The purpose of this article is to give an account of the more important surgical instruments that are now in general use, and to show by what modifications, and from what discoveries in science, the present methods of an operation have come to be what they are. 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 operatingtheatre. Take, for instance, a scalpel and a saw that are figured in Ambroise Pare's (1510-1590) surgical writings. The scalpel folds into a handle like an ordinary pocket-knife, which alone was enough in those days to keep it from being a eptic. The handle is most elegantly adorned with a little winged female figure, but it does not commend itself as likely to be surgically A B C FIG. i. - Needle-holders. A, Hagedorn's; B, Macphail's; C, Allen and Banbury's, for Hagedorn or ordinary needles. clean. The saw, after the same fashion, has a richly chased metal frame, and, at the end of the handle, a lion's head in bold relief, with a ring through its mouth to hang it up by. It may be admirable art, but it would harbour all sorts of germs. If one contrasts with these artistic weapons the FIG. 2. - Tenotomy Knives forged in one piece.
instruments of 1850, one finds no such adornment, and for general finish Savigny's instruments would be hard to beat; but the wooden or ivory handles, cut with finely scored lines like the cross-hatching of an engraving, are not more likely to be aseptic than the handles of Pare's instruments. At the present time, instead of such handles as these, with blades riveted into them, scalpels are forged out of one piece of steel, their handles are nickel-plated and perfectly smooth, that they may afford no crevices, and may be boiled and immersed in carbolic lotion without tarnishing or rusting; the scalpel has become just a single, smooth, plain piece of metal, having this one purpose that it shall make an aseptic 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 simple, smooth, unrusting metal instrument, that can be boiled and laid in lotion; it is a foreign 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 arrest of bleeding from a divided bloodvessel. In Pare's time (he was the first to use the ligature in amputation, but the existence of some sort of ligature is as old as Galen) the ligature was a double thread, bon fil 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 Pare to the time of Lord Lister no great improvement was made. In the middle of last century it was no uncommon thing for the house-surgeon at an operation to hang a leash of waxed threads, silk or flax, through his button-hole, that they might ?_:...- ..._,.
FIG. 3. - Amputating Saws.
be handy during the operation. Then came Lord Lister's work on 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 short, and left in the depth of the wound, with 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 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 kangaroo-tendon, or some other animal substance. But whatever 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 common cause of suppuration. Therefore the wound was not closed along its whole length, but the ligatures were left long, 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 hope of avoiding this trouble, they were made of silver wire, which was inconvenient to handle, and gave 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 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 Sir William Fergusson that he once told his students, "You may say what you like, gentlemen, but after all, there's no better dressing than cold water." This is not the place to try to tell the long history of the quest after a perfect surgical dressing, and the advance that was begun when Lord Lister invented his carbolic paste. The work was done slowly in the international unity of science during many years. The perfect antiseptic dressing must fulfil many requirements: it must be absorbent, yet not let its medicament be too quickly soaked out of it; and it must be antiseptic, yet not virulent or poisonous. Of the many gauzes now available, that which is chiefly used is one impregnated with a double cyanide of zinc and mercury. Its pleasant amethystine tint has no healing virtue, but is used to distinguish it from other gauzes - carbolized gauze, tinted straw-colour; iodoform gauze, tinted yellow; sublimate, blue; chinosol, green. The chinosol gauze is especially used in ophthalmic surgery; for general surgery the cyanide gauze is chiefly employed. The various preparations of absorbent 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 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 antiseptic influence may act at once.
The whole subject of surgical instruments may be considered in more ways than one. It may be well, for the sake of clearing the ground, to take first some of the more common instruments of general B FIG. 4. - Artery Forceps.' A, Pean's; B, Spencer Wells's.
surgery, and then to 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 electricity.
FIG. 5. - Retractors.
Of the essential instruments that are common to all operations, we may well believe that they have now become, by gradual development, perfect. Take, for instance, the ordinary surgical needle. In the older forms the eye was slit-shaped, not easily threaded, and the needle was often made of a triangular outline, like a miniature bayonet. At the present time the needles used in general surgery are mostly Hagedorn's, which have a full-sized round eye, easy for threading, are flat for their whole length and have a fine cutting edge on one side, near the point. Thus they enter the skin very easily, like a miniature knife, and the minute wound they make is not a hole, but a tiny slit that is at once 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 gold 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 close to the blades. At the present time the forceps in general use, named after Dr Nan in France and after Sir Spencer Wells in 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 free when the ligature is tied by a moment's extra pressure on the handles.
Among other instruments in universal use are divers forms of retractors, for holding gently the edges of a wound: the larger patterns are made with broad, slightly-concave, highly-polished surfaces, that they may, so far as possible, reflect light into the wound. Among tourniquets, the old and elaborate Petit's tourniquet, which was a band carrying a pad screwed down over the main artery of the limb, has given place to the elastic tourniquet with Esmarch's bandage. For example, in an amputation, or in an operation on a joint or on a vessel or a nerve in a limb, the limb is FIG. 6. - Tourniquet (Esmarch's).
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.
FIG. 7. - Lithotrite (Bigelow's).
It is not possible to describe here the many forms of other ordinary instruments of general surgery - probes, directors, scissors, forceps, and many more - nor those that are used in operations on the bones. Nor again can the numerous instruments used in special departments of surgery be discussed in detail. But, with regard to the special FIG. 8. - Tonsillotome (Mathieu's).
surgery of the eye, and of the throat and 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 recent date. The opthalmoscope was the work of Helmholtz. The laryngoscope was invented by Manuel Garcia in the middle of the FIG. 9. - Ophthalmoscope (Landolt's).
19th century; and the use of a frontal 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 internal diseases of the eve; before the laryngoscope the diseases of the larynx were invisible, and were mainly a 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 FIG. io. - Laryngoscope (Lenncx Browne's).
forces was the invention of proper instruments of diagnosis. The textbooks that were written immediately before those instruments became available were not far in advance of Ambroise Pare, so far as these special departments are concerned.
It may be well next to consider in what ways the conduct of an operation is influenced by those two great discoveries of anaesthetics, and the more gradual development of the principles of antiseptic and aseptic surgery; with special reference to the use of the instruments of surgery. The jubilee year of anaesthesia was 1896; the first use of nitrous oxide was on the 11th of December 1844; the first operation under ether was on the 30th of September 1846; the first use of chloroform was on the 4th of November 1847. The choice of the anaesthetic, or of some combination of anaesthetics, that is best suited to each particular case, is a matter of careful consideration; but, on the whole, the tendency in England is to keep to the via media between the more general use of chloroform in Scotland and the more general use of ether in the United States. Of the methods of administering chloroform there is no need to say much; by some FIG. i I. - Inhaler (Junker's).
anaesthetists no instrument is used save a fold of lint or some such stuff, or a piece of flannel made into a sort of cone or mask. Use is generally made of a modification of "Junker's inhaler," whereby the vapour of chloroform is administered by means of a hand-ball. For the administration of ether some form of Clover's inhaler is generally used, whereby the ether in a small metal chamber passes as vapour into an indiarubber bag, and there is combined with the patient's breath in pro portions determined by the anaesthetist throughout the operation. The metal chamber is so designed that by turning it the exact proportion of ether to air is fixed in accordance with the requirements of the case. Of late years, by the use of an iron cylinder of nitrous oxide, connected by a tube with a Clover's inhaler, it is possible to begin with nitrous oxide, and to go on, without interruption, with ether. More recently an admirable method has been devised of administering nitrous oxide with the admixture of air or of oxygen in such a way that the anaesthesia pro duced by the gas may be maintained for time enough to allow of an operation of some length.
FIG. 12. - Gas and Ether Apparatus (Hewitt's) .
The 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 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 boil or steam either himself or his patient. __ t The preparation, therefore, of the surgeon's hands, and of the skin over the area of operation, is made not only by scrubbing with 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 immersion in antiseptic lotion.
The sterilization of all instruments and dressings is a simple matter: the usual sterilizer is a vessel like a fish-kettle, with a perforated metal 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 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 be 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 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 Galvano-Cautery. - The original form of the cautery, the fer ardent of Pare's time, for the arrest of 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 Claude Andre Paquelin (b. 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 platinum gauze, and, by means of a bottle and handbellows, they could be kept heated with benzene-vapour. Thus, when they had once been raised to a glowing heat by holding them FIG. 4. - Galvano-cautery Set.
over a spirit-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 battery or (by means of a converter) with the ordinary house supply of electricity. In this way it is possible to apply a glowing point with a fineness and accuracy of adjustment that were wholly impossible with Paquelin's cautery.
This method is of great value, in suitable cases, for the arrest or obliteration of small growths. The passage of the electric current between needles introduced into or under the skin brings about a gradual shrinking or cicatrization of the tissues subjected to _ _? it, without the production - of any unsightly scar.
3. Electro-Motor Power. - During recent years the use of a small electro-motor machine has come into the practice of surgery for certain operations on the bones; especially for the operation for disease involving the mastoid bone. It is, of course, a better method for the use of a fine drill or burr, for example, than the "dental engine," where the power is generated by a pedal turning a 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 cranial bones.
4. The X-Rays. - This, the most unexpected and, as it were, the most sensational discovery that has been bestowed on physicians and surgeons since the discovery of anaesthetics, is now used over a very wide and varied field of practice. Its value does not stop at the detection and localization of foreign bodies; indeed, this is but a small part of its work. It is used constantly for cases of actual or suspected fracture or dislocation; for cases of congenital or acquired FIG. 6. - Cystoscope (Nitze's) .
deformity; for cases involving difficulties of diagnosis between a swelling of the bone due to inflammation and a swelling due to a tumour; and for obscure cases of spinal disease, hip disease and the like. Moreover, it has been found possible, by Dr Hugh Walsham, and others to obtain pictures of the thoracic organs that are a very valuable guide in many obscure cases of disease of the lungs or of the pleura, and in many cases of thoracic aneurism or of intra-thoracic tumour. Every year the number and the range of the cases where the X-rays are helpful for diagnosis and for treatment become greater; and it is impossible to say at what point the surgical value of this discovery will find its limits. Beyond these uses, it is probable that the X-rays will maintain and extend the importance that they already have in the direct treatment of certain cases of disease of the skin (see X-RAY Treatment). Fig. 17. - Urethroscope (Fenwick's), also 5. The Electric Light. - used for ear, nose, throat, &c. Beside the general superiority of this light to other 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 re9. - ' flector, and a small window. Its other end is fitted with a lens, and is connected by a switch with the main current. With this instrument, in skilled hands, it is possible to inspect the interior of the 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-illumination of the facial bones in cases of suspected disease of the central cavity of the superior maxillary bone. A small glowlamp is held in the closed mouth, in a darkened room, and by a comparison of the shadows on the two sides of the face, thus trans-illuminated, an exact diagnosis can often be obtained as to the presence or absence of pus in this central cavity. Again, a small glow-lamp, duly sterilized, is often operations on the abdominal cavity.
The bactericidal properties of light have long been demonstrated by Bie and others. Professor Niels Finsen of Copenhagen first used the ultra-violet rays of solar light in the treatment of skin diseases, ??11I II FIG. 13 - Instrument Sterilizer.
FIG. 15. - Electrolysis Needle-holders.
FIG. 18. - Finsen-Reyn Lamp.
of great value in deep notably of lupus. He later invented the lamp which bears his name. The original Finsen lamp comprised a voltaic arc of 60 to 80 amperes round which four tubes collected the light by quartz lenses, the light being cooled by passing through water and the tubes being surrounded by a water-jacket. The usual exposure was one hour. In the Finsen-Reyn modification now used, a single 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 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 forty-five minutes.
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 order to modify the intensity of the radiation. This is done by enveloping the tubes containing FIG. 19. - Radium Applicators.
the radium in cases of silver, lead or nickel of various thicknesses. In this, known as the method of Dr Dominici, the a. and 1 3 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, London, and that of the radium applicators by permission of Messrs Siemens Brothers, London.