bandage is taken from the basin drop a fresh one into the water. Apply four thicknesses of bandage, and finish the dressing by sprinkling dry plaster over the bandage and smoothing it with wet hands. The ordinary plaster will set in from fifteen to thirty minutes. If it is desired to have it set more rapidly, put salt or alum in the water; if to have it set more slowly, pour stale beer into the water. The plaster bandage is removed by sawing it down the front or by moistening with dilute hydrochloric acid and then cutting through the moistened line with a strong knife. Gigli has devised a mode of application which enables us to remove the dressing with ease. A layer of cotton is placed around the limb. A piece of parchment paper which has been wet and shaken out is placed over the cotton. A cord greased with vaselin is laid upon the paper in a position corresponding to the line we will wish to saw through the plaster. Apply the plaster bandage and see that the ends of the cord project beyond the bandage. When desiring to remove the bandage take a steel wire, make nicks on one side of it by means of a file, and attach the string to the wire. Pull the wire under the bandage. Attach each end of the wire to a wooden handle and saw through the plaster.'

Silicate-of-sodium Dressing.-Protect the part as is done for a plaster bandage. Bandage the limb loosely with an ordinary gauze bandage, paint this bandage with silicate of sodium, apply another bandage and paint it, and so on until six layers are applied. Gauze bandages soaked in silicate are better than ordinary bandages. Silicate dressings require from twelve to eighteen hours to dry, and they are removed by softening with warm water and then cutting.

XXXV. PLASTIC SURGERY.

Plastic surgery includes operations for the repair of deficiencies, for the replacement of lost parts, for the restoration of function in parts tied down by scars, and for the correction of disfiguring projections. A plastic operation can be successful after lupus only when the disease has been cured. It is useless to do a plastic operation during active syphilis, and a plastic operation for a syphilitic loss of substance is to be performed only after the patient has been thoroughly treated and the disease has been apparently cured. The first step of a plastic operation consists in making raw the surfaces which are to be brought together; the

1 La Semaine Méd., Nov. 3, 1895.

second step is the complete arrest of bleeding; the third step is the approximation of the surfaces without tension; the fourth step is to close any gap from which tissue may have been transplanted; and the final step is the application of the dressings.' The following are the methods used: 2

Displacement is the method of stretching or of sliding: (1) approximation after freshening the edges (as in harelip; (2) sliding into position after transferring tension to other localities (linear incisions to allow of stretching of the skin over large wounds). Interpolation is the method of borrowing material from an adjacent or a distant region or from another person: (1) transferring a flap with a pedicle, which flap is put in place at once or is gradually gotten into place by a series of partial operations (as in rhinoplasty, when a flap is transverse from the forehead); (2) transplanting without a pedicle, which is performed by placing in position and by fixing there portions of tissue recently removed from the part, from another part of the same individual, or from a lower animal (as replacement of the button of bone after trephining, transplanting a piece of bone from a lower animal to remedy a bone-defect in a human being, or the grafting of a piece of nerve from a lower animal or an amputated human limb to remedy a loss of nerve in a human being in nerve-grafting, or skin-grafting). Retrenchment is the removal of redundant material and the production of cicatricial contraction.

Skin-grafting.-In Reverdin's method the surface to be grafted should possess healthy granulations which are at the skin-level. The grafts should, if possible, come from the person to be grafted.

Grafts may come from another person or from a lower animal, but such grafts are not apt to grow, and even when they do grow fail to furnish a secure cicatrix. Frogskin furnishes unsatisfactory grafts. Arnot has employed the lining membrane of a hen's egg, cut in strips and applied upon the wound with the shell-surface uppermost. Lusk has blistered the skin with cantharides and grafted portions of the epidermis. In order to graft small fragments of human epithelium, cleanse the skin from which the grafts are to come, the ulcer, and the skin about it, and, if corrosive sublimate is used, wash it away with a stream of warm normal salt solution. Thrust a sewing-needle under the epidermis to raise it, cut off the graft with a pair of scissors, and place the cut surface of the graft upon the 1 American Text-book of Surgery.

2 Ibid.

ulcer.

After applying a number of grafts, place thin pieces of gutta-percha tissue over the grafts and extending on each side of the ulcer, and so placed as to have distinct intervals between them, the gaps permitting drainage. This tissue, after being asepticized, is moistened with warm normal salt solution (of 1 per cent.). Dress with a pad of aseptic gauze moistened with salt solution; place over this gauze a rubber-dam, and over the latter absorbent cotton and a bandage. In the case of children apply a light silicate bandage. Put the patient in bed. In forty-eight hours remove all the dressings except the gutta-percha tissue, irrigate with normal salt solution, and reapply the dressings. All signs of the grafts will often have disappeared. In a day or two, at the site of grafting, bluish-white spots should appear, which are islands of epidermis. Each graft is capable of forming about half an inch of cicatrix. Grafting also stimulates the edges of the ulcer to cicatrize and contract. At the end of seven days the special dressings can be dispensed with. The spot from which the grafts are taken is dressed antiseptically. Reverdin's method does not limit cicatricial contraction to any great degree, and the new skin is apt to break down.

Thiersch's Method.-Thoroughly asepticize the ulcer, the surrounding skin, and the site from which the graft is to come (the inner side of the arm or the thigh), and wash away the mercurial preparation with normal salt solution. Apply dressings wet with salt solution. On bringing the patient into the operating-room remove the dressings from the ulcer, scrape the ulcer and its edges, irrigate with salt solution, and compress to arrest hemorrhage. Grafts are then obtained by putting the prepared skin upon the stretch and cutting strips with a razor. While the razor is being used the part is constantly irrigated with salt solution. Mixter's apparatus enables one to perform this operation with great neatness and speed. This apparatus consists of a knife and an open square with sharp points on the under surface. The square is forced down upon the front of the thigh, the epidermis mounts up in the opening to above the level of the metal sides, and the grafts may be cut with ease. In Halsted's clinic the skin of the thigh is made tense by pressing upon it with a piece of asepticized wood, the wood is drawn slowly along, and is followed closely by the sharp catlin, with which the surgeon cuts long grafts. The grafts are pressed into place, and each graft overlaps a little the edges of the wound and the adjacent grafts. The skin-wound is

dressed antiseptically, and the grafted area is dressed as in Reverdin's method. Recently it has been suggested that a ring of aseptic gauze be made to encircle the limb below the grafted area, and another ring above the grafted area; on these pads little strips of wood wrapped in aseptic gauze are so laid as to make a cage, and around this cage the dressings are applied (moist chamber plan).

FIG. 280.-Mayer's dressing for Thiersch's method of skin-grafting (Am. Text-Book of Surgery.

Krause's Method. In this method the grafts are composed of the entire thickness of the skin. The ulcer is extirpated and asepticized and bleeding is arrested. The flap is cut one-sixth larger than the surface to be covered. Fat is kept out of the graft. The bit of tissue is laid upon the ulcer, the edges of the graft being brought against the edges of the

FIG. 281.-Indian method of rhinoplasty. FIG. 282.-Italian method of rhinoplasty. ulcer. It is not necessary to employ sutures. The part is dressed in a moist chamber. If the graft perishes, remove it.

Rhinoplasty.-The complete operation may be performed by transferring a flap from the forehead. This is known as the Indian operation. The edges of the defect are made raw. A model of the desired nose is made out of guttapercha, and its outlines are marked upon the forehead, and the cut is made one-quarter of an inch outside of the outline so as to allow room for retraction. The flap is turned down and sutured in place (Fig. 281), care being taken not to cut off the blood-supply in the pedicle. Plugs of gauze or tubes are inserted to support the flap.

The complete operation can be performed by the Italian method (Tagliacotian method). In this method the flap is marked out on the arm, and is made twice the size of the desired nose, and the flap is left attached by a broad pedicle. The nasal defect is sewed, and the flap is sutured in place, the hand being held upon the head by a special apparatus (Fig. 282). The raw surface upon the arm is dressed. In about three weeks the flap is cut loose from the arm, and is pared and corrected as may be necessary.

The operations for harelip and cleft palate, and plastic operations on muscles, nerves, tendons, and bones, are considered in other portions of the work.

XXXVI. DISEASES AND INJURIES OF THE GENITOURINARY ORGANS.

Hematuria. By this term is meant the voiding of bloody urine or pure blood, the blood arising from any portion of the urinary apparatus, and the condition being a symptom and not a disease. Hematuria may be a symptom of disease or of injury of some part of the urinary system, of blood-disorganizations (purpura, scurvy, or variola), or of metallic poisoning (mercury, lead, or arsenic). The color of the urine in hematuria may be anything between a light red and a decided black, but these colors may be produced by agents other than blood. Senna and rhubarb make urine red; carbolic and salicylic acids, brown; beet-root and sorrel, the color of blood; methylene-blue, blue. In jaundice, melanosis, and splenic fever the urine becomes brown. Be sure that bloody urine in the female is not due to admixture with menstrual blood.

Tests for Blood.-Spectroscope Test.-Fresh urine. diluted with water shows the two absorption-bands of oxyhemoglobin. The addition of ammonium sulphid causes the two bands to give place to the band of reduced hemo