The essentials of bandaging /

by Berkeley Hill

Fig. 114.—Irrigating a wound.

Irrigation.—The continual flow of ice-cold water is used to prevent inflammation of certain wounds. In using cold, it is particularly necessary that the temperature of the water remain steady, for alterations of temperature cause alterations in the capacity of the blood vessels, and promote congestion rather than diminish it; hence irrigation, badly attended to, becomes an evil instead of a benefit. The simplest way (see fig. 114) of contriving irrigation is to lay the limb in an easy position on pillows, protected by a sheet of india-rubber cloth, weighted at one corner to draw the cloth into a channel, down which the water trickles into a receiver under the bed; over the limb a jar, wrapped in blanket, is suspended. This is filled with water from time to time, and kept charged with lumps of ice. A syphon is made by a few feet of fine india-rubber tubing reaching from the bottom of the jar to the wound, the escape of water through the tube being moderated by drawing the end more or less tightly through a bit of cleft stick. It is sufficient that the wound should be kept constantly and thoroughly wetted; more than that is waste of cooling power.

Esmarch’s Irrigator.—This is a simple contrivance for washing out wounds and sinuses with a stream of water. It consists of a tall can of block tin (see fig. 115), with an orifice at the lower end, to which a couple of feet of india-rubber tubing are attached. The tube is fitted with an ivory nozzle and a hook, so that when the stream is not wanted the flow of water is stopped by hanging the nozzle on the upper edge of the can. The stream can be made more or less forcible by raising or lowering the can above the wound.

Fig. 115.—Esmarch’s Irrigator.

The Administration of Chloroform.—In administering chloroform the main points to be borne in mind are—1. If the patient is fit to undergo an operation at all he may inhale chloroform. 2. The patient should be fasting; this is the most effectual preventive of sickness. 3. He should be in an easy position, clad in a loose but warm night-dress, which does not interfere with ordinary or artificial respiration, should that be suddenly required. 4. The patient must never inhale more than 4 per cent. of chloroform vapour in the air he respires; on the other hand, the vapour may circulate in the blood without harm for an indefinite time, provided it never pass beyond a certain concentration. 5. Chloroform is a sedative and depressant; the pulse gives the earliest indication of syncope, and the respiration should be constantly watched the whole time chloroform is inhaled. It should be noted that the pulse often fails suddenly at the first flow of blood in an operation. Again, when the patient is deeply narcotised, the jaw may gape and the tongue sink back till it closes the glottis. From this cause respiration sometimes ceases, and danger quickly arises if the chin is not drawn up to raise the epiglottis. In beginning to inhale, the quantity of vapour should be small, and gradually increased. The patient must be cautioned not to talk, to avoid the irritation and coughing chloroform sometimes excites while he is speaking. He should also shut his eyes lest the vapour make them smart. After inhalation has been continued a few minutes the patient is often quiet and inattentive, though easily roused by pain. His condition at this stage should be tested by asking him to give his hand, or by pinching him gently; if no notice be taken of these, the conjunctiva should be touched, and the amount of winking thus excited will enable the chloroformist to judge if the patient will resist when the knife is applied. Patients vary much in the time passed before recovering consciousness; if they remain soundly asleep, breathing freely and with good pulse, it is better to avoid rousing or moving them until they wake spontaneously; such patients suffer less confusion and vomiting than those who are quickly alive to what is going on around them.

Signs of Danger.—Sudden failure or irregularity of the pulse, with pallor and arrested breathing, are of great importance; if these occur, the chloroform must be at once removed, a free supply of fresh air ensured, the tongue drawn gently forward, and if the breathing do not quickly begin, it must be set up artificially (see p. [183]) without loss of time, and continued, if necessary, for at least an hour before recovery is despaired of. Stertorous breathing is not alarming unless accompanied by feeble pulse, shallow respiration, and dilatation of the pupils; with these it becomes a sign of a comatose condition.

As subordinate adjuvants for faintness the following are useful:—moistening the tongue and lips with brandy from time to time, or letting the patient sip a small quantity from the spout of a feeding cup. In complete syncope, galvanism to the epigastrium, a hot iron or scalding water to the præcordia may be employed, but should never interfere with the maintenance of artificial respiration, which is of far greater efficacy in restoring suspended animation than anything else.

Chloroform is safely given on a handkerchief, or in various ways, if the administrator is careful to watch the pulse and respiration, and to guard against the patient, by a sudden deep inspiration, taking too large a dose of vapour at once. Exact measurement of the quantity of liquid poured on the handkerchief at a time is of no value, as it is no index of the concentration of the air respired by the patient. Of far greater consequence is it to insure a free supply of atmospheric air, by keeping the evaporating surface a few inches from the mouth and nostrils.