CHAPTER XIX

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ABSTRACTION OF BLOOD; COUNTERIRRITATION; PARACENTESIS; TRANSFUSION; CATHETERIZATION; SKIN GRAFTING; BANDAGING.

Abstraction of blood, usually of venous blood, known as venesection, was a practice frequently indulged in years ago. At one time in the history of medicine it seemed to be the measure regarded as a panacea for all ills. The reaction from the period of excessive bloodletting came during the previous century, and was so strong that the practice was for a generation or so almost abandoned. The eminent surgeon S. D. Gross wrote a paper entitled “Bleeding as a Lost Art.” Bloodletting is an expedient of great value in a somewhat restricted class of cases, but is capable of affording such relief in certain emergencies that practitioners should be ready to resort to it at any moment when it may be required.

After removal of a certain amount of fluid blood pressure is naturally reduced and at the same time equalized, while when the right side of the heart is overburdened with its task it is thus made to beat more easily and regularly; thus indirectly there may be brought about a subsidence of violent heart effort, a reduction of the respiration rate, a lowering of temperature, and sometimes a diminution in the

## activity of morbid processes which may be beneficial, and even

life-saving. Even after moderate bleeding, say a half-pint, the amount of urine is increased and the proportion of solids raised. More air is taken into the lungs, and oxygenation is thereby much improved.

The indications for venesection are:

Excessive vascular tension.

Intensity of pathological tissue activity which is leading to serious disturbances.

The removal of a certain proportion of toxic material from the blood.

There may be added later the introduction of balanced physiological salt solution as recommended in the treatment of shock, and of some of the acute toxemias, _e. g._, delirium tremens.

The effect on an embarrassed and overfilled right heart of the abstraction of blood is prompt. Nowhere is this more conspicuous than in the early stages of pneumonia, and in some cases of heart failure during administration of an anesthetic where a dilated heart seems to become so overfilled as to be unable to empty itself. In profound uremia, especially in puerperal eclampsia, the relief afforded by it is usually immediate and permanent.

VENESECTION.

The question of the amount of blood to be withdrawn must be settled at the time and for each individual case. The pulse is watched, as well as the patient’s face; the best indications when to cease being noted in this way. From 500 to 1000 Cc. may be removed according to the condition of the patient and the degree of emergency. While the operation is a trifling one, it should, nevertheless, be performed with strict aseptic precautions. One of the veins at the bend of the elbow, usually in the left arm, is commonly chosen, although in rare instances, when there is intense cerebral venous congestion, the external jugular may be selected. At the elbow the median basilic vein crosses the brachial artery, being separated from it only by a thin prolongation of the biceps tendon. It was especially in opening this vein at this point with the old-fashioned lancet, which was plunged perpendicularly to the surface and directly into the vein, that injury to the artery occasionally occurred, thus leading to varicose aneurysms and aneurysmal varices.

The skin should be thoroughly cleansed; a reasonably tight constriction is made about the middle of the arm by a bandage, not so tight as to completely occlude the radial pulse; the arm is allowed to hang downward and the patient encouraged to grip some object in order to better fill the vein. This soon becomes prominent, after which an oblique incision is made through the skin above it, so that the vessel itself is exposed. Then with a sharp bistoury the external surface of the vein is pricked with the point, and a cut made outward. The opening in the skin should be free; the skin may be frozen, or in very sensitive patients local anesthesia may be first produced with cocaine. By tightening and releasing the grasp, that is by closing and opening the hand, the flow of blood may be hastened. When it is time to cease, the bandage should be removed and an aseptic pad be applied over the site of the wound, suitable pressure being made, and the arm kept at rest for two or three days.

When the jugular or some other vein is selected the procedure is essentially the same.

=Arteriotomy.=--Arteriotomy, or the opening of an artery for bloodletting purposes, is resorted to only in rare instances, and in an emergency. The temporal artery is the one usually selected because of its accessibility and the ease with which its outflow can be controlled. Its position is determined by its pulsation; it should then be exposed by incision through the skin, and opened exactly as is a vein, _not cut through_, lest it retract and furnish an insufficient amount of blood. It should, however, be divided and tied before application of the dressings.

=Cupping.=--By the application of “cups,” blood is drawn to the surface, but ordinarily not abstracted, unless the surfaces have been previously scarified or incised. _Dry cupping_ has the effect of attracting blood to one portion of the body, thus drawing it from another and congested part. It has the temporary effect of a venesection. Cupping glasses are small tumblers which are rinsed in alcohol; their edges are wiped and the remaining film within the glass is ignited from a candle or flame. The glass is then instantly applied to the affected area. The oxygen within the contained air is sufficiently consumed to create a slight vacuum and the skin quickly becomes congested, being sucked upward into the glass. These cups may be allowed to remain for a few moments, or until they drop off. Care should be exercised with alcohol and a lighted lamp around a patient who may be unconscious or excitable, as serious burns have followed carelessness in this regard. Small vacuum pumps, like the Allen surgical pump, have been provided for this purpose, and give very satisfactory results.

There was formerly employed for the purpose of _wet cupping_ a small spring instrument, containing several sharp knives, by which a series of incisions were made in order that blood might be drawn. This instrument cannot be kept clean and is not used at present. When wet cupping is desired the part should be scarified with a sharp knife and the cup applied as above.

=Leeching.=--Leeches figure largely in literature of the past, but are not often used, although they may be made effective, especially when applied behind the ears in cases of cerebral congestion. The American leech can be relied on only to abstract about a teaspoonful of blood, while the Swedish will draw three or four times that amount. The region to which they are applied must be washed, and, if necessary, shaved. The part should then be smeared with milk, blood, or sugar-water. The leeches should be put in a basin of fresh water, after which they are placed upon a dry towel for two or three minutes. Each one is then taken up in a small glass or test-tube and inverted over the spot chosen. As soon as the animal fastens itself upon the skin the glass may be removed. Leeches are often capricious and will sometimes wait considerable time before attaching themselves. When full of blood they usually relax and drop. If it be desired to remove them a little salt will make them relax. Leeches should never be applied over loose cellular tissue nor over superficial vessels or nerves. If used in the interior of a cavity they should be prevented from passing too far.

COUNTERIRRITATION.

Counterirritation is a valuable means of accomplishing that which is sometimes induced by leeches--namely, attracting blood to the surface for the relief of deep congestion. In fact it comprises more than this, since there is some deep influence exerted through the medium of the nervous system; it not only equalizes the circulation, but tranquillizes a disturbed innervation. The milder and more domestic means include the use of the so-called rubefacients--hot water, mustard, and turpentine. These are of little use in surgical conditions which call for counterirritation; their use should be controlled with caution lest mere counterirritation be converted into actual burning.

By the use of _vesicants_ a blister is produced, _i. e._, an effusion of serum and lymph beneath the superficial and outside of the deeper layer of the skin. Mustard and cantharis are the principal vesicants in common use. The former may be used in full strength, in which case it is active, or it may be reduced with wheat flour or linseed meal. To bring out the full strength of mustard, hot water should not be used in its preparation, as it renders it almost valueless. A mustard paste or plaster should be watched at intervals, and it should be removed when the desired effect has been obtained--at all events, when the surface to which it has been applied is covered with vesicles.

Cantharis, or Spanish fly, is used either in the form of the cantharidal cerate or mixed with collodion, the latter being the neatest and most pleasant preparation. Several layers are painted on the surface where its effect is desired. This is then protected, and vesication will be found to have been produced within an hour or two, except where the skin is most resistant. The stronger chemicals, like ammonia, chloroform, strong iodine, and nitrate of silver solutions, will be found to be active blistering agents, but should be used with caution.

Two other methods of irritation were at one time in favor--namely, the _seton_ and the _issue_. The former consisted of a bundle of threads or a wick, drawn into a large needle with a lancet-shaped point; the skin was picked up into a fold, the needle made to traverse it, and the wick was thus drawn through and cut off, so as to be left in place. The issue was made by drawing a blister with a powerful agent, and then preventing it from healing by the use of an irritating foreign body. These procedures have been abandoned by the medical profession, but are still in vogue among veterinary surgeons.

=The Actual Cautery.=--In some one of its improved forms the Paquelin cautery has replaced all the old cruder methods of cauterization. When properly employed its counterirritant effect can be made most serviceable for the relief of pain, or for any desired form or degree of counterirritation. Applied over the upper abdomen, with the lightest possible touch, in such a way as to deserve the term “_flying cautery_,” it will sometimes afford great relief in nausea and vomiting, especially when these symptoms are purely reflex.

Used over the course of the larger nerves it does much to relieve the pain of neuritis; while over swollen joints and swollen testicles it affords great relief from the pain of chronic arthritis and chronic or acute epididymitis. In deep-seated congestions and inflammations _ignipuncture_ may be made with a small cautery point, by plunging it through the skin into the underlying tissues, and into bone. The relief of tension as well as the counterirritation will give great relief. When practised in this manner local or general anesthesia may be used. Except when thus used it will rarely be necessary to do more with it than to disturb the exterior of the skin. When skilfully used this can be done with the production of very little pain.

PARACENTESIS.

Paracentesis is the technical name given to the act of tapping, or the withdrawal of fluid from any of the closed cavities of the body. It includes _aspiration_, _tapping_, and _incision_.

=Aspiration.=--By aspiration is meant the removal of fluid without the admission of air; it comprises the use of a suction apparatus, usually known as an aspirator, which may be had in various forms and sizes. A small so-called _exploring syringe_ will answer for small cavities, while for large collections of fluid, such as may be met with in the thorax, more elaborate apparatus is used, consisting of a suction pump connected by tubing with a bottle in which the vacuum is produced. By another tube this bottle is connected with a hollow needle used for the withdrawal of the fluid. Absolute asepsis should be observed, even in this minor procedure. The skin should be cleansed, and the needle, instrument, and hands should be sterilized. The pain of puncture may be prevented by use of the freezing spray, of cocaine injected locally, or by touching the skin with a drop of pure carbolic acid. The vacuum is commonly resorted to in the removal of fluid from the thorax, the spinal and the cranial cavities, and from joints; also in small collections of pus in any part of the body.

=Tapping.=--Tapping means a somewhat similar procedure with a larger instrument known as a _trocar_ and a surrounding _cannula_, without the aid of the vacuum. Precaution should be taken in every regard that the instruments and the parts should be sterilized.

The trocar, inserted in the cannula, should be plunged quickly into the cavity at the site selected. Considerable resistance will be offered by the skin. If the trocar be small it is enough to anesthetize the skin; if large, a small incision will permit of its better use. The instrument makers have provided cannulas of various descriptions, to which tubing may be attached, so that the fluid may be conducted into a suitable receptacle, and wetting the patient avoided. It is well to draw the skin aside and not to make the instrument pass directly into the cavity to be tapped unless it contain pus and it be desired to keep it open. If this precaution is taken the skin will cover the deep opening after it slips back into its position, and will act as a valve to prevent leakage. In this way infection may be avoided.

When fluid has ceased to be serous and has become purulent, as in empyema, it is often so thick that it will not flow through any hollow instrument. In such an event free incision should be made. When the thorax is involved incision is made between the ribs, and in order to maintain drainage a good-sized drainage tube should be inserted. This at times may be so compressed between the ribs that an inch or more of one rib should be exsected to provide against this possibility.

TRANSFUSION AND INFUSION.

Though much has been said concerning the indications for these procedures no explicit directions have been given. While they are often emergency measures they are, nevertheless, frequently practised. In well-regulated institutions the conveniences are always at hand for instant resort when needed; but it would be well for every general practitioner to have ready at all times the few things that are required, for at least hypodermoclysis. In country practice, however, a clean fountain syringe, a suitable aspirator needle (both carefully sterilized), some boiled water, table salt (when nothing else is at hand), and soap and water for sterilization of the operator’s hands and the patient’s skin are all that are necessary. In every outfit there should be a needle which may be used for this purpose. It may be carried in a glass tube, always sterilized, and ready for use. No fountain syringe should be used which has not been freshly boiled, except in an emergency. Tablets containing common salt in definite amount, so that a solution of given strength can be made by adding them to a definite amount of water, can be procured. With such a needle, a few tablets, and a fountain syringe the surgeon is prepared for any emergency.

For intravenous infusion for which no pressure is required, an ordinary funnel, with rubber tubing attached, will be sufficient without the use of a rubber bag.

The use of salt solution has supplanted the _transfusion of blood_. This requires a source of blood which is not always at hand and an amount of attention which can rarely be given in emergencies; moreover, it has been shown that the injection even of defibrinated blood is a dangerous procedure, because of liberation of hemoglobin and destruction of white corpuscles, with the liability to coagulation of the blood from increase of fibrin ferment, and the possible death of the patient. Direct transfusion from another person into the veins of the patient is also difficult, and has rarely been of service.

As already stated in the chapter on Shock, the best solution for infusion is composed of calcium chloride 2 parts, potassium chloride 3 parts, sodium chloride 9 parts, sterile water, 1000 parts. The addition of one part of sodium bicarbonate will sometimes prove of advantage, while in diabetic cases this may be increased to three parts to a thousand. It has also been suggested to add a small proportion of sugar, even up to thirty parts, to this solution, in order to increase osmotic action and better preserve the red corpuscles from injury. It is supposed also to give a certain nutritive value.

When the fluid is injected into the venous system all that is desired is that it barely enter; consequently the receptacle containing the fluid should be held but a few inches above the level of the opening. When hypodermoclysis is practised more pressure will be needed and a greater difference of level should be maintained. In the veins the amount injected should not exceed 100 Cc. each minute. From 500 to 1500 Cc. may be used altogether. There need be no hesitation in introducing it at a temperature considerably above the body normal, and in cases of shock it may be introduced even at 115° F. The character of the pulse will afford the indication as to the amount of fluid to be used as well as the wisdom of repeating the measure after an interval.

For _intravenous infusion_ a vein in the arm is usually exposed and the needle point carefully inserted. It is an advantage to have for this purpose a special needle, made with a blunted extremity, enlarged a little, so that by the use of a temporary ligature the vein may be held tightly around the cannula, for such it really is, and the escape of fluid be prevented. After withdrawal of the needle a double ligature should be placed for purposes of security. The limb should also be kept at rest for a few days.

For _hypodermoclysis_ from 500 to 1000 Cc. may be employed; the anterior abdominal wall, the flank, the thigh, and the retromammary tissues are the best regions in which to inject the solution. Absorption will be assisted by gentle massage. Local anesthesia by the freezing spray, or by cocaine, will rob the procedure of its discomfort. Adrenalin may be added to the solution, whose formula is given above, in emergency cases where it seems to be especially needed. In instances where infusion is practised for the purpose of washing out the blood, _i. e._, in the acute toxemia of uremia, alcoholism, etc., nothing of the kind will be required; but in conditions of lowered blood pressure, _i. e._, shock, it will prove of great value, as already indicated.

CATHETERIZATION.

Catheters, as such, are intended for the withdrawal of urine from the urinary bladder, or for the introduction and withdrawal of cleansing fluids. They are made of metal, glass, gum, and silk, or other similar material, in various sizes, while some are specially formed or bent in order to pass more easily over the obstruction offered by a median prostatic enlargement. Various forms are sold in the surgical depots, from which the purchaser may make a choice. Next to the simple tubular forms the elbowed or Coudé catheters are of the greatest value.

Catheters should be sterilized before use. Those used occasionally should be cleaned after use and dried, while those in daily use may be kept in an antiseptic solution after cleansing. The cleansing of a catheter should include not only attention to the exterior, but also removal from its bore of all clots, debris, etc. Some pressure behind the fluid used for this purpose is advisable. A clean metal or glass catheter may be sterilized in a flame just before use. All flexible catheters should be boiled just prior to their insertion, or they should be taken out of an air-tight receptacle in which they have been kept in contact with some antiseptic, or in an antiseptic vapor. For the latter purpose _paraform_ offers an excellent material, as there is given off from it formaldehyde vapor, which is a powerful bactericide. It comes in crystals and in tablets. Rubber catheters should be boiled in a 5 to 10 per cent. solution of ammonium sulphate.

The urethra should also be cleansed, especially the meatus, in either sex. Cases of cystitis may be directly traced to infection introduced by a catheter, the result being the same whether the germs be not removed from the instrument or are carried in by it from the anterior urethra. This is particularly true in paralytics who have no power of expelling the urine, and in prostatics who need regular catheterization.

The technique of using the metal catheter in the male is the same as that of introducing a sound. A lubricant is necessary for the easy introduction of the instrument, and a sterilized ointment or oil will serve the purpose. Olive oil, mixed with iodoform, as often used, is not sterile. The hands of the operator should also be clean, and no part of a clean instrument should be allowed to come into contact with any portion of the patient’s surface. On this account the parts exposed should be covered with sterile towels.

The catheter being intended to afford relief with the least amount of discomfort, a smaller instrument may be used than would be inserted were it meant for the dilatation of a stricture. Occasionally, and in a sensitive patient or hyperesthetic urethra, a little cocaine solution may be used to advantage, especially if force or pressure need be made in order to overcome spasm of the cut-off muscle. The metal instrument is too rigid in some cases, while the gum catheter is too flexible. Under these circumstances, the silk instrument may be used.

If the tip of the instrument be kept close to the floor of the urethra it will rarely catch in any fossa or lacuna, particularly if the size has been correctly chosen. When apparent obstruction occurs at the triangular ligament the instrument should be withdrawn a little, tilted differently, or lifted a little so that it is made to hug the roof of the urethra rather than to press upon its floor. By a little manipulation of the end of the instrument any obstruction at the neck of the bladder may also be overcome. A sudden depression of the outer end as the catheter reaches this part, or a little pressure by the finger of the disengaged hand in the perineum, will give much help. It is well, occasionally, to introduce one finger into the rectum in order that by it the instrument may be better guided along its course. Only in cases where there has been previous disease or where unsuccessful attempts have already been made to pass an instrument will much real difficulty be found; that is, only in those already suffering from stricture, or from enlarged prostate with the difficulties which it affords, will one have to resort to manipulation requiring more than ordinary dexterity. In some of these cases even the expert is likely to meet with difficulty, rarely with absolute disappointment. Should it be impossible to empty a distended bladder with a catheter _suprapubic puncture_ with the _aspirator needle_ should be made.

When difficulty is experienced it is enhanced by spasm of the deep muscles, as a reflex from the soreness produced by repeated efforts and by hemorrhage.

Hemorrhage from this source is rarely of serious character and quickly ceases. In certain instances where it is aggravated much can be accomplished by leaving the catheter _in situ_ for a few hours, or even for two or three days.

False passages will occur sometimes in spite of at least ordinary care, and are always serious in their nature. Extravasation of urine may result, with more or less disastrous consequences, or speedy septic infection may quickly terminate the life of the individual. They are to be avoided, as far as possible, by the use of instruments of large rather than of small size, with blunt tips, and by delicacy of manipulation. For this purpose it is well to avoid the use of catheters which require a wire stylet for the maintenance of their proper curve, lest during manipulation the point of the wire may work injury. The various accidents due to or connected with catheterization will be dealt with in their proper places in connection with the surgery of the urethra and bladder.

There are certain constitutional complications, however, which deserve mention. One of these is known as _urethral fever_, which comes on usually with a chill, followed by more or less rise in temperature, and with general disturbance of the system. It is to be regarded as a manifestation of septic intoxication, the hope being that the disturbance may not go beyond this degree. In cases that have once suffered from this intoxication precautions should be doubled. The deep urethra should be irrigated before and after the withdrawal of the urine, the patient should be kept in bed, and urotropin and quinine may be administered before and after the discharge of urine. Much may be done in the prevention of this as of other unpleasant occurrences, such as pain, excitement, suppression of urine, syncope, etc., by the previous use of cocaine and by due regard for gentleness. Should a septic process be set up in the deep urethra it may lead to sapremia of urethral origin, and to septicemia and pyemia. Septic complications accompanied by any local indications, such as swelling, should make the surgeon watchful for the time when an incision must be made for relief of tension or escape of pus.

Postoperative suppression of urine, which may occur even after catheterization, may be treated by giving 0.08 to 0.15 Cg. of sulphate of sparteine every three or four hours (McGuire).

SKIN GRAFTING.

The whole method of skin grafting is based on the fact that if epithelium be removed from any portion of the body and planted on favorable soil elsewhere it will take root and grow, reproducing only itself and no other kind of tissue. It is closely analogous to sewing seed upon a favorable soil, or even to sodding. Furthermore it is not necessary that epithelium be furnished from the individual upon whom it is to be implanted; it may come from another of the same species or even from a different species. Thus the skin of the frog has been used for grafting upon human beings, and even the lining membrane of the egg. Nor is it necessary that the epithelial cells should be apparently alive when thus employed. Very thin shavings of human skin which have been dried, or have been kept from decomposing by some antiseptic, have been successfully used; nevertheless the ideal method consists in taking what is needed from the individual who needs it.

The term skin grafting is now applied to the employment of very thin layers of the epidermis, _i. e._, as thin as can be shaved off with a sharp razor, and it does not apply to the autoplastic methods of skin transplantation.

Hamilton, of Buffalo, and Reverdin, of Geneva, a number of years ago independently discovered that minute particles of healthy skin might be implanted upon healthy granulations and that from such minute grafts epithelium would be produced and a fresh epidermal covering be afforded. This method was in use for years and was a great advance on what had previously been done. Then Hamilton, of Edinburgh, suggested the use of thin slices of clean sponge, in order that thereby a trellis might be offered for the growing and climbing granulation tissue; this served a good purpose in many cavities. But the greatest advance came when Thiersch demonstrated that large areas might be covered with skin shavings, and that thus in a few days there would be accomplished that which took weeks or months by older methods. His original plan comprehended only the use of these grafts upon granulation tissue; later it was found that they might be applied to fresh raw tissue, even to denuded bone. Thus originated the so-called _Thiersch method of skin grafting_.

The surface to which these grafts are applied must be thoroughly cleansed as well as the surface from which they are removed. If an ulcerated surface is to be prepared for grafting it should be scraped thoroughly with a sharp spoon; all sloughing or suspicious tissue should be carefully removed, and all oozing allowed to subside. Not until the surface is prepared is it advisable to remove the grafts. These are best removed by putting upon the stretch the skin of the selected area, so as to render it taut and as nearly flat as possible. The razor used for the purpose should be sterilized and sharp. Salt solution may be allowed to drip upon the razor while the surgeon is using it. It is rarely practicable to remove a strip over 5 Cm. wide or 25 Cm. long. The endeavor should be to remove only the superficial layer of the skin, and when properly done this removal should be followed by but a trifling oozing of blood. If bleeding be profuse the layer removed has been too thick. Grafts of sufficient number and size are removed to nearly cover the desired area. The more completely it is covered the more acceptable will be the final appearance of the surface. If the grafts adhere, we may confidently rely upon their furnishing enough fresh epithelium to fill in the irregular defects between the edges. The grafts when cut should be raised with a razor and a spatula and gently spread out upon the prepared surface, and so pressed and treated that no air bubbles are retained beneath them. If the surface be dry enough they will adhere to the very thin coagulum of blood which glazes it, and after a few moments it will take friction to disturb them.

Should the margin of the surface to be grafted be old and indurated it is best to trim off any depression that exists, so that the new skin may not be let in below the surface of the surrounding skin.

The _dressing_ should consist of a layer of sterilized oiled silk, gutta-percha tissue, or green protective, laid on in strips, in order that excessive fluid may escape between them. A little antiseptic powder may be dusted upon the grafts, if such be the choice of the surgeon, but if the operation has been properly managed this will hardly be necessary. Careful regulated pressure should be made outside of the protective, by cotton and a suitable dressing, and then the part, if a limb, may be bound upon a splint in order to ensure physiological rest. _Silver, tin, or aluminum foil_ also make a good protective, and, on theoretical principles, are even better than the textile materials.

Some surgeons leave these dressings for several days. I have found it an advantage to remove them within thirty-six hours, as sometimes the grafts appear to be macerated in the fluids and to lose their first cohesion to the prepared surface. The main thing about the dressing is that it should be non-adhesive and restful. After three or four days, when the grafts have completely adhered, any ointment dressing may be used. It may happen that only a portion of the entire number of grafts serve their purpose, and that others fail to do their work. Even when the failure has been apparently considerable it will often be seen that individual epithelial cells have adhered and later will grow. The unhealed portions of such a surface now fall within the definition given earlier of an ulcer, and should be subjected to the same treatment.

Grafting may be repeated as often as seems to be necessary. The best surfaces from which to take the grafts are usually the outer aspects of the arms and thighs. The places from which they are removed need only the simplest antiseptic dressings. If the grafts have been of sufficient thinness the scars left by their removal are scarcely permanent and rarely disfiguring.

Wight, of Brooklyn, has suggested that advantage be taken of the properties of high-frequency discharges from a suitable apparatus to secure their hemostatic and coagulant effect. He has shown that such electrical discharge will clot blood and coagulate albumin, this effect being partly due to the formation of nitric acid from the air. In this way it is theoretically possible to so seal the surfaces as to fix grafts firmly in place. The apparatus calls for a pointed electrode, passed at a distance of about 1 Cm. above the entire surface, until the clot is firm and reasonably dry, all serum that is expressed in the process being removed with sponges. Where the apparatus can be employed this affords an effective way of fixing the grafts and preventing their displacement.

Surface epithelium from an animal source may be used when necessary--as from a young pig after it has left the packing-house, a young calf, or some smaller animal. All that is required is _epithelium_. That from a negro will reproduce only pigmented cells like the original. At the time when amputating a limb about which there is still left healthy unbroken skin, shavings may be removed from it and preserved for a week or two between dry sterilized towels or in a weak antiseptic solution; these may then be utilized for skin grafting during the ensuing few days.

[Illustration: FIG. 30

Figure-of-8 bandage of leg.]

[Illustration: FIG. 31

Velpeau’s bandage.]

[Illustration: FIG. 32

Ascending spica bandage of the groin.]

BANDAGING.

Bandaging is a subject now taught so generally by actual demonstration, and so simplified, that it scarcely seems necessary to more than present a few illustrations showing how simple bandages can be applied in the most effective manner.

The purposes of a bandage are either to afford means of retaining splints and dressings, to exert pressure, or to afford physiological rest. After every operation of importance it is necessary to apply and retain an occlusive and aseptic dressing, under which the wound may heal or into which wound discharges may be received; but the ideal dressing affords more than this--it furnishes _support and rest._

[Illustration:

FIG. 33

FIG. 34

Spica bandage of shoulder.]

[Illustration:

FIG. 35

FIG. 36

Third roller of Desault’s bandage.]

There is danger in the injudicious use of any bandage, as by the exertion of undue pressure it may interfere with wound healing, or may even lead to gangrene. If applied loosely at the extremity and too tightly above it will lead to venous obstruction and possibly secondary hemorrhage. Moreover a bandage which seems properly arranged may become so tight as to be painful and even unbearable after swelling has occurred. There is but one safe rule, and that is to take note of the appearance of the part as well as of the sensations of the patient. An abdominal bandage may have been placed with a proper degree of snugness at the conclusion of an operation, and yet be altogether too tight when the abdomen becomes distended with a little gas. There is then always room for discretion and good judgment in the matter of bandaging. It may be necessary to apply a bandage quite firmly at first in order to repress hemorrhage, with the intention to relax it after a few hours.

A splint may be a necessary feature in a surgical dressing; after amputating at the lower part of the leg it is advisable to bind the limb upon a splint in order that the necessary physiological rest may be thus afforded. The first requisite of a bandage is not its appearance but its effectiveness; a due regard for the esthetic in surgery will, however, dictate that it be made as presentable as possible.

[Illustration: FIG. 37

T-bandage.]

[Illustration: FIG. 38

Kelly’s bandage with perineal straps.]

For the roller bandages of cotton cloth, universally in use twenty-five years ago, there have been substituted bandages of thin gauze or crinoline, which have scarcely body enough to be applied, as was the roller, or else of flannel, made wider and necessarily thicker, which are more flexible, comfortable, and applicable.

[Illustration: FIG. 39

Barton’s head bandage as employed for suspension in applying plaster-of-Paris bandage.]

Crinoline impregnated with starch is also in general use and makes a serviceable bandage for head injuries. When prepared with plaster of Paris it is capable of affording absolute support and even rigidity.

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