the tissues to a greater or less extent according to their density,
and the shadows cast by it can be recorded on a photographic plate, or
may be viewed with the naked eye by means of a screen composed of a
thin layer of barium platinocyanide, a substance which becomes highly
fluorescent in the presence of this radiation.

One or the other of these methods is used for the recognition of
pathologic conditions existing in the human tissues.

The fluorescent screen appears at first sight to be an easy way of
recognizing abnormalities. Its value in the examination of the thorax,
where the movements of the heart, lungs, and diaphragm have to be
observed, is undoubtedly very great; but as an accurate means of
recognizing any abnormality, it is untrustworthy. For instance, it is
possible to fail to recognize simple transverse fracture of the tibia
by its means. Its use is therefore to be deprecated in cases where
great accuracy is necessary, and it is safer and better to make use of
the more certain method, the photographic plate.

A further objection to the use of the screen is that the constant
exposure of the hands and other parts of the body of the observer may
result in an intractable, dangerous and chronic dermatitis.

By using a photographic plate the danger of dermatitis can be avoided,
since it is not necessary to expose the hands at all; and at the same
time greater accuracy is ensured and a permanent record is obtained.

Although examination by radiography is a somewhat tedious procedure in
comparison with direct observation by the fluorescent screen, yet it
is less difficult if the photographic side of this method is
approached in a proper and businesslike manner.

+Interpretation of Radiograms.+ A successful result in X-ray examination
involves a clear understanding of the meaning of the radiogram
produced. Even with the most accurate knowledge of anatomy, it is
difficult to interpret X-ray shadows; for a radiogram is only a
shadow, and the outline of the part thus demonstrated is liable to
great variation. For example, in the case of injury to bone, it is
always possible to secure strong and accurate X-ray shadows of the
part, and no error ought to be made in diagnosis, yet errors of this
kind are not uncommon.

To avoid such mistakes, it is imperative that the quality of the
radiogram secured should be the best possible. For instance, in the
examination of the ankle-joint and the bones of the foot, a radiogram
which is flat, indistinct, and altogether wanting in detail, is of no
value, while a radiogram of good quality of the same ankle-joint and
foot, is of value. The interpretation of the latter is easy, while
that of the former would be almost impossible, and certainly
inaccurate.

The usual practice in securing radiograms is to place the subject in a
position considered likely to give the best results, and then roughly,
almost at random, to place the tube in some unknown relation to the
part of the body under examination. The resulting shadow is often of
no value because it is wanting in detail and depth. One method of
avoiding this fault is to produce stereoscopic views of the part
examined.

Two views having been secured in stereoscopic register, and placed in
a stereoscope, the part can be viewed in relief. Theoretically, then,
by this means one is able to view the parts of the body opaque to the
X-rays as they would appear to the naked eye. In practice, however,
this method, though it may prove of value in exceptional
circumstances, is laborious. Moreover, though the parts may be made to
appear in relief, they are not really as one would see them with the
naked eye, but are still X-ray shadows.

A more practical method is to ensure that in all cases radiograms of
any part of the body be absolutely comparable with one another by
taking care to maintain the same relationship between the X-ray tube
and the part under examination. For example, in making an examination
of the ankle-joint, the limb is placed in a prescribed position, and
the anode of the X-ray tube, that is, the actual source of the X-ray,
is brought into accurate relationship to the tip of the internal
malleolus by a simple mechanical contrivance, the details of which
need not be dealt with here. This relationship between the tube and
the ankle can always be reproduced, and therefore the shadow of a
normal ankle-joint can always be obtained under the same conditions
for comparison with the radiogram of the suspected ankle.

In this way, not only is the surgeon able to select the view of the
part which will have the depth and detail necessary for proper
interpretation, but, the shadow being familiar, he can more easily
recognize any abnormality.

A radiogram secured under the conditions usually adopted, shows
definite and known anatomic relationship between the bones and the
X-ray tube, namely, with the anode of the tube directly opposite the
tip of the internal malleolus.

To render this method of examination more perfect, there has been
devised a system of radiography containing a definition of the
relationships between the tube and the various parts of the body which
have been found to give the most useful views, and also radiograms of
the normal appearances of each part at the ages respectively of 5, 15,
and 25 years.

By using this system the surgeon can secure a radiogram of any part of
the body, of the requisite standard in quality, while he has at hand a
normal radiogram of that part for comparison with the abnormal.

Having secured a radiogram of good quality, it is necessary for the
purpose of interpretation that it should be viewed in a suitable
light. The best for the purpose is a bright light shaded with opal in
a dark room. The negative may be viewed at its best while still wet.
Considerable loss of detail follows the taking of prints, which for
this reason may greatly detract from the value of the radiogram.

It is a mistake to suppose that X-ray examination in the diagnosis of
diseases can replace the older and well-tried clinical methods of
investigation; it is merely a useful means of acquiring knowledge
which, in conjunction with accurate clinical investigation, leads to a
more accurate diagnosis and prognosis, and is often most useful by
suggesting a more suitable line of treatment. It must be remembered
that this method of investigation has been in use only a comparatively
short time. In some diseases no definite statement is yet possible
that may not prove in the future to be misleading.

At present the therapeutic use of the X-ray is rightly falling into
the hands of the dermatologist and the medical clinician. In surgery,
outside of the conditions mentioned above, its use is limited to
lupus, keloid, epithelioma, sarcoma and carcinoma, both before and
after operation.

CHAPTER XIX

+DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING+

+DRESSINGS+

+Dressings.+ These may be either dry or wet.

_Dry dressings_ consist of gauze and bandage or of cotton and
collodion (the cocoon dressing.)

The most convenient form in which sterile gauze can be obtained is in
small squares in individual envelopes. Large packages are contaminated
with the first opening and are inconvenient.

The cocoon dressing is occlusive and should never be applied over an
infected area. It is applicable to sensitive areas for protection, and
to operated areas not liable to infection.

Protective varnishes, such as collodion, compound tincture of benzoin,
or pure ichthyol, are useful where little protection is indicated.

_Wet dressings._ Two distinct therapeutic actions may be derived from
the wet compress, depending upon whether or not an impervious covering
is employed. These actions are _antiphlogistic_ and _hyperemic_, and
these in turn may be either _antiseptic_ or _astringent_. The wet
dressing, without a covering, is cleansing and heat reducing, because
of evaporation. There should be frequent replenishment of the solution
in the treatment of any infected wound or where it is desirable to
reduce inflammation.

A wet dressing with an impervious covering is contraindicated in the
presence of pus, the warmth and moisture of such a dressing being
congenial to the growth and to the multiplication of bacteria.

It is evident, therefore, that a wet dressing with an impervious
covering can safely be employed only in conditions where the skin is
unbroken, such as sprains and bruises.

The two general therapeutic actions, aside from those of causing
hyperemia, are antiseptic and astringent. For the relief of pain and
for the reduction of inflammation, wet dressings are the most
effective form of treatment because (1) they are aseptic; (2) they
permit free drainage; (3) no new granulations are disturbed in
changing the dressing.

A great many different solutions are used and among these are:

   1. sterile water;

   2. ordinary saline solution (a teaspoonful of salt to a pint
   of water);

   3. saturated solution of boric acid (prepared by dissolving a
   teaspoonful of boric acid powder in a pint of water);

   4. Thiersch’s solution (prepared by dissolving 15 grains of
   salicylic acid and 90 grains of boric acid in a pint of
   water);

   5. Burow’s solution (a solution of aluminium acetate prepared
   by dissolving 675 grains of alum and 270 grains of lead
   acetate in a pint of water.U.S.P. formula);

   6. solution of bichloride of mercury (varying in strength from
   1 to 3000, to 1 to 10000);

   7. 2 per cent. solution of creolin or lysol;

   8. U.S.P. lead and opium wash;

   9. aqueous solution of ichthyol (varying from 5 to 50 per
   cent. according to the indications);

   10. black wash (made by dissolving 64 grains of calomel in a
   pint of lime water—this solution only being used in luetic
   cases).

   11. white wash (prepared by mixing zinc oxide, 2 drams,
   solution of subacetate of lead, 3 drams, glycerine, 4 ounces
   and lime water, 4 ounces);

   12. Dakin’s solution (hypochlorite of soda), prepared as
   follows:

   chlorinated lime (bleaching powder) 200 gm.
   sodium carbonate,dry                100 gm.
   sodium bicarbonate                   80 gm.

Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary
water and let stand over night. Dissolve the sodium carbonate and
bicarbonate in 5 litres of cold water; then pour this into the flask
and shake it vigorously for a minute and let it stand to permit the
calcium carbonate to settle. After half an hour, siphon off the clear
liquid and filter it to obtain a perfectly limpid product. The
antiseptic solution is then ready for surgical use: it contains about
0.5 gm. per cent. of sodium hypochlorite with small amounts of neutral
salts. It is practically isotonic with blood serum. Never heat the
solution, and always keep it from the light. If in an emergency it is
necessary to triturate the chlorinated lime in a mortar, do so only
with water, never with the solution of the soda salts.

This solution has been used extensively abroad in the treatment of
infections and wounds and has given splendid results.

(A proper quantity of Dakin’s solution for office purposes would be
about one-tenth of the prescription above given.)

+DUSTING POWDERS+

These are employed either as antiseptics or as astringents or for both
purposes. Their use is limited, and they are employed only where the
secretion is scanty.

Among the various powders used are: aristol, dermatol, boric acid,
orthoform, calomel, protonuclein, zinc oxide, alum, scarlet red, etc.

_Thymoliodide_, or _aristol_, is a splendid antiseptic powder and
enjoys the advantage over iodoform of being inodorous.

_Iodoform_ should only be used in tubercular conditions.

_Dermatol_, or _bismuth subgallate_, combines the astringent and
mildly antiseptic qualities of bismuth and gallic acid.

_Boric acid_ is mildly antiseptic.

_Calomel_ should only be used in syphilitic conditions.

_Zinc oxide_ and _alum_ are both astringent.

Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated
for the stimulation of granulations.

+Solutions.+ Among the various solutions used are silver nitrate, in
various strengths, zinc and copper sulphate, ichthyol, balsam of Peru,
nitric acid, sulphuric acid, trichlorand monochloracetic acid.

_Silver nitrate_ is employed for its astringent action, as are also
the _copper_ and _zinc sulphates_.

Balsam of Peru is used for its stimulating action.

The stronger acids are employed for their escharotic qualities.

“Red wash” (made up from the following formula: zinc sulphate 20
grains, compound tincture of lavender 30 minims, distilled water to
make 8 ozs.) has a powerful astringent action and promotes
cicatrization, especially when there is a tendency for the
granulations to become exuberant.

In the treatment of chilblains, a strong astringent is desirable to
constrict the diluted capillaries.

The stronger _lotio alba_ of the national formulary, containing equal
parts of the saturated solutions of zinc sulphate and potassium
sulphuret, is markedly astringent and has a drying effect upon the
skin.

+STYPTICS+

+Styptics.+ These may act either by causing clot formation in the cut
arteries, or by causing the retraction of their edges. In the latter
class are included such drugs as _hydrastine_ and _adrenaline_.

The disadvantage of using these drugs lies in the fact that secondary
hemorrhage is possible when their constrictor action is over. The
styptics causing clot formation are therefore to be recommended. They
should be non-irritating, antiseptic, and styptic, at the same time.
Such a preparation is practically unknown.

_Peroxide of hydrogen_ on a pledget of cotton, placed over the
bleeding area, may effect a clot formation.

The U.S.P. _liquor ferri subsulphatis_, better known as Monsel’s
solution, is the best and most effective styptic that we have.
Monsel’s solution, however, is not antiseptic and entrance of bacteria
into the wound is possible, unless, it is applied with a sterile
applicator or is dropped directly upon the wound from the bottle.

The U.S.P. _tincture of iodine_ in equal parts of water, applied to
the bleeding area may, besides sterilizing it, stop bleeding.

Should none of the above effect a stoppage of the bleeding, other
means must be sought. A bit of sterile gauze pressed quite firmly
against the area, should next be tried. If this fails, a wooden
applicator, prepared with Monsel’s solution may be employed. A cotton
wound applicator, unless dipped into a strongly antiseptic solution,
contains millions of bacteria from the fingers. The use of the ancient
styptic stick of alum, copper or silver is discountenanced everywhere
as uncleanly.

+SOLVENTS+

+Solvents.+ Under this heading, those substances which are known to
soften tissue will be considered.

_Sodium hydroxide_, up to a saturated strength, or an ointment of
_salicylic acid_, 5 per cent. to 50 per cent., depending upon the
density of the tissue to which it is applied, are the ones commonly
used.

These two drugs have the power to macerate dry, hard tissues.

Experience is necessary for the proper use of tissue solvents as the
length of time that they are allowed to act is of as much importance
as the strength of the solution.

Sodium hydroxide solution can be instantly neutralized with any acid
and for this reason is preferable.

+OINTMENTS+

+Ointments.+ In the list of ointments, the much vaunted virtues of
advertised compounds are usually found.

Ointments and oils are used in the treatment of wounds and ulcers,
either to stimulate granulations or to soften thick epidermis.

Ointments should never be used where there is a profuse discharge, as
eczema is a complication which very often follows such treatment.

A great many different kinds of ointments are used and among these
are:

   _Sulphur_ in 10 per cent. strength, or _ammoniated mercury_ up
   to 5 per cent., where a paraciticide is indicated.

   _Balsam of Peru_ in 10 per cent. strength for the stimulation
   of granulations; or _balsam of Peru_ and _castor oil_, equal
   parts; also _boric acid_, or _ichthyol_ for their antiseptic
   properties.

   Ten per cent. _mercurial_, for syphilitic cases.

   _Lassar’s paste_ (which consists of salicylic acid, one dram,
   starch and zinc oxide, each one ounce, and vaselin to make 4
   ounces) is used when there is an eczema present.

One of the oldest as well as one of the best applications is balsam of
Peru, which has a powerful effect in increasing the growth of
granulations, but often after this has occurred the granulations are
apt to become exuberant with little tendency to cicatrization.

The ointment which has given the best results is _scarlet red_, an
aniline dye, which is known chemically as a sodium salt of a
disulphonic acid derivative. Scarlet red (Biebrich) was originally
prepared as a dye for wool and silk, and is so named because of the
fact that it was first manufactured in the town of Biebrich. It was
first used for medicinal purposes in 1907 in an 8 per cent. strength;
because this strength was found to be too irritating, it was
alternated with a bland ointment every 24 hours. It is now used only
in strengths varying from one-half to five per cent., for the latter
has proved to be as strong as necessary. When applied to granulating
surfaces, scarlet red is sometimes absorbed in sufficient amount to
color the urine a bright red, and a number of acute cases of nephritis
have been reported from its use.

Its application to granulating surfaces causes healing, not by the
formation of scar tissue, but in every case by producing a high grade
of normal skin (this can be demonstrated by sections), which very soon
becomes freely movable on the underlying tissue. The return of
sensation in the healed area takes place from the periphery inward,
instead of upward from the underlying tissue.

Scarlet red ointment should be applied in the following manner: after
thorough cleansing of the part with tincture of green soap and water,
then ether and finally 93 per cent. alcohol, the ointment should be
spread in a thin layer over the entire surface on a piece of sterile
gauze, and over this an ordinary dry sterile dressing. If the ointment
is applied too thickly it may cause granulation tissue to break down,
and for this reason it should be spread in a thin layer upon the
granulating surface or its edges. Usually the dressing should be left
undisturbed for from 24 to 48 hours, then reapplied, as indications
warrant. The patient should invariably be informed that the dressing
will be stained red, so as to forestall unnecessary alarm, due to the
belief that a hemorrhage has occurred. He should also be apprised of
the fact that stains on the linen are hard to eradicate. In removing
the dressing, if it is adherent to the granulations, some peroxide of
hydrogen should be used to loosen it. The skin about the granulating
surface is best cleansed by benzine as this removes all traces of
scarlet red better than any other solution. The three formulas that
are recommended are the following:

                                               Strength

                                            Grains. Percent.
   Scarlet red (medicinal Biebrich)           15     1
     ungt. acidi borici q.s., ad. 3 ounces.

   Scarlet red (medicinal Biebrich)           45     3
     ungt.zinci oxidi q.s., ad. 3 ounces.

   Scarlet red (medicinal Biebrich)           75     5
     balsam Peru, 75 minims.
     Petrolati q.s., ad. 3 ounces.

The first is indicated where its use is desired over a large area and
for a long time; the second, where an astringent action is required
because the granulations are profuse; the third, where the
granulations are sluggish and require stimulation.

The ointment in a 10 per cent. strength is not recommended because it
is too irritating.

In cases of chronic leg ulcers, especially those associated with
enlarged veins, it is impossible to effect a cure until the chronic
congestion of the limb is relieved and the blood supply of the part
approaches the normal.

Often all that is necessary is a gauze, muslin or flannel bandage,
properly applied over the dressing and extending from the ankle to the
knee.

A rubber bandage when applied with moderate, even pressure, has for
its purpose the relief of congestion, but in a great many cases the
rubber has an irritating effect on the skin.

When the granulations are almost on a level with the surrounding skin,
and also when there is considerable thickening of the edges of the
ulcer, the best means of keeping up an even pressure and causing
absorption of the thickened margins, as well as of hastening the
epithelial growth, is to apply zinc oxide adhesive plaster in strips,
one-half to one inch in width. These strips should overlap to the
extent of about one-third of their width; should extend about
three-fourths of the way around the limb, and should be evenly and
smoothly applied. They should be started about one inch below the
ulcer and should run from two to three inches above it.

+BANDAGING+

+Bandaging of Leg.+ The final stage after the dressing has been put on,
consists in the application of the bandage. A bandage possesses
advantages over strapping in being less irritating to the skin; in
being more quickly put on and taken off; in being more easily removed
without disturbing the surface, and in more completely allowing the
formation of the granulations.

The bandage is also superior to a laced stocking, as the latter does
not properly embrace the foot.

The bandage material can be either gauze, muslin or flannel. The last
is considered the best because this material is thin, yielding and
elastic and yet almost any degree of compression can be exercised with
it.

In edematous swelling in general, the flannel appears very suitable,
as it is soft to the skin and accommodates itself to the greater or
less distension of the limb, arising from the increase or diminution
of the fluid. The bandage should be at least six yards long, if
required for an ordinary adult, and the width should be from two to
three inches. Every portion of the limb, from the toes to the knees,
should be equally and evenly compressed. Compression is of such
absolute importance that without it everything else will be
comparatively ineffectual. This being so, very much will depend on the
manner in which the bandage is employed.

Without practice, it is not easy to properly apply a bandage to the
leg, and probably this difficulty is the chief reason why preference
is often given to adhesive plaster, as this sticks wherever it is put.

The blistering and excoriation often produced by strapping, and the
time consumed in its application, are sufficient reasons for acquiring
skill in the art of bandaging; an art whose comforts and advantages
are appreciated by the patient.

Before using, the bandage should be rolled up very tightly, so that it
may be grasped easily and held in the hand firmly without slipping. In
putting it on, unwind only that portion which is being applied to the
limb, because if it be loose in the hand, or if a considerable piece
be unrolled at a time, it cannot be applied firmly or smoothly. The
bandage should always be carried up to the knee, even if the ulcer or
wound be seated on the lower part of the leg or on the foot itself, as
the object of its application is not merely to cover the ulcer but
also to support the vessels of the limb. If the bandage be
discontinued on any part of the leg, it is liable to become loose and
fall down.

It is desirable also that the patient should not wear a garter above
the bandage, as anything unequally tight in the course of the veins is
calculated to obstruct the free passage of the blood.

The firmness with which the bandage is put on is, of course, chiefly
for the purpose of gaining the good effects of compression on the
structures beneath, but besides, it contributes very much in making
the bandage remain in its position when applied. Encircle the limb
with it in a loose, careless manner, and it will fall down almost
immediately the patient begins to walk about. Tight bandaging is
extremely well borne if performed in a complete and methodical way,
beginning at the lowest portion of the foot around the first joints of
the toes and ending just below the knee.

The proper application of the bandage is of such great importance,
especially in the treatment of varicose ulcers of the leg, that it
should, when possible, always be done by the doctor himself. It is
difficult for the most skilled layman to put a bandage on his own leg.
The real practical difficulty lies with those patients who live at a
distance from the doctor and who can only visit him once a week or at
ten day intervals. These must be taught to dress and bandage the
limb, and generally some friend or relative will learn to superintend
the details.

The length of time which elapses before the bandage and dressings are
removed and reapplied must necessarily be determined by the
circumstances of each case. When the ulcer is very extensive and the
discharge proportionately great, it may be advisable to dress the leg
every day at the beginning of the treatment. Generally speaking, an
ulcer of the leg is disturbed too often. To take off a dressing and
put on another, even though done with the greatest care, interrupts
the healing process and the natural steps to cure. Let the dressing
remain on until some uneasiness points to the propriety of taking it
off, for the purpose of allowing the escape of the discharge. Delay
the removal of the dressings as long as possible without carrying the
forbearance too far. Avoid extremes of waiting too long or of meddling
too soon. Taking the average case, an interval of three days may in
general be safely permitted.

+Spiral Bandage of the Great Toe.+ In applying this bandage, the initial
extremity of the roller is secured by two or three turns around the
ankle and the bandage is carried obliquely across the dorsum of the
foot to the base of the toe to be covered, and next to its tip, by
oblique turns; a circular turn is then made and the toe is covered by
ascending spiral or spiral reverse turns until its base is reached,
from which point the bandage is carried obliquely across the dorsum of
the foot and finished by one or two circular turns around the ankle.
The end of the bandage may be secured by a pin or may be split into
two tails and secured by tying.

+Spica Bandage of Great Toe.+ This bandage is applied by placing the
initial extremity of the roller upon the ankle and fixing it by two
circular turns; the roller is then carried obliquely over the dorsal
surface of the foot to the distal extremity of the great toe; a
circular turn is next made and the bandage is carried upward over the
back of the great toe to the ankle, around which a circular turn
should be made; ascending figure of eight turns are then made around
the great toe and the ankle, each turn overlapping the previous one,
two-thirds, and each figure of eight turn alternating with a circular
turn around the ankle. These turns are repeated until the great toe is
completely covered with spica turns and the bandage is completed by
circular turns around the ankle.

+French Bandage of the Foot.+ In applying this bandage the initial
extremity of the roller should be fixed on the leg just above the
ankle and secured by two circular turns around the leg; the bandage
should be carried obliquely across the dorsum of the foot, to the
metatarsophalangeal articulation, at which point a circular turn
should be made around the foot; the roller should then be carried up
to the foot, covering it with two or three spiral reverse turns; after
this a figure of eight turn should be made around the ankle and
instep; this should be repeated once to cover the foot, with the
exception of the heel, and the bandage continued up the leg with
spiral reverse turns.

+Spica Bandage of the Foot.+ In applying this bandage, the initial
extremity of the roller should be fixed just above the ankle and
secured by two circular turns; the bandage should then be carried
obliquely over the dorsum of the foot to the metatarsophalangeal
articulation; a circular turn around the foot should be made at this
point and the bandage continued upward over the metatarsus by making
two or three spiral reverse turns; it should then be carried parallel
with the inner or the outer margin of the sole of the foot, according
as it is applied to the right or left foot, directly across the
posterior surface of the heel, and from this point it should be
conducted around the outer border of the toe and over the dorsum,
crossing the original turn in the median line of the foot, thus
completing the first spica turn. These spica turns should be repeated,
gradually ascending, by allowing each turn to cover three-fourths of
the preceding one, until the foot is covered, with the exception of
the posterior portion of the sole of the heel; the turns should cross
one another in the medium line of the foot and should be kept parallel
throughout their course.

+Bandages for the Foot and Leg.+ Whenever possible the patient should be
kept in bed, or, at least, in the recumbent position with the leg
elevated, but when circumstances do not permit of this the veins can be
supported in various ways. Elastic stockings are excellent but
expensive, and not durable. Bandages of rubber cloth, or woven bandages
rendered elastic by the character of the mesh, or Martin’s plain rubber
bandage may be employed. The last named is put on smoothly but not too
tightly, for in walking the leg swells, so that a uniform pressure is
established. As the rubber prevents evaporation it acts like a wet
compress, stimulating the granulations, but very often producing eczema
around the ulcer. The rubber bandage should be washed carefully at night
with soap and cold water and must be kept clean. In one patient a firm
elastic stocking of vulcanized rubber will give the greatest ease and
comfort, while in another the resulting irritation will prove
unbearable. As regards the flannel bandage it has already been described
at some length.

The essential feature of ambulatory treatment is a good dressing to
prevent congestion, and Unna’s paste is ideal for this purpose. The
paste necessary for the bandage is prepared as follows: first dissolve
four parts of the best gelatin in ten parts of water by means of a hot
water bath. While the fluid is hot add ten parts of glycerine and four
parts of powdered white oxide of zinc; stir briskly until the mixture
is cold. Another formula for the paste, and the one recommended,
consists of the following: white gelatin, 2-1/2 ounces; water, 8
ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as
above. The paste should always be melted before use by placing the
receptacle in a hot water bath or in an ordinary copper sterilizer,
such as that employed for boiling instruments. A small tin can be
used, and a piece of paste about four inches square is cut into fine
pieces and put in the can. This is placed in the sterilizer, into
which is poured water to a depth of about two inches, so that the can
is but slightly immersed. No top should be placed on the can. An
ordinary stove or gas range can be used for heating purposes. A very
important fact to remember is that no water is to be put into the can
with the paste.

The leg is next cleansed, and after the paste has been thoroughly
melted it is applied from the base of the toes to the knee, as hot as
the patient can comfortably tolerate it, by means of an ordinary small
paint-brush. Then a layer of gauze bandage (two to three inches in
width, according to the limb) is applied, then a layer of paste, and
in this manner two or three thicknesses of bandage are used, depending
on the case. In thin people, it is necessary to use only one or two
layers of bandage, whereas in stout persons several layers may be
required. After the last application of the paste, some non-absorbent
cotton is spread on the bandage, giving it the so-called “moleskin”
plaster finish. Another way of finishing the dressing is to dust some
ordinary talcum powder on the last layer of the paste, giving the
bandage the appearance of a plaster-of-Paris dressing. If there is an
ulcer, a window can be cut out, thus providing for the drainage of the
secretions. The length of time this dressing should be left on depends
on a number of conditions, especially the amount of secretion, and
whether the patient has to remain on his feet very much. Ordinarily,
the bandage can remain on for one week, but indications may be such
that it need not be removed sooner than the tenth day, and in some
instances it can be kept on for three or four weeks. To remove it, an
ordinary bandage-scissors is used to cut the dressing, and it peels
off without disturbing any of the granulations on the ulcer.

+PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION+

The value of nitrate of silver and red wash as stimulants of the
healing process has already been mentioned. They are also of value in
producing cicatrization and in promoting the covering of new
epithelium over the ulcer or wound. If the solid stick of nitrate of
silver be applied very lightly to the edges just inside the pale
bluish line of advancing epithelium, so as to produce a white film on
the surface, this slight cauterization will be found to aid in
strengthening and cornifying the new, delicate and previously
invisible epithelial cells and in preventing them from being washed
away by the discharge from the ulcer. The solid stick of nitrate of
silver is also of benefit in destroying the exuberant granulations
which project above the surface of the surrounding skin; often, by
piercing these flabby granulations in several places with the solid
stick held perpendicular to the surface, cicatrization is hastened.
After the granulations are level with the surrounding skin the
covering of the ulcer or wound with new epithelium is hastened by the
application of some smooth surface along which the epithelium can
spread. For this purpose zinc oxide plaster or some thin rubber may be
used.

In some old chronic cases, healing is prevented by the fact that the
base of the ulcer cannot contract owing to its being bound down by
fibrous scar tissue. This binding down of the base and edges of the
ulcer also tends to cut off the blood supply, and therefore in this
additional manner healing is hindered. For the relief of this
condition a number of procedures have been devised. Mattress sutures,
introduced through the normal skin beyond the edges of the ulcer and
passing beneath it, out through the skin on the other side, is one
method. By tightening these sutures, over a button or metal plate, the
ulcer can be lifted from the underlying tissues. Another method,
called “starring of the ulcer,” consists in a series of radiating
incisions through the base and edges of the ulcer, the part from which
the incisions radiate corresponding with its centre. In this and in
the following operations, in order to obtain a favorable result, it is
necessary that the incisions pass completely through the cicatrical
tissue which forms the base and edges of the ulcer into normal tissue.
“Cross-hatching” of the base of the ulcer by means of a series of
incisions at right angles to one another, and at a distance of about
one-half inch apart, is often of value in aiding the healing of a
chronic ulcer, the continued existence of which and failure to heal
having been due to its thickened, adherent base and edges.
Circumcision of a chronic ulcer consists in making a circular incision
around it through the normal skin. A modification of this method
consists in making a series of overlapping, short, curved incisions
surrounding the ulcer, instead of a single circular incision. In these
last two methods it is necessary that the incisions be made through
normal skin, and that the wounds be made to gape, if necessary, by
packing them with gauze.

When the ulcer or wound is of considerable size, it is often
impossible to secure healing even by these methods. It may for a time
appear as if it were going to heal, and a pale blue line of newly
formed epithelium may spread out from the edges, but instead of the
epithelium continuing its progress, at a subsequent dressing it will
be found to have disappeared. In these cases, as well as in those in
which the size of the ulcer would necessitate a long delay for a cure
or in which the subsequent contraction of the scar would produce
deformity, skin grafting, skin transplantation, or some form of flap
operation is indicated.

+SKIN GRAFTING TO OBTAIN A SOUND SCAR+

A very important object in the treatment of all ulcers is to obtain a
sound scar. In ulcers affecting the lower extremity in elderly people,
the scar resulting from spontaneous healing is weak and readily breaks
down if the patient does much standing or walking. The patient is
therefore frequently obliged to give up work in order to get the ulcer
re-healed, or must be content to employ means which merely prevent its
extension and relieve some of the discomfort. When the best possible
scar is desired, and when it is important to avoid marked contraction,
it is necessary to adopt some method of skin-grafting.

There are three plans by which rapid healing of an ulcer may be
brought about: Reverdin’s epidermis grafting; Thiersch’s skin
grafting, and the use of the whole thickness of the skin.

+Reverdin’s Method.+ In this procedure small thin portions of the
superficial layer of the skin are snipped off with a curved scissors.
Pieces about the size of a hemp seed are planted on the surface of the
granulations at short distances from one another. Epidermic growth
occurs from each of these little points, and the result is that
numerous small islands of epithelium form over the surface of the
ulcer. If the grafts be close enough together and the conditions be
favorable to healing, these islands soon coalesce and thus rapid
cicatrization is obtained. The grafts should not be too far apart,
because they appear to have only a limited power of reproduction.

+With a view to obtaining a sounder scar+, thicker and more extensive
portions of the skin must be taken and the grafts must be applied
close together. There are two ways of doing this: either by using the
whole thickness of the skin or by employing Thiersch’s method, in
which about half the thickness of the skin is shaved off.

The procedure where the whole thickness of the skin is employed need
not be described, partly because the results are not satisfactory and
partly because all the conditions for which it was introduced are
better fulfilled by Thiersch’s method.

Skin grafts may be taken either from the patient himself or from
another individual. When the patient is much debilitated, the
cutaneous epithelium shares in the general malnutrition and under
these circumstances a graft from a healthy subject might succeed
better than one taken from the patient.

+Thiersch’s Method.+ In employing this method the skin which is to be
used for the grafting must first be shaved and disinfected in the
usual manner, as has been previously described. The presence of hairs
on the grafts seems to interfere materially with their union.

+Preparation of the Ulcer.+ _Preliminary._ It is of no use to graft a
sore which is actually ulcerating; it must be brought into a healthy
condition, and healing must have commenced before transplantation is
likely to be successful. The best criterion that healing is taking
place is the presence, at the edges, of the dry line which indicates
recently formed epithelium. Some surgeons wait for a considerably
longer time before grafting in order to get a firm layer of
granulations, but experience shows that it may be safely resorted to
as soon as healing begins around the edge. A second essential is that
the ulcer shall be clean. If the discharges be septic, the graft,
which is, after all, merely a piece of dying tissue, will become
impregnated with decomposing pus and may rapidly become loosened, die,
and undergo decomposition. The methods of rendering the ulcer aseptic
have already been described.

_Operative._ The following is the method of procedure: after the
patient has been placed under an anesthetic, the granulations over the
whole surface of the ulcer are forcibly scrubbed off with a firm
nail-brush, or are evenly scraped away, taking care, however, to
remove only the soft layer of granulations and not to go through the
deeper one of newly formed fibrous tissue into the fat. A surface is
thus left which is smooth, highly vascular, and firm, and which
consists of the deeper layers of granulation tissue that have already
become organized into fibrous tissue. In cases of ulcer of the leg it
is also advisable to remove those portions of the edge which have
already become covered with new epithelium. If the transplantation be
limited to the parts actually unhealed, the result is disappointing as
a rule, for while the part grafted remains sound, the margin where
spontaneous healing had occurred, is apt to break down, and thus a
narrow line of ulceration appears at the edge of the ulcer.

After the layer of granulations has been removed and the newly healed
edge of the ulcer has been cut away, the bleeding must be arrested
completely before the grafts are applied. The most rapid method is to
pour a few drops of adrenalin chloride (1 to 1000) solution over the
raw surface, when the oozing ceases immediately. If adrenalin be not
at hand the following plan will be found satisfactory: any spouting
vessel is clamped and a large piece of sterilized gauze or thin sheet
rubber is applied over the raw surface of the wound; outside this,
several sponges are placed and a sterilized bandage is bound firmly
over them. If the sore be small and an assistant be available, he may
apply the pressure. Pressure is employed indirectly through the
protective in this way, because if it were made directly upon the
surface of the wound by means of the sponges, bleeding would
recommence when the latter were removed, as they stick to the raw
surface.

While the bleeding is being arrested the surgeon cuts his skin grafts
from any part of the body, as he thinks fit As a rule they are taken
from the front of the thigh, but the side of the abdomen may be
selected. The area from which the grafts are to be cut is disinfected,
and the surgeon grasps the limb from behind with his left hand in such
a way as to make the skin over the front of the thigh as tense as
possible; in doing this he pushes the soft parts well forward so as to
make the anterior aspect of the limb as flat as possible. The skin is
further put on the stretch vertically by an assistant, who pulls it
upward and downward. These precautions are important, as without them
it is almost impossible to cut a graft of even width. The razor, which
should have a very broad blade, is dipped into a boric acid solution
and is kept constantly wet with it whilst the grafts are being cut.
Unless this be done, the graft adheres to the blade and may be either
partially or wholly cut through before a sufficient length can be
obtained. The razor is made to penetrate through about half the
thickness of the skin, and then, by a lateral sawing motion, the
grafts are cut as broad and as long as possible. After a little
practice it is easy to cut them about two inches in breadth and about
four or five inches in length.

If one graft be insufficient, it is best to slide it off the razor and
leave it on the bleeding surface; in this way it is kept warm and
moist. Some surgeons put the graft into warm saline solution, and it
is said to then spread out more easily afterwards. Small skin grafts
can be cut under local anesthesia.

+Application of Grafts.+ When a sufficient number of grafts have been
cut, the bandage, sponges and protective are removed from the raw
surface of the ulcer and the grafts are applied to it if the bleeding
has stopped, as is generally the case. The raw surface usually has a
thin layer of blood-clot upon it, and this should be wiped away.

Each graft is lifted with forceps or the fingers and applied with the
cut surface downward, and then is carefully unfolded by means of two
probes and stretched evenly over the surface. The grafts should
overlap the edges of the skin and also each other, so that no part of
the raw surface is left exposed, for granulations always spring up on
the uncovered parts and are apt to destroy the grafts in their
vicinity; moreover, a thin scar is left at these points which may
break down subsequently. The graft is always thinner at its edges than
at its centre, and it is these thin edges which overlap each other or
the margin of the skin; there is no real sloughing of these
overlapping portions.

The dressing should be left on the grafted surface for about five
days; in some cases even for a week. If the wound be aseptic, no
suppuration or decomposition takes place beneath it. Before being
removed, the dressing should be thoroughly soaked with a 1 in 2500
sublimate solution, for otherwise it may stick at the edge and adhere
to the graft, which may thus be peeled off, unless great care is
taken. The parts should be gently cleansed with the same solution, and
a dressing similar to that put on originally should be employed for
about another week. At the end of that time the grafts are fairly,
firmly adherent and then a 5 per cent, boric acid ointment is the best
application.

It will be found that even at the first dressings the grafts present a
pink color and are adherent to the deeper surface, though they are
still readily detachable. In the course of about a week the old
cuticle peels off, but no raw surface is left. Later on, there is a
great tendency to the formation of new epithelium, cornification, and
drying-up, and it is to avoid the latter condition that ointments are
so useful; in fact, until the scar is absolutely sound, it is well to
keep the surface covered with some greasy application, the best being
the 5 per cent, boric acid ointment.

For many months the grafted surface is likely to scale or crack, and
this might prove a starting-point for the occurrence of sepsis which
would cause the newly grafted area to slough. It is important to keep
the scar as supple as possible, and therefore it should be constantly
anointed with cold cream, vaselin, or lanolin. Grafted surfaces upon
the face, however, do not manifest this tendency for any length of
time.

+Time Required for Cure.+ It is important to know when the patient may
be allowed to walk about after an ulcer of the leg has been
skin-grafted. If he begins too soon, the grafts will almost certainly
become detached. That this will be so is evident from a consideration
of the mode by which the adhesion of the grafts takes place. At first
they adhere to the surface of the sore, simply by means of the effused
and coagulated length. Cells rapidly spread into this length and in
the course of two or three days the space between the grafts and the
raw surfaces is occupied by a mass of young cells. In this tissue, new
blood vessels develop and penetrate into the graft, whilst, at the
same time, the cells of the latter grow and assist in the development
of the young tissue and of the blood vessels. Thus the graft becomes
vascularized; but for a considerable time the tissue between it and
the surface of the sore contains many young blood vessels with
delicate walls, and therefore, if the patient stands erect and allows
the pressure of the column of blood to fall on these vessels, they
rupture, and bleeding occurs beneath the graft and leads to its
detachment.

It requires a long time before the graft is firmly incorporated with
the tissue beneath by the development of elastic fibres; indeed, it
may be reckoned that this union is not complete until from three to
six months have elapsed. The graft will, in all probability, be
destroyed if the patient walks about within three months of the
transplantation. Hence, unless that time can be devoted to the
treatment, it is not worth employing skin-grafting for ulcer of the
lower limbs. By this, however, it is not implied that it is necessary
to keep the patient in bed for the entire time, but merely that the
foot must not be allowed to hang down, nor must any weight be borne
upon it.

At the end of about six weeks the patient may be allowed to get up and
lie on a sofa or sit with the leg on another chair, but the limb must
not be permitted to hang down. After about three months he may be
allowed to get about, but in order to prevent the detachment of the
grafts, he should be fitted with a knee-rest and peg on which he
walks, the leg projecting out behind him. If possible he should not
put his foot to the ground until six months have elapsed. In cases of
sores on other parts of the body, when the erect posture does not
cause congestion of the part, the patient may be allowed to walk about
after the first three weeks.

+Results.+ The scar which results after skin-grafting performed in this
manner is of a satisfactory character, and ulcers which have been
intractable for years may be closed satisfactorily by this means. In
order to obtain anything in the nature of a permanent cure, however,
the prescribed period of rest must be adhered to rigidly.

CHAPTER XX

+LOCAL ANESTHESIA+

+History.+ From Corning we learn that the ancient Assyrians alleviated
and even entirely prevented the pain incident to circumcision by
compressing the veins in the neck. Unconsciousness was probably
induced in this way together with pressure on the carotids.

In India, centuries ago, the effects of opium and of Indian hemp were
known and employed, and the ancient Egyptians were also conversant
with the soporific effects of many drugs. We learn, from the same
authority, much which he gathered from literature about the history of
local anesthesia, and it is from Corning’s well-known book on local
anesthesia that most of this history is quoted.

In Peru, the Spanish conquerors learned that the coca loaf was held in
high esteem by the natives, inasmuch as they observed that it was
chewed by the high priests and nobility only, the vulgar being denied
this privilege except as a reward of great merit or of distinguished
valor. The leaf was regarded with awe and superstition and was
supposed to possess supernatural powers. After the fall of the Incas,
the Spanish not only permitted but encouraged the general use of the
leaf in order to obtain more work from the natives, a result which the
drug seemed to effect. It was also a source of great revenue to them
and was sold at exorbitant profit to the natives who became enslaved
to its effects but were able to endure great hardship while under its
influence.

Chemists throughout the world, recognizing the potent action of the
coca leaf, were soon engaged in the effort of extracting its active
principle.

In 1859, after many had tried and failed, cocaine was evolved from
crude extractives. Authorities differ as to whether it was Mann or
Neimann, a pupil of Woehler, who first presented cocaine to the
chemical world; however, fifteen added years elapsed before practical
use for it was found. In 1862, Professor Schraff discovered that the
tip of the tongue was rendered numb, and insensible when a little of
the cocaine alkaloid was applied to it and that it remained so for a
considerable length of time. Significant though this experiment was,
the action of cocaine on the nerve-filaments was not recognized and
the matter was not followed up until Dr. Karl Koller, of Vienna, began
his experiments which resulted in a universal awakening to the use of
a substance which, though known, had been allowed to remain unnoticed
for ages.

Its anesthetic effect upon the eye was demonstrated by Koller at the
Opthalmologic Congress at Heidelberg in 1884. Dr. H. D. Noyes was
first to direct the attention of the American practitioners to
Koller’s results in the use of the drug. Its introduction was one of
the greatest triumphs of modern surgery. It makes possible the discard
of the systemic anesthetics in all minor surgical operations and also
in many operations of considerable magnitude.

In the laboratory of Professor Stricker, Koller experimented on the
eyes of a number of animals and thus reports his findings:

“A few drops of a watery solution of muriate of cocaine dropped on the
cornea of a guinea pig, rabbit, or dog, or instilled into the
conjunctival sac in the ordinary way, caused, for a short time, a
winking of the eyelids, evidently in consequence of a slight
irritation. After one-half to one minute the animal again opens its
eyes which gradually assume a staring look. If now the cornea is
touched with a pin head (in which experiment we have carefully avoided
touching the eyelashes), the lids are not closed by reflex and the
eyeball does not move, the head is not thrown back as usual, the
animal remains perfectly quiet, and, on application of a stronger
irritation we can convince ourselves of the complete anesthesia of the
cornea. In this way I have scratched and transfixed the cornea of the
animals used for experiment with needles, and have excited them with
electric currents so strong as to cause pain in my fingers, and to
become quite intolerable to the tongue. I have cauterized the cornea
with the nitrate of silver stick until it became milky white; during
all of this the animal did not move. The last experiment convinced me
that the anesthesia involved the whole thickness of the cornea and did
not affect the surface only. But if I incised the cornea, the animals
manifested intense pain, when the aqueous humor escaped and the iris
prolapsed. I have been unable hitherto to decide, by experiments on
animals, whether or not the iris could be anesthetized by dropping the
solution into the corneal wound, or by prolonged instillations into
the conjunctival sac; for experiments to test the sensibility of
non-narcotized animals are very complicated and difficult and do not
yield unambiguous results. The last question which I subjected to
experimentation on animals, viz., whether or not the inflamed cornea
could be anesthetized by cocaine, was answered in the affirmative. The
cornea in which I had incited a foreign-body-keratitis, became as
insensible as a healthy one.

“Complete anesthesia of the cornea from the use of a two per cent.
solution lasts ten minutes on an average. After such successful
experiments on animals I did not hesitate to use cocaine also to the
human eye, trying it first on myself and on some of my friends, and
then on a great number of other persons, obtaining, without exception,
the result of a perfect anesthesia of the cornea and conjunctiva.”

Soon after Dr. Koller’s report appeared, cocaine was used for a great
many operations upon the eye, and its application to mucous membranes
in general was soon taken up by practitioners everywhere.

Rectal, vaginal, otologic, rhinologic, oral and urethral anesthesia
were soon found to be easy of accomplishment and many operations in
these fields were performed under cocainization. The hypodermic
injection of cocaine was experimented with and reported upon in 1884
by Drs. N. J. Hepburn, R. J. Hall, and Halsted.

+PHYSIOLOGIC EFFECTS+

+Nerve Pressure; Anemia.+ That motor and sensory paralysis followed
pressure upon a nerve has been well known for many years, and this has
been utilized in the effort to produce anesthesia, artifically by
applying a rubber tube or bandage around a finger or extremity, with
the hope that “ligation anesthesia” would follow the arrest of
circulation. This, however, has been unsuccessful as all that was thus
accomplished was a slight sensation of numbness with no arrest of the
sense of pain. This method could only be successfully carried out,
were the nerves themselves subjected to sufficient pressure to injure
them. Return to normal sensibility and motor function could not be
expected for months.

+Cold.+ The addition of common salt to ice hastens its liquefaction and
consequently renders the mixture more cold. This knowledge has been
applied in a method of producing anesthesia of limited areas of the
skin. A gauze bag of the correct shape and size is filled with salt
and ice mixed, and applied to the area to be anesthetized.

This method was used as far back as 1848, by Arnott, but was soon
improved upon by Richet and others who used ether or rhigolene sprayed
on the part to be anesthetized. It was found that extremely low
temperatures could be obtained in this way, especially if a current of
air were blown across the field of operation to hasten evaporation,
and that a good local insensibility could be brought about if the
circulation of warm blood could be either stopped or retarded with an
Esmarch bandage or tourniquet. The method of obtaining local
anesthesia through the agency of cold was found to be best
accomplished by ethyl chloride and this substance is used in
preference to any of the others previously mentioned, at the present
time. Some years ago Dr. Martin W. Ware of New York experimented with
both ethyl chloride and ethyl bromide and he found that the former was
more serviceable in producing local anesthesia.

+The Sensibility of Various Tissues.+ Karl G. Lennander, of Upsala,
Sweden, shortly before his death, completed a chapter on local
anesthesia for Keen’s “Surgery” in which is set forth an elaborate
account of the sensibility to heat, cold, pressure, and pain of the
various nerve terminals throughout the body. In this great work he has
given the world the results of many experiments on living tissues,
experiments investigating the degree and kind of the tissues
sensibilities; thus it is learned that “all internal organs receiving
their nerve supply only from the sympathethic nerve and from the
vagus, below the branching-off of the recurrent nerve, have no
sensation, and that the abdominal and pelvic viscera are devoid of
nerves to convey the sense of pain, heat, cold, or pressure.”

From the same authority we are taught that the parietal peritoneum is
highly sensitive but that the visceral covering is devoid of all
sensibility, enabling the operator much freedom of manipulation within
the abdominal cavity.

In a work of this limited size the sensibility of the various tissues
cannot be fully treated but it should be borne in mind that the
integument and the subcutaneous tissue, fat and muscles as well as the
tendons, their sheaths, the muscles and periosteum and perichondrium
covering the bones and cartilages throughout the body, are all highly
sensitive to pain. It is also equally true that the bone substance,
the bone marrow, and the cartilages are devoid of any of the four
modalities of sensation. Articular surfaces covered with cartilage
have no sensation, neither have the fibrocartilages any sensation.

+GENERAL CONSIDERATIONS+

+Effect of General Anesthesia.+ Local or regional anesthesia is
obviously the method of choice in all cases in which it is
applicable. Not only is it desirable in the minor surgical operations
and the more important ones upon patients suffering with a cardiac or
nephritic derangement, where a general anesthetic is positively
contraindicated, but in every instance where it is at all possible,
the dangers and annoyances of general anesthesia should be avoided,
and the regional or local anesthesia should be employed.

Among the advantages, aside from the number of assistants required and
the discomfort immediately following the administration of a general
anesthesia, are the absence of remote ill effects of the invasion
throughout the entire system of a noxious chemical substance and its
direct deleterious effects on many large organs such as the lungs,
heart, kidneys, and liver, and the assurance, when a proper drug,
dosage, and technic are employed, that death cannot be ascribed to the
anesthetic.

Of remote ills of general anesthesia no estimate can be made, but that
they are legion and of great severity is established. Deaths from
general anesthetics in persons apparently able to bear them well, are
extremely numerous. It has been estimated that one in fifteen thousand
succumbs from ether anesthesia and this number would probably swell
greatly were it possible to obtain the exact figures. Even this
minimum of danger does not exist in local anesthesia.

An accurate knowledge of the neural anatomy of a particular region
enables the operator to anesthetize large areas and to operate with
entire freedom from the necessity of observing the appearance and
conduct of his patients, many of whom, notably the alcoholic ones,
behave badly, become cyanotic and breathe intermittently when under
the effects of inhalation anesthetics. The absorption into the body of
the substances employed by inhalation may also exert a baneful
influence by reducing the powers of resistance upon an economy already
lowered by disease, and also by retarding convalescence.

+Advantages of Local Anesthesia.+ In minor or trivial affairs the
elimination of pain is not to be considered lightly, for every
patient, even the strongest, will appreciate anything which will
expedite a cure and at the same time will relieve him of suffering.
Rather than lose time from their work or suffer the nausea and dangers
of general anesthesia, these patients often bear for years conditions
which could easily be cured by operations under local anesthesia. In
this class one must first think of hemorrhoids; of cysts; of fatty
tumors; of foreign bodies in the hands and feet; of verruca and of
ingrown nails. These conditions would be promptly relieved were the
element of pain in surgical interference not to enter as a factor.

With a perfect technic, local anesthesia can also be employed with
entire satisfaction for certain major operations, where the subject is
suitable. Thus, herniotomies are performed with entire success,
especially those cases complicated by strangulation in which the
dangers arising from fecal vomiting and inspiration pneumonia, are
greatly decreased by omitting the general anesthesia.

In many of the more severe conditions not to be classified as minor
surgery, the surgeon may consider the comfort of the patient and his
own convenience and employ local in preference to general anesthesia,
even tho the patients may be of the most robust type.

In this group may be mentioned benign tumors at any visible part of
the body, hernias, many scrotal and anal diseases and some conditions
peculiar to the extremities, such as varicose veins. These conditions
lend themselves kindly to local insensitization.

In certain emergencies where an operation must be performed
immediately, such as tracheotomy, thoracentesis and strangulated
hernia, local insensibility is imperative. In these operations local
anesthesia is also more desirable because of the ill effects of
vomiting, which are thus eliminated.

Weakness of the patient enters also as a demand for the exhibition of
a local anesthesia in such operations as resection of a rib for
empyema, in which instance the action of the heart or lungs is
embarrassed. Other operations performed under local anesthesia for the
same reason (weakness of the patient) are the exploratory operation
for a probable inoperable cancer and the palliative operations such as
gastrostomy, enterostomy and colostomy.

+SOME VALID OBJECTIONS TO THE USE OF LOCAL ANESTHESIA+

There are, however, valid objections to the general application of
local anesthesia and the cases for its use should be selected with
care. It does not produce relaxation nor does it give the surgeon
perfect control over his patient. These are considerations which must
be taken into account, especially in operating on patients of highly
nervous temperaments. Though the patient may be convinced that he will
suffer no pain, the mental attitude toward the local anesthesia,
together with fear, may operate so strongly as to constitute a shock
to the nervous system so great that a general anesthetic should be
used and the local method abandoned, even were it apparently
indicated.

Again, the injection of anesthetic drugs in cicatrical and inflamed
tissues is quite difficult of accomplishment and because of the
peculiarity of these tissues, diffusion throughout a given area is
imperfect, hence insensibility is not complete.

The extravagant claims of enthusiastic advocates of this method of
anesthesia have retarded its progress. Thus, in the hands of the
competent operator it was given but a perfunctory trial to be
discarded as impossible. At the present time, however, local
anesthesia bids fair to become the method of choice, other things
being equal, for many major operations not yet thus performed. Recent
investigations alone these lines have developed methods of its
application whereby it is possible to render insensible large areas of
the integument, and regional anesthesia is performed by anesthetizing
nerves proximal to the seat of operation, thus rendering amputations
feasible.

A single element which has entered as a factor in retarding the
progress of local anesthesia in general surgery, is that of regarding
the operation as one fitted to the method rather than to the patient
under consideration. It is obvious that this is a fallacy and the main
issue in deciding between general and local anesthesia is: what will
the patient best tolerate? In coming to a decision in the matter one
should make a general survey and weigh first the general health of the
patient; whether he be in perfect systemic condition or undermined by
disease, whether the shock will be greater from one method than the
other, and whether the part of the body to be operated on is one which
will lend itself better to one method than to the other.

These elements are being and will continue to be considered as
preliminary to operative procedure and in consequence, general
anesthesia will cease to be given in a routine way.

+GENERAL PRINCIPLES AND ESSENTIALS+

The first essential to the successful production of local anesthesia
is a proper equipment and one that is in good working order. Not only
is it necessary to employ the best drug to this end but also to use a
syringe having perfect mechanical construction and one not injured by
boiling; as also needles of the length, lumen and shape suitable for
the surface to be injected.

The old leather pocket syringes, on account of their not bearing water
at high temperature without deterioration, should not be employed;
this applies also to that variety of glass barreled metal-mounted
syringe in which the glass is screwed into the metal end pieces.

The best syringes are those made of all metal or of all glass, the
latter being preferred because one may see the contents and express
out the air before injecting. Syringes of this type, because of the
accurate fitting piston, must be thoroughly dried out after use, as
the piston may stick fast within the barrel. All-glass or all-metal
syringes must be selected with care as they are often imperfect, the
calibre of the barrel being unequal in different parts of its length
causing the piston to fit tightly in some parts, and thus to work
with difficulty; and in other parts fitting loosely, allowing the
fluid to escape backwards.

Syringes are also made in various sizes and shapes to meet certain
requirements. For the edematization of large areas of loose tissue,
where a considerable amount of a weak solution is intended, the use of
a large barreled syringe will be found to save time and the annoyance
of refilling.

For such work a five or ten c.c. syringe would be the most useful. The
ordinary hypodermic syringe is about of two c.c. capacity (thirty
drops), and serves the purposes of every-day work. It does very well
for the amount of an anesthetic solution employed in opening an
abscess or in the removal of a small cyst or lipoma or papilloma.

A barrel, large in diameter, requires more pressure on the piston in
its operation unless the needle employed is also correspondingly
large. For this reason, if the tissue in which the solution is to be
injected is not loose or cellular, it will be found better to use a
syringe in which the barrel is long and narrow. Such is the shape of
the syringe intended for the injection of the gums, the peridental
membrane, and also for the periosteum, cartilage or bony cellular
structure. A long instrument is also required for use in the large
cavities of the body such as the mouth, the vagina, or the rectum. In
these localities, an extension fitting is often required to lengthen
the instrument sufficiently to reach the desired part. It is also
possible to attain this end by using a long needle; this, however,
sacrifices rigidity.

For accomplishing the best results, the needles must also be selected
for the work at hand. For the initial puncture in sensitive or
inflamed tissue, it is proper to use a needle of the finest lumen so
as to cause the least possible amount of pain. The ordinary needle,
which comes with the usual hypodermic outfit, is about the proper
length for the ordinary work already mentioned, but could be improved
upon for anesthesia by being made a little finer in calibre. This
length (three-quarters of an inch) will be frequently found
insufficient to reach the deeper tissues and in the removal of a more
or less rounded growth, a longer needle must be selected at the start.
Curved or angular ones are only needed in dentistry, where strength is
also a consideration. Strength is afforded in those of short length by
means of a reinforcement at the hub. Needles so augmented may also be
of use in operations upon bone or dense structures in general; the
curve, however, is not essential.

The surgeon should be fully conversant with the details of the
operation which he is about to perform. His work should be definitely
in his mind, for in operations under local anesthesia, there is no
justification for a change of procedure after the beginning of the
work. Account should be taken of the nature of the tissues to be
anesthetized, for it is known that cicatricial tissues and
inflammatory areas do not lend themselves to the action of these
drugs. In a cicatrix, the diffusibility of the solution is impeded,
and in an inflammatory or necrotic tissue, the changes in the quantity
and quality of the fluids present, alter the action of the anesthetic.

In considering the personal element of the patient one meets a
difficulty which is by no means minor, and full explanation for the
selection of the local anesthetic with many assurances of the
painlessness of the operation are frequently necessary. This is
especially true with one of highly emotional temperament, and, to
allay fear in such a patient is not always easy.

Whatever may be said regarding the mental state of the patient who is
to receive an anesthetic, whether general or local, the surgeon must
remember that to be calm does not always lie within the control of his
subject, and it will be found that a hypodermic injection of morphine
(gr. one-eighth to one-quarter) an hour before the start of the
anesthetic, will often render possible the use of the injection method
in a patient with whom it would otherwise have been impossible.
Morphine injections, as suggested, are of advantage in patients on
whom a major operation is contemplated; they loosen the musculature
and diminish the sensations of parts not anesthetized.

The deliberate and confident manner and word of the surgeon go a long
way in guiding the feelings of his patient, and a worried or
apprehensive surgeon makes for a doubtful and sensitive patient, ready
to cry out at the first prick of the needle. Therefore it is a part of
good general technic for the surgeon to deport himself in a way
conducive to cheerfulness, and conversation must be guided along these
lines.

There are many who will writhe and groan at sensations (which they
will admit later were not painful) incident to local anesthesia, such
as the grating vibrations of instrumentation. Such a patient is not
well fitted for the method and it is for the discerning surgeon to
recognize such in advance, that he may operate under the most
favorable circumstances.

+Preparation of the Patient.+ Proper evacuation of the bowels and a
stomach free of undigested parts of a previous meal, are desirable.
The subject of an anesthetic should not be purged or starved as these
are weakening processes and also disturb the tranquility so essential
to a perfect anesthesia. The skin should be prepared so as to
accomplish surgical cleanliness without irritating it so as to retard
healing. It was once thought that soap, water, alcohol, ether and
bichloride were absolutely necessary to this end. It has, however,
been found that iodin, applied in the ten per cent. tincture to the
site of incision, fulfills every requirement. Where shaving is
necessary, it should be done first. In operations about the anus and
scrotum, iodin is contraindicated because of its irritating
properties; it is painful in these parts and dermatitis is frequently
the result of its use.

+Instruments.+ The instruments should be prepared and ready before the
anesthetic is given, regardless of the form of anesthesia employed.
The surgeon’s hands should be rendered aseptic, no matter how trivial
the procedure before him, and every precaution should be taken to
guard against infection, which is always possible in any surgical
procedure however insignificant.

+Technic.+ Various methods of accomplishing the insensitization of a
part may be employed. Thus, if the skin alone is to be incised, it
alone will require injection and by careful insertion of the end of
the needle it may be kept just under the epidermis, thus injecting the
anesthetic endermatically in and about the papillae of the papillary
layer.

+Endermic Method.+ This method is an end-organ anesthesia, and the
solutions employed are strong and act because of their drug content.
It is not in any sense a pressure anesthesia. The skin should be
picked up and pinched hard for the better insertion of the needle
directly into the skin substance. It is therefore endermic and the
skin is seen to become blanched as the needle advances delivering its
solution on the way. But little of the fluid is pressed out as the
needle advances. When the syringe is empty or the needle has advanced
to the limit of its length, refill and insert just inside of the last
blanched spot and proceed in a line until the end of the contemplated
line of incision is reached.

Pressing out too much of the solution at one time causes a burning
sensation and should therefore be avoided as the only pain should be
that of the initial prick of the needle. Care, however, should be
taken to inject just sufficient of the solution to penetrate beyond
the zone of operation laterally, to insure sufficient space for the
insertion of sutures into anesthetized tissues. Only a small quantity
of fluid is necessary in this procedure as it comes in direct contact
with nerve terminals. By touching the injected line with the needle in
several places along its length and inquiring of the patient if it is
felt, we may make sure of the completeness of the anesthesia before
making the incision which should begin and end inside the anesthetized
area.

+Subdermic Method.+ An appreciable area of skin and subcutaneous tissue
may be incised by anesthetizing as previously described, together with
depositing the fluid well under the skin, thus affecting many terminal
nerve branches before they reach their final distribution in the skin,
and widening the anesthetized area considerably.

This method is applicable to such work as the removal of small
growths, and the deep incision of a carbuncle. Beneath the skin in the
loose connective tissue the fluid is deposited and causes anesthesia
by acting upon the nerves just before their emergence into the skin.
The two methods may be combined. It is not possible to inject directly
into thin skin or mucous membrane and it is therefore employed in such
operations as circumcision, where the nerve terminals must be
anesthetized by the diffusion of the anesthetic from its position
under the skin. A little time should be allowed before beginning the
operation to permit of the diffusion of the drug. This applies also to
such operations as that for ingrown toe-nail where the deeper tissues
down to the root of the matrix are involved.

+Edemitization Method.+ This is the method of Schleich and it is to him
that the credit must be given for a procedure which has done more to
encourage the use of local anesthetics in operative surgery than any
other. He employed weak solutions of cocaine and other local
anesthetics in great volumes of water in order to gain the combined
action of both drug and of pressure. The method is described under the
heading of “Cocaine.” It was designed to obtain anesthesia with
cocaine with the elimination of the toxic effects of the latter.

There are decided disadvantages to the filling up of the tissues with
fluid; healing is delayed; relations are distorted and coaptation of
the edges is difficult. This is probably the method of selection where
an indefinite amount of manipulation is expected and where the length
and depth of the incision may need to be augmented. A large quantity
of a very weak solution is employed and the tissues in all directions
are injected until visibly distended.

+Nerve Blocking Method.+ By injecting a small quantity of a fairly
strong anesthetic solution either directly into a nerve or beneath its
sheath, the entire area supplied by it will be anesthetized. This
method of nerve blocking may be spoken of as _endoneural_ when the
injection is made directly into the nerve trunk, and _perineural_ when
made into its sheath or immediately outside of the nerve. The
injection of fluid around nerves too small to inject directly is also
spoken of as perineural nerve blocking. (Hertzler).

+DRUGS EMPLOYED+

The essential qualities of a good local anesthetic are:

   1. Reliability in producing anesthesia.
   2. Constitutional and local harmlessness.
   3. Non-irritating qualities.
   4. Ability to be rendered aseptic by boiling.

No one local anesthetic can be exclusively relied upon to fulfill all
of these requirements at all times. Each one has its advocates and
from the large number offered, it is possible to select several which,
while not being perfect, are preferable to cocaine in that they
obviate the disagreeable train of symptoms peculiar to that drug.

By local anesthetics are understood certain chemical compounds, weak
solutions of which, when brought in contact with sensory nerves
paralyze them without lastingly injuring them. This effect is
dependent upon the presence in these agents of certain atom groups
which Ehrlich named _anesthiferous_. It is possible that just these
atom groups enter into certain chemical combinations with the nerve
substance and that the nerve thus remains paralyzed until the newly
formed compounds are split up and the poison is washed away by the
circulating blood.

Cocaine is the original type of a local anesthetic. Einhorn has made
possible its synthetic production and has also opened the field for a
great number of experiments of scientific and practical importance
leading to the discovery of new local anesthetics obtained by
exchanging the non-anesthiferous atom groups of cocaine for other
groups different for each of the various new agents; thus eucaine,
orthoform, anesthesine, alypin, and others have been obtained.

+Cocaine+ occurs as a white, crystalline powder, readily soluble in
water and in alcohol. It is an alkaloid which effects all living
protoplasm. It first excites, then paralyzes. In greater
concentrations it paralyzes immediately. Its effect is very ephemeral,
producing no lasting harm to the cocainized protoplasm. Its effect is
most readily understood by assuming that cocaine poisons the
protoplasm by entering with it into combinations which are easily
broken up. The products of decomposition, among which cocaine cannot
be recovered, are slightly or not at all poisonous and are carried
away by the circulation.

+Effect on the Mucous Membrane.+ The external application of cocaine in
solutions of varying strengths has been of great service since its
introduction by Roller in 1884, and many operations on the eye and on
its coverings are now greatly facilitated, by reason of its use. Small
quantities only are required, hence there is little fear of its
toxicity. Its anesthetic qualities by contact are also made use of in
operations in and about the nose and throat. Here comparatively mild
solutions are used liberally but care must be exercised against its
noxious effects; it is usually employed in freshly prepared solutions
which are held to be less toxic. Where extensive areas of mucous
membranes are to be anesthetized, as in the rectum or urethra or
bladder, one of the less toxic drugs is preferable.

+Strength of Solutions.+ In the eye, it is customary to employ a 4 per
cent. solution. For work in the nose, 2 per cent. is generally
considered sufficient. In the latter connection, it is often combined
with adrenalin solution in small amounts to mitigate its depressing
effects as well as to control bleeding. The latter effect is but
transient and is omitted by many as unsatisfactory because of the more
profuse subsequent hemorrhage. In this respect cocaine and adrenalin
are similar. They both cause constriction of the minute superficial
vessels and immediate blanching of the membrane; work in the nose is
hence greatly facilitated, the field of operation being clear and
enlarged by the shrinkage of the encroaching membrane, but it is
incumbent upon the operator to keep his patient under observation at
least an hour after the completion of the operation that he may be
certain of the degree of hemorrhage after the effects of the drugs
have passed away. For the above reason many operators prefer a general
anesthetic or one of the local anesthetic drugs which exert no
constrictor action so that they may know, _ab initio_, the exact
degree of bleeding.

Whatever drug is used, strong solutions are seldom necessary for
application to the mucous membranes but the necessary time for its
absorption is a prime requisite. To secure anesthesia of the
conjunctiva and cornea, the solution is dropped into the eye at the
outer canthus and as it flows off with the tears, it must be
replenished three or four times until anesthesia is accomplished. In
the nose, a spray over the site of incision or a pledget of cotton
saturated with the anesthetic solution and allowed to rest in contact
with that locality, will suffice. The flow of mucus from the nasal
mucosa is stimulated by the presence of the cotton pledget and it soon
becomes entirely coated with a thick mucus which no longer is able to
impart to the membrane its anesthetic solution and must therefore be
renewed several times before complete insensibility of the part is
assured. The topical application of a strong solution on a cotton
wound applicator to a limited area or spot is also efficient.

+Application by Injection.+ In order to bring the anesthetic in contact
with the nerves, it is necessary, where a skin surface is to be
incised, to inject the solution as already described. The technic,
previously detailed, applies here, and any of the methods may be
employed for the injection of solutions of cocaine, some preferring a
single method to the exclusion of all others. The locality to be
treated will also influence the operator as to method.

+Endermically.+ The endermic method is the one most generally employed
in securing cocaine local anesthesia by injection. The papillary layer
of the skin is well infiltrated with a mild solution (one-eighth per
cent. to one-half per cent.), frequently with adrenalin 1-1000, in the
proportion of 15 to 20 drops to the ounce of the solution. The
strongest of the formulas of Schleich may also be used for endermic
infiltration.

The skin is injected to a fair degree of tension and a white ridge
marks the line of injection which should be sufficiently extensive to
permit the manipulation of the cut edges.

+Edemitization.+ Schleich’s solutions are here of extreme value because
large amounts of solution are necessary to produce the degree of
distention required because of the minute quantity of cocaine present,
though the added salt and morphine assist considerably.

+Nerve Blocking and Perineural Blocking.+ Here a stronger solution must
be employed; 1 per cent., or even stronger, is injected in small
quantities, either into the substance of the nerve or under its
sheath, as already described.

+Strength of Solution.+ Schleich has worked out a method whereby very
weak solutions of cocaine may be used advantageously. His plan is to
enhance the action of the drug by the admixture of morphine in minute
quantities and of sodium chloride in proper strength. These
substances, in themselves, were found to possess anesthetic powers.
Large quantities of Schleich’s solutions may be injected—even several
ounces, without ill effects as they contain so little cocaine. The
formulas used by him are:

   1. Cocaine hydrochlorate   0.2
      Morphine hydrochlorate  0.02
      Sodium chloride         0.2
      Distilled water       100.

   2. Cocaine hydrochlorate   0.1
      Morphine                0.02
      Sodium chloride         0.2
      Distilled water       100.

   3. Cocaine hydrochlorate   0.01
      Morphine                0.005
      Sodium chloride         0.02
      Distilled water       100.

It will be seen that the strength of cocaine in the respective
solutions is from one-fifth to one-hundredth of a gram.

The solutions used in the early days of cocaine anesthesia were much
stronger than were found necessary afterward and it has now become the
rule to employ weak solutions and to give them time to penetrate the
tissues. The less toxic action of mild solutions, even when like
amounts of the drug are employed, makes it incumbent upon the operator
to follow this plan and the element of time is so important in the
matter of securing a perfect local anesthesia that it is customary to
wait fifteen or twenty minutes after the completion of the injection
before making the incision. The weakest solution possible is the one
of choice in the use of this anesthesia.

+Toxicology.+ The repeated use of cocaine in the same patient should be
avoided on account of the danger of establishing the cocaine habit.
The drug should be given with the greatest care, especially in
operations about the head, neck, face, and urethra, as several deaths
and many alarming cases of syncope, delirium and paralysis or tetanic
fixation of the respiratory muscles have followed its use. Because of
its marked depressing effect upon vital organs, it should never be
given unless the patient is in the recumbent position. The
administration of one drop of a one per cent. solution of trinitrin
given at the first onset of the constitutional effects and repeated if
necessary every five minutes, will entirely prevent any unpleasant
effects as it is a true physiologic antidote.

If the surgeon has a case in which he intends to use large amounts of
cocaine, it is best to have at hand and ready for use the following
agents: a hypodermic and a rectal syringe, a battery, cardiac and
respiratory stimulants, oxygen, and a catheter.

If the patient becomes very delirious and is in no way depressed,
chloral or hyoscine should be given. In all cases of cocaine poisoning
the patient should be catheterized to prevent re-absorption and should
then be treated symptomatically.

Strong solutions should never be employed for any purpose except in
cases where, by previous experience with the mild ones, it is known
that no idiosyncrasy exists.

The central nervous system, and next the sensory and motor nerves, are
affected by cocaine. Respiratory paralysis follows the introduction of
appreciable amounts of cocaine into the circulation and respiratory
depression may follow the introduction of smaller quantities. A given
quantity of the drug in great dilution will, under normal conditions,
give no toxic symptoms, whereas the use of the same amount in a more
concentrated form will give rise to pallor, cyanosis and even syncope
and collapse. It is said that a maximum dose of cocaine can never be
fixed; this, however, seems of less importance than knowing the
minimum dose, for while it is true that many bear it well, this drug
so frequently gives rise to toxic symptoms, and the idiosyncrasy for
it is so common, that one can never be certain of an exact dosage.
Various pharmacopias place the maximum dose at 0.05 grm. (about
seven-eights of a grain).

Bearing in mind that a great dilution of a given amount makes for
safety, we are astonished to learn that 7 c. c. (about 2 drams), of a
1 per cent. solution introduced into the urethra has caused death.
(Czerny).

Hertzler cites numerous instances in which a few drops of a more
concentrated solution (2 per cent. to 4 per cent.) have caused death.
It is therefore obvious that the use of this drug must be guarded by a
technic so perfect that but the smallest quantity of a very weak
solution shall be permitted to enter the circulation.

+Adjuvants, Substitutes and Safeguards.+ The numerous disadvantages in
the general use of this most efficient but most treacherous local
anesthetic have operated so strongly that efforts have constantly been
made to find a substance which, when used with it, would correct its
toxic effects.

The desirability of employing large quantities of an anesthetic
solution so as to enable the operator to infiltrate large areas of
tissue has led to the method of preparing very dilute solutions and
mixing them with various chemical substances which in themselves
would act as mild anesthetics and at the same time increase the
diffusibility of the cocaine. With any of these substances, cocaine
still remains toxic and the quantity injected must be kept account of
when an operation of any extent is being performed even though the
solution be never so mild.

A valuable preventive to this absorption is found in the application
of a constricting band or tourniquet to impede the return circulation
and allow the washing out of much of the drug before the obstruction
is removed. It is evident that no method has yet been devised whereby
the use of cocaine is rendered safe and it is for this reason that
chemists throughout the world have sought to produce either a new
anesthetic drug or to evolve a drug synthetically, from cocaine, minus
its toxicity. This has been done, but cocaine still has its adherents
because of its superior qualities.

Quinine and urea hydrochloride is one of the new substitutes which has
found much favor. Among the synthetic derivatives may be mentioned
alypin, novocaine, stovaine, betaeucaine, tropacocaine, anesthesin,
subcutin and many others. Each of these has its advocates and all of
them have some advantage over cocaine; they have disadvantages as
well, which, however, in the hands of skilled operators, may be
overcome.

+Quinine and Urea Hydrochloride.+ Among the quinine salts and
combinations, the above has found most favor. It consists of a
molecule of quinine hydrochloride and one of urea. It occurs as a fine
crystalline powder and is readily soluble in water, forming an acid
solution.

This substance is one of the most recent and best substitutes for
cocaine, being capable of a wide range of usefulness and practically
devoid of any toxicity. It causes redness on being injected and, in
strong solutions, may delay healing considerably, this constituting
the main disadvantage to its use. After the use of this anesthetic,
primary union is not usual.

In a one per cent. solution, anesthesia is accomplished by any of the
methods already described. Weaker solutions require a more perfect
technic, and are therefore not generally employed. They, however, are
indicated where it is imperative to secure primary union and when for
some reason no other local anesthetic is available. The scar formation
which almost always follows the use of this anesthetic would indicate
that some other drug be employed in operations about the face and
neck. This anesthetic is preferred by many because of its safety in
large quantities and because of the length of insensibility following
the injection of solutions of from 1 per cent. to 2 per cent.
strength.

Notwithstanding knowledge of the facts above enumerated as to the
difficulty of primary union and the likelihood of scar formation in
connection with the use of urea and urea-hydrochloride for purposes of
local anesthesia, this drug is still considered a most valuable and
useful one for providing local anesthesia for operative purposes.

+Novocaine.+ This drug is one-seventh as toxic as cocaine but is also
weaker in action. It does not cause vascular constriction but has a
preliminary vasodilator action. Like quinine, it has a decidedly
irritating action when injected. It has a decidedly toxic effect when
used in stronger solutions than 2 per cent. and causes tonic and
clonic spasm. In a 1 per cent. solution it is probably safest and best
as an anesthetic and one-half ounce of such a solution may be injected
without fear of unpleasant consequences.

Its dose is said to be about seven grains, but this may often be the
cause of alarming symptoms, and half of this quantity would perhaps be
a safe limit. The duration of anesthesias of fairly strong solutions
is about fifteen minutes; the action is more prolonged if used with
adrenalin.

Various combinations of drugs besides adrenalin are employed with
novocaine. Fischer recommends its use with thymol, but even so, it is
not efficient for a longer period than twenty or twenty-five minutes.

Novocaine is frequently used in alcoholic solutions for injection in
neuralgic subjects. The commercial tablet of novocaine and adrenalin
is convenient for office use.

+Alypin.+ This substance occurs as a crystalline powder, easily soluble
in water, alcohol and ether, and makes a neutral solution.

Alypin is in every respect the equal of cocaine though not quite as
strong. Schleich has found that its use, in conjunction with minute
quantities of cocaine, permitted of a reduction of the entire amount
of anesthetics necessary to accomplish insensibility.

In its use on mucous membranes it does not cause any anemia and
therefore no secondary bleeding occurs. This is a great advantage also
in the examination of mucous membrane lined cavities, such as the eye,
nose, throat and urethra, inasmuch as after the application of
cocaine, the blanching of the membrane conveys no idea of the real
condition of the parts.

Because of the results he obtained, Schleich now recommends the
following solutions for infiltration:

   1. Cocaine           0.1
      Alypin            0.1
      Sodium chloride   0.2
      Distilled water 100.

   2. Cocaine           0.05
      Alypin            0.05
      Sodium chloride   0.2
      Distilled water 100.

   3. Cocaine           0.01
      Alypin            0.01
      Sodium chloride   0.2
      Distilled water 100.

For other operative procedures of a minor character, it has been found
that one-fourth per cent. to one-eighth per cent. is sufficient. For
application to mucous membranes, as in the urethra, nose and throat, 1
per cent. to 2 per cent. has proved effective.

+Stovaine.+ Stovaine is used more for spinal anesthesia than for local
purposes; it is said to work well in inflamed tissues.

Several drugs have been used because of their lessened toxicity and
many are constantly being tried but to be abandoned because of their
inefficiency or irritating qualities. None of them are as efficient as
cocaine and the weak solutions of Schleich are about as active as
stronger solutions of many of these and are not more toxic.

Among the other cocaine substitutes in general use are betaeucaine,
tropacocain, anesthesin, and subcutin.

These all find a special field of usefulness, but for general work,
are limited, because of some disadvantages which each and all of them
possess.

Individual selection plays an important part in the use of a local
anesthetic, and one operator, by practical experience, may obtain
results with a given drug, which another fails to achieve.

The essential feature to be remembered by the practising chiropodist
is, that the use of any drug employed for anesthetizing purposes, even
though but local, should be safeguarded in every way.

+Cold.+ The methods of using ether, rhigolene, or ice and salt, to
produce cold, are slow and unsatisfactory. If cold is to be used to
produce local anesthesia the most efficient and convenient method of
applying it is by means of _ethyl chloride_. This fluid is very
volatile and is best controlled by having it in air-tight tubes. When
not in use, a valve covering one end of the tube prevents leakage.
When the valve is pressed upon, the orifice of the tube is opened and
the heat of the hand forces out a fine stream of the liquid which is
directed upon the parts to be frozen. Rapid evaporation causes intense
cold. The nozzle should be held about fifteen inches from the area to
be acted upon. When the spray strikes the integument, redness almost
instantly results but in a few seconds the part becomes hard and
white. This condition indicates local insensibility and lasts about
two minutes. If the action is slow, it can be much hastened by gently
blowing upon the parts to increase the rapidity of evaporation.

The refrigeration method of local anesthesia is of limited usefulness
and is recommended only for the opening of felons and abscesses, for
removing wens from the scalp and back, and for producing a painless
area in which a puncture is to be made. It must be borne in mind that
sloughing and ulceration of the skin are liable to follow the use of
cold.

Work under this form of anesthesia must be done with rapidity not
always consistent with thoroughness, and should therefore be employed
only when a single incision or puncture is indicated.

The pain incident to subsequent thawing is severe and, in general, is
about as hard to bear as an incision without an anesthetic.

For the purposes of practical podiatry, the chiropodist is advised to
use a substitute for cocaine rather than the cocaine itself when local
anesthesia is necessary. In the clinics of the School of Chiropody of
New York, novocaine, quinine and urea hydrochloride, and alypin are
preferred, and no single instance of toxemia has ever been
experienced. There have been cases in which the anesthesia did not
prove thoroughly effective, but, in the main, these drugs have well
answered the purposes of their use.

THE END

GLOSSARY

+A+

+a-an.+ Without, as in atypical—without type, and as in analgia—without
pain.

+ab.+ From, away from, as in abaxial, lying outside of or away from any
body or part.

+abduction.+ To move away from the axis (median line) of the body.

+ab initio.+ From the beginning.

+abrade.+ To scrape away.

+acid.+ A compound of an electro-negative element or radical with
hydrogen.

   +acetic acid.+ A product of the oxidation of ethylic alcohol and
   of the destructive distillation of wood, applied locally as a
   counterirritant.

   +benzoic acid.+ External uses, antiseptic.

   +carbolic acid.+ Used in podiatry, as an antiseptic, as a
   disinfectant and as an anesthetic.

   +chromic acid.+ Has caustic properties.

   +dichloracetic acid.+ Used as a caustic application to venereal
   sores.

   +glacial acetic acid.+ Employed externally as a caustic for
   removal of warts and helomata.

   +hydrochloric acid.+ Externally employed as an escharotic.

   +monochloracetic acid.+ Used as a caustic for helomata and
   verrucae.

   +nitric acid.+ Used as a caustic against verrucae.

   +nitrohydrochloric acid.+ An active caustic agent.

   +oxalic acid.+ Removes ink stains.

   +sulphocarbolic acid.+ Antiseptic and disinfectant.

   +trichloracetic acid.+ Employed as an escharotic for venereal
   and other warts.

+abscess.+ A circumscribed cavity containing pus.

+acidulated.+ Rendered acid.

+actinomycosis.+ An infectious disease due to the ray fungus.

+actual cautery.+ A substance which acts by virtue of its heat, not
chemically.

+adenoma.+ A tumor of glandular epithelium.

+adde.+ Add, used in prescription writing.

+adduction.+ To turn towards the axis or median line of the body.

+adhesive.+ Sticking together.

+adjacent.+ Next to.

+adjuvant.+ A remedy which added to a prescription aids the action of
the main ingredient.

+adrenalin.+ Trade name of a principle obtained from the suprarenal
glands which has astringent and hemostatic properties.

+aerobic.+ Unable to live without oxygen.

+albuminoid.+ A substance resembling true proteids in origin and in
composition.

+albuminous.+ Resembling or containing albumin.

+albuminuria.+ Albumin in the urine as voided.

+albumose.+ An intermedial product of the splitting of proteids by
enzymes.

+albumosuria.+ Albumose in the urine.

+algia.+ Pain, as in neuralgia, nerve pain.

+alkaloidal. An organic base of vegetable origin causing toxicologic
effects.

+alveolar.+ Pertaining to the alveoli.

+ambi.+ Both, as in ambidexterity, the ability to use both hands with
equal ease.

+ambulatory.+ Walking, able to walk.

+ameba.+ A small one-celled animal that constantly changes its shape by
sending out processes of its protoplasm.

+amyl nitrite.+ A drug used to dilate the blood vessels.

+anal.+ Relating to the anus.

+anemia.+ A condition in which the blood is reduced in amount or is
deficient in red blood cells or in hemoglobin.

+anerobic.+ Living without air.

+anesthesia.+ Loss of sensation.

+anesthesin.+ An ethylic ether used as a local anesthetic.

+aneurism.+ A saclike dilation in the wall of an artery as the result of
weakness of its tissues.

+angioma.+ A tumor formed of blood vessels.

+animal.+ An organic being, with life and power of motion.

+ankylosis.+ Stiffening of a joint.

+anthrax.+ The disease produced by the bacillus anthracis.

+anti.+ A prefix signifying against; in relation to symptoms and
diseases, curative.

+antidote.+ An agent which neutralizes or counteracts the effects of a
poison.

+antipyretics.+ Agents reducing fever.

+antiseptic.+ Preventing, or destroying the germs of putrefaction or
suppuration.

+antitoxin.+ A substance in the serum, which binds and neutralizes
toxin.

+anus.+ The orificial extremity of the rectum.

+apposition.+ Contact of two bodies or two surfaces.

+argyrol.+ A soluble, non-irritating silver preparation used in the
treatment of various inflammations of mucous membranes.

+arsenic.+ A metalic element in chemistry.

+arterial.+ Pertaining to an artery.

+arteries.+ Vessels carrying blood from the heart.

+arteriosclerosis.+ A fibrous overgrowth of the inner coat of an artery.

+arthritis.+ Inflammation of a joint.

+arthrotomy.+ Cutting into a joint.

+articulation.+ A joint.

+aseptic.+ Free from septic matter.

+asepticize.+ To render aseptic or sterile.

+aspiration.+ The withdrawal by air or by suction of fluid from any body
cavity.

+astringent.+ An agent producing contraction of organic tissues or the
arrest of a discharge.

+atrophy.+ The wasting or diminution of the size of a part from lack of
nutrition.

+autoclave.+ Instrument for sterilizing by steam.

+axis.+ A straight line passing thro a spherical body between its two
poles and about which the body may revolve.

+B+

+bacillus.+ A genus of schizomycetes, the most important group of
bacteria.

+bacteria.+ Microorganisms, microbes, schizomycetes.

+benign.+ Not malignant; mild.

+betaeucaine.+ A local anesthetic used as a substitute for cocaine.

+bi.+ A prefix denoting two, twice or double, as biceps—two heads.

+bicarbonate.+ A compound of two equivalents of carbonic acid and one of
a base.

+bichloride.+ A chloride with twice as much chlorin as a protochloride.

+blast.+ Germ, as in blastoderm, the primitive cell layer in the
beginning embryo, consisting of three layers.

+blastomycetes.+ Yeasts; budding fungi.

+blistering.+ Producing a blister.

+brain.+ The large mass of nerve tissue contained in the cranium,
especially the cerebrum.

+bromide of potassium.+ A salt of potassium.

+bromidrosis.+ Fetid or foul smelling perspiration.

+bubo.+ Enlargement of a lymphatic gland usually in the groin.

+budding.+ Gemmation. A form of tissue division by a bud-like process.

+bulla.+ A large bleb or blister.

+bunion.+ An inflammatory swelling of the bursa over the
metatorsophalangeal joint of the great toe.

+bursa.+ A small sac interposed between movable surfaces.

+bursitis.+ Inflammation of a bursa.

+buttock.+ The prominence formed by the gluteal muscles of either side.

+C+

+calcareous.+ Having the nature of lime.

+calcification.+ A degeneration of tissues into salts of calcium or
magnesium.

+callosity.+ A circumscribed thickening of the epidermis as a result of
friction or intermittent pressure.

+cancellous.+ Resembling lattice work.

+canthus.+ The slit between the eyelids.

+capillary.+ Any one of the small blood vessels which serves to connect
an artery and a vein and to allow of the passage of nutrient matter
and oxygen from the blood into the tissues and of waste matter from
the tissues into the blood.

+carboluria.+ Carbolic acid in the urine.

+carbuncle.+ A phlegmonous inflamation of the skin and subcutaneous
tissues.

+carcinoma.+ A malignant epithelial growth.

+cardiac.+ Pertaining to the heart or cardium.

+caries.+ Molecular bone decay.

+carotid.+ The principle artery of the neck.

+cartilage.+ A non-vascular elastic tissue, softer than bone.

+cartilaginous.+ Partaking of the nature of cartilage.

+caseation.+ Transformation of necrotic tissue into a mass resembling
cheese.

+caseous.+ Cheesy.

+catheter.+ A hollow cylinder of silver, rubber or other material
designed for passage thru the urethra and other channels.

+caustic.+ Corrosive; capable of tissue destruction; syn. escharotic.

+cautery.+ An agent which by heat or chemical action scars tissues.

+cavities.+ Hollows.

+cele.+ Tumor, as in hydrocele, a watery tumor.

+cell.+ A small protoplasmic mass, usually nucleated.

+cellular.+ Composed of cells.

+cellulitis.+ Inflammation of cellular tissue.

+cephalic.+ Head, as in hydrocephalic, water on the head (brain).

+chancre.+ The primary syphilitic manifestation. A syphilitic
induration.

+Charcot’s disease.+ A form of tabes.

+chemotaxis.+ The attraction or repulsion exhibited by certain chemicals
to living cells.

+chimatlon.+ Mild, chilblain; severe, frost-bite.

+chiropodial orthopedics.+ That branch of podiatry which has to do with
the treatment of chronic diseases and deformities of the foot and of
the foot joints.

+chiropodist.+ Literally, one who treats the feet and hands. Actually,
one who specializes in the treatment of foot lesions not requiring
major surgical operative procedures.

+chloral.+ An oily liquid formed by the action of chlorine gas on
alcohol.

+chlorosis.+ A form of anemia occurring chiefly in young girls.

+chondritis.+ Inflammation of cartilage.

+chondroma.+ A tumor of cartilage tissue.

+chronic.+ Of long standing.

+chyle.+ The milky fluid found in the mesenteric lymph-vessels as the
result of fatty digestion.

+cilia.+ The eyelashes; hairlike processes of certain cells.

+circumcision.+ Removing part or all of the foreskin.

+clot.+ The solid portion resulting from the coagulation of blood.

+coagulation.+ Clotting; in the blood, the result of fibrinogen changing
to fibrin.

+coalesce.+ To merge in growth.

+coaptation.+ The fitting together of two opposing surfaces.

+cocaine.+ An alkaloid derived from coca. Useful to produce local
anesthesia.

+cocci.+ Round, spheroidal or oval shaped bacteria.

+cocoon.+ Shaped like the protection of the silk-worm larva.

+colostomy.+ Opening into the colon to establish an artificial anus.

+collodion.+ A solution of pyroxylin in ether and alcohol.

+compression.+ Decreasing volume and increasing density by pressure.

+concomitant.+ Accompanying. Accessory.

+condyle.+ A rounded articular surface at the extremity of a long bone.

+congenital.+ Existing at birth.

+congestion.+ Hyperemia of a part.

+conjunctiva.+ The mucous membrane covering the anterior surface of the
eyeball.

+connective tissue.+ The uniting tissue of the body.

+constitutional.+ Relating to the system as a whole.

+constriction.+ The act of drawing together, a narrowing or binding.

+continuity.+ Connected; the quality or state of being continuous.

+contra.+ A prefix meaning against.

+contused.+ Bruised.

+corium.+ The deep or connective tissue layer of the skin; the true
skin.

+cornea.+ A transparent membrane forming the outer coat of the eyeball.

+cornification.+ Conversion into a hard or horny substance or tissue.

+corpuscles.+ Minute bodies. Primary atoms of the blood.

+corrosive.+ A substance that eats or destroys.

+cortex.+ The external gray layer of the brain; the outer covering in
plant life.

+cortical.+ External, in contradistinction to other parts, in tissue or
plant.

+cosmetic.+ An agent or a means for beautifying the body.

+counterirritant.+ Means or medications to produce irritation to relieve
deeper congestion.

+crepitus.+ The grating of fractured bones.

+crisis.+ A sudden favorable change in the course of an acute disease.

+cryptogam.+ A group of plants without flowers and without
embryo—containing seeds.

+cuneiform.+ A wedge-shaped bone found in the carpus (one) and in the
tarsus (three).

+cupping.+ Blood-abstraction by means of cupping-glasses.

+curette (curet).+ Spoon-shaped instrument for scraping.

+cutis.+ The skin.

+cyanosis.+ Blue discoloration of the skin from non-oxidation of blood.

+cyte.+ Cell or corpuscle, as in leucocyte, white blood cell.

+D+

+dactyl.+ Finger, as in dactylitis, inflammation of one or more fingers.

+debris.+ Scattered fragments.

+decomposition.+ Decay. Breaking up into its original elements.

+deformity.+ A deviation from normal in shape or in size.

+deleterious.+ Injurious, noxious, harmful.

+demarcation.+ A tissue boundary mark.

+dentine.+ The bony structure of the teeth.

+derma.+ The skin.

+dermatitis.+ Inflammation of the skin.

+devitalize.+ To destroy vitality.

+diabetes (mellitus).+ A disease of metabolism characterized by the
presence of sugar in the voided urine.

+diagnosis.+ Determination of the nature of a disease.

+diapedesis.+ The passage of the blood-corpuscles through the
vessel-walls without rupture of the latter.

+diaphoresis.+ Excessive perspirattion.

+diaphragm.+ The muscular wall between the thorax and the abdomen.

+diaphysis.+ Relating to the shaft of the bone.

+diffusion.+ A scattering about.

+digit.+ A finger or toe.

+dilatation.+ An expansion of a vessel or an organ.

+discutient.+ An agent which causes the dispersal of a tumor or of a
pathologic neoplasm of any kind.

+disease.+ A pathologic condition of any part or organ of the body.

+disinfection.+ Freeing from infection.

+disintegration.+ Separation of component parts.

+dislocation.+ Displacement of an organ or of a part.

+dissection.+ A separation by cutting of the parts of the body.

+distortion.+ Mechanical derangement of a part interfering with its
function.

+dorsal.+ Pertaining to the back.

+dorsum.+ The back, the posterior part of an organ.

+drainage.+ (Surgically) The gradual removal of the contents of a
suppurating cavity.

+d.s. or s.+ Used in prescription writing, meaning to give directions.

+dynia.+ Pain, as in pleurodynia, pain in the pleura.

+E+

+ecchymosis.+ An extravasation of blood or slight hemorrhage under the
skin resulting in a purplish patch.

+echinococcus.+ The larval stage of the dog tapeworm, occurring also in
human organs or tissues.

+ectomy.+ To cut out, as in prostatectomy, removal of a part or all of
the prostate.

+eczema.+ Inflammation of the skin (acute or chronic, moist or dry),
accompanied by itching and burning.

+edema.+ Accumulation of serum in the cellular tissue.

+edematous.+ Relating to edema.

+effusion.+ Escape of fluid from within, out.

+embolism.+ The obstruction of a blood vessel by an embolus cleavage.

+embolus.+ A plug composed of detached clot in the circulation.

+embryonic.+ Rudimentary.

+emigration.+ The outward passage of a wandering cell through the walls
of a blood-vessel.

+empyema.+ Pus in a cavity.

+en or endo.+ Within, as in endocardium, inner lining of the heart.

+encapsule.+ To inclose in a sheath.

+endermatically.+ Within or through the skin.

+endoneural.+ Within the nerve.

+endosteum.+ Membrane covering bone surface in the medullary cavity.

+endothelial.+ Pertaining to or consisting of endothelium. A lining
cavity not communicating with the outer air.

+enteroclysis.+ A high enema.

+enterostomy.+ Establishing an artificial anus through the abdominal
wall.

+epidermis.+ The outer layer of the skin constituting the outer
investment of the body.

+epiphyseal.+ Pertaining to the epiphysis.

+epiphysis.+ A piece of bone that in early life is separated from a long
bone by cartilage, but later becomes part of the bone.

+epithelial.+ Pertaining to epithelium.

+epithelioma.+ A cancerous growth originating from squamous epithelium.

+epithelium.+ The cells covering all cutaneous and mucous surfaces,
together with the secreting cells of glands developed from the
ectoderm.

+erysipelas.+ An acute specific inflammation of the skin and
subcutaneous tissues, accompanied by fever and constitutional
disturbances. Caused by the streptococcus erysipelatos.

+erythema.+ Redness of the skin.

+eschar.+ A scar.

+escharotic.+ A substance producing an eschar.

+esia.+ Sensation, as in anesthesia, loss of sensation.

+ethyl bromide.+ A colorless liquid, used for both general and local
anesthesia.

+ethyl chloride.+ A colorless liquid, whose spray produces local
anesthesia.

+etiology.+ Cause as related to disease.

+eucaine.+ A synthetic compound capable of producing local anesthesia.

+evacuated.+ Removal of waste material from the body.

+evaporation.+ Turning into vapor.

+eversion.+ Turning outward. Turning back an eyelid so as to expose the
conjunctiva. Turning the inner border of the foot outward.

+ex.+ Out of or from, as in exostosis, a bony outgrowth.

+exacerbation.+ Increased severity of a disease or of its symptoms.

+excretion.+ The product of a gland or of cells not useful to the
economy, in contradistinction to secretion.

+excoriation.+ Removal of the superficial protective layer of the skin
or mucous membrane.

+exfoliate.+ To strip off in layers. To desquamate.

+exostosis.+ A bony tumor springing from bone.

+extravasation.+ Effusion of fluid into the tissues.

+F+

+facet.+ A small plane, articulating surface.

+facient.+ To make, as in rubefacient, to make red.

+facultative.+ Pertaining to functional or acquired power.

+Faradic.+ Pertaining to induced electric currents.

+fauces.+ The space between the cavity of the mouth and the pharynx.

+felon.+ Paronychia. Whitlow.

+femur.+ The thigh bone.

+ferment.+ An organic substance which in small quantities is capable of
setting up changes in another organic substance without itself
undergoing much change.

+fermentation.+ Such changes as are effected exclusively by the vital
action of ferments.

+fibrin.+ Active agent in blood coagulation.

+fibroma.+ A tumor of fibrous tissue.

+fibrous.+ Composed of fibres.

+fibula.+ External and smaller of the two bones of the leg.

+fissure.+ A crack in the tissues.

+fistula.+ A pathologic sinus leading from an abscess cavity to the
surface.

+flagella.+ The whiplike processes with which certain cells, as the
ameba, are provided.

+flexion.+ Bending.

+fluorescence.+ Power of a body to change wave-rate (or color) of light
passing through it.

+focus.+ Point at which light rays meet. The starting point of a disease
process.

+follicle.+ A small secretory cavity or sac.

+form.+ Shape, as in vermiform, resembling a worm in shape.

+formaldehyde.+ A gas possessing powerful disinfectant properties.

+fracture.+ A break, as of a bone.

+fulcrum.+ The point against which lever is placed to get purchase.

+fungating.+ Rapidly growing (path.).

+fungus (plural fungi).+ A cellular vegetable organism which feeds on
organic matter. Example, bacteria.

+furunculosis.+ The systemic condition marked by boil-formation.

+G+

+gangrene.+ A necrosis with putrefaction.

+gastrostomy.+ Making an artificial opening into the stomach.

+gelatinous.+ Resembling gelatine, a semi-liquid substance.

+genesis.+ Birth of, belonging to, as in genesial, relating to
generation.

+germicide.+ An agent destructive to germs.

+globular.+ Shaped like a globe.

+gonorrhoea.+ A specific inflammation of the mucous membrane of the
genital tract; germal cause, gonococcus.

+gout.+ Podagra. A disease of metabolism characterized by paroxysmal
pains in the foot, particularly in the great toe.

+gradus.+ Step by step, as in graduated, marked by lines or in other
ways to denote capacity.

+granular.+ Composed of grains or granulations.

+granuloma.+ A collection of epitheloid cells at an irritated point.

+gumma.+ A gummy tumor resulting from a peculiar caseation of a teritary
syphilitic inflammatory deposit.

+H+

+habitat.+ The natural locality of an animal or a plant; impregnated;
saturated with.

+hallux rigidus.+ First phalanx of the great toe is flexed at an angle
of 30° with extension of the second phalanx.

+hallux valgus.+ Outward rotation of big toe beyond an angle of 15°.

+hallux varus.+ Pigeon toe.

+heloma.+ Same as corn or callus.

+heloma durum.+ Hard or indurated corn.

+heloma miliare.+ A millet-seed corn.

+heloma molle.+ Soft corn.

+heloma vasculare.+ A corn of the vascular variety.

+hema.+ Blood, as in hemoglobin, an iron compound in the red blood.

+hematoma.+ A tumor containing blood.

+hemorhage.+ A flow of blood.

+hemophelia.+ Abnormal tendency to hemorrhage.

+hemostatic.+ Capable of arresting hemorrhage.

+hereditary.+ Transmitted from parent to offspring.

+hernia.+ Rupture; protusion of a structure thro the wall which
ordinarily contains it.

+herniotomy.+ Operation for the relief of hernia.

+hidros.+ Perspiration, hyperidrosis, excessive sweating.

+histology.+ Microscopic anatomy.

+hyascine.+ An alkaloid of hyoscyamus and stramonium.

+hydro.+ Water, hydrotherapy, treatment of disease by means of water.

+hydrarthrosis.+ A serous effusion in a joint.

+hyper.+ Above or over, hyperemia, the presence of an increased or
overamount of blood in a part.

+hyperemia.+ Excessive amount of blood.

+hyperidrosis.+ Excessive sweating.

+hyperplasia.+ Overgrowth of a part due to a multiplication of its
elements.

+hypertrophy.+ Abnormal, increased size of a part or of an organ.

+hypnotic.+ Causing sleep.

+hypo.+ Under, as in hypodermic, beneath the skin, or subcutaneous.

+hypodermatic (hypodermic).+ Subcutaneous, applied to injections
underneath the skin.

+hypodermoclysis.+ The hypodermic injection of fluids to supply a lack
of blood.

+hysteria.+ A functional neurosis with abnormal sensations, emotions or
paroxysms.

+I+

+ic.+ Relating to, as in caloric, relating to temperature.

+ichthyol.+ A brownish oil; principally used in the form of ammonium
ichthyol as an antiseptic.

+immersion.+ The plunging of a body into a liquid.

+immobilization.+ The act of rendering a part immobile (immovable).

+immunity.+ Freedom from risk of infection.

+incubation.+ The development of an infectious disease from the
infection period to the appearance of the first symptoms.

+indolent.+ Inactive, sluggish.

+induration.+ Hardening as of tissues.

+ine.+ (Phar.) Alkaloid, as in morphine, an alkaloid.

+infection.+ Invasion by pathogenic microorganisms which act injuriously
upon the tissues, causing disease.

+inflammation.+ A morbid condition characterized by hyperemia, pain,
heat, swelling and disordered function.

+infra.+ (L. below). A prefix denoting below, as infracostal, below a
rib.

+innervation.+ Distribution of the nerves in a part.

+inoculation.+ The introduction of a specific virus into the system.

+inorganic.+ Devoid of organized structure.

+in situ (Latin).+ In position.

+integument.+ The enveloping membrane of the body.

+intercellular.+ Between the cells.

+intermittant.+ Occurring at intervals.

+interosseous.+ Between bone tissue.

+interstices.+ Spaces, intervals, pores.

+interstitial.+ Lying or placed between.

+intra.+ (L. within). A prefix denoting within or inside, as
intraneural, within a nerve.

+intravenous.+ Within a vein.

+inunction.+ Administering a drug in ointment form by rubbing into the
skin.

+inversion.+ The reversion of the normal position of an organ, turning
inward, inside out, etc.

+involucrum.+ An enveloping membrane.

+iodide.+ A compound of iodin with another element, as iodide of
potassium.

+iodin (iodine).+ A non-metallic chemical element.

+iodoform.+ A lemon yellow crystalline powder; used as an antiseptic to
wounds and sores.

+iritis.+ Inflammation of the iris, the anterior division of the
vascular tunic of the eye.

+iron.+ A metallic element.

+irrigation.+ The washing out of a cavity or wounded surface with a
stream of fluid.

+itis.+ Inflammation, as in pericarditis, inflammation of the
pericardium.

+J+

+jaundice.+ A yellow tissue-staining from bile.

+jaw.+ One of the two bony structures of the mouth in which the teeth
are set.

+jugular.+ Relating to the throat or neck.

+juice.+ Tissue fluid of a plant or animal.

+jute.+ Fiber used in surgical dressings.

+juxta.+ Prefix; meaning close to or next.

+K+

+kalium.+ Latin for potassium.

+kaolin.+ Fuller’s earth; used as a poultice with glycerin.

+karyokinesis.+ Indirect nuclear division, mitosis.

+keratin.+ A scleroprotein present in skin appendages, hair, nails, etc.

+keratitis.+ Inflammation of the cornea.

+kerato.+ A prefix denoting horny tissue or cells.

+keratodermia.+ Hypertrophy of horny layer of epidermis.

+keratosis.+ Circumscribed over-growths of horny layer of skin.

+kinetic.+ Relating to motion or to muscular movements.

+kneading.+ To work and press into a mass.

+knee.+ Articulation between femur and tibia covered in front by the
patella.

+knee-jerk.+ Patellar reflex.

+L+

+lacerated.+ Torn.

+lacuna.+ A small gap or hollow space.

+lacuna, osseous.+ A space in the Haversian system occupied by
bone-corpuscle.

+lacunar resorption.+ Absorption of lacunae.

+lamella.+ One of the plates forming the Haversian system of bone.

+lancet.+ A surgical knife with a two-edged blade.

+lancinating.+ A sharp, cutting pain.

+Lassar’s paste.+ An ointment containing salicylic acid, talcum and zinc
oxide.

+laughing gas.+ Nitrous oxide gas.

+lead and opium wash.+ See Wash.

+leucemia.+ A disease of the blood marked by persistent leucocytosis.

+leucocyte.+ White blood corpuscle or a white cell.

+leucocytosis.+ An increase in the number of white cells in the blood.

+leukos.+ White, as in leucocyte, a white blood cell.

+ligament.+ A band or sheet of fibrous tissue connecting two or more
bones, cartilages or other structures or serving as support for
fasciae or muscle.

+ligature.+ A thread or the like tied about a blood vessel or other
structure to constrict it.

+linimentum. Liniment.+ A medicament in alcohol, oil or water, applied
by friction to the skin.

   +l. aconiti et chloroformi.+ Anodyne application.

   +l. ammoniae.+ Counter irritant.

   +l. ammonii iodidi.+ Discutient.

   +l. calcis.+ To mollify burns and scalds.

   +l. camphorae.+ A mild counterirritant.

   +l. chloroformi.+ Anodyne and rubefacient.

   +l. crotonis.+ Counterirritant.

   +l. hydrargyri.+ Anti-syphilitic.

   +l. iodi.+ Discutient.

   +l. opii.+ Anodyne.

   +l. saponis.+ A base for other liniments.

   +l. sinapis.+ Counterirritant.

   +l. terebinthinae.+ Soothing application.

+lint.+ A soft absorbent material used in surgical dressings.

+lipoma.+ A fatty tumor.

+liquor.+ Solution of a nonvolatile substance.

   +l. acidi chromici.+ Used, well diluted, as a wash in
   bromidrosis.

   +l. alumini acetatis+ (Burows’ solution). For external use as an
   astringent and antiseptic.

   +l. antisepticus.+ A mouthwash.

   +l. bromi.+ Antiseptic.

   +l. Burowii.+ Astringent and antiseptic (See l. alum. acet.)

   +l. caoutchouc.+ For rubber skin.

   +l. cresolis compositus.+ Antiseptic and disinfectant where
   vesicles form.

   +l. ferri persulphatis.+ Styptic.

   +l. ferrisub sulphatis.+ Monsel’s solution. Styptic.

   +l. hydrargyri nitratis.+ Caustic application.

   +l. iodi carbolatus.+ Antiseptic counterirritant.

   +l. plumbi subacetatis.+ For bruises and sprains.

   +l. sodii boratis compositus.+ Dobell’s solution. An alkaline
   antiseptic preparation.

   +l. sodii ethylatis.+ Employed externally as a caustic.

   +l. sodii silicatis.+ Used in surgery for applying splints.

   +l. zinci chlorodi.+ Disinfectant and deodorant.

+listerine.+ Trade name of a solution containing boric acid, benzoic
acid, thymol and other substances.

+Lister’s method.+ Antiseptic surgery.

+lith.+ Stone, as in lithology, the branch of medical science, relating
to calculi or concretions.

+litter.+ A stretcher for carrying the sick or wounded.

+locomotor ataxia (tabes dorsalis).+ Hardening of the posterior columns,
ganglia, roots and peripheral nerves of the spinal cord.

+logos.+ Treatise, as in Pathology, a branch of medical science which
treats of disease in all its relations.

+lotio.+ Latin for lotion or wash.

   +l. hydrargyri flava.+ Yellow mercurial wash.

   +l. hydrargyri nigra.+ Black mercurial wash. (Both of the above
   are used as applications to venereal sores).

   +l. plumbi et opii.+ Lead and opium wash. Applied to sprains and
   bruises.

+luetic.+ Syphilitic.

+luetin test.+ A skin test for the diagnosis of syphilis.

+lumen.+ The space in the interior of a tubular structure, such as an
artery.

+lunula.+ The opaque, whitish, semi-lunar area near the root of the
nail.

+lymph.+ A clear yellow fluid found in the lymph spaces or lymphatic
vessels of the body.

+lymphangioma.+ New formation of lymphatic vessels.

+lymphangitis.+ Inflammation of lymphatic vessels.

+lymphoma.+ A tumor of lymphoid tissue.

+lysis.+ Solution, as in analysis, the breaking up of a chemical
compound into its simpler elements. Also the gradual subsidence of
symptoms in a disease as distinguished from crisis.

+lysol.+ Trade name of a mixture of soaps and phenols; used as a
disinfectant.

+M+

+macrococcus.+ A large unicellular microorganism.

+macros.+ Large, as in macroscopic, an object visible to the naked eye.

+macula.+ Spot, as in macular, relating to or marked by macules, or
spotted.

+magnesium sulphate.+ Epsom salts; a purgative.

+malignant.+ Resistant to treatment and tending to grow.

+malleolus.+ A process of bone the shape of the head of a hammer.

+mania.+ Frenzy, as in megalomania, a delusion of grandeur.

+manifestation.+ Clear to the eye or to the mind.

+manus.+ Hand, as in manual, relating to or performed with the hands.

+marrow.+ The soft substance filling the medullary cavities and
cancellous extremities of the long bones.

+massage.+ A scientific method of manipulating the body by rubbing,
pinching, kneading, tapping, etc.

+matrix.+ The formative portion of a nail or of a tooth.

+measles.+ An acute exanthematous disease.

+medullary.+ Relating to the medulla or marrow.

+membrane.+ A layer of tissue covering a part or connecting two
structures.

+mercury. Quicksilver.+

+metastasis.+ A change in the seat of disease.

+metatarsalgia.+ Pain in the metatarsus.