Surgical instrument

“ And accordingly there is among the appliances of medical men an instrument by which the private parts are dilated with a priapiscus worked by a screw, and also a ring-knife whereby the limbs are cut off in the womb with judicious care, and a blunt hook by which the whole mass is extracted and a violent form of delivery in this way effected. There is also a bronze stylet with which a secret death is inflicted ”

“ The good surgeon is careful to use the right sort and pattern of instrument, and the chief fact about the surgery of the present day, that it is aseptic or antiseptic, is recorded in the make of surgical instruments and in all the installation of an operating-theatre. ”

“ The surgical epilation forceps is, as we have seen, usually a simple instrument. Occasionally we meet with a forceps combined with some other instrument. These are, as a rule, toilet articles. A pocket ear-scoop and epilation forceps combined was found in Paris. Precisely similar articles of steel may be bought in chemists’ shops to-day. Another has a small unguent spatula combined with a forceps, while others carry olivary probes. ”

“ The same instrument, if pushed horizontally backward through the second, third, or fourth interspaces of the costal cartilages close to the sternum, would wound, on the right of the sternal line, the vena cava superior, G, Plate 1; on the left, the pulmonary artery, B, and the descending thoracic aorta. In the healthy living body, the thoracic sounds heard in percussion, or by means of the stethoscope, will vary according to the locality operated upon, in consequence of the variable thickness of those structures (muscular and osseous, &c.,) which invest the thoracic walls. ”

“ Before the nineteenth century, one may find illustrations of bloodletting instruments in the major textbooks on surgery, in encyclopedias such as that of Diderot, and in compendia of surgical instruments written by surgeons. The descriptions following the drawings are often meager and give little indication of where, when, and how the instruments were produced. Until well into the nineteenth century, the tools used by barber-surgeons, surgeons, and dentists were made by blacksmiths, silversmiths, and cutlers. These craftsmen generally left little record of their work. ”

“ It is rather an instrument which could be inserted in an incision made by a scalpel, and which could be closed after the abstraction of a certain amount of fluid—the obturator acting as an improvement on the pledget of wool described by Celsus—but otherwise inserted like the previous example. A tube on similar principles to the ascites cannula was employed in empyema (Hippocrates, ii. 259) :
‘After opening let out pus once a day. ”

“ The ancients made frequent use of injections into the various orifices of the body. The apparatus used was a bladder or skin of an animal fixed to a tube. This form of instrument remained in use till the beginning of the nineteenth century, although the elaborate enema syringe, on the principle of the force pump, had been in use since the fifteenth century at least. The following passage from Heister (anno 1739) is interesting as showing exactly the method of its manipulation:
Pl. ”

“ Of the surgical instruments all forms agree in having no teeth. The simplest form consists of a strip of metal bent on itself straight as in Pl. XXVI, fig. 3, or with the jaws turned inwards, as in Pl. XXVI, fig. 5. These are often pocket forceps. A ‘pocket-companion’, consisting of a toilet forceps, an ear-pick and a nail-cleaner, such as is seen in Pl. XXVI, fig. 4, is a common object in museums, such as the Guildhall Museum, where this object is. A variety of epilation forceps with rounded legs is seen in Pl. ”

“ Now for suturing tissues, and more especially tissues of such toughness and thickness as the abdominal parietes, a round needle is absolutely of no use. A surgical needle not only requires to have cutting edges, as our three-cornered needles have, but these edges need to be in good condition to work well. ”

“ A big sheet is thrown over the lower part of his body, another over the upper part, a third, with an oval opening in the centre of it, thrown over the region to be operated upon. The instrument nurse takes a boiled knife out of a sterilized dish of distilled water, hands it to the surgeon, who takes it in his gloved hand, and the operation begins. ”

“ It is self-evident that no clear conception of a surgical operation, ancient or modern, can be formed from a written description without some previous knowledge of the instruments intended to be used. ”

“ 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 [Pg 134] the patient, he draws the penis on to the instrument till the triangular ligament is gained. ”

“ The Patient being set in a Chair, a Servant is employ'd in pulling back the Skin to the Root of the Penis, to the end that the Incision may be made directly at the bottom of the Glans: Then the Surgeon having drawn out the bottom of the Præputium, introduceth a small Instrument with a very sharp Point on its flat side, at the end of which is fixt a Button of Wax, pierceth the Præputium at the bottom of the Glans on the side of the Thread, and finisheth the Incision by drawing the Instrument toward himself. ”

“ The hand of the surgeon may also be rested on the back of the couch, as, if ambidextrous, he will invariably take his position behind the patient, in order that he may have the command of the upper eyelid in his own hands. The incision is made either in the lower or upper half of the cornea. The knife should have a very keen edge, and become gradually broader and thicker, from its point backwards: in using a narrow instrument there is danger of the aqueous humour escaping. The best knife is Beer’s, well made. ”

“ But you may now ask what all this physiology and chemistry of the plasma has to do with a report on surgery. I propose to use it for the purpose of explaining some peculiarities in the process of repair in surgical cases.
A few months ago I had a case of delayed union in a fracture of the tibia, at the hospital, and spent more time in waiting for nature, unassisted, to accomplish a cure, than I should ever spend again. One week after putting the patient on the use of ten grain doses of hypophosphite of lime, I had the pleasure of seeing bony union commencing. And why? ”

“ The Patient being plac'd in a convenient Posture, and having his sound Eye bound up, to take away the sight of the Instruments; the Operator causeth the other Eye to be kept steady with a Bolster held with an Instrument, and makes an Incision with a Lancet in form of a Crescent upon the Tumour, taking care to avoid cutting the Eye-Lid and the little Cartilage which serves as a Pulley to the great Oblique Muscle. ”

“ Those which exist are of bronze. Probably the majority were of steel, and of these none have survived. I give a photograph of a three-cornered needle from my collection (Pl. XVII, fig. 4) . It is imperfect at the point. It measures 7·2 cm. in length, and the sides are each 2 mm. in breadth. It is important to emphasize the fact that only needles with cutting edges are to be looked on as surgical, because it is not unusual to find needles, which are round and of large calibre, described as surgical, although they are quite unfitted for surgical work. Such is the one figured by Vulpes (op. cit.) ”

“ A surgical appliance comprising a metal plate having openings therein, metal pockets permanently fixed to said, plate registering with the openings and adapted to receive the penis and testicles of a patient, said pockets having perforations therein. metallic devices securing said plate against the body of the patient, substantially as described. ”

“ The groove is made somewhat deeper than in the common staff, to prevent any risk of the knife slipping out. The extremity is not grooved, but rounded [25] like a common sound, to prevent abrasion of the prostate or mucous lining of the bladder. The handle is somewhat larger, to afford a better purchase to the hand of the operator.
The advantage of a straight over a curved line as a conductor to a cutting instrument, is too obvious to require any comment; but its chief superiority consists in allowing the surgeon to turn the groove in any direction he may wish. ”

“ Nothing appears more simple than to cut out a ball which can be felt at the distance of an inch, or even half an inch below the skin, but the young surgeon often finds it more difficult than he expected, because he makes his incision too small; and cannot at all times oppose sufficient resistance to prevent the ball from retreating before the effort he makes for its expulsion with the forceps or other instrument. ”

“ The surgeon wishes to know whether he will lie still under the knife, or whether he will make a resistance and outcry which he would probably not make in his waking state. Some surgeons have recommended that the patient should be pricked with the point of a knife or some other instrument. This is not a good or satisfactory plan, however, for a person will often show no sign of feeling a slight prick, when a severe incision would rouse him to resistance. ”

“ The incision. The surgeon, standing behind the patient’s head and holding the knife with the edge directed upwards, in the right hand for the right eye and in the left hand for the left, fixes the eye with a pair of forceps held in the other hand, by grasping the conjunctiva below and to the inner side as close to the limbus as possible (Fig. 94) . Most continental surgeons stand in front of the patient and cut upwards. The point of the knife is then passed on the flat into the anterior chamber from the outer side, 1.5 millimetres behind the corneo-sclerotic junction. ”

“ Many surgeons of great and deserved repute have invented each a single instrument, such as Beer’s knife or Tyrrell’s hook; and some have invented more than one, chiefly because they have struck out some new procedure for which new appliances were indispensable. ”

“ It should be so made that the rounded shaft of the needle is just large enough to play freely in the wound made by the broader point, and yet not so small as to allow the aqueous humour to escape rapidly. The pupil has been dilated, the patient is lying on his back, and the globe is fixed by forceps attached to the conjunctiva of the inner side of the eye, and held by an assistant. The surgeon then enters the needle close to the sclerotic margin of the cornea, carries it fairly on in the anterior chamber, till the centre of the pupil is reached. ”

“ The blades must be made fairly to grasp and contain the stone in their hollow, for if they only nibble at the end of an oval stone, extraction is impossible. Extraction should then be performed slowly, with alternate wrigglings of the forceps from side to side, so as gradually to dilate, not to tear, the prostate, and the operator must remember to pull in the axis of the pelvis, not against the os pubis or the promontory of the sacrum. ”

“ In order to discover the foreign body, probes will sometimes be required; the finger often answers the purpose best, unless when the182 wound is of considerable depth. If, on examination, the ball cannot be discovered, and if there is reason to think that it has followed an indirect course, the surgeon will, sometimes, be assisted in his search by placing the patient in that position in which he received the wound, and then judging of the circumstances most likely to affect the foreign body in its passage. ”

“ When the Surgeon hath convey'd his Knife into the Fistula, having the Fore-finger of his Left-hand in the Anus or Fundament, he pulls off its Head, holding the Handle with one Hand, and the Stilet that pierceth the Anus with the other ”

“ Care, however, should be taken to inject just sufficient of the solution to penetrate beyond the zone of operation laterally, to insure sufficient space for the insertion of sutures into anesthetized tissues. Only a small quantity of fluid is necessary in this procedure as it comes in direct contact with nerve terminals. By touching the injected line with the needle in several places along its length and inquiring of the patient if it is felt, we may make sure of the completeness of the anesthesia before making the incision which should begin and end inside the anesthetized area. ”

“ The posterior surface of the joint being exposed, the surgeon, with a strong straight bistoury, makes a transverse incision into the joint just above the olecranon. It should begin just far enough outside of the internal condyle to avoid the ulnar nerve, which the surgeon should protect by the forefinger of his left hand, and should extend transversely across to the outer condyle. ”

“ A strong screw must be fastened in the wall near the window at the height of about seven feet to support the fountain syringe, which will be filled with whatever solution the surgeon requires for irrigating the wound.
One slop-jar stands at the side or end of the large table, the other beside the table that holds the basin of sponges.
The bureau (covered with a sheet) or the mantle-shelf will serve to hold the dressings and rubber gloves. A small stand or table will be needed by the doctor who gives the anesthetic for his hypodermic, clean towels, and ether or chloroform. ”