A System of Operative Surgery, Volume 4 (of 4)

by Unknown

The bowels should be opened by an aperient the night before the operation, as it is desirable to keep them confined for the first two days afterwards, so as to avoid straining. During the first week after a major operation, when the patient is confined to bed, they should be evacuated in the supine position.

The best time for operating, if possible, is the morning, as the patient has had a night’s rest and is less likely to lose self-control. Usually there is some pain after the cocaine has gone off, and the patient is better able to stand it during the daytime.

Anæsthetics. General anæsthesia should be induced in all patients with congested eyes, in small children, patients who are deaf, and those who show a want of self-control. Chloroform should be used for all intra-ocular operations, and should be given to the full surgical degree. It should be given on a towel or an inverted mask specially made for the purpose, a Junker’s inhaler being used during the time the actual operation is being performed. As the surgeon usually stands at the head of the patient, the anæsthetist should stand on the side away from the eye being operated on. The local use of cocaine in addition to general anæsthesia is indicated when operating on patients to whom it is advisable to give as little anæsthetic as possible.

Local anæsthesia is obtained by the use of a 4% solution of cocaine instilled four or five times before the operation at intervals of three minutes; a drop of the solution should also be instilled into the eye which is not being operated on, to prevent an accidental reflex stimulation of the conjunctiva and screwing up of the eyes. Adrenalin (1–1,000) may be used in conjunction with the cocaine; it is especially useful in squint operations, as it lessens the hæmorrhage. Eucaine and stovaine have been used, but are not nearly so satisfactory. Under ordinary circumstances the only pain felt during an intra-ocular operation is during removal of the iris; this is obviated to a great extent by instilling the cocaine at least 15 minutes before the operation is performed, so as to allow time for its diffusion into the anterior chamber. The patient should be warned when to expect the pain, so that he may not move; his self-control may be tested beforehand by pricking the nose with a pin.

Fig. 74. Window of the Operating Theatre, King’s College Hospital. The windows are fitted with outside blinds so that either can be used separately, or the surgeon may stand in the angle and operate with his back to the light. A recess beneath the window allows the patient’s face to be brought close to the light on dark days.

The theatre. The theatre should possess, as far as possible, all the modern improvements found in an up-to-date general surgical operating-room. The light should proceed from a single large window, which, if possible, should face the north. The window should consist of a single pane of glass or of two panes forming the angle of the theatre; it should begin about 5 feet from the floor and should extend to the ceiling (Fig. 74). The advantage of an angular window is that it allows the operator to stand with his back to the light in the angle, and so enables onlookers to see. No top light should be allowed, as it produces a corneal reflection which may prevent the operator from seeing the position of his knife in the anterior chamber. Beneath the window there should be a recess for the end of the operating table, so that the patient’s face can be brought close to the window if necessary (Fig. 74). This recess is formed by building the main wall of the theatre further out than the window, which has to be supported by a transverse girder.

Fig. 75. Bull’s-eye Electric Hand-lamp. For use when artificial illumination is required.

The window should be fitted with outside blinds so that the theatre can be easily darkened for the operations, such as capsulotomy, which require the use of artificial light. The best artificial light is a small enclosed electric hand-lamp fitted with a bull’s-eye, by means of which the operation field can be brilliantly illuminated while the surrounding area is left in comparative darkness (Fig. 75). Failing this, a single powerful lamp with a ground-glass globe, placed in front of the patient, will serve, the rays of light being brought to a focus on the eye by means of a large convex lens of about + 10 D.