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SURGICAL INSTRUMENTS AND APPLIANCES
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SURGICAL See also:INSTRUMENTS AND APPLIANCES . The purpose of this See also:article is to give an See also:account of the more important surgical instruments that are now in See also:general use, and to show by what modifications, and from what discoveries in See also:science, the See also:present methods of an operation have come to be what they are. The See also:good surgeon is easeful to use the right sort and See also:pattern of See also:instrument, and the See also:chief fact about the See also:surgery of the present See also:day, that it is aseptic or antiseptic, is recorded in the make of surgical instruments and in all the See also:installation of an operating-See also:theatre. Take, for instance, a scalpel and a saw that are figured in Ambroise See also:Pare's (1510-1S9o) surgical writings. The scalpel folds into a handle like an See also:ordinary See also:pocket-See also:knife, which alone was enough in those days to keep it from being aseptic. The handle is most elegantly adorned with a little winged See also:female figure, but it does not commend itself as likely to be surgically A B C Frc. r.—See also:Needle-holders. A, See also:Hagedorn's; B, Macphail's; C, See also:Allen and Hanbury's, for Hageaorn or ordinary needles. clean. The saw, after the same See also:fashion, has a richly chased See also:metal See also:frame, and, at the end of the handle, a See also:lion's See also:head in bold See also:relief, with a See also:ring through its mouth to hang it up by. It may be admirable See also:art, but it would See also:harbour all sorts of germs. If one contrasts with these See also:artistic weapons the Fm. 2.-Tenotomy Knives forged in one piece. instruments of 185o, one finds no such adornment, and for general finish See also:Savigny's instruments would be hard to See also:beat; but the wooden or See also:ivory handles, cut with finely scored lines like the See also:cross-hatching of an See also:engraving, are not more likely to be aseptic than the handles of Pare's instruments. At the present See also:time, instead of such handles as these, with See also:blades riveted into them, scalpels are forged out of one piece of See also:steel, their handles are See also:nickel-plated and perfectly smooth, that they may afford no crevices, and may be boiled and immersed in carbolic lotion without tarnishing or rusting; tha scalpel has become just a single, smooth, See also:plain piece of metal, having this one purpose that it shall make an aseptic See also:wound. In the same way the saw is made in one piece, if this be possible; anyhow, it must be, so far as possible, a See also:simple, smooth, unrusting metal instrument, that can be boiled and laid in lotion; it is a See also:foreign See also:body that must be introduced into tissues susceptible of infection, and it must not carry infection with it. Or we may take, at different periods of surgery, the various kinds of ligature for the See also:arrest of bleeding from a divided See also:blood-See also:vessel. In Pare's time (he was the first to use the ligature in amputation, but the existence of some sort of ligature is as See also:Rontgen Rays. old as See also:Galen) the ligature was a See also:double See also:thread, bon flu qui soit en double; and he employed a forceps to draw forward the cut end of the vessel to be ligatured. From the time of Ambroise Fare to the time of See also:Lord See also:Lister no See also:great improvement was made. In the See also:middle of last See also:century it was no uncommon thing for the See also:house-surgeon at an operation to hang a leash of waxed threads, See also:silk or See also:flax, through his See also:button-hole, that they might be handy during the operation. Then came Lord Lister's See also:work oa the absorbable ligature; and out of this and much other experimental work has come the present use of the ligature in its utmost perfection—a thread that can be tied, cut See also:short, and See also:left in the See also:depth of the wound, with See also:absolute certainty that the wound may at once be closed from end to end and nothing more will ever be heard of the ligatures left buried in the tissues. The choice of materials for the ligature is wide. Some surgeons prefer See also:catgut, variously prepared; others prefer silk; for certain purposes, as for the obliteration of a vessel not divided but tied in its course for the cure of aneurism, use is made of See also:kangaroo-tendon, or some other See also:animal substance. But what-ever is chosen is made aseptic by boiling, and is guarded vigilantly from contamination on its way from the sterilizer into the body of the patient. The old ligatures were a See also:common cause of suppuration. Therefore the wound was not closed along its whole length, but the ligatures were left See also:long, See also:hanging out of one end of the wound, and from day to day were gently pulled until they came away. Certainly they served thus to drain the wound, but they were themselves a chief cause of the suppuration that required drainage.
Sutures, like ligatures, were a common cause of suppuration in or around the edges of the wound. Therefore, in the See also:hope of avoiding this trouble, they were made of See also:silver See also:wire, which was inconvenient to handle, and gave See also:pain at the time of removal of the sutures. At the present time they are of silkworm-gut, catgut, silk or horsehair; they are made aseptic by boiling, and can be left any number of days without causing suppuration and can then be removed without pain.
Next may come the See also:consideration of surgical dressings. In the days when inflammation and suppuration were almost inevitable, the dressings were usually something very simple, that could be easily and frequently changed—ointment, or wet compresses, to begin with, and poultices when suppuration was established. It is reported of the great See also:Sir See also: The chinosol gauze is especially used in ophthalmic surgery; for general surgery the cyanide gauze is chiefly employed. The various preparations of absorbent See also:wool (i.e. wool that has been freed of its grease, so that it readily takes up moisture) are used not only for outside dressings, but also as See also:sponges at the time of operation, and have to a great extent done away with the use of real sponges. The gauzes in most cases are used not dry, but just wrung out of carbolic lotion, that their See also:anti-septic See also:influence may See also:act at once. The whole subject of surgical instruments may be considered in more ways than one. It may be well, for the See also:sake of clearing the ground, to take first some of the more common instruments of general surgery, and then to See also:note the working out, in the operations of surgery, of the three great principles—the use of anaesthetics, the use of antiseptic or aseptic methods, and the surgical uses of See also:electricity. Of the essential instruments that are common to all operations, we may well believe that they have now become, by See also:gradual development, perfect. Take, for instance, the ordinary surgical needle. In the older forms the See also:eye was slit-shaped, not easily threaded, and the needle was often made of a triangular outline, like a See also:miniature See also:bayonet. At the present time the needles used in general surgery are mostly Hagedorn's, which have a full-sized See also:round eye, easy for threading, are See also:flat for their whole length and have a See also:fine cutting edge on one See also:side, near the point. Thus they enter the skin very easily, like a miniature knife, and the See also:minute wound they make is not a hole, but a tiny slit that is at once See also:drawn together and, as it were, obliterated by the tying of the suture. Or, for another simple instrument in universal use, take the catch-forceps that is used for taking hold of a bleeding point till it is ligatured. This forceps is as old as the time of Pare, but he made use of a very heavy and clumsy pattern. Up to the last few years the artery-forceps was made with broad, curved, fenestrated blades, with the catch set See also:close to the blades. At the present time the forceps in general use, named after Dr Nan in See also:France and after Sir See also:Spencer See also:Wells in See also:England, is made with very narrow grooved blades, and the catch is placed not near the blades, but near the handles: thus it takes a surer hold, and can be set See also:free when the ligature is tied by a moment's extra pressure on the handles. Among other instruments in universal use are See also:divers forms of retractors, for holding gently the edges of a wound: the larger patterns are made with broad, slightly-See also:concave, highly-polished surfaces, that they may, so far as possible, reflect See also:light into the wound. Among tourniquets, the old and elaborate See also:Petit's tourniquet, which was a See also:band carrying a See also:pad screwed down over the See also:main artery of the See also:limb, has given place to the elastic tourniquet with See also:Esmarch's bandage. For example, in an amputation, or in an operation on a See also:joint or on a vessel or a See also:nerve in a limb, the limb is raised, and the Esmarch's elastic bandage is applied from below upward till it has reached a point well above the site of the operation; then an elastic tourniquet is wound round the limb at this point, the bandage is removed, and the limb is thus kept almost bloodless during the operation. b1G. 7.—Lithotrite (See also:Bigelow's). It is not possible to describe here the many forms of other ordinary instruments of general surgery—probes, See also:directors, See also:scissors, forceps, and many more—nor those that are used in operations on the bones. Nor again can the numerous instruments used in See also:special departments of surgery be discussed in detail. But, with regard to the special surgery of the eye, and of the See also:throat and See also:ear, it is to be noted that the chief advance in treatment arose from the invention of the present instruments of diagnosis, and that these are of comparatively See also:recent date. The opthalmoscope was the work of See also:Helmholtz. The laryngoscope was invented by See also:Manuel See also:Garcia in the middle of the 19th century; and the use of a frontal See also:mirror, for focussing a strong light on the membrana tympani, in the, examination of the ear, was in use somewhat earlier. Before the ophthalmoscope it was impossible to study the See also:internal diseases of the eye; before the laryngoscope the diseases of the larynx were invisible, and were mainly a See also:matter of guess-work, and of vague and often futile treat-
ment. Before the use of the frontal mirror the diseases of the ear were hardly studied, in that sense in which they are studied now. The wonderful advance of the special departments of surgery was, of course, the result of many forces, but one of the chief of these
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Fm. lo.—Laryngoscope (See also:Lennox See also: Of See also:late years, by the use of an See also:iron See also:cylinder of nitrous oxide, connected by a See also:tube with a Clover's inhaler, it is possible to begin with nitrous oxide, and to &o on, without interruption, with ether. More recently an admirable method has been devised of administering nitrous oxide with the admixture of air or of FIG. 1z.—See also:Gas and Ether Apparatus See also:oxygen in such a way (See also:Hewitt's). that the anaesthesia pro- duced by the gas may be maintained for time enough to allow of an operation of some length. The See also:series of discoveries which, in its application to surgery, has brought about the present antiseptic and aseptic methods of operation, is concerned both with the shape or use of the instruments of surgery and with their preparation for use. The See also:mere sterilization, by boiling or by steaming, of all instruments and dressings, is enough to ensure their freedom from the ordinary micro-organisms of suppuration; but the surgeon cannot See also:boil or See also:steam either himself or his patient. The preparation, therefore, of the surgeon's hands, and of the skin over the See also:area of operation, is made not only by scrubbing with See also:soap and hot water, but by careful use of antiseptic lotions. Again, ligatures and sutures, which must be kept in stock ready for use, are kept, after careful sterilization, in antiseptic lotion, or are again sterilized immediately before an operation. Again, all towels used at an operation must be prepared, either by sterilization or by See also:immersion in antiseptic lotion. The sterilization of all instruments and dressings is a simple matter: the usual sterilizer is a vessel like a See also:fish-See also:kettle, with a perforated metal See also:tray in it, so that the instruments can be immersed in boiling water, and can be lifted on the tray and transferred straight from the sterilizer into vessels containing sterilized water or antiseptic lotion. For the sterilization of dressings an upper vessel is fitted to the sterilizer, so that the steam may permeate the dressings placed in it. In See also:hospital practice it is used also to sterilize all towels, aprons and the like in a large cylindrical vessel. Sterilization by boiling or steaming, together with the use of antiseptic lotions, or of water that has been boiled, for all such things as cannot he boiled or steamed, is the essential principle of the surgery of the present day; and practically the antiseptic method and the aseptic method have become one, varying a little this way or that according to the nature and circumstances of the case. Beside anaesthetics and See also:antiseptics, there is a third series of discoveries that has profoundly influenced surgery—the use of the forces of electricity. The uses of electricity are fivefold. 1. The Gaivano-Cautery.—The See also:original form of the cautery, the fer ardent of Pate's time, for the arrest of See also:haemorrhage after amputation, was a terrible affair. Happily for mankind, his invention of the ligature put an end to this use of the cautery, but it was still used in a small number of other cases. Subsequently See also:Claude See also:Andre Paquelin (h. 1836) invented a very ingenious form of cautery, a series of metal blades or points of different shapes and sizes, that could be fitted to a handle: these points were hollow inside, and were filled with fine See also:platinum gauze, and, by means of a See also:bottle and hand-See also:bellows they could be kept heated with See also:benzene-vapour. Thus, when they had once been raised to a glowing See also:heat by holding them emie=z over a spirit-See also:lamp, they could be kept at any desired heat. This instrument is still in use for a few cases where very rapid and extensive cauterization is necessary. But for all finer use of actual heat the galvano-cautery alone is used—a series of very minute points of platinum, with a suitable trigger-handle, connected with a See also:battery or (by means of a converter) with the ordinary house See also:supply of electricity. In this way it is possible to apply a glowing point with a fineness and accuracy of See also:adjustment that were wholly impossible with Paquelin's cautery. 2. See also:Electrolysis.--This method is of great value, in suitable cases, for the arrest or obliteration of small growths. The passage of the electric cur-See also:rent between needles introduced into or under the skin brings about a gradual shrinking or cicatrization of the tissues subjected to it, without the See also:production of any unsightly scar.
3. Electro-Motor See also:Power.—During recent years the use of a small electro-motor See also:machine has come into the practice of surgery for certain operations on the bones; especially for the operation for disease involving the mastoid See also:bone. It is, of course, abetter method for the use of a fine See also:drill or See also:burr, for example, than the" dental See also:engine," where the power is generated by a pedal turning a See also:wheel, and it will probably come into wide use both for dental surgery and for those operations of general surgery that require very gradual and delicate removal of small circumscribed areas of bone, especially of the See also:cranial bones.
4. The X-Rays.--This, the most unexpected and, as it were, the most sensational See also:discovery that has been bestowed on physicians and surgeons since the discovery of anaesthetics, is now used over a very wide and varied See also: Beyond these uses, it is probable that the X-rays will maintain and extend the importance that they already have in the See also:direct treatment of certain cases of disease of she skin (see X-See also:RAY TREATMENT). FIG. I7.—Urethroscope (See also:Fenwick's), also 5. The Electric Light.— used for ear, See also:nose, throat, &c. Beside the general superiority of this light to other See also:lights for the routine work of surgery, there are several special uses for it. Of these, the most important is the cystoscope, a long narrow tube, shaped and curved somewhat like a catheter, and having at its end a very minute glow-lamp and reflector, and a small window. Its other end is fitted with a See also:lens, and is connected by a switch with the main cur-rent. With this instrument, in skilled hands, it is possible to inspect the interior of the See also:bladder, and in many cases to make an exact diagnosis under circumstances where otherwise it would be impossible. Another instance of the value of the electric lamp in diagnosis is given by the trans-See also:illumination of the facial bones in cases of suspected disease of the central cavity of the See also:superior maxillary bone. A small glowlalnp is held in the closed mouth, in a darkened See also:room, and by a comparison of the shadows on the two sides of the See also:face, thus trans-illuminated, an exact diagnosis can often be obtained as to the presence or See also:absence of pus in FIG. i8.—Finsen-Reyn Lamp. this central cavity. Again, a small glow-lamp, duly sterilized, is often of great value in deep operations on the abdominal cavity. The bactericidal properties of light have long been demonstrated by Bie and others. See also:Professor Niels Finsen of See also:Copenhagen first used the ultra-See also:violet rays of See also:solar light in the treatment of skin diseases. notably of See also:lupus. He later invented the lamp which bears his name. The original Finsen lamp comprised a voltaic arc of 6o to 8o amperes round which four tubes collected the light by See also:quartz lenses, the light being cooled by passing through water and the tubes being surrounded by a water-jacket. The usual exposure was one See also:hour. In the Finsen-Reyn modification now used, a single See also:collecting tube fitted on an adjustable stand is placed in front of a scissors arc lamp consuming 20 amperes. The rays are cooled and water-jacketed as in the original. A suitable quartz See also:compressor with a chamber containing circulating water is pressed upon the skin of the part to be treated and held at right angles to the impinging rays. The time of exposure is now reduced to See also:forty-five minutes. See also:Radium when used in surgery is applied by means of applicators, either having the fixed salts on square or oblong metallic plates or cloths or by applicators having free radium in sealed metal tubes. These tubes are sometimes buried in the tissues. Sometimes a method of " screening " is adopted in See also:order to modify the intensity of the See also:radiation. This is done by enveloping the tubes containing the radium in cases of silver, See also:lead or nickel of various thicknesses. In this, known as the method of Dr Dominici, the a and rays are intercepted by the metal screens and the highly penetrative rays only applied to the morbid tissues. The illustrations in this article are by permission of Messrs Allen & Hanbury, See also:London, and that of the radium applicators , by permission of Messrs See also:Siemens See also:Brothers, London. Additional information and CommentsThere are no comments yet for this article.
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