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A
BACTERIOLOGY
AND
SURGICAL TECHNIQUE
| FOR NURSES
BY<1 Vj
EMILY M* A° STONEY
Superintendent of the Training School for Nurses, St. Anthony’s Hospital, Rock
Island, Ill.; Author of ‘‘ Practical Points in Nursing,’’ ‘‘ Practical
Materia Medica for Nurses,” etc.
“Every bit of knowledge that we cannot use for the uplifting of our physical,
intellectual, or entotional life ts so much waste of time and labor. Everything taught
ts worth the knowing, but not worth the putting away in the pigeon-holes of memory,
to be recalled some day by accident.’’
LEE EST ke 7 oD
PHILADELPHIA
W. B. SAUNDERS & COMPANY
1900
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COPYRIGHT, 1900 ;
— By W. B. SAUNDERS & COMPANY
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THIS VOLUME IS DEDICATED BY THE AUTHOR
UL REMEMBRANCE OF MUCH ENCOURAGE-
_ MENT AND PERSONAL KINDNESS
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CHAPTER SANG
PREPARATION OF PATIENT FOR OPERATION; CARE OF PATIENT
DURING AND AFTER OPERATION |. 22g. 2 23) = eee
CHAPTER INI
SEQUEL OF OPERATIONS; SHOCK, HEMORRHAGE, SEPTIC PERI-
TONITIS, ACCIDENTS DURING OPERATIONS, ETC: 575°. = =) open
CHAPTER XV.
OPERATIONS IN PRIVATE PRACTICE 2) > 2a ieee eee
CHAPTER Vie
GYNECOLOGIC EXAMINATIONS AND OPERATIONS . . . = =.) . mee
CHAPTER JV
SIGNS OF DEATH; -AUTOPSIES 2.5 = 2a) Shee ee
FAKE:
BACTERIOLOGY; ANTISEPTICS.
CAP Pik
HISTORY OF BACTERIOLOGY.
THE eye is one of the most beautiful and delicately
contrived organs in the body, and yet its vision un-
aided is very limited in its scope. We see so much
that we rarely stop to think of what an enormous
world exists in and all about us which we cannot see
at all—a world peopled by organisms so very small
that they can be seen and studied only by the aid of
the most powerful magnifying lenses, and so num-
erous that they are quite bevond any calculation.
Bacteria exist nearly everywhere; they are almost
universal, except that they are not found deep down
in the ground nor high upin the air. They andtheir
spores, or seeds, float in the air we breathe, swim in the
water we drink, grow upon the food we eat, and lux-
uriate in the soil beneath our feet. Wherever man,
animals, and plants live, die, and decompose, bacteria
are sure tobe present. The surface of the body never
escapes their establishment, and so deeply are some
individuals situated beneath the epithelial cells that
the most vigorous scrubbing and washing and the use
9
IO BACTERIOLOGY.
of powerful disinfectants are necessary to remove them
from the surgeon’s hands.
The mouth is said to be always replete with them;
and, since many are swallowed, the digestive tract
always contains them. The germ of pneumonia, for
instance, is said to be habitually present in the mouth
of almost every healthy person; consequently, its
entrance into the lungs is only a matter of accident.
The existence of these bacteria has been known for
inany years, but it is only during the past few decades
that any great advancement 1n our knowledge of them
has been made.
Over two hundred years ago a man named Athana-
sius Kircher, a German, mistook blood-corpuscles
and pus-corpuscles for small worms, and built up a
new theory of the causes of disease and putrefaction
with these worms as a basisof it. At the same time,
Christian Lange, a professor 1n the medical school at
Leipzig, expressed his opinion that the rash that
appeared onthe skin in the eruptive fevers;scre,
was the result of putrefaction conveyed by small liv-
ing worms in the body. Shortly after these obser-
vations came those of Anthony van Leeuwenhoek,
a native of Delft, in Holland, who, in his early years,
had learned the art of polishing lenses, and who was
able, ultimately, to produce the first really good
microscope that had yet been constructed. He saw,
and described with astonishing clearness, various
forms of bacteria found in the material taken from
the teeth of an old man who never cleaned his teeth.
He gave an accurate description of the rod-shaped
bacteria, motile and motionless; of the longer threads,
now called bacilli; of the spiral threads, or spirilla;
AISTORY OF BACTERIOLOGY. II
and of rounded micro-organisms, or micrococci.
Although he did not attempt to theorize as to the
meaning of these organisms in the mouth at the
time, later on, in 1713, after finding similar organ-
isms in the greenish pellicle formed on the surface
of the water in an aquarium, he came to the conclu-
sion that the various forms of bacteria found in the
inaterial scraped from the teeth found their way into
the mouth through the medium of the drinking-water
that haa been stored in barrels, and that some of
these found there a nidus in which they multiplied.
This was the real beginning of bacteriology; and
from this origin the study advanced with considerable
rapidity in spite of ridicule and much opposition.
Various opinions regarding the connection of these
gerins with disease and putrefaction, were put for-
ward; but it was not until 1831 that any important
advance was made in our knowledge of this connec-
tion. Previous to that time a large mass of facts in
regard to these little living organisms was being
eradually accumulated, and fresh discoveries were
constantly made by various workers; but since no
systematic attempts to classify the newly observed
facts were made, the scientific results were very small.
The first real advance made in our knowledge of
the presence of a ‘“‘contagium vivum,”’ or living con-
tagious element in the production of disease and fer-
mentations, was inade by Frederick Muller, of Copen-
hagen, and was the result of a systematic attempt to
arrange the knowledge which had been accumulated
during all those years. From that time to the present,
the science has made great strides; so that we have
now an accurate knowledge of the bacteria which
I2 \ "BACTERTOLOG ¥.
cause a number of different diseases. The knowledge
of methods and details of work is now so general that
the science of bacteriology is rapidly growing, and
has revolutionized already very many branches of
medicine.
In 1840, Henle was led to believe that the cause of
iniasmatic, infective, and contagious diseases must be
looked for in living fungi, or other minute living
organisms. Unfortunately, at that time the methods
of study employed prevented him from demonstrating
the accuracy of his belief. Itwas left for Pasteur and
Koch to complete the work. Davaine, in 1848, was
the first to see and to recognize disease-producing
bacteria—he saw anthrax-bacilli in the blood of sheep
dead of splenic fever.
Pasteur then took up the work; and in 1857 his
faultless demonstration of the germ-theory of disease
was brought out as a result of his experiments on fer-
mentation and putrefaction, and on the bacteria of
wine and those of the silkworm. He showed that the
acetic fermentation, viscosity, bitterness, and turning
flat of wines are due to the action of certain organized
ferments, and demonstrated a causal relation between
certain lowly-organized parasitic organisms and spe-
cial diseases 1n animals and insects. Upon Pasteur’s
observations Lord Lister based his successful system
of the treatment of wounds, known as ‘antiseptic
SUES eryy ?
We all know of the wonderful success which now
marks the operations of major surgery, and of the
daring boldness of operators who attempt what was
utterly impossible as long as antiseptic surgery was
unknown. Lister, accepting the truth of Pasteur’s
HISTORY OF BACTERIOLOGY. 13
statement—that germs are the producers of fermenta-
tions—concluded that germs entering wounds from the
outside might be the cause of suppuration; and since
germs are always and everywhere floating in the air,
suspended in water, and attached to the surgical in-
struments, dressings, and sponges used in operations,
he judged correctly that it was highly advantageous
to employ an antiseptic agent in order to kill any of the
suspended or adherent organisms before any materials
could be allowed to come in contact with wounded
tissues; consequently, the hands of the operator and
his assistants, the surgical instruments, sponges, dress-
ings, sutures and ligatures, were kept constantly satu-
rated with a solution of carbolic acid (1 : 40), and the
operation was performed under a spray of carbolic acid
(1:20). Carbolized dressings were used; and if the
discharge was profuse, the dressings were changed
once in twenty-four hours under a constant use of the
spray. The researches of a later date have shown, how-
ever, not only that the atmosphere cannot be disin-
fected, but also that the air of ordinarily quiet rooms,
while containing the spores of numerous saprophytic
organisms, rarely contains many pathogenic bacteria.
We also know that a direct stream of air, such as is
generated by an atomizer, causes more bacteria to be
conveyed into a wound than ordinarily would fall
upon it, thereby increasing instead of lessening the
danger of infection. Lister, we must remember, was
not the discoverer of carbolic acid nor of the fact that
it would kill bacteria; but, convinced that inflamma-
tion and suppuration were caused by the entrance of
germs from the air, instruments, sponges, and dress-
ings, into wounds, he suggested the antisepsis which
14 BACTERIOLOGY.
would result from the use of sterile instruments, clean
hands, dressings, towels, and the like; and made ap-
plications intended to keep the surface of the wound
moistened with a germicidal solution in order to kill
such germs as might accidentally enter. He also
introduced the practice of concluding operations by
the application of a protective dressing, such as would
tend to preclude the entrance of germs at a sub-
sequent period. Lyjsterism has spread slowly but
surely to all the departments of surgery and obstetrics.
Since Lister’s treatment was first inaugurated,
many details of its application have been variously
modified and great additions to our knowledge have
been made. In bacteriology much important work
has been done, and great advances are being con-
stantly made. ‘There are a number of diseases, each
one of which has been definitely proved to be caused
by a germ of its own, a germ which causes no other
disease. There is also a list of diseases in which the
proof is not yet conclusive, but for which the proba-
bility is that a specific germ will be found. The
following data have been gathered chiefly from the
works of McFarland and Woodhead.
In 1845, Langenbeck discovered that the specific
disease of cattle known as actinomycosis could be
coinmunicated to man. His observations, however,
were not given to the world until 1878, one year
after Bollinger had discovered the cause of the
disease 1n animals. |
In 1847, Semmelweis, on the basis of his own
observations, formulated the precept that puerperal
fever is the result of the introduction of organic
ferments into the puerperal genital tract. This dis-
HISTORY OF BACTERIOLOGY. 15
covery, established by himself and confirmed by the
observations of many others, marked an era in ob-
stetrics. [he organic ferments have since been
identified as specific bacteria. Semmelweis, in this
way, anticipated in practical antisepsis the discover-
ies of Lister and Pasteur; while the late Oliver Wen-
dell Holmes, in a paper entitled ‘‘ Puerperal Fever a
Private Pestilence,’’ published in 1843, and repub-
lished in 1855, in treating of its prophylaxis, an-
ticipated the teaching of Semmelweis. Semmelweis
was first led to recognize the source of puerperal in-
fection by the case of Prof. Koletschka, of the
University of Vienna, who, having received a dis-
section-wound, became thereby fatally infected. In
consequence of this, Semmelweis concluded that
there was an identity between this infection and that
of which so many hundreds of puerperal women
died. In the school for instruction in practical ob-
stetrics, with which he was connected, there were
two departments, one for medical students, the other
for midwives; the students going as a rule directly
to the obstetric ward from the autopsy-room. He
first noted the much greater mortality in the stu-
dents’ ward, and in May, 1847, began to require the
students to wash their hands in chlorin-water before
making vaginal examinations, thereby reducing the
puerperal mortality to a point lower than had been
ever before reached.
In 1863, Davaine established by experiments the
bacterial nature of splenic fever, or anthrax.
In 1869, the first complete study of a contagious
affection was made by Pasteur, in two diseases affect-
16 BACTERIOLOGY.
ing silkworms—pébrine and flacherie—which he
showed to be due to micro-organisms.
In 1875, Koch described more fully the anthrax-
bacillus, gave a description of its spores and the
properties of the same, and was enabled to cultivate
the germ on artificial media; and, to complete the
chain of evidence, Pasteur and his pupils supplied
the last link by reproducing the same disease in -
animals by artificial inoculation from pure cultures.
The study of the bacterial nature of anthrax has been
the basis of our knowledge of all contagious mala-
dies; and most advances in technic have been made
first through the study of the bacillus of that disease.
In 1879, Hansen announced the discovery of bacilli
in the cells of leprous nodules. ‘They were subse-
quently clearly described by Neisser. From the
nature of the symptoms and from the course of the
disease, leprosy up to this time was long considered
to be a disease similar to tuberculosis, and the dis-
covery of the bacillus paved the way for the recep-
tion of Koch’s discovery of the tubercle-bacillus.
In the same year Neisser discovered the gonococ-
cus to be the specific cause of gonorrhea.
In 1880, the bacillus of typhoid fever was first
observed by Eberth, and independently by Koch.
In 1880, Pasteur published his work upon
‘‘chicken-cholera,’’ an epidemic disease which affects
turkeys, pigeons, chickens, ducks, and geese, and
which causes almost as much destruction among
them as the occasional epidemics of cholera and
small-pox produce among man.
In the same year Sternberg described the pneumo-
coccus, calling it ‘‘ Micrococcus Pasteuri,’’ which he
HISTORY OF BACTERIOLOGY. ¥7
secured from his own saliva; and in the same year
Pasteur also found the same organism in saliva;
though it is to Fraenkel, Talamon, and particularly
Weichselbaum, that we are indebted for the dis-
covery of the relation which the organism bears to.
pneumonia. |
In 1882, Robert Koch made himself immortal by
the discovery of and work upon the bacillus of tuber-
culosis, one of the most dreadful, and unfortunately
most common, diseases of mankind. While great
men of the earlier days of pathology clearly saw that
the time must come when the parasitic nature of this
disease would be proved, and some, as Klebs, Ville-
min, and Cohnheim, were ‘‘ within an ace’’ of the
discovery, it remained for Koch to succeed in dem-
onstrating and isolating the specific bacillus, and to
write so accurate a description of the organism and
the lesions it produces as to render the discovery one
of the most compiete ever made in the history of
medical science.
In the same year Loeffler and Schtitz reported the
discovery of the bacillus of glanders, an infectious
disease almost confined to certain of the lower ani-
mais; although occasionally persons whose habitual
association with and experimentation upon animals
bring them into frequent contact with such as are
diseased, have become accidentally infected.
In 1884, Koch discovered the ‘‘ comma-bacillus,”’
the cause of cholera.
In the same year Loeffler discovered the diphthe-
tia-bacillus, and Nicolaier that of tetanus.
On October 26, 1885, Pasteur made the first ap-
plication to human medicine of his method for the
2
18 BACTERIOLOGY.
cure of hydrophobia, nearly ten years before the time
we began to understand the production and use of
antitoxins.
In 1890, Koch issued to medical men what is now
known as tuberculin, a brownish, syrup-like fluid
used in the diagnosis and treatment of tuberculosis.
In 1892, Canon and Pfeiffer discovered the bacillus
of influenza.
In the same year Canon and Pielicke first found a
bacillus now thought to be the specific cause of
measles.
In 1894, Yersin and Kitasato indepentielll 1SO-
lated the bacillus causing the bubonic plague then
prevalent at Hong-Kong, and now threatening
Europe.
Sanarelli, in 1896, reported the discovery of the
micro-organism of yellow fever. His coriclusions
were based on the presence of a certain germ in 58
per cent. of cases examined, and the production of
symptoms and pathologic changes in the lower
animals resemble those present in man. Sanarelli’s
observations have been confirmed by a commission
of the U. S. Marine-Hospital Service; but Sternberg
and his assistants doubt the specific relation of the
Bacillus icteroides, as it is called, to yellow fever.
Epidemic cerebrospinal meningitis, or spotted
fever, is now known to be caused by a specific germ
present in the cerebrospinal fluid of patients suffering
from this disease. ‘The route of infection is not
fully determined, but it is probably through the
nose.
Malta-fever, a disease of the Mediterranean islands,
and occasionally of the Antilles and Central and
HISTORY OF BACTERIOLOGY. I9
South America, is due to a micrococcus discovered
by Bruce, and called Bacillus melitensis.
Malarial fever is an infectious disease; but, unlike
those mentioned, it is not caused by a vegetable germ,
a bacterium, but by a microscopic animal, the Plasmo-
dium malari@, which is found in the blood of the
afflicted individual. How it enters the blood is not
definitely known, but the best authorities hold that
its entrance is brought about by the stings of mos-
quitoes.
There is a widespread belief that malignant
tuimors—cancers and sarcomas—are due to infection
with parasites. ‘The nature of the parasite is as yet
unknown; but the latest researches point to a tiny
organism, a yeast-plant or blastomycete.
CHAP Reese.
BACTERIA AS THE CAUSES OF DISEASE.
DISEASES may be divided into two great classes—
the constitutional, which are due to such causes as
errors in diet, alcoholic excesses, overwork, or age;
aud the infectious or contagious, which are due to the
introduction into the body of a living poison. Weno-
longer look upon infectious and contagious diseases
as due to an unexplainable something, whose source
we cannot know, whose course we cannot predict, and
whose end cannot be hastened by any efforts on our
part. Investigation has shown that we are no longer
fighting an unknown enemy in the dark, but that we
have before us a definite, living thing, whose part in
the plan of creation is as surely fixed as our own,
whose life-history can be told, and whose growth 1s
as dependent on the right amount of light, food, heat,
and air as that of the rose in our garden.
The word éacterza is a general name for all the
plant micro-organisms. Of these there are many
different classes with different names. ‘They vary
much in shape and size, some being round, some
thread-like, some rod-shaped, and some of a spiral
form. Each single organism consists of a small speck
of protoplasm or vegetable albumin, to which may be
given the name of a cell; and these cells are so minute
that they can be seen only with the aid of the best
20
meer en?A AS THE CAUSES OF DISEASE. 21
inicroscopesatourcommand. The rounded organisms,
or micrococci, as they are called, are seldom more than
=), 0: an inch im diameter; the elongated cells
average a little more perhaps, and are from yg ho9
Og Se =e ee BE G
of G0 S&S B | ie Mae ae bola os 9 ote.
Oa a 5 6 7 8 9 10 «33
FIG. 1.—Various forms of bacteria: 1 and 2, round and oval micro-
cocci; 3, diplococci; 4, tetracocci, or tetrads; 5, streptococci; 6, bacilli; 7,
bacilli in chains, the lower showing spore-formation; 8, bacilli showing
spores, forming drumsticks and clostridia; 9 and to, spirilla ; 11, spirochetz
(McFarland).
fo, of an ich in-length. Different forms nat-
urally vary from this standard of size; but these fig-
ures will give a good idea as to the actual size of
the forms under consideration.
The fungi connected with disease in man are divided
into three classes :
1. Moulds, or hyphomycetes.
2. Yeasts, or blastomycetes.
3. Bacteria, or schizomycetes.
Some bacteria, or schizomycetes, induce the various
fermentations; while others are productive of putre-
faction, and are called saprophytes. Others, again,
known as the pathogenic bacteria, are the cause of
various diseases; while those which do not ordinarily
cause disease are known as the non-pathogenic bac-
teria. The chief forms of bacteria are:
1. The coccus—berry-shaped or spherical bacte-
rium.
2. ‘The bacillus—rod-shaped bacterium.
3. The spirillum—corkscrew bacterium.
22 BACTERIOLOGY.
And these, which are species relatively monomorphous
—2. €., preserve their shape—are practically the only
ones with which we have to do.
The cocci are named according to their arrange-
ment with one another; if, for instance, they are in
pairs, they are called diplococci; 1f ina chain, they are
Q b GC (E &
6 0
O 3
SF + pie
- ht z i
Fic. 2.—Diagram illustrating the morphology of cocci: a, coccus or
micrococcus ; 6, diplococcus; ¢, d, streptococci; é, 7, tetragenececeryas
merismopedia; ©, 2, modes of division of cocci; 2, sarcinze; 7, coccus with
flagella; 2, staphylococci (McFarland).
called streptococci; if in a cluster, like a bunch of
grapes, they are called staphylococci; and if in an
irregular mass, stuck together by a thick substance,
they constitute a zodglea. ‘Those developing in fours
are called tetrads; in eights, sarcine.
The cocci are also named according to their func-
tions, as, for instance, ‘‘ pyogenic,’’ or pus-forming;
the specific name also describing the form, arrange-
ment, color, and function; for example, Staphylo-
coccus pyogenes aureus signifies a spherical colorless
micro-organism forming a yellow pigment, arranging
itself with its fellows into the form of a bunch of
grapes, and producing pus.
Bacteria reproduce in two ways: By direct division
(fission) and by the development of spores or seeds
BAGCIERIA AS THE CAUSES OF DISEASE. 23
(sporulation). The most common mode is by binary
division, one body dividing itself so as to form two
other bodies; these two re-dividing, and so on. It
can readily be imagined how quickly an appalling
increase in their numbers can be thus brought about;
but fortunately this multiplication only takes place to
advantage under certain favorable conditions; if these
are not present, the bacterium begins to degenerate,
but usually does not die until it has left behind a spore.
When the formation of a spore is about to commence,
a small bright point appears in the protoplasm, and
increases in size until its diameter is nearly or quite
as great as that of the bacterium. As it nears perfec-
tion a dark, highly refracting capsule is formed about
it. As soon as the spore arrives at perfection the bac-
CS> ee) ' O98 CS on
a b c a e re
Fic. 3.—Diagram illustrating sporulation: a, bacillus inclosing a small,
oval spore; 4, drumstick-bacillus, with terminal spore; c, clostridium, with
central spore; d, free spores; e and /, bacilli escaping from spores
(McFarland). |
terium seems to die, as if its vitality were exhausted
in the development of the permanent form. As soon
as the young bacillus escapes it begins to increase in
size, develops around its soft protoplasm a character-
istic membrane, and having once established itself
presently begins the propagation of its species by fission.
In those forms of organism in which spores are not
found the germs die very rapidly unless the conditions
for their nutrition and multiplication remain very
favorable. If all bacteria were of this kind, it would
be possible to exterminate them with consider-
24. BACTERIOLOGY.
able rapidity. Spores will survive a great heat, a
heat which will kill the organism from which the
spore caine; they will also. live under a treatment
with germicidal solutions which renders the bacteria
inactive. In other words, the spores are much more
resistant to the effect of germicides than the bacteria
themselves. Cold does not kill them; they live
through it and develop whenever favorable surround-
ings for their growth present themselves. ‘They may
lie dormant in the system for years, waking into
activity only when they come into contact with some
damaged, weakened, or diseased part which affords
them a nest in which to develop and multiply, the
cellular activity of the weakened part being unable to
cope with the organisms.
The conditions which influence the growth of bac-
teria are, first, a temperature ranging from 85° to 104° ©
F., some forms requiring a higher and some a lower
temperature. Some forms of bacteria are not influ-
enced in their growth by the presence or absence of
light. To-some, sunlight is destructive. ~ A tew
hours’ exposure to the sun is fatal to the anthrax-
bacillus and to cultures of the Bacillus tuberculosis.
The rays of the sun, however, must come into contact
with the germs and are usually active only on the
surface of cultures.
The majority of bacteria grow best when exposed
to the air: Some develop better if the air 1s qarge
held; some will not grow at allif the least amount
of oxygen is present. ‘Those that grow in oxygen are
called the aérobic bacteria, and those that will not
erow in the presence of oxygen are the anaerobic ~
bacteria. |
meer easA AS THE CAUSES OF DISEASE. 25
A certain amount of water is always necessary for
the growth of bacteria, though the amount required
may be very small. If dried, no form will multiply
and very many forms will die. ,
A soil consisting of highly organized compounds is
also necessary for their growth and multiplication, and
slight modifications in it may prove fatal to some
forms of bacterial life, but be highly advantageous to
others.
With age bacteria lose their strength and die. So
we see that a suitable soil, and a proper amount of
light, heat, and air are absolutely necessary for the
erowth and development of bacteria, for they carry
on all the functions of a higher organized life; they
breathe, eat, digest, excrete, and multiply.
The disease-producing bacteria effect entrance into
the interior of the body through the skin and super-
ficial mucous membranes, wounds, alimentary canal, _
respiratory tract, and placenta.
The entrance of bacteria into the tissues through
the sound skin is very rare indeed, although some
authorities claim that infection has taken place
through the rubbing of bacteria or their spores upon
the skin. ‘The dangers of infection through the
broken skin are well recognized; hence every wound,
no matter how slight, should be protected as soon as
possible.
Bacteria enter the alimentary canal through the
food and drink. ‘Typhoid infection has taken place
through the rectum, its occurrence being due to the
wearing of underclothing previously worn by typhoid
fever patients, and to the use of enema syringe tips
which had not been sterilized after their previous use.
26 BACTERIOLOGY.
Bacteria enter the respiratory tract through the
mouth and nose, as in a deep inspiration, or an act
of coughing, sneezing, or the like. Pneumonia
and tuberculosis are said to be the result of in-
spiration of the specific organisms. The direct
transmission of bacteria from a parent to the fetus
has long been a disputed question, but is now gener-
ally conceded. ‘The micro-organisms pass through
the placenta and infect the fetus. Tuberculosis of
the ovaries, Fallopian tubes, and uterus may origi-
nate through the blood, and infection from without
through the vagina. Infection through the blood is
evidenced by the general tuberculosis of all the vis-
cera. Infection from without may result in tuber-
culosis of the uterus, ovaries, and Fallopian tubes.
The channels by which bacteria can enter the
body are, then very numerous; and there is scarcely
a moment in which some part of the body is not in
contact with them. All the disease-producing germs
have their favorable seat 1n some part of the body
where they grow more or less luxuriantly, and in the
secretions and excretions of which the chief source
of their infection lies. ‘The pneumonia-germ prefers
the lungs; the typhoid fever germ selects the lower
portion of the small intestine; the diphtheria-germ
the throat; the cholera-germ the intestinal tract;
the germ of tuberculosis prefers the lungs, but it is
called a ‘‘ medical tramp,’’ because it will lodge in
any part of the body and make its home there.
Hence we hear of tuberculous glands of the neck,
tuberculous knee, intestinal tuberculosis, tuberculosis
of the kidney, bladder, uterus, ovaries, Fallopian
tubes, tuberculous peritonitis, etc. A tuberculous
BACTERIA AS THE CAUSES OF DISEASE. 27
—
area is always a danger to the system, and may infect
distant organs or give rise to a general tuberculosis.
To prove that a microbe is the cause of a disease it
must fulfil Koch’s circuit. It must always be found
associated with the disease, and it must be capable
of forming pure cultures outside the body. ‘These
cultures must be capable of reproducing the disease,
and the microbe must again be found associated with
the morbid process thus reproduced. In other words,
we must prove the bacteria to be always present; we
must then isolate them, then prove that they can
produce the disease in a healthy animal, and, finally,
having succeeded in doing all this, we must prove
that no other form of bacteria can produce the
disease, and that where these bacteria cannot he
obtained the existence of the disease is impossible.
All these requirements have been met in many
instances, and now there are a large number of dis-
eases each one of which has been definitely proved to
be caused by a germ of its own, a germ which pro-
duces that disease and no other. Most of the germs
need a special train of circumstances in order that they
inay be active, so that, fortunately for us all, the
mere presence of the germ itself is not sufficient to
produce the disease. For instance, we know that
diphtheria is caused by a germ of its own which
causes that disease and no other; still, exposure to
that germ does not invariably produce diphtheria—if
it did, we should all be infected with it. This is
because other conditions than the mere presence of
the germs are needed to produce the disease. The
gerins must be active, and they can act only under
certain conditions. It will usually be found that the
28 BACTERIOLOGY.
attack of the disease has been’ preceded by aytoeae
inflammation of the throat, thus making a suitable
place for the specific action of the diphtheria-germs.
In typhoid fever the germs require a suitable condi-
tion of the bowels before they can produce the dis-
ease. This is also true of cholera, and explains why
taking care of the health makes such a difference in
the taking of this disease. The germs find their way
into the body through the food and drink. Cases are
reported that show how the germs enter drinking-
water, which is sprinkled over vegetables sold in the
streets of cholera-infected districts, how they are car-
ried about in clothing, and taken to articles of food
upon the table by flies which have preyed upon chol-
era excrement. Healthy lungs are not a suitable loca-
tion for the development and activity of the germs of
tuberculosis. If we are not fully in good health, or
if we inherit a tendency to this special disease, we
may acquire it very readily, since we often inhale the
germs of it. Should the disease take root-im ome
lungs, it may be controlled to a certain extent bya
change of climate and surroundings; by going, for
example, from a low and damp locality to the mild
and dry atmosphere of Colorado, the Carolina moun-
tains, Southern California, or of ‘the other Semme
western States, where there are few cloudy days and
where violent atmospheric changes are rare.” Wie
germs there cannot be so active, for the air 1s stimu-
lating, pure, and invigorating to the nervous system.
The rarefaction of the air causes deep and strong
involuntary respiratory movements, and there is con-
sequently enforced a better ventilation of the lungs
and a better oxygenation of the blood, in conse-
Pee eniA AS THE CAUSES. OF DISEASE. 29
quence of which there follow more active tissue-
changes throughout the body and a strengthening
of the respiratory muscles.
On finding favorable conditions it takes germs some
days to develop and produce the disease; this time is
known as the period of incubation.
The question is often asked, Why, when we are so
constantly in contact with disease-germs, do we not
contract the diseases? All bacteria leave the body
through the skin, lungs, kidneys, or bowels; and
by a faithful use of disinfectants and antiseptics
the germs may be kept confined to their original
position. After their escape from the body they are
dificult to control. ‘The scales of skin or dandruff
from a case of scarlet fever, measles, or small-pox, or
the dust that arises from the dried sputum of a
pneumonia or tuberculosis patient, or the poisonous
material which may enter our drinking-water from
too close proximity of the well and the sewer into —
which typhoid discharges have been emptied, may
readily be the means of propagating disease. These
sources of infection should be scrupulously avoided.
_ Another protective factor is the natural or acquired
power of resistance to disease-producing germs.
Immunity is either natural or acquired. Of
acquired immunity we have two varieties, that which
comes from acclimatization, and artificial immunity.
By natural immunity is meant the natural and
constant resistance to disease-producing germs. The
individual is immune by Nature, and sometimes by
racial characteristics. Acquired immunity is a
power of resistance attained through various cir-
cumstances. ‘I‘hus, a single attack of some of the in-
30 BACTERIOLOGY.
fectious and contagious diseases usually confers 1m-
munity against subsequent attacks. Such immunity
generally follows an attack of typhoid fever, small-
pox, scarlet fever, mumps, whooping-cough, measles,
or yellow fever. Second attacks may occur; but, as
a tule, a patient who has had an attack of one of
these diseases has immunity for life. Influenza,
pneumonia, cholera, diphtheria, and erysipelas are
among the diseases in which one attack is not
protective. Vaccination usually insures immunity
against small-pox; but this is ordinarily not so com-
plete or permanent as that resulting from an attack
of the actual disease.
Acclimatization immunity 1s exemplified by vari-
ous diseases which do not trouble natives or those
long resident, but which may affect strangers not im-
mured to the climate.
Racial immunity is that 1n which certain races are
safe from certain diseases; for instance, negroes sel-
dom suffer from yellow fever, but are more suscep-
tible than whites to small-pox. It is asserted that the
Arabs seldom or never have typhoid fever. An analo-
gous example is afforded by the fact that white mice
are not affected by the same diseases as the gray
mice are, even though subjected to the same influ-
ences in respect to climate, food, etc.
Artificial immunity may be produced in various
ways. It is said that an injection of the antitoxin of
diphtheria will give protection against the disease for
from four to eight weeks. ‘Tetanus has been prevented
in a similar manner. It is impossible here to enter,
except to a slight degree, into the consideration of
the many theories of immunity, since they are very
meertenlA AS THE CAUSES OF DISEASE. oi
intricate, and not one has been advanced so far that
ean clearly explain it. The theory of phagocytosis
and the theory of antitoxins are the two most im-
portant.
Phagocytosis is the destruction of bacteria by the
white cells of the blood and the cells of fixed tissues.
The cells which eat up and destroy the germs are called
‘‘ phagocytes.’’ When the two meet a battle occurs,
the bacteria fighting the cells with their active fer-
ments, while the cells on their side put forth every
effort to protect the body against the assaults of the
disease. Ina majority of the cases the bacteria win
to the extent that the phagocytes die; but others take
their place until the infection is overcome or the
patient dies. The white blood-cells and tissue-cells
having thus been educated to withstand the poison,
their descendants inherit this capacity and are born
insusceptible. This theory was suggested by Carl
Roser in 1881. Sternberg and Koch afterward put
forth the same view, but it is usually credited to
Metschnikoff, who published his observations in
1884. The theory is now known as the ‘‘ Metschni-
koff theory of phagocytosis,’’ and assumes an educated
white corpuscle and body-cell.
The other theory—the so-called antitoxic theory—
is founded on numerous more or less convincing ex-
periments. If an animal be injected with certain
pathogenic bacteria or their toxins in gradually
ascending doses, it can be immunized to doses that
under other circumstances would prove fatal. The
blood-serum of an animal thus immunized has the
power, when injected into another animal, of ren-
dering it also immune to the bacteria that have
32 BACTEKIOLOG Y.
originally been used; and in some cases the serum
is even capable of curing the disease after it has
developed in another animal. These properties with
which the blood-serum has become endowed depend
upon the presence of what are called antitoxins and
antibacterial bodies. In man also, after recovery
from certain infectious diseases, it is possible to
demonstrate in the. blood-serum the presence of anti-
toxic substances; and it is now the general belief
that immunity, at least of the acquired form, is due
to such antitoxins. "The uses and practical prep-
aration of antitoxins will be described in the next
chapter.
The most important of the special surgical micro-
organisms—z. e¢., those most frequently met with in
surgical work—are the following, the majority being
pus-producers : |
1. Staphylococcus Pyogenes Aureus.—This is the
most common form; it 1s quickly killed by carbolic
acid (1 : 20), bichlorid of mercury (1 : 1000), or by a few
moments’ boiling. It is foundin the mouth, alimen-
tary canal, and under the nats; it lives in the eyes,
nose, ears, mouth, in the superficial layers of the skin,
and is distributed in the water, soil, and air, especially
in the dust of houses and surgical wards where the
proper precautions are not taken.
2. Streptococcus pyogenes 1s a most important path-
ogenic micro-organism, and is thought by many
authorities to be identical with the streptococcus of
erysipelas. The Streptococcus pyogenes is frequently
associated with internal diseases, and has been found
in the uterus in cases of infective puerperal endome-
tritis, ulcerative endocarditis, acute septicemia, and
BACTERIA AS THE CAUSES OF DISEASE. 33
other diseases. It is one ofthe most common causes
of post-operative peritonitis.
3. The Bacillus colt communzs is always present 1n
the intestine, and is thought to be a frequent cause
of acute suppurative peritonitis.
4. The Staphylococcus pyogenes albus resembles the
aureus i form, but is less virulent. It is a common
cause of suppuration, and although it has been found
alone in acute abscesses, it is usually associated with
other pyogenic cocci, chiefly the Staphylococcus pyo-
genes aureus.
5. The Staphylococcus epidermutidis albus 1s a micro-
coccus which is almost always present upon the skin,
not only upon the surface, but also in the Malpighian
layer.
6. The Staphylococcus pyogenes citreus is not quite
so common nor so pathogenic as the other forms, and
is less important.
7. The Bacillus pyocyaneus exists in pus(especially
in open wounds), and gives to it a peculiar bluish or
greenish color.
8. The Bacillus aérogenes capsulatus is a gas-pro-
ducing bacillus that sometimes causes death after
operations on the uterus; it may also enter through
accidental wounds.
9. The Baczllus tuberculosis is the cause of all tuber-
culous processes. The chief cause of the spread of
infection is found in the dried sputum, which becomes
pulverized and is then inhaled as dust; and since
one patient may expectorate as many as four billion
bacilli in twenty-four hours, his capacity for harm is
very considerable. ‘The bacilli retain virulence for five
34 BACTERIOLOG Y.
months in dried sputum, and in putrid sputum for
forty-three days.
10. The Micrococcus lanceolatus, known also as
Streptococcus lanceolatus, pneumococcus, and Diplo-
coccus pneumonie, is the cause of croupous pneu-
monia and of many of the acute inflammations of the
serous membranes of the body. It is also a pus-pro-
ducer, and has been found in empyema and acute
abscesses.
11. The baczllus of tetanus is found particularly in
garden-soil, in the dust of halls, walks, cellars, street-
dirt, and in the refuse of stables. It is not a pus-
producer. Tetanus 1s a disease due to the absorption
of its toxins, which poison the nervous system pre-
cisely as would dosing with strychnin.
12. The diphtheria-bacillus causes the dreaded dis-
eases diphtheria and membranous croup, as well as
inflammations of the eyes and nose; at times it also
attacks open wounds.
CHAPTER III.
THE THEORY OF ANTITOXINS.
GREAT progress has been made of late in the field
of serum-therapy, though much remains open to ques-
tion and many recorded factscannot yet be explained.
The field for the investigator is perhaps larger than
ever before. For a better understanding of the sub-
ject of antitoxins and their therapeutic application, a
few essential facts should be bornein mind. An anti-
toxin is not the direct result of bacterial action, but
is properly described as an unknown body resulting
from the resistance of the healthy organism to the
toxins of pathogenic bacteria. According to the pre-
vailing theory, antitoxins are the products of the
body-cells, formed under the influence of the bacterial
toxin. In therapeutic practice the antitoxic body
comes to us in the blood-serum of an animal, usually
the horse. When properly prepared and properly
kept in aseptic containers the antitoxins are not at all
dangerous; they are as innocuous as an equal amount
of blood-serum or normal salt solution administered in
the same way. Antitoxins are used both to counteract
the effects of the toxins which are elaborated by path-
ogenic bacteria in the body, and to render the sys-
tem immune, so that it may resist the action of the
bacteria should they gain access to the body. The
antitoxins do not destroy the bacteria; in other words,
35
36 BACTERIOLOGY.
they are not germicides. In fact, the antitoxic serums
are themselves good culture-media. One theory of
their action is that they neutralize the toxin, thus
giving the natural bactericidal powers of the body an
opportunity to exercise their function.
The following is a brief description of the process
employed in-the laboratory of Parke, Davis & Co.,
for the preparation of diphtheria-antitoxin :
Young horses in perfect condition are selected and
kept under careful observation by an expert veterina-
rian for three or four weeks. During this time they
are carefully tested with tuberculin for the possible
existence of unsuspected and undeveloped tubercu-
losis, and with mallein for glanders. When a horse
is found to be perfectly healthy it receives its first
dose of diphtheria-poison, or more properly a solution
of the toxin of the diphtheria-bacillus. This is pre-
pared in the following manner: A culture is obtained
from the throat ofa patient suffering from a virulent at-
tack of diphtheria. The diphtheria-bacillus is isolated
from this culture and planted in a flask of bouillon
or beef-tea, which is then kept in an incubator from
three to four weeks. At the end of this time it has
attained its maximum toxicity and the bacteria begin
to die of their own poison. ‘The toxin which they
have elaborated in the course of their existence is held
in solution in the beef-tea. This bouillon solution
of toxin is then filtered through porcelain to remove
the bacterial cells and any other extraneous matter.
It is then ready for injection into the horse. About
one-tenth of one cubic centimeter is injected intra-
venously. ‘The horse responds with all the constitu-
tional symptoms of diphtheria, such as a chill, fever,
fee, THA ORY OF ANTITOXINS. 37
loss of appetite, more or less pharyngeal paralysis,
with regurgitation of food. Sometimes death occurs
from heart-paralysis. Upon recovery, which comes
within a few days, a slightly larger dose is given.
This treatment is continued for about one year, at the
end of which time the horse will take from 2000 to
3000 times the initial dose without reaction. It is
then ready for bleeding. About 6000 cubic centi-
meters of blood are drawn from the external jugular
vein. This is allowed*to clot, and the serum obtained
is known comnnercially as antitoxin. It 1s customary
to add an antiseptic, such as trikresol, to preserve the
serum.
In preparing the streptococcus antitoxin a culture
is made of bacteria obtained from two sources—ery-
sipelas and puerperal septicemia. ‘This is done be-
cause some eminent bacteriologists believe that the
streptococcus of erysipelas 1s not identical with the
streptococcus of puerperal fever. It is but fair to say,
however, that others equally eminent assert the iden-
tity of the two streptococci. ‘To meet the possibility
of the non-identity of the organisms, a culture ob-
tained from the two sources is used. Its virulence is
increased by passing it through rabbits. After pass-
ing through about fifty rabbits a culture is planted in
beef-tea, and the same course pursued as for diphthe-
ria-antitoxin. Antitubercle serum is obtained by im-
munizing horses with the original Koch’s tuberculin.
As to the therapeutic action of antitoxin, little or
nothing is known positively. It seems reasonable to
conclude from experimental evidence that the antt-
toxin neutralizes the toxin in the body and thereby
gives the natural germicidal powers an opportunity
38 BACTERIOLOGY.
to dispose of the bacteria. It may be that it has the
additional property of stimulating the phagocytic and
possibly other bactericidal functions. ‘The following
experiments made by Martin and Cherry in England,
and described in the Journal of the American Medical
Association of August 27, 1898, are of interest in this
connection. Behring, Ehrlich, and Kanthack have
advocated the theory that the antagonism between
toxins and antitoxins is a chemic one, somewhat anal-
ogous to the neutralization of an acid by an alkali;
while Buchner, Metschnikoff, and others have. main-
tained that it is indirect and operates through the
cells of the organism. Martin and Cherry used a
snake-venom antitoxin. A large number of guinea-
pigs wereused. At 60°C. the antitoxin was destroyed,
while the venom retained its virulence. In the con-
trol-experiment with the venom only, all the animals
died within a fewhours. A number of mixtures were
made of 1 c.c. of antitoxin with twice the fatal dose
of venom; others with three or four times the fatal
dose. ‘These mixtures were allowed to stand at the
usual laboratory temperature (20° to 23° C.) for two,
five, ten, fifteen, and thirty minutes respectively, then
heated to 68° C., and afterward injected.
As remarked above, this heat destroyed the anti-
toxin, so that none was injected. ‘The animals sub-
jected to the mixture of the stronger doses of ten min-
utes or less died or were seriously affected; all of those
receiving the fifteen-minute mixture survived; while
the thirty-minute mixtures produced no symptoms
whatever. Similar results were obtained with diph-
theria-antitoxin and toxin. ‘These experiments seem —
to show, as far as anything can, that the neutraliza-
THE THEORY OF ANTITOXINS. 39
tion of toxins may occur in the test-tube, and that the
vital processes in the organism and the body-cells are
not essential. ‘These gentlemen made further exper-
iments by passing a mixture of toxins and antitoxins
through a Pasteur-Chamberland filter. This was po-
rous for toxin, but not for antitoxin, owing to the
difference in the size of their molecules. The toxin
which passed through the filter, after having been
mixed with antitoxin, was neutral. The unavoidable
conclusion from this experiment is that the toxin was
neutralized before filtration.
Experiments have been tried in order to prove the
theory that toxins are albumoses and antitoxins globu-
lins; but these experiments do not appear to be con-
clusive as to this point.
The supposition that the administration of antitoxin
is followed by a stimulation of the germicidal powers
of the body seems to be reasonable, at least in the
case of the antistreptococcic serum, since the strepto-
cocci disappear with the passing away of the signs
and symptoms. On the other hand, the Klebs-Loeff-
ler bacillus is found in the throat for weeks and even
months after the disappearance of all symptoms of
diphtheria in cases treated with the antitoxin.
The present status of diphtheria-antitoxin may be
presented in a few words. It has established itself as
a specific in the treatment of this disease. During
the past year the use of larger doses has become more
general, and it seems certain that better results were
obtained. The administrators of the Chicago Depart-
ment of Health give 2000 units in all cases of sus-
pected diphtheria, and employ 1000 units as an im-
munizing dose. During the months of November
40 BACTERIOLOGY.
aud December, 1898, this department treated 219
cases of bacteriologically proved diphtheria—all char-
ity cases—with a death-rate of 4.1 per cent. Some
twoand a half years ago, when antitoxin was not used,
the death-rate from diphtheria treated by this depart-
ment was about 35 per cent.
Antistreptococcic serum gives promise of being
second only to the diphtheria-antitoxin in point of
therapeutic value. It has been most successful in
erysipelas and puerperal septicemia. Cases of scarlet
fever are reported in which it has been useful in
shortening the duration of the disease and in pre-
venting unfortunate complications and sequele, such
as otitis media and other suppurative processes due to
streptococcl. |
A mixture of the toxin of the streptococcus of
erysipelas and the products of a harmless germ, the
Bacillus prodigiosus, 1s used by Coley and others as an
injection in malignant tumors that are past the stage
of operation or are so situated that an operation is im-
possible.
It is to be regretted that tetanus-antitoxin does not
in clinical use do all that it will do in the laboratory.
It has been used in a considerable number of cases,
but in nearly every instance without any result that
would justify us regarding it as a great curative
agent. Nevertheless, it should be used early in
every case of tetanus and in large doses, because it is,
like the other serums, harmless and the patient has a
somewhat better chance of recovery.
One or two cases have been successfully treated
with intracerebral injections of antitoxin, the theory —
being that the antitoxin should be placed where it
THE THEORY OF ANTITOXINS. 4!
could neutralize the toxin which is producing the
convulsions by means of its action on the nerve-
centers. The value of this method of administration
has not been proved.
As a preventive measure the use of tetanus-anti-
toxin is strongly commended.
The antitubercle serum has not shown itself to
have more value than a great number of other
remedies vaunted as specifics in tuberculosis.
Method of Injecting Antitoxin.—The serums and
toxins are given hypodermically, the injection being
made into the back, thigh, side of the breast, or over
the chest. Perfect antisepsis for the operation is
absolutely necessary. ‘The puncture-wound is closed
with a collodion dressing. It 1s not necessary to use
mmassage for the purpose of causing more rapid ab-
sorption of the injected serum—the swelling gener-
ally disappears in a short time of itself. Sometimes
the site of the injection becomes very painful. In
_ certain cases, pains in the joints and various skin-
eruptions (erythema, hives) develop after the injec-
tion. ‘They are not of great moment, but the physi-
cian’s attention should be called to them.
The reaction following an injection of Coley’s
mixture is sometimes severe, and may correspond
to the symptoms beginning an attack of erysipelas—
chill, local redness, and high temperature.
CEPA Pl He oy,
ANTISEPTICS, DISINFECTANTS, AND
DEODORANTS.
SUBSTANCES which retard or check the growth of
bacteria amid otherwise suitable surroundings are
called antiseptics.
Articles and wounds which are entirely free from —
bacteria and their spores are termed aseptic or sterile.
Disinfectants or germicides entirely destroy the
vitality of bacteria. Excessive heat, dry or moisemas
a true disinfectant, because it entirely destroys bac-
teria, while cold is an antiseptic; it does not kill bac-
teria, but retards their development.
A chemic agent which will cause the death of bac-
teria 1s called a germucide. |
A deodorant is an agent that destroys bad odors.
A disinfectant is an antiseptic, and may be a deodo-
rant; but because a substance has the power to de-
stroy bad odors it does not follow that it has the power
to destroy the bacteria which are the cause of the
odor. Carbolic acid, for instance, is a disinfectant
and deodorant; while Platt’s chlorides is a prompt
deodorant, but has almost no disinfectant power.
The power of a chemic agent to destroy bacteria
depends on several conditions :
First. The kind of bacteria, some being easily killed
42
mvitole ICS, DISINFECTANTS, AND DEODORANTS. 43
by an agent which is entirely harmless to others.
Spores are much more resistant than the bacteria from
which they are derived.
Second. The number of bacteria present.
Third. The temperature at which the exposure to
the disinfecting agent is made; the higher the tem-
perature the greater the effect.
Fourth. The strength of the solution; a small quan-
tity of a strong solution of corrosive sublimate 1s
much more efficient than a large amount of a weak
solution. :
Fifth. The nature and quality of the associated
material. If the bacteria are associated with a large
amount of organic matter, the chemical agent used
may combine with the latter and may thus be con-
verted into an ineffective material before it has an op-
portunity to act upon the bacteria. This result must
be especially guarded against in the disinfection of
sputum and fecal matter. |
The agents capable of destroying bacteria are num-
berless; but there are many which cannot be employed
in practice because they are too weak or act too slowly,
or are too poisonous, or too expensive for general use
in the required quantity, or are too destructive to the
objects with which they come in contact. Water at
a high temperature cannot be used for the disinfec-
tion of the hands of the surgeon or of the field of oper-
ation, or of organic substances in general. Corrosive
sublimate cannot be employed in the sterilization of
instruments, since it corrodes and blackens them; it
also discolors clothing and furniture when used in
strong solutions. Potassium permanganate stains
everything with which it comes in contact; it also
44 ANTISEPTICS.
causes pain and burns if used in very strong solu-
tions.
By long-continued action in concentrated solution
some of the agents which arrest the growth will finally
lead to the death of those bacteria which have been
subjected to them. Many agents, however, which
arrest the growth of bacteria, are not capable of de-
stroying them, and particularly their spores. Cold,
for example, will arrest the development of bacteria
but has no power to destroy anthrax-spores even when
applied with the most extreme intensity. ‘The resist-
-ance of spores is one of the strangest phenomena in
nature; some can be boiled and some can be subjected
to the intensely cold action of liquid air without per-
ishing. ‘The chief disease-producing bacteria which
form spores and those which do not are :
Non-spore-forming :
I. Streptococcus pyogenes.
2. Staphylococcus pyogenes aureus, albus, and
citreus.
3. Streptococcus of erysipelas (believed to be iden-
tical with the Streptococcus pyogenes).
4. Diphtheria-bacillus.
5. It is doubtful whether the tubercle-bacillus is
spore-forming. The weight of opinion favors the
absence of spores in this organism.
Among the spore-forming pathogenic organisins
ate:
1. Bacillus of malignant edema.
2. The tetanus-bacillus.
3. The anthrax-bacillus.
The germicidal or disinfecting agents at our com-
mand are of two kinds chiefly, heat and chemic
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 45
agents. The term ‘“‘ disinfection’’ 1s employed for
the action of chemic agents, and ‘“‘sterilization’”’ for
the action of heat.
Among all germicidal or disinfecting agents heat is
entitled to the first place, and fire, for its thorough-
ness, is superior to all others. All infected articles
of little value, books, playthings, etc., that can be
burned should be thus destroyed, as should also spu-
tum and bowel-movements. The very best way to
treat the latter is to mix them with sawdust and then
to burn them.
In surgical work, for the perfect sterilization of.
articles capable of withstanding it, fire is preferable
because of its certain action. Edged instruments and
forceps may be exposed for a very short time to the
direct flame; but if continued too long the temper of
the steel is affected.
We must remember that after sterilization there is
always the danger of contamination, and the articles
must, therefore, be carefully protected immediately
after sterilization. If they are left uncovered for dust
to collect upon them, the object of sterilization is
defeated.
Heat may be applied in the form of hot air, moist
air (steam), or boiling water.
Bowling water kills germs on contact, and de-
stroys anthrax-spores, as a rule, in from two to four
minutes.
Moist heat (steam) is the next most powerful agent.
It is more thorough and more penetrating than hot air.
steam exerts its full influence only when the air is
saturated with it. Saturated steam may be simple
steam (quiescent), live steam (circulating steam),
46 ANTISEPTICS.
high-tension steam (confined under a certain press-
ure), or superheated steam (that which has been
heated secondarily by conducting it through iron
pipes which have been raised by flame to a tempera-
ture of about 100° C.).
Live steam destroys anthrax-spores in from five to
fifteen minutes, according to their degree of resist-
ance. |
Disinfection by steam is applicable to clothing,
linen, blankets, towels, surgical dressings, instru-
ments, curtains, carpets, brushes, mattresses, pillows
(the two latter should be ripped open), and a number
of delicate fabrics. It is not applicable to linen
soiled by feces, blood, or pus, since the stains would
become fixed by the process, nor to rubber articles.
Under certain conditions many articles are exposed to
the action of steam for one hour on three successive
days, being kept during the intervals at a tempera-
ture of 70° to 80° C. to favor the development of
bacteria. This is called “‘intermittent’’ “ory ae
tional’? sterilization, the object of which is to kill all
bacteria that may have developed from spores that
escaped the first steaming. The last sterilization is
for the purpose of making sure.
Ffot air is inferior to both steam and hot. water.
Steam at a temperature of 100° C. is more effectual
than hot air at a much higher temperature. Accord-
ing to investigations, exposure to a temperature of
L560" -C.5(302" 42 ¥ aor one and a half hours in a hot-
air sterilizer will kill all known bacteria and their
spores.
The list of chemic substances used as germicides
is constantly changing, and those which are now
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 47
considered the most valuable may in a little while be
considered not so effectual as newer ones. Among
the recognized antiseptics and disinfectants now in
use are:
Carbolic acid, derived from coal-tar by distillation.
When pure, it is a solid, white, or faintly rose-
colored, crystalline body, readily soluble in water,
alcohol, or glycerin. On exposure to air it absorbs 5
per cent. of moisture. A solution frequently employed
meme Or 5 percent. strength. ‘I’o make a 5 per cent.
solution, 1 part cf carbolic acid is added to 20 parts
of very hot water and the whole shaken thoroughly.
Any excess of carbolic acid above that strength
falls to the bottom of the vessel as pinkish globules.
Before using the solution care must be taken that the
globules have been dissolved, or they will burn any
living tissue with which they come in contact. Car-
bolic acid is considered now to be the most reliable
and useful of all the germicides and antiseptics. It
has the advantage over corrosive sublimate in that it
does not discolor instruments nor clothing; but, on
the other hand, it irritates and benumbs the skin.
Pure carbolic acid is a reliable disinfectant for instru-
ments. If an instrument that is indispensable hap-
pens to fall to the ground during an operation, it is
laid for a few moments in pure carbolic acid, and
then rinsed with sterile water, and is ready for use.
Long-continued submersion in the acid will, how-
ever, deprive knives and scissors of their temper and
edge. Symptoms of poisoning have been produced
by the absorption of the drug from surgical dressings
and from the use of carbolic solutions for irrigation.
The first evidences of poisoning are a very dark
48 ANTISEPTICS.
greenish or a blackish coloration of the urine, head-
ache, giddiness, ringing or singing in the ears, and
lassitude: ‘The odor of carbolie acid is to a” Ger
tain extent a protective against accident; yet fatal-
ities occasionally occur. The antidote of carbolic
acid is milk and lime-water or flour and water.
The strength of the solutions used varies from
1:80 to 1:20. The acid is bought usially aaa
liquid form, having a strength of 95 per cent. ‘To
make a solution 1:20 (5 per cent.), 1:40 (@% pee
cent.), 1:50 (2° per cent.), 1:80 (1% per cemeuee
ounce of the 95 per cent. solution is added to 20, 40,
50, or 80 ounces of water. When obtained in the
solid form, it may readily be liquefied by placing the
bottle in a vessel of hot water.
Corrosive sublimate, or bichlorid of mercury, has,
like carbolic acid, the advantage of being both effica-
cious and cheap. It has the disadvantages that it
is decomposed by alkalies, that it 1s precipitated by
albumin, and that 1t corrodes metals. It is used in
strengths of from 1:10,000 to 1:500. ‘The solution
should be made as it 1s needed, because in old solu-
tions most of the soluble corrosive sublimate has
been converted into insoluble calomel, and the solu-
~ tion is not germicidal. By using the compressed
tablets now on the market fresh solutions are readily
made. A tablet usually contains the requisite amount
of corrosive sublimate to make when added to one
pint of water a I: 1000 solution, and by increasing or
diminishing the amount of water the strength of the
solution may be altered at pleasure. The tablets
are very convenient, and almost compel accuracy
in the preparation. Corrosive sublimate is of less
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 49
value for the disinfection of the excreta than car-
bolic acid, as it hardens the albuminous material
which covers the outside of all fecal masses, and
thus protects the inside from the desired action.
Tartaric acid, chlorid of sodium, or chlorid of ammo-
nium is often added to prevent this. Compressed
tablets, each containing tartaric acid or ammonium
chlorid and 7% grains of corrosive subliimate, or
equal parts of chlorid of sodium and corrosive sub-
limate, are in common use. ‘The convenient form in
which this drug is put up and the readiness with
which it can be used in surgical and medical work
have made its adoption universal. Its poisonous
character must be kept constantly in mind. ‘The
first symptoms of poisoning in consequence of the
absorption of the bichlorid are profuse salivation,
fetid breath, a metallic taste in the mouth, sore
teeth, spongy gums, and swollen tongue. Should
any of these symptoms appear they should at once
be reported to the surgeon. As the solution has no
odor, it is occasionally swallowed in mistake. Should
this occur, symptoms of a violent gastro-enteritis
appear—vomiting, burning pain, bloody stools; the
kidneys are also affected, and an acute Bright’s dis-
Ereeeteveliops. [The immediate treatment of this
acute poisoning consists in the giving of white of
egg, flour, or milk and lime-water, and washing out
of the stomach.
There are other products of coal-tar distillation akin
to, but not so poisonous as, carbolic acid. Among
them are the following:
Creolin.—This is a non-irritant and practically
non-toxic germicide. Though toxic symptoms have
4
50 ANTISEPTICS.
been reported, it certainly is the least poisonous of
the powerful germicides now in use. Its chief disad-
vantage is that when mixed with water it forms an
opaque emulsion; consequently it is inapplicable for
the sterilization of instruments, since they could not
readily be foundinit. For cleansing the hands and
for irrigation, creolin is used in strength of from
2 to 5 per cent. To make a 2 per cent solmima
21% teaspoonfuls of creolin are added to 1 pint of
water.
Lysol is a brown, oily-looking, clear liquid, with a
creosote-like odor, obtained from tar-oils) When
added to ordinary hard water it forms a clear, soapy
liquid, as it precipitates the lime-salts in the water,
but is clear if distilled water, alcohol, or glycerin
be mixed with it. Its antiseptic properties under
no circumstances are impaired. On account of its
saponaceous character 1t cannot be used for instru-
ments, because it renders them slippery. It is much
emploved in surgery and gynecology, in solutions of
from 1 to 5 percent. To makeat per cent. solution,
5 drams are added to % gallon of water. Its chief
advantage over other antiseptics lies in its non-irri-
tant and much less poisonous properties. It can be
used for the disinfection of everything in the sick-
room.
Sozal is an antiseptic obtained in small crystals
which have an odor of coal-tar. It is said to possess
the same advantages as corrosive sublimate without
its toxic properties. The crystals are readily soluble
in water, glycerin, or spirit. |
Saprol is a dark-brown oily fluid with an odor of.
carbolic acid. When mixed with water it divides
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. FI
into oil drops, some of which fall to the bottom of
the vessel, while others float on the top of the water,
consequently it cannot be used for surgical purposes.
It is a powerful disinfectant, especially valuable in
disinfecting excreta, and possesses the property of
diffusing evenly through the material~to which it is
added.
Other disinfectants outside of the coal-tar products
are : |
Todoform is largely used as a surgical dressing. It
has no decided antiseptic properties. It does good by
absorbing the liquids of the wound, thereby remov-
ing the nidus for germ-growth. When applied to
large moist surfaces it gives off free iodin. It prevents
decomposition and inhibits, but does not destroy, the
germs of putrefaction and pus-formation if they are
present before its use. When applied to raw sur-
faces it is occasionally absorbed into the system,
and causes symptoms of poisoning. On account
of this danger salol is often substituted for it, as
is also a mixture of iodoform, 1 part to 7 parts of
boric acid, it being both antiseptic and unirritating.
The symptoms of absorption are headache, loss of
peeetite, tise of temperature, a rapid, feeble pulse,
restlessness, and insomnia. ‘These symptoms may
pass away if the dressing is removed and discontinued.
In grave cases there is marked anxiety, a bright-
red eruption appears on the face and limbs, and
there is retention of urine, with stupor, delirium,
collapse, and death. Some patients are very sus-
Geprivie to the toxic effects of the drug. It has a
penetrating odor, which many persons find disagree-
able. Spirit of turpentine will at once remove the
52 ANTISEPTICS.
objectionable odor from the hands, instruments, and
vessels that have been in contact with the drug. Iodo-
form darkens upon exposure to a bright light and is
likely to cake when it becomes moist. It is used for
impregnating gauze-dressings, for dusting on ulcers
and wounds, and for injections, dissolved in ether or
olive oil, into sinuses or tuberculous abscesses. It is
also used in the form of ointment.
Todol is a pale yellow crystalline powder, almost
insoluble in water, but readily soluble in ether and
alcohol, less so in glycerin or oils. It is often used
as a substitute for 1iodoform, having the same proper-
ties. Like iodoform, it darkens if exposed to a bright
light. It is used in the form of powder, solution, and
ointment, and has the advantage of not being so poi-
sonous as 1odoform.
Formaldehyd is a gas formed by the partial oxida-
tion of wood alcohol. Its use is greatly facilitated by
having it combined with water and in a known def-
inite proportion, so that the quantity used may be
certain and definitely known. Its solution in water
is called formol, formal, and formalin, and contains
about 4o per cent. of formaldehyd gas. Formal-
dehyd is non-poisonous, colorless, with a pungent,
irritating odor, and possessing great antiseptic, disin-
fectant, and deodorant powers. Its activity as a ger-
micide is considered to be equal, if not superior, to
that of bichlorid of mercury, and it is available in
many cases in which the latter cannot be used. It
does not corrode or tarnish metals, nor injure the
finest fabrics either in texture or color. As a deodo-
rant it removes immediately the odor of feces, urine,
septic or gangrenous material. It 1s used externally
Ss Fae S| Se
ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 53
in the form of solution, spray, or vapor, and is some-
times added to powders. In solution as a wash or
irrigation in wounds, etc., it 1s employed in strengths
varying from 0.5 to 20 per cent. As a dusting-pow-
der it is used in combination with gelatin. Sheets
of moist gelatin after exposure to formalin fumes are
ground to a coarse powder, and are used in the dress-
ing of wounds. A slight disadvantage is that for four
or five hours after its use on a raw surface it produces
more or less pain of a burning nature. In the form
of vapor it is used for sterilizing instruments and sur-
gical dressings, and for the fumigation of the sick-
room and its contents. ‘The simplified method of
fumigating consists of diluting one pound of forma-
lin with three times its volume of hot water, and
boiling over a flame for half an hour. ‘The generated
gas is very penetrating, and having the same specific
gravity as the air soon permeates the room in which
it is confined, and kills all germs, not protected by
moisture, in about three hours. Special portable
forms of apparatus have been devised for purposes
of room-disinfection. Spray disinfection of rooms
with a 2 per cent. formalin solution is also very
satisfactory.
For the sterilization of instruments a I : 2000 solu-
tion is used. Formalin is also used in the preparation
of catgut. The catgut is wound on a glass spool,
not too tightly, and soaked for two days in equal parts
of ether and alcohol, after which it is rinsed in pure
alcohol for a few moments and transferred to glass
bottles with tightly fitting covers, and which have
been previously sterilized, containing equal parts of
formalin and alcohol, enough more than to cover the
54 ANTISEPTICS.
catgut. After one week the catgut is taken out and
boiled for half an hour in normal saline solution, and
is then placed in sterilized bottles containing alcohol
until needed.
Formaldehyd vapor when inhaled irritates the
lungs. It also irritates the eyes and nostrils, causing
them to smart.
A fatal case of formalin-poisoning is reported, the
amount taken being about 3 ounces of a4 per cent.
solution. Immediately after taking there were pain
in the stomach and vomiting. ‘The vomited matter
was blood-stained and had the pungent odor of for-
malin. The patient died of heart-failure thirty-two
hours afterward. ‘The treatment consisted in albu-
min-water, free emesis, heart-stimulants, and normal
saline solutions given both hypodermically and intra-
venously.
Arvstol (thymol iodid) is a reddish-brown powder
containing about 45 per cent. of iodin. It 1s used as
a substitute for iodoform. It has not the disagreeable
odor of iodoform, and its use is attended with less —
danger of poisoning. It is used in the form of fine
powder or ointment, the strength of the latter vary-
ing from % to 1 dram to 1 ounce of pure lard.
ee ae a a
CH AUPE RV.
ANTISEPTICS (Continued).
Peroxtid of hydrogen is a popular antiseptic. It
is an excellent agent for the destruction of pus-
cocci. When poured or injected into a wound,
effervescence takes place, the result of chemic reac-
tion between the wound-secretions and the hydro-
gen peroxid. ‘This active frothing serves to carry
off any shreds of tissue in the wound that cannot
easily be reached. ‘The peroxid is also applied to
the throat in diphtheria to destroy and remove the
false membrane. It readily decomposes by coming
in contact with metals; consequently, if used as a
spray, a glass atomizer must be employed. The per-
oxid of hydrogen in common use is a clear, odorless
fluid, having a bitter taste. The official solution
contains 3 per cent.of the pure dioxid, which corre-
sponds to about ten volumes of available oxygen, and
it is upon its readiness to yield oxygen that its
activity depends. ‘The solution should be kept in a
cool, dark place, and the cork forced tightly into the .
bottle.
Boracic acid (boric acid) is a mild antiseptic. It is
non-itritating and practically non-poisonous. It is
therefore frequently used to wash out cavities, for
injections, and in ophthalmic and aural practice. It
is used in the form of powder, solution, ointment, and
gauze. In solution, a saturated solution is used (a sat-
55
56 ANTISEPTICS.
urated solution 1s one in which the water dissolves as
much as it will of the drug; the remainder lying at the
bottom of the vessel as an indication that the solution
is sufficiently strong). It is easily made by placing
one-half pound of boric acid in a half-gallon bottle
filled with boiled water and shaking thoroughly until
saturated. It is impossible to use a solution which
is too strong, because the water cannot take up any
more than I in 30 (about 4 per cent.), which is the
usual strength used. In rare cases it acts as an irri-
tant to the skin and produces an eczematous condi-
tion.
Boroglycerid 1s a non-poisonous antiseptic solution
made from boric acid and glycerin, and is used as a
wash, an irrigation, and for saturating tampons.
Thiersch’s solution is an antiseptic of moderate
power, wnirritating and non-poisonous; it contains
salicylic-.acid, 2 parts; boric acid; 12 —partsesaaee
water, 1000 parts.
Alcohol.—Absolute alcohol is an antiseptic and dis-
infectant used for cleansing the skin, for the prepara-
tion of sutures and ligatures, and for the disinfec-
tion of cutting-instruments. To sterilize the hands,
they are scrubbed for five minutes with soap and hot
water, then scrubbed for the same length of time in
absolute alcohol, and finally rinsed in an antiseptic
solution. ‘Ihe results obtained by the disinfection
and cleansing of the skin with alcohol have been as-
cribed to the solvent action of the alcohol upon the
fatty matters on the skin, thus allowing corrosive
sublimate and other antiseptics to come into 1mme-
diate contact with the bacteria. Scrubbing the
hands in absolute alcohol for five minutes takes up
ANTISEPTICS. 57
both the fatty matters of the skin and also the bac-
teria, which are thus washed away.
Potassium permanganate, or permanganate of
potassium, is an antiseptic, disinfectant, and deodor-
ant, depending for its action on its oxidizing prop-
erties. It parts with its oxygen very readily to
organic substances and becomes inert. Its chief dis-
advantage is that it stains everything a brownish-
black color. It is used in solutions varying from
1:100 to 1:10. When employed for sterilizing the
hands, it is followed by oxalic acid solution, which
has the property of removing the stain. It 1s also
used on wounds, especially those which have an
offensive discharge, as, for example, gangenous
ulcers, on which it acts as a deodorant as well as a
disinfectant. It may also be employed to disinfect
bowel-movements, to flush water-closets, etc. Its
advantages are that it 1s non-poisonous in ordinary
eametis, rapid and complete im its action; and
shows by its change of color from reddish-purple to
a brown whether it 1s acting or whether it is ex-
hausted. The strength of the solution generally used
is from 20 to 16 grains of the crystal to 1 pint of
water.
Oxalic acid is a powerful germicide, though it is
not used alone, but to remove the stains of potassium
permanganate from the skin. It is very poisonous
and quite irritating, but the irritation can in a meas-
ure be avoided by immersing the hands and forearms
afterward in either plain water or lime-water. or - ' ys
“ae 2 . q ¥, i 3 é ‘ td
STERILIZATION. 63
The material used in the construction and furnish-
ing of an operating- and dressing-room should be of
marble, metal, porcelain, and glass, all of which can
readily be made aseptic. ‘The water-faucets should
be controlled by automatic foot-valves, so as to avoid
Fic. 4——Wheeled stretcher.
contamination by turning on the spigots with the
hands after they have been rendered aseptic.
The operating-room should be kept clean, and
should be swept and dusted every day, and rubbed
over with a damp cloth; in short, it should be
in such a condition as to be ready for an operation at
afew moments’ notice. The supplies for dressings
should not be allowed to run down, and the instru-
ments should always be in a first-class condition. The
emergency bundle, containing everything necessary
for an emergency operation, should be kept in read1-
ness. ; |
Sterilization.—Sterilization may either be dry or
OA
v
SURGICAL FLECAIVIE.
moist; moist heat is preferable, because it is more
thorough and more penetrating than dry heat. For
dry sterilization the towels and dressings are placed
in covered tin pans in an oven the temperature in
which ranges from-160°, to. 212° F.- Por nieietiee
steam sterilization, a Kellogg, a Sprague, or an Arnold
steam sterilizer is used. The heat must be con-
tinued for fully one hour before the operation.
Regarding the sterilization of instruments surgeons
differ; some prefer to have their instruments wrapped in
a towel and put into the Schimmelbusch or Arnold
sterilizer and allowed to boil for half an hour in a 1
per cent. solution of carbonate of sodium to prevent
their rusting. ‘The water must boil before the instru-
ments are placedinit. All edged instruments to be
boiled in the soda solution should be wrapped in cot-
ton and packed so firmly that they will not be tossed
against one another by the solution as it becomes
agitated in boiling. ‘This agitation seems to be the
reason why they lose their edge. Many operators
prefer to have their edged instruments and needles
placed in a dish containing 95 per cent. carbolic acid
for half an hour; then just before the operation they
are taken out and rinsed with sterilized water.
After sterilization the instruments are transferred
to the instrument-table, or to shallow porcelain or
glass trays, in which they lie covered with sterilized
towels until required.
Instruments and dressings are now sterilized with -
formaldehyd with excellent results, one great advan-
tage being that neither the solution of formalin nor
the gas injures the instruments in any way or dulls -
the edge of knives, scissors, or needles. A Schering
PrATe.2,
Sterilizing Room, Medico-Chirurgical Hospital, Philadelphia.
STERILIZATION. 65
lamp is usually used either with a 40-per-cent. solu-
tion of formaldehyd or with formalin pastils. The
best results seem to be obtained with the pastils. One
FIG. 5.—Apparatus for sterilization of instruments, etc.
pastil is constantly being evaporated in the upper cup
of the lamp; but when rapid evaporation is required
7
ae i TT
oo
FIG. 6.—Instrument-sterilizer.
the upper cup is removed and the pastils are placed
in the lower part.
During the operation, instruments which have
5
66 SURGICAL TECHNIC.
fallen to the floor and are needed for further use are
rinsed in cold water and laid for a few moments in
the 95 per cent. carbolic acid, then rinsed with steril-
ized water.
After the operation the instruments should be
taken apart, washed in cold water to remove all
blood, pus, and tissue-particles, and then thoroughly
scrubbed with green soap. Instruments with perma-
nent joints, which fortunately are seldom seen now,
Ke =
|
A
FIG. 7.—Sterilizer for instruments and dressings: a, for dressings ; 4, for
instruments; c, water and solution of carbonate of sodium to prevent rust-
ing.
must receive special attention, since it is difficult to
get them surgically clean. After being scrubbed the
instruments are rinsed in hot sterilized water, wiped
dry with a soft towel, and then laid away in the
case. The knife-blades must be rolled in cotton.
The important points to be remembered in cleaning
instruments after an operation are:
— ST a ee _
:
~~ ae
STERILIZATION. 67
First, all instruments that can be so dealt with
must be taken apart and the rough catches thoroughly
cleansed.
Second, they must be dried carefully in order to
prevent rusting; for instruments once rusted seem
always to have a tendency to return to that cond1-
tion.
Instrument-trays are made of glass, porcelain, agate-
ware, or hard rubber; and are rendered aseptic by
being first scrubbed with green soap and warm water,
after which they are filled to the brim with r: 500 cor-
rosive sublimate, which is allowed to remain in them
for halfan hour. When needed they are rinsed with
salt solution or sterile water. Many surgeons prefer
the trays filled with enough sterile water to cover the
instruments, while others again prefer the instru-
Fic. 8.—Agateware tray.
ments to be laid dry on the glass table, which has
been previously covered with a sterilized sheet or
towels.
Hvety operating-room nurse should be familiar
with the names of the instruments necessary for each
different operation, so as to be able to lay them out
when occasion requires. Many nurses get together
after school-hours and ‘‘ make believe’’ an operation
is to take place. Each nurse has her duty assigned
68 SURGICAL TECHNIC.
to her, and each tries to fulfil it in a thoroughly
professional, dignified, and quiet manner. Practice
of this kind is never lost.
In the operating-room should be kept two large
ledgers, in one of which the house-surgeons, after
making the morning rounds with the visiting sur-
FIG. 9.—Hard rubber tray.
geons, should record the number of operations to be
performed the next day, the time, name of operator,
etc. The operating-room nurse is thus made ac-
quainted, by consulting the book, of the amount of
work before her for the next day, and the character
of the operations for which she has to prepare.
SS ee
[Ce Se
r B=),
7 eres
<> —
SS S—=
FIG. 10.—Robb’s aseptic ligature-tray ; white porcelain.
On the morning of the operations she makes out a
list of the floor and number of private room or letter
of ward and number of bed, from which the patients
are to be brought to the operating-room, and the order
STERILIZATION. 69
in which the operator wishes them. ‘This list is given
to the male attendant, who brings up the patients in
succession, in such a way that while one patient is
being operated on the next is being anesthetized. The
head nurse in the operating-room has two or three
sets of instruments, and during one. operation an as-
sistant nurse is sterilizing the instruments and making
preparations for the next operation. ‘There is then
no waiting on the part of the operator, for as the
patient operated on is wheeled out of the operating-
room the next patient is wheeled in. The following
chart will give an idea as to the way the book 1s made
out and the order in which the operations are writ-
ten. The emergency-operations, accidents, etc., are
also recorded, but after the performance of the ope-
ration.
| |
Date.. | Operation. Floor. | Time. | Operator. |Room)Ward.| 9 |Floor.
aa)
| | | } 2
Mar. 11. Laparotomy. | 4th. ; 8. am.; Dr. Murphy. 19 3d.
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“« | Cholecystostomy. s go. "+ €° Renser, 16 dratits.
Glycerin, 7 “i
Water (distilled), : 4% ounces.
Mix and rub thoroughly into the meshes of gauze,
cut, and preserve the same as iodoform gauze.
In emergency cases old sheets and clean linen may
be cut to the desired size and sterilized in an oven.
Collodion Dressing.—Collodion is a preparation of
pyroxylin in alcohol and ether. On evaporation of
the alcohol and ether a thin, impervious film of col-
lodion is left. The collodion is either painted over
the surface of the wound by means of a clean stick of
wood or an applicator with sterile cotton fixed to the
end, or thin layers of absorbent cotton are saturated
with it, laid on the wound, and allowed to dry. Col-
lodion is used only when the wound is aseptic. Vari-
ous antiseptic agents, such as iodoform, boric acid,
etc., may be dissolved or suspended in the collodion.
The surface of the wound must be perfectly dry, or
the collodion will not adhere. An ordinary dry
102 SURGICAL.” LECHIVIC.
dressing may be applied over the collodion as a further
protective.
Florsley’s wax 1s made of seven parts of beeswax
to one part each of almond oil and salicylic acid.
Rubber adhesive plaster 1s at times used in the later
stages of wound-healing, for the purpose of drawing
the edges together. The chief objection to its use is
that it cannot be thoroughly sterilized. A protective
dressing may be applied over it in the usual way.
Rubber plaster 1s also used to take the place of band-
ages where these are inconvenient or difficult of
application.
Otled silk or rubber protective is used when it is
desirable to prevent sticking of the dressings to the
wound, as in ulcers, skin-grafting, ete. “Ihe miate
tial is applied in narrow strips which overlap each
other like shingles. The strips are sterilized by wash-
ing in cold soap-suds and soaking them in a1: 250
solution of corrosive sublimate. ‘They are then rinsed
in sterile water or saline solution, in which they are
allowed to float until needed by the surgeon.
Tents are small strips of rolled gauze used to
keep a wound open for the escape of pus. They
are rarely employed at present, having been replaced
by the drainage-tube. The term tent more fre-
quently designates a conical or cylindrical pencil of
sponge, sea-tangle, and other substance, employed for
dilating a narrow channel, such, for instance, as the
cervical canal. When introduced, the tent expands
from the absorption of moisture, and this dilates the
part.
Tampons are made of absorbent cotton, lambs’
wool, or gauze, and are about seven inches he one
BANDAGES. 103
and one-half inches wide, and one-half an inch thick.
They are folded and tied in the middle with a strong
white thread or fine twine, leaving long ends by
which to remove the tampon. ‘The so-called kite-tail
tampon is made by fastening several of these pieces
of cotton toa thread about two inches apart. The
tampons may after sterilization be kept in a dry,
sterile jar, or they may be thoroughly soaked in water
and then kept in glycerin. ‘Tampons are principally
used for introduction into the vagina. Previous to
introduction they may be dipped into various special
solutions. ‘They are generally removed from the
vagina on the day after the application.
Bandages.—In addition to the well-known roller-
bandage, special bandages find frequent employment,
5 | | 2 ‘
ma b ei iy:
y)
u Hi
iil
\
\
A =
= ==
——
FIG. 16.—T-bandage.
Fic. 15.—The Scultetus bandage.
particularly after abdominal operations. The most
important are the Scultetus and the T-bandages.
The Scul/etus bandage is used for surrounding the
abdomen. It is made by taking two pieces of
flannel or of cotton, each one yard long and four
inches wide, the two pieces being placed four inches
IO4 SORGCICAL STERCANIC.
apart; across them are sewed five other pieces of tlie
same length and width, each piece being overlapped
by the one above it by one-half its breadth. ‘This
bandage is placed under the patient’s back, the cross-
strips are folded over the abdomen from below
upward, and the lower ends of the vertical strips are
brought up between the thighs and pinned to the
front of the bandage. This keeps the bandage from
wrinkling and retains it in position.
T-bandage.—The T-bandage, which is used to
secure dressings on the anus or the perineum, is
made of two strips of bandage, each about five inches
wide. To the middle of one strip, which is to go
around the waist, the end of the other strip is sewed,
which forms a letter T. ‘This latter strip is brought
forward between the thighs and pinned to the front,
thus securing the perineal dressing.
Antiseptic Powders. — Reference has already
been made to these. Those most frequently em-
ployed are iodoform, boric acid, acetanilid, dermatol,
and mixtures of these various kinds. Jodoform and
boric acid are generally combined in the proportion
of one of the former to seven of the datten ee
powders are kept in sterilized glass salt-cellars with
silver-tops, which are covered with gauze when not
in use, or in sterile wide-mouth bottles over which a
piece of gauze is stretched. As the bottle may not
be thoroughly clean on the outside, it should be
handed to the surgeon wrapped in a sterile towel up
to the top.
The thermocautery, known also as the Paquelin
cautery, because of its invention by Paquelin, of ©
Paris, 1s frequently employed in surgery to control
THE THERMOCAUTERY. 1O5
bleeding, and also to produce counter-irritation.
The efficacy of this instrument depends on the fact
that when the vapor of some highly combustible car-
bon compound is driven over heated platinum its
rapid incandesceiice is sufficient to maintain the heat
of the metal. Platinum points of various shapes and
sizes are attached to a rubber tube, which is con-
nected with a metal container half full of benzine
or alcohol, the vapor of which is pumped through
the tubing and holder into the platinum point. In
Fic. 17.—Paquelin’s thermocautery.
order to prepare the instrument for use, a sponge
is first placed in the bottom of the container, and
over that is poured a small quantity of benzine or
alcohol. ‘Two pieces of rubber tubing, the one with
a bulb, and another to the handle of which 1s screwed
the platinum point, are connected by means of the
feonper 40 the container. The tip of the platinum
point is held im the flame of an alcohol lamp until
it begins to glow, after which the flame is extin-
guished, and the action of working the bulb gently
106 SURGICAL -THOCAIVIC,
forces the air charged with benzine through the
tubing to the point, where it ignites and keeps the
point glowing.
After using, the container should be completely
closed, and the points while hot must be removed
from the handle and laid away to cool; they must
not be put into water, but wiped perfectly clean.
The handle when cool must be removed from the
tubing, and each part must be carefully laid in its
own compartment in the case.
Normal saline solution is made to correspond as
nearly as possible in specific gravity with the normal
serum of the blood. The formula suggested by Dr.
Locke of Boston and Dr. H. A. Hare, contaimie
in one quart calcium chlorid 0.25 gm., potassium
chlorid o.1 gm., sodium’ chlorid 9 gm., 16 uStely,
employed. It not only gives the Ieart “a ~bemen
fluid to work upon, but it restores to the blood that
coagulable quality which is diminished or lost by
hemorrhage. ‘Tablets containing this formula have
been devised, and are usually used. One tablet added
to one quart of water gives the correct strength. In
absence of the tablets one teaspoonful of table salt
is added to one pint of water. It is absolutely neces-
sary whatever formula is used that the solution and
all the apparatus used be properly sterilized. If the
water contains particles that cannot be strained out
and there is no filter at hand, the water should stand
until the sediment settles, when the fluid can be
poured off, resterilized, and used. ‘This solution is
placed in an irrigator or a fountain-syringe which has
been thoroughly sterilized with hot water and corro- ~
sive-sublimate solution, and subsequently rinsed with
IRRIGATION. 107
boiled water. A long hypodermic needle, which has
also been thoroughly sterilized, is fastened to the end
of the rubber tube connected with the irrigator or
fountain-syringe. The solution may be kept in a
pitcher and poured into a glass funnel to which the
rubber tube is attached. The temperature of the solu-
tion should be about 100° F. The solution is intro-
duced under the skin of either the chest, the abdo-
men, the thigh, the arm, or between the shoulder-
blades. From a pint to two quarts are injected at
one time. The part selected for the injection is to
be sterilized thoroughly in advance. Saline infusion
is also given by the rectum, a long rectal tube being
used.
In hospitals it is customary to keep on hand flasks
of saline solution. These flasks are sterilized before
filling; afterward they are stopped with sterile cot-
ton-plugs and sterilized again by boiling for one
hour on three successive days.
Normal salt solution is used for irrigation and for
injections in cases of shock, in acute diabetic and
uremic coma, hemorrhage, puerperal infection and
eclampsia, etc.
Irrigation.—Irrigation, or flushing, is employed
to cleanse wounds and wash out cavities, such as
the uterus, the abdomen, etc. The solutions em-
ployed are various. Many surgeons use sterile salt-
solution or plain boiled water. Antiseptic solutions,
such as bichlorid solution (1 : 10,000 to i : 1000), boric
acid solution, etc., are used especially for septic
wounds and surfaces. For purposes of irrigation a
concial glass vessel, with a tube at the bottom to
which a rubber tube is attached, is commonly em-
108 SURGICAL TECHNIC.
ployed; a fountain-syringe will also answer the pur-
pose. The irrigating-nozzle is usually of glass.
The solution should be warm; when it is desired te
check hemorrhage, it is used quite hot (110°-120° F.).
CRAP VER x.
SUTURES AND LIGATURES; SPONGES; DRAIN-
AGE; DRAINAGE-TUBES; GAUZE DRAINS;
RUBBER DAM; RUBBER AND COTTON
GLOVES.
Sutures, which are used to bring together the
edges of a wound, may be of silver wire, silkworm-
gut, twisted Chinese silk, kangaroo-tendon, catgut,
and horse-hair. Of these, silkworm-gut, catgut, and
silk are most commonly used.
Catgu¢ is made from the intestine of thesheep. It
is largely used for suture-material within the abdom-
inal cavity or deeper layers of tissues, because it is
absorbed by the fluids of the body, and does not
remain after the healing of the external wound to
constitute a foreign body.
Kangaroo-tendon is prepared from the split sinews
of the tail of that animal, and was introduced by
Dr. H. O. Marcy of Boston. It is obtainable in any
size, and comes in pieces of about twenty inches in
length. Its advantage over catgut consists in its
ereater streneth. It is more easily sterilized, and.
does not lose its strength during perfect sterilization.
It is particularly of value in buried sutures and liga-
tures and continuous sutures at the surface.
To prepare the kangaroo-tendon the following
109
IIo SORGICAL “TECHNIC.
method may be used: The tendon having been
soaked in absolute ether for forty-eight hours, is
boiled at a temperature of 100° C. in alcohol for
one hour. This temperature is maintained by means
of a water-bath. It is then put in mercuric chlorid
solution, consisting of mercuric chlorid 40 grains,
tartaric acid 200 grains, and alcohol 12 ounces, for
ten minutes. It is then placed with sterilized forceps
in sterilized glass-stoppered jars containing bichlorid
of palladium ;; grain to 1 pint of absolute alcohol.
Silkworm-gut 1s prepared for use by soaking for
forty-eight hours in ether and one hour in 1: 1000
corrosive sublimate; it is then kept in a long tube of
alcohol, though many surgeons prefer it made asep-
tic by boiling two hours before the operation. It is
seldom used as a buried suture, but chiefly in closing
wounds with interrupted sutures.
Catgut.—'There are various methods of sterilizing
catgut, among them the methods of Leavens and Fow-
ler, by which catgut is kept in alcohol in sealed tubes,
the preparation by formalin recently proposed by Senn,
cumol catgut, etc., all equally effective if judiciously
carried out. The gut used should be of the very best
quality. The following are the most popular methods
of preparation :
I. Six strands of catgut, each fourteen inches long,
are wound on glassreels and soaked in ether for twenty-
four hours to remove all fatty substances. The spools
are then removed with sterilized forceps and dropped
into covered glass jars, cotitaiiing 95 per ceme
alcohol, care being taken that the catgut is com-
pletely submerged and that allowance is made for _
evaporation. ‘The mouth of the jar is covered with
SUTURES AND: LIGATUORES. Iil
absorbent cotton and the jar placed on a water-bath,
the water of which is gradually heated until the
alcohol boils, when the jar is removed. ‘This opera-
tion is repeated on two successive days. On the third
day of sterilization the absorbent cotton 1s removed,
and a glass cover, fitted with a rubber protective to
prevent evaporation, 1s screwed on.
2. The catgut is soaked for twelve hours in a corro-
sive sublimate solution (1 : 1000), and afterward from
twenty-four to forty-eight hours in oil of juniper.
The spools are then transferred to covered glass Jars,
containing sufficient absolute alcohol to cover the cat-
eut completely. The alcohol is changed every two
weeks.
3. Strands of catgut are soaked for twenty-four
hours in oil of juniper, after which they are wound
upon glass reels, and placed in covered glass jars con-
taining absolute alcohol.
The method used by Dr. F. W. Johnson, of Bos-
ton, Mass., is as follows: The gut 1s soaked in ether
Meeeeewcrea,) days. It is then cut into the desired
length, each length being thoroughly stretched (the
stretching prevents kinking and twisting). The gut
is then soaked for twenty-four hours in absolute
alcohol, to take out as much of the water as possible.
It is then covered with a solution of bichromate of
potassium in absolute alcohol (fifteen grains to the
Seaey sand remains in this twelve hours. Each
length is coiled up, wrapped in waxed paper, and put
in an envelope, which is sealed. The-sealed envel-
Opes are put in a dry oven, and baked for one hour
at a temperature of 100° C. ‘This removes all moist-
ure. On the following day the sealed envelopes are
LIi2 SURGICAL TECHNIC.
baked three hours at a temperature of 140° C. The
gut is now ready for use. The envelopes are kept in
a glass jar. An assistant tears open one end of an
envelope, undoes the wax paper without touching
the catgut, and hands it to the operator. In this
way the gut is touched by no one, and touches
nothing until picked up by the fingers of the opera-
tor. (Bar preparation of catgut by fee os see
Formaldehyd, p. 53.)
Silk is sterilized by being boiled for two et
before the operation. Five yards each of various
=i
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he
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i /; el NT] i | fiz yo. She
ee
au i|
3
= Z|
KS
FIG. 18.—All-glass ligature-box, hospital size; six large spools.
sizes of twisted Chinese and pedicle silk are wound
on glass spools and allowed to boil for two hours
before the operation. When called for by the oper-
ator the pan containing the silk 1s handed to him,
and he takes out the required size with sterilized
forceps. In this way the sutures and ligatures are
touched by no one but the surgeon himself. It is
always a good plan to sterilize fresh silk for each
een .
EE ey ae hie
SPONGES. 113
major operation. By so doing we are sure of it
being perfectly aseptic.
Silver wire is sterilized by means of dry heat or by
boiling in a 1 per cent. soda solution with the instru-
mments. Usually the latter is preferred.
The zzterrupted suture 1s made by passing catgut
or silk through the skin from one side of the wound
to the other; then both ends are drawn together and
tied ina double knot. The coztzniwous suture is the
ordinary over-and-over stitch from one end of the
wound to the other. The dz/¢tonm suture is made by
passing wire across the bottom of the wound, bring-
ing out the ends about one inch from the edge of the
wound, and securing each end with a button. ‘The
shotted suture is one 1n which the ends of the suture,
after it is introduced, are passed through a perforated
shot, which is then clamped.
Stitch abscesses are usually produced by unclean
suture-material. ‘They may be caused by tying the
stitches too tightly; but as a rule they occur when
the sutures are not carefully sterilized. This is the
reason why so many operators prefer their silk and
silkworm-gut boiled immediately before using.
Sponges.—Sponges are used to wash wound-sur-
faces and to absorb or soak up fluids. The sponges
most commonly employed are in the form of the
gauze pads, the cut edges being folded over and
loosely hemmed, and of square pieces of gauze, each
piece being rolled loosely in the form of a ball, the
free end being twisted and tucked in. The marine
sponges are not often used at the present time. Gauze
sponges are never employed more than once. ‘Those
used in operations are afterward destroyed; those not
8
I14 SURGICAL FECHNIC.
used are resterilized, placed in sterilized towels, and
deposited in covered glass jars, which are not uncoy-
ered until called for at an operation.
The great advantage of gauze over a marine sponge
is that it can be thoroughly sterilized.
If marine sponges are required for an operation, the
dark-colored ones should be bought. They do not look
so attractive, but they are the finest sponges; they are
‘uncut’ and ‘‘unbleached,’? and give more Services
than the clearer-looking ones, which are partly or
wholly bleached. The bleached and cheaper sponges
have been- made by cutting one large sponge into
several small ones; or by cutting off portions that
were torn in taking the sponges from the ocean.
Marine sponges should be prepared as follows: 1.
Lay them in a stout cloth and pound sufficiently to
break up grit and lime. 2. Rinse with warm water
until it remains clear. 3. Immerse in hydrochloric
acid solution {two drams to one quart of water) for
twenty-four hours. 4. Immerse in saturated solution of
permanganate of potassium, followed with oxalic acid,
then pass them through lme-water to take out all
the oxalic acid, and rinse welltm plain sterile water;
after which they are.immersed for twenty-four hours
in a I:1000 corrosive sublimate solution. They are
preserved until used in a 2 per cent. carbolic gem
solution. |
When wanted for use the sponges are lifted out of
the jar with long dressing-forceps and rinsed in plain
sterile water.
Gauze pads for abdominal operations are made of
eight thicknesses of gauze about eight inches square,
See ee oe ee F
BRUSHES. 115
with the edges tucked in and hemmed to prevent
fraying.
Gauze, now considered the most valuable of
dressings for wounds, is cut into sections of tour
thicknesses and folded into dressings. f-- “* » > —
CHAP ETH Rx LE:
CATHETERIZATION; DOUCHES; ENEMATA;
WASHING OUT THE BLADDER; LAVAGE.
THE use of the catheter is ordinarily very simple,
and yet it may truthfully be said that there is no
operation which is performed with so little regard for
asepsis. Asepsis and antisepsis are as important
here as they would be in preparing for an abdominal
operation.
Cystitis is often caused by the introduction of germs
into the bladder by means of a dirty catheter, or by
not cleansing the external genitals, vestibule, and
meatus before the operation. Normal urine is to be
considered sterile unless there is some disease of the
kidneys or bladder; and when infection occurs we
may assume that the germs have gained entrance
from without. ‘The catheter may be of glass. When
a glass catheter is not at hand,a silver or rubber
one may be used. When of glass or silver or rubber
it should be boiled twenty minutes before being
used.
Sees Catheters are the best: they ate easily
rendered aseptic, and show whether they are or are
not perfectly clean. Sterilization is most important
before using the catheter and immediately afterward.
There is no danger of the catheter breaking, as so
123
12a. SOR GICAL FeO NIC,
iuany patients fear, if it is not cracked before being
introduced. Besides the catheter, which is taken to
the bedside in a basin of very hot water, there are
needed a basin of corrosive-sublimate solution
(1: 1000), sterilized gauze or cotton, and a vessel
to receive the urine. A lubricant of stergeaee
to render the entrance of the instrument as easy as
possible is used only when a guim-elastic or rubber
catheter is employed. A mixture of carbolic acid
solution (1:40) and glycerin serves for this pur-
pose.
Introduction of the Catheter.—The patient lies
on her back with the knees drawn up and sepa-
rated, the upper clothing being divided over each
knee to guard against unnecessary exposure. ‘The
labia are separated with sterilized sponges and the
parts washed with the corrosive solution. The
catheter is inserted into the urethra, the opemme
of which is just above the vaginal entrance. If there
is any difficulty, the catheter should be withdrawn a
little, and gently pointed a little downward or up-
ward, to the right or to the left. If the flow should
cease before enough urine has been drawn, the cathe-
ter is withdrawn a little or is inserted a little farther
than before. Before removing the catheter a finger
should be placed over its end, to prevent any drops
of urine.wetting the bed. After the operation(iie
parts are again washed, and the catheter boiled and
placed in a bottle containing a solution of carbolic
acid (1 : 20), unless the catheter is of rubber; fone
bolic acid ruins rubber.
When the bladder is partially paralyzed from result
of an operation, or otherwise, a rectal injection of
EXAMINATION OF STOMACH-CONTENTS. 125
very warm water will often cause the bowel and
bladder to empty themselves at the same time, thus
doing away with the necessity of using a catheter.
The urine for examination by the physician is best
drawn with the catheter, to prevent contamination
from vaginal discharges.
A distended bladder must be emptied gradually,
and as the last amount of urine is being drawn the
flow should be slowed, to prevent any injury to the
mucous membrane of the bladder from drawing it
into the eye of the catheter.
Irrigation of the Bladder.—‘To irrigate the
bladder a fountain-syringe, cleansed with boiling
water and a disinfectant, is needed; also a glass
catheter, which is sterilized in the same way as for
catheterizing. ‘The parts, of course, are cleansed in
the manner described. ‘The patient 1s first catheter-
ized; the catheter is then rinsed with boiling water
and attached to the rubber tubing of the syringe
which contains the irrigation solution (boric acid or
salt solution), the temperature of the latter being
about 100° F. The solution must run warm before
the catheter is inserted. The rapidity of the flow is
regulated by raising or lowering the irrigator. The
quantity of solution introduced is governed by the
feelings of the patient ; usually 200 c.c. is all that
can be tolerated, after which the tube is disconnected
and the fluid is drawn off. If a double catheter 1s
ieee, the tubing is.not removed. .The irrigation is
repeated until the washings come away perfectly clear
and clean.
Examination of Stomach-contents. — Many
times the nurse is called upon to give a test-break-
126 SURGICAL TECHNIC.
fast and to send the stomach-contents to the labora-
tory for examination.
A test-breakfast usually consists of a cup of tea
without miik or sugar, and two soda-crackers; or in-
stead of the crackers a small piece of rare steak or
small piece of bread without butter is given. One
hour after, the stomach-contents are obtained by pass-
ing the stomach-tube. As soon as the tube comes in
contact with the walls of the stomach they contract
and force out the contents. If vomiting does not
occur, it may be excited by pouring down the tube
about two drams of lukewarm water. The contents
are measured, and placed ina clean bottle labelled with
the patient’s name, the date, quantity, and hour that
the breakfast was given and contents secured; the
bottle is then sent immediately to the laboratory.
Douches.—Properly given, the vaginal douche
relieves inflammation, checks hemorrhage, acts as a
stimulant and cleansing agent, and checks secretion.
The amount of water used is from five to six quarts,
of a temperature of 110° F. The temperature must
always be tested with a bath-thermometer, not with
the hand. ‘The Baker douche apparatus is an excel-
lent contrivance. Inits absence a fountain-syringe
may be used.
When taking a douche the patient should lie on
her back, with the thighs flexed on the abdomen and
the legs flexed on the thighs. In this position the
water comes in contact with the whole vagina. |
The pail or fountain-syringe must be hung about
four feet above the bed, so that it will taker atone
twenty minutes for the water to run out. Air must.
be expelled, and the water must run warm before the
DOUCHES. 127
tube is inserted into the vagina. ‘The vaginal tube
must always be sterilized before and after using, and
every patient should have her own tube.
Many patients in private practice object to taking
douches, and will neglect them on account of the in-
convenience; but this they can overcome by taking
the douches in the bath-tub. Half-way across the
bottom of the tuba piece of board is placed, on which
the patient can lie. ‘The douche-board designed by
Prof. Byron Robinson, of Chicago, has proved very’
beneficial and convenient to patients by giving them
a comfortable and simple method of taking a douche.
It can be used without legs, on a bath-tub, and with
legs (some twelve inches long) may be used in any
room.
FIG. 22,—Douche-board.
Antiseptic Douches.—Corrosive sublimate, car-
bolic acid, creolin, and boric acid are used for anti-
septic dowches; and to prevent absorption and irrita-
tion a plain water douche is often given after any of
these antiseptics.
128 SURGICAL. TECHNIC
A patient should lie quietly for one hour after tak-
ing a douche; if only.one is used a day, it is best to
give it at night, because then the uterus is most con-
gested and needs the hot water most, and the tempo-
rary weak feeling which follows a douche will be gone
before morning.
Rectal Injections (Enteroclysis) and Irriga-
tion.—The therapeutic range of this procedure is not
confined to the treatment of local troubles. It has
long been used as a means of cleansing the lower
bowel of accumulated feces. In the treatment of
rectal ulcers and inflammations it has been employed
both to relieve the irritation produced by fecal matter
and to apply various medicaments to the parts. For
the prevention of shock normal saline solution is
injected—one or two pints. This, by illne gene
blood-vessels, enables the patient to withstand the loss
of blood from the nerve-centers. After the operation
shock and hemorrhage are counteracted by its use,
and at the same time the thirst is relieved and rest-
lessness quieted. In septic conditions, both local and
general, by diluting the toxic materials in the circu-
lation and promoting their excretion by the skin,
kidneys, and bowels, saline rectal injections play an
important part in the treatment.
In patients whose digestive tracts are too weak to
hold food or medicine rectal feeding or rectal medi-
cation is employed. The rectum should be washed
out thoroughly before the injection is given. Iiihe
rectum is intolerant and will not retain what 1s. in-
jected, it is well to turn the patient on’‘her left side
and raise the hips on a pillow or a folded blanket.
A long rectal tube should be used as for a high
RECTAL INJECTIONS. 129
enema. ‘The physician will give directions as to the
temperature of the solution. In fever patients and
in the hemorrhage of typhoid fever great relief and
comfort are afforded by using very cold or iced water.
In shock or hemorrhage a temperature of 100° F. is
usually preferable. In long-continued lavage for
local trouble the patient’s preference as to the tem-
perature is generally consulted.
A stimulating and nutrient enema, black coffee,
or hot saline solution is given when symptoms of
shock appear either during or after an operation ;
it should be injected high up into the colon. The
rectum should be thoroughly cleansed at least once
daily with warm saline solution, which will also
aid the absorption of the nutrient enema. When
feeding by rectuin in gynecologic cases, it should
be remembered that tight tamponing of the vagina
may interfere with absorption in the rectum. If the
presence of hemorrhoids 1s a drawback, a 2 per cent.
solution of cocain may be used before injecting the
fluid.
Stimulating enema -
Whiskey, - 2 ounces.
Ammonium carbonate, I5 grains.
Beef-tea, A ounces.
Or
Brandy, 2 ounces.
Tincture of digitalis, 20 minims.
Milk, 4 ounces.
130 SURGICAL TECHNIC.
for tympanttes :
Tincture of asafetida, 2 ounces.
Spirits of turpentine, I ounce.
Magnesium sulphate (Ep-
som salt), 2 ounces.
Wari water, I pint.
Purgative enemata:
1. Warm soap-suds, y pint.
2. Common black molasses, I2 ounces.
Warm soap-suds, Oye as
3. Molasses, black, 4 ounces.
Glycerin, aes
Magnesium sulphate, I ourice.
Spirits of turpentine, Prey
Warm soap-suds, 8 ounces.
4. Glycerin, 4 ounces.
Turpentine, I ounce.
Magnesium sulphate (Ep- —_
som salt), 2 ounces.
5. Inspissated ox-gall, Y% ounce.
Warm water, I quart.
6. Spirits of turpentine, 10 drops.
Mucilage of acacia, l% ounce.
To be given high.
722 eta. % ounce.
Magnesium sulphate, tie tes
Olive oil, Ber tyees
Boiling water, I pint.
Infuse the senna in the water. Then dissolve
the magnesia, add the oi], and thoroughly mix
by stirring.
Sree) BR ETE.
OPERATIONS ; PREPARATION OF THE OPERAT.-
ING=-ROOM; THE SURGEON AND HIS
ASSISTANTS.
SURGERY has two objects, to prolong life and to
relieve suffering. If it accomplishes either of these
objects it succeeds. ‘To prolong life or to relieve suf-
fering divides operations into several classes, because
they occur with more or less urgency according to
the condition the patient is in.
We often hear it said of an operation that it is one
of necessity; of another, that it 1s one of emergency;
and of another, that it is one of expediency. For
convenience, operations-are divided into two classes.
First, operations of necessity; second, operations of
expediency; and the first class may be subdivided
into emergency and elective operations.
Operations of expedzency are those which it would be
well to perform for the health of the patient, as, for
instance, the removal of a malignant growth of the
breast. If left to itself, the growth will slowly and
eradually invade the internal organs and in a very
few years will end life; while if removed, the patient
will in all probability live a number of years, and
there may be immunity for a long period before the
disease returns.
131
132 SURGICAL TECHNIC.
Operations of zecesszty are performed to save the
life of the patient, as, forexample, in cases of intes-
tinal obstruction, in hemorrhage from rupture of an
extra-uterine pregnancy, etc.
Emergency operations are those which must be
performed immediately, without any choice, such
as tracheotomy. |
An elective operation is at the choice of the patient;
if it is done at all, itcan only be done as a last chance
and forlorn hope.
Preparation of the Operating-room.—The op-
-erating-room should be made as aseptic as possible;
the walls and floor should be washed with corrosive-
sublimate solution (1:2000). The operating-table,
stands, chairs, and other furniture, which are usually
of glass and iron, should be washed with the subli-
mate solution. ‘The sterilizer, which has been packed
with the dressings, blankets (2), sheets (2), towels,
caps, suits, and gowns for the operator, assistants,
and nurses, should be started two hours before the
operation. The instruments should boil half an hour
before the operation in a I per cent. soda solution.
Everything that will be needed for the operation and
for possible accidents must be in the operating-room,
and within easy reach. The solutions used should be
quite warm, both for the surgeons and patient. We
often come across a nurse who when she has filled
the basins will put in her dirty hand to see if the
water is too hot or too cold. We can readily tell
from the outside of the basin if the water is of the
proper temperature.
At all major operations four nurses are necessary—
the head nurse, who has charge of the instruments;
PLATE 3.
Clinical Amphitheater, Medico-Chirurgical
Hospital, Philadelphia.
|
.
|
er eee eee
PREPARATION OF THE OPERATING-ROOM. 133
a second nurse, to take charge of the sponges; a third
nurse, to keep ready for the operator a basin of ster-
ile water to enable him at any time to quickly rinse
his hands to remove septic fluid or to free his fingers
from blood and clots, and attend to the irrigation,
etc.; a fourth nurse, to handle unsterilized articles.
Each nurse should have a clear idea of her duties,
-and discharge them without undertaking the duties
belonging to another. If the dry technic is used, the
head nurse can hand the sponges as well as the in-
struments, and this gives auurse to wait on her exclu-
sively. Under no consideration should the head
nurse be left alone for a single moment, as the
operator might call for something which she, being
‘surgically clean,’’ could not touch, and so cause a
probable delay in the operation.
The duties of the nurses in the operating-room are
the same for all operations. The dress must be of
washable material, preferably white; it should be 3
fresh for the operation and as far as possible sterilized.
A dress that has been through the wards is not
clean; neither is one that has been worn a day or
half a day. ‘The dress-sleeves should be unbuttoned,
so that they can be rolled up above the elbow, to allow
the arms to be made as sterile as possible, and so
that the sleeves may not come in contact with any-
thing used in the operation itself. The finger-nails
must be cut short. On first going to the operating-
room the hands and forearms should be scrubbed with
a brush and green soap and running water as hot as can
be borne for ten minutes by the clock. The cleaning
of the finger-nails is very important, as many of us
would be surprised to find the large number of germs
134 SURGICAL ~TECHNIC.
taken from under the finger-nails as the result of one
cleansing.
The hands and forearms are then rendered absolutely
sterile by putting them first into a saturated solution of
permanganate of potassium until they are of a deep-
brown color from the tips of the fingers to the elbow,
then into a hot saturated solution of oxalic acid until
all the permanganate stain has been removed; they are
then washed in sterilized hot water, and finally are
soaked for three minutes in a solution of corrosive
sublimate (1 : 1000). The solutions reach those corners
and crevices in the finger-nails that cannot be reached
by the brush.
Some surgeons prefer ether and alcohol for cleans-
ing the skin. After the hands have been scrubbed
thoroughly in hot soap-suds and the finger-nails
cleaned, the hands are washed in ether, which re-
moves from the skin all oily and fatty substances;
they are next washed in pure alcohol for one minute,
and finally soaked for three minutes in a solution of
corrosive sublimate (1: 1000). ‘The field of operation
is cleansed in the same manner with ether, alcohol,
and the sublimate solution.
The nail-brushes used should be absolutely sterile.
They must be new, and need to be boiled for two
hours on the day before the operation, and then put
into a glass jar containing corrosive sublimate
(1 : 1000). A dirty nail-brush is the haven of myriads
of germs and their spores, and by using such a one
we place more germs on our hands than were there
before they were touched. |
In some hospitals it is the custom to put on ster-
ilized rubber gloves, to protect the hands from con-
PLATE*A,
Surgical Operating Room, Medico-Chirurgical Hospital, Philadelphia.
PREPARATION OF THE OPERATING-ROOM. 135
tamination until the operation begins. The nurses
next put on sterile caps and gowns. After mak-
ing the hands aseptic it is essential that they do not
come in contact with anything that has not been
made aseptic before the operation is commenced, for
such is very easy to occur unless the nurse is con-
stantly on her guard against it.
The surgeon and his assistants prepare for the
operation very much the same as does the nurse.
Many surgeons before operating take a corrosive-
sublimate bath (1:5000), after which they put on
clean linen suits or long gowns and prepare their
hands and forearms, after which they put on sterilized
-suits. The suits, which have been sterilized in bags
or folded in a sheet, are taken from the sterilizer by
the head nurse, and placed in the dressing-room about
one hour before the arrival of the surgeons, so that they
may be perfectly dry when required for use. They
should not be hung over the back of a chair, or laid
over a table for dust to collect upon them. We must
bear in mind that after sterilization there is always
the danger of contamination, and the articles must
be carefully protected as soon as they are removed
from the sterilizer. To avoid confusion, each suit
and bag should be distinctly marked with the owner’s
name, as should also the white canvas shoes which
some surgeons wear. ‘The caps must be laid in the
dressing-room, together with long strips of sterilized
gauze to cover the beard and mustache.
Spectators should remove their coats and wear long
linen gowns. The nurses should not leave the
operating-room unless it is absolutely necessary, and
there should be no unnecessary opening of doors,
136 SURGICAL TECHNIC.
which allows cold air to enter. Constant moving
also causes dust to become stirred up. The tem-
perature of the operating-room should be 80° F., and
the air kept perfectly pure by thorough ventilation,
which should be so arranged that draughts will be |
avoided.
With the kind permission of Dr. F. W. Johnston,
of Boston, I extract the following from his paper on
‘Two Years’ Work with the Sprague Sterilizer in
the Gynecologic Department at St. Elizabeth’s Hos-
pital, Boston, Mass.,’’? which shows the great neces-
sity of absolute cleanliness and how easily infection
takes place from dust in the room:
‘‘T was especially anxious to ascertain if any pus-
producing organisms should be found in the dust.
‘The operating-room is kept as clean as soap and
water and corrosive sublimate can effect the cleanli-
ness of its floor and walls.
‘The following is the report of E. A. Darling,
Assistant in Bacteriology, Harvard Medical School:
‘“Four Petri double dishes containing films of
sterilized and coagulated blood-serum were exposed
in various parts of the operating-room during a cel-
iotomy, the period of exposure varying from one hour
and twenty minutes to one hour and fifty minutes.
‘“The plates were exposed during the middle of
the forenoon of December 28, 1897.
‘“One dish was placed on the floor, where we sup-
posed the dust would be kept in the most active
notion by our feet and the nurse’s dress; one was
placed on the stand holding the sponge-pails; one
was placed on the patient’s knees raised in the Tren-
delenburg position; and one was placed on the table
ies
5
qi
b*
“2
.
4
r
;
;
PREPARATION OF THE OPERATING-ROOM. 137
beside the instrument-tray. The dishes were un-
covered just as the knife went through the skin.
“At the conclusion of the operation the dishes
were covered, conveyed to the bacteriologic labora-
tory, and placed in the incubator at 37° C. for several
days.
‘After twenty-four to seventy-two hours the plates
were opened and the colonies counted.
“At the same time an attempt was made to de-
termine the varieties of bacteria present, and_par-
ticularly to demonstrate the presence or absence of
the pyogenic forms.
‘“Cover-glass preparations and cultures were made
from as many different kinds of colonies as could be
distinguished.
‘The results are, in brief, as follows:
“Plate A. Sponge-table, exposed 1 hour 50 min-
utes: after 24 hours showed 216 colonies; 72 hours,
296 colonies.
‘“Plate B. Knees of patient, exposed 1 hour 20
minutes: after 24 hours showed 156 colonies; 72
hours, 280 colonies.
‘“Plate C. Floor, exposed 1 hour 50 minutes:
after 24 hours showed 296 colonies; 72 hours, 428
colonies.
‘“Plate D. Jzstrument-table, exposed 1 hour 4o
minutes: after 24 hours showed 216 colonies; 72
hours, 256 colonies.
‘The varieties of bacteria present were studied
‘minutely on Plate B (the one on the patient’s knee),
less carefully on Plate D (the one on the instrument-
tray). Of the recognized pyogenic cocci, two varie-
ties were found—the Staphylococcus albus (15 colo-
138 SURGICAL TECHNIC.
nies on Plate B, 20 colonies on Plate 1D) anda
Staphylococcus aureus (3 colonies on Plate B, 4 colo-
nies on Plate D).
‘“The remaining colonies on both plates were sar-
cinze of several kinds, yellow, orange, and white
moulds, and several varieties of unrecognized bacilli
and cocci.
‘‘As would be expected, the plate from thesfloor
showed the largest number of colonies. Plate B (the
one on the patient’s knee) most interested ine.
‘The finding by Dr. Darling of fifteen colonies of
the Staphylococcus albus and three colonies of the
Staphylococcus aureus on this small plate within a
few inches of the opened abdominal cavity was cer-
tainly a grand object-lesson, and has given lots of
food for reflection.”
Chet Rh cE.
PREPARATION OF PATIENT FOR OPERATION ;
CARE OF PATIENT DURING AND AFTER
OPERATION.
THE methods given here for preparing the patient
for abdominal operations may serve as a reliable
euide to the nurse, who is more or less responsible
for preparatory treatment. ‘The methods of prepara-
tion of all kinds are subject to change in detail,
because surgical methods are constantly advancing
and changing, though the general principles remain.
It should be remembered that patients rally much
better from an operation when they have been
properly prepared both externally and internally.
Day Before Operation.—The patient receives a
full bath and the hair is washed. A cathartic is
given—castor oil, citrate of magnesium, or salts.
The diet should be nourishing and light. Milkis not
given before an abdominal operation, because the
stomach may not digest it thoroughly, and its curds
may reinain in the intestines and ‘act as an irritant.
Gruel is nourishing and easily digested. No food ts
given after midnight.
PREPARATION OF FIELD OF OPERATION.
I. Scrub the parts with green soap and stiff brush.
2. Shave from nipples to rectum.
139
I40 , SORGICAL SECHINVIE.
3. Scrub again and rinse thoroughly with sterile
water. |
4. Rub well with alcohol, followed with ether, to
remove fats.
5. Wash with corrosive sublimate (1 : 1000), and put
on an antiseptic dressing, consisting of five dressing-
pads, one layer of common cotton, one dressing over
that, then abdominal binder. ‘The patient must be
instructed not to put her fingers underneath the
dressing nor to disturb it in any way.
Prepare the vaginal canal by giving a warm
douche (lysol, 1 per cent.), and cover the vulva with
a dressing. Use perineal straps to keep the dress-
ing and abdominal binder in position. See that the
dressings are kept wet with the antiseptic ordered
until the patient 1s taken to the operating-room.
This preparation should be made twelve hours before
an operation.
Some surgeons will direct the application of a
poultice of green soap, which 1s removed early on the
morning of the operation, the part being scrubbed
with hot water and a brush to remove the soap, a
warm corrosive-sublimate poultice (1 :1000) being
then applied. A green-soap poultice is a thin layer
of green soap spread over a pad of gauze, absorbent
cotton, or a towel, and covered with a dry towel and
a bandage. The antiseptic pad, or the ponlives
thoroughly softens the scarf-skin, which in about
twelve hours can be scrubbed off, leaving the true
skin.
Biniodid of mercury is sometimes dissolved in
the ether, making a solution of 1:1000, whieh
besides removing all fatty substances from the skin, is
ARRANGING THE PATIENT. I4I
also a disinfectant. When the skin 1s very dirty it 1s
scrubbed with turpentine, then with alcohol, and
then with the biniodid solution. The nose and mouth
should be thoroughly sprayed with a saturated solu-
tion of boric acid every three hours.
Day of Operation.—Flush out the colon and
give a bath; take off all flannels, put on a gown open
at the back, and cotton-flannel stockings. Cleanse
teeth, mouth, nose, and throat with a boric-acid solu-
tion and brush. Catheterize just before sending the
patient to the anesthetizing-room if the operation is
on the uterus or its appendages. Always catheterize
in other operations if the patient is unable to urinate.
Envelop the hair in a sterilized towel.
Remove all rings and ear-rings; also false teeth,
whether a whole or a partial set, as there 1s danger
of their being swallowed, and put them in a tumbler
of cold water. Envelop feet and lower limbs in a
warm blanket securely pinned around the hips with
safety-pins. Besides preserving the heat, this ar-
rangement will prevent the patient from tossing the
limbs about while taking the anesthetic. Many
operators give morphin (grain +) and atropin (71)
of a grain), hypodermically, half an hour before
the ‘operation, to stimulate the heart and prevent
vomiting.
_ Arranging the Patient for the Operation.—
The patient having been placed on the operating-
table, the clothes are removed from the part to be
operated upon, and sterilized blankets are tucked
about the chest, the edges being tucked under the
back to reduce as far as possible the loss of body-
heat, and the bandage and pad are removed from
142 SURGICAL TECHNIC.
the field of operation, which is again thoroughly
cleansed with soap and water and disinfectants. An
assistant nurse hands the sterilized water, green soap,
and scrubbing-brush to the assistant surgeon. ‘The
soap-suds are rinsed off with sterile water, after which
the part is sponged with permanganate of potassium,
oxalic acid, lime-water, and sterile water, or with
ether, alcohol, and bichlorid solution. ‘This final
scrubbing should be done in the anesthetizing-room
if possible, while the patient 1s being anesthetized,
to avoid delay in the operating-room. A sterilized
sheet, having an oval opening in the center through
which the section is made, and towels are then
arranged around the field of operation. One towel is
laid along the side, turned over and fastened with
clamps to the sheet, so as to form a pocket in which
the surgeon places the instruments he needs to have
close at hand. The instruments are taken from the
sterilizer and laid in trays containing sterile water or
laid upon dry sterile towels.
Some surgeons use the prepared sponges. ‘These
must be reliably counted before the operation by the
operator and assistants, and the number written down,
so as not to trust to memory. Sponges must be
squeezed alinost dry before they are handed to the
surgeon, because it 1s only in an almost dry condition
that they are of service. The nurse should not,
while waiting to hand a fresh sponge, rest her hands
or forearms: on the pail. She should count. ite
sponges before the surgeon begins to sew up the
wound, and should be very sure that she has the
exact number employed in the operation. ‘The large -
square sponges used for covering the intestines, or
ARRANGING THE PATIENT. 143
walling off small areas, should have a long piece of
silk attached, and to this a forceps, so that if one
should slip out of sight it can be readily located and
recovered without undue handling of the bowel.
After being used, the sponges are put into a pan or
basin, and should not be disposed of until they have
been accounted for before the abdomen is closed.
Whatever has been removed from the body must be
placed in a basin and laid aside in a safe place until
the surgeon gives his directions as to whether or not
he wishes it to be sent to the laboratory for examina-
tion to make sure of its character, with a view to
clearing up some obscure point about the nature of
the disease.
The head nurse attends to the instruments, sutures,
and ligatures. If the dry technic is used, a basin
of dry gauze sponges is placed on a table within easy
reach of the operator’s assistants.
The assistant nurses must be on the alert to change
the hand solutions when necessary, and to wipe the
moisture from the face of the operator and his assistant
with a sterilized towel, to prevent drops falling
into the wound, and this must be done at a moment
when the surgeons are not bending over the wound.
They must move about the room very quietly but
quickly. If asked to do anything that they do not
understand, they should always inform the head nurse,
who will make the duty clear. When emergencies
arise and the operator is dealing with exceptional
difficulties, the nurses must be on the alert to do
quickly anything they may be called upon to do,
each nurse discharging her duties without under-
taking those belonging to another. It is absolutely
144 SURGICAL TECHNIC.
necessary on such occasions to exercise self-control,
and to follow the directions given without excitement
or confusion.
Just before the wound is closed the soiled towels
are retnoved and replaced by fresh ones. After the
dressing has been applied the patient is raised, wiped
perfectly dry, and a bandage put on. While the
patient is waiting to be transferred to bed, hot-
water bottles, well covered, should be applied to all
parts of the body. The blankets used to cover the
feet and chest of the patient during the operation
should be tucked closely about the body and under-
neath, and not merely be thrown over.
Pneumonia and pleurisy after operation may follow
as the result of chilling when in the operating-
room, or exposure during the removal from the oper-
ating-room to the patient’s room.
When the patient 1s replaced in bed, which has
been thoroughly warmed during the operation, the
nurse should be present to take charge. ‘The pillow
should be removed, and a towel placed for the head
to rest upon. The foot of the bed is elevated, this
posture being maintained for twenty-four hours, after
which the bed is lowered. The heaters are placed
about the patient’s body, one thing being kept con-
stantly in mind—not to burn the patient. A towel
should be placed under the chin of the patient, and
a small basin should be at hand to receive the vomited
mucus, and this should be removed during quiet
intervals. Postanesthetic retching and vomiting may
be relieved by saturating a towel with fresh, strong
vinegar and holding it a few inches from the patient’s
face, laying it over the nostrils, or hanging it from
ARRANGING THE PATIENT FOR THE OPERATION. 145
the bedstead so that it will be near the patient’s
head. Oxygen hastens the recovery of consciousness
and lessens the nausea. If administered with the
anesthetic, there is almost complete absence of nau-
sea—usually none as soon as the patient is fully con-
scious.
Dryness of the mouth and lips, and thirst (which
is often a troublesome feature), may be relieved by
placing wet cloths on the lips, by allowing the patient
to rinse out the mouth with cool water, and by fre-
quent bathing of the hands and face with alcohol and
tepid water or with plain water. If thirst is extreme,
an enema of saline solution (one pint) is given
slowly.
The patient should not be left alone for a single
moment during the first thirty-six hours after an ab-
dominal section if it can be avoided. The patient
can do nothing for herself, and every want should be
instantly supplied. I have known patients so eager to
allay their thirst that they would get out of bed and
drink water from the water-pitcher on the-wash-stand
and reach down for the hot-water bottle at the feet and
drink part of the contents. One ward patient drank the
water from an irrigator standing by the side of the
next bed; another patient while in a semiconscious con-
dition took the drainage-tube out of the abdomen, and
when found by the nurse after a moment’s absence
from the room was sitting up on the edge of the bed.
Watching a patient recover from anesthesia is often
monotonous; but if this duty is closely attended to,
many dreadful accidents will be avoided.
A roll should be placed under the knees, so as to
relax the abdominal muscles and also te remove the
10
146 SURGICAL TECHNIC.
strain the patient would have to make in order to
keep up the knees. A small flat pillow placed under
the hollow of the back will relieve the backache of
which so many patients complain.
Bladder and Bowels.—The catheter should be
passed every six or eight hours if necessary, accord-
ing to directions, the most rigid aseptic precautions
being taken. Flatulence may be very distressing;
consequently passage of gas by the rectum is of good
omen, as it shows that the bowels have regained their
normal tone and there is no obstruction. After an ab-
dominal operation the muscular walls of the intes-
tines share in the weakness of the patient, and are
not strong enough to overcome the contraction of the
sphincter muscle. The accumulation of gas distends
the muscular fiber of the intestines, and, if not re-
lieved, would soon result in paralysis of the intes-
tines. To prevent this a rectal tube is imserkeamies
keep the sphincter dilated and to allow the gas to
escape when it reaches that point. Purgatives, such
as calomel (grain 1 every hour until 1o grains have
been taken), are usually given as soon as possible
after the patient has recovered from the anesthetic,
to stimulate the intestines, and keep up peristaltic
action.
Much fluid is not given for a certain number of
hours after the operation, as it might cause vomit-
ing, and also because, as we have seen, bacteria
require heat and moisture for their development.
If they can lie in a small pool of fluid, they will de-
velop rapidly. We cannot deprive them of warmth
unless we almost freeze the patient, but we can
deprive them of moisture. Should any bacteria
BLADDER AND BOWELS. 147
have found their way during the operation into the
abdominal cavity, they will be rendered inert by
the absence of moisture, and will be taken by the
leukocytes into the lymphatic vessels and glands and
be devoured.
After twelve hours, if there is no vomiting, very
hot water, or toast-water is given in teaspoonful
doses every fifteen or twenty minutes, the quantity
being gradually increased and the intervals length-
ened. ‘The familiar cup of freshly made tea is some-
times the best drink to begin with; it is always:a
pleasure under the circumstances to see the patient
enjoy it, since it is not only refreshing but stimu-
lating. If the stomach behaves well, tablespoonful
doses of gruel or beef-essence may be given every
half hour. Miulk is not given asa rule, as the curd
may pass along the intestines and act as an irritant.
For the first three days, and if there is no vomiting,
nothing but liquids is given; and after the third day
soft and easily digestible food, which is gradually
changed to a more solid diet.
The external genitals should be kept perfectly
clean, ‘the body bathed, the bed and body-linen kept
sweet and clean, the teeth brushed, and the hair
coinbed. Every want of the patient should be an-
ticipated, and she should be made as comfortable as
possible. Sponging the palms of the hands, the
arms, and the legs will add to the comfort of the
patient. The luxury of a change into a fresh bed
will often secure a good night’s rest. Under no con-
sideration should morphin be given except by the
surgeon’s directions, and every moral influence should
148 SURGICAL TECHNIC.
be exerted to induce the patient to endure pain rather
than resort to the drug. |
The nurse should not ascertain whether the patient
is comfortable by continual questioning, but by unob-
trusive observation. Questioning may alarm a patient
and lead her to think too much about herself.
No visitors should be admitted without the sur-
geon’s consent. ‘The mind of the patient ase6epe
kept perfectly free from worry and excitement, and
the whole atmosphere of the room should be bright,
pleasant, and cheerful, no matter what trouble is
going ou outside.
A slight rise of temperature the day following oper-
ation usually marks reaction from shock. On the
eighth day the dressings are removed and the stitches
taken out. The following week the patient sits up,
and at the end of the third week she goes home.
The following diet-list dating from the third day
will be of assistance in varying the food.
Birsr DaAy:.
Breakfast.—Mutton-broth with bread-crumbs.
Lunch.—Mailk-punch.
Dinner.—Raw oysters, thin bread (with crust re-
moved) and butter, sherry wine.
Lunch.—Cup of hot beef-tea.
Supper.—Milk-toast, jelly.
SECOND Day.
Breakfast.—Oatmeal with sugar and cream, cup
of cocoa.
Lunch.—Sott eustand:
Dinner.—Small piece of tenderloin steak, chewed
but not swallowed, baked potato.
z DIET-LIST. 149
Lunch.—Glass of milk.
Supper.—Buttered milk-toast (crust removed),
jelly, cocoa.
THIRD DAY.
Breakfast.—Soft-boiled egg, bread and _ butter,
coffee.
Lunch.—Milk-puich.
Dinner.—Chicken-soup, tender sweetbreads, Ba-
varian cream, light wine.
Lunch.—An egg-nog.
Supper.—Tea, raw oysters, bread and butter.
POuURTH - Day.
Breakfast.—Oatmeal with sugar and cream, a ten-
der sweetbread, creamed potatoes, coffee, graham
! bread and butter.
Lunch.—Glass of milk.
Dinner.—Chicken panada, baked potato, bread,
tapioca-creaim.
Lunch.—Cup of hot chicken-broth.
Supper.—Buttered dry toast (crust renioved), wine
jelly, banquet crackers, tea.
Pinte DAy:
Breakfast—An orange, scrambled egg, oatmeal
with sugar and cream, soft buttered toast, coffee.
- Lunch.—Milk-punch. :
Dinner.—Cream of celery soup, a small piece of
tenderloin steak, baked potato, snow pudding, wine,
bread.
Lunch.—An egg-nog.
Supper.—Calf’s foot jelly, soft-boiled egg, bread
and butter, cocoa.
150 SURGICAL . SECHINIC.
’ SrxtH DAY.
Breakfast.—Oatmeal, poached eggs on toast, coffee.
Lunch.—Cup of chicken-broth.
Dinner.—Chicken-soup, small slice of tender roast
beef, baked potato, rice-pudding, bread.
Lunch.—Glass of milk.
Supper.—Baked apples, raw oysters, bread and
butter, orange-jelly, tea.
SEVENTH DAY.
Breakfast.—Orange, mush and milk, scrambled
eggs, cream-toast, coffee.
Lunch.—Cup of soft custard.
Dinner.—Mutton-soup, small piece of tender beef-
steak, creamed potatoes, sago-pudding, bread, wine.
Lunch.—Cup of beet-tea:
Supper.—Sponge-cake with cream, buttered dry
toast, wine-jelly, cocoa.
EIGHTH Davy.
_ Breakfast——Broiled fresh fish, oatmeal, graham
bread, coffee.
Lunch.—Chicken-broth.
Dinner.—Potato-soup, breast of roasted chicken,
inashed potatoes, macaroni, blanc mange.
Lunch.—Cup of mulled wine.
Supper.—Cream-toast, lemon-jelly, chocolate.
The diet for other days may be selected from pre-
vious ones. The change of diet may cause a tem-
porary rise in the temperature and pulse.
CEA DB Po
SEQUEL4Z OF OPERATIONS; SHOCK, HEMOR-
RHAGE, SEPTIC PERITONITIS, ACCIDENTS
DURING OPERATION, ETC.
As a rule, the average abdominal case passes into
convalescence, especially when the case is in skilled
hands and the operation has been performed in a
finished surgical way. Complications, however, are
liable to arise in the simplest case, and throw great
responsibility on both surgeon and nurse. It is in
these cases that the knowledge and skill of the nurse
mean so much, and where the greatest triumphs of
surgery are scored.
A nurse has no moral right to take charge of a
surgical case unless she has at her fingér-ends the
complications liable to arise, their symptoms and the
various means of meeting them until the arrival of
the surgeon.
Shock is great depression of the vital functions
of the body brought on by injury or surgical opera-
tion. It is produced through the agency of the ner-
vous system. ‘The greater the injury, the longer the
anesthesia, the greater the shock. ‘The anesthetic
enables the patient to undergo the operation without
consciousness, but it does not prevent shock coming
on afterward from the opening of the abdomen, the
uncovering of the viscera, the handling of the intes-
tines, and the exposure of the delicate sympathetic
151
152 SURGICAL TECHNIC.
nerves -in that part to the air and to touch. If fo all
this is added a long anesthesia, then the prostration
produced by the anesthetic is added to the effects of
the operation.
Different individuals are differently affected: most
persons are more susceptible to shock after months
of hard work, or when the system is run down after
an illness. Invalids stand shock very well, and in-
different persons stand it better than those who are
despondent. The mental influence is very great:
anything that depresses the mind aggravates shock.
It 1s here that the offices of the Church have such
an effect on some patients, in quieting apprehension
and in adding fortitude.
Age modifies shock. In old people shock is
usually more severe and prolonged, especially if
there is. any organic disease. Children @cemmen
readily from shock if there has been very little loss
of blood. Shock is combated to a certain extent by
the patient’s drinking a large amount of fluid for
forty-eight hours before the operation, so that the
blood-vessels of the vital organs will be well supplied
with fluid during the operation. Experiments have
been made which show that when the abdomen is
‘opened the abdominal veins dilate, and as a conse-
quence a large amount of the blood in the body flows
into them, thus leaving the heart and the vessels con-
veying blood to the important nerve-centers at the
base of the brain with very little fluid to work upon,
and shock ensues. The output of the heart, as we
know, is in proportion to the venous pressure, and
if this is lowered the heart and the important nerve-
centers at the base of the brain will be supplied
SHOCK. 153
with a diminished amount of blood. The intra-
venous injection of saline solution causes a rise in
the venous pressure and an increase in the output of
the heart. ‘The signs of shock may be and have been
mistaken for those of hemorrhage on account of the
two presenting so many points of likeness; but in
shock the symptoms are present from the first, while
in hemorrhage they do not come on for some hours
after the operation.
Two very important points to be considered in case
of shock or of hemorrhage are the temperature and
the condition of the patient’s mind. In shock the
temperature at first is normal or very little below nor-
mal, and the senses are dull in proportion to the degree
of shock present; in hemorrhage the temperature is
subnormal, the mind is bright, keen, and alert, and
there is an anxious expression on the face, as if the
patient were anticipating danger.
The symptoms of shock are a weak, rapid, and ir-
regular pulse; sighing, rapid, irregular, and shallow
respiration; a normal or slightly subnormal tem-
perature; a pale face with a pinched look; a cold,
Serseity skin, and dulness of the mind. ‘There
may be involuntary movements of the bowels and
urine as a result of loss of muscular power; nausea
and vomiting may also be present.
The treatment of shock consists in lowering the
patient’s head and raising the foot of the bed, to in-
crease the supply of blood to the vital centers; in
the application of heat to all parts of the body,
particularly the sides, between the legs, and to the
feet; in placing a mustard-plaster over the heart;
in administering whiskey, brandy, or nitroglycerin
154 SURGICAL TECHNIC.
hypodermically; in giving hot black coffee by the
rectum, or saline solution hypodermically or by
the rectum. Strychnin is a powerful stimulant, and
should be given in doses of 35 grain every half hour
for four doses. Tincture of digitalis in 15-minim
doses may be given every half hour for four doses.
As a rule, in cases of shock there is a disposition
on the part of nurses to do too much. Everything
must be done ina prompt, quiet manner. For imme-
diate stimulation in threatened collapse nitroglycerin
is valuable. It is used for quick effect only, and
not for prolonged stimulation of the heart’s action.
Stimulants must be given carefully, and time
allowed to observe the effects produced, other meas-
ures being determined accordingly. An enema of
one-half ounce of turpentine, a well-beaten raw egg,
and three ounces of warm water constitutes a power-
ful stimulant.
It must be remembered that in severe shock the
function of absorption by the stomach and intestines
is almost wholly suspended, and anything given by
the rectum must be introduced high up. When the res-
piration of the patient is fast failing, everything de-
pends on maintaining the heart’s action. To this
end artificial respiration must be persistently prac-
tised. A serious danger in performing artificial res-
piration is that in our hurry we may make the
notions too rapidly and not give the lungs time to
fill thoroughly nor allow the air to be expelled before
filling the lungs again. ‘The motions should not be
more frequent than sixteen to eighteen in the min-
ute, so as to imitate as nearly as possible the nat-
ural rhythm of respiration. External heat is a most
HEMORRHAGE. 155
powerful heart-stimulant, and often when the heart’s
action fails it may be restored by heat over the heart
and by hot fluids taken into the stomach.
Recovery may be rapid or very slow; it is mani-
fested by ‘‘reaction’’—the pulse becomes more full,
slow, and regular, the temperature rises, the body
becomes warm, and a general improvement takes
place. In rare cases the reaction becomes excessive
and develops into traumatic delirium, which may be
mild, low, and muttering, or of the wildest character.
The skin is hot and flushed, the pulse full and regu-
lar, and the temperature above normal. This condi-
tion may subside and recovery take place, or it may
be followed by collapse.
Hemorrhage may be caused by the slipping of a
ligature or by the displacement of clots, as the result
of restlessness or reaction of the circulation, and
generally occurs within the first twenty-four hours
after the operation. ‘The hemorrhage which comes
from torn adhesions and bleeding surfaces is a
free oozing, and seldom affects the pulse. When a
drainage-tube has been used, it will usually indicate
fiat, tere is hemorrhage by a flow of ° blood
through the tube. This, however, cannot be relied
upon, as only a moderate quantity of blood may
flow through the tube, the abdomen being filled
with clots.
The symptoms of internal hemorrhage are restless-
ness, thirst, faintness, an anxious expression, pale
face, dilated pupils, cold skin, frequent and irregular
or sighing respiration, subnormal temperature, and a
weak, rapid pulse (120-140). In rare cases the pulse
is not greatly accelerated.
156 SURGICAL TECHNIC.
Treatment.—The patient must be kept perfectly
quiet on her back, the head being lowered and the
foot of the bed elevated. If symptoms of shock
supervene, heat is to be applied to all parts of the
body by warm blankets and hot-water bottles.
Stimulants are given only when the pulse is failing,
as they excite the heart’s action and increase the
hemorrhage. When the hemorrhage has been exces-
sive, infusion of saline solution is resorted to, the
fluid that the body has lost being thus replaced.
Bandaging the limbs from their extremities upward
is sometimes of use in keeping the blood in the vital
organs. When the hemorrhage comes from a slipped
ligature with large vessels pouring blood into the
abdominal cavity, the abdomen is reopened and the
vessel ligated. Everything should be ready for
operative interference when the surgeon arrives, the
same aseptic precautions being observed as in the
original operation. For the free oozing from torn
adhesions the tube is emptied frequently—every ten —
minutes. .The drier the pelvic cavity 1s kepiyieie
sooner will the hemorrhage cease.
A noted surgeon has said that if an abdominal case
escapes shock or hemorrhage, there is still a third
danger to which the patient is liable, that of septic
peritonitis. This is due to the entrance of germs
into the peritoneal cavity, either from without or
from ruptured abscesses or wounds. It may set in
at any time from a few hours to six days after ope-
ration. ‘The symptoms are pain in the abdomen and
exquisite tenderness, distention, vomiting, constipa-
tion, icterus, restlessness, sleeplessness.
The temperature rises a little, rarely going for a
soll Le tie Ice Ste
:
HEMORRHAGE. fay,
few days above 100° or ro1° F.; but the pulse creeps
up rapidly to 115, 120, or 130 beats per minute, and
is weak and thready; although sometimes it is hard
and ‘‘wiry’’ in the beginning. Then the temper-
ature rises to 103° F. or above. ‘The rectal or vag-
inal temperature may show a much higher rise than
that of the mouth or axilla. In one typical instance
the temperature taken in the mouth ranged between
Tor° and 102° F., the skin was cold and clammy,
and the patient complained of intense thirst and a
‘“burning up’’ feeling. The vaginal temperature
was 108° F. In some of the worst cases the writer
has seen the temperature was below normal, but the
prostration was severe. The abdomen is distended,
due to distention of the transverse colon by gas.
There are nausea and vomiting. First the contents of
the stomach are vomited, then bile, then a dark coffee-
colored fluid which becomes more and more fecal in
odor; a cold perspiration appears; the patient has a
very anxious, pinched expression, and is restless and
talkative; the eyes are unusually bright, and there 1s
a faint vellowish look about the skin and conjunc-
tive. As the disease continues the general system
becomes poisoned.
The ¢reatment consists in ridding the system of
the poison through the skin, bowels, and kidneys.
High enemata of turpentine, glycerin, oil, salts, or
molasses are usually given until the bowels are
thoroughly moved or large quantities of gas are
passed, because it is by putting the bowels into an
active state that the threatened paralysis of the intes-
tines can be overcome, and they can take up from
the peritoneal ‘cavity the poisonous materials that
158 SURGICAL. TECHNIC.
are causing the disturbance. It is only when the
intestines are so paralyzed that they cannot be moved
that a fatal result ensues. Strychnin, being a power-
ful heart-stimulant, is given in doses of grain 3
every hour until its physiologic effects are pro-
duced... It must be stopped at the irstapg@eae
ance of twitching of the muscles of the face or
of the limbs and stiffness of the neck. Vomiting
may be relieved by washing out the stomach, by
the application of a mustard-plaster over the region
of the stomach, or by cocain in \%-grain doses for
four doses. If improvement does not follow, the
surface of the body becomes cold and clammy; the
face pinched and sunken and of a dusky hue; the
restlessness increases, also the thirst, which becomes
very great, and to the last the patient calls for water,
which is vomited immediately after being taken, but
which it is cruel to withhold. The mind usually
remains clear to the end.
Antistreptococcic serum has been used with fairly
good results. It comes in glass tubes, sealed her-
metically, and is injected hypodermically with an-
tiseptic precautions into the thigh or the side of the
breast, where there is considerable loose subcuta-
neous connective tissue. Another procedure of value
is infusion of normal saline solution for the purpose
of diluting the toxins in the blood and of removing
them by the increased flow of urine which infusion
brings about. |
Tympanites is often one of the earliest signs of
septicemia, and when accompanied with a high tem-
perature is usually a cause for anxiety, though it may
be due to constipation, and in such cases is usually
— ee
SINUS. 159
without significance. ‘The treatment consists in the
application of turpentine stupes, the use of brisk
purgatives or high enemata, and the insertion of the
rectal tube for about ten inches.
Fermentation-fever is due to the absorption of
fibrin-ferment and the products of aseptic tissue-
necrosis. It causes a slight rise in temperature
which need occasion no anxiety.
Intestinal obstruction may be due to strangula-
tion of a knuckle of intestine beneath inflammatory
bands, or to its enclosure between the sutures in the
wound. ‘There is usually distention of the abdomen.
Note should always be made if gas is heard rumbling
in the intestines, and also if gas is passed and how
often; also the result of the enemata which are ad-
ministered to relieve the distention.
Hernia is a sequel rather than a complication of
abdominal operations, and is due to a failure of union
between the cut edges of the muscles and fascie.
Asa tule, it does not occur until some weeks after
the patient has returned home. It is to prevent this
accident that such stress is laid upon not allowing
the patients to help themselves in any way without the
surgeon’s permission, so that the abdominal muscles
may have sufficient time to become firmly united.
This is also the reason why patients should wear an
abdominal supporter for some months after their dis-
eieeec. If hernia occurs, it is usually treated by a
secondary operation.
A sinus is often caused by imperfectly sterilized lig-
atures, which may cause an abscess around the point
of ligation. This abscess may discharge itself into
the intestine or vagina, or into the tract occupied by
160 SURGICAL TECHNIC.
the drainage-tube through the abdominal wall. The
sinus keeps open until the ligature is discharged or
removed by another operation.
Accidents during Operation.— Many times in dif-
ficult abdominal or vaginal operations the walls of the
bladder may be torn, or one of the ureters or the in-
testine may be injured. When the ureter or bladder
is injured, the urine sometimes passes through the
incision to the dressing. This is called a urinary
fistula. When the intestines are injured, fecal matter
isdischargedthroughthe wound. Thisisa fecal fistula.
Vaginal hysterectomy is the most serious of vagi-
nal operations, but the nursing is the same as every
operative case requires.. If clamps are msedseiew
usually remain attached for forty-eight hours. ‘The
handles are usually supported on a pad of absorbent
cotton. In the handling of the clamps great care
must be used, as, for instance, when the patient is
lifted on the bed-pan one nurse should lift the clamps.
Hysterectomy is the complete removal of the
uterus and ovaries, either through the vagina (vagi-
nal hysterectomy) or through the abdomen. Regard-
ing the question of insanity which may follow a hys-
terectomy or the removal of a large fibroid tumor,
one must know that a large amount of blood is
taken from the body ; that the cutting and tying of
the large blood-vessels alter the circulation ; and that
the operation is also more or less a shock to the
nervous system, and may affect the brain. Insanity
is zot a complication of this operation, the recovery
from which is usually rapid ; but. when insanity does
set in, this is commonly the cause, and the patient
generally recovers.
CHAP EER XVI
OPERATIONS IN PRIVATE PRACTICE.
IN private practice the preparation of the patient is
just the same and should be carried out as thor-
oughly asin a hospital. If it 1s not possible within
twenty-four or thirty-six hours to make the prepa-
ration, then we cannot say that our attempts. to
obtain asepsis approach perfection. In emergency
cases when there is not sufficient time to permit a
thorough cleansing, freedom from sepsis is not so
certain, and these cases do not cause the same anxiety
as those that are sent to a hospital, where every effort
to obtain complete asepsis is made. We must remem-
ber, in making the preparations, to make as little
bustle and noise as possible, and to carry on the
preparations in a quiet and cheerful manner, so as not
to frighten the patient and family. When the sur-
geon and his assistants arrive they must be shown
to a room in which they can change their clothing.
The patient is not anesthetized until everything is
in readiness. :
One difficulty which a nurse will have to encounter
in private practice is likely to trouble her a great deal,
inasmuch as she will find surgeons who conduct de-
tails of cases in a way to which she is not accus-
tomed, and which may appear to her wrong, and
which indeed may very often be crude and unscien-
1 161
162 SURGICAL TECHNIC.
tific. In these cases she should not be too ready to
show her superior wisdom and instruct the surgeon,
and inform him under whom she received her train-
ing, because there is not the slightest likelihood that
he will act upon her suggestions, but will naturally
be offended.
The directions for preparing for the operation
will be given by the surgeon in charge. In some
houses there may be a separate room for the opera-
tion, while in others the nurse will have to pre-
pare the patient’s bedroom. In the latter case the
brightest end of the room must be selecteei aims
the operation, to afford the surgeons plenty of light.
A screen must be put up before the bed, so that the
patient will not see the preparations. ‘The nurse
should remove from the room all movable furniture;
lay oilcloths or newspapers covered with a damp
sheet on the carpet, and pin them: securely to it,-amd
fasten a curtain across the window, so that the opera-
tion cannot be viewed from the opposite side of the
street. The remaining furniture and window-frames
should be washed with carbolic-acid solution (1 : 60),
and on the morning of the operation showld@he
mopped with a cloth wrung out of the solution. The
articles necessary for the operation can be placed on
the operating-table, covered with a sterile sheet, and
be left outside the room until the patient is partly
etherized,. when they may be carried in.
If a separate room can be had, one with a northern
light is to be preferred; and if possible it should be
neat the bath-room. Unless the nurse has twenty-
four hours’ notice in which to prepare the room
OPERATIONS IN PRIVATE PRACTICE. 163
for operation, it should not be disturbed, because
if swept and dusted immediately before the opera-
tion dust is stirred up and the air is so filled with
germs that it would not be safe to open the ab-
domen in the room. If the nurse has a few days in
which to prepare for the operation, all unnecessary
furniture should be removed, the hangings taken
down, the room thoroughly swept, and the walls and
remaining furniture washed with carbolic-acid solu-
tion (1:60) and exposed to the action of the sun and
air for about twelve hours, when the windows are to
be closed, the room thoroughly dusted with a damp
cloth and not again disturbed. The 4ztchen, if not
too remote, makes the best operating-room ; it is
warm, hot and cold water are close at hand, and
there is no danger of soiling carpets or hangings.
A word regarding the bed. If possible, it should
be an iron bedstead with a fresh horsehair mattress
and pillow. ‘The tall wooden bedsteads which we
so often find are perhaps heirlooms which have wit-
nessed every illness that has visited the family, and
also the deaths. They cannot be disinfected so
thoroughly as can iron bedsteads. |
The operating-table should not be wider than
twenty-five inches nor higher than _ thirty-seven
inches, because if low and wide the surgeon will have
to stoop and bend forward. A kitchen-table, or a
dining-room table with the leaves hanging, and a
small table at one end for the patient’s head, or two
dressing-tables, one placed across the head of the
other, will make a good narrow operating-table; or
three chairs, with two planks, a leaf from an exten-
164 SURGICAL TECHNIC.
sion-table, or an ironing-board laid across them, may
suffice.
The table may be covered with rubber enaae oil-
cloth, two sheets, and a blanket. A word of caution
here: the nurse should not use any old blanket or
comforter to cover the operating-table, for it is likely
to be filled with germs.
Two wooden chairs should be at hand in case the
Trendelenburg position is necessary, and two wooden
boxes for the surgeons to stand upon when using this
position.
The evening before the operation the nurse should
boil a washboiler full of water and then fill covered
pitchers, the washboiler and pitchers having first been
made thoroughly aseptic. The water is conveyed
from the boiler tothe pitchers by means of a perfectly
clean pitcher or tin ladle
On the morning of ee operation there should be
sterilized in the boiler or in an oven six sheets, two
blankets, twelve towels (not new). The heat should
be kept up for fully one hour before the operation.
_ The dry technic, by which is meant the use of dry
sponges and gauze, is usually employed in private
practice, especially when the water-supply is at all
questionable. |
There will be needed several clean recently boiled
basins for the various solutions, ete. Two tables will
be neéded—one for the instruments, the other for the
assistant. They should be covered with freshly
washed and ironed sheets or towels. There will also
be needed a pail or a washtub for the soiled water,
a tin dish or a flat bake-pan for the instruments,
:
;
OPERATIONS IN PRIVATE PRACTICE. 165
brandy, a hypodermic syringe filled with the re-
quired solution, usually strychnin sulphate (5'5 grain),
a small tumbler, a Davidson or a fountain syringe,
table-salt for salt-solution, safety-pins, two new nail-
brushes, ready for use in a 1:40 carbolic acid soiu-
tion, castile soap, green soap, a razor, hot-water
bottles, two blankets, alcohol, vinegar, and matches.
The surgeon will bring the necessary dressings with
the instruments, which must be sterilized in the same
way as in the hospital.
The instruments are to be wrapped in a towel and
allowed to boil for ten minutes in a saucepan, tin
pail, or a fish-kettle of boiling water, to which have
been added two teaspoonfuls of washing-soda to each
pint of water, to prevent rusting. One end of the
towel must be left hanging out of the kettle as a
handle by which to lift out the instruments. The
pail of water should be on the fire and the water
boiling when the surgeon arrives, so that the instru-
ments can be put in at once.
Meethe nurse is asked to-give the anesthetic, she
should not attempt anything else. None but novices
give the anesthetic and watch the operation. The
experienced anesthetizer constantly watches the
patient. If the nurse is asked to assist the surgeon,
she must be neither too enthusiastic, nor too quick,
nor too slow. When the operation is over her duties
will have nothing peculiar about them. She must
see the patient safely out of the anesthetic influence,
and carry the case along as she would any other.
Sometimes a nurse is called to an emergency oper-
ation in a very poor family, where there are no con-
166 SURGICAL. TECHNTC.
veniences. In such instances the kitchen can be
cleaned and prepared as an operating-room ina few
minutes. If she is called in the night and goes to
the case with the surgeon, she should, while the sur-
geon is making his examination of the patient, start
a fire and put on the washboiler, to make sure of
plenty of boiling water. She should then get six
sheets and twelve towels, 1f possible. There may be
no clean towels, and the nurse will have to wash
some dirty ones. The sheets and towels can be soaked
first in boiling water and afterward placed in corrosive-
sublimate solution (1:1000), until the surgeon is ready
to use them. Boiling water is one of the best anti-
septics, as it kills germs on contact. Unfortunately
it cannot be used in rendering our hands and the field
of operation aseptic, but it can be used in the prepa-
ration of the sheets, towels, sponges, and instru-
ments.
The kitchen should be rendered as clean as pos-
sible. The kitchen-table should be prepared for the
operating-table, and there should be twosmall tables,
one for the instrument-tray and one for the sponges.
If small tables cannot be had, chairs covered with a
sheet or towels wrung out of the corrosive solution
will answer the purpose. If there is no gaslight, as
many lamps as can be obtained should be arranged -
near the surgeon, but not too near the ether, because
ether is inflammable.
After the surgeon has made the examination the
part must be shaved, washed, and a towel wrung out
of corrosive sublimate solution applied, an enema
given to clear the bowels, and the urine drawn.
OPERATIONS IN PRIVATE PRACTICE. 167
While the patient is being anesthetized the nurse
may arrange the tables and wash a flat bake-pan
or meat-pan for the instruments. If sponges have
been forgotten, a clean sheet can be torn up and
folded into flat sponges. China basins can be used
for the antiseptics, the sponges, and the surgeon’s
hands; china pitchers for hot and cold water; a
washtub for the soiled water; and hot bricks, plates,
or beer bottles for heaters.
CHAP TE Rok. Var:
GYNECOLOGIC EXAMINATIONS AND
OPERATIONS.
PERFECT asepsis is of special importance in gyne-
cologic exafninations and operations, because in many
instances the peritoneal cavity, which is highly suscep-
tible to septic influences, is invaded by them. Wemust
bear in mind that the whole genital tract communt-
cates directly with the peritoneum, and infection at
any point may cause peritoneal sepsis. Infection has
taken place through the introduction of a dirty
sound, and fatal peritonitis has followed perineor-
thaphy and trachelorrhaphy.
The technic for major operations is usually perfect,
but for minor operations carelessness is liable to
creep in. We have no right to expose a pattentqce
danger no matter how small the operation to be per-
formed; and if our technic is not as perfect as we can
make it with the means at our command, then we
expose the patient to the greatest of all dangers, that
of peritoneal sepsis, which usually means death. Suc-
cess 1n surgery is due to minute attention to a care-_
ful technic, and a careless nurse may be the means of
introducing sepsis, which may result in death after a
most brilliant and skilfully performed operation. The
most skilful surgeon is dependent upon his assistants
for the perfection of his technic, and only those nurses
168
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7
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4
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a
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a
.
4
3
J
SIMS’ POSITION. 169
who have been thoroughly instructed in the practice
of asepsis and antisepsis should be allowed to assist at
an operation or examination, however small.
GYNECOLOGIC EXAMINATIONS.
The positions which a patient may occupy when
undergoing an examination are the knee-chest, dor-
sal, Sims, and the upright.
The upright, or the erect, position is rarely used
for the purpose of making a diagnosis, but is some-
times preferred in verifying a diagnosis, especially
that of uterine displacement, previously made with
the patient in another position. Around the waist is
pinned a sheet, which extends to the floor, under
which the clothing of the patient is drawn up. The
patient stands with limbs separated, one foot resting
on a stool or the rung of a chair.
Dorsal Position.—The patient lies on her back
with the knees drawn up and separated; the hips
are brought down near the edge of the table, leaving
sufficient room for the heels to rest together comfort-
ably, eight or ten inches apart, without slipping from
the table. A sheet having an oval slit in the centre
long and wide enough to expose the parts is thrown
over the patient. In this position there 1s naturally
a certain amount of flexion of the pelvis upon the
trunk, and almost complete relaxation of the abdomi-
nal muscles is secured. |
Sims’ Position (a/so called the Latero-abdominal
Position).—\n the Sims position the patient lies on
the left side of her chest, with her head and left
cheek resting on a low pillow, and the left arm is
170 SORIGIGAL, “27 CHNIC.
drawn behind the body or hangs over the edge of the
table. The hips are brought down to the left-hand
corner of the table, so that her body hes diagonally
across it, the head and shoulders being at the right-
hand side, with the right hand and arm hanging over
the table-edge. The thighs are flexed upon the abdo-
men, the right thigh being so flexed that it lies just
above the left knee, and the feet rest upon a board ex-
tending from the right-hand corner of the table. This
position 1s one in which there is a tendency for the
intestines to ascend, and this causes the vagina to be
filled with air and thus brings the uterine cervix
within easy reach.
The knee-chest, or gexupectoral, position is much
used for inspection of the rectum, bladder, vagina,
and cervix of the uterus. In some cases of displace-
inent of the uterus the patient may have to take
this position many times daily. The patient first
kneels on the edge of the table, then bends forward
and rests her chest on a low pillow, her head lying
just beyond, so that her back slopes down evenly, her
arms clasping the sides of the table. In this position
the abdominal organs are thrown toward the dia-
phragm; the air enters the vagina and balloons it
out, so to speak, so that there is an unobstructed view
of the canal and the cervix.
Examination of the Rectum.—The patient is
usually placed in the knee-chest position. Either the
rectal speculum, or in its absence a Sims speculum
(small blade), is used. When the instrument is intro-
duced the rectum becomes distended with air so that
its walls are well exposed. If the patient is not in
PREPARATION FOR GYNECOLOGIC EXAMINATION. 171
such a position that the buttocks are in a good
light, a head-mirror, or an electric headlight may be
needed. It is well to have these at hand in case they
should be called for.
For an examination of the bladder the knee-chest
position is sometimes used; though, asa rule, the dor-
sal position is chosen, with the hips elevated high
above the abdomen by means of cushions or pillows,
which allows the intestines to gravitate toward the
chest; and when the urethra is opened the bladder
becomes distended with air and its interior is thus
easily seen. Sometimes the patient is anesthetized for
the examination, since it is usually very painful; but
local anesthesia of the urethra is often sufficient:
Preparation for Gynecologic Examination.—
To prepare a patient for examination the genital
parts should be cleansed, so that there will be no
danger of carrying septic material to the upper part
of the genital tract; the bladder and bowels should
be emptied. ‘The uterus lies between the bladder and
the rectum, and the distention of either of these
organs will alter the position of the uterus. As a
rule, no douche should be given before the examina-
tion, since the surgeon may want to see the character
of the discharge. Ail bands around the waist must
be loosened, also the corsets; a single tight band
around the waist will crowd down the contents of the
abdomen and displace the uterus. Around the patient
is thrown a sheet, beneath which she can raise her
clothing above the waist, and then step upon a chair
aud thence to the operating-table without there being
the slightest exposure.
172 SURGICAL TECHNIC.
For examination in private practice the patient
may lie on a small table covered with a shawl, a
comforter, or blanket. There must be at hand a
table, covered with a towel, on which are placed two
bowls, one containing corrosive-sublimate solution
(1: 1000), and the other containing warm water,
green soap, vaselin, and towels.
The speculum should be warmed by placing it in
the warm sterile water. The same aseptic precau-
tions are used during an examination as during
an operation. The instruments should be sterilized.
Sometimes a cleansing douche of corrosive sublimate
(1 : 2000) is administered after an examination.
PREPARATION FOR OPERATION.
The preparation for gynecologic operations, such
as perineorrhaphy, etc., are the same as for an abdom-
inal operation, excepting the difference of the field
of operation to be prepared. In case the operation is
a minor one upon the uterus or vagina, the prepara-
tions may be somewhat modified according to the
individual preference of the operator; but the general
rules of asepsis are always the same; and they must
be the more strictly observed in these operations be-
cause the dangers of infection are increased by our
inability to get the genital tract thoroughly clean.
In abdominal surgery there is not this difficulty.
The preparation of a patient in a private house for
a minor gynecologic operation should be as thorough as
in a hospital. If the operation is to be performed
with the patient in bed, there will be needed a wide
board or an ironing-board for insertion between the
3
é
q
‘
LS
AFTER-CARE. 173
mattress and sheet, thus making a hard surface for
the patient to lie upon.
A piece of rubber cloth or oilcloth will serve for
the pad. ‘The material used is folded at the top and
sides, covered with a towel, and the unfolded end
draped into a pail or wash-tub. When the patient is
anesthetized the bed is turned toward the window to
afford the surgeon a good light—a northern light if
possible. A bay window should be avoided, because
it gives cross-lights.
The limbs are flexed, the hips brought to the
edge of the bed, and the pad placed under them, so
that the water used in bathing the external parts
is conducted by the cloth into the pail or tub.
When holding the patient’s limbs the nurse should
let the heel of one foot rest 1n the palm of her hand;
the knee of the patient will then rest against the
chest of the nurse, whose free hand is passed over
aud holds the other limb in position at the knee.
ii-the nurse is asked to hold the speculum, she
should grasp the handle from below with her right
hand; the angle of the speculum will thus he in the
hollow between the thumb and forefinger, and the
convexity of the blade will rest on the dorsum of the
hand. ‘The upper labia and buttocks are raised by
the left hand. If the speculum or regular retractors
‘cannot be obtained in the emergency, retractors can
be improvised by bending the handles of four large
spoons to the appropriate angle. Two are used to
retract the lateral walls, the other two being applied
to the anterior and posterior parts of the vagina.
After-care.—After a vaginal operation, trachelor-
174 SURGICAL TECHNIC.
rhaphy, etc., the patient will probably be catheterized
fora few days. We must always remember the risk
of cystitis. Many patients have fully recovered from
the operation proper, but convalescence has been
delayed by this complication.
After passing the catheter the nurse should be care-
ful that when removing it the urine does not drop
on the stitches; the parts are afterward sprayed with
the ordered solution and dried. When giving
douches the nurse must insert the tube carefully
away from the stitches ; and after the douche is over
she should separate the labia and wipe the vagina dry
with sterilized cotton or gauze held in dressing-for-
-ceps. The same care must be used when giving
enemas, 1n order that the rectal and vaginal stitches
be not broken by the tube. ‘The patient must be in-
structed not to strain when the bowels are moved, or
the stitches may break. When dressings are applied,
they may require frequent changing in order to keep
them clean and free from discharges. Strict antisep-
sis inust be observed, the genital parts must be kept
perfectly clean, otherwise septic material will readily
find access and probably result in infection of the
wound and suppuration, or a stitch-abscess. If the
uterus 1s packed with gauze, the pulse and tempera-
ture are usually taken every two hours ; and should the
temperature rise to 101° F. the packing is removed.
Diet.—A liquid diet is usually ordered until after
the third day, when the bowels will have been
moved; after which, if all is well, the amount of food
is increased until it attains its customary proportions.
The patient is generally kept in bed two weeks,
DIET. | 175
and the sutures removed on the ninth day in the
order in which they were introduced. After the re-
moval of the stitches many operators order a vaginal
douche two or three times a day, the amount of water
varying from four to six quarts. This treatment is
successful only when the douches are given at the
proper time and temperature.
CHAPTER Y ie
SIGNS OF DEATH; AUTOPSIES.
WINSLOW, one of the professors at the University of
Paris, and who had twice been taken for dead, was the
first to make a scientific investigation of the signs of
death. After Winslow came Louis, and since their
time eminent men, especially in countries prescribing
tapid burial, have endeavored to find certain and
reliable signs of death before decomposition begins.
SIGNS OF DEATH.
Absence of respiration is not a sure sign of death,
as 1t may be due to syncope or to the person being in
a trance; nor is absence of the heart-beat, unless
determined by means of a stethoscope in experienced
hands. Coldness and rigidity may be due to collapse
or catalepsy or in persons who are frozen stiff.
In doubtful cases of apparent death which occur
suddenly or from external violence the following
tests are usually applied :
1. The absence of the heart’s action is carefully
determined by a stethoscope or phonendoscope.
2. Absence of the circulation is ascertained by
tying a string tightly around a finger or a toe; if the
tip becomes blue, life is not extinct, though this may
occur in cases where there has been great loss of
176
q
’
SIGNS OF DEATH. 177
blood, and in other cases where the heart is too weak
to send the arterial blood into the capillaries of the
fingers.
3. Absence of respiration is determined by placing
the surface of a mirror before the mouth; if the sur-
face becomes imnoist, respiration has not ceased.
4. If a subcutaneous injection of aqua ammonia is
given a red or purple spot will form if life still exists.
5. If a needle is inserted into the flesh of a living
person blood will escape, but not if life is extinct ;
still, if there has been a large loss of blood, there wili
be no escape of blood in the living.
Rigor mortis (post-mortem rigidity or stiffness of
death) begins in the upper part of the body, usually
in the maxillary muscles, and spreads gradually from
above downward. It disappears in the same order.
It comes and goes quickly after great muscular effort
or excitement, and when once it has been broken
up it does not return. The time it sets in after death
varies from ten minutes to twelve or even twenty-four
hours. Rigor mortis is considered the most positive
sien of death, because it indicates death of the mus-
cle itself.
Death of the body as a whole takes place first, and
at intervals of an hour or even several hours death of
one or other of the involuntary muscles follows.
Hypostasis, or congestion of blood in the capil-
laries, which forms in all the dependent parts of the
body, is considered a valuable sign of death, but this
purple color may be due to contusion, and has been
seen in cholera patients before death.
The body-temperature at and from one to two
12
178 SURGICAL TECHNIC.
hours after death may be very high, 107° or 112° F.
Patients dying from cholera and yellow fever have
high temperatures for several hours after death; but,
as a rule, the body 1s cold to the touch in from six to
ten hours.
AUTOPSIES.
' Every nurse should do all in her power to assist
the physician or surgeon to obtain autopsies, and
with a little tact the necessary permission can usually
be obtained.. Every well-conducted autopsy adds
more or less to medical knowledge. It verifies the
diagnosis of the illness, and in many cases it explains
or shows the cause of symptoms the explanation of
which could not be determined before death. In
surgical work, when a patient dies in less than
twelve or fourteen hours after an operation, the au-
topsy, when made by a competent bacteriologist and
pathologist, will show whether death was due to
sepsis or to some organic disease over which the sur-
geon had no control.
In a private house the autopsy should be held in
the room giving the best light, and if possible in the
daytime in order to obtain the correct color-interpre-
tation; for if made in artificial light the observations
will not be entirely trustworthy.
At the present time an autopsy is perferably held
almost immediately after death, and before putre-
factive changes have taken place. ‘The undertaker
should always be warned not to inject the body, be-
cause the fluids usually employed, which contain
among other things corrosive sublimate and arsenic
in large quantities, change the color and consistency
AUTOPSIES. 179
of the organs to such an extent that it is difficult to
recognize the pathologic processes. Then, again, the
punctures made during the embalming process may
open an abscess or other cavity, and thus distribute
the contained pus or exudates. Embalming-fluid -
has been poured into the mouth, and having found
its way into the lungs and stomach, has greatly
changed the appearance of those organs.
The clothing on the body should be removed and
a large sheet spread over it; or if preferred, a night-
dress or skirt open down the middle may be put on.
The things a nurse should provide are:
1. Large rubber sheet, old oil-cloth, old quilts, or
papers to put under trestle to protect the floor. -
2. Small table for instruments, a marble-top table
if possible, unless there is a marble-top stationary
bowl in the room.
3. Three washbowls: one for corrosive sublimate,
one for dirty instruments, and one for organs re-
moved.
A. ‘Two pails for dirty water.
5. Old towels and a number of old sponges.
6. Plenty of hot and cold water.
7. About four quarts of fine sawdust, or oakum,
or excelsior packing, absorbent cotton, or common
cotton for filling up cavities, any one of which will
prevent fluid oozing through tlfe incisions. When
these are not obtainable, bran, cloth, or newspapers
may be used. Fine sawdust is the best material, as
it packs easily, does not interfere with the sewing
by getting into the stitches, and keeps the needle
dry.
180 SURGICAL * FECHNIC
8. Six wide-mouthed bottles in which to place
specimens from the various organs, and which can
be securely corked.
9. Mucilage and labels on which to write the his-
tory of each specimen in the bottle. _
10. About three yards of fine twine or carpet-
thread, and a large darning-needle or a large curved
needle.
Should the autopsy take place in a house where
there are no conveniences, the body can be left lying
on the undertaker’s stretcher covered with a sheet,
the clothing removed, and a large napkin put on.
There should be several old newspapers to protect
the floor, and on which to place the dirty instru-
ments and organs removed; an old sheet, a pail,
a wash-bowl, and a pitcher of warm water can always
be obtained.
The sheet is torn into four pieces. Two pieces are
used, one for each side of the neck and trunk, cover-
ing the arms, leaving the chest and abdomen free for
the surgeon to operate; the third piece is placed be-
neath the head; and the fourth piece 1s tuckediae
below the genitals, thus covering the lower extremi-
ties. The bowl contains the large dampened sponge,
and, together with the pail, should be placed within
convenient reach.
Absolute cleanliness is essential at a private autopsy.
Blood-stains must be washed from the walls, floor,
dishes, the rubber .or otl-cloth; the papers) @id
sponges, and cloths should be burned, and the body
must be washed perfectly clean. ‘The room must be
left in perfect order—just as it was before the post-
AUTOPSIES. 18k
mortem. Ground coffee thrown on a few live coals
will remove all odor from the room.
For removing the odor from the hands, turpentine
will be found serviceable, or a solution of per-
amanganate of potassium and oxalic acid, or a dilute
solution of formaldehyd. ‘The result of the autopsy
must be kept secret and revealed to no one. ©
INDEX.
ABDOMINAL operation, instruments
for, 78
Abscess-stitch, 113
Absorbent cotton, 99, 115
Accidents during operation, 160
Acclimatization immunity, 30
Acquired immunity, 29
Actinomycosis, communication of, to
man, 14
Adhesive plaster, rubber, 102
After-care for synecologic ——
173
Alcohol as an antiseptic, 56
sterilization of hands with, 56
Allis’s aseptic ether-inhaler, go
Ammonia, subcutaneous injection of,
as test in supposed death,
177
Amputation of limb, instruments for,
80
Anesthesia, 86-98
bronchorrhea i in, 19
dilated pupils in, Q2
infiltration-, 97
preparation for accidents in, 89
primary, 93
vomiting during production of, gI
Anesthetics, administration of, 86
chloroform, 94
ether, administration of, ‘89
ethyl bromid, 95
general, 86
local, $6, 95
cocain, 95
hydrochlorate, 96
ethyl chlorid, 97
eucain, 96
ice, 96
phenate of cocain, 97
Anesthetics, orthoform, 59
hydrochlorid, 60
Schleich’s, 95
Anthrax, discovery of bacterial na-
- ture of, 15, 16
Antiseptic douches, 127
dressings, 99
powders, 104
surgery, Lister’s system, 12, 13
Antiseptics, 42-61
alcohol, 56
aristol, 54
balsam of Peru, 59
boiling water, 45
boracic acid, 55
boroglycerid, 56
carbolic acid, 47
chlorinated lime, 58
coal-tar derivatives, 47
Condy’s fluid, 58
corrosive sublimate, 48
creolin, 49
dermatol, 61
formaldehyd, 52
formalin, 53
heat, 45
moist, 45
hot air, 46
hydrochloric acid, 58
hydrogen peroxid, 55
ichthyol, 59
iodoform, 51
iodol, 52
Labarraque’s solution, 58
listerine, 61
lysol, 50
methyl-blue, 58
methyl-violet, 58
mustard, 60
183
184
Antiseptics, normal salt solution, 60
orthoform, 59
hydrochlorid, 60
oxalic acid, 57
potassium permanganate, 57
protargol, 61
INDEX.
Bacillus of bubonic plague, discovery
of, 18
glanders, discovery of, 17
influenza, discovery of, 18
leprosy, discovery of, 16
of Malta fever, discovery of, 18
of
of
of
pyoktanin, 58
resorcin, 60
saprol, 50
ae bicarbonate, 61
sozal, 50
Steam, 45
live, 46
sulphuric acid, 58
thymol iodid, 54
vinegar, sterilized, 60
Antistreptococcic serum for
peritonitis, 158
Antitoxin, administration of, followed |
by stimulation of body’s ger-
micidal powers, 39
in therapeutic practice,
method of injecting, 41
mixture of Coley, for tumors, 40
of diphtheria, preparation of,
status of, 39
streptococcus, 40
preparation of, 37
tetanus, 40
theory of, 35
theory of immunity, 31
therapeutic action of, 37
tuberculosis, 41
preparation of, 37
Aristol, 54
Artificial immunity, 30
Asepsis in gynecologic operations,
168
Autopsies, 178
cleanliness in, 180
instruments, etc., for, 179
preparation of body for, 179
time for, 178
septic |
,-
2)
BACILLUS, 21
aérogenes capsulatus,
coli communis, 33
comma, discovery of, 17
diphtherize, 34
discovery of, 17
icteroides, discovery of, 18
melitensis, discovery of, 18
979
JI
of measles, discovery of, 18
of tetanus, 34
discovery of, 17
of yellow fever, discovery of, 18
pyocyaneus, 33
tuberculosis, 33
discovery of, 17
typhosus, discovery of” 16
| Bacteria, 20
as causes of disease, 20
channels of entrance into body,
25, 20
conditions influencing growth of,
Ao.
disease-producing,
distribution of, 9
entrance of, through alimentary
canal, 25
through respiratory tract, 26
through skin, 25
forms of, 21
Koch’s. circuit, to prove specific
paboee powers of, 27
pyogenic, 22
reproduction of, 22
by binary division, 23
by fission, 22, 23
by sporulation, 22, 23
sizes of, 20, 21
Bacteriology, 9
history of, 9
progress of, 12
Balsam of Peru, 59
Bandages, 103
Scultetus, 103
P= 2102) 404
Bed for private operations, 163
Bicarbonate of sodium, 61
Bichlorid gauze, 100
Binary division of bacteria,
Bismuth gauze, IOI
Bladder, attention to, after
tions, as
irrigation of, 12
operations on, Se for, 84
Boiling water as germicide, 45
44
99
23
| opera-
? Se =a SSC OCC
INDEX. 185
Boric acid, 55
Boroglycerid, 56
Bowels, attention to, after operations,
146
Brain, operations on, instruments for,
So
Bronchorrhea in anesthesia, 91
Brushes, 115
_Bubonic plague, bacillus of, dis-
covery of, 18
Button-suture, 113
CANTON-FLANNEL roll for instru-
ments, 75
Carbolic acid, 47
Catgut, 109
preparation of, T10
sterilization of, 110
with formalin, 53
Catheterization, 123
Catheters, 123
glass, 123
introduction of, 124
Cautery, Paquelin, 104
Cerebrospinal meningitis, epidemic,
specific germ as cause of,
18
Cervix, dilatation of, instruments for,
78
Charts, keeping of, 71
Chicken-cholera, 16
Chlorinated lime, 58 .
Chloroform, 94
Cholera, chicken-, 16
Circulation, absence of, as sign of
@esth, £76
Coal-tar derivatives, 47
Cocain, 95
hydrochlorate, 96
phenate, 97
warer.2r >
morphology of, 22
Coley’s antitoxin mixture for tumors,
40
Collodion dressing, 1o1
Comma bacillus, discovery of, 17
Condy’s fluid, 58
Continuous suture, 113
Corrosive sublimate, 48
swallowing of, 49
Cotton, absorbent, 99, 115
Creolin, 49
Cystoscopic examination, instruments
for, 85
Cysts or tumors, instruments for, 78—80
| Dam, rubber, 119
Death, signs of, 176
absence of circulation, 176
of heart-beat, 176
of respiration, 176, 177
hypostasis, 177
insertion of needle, 177
rigor mortis, 177
subcutaneous injection of am-
monia, 177
temperature, 177
stiffness of, 177
Delirium, traumatic, from shock, 155
Deodorants, 42
Dependent pockets, 116
Dermatol, 61
Diet after operations, 146-150
gynecologic, 174
Diphtheria antitoxin, preparation of,
36
status of, 39
bacillus of, 34
discovery of, 17
Diplococci, 22
Diplococcus pneumoniz, 34
Disease, bacteria as causes of, 20
conditions necessary for causation
of, 27
in man, fungi connected with, 21
Disinfectants, 42
Disinfection, 45
by steam, 46
Dorsal position, 169
Douche-board, 127
Douches, 126
administration of, 126
antiseptic, 127
Drainage, 116
postural, 117
‘Drainage-tubes, care of, 117
glass, 116, 119
rubber, preparation of, 118
Dressing-rooms, 62
Dressings, antiseptic, 99
collodion, 101
surgical, 99
Dust, infection from, in operations,
136-138
186
EAR, operations on, instruments for,
$25 33
Emergency bundles, 115
operations, preparations in, 165,
166
Emulsion of iodoform, 100
Fnema, 129, 130
for tympanites, 130
purgative, 130
stimulating, 129
Enteroclysis, 128
Etner, administration of, 89
nausea after, 93
to children, 93
vomiting after, 93
death from, 93
Ether-inhaler, Allis’s, 90
Ethyl bromid, 95
chlorid, 97
Eucain, 96 .
Examinations, gynecologic, 168, 169.
See also Gynecologic exami-
nations.
of rectum, 170
Excretions, disinfectants for, 58
FERMENTATION-FEVER, 159
Finger cots, 120
Fission, 22, 23
Formaldehyd, 52
as dusting-powder, 53
inhalation of, 54
sterilization of instruments and
dressings with, 64
Formalin, 53
poisoning by, 54
sterilization of catgut with, 53
Fungi connected with disease in
man, 21
GAUZE, 99, 115
bichlorid, 100
bismuth, IOI
iodoform, 100
pads, 114
potassium permanganate, IOI
requirements of, for dressings, 99
Genupectoral position, 170
Germicides, 42
Germs, incubation-period of, 29
Glanders, bacillus of, discovery of,
i
ANDES.
Glass ligature-box, 112
Gloves, 119
rubber, 119, 120
Gonococcus as cause of gonorrhea,
16
discovery of, 16
Gonorrhea, gonococcus of, 16
Green soap, 120
Gynecologic examinations, 168, 169 .
asepsis in, 168
positions in, 169
dorsal, 169
genupectoral, 170
knee-chest, 170
latero-abdominal, 169
Sims’, 169
upright, 169
preparations for, 171
operations, 168. See also Ofera-
tions, gynecologic.
instruments for dressing after, $4
HEART-BEAT, absence of, value of,
| as sign of death, 176
_Heat, germicidal powers of, 45
| moist, as germicide, 45
'Hemorrhage following operations,
155
symptoms, 155
treatment, 156
| Hernia, 159
| Horsley’s wax, £02
_Hot air as germicide, 46
_Hydrochloric acid as disinfectant, 58
| Hydrogen peroxid, 55
'Hydrophobia, first application of
| Pasteur’s treatment, 17
_Hypostasis as sign of death, 177
| Hysterectomy, 160
insanity after, 160
vaginal, 160
instruments for, 78-80
IcE as local anesthetic, 96
Ichthyol, 59
Immunity, 29
acclimatization, 3
acquired, 29
antitoxin theory of, 31
artificial, 30
natural, 29
racial, 30
INDEX. 187
Immunity, theories of, 30-32
phagocytosis, 31
Incubation-period of germs, 29
Infection from dust in operations,
36-138
Infiltration-anesthesia, 97
) _ Inflammation, 121
a causes of, 122
Influenza, bacillus of, discovery of, 18
Injection of antitoxin, 41
Injections, rectal, 128
Insanity after hysterectomy, 160
Instruments and dressings, sterilizer |
for, 66
canton-flannel roll for, 75
3 for cystoscopic examination, 85
for dressing after gynecologic
operations, $4
for operations, 76-85
abdominal, 78
amputation of limb, 80
curetting of uterus, 78
cysts or tumors, 78—80
q dilatation of cervix, 78
— on bladder, 84
on brain, 80
on ear, 82, 83
on mouth, 81
on nose, 82
on rectum, 83
on spine, 80
on throat, 81
on urethra, 84.
perineorrhaphy, 76
trachelorrhaphy, 77
vaginal hysterectomy, 78-80
sterilization of, 64 .
apparatus for, 65
with formaldehyd, 64
Instrument-trays, 67
agateware, 67
hard-rubber, 68
Interrupted suture, 113
Intestinal obstruction, 159
Iodoform, 51
emulsion, 100
gauze, 100
poisoning, 51
Todol, 52
Irrigation, 107
of bladder, 125
of rectum, 128
JOHNSON’S method for preparation
of catgut, I11
IXANGAROO-TENDON, 10g
IXnee-chest position, 170
KXKoch’s circuit to prove specific path-
ogenic powers of microbe, 2
LABARRAQUE’S solution, 58
Latero-abdominal position, 169
Leprous nodules, discovery of ba-
cilli of, 16
Ligature, 109. See also Szetizves.
Ligature-box, glass, 112
Ligature-tray, Robb’s aseptic, 68
Limb, amputation of, instruments
for, 80
Lime, chlorinated, 58
Eisterine, 61
Listerism, 13
Lister’s system of antiseptic surgery,
12, 13 ;
Lysol, 50
MALARIAL fever, cause of, 19
Malta fever, bacillus of, discovery of,
18
Measles, bacillus of, discovery of, 18
Methyl-blue, 58
Methyl-violet, 58
Metschnikoff’s theory of phagocyto-
Sis; 3
Micrococcus lanceolatus, 34
Pasteuri, discovery of, 16
Mouth, dryness of, after operations,
145
operation on, instruments for, 81
| Mustard as antiseptic, 60
NATURAL immunity, 29
Nausea after etherization, 93
Needles, 115
insertion of, as test in supposed
death, 177
Nodules of leprosy, discovery of ba-
cilli of, 16
Nose, operations on, instruments for,
$2
Nurses, duties of, in operations, 132,
133, 142-144
preparations of, for operations, 133,
134
188 INDEX.
OBSTRUCTION, intestinal, 159 Operations, septic peritonitis after,
Operating-room, care of, 62 | 156. See also Feriéonttis,
preparation of, 132 | seplic, after operations,
Operating-table for private opera-| sequel of, 151
tions, 163 | shock after, 151. See also Shock
Operation blank, 74 | following operations.
Operations, 131 | thirst after, 145
accidents during, 160 _Orthoform, 59
arranging of patient for, 141 | hydrochlorid, 60
attention to bladder after, 146 | /Oxalic acid, 57
to bowels after, 146
care of patient after, 144-150 Paps, gauze, 114
diet after, 146-150 | Paquelin cautery, 104
dryness of mouth after, 145 | Parasites as cause of malignant
duties of nurses in, E32, 133, 142- tumors, Ig
144 | | Patient, arranging of, for operations,
gynecologic, 168 141
after-care, 173 | care of, after operations, 144-150
asepsis in, 168 preparation of, for operations, 139.
diet after, 174 | See also Operations, prepara-
preparations for, 172 | tion of patient for.
hemorrhage after, 155. See also Perineorrhaphy, instruments for, 76
FHlemorrhage following opera- | Peritonitis, septic, after operations,
Zions. 156
infection in, from dust, 136-138 | symptoms, 156
in private practice, I61 | treatment, 157
bed for, 163 | with antistreptoecoccic se-
furniture, instruments, etc., | rum, 158
for, 164 Peroxid of hydrogen, 55
operating-table for, 163 Phagocytosis theory of immunity,
preparations for, 162 a1
in emergency cases, 165, | Pheaae of cocain, 97
166 |Plasmodium malariz as cause of
sterilization of instruments for, | malaria, 19 .
165 Plaster, adhesive, rubber, 102
of sheets, towels, etc., 164 Pleurisy after operations, 144
instruments for, 76. See also /- | Pneumococcus, 34
struments for operations. discovery of, 16
of election, 132 Pneumonia after operations, 144
of emergency, 132 croupous, bacillus of, 34
of expediency, 131 Post-mortem rigidity, 177
of necessity, 132 Potassium permanganate, 57
pleurisy after, TAA | gauze, IoI
pneumonia after, 144 . Powders, antiseptic, 104
preparation of field of, 139 Private operations, 161. See also
of vaginal canal, 140 | Operations tn private practice,
of nurses for, 133, 134 Protargol, 61
of patient for, 139 Puerperal fever, organic ferments as
day before operation, 139 cause of, 14
day of operation, 141 Pupils, dilated, in pie G2.
of surgeon and assistants for, Purgative enemata, 13
135 Pus, E22
SS
a
{
INDEX. 189
Pushing lower jaw forward to pre-
vent obstruction to breathing,
go
Pyogenic bacteria, 22
Pyoktanin, 58
blue, 58 i
RACIAL immunity, 3
Rectal injections, 128
Rectum, examination of, 170
irrigation of, 128
operations on, instruments for, 83
Resorcin, 60
Respiration, absence of, as sign of
death, 177
value of, 176
artificial, for shock following opera-
tions, 154
Rigor mortis, 177
Robb’s aseptic ligature-tray, 68
Robinson’s douche-board, 127
Rubber adhesive plaster, 102
dam, I19
drainage-tubes, preparation of, 118
gloves, 119, 120
protective, 102
SALT solution, normal, 106
as antiseptic, 60
Saprol, 50
Sarcinz, 22
Schleich’s anesthetic, 95
Scultetus bandage, 103
Sequelze of operations, 151
Shock following operations, 151
artificial respiration in, 154
symptoms, 153
treatment, 153
traumatic delirium from, 155
Shotted suture, 113
moms Ol death, 170.
Death, signs of.
Silk, protective, oiled, 102
sterilization of, 112
Silkworm-gut, 110
Silver wire, 113
Sims’ position, 169
Sinus, 159
Small-pox, vaccination for, 30
Soap, green, 120
Sodium bicarbonate, 61
Sozal, 50
See also
Spine, operations on, instruments for,
SO
Spirillum, 21
Splenic fever, discovery of bacterial
nature of, 15, 16
Sponges, 113
gauze, 113, 114
marine, 113, 114
Spores, resistance of, 24, 44
Sporulation, 22, 23
Spotted fever, specific germ as cause
of, 18
Staphylococci, 22
Staphylococcus epidermidis albus,
33
pyogenes albus, 33
aureus, 32
CiLreus; 33
Steam as germicide, 45
disinfection by, 46
live, as germicide, 46
Sterilization, 45, 63
dry, 64
fractional, 46
intermittent, 46
moist, 64
of catgut, 110. See also Ca/ewt.
of hands with alcohol, 56
of instruments, 64. See also /n-
struments, sterilization of.
of sheets, towels, etc., for private
operations, 164
of/sthk, 112
Sterilizer for instruments, 65
and dressings, 66
Stitch-abscesses, T13
Stomach-contents, examination of,
B25
Streptococci, 22
Streptococcus antitoxin, 40
preparation of, 37
lanceolatus, 34
pyogenes, 3
Stretcher, wheeled, 63
Sulphuric acid as disinfectant, 58
Surgeon and assistants, preparalions
of, 135
Surgeon’s kit, 73
contents of, 73
packing of, 73
Surgery, antiseptic, Lister’s system,
12; 13
190
Surgical dressings, 99
technic, 62
Sutures, 109g
button, 113
catgut, 109. See also Cafgutr.
continuous, 113
interrupted, 113
kangaroo-tendon, 109
shotted, 113
silk, 112
silkworm-gut, 110
silver wire, 113
TAMPONS, 102
T-bandage, 103, 104
Temperature in death, 177
Tents; 162
Test-breakfast, 126
Tetanus antitoxin, 40
bacillus of, 34
discovery of, 17
Tetrads, 22
Theory of antitoxins, 35
Thermocautery, 104
Thiersch’s solution, 56
Thirst after operations, 145
Throat, operations on, instruments
for, 81
Thymol iodid, 54
Trachelorrhaphy, instruments for,
Traumatic delirium from shock, 155
Trays, instrument... 67. See) also
Lnstrument-trays.
ligature-, Robb’s aseptic, 68
Tuberculin, 18
INDEX.
Tuberculosis, antitoxin of, 41
preparation of, 37
bacillus of, 33
discovery of, 17
Tubes, drainage-,. 117. Seen ass
Drainage-tubes.
Tumors, malignant, parasites as
cause of, 19
treatment of, by Coley’s antitoxin
mixture, 40
Tympanites, 158
enema for, 130
Typhoid fever, discovery of bacilli
of, 16
UPRIGHT position, 169
Urethra, operations on, instruments
for, 84
Uterus, curetting of, instruments for,
78
VACCINATION, 3
Vaginal canal, preparation of, for
operation, I40
hysterectomy, 160
instruments for, 78-80
Vinegar, sterilized, as antiseptic, 60
Vomiting after etherization, 93
during anesthetization, 91
WHEELED stretcher, 63
YELLOW fever, bacillus of, discovery
of, 18
ZOOGLEA, 22
CATALOGUE
OF
BooKs & NURSING
AND BOOKS SPECIALLY IN=
TERESTING FOR NURSES
Books sent to any address, prepaid, on receipt of
the price herein given
PAGE
American Pocket Medical Dictionary... As APRS Oe RNY dog 2
erie t- Fook Of Nursing o.... 4. 3. ecw 0 ae ae eae a we Shes:
eae comoendinin Of Insanity . . 0 ws ee esas 4 ese ee Siena
i Eemer SeavrechianoO-.MeLaDyY 2. 6b ks cr ws ew lore ss «8 ee ee 4
PReECme eran tne Baby. ss ois ee Se Lee Or eee 5
Grifath’s Infant’s Weight Chart ...... SIE UAE on Ta ig = oan ig Pe sos 5
RS SSMS CUS SSS al A et Rae See 4
eres Ot Pi ySiOlory so aa ee 7
ReGes irE In GICKHeESS and in Health. . 2... . tw we ww 8
Duma meTaACIre (Mart 5 50. ls ke ale ee WU ly wl 8
Martin’s Essentials of Minor Surgery and Bandaging ........ 7
Pee ermine in marly Infancy . 0. i. cele ee ee ee 5
Morris’s Essentials of Materia Medica, Therapeutics, and Prescrip-
PMR IOA CR Cee Y at Une ia tal de ch, ght shea be oe hy 5 eee Wg th ed Bele oe 6
anes I CTIONATY: (66015. > ise ees) 6 Swe ee ae 8
Smee cer scentiais of Anatomy 2)... sac i ee ee a 7
Pye’s Elementary Bandaging and Surgical Dressing ......... 4
Repeemibnemedian) lavoiene «2 ie Ee ee 5
Stevens’s Manual of Materia Medica and Therapeutics ....... 6
mes Soveanuial of Practice of Medicine ......-.:.:%...-. 6
Peemeesiteria Medica for Nurses . soe ee ee le 3
eee etical POints in. Nursing? 9... 6k a ee ew 2
— vt stat st
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IN PREPARATION.
An American Text=Book of Nursing.
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Pennsylvania.
8
aarti
0 021 068 935 7