Emergencies of a general practice

Front matter

EMERGENCIES

OF A

GENERAL PRACTICE

Preface

The scope of this book is expressed in the title. The author has attempted to record some of the observations and practical experiences of a somewhat active service of forty years in emergency practice, the class of work where the attending physician is called on to think quickly and to act with rapidity and good judgment. Reference is also made to certain pathologic conditions, appendicitis, tubal rupture, acute pancreatitis, etc., emergency cases though distinctly surgical. The general practitioner should be familiar with the clinical symptoms of these conditions, the prompt recognition of which will not only tend to relieve him of personal responsibility, but will enable him to insist upon surgical assistance at a time most opportune to his patient.

Amputations, fractures, and dislocations are considered strictly from an emergency standpoint, or physician's first aid. Special forms of amputation and the more modern classical bone surgery are not alluded to, due to the many excellent textbooks on these subjects. The object of the author is to consider the common, unheralded, everyday accidents or emergencies that may and do arise to confront the general practitioner at a time when least expected. Definite information along this particular line is limited, not obtainable from textbooks, and certainly not available in time of great need; therefore the author feels that a work of this character devoted exclusively to this subject will prove of practical value and material assistance to many practitioners.

Nathan Clark Morse.

Eldora, Iowa.

41 25"25

Chapter I

Preliminary Remarks, Emergency Instruments, Employment of Adhesive Plaster in Wound Dressings

Preliminary Remarks, Emergency Instruments, Employment of Adhesive Plaster in Wound Dressings, 17; Asepsis, 21; Closure of Wounds, 23; Adhesive Plaster, 24.

CHAPTER II Removal of Foreign Bodies

Foreign Bodies in the Nasal Passages, 28; Foreign Bodies in Pharynx, 30; Foreign Bodies in the Larynx and Trachea, 34; Foreign Bodies in the Ears, 42; Foreign Bodies in Urethra and Bladder, 44; Foreign Bodies in the Eye, 45; Foreign Bodies in the Rectum, 49; Foreign Bodies in the Stomach, 51.

Chapter III

Treatment of Asphyxiation From Drowning, Smoke, Gas, Electric Shock. Description of Mechanical Devices for Artificial Respiration

Drowning, 54; Mechanical Devices for Artificial Respiration, 61; Poisoning from Carbon Monoxide Gas, Illuminating Gas, etc., 74; Crile's Method of Direct Transfusion of Blood in Asphyxia from Gas and Smoke, 81 ; Resuscitation from Electric Shock, 82 ; Treatment of Electric Burns, 86 ; Lightning, 87 ; Suffocation, 88; Sewer Gas Poisoning, 90; Ammonia Gas Poisoning, 91.

CHAPTER IV Surgical Emergencies

Surgical Shock, 93 ; Wounds, 98 ; Nonpenetrating Wounds of the Abdominal Wall, 106; Abdominal Contusions with Injury to the Intestines, 106; Gunshot and Stab Wounds of the Lungs, 112; Gunshot and Stab Wounds of the Liver, 115; Nonpenetrating Wounds of the Liver, 117; Icterus, or Jaundice, 119; Penetrating Wounds of the Abdomen, 121 ; Penetrating Wounds of the Stomach, 125; Puncture Wounds of the Bladder, 126; Stab Wounds of the Neck, 127; Wounds of the Rectum and Anus, l.'JO; Bruises and Sprains, 130.

CONTENTS

CHAPTER V Surgical Emergencies (Cont'd)

Acute Appendicitis, 134; Peritonitis, 137; Tubal Rupture — Ectopic Gestation, 139; Strangulated Hernia, 143; Intestinal Obstruction, Intussusception, Volvulus, Meckel's Diverticulum, 145; Epistaxis, 147; Treatment of Wounds, 150; Scalp Wounds, 152; Wounds of Tongue, 154; Wounds of the Face and Lips, 155; Indentures of the Skull, 156; Tendons, 157; Injuries of the Knee, 158; Injuries of Scrotum, 163; Prolapsus Ani, 164; Paraphimosis, 165; Phimosis, 165; Puncture Wounds of the Uterus, 166; Puncture Wounds from Nails, Glass, Fishhooks, etc., 167; Injuries of the Ear, 169; Injuries to the Eyes from Mortar, Lime, Plaster, and Other Combinations of Lime and Sand Used for Building Purposes, 170; Removal 'of Gunpowder, Percussion Cap Particles, Torpedoes, etc., 171; Penetrating Cuts or Wounds of the Eye, 172; Injuries to the Eyelids, 173; Wounds of the Eyelids, 174.

CHAPTER VI Medical Emergencies

Hemoptysis, 176; Diabetic Coma, 181; Cerebral Hemorrhage, or Apoplexy, 182; Angina Pectoris — Neuralgia of the Heart, 186; Acute Indigestion, 188; Intestinal Colic, 189; Renal Colic, 191; Biliary Colic, 192; Laryngitis Stridulosa, 193; Ophthalmia Neonatorum, 194; Hiccough, 196.

CHAPTER VII Miscellaneous Emergencies — Paraffin Method of Treating Burns

Ptomaine or Food Poisoning, 199; Ivy Poisoning, 207; Powder Burns or Stains, 208; Burns and Scalds from Fire, Gasoline, Kerosene, Steam, or Boiling Water, 209; Paraffin Method of Treating Burns, 214; Isolation, or Thermic, Fever, 218; Trichiniasis — Trichinosis, 223; Rabies— Hydrophobia, 224; Tetanus, 227; Convulsions of Children, 223; Exposure to Cold — Frost Bites, 235; Snake Bite, 237; Stings: Bee, Wasps, Hornets, Yellow Jacket, Scorpion, etc., 238; Bites of the Dog, Cat, Hog, Rat, Skunk, Weasel, and Other Animals, 241; Retention of Urine, 242; Extraction of Teeth, 244.

CHAPTER VIII Fractures and Dislocations

Fractures, 251 ; Ordinary Fractures and Their Treatment, 251 ; Fractures of the Skull, 25(>; Fracture of the Nose, 259; Fracture of the Malar, or Cheek, Bone, 261; Fracture of the Inferior Maxilla, 2b"2 ; Fracture of the Scapula, 268; Fracture of the Clavicle, 270; Fractures of the Arm, 275; Fractures of the Radius and Ulna, 279; Fracture of the Olecranon Process of the Ulna, 289;

CONTENTS

Fracture of the Ribs, 289; Fractures of the Femur, 291; Fracture of the Patella, 297; Fractures of the Tibia or Fibula, 29S; Pott's Fracture of the Ankle, 305; Compound Fractures and Dislocations, 307; Dislocations, 309; Dislocations of the Inferior Maxilla, 309; Dislocation of the Clavicle, 310; Dislocation of the Humerus, 310; Simple Method of Reduction of Shoulder Dislocations, 312; Dislocation of the Elbow, 316; Dislocation of the Wrist, 317; Dislocation of the Fingers, 318; Dislocations of the Hip Joint, 319; Dislocations of the Knee Cap, or Patella. 322; Dislocations of the Knee Joint, 323; Dislocation of Ankle Joint, 324; Dislocation of the Cartilage of the Knee, 325; Dislocation of Tarsal Bones, 326.

CHAPTER IX Amputations

Amputations, 328 ; Time of Operation, 329 ; Method of Amputation, 329 ; Amputations of the Forearm, Arm, and Shoulder, 331 ; Amputation of the Wrist, 333 ; Amputation of the Fingers, 334 ; Buzz Saw Accidents, 335 ; Amputation of the Leg, 338; Amputation of the Thigh, 341; Amputations of the Hip, 343.

CHAPTER X Obstetric Emergencies

Abortion, 346; Retention of the Placenta, 348; Cesarean Section, 350; Placenta Previa, 354; Mechanical or Forceps Delivery, 357; Inversion of the Uterus, 363; Postpartum Hemorrhage, 365; Uterine Hemorrhage in Young Girls, 367; Rupture of the Uterus, 367; Puerperal Eclampsia, 369; Prolapse or Presentation of the Umbilical Cord, 372.

CHAPTER XI Poison from Drugs Used as Medicines

Poisoning from Acetanilide, Antifebrin, Antipyrine, or Phenacetin, 374; Poisoning from Aconite — Aeonitine, 375; Aniline, 376; Alcoholic Poisoning, 377; Poisoning from Belladonna, or Atropine, Hyoscyamus, Hyoscy amine, Stramonium, Daturine, Dulcamara, Solanine, Duboisia, or Duboisine, 382; Poisoning from Bismuth Subnitrate, 383 ; Poisoning from Chloral Hydrate, 386; Poisoning from Calabar Bean, Physostigma, Physostigmin Sulphate, Eserine, -387; Poisoning from Cocaine, 387; Poisoning from Chloroform and Sulphuric Ether, 389; Poisoning from Croton Oil, 389; Poisoning from Digitalis — Digitalin (Foxglove), 391; Poisoning from Oil of Tansy, Oil of Savin, Oil of Pennyroyal, Oil of Dog Fennel, etc., 392; Poisoning from Opium, Laudanum, or Tincture Opium, Paregoric, Morphine Sulphate, Morphine Acetate, Codeine, Dionin, Heroine, Cannabis Indica, etc., 393; Poisoning from Aspidium, or Male Fern, 396; Poisoning from Phenol, or Carbolic Acid, 397; Lysol Poisoning, 400; Poisoning from Quinine, 400; Santonin Poisoning, 401; Poisoning

CONTENTS from Strychnine and Nux Vomica, 402 ; Poisoning from Salicylic Acid, Sodium Salicylate, Aspirin, Ammonium Salicylate, Strontium Salicylate, Salol, etc., 403; Poisoning from Sulphonal, Trional — Paraldehyde, 404; Poisoning from Veratrum Viride (American Hellebore), 405; Poisoning from Veronal, 406; Poisoning from Wormwood, Artemisia, Absinthium, 407.

CHAPTER XII Poisoning from Acids and Alkalies, and Ordinary Poisons

Preliminary Remarks, 408; Poisoning from Acids, 410; Burns from Acids, 412; Poisoning from Alkalies, 413; Poisoning from Antimony: Tartar-Emetic • — Butter of Antimony, 415; Poisoning from Emetine Hydrochloride, 417; Poisoning from Arsenic, 418; Poisoning from Bromine, 422; Poisoning from Bromoform, 423; Poisoning from Castor Oil Beans or Seeds, 423; Poisoning from Copper — Blue Vitriol, Verdigris, etc., 424; Poisoning from Ink or Writing Fluid, 425; Poisoning from Indelible Ink., 426; Poisoning from Jequirity — Wild Licorice, 427; Poisoning from Kerosene* — Coal Oil, 427; Poisoning by Mercury, 429; Poisoning from Calomel, 429; Poisoning from Corrosive Sublimate, 430; Poisoning from Oxalic Acid, 435; Tobacco Poisoning, 437; Poisoning from Wood Alcohol, 438; Poisoning from Formaldehyde, 441.

1. Leather grip for emergency outfit 19

2. Aseptic operating case 19

3. Applying sterile gauze to a wound of the forearm 22

4. Sterile dressings held in place by adhesive strips 22

5. Handy-Fold package. Gauze laid over wound 23

6. Actual sizes B & B dermal sutures 24

7. Insertion of skin suture 24

8. Method of applying a unilateral adhesive plaster support of the

thorax, either for pleurisy or fixation of injured or fractured ribs 25

9. A very convenient and unique head bandage, reinforced by ZO plaster 26

10. Method of dressing boils, carbuncles, etc., on back of neck 26

11-12. Showing use of zinc oxide adhesive plaster 27

13. Noyes' alligator action forceps 29

14. Tyding's forceps 31

15- A. Luer's throat forceps, alligator action, opening antcroposteriorly . 32

15-B. Fraenkel's plain throat forceps . . . . • 32

17. Ferguson's bristle probang 33

18. Trousseau's esophageal dilator 36

19. Faueher's soft rubber stomach tube with funnel end 36

20. Laryngoscope and mouth lamp 36

21. Tobold's throat forceps, with six attachments 37

22. Brophy's retractor 38

23. Weitlaner's retractor 38

24. Luer's tracheotomy tube 39

25. Laryngoscopic set 40

26. Modification of Killian's tracheoscope 41

27-28. Types of electric head lamps 42

29. Hartmann's ear forceps 43

30. Braasch's direct catheterization cystoscope 45

31. Taking a foreign body out of the eye 47

32. Wheeler's corneal curette 48

33. A popular method of dressing the eye after removal of foreign bodies 48

34. Polk's placenta forceps 50

35. Articles found in stomach of an insane patient 52

36. Author's method of removing water from the stomach and lungs . . 57

37. Illustrating the Sylvester method of artificial respiration .... 57

38. Sylvester method, second position, forcing the air from the lungs . . 59 ,'59. Sylvester method of expelling fluid from stomach and lungs ... 59 40. Shafer, or prone, method. Inflating the lungs 60

41. Shafcr's method of expelling the air from the lungs 60

42. Method of attaching oxygen generator to lungniotor 61

43. Lungniotor and oxygen generator in use 64

44. Oxygen generator of lungmotor 65

45. Showing throat tube in place in throat, and inflated to fit the throat 66

46. Tongue forceps shown on tongue, which is well drawn forward . . 67

47. The life motor 70

48. Draeger type of breathing apparatus 71

49. Mine rescue 73

50. Schiifer method of artificial respiration 84

51. Schafer method of artificial respiration 85

52. Severe type of electric burn 86

53. Meinecke's hypodermoclysis apparatus 95

54. Meinecke drop attachment 96

55. Murphy-Magnuson 's saline solution apparatus 97

56-57. Crushing injuries to feet sustained beneath car wheels .... 99

58. Carrel's apparatus for administering Dakin 's solution .... 102

59. Gunshot wound of face — Carrcl-Dakin method of treatment . . . 103

60. Gut resected 110

61. Murphy button dropped into end of gut 110

62. Lateral anastomosis with Murphy button Ill

63. Gunshot wound of chest and arm 113

64. Illustrates a half spica retentive bandage for breast dressing follow-

ing injuries of the chest or liver 114

65. Stab wound exposing a portion of the liver 116

66. Fatal stab wound of the neck 128

67. Temporary method of controlling hemorrhage from veins in the neck 128

68. Proper position for foot in applying Gibney dressing 131

69. Gibney ZO dressing complete 131

70. Appendicitis complicated by adhesions 135

71. Diseased appendix showing needle found therein 136

72. Ectopic pregnancy 140

73. Adhesions following ectopic gestation and rupture of tube .... 142

74. Curtis' nasal speculum 148

75. Convenient lamp condenser and mirror for nose and throat treatment 149

76. Student's lamp, for oil, adapted for condenser 149

77. Nasal gauze packer 150

78. Ordinary scalp wound prepared for suture 152

79. Recurrent bandage of the injured side of head 153

80. An excellent method of dressing scalp wounds 153

81. Fixed dressing of finger 157

82. A gunshot wound of the knee joint in a young man 159

83. Gunshot wound of the knee 159

84. Senn's method of draining an infected knee joint 161

85. Showing 38 caliber bullet in knee joint 161

86. Modified Cabot splint 162

87. Splinter forceps 168

88. Esmarch's tourniquet 168

89. Politzer's ear operating instruments 209

90. Extensive scald from bursting of steam pipe (before treatment) . 210

91. Serious burns from gasoline, following explosion of stove .... 211

92. Extensive scald from steam 212

93. Freshly burned area 214

94. Douching the burn with Dakin's solution 216

95. Drying the wound with the electric hot-air drier 216

96. Paraffin atomizer 217

97. Application of paraffin with brush 217

98. Final dressing 217

99. Soft rubber catheter 243

100. McLean's male prostatic catheter 243

101. Dental forceps 245

102-103. Showing points for injection of anesthetic in gum 247

104. Root forceps 249

105. Method of correcting deformity in overriding fracture of sternum . 252

106. The method shown in Fig. 105 has been supplemented by direct up-

ward pressure on the inner ends of the clavicles with the finger

tips 252

107-108. Fracture of the spine in the lower dorsal region 254

109. Depressed fracture of skull in left parietal region 257

110. Explosive effect of the modern high pressure missile at close range . 257

111. Bullet in head 258

112. Pronounced swelling and ecchymosis of eyes following scalp wound . 258 113-114. Old fracture of nasal bones with lateral displacement .... 260

115. Separation and angular displacement of lateral and septal cartilages 260

116. Fracture of nasal bones with displacement to right 260

117. Fracture of the posterior portion of the malar and the anterior end

of the zygoma on the left side of the face 261

118. Dental splints 262

119. Fracture of mandible at symphysis 263

120. Fracture of lower jaw about twenty-four hours following injury . 263

121. Fracture of lower jaw immediately following injury 264

122. Fracture of the right side of mandible about six weeks after injury 264

123. Four-tailed bandage made with adhesive plaster 265

124. Same as Fig. 123 with superfluous gauze cut away 265

125. Metal dental splint for cementing to the lower teeth 265

126. Same splint with the teeth in occlusion 266

127. Loops of wire passed about teeth of lower jaw preparatory to wiring

the jaws together 266

128. Loops of wire passed about the upper teeth 266

129. Two points of fixation in wiring the maxilla 1 together 266

130. Opposite side in same case showing line of fracture and two addi-

tional points of fixation 266

131. Simple method of wiring the upper to the lower teeth in fracture

of the lower jaw 267

132. Fracture of superior maxilla 267

133. Grasping the body of the scapula to detect the presence of fracture . 268

134. Oblique strapping with adhesive plaster to immobilize body of scapula 269

135. Fracture of the right clavicle about twenty minutes after accident 270

136. Fracture of left clavicle about twenty-four hours following injury . 271

137. Fracture of the right clavicle with the usual symptoms . . . . 271

138. First strap of adhesive encircles the arm and then the body, pulling

the arm backward 272

139. Second strap of adhesive passing down the posterior aspect of the

arm, under the elbow and over the opposite shoulder . . . . 272

140. Third strap of adhesive which passes down the outer side of the

arm, under the elbow and under the hand to the opposite shoulder 272

141. Another view of dressing showing attachment of straps posteriorly . 272 142-143. The C. F. Taylor brace which is particularly satisfactory in the treatment of fractures of the clavicle in children 273

144. First step in application of Sayre dressing. Circular pad to arm . 274

145. Second step in Sayre dressing. Arm pulled slightly backward . . 274

146. Third step in Sayre dressing 274

147. Finished Sayre dressing 274

148. Apparatus which may be used in fracture of upper end of humerus

or clavicle 276

149. The Dupuy wire extension splint 276

150. Fracture of both bones of the forearm with the usual backward dis-

placement of the hand 276

151-152. Fracture of both bones of the forearm with the usual deformity 277 153-154. Same case as shown in Fig. 152 after reduction has been accomplished and splints applied 278

155. Fracture of both bones of the forearm prior to reduction .... 278

156. Ventral splint applied following reduction and held in position by

two straps of adhesive 279

157. Same dressing opened up for inspection during after-treatment . 279

158. Low fracture of surgical neck of right humerus 280

159. Same case (Fig. 158) seen in recumbent position 280

160. Cigar box boards cut to proper size to make diagonal axillary pad . 281

161. Plaster shoulder cap in position 281

162. Oblique fracture of humerus a little below its middle with overriding

and angular displacement of the fragments 282

163. Transverse fracture of the lower end of the humerus 282

164. Same case as in Fig. 163 in sitting position 283

165-166. Compound comminuted fracture of lower end of humerus . . . 283

167. Levis 7 metallic splint 284

168. Simple Colles' fracture the result of a fall on the hand .... 284

169-170. Radial and ulnar views of recent Colles ' fracture 284

171. Oblique Colles' fracture a few minutes following injury ..... 2S5

172. Radial and ulnar views of Colles' fracture just before reduction . 285

173-174. Two methods of grasping the wrist in reducing Colics' fracture 285

175. Emergency splint for Colles' fracture 286

176. Walker's splint for Colles' fracture 286

177. Severe compound fractures of the proximal phalanges of the fourth

and fifth fingers 286

178. Plaster splint applied to thumb 287

179. Plaster splint applied to dorsal surface of middle finger and back

of hand 287

180. Splint of cigar box wood padded, bandaged, and placed in position to

immobilize middle finger 288

181. The finger splint padded and held in position by strips of adhesive . 288

182. Adhesive plaster applied for fractured ribs 290

183. Shows adhesive plaster applied to the leg to secure longitudinal

traction on the lower extremity. Buck's extension 292

184. Shows Buck's extension completed 292

185. Buck's extension 293

186. Turck's modification of Buck's extension 294

187. The ambulatory pneumatic splint with hip attachment 295

188. Dupuy's combination leg splint 296

189. Fracture of the patella 297

190. Fracture of upper end of tibia 298

191-192. Fracture of both bones of the leg near junction of lower and

middle thirds, seen a few minutes after the accident and again

four days later 299

193. Fracture box 299

194-195. Leg is seen in fracture box with proper padding in place and side of box let down for inspection and readjustment of dressing, and again with fracture box closed and fastened .... 300

196. Adhesive plaster applied for traction and countertraction with the

short Desault splint 300

197. Short Desault splint in position, with padding about leg .... 300 198-199. Fracture of both bones of the leg just above the ankle . . . 301 200-201. Fracture of both bones of the leg just above the ankle with pronounced inward displacement of the foot 302

202. Cabot posterior wire splint 303

203. Levis' metallic splint for tibia and fibula . 303

204. Modified Cabot splint fracture of both legs 303

205. Pott's fracture of ankle 304

206. Shows the making and use of Dupuytren's splint for the treatment

of Pott's fracture 304

207-208. Stimson's plaster splints applied to a Pott's fracture and held

in position by strips of adhesive plaster 305

209-210. Simple Pott's fracture the result of a fall on the foot .... 306

211. Pott's fracture of the left ankle a few minutes following injury . . 306

212. Compound fracture of leg illustrating Carrel-Dakin irrigation . . 307

FIG. PACE

213. Compound fracture, great loss of superficial tissues, periosteum

stripped free from tibia 308

214. Outlined x-ray of a low subcoracoid dislocation of shoulder . . . 312

215. Examining depression below the shoulder 313

216. Subglenoid dislocation of right shoulder 313

217. Same case. The head of the humerus lies between the two index

fingers 313

218. Same case after luxation had been reduced 314

219. Posterior dislocation of right shoulder 314

220. Palpation of displaced head 314

221-222. Simple backward dislocation of the elbow about half an hour

following the accident 315

223. Forward luxation of the head of radius 316

224. Dislocation of the wrist 317

225-226. Recent backward dislocation of the second phalanx of the middle finger the result of a twisting strain 318

227. Ventral dislocation of second knuckle 319

228. Backward dislocation of left index finger 319

229. Reduction of the common backward dislocation of th° hip .... 320

230. Stimson's method of reducing posterior luxations 321

231. Preston's modification of Bigelow's method 321

232. Backward dislocation of left knee 323

233. Backward dislocation of ankle 324

234-235. Case of backward dislocation of the caleanenm and scaphoid on

the astragalus 325

236. Forward dislocation of astragalus 326

237. Ideal incision for amputation of arm 332

238. Lines of incision for amputations of fingers and wrist. 333

239. Amputation of thumb 334

240. Amputation of great toe 336

241. Lines of incision for amputation of all the toes 336

242. Amputation of ankle joint now rarely performed 33S

243. Amputation at lower third of leg 339

244. Amputation of leg 340

245. Lines of incision for amputation of thigh and hips 342

246. Hip joint amputation. Pins and lubber tube tourniquet in position 344

247. Uterine packer 347

248. Incision for abdominal Cesarean section 351

249. Examination of fetus in abdominal Cesarean section 352

250. Closure of uterus in abdominal Cesarean section 352

251. The Morse forceps 362

Chapter I

PRELIMINARY REMARKS, EMERGENCY INSTRUMENTS, EMPLOYMENT OF ADHESIVE PLASTER IN WOUND DRESSINGS

In emergency practice, success very frequently depends upon the possession of a variety of useful instruments, with which every practitioner should be provided and always have within easy access. Of the instruments which may properly be classed as indispensable may be mentioned: a good nasal speculum, alligator forceps, a number of good hemostats, a curved throat or laryngeal forceps, vulsella and dressing forceps, stomach tube, bristle probang, a good head-band mirror with electric light or pocket flashlight, and other like instruments.

There are, however, a vast number of specially constructed novel and costly instruments, which in rare or selected cases, might be used to advantage; but such instruments, seldom required, occupy too much space and hence the practitioner Avho can accustom himself to the employment of the more simple, common everyday useful tools will possess a distinctive advantage over the man who depends upon a number of special instruments, not always possible to obtain.

The best instruments are now constructed entirely of steel, or steel and aluminum, in order to permit their being sterilized more readily by boiling. All scissors, forceps, and other like instruments should be held together by screws, or properly riveted, since all forms of mortice or loose locks sometimes permit the blades to fall apart when hurriedly grasped or held by one blade.

In these days of preparedness, a good emergency grip is synonymous with having good reliable ammunition at hand and our forces organized for offense and defense. Every practitioner, more especially those who reside in rural districts or small towns, should be provided with emergency cases or grips which, when kept in proper condition, are always a source of satisfaction, not only to the practitioner himself, but the public soon learns to appreciate^ the fact that certain doctors are always prepared to respond promptly, to meet any kind of an emergency.

For a number of years, the author has kept three leather grips or emergency outfits within easy access and has found these less cumbersome and much more convenient than to attempt to carry all that is needed in one satchel. The larger bag is similar to those supplied by all instrument houses, constructed of good leather, with solution trays, etc., and is intended to be taken in responding to major cases, railroad injuries, and other like accidents. This grip (Fig. 1) contains the following:

% lb. roll sterilized cotton.

2 yds. sterilized gauze, 1-yard packages.

1 spool ZO adhesive plaster, 2-inch.

1 spool ZO adhesive plaster, 1-inch. 4 roller bandages, 3-inch."

4 roller bandages, 2-inch.

2 roller bandages, 1-inch.

1 card braided silk, 3 sizes.

1 pkg. catgut ligatures, in bottle.

25 silkworm-gut ligatures, in bottle.

1 pkg. parresine with brush.

2 doz. gauze sponges.

1 oz. antiseptic dusting box. 50 chlorazenc tablets.

2 oz. 95% carbolic acid in screw-cap bottle. 2 oz. chloroform in screw-cap bottle.

8 oz. sulphuric ether in screw-cap bottle.

4 oz. styptic cotton.

1 bottle drainage tubes, assorted sizes.

1 doz. assorted needles in case.

1 lot safety pins.

1 good quality razor.

1 bandage scissors.

1 tube antiseptic soap.

1 Esmarch tourniquet.

1 aspirating hypodermic syringe.

1 fountain syringe.

1 aseptic operating case (Fig. 2).

EMERGENCY INSTRUMENTS

Fig. 1. — Leather grip for emergency outfit.

Fig. 2. — Aseptic operating case.

The second case, which is much smaller and more convenient to carry, contains the following:

doz. tincture iodine ampules.

1 nasal speculum.

2 alligator straight and curved forceps.

1 four pronged tenaculum or vulscllum forceps.

1 tongue forceps. 6 hemostats.

2 scalpels.

1 esophageal bristle probang.

1 stomach tube.

1 tonsil hemostat.

1 nasal gauze packer.

% doz. soft catheters.

1 aspirating hypodermic syringe.

6 wooden tongue depressors.

1 pair dressing scissors.

1 tourniquet.

2 spools 1-inch and 2-ineh ZO adhesive plaster. 1 pocket flashlight.

y>2 doz. 2 }4-inch rolled bandages.

1 pkg. absorbent cotton.

2 yds. moist sterile gauze.

1 pocket surgical case — needles, etc.

V2 doz. assorted sizes catgut sutures, plain and chromic.

1 tube sterile lubricant.

The third grip contains the following:

2 stomach-tubes, large and small. 1 fountain syringe.

1 curved dressing forceps. 1 straight scissors, ^-lb. roll cotton.

V2 lb. alcohol.

y>2 doz. ampules sulphuric ether.

V2 doz. ampules camphor oil.

1 large hypodermic syringe.

8 oz. whisky — metal-covered bottle.

4 oz. chloroform.

1 mouth speculum.

1 case containing 6 one-ounce glass-stoppered bottles containing:

aromatic spirits of ammonia.

sulphuric ether.

sol. sodium chloride iron.

ASEPSIS

1 small hypodermic surgical case containing:

hypodermic tablets: apomorphine, y 10 gr. ; morphine sulphate, 14 gr. with atropine, Msg strychnine nitrate, % 0 gr. lb. parresine and brush.

3-yd. roll sterile gauze.

2-oz. tube oxide zinc ointment.

2 spools 1-inch and 2^-inch ZO adhesive plaster. V2 doz. 2V4-inch rolled bandages.

1 doz. Handy-Fold Package picric acid gauze, B&B.

ASEPSIS

The wonderful advancement in modern surgery, the alleviation of pain and prompt healing of wounds without serious infection is now justly attributed to surgical cleanliness, or asepsis; therefore, the treatment of all cuts, open wounds of whatsoever kind and nature, whether treated at a hospital or private home, demands that the closest attention be paid to the modern rules of surgical asepsis and it is likewise fully established that the physician who first assumes charge of the case, or the person who administers first aid, very often holds within his hands the question of infection or noninfection of the patient.

The forbearance of any unnecessary handling or prolonged examination of the open wound or involved tissue, however tempting to the novice, is now insisted on, and modern surgery demands that the fingers, however supposedly sterile, or even sterile gauze, must not, under any circumstances, be thrust into a wound, since removal of any foreign substance is best and more safely accomplished by means of sterile instruments. The former custom of scrubbing the skin with a stiff brush, and even the wound itself, using an abundance of soap and water, is now considered obsolete and uncalled for ; at most, in foul or greasy wounds the adjacent skin may be gently swabbed with a strip of gauze saturated with a little ether or gasoline. The wound itself, having been kept as dry as possible, is next treated by pouring upon and into every accessible part thereof, a 5 per cent freshly prepared solution of tincture of iodine, or one of the more recent chloramide solutions may be used to advantage.

The wound is then brought together by proper suture or sterile zinc oxide adhesive strips, over which is placed an abundance of dry sterile dressings, held finally by a roller bandage or adhesive strips. (Figs. 3 and 4.)

The average general practitioner is poorly equipped for good aseptic detail work even in minor surgery. Many surgical cases are sometimes unavoidably compelled to return from the hospital

Fig. 3. — Applying sterile gauze to a wound of the forearm.

l*ig. 4. — Sterile dre>sings held in place by adhesive strips.

to their homes with partially closed operative wounds, to become later infected from lack of proper aseptic dressings or carelessness in detail work, which operate to the detriment of the wound healing. To better prepare the practitioner for successfully treat-

CLOSURE OP SKIN WOUNDS ing this class of cases, certain manufacturers placed on the market small packages of dressings particularly suited to this class of cases.

Fig. 5 illustrates B&B's Handy-Fold package and method of its proper application. Each dressing is wrapped in a separate parchine paper envelope and sterilized after sealing. The dressings may be made larger or smaller by the simple process of folding or opening the gauze and thereby fitted to apply to any size wound or any part of the body.

Fig. 5. — Note Ilandy-Fold package. Gauze laid over wound, having been touched only

by sterile forceps.

CLOSURE OF SKIN WOUNDS

Widely gapping skin wounds of the face, neck, or other exposed parts are best closed by means of subcutaneous suture or possibly oxide of zinc adhesive plaster. Of the various materials, such as silk, silkworm-gut, chromic catgut, horsehair, or linen, horsehair has been most commonly accepted for skin suture; but it is very difficult to sterilize and the individual strands lack uniformity in diameter, are short and lacking in tensile strength, so much so that the cut edges of a long incision can not be held in close apposition. Catgut is not a good skin suture, since it is irritating to many sensitive skins; and in the process of its early absorption, seems to invite infection. Recently the author has tried with satisfaction, a new dermal suture, prepared by a chemical process from silk, introduced by Bauer and Black, and colored by pyoktanin, which in physical appearance closely resembles horsehair. These dermal sutures possess the advantage of length, strength and uniformity in diameter. They are supplied in three sizes and 40 inches in length.