultice. 
 This may be made from the fresh leaves, or one-half 
 ounce of the succus conii may be added to an ordinary 
 bread poultice.
 
 CANCER 119 
 
 Marsden's Paste for Cancer,, The celebrated 
 "Marsden's paste" used by most "cancer doctors" con- 
 sists of 
 
 Arsenous acid i ounce 
 
 Powdered acacia i ounce 
 
 Water '. 5 drams 
 
 Some of this arsenical mucilage is smeared over the malig- 
 nant growth morning and evening, care being taken not 
 to cover healthy skin. Separation of sloughs is encour- 
 aged by poulticing, which also gives temporary respite 
 from suffering, because the arsenic causes intense destruc- 
 tive inflammation. Absorption is not possible if plenty 
 be applied; a small quantity on a raw surface might lead 
 to arsenical poisoning, but a large amount produces such 
 severe inflammation that perfect safety is assured, since 
 inflamed tissues lose the power of absorption. But 
 the treatment is very painful and tedious and so has fallen 
 into well-deserved disuse by the regular profession. One 
 can do in five minutes with the Paquelin cautery without 
 pain (under cocaine) what the cancer quacks require 
 weeks of terrible suffering to accomplish. 
 
 Methylene-Bltte for Cancer. After the excite- 
 ment over reported cures of cancer by use of pyoktanin 
 subsided, a few careful investigators continued their 
 experimental treatment upon inoperable carcinoma. It 
 has been conclusively demonstrated that the internal 
 use of methylene hydrochloride in pill form is followed 
 by remarkably good effects. The dose at the beginning 
 is 2 grains daily, to be gradually increased to 3, 4 and 6 
 grains. To relieve the strangury sometimes produced, 
 it is necessary to combine with the pills 3-4 grain of extract 
 of belladonna distributed over the twenty-four hours. 
 Arsenous acid, strychnine, or a cathartic may, if neces- 
 sary, be incorporated in the prescription. The patient 
 must be warned that the urine will turn blue and will
 
 120 SURGICAL THERAPEUTICS 
 
 permanently stain clothing. In some instances the 
 patients gain remarkably in weight and strength and 
 the tumor-mass may be decidedly reduced in size. Life 
 has, apparently, been prolonged from two to eight years, 
 but no patient has been cured. 
 
 Prevention of Cancer, While we have not yet 
 learned the remote cause of cancer, certain things have 
 been demonstrated as the direct cause; an avoidance of 
 these may prevent the appearance of the malady in those 
 predisposed to its development, as well as ward off a 
 return in those patients who have been subjected to opera- 
 tion. The directions given by Keetley are: (i) Steril- 
 ize all food. A large proportion of cancers attacks the 
 alimentary canal, and especially the parts where food 
 and feces tarry. (2) Insist upon sufficient and regular 
 toilet and protection of the nipples and of the genitalia. 
 It is significant that these organs are especially often 
 polluted by stale secretions and discharges, and are more 
 frequently handled by their owners than any other part 
 of the person usually covered by clothing. (3) Order 
 due care of the mcruth and teeth. (4) The dressings of 
 discharging malignant sores and tumors should be burned, 
 and patients and attendants must be instructed especially 
 not to pollute either the fingers or the underlinen. (5) 
 Non-malignant sores and tumors should be cured, and 
 especially not allowed to drift on if chronic. (6) Can- 
 cerous and doubtful tumors and ulcers should be excised 
 promptly. (7) Abstinence should be practised from 
 alcohol, tobacco, and from foods which leave waste prod- 
 ucts, of which the kidneys, the bowels, and the skin can 
 not easily and thoroughly get rid, and which thereby 
 provoke and sustain the chronic inflammations and ulcers 
 which so often pave the way for cancer. (8) Physical 
 familiarity should be avoided, except with those who are 
 nearest and dearest to us. (9) Much thought should be
 
 CANCER 121 
 
 given, especially by mistresses and housekeepers, to the 
 service as well as to the cooking of food, with a view to 
 disease-prevention. Special attention should be paid to 
 the sterilization of milk and its products: cheese and 
 butter. 
 
 Radium Treatment of Cancer. McFarlane's inves- 
 tigation shows that of the many thousands of cases of 
 cancer subjected to the radium-treatment 13 rodent ulcers 
 were reported cured, 14 epidermoid cancers cured, i 
 malignant wart cured, n cases of cancer of the esophagus 
 slightly improved, 27 carcinomas unaffected, i malignant 
 wart unaffected, i malignant mole unaffected, i rodent 
 ulcer unaffected. The advantages of radium are its 
 portability, and the ease with which it can be applied 
 and accurately localized." From the foregoing summary 
 we may conclude that it has a distinct, though altogether very 
 limited, field of usefulness in the treatment of malignant 
 disease. Its action is similar to that of the Roentgen ray, 
 but much weaker. It is preferable to the Roentgen ray 
 in the treatment of small rodent ulcers, and is available 
 for use in inaccessible cavities. 
 
 Trypsin in Cancer. Results from the use of trypsin 
 in cancer are not yet definite. The best report yet pub- 
 lished is that of Morton who instituted a series of experi- 
 ments consisting of the consecutive use of trypsin in a 
 group of about 30 cases of cancer, both hospital and pri- 
 vate. Two of these, patients with facial cancer, are 
 cured to date. In one case, a remarkable process of 
 retrogression by degeneration and atrophy of a carcinoma- 
 tous breast-gland to final and curative obliteration, has 
 been demonstrated microscopically. In all cases signs 
 of amelioration in the progress of the disease have been 
 observed. It has been demonstrated that both local 
 and constitutional reaction may be produced by the use 
 of trypsin. Enlarged glands have rapidly diminished in
 
 122 SURGICAL THERAPEUTICS 
 
 size. Trypsin has a decided effect, Morton declares, in 
 reducing cancer cachexia, and in improving the general 
 health. Even in severe cases of uterine cancer involving 
 the associated pelvic organs the disease may be brought 
 to a halt. The influence of amylopsin seems to have had 
 much to do with favorable results. 
 
 CANCRUM ORIS 
 
 This disease, frequently called "noma," has been 
 described as a gangrenous stomatitis, or gangrenous 
 ulceration of the mouth, though it is not a true gangrene. 
 It is a disease of early life, attacking children between 
 the ages of one and five years, and consists of foul, deep 
 ulcers of the mucous surface of the cheeks or lips. While 
 there is no pain, general weakness is pronounced and 
 unless the disease is quickly checked the child dies from 
 exhaustion or from septic fever. Under perfect anesthesia 
 the ulcer must be burned with the Paquelin cautery to 
 the uttermost recess, and then dressed as a simple burn. 
 As the disease is due to general debility, good food and 
 tonics are radically indicated. Alcoholic drinks (wine) 
 and strychnine with triple arsenates do good if accom- 
 panied by proper food. The wound, though large, will 
 heal by granulation if kept covered by antiseptic dress- 
 ings, but changed often on account of wetting by saliva. 
 Any tendency to spread at some particular point must be 
 combatted by instant, and free, use of cautery. 
 
 CANKER 
 
 Canker is a name used by the laity to mean an ulcer 
 in the mouth: ulcerative stomatitis. If the ulcer be 
 burned twice or three times in a week with pure nitrate 
 of silver and a mouth-wash of saturated solution of potas- 
 sium chlorate given, the "canker" will readily heal in a 
 few days.
 
 CARBUNCLE 123 
 
 CARBUNCLE 
 
 From a streptococcal infection in the deeper layers 
 of the skin there is formed a hard, circumscribed, pain- 
 ful inflammation of the subcutaneous cellular tissue, 
 with tendency to form several openings through the skin. 
 It is much more serious than a boil (a simple staphylo- 
 coccus infection) and is accompanied by chill, fever and 
 decided constitutional -symptoms, chief of which is pro- 
 found weakness; indeed under old lines of treatment it 
 was presumed that a carbuncle in an old person meant 
 death. It certainly does not if he will submit to radical 
 operation: excision of all implicated tissue under com- 
 plete anesthesia, the knife not being allowed to touch 
 infected tissue; if this is not permitted the next-best thing 
 is to eradicate it thoroughly by burning with the Paquelin 
 cautery under cocaine anesthesia. If neither can be 
 done, the mass should be split deeply from side to side, 
 with a cross-cut from top to bottom, and kept covered 
 with ichthyol and belladonna ointment until the infected 
 mass (popularly called "the core") drops out, when it 
 may be treated as a simple sore. Stimulants and two- 
 decigram (three-grain) doses of quinine four times a day 
 with two milligrams (1-30 grain) of strychnine sulphate 
 should be ordered, together with a mos.t nourishing diet. 
 
 Belladonna for Carbuncles. A most soothing, agree- 
 able application for a forming carbuncle is equal parts of 
 extract of belladonna and ichthyol smeared on cloth 
 and applied to the inflamed area and an inch or more 
 of adjacent skin. If used early, suppuration sometimes is 
 arrested, and always much suffering i? prevented. 
 
 To Reduce Suppuration. During the progress of 
 a carbuncle it is advisable to administer a centigram 
 (1-6 grain) of calcium sulphide every hour during the 
 height of the fever and discomfort; and about 25 eg. (1-2
 
 124 SURGICAL THERAPEUTICS 
 
 grain) four times a day later on. It seems to prevent 
 the formation of new foci as well as to reduce the amount 
 of local inflammation, quickly liquefying the central mass 
 and promoting the formation of healthy granulations. 
 It is claimed that if given before suppuration begins the 
 process is arrested, and a hard lump forms at the site of 
 streptococcus infection a lump which disappears in a 
 few days without suppurating. 
 
 CARCINOMA 
 
 Defined as "a malignant tumor characterized by a 
 network of connective tissue whose areolae are filled 
 with cell-masses resembling epithelial cells". (Gould). 
 According to variation hi location cancer appears under 
 several distinct types. 
 
 Alveolar. One with an alveolar structure, i. e., 
 little pockets, or cysts, filled with cancer-cells. 
 
 Carcinoma Taberosum. Scirrhus in which the 
 nodules are of very large size. Rare. 
 
 Benign tumors sometimes undergo a cancerous change, 
 or "degeneration;" their names being added to carcinoma, 
 thus, adenocarcinoma, etc. 
 
 Every tumor suspected of malignancy should be 
 removed, particularly in the breast. Only in early excis- 
 ion is there hope of cure; decidedly applicable to cancer 
 of the uterus. 
 
 If consent can not be secured to early removal, burn- 
 ing is next desirable: preferably with the Paquelin cautery. 
 This is especially useful for superficial epitheliomata. 
 
 Pastes (Marsden's, Cauquoin's and others) do the 
 same thing as the Paquelin but take weeks to accomplish 
 what the Paquelin does in five minutes, and are very pain- 
 ful; many times unsatisfactory. 
 
 The x-ray may be used for cases too far advanced for 
 operation, for superficial growths and ulcerations and
 
 CARIES 125 
 
 for recurrent growths after removal. It must never be 
 used as the treatment of choice in any case amenable to 
 operative treatment. 
 
 Radium has given no cures as yet. Like the Roent- 
 gen ray, however, its use gives surprising relief from pain, 
 retards the growth and helps sustain the patient. 
 
 Tonics and stimulants are indicated always. 
 
 Morphine must be given in inoperable carcinoma 
 to any extent needed to alleviate pain. It is very repre- 
 hensible to withhold opiates in hopeless cases on merely 
 sentimental grounds. [See "Cancer."] 
 
 Colloid. A form found in the alimentary canal, 
 uterus, peritoneum, etc., in which the delicate connec- 
 tive-tissue stroma is filled with colloid material, i. e., a 
 jelly-like material thicker than mucus, filling the alveoli. 
 
 Encephaloid. A type of rapid growth, made up of 
 a small amount of stroma and large alveoli, with a greater 
 number of cells and blood-vessels than the other varieties. 
 
 Epithelioma. A carcinoma of skin or mucous mem- 
 brane. 
 
 Lipomatotts. One which contains cells infiltrated 
 with fat. 
 
 Medullary. Another name for encephaloid. 
 
 Melanotic. One in which the cells are filled with 
 pigment, sometimes until appearing almost black. 
 
 Scirrhus. A hard, slow-growing cancer, most often 
 found in the breast, consisting of a stout, fibrillated stroma, 
 closely filled with large, nucleated cells. 
 
 CARIES 
 
 Necrosis of bone may follow injury if there be infection 
 by pus-germs or by tuberculosis. The inflammatory 
 process may be so slow as to warrant the expression 
 "chronic," the inflammation being followed by rarefica- 
 tion or absorption of much of the bony tissue; and usually
 
 126 SURGICAL THERAPEUTICS 
 
 succeeded by formation of pus. Sometimes as a result 
 of a severe blow a part of the bone is splintered off 
 (spicula) in such a way that its nutritive arteries are all 
 ruptured; in which case molecular death occurs followed 
 later by pus-infection in most cases. 
 
 When the necrosis is due to tuberculosis the con- 
 dition is described as caries fungosa, the sequestrum 
 or point of absorption being covered with granulations 
 which grow from the inner surface of the cavity. 
 
 Occasionally instead of the tuberculous cavity being 
 filled with pus there is found a condition known as caries 
 sicca: a dry necrosis with obliteration of the joint, accom- 
 panied by sclerosis and concentric atrophy of the articu- 
 lar extremity of the joint. 
 
 In most cases of caries there is nothing to be done except 
 to cut down upon the affected part, remove by curettage 
 or otherwise all of the dead bone, pack with iodoform 
 gauze and cause the cavity to close by healthy granula- 
 tions. The earlier this can be done the better the ending. 
 
 The only exceptions to this rule of practice are, per- 
 haps, destructive osteitis of the spine (Pott's disease) 
 and destructive tuberculosis of the hip (hip-joint disease). 
 Even in these cases operation is sometimes advisable; 
 but the results are usually deplorable and lead to cen- 
 sure of the operator. 
 
 Caries of the Acromion. This is very rare. Treat 
 by cureting and packing, avoiding opening the shoulder- 
 joint. Weak joint is to be predicted. 
 
 CARTILAGE: DISEASES OF 
 
 Chondralgia. Pain in or about a cartilage is always 
 suggestive of a tuberculous focus; but then it is a dull ach- 
 ing, while chondralgia is acute, sharp, like neuralgic pains 
 elsewhere. The treatment is the same as for neuralgia: 
 anodynes temporarily (acetanilid, codeine, etc.) with strych-
 
 CATGUT: IODINE 127 
 
 nine and iron to improve the general condition. In unyield- 
 ing cases chondrectomy has been practised; but excision 
 must be reserved as the dernier ressort. 
 
 Chondritis. Inflammation of a cartilage can hardly 
 be differentiated from synovitis (which see). 
 
 Chondromyxoma. A tumor made up of cartilaginous 
 cells (chondroma) with also mucous elements present 
 (myxoma). Treatment: excision. 
 
 Chondrosarcoma. A tumor of mixed cartilaginous 
 and sarcomatous tissues. Early removal. 
 
 CASTOR OIL: TO RENDER PLEASANT 
 
 Some surgeons insist that nothing can take the place of 
 castor oil as an easy purge both before and after opera- 
 tion. To them this method of disguising its taste (advised 
 by Carleton) will be of interest: 
 
 Vanillini grs. 20 
 
 Olei menth. pip dr. i 
 
 Saccharini drs. i 1-2 
 
 Alcoholis ozs. 3 
 
 Tinct. persionis oz. 1-2 
 
 Olei ricini, q. s. ad gal. 1-2 
 
 Dissolve the vanillin, oil of peppermint and saccharin in 
 the alcohol. Add the tincture of cudbear to the oil and 
 shake thoroughly. Finally unite the two mixtures. This 
 mixture looks well, tastes well and is pleasant to take. 
 
 CATGUT: IODINE 
 
 Catgut prepared by the iodine method is rapidly gain- 
 ing in popularity among many operators. The advantages 
 claimed for it are: (i) If properly handled it is abso- 
 lutely sterile. (2) In the course of its preparation it does 
 not lose any of its tensile strength. (3) It is readily and 
 simply prepared and without any undue expense. (4) It 
 should be absorbed completely, but only after it has served
 
 128 SURGICAL THERAPEUTICS 
 
 the purposes for which it is introduced. The method of 
 preparation is that of Bartlett: the gut immersed for eight 
 days in a mixture consisting of tincture of iodine, one 
 part, proof spirit, fifteen parts. Bacteriological investiga- 
 tion shows the gut to be then sterile. It can be stored 
 indefinitely in the solution in which it is prepared without 
 becoming brittle. It is soft and very nice to handle. 
 
 CERVICAL RIBS 
 
 A peculiar form of (usually) bilateral cervicobrachia* 
 neuralgia depends upon cervical rib-formation. The pain 
 starts at the back of the neck and radiates into the arms, 
 and the slightest movement or touch is agony. Outside 
 of the attacks passive movements of the head to right or 
 left are possible without pain, but bending forward causes 
 pain localized in the cervical ribs and shoulders. The 
 pains appear at once on reclining, and the patient nearly 
 always has learned to sleep in a chair. Large doses of 
 morphine have scarcely any influence. In such cases the 
 Roentgen ray will show a cervical rib on each side, corre- 
 sponding to the seventh cervical vertebra. The trouble 
 sometimes does not manifest itself until the patient begins 
 to have the senile stoop the kyphosis impinging upon the 
 nerves. Extension treatment, restoring the vertebrae to 
 their natural position, has done good service and rendered 
 cervical measures superfluous; in others removal of the 
 rib is the only means of relief. 
 
 CHANCRE 
 
 This term was formerly used to express any sore of 
 venereal origin. Now its meaning is limited to the initial 
 lesion of syphilis. It is also called "Hunterian chancre," 
 "hard chancre" (to distinguish it from chancroid, the 
 softer sore). It should be remembered that the chancre 
 may be located not alone upon the sexual organs, but in
 
 CHANCROIDS 129 
 
 the mouth, the anus, etc. Authorities upon syphilis now 
 agree that there is nothing gained by excision or other 
 treatment of chancre; as soon as its true character is ascer- 
 tained mercury must be begun. (See "Syphilis".) 
 
 CHANCROIDS 
 
 These are contagious ulcers, inflammatory in type, 
 not syphilitic, with a tendency to continue indefinitely and 
 spread by infection of any abraded surface receiving their 
 discharge. They are not serious if properly treated before 
 large areas are involved, thus forming the socalled "ser- 
 piginous chancroid" or "phagedena." 
 
 The best treatment is: Inject a few minims of a 
 2-percent cocaine solution; the needle must be boiled for 
 twenty minutes after using! Then burn thoroughly with 
 Paquelin cautery at bright-red heat. Besides being more 
 efficacious than any other method of cure this possesses the 
 advantage of being something tangible for which the patient 
 is more willing to pay than for a mere application. Some 
 patients, however, object to the cautery; such may be 
 treated by cauterization with nitric acid, applied by means 
 of a little absorbent cotton wound around a wooden tooth- 
 pick; but the burning must be thorough to insure perfect 
 cure. If the cauterization be done soon enough and of 
 sufficient degree, once will be enough. When the ulcerated 
 surface is very extensive, cocainization should not be at- 
 tempted; the work ought to be done with the patient in 
 full surgical narcosis. 
 
 Formerly Ricord's paste was much used. Its composi- 
 tion is: sulphuric acid with enough powdered charcoal 
 added to make a thick paste. This is applied to the ulcer 
 freely. After a few days the charcoal drops off, leaving 
 a healthy, granulating surface if the acid has done its 
 desired duty. It is painful, whereas the cauterization by 
 Paquelin cautery is attended by singularly little pain.
 
 130 SURGICAL THERAPEUTICS 
 
 After the burning, or after the paste has dropped off, 
 a simple antiseptic ointment may be applied. lodoform 
 is much employed by genitourinary men, but on account 
 of its unpleasant odor other iodine salts of bismuth or 
 calomel may be substituted. A good formula is: 
 
 Bismuth subiodide 8.0 (drs. 2) 
 
 Vaseline 32.0 (oz. i) 
 
 This is to be applied three or four times a day. 
 
 When the patient is in excellent health and the chan- 
 croid a merely superficial ulceration, burning may some- 
 times be omitted. In such cases the ulcer must be cleaned 
 once daily by hydrogen dioxide, full strength, dried care- 
 fully and dusted with a powder consisting of equal parts 
 of bismuth subiodide and boric acid. If there be an 
 unusual amount of discharge tannic acid may be added; 
 thus: 
 
 Bismuth subiodide 8.0 (drs. 2) 
 
 Boric acid 8.0 (drs. 2) 
 
 Tannic acid 4.0 (dr. i) 
 
 A little of this may be applied three or four times a day. 
 
 The chief objection to this mild course of treatment 
 is the constant danger of the trouble suddenly spreading 
 and the even greater one of the formation of buboes. So 
 long as there is a trace of the chancroidal poison left in 
 the ulcer these dangers persist; therefore the more energetic 
 method is always the safest, and in the end is the speediest 
 way of cure. And it is imperative whenever a chancroid 
 previously doing well suddenly begins to spread. 
 
 Sometimes when first seen the tissues around the chan- 
 croid are quite hard, tender and inflamed. It is then best 
 to put the patient to bed and use hot, antiseptic fomenta- 
 tions: cloths wrung out of hot solution of phenol, 5 percent; 
 or one dram of nitric acid to the pint of water may be used 
 instead the growth of all pathogenic bacteria is inhibited 
 by acids.
 
 CHILBLAINS 131 
 
 Buboes. When chancroidal buboes form the glands 
 should be protected by a gauze pad applied with slight 
 pressure of bandage. When the glands continue to enlarge 
 they may be painted with iodine once or twice; and if 
 they become hot and painful lead and opium wash may 
 be applied. As soon as suppuration is detected the abscess 
 must be freely opened and treated just as any other abscess. 
 If it assume a chancroidal or phagedenic character it must 
 be managed just like the original chancroid. (See "Bubo".) 
 
 Phagedena. When the chancroid extends rapidly, 
 with alarming destruction of tissue, free cauterization must 
 be done immediately. A few hours' delay may mean ex- 
 tensive sloughing, necrosis extending to the thighs or to 
 fatal perforation of the abdominal walls (occurring in the 
 worst neglected cases). Every part of the ulcer must be 
 burned every little nook and earner, every sinus laid 
 bare. The extensively charred surface must then be 
 treated as any other burn, i. e., by antiseptics and exclusion 
 of air. After it is found that the sloughing has been ar- 
 rested the wound should be dressed as rarely as possible, 
 as each manipulation interferes with granulation. 
 
 To weakened patients good food and strong tonics must 
 be given iron, quinine and strychnine being best. 
 
 CHILBLAINS 
 
 A good application to chilblains is tincture of chloride 
 of iron, full strength, at bedtime. Perhaps a better treat- 
 ment is to bathe the feet in hot water with a tablespoonful 
 of salt added to each quart; dry carefully and rub in this 
 ointment: 
 
 Menthol i.o (grs. 15) 
 
 Ichthyol 4.0 (dr. i) 
 
 Vaseline 32.0 (oz. i) 
 
 In the morning a simple footbath with soap and water 
 should be taken. In three or four davs the trouble should
 
 132 SURGICAL THERAPEUTICS 
 
 entirely disappear instead of being a source of annoyance 
 all winter. 
 
 An ointment of one part of chlorinated lime and nine 
 parts of petrolatum is very useful in chilblains. It often 
 quickly cures the most obstinate cases. 
 
 A celebrated plaster for the cure of chilblains is "De 
 Rheim's plaster;" it has this composition: 
 
 Capsicum pods 32.0 (oz. i) . 
 
 Strong alcohol 64.0 (ozs. 2) 
 
 Macerate for several days and add 
 
 Mucilage of acacia 64.0 (ozs. 2) 
 
 This is to be well stirred and brushed over sheets of silk 
 or tissue-paper and applied to the chilblain, the skin over 
 which must be unbroken, however. 
 
 CHOLANGITIS 
 
 Inflammation of a bile duct is rarely to be distinguished 
 from cholecystitis, there being the same ague-like chill, 
 fever, sweating and jaundice which accompany the more 
 extensive trouble; indeed it is doubtful if even the medical 
 examiners of the Civil Service Commission can make other 
 than a theoretical differential diagnosis. But it matters 
 not the therapy is the same. (See "Cholecystitis".) 
 
 Inflammation of the gall-bladder is almost always due 
 to infection of an abraded surface by the bacillus coli 
 communis, so the spilling of a few drops of pus during 
 operation is not greatly to be feared, the healthy peritoneum 
 can usually take care of much pus of such origin; but it 
 may also originate from infection by typhoid bacilli, by 
 those of epidemic influenza and by the two chief pus- 
 producers: staphylococci and streptococci. The occurrence 
 of jaundice is a mere incident not more than ten percent 
 of all gallstone cases have jaundice, though occlusion of
 
 CHOLECYSTITIS 133 
 
 the cystic duct by gallstone is an almost constant accom- 
 paniment of cholecystitis, icterus appearing when the 
 common duct is closed either by stone or inflammatory 
 swelling. The relation of gallstones to cholecystitis has 
 not been definitely determined; certain it is that calculi 
 often form as the result of a cholecystitis which does not 
 go on to abscess-formation because the duct is not clogged; 
 and equally sure is it that the stones later may so injure 
 the mucosa that secondary infection occurs with the forma- 
 tion of abscess of the most threatening character. The 
 treatment to be adopted, then, must depend upon the stage 
 to which the inflammation has progressed: that of a simple, 
 non-obstructive cholecystitis differing materially from that 
 indicated in an abscess of the gall-bladder. It is in the 
 treatment of a non-suppurative cholecystitis, perhaps with 
 a temporary blocking of the common duct, and its conse- 
 quent icterus ("catarrhal jaundice" as it is frequently 
 called), that the most brilliant results are obtained by 
 internal medication; with the claim that "gallstones" may 
 be "cured" without operation. The truth is that a gall- 
 stone in a normal gall-bladder amounts to no more than a 
 piece of gum in a healthy mouth! By proper therapy the 
 majority of cases of cholecystitis may be cured and the 
 unremoved stone causes no further trouble perhaps for 
 many years or always. This proper treatment consists in 
 the use over a long period of time of sodium succinate, 
 which if persisted in will prevent recurrences of the attacks. 
 The paroxysms may usually be relieved by glonoin, hyoscy- 
 amine and strychnine. In very severe cases the H-M-C 
 combination is most effective. 
 
 Cure of Cholecystitis. Most surgeons experienced 
 in surgery of the gall tract now know that simple removal 
 of gallstones does not cure all the trouble in most cases. 
 Dr. Hugh Taylor, of Richmond, in a good article entitled 
 "The Scope of Surgery in Bile-Duct Infections, " remarks :
 
 134 SURGICAL THERAPEUTICS 
 
 "cholecystostomy removes the gallstones, but in the re- 
 corded experience of many does not cure the patient. Why ? 
 Because it does not cure the cholangitis and cholecystitis. 
 
 Cholecystectomy often leaves an infectious inflammation 
 involving the cystic, common or hepatic ducts and their 
 ramifications. More and more the conviction has been 
 forced that even hi uncomplicated cases removal of the 
 gallstones does not give satisfactory end-results because 
 we have only eliminated one of the sequences and not the 
 disease. A study of this subject at the hands of those 
 whose opinions merit our greatest consideration impresses 
 the fact that the key to success is drainage (by cholecystos- 
 tomy or through the hepatic or common duct), prolonged 
 drainage, until the infections in the gall-bladder and ducts 
 have subsided." Dr. Maurice Richardson tersely puts it: 
 " From study and experience, therefore, I am led to the con- 
 clusion that the essential thing in the surgery of the biliary 
 tract is full, free drainage, allowed to persist until it closes 
 spontaneously." Moynihan, in his work on "Abdominal 
 Operations," page 526, writes: "The great principle which 
 has to be carried out in all gallstone^ surgery is drainage," 
 drainage to prevent leaking, "and cure that condition of the 
 mucosa (stone-forming) which was responsible in the 
 first instance for the formation of gallstones." There- 
 fore cases not yielding promptly should be operated on. 
 
 Cholecystitis: Therapy of. Bilein is helpful in 
 inflammation of the gall-bladder and for gallstones 
 not subjected to surgical treatment. It consists of the 
 alkaline salts of the bile-acids, the active agents of the bile; 
 The dose is from one to three centigrams, four times a day 
 (1-8 to 1-2 grains). It is often given in combination with 
 an equal amount each of calomel and podophyllin, making 
 an active hepatic stimulant and socalled cholagog. When 
 given alone it should be followed by a saline laxative. 
 Of course for entire arrest of symptoms it is important
 
 CHOLECYSTITIS 135 
 
 that the patient be given a long course of treatment with 
 sodium succinate for a year if necessary. 
 
 Treatment After Cholecystostomy, After the gall- 
 bladder has been opened and drainage established the 
 external layers of gauze and cotton must be changed as 
 often as they become soaked with bile, blood or mucus: 
 about every four to six hours the first day and twice daily 
 thereafter; but the layers of gauze next the wound should 
 not be disturbed until the third or fourth day, when the 
 drainage may be withdrawn. Next day the gall-bladder 
 may be washed out with peroxide of hydrogen, but no 
 water; a small strand or wick of gauze may be inserted 
 into the opening, but care must be taken that it does not 
 slip into the gall-bladder; in one of my cases a long piece 
 of iodoform gauze was carried in the gall-bladder more 
 than two years (with no discomfort save the annoyance of 
 a fistula which would discharge a little bile and mucus 
 every few weeks). After gallstone disease the gall-bladder 
 should be drained three weeks, great care being exercised 
 not to infect with staphylococcus or streptococcus, i. e., 
 plenty of bichloride gauze (i in 2000) must be used at each 
 dressing, and hands and syringe must be sterile; it is best 
 to use rubber gloves in changing the dressings, as they may 
 be rendered sterile very easily. Internally calomel should 
 be given as early as the third day, and thereafter the bowels 
 kept loose by podophyllin, or saline laxatives. 
 
 Typhoid a Cause of Cholecystitis. Inflammation 
 of the gall-bladder due to infection by the typhoid bacil- 
 lus is quite common and may lead to abscess. In most 
 cases of cholecystitis, however, there is mixed infection 
 of the typhoid bacillus and colon bacillus or typhoid 
 bacillus and staphylococcus. The abscess may not 
 develop until many months after the typhoid fever. The 
 Eberth bacilli may be present not only in the contents 
 of the gall-bladder but also in its walls, there sometimes
 
 136 SURGICAL THERAPEUTICS 
 
 being necrotic patches caused by the bacilli, and rarely 
 perforative peritonitis occurs from this origin. There 
 can be little doubt that gallstones owe their origin to 
 infection of the gall-bladder by the germs of typhoid. 
 Strange to say, a serious cholecystitis may originate from 
 infection with typhoid and colon bacilli, go on its course 
 without symptoms other than trifling discomfort, and 
 end in perforation before the patient sends for a physi- 
 cian. Rarely a tumor is known to be present (a dis- 
 tended gall-bladder containing bile mixed with mucus 
 and pus), but there will be little complaint until rupture 
 occurs, with profound shock and intense and sudden 
 pain, the latter generally at the inguinal region. 
 
 Opening the abscess and establishing free drainage 
 constitute the proper treatment. 
 
 CHORDEE 
 
 During gonorrhea painful erection is liable to occur, 
 the penis being bent downward by the unyielding inflamed 
 urethra. Application of ice affords the quickest relief, 
 but it is objectionable because the reaction following it 
 may lead to worse chordee. Wrapping very tightly with 
 a narrow bandage, beginning at the glans, is better, fol- 
 lowed by two grams (30 grains) each of potassium bro- 
 mide and chloral in 4 ounces of water, given by the 
 rectum. 
 
 Prevention of Chordee. For the prevention of 
 chordee during the acute stage of gonorrhea, gelseminine 
 is worthy of trial. A tablet of a half milligram (1-134 
 grain) may be given every two hours during the day for 
 several days; with it should be given a tablet of caulophyllin 
 containing one centigram (gr. 1-6). The urine should be 
 kept bland and unirritating by the use of sandalwood oil 
 or copaiba, or by lithium benzoate, one decigram (or about 
 two grains) four or five times a day. Large quantities
 
 CIRCUMCISION 137 
 
 of water should be drunk and alcohol scrupulously excluded 
 until the severe stage of clap has passed. 
 
 CICATRICIAL DEFORMITIES 
 
 Deformities due to contraction of scar-tissue are gen- 
 erally best left alone. Rarely the scar can be dissected 
 out and healthy skin brought from a nearby part to cover 
 the denuded area. If done with such perfect asepsis as 
 to secure healing by primary union the operative pro- 
 cedure may succeed; but if suppuration occur the sec- 
 ondary scar may be worse than the original. 
 
 CIONITIS 
 
 Inflammation of the uvula is not very common, but 
 gives much discomfort when it does occur. Perhaps the 
 best application is a saturated solution of potassium chlor- 
 ate with a little tincture of hydrastis added. It may be 
 used as a gargle. When the attacks are often repeated, 
 as may be, the uvula should be amputated, about two- 
 thirds being removed. The hemorrhage may be checked 
 by using antipyrin powder on a pledget of cotton; or if 
 excessive, by ligature. Removal is especially indicated 
 if there be cionoptosis: prolapse of the uvula. 
 
 CIRCUMCISION 
 
 This must be performed in every case of balanitis' 
 in concealed chancre, in all chancroids when the glans 
 cannot be readily exposed, in paraphimosis and most 
 cases of phimosis. Many nervous symptoms of child- 
 hood depend upon or are aggravated by retained smegma 
 and adherent prepuce; many inveterate masturbators 
 owe their trouble to the same cause so every boy's pre- 
 puce ought to be examined from time to time and early 
 circumcision made in every case where there is any ser- 
 ious trouble present. Practically all doctors are too 
 careless about this matter.
 
 138 SURGICAL THERAPEUTICS 
 
 CONDYLOMA 
 
 This condition (known also as moist wart, fig-wart, 
 cauliflower excrescence and venereal wart) is properly 
 designated -verruca acuminata. It is a warty growth 
 which occurs in parts subjected to maceration in sweat, 
 or bathed in venereal secretions or mucous discharges, 
 like the genital and anal folds and the vulva. The warts 
 may be flat or acuminate, whitish, pinkish or reddish, 
 pedunculated or sessile; usually they are more or less 
 associated groups or masses of vegetations smeared with 
 a nasty secretion. They bleed on manipulation. 
 
 Genital Condylomata. Condylomata of the gen- 
 italia are most easily removed by use of the Paquelin 
 cautery. But sometimes patients object to anything 
 which can be regarded as an operation even though done 
 under local anesthesia. In such a case the growths may 
 be touched with pure acetic acid, without great pain; 
 and the patient directed to keep the affected parts con- 
 stantly moist with a solution of one dram of the acid to 
 a pint of water. 
 
 Acetic acid, pure 4.00 
 
 Water 500.00 
 
 Under this treatment the warty growths will speedily and 
 painlessly disappear. When the affected area is extensive, 
 excision and cauterization are indispensable. 
 
 CONJUNCTIVITIS 
 
 It is now pretty generally agreed among ophthalmic 
 surgeons that protargol is a more satisfactory agent than 
 either argyrol or silver nitrate for the treatment of acute 
 mucopurulent conjunctivitis, and that argyrol is better 
 than silver nitrate. Protargol is perfectly safe up to 
 33 percent, and may probably be used in even stronger
 
 CONVALESCENCE 139 
 
 solutions. Its application causes much less pain than 
 silver nitrate, but more than argyrol. Silver nitrate in 
 strong solutions is a very dangerous agent. 
 
 CONSTIPATION FROM MECHANICAL CAUSES 
 
 Gant calls attention to the necessity for considering 
 the mechanical causes of constipation, which are often 
 overlooked, and the trouble attributed to the better-known 
 causes. In this class of cases, no matter how much time 
 is spent in trying to educate the patient and improve his 
 general condition, it is impossible to secure the desired 
 result until the obstruction is removed. To accomplish 
 this it is usually necessary to resort to some operative 
 measure. The following are the most frequent mechan- 
 ical causes of constipation: congenital deformities, which 
 occur oftener in the rectum and at the anus than else- 
 where in the gut; extraintestinal pressure, from uterine 
 displacements, tumors, inflammatory disease, etc., which 
 cause constipation by compression; strictures; malignant 
 and nonmalignant neoplasms; foreign bodies, either 
 swallowed or formed within the gut; fecal impaction. 
 
 CONVALESCENCE 
 
 Iron Tonic for Convalescents. Patients who have 
 lost much blood often do better during convalescence if 
 given arsenic at mealtime and a good iron mixture an hour 
 afterwards. A most excellent combination is the following: 
 
 Tincture of iron chloride 10.0 (drs. 2 1-2) 
 
 Dilute acetic acid 8.0 (drs. 2 ) 
 
 Syrup 112.0 (ozs. 3 1-2) 
 
 Whisky 384.0 (ozs. 12 ) 
 
 Mix thoroughly and add: 
 
 Ammonium carbonate 1.5 (grs. 20 ) 
 
 Direct: A tablespoonful one hour after each meal. 
 Chemists will declare this is an "impossible" prescription
 
 140 SURGICAL THERAPEUTICS 
 
 on account of the chemical changes which take place on 
 mixing. But if the bottle be corked tightly at once and 
 kept corked between doses it makes the most agreeable 
 liquid iron-mixture there is, patients often asking for 
 "another bottle of that nice 'wine' tonic." 
 
 Ntix Vomica Daring Convalescence. After seri- 
 ous operation the tongue may remain covered with 
 a pasty, white coating for many days after all 
 disturbance from the surgical work has subsided; the 
 appetite being a little slow in appearing. This does not 
 mean chronic sepsis, even of mild degree, but may be 
 ascribed merely to the stomachic disturbance which is 
 like that attending cirrhosis of the liver when the condi- 
 tion of the tongue is precisely similar. One centigram 
 (1-12 grain) of calomel may be given every hour until 
 the bowels move freely; and next day one or two drops 
 of the tincture of nux vomica in half of a glassful of water 
 every two hours. After twenty-four or forty-eight hours 
 of this treatment the tongue will clean, the appetite return 
 and the general condition improve rapidly. This is of 
 particular interest in abdominal section without drain- 
 age where the conscientious surgeon, whatever his experi- 
 ence, is always a little anxious until the bowels are mov- 
 ing freely and the tongue has cleaned. 
 
 The Ideal Tonic for Convalescents. But all 
 things considered probably the best tonic medication is 
 to be procured in granule form, and for this purpose it 
 is hard -to find a better formula than the "triple arsenates 
 with nuclein." Its formula is: Strychnine arsenate, 
 gr. 1-134; quinine arsenate, gr. 1-67; iron arsenate, gr. 
 1-67, with 4 drops of nuclein solution. To the tonic 
 properties of strychnine and quinine are added the blood- 
 making elements, with iron and arsenic, with the cell 
 stimulant, nuclein, which is particularly useful in these 
 cases. If the appetite is pOor give quassin, hydrastin
 
 CORNEAL ULCERS 141 
 
 if the mucosa needs stimulation, while if the gastric secre- 
 tions are inactive hydrochloric acid may be indicated. 
 Attend always to the condition of the bowel. 
 
 Tonic Daring Convalescence. The prejudice against 
 pleasant medicines such as tablets, granules, elixirs, etc., 
 which is found in some communities, must not be met by 
 a flat refusal to use the kind of medicines to which the 
 people have been accustomed; a campaign of education is 
 best, gradually supplanting the nasty by the nice. In every 
 such locality will be found individuals who demand "bit- 
 ters" to be taken during convalescence from operations, 
 etc. To such the following may be given to their 
 entire satisfaction. 
 
 Dilute nitrohydrochloric acid 8.0 
 
 Tincture of nux vomica 4.0 
 
 Compound tincture of cardamon 64.0 
 
 Compound tincture of gentian 164.0 
 
 Whisky 1 28.0 
 
 Direct: One tablespoonful before each meal. It cer- 
 tainly makes the patient eat. 
 
 CORNEAL ULCERS 
 
 Every ophthalmic surgeon will probably agree with 
 Jones that every injury of the cornea should be assumed 
 to be infected. The eye should be promptly irrigated 
 with a saturated solution of boric acid, or bichloride of 
 mercury solution, one in four thousand, and kept as nearly 
 aseptic as is possible by the free use of a bichloride 
 and salt ointment containing bichloride of mercury, one- 
 fifth grain, and sodium chloride, one grain, to vaseline. 
 one ounce. If pain is a factor, one may add five grains 
 of cocaine, allowing the druggist to use a small quantity 
 of liquid albolene better to enable the cocaine to dissolve. 
 If the injury is as much as twelve hours old and the proper 
 antiseptic precautions have not been taken, it is well to
 
 142 SURGICAL THERAPEUTICS 
 
 touch the wound with tincture of iodine applied by a 
 few shreds of absorbent cotton wound around a small 
 probe or smooth wooden toothpick. All applications 
 to the cornea being painful, a previous instillation of a 
 four-percent solution of cocaine should be made. 
 
 When the ulcer has declared itself, the first procedure 
 is to curet thoroughly with a small-size. Meyhoefer's cor- 
 neal curet, then touch with tincture of iodine. If after 
 twenty-four hours there is no marked improvement, 
 cauterization, either with carbolic acid after the same 
 manner as the application of iodine, or with the 
 actual cautery, should be thoroughly done. For the 
 latter, the suitable instrument is Gruening's cautery 
 probe. These two instruments are very inexpensive 
 and should be in the office of every country doctor. 
 Atropine sulphate, one percent, should be instilled every 
 four hours for the first day, then twice a day. Hot appli- 
 cations of boric acid, a teaspoonful to a pint of water 
 as hot as can be borne, bathing the eye for ten minutes 
 at a time, every hour, are very beneficial. A shade or 
 smoked glass may be worn to shield the eye from light. 
 
 The cauterization may be repeated in two or three 
 days, if necessary; often one application suffices. 
 
 CORNS 
 
 Corns are divided into hard and soft the latter being 
 those situated between the toes and differing from the 
 hard variety merely by being softened by maceration. The 
 treatment of each is the same: First, permanent removal 
 of the shoe which causes the pressure and friction, and 
 second, application of salicylic acid in some manner. To 
 relieve the suffering from inflammation around a corn, 
 or that from "soft corns," the foot should be bathed in 
 very hot water for a half hour; then dried carefully and the 
 surface touched with saturated solution of silver nitrate.
 
 CYSTITIS 143 
 
 The inflamed area around the corn may be surrounded 
 by a piece of gauze smeared with belladonna ointment, 
 covered with oiled silk, left on over-night. The burning 
 is to be repeated every fourth or fifth evening. For or- 
 dinary corns this may be ordered: 
 
 Salicylic acid 2.0 (grs. 30) 
 
 Extract of cannabis indica 0.5 (grs. 8) 
 
 Collodion 16.0 (oz. 1-2) 
 
 To be applied every night with a camelshair brush. It 
 often irritates a little for two or three days, but that soon 
 passes away and a cure is effected. 
 
 Soft Corns. The following formula is useful: 
 
 Acidi salicylici 4.0 (dr. i) 
 
 Menthol 4.0 (dr. i ) 
 
 Olei theobromatis 1 20.0 (ozs. 4) 
 
 Apply every night after soaking the feet in warm water. 
 
 CRADLE 
 
 In surgery the arculus or cradle is very useful in keep- 
 ing bed-clothes from coming in contact with a painful part. 
 It is easily made of wire or of hickory branches. 
 
 It is particularly useful for bruises or wounds of the 
 extremities, but may be made large enough to keep the 
 bed-clothes from the abdomen in appendicitis, etc. 
 
 CYSTITIS 
 
 Acute Cystitis. Acute cystitis may arise from gonor- 
 rhea, from infection by dirty sounds or catheters and 
 from injury. For the reduction of the fever which is pres-
 
 144 SURGICAL THERAPEUTICS 
 
 ent at the beginning, aconite is the best remedy, either as 
 the tincture or as a granule of aconitine : one-half milligram 
 (gr. 1-134) every hour or two until the temperature drops 
 satisfactorily. For the pain half a tablet of hyoscine- 
 morphine-cactin may be given every two or three hours 
 by the mouth. Sodium benzoate in dosage of one centi- 
 gram (gr. 1-6) every two or three hours gives good results, 
 either alone or in combination with phenol salicylate two 
 decigrams (3 grains). These should not be administered 
 until after the temperature has come down to near the 
 normal. While the aconitine is being given to check the 
 fever large quantities of water should be drunk, with good 
 doses of potassium citrate. During the height of the at- 
 tack an exclusive liquid diet preferably milk is to be 
 ordered. Occasionally the suffering is so great from the 
 irritation at the neck of the bladder that good sleep is im- 
 possible. A suppository of belladonna and extract of 
 opium in cacao butter, at bedtime, will give a good night's 
 rest: 
 
 Extract of belladonna o.i 
 
 Extract of opium .0.2 
 
 Cacao butter q. s. 
 
 Mix and make four suppositories. Each morning after 
 this is used an effervescing saline laxative (Abbott's) must 
 be taken, followed by an enema after the bowels are moved. 
 A few days' rest in bed is imperative. 
 
 Cystitis: Chronic* A very distressing sequel to any 
 operation in which the bladder has to be catheterized re- 
 peatedly is a chronic cystitis. The irritation may persist 
 for months in spite of the most energetic treatment. Prob- 
 ably the most satisfactory remedy is lithia; it may be given 
 as an effervescent tablet in a glassful of water three times 
 a day for long periods, or lithium benzoate may be used 
 in doses of one or two decigrams (one grain to three 
 grains) every four hours during the day until the stomach
 
 CYSTIC DISEASE 145 
 
 rebels. If there is much annoyance from having to urinate 
 at night two grams of potassium bromide with a teaspoon- 
 ful of tincture of hyoscyamus may be ordered at bed- 
 time. To some patients arbutin (from uva ursi) in doses 
 of one centigram (gr. 1-6) four to six times a day brings 
 relief. Others are benefited by half-gram doses of phenol 
 salicylate (salol) four times a day. Extreme cases demand 
 irrigation of the bladder with a saturated solution of boric 
 acid three times "a week; after a few washings it is w r ell 
 to inject a dram of fluid extract of hydrastis in two ounces 
 of water, at the end of an irrigation leaving it in the blad- 
 der. As a rule, the less local treatment the better. Two 
 quarts of water drunk daily will do much toward cure. 
 
 For Gonorheal Cystitis.. Of decided value in gon- 
 orrheal cystitis is arbutin in doses of five grains every three 
 or four hours. In cystitis due to other pyogenic microor- 
 ganisms it is soothing but not- so effective. 
 
 Phenol Salicylate for Cystitis. One of the most 
 valuable of all drugs used for cystitis is salol (salicylate of 
 phenol). This consists of about 6$-percent salicylic acid 
 and 35-percent phenol; is decomposed slowly in the intes- 
 tine by the pancreatic fluid into its original constituents; 
 and is eliminated through the urine as urate of salicyl, 
 though if given in large quantities some seems to pass 
 into the bladder unchanged. In five-grain doses every 
 three hours it effectually prevents decomposition of urine 
 in the bladder and keeps it from becoming alkaline. It 
 cannot be continued very long on account of producing 
 phenoluria. "\Yhenever the urine becomes smoky, boric 
 acid should be substituted for a few days. 
 
 CYSTIC DISEASE 
 
 Cystalgia. Pain in the bladder may be neuralgic, but 
 is usually due to stone, to infection or to stricture. (See 
 "Irritable Bladder.")
 
 146 SURGICAL THERAPEUTICS 
 
 Cystatrophia, A true atrophy of the bladder is rare, 
 and can have no remedy. Contracted bladder may some- 
 times be helped by gradual dilation, the best means being 
 daily irrigation, each day adding not to exceed one dram 
 of fluid to the amount injected through a fountain syringe. 
 A saturated solution of boric acid is best. 
 
 Cystobtfbonocele. This is the name applied to a 
 hernia of the bladder through the inguinal ring. It is 
 chiefly of interest in that it sometimes is opened by mis- 
 take for the hernial sac hence should always be borne 
 in mind in operations for incarcerated inguinal hernia of 
 the direct type. It is cured as is any other hernia : by clos- 
 ure of the opening by sutures. 
 
 CYSTS 
 
 Cyst adenoma* An adenoma is sometimes found 
 to contain cysts; when the name cystadenoma is given 
 to the growth. Treatment is the same as adenoma 
 (which see). 
 
 Cystocarcinoma. A cancerous tumor sometimes un- 
 dergoes a cystic degeneration in some part, when it is called 
 cystocarcinoma. The treatment is the same as cancer 
 (which see). 
 
 Dermoid Cysts are congenital tumors which con- 
 tain bone, teeth, hair, etc., occurring chiefly in the ovary, 
 though they may be found in the testicle, the abdominal 
 wall, etc., a favorite site being the region of the coccyx. 
 Early excision is advisable. 
 
 Echinococcus Cysts are those found in various tissues 
 and organs of the body, originating from the larvae of 
 taenia echinococcus, the tapeworm of the dog, which are 
 taken into the stomach. They are frequent among Ice- 
 landers and Esquimaux, those who are thrown into close 
 company with dogs; and in the temperate zone are occa- 
 sionally met in those who eat scraps from garbage-cans,
 
 DACTYLOLYSIS 147 
 
 etc. The liver is perhaps most often the site of this form 
 of trouble, Glisson's capsule being pushed off and the 
 parent-cyst developing daughter-cysts until almost the entire 
 abdomen is filled. The only treatment is incision, thor- 
 ough emptying of the cyst, cauterization with iodine and 
 phenol (of each equal parts) and packing; allowing the 
 cavity to agglutinate and the wound to close by granulation 
 without suppuration. 
 
 Miillerian Cysts are tumors developing in the 
 remnants or rudiments of the inferior (or vaginal) portion 
 of the duct of Miiller, and containing mucus or blood or 
 even pus. 
 
 Retention Cysts are those which originate in the 
 non-expulsion of the secretion of a gland, by reason of 
 the closure of the duct as sebaceous cysts, mucous cysts, 
 ranula, etc. Removal; or incision and cauterization. 
 
 Wblffian Cysts are those which develop in the 
 inferior vestiges of the canal of Wolff. They are found 
 in the anterior or anterolateral wall of the vagina, and 
 are sometimes prolonged toward the cervix and even into 
 the lower part of the broad ligament. Extirpate. 1 
 
 DACTYLITIS 
 
 Inflammation of a finger or toe may be (i) traumatic, 
 (2) rheumatic or (3) syphilitic. The first is to be treated 
 by antiseptic applications; the second by antirheumatic 
 remedies; the third by iodides and mercury. If pus forms 
 it must be evacuated very early to prevent burrowing along 
 the tendons with consequent great deformity. It is easy 
 to open and easy to cure. 
 
 DACTYLOLYSIS 
 
 The falling off of a finger or toe, due to gangrene, 
 leprosy, Reynaud's disease, etc., is a very rare surgical 
 accident. Treatment consists merely in the application
 
 148 SURGICAL THERAPEUTICS 
 
 of antiseptic dressings to the stump and attention to the 
 disease which is the cause of the spontaneous ampu- 
 tation. 
 
 DEPILATORY 
 
 Most of the liquid depilatories on the market are solu- 
 tions of barium sulphide. To remove the hair from the 
 downy surface of a woman's skin iodine-collodion has been 
 used, the collodion being painted on the part a'nd removed 
 when dry, bringing the adhering hairs with it. The fol- 
 lowing formula has been proposed: 
 
 Tincture of iodine (iini2) 3 parts 
 
 Oil of turpentine 6 parts 
 
 Castor oil 8 parts 
 
 Alcohol (go-percent) 19 parts 
 
 Collodion 100 parts 
 
 This is painted on the part and as the film comes off the 
 hairs are supposed to come with the firm. There is, how- 
 ever, nothing so satisfactory as a paste formed by adding 
 water to a specially prepared barium powder. For such 
 the following is a good formula: 
 
 Barium sulphide 25 parts 
 
 Powdered soap 5 parts 
 
 Powdered talc 35 parts 
 
 Corn starch 35 parts 
 
 Perfume q. s. 
 
 One teaspoonful of the powder is made into a paste with 
 three teaspoonfuls of water and applied to the parts with 
 an ordinary shaving brush in a moderately thick and even 
 layer. After four to five minutes the parts should be moist- 
 ened with a sponge, when, after another five minutes, the 
 hair can be removed by washing off the mass. It is impor- 
 tant to use barium sulphide in as fresh a condition as pos- 
 sible; that oxidized by exposure to air should not be em- 
 ployed.
 
 ECZEMA 149 
 
 DUSTING POWDER: RESORCIN AS 
 
 Rarely from an infected wound there is too free dis- 
 charge and an antiseptic dusting powder is desired. A 
 most admirable one is: 
 
 Resorcin i part 
 
 Boric acid 20 parts 
 
 Mix thoroughly. This may be dusted freely on the 
 affected surface. It is much more pleasant than iodoform, 
 yet possesses all the antiseptic value of that malodorous 
 powder. 
 
 DYSPEPSIA: SURGICAL CURE OF 
 
 S>me marvelous cures are being reported of apparently 
 incurable chronic "indigestion" by removal of gallstones 
 previously unsuspected by the victim. Cases dependent 
 upon gastric or duodenal ulcers are also relievable by a 
 not dangerous operation. 
 
 DYSPHAGIA: BROMIDES FOR 
 
 Occasionally a child is brought to the surgeon for 
 presumed stricture of the esophagus "congenital spas- 
 modic stricture" it may have been pronounced. Investi- 
 gation reveals the queer fact that since birth the little 
 patient has been able to- swallow solid food but that every 
 attempt to drink any fluid is followed by choking: violent 
 expulsive efforts, coughing, even strangling. The most 
 careful examination reveals nothing in the way of organic 
 cause it is purely nervous. A few days' treatment with 
 elixir of bromide of potassium will almost invariably relieve 
 the trouble. It may be necessary to repeat the medicine 
 every three or four weeks for some months before a com- 
 plete cure is effected. 
 
 ECZEMA 
 
 The tendency of eczema to produce ulcers in certain 
 regions of the body places this disease within the category
 
 150 SURGICAL THERAPEUTICS 
 
 of surgical affections. Hundreds of prescriptions have been 
 suggested for this sometimes intractable condition. Merck's 
 Archives gives the following, which are among the best. 
 In acute eczema, blue mass or compound cathartic pill, 
 followed next morning by an effervescent saline laxative 
 will be found advisable. Natural mineral waters are useful. 
 When both iron and magnesium sulphate are indicated 
 the following may be used: 
 
 Magnesii sulph 64.0 (ozs. 2) 
 
 Acidi sulphur, dil 16.0 (drs. 2) 
 
 Ferri sulph ". 0.6 (grs. 10) 
 
 Sodii chlor 4.0 (dr. i) 
 
 Tinct. cardamom, comp ... 4.0 (dr. i) 
 
 Aquae dest 256.0 (ozs. 8) 
 
 Filtra. Sig: One tablespoonful before breakfast in a 
 tumblerful of cool or hot water. 
 
 In case of renal derangement diuretics are indicated, 
 and in gouty cases, colchicum and Vichy water. 
 
 When both diuretics and alkalies are indicated, the 
 following may be used: 
 
 Magnesii sulph 16.0 (oz. 1-2) 
 
 Magnesii carb 4.0 (dr. i ) 
 
 Tinct. colchici 2.0 (dr. 1-2) 
 
 Ol. menth. pip o.i (min. 2 ) 
 
 Aquae dest 192.0 (ozs. 6 ) 
 
 The following is a useful lotion: 
 
 Phenol 3.0 (grs. 45) 
 
 Zinci oxidi 4.0 (dr. i ) 
 
 Glycerini 8.0 (drs. 2) 
 
 Aquae calcis q. s. ad. 252.0 (ozs. 8) 
 
 In this formula, when carbolid acid (phenol) does not 
 act favorably, dilute hydrocyanic acid may be substituted. 
 Tragacanth mucilage may be used instead of glycerin, or
 
 ECZEMA 151 
 
 both may be omitted and half the amount of lime water 
 may be replaced by an equal quantity of elder-flower water: 
 
 Acidi hydrocyanici dil 4.0 (dr. i) 
 
 Zinci oxidi 4.0 (dr. i) 
 
 Calaminae 4.0 (dr. i ) 
 
 Aquae calcis 128.0 (ozs. 4) 
 
 Aquae sambuci 1 28.0 (ozs. 4) 
 
 Use as a lotion three or four times a day. 
 It must be borne in mind that a disturbed nervous 
 system, associated with a chronic intestinal indigestion, 
 will always be found back of the eczematous manifestations; 
 so arsenic and strychnine are frequently indicated, but 
 particularly must attention be directed to proper food 
 selection. 
 
 Influence of Diet in the Treatment of Eczema. 
 Ravogli says that next to the kidneys the skin must be con- 
 sidered as an organ of elimination; indeed it has more 
 eliminating power for some products than the kidneys 
 themselves. The occurrence of eruptions after the inges- 
 tion of certain foods is not accidental. The skin is active 
 in eliminating substances which are detrimental to the 
 general economy. Individuals subject to eczema should 
 subsist upon good, wholesome home cooking. The food 
 should be fresh and of unquestionable nature. When prod- 
 ucts of fermentation develop in the stomach or in the 
 intestines it must be admitted that there is a diseased con- 
 dition of the functional activity of these organs. There 
 is usually a catarrhal condition of the mucosa of the stom- 
 ach or a nervous condition which brings about "dyspepsia." 
 The same may be present in the intestines. The diet in 
 such cases must protect the parts as much as possible and 
 eliminate non-irritating qualities. Food which leaves the 
 smallest possible residue should be eaten. As a rule 
 therefore a coarse diet is better than a light diet. One 
 should advise the use of graham and rye bread together with
 
 152 SURGICAL THERAPEUTICS 
 
 honey, fruit juices, stewed plums, leguminous plants, 
 boiled and baked potatoes; plenty of fresh milk, cream, 
 and butter are also adyised. Meats, beef, veal, fresh pork, 
 boiled ham, chicken, with plenty of vegetables are to be 
 given without fear, as well as fresh white-fish, trout and so 
 forth. Dark meats, venison, corned beef, mackerel, lobster, 
 eel, and strong cheese are forbidden. Candies and sugar 
 must not be taken. Fresh country air and natural mineral- 
 spring waters are very helpful in the treatment of these 
 cases. The influence of diet on the treatment of eczema 
 in gouty people is almost incredible. 
 
 Surgeon's Eczema. By reason of much hand scrub- 
 bing, long continuance of the hands in fluids and exposure 
 to cold air before perfect drying, the hands of busy opera- 
 tors are apt to become sore from a kind of dry eczema, 
 especially in very cold weather. Applications of vase- 
 line camphor-ice each night will prevent this; so also 
 the use of the following: 
 
 Phenol 5.00 
 
 Oil of cade 10.00 
 
 Lanolin 500.00 
 
 Oil of rose q. s. 
 
 This is to be well rubbed in each night, with especial 
 attention to palmar surfaces. 
 
 EMPYEMA 
 
 The treatment of pyothorax may be summed up in 
 two words: proper drainage. What constitutes proper 
 drainage is the only source of controversy, but the fol- 
 lowing may be said to be definitely settled: (i) Empy- 
 ema of childhood may be successfully treated by mere 
 incision under perfect antiseptic precautions in a large 
 percentage of cases; persistent discharge (more than six 
 weeks) may necessitate excision of a small piece of rib. 
 (2) In some instances of the disease in adult life the
 
 ENEMA: NUTRIENT 153 
 
 Estlander operation is sufficient; removal of three or four 
 inches of one or two ribs. (3) If the discharge con- 
 tinues more than two months after an Estlander opera- 
 tion, the more extensive Schede operation must be resorted 
 to: excision of the entire chest- wall, including the parietal 
 pleura, over as much of the thorax as the abscess-cavity 
 underlies; that is, all of the external surface of the abscess- 
 cavity must be cut away, leaving nothing but the pyogenic 
 visceral surface, which must be cleaned by rubbing with 
 gauze, the skin being then allowed to fall in upon the 
 more or less collapsed lung. If this extensive area be 
 kept clean by simply wiping it carefully every second or 
 third day, healthy granulations will spring up; and as 
 the cavity is obliterated, the lung will expand until by 
 the time the wound closes, very .little depression will 
 remain in most cases. The cavity should not be irrigated 
 with water, hydrogen dioxide or any other liquid, as a 
 rule; all that is needful is cleaning away the excess of pus 
 without disturbance of the granulations and loosely pack- 
 ing with plain gauze covered by an abundance of absorb- 
 ent cotton. By this simple treatment convalescence is 
 much more rapid and the resultant deformity less marked 
 than when the surgeon does too much in the way of irri- 
 gating, washing, sponging and using antiseptic agents. 
 Internally the patient should be given the best of food, 
 codliver oil or cream in large quantities, tonics and stimu- 
 lants; for the primary lesion usually is of tuberculous 
 character and unless free drainage is secured and the 
 general health supported, pulmonary tuberculosis will 
 follow; but if the proper treatment is carried out, recovery 
 may be secured in a majority of cases. 
 
 ENEMA: NUTRIENT 
 
 After abdominal section (and some other serious 
 operations as well) rectal feeding becomes a necessity.
 
 154 SURGICAL THERAPEUTICS 
 
 An excellent nutrient enema is made by dissolving a table- 
 spoonful of sugar in a teacupful of hot water and boiling 
 in it, for a few minutes, a teaspoonful of starch; add a 
 wineglassful of wine; beat up two eggs in a tablespoon- 
 ful of milk and mix with the other and inject. It may 
 be repeated every four to six hours until the patient is 
 able to take nourishment by the mouth. 
 
 ENURESIS NOCTURNA 
 
 That "wetting the bed" by a child should be a symp- 
 tom of nasopharyngeal adenoids seems at first glance to 
 be ridiculous; but we cannot but be convinced of the 
 accuracy of the observation when one notes the results 
 in twenty-three children suffering from enuresis nocturna 
 who were found to have adenoid growths and removal 
 was practised. Of the twenty-three operated upon, 
 there were twelve in which the enuresis (of several years' 
 duration) practically ceased immediately, or within a 
 short time after operation, and did not return during 
 the time it was possible to keep the children under obser- 
 vation. In five more, recurrence was noted only after 
 long intervals, or only after a cold causing temporary 
 nasal obstruction; in two improvement was moderate; 
 hi one there was no return (period of observation after 
 operation only nine days); while in only three removal 
 of the adenoids had no apparent effect upon the enuresis. 
 
 Three explanations are allowable as to the effect of 
 operation hi overcoming the enuresis: One is the impress 
 upon the nervous system by the shock of operation; the 
 second (and a far more plausible one) finds in the reestab- 
 lishment of nasal respiration a removal of the exciting 
 cause of enuresis; while the third (my own) is that the 
 adenoids excite the sexual centers of the nasal mucous 
 membrane and cause the bladder to act unwisely. (See 
 note on "Nasal Dysmenorrhea.") This latter relation is in
 
 EPILEPSY: TRAUMATIC 155 
 
 accordance with the theory of Major, which presumes 
 the cause of the enuresis to be the overloading of the 
 blood with carbonic-acid gas. Gronbeck does not regard 
 all cases of enuresis as due to adenoids; but says that 
 impeded nasal respiration should always be regarded as 
 a possible factor and that in children the most frequent 
 cause of such trouble is nasopharyngeal lymphoid growths. 
 
 EPIDIDYMITIS 
 
 According to Mackinney best results are obtainable 
 in gonorrheal epididymitis by the application of a sat- 
 urated solution of magnesium sulphate, in conjunction 
 with elevation of the scrotum. After the acute symptoms 
 are relieved an ointment composed of equal parts of the 
 ointments of belladonna and mercury, together with the 
 same quantity of ichthyol ointment, lo-percent, and 
 lanolin, should be employed to hasten the absorption of 
 the exudate. 
 
 As a local application for epididymitis there is nothing 
 superior to 
 
 Aqueous extract of opium 8.0 (drs. 2) 
 
 Guaiacol 8.0 (drs. 2) 
 
 Lanolin 32.0 (oz. i) 
 
 Half vaseline may be used after the first boxful; it 
 does not permit such rapid absorption. The salve is 
 equally soothing and remedial in orchitis. 
 
 EPILEPSY: TRAUMATIC 
 
 Far more cases of epilepsy depend upon trauma 
 than is generally supposed. Those in which depressed 
 fracture or other local irritation can be determined are 
 fit subjects for operative treatment; but the friends of 
 the patient should be thoroughly impressed with the 
 idea that the patient must be kept under internal 
 treatment for at least a year after operation. In truth
 
 156 SURGICAL THERAPEUTICS 
 
 more epilepsy is absolutely curable than taught in our 
 books. But in assuming treatment of any case there 
 should always be a written agreement that the patient 
 shall be under control at least two years, during which 
 time one should treat every function of the individual 
 so as to keep his general health in the best possible con- 
 dition. Of course, institutional treatment is better in 
 most cases than private treatment. Bromides and elim- 
 inatives are the basis of therapy; but solanine in doses of 
 1-67 grain four times a day, pushed up gradually to 1-12 
 grain, is earnestly advocated. Above all, the food must 
 be of the most simple, easily digestible kind, and never 
 eaten in excess; and the colon must be kept as nearly 
 empty as possible. 
 
 EPISTAXIS 
 
 When nosebleed is persistent the nares may be plugged 
 by tamponing with a long, narrow strip of iodoform gauze 
 through each nostril; or a string may be passed through 
 from front to back, brought out of the mouth and attached 
 to a roll of gauze large enough to plug the posterior nares 
 when it is pulled up behind the soft palate, and against 
 this, held firmly by the string, the gauze tampon may be 
 packed tightly upon the side from which the hemorrhage 
 occurs. Aconitine, one milligram (1-67 grain), and vera- 
 trine, half a milligram (1-134 grain), may be given every 
 half hour until the pulse becomes soft. Lemon juice 
 or even vinegar may be injected into the nostril in less 
 serious cases. Injection of adrenalin sometimes arrests 
 it instantly; and a 2o-percent solution of antipyrin also 
 acts energetically as a styptic. Ice to the back of the 
 neck is a "home remedy" often very effective. 
 
 ERYSIPELAS 
 
 Convalescence from Erysipelas. During conval- 
 escence energetic use of tonics is indicated. Iron and
 
 ERYSIPELAS 157 
 
 bitters are each commendable. The following combina- 
 tion is good: 
 
 Tincture of chloride of iron.. 16.0 (drs. 4) 
 
 Simple syrup 50.0 (drs. 12) 
 
 Whisky 192.0 (ozs. 6) 
 
 Mix. Direct' One tablespoonful one hour after each 
 meal. 
 
 Arsenic, two milligrams, and strychnine the same, may 
 well be given at meal time in a capsule with quinine. 
 
 Facial Erysipelas. Early in an attack of erysipelas 
 of the face it is a good plan to cover the affected area 
 with equal parts of ichthyol and extract of belladonna, 
 a piece of rubber tissue or oiled silk being placed over 
 it to keep out the air. A half centigram (gr. 1-12) of 
 pilocarpine may be given hypodermically, and repeated 
 by mouth every two hours until profuse perspiration is 
 induced; then one every four to six hours to keep the skin 
 constantly moist. The bowels must be kept active, pref- 
 erably by saline laxatives. If the temperature runs high 
 a few doses of acetanilid (half gram, repeated in two 
 hours twice in twenty-four hours) may be given early 
 in the trouble, but must be watched carefully later. Stimu- 
 lants and food are indicated always. Sulphate of strych- 
 nine (one-fourth centigram 1-20 grain) may be given 
 every six hours when the patient is weak. 
 
 Local Applications in Erysipelas, The erysipelatous 
 area may be painted with pure phenol, or with a solution 
 of 160 grains of silver nitrate to the ounce of water, though 
 this sometimes causes a slough, and then covered thickly 
 with a paste made of equal parts of ichthyol and lanolin; 
 rubber tissue should be placed over this and then a pad 
 of absorbent cotton held in place by a bandage. This 
 dressing must be changed twice a day. If there be great 
 pain belladonna ointment may be substituted for the 
 lanolin.
 
 158 SURGICAL THERAPEUTICS 
 
 Treatment of Facial Erysipelas. For more than 
 a quarter of a century Prof. W. F. Waugh has not had a 
 case of facial erysipelas which did not promptly yield to 
 treatment, consisting of pilocarpine in sthenic cases and 
 iron in asthenic ones; with practically no attention to 
 local measures save exclusion of the air. In sthenic cases 
 the pilocarpine is given every hour until sweating occurs. 
 When this takes place the edges of the involved area 
 begin to recede. This remedy is then suspended for a 
 day, and if the eruption continues the treatment is resumed 
 until it is evident that the remedy has perfect control of 
 the disease. In asthenic cases the tincture of the chloride 
 of iron, thirty drops, is given every four hours, and nour- 
 ishment is crowded, when improvement sets in at once. 
 
 ESOPHAGUS: FOREIGN BODY IN 
 
 Candler suggests that apomorphine, half a centigram 
 (gr. 1-12) injected hypodermically, will quite often cause 
 the expulsion of the offending substance. Give enough 
 apomorphine and the stomach will empty itself within 
 five minutes. As the drug relaxes muscular tissues gen- 
 erally, it serves in this instance a double purpose. 
 
 FECAL DISORDERS 
 
 Fecal Fistulas. In spite of every precaution dur- 
 ing operation a fecal fistula will form now and then, espe- 
 cially in dealing with periappendical abscess. Fortunately 
 far more than a majority of the cases heal spontaneously 
 in a very few days to a year, a year being the practical 
 limit in which nature may be expected to cure the con- 
 dition. Those sinuses running through the vaginal canal 
 are usually a better prognosis than the abdominal wall. 
 When secondary section is made to close the opening 
 in the gut a large proportion of the cases die from exhaus- 
 tion or complicated conditions; the operation itself cures 
 about 50 percent. Therefore it is best to exhaust medi-
 
 FEET: DISORDERS OF 159 
 
 cal and local treatment before any operation is tried. 
 The diet should be non-fermenting and easily digestible, 
 the patient kept in bed for a long time and the parts kept 
 surgically clean as far as possible, and every effort made 
 to close the wound at the intestinal opening. After the 
 sinus is gotten as clean as it may be from packing and 
 cleansing, the bowel should be thoroughly cleared out 
 and then peristalsis checked by the free use of morphine, 
 allowing if possible a rest of one week with concentrated 
 food. The moving of the bowels is then done by enemas. 
 The surgical treatment consists in removal of the sinus 
 and a wedge-shaped piece of gut. 
 
 For Fecal Impaction. In cases of fecal impaction 
 try rectal injection of a pint of kerosene. It often "works" 
 admirably. 
 
 FEET: DISORDERS OF 
 
 Flat-Foot These cases are separable into three 
 classes: (i) The flabby, easily moved foot which, on 
 weight-bearing, becomes pronouncedly flat, due to a 
 laxity of the muscles and ligaments. The condition is 
 associated with vasomotor disturbances and varicose 
 veins, and is due possibly to altered circulatory condi- 
 tions. If a pad is used to correct the condition, tonics 
 and massage are also indicated. Instead of the pad it 
 is better to raise the inner side of the sole and heel and 
 by thus causing inversion and adduction, bring about a 
 physiological raising of the arch. (2) The spasmodic 
 form, resulting from a persistence of the above, or due 
 to injury such as a sprain or Pott's fracture, rheumatic 
 fever or gonorrhea. The spasm must be overcome by 
 rest or manipulation, putting the foot in an overcorrected 
 position in plaster. If need be, tenotomize the extensor 
 communis digitorum and peronei muscles. (3) Rigid flat 
 feet with great alterations in the relations of the bones
 
 160 SURGICAL THERAPEUTICS 
 
 and seeming ankylosis. Here operation is called for: 
 Exsection of the astragalo-scaphoid joint. 
 
 Sweating Feet, The following formula is an excel- 
 lent one for sweating of the feet: 
 
 Potassium permanganate 13 parts 
 
 Alum i part 
 
 Talc 50 parts 
 
 Zinc oxide 18 parts 
 
 Calcium hydrate 18 parts 
 
 Another formula highly recommended is: 
 
 Salicylic acid 2 parts 
 
 Zinc stearate i part 
 
 Talc 40 parts 
 
 Compound tincture of vanilla q. s. 
 
 The last-named ingredient is simply to cover the 
 odor. 
 
 Swollen Feet. Swelling of the feet may be found 
 in (i) dropsy, especially from a weak heart, (2) those who 
 take but little exercise but are rheumatic or gouty, par- 
 ticularly found in elderly people, and (3) those who are 
 compelled to stand or walk too much, notably if bad 
 shoes are worn. In every one of these, however, small 
 doses of arsenic (a milligram or two three times a day) 
 will do good; and in the first and last varieties strychnine 
 may be added in the same dose but must not be con- 
 tinued longer than three weeks. In every case careful 
 examination of the respiratory, circulatory and renal 
 system must be made before deciding the condition to be 
 trivial 
 
 Tender Feet. From too tight shoes, from standing 
 too long, from abrasions of the skin, from too thin soles, 
 etc., the feet often become tender and quite painful. Bath- 
 ing in very hot water every night is comforting. If the
 
 FINGER3: CONTRACTURES O 161 
 
 skin continues tender, the feet should oe rubbed morn- 
 ing and evening in 
 
 Salicylic acid 5.0 (drs. i 1-2) 
 
 Borax 10.0 (drs. 3 ) 
 
 Glycerin 128.0 (ozs. 4 ) 
 
 Water 128.0 (ozs. 4 ) 
 
 Sometimes the arch of the foot is weak and in need 
 of a light steel spring in the bottom of the shoe. The 
 use of rubber heels relieves many cases of footache. 
 
 FELON: TO ABORT 
 
 Over a forming whitlow apply absorbent cotton sat- 
 urated with alcohol, and cover with a piece of rubber 
 tissue (or even a large finger-cot) in such a way as to 
 exclude the air. In from sixty to seventy-two hours 
 relief will be complete, and a cure effected in a majority 
 of cases practically all if seen early. 
 
 FEVERS: SURGICAL 
 
 Aconitine is a valuable drug in controlling the fever 
 which naturally follows infection of a wound such as 
 a crushed foot or an abscess or boil. It may be given 
 in doses of one-half milligram (gr. 1-134) every half hour 
 until the temperature falls. If dispensed in granule form 
 the patient must be instructed to swallow it quickly, throw- 
 ing it well back into the throat, or disagreeable and per- 
 sistent numbness of the tongue will be produced; or it 
 may be given dissolved in at least an ounce of water. A 
 small capsule may be used if preferred. This dosage is for 
 the "amorphous" aconitine. It must be remembered 
 that there is a "crystalline aconitine" upon the markets 
 several times as strong the dose of which is 1-500 grain. 
 
 FINGERS: CONTRACTURES OF 
 
 Sometimes contracture of the fingers following the 
 treatment of a cellulitis of the hand and forearm may
 
 162 SURGICAL THERAPEUTICS 
 
 be due, not to the cellulitis itself nor to the incisions made 
 to relieve it, but to fibrosis and shortening of the flexors 
 in the forearm, the result of too tight bandaging or strap- 
 ping. Such a condition Volkmann's ischemic muscle 
 contracture must, therefore, be distinguished from the 
 stiff, flexed fingers produced by cellulitis. Passive motions 
 and massage are helpful in both conditions, but in the 
 former shortening of the radius and ulna is necessary to 
 accommodate the contractured muscles. 
 
 FISTULA: TREATMENT AFTER OPERATION 
 
 At the completion of operation for fistula of the anus 
 a hard-rubber tube is introduced well above the cut sphinc- 
 ter and gauze tamponed around it firmly. This permits 
 the escape of gas while the barrier of beginning granulation 
 starts upon the raw surface. That granulation may be- 
 come fairly well established before irritation by the passing 
 feces is permitted it is best to keep the bowels from moving 
 for six days if possible, a liquid diet being advised. If the 
 packing is saturated with the wound-discharge before this 
 time it may be removed and fresh gauze inserted; but as 
 this is very painful it is better to leave the original packing 
 several days even if it does become very foul of odor. When 
 the gauze is removed a high enema of olive oil, or an ox- 
 gall enema may be given. Later a saline laxative is to be 
 ordered. After the bowels have moved the wound should 
 be cleaned by gentle washing, the two raw surfaces being 
 carefully separated, iodoform dusted in freely and a strip 
 of iodoform gauze carried well into the rectum and packed 
 loosely into the cut; with a pad of absorbent cotton over 
 all, supported by a T-bandage. If possible the dressing 
 should be made twice daily for some days; later once daily; 
 and as the discharge lessens, every second day, though the 
 patient is instructed to clean it as well as possible after 
 each bowel-inovement. Should granulation be too slow,
 
 FRACTURES 163 
 
 dressing with balsam of Peru daily will soon stimulate the 
 surfaces sufficiently to insure early healing. The patient 
 should, when circumstances permit, lie in bed two weeks; 
 but most will insist upon being at work in ten days which 
 does not greatly retard healing if operation has been done 
 properly. Most careful attention must be paid to building 
 up the general health of the patient during convalescence. 
 Temporary loss of sphincteric control need not occasion 
 anxiety. 
 
 FRACTURES 
 
 Colles's Fracture, The inflexible rule in Colles's 
 fracture should be to refuse treatment unless the patient 
 will permit reduction in complete surgical narcosis. If 
 dressings are applied without anesthesia great deformity 
 is almost sure to follow. But if all muscles be relaxed 
 it is easy to exert sufficient force to overcome the defor- 
 mity at once, when if pains be taken to maintain the nor- 
 mal position of the ulna by a sufficiently hard and prop- 
 erly applied pad, placed on the palmar side of the end 
 of the ulna, an excellent result can be predicted. If, in 
 addition, early massage and movements of the fingers, 
 both active and passive, be employed, the very best 
 results can be obtained in the great majority of cases. 
 When the desired method cannot be adopted the wrist 
 may be put as nearly straight as possible and several 
 straps of adhesive plaster wrapped around wrist and 
 forearm. 
 
 Fracture of the Acromion. Raise shoulder by 
 supporting elbow in sling; place pad in axilla; bind arm 
 to side by broad bandage around body. Ligamentous 
 union may be expected. Liberate in three weeks. 
 
 Fracture of the Fingers. Pull the broken finger 
 until it is straight and apply a small splint extending 
 well up into the palm of the hand and bandage rather
 
 164 SURGICAL THERAPEUTICS 
 
 tightly. Tighten the bandage in a day or two when 
 swelling subsides and leave splint on for ten days. When 
 the fracture occurs into a joint, passive motion must 
 be instituted as soon as the splint can be removed. 
 
 Fracture of the Forearm. When both bones of the 
 forearm are broken the fragments should be replaced under 
 chloroform. A thin, hard splint, extending well down into 
 the palm (and also well above the elbow if the break is 
 within two inches of that joint), should be placed on the 
 front and a smaller one on the back, held by a two-inch 
 bandage snugly applied. The splints should be well 
 padded. Bandages must be tightened on the third or 
 fourth day, great care being taken that the fragments are 
 not displaced. In children plaster of paris may be applied 
 after the swelling is gone. The splint must be worn three 
 weeks. Advocation of early passive motion is to be 
 condemned. 
 
 Fractures of the Head of Radius. The x-ray has 
 shown that fractures of the head of the radius are common 
 instead of rare as taught heretofore. It shows that in the 
 uncomplicated variety (probably the most frequent), a 
 vertical line of fracture separates the anterior third or half 
 of the head. Thomas says: In a fall on the hand with 
 the elbow extended, only this portion of the head is in con- 
 tact with the capitellum of the humerus, so that the down- 
 ward impact breaks it off; the resistance of the intact coro- 
 noid process prevents separation of the fragments and 
 consequent rupture of the orbicular ligament; the lines of 
 fracture on the upper surface of the head tend to radiate 
 from the periphery towards the center, so that when less 
 than a half of the head is detached the small fragment is 
 angular in shape; it fits closely into a corresponding depres- 
 sion in the remaining portion of the head, and is held there 
 by the untorn orbicular ligament. As a result, the head 
 will move as a whole within the ligament, movement of
 
 FRACTURES 165 
 
 one fragment on the other being impossible. Sometimes 
 the line of fracture is straight, especially when the detach- 
 ment includes half of the head, and in these cases crepitus 
 will be possible. Absence of crepitus in the presence of 
 positive fracture is peculiar, but the localized and severe 
 pain and tenderness, and the limitation of motion in the 
 elbow, are sufficiently characteristic to establish the diag- 
 nosis in most cases, much more so than in the average case 
 of fractured rib. The fact that this fracture is always 
 intracapsular makes it important from the standpoint 
 of prognosis, although the close splinting of the fragments 
 by the untorn orbicular ligament favors a good result in 
 most cases. It is probable that most of the obscure 
 "sprains" of the elbow, followed by more or less ankylosis, 
 are in reality fractures of the head of the radius. Fixation 
 of joint for three weeks is all the treatment usually needed. 
 It will rarely be necessary to excise the head of the radius, 
 as is done by Stimson in most of his cases, or to excise 
 the detached fragment, as is done by Cheyne. 
 
 Fracture of the Humerus. Reduce fracture as well 
 as possible and put in wooden splints until swelling is 
 gone. On the fourth to the sixth day chloroform the patient, 
 remove the splint, put the fractured ends in exact apposition 
 and apply a plaster-of-paris splint over a layer of cotton 
 batting, including shoulder and elbow bent at nearly right 
 angle. Have the forearm carried in a sling. Remove the 
 plaster in four weeks and use passive motion. 
 
 If the break is into the elbow, passive motion should 
 be begun at the third week, the wooden splint being reap- 
 plied after each treatment. A good joint can usually be 
 secured in children, if motion be made daily after the end 
 of the third week. 
 
 Fracture of the Leg, Chloroform the patient and 
 correct the deformity. Put in splints from the sole of the 
 foot to above the knee one on each side of the leg, well
 
 166 SURGICAL THERAPEUTICS 
 
 padded and bandage so as to immobilize the ankle and 
 knee. In four days remove the splints, with the help of 
 another doctor who will prevent displacement of the frag- 
 ments; wrap the leg in cotton-batting and apply four 3- 
 inch plaster-of-paris bandages, including the ankle and 
 knee. Let the patient out on crutches at the end of one 
 week; no weight is to be borne on foot. Remove the 
 plaster at the end of three weeks four weeks in the case 
 of debilitated patients and permit the patient to walk 
 with a cane. 
 
 Fracture of the Olecranon. -In fracture of the 
 olecranon Murphy advises subcutaneous wiring. It may 
 be done without opening the joint and without any danger 
 of infection if one is very careful as to aseptic details. 
 
 Fracture of the Patella. Incision over the frac- 
 ture, withdrawal of the soft tissues from between the 
 fragments and suturing with twenty-day chromic gut, con- 
 stitute the essential features of the most approved treat- 
 ment of fracture of the patella. 
 
 The mortality of cases properly operated upon is no 
 higher than that of those not cut. In a case not operated 
 upon, the patient generally does not get full use of the 
 limb, cannot kneel well and has difficulty in going up-stairs 
 or up-hill. Only those cases in which there is no separa- 
 tion of the fragments give ideal results from non-opera- 
 tive treatment. In cases treated by aseptic suture there 
 is generally complete return of function, and these only 
 require half as long as the average for union to occur. 
 All cases in which the fragments are widely separated 
 should be operated on at once. Where the fragments 
 can be brought into perfect apposition easily the circular 
 subcutaneous suture around the patella is perhaps satis- 
 factory, but generally the bone should be exposed and 
 united by silver wire or No. 4 chromic gut passed through 
 holes bored from the anterior surface near the break and
 
 FRACTURES 167 
 
 coming out on the back part of the fractured surface, 
 so that the joint proper is not entered. The ligaments 
 are sewed with plain catgut. To get -perfect function 
 it is necessary to begin use of the joint early and to force 
 exercise in spite of pain and stiffness. Massage and 
 passive motion must be begun eight or ten days after 
 operation, and walking in three weeks. 
 
 Fracture of the Thigh. Dress the fracture by put- 
 ting the thigh between sand-bags or in a splint box lined 
 with pillows until the worst of the swelling has disappeared. 
 On the fourth or fifth day anesthetize the patient, reduce 
 the fracture and apply a long splint from below the foot 
 to near the axilla, and a shorter one from the perineum 
 to beyond the foot both being well padded. Bandage 
 tightly, including the foot and lower part of the abdomen 
 and hip. Apply a weight of from ten to sixteen pounds, 
 suspended from the foot over a pulley at the end of the bed, 
 using weight enough to counteract the tendency to short- 
 ening. Keep the patient quiet for six weeks. From one 
 to two inches shortening may be expected, but if the pa- 
 tient be kept quiet and the weight be well borne there may 
 be practically none. 
 
 Fracture of the Ulna. This is produced by a direct 
 blow, or by falling with the arm across a sharp edge of 
 board, stone, etc. Often more attention to the injured 
 soft parts is required than to the fracture itself. A firm 
 piece of pasteboard suffices for a splint. Fixation for 
 two weeks is required. Fractures of the coronoid process 
 of the ulna are not very common. They are recognizable 
 and are not especially hard to manage. Fixation of the 
 elbow-joint at or beyond a right angle by means of a 
 plaster-of-paris bandage over a lightly padded gauze or 
 flannel bandage gives a good result after three weeks' 
 immobilization. But when left unreduced for weeks, re- 
 section of joint has to be performed.
 
 168 SURGICAL THERAPEUTICS 
 
 Operative Treatment of Fractures. Some cases 
 of even simple fracture are better treated by operation. 
 Kelley, of Philadelphia, thinks the advantages are: (i) 
 Relief of pain from movement of fractured ends and from 
 tension due to extra vasated blood. (2) The possibility 
 of accurately approximating and retaining in position the 
 fractured portions of bones. (3) Prevention of shortening 
 and deformity. (4) The possibility of removing clots 
 and repairing neighboring structures. (5) Excessive callus 
 formation is prevented, and in fractures involving joints, 
 subsequent limitation of motion and deformity is also 
 prevented. (6) Pressure on adjoining structures is re- 
 moved. (7) Associated dislocations may be properly 
 reduced. (8) The period of disability is considerably 
 lessened. (9) The skeletal mechanics of the patient are 
 left as before the fracture. These advantages, he thinks, 
 vastly outweigh the possible dangers of infection or necrosis 
 of the fractured ends, and of an external scar. When 
 conservative methods fail to insure perfect approximation 
 and retention and when the preservation of the skeletal 
 mechanism is important, especially in laborers, there should 
 be no hesitancy in converting a closed fracture into an 
 open one. Absorbable sutures are to be preferred for 
 uniting the bones, and as all methods require some sort of 
 external retentive apparatus, it would seem that the ideal 
 form of internal fixation is by the heavy (No. 3) chromi- 
 cized catgut. The operative treatment of open fractures 
 and of separated epiphyses and fractures associated with 
 locations thus comes under the department of operative 
 surgery. 
 
 Swbperiosteal Fracture. Severe localized pain after 
 traumatism, especially in children, may be due to sub- 
 periosteal fracture, notably in injuries to the head of the 
 humerus or the femur. Extreme localized tenderness is 
 the characteristic symptom. An abnormal mobility and
 
 GALLSTONES 169 
 
 marked deformity are absent, and crepitus may not be 
 e icited. The break is usually almost transverse. It is 
 to be treated by suturing with chromic catgut through 
 drill-holes, in case the existence of the fracture is recog- 
 nized only late. Of course if it is known early that the 
 fracture is present, perfect immobilization will give satis- 
 factory results. 
 
 GALLIC ACID OINTMENT 
 
 Practitioners of the last century were very fond of gallic 
 acid on account of its astringent properties. Now it is 
 rarely used except in the form of the unguentum acidi 
 gallici of the United States Pharmacopeia. This is pre- 
 scribed for psoriasis and as an application to old sores and 
 ulcers which are discharging too freely. 
 
 GALLSTONES 
 
 Thousands of patients suffer from gallstones and don't 
 know it; almost as many thousands of doctors continue 
 pouring pepsin and hydrochloric acid into stomachs sup- 
 posed to be the source of "indigestion" or "dyspepsia" 
 instead of examining carefully and ascertaining the true 
 cause of suffering. A test breakfast and analysis of the 
 stomach-contents can be made by any recent graduate 
 (and many an older one as well) but it is often regarded 
 as "too much trouble." Nothing is too much trouble 
 which will relieve a long-suffering "chronic." If more 
 time were spent in careful examination of obscure cases 
 and less in efforts to get more patients from competitors 
 the world would be better off. The ambition of too many a 
 practiser of medicine is to reach that frightful stage at which 
 he can exclaim: "I am too busy to read medical books 
 and journals." God pity the patient of such! In a very 
 large proportion of cases unsuspected gallstones and chole- 
 cystitis will be found to be the cause of the indigestion and 
 pain; removal will effect a cure.
 
 170 SURGICAL THERAPEUTICS 
 
 Avoiding Secondary Operations for Gallstones. 
 It is a well-known fact that quite a large number of 
 patients operated on for gallstones have to submit to 
 a second operation for stones accidentally left behind, 
 or for those which form after the cholecystostomy. Con- 
 cerning the latter Richardson has shown that after 
 operations for gallstones, in about 15 percent of all cases 
 there is a new gallstone formation necessitating a sec- 
 ond operation. This usually can be avoided by increas- 
 ing the amount of bile-salts by their administration by 
 the mouth. Operation for gallstones is unfortunately 
 imperative where there is occlusion of the duct, but after 
 operation, in order to prevent a reformation of stone, 
 care should be taken to increase the amount of bile-salts 
 to hold the cholesterin and bilirubin in solution. It is 
 claimed that not only here but also in hepatic colic, if 
 sodium glycocholate is steadily and regularly adminis- 
 tered, no more stones will be formed and those remaining 
 in the gall-bladder will be gradually dissolved. The 
 "bile in" of Abbott should be very useful in this connec- 
 tion, combining as it does all the important bile salts. 
 During the process of solution they become soft and fri- 
 able so that they can easily be crushed between the fin- 
 gers. In chlorosis and anemia and in those diseases in 
 which there is destruction of hemoglobin, the elimination 
 of the excessive bilirubin formed is accelerated by an 
 increased flow of bile, and as the anemias are largely 
 the result of malnutrition, stimulation of the liver is of 
 great therapeutic value. 
 
 Fever with Gallstones. Gallstone colic, however 
 severe, gives rise to practically no fever unless infection of 
 the gall-bladder has occurred by the colon bacillus or one 
 of the common pus-producing cocci; in case high fever 
 accompanies the attack, operation is imperative. Long says : 
 Fever accompanying gallstones depends always upon infec-
 
 GALLSTONES 171 
 
 tion of the gall-bladder or ducts and varies from normal 
 to io5F. The peculiarity of gallstone fever is the sharp 
 rise of temperature which lasts only a few hours and drops 
 suddenly back to normal. It is often spoken of as "a 
 steeple temperature." It is not at all infrequent for a 
 patient to have at irregular intervals a chill, accompanied 
 by a terrific colic, and followed by a sudden rise of tem- 
 perature to io5F.; a dose of morphine will relieve the 
 pain and in a few hours the temperature will be normal. 
 It will be found at operation that there is a suppurating 
 cholangitis with more or less stones in the gall-bladder 
 and one in the common duct. 
 
 Gastric Pain vs. Biliary Colic. That the gas- 
 tric crises of an unrecognized locomotor ataxia may be 
 mistaken for gallstone colic has not been made sufficiently 
 clear; nor has sufficient emphasis been laid upon the 
 proneness of "morphine fiends" to simulate gallstone 
 colic in order to get a hypodermic injection while among 
 strangers where the usual "dope" cannot be obtained. 
 Patients who present themselves apparently in great pain 
 and requesting immediate relief, should always be looked 
 upon with suspicion. Thoroughness in examination and 
 careful inquiry into personal and family history will 
 unquestionably reveal many cases of malingering as well 
 as clear up the diagnosis of apparently complicated cases. 
 The possibility of apparent gallstone colic being gastric 
 crisis of ataxia, should be borne in mind when strange 
 patients request treatment. It must be remembered also 
 that gastric crises of ataxia may simulate acute gastric 
 lesions, appearing like gastric ulcer. One can only then 
 arrive at a right conclusion in non-gastric diseases and 
 troubles other than biliary ones with gastric symptoms, 
 after a thorough examination of the patient's whole body 
 and a most careful study of all the secretions and 
 excretions.
 
 172 SURGICAL THERAPEUTICS 
 
 Non-Surgical Cure of Gallstones. The statement 
 is often made that gallstones may be "cured" by copious 
 draughts of olive oil, by free use of bilein, etc. The truth 
 of the matter is that gallstones of themselves are of little 
 importance a large proportion of men and women past 
 50 years would be found to have gallstones if the gall- 
 bladder were opened; it is only when an autoinfection of 
 the mucous membrane occurs that trouble arises. 
 
 The infection may take the form of (i) an acute chole- 
 cystitis, without occlusion of the cystic duct, (2) acute inflam- 
 mation of the gall-bladder with stoppage of the outflow 
 abscess of the gall-bladder, (3) milder infection, as from 
 the bacillus coli communis, with or without cessation of 
 drainage; all associated with a catarrhal condition of the 
 intestines. These facts explain the apparent efficacy of 
 many of the vaunted gallstone remedies. Most contain 
 more or less drastic purgatives, and they give unmistakable 
 relief, although they have the drawbacks of all purgatives 
 in catarrh of the intestines; aggravating the condition after 
 a time. The most promising field for internal treatment 
 is chronic choledochitis without repeated chills and remit- 
 tent fever, but it requires the greatest patience. A cure 
 is seldom realized in less than four or five months, but it 
 is possible to avoid an operation by careful dietetic and 
 therapeutic management during all of this time. If the 
 patient is under constant medical supervision, the develop- 
 ment of serious complications need scarcely be feared. 
 
 The main point in internal treatment is repose, and 
 this nust be absolute until the last trace of the cholecystitis 
 has completely retrogressed. This may occur sometimes 
 in four or five weeks, in other cases not until eight or 
 ten weeks or still longer. After all traces of swelling of 
 the gall-bladder and of the slightest tenderness have van- 
 ished, the patient must be made to take plenty of out- 
 door exercise, abstain from too much fat, sugar and starch,
 
 GANGLION: CURE OF 173 
 
 and keep the bowels thoroughly active by saline laxative. 
 Finally, if repeated attacks of gallstone colic become 
 troublesome, or if jaundice become prominent, operative 
 treatment must be insisted upon. The succinate of 
 sodium in doses of 5 grains four times daily has proven 
 actually curative in a very large percentage of cases, 
 according to the experience of Prof. W. F. Waugh, who 
 has used this remedy very extensively. It certainly de- 
 serves a trial. 
 
 Pain of Gallstones. Certain patients subject to 
 gallstone colic are relieved by the use of gelsemium taken 
 at the very onset of the attack. The method of admin- 
 istration is this: At the first intimation of an on-coming 
 paroxysm five drops of the tincture of gelsemium are 
 taken, followed in fifteen minutes by a second dose. Fif- 
 teen minutes later a teaspoonful of sodium bicarbonate 
 is taken in a tumblerful of very hot water; and in another 
 quarter hour a third dose of gelsemium is taken. If re- 
 lief is to be afforded by this plan no more will be needed; 
 in rare instances the first dose alone checks the spasmodic 
 contraction which gives rise to the attack. 
 
 Sodium Oleate for Gallstones. A preparation now 
 widely used for jaundice is oleate of sodium. It is used 
 principally for catarrhal jaundice but is also capable 
 of improving jaundice due to obstruction by gallstones, 
 if it be given just after the attack of colic has subsided. 
 It is said to reduce the frequency of attacks in those sub- 
 ject to frequent but not very severe spells. 
 
 GANGLION: CURE OF 
 
 Sometimes patients will not submit to operations for 
 ganglion. What is the best non-operative treatment? 
 Gates says that the best treatment is injection of campho- 
 phenol. He has never failed to effect a cure by this agent. 
 It is prepared by mixing equal parts of camphor "gum"
 
 174 SURGICAL THERAPEUTICS 
 
 and crystalline carbolic acid. The result is a pure white, 
 slightly oily fluid, with the odor of camphor. It is non- 
 toxic, having all the good but none of the bad properties 
 of carbolic acid. To use it, the region of the ganglion 
 should be prepared as for an operation. The preparation 
 of campho-phenol in quantity of 15 or 20 drops should be 
 injected directly into the ganglion by means of a hypo- 
 dermic syringe, the needle of which has just been boiled. 
 There is some reactionary swelling, but this soon 
 subsides, and Gates claims that a complete cure is 
 always obtainable by one injection. The limb should be 
 kept at rest on a splint, or the patient should remain 
 in bed a few days. 
 
 GANGRENE 
 
 Amputation for Diabetic Gangrene. Most surgical 
 writers condemn any surgical measures in diabetic gangrene, 
 following Treves who said: "Diabetic gangrene is not 
 within the scope of surgery; an amputation in such cases 
 is almost invariably fatal. " But death is certain without 
 it; so, if the case be seen early, before much of the foot is 
 affected, and the patient will consent, amputation at the 
 middle of the thigh should be made. Under modern 
 methods there is no more shock with this amputation than 
 with one lower on the leg; hence the rule should be: Very 
 high amputation, or none. 
 
 Carbolic Acid Gangrene. Many cases of serious 
 gangrene have followed the injudicious use of phenol, 
 particularly when wet phenolized dressings have been cov- 
 ered with rubber tissue or oiled silk, most often, too, when 
 the original injury or sepsis is trivial in degree. The ap- 
 pearance of the gangrenous part in such cases is character- 
 istic. The skin at first is dry, wrinkled, and grayish white 
 in color; later it becomes darker and more shriveled. At 
 the junction of the living and dead tissue there is some
 
 GANGRENE 175 
 
 hyperemia, and eventually a line of demarcation forms. 
 As it is difficult to tell how much is actually destroyed, 
 it is proper to wait for the line of demarcation before 
 amputation is performed. As a rule there is but little. 
 In no one of the cases the author has seen has there been 
 any swelling of the proximal part, but such swelling has 
 been described in some cases. The condition is, as a rule, 
 similar to a typical case of dry gangrene. Various explana- 
 tions have been given as to the occurrence of gangrene 
 under the conditions mentioned. It may follow the use 
 of solutions as weak as one- or two-percent strength. It 
 has been suggested that some individuals have an idio- 
 syncrasy, and are locally much more susceptible to the hurt- 
 ful action of the drug than are others, and that in them 
 stasis, followed by thrombosis, occurs more readily, and 
 gangrene results. It is a fact that the portion which 
 becomes gangrenous is generally a terminal part of the 
 body for example, a finger or a toe. 
 
 Diabetic Gangrene. Encouraging results are some- 
 times obtained in this usually incurable condition from the 
 administration of nuclein. Locally, mild antiseptic appli- 
 cations are indicated. If amputation is to be advised it 
 must be early and far above the site of local lesions; it 
 may be made under a single dose of the hyoscine-morphine- 
 cactin anesthetic, plus cocaine locally. 
 
 Internal Medication in Gangrene. While it is 
 true that very little can be done for gangrene (even diabetic) 
 by internal medication, it is equally true that some kind of 
 medicine must be given or patient and friends will be dis- 
 satisfied and some surgeon found who knows enough to 
 treat a patient as well as treat a disease! Of drugs advised 
 probably first choice should fall on nuclein one of the 
 " defensive proteids " of the living body which has recently 
 been much employed in general debility, the dose of which 
 is from two to five drops of the solution or one to three
 
 176 SURGICAL THERAPEUTICS 
 
 of the two-drop tablets in which it may be obtained. Four 
 doses a day may be given. Alcohol may be of benefit in 
 some cases, but as a rule one-twentieth grain of sulphate 
 of strychnine four times a day will better hold up the pa- 
 tient's strength. The "triple arsenates" arsenate of 
 strychnine, arsenate of quinine and arsenate of iron, one 
 milligram of each (gr. 1-67) four times a day give much 
 satisfaction in keeping the patient from sinking before 
 "demarcation" occurs, if that is to be waited for. 
 
 GASTRIC ULCER 
 
 Before resorting to surgical treatment the Lenhartz 
 method should be tried. It is as follows: (i) Absolute 
 rest in bed for at least four weeks; (2) avoidance of all 
 mental excitement; (3) almost constant use of ice-bags 
 over the stomach for. two weeks; (4) daily administration 
 of from 200 to 300 Cc. of iced milk by spoonful and two 
 to four beaten eggs; (5) the use for ten days of 2 Gm. 
 (30 grains) of bismuth subnitrate at a dose. Importance 
 is attached to the use of beaten eggs. They are beaten 
 whole with a little sugar and kept in contact with ice. 
 
 Feeding. The strength must be maintained by 
 nutrient enemas, and by good claret, iced, swallowed in 
 small quantities at frequent intervals. After the stomach 
 has rested for a few days foods which are digested chiefly 
 in the intestine may be guardedly tried. Excision of 
 the ulcer is justifiable. 
 
 Gelatin for Gastric Hemorrhage. Excellent re- 
 sults are reported in the treatment of gastric and intes- 
 tinal hemorrhage by the internal administration of a 
 preparation of fluid gelatin. Prompt effect of the 
 remedy in such cases as typhoid fever, gastric carcinoma, 
 ulcer of the stomach, and melena has been reported. In 
 none of these cases was any other medicine resorted to 
 except the gelatin treatment, yet prompt cessation of
 
 GASTRIC ULCER 177 
 
 the bleeding followed in nearly all. The formula for this 
 gelatin mixture is as follows: 20 grams of gelatin is boiled 
 during six hours with enough water to make 130 cubic 
 centimeters. It then remains fluid, and 2 grams of citric 
 acid is added. It may be flavored with a little syrup 
 of orange, and is given in doses of one or two tablespoon- 
 fuls every two hours. 
 
 Removal of Gastric Ulcer. It is far better, when 
 possible, to remove the ulcers near the pylorus (even 
 though there be three or four) than to make a gastro- 
 jejunostomy. If they can be excised without danger 
 of causing cicatricial stricture of the pylorus, the advan- 
 tages of simple excision are that the site of the disease 
 (and the source of hemorrhage) is removed, the normal 
 relation of the viscera is not disturbed, convalescence is 
 speedier and the ultimate results are better. Of course 
 if there be great dilation of the stomach it wJll be better to 
 make a gastroenterostomy at the lowest part of the stomach, 
 but on account of the danger of formation of "vicious 
 circle" it should be avoided whenever possible. Ulcers 
 of the duodenum should be treated in the same way. 
 
 To Check Hemorrhage. The patient must be 
 kept perfectly quiet, a small dose of morphine being 
 injected if necessary. Ergot is advised by some but 
 must not be continued if it cause vomiting, as vomiting 
 is a source of great danger. Small pieces of ice may be 
 swallowed, whole. 
 
 To Check Pain. When patients will not submit to 
 operative treatment for gastric ulcer the pain may be 
 controlled far better than by the use of morphine by 
 simply having the patient take a teaspoonful of bicarbo- 
 nate of sodium in lime water, with a few drops of essence 
 of peppermint added. 
 
 To Stop Vomiting. Bismuth subnitrate may be 
 given by the stomach; but the best way is to give 2 grams
 
 178 SURGICAL THERAPEUTICS 
 
 (30 grains) each of chloral and potassium bromide in 
 four ounces of water, by the rectum. 
 
 GAUZE: THE CARE OF 
 
 While it costs more, it is best to buy plain, sterilized 
 gauze, as well as bichloride gauze, in one-yard packages, 
 for use in minor surgery and for dressing of wounds which 
 mnst be kept aseptic. For use at operations five-yard 
 rolls in pasteboard boxes (hermetically sealed after sterili- 
 zation) are best; but if the operation be one of magni- 
 tude, such as abdominal section, pieces should be cut 
 from the roll and boiled at the time . of operation. If 
 any part of a roll be left it should be carefully wrapped 
 up in the clean container in which it came and saved 
 for dressing infected cases. 
 
 The average doctor buys a jar containing five yards 
 of gauze, opens it, cuts off what he needs with scissors 
 taken from an instrument-case or satchel, and says he 
 has used an "aseptic" dressing. This is not true unless 
 the shears be taken out of the sterilizer or boiler, for they 
 have become contaminated in the satchel or case; even 
 letting them lie in alcohol for a few minutes does not 
 insure sterility. After the jar has once been opened 
 and some of the gauze cut off, the remainder is not strictly 
 sterile and should never be used as a dressing for a per- 
 fectly clean wound; hence the advice to buy in yard 
 packages for strictly aseptic cases. 
 
 A large, clean jar should be kept in every surgeon's 
 dressing-room into which the remains of these yard pieces 
 may be thrown, because some wounds do not require a 
 full yard or full two yards, and these small pieces may 
 be employed for dressing infected wounds. It is really 
 better to have one dry jar and one containing i in 2000 
 corrosive sublimate solution, or i in 40 phenol solution, 
 so that one may have constantly at hand both dry and
 
 GLEET 179 
 
 moist gauze for infected wounds. When an operation 
 is performed in a private house the packages should not 
 be opened until the instruments are to be boiled; any 
 left-over gauze may be wrung dry and carried to the office 
 to add to the moist-jar; but if the case has been one of bad 
 pus-infection the remaining gauze must be boiled twenty 
 minutes before dropping into the moist jar even though 
 the solution be strongly germicidal. Too much attention 
 cannot be exercised in the care of gauze for dressings. 
 
 GENITOURINARY SUPPURATION 
 
 Infections of the genitourinary tract attended by the 
 formation of pus are greatly lessened in virulence by 
 small quantities of formaldehyde, a drug which is excreted 
 chiefly by the kidneys. Pyelitis, pyelonephrosis, cystitis, 
 prostatitis and even gonorrheal urethritis speedily improve 
 after its administration. A most excellent combination 
 for each of these diseases is: 
 
 Formin 0.2 (grs. 3 ) 
 
 Arbutin 0.04 (gr. 1-2) 
 
 Ammonium benzoate 0.2 (grs. 3 ) 
 
 One such tablet is to be taken in from four to eight 
 ounces of water every three to six hours. From it formalde- 
 hyde is generated slowly, and gradually eliminated through 
 the kidneys, thus exercising an antiseptic action from 
 the very glomeruli of the kidney to the end of the tractus 
 genitalis. 
 
 GLEET 
 
 Under the name "gleet" are included (a) the discharge 
 (often only a "morning drop" obtained by stripping the 
 urethra) of a chronic urethritis, and (b) the mucopurulent 
 discharge accompanying recent strictures. Both were 
 formerly regarded as of minor importance and were not 
 considered a bar to marriage. Now it is known that such
 
 180 SURGICAL THERAPEUTICS 
 
 discharges are a menace to the happiness, and often the 
 life, of any woman previously free from infection with whom 
 the patient may have intercourse; so long as there is a 
 morning drop, so long as clap-shreds are to be seen in the 
 morning urine, there is danger of infection and the victim 
 should not be permitted to marry. 
 
 If there is a stricture it should be treated by proper 
 measures. (See "Stricture.") But usually the gleet depends 
 upon a chronic urethritis or at least an infection of some 
 of the deep follicles of the urethra, or upon an ulcerated 
 spot within an inch or two of the meatus externus. When 
 passage of a sound shows no stricture and when the endo- 
 scope reveals no ulcer within the first two inches of the 
 urethra it may be taken for granted that the discharge is 
 due to a chronic inflammation, and an injection ordered 
 as follows: 
 
 Zinc sulphate i .o 
 
 Lead acetate i .o 
 
 Alum i .o 
 
 Water 160.0 
 
 Mix and use as an injection thrice daily. At first the dis- 
 charge will increase, but in from 3 to 6 weeks the trouble 
 will entirely disappear in the favorable cases. 
 
 Ricord's formula is still a favorite with some genito- 
 urinary surgeons: two parts of rose water to one part of 
 claret wine, lessening the amount of water daily until full- 
 strength wine can be tolerated as an injection. 
 
 When the discharge does not yield to these injections 
 there is some point of granulation which must be found 
 by repeated endoscopic examinations, and, when detected, 
 cured by passing graduated steel sounds beyond the abraded 
 surface, three or four times a week ; or later, if necessary, 
 by burning with a 25-percent solution of nitrate of silver, 
 through an endoscope, by means of a little cotton on the 
 end of a probe.
 
 GOITER 181 
 
 The urine should be kept non-irritating by use of arbu- 
 tin or similar remedies. 
 
 GLOSSITIS 
 
 Inflammation of the tongue of very serious character 
 sometimes follows slight injury, as from injudicious seizure 
 with forceps by an excitable and not too wise anesthetizer; 
 and it may arise from systemic infection, sometimes with 
 enormous swelling, high fever, great discomfort and some 
 danger. Locally antiseptic mouth-washes are valuable, 
 potassium chlorate being good in saturated solution with 
 a little phenol added; or the patient may be given frequently, 
 to suck, a "menthol compound" tablet, to be had of 
 manufacturing chemists, of this composition: 
 
 Boric acid 02 (gr. 1-4 ) 
 
 Benzoic acid 02 (gr. 1-4 ) 
 
 Sodium fluoride 04 (gr. 1-2 ) 
 
 Sodium bisulphide 04 (gr. 1-2 ) 
 
 Thymol 04 (gr. 1-2 ) 
 
 Menthol 04 (gr. 1-2 ) 
 
 Eucalyptol 04 (gr. 1-2 ) 
 
 Camphor 005 (gr. 1-16) 
 
 Hydrastine 005 (gr. 1-16) 
 
 This is a non-toxic, alkaline antiseptic which may be used 
 freely. The bowels must be emptied quickly with calomel 
 and podophyllin followed by saline laxative; and rectal 
 feeding then instituted, as the patient's strength often fails 
 rapidly. 
 
 GOITER 
 
 Patients affected with goiter often want to take medi- 
 cine in addition to the local application of iodine (tinc- 
 ture or the decolorized tincture). Potassium iodide, 
 half a gram, thrice daily, seems to hasten subsidence of 
 the swelling in some cases. Other patients take iodo- 
 form with apparent advantage, in a capsule or tablet,
 
 182 SURGICAL THERAPEUTICS 
 
 one centigram three to six times a day. Phytolaccin (the 
 active principle of phytolacca decandra) has been lauded, 
 and is given in doses of one centigram (1-6 grain) four 
 times a day. Strict attention should be paid to diet, 
 rich foods being prohibited, and the bowels kept active 
 securing at least two movements daily, by the use of 
 salines and an aloin pill. Donovan's solution was much 
 used long ago, but arsenic iodide, one milligram (1-67 
 grain) four times a day, will be found more agreeable. 
 
 Exophthalmic Goiter* Physiologists, pathologists 
 and surgeons now all agree with the statement of 
 Hartley that "clinically" it makes no difference 
 whether the secretion of the thyroid gland is increased 
 or is chemically altered as the result of changes in the 
 blood, in the alimentary canal, or in the central nervous 
 system; the fact remains that "the removal of the 
 growing gland does away with the symptoms, and upon 
 the failure to remove the diseased gland depends no cure." 
 It is, of course, best that medicinal treatment should 
 precede surgical interference, because of the undoubted 
 cures that have taken place. This treatment may be 
 combined with the use of the x-ray (Mayo) or with the 
 administration of milk or serum from thyroidectomized 
 goats, sheep, etc. (Lanz and Moebius.) This method 
 of treatment should not be continued too long, unless 
 operative treatment is contraindicated, since the disease 
 itself tends to diminish the vital resistance and to exhaust 
 the nerve-centers. The earlier the diagnosis and the opera- 
 tion, the easier the operation, and the less dangerous and 
 difficult the after-treatment. Hartley found that the severer 
 types derive great benefit from rest in bed for two or three 
 weeks previous to the operation. The nervous excita- 
 tion, the tachycardia, and the muscular tremor are so 
 much improved that operation is often undertaken under 
 much more favorable conditions.
 
 GOITER 183 
 
 Just what cases should be subjected to operation has 
 not been decided, though as a broad rule it may be said 
 that when the bronchocele is the most prominent fea- 
 ture and when internal medication by iodides, tincture 
 of strophanthus, digitalin, etc. fails, thyroidectomy is to 
 be advised. On the other hand, if exophthalmos and 
 tachycardia be most prominent, excision of the superior 
 and middle gangalia of the cervical sympathetic is to be 
 preferred. 
 
 Recently a serum treatment has been employed with 
 excellent effect in a few cases. It is prepared by inject- 
 ing the purined neucleoproteids of the thyroid into some 
 animal: a rabbit or sheep. Beebe, of New York, reports 
 that the serum treatment causes an increase in the per- 
 centage of hemoglobin and the number of erythrocytes, 
 (possibly due to the general health improvement and not 
 to any direct action on the blood-forming organs). The 
 therapeutic use of the serum is based on the theory that 
 exophthalmic goiter is a toxemia and the toxin in ques- 
 tion is a thyreoglobulin. This theory best explains the 
 striking results obtained in some acute cases with soft 
 thyroids, probably in a simple state of hypertrophy and 
 containing a large amount of colloid matter with but a 
 slight number of cells. 
 
 The majority of cases, however, are of the chronic 
 type and do not show at once this rapid improvement. 
 The gland is more cellular and the cytotoxic element in 
 the serum, in the small doses given, is probably too feeble 
 to cause immediate or rapid diminution of the gland. 
 More rapid destruction, moreover, might be dangerous 
 in these cases. There is some reason to think that the 
 serum does have a cytolytic effect; the main fact is that 
 there is a reduction in the size of the gland, and in a few 
 cases it has been restored to apparently normal size. Con- 
 sidering all the facts, Beebe thinks it fair to conclude
 
 184 SURGICAL THERAPEUTICS 
 
 that the serum has considerable value in the medical 
 treatment of exophthalmic goiter. The improvements 
 and cures under its use have been too numerous to be 
 ascribed to coincidence, and he believes that under favor- 
 able conditions much can be accomplished by careful 
 serum therapy. Of internal remedies best results have 
 been obtained from the use of hydrobromide of quinine. 
 From one to two grams (15 to 30 grains) must be given 
 every 24 hours for a long time preferably in four to six 
 doses. 
 
 Operation for Goiter. Extensive experience cor- 
 roborates the assertion of Hardon, who has made a care- 
 ful study of the subject, (i) Every irregular tumor of 
 the thyroid, no matter how small, should be removed, 
 as only by following this line of procedure can we hope 
 to save the lives of those having malignant growths. (2) 
 Every regular tumor of the thyroid causing symptoms 
 other than deformity, should be resected when, after a 
 few months' medical treatment, its growth is not checked, 
 and no improvement is shown. (3) Avoidance of trauma, 
 care of the stump, free drainage and salt solution to keep 
 full blood- and lymph-vessels, to prevent as far as pos- 
 sible wound absorption, constitute the chief points in 
 operation. 
 
 Operation in Exophthalmic Goiter. One must re- 
 member that the worst cases are sometimes those in 
 which no exophthalmos is present. Operation is the only 
 cure yet known; it is not dangerous if done under hyoscine- 
 morphine anesthesia, plus cocaine locally, with clean hands 
 and in properly selected cases. But thyroidectomy should 
 never be attempted in any case when the patient has a 
 dilated heart or an endocarditis of long-standing. Cases 
 most favorable for operation are those in which the gland 
 is more enlarged upon one side than the other; those in 
 which there is a definite tumor formation; those in which
 
 GONORRHEA 185 
 
 the gland is not excessively vascular; and those in which 
 the enlargement has preceded the Graves' symptoms for 
 months or years. Like other goiters the bronchocele of 
 Graves' disease is 'often benefited by the local use of iodine. 
 
 Removal Under Local Anesthesia. In some cases 
 conditions are such that removal is not possible under 
 general anesthesia. Here one may inject one dose of 
 hyoscine (gr. i-ioo) and morphine (gr. 1-4) an hour before 
 operation and then use a local anesthetic. The solution 
 best to be employed consists of sodium chloride, 12 grains, 
 beta eucain, 3 grains, water 3 1-2 ounces. This is boiled 
 and then 10 minims of commercial adrenalin solution 
 are added. The solution is ready for use as soon as 
 cooled. 
 
 Treatment by Iodine. Bronchocele not sufficiently 
 prominent to demand excision may be greatly reduced 
 by the use of iodine. Perhaps the best way is to apply 
 externally, by means of a camelshair brush using tinct- 
 ure of iodine to which has been added just enough aqua 
 ammonia to decolorize. A little of this "colorless tincture 
 of iodine" used twice daily will often cause almost total 
 disappearance of a goiter not cystic. It may also be made 
 to enter the deep tissues by cataphoresis (negative pole 
 of a galvanic battery), enabling one to get speedier results. 
 Or from five to fifteen minims may be injected into the 
 fibrous tissue by hypodermic syringe. Great care must 
 be exercised in such injections because if the iodine is 
 thrown into the connective tissue instead of the gland, 
 ulceration will follow, with ugly scar-formation. 
 
 GONORRHEA 
 
 A urethritis due to infection with Neisser's coccus (gono- 
 coccus) is an acute inflammation which requires six weeks' 
 treatment in the first attack, and ^rom two to three weeks 
 in subsequent ones.
 
 186 SURGICAL THERAPEUTICS 
 
 During the early stage, when the inflammation is limited 
 to the anterior urethra, the best treatment consists of inter- 
 nal remedies calculated to make the urine bland and unir- 
 ritating; but if the patient insists upon having an injection 
 from the first he must be instructed not to throw it in far, 
 as by so doing he will force the pus into the deep urethra 
 and by so doing may cause posterior urethritis or even 
 cystitis. 
 
 Irrigation treatment is advised by most writers; it should 
 not, however, be used indiscriminately but reserved for 
 cases in which the deep urethra is involved. Permanganate 
 of potassium is used in mild solution. 
 
 During the acute stage, when the penis is swollen and 
 edematous, with redness and eversion of the meatus and 
 great tenderness in the urethra, injections do much harm; 
 if anything is used it should be of the mildest kind, like one 
 or two grains of alum to an ounce of water and a little aqueous 
 extract of opium. Excellent results are obtainable from 
 injection of a one-percent cocaine solution with two-per- 
 cent phenol added, about five minutes before each passage 
 of urine. Later, when the severe symptoms of infection 
 have subsided and the discharge becomes copious, the 
 stronger injections may be ordered, three grains each of 
 alum, acetate of lead and sulphate of zinc to the ounce 
 of water giving the best results of any. At first this may 
 be used four times a day; the second week three times, 
 the third only three, and the fourth only at night, unless 
 the discharge ends in gleet (which see). 
 
 Internal treatment is important. In the early stage 
 salicylate of phenol (salol) is by all odds the best remedy. 
 With it cubebs may be combined, a remedy which distinctly 
 modifies ardor urines: 
 
 Phenol salicylate 8.0 (drs. 2) 
 
 Oleoresin of cubebs 4.0 (dr. i) 
 
 Codeine sulphate 0.2 (grs. 3)
 
 GONORRHEA 187 
 
 Mix and make sixteen capsules. Direct: One every 
 four hours. The codeine may be reduced a half in the 
 second prescription and elided altogether in the third. 
 
 Potassium bromide at bedtime is good to produce sleep 
 and limit chordee; dose one to two grams (15 to 30 grains); 
 or lupulin may be given in the dose of two grams (Hare). 
 Opium and belladonna suppositories may be ordered if 
 indicated. 
 
 Potassium citrate in ten-grain tablet, to be dissolved 
 in a glass of water and taken two hours after each meal, 
 is excellent after the first week, though the salol may also 
 be continued. 
 
 When fever is present (in the first few days) aconitine 
 is indicated. A milk diet aids in affording relief at this 
 stage; and an unirritating diet is essential throughout. 
 
 When the posterior urethra is affected the irrigation 
 treatment is indicated. This is done with weak solution 
 of potassium permanganate, having a pale wine-color. 
 A fountain syringe is filled with this, a blunt nozzle applied 
 and pressed into the mouth of the urethra as the fluid begins 
 to flow. The patient is directed to relax himself perfectly 
 just as if beginning to urinate, when the fluid will readily 
 flow into the bladder, filling it to the limit; this is expelled 
 and another bladderful introduced, and so on until at least 
 two quarts of the hot solution are used. This is repeated 
 two or three times daily. 
 
 The bowels must be kept open, the diet regulated, and 
 as little exertion as possible enjoined until the disappear- 
 ance of acute symptoms. Here copaiba seems excellent 
 and oil of sandalwood (each in capsule) gives much satis- 
 faction. 
 
 When the posterior urethritis is at its height opium 
 and belladonna suppositories are almost a necessity; or if 
 they constipate too much a clyster of four ounces of starch 
 water containing two grams (30 grains) each of potassium
 
 188 SURGICAL THERAPEUTICS 
 
 bromide and chloral hydrate may be given at bedtime for 
 several nights. In the worst cases codeine or morphine 
 must be given, though with care. 
 
 Chronic gonorrhea usually means either a granular 
 spot which must be burned with silver through an endo- 
 scope or a stricture which must be treated with sounds or 
 otherwise. (See "Gleet".) The "candle drainage bougies" 
 are excellent in many cases. 
 
 Gonorrhea: Lingering. After a gonorrhea has run 
 for five or six weeks the patient becomes uneasy and wants 
 "something better." To such a one, and to the man with 
 "gleet" the following may be given: 
 
 Alum 0.8 
 
 Lead acetate 0.8 
 
 Zinc sulphate 0.8 
 
 Glycerin 16.0 
 
 Water 112.0 
 
 Direct: Use as an injection three or four times a day. 
 Shake well before using; hold the injection two minutes 
 if possible. Chemists claim that this prescription should 
 not be written, since it contains "incompatibles" and a 
 precipitate is formed. This is exactly what is wanted; it 
 is the retention of some of this precipitate in the urethra 
 for hours which does the good. 
 
 Gonorrhea in Women. For the vulvovaginitis due 
 to Neisser's coccus one may use an injection twice a day 
 of a quart of i in 2000 or i in 4000 solution of potassium 
 permanganate in hot water, followed by a solution of mer- 
 cury bichloride i in 2000, and a dressing of 5 percent 
 ichthyol in glycerin. Resorcin, in doses of i gram (15 
 grains) may be given internally, three times daily, with 
 advantage. Twice a week silver nitrate, ten grains to the 
 ounce of water, should be used to swab the mucous mem- 
 brane, and following this, a powder of alum, 3 parts, tannin, 
 2 parts, should be insufflated. Frequent bathing and other
 
 HANDS 189 
 
 hygienic means should be employed. If there is compli- 
 cating cervicitis and metritis, dressings of ichthyol, 10 
 parts, iodoform 5 parts, glycerin, 200 parts, should be 
 used. Local applications of tincture of iodine or of zinc 
 chloride, i in 50, may be employed, and intrauterine 
 injections of about i 1-2 ounces of the following solution: 
 Alum, 2 1-2 parts; tincture of iodine and alcohol, each 25 
 parts. Urethritis should be treated by the balsams, the 
 alkalis, and by irrigations of silver nitrate or protargol 
 solutions, or a i-percent aqueous solution of thallin sulphate. 
 
 HANDS 
 
 Acute Phlegmons of the Hand. According to 
 Knavel there are five great spaces, with their tributaries, 
 in which pus can accumulate in phlegmons of the hand: 
 First, the dorsal subcutaneous, which is an extensive area 
 of loose tissue, without definite boundaries, allowing pus 
 to spread over the entire dorsum of the hand. Second, the 
 dorsal subaponeurotic, limited upon its subcutaneous side 
 by the dense tendinous aponeurosis of the extensor tendons, 
 upon the deep side by the metacarpal bones, having the 
 shape of a truncated cone, with the smaller end at the 
 wrist and the broader at the knuckle. Laterally the apo- 
 neurotic sheet shades off into the subcutaneous tissue. 
 Third, the hypothenar area, a distinctly localized space. 
 Fourth, the thenar space, occupying, approximately, the 
 area of the thenar eminence, to the flexion-adduction crease 
 of the thumb, not going to the ulnar side of the middle 
 metacarpal. It should be remembered that this space 
 lies deep in the palm, just above the abductor transversus. 
 Fifth, the middle palmar space, with its three diverticula 
 below along the lumbrical muscles, limited by the middle 
 metacarpal bone upon the radial side, overlapped by the 
 ulna bursa upon the ulnar side, and separated from the 
 thenar space by a partition which is very firm everywhere
 
 190 SURGICAL THERAPEUTICS 
 
 except at the proximal end, where it is rather thin. A 
 small isthmus can be found leading from the proximal 
 end of the space under the tendons and ulna bursa at the 
 wrist up into the forearm. 
 
 Defective Hand Cleaning. In attempting to secure 
 asepsis of the hands for operation or dressing of wounds the 
 surgeon is apt to scrub inadequately two parts of the hands : 
 the center of the palm and the spaces between the fingers 
 near their base. Of course the chief danger is in the dirt 
 under the finger-nails and around the roots of the nails, 
 but the other two points should always be remembered. 
 
 Eczema of the Hands. By reason of much scrubbing 
 and enforced application of hot water to the hands, many 
 surgeons develop eczema of the hands especially those 
 who use the potassium permanganate and oxalic-acid solu- 
 tions. No application has proved so serviceable in keeping 
 the skin soft, supple and pliable as the oleate of bismuth 
 ointment, the composition of which is as follows: 
 
 Bismuth oxide 4.0 (dr. i) 
 
 Oleic acid 32.0 (oz. i) 
 
 White wax 12.0 (drs. 3) 
 
 Vaseline 64.0 (ozs. 2) 
 
 The addition of a few drops of the oil of rose renders 
 the ointment more agreeable. 
 
 Neuroma of Hand. Quite frequently piano players, 
 telegraphers and others who make constant use of their 
 fingers develop neuromas between the metacarpal bones 
 small, painful tumors of a few months' growth. These 
 should be removed under cocaine with most careful anti- 
 septic precautions lest thecitis or neuritis be set up. Great 
 care must be exercised not to injure the nerve. 
 
 Phenol Solution for the Hands. Some doctors 
 claim that solutions of bichloride of mercury make the 
 hands too rough if used frequently. For these a solution 
 of phenol may be substituted, though it is not so effective.
 
 HANDS 191 
 
 To be of any use whatever, it must be made as strong as 
 i in 40 for the hands (and i in 20 for cleaning the skin to 
 be cut). That means one full ounce of liquefied phenol 
 (95-percent carbolic acid of the old Pharmacopeia) to a 
 little more than a quart of water. Indeed, it is better to 
 use one ounce to the quart, to be sure that no mistake 
 is made and a useless solution employed. If the hands be 
 dipped in this solution during the course of an abdominal 
 section they must be rinsed in plain water before being put 
 back into the peritoneal space. Phenol cannot be used 
 often upon the hands without serious results. 
 
 To Clean the Hands Quickly. When it is necessary 
 to clean the hands quickly (as in emergency work, or 
 merely to make a hurried dressing), mix equal parts of 
 hydrogen dioxide and liquor potassae. Scrub the hands as 
 carefully as possible; then of this mixture pour about one 
 teaspoonful in the hollow of one palm and thoroughly 
 wash the hands with it. Next carefully clean the nails, 
 and then pouring a second teaspoonful the same as before, 
 saturate the nail-brush and go over the whole surface of 
 both hands, taking special care to scrub under and around 
 the nails. After this is done it is best to pour the third 
 and last spoonful in the hand and wash thoroughly in it 
 for about three minutes. Then scrub the hands thoroughly 
 with thymol soap (any other liquid germicidal soap would 
 do as well) and rinse them either in sterilized water 
 or in bichloride solution i in 1000. This partial steriliza- 
 tion makes the hands soft and white. Experience with 
 this method shows it to be valuable also to sterilize the 
 skin of patients before operations; and with the same ease. 
 It is well, however "to make assurance doubly sure" 
 to wash the hands for two minutes in dilute alcohol, one- 
 third water to two-thirds alcohol, before the final rinsing. 
 
 Turpentine for the Hands. Pure oil of turpentine is 
 a strong antiseptic and is very useful in cleaning the hands
 
 192 SURGICAL THERAPEUTICS 
 
 for operation when one cannot use the permanganate of 
 potassium and oxalic acid method (which ought to be 
 employed when one has recently had the hands in pus and 
 yet must operate). It is generally used improperly. The 
 correct procedure is to scrub the hands with soft soap and 
 warm water running water if possible, if not, the bowl 
 emptied and refilled at least twice for at least five minutes; 
 then to dry the hands thoroughly upon a clean (but not 
 necessarily sterile) towel; and then to cut the finger-nails 
 "to the quick." The turpentine is then poured over the 
 hands and rubbed in thoroughly around the roots and ends 
 of the nails and between the fingers; two minutes at least 
 being devoted to this. Finally the hands and finger-nails 
 are to be scrubbed in soap and clean warm water and then 
 soaked two minutes (by the watch) in 65-percent alcohol. 
 They are then ready for immersion in the i in 2000 sub- 
 limate solution. 
 
 HEMATEMESIS 
 
 Vomiting of blood may be from (a) an injury to the 
 stomach, (b) from gastric cancer or (c) from gastric ulcer. 
 Injury to the stomach by penetrating wound means an 
 abdominal section; if by a blow, internal medication may 
 be relied upon. Hemorrhage from carcinoma of the 
 stomach can be treated by medicine only. Hematemesis 
 dependent upon gastric ulcer should be treated by total 
 abstinence from gastric feeding and by internal remedies; 
 if it occur more than twice, by abdominal section and 
 excision of the affected area, with cr without a gastroen- 
 terostomy, as indicated. 
 
 Tho non-operative measures are, first, swallowing small 
 pieces of ice, whole. 
 
 A pill containing acetate of lead in dose of one decigram 
 (i 1-2 grains) with half that amount of pulverized opium 
 is a combination employed for many years.
 
 HEMOPHILIA 193 
 
 One and a half grams (23 grains) of tannic acid may be 
 given in three or four capsules and repeated in an hour 
 if needed; but it sometimes of itself excites vomiting. 
 
 Ergotin may be given every half hour four times, but 
 is dangerous in the dosage usually advised. 
 
 Adrenalin chloride, hypodermically, is highly com- 
 mended. 
 
 As in other forms of hemorrhage, a full dose of atropine, 
 repeated as necessary, controls the bleeding better than any 
 other internal remedy. 
 
 Curative Treatment* If hemorrhage recur again 
 and again, abdominal section is always to be advised, as 
 in most cases the cause of hemorrhage (unless cancer) can 
 be removed, and the disease thus cured, without great 
 danger. 
 
 Oxide of Silver for Hematemesis. Gastric ulcer 
 not subjected to operative treatment may lead to alarming 
 hematemesis. Silver oxide is advised to control the bleed- 
 ing, doses of a centigram (1-6 grain) three or four times a 
 day giving good results when there is a tendency to slight 
 daily recurrences. It not only acts as a local astringent 
 but it is said to be a powerful nerve sedative, thus helping 
 to allay the nervous agitation arising from fear; and this 
 is a most important feature of many cases. 
 
 HEMOPHILIA 
 
 This subject is so intimately associated with surgery 
 that every operator must have it in mind in deciding 
 about operating upon a stranger, fatal hemorrhage having 
 taken place more than once from a trifling incision. Never- 
 theless, conditions sometimes demand operative work, 
 under which circumstances the dangers must be fully 
 explained. Excessive care must be taken as to hemo- 
 stasis. The diseased condition is amenable to treatment, 
 the Ions-continued administration of calcium chloride
 
 194 SURGICAL THERAPEUTICS 
 
 having been followed by. cure in some instances. Even 
 the arthritic lesions have been vastly benefited by the 
 same remedy. 
 
 Joint Lesions in Hemophilia. The liability of the 
 joints to become affected in hemophilia must never be 
 forgotten when a patient complains of some chronic irri- 
 tation of a joint. The symptoms vary according to the 
 stage of the disease, and may be grouped in three classes: 
 (i) In some, intraarticular hemorrhage is the only lesion; 
 the joint suddenly becoming swollen and painful, usually 
 without history of even a trifling injury, when if the exis- 
 tence of hemophilia is known, there should be little dif- 
 ficulty in recognizing the character of the trouble but in 
 case of doubt aspiration will show the presence of blood 
 and make the diagnosis unmistakable. No attempt 
 should be made to evacuate the joint, as it will instantly 
 refill. Immobilization and internal medication are the 
 only measures indicated. (2) The pain, fever, slight 
 swelling and tenderness subside in a week or ten days 
 when if treatment is unsuccessful, there is recurrence of 
 the hemorrhage with even more distention; and after 
 several repetitions there are marked articular and peri- 
 articular changes thickenings so that motion becomes 
 limited, this constituting the second stage of the arthro- 
 pathy. (3) In the third stage there is complete ankylosis 
 for which absolutely nothing can be done. 
 
 HEMOPTYSIS 
 
 Candler advises to give, at once, hypodermically, 
 atropine sulphate, gr. 1-250. Ergotin or sclerotonic acid 
 may follow. A small dose of morphine will quiet patients; 
 but one should not give this drug, however, till hemor- 
 rhage has been controlled, and then not let the patient 
 know morphine is given. It should always be borne in 
 mind that ether or ethyl chloride sprays to nape of neck
 
 HEMORRHAGE 195 
 
 and over the sternal notch often check hemorrhage, and 
 nasal sprays of liquor ferri subsulphatis, one dram in 
 eight ounces of water, will prove extremely useful. A 
 certain quantity of fine spray will enter the bronchi. 
 
 HEMORRHAGE 
 
 Hemorrhage of sufficient importance to demand a 
 doctor's attention usually demands ligation of the bleed- 
 ing vessel, enlarging the cut sufficiently (generally under 
 cocaine anesthesia or freezing) to permit it to be seized 
 with forceps. 
 
 When this cannot be done (for one reason or another) 
 a compress soaked in a solution of antipyrin may be 
 applied as firmly as possible; or a tight packing of iodo- 
 form or sublimated gauze may be put in. Constriction 
 of an extremity by an Esmarch or Martin bandage should 
 not be continued longer than two and one-half hours. 
 Bleeding from particular organs will be discussed under 
 the respective headings devoted to them. 
 
 Internal Hemorrhage. From the use of enemas 
 of hot milk remarkable results are claimed by Solt. He 
 advises introduction by means of a piston syringe; the 
 intermittent flow gives better results than a constant 
 stream from a fountain syringe. By this means it is said 
 that hemorrhages from the uterus, bladder, stomach, 
 lungs, and in fact from every part of the body have been 
 checked. In some cases more approved hemostatics 
 had been used for hours without result, and the milk 
 was immediately successful. At least a quart should be 
 given at once, with nothing added but a little salt to make 
 it absorb more rapidly. The enema should be repeated 
 in an hour, even if there is no return of the hemorrhage. 
 Of course the usual local measures are employed at the same 
 time, when the source of bleeding can be reached. The 
 method of its action is not certain, but milk contains a
 
 196 SURGICAL THERAPEUTICS 
 
 large number of substances which are recommended as 
 hemostatics iron, phosphoric acid, sulphuric and nitric 
 acids, but above all, lime salts. The enzymes and leu- 
 cocytes also tend to cause an increase in the fibrin fer- 
 ment. The milk loses its hemostatic power if it is given 
 by the stomach. But while one is experimenting with 
 milk he must not forget that atropine is one of our best 
 general hemostatics. 
 
 HEMORRHOIDS 
 
 The proper treatment of piles may be summed up in 
 a few words. External tags (old piles) may be snipped 
 off under cocaine or ethyl-chloride freezing. A large, 
 recent, external pile may be cut around, ligated and 
 removed. Internal hemorrhoids demand divulsion of 
 the sphincter ani under complete anesthesia, and then 
 removal by (i) excision and sewing up of the cut after 
 ligation of vessels, (2) ligation in an incision made around 
 the base and then excision, or (3) use of a clamp and 
 cautery. The last-named gives least pain and most 
 satisfactory results if properly done. 
 
 When the patient will not consent to operative meas- 
 ures the injection method may be used, treating by inject- 
 ing only one pile at one sitting, introducing 15 to 20 drops 
 of pure phenol, or equal parts phenol and fluid extract 
 of ergot, the fluid to be thrown exactly into the center 
 of the pile-mass as otherwise sloughing may be induced. 
 
 If neither plan of treatment will be permitted, pal- 
 liative measures alone can be practised. These are (i) 
 astringent injections (tannic acid one gram 15 grains 
 to the pint of water, or twice that strength of alum, or 
 one in eight of tincture of hamamelis) especially when 
 there is bleeding from internal hemorrhoids. (2) Use of 
 astringent washes, like witchhazel or liquor antisepticus, 
 U. S. P. Very hot water frequently applied is very
 
 HEMORRHOIDS 197 
 
 comforting. If the pile can be well greased and pushed 
 above the sphincter immediate comfort will result if it 
 be one which originated above the sphincter and came 
 down with bowel-movement, as is often the case. (3) 
 Application of astringent ointments like 
 
 Gallic acid 0.5 (grs. 8 ) 
 
 Extract of belladonna 0.3 (grs. 5 ) 
 
 Cocaine hydrochloride o.i (grs. i 1-2) 
 
 Lanolin 16.0 (oz. 1-2) 
 
 Apply three or four times a day. 
 Aesculin in Hemorrhoids. When a patient will 
 not submit to operation for piles, suppositories of tannic 
 acid may be ordered or an ointment prescribed; but better 
 results may often be obtained from laxatives (cascara 
 preparations are much better than anything contain- 
 ing aloes a drug which aggravates hemorrhoids and 
 often causes much anal irritation and itching) and from 
 aesculin. This glucoside is the active principle of the 
 horse-chestnut, a bitter tonic and stimulant to the cir- 
 culation, having especial tendency to overcome stasis 
 in the portal circulation including the hemorrhoidal 
 veins. It is obtainable in granule form, each granule 
 containing i milligram (gr. 1-67). From three to five 
 of these granules may be ordered administered every 
 two hours uutil the burning and itching are decidedly 
 relieved. 
 
 Hemorrhoids and Rectal Fissure. Altogether too 
 many people are allowed to suffer from hemorrhoids 
 and anal fissure without examination. It is so easy to 
 give a little "pile-ointment" or a few suppositories; it 
 is so "nasty" to make a careful examination. And so 
 patients either suffer for years or drift into the hands of 
 the "pile-specialists." Yet a rectal speculum costs but 
 $2.00 and a Paquelin cautery only $8.00; these with a 
 little chloroform and some common-sense may be made
 
 108 SURGICAL THERAPEUTICS 
 
 to cure these conditions unless excessively bad to 
 the unbounded relief of the patient and the great credit 
 of the family doctor. Less ointments, more fire, should 
 be the rule. 
 
 Hemorrhoids: Treatment after Operation. 
 When piles have been removed either by ligature or 
 clamp and cautery, the sphincter having always been forcibly 
 dilated prior to operation, it is imperative that the rectal 
 packing extend very high into the gut and that it be tamped 
 in very tightly. This pack is, preferably, iodoform gauze, 
 though dry bichloride gauze will do. Over this a pad 
 of absorbent gauze or cotton is placed, held by a T-bandage 
 applied tightly. The outside gauze may be changed every 
 day, if desired, b.ut the packing must not be disturbed 
 for from four to six days, during which time peristalsis is 
 to be controlled by opium or morphine by the mouth. 
 When accumulation of gas becomes distressing, however, 
 the plug must be removed and the bowels permitted to 
 move. In many cases it is best to give a good saline laxa- 
 tive and let the bowel-movement force the packing out 
 assisted by the patient's own fingers as this will cause 
 far less suffering than if removed by doctor or nurse. If 
 it be left until the fifth or sixth day, however, it usually 
 slips out without much discomfort. An enema should 
 be taken immediately after the first bowel-movement, 
 and daily thereafter for a week. 
 
 Inflamed and Protruding Piles. The following 
 combination is recommended in the treatment of inflamed 
 and protruding piles: 
 
 Cocaine hydrochloride 0.17 (grs. 2 1-2) 
 
 Sol. adrenalin chloride (i : iooo)..2.oo (dr. 1-2) 
 
 Bismuth subnitrate .0.67 (grs. 10 ) 
 
 Petrolatum (liquid) 30.00 (oz. i ) 
 
 M. Ft. unguentum. Sig. : Bathe the parts in cold 
 water and apply the ointment after each stool.
 
 HEPATIC COLIC 199 
 
 Injection of Hemorrhoids. An injection highly 
 praised for cure of a single pile, when a patient will not 
 submit to operation, consists of: 
 
 Tannic acid 1.5 (grs. 20) 
 
 Phenol 8.0 (drs. 2) 
 
 Glycerin 8.0 (drs. 2) 
 
 Water 16.0 (oz. 1-2) 
 
 This makes a 25-percent solution of phenol, which, plus 
 the astringent tannin, quickly coagulates the blood, when 
 thrown into the pile. It is so prompt in its solidification 
 of the hemorrhoid that the point where the hypodermic 
 needle entered often remains open. As much as a syringe- 
 ful may be injected (through a rectal speculum) into a 
 large hemorrhoid. There is not much pain or discom- 
 fort after its use; and the pile is usually cured. Only one 
 should be injected at one sitting. 
 
 Nitric Acid for Piles. For many years nitric 
 acid has held high favor in the management of bleeding 
 hemorrhoids. Internal piles are treated by the appli- 
 cation of a drop or two (through a speculum) to the hemor- 
 rhoidal mass; not to the whole surface, but simply to 
 one or two points. It is not painful. Two or three appli- 
 cations to the dilated vessels are sufficient. For bleed- 
 ing piles a dram of the dilute acid is added to half a pint 
 of water and applied with a little absorbent cotton. Quite 
 promptly the bleeding ceases, the protruding mass shrinks 
 from constriction of the vessels and the heavy, dull, weary- 
 ing discomfort subsides, even though the pile-tumor 
 cannot be returned within the sphincter. 
 
 HEPATIC COLIC 
 
 Colic due to the passage of a small stone down the 
 cystic and common ducts or to the attempted entrance 
 of a large stone into the cystic duct is one of the most
 
 200 SURGICAL THERAPEUTICS 
 
 fearful of all pains. For its relief there is nothing so 
 satisfactory as the injection of one tablet of 
 
 Morphine hydrobromide 0.02 (gr. 1-4 ) 
 
 Hyoscine hydrobromide o.ooi (gr. 1-67) 
 
 Cactin o.ooi (gr. 1-67) 
 
 or the hyoscine-morphine-cactin tablet [H-M-C, Abbott] 
 now on the market. It may be repeated in an hour and 
 a third dose may be given two hours later if necessary. 
 It does not give so great relief when taken by mouth. 
 If instant relief is demanded a little chloroform may be 
 given by inhalation until the opiate has time to take effect. 
 Hot fomentations of turpentine to the abdomen over the 
 region of the gall-tract may afford some comfort to the 
 patient; but it must not be applied by hard rubbing, since 
 manipulation might rupture a distended gall-bladder. 
 It is a common custom, nowadays, to give large doses 
 of olive oil. This is not objectionable if it does not cause 
 vomiting (anything which produces emesis is dangerous), as 
 it relaxes the bowels and possibly helps the passage of 
 small calculi. The lumps of "human soap" resultant 
 from action of the intestine upon the oil must not be mis- 
 taken for gallstones, which they closely resemble. Half 
 a pint of the oil may be given within two or three hours. 
 After the attack, to prevent recurrence, an outdoor life 
 should be ordered, with salines at night, and a good, 
 nutritious diet devoid of much fat, without wines or beer, 
 should be enjoined; too much emphasis cannot be laid 
 upon the necessity for careful, thorough mastication of 
 the food, by which the quantity taken may be reduced 
 fully one-half. One should not be hasty about urging 
 operation, because after relief of one paroxysm the patient 
 may carry the stone for many years without any discom- 
 fort whatsoever; but if the attacks return again and again 
 nothing will afford relief but removal. If the gall-bladder 
 be badly affected it also may be removed.
 
 HEPATITIS 201 
 
 HEPATITIS 
 
 Inflammation of the liver is not a surgical affection 
 save when it ends in suppuration. But as the province 
 of the surgeon is to prevent as well as cure suppurative 
 conditions the proper treatment of hepatitis may well be 
 considered here. By the term hepatitis is meant the true, 
 acute, inflammatory process which results from the intro- 
 duction of pathogenic microorganisms through wound 
 or otherwise and not that condition generally called 
 "chronic hepatitis" which is not an inflammation at all. 
 
 The first essential is to secure perfect rest in bed, to 
 which end the application of a huge mustard-plaster 
 aids; or hot cloths may be ordered for the right side, 
 to minimize the pain. Calomel in two centigram doses 
 (gr. 1-6) every hour until free purgation results is an 
 almost universal treatment now, and it may well be fol- 
 lowed by effervescing saline laxative (Abbott's). To check 
 the fever the best drug is aconitine in doses of two mil- 
 ligrams every hour until the desired result is obtained 
 and then as often as necessary to keep the temperature 
 down. Active kidney secretion must be promoted by 
 the use of potassium citrate, one to four grams. (15 to 60 
 grains), three or four times a day. If the pain is severe 
 half -decigram doses of codeine sulphate (1-2 to i grain) 
 every three or four hours may be given by mouth. 
 
 If in spite of this treatment the trouble goes on to 
 the formation of an abscess, as indicated by rigors, sub- 
 normal temperature, night-sweats, hectic fever, etc., 
 the pus must be liberated as soon as possible. The liver 
 must be exposed over a considerable area, by cutting 
 away the ribs, usually; and if adhesions have not formed 
 between Glisson's capsule and the parietal peritoneum, 
 gauze must be packed between the liver and belly-wall 
 in every direction until the adhesion does take place. In
 
 202 SURGICAL THERAPEUTICS 
 
 forty-eight hours, without removal of the gauze, the pus 
 may be sought by use of an exploring needle of large size 
 thrust in various directions until the abscess is found; it 
 must then be opened by free incision, wiped out with gauze, 
 thoroughly, and then gently packed with gauze for drain- 
 age. It should not be washed out with hydrogen dioxide 
 before the first week of drainage. Subsequently it is 
 to be managed as any other huge abscess which must 
 heal by granulation from the depths. Dysentery is 
 likely to prove troublesome after evacuation; it may be 
 controlled by use of opium, camphor and acetate of lead, 
 a most satisfying prescription being half a decigram of 
 each (3-4-grain) in a capsule every three or four hours. 
 
 HERNIA 
 
 It is said that one in every eight men has some form 
 of hernia. Yet how many doctors think of advising an 
 operation? They know that operation is perfectly safe 
 and cure almost certain (in my own work now covering 
 several hundreds of cases there has never been a death 
 and less than five per cent of recurrences); yet they pre- 
 fer merely to fit a truss rather than urge radical cure. 
 It is hard indeed to account for their indifference to the 
 future welfare of their rupture cases probably timidity 
 and a feeling engendered by the failures of a few years 
 ago that cure is not sure. It is the duty of every doctor 
 to explain the advantages of operative treatment to every 
 patient afflicted by hernia and only permit the wearing 
 of a truss under serious protest. 
 
 One of the instances in which scopolamine-morphine 
 anesthesia is particularly indicated is reduction of strangu- 
 lated hernia. The relaxation is almost as complete as 
 in chloroform narcosis and there is not the vomiting which 
 usually follows general anesthesia and which sometimes 
 cannot be distinguished from early stercoraceous emesis.
 
 HERNIA 203 
 
 Diaphragmatic Hernia. The colon or a part of the 
 stomach may crowd through a hiatus in the diaphragmatic 
 muscular tissue, carrying the parietal peritoneum and the 
 pleura with it as a sac forming a diaphragmatic hernia. 
 The only possible treatment is an abdominal section close 
 to the ensiform, withdrawal of the hernial contents and 
 closure of the hole with 2o-day chromicized catgut. Recur- 
 rence may be anticipated. 
 
 Hernia Cerebri. Hernia cerebri is due to infection 
 of the brain near the opening through which the inflamed 
 tissue protrudes. Therefore the treatment must be largely 
 antiseptic, but antiseptic in a mild way, since active agents 
 like bichloride increase the congestion. Probably the best 
 treatment consists in enlarging the opening, if possible, 
 for a half inch on every side of the extruding brain-mass 
 and dusting the wound and brain with iodoform, applying 
 antiseptic gauze over it from time to time. Secretions 
 should be gently wiped, not washed, away. If abscess 
 forms (not common) it must be opened and drained. 
 Great patience must be exercised as the hernia sometimes 
 persists for weeks and then gradually recedes. If persistent, 
 the brain finally becomes a mass of granulation-tissue which 
 so utterly destroys the cortex, that the whole thing may as 
 well be removed by burning with Paquelin cautery. 
 
 Hernia in Children. Hernias in children are most 
 often of the umbilical and inguinal variety; though there 
 are many cases of femoral hernia reported this condition 
 is comparatively rare before the age of puberty. Those 
 who have much to do with the surgical treatment of chil- 
 dren are struck by the number of cases of hydrocele of the 
 cord which have been treated as though this condition 
 were hernia. This perhaps is the only condition, certainly 
 the only condition in infancy, which is likely to lead to 
 error in diagnosis. Umbilical hernia of infancy rarely calls 
 for operation, being readily cured by pressure, best applied
 
 204 SURGICAL THERAPEUTICS 
 
 through the medium of a pad with a flat surface secured 
 in position by adhesive straps. As to the treatment of 
 inguinal hernias, the general opinion of the profession is 
 undergoing a change. It was formerly held that the great 
 majority of such ruptures could be cured, and permanently 
 cured, by a properly fitting truss. Some cures certainly 
 have thus been effected. As to whether or not this cure is 
 a permanent one, some are not decided; others contend that 
 the hernia will come down again when the boy reaches 
 manhood, with its strains. Certain it is that operation is 
 safe, and is almost sure to give perfect and permanent 
 cure if properly performed. 
 
 Inguinal Hernia in Yotmg Children. This is a 
 condition which should not be neglected. As a rule it is 
 best, before resorting to operation, to try to cure the rup- 
 ture by means of a truss or other mechanical measures, with 
 the following exceptions to the general rule: Operate (i) in 
 case of strangulation, or where strangulation has been 
 reduced by taxis; (2) upon all cases not controlled by truss; 
 (3) when truss- wearing causes pain; (4) when the patient 
 cannot be-observed regularly; (5) in cases associated with 
 reducible hydrocele, or fluid in the hernial sac. But opera- 
 tive treatment being perfectly safe, and absolutely sure 
 to effect a cure if properly done, every patient should be 
 subjected to the Bassini method, which deservedly occupies 
 first place in the treatment of inguinal hernia, for it deals 
 thoroughly with the sac and with the canal. There are 
 two points in this operation deserving of special emphasis: 
 First, in splitting the aponeurosis of the external oblique, 
 the division should be made in the cleavage line, as high 
 above Poupart's ligament as possible; if the division is 
 made directly over the inguinal canal, the lower flap of 
 aponeurosis is so short that it is difficult to put in the 
 second row of sutures without tension and subsequent 
 danger of sloughing and splitting. 'The longer flap obviates
 
 HERNIA 205 
 
 this danger and gives a stronger wall. The other point is 
 this: Lloyd has demonstrated that in recurrences the 
 relapse is at the lower end of the wound, and the rupture 
 is of the direct type; therefore, it is of the greatest import- 
 ance accurately to coapt the internal oblique and trans- 
 versalis muscle to Poupart's ligament at the lower end of 
 the wound. Children bear surgical work remarkably well, 
 and there is no major operation in surgery attended with 
 as little shock and giving as satisfactory results, as the 
 operation for the radical cure of inguinal hernia. The 
 curability of rupture in early childhood by operation is a 
 settled question. The safety of the method is generally 
 acknowledged. The only question then is, shall we operate 
 or shall we apply a truss ? The former plan requires about 
 two weeks to effect a cure, the latter requires two or more 
 years, and is far more uncertain. 
 
 Injection. Schwalbe's method of treatment consists 
 in reducing the hernia and then injecting pure alcohol 
 around the sac on every side. The resulting irritation of 
 serous surfaces and long-continued induration sometimes 
 causes obliteration of the sac in favorable cases. 
 
 Local Anesthesia in Operations for Hernia.. 
 Bodine claims that by proper cocainization this operation 
 can be rendered absolutely painless. It is necessary to 
 employ only a one-fifth of one-percent solution and never 
 inject more than one-half grain of cocaine, so that serious 
 symptoms of poisoning never occur. This solution is 
 used for skin infiltration and cocainizing the nerve trunks; 
 for the deeper tissues a solution half this strength is used. 
 The solution should always be fresh, as aqueous solutions 
 of cocaine are certain to deteriorate. The method is as 
 follows: The skin is first infiltrated, the proper depth to 
 which the needle is penetrated into the skin being such 
 that the needle is always visible just beneath the surface. 
 The skin having been anesthetized the needle is plunged
 
 206 SURGICAL THERAPEUTICS 
 
 through the skin and the tissues around the external ring 
 are infiltrated. The skin incision down to the aponeurosij 
 is then made. If there is much fat this is also infiltrated 
 with a i in 1000 solution. The ilioinguinal nerve is then 
 exposed and is cocainized at the higher point. The dis- 
 section can be carried out further into the external ring; 
 the two flaps of fascia are retracted, exposing the shelving 
 border of Poupart's ligament externally and the conjoined 
 tendon on the inner side. The iliohypogastric nerve can 
 be searched for, and if found, cocainized; which will 
 materially assist in securing painlessness of the operation. 
 If it is not found the margins of the internal ring and the 
 adjacent part of the conjoined tendon are injected with a 
 one-tenth of one-percent solution. Along the center line 
 of the long axis of the protrusion a line of infiltration with 
 the same solution is made. The sac is then opened and 
 the contents dealt with as occasion requires; there being 
 practically no sensation in the omentum and intestines 
 no application of cocaine to them is necessary. The neck 
 of the sac is infiltrated, dissected away from the under- 
 lying cord, ligated and amputated. The genitocrural nerve 
 is sought for, and if it is found and cocainized the operation 
 can be completed in any manner the operator prefers 
 without additional cocaine. If the nerve is not found, the 
 operation must be completed as speedily as possible, as 
 there will quickly be a return of sensation. The ultimate 
 results are as good as under general anesthesia. 
 
 Redaction of Hernia. When the contents of a her- 
 nial sac, previously reducible, cannot be returned to the 
 abdomen the patient should be given, hypodermically, 1-4 
 grain of morphine and 1-250 of hyoscyamine, or even the 
 latter alone, repeating if necessary. In half an hour a 
 good dose of strychnine should be injected if the pulse is 
 weak. Then with the patient upon his back, a pillow 
 under the hips and knees drawn up (and supported by
 
 HICCOUGH AFTER OPERATION 207 
 
 some one) to relax all muscles a few drops of chloroform 
 may be given by inhalation; relaxation will be complete 
 in a few minutes and the hernia may spontaneously dis- 
 appear. If not, gentle taxis may be instituted; but no force 
 must be used and efforts at reduction should not be con- 
 tinued more than fifteen minutes. The H-M-C combina- 
 tion seems admirably adapted for these cases. If the 
 trouble cannot be relieved in that time operation is needed, 
 and soon. 
 
 Strychnine in Strangulated Hernia. Often the 
 nervous depression in strangulated hernia is alarmingly 
 apparent when the surgeon reaches the patient's bedside; 
 indeed it is so great that strong men die from the shock 
 of what, under other conditions, would be a trivial operation. 
 When this condition is present, the first thing to be done 
 after ascertaining the nature of the trouble is to inject 
 four milligrams (about 1-15 grain) of strychnine sulphate. 
 In a few minutes a dose of the hyoscine-morphine-cactin 
 anesthetic may be injected, and by the time everything is 
 ready for operation (which may often be done under cocaine) 
 the general condition of the patient will be much improved. 
 
 HICCOUGH AFTER OPERATION 
 
 Occasionally a persistent hiccough occurs some hours 
 after injury or serious operation and becomes quite dis- 
 tressing to the patient. Possibly the best thing to control 
 it, after application to the throat of clothes wrung out of 
 ice-water has failed, is "Hoffmann's anodyne," the spiritus 
 setheris compositus of the U. S. P. It is composed of 
 ether, alcohol and heavy oil of wine, hence is a stimulant 
 of almost instant action, yet prolonged as well; the ether 
 is taken up immediately, the alcohol somewhat later and 
 the oil of wine quite a time afterward. The dose is one to 
 two teaspoonfuls every hour until relieved. Sometimes a 
 capsule of camphor with musk arrests hiccough which has
 
 208 SURGICAL THERAPEUTICS 
 
 resisted all other medication; but pure musk is very hard 
 to get and is of great cost. 
 
 HIP-JOINT DISEASE 
 
 Coxalgia. Technically "pain in the hip-joint"; often 
 employed, incorrectly, by the older writers as ynonymous 
 with "hip-joint disease". 
 
 Coxarthrocace. Fungoid inflammation of the hip- 
 joint is a form of tuberculosis. (See "Tuberculosis of 
 Joints".) 
 
 Coxitis. Inflammation of the hip-joint does not differ 
 from that of any other joint (see "Arthritis") when o" 
 any origin other than tuberculosis. 
 
 HYDROCELE 
 
 All things considered, it is best to advise excision in 
 most cases of hydrocele. Plastic methods (injection of 
 some irritating fluid into the almost emptied sac) are not 
 without danger and frequently fail, though 95-percent 
 carbolic acid, one dram, is generally regarded as harmless 
 and often cures. But removal of the sac, save enough to 
 cover the testicle, is so perfectly safe in clean hands and 
 so sure that one should not hesitate to insist upon it as 
 a method of choice. 
 
 Injection of Hydrocele. When a patient will not 
 submit to the simple, safe (in aseptic hands) operation for 
 hydrocele the injection method may be tried. The best 
 fluid is tincture of iodine in full strength. Some prefer 
 half iodine tincture and half pure phenol (carbolic acid). 
 The scrotum is thoroughly scrubbed and dried, washed 
 with ether and rinsed with 6 5 -percent alcohol; then 
 surrounded with a sterile towel, preferably taken from the 
 boiler in which the trocar, canula and hypodermic syringe 
 have been cooked. The trocar and canula are thrust into 
 the sac, avoiding wounding of the testicle, and the fluid
 
 INCONTINENCE OF URINE 209 
 
 allowed to escape. Then the iodine is injected either 
 through the canula or with the hypodermic needle intro- 
 duced through the same hole. The sac is gently rubbed 
 so as to distribute the iodine and the external opening is 
 closed with collodion. The inflammatory reaction is not 
 severe, but adhesion is sometimes secured between the 
 scrotal and the testicular layers of the tunica vaginalis, with 
 final obliteration of the sac. 
 
 HYDROGEN DIOXIDE 
 
 Entirely too much "peroxide" is used hi the treatment 
 of suppurating wounds as also too much water and liquid 
 antiseptics of all sorts. The best treatment for a suppurat- 
 ing, granulating surface is merely to wipe out, gently, with 
 a little absorbent cotton or gauze, all . surplus secretion, 
 exercising great care not to disturb the delicate granulations 
 from which the new tissues must be formed. This is 
 particularly applicable to pyothorax. The hydrogen dioxide 
 is applicable chiefly to those suppurating cavities which 
 do not drain well and cannot be reached with the cotton; 
 and also to those suppurating surfaces which show a ten- 
 dency to be abnormally slow in healing here the irritating 
 effect being just sufficient to stimulate the sluggish granula- 
 tions. 
 
 HYPODERMOCLYSIS: CAUTION IN 
 
 When injecting large quantities of normal salt solution 
 beneath the skin one must not allow too much fluid to 
 accumulate at one area, otherwise necrosis may occur. 
 It is best, therefore, to shift the needle to various parts 
 not by swinging it from side to side, but by partly with- 
 drawing it and reinserting it to another area. 
 
 INCONTINENCE OF URINE 
 
 Women occasionally complain that they pass their 
 urine during sleep. To such patients santonin may be
 
 210 SURGICAL THERAPEUTICS 
 
 given in doses of one to two decigrams (i 1-2 to 3 grains) 
 three times daily. It often checks the incontinence after 
 everything else has been used; but equally often it does 
 little or no good. Wetting the bed by little girls usually 
 means masturbation; even small children, mere babies, 
 practise it; in which cases bromides and salicin are 
 advisable. 
 
 INFECTIONS: LOCAL 
 
 The treatment of these troublesome and sometimes 
 fatal conditions is well described by Weider, of Philadelphia. 
 He decries the folly of waiting until an abscess or boil 
 "points," thereby increasing the opportunity for further 
 infection as well as prolonging the most painful period of 
 the entire process,' and calls attention to the fact that any 
 kind of a poultice can do nothing but accentuate all the 
 undesirable features of this waiting. 
 
 The most immediate relief of pain, the quickest process 
 of repair, and the surest preventive against secondary 
 infection are secured by immediate incision over the point 
 of greatest tenderness, no larger than necessary, but deep 
 enough to allow some bleeding, and reaching if possible 
 the focus of infection. The wound should be allowed to 
 bleed as freely as it may, and then, whether or not pus be 
 found, should be thoroughly swabbed out with phenol, 
 lightly packed with gauze, and a wet bichloride dressing 
 applied. 
 
 The patient is given tablets of bichloride of mercury, 
 instructed how to make a i in 1000 solution, and told to 
 use it, as hot as he can bear it, three times a day, soaking 
 the affected part for a half hour, without removing the 
 dressing. In the majority of cases, if seen in time, this 
 treatment is abortive, and when the patient appears next 
 day all symptoms will be found improved. Should the 
 process, however, have gone on to actual pus-accumulation
 
 INFECTIONS: LOCAL 211 
 
 or to necrosis, the symptoms of inflammation will have 
 greatly subsided and the pain have either disappeared or 
 be markedly lessened, and there will be found more or less 
 discharge, purulent or otherwise. The use of the probe 
 will then invariably indicate the seat of infection, either as 
 an accumulation of pus or as the characteristic "core." 
 If the former, it should be freely exposed, using scissors 
 preferably; if the latter, it should be removed with forceps, 
 experience having pioved the use of the curet inadvisable 
 in these cases. Light packing and the repetition of the 
 bichloride dressing is then resumed. 
 
 Weider closes his article with the following summary: 
 
 "i. Poultices, socalled antiphlogistics, etc., are use- 
 less in the treatment of local infections and do harm by 
 causing greater destruction of tissue and delaying proper 
 remedies. 
 
 "2. Immediate incision over the point of greatest 
 tenderness should always be practised, followed by carbo- 
 lization of the wound to destroy the nidus of infection, 
 and then a wet bichloride dressing should be applied. 
 
 "3. Free incision with constant wet drainage should 
 be the rule in the presence of pus. 
 
 "4. Dry drainage, especially when saturated with 
 coagulative powders, is ineffectual and harmful because of 
 the 'caking' that occurs on the surface, sealing the 
 cavity. 
 
 "5. Cases, especially with drainage, should receive 
 soakings with hot bichloride solutions thrice daily. Hot 
 salt solution or water may be used if the bichloride appears 
 too dangerous. 
 
 "6. Waxed paper should not be used over wet dress- 
 ings, as it forms them into moist warm poultices, which 
 are objectionable. 
 
 "7. Never curet infections primarily, excepting car- 
 buncles, which should always be cureted and carbolized.
 
 212 SURGICAL THERAPEUTICS 
 
 "8. Gauze selvage, when soaked in bichloride solution, 
 makes a conveniently handled and effectual packing. 
 
 "9. Palmar infections of the fingers and hands are 
 more serious than dorsal infections. 
 
 " 10. In incising for the palmar infections of the fingers, 
 continue the incision until pus or the bone is reached, and 
 do it without delay." 
 
 INFLAMMATION: BIER'S METHOD OF CURE 
 
 The application of dry heat for the cure of inflammation 
 (known as the Bier method) has been given extensive trial 
 recently. 
 
 The patients selected for treatment were those in whom 
 no cure could be expected by simply placing the part at 
 rest; as a rule they were patients in whom operative pro- 
 cedures were indicated but who declined. The cases in- 
 cluded acute cellulitis of the extremities, bursitis, phlegmon 
 of the tendon-sheaths of the hands, lymphangitis, furuncles, 
 osteomyelitis, tuberculous gonitis, gonorrheal gonitis, 
 erysipelas of the extremities, epididymitis, etc. The best 
 results were obtained in the acute inflammations. The 
 method gives better functional results, it lessens the duration 
 of treatment and relieves pain. Bier especially emphasizes 
 the alleviation of pain. The technic of the method is not 
 simple and easy; one needs months in order to know it 
 thoroughly. Experience and judgment are necessary for 
 success. 
 
 INGROWING NAILS: TREATMENT OF 
 
 Free application of dried powdered alum is sufficient 
 to cure most cases of ingrowing nails in about five days. 
 The applications are never painful in the least, and the 
 destruction of the pathologic tissue results in the formation 
 of a hard, resistant and non-sensitive bed for the nail, 
 a perfect cure for the ingrowing tendency. The non-
 
 INTESTINAL OBSTRUCTION 213 
 
 toxicity of the alum, its easy application, and the good 
 results render it the treatment of choice for cases in which 
 surgical intervention is not contemplated. A fomentation 
 of soap and water is applied in the space between the nail 
 and its bed, tamponing with cotton to keep the alum in 
 place, and repeating the application daily. The suppura- 
 tion rapidly subsides, and pain and discomfort are relieved 
 very soon. 
 
 A very good way to treat ingrowing toe-nail when the 
 patient does not desire an operation is to make a solution 
 of liquor potassae, U. S. P., in water two drams to the 
 ounce: 
 
 Liquor potassre 8.0 
 
 Water 32.0 
 
 and saturate a small bit of absorbent cotton with this. 
 The cotton is to be pressed gently in between the upper 
 surface of the nail and the mass of tender granulation- 
 tissue. The alkali soon permeates the substance of the 
 nail without irritating the sore; but the cotton must be kept 
 constantly moist to do the work well. The softened part 
 of the nail is to be carefully wiped off every morning. In 
 a few days the nail will have become so thin and soft that 
 it can be cut away without pain. The applications must, 
 however, be continued until all granulations disappear 
 and healing is well under way. 
 
 INTESTINAL OBSTRUCTION: TREATMENT 
 AFTER 
 
 It is important that the patient be disturbed as little as 
 possible, yet an enema is a good thing to start the peris- 
 taltic wave downward soon after the bowel has been opened, 
 early and thorough evacuation being essential to recovery, 
 for retention of the poison in the intestinal tract is as dan- 
 gerous as the obstruction which caused the toxic agents 
 to form. Thirst is, therefore, to be quenched by small
 
 214 SURGICAL THERAPEUTICS 
 
 sips cf iced, effervescent solution of citrate of magnesia; 
 but little water ought to be given by mouth during the 
 first twenty-four hours. Large enemas of warm, slightly 
 salt, water may be given with advantage every six hours. 
 Perfect quietude is imperative anxious friends must be 
 driven out and the patient made to sleep if possible. The 
 first few hours after relief of intestinal obstruction are 
 critical ones, and too great care cannot be exercised to se- 
 cure perfect tranquillity for the patient. No matter how 
 much complaint may be made of pain, morphine must not 
 be given it increases the danger of paresis of gut almost 
 always an exceedingly serious menace to life. No food 
 should be given by mouth until more than forty-eight hours 
 have elapsed, but a few nutrient enemata are advisable 
 if the patient be weak or complains of hunger. Liquid 
 diet for the next two days is to be ordered. 
 
 -.INTUSSUSCEPTION 
 
 Nothing but operative treatment is to be advised 
 in these cases; but when the relatives will not consent to 
 immediate abdominal section, the surgeon may still do 
 something while waiting. But, first of all, he should freely 
 explain that early surgical interference is indicated in order 
 to free the bowel from a position which threatens to render 
 it necrotic by disturbance of the mesenteric circulation; 
 this nutritional disturbance of the bowel, due to occlusion 
 of the mesenteric vessels, must be relieved as soon as pos- 
 sible, before the infection of the peritoneal cavity promptly 
 annihilates the results of the operation. But, before urging 
 operation, the doctor must be pretty sure of his diagnosis, 
 since it is humiliating to be discharged and have some 
 "granny" cure the patient by a simple enema. 
 
 The diagnosis of intussusception is easy. It depends 
 upon feeling the "lump" of the invagination, and the 
 passage of bloody mucus per anum. But the examination
 
 IODINE: COLORLESS 215 
 
 of the abdomen should invariably be conducted under 
 general anesthesia. The most important therapeutic indi- 
 cation consists in the reestablishment of the obstructed 
 mesenteric circulation. It is t ) be then explained to the 
 friends that all internal therapeutic measures are to be 
 rejected as inadequate to deal with the condition of the 
 incarcerated segment of the bowel. As soon as the diag- 
 nosis is positive, laparotomy should be performed, because 
 this form of treatment alone can be relied upon to reestab- 
 lish normal conditions. 
 
 Disinvagination is always accomplished by gradually 
 crowding the invaginatum from the tip through the entire 
 sheath of the invaginans, using the thumb and index finger 
 of both hands. After the invaginated bowel-segment has 
 been reduced, bit by bit, through these manipulations, 
 cautious traction may be employed for the purpose of 
 determining that the surfaces of intussusceptum and 
 intussuscipiens slip smoothly by each other. It is a serious 
 mistake, however, to attempt the reduction of the invagina- 
 tion only by means of traction, because the mechanical 
 conditions of the intussusception are not recognized in 
 this manipulation. The outcome of a given case depends 
 not alone upon the duration of the intussusception, but also 
 upon the degree of the obstruction of the mesenteric circu- 
 lation. 
 
 Opiates should never be given; nor on the contrary, 
 should physic. But the lower bowel should be washed 
 out repeatedly with warm water to which has been added 
 a little soap and glycerin. Then the anesthetic is admin- 
 istered. If the diagnosis is then sure operation should be 
 urged; if refused it is far better to withdraw from the case. 
 
 IODINE: COLORLESS 
 
 When patients object to the discoloration of skin pro- 
 duced by painting with tincture of iodine, as in the treat-
 
 216 SURGICAL THERAPEUTICS 
 
 ment of goiter, it is very easy to make colorless iodine, 
 and make it instantly, without waiting a minute for the 
 change : 
 
 Tincture of iodine 24.0 (drs. 7 ) 
 
 Aqua ammonia 6.0 (drs. i 1-2 ) 
 
 Carbolic acid 6.0 (drs. 10 to 12) 
 
 Shake well and wait just a moment and all color will be 
 gone. The therapeutic value is not seriously affected. It 
 is of much value as a local application in several surgical 
 conditions notably in goiter; but care must be used not 
 to cause blistering. 
 
 IODOFORM 
 
 Absorption. Many surgeons use iodoform as a powder 
 for its drying and antiseptic properties as well as for 
 injection of tuberculous cavities (joints, etc.). Some pa- 
 tients, notably those of pink skin and red hair, are easily 
 poisoned, both locally and systemically. The local mani- 
 festation is a deep erythema, and sometimes the formation 
 of vesicles. The symptoms of absorption are (i) thick 
 coat upon the tongue with metallic taste; (2) slight nausea 
 with loss of appetite and, later, in extreme cases, vomiting 
 and diarrhea; (3) increase of pulse to 120 or 140 per minute, 
 with irregularity and palpitation in severe poisoning; (4) 
 delirium with hallucinations or melancholia. As these 
 symptoms are much like those of staphylococcus infection, 
 great uneasiness may be felt upon their appearance, but 
 discontinuance of the iodoform application or withdrawal 
 of the iodoform-gauze pack from the vagina (after vaginal 
 hysterectomy), from the abdomen (after appendectomy or 
 pelvic operations) or other wound will generally be followed 
 by prompt disappearance of the symptoms; but rarely they 
 persist for days or weeks and fatal results have been 
 reported. Gram doses of sodium bicarbonate are recom- 
 mended as an antidote.
 
 IODOFORM 217 
 
 lodoform Injections into Joints. There can be no 
 doubt but that most brilliant results are obtainable in some 
 cases of tuberculous arthritis and synovitis by injection of 
 lo-percent iodoform emulsion. But, on the other hand, 
 most deplorable results have followed its use by incompetent 
 or careless surgeons as well as physicians. It must be 
 borne in mind that iodoform powder itself is not sterile 
 nor is it germicidal; most pyogenic microorganisms thrive 
 in an emulsion of iodoform, and the glycerin, too, is apt 
 to be infected. So the iodoform must be sterilized by 
 soaking in i in 1000 bichloride solution for 24 hours, then 
 placed upon a sterile plate and the water evaporated. The 
 glycerin is boiled and poured into a mortar which, with its 
 pestle, has just been taken from the boiler or sterilizer. 
 Then the iodoform is added and the whole thoroughly 
 triturated and poured into a wide-mouthed, sterilized 
 bottle. From this the iodoform emulsion is drawn out by 
 the freshly boiled syringe (the glass stopper being instantly 
 returned to the iodoform-container) and injection made by 
 a sterile needle thrust through the properly cleaned skin. 
 
 lodoform Wax-Filling. "\Yhen large amounts of 
 bone are necessarily removed (for necrosis, tuberculosis, 
 etc.) the cavity may be filled by 
 
 lodoform powder 60.0 
 
 Spermaceti 20.0 
 
 Oil of sesame 20.0 
 
 Mix in a mortar just out of a sterilizer and put into 
 a sterile (boiled) jar. This remains fluid at i32F. The 
 cavity in the bone must be perfectly clean and dry, and 
 every part of the cavity must be permeated by the mass; 
 drainage usually is not necessary, but if thought advisable, 
 can be made by the insertion of a few strands of plain 
 catgut. While this filling is for temporary use only, being 
 pushed out by the growth of new tissue, the wound some- 
 times heals by first intention and the filling is absorbed
 
 218 SURGICAL THERAPEUTICS 
 
 in time. Though a foreign substance, it is well borne by 
 the tissues; pulse and temperature sometimes increase, 
 but usually for only two or three days. Symptoms of iodo- 
 form poisoning are rare. This method gives its best re- 
 sults in cases of chronic circumscribed osteomyelitis, 
 chronic tuberculous osteomyelitis and the acute form 
 attended by necrosis. 
 
 JAUNDICE 
 
 Phosphate of Sodium in Jaundice. It has become 
 a common thing to give phosphate of sodium in gallstone 
 disease as well as in every other condition in which jaundice 
 is a prominent symptom. The fact is that it is useful 
 chiefly in catarrhal jaundice and that its good effects in 
 that trouble are due to its cathartic action and not to any 
 specific influence on the disease. It is quite irritating to 
 some stomachs far more so than rochelle salt or Abbott's 
 saline laxative, which ought to be used instead of the more 
 disagreeable sodium salt. 
 
 JOINTS: ACUTE INFECTIONS OF 
 
 The acute infections of the joints are few in number, 
 but of great importance. They have been enumerated by 
 Lovett as (a) acute osteomyelitis of the articular end of 
 one of the long bones, involving the joint secondarily; 
 (b) acute suppurative synovitis, or joint abscess; (c) acute 
 plastic synovitis leading to joint obliteration; (d) acute 
 serous synovitis. Tuberculous and chronic joint diseases 
 are not considered in this classification, being essentially 
 of a chronic character. 
 
 Acute Osteomyelitis is an acute suppurative inflam- 
 mation of bone due to infection of the bone-marrow by 
 pyogenic organisms. The treatment of such cases consists 
 in the earliest possible free drainage of the joint, with care- 
 ful search for the infected area of bone, which should be
 
 JOINTS: ACUTE INFECTIONS OF 219 
 
 opened, cureted and packed, allowing healing to occur 
 under strict antiseptic precautions, in order to prevent 
 a secondary mixed infection. 
 
 Actfte Serous Synovitis. Occurs in connection with 
 general infectious disease. It is often classed under the 
 name of articular rheumatism. It does not differ clinically 
 or pathologically from what is generally regarded as acute 
 articular rheumatism. It may be produced experimentally 
 by the injection of cultures of pyogenic organisms. 
 It cannot as yet, however, be regarded as a specific infec- 
 tious disease. Evidence rather tends to identify it as "an 
 attenuated pyemia." 
 
 Acute infections of the joints of undoubted bacterial 
 origin occur in two grades of severity in connection with 
 many infections. In many cases the source of infection can 
 not be established, and in such cases it is important to 
 remember that the function of the tonsils and the presence 
 of pyogenic bacteria in the mouth are a ready source of 
 infection. That acute articular rheumatism is an infection 
 seems probable from bacterial and especially from clinical 
 evidence; but this has not as yet been definitely proved. 
 
 Actfte Strppurative Synovitis, or joint abscess, 
 occurs as a result of various infective organisms and appears 
 in infectious diseases of a wide range, such as cerebro- 
 spinal meningitis, diphtheria, dysentery, erysipelas, epi- 
 demic parotitis, glanders, gonorrhea, epidemic influenza, 
 measles, pneumonia, pertussis, puerperal fever, pyemia, 
 septicemia, scarlet-fever, smallpox, tonsillitis, typhus fever, 
 typhoid fever, after the use of sound and catheters, and 
 possibly in malaria. The treatment consists of free drain- 
 age of the joint as soon as evidence of suppuration can be 
 established. 
 
 Ankylosis of Joints. Union of the bones forming a 
 joint may be (a) fibrous or (b) bony. The x-ray will 
 determine which is present in case of doubt. It will also
 
 220 SURGICAL THERAPEUTICS 
 
 reveal "false" ankylosis which is due to mere rigidity of 
 the surrounding parts. 
 
 The treatment of the false or spurious, as well as of the 
 fibrous or ligamentous, consists in forcibly breaking down 
 all adhesions (under chloroform) and the persistent use of 
 passive motion. A stimulating liniment (chloroform lini- 
 ment is pleasing) may be given. 
 
 Bony ankylosis cannot be cured. If the joint be in an 
 awkward position the bone may be broken and allowed 
 to unite in a better one. 
 
 Gonorrhea of Joints. Socalled "gonorrheal rheu- 
 matism" is an acute infection of the synovial membrane 
 by the gonococcus; in reality, with the exception of the 
 mild, evanescent cases which are due to toxemia, it is 
 truly a pyemic condition. The gonococcus directly invades 
 the affected tissue, and the foci are located either in the 
 synovial membranes, constituting an arthritis, or they 
 are in the articular ends of the bones, constituting an 
 osteoarthritis. In osteoarthritis the bone focus is always 
 primary, and is never caused by extension of the inflam- 
 mation from the interior of the joint. Hence, a gonor- 
 rheal arthritis remains an arthritis and never involves 
 the bones, no matter how long it exists or what its inten- 
 sity. Gonorrheal joint disease may be recurrent, but 
 never chronic. The cases which have been called chronic 
 are those in which the initial acute inflammation has 
 left behind bands of adhesion or other structural change in 
 the synovial membrane in arthritis, and bony outgrowths, 
 or anyklosis, in osteoarthritis. These changes, unless 
 treated mechanically, or by operation, are permanent. 
 
 The treatment during the acute stage must be on 
 general lines, and must depend upon existing conditions. 
 
 The treatment of deformity must be based upon the 
 sajne principles which govern the treatment of all deform- 
 ities. Cases that are treated properly during the acute
 
 JOINTS: ACUTE INFECTIONS OF 221 
 
 stage will usually get well without disability. It lies 
 with the general practitioner and the genitourinary sur- 
 geon to prevent the serious, often life-long, disability 
 which sometimes follows in the train of a gonorrheal 
 joint infection. 
 
 Joint-Inflammation (Arthritis). Inflammation of 
 a joint may follow an injury, with infection of the joint 
 by germs of pus even the bacillus of typhoid fever 
 (Eberth's bacillus) and of the grippe (Pfeiffer's bacillus) 
 may cause suppuration in the joints, conspicuously the 
 knee. Such infections (with pyogenic bacteria) alone 
 constitute true arthritis. 
 
 But by long usage, and by reason of modern patholo- 
 gists having failed to give any definite substitute for the 
 name, certain chronic conditions must be classed under 
 the head arthritis. They are the following: 
 
 a. Arthritis fungosa. Tuberculosis of the joints, 
 "scrofula" or "white swelling" of the old writers. 
 
 b. Arthritis deformans. A peculiar affection of the 
 joint known also as arthritis pauperum, chronic rheuma- 
 toid arthritis, osteoarthritis, rheumatic gout, nodular 
 rheumatism and arthritis proliferans. It is character- 
 ized by an overgrowth of the articular cartilages and 
 synovial membranes with destruction of such parts of 
 the cartilage as are subjected to pressure within the joint, 
 with the consequent deformity. It is most often seen 
 in advanced life but sometimes is met in young persons 
 who have the rheumatic diathesis to a marked degree. 
 
 c. Arthritis uritica. Changes in the joints due to 
 gout. The calcareous, gouty deposits or concretions 
 around a joint frequently create quite a deformity, but 
 can be remedied only rarely, e. g., by blistering with can- 
 tharrides. They are called arthritoliths. 
 
 These various conditions are of surgical interest 
 chiefly from the standpoint of differential diagnosis;
 
 222 SURGICAL THERAPEUTICS 
 
 but the condition hitherto described as "fungous arthritis" 
 is of enormous import to surgeons, since it embraces tuber- 
 culosis of the joints (which see). 
 
 Joints: Secondary Impotence of. As a result of 
 (a) direct injury, (b) prolonged immobilization and (3) 
 the effect upon the mind of the patient, permanent impair- 
 ment of a joint may follow even a trifling traumatism. 
 Reflex amyotrophy of articular origin also should have 
 a place in surgical pathology, as it explains the patho- 
 genesis of many articular affections, such as passive dis- 
 locations, painful flat-foot, genu valgum of adults, scoliosis 
 and others. The functional impotence is sometimes 
 secondary to spinal lesions, which result from the articu- 
 lar trauma and consist of diminution of motor-cells in 
 the anterior horns. Later, the nerves to the joints undergo 
 partial degeneration and muscle-fibres atrophy. Trophic 
 centers which preside over the nutrition of periarticular 
 tissues are probably involved also. Reaction to electric 
 currents serves to establish prognosis. Early cases are 
 usually curable, chronic, incurable. In the incurable 
 patients, static electricity will relieve pain and spasm, 
 faradization being contraindicated. 
 
 Plastic, or Ankylosing Synovitis. In this an acute 
 or severe joint inflammation is followed by a partial or 
 complete obliteration of the joint, without suppuration; it 
 is most familiar as an accompaniment of gonorrhea. Little 
 can be said, however, of its etiology and no satisfactory 
 treatment has been formulated. 
 
 Tuberculosis of Joints. It may begin in either 
 the synovial membrane or the bony structures contiguous 
 to the joint. Immobilization and perfect rest some- 
 times effect a cure. When recognized early (it is too 
 often mistaken for rheumatism) injection of the affected 
 joint with lo-percent iodoform emulsion will quite often 
 cure. The iodoform must be fresh; the glycerin steril-
 
 KIDNEY 223 
 
 ized by boiling. The glass mortar and pestle are boiled 
 ' twenty minutes. Then one part iodoform (say, one ounce) 
 is triturated in 10 parts of the glycerin and the emulsion 
 poured into a sterilized bottle and kept tightly corked; 
 or better, put in a fruit-jar which can be closed perfectly. 
 At the time of the injection the skin is to be sterilized 
 and the syringe boiled. About one ounce of the emul- 
 sion (well shaken) may be thrown into a large joint like 
 the ankle or elbow. Some fever may result, during which 
 the joint is to be kept quiet. After it subsides, together 
 with the immediate soreness, the joint may be used mod- 
 erately. The injection may be repeated in three or four 
 weeks and the joint put in plaster-of-paris for three weeks. 
 If the iodoform treatment, and surgical rest do not cure 
 in a few months, operative treatment is usually advisable, 
 except in Pott's disease and sometimes in tuberculosis 
 of the hip-joint. 
 
 Internally the treatment is essentially tonic and sup- 
 portive practically the same as for any other form of 
 tuberculosis. 
 
 KIDNEY 
 
 Alkalis for Stone in the Kidney. Before resort- 
 ing to operative measures for stone in the kidney it is 
 best to give large doses of potassium citrate for two or 
 three weeks, unless there are evidences of infection by 
 pyogenic bacteria. Patients who complain of much pain 
 in the back, who pass bloody urine, and even those who 
 are discharging small quantities of pus, are not infre- 
 quently entirely relieved by this course of treatment. 
 The explanation is that the source of irritation is merely 
 a number of small uric-acid stones; and by elimination of 
 an excess of alkali by the kidney these are slowly dis- 
 solved, or at least sufficiently diminished in size to permit 
 their passage down the ureter. Certain it is that under
 
 224 SURGICAL THERAPEUTICS 
 
 this line of treatment such small stones are discharged 
 from the bladder in some cases, with perfect relief of all 
 symptoms. If no benefit is derived at the end of three 
 weeks, it may be concluded either that the stone is too 
 large to be affected or that it is not of simple uric-acid 
 formation. The onset of fever or the appearance of 
 much pus in the urine demands early operation. 
 
 Displaced Kidney. Nervous and pelvic symptoms 
 dependent upon wandering kidney are more frequent 
 than many believe. If more kidneys had been anchored 
 and fewer ovaries removed, gynecologists would not have 
 been so severely criticized by neurologists as they have 
 been; and many a suffering invalid would have been cured 
 instead of merely improved (by the rest in bed). When- 
 ever a kidney is found completely below the ribs it is 
 making serious traction on the nerves and vessels, it is 
 causing trouble and should be replaced and sutured. It 
 is almost phenomenal how quickly and permanently many 
 chronic invalids may be restored to perfect health by 
 fixation of a loose kidney which had escaped recognition 
 for perhaps years. Why? Not because the doctor did 
 not know about loosened kidney, but because he had been 
 "too busy" to make careful examination; or had been 
 too deeply interested in "local treatments" of a wholly 
 innocent uterus through a speculum (for dollars?); or too 
 much of a doser to believe hi surgical measures. Some 
 become so wholly absorbed in the administration of drugs 
 as to lose sight of the necessity for operative treatment 
 of certain conditions. This is deplorable, but true. Others, 
 knowing, fear to advise operation, as the patients may 
 lose faith in them if they admit there is anything they 
 cannot cure! This is cowardly, but also true. 
 
 Kidney Operations: Treatment After. Three 
 things are prominent after kidney operations, especially 
 nephrectomy: vomiting, pain and drainage. The first
 
 KIDNEY 225 
 
 two may be controlled, usually, by hypodermics of 
 hyoscine hydrobromide (gr. i-ioo) and morphine (gr. 
 1-4) every three to six hours, this combination being better 
 than plain morphine which has a tendency to check urine- 
 secretion; and i -zoo grain of digitalin may be added with 
 advantage. Immediately after operation (when the pelvis 
 of the kidney is opened or the kidney removed) the tempera- 
 ture rises to 104 105 F. in a few hours, but it usually drops 
 to normal as soon as the opposite kidney begins to function- 
 ate actively. Should the temperature become subnormal 
 and vomiting persist, acute sepsis is coming on and must be 
 combated earnestly, with particular attention to elimination 
 and to drainage. The bowels must be kept active and per- 
 spiration induced (pilocarpine hypodermically and much 
 water by mouth). The wound is best opened up wide, 
 even if it has been partly sutured, washed out and packed 
 with gauze. Hypodermoclysis is of value; also sulphate of 
 strychnine and sparteine hypodermically. 
 
 Prolapsed Kidney and Insanity. Our hospitals 
 for the insane contain thousands of patients (particularly 
 women) who suffer from wandering kidney. Many of 
 these unfortunates, indeed, might have been saved loss 
 of their equilibrium by timely suspension of the loosened 
 kidneys. This must not be construed as a statement 
 that wandering kidney is a cause of insanity, but simply 
 that the irritation resulting from the dragging of the dis- 
 placed organ is enough to unbalance mentality. This 
 declaration also must not be taken as a mere supposition; 
 it is the result of many years' study. Asylum physicians 
 declare it is not true because most asylum physicians 
 (chosen by political pull rather than by any fitness for 
 their positions) are not capable of making a diagnosis, 
 save in exceptional cases. It is not improbable that some 
 of these patients might be greatly helped if not entirely 
 cured by correction of this source of nerve-irritation.
 
 226 SURGICAL THERAPEUTICS 
 
 Tuberculosis of Kidney. The old idea that renal 
 tuberculosis is secondary to that of the bladder is now 
 exploded, and its hematogenous origin is very generally 
 recognized. This view, based upon clinical experience, 
 is also supported by the experimental findings of Baum- 
 garten, that tuberculous infection in the genitourinary 
 system follows the flow of the secretions, from the testicles 
 to the prostate and from the kidneys to the bladder. Renal 
 tuberculosis is generally at first unilateral, and in spite 
 of the fact that it may occasionally become latent for 
 longer or shorter periods, its usual course is progressive, 
 and experience has demonstrated that early nephrectomy, 
 before involvement of the bladder occurs, is the best 
 treatment for renal tuberculosis. The existence of tuber- 
 culosis elsewhere, if not too far advanced, is not a contra- 
 indication; even bad cases of vesical tuberculosis may 
 improve or recover after operation. Removal of the 
 ureter is rarely necessary. 
 
 In the comparatively small but constantly increasing 
 number of patients in whom the diagnosis can be made 
 before much destruction of kidney-tissue or involvement 
 of other organs has taken place, hygiene and climate 
 should have a chance before the kidney is removed. By 
 careful attention to diet, elimination of waste-products 
 by an active colon, outdoor life, tonic treatment and the 
 use of some formalin preparation to sterilize the urine, 
 one may often do away with the necessity for an opera- 
 tion. For the more numerous later cases nephrectomy 
 is always the operation of choice, and should be done in 
 every instance, if the patient can stand it and he has another 
 kidney capable of doing a fair amount of work, whether 
 the disease has passed beyond the limits of the organ to 
 be removed or not, and whether the other kidney be in- 
 volved or not. But when it is presumed that the other kid- 
 ney is seriously crippled, it is better to leave the patient
 
 KIDNEY 227 
 
 to internal treatment alone; attempts at drainage lead to 
 sepsis too often. 
 
 Wandering Kidney. In abnormally loose kidney 
 the pathological epiphenomena may be: (i) Those due 
 to the kidney; (2) those due to traction upon viscera con- 
 nected with the kidney; 
 
 1. There is a traction upon the renal vessels more 
 on the right than on the left, which results in a nicking 
 constriction, torsion, or even rupture of the intimal coat 
 with thrombosis; a serious congestion (stasis) with en- 
 enlargement of the organ often follows this interference 
 with the blood-supply. The ureter with this downward dis- 
 placement is kinked or twisted, hydronephrosis occurring, 
 which is relieved by recumbence; or the acute angle of 
 the insertion of the ureters into the pelvis may become 
 hypertrophied, a valvular formation resulting, giving rise 
 to an intermittent or permanent hydronephrosis. Pelvic 
 congestion, plus infection, is the forerunner of calculi, 
 undermining the kidney substance and kidney, or peri- 
 nephritic abscess in the majority of cases. 
 
 2. The peritoneal and cellular attachments of the 
 kidney to surrounding organs are of the greatest import- 
 ance. A well-defined dislocated kidney of the right side 
 producing decided traction upon the reflections of the 
 liver, duodenum, and pylorus mechanically interferes 
 with the normal functions of these organs, obstruction of 
 the biliary and pancreatic channels, cholecystitis, chole- 
 lithiasis, biliary cirrhosis, pancreatitis, pyloric and gastric 
 ulcer and duodenitis being some of the lesions in this loca- 
 tion which are directly traceable to the wandering, mis- 
 placed kidney. (Byron Robinson). 
 
 Kidneys prolapsed to such a degree that the entire 
 organ may be easily palpated, should, generally, be sub- 
 jected to operation; those which do not fall far below the 
 rib-margin may be held up fairly well by a straight-front
 
 328 SURGICAL THERAPEUTICS 
 
 corset, put on while the patient is in the recumbent posi- 
 tion, or by a specially built supporter. It should always 
 be remembered that while wandering kidney is essentially 
 a surgical disease it is often associated with neurasthenia, 
 so that mere fixation does not entirely relieve: iron, arsenic, 
 strychnine and food as well as laxatives are imperatively 
 indicated. 
 
 KNEE: INFLUENZA OF 
 
 Infection of the knee-joint with the organism of influenza 
 (Pfeiffer's bacillus) is not at all uncommon, in fact it seems 
 to be more frequent than either typhoid or pneumococcus 
 infection of that articulation. A peculiar feature of this 
 form of disease is that long intervals of months or years 
 may lie between the acute attack of influenza and these 
 articular troubles. In a number of cases the influenza 
 never subsides entirely, this chronic influenza (the existence 
 of which is not universally admitted) being shown by the 
 persistence of certain subjective sequelae of influenza, 
 especially of a neurasthenic character, with a marked 
 tendency to take cold, also chilliness and profuse per- 
 spiration on the slightest provocation; also, often, by the 
 persistence of the "strawberry tongue"; and frequently 
 by persisting tenderness along the intercostal nerves. 
 
 At the beginning of the joint-trouble the symptoms 
 may be acute (or subacute) and are generally regarded 
 as "rheumatism," but they soon are seen to be chronic. 
 The chief site of complaint is the condyle, with pain like 
 that of osteomyelitis of the epiphyses, frequently followed 
 by a persistent weakness of the knee, with tenderness on 
 pressure of the condyle. The existence of this form of 
 bone-disease has only recently been suspected, most sur- 
 geons having formerly regarded this tenderness of the 
 bone as a purely nervous phenomenon. Severe cases 
 with a high fever and much pain are very exceptional,
 
 LEUKEMIA 229 
 
 and practically never end in suppuration, provided they 
 are properly treated by placing the limb at rest. Resection 
 is but rarely required. Thick brownish red pus is some- 
 times found in a circumscribed intraarticular focus. Bac- 
 teria, as a rule, can not be demonstrated. 
 
 The treatment of these patients having influenza of 
 the knee should consist in complete rest of the limb, pref- 
 erably rest in bed, but this will hardly prove feasible in 
 chronic cases. Internally it is best first to prescribe 
 sodium salicylate with antipyrin, which will be found to 
 be successful also in long-standing cases. Quinine is 
 administered in the presence of enlargement of the spleen. 
 Hot-air-baths or Bier's congestion method may prove useful 
 in certain cases, whereas ointments and other remedies for 
 gout and rheumatism will be found to be of no value. 
 The patient should be instructed to guard as carefully 
 as possible against taking cold. 
 
 LEUKEMIA 
 
 X-Ray Treatment. Prompt subsidence of the enlarge- 
 ment of the glands found in leukemia may be expected 
 from the careful use of x-radiance. Nor is the diminution 
 limited to those subjected to the direct influence: the glands 
 at a distance from the exposed part will also yield. In 
 application of the ray the spleen and the glands of the neck 
 are the parts placed close to the tube; it is not necessary to 
 ray the bones in the splenomedullary variety of the dis- 
 ease. It is possible that Roentgenization of the liver also 
 might prove beneficial. It is best to eliminate the non- 
 penetrating rays, since these have no effect on deep struc- 
 tures while they irritate or burn the skin. This is ac- 
 complished by filtering the rays through diachylon (usually 
 four layers) which readily adheres to the skin and screens 
 the ray in such a way that the irritating action is arrested 
 while the curative rays are uninterrupted. The neck
 
 230 SURGICAL THERAPEUTICS 
 
 should be rayed even if the cervical glands are not 
 enlarged. 
 
 But the leukemia is simply benefited, not cured, so 
 far as now demonstrable by the Roentgen ray. Even the 
 splenomyelogenous variety improves under its influence. 
 The action seems to be of two kinds: the local influence on 
 the spleen and glands characterized by inflammatory 
 reaction, if treatment is pushed vigorously, and later by 
 the breaking down and disintegration of gland-tissue and 
 the formation of leucotoxin, which either has an inhibitory 
 action on the manufacture of leucocytes by the bone-mar- 
 row or destroys the leucocytes already formed. In no 
 case has the splenic tumor disappeared entirely. With a 
 discontinuance of the Roentgen ray, the disease, at varying 
 periods, returns. Acute cases are not benefited at all by 
 treatment. Chronic cases respond more rapidly than 
 subacute cases. The probability is that the ray holds 
 the disease in abeyance but does not cure the patient, 
 and above all, exerts the "suggestive" influence upon a 
 mind ready to grasp any chance of escape from a disease 
 pronounced incurable. 
 
 LID ABSCESSES 
 
 Abscesses of the lids do not differ materially from foci 
 of suppuration elsewhere save in their causes and peculiar 
 treatment necessitated by the proximity of the delicate 
 conjunctiva. They occur much more frequently in chil- 
 dren than in adults, and are due either to trauma or to 
 some illness of pus-producing germ: grippe, scarlet-fever, 
 etc., the worst being those due to infection with strepto- 
 cocci; when such is the cause, and the child weakens, a 
 gangrenous condition may arise. As soon as noted, hot 
 compresses may be applied, calcium sulphide given inter- 
 nally, and efforts made to strengthen the patient as much 
 as possible: forced feeding and tonic remedies. As soon
 
 LIVER 231 
 
 as it is seen that pus is sure to form the abscess must be 
 opened by free incision and kept clean by frequent bathing 
 in mild antiseptic solutions like the liquor antisepticus 
 alkalinus of the U. S. P. 
 
 LIVER 
 
 Abscess of Liver. In cases of doubt, when symptoms 
 point pretty clearly to the liver, aspiration and explora- 
 tory incisions are justifiable, but when the liver itself gives 
 rise to no suspicions, operative measures are not advisable. 
 There are some cases in which the liver is not enlarged, 
 and it is only by exclusion that this organ comes under 
 suspicion. Axisa has found, by observations, that a leuco- 
 cytosis with a simultaneous alimentary levulosuria, espe- 
 cially if accompanied .by a reverse relation between the 
 ammonia and urea in the urine, point to an inflammatory 
 process in the liver, even if the diagnosis is not thus ren- 
 dered absolutely certain. On repeated examinations, if 
 the blood and urine continue to give these results, the 
 diagnosis is tolerably sure and exploratory abdominal sec- 
 tion is to be made. The only treatment is thorough evacua- 
 tion of every focus of suppuration. 
 
 Cirrhosis of the Liver. While cirrhosis of the liver 
 cannot be cured by surgical means its most distressing 
 and alarming symptom, ascites, may be done away with 
 by the Talma-Morrison operation. In many instances 
 the patient has not only been relieved temporarily but life 
 has been prolonged many years. By stripping the parietal 
 peritoneum from its attachments, over a large area, and 
 suturing the great omentum into the pocket thus formed, 
 a free anastomosis is soon established between the veins 
 of the omentum and those of the belly-wall, with the 
 result that the engorgement of the portal circulation is 
 speedily and permanently relieved, to the great benefit of 
 the patient.
 
 232 SURGICAL THERAPEUTICS 
 
 Cirrhosis of the Liver: lodoform for. lodoform 
 (dose i decigram to a half gram: i grain to 7 grains) has 
 been highly extolled as a remedy for cirrhosis of the liver, 
 especially for the stage of hypertrophy. This may be 
 given three times a day, but its use must be long-continued 
 to effect great improvement. The urine must be carefully 
 watched for hematuria and albuminuria; and instantly dis- 
 continued, or the dose reduced to the minimum, on the 
 appearance of either, as death has occurred from too much 
 iodoform, the autopsy showing glomerular nephritis. 
 
 LUMBAGO-MYALGIA: MUSCULAR STRAIN 
 
 Frequently in a socalled lumbago the trouble is a strain 
 of the muscles of the back and loins and not of neuralgic 
 character at all. The injection of half a gram (8 grains) 
 of antipyrin into the muscles at the most painful spot will 
 give instant and permanent relief; even the injection of 
 pure water does good in some cases. Ironing the back 
 with a hot flat-iron will cure other cases, as will also 
 deep massage of the affected muscles. ^Following, either 
 a belladonna plaster should be applied, as it cheers the 
 patient's mind and eases his back. If persistent, a blister 
 may be applied. It should always be borne in mind that 
 a great many backaches depend upon an overloaded 
 colon and that a good saline laxative will afford a more 
 prompt relief than any other treatment. 
 
 LUNG 
 
 Lang Complications after Abdominal Section. 
 Septic pneumonia may follow any operation for abscess 
 of any part of the abdominal cavity; but the larger pro- 
 portion of pulmonary complications occur after operations 
 above the umbilicus rather than after those in the lower 
 half of the abdomen. Postoperative pneumonia has an 
 average mortality of 65 percent. In about a quarter of
 
 LUPUS 233 
 
 the cases the pneumonia is due to aspiration from ether- 
 anesthesia. Carcinomatous cachexia affords an unmis- 
 takable predisposition to lung complications. Pneumonia 
 is observed rarely after operations on the gall-bladder, 
 while it occurs in about 35 percent of the gas;rostomies 
 on account of cancer, and in 6 percent of resection of the 
 stomach. Appendicitis and complicating peritonitis are 
 responsible for most of the cases of pneumonia; aspiration 
 during the anesthesia is the usual cause, a tendency to 
 thrombosis and embolism of the lungs being quite rare. 
 
 Surgery of the Lang. The surgery of the lung is 
 yet in its infancy. Much is to be expected in future, 
 when technic has been perfected. At present surgical 
 treatment is confined practically to bronchiectasis, gangrene 
 and localized abscesses. What has thus far been accom- 
 plished? Garre has collected statistics thus: Of 400 
 cases of lung abscesses, gangrene and bronchiectasis, 300 
 were reported as "cured" by the pneumotomy. The 
 mortality of the operation was 25 percent. In how many 
 of these cases "cure" was permanent is impossible to say 
 from the literature. Garre's own experience leads him 
 to believe that in the acute cases (gangrene and acute 
 abscesses) one may practically always expect permanent 
 cure. The prognosis is less favorable for gangrene than 
 for abscess. For bronchiectasis the reported percentage of 
 cures he found to be 60 percent; but these "cures" were 
 not always definite. Of 47 cases of lung tuberculosis, 
 surgically treated, 26 showed marked improvement or 
 "stillstand" of the tuberculous process. In actinomycosis 
 the prognosis is decidedly bad, but there are four cases 
 in the literature reported as cured. 
 
 LUPUS 
 
 Lupus is a chronic disease of the skin (and sometimes 
 mucous membranes), of tuberculous origin, characterized
 
 by the formation in the connective tissue of nodules of 
 granulation-tissue; terminating in ulceration. The most 
 certain remedy is early and complete excision. Next-best 
 is cauterization with the Paquelin cautery thorough 
 eradication. The Roentgen ray has also given excellent 
 results in this trouble, possibly better than in 'any other 
 disease. In the treatment of lupus Brooke's formula is 
 much used: 
 
 Zinc oxide 8.0 (drs. 2) 
 
 Starch 8.0 (drs. 2) 
 
 Vaseline 16.0 (drs. 4) 
 
 Mercury oleate 32.0 (oz. i) 
 
 Salicylic acid 1.5 (grs. 20) 
 
 Ichthyol 1.5 (gtt. 20) 
 
 Oil of lavender to scent. 
 
 Umber or Armenian bole may be added in sufficient quantity 
 to make the ointment match the skin and thus be less 
 conspicuous. 
 
 LYMPHADENITIS (TUBERCULOUS) 
 
 In the management of tuberculous adenitis the internal 
 treatment and the local are rather more important than 
 the operative. Yet no one should persist in internal medi- 
 cation and local applications until burrowing abscesses 
 have formed or the glandular substance has broken down 
 and is about to discharge through the skin; for such 
 treatment would lead to disaster the formation of indo- 
 lent, discharging sinuses, with danger of systemic trouble 
 from mixed infection for as soon as the "cold abscesses" 
 open there is engrafted on the tuberculous soil the staphylo- 
 coccus, even if not the streptococcus. Hence it is very 
 easy to wait too long, especially as the patient makes but 
 little, if any, complaint. But so long as the tuberculous 
 focus seems limited within the capsule (evidence: non- 
 adherence to surrounding tissues) it is safe to abstain from
 
 LYMPHOSARCOMA VS. HODGKIN'S DISEASE 235 
 
 surgical interference often for weeks and sometimes per- 
 manently. Non-operative treatment consists of (a) general 
 measures: increase of food, maximum of outdoor life in 
 the sunshine, encouragement of proper elimination by 
 kidneys and bowels (excess of water and saline laxatives, 
 but no physic); (b) the administration of drugs calculated 
 to strengthen: notably iron, arsenic and strychnine, creosote, 
 with small quantities of alcohol just before each meal 
 (sweet wines or whisky with glycerin or syrup just before 
 eating causes a patient to take more food than he does 
 without the alcoholic agent); and (c) local use of either 
 tincture of iodine painted on the affected gland its absorp- 
 tion aided perhaps by the negative pole of a galvanic 
 battery (50 to 75 milliamperes) or an ointment of ichthyol 
 in lanolin. Massage, aside from the gentle rubbing in 
 of ointment, must never be permitted; rupture of the 
 capsule of a non-inflamed tuberculous gland is likely to 
 have early phthisis as a result. As soon as the gland 
 softens, or becomes adherent it should be excised. Recur- 
 rence is to be anticipated in near-by glands. 
 
 LYMPHOSARCOMA VS. HODGKIN'S DISEASE 
 
 It is now claimed by some pathologists that lymphosar- 
 coma affecting the glands of the neck is not the same as 
 Hodgkin's disease, though the two names have heretofore 
 been used interchangeably by most authors. Lymphosar- 
 coma, it is said, can be distinguished from true sarcoma 
 on the one hand and from lymphatic leukemia and the 
 lymphosarcomatosis of Sternberg on the other; while the 
 lesions of Hodgkin's disease are of still different character. 
 There are some cases, however, in which it is difficult to 
 differentiate even by microscopic examination, bearing like 
 evidences of leukemia and Hodgkin's. But in any case, 
 any rapidly growing tumors of the lower part of the neck 
 should be removed, the region subjected to vigorous x-ray
 
 236 SURGICAL THERAPEUTICS 
 
 treatment as soon as possible, and large doses of arsenic 
 administered internally. 
 
 MACEWEN'S CHROMIC CATGUT 
 
 The MacEwen method of preparing catgut is: To one 
 ounce of water and glycerin add 12 grains of chromic- 
 acid crystals. Immerse the catgut, carefully washed, in 
 ether for twenty-four hours to remove surplus fat, and 
 then soak for ten days in the chromic solution. For 
 preservation MacEwen uses 5-percent phenol solution, 
 but most surgeons now prefer alcohol, 65 percent. 
 
 MALIGNANT PUSTULE 
 
 As soon as malignant pustule is recognized the affected 
 area should be treated by use of the Paquelin cautery, 
 drawing a deep gutter around the group of vesicles by 
 successively inserting the fine cautery point deeply into 
 the skin; when the pustule is thus isolated it is opened 
 with a crucial incision. Subsequently it is not necessary 
 to use the cautery. But at a distance of five or ten centi- 
 meters from the pustule, one should make a second circle 
 by injecting iodine repeatedly under the skin, using the 
 ordinary tincture of iodine. A few drops are to be injected 
 at each place, using altogether a hypodermic syringeful. 
 In severe cases it is necessary to repeat this injection on 
 the following day. If there should be much edema present 
 at the time, free incisions must be made, sufficiently numer- 
 ous to relieve tension. Compresses of moist sublimate 
 gauze are placed upon the pustule for a dressing. Rarely, 
 when the patient becomes very weak, it is best to give 
 injections of camphorated oil. The results of this mode 
 of treatment are excellent. The edema, which usually 
 is great, either does not appear or quickly subsides; the 
 general condition improves rapidly, and the danger is 
 considerably diminished.
 
 MASTOIDITIS 237 
 
 MARTIN'S BANDAGE 
 
 The name "Martin's bandage" is vised for a long, 
 india-rubber bandage from 6 to 20 feet long which is 
 often employed in the treatment of varicose veins, ulcers 
 of the leg and for chronic effusion in joints. It may also 
 be used as a tourniquet, being rather better than the 
 Esmarch, so much employed. 
 
 MASTOIDITIS 
 
 Inflammation of the mastoid varies greatly in the indi- 
 cations for treatment, the proper management depending 
 considerably upon the cause. Therefore it is necessary, 
 as Williams points out, to differentiate between forms due 
 to chronic and those arising from acute suppurative 
 conditions of the middle ear, and between acute inflamma- 
 tions of hitherto healthy mastoids and acute exacerbations 
 of chronic disease. 
 
 We should operate upon the mastoid: In acute sup- 
 purative inflammation of the middle ear, accompanied 
 by symptoms of mastoid involvement, or by head symp- 
 toms of any kind which persist for more than two days 
 despite free drainage from the middle ear and proper 
 palliative treatment; when there is an obvious abscess behind 
 the ear as a result of acute mastoid disease; for profuse dis- 
 charge from the ear persisting in spite of treatment beyond 
 two months after an attack of acute suppurative otitis 
 media; for acute mastoid disease occurring in the course of 
 chronic otorrhea; for chronic suppuration of the middle 
 ear which persists in spite of years of treatment by free 
 drainage, cleanliness and local applications; for cholestea- 
 toma, fistulous openings in the mastoid and facial paralysis 
 occurring in chronic otorrhea. Intra cranial complica- 
 tions of ear disease always demand opening into the mastoid 
 as a part of the search for the more serious lesion, provided
 
 238 SURGICAL THERAPEUTICS 
 
 that a more complete mastoid operation has not already 
 been performed. 
 
 He who would operate under such conditions must 
 have a thorough knowledge and experience in the prin- 
 ciples and technic of modern operative surgery, with 
 a very special knowledge of the anatomy of the temporal 
 bone and of all its associated structures. He should have 
 operated previously on the cadaver, and he should have 
 assisted often in mastoid operations upon the living subject. 
 
 When symptoms point to infection of the mastoid cells, 
 the ear must be thoroughly cleaned out by washing with 
 hydrogen dioxide, dried and filled with powdered boric 
 acid. Sufficient codeine sulphate should be given to con- 
 trol the pain; alone if there is little rise in temperature 
 with acetanilid if there be much fever. As soon as fever 
 persists and swelling is noted the cells and antrum must 
 be promptly and thoroughly opened and drained. A per- 
 sistent elevation of temperature after a radical operation 
 for mastoiditis should lead one to suspect the possibility 
 of a complicating brain abscess. If the fever shows wide 
 fluctuations of temperature a sinus thrombosis is more 
 probably the cause. In either case the services of an 
 experienced general surgeon (not a mere aurist) should be 
 sought and the diseased focus drained. 
 
 MOLES: REMOVAL OF 
 
 Small moles may readily be removed by the application 
 of a solution of sodium ethylate. A drop of the solution 
 is placed on the blemish, a scab forms, and when the scab 
 drops off, the mole (or even a small nevus) will have dis- 
 appeared, leaving only a trace of a scar. 
 
 Moles and Cancer. The liability of old warts and 
 moles to take on epitheliomatous degeneration late in life 
 is now so well proven that it is best to remove all such 
 growths whenever a patient is under general anesthesia for
 
 MYOSITIS 239 
 
 other work, and they should be removed under local 
 anesthesia whenever they show signs of becoming ulcerated 
 or of increasing in size. 
 
 MOUTH ULCERS 
 
 Persistent ulcers of the mouth, not of syphilitic origin, 
 are best treated by burning with stick silver nitrate, 
 then using a saturated solution of chlorate of potassium 
 containing a little thymol as a mouth-wash. The burning 
 may be repeated every two days; but few treatments will 
 be needed. Ulcers which persist in spite of this treatment 
 are (i) tuberculous, (2) syphilitic, or (3) cancerous, and 
 demand careful investigation; excision of a small piece 
 of involved tissue, under cocaine anesthesia, for examina- 
 tion, is justifiable in suspicious cases. 
 
 MUSCLES 
 
 Angioma. -According to Seitter angiomata of the 
 muscles have a great tendency to become malignant and 
 to recur after removal. Hence, he advises that the entire 
 muscle must be excised, unless the angioma is distinctly 
 encapsulated. If the growth is very large it may be neces- 
 sary to remove an entire group of muscles or even amputate 
 the limb. 
 
 MYOSITIS 
 
 As remedies for muscular inflammation we may 
 enumerate: rest, as secured by mechanical devices, splints, 
 bandages, etc.; local sedatives, such as lead in lotion or 
 ointment, bismuth subnitrate mixed to creamy consistency 
 with water and applied for one or two days; cold or hot 
 water applications; gentle massage with camphor or with 
 mild mercurial ointments to subdue active inflammation 
 and excite the absorption of debris; mild applications of 
 the faradic current, the positive pole, too weak to excite
 
 240 SURGICAL THERAPEUTICS 
 
 pain; and iodine in ointment or tincture. Internally our 
 treatment is limited to keeping the bowels clear and clean, 
 restraining the fecal toxin-absorption that reacts so un- 
 favorably on enfeebled tissues, and possibly the use of 
 minute doses of veratrine, which has a specific application 
 to muscular fiber. 
 
 Myositis of Abdominal Wall* In the management 
 of cases presumed to be of internal origin it must be re- 
 membered that a purely local inflammation of the abdom- 
 inal muscles, from trauma, may closely simulate intra- 
 abdominal pathologic conditions; and especially so since 
 vomiting may persist for some hours after reception of 
 the injury, with considerable fever following. Many 
 abdomens have been opened for this condition, and every- 
 thing within the belly found normal. All that is necessary 
 in these cases is rest, plus early incision under perfect 
 asepsis, if pus forms. 
 
 MYXEDEMA: POST-OPERATIVE; 
 
 Following removal of goiter (or other disease demand- 
 ing total thyroidectomy) myxedema may . appear : of one 
 or other of two different types, the cretinous and the adult 
 myxedematous, according to the age of the patient at 
 which the gland is removed. Most cases occur in the 
 white race; it is found most frequently in cold climates, 
 and is probably more frequent in Europe than in any 
 other continent, Great Britian producing the majority 
 of the cases. Females are more prone to the disease 
 than males. 
 
 An important element in the treatment is the main- 
 tenance of body-warmth, which is best secured by mov- 
 ing to a warm climate and by the wearing of warm clothes. 
 The bowels must be regulated and a good, nutritious 
 diet provided. Until recently a great many different 
 drugs were advised. But none of them were of especial
 
 MYXEDEMA: POST-OPERATIVE 241 
 
 value. Various tonics, as iron, quinine, hypophosphites, 
 were tried. Diuretics and diaphoretics were also used. 
 Jaborandi (and pilocarpine) given over a long period of 
 time did in some cases prove of benefit, tending to increase 
 the secretion of the thyroid gland. Glonoin and a host 
 of other remedies were tried. Now Davis says thyroid 
 therapy is the foremost treatment. 
 
 The first thing in the administration of thyroid prepa- 
 ration is to determine the most suitable constant daily 
 use of the drug; this can only be done by trial and must 
 be determined for each case. It is best to begin with a 
 small dose (one five-grain tablet, or two grains of the 
 extract) once a day, and gradually increase in frequency 
 and amount until the symptoms begin to subside. This 
 stage of the treatment has to be carried on with great 
 care in all cases in which the disease has lasted for some 
 years, in the aged and in those who show any indication 
 of arterial or cardiac degeneration. 
 
 The first effect noticed is the rising of the body tempera- 
 ture to normal. Next there is a gradual or even sudden 
 diminution in the subcutaneous edema, with a consequent 
 loss in the body weight. There is also a restoration of 
 the secretion of the skin, which becomes moist and soft 
 and loses its harsh, dry, roughened character. Very fre- 
 quently the old skin is desquamated in the form of large 
 flakes until an entirely new epidermis is exposed. The 
 hair begins to grow in the form of a fine, thick crop over 
 the scalp, pubes, and axilla. The menses return to their 
 normal regularity and quantity. The urine is some- 
 times increased considerably in amount, and the albu- 
 minuria and cylindruria disappear. The anemia, how- 
 ever, may not clear up, but may be increased and accom- 
 panied by the appearance of a true edema of the feet. 
 Both these, however, usually disappear in a few weeks 
 when the patient regains his normal strength. With the
 
 242 SURGICAL THERAPEUTICS 
 
 physical improvement there is a corresponding improve- 
 ment, pari passu, in the mental and nervous symptoms. 
 Danger of myxedema should not deter operation in urgent 
 cases. 
 
 NECK: FURUNCULOUS ACNE OF 
 
 From the irritation of a collar-button a papular eruption 
 occasionally occurs upon the neck, which if not properly 
 handled soon becomes a furuncle (staphylococcus abscess) 
 or even a carbuncle (streptococcus abscess). The best 
 agent to employ in all these cases is sulphur. And the 
 best formula is the sulphur wash of Widal: 
 
 Precipitated sulphur 10.0 
 
 Alcohol (go-percent) 10.0 
 
 Distilled water 50.0 
 
 Rose water 50.0 
 
 After shaking the bottle, this is to be applied with a piece 
 of absorbent cotton, each night, and in the morning the 
 spot is washed with soap. This is the fundamental treat- 
 ment of all cases of acne and will cure fifty percent of all 
 the cases. If there is a deep suppuration, the hair of 
 the neck should be epilated with tweezers. If the furuncle 
 enlarges and becomes much indurated, the galvano- 
 cautery is useful. If there is ulceration and a fistulous 
 granulating surface, it should be touched with a pencil 
 of silver nitrate. 
 
 NOSEBLEED 
 
 When the usual methods for the control of epistaxis 
 fail, a little adrenalin solution may be injected by hypo- 
 dermic syringe beneath the mucous membrane behind 
 the bleeding point. If the injection be made at the proper 
 point, the ingoing arterial current carries the solution 
 directly to the point of leakage, with instant constriction 
 and blanching of the mucous membrane and complete 
 arrest of the hemorrhage.
 
 OPERATION: MANAGEMENT AFTER 243 
 
 OPERATION TABLE: IMPROMPTU 
 
 Frequently the only available table to use for an opera- 
 tion in a private house is the extension dining-table. 
 This is entirely too broad, and very clumsy. In such a 
 case a most excellent table may be made by opening the 
 table full length, taking two of the leaves and placing 
 them lengthwise of the table, thus making a narrow strip 
 
 upon which the patient may lie, and at which it is easy 
 for the surgeon and his assistant to work, as they stand 
 in the openings on either side. Blankets and rubber 
 sheet are to be strapped to the narrow section, thus mak- 
 ing a comfortable bed. The three parts of the table are 
 then covered with separate sterilized sheets and the Kelly 
 pad placed at field of operation. 
 
 OPERATION: MANAGEMENT AFTER 
 
 Acid Drinks After Operation. When there has 
 been much loss of blood or when anesthesia has been pro- 
 longed there is always great thirst after operation a 
 thirst which becomes very distressing if fever follows, as 
 it invariably does in infected wounds. The desire for 
 water arises not so much from true thirst as from a 
 harassing dryness of throat and mouth. Much of this may 
 be relieved by frequent mopping of lips and tongue with 
 a cloth wrung from ice-water. If the patient be given 
 all the water desired the stomach will soon beccme over- 
 loaded and troublesome vomiting arise; if not, there will 
 be produced loss of appetite and acute indigestion, and 
 later flatulence and even diarrhea. If lemon juice, lime 
 juice or dilute phosphoric acid be added to the water drank
 
 244 SURGICAL THERAPEUTICS 
 
 a far less quantity will be required to satisfy; frequently 
 after a small glass of sour lemonade the patient's irrita- 
 bility will disappear, the restlessness will subside, the 
 pulse-rate will lower and sleep supervene. 
 
 Anuria After Operations. Very rarely there is 
 total suppression of urine immediately after severe opera- 
 tion the exact cause of which is unknown; if the kid- 
 ney-secretion is not promptly started up, death is certain 
 to occur within a few hours. As soon as the anuria is 
 noted, one-tenth grain of pilocarpine may be given hypo- 
 dermically; this will induce almost instantly a profuse 
 perspiration which will eliminate a certain proportion of 
 retained poisons. Then hypodermoclysis must be resorted 
 to, a full quart of hot normal salt solution being thrown 
 into the cellular tissues of the buttocks or breast. If this 
 does not cause urine to flow into the bladder within an 
 hour, intravenous injection of normal salt solution must 
 be made, one liter (or about one quart) being used. In two 
 hours this must be repeated if the first does not suffice. 
 Backache After Operations. Patients complain 
 bitterly of backache, particularly after pelvic operation 
 due in great measure undoubtedly to the ligatures upon 
 the broad ligament and other structures. Martin says 
 there are two other causes: The annoying backache 
 which accompanies and follows the true postoperative 
 pain is vaguely referred to the ether, regarded as a neces- 
 sary consequence of this, and is accorded little considera- 
 tion; yet it may constitute the major distress from which 
 patients suffer. It is observed after all forms of severe 
 trauma, and is due either to renal congestion or to pro- 
 longed dorsal decubitus. When due to renal congestion 
 the normal saline enemata are particularly serviceable. 
 The decubitus pain is best relieved by change in position. 
 In the vast majority of surgical cases, including those 
 subject to intraabdominal operation, the fixed dorsal posi-
 
 OPERATION: MANAGEMENT AFTER 245 
 
 tion is not only unnecessary but probably distinctly harm- 
 ful. Attention to these points will often save the patient 
 from considerable unnecessary suffering. 
 
 Black Vomit After Operations. The appearance 
 of black vomit after an operation is serious, but par- 
 ticularly is it so in abdominal surgery. A little bile 
 may be thrown up during the vomiting which follows 
 prolonged anesthesia. This should not cause anxiety; 
 but when the ejecta become darker and the vomiting 
 "soft and easy" without much straining, it means oncom- 
 ing acute sepsis, and usually death, unless prompt and 
 effective treatment is instituted. Three things are neces- 
 sary: (i) The use of ox-gall and turpentine enema 
 (ox-gall, one dram; turpentine, two drams; soap-suds one 
 pint) thrown high in the sigmoid; (2) the internal admin- 
 istration of half a centigram (gr. 1-12) of calomel every 
 hour it has a quieting effect on the stomach; and (3) 
 the hypodermic injection of one milligram (gr. 1-67) of 
 eserine salicylate every hour, four doses. If the bowels 
 do not move freely inside of eight hours the calomel must 
 be stopped and a milligram of ekterin given by mouth 
 every hour. Washing out of the stomach with warm 
 water twice a day does much to help arrest the emesis. 
 
 Fever After Operations. Shortly after every ser- 
 ious operation the temperature rises to 99.5 to 100.5 F.; 
 and remains elevated for some hours. It is dependent 
 upon the absorption of the fibrin-ferment of the blood 
 left in the wound, even in spite of drainage perhaps, and 
 need not be regarded seriously. But if the fever continue 
 more than twenty-four hours it should be looked after 
 it usually means either (i) malaria or (2) staphylococcus 
 or other pus-infection. If a microscopic examination of 
 the blood be made the plasmodium should be revealed 
 whenever malaria is the cause; when a microscope can- 
 not be utilized it is best to administer four 5-grain cap-
 
 246 SURGICAL THERAPEUTICS 
 
 sules of quinine one every four hours until four have 
 been taken. Many patients suffer from "latent malaria" 
 and an accident or operation merely arouses the plas- 
 modium into an activity which is recognizable. 
 
 Glonoin After Operations. When there has been 
 great shock from operation and the patient seems about 
 to die from syncope, one one-hundredth grain of glonoin 
 (nitroglycerin, trinitrin) may be given hypodermically. 
 It promptly dilates the cerebral capillaries, and if the 
 shock be purely of nervous origin i. e. not due to loss 
 of blood a favorable change should be noted very soon. 
 If not, a second dose may be given in ten minutes; but a 
 third must not be injected. If no hypodermic needle is 
 at hand the glonoin tablet may be put under the tongue, 
 whence it is absorbed with surprising rapidity. 
 
 Hiccough After Operation. Occasionally a per- 
 sistent hiccough occurs some hours after severe injury 
 or serious operation and becomes quite distressing to the 
 patient. Possibly the best thing to control it, after appli- 
 cation to the throat of cloths wrung out of ice-water has 
 failed, is "Hoffmann's anodyne," the spiritus aetheris com- 
 positus of the U. S. P. It is composed of ether, alcohol 
 and heavy oil of wine hence a stimulant of almost instant 
 action, yet prolonged as well; the ether is taken up immedi- 
 ately, the alcohol somewhat later, and the oil of wine 
 quite a time afterward. The dose is one to two teaspoon- 
 fuls every hour until relieved. Sometimes a capsule of 
 camphor with musk arrests hiccough which has resisted 
 all other medication; but genuine musk is very hard to 
 obtain at present. 
 
 Intestinal Indigestion After Operation. Follow- 
 ing certain abdominal operations (particularly those in 
 which there is prolonged drainage of the gall-bladder with 
 external discharge of large quantities of bile) intestinal 
 indigestion is something very distressing and persistent.
 
 OPERATION: MANAGEMENT AFTER 247 
 
 In such cases prompt relief may be afforded usually by 
 ordering a pill or granule of bilein and pancreatin with 
 strychnine and the intestinal antiferments, such as 
 
 Bilein o.oi (gr. 1-6) 
 
 Strychnine arsenate 0.0005 (gr. 1-134) 
 
 Pancreatin 0.06 (gr. i) 
 
 Sodium sulphocarbolate 0.2 (grs. 3) 
 
 Sodium carbonate 0.2 (grs. 3) 
 
 Mix. One, two or three may be given one hour 
 after each meal. In a day or two there will be marked 
 diminution of intestinal distress, with almost perfect relief 
 as soon as the excess of fermentation can be arrested. 
 
 Keeping Patients on their Back* Most surgeons 
 insist upon patients lying upon their backs for many 
 days after a severe operation, patients who would 
 strangle, choke, snort and become blue in the face if 
 they were to sleep upon their backs in health. It is 
 unnecessary cruelty in most cases. If in an abdominal 
 section the blood-vessels have been properly tied, the 
 patient may usually be permitted to lie upon the side the 
 second night; indeed, in appendicitis it is advisable that 
 the patient lie upon the right side instead of the back; 
 for if drainage has been a necessity, this position will 
 facilitate drainage, and if not, the position permits the 
 cecum to drop into its normal position most readily. In 
 most other operations the position which is most comfort- 
 able to the patient is usually the best for ultimate results. 
 Ox-Gall Enema. This excellent injection, so often 
 used after abdominal section, is made thus: 
 
 Inspissated ox-gall ozs. 2 
 
 Glycerin oz. i 
 
 Warm water ozs. 5 
 
 To this may be added, when there is need for early escape 
 of gas, one-half ounce of oil of turpentine. It is to be thrown 
 well up into the sigmoid when possible.
 
 248 SURGICAL THERAPEUTICS 
 
 Phlebitis Following Operation. Just why throm- 
 bosis of the femoral vein should follow an abdominal 
 section has not yet been made clear by pathologists; yet 
 phlebitis is not at all infrequent after the abdomen has 
 been opened for even non-infective conditions like fibroid 
 tumor. Strange to say, the left thigh is most often involved 
 even though the operative work is limited to the right 
 side of the pelvis, as in appendicitis. On the fifth to 
 eleventh day the patient complains of pain in Scarpa's 
 triangle, the thigh begins to swell and great tenderness of 
 the entire thigh as well as of the calf quickly follows. 
 The temperature rises to 100 or ioiF. and the patient is 
 very uncomfortable and restless. Within thirty-six hours 
 the picture of "milk-leg," or phlegmasia alba dolens of 
 the old writers, is complete. The trouble lasts for about 
 two weeks, under favorable conditions, but may go on to 
 suppuration and general sepsis in the worst cases. Band- 
 aging and other forms of compression must be avoided, 
 although they afford comfort, because they may cause 
 detachment of the clot with fatal pulmonary embolism. 
 It is best to apply heat by means of the hot water-bag, 
 or by flannels wrung from very hot water and covered 
 with oiled silk. Some of the kaolin and glycerin com- 
 pounds with thymol spread on cloth and covered with 
 rubber tissue afford relief and make the patient feel that 
 something is being done for him a matter of great impor- 
 tance because subjects of this disease become very dis- 
 couraged. The cataplasma kaolini of the U. S. P. is 
 excellent: 
 
 Kaolin i 577 .o 
 
 Boric acid 45.0 
 
 Thymol 0.5 
 
 Oil of wintergreen 2.0 
 
 Oil of peppermint 0.5 
 
 Glycerin 375.0
 
 OPERATION: MANAGEMENT AFTER 249 
 
 Internally three grains of quinine, two of acetanilid 
 and one-eighth of sulphate of codeine may be given every 
 three hours, for the first day; after that small doses of 
 aconitine or of veratrine are of benefit, with a sufficient 
 quantity of codeine sulphate to relieve suffering. The 
 bowels must be kept loose with citrate of magnesia or 
 saline laxative. During convalescence small doses of 
 iron and arsenic are of value, with port or sherry wine. 
 Pulmonary Embolism Following Operation. Ac- 
 cording to Dearborn, who has reviewed the work of 
 twenty-five surgeons, thrombosis and embolism are more 
 common after operations in the pelvis than after opera- 
 tions in any other part of the body. In a resume of 7,130 
 gynecologic operations Schenck reports forty-eight cases 
 of thrombosis. Krusen has recently reported five cases, 
 four of which ended fatally, occurring in twelve years 
 of his gynecologic practice. The symptoms in all these 
 cases, as nearly as could be observed, were very similar. 
 The attack was characterized by precordial distress, 
 severe pain and dyspnea, associated with quickened pulse: 
 the patient has an extremely anxious expression, gasps 
 for breath with the aid of all the auxilliary respiratory 
 muscles, the face becomes cyanosed; cold, clammy sweat 
 occurs; the mind remains clear, as a rule, and death occurs 
 in a few minutes, in spite of energetic stimulation. 
 
 To Increase the Appetite After Operation. Very 
 frequently after operations patients complain that they 
 have no appetite, due probably in great part to enforced 
 inactivity. When such complaints becomes annoying an 
 enormous appetite may be produced sometimes by this 
 combination: 
 
 Lysol i.o (gr. 16) 
 
 Ext. gentian, 
 
 Pulv. glycyrrhiz., aa q. s. 
 
 Misce et ft. capsul. xvi.
 
 250 SURGICAL THERAPEUTICS 
 
 Give one capsule before each meal. Burger reports 
 a number of cases of anemia and scrofula in children 
 which he cured with lysol alone, simply through the agency 
 of the ravenous appetite which it excites. But, really, 
 there is nothing much better to excite appetite than the 
 granules of quassin, which should be given in solution 
 or dissolved in the mouth. 
 
 Vomiting After Operation, To check persistent 
 vomiting, and to secure sleep the first night after opera- 
 tion, two and a half grams (forty grains) each of bromide 
 of potassium and chloral hydrate may be given in clyster, 
 not more than four ounces of water being used. Almost 
 instant comfort and quiet follows the few minutes of local 
 irritation. 
 
 OPERATIONS: PREPARATION FOR 
 
 Colonic Flashing Before Operation. When pre- 
 paring a patient for operation for cholecystitis or for gall- 
 stones, if there be marked jaundice of long standing, it 
 is well to wash out the colon every day for a week or more, 
 using about a half gallon of normal salt solution injected 
 slowly through a long rectal tube. At the same time the 
 patient should be encouraged to drink much water. 
 
 Covering the Wound. As much as possible of 
 every cut surface should be protected by covering with 
 gauze or boiled towel ; and just as little handling of the 
 wound should be done as is consistent with good work. 
 
 Maintenance of Hand-Cleanness. For every pro- 
 longed operation there should be upon a convenient chair 
 or table a large bowl of sterile water in which the hands 
 may be frequently dipped. 
 
 If during the operation the hands accidentally come 
 in contact with the table, the patient's clothing, the pad, 
 the assistant's face or clothes, they must at once be washed 
 for a moment in the alcohol and then in the sublimate.
 
 OPERATIONS: PREPARATION FOR 251 
 
 If the operator sweats freely he should wash several 
 times in the sublimate solution during a tedious opera- 
 tion, as the sweat brings up microorganisms from the 
 depths of the skin. 
 
 Preparing the Skin for Operation. If time per- 
 mits, the ideal way to prepare the skin for operation is 
 this: (i) Shave the site of operation and at least six 
 inches in each direction from it; (2) scrub as thoroughly 
 as patient will permit, using a fairly stiff brush with plenty 
 or potash soap (soft soap), if at hand if not, then any 
 toilet soap; the surgeon or nurse who uses a piece of absor- 
 bent cotton for this is not to be trusted, but a piece of gauze 
 may be substituted for a brush if the latter is not obtain- 
 able; (3) apply a soap-poultice for eight or ten hours; 
 
 (4) gently scrub with soap and water with a piece of gauze; 
 
 (5) dry the surface and wash one minute with common 
 ether; (6) wash two minutes with alcohol; (7) cover with 
 a large pad of bichloride gauze and bandage. At time of 
 operation a little more ether followed by alcohol should 
 be used especially if the patient has sweated, and just 
 before cutting the surface may be rinsed with sublimate 
 solution i in 2000. 
 
 When there is not time for this elaborate preparation 
 the following steps are to be taken better after the patient 
 is asleep: (a) Scrub five minutes with a good brush and 
 soft soap with very hot water, depressions like the navel 
 to have special attention; (b) dry with a clean towel; (c) 
 wash with ether, or with oil of turpentine if ether is 
 not at hand; (d) if turpentine is used the surface must be 
 scrubbed again with soap and water, if not, 65-percent alco- 
 hol is to be used for two minutes, with particular care directed 
 to the proposed line of incision; (e) wash for two minutes 
 with i- in 2000 bichloride solution or i in 20 carbolic acid, 
 using a piece of gauze repeatedly saturated with the solu- 
 tion. Finally surround the field of operation by towels
 
 252 SURGICAL THERAPEUTICS 
 
 just out of the sterilizer or boiler and not touched by any- 
 body save surgeon or assistant. 
 
 Preparation Before Scrubbing. Before the hands 
 are sterilized everything should be placed as desired for 
 operation: the tables for instruments and dressings, 
 the operation-table where the best light is obtainable, 
 the solutions made for hands and patient, the Kelly- 
 pad and slop-jar put in proper position, and cotton, 
 bandages, safety-pins, etc., all arranged where they can 
 be readily reached; for after the hands are properly 
 cleansed nothing not sterile should be touched if avoid- 
 able, since contamination of hands means repeated wash- 
 ings and delay. 
 
 Preparation of Hands. First and foremost thor- 
 ough scrubbing is most important. Few doctors realize 
 the importance of perfect hand-cleanness; fewer still 
 take the trouble to do the work as it should be done. 
 Indeed the chief danger of inexperienced operators is 
 dirty finger-nails. 
 
 Immersion. Without drying them the hands are 
 next thoroughly immersed in the antiseptic solutions to 
 be used. 
 
 If the permanganate-oxalic method is to be adopted 
 the hands and arms are washed in the saturated solu- 
 tion of permanganat e of potassium until they are stained 
 a very deep-brown color; then they are decolorized by 
 washing in a strong solution of oxalic acid; next they are 
 immersed in 65-percent alcohol for not less than two 
 minutes not mere " washing" but putting fingers and 
 hands in the solution which must cover them at the last 
 washing the forearms with the alcohol; and finally wash- 
 ing and soaking not less than three minutes in sublimate 
 solution: i in 2000. 
 
 Scrubbing. With a stiff brush, good soap (liquid 
 ethereal or potash soap is best, but any soap except "laun-
 
 OPERATIONS: PREPARATION FOR 253 
 
 dry" will do) the hands and fingers must be scrubbed 
 five minutes, by the clock. This seems a long time; 
 the average doctor of both country and city unless requested 
 to wash again and again, will scrub less than two minutes 
 and think he is clean! At the end of five minutes the 
 hands must be dried carefully upon a clean, but not 
 necessarily "sterile", towel. It is common for doctors 
 outside of hospitals to call any freshly washed and ironed 
 towel "sterile." After the hands are dry the finger- 
 nails should be cut to the quick; and then the fuzzy, dirty, 
 tender skin under the nail just at the point of junction 
 with nail carefully cut away with a sharp blade; this is 
 the neglected, infection-carrying part of the hands, the 
 careless attention to which is yearly causing more deaths 
 than all the armies of the earth! 
 
 When the nails have been properly cut and the finger- 
 tips attended to, the soap, brush and hot water are again 
 used. If hot water can be used while running, it is best 
 to continue washing under the spigot; if not, fresh hot 
 water must be used in the bowl. Scrubbing must now 
 be continued for not less than five minutes, by the clock 
 again, particular attention being paid to the ends of the 
 fingers, to the spaces at the root of the nails, to the palms 
 of the hands and to the spaces between the fingers. 
 Especial care must be exercised to scrub the right hand 
 as much as the left. 
 
 Not one physician in a thousand prepares his hands 
 properly when getting ready to assist in an operation or 
 to do major work himself in emergency; not fifty percent 
 of the men engaged chiefly in operative surgery are as 
 careful as they should be in their attention to their own 
 as well as their assistants' hands. Entirely too many 
 men who claim to be surgeons content themselves with 
 three or four minutes devoted to preparation of the hands. 
 The man who occupies less than twenty minutes in
 
 254 SURGICAL THERAPEUTICS 
 
 efforts to secure hand-sterilization in a capital operation 
 (not emergency) should be deemed guilty of manslaughter 
 if the patient previously non-infected should die of sepsis. 
 And this is not the wild statement of a "crank" but the 
 declaration of a surgeon who in a quarter-century's work 
 has seen entirely too many lives sacrificed by the criminal 
 carelessness of ignorant or thoughtless socalled surgeons 
 or assistants. 
 
 Purgation Before Operation. Before every ser- 
 ious operation the bowels should be moved freely if pos- 
 sible. Notably this is desirable in abdominal and pelvic 
 surgery where the intestines should be free from feces 
 and gas slipping under the fingers like ribbons. To 
 produce this result compound licorice powder is com- 
 monly used, about 2 grams (30 grains) being a laxative 
 and twice that quantity for free catharsis. It should be 
 given at night, with an enema in the morning. If opera- 
 tion is to be made late in the day, epsom salt, rochelle 
 salt or Abbott's " saline laxative" may be taken early in 
 the morning of the day of operation. Care must be taken 
 not to give so much physic to a weakened patient as to 
 cause exhaustion, with possible death from shock. 
 
 Solutions. When a minor operation is to be per- 
 formed careful scrubbing of the hands and immersion 
 in sublimate solution is all that is required, unless the 
 hands have been recently in pus. When a major opera- 
 tion is to be made, potassium permanganate and oxalic- 
 acid solutions must be employed if pus cases have been 
 handled within two or three days. If not, alcohol and 
 sublimate may be relied, upon alone, if the work is not 
 to be of very great length. 
 
 a. Permanganate Solution. Into one bowl holding 
 at least half a gallon of boiled water a handful of per- 
 manganate of potassium is thrown as much as will 
 dissolve and leave a little on the bottom.
 
 OPERATIONS: PREPARATION FOR 255 
 
 b. Oxalic Solution. In a similar bowl in a quart 
 or more of water a like amount of oxalic acid is dissolved. 
 
 c. Alcohol. A third bowl should contain 8 ounces 
 of pure alcohol with four ounces of boiled water added. 
 
 d. Sublimate. Enough tablets of bichloride of mer- 
 cury should be dissolved in two quarts of water to make 
 a solution of the strength of i in 2000. A porcelain bowl 
 must be used. It should be wide enough to admit the 
 hands with perfect freedom so that the unsterilized edges 
 will not be constantly hit by the hands. 
 
 e. Water. Each of the two last-mentioned bowls 
 must have been thoroughly scrubbed out and carefully 
 scalded in boiling water (or better, boiled in a large kettle 
 or wash-boiler) and not handled by anyone except the 
 operator before using. 
 
 In a private house somebody must stand by these 
 solutions (particularly the alcohol) to keep flies from 
 alighting upon and contaminating them a matter of 
 greatest import. One fly may upset hours of work, and 
 kill a patient if unnoticed. 
 
 Substitutes. If the hands have not been in pus 
 lately the permanganate and oxalic-acid solutions may 
 be omitted. In such case, after the hands have been 
 well scrubbed and the nails attended to, turpentine may 
 be poured upon them and rubbed into the skin and around 
 the nails for at least two minutes; then scrubbing with 
 soap and hot water proceeded with, and the alcohol and 
 sublimate solution employed. 
 
 If alcohol cannot be obtained, tincture of camphor 
 (used in so many houses) may be used, though not very 
 good. 
 
 Rubber Gloves. The same care should be taken 
 in efforts to sterilize the hands when rubber gloves are 
 to be used as they may be pricked or torn at any moment. 
 It is perhaps best that the operator should work with-
 
 256 SURGICAL THERAPEUTICS 
 
 out gloves, but it is desirable that the assistant shall wear 
 them as most operation-infection comes from the fingers. 
 
 OPSONIC TREATMENT IN SURGERY 
 
 Just what will be the ultimate results of the application 
 of Wright's theory of the opsonins to surgical practice 
 cannot be foretold; but Ohlmacher, of Detroit, gives his 
 own experience with the use of bacterial vaccines, prefer- 
 ably autogenous, in various surgical conditions. While 
 not neglecting to take the opsonic index when practicable, 
 he was compelled to rely largely on the clinical manifesta- 
 tions as a guide to the repetition and size of dose, always 
 endeavoring, of course, to give the injections at the right 
 time, when the positive phase is beginning to fall, and 
 not in the negative phase. 
 
 As Wright points out, the great cause of failure in 
 previous tuberculin treatment of tuberculosis was the 
 giving of too large injections and too frequent repetition 
 of the dose, causing a marked negative phase and keeping 
 it up. Ohlmacher thinks that his results might have 
 been better than they were had he been able to make 
 more systematic opsonic determinations, which often show 
 a fall of resistance before the symptoms indicate it. He 
 has had remarkable success in various types of staphylo- 
 coccus infections, obstinate cases of acne and furunculosis, 
 impetigo, palmar abscess, and in a very distressing case of 
 what has been called psoriasis, but which he thinks was an 
 extraordinary case of staphylococcic dermatitis, and which 
 yielded rapidly to opsonic treatment with an autogenic 
 culture of staphylococcus aureus. He had also very satis- 
 factory results with a case of very annoying bladder infec- 
 tion from the colon-bacillus, similarly treated after other 
 treatment had failed. 
 
 A very striking case was one of sacculated pneumococcus 
 empyema, in which perfect recovery occurred in seven
 
 OSTEOMYELITIS 257 
 
 days after two injections following a small puncture. Ohl- 
 macher believes that even the generally condemned method 
 of aspiration would have been sufficient in this case when 
 reinforced by opsonic therapy. Owing to delay in obtain- 
 ing Koch's tuberculin R., the standard vaccine for tuber- 
 culous cases, his experience with tuberculosis has as yet 
 been limited, but he has been- able to obtain a strain of 
 gonococcus culture with which he has had striking success 
 in the treatment of gonorrhea and its complications, includ- 
 ing gonorrheal rheumatism and conjunctivitis. From what 
 he has already seen, he is prepared to say that, with proper 
 artificial autoinoculation, we can obtain constitutional and 
 local improvement in many subacute and chronic affec- 
 tions entirely beyond anything previously possible in 
 medicine. 
 
 OSTEOMALACIA 
 
 This disease has been temporarily greatly relieved by 
 ovarian transplantation. But in every case thus far re- 
 ported there has been a speedy change for the worse. 
 
 OSTEOMYELITIS 
 
 Inflammation of the bone-marrow is a thing often for- 
 gotten by the busy practitioner; a wrong diagnosis is the 
 rule. With young adults particularly the symptoms of 
 general infection may be so prominent as to overshadow 
 the local trouble. Absorption of toxins may so overwhelm 
 the patient that he cannot give any testimony as to the 
 presence of the bone affection, and unless a very careful 
 examination is made the local lesion may be overlooked, 
 especially in parts thickly covered by muscle. A diagnosis 
 of delirium tremens has been made under these conditions, 
 when the subject had been drinking. The treatment con- 
 sists in locating the point of infection and boring a good- 
 sized hole to it, with injection of lo-percent iodoform
 
 258 SURGICAL THERAPEUTICS 
 
 emulsion; and careful antiseptic dressings. Internally 
 opium, quinine and stimulants are indicated. 
 
 OZENA TREATED SURGICALLY 
 
 Sondermann recommends treatment of ozena by the 
 following surgical measures: A rubber condom is intro- 
 duced collapsed into the nose. It is then inflated by a 
 connecting tube and bulb, when it fits closely against the 
 walls of the nose, adapting itself to all nooks and crevices. 
 After from five to ten minutes the stopcock is turned and 
 the air allowed to escape from the condom, after which it 
 is easily removed and transferred to a vessel containing 
 water. Many of the crusts stick to it, while those remain- 
 ing in the nose are loosened and can be readily expelled 
 spontaneously. During the first week the patient repeats 
 this twice a day and later once a day. Th!s procedure is 
 supplemented by cleaning of the nose thoroughly, drying 
 and blowing in aristol or boric acid mixed with a little 
 antipyrin. The disease is now regarded as contagious. 
 
 PAGETS DISEASE 
 
 Malignant papillary dermatitis (cancerous ezcema of 
 the nipple) may occur both in male and female, though 
 usually in women from irritation of suckling. It is essen- 
 tially a carcinoma of slow development; and if it does not 
 yield promptly to the x-ray, amputation of the breast should 
 be insisted upon. 
 
 PAIN 
 
 Chloro-Phenol for Pain. When chloral hydrate and 
 phenol in equal parts are rubbed together there is formed 
 a syrupy liquid which is strongly antiseptic and anodyne 
 when used locally. For the pain of inflammatory troubles 
 it may be gently rubbed in or applied on flannel. It is 
 especially effective in the control of certain neuralgic pains, 
 notably pleurodynia.
 
 PANCREATITIS 259 
 
 Painful HeeL Some patients complain of pain in 
 the heel, most prominent for a little while after getting 
 out of bed. It is often one of the sequels of gonorrheal 
 infection. It may also be due to a calcaneobursitis of 
 traumatic as well as gonococcic origin. In others still 
 there may be a small exostosis of the calcaneum, which also 
 is most frequently due to a gonorrheal infection, possibly 
 of many years before. Also it may be due to simple "weak 
 foot" in very heavy patients, in which case either strapping 
 or use of a brace to the arch of the foot will relieve. But 
 in most instances the "two-glass test" will show "clap- 
 threads" in the urine; and persistent treatment for the 
 hitherto unsuspected chronic gonorrhea will cure the pain- 
 ful heel and other symptoms usually attributed to "rheuma- 
 tism" or "gout." And for the internal treatment of 
 gonorrheal "rheumatism" it is a good thing to know that 
 calcium sulphide is often quickly curative. 
 
 Post-Operative Pain. The temptation to use mor- 
 phine to allay the pain following serious operation should 
 not be yielded to save in extreme cases; morphine locks up 
 the secretions and obscures symptoms which may be of 
 importance. For the ordinary pain one grain of phosphate 
 of codeine may be given hypodermically and repeated 
 every four hours as long as may be necessary it does not 
 give rise to "habit" as does morphine. For pelvic pain two 
 grams (30 grains) of antipyrin may be given with good 
 effect dissolved in four ounces of starch water and thrown 
 into the rectum. If morphine must be given it is least 
 objectionable in the "anesthetic tablet": morphine, gr. 1-4; 
 hyoscine hydrobromide, gr. i-ioo; and cactin, gr. 1-67; used 
 hypodermically, to be repeated in four to six hours if needed. 
 
 PANCREATITIS 
 
 Acute inflammation of the pancreas sometimes demands 
 surgical intervention, though generally fatal even when
 
 260 SURGICAL THERAPEUTICS 
 
 operated upon. The pains are usually localized at the 
 epigastrium, but when gallstones are present, may also be 
 situated in the region of' the gall-bladder or in the ileo- 
 cecal quadrant of the belly. The attack may be ushered 
 in with an acute seizure of bilious vomiting, quickly sub- 
 siding, unlike the vomiting of appendicitis and gallstone 
 colic. The tongue is dry and parched, though there may 
 be but a trifling amount of fever. Obstinate refusal of the 
 bowels to move is a prominent symptom, though there is 
 but moderate distension from flatus. A peculiar feature 
 is that, when the abdominal wall is thin, the omentum may 
 be felt bunched up at two or three points. 
 
 The presence of this condition without any signs pointing 
 directly to other intraabdominal pathological disturbance 
 should arouse suspicion of pancreatitis. In case of doubt 
 it is better to give the patient the benefit of an explora- 
 tory section, especially if there be a trp,ce of sugar in the 
 urine. It is essential to remember that the amount of 
 hemorrhagic effusion which escapes into the abdominal 
 cavity in some cases and the extent of the fat tissue-necrosis 
 are not responsible for the fatal outcome. Death is evi- 
 dently due to absorption of poisons from the diseased pan- 
 creas, and the tension in the retroperitoneal tissue around 
 the pancreas evidently promotes absorption. This fact 
 must be borne in mind in operating, and provision must 
 be made for reducing the tension and for improving the 
 condition of the circulation through the gland. By this 
 means it may be possible to check the poisoning of the 
 organism from the decomposing gland by exposing and 
 draining it directly. It is also possible that immunization 
 with trypsin may prove effectual in acute pancreatitis. 
 
 PARALYSIS: POST-OPERATIVE 
 
 Following an operation of more than an hour's duration 
 there may be temporary paralysis of one arm. Some authors
 
 PERICARDITIS 261 
 
 have attributed this to the deleterious effect of chloroform; 
 but it occurs after ether narcosis and also as a postopera- 
 tive accident in anesthesia produced by the hyoscine- 
 morphine-cactin combination. It is due entirely to the 
 position of the arm; by reason of the entire weight of the 
 arm (and occasionally a considerable part of the thorax) 
 being thrown across the sharp edge of the operation- 
 table, pressure-paralysis is induced, just as one's foot "goes 
 to sleep" when the thigh hangs over the rail of a chair. 
 It lasts from a few hours to as much as two or three weeks. 
 If the patient becomes anxious about it, massage may be 
 ordered or the faradic current may be applied (not because 
 it possesses any value but that the patient may feel that 
 something is being done). In persistent cases the galvanic 
 current may be used with intramuscular injections of one- 
 thirtieth grain of sulphate of strychnine once daily. 
 
 PERICARDITIS 
 
 Pericarditis becomes a surgical disease when the effusion 
 becomes so great that there is serious interference with the 
 heart's action, and when the serum becomes infected by 
 pyogenic bacteria. Before making an attempt to remove 
 the effusion the patient should be given a big drink of 
 whisky, and a quarter grain of morphine with i-ioo grain 
 hyoscine hypodermically. The skin must be as thoroughly 
 cleaned as for the most serious operation and the needle 
 must be taken directly from the boiler. Five minutes before 
 operation a little of a 2-percent solution of cocaine should 
 be injected beneath the skin and into the muscle. In 
 aspirating, the needle may be introduced through the eighth 
 intercostal space; or if the diaphragm be displaced down- 
 ward strongly the puncture may be made just to the left 
 of the ensiform. On account of the danger of wounding 
 the heart as the pericardium contracts it is better to use 
 a small trocar and canula rather than a sharp needle.
 
 262 SURGICAL THERAPEUTICS 
 
 The fluid should be permitted to escape very slowly. When 
 the pericardium is full of pus, excision of rib, free incision 
 and drainage offer the only escape from death by sepsis. 
 
 PERIOSTITIS: CHRONIC 
 
 Chronic thickening of the periosteum positively known 
 to be non-syphilitic in origin will often yield to small doses 
 of potassium iodide, one gram (fifteen grains) three times 
 a day. It is best given in compound syrup of trifolium or 
 simple elixir. 
 
 PERITONITIS 
 
 Acute peritonitis is always due to direct infection with 
 pyogenic microorganisms, as from a leaking appendix, 
 a perforated gall-bladder or other viscus, a ruptured pus- 
 tube, etc. The disease can be cured, then, by immediate 
 removal of the cause, with drainage. The following points 
 are of importance: (i) Acute general peritonitis can be 
 cured by operative means, provided it is recognized early. 
 (2) Early recognition is aided by a knowledge of the 
 etiology of the disease, and accurate observation of the 
 patient's symptoms, local and general. (3) On examina- 
 tion of the patient the most important early signs of perito- 
 nitis are localized pain, becoming general, muscular rigidity, 
 rapid and increasing pulse-rate, and rising temperature. 
 (4) Early diagnosis should be followed by prompt opera- 
 tive treatment, as this offers in most cases the only chance 
 for recovery. To relieve pain, until operation can be done, 
 phosphate of codeine may be given, hypodermically, as 
 often as needed, in half-grain doses. 
 
 For Pain of Peritonitis. To control the pain of the 
 adhesive peritonitis, which often saves the patient's life in 
 appendicitis, as well as that of the postoperative form, 
 aconitine is of much value. Opium in every form does 
 harm, though sometimes a grain of phosphate of codeine
 
 PERITONITIS 263 
 
 has to be given; but little will be needed if a half milligram 
 of aconitine every hour be given until the pulse is soft 
 and the fever lowered. 
 
 Tuberculous Peritonitis. Concerning this condition 
 it may be said: (i) The exciting cause of tuberculous 
 peritonitis is the bacillus tuberculosis. (2) This disease 
 occurs most frequently between the ages of twenty and 
 forty, and, according to clinical experience at least, is more 
 common in females than in males. (3) It is, in the great 
 majority of cases, secondary to a tuberculous focus in some 
 other part of the body, most frequently the lungs. (4) 
 There seems to be no doubt that infection through the 
 fallopian tubes may occur, but its frequency is disputed. 
 (5) The onset of the disease is usually slow and insidious 
 and its clinical course presents few definite or characteristic 
 symptoms. (6) The diagnosis is generally difficult, and 
 is often not made until operation or autopsy. (7) The 
 prognosis in the ascitic form of the disease is comparatively 
 good, if treated by abdominal section, and in the non-exu- 
 dative variety bad. In any form it is of course corresponding- 
 ly modified by the existence of tuberculous disease in other 
 parts of the body. (8) The treatment in most cases should 
 be operative, consisting in laparotomy, with removal of 
 the fallopian tubes when practicable. (9) No satisfac- 
 tory explanation has as yet been offered as to the reason 
 for the cure which so often follows operative treatment 
 in this disease. (10) Very soon after the abdominal 
 section a general antituberculosis treatment should be 
 adopted with special attention to proper diet and out-door 
 life. 
 
 We have been taught to believe that simple abdominal 
 section with considerable manipulation of the viscera and 
 evacuation of the ascitic fluid will cure tuberculous peri- 
 tonitis. But while it is true that certain patients have 
 apparently been cured by such mild procedures, a much
 
 264 SURGICAL THERAPEUTICS 
 
 larger number have gone on to fatal termination. The 
 mistake has been made of treating a symptom (ascites) 
 instead of the disease. Radical removal of every local 
 deposit of tubercle wherever found is the only certain cure. 
 In a small percentage of cases it cannot be found; here the 
 only resource is irrigation, manipulation and closure. In 
 a larger percentage of cases the lesions are so numerous or 
 so situated that they cannot be removed; here gentle rub- 
 bing of the affected surfaces with gauze may do good. In 
 all cases, whether the local focus be removed or not, the 
 most energetic constitutional treatment must be instituted: 
 forced feeding and tonics do fully ^as much in abdominal 
 tuberculosis as in pulmonary. But unless the primary 
 seat of the disease is found and the source of trouble re- 
 moved, a guarded prognosis should be given regardless of 
 how much the patient may gain after operation. Medica- 
 tion is the same as that for any other abdominal section 
 during the first few days, and then the same as for phthisis. 
 
 When operation is declined, or is contraindicated, the 
 abdomen may be smeared, twice a day, with this oint- 
 ment: 
 
 Yellow mercuric oxide 1.5 (grs. 20) 
 
 Belladonna ointment 32.0 (oz. i) 
 
 Lanolin 32.0 (oz. i) 
 
 This relieves the pain to a remarkable degree, especially 
 with children in whom the skin is sufficiently thin and 
 tender to permit free absorption. 
 
 PHLEBITIS 
 
 Immobilization of the extremity affected should be the 
 rule for a much longer period than generally advised, 
 especially in thrombosis of the femoral vein. Massage ought 
 not to be begun before one month after the last rise of the 
 temperature; tarsal and metatarsal articulations will be first 
 mobilized, later larger joints. Only gentle massage will
 
 PLEURITIS 265 
 
 be resorted to and the patient progressively trained to 
 resume the standing position. 
 
 PLEURITIS 
 
 Pleurisy becomes a surgical disease as soon as it is 
 apparent that the effusion is not being absorbed or that the 
 serum is infected with pyogenic bacteria. When it is 
 decided that the serum accumulated in the pleura is to be 
 evacuated the skin must be scrubbed carefully with soap 
 and water; a few drops of cocaine are then to be injected 
 beneath the skin and into the intercostal muscles, but not 
 into the pleura; a large aspirator-needle is boiled for at 
 least ten minutes; the skin is pulled a little upward or 
 downward and from over an intercostal space and the 
 needle thrust quickly and directly into the pleural space. 
 A boiled stilet must be at hand to push through the needle 
 from time to time if it become clogged by flakes of lymph. 
 The fluid must be allowed to escape slowly so that the lung 
 may expand (if adhesions have not formed). 
 
 When all has been withdrawn the needle is taken out 
 by a short, quick jerk and the skin allowed to slip over 
 the opening. A little piece of gauze may be placed over 
 the skin-puncture and held in place by a strip of adhesive 
 plaster. 
 
 When pus is present the operation of choice for child- 
 ren is the Estlaender: removal of a small part of one rib, 
 or even a mere slit in the parietal pleura sometimes effect- 
 ing a perfect cure if the subsequent dressings be made 
 with sufficient care as to asepsis; for adults the Schede 
 operation (excision of the chest -wall including the parietal 
 pleura, over at least one-third of the entire side affected) 
 is the only one which promises complete cure, since it 
 permits the skin and muscles to fall in on the visceral 
 pleura and so obliterate the huge pus-sac. It is remarkable 
 how much the lung will expand after such a formidable
 
 266 SURGICAL THERAPEUTICS 
 
 operation. The most energetic antituberculous and tonic 
 treatment must be kept up for months. 
 
 POULTICES 
 
 Charcoal Poultices. Charcoal poultice, like all 
 other poultices, has fallen into disuse on account of the 
 nastiness, other and better agents being employed; but 
 sometimes patients are found who demand poultices, and 
 when there is an ugly sloughing (and especially a sloughing 
 old wound or ulcer) the charcoal poultice may be ordered. 
 It possesses the advantage of being a powerful deodorant, 
 and sometimes it does seem to do more good at the begin- 
 ning of treatment of such ulcers than the modern "anti- 
 septic" applications. It should be made thus: Wood 
 charcoal, pulverized, one-half ounce, divided in two parts; 
 bread-crumbs, two ounces; linseed meal, one ounce and a 
 half; boiling water, ten ounces. The breadcrumbs and 
 linseed meal are macerated for ten minutes with heat to 
 keep the mass just below boiling, and then half of the 
 charcoal is stirred in and one-half ounce of liquid phenol 
 added, care being taken that it be well mixed. The poul- 
 tice is then spread on a cloth, the remaining half of the 
 charcoal sprinkled on and the mass applied quickly to the 
 sore and covered with a piece of oil-cloth or rubber-tissue. 
 
 Soap Poultices in Suppuration. When there is 
 much pain from a suppurative process, like periostitis, 
 adenitis, abscess or forming whitlow, much comfort may 
 be obtained from application of a soap poultice. Several 
 thicknesses of gauze are saturated with soft soap the 
 green soap, ethereal soap or potash soap of the U. S. P. 
 is best and applied to and around the affected area and 
 covered with rubber-tissue or oiled silk, held in place by 
 bandages. Better is a mixture of soap and alcohol: 
 
 Green soap 2 parts 
 
 Alcohol i part
 
 PROSTATECTOMY: INDICATIONS FOR 267 
 
 This is to be applied in the same way and should be 
 allowed to remain all night. It is also a good mixture to 
 be used in acute synovitis. It is not a good thing to apply 
 to a wounded or granulating surface as the alkali is too 
 irritating. 
 
 PROCTITIS: ACUTE 
 
 An acute irritation of the rectum is sometimes followed 
 by a painful condition associated with discharge of mucus. 
 Acute rectal catarrh this state of affairs is called by the older 
 pathologists. Severe tenesmus with mucous diarrhea accom- 
 panies it, persisting for several days if left alone. An injec- 
 tion of a solution of chlorate of potassium is best for this: 
 
 Potassium chlorate 6.0 (grs. 90) 
 
 Water 128.0 (ozs. 4) 
 
 This should be slightly warmed and thrown into the rec- 
 tum. There will be some expulsive efforts at first but the 
 clyster must be retained twenty minutes if possible. It 
 may be used twice a day, but two or three injections usually 
 suffice. 
 
 PROSTATECTOMY: INDICATIONS FOR 
 
 The question, When should the prostate be removed? 
 is thus answered by John B. Murphy: 
 
 1. Prostatic enlargement to a pathological degree. 
 
 2. Painful and frequent urination. 
 
 3. As a cure for catheter life. 
 
 4. As a cure for secondary cystitis. 
 
 5. For the relief of pressure on the rectum. 
 
 6. Priapism in the aged with perineal irritation. 
 Goodfellow declares that "there are no contraindications 
 
 to the operation unless the condition of the patient is such 
 that no operation of any kind is warranted,"
 
 268 SURGICAL THERAPEUTICS 
 
 PROSTATIC HYPERTROPHY AND STONE 
 
 That there is a decided relation between stone in the 
 bladder and hypertrophy of the prostate is the claim of 
 Prof. Reginald Harrison, of London. He says the explana- 
 tion is this: (i) The enlarged prostate forms a hindrance 
 to the spontaneous exit of small stones of urates or oxa- 
 lates that are formed in the kidneys in old age. (2) The 
 difficult micturition, and the ammoniacal disintegration 
 of the urine, can lead to cystitis and the formation of phos- 
 phatic concretions. (3) Litholapaxy does not accomplish 
 the result desired. Only removal of the prostate at the 
 time the stone is excised will effect a perfect cure. Har- 
 rison prefers the suprapubic method, which makes possible 
 the removal of the stones, with prostatectomy. 
 
 PROSTATORRHEA: HYOSCYAMINE FOR 
 
 Prostatorrhea with irritable deep urethra may be greatly 
 benefited by the internal use of hyoscyamine. One quarter 
 of a milligram (0.00025, or I " 2 5 g ram ) m granule form 
 may be ordered four times a day, either alone or with 
 one centigram (1-6 grain) of concentrated hydrastin. If 
 there be scanty urination much water must be drunk and 
 barosmin (the resinous product of buchu) be taken in doses 
 of one milligram three times a day. 
 
 PRURITUS ANI 
 
 Nearly all cases of persistent itching of the anus may 
 be traced to one of these causes: (i) The most common 
 is superficial ulceration or abrasions of the anal canal. 
 (2) Next, catarrhal diseases of the rectal mucosa which 
 cause discharge from the anus. (3) External hemor- 
 rhoids or skin-tags which prevent proper cleansing of the 
 parts. (4) Small polyps of the anal canal, protruding 
 internal hemorrhoids, prolapse and fissures, etc. The
 
 PYLORIC STENOSIS: SURGICAL TREATMENT 269 
 
 treatment consists (in addition to removing the cause) in 
 restoring the altered perianal skin to the normal. For 
 this purpose nitrate of silver followed by citrine oint- 
 ment are the best applications. 
 
 Prescriptions for Pruritus Ani. Cowles recom- 
 mends the following formulas: 
 
 Ungt. hydrargyri ammoniat.. 1.6 (grs. 25) 
 
 Adipis benzoinati 30.0 (oz. i) 
 
 M. Sig.: Apply locally as directed, or 
 
 Hydrargyri chloridi mitis 8.0 (drs. 2) 
 
 Sig.: Use locally as a dusting powder as directed. 
 If there is much thickening of the skin surrounding the anus 
 some preparation of salicylic acid should be used, for 
 example : 
 
 Acidi carbolici i. (grs. 15) 
 
 Acidi salicylici 0.6 (grs. 10) 
 
 Ichthyoli 1.6 (min. 25) 
 
 Petrolati 30.0 (oz. i) 
 
 M. Sig.: Apply locally as directed. 
 A hot sitz-bath or the application of hot compresses often 
 confers immediate relief. The following formula is recom- 
 mended by Morris: 
 
 Acidi carbolici 1.5 (grs. 22) 
 
 Cocainae hydrochloridi 0.6 (grs. 10) 
 
 Petrolati 30. (oz. i) 
 
 M. Fiat unguentum. Sig.: Apply locally as directed. 
 Caution should be taken not to allow its use long enough 
 to induce the cocaine habit. 
 
 PYLORIC STENOSIS: SURGICAL TREATMENT 
 
 Socalled idiopathic dyspepsia is comparatively rare; 
 functional dypepsia and indigestion have their origin quite 
 commonly in a narrowing of the pylorus, which interferes 
 with normal drainage of contents. This narrowing is 
 sometimes congenital, but more often due to cicatricial
 
 270 SURGICAL THERAPEUTICS 
 
 contracture following the healing of pyloric ulcer. Of late 
 it is being found that duodenal ulceration is not uncommon 
 either independent of or associated with pyloric ulcer. 
 Ulceration being the most common of the causes of 
 obstruction from within, so likewise are adhesions 
 the most frequent exciting factor from the outside 
 of the lumen. These may be caused by localized perito- 
 nitis, due to gall-bladder infections, pancreatitis, etc. The 
 result upon the stomach of outlet stenosis depends upon its 
 completeness. It is most often the symptom-syndrome of 
 indigestion, and extends over many years' duration, grow- 
 ing ever progressively worse. Putrefaction of stomach- 
 contents and dilation and atony are among the later mani- 
 festations. So likewise is a" residuum. 
 
 The predisposition of ulcer to ultimate cancer-formation 
 the socalled cancer on an ulcer base is great. The 
 treatment of this condition is essentially surgical, and is 
 to be summed up in the one word, "drainage." Medi- 
 cines are of use only as they act as antiseptics on the 
 fermenting, putrifying stomach-contents, and thus control, 
 to a degree, putrefaction and fermentation with consequent 
 gas-formation and stomach-distension. Muscular power 
 of the stomach is insufficient to force a normal food-supply 
 through the narrowed outlet, so muscle excitants and tonics 
 are of no avail. Lavage is superior to medication of any 
 kind. This may be dangerous in the stage of acute ulcera- 
 tion. The best operation is a posterior gastroenterostomy 
 without loop and with suture. There being no loop of 
 jejunum, and the stomach being tapped at its lowest point, 
 there is very little danger of establishment of a "vicious 
 circle, " and an enterostomy is unnecessary, and with this 
 latest technic is quite impossible. The two organs, stomach 
 and jejunum, are anastomosed at the point where they 
 normally lie almost in contact. Too strong a plea cannot 
 be made for early rather than late operations.
 
 RECTUM 271 
 
 PYURIA 
 
 When the flow of pus is excessive in suppurative pyelitis 
 as well as when excessive amounts of albumin are passed 
 in nephritis, a marked diminution may be produced by arbu- 
 tin, the glucosidic, active principle of uva ursi a drug for 
 long used in crude forms as a diuretic and tonic to mucous 
 membranes. The dose is from one to five grains every 
 two or three hours. 
 
 RECTUM 
 
 Cathartics in Prolapsus Recti. After the rectum 
 has been returned beyond the sphincter the question arises, 
 "what is the best way to move the bowels?" for straining 
 at stool is the cause of the prolapse and may induce its 
 immediate return. Podophyllin in doses of one milligram 
 (gr. 1-67) every hour, six times, will cause very gentle move- 
 ments without straining. Two or three tablets should be 
 given at bedtime for a week or more. 
 
 Examination in Rectal Surgery. Brickner very 
 aptly says : Don't fail to make a digital rectal examination 
 in cases of appendicitis and in all ailments when the diag- 
 nosis is obscure. Nor should it ever be omitted before an 
 operation upon anal disorders. It may save the embarass- 
 ment of a subsequent discovery that a patient's hemor- 
 rhoids, for example, were but an expression of a carcinoma 
 higher up in the rectum. 
 
 Local Anesthesia in Rectal Work. The technic 
 advised by Tuttle consists in anesthetizing the lesser sphinc- 
 terian nerve of Morestin and the inferior hemorrhoidal 
 nerve by a single puncture of the hypodermic needle back 
 of the posterior anal commissure, and introduction of 
 from 20 to 30 minims of o. 5-percent eucaine or cocaine solu- 
 tion so that the sphincter can be thoroughly stretched. After 
 this is done the hemorrhoids, or other conditions upon which 
 operation is proposed, are anesthetized by the local injec-
 
 272 SURGICAL THERAPEUTICS 
 
 tion of small quantities of one-tenth-percent solution of 
 eucaine, cocaine, stovaine or novocaine. Sometimes it 
 is necessary in very sensitive patients to anesthetize the 
 branch of the pubic nerve which supplies the sphincter at 
 the anterior commissure by the introduction of small quan- 
 tities of the solution at this point. 
 
 Prolapse of the Rectum. When it is found that 
 protrusion of the rectum is accompanied by' a pocket 
 of peritoneum so that excision is highly dangerous, 
 one may resort to ventral fixation of the sigmoid 
 colopexy, as it has been called. About 75 percent of 
 all cases may thus be cured; and in safe hands there 
 is no mortality. The technic is, briefly, as follows: 
 After proper sterilization of hands, instruments, dressings 
 and field of operation, an inci3ion is made, parallel to and 
 about one inch above Poupart's ligament. The pelvic 
 colon is recognized and drawn up until the prolapsed rec- 
 tum is reduced and the anus resembles a funnel-like depres- 
 sion. The lowermost portion is chosen as the point of 
 fixation to the abdominal wall. An oval piece of the parietal 
 peritoneum is removed in the iliac fossa and the colon is 
 sutured to the two edges of the peritoneum by 3o-day 
 chromicized catgut suture. At the lower portion of the 
 external margin, the superficial muscle-fibers, iliac fascia 
 and the peritoneum are united to the colon, the inner suture 
 attaching the colon along its mesenteric border. The 
 abdominal wound is closed without drainage. 
 
 Rectum: Prolapse of. In Van Buren's method 
 the patient is anesthetized and the smallest tip of a Paque- 
 lin cautery (heated only to a dull-red) is drawn over the 
 entire length of the prolapsed gut, just burning through 
 the mucous membrane. Five or six grooves are to be 
 burned, parallel to each other. The mass is then pushed 
 well above the sphincter, and the sphincter burned at two 
 points on opposite sides well into the substance of the
 
 RECTUM 273 
 
 muscle. Finally the rectum is packed with iodoform gauze 
 which is removed on the third or fourth day. 
 
 Retro-Rectal Abscess. An abscess forming behind 
 the rectum is best opened by a semicircular incision between 
 the anus and coccyx. This should be as free as the situa- 
 tion will permit without cutting the sphincter. When evacu- 
 ated the cavity should be mopped out with absorbent cotton 
 and loosely packed with gauze. This should be removed 
 daily and the wound washed out with some mild antiseptic 
 solution. It is essential that the sphincter ani be choroughly 
 stretched at the time of operation. Should granulation 
 be slow it may be stimulated by use of iodoform as a dust- 
 ing powder, or by daily application of balsam of Peru. 
 
 Treatment of Non-Malignant Strictures of the 
 Rectum. When it is found that " chronic diarrhea" or 
 "chronic dysentery" depends upon non-malignant stricture 
 the proper treatment is that outlined best by Kelly: 
 enforced rest, nutritious and non-irritating diet, keeping 
 the upper bowel emptied, cleansing solutions of mild 
 antiseptics, healing applications and packs. A stricture of 
 moderate caliber may be cured by gradual dilation with 
 bougies; by the elastic pressure of a rubber bag, distending 
 by air and made to distend in a uniform manner by a silk 
 covering (Sweetnam's plan), and by digital distension and 
 massage. If a contracting bowel is watched and thus 
 treated, the patient may go on for a long time, for years 
 even, in great comfort, though the disease is not cured and 
 patients should be told so. 
 
 However, in really bad cases resection is necessary and 
 may be practised even when the disease extends over an 
 area as long as 20 cm. A posterior incision with the 
 removal of the coccyx, and sometimes of the last sacral 
 vertebra, with the preservation of the anal sphincters and 
 ampulla when possible, and an end-to-end anastomosis of 
 the bowel, is the best procedure. It is sometimes worth
 
 274 SURGICAL THERAPEUTICS 
 
 4 
 
 while in the attempt to save the bowel, when the local 
 process persists in advancing, to make an artificial anus 
 completely diverting the fecal current. The bowel may then 
 heal and the extensive surrounding inflammation undergo 
 resolution, when after months (or a year or more), and 
 generally after a successful resection, the artificial anus 
 may be closed by abdominal section. 
 
 In a high grade of tuberculous or syphilitic stricture, 
 when an extensive area is involved, it is often best to make 
 an artificial anus and extirpate the diseased bowel. Kelly 
 prefers to do this by amputating the bowel above first, 
 and ligating such hemorrhoidal vessels of the lower end 
 as are within reach, and then to complete the extirpation 
 from below by an incision from sacrum to anus. Advanced 
 tuberculosis always demands extirpation, and syphilis calls, 
 of course, for persistent specific treatments in addition to 
 whatever local means may be employed. 
 
 What Shall We Do for Cancer of the Recttim? 
 This is a question every physician is liable to have to ans- 
 wer, one of great importance to the patient, and one upon 
 which surgeons have not yet agreed. From my own work 
 I am satisfied as to the justifiability of operating in every 
 case that is not so far advanced as to be regarded upon 
 the brink of the grave. There can be no question that if 
 recognized early and properly removed, carcinoma of the 
 rectum can be cured. The method of extirpation is a mat- 
 ter of selection, to accord with the surgeon's predilection 
 and the nature and stage of each particular case. It is 
 sufficient, however, for the average physician to recognize 
 the fact that cancer of the rectum is not an absolutely hope- 
 less condition, so far as life is concerned. Furthermore, 
 he should know and explain to the subject of the disease 
 that even if the neoplasm does recur, life will have been 
 prolonged from one to four years and much suffering have 
 been saved. For even in very advanced cases it is best
 
 RICKETS 275 
 
 to make an inguinal colotomy, inverting the lower end of 
 the gut and dropping it into the pelvis, so as completely to 
 prevent the passage of feces over the inflamed and sensitive 
 surface at the site of ulceration. By so doing the comfort 
 of the patient may be enhanced and life prolonged at least 
 a year. And as now performed inguinal colostomy is prac- 
 tically without danger. If really necessary it can be done 
 under cocaine anesthesia. 
 
 RESPIRATORY FAILURE: STRYCHNINE FOR 
 
 During or at the termination of operations of great 
 magnitude entirely too much strychnine is being given 
 everywhere ; it is not at all uncommon to see a half centigram 
 (1-15 grain) injected at one time for "heart-failure." 
 Strychnine should not be given with the object of correcting 
 heart-failure ; it is a stimulant to the respiratory center and 
 should be given when the breathing is shallow and too slow. 
 It is therefore especially indicated in anesthesia from the 
 hyoscine-morphine-cactin tablet when the number of respir- 
 ations falls below six per minute. It should not, however, 
 be given until the end of operative work, whenever possible, 
 as it is apt to cause the patient to become nervous and 
 somewhat excited. 
 
 RICKETS 
 
 There being in this interesting disease of early child- 
 hood a deficiency of the elements which should enter into 
 the formation of bones that is a "bone-salt starvation" 
 the great indication, aside from proper food, is to supply 
 the deficiency. Zinc phosphide is highly praised ; from one 
 milligram to one centigram (gr. 1-67 to gr. 1-6) should be 
 given three times a day, according to age and the way 
 it is borne. 
 
 In rickets there is always a tendency of the digestive 
 apparatus to fail in its function, so great care must be
 
 276 SURGICAL THERAPEUTICS 
 
 exercised not to give zinc, lime, etc., in doses too large to be 
 accepted by the stomach and bowels without irritation. 
 The syrup of the lactophosphate of lime is a most praise- 
 worthy preparation; but some children cannot take it for 
 any great length of time ; it may be tried in doses of a half 
 teaspoonful thrice daily with a child of two or three years. 
 On account of this tendency to stomachic irritation, too, 
 codliver oil cannot often be given, though the most eminent 
 authorities advise it ; rich cream does better; when anemia 
 is marked and there are evidences of tuberculosis (formerly 
 called "scrofula") forced feeding may be necessary, with 
 the exhibition of syrup of the iodide of iron, one drop three 
 times a day being better than larger dosage. 
 
 If there is the slightest tendency to constipation (as 
 when the patient is taking iron) laxatives must be ordered 
 at bedtime, preferably sodium phosphate. Phosphorus 
 (or the phosphates) must be given freely on account of the 
 influence phosphorus has upon the growth of bones. One 
 or two decigrams of phosphate of lime (i to 3 grains) 
 may be given in milk three times a day without the knowl- 
 edge of the child. The phosphates of iron and strychnine, 
 each in 1-67 grain dose, are both very valuable. Baths, 
 followed by massage, are excellent, but care must be exer- 
 cised not to bathe the patient too frequently since hot 
 baths weaken to a marked degree, and in these cases every 
 energy must be directed toward building up the patient. 
 If there be a marked tendency to bending of the legs, the 
 little patient must be kept, as much as possible, from walk- 
 ing. Out-door life is indispensable; and good food also. 
 
 RODENT ULCER 
 
 This form of malignant disease may sometimes be cured 
 by electric treatment which ought to be tried before more 
 serious measures are adopted. The treatment can be car- 
 ried out with an ordinary portable galvanic (not faradic)
 
 RUBBER GLOVES: MURPHY'S SUBSTITUTE 277 
 
 battery. The process is based on the principle of the intro- 
 duction of the zinc ions into the tissues of the ulcer by 
 means of a continuous current. By this plan the ulcer is 
 made to assume the appearance of an ordinary simple 
 sore, and in many instances it is healed in a few weeks 
 after a single application. An ordinary medical contin- 
 uous-current battery, with a galvanometer, a pair of wires, 
 a flat pad for completing the circuit at the negative pole, and 
 a rod or other electrode of zinc attached to the positive pole, 
 completes the outfit. The zinc must be covered with three 
 or four layers of gauze, which serve as a reservoir to hold 
 the zinc solution, a 2-percent solution of the sulphate 
 being suitable. The zinc should be freshly cleaned or 
 amalgamated, and the solution should be made with dis- 
 tilled water. It is as well not to touch the zinc electrode 
 or its covers with the fingers unnecessarily, because every 
 touch imparts a trace of sodium chloride from the skin, 
 and tends to reduce the efficiency of the process a little by 
 bringing in some foreign ions. The circuit is completed 
 through the usual pad electrode applied to any convenient 
 part of the patient, the zinc electrode of suitable size is 
 held on the rodent ulcer, and the current is slowly turned 
 on until a current of 5 , 8 or 10 milliamperes is reached, accord- 
 ing to the size of the electrode used; the seance continuing 
 about fifteen minutes. 
 
 RUBBER GLOVES: MURPHY'S SUBSTITUTE 
 
 Operators (or assistants) who cannot wear rubber gloves 
 for operations like hernia may employ the solution of gutta- 
 percha in benzin. It is prepared as follows: Gutta 
 chips are cut in small pieces, washed in full-strength 
 (4o-percent) formalin and dried in sterile gauze. Macerate 
 in sterilized benzin for three days, and filter through 
 sterilized cotton, twice. Benzin is rendered sterile by 
 putting it in a strong, well-corked bottle and boiling for
 
 278 SURGICAL THERAPEUTICS 
 
 twenty minutes, the water being only warm when the bottle 
 is placed in it. But as this solution deteriorates, like rub- 
 ber, it is best to buy sterilized gutta-percha (on the market 
 in sealed envelopes graduated for 4-, 8- and i6-ounce mix- 
 tures) and dissolve a little in the benzin each time. 
 
 Method of Use* The hands are thoroughly scrubbed 
 and washed in 65-percent alcohol for three minutes. They 
 are then dried with a sterile towel. The solution is best 
 applied by dipping the hands into a small basin containing 
 the solution. It should be worked in around the nails and 
 tips of the fingers, and should be applied as high as the 
 elbows. Between operations the hands may be washed 
 with soap and water, spirit of soap, alcohol, bichloride 
 solutions, phenol or formalin solution, without interfering 
 with the rubber coating. Brushes, however, should not 
 be used. After cleansing the hands and before proceeding 
 with another operation, the fingers should be redipped, as 
 the coating wears off, but one application on the hands 
 and forearms is sufficient for the entire day. The skin of 
 the operator does not become "water logged" or shriveled 
 with the solution, as it does with the rubber gloves. The 
 coating is best removed by washing the hands in benzin 
 and drying rapidly with a towel. 
 
 SAPREMIA 
 
 This is an acute febrile condition, the result of absorp- 
 tion of the products of putrefaction. The proper treat- 
 ment is instant removal of the cause, with physic and 
 antipyretic agent, a dose of acetanilid followed by aconitine 
 being very satisfactory. The most frequent cause of 
 sapremia, it should be remembered, is retention of frag- 
 ments of placenta or decomposing blood-clot; emptying 
 the uterus promptly relieves the trouble if free drainage 
 through the cervix be provided and the vagina be kept 
 clean by douching.
 
 SCARS 279 
 
 SARCOMA 
 
 This is an exceedingly malignant tumor made up of 
 embryonal connective tissue, the small-celled and those of 
 soft consistency being particularly malignant. It is likely 
 to appear much earlier in life than carcinoma. It is most 
 often found in the skin, periosteum, intermuscular septa, 
 subserous connective tissue and the eye. Whatever the 
 type, the earlier it is removed the better. Neighboring 
 lymphatic glands are not implicated as in carcinoma but 
 extension along blood-vessels must be looked for. When 
 not removable it is to be treated by x-ray and by injec- 
 tion of Coley's serum (mixed toxins of streptococcus and 
 bacillus prodigiosus) from which excellent results are occa- 
 sionally obtainable. 
 
 SCALDS- 
 
 Severe scalds should be treated practically the same as 
 burns of the second degree, exclusion of the air from the 
 burned surface being of especial necessity. If the affected 
 surface be extensive the kidneys must be watched carefully, 
 as a great strain is thrown on them and if they fail in their 
 work death will follow. Morphine must be given with 
 care. If the urine is drawn after two or three hours and 
 found very highly colored a gram (15 grains) of citrate of 
 potassium dissolved in a glassful of water must be given 
 every six hours. 
 
 SCARS 
 
 Cicatrices which cause much deformity may sometimes 
 be remedied in great measure by excision and transplanta- 
 tion of healthy skin into the gap; or even by a Thiersch 
 graft. When operation is not possible, or not desired, 
 treatment by electricity may be tried. In some cases the 
 scars have softened, the discolorations have disappeared, 
 the surface taking on more nearly the appearance of normal 
 skin. The application is made with two large electrodes
 
 280 SURGICAL THERAPEUTICS 
 
 moistened with a lo-percent salt solution. The negative 
 electrode, which is applied to the sacrum, has an area of 
 30 square inches. This is connected with the positive pole 
 of the induction coil, and this electrode has a surface of 
 about 1 6 square inches. The apparatus should have a 
 commutator that will enable the operator to use either the 
 galvanic or faradic current alone or the two combined. 
 The strength of the constant current employed to be only 
 from 3 to 4 milliamperes. The induction current should 
 be sufficiently intense to provoke appreciable contraction 
 of the muscles. Each treatment should last from fifteen 
 to twenty minutes. 
 
 Ugly Scars* For a period varying from a few months 
 to a year or two, scars remain red or purple, sometimes 
 causing great disfigurement. Nothing can be done except 
 to wait; after a long time they become pale and finally white. 
 If in such location that they can be removed and unin- 
 jured skin secured to cover the denuded area it is proper to 
 excise them under strictest antisepsis, suppuration causing 
 as much cicatricial tissue as was cut out, and sometimes 
 more. 
 
 SCOLIOSIS 
 
 Every 'case of curvature of the spine should be treated, 
 howsoever slight it may be, not on account of present de- 
 formity but because it may be followed by tuberculosis 
 and is an indication of a morbid condition of the general 
 health. According to Codicilla, a careful research has 
 demonstrated that scoliosis is a form of contracture, and for 
 such conditions the rational treatment is active and passive 
 movements in the deformed portions of the spine alone, 
 the normal portions remaining fixed. The best results were 
 obtained by the author with the apparatus of Schulten. 
 The apparatus of Zander is easier of application and also 
 gives excellent results.
 
 SEMINAL VESICLES: TUBERCULOSIS OF 281 
 
 SEMINAL EMISSIONS 
 
 These usually depend upon an irritable deep urethra 
 or excitable sexual center in the spinal cord. A Xo. 16 
 (American scale) catheter introduced every third day for 
 two weeks, and allowed to remain two minutes the first 
 time and one minute longer every time until ten minutes are 
 reached, will diminish this ; after which a few injections of 
 solution of nitrate of silver (10 grains to the ounce) through 
 a Guion's or Ultzmann's syringe ten drops behind the 
 ''cut-off muscle" twice a week will permanently relieve the 
 hyperesthesia. Hyoscine hydrobromide (i-ioo grain) at 
 bedtime, alone or with 20 grains of potassium bromide, 
 relieves the spinal irritation. One emission a week demands 
 no treatment whatsoever. 
 
 SEMINAL VESICLES: TUBERCULOSIS OF 
 
 When it is definitely determined that tuberculosis of 
 the seminal vesicles is present (either alone or associated with 
 tuberculo.-is of the testicle or epididymis) removal is the 
 only rational treatment if the patient desires to live any great 
 length of time. It is practically always associated with 
 disease of the testicles and vas deferens, although its 
 severity bears no relation to the extent of these lesions and 
 both vesicles may be involved in one-sided orchitis. The 
 symptoms are not striking as a rule. There is usually 
 vesical tenesmus, and there may be rectal tenesmus and 
 pain at stool. Examination reveals an obliteration of the 
 groove normally felt between these organs and the prostate 
 gland. Occasionally there is a fistula leading to the per- 
 ineum. The prostate is enlarged in about one-third of the 
 cases. Treatment may not be necessary in early cases, 
 the lesion sometimes healing spontaneously after removal 
 of the diseased testicle. If, however, there is a fistula or 
 extreme difficulty at stool, or if the organ is as large as the 
 last joint of the surgeon's thumb, it should be removed,
 
 282 SURGICAL THERAPEUTICS 
 
 unless there is tubercular disease of the bladder or kidney, 
 which may be looked upon as contraindications. The 
 operation of choice is perineal excision by a Y-shaped 
 incision, the shaft of the Y pointing forward in the middle 
 line and the arms embracing the front of the anus. Drain- 
 age and healing by granulation are always to be provided 
 for. 
 
 SEPTICO-PYEMIA 
 
 This is a name applied to a condition in which septi- 
 cemia is followed or accompanied by pyemia. Leube uses 
 the words "spontaneous septicopyemia " for a form of 
 pyemia which appears without obvious cause, or at least 
 following a skin-wound or bruise so trifling as to scarcely 
 be remembered. It is characterized by pain and tender- 
 ness in the muscles and joints with high fever, irregular 
 chills, fetid breath and septic diarrhea. There are also 
 present from time to time ecchymoses of the conjunctiva, 
 vesicles of the skin which contain blood, enlargement of 
 the spleen, and albuminuria. Death by coma usually 
 ends the scene. A supportive and eliminative treatment, 
 with the injection of Marmorek's serum, if the presence of 
 streptococci can be demonstrated, constitute all the ther- 
 apeutic measures that are beneficial. 
 
 Experiments made in Germany on animals go to prove 
 that the intravenous injection of antiseptics are of no value 
 in blood poisoning, but good results are recorded from hot 
 baths, which promote elimination by the skin and lymphatic 
 system. The internal administration of calcium sulphide 
 is worthy of trial. 
 
 Headache of Sepsis. For the relief of headache 
 acetanilid may be given guardedly if the heart be weak. 
 A dose of ten grains may be ordered; it may be repeated 
 in one hour if indicated, but no more should be permitted 
 until twenty-four hours have elapsed. A tablet called
 
 SEXUAL DISORDERS 283 
 
 "acetanilid and codeine compound" will be found prefer- 
 able in some cases. It consists of 
 
 Acetanilid grs. 3 1-2 
 
 Sodium bromide gr. i-io 
 
 Sodium bicarbonate gr. 9-10 
 
 Codeine sulphate gr. 1-4 
 
 The dose is one or two when needed for pain; to be 
 repeated once only if the first dose does not produce comfort. 
 
 SEQUESTRUM: REMOVAL OF 
 
 Whenever, in the healing of a fracture, a detached 
 fragment of the bone does not grow into the callus and form 
 once more a part of the living bone, it becomes necrotic and 
 a source of irritation. The only treatment is by removal. 
 The same is true of a sequestrum formed by tuberculous 
 disease, but in this kind of trouble the cavity must be cureted 
 and packed with iodoform and iodoform gauze, and allowed 
 to heal by granulation from the bottom. 
 
 SEXUAL DISORDERS 
 
 Sexual Debility: Senecin for If there is any drug 
 which may properly be called a "sexual tonic" it is senecin: 
 the active agent of senecio aureus or "squawroot. " The 
 dose is one to two milligrams (gr. 1-6 to gr. 1-2) three 
 or four times a day. It is most highly recommended for 
 women who complain chiefly of a sensation of weight and 
 dragging in the pelvis, yet who have neither prolapse nor 
 laceration of the pelvic floor as a cause. 
 
 Sexual Depressant: A Good For the control of 
 nymphomania, as well as depressant of eroticism or ere- 
 thism in morbidly excitable patients who are compelled 
 by circumstances to observe enforced continency, the follow- 
 ing combination may be prescribed: 
 
 Calcium sulphide o.oi 
 
 Salicin o.oi 
 
 Camphor monobromate o.oi
 
 284 SURGICAL THERAPEUTICS 
 
 These may be obtained in granules of one-sixth of a* 
 grain each, or may be dispensed in capsules with some 
 convenient vehicle. If in granules, the dose is one or two 
 every four or six hours. Four may be taken a little before 
 bedtime so that erotic dreams and sensations may be 
 avoided during the hours of sleep. The camphor 
 monobromate may be increased to 4 or 5 grains if 
 necessary. 
 
 Sexual Irritation: Symptoms of The intimate con- 
 nection which exists between the sexual sphere and the 
 skin is well shown in certain pathological conditions of the 
 latter, dependent upon the irritation of the former. The 
 appearance of many pimples upon the face is a common 
 accompaniment of the menstrual period with perhaps a 
 majority of women; and the occurrence of persistent acne 
 in girls at adolescence, when there is an unusual degree 
 of sexual disturbance (masturbatory or otherwise) is well 
 known. It dies out, usually, with the completion of adoles- 
 cence or by the complete sexual gratification of married 
 life; but it is apt to appear at the time of the menopause, 
 since this is a period of sexual excitement with many 
 women. 
 
 Sexual Neurasthenia. As an aphrodisiac as well as 
 general tonic in sexual neurasthenia "the three arsenates" 
 with nuclein will often give satisfactory results. A tablet 
 consisting of 
 
 Strychnine arsenate 0.0005 (gr. 1-134) . 
 
 Quinine arsenate o.ooi (gr. i- 67) 
 
 Iron arsenate o.ooi (gr. i- 67) 
 
 Nuclein solution 0.25 (drops 4) 
 
 may be ordered, of which one is to be taken every two 
 hours, or three after each meal and at bedtime. In the debility 
 of advancing age this has given most excellent results. 
 Nuclein is declared to be the most powerful known stimu- 
 lant to the sexual organs.
 
 SHOCK 285 
 
 SHOCK 
 
 In that form of shock due to severe impression on 
 the central nervous system, as when a large bone is sud- 
 denly shattered or a cavity penetrated or an important 
 viscus is wounded or a limb injured by a pistol or rifle ball, 
 the effect is often profound the most prominent symptom 
 being the general distress of mind and alarm which the 
 patient shows upon his face and which comes on almost 
 instantaneously upon the infliction of the injury. The patient 
 trembles and totters, is pale, complains of being faint, 
 perhaps vomits, and sinks to the ground; his features express 
 extreme anxiety and distress. This emotion is in great 
 measure instinctive and seems to be a sympathy of the 
 whole frame with the part subjected to serious injury, ex- 
 pressed through the nervous system. The first indication 
 is to check hemorrhage; the second to stimulate the heart. 
 Whisky is not bad. A hypodermic injection of glonoin 
 is next advisable, followed by atropine to maintain its 
 influence; and later one of strychnine, with a little mor- 
 phine if pain is a prominent symptom. 
 
 Post-Operative Shock. After a serious operation 
 there is of necessity a period characterized by weak and 
 rapid heart-action, the result of hemorrhage and pain ; but 
 this should be transient. Martin says if in an adult the 
 pulse remains above 144 for more than six hours the condi- 
 tion is distinctly dangerous. After twelve hours the prog- 
 nosis is bad, and after more than twenty-four hours nearly 
 but not quite hopeless. Whatever be the cause of this condi- 
 tion, its cure is dependent upon active stimulation supple- 
 mented by elimination. Therefore in addition to external 
 heat dilute hot rectal injections are highly important. Of 
 these coffee takes first rank, one pint of this at a tem- 
 perature of from 112 to 116 degrees being thrown into 
 the rectum. The stomach under these circumstances is
 
 285 SURGICAL THERAPEUTICS 
 
 non-absorbent and extremely prone to acute dilation. 
 Therefore, unless dilated, it should be left alone. In the 
 cases associated with acute dilatation, or followed by long- 
 continued vomiting, the stomach should be emptied by tube 
 and irrigated with hot, salt solution, but there is danger of 
 reflex cardiac inhibition. 
 
 Shock "With Abdominal Pain. Very often in abdo- 
 minal disease and acute trauma the patient's mind becomes 
 dulled: apathy and later unconsciousness appears; urine 
 excretion is diminished or absent, the pulse and respira- 
 tion become impreceptible, temperature subnormal, pupils 
 dilated, slowly responsive or fixed, and death occurs 
 speedily, in the severe types of disease or injury. Vomit- 
 ing is frequently prominent, but comes from acute sepsis, 
 not peritonitis. A death of this kind very soon after an 
 injury or rupture of an abscess may usually be said to 
 be due to shock; but if death be delayed more than a 
 few hours it is from acute sepsis. "Deferred " or "delayed" 
 shock is sepsis, pure and simple. But there is a true 
 shock associated with acute pain: Severe traumatism 
 (especially if productive of sudden, complete rupture of 
 liver or spleen or perforation of bowel, uterus or bladder) ; 
 violent hemorrhage; acute pancreatitis; sudden complete 
 blocking of the ureter, the biliary passages, or even the 
 pancreatic duct; mesenteric embolism; sudden strangula- 
 tion of the gut or even omentum by constriction of a hernia 
 or twist; torsion of the pedicle of an ovarian or uterine 
 tumor all these are always more intensely shocking than 
 the same lesions when slowly produced, and are always 
 accompanied by much suffering. From this kind of shock 
 the temperature slowly rises, often going to 100; but the 
 chief guide is the pulse. A progressive, even slight, hurry- 
 ing and weakening of the pulse, with or without persistent 
 lowering of body- temperature, is indicative either of per- 
 sistence of the exciting cause, the superaddition of more
 
 SKULL: WOUNDS OF 287 
 
 or less sepsis or of gangrene; and, especially if accom- 
 panied by cessation of pain, may be regarded as a pretty 
 constant indication for immediate operation. 
 
 SILICATE OF SODIUM SPLINTS 
 
 This formula, for the manufacture of a firm, durable 
 splint very valuable in the fixation of certain fractures 
 after the swelling has subsided has been sold to many 
 physicians for ten dollar; sometimes more: 
 
 Powdered starch ounce i 
 
 Isinglass or gelatin i ounce i 
 
 Solution of sodium silicate quart i 
 
 Powdered boric acid ounce 1-2 
 
 Mix the starch with the solution of sodium silicate 
 by shaking through a pepper-box and stirring constantly 
 till mixed. Reduce the gelatin to the consistency of 
 mucilage with boiling water and mix well with the first 
 two. (Better swell with cold water first.) Then put 
 in a jug of double the capacity and ferment at room or 
 sun temperature for three or four days. Then add the 
 boric acid, mix well, and it is ready for use. If too thick 
 after standing, thin it with boiling water. Keep the 
 jug well corked. 
 
 Apply a silk stocking or roller bandage, then a coat 
 of the preparation with a brush, and repeat till three or 
 four layers are applied or until the splint is thick enough. 
 It may be cut after hardening and eyelets and laces put in. 
 
 SKULL: WOUNDS OF 
 
 Every suspicious wound of the scalp should be thor- 
 oughly explored to see that there is no fracture beneath; 
 in case of doubt the wound to be enlarged for perfect 
 inspection. The following rules laid down by Adams 
 are to be carefully observed: 
 
 Gutter fractures should be invariably operated upon 
 as early as possible to get rid of bone fragments, clot and
 
 288 SURGICAL THERAPEUTICS 
 
 debris, and to provide outlet for the products of infec- 
 tion which is common to these cases. Without early 
 operation these wounds suppurate, and the operation 
 is too late. (Von Manteuffel.) 
 
 In transverse perforating wounds cleanse orifices and 
 await symptoms. 
 
 In superficial penetrating wounds with lodgment, 
 exploration with removal of bone fragments and bullet 
 should be made if practicable. 
 
 In transverse penetrating wounds cleanse the orifice 
 of entrance, await symptoms, and practise radiography. 
 
 Cases of compression by blood extravasation with 
 localizing symptoms are rarely seen. When extravasa- 
 tion can be localized and is accessible, it should be treated 
 on general surgical principles. 
 
 In some cases of penetration there may be fracture 
 of the skull opposite the point of entrance, without exit 
 opening. 
 
 Such a condition requires exposure and removal of 
 bone fragments; the bullet in such cases is rarely found 
 near the second fracture, generally having been diverted 
 to some other region by ricochet on the skull- wall. 
 
 The question of removal of a bullet lodged in the 
 cranium is one of special interest, inasmuch as a wide- 
 spread belief prevails that a lodged bullet is per se a most 
 dangerous thing. The danger lies in the damage done 
 to the brain by the passage of the bullet through its sub- 
 stance, and, unless symptoms arise which can be traced' 
 to persistent irritation by the presence of the bullet, or 
 radiography demonstrates that the bullet is in such a 
 position as sooner or later to produce irritation, no attempt 
 should be made to remove a deeply seated bullet from 
 the cranial cavity. Whenever we are confronted by the 
 question of the removal of a deeply lodged bullet, it should 
 be definitely ascertained that the symptoms present are
 
 SOAP SUPPOSITORIES 289^ 
 
 due to irritation from the presence of the bullet itself, 
 and not to its having inflicted damage on certain regions 
 of the brain on its way to its present location, for the 
 removal of the bullet could in no way affect the injured 
 cerebral tissue. 
 
 SNAKE-BITES 
 
 With any snake-bite the wound should be filled with 
 potassium permanganate, well rubbed in; and a few 
 drops of 25-percent solution should be injected around 
 the site of the injury If seen early, a tourniquet should 
 be applied a little above the wound," gradually loosened, 
 a little each hour. The Western treatment as much 
 whisky as necessary to produce a "dead drunk" is 
 efficacious chiefly because it does away with the deadly 
 fear. Two tablets of hyoscine-morphine-cactin (H-M-C, 
 Abbott), an hour apart hypodermically, will do almost 
 as well, though the profuse perspiration induced by the 
 whisky probably helps . to quickly eliminate the poison. 
 Pilocarpine hypodermically is also of benefit for this 
 same reason. A good saline cathartic is also excellent 
 given as soon as possible. When the heart flags (from the 
 acute sepsis) strychnine, digit alin and sparteine may 
 be administered, hypodermically. Hypodermoclysis is 
 of value, also, to stimulate the flagging heart and help 
 rapid elimination. Incision and sucking of the wound 
 at time of bite often extracts much of the poison. 
 
 SOAP SUPPOSITORIES 
 
 When glycerin suppositories are not obtainable, a 
 cheap and efficient substitute is soap. A piece about 
 the size of a man's thumb is made smooth, is wetted and 
 pushed as far up the rectum as a finger will carry it. 
 Loose, easy bowel-movement soon results. It is par- 
 ticularly applicable to young children who fight at every 
 attempt to give an enema.
 
 290 SURGICAL THERAPEUTICS 
 
 SPERMATOCELE 
 
 This form of "retention tumor" is quite rare. If 
 the obstruction to the outflow of semen be complete the 
 tumor may eventually attain considerable size as pre- 
 senting clinically. It contains non-albuminous fluid with 
 great numbers of spermatozoa. Their origin is not always 
 the same, but in the main is that of retention-cysts formed 
 in various ways, either externally or internally, by obstruc- 
 tion of the seminal tubules. Their diagnosis before 
 tapping is not easy, but may be helped by ascertaining 
 the position of the testis. Treatment either by injection 
 of irritating solutions or by operation is exceedingly simple 
 and satisfactory 
 
 SPINA BIFIDA 
 
 When parents will not consent to operative measures 
 or when the case is presumed not to be favorable for sur- 
 gical treatment Morton's method may be adopted: injec- 
 tion into the sac of one dram of a preparation of 10 grains 
 of iodine and 30 grains of potassium iodide in one ounce 
 of sterilized glycerin. About one dram of cerebrospinal 
 fluid is permitted to run through the needle before the 
 injection is made. The point of entrance is covered with 
 bichloride gauze and a bandage not too tightly applied. 
 
 SPINE: DEFORMITIES OF 
 
 The present status of these troubles is well summarized 
 by Cokenower, thus: (i) The statistics and histories 
 of all cases of deformities of the spine, even in children, 
 shortens longevity, and especially so with extreme scoliosn 
 when the average age does not exceed 30. (2) All 
 deformities of the spine can be relieved if treatment i.; 
 begun early or so soon as any deformity exists, and those 
 without bone deviations are simple and amenable to 
 successful correction, and those with osseous change,
 
 SPLEEN: ABSCESS OF 291 
 
 even in children, can be improved, but not so in ado- 
 lescence and adults. (3) The law of growth and develop- 
 ment of osseous as well as soft tissue is fully demonstrated 
 in the abnormalities, distortions, deformities and actual 
 and permanent normal functional disturbances; when 
 the equilibrium of the normal axis of the body has been 
 destroyed, no matter whether it be (he result of torticollis, 
 knock-knee, bow-legs, club-foot, short-leg or any other 
 cause, the results are the same according to severity. 
 (4) The medicinal and mechanical treatment should be 
 augmented with hygiene, gymnastics and all other prop- 
 erly guarded means that will develop the body, give tone 
 and power to the muscles, increase vital functions and 
 materially improve the general health. 
 
 SPLANCHNOPTOSIS 
 
 This is a name given to general prolapse of the abdo- 
 minal organs; including gastroptosis, enteioptosis and 
 prolapsus uteri, and sometimes hepatoptosis and spleno- 
 ptosis. With these are associated certain nervous symp- 
 toms generally called "Glenard's disease." Relief of 
 the ptoses by either mechanical support or by surgical 
 intervention rarely, therefore, cure the patients unless 
 followed by judicious internal medication continued over 
 a long period of time. 
 
 SPLEEN: ABSCESS OF 
 
 A few cases of abscess of the spleen have been cured 
 by making a large incision (sometimes with removal of 
 a part of eleventh and twelfth ribs) and opening the abscess 
 after carefully surrounding with gauze. When thoroughly 
 evacuated the abscess-cavity is to be tightly tamponed 
 with iodoform gauze and the splenic peritoneum sutured 
 to the parietal around the entire circumference, the parietal 
 peritoneum being dissected off for a considerable distance
 
 292 SURGICAL THERAPEUTICS 
 
 if necessary, in order to render it sufficiently loose to per- 
 mit sewing without undue strain upon it. Then gauze is 
 to be carefully packed in between this line of sutures and 
 the gauze-pack, to prevent, if possible, leakage of pus 
 for a few hours, until protective adhesions can form. 
 When the patient's condition is such that prolonged opera- 
 tion is impossible it may be necessary to rely upon careful 
 packing alone, the abdomen being bandaged tightly for a 
 few hours and patient kept lying upon the left side, to force 
 spleen against abdominal wall and thus favor promotion 
 of the adhesions upon which life depends. Splenectomy 
 is rarely possible on account of the deplorable condition 
 of the patient by the time a diagnosis is made. Sub- 
 sequent treatment is merely free drainage and tonics inter- 
 nally. 
 
 SPONDYLITIS 
 
 This name is frequently used as a synonym of Pott's 
 disease, inflammation of one or more vertebrae of tuber- 
 culous origin. It is treated by immobilization and gen- 
 eral antituberculous medication. Spondylitis deformans 
 is an affection generally described as an "inflammation" 
 of the vertebras of gouty or rheumatic origin, terminating 
 in ankylosis and deformity. There are no curative meas- 
 ures, though rarely an improvement follows systematic 
 muscular training with some mechanical assistance. 
 
 SPRAINS 
 
 This is a name applied to an injury to a joint, the 
 pathology being a strain of muscle, tendon or ligament, 
 frequently with more or less tearing of the implicated 
 structures and with an outpouring of- blood from the 
 rupture of small vessels. Very often that which is gen- 
 erally called "sprain" includes epiphyseal separation 
 or fracture of bone as well as injury to the soft parts.
 
 STATUS LYMPHATICUS 293 
 
 A special form is known as "riders' sprain" an injury 
 to the adductor longus muscle of the thigh, from a sud- 
 den effort to retain one's seat when the horse springs 
 sidewise. The soreness sometimes persists for many 
 days in spite of active massage and application of stimu- 
 lating and pain-relieving liniments. 
 
 Ichthyol for Sprains. To remove the swelling 
 which follows a severe sprain, especially of the ankle, 
 when the ambulatory instead of fixation-treatment is to 
 be adopted, ichthyol may be ordered for frequent and 
 deep massage. On account of its nasty smell phenol 
 may be added, or oil of citronella. It should be com- 
 bined with lanolin to get best results: 
 
 Ichthyol 8.0 (drs. 2) 
 
 Lanolin 32.0 (oz. i) 
 
 Oil of citronella 2.0 (grs. 30) 
 
 Mix. Directions: Apply by deep massage three or 
 four times a day. 
 
 STATUS LYMPHATICUS 
 
 This peculiar condition, associated with an enlarged 
 thymus gland and hyperplasia of the lymphatic glands, 
 is presumed to be the cause of death in some of the 
 fatalities reported from ether (and chloroform) anesthesia. 
 The number of recorded cases in which status lumphaticus 
 has been found in adults is increasing. Many of the sud- 
 den deaths which follow chloroform narcosis are reported 
 from Europe, and are found to be due to this cause. The 
 recognition of status lymphaticus by American surgeons 
 by whom ether is more often used than chloroform has 
 shown that death in such cases may follow ether narcosis. 
 It is possible that the anesthetic may have nothing to do 
 with death in these cases. The iccognition of status lym- 
 phaticus is very difficult during life. A slight increase 
 of dulness to the lefc of the iter um or enlarged lymph
 
 294 SURGICAL THERAPEUTICS 
 
 nodes, together with a pale skin and well developed super- 
 ficial fat, raises a suspicion of such a stale, but these signs 
 can hardly be relied upon to identify the condition. 
 
 In the treatment of failure of respiration the condition 
 in artificial respiration is of little use, and the heart stops 
 so quickly that drugs have little time to reach the cardiac 
 and respiratory centers even if given hypodermically 
 after the collapse is first noticed. It is possible to antici- 
 pate shock by giving digitalis before the operation and 
 morphine and hyoscine hypodermically just before the 
 anesthetic is started. Intravenous injection of adrenalin 
 in normal saline solution, i in 50,000, has been shown by 
 Crile to stimulate the heart and rapidly increases blood- 
 pressure, and is unquestionably a useful procedure in 
 these cases. 
 
 STERILIZATION IN SURGERY 
 
 Sterilization of Instruments* All instruments to 
 be used in aseptic operations must be boiled for twenty 
 minutes just before using. This applies to knives and 
 scissors as well as other utensils, but in order to be certain 
 that they are not dulled by this process about one teaspoon- 
 ful of washing soda sodium carbonate, not the bicarbonate 
 used in cooking, which is useless for this purpose must 
 be added to each quart of water. In hospitals the instru- 
 ments as well as gauze may be sterilized by steam, but 
 it requires a long time, whereas by boiling, the things are 
 ready by the time the hands are cleansed. The water 
 may be poured off and the pan allowed to stand for a few 
 minutes to cool in a place where there is no dust, or cov- 
 ered by a towel out of boiling water. When everything 
 else is ready the instruments are to be taken from the boiler 
 and laid upon towels just taken from the sterilizer or boiler 
 (and not handled by anyone) or, better, placed in three or 
 four pans properly sterilized. They must be so placed
 
 STERILIZATION IN SURGERY 295 
 
 that wind does not blow over them and that no one save 
 operator or assistant shall touch them. 
 
 Sterilization of Pans. In most hospitals and in 
 practically every operation in a private house too little 
 attention is paid to the sterilization of pans. In hospitals 
 they may be rendered surgically clean by placing them 
 in the sterilizer for an hour in steam of high pressure; 
 if not, they must be cleaned as in a private house, viz., 
 (i) by thorough scrubbing outside and in with soap and 
 water, (2) drying with a clean towel and (3) pouring a 
 little alcohol over each and setting it afire. This, however, 
 sterilizes only the interior of the pan or basin. A better 
 way if there be time enough is to put a wash-boiler on 
 the kitchen stove, fully two-thirds filled with clean well- 
 water or cistern-water and boil all the pans and trays for 
 twenty minutes. In the pot should be placed (a) two pans 
 for instruments, (b) one smaller pan or platter for sutures 
 and ligatures, (c) one small bowl for alcohol, (d) one 
 large earthen bowl for sublimate solution, (e) one large 
 bowl for boiled water, (f) one long-handled dipper. After 
 these have boiled the required time they are to be 
 taken out by means of a sterilized 8-inch clamp or for- 
 ceps, and no one beside the surgeon or assistant permitted 
 to touch them. A sterilized towel should be hung over 
 one end of the boiler for the long-handled dipper to lean 
 against because the upper part of the boiler will not be 
 surgically clean and the water wilt be contaminated by 
 the dipper's falling into it if this precaution is not taken. 
 With the same pains or in the same pot may be boiled 
 the towels or torn-up sheets or old cloths which are to be 
 used around the field of operation. And the water may 
 be used for making the solutions and for washing purposes: 
 hands, skin of patient, etc. In private houses extreme 
 vigilance is essential to prevent too willing neighbors from 
 sticking their dirty fingers into the water, dipping hot
 
 296 SURGICAL THERAPEUTICS 
 
 water out of the surgeon's boiler, etc. It is therefore best 
 to have the room emptied while completing operations. 
 
 STOMACH 
 
 Cancer of Stomach. There can be no doubt but that 
 cancer of the stomach is curable by early operation; the 
 trouble is to determine its existence very early, and to con- 
 vince the patient of the seriousness of his condition; and 
 often life may be prolonged and rendered far more com- 
 fortable very late in the disease. For this reason an 
 exploratory operation should be done, even in cases where 
 the disease is advanced and a tumor is perceptible. When 
 the disease is too extensive for any radical operation to 
 be done, the palliative operation of gastroenterostomy is 
 indicated. It can be done with very small risk and may 
 considerably prolong life. Besides, some cases, thought 
 to be cancer, too extensive for removal, have cleared up 
 after a gastroenterostomy, the patients getting quite well. 
 In cases of disease of the cardiac end of the stomach too 
 extensive for removal, the operation of gastrostomy may 
 considerably prolong life and prove of great comfort to 
 the patient by preventing death from starvation. Even 
 when the disease is too 'extensive for either removal or a 
 gastroenterostomy, the operation of jejunostomy may prove 
 of service to the patient. When a radical operation can 
 be performed, the thorough removal of the disease may 
 bring about as much relief to the patient as does the opera- 
 tion for the removal of cancer of the breast, uterus, and 
 other organs of the body. Following any of these opera- 
 tions food is to be selected of such character that all of the 
 digestion shall be intestinal; otherwise fatal diarrhea will 
 be set up. 
 
 After-Treatment of Stomach Operations. Upon 
 being returned to bed the patient should be placed with 
 head and shoulders considerably elevated, unless severe
 
 STREPTOCOCCIC FEVER: OPERATION IN 297 
 
 shock demands temporary lowering of the head, because 
 such position best relieves tension on the sutures and 
 facilitates passage of gastric mucus through the pylorus 
 or anastomosis hole. Later the patient may be turned 
 upon the right side for a rest, once or twice daily. 
 
 Should vomiting persist after the second day the stomach 
 must be carefully washed out, a little sodium bicarbonate 
 being added to the water. This lavage must be done with 
 extreme gentleness, with the patient lying quietly upon 
 his back. 
 
 STREPTOCOCCIC FEVER: OPERATION IN 
 
 When the infective agent in puerperal fever is the strep- 
 tococcus, as demonstrated by its appearance on the eighth 
 to eleventh day and proven by bacteriological findings 
 from examination of a little of the intrauterine debris, 
 cureting is distinctly contraindicated. Since in the milder 
 forms of streptococcic endometritis the leucocyte-wall is 
 the barrier against systemic infection, use of the curet opens 
 the lymphatics and disseminates the pyogenic bacteria; 
 while in the severer type the leucocyte-zone is not estab- 
 lished but the streptococci are already in the deeper 
 strictures where they cannot be reached by the curet and 
 once more the only influence of that instrument is to help 
 further bacterial invasion. This is, therefore, the exact 
 opposite of sapremia, the acute fever which arises on the 
 second to the fifth day from the germs of putrefaction, in 
 which instant removal of the decomposing material with 
 the Volkmann spoon or large curet is imperative if life is 
 to be saved. All that is necessary in streptococcic infec- 
 tion, then, is to insert a small strand of gauze through the 
 os to insure good drainage and to employ internal remedies 
 to assist nature to carry the patient through the acute stage 
 until the inflammation localizes itself, after which pus can 
 be evacuated whenever found.
 
 293 SURGICAL THERAPEUTICS 
 
 STRICTURE 
 
 Urethral stricture may sometimes be remedied by 
 gradual dilation with sounds. Forcible dilation (divulsion) 
 with an Otis's dilator formerly was very popular but has 
 fallen into disrepute of late. Internal urethrotomy is much 
 in favor with some ; but when gradual dilation is not possible 
 or the patient demands early relief external urethrotomy is 
 to be preferred. A large sound must be passed every week 
 for many months, regardless of the discomfort. 
 
 Strictures Cured by Thiosinamin. Some most re- 
 markable results have been reported in the treatment of 
 strictures (especially of the esophagus) by this drug. 
 Therapeutic Medicine says: Thiosinamin is a white crystal- 
 line powder, slightly soluble in water, easily soluble in 
 alcohol and having a faint odor of garlic. It has been 
 used in dermatology to promote the absorption of scars 
 and cicatrices following lupus, psoriasis, contractures, 
 keloids, etc. It has also been used in the treatment of 
 stenosis of the esophagus. It is hard to say whether the 
 drug actually dissolves or absorbs the scar-tissue, but the 
 good effects (which may also be due to the scar becoming 
 elastic and yielding) cannot be questioned. 
 
 The drug is given subcutaneously in a 10- percent aqueous 
 solution, a syringeful daily, and marked improvement gen- 
 erally follows in a month's time. It may be used in 
 combination with sodium salicylate after the following 
 formula: 
 
 Sodium salicylate i.o (grs. 15 ) 
 
 Thiosinamin i.o (grs. 15 ) 
 
 Water 10.0 (drs. 2 1-2) 
 
 Injections of thiosinamin near a scar bring about marked 
 improvement. The quantity injected each time is a 
 syringeful containing one decigram (i 1-2 grains) of the 
 drug. The above combination of thiosinamin with sodium
 
 SUPPURATION 299 
 
 salicylate is practically equivalent to Mendel's fibrolysin, 
 which has been used for the same purpose. 
 
 STYES 
 
 Staphylococcus infection of a meibomian gland is just 
 the same as any other boil except that it affects the mar- 
 gin of the eyelid instead of a hair-follicle on the surface of 
 the body. When the infection first becomes apparent it is 
 good practice to apply: 
 
 Yellow oxide of mercury 0.5 
 
 Lanolin 30.0 
 
 By using this as an inunction, every three or four hours, 
 suppuration may sometimes be prevented. As soon as 
 pus forms the little abscess should be opened and the 
 pus carefully evacuated. Then the eyelid (especially at 
 its margin) should be washed frequently with saturated 
 solution of boric acid to prevent infection of adjacent glands 
 and follicles. If the pain be severe a little acetanilid may 
 be prescribed: one-third of a gram (5 grains) three or 
 four times a day either alone or with half a decigram 
 (gr. 3-4) of codeine. As a rule, styes, like boils, are found 
 in patients with bad general health; so iron, strychnine 
 and arsenic are also indicated, with the use of a small 
 dose of epsom salt once daily until the "crop" of styes is 
 entirely eradicated. 
 
 SUPPURATION 
 
 Calcium Sulphide in Suppuration. It is hard to 
 explain how a purely local process like the discharge of 
 pus from a sore may be affected by medicines given inter- 
 nally; but clinical evidence is abundant that when an 
 infected wound is discharging a thin, watery, nasty pus 
 and persistently refuses to granulate and heal, the use of 
 sulphide of calcium will soon effect a marked change. 
 Under its influence the discharge becomes at first more
 
 300 SURGICAL THERAPEUTICS 
 
 b 
 
 abundant but soon diminishes and the pus becomes thick 
 and creamy the "laudable pus" of older writers the 
 pus which is present upon a healthy wound granulating 
 under staphylococcus infection only. The best dosage is 
 five centigrams (about a half grain) in form of a granule 
 four times a day. 
 
 Deep Glandular Suppuration. Quite often the 
 deep cervical glands become infected, particularly in weak 
 children who have had measles or scarlet-fever. In such 
 cases, or in any case where deep-seated suppuration is 
 suspected, sulphide of calcium sometimes acts beautifully. 
 Unless the pus can be located and drainage established, 
 the pain, fever and constitutional disturbance may become 
 dangerous, a fatal result often having been observed. If 
 one centigram (about one-sixth of a grain) of calcium sul- 
 phide be given every hour when the patient is awake, the 
 pain soon lessens, the fever subsides, the abscess becomes 
 well defined and may be opened much sooner it will even 
 "break" of itself in four or five days instead of the two or 
 three weeks it would otherwise require. 
 
 SUTURE-MATERIALS 
 
 Catgut. Plain catgut is used for all ligations and for 
 suturing all deep structures excepting the intestines. 
 
 Chromicized Catgut. Some surgeons are now using 
 chromicised catgut (twenty-day) for sewing the skin. It 
 certainly is very satisfactory, and may be left to be 
 absorbed when one does not want to open the dressings 
 for weeks. It is also of great use for closing the cervix 
 when operating for lacerated cervix and lacerated perineum 
 at the same sitting; the ten-day kind being used. It may 
 be employed with best advantage as a buried suture, 
 especially in operations for hernia. 
 
 Silkworm-Gut. For suturing the skin silkworm-gut 
 has been found to be le$s irritating, and better, than any
 
 SYNOVITIS 301 
 
 other material excepting silver wire. It is sterilized by 
 boiling with the instruments for 20 minutes at time of 
 operation, though in case of extreme haste it may be simply 
 washed with soap and water and immersed in alcohol for 
 two minutes. It should never be used as a buried suture. 
 Stitches, as a rule, should be removed from the seventh 
 to twelfth day. 
 
 Silver Wire. This is excellent for skin-sutures, but is 
 expensive. It is now used chiefly for the repair of the 
 cervix and perineum, and as a buried suture where perma- 
 nent apposition is to be maintained, as in hernia. 
 
 SYNOVITIS 
 
 Inflammation of a synovial membrane is quite common 
 by reason of infection through trauma, gonorrhea, etc. 
 Various pathological conditions are generally grouped under 
 this head, as syphilis, tuberculosis, etc., but these are 
 not true synovitis but specific infections characteristic of 
 each cause and partaking but little of the general pathology 
 found in true synovitis for the word should be limited to 
 infection by pyogenic microorganisms. The trouble has 
 been that the older pathologists have seen a tuberculous 
 infection of the synovial membrane (known to be such) 
 become secondarily involved in a true pus-producing inflam- 
 mation and have not recognized the trouble as one of mixed 
 infection. Various forms described in text-books are like- 
 wise dependent upon invasion of the joint by pus-producing 
 bacteria, as "metritic" (staphylococcic or streptococcic), 
 secondary to uterine infection; "puerperal" (also staphylo- 
 coccic, streptococcic, etc.), occurring after child-birth; 
 "scarlatinal" (streptococcic), associated with scarlet-fever; 
 "exanthematous," etc. Various forms of bacteria may, 
 under peculiar circumstances, become pus-producing and give 
 rise to serious synovitis, as the bacillus typhosus, Pfeiffer 
 bacillus(influenza),pneumococcus and, typically,gonococcus.
 
 302 SURGICAL THERAPEUTICS 
 
 Acute Synovitis. Acute synovitis may be treated by 
 compression with bandage or may be surrounded by the 
 kaolin and glycerin compound (cataplasma kaolini U. S. 
 P.). Later lead and opium may be used, applied hot, 
 the joint covered with flannel and rubber tissue over all. 
 Later, if effusion persist, the serum may be removed through 
 a large needle. The skin must be prepared with extreme 
 care (as thoroughly as for an abdominal section indeed 
 at the knee more carefully, because opening of the knee- 
 joint is more dangerous than cutting into the belly) ; the 
 needle must be boiled just before using; and the hands 
 must be perfectly clean, or rubber gloves used. After with- 
 drawal of the fluid the opening must be closed by collodion 
 or a pad of sterile gauze. Internally one may use the 
 acetaniiid compound of the U. S. P.: 
 
 Acetanilid 70.0 
 
 Caffeine . . 10.0 
 
 Sodium bicarbonate 20.0 
 
 A half-gram (seven grains) may be ordered three times 
 a day, either alone or with a half grain of codeine sulphate. 
 The bowels must be kept open. 
 
 Gonococcal. When the gonococcus infects the synovia 
 (by blood-transmission or otherwise) it produces an acute 
 inflammation which has erroneously been called "gonor- 
 rheal rheumatism." It has nothing whatever to do with 
 rheumatism, but is a true inflammation due to the action of 
 a specific microorganism. It may be treated the same as 
 any other acute synovitis until it is seen that nature cannot 
 care for the trouble, the recuperative power of the synovial 
 : embrane being overwhelmed, and pus accumulates. 
 Then the joint must be opened and drained under strictest 
 antiseptic pr : cautions so as not to t igraf t a staphylococcus 
 infection upon the membrane. 
 
 Other Forms. Synovitis dependent upon milder in- 
 fections, such as typhoid germs, the bacillus of influenza,
 
 SYNOVITIS 303 
 
 the coccus of pneumonia, etc. (and often even thegonococ- 
 cus) so long as they are unmixed with true pyogenic poisons 
 may be treated by less energetic measures: rest, cooling 
 applications like lead and opium wash, icebags, cataplasma 
 kaolini, and alcoholic lotions such as tincture of arnica, 
 tincture of camphor, etc. The essential element is enforced 
 rest, and later massage. Internally acetanilid may be given 
 to control pain, aconitine to reduce fever (if much), codeine 
 to induce sleep if pain is great or chloral and bromide if 
 there is not much suffering. Salicylate of phenol (salol) 
 acts well in many cases. 
 
 Staphylococcal. Infection by staphylococcus (acute 
 inflammation of the synovial sac following an ordinary 
 punctured wound) is somewhat serious if the joint be a 
 large one like the knee or elbow. Immediate free incision 
 is advisable, followed by irrigation with large quantities 
 of normal salt solution; and the establishment of perfect 
 drainage. All this must be done under the strictest anti- 
 septic precautions to prevent engrafting a streptococcus 
 infection upon the less virulent type already present. 
 Drainage may usually be discontinued about the third to 
 sixth day unless fever and great swelling continue. In 
 case there is a great amount of injury to the joint it is 
 well at time of first treatment to fill the joint with phenol- 
 camphor solution (see formula elsewhere) . In many cases 
 a useful joint may be expected. 
 
 Streptococcal. Infection with the streptococcus (ery- 
 sipelas) is a most serious condition. The most energetic 
 antiseptic treatment must be employed as soon as the 
 symptoms (and microscopic examination of the discharges) 
 show the presence of this type of inflammation. Multiple 
 incisions, with through-and-through drainage by means of 
 gauze strips, injection of iodoform emulsion, free use of the 
 phenol-camphor solution, and systemic treatment to sus- 
 tain the power of nature must be attended to promptly.
 
 304 SURGICAL THERAPEUTICS 
 
 In many ca es amputation well above the infected areas 
 offers the only hope of life, when a large joint is implicated; 
 an 1 when indicated there must be no delay. 
 
 SYPHILIS 
 
 As soon as it i3 seen that a suspicious sore is syphilis 
 the patient should be put upon energetic mercurial treat- 
 ment. One of the best prescriptions for secondary syphilis 
 i;: 
 
 Hydrargvri cum creta grs. 20 
 
 Pulv. ipecac, et opii grs. 20 
 
 Misce et ft capsul. No. XX. Sig. : One three times 
 a day. The Dover's powder in this dosage just about 
 equalizes the tendency of the mercury to cause diarrhea. 
 When there is need of extreme haste (as when the eruption 
 on skin is conspicuous) the official ointment (unguentum 
 hydrargyri) may be rubbed freely in the groins and axilla 
 twice daily; and rarely mercurial baths may be ordered. 
 
 Recently the administration of mercury hypodermically 
 has become quite popular, and it does seem to give better 
 results than the older methods, though it is attended by 
 some pain. Hebra's solution seems to be most popular: 
 One-percent solution of bichloride of mercury is added to a 
 6-percent solution of salt, in equal quantities. Of this 
 solution from 20 to 30 minims are injected, representing 
 from a twelfth to an eighth of a grain of the sublimate. 
 The injection is made directly into the body of the gluteus 
 maximus muscle, three to five times a week; or every day 
 if too much local soreness does not result, abscesses not 
 infrequently occurring, even when great care is taken to 
 clean the skin with alcohol. From twenty to thirty injec- 
 tions usually cause total disappearance of all symptoms. 
 But this treatment should be supplemented by a year's 
 use of good-sized doses of mercury internally. The most 
 commonly used preparation is the protoiodide (hydrargyri
 
 SYPHILIS 305 
 
 iodicLim viride) the average dose of which is one centigram 
 (gr. 1-6) three times a day. 
 
 Iodine and iodides are given entirely too indiscrimi- 
 nately. They are chiefly useful in tertiary lesions: joint 
 affections, gumatous tumors, chronic ulcers, etc.; and here 
 they frequently have to be given in extraordinary dosage. 
 It is usual to begin with two grams at a dose (30 grains) 
 three times a day, of either potassium iodide or other salt 
 and rapidly increase the quantity until at least ten times 
 that dosage is reached, the limit being the tolerance of the 
 stomach. It may be taken in Vichy water, in milk, in 
 syrup of sarsaparilla or in syrup of trifolium; if in simple 
 water it must be highly diluted. It is often necessary, to 
 continue the enormous dosage for many weeks, particularly 
 in brain tumor of syphilitic origin; occasionally stopping 
 for a few days to let the stomach rest. 
 
 After the tertiary symptoms for which the iodide is 
 given have disappeared, it is well to let the patient's 
 stomach rest for a fortnight and then order mercury to 
 be taken for several months. "Mixed treatment" is 
 wholly irrational and cannot be too strongly condemned: 
 the patient needs either mercury or the iodides; the rem- 
 edy to be selected depends upon the character of the 
 lesions. 
 
 Pilocarpine in Syphilis. Wm. J. Robinson, of 
 New York, advocates the use of pilocarpine as an adjuvant 
 to mercury in cases in which the system has become sat- 
 urated with mercury and it has ceased to have the desired 
 effect. The glands continue hard, swollen, and tender, 
 and stomatitis is marked. Gastrointestinal, hepatic, 
 renal and skin activity have been neglected. The pilo- 
 carpine causes the elimination of mercury that was stored 
 up in the salivary glands and acting as a toxic body. In 
 the bowels and kidneys the elimination has been too 
 great for the organs, and the pilocarpine causes the skin
 
 306 SURGICAL THERAPEUTICS 
 
 to act and carries the mercury to the seat of the skin 
 lesions. The author recommends its use in doses of 
 1-30 to 1-8 'grain, two or three times a day, without other 
 drugs. It is of much value in secondary manifestations, 
 and is a most remarkable glandular eliminant. In some 
 cases supersaturation with mercury produces intolerance 
 of the drug, and the use of pilocarpine for a short time 
 will enable one to resume mercury with excellent effect. 
 
 Syphilitic Fever. It has often been observed, but 
 is frequently forgotten, that syphilitic fever may begin 
 in the early secondary period and last into the tertiary 
 period. It may or may not be accompanied by visceral 
 manifestations, especially in the liver, but the fever does 
 not seem to be dependent on these lesions. It may fall 
 spontaneously without specific treatment, but easily re- 
 turns. When it appears late in the disease large doses of 
 potassium iodide are given until it falls by lysis ; but in the 
 late secondary stage of lues mercury in large doses checks 
 it much more promptly than does the iodides. 
 
 Syphilis in Children In country practice as well 
 as in city work syphilis of childhood is often unrecognized; 
 and especially is luetic disease of bone miscalled "rheu- 
 matism." This trouble almost always begins as a 
 periosteal thickening with some tenderness; rarely with 
 a little fever. It affects the heads of the long bones first, 
 as a rule, but sometimes also the shafts; as the thickening 
 around the bones increases the soft ti-ssues gradually 
 become infiltrated, the exudation of deposit extending 
 toward the surface until the implicated part of the limb 
 appears much swollen, the skin finally assuming a tense, 
 shining and slightly reddened appearance, with much 
 pain and decided tenderness. A diagnosis of tuberculosis 
 should not be made (there is absence of the character- 
 istic spindle-shape; nor should it be mistaken for rheu- 
 matism); there is but little impairment of joint-function
 
 TALMA OPERATION 307 
 
 save that due to the swelling; the presence of Hutchinson 
 teeth or of iritis makes recognition sure. In these cases 
 iodides are of more value than mercury; they should be 
 given to the limit of tolerance. A child of three years 
 will often take two grams (30 grains) of sodium iodide 
 three times a day. 
 
 Syphilitic Periostitis. This is usually best treated 
 by gently rubbing in of mercurial ointment twice or three 
 times a day, with good doses of calomel internally; and 
 rest. If the pain becomes severe acetanilid may be ordered 
 in half gram (8 grain) doses. 
 
 Syphilitic Ulcers. In addition to the internal 
 treatment local measures must often be adopted. If 
 the patient's occupation will permit, iodoform powder 
 is the best to use; but if the smell renders it impossible 
 bismuth subiodide may be substituted, using one part 
 of that drug to five parts of powdered boric acid. 
 
 TALMA OPERATION: HEPATIC STIMULANT 
 AFTER 
 
 After performance of the Talma-Morrison operation 
 for cirrhosis of the liver (suturing the great omentum to 
 Glisson's capsule and to the peritoneum) it is well to give 
 a good "hepatic stimulant." By the action of a pill or 
 granule containing 
 
 Juglandin 0.005 (g r - I " 12 ) 
 
 Quassin o.oi (gr. 1-6 ) 
 
 Strychnine arsenate 0.005 ( r - I " I 34) 
 
 free bowel movement may be secured and maintained, 
 with much freer flow of bile than usual. It is best to begin 
 .% with three before each meal, then reduce to two and f nally 
 to one. Reaccumulation of ascites may be prevented 
 by the early and persistent use of this combination. Boldine 
 is also highly recommended in these cases, the dosage
 
 308 SURGICAL THERAPEUTICS 
 
 being two to six of the i-67-grain granules three or four 
 times daily. 
 
 TESTICLE: UNDESCENDED 
 
 There is no unanimity of opinion as to the most favor- 
 able age for operation nor as to the technic for cryptorchid- 
 ism. One should consider the age, whether unilateral 
 or bilateral, whether pain or psychical symptoms are 
 present, presence of complications, position and degree 
 of atrophy of the undescended testes. The non-opera- 
 tive treatment consists in massage and manipulation with 
 a view to bringing the organ into the scrotum, o a truss 
 above the gland to force and hold it down. But as such 
 testicles have been proved to be invariably functionless 
 the best treatment is excision, with careful obliteration 
 of the inguinal canal to prevent hernia. 
 
 TETANUS 
 
 The first thing to do when symptoms of tetanus arise 
 is to thoroughly open the wound, cauterize its every part 
 with a red-hot Paquelin cautery and pack loosely with 
 iodoform gauze. Next begin with chloral and bromides 
 in enormous doses, the more the better; four grams (60 
 grains) every three or four hours frequently are required 
 to prevent the spasms. Next give a cathartic. Then 
 administer pilocarpine until profuse sweating is pro- 
 duced and keep it up. As soon as the tetanus antitoxin 
 is obtained give it in large doses both by intraspinal and 
 subcutaneous injections from 60 Cc to 80 Cc a day to 
 begin with, increasing to as much as 160 on the fifth day. 
 About 200 Cc may be given altogether on the sixth day, 
 by which time the patient will be either dead or con- 
 valescent. 
 
 Tetanus Cured by Spinal Injection. Very recently 
 successful results have been reported in the treatment of
 
 TOOTH-PASTE 309 
 
 tetanus by spinal injections. Sixteen Cc of cerebral 
 fluid are withdrawn and 3 Cc of the fol owing solution 
 injected: i 1-2 grains of betaeucaine, 1-3 grain of morphine 
 sulphate and 3 grains of sodium chloride, with sufficient 
 water to make 3 1-2 ounces. This procedure has been 
 repeated four times in the cured cases. 
 
 TONGUE FORCEPS CONDEMNED 
 
 No anesthetist should use tongue-forceps they are 
 utterly inexcusable. If the tongue drops back into the 
 throat and chokes the patient, elevation of the jaw by 
 placing two fingers under the angle on each side and 
 throwing the head upward and backward therewith, 
 will produce instant relief, unless there be accumulation 
 of mucus in the throat, in which case the head must be 
 turned to one side and a swab introduced to clean out 
 the obstruction. When extensive operation is to be done 
 in either mouth or throat a strong silk thread should be 
 passed through the tongue far back and tied in a huge 
 loop; this will enable the assistant to hold the tongue up 
 out of the way without the serious mutilation which results 
 from the use of forceps on the tongue. 
 
 TOOTH-PASTE 
 
 Chlorate of potassium in any strength above 20 percent 
 will quickly destroy any of the fungi usually found in 
 the mouth, including the germs of putrefaction. A most 
 commendable tooth-paste is this: 
 
 Chlorate of potassium 50.0 
 
 Precipitated chalk 20.0 
 
 Florentine orris root 15.0 
 
 Glycerin 1 5.0 
 
 Thymol 0.2 
 
 Mix and make a paste; a little more glycerin may be 
 added if necessary. This not only cleans and whitens
 
 310 SURGICAL THERAPEUTICS 
 
 the teeth but stimulates the circulation in the gums, arrests 
 fermentation of particles of food left between the teeth, 
 Lweetens the breath and leaves a pleasant taste in the 
 mouth. 
 
 TORTICOLLIS 
 
 Acute torticollis (inflammatory or transient spasmodic 
 wry-neck) may sometimes be relieved inside of ten minutes 
 by the following method: Put a large handful of crushed 
 capsicum pods in a pint of hot or cold water and let it 
 stand for thirty-six hours. Soak a piece of gauze in this 
 liquid and apply to the affected part, covering the gauze 
 with oiled muslin or oiled silk. This never blisters but 
 nearly always relieves. Chronic cases can be cured 
 only by division of the scalenus anticus (rarely) or of the 
 sternocleidomastoid (usually) and maintaining the head 
 in overcorrection for three weeks. 
 
 TRACHEOTOMY 
 
 In making a tracheotomy one should avoid making 
 too small incisions, as bleeding vessels can thus be more 
 readily brought to view and hemorrhage more easily 
 controlled. After the operation the inner tube should 
 be removed and cleaned every two hours. And the patient 
 must be watched every moment for the first 48 hours 
 lest mucus accumulate in the tubes and strangulation 
 follow. 
 
 TRANSFUSION OF BLOOD 
 
 This operation is again coming into vogue, and 
 under the aseptic technic lives are being saved by it. 
 When a patient has bled to unconsciousness, is pulseless 
 and cold, there may be hope of restoring life if the source 
 of hemorrhage has been found and the leakage stopped. 
 The radial artery of the donator is bared and opened 
 and a small glass or aluminum tube, sterilized, introduced
 
 TRENDELENBURG POSITION 311 
 
 into it and held by a catgut ligature around its end; a 
 little blood being allowed to flow (to determine that the 
 current has been established) the end of the tube is closed 
 and all wrapped in a very hot, moist towel. The basilic 
 vein of the donee is next exposed and opened as for vivi- 
 section, the distal end tied but the proximal left open. 
 The end of the vein being lifted out sufficiently, blood 
 is permitted to flow from the tube long enough to be sure 
 all air is expelled, and then (with blood still running) tfre 
 end of the tube is slipped into the vein and tied around 
 with gut. Blood is permitted to flow for about thirty 
 minutes when the vein and artery are each closed by 
 ligation. The donor's blood will drop from the normal 
 5 1-2 or 6 million to near 4,500,000 in that time (hem- 
 oglobin from 100 to about 70) while the donee's will 
 rise correspondingly. 
 
 TRENDELENBURG POSITION: A 
 PRECAUTION 
 
 In performing celiotomy for pelvic troubles where the 
 Trendelenburg posture is employed, the incision in the 
 abdominal* wall should not be closed while the patient 
 is in that position, as emphysema of the abdominal wall 
 is likely to follow with distressing symptoms. Meinert, 
 of Dresden, has known eight cases of this kind, and 
 Leopold alone has had eight. The emphysema occurs 
 between the peritoneum and muscle (the peritoneum 
 sometimes being easily separated from the muscle, par- 
 ticularly where there has been considerable manipula- 
 tion in the peritoneal cavity), and in the subcutaneous 
 areolar tissue. It is not harmless, but it increases the 
 rapidity of the pulse, causes considerable pain, and makes 
 the patient restless. It also may extend into the inguinal 
 region, or even, as in one of Leopold's cases, to the axilla. 
 Healing will be seriously interfered with. The trouble
 
 312 SURGICAL THERAPEUTICS 
 
 may be avoided by placing the patient in the horizontal 
 position before closing the abdomen. The greater part 
 of air admitted to the belly is thus expelled. 
 
 TRIFACIAL NEURALGIA 
 
 In the surgical treatment of trifacial neuralgia re- 
 member: (i) Avulsion of the distal branches should be 
 the first operation. (2) Avulsion with ligation of the com- 
 mon and external carotid arteries should be second choice. 
 (3) Removal of the branches of the nerve (Lexer) should 
 be the third choice. (4) Lexer's method combined with 
 that of LaPlace, and ligation of the common and external 
 carotid arteries, the fifth. (6) Removal of the ganglion 
 and neurectomy of the distal branches, the sixth. (7) 
 Removal of the ganglion combined with neurectomy 
 and ligation of the common and external carotid arteries, 
 the seventh. (8) Neurotomy or else the injection of osmic 
 acid affords only temporary relief. (9) Plugging the fora- 
 minse with fragments of bone cut from the neighboring 
 plate will prevent regeneration of the nerves passing 
 through them. (10) The method of Kroenlein is an 
 innovation, having given better results with less deformity, 
 mortality, loss of time, motor paralysis and less risk of 
 loss of vision, (n) Relapse occurs after intracranial 
 operations, but in such cases removal of the ganglion is 
 supposed to have been incomplete. (12) Intracranial 
 operations for the removal of the ganglion should be 
 abandoned because of the high mortality, except in cases 
 in which the condition is desperate and other measures 
 have failed. (Ricketts.) 
 
 TUBERCULOSIS: SURGICAL 
 
 Tuberculosis from Decayed Teeth. When glands 
 of the neck are the site of tuberculous enlargement one 
 should not only examine the tonsils, as advised by Prof.
 
 TUBERCULOSIS: SURGICAL 313 
 
 Waugh, but also the teeth. Very often a tubercular 
 peridentitis acts as the cause of the enlargement of the 
 glands, especially those anterior to the sternocleidomas- 
 toid muscle. Removal of the buccal irritation will some- 
 times cure the adenitis, so that a disfiguring operation 
 will not be needed. 
 
 Tuberculosis: Genital. Primary tuberculosis of the 
 genitalia may be found in very young children, Demme 
 having reported cases at seven and thirteen months. 
 Other authors report tuberculous vulvar tumors in a 
 child of two years and ulcefation in a child of four and 
 one-half years. Tubal tuberculosis is quite rare, how- 
 ever. Carpenter's method of combined rectal and biman- 
 ual examination revealed genital tuberculosis in all cases 
 ranging in age from fourteen months to nine years. In 
 the practice of McNaughton Jones in the youngest patient 
 there was a hard mass in the umbilical and hypogastric 
 regions with the right ovary adherent to it. As regards 
 diagnosis, the most important thing is local examination 
 of the vulva, vagina and portio vaginalis, assisted by a 
 bimanual examination (through the rectum) of the uterus 
 and adnexa under anesthesia; a microscopic and bac- 
 teriologic examination of some portion of the affected 
 tissues is desirable, if obtainable, as would be a similar 
 examination of fragments from the uterine cavity after 
 curettage in older patients. The presence of tuberculosis 
 in other organs adds to the probability of the suspected 
 growths being tubercular. The appearance of the ulcers, 
 if present, is similar to that of tuberculous ulcers -else- 
 where. Much information may be gained by recogni- 
 tion of tuberculosis of the pelvic peritoneum, which almost 
 always accompanies similar disease of the genitals, and 
 which may, according to Hegar, be detected on internal 
 examination of nodules that are almost pathognomonic. 
 These nodules are found chiefly on the posterior surfaces
 
 314 SURGICAL THERAPEUTICS 
 
 of the sacrouterine ligaments and frequently the tube has the 
 form of a rosary with very hard nodules. A nodule in the 
 pars uterina is also a fairly reliable sign of tuberculosis. 
 
 Tuberculosis: Ileocecal. Those who have given 
 much study to intraabdominal surgery will quite agree with 
 Hartmann, who says it is not at all uncommon, there being 
 two forms of the disease: (i) Ulcerative caseous tubercu- 
 losis, accompanied by pericecal inflammation, sometimes 
 described as the enteroperitoneal form, and (2) hyperplastic 
 tuberculosis, resembling in its aspect and evolution certain 
 strictures of the rectum, formerly known as inflammatory 
 or syphilitic, and now shown to be tuberculous. 
 
 Etiologically ileocecal tuberculosis is equally observed 
 in both sexes. The disease seems to present its maximum 
 frequency between the ages of twenty and forty years. 
 Before twenty and after forty it becomes rare. The patient 
 may be affected with lung tuberculosis, but generally to a 
 slight degree, or even not at all. There is, between local- 
 ized cecal tuberculosis and ordinary tuberculous enteritis, 
 a great difference, the tuberculous enteritis appearing in 
 the late stages of lung tuberculosis. Infection is probably 
 brought about by ingesta, and localizes itself in the cecum 
 because of the stagnation of intestinal contents which favors 
 inoculation. 
 
 Clinically the surgical forms of ileocecal tuberculosis 
 manifest themselves chiefly by two kinds of symptoms. 
 Some of the cases exhibit the reaction of the peritoneum 
 and its surroundings, simulating appendicitis. Others are 
 the result of intestinal stricture, and are suggestive of neo- 
 plasms, all the more because direct examination almost 
 always reveals the existence of a tumor. 
 
 In the enteroperitoneal form the symptoms are those of 
 suppuration, complicated with the evolution of a pulmonary 
 tuberculosis. Exceptionally the abscess bursts into the 
 peritoneal cavity, and death occurs within two or three days.
 
 TUBERCULOSIS: SURGICAL 315 
 
 The hyperplastic form has an insidious onset, with loss 
 of appetite, slow digestion, and vague disagreeable sensa- 
 tions in the right iliac fossa. A tumor can usually be felt; 
 it is smooth and preserves the normal shape of the colon. 
 The disease never retrocedes, and unless operated for, 
 invariably proves fatal. Its average duration is two and 
 a half to three years. 
 
 In diagnosis it is often mistaken for neoplasm, but the 
 progress of the latter is usually more rapid, and the tumor 
 is nodu'ar and irregular in outline. The enteroperitoneal 
 form can readily be mistaken for appendicitis. Actinomy- 
 cosis can only be suspected when the abdominal walls are 
 rigid and board-like. 
 
 The treatment of ileocecal tuberculosis is surgical, the 
 abdomen must always be opened. Ca es of glandular 
 tuberculosis with subserous nodules, signs of slight localized 
 peritonitis, and without symptoms of lesions in the intestinal 
 mucous membrane, may be cured by simple exploratory 
 celiotomy. But more often a more extensive operation is 
 necessary. It is never necessary to remove the disease in 
 two sittings, as the obstruction is never extensive. It is 
 important to remove with the cecum the glands occupying 
 the ileocecal angle, which are often enlarged and often 
 caseous. 
 
 After-treatment is essentially that of tuberculosis else- 
 where : outdoor life, good food, and tonics used judiciously. 
 
 Tuberculosis: IntraperitoneaL Late investigations 
 seem to support Lawrence's statements: (i) That intraperi- 
 toneal tuberculosis is frequently a local disease. (2) It 
 probably occurs much more frequently in the female than 
 in the male. (3) In a large majority of cases it is primarily 
 visceral and the general peritoneum is secondarily involved. 
 (4) The surgical treatment is rational, sometimes agreeably 
 surprising in results, and again bitterly disappointing. (5) 
 In this, as in many other surgical conditions, early diagnosis
 
 316 SURGICAL THERAPEUTICS 
 
 and early operation will bring more certain results. (6) 
 In this condition the greatest obstacle to overcome is the 
 idea that it is a secondary condition. (7) No case of 
 intraperitoneal tuberculosis should be denied the benfits 
 of operation, no matter how extensive, as long as there is 
 no positive pulmonary or pleuritic involvement, for the 
 reason that some apparently hopeless cases fully recover. 
 (8) When there is a tubercular peritonitis, a sequel of 
 tubercular tubes, ovaries or appendix, the primary focus 
 should always be removed. (9) In these tubercular cases 
 the mesenteric glands have not frequently been found in- 
 volved, and when they are, operation accomplishes very 
 little good. (10) In tubercle of tubes and ovaries the 
 adhesions are usually firm, sometimes, though not usually, 
 very vascular, and not infrequently involve loops of the 
 small intestine ; hence the greatest care is necessary to avoid 
 serious injury to the bowel and at the same time separate 
 completely all adherent surfaces and provide complete 
 drainage, (n) Drainage is the factor in recovery, when 
 properly carried out. 
 
 Tuberculous Lymphadenitis. In the management 
 of tuberculous adenitis the internal treatment, and the local, 
 are rather more important than the operative. No one 
 should persist in internal medication and local applications 
 until burrowing abscesses have formed or the glandular 
 substance has broken down and is about to discharge 
 through the skin; for such treatment would lead to disaster: 
 the formation of indolent, discharging sinuses, with danger 
 of systemic trouble from mixed infection; for as soon as 
 the "cold abscesses" open there is engrafted upon the tuber- 
 culous soil the staphylococcus, even if not the streptococcus. 
 Hence it is very easy to wait too long, especially as the pa- 
 tient makes little, if any, complaint. 
 
 But so long as the tuberculous focus seems limited with- 
 in the capsule (evidence: non-adherence to surrounding
 
 TUBERCULOSIS: SURGICAL 317 
 
 tissues) it is safe to abstain from surgical interference, 
 often for weeks and sometimes permanently. Non-operative 
 treatment consists of (a) general measures, i. e., increase 
 of food, maximum of out-door life in the sunshine, encour- 
 agement of proper elimination by kidneys and bowels 
 (excess of water and saline laxatives but no physic); (b) 
 the administration of drugs calculated to strengthen, notably 
 iron, arsenic and strychnine (the "triple arsenates with 
 nuclein" is an excellent combination), creosote, with small 
 quantities of alcohol just before meals (sweet wines or 
 whisky with glycerin or syrup just before eating causes 
 a patient to take more food than without the alcoholic agent) ; 
 and (c) local use of either tincture of iodine painted on the 
 affected gland its absorption aided perhaps by the negative 
 pole of a galvanic battery, 50 to 75 milliamperes or an 
 ointment of ichthyol in lanolin. Massage, aside from the 
 gentle rubbing in of ointment, must never be permitted; 
 rupture of the capsule of a non-inflamed tuberculous gland 
 is likely to have early pulmonary consumption as a result. 
 As soon as the gland softens, or becomes adherent, it should 
 be excised. 
 
 Tuberculous Peritonitis. We have been taught to 
 believe that simple abdominal section with considerable 
 manipulation of the viscera and evacuation of the ascitic 
 fluid will cure tuberculous peritonitis. But while it is 
 true that certain patients have apparently been cured by 
 such mild procedures, a much larger number have gone 
 on to fatal termination. The mistake has been made of 
 treating a symptom (ascites) instead of the disease. Radical 
 removal of every local deposit of tubercle wherever found 
 is the only certain cure. In a small percentage of cases it 
 cannot be found; here the only resource is irrigation, mani- 
 pulation and closure. In a larger percentage of cases the 
 lesions are so numerous or so situated that they cannot 
 be removed ; here gentle rubbing of the affected surfaces with
 
 318 SURGICAL THERAPEUTICS 
 
 gauze may do good. In all cases, whether the local focus 
 be removed or not, the most energetic constitutional treat- 
 ment must be instituted; forced feeding and tonics do fully 
 as much in abdominal tuberculosis as in pulmonary. But 
 unless the primary seat of the disease is found and the source 
 of trouble removed a guarded prognosis should be given 
 regardless of how much the patient may gain after operation. 
 Medication is the same as that for any other abdominal 
 section during the first few days, and then the same as for 
 phthisis. 
 
 Tuberculous Testicle: X-Ray for* In a late paper 
 Professor W. B. De Garmo, of the New York Post- Graduate 
 Medical School, reports what he believes to be the pioneer 
 case of tuberculosis of the testicle successfully treated by 
 the x-ray. The patient was a robust man, age 56, who had 
 always enjoyed good health. He had gonorrhea twenty- 
 five years previously, but denied syphilitic infection. For 
 the past five years the left testicle gradually increased in 
 size and was the seat of considerable pain. During the last 
 eight months there was gradual decrease in weight. The 
 testicle was the size of an orange, hard, nodular and tender 
 to pressure. After several months' delay the patient con- 
 sented to removal of the testicle, which was done, and on 
 examination it was found to be tuberculous. About two 
 months later the right testicle became involved. The 
 patient refused to have it removed, and the x-ray was ap- 
 plied. When treatment was begun the testicle was several 
 times its normal size and had the clinical appearance of 
 tuberculosis. One hundred and twenty-six treatments of 
 ten minutes each were given within a period of ten months. 
 A medium tube was used at about 10 inches. The first 
 application relieved the pain. Swelling and tenderness 
 gradually subsided, until at the last treatment the testicle 
 was apparently in a "normal condition." But in testicles 
 thus treated the spermatozoa are rendered sterile.
 
 TUBERCULOSIS: SURGJCAL 319 
 
 Surgery of Pulmonary Tuberculosis. A number 
 of cases have been recorded in which a localized abscess of 
 the lung, of tubercular origin but of staphylococcus engraft- 
 ment, has been opened and drained, with recovery. But 
 it has remained for Lionel Strutton, of Kidderminster, 
 England, to make phthisis pulmonalis an exclusively sur- 
 gical disease by removal of an entire lung. The patient, 
 a female, age 28, had definite signs of disease at the right 
 apex; the illness was of four years' duration; in the last 
 year and a half there was a continuous cough with expectora- 
 tion and night-sweats. There was dulness as far as the 
 third rib, tubular breathing and crepitant rales; but no 
 apparent involvement of the opposite side, so under ether 
 anesthesia an incision three inches long was made, with 
 its center over the third rib, two inches from the sternum; 
 about four inches of the third rib was removed. 
 
 On opening the pleura the latter was found everywhere 
 adherent; the adhesions were loosened carefully with the 
 hand as far as the third rib; this portion of the lung was 
 surrounded with a serre-noeud and was cut away, leaving a 
 stump of about the size of a five-shilling piece. For the first 
 twenty-four hours the patient was in a condition of collapse. 
 During the next few days there was considerable hemor- 
 rhage both from the wound and from the mouth. On the 
 seventh day hemorrhage ceased, but symptoms of sepsis 
 intervened which required a counter-opening in the back, 
 through which a large drainage tube was passed. The wire 
 came away on the eighteenth day and recovery was unevent- 
 ful. The wound was entirely healed three months later. 
 Soon after this, all cough and expectoration ceased. The 
 excised portion of the lung was tuberculous and con- 
 tained a cavity. Six months later the patient was reported 
 well. 
 
 Surgical Tuberculosis. In all forms of surgical 
 tuberculosis (bone-destruction, peritonitis, nephritis, sal-
 
 320 SURGICAL THERAPEUTICS 
 
 pingitis, etc.) the following plan should be rigidly enforced: 
 (i) The " open-air treatment" should be organized to 
 meet the circumstances and requirements of the particular 
 case. (2) In every case the patient's power of resistance 
 to the disease should be periodically measured by suitable 
 blood examination. (3) When resistance is found low 
 and there is no evidence of an excessive autoinoculation, 
 use should be made of therapeutic inoculations of Koch's 
 new tuberculin in doses that are accurately controlled both 
 as regards their amount and repetition by examination 
 of the blood. (4) In cases where there is evidence of 
 excessive autoinoculation absolute rest, with complete 
 fixity of the diseased part, should be prescribed. 5) 
 When it is evident that the diseased area is circumscribed 
 and cut off from the circulation of tissue-fluids, efforts should 
 be made to improve the circulation through the diseased 
 area. The means at our disposal are fomentations, the use 
 of certain mild irritants, e. g., liniment of iodine, light 
 therapy, general massage and local massage with carefully 
 regulated movements. (6) Operative procedures should 
 be directed to the removal of the dead, inert material, 
 whether pieces of bone or collections of pus, and should be 
 conducted with the most scrupulous aseptic precautions. 
 (7) The most careful attention should be paid to diet and 
 digestion, proper elimination through the alimentary canal 
 being of exceedingly great importance. (8) Remedies 
 proper for pulmonary tuberculosis are to be prescribed with 
 just as much thoughtfulness as in the more acute forms of 
 tubercular disease. 
 
 TUMORS 
 
 The word "tumor" is loosely used among surgeons to 
 express any sort of enlargement or swelling of a part, 
 whether the result of inflammatory action or not. Strictly 
 speaking a tumor is a new growth, not the result of inflam-
 
 TYMPANITES 321 
 
 mation or hyperplasia. Most authorities adopt the classi- 
 fication giver by Gould's Medical Dictionary based in 
 great part on the blastodermic origin of the dominant 
 tissue of the growth as follows: 
 
 A, MESODERMIC TUMORS 
 
 Round-cell \ ^Tge 
 I Small 
 I Lymphosarcoma 
 
 1. Sarcoma 
 
 2. Fibroma 
 
 j Soft 
 
 3. Myxoma 
 
 4. Lipoma 
 
 Spindle-cell 4 Large 
 I Small 
 Giant-cell 
 Melanotic 
 Alveolar 
 Endpthelioma 
 Angiosarcoma 
 Cylindroma 
 Chloroma 
 Psammoma 
 
 , j Hyaline 
 
 5. Chondroma -j Fibrous 
 
 j O. durum or O. eburneum 
 
 I O. spongiosum or O. medullare 
 
 ] Telangiectatic 
 
 7. Hemangioma -J Cavernous 
 
 8. LymphangiomaJ Simple 
 
 9. Myoma \ o. 
 
 j Rhabdomyoma 
 
 B. ECTODERMIC AND ENTODERMIC TUMORS 
 
 1. Glioma 
 
 N. myelinicum 
 
 2. Neuroma { N. amyelinicum 
 
 Adenoma ( Tubular 
 
 I Racemose 
 
 3. Epithelioma ( Carcinoma \ Squamqus 
 
 ; Cvlinc" 
 
 IN. 
 
 1 N - 
 I Ad 
 
 Cai 
 
 j ! Cylindric 
 
 L Glandular 
 ' Epithelial cystoma \ C. simplex 
 
 I C. papilhferum 
 
 C TERATOID TUMORS OR TERATOMATA 
 
 1. Dermoid cysts 
 
 2. Cholesteatoma 
 
 The treatment of each will be discussed under their 
 distinctive titles. 
 
 TYMPANITES 
 
 The distressing bloating of the abdomen which follows 
 some intraperitoneal operations and which is so prominent
 
 322 SURGICAL THERAPEUTICS 
 
 in peritonitis may frequently be controlled by half a milli- 
 gram (1-134 grain) of physostigmine every two or three 
 hours. It is claimed by Abbott that the same dose of 
 picrotoxin will have a similar effect. 
 
 Alum for Tympanites. Gaseous distension of the colon 
 is often distressing after abdominal operations. A good 
 treatment consists of dissolving one ounce of alum in half 
 a gal on of warm water and injecting with a high rectal tube. 
 
 Ergotin for Tympanites. To reduce the distressing 
 distension of the abdomen following intraperitoneal opera- 
 tions the hypodermic use of ergotin is advisable. If ergot 
 is given by the mouth it will almost invariably excite vomit- 
 ing which will increase the distension. So two drams of 
 the fluid extract may be given by rectum and repeated in 
 two hours; or 1-4 grain of ergotin may be injected into the 
 buttock or thigh not the arm, as abscesses sometimes 
 foVow its use. 
 
 TYPHOID SPINE 
 
 Inflammation of the joints following typhoid fever has 
 long been recognized as a surgical complication or sequel 
 of that disease, but has only of late been known to be due 
 to infection of the synovial membrane or the bone by 
 the Eberth bacillus one of the germs which become pyo- 
 genic under certain conditions. The knee has been the 
 joint most often involved, but of late it has been shown 
 that the spine may also be implicated; the patient com- 
 plaining of pain in the back, with its accompanying dis- 
 ability. An intensely neurotic condition develops, with 
 paresthesias, anesthesias, spasm or atrophy of muscles, 
 general weakness in fact, a condition so like "traumatic 
 spine" or the neurasthenia which follows a severe injury 
 that the condition has usually been regarded as of central 
 nervous origin and the spondylitis overlooked. Indeed, 
 there may be little to attract attention to the bones or
 
 ULCERS 323 
 
 joints of the spine stiffness and sensitiveness with pain, 
 these being all of the local signs in some cases ; but in the 
 more serious ones there may be actual deformity, and 
 examination with the x-ray may show some deposit around 
 the site of local infection. Primarily the focus is limited 
 to the periosteum in most cases, but the interior of the 
 bone may be the locus minoris resistentia or may become 
 the seat of secondary infection very early in the disease. 
 In the more fortunate cases, treated by proper quietude and 
 supportive measures, the disease disappears without sup- 
 puration a mere typhoid periostitis or osteomyelitis ; but in 
 the worst ones pus forms and may cause serious trouble 
 unless recognized and evacuated. When the focus of sup- 
 puration can be located, the proper treatment is to open the 
 abscess, curet away the diseased bones and pack with 
 gauze, the utmost care being taken, both at operation and 
 in the subsequent drainage, to maintain the strictest asepsis, 
 so as to prevent the engrafting of a staphylococcus or strepto- 
 coccus infection upon the minor pyogenic one already 
 present. By such treatment extensive deformity may be 
 prevented. These abscesses have heretofore been con- 
 founded with those originating as a tuberculous spondylitis. 
 Internal medication should be supportive, iron, arsenic, 
 strychnine and wine being particularly useful. 
 
 ULCERS 
 
 Some ulcers become very chronic, especially those of 
 the legs dependent upon ruptured varicose veins. When 
 they are irritable, soothing applications are indicated, 
 oxide of zinc ointment being a favorite with many doctors. 
 Others prefer an ointment of carbonate of lead, the lead 
 being rubbed up with linseed oil; but if the ulcerated sur- 
 face be extensive and granulations not active, lead poisoning 
 may occur. When the ulcer is indolent various applica- 
 tions have been recommended to promote healing all
 
 324 SURGICAL THERAPEUTICS 
 
 with more or less success generally less; for these ulcers 
 are very hard to heal without operative treatment re- 
 quiring at least curettage. 
 
 Bismuth benzoate has been much praised to stimulate 
 the healing process; the ulcer being cleansed by use of 
 hydrogen dioxide, or one in 1000 sublimate, or one in 40 
 carbolic acid, is dried by gently applying absorbent cotton 
 or gauze (better), the surface is dusted freely with the 
 bismuth, covered with dry gauze and cotton held in place 
 by adhesive strips rather than bandage. Some burning 
 follows the application, but this subsides in a few minutes. 
 The dressing has to be reapplied every day. 
 
 Nitric acid is also used to stimulate these indolent ulcers: 
 10 to 30 drops to the ounce; and sulphuric acid has been 
 likewise employed. When there is too free discharge 
 gallic-acid ointment (which see) has been lauded for many 
 years. When the granulations are exuberant they may be 
 best cauterized by application of a piece of blu6 vitriol 
 copper sulphate. Occasionally the best treatment is to 
 scrape away all granulations, after injecting cocaine behind 
 the raw surfaces, and disinfect by saturated solution of 
 potassium permanganate, dry the surface with gauze, cover 
 deeply with powdered boric acid, apply gauze wrung from 
 phenol-camphor, protect with oiled silk and put on a 
 Martin bandage over the leg or arm. This dressing must 
 be changed every forty-eight hours for a long time. When 
 all local (non-operative) measures fail, in persistent leg 
 ulcers the Schede operation should be advised as it fre- 
 quently gives most brilliant results in cases which have 
 persisted for years. Most careful attention must be paid 
 to building up the general health, if impaired, arsenic 
 being especially beneficial if used for a long time. 
 
 Calcium Iodide for Ulcer of the Leg This remedy, 
 has proved curative in ulcers which have for years stub- 
 bornly resisted all kinds of treatment. Patients who have
 
 ULCERS 325 
 
 without avail been simply saturated with potassium iodide, 
 in a week or two show clean granulating surfaces, and 
 the ulcers have, in almost all cases, healed up. In all cases 
 the induration around the ulcers soon diminishes or en- 
 tirely disappears. A few cases of syphilitic necrosis of the 
 nasal bones have derived considerable benefit from its 
 administration and great relief is to be obtained in head- 
 aches associated with syphilis. The dose given in all cases 
 is two grains in mixture three times a day, and there does 
 not appear to be any increased advantage from augmenting 
 the dose. Any mild external application, without distinc- 
 tion, seems efficacious; in most cases it is perhaps best to 
 use a mild mercurial or iodoform ointment. 
 
 Dusting Powder for Ulcer of Leg As a dusting 
 powder for varicose or eczematous ulcers of the leg this 
 formula may be tried: 
 
 Dry aluminum acetate 32.0 
 
 Balsam of Peru 8.0 
 
 Borated talcum 40.0 
 
 This may be applied freely and covered by antiseptic gauze, 
 cotton and bandage; or gauze strips, paraffined, may be 
 substituted, the powder adhering well to these. 
 
 Inflammation of Ulcers. Chronic ulcers, particularly 
 varicose ulcers of the leg, sometimes take on an acute inflam- 
 mation, they and the surrounding parts becoming exceed- 
 ingly painful. A very useful application in such cases is 
 digitalis. A teaspoonful of the dried leaves thrown into a 
 pint of boiling water makes a strong infusion in which 
 gauze may be soaked and applied to the inflamed surface, 
 acting better if covered by rubber tissue. After some hours' 
 treatment by this a kaolin-glycerin paste may be substituted. 
 Medicines for Ulcers. In the treatment of ulcers 
 not all of one's attention should be directed to the local 
 measures internal medication is often of great importance. 
 Chronic ulcers are frequently associated with a "run-down"
 
 326 SURGICAL THERAPEUTICS 
 
 condition, an anemia which requires both iron and strych- 
 nine. To each teaspoonful dose of the National Formulary 
 "elixir of quinine, iron and strychnine" may be added three 
 or four drops of the official liquor acidi arseniosi ; to be taken 
 three times daily. Better still and much more convenient, 
 as well as more effective, are the arsenates of iron, quinine 
 and strychnine, with nuclein. In some cases attended with 
 free discharge, echinacea seems to do much good a tablet 
 of a half grain of solid extract four times a day being a 
 pleasant mode of administration of such an unpleasant 
 drug. Stillingin, one centigram (1-6 grain), may be given 
 simultaneously. 
 
 Syphilitic Ulcers, Ulcers of syphilitic origin may be 
 well treated by local use of iodoform. After thorough 
 cleaning the ulcerated surface may be covered by powdered 
 iodoform and gauze applied. But as the iodoform is apt 
 to cake, most genitourinary surgeons prefer to use some- 
 thing like this: 
 
 Iodoform 1.5 (grs. 20) 
 
 Oil of eucalyptus 16.0 (oz. 1-2) 
 
 Apply on gauze and cover with oiled silk. When the pa- 
 tient must be on the street bismuth subiodide may be 
 substituted for the iodoform, on account of the unpleasant 
 odor of this drug; but it is not nearly so satisfactory as is 
 iodoform which more readily gives up its iodine. 
 
 Ulcers of the Leg. There are few things more trying 
 to the patience of the surgeon than the management of 
 chronic ulcers of the leg, particularly when the patient can- 
 not or will not remain quiet and give the leg the benefit 
 of rest and elevation. For the latter cases the following 
 line of treatment will often be found satisfactory: Inject 
 cocaine solution at several points around the ulcer; when 
 insensitive, thoroughly scrub with brush and antiseptic 
 soap with hot water, and scrape away any hypertrophic 
 granulations present with a sharp spoon and touch the
 
 ULCERS 327 
 
 whole surface with nitrate of silver. The leg is then shaved 
 and washed and a moderately thick layer of warm paste 
 applied to the leg by an ordinary brush, the paste coming 
 just to the margin of the ulcers and not on to it. The 
 composition of this paste (Unna's formula) is: 
 
 Zinc oxide 30 parts 
 
 White gelatin 40 parts 
 
 Glycerin 50 parts 
 
 Water 90 parts 
 
 Mix, after soaking and heating. 
 
 This is to be applied while still warm. The surface of the 
 ulcer is next dried and covered with powdered iodoform, 
 abundantly. A quantity of bichloride gauze is now placed 
 over and around the ulcer and a roller bandage firmly 
 wound around the leg, beginning at the toes and ending 
 several inches above the ulcer. As soon as the gelatin 
 has dried, the patient can be allowed to go about his busi- 
 ness. This dressing must be removed on the third day 
 and the ulcer cleaned with hydrogen dioxide, the surround- 
 ing surface being washed with soap and water, another 
 coating of the paste applied, and the iodoform gauze and 
 bandage used as before. This mode of dressing must be 
 repeated every third day as long as there is much dis- 
 charge, but as this diminishes the interval can be lengthened 
 until as much as a week may safely intervene. This treat- 
 ment is perfectly protective, exerts an even pressure over 
 the leg much more effectively than the old way of applying 
 a rubber bandage, while the paste prevents the septic 
 discharge from coming in contact with the healthy skin. 
 After the first application there is no pain attending the 
 treatment. 
 
 Ulcers of the Mouth. Persistent ulcers of the 
 mouth, not of syphilitic origin, are best treated by burning 
 with stick nitrate of silver, with a saturated solution of 
 potassium chlorate containing a little thymol as a mouth-
 
 328 SURGICAL THERAPEUTICS 
 
 wash. The burning may be repeated every two days; 
 but few treatments will be needed. Ulcers which persist 
 in spite of this treatment are (i) tuberculous, (2) syphilitic 
 or (3) cancerous, and demand careful investigation; excision 
 of a small piece of involved tissue, under cocaine anesthesia, 
 is justifiable in suspicious cases, for microscopic ex- 
 aminations. 
 
 URACHUS 
 
 Cysts of. In the differentiation of intraabdominal 
 growths a tumor in the midline between pubes and umbili- 
 cus must always be carefully examined to exclude a cyst 
 of the urachus. If it has not been discharging at the navel 
 it might easily be mistaken for an ovarian tumor, a fibroid 
 of the uterus, a growth in the mesocolon, or a distended 
 bladder. But almost always there has been some kind of 
 a discharge from the umbilicus; urine, if the urachus be 
 still open into the bladder, a milky fluid, if there be a true 
 cyst of the urachus. When there is a discharge present, 
 it must be identified beyond question, for besides urine and 
 cyst-contents there may be discharged (i) pus from an ab- 
 scess in (a) the abdominal wall, (b) the fallopian tube, (c) 
 an appendical inflammation, (d) a fecal fistula or (e) some 
 other source; (2) contents of a dermoid cyst, or (3) secre- 
 tion from a moist eczema of the umbilicus. 
 
 UREA: TO INCREASE EXCRETION OF 
 
 In many surgical conditions there is a deficient excre- 
 tion of urea. One of the most highly recommended remedies 
 for this is boldine, the alkaloidal active principle of boldo 
 leaves. This is said to speedily increase the production 
 of urea and expedite the excretion of solids by the kidneys. 
 The usual dose is one milligram (1-67 grain) every three 
 hours, or two milligrams four times a day. It may be 
 prescribed also when there is an insufficient flow of bile.
 
 URETHRA 329 
 
 UREMIA 
 
 Symptoms of uremia appearing after operations (parti- 
 cularly those on the kidney) demand immediate and vigor- 
 ous treatment. Probably the best thing to do is to begin 
 immediately with one milligram (1-67 grain) of elaterin, 
 every hour by mouth and continued until very free watery 
 bowel-movements are obtained; and with it one-half centi- 
 gram (1-12 grain) of calomel, as this drug In such doses 
 stimulates kidney-action. At the same time nitrate of 
 pilocarpine should be injected hypodermically (dose one 
 centigram, or 1-6 grain) every hour until profuse sweating 
 results. If coma or convulsions occur, hypodermoclysis 
 must be resorted to one liter (a quart) of normal salt solu- 
 tion to be thrown into the cellular tissue of the breasts 
 or buttocks and repeated in two hours if necessary. One 
 grain of sulphate of sparteine every three hours is highly 
 recommended hypodermically. 
 
 URETHRA 
 
 Foreign Body in Urethra* It is not often necessary 
 to make an external urethrotomy to remove a foreign body 
 from the urethra, unless it be beyond the "cut-off" muscle. 
 
 Schroeter has been successful with the following simple 
 procedure: If any urine can escape past the foreign body, 
 the outer orifice is closed with the fingers and the patient 
 is instructed to urinate as much as he can, forcing the urine 
 into the urethra until it is greatly distended. The orifice 
 is then abruptly released and the escaping fluid sweeps out 
 the foreign body with it. If no urine can pass the foreign 
 body, he applies a constricting band above it and then 
 injects water into the urethra to distend it from below, 
 compressing the orifice and allowing the fluid to escape 
 suddenly when the urethra has been sufficiently distended 
 by the water.
 
 330 SURGICAL THERAPEUTICS 
 
 Hemorrhage from Urethra. Hemorrhage from the 
 urethra may come from an acute trauma or from the 
 surface of an ulceration. When the hemorrhage occurs in 
 association with an erection the condition is sometimes 
 called stymatosis. When the bleeding point is in the 
 anterior urethra an injection of adrenalin solution may 
 arrest it, especially if an ice-bag be applied to the penis 
 to reduce congestion. In bad cases a large sound may be 
 introduced and the organ bandaged very tightly, thus con- 
 trolling the bleeding by pressure. When the blood comes 
 from the deep urethra, if injections fail and the loss of blood 
 is serious, an external urethrotomy may have to be made 
 to tie the injured vessel or to control by packing. 
 
 Inflammation of Urethra. Urethritis is almost 
 invariably gonorrheal in character unless directly traceable 
 to a recent trauma. Examination of the discharge, in case 
 of dispute or of doubt, will instantly determine the character 
 of the discharge: Neisser's coccus does not occur in simple 
 urethritis. If found to be a pure staphylococcus infection 
 the treatment will consist in simply keeping the canal clean 
 by injections of saturated solution of boric acid or the 
 application of iodoform powder through an endoscope. 
 Persistent cases may require an application or two of a 
 solution of silver nitrate by an Ultzmann or Guion syringe. 
 
 Tuberculosis of Urethra. It is doubtful if primary 
 tuberculosis of the anterior urethra ever occurs, though 
 numerous cases of secondary involvement have been re- 
 corded, and infection from the mouth of the rabbi may 
 follow ritual circumcision. It presents but few points for 
 clinical observation: pain on urination, hemorrhage from 
 the urethra, strictures without preceding gonorrhea or 
 trauma, seropurulent discharge, which may for a long time 
 contain no tubercle bacilli, or may contain them. But the 
 posterior urethra affords a most excellent field for the de- 
 velopment of local tuberculosis, the prostatic portion being
 
 VARICOSE VEINS 331 
 
 especially prone to implication. The most common form 
 is a simple mass of granulation-tissue, but in bad cases 
 ulceration and abscesses may form, with cheesy cavities here 
 and there, associated almost invariably with secondary 
 tuberculosis of the prostate. In some cases mere destruc- 
 tion of granulations by passage of sounds, followed by instal- 
 lations of lo-percent iodoform emulsion daily will effect 
 a cure. In others external urethrotomy is necessary, with 
 curettage of the diseased areas under the guidance of the 
 eye. In the worst cases, associated with tuberculosis of 
 the prostate, a prostatectomy is the only means of cure. 
 Most careful attention must be directed to the building up 
 of the general health, both before and after operative 
 measures. 
 
 URINE: IRRITATION FROM 
 
 After operations upon the bladder when it is necessary 
 to leave the vesical wound open, there is always great irri- 
 tation of the skin from the dribbling urine, continuing 
 several weeks. The temptation is to prescribe some drying 
 powder like borated talcum, oxide of zinc or carbonate of 
 calcium all of which have been so long used in intertrigo; 
 but if a dusting powder be used it will cake, adhere to 
 the skin and crack, itself becoming a source of local irrita- 
 tion and an annoyance to the patient. Better is some 
 greasy application, e. g., carbolized vaseline; frequent 
 washing with a mild soap and warm water followed by an 
 ointment of boric acid and vaseline gives the best results. 
 
 VARICOSE VEINS 
 
 These are best treated by ligation and excision; or if 
 very bad, on the leg, by the Schede operation or removal 
 of the long saphenous. If the patient refuse operative treat- 
 ment the part may be bandaged regularly to give comfort 
 and support the weakened vessels. In bad cases a Martin 
 bandage (rubber) or silk elastic stocking may be needed..
 
 332 SURGICAL THERAPEUTICS 
 
 As regards hygiene Robin says: The most effective 
 agent to stimulate the flow of blood in the veins is muscular 
 action, so the patient should be made to exercise as much as 
 possible, stopping if there is any pain. When not in motion, 
 he should not stand. Internally, remedies should be given to 
 stimulate the walls of the veins, as tincture of hamamelis, 
 tincture of viburnum prunifolium, tincture of centaurea, aa. 
 part. aeq. ; dose, six drops each morning. Potassium iodide 
 will prevent the sclerotic changes in the walls of the veins, 
 and should be given in doses of about a grain twice a day. 
 Locally, the limb should be wrapped every night in cloths 
 wet with Goulard's lotion, or in case this is r efused, spread 
 thinly with the following ointment: Potassium iodide, 
 dr. i; ergotin, grs. 45; ext. nux vomica, grs. 15; benzoinated 
 lard, oz. i. For the poorer classes the bandage of Velpeau 
 is better than an elastic stocking. If a stocking is used it 
 must rise well above the knee. Massage is advantageous 
 and is most effective after a bath; all hard or tender points 
 must be avoided in this rubbing, lest thrombosis and embo- 
 lism occur. 
 
 A strong solution of potassium permanganate one to 
 five percent forms one of the very best applications for 
 varicose ulcers of the leg, whether recent or of old standing. 
 Apply on a cloth (absorbent lint is the best) ; cloths should 
 be saturated every two to six hours, and the same cloth 
 can be used for several days. 
 
 An ointment of one part silver nitrate, two parts balsam 
 of Peru and 97 parts petrolatum is not strictly compatible, 
 but it forms a splendid ointment for varicose ulcers. 
 
 VARICOCELE: CURE OF 
 
 When operating for varicocele it is far better to make 
 the incision over the external ring, as in herniotomy, than 
 the usual incision in the scrotum. The cord, veins and 
 artery may be pushed out of the opening and the veins
 
 VOMER: FRACTURE OF 333 
 
 separated from the others and ligated. The operation is 
 much simpler and easier, involves less laceration and hem- 
 orrhage, and the danger of embolism, thrombosis and 
 septic infection is greatly minimized. It is wholly unneces- 
 sary to touch either the wounds in skin and tunica vagi- 
 nalis or the cord and veins finger-infection here being very 
 serious, since the wound must be closed without drainage. 
 It is best sealed with collodion, over which a protective 
 gauze-pad should be placed. 
 
 VESICULITIS 
 
 Inflammation of the seminal vesicles is generally due 
 to gonorrhea. It may result in stricture of the ejaculatory 
 ducts, and be followed by abscess, atrophy, and degenera- 
 tion of the seminal vesicles. Ulcers, venereal or otherwise, 
 forming at the mouths of these ducts and finally healing, 
 may by the formation of cicatricial tissue so nearly close 
 the lumen of the ducts as to prevent the free escape of the 
 fluid into the urethra. Treatment is symptomatic and non- 
 surgical except when abscess forms, this demanding inci- 
 sion and drainage in bad cases. 
 
 VOLVULUS 
 
 This is a form of obstruction of the bowel dependent 
 upon twisting of the gut upon itself or upon its mesenteric 
 axis in such a way as to occlude the lumen. It is found most 
 often in the sigmoid, hence in operating for intestinal ob- 
 struction the hand invariably should be first passed to the 
 sigmoid to see that volvulus is not present there. In early 
 operation lies the only hope of cure. 
 
 VOMER: FRACTURE OF 
 
 Chloroform patient and, if adult, pass little finger through 
 one nostril and plug opposite tightly with iodoform gauze 
 up to and beside fracture; withdraw finger and pack oppo-
 
 334 SURGICAL THERAPEUTICS 
 
 site side. In three days withdraw packing and wash out 
 two or three times daily with spray of thymol solution. 
 In children, hemostatic forceps may be used instead of 
 finger to push displaced fragments into proper position. 
 
 Great care should be taken to get the nasal septum 
 into exactly the mid-line, as there may be serious trouble 
 later on if this is not done. Besides, if fracture of the 
 vomer is not properly set, deformity may follow. 
 
 WARTS 
 
 Removal of. For the removal of warts as well as 
 corns salicylic acid is extremely efficacious. It is best used 
 in the following form: 
 
 Salicylic acid 5 
 
 Extract of cannabis indica i 
 
 Collodion 60 
 
 This is to be painted on the wart or corn at bedtime, 
 with a camelshair brush. In four or five days the growth 
 may be readily peeled off with a knife, leaving a tender 
 but entirely healthy skin at its site. . Or, excision may be 
 done, closing cut with collodion. 
 
 WICKERSHEMER'S FLUID 
 
 For the preservation of specimens Wickersheimer's 
 fluid is much used, a strong solution for injecting large 
 masses, a weak one for immersion. 
 Stronger Solution: 
 
 Arsenous acid 16 
 
 Sodium chloride 80 
 
 Potassium sulphate 200 
 
 Potassium carbonate 20 
 
 Potassium nitrate 25 
 
 Glycerin 4000 
 
 Wood-alcohol 750 
 
 Water 10,000
 
 WOUNDS 335 
 
 Weaker Solution: 
 
 Arsenous acid 12 
 
 Sodium chloride 60 
 
 Potassium sulphate 150 
 
 Potassium carbonate 15 
 
 Potassium nitrate 18 
 
 Glycerin 4000 
 
 Wood-alcohol 750 
 
 Water 10,000 
 
 After injection with the stronger solution the specimen 
 is to be put in the weaker and the jar closed tightly to pre- 
 vent evaporation. 
 
 WOUNDS 
 
 Balsam of Peru for "Wounds. Balsam of Peru is 
 a much-neglected agent in the treatment of wounded sur- 
 faces, especially those attended by suppuration and conse- 
 quently slow granulation, as operation for fistula in ano. 
 Experience has shown that the balsam has certain properties 
 which surpass those of any other substance at our disposal 
 for the treatment of certain wounds, especially in crushed 
 and soiled tissues. Severe inflammation never develops 
 in an infected wound (like that of a crush in railway work) 
 which has been treated with the balsam in the first twenty- 
 four hours. It is poured freely into the wound and every 
 crevice is filled. It attracts the leucocytes to the spot and 
 has a kind of mummifying effect on the dead tissues, while 
 it mechanically checks the development of microorganisms. 
 
 Dry Heat Applied to Wounds. If after gauze, 
 cotton and bandage have been applied over a wound, 
 especially an infected one, the wound is subjected to a 
 high degree of dry heat for some time, healing will be greatly 
 hastened. If the sun is shining very hot, the wounded 
 extremity or part may be placed so that the sunshine burns 
 it until every trace of moisture is gone; or it may be
 
 336 SURGICAL THERAPEUTICS 
 
 placed very near to a hot stove or furnace for some time 
 even the heat of a Bunsen burner does good but takes 
 longer. In adopting this mode of treatment no special 
 pains need be taken to clean the burned or injured surface ; 
 it should not be washed with antiseptic solutions but simply 
 cleaned with dry gauze as well as possible, the surrounding 
 surface being also cleaned without water. Dry bichloride 
 gauze (iodoform is better for this purpose) is applied in 
 several layers which of course become instantly moist- 
 ened by the blood or serum and a thin layer of cotton 
 placed over this, with bandage over all. The dry heat 
 is then applied a "hot-air apparatus" will not do, as the 
 sweating interferes with the desired desiccation and the 
 patient told to return in three or four days. Healing is by 
 "third intention" of the old writers: healing under a scab 
 artificially produced. In some cases suppuration is prac- 
 tically prevented. 
 
 For Contused Wounds. The old treatment of rub- 
 bing severe contusions with tincture of arnica, etc., has 
 been superseded by, first, a hot bath with free use of soap 
 the affected part being gently but persistently rubbed 
 with soft soap then with tincture of green soap (an alcoholic 
 solution of common soap will do), and then careful drying; 
 and, second, the application of dry antiseptic gauze held in 
 place by a bandage not too tightly applied. Next day 
 the soap-bathing may be repeated, and if there be suspi- 
 cion of infection an ointment may be used, such as 
 
 . Silver nitrate 0.3 (grs. 4 ) 
 
 Balsam of Peru 6.0 (drs. i) 
 
 Vaseline 90.0 (ozs. 3 ) 
 
 This is rubbed thoroughly into the skin and the anti- 
 septic protective applied as before. After three or four 
 days the infective process will be either under control or 
 so far advanced as to require one or more incisions. These, 
 if needed at all, should be free ones.
 
 WOUNDS 337 
 
 Suturing Wounds. The skilful surgeon knows how 
 to sew the skin without the use of needle-forceps and still 
 without handling the cut edges with his fingers. By press- 
 ing the edges together the needle may be pushed through 
 without any contamination of raw surfaces. Professor 
 Mikulicz, the distinguished German surgeon (just dead), 
 remarked: "Whoever has an opportunity of watching a 
 surgeon operate can generally judge at first glance from 
 his manner of suturing, the degree of perfection which 
 his technic has attained." For it is here that the dex- 
 terity of the surgeon most distinctly manifests itself. In 
 spite of the numerous ingenious devices for facilitating 
 the insertion of sutures, none of them surpasses the hand. 
 The surgeon who has learned to apply stitches accurately 
 and rapidly will often be able to shorten materially the 
 period of operation, and thereby greatly diminish the 
 risk of shock, and especially is this necessary in operative 
 work upon the gastrointestinal tract; by the time the 
 intraabdominal work is completed the patient is often so 
 near collapse that a life may be saved by the knowledge 
 of how to suture rapidly. Mikulicz has well pointed out 
 that in the development of the purely scientific part of 
 surgery there is danger of forgetting what might be termed 
 the mechanics of the art. 
 
 Treatment of Aseptic Wounds. It is very hard 
 to induce the average doctor not to "meddle" with a clean 
 wound. Unless he has had practical hospital training and 
 has learned to say "no" positively and firmly he cannot 
 resist his curiosity to see how healing is progressing on the 
 demand of the patient that the wound be dressed. It is 
 extremely difficult to make the average patient understand 
 (and many a doctor, too) that an aseptic wound should 
 never be exposed until the tenth to twelfth day, when the 
 stitches are to be removed; then, if no infection be found, 
 that it should not again be touched for another ten days.
 
 338 SURGICAL THERAPEUTICS 
 
 When drainage has been used, however, unless it be of 
 catgut, the dressings must be changed in about forty-eight 
 hours (the outside cotton and gauze much sooner, and 
 often if there be much seepage) ; and here lies a great dan- 
 ger. For if the greatest care be not exercised infection is 
 sure to occur, and an infection at first dressing is just as 
 bad as a dirty operation. Therefore, when an early dress- 
 ing is imperative to remove a gauze, tube or silkworm- 
 gut drain, it is necessary (a) that the hands be scrubbed 
 and sterilized as for an abdominal section, or, better, sterile 
 rubber gloves be put on ; (b) that the gauze be freshly boiled, 
 or just out of a sterilizer without having been handled; 
 (c) that some one besides the doctor remove the outside 
 dressings, down to the gauze, so that the doctor's hands or 
 gloves shall not be contaminated; (d) that as small a por- 
 tion of the wound be exposed as possible during removal 
 of the drain, and then the whole wound be quickly covered 
 by the sterile gauze at hand, and (e) that greatest care be 
 taken that nothing touch the surface near the wound. 
 Attempts at "irrigating" or "washing" are especially to 
 be condemned; it is far better to leave a little blood or 
 serum on the wound or skin than to make any great effort 
 to clean them away. 
 
 If sutures are to be tied and cut after removal of the 
 drain the scissors must be taken directly from the pan in 
 which they have just been boiled. It is well, also, to have 
 a pair of hemostats boiled in the same pan to be used in 
 pulling out the drain, catching any bleeding point, etc. 
 The patient's hands should be held so that there is no 
 possibility of an involuntary movement contaminating the 
 wound or the doctor's hands; and when possible, sterilized 
 towels should be placed over the bed and patient's clothing 
 before the deeper layers of gauze are removed, in order to 
 insure absolute sterility of the wound.
 
 WOUNDS 339 
 
 At the time for removal of stitches there may be one 
 or two little stitch-abscesses a drop of pus around the 
 stitch from the mild infection of the staphylococcus epider- 
 midis albus, all the rest of the cut being healed. Such 
 being the case all the other stitches are to be cut and 
 removed before the infected one otherwise the scissors 
 will carry the infection to the other sutures and multiple 
 abscesses follow. Besides, such a wound should not be 
 washed with hydrogen peroxide or other antiseptic, as the 
 fluid will carry the pus to the other stitch holes. The best 
 way is to take a small bit of absorbent cotton on the end 
 of a wooden tooth-pick (or a probe a detestable instrument 
 by the way) and carefully remove the pus on the surface. 
 If there seems to be a drop or two deeper down around 
 the suture the wound may be gently squeezed from side to 
 side and the pus wiped away. A little boric acid sprinkled 
 on the surface and a little plain gauze dressing for a few 
 days will be all that is required generally; but it is well 
 to make the second dressing in four or five days instead of 
 ten, as in a .perfectly healed wound. 
 
 Occasionally there will be found more than a little pus 
 around the stitches, three or four being infected and the 
 surrounding skin a little reddened and tender. Here is 
 a mild staphylococcus infection of the wound and it may 
 be serious even, though mild. It seems to be purely super- 
 ficial and all that is needed is to remove the stitches, clean 
 the surface as thoroughly as possible, and apply bichloride 
 gauze i : 2000. In two or three days the dressings should 
 be removed, and if the trouble be no better the treatment 
 appropriate for infected wounds in general must be adopted. 
 
 Treatment of Infected Wounds. Every wound 
 received accidentally is an infected one. Wounds 
 inflicted by a surgeon -should, theoretically, be aseptic, 
 free from infection; but unfortunately many are not so 
 because of (i) dirty fingers, (2) unclean instruments,
 
 340 SURGICAL THERAPEUTICS 
 
 (3) non-sterile gauze, (4) failure to drain when (a) the 
 patient is very fat, (b) there is much oozing, (c) dead 
 spaces have been left by unskilful suturing or (d) the 
 skin was not properly prepared, so that stitch-abscesses 
 have formed with subsequent general infection of the 
 wound. 
 
 The first principle of treatment of an infected wound 
 is free drainage. Therefore contaminated wounds should 
 not be closely sutured, save in the scalp where the exces- 
 sive vascularity permits healing to occur more speedily 
 than elsewhere. If closed without drainage, extensive 
 suppuration is almost certain to occur often with dis- 
 astrous results: erysipelas, septicemia, lockjaw. 
 
 i. Simple Incised Wounds. No amount of scrub- 
 bing, irrigation or application of antiseptic agents can 
 transform an infected wound into a sterile one, which 
 may be closed completely. Nevertheless efforts at attain- 
 ing "near asepsis" should be made, varying according 
 to the character and location. When the wound is a clean 
 cut, as from a razor, sharp knife, sickle or other weapon 
 that is not presumed to be swarming with bacteria, 
 though not surgically clean, the proper treatment is to 
 scrub the surrounding surfaces and the edges of the incis- 
 ion with soap and water, then wash with alcohol for a 
 half minute and finally apply gauze saturated with solu- 
 tion of bichloride of mercury, i : 2000, or phenol, i :4o; 
 finally flushing the wound itself with the sublimate or 
 phenol solution. 
 
 In the absence of these agents oil of turpentine makes 
 a fairly good antiseptic agent. 
 
 A wound thus prepared is in fairly good shape for 
 closure. Very small wounds may be closed without 
 drainage, as may also practically all cuts about the scalp 
 and face. But in every other part of the body some kind 
 of drain must be inserted. In many instances, if hemor-
 
 WOUNDS 341 
 
 rhage is completely :ontrolled, two or three strands of 
 catgut may be pushed to the depths of the wound at one 
 or two places (according to size of cut) and left projecting 
 through the skin; if there be much oozing or the cut be 
 deep it is better to put in a little strip of gauze in one or 
 two places. 
 
 For this partial closure of an infected wound silk- 
 worm gut is the ideal suture, except for wounds of the 
 face and scalp, where lo-day chromicized catgut No. i is 
 to be preferred. 
 
 When the wound has thus been cleaned, closed and 
 drained, it should be covered by several layers of gauze, 
 preferably wrung out of the sublimate or phenol solution; 
 a pad of absorbent cotton applied; and a bandage so 
 placed as not to press tightly upon the wound, as this 
 would interfere with the free drainage desired. 
 
 The closure of such wounds by collodion cannot be 
 too strongly condemned. The application of dusting 
 powders, like iodoform, bismuth, etc., is also highly objec- 
 tionable. Such wounds should be dressed on the third 
 or fourth day. The gauze removed, the wound-surface 
 is first carefully inspected, and if found free from inflam- 
 mation or much discharge, the drains are withdrawn by 
 sterile forceps and the surfaces quickly covered with 
 gauze, without handling or washing. If there be much 
 discharge the surface must be cleaned by gently wiping 
 with clean gauze or cotton and the antiseptic dressing 
 applied. If inflammation of a severe degree be deemed 
 impending some of the sutures may be cut and the wound 
 permitted to gape. In some cases the wound should be 
 inspected again in forty-eight hours. 
 
 Badly Lacerated Wounds. The method of cleaning 
 a badly lacerated wound is the same as that of the simple 
 wound except as to the management of the wounded 
 surfaces themselves.
 
 342 SURGICAL THERAPEUTICS 
 
 If there be grease and much dirt in the wound it is a 
 good plan to clean it out with gasolin, followed by 65- 
 percent alcohol and then i : 2000 sublimate solution. All 
 scraps of injured skin, muscle, etc., which are so injured 
 as to be certain to die must be trimmed away with scis- 
 sors leaving them only makes infection worse and delays 
 healing many days. 
 
 It is in these deep, lacerated wounds that antiseptics 
 like iodoform do good. A very useful preparation is 
 
 Camphor 39 parts 
 
 Phenol 21 parts 
 
 Liquid petrolatum 40 parts 
 
 This may be poured into the wound freely, the excess 
 being permitted to run into the gauze, which is applied 
 over the hole. It is especially valuable in wounds involv- 
 ing joints. 
 
 Or if the bone be injured it is usually better to fill the 
 depths with iodoform and cover with lo-percent iodo- 
 form gauze. 
 
 Sometimes the wound may be partly closed by stitches 
 patients prefer to have it so. But often it is best just 
 to pack the cavity loosely with sterile gauze. 
 
 This kind of wound should be dressed in forty-eight 
 hours, or sooner if the gauze and cotton become saturated 
 with serum and pus or if high fever develop. At the first 
 dressing it is best not to disturb the depths unless there 
 be fragments of tissue to remove or necessity for provid- 
 ing freer drainage. 
 
 At the second or third dressing wound-secretion will 
 be abundant. If putrefaction is going on there will be 
 a disagreeable "stinking" odor, and it may be neces- 
 sary to trim out dying tissue and pour in a considerable 
 quantity of liquid phenol (95-percent carbolic acid), almost 
 instantly neutralizing it by pouring in pure alcohol. Then 
 the dressings are applied as before.
 
 WOUNDS 343 
 
 After a few days the amount of discharge may be 
 very great, from a large wound, so great that the surgeon 
 desires to lessen it. For this purpose may be used 
 
 Resorcin i part 
 
 Boric acid 20 parts 
 
 Apply freely to all parts of the infected surfaces and cover 
 with gauze and cotton. 
 
 The practice of covering the dressings of these wounds 
 with rubber tissue or oiled silk cannot be too severely 
 criticized: such "protective" simply adds to the capacity 
 of the bacteria to multiply. 
 
 In some cases, when granulation seems to be delayed 
 too long, it is good practice to cover the wounded sur- 
 faces with a few layers of bichloride gauze held in place 
 by strips of adhesive plaster around the edges and place 
 the patient where the wind may blow over the sore; or in 
 winter to place the patient near a fire so that by evapora- 
 tion of the watery part of the discharge the process of 
 nature's "healing under a scab" may be simulated. 
 
 After granulation has been well begun the less the 
 surface is disturbed the better. Dressings should be 
 changed only when becoming foul; and the discharges 
 must be merely mopped away in the gentlest manner 
 possible all water, hydrogen dioxide, sublimate solu- 
 tion, etc., should be banished, save for cleaning the skin 
 contiguous to the wound; and as a rule the less that is 
 disturbed, also, the better. Plenty of clean gauze and 
 cotton, with a loose bandage, and perfect quietude, will 
 now do more than all the antiseptics made. It is hard 
 to make the average nurse leave such wounds alone 
 she invariably wants to "do something," and not seldom 
 the patient and the doctor also. "Blessed is he who 
 has learned to do nothing well." 
 
 (3) Punctured Wounds. Punctured wounds are 
 extremely dangerous, since they are always infected and
 
 344 SURGICAL THERAPEUTICS 
 
 do not by their nature permit drainage without enlarge- 
 ment by the surgeon. Penetrating wounds of the abdo- 
 men are particularly serious, and the invariable rule 
 should be to enlarge and explore them or to make a median 
 section if viscera are known to be injured. 
 
 Every penetrating wound of any great magnitude 
 should be treated by thorough cleaning of the adjacent 
 skin and wide incision to the bottom of the original injury, 
 however deep it may be. Then, unless some internal 
 organ or delicate tissue prohibit, the surface may be 
 cauterized with pure phenol, followed in half a minute 
 by pure alcohol. Before this is done, however, careful 
 search should be made for foreign bodies if the nature 
 of the accident is such that particles of clothing, dirt, 
 splinters, etc., may have been carried into the depths, 
 and the incision partially closed by sutures so introduced 
 as not to interfere with free drainage. 
 
 The only exception to this rule of treatment is in gun- 
 shot wounds of the lung; and rarely in shot-wounds of 
 the brain. 
 
 (4) Badly Contused Wounds. When large surfaces 
 have been badly bruised without apparent destruction 
 of the deep structures the best management is to clean 
 the skin with 65-percent alcohol (the virtues of the "old- 
 fashioned" tincture of arnica are ascribable to the effect 
 of its alcohol) and then cover with several layers of gauze, 
 either dry or saturated with the mixture of camphor and 
 phenol above mentioned. 
 
 When there is much pain from the bruising another 
 phenol combination may be employed, and which has the 
 following composition : 
 
 Chloral hydrate i part 
 
 Phenol i part 
 
 Mix in a mortar sterilized by boiling and keep in a 
 bottle similarly cleaned. Gauze or clean flannel may
 
 WOUNDS 345 
 
 be saturated with this and applied to the sore. It is 
 both antiseptic and anodyne. 
 
 Such a wound ought to be redressed in forty-eight 
 hours in order to see that the deeper tissues are not slough- 
 ing. As soon as it is apparent that sloughing is sure to 
 occur it is best to open the wound freely, in several places 
 if necessary, to permit early and free drainage. By this 
 measure one may often prevent a deep slough and a long, 
 tedious period of suppuration. 
 
 If in spite of the most careful antiseptic treatment 
 constitutional symptoms arise the treatment for the par- 
 ticular kind of sepsis must be instantly adopted, i. e., 
 staphylococcic, streptococcic, saprophytic, etc. 
 
 Post-Operative Complications 
 
 Postoperative Cystitis. One of the most annoy- 
 ing symptoms after operation, requiring frequent catheteri- 
 zation, is the irritation of the neck of the bladder com- 
 monly called "cystitis" though as a matter of fact the 
 trouble only rarely becomes a true inflammation of the 
 bladder. But an infection of the whole bladder may 
 occur a matter of greatest import. Hence the necessity 
 of the greatest care in catheterization. 
 
 Prevention. The nurse must be instructed to boil 
 the catheter each time before its introduction, and to 
 scrub carefully her hands before taking the instrument 
 from the boiler in doing which the fingers should touch 
 only that part which is not to go into the bladder. A 
 small, smooth, glass tube is often preferable to the rectal 
 or rubber catheter, but care must be taken that it is not 
 broken while in the urethra. Of importance equal to 
 that of sterilization of instrument and cleansing of hands 
 is that the meatus be carefully exposed and cleaned 
 immediately before introduction of the catheter. If 
 the patient will permit, 6 5 -percent alcohol should be
 
 346 SURGICAL THERAPEUTICS 
 
 used, on a little gauze or absorbent cotton, for mopping 
 the urethral orifice, but many women protest so strenu- 
 ously, because of the smarting it produces, that it cannot 
 be employed, in which case 5 -percent carbolized water 
 must be substituted. 
 
 But sometimes, in spite of all these precautions, infec- 
 tion does occur; or as a result of trauma, or of too long 
 retention, bladder irritation does arise. What then 
 is to be done? 
 
 For Acute Cases. For relief of the intense suffering 
 opiates sometimes must be given; the phosphate of codeine 
 hypodermically in doses of seven centigrams (one grain) 
 as often as needed being best, since it interferes less with 
 peristalsis and the secretions than any other alkaloid 
 of opium. Rest in bed during the acute stage is abso- 
 lutely imperative. 
 
 One of the most valuable of all drugs used for cystitis 
 is salicylate of phenol (salol). This consists of about 
 65-percent salicylic acid and 35-percent phenol, is decom- 
 posed slowly in the intestine by the pancreatic fluid into 
 its original constituents, and is eliminated through the 
 urine as urate of salicyl, though if given in large quantities 
 some seems to pass into the bladder unchanged. In 
 5-grain doses every three hours it effectually prevents 
 decomposition of the urine in the bladder and keeps it from 
 becoming alkaline. It cannot be continued very long 
 on account of producing phenoluria. Whenever the urine 
 becomes smoky, boric acid should be substituted for a 
 few days, thus: 
 
 Saturated solution of boric acid 192.0 (ozs. 6) 
 
 Tincture of hyoscyamus 64.0 (ozs. 2) 
 
 Directions: One tablespoonful every six hours. 
 
 The patient must be put on a milk (or liquid) diet for 
 some days and directed to drink as much water as pos- 
 sible.
 
 WOUNDS 347 
 
 Irrigation of the bladder, during the acute stage, 
 may be practised, a saturated solution of boric acid being 
 excellent, or one-half of one percent (i : 200) formaldehyde 
 solution may be tried in each instance leaving a little 
 of the solution in the bladder. The irrigation may be 
 made each time the catheter is used, if catheterization 
 is still continued. As a rule, however, the cystic irritation 
 appears some days after discontinuance of the use of the 
 catheter, in which case irrigation should be ordered 
 twice daily. 
 
 Chronic Cystitis. In spite of the most energetic treat- 
 ment, however, the irritation of the bladder may per- 
 sist for months. 
 
 Probably the most satisfactory remedy is lithia; it 
 may be given as an effervescent tablet in a glassful of 
 water three times a day for long periods; or the benzoate 
 of lithium may be used in doses of one or two decigrams 
 (i to 3 grains) every 4 hours during the day until the 
 stomach rebels. 
 
 If there is much annoyance from having to urinate 
 at night, 2 grams (grs. 30) of bromide of potassium with 
 a teaspoonful of tincture of hyoscyamus may be ordered 
 at bedtime. 
 
 To some patients arbutin (from uva ursa) in doses 
 of one centigram (gr. 1-6) four to six times a day brings 
 relief. Others are benefited by half-gram' doses (grs. 
 7 1-2) of salicylate of phenol four times a day. 
 
 Extreme cases demand irrigation of the bladder with 
 a saturated solution of boric acid three times a week; 
 after a few washings it is well to inject a dram of fluid 
 extract of hydrastis in two ounces of water, at the end 
 of an irrigation, leaving it in the bladder. As a rule, 
 however, the less local treatment the better in the end. 
 Patience and two quarts of water drunk daily will do 
 much toward cure.
 
 348 SURGICAL THERAPEUTICS 
 
 For internal use in chronic cystitis this formula is 
 highly praised: 
 
 Venice turpentine 5.0 (grs. 75) 
 
 Castoreum 2.0 (grs. 30) 
 
 Camphor 4.0 (grs. 60) 
 
 Calcined magnesia sufficient 
 
 Make into 40 pills. Directions: Three to six pills 
 daily. 
 
 Briefly summarized, other treatment is: Remove 
 any discoverable source or sources of irritation which 
 act through the medium of the urine; also any mechanical 
 source of vesical irritation should receive appropriate 
 treatment. 
 
 The urine should be rendered bland by the use of a 
 milk diet, the ingestion of considerable quantities of 
 water, the administration of potassium citrate if too acid, 
 or of boric acid and phenol salicylate (salol) if alka- 
 line. 
 
 Pelvic congestion should be relieved by hot vaginal 
 douches, placing the patient in the knee-chest position, 
 and the correction of constipation. 
 
 The inflamed cystic membrane may be relieved by 
 the administration of santal-wood oil, copaiba or creosote 
 by mouth, or injections of boric acid, carbolic acid, or 
 nitrate of silver in suitable strengths. 
 
 The general health should be improved by tonics, 
 and so on. 
 
 Postoperative Delirium. Some hours after an 
 operation, when the patient ought to be clear-headed, 
 delirium may appear. This is generally of mild degree 
 and may depend upon 
 
 1. The effects of the anesthetic. 
 
 2. Mild infection. 
 
 3. Prolonged abstinence from food. 
 
 4. Absorption of iodoform.
 
 WOUNDS 349 
 
 1. When postoperative delirium is due to the anes- 
 thetic it usually is present as soon as the patient awakens, 
 though rarely it is not noted until the day after the opera- 
 tion. It is more liable to follow ether than chloroform, 
 and is not at all infrequent after the use of the hyoscine- 
 morphine form of anesthesia, especially when an impure 
 scopolamine is substituted for hyoscine. It subsides in 
 a few hours, or at least as soon as the bowels have been 
 moved freely, and need not, therefore, occasion any 
 special anxiety. 
 
 2. Delirium arising from a mild infection, however, 
 is a quite serious matter, if persistent. It is most likely 
 to appear on the third or fourth day after operation, and 
 if the infection be severe instead of mild, may be regarded 
 as a most unfavorable sign, since it often is but the fore- 
 runner of the fatal termination of the sepsis. Upon its 
 appearance the' most energetic measures must be insti- 
 tuted: thorough purgation followed by sustaining reme- 
 dies, and the most careful inspection of the wound with 
 active work to render the injured surfaces inoccuous 
 by perfect drainage, cleanness of dressings, etc. 
 
 In the worst cases a low, muttering delirium replaces 
 sleep at night; in which cases one gram (grs. 15) each of 
 potassium bromide and chloral hydrate may be given 
 in 4 ounces of starch water by rectum at bedtime. This 
 will insure a good night's rest and the patient often awakens 
 quite refreshed and clear of mind. The curative treat- 
 ment is purely eliminative: purgation, diuresis and dia- 
 phoresis by proper agents, but above all, drainage. The 
 prognosis is always grave. 
 
 3. The delirium of hunger is, of course, most likely 
 to be present after operations on the stomach and intes- 
 t'nes, when on'y rectal feeding is possible for some days, 
 though it may follow an operation when there is long- 
 continued suffering and prolonged liquid diet. If not
 
 350 SURGICAL THERAPEUTICS 
 
 recognized and corrected, melancholia or even acute 
 mania may develop, the mental equipoise being lost for 
 a long time. Usually the mental disturbance disappears 
 spontaneously as soon as solid food is given in sufficient 
 quantity to supply the good red blood essential to clear 
 cerebration. It is needless, perhaps, to say that the 
 only treatment consists in stimulation and nourishment. 
 
 4. lodoform delirium was quite common when it was 
 the custom to pack all septic cavities with iodoform gauze. 
 Now most surgeons use this form of gauze only to drain 
 the pelvis (as after .vaginal hysterectomy), to fill tuber- 
 culous cavities, to drain the uterus and to tampon an 
 appendical abscess; so iodoform delirium is not so fre- 
 quently seen as it was some years ago. As soon as delir- 
 ium is noted in any case where iodoform has been employed 
 a change in the character of the dressing must be promptly 
 made, and especially if the urine show elimination of 
 iodine. The delirium will commonly subside in a fe\\ 
 hours after removal of the cause; but in rare instances 
 recovery is deferred for a long time. 
 
 Postoperative Erysipelas, Erysipelas may appear 
 in a wound (i) by reason of contamination at time of injury 
 as in stab-wounds of the belly, (2) by imperfect efforts 
 at cleaning the hands of operator or assistants, and (3) 
 by infection during a change of dressings. 
 
 It is claimed that transmission of the pathogenic 
 bacteria from one part of the body to another through 
 the circulation is possible, but it is extremely doubtful: 
 very severe erysipelas may be present on the face, yet 
 a wound of the foot heal by primary union. The cause 
 of the trouble is the introduction into the wound of the 
 streptococcus pyogenes. 
 
 The trouble may make its appearance at any time 
 from the fourth to the eleventh day. Usually the patient 
 seems to be doing well until the fourth or fifth day (or
 
 WOUNDS 351 
 
 later), when headache and general discomfort come on, 
 with coated tongue and loss of appetite; and the site of 
 injury which up to this time has been free from any great 
 pain suddenly gives a sensation of tension, smarting and 
 tenderness. A severe chill soon follows (or in extreme 
 cases may be the first symptom) with sudden rise of 
 temperature to 104 or io5F. Associated with this 
 r'se in temperature there will be nausea and often 
 vomiting, without other signs of peritoneal infection 
 (tympanites, etc.), and sometimes also a mild delirium. 
 
 If the wound be examined at the beginning of the 
 trouble as after the chill it will be found that instead 
 of being perfectly clean and free from irritation, as an 
 aseptic wound should be, there is a beginning crimson 
 blush along the wound-margins, with slight swelling. 
 A little later there may be considerable edema of the skin, 
 which often assumes a purplish hue, and extension of 
 the area of redness, which is sharply defined from the 
 unaffected skin; and still later small bullrc may form. 
 
 In the meantime the general condition remains bad: 
 high fever, great uneasiness even to delirium, diminution 
 of urine, with occasional albuminuria. If the wound is 
 not promptly opened and thoroughly drained, typical 
 streptococcic septicemia develops and death may occur, 
 from pyemia or general exhaustion. 
 
 But if the infection is quickly attended to, the symp- 
 toms gradually subside and in from six to ten days there 
 is a satisfactory decline in temperature, the tongue cleans, 
 the appetite returns and convalescence is assured. 
 
 During the favorable change the local symptoms 
 ako improve: the redness and edema gradually disap- 
 pear, suppuration is established and desquamation occurs 
 the streptococcic infection with general sepsis has been 
 superseded by a local staphylococcus infection, to be 
 followed bv healing bv granulation.
 
 352 SURGICAL THERAPEUTICS 
 
 In very bad cases, when deep cellular infection has 
 occurred, there may be sloughing of considerable tissue, 
 with consequent long-delayed healing. In the most 
 virulent type large areas of skin and deeper tissues become 
 necrotic usually followed by death. 
 
 In one case under my care the entire uterus, the vagina, 
 all of the bladder excepting a very small portion between 
 the ureters, the perineum, and the rectum well up into 
 the sigmoid, all sloughed away; yet the patient is still 
 alive. 
 
 Treatment must be both local and constitutional; 
 and both must be energetic. Here the "therapeutic 
 nihilist" loses his patients; the man who is a "doctor" 
 as well as "surgeon" saves his. 
 
 The first indication is to cut the stitches, if any, clean 
 tne wound and loosely pack it with antiseptic gauze in 
 such way as to secure freest drainage. Probably the 
 best local antiseptic is creolin: 8 grams to the liter of water 
 (or one dram to the pint); the dressings to be kept sat- 
 urated with this. 
 
 On the next day after discovery of the infection, if 
 it is seen that the disease is inclined to spread, a little 
 of a 2-percent solution of cocaine may be injected into 
 the cellular tissue a little beyond the infected area, on 
 four sides; this to be followed by injection of a 2-percent 
 solution of phenol about 15 minims to be used in each 
 of the four injection-points, but the position of the needle 
 so changed that not more than 5 drops are left in any 
 one place. This injection may be repeated next day, 
 in larger dosage, if the erysipelatous blush has extended. 
 
 Later, when itching and burning are annoying, 10- 
 percent ichthyol ointment mixed with extract of bella- 
 donna may be applied, using lanolin as the vehicle. It 
 not only allays irritation but seems to exert a salutary 
 effect on the course of the disease.
 
 WOUNDS 353 
 
 In the very bad cases, when there is deep cellular 
 inflammation in the tissues surrounding the wound, it 
 is imperative not only to cut the stitches and drain the 
 wound but also to make numerous free and deep incis- 
 ions into the edematous tissues; these permit escape of 
 the infected fluids and allow the antiseptic -solutions to 
 reach many foci of infection. Rarely the application 
 of a hot charcoal and phenol poultice or the use of the 
 cataplasma kaolini, U. S. P., for a few hours, followed 
 by the creolin solution, seems to be of advantage in these 
 phlegmonous cases. 
 
 Internally the best manner of combating the trouble 
 it to give 2 decigrams (grs. 3) of quinine sulphate with 
 5 centigrams (gr. 5-6) of codeine sulphate every 4 hours, 
 in capimle; or if vomiting is severe, codeine phosphate 
 may be given hypodermically with quinine bisulphate 
 (using 4 decigrams, or grs. 6) every six hours. Pilocar- 
 pine nitrate must be alternated with this, either by mouth 
 or hypodermically, until profuse sweating occurs. One 
 centigram (gr. 1-6) may be given by mouth every 4 hours; 
 or half this quantity subcutaneously. 
 
 After the first twenty-four hours this line of treat- 
 ment is to be discontinued and a good saline laxative 
 given. After the bowels have been moved freely, if fever 
 continues high, half a milligram (gr. 1-134) of aconitine 
 may be given every hour until the pulse becomes soft and 
 the temperature drops; and then one every 4 to 6 hours 
 as indicated. The phosphate of codeine may be con- 
 tinued as often as needed to keep the patient comfortable. 
 
 In extraordinarily severe cases a few doses of Mar- 
 morek's antistreptococcus serum may be injected, though 
 it is of doubtful value as now prepared. 
 
 When delirium is prominent and sleep disturbed 
 an enema of one gram (grs. 15) each of chloral and potas- 
 sium bromide in a cupful of starch water may be given
 
 354 SURGICAL THERAPEUTICS 
 
 at bedtime and repeated in one hour if needed. It not 
 only allays nervousness and promotes sleep but also 
 arrests vomiting, if present. 
 
 Hyoscine hydrobromide also checks the tendency (o 
 delirium: dose, one milligram (gr. 1-67) every 4 to 6 hours. 
 If the patient is very weak, stimulants are indicated, 
 used carefully; egg-nog, milk-punch, and sherry, with 
 egg, being particularly beneficial. When the heart seems 
 inclined to fail, strychnine sulphate is indicated, in doses 
 of two milligrams (gr. 1-34) hypodermically. And when 
 the urine is scanty as well (from weak heart chiefly), 
 sparteine sulphate is to be. given: dose, one decigram 
 (grs. i 1-2) every three or four hours. 
 
 If extreme weakness should come on, with tendency 
 to heart-failure, camphorated oil may be injected 10 
 drops every four to six hours. 
 
 With all of this, forced feeding is essential, especially 
 in the weak and debilitated. In many instances it is 
 advisable to use nutrient enemata as often as every six 
 hours until the patient has been carried past the critical 
 point. 
 
 During convalescence a tonic treatment is to be insti- 
 tuted, with a mild laxative at bedtime. 
 
 Postoperative Insanity. While most cases of post- 
 operative delirium terminate quite soon either in death or 
 recovery, a few linger on until a true postoperative insanity 
 is present. And occasionally an acute mania follows 
 the operation very speedily. Sometimes, too, the mental 
 depression preceding and following operation deepens 
 until the victim becomes first neurasthenic and then 
 melancholic. 
 
 4 It is a peculiar fact that the severity of the operation 
 has 'no bearing upon the development of postoperative 
 insanity (or postoperative neuroses), some of the worst 
 cases following insignificant surgical measures.
 
 WOUNDS 355 
 
 Without doubt most cases of insanity following opera- 
 tions occur in patients predisposed to this form of men- 
 tal disorder, who were upon the border-land of aliena- 
 tion prior to operation. But it is very hard to convince 
 the laity that the insanity is not due to the operative work 
 alone. In this class of cases the anesthetic is probably 
 the disturbing element. 
 
 In most instances, however, the delirium at the out- 
 set of the trouble is accompanied by a comparatively 
 slight rise of temperature, showing that the mental dis- 
 turbance is clearly due to a mild form of sepsis. 
 
 Perhaps the worst cases are those in which the delir- 
 ium waxes into an acute mania requiring removal to 
 an asylum but even then a large proportion can be 
 restored to health. 
 
 While of almost equal import, melancholia is, fortunately, 
 not so common. It is prone to be associated with sui- 
 cidal impulses; and many deaths have been recorded from 
 this cause. Hence at the very first appearance of severe 
 mental disturbance in the patient a constant attendant 
 must be provided. 
 
 The treatment does not vary from that of insanity 
 from any other cause: Good food, free elimination, 
 perfect tranquillity, isolation if indicated, and judicious 
 use of tonic remedies such as strychnine, iron, etc. An 
 exceedingly useful combination in these cases is the 
 following: 
 
 Valerianate of zinc 1.5 (grs. 20) 
 
 Valerianate of quinine 1.5 (grs. 20) 
 
 Valerianate of iron 1.5 (grs. 20) 
 
 Phosphate of codeine 0.2 (grs. 3) 
 
 Make into 20 capsules. Directions: One capsule one 
 hour after each meal, with a mild cathartic at bedtime. 
 Chloral hydrate will be found one of the best hypnotics 
 in most of these cases.
 
 356 SURGICAL THERAPEUTICS 
 
 Postoperative Jaundice. Jaundice following opera- 
 tion may be due to 
 
 1. Trouble with biliary tract. 
 
 2. Septic infection. 
 
 3. Acute yellow atrophy of liver. 
 
 4. Jaundice unrecognized before operation. 
 
 1. From the first to the third day after a perfectly 
 aseptic operation jaundice may appear, especially if there 
 has been much vomiting; a jaundice accompanied by 
 the presence of bile in the urine and other symptoms 
 of cholecystitis: "catarrhal jaundice." This may be 
 due to the anesthetic, though how chloroform or ether 
 may set up an acute cholecystitis is not explainable. 
 Possibly latent trouble in the gall-bladder may be aroused 
 by the vomiting from the anesthetic into making itself 
 recognizable; or it may be the trouble is due to simple 
 biliary retention by reflex irritation. 
 
 This variety of jaundice is of benign character, dis- 
 appearing in a few days in from six to ten days after 
 free bowel-movements have been secured. 
 
 The best treatment is a half centigram (gr. 1-6) of 
 calomel every half hour until 10 or 12 doses are taken; 
 followed by a bottle of citrate of magnesia or a good dose 
 of other saline laxative. Then a few days on sodium 
 phosphate, t. i. d., and a light diet will complete the cure. 
 But the patients who suffer from postoperative "catar- 
 rhal" jaundice should be told that there may be trouble 
 in later years from a gallstone, unsuspected before the 
 operation, which was the cause of this attack of jaun- 
 dice by being temporarily driven into the gall-duct by 
 efforts at vomiting. 
 
 2. More often, however, the yellowness of the skin is 
 dependent upon septic infection. This darkening of the 
 skin, however, does not appear later than it does in the 
 simple, catarrhal form, commonly not until the sixth to
 
 WOUNDS 357 
 
 twelfth day. It is especially likely to occur in connection 
 with septic pneumonia; and when it so appears it is to be 
 regarded as an indication of a fatal termination. In most 
 instances other signs of sepsis will be present and the 
 yellow skin be of minor importance. 
 
 The treatment is, naturally, that for septicemia in gen- 
 eral: eliminative and supportive, with absolutely perfect 
 drainage of wound if possible. 
 
 3. Acute yellow atrophy of the liver is a condition which 
 very rarely follows the prolonged use of chloroform, the 
 theory of its production being that the chloroform is re- 
 tained in the liver in large quantities, combining with the 
 lecithin and cholesterin therein present. Pregnant women, 
 past the fourth month of gestation, are more often affected 
 than any other patients. It may occur as the direct result 
 of sepsis, but cases have been reported without septic 
 infection. By some it has been believed to occur only in 
 patients suffering from syphilis; but two of my cases were 
 in non-luetic subjects. 
 
 The trouble begins with continued nausea and other 
 signs of gastric irritation, icterus making its appearance 
 on the third day or later; and by the time the skin becomes 
 quite yellow the patient is semicomatose with restlessness 
 (i. e., stupor with delirium) and even mild mania may be 
 present. Soon after this, convulsions may appear and 
 fatal coma supervene. Recovery is exceedingly rare; 
 though a few cases have been known to present the typical 
 symptoms of jaundice, marked diminution of the liver- 
 dulness, pain in region of liver, bloody vomiting, bloody 
 stools, nose-bleed, stupor, subnormal temperature, etc., and 
 yet not end in death. Jaundice may be very pronounced; 
 yet in cases of speedy dissolution there may be time for 
 only a slight change in color. The spleen is usually 
 enlarged. Hemorrhagic ecchymoses in the skin have been 
 noted.
 
 358 SURGICAL THERAPEUTICS 
 
 Treatment consists in thorough evacuation of the 
 bowels followed by large doses of the phenolsulphonates 
 (sulphocarbolates) of zinc and sodium, naphthalin or salicy- 
 late of phenol (salol) every hour or two. Nutrient enemata 
 are of importance. Diuretics are especially indicated. 
 Small doses of calomel (half a centigram, or gr. 1-6) every 
 hour are highly praised. For the restlessness gram-doses 
 of sodium bromide either by mouth or rectum, prove most 
 satisfactory. When stupor becomes marked, hypodermo- 
 clysis is to be employed: one liter (quart) of normal salt 
 solution to be injected in the buttocks or breasts twice 
 daily. 
 
 4. It is a peculiar fact that sometimes the existence of 
 jaundice is not suspected until the first incision is made. 
 Then the intense yellowness of the fat and the tendency 
 to bleed excessively shows that icterus is present, though 
 the discoloration of skin and conjunctiva had not been 
 sufficiently decided to attract attention. While this con- 
 dition of affairs is not strictly a postoperative jaundice, 
 the friends of the patient will so regard it with anxiety, 
 because the yellow color soon becomes intensified. 
 
 So far as the surgeon is concerned it means chiefly more 
 care in hemostasis. Not only is there great tendency to 
 bleed during the operation but oozing from the wound may 
 give trouble for days afterwards ; notably so when drainage 
 is practised. To check this, 4 grams (grs. 60) of calcium 
 chloride may be given by rectum three times a day until 
 the tendency to bleed is arrested. To the wound itself a 
 solution of antipyrin (1:50) may be applied freely; but 
 tight packing generally controls the oozing. 
 
 Postoperative Pain. One of the principal objections 
 against operative treatment, on the part of patients, is the 
 pain which is presumed to follow surgical work. With the 
 wide adoption of hyoscine-morphine anesthesia this will, 
 in great measure, pass away, because this form of surgical
 
 WOUNDS 359 
 
 anesthesia gives many hours of perfect comfort after the 
 patient leaves the operation-room. But when ether or 
 chloroform is used there is a period of some hours during 
 which there is often much suffering. 
 
 The tendency of most surgeons is to use morphine 
 hypodermically freely for this postoperative pain entirely 
 too freely in many instances. There are cases in which it 
 is demanded; but in abdominal surgery it is objectionable, 
 first, because it increases the tendency to vomit and second, 
 because it checks the secretions and arrests peristalsis. 
 Of course, when there is a wounded intestine (as in appen- 
 dicitis) and adhesions are desirable, morphine must be 
 given; not so much, however, to arrest pain as to prohibit 
 peristalsis. 
 
 In other cases the milder and far less objectionable 
 codeine may be used, the rule being to inject one grain 
 (Gm. 0.07) of the phosphate, and repeat it in one, two or 
 three hours, as needed, to make the patient comfortable. 
 The phosphate of codeine is preferable to the common 
 sulphate because it is more freely soluble in water than 
 any of the other. 
 
 To quiet nervousness, an enema of i gram (grs. 15) 
 each of potassium bromide and chloral hydrate is far 
 superior to any opiate. 
 
 Postoperative Pulmonary Embolism. Thrombosis 
 and embolism are more common after operations in the 
 pelvis than after operations in any other part of the body.- 
 In a resume of 7130 gynecological operations Schenck re- 
 ports 48 cases of thrombosis. The symptoms are as fol- 
 lows: The attack is characterized by precordial distress, 
 severe pain and dyspnea, associated with quickened pulse; 
 the patient has an extremely anxious expression, gasps 
 for breath with the aid of all the auxilliary respiratory 
 muscles; the face becomes cyanosed; cold, clammy sweat 
 occurs; the mind remains clear, as a rule, and death
 
 360 SURGICAL THERAPEUTICS 
 
 occurs in a few minutes, in spite of energetic stimu- 
 lation. 
 
 Postoperative Shock. Shock immediately following 
 operation depends upon: 
 
 1. Excessive hemorrhage. 
 
 2. Too much chloroform or ether. 
 
 3. Injury to important nerves. 
 
 4. Fear of death. 
 
 Theoretically there is a difference between "collapse" 
 due to loss of blood and "shock" dependent upon some 
 tremendous depressing influence upon the nerve-centers; 
 practically there is none. 
 
 The first variety is characterized by loss of pulse, by 
 gasping, by paleness and clamminess of the skin. 
 
 The second form is recognized by disturbance in respira- 
 tion, by irregular or imperceptible pulse, by coldness of 
 extremities, and by widely dilated pupil. 
 
 The third is distinguished by a peculiar lividity of the 
 face, pinched expression, quickened and shallow respira- 
 tion, and the peculiar restlessness which so often immedi- 
 ately precedes death in one who is partly conscious. 
 
 In the first form, especially, and in the second also, 
 sometimes the evidences of shock appear without warning. 
 Everything seems to be progressing well during operation, 
 when suddenly an assistant exclaims, "The patient is not 
 doing well" and operation has to be brought to a hurried 
 end in order to prevent death upon the table. 
 
 In other instances everything may have gone well at 
 operation, with considerable anxiety as to shock because 
 either of excessive loss of blood or prolonged and serious 
 operative work, and a little while after the patient has been 
 put in bed the pulse becomes thready, the respiration shal- 
 low and irregular and the extremities cold a condition 
 extremely common when the anesthetist has been too free 
 with the chloroform, and, in less degree, wkh ether. With
 
 WOUNDS 361 
 
 the adoption of the hyoscine-morphine form o surgical 
 anesthesia shock is practically eliminated, save that form 
 dependent upon excessive blood-loss; even the severance 
 of huge nerve-trunks does not change the frequency of 
 pulse or of respiration as it does under the older forms of 
 anesthesia. 
 
 Prevention. The most important prophylactic of shock, 
 then, is the selection of the anesthetic. If a child is to 
 be operated upon, if the work is to be of only short dura- 
 tion or if the subject is of advanced age, chloroform is to 
 be selected. If the operation is upon some other who is 
 not a fit subject for hyoscine-morphine injection, ether is 
 to be preferred. But whenever possible, two doses of the 
 hyoscine-morphine injection should be given, supple- 
 mented at the proper time by a little cocaine locally or the 
 inhalation of a few drops of chloroform or ether; or in 
 proper cases three full doses of the anesthetic tablet may be 
 employed, with excellent anesthesia and surprising free- 
 dom from shock, except such as may possibly result from 
 loss of blood. 
 
 The next consideration is conservation of the strength 
 of the patient. If there be extreme weakness and the 
 general condition may be improved by waiting it is better 
 to put off the operation until proper treatment may be 
 given. Entirely too many patients weakened by prolonged 
 suffering are admitted to hospitals on one day and sub- 
 jected to operation the next. Forced feeding for three or 
 four days, with injection of 2 milligrams (gr. 1-34) of 
 strychnine every six hours, will do much to ward off shock. 
 The use of an ounce of whisky a few hours before opera- 
 tion is a good thing in some cases. With the hypodermic 
 form of anesthesia, too, the patient, if extremely weak, 
 may be given a little food two hours before the first in- 
 jection, so that the weakness of fasting is not added to that 
 of disease and operation.
 
 362 SURGICAL THERAPEUTICS 
 
 Treatment. (i) The treatment of the first kind of 
 shock differs in marked degree from that appropriate to 
 the others. Here the use of hypodermoclysis is to be com- 
 mended: the injection of a liter (quart) of salt water 
 under the skin soon restores the amount of blood-serum to 
 something near the normal. If this is done while the opera- 
 tion is still being performed, great care must be exercised 
 not to soil the field of work nor to dirty the hands of the 
 surgeon which may be close by. 
 
 As soon as it is seen that shock is appearing the pa- 
 tient's head must be lowered so that profound anemia of 
 the brain may not cause death. If the shock occurs during 
 operation the Trendelenburg position must be adopted, 
 though not to an exaggerated degree; after the patient 
 has been returned to bed, the foot of the bed should be put 
 on a chair so that for several hours gravity helps to coun- 
 teract shock; and no pillow should be allowed beneath 
 the head. In extreme cases both legs may be bandaged 
 from the toes upward to the hips to force most of the blood 
 into the abdomen, chest and head; and the arms may be 
 held up by the nurses. No doubt many lives might be 
 saved by resorting to these simple measures if surgeons 
 would but take the trouble to give the necessary instruc- 
 tions and then see that they are carried out. 
 
 As soon as possible artificial heat must be applied 
 hot water-bags or bottles being placed around the body 
 and legs of the patient, and blankets applied so as to re- 
 tain the heat. 
 
 Here the hypodermic use of strychnine can do no good 
 and it may do harm. Glonoin in dose of one milligram 
 (or gr. i-ioo tablet) either under the tongue, whence it is 
 almost instantly absorbed, or hypodermically will do more 
 good than anything else medicinally. After a few minutes 
 digitalin may be injected, and still later, if the pulse flags, 
 10 minims of camphorated oil may be injected.
 
 WOUNDS 363 
 
 If the shock continues for some hours, hypodermoclysis 
 may be repeated, using the buttocks instead of the mam- 
 mary region; and rectal injection of hot salt solution may 
 be given also; or better, hot water with or without a little 
 beef extract; and in some cases hot coffee. 
 
 As the shock disappears the bandages may be removed 
 from the extremities; later the bed may be lowered to the 
 level ; and finally a pillow may be allowed. 
 
 2. The treatment of shock dependent in great measure 
 upon excess of anesthetic must of necessity differ from that 
 just described. 
 
 In the first place, unless there has been decided loss of 
 blood also, the injection of normal salt solution is quite 
 unnecessary, even if not harmful. In the second place, 
 the indications are squarely to counteract the effect on (a) 
 the respiration and (b) the circulation. 
 
 If the trouble is discovered while the patient is still on 
 the operation-table the anesthetic (if an inhalant one) 
 must be discontinued instantly and the work completed 
 as speedily as possible. If respirations cease, artificial 
 respiration must be instituted and maintained for hours, 
 if necessary many lives have been sacrificed by too early 
 discontinuance of artificial respiration. One hour is the 
 shortest excusable time for cessation of efforts to induce 
 respiration. The sphincter ani may be forcibly dilated. 
 When respiration has been restored it is best to finish the 
 operative work, if possible, since it may be days before 
 the conditions would warrant the administration of an 
 anesthetic again. But cocaine should not be injected 
 (as has been suggested by someone) since it has a ten- 
 dency to produce cerebral anemia sometimes of alarm- 
 ing degree. 
 
 The head may be depressed in this form of shock, also, 
 with advantage; and if oxygen be at hand, its inhalation 
 is excellent in effect.
 
 364 SURGICAL THERAPEUTICS 
 
 Here strychnine hypodermically is of advantage; and 
 if the face be pale, glonoin may precede it. Failing pulse, 
 after return to bed, calls for camphorated oil. 
 
 An enema of a pint of strong coffee is of decided ad- 
 vantage in awakening one too deeply asleep from any 
 anesthetic. It is notably indicated in prolonged sleep, 
 with shock, following the use of hyoscine-morphine injec- 
 tion. 
 
 Inhalation of ammonia is also of use in arousing pa- 
 tients. 
 
 Early administration of small quantities of champagne 
 (or diluted whisky) by the mouth is ^advisable. 
 
 When the heart's action continues weak for a long 
 period large doses (4 grams, or i teaspoonful) of spiritus 
 setheris compositus may be given every hour, properly 
 diluted. 
 
 3. When shock comes on immediately after extensive 
 trauma (as at the end of an amputation of the breast or 
 extirpation of a huge fibroid) without excess of anesthetic 
 or great bleeding, its character should be instantly recog- 
 nized and proper measures immediately adopted. If it 
 appears soon after the patient has been returned to bed 
 it might be mistaken for concealed hemorrhage; but the 
 prostration is different, the veins are prominent with cya- 
 nosis, there is restlessness, etc., which make the kind of 
 shock usually recognizable. 
 
 In this condition the Trendelenburg position does no 
 good. A hot water-bag placed over the heart seems to 
 be of service. Warmth to the extremities is imperative. 
 
 A hypodermic injection of atropine will send the blood 
 out of the deep structures into the capillaries. 
 
 It may be followed in a few minutes by one milligram 
 (gr. 1-67) of digitalin. 
 
 Thirty drops of a i : 1000 solution of adrenalin by mouth 
 every half hour until reaction sets in is highly recommended.
 
 WOUNDS 365 
 
 Sparteine in doses of half a decigram (gr. 3-4) may be 
 injected an hour after the digitalin is given. 
 
 An enema of salt solution, very hot, often helps to revive 
 a patient apparently near to death; or hot coffee may be 
 substituted. 
 
 4. Shock due to fear the "nervous collapse" of some 
 authors is totally eliminated by the use of the hyoscine- 
 morphine combination for surgical anesthesia. The perfect 
 tranquillity for hours following operation is in striking 
 contrast to the anxiety, nervousness and discomfort of the 
 early hours following the ordinary anesthesia by ether or 
 chloroform. 
 
 When the older form of anesthesia is employed, however, 
 shock sometimes does occur, the collapse usually making its 
 appearance several hours after completion of the work. 
 
 A small dose of codeine phosphate hypodermically 
 (half a decigram, gr. 3-4) either alone or with 2 centigrams 
 (gr. 1-32) of strychnine generally calms the patient and 
 allows the circulation to resume its normal character. 
 
 If the nervousness continue, however, an enema, con- 
 taining one and a half gram (grs. 20) of potassium bromide 
 and one decigram (gr. i 1-2) of aqueous extract of opium, 
 may be given and the patient left alone. 
 
 Postoperative Thirst. While postoperative thirst 
 is not so distressing after hyoscine-morphine anesthesia 
 as under the old ether and chloroform narcosis, it still is 
 a matter of importance, particularly in abdominal surgery 
 where it is often desirable that twenty-four hours shall 
 elapse before anything is taken into the stomach. It is 
 especially pronounced when there has been great loss of 
 blood, unless the normal amount of serum has been partly 
 restored by hypodermoclysis. 
 
 To overcome this thirst a liter (quart) of water may be 
 injected into the rectum or colon unless some special con- 
 traindication exists; preferably just after the patient 'has
 
 366 SURGICAL THERAPEUTICS 
 
 been returned to bed. When thirst becomes urgent, 
 moistening the lips and tongue frequently with a cloth 
 dipped in ice-water is a most comforting expedient; but 
 the patient should not be permitted to suck ice, since 
 holding bits of ice in the mouth above all other things 
 increases the tendency to vomit. Later a little juice of 
 lemon may be permitted it helps to appease thirst remark- 
 ably. In ordinary cases a teaspoonful of water every 
 fifteen minutes may be given after the first four or five hours ; 
 in abdominal sections after twelve hours, unless vomiting 
 occur if it does, twenty-four hours must be allowed to 
 pass before a drink is permitted. 
 
 When thirst causes great restlessness and nervousness 
 a capsule of 5 grains of chloretone with a little sip of water 
 seems to give great relief. After twenty-four hours, if 
 vomiting does not occur, cold water may be allowed freely, 
 save in the most exceptional cases, as where there is too 
 free drainage from the abdomen. 
 
 Postoperative Vomiting. Vomiting immediately 
 after an operation usually means nausea from the anesthetic. 
 Persisting for one or two days it may be but a con- 
 tinuation of this nausea, or it may depend upon oncom- 
 ing sepsis. Vomiting beginning twenty-four to forty-eight 
 hours after operation generally indicates acute sepsis. 
 
 With the use of ether, retching and distressing nausea 
 (and sometimes vomiting) may persist for many hours in 
 spite of the utmost care as to proper preparation. When 
 chloroform is employed there may be no great nausea with 
 children or with other patients if the operation be of short 
 duration; but if anesthesia is prolonged there is apt to be 
 very distressing vomiting for many hours. When it is 
 anticipated that the operative work will be long-continued, 
 one gram (grs. 15) of chloretone maybe given an hour before 
 operation, by the mouth; this greatly diminishes the ten- 
 dency to postoperative vomiting.
 
 WOUNDS 367 
 
 With the use of the hyoscine-morphine anesthesia there 
 is practically no nausea or vomiting, even though only 
 two doses are given, supplemented by a little chloroform. 
 
 In the treatment of vomiting due to the anesthetic the 
 first thing is to have the patient keep quiet; nervousness 
 and an inclination to talk unquestionably increases the 
 tendency to vomit. The next thing of importance is to 
 withhold water, so long as nausea persists nothing should 
 be taken into the stomach. Holding ice in the mouth only 
 increases nausea. 
 
 Rarely (especially after ether), when the patient is 
 retching and straining it is a good plan to give a pint or 
 more of water at once and let the patient throw off this; 
 then abstain from water for some hours. The application 
 of an ice-bag to the throat seems to diminish nausea, par- 
 ticularly with nervous women. 
 
 If the vomiting continue more than twelve hours it is 
 best to wash out the stomach by passing a stomach-tube 
 and pouring in a liter (quart) of normal salt solution; and 
 if early catharsis is desired, leaving a large dose of epsom 
 salt in the stomach before removing the tube. 
 
 If the emesis becomes alarming, four hypodermic in- 
 jections of eserine salicylate should be made, using one 
 milligram (gr. 1-67) every hour. This generally arrests 
 the vomiting, even from obstruction of the bowels, and 
 makes the patient more comfortable than will any form 
 of opiate. 
 
 Sometimes, when the vomiting is dependent principally 
 upon nervousness, a clyster containing one gram (grs. 15) 
 each of chloral hydrate and potassium bromide in starch 
 water will not only check it but give four or five hours of 
 sleep, from which the patient awakens refreshed and calm. 
 
 As soon as the ejecta change from bile-stained fluid to 
 dark, greenish brown there is acute sepsis present, and 
 proper attention must at once be directed to correction of
 
 333 SURGICAL THERAPEUTICS 
 
 the cause of trouble preceded, always, by lavage of the 
 stomach and stimulation to the highest possible degree; 
 for without energetic measures "black-vomit" means 
 death. 
 
 WRIST: GANGLION OF 
 
 A wrist ganglion is a hernial pouch of a tendon sheath 
 upon the back of the wrist. It may be treated the same 
 as ganglion elsewhere, though with even more strict anti- 
 septic precautions on accoun of the danger of infecting 
 the joint. (See ganglion). 
 
 X-RAY 
 
 X-Ray Barns. For the simple dermatitis following 
 too severe application of x-radiance, some simple, bland 
 ointment (like unguentum aquae rosae or zinc ointment) is 
 best; antiseptics, even of mild strength, irritate too much. 
 Nature usually takes care of the case in a few days or 
 weeks. But only too often pain becomes more and more 
 pronounced and a slough appears, with great prostration 
 and loss of flesh. It is well, upon the first appearance 
 of pain, to anesthetize the patient and clean the field care- 
 fully without chemical irritants; estimate the amount of 
 slough, and make a wide incision, and remove all tissue 
 until a good supply of blood is found. 
 
 If the burn appears in a favorable place ordinarily the 
 incision should be carried about five-eighths of an inch in 
 depth, giving an ordinary wound that will granulate readily 
 and will be without the terrible pain which accompany 
 most of the burns. This, of course, cannot he done readily 
 on the feet and hands, owing to a lack of tissue, so that 
 recourse must be had to the use of drugs or procedures that 
 will promote healing and allay the pain. 
 
 The use of normal salt solutions sometimes works
 
 X-RAY 369 
 
 wonders as a moist dressing. Once in a while warm boric 
 acid solution may be used with comfort. Aseptic blood 
 preparations or sterilized milk with a boric-acid preserva- 
 tive may be used, but, as a general proposition, ointments, 
 etc., are objectionable, and tend to aggravate the pain. 
 Frequent and deep cureting is indicated if the ulcer become 
 chronic and should be carried out as long as the yellowish 
 white membrane exists in the wound. 
 
 X-Ray Treatment of Cancer. One of the best 
 and most impartial observers, Williams, of Richmond, 
 after long trial and careful study reaches the conclusion 
 that for superficial malignant growths, unless they have 
 invaded adjacent bones and cartilages, the ray should 
 be used because when rightly applied the result is so 
 uniformly successful. Its application is painless, there 
 is less scar and deformity and a recurrence is in propor- 
 tion to the thoroughness of the treatment. Carcinomas 
 on the lip or connected with any mucous membrane should 
 be excised, because for some reason they seem to be espe- 
 cially resistant to the ray. 
 
 For malignant growths of the deeper structures, 
 including the breast, radical surgical procedure should 
 be recommended, always. It is but rational that the 
 surgical operation should be followed by sufficient expos- 
 ures to the ray to destroy malignant cells that have been 
 left. It is possible to destroy such cells an inch or two 
 from the surface, and the patient should have every pos- 
 sible chance to have the malignant cells completely eradi- 
 cated or destroyed. Recurrent growths of the breast 
 often yield readily to x-ray treatment because the recur- 
 rence is so near the surface. The prognosis in these cases 
 depends on whether the neighboring glands or the thoracic 
 cavity are invaded. Morton, of New York recently 
 said that his opinion of the status of the x-ray is that it
 
 370 
 
 SURGICAL THERAPEUTICS 
 
 is at a period of partial therapeutic eclipse by reason 
 of its being abused by ignorant workers. Many doctors 
 think that all they have to do is to buy a machine and 
 administer the x-ray to get cures. As to the particular 
 radiation that comes out of a tube, he believes in ,he 
 therapy of a high vacuum tube, 7 to 12 inches alternating 
 spark, because we have to deal not with deep lesions only, 
 but with intermediate lesions as well as superficial. A tube 
 that gives no yellow color whatever is the safest; it obliter- 
 ates the chance of injury to the patient and gives the 
 best therapeutic effect.
 
 INDEX 
 
 Abdomen, Actinomycosis of 29 
 
 Distension of 321 
 
 Abdominal Pain in Shock 286 
 
 Section i 
 
 Calomel after 2 
 
 Chronic Obstruction after 18 
 
 Codeine after 3 
 
 Elaterin after 3 
 
 Enemas after 4 
 
 Eserine Salicylate in 13 
 
 Fowler's Position after 6 
 
 Hypodermic Stimulation 1 1 
 
 Hypodermoclysis in 10 
 
 Lung Complications after 232 
 
 Obstruction of Bowels after 12 
 
 Opium after 4 
 
 Peritonitis following 4 
 
 Phlebitis after 1 1 
 
 Preparation for 19 
 
 Secondary 9 
 
 Shock after 10 
 
 Stomach Irritation after 8 
 
 Tumors I 
 
 Wall, Abscess of 240 
 
 Abscess 20 
 
 Alveolar 20 
 
 Anal 74 
 
 Atheromatous 90 
 
 Bursal 20 
 
 Cerebral 21 
 
 Cold 21 
 
 Colon Bacillus 23 
 
 Fecal 21 
 
 Irrigation of 26 
 
 Lid 230 
 
 Liver 231 
 
 Mammary 22 
 
 Metastatic 22 
 
 Pain of 22 
 
 Psoas 22 
 
 Retrorectal 273 
 
 Spinal 23
 
 372 INDEX 
 
 Abscess, Splenic '. 291 
 
 Stitch 23 
 
 Thecal 24 
 
 Tropical 24 
 
 Tubercular 25 
 
 A. C. E. Mixture 37 
 
 Acetonuria 26 
 
 Achondroplasty 28 
 
 Acne of Neck, Furunculous 242 
 
 Acromegalia 28 
 
 Acromion, Caries of 126 
 
 Fracture of 163 
 
 Actinomycosis 28 
 
 of Abdomen 29 
 
 of Appendix 29 
 
 Bovis 92 
 
 Adenitis 30 
 
 Adenoids 32 
 
 Adenoma 33 
 
 Adhesions in Abdominal Surgery i 
 
 Ainhum 33 
 
 Alveolar Abscess 20 
 
 Cancer 116, 124 
 
 Amputation in Diabetic Gangrene 1 74 
 
 Amputations 34 
 
 Anam Ulcer 35 
 
 Anesthesia 35 
 
 Accidents of 44 
 
 A. C. E 37 
 
 Brucine 35 
 
 Chloroform '. 38 
 
 Cocaine 37 
 
 Combined 37 
 
 Ether 37 
 
 Ethyl Chloride 38 
 
 Heart-failure 55 
 
 H-M-C 47 
 
 H-M-C, Precautions in 59 
 
 Local 35 
 
 Lumbar 63 
 
 Phenol 65 
 
 Scopolamine 47 
 
 Shock from 364 
 
 Tropacocaine 63 
 
 Vomiting after 66 
 
 Vomiting during 45 
 
 Anesthetic, Phenol as a Local 65 
 
 Aneurism 67 
 
 of Aorta 67 
 
 Calcium Chloride for 68 
 
 Iodides for , 68 
 
 Threatened Rupture of 69
 
 INDEX 373 
 
 Angioma 69 
 
 Ankle, Diseases of 70 
 
 Sprained 70 
 
 Ankylosis 219 
 
 . from Hemophilia 194 
 
 Ankylosing Synovitis 222 
 
 Anthracemia 71 
 
 Anthrax 71 
 
 Antiseptic, Bichloride as an 97 
 
 . Dusting Powder 72 
 
 Phenol as an 72 
 
 Solution, Harrington's 73 
 
 Solutions 72 
 
 Thymol as an 74 
 
 Anuria in H-M-C Anesthesia 55, 74 
 
 after Operation 244 
 
 Postoperative 74 
 
 Sparteine for 55, 75 
 
 Anus, Abscess of 75 
 
 Artificial 76 
 
 Cancer of 76 
 
 Chancre of 76 
 
 Diseases of 75 
 
 Fissure of 76, 197 
 
 Fistula of 78 
 
 Imperforate 78 
 
 Polyps of 79 
 
 Prolapse of 79 
 
 Pruritus of 79, 268 
 
 Aorta; Aneurism of 67 
 
 Inflammation of 80 
 
 Aortitis, Acute 80 
 
 Appendectomy, Treatment after 85 
 
 Appendicitis 80 
 
 Actinomycotic 29 
 
 Bowel Movement in 81 
 
 Distension in 82 
 
 Fever in 81 
 
 Hernia with 83 
 
 Nonoperative Treatment 81 
 
 Pain in 81 
 
 Peritonitis with 84 
 
 Postoperative Treatment 85 
 
 Pregnancy with 83 
 
 Treatment after 85 
 
 Tumor of 83 
 
 Vomiting in 82 
 
 Appendix, Actinomycosis of 29 
 
 in Hernia Sac 83 
 
 Apoatropine in Anesthetics 51 
 
 Arteries, Diseases of 86 
 
 Inflammation of 86
 
 374 INDEX 
 
 Arteries Wounds of 86 
 
 Arteritis 86 
 
 Arthritis 87 
 
 Deformans 87, 221 
 
 Fungosa 221 
 
 Infective 218 
 
 Uritica 221 
 
 Arthropathy 87 
 
 Ascites 89 
 
 Aspirator, Use of 90 
 
 Atheroma 90 
 
 Autosuggestion after Injury '. 91 
 
 B 
 
 Bacilli 92 
 
 Back, Sprains of 91 
 
 Ache after Operation 244 
 
 Bacteria of Surgery 92 
 
 Balanitis 95 
 
 Balanoposthitis 95 
 
 Balsam of Peru for Wounds 335 
 
 Bandage, Martin's 227 
 
 Basedow's Disease 182 
 
 Bed Sores 96 
 
 Bee Stings 96 
 
 Belladonna for ..Carbuncle 123 
 
 Bichloride Solutions 97 
 
 Bier's Treatment of Inflammation 212 
 
 Biliary Colic 171, 173 
 
 Bites 289 
 
 Black Eye 98 
 
 Leg 7 1 
 
 Vomit 98 
 
 Vomit after Operation 245 
 
 Bladder, Atony of 98 
 
 Atrophy of 146 
 
 Carcinoma of 102 
 
 Catarrh of 99 
 
 Cysts of 102 
 
 Diseases of 98 
 
 Extrophy of gg 
 
 Fibroma of 102 
 
 Hernia of 99 
 
 Inflammation of 99, 143, 345 
 
 Inversion of 99 
 
 Irritable 99 
 
 Myoma of 102 
 
 Nervous 100 
 
 Papilloma of 102 
 
 Paralysis of 100 
 
 Prolapse of 100
 
 INDEX 375 
 
 Bladder, Sacculated 101 
 
 Sarcoma of 102 
 
 Stone in 101 
 
 Treatment after Operation on 101 
 
 Tuberculosis of 102 
 
 Tumors of 102 
 
 Ulcer of 103 
 
 Wounds of 104 
 
 Bleeders 193 
 
 Bleeding 195 
 
 Internal 195 
 
 Blepharadenitis 104 
 
 Blepharitis 104 
 
 Blepharoadenoma 104 
 
 Blepharoedema 104 
 
 Blisters 105 
 
 Blood Poisoning 282 
 
 Transfusion of 105, 310 
 
 Bockhart's Blood-serum Mercury 106 
 
 Boils 106 
 
 Compared with Carbuncles 107 
 
 Prevention of 108 
 
 Bones, Caries of 125 
 
 Diseases of no 
 
 Necrosis of . 125 
 
 Bowel, Obstruction of 12, 333 
 
 Bowels, Treatment after Operation for Obstructed 213 
 
 Bow Legs no 
 
 Brain, Hernia of 203 
 
 Breast, Cancer of in 
 
 Diseases of in 
 
 Breasts, Inflammation of 1 1 1 
 
 Blight's Disease 112 
 
 Bronchocele 181 
 
 Brooke's Formula for Lupus 234 
 
 Brucine for Local Anesthesia 35 
 
 Bubo 112 
 
 Buboes, Chancroidal 131 
 
 Phenol for 112 
 
 Sympathetic 113 
 
 Treatment of 113 
 
 Welander's Treatment of 113 
 
 Bubonocele 112 
 
 Burns 114 
 
 Phenol for 1 14 
 
 X-Ray 369 
 
 Bursa, Inflammation of 115 
 
 Bursal Abscess 20 
 
 Bursitis 115
 
 376 INDEX 
 
 Calcium Chloride for Aneurism 68 
 
 Iodide for Ulcers 327 
 
 Sulphide in Suppuration 300 
 
 Calculus, Urinary 223* 
 
 Calomel in Abdominal Surgery 2 
 
 Campho-phenol Solution 342 
 
 Cancer 116, 124 
 
 and Moles , 238 
 
 Condurango for 1 18 
 
 of Anus 76 
 
 of Breast in 
 
 of Rectum 274 
 
 of Stomach 270, 296 
 
 Marsden's Paste for 1 19 
 
 Methylene Blue for 1 19 
 
 Prevention of 120 
 
 Radium Treatment of 121 
 
 X-Ray for < 368 
 
 Cancrum Oris 122 
 
 Bacillus of 93 
 
 Canker 121 
 
 Carbolic Acid Gangrene 1 74 
 
 Carbuncle 123 
 
 Belladonna for 123 
 
 Carbuncles and Boils 107 
 
 of Eyelid : 104 
 
 Treatment of : 107 
 
 Carcinoma 1 1 6, 1 24 
 
 Tuberosum 124 
 
 Caries 125 
 
 Cartilage, Disease of 126 
 
 Castor Oil, Pleasant 127 
 
 Cataplasma Kaolini 248 
 
 Cataphoresis, Cocaine by 35 
 
 Catgut, Iodized 127 
 
 Cerebral Abscess 21 
 
 Hernia 203 
 
 Cervical Ribs 128 
 
 Cessation of Respiration in Chloroform Anesthesia 44 
 
 Chancre 128 
 
 of Anus 76 
 
 Chancroids 129 
 
 Charcoal Poultices 266 
 
 Charcot's Joint 87 
 
 Chilblains 131 
 
 Chloroform Anesthesia 38 
 
 Dropper 40 
 
 Mask 42 
 
 Vomiting 45 
 
 Chlorophenol 258
 
 INDEX 377 
 
 Cholangitis 132 
 
 Cholecystitis 132 
 
 from Typhoid 135 
 
 Cholecystostomy, Treatment after 135 
 
 Choledochitis 172 
 
 Chondralgia 126 
 
 Chondritis 127 
 
 Chondrosarcoma 127 
 
 Chordee 136 
 
 Prevention of 136 
 
 Cicatrices 279 
 
 Cicatricial Deformities 137 
 
 Cionitis 137 
 
 Circumcision 137 
 
 Cirrhosis of Liver 231 
 
 of Liver, Operation for 307 
 
 Clap 185 
 
 Chronic 180 
 
 Clark's Treatment of Peritonitis 5 
 
 Cleaning Hands Quickly 191 
 
 Cocaine by Cataphoresis 35 
 
 Hypodermically 36 
 
 on Mucous Membranes : . . 37 
 
 Codeine in Abdominal Surgery 3 
 
 Cold Abscess 21 
 
 Colic, Biliary 171, 173 
 
 Gallstone 199 
 
 Hepatic 199 
 
 Colitis after Appendectomy 84 
 
 Colles's Fracture 163 
 
 Colloid Cancer 1 16, 125 
 
 Colon Bacillus 92 
 
 Bacillus Abscesses 23 
 
 Colonic Flushing before Operation 250 
 
 Colorless Iodine 215 
 
 Combined Anesthetics 37 
 
 Complications, Postoperative 345 
 
 Condurango for Cancer 1 18 
 
 Condyloma 138 
 
 Confinement, H-M-C in ._. . ,^^.,-^r 57 
 
 Conjunctivitis 138 
 
 Constipation, Mechanical 139 
 
 Contractures of Fingers 161 
 
 Convalescence 139 
 
 Iron Tonic in 139 
 
 Nux Vomica in 140 
 
 Tonic for 140 
 
 Cornea, Ulcer of 141 
 
 Corns 142 
 
 Corrosive Sublimate Solutions 97 
 
 Covering the Wound 250 
 
 Coxalgia 208
 
 378 INDEX 
 
 Coxarthrocace 208 
 
 Coxitis 208 
 
 Cradle, Surgical 143 
 
 Cresol for Antisepsis 72 
 
 Cryptorchidism 308 
 
 Cure of Gallstones 172 
 
 Cystadenoma 146 
 
 Cystalgia 145 
 
 Cystatrophia 146 
 
 Cystitis 99 
 
 Acute - 143 
 
 Chronic 144, 347 
 
 Gonorrheal 145 
 
 Postoperative 345 
 
 Cystobubonocele 146 
 
 Cystocarcinoma 146 
 
 Cystocele (Prolapse o % f Bladder) 100 
 
 Cysts 146 
 
 Adenomatous 146 
 
 Carcinomatous 146 
 
 Dermoid 146 
 
 Echinococcal 146 
 
 Muellerian 147 
 
 Retention 147 
 
 Wolffian 147 
 
 Cyanosis of Child in H-M-C Deliveries 57 
 
 D 
 
 Dactylitis 147 
 
 Dactylolysis 147 
 
 Debility, Sexual 283 
 
 Decolorized Iodine 215 
 
 Deformities, Cicatricial 137 
 
 of Spine 290 
 
 Delirium of Erysipelas 354 
 
 of Hunger 350 
 
 of lodoform 350 
 
 Postoperative 349 
 
 Depilatory 148 
 
 Dermoid Cysts 146 
 
 Diabetic Gangrene 1 74, 175 
 
 Diaphragm, Hernia through 203 
 
 Diphtheria, Germ of 93 
 
 Diplococcus Albicans Tardissimus 94 
 
 Intercellularis Meningitidis 94 
 
 Pyogenes Ureae 94 
 
 Ureae Trifoliatus 94 
 
 Displaced Kidney 224, 227 
 
 Dobell's Solution 72 
 
 Drainage of Ankle 70 
 
 Drop-Method of Ether Administration 37
 
 INDEX 379 
 
 Dropsy, Abdominal 89 
 
 Dusting Powder 72 
 
 Powder, Resorcin as 149 
 
 Powder for Ulcer of Leg 327 
 
 Dysentery, Amebic 34 
 
 Dyspepsia, Surgical Cure of 149 
 
 Dysphagia 149 
 
 E 
 
 Eberth's Bacillus 94 
 
 Echinococcus Cysts 146 
 
 Echyaditis 80 
 
 Ecchymosis 98 
 
 Ectodermic Tumors 312 
 
 Eczema . 149 
 
 Diet in 151 
 
 Surgeon's 152 
 
 Elaterin in Abdominal Surgery 3 
 
 Embolism, Pulmonary, after Operation 249 
 
 Emergency Chloroform Dropper 40 
 
 Chloroform Mask . 42 
 
 Surgery, H-M-C in 58 
 
 Emesis after Anesthesia 66 
 
 Emissions, Seminal 281 
 
 Empyema 152 
 
 Encephaloid Cancer 125 
 
 Endarteritis 86 
 
 Enema, Nutrient 153 
 
 Ox-Gall . . . : 247 
 
 Enuresis from Adenoids 32 
 
 Nocturna ' 154 
 
 Epididymitis 155 
 
 Epilepsy, Traumatic 155 
 
 Epistaxis 156 
 
 Epithelial Cancer 116 
 
 Epithelioma 125 
 
 Epityphlitis 80 
 
 Ergotin for Tympanites 322 
 
 Erysipelas 156 
 
 Convalescence from 156 
 
 Facial 157 
 
 Local Applications in 157 
 
 Postoperative 351 
 
 Treatment of Facial 158 
 
 Eserine Salicylate after Abdominal Section 13 
 
 Esophagus, Foreign Body in 158 
 
 Ether by Drop-Method 37 
 
 Ethyl Chloride Anesthesia 38 
 
 How to Give 45 
 
 Exophthalmic Goiter 182 
 
 ^Operation for 184
 
 380 INDEX 
 
 Exostoses 1 10 
 
 Exstrophy of Bladder 99 
 
 Eye Lid, Inflammation of 104 
 
 F 
 
 Facial Erysipelas 157 
 
 Treatment of 157 
 
 Fear, Shock from 365 
 
 Fecal Abscess 21 
 
 Disorders 158 
 
 Fistula 158 
 
 Impaction 159 
 
 Feet, Disorders of . 159 
 
 Sweating 159 
 
 Swollen 159 
 
 Tender 160 
 
 Felon 161 
 
 Femur, Fracture of 167 
 
 Fetal Rickets 28 
 
 Fever of Appendicitis 81 
 
 with Gallstones 170 
 
 after Operation 245 
 
 Putrefactive 278 
 
 Streptococcic 297 
 
 Surgical 161 
 
 Syphilitic 307 
 
 Fingers, Contractures of 161 
 
 Fracture of 163 
 
 Inflammation of 147 
 
 Fissure of Anus 76, 197 
 
 of Rectum 197 
 
 Fistula of Anus 78 
 
 Fecal 158 
 
 Treatment after Operation 162 
 
 Fiat-Foot 159 
 
 Floating Kidney 224, 227 
 
 Fore Arm, Fracture of 164 
 
 Fowler Position in Peritonitis 6 
 
 Fractures 163 
 
 Acromion 163 
 
 Colles's 163 
 
 Finger . . 163 
 
 Fore Arm 164 
 
 Humerus 165 
 
 Leg 165 
 
 Olecranon 166 
 
 Operative Treatment of . 168 
 
 Patella 166 
 
 Superiosteal 168 
 
 Thigh 167 
 
 Ulna 167
 
 INDEX 381 
 \ 
 
 Fractures Vomer 333 
 
 Furunculous Acne of Neck 242 
 
 G 
 
 Gall Bladder, Inflammation of 132 
 
 Gallstone Colic 199 
 
 Gallstones 169 
 
 Fever with 170 
 
 Pain of 171 
 
 Secondary Operations 170 
 
 Sodium Oleate for 173 
 
 Ganglion, Cure of 173 
 
 of Wrist 368 
 
 Gangrene 1 74 
 
 Carbolic Acid 174 
 
 Diabetic 1 74, 175 
 
 Internal Medication 175 
 
 Gastric Hemorrhage 176, 177 
 
 Lavage 8 
 
 Pain 171 
 
 Ulcer 176 
 
 Ulcer, Removal of 177 
 
 Gauze, Care of 1 78 
 
 Gelatin for Gastric Hemorrhage 176 
 
 Genital Tuberculosis 313 
 
 Genitourinary Suppuration ' 1 79 
 
 Genu Valgum no 
 
 Varum .' no 
 
 Germicides 71 
 
 Glands, Inflammation of 30 
 
 Enlarged, Iodine for 30 
 
 Inflammation of Inguinal 113 
 
 Scrofulous 31 
 
 Suppuration of 299 
 
 Gleet 179 
 
 Glonoin after Operation 246 
 
 Glossitis 181 
 
 Gloves, Rubber 255 
 
 Rubber, Substitute for 277 
 
 Goiter 181 
 
 Exophthalmic 182 
 
 Gonococcal Synovitis 302 
 
 Gonococcus 94 
 
 Gonorrhea 185 
 
 Chronic (Gleet) 179 
 
 of Joints 220 
 
 Lingering 188 
 
 Gout 87 
 
 Graves's Disease . . . 182
 
 382 INDEX 
 
 H 
 
 Hair, Removal of : . 148 
 
 Hand Cleanness, Maintenance of 250 
 
 Hands, Cleaning Quickly 191 
 
 Diseases of 189 
 
 Eczema of 190 
 
 Neuroma of 190 
 
 Phenol for 190 
 
 Phlegmon of 189 
 
 Turpentine for 191 
 
 Preparation of, for Operation 252 
 
 Harrington's Solutions 73 
 
 Head of Radius, Fracture of 164 
 
 Heart Failure in H-M-C Anesthesia 55 
 
 Heel, Painful . 259 
 
 Hematemesis 177, 192 
 
 Hemophilia 193 
 
 Joint Lesions in 194 
 
 Hemoptysis 194 
 
 Hemorrhage 195 
 
 Internal 195 
 
 Lung 194 
 
 Stomach 176, 177, 192 
 
 Urethral 328 
 
 Hemorrhoids 196 
 
 Aesculin for 197 
 
 and Fissure 197 
 
 Inflamed . 198 
 
 Injection of . . , 199 
 
 Nitric Acid for 199 
 
 Hepatic Colic 199 
 
 Hepatitis 201 
 
 Acute (Tropical) 24 
 
 Hernia, Appendicitis in 83 
 
 of Bladder 99 
 
 Cerebral 203 
 
 of Childhood 203 
 
 Diaphragmatic 203 
 
 Inguinal 204 
 
 Injection of 205 
 
 Internal 14 
 
 Reduction of 206 
 
 Strangulated 207 
 
 Herniotomy under Local Anesthesia 205 
 
 Hiccough after Operation 207, 246 
 
 Hip Joint Disease 208 
 
 Hodgkin's Disease 235 
 
 Humerus, Fracture of 165 
 
 Hunger, Delirium of * 350 
 
 Hydrocele 208 
 
 Injection~of 208
 
 INDEX 383 
 
 Hydrogen Dioxide 209 
 
 Hydrops Abdominis 89 
 
 Hypertrophy of Bones no 
 
 of Prostate 268 
 
 Hypodermoclysis in Acetonuria 27 
 
 Caution in 209 
 
 in Peritonitis 10 
 
 Hyoscine-Morphine-Cactin (H-M-C) Anesthesia 47 
 
 Advantages of 62 
 
 Anuria in 55 
 
 Disadvantages of 62 
 
 Dosage of 52 
 
 Effects of 60 
 
 Emergency Surgery, Use in 58 
 
 in Labor 57 
 
 Mottled Skin from 54 
 
 in Peritonitis 7 
 
 Precautions in Using 59 
 
 Respiratory Failure from 54 
 
 Safety of 53 
 
 Shock in 56 
 
 Statistics of 58 
 
 Hyoscyamine for Prostatorrhea 268 
 
 I 
 
 Ichthyol for Sprains 293 
 
 Icterus 218 
 
 from Sepsis 357 
 
 Ileocecal Tuberculosis 314 
 
 Ileus Paralyticus 12 
 
 Impaction, Fecal 159 
 
 Imperforate Anus .. 78 
 
 Impotence of Joints 222 
 
 Incised Wounds 340 
 
 Incontinence of Urine 209 
 
 Indigestion after Operation -. 246 
 
 Infantile Hernia 203 
 
 Syphilis 306 
 
 Infections, Local 210 
 
 Influenza, Bacillus of vrrrrrrTT 93 
 
 of Knee 228 
 
 Ingrowing Nails 212 
 
 Inguinal Glands, Inflammation of 113 
 
 Hernia of Children 204 
 
 Injection of Hemorrhoids 199 
 
 of Hernia 205 
 
 of Hydrocele 208 
 
 of Joints with lodof orm 217 
 
 Treatment of Tetanus 308 
 
 Injury, Suggestion after \ . ._ 91 
 
 Insanity afterJHead^Injury^ 27
 
 384 INDEX 
 
 Insanity Following Operation 355 
 
 and Prolapsed Kidney 225 
 
 Instruments, Sterilization of 295 
 
 Internal Hemorrhage 195 
 
 Intestinal Indigestion after Operation 246 
 
 Obstruction, Treatment after Operation 213 
 
 Thrombosis 15 
 
 Intraarticular Hemorrhage 194 
 
 Intraperitoneal Tuberculosis 315 
 
 Intussusception 214 
 
 Inversion of Bladder 99 
 
 Iodides for Aneurism 68 
 
 Iodine Catgut 127 
 
 Colorless 215 
 
 for Enlarged Glands 30 
 
 for Goiter 185 
 
 lodof orm . 216 
 
 Absorption of 216 
 
 for Cirrhosis of Liver : 232 
 
 Delirium 350 
 
 Injections 217 
 
 Wax Filling 217 
 
 Iron in Convalescence 139 
 
 Irrigation of Stomach 8 
 
 Irritation from Urine 331 
 
 J 
 
 Jaundice 218 
 
 from Infection 357 
 
 Postoperative 356 
 
 Joint,. Charcot's 87 
 
 Inflammation 221 
 
 Lesions in Hemophilia 194 
 
 Joints, Acute Infections of 218 
 
 Ankylosis of 219 
 
 Gonorrhea of 220 
 
 Hemorrhage into 194 
 
 Inflammation of 87, 300 
 
 lodoform Injections in 217 
 
 Secondary Impotence of 222 
 
 Syphilitic 87 
 
 Tuberculosis of 222 
 
 K 
 
 Kidney, Diseases of 223 
 
 Displaced 224, 227 
 
 " Insanity and Prolapse 225 
 
 Stone in the 223 
 
 \ Treatment after Operation on 224 
 
 Tuberculosis of ,,,,,,..... T . T .,.,.,.,.,.,,,,.. 226
 
 INDEX 385 
 
 Klebs-Loeffler Bacillus 93 
 
 Knee, Influenza of 228 
 
 Knives, Sterilization of 73 
 
 Koch's Bacillus 94 
 
 L 
 
 Labor, H-M-C in 57 
 
 Lacerated Wounds 342 
 
 La Grippe, Bacillus of 93 
 
 Lateral Curvature of Spine 280 
 
 Leukemia 229 
 
 Leg, Fractures of 165 
 
 Ulcers of 325 
 
 Leptothrix Puerperale 93 
 
 Lid Abscesses . N 230 
 
 Lipomatous Cancer 125 
 
 Liver, Abscess of 231 
 
 Abscess, Tropical 24 
 
 Acute Yellow Atrophy t>f 357 
 
 Cirrhosis of 231 
 
 | Diseases of 231 
 
 1 Inflammation of 201 
 
 Talma Operation on 307 
 
 Local Anesthesia 35 
 
 for Herniotomy : 205 
 
 in Rectal Surgery 271 
 
 Applications in Erysipelas . .- 157 
 
 Infections 210 
 
 Lockjaw 308 
 
 Loosened Kidney 224, 227 
 
 Lumbar Anesthesia 63 
 
 Lumbomyalgia 232 
 
 Lung Complications after Abdominal Section 232 
 
 it Diseases of 232 
 
 T Hemorrhage from 194 
 
 K Surgery of the 233 
 
 Lupus 233 
 
 Lustgarten's Bacillus 93 
 
 Lymphadenitis 234 
 
 In Tuberculous 316 
 
 Lymphosarcoma 235 
 
 M 
 
 Macewen's Chromic Catgut 236 
 
 Malignant Eczema 258 
 
 Pustule 71, 236 
 
 Mammary Abscess 22 
 
 Marmorek's Serum Useful 354 
 
 Marsden's Paste for Cancer 1 19 
 
 Martin's Bandage 237
 
 386 INDEX 
 
 Mastitis 1 1 1 
 
 Masturbation from Adenoids 32 
 
 Mediastinum, Cancer of 1 18 
 
 Mercury, Bockharts' Blood-Serum 106 
 
 Mesodermic Tumors 312 
 
 Methylene Blue for Cancer 119 
 
 Micrococcus Cereus Albus 94 
 
 Cereus Flavus 94 
 
 Gonorrheae 94 
 
 Osteomyelitidis 94 
 
 Moles and Cancer 238 
 
 Removal of 238 
 
 Mouth, Ulcers of 121, 239, 327 
 
 Mucous Membranes, Cocaine on 37 
 
 Muellerian Cysts .' 147 
 
 Murphy's Substitute for Rubber Gloves 277 
 
 Muscular Strain 232 
 
 Myositis of Abdominal Wall , 240 
 
 Myxedema, Postoperative 240 
 
 N 
 
 Nails, Ingrowing 212 
 
 Neck, Furunculosis of 242 
 
 Necrosis of Bone 125 
 
 Neisser's Micrococcus 94 
 
 Nervous Collapse 365 
 
 Neuralgia, Trifacial 312 
 
 Neurasthenia, Sexual , 284 
 
 Newly-born, Artificial Respiration in Case of 87 
 
 Nicolaier, Bacillus of -. 94 
 
 Nipple, Paget's Disease of 258 
 
 Nitric Acid for Piles 199 
 
 Nocturnal Enuresis 154 
 
 Noma 122 
 
 Bacillus of 93 
 
 Nonmalignant Stricture of Rectum 273 
 
 Nonsurgical Cure of Gallstones 172 
 
 Nose Bleed 156, 242 
 
 Nux Vpmica in Convalescence 146 
 
 O 
 
 Obstruction of Bowels 12 
 
 of Bowel from Imperfect Operation 16 
 
 of Bowel from Packing 17 
 
 Oidium Albicans 94 
 
 Ointment, Gallic Acid 169 
 
 Olecranon, Fracture of 166 
 
 Operation, Anuria after 244 
 
 Appetite after, to Increase 249 
 
 Backache after 244
 
 INDEX 387 
 
 Operation, Black Vomit after 245 
 
 Complications following 345 
 
 Delirium following 349 
 
 Erysipelas after 351 
 
 Fever after 245 
 
 Glonoin after 249 
 
 for Bright's Disease 112 
 
 for Fractures 168 
 
 for Goiter 184 
 
 Hiccough after 207, 246 
 
 Icterus from 356 
 
 Insanity after 355 
 
 Jaundice after 356 
 
 Management after 243 
 
 Pain after 229, 359 
 
 Phlebitis after 248 
 
 Position after 247 
 
 Preparation before Scrubbing 252 
 
 of Hands 252 
 
 Preparations for 250 
 
 Pulmonary Embolism after 360 
 
 Purgation before 254 
 
 Shock after 360 
 
 Solutions for 254 
 
 Table, Impromptu 243 
 
 Thirst after 366 
 
 for Streptococcic Fever 297 
 
 Vomiting after 250, 366 
 
 Operations, Imperfect 1 1 1 
 
 Opium in Abdominal Surgery 4 
 
 in Peritonitis 5 
 
 Opsonic Treatment in Surgery 256 
 
 Osteomalacia 257 
 
 Osteomyelitis 218, 257 
 
 Germ of 94 
 
 Oxide of Silver for Hematemesis 193 
 
 Ozena 258 
 
 Paget's Disease 258 
 
 P 
 
 Pain 258 
 
 after Operation 259 
 
 Chlorophenol for 258 
 
 Gastric 171 
 
 of Abscesses 22 
 
 of Appendicitis 81 
 
 of Gallstones 171, 173 
 
 of Gastric Ulcer 177 
 
 of Peritonitis 262 
 
 Postoperative 259, 359 
 
 Painful Heel 259
 
 388 INDEX 
 
 Painful Swallowing 149 
 
 Panarthritis 70 
 
 Pancreatitis 259 
 
 Pans, Sterilization of 294 
 
 Paralysis of Bladder 100 
 
 Parotitis, Syphilitic 305 
 
 Pasteur's Vibrion Septique 93 
 
 Patella, Fracture of . 1 66 
 
 Penis, Inflammation of Glans 95 
 
 Pericarditis 261 
 
 Periostitis, Chronic 262 
 
 Peritonitis 262 
 
 from Appendicitis 84 
 
 Fowler's Position for 6 
 
 H-M-C in 7 
 
 Hypodermoclysis for 10 
 
 after Operation 4 
 
 Irrigation for 9 
 
 Localized 9 
 
 Pain in 262 
 
 Suppurative 84 
 
 Tubercular 263, 317 
 
 Perityphlitis (See Appendicitis) 
 
 Peroxide of Hydrogen 209 
 
 Phagadena (Tropical) 35, 131 
 
 Phenol for Antisepsis 72 
 
 as Local Anesthetic 65 
 
 for Buboes 112 
 
 for Hands 190 
 
 Gangrene 174 
 
 Salicylate for Cystitis 145 
 
 Phlebitis 264 
 
 after Abdominal Section 1 1 
 
 following Operation 248 
 
 Phlegmon of Hands 189 
 
 Phthisis, Surgery of 319 
 
 Piles 196 
 
 Aesculin for 197 
 
 and Fissure 197 
 
 Inflamed 198 
 
 Injection of 199 
 
 Nitric Acid for 199 
 
 Treatment after Removal 198 
 
 Pilocarpine for Acetonuria 27 
 
 in Syphilis 306 
 
 Pleuritis 265 
 
 Suppurative 152 
 
 Pneumonia, Bacillus of 93 
 
 Polyps of Anus 79 
 
 Position after Operation 247 
 
 Postoperative Anuria 74, 244 
 
 Complications 345
 
 INDEX 389 
 
 Postoperative Cystitis 345 
 
 Delirium 349 
 
 Erysipelas 351 
 
 Hiccough 246 
 
 Ileus 4 
 
 i Indigestion 246 
 
 ; Insanity 355 
 
 Jaundice 356 
 
 Obstruction of Bowels 18 
 
 Pain 359 
 
 Paralysis 260 
 
 Peritonitis 4 
 
 Phlebitis n, 248 
 
 Pulmonary Embolism 360 
 
 Shock 1' 285, 360 
 
 Thirst 366 
 
 Treatment in Appendicitis 85 
 
 of Bladder Operation 101 
 
 of Fistula 162 
 
 [ of Hemorrhoids 198 
 
 of Intestinal Obstruction 213 
 
 in Kidney Lesions 224 
 
 in Stomach Operations 296 
 
 Vomiting 245, 250, 366 
 
 Pott's Disease 292 
 
 Poultices 266 
 
 Charcoal 266 
 
 Soap 266 
 
 Precautions in H-M-C Anesthesia 59 
 
 Pregnancy, Appendicitis in 83 
 
 Preparation of Hands for Operation 252 
 
 for Operation 250 
 
 of Skin for Operation 251 
 
 Preservative Fluid, Wickersheimer's 334 
 
 Prevention of Adhesions i 
 
 of Bedsores 96 
 
 of Boils 108 
 
 of Cancer 120 
 
 of Chordee 136 
 
 of Shock , , 361 
 
 Proctitis 267 
 
 Prolapse of Anus 79 
 
 of Bladder 100 
 
 of Rectum 271, 272 
 
 Prolapsed Kidney and Insanity 225 
 
 Prostate, Hypertrophy of 268 
 
 Prostatorrhea 268 
 
 Prostatectomy, Indications for 267 
 
 Protruding Piles 198 
 
 Pruritus Ani 79, 268 
 
 Treatment of 269 
 
 Psoas Abscess . 22
 
 390 INDEX 
 
 Pulmonary Embolism 360 
 
 following Operation 249 
 
 Punctured Wounds 344 
 
 Purgation before Operation , 254 
 
 Pus in Urine 271 
 
 Pustule, Malignant 71, 236 
 
 Putrefactive Fever 278 
 
 Pyemia 271, 282 
 
 Pyloric Stenosis .- 269 
 
 Pyothorax 152 
 
 Q 
 
 Quarter Evil 71 
 
 R 
 
 Radium for Cancer 121 
 
 Radius, Fracture of Head 164 
 
 Rectum, Cancer of 274 
 
 Diseases of 1 271 
 
 Examination of 271 
 
 Fissure of 197 
 
 Fistula of 78 
 
 Inflammation of 267 
 
 Local Anesthesia in Surgery of 271 
 
 Prolapse of 271, 272 
 
 Stricture of 273 
 
 Resorcin as Dusting Powder 149 
 
 Retention Cysts 147 
 
 Retrorectal Abscess 273 
 
 Respiration, Artificial 87 
 
 in Adults 88 
 
 Difficult, in Newly-born, after H-M-C 57 
 
 Respiratory Failure 54, 275 
 
 in Chloroform Narcosis 44 
 
 in H-M-C Anesthesia 54 
 
 Rheumatism 87 
 
 Ribs, Cervical 128 
 
 Rickets, Fetal 28 
 
 Ricord's Formula for Gleet 180 
 
 Rodent Ulcer 276 
 
 Rubber Gloves 255 
 
 Gloves, Murphy's Substitute 277 
 
 Rupture ". 202 
 
 of Aneurism 69 
 
 Ruptures of Childhood 203 
 
 S 
 
 Saccharomyces Albicans 94 
 
 Sapremia ". 278 
 
 Saprogenic Bacteria 94
 
 INDEX 391 
 
 Saprophytic^Bacteria 95 
 
 Sarcoma 279 
 
 Scalds 279 
 
 Scars 279 
 
 Schimmelbusch's Bacillus 93 
 
 Scirrhus 125 
 
 Scoliosis 280 
 
 Scopolamine vs. Hyoscine 47 
 
 Scrofulous Glands 31 
 
 Secondary Impotence of Joints 222 
 
 Operations for Gallstones 1 70 
 
 Seminal Emissions 281 
 
 Vesicles, Inflammation of , _ 333 
 
 Vesicles, Tuberculosis of . v 281 
 
 Senile Gangrene, bacillus of 93 
 
 Sepsis 282 
 
 Headache of 282 
 
 Septicemia 282, 297 
 
 Septicopyemia 282 
 
 Septic Jaundice 357 
 
 Sequestrum 283 
 
 Sexual Debility 283 
 
 Depressant 283 
 
 Disorders . 283 
 
 Irritation 284 
 
 Neurasthenia 284 
 
 Shock 285 
 
 Due to Fear 365 
 
 from Anesthesia 364 
 
 in H-M-C Anesthesia 56 
 
 Postoperative 285, 360 
 
 Prevention of 361 
 
 Treatment of 362 
 
 with Abdominal Pain 286 
 
 Skin, Necrosis of 96 
 
 Preparation for Operation 251 
 
 Silver Oxide for Hematemesis 193 
 
 Skull, Wounds of 287 
 
 Smegma Bacillus 94 
 
 Snake Bites 289 
 
 Soap Poultices 266 
 
 Suppositories '. 289 
 
 Sodium Oleate for Gallstones 173 
 
 Solution, Antiseptic 72 
 
 Dobell's 72 
 
 Harrington's 73 
 
 Solutions for Operation 254 
 
 Sparteine for Anuria 55 
 
 Spermatocele 290 
 
 Spina Bifida v . 290 
 
 Spinal Abscess 23 
 
 Injection for Tetanus 308
 
 392 INDEX 
 
 Spine, Curvature of 280 
 
 Deformities of 290 
 
 Splanchnoptosis 291 
 
 Spleen, Abscess of 291 
 
 Splints, Silicate of Sodium 287 
 
 Spondylitis 292 
 
 Sprains 292 
 
 of Ankle 70 
 
 of Back 91 
 
 Staphylococcal Synovitis 301 
 
 Staphylococcus Epidermidis Albus 95 
 
 Pyogenes Albus : 95 
 
 Aureus 95 
 
 Citreus 95 
 
 Statistics of H-M-C Anesthesia 58 
 
 Status Lymphaticus 292 
 
 Stenosis of Pylorus 269 
 
 Sterilization of Instruments 295 
 
 of Knives 73 
 
 of Pans 294 
 
 in Surgery .' 294 
 
 Stings of Bees 97 
 
 Stitch Abscesses 23 
 
 Stomach, Cancer of 1 18, 296 
 
 Diseases of 296 
 
 Hemorrhage from 176, 177^ 192 
 
 Irrigation of 8 
 
 Operations, Aftertreatment of 296 
 
 Ulcer of 176 
 
 Stomatitis, Ulcerative 121 
 
 Stone and Enlarged Prostate 268 
 
 in Kidney 223 
 
 Strain of Muscles 232 
 
 Strangulated Hernia 207 
 
 Streptococcal Synovitis 301 
 
 Streptococcic Fever 297 
 
 Streptococcus Pyogenes 95 
 
 Stricture 298 
 
 of Rectum 273 
 
 Strychnine for Respiratory Failure 275 
 
 in Strangulated Hernia 207 
 
 Styes 104, 299 
 
 Subperiosteal Fracture 168 
 
 Suppositories, Soap 289 
 
 Suppuration '. 20, 299 
 
 Calcium Sulphide in 300 
 
 Deep Glandular 299 
 
 Genitourinary 179 
 
 in Carbuncle 123 
 
 Soap Poultice for 266 
 
 Tubercular 25 
 
 Suppurative Peritonitis 84
 
 INDEX 393 
 
 Suppurative Synovitis 219 
 
 Surgeon's Eczema 152 
 
 Surgery, Bacteria of 92 
 
 H-M-C Anesthesia in 58 
 
 of Lung 233 
 
 of Pulmonary Tuberculosis 319 
 
 Rubber Gloves in 255 
 
 Sterilization in 294 
 
 Surgical Autosuggestion 91 
 
 Cradle 143 
 
 Cure of Dyspepsia 149 
 
 Fevers 161 
 
 Tuberculosis 312 
 
 Suture Material 302 
 
 Suturing Wounds 337 
 
 Swallowing, Painful 149 
 
 Sweating Feet 160 
 
 Swollen Feet 160 
 
 Sympathetic Buboes 113 
 
 Synovitis 219, 300 
 
 Acute 302 
 
 Ankylosing 222 
 
 Gonococcal .' 302 
 
 Plastic 222 
 
 Staphylococcic 301 
 
 Streptococcic 301 
 
 Syphilis 304 
 
 Bacillus of 93 
 
 of Childhood 306 
 
 Primary 128 
 
 Treatment by Blood-serum Mercury 106 
 
 Syphilitic Fever 307 
 
 Joints 87 
 
 Parotitis 305 
 
 Ulcers 305, 327 
 
 T 
 
 Table, Impromptu Operation 243 
 
 Talma Operation 307 
 
 Tender Feet 160 
 
 Tendon Sheath Abscess 24 
 
 Teratoid Tumors 312 
 
 Teratoma 321 
 
 Testicle, Tuberculous 318 
 
 Undescended 308 
 
 Tetanus 308 
 
 Bacillus of 94 
 
 Thecal Abscess 24 
 
 Thecitis 24 
 
 Thigh, Fracture of 167 
 
 Thiosinamin for Stricture 298
 
 394 INDEX 
 
 Thirst, Postoperative 366 
 
 Thrombosis of Intestinal Vessels 15 
 
 Thymol as an Antiseptic 74 
 
 Toe, Inflammation of 147 
 
 Nails, Ingrowing 212 
 
 Tongue Forceps Condemned- 309 
 
 Inflammation of 181 
 
 Tooth Paste 309 
 
 Torticollis 310 
 
 Tracheotomy 310 
 
 Trendelenburg's Position, a Precaution 311 
 
 Tricomi, Bacillus of 93 
 
 Transfusion of Blood 105, 310 
 
 Traumatic Autosuggestion 91 
 
 Epilepsy 155 
 
 Tropacocaine for Anesthesia 63 
 
 Tropical Abscess 24 
 
 Trypsin in Cancer 121 
 
 Tubercular Abscess 25 
 
 Peritonitis 263 
 
 Tuberculosis, Abscesses in 25 
 
 Bacilllus of 94 
 
 from Decayed Teeth 312 
 
 Genital 313 
 
 Iliocecal 314 
 
 Intraperitoneal 315 
 
 of Bladder 102 
 
 of Glands 31 
 
 of Joints 222 
 
 of Kidney i 226 
 
 of Seminal Vesicles ., 281 
 
 of Testicle 318 
 
 of Urethra 329 
 
 Pulmonary, Surgery of 319 
 
 Surgical 312 
 
 Tuberculous Adenitis 30 
 
 Glands 31 
 
 Lymphadenitis 234, 316 
 
 Peritonitis 3*7 
 
 Tumors 320 
 
 Abdominal i 
 
 Actinomycotic 28 
 
 Adenoma 33 
 
 Angioma 69 
 
 Appendical 83 
 
 Bladder 102 
 
 Condyloma - 138 
 
 Cystic 146 
 
 Dermoid 164 
 
 of Abdomen i 
 
 List of 321 
 
 Neuroma of Hand ^ I 9
 
 INDEX 395 
 
 Turpentine for Hands igi 
 
 Tympanites 321 
 
 Alum for 322 
 
 Typhlitis See Appendicitis. 
 
 Typhoid and Cholecystitis 135 
 
 Calcium Iodide for 327 
 
 Dusting Powder for 327 
 
 Gastric 176 
 
 of Bladder 103 
 
 Rodent 276 
 
 Spine 322 
 
 Syphilitic 305, 327 
 
 U 
 
 Ulcers 323 
 
 of Cornea 141 
 
 of Leg 325 
 
 of Mouth 121, 239, 327 
 
 Ulna, Fracture of 167 
 
 Undescended Testicle 308 
 
 Urachus, Cysts of 330 
 
 Tumors of 330 
 
 Uranalysis in Surgery 27 
 
 Urea, to Increase Amount of 330 
 
 Uremia 330 
 
 Urethra, Diseases of ' 328 
 
 Foreign Body in 328 
 
 Hemorrhage from 328 
 
 Inflammation of 329 
 
 Stricture of 298 
 
 Tuberculosis of 329 
 
 Urethritis 329 
 
 Chronic 180 
 
 Specific 185 
 
 Urinary Calculus 223 
 
 Urine, Incontinence of 209 
 
 Irritation from 331 
 
 Pus in 271 
 
 Uvula, Inflammation of .^nr.^^rrr^.T. 137 
 
 V 
 
 Varicocele, Cure of 332 
 
 Varicose Veins 331 
 
 Veins, Inflammation of 1 1 
 
 Varicose 331 
 
 Vesiculitis 333 
 
 Tuberculosis of 281 
 
 Vibrion Septique de Pasteur 93 
 
 Volvulus 14. 333 
 
 Vomer, Fracture of 333
 
 396 INDEX 
 
 Vomit, Black 98 
 
 Vomiting after Anesthesia 66 
 
 I after Operation 250 
 
 in Appendicitis 82 
 
 in Chloroform Anesthesia 45 
 
 in Gastric Ulcer 177 
 
 Postoperative 366 
 
 W 
 
 Wandering Kidney 224, 227 
 
 Warts, Removal of 333 
 
 Washing Out of Abscesses 26 
 
 Wax Filling, lodoform 217 
 
 Welander's Treatment of Buboes 113 
 
 Wetting the Bed 154 
 
 Whitlow 161 
 
 Wickersheimer's Fluid 334 
 
 Wiring of Aneurism 67 
 
 Wolffian Cysts 147 
 
 Wounds 335 
 
 Balsam of Peru for 335 
 
 Contused 344 
 
 Covering 250 
 
 Dry Heat for 335 
 
 Incised 340 
 
 Lacerated 342 
 
 of Arteries 86 
 
 of Bladder 103 
 
 of Skull 287 
 
 Punctured 344 
 
 Suturing of 337 
 
 Treatment of Infected 340 
 
 Wrist, Ganglion of 368 
 
 Wry Neck 310 
 
 X 
 
 X-Ray Burns 369 
 
 for Arthritis Deformans 87 
 
 for Cancer 368 
 
 for Leukemia 229 
 
 for Sprained Ankle 70 
 
 for Tubercular Glands 30 
 
 for Tuberculous Testicle 318 
 
 Yellow Atrophy of Liver 357
 
 Alkaloidal Practice 
 
 A Practice of Medicine with Special Reference to 
 the Use of the Active Principles 
 
 By William F. Waugh, M. D. and Wallace C. Abbott, M. D. 
 
 Here is a book which is years in advance of any other work on 
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