A text-book on surgery; general, operative, and mechanical

Front matter

m

Cornell University Library

The original of tiiis book is in the Cornell University Library.

Chapter I

FAaE Surgical dressings — Ligatures and sutures — Preparation of material — Silk, silk-worm gut, silver wire — Antiseptic solutions — Corrosive sublimate, carbolic acid, iodoform, alcohol, chloride-of-zinc — Irrigators — Sponges — Drains: rubber, bone, catgut, and horse-hair — Protective — Carbolized, sublimated, and iodoformized gauze — Borated and absorbent cotton — Peat — Sawdust — Jute — Wood-wool 1

Chapter II

Bandaging— Materials and methods of preparing — Application of the various methods — Simple spiral, reverse spiral, figure-of-8 turn, figure-of-8 reverse — Hand and fingers — Forearm, arm, and shoulder — Toes, foot, leg, and thigh — Spica — Head and face — Knotted bandage — Handkerchief bandages .9

Chapter VI

Wounds — Process of repair — Cicatrization — The tourniquet — Closing wounds — The interrupted, oontimious, mattress, quill, wire, and pin sutures — Transfusion — Intra-venous injection of a saline solution — Poisoned wounds — Snake-bite — Tarantula-poison — Wounds by bees, wasps, hornets, and centipedes — Hydrophobia — Glanders — Malignant pustule — Bissection wounds — Erysipelas — Dermatitis — Erythema — Cellulitis — Tetanus — Shot-wounds 65

Chapter VII

Burnsandscalds— Skin-grafting— Frost-bite— Furuncle— Carbuncle— Ulcers— Gangrene— Dry or senile gangrene — Hospital gangrene 90 vi CONTENTS.

Chapter VIII. Page

Amputations — Method of operating— Circular solid flap, with perpendicular slit — Oblique solid fl^aps by transfixion — The same, by cutting from the surface inward— Skin-flaps — Circular method — Modified circular — Oval — Double crescentic — Double rectangular — Mixed flaps — Open method — Special amputations — Fingers- Hand — Forearm — Elbow-joint — Arm— Shoulder— Toes— Through the metatarsus— Through the tarsus— Methods of PirogofE, Chopart, Forbes, Hey, Lisfranc, Le Fort, Lignerolles, and Hancock— Tibio-tarsal disarticulation — Method of Syme— Leg — Method of Stephen Smith — Knee-joint— Thigh — Hip-joint — Method of Erskine Mason, etc 103

Chapter IX

Surgical diseases and surgery of the 'lymphatic vessels, veins, and arteries — Lymphangitis — Adenitis — Phlebitis — Arteritis — Arterial thrombosis and embolism — Vascular tumors — Arterial varix — Cirsoid arterial tumor — Angeiomata — Venous varix or varicose veins — Moles — Port-wine mark 158

Chapter X

Aneurism — Varicose aneurism — Aneurismal varix — Method of Tufnell and Valsalva — Ligature by the methods of Antyllus, Wardrop, Anel, Hunter, and Brasdor — Digital and mechanical pressure— Galvano-puncture, massage, flexion, introduction of wire, horse-hair, catgut, etc. — Aneurism of the thoracic aorta — Innominate — Common external and internal carotid arteries — Subclavian — Abdominal aorta— Iliac arteries — Femoral — Popliteal . . 198

Chapter XI

Ligation of arteries — Innominate — Common, external, and internal carotid and internal jugular vein — Superior thyroid, lingual, facial, ascending pharyngeal, occipital, posterior auricular, temporal, and internal maxillary — Subclavian — Vertebral and internal mammary— Axillary — Brachial — Radial — Ulnar — Intercostal^ Abdominal aorta — Iliac arteries — Gluteal, internal pudio, and sciatic — Femoral — Profunda femoris — Popliteal — Posterior tibial — Anterior tibial — Dorsalis pedis 230

Chapter XII

Surgical diseases and surgery of the bones — Ostitis — Osteo-periostitis — Osteomalacia — Rachitis — Fractures — Of the skull — Trephining — Nasal bones — Malar — Superior maxilla — Inferior maxilla — Clavicle — Acromion and coracoid process — Glenoid process — Spine of the scapula — Humerus — Condyles — Olecranon process — Ulna — Radius — Colles's fracture — Carpus — Metacarpus — Phalanges — Sternum — Ribs — Vertebrae — Sacrum — Coccyx — Os innominatum — Femur — Patella — Leg — Pott's fracture — Tarsus and metatarsus — Ununited fractures . 271

Chapter XIII

Surgery of the articulations — Dislocations — Lower jaw — Clavicle — Shoulder-joint — Elbow-joint — Wrist-joint — Carpo-metacarpal joints — Phalanges — Hip-joint — Knee-joint — Patella— Tarsus — Vertebrae — Ribs — Arthritis — Hip-joint disease, or morhus coxcb — Knee-joint disease— Ankle-joint— Shoulder-joint— Elbow-joint— Wrist-joint— Exsections of the joints . . . ■ 319

Chapter XIV

Regional surgery— The head— Tumors of the scalp — Abscess— Pneumatocele— Encephalocele — Meningocele — Neoplasms of the meninges — Hydrocephalus — Wounds of the scalp — Of the

CONTENTS. vii

PAGE

brain — Cerebral localization — Surgery of the face — Surgery and surgical diseases of the eyelids and of the orbital cavity (not including lesions of the globe) — Sebaceous tumors — Hordeolum — Chalazion — Blepharitis — Conjunctivitis— Ophthalmia neonatorum — Gonorrhceal ophthalmia — Symblepharon — Ectropion — Entropion — Ptosis — Trichiasis — Epiphora — Neoplasms of the orbital cavity — Surgery of the ear — The nose — Epistaxis — Foreign bodies — Rhinolites — Neoplasms — Deviation of the septum — Plastic surgery of the nose, lips, and cheeks — Lupus — Hare-lip — Cleft-palate — Cheiloplasty — Parotid gland and duct — Submaxillary gland — The jaws — Removal of tumors from the antrum of Highmore — The teeth — Palate — Staphylorraphy — Tongue and buccal cavity — Tonsils .... 373

Chapter XV

The neck — Wounds — Abscess — Tumors — Thyroid body — Thyrotomy — Laryngotomy — Laryngo-tracheotomy — Tracheotomy — Exsection of the larynx — Intubation of the larynx — Foreign bodies in the air-passages — Neoplasms of the larynx and trachea — Pharynx — CEsophagus — Foreign bodies— CEsophagotomy for stricture — New formations — CBsophagectomy 444

Chapter XVI

Thorax — Mammary gland — Mastitis — Abscess — Hypertrophy— Tumors — Exsection of the clavicle— Empyema — Wounds of the chest 465

Chapter XVII

Abdomen — Stomach — Gastrostomy — pylorectomy — Gastrectomy — Gastro - pyloreotomy — Gastro-enterostomy— Duodenum — Obstruction of the alimentary canal — Impaction of fecal matter — Foreign bodies — Intussusception — -Volvulus — Constriction by bands — Adhesions — Omental and mesenteric slits — Diverticula — Neoplasms — Stricture — True hernia — Abdominal section for intestinal occlusion — Exsection of the intestine — Fecal fistula — Enterocele — ^Epiplocele — Inguinal hernia — Congenital — Infantile — Femoral, umbilical, ventral, diaphragmatic, gluteal, obturator, lumbar, and vaginal hernia — Colostomy — Peritonitis— ^Abdominal abscess — Liver — Hepatic abscess — Hydatid cyst — Spleen — Wounds of the abdomen — Intestinal suture 477

Chapter XVIII

Rectum and anus — Atresia ani et recti — Pruritus ani — Foreign bodies— Pistulffi in ano et recto—Fissure—Ulcers— Stricture — Neoplasms of the rectum and anus — Neuralgia — Prolapsus— Haemorrhoids 538

Chapter XIX

Genito-urinary organs— Kidneys— Suppression of urine- Nephrotomy and nephrectomy— Ureters— Bladder — Wounds — Infiltration of urine — Cystitis— Paralysis — Incontinence— Neoplasms— The urine— Stone — Lithotrity — Lithotomy— Prostate body— Spermatorrhoea — Aspermatism— Urethra — Gonorrhoea — Balanitis— Posthitis — Gonorrhoeal rheumatism — G-leet— Strictur^—Meatomy— Internal urethrotomy— Dilatation — Modified internal urethrotomy— External urethrotomy or perineal section — Sounds — Foreign bodies in the urethra—Congenital and acquired malformations — Neoplasms — Cancer of the penis — Amputation— Humphrey's operation — Phimosis — Circumcision — Dilatation of the prepuce — Ulcers of the penis— Syphilis— Scrotum— Hydrocele-Varicocele— Epididymis— Testicle — Hysterotomy — Hysterectomy — Ovariotomy 555 viii CONTENTS.

Chapter XX

Deformities of the spine — Torticollis — Lateral and rotary-lateral curvature — Scoliosis — Cyphosis— Spondylitis— Spina bifida — Deformities of the lower extremity — Preternatural mobility of the hip — Subrtroohanteric osteotomy — Genu valgum — Genu varum — Talipes — Polydactylus—Syndactylus— Hallux valgus— Hammer-toes — In-growing Nail — Deformities of the upper extremity — Club-hand — Web-finger — Snap-flnger 691

Chapter XXI

Tumors — Carcinoma — Epithelioma — Lymphadenoma — Sarcoma -— Papilloma — Adenoma — Cysts — Lipoma — Fibroma — Myxoma — Myoma — Neuroma— Angioma — Lymphangioma — Chondroma — Osteoma 746

TEXT-BOOK O]^ SURGERY,

Chapter I. Sueghoal Dkessing8

The materials used in the performance of a surgical operation, and in its after-treatment, form such an important part of the surgeon's outfit that I have determined to devote the initial chapter of this book to a description of the methods of preparing and preserving the apparatus needed for dressing wounds in the antiseptic practice of to-day.

This practice, which embodies the great principles of cleanliness and carefulness in surgery, is now so well established among the best surgeons in America and Europe that any argument in its favor, as compared with the methods of one or two decades ago, I consider to be wholly unnecessary.

Ligatures and Sutures. — Catgut, silk, silk-worm gut, and silver wire Tvill meet every requirement in tying vessels and closing wounds. Catgut has practically superseded all other substances as a ligature. The conditions which would justify the application of a silk, metal, or any nonabsorbable ligature to an artery are rarely present. Strings or cords made from animal tissues, as buckskin, ox-aorta, nerve, tendon, and whalebone, known under the general name of "broad ligatures," have been successfully employed in the occlusion of the larger vessels, but their use is limited in comparison with that of the violin-strings, which are easily obtained, prepared and preserved, and are, moreover, cheap.

In the preparation of catgut select four sizes of the best quality of violin- strings in about this proportion : one dozen each of the E and A strings, six D strings, and two or three harp-strings about twice as large as that of D, violin. The smaller sizes are most generally needed for the smaller vessels and bleeding points, the D string is best adapted to vessels as large as the radials, ulnars, or tibials, while the larger or harp-strings should be used upon the iliacs, subclavians, common carotids, and femorals.

Preparation. — Cut and remove the small red threads which are tied around each bunch, and place the catgut in a glass bottle or jar which 1

A TEXT-BOOK ON SURGERY.

Fig. 1.

contains enougli pure oil of juniper -terries to completely cover them. The vessel should be tightly corked to prevent evaporation. Within twenty-four hours the material is safely aseptic, and will remain so indefinitely if kept immersed in the fluid. The strength of the gut is not impaired, while its firmness is increased by the oil.

If oil of juniper can not be obtained, 95 per cent alcohol is equally aseptic, and may be used instead. Alcohol, however, softens the strings more than juniper, and is not to be preferred. Fig. 1 represents a convenient apparatus for holding these ligatures. It consists of a glass jar or bottle, with a wide mouth, in which a perforated cork is fitted. Within the bottle are several glass spools upon which the ligatures have been wound. The ends project through the perforation in. the cork, and are held here by a smaller cork fitted into the perforation. Upon removing the smaller plug, the threads may be drawn out and cut off as required. Another vessel is pictured in Pig. 2. In this the ligatures are wound around a central shaft, which is pulled completely out of the bottle when the threads are needed.

Macewen has introduced a chromic-acid catgut ligature, which resists absorption much longer than juniper or alcohol gut. His method is : chromic acid one part, water five parts (by weight). To one part of this solution add twenty parts of glycerin, and allow the violin-strings to remain immersed for seven or eight months. They are then preserved in carbolic acid one part, to glycerin ten (1 to 10). Thus prepared, catgut will resist absorption from twenty to sixty days.

kilk is invaluable for sutures. It is not to be used for ligatures, except in certain operations within the abdominal cavity, or in wound* which are to be treated by the open method. This material should be selected of all sizes. I prefer the twisted to the braided threads, although the latter is less likely to become tangled. The very finest hlacTc iron-dyed silk is needed in the plastic surgery of the neck and face, in the white individual. White sutures often become so discolored that they are with difliculty found when the time for their reinoval arrives. The larger silk sutures, such as those employed in tying haemorrhoidal masses, should be so strong that any ordinary force can not break them. All silk threads should be kept dry, and well wrapped in protective or oil-silk, or corked in jars. A half -hour before using them they should be soaked in a 5-per-cent solution of carbolic acid.

Silk-worm gut comes in bristles, or stiff threads, about ten inches in length. It may be used as a suture in any part of the economy, but it is essential only in the operation for cleft palate. It is not absorbable, is very strong, ties easily, and does not slip. It should be kept in an ordiflG. 2.

SURGICAL DRESSINGS. 3

nary dry box, and need not be rendered aseptic for operations on the palate.

Silver wire is invaluable as a suture-material. Beyond tbe operations upon the genito-urinary organs of the female, where it is indispensable, it is preferable to silk in many wounds of other portions of the body. The sizes most required range from Nos. 24 to 31, inclusive. A most convenient way of carrying sUver for immediate use is to cut it in pieces about ten inches in length, and place it in a metal cylinder (Fig. 3), which is divided into three or four compartments, and closed by a screw-top. Or the wire loops maybe wrapped in protective or blotting-paper, and thus kept free from moisture in order to prevent rust. They are rendered aseptic by immersion in 1 to 20 carbolic acid one half-hour before using them.

Solutions. — For irrigating wounds, submerging instruments, and disinfecting in general, solutions of corrosive sublimate and carbolic acid are necessary, and pure alcohol, iodoform, and chloride-of-zinc solutions may at times be used.

Koch has demonstrated that, as a germ-killer, corrosive sublimate excels aU known agents. The sublimate solutions vary in the proportion of one part of the bichloride to five hundred parts of distilled water by weight, or 1 to 500, 1 to 1,000, 1 to 3,000, 1 to 3,000 for use outside of the great cavities, and 1 to 8,000, 1 to 15,000, and 1 to 20,000 within the cavities.

The sublimate solutions are only used for irrigation and for disinfecting the hands, sponges, and gauze. All instruments are submerged in carbolic-acid solutions or in alcohol.

The stronger solutions, 1 to 500 and 1 to 1,000, are rarely employed in irrigation, and then only when the part exposed has been made bloodless by the Esmarch bandage. Even when thus employed for the disinfection of an abscess cavity, ulcer, or sinus, the excess of sublimate should be immediately washed away by flooding the part with the 1 to 3,000 solution. In any ordinary operation no stronger sublimate than 1 to 3,000 will be required ; a 1 to 10,000 solution may be used in the peritoneal or thoracic cavity where the conditions are such that the fluid may run out or be removed at once by sponges. I have filled the entire abdominal cavity ^lo- swith warm sublimate, 1 to 18,000, mopping it out with sponges, and repeating this procedure three times without any bad symptom resulting.

For convenience, any required solution may be made from the following : Corrosive sublimate, gr. xxx ; water and glycerin, each, | ss. Some add to this about gr. x of table-salt. One teaspoonful of this solution added to a pint of water approximates 1 to 2,000, Water containing lime should not be used. Tablets of corrosive subKmate are now maiiufactured, and are very convenient for transportation. Each tablet contains

A TEXT-BOOK ON SURGERY.

Fia. 4. — Weir's antiseptic spray-machine.

enoTigh, sublimate to make, when dissolved in a pint of water, a 1 to 1,000 solution. It is best to make fresh solutions when needed, for, unless kept tightly corked and away from light, they deteriorate in value.

Garbolic acid (1 to 30, or a 5-per-cent solution) is employed for the cleansing and submersion of all instruments used in a surgical operar

tion. It is not used in irrigation on account of its irritating properties.

The steam and carbolic spray so much in vogue a few years since is now only used to lay the dust, or as an aid toward the more thorough cleansing of operatingrooms and wards which are especially exposed to infection. The spray-machine (Fig. 4) is started one half-hour before the operation is to commence, and is allowed to run until that time. The strength of the solution in the bottle is 1 to 20.

As ordinarily sold, carbolic acid is dissolved in alcohol, and is about 95 per cent strong. In this condition an ounce by measurement is an ounce by weight. To this quantity add glycerin f j, and water Sxix, which will make a 1 to 20, or 5-per-cent solution. All instruments are immersed in this solution a half-hour before the operation, except the blades of the knives, which should be dipped in only a minute or two before being used.

Pure alcohol is also used for this purpose by some operators who dislike the benumbing effects of the acid.

Iodoform, one part dissolved in seven parts of etheT, is used at times to wash the parts where an operative wound is to be made. It is not an uncommon practice with some of the German surgeons to immerse all the ligatures and suture-material in this solution for about twenty minutes before the operation is begun.

Ohloride-of-zinc solution in water (1 to 12, about 8 per cent) may be used to wash out ulcers or old sinuses which are in the neighborhood of, or communicate with, the wound of operation. This and the iodoform solution are not, however, essential, and are now rarely employed.

Irrigators. — A rubber bag, capable of holding two quarts of solution, with extra long tubing attached, makes a convenient irrigator for use and transportation. The ordinary fountain-syringe, represented in Pig. 5, is commonly used. The nozzles should be of smooth glass, sufficiently heavy to resist breakage, about three or four inches in length, not more than a quarter of an inch in gross diameter, slightly pointed, and with a lumen of one eighth of an inch. Sublimate solution should not be allowed to remain in contact with rubber for any considerable time on account of

SURGICAL DRESSINGS.

its corrosive action. When an operation or dressing is completed, after the sublimate escapes, pure water should be run through the irrigator.

A good emergency irrigator is shown in Pig. 6. It is made by placing a perforated cork in an ordinary wine-bottle, fitting a piece of glass tube, or cane, or goose-quill into the perforation to which the rubber hose is attached. The bottom of the bottle is broken

FiQ. 6.— (Esmaroh.)

Pig. 5.

in, and a string netting, thrown around for, suspension, completes the apparatus. If there is no stop-spring to shut off the flow, it may be readily arrested by placing the nozzle in the upper end of the bottle. The assistant who attends to the irrigator can always regulate the flow by slight pressure of the tube between the thumb and finger, just where the nozzle is attached. Tin or brass vessels may also be employed, but the corrosive action of the mercury soon destroys the metal.

When no irrigator can be had, the sublimate solution may be poured on from a pitcher or cup.

For continuous irrigation, as in an amputation treated by the open method, a constant dripping may be secured by twisting a piece of musUn or cotton cloth into a loose wick-like string, moistening it, and placing one end in a vessel holding the solution, while the other hangs over the edge from a point where the fluid wiU fall on the wounded surface (Pig. 7).

Bponges. — In selecting sponges, secure those of softest and finest texture, measuring, when dry, from one to two and three inches in diameter, the greater number spherical in shape, with a half-dozen flat pieces a half -inch thick, three or four inches wide, and from six to ten inches long. When purchased in the rough they should be thoroughly whipped until all the sand is removed, and then washed in cold or lukewarm

A TEXT-BOOK ON SURGERY.

water. Two methods may be employed for bleaching. The simpler way is to soak them for from six to eighteen hours in a mixture of one part

Fig. 7.

of Uquor sod«e chlorinatjB to five of water, rinse them in clear cold water, and dry thoroughly. A more complicated but very efficacious method is the following :* Place the sponges in a solution of permanganate of potassa, 1 to 100 (about gr. v- § j of water), for one half -hour ; rinse in clear cold water, squeeze thoroughly, and immerse them in a solution of oxalic acid (1 to 50) for ten minutes. Rinse again in clear water, leave them there for one hour, and then dry quickly in a warm oven. Sponges may be kept dry either in tightly corked glass or stone jars, or wrapped up in protective, and put away in a clean drawer. They may also be kept indefinitely in a 1 to 30 carbolic-acid solution, but should not be kept any length of time in sublimate solution, f When a sponge has been once used it should be destroyed, unless the circumstances are such that other and fresh pieces can not be obtained for a succeeding operation. Even under such conditions, if they have been brought in contact with septic matter, it should be imperative to destroy the sponges and proceed without them, using clean cloths, or towels, or borated or absorbent cotton in their stead.

To cleanse sponges which have been used, wash them thoroughly in different changes of warm water (not hot), and, when they no

* To Mr. Angelo, druggist, of Fonrth Avenue and Thirty-first Street, New York, I am indebted for this formula.

f Mr. Charles G. Am Ende, 168 Washington Street, Hoboken, New Jersey, prepares sponges that are soft, clean, and very satisfactory, as well as cheap.

SURGICAL DEESSINGS.

longer discolor clear water, immerse them in 1 to 500 sublimate for one hour.

In all operations, sponges, before being used in the wound, should be dipped in 1 to 3,000 sublimate solution, and then squeezed as dry as possible.

Drains. — Rubber tubing, Neuber's bone drains, and twists of catgut or Tiorse-hair, are chiefly to be relied upon in draining wounds. Rubber is most generally useful. The softest tubing should be selected, of various sizes, from that which has a lumen of one half -inch in diameter down to one sixteenth. Before it is inserted it should be bent over the finger, and with a pair of curved scissors clipped full of holes about a half -inch apart, as seen in Fig. 8. Rubber drains should be kept dry in clean jars, from which they are taken and placed in 1 to 30 carbolic acid solution when the operation for which they are needed is begun. When a wound is to be dressed only once — the "permanent dressing" — absorbable animal drains should be inserted. For this purpose Neuber's bone tubes (Fig. 9) are preferable. They are made from the bones of young and healthy animals. The crude bone is cut of proper length and size, bored out, turned on a lathe round and smooth, and perforated laterally. Immersion in 33- per-cent muriatic acid for twelve hours completely decalcifies them, after which they are kept (as recommended by the inventor) in 1 to 20 carbolic-acid solution, frequently renewed. I prefer to keep them in alcohol, 95 per cent, or oil of juniper, which preserves them aseptic and hardens them, rendering a too rapid absorption less likely. The tubes are from three to five inches long. There are four sizes : the caliber of No. 1 is six, No. 2 is five. No. 3 is four, and No. 4 three millimetres in diameter (one millimetre is approximately ^ of an inch). The walls are from one to one and a half millimetre in thickness.

These drains can be prepared readUy from the bones of fowls by scraping the periosteum off and the marrow out, soaking in muriatic acid (33-per-cent solution) as above, and then in ether for a few hours before transferring them to the alcohol.* Bone drains will be absorbed in from five to twenty days, and are excellent in permanent dressings.

Catgut or Tiorse-Tiair twists or skeins are at times employed for draining small wounds, and are very satisfactory. The violin-strings are twisted into a bunch, as shown in Fig. 10, and laid in the wound atvari-

Fig. 8.

* If the bones used are from fowls which have been cooked, Macewen recommends that the hydrochloric-acid solution should be one to five of water, and that the tube, when in-, serted into the wound, should be threaded with horse-hair to prevent coUapse from pressure, and to facilitate the removal of clots without taking out the tube and irritating the wound.

ous points, so as to project at the lower angles or in such positions as will secure the most perfect drainage. The hair is taken from the mane or tail, washed clean, and immersed for twenty-four hours in oil of juniper. It is twisted in the same manner as the catgut.

Protective. — Thin rubber tissue, oilrsilJc,. or Mackintosh cloth, maybe used to protect the part from atmospheric changes, and to prevent the evaporation and volatilization of the antiseptic agents. The former is preferable, and the oil-silk is next in order. Rubber tissue must be kept in a cool, dry spot, and should be dipped in 1 to 3,000 sublimate before it is applied.

Gauze. — Ordinary cotton muslin of light texture, commonly known as cheese-cloth, impregnated with corrosive sublimate or iodoform, is widely used as antiseptic gauze.

Garholized gauze has passed out of use.

To make sublimate gauze proceed as follows : Cut a bolt of cheese-cloth into pieces a yard long, and place in boiling water for eight hours. Then rinse thoroughly in cold water, and bleach in liquor sodse chlorinatse (one part to five of water) for twenty-four hours. Rinse again in clear water, and leave the cloth in a tightly covered jar or tank of 1 to 500 sublimate indefinitely. When the gauze is about to be used, squeeze the water out of it and wet it in fresh 1 to 3,000 solution, and again squeeze it until it is only fairly moistened, not dripping, with the solution. Am Ende' s sublimate pink gauze is an excellent preparation. It is stained with eosine, which is a cOlor-test upon the purity of the gauze, for, if the mercury is decomposed or volatilized, the eosine goes with it and the gauze is left white.

lodoformized gauze is made by moistening the washed cheese-cloth in 1 to 3,000 sublimate, sprinkling it with powdered iodoform from a. pepper-box, and then working the powder into the meshes of the cloth until it is a golden-yellow color. It should be made fresh, although it may be preserved for one or two weeks in tight glass jars, wrapped in red or blue paper to prevent the decomposition of light.

Borated absorbent cotton is now almost indispensable in surgical practice. It is used not only to protect the part and to exercise compression, but, for purposes of cleansing and dressing wounds, it has entirely superseded sponges, and is not only cheaper, but preferable in every respect. It is so difficult to prepare, however, that the practitioner is almost compelled to patronize the manufacturer. When an emergency demands it, ordinary ginned cotton of clean fiber may be bleached and softened by treating it in the same way as given for the cheese-cloth. It can be charged with boracic acid by immersing it in a solution containing gr. XV to 5 j of water. It is then dried and wrapped in protective until needed for use.

WeU-prepared borated cotton is, next to gauze, the most suitable absorbent of discharges from wounds. Beyond these two substances nothing is really needed. Pads or bags of peat, sawdust, jute, wood-wooly etc., are practically useless.

CHAPTER II. BANDAGINa

Bandages are employed in surgical practice to retain dressings in position, to secure compression and support to any portion of the body, to maintain any required degree of immobility, and to render an extremity partially or completely bloodless.

They are made of cotton muslin of various degrees of fineness, crinoline, woolen goods, and India rubber. Cotton bandages are most generally employed, but, on account of the greater elasticity of flannel, these are preferable for certain special dressings. Crinoline is only used for plaster-of -Paris bandages. Martin's rubber bandage and Esmarch's bloodless tourniquet are very useful in maintaining the firm compression of a* part, either as a means of support or of emptying the vessels.

The muslin should be soft, not starched, and of two kinds — a fairly heavy quality, and the light cheese-cloth. Both should be cut in pieces from eight to ten yards in length. The former can be torn ; the latter must be cut. The selvage edge is removed, and the cloth divided into strips varying in width from four, three, two and a half, and two inches, with some one inch or less in width. For the chest and abdomen the wide bandages are needed, the two- and three-inch strips for the arms, legs, head, and neck, and the narrow strips for the hands and fingers. All the loose raV-elings along the edges should be pulled off, and the bandages made into compact, smooth rollers.

Bandages may be rolled by hand, yet it is a tedious and tiresome business, and an utter waste of time, when the work can be better and more rapidly done by machinery.

In Fig. 11 is pictured a bandage-roller, simple in construction and cheap. It should be fastened to the edge of a solid table by screws or movable clamps. The end of the strip to be wound is passed in and out over the four bars at the base and apex of the machine, and then fig. ii.