MISCELLANEOUS.
=Hair Suture.=—This is useful to bring the margins of small scalp
wounds together, where plasters are not employed. It consists in
taking a lock of hair ½ or ¾ of an inch on each side of the wound,
and tying them together over a double thickness of lint; by this
means the margins of the wound are kept together, and the dressing in
place. The slits left after the removal of small sebaceous tumours
are very conveniently treated in this way.
[Illustration: Fig 70.—Eye Douche.]
=The Eye Douche= is a small elastic bottle fitted with a nozzle and
flexible tube, ending in a rose, through which, by means of a valve,
the water is drawn from a vessel and driven in a fine spray over the
eye held open to receive it (see fig. 70). The syringe in fig. 70 is
very useful for a variety of purposes.
=Eye-Drops.=—Little bottles are sold by chemists for this purpose,
with a tubular stopper; at one end of the stopper is a fine jet, the
other is closed by a piece of indian rubber stretched over it; on
pressing this a drop escapes from the jet. In dropping astringents
into the eye the patient should put his head well back; while the
surgeon raises one lid from the eye, drops in the lotion, and then
raises the other and drops it in again, and tells the patient to
move his eyelids about a little to force the lotion over the whole
conjunctiva.
[Illustration: Fig. 71.—Syringe for sending a continuous current into
the nose or ear, &c.]
=Syringing the Ears= is best performed by a syringe having a long
nozzle to direct the current of soap and water down the meatus on
to the wax. Figure 71 consists of a syringe with double opening
and air chamber; when in action it supplies a continuous gentle
current, which breaks up the concretions more speedily and with
less discomfort to the patient than the intermitting jet of a
common syringe; but an important part of the apparatus is the long
slender nozzle to direct the stream well into the meatus. The
instrument-makers supply a little spout or shoot to hang under the
ear, to turn off the water into a basin clear of the neck. If time
permit, the patient should keep the ear charged with olive oil for a
few days before syringing, that the wax may be softened. After the
wax is removed, the irritation of the canal is best allayed by a
little glycerine or olive oil put into the meatus, and covered by a
pledget of cotton wool, large enough to fill the concha and too large
to enter the passage, where it may be lost sight of.
=Ice-Cold Injection.=—In obstinate epistaxis the nares are sometimes
plugged, but, before proceeding to this painful mode of treatment,
a simpler plan should first be tried; namely, the _injection of
ice-cold water_ into the nostril along which the blood flows. The
stream should be directed upwards that the water may first dislodge
the clots entangled in the meatuses, and then flow over the bleeding
surface. This is best done by employing a clyster or douche bottle
(see fig. 71), one tube of which lies in a vessel of ice-cold water
(containing solution of gallic acid or other styptic if desired,
though cold water alone usually suffices), the other tube, having a
long narrow nozzle, is passed up the nostril and directed upwards
among the spongy bones. With this apparatus the water is injected
steadily for half an hour, before being abandoned as unsuccessful.
The patient is kept still, sitting upright in a cool room. If these
means fail to check the flow of blood, the nares may then be plugged.
=Plugging the Nares.=
_Apparatus._—1. A flexible catheter, No. 7, or Belloc’s sound.
2. Whipcord.
3. Lint.
4. Scissors.
Step 1. Roll up a strip of lint tightly into a mass, 1 inch broad and
½ an inch thick, trim the ends away with scissors till the mass is of
a size to enter a posterior naris, then tie the wedge in the middle
of a yard of doubled whipcord. If blood trickle down both nostrils
both must be plugged, and two such plugs must be prepared; next, make
two similar rolls of lint, and tie these up with a short piece of
silk or twine to prevent their unrolling.
Step 2. Pass along the interior of the catheter a yard of twine,
and draw its end through the eye of the catheter a few inches, then
introduce the catheter through the naris directly backwards, not
upwards nor downwards, because, when the patient is upright, the
floor of the nose is nearly horizontal. When the catheter has reached
the pharynx, the finger, or a forceps, must be passed through the
mouth to catch the string hanging from the end of the catheter and
bring it out of the mouth, where it is held while the instrument is
withdrawn from the nose. The step is repeated in the other nostril if
required.
Step 3. Next wash out the nostrils with a few syringefuls of
ice-cold water, in which some tannin is suspended.
Step 4. Fasten the double string of the plug to the end of twine
hanging out of the mouth (see fig. 72), and then draw out the other
end through the nose; this will carry the plug to the pharynx, where
the finger guides it over the soft palate and thrusts one of its ends
into the naris, where the strings draw it tight. The plug for the
anterior nostril is then put in place, and the strings tied tightly
over it (see fig. 73). Thus the plug in front keeps the plug behind
in place and _vice versâ_. The end of string from the posterior
nares, left hanging out of the mouth, must next be tied to the string
of the anterior plug to keep it out of the patient’s way, till wanted
to withdraw the posterior plug, when that is to be removed. If blood
run from both sides, the other nares are stopped by a repetition of
this operation.
[Illustration: Fig. 72.—Plugging the nares. Belloc’s sound passed
through the nares, and projecting at the mouth.]
This apparatus is very painful, and, if borne so long as a couple
of days, should always be taken out then. If bleeding recur, which
is very unlikely, fresh plugs must be introduced. Sometimes the
posterior plugs are soaked in styptic solutions; this is bad, because
the bleeding part is not at the posterior nares, and the styptics
increase the soreness the plugs themselves produce.
[Illustration: Fig. 73.—Plugging the nares; the strings from the
posterior plug tied over the anterior plug.]
[Illustration: Fig. 74.—Belloc’s Sound, for drawing a thread from the
mouth along the nares.]
=Belloc’s Sound.=—Fig. 74 is a curved silver cannula like a female
catheter, furnished with a long spring stylet, that arches round in a
circle when thrust out of the cannula, and has a hole at the end to
carry a thread. The long stylet can be unscrewed into two parts, when
not in use. The figure represents the instrument with the stylet
ready for protrusion, and the same arching forwards after it is
protruded.
The cannula is passed along the nares till the end reaches the
pharynx, then the stylet is protruded and arches forward till it
reaches the teeth, when a thread is passed through the hole, and
the stylet being withdrawn, the thread is carried with it into the
pharynx and through the nostril, where it can be used to draw the
plug into its place at the posterior nares.
=Tooth Drawing.=—A surgeon is frequently required to draw a tooth on
emergency, and should be provided with instruments (see fig. 75).
Seven pairs of forceps and an elevator are sufficient for all he is
likely to deal with. They are differently shaped for the different
teeth, which vary much at the neck, the part grasped in the forceps.
[Illustration: Fig. 75.—Tooth Forceps.]
For the operation the patient should be seated in a high-backed
chair; the surgeon stands at his right side, holds the jaw with his
left hand, while with the right he thrusts the beaks of the forceps
between the gum and the tooth on its lingual and buccal aspects;
having reached the neck, he holds the tooth firmly, pushing it
inwards and outwards with a rotary motion of the wrist (except for
the molar teeth). Sudden tugs break the tooth and leave the fang
behind; when loosened by rotation and lateral motion, the forceps
readily lift the tooth out of its socket.
For the _upper incisors_ the beaks of the forceps are straight,
slightly hollowed inside, to give them hold of the teeth, and have
crescentic edges (see fig. 76).
The _upper incisors_ and _canines_ can be drawn by the same pair, as
the shape of these teeth at the neck varies to a small extent.
For the _lower incisors_ a very narrow forceps is necessary. The
beaks (fig. 77) should be curved at the joint sufficiently to form
an angle of 25° with the handles, that the latter may clear the
upper jaw. The edge of the beaks is crescentic, similar to that of
the upper incisors. These forceps are also very useful for removing
roots, as their fineness enables them to sink between the stump and
the alveolus with ease.
[Illustration: Fig. 76.—Upper incisor tooth and forceps.]
[Illustration: Fig. 77.—Lower central incisor and forceps.]
[Illustration: Fig. 78.—External aspect of upper bicuspid tooth, and
bicuspid forceps.]
For the _bicuspids_, beaks with crescentic edges also are used, but
the inside of the beak is more hollowed to fit the round neck of
these teeth (see fig. 78). All the bicuspids can be drawn with the
same pair, but it is convenient to have forceps bent at the joint to
clear the upper jaw when extracting a lower bicuspid (see fig. 79).
[Illustration: Fig. 79.—Lower bicuspid forceps.]
For the _upper molars_ two forceps are required, one for each side of
the jaw; the beaks of these are well hollowed to admit the crown of
the tooth. The inner beak terminates in a crescentic border to fit
the large internal fang (see figs. 80 & 81); the outer beak has two
smaller grooves separated by a point, that passes between the two
external fangs.
In drawing these teeth the forceps should be thrust as high as
possible and held firmly, while the fangs are loosened by moving the
tooth from side to side, but from the multiplicity of fangs, rotary
motion is not available.
[Illustration: Fig. 80.—Left upper molar tooth and forceps.]
[Illustration: Fig. 81.—Right upper molar forceps.]
The _wisdom molars_ are often difficult to seize from being almost
buried in the jaw; as they resemble a bicuspid in shape, bicuspid
forceps (fig. 78) should be employed; if this fails to penetrate
between the tooth and the alveolus, the narrow incisor forceps (fig.
77) can be driven up till it grasps the tooth. Not unfrequently the
fang of this tooth in the lower jaw is curved backwards and prevents
extraction when the tooth has been loosened; this difficulty may be
overcome by pushing the crown of the tooth a little backwards so as
to tilt the fang forwards out of place.
When the molars are closely set, or the tooth to be extracted is
overhung by its neighbour, it is often difficult to avoid tearing the
gum extensively and even carrying away more than one tooth; tearing
the gum is easily avoided by lancing it before applying the forceps,
and slow and steady movements of the wrist usually prevent the latter
accident, or the overhanging tooth may be filed away before the
forceps are applied.
The _inferior molars_ (fig. 82) have forceps, whose beaks are doubly
grooved and pointed, to enable them to seize the neck on each side
between the two fangs.
[Illustration: Fig. 82.—Inferior molar tooth and forceps.]
[Illustration: Fig. 83.—Elevator.]
In _raising stumps_, so much decayed that the forceps will not hold
them, the elevator must be employed; this instrument (fig. 83),
straight, pointed, and a little grooved at the point, is thrust
down between the alveolus and the tooth; the jaw being then the
fulcrum, the elevator is the lever to push _forwards_ the fang; when
thus loosened it is easily lifted out. In working with an elevator
there is some risk of thrusting the point through the alveolus, and
wounding the tongue or floor of the mouth, hence it should always be
guided and covered by the left forefinger. In removing the fangs of
incisors the narrow forceps are most useful, and should it not be
possible to penetrate between the fang and the alveolus, the alveolar
border may be included in the grasp of the forceps and brought away
with the tooth. The injury thus inflicted is very unimportant and
much pain is saved.
After the tooth is extracted the mouth should be well washed
with warm water a few times, the attending bleeding being of no
importance, except in individuals of hæmorrhagic diathesis, in whom
measures should be at once taken to arrest the flow.
_To stop a bleeding socket_ the alveolus must be well cleared of
clots, and fragments of sponge, soaked in a solution of perchloride
of iron, one part of the salt to three of water, packed into the
cavity. A plug of cork is placed between the jaws, and a four-tailed
bandage (see page 32) carried round the head to keep them firmly
closed. Should this plan fail, the socket must be cleared again, and
the wire of the galvanic cautery pushed well down to the bottom and
then heated till it has cauterised the cavity (see page 168).
=Nipple Shields and Artificial Nipples= made of flexible ivory,
vulcanized india-rubber, &c., are required when the nipple is chafed
and excoriated by the child’s sucking, especially if his mouth be
attacked by thrush, as is usually the case. When the nipple is sore
it should be well washed and dried after suckling, covered with
glycerine of starch or plastic collodion and protected by a shield.
If much inflamed it may be wrapped in lint dipped in alum water or
solution of sulphate of zinc (one grain to the ounce), and deep
chinks should be freely rubbed with lunar caustic. The breast should
be regularly emptied by the breast-pump if the child’s sucking gives
much pain, lest the accumulation of milk in the ducts cause milk
abscess.
=Plugging the Vagina= is employed in cases of rapid hæmorrhage from
the womb, &c.
_Apparatus._—1. A silk pocket-handkerchief.
2. A dry new fine sponge or pellets of cotton wool.
3. Silk thread.
4. A body roller or folded sheet.
The sponge should be cut into pieces the size of nuts; if the
sponge is compressed it answers better. When prepared, the vagina
should be cleared of coagula by a syringeful of ice-cold water; the
handkerchief, unfolded and thrown over the right hand, is passed up
the vagina till its centre reaches the os uteri, the borders and
ends then project from the vagina. The interior of the handkerchief
is next filled by firmly packing the sponge in bit by bit until the
vagina is distended by the mass; the ends of the handkerchief are
then tied together. The sponge swells as it absorbs the blood, and
compresses the bleeding vessels by its distention.
The abdomen and uterus are then supported by a body roller, or folded
sheet, wrapped tightly round the hips and waist, while the patient,
lightly clad, is kept quiet in a cool chamber.
When the plug has answered its purpose it is removed, by withdrawing
the sponge bit by bit, and the vagina is washed with tepid water.
_The kite’s-tail plug._—Masses of cotton wool the size of a hen’s
egg are tied at two inches distance from each other along a long
string. When about a dozen are tied on, a speculum is introduced, and
the first ball of wool is passed to the bleeding point and pushed
firmly against it, and then another, and so on, until the vagina is
firmly packed. An end of string is left hanging out of the vulva,
whereby the plug may be removed when necessary. Each mass comes away
successively with ease as the string is pulled out of the vagina.
=Injecting the Urethra= often fails from the inefficient mode in
which it is done. The syringe employed should be short enough to be
worked easily with one hand, and need not contain more than one or
two tea-spoonfuls, as the capacity of the urethra does not exceed
that amount. One of such a size is just 2 inches in length, and
easily worked by one hand. The opening through the nozzle should also
be wide, that a forcible stream may be injected into the urethra.
The patient should fill the syringe, then place on a chair or stool
before him a chamber pot, and, having just made water to clear out
the discharge collected in the urethra, he inserts the slightly
bulbous nozzle into the meatus urinarius. He then grasps the sides
of the glans with the left forefinger and thumb to close the mouth
of the passage. The right forefinger next presses down the piston
slowly, so that the whole of the injection passes into the canal and
distends it; keeping the meatus shut with his left finger and thumb,
the patient lays down the syringe and rubs the under part of the
penis backwards and forwards, that the injection may be forced into
any folds or follicles of the mucous membrane. Having thus occupied
about thirty seconds, he releases the mouth of the passage, when the
fluid is ejected sharply into the vessel placed ready to receive
it. This rapid ejection is a test of the proper performance of the
operation.
In counselling the use of astringent solutions, the surgeon should
always caution the patient not to employ one that produces severe
smarting, which lasts more than a few minutes after injection. If it
causes much pain, the solution is too strong.
=Catheters and Bougies.=—Silver catheters are made in sizes,
increasing from No. ¼ to No. 12, the first having a diameter of
0·64 inch, the latter 0·25 inch. Larger ones than these are seldom
employed.
[Illustration: Fig. 84.—Silver catheter.]
[Illustration: Fig. 85.—English Flexible catheter.]
The curve preferred by different surgeons varies much; that depicted
in fig. 84 is the one used by Sir Henry Thompson; it begins at 3¼
inches from the point, and ends when the point is at right angles
with the stem. Each catheter is fitted with a wire stylet.
The flexible catheters are of many kinds; the English gum-elastic
(fig. 85), the French black flexible (fig. 86), and the vulcanised
india-rubber (fig. 87), catheters, being the three varieties most
generally employed. English flexible catheters should be kept on
stylets well curved at the last 3 inches, that, when the stylet is
withdrawn, for the catheter to be passed, the latter may retain
sufficient curve to pass over the neck of the bladder easily.
[Illustration: Fig. 86.—French bulbous-ended catheter.]
[Illustration: Fig. 87.—Vulcanised india-rubber catheter.]
=Sounds= are solid, being of steel, plated or gilt. Their curve
varies, and is generally 20 or 30 degrees more obtuse than that of
the catheters.
=Bougies= are made of the same materials as the flexible catheters;
they are kept straight, and the more supple they are the better,
the black bulbous-ended bougies being the most useful variety for
dilating the urethra.
[Illustration: Fig. 88.—The Olive-headed bougie.]
=Olive-headed Bougies= (_Bougies olivaires_) are used for exploring
the urethra in cases of gleet, where the discharge is often kept
up by a stricture or a tender patch of chronic inflammation of the
mucous membrane. They are made of metal, or of black gum mounted
on a very flexible leaden wire; the latter kind are far preferable.
The stem of the instrument is slender, no bigger than a No. 3 or No.
4 bougie; the end terminates in a conical point about ¼ or ⅜ of an
inch long, expanding at its base to any required size. These bougies
are most useful from No. 4 to No. 16 of the English scale, or from
No. 10 to No. 24 of the millimetrical scale. The stem should be
marked with white rings an inch apart, so that when the instrument
is passing over a tender part, or is arrested by a stricture, the
distance of the impediment down the urethra can be at once estimated.
In withdrawing the instrument, the wide base of the olive shows
the exact position and length of those strictures which are not
too narrow for the olive-head to slip by, for it is nipped by the
stricture and released as soon as the narrowing is passed. By using
instruments large enough to fill the normal urethra, an induration
beneath the mucous membrane can be detected in its earliest stage
before it has produced symptoms diagnostic of stricture.
Rigid instruments have one advantage over flexible ones, in that
their points can be guided by the surgeon; the points of flexible
instruments cannot be directed, hence the introduction of the latter
into a stricture is less easily managed, consequently bougies with
various kinds of points should be kept. But flexible instruments
cause far less irritation than rigid ones, and should always be
employed instead of the latter when possible: with patience and
practice much of the difficulty attending their introduction is
overcome. The French bougies, with tapering ends and bulbous points,
slip more easily through a stricture than instruments having the
same diameter throughout, and bougies with fine tapering points can
sometimes be introduced where others fail.
_Passing Catheters._—In passing instruments along the urethra the
conformation of its interior should be borne in mind. From the
meatus to the triangular ligament, the normal urethra, when gently
stretched, becomes a straight tube; having, nevertheless, just within
the meatus, a pouch in the roof, the lacuna magna, where the point of
the instrument may catch if not turned downwards. At the bulbous part
the urethra enlarges in capacity by having a slight downward curve in
its floor, just before the triangular ligament is reached. In this
depression, the beak of the catheter is apt to sink below the level
of the passage through the ligament, which is always a fixed point.
Beyond the triangular ligament the urethra curves gently upwards,
has a floor beset with irregularities, in which the point of the
instrument easily catches, if not raised as it passes along the curve.
_A Silver Catheter_ is passed most easily while the patient is in a
horizontal position, with the shoulders low and the thighs separated.
The surgeon stands on the left side of the patient, and holds the
catheter, previously warmed and lubricated with oil or lard, lightly
between the thumb and two first fingers of the right hand, the beak
downwards and the stem across the patient’s left groin. Then taking
the penis between the middle and ring fingers of the left hand, the
palm being upwards, he pushes back the foreskin with the thumb and
forefinger, and steadies the meatus while introducing the beak of
the catheter. This done, he draws the penis gently along the catheter
as the point is lowered to the perinæum, but without raising his
right wrist until the instrument has travelled 5 or 6 inches along
the passage and reached the triangular ligament. The surgeon then
carries his right wrist to the middle line of the patient’s body,
and while pushing the point onwards, raises the hand round a curve
till it again sinks between the patient’s thighs. When the bladder
is reached he withdraws the stylet that the urine may escape. Three
points of difficulty are usual in passing catheters; the lacuna magna
just within the meatus, the triangular ligament, and the prostatic
part of the urethra just before the bladder is reached. The first is
escaped by keeping the beak along the floor of the urethra for the
first two inches; the second is best avoided by raising the wrist
as the instrument passes the triangular ligament, and directing the
beak against the upper surface of the urethra, lest, being in the
enlarged bulbous part, it sink below the opening in the ligament; the
third difficulty is overcome by depressing the hand well as the point
approaches the bladder.
_To pass the catheter in the upright position_, the patient is placed
against a wall or firm object, with his heels eight or ten inches
apart and five from the wall, that he may rest easily during the
operation. The surgeon sets himself opposite the patient and grasps
the penis with the two middle fingers of the left hand, the palm
upwards; he next exposes the meatus with the thumb and forefinger,
and his right hand holding the catheter by its middle obliquely
across the left side of the patient, he draws the penis on to the
instrument till the triangular ligament is gained. He then carries
the shaft of the catheter to the middle line and, holding it by its
end, brings the right hand downwards and forwards, to carry the point
upwards over the obstruction at the neck of the bladder.
The operation should be done slowly and with great gentleness, giving
the urethra time “to swallow the instrument,” as the French surgeons
express it. Hasty or forcible movements tend to thrust the point
against the wall of the urethra, where it hitches, if it does not
penetrate and make a false passage. However easy the introduction
may have been, the withdrawal of the catheter should be always done
slowly to avoid giving pain to the patient.
When the canal suddenly contracts, as from a stricture, the point
of the sound often stops at the obstruction; by withdrawing the
instrument a little, and diverting its point to another side or
along the upper part of the urethra, a part where the obstruction
is less abrupt will often be found to let the catheter glide into
the stricture. The floor of the urethra should always be avoided, as
false passages nearly always branch off from the floor close to the
stricture.
Difficult narrow strictures are most easily overcome by injecting
a drachm of warm olive oil into the urethra, and then passing fine
black gum or whalebone bougies (_bougies filiformes_) along the
urethra. These, from their fineness (their diameter is only ⅓ or ⅔
of a millimetre, about 1/100 inch), are very apt to catch in false
passages; if so, the bougie should be left engaged in the false
passage, and held in the left hand while another bougie is passed
along the urethra; if, in its turn, this one gets into a false
passage, it also should be left, and a third passed; and so on till
all the false routes are occupied, or a bougie enters the stricture
and reaches the bladder, which is known by the readiness with which
it will pass backwards and forwards. The other bougies should then be
withdrawn, and the bougie which has passed the stricture be tied in
for twenty-four hours, until the passage is sufficiently dilated to
allow a small catheter to replace it. If the patient is not suffering
from retention of urine, there need be no anxiety about evacuating
his bladder, as urine will find its way alongside the bougie when
he attempts to make water. In passing to relieve retention, No. ½
English flexible catheter should be used instead of bougies; but
when the stricture is too narrow for these, a bougie may still be
tried, as the urine will generally dribble alongside the bougie with
sufficient rapidity to relieve the patient.
_English flexible Catheters_ should be kept on stylets curved as
represented in fig. 85, that the first 3 inches of the instrument,
when the stylet is withdrawn, may retain sufficient curve to ride
over the impediment at the neck of the bladder. In warm weather,
after being oiled, they should be dipped in cold water just before
using, to render them a little stiffer, and less likely to lose their
curve while traversing the urethra.
They may also be passed while the patient lies or stands, and the
movements are the same as for the silver catheter.
_Bulbous-ended or probe-ended Catheters and Bougies_ (_Bougies à
boule_) are always straight; their suppleness, their tapering
ends, and their smooth rounded point enable them to glide along the
urethra, and to accommodate themselves readily to the windings of the
passage; for which reason they are the easiest to pass both for the
patient and the surgeon. In passing them they are slightly warmed, if
the weather is cold, to restore their flexibility, and gently pushed
along the canal till the bladder is reached.
_Vulcanised India-Rubber Catheters_ (fig. 87) are used when the
bladder is to be kept empty; their suppleness renders them very
unirritating, and as phosphates crust on them very slowly, they may
be worn for a week without being changed.
They are easily passed by threading them on a stylet with the
appropriate curve, and lubricating them with white of egg or water,
not with grease, which injures them. The stylet is withdrawn after
they are passed.
=To pass a Catheter in the Female.=—The patient may lie on one
side or on her back; if on her side the knees should be well drawn
up; if on her back, the thighs must be somewhat separated. Before
introducing the catheter, a wine bottle or narrow-necked bed urinal
should be placed in the bed ready to receive the urine. If the
ordinary slightly curved female catheter be not at hand, a No. 7 or 8
flexible one does just as well.
Having oiled the instrument, go to the patient’s back, and take the
catheter in the right hand if the patient lies on her right side, and
in the left hand if she lies on her left side; if she lies on her
back, go to either side and take the catheter in the hand nearest her
feet. Hold the stem of the catheter in the palm, so that the beak
lies against the tip of the forefinger, while the thumb and second
and third fingers grasp the stem. Then passing the hand under the
bed-clothes, seek the buttock; from that pass the forefinger to the
perinæum, and let it enter the vulva, keeping the back of the finger
against the posterior part, then pass it between the nymphæ to the
entry of the vagina. This is known by the tip of the forefinger being
lightly grasped, unless the vagina is very wide. Keeping the finger
just within the entry, feel for the arch of the pubes in front;
having found this, withdraw the tip of the finger slightly from the
vagina: in doing this, it will strike a small projection of mucous
membrane hanging just at the anterior margin of the entry. Keep the
finger steady against this, while the other hand pushes the catheter
gently onwards, which then rarely fails to enter the urethral opening
close above the projection of mucous membrane. Having penetrated the
urethra, arrange the catheter in the receptacle for the urine, and
push the instrument into the bladder.
=To Wash out the Bladder.=
_Apparatus._—1. A flexible catheter; Nos. 8 or 9 are convenient
sizes; but a smaller one can be employed.
2. A caoutchouc bottle, holding six ounces, and fitted with a
tapering nozzle and stop-cock. (Fig. 89.)
[Illustration: Fig. 89.—Elastic india-rubber bottle for injecting.]
During the operation the patient should stand, if possible, as the
mucus is thus more easily cleared from the bladder. The surgeon
first fills his bottle completely with tepid water, that no air
may remain; then directing his patient to stand against a wall or
some firm object, passes the catheter and draws off the urine. He
next inserts the nozzle into the catheter, and, turning the cock,
compresses the bottle slowly until two or three ounces of water have
run into the bladder; this he lets escape by removing the bottle
for a minute, and then repeats his operation till the water returns
clear, without exhausting the patient’s strength. Three or four small
injections wash the sediment and mucus from the bladder as quickly,
and with far less fatigue or risk of spasm than a prolonged flow
of water through a stiff double current catheter. In this way the
bladder may be washed twice or thrice daily to the great comfort of
the patient.
Injections of solutions of nitrate of silver, carbolic acid, alum,
&c., in the proportion of 1 part to 100, or to 50 of water, can be
used instead of water for this purpose.
=To Tie in a Silver Catheter.=
_Apparatus._—1. A few yards of tape ¼ inch wide.
2. A roller.
3. A spigot of wood; or,
4. A yard and a half of fine india-rubber tubing.
[Illustration: Fig. 90.—A silver catheter tied in the urethra.]
A narrow roller is tied round the hips; from this, on each side, a
tape is passed round the thigh at the groin, and fastened before and
behind to the roller round the hips (see fig. 90); a narrow tape run
through the rings of the catheter connects them with the loops in
the groins. The tapes are tied short enough to prevent the catheter
slipping out; a yard or two of narrow india-rubber tubing, fixed on
to the end of the catheter, conveys the urine to a pan under the bed,
and keeps the bed dry, or a spigot of wood fitted to the catheter may
be inserted, for the patient to draw out when he desires to void his
urine.
=To Tie in a Flexible Catheter.= (Fig. 91.)
_Apparatus._—1. A piece of soft twine, or Berlin wool, about 15
inches long.
[Illustration: Fig. 91.—A flexible catheter tied in the urethra;
the string fastened behind the corona glandis, and concealed by the
foreskin.]
A catheter is first passed into the bladder, and the urine runs off.
The catheter is then gently withdrawn, till the stream ceases, that
the end of the instrument may remain just without the neck of the
bladder. The string should be tied round the catheter ½ an inch from
the meatus, its ends gathered together and tied in a knot about 1
inch farther on. The foreskin is then drawn back, the ends passed
beneath the glans and tied round the penis behind the corona; the
superfluous string is snipped off, and the foreskin brought forward.
The catheter is cut off obliquely ½ an inch beyond the string and
then stopped with a spigot, direction being given to the patient to
withdraw the spigot, and push the catheter a little further in when
he wants to make water.
=To Tie a Patient in Position for Lithotomy.=
_Apparatus._
Two bandages, each 3 yards long and 2 inches wide, of calico or
saddle-girth, with tapes sewed on the ends.
[Illustration: Fig. 92.—Tying for lithotomy.]
The patient is laid on his back, a slip-knot made in the middle of
the bandage and passed over the wrist; the hand is then made to grasp
the foot, the thumb above, the fingers under the sole (fig. 92); one
end of the bandage is carried behind and inside the ankle to the
dorsum of the foot, where it meets the other end passing in front of
the ankle. The ends are then carried under the sole, brought up and
tied in a double bow over the back of the hand.
=Bedsores= are best treated by great cleanliness, and by washing
the skin exposed to the discharges with spirit of wine every day.
Brown-Sequard recommends cold and heat to be applied daily, by means
of an ice bag for ten minutes, followed by a warm poultice for an
hour. The pressure of the skin over the sacrum or trochanters is
prevented by a ring of soft thick felt, covered on one side with
adhesive plaster, and applied like a corn plaster _around_ the
prominent bone.
In addition to these local applications, the pressure of the body
should be evenly distributed over its under surface by placing the
patient on a water cushion, or, better, on Arnott’s water-bed.
[Illustration: Fig. 93.—Water-bed.]
_Arnott’s Floating Bed._—In the hydrostatic or floating bed of Dr.
Arnott, the patient floats on the surface of a trough of water,
into which he sinks until he has displaced his own weight of water;
his floating apparatus, or raft, so to speak, being a sheet of
waterproofing, and a thin mattress or folded blanket, on which he
lies. The bed consists of a trough running on large castors, about
8 feet long, 2 feet 8 inches wide, and 1 deep, with a tap at the
bottom for letting out the water, and a spout in one corner to fill
it by. Over the top a macintosh cloth is spread, its edges being
firmly nailed to the margin of the trough, but the cloth is left
slack enough to float easily on the surface of the water when the
trough is partly filled. This slackness is requisite to allow the
water displaced by the weight of the patient’s body to rise up
around him without tightening the cloth, or the floating principle
of the bed is not carried out, and the pressure of the patient’s
weight not evenly distributed over his body (see fig. 93). Three
or four blankets are laid evenly over the macintosh, and these
again protected from the moisture of the patient by a macintosh
under-sheet. If a mattress is used, it must be very thin, and supple
enough to let the surface of the water adjust itself to the patient’s
body and receive the pressure evenly. The water employed to fill the
bath should be about 50°.
[Illustration: Fig. 94.—Water-cushion.]
_Water Cushions_ are flat cushions of stout macintosh cloth, half
or two-thirds full of water, and laid on the mattress beneath
the blanket and sheet (see fig. 94). They are more portable than
the water-bed, but they are simply soft pillows, and do not
counter-balance the weight of the patient in the manner of the
floating bed.
=The Stomach-Pump= is used for emptying the stomach, or for injecting
fluid food when patients refuse to swallow.
It consists of a brass syringe holding 4 ounces, of which the nozzle
is connected with two tubes, one at the end, the other at the side.
The passage through these is directed by a valve which is governed
by a lever lying on the barrel (see fig. 95). When the lever is at
rest, the current passes in and out of the syringe by the lateral
tube; when depressed, by the direct tube. The elastic tubes with
smooth nozzles, about 2 feet long, are fitted to the syringe. There
is also a gag of hard wood, having a hole in the middle, through
which the tube passes on its way to the stomach, to protect it from
the patient’s teeth.
[Illustration: Fig. 95.—The stomach-pump.]
When the pump is employed to remove the contents of the stomach,
two washhand-basins are placed at hand, one empty, one full of
tepid water. The patient is seated in a high-backed chair to steady
his head; one assistant holds his hands, while a second screws the
small end of the gag between the teeth and forces open the mouth,
across which it is then easily fixed. The flexible tube, being well
oiled, is next passed across the pharynx and down the gullet slowly
and cautiously, without staying for any effort of vomiting it may
induce; when about 20 inches are passed through the gag the nozzle
has reached the stomach. First, two or three syringefuls of water
are injected into the stomach; then, removing the second tube from
the basin of water to the empty basin, the action of the syringe
is reversed, by pressing on the lever as the piston is raised, and
letting it fly up when the piston is depressed. Thus two syringefuls
may be withdrawn, then fresh water is again injected and withdrawn,
until the contents of the stomach are removed and the water returns
clear. Precaution must be always taken not to exhaust from the
stomach before water is injected, lest the coats of that organ be
injured by being sucked against the nozzle of the tube.
If desirable, antidotes may be dissolved or suspended in the water
injected. When the pump is used for feeding patients, one or two
pints of beef tea, eggs beaten with milk or wine, Liebig’s soup, &c.,
are the kinds of food suited for the purpose. Each time the pump is
used, it should be thoroughly cleaned by syringing through it plenty
of warm water, and the tubes must be unscrewed to wipe the joints
carefully.
=Transfusion of Blood.=—The points of greatest importance in
performing this operation are:—
1. That the supply of blood come from a vigorous adult.
2. That the transfer be made within two minutes of the blood’s escape
from the vein of the supplier.
3. That, to prevent coagulation, the blood should pass over as small
a surface, and suffer as little exposure as possible in transit.
4. Care must be taken to prevent air entering the vein with the blood.
The apparatus described below is that devised by Dr. Graily Hewitt,
and depicted in the Obstetrical Society’s Transactions for 1864,
page 137. It consists of a glass syringe holding two ounces (fig.
96), with a piston easily attached and removed; its nozzle is
curved and fits the mouth of a cannula of silver. The nozzle of the
syringe is provided with a little stopper attached by a chain; a
stylet likewise fills the cannula, to be withdrawn when the blood is
injected through the latter.
[Illustration: Fig. 96.—Graily Hewitt’s syringe for transfusion of
blood.]
The success of the operation depends in great measure on the rapidity
with which it is performed, and requires the aid of two assistants
that the various steps may follow each other as quickly as possible.
_Apparatus._—1. Syringe, cannula and stylet.
2. Lancet.
3. Scalpel.
4. Forceps.
5. Three yards of tape, one inch wide, and lint.
6. A silver wire suture.
7. A basin of cold water.
8. Brandy and Sal Volatile.
Step 1. See that the piston-rod works properly in the syringe, and
that the instrument is fit for use; then place it in the basin of
cold water with the cannula to lie till wanted.
Step 2. Place the person supplying the blood on a couch or easy
chair in the same chamber, but so that he cannot see the recipient,
lest he faint and his blood consequently flow feebly. Tie up the arm
as for venesection; lay ready the lancet, and direct the assistant,
in charge of the supplier of blood, to keep his thumb on the vein
when it is opened, that the flow may be checked when blood is not
required.
Step 3. Place a tape round the arm of the recipient, above the point
for injection, and another below it at a convenient distance, and
lay bare a vein (usually the median basilic) for an inch and a half
of its course; holding the vein by the forceps, make a slit with the
scalpel and introduce the cannula, which is then intrusted to the
second assistant. The stylet is withdrawn, and a minute drop of blood
escapes through the cannula, showing that the point has been properly
introduced into the vein. The assistant replaces the stylet and
slackens the ligature, while the surgeon proceeds to fill his syringe.
Step 4. The surgeon, going to the supplier of blood, makes a large
opening in the vein with a lancet, or if the first assistant be a
surgeon also, he may do this while the chief operator is preparing
the vein of the recipient. When the vein is open and the blood
flowing freely, the barrel of the syringe is inverted over it and
filled with blood; when full, the nozzle is stopped by the plug and
the piston attached while the syringe is carried to the recipient.
Step 5. This being reached, the plug is pulled out, the nozzle
inserted into the cannula, and the blood _slowly_ injected by
depressing the piston gently, but without quite emptying the syringe.
A minute should be spent in injecting one ounce and a half, and a
pause of five minutes ensue before a second supply is introduced.
This interval may be employed in cleaning the syringe, &c., and
procuring a fresh supply of blood; 3-4 ounces of blood are usually
sufficient, but 10 ounces have been injected on some occasions.
The perturbation of the supplier (generally a near friend of the
recipient), renders it necessary he should drink freely of brandy and
water, that the blood flow forcibly when required.
Step 6. When sufficient blood has been introduced, both patients’
wounds are dressed, as after venesection (see page 20), the long
incision of the recipient being closed by a point of suture under the
pad.
=Tourniquets.=—Tourniquets are of several kinds.
_The Ring Tourniquet_ (fig. 97) is used when pressure is desired
on the main artery of such a limb as the arm. It is less easily
displaced than the Signoroni, but, like that, soon becomes irksome by
its continual pressure.
[Illustration: Fig. 97.—Ring tourniquet.]
When hæmorrhage has to be temporarily arrested, that of _Petit_ (fig.
98) is generally used. It consists of a strap of stout webbing and
buckle, that can be rapidly tightened by a few turns of a screw. To
use this tourniquet, lay a roller over the artery and carry the end
once or twice round the limb to steady the roller, then pass the
strap over the roller, keeping the buckle about two inches away from
the screw and the screw on the anterior or outer aspect of the limb,
not over the pad, lest that be displaced when the screw is tightened.
The tourniquet should be screwed up as quickly as possible, that the
limb be not charged with blood by obstructing the venous, before the
arterial flow is checked.
[Illustration: Fig. 98.—Petit’s tourniquet applied to the popliteal
artery.]
[Illustration: Fig. 99.—The horse-shoe tourniquet.]
In _Signoroni’s Horse-shoe_ tourniquet (fig. 99) the extremities of
the shoe can be approximated to each other by a rack screw working a
hinge. The ends are furnished with pads, one broad and flat to bear
on the limb away from the artery, the other rounded to compress the
vessel itself. This tourniquet does not arrest the whole circulation
in the limb. It can therefore be applied for a longer time than
Petit’s. However, it easily slips out of place, and soon becomes very
irksome and painful.
[Illustration: Fig. 100.—Lister’s tourniquet for compressing the
aorta.]
_The Abdominal Tourniquet_ of Professor Lister is a very effectual
contrivance for compressing the aorta during amputation through the
hip joint, and operations where a tourniquet cannot be placed on the
limb. It consists (see fig. 100) of a semicircular bar, with a broad
pad to fit on the lumbar vertebræ behind, while in front it holds
a long screw-pin carrying a pad. This instrument passes round the
left side, and its pad is forced down into the abdomen, one inch to
the left of the umbilicus, until the aorta is compressed against the
spine.
[Illustration: Fig. 101.—Carte’s tourniquets for femoral aneurism.]
_Carte’s Tourniquets_ (fig. 101) are employed to control and diminish
the flow of blood through an aneurism. They are intended to be
worn for several days, and are fitted with many contrivances for
obtaining a continuous pressure on the artery without completely
arresting the flow of blood. They are always used in pairs; in the
figure, one presses the external iliac on the pubes, the other the
femoral artery. The first is fastened to the body round the hips,
the second round the thigh. They are constructed as follows: an arm
attached to a pad reaches round the limb to the artery, over which it
supports a ball and socket joint turning in any direction, but fixed
by a screw clamp. This joint has a long screw carrying the compress
down to the artery. There is a little play of the screw in the ball
of the joint, controlled by india-rubber bands, that the compress
may yield slightly before the arterial pulse. In the solidification
of an aneurism by this means, the flow of the blood is intended to
continue; hence the current through the vessel need not be completely
obstructed by the pressure of the tourniquet, and the elastic bands
prevent that pressure from becoming insupportable.
When the tourniquets are applied, the patient must lie on a flat hair
mattress, have his limb well washed and dried, lightly but evenly
bandaged, and somewhat raised. If the thigh is hairy it should be
shaved where the pads will press, and dusted with powdered French
chalk. The tourniquets are next adjusted, as seen in fig. 101; the
patient is taught to change the pressure when it grows irksome, by
screwing down the second pad, and then releasing the first.
_To improvise a Tourniquet._—A tourniquet may readily be formed on
emergency from a handkerchief, a stone, and a stick. Fold a stone the
size of an egg in the middle of a handkerchief, lay it over the main
artery, tie the ends of the handkerchief round the limb, slip the
stick underneath and twist it round, till the tightened handkerchief
draws the stone on to the artery and arrests the flow of blood (see
fig. 102).
[Illustration: Fig. 102.—An improvised tourniquet.]
=Fumigation.=—Mercurial vapour baths are contrived in various ways.
The following plan succeeds perfectly well when the whole surface of
the body is to be exposed to the vapour (fig. 103).
[Illustration: Fig. 103.—Mercurial fumigation.]
[Illustration: Fig. 104.—Lamp for fumigating.]
_Apparatus._—A Langston Parker’s lamp made by Savigny and other
instrument makers. In this a spirit lamp, holding the required amount
of spirit is protected in a cage, on the top of which is a receptacle
for the calomel, and a small saucer for water (fig. 104). The flame
beneath boils the water and volatilises the calomel. Water is added,
because the calomel vapour, when associated with steam, acts more
efficiently than with dry air.
The lamp is placed under a high wicker chair, on which the patient
sits undressed, and round his neck, a frame is tied, made of cane
hoops, with a calico cover sewn over them; this falls to the ground
and encloses his body in a chamber, where the vapour is confined
while absorbed into the skin. A blanket thrown over the frame
completes the preparation. If a hoop frame be not at hand a lady’s
wire-hooped petticoat answers the purpose quite as well.
[Illustration: Fig. 105.—Lamp for local fumigation.]
The patient, in four or five minutes, usually breaks into a violent
perspiration, his pulse quickens much, sometimes even syncope occurs;
hence, he should not be left alone until the bath is over. This, if
the flame is strong and the quantity of calomel not very great—one or
two scruples being a common dose—occupies a quarter of an hour. When
the bath is over the patient should at once get into bed, and lie
there a few hours; then he may rise and be well sponged with tepid
water. Moderate but tolerably speedy mercurialisation of the system
is thus induced.
=Local Fumigation= is employed when the disease is confined to a
few obstinate patches of eruption. For this purpose an earthenware
alembic (fig. 105) is fitted to the lamp used for general fumigation;
the calomel is thrown into the bottom of the alembic. The flame plays
over the outside, and heating it, sublimes the calomel; which reaches
the mouth of the alembic and condenses on any part to which it is
applied.
The _throat_ may be fumigated by inhaling the vapour as it escapes
from this alembic, or by sucking air through the spout of an
earthenware teapot in which the calomel has been placed, and heated
by a spirit lamp underneath.
=The Hot Air-Bath= is easily obtained by undressing the patient,
putting him to bed on a mattress, and fastening across the bed two
or three lengths of cane or stout wire, over which a blanket is next
thrown. The patient’s body is thus enclosed in a small chamber, the
air of which is then heated by putting inside, on an earthenware
plate, a spirit lamp, surrounded by a kitchen lemon-grater to protect
the bed clothes from its flame. Sheets should be dispensed with while
the lamp is alight, lest they catch fire. The temperature of the air
should be watched, lest it grow hot enough to scorch, but it must be
kept up till the patient breaks into a sharp perspiration, when the
lamp may be removed and the patient allowed to cool slowly down.
The action of the bath is greatly accelerated by sponging the patient
all over as he lies in bed with tepid water, when the air grows warm.
Lamps protected with wire gauze, and furnished with a cradle to keep
the bed clothes up, are sold at the instrument-makers, but the above
arrangement answers just as well as more elaborate apparatus.
=The Vapour Bath.=—The patient is put to bed as in the hot-air bath,
and a few feet of vulcanised india-rubber tubing, fastened to the
spout of a tea-kettle on the fire, bring a supply of vapour into the
bed.
The vapour bath may precede the hot-air bath, and will quicken the
action of the latter very greatly.
[Illustration: Fig. 106.—Dr. Horace Swete’s village ambulance or sick
carriage.]
=Carriage for transporting the Sick.=
The army ambulance and the carriage of the Invalid Carriage Society
are excellent means for transporting sick from their homes, or
wounded persons from the scene of injury to the hospital. As their
cost is somewhat considerable, a cheap carriage (see fig. 106) has
been devised by Dr. Horace Swete, of Weston-super-Mare, for the
use of the district in which he is residing, and which may be kept
for use at workhouses, hospitals, and in remote districts. It is
constructed of varnished wood and iron, and in the following manner.
The dimensions of the carriage are—length, 7 feet 6 inches; breadth,
3 feet 9 inches; height, 4 feet 9 inches. Its weight is under 3 cwt.,
and its total cost 21_l_.
The body is like a skeleton hearse, without fixed floor or sides.
The sides are closed by vulcanised india-rubber curtains, or by
glass sliding panels. The back, a wooden panel, opens like a door.
A wooden tray slides on three rollers at the bottom, and on this a
mattress covered with vulcanised india-rubber is placed to receive
the patient. For infectious cases straw should be used instead of the
mattress, as it may be burnt when the patient is removed. The tray is
narrow, and fitted with handles, that it may be carried up a narrow
staircase. The vehicle runs on four wheels, is fitted with lamp,
handle, shafts, and driving box, and is well hung on good springs.
The material of the carriage admits of being washed, and thus readily
purified, after conveying an infectious case.
=Cupping=—_Dry, and Bleeding Cupping._
_Apparatus._—1. A series or nest of exhausting glasses.
2. Different sized boxes of lancets for incising the skin, called
scarificators.
3. A spirit lamp (fig. 107).
The glasses are 6 oz., 4 oz., 2 oz., and 1 oz. in size, of rounded
shape, with thick smooth edges.
In _dry cupping_ the object is to relieve internal congestion by
drawing the blood into the subcutaneous cellular tissue. The back
and loins, where the skin is tolerably loose, are most suitable
places for this proceeding.
[Illustration: Fig. 107.—Cupping glasses, lamp, scarificator, and
spirit bottle.]
_The Operation._
Step 1. Light the spirit lamp, direct the patient to sit forwards,
and lay bare the back ready for the glasses, which should be placed
on the bed within reach of the operator’s right hand.
Step 2. Rarify the air in a glass by plunging the flame into it a few
moments, and then quickly clap the mouth of the glass on the skin;
leave it there while a second and third glass are heated and applied,
when the first should be removed and its vacuum restored before it is
replaced. In putting the glasses on again, their rims should not lie
exactly in the rings marked on the skin by previous applications, or
the bruises may inflame and slough afterwards at these parts. The
application and removal of the glasses should be done as lightly as
possible to prevent all unnecessary pain.
A few repetitions of this incomplete vacuum causes the skin to puff
up readily into the glasses, and much blood is thereby attracted into
the cellular tissue.
_Bleeding or Bloody Cupping._—When it is desired to take blood from
the body the skin is punctured or scarified by the scarificators,
half a dozen incisions being made at a blow by as many lancets
protruding from a box, when a spring it holds is touched; the glasses
are then laid over these incisions, and the necessary amount of blood
removed by their exhausting power.
[Illustration: Fig. 108.—Junod’s vacuum boot for attracting the blood
to the lower extremities.]
_Junod’s Boot_ is a tin case, shaped like a boot (see fig. 108),
but capacious enough to allow a limb when placed within it to swell
freely. It is sometimes employed to draw blood and serum into the
lower extremities during congestion of internal organs. When used,
the leg is passed into the boot, and the mouth of the boot closed
round the limb by a packing of india-rubber tied firmly round the
boot and limb, and well smeared with simple ointment. The air is
then exhausted from the inside of the boot by a small brass syringe,
which screws into a hole in the leg of the boot, as depicted in the
figure. The patient should wear the boot some two or three hours,
while the vacuum is kept up by an occasional exhaustion of the
syringe. Both limbs may be subjected to exhaustion, but the patient
must remain in bed for twenty-four hours after the operation; this is
generally necessary for other reasons, and he must wear a bandage for
a few days when he gets about.
=Leeches.=—Each leech should draw about 2 drachms of blood, and if
the bite is well fomented, another drachm will escape from the wound
afterwards.
Before the leeches are applied, the skin should be well washed with
soap and warm water, and carefully dried. The leeches should not
be taken from their box, but the box inverted over the part, when
they will quickly fasten themselves. If the leeches are applied in
a dependent position, a soft napkin may be pinned round the box to
support them as they grow heavy, and to enable them to suck as long
as possible. They should be allowed to drop off; if pulled off they
are apt to tear the wound, or leave part of their suckers in it,
which causes much irritation afterwards.
The leech is put in a little glass when applied to the gums or the
cervix uteri, and held against the part he is to suck.
If the leeches do not bite readily the part should be smeared with
blood or warm milk, and the leeches put into lukewarm water a few
minutes; immersion in small beer is also said to stimulate them to
bite.
If the bites bleed longer than is desired, they may be stopped by
pinching the skin between the finger and thumb, wiping the bite
thoroughly dry, and filling it with a little bit of amadou or fine
sponge, soaked in solution of perchloride of iron; a larger piece of
amadou is placed over the first, and the whole compressed with a turn
of a bandage or long strip of plaster. If this fails, a sewing needle
may be passed through the skin beneath the floor of the bite, and the
bleeding surface constricted by twisting a thread round it under the
needle.
Leech-bites should never be left bleeding, especially in children,
for a dangerous amount of blood may be lost from them in a few hours.
=Tents= are instruments made of some substance that enlarges as it
absorbs liquid; they are employed to dilate apertures of sinuses or
natural passages, as the cervix uteri, &c., and are generally short
rods 2 to 3 inches long, and 1/10 to ¼ inch in thickness, made of a
whalebone stem, wound round with compressed sponge, which is smeared
with wax to keep it in shape. Slips of gentian root, or of laminaria
digitata, which rapidly enlarge as they imbibe moisture, are also
employed for this purpose.
=Setons= are strips of varnished calico, 6 or 8 inches long and ⅓
broad; a thread is fastened to each end, which are tied together
while the seton is worn. It is employed to excite irritation either
along the course of a sinus, or in some superficial situation, as
the nape of the neck, to relieve congestion of internal parts. In
sinuses, a few threads of silk usually produce the required amount of
irritation.
=Chassaignac’s Drainage-tubes= are a form of seton; they are
india-rubber tubes of the calibre of a wheat straw, of any requisite
length, and perforated with holes at frequent intervals; they are
carried into the cavity to be drained, by hitching the prong of a
forked probe, made for the purpose, through one end of the tube and
thrusting it along the sinus, or across the abscess. The skin is then
incised over the further end of the sinus to bring the probe out, and
the ends of the tube are tied together.
The advantages of these tubes are, the small amount of irritation
they provoke, and the ready exit furnished for the matter along their
interior.
=Issues= are a contrivance for keeping up irritation of the surface.
A piece of diachylon plaster the size of a half-crown, with a hole
in the centre as large as a pea, is laid over the skin where the
issue is to be formed. A bit of potassa fusa is laid in the hole and
kept _in sitû_ by a second plaster, for an hour or till the skin is
destroyed under the hole. The plasters are then removed, the wound
washed, and a fresh piece of the same size put on, having at its
centre a slit ¼ inch long, under which a pea is slipped into the sore
and covered over by another smaller piece of plaster. The discharge
that soon sets up must be washed away twice daily, and the plaster
and pea renewed from time to time as they become soiled.
=Trusses= for ruptures. These are various, in shape, strength of
spring, &c.
Whatever variety of truss is employed, care should be taken that the
pressure is made in the right direction, and that it is sufficient,
but not too great for the strain it has to support.
In reducible hernia the pressure for _inguinal rupture_ should be
exerted on the inguinal canal and directly backwards (see fig. 109).
For _umbilical rupture_, the pressure should be also backwards, and
confined as much as possible to the aperture in the wall of the
belly. In _femoral_ rupture the pressure should be directed upwards
as well as backwards into the femoral ring (see fig. 110). The pad in
all should be large enough to well cover the passage through which
the rupture passes. The ease and comfort of a truss much depend on
the completeness with which it fulfils these conditions.
[Illustration: Fig. 109.—Inguinal truss.]
[Illustration: Fig. 110.—Femoral truss.]
The adequacy of a truss should always be tested by directing the
patient to separate his legs, lean forward over the back of a chair,
and cough or strain deeply. If the truss support the rupture during
this exertion it fits satisfactorily.
For _irreducible_ hernia large air-, or spring-padded trusses are
made, which prevent further descent of the viscera, but they are
exceedingly difficult to fit and often unsatisfactory in use.
In _inguinal hernia_ the truss consists of a _pad_, a _spring_, and a
_neck_, with _guide straps_.
The _pad_ is made of various materials, fine carded wool is among the
best when well stuffed into a proper shaped leather pad, and in most
cases a fixed pad is better than a moveable one.
The pad should compress the _canal_ and be convex if the patient is
stout. Its size ought to be sufficient to compress the canal and the
margins for a short distance on each side, but the pad should be as
small as will ensure fair compression. A very flaccid bellywall,
and a large gap or protrusion require a large surface on the pad.
The _spring_ should be supple and padded behind to rest on the two
sacro-iliac synchondroses, without bearing on the spine. The spring,
narrowing as it comes forward, embraces the pelvis; and opposite the
anterior iliac spine inclines downwards, because the hernia is a
little lower than the resting-place of the spring behind. When the
rupture is almost reached, the spring takes a slight elbow or bend
(the neck), that its pressure may be directed against the hernia more
fully. _Understraps_, generally not necessary, should be omitted if
possible.
In trusses for children when the testis is not descended, the pad
should have a notch at its lower border in which the testis may rest
uncompressed.
In the truss for _femoral hernia_, the _spring_ bears behind the body
and encircles the hips in the same manner as in the inguinal truss,
but when opposite the femoral artery it turns abruptly downwards to
reach the saphenous opening. The _pad_ should fit the hollow where
the rupture issues and be not oval, but rounded. The _under-strap_
should be attached to the stud at the lower end of the pad, and pass
round the perinæum and fold of the buttock, and be attached to the
neck of the spring close to the pad. It should be made of knitted
bandage that it may be changed and washed frequently.
_When measuring_ a patient for an inguinal truss, the circumference
of the body round the hips (between the crista ilii and the great
trochanter) should be first taken, and then that between the
symphysis pubis and the anterior iliac spine, half of which distance
denotes the position of the internal abdominal ring, which with the
inguinal canal has to be supported by the pad of the truss. For a
femoral hernia the same measurement should be taken round the body,
and also the distance of the saphenous opening from the symphysis
pubis and from the anterior superior iliac spine. This will enable
the maker to put the pad at the proper angle with the spring, so that
it compresses the saphenous opening, and clears the crest of the
pubes.
Every patient should, while he wears a truss, show himself from time
to time to the surgeon to see that any defect in his apparatus may be
quickly remedied. It is a useful precaution also to keep two trusses
at hand, so that if one breaks, the patient may at once apply the
other.
Salmon and Ody’s truss consists of a spring passing round the hip
from a circular pad _b_, which bears on the sacrum to a second oval
pad _a_. Both pads are attached to the spring by a ball and socket
joint. There is also a slide for shortening or lengthening the spring
if desired (fig. 111). This truss is worn round the _sound_ side of
the body and reaches beyond the middle line to the hernial opening,
with the object of directing the pressure of the spring outwards and
backwards, or exactly counter to the course of the hernia inwards.
[Illustration: Fig. 111.—Salmon & Ody’s truss.]
_Umbilical hernia._—Spring trusses are not adapted for restraining
umbilical hernia. The support consists of a broad belt fitted to
the belly, made in front of elastic webbing, and on each flank, of
white jean. Behind, the belt is fastened by straps and buckles, or by
lacing, the better plan. In the centre, the elastic part carries a
nearly flat air-cushion, measuring about 3 inches transversely and 2½
vertically. This cushion is placed against the aperture of the belly,
and presses back the protrusion. The size of the pad varies with the
size of the hernia, but it should always largely exceed the extent
of the gap in the abdominal wall. The pad, when the apparatus is
used for an infant, should not be too prominent, as it is then more
difficult to keep in place, and also by pressing into the aperture
hinders it from closing. The pad for an infant is best made of a disc
of ivory, 1½ inch broad and ½ an inch to 1 inch thick, stitched in
a little case in the centre of the girdle. The quantity of elastic
tissue should be much less in the infant’s belt than in those for
adults that the belt may be frequently washed. The difficulty of
keeping the belt in place is obviated by attaching two bands to the
upper border, to pass over the shoulders and cross behind before
fastening to the belt, like braces. Two similar ones may be fastened
to the lower border and carried under the thighs. These bands should
be of soft webbing, and several pairs kept in store, that they may be
frequently changed and washed.
=Cauteries.=
_Cautery irons._—These are masses of iron of different shapes; some
pointed, others rounded like buttons, &c., set in a stem a foot long,
fixed in a thick wooden handle. They are heated in a charcoal brazier
or common fire to bright redness if required to destroy deeply, but
short of redness if intended only to scorch the surface.
As these irons are inconvenient for many cases from their bulk, and
yet soon lose their heat if made small, other cauteries have been
devised to which the heat can be quickly renewed.
[Illustration: Fig. 112.—Gas cautery for large surfaces.]
_Gas Cautery._—The late Mr. Alexander Bruce perfected an instrument
which employs the gas flame as a source of heat (see figs. 112,
113). A blowpipe flame plays on platinum discs of various sizes, and
keeps them at a glowing heat. This hot solid point can be thrust into
the tissue wherever it is desired.
A larger form is also made for cauterising the pedicle in Ovariotomy,
&c. In this a large flame is blown on a wedge-shaped surface of
platinum, 1 inch long and ½ inch broad, and continued backwards for 2
inches by wire gauze to confine the flame against the platinum. The
flame behind these platinum discs quickly heats them again if cooled
by the blood. This cautery is very portable, and easily made ready
for use.
[Illustration:
Fig. 113.—Gas cautery. A. Elastic gas reservoir. B. Gas jet. C.
Tube for convoying air to the flame. 3. Platinum disc to be heated
by the flame.
]
Mr. Clover has also devised a cautery, very useful for small growths.
A silver bead, the size of a pea, is set at each end of a horizontal
metal rod 4 inches long, which rotates on a vertical pivot half a
circle backwards and forwards, so that one or other bead is thrown
into the flame of a spirit lamp placed at a proper distance; when the
bead is heated, a touch of the finger causes the central pivot to
rotate, which brings the hot bead away from the lamp, and carries the
cold one into the flame, to be heated while the first is used.
_Galvanic Cautery._—The instrument consists of a platinum wire, made
to glow by passing through it a powerful galvanic current. The wire
should be thick (about 1/12 of an inch), and all the other conducting
surfaces sufficiently large to offer no impediment to the current
where heat is not desired. The battery best adapted for this purpose
is a Grove’s battery.
The main advantage of a galvanic cautery is that the wire can be
passed while cold exactly where it is required, and then heated
when it is in place. It is exceedingly useful in fistulæ between
the urethra and rectum, or in destroying vascular growths, nævi,
&c., where it is desirable not to destroy all the skin covering the
tumour. Again, by this means, an intense heat can be applied to a
very limited area, and more quickly renewed than by any other plan,
for the wire, even when plunged in the tissue, is never far below a
red heat.
Of _chemical caustics_ a host exist; those most commonly employed
are:—nitrate of silver, solid, or in saturated solutions (2 drachms
to the oz. of water, &c.); fuming nitric acid; solution of nitrate
of mercury in nitric acid; oil of vitriol made into a paste with
powdered charcoal; chloride of zinc mixed with dry starch, then
rolled into cakes and cut in slices; Vienna paste, that is, equal
parts of potassa fusa and quick lime worked into a paste with spirits
of wine; potassa fusa itself; solution of chromic acid. Some surgeons
prefer one, some another; as a rule, the liquid caustics are employed
where the surface to be destroyed is uneven and spongy, and solid
caustics where the surface is smooth, and a long continued action is
desired.
_Vesicants and irritants._—Of the commonest are _mustard poultices_,
made by mixing mustard flour in a basin with luke-warm water, _i.e._
about 100° F., to a paste and spreading it on muslin, which is again
folded over the exposed surface of the mustard. Boiling water and
vinegar should not be used, for they lessen the pungency of the
poultice. If the full effect be desired the poultice should remain
on the skin fifteen or twenty minutes. If only slight reddening is
wanted, the mustard flour should be diluted with its bulk of linseed
meal before mixing it with water.
A stronger vesicant is _Corrigan’s hammer_, a button of polished
steel with a flat surface, fixed to a handle; when used it should
be plunged for a couple of minutes in boiling water, or heated over
a spirit lamp, but care must be taken not to overheat it, or it
will bring the cuticle away with it. It is pressed on the skin for
ten or fifteen seconds; this is sufficient to cause reddening and
vesication.
_Blisters_ are raised by the emplastrum lyttæ, lin. cantharidis,
or _pâte epispastique_, which is milder in its effect than the two
preceding preparations of Spanish fly. Solution of iodine and iodide
of potash, in three times their bulk of spirit of wine, also produces
a blister when laid on freely.
_Poultices_ are made of linseed meal, bread, or starch, and are means
for applying warmth and moisture without absolutely wetting. Bread
poultices sodden the parts to which they are applied most, and starch
least, of the three kinds.
Before making a poultice all the materials should be at hand and
thoroughly warmed before a good fire. They are—boiling water, a
broad knife or spatula, soft old linen or muslin, oil silk, tapes,
strapping plaster, bandages, a piece of old blanket, flannel or
cotton wadding, safety pins, or needle and thread.
The linen on which the poultice is to be spread should be cut of the
intended size, and when for use about the neck or shoulder should
have some tapes sewn on to it to tie it on to the body. The oil silk
should be large enough to cover the poultice next which it is laid to
keep in the moisture. The flannel or wadding are used to wrap over
and keep in the heat of the poultice; the strapping or bandage to fix
every thing _in situ_ as required.
When poultices are continued long, their surfaces should be smeared
with lard before application; this protects the skin somewhat from
the irritation that arises; also when the poultice is to be laid
between folds of skin or on hairy situations, as the buttocks and
perinæum, it is better to cover the poultice with a thin cambric
handkerchief lest some of the meal stick to the parts.
_The Linseed Poultice_ is made as follows: pour boiling water into a
well-heated basin till the basin is half full, then scatter meal with
the left hand on the water while that is kept continually stirred
with a broad knife, adding more and more meal until the mass becomes
quite soft and gelatinous, but too stiff to cling to the knife; then
turn it out on the linen, also well heated at the fire, and spread it
in a layer about ½ an inch thick, turn up the edge of the linen for
½ an inch all round, and carry the poultice at once to the patient.
If it has to be carried far the poultice should be laid between two
very hot plates; apply it to the part to be poulticed, lay on the
oil silk, and cover that with the hot flannel or cotton wadding, and
fasten these in place with pins or a stitch. Wadding is put where the
part is irregular, as the neck or axilla; unless the wadding is well
placed and the poultice is fastened by strings, it will soon fall
into a narrow band leaving the part exposed that it should warm and
moisten.
_The Bread Poultice_ is made as follows: the materials being all at
hand, as detailed in the directions for making a linseed poultice,
crumble the inside of a moderately stale loaf until about half a
pint or a pint of crumbs are prepared; then pour boiling water into
a basin, and throw in crumbs gradually in the same manner as the
linseed meal, until a soft porous mass is prepared. The remaining
steps are the same as those for making the linseed poultice.
The poultice can be made to hold more water if it is turned into a
saucepan after mixing, and a little more water added while it simmers
for half an hour at a slow fire. Any superfluous water must be
drained off, and the poultice covered with muslin when it is made in
this way.
_The Starch Poultice_ is made as follows: rub a little starch in a
basin with cold water till it has the consistence of cream, then mix
in _boiling_ water till the starch is a thick jelly, and spread it on
the linen while hot. Starch poultices retain their heat a long time,
but yield very little moisture to the part. They are chiefly used as
emollients to inflamed affections of the skin, &c.
_Hot fomentations_ are a means for applying heat when moisture is
not desired. A ready mode is to take a piece of blanket or thick
flannel, soak it in boiling water and dry it by wringing in a folded
towel, and then wrap it over the part to be fomented with a piece
of oil silk or a hot dry flannel over it. Laudanum, turpentine, and
other applications are sprinkled over the flannel, when soothing or
counter-irritating effects are required in addition to the warmth.
A bag of bran makes a light warm fomentation if heated in a steam
kitchen, or steamer for boiling potatoes.
When absolutely _dry heat_ is desired, chamomile flowers, bran, or
sand, may be heated in an oven, and poured into hot flannel bags.
Dry heat is also very agreeably obtained by filling _india-rubber
bags_ and _cushions_ with hot water: they are rather heavy, but
retain their heat many hours.
_Lister’s Method of Dressing Wounds with Carbolic Acid._—The
properties of carbolic acid which concern the surgeon may be briefly
recapitulated as follow:—
It is highly volatile, and the putrefaction of organic fluids
is indefinitely postponed where its vapour is present. Carbolic
acid is soluble in different degrees in water, alcohol, ether,
glycerine, fixed oils, gutta percha, india-rubber, and shell-lac.
Its varying affinity for these substances enables the surgeon to
modify the application of carbolic acid in various ways; these
modifications are necessary to fully utilise its properties. Water
dissolves the crystallised acid but sparingly, 1 part in 20 being a
concentrated solution, and allows it to escape readily. The aqueous
solution is therefore useful where the effects of the acid are
required copiously, but only temporarily. Glycerine and the fixed
oils dissolve a far greater amount of the acid, and part with it
unwillingly. Their solutions are adapted for the continuous but
abundant application of the antiseptic. Shell-lac, and some other
substances, hold the carbolic acid still more tenaciously, and are
valuable as solid storehouses which yield up the antiseptic in small
quantity for a considerable period.
Carbolic acid stimulates raw surfaces, and when concentrated even
destroys animal tissues. It is a local anæsthetic; with moderate
doses, wounds lose their sensibility after the first smarting of
the application has passed off. When given in large quantities the
acid produces a peculiar kind of delirium, and temporary paralysis
of sense and motion: fatal results have followed its internal
application.
It is rapidly absorbed into the blood from wounded surfaces, and
through the skin, whence it is discharged from the body by the lungs
and kidneys. The urine of patients dressed with carbolic acid, though
of normal colour when passed, assumes a dark greenish-brown hue after
a few hours’ exposure to the air and light.
How much of the antiseptic must float in the atmosphere to prevent
fermentative changes has not yet been determined; Bucholtz found that
1 part of carbolic acid in 600 of milk almost entirely prevented
lactic fermentation, while 1 in 285 did so altogether. Alcoholic
fermentation in sugary fluids was arrested by a similar quantity.
When using the acid in dressing wounds, the watery solution, the
solid mixture, and the oily solution are necessary. The first to
neutralise the effects of exposure to the atmosphere and water before
the wound is closed; the second solid mixture in the form of plaster
to provide a very scanty but continuous supply of carbolic vapour
close to the wound: too scanty to irritate the raw surface, yet
enough to check putrifaction in the discharge oozing from it. The
third, or oily solution, is to supply the carbolic vapour abundantly
to the linen dressings, appointed to receive the discharge when it
has passed from the vicinity of the wound. The tin is used to afford
as close a cover as possible to the breach of surface; for this
purpose it must be as flexible as possible that it may fit the wound
exactly.
The carbolic plaster is made of 3 parts of shell-lac and 1 part of
carbolic acid crystals melted together and spread on calico. To
render the lac plaster non-adhesive that it may not stick to the
tender wound, it is painted with solution of gutta percha, which
dries and leaves a thin film of that substance covering the plaster.
This film is easily removed by rubbing the surface with a rough towel
should an adhesive quality be desired. In either state the carbolic
acid continues to volatilise slowly when the plaster is laid over the
wound.
When adopting this method of treating wounds the following materials
are necessary:—
1. Aqueous solution of crystallised carbolic acid (1 part in 20).
2. Carbolic oil: 1 part of carbolic acid in 5 of olive oil.
3. Lister’s shell-lac plaster.[1]
4. Sheet tin.
5. Lint; old linen.
6. Diachylon plaster.
7. Glass syringe.
8. Scissors.
9. Thin calico or muslin.
10. Bandage.
11. A wooden splint to rest the limb upon.
_To Dress recent Wounds._—When the apparatus is ready, the piece of
tin is cut and fitted to the wound, so that it shall overlap the
wound to a small extent on all sides; then a piece of lac plaster,
large enough to overlap the tin one or two inches all round; this
plaster may be cut and notched when the surface is irregular to make
it lie pretty closely; then strips of diachylon, about two inches
broad, are cut ready. The parts around the wound are well cleaned;
dirt and clots cleared from the wound with cold water, containing
about 1 of carbolic acid to 40 of water, and the interior of the
wound is freely syringed with water containing 1 of acid in 30 or
even 1 in 20 parts. The sides are brought together with sutures,
if necessary, in the ordinary way, and the tin laid on the wound;
the tin is freely wetted with carbolic water, and the lac plaster
laid over it and kept _in situ_ by strips of diachylon plaster. In
dressing recent wounds the most dependent side of the lac plaster is
left unattached, that the serous discharge, which is often copious,
may readily escape. To receive this discharge, a piece of calico,
soaked in carbolic oil, is laid over the wound now covered in,
and all kept in place by a folded towel or a roller bandage. This
oily cloth is to be changed from time to time as it gets soaked
with discharge: at first this change is necessary every night and
morning, but after three or four days once a day is often enough. The
shell-lac plaster and tin need not be removed for a week unless the
wound grow hot and painful, when they can be removed at any time if
the surface of the wound is immediately smeared with carbolic oil,
and kept well imbued with the antiseptic while it is being examined.
Should it contain pent-up discharge, the sutures must be loosened and
the discharge washed out by injecting the 1 in 30 aqueous solution.
The tin and lac plaster may be then replaced, and the dressing
renewed. The same precaution must be followed when the sutures have
to be removed. Usually there is very little swelling and no pain,
and the healing process goes on tranquilly if undisturbed. Should
bruised parts slough, they may be trimmed away with scissors dipped
in carbolic oil. When the wound has once been washed with carbolic
acid, the antiseptic should not enter the wound a second time, as its
irritant qualities excite inflammation in the wound.
_Chronic abscesses_, besides recent wounds, are treated with carbolic
acid. The surface to be punctured is covered with a piece of thin
muslin soaked in carbolic oil, and the knife to be used is dipped in
the oil also. Then, a second piece of muslin being ready, the surgeon
opens the abscess through the muslin, and as he withdraws the knife
an assistant lays on the second piece of muslin over the wound.
The matter drains away from under this curtain, and the access of
atmospheric air is prevented. When the matter ceases to flow, the lac
plaster is laid on, and the oily cloth outside, which can be changed
as often as is requisite. Abscesses so treated usually soon cease to
secrete matter, shrink, and fill up without delay. If the abscess has
burst or had communication with the external air, the interior must
be filled with watery solution 1 to 20 before it is dressed, that
fermentation in the cavity may be prevented; the further treatment is
the same as for a recent wound.
[Illustration: Fig. 114.—Irrigating a wound.]
=Irrigation.=—The continual flow of ice-cold water is used to prevent
inflammation of certain wounds. In using cold, it is particularly
necessary that the temperature of the water remain steady, for
alterations of temperature cause alterations in the capacity of the
blood vessels, and promote congestion rather than diminish it; hence
irrigation, badly attended to, becomes an evil instead of a benefit.
The simplest way (see fig. 114) of contriving irrigation is to lay
the limb in an easy position on pillows, protected by a sheet of
india-rubber cloth, weighted at one corner to draw the cloth into a
channel, down which the water trickles into a receiver under the bed;
over the limb a jar, wrapped in blanket, is suspended. This is filled
with water from time to time, and kept charged with lumps of ice. A
syphon is made by a few feet of fine india-rubber tubing reaching
from the bottom of the jar to the wound, the escape of water through
the tube being moderated by drawing the end more or less tightly
through a bit of cleft stick. It is sufficient that the wound should
be kept constantly and thoroughly wetted; more than that is waste of
cooling power.
_Esmarch’s Irrigator._—This is a simple contrivance for washing out
wounds and sinuses with a stream of water. It consists of a tall can
of block tin (see fig. 115), with an orifice at the lower end, to
which a couple of feet of india-rubber tubing are attached. The tube
is fitted with an ivory nozzle and a hook, so that when the stream is
not wanted the flow of water is stopped by hanging the nozzle on the
upper edge of the can. The stream can be made more or less forcible
by raising or lowering the can above the wound.
[Illustration: Fig. 115.—Esmarch’s Irrigator.]
=The Administration of Chloroform.=—In administering chloroform the
main points to be borne in mind are—1. If the patient is fit to
undergo an operation at all he may inhale chloroform. 2. The patient
should be fasting; this is the most effectual preventive of sickness.
3. He should be in an easy position, clad in a loose but warm
night-dress, which does not interfere with ordinary or artificial
respiration, should that be suddenly required. 4. The patient must
never inhale more than 4 per cent. of chloroform vapour in the air he
respires; on the other hand, the vapour may circulate in the blood
without harm for an indefinite time, provided it never pass beyond a
certain concentration. 5. Chloroform is a sedative and depressant;
the pulse gives the earliest indication of syncope, and the
respiration should be constantly watched the whole time chloroform
is inhaled. It should be noted that the pulse often fails suddenly
at the first flow of blood in an operation. Again, when the patient
is deeply narcotised, the jaw may gape and the tongue sink back till
it closes the glottis. From this cause respiration sometimes ceases,
and danger quickly arises if the chin is not drawn up to raise the
epiglottis. In beginning to inhale, the quantity of vapour should be
small, and gradually increased. The patient must be cautioned not
to talk, to avoid the irritation and coughing chloroform sometimes
excites while he is speaking. He should also shut his eyes lest the
vapour make them smart. After inhalation has been continued a few
minutes the patient is often quiet and inattentive, though easily
roused by pain. His condition at this stage should be tested by
asking him to give his hand, or by pinching him gently; if no notice
be taken of these, the conjunctiva should be touched, and the amount
of winking thus excited will enable the chloroformist to judge if
the patient will resist when the knife is applied. Patients vary
much in the time passed before recovering consciousness; if they
remain soundly asleep, breathing freely and with good pulse, it is
better to avoid rousing or moving them until they wake spontaneously;
such patients suffer less confusion and vomiting than those who are
quickly alive to what is going on around them.
_Signs of Danger._—Sudden failure or irregularity of the pulse, with
pallor and arrested breathing, are of great importance; if these
occur, the chloroform must be at once removed, a free supply of fresh
air ensured, the tongue drawn gently forward, and if the breathing
do not quickly begin, it must be set up artificially (see p. 183)
without loss of time, and continued, if necessary, for at least an
hour before recovery is despaired of. Stertorous breathing is not
alarming unless accompanied by feeble pulse, shallow respiration, and
dilatation of the pupils; with these it becomes a sign of a comatose
condition.
As subordinate adjuvants for faintness the following are
useful:—moistening the tongue and lips with brandy from time to time,
or letting the patient sip a small quantity from the spout of a
feeding cup. In complete syncope, galvanism to the epigastrium, a hot
iron or scalding water to the præcordia may be employed, but _should
never interfere with the maintenance of artificial respiration, which
is of far greater efficacy in restoring suspended animation than
anything else_.
Chloroform is safely given on a handkerchief, or in various ways, if
the administrator is careful to watch the pulse and respiration, and
to guard against the patient, by a sudden deep inspiration, taking
too large a dose of vapour at once. Exact measurement of the quantity
of liquid poured on the handkerchief at a time is of no value, as
it is no index of the concentration of the air respired by the
patient. Of far greater consequence is it to insure a free supply of
atmospheric air, by keeping the evaporating surface a few inches from
the mouth and nostrils.
[Illustration: Fig. 116.—Clover’s apparatus for administering
chloroform.]
The safest mode of giving chloroform is by _Clover’s Inhaler_ (fig.
116), now used in many London hospitals and elsewhere. It renders it
impossible to give the patient too strong a dose, by preparing an
atmosphere of known strength for him to breathe. Clover’s apparatus
consists of a bag of 8,000 or 10,000 cubic inches capacity, suspended
by a loop behind the chloroformist’s back, from this a flexible tube
brings the vaporised air to a mask, fitting over the nose and mouth
of the patient. This mask has a flexible metal border for adjusting
it to different faces; and a valve that opens and closes, to allow
more or less common air to be respired with that drawn from the
reservoir if desired.
The reservoir is supplied by injecting into it, from a bellows, 1,000
cubic inches of air, drawn through an evaporating box heated by
hot water, into which 32½ minims of chloroform are injected from a
graduated syringe each time the bellows are filled. By these means,
an atmosphere of known strength is prepared for the inhalation; that
is one containing about 4° of vapour. This apparatus is very easy
to use, and the most efficient in producing anæsthesia quickly and
pleasantly.
=Artificial Respiration.=—Many plans are employed; but the two most
efficient are those to be described.
[Illustration: Fig. 117.—Artificial Respiration. Marshall Hall’s
method. 1st position.]
_Marshall Hall’s Method._—Lay the patient on the floor, with the
clothing round his neck, chest, and abdomen loose; if wet, remove it,
and throw over his body a warm blanket. Clear out the mouth, and turn
the patient _on his face_, one arm being folded under his forehead
(see fig. 117), and the chest raised on a folded coat or firm
cushion. Next, turn the patient well on his side, while an assistant
supports the head and arm doubled underneath it (see fig. 118), and
confines his attention to keeping the head forward and the mouth
open during the movements to and fro. When two seconds have elapsed
turn the body again face downwards, and allow it to remain so for
two seconds, and then raise it as before. This series of movements,
occasionally varying the side, should be repeated about fifteen times
a minute, and continued until spontaneous respiration is restored,
or, until two hours have been thus spent in vain.
[Illustration: Fig. 118.—Artificial Respiration. Marshall Hall’s
method. 2nd position.]
[Illustration: Fig. 119.—Artificial Respiration. Silvester’s Method.
Expanding the Chest.]
[Illustration: Fig. 120.—Artificial Respiration. Silvester’s method.
Compressing the Chest.]
_Silvester’s Method._—Lay the patient on a flat surface, the head and
shoulders supported on his coat folded into a firm cushion. Loosen
all tight clothing, and if wet replace it by a warm dry blanket, his
arms being outside the blanket. Clear the mouth of dirt, blood, &c.,
draw the tongue forwards, and fasten it to the chin by a piece of
string or tape tied round it and the lower jaw. Next, standing at the
patient’s head, grasp the arms at the elbows, and draw them gently
and steadily upwards till the hands meet above the head (see fig.
119); keep them so stretched for two seconds. Then slowly replace
the elbows by the sides, and press gently inwards for two seconds
(see fig. 120). These movements are repeated without hurry about
fifteen times in a minute, until a spontaneous effort to breathe is
made, when exertion should be directed to restoring the circulation
by rubbing the limbs upwards towards the body, and by placing hot
bottles at the pit of the stomach, to the armpits, between the
thighs, and to the feet. Should natural breathing not commence,
artificial respiration should be continued for two hours before
success is despaired of.
[Illustration: Fig. 121.—The Spray-producer.]
=Richardson’s Ether Spray-Producer= (fig. 121) consists of a tube on
which two india-rubber bags are placed; one, protected by a silk net,
acts as a reservoir; the other, furnished with a valve, is the pump;
these drive a constant stream of air over the tip of a fine tube
projecting from a flask of ether; this sucks up the ether and throws
it in fine spray on the surface to be chilled by its evaporation. The
ether for this purpose must be very pure and dry, having a specific
gravity of ·720, or the evaporation will not be sufficiently rapid
to produce congelation. The first effect of the spray is a numbing
aching pain with reddening of the surface. This is succeeded by a
pricking pain. In ten seconds, if the ether be good, a dead white hue
spreads rapidly over the skin, and when this appears the surface is
quite insensible.
The bottle and elastic air-pump may be attached to the glass jet
seen in the corner of fig. 121, which then makes an apparatus for
injecting astringent solutions in spray over the nasal passages, the
throat, and air-tubes; but the tubes used for watery fluids are much
wider than that for pulverising ether into spray. Tannin in solution
of 3-10 grains to the ounce of water, sulphate of zinc, or alum in
similar quantity, may be thus inhaled with much benefit by persons
suffering from chronic congestion of the mucous membranes.
=Injecting Chloroform Vapour into the Uterus= is a ready means of
relieving pain in cancer of that organ; special apparatus is made
for the purpose, but an ordinary elastic clyster syringe will answer
the purpose, if the flask is unscrewed and a few drops of chloroform
are poured into it, from time to time, while air is pumped through
the delivery tube, which is passed up the vagina to the ulcerated
cervix-uteri.
=Subcutaneous Injection.=—The syringe for this operation (fig. 122)
consists of a graduated glass tube holding six minims. The piston
works in a silver continuation of the graduated tube, and is thus
kept clear of the solutions used for injection. To the nozzle of
the syringe fine sharp-pointed cannulæ are screwed on; they are of
different lengths, some of steel, others of steel gilt; the gilding
renders the points very blunt, and consequently much more painful to
insert. In filling the syringe, care should be taken not to draw the
fluid above the level of the graduation on the tube, that the exact
amount injected may be read off as the liquid sinks in the tube. The
finer the cannula, and the sharper its point, the less pain is caused
by its introduction.
[Illustration: Fig. 122.—Subcutaneous Injection.]
The solution of morphia should contain a grain in six drops and
be as little acid as possible. In injecting morphia, it should be
recollected that ⅙ grain is the usual dose to allay pain, and produce
sleep; doses even far smaller often suffice for this purpose, though
very much greater quantities can be administered by injection, where
long use has rendered the patient tolerant of the drug. Some persons
dread the puncture considerably; for them the pain may be entirely
prevented by numbing the surface with ether-spray (see page 186)
before inserting the syringe, though usually the prick is of so
little consequence that any precaution of this kind is unnecessary.
The cannula should be thrust completely through the skin into the
subcutaneous cellular tissue; if the fluid is injected into the
skin itself, inflammation and suppuration of the puncture sometimes
ensues. After the cannula is withdrawn, the finger should be placed
for a few seconds over the puncture, or much of the fluid will leak
out again. When large quantities of solution (one or two syringefuls)
are injected the cannula need not always be withdrawn, the nozzle
can be unscrewed and the syringe charged again; but more than ten or
twelve drops injected into one place generally causes much pain, even
where the cellular tissue is very loose.
The syringe and cannula should be carefully cleaned, by sending
plenty of cold water through them each time they are used, or the
cannula will rust and become unfit for use.
=Collodion= is much used in drawing the edges of small wounds
together, &c. Preston’s plastic collodion, or the flexible collodion
of the British Pharmacopœia, 1867, have advantages over the common
form by furnishing a tougher pellicle, yielding to the movements of
the skin beneath without cracking. Collodion should be kept for use
in a small wide-mouthed bottle, with stopper and brush, and when
employed should be laid on quickly in a thick mass, so that the
crust it leaves shall be of one layer. A tougher crust is obtained
if a piece of muslin is soaked in the collodion and then laid on the
wound, than if the collodion is used alone.
=Vaccination.=—The lymph of the vaccine vesicle, taken between the
seventh and tenth days, is preserved for use on lancet-shaped slips
of bone 1 inch long, called _points_. These are dipped in the lymph
as it exudes from the vesicle, and exposed to the air till dry; they
are then wrapped in paper ready for use. When used, the lymph should
be moistened, by holding them over a vessel of steaming water a few
seconds before inserting them in the wound made to receive the lymph.
The points often lose the virus in a few days, and should, if
possible, be used the same day they are charged.
The lymph may be much longer preserved if hermetically sealed in
_glass tubes_. These are about the thickness of a darning-needle, 3
inches long, and open at both ends. When the tube is to be charged,
one end is inserted in the lymph exuding from a punctured vesicle; a
drop then enters the tube by capillary attraction, but filling not
more than half its interior: a few shakes of the hand will send the
drop a little further in. The lymph end of the tube is then taken
in the thumb and forefinger, while the unoccupied part of the tube
is passed once or twice quickly through the flame of a candle. This
rarifies the air, and while it is warm the end is closed by melting
it at the edge of the flame. The second end is then closed in the
same way as the first. When the lymph is wanted for use, the ends
of the tube are broken, and the lymph blown out on the point of
a lancet. Lymph preserved in these tubes retains its efficacy an
indefinite time. The National Vaccine Institution, Russell Place,
Fitzroy Square, London, W., supplies to medical practitioners both
points and tubes gratis on application.
In performing the operation the common lancet does very well; but two
or three forms of narrow-grooved lancets are employed by surgeons
for this purpose. The operation is most successful when the lymph is
transferred direct from arm to arm; the lancet making the puncture is
then charged at the vesicle of a child vaccinated a week before, and
points are unnecessary. When making the puncture the surgeon grasps
the child’s arm in his left hand, puts the skin on the stretch over
the insertion of the deltoid with his left forefinger and thumb,
pushes the lancet downwards between the cutis and cuticle, about
1-10th of an inch, to raise the latter in a little pocket; he then
charges his lancet with lymph and inserts it in the pocket, or if
using points, inserts the moistened point for a minute, taking care
as he withdraws the point to press the skin down on the point with
his left thumb, that the lymph may be well wiped off the point and
left in the wound. This process is repeated four or five times and
the operation is complete. The corium should not be penetrated, or it
will bleed freely and the blood will wash away the lymph; one drop of
blood is of little consequence; indeed, it shows that an absorbing
surface has been reached.
The phenomena following the insertion of the vaccine virus in an
infant’s arm are as follows:—On the second day the puncture is
slightly elevated; on the third it begins to grow red; on the fifth
it is marked by a distinct vesicle with a depressed centre and red
areola; on the eighth the vesicle is perfect, of pearl-like aspect,
full of clear lymph; the areola, often little marked by the eighth
day, rapidly increases on the ninth and tenth days, and reaches an
inch or more in diameter. This bright-red inflammatory action in
the skin is essential to show the system is properly infected with
the vaccine disease; by the twelfth day the areola has lessened,
the lymph is yellow, and often escapes by rupture of the vesicle;
on the fourteenth day the vesicle has dried to a scab, that falls
on the twenty-first day, leaving a dotted cicatrix, the vestige of
the multilocular structure of the vesicle. The three important marks
diagnostic of the vaccination being satisfactory, are—1, the pearly
multilocular vesicle of the 8th-9th day; 2, the widely-spread areola
on the 9th-12th day; 3, the well-marked foveated cicatrix after the
scab has fallen.
Observation shows that the number of people who take small-pox after
vaccination is very small indeed, when more than three well-marked
scars exist; and this number at least should be secured by making
five insertions of lymph at the time of vaccination.
FOOTNOTES:
[1] Lister’s shell-lac plaster can be obtained of the Glasgow General
Apothecaries’ Company, and the sheet tin of Messrs. Compton & Co.,
148, Fenchurch Street, E.C.
LIST OF THE INSTRUMENTS AND APPLIANCES REQUISITE, OR OCCASIONALLY
USEFUL, IN MOST OF THE IMPORTANT AND ORDINARY OPERATIONS IN SURGERY.
PREPARATIONS AND REQUISITES FOR OPERATIONS IN GENERAL.
THE OPERATING ROOM.
THE SICK BED AND BED-ROOM.
SEDATIVES AND RESTORATIVES.
THE ARREST OF HÆMORRHAGE.
OPERATING ROOM.
_Having a good Light and Windows that open readily, and a Fire in
Winter._
1. Firm table, 4 feet long, 2 feet wide, and 3½ feet high.
2. Pillows.
3. Blankets.
4. Towels.
5. Old linen.
6. Mackintosh sheets.
7. Old carpet, or old sheet to cover the floor.
8. Tray of sawdust or sand.
9. Bandages.
10. Strapping plaister.
11. Lint.
12. Oiled silk.
13. Cotton wool.
14. Tow.
15. Perchloride of iron.
16. Basins, large and small.
17. Hot and cold water, ice.
18. Bucket and slop-jar.
19. Sponges.
20. Chloroform and inhaler.
21. Oil.
22. Pins.
23. Scissors.
24. Brandy.
25. Ammonia.
26. Fire for heating cauteries.
SICK ROOM AND BED.
1. Iron bedstead.
2. Wool and hair mattress.
3. Several pillows, soft and of different sizes.
4. Air and water cushions.
5. Blankets, small single ones.
6. Pieces of soft flannel.
7. Six sets of sheets and pillowcases.
8. Old soft linen.
9. Cotton-wool.
10. Towels.
11. Soft pocket-handkerchiefs.
12. Three pieces of Mackintosh, 2 feet 6 inches square.
13. Bed cradle.
14. Light bedgowns.
15. Flannel jacket, and flannel Zouave drawers.
16. Hot-water bottle.
17. Bed-pan.
18. Bed-urinal and bed-stool.
19. Basins.
20. Cold water.
21. Condy’s fluid.
22. Sir W. Burnett’s fluid.
23. A bed-rest chair.
24. Night lights.
25. A fire, or in summer a lamp to burn in the fireplace, to create
a draught of air.
26. Enamelled saucepan.
27. Two feeding cups.
28. Spittoon.
29. Tea-equipage.
30. Tea-kettle.
31. Medicine measure.
32. Apparatus for keeping food warm, with lamp.
33. Flowers.
Before a room is occupied by a patient who has been operated on, it
should be thoroughly cleaned; the walls and ceiling should be well
brushed, the carpet taken away and the floor thoroughly scrubbed
with soda. All curtains and chintz furniture should be removed, old
window-blinds replaced by new green ones, and the window made to
open readily at the top and bottom. A fire or oil-lamp should be
lighted in the fireplace to maintain a circulation of air. If the
season require a fire, the iron fender should be removed and replaced
by a wooden tray of sand or ashes, to prevent the noise of cinders
and fire-irons falling on the fender and hearth. It is well also
to flush all the drains, water-closets and sinks in the house with
disinfecting fluid one or two days before the operation, and a store
of Sir William Burnett’s, or similar disinfecting fluid, should be
made ready to clear away the fœtid odours of discharges as they arise.
When possible, it is a great advantage to have two beds of similar
height and size, that the patient may occupy them alternately. The
cool bed refreshes the patient greatly, and the vacated bed is easily
cleaned and aired without fatigue to the sick person.
SEDATIVES.
1. Tincture of opium.
2. Solution of morphia and hypodermic syringe.
3. Morphia suppository.
4. Ice.
RESTORATIVES.
1. Brandy, champagne, sherry.
2. Eau-de-cologne.
3. Liquor ammoniæ.
4. Smelling salts.
5. Spirit of chloroform.
6. A fan.
7. A Rimmel’s perfume vaporiser.
8. Beef-tea.
9. Chicken-broth.
10. Milk.
11. Lime-water.
12. Soda-water.
13. Eggs.
14. French bread.
15. Biscuits.
16. Arrow-root.
17. Liebig’s extract of meat.
THE ARREST OF HÆMORRHAGE.
1. Artery forceps.
2. Torsion forceps.
3. Tourniquet.
4. Tenaculum.
5. Hare-lip pins.
6. Acupressure needles.
7. Nævus needle.
8. Wire nippers.
9. Solution of perchloride of iron (equal parts of the salt and
water).
10. Solid perchloride of iron.
11. Richardson’s styptic colloid.
12. Ice, ice-cold water.
13. Cautery irons.
14. Galvanic cautery wire.
15. Ligatures, silk, fine hemp, and whipcord.
16. Lint.
17. Amadou.
18. Bandages.
19. Compressed sponge.
20. Scissors.
(See List for the Ligature of Arteries.)
INSTRUMENTS AND APPLIANCES FOR OPERATIONS ABOUT THE HEAD AND NECK.
TREPHINING THE SKULL.
OPERATIONS ON THE EYE.
HARE-LIP.
RESECTION OF THE JAW.
EXCISION OF THE WHOLE TONGUE.
CLEFT PALATE.
EXCISION OF TONSILS.
LARYNGOTOMY.
TRACHEOTOMY.
TREPHINING THE SKULL.
1. Scalpel.
2. Trephines—several crowns.
3. Hey’s saw.
4. Elevator.
5. Stout dissecting forceps.
6. Brush to clean away the bone-dust.
7. Probe.
8. Quill, cut like a tooth-pick, to clear the groove of bone-dust.
9. Lenticular knife.
10. Small polypus forceps.
11. Sponges.
12. Lint.
13. Ice.
OPERATIONS ON THE EYE.
_Strabismus._
1. Chloroform, if used.
2. Laurence’s, or other head-fixer.
3. Specula of different sizes.
4. Toothed forceps.
5. Strabismus scissors and hooks.
6. Fine curved needles, and _finest_ thread.
7. Lint.
8. Ice, or cold water.
_Extirpation of the Eyeball._
1. Chloroform.
2. Head-fixer.
3. Speculum.
4. Toothed forceps.
5. Curved scissors.
6. Strabismus hook.
7. Small and large sponges.
8. Dissecting forceps.
9. Ice-cold water.
10. Perchloride of iron.
11. Fine curved needles, and _finest_ silk thread.
12. Lint.
13. Pulled lint.
14. Basin.
15. Bandage.
_Cataract_ (_Congenital_).
1. Atropine drops.
2. Chloroform.
3. Head-fixer.
4. Speculum.
5. Lacerating needles.
6. Toothed forceps, to fix eyeball.
7. Lint.
8. Cold water.
9. Gelatine plaster.
_Cataract_ (_Senile_).
1. Atropine drops.
2. Chloroform.
3. Head-fixer.
4. Speculum.
5. Lacerating needles.
6. Toothed forceps.
7. Cataract knives.
8. Scoop.
9. Platinum spatula, to adjust edges of wound.
10. Small sponges.
11. Basin and water.
12. Gelatine plaster.
13. Wool and bandage.
14. Lint.
_Iridectomy._
1. Chloroform, if used.
2. Head-fixer.
3. Specula.
4. Toothed forceps.
5. Right-angled knives.
6. Iris forceps.
7. Iris hooks.
8. Capsule scissors, if required.
9. Light curved scissors.
10. Lint.
11. Gelatine plaster.
12. Wool and bandage.
13. Atropine drops.
14. Small sponges and basin.
15. Hot and cold water.
HARE-LIP.
1. Scalpel.
2. Artery forceps, or sharp hook.
3. Hare-lip pins.
4. Wire nippers.
5. Dentist’s silk twist.
6. Strapping plaster.
7. Silver suture.
8. Collodion.
9. Scissors.
10. Cheek compressor.
11. Sponges.
12. Large towel to wrap the child in.
13. Chloroform and inhaler.
When the bone has also to be bent back—
14. Bone nippers.
15. Sequestrum forceps.
16. A knitting needle; and
17. Spirit lamp to check deep hæmorrhage by the actual cautery.
RESECTION OF THE JAW, AND TUMOURS CONNECTED WITH IT.
1. Scalpels.
2. Artery forceps.
3. Torsion forceps.
4. Ligatures.
5. Retractors.
6. Tooth forceps.
7. Narrow saw.
8. Hey’s saw.
9. Bone-cutting forceps.
10. Lion’s-tooth forceps.
11. Sequestrum forceps.
12. Gouges.
13. Chisel.
14. Gag.
15. Hare-lip pins.
16. Wire nippers.
17. Actual cautery.
18. Perchloride of iron.
19. Ice.
20. Sutures, silk and wire.
21. Solution of chloride of zinc.
22. Lint.
23. Bandages.
24. Plaster.
25. Collodion.
26. Mackintosh sheet.
27. Small sponges tied on sticks.
28. Larger sponges.
29. Chloroform and inhaler.
EXCISION ON THE WHOLE TONGUE.