The essentials of bandaging /

Hair Suture.—This is useful to bring the margins of small scalp wounds together, where plasters are not employed. It consists in taking a lock of hair ½ or ¾ of an inch on each side of the wound, and tying them together over a double thickness of lint; by this means the margins of the wound are kept together, and the dressing in place. The slits left after the removal of small sebaceous tumours are very conveniently treated in this way.

The Eye Douche is a small elastic bottle fitted with a nozzle and flexible tube, ending in a rose, through which, by means of a valve, the water is drawn from a vessel and driven in a fine spray over the eye held open to receive it (see fig. 70). The syringe in fig. 70 is very useful for a variety of purposes.

Eye-Drops.—Little bottles are sold by chemists for this purpose, with a tubular stopper; at one end of the stopper is a fine jet, the other is closed by a piece of indian rubber stretched over it; on pressing this a drop escapes from the jet. In dropping astringents into the eye the patient should put his head well back; while the surgeon raises one lid from the eye, drops in the lotion, and then raises the other and drops it in again, and tells the patient to move his eyelids about a little to force the lotion over the whole conjunctiva.

Syringing the Ears is best performed by a syringe having a long nozzle to direct the current of soap and water down the meatus on to the wax. Figure 71 consists of a syringe with double opening and air chamber; when in action it supplies a continuous gentle current, which breaks up the concretions more speedily and with less discomfort to the patient than the intermitting jet of a common syringe; but an important part of the apparatus is the long slender nozzle to direct the stream well into the meatus. The instrument-makers supply a little spout or shoot to hang under the ear, to turn off the water into a basin clear of the neck. If time permit, the patient should keep the ear charged with olive oil for a few days before syringing, that the wax may be softened. After the wax is removed, the irritation of the canal is best allayed by a little glycerine or olive oil put into the meatus, and covered by a pledget of cotton wool, large enough to fill the concha and too large to enter the passage, where it may be lost sight of.

Ice-Cold Injection.—In obstinate epistaxis the nares are sometimes plugged, but, before proceeding to this painful mode of treatment, a simpler plan should first be tried; namely, the injection of ice-cold water into the nostril along which the blood flows. The stream should be directed upwards that the water may first dislodge the clots entangled in the meatuses, and then flow over the bleeding surface. This is best done by employing a clyster or douche bottle (see fig. 71), one tube of which lies in a vessel of ice-cold water (containing solution of gallic acid or other styptic if desired, though cold water alone usually suffices), the other tube, having a long narrow nozzle, is passed up the nostril and directed upwards among the spongy bones. With this apparatus the water is injected steadily for half an hour, before being abandoned as unsuccessful. The patient is kept still, sitting upright in a cool room. If these means fail to check the flow of blood, the nares may then be plugged.

Plugging the Nares.

Apparatus.—1. A flexible catheter, No. 7, or Belloc’s sound.

2. Whipcord.

3. Lint.

4. Scissors.

Step 1. Roll up a strip of lint tightly into a mass, 1 inch broad and ½ an inch thick, trim the ends away with scissors till the mass is of a size to enter a posterior naris, then tie the wedge in the middle of a yard of doubled whipcord. If blood trickle down both nostrils both must be plugged, and two such plugs must be prepared; next, make two similar rolls of lint, and tie these up with a short piece of silk or twine to prevent their unrolling.

Step 2. Pass along the interior of the catheter a yard of twine, and draw its end through the eye of the catheter a few inches, then introduce the catheter through the naris directly backwards, not upwards nor downwards, because, when the patient is upright, the floor of the nose is nearly horizontal. When the catheter has reached the pharynx, the finger, or a forceps, must be passed through the mouth to catch the string hanging from the end of the catheter and bring it out of the mouth, where it is held while the instrument is withdrawn from the nose. The step is repeated in the other nostril if required.

Step 3. Next wash out the nostrils with a few syringefuls of ice-cold water, in which some tannin is suspended.

Step 4. Fasten the double string of the plug to the end of twine hanging out of the mouth (see fig. 72), and then draw out the other end through the nose; this will carry the plug to the pharynx, where the finger guides it over the soft palate and thrusts one of its ends into the naris, where the strings draw it tight. The plug for the anterior nostril is then put in place, and the strings tied tightly over it (see fig. 73). Thus the plug in front keeps the plug behind in place and vice versâ. The end of string from the posterior nares, left hanging out of the mouth, must next be tied to the string of the anterior plug to keep it out of the patient’s way, till wanted to withdraw the posterior plug, when that is to be removed. If blood run from both sides, the other nares are stopped by a repetition of this operation.

This apparatus is very painful, and, if borne so long as a couple of days, should always be taken out then. If bleeding recur, which is very unlikely, fresh plugs must be introduced. Sometimes the posterior plugs are soaked in styptic solutions; this is bad, because the bleeding part is not at the posterior nares, and the styptics increase the soreness the plugs themselves produce.

Belloc’s Sound.—Fig. 74 is a curved silver cannula like a female catheter, furnished with a long spring stylet, that arches round in a circle when thrust out of the cannula, and has a hole at the end to carry a thread. The long stylet can be unscrewed into two parts, when not in use. The figure represents the instrument with the stylet ready for protrusion, and the same arching forwards after it is protruded.

The cannula is passed along the nares till the end reaches the pharynx, then the stylet is protruded and arches forward till it reaches the teeth, when a thread is passed through the hole, and the stylet being withdrawn, the thread is carried with it into the pharynx and through the nostril, where it can be used to draw the plug into its place at the posterior nares.

Tooth Drawing.—A surgeon is frequently required to draw a tooth on emergency, and should be provided with instruments (see fig. 75). Seven pairs of forceps and an elevator are sufficient for all he is likely to deal with. They are differently shaped for the different teeth, which vary much at the neck, the part grasped in the forceps.

For the operation the patient should be seated in a high-backed chair; the surgeon stands at his right side, holds the jaw with his left hand, while with the right he thrusts the beaks of the forceps between the gum and the tooth on its lingual and buccal aspects; having reached the neck, he holds the tooth firmly, pushing it inwards and outwards with a rotary motion of the wrist (except for the molar teeth). Sudden tugs break the tooth and leave the fang behind; when loosened by rotation and lateral motion, the forceps readily lift the tooth out of its socket.

For the upper incisors the beaks of the forceps are straight, slightly hollowed inside, to give them hold of the teeth, and have crescentic edges (see fig. 76).

The upper incisors and canines can be drawn by the same pair, as the shape of these teeth at the neck varies to a small extent.

For the lower incisors a very narrow forceps is necessary. The beaks (fig. 77) should be curved at the joint sufficiently to form an angle of 25° with the handles, that the latter may clear the upper jaw. The edge of the beaks is crescentic, similar to that of the upper incisors. These forceps are also very useful for removing roots, as their fineness enables them to sink between the stump and the alveolus with ease.

For the bicuspids, beaks with crescentic edges also are used, but the inside of the beak is more hollowed to fit the round neck of these teeth (see fig. 78). All the bicuspids can be drawn with the same pair, but it is convenient to have forceps bent at the joint to clear the upper jaw when extracting a lower bicuspid (see fig. 79).

For the upper molars two forceps are required, one for each side of the jaw; the beaks of these are well hollowed to admit the crown of the tooth. The inner beak terminates in a crescentic border to fit the large internal fang (see figs. 80 & 81); the outer beak has two smaller grooves separated by a point, that passes between the two external fangs.

In drawing these teeth the forceps should be thrust as high as possible and held firmly, while the fangs are loosened by moving the tooth from side to side, but from the multiplicity of fangs, rotary motion is not available.

The wisdom molars are often difficult to seize from being almost buried in the jaw; as they resemble a bicuspid in shape, bicuspid forceps (fig. 78) should be employed; if this fails to penetrate between the tooth and the alveolus, the narrow incisor forceps (fig. 77) can be driven up till it grasps the tooth. Not unfrequently the fang of this tooth in the lower jaw is curved backwards and prevents extraction when the tooth has been loosened; this difficulty may be overcome by pushing the crown of the tooth a little backwards so as to tilt the fang forwards out of place.

When the molars are closely set, or the tooth to be extracted is overhung by its neighbour, it is often difficult to avoid tearing the gum extensively and even carrying away more than one tooth; tearing the gum is easily avoided by lancing it before applying the forceps, and slow and steady movements of the wrist usually prevent the latter accident, or the overhanging tooth may be filed away before the forceps are applied.

The inferior molars (fig. 82) have forceps, whose beaks are doubly grooved and pointed, to enable them to seize the neck on each side between the two fangs.

In raising stumps, so much decayed that the forceps will not hold them, the elevator must be employed; this instrument (fig. 83), straight, pointed, and a little grooved at the point, is thrust down between the alveolus and the tooth; the jaw being then the fulcrum, the elevator is the lever to push forwards the fang; when thus loosened it is easily lifted out. In working with an elevator there is some risk of thrusting the point through the alveolus, and wounding the tongue or floor of the mouth, hence it should always be guided and covered by the left forefinger. In removing the fangs of incisors the narrow forceps are most useful, and should it not be possible to penetrate between the fang and the alveolus, the alveolar border may be included in the grasp of the forceps and brought away with the tooth. The injury thus inflicted is very unimportant and much pain is saved.

After the tooth is extracted the mouth should be well washed with warm water a few times, the attending bleeding being of no importance, except in individuals of hæmorrhagic diathesis, in whom measures should be at once taken to arrest the flow.

To stop a bleeding socket the alveolus must be well cleared of clots, and fragments of sponge, soaked in a solution of perchloride of iron, one part of the salt to three of water, packed into the cavity. A plug of cork is placed between the jaws, and a four-tailed bandage (see page 32) carried round the head to keep them firmly closed. Should this plan fail, the socket must be cleared again, and the wire of the galvanic cautery pushed well down to the bottom and then heated till it has cauterised the cavity (see page 168).

Nipple Shields and Artificial Nipples made of flexible ivory, vulcanized india-rubber, &c., are required when the nipple is chafed and excoriated by the child’s sucking, especially if his mouth be attacked by thrush, as is usually the case. When the nipple is sore it should be well washed and dried after suckling, covered with glycerine of starch or plastic collodion and protected by a shield. If much inflamed it may be wrapped in lint dipped in alum water or solution of sulphate of zinc (one grain to the ounce), and deep chinks should be freely rubbed with lunar caustic. The breast should be regularly emptied by the breast-pump if the child’s sucking gives much pain, lest the accumulation of milk in the ducts cause milk abscess.

Plugging the Vagina is employed in cases of rapid hæmorrhage from the womb, &c.

Apparatus.—1. A silk pocket-handkerchief.

2. A dry new fine sponge or pellets of cotton wool.

3. Silk thread.

4. A body roller or folded sheet.

The sponge should be cut into pieces the size of nuts; if the sponge is compressed it answers better. When prepared, the vagina should be cleared of coagula by a syringeful of ice-cold water; the handkerchief, unfolded and thrown over the right hand, is passed up the vagina till its centre reaches the os uteri, the borders and ends then project from the vagina. The interior of the handkerchief is next filled by firmly packing the sponge in bit by bit until the vagina is distended by the mass; the ends of the handkerchief are then tied together. The sponge swells as it absorbs the blood, and compresses the bleeding vessels by its distention.

The abdomen and uterus are then supported by a body roller, or folded sheet, wrapped tightly round the hips and waist, while the patient, lightly clad, is kept quiet in a cool chamber.

When the plug has answered its purpose it is removed, by withdrawing the sponge bit by bit, and the vagina is washed with tepid water.

The kite’s-tail plug.—Masses of cotton wool the size of a hen’s egg are tied at two inches distance from each other along a long string. When about a dozen are tied on, a speculum is introduced, and the first ball of wool is passed to the bleeding point and pushed firmly against it, and then another, and so on, until the vagina is firmly packed. An end of string is left hanging out of the vulva, whereby the plug may be removed when necessary. Each mass comes away successively with ease as the string is pulled out of the vagina.

Injecting the Urethra often fails from the inefficient mode in which it is done. The syringe employed should be short enough to be worked easily with one hand, and need not contain more than one or two tea-spoonfuls, as the capacity of the urethra does not exceed that amount. One of such a size is just 2 inches in length, and easily worked by one hand. The opening through the nozzle should also be wide, that a forcible stream may be injected into the urethra.

The patient should fill the syringe, then place on a chair or stool before him a chamber pot, and, having just made water to clear out the discharge collected in the urethra, he inserts the slightly bulbous nozzle into the meatus urinarius. He then grasps the sides of the glans with the left forefinger and thumb to close the mouth of the passage. The right forefinger next presses down the piston slowly, so that the whole of the injection passes into the canal and distends it; keeping the meatus shut with his left finger and thumb, the patient lays down the syringe and rubs the under part of the penis backwards and forwards, that the injection may be forced into any folds or follicles of the mucous membrane. Having thus occupied about thirty seconds, he releases the mouth of the passage, when the fluid is ejected sharply into the vessel placed ready to receive it. This rapid ejection is a test of the proper performance of the operation.

In counselling the use of astringent solutions, the surgeon should always caution the patient not to employ one that produces severe smarting, which lasts more than a few minutes after injection. If it causes much pain, the solution is too strong.

Catheters and Bougies.—Silver catheters are made in sizes, increasing from No. ¼ to No. 12, the first having a diameter of 0·64 inch, the latter 0·25 inch. Larger ones than these are seldom employed.

The curve preferred by different surgeons varies much; that depicted in fig. 84 is the one used by Sir Henry Thompson; it begins at 3¼ inches from the point, and ends when the point is at right angles with the stem. Each catheter is fitted with a wire stylet.

The flexible catheters are of many kinds; the English gum-elastic (fig. 85), the French black flexible (fig. 86), and the vulcanised india-rubber (fig. 87), catheters, being the three varieties most generally employed. English flexible catheters should be kept on stylets well curved at the last 3 inches, that, when the stylet is withdrawn, for the catheter to be passed, the latter may retain sufficient curve to pass over the neck of the bladder easily.

Sounds are solid, being of steel, plated or gilt. Their curve varies, and is generally 20 or 30 degrees more obtuse than that of the catheters.

Bougies are made of the same materials as the flexible catheters; they are kept straight, and the more supple they are the better, the black bulbous-ended bougies being the most useful variety for dilating the urethra.

Olive-headed Bougies (Bougies olivaires) are used for exploring the urethra in cases of gleet, where the discharge is often kept up by a stricture or a tender patch of chronic inflammation of the mucous membrane. They are made of metal, or of black gum mounted on a very flexible leaden wire; the latter kind are far preferable. The stem of the instrument is slender, no bigger than a No. 3 or No. 4 bougie; the end terminates in a conical point about ¼ or ⅜ of an inch long, expanding at its base to any required size. These bougies are most useful from No. 4 to No. 16 of the English scale, or from No. 10 to No. 24 of the millimetrical scale. The stem should be marked with white rings an inch apart, so that when the instrument is passing over a tender part, or is arrested by a stricture, the distance of the impediment down the urethra can be at once estimated. In withdrawing the instrument, the wide base of the olive shows the exact position and length of those strictures which are not too narrow for the olive-head to slip by, for it is nipped by the stricture and released as soon as the narrowing is passed. By using instruments large enough to fill the normal urethra, an induration beneath the mucous membrane can be detected in its earliest stage before it has produced symptoms diagnostic of stricture.

Rigid instruments have one advantage over flexible ones, in that their points can be guided by the surgeon; the points of flexible instruments cannot be directed, hence the introduction of the latter into a stricture is less easily managed, consequently bougies with various kinds of points should be kept. But flexible instruments cause far less irritation than rigid ones, and should always be employed instead of the latter when possible: with patience and practice much of the difficulty attending their introduction is overcome. The French bougies, with tapering ends and bulbous points, slip more easily through a stricture than instruments having the same diameter throughout, and bougies with fine tapering points can sometimes be introduced where others fail.

Passing Catheters.—In passing instruments along the urethra the conformation of its interior should be borne in mind. From the meatus to the triangular ligament, the normal urethra, when gently stretched, becomes a straight tube; having, nevertheless, just within the meatus, a pouch in the roof, the lacuna magna, where the point of the instrument may catch if not turned downwards. At the bulbous part the urethra enlarges in capacity by having a slight downward curve in its floor, just before the triangular ligament is reached. In this depression, the beak of the catheter is apt to sink below the level of the passage through the ligament, which is always a fixed point. Beyond the triangular ligament the urethra curves gently upwards, has a floor beset with irregularities, in which the point of the instrument easily catches, if not raised as it passes along the curve.

A Silver Catheter is passed most easily while the patient is in a horizontal position, with the shoulders low and the thighs separated. The surgeon stands on the left side of the patient, and holds the catheter, previously warmed and lubricated with oil or lard, lightly between the thumb and two first fingers of the right hand, the beak downwards and the stem across the patient’s left groin. Then taking the penis between the middle and ring fingers of the left hand, the palm being upwards, he pushes back the foreskin with the thumb and forefinger, and steadies the meatus while introducing the beak of the catheter. This done, he draws the penis gently along the catheter as the point is lowered to the perinæum, but without raising his right wrist until the instrument has travelled 5 or 6 inches along the passage and reached the triangular ligament. The surgeon then carries his right wrist to the middle line of the patient’s body, and while pushing the point onwards, raises the hand round a curve till it again sinks between the patient’s thighs. When the bladder is reached he withdraws the stylet that the urine may escape. Three points of difficulty are usual in passing catheters; the lacuna magna just within the meatus, the triangular ligament, and the prostatic part of the urethra just before the bladder is reached. The first is escaped by keeping the beak along the floor of the urethra for the first two inches; the second is best avoided by raising the wrist as the instrument passes the triangular ligament, and directing the beak against the upper surface of the urethra, lest, being in the enlarged bulbous part, it sink below the opening in the ligament; the third difficulty is overcome by depressing the hand well as the point approaches the bladder.

To pass the catheter in the upright position, the patient is placed against a wall or firm object, with his heels eight or ten inches apart and five from the wall, that he may rest easily during the operation. The surgeon sets himself opposite the patient and grasps the penis with the two middle fingers of the left hand, the palm upwards; he next exposes the meatus with the thumb and forefinger, and his right hand holding the catheter by its middle obliquely across the left side of the patient, he draws the penis on to the instrument till the triangular ligament is gained. He then carries the shaft of the catheter to the middle line and, holding it by its end, brings the right hand downwards and forwards, to carry the point upwards over the obstruction at the neck of the bladder.

The operation should be done slowly and with great gentleness, giving the urethra time “to swallow the instrument,” as the French surgeons express it. Hasty or forcible movements tend to thrust the point against the wall of the urethra, where it hitches, if it does not penetrate and make a false passage. However easy the introduction may have been, the withdrawal of the catheter should be always done slowly to avoid giving pain to the patient.

When the canal suddenly contracts, as from a stricture, the point of the sound often stops at the obstruction; by withdrawing the instrument a little, and diverting its point to another side or along the upper part of the urethra, a part where the obstruction is less abrupt will often be found to let the catheter glide into the stricture. The floor of the urethra should always be avoided, as false passages nearly always branch off from the floor close to the stricture.

Difficult narrow strictures are most easily overcome by injecting a drachm of warm olive oil into the urethra, and then passing fine black gum or whalebone bougies (bougies filiformes) along the urethra. These, from their fineness (their diameter is only ⅓ or ⅔ of a millimetre, about ¹/₁₀₀ inch), are very apt to catch in false passages; if so, the bougie should be left engaged in the false passage, and held in the left hand while another bougie is passed along the urethra; if, in its turn, this one gets into a false passage, it also should be left, and a third passed; and so on till all the false routes are occupied, or a bougie enters the stricture and reaches the bladder, which is known by the readiness with which it will pass backwards and forwards. The other bougies should then be withdrawn, and the bougie which has passed the stricture be tied in for twenty-four hours, until the passage is sufficiently dilated to allow a small catheter to replace it. If the patient is not suffering from retention of urine, there need be no anxiety about evacuating his bladder, as urine will find its way alongside the bougie when he attempts to make water. In passing to relieve retention, No. ½ English flexible catheter should be used instead of bougies; but when the stricture is too narrow for these, a bougie may still be tried, as the urine will generally dribble alongside the bougie with sufficient rapidity to relieve the patient.

English flexible Catheters should be kept on stylets curved as represented in fig. 85, that the first 3 inches of the instrument, when the stylet is withdrawn, may retain sufficient curve to ride over the impediment at the neck of the bladder. In warm weather, after being oiled, they should be dipped in cold water just before using, to render them a little stiffer, and less likely to lose their curve while traversing the urethra.

They may also be passed while the patient lies or stands, and the movements are the same as for the silver catheter.

Bulbous-ended or probe-ended Catheters and Bougies (Bougies à boule) are always straight; their suppleness, their tapering ends, and their smooth rounded point enable them to glide along the urethra, and to accommodate themselves readily to the windings of the passage; for which reason they are the easiest to pass both for the patient and the surgeon. In passing them they are slightly warmed, if the weather is cold, to restore their flexibility, and gently pushed along the canal till the bladder is reached.

Vulcanised India-Rubber Catheters (fig. 87) are used when the bladder is to be kept empty; their suppleness renders them very unirritating, and as phosphates crust on them very slowly, they may be worn for a week without being changed.

They are easily passed by threading them on a stylet with the appropriate curve, and lubricating them with white of egg or water, not with grease, which injures them. The stylet is withdrawn after they are passed.

To pass a Catheter in the Female.—The patient may lie on one side or on her back; if on her side the knees should be well drawn up; if on her back, the thighs must be somewhat separated. Before introducing the catheter, a wine bottle or narrow-necked bed urinal should be placed in the bed ready to receive the urine. If the ordinary slightly curved female catheter be not at hand, a No. 7 or 8 flexible one does just as well.

Having oiled the instrument, go to the patient’s back, and take the catheter in the right hand if the patient lies on her right side, and in the left hand if she lies on her left side; if she lies on her back, go to either side and take the catheter in the hand nearest her feet. Hold the stem of the catheter in the palm, so that the beak lies against the tip of the forefinger, while the thumb and second and third fingers grasp the stem. Then passing the hand under the bed-clothes, seek the buttock; from that pass the forefinger to the perinæum, and let it enter the vulva, keeping the back of the finger against the posterior part, then pass it between the nymphæ to the entry of the vagina. This is known by the tip of the forefinger being lightly grasped, unless the vagina is very wide. Keeping the finger just within the entry, feel for the arch of the pubes in front; having found this, withdraw the tip of the finger slightly from the vagina: in doing this, it will strike a small projection of mucous membrane hanging just at the anterior margin of the entry. Keep the finger steady against this, while the other hand pushes the catheter gently onwards, which then rarely fails to enter the urethral opening close above the projection of mucous membrane. Having penetrated the urethra, arrange the catheter in the receptacle for the urine, and push the instrument into the bladder.

To Wash out the Bladder.

Apparatus.—1. A flexible catheter; Nos. 8 or 9 are convenient sizes; but a smaller one can be employed.

2. A caoutchouc bottle, holding six ounces, and fitted with a tapering nozzle and stop-cock. (Fig. 89.)

During the operation the patient should stand, if possible, as the mucus is thus more easily cleared from the bladder. The surgeon first fills his bottle completely with tepid water, that no air may remain; then directing his patient to stand against a wall or some firm object, passes the catheter and draws off the urine. He next inserts the nozzle into the catheter, and, turning the cock, compresses the bottle slowly until two or three ounces of water have run into the bladder; this he lets escape by removing the bottle for a minute, and then repeats his operation till the water returns clear, without exhausting the patient’s strength. Three or four small injections wash the sediment and mucus from the bladder as quickly, and with far less fatigue or risk of spasm than a prolonged flow of water through a stiff double current catheter. In this way the bladder may be washed twice or thrice daily to the great comfort of the patient.

Injections of solutions of nitrate of silver, carbolic acid, alum, &c., in the proportion of 1 part to 100, or to 50 of water, can be used instead of water for this purpose.

To Tie in a Silver Catheter.

Apparatus.—1. A few yards of tape ¼ inch wide.

2. A roller.

3. A spigot of wood; or,

4. A yard and a half of fine india-rubber tubing.

A narrow roller is tied round the hips; from this, on each side, a tape is passed round the thigh at the groin, and fastened before and behind to the roller round the hips (see fig. 90); a narrow tape run through the rings of the catheter connects them with the loops in the groins. The tapes are tied short enough to prevent the catheter slipping out; a yard or two of narrow india-rubber tubing, fixed on to the end of the catheter, conveys the urine to a pan under the bed, and keeps the bed dry, or a spigot of wood fitted to the catheter may be inserted, for the patient to draw out when he desires to void his urine.

To Tie in a Flexible Catheter. (Fig. 91.)

Apparatus.—1. A piece of soft twine, or Berlin wool, about 15 inches long.

A catheter is first passed into the bladder, and the urine runs off. The catheter is then gently withdrawn, till the stream ceases, that the end of the instrument may remain just without the neck of the bladder. The string should be tied round the catheter ½ an inch from the meatus, its ends gathered together and tied in a knot about 1 inch farther on. The foreskin is then drawn back, the ends passed beneath the glans and tied round the penis behind the corona; the superfluous string is snipped off, and the foreskin brought forward. The catheter is cut off obliquely ½ an inch beyond the string and then stopped with a spigot, direction being given to the patient to withdraw the spigot, and push the catheter a little further in when he wants to make water.

To Tie a Patient in Position for Lithotomy.

Apparatus.

Two bandages, each 3 yards long and 2 inches wide, of calico or saddle-girth, with tapes sewed on the ends.

The patient is laid on his back, a slip-knot made in the middle of the bandage and passed over the wrist; the hand is then made to grasp the foot, the thumb above, the fingers under the sole (fig. 92); one end of the bandage is carried behind and inside the ankle to the dorsum of the foot, where it meets the other end passing in front of the ankle. The ends are then carried under the sole, brought up and tied in a double bow over the back of the hand.

Bedsores are best treated by great cleanliness, and by washing the skin exposed to the discharges with spirit of wine every day. Brown-Sequard recommends cold and heat to be applied daily, by means of an ice bag for ten minutes, followed by a warm poultice for an hour. The pressure of the skin over the sacrum or trochanters is prevented by a ring of soft thick felt, covered on one side with adhesive plaster, and applied like a corn plaster around the prominent bone.

In addition to these local applications, the pressure of the body should be evenly distributed over its under surface by placing the patient on a water cushion, or, better, on Arnott’s water-bed.

Arnott’s Floating Bed.—In the hydrostatic or floating bed of Dr. Arnott, the patient floats on the surface of a trough of water, into which he sinks until he has displaced his own weight of water; his floating apparatus, or raft, so to speak, being a sheet of waterproofing, and a thin mattress or folded blanket, on which he lies. The bed consists of a trough running on large castors, about 8 feet long, 2 feet 8 inches wide, and 1 deep, with a tap at the bottom for letting out the water, and a spout in one corner to fill it by. Over the top a macintosh cloth is spread, its edges being firmly nailed to the margin of the trough, but the cloth is left slack enough to float easily on the surface of the water when the trough is partly filled. This slackness is requisite to allow the water displaced by the weight of the patient’s body to rise up around him without tightening the cloth, or the floating principle of the bed is not carried out, and the pressure of the patient’s weight not evenly distributed over his body (see fig. 93). Three or four blankets are laid evenly over the macintosh, and these again protected from the moisture of the patient by a macintosh under-sheet. If a mattress is used, it must be very thin, and supple enough to let the surface of the water adjust itself to the patient’s body and receive the pressure evenly. The water employed to fill the bath should be about 50°.

Water Cushions are flat cushions of stout macintosh cloth, half or two-thirds full of water, and laid on the mattress beneath the blanket and sheet (see fig. 94). They are more portable than the water-bed, but they are simply soft pillows, and do not counter-balance the weight of the patient in the manner of the floating bed.

The Stomach-Pump is used for emptying the stomach, or for injecting fluid food when patients refuse to swallow.

It consists of a brass syringe holding 4 ounces, of which the nozzle is connected with two tubes, one at the end, the other at the side. The passage through these is directed by a valve which is governed by a lever lying on the barrel (see fig. 95). When the lever is at rest, the current passes in and out of the syringe by the lateral tube; when depressed, by the direct tube. The elastic tubes with smooth nozzles, about 2 feet long, are fitted to the syringe. There is also a gag of hard wood, having a hole in the middle, through which the tube passes on its way to the stomach, to protect it from the patient’s teeth.

When the pump is employed to remove the contents of the stomach, two washhand-basins are placed at hand, one empty, one full of tepid water. The patient is seated in a high-backed chair to steady his head; one assistant holds his hands, while a second screws the small end of the gag between the teeth and forces open the mouth, across which it is then easily fixed. The flexible tube, being well oiled, is next passed across the pharynx and down the gullet slowly and cautiously, without staying for any effort of vomiting it may induce; when about 20 inches are passed through the gag the nozzle has reached the stomach. First, two or three syringefuls of water are injected into the stomach; then, removing the second tube from the basin of water to the empty basin, the action of the syringe is reversed, by pressing on the lever as the piston is raised, and letting it fly up when the piston is depressed. Thus two syringefuls may be withdrawn, then fresh water is again injected and withdrawn, until the contents of the stomach are removed and the water returns clear. Precaution must be always taken not to exhaust from the stomach before water is injected, lest the coats of that organ be injured by being sucked against the nozzle of the tube.

If desirable, antidotes may be dissolved or suspended in the water injected. When the pump is used for feeding patients, one or two pints of beef tea, eggs beaten with milk or wine, Liebig’s soup, &c., are the kinds of food suited for the purpose. Each time the pump is used, it should be thoroughly cleaned by syringing through it plenty of warm water, and the tubes must be unscrewed to wipe the joints carefully.

Transfusion of Blood.—The points of greatest importance in performing this operation are:—

1. That the supply of blood come from a vigorous adult.

2. That the transfer be made within two minutes of the blood’s escape from the vein of the supplier.

3. That, to prevent coagulation, the blood should pass over as small a surface, and suffer as little exposure as possible in transit.

4. Care must be taken to prevent air entering the vein with the blood.

The apparatus described below is that devised by Dr. Graily Hewitt, and depicted in the Obstetrical Society’s Transactions for 1864, page 137. It consists of a glass syringe holding two ounces (fig. 96), with a piston easily attached and removed; its nozzle is curved and fits the mouth of a cannula of silver. The nozzle of the syringe is provided with a little stopper attached by a chain; a stylet likewise fills the cannula, to be withdrawn when the blood is injected through the latter.