Chapter V: Miscellaneous (2)

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.

_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.

_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.

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.

_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.

_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.

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.

=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.

=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.

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.

_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.

_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.

=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.

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.