damental condition of success, we will now consider it as practiced and prescribed by Lister. A diagram will make this plain. 1. Represents a wound containing a drainage tube. 2. Is a protective of oiled silk in contact with the wound, overlapping its edge, and traversed by the drainage tube. 3. A layer of folded and carbolized muslin, which largely overlaps the protective. 4. A final layer of folded carbolized muslin, containing a single rubber cloth. The latter has the distinct duty of diverting the discharge and delaying its direct progress to the surface. It thus retards decomposition, which occurs in the fluid soon after it has soaked its way to the air, and is then rapidly communicated to the wound. 5. Represents the path of the discharged fluid, when diverted by the rubber cloth. The same dressing is to be wrapped about the extremity of a stump, or carefully fitted to the curved surfaces of the chest and shoulder, — for example, after excision of a breast, and the whole is then bandaged. A dry spot of discharge appearing on the surface of the bandage may perhaps be overlooked. But if the discharge soaks through it, and the stain grows larger, the whole dressing must be renewed at once. This happens the day after the operation; then perhaps several times in a week; later, more rarely. It is desirable that the carbolized covering should exert an antiseptic influence for many days, or, as sometimes in a knee excision, for several weeks, without renewal. This is the object of the muslin, a coarse and cheap fabric impregnated with carbolic acid, which is mixed with rosin to hold and slowly deliver it, and with paraffine to make the rosin flexible.1 Briefly to recapitulate: the wound is covered with oiled silk, and with fifteen or twenty layers of carbolized muslin containing a rubber cloth, and then bandaged. Every precaution is taken to prevent the contact of germs, 1 The following is the method of making the carbolized muslin :Crystallized carbolic acid Common resin Solid paraffine Melt the two latter in a water bath, and add the acid while stirring. one part. five parts. seven parts. The muslin employed in our hospital is of cotton, and known as Colerain or strainer cloth. The hot mixture is sprinkled upon the muslin with a large brush. To further diffuse the carbolized mixture, the muslin is then folded small, and subjected to pressure in a tin can, for several hours, at the temperature of boiling water. whether during an operation or a dressing; the wound, the skin, the cloths, the surgeon's hands, the instruments and sponges, being all repeatedly washed in a carbolic solution. LISTER'S ATOMIZER. The atomizer, which blows a cloud of spray, of the strength of one in forty, upon a wound, whether during an operation or a dressing, is an essential feature of Lister's method. It certainly adds nothing to the immediate comfort of the surgeon. But it seems to be an available substitute for a part of the washing and slopping incident to the use of antiseptics in a fluid form. and is in that respect a great convenience. This is especially true of a dressing in bed. Its efficiency could hardly have been anticipated, but there is no reason to doubt it. Lister seems to have first tried a jet of fluid. The result of a complete Lister dressing, spray included, is sometimes marvelous, as, for example, in a resection of the knee, which may require to be dressed two or three times during the first ten days, and only as often during the next two or three months. This method might be advantageously practiced for the first time under a sunbeam where the enemy is visible. Other methods will in time doubtless supersede it, but there is no reason to suppose that its principles can be neglected without largely impairing the average result. The fighting manual of exclusion may change from year to year, but an uncompromising hostility to germs will continue to be an abiding article of surgical faith. DRAINAGE. Fluid con We are now to consider another point of great importance. tents accumulate in a closed wound. If you remove a fatty tumor from the back, you will find it difficult to get a permanent union by first intention. A sanious fluid collects beneath the uniting integuments, and the wound becomes an abscess. This often happens after excision of the breast, of tumors under the angle of the jaw, and beneath the flaps of amputation. Ligatures and stitches encourage such abscesses, and are often responsible for them. It is therefore a cardinal point in the treatment of every closed wound to evacuate this sanious fluid by inserting in the wound, before dressing it, a "tent" over which the flaps may heal. Such a tent is a small rubber tube perforated with holes, and inserted in a dependent part of the incision, deep enough to insure its drainage. It passes through the oiled-silk protective, and is then cut off and secured by a string, so that it may deliver the fluids outside the silk into the muslin. Every considerable sinus afterwards occurring about a wound must be thus drained. During the healing of a wound nothing is so insidious as the burrowing of pus, which may occur even when it is not wholly imprisoned. It travels by its own weight. I have formerly and repeatedly impressed on you the necessity of free incisions for its evacuation at the nearest surface which it is safe to cut. In these days such incisions should be tubed, and their interior injected and carbolized. If you cannot cover them with antiseptic dressing, let them be carefully and thoroughly injected with a carbolic solution of one in sixty, or one in forty, twice a day, and placed under a carbolic drip. The drainage tube is withdrawn gradually and slowly, in view of the fact that any premature closing of the interior surely results in abscess. Horse-hair and other materials have been suggested as substitutes for the rubber tube, but not, as I think, with advantage. LIGATURES. A common silk ligature, cut short and left upon an artery, after some months decomposes and disappears. But catgut, even when carbolized, and whether employed as ligature or stitch, deliquesces in a few days, and so repays the trouble of its use. Once applied, it needs no thought, and in fact generates in its immediate neighborhood a wholesome carbolic atmosphere. ANTISEPTIC SUBSTITUTES. If you have no atomizer, drench the wound or compound fracture inside and out with a solution of one in forty; or wipe it out and pour in carbolized oil,' as originally recommended by Lister in the treatment of compound fracture, and then get the wet and wide-spread dressing quickly into place, with oiled silk next the wound, — or, if you have none, wet and carbolized cotton batting, or folded cotton cloth, or both. A limb thus dressed, or even without dressing, may be placed under a drip, as in the two cases of open kneejoint in our wards, where a wick-yarn siphon leads the antiseptic fluids to a cloth lightly laid on the gaping wound, while another below the limb conducts it from a rubber sheet to the floor. On the body a drip is less available than on a limb. You may remember that a pile of burnt flour is an old and good dressing for certain ulcers. Carbolized sawdust or bran has been advantageously substituted for flour upon a carbolized wound. Guerin's cotton-wool dressing effectively filters the air, especially if the inner layers be wet and carbolized. But the outer and dry layers should be several inches in thickness, and largely overlap the wound or wrap the limb. The surgeon undoubtedly obtains excellent results by this method, — the carbolic element, which adds greatly to its efficiency, having been adopted from Lister. CARBOLIC POISONING. When a large surface has been dressed with a carbolic lotion for a considerable time, the system may suffer from its absorption. The most striking toxic indication is a dark bluish-green color in the urine; there is also prostration. It is then necessary to discontinue the carbolized fluid. Salicylic acid may be substituted.2 I have purposely deferred until the conclusion of this lecture two matters of importance. The first is the relation of repair to the pulse and temperature; the second, its relation to coagulum. The first of these points has great practical interest. 1 One part carbolic acid in six to fifteen parts of linseed oil. 2 Water dissolves, of salicylic acid, only about one part in three hundred; but the addition of eight parts of borax to boiling water enables it to dissolve ten parts in one hundred. Alcohol dissolves salicylic acid, and the solution may be then mixed with water to impreg nate cotton-wool. The addition of a little glycerine keeps the pungent dust from the atmos phere, if the cotton be used after drying. I. INDICATION OF ABSCESS IN THE WOUND. In the old method of dressing wounds, hæmorrhage and suppuration announce themselves at the surface. But you will ask, as I did, How can we ascertain whether a mass of antiseptic covering may not imprison or conceal an abscess fatal to union, and possibly disastrous to the patient? Fortunately, an abscess in the wound unfailingly and at once reveals itself by an elevation of pulse and temperature. An abrupt protrusion upon the zigzag lines of the carefully kept chart peremptorily directs attention to the wound and a renewal of the dressing. Such an abscess must be at once freely evacuated, carbolized, and tubed, whether it be again protected by a close dressing or by a lighter antiseptic covering. II. COAGULUM. When dealing with a wound which is to be covered by integument, the surgeon cannot exercise too much patience in tying all the vessels. Fluids may, notwithstanding all his care, collect in the cavity. The mere washing of a freshly cut surface with a carbolic solution of one in forty excites the capillaries so that effectual drainage becomes essential. In a closed wound we aim by the careful drainage of blood and serum to secure a permanent contact of the surfaces. But in an open wound a coagulum may be turned to good account. Its exact behavior is less important. Physiologists incline to the opinion that it does not itself become transformed, but that new tissue penetrates into its interstices. It may thus become an admirable dressing, provided only we prevent its death and deliquescence. This is quite possible by thorough antiseptic protection. CASE OF ESOPHAGOTOMY.1 BY A. B. ATHERTON, M. D., FREDERICKTON, N. B. PREVIOUS history: Mrs. F., aged seventy, multipara, has had asthma for ten or fifteen years, and suffers nearly all the time from a cough, with considerable expectoration. Otherwise her health is good. The patient was always thin. At noon, August 28, 1877, while eating some lamb, she swallowed a piece of bone, which stuck in her throat and caused a good deal of choking. While I was being sent for, she succeeded, by external manipulations with thumb and fingers, in working the foreign body down as far as the lower part of the neck. I was soon in attendance, and by means of œsophageal forceps and horse-hair snare endeavored to withdraw the foreign body, but without success. I also made some slight attempts to push it down into the stomach, but it could not be moved from its position. Much distress and pain were caused both by presence of the bone and by my efforts to dislodge it. August 29th. The suffering was so great that scarcely any sleep had been obtained. The cough was very troublesome, and she felt something sticking in the throat when she tried to expectorate. She swallowed with pain and difficulty. Pulse 100, feeble. Esophagotomy was advised and consented to. 1 Communicated to the JOURNAL, at the author's request, by D. W. Cheever, M. D. Operation. Chloroform was given for a few minutes, till she was partially anæsthetized, and then ether was substituted. An incision three or four inches long was made on the left side of the neck at the inner side of the sterno-mastoid, but not quite so obliquely as that muscle runs. The anterior jugular vein lay so much in the way that it was divided, and bleeding from it was controlled by torsion. After getting through the superficial fascia and platysma muscle, there came into view the anterior belly of the omo-hyoid, which with the sterno-mastoid and carotid vessels was drawn to outer side. By use of director and handle of knife the posterior part of the trachea was reached. Now a sponge probang was passed through the mouth into the œsophagus, till it brought up against the obstruction. The sponge could be felt somewhat indistinctly at the bottom of the wound, and, after considerable searching, just below it and at the lower end of the incision was discovered a hard body with a rather sharp outline. A slight touch of the knife brought into view the upper end of a piece of bone, which was seized by forceps and extracted. It proved to be a portion of lamb's rib, having obliquely cut ends. and measuring rather more than one and one half inches from tip to tip. It lay nearly straight up and down in the oesophagus, but its rough, jagged ends prevented its being readily dislodged. I omitted to mention that upon coming down upon the deep tissues I found them swollen, and the parts about the œsophagus infiltrated with what appeared to be sero-purulent matter. Also some bubbles of gas escaped before I cut into the oesophagus. The wound was sopped with carbolic acid and water, one to eight. Also three stitches were put in the upper part of the incision. The rest was left open. Carbolized oil dressing. Eight P. M. Patient has had a good deal of distress from thin mucus in air passages, giv. ing rise to almost constant cough and expectoration; also considerable pain in neck, and soreness in chest and between scapula. Latter relieved somewhat by poultices. Pulse 112. Oat-meal gruel (strained) given by enema; one half pint in quantity. August 30th. Enema was not retained. Slept but little. Otherwise as yesterday evening. About four ounces of gruel given this morning. Twelve A. M. Enema not retained long. Repeated at visit. Nine P. M. Enema came away in half an hour. One of beef tea given this evening, two or three drachms of brandy being added. August 31st. Slept rather more than on previous night. Retained enema. A good deal of pain and soreness of neck, increased by cough. Pulse 96. Enema of last evening repeated. Nothing but a little water allowed by mouth since operation. September 1st. Last two enemata given yesterday were returned almost immediately. Very restless all night. Pulse 96. Very feeble. Patient looks haggard, and moves in bed with difficulty. Wound appears sloughy since yesterday, and smells foully. Enema given at visit, but was soon returned. Four P. M. A tube passed into stomach and one half pint of brandy and milk injected. Nine P. M. Seems rather better, and moves with greater ease. Pulse 88. Enema of beef tea and brandy tried again. No opiate added, through fear of ill effects upon expectoration. For same reason none has been given by mouth since operation. September 2d. Retained enema, but slept little. Cough very troublesome, and expectoration thicker and more purulent. Looks about as yesterday morning. Pulse 92. Weak. Tube introduced into stomach and more than one half pint of milk with a tablespoonful of brandy injected. Two P. M. Beef tea and brandy injected into stomach. Seven P. M. Looking brighter. Cough still pretty severe. One pint of milk and an ounce of brandy administered by tube. September 3d. Slept pretty well. Cough not so bad. Swallows some nourishment, and thinks that when head is turned to right side very little runs out of wound. Asks to stop, therefore, taking food by tube. Pulse 92 Sutures removed from wound, which still looks sloughy. Two P. M. One pint of milk and |