OF medicine national library of medicine NATIONAL IIBRARY OF MEDIC IN t Eitcmoo U1N Aavaan ivnoiivn M 3NIDI03W JO Aavaad aNiDiaiw jo Aavaan ivn NLM005601736 AV " VA = ^ V V V. :i - '"%/ RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICI avaan ivnouvn 3Noiaaw jo Aavaan ivnoiivn 3noiq3w jo Aavaan ivnoii' RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICII ovaan ivnoiivn 3noiq3w jo Aavaan ivnoiivn 3noio3w jo Aavaan ivnou> RY OF MEDICINE NATIONAL IIBRARY OF MEDICINE NATIONAL IIBRARY OF MEDICII RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY Of MEDICII ivaan ivnoiivn 3nidio3w jo Aavaan ivnoiivn snidiqsw jo Aavaan ivnoii1 xSh!,c#\! ^l-#- ! ^ EXTRACT FROM THE INTRODUCTION IN THE OPENING NUMBER OF . "THE CLIMATOLOGIST." AUGUST, .1891. "The object of this Journal is to,promote original investi- gation', to publish papers containing the observations and ex- perience, of physicians in this country and Europe on all matters relating to Climatology, Mineral Springs, Diet, Preventive Medicine, Race, Occupation, Life Insurance, and Sanitary Science—and in that way to supply the means by which the general practitioner and the public at large will become better acquainted with the diseases of this country and Europe, and better armed to meet the requirements of their prevention or cure. The study of these subjects in this country is exciting great and increasing interest, and all admit that, from the little knowledge already possessed of its resources, possibly every \ known combination of atmospheric condition, soil, altitude, cli- mate, or mineral springs, is to be found on this continent. It is . confidently expected that such a. journal vj\\\ receive encourage- ment and be an authority upon all questions which are included in its title. " Original papers upon diseases of localities—those incident to occupation, race, or climate, the study of epidemics, the J questions of proper food, of the water supply, its potability I and distribution, matters-relating to drainage and diseases de- pendent on it—as well as experimental studies, or laboratory i investigations on bacteriology, will form a prominent portion #of the material presented during the year, and it is to be hoped I that physicians of all sections of the country will send papers I upon these or any other subjects which will be of general in- terest - I " Special attention will also be paid to the subject of health f'esorts, descriptions of Sanitariums with special reference, to itheir suitability to certain cases, and the proper selection of (Patients likely to be benefitted by them. The utmost care will e taken that this Journal shall assume and maintain the .lighest scientific character. It will be absolutely independent ta its principles—/"^ towards all. It will depend for its main- enance upon the support given to it by the prefession, as it is pot published in the interest of any special section or clique," PRICE: Cloth, $1.00; Interleaved. Pq%Taking Notes, SI.25 ADDITIONS TO THE SERIES OF 1100? QUESTIO0-COjnPE0DS. FOR SEASON OF 1891-92. Essentials of Diagnosis. By S. SOLIS-COHEN, M. D. IVo. IO Essentials of Hygiene. ILLUSTRATED. * By ROBERT P. ROBINS, M.D. (In Preparation.) No. SO Essentials of Bacteriology. ILLUSTRATED. By M. V. BALL, M. D» JVo. SI Essentials of Nervous Diseases and Insanity! ILLUSTRATED. By JOHN C. SHAW, M. D. Essentials of Medical Physics. ILLUSTRATED. By FRED. J. BROCKWAY, M.D. (In Preparation.) INo. S3 Essentials of Medical Electricity. By DAVID D. STEWART, M. D., and EDWARD S. LAWRENCE, M. D. 1 ILLUSTRATED. , These small works, which can be con veniently carried in the pocket, contain in a condensed form the teachings of the most popular text-books. The authors are nearly all connected with the various colleges as Demon' strators or Lecturers, and are therefore thoroughly conversant, not only with the wants of the average student, but also with the points that are absolutely necessary to be remembered in the JExamination-Jtoont. These books are * constantly in the hands of their authors for revision, and are kept well up to the times, their fast sale allowing them to be almost entirely rewritten whenever necessary, instead of having to wait for the edition to be sold, as is the case with ^ an ordinary text-book. ■« THE ADVANTAGE OK QUESTIONS AND ANSWERS.—The usefulness of arranging the subjects in the form of questions and answers, will be apparent since the stndent, in reading the standard works, often is at a loss to discover 4 Che important points to be remembered, and is equally puzzled when heattemptR j to formulate ideas as to the manner in which the questions could be put in a examination-room. ' NOW READY. NANCREDE'S ESSENTIALS OF ANATOMY —AND— MANUAL OF PRACTICAL DISSECTION, WITH HANDSOME FULL-PAGE LITHOGRAPHIC PLATES IN COLORS. OVER 200 ILLUSTRATIONS. Price, Extra Cloth or Oilcloth for the Dissec- tion Room,......$2.00, Net. Medical Sheep,......2.50, Net. For sale by all booksellers, or sent, postpaid, on receipt of price by W. B. SAUNDERS, Medical Publisher, 913 "WALNUT STREET, PHILADELPHIA, PA. NOW READY. ADDITIONS TO THE SERIES OK SAUNDERS' QUESTION-COMPENDS, SINCE LAST SEASON (1889-90.) Nos. 8 and 9.—Essentials of Practice of Medicine. (Double num- ber, over Ave hundred pages.) By Henry Morris, M.D., Author of Es- sentials of Materia, Medica and Therapeutics, etc., etc. No. 10.—Essentials of Gynaecology, with numerous illustrations. By Edwin B. Craiqin, M.D., Attending Gynaecologist, Roosevelt Hos- pital, Outpatients Department; Assistant Surgeon New York Cancer Hospital, etc., etc. No. II.—Essentials of Diseases of the Skin. 75 illustrations. By Henry \V. Stel wagon, M. D., Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia; Physician to Philadelphia Dis- pensary for Skin Diseases ; Chief of the Skin Dispensary in the Hospital of University of Pennsylvania; Physician to Skin Department ot the Howard Hospital; Lecturer on Dermatology in the women's Medical College, Philadelphia, etc., etc. No. 12.—Essentials of Minor Surgery and Bandaging, with an Appendix on Venereal Diseases. Illustrated. By Edward Martin, M. D., author of the " Essentials of Surgery," etc., etc. No. 13.—Essentials of Legal Medicine, Toxicology and Hygiene. One hundred and thirty fine Illustrations. By C. E. Armand Semple, M.D., Author of "Essentials of Pathology and Morbid Anatomy," etc., etc. No. 14.—Essentials of the Refraction and Diseases of the Eye. Illustrated. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medi- cine; Member of the American Ophthalmological Society ; Fellow of the College of Physicians of Philadelphia; Fellow of the American Academy of Medicine,etc..etc.,and Essentials of Diseases ofthe Nose and Throat. Illustrated. By E. Baldwin Gleason, M. D.. Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylva- nia ; Assistant in the Nose and Throat Department of the Union Dispen- sary; Member of the German Medical Society, Philadelphia, Polyclinic Society, etc., etc. No. 15.—Essentials of Diseases of Children, illustrated. Bv William M. Powell, M. D., Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania; Examining Physician to the Children's Seashore House for Invalid Children, at At- lantic City, N. J.; formerly Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania, and Chief of the Medical Clinic of the Philadelphia Polyclinic. No. 16.—Essentials of Examination of Urine, colored •• Vogel Scale," and numerous Illustrations. By Lawrence Wolff, M.D., author of " Essentials of Chemistry," etc,, etc.; price, 75 cents. No. 17.—Essentials of Diagnosis. By David n. Stewart, m. d. Lecturer on Diseases of the Nervous System at the Jefferson Medicai College; Late Chief of the Medical Clinic Jefferson Medical College Hos- pital ; Physician to St. Mary's and St. Christopher's Hospitals; Fellow of the College of Physicians of Philadelphia, etc., etc. No. 18.—Essentials of the Practice of Pharmacy. By l e Sayre, Professor of Pharmacy and Materia Medica in the University of Kansas. For Sale by all booksellers. PRICE: Cloth, $1.00; Interleaved for Taking Notes, $1.25. SAUNDERS' QUESTION-COMPENDS, No. 12. ESSENTIALS OF MINOR SURGERY AND BANDAGING, WITH AX APPENDIX ON VENEREAL DISEASES. ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS. PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE. EDWARD MARTIN, A.M., M.D., INSTRUCTOR IN OPERATIVE SURGERY, UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE HOWARD HOSPITAL; ASSISTANT SURGEON TO THE UNI VERSITY HOSPITAL; AUTHOR OF "ESSENTIALS OF SURGERY," ETC., ETC. ILLUSTRATED. PHILADELPHIA: W. B. SAUNDERS, 913 Walnut Street. 1890. Wo 1340 Entered, according to Act of Congress, in the year 1890, by W. B. SAUNDERS, In the Office of the Librarian of Congress, at Washington, D. 0. Press of Wm F. Fell & Co., 1220-24 SANSOM ST., PHILADELPHIA. PREFACE. The modest aim of this volume is well expressed in the title-page. It is designed to aid the student in acquiring the principles primarily essential to a thorough knowledge of the subjects treated. Many omissions have necessarily been made, omissions which each must supply by reading and study after the hurry and rush of the medical school has given place to the quiet of beginning practice. If the principles here laid down enable the overworked student to formulate his knowledge upon subjects usually treated as of minor importance in the surgical course, but in reality chiefly essen- tial in the early years of his professional life, the author will feel well repaid for the time and labor bestowed upon the work. TABLE OF CONTENTS. PAGE The Roller Bandage,................ 17 Roller Bandages of the Extremities,........... 22 of the Trunk,............... 27 of the Lower Extremity,.......... 35 Head Bandages,...................... 41 T-Bandage......................... 49 Many-Tail Bandage,.................... 49 Crossed Bandage of the Perineum,.............. 50 Handkerchief Bandage, .................. 51 of the Head,............ 51 of the Trunk,............ 53 of the Extremities, ......... 56 Plaster-of-Paris Bandages,................. 59 Adhesive Plasters and Strapping,.............. 62 Knots and Sutures,..................64 Antiseptics,....................... 71 Sponges,......................... 74 Catgut,.......................... 75 Silk,........................... 75 Dressings,......................... 75 Drainage,......................... 77 Antiseptic Operation,.................... 77 Anaesthetics, ....................... 79 Counter Irritants,..................... 87 vii V1U TABLE OP CONTENTS. PAGE Depletion, ........................ 92 Cupping,....................... 93 Leeching,..........:............ 94 Transfusion, ..................... 95 Hypodermic Medication,.................. 96 Fracture-Dressings, .................... 9!) Luxations,........................Ill Venereal Diseases,.....................118 Chancroid,......................118 Gonorrhoea,......................124 Chronic Gonorrhoea,.................140 Syphilis,.................•......153 ESSENTIALS OF BANDAGING. For what purposes are bandages applied ? The general indications for the application of bandages are, to retain splints and dressings, and to make pressure. THE ROLLER BANDAGE. Describe the roller bandage. The roller bandage may be made of muslin, calico, gauze, or any thin, strong fabric. Usually unbleached muslin is used. A piece from three to twelve yards in length is procured, the selvedge is re- moved, and it is then torn into strips varying in width from half an Fk;. l. Double and Single-headed Roller. inch to three inches. Each strip is freed of loose threads at its edges, and is rolled tightly in the form of a cylinder. The rolling may be from each end toward the middle, forming two cylinders; this is called the double-headed roller. How is the bandage rolled ? This is usually done upon a small machine provided for the pur- pose. Where this is not at hand, a core should first be made by 2 17 18 ESSENTIALS OF BANDAGING. folding one end of the bandage upon itself for about eight inches of its length. This doubling is again folded in, and the process is con- tinued till a central mass is formed. This core is made still larger by placing it upon the thigh and including one or two feet of the length of the bandage by rolling it between the thigh and the palm of the hand. When the centre is sufficiently large, it is taken be- tween the thumb and middle finger of the left hand while the con- tinuation of the strip passes between the thumb and the index finger of the right hand. By seizing the body of the bandage in the right middle, ring and little fingers, with the hand in supination and Fig. 2. Boiling the Bandage. carrying the latter to pronation, the cylinder is made to perform a half revolution, with the thumb and little finger of the left hand representing the supports of its axis. As the right hand is again carried to supination, a certain portion of the length of the bandage, passing between its thumb and index finger, is wound tightly upon the core ; again grasping the latter and repeating these movements the roller bandage is gradually completed. It should be so tightly wound that it is impossible to push out the core by a firm pressure of the thumb upon one end of the cylinder, and should be so thoroughly cleared of loose threads that there is no possibility of these impeding the surgeon when the bandage is applied. THE ROLLER BANDAGE. 19 How should a bandage be pinned ? Small safety pins should be used, when obtainable. The terminal extremity of the bandage should be folded upon itself for one or two inches of its length, and one or two pins, depending upon the width of the bandage, should secure this reduplication to the turns beneath. Where ordinary pins are used, the points should be di- rected downward and should always be buried in the folds of the bandage; when applied to secure dressings of the extremities the points should be directed toward the fingers or toes. Name the parts of a roller bandage. The free end, left after the formation of the cylinder, is termed the initial extremity ; the end enveloped in the core is termed the terminal extremity. Further, the bandage has an upper and a lower border, and an internal and external surface. The cylinder formed by the rolled bandage is termed the body of the roller. How is a roller bandage applied ? The bandage is nearly always applied from left to right. The body of the roller is taken in the palm of the right hand in such a way that the thumb lies parallel with the long axis of the cylinder ; the external surface of the initial extremity is applied to the surface to be covered in, and is held in place by pressure of the thumb of the left hand until it is caught by the bandage carried around the part. This first turn is further secured by adding an additional circular turn. If the limb, or the part to be bandaged is cylindrical in shape, it may be covered in by the application of spiral turns, or those which pass upward, each one overlapping the other. Where, however, a conical part is to be covered, the spiral reversed turns are required. In surgical dressing all of the following turns may be required :— 1. Circular turns, or those which pass around a part, one directly overlying the other. Nearly all bandages are started by two circular turns. 2. Oblique turns, or those in which the bandage passes up the limb without overlapping, leaving a space between each turn. In applying loose dressings to bruises or extensive bums this bandage is of service. 3. Spiral turns, or those in which the entire surface involved is 20 ESSENTIALS OF BANDAGING. Fig. 3. The Oblique Turn. covered by the bandage. These differ from the oblique turns only in the fact that each time the bandage is carried around the limb it overlaps the preceding turn. In bandaging poorly developed arms and legs, or in applying dressings to the chest or abdomen, these turns are used. 4. Recurrent Turns.—By means of these the end of a stump or the top of the head is covered in. The initial extremity of the roller being secured, the latter is carried directly across the apex of the projecting surface and well down upon the other side, where it is held in place by the finger of the bandager, or of an assistant. The bandage is now carried back to its point of starting, caught by the finger, and carried as before across the surface to be covered. Each of these turns overlaps the other for two-thirds of its width. When the surface to be protected is entirely covered by the bandage the latter is carried once or twice circularly about the part, thus securing the loops made by reversing the direction of the bandage in applying the recurrent turns. 5. Spica and figure-of-eight turns are those in which the bandage forms, by oblique turns—first passing upward arid then returning upon themselves—two loops, which present the form of an eight. By overlapping the crossings of these loops a series of angles or spicas is formed. For instance, a bandage is carried obliquely upward across the knee, around the back of the thigh obliquely downward across the knee again, and around the back of the upper part of the calf, returning to the point of starting, thus forming a figure-of-eight. If these turns are repeated, each over- lapping its predecessor, and passing upward or downward, a series of angles or spicas will be formed. 6. The spiral reversed turns are those in which the bandage is folded back upon itself, thus accommodating its surface to conical or irregularly-shaped parts. Describe the spiral reversed bandage. This turn, the most difficult of all to acquire, consists in folding the bandage over so that the surface previously in contact with the skin is turned outward with each reverse. This is accomplished THE ROLLER BANDAGE. 21 after having fixed the bandage by one or two circular turns, by overlapping the latter as though an oblique were about to be formed. In place of this, however, the thumb of the left hand fixes the bandage, while the latter is folded over by carrying the hand containing the roller from the position of supination to one of pronation. The body of the roller is now passed beneath the limb from the right to the left hand ; not till it is received in the left hand is traction exerted. This traction causes a perfectly smooth fold, and accurately adapts the bandage to a conical or irregular Fig. 4. The Spiral Reversed Turn. surface. This process is repeated each time the bandage is carried around the limb, or as often as required to accomplish perfectly uniform pressure. An effort should be made to have the angles formed between the turned down border of one fold and the lower border of the next perfectly in line. It must be remembered that this line represents the portion of the bandage which exerts the greatest pressure, hence it should not be placed where such pressure would be undesirable, as, for instance, over the ulna or over the crest of the tibia. What points must be especially observed in applying the roller bandage ? 1. That it should not be too tight. As a means of gauging this point when limbs are bandaged, the fingers and toes are left exposed. If, after the application of the most elaborate bandage, the patient complains of pain, and there are marked signs of venous congestion, not relieved by elevation of the part, the bandage must be immediately removed and replaced more carefully. 2. That it should fit accurately and neatly to the part. 22 ESSENTIALS OF BANDAGING. 3. That if firm pressure is required, this should be uniform. In ease pressure is required at any portion of the extremities, the roller bandage must include the whole of the limb lying beyond the point of pressure. 4. That reverses, recurrent turns, and points of crossing should be secured by pins. Roller Bandages of the Extremities. Describe the spiral of one finger. This bandage should be three-quarters of an inch wide, and one and a half yards long. The roller is fixed by a repeated circular turn about the wrist; it is then carried down across the back of the hand to the finger, the extremity of which is reached by an oblique turn. The whole Fig. 5. Spiral of One Finger. finger is then covered in to its palmar extremity, the bandage passing upward by means of spiral or reversed turns ; on reaching the web of the finger, the roller is carried across the back of the hand to the point of starting, and the dressing is completed by a circular turn about the wrist. Describe the spiral of four fingers (gauntlet). The roller should be one inch in breadth and five yards long. The turns are precisely the same as in the spiral of one finger. The first finger covered in is the index of the right hand, or the little finger of the left. As each finger is completely covered the roller is carried up across the dorsum of the hand, once around the wrist and down across the back of the hand to the next finger. The thumb also may be included, if necessary. ROLLER BANDAGES OF EXTREMITIES. 23 In cellulitis, burns, or poisoning involving a considerable portion of the surface of the hand, this dressing will be found useful. Describe the spica of the thumb. This roller should be three yards long and three-quarters of an inch wide. It may be ascending or descending. The ascending spica of the thumb overlaps from the extremity of this digit toward the wrist. The bandage is fixed at the wrist by a repeated circular turn; is then carried obliquely across the metacarpus of the thumb to the distal extremity of the first phalanx, around Fig. 0. Fig. 7. Gauntlet, also taking in the Thumb. Spica of Thumb. which a circular turn is made. From this point the roller is carried across the dorsum of the thumb to the wrist, half around the wrist, obliquely upward to the position of the circular turn around the phalanx, half around this and obliquely downward to the wrist. These turns are repeated, each one overlapping its predecessor toward the wrist for one-half of its width, till the dorsal surface of the metacarpus is completely covered, when the bandage is com- pleted by a circular turn around the wrist. The angles made by the crossing of the ascending and descending turns should be placed exactly in line with each other, slightly toward the palmar surface of the thumb. The ascending spica is formed in the same way, excepting that 24 ESSENTIALS OF BANDAGINO. the first crossing turns are made as near the wrist as possible, and the subsequent turns overlap toward the phalanx. Describe the demi-gauntlet. This roller should be three yards long and one inch in breadth. It is fixed by a double circular turn at the wrist; it is then earried obliquely across the back of the hand to the index finger of the right side, the little finger of the left. It is looped around the finger and carried back to the wrist; after a circular turn it is again carried across the dorsum of the hand and looped around the next finger, and again carried to the wrist. By the same turns loops are carried around the remaining two fingers. On the completion of the bandage the back of the hand is practically covered in, the fingers being left free. This dressing is useful for retaining dressings to the back of the hand. Describe the spiral reversed of the upper extremity. This bandage should be twelve yards long and one and one-half inches in width. It should be applied, when possible, with the back of the patient's hand turned toward the face of the dresser. The bandage is fixed by a repeated circular turn at the wrist; it is then carried obliquely across the back of the hand and circularly around the four fingers, held in close apposition, at the level of the second joint of the little finger. Two or three spiral reversed turns are now made, running up the hand to the web of the thumb, the angle of reverses being directly in the middle line. The remaining portion of the dorsum of the hand, and the metacarpal bone of the thumb are covered in by two or three figure-of-eight turns. These are made by continuing the bandage obliquely downward, around the thenar eminence of the right hand, the hypo-thenar eminence of the left, across to the opposite border of the hand and up again over the dorsum, the upper border of the bandage making an angle with the upper border of the descending turn, which is in line with the angles formed by the reverses. These turns are overlapped toward the wrist until the back of the hand is entirely covered. The wrist and lower portion of the forearm are now included in two or three circular turns. As soon as the forearm begins to increase in size, spiral reverses will be required to make the bandage fit neatly. ROLLER BANDAGES OF EXTREMITIES. 25 These are made as described above. The body of the roller is turned over, so that its upper border looks downward, the roller is passed beneath the arm from the right to the left hand, and the bandage is drawn taut so that the fold lies perfectly smooth. The roller is car- ried over the limb and is again passed to the right hand, and another reverse is formed. This is continued until the elbow is reached. Here figure-of-eight turns are required, though reverses may be used. The former, however, hold their position much better. The figure-of-eight turns are made by carrying the bandage upward obliquely across the bend of the elbow to a position somewhat above the condyle ; here the bandage is continued around the back of the arm, till it reaches a point above the opposite condyle ; it is then carried obliquely downward, forming an intersection with the first turn, and around the back of the forearm, overlapping the upper spiral reversed turn toward the elbow joint. It is again carried across the front of the elbow and around the back of the arm, over- lapping the preceding turn downward; these turns are repeated until those overlapping downward and those overlapping upward are separated posteriorly by a narrow interval; this is covered in by a circular turn, and the bandage is continued up the arm, generally by spiral turns, since this portion of the limb is very nearly cylin- drical. If there be much variation in shape or size, however, spiral reversed turns may be required. The bandage is finally completed just below the shoulder by a circular turn, and secured in place by pins. Describe the spica of the shoulder. This roller should be ten yards long and two and a half inches wide. The shoulder may be covered in by either causing the turns to ascend or descend; in the ascending spica the turns overlap upward, in the descending spica they overlap in the opposite direc- tion. The ascending spica is formed by fixing the bandage by a repeated circular turn around the arm as close to the axillary folds as possible. The bandage is now made to pass obliquely upward, across the cir- cular turn upon the outer aspect of the shoulder, directly across the chest if the dressing is being applied to the right side, or across the back, if the dressing is applied to the left side, beneath the axilla of the opposite side of the body, back again to the injured 26 ESSENTIALS OF BANDAGING. shoulder, and across the outer aspect of the arm, intersecting the first turn and forming an angle with it directly in the middle line of the shoulder. The roller is then carried under the axilla, over the shoulder, overlapping the first turn for two-thirds of its width, across the thorax to the opposite axilla, and back again to the side Fig. 8. Ascending Spica of the Shoulder. which is being bandaged, making another angle by intersecting the second turn on the outer aspect of the shoulder. These turns are repeated till the shoulder is covered to the root of the neck, the extremity of the bandage being pinned at any convenient point. The descending spica differs from the ascending only in the fact that the first spica turns cross at the root of the neck, and are then ROLLER BANDAGES OF THE TRUNK. 27 overlapped downward till the circular turn about the arm is reached and partially covered in. This dressing is useful in injuries of the shoulder. It exerts uniform pressure upon this part, if properly applied, and enables dressings to be retained. Care must be taken to see that the axillary turns make no undue pressure upon the blood-vessels. Describe the Velpeau bandage. This bandage should be fourteen yards long and two and a half Fig. 9. Fig. 10. The Repeated Oblique or Shoulder The First Circular Turn of the Velpeau. Turn of the Velpeau. inches wide. For its proper application the hand of the side to be bandaged must be placed upon the opposite shoulder at the base of the neck, the elbow being closely applied to the chest. As excoria- tion always results from keeping skin surfaces long in contact, a sheet of lint or absorbent cotton should be placed between the arm and the body. The initial extremity of the roller is placed at the angle of the scapula of the sound side ; the bandage is then carried over the top of the shoulder of the injured side, downward to the outer aspect 28 ESSENTIALS OF BANDAGING. of the middle third of the humerus, and thence directly across the chest and around to the point of starting ; this turn is repeated to fix the roller. Having reached the side of the chest in the axillary line of the sound side on repeating this turn, the bandage is carried transversely across the back, around to the front of the body, across the outer aspect of the arm, covering in the external condyle of the humerus at a point so low that the olecranon cannot be seen from the front, and on around to the point of starting, when it is again carried over the shoulder and down across the middle third of the humerus, overlapping the first shoulder turn at this point for about Fig. 11. Velpeau Completed. five-sixths of its width. Another circular turn of the bandage is now made about the body, overlapping the first circular turn for about one-third of it* width; this is followed by a shoulder turn overlapping as before (five-sixths). The bandage is continued by alternating the shoulder and the circular turns, and the overlapping is so planned that by the time the shoulder turns have reached the point of the elbow the circular turns have ascended as far as the wrist. The anterior border of the shoulder turns should extend to but not beyond the olecranon, as otherwise this last turn is liable to slip, thus loosening the whole bandage. The roller may be pinned ROLLER BANDAGES OF THE TRUNK. 29 at any point where it ends, preferably somewhere in the axillary fine, or posteriorly, where the terminal extremity is out of sight. This bandage is useful in the treatment of fractures of the clavicle. Describe the Desault roller. For this bandage a wedge-shaped pad and three distinct rollers are refiuired. The first roller fixes the pad in the axilla, the second secures the arm to the side, and the third, by pressure upon the dorsal surface of the upper portion of the forearm, forces the shoul- der upward and backward. Fig. 12. Desault—First Roller. Desault—Second Roller. The first roller should be five yards long and two and a half inches wide. The pad being placed in the axilla of the injured side, with its base applied to the axillary folds, four spiral turns are passed about the chest and over the pad, securing the latter in position. To prevent these turns from slipping down, the bandage is further secured by passing it obliquely across cither the chest or the back, depending upon whether the dressing is applied to the left or the 30 ESSENTIALS OF BANDAGING. right side, over the top of the shoulder, under the axilla of the sound side, and back again to the position of the pad. The roller is then continued across the opposite aspect of the thorax, over the shoulder and beneath the axilla of the sound side, and is carried back to the pad. Two or three of these turns are made, holding the bandage firmly in place. Fig. 14. Desault—Third Roller—Rear View, The second roller should be seven yards long and two and one-half inches wide. It is made up of spiral turns embracing the chest and the arm of the injured side, and overlapping downward from the point of the shoulder to the olecranon. The upper turns are applied loosely; the lower are drawn as tight as is compatible with the comfort of the patient. The object of these turns is to force the shoulder outward ROLLER BANDAGES OF THE TRUNK. 31 by drawing the elbow close to the side, the axillary pad acting as a fulcrum ; each turn should overlap its predecessor for two-thirds of its width. The third roller should be seven yards long and two and one-half inches wide. Its proximal extremity is fixed in the axilla of the sound side ; the body of the bandage is then carried obliquely across the chest, Fig. 15. Desault—Third Roller—Completed Bandage. over the top of the injured shoulder, down along the posterior sur- face of the humerus, and forward and upward around the upper fifth of the ulna (the forearm being flexed at a right angle and lying across the chest) to the point of starting. It is then continued pos- teriorly across the upper portion of the scapula of the sound side over the top of the injured shoulder, directly downward from this point, parallel with the humerus, to the upper fifth of the fore- arm, around the back of which it is carried, and is then continued 32 ESSENTIALS OF BANDAGING. upward and backward across the dorsal surface of the thorax to t lie point of starting. These turns are repeated at least three times, each one exactly overlying and not overlapping its predecessor. The bandage may be pinned at any convenient point. The dressing is finally completed by slinging the forearm at the wrist. The Desault bandage is applied in the treatment of fractures of the clavicle. The third roller is useful in dressing fractures of the acromion or coracoid process, or of the anatomical neck of the humerus. It is sometimes applied in the after-treatment of luxa- tions of the humerus. Describe the spiral of the chest. This requires a roller seven yards long and from three to six inches in width. The bandage is started by a circular turn around the waist, once repeated. The roller is then carried up to the axilla by successive spiral turns, each overlapping its predecessor by one-half the width of the bandage. When the whole chest is thus covered in, the bandage is further secured by pinning it in front, carrying it over one shoulder, and pinning it behind to the circular turns. From the second point of fixation the bandage is carried over the opposite shoulder and is finally pinned to the circular turns in front. This practically forms a pair of suspenders for the dressing and prevents it from slipping down. The circular turns should be further pinned to each other. Describe the anterior figure-of-eight of the chest. This requires a roller about seven and a half yards long and two and a half inches wide. It is fixed by a circular turn about the upper portion of the right arm. The bandage is then carried over the top of the shoulder, across the chest, beneath the axilla of the left side, over the top of the shoulder and obliquely downward over the front of the chest again to the axilla of the right side ; up behind the shoulder and over it, obliquely downward to the opposite axilla ; these turns are continued until as many as are required have been applied. This dressing is useful for approximating the shoulders and for retaining applications to the front of the chest. ROLLER BANDAGES OF THE TRUNK. 33 Describe the posterior figure-of-eight of the chest. This bandage differs from the auterior figure-of-eight only in the fact that it is started by a repeated circular turn about the left humerus, as near the axillary folds as it can be applied. The roller is then carried upward over the top of the shoulder, across the back to the right axilla, over the top of the right shoulder and back again across the back to the left axilla ; these turns being re- peated, excepting the circular one about the arm, and as many being applied as are required. This dressing is sometimes used in the treatment of fractures of the clavicle, or may be employed to retain applications to the dorsal aspect of the chest. Fig. 16. Double Spica of the Breast. Describe the spica of the breast. This roller may be single or double, depending upon whether one or both breasts arc to be included. The single spica of the breast requires a roller ten yards long and two and one-half inches wide. The initial extremity of the bandage is fixed at the angle of the scapula of the affected side ; the bandage is carried upward to the top of the shoulder on the sound side, over this, downward across the chest so that the- upper border of the bandage just includes the lower limits of the mammary gland, and on to the point of start- ing. This turn is repeated to secure the initial extremity of the roller. When, on repeating this turn, the lower border of the breast is reached, the bandage is carried, circularly, completely around the 3 34 ESSENTIALS OF BANDAGING. chest, its lower border intersecting, below the breast and slightly beyond the nipple line, the first oblique turn. It is then con- tinued to the point of starting, where it follows the course of the first turn over the top of the sound shoulder and down beneath the affected breast, overlapping its predecessor for two-thirds of its width. Another circular turn is now applied, overlapping upward to the same extent. These turns are repeated, alternating the oblique over the shoulder with the circular turns about the chest, till the breast is completely covered in. The angles formed by the intersection of these turns at the outer side of the breast should all lie in a straight line, parallel to the long axis of the body. The double spica of the breast requires a roller fourteen yards long and two and a half inches wide. Since bandages of this length are difficult to manage on account of their bulk, it is customary to use two bandages, pinning the terminal extremity of one, after it has been applied, to the initial extremity of the other. This bandage is started by placing the initial extremity of the roller at the angle of the left scapula ; the bandage is carried upward over the right shoulder, downward under the left breast and back to the point of starting ; this turn'is repeated, for the purpose of fixing the initial extremity. The roller is then carried directly across the back and around the side of the chest till it passes beneath the right nipple, its upper margin just including the-lower border of the mam- mary gland. From this point it is carried obliquely upward across the chest, over the top of the left shoulder, and obliquely down- ward over the back and toward the right side ; a circular turn is then made about the entire chest, after which another oblique turn is formed, passing over the right shoulder and under the left breast, across the dorsal aspect of the thorax, around the side of the chest, under the right breast, upward across the front of the chest, and over the top of the left shoulder, after which a second circular turn is made. Each of these turns overlaps its predecessor for two-thirds of the width of the bandage. In this double spica of the breast there are two oblique shoulder turns for each circular chest turn, the left breast being taken in by a turn passing downward from the right shoulder, the right breast by a turn passing upward toward the left shoulder, before the bandage is carried completely around the chest. ROLLER BANDAGES OF LOWER EXTREMITIES. 35 In case of abscess, or swelling of the breast, this bandage is some- times used. It enables very firm pressure to be applied to this region. Describe the spica of the foot. This requires a roller five yards long and two and a half inches wide. It is started by a repeated circular turn about the ankle. The roller is then carried across the dorsum of the foot to the metatarso- phalangeal articulation of the great toe; at this point a circular turn is made about the foot, and to this is added a spiral turn, overlapping the circular turn upward for three-fourths of its width ; the roller is then carried over the dorsum of the foot, along its lateral aspect, and around the back of the heel, so that the lower border of the bandage is a trifle below the level of the sole ; the roller is carried back from the heel along the side of the foot, and over its dorsum, crossing the beginning of Spica of the Foot the turn which passes around the heel exactly in the middle line. The bandage is again passed around the sole of the foot, across its dorsum, along the side, around the back of heel, arid back again to the dorsum, intersecting the beginning of the second heel turn at this point. These turns are continued till the whole foot is completely covered in, excepting a small portion of the sole of the heel, when the bandage may be either cut and pinned at the ankle, or may be carried up the leg. The spicas or angles of inter- section of the turns passing across the dorsum of the foot should all lie precisely in the middle line. Each of these figure-of-eight turns must be, through its whole extent, parallel to its predecessor, and must overlap for three-fourths of the width of the bandage. This bandage affords a ready means of exerting a firm pressure upon the whole surface of the foot. Describe the spiral reversed of the foot covering in the heel. This requires a roller four yards long and $wo and one-half inches wide. / The bandage is fixed by a repeated circular turn about the ankle ; it is then carried obliquely down over the top of the instep and a circular turn is made around the foot at the level of the metatarso-phalangeal 36 ESSENTIALS OF BANDAGING. articulation of the great toe. The dorsum of the foot is now cov- ered in by three spiral reversed turns, each overlapping toward the Fig. 18. Spiral Reversed Covering in the Heel. ankle two-thirds of the width of the roller, and the angle of reverses being kept in the middle line. When the top of the instep is Fig. 19. reached the bandage is carried over the dorsum of the foot around the point of the heel, back to the dorsum of the foot, down around ROLLER BANDAGES OF LOWER EXTREMITIES. 37 the sole of the heel, obliquely upward and backward from this point behind the malleolus and around the back of the heel, forward over the malleolus, over the top of the instep, downward again across the sole of the heel, upward and backward behind the malleolus, across the back of the heel and across the malleolus and the dorsum of the foot. The bandage may be further secured by an added circular turn, passing from the top of the instep around the point of the heel. It is terminated by one or two turns about the ankle. These heel turns can be applied by remembering that the bandage Fig. 20. Fig. 21. Spiral Reversed of the Lower Figure-of-eight for the Extremity. Knee. goes over the instep, under the heel, bacl& of the heel, the words over, under and back conveniently summarizing the direction in which the roller should be carried. In wounds or in pathological conditions of the heel this bandage will be found useful. Describe the spiral reversed of the lower extremity. This requires a roller twelve yards long and two and one-half inches wide. The bandage is started by a repeated circular turn about the ankle. It is then carried obliquely down over the top of the instep, 38 ESSENTIALS OF BANDAGING. and around the foot at the level of the metatarso-phalangeal articu- lation of the great too. The instep is covered in either by spica turns, as in the case of the spica of the foot, or by spiral reversed turns. The heel is left exposed. The bandage is then carried around the ankle and up the leg, beginning the reverses as soon as the increasing diameter of the limb requires it. The knee may be covered by spiral reversed turns or by the figure-of-eight of the knee. If the latter is employed the bandage is carried upward across the popliteal space, around the front of the thigh, downward across the popliteal space, and around the front of the upper portion of the leg, overlapping the last spiral reversed turn for two-thirds of its width. The roller is again carried across the popliteal space and around the thigh, overlapping downward the previous turn in this region for two-thirds of its width. It is now carried down again and around the leg, overlapping toward the patella. These turns are continued, both the upper and lower overlapping toward the patella,. till the descending and ascending turns almost meet, when the remaining space is covered in by a circular turn passing directly across the centre of the patella. The bandage is now continued up the thigh by spiral reversed turns until the groin is reached. It may be pinned at this point, or further secured by one or two spica turns of the groin. Describe the spica of the groin. The spica of the groin may be either single or double, depending upon whether one or both groins are included in the dressing; further, it may be either ascending or descending, depending upon whether the overlapping is from below upward or in the reverse direction. The single ascending spica of the groin requires a roller ten yards long and two and a half or three inches wide. The bandage is fixed by a repeated circular turn applied as close to the ileo-femoral fold as possible. If the right side is being dressed the bandage is then carried obliquely across the pubes, around the body beneath the iliac crest of each side, and down across the ri°-ht thigh, intersecting the beginning of the body turn and forming the fir.st angle or spica, which should be placed slightly to the inner side of the middle line of the anterior surface of the thigh. The band- ROLLER BANDAGES OF LOWER EXTREMITIES. 39 age is then carried around back of the thigh, forward across the front, overlapping the first turn for two-thirds of its width, around the body and back again across the thigh, making the second angle of crossing. These turns are repeated, overlapping upward till a sufficient surface is covered in. The bandage may be secured by a circular turn around the waist. The descending spica of the groin is similar in its turns to the Fig. 22. Single Ascending Spica of the Groin. ascending, excepting in the fact that the first intersection or cross- ing of the bandage is carried far above the circular turn around the thigh, in place of overlapping it. This is accomplished by carrying the bandage, after the double-thigh turn has been made to fix it, across the front of the belly some distance above the pubes, and around the body above the crest of the ileum. Each succeeding turn overlaps downward until the last spica overlaps the circular turn about the thigh. 40 ESSENTIALS OF BANDAGING. Tlie double spica of the groin requires a bandage fourteen yards long and two and one-half inches wide. It is fixed by a cnvular turn around the waist once repeated ; the roller is then carried obliquely downward across the belly, across the fold of the left groin, around the back of the left thigh, forward and upward parallel to Poupart s ligament, forming the first intersection with the turn passing down- Fig. 23. Double Spica of the Groin, ward, around the back, downward parallel to the right Poupart's ligament, around the back of this thigh, upward and across Poupart's ligament, forming the second intersection, and across the belly, form- ing with the first oblique abdominal turn the third intersection. These turns are repeated, being carried around the back, around the left thigh, around the back, around the right thigh, around the HEAD BANDAGES. 41 back, and so on until the required surface is covered in. The bandage may overlap upward or downward, forming either the ascending or the descending double spica of the groin. HEAD BANDAGES. Describe the Barton bandage. This requires a bandage five yards long and two inches wide. The dresser, standing in front of the patient, places the initial extremity of the roller directly behind the left ear; the body of the Fig. 24. Barton's Bandage. bandage is carried downward under the occiput, and upward behind the right ear, then directly across the top of the head from the right to the left side, downward in front of the left ear, under the chin, upward in front of the right ear, and across the top of the head, from 42 ESSENTIALS OF BANDAGING. the left to the right side, to the point of starting ; thence across tin- junction of the occiput and back of the neck, directly forward under the ear, along the ramus of the lower jaw, around the symphysis or front of the chin, back again along the ramus of the lower jaw, and beneath the right ear to the upper portion of the back of the neck. From this point the bandage is carried upward behind the right ear across the top of the head, and is continued exactly as were the first turns. These turns are repeated three times. Note that each succeeding turn overlies and does not overlap its predecejssor, and that the angle made by the crossing of the bandage Fig. 25. on top of the head, must be exactly in the middle line, and its anterior margin must lie about two inches posterior to the junction of the scalp and forehead. All the intersections of this bandage are pinned. It may be made still more secure by carrying an additional circular turn from the occiput around the forehead. This dressing is useful in the treatment of fractures of the jaw. It is also of service when tight pressure is required at any portion of the surface covered by it. Describe the Gibson bandage. This requires a roller five yards long and two inches wide. HEAD BANDAGES. 43 The initial extremity is placed upon the top of the head, and the roller is carried downward in front of one ear, under the chin, upward in front of the other ear, and on to the point of starting. This turn is twice repeated, when the bandage is reversed in the tem- poral region above the ear, and carried around the head three times, including the forehead, the temporal regions and the occiput; on Fig. 26. Gibson's Bandage. the completion of the third turn the bandage is carried obliquely downward behind the ear to the back of the neck, forward along the ramus of the jaw, around the front of the chin, and backward along the opposite side of the jaw to the back of the neck ; this turn is repeated three times. The bandage is then completed by reversing it in the posterior middle nock line, and carrying it directly forward to the frontal part of the circular occipito-frontal turn. All the inter- sections are pinned. 44 ESSENTIALS OF BANDAGING. In applying this bandage each turn overlies its predecessor, and does not overlap. The difficult part of the dressing is the proper securing of the first vertical turns. Where the head slopes forward from the vertex, these are liable to slip forward ; they should always be passed over the top of the head as far back as possible. This dressing is applicable to the treatment of fractures of the jaw, but is not so satisfactory as the Barton bandage. Describe the oblique of the jaw. This requires a bandage five yards long and two inches wide. Fig. 27. Oblique Bandage of the Jaw. Facing the patient the dresser starts the bandage by placing its initial extremity upon the forehead, and carrying the body of the roller toward the injured side and circularly around the head. This fronto- occipital turn is repeated to fix the bandage. It is then carried above the ear of the injured side, obliquely downward behind it to the back of the neck, around the front of the neck to the angle of the jaw of the affected side, thence upward in front of the ear directly across the top of the head, downward behind the ear of the opposite side, around under the chin, upward again in front of the ear of the HEAD BANDAGES. 45 injured side, overlapping forward for three-quarters of the width of the bandage, across the top of the head, downward behind the oppo- site ear, and so continued until a sufficient number of turns have been applied, when the bandage may be made still more secure by revers- ing above the ear and adding a circular turn including the occiput and forehead. All intersections are pinned. This dressing is of service in the treatment of injuries and wounds of the parotid region. It is commonly advised in the dress- ing of fractures involving the neck of the condyle of the lower jaw. It is, however, difficult to understand how it can be of special ser- vice when applied to this form of injury. Fig. 28. Recurrent of Scalp. Describe the recurrent of the scalp. This bandage should be seven yards long and two inches wide. It is fixed by repeated circular turns around the forehead and occi- put. At the middle of the forehead the roller is reversed, is secured by the thumb of the dresser or an assistant, and is carried directly back across the top of the head until it reaches the lower border of the occipital turn ; here it is again reversed, the reverse is secured by an assistant, and the bandage is carried directly forward, overlapping the preceding turn for three-quarters of its width ; having reached the frontal portion of the circular turn, it is caught by the thumb again and carried directly backward. The bandage is carried to and fro in this way until half the scalp is covered in, when these loopings are fixed by a circular turn. The bandage is again reversed 46 ESSENTIALS OF BANDAGING. at the forehead and the other side of the scalp is included in a simi- lar manner. The dressing is completed by a repeated circular turn, pins being applied to further secure the loops of the reverses. These reversed turns should converge in front and behind to the cen- tral points of the forehead and occiput. This bandage is of service in retaining dressings to the upper part of the scalp. In applying it care must be taken that the circular turn passes from the forehead around the head beneath the superior curved line of the occiput; there is then no tendency for the dressing to slip off, since before it can be removed the circular turn must pass over a greater diameter than it already embraces. Describe the figure-of-eight of the eye. This bandage may be either single or double, depending upon whether one or both eyes are included. The initial extremity of the roller is placed at the middle of the forehead and the bandage is carried away from the injured eye, making a repeated fronto-occipi- tal circular turn ; on the third turn the bandage is carried downward behind the ear of the sound side, around the back of the neck just under the occiput, forward and upward under the ear of the affected side, obliquely across the eye, around the side of the head, thence downward around the back of the occiput, under the ear of the affected side, upward across the eye, overlapping for two-thirds of the width of the bandage either upward or downward as may be required. These oblique turns are repeated until the eye is com- pletely covered in; more than two or three are rarely required. The bandage is then completed by a fronto-occipital turn and all intersections are pinned. For neat bandaging each oblique turn may be alternated with a circular one, both sets of turns overlapping and forming a series of angles in the middleline. The double figure-of-eight of the eye requires a bandage seven yards long and two inches wide ; each eye may be covered in inde- pendently by the turns employed in the single bandage. In this case, after one eye is completely covered, the bandage is carried by a circular turn to the forehead, and is then continued downward across the other eye and under the ear, upward over the parietal eminence, again across the eye and so continued till a sufficient num- ber of turns are applied, when the dressing is completed by a cir- HEAD BANDAGES. 47 cular turn ; or the bandage having been fixed by a repeated circular turn as in the single figure-of-eight, is carried under the ear and over the eye as before, then around the occiput, forward over the ear, obliquely downward over the opposite eye, thence under the ear, around the back of the neck, under the opposite car, obliquely up- ward over the eye, around the occiput again, forward and downward across the opposite eye and so continued, forming two or three angles of intersection in line with the bridge of the nose and over- Fig. 29. Fig. 30. Figure-of-Eight of One Eye. Figure-of-Eight of Both Eyes. lapping regularly upward. The dressing may be secured by one or two circular fronto-occipital turns. The applications of this bandage are obvious. As a matter of clinical experience it is found best to employ thin flannel cut bias for these bandages, since otherwise undue pressure may be exerted. The comfort of the patient will be further con- sulted by placing small pads of cotton in and behind each auricle and passing the bandage directly over these organs, in place of making an effort to leave them free 48 ESSENTIALS OF BANDAGING. Describe the occipito-facial bandage. This requires a roller four yards long and two inches wide. The initial extremity of the bandage is placed upon the crown of the head, or, if the latter does not slope abruptly forward, two inches anterior to this point; the roller is then carried downward under the chin and upward to the point of starting ; this turn is repeated twice; the bandage is then reversed just above the position of the ear, and three circular turns are made embracing the occiput and forehead; the intersections are pinned. Fig. 31. Occipito-facial Bandage. This bandage may be employed to make pressure in the submental region, or upon any part of the scalp covered by it. Describe the fronto-occipito-cervical figure-of-eight. This requires a bandage three yards long and two inches wide. It is fixed by a repeated fronto-occipital turn placed just above the ear, the bandage is then carried obliquely downward behind the ear, across the back of the neck, forward around the front of the neck to the back of the neck again, obliquely upward above the opposite ear, HEAD BANDAGES. 49 across the forehead, downward behind the ear again and around the neck, and is so continued till three complete turns are made, when it is pinned at any convenient point. This bandage is useful in retaining dressings to the back of the neck. Describe the fronto-occipito-mental figure-of-eight. This requires the same length of bandage as the preceding, and is applied in exactly the same way, except in place of carrying a turn around the neck it is carried around the front of the chin. This enables the dresser to apply much more pressure than is possible in the preceding bandage. Describe the T bandage. Two strips of bandage, each four feet long and three inches in width, are required; to the middle of one strip, and passing at right angles to it, one extremity of the other strip is pinned or sewed. This bandage is of use in retaining dressings to the rectum or perineum. The horizontal limb is secured around the waist, the vertical limb is carried down along the perineum and is brought for- ward. It is then split down to the scroto-perineal junction, and the two ends are carried upward and forward, one to each side, and are secured to the circular turn around the body. Describe the many-tailed bandage. This was originally called the bandage of Scultetus, and consisted of a number of short pieces of bandage, often as many as 18 or 20, each placed parallel to its predecessor and overlapping for two-thirds of its width. These pieces were secured in their relative positions by being stitched to another piece passed vertically along their middle. If a limb were to be bandaged, all of the imbricated pieces could be slipped under at once ; the limb could then be allowed to rest upon the bed and the pieces could be folded over, commencing at one end and folding over in turn each extremity of every piece, passing upward. In this form the bandage is now rarely used, since frequent dressing of parts which cannot be readily moved is not so often required. The many-tailed bandage commonly used is made of a piece of flannel or muslin from six to eight inches in width, and of sufficient 4 50 ESSENTIALS OF BANDAGING. length to go one and one-half times around the part to be bandaged. The strip is torn from each extremity toward the middle for about one-third of its length ; two or three tears are made in such a way that the extremities are divided into three or four pieces of equal width. This bandage is very useful in making pressure and in retaining dressings after laparotomy. Describe the four-tailed bandage. This requires a piece of muslin from four to twelve inches in width and from eighteen to twenty-four inches in length. It is torn down the centre from each end to within from two to six inches of its middle. This bandage is sometimes used in the treatment of fractures of the lower jaw or in fractures of the clavicle. Describe the crossed bandage of the perineum. This requires a bandage seven yards long and two and a half to three inches wide. It is fixed by a circular body turn around the pelvis, placed be- neath the iliac crests. It is then carried downward along the right groin, across the perineum, around the back of the left thigh at the position of the ilio-femoral fold, upward above the trochanter and below the crest of the ileum, completely around the body until it is just above the left trochanter, down along the left groin, across the perineum, around the back of the right thigh at the ilio-femoral fold, upward and forward just above the right trochanter, and is continued by repeating these turns till a firm dressing is formed. This bandage is useful for retaining dressings to the scrotal and perineal regions. Describe the figure-of-eight bandage of the lower extremity. This requires a bandage 2\ inches wide and 12 yards long; the bandage is fixed by a repeated turn around the ankle; it is then carried across the instep, around the foot, and up to the ankle by one or two reversed turns. It is carried around the ankle again and up the leg by one or two spiral turns overlapping for two-thirds of the width of the bandage. The roller is then continued by an oblique turn to that portion of the leg just below the knee joint where the calf HANDKERCHIEF BANDAGES OF THE HEAD. 51 grows smaller ; it is carried around the leg at this point and continued obliquely downward again until it overlaps the spiral turns above the ankle. It is brought around the back of the leg and carried oblique- ly upward, catching again upon the lesser diameter above the calf; it is then continued downward, overlapping the preceding turn upward. These turns are repeated until the whole leg is covered in. This bandage is exceedingly useful, from the fact that it remains indefinitely upon a muscular calf, even though the patient be active upon his feet. HANDKERCHIEF BANDAGES. Describe the handkerchief bandage. This requires muslin, calico, or any thin, strong, soft fabric cut in the form of either a square or a triangle. The square should measure thirty-two inches. The triangle is made by dividing this square obliquely across from angle to angle, or by simply folding the square in the form of a tri- angle. The parts of the triangle are the base, the apex (the angle opposite the base), and the angles or ends. The cravat is formed by folding the apex in toward the base and repeating the folding till a bandage about two inches in width is formed. The names of the handkerchief bandages have been devised with the idea of indicating their method of application ; the first name is that of the part to which the base of the triangle is applied, the second name is that of the part around which the ends are car- ried. Thus the occipitofrontal triangle would imply that the base of the bandage is applied to the occiput and that the ends are car- ried around the forehead. Handkerchief Bandages of the Head. How is the occipito-frontal triangle applied? Apply the base to the occiput, letting the apex fall over the fore- head. Cany the two ends forward around the head and tie in front, 52 ESSENTIALS OF BANDAGING. or cross, and pin at the sides. Turn the apex up and pin to the body of the bandage. How is the fronto-occipital triangle applied ? As the preceding, except that the base is applied to the forehead, and the apex falls over the occiput. How is the bi-temporal triangle applied ? As the preceding, except that the base is applied over one temple, the apex falls over the other. In the choice of these three bandages, the base is applied over the seat of injury, or where most pressure is desired. Fig. 32. Fig. 33. Beginning of Square Cap of Head. Square Cap of Head Completed. How is the vertico-mental triangle applied ? Apply the base to the vertex with apex back ; carry the ends down under the chin, and either tie, or cross and pin. Bring the apex to one side and pin. How is the auriculo-occipital triangle applied ? This does not conform to the rule in naming. Place the base in front of the ear, apex back, carry one end under the chin, the other over the top of the head and tie or pin in front of the ear on the sound side. How is the square cap applied ? Fold the handkerchief so that a quadrilateral is formed, with one HANDKERCHIEF BANDAGES OF THE TRUNK. 53 border overlapping the other three inches. Apply this quadrilateral to the scalp, with the projecting border next the surface and hang- ing over the eyes. Bring the ends of the short fold under the chin and tie. Fold back the long border exposing the forehead, pull the ends forward till the bandage fits about the head, then cany them back and tie beneath the occiput. How is the fronto-occipito-labialis cravat applied? Fold the triangle into a cravat. Place the body upon the fore- head, carry the ends back, cross at the back of the neck, and bring them forward, tying or pinning over the upper or lower lip, as required by the injury. Used to approximate lip wounds, and to check bleeding from the coronary arteries. How is the occipito-sternal triangle (compound) applied ? Apply a sterno-dorsal (straight around) cravat about the chest. Flex the head upon the chest and apply the base of a triangle, apex forward, to the occiput, carry the two ends down to the sterno-dorsal cravat and secure. The apex of the triangles may be folded back and pinned. Used in cut-throat wounds of the neck. How is the parieto-axillaris triangle (compound) applied ? Apply an axillo-acromial cravat (around the shoulder). Place the base of a triangle over the parietal eminence of the opposite side, carry the ends around the head and cross them ; incline the head laterally, and secure the ends of the triangle to the shoulder cravat. Used to approximate the lips of wounds at the side of the neck. Handkerchief Bandages of the Trunk. How is the axillo-cervical cravat applied ? Place the body of the cravat in the axilla, carry the ends over the shoulder, across each other, and around the neck. Used to retain dressings in the axilla. How is the bis-axillary cravat (simple) applied? Place the body in the axilla, cross the ends over the shoulder and carry one across the chest, the other across the back, to the axilla of the opposite side, where they are tied or pinned. Used as the preceding bandage. 54 ESSENTIALS OF BANDAGING. How is the bis-axillary cravat (compound) applied ? Place the body of one cravat in the axilla, carry its ends over the shoulder and tie (axillo-acromial cravat). Place the body of another cravat in the opposite axilla, and carry the ends obliquely acr< >ss the chest and back to the first cravat, tying them together when one end has passed through the loop of the first cravat. Used to retain dressings in both axillae. How is the bis-axillo-scapulary cravat (simple) applied ? Place the body to the front of the shoulder, with the lower end one-third longer than the upper. Carry the upper end over the Fig. 34. Bis-axillo-scapulary Cravat (Compound). shoulder, the lower end under the axilla; continue the long end obliquely across the back to the opposite shoulder, around it, and back to the short end, to which it is tied. This forms a posterior figure-of-eight, and is used as a temporary dressing for fractured clavicle. How is the bis-axillo-scapulary cravat (compound) applied? Loop one cravat loosely about the shoulder, and tie. Place the body of the other cravat in front of the opposite shoulder, carry the ends back, one over the shoulder, the other beneath the axilla. Tie in a single loose knot, carry one end through the loop of the first cravat, and tie in a double knot. HANDKERCHIEF BANDAGES OF THE TRUNK. 55 Used to draw the shoulders forcibly back, as in fracture of the clavicle. How is the dorso-bis-axillary triangle (compound) applied ? Breakfast shawl. Carry a cravat around the chest and tie in front (dorso-sternal). Place the base of a triangle, apex down, on the back of the neck, carry each end over the corresponding shoulder, and tie to the dorso-sternal cravat in front. The apex is fastened around the body of the cravat behind. Used to retain dressings to the shoulder or back. How is the mammary triangle applied ? Place the base of the triangle under the breast, and its apex over Mammary Triangle. Gluteal Triangle. the shoulder of the same side. Carry one end across the opposite side of the neck, the other under the axilla of the affected side. Tie at the back, and secure the apex beneath the knot. Used to support the breast, to make pressure, to retain dressings. How is the scroto-lumbar triangle, or suspensory, applied ? Tie a cravat about the waist. Place the base of a triangle beneath the scrotum, carry the two ends up and secure them to the cravat. Finally secure the apex by carrying it under the cravat, folding it in front, and pinning. Used as a suspensory of the scrotum. 56 ESSENTIALS OF BANDAGING. How is the abdomino-inguinal (simple) handkerchief bandage applied ? For this bandage one long cravat may be made by tying two together. Place the body of the cravat back of the thigh in such a manner that one end may be two-thirds longer than the other. Bring the ends to the front, cross over the groin, and carry them around opposite sides of the body, knotting or pinning in front. Used as a spica of the groin, to retain dressings on buboes, or to make pressure upon them. How is the abdomino-inguinal (compound) handkerchief bandage applied ? Place the centre of the cravat (three, knotted .or sewed together) over the lumbar vertebrae, carry the two ends forward on each side just below the iliac crests, obliquely downward and inward over the front of the groins, backward between the thighs, outward around each thigh to the front; cross over the pubes and pin to the body of the cravat. How is the gluteal triangle (compound) applied ? Tie a cravat about the waist. Place the base of a triangle ob- liquely at the gluteal fold, and tie the ends around the thigh. Carry the apex up and under the cravat, fold it over, and pin. Used to retain dressings to the gluteal region. Handkerchief Bandages of the Extremities. How is the palmar triangle applied ? Place the base of the triangle on either the palmar or dorsal sur- face of the wrist, fold the apex over the hand and back to the wrist, carry the ends around the wrist and apex and tie ; fold the apex back, and pin to the body of the bandage. How is the triangular cap of the shoulder applied? 1. Place the base on the shoulder, apex hanging down over the arm ; carry the ends under the axilla, across each other, around the arm, taking in the apex, and tie. Fold the apex upward, and pin to the body of the bandagfc. 2. Place the base of the bandage on the upper part of the arm, with the apex covering the shoulder ; carry the ends around the ami, HANDKERCHIEF BANDAGES OF THE EXTREMITIES. 57 across each other in the axilla, and up around the shoulder, taking in the apex. Fold the apex down and pin. Used to retain dressings to the upper part of the arm or shoulder. How is the triangular cap of a stump applied? Place the base under the stump, carry the apex over its end. Secure the apex by carrying the ends around the limb, and pinning or knotting. Fold the apex up, and pin to the body of the bandage. How is the cervico-brachial triangle applied ? Sling of the arm. Place the base of a triangle at the wrist of the flexed forearm, carry the ends over the shoulders, around the Fig. 37. Cervico-brachial Triangle. back of the neck, and tie. Draw the apex back beyond the elbow, fold it posteriorly, and pin it in this position. If the triangle is not long enough, a cravat may be tied loosely around the neck, and the ends of the triangle knotted in this. How is the metatarso-malleolar cravat applied ? Place the body obliquely across the back of the foot, carry one end around the foot, the other around the ankle, and tie in front, over the back of the foot. How is the malleolo-phalangeal triangle applied ? Place the base in the hollow of the foot. Fold the apex around the toes and in front of the ankle joint. Carry the ends around 58 ESSENTIALS OF BANDAGING. the foot, cross on the dorsum, and continue around the malleoli; then back to the dorsum, securing here, or continuing to the side and pinning. How is the cervico-tibial triangle applied ? Carry a cravat from the top of the shoulder of the sound side to the axilla of the injured side, around the body to the point of starting, and tie. Flex the leg and place the base of a triangle on the tibia just above the ankle. Carry the ends up and tie through the cravat. Bring the apex around the knee, and pin to the body of the handkerchief. Used to support the leg when it is fractured, and the patient is required to walk. How is the figure-of-eight of the knee applied ? Place the body of the cravat just above the patella, carry the ends back, cross in the popliteal space, bring them forward just below the patella, and tie. Used to approximate the fragments of a fractured patella. How is the tarso-patellar cravat applied ? Place one cravat as a figure-of-eight of the knee, loop another cravat around the foot, just anterior to the ankle ; catch the body of a third cravat through this loop, and carry its ends under both the lower and upper segments of the figure-of-eight, and secure by pinning. Used to approximate the fragments of a broken patella. How is the tibial cravat applied ? Place the body obliquely across the calf, carry the ends around the leg, one below the patella, the other above the malleoli. Used to retain dressings. How is Barton's cravat applied? Place the body of the cravat around the posterior surface of the point of the heel, with the end corresponding to the outer side of the foot one-third longer than the other. Hold the inner end (short) parallel with the foot, while the long end is carried across the in- step, turned once around the inner end, across the sole of the foot, and looped around itself as it crosses obliquely over the instep. The two ends are knotted, drawn upon, and the cravat so arranged that traction exerts equal pressure upon dorsum and heel. Used to make extension for fractured femur. PLASTER-OF-PARIS DRESSINGS. 59 Plaster-of-Paris Dressings. Describe the plaster-of-Paris bandage. To be of service, in fixed dressings, plaster-of-Paris must be dry and fresh. The best grade, that used by artists, is to be preferred in surgical practice. It may be applied without previous prepara- tion by making it into a thick paste, by the addition of water, and smearing it generously over a wet muslin bandage after the latter has been applied to a limb, adding one or two more layers of band- age and of plaster, to give additional strength. It is usual, however, to prepare the plaster bandages previously; for this purpose a sufficient quantity of crinoline is procured and cut into strips five yards long and three inches wide; into the meshes of this loose fabric the plaster is then thoroughly rubbed; the strips are rolled loosely and stored in a tight tin can. Where a great many plaster bandages are used, a machine, ingeniously devised for the proper distribution of the plaster through the fabric, may be employed ; this may be as well accomplished, however, by the hand. A small quantity of the plaster is poured into a pan or an open newspaper, and by means of the fingers can be evenly distributed through the meshes of the crinoline as the latter is rolled. The part to be covered is protected from direct contact with the plaster, either by a tightly-fitting garment in which there are no wrinkles, or by a thin flannel bandage; the latter should not be pinned. The rolls of plaster bandage are then placed in water until they are thoroughly soaked through, when the excess of moisture is slowly and gently squeezed out and the bandage is applied with just sufficient pressure to make it lie smoothly, employing as few reversed turns as possible. As the bandage is unrolled an assistant follows it around rubbing in the plaster and making it perfectly smooth with his wet hands. "When two or three layers of bandage have been applied a couple of handfuls of dry plaster are mixed with enough water to make a thick paste ; this is smeared over the outside of the bandage and smoothed with the hands. In ten or fifteen minutes the bandage should be fairly well set, though several hours must be allowed to elapse before it is put to any special strain. At the posi- tion of joints, or at any part of the bandage where breaking from 60 ESSENTIALS OF BANDAGING. motion is liable to occur, thin strips of wood, zinc, or other strong material may be incorporated with t he dressing. If the plast er band- ages are in the first place wet in hot salt water, hardening will take place much sooner. In cleaning the hands after the bandage is applied the dresser should not use soap but should employ simply warm water to which a little washing soda has been added. The removal of the bandage is, at times, a matter of some diffi- culty. This may be accomplished most readily by splitting it up with a sharp knife before it is thoroughly hardened. To avoid cut- ting the surface of the body a narrow lead strip is usually placed outside the flannel bandage, in the long axis of the limb. It should be of sufficient length to project above and below the plaster after it is applied. The cutting can be done safely upon this as a base. Where the bandage is not previously cut, a little vinegar or dilute hydrochloric acid and a sharp knife will be found far more effica- cious than the plyers and saw usually employed. The bandage having been wet in the line of incision is quickly and readily cut through, with little disturbance of the parts. The line of cutting should be kept thoroughly wet with the vinegar. Under what circumstances is the plaster bandage applied ? 1. In the treatment of fractures where deformity is absent oris readily reduced, and where great swelling is not present. 2. In sprains and in chronic inflammations of joints. 3. In diseases, deformities, and injuries of the spinal column. 4. As a permanent splint and dressing after operation upon bones or joints. 5. As a splint after the performance of tenotomy and other ortho- paedic operations. How is the plaster-of-Paris bandage trapped ? The surgeon may desire to inspect a wound or to provide for drainage without removing a plaster bandage. This is accomplished by cutting a trap or window in the dressing. In the region where the opening is desired a thick compress of gauze is placed. This forms a projection, when the bandage is completed, which not only marks the position of the trap, but which enables the dresser to cut through the plaster without fear of injuring the patient. PLASTER-OF-PARIS DRESSINGS. 61 How is the plaster-of-Paris jacket applied? The plaster-of-Paris jacket is applied, in cases of Pott's disease, for the purpose of fixing the spine and to relieve the diseased ver- tebrae from the weight of the upper portion of the body ; further, a certain amount of extension may be obtained if the dressing is applied carefully. The body of the patient is first thoroughly cleansed with boric acid lotion ; a tight-fitting undershirt is then put on ; better than this is a stockinette garment or one of silk made to fit perfectly to the figure. In any case the shirt should reach down to below the trochan- ters of the femur. Bony prominences should be carefully protected by thick pads of absorbent wool around such projections. In very thin subjects the iliac crests will require padding. Over the umbili- cus a folded towel is placed ; this is called the " dinner pad " and is to be removed after the bandage hardens. In females who have passed the age of puberty the breasts must be protected by thick layers of cotton wool. All padding is placed between the shirt and the skin. When everything is prepared for the application of the plaster the patient is suspended by the head and shoulders; the ex- tension accomplished by this means must be slight, otherwise it becomes unbearable long before the bandage is completed. Suffi- cient traction to raise the patient from the ground so that his toes are touching and supporting the major part of his weight is all that is required. Either the regular extension apparatus may be em- ployed, or, in the absence of this, one may readily be improvised. A hook, a cross-beam, or anything over which a rope may be passed, a rope, a stout stick two feet in length, and bandages are sufficient for all practical purposes. A broad bandage is doubled upon itself, and at the point of doubling slit up the middle, in its long axis, for eight inches ; the bandage is opened and the head passed through this slit; on making traction upward one portion of the bandage catches the occiput while the other supports the chin. This occipito- mental sling is to be secured to the middle of the stick, which is in turn suspended by the rope immediately above the patient's head. At each end of the stick two bandages are looped enabling the pa- tient to support himself by his hands. By hoisting on the rope the patient is lifted from the floor to the desired extent. The toes should always be allowed to rest upon the floor. The plaster-of- 02 ESSENTIALS OF BANDAGING. Paris bandages are then placed in water and allowed to remain until thoroughly wet through ; they are then gently squeezed out, to rid them of excess of water, and are applied to the b< »dy, from just above the trochanters of the femur to the lower borders of the axillary folds. As the bandage is carried around the trunk, an assistant rubs and smooths every layer with his wet fingers. The turns are applied with no more pressure than is sufficient to make them lie smoothly. In children, five or six bandages are generally required. The dressing is completed by taking some powdered plaster-of-Paris, mixing it with water until a thick paste is formed, and thickly smearing the latter over the entire dressing until a perfectly smooth, uniform surface is formed. If possible, the patient should remain suspended till the bandage becomes well set. This requires ten to fifteen minutes ; if this is too fatiguing, the patient should be laid upon his back, two assistants supporting him upon either side and preventing him from bending his body. After the bandage is thoroughly hardened the " dinner pad " is removed. Adhesive Plasters and Strapping. What kinds of adhesive plasters are commonly used ? The adhesive plasters in common use are of three varieties—the resin plasters, isinglass plasters, and the rubber adhesive plasters. The resin plaster, commonly called surgeon's adhesive plaster, is the one most commonly employed. It is slightly stimulating to the surface, adheres firmly, and causes but little irritation. The thin paper, covering the plaster surface is taken off, and the plaster is cut in strips of proper width and length. The strips are heated by passing them through the flame of an alcohol lamp, or by holding the unplastered side against a hot vessel. The rubber adhesive plaster requires no heat; it adheres even more closely than the resin plaster, but is liable to cause a certain amount of irritation. It must be kept in contact with the surface fur some little time before it firmly adheres. In applying it care should be taken to shave off all hairs, as, otherwise, its removal is quite painful. The isinglass plaster must be moistened before it will adhere. To ADHESIVE PLASTERS AND STRAPPING. 63 avoid the danger of infection it should be dipped in an antiseptic solution before being applied to a fresh surface. It is useful in dressing small wounds. For what purposes are straps applied ? (1) To retain dressings. (2) To approximate wounds. (3) To make firm and uniform pressure. Describe the method of strapping the testicle. Indications.—Orchitis, or epididymitis, after the swelling has reached its height. Application.—Shave the scrotum; cut twelve to eighteen strips of resin plaster, each about ten inches long and half an inch wide. Seize the swollen testis and pass the thumb and finger around the scro- tum at its upper portion, making circular constriction, and enclosing the injured organ in a tense pouch of skin ; about the neck of this pouch the first strap is passed tightly ; this holds the testis in place and enables the operator to apply pressure by means of subse- quent strips. These are regularly imbricated one above the other, the first beginning at the circular strip and passing directly across the most prominent part of the tumor. Every part of the skin must be completely covered, and the strips must be applied evenly and regu- larly, so that uniform pressure is made. This dressing gives great relief to the intense pain which charac- terizes inflammation of the testes, and greatly accelerates resolution. Describe strapping of the breast. Straps of resin adhesive plaster should be cut, each two inches wide, and long enough to pass from the spine of one scapula forward, obliquely upward under the breast, and across the shoulder to the spine of the opposite scapula. The first strap is applied in this way; the next strap is applied around the body, overlapping the first strap beneath the .breast; the third strap is applied obliquely, again over- lapping the first; then co-rues the circular strap. This method of application is continued until the breast is entirely covered. This dressing is useful in inflammation of the breast, and is to be preferred to the roller bandage from the fact that it does not pass completely around the chest, and thus breathing is not interfered with. 64 ESSENTIALS OF BANDAGING. Describe strapping of the ribs. Strips of resin plaster, two and a half inches wide, and long enough to reach from the sternum to the spine are employed for this dressing. These strips are applied parallel to the course of the ribs. The first strap is secured posteriorly and is carried around the side of the chest as close to the axillary folds as possible. The next strap overlaps this downward for two-thirds of its width ; the straps are thus applied until the injured side of the chest is covered in. This dressing is employed for fractures of the ribs and for hem- orrhage from the lung. Describe the strapping of an ulcer. This dressing requires straps, each one inch wide, and long enough to pass two-thirds around the limb involved. First, the ulcer must be thoroughly cleansed, and the parts about it well dried. The straps are then applied, beginning two inches below the lower bor- der of the ulcerated surface. The first strap is applied obliquely to the long axis of the limb, with its middle directly below the middle of the ulcer. The next strap is applied at right angles to the first, the angle of crossing lying directly below the ulcer; each suc- ceeding strap is applied overlapping upward for two-thirds of the width of the straps, until the ulcer is covered, and the dressing is continued two inches above its upper margin. When the ulcerated surface is reached the tissues of each side should be drawn together, the straps should then be secured to one side, drawn across and fastened to the opposite side, endeavoring thus to bring the tissues in closer ap- proximation. Over this dressing a sheet of lint, or a thin, even pad of absorbent cotton is laid, and the dressing is completed by a tight spiral reversed or figure-of-eight bandage. This dressing is peculiarly valuable in the treatment of chronic ulcers. Knots and Sutures. Describe the square knot. Either this or the surgeon's knot is the one commonly employed to secure bleeding vessels. The square knot is formed by passing one end of a cord or ligature over and around the other end. This forms a single knot which is KNOTS AND SUTURES. 65 drawn tight. The two ends are then carried toward each other and the same end is again carried over and around the other. On draw- ing this tight the square knot is formed. The surgeon s knot is formed by carrying one end twice around its fellow; after tightening of this double turn, the same end is carried over its fellow again, and around, as in case of the square knot. The surgeon's knot is harder to draw tight than the square knot, but there is less liability of the first turn slipping while the second securing turn is being formed. Dressers are usually cautioned not to make what is called the granny knot. The difference between this and the square knot lies in the fact that one end having been carried across and around its fellow, the knot is completed by carrying this same end under and Fig. 38. Square Knot. then around its fellow, or what amounts to the same thing, carrying the end which was first crossed, over and around the end which ori- ginally crossed it. In reality this forms a secure and reliable knot, and the objections to it are probably purely theoretical. The square knot and surgeon's knot are commonly employed in securing ligatures and in tying sutures. Of what materials are sutures generally made ? Sutures are usually made of silk, silver wire, catgut, silkworm gut, or horsehair. Of these, the catgut alone is absorbable ; the others must be removed after application. Describe the continuous suture. (1) This is also called the glover's suture. The needle is passed 5 66 ESSENTIALS OF SURGICAL DRESSING. in one side of the wound, is brought out the other, and the knot is tied ; the thread is then carried directly across the wound, the needle is again plunged in the same side as in the first place, is Fig. 39. The Continuous, or Glovers' Suture. carried in to the depth of the wound, is brought out at the opposite side and the thread is drawn tight. This practice is repeated until the wound is completely closed; the short end of the Fig. 40. The Interrupted Suture. thread is drawn sufficiently through the eye of the needle to allow it to project from the side of entrance when the last stitch is formed ; to this single thread the double thread is tied. This forms KNOTS AND SUTURES. 67 a continuous over-hand suture, and is applicable to superficial wounds. Describe the interrupted suture. # The interrupted suture is formed by entering the needle at one side of the wound, carrying it down to the deepest part and bringing it out on the opposite side ; the suture is then tied with either the surgeon's or the square knot, and is cut. Each stitch is made sepa- rately, as many being placed as are required to close the wound. In this suture the stitches are in no way connected, so that were one to break the others would still continue to hold. What other sutures are commonly employed ? The Plate Suture.—The end of the suture is secured in a broad leaden button or plate ; the needle is then plunged in at one side of Fig. 41. The Plate Suture. the wound to its deepest part, is brought out at the opposite side and is secured to another plate or button. This suture is valuable where there is much tension, since it gives a broad surface for the application of pressure. The Pin Suture.—A harelip pin is entered at one side of the wound, carried directly across its deepest part and brought out through the skin of the opposite side. Around the head and point of this pin is then carried a thread in the form of a figure of 8, approximating the lips of the wound and making sufficient pressure to check hemorrhage from vessels even as large as the coronary artery. This form of suture is of value when it is desired to produce close approximation, and at the same time check bleeding. 68 ESSENTIALS OF SURGICAL DRESSING. The Quill Siture.—Two quills are cut, each the length of the wound. Each needle carries a double thread knotted at its end.' The needle is entered at one side of the wound, some little distance from its edge, is carried across the depth of the wound and brought out at the other side. Through the loops formed by the knotting Fio. 42. The Pin Suture. of the doubled suture is passed a quill. These threads are then drawn tight, the needles are cut away, and the two ends of each thread are tied around a quill, placed on the other side of the wound, parallel to its long axis. This is applied for precisely the same purpose as is the plate or button suture; great tension is Fig. 43. The Quill Suture. allowable, since it is distributed over a large surface, and thus wounds are drawn in close apposition. The Lembert Suture.—This suture includes only the serous, muscular and submucous coats of the bowel. The needle is entered KNOTS AND SUTURES. 69 at one side of the wound and caused to penetrate directly through the wall of the bowel until the sense of increased resistance caused by the tough submucous connective tissue is felt; it is then pushed along at right angles to the long axis of the wound, and its point is made to emerge on the same side of the wound as it originally entered, the thread including about a fifth of an inch of the outer coats of the gut. The thread is then carried directly across the wound, the needle is thrust from without inward dqwn to the submucous coat of the bowel, then brought out again, including the outer coats as before, and the suture is tied. This thread may be interrupted or continuous. In either case the stitches are placed from an eighth to a tenth of an inch apart. When the thread is Fig. 44. The Lembert Suture. drawn tight the two serous surfaces are approximated. Fine catgut or China silk should be employed for this suture. The needle should be small, sharp, and with a perfectly rounded point, having no cutting edges. The ordinary milliner's needle answers well. The Czerny Suture differs from the Lembert in the fact that the edges of the wound are brought together directly by carrying the needle through .the serous membrane, out at the wound surface without penetrating the mucous membrane, in at the wound surface of the opposite side superficial to the mucous membrane, and out through the serous membrane. By these sutures the lips of the wound are approximated ; further security against leakage is insured by a row of Lembert's sutures, turning in the wound and thus 70 ESSENTIALS OF SURGICAL DRESSING. securing apposition of serous surfaces. This is termed the Czerny Lembert suture. Fig. 45. The Czerny Suture. Sutures of Relaxation are those which are brought out at some distance from the wound, and which are employed for the purpose of bringing the parts together where otherwise there would Fig. 46. Sutures of Approximation and Coaptation. be dangerous tension upon the stitches which close the skin wound. For this purpose quill sutures or plate sutures are commonly employed. Sutures of Approximation are those which are carried deep, and are designed to approximate the subcutaneous parts of the wound. Sutures of Coaptation are those which puncture only the skin. They should be applied so accurately that they practically hermeti- cally seal the wound. ANTISEPTICS. 71 When should sutures be removed ? This depends upon the amount of tension exerted upon them. They should not be allowed to remain longer than 8 to 10 days, as a rule. Sutures about the face should be taken out in one day in cases of ordinary wounds ; about the trunk or extremities in from 3 to 5 days. After laparotomy or where newly-formed tissues will probably be subject to great strain, it is customary to leave the sutures for from 8 to 12 days. How are sutures removed ? The knot is seized with a pair of fine dressing forceps, slight ten- sion is exerted upon it, and by means of a pair of sharp-pointed scis- sors the thread on one side of the wound is divided; the scissors are then placed flat upon the surface close to the point of exit of the divided thread, and the latter is drawn out by means of the for- ceps. Where silver wire has been employed, after cutting the suture the wire should be straightened out as much as possible before drawing it from the wound. Catgut if properly prepared will be absorbed in a few days. The knots only will have to be taken from the surface. What is meant by secondary suture ? Under certain circumstances, as for instance, when a cavity has been opened, and the surgeon is not certain that suppuration may not follow, the sutures are inserted as usual but are not drawn tight, the wound is packed with iodoform or other antiseptic gauze and the dressing is applied. After a few days the gauze packing is removed and if the condition of the wound is satisfactory the sutures are knotted. ANTISEPTICS. What chemicals are required in antiseptic surgery ? The chemicals usually employed are bichloride of mercury, car- bolic acid, iodoform, and alcohol. In addition, creolin, sulphate of zinc, boric acid, and peroxide of hydrogen are of value. How is bichloride of mercury used ? It is used in watery solutions varying in strength from 1-500 to 72 ESSENTIALS OF SURGICAL DRESSING. 1-2000. The strength of 1-500 is used solely as a means of cleansing external parts. In the strength of 1-2000 it is used for irrigating. Where large cavities are to be washed out the strength should not exceed 1-5000. The irrigating solution is made still more efficient by the addition of tartaric acid. This prevents the neutralization of the mercury by albumin. If it is desired to keep solutions of mercury for any length of time ordinary salt should be added, as otherwise the chloride of mercury is precipitated in the form of an oxide. (See Appendix for Formulae.) Mercuric solutions are also useful for the purpose of sterilizing dressings and rendering them antiseptic. An alcohol solution of mercury, 1-1000, is employed for the pres- ervation of silk ligatures. What symptoms denote poisoning from absorption of bi- chloride solution? There is at first a feeling of giddiness and faintness, and the patient is very restless. This may be followed by vomiting, fcetid breath, salivation, and inflammation and ulceration of the gums and mucous membrane of the mouth. In severe cases there is often diarrhoea, the stools being blood-stained, and bleeding from the mouth and nose. Albumin and mercury are found in the urine. To avoid toxic absorption the dressings must be wrung out as dry as possible. Very great care must be employed in children and in cachectic patients ; and in irrigating the uterine or any large cavity even the most dilute solutions should not be employed. How is carbolic acid used? It is employed in the strength of 1-20 and 1-40. The 1-20 solu- tion is used for the sterilization of instruments and for the cleansing of surfaces. The 1-40 solution may be used for irrigation, and the washing of sponges during an operation. The 1-20 solution benumbs and cracks the hands of the operator, hence, immediately before operating, this liquid, in which the instruments have been lying for half an hour, must be diluted by the addition of an equal volume of water, making the lotion of a strength of 1-40. On account of its volatility, the 1-20 solution may be used for the sterilization of dressings which are placed in contact with the wound. The heat ANTISEPTICS. 73 of the body very quickly causes evaporation of all the carbolic acid, leaving simply a sterile, non-irritating surface. What symptoms denote poisoning from absorption of carbolic solution ? The urine becomes olive-green; the intensity of the coloration, however, is not indicative of the severity of the poisoning. The patient complains of headache, giddiness, anorexia and vomiting. In severe cases the symptoms are followed or accompanied by haemoglobinuria and bloody diarrhoea, death following from collapse. Czerny describes a chronic form of poisoning termed carbolic maras- mus, and characterized by headache, weakness, anorexia and an irritative cough. Describe the uses of iodoform. Iodoform must first be sterilized by a thorough washing in 1-2000 bichloride solution. It is then kept in boxes which are tightly closed. It is employed in the preparation of antiseptic gauze, and in the preparation of injection oils for the treatment of tubercular abscesses (iodoform one part, olive oil ten parts); it makes with collodion a dressing for superficial wounds ; it is used as a dusting powder to the surface of wounds, and as an application to infected and suppurating wounds. What symptoms denote poisoning by iodoform ? This drug exerts its toxic action chiefly on the heart and brain ; usually the heart first shows the effect of an overdose, the pulse becoming more frequent and irregular. The patient complains of great debility, sleeplessness and headache, and suffers from extreme mental depression. In more severe cases, in addition to the above symptoms, uncon- trollable restlessness develops into delirium, hallucinations, or any of the various forms of acute insanity. These symptoms may last for weeks, and not infrequently end in death, from cardiac or pul- monary depression. In the most fatal cases, the symptoms of acute meningo-encepha- litis are followed by coma, involuntary passage of urine and faeces, and other signs of brain palsy ; here a fatal termination is the rule. 74 ESSENTIALS OF SURGICAL DRESSING. Describe the uses of creolin. Creolin may be employed precisely as is carbolic acid. It is devoid of the toxic properties of the former and does not produce irri- tation of the skin. It forms with water a mixture rather than a solu- tion ; the opacity of this latter is an objection to its use as a sterilizer of instruments. In the strength of 3 to 5 per cent, it is an efficient germicide; it is commonly used much weaker, but bacteriological investigations have shown that this is not safe. Describe the use of boric acid. Though not possessing great power as an antiseptic, solutions of this acid are of great utility from the fact of its being non-toxic. Saturated solutions are commonly employed (1 to 30 per cent.). In disinfecting mucous membranes or large absorbing cavities boric acid is found serviceable. Describe the uses of chloride of zinc. Chloride of zinc is commonly used in the strength of 40 grs. to the ounce. In this strength it is a powerful antiseptic. It is employed upon raw surfaces known to be infected or where infection is feared. Describe the use of peroxide of hydrogen. Peroxide of hydrogen is employed in the sterilization of suppura- ting cavities. It comes in what is called the 15-volume solution, and may be used in dilutions of from 10 per cent, upward, or in full strength. It is said to immediately destroy the pus microbes. To granulating surfaces it is best applied in the form of a spray. Sponges. - How are sponges prepared for operation? Sponges may be prepared by being thoroughly washed in hot water, dried, and well beaten until they are freed from sand. Cal- careous particles may be further removed by steeping them in a 10 per cent, solution of hydrochloric acid. After thorough washing in pure water, they can be stored in 1-20 carbolic acid solution. A much more thorough way of preparing sponges is by beating out the sand, subsequently washing them in lukewarm water then SILK. to steeping them for twelve hours in a mixture of one part of solution of chlorinate of soda to five parts of water. They are then well rinsed and dried. They may be kept either dry in tightly closed jars, or in 1-20 carbolic solution. It is not advisable to use sponges more than once. Where this is necessary, however, ■ they are best cleansed by being steeped in a concentrated solution of washing soda, well washed in clear water, and immersed for an hour in 1-500 sublimate solution. Catgut. How is catgut prepared ? The bundles of catgut which come in commerce are freed from their bindings, and are completely immersed in oil of juniper berries for one week, when they are removed and placed in absolute alcohol, and are kept indefinitely in this material. The chromic catgut is made by tanning this material with chromic acid. A 1-20 solution of carbolic acid is prepared, and enough chromic acid is added to make a solution of 1-5000 of the latter drug. The catgut is immersed in this solution for four to six hours, or until the gut, when lifted out, is of the same amber color as the acid. It is then dried and packed in air-tight flasks. When used it should be soaked for half an hour in 1-20 carbolic or 1-1000 sub- limate solution. Silk. How is silk sterilized ? Silk is sterilized by boiling for half an hour. It is subsequently stored in either 1-20 carbolic solution, or in absolute alcohol, to which may be added sufficient mercury to make a 1-1000 solution. Dressings. What dressings are usually employed in antiseptic surgery? llicMoridr Gauze.—This is prepared by boiling ordinary cheese cloth for two hours in water made moderately alkaline with washing soda. The grease is thus removed and the fabric is rendered absorb- ent. The soda is then washed out and the cheese cloth is again 76 ESSENTIALS OF SURGICAL DRESSING. boiled in pure water for two hours, after which it is wrung out, and is stored in sublimate solution, 1-500. When the dressing is to be applied, the 1-500 mercuric solution is wrung out, the fabric is dipped in 1-3000 solution, is again wrung out as dry as possible, and is then placed on the wound. After the second boiling the cheese cloth may be dried in the sun and stored in air-tight jars or boxes. When used it can be dipped first into 1-500 solution, afterward into the weaker lotion of 1-300U. Iodoform Gauze.—This is most readily prepared precisely as the bichloride gauze, except that after the cheese cloth has been thor- oughly wrung out in 1-3000 corrosive sublimate solution it is sprinkled liberally with iodoform, and the latter is rubbed thor- oughly into its meshes. The layers which lie in immediate contact with the wound may be wrung out in a 1-20 carbolic solution. The more superficial layers are dipped in a 1-3000 bichloride solution, and are then dried as far as possible by squeezing before they are applied. Bichloride cotton forms the outer layer of the dressing. Protective.—Any smooth, readily sterilizable surface will answer for this part of the dressing. Lister's protective, gutta-percha tissue, oiled silk, or even waxed paper, may be used. The purpose of the protective is to prevent the wound from being irritated either by the antiseptics employed in the gauze, or by the irregular structure of the latter. A small piece is taken, just large enough to cover the wound, and is dipped into 1-20 carbolic solution. The latter evapo- rates shortly, and leaves a sterile surface in contact with the wound. Many surgeons dispense with the protective entirely. Cotton. —Bichloride, borated, salicylated or plain absorbent cotton may be used. The bichloride cotton is the best. Bandages.—These are commonly made of gauze, and conform in size to the regular roller bandage. The first roller applied should be wrung out of a 1-3000 bichloride solution. Pins. — Either the ordinary pins or safety-pins are employed. They should be disinfected by means of carbolic lotion 1-20, and should be kept in absolute alcohol. Describe Lister's new antiseptic dressing. Gauze prepared as above is impregnated with a mixture of the cyanide of zinc and mercury and hematoxylin. This gauze is either DRAINAGE. 77 freshly prepared by diffusing the powder iu a 1-3000 bichloride solu- tion, incorporating it with the gauze, wringing out the latter, and applying it directly, or is stored damp in air-tight jars, to be used as required. The first layers applied directly over the wound are wrung out in 1-20 carbolic lotion ; the more superficial part of the gauze dressing is rendered still more antiseptic by saturation in 1-3000 bichloride solution. Over the gauze is placed a thick layer of bichloride cotton. Drainage. By what means are wounds drained ? Either by drainage-tubes of rubber, bone or glass, or by catgut or horse-hair drains. The most efficient way to drain a wound is to leave it open and pack it with iodoform gauze. When it is possible the drainage-tube, abundantly provided with fenestra cut in its sides, should pass through the wound from side to side, so that it may be readily washed out in case it becomes blocked, or may be cleaned, if necessary, by means of a soft catheter. Where deep cavities are to be drained, the tube should be carried to that part where accumulation of fluid is most liable to take place. The bone drainage-tube is used when the surgeon does not intend to remove his dressing till the wound is healed. Iu comparatively small wounds catgut or horse-hair may be employed. The former is absorbable, and should be used when it is intended that the wound shall heal under the first dressing; the latter has to be removed. Drainage-tubes are removed as soon as they cease to carry off dis- charge. This is commonly in the first thirty-six hours. When may drainage be omitted ? In incised wounds, when there is no reason to fear that infection has occurred. Wounds as large as those resulting from excision of the breast, if aseptic, require no drainage. Antiseptic Operations. Describe the preparations for an antiseptic operation. The surface about the seat of operation must be shaved and well washed with hot soapsuds, employing a clean flesh brush vigorously. This is followed by a thorough washing with either alcohol or ether, 78 ESSENTIALS OF SURGICAL DRESSING. which removes the fat from the surface of the skin and from the follicles, and enables the antiseptic solution to act upon any germs which may be present. The next washing consists in a careful cleansing with 1-500 solution of bichloride of mercury. The surface should finally be completely covered with a bichloride towel soaked in a solution of 1-1000. The operators, assistants and nurses then prepare their arms and hands in the following manner : The sleeves are rolled up, the hands and arms are thoroughly scrubbed in soap and water, by means of a nail brush the nails are carefully cleaned, and the hands are again scrubbed in soap suds. Alcohol is then used as a wash for two minutes, and the preparation is completed by washing the hands for three minutes in a solution of bichloride of mercury 1-1000. After this final washing, the hands must touch nothing which has not previously been sterilized ; and, during the course of the operation, the surgeon and the assistants must occa- sionally wash their hands in a 1-1000 solution. When everything is prepared for the operation, the table, the surface of the patient's body, and the clothing, are all covered, first, by rubber cloth or mackintosh, then, over this, are spread bichloride towels, soaked in 1-1000 solution, so that the surgeon shall not inadvertently touch non-sterilized surfaces, or place dressings or instruments upon them. In the meantime the dressings are cut of proper size, wrung out in the proper solutions, and wrapped in bichloride towels. Describe an antiseptic operation. The instruments having previously been soaked in a solution of 1-20 carbolic acid, at the moment the operator is about to begin his work sufficient hot water is poured into the tray containing them to make a solution of the strength of 1-40. The instruments imme- diately required are then selected and placed on one of the bichloride towels in the neighborhood of the proposed operation. A basin con- taining sponges, thoroughly wrung out in bichloride 1-2000, is placed within reach of the assistant. A nurse stands with an empty basin ready to receive the blood-soaked sponges, which are imme- diately wrung out again in 1-2000 solution and placed convenient to the hand of the assistant. Every effort is made to keep the wound exposed as little as possible. During any intervals of opera- tion the assistant must instantly cover the entire wound by sponges ANAESTHETICS. 79 or by a wet bichloride towel. When the upper portion of the wound is the seat of immediate operation the lower portion must be kept covered, and vice versa. Bleeding points are seized in artery forceps or haemostats, and secured by catgut ligatures. On the completion of the operation, bleeding having been entirely checked, the wound is approximated. The edges are brought together with the most scrupulous accuracy, drainage having been employed or omitted, according to the will of the surgeon. Describe an antiseptic dressing. The wound having been carefully approximated, iodoform is dusted upon its outer surface, and a piece of protective, waxed paper, or other perfectly smooth substance, is dipped into a solution of 1-20 carbolic acid, cut so that the ends of the drainage tubes may project through it, and placed directly over the line of suture. This protective must be just large enough to cover the wound, and no larger. Over the protective is placed the deep dressing. This consists of eight or ten layers of gauze wrung out in bichloride solution 1-3000 ; or, iodoform gauze may be employed, when irrita- tion of the skin is feared. The superficial dressing then follows, being composed of eight or ten layers of dry gauze prepared with bichloride. Over and around this is laid bichloride or absorbent cotton, and finally a bandage. Each application must be overlapped throughout its whole extent by the next superficial dressing. ANAESTHETICS. How is anaesthesia produced? General anaesthesia is produced by the administration of nitrous oxide, ether or chloroform. Local anaesthesia is produced by freezing, or by the injection or application of cocaine. Which is the safest anaesthetic ? Nitrous oxide for operations requiring, at the most, not more than two minutes. Ether comes next in order, and should be used, even in brief operations, when muscular relaxation is necessary. 80 ESSENTIALS OF SURGICAL DRESSING. What is the objection to the use of chloroform? Sudden death frequently occurs from cardiac or respiratory arrest, and without premonitory symptoms. This is liable to happen when the patient inhales while in a sitting position, as in the extraction of teeth; or when operations are begun in particularly sensitive re- gions, as the anus or vagina, before anaesthesia is complete. How is nitrous oxide administered? In preparing the patient, the bladder is emptied of its contents, the clothing about the neck is unbuttoned, and false teeth or other loose bodies are removed from the mouth. For the proper administration of this gas a receiver or cylinder attached to a gas-bag, and a mouth-piece provided with a double valve, which prevents the expired air from passing back to the bag, should be provided. The patient should be instructed to take deep, full breaths. In from thirty to sixty seconds, the dusky, congested face, the muscular twitching, and the stertorous breathing denote that the patient is fully under the influence of the gas. How is a patient prepared for the administration of ether or chloroform ? A careful examination of the urine should be made, and the con- dition of the lungs, heart, and vascular system should be determined by auscultation, palpation, and an examination into the clinical his- tory of the case. For at least six hours before the anaesthetic is ad- ministered, no food should be taken into the stomach. Anaemic and excessively nervous patients should receive two ounces of whiskey half an hour before being anaesthetized. In drunkards a quarter of a grain of morphia renders the system much more susceptible to the action of the ether or chloroform. Immediately before inhalation is begun, the clothing is loosened about the neck, chest, and abdomen, and artificial teeth or other foreign bodies are removed from the mouth. The physician should refuse to anaesthetize women, unless there is a third person in the room. Lights, if near, should be held above the level of the ether. How is ether administered ? A towel may be folded in a cone, or simply laid over the mouth and nose, and gathered in at the sides, so that the air is breathed ANAESTHETICS. 81 in through its meshes, and not by way of the space between its borders and the clu-eks. Of the many inhalers, that of Allis is the best. It consists of a framework carrying many folds of an ordinary roller bandage. This gives a broad surface for the rapid evaporation of the ether. If possible the patient should lie flat upon his back. The eyes are protected by a folded towel placed over them. During the first few inhalations, the vapor should be very dilute, excepting in the case of screaming and terrorized children, when the ether should be pushed from the first. As soon as the patient becomes slightly intoxicated, the vapor should be as concentrated as possible. Persistent coughing, swallowing, and attempts at vomiting, indi- cate that the reflexes are not abolished, and are best combated by pushing the ether. When the pulse is slow and full, the respirations deep and snoring, the reflex irritability totally abolished, and the pa- tient completely relaxed, the anaesthesia is carried to the extreme limit of safety. The respiration, the pulse, the pupil, and the color of the skin, must be carefully watched. In what ways is the administration of ether complicated ? In the first stage the patient, though still partly conscious, may cease to breathe. This is called respiratory forgetfulness, and is best corrected by sudden pressure on the front of the chest, or by a dash of ether on the epigastrium. In the second stage there is sometimes a tonic spasm, involving the respiratory muscles and accompanied by marked venous congestion. The ether should be withdrawn till this complication disappears. If the patient has eaten solid food within a few hours and vomits, he should be rolled over on his side; it is not sufficient to twist the head laterally. In the third stage respiration may be seriously embarrassed by mucus collecting in the throat. This should be mopped out with small sponges firmly secured to holders. If there is laryngeal or pharyngeal obstruction, often denoted by a high-pitched, crowing sound on inspiratory effort, the lower jaw should be pushed forward and the head should be extended by upward pressure of the fingers placed beneath the ramus of the submaxillary bone. Asphyxia sometimes threatens, from excess of ether, from drop- 6 82 ESSENTIALS OF SURGICAL DRESSING. ping back of the tongue, or from closure of the glottis. The surface becomes blue, the pulse frequent and irregular, and there is often laryngeal or crowing stertor, and absence of respiratory efforts. Immediately the head must be extended and the lower jaw must be thrust forward. This acts upon the hyoid bone, elevates the epi- glottis and opens the glottis. Artificial respiration is promptly in- stituted, the foot of the table being raised. Ether or ice water is dashed on the bared epigastrium, and the electric brush is applied intermittently, the sponge electrode being placed over the sternum or any indifferent part, while the wire points are touched to the epigastrium or other sensitive parts of the body during an inspiratory Fig. 47. Method of Pushing the Lower Jaw Forward, where there is Obstruction to Breathing. effort. Finally, tracheotomy may be performed, when the lungs can be inflated directly. A twentieth of a grain of strychnia should be given hypodermically as soon as dangerous symptoms appear; this may be repeated once if the subsequent course of the case makes it necessary. Alcohol and ammonia seem to be of no service, while ether injected hypodermi- cally is obviously not to be commended. What symptoms denote that the patient should have more air? A feeble, infrequent pulse. Lividity of the surface. Laryngeal stertor. Pallor and tonic spasm. A pupil suddenly becoming widely dilated (a sign of imminent death). Reversal of the normal respi- ratory movements of the belly, denoting diaphragmatic palsy. ANAESTHETICS. 83 How is artificial respiration performed when dangerous symptoms develop during anaesthesia ? The table is tilted up till it makes an angle of 45° with the hori- zon, the head being low. The head is extended so that it rests near the crown upon the surface of the table, the eyes looking upward and somewhat back- ward. At the same time the under jaw is pushed well forward by pressure applied behind the rami. In the absence of assistants, the drawing forward of the hyoid bone and consequent opening of the glottis may be accomplished by letting the head hang over the end Fig. 48. Sylvester's Method—Expiration. of the table. The surgeon, standing at the head of the patient, then seizes him by the arms just above the elbow joints, carries the arms partly across the chest toward each other, and throws his weight downward so that the lungs are emptied of the anaesthetic vapor which may remain in them. The arms are swept in a semi- circle directly out from the sides and upward till they extend above the head. Firm traction is made for two seconds to further fill the chest with air. The arms are then carried down to the chest wall again, where by pressure the lungs are made to expel the inspired air. These motions are repeated from twelve to sixteen times a minute, and practically constitute the Sylvester method of artificial 84 ESSENTIALS OF SURGICAL DRESSING. respiration. Howard's method, which is exceedingly efficient, is as follows : " Make the head hang back as low as possible. Place the patient's hands above his head. Kneel with the patient's hips be- FlG. 49. tween your knees, and fix your elbows firmly against your hips. Now, grasping the lower part of the patient's naked chest, squeeze his two sides together, pressing gradually forward with all your Fig. 50. Howard's Method—Expiration. weight for about three seconds, until your mouth is nearly over the mouth of the patient, then, with a push, suddenly jerk yourself back. Best about three seconds, then begin again, repeating these ANaESTHETTCS. 85 bellows-blowing movements with perfect regularity for at least one hour, or until the patient breathes naturally." Under what circumstances is chloroform preferred to ether ? Where there is emphysema of the lungs or bronchitis, particularly in the aged or the very young. Where there is vascular degenera- tion, or disease of the kidneys. Where operations about the mouth, which may require the application of the actual cautery, are per- formed. Where it is necessary to give an anaesthetic to an infant. How is chloroform administered? The patient is prepared as for the administration of ether. Not more than a drachm of chloroform is poured upon a towel, and the latter is held close to the mouth, but not touching it, otherwise painful blistering may occur. During the first few inhalations suffi- cient air is allowed to avoid giving the patient a sense of suffocation. Deep, full breaths should be taken, children being directed to blow out. Absence of reflexes, particularly that elicited by touching the conjunctiva, and complete muscular relaxation, denote that the patient is completely anaesthetized. Then, and not till then, should the operation begin. The pupils during full anaesthesia are com- monly contracted. Death occurs from respiratory arrest, though cardiac syncope, with a fatal issue, is common. The complications and their treat- ment are the same as in ether. Prolonged administration seems to have been followed occasionally by fatty degeneration of the heart muscle. Under what circumstances is the administration of chloro- form especially dangerous ? In timid, anaemic, violently hysterical patients, and in those exhibiting the signs of a feeble or fatty heart, as denoted by weak irregular pulse and sluggish peripheral circulation. In angina pectoris this anaesthetic should not be given, and a singularly high mortality has attended its employment in operations about the anus. How is cocaine employed for the production of local anaes- thesia ? Mucous membranes are anaesthetized by the application of solu- tions varying in strength from 4 to 10 per cent. The surface to be 86 ESSENTIALS OF SURGICAL DRESSING. anaesthetized should first be cleansed by a boric acid wash or spray; the cocaine is then applied, and in three minutes the application is repeated. In two more minutes the part will be found to bat ient should wear a knee-cap for many months. How are luxations of the patella reduced ? In reducing lateral luxations the leg is extended upon the thigh and-the thigh is flexed upon tjie abdomen. The margin of the patella furthest removed from the joint is then forcibly depressed. This tilts up and frees its inner border, and the bone is at once snapped into place by the quadriceps. Rotary luxation of the patella is reduced by alternate flexion and extension or by direct pressure. How are luxations of the semilunar cartilages reduced ? By forced flexion, followed by sudden extension. A knee-cap should be worn for one or two years. How are luxations of the ankle joint reduced? The leg is flexed on the thigh and the foot is moderately extended, to relax muscles. Extension is then applied to the foot and counter- extension to the thigh, when by manipulation and pressure the bones can usually be restored to their proper position. The after treatment consists in the subduing of inflammation and the applica- tion of a plaster bandage. Luxations of the tarsal bones are reduced by extension, counter- extension and direct pressure. If this fails the tenotome must be used freely. VENEREAL DISEASES. Chancroid. What is a chancroid ? A chancroid is an ulcer caused by contact with the secretions of a similar ulcer. What are the characteristics of a chancroid ? It has no distinct period of incubation. It may develop in twenty- four hours, though it usually appears in from three to five days after contagion. CHANCROID. 119 A papule first appears; this becomes a vesicle, a pustule, and shortly an ulcer. It is frequently multiple, causing the appearance of other sores upon surfaces with which it comes into contact, It is distinctly inflammatory in type ; the edges are punched out, irregular, and frequently undermined; the discharge is abundant, the surface is covered by a tough, gray, adherent slough. It is auto-inoculable; that is, the secretions inoculated upon another part of the body will produce a similar sore. It is not indurated, and the parts surrounding are no harder than is common to any other inflammation of equal severity. It has no distinct tendency toward spontaneous cure. It produces mono-ganglionic, unilateral lymphatic enlargement in the groin; that is, there is a single bubo on one side of the body. If the ulcer attacks the fraenum there may be bilateral lymphatic involvement. As a consequence of chancroid there may be simple inflammatory bubo, which usually undergoes spontaneous resolution, or, if it suppurates, discharges laudable pus and readily heals, or virulent chancroidal bubo, which exhibits all the characteristics of the original sore. The chancroid is not followed by secondary eruptions. What is the favorite seat of chancroid ? Chancroids may be found on any part of the body, but they are usually placed about the genitalia. In this region they commonly appear about the fraenum, though they may be found on the pre- puce, the glans, the meatus, or any other portions of the organs. How may the chancroid be complicated ? By inflammation. This complication may occur from mechanical irritation, from excess, or from improper dressing. It is denoted by swelling, pain, blood-stained secretion, and rapid extension. The ulcer shows a marked tendency to undermine the skin, and buboes very commonly accompany this complication. By sloughing or phagedena. Constitutional debility predisposes to this complication. It is characterized by the phenomena of inflammation, together with rapid and extensive destruction of tis- 120 ESSENTIALS OF SURGICAL DRESSING. sue. There is usually much pain, and violent hemorrhages may occur. By serpiginous xdceration. This is attended by very slight con- stitutional disturbance. The process slowly but steadily extends, undermining the surrounding healthy skin ; the edges are uneven and sharply cut; the discharge is thin and sanious. By phimosis and paraphimosis. These conditions may prove serious complications, since in the one case it is difficult to reach the ulcer and apply the proper treatment, in the other the resulting congestion is so great as to markedly increase the inflammatory phenomena. With what other ulcerations may the chancroid be con- founded ? With herpes, with chancre, with other forms of syphilitic erup- tion, or with the excoriated form of balanitis. How is a chancroid distinguished from a chancre ? While the chancroid develops at once after exposure to contagion, the chancre has a period of incubation varying from two to three weeks ; moreover, the chancre is generally single, is apparently non- inflammatory in type, giving usually a scanty secretion. It is fol- lowed by a polyganglionic, bilateral, lymphatic involvement, these buboes almost never suppurating. It is not auto-inoculable, it is dis- tinctly indurated, and is followed by secondary eruptions. In spite of the marked difference between typical examples of the two affections, sores will be encountered in which it is impossible to say whether the principal features belong mainly to syphilis, or to the chancroid as a local venereal ulcer. In these cases the test is afforded by inoculation. If, on inoculating the patient with pus of this ulcer, a chancroid is produced, it can be said with certainty that the initial lesion is a simple venereal sore or chancroid. The pre- ferable positions for inoculation are either beneath the nipple or on the outer surfaces of the thigh, since in these regions the sore runs a mild course and is not liable to be followed by chancroidal bubo. In chancroid within the urethra this is a valuable mode of diagno- sis ; also in cases of marked phimosis accompanied by symptoms presumably chancroidal, auto-inoculation will enable the surgeon to arrive at a reliable conclusion. It must be borne in mind that the CHANCROID. 121 fact of auto-inoculation succeeding simply shows that the sore is a chancroid, and does not exclude the possibility of syphilis subse- quently developing, since it is perfectly possible for the contagious matter of both diseases to be received at the same time. What conditions predispose to the development of a chan- croid ? The presence of abrasions or ulcerations, a redundant prepuce, lack of local cleanliness. How are chancroids treated ? Since the danger of rapidly destructive inflammation attacking chancroids is never absent until they are completely cicatrized, since even the most superficial sores preserve the virulent character- istics of the most marked ulcerations, and may at any time be fol- lowed by the simple or chancroidal bubo, the most satisfactory method of treatment consists in the immediate destruction of the entire ulcerated surface, thus substituting healthy granulation for a chancroidal ulcer. This is most readily accomplished by means of the hot iron, or by sulphuric or nitric acid. The important point in this treatment is to thoroughly destroy every portion of the ulcer, since the most minute part left untreated will re-inoculate the entire granulating surface. The hot iron is to be preferred to other cauterants. The ulcera- tion frequently undermines the skin, extending sometimes to the depth of one or two inches beneath what appears to be a per- fectly healthy surface. Every sinus and recess must be acted upon by the cauterant, even at the sacrifice of a great deal of tissue. As a dressing a few layers of dry antiseptic gauze can be applied to the burned surface. On separation of the eschar a healthy ulceration is left, which heals under cleanliness, protec- tion, and the application of the ordinary dusting powders. Where the cautery is objected to, nitric acid may be used. The pain of this application may be blunted by the use of a few drops of a 20 per cent, solution of cocaine. This is applied to the surface of the ulcer; the latter is then dried by absorbent cotton, and the acid is applied by means of a glass rod. Subsequent dressing is the same as after the actual cautery. A very convenient way of burning chancroids consists in the appli- 122 ESSENTIALS OF SURGICAL DRESSING. cation of a plaster made by pouring concentrated sulphuric acid upon pulverized charcoal until a mixture of about the consistency of molasses is made. The chancroid is cleaned carefully, dried as far as possible, and this paste is packed into every recess. The advan- tage of this dressing lies in the fact that the acid shortly evaporates or is neutralized, thus leaving a charcoal dressing to cover the ulceration. By the time this drops off cicatrization is commonly well advanced. Where there is objection to any form of cauterization milder meas- ures may be employed, and these are in the great majority of cases successful, especially where the sore has invaded healthy tissues and the patient is obedient to medical direction. The most satisfactory palliative treatment consists in washing the sores three times a day in a nitric acid solution, made by adding a drachm of strong nitric acid to a pint of water. The surface of the sore is then dusted with iodoform, to each drachm of which has been added two drops of attar of roses, or with zinc oxide, bismuth subnitrate, or calomel. Where discharge is profuse, daily spraying with peroxide of hydrogen, full strength, will be found serviceable. If the chancroid becomes complicated by inflammation, in addition to the constitutional treatment suitable to inflammation, evaporat- ing lotions will be found of service. Alcohol and dilute lead water, equal parts, may be applied, a piece of lint being wrung out in this solution and placed about the inflamed parts; this lint should be kept constantly wet. Soaking the chancroid in exceedingly hot water many times during the day is often of service, the dressing during the intervals of this treatment con- sisting of many layers of gauze wrung out in 1-10,000 bichloride solution and surrounded with waxed paper or other impervious material: If the ulcer becomes phagedenic, a general tonic and stimulating systemic treatment is indicated. If the sloughing process is extend- ing very rapidly, threatening great destruction of tissue, the actual cautery should be used unsparingly. Prolonged warm baths con- tinued for hours, or even days, are at times attended by most happy results. Serpiginous ulceration is exceedingly resistant to all treatment; the constitution is usually at fault, and every effort should be made CHANCROID. 123 to build up the general health. Beyond the actual cautery and pro- longed warm baths, local treatment seems to be of little avail. The simple inflammatory bubo is treated by rest, counter-irritation around the focus of swelling, and pressure. Pressure may be applied by means of a compress and spica bandage, or, if the patient is con- fined to bed, by means of a shot bag or sand bag placed over the inflamed part. Threatening suppuration can sometimes be aborted by the injection of 10 to 20 minims of a 5 per cent, solution of car- bolic acid into the centre of the gland. When fluctuation is detected a free opening should be made; laudable pus escapes and the abscess heals kindly. Until it is evacuated the virulent bubo cannot be diagnosed from that due to simple inflammation, and the same treatment is appli- cable as in the first instance. If on incising the swelling a thin, sanious pus is discharged and the incision steadily enlarges, being attacked by the characteristic chancroidal ulceration, the treatment is the same as iu the case of a chancroid. Repeated washings with carbolic lotion, or a weak nitric acid solution, followed by a liberal application of iodoform, may be tried. If the ulceration steadily extends, every sinus and recess must be slit up, all sloughs removed by the curette, and the whole surface thoroughly cauterized, prefer- ably by nitric or carbolic acid. Where phimosis complicates the chancroid, the discharge must be kept constantly washed away by repeated injections of warm water, followed by one or two syringefuls of dilute carbolic solution, dilute nitrate of silver solution, 4grs. to the ounce, or the nitric acid lotion. If pain, swelling and discharge denote a rapid increase of trouble, the prepuce should at once be slit up, and the chancroid scraped and cauterized. The cauterant should also be applied to the edges of the incision. If paraphimosis complicates the chancroid, cooling and evaporat- ing lotions are indicated, unless there is a sufficient degree of con- striction present to threaten gangrene. When reduction cannot be effected in other ways, incision of the constricting ring of tissue will be required. 124 ESSENTIALS OF SURGICAL DRESSING. Gonorrhoea. Describe the urethra. The urethra varies in length from eight to nine inches. It con- sists of three portions, spongy, membranous, and the prostatic. The spongy portion extends from the meatus to the anterior layer of the triangular ligament, and is about six inches in length. The meatus is the narrowest portion of the urethra. One and one-half inches posterior to it is the lacuna magna, a large mucous follicle placed on the upper surface of the urethra with its opening directed forward. In this follicle small instruments may readily catch unless their points are kept along the floor of the urethra. The bulbous portion of the urethra lies just in front of the anterior layer of the triangular ligament. At this point the canal is considerably dilated. This is the widest and most dilatable portion of the whole urethra. The membranous portion of the urethra is that part of the tube which lies between the anterior and the posterior layers of the tri- angular ligament. It is about three-quarters of an inch in length, and is placed one inch below the pubic arch. It is cylindrical in shape, and, excepting the meatus, the narrowest part of the urethra. It is surrounded by the compressor-urethrae muscle. The prostatic portion of the urethra is about one and a quarter inches long. It passes through the upper portion of the prostate gland. The urethra is further divided into an anterior and posterior part. The anterior part is that portion external to the anterior layer of the triangular ligament. It is surrounded by erectile tissue. The posterior part includes the membranous and prostatic urethra, and is enveloped in a thick layer of strong muscular tissue. The compressor-urethrae muscle surrounding the membranous portion of the urethra is readily excited to reflex spasm ; hence, fluids injected into the urethra rarely reach further than this point, and discharges occurring within or behind the membranous urethra are more prone to flow into the bladder than to escape externally. What is gonorrhoea ? Gonorrhoea is a contagious specific inflammation affecting mucous membranes, particularly those of the genito-urinary tract. GONORRHOEA. 125 What is the cause of gonorrhoea? The gonococcus introduced into the urethra. The contagion may be mediate or immediate. Immediate by means of direct personal contact; mediate through the medium of clothing or other articles containing the specific microorganism. A non-specific urethritis may develop from contact with foul and irritating discharges; this ordinarily undergoes spontaneous resolu- tion in a few days. Gonorrhoea begins in the male usually in the fossa navicularis and passes backward. In the female it commonly begins in the urethra or in the cervix, though vulvitis and vaginitis are frequently the first conditions observed by the surgeon. What are the symptoms of gonorrhoea ? In from three to five days after exposure to contagion a tickling sensation is noticed at the meatus; this is shortly changed to a burning, noticed particularly during urination. On examination the lips are somewhat reddened and everted, and there is a slight muco- purulent discharge; this discharge rapidly increases. The ardor urinae becomes intense ; there is a profuse flow of pus ; painful erec- tions occur during the night, and the patient is compelled to urinate frequently. These symptoms continue for from fourteen to twenty days, the inflammation in the meantime having extended back to the bulb, as denoted by a feeling of fullness and heat in the perineum. At about the end of the third week the symptoms rapidly subside, the discharge becomes scanty and mucous in character until it is finally reduced to a drop, which is noticed in the morning as glueing the lips of the meatus together. If the case runs a favorable course this disappears, and in about six weeks from the beginning of the attack recovery is complete. The disease, however, may extend back to the posterior part of the urethra and assume a chronic form. Extension of the disease to the posterior urethra rarely takes place before the third week. The extension may be accompanied by no subjective; symptoms, or may be denoted by vesical tenesmus, by haematuria, by burning or lancinating pains in the deeper part of the perineum, exacerbated by micturition and defecation, and by frequent pollutions accompanied by pain in the deep urethra. The discharge 126 ESSENTIALS OF SURGICAL DRESSING. is similar to that of anterior urethritis. It does not appear at the meatus, however, but passes back into the bladder. What are the stages of acute anterior urethritis ? (1) Increasing stage. (2) Stationary stage. (3) Subsiding stage. What are the symptoms of the increasing stage ? Ardor urinae ; purulent discharge, increasing in quantity ; painful erections; frequent urination, the stream passed being small, forked and irregular. These symptoms may, in individual cases, be present in all degrees of severity. What are the complications of the first stage ? Balanitis and Posthitis. Inflammation extending over the mucous layer of the glans penis and the foreskin. Phimosis, or inability to retract the foreskin, usually due to oede- matous swelling. Paraphimosis, or inability to draw the retracted foreskin forward. What are the symptoms and complications of the second or stationary stage of acute gonorrhoea ? The inflammation gradually extends backward. The symptoms of the first stage continue, alternating in severity from day to day. The following complications may be developed :— Follicular Abscesses. These appear as small, round, tender tumors along the floor of the urethra. They may evacuate their contents either into the urethra or externally. Periurethral Abscesses. These are most commonly found about the fossa navicularis or the bulbous portion of the urethra, where the disease is most persistent. Lymphangitis. This is commonly due to retention of the dis- charge beneath the prepuce. The latter becomes swollen, and there is a thick, tender, reddened, cord-like line extending along the dorsum of the penis. Bubo. But one gland is commonly affected, this may undergo spontaneous resolution or may suppurate. Cowperitis. Characterized by intense throbbing pain, painful G0N0RRH03A. 127 urination, especially at the end of the act, owing to the contraction of the compressor urethrae muscle, and the detection of the hard inflamed glands by examination along the perineum or through the rectum. The second stage lasts one or two weeks. Give the symptoms and complications of the stage of sub- sidence. The symptoms are the same as those of the preceding stages, excepting that they steadily grow less in severity. The complica- tions which may develop at this period are prostatitis and epididy- mitis. Prostatitis is characterized by pain at the neck of the bladder, increased by defecation and micturition. The pain becomes very intense, and the perineum feels full, hot and throbbing. On examination per rectum the diagnosis is made positive by the detection of a hot, tender, enlarged prostate. This inflammation is commonly accompanied by the characteristic constitutional symp- toms of acute inflammation. It may terminate in resolution, in abscess, or in chronic inflammation. It may take the form of simple congestion, denoted by the symp- toms detailed above, together with enlargement and tenderness found on rectal examination. This is the most frequent form of inflam- mation which attacks the prostate in the course of acute posterior urethritis. It usually subsides in a few days. Or the inflammation may appear as an acute folliculitis, due to some cause exciting a renewed intensity of posterior urethritis, such as excessive drinking or coitus. The symptoms are the same as before ; the patient complains of shooting pains during the passage of the last drops, there is a burning pain during urination located in the deep urethra, and rectal examination shows the prostate not materially enlarged, but presenting one or two sharply defined nodules, usually in one lobe only; these are indurated, markedly contrasting with the soft condition of the remainder of the gland. The nodules are painful on pressure. Parenchymatous jirosfotitis, in addition to the symptoms accom- panying the other forms, produces marked constitutional reaction. The local symptoms, too, are exceedingly severe, and rectal tenesmus may accompany the spasm of the bladder. Examination shows the 128 ESSENTIALS OF SURGICAL DRESSING. prostate very greatly enlarged, this tumefaction sometimes being sufficient to cause retention of both urine and faeces. At the end of from five to seven days the inflammation m?y undergo spontaneous resolution, or suppuration may occur. In the latter case the pain becomes aggravated and throbbing, and the patient complains of rigors or chills; pus formation is exceed- ingly rapid. At times these prostatic abscesses develop, although the patient complains of very slight symptoms. Epididymitis is characterized by pain of an intense and sickening character, radiating from the epididymis along the cord and the loins. The epididymis is swollen and tender; there is commonly marked fever. Epididymitis is very frequently accompanied by effusion into the tunica vaginalis. In this case the swelling may be diffused rather than localized at the back of the testis. Describe subacute or catarrhal gonorrhoea. This form of gonorrhoea usually occurs in persons who have had previous attacks. It is characterized by very free discharge, with absence of other symptoms or complications. It yields readily to treatment, but does not entirely disappear, a drop or two of muco- pus being discharged daily. What are the complications of subacute gonorrhoea? Gonorrheal rheumatism or urethral synovitis. This is character- ized by comparatively slight constitutional symptoms at first, and by rapid development of synovitis, affecting by preference the knee, the ankle, the wrist, the finger or the elbow. Gonorrheal endocarditis, gonorrhoea! ophthalmia. Describe irritative or abortive gonorrhoea. The symptoms are those of beginning acute gonorrhoea ; that is, there is redness, itching and tingling of the meatus, with a slight discharge. The disease, however, does not advance beyond this point. These symptoms may persist for several days and then dis- appear ; there may be no complications nor sequelae. How is acute gonorrhoea diagnosed? By the presence of the gonococcus. These microorganisms are usually abundant and readily found ; this is so universally true that failure to discover them on careful examination justifies the conclu- GONORRHOEA. 129 sion that an acute case of urethritis is not really gonorrhoeal in nature. What are the characteristics of the gonococci? Under a high magnifying power they resemble coffee beans, their concave sides being directed toward each other. They are found in groups or colonies associated in twos ; they do not appear in chains ; colonies of the gonococci are nearly always found within pus and epithelial cells. The staining of the gonococci is characteristic; the most con- venient way of effecting this is to place a fraction of a drop of the gonorrhoeal discharge upon a cover-glass, place over this another glass, and by pressing the two together diffuse the matter over the surface; place the cover glass in the air to dry, then pass it three times, slowly, through the flame of an alcohol lamp. This cover-glass preparation is then dropped pus side downward upon a solution made by coloring distilled water with a few drops of an alcoholic solution of fuchsin. Subsequent decolorization by Gram's method makes the diagnosis still more sure, since the gonococcus readily gives up its stain, thus differing from other microorganisms. How is acute anterior urethritis distinguished from that attacking the posterior urethra ? By an examination of the morning urine. If the disease invades the anterior urethra alone, the discharge which is accumulated during the night will be washed away by the first portion of urine passed on rising, and the last portion will be clear. If the discharge takes place from the membranous or prostatic portion of the urethra it will flow backward, and will be diffused in the urine contained in the bladder ; hence, though the first portion of the urine may con- tain an excess of pus and mucus washed from the anterior urethra, the last portion will also be found to contain the characteristic g< morrhoeal discharge. What elements in the urine denote the continuance of urethral inflammation ? Pus, mucus and clap-shreds. Clap-shreds consist of small fila- ments, which can be seen floating in the urine by the naked eye. On microscopic examination they are found to be composed of pus 9 130 ESSENTIALS OF SURGICAL DRESSING. cells entangled in mucin, the mucous discharge of the urethra having been coagulated by contact with the acid urine. What is the prognosis of acute gonorrhoea ? The prognosis must always be guarded, particularly in the case of strumous, feeble, or cachectic individuals. Though this disease com- monly runs an uncomplicated course and ends shortly in complete cure, it may continue for months or years. A first infection usually runs a more rapid course than subsequent attacks. When the disease remains limited to the anterior urethra the chances for rapid recovery are much more favorable than when it has extended to the posterior urethra. What is the treatment for acute anterior urethritis ? Prophylactic.—Prolonged and repeated coitus has a marked in- fluence in encouraging the entrance of the gonococcus into the urethra. Hence a brief contact is desirable from a prophylactic standpoint. Immediate urination after coitus and thorough washing of the penis should also be practised. The wearing of a clean stroug rubber pouch is the most effective way of guarding against contagion. Curative.—As much bodily and mental rest as possible should be recommended ; rest in bed is a most efficient means of shortening the disease, or at least of insuring a mild course. This, however, is rarely possible, since the necessity for secrecy forces the patient to continue his daily routine of life. Violent physical exertion should be positively interdicted. Diet should be light, with a minimum amount of meat, and total avoidance of puddings, pies, highly seasoned foods or indigestible articles. An exclusively liquid diet, together with large quantities of alkaline waters, is not to be recom- mended, since this frequently disorders the stomach. A suspensory bandage arranged to support and elevate the ex- ternal genitalia should be worn from the first. Sexual excitement, even that resulting from meretricious reading matter, must be strictly avoided. The patient should sleep on a hard bed with the lightest covering compatible with comfort. The bowels must be kept open. If the ardor uriiue becomes so marked as to cause serious dis- comfort a prescription such as the following should be given :— GONORRHOEA. 131 li. Potass, bicarb.,...........f^vj Tr. hyoscy.,............f.^iv Muciiag. ulm.............f J vj. M. SiG.—Tablespoont'ul in a glass of Vichy water every 3 hours. Great relief will be obtained by immersing the penis in hot water during urination, or by the application of a 4 to 10 percent, solution of cocaine to the meatus just before the water is passed. This may be conveniently accomplished by wrapping the end of a match in a small piece of absorbent cotton, dipping the latter in a cocaine solu- tion and passing it within the urethra to the depth of one inch. In three minutes the effect of the drug will be produced. If the penis swells and becomes oedematous it may be wrapped in cloths saturated in the following solution :— r£. Ext. hamamel. fl., Alcohol., Aquae,........aa......f^iv. M. Sig.—Locally. Painful erections are best combated by camphor, lupulin, and bro- mide of potassium administered by the mouth, though care must be taken that the stomach is not disordered thereby. To be efficient these drugs must be administered in full doses ; from thirty to sixty grains of bromide may be taken at bedtime, and the dose may be rej teated during the night if the symptoms require it. Lupulin should be given in from five- to ten-grain doses. Probably the best means of controlling painful erections is the ad- ministration hypodermically of a quarter of a grain of morphia together with a sixth of a grain of atropia, into the perineum, either on retiring or during the night. The patient should be instructed to rise once or twice and micturate. Suppositories may also be employed. Of these perhaps the best is one containing extract of hyoscyamus, gr. i ; extract of opium, gr. j. When the discharge is free it will be necessary to devise some plan by which it may be prevented from soiling the clothing. This may be accomplished by retracting the prepuce, covering the glans penis with absorbent cotton and drawing the foreskin forward; or by cutting, in a small, square piece of muslin rag, a slit sufficiently large to admit the head of the penis ; this opening is carried back until it is behind the corona, a wad of cotton is then applied to the 132 ESSENTIALS OF SURGICAL DRESSING. meatus and the foreskin is drawn forward. This dressing separates the mucous surfaces of the glans and prepuce and prevents the development of balanitis, while, at the same time, it allows of the retention of a comparatively large wad of cotton. Where the dis- charge is very free and this is not sufficient, or where the conforma- tion of the organ is such that this dressing cannot be retained, the patient may be instructed to pin a small muslin bag or the foot of a stocking to his shirt; in the bottom of this bag is placed a sufficient quantity of cotton, which receives the discharge, the penis being so dressed that it hangs in the bag. During the increasing stage of gonorrhoea, local or systemic remedies must be used with extreme caution, since there is great danger of increasing inflammation, and thereby favoring the growth 1 and the extension of the gonococci. From the beginning of the attack the following remedies may be administered by the mouth, with the idea of rendering the urine aseptic and thus inhibiting the growth of the germs :— R. Salol,..............gr. x Balsam of copaiba,........nr j. Encapsulat. Sig.—Take one such capsule four times a day. Injections or local applications should rarely be used until the height of the inflammatory stage is past. This will be in from seven to fourteen days. Then the following injection will be found use- ful :— R. Sulphocarbolate of zinc, .....gr. v Bichloride of mercury,......gr. ij Hydrogen peroxide (Marchand), . . f ^ iss Water,.....q. s.,......f^viij. This injection must be given in such a strength that it does not cause severe pain or excite marked inflammatory reaction. The general principles covering all injections are that the urethra should be cleansed by urination immediately before the introduction of the injection, that the latter should be introduced gently and with uniform pressure, and that a sufficient quantity should be introduced to distend the entire anterior urethra. The best syringe for this purpose is one provided with a conical point, which fits the meatus GONORRHOEA. 133 rather than enters the urethra, and which has a piston-rod which slips easily and without any irregular or jerking motion. A soft rubber bulb provided with a conical point, answers the requirements of an injection apparatus better than any of the instruments pro- vided with a piston-rod. The injection should be made at first twice a day, the patient being instructed to add water to the solu- tion employed until it is no longer acutely painful. As the dis- ease becomes more chronic in type the injections may be employed more frequently, five or six a day being administered. In place of the solution given above, any of its ingredients may be given indi- vidually, rose water being used as an excipient. A very successful means of treatment and one which may be Fig. 70. Tube for Irrigating the Anterior Urethra. employed in the very beginning of the disease, consists in copious injections of hot bichloride of mercury solutions 1-40,000. Two to four pints of this lotion are injected twice a day, by means of either a nozzle fitting into the meatus and provided with an entrance and exit pipe, or a catheter provided with a bulb at its extremity and with the openings pointed backward. If the latter is used it is introduced down to the membranous portion of the urethra ; to its extremity is attached the pipe coming from the irrigating apparatus, and the bichloride lotion is allowed to flow from behind forward. Starting with a temperature of about 105°, the solution is gradually made as hot as the patient can endure. The abortive plan of treatment has been revived in recent times. 134 ESSENTIALS OF SURGICAL DRESSING. Fig. 71. For this purpose solutions of nitrate of silver, varying in strength from eight to sixteen grains to the ounce, may be employed. After urination, a syringeful of this solution is injected into the urethra. This is retained for one or two minutes, it is then allowed to escape and a one per cent, solution of sodium chloride is injected, to neutralize any excess of nitrate of silver which may remain. These injections may be repeated every third day, and are said to be frequently followed by a cure of disease in from seven to twelve days. The inflammation following these injections is combated by entire rest, the application of heat or cold, evaporating lotions, etc. The pain attendant upon them may be greatly diminished by the previous injection of a four- per cent, solution of cocaine. It must be borne in mind that, even though the discharge has ceased entirely, it is not safe to suddenly discontinue the injections. These should be continued for at least twelve days after the subsidence of all symptoms, and should then be dropped very gradually. Dur- ing the subsiding stage of the disease, if the discharge seems to resist the injections advised above, the use of soluble urethral bougies is frequently attended by very satisfactory results. A bougie containing sulphate of zinc half a grain, oxide of zinc two grains, and hydrastis canadensis five grains, may be introduced on ^gT^ retiring, and may be secured in place by a small pledget of cotton strapped over the meatus by adhesive plaster. Recatb^teeCrs.on How do you determine as to whether or not acute anterior urethritis is cured? By an examination of the morning urine. If this contains no pus, no mucus, and no clap-shreds, the disease can be regarded as GONORRHOEA. 135 definitely cured. If however, pus and clap-shreds are found, even though the patient declare positively that he is entirely free from symptoms, treatment must not be intermitted. Frequently there will remain for months after a gonorrhoea is definitely cured a slight discharge of mucus. This perhaps is a clear drop, particularly noticeable in the morning, and annoying the patient by gluing the lips of the meatus together. For this condition local treatment is usually worse than useless. Strong astringent medication will cause irritation and subacute inflammation of the urethral mucous membrane, and will probably cause the discharge to become purulent. The hyper-secretion of mucus will gradually diminish, however, under general hygienic and constitutional treat- ment, If microscopic examination shows absence of pus the surgeon should not be induced to consent to local treatment, even though this discharge persist for weeks or months. What is the treatment of acute posterior urethritis ? As in the case of anterior urethritis, during the continuance of hyper-acute inflammation all local treatment must be avoided; even topical applications to the anterior urethra must be stopped the moment frequent and painful micturition together with other symp- toms of the extension of the disease into the posterior urethra appear. The symptom demanding most attention is usually violent tenesmus, often accompanied by bleeding. The patient is tortured by a constant desire to urinate, a desire entirely unrelieved by passing the few drops which remain in the bladder, and at the end of the act he may have a free flow of blood. Here the general antiphlogistic treatment of urethritis is applicable. The urine must be made bland by moderate dilution by means of slightly alkaline effervescing waters, partial milk diet, or the free administration of bicarbonate of soda or citric acid. The bowels must be kept soluble, and bromides and other sedatives may be administered by the mouth. The most prompt relief will follow hypodermics of morphia and atropia introduced into the perineum, or the employment of opium and belladonna suppositories. Prolonged warm baths are also of great service, and should be taken night and morning. At times reflex spasm is so great that dysuria develops. The catheter should be used only as a last resort, 136 ESSENTIALS OF SURGICAL DRESSING. and the softest instruments that can be introduced should be employed. Even during the height of inflammation the capsules advised before may be administered, unless they seem to aggravate the local condition ; if this is the case they must at once be discon- tinued. If the acute symptoms have disappeared, after three or four days local treatment may be instituted. Applications, to be of service, must, of course, be brought in contact with the inflamed mucous membrane; this can be accomplished only by means of instruments carried into the posterior urethra. A soft rubber catheter, together with an ordinary surgical syringe, the nozzle of which fits into the extremity of a catheter, will answer well for this local treatment. The catheter should be introduced until urine begins to flow, when it is withdrawn until the flow ceases. The nozzle of the syringe is then inserted into the end of the catheter, and from an ounce to an ounce and a half of the following prescrip- tion injected, the catheter being slowly withdrawn during the course of the injection. Since posterior urethritis is always accompanied by inflammation of the anterior urethra, it is perfectly proper to apply the injection to the whole mucous canal. Carbolic acid,..........2 grains, Distilled water, ......... 2 ounces. Or- Nitrate of silver,.........£ to 2 grains, Distilled water,........2 ounces. Not more than two ounces of either of these solutions should be injected at one time, and the injection should not be repeated more frequently than once every second day. The nitrate of silver injec- tions are particularly valuable, and the strength of the solution should be gradually increased as the mucous membrane becomes more tolerant of the action of the drug. The inflammation of the posterior urethra is usually cured before that of the anterior portion of the tube. When examination shows that the second urine is clear, while the first contains pus and mucus, posterior applications may be discontinued. The treatment of anterior urethritis may then be kept up by the ordinary clap syringe, as advised above. GONORRHOEA. 137 How are the complications of acute urethritis treated ? Balanitis and Posthitis are treated by retracting the prepuce and bathing the penis in dilute carbolic lotion, 2 per cent., or weak bichlo- ride solution. The parts are then carefully dried with absorbent cot- ton, dusted with a little bismuth powder or oxide of zinc, and a layer of absorbent cotton is laid over the glans penis so that the mucous surfaces do not come in contact when the foreskin is drawn forward. Where there are superficial ulcerations these may be quickly healed by brushing with a 4 per cent, solution of nitrate of silver, or by touching with the solid stick. If the discharge is very profuse powdered tannin acts well as a dusting powder. Ph imosis requires careful cleansing ; the whole prepuce should be douched out by means of an ordinary injection syringe, and this process should be repeated many times until all the discharge is cleared away. A solution of nitrate of silver, four grains to the ounce, is then injected, and the penis is wrapped in cloths wet with lead water and laudanum. The pus should be evacuated by means of these washings at least six times during the day, and the nitrate of silver solution should be employed morning and night. Very marked oedema may require scarification. At times splitting up of the foreskin or circumcision may be necessary. Paraphimosis should, if possible, be reduced as soon as discovered; this may sometimes be effected by manipulation, or if this fails the glans may be covered with lint and enveloped from before back- ward in an elastic band. A director is then slipped beneath the constricting ring, the elastic wrappings are removed and an effort made to draw the prepuce forward. If this fails the paraphimosis must be reduced by making an incision. Follicular a>ulperiurethral abscesses are in the first place treated according to the principles governing the therapeutics of all acute in- flammations ; both the local and general treatment of gonorrhoea must at once be discontinued. Cold compresses, or hot fomentations, or the hot-water bag may be employed. If fluctuation is detected an ex- ternal opening should be made. Where urinary infiltration is threat- ened, or has already occurred, the treatment consists in free incision, and the insertion of a soft catheter into the bladder, the latter being allowed to remain. Should the inflammation undergo partial resolu- tion, but leave an indurated nodule, local inunctions of mercury 138 ESSENTIALS OF SURGICAL DRESSING. ointment may be advised. Where this induration is at all ex- tensive erections must be carefully guarded against until absorption has taken place, as otherwise rupture and serious hemorrhage may follow. Inflammation of the follicles of the meatus are treated by thrust- ing the sharp point of a stick of nitrate of silver into the glands. Coicperitis. In addition to the general treatment suitable to inflammations this complication may be combated by ice bags to the perineum. Cowperitis is subject to the same treatment as periure- thral abscesses. Prostatitis demands prompt suspension of local treatment directed against the gonorrhoea. The bowels must be kept soluble and the urine should be rendered bland and antiseptic. Troublesome symptoms are combated by perineal hypodermics of morphia and atropia. Rest in bed, counter-irritation applied to the perineum, preferably by means of small, repeated blisters, and copious injections of very hot water, are usually successful in preventing suppuration. A fountain syringe is provided, large enough to hold two quarts of fluid, a supply pipe from this is attached to a two-way rectal tube, and the latter is introduced into the anus so that the stream flowing from the irrigator impinges directly upon the inflamed and enlarged pros- tate. Starting at about 105° the temperature of the injection fluid is gradually raised until it is made as hot as the patient can endure. Two quarts of water are thus injected twice a day, and a hot water bag is worn against the perineum during the intervals of treatment. At times injections of cold water seem to produce a more prompt effect. The choice will depend to a great extent upon the feelings of the patient. When suppuration takes place the abscess cavity must be incised through the perineum and treated in accordance with ordinary surgical principles Should retention of the urine occur, not relieved by prolonged hot baths and opium and belladonna suppositories, a soft catheter may be passed. What is the treatment of epididymitis ? The treatment of acute epididymitis is conducted on the same general lines as in the case of any local inflammation. Rest, eleva- tion, counter-irritation, etc., are all indicated. GONORRHOEA. 139 The dressing which is most satisfactory in the treatment of this affection is applied as follows :— The testicles are enveloped in a thick layer of cotton ; outside of this, and of sufficient size to envelope the entire scrotum, is placed a piece of rubber or other impervious material. The dressing is then completed by a suspensory bandage gored at the sides and provided with lacings, so that it may be tightened to accurately fit the testicles. By means of this dressing the patient may pursue his ordinary avoca- tions without inconvenience to himself and without materially com- plicating or lengthening the course of his disease. This dressing accomplishes the good derived from pressure, heat and moisture— Fig. 72. Suspensory Bandage for Epididymitis. all powerful means of combating acute inflammations. It may be used from the beginning, and is frequently followed by relief of pain within half an hour of its application. Since epididymitis is frequently complicated by effusion into the tunica vaginalis, the latter may be punctured, and the evacuation of serum thus accomplished often markedly alleviates the suffering of the patient. The knife should not be carried into the substance of the epididymis or through the tunica albuginea testis. After all symptoms of acute inflammation have passed there is frequently left an indurated spot about the tail of the epididymis. Every effort should be made to cause the absorption of this induration, since, if it remains, it may entirely cut off the secretion of the testicle, and, 140 ESSENTIALS OF SURGICAL DRESSING. where the disease is bilateral, may result in sterility ; hence contin- uance of the dressing described above, combined with local applica- tions of mercury and belladonna ointment, is desirable. Chronic Gonorrhoea. What are the causes of chronic urethral discharge ? (1) Urethral catarrh. (2) Chronic gonorrhoea, and localization of the disease, producing granular surfaces. Stricture of the Urethra. This is the usual cause of gleet. How can the nature of chronic urethral discharge be deter- mined? Urethral catarrh immediately follows gonorrhoea, and presents no symptoms beyond a thin watery discharge. Microscopic examination of this discharge shows that it is composed of mucus, mucous corpus- cles and epithelium. Pus corpuscles are absent. Chronic gonorrhoea is characterized by a more or less profuse discharge of creamy pus. It is greatly aggravated by any excess, and exacerbations occur, the cause of which cannot be definitely determined. During the exacerbation there is frequently burning during urination, and at times chordee. It is usually located either in the bulbous or membranous portion of the urethra, or about the navicular fossa. Examination by the bulbous bougie detects a tender spot, and pus and blood may be brought away on the shoulder of the instrument. Gleet and stricture often appear some time after the apparent cure of an attack of gonorrhoea. This is characterized by a muco-purulent discharge, and, if the stricture becomes contracted by frequent urina- tion with an imperfect cut off. On passing a bulbous bougie narrow- ing is detected. How can the seat of chronic urethral disease be determined ? It is of the greatest importance to distinguish between chronic urethritis located in the anterior urethra and that which has its seat in the posterior portion of the canal. This can readily be determined by an examination of the urine. If the first portion of the urine passed on rising contains pus, while the second is clear, the seat of GONORRHOEA. 141 Fig. 73. the discharge is necessarily located anterior to the compressor urethrae muscles. If, however, the last urine con- tains the discharge of chronic gonorrhoea this shows that the posterior urethra is invaded. The accurate localization of the process may be further determ- ined by the passage of bulbous bougies, and by the use of the urethroscope. If there is erosion of any part of the urethra, as the bougie slips over this portion the patient will complain of pain. One examination is not sufficient on this point; it is only when, after the repeated passage of instru- ments, pain is referred to one particular spot, that the surgeon can be sure that here is located a focus of disease. If the discharge is persistent in spite of careful treatment the urethroscope should always be used. A straight hard rubber tube, provided with a rounded obturator which projects somewhat beyond the end of the instrument, represents the simplest form of this instrument. To allow of a satisfactory view the tube should be of as large calibre as can be passed into the urethra, and should be just long enough to reach the bladder when the penis is shortened as much as possible. This instrument is introduced until the bladder is reached, the urethro- scopic tube is slightly withdrawn, and the surgeon reflects from a head mirror as strong a light as possible into the urethroscope. As the tube is withdrawn the various portions of the urethra are exposed to view. When pus and blood obstruct the field of vision they can be removed by pledgets of cotton carried in by long applicators. This per- mits of a most accurate diagnosis. The Leiter incandescent urethroscope affords a much better illumination, but the cheaper and simpler instru- ment will be found to give satisfactory results. The extent of inflammation can further be deter- mined by examination of the urine. If the latter contains only clap- Urethroscope. 142 ESSENTIALS OF SURGICAL DRESSING. shreds the probabilities are that the disease is localized; if, how- ever, large quantities of mucus are present it is almost certain that an extensive area of mucous membrane is involved in the inflam- matory process. . Give the treatment of chronic urethral discharge. Urethral catarrh is denoted by profuse mucous discharge; if not accompanied by foci of ulceration or by narrowing of the urethra, it is best treated constitutionally. Open air, nourishing diet, tonics, iodide of iron, in fact everything which tends to improve the patient's general condition, should be advised. If any local treatment is adopted it should be of the mildest char- acter. The internal administration of copaiba, cubebs and salol may be supplemented by very weak injections of a . 5 solution of sulphate of zinc, nitrate of silver, or sulphate of copper. When in addition to the general catarrhal condition, there are likewise areas of ulceration, the general catarrhal congestion has first to be subdued; this is best combated by the means just described, one injection being given twice daily. If the posterior urethra is also involved in the catarrhal process, the same solutions may be used, but should be introduced by means of a rubber catheter passed to the prostatic portion of the urethra; through this the injecting fluid is slowly forced as the catheter is withdrawn from the urethra. These irrigations should be repeated every second or third day, depending upon the amount of reaction they excite. When, on examination, the urine is found to contain only shreds or flocculi, the mucous secretion having disappeared, it may be assumed that the general catarrhal condition is allayed. Treat- ment may now be directed to the ulcerated foci. If the seat of the disease is located in the anterior urethra it may be conveniently reached by the hard rubber endoscopic tube. The astringent solu- tions are applied by means of cotton wound on a long applicator; four per cent, solutions of either nitrate of silver or sulphate of copper may be employed. When used in this strength the medica- tion should be brought in contact only with the diseased surface. When the disease is located in the membranous or prostatic por- tions of the urethra, a few drops of either copper or silver solution, GONORRHOEA. 143 varying in strength from one to two per cent, may be introduced by means of Ultzmann's prostatic catheter; glycerin should be employed as a lubricant for the instrument, since oil protects the mucous mem- branes from the action of the remedies. A very excellent method of treating inflammation of the ixisterior urethra is offered in the Fig. 74. \S.H"1'^0^ Ultzmann's Prostatic Catheter. form of lanolin ointment. For the purpose of applying this a catheter provided with a piston rod must be filled with the oint- ment ; the catheter is then inserted into the prostatic portion of the urethra, and the medication is forced out of the tube by means of the piston rod. The ointment preferred by Finger is as follows :— Nitrate of silver, tannin, or sulphate of copper,...........gr. xv Lanolin,............gj Olive oil,............3 iss. These applications may be repeated every second or third day. A very successful method of treating chronic gonorrhoea, when the lesions consist of foci of ulceration together with a good deal of catarrh, is by means of Unna's medicated sounds. An ointment is prepared as follows :— Nitrate of silver,.........gr. xv Balsam of Peru,........3 ss Yellow wax, ..........3 ss Coca butter,...........^iij- This mass is liquefied by heat, the sound is dipped in it and is then hung up to dry. When these sounds are introduced the heat of the body melts the coating, and thus the whole urethra is medicated by the nitrate of silver. 144 ESSENTIALS OF SURGICAL DRESSING. The soluble medicated bougies also offer an excellent method of applying topical applications to the entire urethra. These are made in long and short sizes. One should be inserted at night and should be kept in place by a pledget of cotton pressed to the meatus and held there by a rubber adhesive strap. The bougies containing sulphate of zinc, hydrastis canadensis, carbolate of zinc and carbolic acid, are most valuable. It must be borne in mind, however, that these applications medicate the entire urethra and are not indicated unless the local ulceration is accom- panied by widespread catarrhal processes. The chronic discharge depends, in the majority of cases, upon the presence of stricture which, in turn, is often accompanied by ulceration of the mucous membrane on the proximal side. These strictures may depend upon swelling and turgescence of the mucous membrane or may be due to a distinct deposit of inflammatory tissue, the process of cicatrization causing narrowing of the urethral canal. What is stricture of the urethra ? True organic stricture is a permanent narrowing of the urethral canal at one or more points, due to disease, injury, or congenital defect. There are also spasmodic or congestive strictures. What are the causes of strictures ? Gonorrhoea, traumatism, ulceration and masturbation. What are the varieties of urethral stricture ? In regard to cause we have an idiopathic, traumatic and inflam- matory. In regard to anatomical appearances bridle stricture. A band of lymph attached only by its ends, stretching across the urethra. An- nular. A circular constriction as though a string were tied about the urethra. Indurated Annular. Cartilaginous. In regard to the possibility of passing instruments strictures are classed as permeable and impermeable. In regard to their behavior on manipulation, they may be simple, irritable, contractile or recurring. What are the favorite seats of stricture ? At the anterior part of the urethra, and just in front of the mem- GONORRHOEA. 145 branous portion. Strictures are never found in the prostatic portion of the urethra. What are the consequences of an untreated stricture ? Hyperaemia and inflammation about the stricture. Dilatation and thinning of the urethral walls behind. Hypersecretion and gleet. Ulceration may take place, followed by extravasation, abscesses, and fistulae. From constant straining the bladder be- comes thickened, hypertrophied and sac- culated. The urine is retained and fer- ments ; cystitis may reach a high grade. The inflammation passes along the ureters, involves the pelves of the kidneys, and may cause death by suppurative pyelitis or nephritis. What are the symptoms of organic stricture of the urethra ? Gleety discharge, especially in the morn- ing; increased frequency of urination, with some pain ; twisting, forking, or diminu- tion in the size of the stream. Retention may be the first and only sign. Later symptoms are due to involvement of other organs; haemorrhoids frequently result from constant straining. How do you diagnose strictures ? By examination of the urethra with bul- bous bougies or the urethrometer. Com- mence with a medium-sized bulbous bougie and increase the size till decided resistance is experienced; or, if the first tried will not pass, diminish the size till one finally enters the bladder, marking on its stem the point where resistance begins ; slowly 10 Fig. 75. Bulbous Bougie. Urethrometer. 146 ESSENTIALS OF SURGICAL DRESSING. withdraw from the bladder, marking again the point where resistance begins ; this will give both the calibre and the width of the stricture. If the obstruction is more than seven inches from the meatus, it is probably due to an enlarged prostate. The possibility of spasm or the catching of the bulb of the bougie in a lacuna or at the triangular ligament must be borne in mind. What special points must be observed in passing a bougie or catheter ? See that the instrument is clean, smooth, and, if it is a catheter, pervious. Warm and oil, place the patient on his back with thighs flexed, bear in mind the course of the urethra, keep the catheter in the middle line, stretch the penis forward and upward, and use no force. What difficulties may occur in passing the catheter ? It may catch in a fold of mucous membrane, or in a lacuna. Avoid by keeping the point on the floor of the urethra at first, then along its roof. It may catch where the urethra enters the triangu- lar ligament. Withdraw a little, and keep the point of the instru- ment along the roof of the urethra. It may make a new false passage, or enter one already made, denoted by a sudden slipping of the instrument, pain, and detection of the point of the catheter outside of the urethra by rectal examination. The handle of the bougie is deflected from the middle line, no urine escapes, the point is not freely movable, and, if the false passage is recent, there will be free bleeding. How do you treat false passage ? Withdraw the instrument at once, and make no further effort to pass it for one or two weeks. Infiltration of urine rarely takes place, the false passage healing promptly. What constitutional effects may follow the passage of an instrument ? Haematuria, due to reflex congestion, syncope, rigors, urethral fever, suppression of urine, pyaemia. How may the dangers from these sequelae be lessened ? Render the urine antiseptic by the administration of salol, gr. x, t. i. d., for two days before treatment. GONORRHOEA. 147 Pass the instrument with the patient in the recumbent position ; give twelve grains of quinine an hour before treating ; inject ten to twenty minims of a 1 per cent, solution of cocaine into the bulbous portion of the urethra, by means of the prostatic syringe, a few minutes before passing an instrument Keep the patient in bed six to twenty-four hours after the instrument is used. Fig. 76. N____________- Filiform Bougies. How are strictures treated ? Strictures are treated by dilatation, urethrotomy, excision or electro- lysis. Dilatation may be intermittent, continuous or rapid. Urethrotomy or cutting may be either external or internal. How do you get through a tight stricture ? The patient may be previously relaxed, before attempting instru- Fig. 77. Filiform Threaded upon a Railroad Catheter. mentation, by a warm bath and a hypodermic of morphia injected into the perineum. A small, soft, well-oiled catheter should first be inserted. If this fails a small steel sound may be made to enter the bladder. If still unsuccessful, a number of filiform bougies may be intro- duced into the urethra as far as they will go ; each bougie is then in 148 ESSENTIALS OF SURGICAL DRESSING. turn manipulated, an effort being made to guide it past the stricture. Patience and perseverance in this method nearly always result suc- cessfully. The railroad catheter may then be threaded upon the extremity of the filiform which has entered the bladder, and may be forced through the stricture without fear of making a false passage. If it is not considered desirable to dilate the stricture immediately the filiform may be allowed to remain in place twenty-four hours, when sufficient softening of the stricture will have taken place to allow the passage of a small catheter. Describe intermittent dilatation. In treating a stricture by dilatation it is necessary to restore the urethral canal to its normal calibre. Partial stretching of the stric- ture is of little avail, excepting that it relieves the most immediate and distressing symptoms. The calibre of the urethra varies in accordance with the size of the penis. If the circumference of the middle of the organ is three inches a French sound No. 30 will be required to accomplish full dilatation ; 3£ inches requires a 32 ; 3£, 34 ; 3|, 36 ; 4, 38, and over 4 No. 40. The seat and calibre of the stricture are first determined by means of the urethrameter, or by bulbous bougies. The patient is instructed to urinate, and is placed on his back with the thighs flexed. The largest flexible bougie which can be passed through the narrowings is introduced and allowed to remain for two minutes. In three days the patient returns, and a larger instrument is introduced, the surgeon rarely running up more than four numbers at a single sitting. This treatment should be continued until the urethra readily receives a sound corresponding to its normal calibre, and the patient is then instructed to return once in two months for a year, lest the stricture should in the meantime contract. Thereafter the passage of a sound once in three or four months will usually be sufficient to prevent a recurrence of the pathological condition. In passing sounds it is customary to run up two numbers at a time, thus, if No. 16 is readily received, No. IS is next introduced, and next No. 20. Soft rubber bougies are, in general, safer instru- struments than steel sounds. The latter, however, can be very thoroughly cleaned, and are more directly under the control of the surgeon. In some cases, where there is marked spasm, it is Fig. 78. Scale for Urethral Instruments. 149 150 ESSENTIALS OF SURGICAL DRESSING. impossible to pass a rubber bougie. In passing sounds the first precaution to observe is that the instruments shall be thoroughly cleaned. This is accomplished by dipping them in alcohol and Fig. 79. Fig. 80. Fig. 81. Soft Rubber Bougie. Steel Sound. Meatus Bougie. igniting the latter, this superficial flaming not destroying the temper of the instrument, and nevertheless rendering the surfaces perfectly sterile. The sound is then dipped in five per cent, carbolic oil, and GONORRHOEA. 151 is passed gently into the urethra. The surgeon stands to the right of the patient, holds the penis in his left hand, and places the bluut extremity of the sound in the meatus. As soon as it has entered to the depth of two inches the handle of the instrument is carried toward the linea alba until it lies parallel with that line and with the plane of the hypogastric portion of the belly. The sound is then gently pressed into the urethra to the depth of 6 to 7 inches, when its extremity will have reached the membranous part, and will enter no further. The handle is now elevated until it stands at right angles to the plane of the hypogastrium. As this movement is effected the instrument enters the membranous portion of the urethra ; it is passed on into the bladder by depressing the handle between the legs. Describe continuous dilatation. The patient is put to bed, a flexible catheter is passed through the stricture into the bladder, and is allowed to remain one or two days. It is then replaced by a large instrument. This method is continued until the stricture is dilated up to the normal calibre of the urethra. Under what circumstances may continuous dilatation be employed ? Where there is very great difficulty in introducing an instrument; where the stricture is irritable or contractile, and there are objections to the performance of internal urethrotomy. Describe internal urethrotomy. The instruments required are, in the first place, the urethrameter, to determine the exact seat and extent of the strictures, and a knife by which the latter may be divided without injury to other portions of' the mucous membranes of the urethra. These indications are met by the Gerster dilating urethrotome, which keeps the part upon the stretch while it is being cut, and which enables the surgeon to determine when the normal calibre of the urethra has been reached. The patient should be prepared as for any surgical operation, by attention to the condition of the stomach and bowels for a few days. In addition ten grains of salol should be given three times daily for ESSENTIALS OF SURGICAL DRESSING. Fig. 82. two days. When from nervous tempera- ment, chronic inflammation of the urethra, or diseased kidneys, there is reason to fear urethral fever, twelve grains of quinia may be given four hours before the operation. The urine should be examined. A most careful diagnosis of the seat and extent of the strictures should be made. The meatus must be either dilated, or divided along its floor until it admits an instrument of the normal calibre of the urethra. The stricture should be completely divided along the roof of the urethra, exactly in the middle line. The free bleeding which occurs usually stops spontaneously in a few minutes. If it continues a bandage may be applied to the penis, or if this fails, a soft catheter may be passed till its extremity lies just beyond the seat of operation, and the bandage may then be applied. When the bleeding is from the deep urethra, firm pressure against the perineum is indicated. For several nights after operation the patient should be watched, as dangerous bleeding may take place from erection occurring in sleep. On the second day after operation, a full-sized sound is very gently passed to just beyond the seat of operation. This is repeated every third day till the parts are entirely healed. What are the indications for internal urethrotomy ? Internal urethrotomy is applicable to all chronic strictures in the pendulous portion of the urethra. This operation is Dilating Urethrotome, especially indicated when the stricture is SYPHILIS. 153 densely indurated and cartilaginous, and when it does not yield to gradual dilatation, or quickly relapses when treatment is suspended, also when it is impossible for the patient to devote the time neces- sary for the cure of stricture by gradual dilatation, and when, every time a bougie is passed, there is a marked tendency to the occurrence of urethral fever. What is the ultimate prognosis in internal urethrotomy ? Internal urethrotomy, if properly performed, usually results in a complete and permanent cure of the stricture. Periurethral ab- scesses, chordee and other complications are rare. What strictures call for external urethrotomy? Dense cartilaginous strictures in the membranous portion of the urethra, or irritable and contractile strictures in the same region, especially when complicated by perineal fistulae. Syphilis. What is syphilis ? Syphilis is a constitutional disease due to inoculation with specific virus. What is the primary lesion of syphilis ? The chancre. What is the period of primary incubation ? The time which elapses between exposure to contagion and the appearance of a chancre. It is usually from two to three weeks, rarely more than five weeks. What is the period of secondary incubation? The time between the appearance of chancre and the development of secondary symptoms. These rarely appear before the first or after the third month succeeding the chancre. When do tertiary symptoms appear ? At a period varying from a few months to many years after the secondaries. Describe the chancre or primary sore. The Cliancre is commonly found about the corona glandis, but it 154 ESSENTIALS OF SURGICAL DRESSING. may appear on any portion of the body. It is contracted directly by contact with chancre, or secondaries (mucous patches); indirectly, from articles used by syphilitics. It appears as an indurated papule, which develops into an abrasion, tubercle, or ulcer. What are the characteristics of the primary sore ? Indurated base. Thin, scanty secretions. Inflammation slight around the sore. Usually single. Not auto-inoculable. Accompanied by polyganglionic, painless buboes, which rarely sup- purate. Appears after an incubation period, and is followed by secondary eruptions. The Hunterian chancre is characterized by greater depth, free discharge, and more marked induration. The mixed chancre exhibits the peculiarities of both syphilitic and chancroidal inflammation, and is due to simultaneous inoculation with both forms of virus. What is the prognosis of chancre ? A sore exhibiting the typical characteristics of chancre is nearly always, but not invariably, followed by secondary eruptions. The chancre rarely produces extensive destruction of tissues and usually undergoes spontaneous cure. What is the treatment of chancre ? The sore should be washed several times daily with black-wash, and dusted with calomel, subiodide of bismuth, iodol, or iodoform. Mercury treatment should not be begun until the secondaries appear. What symptoms denote that the disease will assume a severe type? Extensive and persistent induration of the chancre. General and marked enlargement of the lymphatic glands. Ap- pearance of the secondary eruption before the seventh week. Describe the secondary lesions. General enlargement of the lymphatic glands. SYPHILIS. 155 Eruptions of the skin and mucous membranes ; at times inflam- mation of the iris or periosteum, and falling of the hair. Pathologically, these eruptions are at first due to congestion, which is followed by small, round-celled infiltration. This in turn may result in ulceration. The development of secondaries is preceded by general malaise, fever, and aenemia, lasting a few days and disappearing on the appearance of roseola and sore throat. The skin eruption may simulate the various forms of skin disease. It may be erythematous (s. roseola), papular (s. lichen), vesicular (s. herpes, eczema, and varicella), bullous (s. pemphigus), or pustu- lar (s. ecthyma, acne, or variola). The mucous membrane lesions are pathologically identical with those of the skin. There is first congestion and infiltration (syphilitic sore throat), this is followed by maceration of the epithelium (mucous patches), finally ulcers result. What are the characteristics of syphilitic skin eruptions ? Absence of itching. Symmetrical arrangement (on the two sides of the body). Reddish-brown or coppery color (raw ham). Polymorphous (many kinds of eruption at the same time). Therapeutic test (use of mercury). Describe the mucous patch. Synonyms.—Condyloma ; mucous tubercle. Pathology.—A congested, infiltrated macule, the surface of which is, from its peculiar position (upon mucous membrane, about the anus, on the scrotum, in the gluteal folds), continually moist, in consequence of which the epithelium becomes sodden. Appearance.—-A somewhat elevated, flat macule, covered with a dirty whitish, offensive exudation. Give the treatment of secondary syphilis. Mild forms of the disease are said to have a natural tendency toward spontaneous resolution. Where the patient is of a vigorous constitution and is willing to submit to persistent surface eruptions the treatment may be purely expectant, every attention being paid to general hygiene, and no specific medication being administered for 156 ESSENTIALS OF SURGICAL DRESSING. the eradication of the disease. When practicable, nine or twelve months camping out may enable the patient to thoroughly eradicate the syphilitic taint. If the disease is severe in type, or attacks persons not previously in the enjoyment of good health, vigorous medication will be required. The only drugs which seem to act powerfully upon the syphilitic lesions are iodine, iodide of potassium and mercury. Of these mer- cury seems to be most efficacious during the secondary period of the disease. It may be given in various forms and by various methods. The protiodide of mercury is the form in which the drug is usually administered ; of this a quarter of a grain is given three times a day as soon as the early secondaries (enlargement of the lymphatic glands, mucous patches, etc.) make it positive that the patient is infected with syphilis. Every other day this quantity is increased by one quarter of a grain, the drug being administered in pill form ; the quantity given is steadily increased until the constitutional effects of mercury are produced. When protiodide is administered the first effects of the drug are frequently manifested by two or three painful, watery, alvine evacuations. If the drug is still continued the offensive breath and beginning mouth tenderness of ptyalism will next be noticed. The daily quantity must then be cut down one half, and continued for eighteen months unless new symptoms appear, when the dose may be temporarily increased. After eighteen months iodide of potassium, from five to ten grains three times a day, is given in addition to the regular quantity of mercury. This mixed treatment is continued for six months or a year. The patient may then be allowed to discontinue treatment. In the meantime he is kept carefully under observation for the detection of any new manifestation of the disease. If such mani- festations appear the mixed treatment must be resumed and con- tinued from four to twelve months. During the latter part of this prolonged treatment the mercury may be suspended and the iodide of potassium alone administered. In case the protiodide pills produce disorder of the stomach or bowels before they can be taken in sufficient quantity to modify the manifestations of the disease, a small quantity of watery extract of opium may be administered. SYPHILIS. 157 At times it will be found that protiodide causes much irritation, even when opium is added, and that it is impossible to give it in sufficient dose. In this case the form of mercury can advantageously be changed. The following formula is a very excellent one. 1£. Mass, hydrarg.,.........gr. ij Ferr. sulph. exsiccat.,......gr. j. M. Ft. pill No 1. Sig.—1 t. i. d. Increase as required. When iodide of potassium is added to the mercury it is con- venient to administer these two drugs together. The following prescription may then be employed :— R. Hydrarg. chlor. corros.,.....gr. iss-iij Potass, iodid.,.........giv-viij Syrup, zingib.,.........f3 iij Aquae,......q. s.....f ^ vj. M. SiG.—Teaspoonful in water three times a day. If the iodide is administered alone it should be ordered in the form of the saturated solution. R. Potassium iodide,........% j Distilled water, q. s., . . ad . . ^j. M. Each minim contains 1 grain; the required number of minims should be taken in milk, which disguises the taste of the iodide During the course of the mercury treatment it is most important to maintain the general health of the patient. Tonics, such as quinine, iron and cod-liver oil should be administered, unless they have a tendency to disorder the stomach. The life of the patient should be most carefully regulated in accordance with hygienic rules. Stimulants, if used at all, must be taken in extreme modera- tion and with food. At times no form of mercury can be taken by the mouth ; it may then be administered by inunction, by vaporization, or by hypo- dermic m cdication. "When given by inunction, the patient is instructed to take a warm bath in the evening on retiring. One drachm of mercury ointment is then rubbed for fifteen minutes into the inner surface of the arm and forearm, and the corresponding side of the chest. A silk 158 ESSENTIALS OF SURGICAL DRESSING. or .flannel undershirt is next donned, and the patient puts on his ordinary night garments. This undershirt must be worn for one week. The next night the rubbing is repeated as before, but upon the opposite side of the body. The following night the ointment is rubbed into the left groin and the inner surface of the left leg and thigh ; next into the right groin, leg and thigh, and the fifth night into the surface of the belly and anterior portion of the chest. On the sixth night a warm bath is taken, after which the ointment is nibbed in as upon the first night. In place of blue ointment the oleate of mercury may be employed, although this is more irritating to the skin than the mercury oint- ment. A very convenient method of practising inunctions, though not so prompt in effect as the one described above, is that advocated by Sturgis. Before starting the inunction the patient is directed to take a hot foot-bath; into the sole of the right foot is then rubbed a half drachm of a twenty per cent, solution of oleate of mercury, and the next night a similar quantity is rubbed into the left foot; thus alter- nating, the mercury is rubbed in every night. The same stockings must be worn continuously for one week, after which the feet are thoroughly cleansed and the treatment is intermitted for two or three days. The quantity of mercury thus rubbed in may be in- creased to suit the requirements of the case. When it is not practicable to give mercury, either by the mouth or in the form of inunction, it may be administered in the form of vaporization. To accomplish this the patient is seated, naked, upon a chair and surrounded with blankets, the head only being left out. Beneath the tent thus formed is placed a large vessel filled with boiling water. After the skin is thoroughly softened by means of this steam bath, from half a drachm to a drachm of calomel is placed upon a metal dish and is vaporized by the heat of an alcohol lamp, the whole being placed beneath the chair, and the vapor being pre- vented from escaping by keeping the blankets applied closely about the patient's neck. In fifteen minutes the patient is wrapped in the blankets which have formed the vapor tent arid is put to bed. These blankets may be removed in from half an hour to an hour. When other means of introducing mercury are not available, or when it is particularly important that an immediate effect should be SYPHILIS. 159 produced, the drug may be administered hypodermically. Both the soluble and insoluble preparations of mercury are employed, but on account of the pain and local inflammation produced by the latter the former are greatly to be preferred. The hypodermic solu- tion may be prepared according to the following formula :— R . Bichloride of mercury,.........gr. iij Chloride of sodium,..........3 ss Distilled water,............g x. SiG.—Ten to twenty minims of this may be injected daily. In regard to the choice of method by which mercury can be intro- duced into the system, there is little doubt but that inunctions act most powerfully upon the manifestations of the disease, and at the same time are less likely to exert the deleterious influences of the drug upon the system. Where a quick action is imperative, the hypodermic medications should be employed. Where the convenience of the patient is con- sulted, however, and this usually governs the method of adminis- tering the mercury, it may be given by the mouth. Although long-continued treatment is ordinarily advised, many authorities administer drugs only till the symptoms of the disease disappear, and then discontinue the treatment until further mani- festations justify its resumption. Under no circumstances should a patient be salivated. This condition distinctly and seriously compli- cates the natural course of a case of syphilis. The so-called tonic doses of mercury, that is, half the quantity necessary to produce Aie first symptoms of ptyalism, seem to exert a decidedly beneficial effect upon the blood aside from the specific action upon the syph- ilitic manifestations. In addition to the general treatment of syphilis, local lesions may be materially modified by topical applications. The rapid disappearance of the secondary eruptions appearing upon the hands and face may be accomplished by the use of heat. The infected portion of the skin may be covered with a layer of lint wrung out in hot water; to this is applied a hot-water bag. This treatment is continued for half an hour, and is repeated three times a day. During the night the patient may wear a face mask smeared with 160 ESSENTIALS OF SURGICAL DRESSING. oleate of mercury three to five per cent, or with five to ten per cent, ointment of ainmoniated mercury. Gloves may be worn, the inner surfaces of which are coated with the same preparations. Mucous patches, if found on the skin, should be washed with mild solutions of bichloride of inercury, dusted with calomel, and kept dry by introducing a layer of absorbent cotton between the skin surfaces. Mucous patches in the mouth are treated by astringent gargles such as myrrh, hydrastis and chlorate of potash. Each patch should be touched with the solid stick of nitrate of silver, or, by means of a glass rod, with the acid nitrate of mercury. The pain of this last application may be prevented by the previous application of cocaine. Should the patient become salivated, he should be instructed to rinse out the mouth many times each hour with a warm solution of chlorate of potash, fifteen grains to the ounce. Of this one tea- spoonful should be swallowed daily. To this chlorate of potash mouth-wash may be added belladonna, one-half a drachm to the ounce, and tincture of myrrh. No effort should be made to check the diarrhoea, since this is one of the ways in which the drug is eli- minated. Local application of cocaine to the gums will greatly relieve the sufferings of the patient. Ulcerating syphilides are cleansed and dressed according to gen- eral surgical principles. When iodide is indicated and the patient cannot tolerate it, iodine may be employed in its place. The following formula may be ordered:— R . Tincture of iodine,........5j ij Simple syrup,..........,§ij. Sig.—A teaspoonful, diluted with water, three times a day with meals, to be increased as required. Describe the tertiary lesions of syphilis. Between the secondaries and tertiaries proper there are certain symptoms which sometimes appear, called reminders. Among these are skin eruptions, enlargement of the testicle, choroiditis, ulcera- tion of the tongue, disease of the arteries, and psoriasis of the palms. The tertiary lesion of syphilis is the gumma. This has no ten- dency to spontaneous cure, and is characterized by the formation of SYPHILIS. 161 round-celled infiltrations, which commonly involve the surrounding tissues, and either break down in the centre, leaving ulceration, or are absorbed, leaving a fibroid thickening and scarring (syphilitic stric- ture of oesophagus, etc.). The gumma may attack the periosteum, causing nodes, caries or necrosis ; the cutaneous or mucous surfaces, causing ulcers on any part of the body. These ulcers of tertiary syphilis are symmetrical, and are not contagious. Give the treatment of tertiary syphilis. Mercury and potassium iodide, or iodide of potassium alone or combined with tonics. Commence with ten grains of potassium iodide three times a day, gradually increasing the dose till the desired effect is accomplished. During the course of the iodide treatment the disappearance of symptoms may be greatly hastened by mercury inunctions, twelve of these being given at a time, with intervals of one or two weeks between each course. What are the characteristics of the tertiary ulcer ? A tertiary ulcer begins as a gumma or lump, which, when it breaks, exposes a gray slough, surrounded by granulation tissue. The edges are rounded and sharply cut. Other signs of syphilis can be found. The affection yields to specific treatment. The gumma frequently affects the leg, causing an ulcer ; such ulcers are commonly found upon the upper third of the limb. What is meant by syphilitic cachexia ? When syphilis affects persons before feeble, or weakened by struma or debilitating diseases, it frequently assumes a malignant form. Treatment seems only to aggravate the symptoms, at the same time producing profound anaemia. The viscera undergo serious patho- logical alterations, absorption practically ceases, and the disease terminates fatally. In these cases specific constitutional treatment is worse than useless. Tonics, stimulants, and general hygienic treatment represent all that can be done for the patient. What is congenital syphilis ? Syphilis transmitted to the foetus through the spermatozoa of the father, or the ovum of the mother. What are the characteristics of congenital syphilis ? Manifestations are rare before four to six weeks after birth ; then 11 162 ESSENTIALS OF SURGICAL DRESSING. there may be secondaries, as snuffles or coryza, macular or papular eruptions, mucous patches, ulcerations about the mouth and lips (rhagades), stomatitis, which, by its effect upon the dental sacs of the permanent teeth, causes subsequent development of Hutchinson's teeth. After some years tertiaries develop. These commonly take the form of interstitial keratitis, and gummatous developments. Describe Hutchinson's teeth. The upper permanent median incisors chiefly show this lesion, which consists in a dwarfing of the entire tooth, an extreme diminu- tion in its free end, and a narrowing of the cutting edge, with a central notch or crescent. Give the treatment of hereditary syphilis. This is conducted upon the same lines as is the treatment of ac- quired secondaries. Mercury is best given by inunction, gr. x of unguent, hydrarg. being rubbed over the abdomen and covered by the belly-band every night. When the symptoms disappear mer- cury treatment should be discontinued. A non-infected woman should not be allowed to suckle a syphilitic child. The tertiaries are treated by mercury, together with iodide of potassium and tonics. What is Colles's law ? A syphilitic child suckled by its mother will not infect her, though she be (apparently) free from venereal disease. This is because she is already infected with the disease, which attacks her in a latent form. SYPHILIS. 163 ANTISEPTIC FORMULiE. Watery solutions. Bichloride of mercury,......1-1000-1-2000. For making solutions, which are to be kept for some length of time, sodium chloride should be added in quantity equal to that of the bichloride. A convenient solution for preparing lotions of the strength ordi- narily used is the following :— R. Bichloride of mercury,......2 Sodium chloride, ........1 Dilute acetic acid,........1 Water,.............16. M. This makes a ten per cent, bichloride solution ; by adding water in appropriate quantity 1-1000 and 1-2000 solutions are readily made. The watery solutions of other antiseptic solutions are commonly used in the following strengths :— Carbolic acid,..........1-20 or 1-40 Salicylic acid,..........1-300 Boric acid,...........1-30 Chloride of zinc,.........1-10 or 1-20 Permanganate,.........1-1000 Carbolized oil,..........1-10 Iodoform collodion,.......1-10 Creolin,.............1-20 or 1-40. Ointments. Iodoform. R. Iodoform,...........• 5 Vaseline,............30 Oil of almonds,.........10 M. 164 ESSENTIALS OF SURGICAL DRESSING. Boric acid. R. Boric acid,.......... . 3 Paraffine,............10 Vaseline,............5 IvL INDEX. ABSCESS, periurethral, 137 Ammonia, vesication by, 88 Anaesthetics, 79 cocaine, 85 cold, 86 chloroform, 80-85 ether, 80 nitrous oxide, 80 Antiseptic dressings, 75-79 formulae, 162 operation, 77 Antiseptics, 71 bichloride of mercury, 71 boric acid, 74 carbolic acid, 72 chloride of zinc, 74 creolin, 74 iodoform, 73-163 peroxide of hydrogen, 74 Artificial respiration, 83 Howard's method, 84 Sylvester's method, 83 BALANITIS, 126 Treatment, 137 Bandages, handkerchief, 50 Barton's, 58 of extremities, 56 of head, 51 of trunk, 53 four-tailed, 50 many-tailed, 49 plaster-of-Paris, 59 roller, 19 Barton's, 41 crossed of perineum, 50 Desault, 29 figure-of-eight, 50 Gibson's, 42 of head, 41 of lower extremity, 35 spiral reversed, 20 of trunk, 27 turns, 19 Bandages, roller, upper extremity, 22 Velpeau, 27 suspensory, 139 T, 49 Bichloride of mercury, 71 Bleeding, 92 Boric acid, 74 CACHEXIA, syphilitic, 161 Cantharides, 89 Capsicum, 88 Carbolic acid, 72 Catarrh, urethral, 140 Catgut, 75 Catheter, prostatic, 143 Cautery, 91 Chancre, 153 Hunterian, 154 treatment, 154 Chancroid, 118 Chloride of zinc, 74 Chloroform, 80-85 Cocaine, 85 Colles' law, 102 Counter-irritation, 87 Cowperitis, 138 Creolin, 74 Cupping, 93 DEPLETION, 92 Drainage, 77 Dressings, 75 antiseptic, 75 Lister's new, 76 FOLLICULITIS, 127 treatment, 137 Fomentations, 87 Fracture dressings, 99 clavicle, 100 femur, 107 forearm, 104 hand, 107 165 166 INDEX. Fracture dressings, humerus, 102 leg, 110 maxilla, 100 patella, 109 ribs, 64 scapula, 101 GLEET, 140 treatment, 142 Gonococcus, 125 Gonorrhoea, 124 chronic, 140 Gonorrhoeal rheumatism, 128 H OWARD, artificial respiration, 34 Hypodermics, 96 accidents, 98 IODOFORM, 73 Issue, 90 KNOTS, 64 Kocher's reduction of shoulder luxation, 113 LEECHING, 94 Luxation, 111 ankle, 115 elbow, 115 hand,116 hip, 117 jaw, 112 knee, 117 patella, 118 semilunar cartilages, 118 shoulder, 112 wrist, 115 MALIGNANT pustule, 55 Meningitis, 86 Micro-organisms, 44 Mortification, 38 Mucous patch, 155 Mustard, 88 APERATION, antiseptic, 77 PARAPHIMOSIS, 126 treatment, 137 Passage, false, 146 Phimosis, 126 Phimosis, treatment, 137 Peroxide of hydrogen, 74 Plaster-of-Paris bandage, 59 jacket, 6 Plaster, 62 Posthitis, 126 Pott's fracture, 111 Prostatitis, 127 treatment, 137 RHEUMATISM, gonorrhoeal, 128 Rubefacients, 87 SCULTETUS bandage, 49 Seton, 91 Silk, 75 Sounds, 150 Sponges, 74 Strangury, 90 Strapping, 63 breast, 63 ribs, 64 testicle, 63 ulcer, 64 Stricture, causes, 144 diagnosis, 145 treatment, 147 Stupes, turpentine, 87 Sutures, 65 Czerny, 69 Lembert, 68 Sylvester artificial respiration, 83 Syphilis, 153 congenital, 161 lesions, 161 primary, treatment, 162 secondary, " 165 tertiary, 14 TEETH, Hutchinson's, 162 Transfusion, 95 ULCER, syphilitic, 161 Urethra, 124 dilatation, 15 Urethrameter, 145 Urethritis, 125 acute, 126 anterior treatment, 130 posterior treatment, 135 Urethroscope, 141 Urethrotomy, internal, 151 external, 153 CATALOGUE OF MEDICAL AND SURGICAL WORKS, PUBLISHED BY No. 913 Walnut Street, PHILADELPHIA. The aim of the publisher of the works described in the following pages has been to make them of permanent and not transient value to students and members of the medical profession. They are all written or edited by well-known and competent authors, many of international repute. Especial care has been exercised in the selection of clear, readable type, high class illustrations, good paper, and serviceable bindings. *%* For sale by Booksellers in all principal cities of the United States and Canada; or sent post free on receipt of price by the Publisher. MR. SAUNDERS takes pleasure in announcing to the medical profession the preparation of AN American Text-Book of Surgery. GENERAL AND OPERATIVE. BY W. W. KEEN, A.M., M.D., Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Philadelphia. J. WILLIAM WHITE, M.D., Ph.D., Professor of Clinical Surgery in the University of Pennsylvania. P. S. CONNER, M.D., LL.D., Professor of Surgery and Clinical Surgery in the Medical College of Ohio, Cincinnati, Ohio. FREDERIC S. DENNIS, M.D., Professor of the Principles and Practice of Surgery and Clinical Surgery in Bellevue Hospital Medical College, New York. CHARLES B. NANCREDE, M.D., Professor of Surgery in the University of Michigan, Ann Arbor, Michi- gan. ROSWELL PARK, A.M., M.D., Professor of Surgery in the Medical Department of the University of Buffalo, New York. LEWIS S. PILCHER, M.D., Professor of Clinical Surgery in the Post-Graduate Medical School, New York. N. SENN, M.D., Ph.D., Professor of Surgery in Rush Medical College, Chicago, and in the Chi- cago Polyclinic. 2 FRANCIS J. SHEPHERD, M.D., Professor of Anatomy, McGill University, Montreal, Canada. LEWIS A. STIMSON, B.A., M.D., Professor of Surgery* in the University of New York. J. COLLINS WARREN, M.D., Associate Professor of Surgery in Harvard University. CHARLES H. BURNETT, A.M., M.D., Professor of Otology in the Philadelphia Polyclinic and College for Gradu- ates in Medicine. WILLIAM THOMSON, M.D., Professor of Ophthalmology in the Jefferson Medical College, Philadel- phia. Recognizing the fact that for a number of years there has been an increasing demand for a text-book on Surgery which should be at once concise and comprehensive, and at the same time essentially American in its teachings, the various authors have undertaken the preparation of such a work, which, instead of embodying the ideas of a single / INDIVIDUAL, WILL BE COMPOSED OF A SERIES OF TREATISES, EACH WRITTEN BY A TEACHER OF SURGERY, BUT COMBINED INTO A SINGLE AUTHORITATIVE WORK BY MUTUAL CRITICISM AND REVISION. It is intended in this manner to obtain the undoubted benefit of the special knowledge and experience of the different authors in their respective lines of work, while avoiding all unnecessaiy detail. The book as a whole will thus faithfully represent the prevailing views and methods of American surgeons. The names and professional positions of the authors in- dicate without further explanation the general scope and character of the work. It will form a handsome royal octavo volume, printed in beautiful large clear type, on heavy paper, with numerous FINE ILLUSTRATIONS. 3 NOW READY. MEDICAL DIAGNOSIS. BY DR. OSWALD YIERORDT, Professor of Medicine at the University of Heidelberg ; formerly Privat Docent at University of Leipzig ; Professor of Medicine and Director of the Medical Polyclinic at the University of Jena. Translated, with Additions, from the Second Enlarged Germar Edition, with the Author's Permission. BY FRANCIS H. STUART, A.M., M.D. Member of the Medical Society of the County of Kings, N. Y. ; Fenow of the New York Academy of Medicine ; Member of the British Medical Association, etc. NUMEROUS COLORED AND WOOD ENGRAVINGS. Price, Cloth, $4.00; Sheep, $5.00. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a Clinical work by a master teacher, characterized by thor- oughness, fulness, and accuracy. It is a mine of information upon the points that are so often passed over without explanation. The student who is familiar with its contents will have a sound foun- dation for the practice of his profession. The author gives a complete though brief presentation of the Micro- organisms, whose recognition and discrimination are made possible by cultivation, and inoculation, and which, through the labors of those eminent bacteriologists, PASTEUR, KOCH, and others, have already made such marked changes in the application of remedial agents in the cure of disease. 4 IN PREPARATION. READY SHORTLY. A NEW Pronouncing Dictionary of Medicine. BY JOHN M. KEATING, M.D., Fellow College of Physicians of Philadelphia; Visiting Obstetrician to the Philadelphia Hospital, and Lecturer on Diseases of Women and Chil- dren ; Gynaecologist to St. Joseph's Hospital; Surgeon to the Maternity Hospital, etc.; Editor "Cyclo- paedia of Diseases of Children," AND HENRY HAMILTON, Author of " A New Translation of Virgil's jiEneid into English Rhyme; Co-author of "Saunders' Medical Lexicon," etc. A voluminous and exhaustive handbook of Medical, Surgical, and Scientific Terminology, containing concise explanations of the various terms used in Medicine and the allied sciences, with Phonetic Pronunciation, Accentuation, Etymology, etc. The work will form a very handsome royal 8vo volume, beautifully printed from type specially cast for the work, on paper manufactured for this purpose. It will contain most important tables of Bacilli, Micrococci, Leucomaines, Ptomaines, etc. etc., the whole forming the most complete, reliable, and valuable Diction- ary in the market. It has been the aim of the Publisher to place in the hands of stu- dents and the medical profession a work which should contain the names of Hundreds of New Words now being adopted, and at the same time, by leaving out the numerous obsolete terms contained in most Dic- tionaries, keep the volume of such a size as to be most convenient for ready reference. POCKET MEDICAL LEXICON; OR, Dictionary of Terms and Words used in Medicine and Surgery, By JOHN M. KEATING, M.D., Editor of "Cyclopaedia of Diseases of Children," etc.; Author of the "New Pronouncing Dictionary of Medicine," HENRY HAMILTON, Author of "A New Translation of Virgil's ^Eneid into English Verse •" Co-author of a "New Pronouncing Dictionary of Medicine." Price, 75 Gents, Cloth. $1.00, Leather Tucks. /76 90 __| I__19 do _ 70 60 SO _ 30 if water: f -20 — __tSS _ 56 __/10 (22 ./04 — 86 o — 80* _ 72 — 61 — 48 — 40 — 31 — it — 16 — SO —8 Jf — H —8- -T4 —IS (From Appendix to Medical Lexicon.) o' This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market,which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not con- taining the hundreds of new words now used in current lit- erature, especially those relat- ing to Electricity and Bacteri- ology. Annuls of (ii/Hfrrology, l'hiln- lUlphhi Iir, 1HOO. Saunders' Pocket Medical Lexi- con—a very complete little work, invaluable to every student of medicine. It not only contains a very large number of words, but also tables of etymological factors common in medical termim>lo<_'y ; abbreviations used in medicine, poisons and antidotes, etc. Essentials of Anatomy and Manual of Practical Dissection. B\- CHARLES B. NANCREDE, M.D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Koyal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical College,etc. etc. With Handsome Full-page Lithographic Plates in Colors. Over 200 Illustrations. No pains or expense has been spared to make this work the most exhaustive yet concise Student's Manual of Anatomy and Dissection ever published, either in this country or Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. For this edition the woodcuts have all been speci- ally drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole based on the eleventh edition of Gray's Anatomy, and forming a handsome post 8vo volume of over 400 pages. Price, Extra Cloth or Oilcloth for the Dissection-Room, $2.00 Net. Medical Sheep...............2.50 " Times and Register, Philadelphia, August 23,1890.—Nancrede's Anatomy and Dissector—this is a good dissector's manual, with clear type and hand- some cuts. The colored plates are especially commendable. The Southern Practitioner, Nashville, Tenn., September, 1890.—Nancrede's Anatomy and Dissector—truly a " Vade Mecum," a " multum in parvo." The illustrations arc marvels of beauty and clearness of illustration. 7 IN PREPARATION. DISEASES OF THE EYE. BY G. E. de SCHWEIN1TZ, M.D., Ophthalmic Surgeon to Children's Hospital and to the Philadelphia Hospital j Ophthalmologist to the Orthopaedic Hospital and Infirmary for Ner- vous Diseases; Lecturer on Medical Ophthalmoscopy, University of Pennsylvania, etc. A HAND-BOOK OF OPHTHALMIC PRACTICE, Especially useful to the student who has had neither time nor inclination to study the numerous able but more volu- minous text-books. The object of this manual is to present to the student who is be- ginning work in the field of ophthalmology a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the methods of examination, the symptomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into special prominence. Anatomy, physiology, and pathological histology, except in so far as they serve the purpose just stated, have been omitted. The sections devoted to optical principles and the normal and abnormal refraction of the eye in large portion have been written by Dr. James Wallace, Chief of the Eye Dispensary of the University Hospital. The chapter devoted to the application of the shadow-test has been prepared by Dr. Edward Jackson. The book will be suitably illustrated by a number of wood-cuts, many of them from cases in the practice of the author, in addition to which there will be several chromo-lithographs. 8 IN PREPARATION. DISEASES OF WOMEN. By HENRY J. GARRIGUES, A.M., M.D., Professor of Obstetrics in tho New York Post-Graduate Medical School and Hospital ; Gynaecologist to St. Mark's Hospital in New York City ; Gynae- cologist to the German Dispensary in the City of New York; Con- sulting Obstetrician to the New York Infant Asylum; Obstetric Surgeon to the New York Maternity Hospital; Fellow of the American Gynaecological Society ; Fellow of the New York Academy of Medicine ; President of the German Medical Society of the City of New York, etc. etc. ^ It is the intention of the writer to provide a practical manual on Gynaecology, for the use of students and practitioners, in as concise a manner as is compatible with clearness. Syllabus of Obstetrical Lectures In the Medical Department, University of Pennsylvania. By RICHARD C. NORRIS, A.M., M.D., Demonstrator on Obstetrics in the University of Pennsylvania. Price, Cloth, Interleaved for Notes . . . $2.00 Net. The New York Medical Record of April 19, 1890, referring to this book, says : " This modest little work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. Small as it is, it covers the subject thoroughly, and will prove invaluable to both the student and the practitioner as a means of fixing in a clear and concise form the knowledge derived from a perusal of the larger text-books. The author deserves great credit for the manner in which he has performed his work. He has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetri'es. The subject- matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable ; there is no doubtful tone in the directions given. No details are regarded as unimportant ; no minor matters omitted. We venture to say that even the old practitioner will find useful hints in this direction which he cannot afford to depise." y READY SHORTLY. SAUNDERS' Pocket Medical Formulary. BY WILLIAM M. POWELL, M.D., Attending Physician to the Mercer House for Invalid Women, at Atlantic City, N. J. ; Late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital; Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania, and Chief of the Medical Clinic of the Philadelphia Polyclinic. Containing about 2000 Formulae, selected from several hundreds of the best-known authorities. A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through th-} works of the Most imminent Physicians and Surgeons of th-3 world, particularly helpful to the student and young practitioner, as it gives him a taste for writing his prescriptions in an elegant and correct manner, thus avoid- ing incompatible and dangerous prescriptions. The use of this work is to be recommended even to the older prac- tioner, as through it he becomes acquainted with numerous formulae which are not found in the text-books, but have been collected from among the Rising Generation of the Profession, College Professors, and Hospital Physicians and Surgeons. 10 NOW READY. NEW AND REVISED EDITIONS OF SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. The Latest, Cheapest, and Best ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. THE ADVANTAGES OF QUESTIONS AND ANSWERS—The usefulness of arranging the subjects in the form of Questions and Answers will be apparent, Kince the student, in reading the standard works, often is at a loss to discover the important points to be remembered, and is equally puzzled when he attempts to formulate ideas as to the manner in which the Questions could be put in the Examination-Room. These small works, which can be conveniently carried in the pocket, contain in a condensed form the teachings of the most popular text-books. The authors are nearly all connected with the various colleges as Demonstrators or Lecturers, and are therefore thoroughly conver- sant, not only with the wants of the average student, but also with the points that are absolutely necessary to be remembered in the Examination-Room. These books are constantly in the hands of tlieir authors for revision, and are kept well up to the times, their fast sale allowing them to be almost entirely rewritten 'whenever necessary, instead of having to wait for the edition to be sold, as is the case with an ordinary text book. 11 No. 1. ESSENTIALS OF PHYSIOLOGY. II. A. HARE, M.D., Professor of Therapeutics and Materica Medica in the Jefferson Medical Col. lege of Philadelphia; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc.; Secretary of the Convention for the Revision of the Pharmacopoeia, 1S90. NUMEROUS ILLUSTRATIONS. Third Edition, Revised and Enlarged. Price, Cloth . . . $1.00; Interleaved for Notes . . . $1.25. University Medical Magazine, October, 1888.—"Dr. Hare has admirably succeeded in gather- ing together a series of Ques- tions which are clearly put and tersely answered." Pacific Medical Journal, Octo- ber, 1889.—" Hare's Physiology contains the essences of its sub- j ject. No better book has ever been produced, and every stu- dent would do well to possess a | copy." Times and Register, Philadel- I phia, October 5,1889.—" In the second edition of Hare's Physi- ology all the more difficult points of the study of the nervous sys- tem have been elucidated. As the work now appears it cannot fail to merit the appreciation of Specimen of Illustrations. the overworked student." Journal of the American Association, November 23, 1S89.__"Hare's Physiology—an excellent work ; admirably illustrated ; well calcu- lated to lighten the task of the over-burdened undergraduate." 12 No. 2. ESSENTIALS OF SURGERY. CONTAINING, ALSO, Venereal Diseases, Surgical Landmarks, Minor and Operative Su-- gery, and a Complete Description, together with full Illustra- tions, of the Handkerchief and Roller Bandage. By EDWARD MARTIN, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Sur gery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hospital; Assistant Surgeon to the University Hospital, etc. etc. PROFUSELY ILLUSTRATED. FOURTH EDITION, Considerably enlarged by an Appendix containing rail directions and prescriptions for the preparation of the various mate- rials used in ANTISEPTIC SURGERY ; also sev- eral hundred recipes covering the medical treatment of surgical affections. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Medical and Surgical Reporter, B'ebruary, 1889.—" Martin's Sur- gery contains all necessary essen- tials of modern surgery in a com- paratively small space. Its style is interesting and its illustrations admirable." University Medical Magazim, January, 1889.—"Dr. Martin has admirably succeeded in selecting and retaining just what is neces- sary for purposes of examination, and putting it in most excellent shape for reference and memor- izing." Kansas City Medical Record.— " Miirtin's Surgery.—This admir- able compend is well up in the most advanced ideas of modern surgery.'* 13 Specimen of Illustrations. No. 3. ESSENTIALS OF ANATOMY, Including the Anatomy of the Viscera. By CHARLES B. NANCREDE, M.D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; Late Surgeon Jefferson Medical College, etc. etc. ONE HUNDRED AND FORTY FINE WOODCUTS THIRD EDITION. Enlarged by an Appendix containing over Sixty Illustrations of the Osteology of the Human Body. The whole based upon the last (eleventh) edition of GRAY'S ANATOMY. Price, Cloth, $1.00. Interleaved for Notes, $1.25. American Practitioner and News, February 16, 1889. " Nancrede's Anatomy.— For self-quizzing and keep- ing fresh in mind the knowledge of Anatomy gains at school, it would not he easy to speak of it in terms too favorable." Southern Californian Practi- tioner, January 18, 1889. " Nancrede's Anatomy.— Very accurate and trust- worthy." American Practitioner and Nen-s, Louisville, Kentucky. " Nancrede's Anatomy.— Truly such a book as no student can afford to be without." Specimen of Illustrations. 14 No. 4. Essentials of Medical Chemistry ORGANIC AND INORGANIC. CONTAINING, ALSO, Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. BY LAWRENCE WOLFF, M.D, Demonstrator of Chemistry, Jefferson Medical College ; Visiting Physician to German Hospital of Philadelphia ; Member of Philadelphia College of Pharmacy, etc. etc. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Cincinnati Medical News, January, 1889. — " Wolff's Chemistry.--A little work that can be carried in the pocket, for ready reference in solving difficult problems." St. Joseph's Medical Herald, March, 1889.—"Dr. Wolff explains most simply the knotty and difficult points in chemistry, and the book is therefore well suited for use in medical schools." Medical and Surgical Reporter, November, 1889.—" We could wish that more books like this would be written, in order that medical students might thus early become more interested in what is often a difficult and uninterest- ing branch of medical study." Registered Pharmacist, Chicago, December, 1890. — "Wolff's Chemistry." —" The author is thoroughly familiar with his subjects. A useful addition to the medical and pharmaceutical library." 15 No. 5. ESSENTIALS OE OBSTETRICS By W. EASTERLY ASHTON, M.D., Obstetrician to the Philadelphia Hospital. NUMEROUS ILLUSTRATIONS. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Specimen of Illustrations. Southern Practitioner, January, 1890.—Ash ton's Obstetrics.—An excellent little volume containing correct and practical knowledge. An admirable com- pend, and the best condensation we have seen." Chicago Medical Times.—" Ashton's Obstetrics.—Of extreme value to stu- dents, and an excellent little book to freshen up the memory of the practi- tioner." Medical and Surgical Reporter, January 26, 1889.—"Ashton's Obstetrics. —A work thoroughly calculated to be of service to students in preparing for examination."* New York Medical Abstract, April, 1890.—"Ashton's Obstetrics should be consulted by the medical student until he can answer every question at sight. The practitioner would also do well to glance at the book now and then, to prevent his knowledge from getting rusty." 16 No. 6. ESSENTIALS OF Pathology and Morbid Anatomy. BY C. E. ARMAND SE1PLE, B.A., M.B., Cantab., L.S.A., M.R.C.P., Lond, Physician to the Northeastern Hospital for Children, Harkney ; Pro- fessor of Vocal and Aural Physiology and Examiner in Acous- tics at Trinity College, London, etc. etc. ILLUSTRATED. FOURTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. From the College and Clinical Record, September, 1889. —" A small work upon Pathology and Morbid Anatomy, that re- duces such complex subjects to the ready comprehension of the student and practi- tioner, is a very acceptable addition to medical literature. All the more modern topics, such as Bacteria and Bacilli, and the most recent views as to Urinary Path- ology, find a place here, and in the hands of a writer and teacher skilled in the art of simplifying abstruse and difficult sub- jects for easy comprehension are rendered thoroughly intelligible. Few physicians do more than refer to the more elaborate works for passing information at the time Specimen of Illustrations. it is absolutely needed, but a book like this of Dr. Semple's can be taken up and perused continuously to the profit and instruction of the reader." Indiana Medical Journal, December. 1889.—" Semple's Pathology and Morbid Anatomy.—An excellent compend of the subject from the points of view of Green and Payne." Cincinnati Medical Neics, November, 1889.—Semple's Pathology and Mor- bid Anatomy.—A valuable little volume—truly a mult urn in parvo." Nil. 7. ESSENTIALS OP Materia Medica, Therapeutics, AND PRESCRIPTION WRITING. BY HENRY MORRIS, M.D., Late Demonstrator, Jefferson Medical College ; Fellow College of Physicians, Philadelphia; Co-editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc. etc. SECOND EDITION. FOURTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Medical and Surgical Reporter, October, 1889. "Morris' Materia Medica and Therapeutics.—One of the best compends in this series. Concise, pithy, and clear, well-suited to the purpose for which it is prepared." Gaillard's Medical Journal, November, 1889. "Morris' Materia Medica.—The very essence of Materia Medica and Thera- peutics boiled down and presented in a clear and readable style." Sanitarium. New York, January, 1890. "Morris' Materia Medica.—A well-arranged quiz-book, comprising the most important recent remedies." Buffalo Medical and Surgical Journal, January, 1890. "Morris' Materia Medica.—The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct ir a lasting manner." IS Nos. 8 and 9. ' Essentials of Practice of Medicine. By HENRY MORRIS, M.D., Author of "Essentials of Materia Medica," etc. With an Appendix on the Clinical and Microscopical Examination of Urine. By LAAVRENCE WOLFF, M.D., Author of " Essentials of Medical Chemistry," etc. COLORED (VOGEL) URINE SCALE AND NUMEROUS FINE ILLUSTRATIONS. SECOND EDITION, Enlarged by some THREE HUNDRED Essential Formulae, selected from the writings of the most eminent authorities of the Medical Profession. COLLECTED AND ARRANGED BY WILLIAM M. POWELL, M.D., Author of "Essentials of Diseases of Children." Price, Cloth, $2.00. Medical Sheep, $2.50. Southern Practitioner, Nashville, Tenn., January, 1891. "Morris' Practice of Medicine.—Of material aid to the advanced student in preparing for his degree, and to the young practitioner in diagnosing affec- tions or selecting the proper remedy." American Practitioner and News, Louisville, Ky., January, 1891. "Morris' Practice of Medicine.—The teaching is sound, the presentation graphic, matter as full as might be desired, and the style attractive." Southern Medical Record, January, 1891. "Morris' Practice of Medicine is presented to the reader in the form of Questions and Answers, thereby calling attention to the most important lead- ing facts, which is not only desirable, but indispensable to an acquaintance with the essentials of medicine. The book is all it pretends to be, and we cheerfully recommend it to medical students." I'd No. 10. ESSENTIALS OP GYNECOLOGY. EDWIX 13. CRAIGIX, M.D., Attending Gynaecologist, Roosevelt Hospital, Out-Patients' Department Assistant Surgeon, New York Cancer Hospital, etc. etc. 58 FINE ILLUSTRATIONS. SIXTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. (J '-' ■ y/hf\r^y Specimen of Illustrations. ll(i Medical and Surgical Re- porter, April,1890.—"Craig- gin's Essentials of Gynaecol- ogy.—This is a most excel- lent addition to this series of question compends, and properly used will be of great assistance to the stu- dent in preparing for ex- amination. Dr. Craigin is to be congratulated upon having produced in com- pact form the Essentials of Gynaecology. The style is concise, and at the same time the sentences are well rounded. This renders the book far more easy to read than most compends, and adds distinctly to its value." College and Clinical Record, April, 1890. — "Craigin's Gynaecology.—Students and practitioners, general or spe- cial, even derive information and benefit from the perusal and study of a carefully written work like this." No. 11. Essentials of Diseases of the Skin. By HENRY W. STELWAGON, M.D., CJinical Lecturer on Dermatology in the Jefferson Medical College, Philadel- phia; Physician to Philadelphia Dispensary for Skin Diseases; Chief of the Skin Dispensary in the Hospital of University of Penn- sylvania; Physician to Skin Department of the Howard Hospital; Lecturer on Dermatology in the Women's Medical College, Philadelphia, etc. etc. 74 ILLUSTRATIONS, many of which are original. FOURTH THOUSAND. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Specimen of Illustrations. New York Medical Journal, May, 1890.—" Stel wagon's Diseases of the Pkin.—We are indebted to Philadelphia for another excellent book on Derma- tology. The little book now before us is well entitled " Essentials of Derma- tology," and admirably answers the purpose for which it is written." The experience of the reviewer has taught him that just such a book is needed. We are pleased with the handsome appearance of the book, with its clear typo, good paper, and fine wood-cuts." No. 12. ESSENTIALS Minor Surgery, Bandaging, and Venereal Diseases. By EDWARD MARTIN, A.M., M.D., Author of "Essentials of Surgery," etc. 82 ILLUSTRATIONS, mostly specially prepared for this wcrk. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Specimen of Illustrations. Medical News, Phila- delphia, January 10,1891. ' 'Martin's Minor Surgery, Bandaging, and Venereal Diseases.— The best con- densation of the subjects of which it treats yet placed before the profession. The chapter on Genito-Urinary Diseases, though short, is sufficiently complete to make them thoroughly acquainted with the most advanced views on the subject." Nashville Journal of Medicineand Surgery, N o- vember,1890.—"Martin's Minor Surgery,etc.should be in the hands of every student, and we shall per- sonally recommend it toour students as the best text- book upon the subject." Pharmaceutical Era, Detroit, Michigan, December 1, 1890__"Martin's Minor Surgery, etc.—Especially acceptable to the general practitioner, who is often at a loss in cases of emergency as to the proper method of applying a bandage to an injured member." 22 No. 13. ESSENTIALS OF Legal Medicine, Toxicology, AND HYGrlENE. BY C. E. ARMAND SEMPLE, M.D., Author of " Essentials of Pathology and Morbid Anatomy." 130 ILLUSTRATIONS. Price, Cloth.......$1.00. Interleaved for Notes .... 1.25. Southern Practitioner, Nashville, May, 1890. "Semple's Legal Medicine, etc.—At the present time, when the field of medical science, by reason of rapid progress, becomes so vast, a book which contains the essentials of any branch or department of it, in concise, yet readable form, must of necessity be of value. This little brochure, as its title indicates, covers a portion of medical science that is to a great extent too much neglected by the student, by reason of the vastness of the entire field and the voluminous amount of matter pertaining to what he deems more important departments. The lead- ing points, the essentials, are here summed up systematically and clearly." Medical Brief, St. Louis, May, 1890. " Semple's Legal Medicine, Toxicology, and Hygiene.—A fair sample of Saunders' valuable compends for the student and practitioner. It is handsomely printed and illustrated, and concise and clear in its teachings." 23 No. 14. ESSENTIALS OF Refraction and Diseases of the Eye. By EDWARD JACKSON, A.M., M.D., Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine; Member of the American Ophthalmological So- ciety ; Fellow of the College of Physicians of Philadelphia; Fel- low of the American Academy of Medicine, etc. etc. AND Essentials of Diseases of the Nose and Throat, By E. BALDWIN GLEASON, M.D., Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania; Assistant in the Nose and Throat Department of the Union Dispensary; Member of the German Medical Society, Philadelphia ; Polyclinic Medical Society, etc. etc. TWO VOLUMES IN ONE. PROFUSELY ILLUSTRATED. Price, Cloth, $1.00. Interleaved for Notes, $1.25. University Medical Mag- azine, Philadelphia, Octo- ber, 1890.—"Jackson and Gleason's Essentials of Dis- eases of the Eye, Nose, and Throat. — The subjects have been handled with skill, and the student who acquires all that here lays before him will have much more than a foundation for future work." New Yo;X- Medical Rec- ord, November 15, 1890. — "Jackson and Gleason on Diseases of the Eye, Nose, and Throat. — A valuable book to the be- ginner in these branches, to the student, to the busy practitioner, and as an adjunct to more thorough reading. The authors are capable men, and as successful teachers know what a student most needs." 24 Specimen of Eye Illustrations. No. 15. ESSENTIALS OP DISEASES OF CHILDREN. BY WILLIAM M. POWELL, M.D., Attending Physician to the Mercer House for Invalid Women, at Atlantic City, N. J. , Late Physician to the Clinic for the Diseases of Chil- dren in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diag- nosis in the Medical Department of the Uni- versity of Pennsylvania, and Chief of the Medical Clinic of the Phil- adelphia Polyclinic. Price, Cloth......$1.00. Interleaved for Notes .... 1.25. American Practitioner and News, Louisville, Ky., December 20,1890. "Powell's Diseases of Children.—This work is gotten up in the clear and attractive style that characterizes the Saunders' Series. It contains in appropriate form the gist of all the best works in the de partuient to which it relates.1' Southern Pkactittonek, Nashville, Tennessee, November, 1890. " Dr. Powell's little book is a marvel of condensation. Handsome binding, good paper, and d-ear type add to its attractiveness." Annals £~\$ '(Jj Medical Record, New York, £?i- f^^^fe^L August 23, 1890. 1$lfe\^' 18k > '^9B^.^/ '' Wolff 's Examination of 4m$rV \t •'••'■ w5>\.'7 Urine. — A good manual for students, well written, and answers, categorically, many questions beginners are sure to ask." Specimen of Illustrations. Memphis Medical Monthly, Memphis, Tennessee, June, 1890. "Wolff's Examination of Urine.—The book is practical in char- acter, comprehensive as is desirable, aud a useful aid to the student in his studies." 2U No. 18. ESSENTIALS OP PRACTICE OF PHARMACY. BY LUCIUS E. SAYRE, Professor of Pharmacy and Materia Medica in the University of Kansas. Price, Cloth, $1.00. Interleaved for Notes, $1.25. Albany Medical Annals, Albany, N. Y., November, 1890. "Sayre's Essentials of Pharmacy covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book." American Doctor, Richmond, Va., January, 1891. "Sayre's Essentials of Pharmacy.—This very valuable little manual covers the ground in a most admirable manner. It contains practical pharmacy in a nutshell." National Drug Register, St. Louis, Mo., December 1, 1890. "Sayre's Essentials of Pharmacy.—The best quiz on pharmacy we have yet examined." Western Drug Record, November 10, 1890. "Sayre's Essentials of Pharmacy.—A book of only 180 pages, but pharmacy in a nut-shell. It is not a quiz-compend compiled to en- able a grocery clerk to ' down' a board of pharmacy ; it is a finger- post guiding a student to a completer knowledge." 27 Saunders' Question-Compends. Iii Preparation. Ready about September 1, 1891. No. 17. Essentials of Diagnosis. No. 19 Essentials of Hygiene. ILLUSTRATED. By ROBERT P. ROBINS, M.D. No. 20. Essentials of Bacteriology. ILLUSTRATED. By M. V. BALL, M.D. No. 21. Essentials of Nervous Diseases and Insanity. ILLUSTRATED. By JOHN C. SHAW, M.D. No. 22. Essentials of Medical Physics. ILLUSTRATED. By FRED J BROCK WAY, M.D. Ko. 28. Essentials of Medical Electricity. ILLUSTRATED. By DAVID D. STEWART, M.D., and EDWARD S. LAWRENCE, M.D. OTHERS PREPARING. The Fiske Fund Prize Essay for 1890. THE SURGICAL TREATMENT OF Wounds and Obstruction OF THE INTESTINES. BY EDWARD MARTIN, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Sur- gery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hospital; Assistant Surgeon to the University Hospital, etc. etc. AND HOBART A. HARE, M.D., Professor of Therapeutics, Jefferson Medical College; Attending Physician to St. Agnes' Hospital. ILLUSTRATED. Price, Cloth.....$2.00, Net. " In presenting this Essay upon the Surgical Treatment of Wounds and Obstruction of the Intestines to the Trustees of the Fiske Fund, it is proper to outline the scope of our work, and to state briefly the facts and lines of original research upon which our conclusions are based. For over two years we have made experiments in the labo- ratory upon these subjects, and have carried out in every detail all the methods and modifications of operations that have been published or which have occurred to us in the course of our own studies. . . . In addition to the original work involved in studying so important a branch of surgery as the one before us (and which will be found represented, graphically, in part at least by a number of tracings), we have collected and placed before the reader what we believe to be the fullest statistics yet collected upon gunshot wounds of the abdo- men."—Extract from Pkeface. 29 INDEX. PAGE Announcement.........1 American Text-Book of Surgery . . . . 2, 3 vlerordt and stuart's medical diagnosis . . 4 Keating's New Unabridged Dictionary of Medicine 5 Saunders' Pocket Medical Lexicon . . . . 6 Nancrede's Anatomy and Manual of Dissection . 7 DeSchweinitz's Diseases of the Eye . . . .8 Garrigue's Diseases of "Women.....9 Norris' Syllabus of Obstetrical Lectures . . (J Saunders' Pocket Medical Formulary . . .10 Saunders' Series of Question Compends . . .11 Hare's Physiology........12 Martin's Surgery........13 Nancrede's Anatomy.......14 Wolff's Chemistry........15 Ashton's Obstetrics.......16 Semple's Pathology, etc.......17 Morris' Materia Medica......18 Morris' Practice of Medicine.....19 Cragin's Gynecology.......20 Stelwagen's Diseases of the Skin . . . .21 Martin's Minor Surgery, etc......22 Semple's Legal Medicine, etc......23 Jackson and Gleason's Diseases of Eye, Nosi;, and Throat.........24 Powell's Diseases of Children.....25 Wolff's Examination of Urine.....26 Sayre's Practice of Pharmacy.....27 Works in Preparation and in Press . . .28 Martin and Hare's Wounds and Obstruction of the Intestines........29 30 THF CLIMATOLOGIST. A MONTHLY JOURNAL OF MEDICINE DEVOTED TO THE Relation of Climate, Mineral Springs, Diet, Pre- ventive Medicine, Race, Occupation, Life Insurance and Sanitary Science to Disease. Edited by JOHN M. KEATING, M. D. FREDERICK A. PACKARD, M. D. CHAS. F. GARDINER, M. D. ASSOCIATE NORMAN BRIDGE, MD., Los Angeles, Cal. VINCENT Y. BOWD1TCH, M. D. Boston, Mass. SAML. B. BURROUGHS, M.D., Raymond, Tex. J. WELLINGTON BYEK8, M.D., Charlotte, N. C. J. M. DaCOSTA, M.D., Philadelphia, Pa. CHARLES DENISON, M.D., Denver, Colo. GEORGE DOCK, M.D., Galveston, Texas. WM. A. EDWARDS, M.D., San Diego, Cal. J.T. ESKRIDGE, M.D., Denver, Colo. S \MUEL A. FISK, M.D.. Denver, Colo. W. H. GEDDINGS, M.D., Aiken,S. C. JOHN B. HAMILTON, M.D., Chicago, 111. T. S. HOPKINS, M.D., Thomasville, Ga. FREDERICK I. KN1GUT., M.D., Boston, Mass. 11. L. MacDONXELL. M.D., Montreal, Canada. EDITORS: FRANCIS MINOT, M.D., Uoston.Mass. ALFRED L. LOOMIS, M.D , New York Cily. HENRY M. LYMAN, M.D., Chicago, Ills. WILLIAM OSLER, M.D., Baltimore, Md. WILLIAM PEPPER, M.D.. Philadelphia, Pa. BOARDMAN REED, MA)., Atlantic City. N. J. J. BEED, Jr., M.D., Co'orado Springs, Colo. GEORGE II. ROHE, M.D., Baltimore, Md. KAltL VON BUCK, M.D., Awheville, N. C. FREDK. C. SHATTUCK, M.D., Boston, Mass. S. E. SOLLY, M.D., Colorado Springs, Colo. G. B. THORNTON, M.D., Memphis, Tenn. E. L. TRUDEAU, M.D., Saranac Lake, N. Y. J, B. WALKER, M. D., Philadelphia. Pa. J. P. WALL, M.D., Tampa, Florida. J AMES C. WILSON, M.D., Philadelphia, Pa. Yearly Subscription $2.00. Single Numbers 20 Cts. W. B. SAUNDERS, Publisher, 913 Walnut Street, Philadelphia, Pa. EXTRACT FROM THE INTRODUCTION IN THE OPENING NUMBER OF "THE CLIMATOLOGIST." AUGUST, 1891. " The object of this Journal is to promote original investi- gation, to publish papers containing the observations and ex- perience of physicians in this country and Europe on all matters relating to Climatology, Mineral Springs, Diet, Preventive Medicine, Race, Occupation, Life Insurance, and Sanitary Science—and in that way to supply the means by which the general practitioner and the public at large will become better acquainted with the diseases of this country and Europe, and better armed to meet the requirements of their prevention or cure. The study of these subjects in this country is exciting great and increasing interest, and all admit that, from the little knowledge already possessed of its resources, possibly every known combination of atmospheric condition, soil, altitude, cli- mate, or mineral springs, is to be found on this continent. It is confidently expected that such 71 journal will receive encourage- \ ment and be an authority upon all questions which are included in its title. " Original papers upon diseases of localities—those incident to occupation, race, or climate, the study of epidemics, the questions of proper food, of the water supply, its potability and distribution, matters relating to drainage and diseases de- pendent on it—as well as experimental studies, or laboratory investigations on bacteriology, will form a prominent portion of the material presented during the year, and it is to be hoped that physicians of all sections of the country will send papers upon these or any other subjects which will be of general in- terest. " Special attention will also be paid to the subject of health resorts, descriptions of Sanitariums with special reference to their suitability to certain cases, and the proper selection ot patients likely to be benefitted by them. The utmost care will be taken that this Journal shall assume and maintain the highest scientific character. It will be absolutely independent in its principles—fair towards all. It will depend foi NI' 1SJIHN* " ,si imi.w ; k ■- —^---- ■* NATIONAL l. ^RY OF NLM005601736