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Charles Field Mason.

A complete handbook for the sanitary troops of the U. S. army and navy and national guard and naval militia online

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and folded over the base of the chest, being rolled in the undershirt
to confine them.

Assistants must be careful not to interfere with respiration by
leaning on the chest.

Usually there is a stage of excitement marked by flushed face,
increased heart action, some struggling, perhaps tremor and general
rigidity of the body; all these symptoms are more marked in alco-
holics.

The state of complete anesthesia is marked by relaxation so that
the arm drops when lifted, snoring respiration, and the absence of
winking when the eyeball is touched.

The anesthetizer must closely watch the pulse, respiration, and
color of the patient, as well as his pupils and the conjunctival reflex.
In complete anesthesia the pulse and respiration ratio should be
about normal, the pupils should be contracted and should react to
light.

Danger signals are marked especially sudden weakness and
rapidity of the pulse, stopping of respiration, cyanosis, dilatation of
the pupils, and absence of their reaction to light. The return of the
conjunctival reflex winking on touching the eyeball indicates
that the patient is " coming out " of the anesthetic.

Sudden cessation of respiration is often due to the falling back
of the tongue over the opening of the larynx ; in such a case the lower



ANESTHESIA, GENERAL AND LOCAL



469



jaw should be thrown forward by the fingers behind the angles of
the jaw, and if this does not suffice the teeth must be forced apart,
and the tongue drawn forward with tongue forceps (Figs. 253 and
254). If the respiration is not at once resumed artificial respiration
must be resorted to.

Failure of the pulse is an indication for the use of stimulants
and perhaps discontinuance of the ether.

Efforts at vomiting may usually be controlled by giving more
ether, but if it can not be prevented the head should be turned on the
side to allow the escape of the vomited matter.




FIG. 253. Pushing Forward the Jaw for Treatment of Asphyxia.

Accumulation of mucus in the throat should be removed by a
sponge on a sponge-holder.

Chloroform is given by the open or " drop method " so as to secure
a free admixture of air; it is four times as heavy as air and not
inflammable.

The Esmarch inhaler is supplied in the army, but a small hand-
kerchief or a piece of lint folded once answers the purpose very
well. In the absence of a chloroform bottle with dropping attach-
ment, one can be extemporized by cutting a V-shaped trough on
the opposite sides of the cork.

The same precautions must be observed as in ether anesthetic,
remembering that while ether is a heart stimulant chloroform is a
heart depressant and that the great danger with chloroform is heart
failure.



470 MINOR SURGERY

A few drops of chloroform are placed on the inhaler, which is
at first held some distance from the mouth and gradually approached,
but never brought close enough to exclude the air. A few drops are
added from time to time as the chloroform evaporates, but progres-
sively less after anesthesia becomes complete.

The relative advantages of ether and chloroform may be summed
up as follows : Ether is slower, requires much larger quantities,
is less pleasant to take, causes much more irritation and costs more ;
it is usually safer.

In the field chloroform is preferable because of the much smaller




FIG. 254. Drawing Out the Tongue for Treatment of Asphyxia.

quantity which it is required to transport and the shorter time neces-
sary for anesthesia.

In the tropics ether, on account of its greater volatility, is hard to
keep, and much more is required to produce anesthesia.

Local anesthesia is very useful in opening boils and abscesses,
splitting inflammed piles, and in any operations of the fingers or toes.

There are two general classes of local anesthetics, those which
destroy the sensibility of the nerves by freezing and those which
must be injected hypodermically into the part.

Of the freezing agents the best is ethyl chloride, which is fur-
nished in metallic tubes arranged so as to throw a fine spray upon
the part; the tube should be held at a distance of ten or twelve
inches, and when the part suddenly turns white sensation is de-
stroyed. The objection to freezing agents is that the pain in freez-
ing and thawing is almost as great as it would have been from the
incision, and that sloughing may follow undue freezing.



ANESTHESIA, GENERAL AND LOCAL 471

The most generally useful local anesthetic is cocaine hydro-
chloride in solutions of two to ten per cent in water. In the mucous
membrances the anesthesia is produced by the surface application,
but in other tissues it must be used hypodermically. The anes-
thesia commences in a minute or two and lasts about fifteen minutes.
If the cocaine is confined to the part so that the blood can not carry
it away, as when a ligature is thrown around the "base of a finger
or toe, the effect may be maintained indefinitely.

The objection to cocaine is its depressing action on the heart
and the danger of contracting the habit. The maximum quantity
to be used subcutaneously is thirty to forty milligrammes. The solu-
tions do not keep well and should always be freshly prepared and
made with sterile water; the solutions themselves can 'not be ster-
ilized by heat, as heat decomposes the cocaine.

Eucaine-B is sometimes used as a substitute for cocaine, in solu-
tions of the same strength and in the same manner. It is. slower
in its action than cocaine, but not so depressing to the heart, its
effects last longer, and its efficiency is not impaired by heat sterili-
zation.

In Schleich's method very dilute solutions are used, but the tis-
sues, especially the skin, are infiltrated with them. Schleich used
three solutions of different strengths. The medium solution is pre-
pared as follows :



Cocain, hydrochlorid . ,
Morphin, hydrochlorid

Sodii chlorid

Aq. destill



TOO
025
200

ooo



Sterilize solution and add gtt. ij. of five-per-cent phenol.

The stronger solution contains twice as much cocaine and the
weaker one-tenth as much cocaine and one-fifth as much morphine.

To anesthetize the skin it is necessary to inject the solution into
and under it.

In spinal anesthesia a solution of cocaine or eucaine is injected
into the spinal canal between the fourth and fifth lumbar vertebrae,
after withdrawing a small portion of spinal fluid ; anesthesia with-
out loss of consciousness is produced in all parts of the body below
the seat of the injection.

The method has not met with general acceptance on account of
its uncertainty, and because of the severe and even fatal accidents
which have attended its use.



CHAPTER II

ASSISTING AT OPERATIONS

Minor Operations

IN an operation the duty of the noncommissioned officer may
be to prepare and hand instruments, to sponge, to assist in the opera-
tion, or to help in all three ways. He must watch the operation
and operator closely and endeavor to anticipate the wants of the
surgeon.

The sterilized instruments should all be laid out beforehand,
as much as possible in the order in which they will be needed and
those of the same kind grouped together. Needles should be placed
in a shallow glass dish of alcohol and a few should always be
threaded ready for use. In threading, the suture should be held in
the right hand and the needle -held in the left and passed over it;
catgut or tendon may be cut obliquely and flattened between the
handles of a pair of scissors to facilitate threading, but silk must
always be cut square across to avoid unraveling.

lodoform dusters or other unsterilized articles must be wrapped
in sterile gauze.

When the sutures are in sealed glass tubes, the tubes must be
sterilized in an antiseptic solution, broken in a sterile towel, and the
contents dropped in alcohol.

Ligatures should be about nine inches long and sutures twelve
inches.

A complete dressing should be ready in a sterilized towel.

When the intestines are to be exposed hot towels will be needed ;
to have them ready, sterile water is kept hot and the towels are
dipped in when necessary.

Rubber drains usually have a safety pin passed through one end
to prevent them from slipping in; gauze-wick drains are prepared
by rolling a narrow strip of gauze into a wick about the size of a
cigarette and covering it with a layer of rubber tissue.

Instruments should always be handed to the operator with the

(472)



ASSISTING AT OPERATIONS



473



handle toward his hand, and in such a position that they may be
used at once without loss of time; they should not be allowed to
accumulate unnecessarily upon the patient's body, and soiled and
bloody instruments should be replaced by clean ones.

Sponging must be done quickly in the intervals of the surgeon's
work, the sponge should be used with a firm wiping moyement in
the direction from the bottom of the wound toward the surface.

Retractors are held in such a position that they and the hands
of the assistant may be as little in the way as possible; sharp
retractors should be used with care.

In suturing, the needle properly threaded and held in the bite of
the forceps should be handed to the surgeon; the assistant then




fc

(


V

NNN


> -v.


NNM


"IxiNiNi


Ni N


i N N N


TTTN



FIG. 253- The Interrupted
Suture.



FIG. 256. The Continuous Suture.



holds the edges of the wound in the proper position for suturing,
and is ready with scissors to divide the sutures at the proper time.

When there is no surgeon present with the troops and none is
available, the senior noncommissioned officer of the hospital corps
detachment must himself undertake necessary minor operations.

Wounds. Clean, incised, wounds, the edges of which can not be
brought together by the dressing and bandage, should be sutured
or sewed up. Silkworm gut, silk, or catgut may be used, the pref-
erence being in the order named ; sutures of the first two materials
must be taken out after four or five days ; catgut will be absorbed.

Sutures may be interrupted or continuous. In the interrupted
suture (Fig. 255) the needle is passed through the skin and sub-
cutaneous tissues about an eighth of an inch from the edge of the
' wound, and then tied with a reef knot; care should be taken not
to draw the suture tight enough to contract and pucker the skin ; the



474 MINOR SURGERY

remaining sutures are then placed about a quarter of an inch apart.
The interrupted suture is the one ordinarily used.

The continuous suture (Fig. 256) is applied by continuously pass-
ing the needle through the skin without cutting the thread.

If there is any doubt about the cleanliness of the wound or if
there is much oozing from it, the lower angle should be left open
for drainage.

If the wound is in a hairy part the hair must be clipped close,
and the skin about the wound painted with tincture of iodine. The
same precautions as to instruments and the hands are observed as in
operation wounds. If the wound is small and not infected, all the
dressing needed may be a few shreds of cotton sprinkled with
iodoform and held in place by collodion.

Should the. wound contain dirt or other foreign bodies they
should be washed away with sterile water or removed with sterile
forceps ; as such wounds are sure to be infected a free opening must
be left for drainage.

Contused or lacerated wounds, unless the contusion is very severe,
should also be sutured, but not so closely as incised wounds nor
should the sutures be made so tight, as much tension and swelling
art apt to ensue.

Before any wound is sutured all bleeding should be controlled
permanently; if the bleeding is capillary this may be done by ex-
posure to the air, hot water, or pressure ; if the hemorrhage is from
an artery the spurting point must be found, seized with a pair of
artery forceps and twisted, or a catgut ligature may be slipped over
the forceps and the vessel tied.

In furuncle or boil there is a hard, painful swelling with a cen-
tral pustule overlying a small slough or core. The occurrence of
a number of boils in the same neighborhood is usually due to infec^
tion from the first one.

If a boil is seen early enough it may sometimes be aborted
by dipping a sharpened stick in pure phenol and carrying it down
into the core through the central pustule. If seen later the only
thing which will give prompt relief is a free cross cut. the cuts must
be deep enough and long enough to go entirely through the hard-
ened part, otherwise they will fail. Use a very sharp scalpel and
make each cut at one quick sharp stroke. Local anesthesia may
be used. After the incision apply wet antiseptic dressings.



ASSISTING AT OPERATIONS 475

To prevent a succession of boils the skin about the first one
should be kept thoroughly clean and disinfected, the hands should
be disinfected, and the underclothing frequently changed.

Carbuncles differ from furuncles in being more extensive and
severe and in having several openings or heads; the treatment is the
same.

Felon is an abscess below the fascia or periosteum in the end
of the finger; it is due to infection through a hang-nail or some small
wound. The tendency is to spread deeply and not to come to the
surface. The pain is intense and throbbing. The treatment con-
sists in making a free incision down to the bone and gives prompt
relief ; unless this is done necrosis of the bone may result. Apply
a wet dressing.

Abscesses when near the surface may be detected by the soft
fluctuating center surrounded by a hard ring. They should be
opened with a sharp-pointed curved bistoury thrust through the skin
over the top of the abscess and cutting from within outward. After
opening, a drainage tube should be inserted and a wet dressing
applied; the drainage tube may be left in as long as pus continues
to flow.

Alveolar abscess or gum boil is an abscess starting. at the root
of the teeth and usually making its way out at the junction of the
cheek and gum. The symptoms are toothache, pain, and often
great swelling of the face; on opening the mouth pressure on suc-
cessive teeth will show by the pain produced which one is affected,
and often swelling may be seen at the base of the gum. With a
straight bistoury a puncture should be made straight downward at
the base of the gum and over the softest point.

Ulcers are what are commonly called sores. They require wet
antiseptic dressings and often the support of a rubber bandage.

An inflamed hemorrhoid or pile is an extremely painful affec-
tion which may be promptly relieved by a very simple operation.
The patient complains of a painful swelling at the anus, and on
examination a red or purple, hard swelling is found ; this is due to
the formation of a blood-clot in the pile. With or without cocaine
anesthesia run a sharp curved bistoury through the base of the
tumor and cut from within outward; this frees the clot and the
pain now ceases.



CHAPTER III

MINOR OPERATIONS, CONTINUED

Subcutaneous saline infusions are frequently given in hospitals
for shock, hemorrhage, suppression of urine, and other conditions.
The appliances needed are a graduated infusion bottle or a foun-
tain syringe, a large-size aspirating needle, and sterile normal saline
solution at a temperature of 105 to 110 Fahrenheit. In the
absence of an infusion bottle or fountain syringe a large funnel
may be used; a piece of glass tubing inserted in the length of
the rubber tubing will enable the operator to observe the flow of
the infusion. All the appliances must be clean and freshly sterilized
by boiling.

The bottle or other container Js hung up at a height of about three
feet above the patient's body, and while the solution is flowing
from the needle it is thrust quickly into the subcutaneous tissues
and held there (Fig. 257).

The part selected is usually the back between the shoulders,
the axilla, or the buttock. The hands of the operator and the site
of the operation are carefully disinfected in the usual manner.

The amount injected is usually one or two pints distributed in
two or three places ; it will require about half an hour for the fluid
to enter and during this time the temperature of the solution must
be maintained.

After the withdrawal of the needle the skin of the puncture is
pinched up, dried with a gauze sponge, and dabbed with collodion.
a small gauze dressing is then applied.

Rectal continuous saline infusions by the drop method have re-
placed to a large extent the subcutaneous infusions. Any ordinary
irrigating apparatus may be used with a special nozzle and cut-off.

Intravenous saline infusions are done when quick action is
required.

The median basilic or medium cephalic vein at the bend of the

(476)



MINOR OPERATIONS, CONTINUED



477



elbow is exposed by a short incision, after which an aspirating
needle may be inserted direct or the vein opened and a canula tied
in; when a needle is used the preliminary incision is usually small.
The danger is the introduction of air or any foreign body into the
vein which might cause embolism or death.

Intravenous injections of salvarsan and neosalvarsctn for syphilis
are given in the same way as saline infusions with the use of needle
instead of canula. The injection tube and needle should be filled
with salt solution before the prepared solution is poured into the
reservoir, so that salt solution only will escape into the tissues if the




FIG. 257. Subcutaneous Saline Injection.



vein is missed on the first trial. In most cases it is unnecessary to
expose a vein by incision.

Injections of antitoxin for diphtheria are usually given between
the shoulders; the procedure is the same as for hypodermic injec -
tions, the syringe used being of the same type, only much larger.
The usual antiseptic precautions are observed.

Syphilis is now usually treated by intravenous injections of sal-
varsan. Mercury is often used in conjunction with the salvarsan and
preferably by subcutaneous injections of metallic mercury in the



478 MINOR SURGERY

form of "gray oil." The appliances needed are a hypodermic
syringe with a large caliber needle, the gray oil, an alcohol lamp, and
collodion, or adhesive plaster.

The injections are usually made in a vertical line on either side
of the spinal column and about an inch and a half from it arid an
inch and a half apart. The syringe used should preferably be of
a half or one Cc. capacity, and^graduated in fiftieths of a cubic cen-
timeter.

The needles should screw on, as friction needles are forced off
by the psessure necessary to push out the thick preparation of mer-
cury. After the preliminary sterilization the syringe and needles
are kept immersed in a wide-mouth bottle of liquid petrolatum.
The gray oil is kept in a wide-mouth bottle of about fifteen Cc.
capacity, and the bottle is protected from dust and dirt in a tin box ;
the box is kept in a cool place, preferably on ice.

The skin of the patient and the hands of the operator having
been disinfected, the gray oil is warmed over the alcohol lamp until
it will just flow freely, and then drawn into the syringe. The syringe
is next turned point up, and the piston compressed until a drop of
gray oil emerges ; the set-screw of the piston rod is so placed that
the syringe can only deliver the required dose, usually 0.05 Cc. ;
a fold of skin is pinched up vertically between the thumb and ringer,
the needle plunged in obliquely, and the dose is given. The puncture
is compressed by the finger for a moment and then sealed with
collodion or adhesive plaster. No rubbing of the spot is necessary
or desirable. A ten-per-cent suspension of basic salicylate of mer-
cury in liquid petrolatum is frequently used instead of gray oil.

Acupuncture is the process of puncturing the skin and cellular
tissues with hypodermic or other needles for the relief of oedema.

The skin and needles are sterilized, and the former protected with
gauze while the fluid is draining.

Aspiration consists in the withdrawal of fluid from a cavity which
may be the abdomen, thorax, or pericardium.

Aspiration of the abdomen or paracentesis is usually done with a
trocar and canula; after preparation as for any surgical operation,
make a small incision in the skin and insert the trocar and canula.

Aspiration of the chest is required by an accumulation of serum
therein known as hydrothorax, or if purulent empyema. it is done
with an aspirator.



MINOR OPERATIONS, CONTINUED



479



For aspiration of the pericardium an exploring syringe or hypo-
dermic is used.

Lumbar puncture is done for purposes of diagnosis or to relieve
pressure in the spinal canal, the patient is brought to the edge
.of the bed with his knees well drawn up and his head and shoulders
well bent forward to separate the vertebrae. The puncture is
usually made between the fourth and fifty lumbar.




i

FIG. 258. Washing Out the Stomach. First step.



FIG. 239. Washing Out the Stomach.
Second step.



Blood specimens are frequently required for (i) microscopical
examination, (2) Haemoglobin estimates, (3) counts, and (4)
cultures.

For (i) and (2) a drop is taken from a needle puncture of the
lobe of ear; for microscopical examination it is collected on a clean
cover glass.

For counts the blood is also taken from the ear-lobe, but with
a special instrument known as the haemocytometer.

For blood cultures about 10 Cc. must be taken from the median
basilic vein at the head of the elbow. After the usual surgical pre-
cautions, a ligature is bound about the arm above the elbow tight
enough to cause the veins to swell up but not tight enough to stop



480 MINOR SURGERY

the pulse; the hypodermic needle is then pushed directly into the
vein.

The stomach tube is used to remove poisons from the stomach,
to wash it out, and to introduce food-gavage.

For the first-named purpose a tube about five feet long is re-
quired, for the last purpose one two and a half feet long will suffice.
The tube is usually lengthened by a piece of rubber tubing connected
by a glass tube.

The patient sits in a chair with his head thrown back; the tube
having been warmed and dipped in glycerin is passed, together




FIG. 260. Introduction of Metallic Catheter. First step.

with the operator's left forefinger, into the back of the throat ; the
finger guides the tube past the epiglottis to the back of the pharynx,
whence it is pushed slowly and gently into the stomach, its passage
being aided by attempts to swallow.

Sometimes the patient prefers to take the tube into his mouth,
swallow the end and then push it down himself.

Food is introduced through a funnel in the end of the tube.
To remove poisons or wash out the stomach, siphonage must be



MINOR OPERATIONS, CONTINUED 481

secured; to do this pour water into the funnel held above the
patient's head until the tube and funnel are full ; then before all the
water has run out of the funnel lower it below the level of the stom-
ach; this movement may be repeated as often as necessary (Figs.
250 and 259).

When the patient is unconscious the operator must be sure before
he introduces any fluid that the tube has not entered the patient's
larynx.

Sometimes it is desired to obtain a sample of the stomach contents
without admixture with water. To do this, introduce the stomach




FIG. 261. Introduction of Metallic Catheter. Second step.

tube in the manner just described, lower the funnel over the basin,
have trie patient lean forward and strain a little, then gently press
the stomach to express the contents.

In forced feeding, when the patient resists, it is better to pass a
smaller tube along the floor of the nose and thence into the pharynx.

To introduce a metallic catheter or sound into the bladder, place
the patient on his back with the shoulders raised, and the legs drawn
up and rotated slightly outward so as to relax the abdominal mus-
cles ; having sterilized, warmed, and lubricated the instrument, stand
on the left side of the patient, grasp the penis in the fingers of the
left hand and draw it vertically upward with its back toward the
abdomen, hold the catheter lightly in the right hand and introduce
the tip into the meatus. The instrument and penis should now be
carried close to the body over and parallel with the groin (Fig. 260).

The penis is then drawn up over the instrument which is at the
31



482 MINOR SURGERY

same time pushed gently in or allowed to pass by its own weight;
at the same time the handle of the catheter is slowly carried toward
the median line and, after about four or five inches have disappeared
in the urethra, elevated to the vertical position, when, the tip pass-



Online LibraryCharles Field MasonA complete handbook for the sanitary troops of the U. S. army and navy and national guard and naval militia → online text (page 36 of 38)