SUBGEKY. 719 SURGERY. chosen for incision and for a wide area around it is tlioroughly scrubbed and sliavcn and then covered by a soap poultice. Immediately before the operation the skin is again scrubbed, wiped otf with spirits of turpentine, ether, and a 0.1 per cent, solution of corrosive sublimate in alco- hol. If local anifsthesia is sufficient it is se- cured by the injection into the skin and sub- cutaneous tissues of dilute solutions of cocaine. If general amesthesia is necessary, ether, chloro- form, or nitrous oxide may be used, the choice depending upon the duration of the operation and upon the presence or alisence of certain physical changes in the heart, blood-vessels, lungs, and kidneys. In any case the necessary restoratives must be at hand. (3) The Surgeons' Preparations. — The sur- geons' preparations consist in sterilization of their hands and forearms and in the assumption of gowns designed to prevent dust from settling from the clothing upon the wound, instruments, etc. Such gowns are of coarse cotton or linen, and extend from the neck to the feet ; the sleeves only reach the elbow. They are sterilized by steam before using. The hands and forearms of all persons likely to handle the wound, instru- ments, dressings, etc., are thoroughly disinfected and the hands covered by thin rubber gloves previously sterilized by boiling. (4) The Operation. — In addition to the proce- dures necessary to fulfill the purpose of the operation, the most painstaking care is exer- cised to exclude all bacteria from woimds, in aseptic operations; and to kill or remove the bacteria present, and to avoid the introduction of more bacteria, in antiseptic operations. There- fore, besides the elalxirate preparations just de- scribed during the progress of an aseptic opera- tion, much attention must be paid to cleanliness, (a) No substance — finger, instrument, sponge, or dressing — is allowed to come into contact with the wound unless previously sterilized, (b) In- struments, sponges, and the surgeons' and as- sistants' hands are rinsed in. sterile solutions from time to time, (c) If, for any reason, hands or instruments become soiled, they must be re- sterilized before again coming into contact with the wound, (d) No antiseptic fluids are to be used in tlie wound. If any flushing at all is necessary, sterile salt solution only is allowable. For antiseptic operations, the same preparations are made, but here it is often advisable to use antiseptic rather than simple sterile solutions. Otherwise the precautions are the same. The first step in so-called bloody operations is the division of the integument. This is done by cutting implements, as knives and scissors, or, sometimes, by the actual cautery, or the ^craseur. Subsequent steps are accomplished in a variety of ways : To expose deep-seated tissues, retractors arc used. To facilitate dissection, various forms of forceps are used. To puncture cavities, hol- low needles and trocars are used. To scrape out tissue, sharp spoons are used. To divide bones, saws, chisels, and strong cutting foi'ceps are used. The division of tissue involves more or less bleeding. To prevent bleeding, in operations upon the extremities digital or instrumental compression of the afferent arteries is prac- ticed, or the afferent artery may be ligated as a preliminary step. During the progress of the operation the 'bleeding points'— ends of the ves- sels — are seized by clamps, and then ligated with catgut. General oozing is controlled by packing the wound with dry gauze, or by flushing it with very hot salt solution, or by touching tlie surface with the actual canter^', or by elevating the part. At the end of the operation it re- mains to treat the wound so as to secure healing in the shortest possible time, and with a mini- nnnu scar, i.e. to secure union by first intention. For this purpose every obstacle to such union is removed. (a) Bleeding is absolutely stopped, (b) Foreign bodies, including bacteria, are re- moved, (c) The walls of the wound are brought into close contact and no 'dead spaces' allowed to remain, (d) Drainage is provided for, i.e. vents established for the escape of wound secre- tions, (e) The wound is protected from possible bacterial invasion, and the wounded tissues sup- ported and immobilized by dressings. (5) After-Trcatment. — After the dressing has been applied, the patient is moved to his bed and allowed to recover from the anaesthetic. Mor- phine is often given to diminish vomiting and to mitigate anticipated pain. General symptoms, as shock or acute ana?mia, are treated if they exist. No food or drink is given by the mouth until the nausea and vomiting caused by the anaesthetic have ceased. Then small but increas- ing quantities of milk or beef-juice are given until the desired diet is taken. If there is reten- tion of urine, the bladder is emptied with the catheter. The bowels are to be moved by the sec- ond or third day after operation. Drains are removed in two to five days. Sutures are re- moved in five to seven days. If suppuration, due of course to bacteria, develops, the particular inflammation excited is to be treated as indicated by its characteristics. From what has just been outlined it is obvious enough that all of the conditions looking toward the successful issue of a serious operation can be secured only in hospitals of first-class equip- ment; and it is to be noted that this fact is be- coming so generally known that hospitals of the first class are being established and operated not only in the larger cities of this country, but also in the smaller ones and even in villages. Insti- tutions of this kind are of benefit to the com- munities in which they exist and by which they are supported in many ways. Thc.v furnish at a nominal cost, or very often without charge, care for the sick poor that could be supplied in no other way; and the well-to-do may find in them facilities for the treatment of disease and par- ticiilarly for the conduct of operations that can- not be secured even in their own homes. For the community at large they are also of the greatest value, since they afford for the medical men who serve in the hospitals a field which amplifies their experience indefinitely. Again, in the larger cities where medicine is taught as before out- lined the hospitals may be regarded as parts of the laboratory system. The wards are the places in which the student finally gains his practical experience in the recognition of particu- lar disease forms and the treatment of them. SURGERY, MiLiT.RT. The best civil have proved the best military surgeons, as is shovn by the great names in surgical history. Ambroise Par^, Larrey, Pirogoff, Von Bergman, Von Es- march, Billroth, and Lister. Not until the discov- ery of asepsis and antisepsis was the true foun- dation laid for the modern treatment of gun- shot wounds. This discovery so radically changed
