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means of a mouth-gag. Prepare a firm plug of cotton or cloth, one half of an inch thick and three quarters of an inch long, and tie it in the middle of a doubled cord eighteen inches long. Pass a Bellocq's sound threaded with a cord a foot long, keeping its beak applied to the floor through the naris, until it reaches the pharynx. Protrude the spring from the canula, and the eye carrying the cord will be curved into the mouth. Attach to this cord one end of the doubled cord attached to the plug, while the other end of the doubled cord may be cut until it measures six inches in length. Draw the spring into the canula, which will pull the oiled plug into the mouth. Now begin to withdraw the Bellocq's sound, directing, if necessary, the plug up, around, and over the soft palate, with the left index-finger.

Detach the end of the doubled cord protruding from the nostril, and separate it so that there will be two strings. Now stuff into the nostril between the two strings a plug of cotton, over which tie the strings, thus holding in place this anterior plug. Care must be taken not to pull the posterior plug too far into the nostril. It must only engage itself in the posterior naris. The other end of the doubled cord hangs down into the pharynx.

To remove the plugs, cut the string holding the anterior plug and withdraw this plug. Catch with forceps the end of the doubled cord hanging in the pharynx and draw gently upon the posterior plug. The detachment of the posterior plug may be aided by a probe passed through the anterior naris, pressing it backward into the pharynx.

CHAPTER II.

PARACENTESIS.

I. CORNEÆ, TYMPANI, THORACIS, PERICARDII, ABDOMINIS,

VESICÆ; ASPIRATION. II. HYPODERMIC NEEDLE.

Paracentesis Corneæ.—Place the subject on the back, and stand behind the head. Raise the

upper lid of the eye, and apply the pulp of the left index. finger horizontally to the lid and partly to the globe. Depress the lower lid, and apply the middle finger of the same hand in like manner.

Now by pressure, keeping the fingers apart, the globe of the eye is controlled.

The puncture is made with a broad needle held lightly between the right thumb and index-finger. Enter the needle with its flat surface parallel to the iris at either lower lateral margin of the cornea, and direct the point downward as if to puncture the lower margin a little beyond its central point. The needle must never be passed in front of the pupil in traversing the anterior chamber. While withdrawing, rotate the needle as soon as its point has left the anterior chamber, in order to make the wound patulous.

Paracentesis Tympani. — Expose the tympanic membrane by reflected light through an ear-specu

lum. Puncture the tympanum posterior to the han

dle of the malleus with a small, double-edged knife, held between the right thumb and index-finger. Enlarge the puncture vertically, not allowing the point of the knife to scarify the inner wall of the tympanum.

Paracentesis Thoracis.—Prepare the subject for this and the following paracenteses by injecting water into the cavities.

Place the subject on the side. Find the sixth intercostal space, and select a point just above the lower rib bounding this space equidistant from the sternum and from the spine. Puncture with a lancet the skin at this spot. Enter the trocar and canula in this puncture and push through the thoracic wall, determining to what extent the instrument shall be introduced by the right index-finger laid along the upper surface of the instrument. Direct the point of the instrument upward to avoid the upper edge of the lower rib. Withdraw the trocar. The fluid may be allowed to run away, or it can be removed by suction. The intercostal space sinks below the puncture through the skin as the fluid is removed.

Keep the integument pushed against the shaft of the instrument, in order to close the puncture immediately after it is withdrawn.

If a lower intercostal space be chosen, be careful to direct the point of the trocar upward, to avoid puncturing the diaphragm.

Paracentesis Pericardii.Puncture the skin in the center of the fifth intercostal space at any point three quarters of an inch to two inches from the border of the sternum on the left side. The internal mammary artery is situated about half an inch from the sternum. Hold the trocar and canula in the right hand with the right index-finger laid along the instrument to prevent its entering the sac any greater distance than that determined upon. Enter the point of the instrument into the puncture and push the instrument upward and inward into the sac with great care. Withdraw the trocar and allow the fluid to run out, or to be sucked out through the canula. The same precautions against the entrance of air, on the withdrawal of the trocar, must be taken as in paracentesis thoracis.

Paracentesis Abdominis.--Place the subject in the sitting posture, and surround the abdomen with a broad, many-tailed bandage, with an opening through which to operate. Make a puncture through the skin with a lancet at the point bisecting a line drawn from the umbilicus to the symphysis pubis. In this puncture enter the trocar and canula, holding the instrument in the right hand, with the index-finger applied to its upper surface where you wish to limit its introduction. Push the instrument into the abdominal cavity. Withdraw the trocar, leaving in the canula until sufficient fluid has escaped.

The canula may be moved about, or a catheterperforated tube introduced through the canula, to promote the evacuation of the fluid ; withdraw the canula, preventing the introduction of air. Paracentesis Vesicæ.The bladder

may

be tapped above or below the pubes, through the anterior vaginal wall, or through the anterior wall of the male rectum.

Suprapubic.Place the subject on the back; puncture with a lancet the skin just above the symphysis pubis. Enter the trocar and canula through the puncture, and direct its point downward and backward, while pushing it into the bladder. Limit the introduction of the instrument to about an inch ; and if a curved instrument is used, keep the convexity uppermost. Withdraw the trocar, and allow the fluid

to escape.

car.

While withdrawing the canula, close its orifice with the pulp of the index-finger, to prevent urine or air being sucked out along its track. Guard against the entrance of air, as in the other paracenteses.

Subpubic.-Pull the penis down, and puncture the skin just under the symphysis pubis with a lancet. Enter the point of a small curved trocar and canula, with its concavity turned upward, into the puncture, and push the instrument directly backward through the tissues for about two inches; withdraw the tro

After the urine has escaped, withdraw the canula, with the same precautions as in the previous puncture.

Vaginal.—Place the subject on the back with the thighs and legs semiflexed and strongly abducted. Stand between the legs and introduce into the vagina the left index-finger with its palmar surface turned upward until its tip reaches a point an inch posterior to the posterior surface of the pubis. Shield the point of a curved trocar by withdrawing it a little into the canula. Introduce the instrument with its concavity turned upward, and its end following the palmar surface of the left index-finger. When the end reaches the tip of the finger, protrude the point of the trocar. Push the instrument upward and back

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