Medical and Surgical Implements

Third set of edits, suggested by Aurora Damall, in blue.
More recent edits, suggested by Judith, in lime green.
Edits suggested by Aurora and Judith in red.

MEDICAL and SURGICAL IMPLEMENTS

General Overview
A major pastime of White Nehtorians is inventing new toys to be utilized in their healing practices. Certainly, great imagination, if not foresight and caution, goes into creating new tools to examine infirmed people and extract something from them. Clearly, this is not a frivolous pursuit: Why should a modern-day healer limit their bloodletting skills to simple leeching? Why would any progressive-thinking Dalorin restrict their practice to crystals and pleasing aromas, when we now have at our disposal clysters, bezoars, and smelling salts? Hail to the new age of instruments, which brings us ever closer to at last unveiling the magical sling stone that will knock out any disease!

Origin, History
A thorough investigation of the history of medical implements throughout time could fill tomes. The surgical implements we have at our disposal today were born out of necessity. As each new procedure was discovered, new tools were required to fit this new demand.
Some implements share obvious similarities and common traits with weapons of war. For example, the earliest surgical knife was likely just that--a skinning or hunting knife, pared down so as not to damage the person undergoing surgery. As more precision and care was demanded of chirurgeons, and as the practice of surgical procedures grew, the instruments used became more specialized, the blades smaller and sharper, and the size of the tools shrank so that surgical tools could actually fit inside tight enclosed spaces of the body.
Other instruments came out of the visions of healers who saw a need to adapt surgeries to minimize pain, reduce the size of surgical wounds, and speed the recovery process after surgery. Adding retractors, clamps, and pincers to standard surgical procedures meant that surgical cuts could be smaller, which in turn resulted in less blood loss and better healing after surgery. Heating implements which could coagulate bleeding veins also ensured less blood loss during surgery.
Though the chain of command among healers is somewhat hierarchical, and can at times resemble the military order of a company of soldiers, most healers do not see themselves as warriors. In fact, most Dalorins see themselves as a necessary complement to the laborers, smiths, and soldiers who sustain injuries related to their line of work. Just as there is a need for one person to forge the sword, and another person to wield the sword in battle, there is also a need for a healer who will attend the smith for his aching back and the soldier for his gashes at the end of the day.

Improvised Surgical Tools
(entire section appended, as suggested by Aurora and Judith)
Serendipity often does not wait for the optimal time or place to arrive. On the field of battle, many instruments must be fashioned from existing tools at hand. Obviously, it is up to the field chirurgeon to improvise with what is available at that moment, or otherwise accept failure at treating wounds which are sustained far from a healing camp. The list of tools which have been improvised in such circumstances is immeasurably long; a few examples of such makeshift instruments are mentioned here to illustrate the principle of ingenuity under fire.

Scalpels are delicate, and routinely break with minimal shearing or excessive pressure. Dalorins in the past have often resorted to using single-edged knives for urgent surgical procedures. The t'weep is an adequate tool, though somewhat clumsy since the cutting edges on all sides of the knife make this dangerous to both the chirurgeon and, in the case of a slight slip of the fingers, to the wounded soldier. The hunter's arhk, originally intended for skinning animals, may also serve as a standby surgical blade in a pinch.
Fractures in the field of battle are common, whereas properly designed splints are hard to come by in these circumstances. Fortunately, spears, lances, and staves are easily fashioned into splints which are lashed onto a broken arm or leg with whatever lashing material is available: Weapon lanyards, leather slings, or even discarded clothing.
Tourniquets are predictably needed whenever one is far from a healing camp. The main objective in fashioning a tourniquet in the field is to find a long, clean, and supple material which will not slip when knotted above a seeping wound. Again, discarded clothing works to this end if it is passably clean. This author has resorted to utilizing thin, green tree branches, head wraps, and cooking towels in previous emergencies.
Esteemed herbalist mage Dalmac Brandivere has described a treatment for a collapsed airway when away from camp:
"In a case where a man's windpipe was crushed, a daring healer slit the throat area (avoiding the Great Vein) with a friend's dagger and inserted a slim section of Windgrass to hold the broken pipe open. It preserved breath till mages were able to perform a healing spell..."
Some other tubes used for this purpose include yealm reed and icemilk weed. The essential features to look for are a semiflexible tube, hollow, at least a palmspan in length and about 1 to 2 nailbreadths across, and able to support a tether knotted onto the tube which prevents the pipe from dislodging.
Rotten teeth often wait for the most inopportune time to fester and incapacitate the bearer of bad teeth. Of course, the instrument of choice would be the barber's pincers, aided by a course of miyu beans. In less optimal circumstances, bowstrings and garotte cords have seen use in yanking teeth. A different approach would be to use a tanner's awl or a quarryman's chisel, along with a cook's wooden mallet, to "gently persuade" the tooth to come out.
When the miyu beans are gone, the por'mon salve has dried up, and no willow bark tablets remain in the field kit, then a stout mug of ale will always substitute nicely. When hard-pressed, this author has had success prescribing stiff swigs of scumble to bolster soldiers' spirits and cast off aches and woes.

Trephine
Description
The trephine is a two-handed twist screw. One model is shaped like a straight rod with two handles. A second fashion is a rod, about a fore in length, bent at right angles in 4 places, shaped like a straight-brimmed hat: One "brim" is the handle which remains steady, and the instrument rotates inside this handle. The "dome" of the hat is a second handle, which is spun around in a circle, and it is this handle which turns the screw. The other "brim" of the hat ends in a drill or countersink screw.

Usage
With one handle being used to steady the instrument, the trephine bores a hole and removes a circular disc from the skull. This is used to relieve pressure in cases of bleeding inside the skull.

Scalpel
Description
The scalpel is a very small but uniquely sharp knife, consisting of a handle a little longer than a palmspan, and a small metal blade slightly longer than a thumbnail.

Usage
This is the principal cutting instrument in surgical procedures.

Razor
Description
Usually a straight razor, this consists of a handle a palm span in length, and the blade, almost as long as the handle, which folds out from the handle.

Usage
Used for shaving hair at the surgical site.

Spatulae
Description
An L- or J-shaped utensil, with varying lengths of handles, depending on the surgical site (delicate surgery used retractors smaller than one’s smallest finger, and surgery of the belly required two-handed spatulae up to a forearm’s length).

Usage
Used by surgical assistants to open up the surgical field and allow for smaller incisions.

Curved and straight pincers
Description
Pincers are two lengths of metal a palmspan long each, fashioned like an "X" and joined by a hinge in the middle, with blunt teeth lining the opposing edges like an alligator’s jaw. A second model of pincer is shaped like a "V", with the two lengths of metal fused at the apex of the "V".

Usage
Pincers are used to hold and retract skin or membranes.

Stitching needles
Description and Usage
Stitching needles have an eye at one end and a sharp cutting point at the other. Common shapes include long, straight, conical (like a cylinder if you look from the point to the other end) and thick (for closing thick skin, as on the thigh or abdomen); long, curved (like a semicircle) and rectangular prismatic (for suturing tough tissues, such as muscle); intermediate, curved, and conical prismatic (for closing average-thickness skin); and short, curved, conical prismatic (for delicate tissues, such as fingertips or the inside of the mouth).

Injecting needles
Description
The riccio is a rodent, approximately 1 to 2 palmspans long, that is covered in defensive quills. The quills of the riccio, or pricklepig in common speech, may be plucked, rinsed, and used as hollow needles for administering herbal preparations to someone who is too ill to drink.

Usage
A small purse, from the washed-out intestine of an animal, is tightly knotted onto the base of one of these quills. A dose of the preparation to be administered is suctioned up into the purse. Then, the tip of the quill is inserted into a vein in an arm or leg, and the purse is squeezed, ejecting the medicine into the body to course through the blood.

Dilators
Description
Hollow or solid cylinders for widening openings. These vary in length from one to two palmspans, and in girth from two grains up to two nailbreadths. Sophisticated models are hinged, such that a narrow instrument may be inserted and then opened to widen a bodily opening.

Usage
These include urethral dilators for removing bladder stones, and assorted specula.

Wound-draining implements
Description
Wound-draining implements range in size according to their function. The small lancets, a metal case about 3 nailbreadths wide containing a spring-activated tine or sharp wire, are used for scarification and bloodletting. Larger knives are used for draining abscesses and other uses.

Usage
Scarificators and lancets are used to draw a drop of blood, which is smeared between two of the examiner's fingers and studied in a similar fashion as urine.
Larger knives are typically single-sided, such that the healer may push the blade with one fingertip atop the blunt edge, and thus allow more precision in surgical wounds created.

Method of Usage
Blood is checked for viscosity, hotness or coldness, "greasiness", taste, foaminess, rapidity of coagulation, and the characteristics of the layers into which it separates.
First, healthy blood is slightly slippery, but not too thin. Thin blood may suggest several things, all of which merit further inquiry: Blood loss, exhaustion of the sanguine, failure of the heart to produce more blood, or poor blood supply through the veins. Thick blood often indicates dehydration.
Second, blood should normally be hot. Cold blood may indicate a drop in body temperature, or excessive ingestion of alcohol, either of which may be fatal if not remedied by pushing the afflicted person to stay warm and drink profuse hot liquids.
Third, any greasiness of the blood suggests suet seeping into the heart, which may clog the veins, and is best treated with a regimen of exercise.
Fourth, blood normally tastes salty and mildly meaty. If the blood tastes gamy, this indicates spoilage of the blood. A brackish taste signals befoulment of the blood, such as bad spirits infesting the blood. A fruity quality often means the person suffers from starvation, though the reason behind this is yet unknown. Blood with a heady taste suggests recent imbibing of alcohol. Acrid blood points to an excess of choler, which people will often report as a welling up of aceed in their chest, commonly called "heartburn". Any metallic quality in the blood hints at an excess of anima. An astringent character to the taste means an excess of ichor. Earthy-tasting blood signifies an excess of phlegm, and blood which tastes woody comes from an excess of bile.
Fifth, blood should be even and smooth. Foaminess indicates impurities in the blood, but cannot specify what foreign substance has contaminated the blood.
Sixth, blood which forms clots too readily may point out a tumor somewhere in the body, trying to fight out the swelling. Blood which does not clot well may stem from contagion or a weak sanguine constituent.
Finally, after observing blood for ten minutes or so, the examiner should study how the blood separates into layers. The top layer should be thin, cloudy pale or yellow, with little turbulence. The bottom layer should be thick, deep red or crimson-purple, and clotted. If the blood does not separate into layers, this may indicate sickly sanguine which cannot nourish the body.

Urine flasks
Description
A urine flask is a crystal or glass bowl, roughly the size of a cooking pot (about 4 mugs in size), for collection and analysis of excreta. The crucial quality of these flasks is that they be perfectly clear and not sparkle or iridesce, so that examination of urine is not adulterated by a false lustre from the flask.

Usage
Urine is analyzed for:
* Color (colorless to dark yellow or brown, or even blue in certain disorders)
* Clarity (clear to turbid with clots, pus or sand)
* Odor (odorless, putrid, rancid, or ammoniacal)
* Taste (sweet, sour, bitter, tasteless)
* Viscosity (thin to pasty)
* Quantity

Method of Usage
Characteristics of urine are gauged in various ways.
First, a yellow color suggests that the kidneys are working properly. Pale urine suggests flat, torpid anima, and the person is lacking verve. Red urine suggests blood seeping into the urine, which sometimes suggests spoilage within the urine pathways, kidney stones, or rarely a tumor along these same parts.
Next, the clarity indicates absence of infection; any cloudiness suggests bad spirits infesting the urinary pathways. Sand in the urine points to kidney stones showering the urine with small fragments.
Third, healthy urine should be odorless, or only slightly ammoniacal. Too much ammonia in the urine suggests a scantily unhealthy flow of bile, and may show up as yellowish discolouration of the skin. A putrid odor suggests contagion raging within the waterways, and a rancid odor may suggest a tumor rotting the system.
Fourth, the taste of urine can be very telling as to one's ailments. Sweet, sugary urine may indicate either a sweet disposition, or an infirmity wherein a person holds onto too much sugar. Bitter urine suggests a person has an excess of choler, which may manifest as either periodic combativeness and agitation, or its opposite, lethargy and sluggishness. Sour urine usually accompanies spoilage of the waterways.
Fifth, the thickness of the urine can indicate purity of the anima. Urine should be thin and slippery when the anima flows properly. If the urine is too thick, as judged by the examiner, this may indicate whey in the urine--another sign of spoilage.
Lastly, the quantity of urine, which may vary according to how much a person has had to drink, tells whether the anima is flowing profusely--a healthy quality--or is welled up, which can lead to lethargy and forgetfulness.

Cauterization implements
Description
Another L-shaped instrument consisting of a wooden handle a little longer than a palm span, with a metal rod coming out of the handle another palm span or so, bending at a right angle, and ending with a metal implement looking something like a tiny battleaxe head.

Usage
When heated to searing hot over an open flame, this instrument was touched firmly but briefly to an open wound to burn (cauterize) bleeding vessels.

Bezoars
Description
Balls of incompletely-digested hair collected from goats' stomachs.

Usage
Bezoars are universally recognized as a cure-all for poisonings, envenomations, and other forms of spoilage of the blood. The method of use (ingested, steeped in boiling water, placed on the head or over the stomach) is often debated.

Clyster
Description and Usage
A clear water or soapy water infusion to bathe the bowels.

Alcohol lamp
Description
A small vial of alcohol with a wick extending a nailbreath out of the vial.

Preparation
The lamp is the basic component of this apparatus. A glassblower creates a vial with a flat base. Onto this, an alchemist or tinkerer places a stopper of some nonflammable substance, the most common substance used for this purpose being a thin cap of metal. A hole is punched into the top of the stopper, and a wick is inserted through this hole into the vial.
Distillation of alcohol is a somewhat complicated process, best performed by master brewers and alchemists. Sugar water is encouraged to ferment by adding yeast and brought to a low heat, just above body temperature, in a cauldron. Once the sugar water cannot ferment any further, the broth is then rapidly boiled, producing steam. This steam is funneled into a distillation tube. By running cold water over this tube, the steam gathers into droplets of liquid alcohol, which spill into a pot or vial for collection. The best gnome alchemists boast of obtaining a yield of 9 parts alcohol to one part water with this method, though this yield is difficult to replicate. Alcohol purity of one part alcohol to one part water will suffice to fuel the flame for an alcohol lamp.
The alcohol lamp does not burn terribly hot, and the flame provided is only as large as a candle flame. The advantage of an alcohol lamp over an open candle is that the alcohol burns at a more constant temperature, allowing a healer to better control the heat applied to instruments used during surgery.

Usage
Used to heat instruments or specimens.

Calipers
Description and Usage
Calipers consist of a pair of curved tongs joined at one end, like a very delicate crab's claw. These could measure head diameter; this is crucial in discovering someone's personality, or at least how big someone's head is.

Scales
Description and Usage
Scales of different sizes are employed for weighing nearly anything that can be weighed. This includes the smallest samples of bodily products, all the way up to the largest mumbles measured at autopsy.