But I must not tarry any longer in this old French street, or, indeed, in this musty old saleroom, which has thrown off its pensive and meditative humour, and taken on a brisk, practical, and business-like air. Already the auctioneer and his spruce clerk have arrived, and the faces of the knots of people scattered up and down the floor are looking with expectancy towards the little pulpit. It is no longer a place for an idle dreamer like myself, and so I saunter out to the street. The sudden transition from the shadow of the saleroom to the bright white sunshine on the bustling city thoroughfare, together with the sight of the refreshing water-cart, with a group of barelegged, merry children prancing in its cooling spray, instantly dispel my illusions; and in another moment I am as completely in the midst of the living present as I was before in the dead past.
SURGICAL SCRAPS.
There is a curious instrument in the armamentarium of the surgeon called a probang, employed for removing foreign bodies which have become fixed in the esophagus or gullet. It consists of a flexible stem, at one end of which is an arrangement of catgut fibres, and at the other end a small handle. By moving the handle slightly, these threads of catgut—which are stretched all round and parallel to the stem at its lower end—can be bent outwards in a radiating manner, which gives the instrument the appearance of a chimney-sweep’s broom in miniature. When a person is so unfortunate as to get a piece of bone stuck in his throat beyond the reach of the surgeon’s hand, the probang is sometimes found very useful. It can be passed down the gullet, in a closed condition, beyond the obstruction, then opened somewhat like an umbrella, and drawn upwards, carrying with it—if all goes well—the foreign body. The passing of such an instrument is far from being pleasant to the patient; but if it be done with ordinary care and judgment, it will not be attended with any harm. Every one who has known the misery attendant upon getting a good-sized piece of bone impacted in the food-passage, will understand that when the operation has proved successful, the patient is likely to consider the pleasure of seeing the offending fragment caught in the meshes of the probang cheaply purchased by the discomfort attendant upon the passage of the instrument.
Another instrument employed for passing down the esophagus is used for a different purpose. When the gullet has been severely burned internally—as, for instance, from the accidental swallowing of corrosive acids—after the ulcer produced has healed, there is a great tendency to contraction in the scar, and consequent stricture of the esophagus. This may threaten life, by tending to close the passage altogether. To prevent this, instruments called bougies are passed through the constriction from time to time. These bougies are simply firm, smooth, slightly flexible rods with rounded ends, and are various in size as regards their diameters. An instance of the passing of these instruments being turned to account in a very curious way, occurred some years ago in one of the London hospitals. A patient was suffering from stricture of the esophagus, brought about in the manner above described; and the tendency to contraction was in this case so great, that it was only by the frequent passing of instruments that it could be prevented from becoming to the last degree dangerous. Now, it was impossible that the man could remain in the hospital permanently; it was therefore decided to teach him to pass the instrument for himself. He proved capable of this, after a certain amount of instruction; and it then occurred to some one about the hospital that the daily performance of this operation might be made the means by which the man could earn a livelihood. Accordingly, the patient was advised to get a bougie made as much as possible to resemble a sword. This he did; and for a long time afterwards was to be seen about the streets of London making money by what looked like the swallowing of a sword. In his case there was really ‘no deception’ as regards the passing of a long instrument down towards his stomach was concerned, the only deception being that the instrument was not the weapon it represented. His daily street performance thus served him in two ways—it supplied him with food, and also kept open the passage by which that food could be conveyed to his ‘inner man.’
The contraction about which we have spoken as taking place in scars formed after burns of the gullet, and which is so dangerous there, also occurs in burns on the surface of the body, and often leads to a good deal of deformity. Burns, indeed, are a great source of trouble to the surgeon in many ways. For instance, if a burn is very extensive, there may be great difficulty in getting a cicatrice to form over the whole of it. Cicatrisation only begins in the immediate neighbourhood of living epidermis, and therefore a burn or ulcer must heal from the circumference to the centre. But the further that the cicatricial tissue extends from the margin of the burn, the more slowly and the more imperfectly is it formed; and indeed it may fail altogether to reach the centre. This difficulty has often been met by a small operation called skin-grafting. A piece of sound skin about the size of a split pea is pinched up—say, on the outside of the arm—and the epidermis snipped off with a pair of curved scissors, the scissors just going deep enough to cut slightly into the second layer of the skin and draw a little blood. A special kind of scissors has been invented for the purpose, that will only take up just the right amount of skin, so that the operation is thus made even simpler still; and if it is skilfully performed, it causes only very trifling pain. The little fragment of skin thus separated is then placed gently, with its raw surface downwards, on the unhealed surface of the burn. The same thing is repeated again and again, till there are many grafts, if the burn is a large one. Isinglass plaster, or some other similar material, is employed to keep the grafts in position and preserve them from injury. In about four days they should have taken root, and then the covering can be removed. There is now a number of foci from which cicatrisation can start; for, as before said, it will begin from where there is an epidermal covering, and thence alone. After a time, a number of little islands of scar tissue may be seen, which go on increasing until at length they coalesce with one another, and also join that extending from the margin of the burn. This is what happens if all goes well; but, unfortunately, there is a very great tendency for a cicatrice formed from grafts to break down and disappear, so that the result is not by any means always so satisfactory as it at first promises to be.
Another trouble with burns is the great pain which they invariably cause; and numberless are the applications which have been recommended for its relief. The great essential in all such applications is that they should completely exclude the air; for the very slightest irritation to the surface of a burn will give rise to the most excruciating pain. To prevent irritation and to keep the parts at rest is indeed one of the surest ways of relieving pain, not only in the case of burns, but in the treatment of other forms of injury, and also in many kinds of disease. An instance of this is found in the method adopted to relieve the pain in certain joint diseases. Those who have visited the Children’s Hospital in Ormond Street, or indeed any other hospital for children, may remember having noticed that at the foot of many of the beds there was fixed a pulley, over which ran a cord with a weight attached to the end of it. This cord, it may further have been noticed, was fixed at the other end to a kind of stirrup which depended from the patient’s foot. Thus the weight—which consisted of a tin canister partly filled with shot—had the effect of keeping the child’s leg on the stretch continuously. In fact, the little patient looked very much as though he was lying on a kind of rack; and if the visitor could have heard the surgeon order more shot to be poured into the canister, saying that he thought the patient was able to bear more weight, the command would have sounded very like that of a torturer, rather than that of one whose object it was to relieve pain. But the truth is that this rack is a very humane one indeed. It is the rack of modern times, as distinguished from that of past ages; it is the rack of the surgeon, and not that of the inquisitor. The cases in which this apparatus is used are almost always instances of disease of the hip or knee joint. The object of this arrangement of pulley and weight is, by making traction on the foot and leg, to keep the lower of the bones, which go to form the diseased joint, away from the upper, and so avoid the excruciating pain caused by the carious or ulcerated surfaces touching one another.
The benefit in such cases of having a weight drawing on the leg is most marked at night, when the patient wishes to get to sleep. With a good heavy weight, many a patient may sleep comfortably, who would otherwise be in a most pitiable condition through the long watches of the night. The position of such a person without any weight attached would be this. Knowing from past experience what too often followed on his dropping off to sleep, he would endeavour to keep himself from doing so. This, however, would of course be impossible for long, and at last the heavy eyelids would droop, the ward with its long rows of beds would grow dimmer and dimmer, the breathing of the neighbouring sleepers would sound fainter and yet more faint, until sight and hearing failed him, and his long watching ended in sleep. But now that he was no longer on his guard to keep his limb in a state of perfect rest, the irritation of the diseased part would give rise to spasmodic contraction of the neighbouring muscles. This contraction of the muscles would bring the lower bone of the joint, with more or less violence, against the upper; the two highly sensitive ulcerated surfaces would touch, and with a shriek of agony, the child would awake, quivering in every limb. And then, as the pain gradually grew less, again the same terrible drowsiness would begin to oppress him; and after another long spell of watching, he would fall asleep once more, to be once more awakened in the same horrible manner as before. But with a sufficient weight attached, the patient may go to sleep confident of comparative ease; for the weight is too much for the spasmodic action of the muscles to overcome, and the bony surfaces therefore remain separated. And not only does the surgeon’s rack thus save the patient from a terrible amount of pain, but, by allowing him to get good rest of a night, it must increase enormously the probability of ultimate recovery.
IN THE RHINE WOODS.
CUCKOO! CUCKOO!
I hear it again!