To prevent syphilis in the male.-"Immediately after the prophylactic treatment for gonorrhea above described, anoint the whole penis, especially the glans, corona and foreskin, and also the anterior portion of the scrotum, with 33% per cent. calomel ointment, rubbing in thoroughly, taking at least ten minutes for the operation. Cover with oiled silk or wax paper, and allow to remain for several hours before washing the parts. Since the water content of the base renders the calomel more active, it is important that the ointment be made with lanolin instead of the fats usually employed for salves. Care should be exercised that the lanolin is not anhydrous."

BLADDER IRRIGATIONS

The bladder may be irrigated by means of a single catheter by injecting fluid to a sufficient amount, and then disconnecting the catheter from the reservoir and allowing the fluid to run out into a pus pan or other receptacle. Or, a two-way catheter may be used, one tube for the injection and the other tube for evacuation. Or, at times it is best, after filling the bladder, to allow the patient to evacuate the liquid after the catheter has been removed. The elevation of the reservoir should not be over three feet, and the injection should cease as soon as the patient complains of distention. When there is infection and pus in the bladder, great care should be taken not to allow sufficient pressure to force liquid up the ureters. Also, it is often inadvisable to pass catheters through an inflamed urethra, as many irrigation processes have caused secondary inflammation of an otherwise healthy bladder.

The solutions used should be warm, best about 101° F. in the reservoir, and mildly antiseptic and cleansing solutions may be used, as boric acid, borate of sodium, physiologic saline, bicarbonate of sodium, or permanganate of potassium solutions. Sometimes small injections, with a proper syringe, into the neck of the bladder of a weak solution of nitrate of silver, or other silver solution, may be advisable; or a larger injection of a very weak silver solution may be used. One must be sure, however, that these larger silver solutions are almost immediately

completely evacuated. If not, they must be washed out, perhaps with a neutralizing sodium chloride solution.

Bladder washings should not be done unless there seems to be a positive necessity. Many bladder inflammations can be cured by rest, diet, hot sitz baths, free ingestion of water, prostate and seminal vesicle massage when it is indicated in the male, relief of constipation and of disturbed rectal conditions, correction of other coincident pelvic disturbances in the female that may cause reflex bladder irritability, and by proper medication. Chronic cystitis, however, may require for a time daily bladder washings.

Cystoscopic examinations require the bladder to be filled with liquid, and great care must be exercised lest bleeding be caused. Injections of fluids into the pelvis of the kidney by catheterization of the ureters is very difficult, and should be attempted only by a physician or surgeon who has thoroughly acquired the technique.

VAGINAL IRRIGATION

There is considerable difference of opinion as to the frequency with which, in normal women, the vaginal douche should be used. It is claimed by some gynecologists that the daily vaginal cleansing douche is harmless and advisable. Others state that it tends to remove normal secretions and make the mucous membrane unhealthy. It is quite possible that the middle ground should be taken, that with normal secretions and without purulent catarrhal inflammation, and with the patient having a daily or every other day sitz bath, the vaginal douche is unnecessary, though advisable after menstruation.

Various apparatus are offered for vaginal douching; the best is the fountain syringe and a glass tube with a closed end and fenestræ on the sides. The tube should be passed well up toward the uterus, and then gentle warm irrigation from a douche bag may be given. For cleansing purposes the temperature may be anything that the patient desires. When there are indurations or firm exudates in the pelvis, or if it is desired to cause local heat to aid in the absorption or removal of inflammatory exudates, hot douches may be used, as 110° F., or even

hotter. It is a question whether such injections are any more valuable than the sitz bath would be, or as valuable, in fact.

The solutions used may be simple physiologic saline, or boric acid or borate of sodium solutions of a strength of 1 to 2 per cent. The majority of the advertised powders to be used for this purpose are largely and mostly boric acid.

The best vaginal irrigation occurs when the patient lies on her back at the edge of the bed, on a Kelly pad or on some other arrangement for the water to flow out into a receptacle. Or these douches can be well given in the bath tub. The patient should, with her hand, close the orifice of the vagina around the tube to allow the fluid to completely fill the vagina.

Permanganate of potassium solutions, and, at times, stronger antiseptic solutions may be used, when ordered and supervised by a physician. In various conditions of the cervix or the upper vagina antiseptic tampons, made of ichthyol or boroglycerin, have their therapeutic use.

INTRAUTERINE IRRIGATION

This is not a frequent procedure, except after dilatation of the cervix and curettage, but it has been used to stop uterine hemorrhage, the water being at a high temperature, as 125° F. The solution used is always sterile water or physiologic saline, or possibly boric acid solution. The pressure of any uterine injection must not be sufficient to cause liquid or secretions to be driven into the Fallopian tubes. In septic uterine conditions intrauterine irrigation is in complete disrepute, and there probably is no excuse for such treatment as long as there is free drainage. Irrigations in this condition have increased, rather than diminished, infection.

HYPODERMATIC MEDICATION

This is a most useful method of administering drugs when quick action is desired, but with the multiplication of ampules of active drugs and of hypodermic tablets, and with the wave of vaccine treatment that is now rising, the tendency is to use the hypodermic needle too frequently.

An all-glass hypodermic syringe is generally the best; the plunger should be removable so that a tablet may be dropped into the barrel for solution. The proper method of using a hypodermic syringe is as follows: a teaspoonful of clean water should be boiled over an alcohol lamp or gas flame; the barrel of the syringe should then be filled, or half filled (many tablets for hypodermic medication require but one mil of water for their solution and it is unnecessary to cause the disturbance of injecting a greater amount) with the boiled water; the needle end of the syringe is then stopped with the finger (the hands being clean), the plunger is then removed, and the tablet is dropped into the hot liquid; the plunger is then gently re-inserted, the barrel inverted, needle end up, and the solution is agitated until the tablet is thoroughly dissolved. When the plunger of the syringe cannot be removed, the proper method is to fill the syringe with the required amount of boiled water from the spoon; the spoon is then emptied, and the water from the barrel of the syringe is forced out into the spoon, the tablet is dissolved in the water in the spoon, and, after solution has occurred, the fluid is again sucked into the barrel. In either case, the needle, previously sterilized, is now adjusted to the syringe, and the syringe is then held, needle upward, and slowly the air bubbles are forced out until the first drop of liquid appears at the orifice of the needle and the syringe is ready for use.

The parts of the body usually selected for hypodermic injection are the arms and legs, often best the inner surfaces, as the more flexible and the softer the skin, the less pain the injection will cause. The blood-vessels, especially the surface veins, and the nerves must be avoided, and injection should not be made where the skin is close to the bone. The skin of the part selected should be painted with iodine or washed with hot water or alcohol. A portion of the skin is then pinched between the thumb and forefinger of one hand while the other hand introduces the needle into the fold of the skin so pinched, generally upward toward the body, almost parallel to it but at a slight angle, through the skin. The needle must be sharp, clean, and perfectly beveled; it is inexcusable to use a needle with a shoulder. If a proper needle is rapidly thrust through the

skin, there is practically no sensation. The thumb and finger holding the skin is now relaxed and gently holds a larger portion of the tissues to be injected. The piston, or plunger, should then be depressed steadily, not too slowly or too rapidly, until the whole injection has been given. Too slow injection is wearying to the patient; too rapid injection tears the tissues. The needle is now quickly withdrawn, and the part injected should be gently stroked upwards, which aids in the distribution and absorption of the fluid.

The needle should go well through the skin into the loose connective tissue beneath it. All fascia, tendons and muscle sheaths must be avoided. Also, as above stated, where the skin is bound down tightly to the underlying tissues is not a suitable place for a hypodermatic injection. With an aseptic syringe and needle and clean methods an abscess should never occur from a hypodermic injection.

Some drugs, or their preparations, for hypodermatic use, are but slowly absorbed from subcutaneous tissues, or cause pain after they are injected. These should be injected deeply into the belly of a muscle, as a deltoid or a biceps; injections of mercury are often given into the gluteal muscles. Absorption is very rapid of soluble drugs injected intramuscularly, next in rapidity to when they are injected intravenously. The drugs that are best given intramuscularly are: ergot, digitalis, camphor, arsenic and quinine preparations, strophanthin (when not given intravenously), epinephrine and pituitary solutions. All drugs should be thus administered when a patient is in a condition of shock, and hence has a very sluggish surface circulation.

The endermic method, i.e., the injection of substances between the layers of the skin, is used only for local reaction, for vaccine and protein tests.

ASPIRATION

By this term is meant the removal by suction of fluid of any kind from any part of the body. If there is any considerable amount of fluid to be removed, some large vacuum suction apparatus should be employed. A small syringe with a longer needle than the regular hypodermic needle and with a barrel