P64 beg A 4 , satetes ype ty ; ; Yee = e ream oe e ’ . ‘ ~ ratte Ty ! - : ‘ ; i oy: «sce sc cess Bees ena iesad vanes CHAPTER II BACTERIA AS THE CAUSES OF DISEASE poco esos eo err eereeeeeneeere CHAPTER III THE THEORY OF ANTITOXINS see eco eee et ee eer ewe ore eeooeos sr SHO Se ee s CHAPTER IV ANTISEPTICS, DISINFECTANTS, AND DEODORANTS oer eee ere eee eee PART II.—_SURGICAL TECHNIC CHAPTER V BANDAGING AND DRESSINGS er i i ry CHAPTER VI CARE OF OPERATING-ROOM; METHODS OF STERILIZATION; CARE OF INSTRUMENTS 14 CONTENTS CHAPTER VII PAGE INSTRUMENTS NECESSARY IN DIFFERENT OPERATIONS, KEEPING _ or CHARTS, SURGEON’S. Kil, BIG. 076 cick oe cee eee CHAPTER VIII BINEDSPUEGUA ic © an aioe once G's hie eine ASE Rai F cick aay MWe ere ROLE RE te CHAPTER IX GAUZE SPONGES; Paps; DreEsstncs; TAMPONS; DRESSING-ROOM OvutFiTt; DRAINAGE, CARE OF DRAINAGE-TUBES; GLOVES; SUTURES AND LIGATURES; SURGICAL APPLICATIONS....-..... 178 CHAPTER X INFLAMMATION seeee Bie 2 Us Ole cele » 8 BO? 8p Ais) Che) e, 6 (2) o (eK ee» SER aE, tie oo 197 CHAPTER XI CATHF:TERIZATION; DouCHES; ENEMATA; WASHING OUT THE BLADDER; LAVAGE... .._..-. eee t.s i Dink tSicmcer a iar eeae ne ae 20C CHAPTER XII MINOR SURGICAL PROCEDURES...........>%. Ws ae eics oes ee CHAPTER XIII OBSTETRIC NURSING; CARE OF INFANTS, ETC................0-- 233 CHAPTER XIV OPERATIONS; PREPARATION OF THE OPERATING-ROOM; THE SUR- GEOM AND His “ASSISTANTS. «os cua cae CHAPTER XV TRANSPORTATION; PREPARATION OF PATIENT FOR OPERATION; CARE OF PATIENT DURING AND AFTER OPERATION CHAPTER XVI SEQUEL® OF OPERATIONS; SHOCK, HEMORRHAGE, SEPTIC PERI- TONITIS, ACCIDENTS DURING OPERATION, ETC....:.0.0-0.c0++ 263 CONTENTS 15 CHAPTER XVII PAGE PSOE SO PPIRUCE ON Sates role oc Maafice «se edie ene Gin Sioa eb aie ar8 eusee ola ws 276 CHAPTER XVIII OPERATIONS IN PRIVATE PRACTICE, 2 i. 0.c ccc wal ee eee sues 278 CHAPTER XIX GYNECOLOGIC EXAMINATIONS AND OPERATIONS..............000. 288 CHAPTER XX: PPE PIGROEPIES Ss eS ee arcs Lae heen? Fite yh REED a ae 209 CHAPTER XXI SIONS TOE: LOMA DH: ce AUTORSING ode. oc 22 ye warts cles Nae ken wae ws 306 CHAPTER XXII HyGiENE; PERSONAL CONDUCT OF A NuRSE’S LIFE; OF THE RE- NNR SOM CCHSS I amr Tg Aw cd So os. geet ame eM amas ait (GHC TERE Ey ES SE eo lag Ga PR a er BiG PART | BACTERIOLOGY; ANTISEPTICS CHAPTER. 1 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 numerous that they are quite beyond any calculation. Bacteria exist nearly everywhere; they are Almost universal, except that they are not found deep down in the ground nor high up in the air. They and their 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 to be present. They are always on the surface of the body, and so deeply are some bacteria situated beneath the epithelial cells that the most vigorous scrub- 2 17 18 BACTERIOLOGY bing and washing and the use 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 en- trance into the lungs is only a matter of accident. The existence of these bacteria has been known for many years, but it is only during the past few decades that any great advancement in 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 (leukocytes) for small worms, and built up a new theory of the causes of disease and putrefaction upon this basis. At the same time Christian Lange, a professor in the medical school at Leipzig, expressed his opinion that the rash that ap- | peared on the skin in the eruptive fevers, etc., was the result of putrefaction conveyed by small living worms in the body. Shortly after these observa- tions 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 micro- scope that had yet been constructed. He saw, and described with astonishing clearness, various forms of bacteria found in the material taken from the mouth of an old man who never cleaned his teeth. He gave an accurate description of the rod-shaped bacteria, motile and motionless, now called bacilli; of the spiral threads, ——— HISTORY OF BACTERIOLOGY 19 or spirilla; and of rounded micro-organisms, or micro- cocci. Although he did not attempt to theorize as to the meaning of these organisms at the time, later on, in 1713, after finding similar organisms in the greenish pellicle formed on the surface of the water in an aquarium, he came to the conclusion that the various forms of bacteria found in the material scraped from the teeth found their way into the mouth through the medium of the drinking-water that had 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 germs 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 gradu- ally accumulated, and fresh discoveries were constantly made by various workers; but since no systematic at- tempts 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 living contagious element in the production of disease and fermentations was made by Frederick Miiller, of Copenhagen, and was the result of a systematic attempt to arrange the knowl- edge 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 accu- 20 BACTERIOLOGY rate knowledge of the bacteria which cause a number of different diseases. The knowledge of methods and details of work is now so general that the science of bac- teriology is rapidly growing, and has already revolution- ized very many branches of medicine. In 1840 Henle was led to believe that the cause of miasmatic, infective, and contagious diseases must be looked for in living fungi or other minute living or- ganisms. Unfortunately, at that time the methods of study employed prevented him from demonstrating the accuracy of his belief. It was 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 tee 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:in animals and insects. Upon Pasteur’s observations Lord Lister based his successful system . of the treatment of wounds, known as “‘antiseptic sur- gery.” | 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 HISTORY OF BACTERIOLOGY DT unknown. Lister, accepting the truth of Pasteur’s 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 a2 BACTERIOLOGY germs from the air, instruments, sponges, and dress- ings into wounds, he suggested the antisepsis which 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 subse- quent period. This procedure defeats its purpose for usefulness by reason of the moisture retained acting as a direct growth medium for those bacteria already upon or in the skin. Listerism 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 constantly made. There area 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 probability 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 com- municated to man. His observations, however, were not given to the world until 1878, one year after Bollinger had discovered the cause of the disease in animals. HISTORY OF BACTERIOLOGY 23 In 1847 Semmelweis, on the basis of his own ob- servations, formulated the precept that puerperal fever is the result of the introduction of organic ferments into the puerperal genital tract. This discovery, established by himself and confirmed by the observations of many others, marked an era in obstetrics. The organic fer- ments have since been identified as specific bacteria. ‘Semmelweis in this way anticipated in practical anti- sepsis the discoveries of Lister and Pasteur; while the late Oliver Wendell Holmes, in a paper entitled ‘‘Puer- peral Fever a Private Pestilence,’ published in 1843 and republished 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 Univer- sity of Vienna, who, having received a dissection 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 obstetrics 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- dent’s 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 bac- terial nature of splenic fever, or anthrax. 24 BACTERIOLOGY In 1869 the first complete study of a contagious affection was made by Pasteur, in two diseases affect- 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 prop- erties 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 bac- terial nature of anthrax has been the basis of our knowl- edge of all contagious maladies; 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 discovery of the bacillus paved the way for the reception of Koch’s discovery of the tubercle bacillus. In the same year Neisser discovered the gonococcus 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 al- most as much destruction among them as the occasional epidemics of cholera and small-pox produce among men. HISTORY OF BACTERIOLOGY 25 In the same year Sternberg described the pneumo- coccus, calling it ‘Micrococcus Pasteuri,’’ which he secured from his own saliva; and in the same year Pasteur also found the same organism in saliva; though it is to Frankel, Talamon, and particularly Weichsel- baum that we are indebted for the discovery 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 dis- covery, it remained for Koch to succeed in demonstrating and isolating the specific bacillus, and to write so accu- rate a description of the organism and the lesions it produces as to render the discovery one of the most complete ever made in the history of medical science. In the same year Léffler and Schiitz reported the discovery of the bacillus of glanders, an infectious disease almost confined to certain of the lower ani- mals; 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 L6ffler discovered the diphtheria bacillus, and Nicolaier that of tetanus. On October 26, 1885, Pasteur made the first applica- 26 BACTERIOLOGY tion of his method for the treatment of hydrophobia, nearly ten years before the time we began to understand the production and use of antitoxins in human medicine. In 1890 Koch issued to medical men what is 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 1894 Yersin and Kitasato independently isolated the bacillus causing the bubonic plague then prevalent at Hong-Kong. The bacterial cause of yellow fever has not been deter- mined, but its method of transmission is known to be through the bite of the mosquito Stegomyia fasciata. This mosquito, to become infected, must bite the patient during the first three days of the disease, and then the mosquito is harmless until the lapse of at least twelve days. After being bitten by the mosquito the period of incubation is from six to ten days. Dr. Chas. Finlay, of Havana, was the first to pronounce clearly a mosquito theory of the transmission of yellow fever, and it was later proved conclusively by a Commission of the United States Army composed of Reed, Carroll, Agra- - monte, and Lazear. Two of the above, Reed and Lazear, died from allowing themselves to be bitten by infected mosquitoes to prove conclusively that the mosquito, and the mosquito alone, transmitted the disease. Epidemic cerebrospinal meningitis or spotted fever is caused by Diplococcus intracellularis meningitidis. Malta fever, a disease of the Mediterranean islands, and occasionally of the Antilles and Central and South HISTORY OF BACTERIOLOGY 27. 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 malarie, which is found in the blood of the afflicted individual. Malaria is carried solely by a species of mosquito, the Anopheles. There is some grounds for a belief that malignant tumors—cancers and sarcomas—are due to micro- organisms. The nature of the parasite is as yet un- known. Spirocheta pallida or Treponema pallidum, discov- ered by Schaudinn and Hoffmann in 1905, is now generally accepted as the exciting cause of syphilis. The organism is from 6 to 15 “in length and presents from six to fourteen spiral turns. It is found constantly in primary and secondary and with difficulty in tertiary lesions. Its presence in a suspected lesion is regarded as diagnostic, while its absence does not exclude syphilis. CHAPTER SEE 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; and the infectious or contagious, which are due to the introduction into the body of a living poison. We no 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. is as de- pendent on the right amount of light, food, heat, and air as that of the rose in our garden. The word bacteria 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 organ- ism 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 microscopes at our command. The 28 BACTERIA AS THE CAUSES OF DISEASE 29 rounded organisms, or micrococci, as they are called, are seldom more than zst00 inch in diameter; the elongated cells average a little more perhaps, and are from zat00 tO seep inch in length. Different forms natu- rally vary from this standard of size; but these figures will give a good idea as to the actual size of the forms under consideration (Fig. I). The fungi connected with disease in man are divided into three classes: 1. Molds, or hyphomycetes. 2. Yeasts, or blastomycetes. 3. Bacteria, or schizomycetes. Pans ee 5 6 7 8 9 10. Wl 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 10, spirilla; 11, spiro- chete (McFarland). 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 spheric bacterium. 2. The bacillus—rod-shaped bacterium. 3. The spirillum—corkscrew bacterium. And these, which are species relatively monomorphous 30 BACTERIOLOGY —i. e., 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; if in a chain, they are 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 consti- tute a zodglea. Those developing in fours are called tetrads; in eights, sarcine. a b Cc a a> 932990 © A) 2 +) } ee g h i j Fig 2.—Diagram illustrating the morphology of cocci: a, Coccus or micrococcus; 6b, diplococcus; c, d, streptococci; e, f, tetragenococci or merismopedia; g, , modes of division of cocci; 7, sarcine; 7, coccus with flagella; k, staphylococci (McFarland). The cocci are also named according to their func- tions, as, for instance, “‘pyogenic,’’ or pus-forming; the specific name also describing the form, arrangement, color, and function; for example, Staphylococcus pyogenes aureus signifies a spheric colorless micro-organism form- ing a yellow pigment, arranging itself with its fellows into the form of a bunch of grapes, and producing pus. As the surgical nurse carries on a daily warfare for the destruction of pus micro-organisms and prevention BACTERIA AS THE CAUSES OF DISEASE 31 of their growth, she cannot be too familiar with every aspect of these germs. The two most constant pus formers are: (1) the staphylococcus (Fig. 2, k), which, when present in a wound, may cause a free flow of pus; still it generally manifests a milder disease con- dition than the virulent (2) streptococcus germ (see Fig. Noes; ies 2.0, id): ) Staphylococci may be observed under the microscope by placing a drop of the pus upon a cover-glass, after- ward spreading the specimen by applying another cover-glass; dry over an alcohol lamp and stain with a solution of methylene-blue. Wash away the excess and place the specimen face down upon a glass slide. Streptococci are best stained by the so-called Gram method. To a dried and spread drop of pus upon a cover-glass apply an excess quantity of the following: Anilin, 4 parts. Saturated alcoholic solution of basic anilin dye, kas Water, KOOL Stain in this for fifteen minutes; transfer to Gram’s solution: Todin, 4 parts. Potassium iodid, Baer Water, 200° ~<; Stain for four minutes; remove and wash the specimen in 95 per cent. alcohol; finally stain in the followers for half a minute: Bismarck brown, 3 parts. Water, | fOr 32 BACTERIOLOGY Wash in 95 per cent. alcohol; clear the specimen by adding a few drops of carbolxylol; place upon a glass slide for observation. Anyone capable of developing an ordinary kodak film will find but little difficulty in learning this apparently deeply mysterious technic of the bacteriologic laboratory. Bacteria reproduce in two ways: By direct division (fission) and by the development of spores or seeds (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 in- CS> —»5 ( O-9 Ces a b C d € i Fig. 3.—Diagram illustrating sporulation: a, Bacillus inclosing a small oval spore; 6, drumstick bacillus, with terminal spore; c, clostridium, with central spore; d, free spores; e and f, bacilli escaping from spores (McFarland). crease 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- terium seems to die, as if its vitality were exhausted BACTERIA AS THE CAUSES OF DISEASE Ba 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 favor- able. If all bacteria were of this kind, it would be possible to exterminate them with considerable rapid- ity. Spores will survive a great heat, a heat which will kill the organism from which the spore came; they will also live under a treatment with germicidal solu- tions 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 surroundings for their growth pre- sent 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 bacteria are, first, a temperature ranging from 85° to 104° F., some forms requiring a higher and some a lower tem- perature. Some forms of bacteria are not influenced in their growth by the presence or absence of light. To some, sunlight is destructive. A few hours’ exposure to the sun is fatal to the anthrax bacillus and to cultures of the Bacillus tuberculosis. The rays of the sun, how- 3 34 BACTERIOLOGY ever, must come into contact with the germs and are usu- ally active only on the surface of cultures. The majority of bacteria grow best when exposed to the air. Some develop better if the air is with- held; some will not grow at all if the least amount of oxygen is present. Those that grow in oxygen are called the aérobic bacteria, and those that will. not grow in the presence of oxygen are the anaérobic bac- teria. 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 growth 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 BACTERIA AS THE CAUSES OF DISEASE 35 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. 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 inspiration of the specific organisms. The direct transmission of bacteria from a parent to the fetus has long been a disputed question, but is now generally conceded. The micro-organisms pass through the placenta and infect the fetus. Tuberculosis of the ovaries, Fallopian tubes, and uterus may originate through the blood or from with- out through the vagina. Infection through the blood is evidenced by the general tuberculosis of all the viscera. 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 in some part of the body where they grow more or less luxuriantly, and in the secretions and ex- cretions 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 36 BACTERIOLOGY lodge in any part of the body and make its home there. Hence we hear of tuberculous glands of the neck, tuber- culous knee, intestinal tuberculosis, tuberculosis of the kidney, bladder, uterus, ovaries, Fallopian tubes, tuber- culous peritonitis, etc. A tuberculous 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 pro- duce 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 be obtained the existence of the disease is impossible. All these re- quirements have been met in many instances, and now there are a large number of diseases each one of which has been definitely proved to be caused by a germ of its own, a germ which produces that disease and no other. Most of the germs need a special train of circumstances in order that they may 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 BACTERIA AS THE CAUSES OF DISEASE 37 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 germs must be active, and they can act only under cer- tain conditions. It will usually be found that the attack of the disease has been preceded by a local 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 in our lungs, it may be controlled to a certain extent by a 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 mountains, Southern Cali- fornia, or of the other Southwestern States, where there are few cloudy days and where violent atmospheric changes are rare. The germs there cannot be so active, 38 BACTERIOLOGY for the air is stimulating, pure, and sunlight has an inhibitory action upon the tubercle bacillus. The rare- faction of the air causes deep and strong involuntary respiratory movements, and there is consequently en- forced a better ventilation of the lungs and a better oxygenation of the blood, in consequence 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 difficult 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 tuberculous 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 ac- quired immunity we have two varieties, that which comes from having had the disease and artificial im- munity produced by injecting special antitoxins. BACTERIA AS THE CAUSES OF DISEASE 39 By natural immunity is meant the natural and con- stant resistance to disease-producing germs. The indi- vidual is immune by Nature and sometimes by racial characteristics. Acquired immunity is a power of resistance attained through various circumstances. Thus, a single attack of some of the infectious and contagious diseases usually confers immunity 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 rule, 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 complete or permanent as that resulting from an attack of the actual disease. Acclimatization immunity is exemplified by various diseases which do not trouble natives or those long resident, but which may affect strangers not inured to the climate. Racial immunity is that in which certain races are safe from certain diseases; for instance, negroes seldom suffer from yellow fever, but are more susceptible than whites to small-pox. It is asserted that the Arabs sel- dom or never have typhoid fever. An analogous exam- ple 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 influences in respect to climate, food, and surroundings. 40 BACTERIOLOGY Artificial immunity may be produced im various ways. It is said that an myection of the antitoxm 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 in a slight degree, mto the consideration of the many theories of immunity, since they are very intricate, and not ome has been advanced so far the = can clearly explain it. The theory of phagocytosis” Fig. 4 —Phagocyte destroying a bacillus (Landerer). and the theory of antitoxins are the two most impor- tant. 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. In a 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 — BACTERIA AS THE CAUSES OF DISEASE 4I thus been educated to withstand the poison, their de- scendants 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 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 as- | cending 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 rendering it also immune to the bacteria that have 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 antitoxic substances; and it is now the general be- lief that immunity, at least of the acquired form, is due to such antitoxins. The uses and practical pre- paration of antitoxins will be described in the next chapter. The most important of the special surgical micro- organisms—1. e., those most frequently met with in surgical work—are the following, the majority being pus producers: 42 BACTERIOLOGY 1. Staphylococcus Pyogenes Aureus——This is the most common form; it is quickly killed by carbolic acid (1 : 20), bichlorid of mercury (1 : 1000), or by a few moments’ boiling. It is found in the mouth, alimentary canal, and under the nails; 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 is a most important patho- genic micro-organism, and is thought by many authori- ties 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 endometritis, ulcerative endocarditis, acute septicemia, and other diseases. It is one of the most common causes of postoperative peritonitis. 3. The Bacillus coli communis is always present in the intestines, and, while ordinarily active in the proc- esses of digestion, it is thought to be a frequent cause of acute suppurative peritonitis. 4. The Staphylococcus pyogenes albus resembles the aureus in 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 pyog- enes aureus. 5. The Staphylococcus epidermidis albus is a micro- coccus which is almost always present upon the skin, not only upon the surface, but also in the outer layers. BACTERIA AS THE CAUSES OF DISEASE 43 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 Bacillus 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 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 pneumoniz, 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 ab- scesses. 11. The bacillus 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 is a disease due to the absorption of its toxins, which poison the nervous system pre- cisely as would dosing with strychnin. 44 BACTERIOLOGY 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. The Spirocheta pallida is the cause of syphilis and it is transmitted usually by direct inoculation from one infected with the disease, the primary and secondary lesions being most infectious. CHAPTER All 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 facts cannot 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 borne in 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 kept in aseptic con- tainers the antitoxins are not at all dangerous; they are as innocuous as an equal amount of blood-serum administered in the same way. Antitoxins are used both to counteract the effects of the toxins which are elabor- ated by pathogenic bacteria in the body, and to render the system 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, they are not germicides. In fact, the antitoxic serums 45 46 BACTERIOLOGY 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 oppor- tunity 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 elanders. 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 of a 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 75 of I c.c. is injected intravenously. The horse responds with all the consti- tutional symptoms of diphtheria, such as a chill, fever, loss of appetite, more or less pharyngeal paralysis, THE THEORY OF ANTITOXINS 47 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 c.c. of blood are drawn from the external jugular vein. This is allowed to clot, and the serum obtained is known commercially as antitoxin. It is 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 because some eminent bacteriologists believe that the strepto- coccus of erysipelas is not identical with the streptococcus of puerperal fever. It is but fair to say, however, that others equally eminent assert the identity of the two streptococci. To meet the possibility of the non-iden- _ tity of the organisms a culture obtained from the two sources is used. Its virulence is increased by passing it through rabbits. After passing through about fifty rabbits a culture is planted in beef-tea, and the same course pursued as for diphtheria antitoxin. Antitubercle serum is obtained by immunizing 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 anti- toxin neutralizes the toxin in the body and thereby gives the natural germicidal powers an opportunity to dispose of the bacteria. It may be that it has the 48 - BACTERIOLOGY additional property of stimulating the phagocytic and possibly other bactericidal functions. The following experiments made by Martin and Cherry, of Mel- bourne, - Australia, and described in the Jour. Amer. Med. Assoc. 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 chemical 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 were used. 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 few hours. 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 49 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 dif- ference 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-Loff- 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 few years 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 suspected diphtheria, and employ I000 units as an immunizing 4 50 BACTERIOLOGY dose. During the months of November and December, 1898, this department treated 219 cases of bacteriologic- ally proved diphtheria—all charity cases—with a death- rate of 4.1 per cent. Some years ago, when antitoxin was not used, the death-rate from diphtheria treated by this department 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 short- ening the duration of the disease and in preventing unfortunate complications and sequele, such as otitis media and other suppurative processes due to strepto- cocci. A mixture of the toxin of the streptococcus of ery- sipelas and the products of a harmless germ, the Bacillus prodigiosus, is used by Coley and others as an injec- tion in malignant tumors that are past the stage of operation or are so situated that an operation is im- possible. Tetanus antitoxin is valuable as a prophylactic treat- ment, and if used in large doses in the early stages it is the best known method for the treatment of tetanus. The antitoxin may be introduced subcutaneously, intra- venously, and intradurally. Small doses are practically valueless, but large and repeated doses are very successful. Antityphoid vaccine has now practically prevented typhoid fever, but it is useless as a therapeutic agent. Antitoxin in cerebrospinal meningitis is given intra- durally and is moderately successful, especially if given early. THE THEORY OF ANTITOXINS 51 Flexner’s serum in infantile palsy is at present being tried. It is apparently very successful if given early. 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 is not necessary to use massage 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 symp- toms beginning an attack of erysipelas—chill, local redness, and high temperature. Within the last few years certain serum reactions have developed. By the use of these methods the presence or the absence of a disease is detected. For example, syphilis, the presence or absence of it may be deter- mined by a complicated serologic reaction called the Wassermann test. To obtain blood for this test the finger is stuck with a blood sticker and the blood pressed into a test tube until it is three-quarters full. SROs TEES ae a mgt." =: ¥oes E dig Nm or et ~ cat. >.“ x= 2000 . Bo Ee Add bop - £GeS 2% A =)3000 a WE ee ee a I qt. “ I 4000 ae is 33 gr. “ce ac I qt. “ce I : 5000 cc is 3 gr. cc - ria 1 6..+- {830000 si So ei ES PERCENTAGE SOLUTIONS (APPROXIMATELY) To make— 1 dram of a 1 per cent. solution use 3 gr. + of the drug. I dram cc 2 “ce ce “e 15 gr. ce “ce tdram “ = “ cc a3 ai gr. “ “ I oz. wy « ce ‘ 5 gr. a “ “ I Oz. ae 2 cc ac ac Q> gr. ce “ I Oz. cc 4 ce cc ce 19 gr. is c METRIC SYSTEM Solids. Approximate Liquids Approximate equivalent. equivalent. i Sines 0.065 gram. -I minim... 0.06 C.c. : ounces 30.000 grams. 1 gunce. -. \_Z000 ce Tipe. 2 os 500.000 grams. t pint. -.-. 500.00 C.C. I quart.... 1000.00 c.c. or 1 liter. Examples To make— tooo c.c. (1 liter) of a 1 : 500 solution use 2 grams of the drug. 1000 C.C. = ** 11000 a VS i eae oe 5 1000 C.C. 65 Mery 2606 e ie pane °. Labarraque’s solution is a solution of chlorinated soda, and is made from chlorinated lime and sodium carbonate. It is used as an antiseptic in solutions of I : 10, and for cleansing purposes. PART II SURGICAL TECHNIC CHAPTER WV BANDAGING AND DRESSINGS BANDAGING A NURSE will be frequently judged by her ability to ap- ply a bandage properly. Materials.—They may be of unbleached muslin, gauze, black or white, flannel; crinoline, or gauze for plaster-of- Paris; or rubber. Muslin purchased in large rolls is cut in lengths of from 6 to 8 yards. The end of the muslin is cut in the desired widths for bandages and torn in strips. Rolling by Hand.—One end of the bandage is folded upon itself several times and rolled between the thumb and first finger of the left hand until it becomes firm enough to hold between the fingers. The folded por- tion is held between the thumb and index finger of the left hand and rotated by the thumb and second finger of the right hand. The bandage machine consists of an upright and octagonal shaft mounted upon a metallic base which may be screwed toa table. The shaft is turned by hand 5 65 66 SURGICAL TECHNIC or foot, depending upon the type of machine used. The width of the space on the shaft is regulated by a movable upright. The bandage is fed to the roller by the left hand. It should be rolled tense, and when the bandage is finished the crank is reversed automatically, releasing the bandage from the shaft, allowing it to be pulled out (Fig. 6). It is now considered cheaper to buy bandages already rolled in yard lengths and cut as needed (Fig. 7). Ny Fig. 6.—Hand roller-bandage machine. (Fowler’s Surgery.) Application of Bandage.—Bandages are used to hold splints and dressings in place, to give support as in frac- tures. They should be applied moderately tight. If support is the motive, a number of turns will secure this much better than a few tight ones. It is much better to apply a bandage too loosely than too tightly. In applying wet dressings, always remember to allow for shrinkage. A bandage is started by placing the outer surface of the initial extremity upon the starting-point and holding it with index-finger of the left hand. With BANDAGING AND DRESSINGS 67 the roller held in the right hand, two turns are made in the direction which the bandage is to take. To overlap is to make a second turn cover a certain portion of the preceding turn. This is the procedure in all spiral bandages. To recur is to catch a turn at some point and turn it in such a way so that it either exactly retraces its course or turns off slightly in another direction. Fig. 7—Mitre box and Christy knife for cutting bandages. (Fowler’s Operating Room and the Patient.) To Reverse—The bandage is turned laterally upon itself, so that the part that was external is now internal. This is performed by holding the bandage in place with the thumb of the left hand, slightly relaxing the roller while pronating the right hand (Fig. 8). The thumb is now removed and the bandage tightened and continued around the part until the second reverse is reached, where the same procedure takes place. It is very necessary to have the turns in alignment. This may be made in the opposite direction, 7. e., descending or ascending. The 68 SURGICAL TECHNIC object of reversing a bandage is to adapt it to the change in diameter of the part. To Secure.—The end of the bandage is split into two tails. These are passed in opposite directions around the part and tied in place. The end of the bandage may also be pinned, but great care should be used so that the pins do not penetrate the bandage and stick into the part. Fig. 8.—Making the reverse. (Fowler’s Surgery.) Removal.—Each turn should be taken off reversely from the way it was put on. There are three general types of bandage, of which all others are modifications: circular, spiral reversed, and figure-of-8. Barton’s Bandage (2 inches by 6 yards).—The initial end of the roller is placed on the head under the mastoid process and the bandage is carried upward and in front of the parietal eminence, across the vertex of the skull, ee BANDAGING AND DRESSINGS 69 downward in front of the ear, under the chin, upward in front of the opposite ear, over the top of the head, where it crosses the first turn and back to the starting-point. The bandage is then continued forward below the right ear, in front of the chin, and back to the starting-point. These turns should be continued until the end of the bandage is reached. Fig. 9.—Barton’s bandage. (Fowler’s Surgery.) Secure with adhesive plaster or pins introduced where the bandage crosses. In applying this bandage great care should be taken to see that each turn overlaps the preceding turn and that the bandage crosses in the me- dian line of the skull (Fig. 9). Uses.—To retain dressings on face, fractures and dis- locations of lower jaw. Gibson’s Bandage (2 inches by 5 yards).—This ban- dage consists of three turns from the occiput to the fore- head and back again. On the final turn the bandage is reversed as it reaches the front of the ear. It is then 7O SURGICAL TECHNIC carried downward under the chin, thence up on the op- posite side, and back to the reversing point. This turn is repeated three times and the occipitofrontalis portion of the bandage is repeated three times. It is secured by pins placed at the reversing and inter- secting points (Fig. Io). Uses ——Same as Barton's bandage. Fig. 1o.—Gibson’s bandage. (Fowler’s Surgery.) Recurrent Bandage (2 inches by 4 yards)—Fix the roller by a circular turn from the occiput to the fore- head and back again. Continue for two turns. Upon reaching the occiput at the end of the second turn the bandage is reversed, carried forward, across the top of the head to the frontal region, where it is held in place by an assistant and reversed backward and forward, first on one side and then on the other, overlapping the pre- vious turn by ? inch until the entire head is covered. The bandage is then again reversed and the free ends held in place by circular turns around the occipitofrontal BANDAGING AND DRESSINGS 71 region and secured by pins at the reversing points (Fig. aT): Uses.—To retain dressings to the head and scalp and to make compression. Double Head Recurrent (2 inches by 4 yards).—Two bandages. The ends of the bandages are sewed together. Place the portion between the two rollers on the forehead and carry the rollers backward until they meet opposite Fig. 11.—Recurrent bandage of the head. (Fowler’s Surgery.) the occipital protuberance. At this point the bandages are reversed, one going circularly around the head, the other backward and forward over the scalp, each turn being caught by the circular bandage, and so on until the head is entirely covered. The bandages are then continued as circular turns until the bandage is finished. Uses.—To retain dressings to the scalp. Occipitofrontal Bandage (2 inches by 4 yards).—The end of the bandage is placed upon the forehead. To fix 72 SURGICAL TECHNIC it, a circular turn is made around the forehead and the occiput. A circular turn is then made so that it reaches down as far as possible posteriorly and as far up on the forehead as possible. The next turn is made so that the posterior portion is above the occiput and the anterior portion above the eyebrow. These turns may be re- peated as many times as desired (Fig. 12). Uses.—To secure dressings on anterior and posterior portions of scalp. Fig. 12.—Occipitofrontal bandage. Liebreich’s Eye Bandage.—Strip of flannel, white or black, 23 inches by 8 to Io inches, fitted with tapes at the extremities. Apply to one eye obliquely, reverse the tapes by crossing at the occiput with a circular turn, and tying. Apply to both eyes transversely with circular turn of the tapes and tie (Fig. 13). . Crossed Bandage of Eye (2 inches by 6 yards).—The bandage is fixed by a circular turn from the occiput to the forehead. The bandage is then carried from the BANDAGING AND DRESSINGS 73 occiput below the right ear, up over the outer portion of the cheek to the base of the nose, and continued to the occiput, passing below the left parietal eminence. These Fig. 13.—Modified Liebreich’s eye bandage. turns are alternated, the one passing below the ear over- laps the former turns two-thirds. Continue until the de- Fig. 14.—Figure-of-8 of one eye. sired result is obtained. Flannel bandage is more com- fortable (Fig. 14). Uses.—To retain dressings to the eye. 74 SURGICAL TECHNIC Double Crossed Bandage of Both Eyes (2 inches by 6 yards).—The bandage is fixed by two occipitofrontal circular turns. The bandage is then carried forward below the ear, crossing the cheek to the root of the nose, and back to the occiput. A circular occipitofrontal turn is then made, and the bandage carried below the right parietal eminence to the root of the nose; downward across the cheek under the left ear, to the occiput. These turns are repeated as described above until the desired result is obtained (Fig. 15). Use.—To hold dressings on both eyes. Fig. 15.—Figure-of-8 of both eyes. Figure-of-8 of Head and Neck (2 inches by 3 yards).— Fix the bandage by two circular turns around the neck, starting just below the occiput. Then carry the bandage upward above the right ear over the forehead above the left ear and back to the starting-point. Alternate these turns until the bandage is finished. Uses.—To retain dressings to the throat and back of the neck. Suspensory and Compressor Bandages of the Breast (23 inches by 7 yards).—Place the end of the bandage . BANDAGING AND DRESSINGS 7 upon scapula of the injured side. Secure by two oblique turns carried over the opposite shoulder and conducted downward under the breast and carried to the axilla of the same side. Then carry the end of the bandage trans- versely around the chest, covering in the lower portion of the injured or affected breast. Repeat these turns, the oblique turn from the axilla over the shoulder alternating with the transverse turns around the chest until the Fig. 16.—Bandage for the breast. (Fowler’s Surgery.) breast is covered in. Each series of turns in ascend- ing should obscure two-thirds of the foregoing turn (Fig. 16). | . Use.—This bandage is used to hold dressings to the breast and make compression on the breast at the same time. Double Breast Bandage.—The roller is started from the scapula of the affected side, and carried over the. shoulder of the opposite side to the front of the chest, thence under the affected breast and obliquely along the 76 SURGICAL TECHNIC lateral and back of chest to its starting-point. This — turn is repeated in order to secure the end of the bandage. ~ The second turn is a circular one around the chest just _ below the breasts. The third turn is started at the point — of the initial extremity, and the bandage is carried around — the chest wall to the under surface of the second breast. _ From here it is carried over the front of the chest, thence ~ over the opposite shoulder, and back over the chest to the 3 starting-point. First, second, and third turns respec- Fig. 17.—Double breast bandage. (Fowler’s Surgery.) tively are now repeated, each turn covering in two-thirds of the foregoing turn, and in this way both breasts are securely and neatly covered (Fig. 17). Use.—Support and pressure of breast. Figure-of-8 of Back and Chest (23 inches by 7 yards). — Place the initial end of the bandage on the back between the scapule. Carry the bandage upward over the right shoulder, down under the axilla, and back to the starting- point. Continue over the left shoulder to the axilla and BANDAGING AND DRESSINGS 7 77 back to the starting-point. Continue these turns until the bandage is finished (Figs. 18, 19). Uses —To retain dressings on upper part of back and to pull shoulders back. Fig. 18.—Posterior figure-of-8 Fig. 19.—Anterior figure-of-8 bandage of the chest. (Fowler’s bandage of the chest. (Fowler’s Surgery.) Surgery.) - Spica Bandage of the Shoulder (24 inches by 7 yards). —Fix the bandage by circular turns at the insertion of the deltoid. Then carry the bandage across the arm, over the anterior portion of the chest to the axilla, and across the back to the starting-point, then under the arm and repeat as described above, each turn overlapping the previous turn two-thirds. Continue thus until the shoulder is covered. This bandage may be put on in a similar way for the left shoulder, providing one uses the left hand (Fig. 20). Use.—To retain dressings on shoulder. 78 SURGICAL TECHNIC Fig. 20.—Ascending spica of the shoulder. (Fowler’s Surgery.) Velpeau’s Bandage.—Two to three rollers, 2} inches by 7 yards each. The hand of the injured side is placed Fig. 21.—Velpeau’s bandage— Fig. 22—Velpeau’s bandage— first turn. (Fowler’s Surgery.) second turn. (Fowler’s Surgery.) so that the tips of the fingers touch the sound clavicle. The initial end of the bandage is placed over the sound BANDAGING AND DRESSINGS 79 scapula and the bandage carried over the point of the affected shoulder, then backward over the outer surface of the arm, behind the elbow, across the chest to the sound axilla, and under it to the starting-point. Repeat this turn, thence making a circular turn around the chest over the top of the injured elbow and back to the starting-point. The first turn is repeated, overlapping three-quarters of the first turn toward the middle line of the body, then a circular turn, then a shoulder turn until the tip of the Fig. 23.—Velpeau’s bandage completed. (Fowler’s Surgery.) elbow is reached by the shoulder turns, after which only circular turns are made until the arm is encased in the bandage. In applying this bandage, as in any other bandage where skin surfaces come together, a layer of lint or a towel should be placed between the surfaces to prevent excoriation (Figs. 21, 22, 23). Use.—Fracture of clavicle. Descending Spica of Shoulder (25 inches by 7 yards).— The initial end of the roller is placed over the sound scap- 80 SURGICAL TECHNIC ula and the bandage carried upward over the injured — shoulder, downward to the anterior fold, through the axilla, then upward and forward over the shoulder, across the chest, under the opposite axilla to the starting-point, each turn overlapping the preceding turn two-thirds. Repeat these turns until the shoulder is covered. Use.—To retain dressings on shoulder. 7 Desault Bandage (2 inches by 7 yards).—Three to five ~ rollers. Oval pad for axilla. First Roller—The arm is elevated with the oval pad placed in the axilla. The free end of the bandage is — rae Fig. 24.—Desault’s bandage, first _ Fig. 25.—Desault’s bandage, roller. second roller. placed over the pad and held in place by two or three circular turns around the chest. Each turn should over- lap the preceding one two-thirds of its width. It is then brought across the front of the chest, over shoulder, under the axilla, and back to the starting-point. Second Roller.—The arm is brought down to the side of the body with the elbow flexed at a right angle and held in place by circular turns around the chest and arm until the arm is covered, each turn overlapping the pre- BANDAGING AND DRESSINGS 81 ceding turn two-thirds. This may be started from above downward or the reverse. Third Roller —The free end of the bandage is placed in the sound axilla and the bandage carried obliquely across the front of the chest, over the injured shoulder, down the back of the arm to the elbow, thence upward over the forearm to the starting-point. Then upward across the back of the chest, over the injured shoulder, down the front of the arm, around the elbow obliquely, upward across the back to the starting-point. These turns should Fig. 26.—Desault’s bandage, third roller. -be alternated, each turn overlapping the preceding turn until three sets have been completed (Figs. 24, 25, 26). Uses.—Fracture of clavicle and dislocation of shoulder. Jones’ Position for Fracture of the Elbow.—This con- sists in flexing the forearm upon the arm and by holding it in place by a strip of adhesive plaster wound several times around the arm and forearm, and the arm supported by tying the wrist to the neck by means of a bandage. Figure-of-8 Bandage of the Elbow (2 inches by 4 yards). —The bandage should be applied with the elbow flexed. The end of the bandage is applied a few inches below the 6 : 82 SURGICAL TECHNIC elbow-joint. A few circular turns fixes the bandage. The end of the bandage is then carried across the flexure of the joint and a circular turn is made a few inches above the joint. The bandage is then carried obliquely to the start- ing-point and a circular turn is here made. Alternate the circular turns below the joint with those above the joint, each time obliquely crossing the flexure of the elbow. The turns gradually approach the tip of the olecranon Fig. 27.—Figure-of-8 bandage of the elbow. (Fowler’s Surgery.) . from both directions and the bandage is completed by a circular turn (Fig. 27). Uses.—To retain dressings and as part of the spiral reversed of the upper extremity. Spiral Reversed of the Forearm (23 inches by 7 yards). —The end of the bandage is fixed by one or two circular turns around the wrist. It is then carried upward by two or three spiral turns until the increased circumference BANDAGING AND DRESSINGS 83 makes reversed turns necessary. These turns are made by holding the bandage in place with the thumb of the left hand, slightly relaxing the roller held in the right hand, and at the same time pronating the right hand. The bandage is now continued around the forearm, where another reverse is made, and so on until the elbow is reached, where the bandage is ended by circular turns. Use.—To retain dressings on forearm. Spiral Bandage of the Finger (1 inch by 1} yards).— The bandage is secured by circular turns around the Fig. 28.—Spiral bandage of the finger. (Fowler’s Surgery.) middle phalanx, and carried over the tip of the finger by oblique turns. It is then continued, gradually ascending the finger by circular turns, each turn overlapping the preceding one by two-thirds until the base of the finger is reached. It is then passed obliquely across the back of the hand to the wrist, where one or two circular turns are made. It is then carried to the base of the finger, where it is pinned or tied in place (Fig. 28). Use.—To retain dressings to fingers. 84 SURGICAL TECHNIC Spiral Reverse of Finger (1 inch by 1} yards).—The end of the bandage is secured by one or two turns of the bandage around the phalangeal joint, and the bandage carried upward by spiral reversed turns until the base of the finger is reached. Finish by circular turns. Use.—To hold dressings on fingers. Spica Bandage of Thumb (1 inch by 13 yards).—The bandage is fixed by circular turns around the wrist. The bandage is then continued over the back of the hand to the tip of the thumb, across the tip of the thumb, over the back of thumb to the wrist, where a circular turn is Fig. 29.—Spica of the thumb. (Fowler’s Surgery.) made. These turns are repeated, each turn overlapping the preceding turn by two-thirds, until the thumb is covered (Fig. 29). Use.—To retain dressings to the thumb. Demigauntlet Dorsal Bandage (1 inch by 4 yards).— The bandage is fixed by circular turns at the wrist. It is then carried across the back of the hand to the base of the first finger, where a circular turn is made and the ban- dage is returned to the wrist. Each finger is encircled in turn and the bandage is finished by a few figure-of-8 turns around the wrist and hand (Fig. 30). Use.—To hold dressing on back of hand. BANDAGING AND DRESSINGS 85 Demigauntlet Palmar Bandage.—The application is the same as the demigauntlet bandage of the dorsal sur- face of the hand, with the exception that the turns are made across the palmar instead of the dorsal surface of the hand. Use.—To retain dressings to palmar surface of hand. Fig. 30.—Demigauntlet bandage. (Fowler’s Surgery.) Single Spica of Groin, Ascending (23 inches by 7 yards). -—This bandage should be applied with the right hand for the right side and with the left hand for the left side. The bandage is fixed by circular turns around the abdo- men. Upon reaching the anterior superior spine, the bandage descends across the groin around the thigh, up to the anterior superior spine, where a circular turn is made around the abdomen. These turns should be alternated, each turn overlapping the preceding turn by two-thirds. The bandage is completed by a circular turn around the abdomen (Fig. 31). Use.—To retain dressings in groin. 86 SURGICAL TECHNIC Fig. 31.—Ascending spica of the groin. (Fowler’s Surgery.) Descending Spica of the Groin (23 inches by 7 yards). —The descending spica of the groin is applied in the same manner as the ascending, with the exception that the pe Sekai Sas: 2 Fig. 32.—Descending spica of the groin. (Fowler’s Surgery.) turns descend instead of ascend. It is necessary to have the first turn, then, as high as possible (Fig. 32). ’ Use.—To retain dressings to the groin. BANDAGING AND DRESSINGS 87 Double Spica Bandage of Groin.—Instead of using the complicated double bandage, it is advisable to apply a right and left single spica. Figure-of-8 of the Knee (24 inches by 2 yards).—The bandage is fixed by circular turns around the upper portion of the leg. It is then carried across the popliteal space and a circular turn made around the thigh, descend- ing across the popliteal space, and by circular turns car- ried around the leg. These turns are repeated, each turn Fig. 33.—Figure-of-8 of the knee. (Fowler’s Surgery.) overlapping the preceding turn two-thirds until the popliteal space is covered in. The bandage is completed by a few circular turns around the thigh (Fig. 33). Use.—To retain dressings to popliteal space. Recurrent Bandage for a Stump (2% inches by 6 yards). —Fix by circular turns near the lower end of the stump. Continue by recurrent turns covering in the end of the stump. Complete by ascending oblique spiral or spiral reversed turns, each turn overlapping two-thirds of the preceding turn (Fig. 34). 88 SURGICAL TECHNIC Figure-of-8 Bandage of Leg.—The end of the bandage is fixed by one or two circular turns around the ankle. The bandage is then carried upward by spiral turns until the diameter of the leg increases, necessitating oblique turns. The bandage is then carried up across the leg to just below the knee, where a circular turn is made, then downward across the anterior surface of the leg. These turns are repeated, each turn overlapping the previous Fig. 34.—Recurrent bandage of the stump. (Fowler's Surgery.) turn two-thirds of its width until the whole leg is neatly covered. The bandage is completed by one or two circular turns just below the knee. Use.—Retaining dressing to leg. Spiral Reverse of Lower Extremity (23 inches by 7 yards).—The bandage is fixed by circular turns around the ankle, and then carried upward by spiral turns until they no longer lie flat upon the leg. Then, by spiral BANDAGING AND DRESSINGS 89 reversed turns, the bandage is continued up to the knee, around the knee by figure-of-8 turns, and continued up Fig. 35.—Spiral reverse of the lower extremity. (Fowler’s Surgery.) the thigh by spiral reversed turns. The reversed turns are made as in the arm by drawing the bandage taut, holding it in place with the left hand, slightly relaxing the Fig. 36.—Figure-of-8 of the Mig 37. .opicas Of Sthe efoot. foot and ankle. (Fowler’s Sur- (Fowler’s Surgery.) gery.) bandage, pronating the hand so that the part of the ban- dage that was against the skin is now away from it. The gO SURGICAL TECHNIC bandage is continued around the leg until you reach the line of the reverse, where a reverse is again made (Fig. 35). Use.—To retain dressings on the lower extremity. | Spica Bandage of Foot (2 inches by 3 yards).—The bandage is fixed by a circular turn around the ankle and is then carried across the anterior surface of the foot to the base of the toes, thence across the sole of the foot, over the anterior surface of the foot, around back to the heel. These turns are repeated, each turn overlapping the preceding turn by two-thirds until the ankle is covered in (Fig. 37). Use.—To retain dressings to foot. - Fig. 38.—Method of covering the _—‘ Fig. 39.—-Figure-of-8 bandage of heel. the instep. To Cover the Heel (American Method) (Fig. 38).— Circular turns (3) about the ankle (to fix); descend by oblique turn across the back of the foot; circular turn at the base of the toes. Continue by covering the foot with ascending spiral reversed turns until the instep is reached. Cover the heel by circular turns from the instep to the heel, alternating with figure-of-8 turns about the sides of the heel. Complete by circular turns, as- cending the ankle. BANDAGING AND DRESSINGS OI Bandage of the Foot Not Covering the Heel (French) (Fig. 39).—Circular turns at the ankle (to fix). Ob- lique turn across the back of the foot, descending to the base of the toes, where a circular turn is made. Cover in the foot to the instep with spiral reversed turns (ascend- ing). Complete by circular turns about the ankle and lower leg. __ Complete Bandage of the Lower Extremity (see Fig. 35). —This bandage is used for applying compression to the leg to retain dressings. Circular turns at the ankle (to fix); oblique turn, descending across the dorsum of the Fig. 40.—T-bandage. foot, with a circular turn at the base of the toes. Con- tinue by covering in the foot and heel. Ascend the leg by circular, oblique, spiral, or reversed spiral, covering in the calf. Continue by figure-of-8 turns at the knee. Complete by ascending spiral or reversed spiral of the thigh. T-Bandages, Slings, and T-Binders.— Materials.— These are best made from heavy unbleached muslin or flannel. A T-binder should consist of two pieces of material about 4 to 6 inches in width. The horizontal portion Q2 SURGICAL TECHNIC should be sufficiently long to surround the part to be bandaged and the vertical length should be about 18 | inches. The second piece is sewed to the middle of the first (Fig. 40). : Slings are most frequently used to support the fore- arm and are usually designated as the handkerchief and roller. The handkerchief sling consists of a piece of material approximately 1 yard square folded diagon- ally. It is preferable to the roller sling. Fig. 41 —The Scultetus bandage. A roller sling consists of a 3-inch roller bandage which is carried around the neck, then under the wrist, and the two ends drawn sufficiently tight to give the desired sup- port and tied. Scuitetus Bandage.—It is most frequently applied to the abdomen and is made of a piece of muslin or gauze about 16 inches in width and about one and one-half times the circumference of the part. In both free ends slits are made about 2 inches apart and 6 inches deep. It is used to retain dressings that require frequent changing. The opposite ends are tied in a bow-knot. BANDAGING AND DRESSINGS 93 ADHESIVE PLASTER Adhesive plaster dressings are usually used to fix joints, secure splints in fractures, and in strapping ulcers. Rubber Adhesive Plaster.—It is a manufactured prod- uct consisting of a linen material covered by a composite material with caoutchouc asa base. It has the property of adhering to whatever material it comes in contact with. Zinc Oxid Adhesive Plaster.—This plaster is prepared by incorporating rubber adhesive plaster with oxid of zinc. It is equally as adhesive as the rubber plaster, and possesses the advantage that it is not apt to produce irri- tation of the skin. This plaster has largely supplanted both the resin and rubber adhesive plaster in surgical dressings. Resin plaster is made of resin, lead, and wax spread on linen material, and when it comes from the manufacturer is covered by a thin tissue paper. It should always be kept in a cool place, otherwise it deteriorates. For application it is necessary to remove the tissue paper and gently heat. Moleskin adhesive plaster consists of spreading a zinc oxid material on moleskin or a heavy flannel. It is es- pecially useful in abdominal dressings where support is necessary, such as a Rose binder. Sayre’s dressing for fracture of the clavicle requires two strips of zinc oxid adhesive plaster 3 inches wide and sufficiently long to encircle the chest one and one-half times. A piece of linen encircles the injured arm, then ~one end of the strip is circled round the arm with the adhesive side toward the chest. The arm is pulled back- ward and the adhesive plaster carried across the posterior 94 SURGICAL TECHNIC chest under the sound arm and then back to the front part of the chest. Now draw the hand of the injured side forward until it touches the sound clavicle. The remaining strip is placed on the back over the injured arm and carried downward over the tip of the elbow of the injured side, up over the back of the hand, over the sound shoulder to the starting-point. It is well to cut a hole m the center of the adhesive where it crosses the elbow (Figs. 42, 43). a i as ceno Se aad Fig. 43.—Sayre’s dressing—ante- rior view. (Keen’s Surgery.) Chest Strapping.—This consists of strips which are cut in widths of 23 inches and sufficiently long to reach from I inch beyond the spine of the vertebra to 1 inch beyond the sternum. With the patient sitting, the arm of the injured side is held up and the patient is told to exhale, at which time the straps are applied one after the other from below upward, each strip overlapping the other one-third (Fig. 44). BANDAGING AND DRESSINGS 95 Pelvic Binder.—This consists of a strip of moleskin adhesive plaster sufficiently long to pass one and one- half times around the hips. One end of the adhesive is placed just above the trochanter of the injured side, car- ried across the back over the crests of the ilium and back to the starting-point, and continued in this line until all the strip is in place. ft cea fer Sac | == S==. pert TTY PPA LI Sy Fig. 44.—Strapping the ribs (after A. S. Morrow). Figure-of-8 of the Knee.—This is well illustrated in the accompanying diagram. Strips should be 1 inch wide and II to 15 inches long (see Fig. 33). Strapping of Ulcers of the Leg.—Ulcer of the leg may be strapped in the circular or oblique method as is shown in the diagram (Fig. 45). Strapping of the Joints.—This requires strips of zinc oxid adhesive plaster 2 inches wide and sufficiently long to extend two-thirds around the joint. The first strap is applied a few inches below the joint and the strapping 96 SURGICAL TECHNIC continued until the joint is covered. Each strap should overlap the preceding strap by two-thirds. This dressing will be found to be satisfactory in the treatment of sprains of joints, etc. Strapping of the Ankle-joint—Straps of zinc oxid adhesive, 13 by 18 inches, are required. The first strap is started at a point midway between the knee and the as aS esis > = Fig. 45.—Strapping an ulcer of the leg. (Keen’s Surgery.) ankle, applied to the edge of the tendo achilles, carried across the sole of the foot and up the opposite side of the - leg. A strap is next placed so that its middle crosses the point of the heel, the ends being carried forward on the inner and outer surface of the foot. These straps should be alternated until the ankle-joint is covered in. One should avoid having these straps meet in the front of the foot or make circular constriction (Fig. 46). ee jade cca Ni le Sela all ee eS aS eS SlCr BANDAGING AND DRESSINGS 97 Buck’s extension is a method of obtaining traction upon the leg and thigh. The attachment is made by Fig. 46.—Strapping the ankle-joint. (Keen’s Surgery.) adhesive plaster and consists of straps 4% inches wide and long enough to reach from well above the knee to <2 — ee — Fig. 47.—Fracture of the thigh. Completed apparatus and, in addi- tion, a long outside T-splint, straps, and swathe. Weights applied. (Scudder.) ; loosely around the sole of the foot and up the opposite side of the leg to a point opposite the starting-point. A piece of wood, 5 by 3 inches, is then placed in the center 7 98 SURGICAL TECHNIC of the strap. A hole is cut in the center of the board through which a rope is passed. The adhesive surfaces of the plaster are placed on either side of the leg and thigh and are held in place by figure-of-8 turns of adhesive fol- lowed by a muslin bandage. The extension may be obtained by elevating the foot of the bed and tying the rope thereto, or by passing the rope over a pulley and attaching weights (Fig. 47). Montgomery Straps.—They consist of a strip of zinc oxid adhesive from I to 2 inches in width and from 3 to 6 inches in length. The corners of one end of the adhesive are turned in and this end punctured. A strip of tape is sewed or tied to this. These are placed to either side of the wound and tied over the dressing. Use.—To hold dressings in place. Catheter straps are similar to the above, but are nar- rower and shorter. PLASTER-OF-PARIS Plaster-of-Paris bandages, like all other bandages, are made in various lengths and widths. This bandage consists of unwashed crinoline or gauze with the mesh filled with the best dental plaster-of-Paris. The material may be cut in the desired width or length, or the whole width of the material may be rolled at once. If not used at once, they should be kept in covered metal boxes to keep out the dampness. Plaster bandages can be purchased at any good apoth- ecary shop. Application of Plaster-of-Paris Battade: —The part should first be covered by a flannel roller or a bandage made of raw cotton and held in place by a gauze bandage. 4 a : : : & le ; 3 BANDAGING AND DRESSINGS 99 In applying body casts, a union suit of heavy material is advisable. The plaster bandage should be immersed in water until the bubbles cease to escape, the excess water squeezed out, and the bandage applied by circular turns. Reverses in the bandage are allowable, but not advisable. After the application of each bandage, plaster of the consist- ency of thick cream should be rubbed in, as in this way less _ bandage will be required. In applying casts to the leg three to five bandages are usually sufficient. Strips of tin, zinc, or binder’s board may be placed between the layers of the bandage to increase the tensile strength. Plaster bandages set better on dry days. Heavy rubber gloves are desirable to keep the hands of the operator free from plaster, or if they are not used, sugar and glycerin will assist in removing the plaster. After the bandages are applied, great care should be used so that none of the plaster gets into the plumbing, as it will close the drain. Removal of Cast.—This is best done with a heavy knife, cutting obliquely to the plaster. Vinegar, peroxid of - hydrogen, etc., are useful to soften the plaster and assist in its removal. Windows or fenestrations may be cut in the cast. After the cast is dry it is well to confine the free ends in adhesive to prevent rubbing. SPLINTS Splints, padded with cotton-batting, oakum, wool, or hair, may be constructed from white pine, poplar, or willow wood, + to 4 inch (3-12 mm.) in thickness, cut to measured length and width; they may be of 100 SURGICAL TECHNIC pasteboard or binder’s board, molded to shape by soaking in boiling water, or of rawhide similarly worked; of felt; plaster-of-Paris; starch (dissolved in cold water, after which boiling water is added until the proper con- sistence is secured) requires from twelve to forty-eight hours to dry thoroughly (Fig. 48); gum and chalk (equal parts of gum arabic and precipitated chalk, add sufficient boiling water, stirring to obtain a proper consistence of solution) applied upon bandages; hatter’s felt or binder’s Fig. 48.—Splint made from plaster-of-Paris bandage. Complete by molding to the part; trim after setting has taken place. board may be softened in hot water and molded to the injured parts. The coaptation splint consists of thin and narrow board strips (of bass wood or pine) placed in position (side by side, with a slight interval) upon a sheet of adhesive plaster, or they may be quilted between two pieces of sheeting. The splint is held in position by bandaging or by adhesive straps, and may be employed in emergency or to reinforce the ordinary board or bracket splint. Fracture-box consists of a stout board 6 to 8 inches (15-20 cm.) wide by 18 to 30 inches (45-75 cm.) BANDAGING AND DRESSINGS Io!I long, with hinged sides, a foot-board, upright, firmly attached at right angles to the bottom board, padded with a pillow, cotton-batting, or bran; may be used in treat- ing fractures of the lower leg and knee. Bags made from stout muslin or light duck canvas cut 14 inches (35 cm.) wide by 3 feet (90 cm.) to 5 feet (1.5 m.) long, doubled, sewed, and inverted before filling with sand or bran, closed with a draw-string or by stitching, are employed in fractures of the leg and thigh. Compresses to prevent displacement may be made of cotton, lint (folded), oakum, and held in place by adhesive straps, bandage, or placed upon splints when padding. Prevent infection of the soft parts from maceration of the skin surfaces after fracture by a thorough cleans- ing of the parts before applying the first permanent dressing and by “‘alcohol rubs’’ at each subsequent dress- ing. Neuralgic pain in the region after fracture is due to organized blood-clot or exudate. Treat by massage. Swelling, loosening, infection, malposition of the parts will demand an examination or change of dressings and correction by the surgeon. CHAPTER -VI CARE OF OPERATING-ROOM; METHODS OF STERILIZATION; CARE OF INSTRUMENTS In almost all large hospitals there are three operat- ing-rooms, one for general surgical, one for gynecologic, and one for septic operations. This is ideal, but unneces- sary if correct methods of sterilization are employed. Fig. 49.—Kny-Scheerer instrument cabinet, having adjustable shelves and a plate-glass partition in the center, which practically divides it into two closets. Dressing-rooms on each floor are very desirable, for besides having everything at hand with which to 102 t | CARE OF OPERATING-ROOM 103 Fig. 51.—House stretcher. do a dressing properly, the nurse in charge of the patient has the opportunity to return and make up the bed afresh during the patient’s absence. Stretchers are 104 SURGICAL TECHNIC Fig. 52. Improved model sterilizer. used to convey patients to and from the operating- and dressing-rooms. The wheels - generally have rubber tires, the top-board is detachable and has four handles, CARE OF OPERATING-ROOM I05 two at each end. At least two stretchers are necessary on each floor. 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- or elbow-valves, so as to avoid 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 damp-swept and wiped every day; in short, it should be in such a condition as to be ready for an operation Fig. 53.—Sterilizing tube for edged instruments. at a few moments’ notice. The supplies for dressings should not be allowed to run down, and the instruments should always be in a first-class condition. An emer- gency bundle, containing everything necessary for an emergency operation, should be kept in readiness. Sterilization may be either dry or moist; moist heat is preferable, because it is more thorough and more penetrating than dry heat. For dry sterilization the towels and dressings may be placed in covered tin pans in an oven the temperature in which ranges from 160° to 212° F. This method is only used in an emergency. For moist or steam sterilization a Kellogg, a Sprague, or an Arnold steam sterilizer is 106 SURGICAL TECHNIC used. The heat must be continued 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 sterilizer and allowed to boil for fifteen minutes in a I per cent. solution of carbonate of sodium to prevent their rusting. All edged instru- ments to be boiled in the soda solution should be wrapped (ss Fig. 54.—Arnold sterilizer. Fig. 55 —Formalin lamp. in cotton 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 one of the reasons why they lose their edge. In a private house a tray or basin deep enough to allow the instruments being covered by the water are placed on a stove and boiled for fifteen minutes. Many operators prefer to have their edged instruments and needles placed in a dish contain- ing 95 per cent. alcohol for half an hour; then just before CARE OF OPERATING-ROOM 107 WLeIS— oS “Bry 1Z YQ-oolpeyy ‘Woo su Lean gqhal H 1% 1dso ydjeperyg ‘yey “el the operation they are taken out and rinsed with sterilized water. Usually the knives are placed in the last three minutes of the boiling time. _ 4 af f i ‘ t i 108 SURGICAL TECHNIC After sterilization the instruments are transferred to the instrument-table or to shallow porcelain trays, in Fig. 57.—The Rochester sterilizer for instruments and dressings. (De Lee.) which they lie covered with sterilized towels until re- quired. Fig. 58.—The Rochester sterilizer open. (De Lee.) 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 ee ee ee ee ee a ' J CARE OF OPERATING-ROOM 109 green soap. Instruments with permanent joints, which fortunately are seldom seen now, 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, locks oiled, and then laid away in the case. The knife-blades must be rolled in cotton. The important points to be re- Fig. 59.—Latest form of complete sterilizing outfit for dressings, water, in- struments, sheets, towels and operating gowns, basins and trays. membered in cleaning instruments after the operation are: First, all instruments that can be so dealt with must be taken apart and the rough catches thoroughly cleansed in cold water. 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 condition. LO SURGICAL TECHNIC 1a. 1 Hospital, Philadelph -Chirurgica 1cO i , Medi 1zing room ili Fig. 60.—Ster Instrument trays are made of porcelain or agate-ware. Instrument trays, pitchers, etc., are best sterilized in a large steam sterilizer built especially for this purpose. CARE OF OPERATING-ROOM III They should be allowed to remain in the sterilizer until used. Special sterilizers come for the disinfecting of bed-pans, douche-pans, etc. They are placed in a sterilizer containing the soiled contents with the lid of the sterilizer dropped in place and are then sterilized by steam. Later, by turning a spigot, the contents are Fig. 61.—Sterilizer for the disinfecting of bed-pans, douche-pans, etc. (Courtesy of Bernstein Manufacturing Co.) drained off and the receptacles are ready for use. All hospitals should be equipped with this apparatus. Every 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 to her, and each tries Ay ie SURGICAL’ TECHNIC to fulfil it in a thoroughly professional, dignified, and quiet d manner. Practice of this kind is never lost. | ‘In the operating-room should be kept two large ledgers, ! : \ -— ; = (See aS | Fig. 62.—Glass tray. | in one of which the house-surgeons, after making the morning rounds with the visiting surgeons, should record eee Saree Fig. 63.—Pus basin. the number of operations to be performed the next day, the time, name of operator, etc. The operating-room nurse is thus made acquainted, 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. 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 CARE OF OPERATING-ROOM 3 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 Fig. 65.—Metal tray. 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 is made out and the order in which the operations are written. The emer- gency operations, accidents, etc., are also recorded, but _after the performance of the operation. Date. Operation. Floor. | Time. | Operator. |Room/|Ward.| 3 ® | Floor. = S| poe Mar II. Laparotomy. / 4th A.M. Dr. Murphy. aie) 3d : Bei) eas BS ““ 2I “c oe Vaginal hysterec- tomy. [airs 9.00 “| “ Johnson. 24 S se Cholecystostomy. Ey 9.30 “| ‘* Fenger. 16 aS S Appendicectomy. a 10.00 “| “ Morgan. 18} Wat) wn * EOS fi akemdien D 6 ¢ Amputation. breast. e nine) | “Carter. D 9 ce (a3 “cc ce C6 « : : 2 P.M.| “" Andrews. | 24 4th a Appendicectomy. % 3.00 “| “ Fenger. 21 2d i esarean section. Se | 4.00 “1! “ Eyster. 21 4th Appendicectomy. 3d 6.30 “ “ Comegys. | 29 2d Clean operating-room, fourth floor; septic, third floor, 8 II4 SURGICAL TECHNIC The second book gives the date on which the patient was prepared for operation, by whom prepared, etc., as, for example— D f ; : Pr atnet ess | Prepared by nue Dc Operator. Floor. Room. | March ro. | E.A.S. Corros. sub. | Dr. Eyster. Fourth. No. 21. Date of | Sutures Length of Stitches ate Operation. Hour. | used. time prepared.| removed. Condition . March 11. | 4 P.M. | Silkworm- Two hours’ March to. Aseptic. gut. boiling. A book should also be kept in each dressing-room showing the number of cases dressed each day, the dressing used, and progress since the last dressing. It should be kept for the convenience of the dressing- room nurse in making an estimate of dressings for the next day, and for the convenience of the surgeon in knowing what patients are dressed, their condition, and in knowing when they are to be again dressed. It will also recall condition of last dressing. CARE OF OPERATING-ROOM II5 Died or echareed: Remarks. Ward. | Diagnosis. | Operated. | Operator. | Dressed. | _—— ss ee eee No. 20, Appendicitis. | March rr. | Dr. Come- [March 17.| Discharged ad floor. gys. April 2. CHAPTER VII INSTRUMENTS NECESSARY IN DIFFERENT OPERATIONS, KEEPING OF CHARTS, SUR- GEON’S KIT, £IC. IN many hospitals, small ones especially, where there are no medical students or house doctor, the nurse has more responsibility than in larger institutions, and becomes closely familiar with such details as taking the history of the patient; the arranging and sterilization of instruments; assisting the operator, giving the anes- thetic, and writing out the report of the operation. The following charts will be of use in keeping the important features of this line of duty in mind. When taking the patient’s history it is a good plan to allow her to describe her condition in her own words. Any peculiarities of the patient’s manner and other points which may be observed - can be noted, and afterward the questions necessary for making out the charts may be asked. Family History. Age. Health. Disease. Cause of death if dead. Father. Mother. Brothers (number). Sisters (number). Wife or husband. Children (number). Uncles or aunts with epilepsy, insanity, tuber- culosis, or cancer. | 116 INSTRUMENTS Lh7 Personal History. When born. Where lived. Peculiarities of cli- mate. Occupations. Habits (as to eating, drinking, sleeping, etc.). Appetite. Condition of bowels. Nervousness. (When Female.) Sexual History. I. Menstruation: (a) First at what age. (b) Regularity. No. days. (c) Duration. No. days. (d) Amount. [ Color. (e) Character of discharge ; Consistency. L Odor. (f) Intermenstrual discharge. (g) Dysmenorrhea—when. II. Pregnancies as | Sickness or peculiarities. Number. III. Miscarriages { Sickness. ni ewer. IV. Labors: (a) Number. | Easy. (6) Character j ~ noe | Spontaneous. [ Instrumental. (c) Peculiarities. (d) Sickness postpartum, if any. 118 SURGICAL TECHNIC Previous Illness. Starting with childhood, give different sicknesses and age at which same occurred, following life of patient to present time simply with reference to sickness, including appetite, bowels, urine, headaches, pains, coughs. Present Sickness. Date. . Oiee iepe ae ae pains, locations, se- verity, etc. Peculiarities. Progress and changes to present time. Changes. Appetite. Bowels. Urine, etc. Examination. Surgeon’s Kit.—The packing of a surgeon’s bag is often done by the operating-room nurse. Many surgeons use the telescope valise, or kit, as it is more commonly called; while others employ a regular surgeon’s bag. Before the bag is packed the nurse makes out the list of neces- sary articles, and as each article is put in it is checked _off the list. When packed, a copy of the list is securely pinned upon a towel inside, where the surgeon can see it on first opening the bag. The kit is packed by first lay- ing in two large sterilized towels, the ends of which hang over the edges of the bag. ‘Together with the instru- ments, which are placed in a linen instrument-roll, and the dressings the kit should contain three new nail- brushes, soap, razor, hypodermic syringes with tablets of strychnin sulphate (gr. 35), atropin sulphate (gr. ;45), and morphin sulphate (gr. §), cocain hydrochlorate (gr. 4), sterile camphorated oil, ether, and chloroform (with ee . oe INSTRUMENTS 119 cone and mask), alcohol (95 per cent.) 1 pint, tincture of iodin (5 per cent.), tablets of corrosive sublimate and sodium chlorid, iodoform gauze, plain gauze, gauze sponges, white suits, caps, and canvas shoes for the t's THUAN . Nha yin | ik i lit i f i “ Mil ius iN) i HNN WA Fig. 66.—Canton-flannel a for instruments. operator and assistants, Kelly pad, rubber gloves, safety-pins, absorbent cotton, twelve towels, a rubber apron, ligatures, sutures, and rubber and glass drainage- tubes. The glassware should be packed in the middle, Fig. 67.—Instruments wrapped in canton-flannel roll. to prevent breakage. When the kit is packed a third towel is laid over the contents, the edges of the other two are brought up, and all pinned together with safety-pins. The instrument-rolls are very serviceable in econo- mizing space and in keeping the instruments aseptic. 120 SURGICAL TECHNIC OPERATION BLANK Service Of Drees atone ie ea ee Date. March tro, rot6. II. Tite XII. Name... wee ce aw eel) 0 jae: So (eyde\ el eye le) geel ie: ake er (OLe ‘ere o> ein ie een a) lanl ihe . PREPARATION OF PATIENT FOR OPERATION. ANESTHETIC. ANESTHETIST. Temperature. Before operation. After operation. Pulse anc Respirations.—To be taken continuously during operation. PREPARATION OF FIELD OF OPERATION. . POSITION OF PATIENT DURING OPERATION: - PRIMARY MANIPULATIONS. . INCISION AND HISTORY OF OPERATION. . TREATMENT OF WOUND. . DRAINAGE. . CLOSURE OF WOUND. . DRESSING. . RECOVERY FROM ANESTHETIC. AFTER-TREATMENT. ‘UMOP 9S [[v ov SYTeUWIOI pue ‘uonevutrin ‘syusuaAoW [amoq ‘daajs ‘pooy ‘a1nze19dure} ‘uorearrdsas ‘asjnd ‘out y, "WARY [VOIpou UIIpO|—’gog “Sy INSTRUMENTS LWA E esvosid jo £eq tt 4-5 Ly Masao eee aes NSSeasSSeseseeecmy pee see ele EES SEES See eet Peete es i axe ee "| Se sea oes esi als SF) fe | (Es tes Es eee am oc tas Bea fee | Weneseeaseszesis OR cone eee ‘| EeSS0ge Geeeeeet © mae 066) 000 ol OL oGOT o€0T oVOT oSOT o90T oLOT I22 SURGICAL TECHNIC They are made of linen, canton flannel, or toweling, 1 yard long; and through the middle of each are adjustable loops in which the instruments are placed. When soiled the rolls may be washed and sterilized. Needles of various shapes and sizes required for an operation are sterilized with the instruments. Many operators prefer the needles to be threaded, then at- tached to a towel, which is folded, enveloped in another towel, and securely fastened. These bundles are dry ster- ilized and are not opened until called for by the operator or his assistants. After the operation is completed the sutures and ligaments which have not been used are care- fully dried and resterilized. In choosing the needles care must be taken that only sharp needles and strong sutures and ligaments are selected for use. INSTRUMENT LIST The following is a list of instruments generally used. Each operator will require additional instruments. The operating-room nurse should make out a list of the addi- tional instruments each operator requires: SIMPLE DRESSING TRAY Forceps, 1 pair. Scissors, I pair Hemostats, 2 pairs. Groove director. Probe. Glass syringe. HEAD OPERATIONS Trephining, Brain Tumors, Ete. Knives. Trephines. Hemostats. Tourniquet. Cranial rongeur for- Chisel. Gigli’s wire saw. ceps. Mallet. Dural separator. Periosteal elevator. Dural separator. Retractors, toothed. —_ Electrodes. Forceps. Needle-holder. Fine dural needles. Head mirror or head - Scissors. light. INSTRUMENTS 123 Fig. 70.—Lentz’s cranial chain tourniquet. RS, NAA, 3 ‘Ny, Ny SS SS S ss SS SS RS S SS — = =A = =i = f g Fig. 71.—Gigli wire saw and handle. 124 SURGICAL TECHNIC Fig. 72.—Hudson’s cranial trephine, burs and brace. Spinal Puncture Glass or Record syringe and spinal needle. LAMINECTOMY Knives, 2. Scissors, 3 pairs. Rongeur forceps, 2 pairs. Periosteal elevator Needles. Needle-holder. Forceps, 2 pairs. Chisels. Mallet. Forceps, bone-cutting, Retractors. Gigli saw. 2 pairs. INSTRUMENTS 125 EAR OPERATIONS Mastoid Knives. Scissors. Probe. Forceps. Needle-holder. Guard for facial nerve. Retractors, seli-retain- Head mirror or head Hemostats. ing. light Needles. Curets, four sizes. Chisels, Alexander’s. _ Periosteal elevator. Syringe. Rongeur forceps. Ear speculum. Mallet. Groove director. NOSE AND THROAT OPERATIONS Cleft Palate Knives. Scissors. Hemostats, 12. Forceps, rat-toothed. Head mirror. Periosteal elevator. Forceps, plain. Fine needles. Needle-holder. Forceps, swab. Mouth-gag, _ self-re- Retractor. taining. Tonsillectomy Knives. Snare, Beck-Schenk. Tonsillotome. Mouth-gag. Scissors. Tongue depressor. Hemostat, tonsil. Head mirror. Forceps, tonsil-holding. Hemostats. Tonsil punch. Sponge-holders. Adenectomy Instruments necessary for Tonsillectomy and the following: Adenoid curet. Nasal dilator. Postnasal cutting for- Rubber ear syringe. Cotton-holding _for- ceps. ceps. | Adenotome. Tracheotomy Knives. Needle-holder. Tracheotomy tube. Retractors. Hemostats, 12. Trachea cannula. Scissors. | Sharp hooks, 2. Forceps, 2 pairs. 126 SURGICAL TECHNIC Fig. 73.—Buck’s mastoid curet Fig. 74.—Allport’s mastoid re- (four sizes). tractor (self-retaining). Fig. 77.—Hartmann’s round tonsil punch, INSTRUMENTS 127 Fig. 79.—Sinexon’s nasal dilator. Fig. 78.—Tonsil snare. Fig. 80.—Luer’s trachea cannula. 128 SURGICAL TECHNIC i J Y My Qs ~ QS AS. 4 ~ 8 = alps US = =f AIS) -T s N tig PAS tf NA tt Cur) \\ \\ x | ! \ / STD fi -*K A i), cM Roms SS Fig. 81.—DeRoalde’s Fig. 82.—Richards’ Fig. 83.—Ermold’s ton- adenoid curet. tonsil-holding forceps. sillotome. SUBMUCOUS RESECTION. Applicators. Nasal specula, Bal- Knives. Scissors. linger. Septum elevator. Septum punch. Head mirror. Ballinger’s swivel knife. Nasal specula, Killian. Nasal tampons. INSTRUMENTS 129 TONGUE, REMOVAL OF Knives. Tongue forceps. Forceps, bone-cutting. Hayes’ saw. Needles. Needle-holder. Hemostats. Forceps, rat-toothed. Mouth-gag. Scissors. Forceps, plain. GLANDS OF NECK, REMOVAL OF Knives. Forceps, plain and Mayo dissecting scissors. Retractors. toothed. Hemostats. Needle-holder. Needles. Crile clamp. Scissors. Aneurysm needle. GOITER Same instruments as for Removal of Glands of Neck with these added: . Goiter forceps. Goiter compressing Kocher director. forceps. LIGATION oF ARTERIES, CAROTID Same instruments as for Removal of Glands of Neck. EYES Iridectomy Eye speculum. Tris scissors. Tridectomy knife. Cataract knife. Iris forceps, straight Lid retractor. Tris spatula. and curved. Cataract Extraction The same instruments as are required for Iridectomy and the following in addition: Cystotome. Lens tractor. Lens scoop. Removal of Eye and Tenotomy Self-retaining lid re- Strabismus hooks, Scissors. tractor. - smalland large. Small curved needles. Forceps, toothed. Hemostats. Needle-holder. 9 130 SURGICAL TECHNIC ST =— Ss a sell i! eC MITTIN Fig. 89.—Iris scissors; a, Wecker’s. Aspirating set. Knives. Hemostat forceps, plain and toothed. Knives. Grooved director. Retractors INSTRUMENTS I3I CuHEST OPERATIONS Empyema Scissors. Drainage-tubes. Periosteal elevator. Needles. Bone-cutting forceps. Needle-holder. Amputation of Breast Scissors. Needles. Forceps, toothed and MHemostats. plain. Needle-holder. ABDOMINAL OPERATIONS Abdominal Section Usual instruments for any abdominal section, to which will be added instruments required for any special abdominal operation. Knives. Hemostats. Aneurysm needle. Intestinal clamps, medium. Scissors. Forceps, toothed and Clamps, Kocher or plain. Kelly: © Retractors, abdominal. Needles. Needle-holder. Allis’ forceps. HERNIOTOMY Same instruments as are required in above operation and small re- tractors. STOMACH OPERATIONS Same instruments as for Abdominal Section and the following addi- tions: Stomach clamps: Murphy button. INTESTINAL OPERATIONS Resection Same as Abdominal Section. GALL-BLADDER AND LIVER OPERATIONS Same as for Abdominal Section with the following additions: Gall-duct probes. Trocar. Gall-stone scoops. Special drainage-tubes. SURGICAL TECHNIC 132 a, Fig. 91.—Amputating knives: Catling’s medium; 3, Liston’s small; Fig. 90.—Mayo’s operating knife or scalpel. c, Catling’s long; d, Liston’s long. INSTRUMENTS 133 Fig. 92.—Mayo’s oper- Fig. 93.—Curved __ Fig. 94. -Emmet’s an- gular bent scissors. ating scissors. scissors. LT iio rH Wiibn Fig. 96.—I. S. Stone’s tissue forceps. SURGICAL TECHNIC 134 97.—Segond’s volsella forceps. Fig. Oe ZMSONS Fig. 98.—Tait’s hemostat for- 102.—Noble’s Fig. improved Figs. 99—101.—Kelly’s curved Reiner’s needle-holder. round needles. INSTRUMENTS 135 OPERATIONS* UPON THE UTERUS Hysterectomy, Suspension, Etc. Same instruments as for Abdominal Section and the following: Hysterectomy clamps. Forceps, large. DILATION AND CURETMENT Specula, self-retaining. Curet, irrigating. Forceps, uterine. Specula, Sims’. Tenaculum, single and a dressing. Irrigator, uterine. double. s tenaculum. Sound, uterine. Dilators, Goodell, large i’ placental. Curets, dulland sharp. and small. Scissors. Dilators, Hegar’s. Norris or Wiley drain. Dilators, Metranoikter. Curet, Martin’s. PERINEORRHAPHY AND REPAIR OF CERVIX Same as above and— Hemostats. Needle and needle- Tenacula. Knives. holder. Emmet scissors. Scissors. Hooks. Shot forceps. KIDNEY OPERATIONS Knives. Forceps. Hemostats. Scissors. Retractors, large. Kidney elevator forceps. Kidney clamp. Ureteral probe. Needles. Needle-holder. Ureteral catheter. OPERATIONS UPON EXTREMITIES Amputations Forceps, lion-jaw. Martin’s rubber ban- Saws. dage. Periosteal elevator. . sequestrum. Tourniquet. Retractors, metal. * rongeur. Hemostats. Retractors, muslin, two ‘ bone-cutting. Knives. or three-tailed. plain. Scissors. Amputating knives. ‘¢ — rat-toothed. Resection Same and the following additions. Mallet. Chisel. 136 SURGICAL TECHNIC gL: L_L—_= Ce Fig. 105.—Murphy button. Fig. 106.—Mayo-Simpson’s self-retaining retractor. INSTRUMENTS 137 138 SURGICAL TECHNIC Fig. 111.—Auvard’s self-retaining specu- Fig. rr2.—Curets: A, Thomas’ dull; B, Sims’ sharp lum. Fig. 113.—Hoffman’s uterine irrigator. INSTRUMENTS 139 BONE-PLATING AND OSTEOPLASTIC GRAFTING Tourniquet. Hemostats. Forceps. Scissors. Saws. Grooved director. Chisels. Bone-plates. Drills. Retractors, toothed Electric engine and Screws. and plain. saws. Screw-driver. Nails. Needles. Gouges. Curets. Towman bone-holding Needle-holder. Knives. clamp. OPERATIONS UPON MALE GENITAL ORGANS Suprapubic Cystotomy Knives. Retractors, toothed Needles. Forceps. and plain. Hemostats. Needle-holder. Sounds. Drainage-tubes. Scissors. R Suprapubic Prostatectomy Same as foregoing, with— Hemostats. Double tenaculum. Perineal Prostatectomy Same as Suprapubic Cystotomy and— Guide. Young’s tractor. Catheters. Lobe forceps. Retractors. Litholapaxy Catheters. Lithotrite. Stone-searcher. Syringe. Cystoscope. Internal and External Urethrotomy. Sounds, urethral. Catheters, filiform. Guide. Urethrotomes, dilat- Catheters, Gouley. Forceps. ing. - Knives. Needles and needle Hemostats. Scissors. holder. Retractors. Grooved director. Varicocele and Hydrocele Scissors. Grooved director. Needles and _needle- Forceps. Hemostats. holder. Knives. 140 SURGICAL TECHNIC Fig. 114.—Goodell-Lentz uterine Fig. 115.—Simpson’s Fig. 116.—Placental dilator. uterine sound. _ forceps. Fig. 117.— Uterine dilator. ——— INSTRUMENTS I4I Fig. 118.—Bone chisels, gouge, osteotome (Macewen’s), Fig. 119. Bone and mallet. : gouge. 2 —=//) YL fh fp ‘Fig. 120.—Bone-cutting forceps. 142 SURGICAL TECHNIC Fig. 123.—Lithotrite. Fig. 124.—Bigelow’s evacuator. INSTRUMENTS 143 CATHETERS, VARIETIES OF, INCLUDING GOULEY See pictures of all varieties. CysTOSCOPY Electric attachments Knife, small. Catheters. for cystoscope. Key’s installator. Sterile glycerin. Syringe. Irrigating apparatus. Urethroscope. Local anesthetic. CIRCUMCISION ‘Knives. Scissors. Hemostats. Forceps, phimosis. Needles. Needle-holder. RECTUM, RESECTION OF Knives. Forceps. Proctoscope. Scissors. Specula. Grooved director. Double tenaculum. Probe. Needles and _needle- Retractors, toothed Clamp and cautery. holder. and plain. Hemostats. HEMORRHOIDS Same as above. Fig. 125.—Gant’s pile clamp. CHAPTER VIII ANESTHESIA ANESTHETICS are divided into three classes: local, spinal, and general. Local anesthetics are agents which abolish sensation by their local action on the sensory nerves. Spinal anesthetics are those that produce anesthesia by their action upon the spinal ganglion within the spinal canal. General anesthetics are those which produce loss of consciousness. No general rule can be given as to the selection of the anesthetic, but in describing each we will indicate where it is best applicable. Preparation for Anesthesia and Precautions.—A pre- liminary preparation of the patient is advisable before the administration of a general anesthetic. The anesthetic is taken better if the patient has been placed upon a light diet for several days and the bowels regulated. Upon examination of the patient it may be found advisable to give a special preparation for several weeks in order to secure the best results from the operation. Where only a light anesthesia is administered, such as nitrous oxid (laughing-gas), practically no preparation is necessary. Care of the Bowels——Whenever possible the intestinal canal should be emptied several hours before the ad- ministration of the anesthetic. The usual method is 144 ANESTHESIA . 145 to give a cathartic, such as castor oil, magnesia citrate, or magnesium sulphate, the night before and a low soapsuds enema two hours before the operation. Frequently it will be found to be impossible to carry out the above procedure. In such cases a high purgative enema is advisable. Diet—For twenty-four hours before the operation a light diet should be taken. If the operation is to take place in the morning, practically no food should be taken after 8 Pp. M. the night before. If the operation is to take place in the afternoon, nothing should be taken after 8 A.M. If the patient complains of weakness or great hunger a cup of beef-tea may be given up until within three hours of the operation. If the stomach is full at the time of operation, vomiting usually occurs, thereby adding to the dangers of the anesthetic. In cases of emergency, preliminary washing out of the stomach is advisable, especially if the operation is upon the stomach. It should always be practised if the operation is for intestinal obstruction, because in intestinal obstruction patients have drowned from vomiting occurring during anesthesia. Preparation of Mouth and Teeth.—It is advisable to thoroughly cleanse the teeth with a tooth-brush, and if marked Riggs’ disease exists, paint the roots of the teeth with iodin, in this way lessening the danger of aspiration pneumonia. Preliminary Use of Drugs.—The patient should have a good night’s sleep before the operation. Some patients will sleep without any assistance; others will require trional or bromids. Many surgeons order a morphin mapa e 146 SURGICAL TECHNIC hypodermic one hour before the anesthesia. It has the advantage of lessening the stage of excitement and the amount of anesthetic required. It is especially indicated in excitable, vigorous, and alcoholic patients. The chief objections are that it has a tendency to diminish respira- tion and masks symptoms of overnarcosis. It is contra- indicated in children and in the aged. Atropin or scopolamin is frequently combined with the above to diminish the amount of secretion. x — eae SS Se ee | CATHETERIZATION; DOUCHES; ENEMATA 209 rary weak feeling which follows a douche will be gone before morning. Fig. 168.—Apparatus for vaginal douching. (Morrow.) The therapeutic range of this procedure is not confined / . Rectal Injections (Enteroclysis) and Irrigation.— to the treatment of local troubles. It has long been used Fig. 169.—Enlarged view of a glass vaginal douche nozzle. (Morrow.) as a means of cleansing the lower bowel of accumulated feces. In the treatment of rectal ulcers and inflam- mations it has been employed both to relieve the irrita- 14 210 SURGICAL TECHNIC tion produced by fecal matter and to apply various medicaments to the parts. For-the prevention of shock Fig. 170.—Modifica- tion of Dewitt’s appli- ance for regulating flow, and allowing escape of flatus. (Crandon and Ehrenfried.) normal saline solution is injected— I or 2 pints. This, by filling the blood-vessels, enables the patient to withstand the loss of blood. After an operation shock and hemorrhage are counteracted by its use, and at the same time the thirst is relieved and restlessness quieted. Inseptic conditions, both local and general, by diluting the toxic materials in the circulation and promoting their excretion by the skin, kidneys, and _ bowels, saline rectal injections play an im- portant part in the treatment. Dr. John B. Murphy has devised a method whereby salt solution, if given by the drop method, it is possible to have the patient re- ceive a continuous supply of this solution. There are numerous ap- paratus, the simplest of which con- sists of a douche bag and tubing held in place about 2 feet above the bed. The tubing is connected to a specialized dropper as shown in the diagram. A clamp placed im- mediately above regulates the flow. The temperature of the solution is usually about 105° F. Many procedures have been devised to keep the water a CATHETERIZATION; DOUCHES; ENEMATA 211 at aneven temperature. The simplest method of noting the desired temperature is to have the tube run under a hot-water bottle placed at the side of the bed. In patients whose digestive tracts are too weak to hold food or medicine rectal feeding or rectal medication is Fig. 171.—A very simple apparatus for continuous proctoclysis. (Mor- row.) : employed. The rectum should be washed out thoroughly before the injection is given. If the rectum is intolerant and will not retain what is injected, 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 enema. The physician will give directions as to 212 SURGICAL TECHNIC the temperature of the solution. In fever patients and in the hemorrhage of typhoid fever great relief and com- fort 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 temperature is gener- ally consulted. 3 Fig. 172.—Showing the method of administering continuous procto- clysis: a, Adhesive strap fastening the tubing to the thigh; b, vaginal noz- zle bent at an angle of 35 degrees. (Kelly and Noble.) 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 rectum in gyneco- : ee CATHETERIZATION; DOUCHES; ENEMATA 213 logic cases, it should be remembered that tight tampon- ing of the vagina may interfere with absorption in the rectum. If the presence of hemorrhoids is a drawback, a Fig. 173.—Funnel and colon tube for administering nutrient enemata. 2 per cent. solution of cocain may be used before injecting the fluid. Stimulating enema: Whisky, 2 ounces. Ammonium carbonate, 15 grains. Beef-tea, ? 4 ounces. Or, Brandy, 2 ounces. Tincture of digitalis, 20 minims. Milk, 4 ounces. 214 SURGICAL TECHNIC For tympanttes: Tincture of asafetida, 2 ounces. Spirits of turpentine, I ounce. Magnesium sulphate (Ep- som salt), 2 ounces. Warm water, I pint. Purgative enemata: Warm soap-suds 4 pint. 2... “Glycerin, 4 ounces. Magnesium sulphate, I ounce. Spirits of turpentine, I ounce. Warm soap-suds, 8 ounces. 3. o-Ghycerin, 2 | ~ 4 ounces. Turpentine, 1 ounce. Magnesium sulphate (Ep- som salt), 2 ounces. 5. Inspissated ox-gall, 5 ounce. Warm water, I quart. 5. Spirits of turpentine, 10 drops. Mucilage of acacia, ~ - ounce. To be given high. 6. Senna, 7 4 ounce. Magnesium sulphate, ounce. Olive oil, I ounce. Boiling water, I pint. Infuse the senna in the water. Then dissolve the magnesia, add the oil, and thoroughly mix by stir- ‘ring. CHAPTER XII MINOR SURGICAL PROCEDURES Hypodermic Injection.—This procedure is employed to secure rapid medication or in obtaining local anes- thesia by the injection method. When used in the latter capacity it is called intradermic injection. - The aseptic method of employment requires that the syringe, needle, and solution should be sterile. To cleanse the skin about the point of intended puncture z rd \ B\ { Wr, J : il Z giles . aad Rwaleiny S Sa} Fig. 174.—Showing the method of giving a hypodermic injection. (Mor- row.) use first soap and water. Apply ether, alcohol, or tinc- ture of iodin to render the site sterile. Insert the needle-point at the summit of a pinched- up fold of the sterilized skin (Fig. 174). For hypodermic medication the skin of the arm, forearm, or the thigh may be selected, fleshy parts favoring rapid absorption. Avoid superficial veins and deeper vessels, as direct entry of the drug into the blood-current might give rise to a too rapid effect. 215 216 SURGICAL TECHNIC Sutures.—The interrupted suture is 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 in a double knot. The continuous suture is the ordinary over-and-over stitch from one end of the wound to the Fig. 175.—Interrupted suture. Fig. 176.—Continued or Glover’s (Bernard and Huette.) suture. (Bernard and Huette.) other. The button suture is made by passing a double stitch across the bottom of the wound, bringing out the ends about I inch from the edge of the wound and secure each end by passing through a button. The shotted suture is one in which the ends of the suture, after it is Fig. 177.—Button suture. (Bry- Fig. 178.—Metal suturing clamps. ant.) introduced, are passed through a perforated shot, which is then clamped. Counterirritation or revulsion is a method of pro- ducing artificial irritation upon one portion of the body surface to alter the progress of disease in distant parts. It acts directly by drawing blood away from the diseased MINOR SURGICAL PROCEDURES 217 area or through the nervous system, and may be used in cases of localized inflammation or congestion to over- come neuralgic pain and in conditions of general depres- sion or shock. The methods employed may be mild or severe in their effects. Of the milder means used for the purpose, the mustard foot-bath is one of the best. It consists in soak- ing the feet and legs of the patient in a bucket two-thirds full of water at a temperature of from I10° to 140° F., to which has been added one to two tablespoonfuls of ground mustard. The patient’s body should be pro- tected by blanketing during the bath, which may con- tinue for from ten to twenty minutes. Tincture of iodin is used for a similar purpose in chronic inflammation of joints or glands. It may be applied with a swab or brush to the parts. Application must not be made oftener than once in two to four days to patients having tender skins. Mustard-plaster, made by mixing up I part of ground _black mustard to 5 parts of wheat flour or flaxseed in a little water, and applied upon a cloth or folded news- paper to the parts, will often prove useful in widespread inflammation or irritations. A fresh mustard-plaster should not be applied for a longer period than twenty or thirty minutes, else it may give rise to local injury to the skin and directly underlying tissues. Turpentine Stupe.—This method of producing counter- irritation consists in the application to the inflamed parts of a flannel cloth which has been wrung out in hot water and sprinkled or dipped and wrung out in either the spirits or oil of turpentine. The skin should be anointed with vaselin if the application causes too 218 SURGICAL TECHNIC much pain or irritation. Spice-plasters or bags are often - ordered in the treatment of children. The mixture consists of equal parts of ground ginger, cloves, cinna- mon, allspice, to which add and thoroughly mix one- fourth part of Cayenne pepper; wet with hot water, alco- hol, or whisky before applying. The so-called warming plaster consists of Burgundy pitch 12 parts, cantharides cerate I part. Heat and cold are identical in effects. Use-—(1) Locally as a stimulant (if of moderate intensity and applied but for a short time and if fol- lowed by immediate reaction); also as a sedative (if of long application, very intense, and if no reaction occurs). (2) Constitutional: (2) Heat may be used as a pyretic in shock, collapse, insanity; (6) cold as an anti- pyretic in acute fever, sunstroke. A pplication. —(1) Heat—(a) Dry (in the ee of hot-water bags or bottles, hot bricks, hot sand or salt bags, heated stovelids, hot-air-oven apparatus, hot blankets); (6) Moist, poultice (flaxseed, oatmeal, or hops, mixed with water, is sterilized by boiling); hot bath; hot pack; hot douche; hot fomentation (gauze, flannel, or towel wrung out in hot water, hot antiseptic solution; change when cooled). A ready method of pro- ducing diaphoresis (sweating) is by pouring water upon hot bricks wrapped in flannel. (2) Cold—(a) Dry (applied in the form of crushed ice in thin rubber bags, bladders, ice water passed through coils of rubber tubing); cold air (by expos- ure); (6) Moist (irrigation, ice-water compresses, cold pack—wringing sheet out in ice water and wrapping it around the patient; keep it wet by sprinkling); MINOR SURGICAL PROCEDURES 219 tepid bath (gradually reduced); sponge-bath (keep the patient’s body surface moist, fanning him all the time); alternating douche of hot and of cold water. Vaccination is the inoculation of an individual with the virus of cow-pox. . The implements needed are a needle, lancet, or ivory point; fresh virus (bovine or humanized). - Vaccination is performed as follows: (a) Render skin surface aseptic (select by choice upper and outer third of arm, inner side of thigh); (0) abrade the skin until serum exudes; (c) carefully work in the moistened virus; (d) protect surface of spot until dry. Avoid exposure. The times to perform vaccination are: (1) About the third month; (2) seventh year; (3) at puberty; (4) repeat whenever small-pox is prevalent. Liniments.—These are local stimulants useful in mild neuralgic or rheumatic pains: (a@) Ammonia; (b) chloroform; (c) camphor; (d) turpentine. Apply _upon a cloth or by rubbing into the parts for a period of from five to twenty minutes; anoint with vaselin after each application to prevent abrasion. Ointments.—Mildly stimulating and emollient: (a) Mercurial (blue ointment); (0) ichthyol; (c) bella- donna; (d) boric acid; (e) resorcin; (f) iodin. Do not use iodin locally where there will be a possibility of a future cutting operation, because the skin becomes like leather and heals badly. Ointments should be applied upon gauze or lint, nicked to allow for the escape of discharge if present. Cupping.—1. Dry Cups.—In dry cupping no blood is lost. The operation is performed by means of special 220 SURGICAL TECHNIC cupping-glasses or wineglasses. Exhaust the air by burning a little roll of paper, piece of lint, or paper dipped in alcohol and lighted. Before the flame is extinguished rapidly invert the glass upon the skin surface. 2. Wet Cups—(a) Prepare the skin by cleansing with soap and water, dry thoroughly, and apply dry cups; (b) scarify with a bistoury or by means of a spring scarificator upon the cupped sites; (c) reapply the cups Fig. 179.—Instruments for wet cupping: 1, Cupping glasses; 2, swab in alcohol; 3, alcohol lamp; 4, scalpel. (Morrow.) to the incised areas; (d) treat the scarification wounds antiseptically. Cupping is employed to produce local depletion; wet cups are better in serous inflammations. Leeching.—(a) American leech (draws about a tea- spoonful—4 c.c.—of blood). (b) Swedish leech (draws three or four—tI2 or 16 c.c.— teaspoonfuls). MINOR SURGICAL PROCEDURES 221 A mechanical leech consists of a scarifier, cup, and exhausting air-pump attachment. Method.—Prepare the skin surface by cleansing with soap and water; dry thoroughly; apply the leech to the area moistened with blood or milk; confine the leech to the moistened area- by means of an inverted glass tumbler. To remove the leech sprinkle a little salt upon its head. To preserve the life of the leech, strip it of the sucked blood and replace in a jar of water having a per- forated cork. Dress the wound antiseptically, apply a compress, nitrate of silver torsion, acupressure for con- tinuous bleeding. Leeching is employed to secure local depletion. Venesection.—This procedure is performed to relieve tension in elevated blood-pressure, such as in acute kid- ney disease, pneumonia, and pulmonary edema. The simplest method is to insert a large caliber needle directly into the vein after the venous circulation has been dammed back by a tourniquet. Frequently it is necessary to expose and incise a vein. For this proceed- ‘ing the following instruments are necessary: Small scal- pel, scissors, plain and tooth tissue forceps, small retrac- tors, needles, sutures, and ligatures. Under local anesthesia a small skin incision is made over the vein which is exposed and dissected free. A double ligature is then passed under the vein. The upper one is tied and the lower one is left loose. A small opening is then made in the vein between the two ligatures and the blood caught in a basin. When enough has been taken, the lower ligature is tied and the skin wound sutured and a dressing applied. : Intravenous Infusion.—This is the best treatment to 222 SURGICAL TECHNIC combat traumatic and surgical shock, and is used after a severe hemorrhage. The same instruments are used as for a venous section, and, in addition, an irrigating can, rubber tubing, and an infusion needle are necessary. These must all be sterilized. One quart of normal salt solution is the usual fluid used. © In severe shock a dram of adre- nalin chlorid solution is added. At times it is possible to use a sharp-pointed needle for this procedure, and plunge it directly into the vein without incising the skin. (See Venesection.) i ee ee A ee Geen : | Fig. 180.—Giving hypodermoclysis under the left breast. (Ashton.) Hypodermoclysis.—This is another method of giving salt solution in cases of shock and hemorrhage. A sharp- pointed large caliber needle is attached to an irrigating can by rubber tubing. The needle is usually plunged under the breast near the chest wall, the skin being first thoroughly disinfected and the can held about 3 to 4 feet above the patient while the solution is being run in. MINOR SURGICAL PROCEDURES © 223 The breast is massaged so as to quicken the absorption of the fluid. Every nurse should be able to prepare and give hypodermoclysis. " P= Fig. 181.—Bier’s vacuum treatment apparatus for boils. | Bier’s Hyperemia.—This treatment has for its prin- ciple the increase of blood to the part, which therefore increases the number of leukocytes. It is used in infected areas. ‘The principle is the same as cupping, in that a Fig. 182.—Bier’s air suction apparatus for treating stiff knee. vacuum is formed, but it is not as mild. Special appara- tus is needed. It may be obtained in the extremities by placing a tourniquet around the arm or thigh sufficiently tight to particularly obstruct the venous return. 224 SURGICAL TECHNIC Normal saline solution is made to correspond as nearly as possible with the normal serum of the blood. It contains calcium chlorid 0.25 gm., potassium chlorid 0.1 gm., sodium chlorid 9 gm. to I quart of distilled water. It not only gives the heart a better fluid to work upon, but it restores to the blood that coagulable quality which is diminished or lost by hemorrhage. YS yp \ ff j ——— gi ——— ge ee Se Z = I = Qa lili LT = Fig. 183.—Intravenous saline infusion. Manner of incising vein and inserting glass tube. (Senn.) Tablets containing this formula have been devised, and are usually used. One tablet added to 1 quart of water gives the correct strength. In the absence of the tablets I teaspoonful of table salt is added to 1 pint of water. It is absolutely necessary, whatever formula is used, that the solution and all the apparatus used should be properly sterilized. If the water contains particles that cannot MINOR SURGICAL PROCEDURES 225 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, resteril- ized, and used. This solu- tion is placed in an irri- gator or a fountain-syringe Fig. 184.—Apparatus for hypo- Fig. 185.—Improvised appar- dermoclysis. (Hirst.) atus for the irrigation of a wound. (DaCosta.) which has been thoroughly sterilized. The tempera- ture of the solution should be about 110° F. In hospitals it is customary to keep on hand flasks of T5 226 SURGICAL TECHNIC saline solution. These flasks are sterilized before filling ; afterward they are stoppered with sterile cotton plugs and sterilized again by boiling for one hour on three suc- cessive days. Normal salt solution is used for irrigation and for in- jections in cases of shock, in acute diabetic and uremic coma, hemorrhage, puerperal infection, and eclampsia. Fig. 186.—Apparatus for douching the abdominal cavity. (Hirst.) Scarification.—This consists in the making of small linear incisions through the skin and subcutaneous or mucous tissues for the purpose of securing depletion to relieve tension. Puncturation is the operation of making punctures” with a sharp-pointed bistoury through the skin or mucous tissues. It is performed to secure local depletion or to relieve pressure. MINOR SURGICAL PROCEDURES 227. Incision of Abscess for Drainage.—The nurse should have sterilized knife, scissors, hemostats, and tissue for- -ceps. Rubber dam and tubing for drainage, gauze dress- ing, bandages, and pus basin. Some use disinfecting solu- ‘tions, such as iodin, Harrington’s, and bichlorid. These should be at hand, as should also cotton sponges. Hot-air or Baking Treatment.—This treatment is used for acute and chronic conditions of joints and for tenosynovitis, sprains, effusions, and fractures. The part must be protected with blankets or flannel bandages, the temperature at which it is used varies from 100° to 200° F. There are special bakers or types of apparatus on the market for this treatment. Deep puncture and incision with a sharp-pointed bistoury is sometimes performed—(a) To relieve ten- sion; (b) to secure drainage. Plasters.—(a) Belladonna (use as a local sedative in neuralgia, mastitis, adenitis; remove if dryness of throat or disordered vision occurs—the first symp- toms of belladonna-poisoning); (6) mercury (used for its resolvent effect upon indurated glands, chronic arthritis); (c) adhesive, ‘““American surgeon’s adhesive plaster’ (contains rubber and adheres without heating); (d) resin plaster (requires heating to adhere). Collodion and cotton are used to support and sel external flaps and wounds. Massage consists of manual manipulations of a part for the purpose of stimulation. May be applied twice daily, once daily, or every other day; each application may last from twenty minutes to one hour. The movements of massage are: (1) Rubbing (strok- ing movements, gentle at first, afterward of increasing 228 SURGICAL TECHNIC firmness); (2) kneading (rolling, circular, pinching — movements); (3) tapping (percussion over the surface with the leveled finger-tips produced by flexion, ulnar ~ side of the hand, or by the use of a mechanical muscle- — beater); (4) passive motion (elevation, flexion, and contraction of the parts produced by the operator). Clinical Thermometer.—May be of Fahrenheit (com-— mon form) or Centigrade scale. To reduce readings— (1) Fahrenheit to Centigrade: Subtract 32 from the number of Fahrenheit degrees and multiply the re-— mainder by 3; (2) Centigrade to Fahrenheit: Multiply — the number of Centigrade degrees by 3 and add 32. Fig. 187.—Clinical thermometer. Thermometers may be—(a) straight, self-registering | (90° to 110° F.—33.3°-44.4° C.); (6) surface, coiled or bulb (80° to 110° F.—26.6°—44.4° C.). ; Temperature may be taken in—(a) Mouth; (0) axilla; (c) rectum; (d) vagina. Most exact in vagina and rectum. Mouth-temperature is higher than that of © the axilla and less than that of the rectum. Axilla-tem- — perature is somewhat less than a degree below the rectal. © Electricity is used (a) As a muscle tonic; (6) for nerve- sedative action employ that form of electricity which gives — the best contractions with the least amount of pain and — discomfort to the patient; (c) electrolysis (used in the — treatment of aneurysm, tumors, for the removal of super- fluous hair); (d) cautery, ecraseur (is followed by least ~ hemorrhage when used at a dull-red heat). | | | : | MINOR SURGICAL PROCEDURES 229 The thermocautery, known also as the Paquelin cau- tery, because of its invention by Paquelin, of Paris, is frequently employed in surgery to control bleeding, and -also to produce counterirritation. The efficacy of this instrument depends on the fact that when the vapor of some highly combustible carbon compound is driven over heated platinum its rapid incandescence is sufficient to maintain the heat of the metal. Platinum points of various shapes and sizes are attached to a rubber tube, A ps. See Sy 3 CBZ x) Fig. 188.—Paquelin’s cautery. Note that the benzin is contained in the handle of the apparatus. (W. E. Ashton.) which is connected with a metal container half full of benzin or alcohol, the vapor of which is pumped through the tubing and holder into the platinum point. In order to prepare the instrument for use, benzin (above 65° F., Baume) is the best combustible, but wood alcohol, naph- tha, benzol, gasolene, ammonia-water, or ether may: be used. 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 230 SURGICAL TECHNIC water, but wiped perfectly clean. The handle when cool must be removed from the tubing, and each part must he laid in its own compartment in the case. a Where possible electric thermocauteries are preferable | for the reason that they do not get out of order. POISONS AND ANTIDOTES Acids, Mineral.—Give chalk, flour, white of egg, | magnesia (plaster torn off the wall may be used in an emergency); a solution of carbonate of soda; emollient ~ drinks; fixed oils (sweet oil, olive oil, cod-liver oil). 7 Give plenty of water to dilute the acid. Acid, Carbolic—Any soluble sulphate (magnesia), — alcohol acts as a direct antidote if given during the ; first ten or fifteen minutes; whisky may be employed for the purpose. Acid, Hydrocyanic.—Secure plenty of fresh air; carry © on artificial respiration; apply cold affusion; ammonia— inhalation and intravenously in a vein. Aconite-—Give emetics; stimulants (external and internal); keep up the body heat; patient is to be placed ~ flat on his back. . Antimony Tartrate-—Give teccene acids—tannic — acid (gr. v-xv—o.333-I1 gm.), catechu (f3j-ij—4-8 — Exe.) Arsenic.—Give freshly precipitated hydrated ses- — quioxid of iron (made by adding magnesia to any iron solution). 3 Atropin, Belladonna, Stramonium.—Emetics (mus- tard flour in water); apply cold to the head; give physos- tigma (gr. 75—}—0.006-0.013 gm.) or pilocarpin (gr. 4—0.008 gm.). : : MINOR SURGICAL PROCEDURES 231 Cantharides.—Give emetics; emollient drinks; opium (gr. +-3—0.016-0.033 gm.) by mouth and rectum; large drafts of water to flush the kidneys. Chlorin-water.—Give albumin (white of egg, milk, flour). Chloroform.—Secure plenty of fresh air, carry on artificial respiration (inclining head down, pull the pa- tient’s tongue forward); brandy and ammonia intrave- nously ; hypodermic injection (15 min.—1 c.c.) of tincture ei digitalis; gr. = (0.001 gm.) of atropin. _ Colchicum.—Give emetics, followed by demulcent drinks; keep up external heat. If coma is present, brandy, ammonia, coffee. Opium in large dose. Conium.—Give emetics; stimulants (external and internal). Copper Sulphate-—Give yellow prussiate of potash (may be given freely if pure); soap. Corrosive Sublimate.—Give albumin (white of egg —4 gr. (0.266 gm.) of sublimate requires the white of one egg), flour, milk; equal parts of lime-water and milk; emetics or stomach-pump. _ Croton Oil.—Give emetics; wash out the stomach; - mucilaginous fluids containing opium. Digitalis —Give emetics; recumbent position; tincture of aconite (1-5 drops—o.066—0.333 c.c.); opium (gr. +-4—0.16—-0.033 gm.). Elaterium.—Give demulcent.drinks; enemata cf opium; external heat. | Hyoscyamus.—Stomach-pump; give emetics; stim- ulants. (external and internal); physostigma, (gr. 75 0.0006 gm.); pilocarpin (gr. }—0.008 gm.). Illuminating-gas—Hypodermic injection (1 min.— 0.066 c.c.) of nitroglycerin; carry on artificial respiration. 232 SURGICAL TECHNIC Iodin.—Give emetics; demulcent drinks (starch or Y flour in water); opium (gr. 4+-4—0.016-0.033 gm.); | external heat. Lead Salts.—Give any soluble sulphate (magnesia or soda). Follow with emetics, opium (gr. ¢-3—0.016-0.033 | gm.), and milk. Lobelia.—External and internal stimulation. | Morphin; Opium.—Atropin (gr. 7}>—0.006 gm.) hypo- | dermically until respirations number eight a minute; | stomach-pump; stimulants (external and _ internal); brandy; strong coffee; cold affusion; ammonia to nostrils; galvanic shocks; compelling patient to move about; artificial respiration; permanganate of, potassium; cocain (gr. $-3—0.016-0.033 gm.); ‘repeat if necessary. Oxalic Acid.—Give lime (plaster, lime-water, milk of ~ lime). Phosphorus.—Sulphate of copper in emetic dose as a. chemical antidote; emetics; purgatives. No oils. Potash and Soda Salts——Dilute acetic acid; citric © acid; lemon-juice; vinegar; fixed oils; demulcent drinks. — Silver Nitrate—Solution of common salt; demulcent — drinks; emetics. | Strychnin; Nux Vomica.—Give 30 grains (2 gm.) of — chloral and 60 grains (4 gm.) of bromid of potassium; nitrate of amyl. a Tobacco.—Emetics; stimulants (external and internal) ; strychnin (gr. 34—74—0.0022-0.0044 gm.). Zinc Salts —Carbonate of soda; emetics; warm de- mulcent’ drinks. | Poisonous Fish—Emetics to wash out the stomach; purgatives; stimulants. CHAPTER : XIII OBSTETRIC NURSING, CARE OF INFANTS, ETC. PROFESSOR HirsT has employed printed slips contain- ing the following directions to the nurse: BEFORE LABOR I. Have ready towels; ether, } pound; brandy, 2 ounces; vinegar, 4 ounces; hot water; a bottle of anti- septic tablets; a large, new sponge; a roll of narrow tape or skein of bobbin; a fountain-syringe; bed-pan; new, soft-rubber catheter; 4 dozen small, 2 dozen large, pads; small package of salicylated cotton; absorbent cotton. II. Give a rectal injection (a pint of soapsuds with teaspoonful of turpentine) as soon as labor-pains are well established. AFTER LABOR III. No vaginal injection to be given unless ordered. IV. Take the temperature three times a day—morn- ing, noon, and evening. V. Place large pad under patient. Occlusive bandage to be used as directed. VI. The external genitals to be washed off four or five times a day with a warm corrosive sublimate solu- tion, I : 2000. Use absorbent cotton. VII. If, at the end of twelve hours, the bladder can- not be emptied naturally, use a catheter. Afterward, if necessary, catheterize patient three times a day. 233 234 SURGICAL TECHNIC VIII. The patient is to lie on her back; she may be moved from one side of the bed to the other several times a day; her limbs may be rubbed with alcohol and water or bathing whisky once a day. Fig. 189.—Bed arranged for childbirth: The mattress is protected by a mackintosh, over which a clean sheet is spread. ‘The upper bedclothes are rolled up at the foot of the bed. The woman’s buttocks rest upon a square yard of nursery cloth. The chair is for the obstetrician; at his feet is a waste-bucket, into which the pledgets of cotton used to clean the anus are thrown. The table, in easy reach, has upon it a large basin of sub- limate solution, 1 : 2000, in which are many large pledgets of cotton; a small tin cup on an alcohol lamp to boii the scissors for the cord; a half- dozen clean towels; a pot of carbolated vaselin, a tumbler of boric acid solution with squares of clean soft linen in it for the child’s eyes and mouth; a tube of sterile silk for the cord. (Hirst.) IX. The nurse’s hands are to be washed with nail- brush, soap and water, and rinsed in a I : 3000 sub- OBSTETRIC NURSING; CARE OF INFANTS 235 limate solution before catheterizing the patient, cleansing the genitals or breasts. Diet.—First Forty-eight Hours.—Milk, 13-2 pints a day, gruel, soup, one cup of tea a day, toast and butter. Second Forty-eight Hours.—Mailk-toast, poached eggs, porridge, soup, cornstarch, tapioca, wine jelly, small raw oysters, one cup of coffee or tea a day. Third Forty-eight Hours.—Soup, white meat of fowl, mashed potatoes; beets in addition to above. | After sixth day return cautiously to ordinary diet. In addition to three meals a day give three or four glasses of milk through the day. Child.—I. After being well rubbed with sweet oil, the child is to be bathed in water of 90+° F.; this should be the temperature of the daily bath. Use a bath-ther- mometer, or else the water will often be too hot. II. The cord is to be dressed with salicylated cotton. Observe carefully for bleeding. III. It should be bathed daily, about midday, in the warmest part of the room. Use Castile soap and a soft sponge; avoid the eyes. IV. The bowels of a healthy infant are moved four times a day, the urine voided six to twenty times. It is usually necessary to change the diapers eighteen to twenty-four times a day. Use compound or borated tal-. cum powder, lycopodium, zinc oxid, or rice flour. Incase of chafing, cold cream and borated talcum flour. Note the color of stools. Nursing.—The child is to be put to the breast every four hours during the first two days. No other food is to be given it. After the second day it should be nursed every two hours from 7 A.M. to 9 P. M., and twice during == Hike === =n 236 SURGICAL TECHNIC the night (1 and 5 A.M.). After every nursing the nipples are to be carefully washed with a piece of ab- sorbent cotton, warm water and Castile soap, and then smeared with a little sweet oil. Clothing—If born during the winter season a baby should be clothed as follows: A binder of flannel or knit wool twice around abdomen; a knit shirt, diaper, knit woolen shoes, and two skirts, the first flannel (in mid- summer, linen), and finally its dress. The skirts should Sis af Sh ee eee pce Lome, A EE NR 8 ee ” —- Es = m = ” — ye = _- 34 4 ah eS Ses aS ae aa Es Re elt . 4 a ae 1 ' ! 2 ‘o I ! ! | Fig. r90.—The Murphy breast-binder. be supported from the shoulders by sleeves or tapes. A knit jacket may be worn over the dress. A light flannel shawl or cap will protect the child from attacks of head cold (coryza). Feeding.—The average stomach capacity of a new- born infant is I ounce, and it increases I ounce per month up to six months. A child should never be nursed while it lies in its crib, but be taken up in the arms. Young mothers experience great pleasure in suckling a child, and may put it to the breast every fifteen J Glee --- (aes ee oe os ee ee ee ee OBSTETRIC NURSING; CARE OF INFANTS 237 or thirty minutes, giving rise to derangement of the in- fant’s bowels which may become serious. Artificial Feeding.—Asses’ and goats’ milk are most like human milk. An infant cannot begin to digest starchy foods under nine months of age, hence all pre- Fig. 191.—Schultze’s method of artificial respiration: A, Inspiration; B, expiration. (Hirst.) pared foods are injurious according to the amount of starch contained. Milk Mixtures —(a) For first twelve or fourteen days take: Condensed milk, I teaspoonful. Boiled water, 3 tablespoonfuls. Cream, I teaspoonful. Lime-water, I e Stir. 238 SURGICAL TECHNIC (b) After fourteenth day up to third month the fol- lowing may be used: Milk, 1 tablespoonful. Boiled water, 5 teaspoonfuls. Cream, I teaspoonful. Lime-water, I a Maltine (Merck’s), IO grains. Stir. After the third month increase the amount of milk to 5 teaspoonfuls, and reduce the boiled water to 4 tea- spoonfuls. . (c) A mixture for general use may be made according to the following formula: Milk, 1 ounce, 2 tablespoonfuls. Boiled water, I ounce, 2 2 Cream, | 2 teaspoonfuls. Lime-water, 2 - Malt sugar (malt extract), 1 coffeespoonful. Stir together. _ Absolute cleanliness of all milk bottles, spoons, dippers, and rubber nipples is necessary, or deranged digestion if not serious bowel disorders will assuredly result. They should be boiled. Se oe eee CHAPTER XIV OPERATIONS; PREPARATION OF THE OPERAT- ING-ROOM; THE SURGEON AND HIS AS- SISTANTS 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 is 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 expediency 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 gradually 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. Operations of necessity are performed to save the life of the patient, as, for example, in cases of intes- 239 240 SURGICAL TECHNIC tinal obstruction, in hemorrhage from rupture of an. extra-uterine pregnancy, etc. Emergency operations are those which must be per- formed immediately, without any choice, such as trache- otomy. An elective operation is at the choice of the patient, asinahernia. | Preparation of the Operating-room.—The operating- 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 sublimate 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 fifteen minutes for their final sterilization 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 non-sterile hand to see if the water is too hot or too cold. We can readily tell from the out- side 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; a second nurse, to take charge of the sponges; a third nurse, to keep ready for the operator a basin of sterile water to enable him at any time to quickly rinse his OPERATIONS; PREPARATION OF OPERATING-ROOM 241 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 dis- charge 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 instruments, and this gives a nurse to wait on her exclusively. 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 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 anything 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 run- ning water as hot as can be borne for ten minutes by the clock. The cleaning of the finger-nails is very impor- tant, as many of us would be surprised to find the large number of germs taken from under the finger-nails as the result of one cleansing. 7 The hands and forearms are then rendered sterile by putting them first into a saturated solution of perman- 16 242 SURGICAL TECHNIC ganate 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 permangan- ate 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 soapsuds and the finger-nails cleaned, the hands are washed in ether, which removes 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, or painted with 5 per cent. tincture of iodin. In using iodin be sure no water has been on the area for several hours; if so, wash first with alcohol (95 per cent.). Bi- chlorid of mercury should not be used with iodin, as a_ burn will be produced. The nail-brushes used should be absolutely sterile. They must be new, and need to be boiled for one-half hour on the day of the operation. 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. Before going to operation nurses and doctors should be attired in sterile suits, caps, and masks. They should then disinfect their hands and long sleeved gowns and rubber gloves be put on. The cuffs of the sleeves should OPERATIONS; PREPARATION OF OPERATING-ROOM 243 “erydjopepiyg ‘qeydsopy peowsansryD-oorpeyy ‘4ozeoyjTydwe jeowyg— zor “shy be encased in the rubber gloves. After making the hands aseptic it is essential that they do not come in contact with anything that has not been made aseptic before the 244 SURGICAL TECHNIC operation is commenced, for such is very easy to occur unless the nurse is constantly on her guard against it. The surgeon and his assistants prepare for the opera- tion very much the same as does the nurse. Many surgeons before operating take a corrosive sublimate > SSS SSS. SS aA ~ “\—= i = ~ Fig. 193.—a, Long-sleeved gown; 0, the same, showing glove with gauntlet turned up over wristband of gown. (Hirst.) bath (1 :500), after which they put on clean linen suits or long gowns and prepare their hands and_fore- arms. 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 i z ~ S = = OPERATIONS; PREPARATION OF OPERATING-ROOM 245 Or ‘Sq YQ-oo1peyyy “wi001-2ur}e19do jeousing Ioindt ydpepepryd ‘pewdsoyy yes “el 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. 246 SURGICAL TECHNIC 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 sleeveless linen gowns. The nurses should not leave the - operating-room unless it is absolutely necessary, and there should be no unnecessary opening of doors, which allows cold air to enter. Constant moving also causes dust to become stirred up. The temperature of the operating- room should be 80° F., and the air kept perfectly pure by thorough ventilation, which should be so arranged that drafts 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 Hospital, Boston, Mass.,’”’ which shows the great necessity 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, formerly Assistant in Bacteriology, Harvard Medical School: —_— Ee OPERATIONS; PREPARATION OF OPERATING-ROOM 247 “Four Petri double dishes containing films of sterilized and coagulated blood-serum were exposed in various parts of the operating-room during a celiotomy, 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 supposed the dust would be kept in the most active motion 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 Trendelenburg position, and one was ims = ‘ a i al Hil ih me t Arran iT MUTT —neen il Fig. 195.—Petri dish for making plate cultures. placed on the table beside the instrument tray. The dishes were uncovered just as the knife went through the skin. “At the conclusion of the operation the dishes were covered, conveyed to the bacteriologic laboratory, 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 determine the varieties of bacteria present, and particularly to demonstrate the presence or absence of the pyogenic forms. “Cover-glass preparations-and cultures were made from 248 SURGICAL TECHNIC as many different kinds of colonies as could be dis- tinguished. “The results are, in brief, as follows: “Plate A. Sponge table, exposed 1 hour 50 minutes: after 24 hours showed 216 colonies; 72 hours, 296 colonies. “Plate B. Knees of patient, exposed 1 hour 20 min- utes: 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. Instrument table, exposed 1 hour 40 min- utes: after 24 hours showed 216 colonies; 72 hours, 256 colonies. “The varieties of bacteria present were studied mi- nutely on Plate B (the one on the patient’s knee), less carefully on Plate D (the one on the instrument table). Of the recognized pyogenic cocci, two varieties were found—the Staphylococcus albus (15 colonies on Plate B, 20 colonies on Plate D) and the Staphylococcus aureus (3 colonies on Plate B, 4 colonies on Plate D). “The remaining colonies on both plates were sar- cinz of several kinds, yellow, orange, and white molds, and several varieties of unrecognized bacilli and cocci. “As would be expected, the plate from the floor showed the largest number of colonies. Plate B (the one on the patient’s knee) most interested me. “The finding by Dr. Darling of fifteen colonies of the Staphylococcus albus and three colonies of the Staphy- lococcus aureus on this small plate within a few inches of the opened abdominal cavity was certainly an object lesson, and has given lots of food for reflection.”’ CHAPTER XV TRANSPORTATION; PREPARATION OF PATIENT FOR OPERATION; CARE OF PATIENT DUR- ING AND AFTER OPERATION Transportation.—The entire duty of attending to the transfer of a patient to or from home and hospital may fall upon the nurse. The following suggestions are made by Mr. Scully, who conducts a private ambu- lance business in New York. The transportation of a patient, in order that it may be safely and pleas- antly accomplished, requires attention to detail. The nurse or friends of the patient should attend to the requirements for admittance by the hospital authori- ties, such as the hours of admission, financial details, and presentation of a written statement of diagnosis by the family physician. Other things being equal, it is better in the summer months to remove a patient early in the morning or toward evening; in the winter, near midday. Give as much notice as possible in order to secure the best attention from the ambulance service. Have the patient ready at the hour arranged. Nothing is more trying to the patient than to be delayed, either by friends or by non-arrival of the ambulance. Do not disturb the patient by insisting on a perfect toilet; an ample supply of covering is the chief necessity. Neces- _ sary articles of clothing which a patient should bring 249 250 SURGICAL TECHNIC to a hospital are: 4 night-gowns or pyjama suits; 4 suits of underwear; 4 pairs of stockings; slippers, bath- robe; hair-brush and comb; tooth-brush and tooth powder or paste; handkerchiefs, and other toilet articles. The nurse should accompany the patient in the ambulance, to give any needed attention and complete the arrangements with the hospital authorities. Jewelry and valuables should be checked at the hospital office. In transporting to and from railroads and steamships ample notice must be given to make connections. For all distances up to thirty-five miles, direct transportation by ambu- lance is preferable to train service, especially in cases of very sick patients. Preparation for Operation—The methods given here for preparing the patient for abdominal operations may serve as a reliable guide to the nurse, who is more or less responsible for preparatory treatment. The methods of preparation 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 pre- pared 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. Milk is not given before an abdominal operation, because the stomach may not digest it thoroughly, and its curds may remain in the intestines and act as an irritant. Gruel is nourishing and easily digested. No food is given after midnight. PREPARATION OF FIELD OF OPERATION 251 PREPARATION OF FIELD OF OPERATION 1. Scrub the parts with green soap and stiff brush. 2. Shave from nipples to rectum. Chemical hair- remover may be used; acts by dissolving the hair, but may prove too irritating to some skins. 3. Scrub again and rinse thoroughly with sterile water. 4. Rub well with alcohol, followed with ether, to re- move 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. ) A simpler method, and one frequently used, consists in a tub- or bed-bath. Completely shave the parts to be operated upon at least six hours before the operation. Paint the operative area (excepting vulva or rectum) _with tincture of iodin (5 per cent.). Prepare the vaginal canal by shaving the parts and giving a warm douche (lysol, I per cent.) and cover the vulva with a dressing. Use perineal straps to keep the dressing and abdominal binder in position. See that the dressings are kept wet with the antiseptic ordered until the patient is taken to the operating-room. This prepa- ration should be made twelve hours before an operation. Biniodid of mercury is sometimes dissolved in the ether makine a solution -ol- F.:-1000, which, besides removing all fatty substances from the skin, is also a disinfectant. When the skin is very dirty it is scrubbed 252 SURGICAL TECHNIC with benzin, then with alcohol, and then with the bin- iodid solution. 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 solution 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 opera- Fig. 196.—Solution basins stand. - tions 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 is danger of their being swallowed. Envelop feet and lower limbs in a warm blanket securely pinned .around the hips with safety-pins. Besides preserving the heat, this arrangement will pre- vent the patient from tossing the limbs about while taking the anesthetic. Many operators give morphin (gr. 4) PREPARATION OF FIELD OF OPERATION 253 and atropin (79 grain), hypodermically, half an hour before the operation to quiet the patient and prevent an increase in the saliva. 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 re- moved from the field of operation, which is again thoroughly cleansed with soap and water and disin- fectants. An assistant nurse hands the sterilized water, green soap, and scrubbing-brush to the assist- ant surgeon. The soapsuds are rinsed off with sterile water, the - part is sponged with alcohol and bichlorid solution. This final scrub- bing should be done in the anes- thetizing room if possible while the patient is being anesthetized, to avoid delay in the operating-room. A far simpler method is to paint the part with a 5 per cent. solution of iodin. 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. The instruments are taken from the sterilizer and placed in Fig. 197.—Irrigator. 254 SURGICAL TECHNIC trays containing sterile water or upon dry sterile towels. A written statement of the instruments laid out must be made. The number before and after the operation:must tally. ; 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 Fig. 198.—Towels pinned over rubber dam, leaving no skin surface ex- posed. (Hirst.) almost dry before they are handed to the surgeon, be- cause it is 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 the sponges before the surgeon begins to sew up the wound, and then should be very sure that she has the exact number employed in the operation. The large square sponges used for covering the intestines, PREPARATION OF FIELD OF OPERATION 255 or walling off small areas, should have a long piece of tape 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. 2 CTICREIEI? : =o UE Fig. 199.—Dressing table. 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 Eas reach of the operator’s assistants. The assistant nurses must be on the alert to change 256 SURGICAL TECHNIC 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. Ifasked 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 deal- ing 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 undertak- ing those belonging to another. It is absolutely neces- sary on such occasions to exercise self-control, and to fol- low the directions given without excitement or confusion. Just before the wound is closed the soiled towels are removed and replaced by fresh ones and a report. given of the number of instruments and sponges missing, if they are not all accounted for. After the dressing has been applied the patient is raised, wiped perfectly dry, and a bandage put on. The blankets used to cover the feet and chest of the patient during the opera- tion 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 operating-room to the patient’s room. When the patient is 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. PREPARATION OF FIELD OF OPERATION 257 The foot of the bed is elevated, this posture being main- tained for several hours, after which the bed is lowered. This is especially indicated in cases that have had spinal anesthesia. The heaters are placed about the patient’s body outside a blanket; one thing being kept constantly 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. Nausea 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 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 anes- thetic there is almost complete absence of nausea—usu- _ally none as soon as the patient is fully conscious. 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 frequent bathing of the hands and face with alcohol and tepid water or with plain water. If thirst is extreme, an enema of saline solution (I pint) is given slowly. Infections of the Abdomen.—It is now an almost uni- form custom to place the patient in Fowler’s position (sitting), and give them enteroclysis either by the Murphy drop method or frequent small enemas. A Gatch bed is the most satisfactory method of obtaining the Fowler position. The patient should not be left alone for a single moment during the first thirty-six hours after an ab- 17 258 SURGICAL TECHNIC 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. Watch- ing a patient recover from anesthesia is often monoto- nous; but if this duty is closely attended to, many dread- ful accidents will be avoided. A roll should be placed under the knees, so as to relax the abdominal muscles and also to remove the 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 pa- tients complain. Bladder and Bowels.—The catheter should be passed every six or eight hours if necessary, according to direc- tions, 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 abdominal operation the muscular walls of the intestines share in the weakness of the patient, and are not strong enough to overcome the contraction of the sphincter muscle. The accumulation of gas dis- tends the muscular fiber of the intestines, and, if not re- Ati aii sl —_— === — PREPARATION OF FIELD OF OPERATION 259 lieved, would soon result in paralysis of the intestines. To prevent this a rectal tube is inserted to keep the sphincter dilated and to allow the gas to escape when it reaches that point. Purgatives, such as calomel (gr. 35 every hour until 1 grain has been taken), are usually given twenty-four hours after the patient has recovered from the anesthetic to stimulate the intestines and keep up peristaltic action. Much fluid is not given for a few hours after the opera- tion, as it might cause vomiting or acute dilatation of the stomach. | After recovery from the anesthetic, if there is no vomiting, cool water or toast-water is given in teaspoon- ful doses every fifteen or twenty minutes, the quantity being gradually increased and the intervals lengthened. The familiar cup of freshly made tea is sometimes 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 stimulating. If the stomach behaves well, tablespoonful doses of gruel or beef-essence may be given every half-hour. Milk is not given as a rule, as the curd may pass along the intestines and act as anirritant. 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 combed. Every want of the patient should be anticipated, and she should be made as comfortable as possible. Sponging the palms of the hands, the arms, and the legs will lead 260 SURGICAL TECHNIC 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 consideration should morphin be given except by the surgeon’s directions, and every moral influence should be exerted to induce the patient to endure pam 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 surgeon’s consent. The mind of the patient is to be kept perfectly free from worry and excitement, and the whole atmos- phere of the room should be bright, pleasant, and cheerful, no matter what trouble is going on outside. A slight rise of temperature the day following opera- tion 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. Many surgeons now shorten the time im bed to seven days. . The following diet-list, dating from the third day, will be of assistance in varying the food. FourTH Day Breakfast—Mutton-broth with bread-crumbs. Lunch—Milk-punch. Dinner.—Oyster broth, thin bread (with crust removed) and butter, sherry wine. Lunch.—Cup of hot beef-tea. Supper.—Milk-toast, jelly. PREPARATION OF FIELD OF OPERATION 261 FirTH Day Breakfast—Oatmeal with sugar and cream, cup of cocoa. Lunch.—Soft custard. Dinner.—Chicken soup or small piece of white meat of chicken, baked potato. Lunch.—Glass of milk. Supper.—Buttered milk-toast (crust removed), jelly, cocoa. SIXTH Day Breakfast.—Soft-boiled egg, bread and butter, coffee. Lunch.—Milk-punch. | Dinner.—Chicken soup, tender sweetbreads, Bavarian cream. Lunch.—An egg-nog. Supper.—Tea, raw oysters, bread and butter. SEVENTH DAY Breakfast—Oatmeal with sugar and cream, a tender sweetbread, creamed potatoes, coffee, graham bread and butter. Lunch.—Glass of milk. Dinner.—Chicken panada, baked potato, bread, tapi- oca cream. Lunch.—Cup of hot chicken broth. Supper.—Buttered dry toast (crust removed), wine jelly, banquet crackers, tea. EIGHTH DaAy Breakfast.—An orange, scrambled egg, oatmeal with sugar and cream, soft buttered toast, coffee. ~ Lunch.—Milk-punch. 262 SURGICAL TECHNIC Dinner.—Cream of celery soup, a small piece of ten- derloin steak, baked potato, snow pudding, wine, bread. Lunch.—An egg-nog. Supper.—Calf’s foot jelly, soft-boiled egg, bread ata butter, cocoa. Ninto Day Breakfast—Oatmeal, poached egg 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. TENTH 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 beef-tea. Supper.—Sponge-cake with cream, buttered dry toast, wine jelly, cocoa. ; ELEVENTH Day Breakfast.—Broiled fresh fish, oatmeal, graham bread, coffee. Lunch.—Chicken broth. Dinner.—Potato soup, breast of roasted chicken, masked potatoes, macaroni, blanc mange. Lunch.—Cup of mulled wine. Supper.—Cream-toast, lemon jelly, chocolate. The diet for other days may be selected from previous ones. The change of diet may cause a temporary rise in the temperature and pulse. | CHAPTER XVI -SEQUELZ 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 fin- ished surgical way. Complications, however, are liable to arise in the simplest case, and throw great responsi- bility 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 finger-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 operation. It is produced through the agency of the nervous sys- tem. 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 intestines, and the exposure of the delicate sympathetic nerves in that part to the air and to touch. If to all this is added a long anesthesia, then 263 264 SURGICAL TECHNIC the prostration produced by the anesthetic is added to the effects of the operation. Dr. George W. Crile has lately combined local and general anesthetics, so that the nerve- centers will not receive any injuries. He calls his method anoci-association. 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 indifferent persons stand it better than those who are despondent. The mental influence is very great: anything that de- presses the mind aggravates shock. It is 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 recover readily from shock if there has been very little loss of blood. Shock is com- bated 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 consequence a large amount of 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 with a diminished amount of SEQUELZ OF OPERATIONS 265 blood. The intravenous injection of saline solution causes a rise in the venous pressure and an increase in the output of the heart. 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 tem- perature at first is normal or very little below normal, and the senses are dull in proportion to the degree of shock present; in hemorrhage the temperature is sub- normal, 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 irregular pulse; sighing, rapid, irregular, and shallow respiration; a normal or slightly subnormal temperature; a pale face with a pinched look; a cold, clammy 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 increase 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 whisky, brandy, or nitroglycerin hypodermically; in giving hot black coffee by the rectum, or saline solution by hypodermoclysis or enteroclysis. Strychnin is a powerful stimulant, and should be given in doses of sy grain every half-hour for four doses. Tincture of digitalis in 15-minim doses may be given every half-hour for four doses. Asa rule in cases of shock there is a disposition on the part of 266 SURGICAL TECHNIC nurses to do too much. Everything must be done in a prompt, quiet manner. For immediate stimulation in threatened collapse camphorated oil (15 minims) or adrenalin chlorid, hypodermically, are valuable. They are 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 measures being determined accordingly. An enema of 4 ounce of turpentine, a well-beaten raw egg, and 3 ounces of warm water constitutes a powerful 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 motions 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 minute, so as to imitate as nearly as possible the natural rhythm of respiration. Recovery may be rapid or very slow; it is mani- feste’ 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. o 4 ri, > 3 s SEQUELZ OF OPERATIONS 267 The skin is hot and flushed, the pulse full and regular, and the temperature above normal. This condition may subside and recovery take place, or it may be followed by collapse. Fig. 200.—Sylvester’s method of artificial respiration (inspiration). y: (Fowler’s Surgery.) Artificial Respiration.—As soon as respiration ceases the mouth should be examined, if possible, for any obstruc- tion to the air-passages. If obstruction is found to be _ present, it should be removed or tracheotomy performed. 268 SURGICAL TECHNIC The most satisfactory method of artificial respiration consists in placing the patient with the upper portion of the abdomen resting upon a roll of material about 1 foot high. The head should be turned to one side. Then Fig. 201.—Sylvester’s method of artificial respiration (expiration). (Fowler’s Surgery.) rhythmic pressure should be made upon the lower ribs twenty times per minute. | Sylvester's Method.—With the head and neck fully extended and the tongue drawn forward, the elbows are SEQUELZ OF OPERATIONS 269 grasped and the arms gradually extended and then sud- denly compressed against the side of the chest. These motions should not exceed twenty to the minute. Laborde’s Method.—This method may be used alone or in conjunction with the other methods. It consists in alternately drawing the tongue forward and pushing it back. If the above methods are not successful in four Fig. 202.—The Draeger pulmotor or automatic resuscitation device. (Keen’s Surgery.) or five minutes, a lung motor or pulmotor should be employed. 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 opera- tion. 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 270 SURGICAL TECHNIC usually indicate that there 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 Figs. 203 and 204.—Esmarch’s tourniquet, consisting of 9 feet of elastic webbing 23 inches wide, 3 feet tubular strap with chain. face, dilated pupils, cold skin,- frequent and irregular or sighing respiration, subnormal temperature, and a weak, rapid pulse (120 to 140). In rare cases the pulse is not greatly accelerated. Treatment—The patient must be kept perfectly quiet on her back, the head being lowered and the. SEQUEL OF OPERATIONS Bij foot of the bed elevated. If symptoms of shock super- vene, 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 excessive, infusion of saline solu- _ tion is resorted to, the fluid that the body has lost being thus replaced. Transfusion of blood is frequently indi- cated. Bandaging the limbs from their extremities up- ward is sometimes of use in keeping the blood in the vital organs. When the hemorrhage comes from a Fig. 205.—Bellocq’s cannula, used for passing a cord through the nose, to be drawn out of the mouth, and gauze or cotton plugs attached for packing the nasal cavity for hemorrhage. (Morrow.) 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 is kept, the 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 oe ( SURGICAL TECHNIC 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 operation. The symptoms are pain in the abdomen and exquisite tenderness, distention, vomiting, constipation, icterus, restlessness, sleeplessness. The temperature rises a little, rarely going for a few days above 100° or 1o1° 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 temperature rises to 103° F. or above. The rectal or vaginal 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 101° 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 prostra- tion was severe. The abdomen is distended, due to dis- tention 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 expres-- sion, and is restless and talkative; the eyes are unusually bright, and there is a faint yellowish look about the skin and conjunctive. As the disease continues the general system becomes poisoned. The treatment consists in providing drainage for the infection. The patient is placed in Fowler’s position; ‘ | SEQUELZ OF OPERATIONS 273 salt solution is given by the Murphy method; if vomiting occurs, the stomach should be washed out. Any stimu- lants that may be required are given hypodermically. All food by the mouth is stopped. 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, so should not be given. The mind usually remains clear to the end. : Antistreptococcic serum has been used with fairly good results. It comes in glass tubes, sealed hermetically, and is injected hypodermically with antiseptic precau- tions into the thigh or the side of the breast, where there is considerable loose subcutaneous 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 septi- cemia, and when accompanied with a high temperature is usually a cause for anxiety, though it may be due to constipation, and in such cases is usually without sig- nificance. The treatment consists in the application of turpentine stupes, high enemata, and the insertion of the rectal tube for about Io inches. Pituitrin in }-grain doses or eserin salicylate (gy grain) are valuable adjuncts. 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. sme 36 7 fa SURGICAL TECHNIC Intestinal obstruction may be due to strangulation 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 and later nausea and vomiting. 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. Fig. 206.—General operating-table. Postoperative hernia is a sequel rather than a compli- cation of abdominal operations, and is due to a failure of union between the cut edges of the muscles and fascie. As a rule, it does not occur until some weeks after the patient has returned home. It is to prevent this acci- dent that such stress is laid upon not allowing the patients to help themselves in any way without the surgeon's per- mission, so that the abdominal muscles may have sufh- SEQUELZ OF OPERATIONS 275 cient time to become firmly united. This is also the reason why patients should wear an abdominal supporter for some months after their discharge. If hernia occurs, it is usually treated by a secondary operation. A sinus is often caused by imperfectly sterilized lig- atures or non-absorbable ligatures, 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 the drainage-tube through the ab- dominal wall. The sinus keeps open until the ligature is discharged or removed by another operation. Accidents During Operation.—Many times in difficult abdominal or vaginal operations the walls of the bladder may be torn, or one of the ureters or the intestines may be injured. When the ureter or bladder is injured, the urine sometimes passes through the incision to the dress- ing. This is called a urinary fistula. When the intes- tines are injured, fecal matter is discharged through the wound. This is a fecal fistula. Vaginal hysterectomy is the most serious of vaginal operations, but the nursing is the same as every opera- tive case requires. If clamps are used, they usually re- main 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. Postoperative insanity is an extremely rare complica- tion and is usually associated with premature menopause produced by the removal of both ovaries. The symp- toms are usually greatly ameliorated or cured by the administration of ovarian extract. CHAPTER XVil SPECIAL OPERATIONS Operations Upon the Head.—Nursing after opera- tions upon the brain calls for special diligence in watch- ing the patient during the first hours subsequently. Unlooked for symptoms may arise, and a change for better or worse in those accompanying the condition for which operation was performed; delirium, acute mania, or paralysis of some part or of the half of the body may develop, or, having been present, become rapidly altered in degree and aspect. Care to prevent the patient from injuring himself, falling from the bed or disturbing the dressing and doing direct injury after a trephining is necessary. Especially should the nurse be on her guard to prevent such patients being burned by hot-water bottles. Head operations being often long ones, or done for acute conditions in which the degree of shock is marked, the efforts to revive can easily be overdone in the matter of temperature of the hot-water bag with a sub- sequent further complication of the case from a bad body burn. As a general rule, it is safest to never put a bag directly against the patient’s body, but to place it outside the blanket. Eye, ear, nose, and throat cases, besides the general care and watchfulness necessary, require to be observed for shock or hemorrhage, where, as in the case of the eye, serious functional injury might be done; or special symp- toms complained of relating to the particular:sense-organ operated upon. 276 SPECIAL OPERATIONS PIG Operations upon the neck generally require the patient to assume the supine position. The chief danger is from accidental postoperative secondary hemorrhage, and this contingency may occur up to the third or fourth day when due to slipped ligatures. After intubation and tracheotomy operations the nurse must be watchful lest the tube becomes displaced, coughed out, or clogged by exudate or false membrane shreds. Rapid cyanosis or a SS Ml? Fig. 207.—Soft-rubber nasal and Fig. 208.—Syringe cup to hang earsyrmee, (J.P. C. Griffith: ) upon patient’s ear to catch the drip when irrigating the aural canal. blowing-bellows action sounding through the tracheal slit are the signs calling for immediate correction of the diff- culty, to avoid an immediate fatal termination of the case from total closure of wound or tube. If the trache- otomy tube is occluded, remove the inner tube, clean, and insert. If the case is one of tracheotomy with a displaced tube, the nurse should make no attempt at readjustment, but quickly should remove the tube and send for the surgeon. CHAPTER Vit OPERATIONS IN PRIVATE PRACTICE IN private practice the preparation of the patient is just the same and should be carried out as thoroughly as in a hospital. If it is not possible within twenty-four or thirty-six hours to make the preparation, then we cannot say that our attempts to obtain asepsis approach perfection. In emergency cases when there is not suff- cient 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 remember, 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 surgeon 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 details of cases in a way to which she is not accustomed, and which may appear to her wrong, and which indeed may very often be crude and unscientific. In these cases she should not be too ready to show her superior wisdom and instruct the surgeon, and inform him under whom she 278 eS ee OPERATIONS IN PRIVATE PRACTICE 279 received her training, 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. Have the temperature ——— SE re Fig. 209.—Portable operating-table set up for a vaginal operation. (Hirst.) at about 75° F. In some houses there may be a separate room for the operation, while in others the nurse will have to prepare the patient’s bedroom. In the latter case the brightest end of the room must be selected for the opera- tion, to afford the surgeon plenty of light. A screen must be put up before the bed, so that the patient will 280 SURGICAL TECHNIC not see the preparations. The nurse shouid remove from the room all movable furniture; sheet any large piece, as piano; lay oilcloths or newspapers covered with a damp sheet on the carpet, and pin them securely to it, and fasten a curtain across the window, so that the operation cannot be viewed from the opposite side of the street; or the panes may be frosted by lathering with soapsuds or Sapolio. The remaining furniture and window-frames should be washed with carbolic acid solution (1 : 60), and on the morning of the operation should be 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. Have everything ready the night before when possible. If a separate room can be had, one with a northern light is to be preferred; and if possible it should be near the bath-room and convalescent chamber. Fill the bath- tub half full with 1 : 1000 bichlorid solution for wash- ing pitchers, plates, wash-bowls. Unless the nurse has — twenty-four hours’ notice in which to prepare the room far operation, it should not be disturbed, because if swept and dusted immediately before the operation dust is stirred up and the air is so filled with germs that it would not be safe to open the abdomen 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 (I : 200) and exposed to the action of the sun and air for about twelve hours, when the windows are to be closed, OPERATIONS IN PRIVATE PRACTICE 281 the room thoroughly dusted with a damp cloth, and not again disturbed. When the operation must be performed in the patient’s bedroom, push the bed up in one corner. 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 Fig. 210.—Bed arranged for reception of patient: A trough is made under the blanket by hot-water bags on either side. A towel is pinned to the lower blanket under the patient’s head. (Hirst.) often find are perhaps heirlooms which have witnessed 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 25 inches nor higher than 37 inches, because if low and wide the surgeon will have to stoop and bend forward. A kitchen- 282 SURGICAL TECHNIC table, or a dining-rcom 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, Fig. 211.—Kitchen table prepared for gynecologic operation, showing Kelly draining-pad and leg supports. (Hirst.) will make a good narrow operating-table; or three chairs, with two planks; a leaf from an extension-table, or an ironing board laid across them, may suffice. OPERATIONS IN PRIVATE PRACTICE 283 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. The top cover may be rubber bedcloth, oilcloth, or folded sheet, tied to the table by means of a muslin bandage. A Kelly pad may be improvised by means of a blanket rolled army fashion and covered with a piece of rubber cloth. A square-backed wooden chair should be at hand in case the Trendelenburg position is necessary, and two wooden Fig. 212.—The Trendelenburg posture in bed, using a chair to elevate the pelvis. (DeLee.) boxes for the surgeon to stand upon when using this posture. An easier method is to elevate one end of the table upon a box. The lithotomy position can be quickly obtained by using a well-padded cane or broom handle placed under the patient’s knees and bound in place by means of a twisted sheet passed around the patient’s neck, over one shoulder, beneath the other. Improvise a sterilizer for instruments and dressings 284 SURGICAL TECHNIC by using a wash-boiler fitted with a light wood inside crate to hold the dressings above the water. Steril- ize glass tips and syringe bags by placing in a towel hammock or muslin sling hung from the handle of the boiler. The evening before the operation the nurse should boil a wash-boilerful of water and then fill covered pitchers, the wash-boiler and pitchers having first been made Fig. 213—Ether bed with the foot elevated. (Sanders.) thoroughly aseptic. The water is conveyed from the boiler to the pitchers by means of a perfectly clean pitcher or tin ladle. On the morning of the operation there should be steril- ized 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 OPERATIONS IN PRIVATE PRACTICE 285 usually employed in private practice. They can be purchased sterile at any good drug store. There will be needed several clean recently boiled basins for the various solutions, etc. Two tables will Fig. 214.—Household bulb-syringe. (Davidson.) be needed—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 wash-tub for the soiled water, a tin dish or a Fig. 215.—Fountain-syringe. flat bake-pan for the instruments, brandy, a hypodermic syringe filled with the required solution, usually strych- nin sulphate (& grain), a small tumbler, a Davidson or a fountain-syringe, table salt for salt solution, safety-pins, 286 SURGICAL TECHNIC two new nail-brushes, ready for use in a I :40 carbolic acid solution, Castile soap, green soap, a razor, hot-water bottles, two blankets, alcohol, vinegar, and matches. The surgeon will bring the necessary sterile dressings, towels, sheets, etc., in his kit with the instruments. 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. The pail of water should be on the fire and the water boiling when the surgeon arrives, so that the instruments can be put in at once. If the nurse is asked to give the anesthetic she should not attempt anything else. None but novices give the anesthetic and watch the operation. The ex- perienced 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. 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 operation in a very poor family, where there are no conveniences. In such instances the kitchen can be cleaned and pre- pared as an operating-room in a few minutes. If she is called in the night and goes to the case with the surgeon, she should, while the surgeon is making his examination of the patient, start a fire and put on the wash-boiler, to make sure of plenty of boiling water. She should then get six sheets and twelve towels, if 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 ee ek peeled nel, es ce re, ME OPERATIONS IN PRIVATE PRACTICE 2E7 boiling water and afterward placed in corrosive sublimate solution (I : 1000) until the surgeon is ready to use them. Boiling water is one of the best antiseptics, as it kills germs. Unfortunately it cannot be used in rendering our hands and the field of operation aseptic, but it can be used in the preparation of the sheets, towels, sponges, and instruments. The kitchen should be rendered as clean as possible. The kitchen-table should be prepared for the operating- table, and there should be two small 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 pur- pose. 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. To fasten a sheet gown upon the operator, fold the sheet to a proper length, standing in front of the sur- geon, so that the top of the fold is on a level with the axilla; draw ends up under the arms behind. Cross each end to the opposite shoulder and pin in front to form sleeves. Improvise a stretcher by means of two curtain poles passed through a folded and pinned sheet and double blanket. After the surgeon has made the examination the part must be shaved, washed, an enema given to clear the bowels, and the urine drawn. While the patient is being anesthetized the nurse may arrange the tables and sterilize a flat bake-pan or meat-pan for the instru- ments. If sponges have been forgotten, a clean sheet can be torn up and folded into flat sponges. China 288 SURGICAL TECHNIC basins can be used for the antiseptics, the sponges, and the surgeon’s hands; china pitchers for hot and cold water; a wash-tub for the soiled water; and hot bricks, plates, stove-lids, bags of salt or beer bottles for heaters. Cool boiling sterile water for immediate use during operation by pouring out in pitchers, which are then to be set in vessels containing ice-water and cracked ice. In cases of contagious diseases, place all cleaning cloths and left-over dressings in paper bags or news- paper cornucopias to burn. wer he : | CHAPTER XIX GYNECOLOGIC EXAMINATIONS AND OPERATIONS PERFECT asepsis is of special importance in gyne- cologic examinations and operations, because in many instances the peritoneal cavity, which is highly suscep- tible to septic influences, is invaded by them. We must bear in mind that the whole genital tract communi- 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 perineorrhaphy 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 patient to danger no matter how small the operation to be performed; 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. Success in surgery is due to minute attention to a careful 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 who have been thoroughly instructed in the practice of asepsis and antisepsis should 19 289 290 SURGICAL TECHNIC be allowed to assist at an operation or examination, how- ever small. GYNECOLOGIC EXAMINATIONS The positions which a patient may occupy when under- going an examination are the knee-chest, dorsal, Sims, and the upright. Nace e Fig. 216,—Examination in the erect posture. (Hirst.) The upright, or the erect, position is rarely used for é the purpose of making a diagnosis, but is sometimes : preferred in verifying a diagnosis, especially that of © | GYNECOLOGIC EXAMINATIONS AND OPERATIONS 291 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. The heels are placed in foot-rests which extend out from the table about 8 inches. A sheet having an oval slit in the center long Fig. 217.—Dorsal recumbent posture. and wide enough to expose the parts is thrown over the patient. In this position there is naturally a certain amount of flexion of the pelvis upon the trunk, and almost complete relaxation of the abdominal muscles is secured. Sims’ Position (also called the Latero-abdominal Posi- tion).—In 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 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 lies diagonally across it, the head and shoulders be- 292 SURGICAL TECHNIC ing at the right-hand side, with the left hand and arm : hanging over the table-edge. The thighs are flexed upon ~ 1 SSS i Fig. 218.—Sims’ posture, anterior view. ferret A the abdomen, the right thigh being so flexed that it lies — just above the left knee, and the feet rest upon the right- — hand corner of the tableg This position is one in which F there is a tendency for the { intestines to ascend, and this — causes the vagina to be filled — with air and thus brings the q uterine cervix within easy 4 reach. g The lithotomy position is — used when operating upon the rectum and in some conditions ~ of the bladder. The position - is obtained by placing the pa-_ tient upon her back, knees and _ Fig. 219.—Edebohls’ dorsal pos- thighs flexed and separated, ~ ture (lithotomy position). the feet being held in stir-. rups, as seen in the diagram. — The knee-chest, or genupectoral, position is used for inspection of the rectum, bladder, vagina, and cervix of GYNECOLOGIC EXAMINATIONS AND OPERATIONS 293 the uterus. In some cases of displacement of the uterus the patient may have to take this position many times 43 BATU Fig. 220.—Knee-chest or genupectoral posture. daily. The patient first kneels on the edge of the table or bed, 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 clasp- ing the sides of the table. In this position the abdominal organs are thrown toward ' the diaphragm; 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. The Walcher position for increasing the size of the outlet of the pelvis during childbirth; action is secured by means of elastic and body weight extension. Seldom - used. é \ - A\\, \\Y Wy x \ 4 ‘NY \] d \... ‘ 4) } = i £ a ] : Yo Alf ( () x) / L \ nN \ Z y, wal iy I (WN «hele = Y\“2 = \VWCH = \ i Ny Fig. 221.—Walcher posture. Examination of the Rectum.—The patient is usually placed in the Sims position. Either the rectal speculum, or in its absence a Sims speculum (small blade), is used. 294 SURGICAL TECHNIC When the instrument is introduced the rectum becomes ° distended with air so that its walls are well exposed. If the patient is not in 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, as a rule, the dorsal 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, but local anesthesia of the urethra is usually 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 sep- tic 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. Asa rule, no douche should be given before the examination, since the surgeon may want to see the character of the discharge. All 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 cloth- ing above the waist, and then step upon a chair and thence to the examining-table without there being the slightest exposure. _ —— GYNECOLOGIC EXAMINATIONS AND OPERATIONS 295 For examination in private practice, the patient is usually placed transversely across the bed with each foot on a chair and the buttock drawn well down to the edge of the bed. The legs and thighs should be draped with ‘sheets. The usual requirements are: pair of rubber gloves, sterile vaselin, vaginal speculum, uterine forceps, and tenaculum. The speculum should be warmed by placing it in the warm sterile water. The same aseptic precautions 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 abdominal - operation, excepting the difference of the field of opera- tion to be prepared. In case the operation is a minor one upon the uterus or vagina, the preparations 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 because the dangers of infection are increased by our inability to get the genital tract thor- oughly 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 mattress 296 SURGICAL TECHNIC and sheet, thus making a hard surface for the patient to lie upon. A piece of rubber cloth or oilcloth will serve for a Kelly 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 anesthet- ized the bed is turned toward the window te afford the surgeon a good light—a northern light if possible. A bay window should be avoided, because it gives cross-lights. Fig. 222.—Trendelenburg position. (Ashton.) The limbs are flexed, the hips brought to the edge of the bed, and the Kelly 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 in 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 and holds the other limb in position at the knee. If 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 lie in the hollow between the thumb and forefinger, and the convexity of GYNECOLOGIC EXAMINATIONS AND OPERATIONS 297 the blade will rest on the dorsum of the hand. The upper labia 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 ap- plied to the anterior and posterior parts of the vagina. After-care.—After a vaginal operation (trachelor- rhaphy) the patient will probably be catheterized for a 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-forceps. The same care must be used when giving enemas, in order that the rectal and vaginal stitches be not broken by the tube. The patient must be instructed 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 must 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 is packed with gauze, the pulse and temperature 298 SURGICAL TECHNIC are usually taken every two hours; and should the tem- perature 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, and the sutures removed on the ninth day in the order in which they were introduced. After the removal of the stitches many operators order a vaginal douche two or three times a day, the amount of water varying from 2 to 4 quarts. This treatment is successful only when the douches are given at the proper time and temperature. CHAPTER XX DIET: RECIPES From the following carefully prepared and _ long- used foods for the sick the nurse will be enabled to quickly choose a change of diet from day to day, enabling her to secure the fresh, dainty daily surprise for her, patient: Water.—Boiled water is the safest and best for the sick. Reaérated by pouring out in flat receptacle. It may be cooled by keeping in ordinary milk bottles set on ice. : Albumin Water.—Beat up the white of one egg; strain through a cloth; add a glass of water. Stir in a teaspoon- _ ful of lemon juice, one of sugar, and a, pinch of salt. Serve set in a bowl of cracked ice. Apple Water.—Bake two apples soft, mash; pour a cup of boiling water over the mass; cool; strain; sweeten to taste. Serve with shaved ice, or set in a bowl of cracked ice. Lime Water.—Take a lump of unslaked lime the size of an egg, and place it in $-gallon bottle of pure cold water. Keep the bottle corked; after a few moments the lime water is ready for use, the clear liquid being poured off as needed. So long as any lime remains the bottle may be restocked by the mere addition of cold water. Barley Water.—Stir 2 ounces of pearl barley in 13 pints of cold water; boil for half an hour over a slow fire in a 299 300 SURGICAL TECHNIC covered vessel; strain. Add thin cuts of lemon, or pieces of sugar rubbed over the lemon to flavor. Lemonade.—Cut a lemon in half after rolling; squeeze one-half into a glass, removing the seeds; add a little water and stir in a heaping dessertspoonful of sugar. Fill up the glass with water; stir in more sugar if neces- sary. Effervescing Lemonade.—Add half a teaspoonful of bicarbonate of soda to the above, or Vichy water may be used. Egg Lemonade.—Shake up the white of one egg in a cup of water, to which add two teaspoonfuls of lemon juice and sugar; shake. Serve at once. Imperial Drink.—Add a teaspoonful of cream of tartar to I pint of boiling water; squeeze and add the juice of half a lemon; add a dessertspoonful of sugar. Serve cold. Tamarind Water.—Stir a tablespoonful of preserved tamarinds up in a cupful of boiling water; allow to cool; strain. Serve with shaved ice. Currant Juice——To a tablespoonful of currant jelly add a cupful of boiling water, stirring; sweeten to taste; set aside to cool. Serve with ice. Orangeade.—Peel an orange; pour a cupful of boil- ing water over the peeling; squeeze and add the juice of the orange and a dessertspoonful of sugar; let cool; strain. Serve cold with shaved ice. A teaspoonful of lemon juice may be added to vary the taste. Milk Diet.—This consists of 2 or 3 quarts of milk daily. Koumiss.—Dissolve a third of a cake of compressed yeast in a little lukewarm water; add this to 1 quart of DIET RECIPES 301 fresh, warm milk; stir in a tablespoonful of sugar. Put the mixture in stoppered bottles; cork and set away for twelve hours in a temperature of about 70° F. Then put the bottles upside down on ice until ready for use. Toast Water.—Remove the crust from a slice of stale bread; toast without burning. Break the slice up and put the fragments into’a small crock or pitcher; adda couple of pieces of orange peel or lemon. Pour over all I pint of boiling water; cover with a napkin; let cool; strain for use. Must be made fresh. Toast Soup.—Toast a thin slice of stale bread. While hot spread butter over it, having no excess. Break into fragments and place in a pitcher; add ? pint of boil- ing water; add a pinch of salt and pepper. Serve hot. Flaxseed Tea.—Add one-half cup of flaxseed to I quart of boiling water. Boil for one-half hour over a slow fire. Allow to set near the fire for fifteen or twenty minutes; add a teaspoonful of lemon juice; sweeten to taste; strain. Serve hot or cold. Slippery elm bark may be added to the above mixture, allowing 4 ounce of the bark to 1 pint of liquid. Milk and Cinnamon.—To 3 pint of new milk add enough broken cinnamon sticks to flavor; add to this a teaspoon- ful of sugar; strain. Serve cold or hot. Arrowroot Gruel.—Stir up half a tablespoonful of arrowroot flour with a little cold water; add a cupful of water, stirring in half a dessertspoonful of sugar and a pinch of salt. Boil slowly for twenty minutes, stirring constantly; add a cupful of milk; boil; strain. Serve hot. Barley Gruel.—Stir up a tablespoonful of barley flour in a little water; add a cupful of water in which has 302 SURGICAL TECHNIC been mixed haif a dessertspoonful of sugar and a pinch of salt; heat; bring to a boil, continuing it for twenty minutes; stir constantly; add a cupful of milk; bring to a boil; strain. Serve hot. Cracker Gruel.—Dissolve half a teaspoonful of sugar and a pinch of salt in a cupful of water; apply heat. Mix up two tablespoonfuls of grated cracker in a little water and add to the heated water. Boil for five min- utes; add a cupful cf milk and again bring to a boil. Serve hot. Flour Ball.—Tie up half a pint of flour in a square of cheese-cloth very tight; place in a pot of boiling water; cook for five hours. After removing the cloth peel the outside of the ball and grate; dry in the oven and keep in a closed jar. This may be used for making gruels; also to dilute milk for young children. Tapioca Jelly—Soak a cupful of tapioca for two hours; ‘when soft, place in a saucepan; add a dessertspoonful of sugar; the rind and juice of one lemon; a pinch of salt and I pint of water; heat, stirring the mixture until boiling; turn into a mold and set out to cool before serving. Tapioca Soup.—Boil I pint of meat broth; stir in I ounce of washed tapioca. Set on the back of the stove to simmer, covering the vessel. Skim and serve hot. Eggs.—Boil eggs by dropping them into boiling water, and continue for three minutes. Poached Eggs.—Bring water to a boil in a saucepan; add a pinch of salt; slip the egg carefully broken in a saucer into the salted water. Cook until the white is firm but jelly-like; remove with a skimmer and serve ona thin piece of buttered toast; sprinkle a little salt and DIET RECIPES 303 pepper on the top; garnish with parsley sprig. Serve at once. Scrambled Eggs.—Beat up two eggs thoroughly; add two tablespoonfuls of milk; a pinch of salt. Pour into a very hot buttered frying pan; stir constantly for about two minutes. Serve on buttered toast at once. Shirred Eggs.—Heat up the shirring cups. Put in each cup a bit of butter; break into each an egg. Allow to remain on the stove for a moment, then serve hot in the cup, adding a pinch of salt. Panado.—Take a slice of wheat bread and break up into fragments; sprinkle a teaspoonful of ground cinna- mon over the whole; add 1 pint of boiling water; boil for five minutes; add a teaspoonful of sugar and a little grated nutmeg. Serve hot. Milk Toast.—Prepare two slices of crisp toast. Heat a cup and a half of milk to the boiling-point; add a pinch _ of salt and a small bit of butter. Pour the milk mixture over the toast in a closed dish. Serve hot. Rennet.—One pint of warmed milk, sweetened, and flavored with nutmeg, cinnamon, or lemon; add one large teaspoonful of liquid rennet; stir for one minute; set aside to cool and set. Serve with sugar and cream. Boiled Rice.—Rice must continue to boil until every grain is softened without dissolving into a shapeless mass. Plain Rice.—Two tablespoonfuls of rice are to be washed and placed in a shallow baking dish; add two tablespoonfuls of sugar; flavor with lemon peel or vanilla; add 1 quart of milk. Bake for three hours in a moderate oven, stirring every twenty minutes. Cool for an hour before using. Serve cold. 304 _ SURGICAL TECHNIC Tapioca Pudding.—Soak one-half cup of tapioca over night in cold water; put it over the fire and heat to clear- ness. Mix up I pint of milk and two eggs to form a cus- tard by heating the mixture until almost boiling, then stir in two tablespoonfuls of sugar and cook for three minutes in a double boiler, stirring gently all the time. When done it should be as thick as cream. If allowed to cook too much it separates and is spoiled. Add the milk custard to the tapioca; sweeten and flavor to taste; bake in a quick oven. Set aside to cool. Serve cold. Cornstarch.—To one tablespoonful of cornstarch add cold water enough to make a smooth paste. Add to this 1 pint of milk; boil for five minutes, stirring all the time; add a pinch of salt; sweeten to teste, and add a flavoring extract. Serve cold. Beef Essence.—Cut up I pound of fresh lean beef into small pieces; sprinkle a little salt over the mass; ' place the cut-up meat into a stout stone jug; place the jug in a vessel of cold water and bring to a boil; cork the jug tightly when steam begins to issue from the mouth. Continue boiling for at least four hours; strain through a cloth and season the meat juice obtained with pepper and salt to taste. Invalid’s Soup.—To 1 pint of beef essence made quite hot add 3 pint of cream, likewise hot, to which the yolk of a fresh egg has been stirred. Mix carefully together in a lined saucepan; season and serve . Beef Broth.—Take 1 pound of beef (neck or shoulder) and slice it up; place in a pan and salt, then pour on I quart of cold water; place on the fire and bring to a sim- mer; keep so over a slow fire for an hour and a half; set back on the range for half an hour; strain; serve. DIET RECIPES 305 Mutton Broth.—Cut up I pound of good mutton into small pieces and sprinkle with salt; allow to simmer over a slow fire, after adding 1 quart of cold water, for an hour and a half; boil for half an hour; strain; serve. Beef Juice.—Take 3 pound of lean beef and cut it up in pieces of about the size of a pigeon’s egg; toast the pieces over hot coals; squeeze out the juice with a meat presser or lemon squeezer; add a pinch of salt before serving. + Chicken Broth.—Take a small chicken, removing skin and fat between the muscles; divide it in two down the back; remove the lungs as wéll as everything adhering to the side bones and back; cut up the halves in thin slices; place them in a pan and sprinkle with salt, then add 1 quart of cold water: bring to a simmer over a slow fire; allow to remain for an hour and a half. Then remove from the fire to a place where the heat will still be kept up for half an hour longer; strain; serve hot. During the cooking a sprig of celery may be added, or a clove, or half a dozen pepper-corns to give it a flavor. 20 CHAPTER XXI 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 rapid 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 it may be due to syncope or to the person being in a Fig. 223.— Stethoscope. trance; nor is absence of the heart-beat, unless deter- » mined 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 sud- denly or from external violence the following tests are usually applied: 306 SIGNS OF DEATH; AUTOPSIES 307 1. The absence of the heart’s action is carefully deter- mined 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 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 surface becomes moist, 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 per- son blood will escape, but not if life is extinct; still, if there has been a large loss of blood there will be no es- cape of blood in the living. Rigor mortis (postmortem 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 excite- ment, 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 sign of death, be- cause it indicates death of the muscle 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, cadaveric lividity, or congestion of blood in the capillaries, which forms in all the dependent parts 308 SURGICAL TECHNIC 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 hours after death may be very high, 107° or 112° F. Patients dying from cholera and yellow fever have high tempera- tures for several hours after death; but, as a rule, the body is 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 medi- cal knowledge. It verifies the diagnosis of the illness, and in many cases it explains or shows the cause of symp- toms 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 autopsy, when made by a competent bacteriologist and pathologist, will show whether death was due to sepsis or to some organic disease over which the surgeon had no control. In a private house the autopsy should be held in the room giving the best light, and if possible in the day- time, in order to obtain the correct color-interpretation, for if made in artificial light the observations will not be entirely trustworthy. At the present time an autopsy is preferably held al- most immediately after death and before putrefactive changes have taken place. The undertaker should al- ways be warned not to inject the body, because the fluids SIGNS OF DEATH; AUTOPSIES 309 usually employed, which contain among other things corrosive sublimate and arsenic in large quantities, change the color and consistency 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. If the corpse is female, braid the hair in two plaits after combing a part extending from ear to ear over the crown. Coil each plait securely with hair-pins. 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. 3. Three wash-bowls: one for corrosive sublimate, one for dirty instruments, and one for the organs removed. 4. Two pails for dirty water. 5. Old towels and a number of old sponges. 6. Plenty of hot and cold water. 7. About 4 quarts of fine sawdust, or oakum, or excel- sior packing, absorbent cotton, or common cotton for filling up cavities, any one of which will prevent fluid oozing through the incisions. When these are not ob- tainable, 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. 310 SURGICAL TECHNIC 8. Six wide-mouthed bottles in which to place speci- mens from the various organs, and which can be securely corked. g. About 3 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 instruments 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, covering the arms, leaving the chest and abdomen free for the surgeon to operate; the third piece is placed beneath the head; and the fourth piece is tucked in below the genitals, thus covering the lower extremities. 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 oil-cloth; the papers, old 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 postmortem. 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 permanganate 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. CHAPTER XXII HYGIENE; PERSONAL CONDUCT OF A NURSE’S LIFE; OF THE REWARDS; SUCCESS THE care of her own person must not be forgotten by the aspiring nurse, else she may gain the coveted post of trusted helper to physicians at the price of loss of her bodily health. Rest and regularity in conducting her mode of life are the chief factors for securing a continu- ation of sound health which every nurse should possess who attempts the work of caring for the sick. Futile as it may seem to suggest rest and regularity to one whose professional life is largely made up of activity and irregularity of mode of personal life, it is neverthe- less essential for a good nurse to learn how to save up - energy during ordinary times that she may have suffi- cient vital capital force to meet the emergency demands. _ Sufficient sleep and a regular time for eating is as im- portant for the well as the sick, and in the matter of eating it must be recalled that a mouthful of food which has been well masticated before swallowing will give much greater return in energy than many of the hurried mouthfuls which nurses are too prone to take. Attention to the calls for emptying of the bladder and the bowels are for the most part made a matter of con- venience rather than considered as most important functional activities to be attended to without delay. Daily stimulation of the skin of the entire body by bathing, even if but a sponge-bath taken from a wash- ei 312 SURGICAL TECHNIC bowl or a basin, is to be recommended, for while the average nurse may be forced to scrub her hands and arms too often for either health or comfort, there is seldom al- lowed time enough for sufficient body bathing. The presence of decayed teeth, corns, bunions, varicose veins in the legs, and hemorrhoids are all common affec- tions which may be borne a long time, but the nurse who has such things may come to a time of final failure in her professional career. Upon the very first appear- ance of the handicapping conditions mentioned she must seek relief, for the best that medical and surgical advice and treatment can give is hers by right. Aside from the | ordinary affections which arise from ill-fitting shoes, nurses are particularly liable to the condition called ‘“foot-sore,”’ student nurses being special sufferers. While the hard floors of modern hospitals are responsible for the condition during the earliest days of a nursing career, later its control is a matter of proper care of the feet themselves. A nurse must seek foot comfort and health, not by wearing her oldest, run-down shoes, but a well-fitting, ample-sized shoe which allows her toes to lie uncramped. The other essential for com- fort is to keep the feet dry. Perspiration quickly softens the skin of the feet, and allows swelling in the soft cellular tissue beneath to take place. While a per- spiring foot is by no means unhealthy, the relaxation which accompanies it calls for treatment. To overcome the effects of excess the following measures will be found useful: A daily change of shoes; one or more changes of stockings during the day; stimulating foot-baths, alter- nating hot and cold water, accompanied by rubbing with a coarse towel and massage; alcohol bath and rub; SE ————— le ee ee HYGIENE; PERSONAL CONDUCT OF A NURSE’S LIFE 313 painting the soles of the feet with a Io to 20 per cent. formalin solution once or twice a week; talcum powder, rice flour, fuller’s earth dusted in the shoes will be found invaluable in keeping the feet both dry and warm. A daily change may be made at the time of dressing. In - general, high laced shoes with low heels will prove more comfortable than the low light-weight ties. Rubber heels are restful, as they greatly reduce body-jarring. Tendency to flattening of the arches of the feet, mani- fested by a continuous ache upon standing, may be over- come by massage, strapping, and bandaging, or sup- ported by sole-plates. The continual scrubbing and immersions in the various antiseptic solutions of hands and arms which the modern nurse is compelled to undergo often gives rise to discom- fort, if not to well-marked skin disease. Drying up of the normal oil of the skin is the earliest direct cause of roughness, cracking, and scaling skin. There is a pecu- - liar sensitiveness of certain individuals’ skins for such drug solutions as carbolic acid, bichlorid of mercury, and oxalic acid, which act toward them as special irri- tants and which is known by the term “idiosyncrasy.”’ In general, to keep the hands pliant by massage and the free use of cold cream, lanolin, or some such bland oint- ment will suffice. In cases which fail of relief rubber gloves must be worn. The importance of cultivating her powers of observa- tion can hardly be estimated, so much will the nurse’s reliability be thereby increased. After making the first general observation her duty is to note changes, to see and jot down facts, not bias her observing faculty by evolving opinions. 314 SURGICAL TECHNIC A good nurse makes no noise herself, and acts as a per- petual noise preventer in and around the sick-room. The stricter a nurse holds herself to the prescribed uniform of her school the better, thus fancy collars and neckwear, jewelry, hair ornaments, and finger- rings detract her personality from the réle she plays. The calling of a nurse demands that she be always neat and trim in the matters of her personal appear- ance and in clothing effects, and that her professional relationship with the patient, his family, and the physi- cian call for but the ordinary dignity which becomes a woman’s greatest charm when least assumed. While the mental caliber of the successful nurse is from necessity large, she will do well not to continually tax herself with the requirements of her art. Proper amusements have their place, and will the better equip her for the serious work hours. Nurses will do well to study surgical supply catalogues, so as to know the cost of supplies and keep abreast of what is new. A postal request will suffice to supply her. No matter how physically well a nurse may conduct her life, it becomes a necessity for her to secure a change of scene during a month or two of the year, which may be obtained by means of a “traveling case,”’ by connect- ing herself with work in some distant part of the country through correspondence, or the channels of a medical journal’s advertisement columns, or by expending part of her year’s savings for board in the country or at the seashore. Every nurse’s bureau should have its corre- spondence department to provide for this “exchange” system in practice over the country. Besides rest in change of environment the results will be better, because . HYGIENE; PERSONAL CONDUCT OF A NURSE’S LIFE 315 broader, educated nurses. Of the rewards for conscien- tious work the nurse’s outlook is a bright one, for better salaries are offered and more may be expected to be paid in the future for high-class work than ever before. The matter of money loss to nurses, which occurs between “cases,’’ is to be overcome by a mutual division of ex- penses, as is customary in large communities. Five or six nurses ‘“‘keep house’”’ in a few rooms, the one who is professionally unemployed acting as ‘“‘housekeeper.”’ By this means direct communication is kept up between doctors and nurses. While the agency system for hiring nurses is good, a sure plan for a nurse to gain cases is by periodic personal visitations upon doctors. A nurse who calls upon a physician and tells him what she can do and the scale of her prices for her work has made an im- pression and she will be remembered by the doctor when in need of a nurse’s aid. Individual success for the nurse, as in any other voca- tion, must be the sum-up of her whole life’s work. If at the commencement of her career she learns to know her- self as a helper—one whose life’s work is dedicated to the sick and to a loyal devotion to the medical profession, of which she is herself a most important part—such a one is well started in her career and is on the high road toward success and honor. GEOSSARY. A. Abdominal binder. A wide band- age dressing used to support the walls of the abdomen after open operations or the womb after childbirth. Muslin, flannel, or towelling may be used, and is applied snugly by overlapping tails and fastening or by safety-pins. Abdominal operation. An opera- tion which involves opening the ab- dominal cavity as a preliminary. Abdominal section. An opera- tion in which the belly cavity is opened. Abscess. tion of pus. . Acetic fermentation. Souring with the production of acetic acid or vinegar. Actinomycosis. A disease of cattle which may be transmitted to man; it is due to the ray fungus. Active hyperemia. Steady in- crease of the quantity of blood in the vessels of a part. Acupressure. Compression of a blood-vessel by twisting with an in- serted needle. Acute disease. One active in on- set, energetic in course, and of short duration. Aérobic. Requiring the presence of oxygen for development. A circumscribed collec- Albumose. A substance formed during the digestion of albumin. : Alimentary canal. ‘The digestive tube extending from the mouth to the anus. . _ Alterative. A medicine having a gradual and general tendency toward the production of health. Anaérobic. Requiring absence of oxygen for growth to take place. Anesthetic. Producing uncon- sciousness to pain. Aneurysm, A disease of blood- vessels due to stretching or rupturing of one or more of the coats. Aniline derivative. An agent prepared from coal-tar. Anthrax. A contagious disease of cows and sheep often transmitted to man, due to the Anthrax bacillus. Antiseptic. An agent by whose action germs are destroyed or their growth prevented. Antiseptic agent. One which inhibits the growth or destroys germs. Antiseptic surgery. The various procedures which are carried out with the idea of preventing or destroying germ contamination. Antistreptococcic serum. A pro- tective blood-water taken from an animal which has successfully recov- ered from graded injections of virulent pus germs. 317 318 Antitoxin. A defensive proteid | developed in a body for its protection from microbic assaults; a curative blood serum. Aqua ammonia. Ammonia-water. Arterioles. Smallest branching arteries. Artificial inoculation. Attempt to produce a disease by injection or local application of the germs, their products, or the virus producing it. Artificial media. An agent cap- able of supporting germ life outside of the body. ~ Asepsis. Freedom from poisoning; clean. Aseptic. Free from germs; sterile. Astringent, An agent which causes contraction of tissues and the lessen- ing of secretions. Atomizer. An appliance for spray- ing. Aural. Pertaining to the ears. Aural canal. The ear passage. Autopsy. The examination of a dead body, a post mortem. Autopsy room. A room set aside for the examination of dead bodies. septic Axilla. The arm-pit. B. Bacilli. Rod-shaped germs, as tubercle bacilli, the cause of consump- tion. Bacteria. Minute organisms; mi- crobes. Bacteriologist. One who studies and experiments with germ life. Bacteriology. The study of germs. Bed heater. An appliance for heating a bed, as with a hot-water bag, hot bricks, etc. Beef essence. extract. Concentrated beef GLOSSARY Bistoury. A sharp narrow-bladed surgeon’s knife; may be sharp or dull pointed; curved. Blastomycete. germ. Blood serum. ‘The watery portion of animal fluids. Boroglycerid. A pasty compound made by slowly dissolving two parts of boric acid in three parts of hot Yeast-forming glycerin. Bouillon. Strained beef soup; a culture-medium. Bronchi. ‘The first division of the windpipe. Bronchioles. ‘The finest divisions of the windpipe. Bronchorrhea. Excessive flow of mucus from the windpipe. Bubonic plague. An acute, con- tagious disease characterized by a malignant type of fever and forma- tion of buboes or glandular swellings throughout the body. Buttocks. ‘The fleshy parts back of the hips. C. Cancer. A morbid growth whose tendency is to spread and to cause ultimate death. Capillaries. The finest divisions of the blood-vessels. Capillary hemorrhage. Oozing of blood. Carcinoma. One form of cancer; common seat is the female breast. Catalepsy. Condition of partial or complete suspension of will and con- sciousness, with rigidity of voluntary muscles. Catheterization. The act of draw- ing off the urine. Catheterize. urine. To draw off the GLOSSARY Cellular tissue. Loose fatty spaces beneath the skin and between organs. Cerebrospinal fluid. Serous fluid contents of the cavities of the brain and spinal cord. Cervical canal. Channel in the neck of the womb connecting the vagina with the body cavity of the womb. Chemic. Chemical; relating to chemistry. Chill. A nervous symptom usu- ally marking the onset of disease, in which the patient has rigors and com- plains of being cold; in malarial fever the temperature is really highest at this time. Chlorinated soda. Scda which has been combined with chlorin. Chlorin-water. A saturated solu- tion of chlorin in distilled water. Citronella. A fragrant Asiatic grass from which is obtained a volatile oil, useful, when applied to the person, in driving away mosquitoes. Clammy. Moist and cold. Clamp. An instrument with de- tachable handles to apply to the broad ligament; in operations for removal of the uterus through the vagina, six or eight are applied upon each side. A hemostatic forceps to control hemorrhage from vessels that cannot be reached to apply ligation. Clostridium. A bacillus distended at its center by a large spore. Coagulable quality of blood. The power to clot. Cocainization. The act of pro- ducing cocain anesthesia. Collapse. General failure of the vital powers without loss of con- sciousness. Colony. A__ localized, growth of micro-organisms. unmixed 319 Complication. A disease appear- ing during the course of another, which may modify the termination. Contagious. Capable cf being transmitted from one individual to another; catching. Contagious affection. A disease directly transmissible from one person to another. Contagious disease. One which may be directly transmitted from one to another. Convalescence. The feriod of uninterrupted recovery from _ill- ness. Convulsion. A nervous condi- tion giving rise to violent, continued, or intermittent muscular contrac- tions. Corrosive sublimate. of mercury. Coryza. Cold in the head. Cranioclast. An _ obstetrical in- strument to aid in the delivery of a child’s head by crushing. Crystalline. Colorless; crystal. Culture -media. which germs are grown. Cumol catgut. Catgut sterilized for surgeon’s use by superheating in a solution of cumol, a product of coal-tar. Curetting of uterus. Clearing out of the contents of the womb or scraping the membranous lining of Bichlorid clear as Substances upon experimentally its cavity. Cyanosis. The symptoms arising when the supply of oxygen is greatly lessened, as in strangulaticn. Cyst. A circumscribed membran- ous cavity occurring abnormally and containing fluid, semifluid, or solid contents. 320 Cystitis. Inflammation of the bladder Cystoscopic examination A study of the bladder by the use of an in- strument which brings its surface di- | rectly into view. D. Decomposition. rotting; separation into elements. Delirium. Mental state in which | there is a rapid flight of ideas which are incoherent and often unintelli- gible. - Depletion. Reduction of the amount of fluid, as blood or serum, in a part. Diabetic coma. Loss of con- sciousness due to the action of poisons in diabetes. ; Diaphragm. The great breathing muscle separating the chest from the abdomen. Dilatation of cervix. Act of stretching the mouth and neck of the womb. Disinfectant. An agent capable of destroying microbes or the prod- ucts of their growth. Disinfection. The act of render- ing free from micro-organisms or their effects; purifying. Distillation. that the vapors given off may be collected. Douche. for purposes of cleansing and stimula- tion. E. Eclampsia. Convulsions during the childbearing period caused by kidney disease. Act of decaying; The act of heating | a solid or liquid in an apparatus, so | A more or less forcible | flushing of a cavity or part of the body | GLOSSARY | Ecraseur. An instrument used to | squeeze its way through tissue causing _ least amount of bleeding by employing | a gradually tightening wire or string. Eczematous condition. One in | which peeling and crusting of the skin occurs with more or less itchiness. Edema. Swelling due to excess of | serous fluid within a tissue. Effervescence. Bubbling. Elaborated. Developed; duced pro- | Electrolysis. Decomposition by electricity. Elimination. The act of throw- ing, off; expelling. Emergency operation. One made necessary by the serious condition of | the patient. | Emesis. Vomiting. Emetic. A substance causing | Vomiting. Emulsion. A fiuid containing fat suspended in very fine particles, form- | ing an opaque, milky white mixture. Endocarditis. Inflammation of the lining membrane of the heart. The process is usually confined to the valves. Endometritis. Inflammation of the lining of the womb. Enemata. Rectal injections; solu- _ tions used to cleanse the lower bowel. Enteroclysis. The administration | of a rectal injection. Epidemic. A general invasion of a community by a given disease. Epidemic cerebrospinal menin- gitis. A microbic disease giving rise to inflammation of the lining mem- branes of the brain and spinal cord | with convulsions, irregular fever, and a rash. | Epidermic. the skin. Injected; relating to GLOSSARY Epidermis. The surface-covering of the body; the skin. Epithelial cells. Microscopic units; flat upon the skin, goblet- shaped on mucous membranes, form- ing the surface layers of these tissues. Epithelium. Skin covering. Eruptive fever. One attended with a rash; scarlet fever. Erysipelas. An acute contagious skin disease caused by streptococci, giving rise to irregular fever, and with a tendency to relapse. Erythema. Redness of the skin; blushing. Eucalyptus. An Australian gum tree from which is obtained an oil used in medicine. This oil produces sweating, is tonic, stimulant, and anti- septic. Eustachian catheter. A tubular instrument designed to pass through the nasal cavity to the opening of the Eustachian tube. This latter is a canal leading from the back of the mouth to the middle ear. Evaporation. Loss of water by the action of heat. Excretions. Products of body waste; urine. External jugular vein. The larg- est superficial vein in the neck, run- ning downward midway upon both sides. F. Fallopian tubes. shaped pipes, each about four inches long, connecting the womb with the abdominal cavity, through which ova pass. Fascia. Strong, glistening fibrous sheaths separating muscles. Feces. Body and food waste from the bowels. 21 Two trumpet- | EPA! Fermentation. The change ef- fected by the action of a ferment; souring. Fetus. A young child within or taken from,its mother’s womb before it has fully developed. Fibrils. Thread-like connective tissue. Fibrin. Fine elastic strands formed during clotting and inflammation. Fibrin-ferment. A substance causing the formation of fibrin. Fistulz. Disease tracts indisposed to heal. Flacherie. A contagious disease of silkworms caused by micrococci. Flat wines. Wines spoiled by begin ning acid fermentation. Flatulence. Excess of gas in the stomach or bowels; wind colic. Fuller’s earth. A finely powdered earth used as an absorbent. Fumigate. To free from infection by the use of vapors. Fungi. The lowest order of non- flowering plants living upon animal matter; in bacteriology, a micro-organ- ismal moss. G. Gangrene. Local death of the part. Germ theory. The theory that all specific disease is due to the presence or action of micro-organisms. Germicidal solution. A germ killer. Glanders. A disease of horses caused by the bacillus mallei which affects the air-passages and skin and is transmissible to man. Globulins. A form of albumin. Gonococcus. The germ that causes the venereal disease called 322 gonorrhea; consists of a double, dumbbell coccus. Gonorrhea. A _ sexual _ disease caused by the transfer and activity of a germ called the. gonococcus from one individual to another. Granulation tissue. Reddish, bud- like projections found upon the sur- face of a healing wound. Gynecologic. MKelating to the sexual organs of a woman. H. Heart paralysis. A condition in which the heart’s action is rapidly weakened or ceases. Hemorrhage. Bleeding; generally used to designate a profuse loss of blood from the vessel affected. Hemorrhoids. Dilated and elon- gated blood-vessels about the open- ing of the lower bowel; piles. Hernia. An abnormal protrusion of an organ or tissue. High enemata. An injection made high into the bowel by aid of gravity and a rectal tube. Hives. Common name for a skin disease giving rise to an evanescent eruption associated with severe itching. Hydrophobia. A disease of dogs and kindred animals communicated to man by direct inoculation; rabies. Hypodermic injection. Deposit of a solid or fluid beneath the skin by means of a syringe and hollow needle. Hypostasis. The settling of blood or fluid to the lowest parts of the body by gravitation after death, or loss jof pressure-controlling power in a given set of blood-vessels. Hysterectomy. womb by operation. Removal of the GLOSSARY I. Icterus. Bile-stained; jaundiced. Immunity. A condition in which a body resists the development of micro-organisms or the action of their poisons. : Immunizing unit. A _ standard strength agent to subdue the powers of a given quantity of micro-organ- isms or their products. Infectious disease. One capable of being transmitted from one person to another. Infective. ease. Infective puerperal endometritis. Purulent inflammation of the lining of the womb after childbirth. Inflammation. Reaction of a part to an irritant. Infusion. Charging the veins with fiuid by injection. Inoculation. The act of directly implanting disease. Inoculous. Rendered sterile. Insomnia. Unable to sleep. Inspissated. Dried and thickened from loss of water. Intestinal adhesion. Union of two peritoneal surfaces of the bowel caused by inflammatory action. Intestines. The bowels. Intracerebral injection. Deposit within the cavities of the brain. Intravenous. Within the veins. Intravenous injection. An injec- tion forced directly into a vein or cellular tissue. Intubation. Operation of passing a tube through the larynx when closed by disease, as in diphtheria. Isolation. Setting apart from all communication with others. Likely to produce dis- GLOSSARY K. Knuckle of intestine. A short length of gut sharply bent upon itself. Kraske’s operation. Operation devised by the surgeon whose name -it bears for the removal of cancer growing high up in the rectum. The diseased area is exposed by chiselling away the coccyx and portions of the sacrum. L. Lanolin. A bland, fatty substance prepared from sheep’s wool and used as the base of many ointments. Laparotomy sheet. Linen sheet covering containing a longitudinal opening through which patient’s ab- domen is exposed. Lavage. Washing by irrigation. Leprosy. A chronic obscurely contagious disease caused by the bacillus of leprosy, and giving rise - to various inflammatory lesions of the skin and internal organs. Leprous nodules. One form of skin lesion caused by leprosy con- sisting of firm, irregular elevations, which later break down and become ulcers. ; Leukocytes. Unit masses of pro- toplasm or the physical life principle. Ligation. The tying off of blood- vessels, the ovarian tubes, the appen- dix, or a tumor by means of a gut or silk string. Liquefied. Changed from a solid to a liquid state. Listerism. Antiseptic surgery ac- cording to the principles first laid down by Sir Joseph Lister. Litholapaxy. The operation of 323 removal of stone from the bladder by crushing and washing out the frag- ments. Lithotomy. ‘The operation of cut- ting for stone. Lithotrite. An instrument for crushing stones within the bladder. Lubricant. A substance used to diminish friction; rendering slippery. Lymphatic vessels and glands. The great system of absorbents with their connecting channels. M. Malady. Sickness, disease. Malignant tumor. One which has undergone cancerous change. Masticated. Chewed. Meatus. Anatomical name for the mouth of a canal. Media. ‘The means of transmis- sion; substances favorable for the growth of bacteria. Mediastinum. The middle space of the chest cavity between the lungs, and containing the heart and great blood-vessels. Medicaments. Menstruum. solvent for a drug. Miasm. Infection carried in the emanations from the soil. Miasmatic. Caused by infectious particles rising in vapors from the soil; said of malaria before its cause was known. Micrococci. spherical shape. Micro-organisms. Medicines. A fluid carrier or Germs having a Any form of germ life. Minim. A fluid drop. Monomorphous. Having but one form. 324 N. Narcotized. Poisoned by the action oi a narcotic, as opium. Natural rhythm of respiration. Normal breathing. Nerve-center. One of the count- less impulse generators or reflectors in the body. : Neutralizaticn. dering free or open. Nidus. Center of activity. Nutrient. Having food value. The act of ren- 0. Occlusion. Closing up. Ophthalmic. Relating to the eye. Organic ferment. The microbic action which gives rise to souring. Organized exudate. A fiuid dis- charge made solid by the formation of fibrin. Otitis media. Inflammation of the chambers of the middle ear. Ova. Eggs. Ovaries. The two organs in the female. Oxidation. Burning up. Oxygenation of the blood. Re- the red cells in taking up oxygen. 8 Parasitic organisms. Dependent upon other forms of life for their | food; may live in or upon the sustain- | ing organism. Gonococci are para- sites, as are also tapeworms and lice. Pasteur chamber and filter. GLOSSARY Pathogenic bacteria. Disease producers. Pathologist. One engaged in the study of the causes and results of dis- case. Pebrin. A hereditary contagious | disease of silkworms consisting of the | development of peculiar parasitic cor- | puscles which invade the eggs, blood, |and tissues of the worms, causing black spots to appear externally. Pedicle. An elongated support. Pedicle silk. Strong silk used to tie off the base of tumors before re- moval for security against bleeding. ‘Pellicle. Surface scum; an outer limiting membrane. Pelvic cavity. Space within the pelvis. Pelvimeter. Curved dividers used | by the obstetrician im calculating the size of a woman’s pelvis. Pelvis. The bony famepeee at the base of the spinal column sup- | porting the trunk and affording at- | tachment for the thighs. egg-bearing | Perforator. A sharp, spear-headed instrument used by obstetridans to | pierce the skull (to facilitate delivery) of a dead infant or one whose life freshing of the blood by the action of | must be sacrificed for the good of the mother. Perineal lithotomy. The breech | operation of cutting for stone. Perineorrhaphy. The operation of sewing up a torn breech of a woman. Peristalsis. The muscular wave- motion of the bowels. Peristaltic action. The motion An | which propels the contents of the apparatus for sterilizing and filtering | bowels. by the action of superheated steam, varied in pressure by means of an air- pump. Peritoneal cavity. The space oc- cupied by the abdominal organs. Peritoneum. The lining mem- GLOSSARY brane of the belly cavity and cover- ing of the organs contained. Peritonitis. Inflammation of the lining membrane of the organs and cavity of the abdomen. Petri dishes. Small double dishes for the cultivation of micro-organ- isms. Phagocytes. Body cells whose sup- posed function is to devour other cells as micro-organisms. Phagocytosis. The function of active destruction by devouring or englobing of one cell by another. Pharyngeal paralysis. Loss of voluntary power of swallowing, with dropping of the soft palate. Placenta. The late womb con- nection between a fetus and _ its mother. Plague. An acute contagious dis- ease commonly appearing in epidemic form due to micro-organisms char- acterized by bubo formation and high death-rate. Plasma. The fluid portion cf - blood or lymph. Pleurisy. Inflammation of the pleura or membranous covering of the lungs and lining of the chest walls. Pneumonia. Inflammation of the lungs. Precipitated. Thrown down by chemical action. Preparatory treatment. Mak- ing a patient ready for an operation, consists in local cleansing, attention to bowels and bladder, food, etc. Prone. Lying upon the abdomen. Prophylaxis. Preventive meas- ures. Protective dressing. A _ water- proof material placed next to a wound according to the direction of Sir Joseph Lister. 325 Puerperal, Relating to child- birth. Puerperal fever. Elevation of body temperature occurring in infec- tion after childbirth. Puerperal infection. Systemic poisoning by the action of micro- organisms in a child-bearing woman. Pure culture. Containing but one variety of germs. Purgative. A substance which moves the bowels. Pus. Matter given off from an open sore. Putrefaction. Separation of an organic compound into the elements of which it is composed by the action of micro-organisms; rotting. Pyroxylin. Gun-cotton; made by immersing raw cotton in nitric and sulphuric acids. R. Raw surface. An open wound or abrasion; a condition in which the skin or outer lining of a part or organ is broken through. Reaction. The restoration of vital- ity after shock. Rectum. The lower extremity of the large intestine. Recurrent. Returning again. Regurgitation. A back flow. Respiration. Breathing. Retention of urine. That condi- tion in which the urine, while it con- tinues to be formed by the kidneys, cannot be passed from the body; in- ability to pass water. a Revulsion. A rejection; counter- irritation. Rigor. Sense of coldness accom- panied by a superficial convulsive seizure. 326 S. | Salicylated. Containing a given | amount of salicylic acid. Saliva. Spittle. Saprophytic organisms. Those_ living in or on decaying organic mat- . ter. ’ Sarcoma. A form of cancer of | rapid growth and occurring most often in the young. Saturated. Fully filled; Saakek Scapula. The shoulder-blade. _ | Scarify. To cut into. Scarlet fever. An acute conta- gious disease of childhood giving rise | to high fever, rapid pulse, a rose-red | rash, and with a marked tendency to | be followed by kidney disease. Scultetus bandage. An over- | lapping many-tailed bandage dress- | ing. Secretions. Special substances thrown off by functionally active | organs. Sedative. Soothing; softening. | Septic. Relating to putrefaction | Septic discharge. Purulent; con- taining pus germs. Septic peritonitis. Inflammation of the lining membrane of the organs and cavity of the abdomen caused by the action of pus germs. Septicemia. A severe form of blood -poisoning in which both germs and their products are current in the blood. | or pus-germ infection. | | Sequelae. After-effects of dis- | ease. Sequestrum. A dead mass, as a fragment of a dead bone. Serum. The watery part of drawn | blood separating on standing; the fluid | in a blister. GLOSSARY Shock. The constitutional effect of a disease or injury. Sinus. A disease tract or channel left after the discharge of a purulent | collection. Specific bacteria. Germs directly responsible for the given disease. Sphincter muscle. Anatomical name for muscles whose actions are to close openings, as at the mouth and anus. Spica. A spiral bandage done with a roller in a series of figure eights. Most used for the shoulder, groin, thumb, and great toe. Spirilla. Spiral-shaped germs, as the spirillum of cholera (also called the comma bacillus). Splenic fever. Disease due to the anthrax bacillus; wool-sorter’s dis- ease. Spore. A germ seed. Spotted fever. Epidemic cerebro- | spinal meningitis or cerebrospinal fever; a specific infectious disease of the membranes of the brain and spinal cord and accompanied by a peculiar dusky rash. Sterilization. Act of rendering free from germs. Sterilize. To kill all germ life. Stethoscope. An instrument for | listening to the flow of air or blood | inside the body. Stimulation. Arousing to greater action; urging. Subcutaneous injection. One made beneath the skin. Subnormal temperature. Degree of body heat below 98° F. Supine. Outstretched upon the | back. Suppression of urine. A condi- tion in which the kidneys cease to act, no urine being formed. GLOSSARY Suppuration. The last stage of inflammation, manifested by destruc- tion of tissue with pus formation. Suprapubic lithotomy. Cutting operation for stone in the bladder attacked from above. Surgically clean. As nearly as is ' possible to be free from germ life. Sutures. The material with which a surgeon sews; the stitches them- selves. Syncope. Sudden loss of power and consciousness; fainting. fhe Tampon. A gauze or cotton plug; may have a string or tape attached for withdrawal. Technic. The mode of working; plan or method of work. - Tepid. Moderately warm. Tetanus. Lockjaw; a very dan- gerous germ disease characterized by locking of sets of muscles due to the presence of a poison developed by tetanus bacilli. Therapeutics. The science of the application of medicines for the cure of diseases. Thoracic cavity. The chest. Toxicity. Degree of poison. Toxin. Poison formed by germ life. Trachelorrhaphy. Operation for the repair of a torn mouth of the womb. Tracheotomy. Operation of cut- ting open the windpipe below the larynx for the purpose of admitting air to the fungs; done for closure of the upper air-passages. Traumatic delirium. Brain ex- citement following serious body in- jury. 327 Trikresol. A’ refined mixture made from carbolic acid. Tubercles. Local effects of the action of tubercle bacilli consisting of cheesy masses. Tuberculosis. An infectious dis- ease giving rise to general or local disorganization caused by the tuber- cle bacillus; consumption. Tumefaction. A swelling. Turpentine stupe. A piece of cloth or flannel dipped in spirits of turpentine after wringing out in hot water. Tympanites. Distention of the abdomen caused by excess of gas in the stomach and bowels; may become drum-like. U. Ulcer. A sore, attended by dis- charge. Ulceration. Superficial death of a part. Ulcerative endocarditis. A severe inflammation of the heart, ending with destruction of the valve leaflets. Undertaker’s stretcher. A port- able board and trestle inclined table upon which a corpse is laid during the process of embalming. Uremic coma. Loss of conscious- ness and physical condition following the absorption of urinary poisons in the late stages of kidney dis- ease. Ureter. The tube leading from the kidney to the bladder. It is of the diameter of a goose quill and about sixteen inches in length. Urethra. The water pipe from the bladder. Urethral calibrator. An instru- ment for determining the size of the canal. 328 Urination. The act of passing water. Uterine appendages. The ovaries, Fallopian tubes, broad and other at- taching hgaments of the womb. Uterus. The womb; the hollow, pear-shaped pelvic organ which is destined to retain the child from the moment of its conception until the time of its expulsion at birth. V. Vaccination. Inoculation of cow- pox lymph into the arm as a protec- tion from small-pox. Vacuum. Space in which there is no air. Vagina. The female genital canal. Vaginal discharge. A flow from the genital canal. Vaginal hysterectomy. Removal of the womb through the lower gen- ital canal. Vascular. Pertaining to vessels. GLOSSARY Venesection. Bleeding; opening | a vein to let out blood. Venom. Animal poison. Venous pressure. The weight and flow power of the blood stream in the veins. ; Venules. Smallest branching veins. Vertex. The crown of the head; highest point of the skull. Vestibule. The beginning of the female genital canal. : Virulence, Poison-strength. Virulent. Highly poisonous; de- structive. Virus. Any form of organic poison. Viscera. The contents of the large cavities of the body. Viscosity. Stickiness. ‘Vulva. The external genitals, pri- vate parts, the female external organs of generation. W. Wound drainage. A method of providing for the escape of pus or serum drip from a wound. . INDEX ABDOMEN, infections of, after op- eration, 257 Abdominal cavity, apparatus for douching of, 226 operations, instruments for, 131 Abscess, incision of, for drainage, 227 Absorbent cotton, 180 Accidents during operation, 275 Acclimatization, immunity, 39 Acids, mineral poisoning by, 230 Aconite poisoning, 230 Actinomycosis, communication of, to man, 22 Adhesive plaster, 93 figure-of-8 of knee, 95 moleskin, 93 pelvic binder, 95 resin, 93 rubber, 93 strapping of ankle-joint, 96 of chest, 94 of joints, 95 of leg ulcers, 95 zinc oxid, 93 Aérobic bacteria, 34 Age, effect of, on bacteria, 34 Air, effect of, on bacteria, 34 Akoin anesthesia, 171 Albumin water, 299 Alcohol as germicide, 60 rubs after fracture, ror Alimentary canal, entrance of bac- teria in, 35 Allis’ ether inhaler, 152 Alypin anesthesia, 171 Amphitheater, clinical, 243 Amputating knives, 132 Anaérobic bacteria, 34 Anesthesia, 144 care of bowels before, 144 of patient in, 147 Anesthesia, chloroform, 155 conduction, 169 delayed poisoning in, 167 diet before, 145 drugs before, 145 endoneural, 169 ether, 150. See also Ether. ethyl chlorid, 158 first stage, 149 infiltration, 169 intrapharyngeal inhalation, 160 intratracheal insufflation, 161 local, 168 : cocain, 168 cracked ice and salt, 168 ethyl chlorid, 168 method of holding jaw in, 154 nitrous oxid, 156 ether, 158 oil-ether colonic, 166 perineural, 169 physical examination before, 146 precautions in, 144 preparation for, 144 of mouth and teeth for, 145 rectal, 166 scopolamin-morphin, 166 second stage, 140 special methods of, 160 spinal, 172. See also Spinal anesthesia. stages of, 148 third stage, 140 vapor apparatus for, 151 Anesthetic paralyses, postoperative, 167 Anesthetics, varieties of, 144 Anesthetist’s supplies, 147, 148 Aneurysm needle, Deschamp’s, 136 Ankle-joint, adhesive plaster strap- ping of, 96 Anoci-association, 264 329 330 INDEX Anthrax bacillus, discovery of, 20 {| BABCocK’s solution for spinal anes- discovery of bacterial nature of, 23 Antidotes, 230-232 for carbolic acid, 59 for corrosive sublimate, 57 Antimony tartrate poisoning, 230 Antisepsis, origin of, 22 Antiseptics, 53 abuses of, 63 Antiseptic solutions, 64 surgery, 20 Antistreptococcic serum in perito- nitis, 273 therapeutic value of, 50 Antitoxic theory of immunity, 41 Antitoxin, cerebrospinal meningi- tis, 50 . diphtheria, dose of, 49 process of making, 46 status of, 49 method of injecting, 51 reactions from, 51 streptococcus, preparation of, 47 tetanus, 50 therapeutic action of, 47 tuberculosis, preparation of, 47 -Antitoxins, 45 theory of, 45 Antituberculosis serum, 51 Antityphoid vaccine, 50 Apple water, 299 Argyrol as disinfectant, 61 as germicide, 61 Aristol as germicide, 63 Arrowroot gruel, 301 Arsenic poisoning, 230 Artificial respiration, 267 in surgical shock, 266 Asepsis in gynecologic examina- tions, 289 Aspirator, Potain’s, 137 Assistant nurses, duties of, at operation, 256 Atropin poisoning, 230 Autopsies, 306, 308 cleanliness in, 310 instruments, etc., for, 309 preparation of body for, 309 time for, 308 thesia, 177 Bacilli, 29 Bacillus aérogenes capsulatus, 43 anthrax, discovery of, 20 coli communis, 42 comma, discovery of, 25 melitensis, 27 of bubonic plague, discovery of, 26 of diphtheria, 44 discovery of, 25 of glanders, discovery of, 25 of influenza, discovery of, 26 of membranous croup, 44 of pneumonia, discovery of, 25 of tetanus, 43 of tuberculosis, 25, 43 pyocyaneus, 43 typhoid, discovery of, 24 Back, figure-of-8 bandage of, 76 Bacteria, 29 aérobic, 34 agents capable of destroying, 54 anaérobic, 34 as causes of disease, 28 conditions influencing growth of, oss) definition of, 28 distribution of, 17 effect of age on, 34 of air on, 34 of drying on, 34 of sunlight on, 33 entrance of, into alimentary canal, 35 into respiratory tract, 35 forms of, 28, 20 incubation period of, 38 mode of entrance of, 34 pathogenic, 29 reproduction of, 32 by binary division, 32 by fission, 32 by sporulation, 32 sizes of, 28 soil required for, 34 Bacteriology, 17 history of, 17 progress in, 18 Auvard’s self-retaining speculum, | Baking treatment, 227 138 Balsam of Peru, 194 INDEX Bandage, application of, 66 Barton’s, 68 Christy knife for cutting, 67 demigauntlet dorsal, 84 palmar, 85 double crossed, of both eyes, 74 figure-of-8, of back and chest, 76 of head and neck, 74 Gibson’s, 69 Liebreich’s eye, 72 machine for, 65, 66 materials for, 65 mitre box for cutting, 67 occipitofrontal, 71 of breast, compressor, 74 double, 75 suspensory, 74. of eye, crossed, 72 of finger, spiral, 83 reverse, 84 of groin, descending spica, 86 double spica, 87 single spica, ascending, 85 of leg, figure-of-8, 88 of lower leg, spiral reverse, 80 of knee, figure-of-8, 87 of stump, recurrent, 87 of thumb, spica, 84 plaster-of-Paris, 98 application of, 98 _ removal of, 99 recurrent, 70 double head, 71 removal of, 68 rolling by hand, 65 scultetus, 92 shoulder, descending spica of, 79 spica, of shoulder, 77 to overlap, 67 to recur, 67 to reverse, 67 to secure, 68 Velpeau’s, 78 Bandaging, 65 Barley gruel, 301 water, 299 Barton’s bandage, 68 Basin, pus, 112 Bath thermometer, 208 Beck’s bismuth paste, 194 Bed arranged for childbirth, 234 331 Bed, ether, 284 Gatch, 186 Bed-pan sterilizer, 111 Beef broth, 304 essence, 304 juice, 305 Belladonna poisoning, 230 Bellocq’s cannula, 271 Bichlorid of mercury as germicide, 56 Bier’s hyperemia, 223 Bigelow’s evacuator, 142 Bismuth paste, Beck’s, 194 Bladder, care of, after operation, 258 irrigation of, 202 Blastomycetes, 29 Boiling water, sterilization with, 55 Bone gouge, 141 Bone-cutting forceps, 141 instruments, Macewen’s, 141 _| Bone-plating, instruments for, 139 Boric acid as germicide, 63 Bowels, care of, after operation, 258 Breast bandage, compressor, 74 double, 75 suspensory, 74 Breast-binder, Murphy, 236 Broth, beef, 304 chicken, 305 mutton, 305 Brushes, 184 Bubonic plague bacillus, discovery of, 26 Buck’s extension, 97 mastoid curet, 126 Button suture, 216 CABINET for instruments, 102 Cannula, Bellocq’s, 271 Luer’s trachea, 127 Cantharides poisoning, 231 Carbolic acid, 52 as germicide, 58 poisoning, 59, 230 Cargile membrane, 188 Carotid arteries, instruments for ligation of, 129 Catgut, 190 chromicized, 192 iodin, 191 332 Catgut, sterilization of, 190 Catheter, Gouley’s tunneled, 142 introduction of, 201 straps, 93 _ Catheterization, 200 cystitis from, 200 Catheters, glass, 200 sterilization of, 200 Catling’s amputating knives, 132 Cautery, Paquelin, 220 Cerebrospinal meningitis, antitoxin | in, 50 cause of, 26 Cervix, instruments for dilation of, 555 for repair of, 135 Chart, medical, r21 keeping of, 116 Chest, figure-of-8 bandage of, 76 instruments for operations on, 131 | ter, 04 Chicken-broth, 305 Childbirth, bed arranged for, 234 Chlorid of lime as disinfectant, 61 Chlorin-water poisoning, 231 Chloroform anesthesia, 155 _ ‘poisoning, 231 ae knife ae cutting bandages, ie ees catgut, 192 Cigarette-drain, 185 Cinnamon and milk, 301 Circulation, absence of, as sign of | death, 307 Circumcision, instruments for, 143 | Clamps, Michel’s, 194 Clinical thermometer, 228 Clothing for infant, 236 hospital, for patient, 250 Coaptation splints, roo Cocain local anesthesia, 168 poisoning, treatment of, 170 Cocci, 29, 30 morphology of, 30 pus-forming, 30 pyogenic, 30 Colchicum poisoning, 231 Cold, therapeutic use of, 218 Coley’s serum for malignant tumors, | 50 reaction from, 51 INDEX | Collins’ retractor, 137 Collodion, 227 dressing, 183 Colon tube with funnel, 213 Comma bacillus, discovery of, 25 Compresses, 101 Compressor bandage of breast, 74 Conduction anesthesia, 169 | Conium poisoning, 231 | Continuous suture, 216 Copper sulphate poisoning, 231 | Cornstarch, 304 Corrosive sublimate as germicide, 56 5 poisoning, 231 tablets, 57 | Cracked ice and salt for local anes- thesia, 168 | Cracker ‘gruel, 302 | Creolin as germicide, 60 | Crile’s anoci-association, 264 Croton oil poisoning, 231 | Cupping, 218 instruments for, 220 | Curet, Buck’s mastoid, 126 DeRoalde’s adenoid, 128 Sims’ sharp, 138 Thomas’ dull, 138 Curetment of uterus, instruments for, 135 Currant juice, 300 | Cystitis from catheterization, 200 GS ystoscopy, instruments for, 143 | DEATH, signs of, 306 absence of circulation, 307 of heart-beat, 307 of respiration, 307 hypostasis, 307 insertion of needle, 307 rigor mortis, 307, subcutaneous injection of am- monia, 307 temperature, 308 | Delirium, traumatic, 266 INDEX Deodorants, 53 DeRoalde’s adenoid curet, 128 Deschamp’s aneurysm needle, 136 Desmarre’s lid retractor, 130 Dewitt’s appliance for rectal irriga- tion, 210 Diet after childbirth, 235 after gynecologic operations, 298 before anesthesia, 145 milk, 300 recipes, 209 Diet-list after operation, 260-262 Digitalis poisoning, 231 Dilator, Goodell-Lentz uterine, 140 Sinexon’s nasal, 127 uterine, 140 Diphtheria antitoxin, dose of, 40 process of making, 46 status of, 409 bacillus of, 44 discovery of, 25 Diplococci, 30 Diplococcus intracellularis meningi- tidis, 26 pneumoniz, 43 Disease, bacteria as causes of, 28 in man, fungi connected with, 20 Dish, Petri, 247 Disinfectants, 53 - Disinfection, 54 by steam, 55 Dorsal position, 291 Douche, vaginal, 207 antiseptic, 208 apparatus for, 2009 Draeger pulmotor, 269 Drainage, incision of abscess for, 227 of wounds, 185 postural, 186 Drainage-tubes, 185, 188 care of, 187 rubber, preparation of, 187 Dressings, 180 collodion, 183 cotton-gauze, 180 forceps for, 133 gauze for, 180 Sayre’s, 93 table; 255 tray, instruments for, 122 Dressing-room ledger, 114 333 Dressing-room outfit, 184 Drop method of ether anesthesia, 153 Dry cups, 219 Drugs before anesthesia, 145 EAR operations, nas Ecgonin, 169 Edebohls’ dorsal posture, 292 Effervescing lemonade, 300 Egg lemonade, 300 Eggs, 302 poached, 302 scrambled, 303 shirred, 303 Elaterium poisoning, 231 Electricity, 228 Elevator, Langenbeck’s periosteal, 126 Emergency bundles, 184 operations, 286 Emmett’s angular bent scissors, 133 Endoneural anesthesia, 169 Enema for tympanites, 214 stimulating, 213 Enemata, purgative, 214 Enteroclysis, 209 Ermold’s tonsillotome, 128 Esmarch’s tourniquet, 270 Essence, beef, 304 Ether anesthesia, 150 cases suitable for, 150 closed inhaler for, 151 drop method of, 153 Gwathmey apparatus for, 152 open method, 150 semi-open method, 151 vapor method of, 152 bed, 284 inhaler, Allis’, 152 Ethyl chlorid anesthesia, 158 local, 168 tube, 158 Eucain anesthesia, 171 Evacuator, Bigelow’s, 142 Examinations, gynecologic, 280, 290. See also Gynecologic ex- aminations. Extremities, instruments for opera- tions on, 135 Eye, bandage of, crossed, 72 instruments for, 334 Eye, bandage of, Liebreich’s, 72 double-crossed bandage of, 74 instruments for operations on, 129 FECAL fistula, 275 . Feeding of infant, 236 artificial, 237 Feet, care of nurses’, 312 Fermentation fever after operation, 273 Finger cots, 189 spiral bandage of, 83 reverse bandage of, 84 Fire, destruction of germs with, 54 Fish, poisoning by, 232 Fission, 32, 33 Fistula, fecal, 275 urinary, 275 Flacherie, 24 Flaxseed tea, 301 Flesh, proud, 199 Flexner’s serum for infantile palsy, 51 Flour ball, 302 Foot-bath, mustard, 217 Forceps, bone-cutting, 141 dressing, 133 Hudson’s cranial rongeur, 123 iris, 130 Linnartz’s stomach clamp, 136 placental, 140 Richards’ tonsil-holding, 128 Segond’s volsella, 134 Stone’s tissue, 133 Tait’s hemostat, 134 Formaldehyd as disinfectant, 61 generator, 62 Fountain syringe, 285 Fowler position, 186 Fox’s eye speculum, 130 Fracture, alcohol rubs after, ror care of soft parts after, ror Fracture-box, 100 Fungi connected with disease in man, 29 GALL-BLADDER, operations on, 131 Gant’s pile clamp, 143 instruments for) INDEX Gastric lavage, 207 Gatch bed, 186 Gauze for dressings, 180 iodoform, 181 medicated, 180 packing, 183 pads, 179 sponges, 178 sublimate, 180 Generator, formaldehyd, 62 Genupectoral position, 292 Germ theory of disease, 20 | Germicides, 52 abuses of, 63 chemical, 56 Gibson’s bandage, 69 Gigli wire saw, 123 Glanders bacillus, discovery of, 25 Glands of neck, instruments for re- moval of, 129 Glass trays, 112 Glovers’ suture, 216 Gloves, 188 Goodell-Lentz uterine dilator, 140 Goiter, instruments for operation on, 129 Gouge, bone, 141 Gouley’s tunneled catheter, 142 Gowns, 184 operating, 244 Gram’s method of staining, strep- tococcus, 31 solution, 31 Green soup, 196 Griffith’s anesthetizing stethoscope, 148 combined inhaler, 158 wire-frame chloroform inhaler, 155 Groin, descending spica of, 86 double spica of, 87 single spica of, ascending, 85 Gruel, arrowroot, 301 barley, 301 cracker, 302 Guard, Stacke’s, for facial nerve, 126 Gwathmey apparatus for ether anesthesia, 152 Gynecologic examinations, 289, 290 asepsis in, 289 positions in, 290 a INDEX 335 Gynecologic examinations, posi- ; Hydrophobia, Pasteur treatment tions in, dorsal, 291 Edebohls’ dorsal, 292 genupectoral, 292 knee-chest, 292 latero-abdominal, 291 lithotomy, 292 Sims’, 291 upright, 290 Walcher, 293 preparation for, 295 operations, 289 after-care, 297 asepsis in, 289 diet after, 299 HANDs, preparation of, 242 Harrington’s solution as germicide, 60 formula for, 61 Hartmann’s round tonsil punch, 126 Head, figure-of-8 bandage of, 74 nurse, duties of, at operation, 253 operations, instruments for, 122 operations on, 276 Heat, effect of, on spores, 33 sterilization by, 55 therapeutic use of, 218 Hemorrhage after operation, 269 symptoms of, 270 treatment of, 270 Hemorrhoids, instruments for op- erations on, 143 Hemostat forceps, Tait’s, 134 Hernia, postoperative, 274 Herniotomy, instruments for, 131 High-tension steam, sterilization - with, 55 History of patient, taking, 116 Hoffman’s uterine irrigator, 138 Horsehair, 193 Horsley’s wax, 196 Hospital clothing for patient, 249 Hot air, disinfection with, 55 treatment, 227 Hudson’s cranial rongeur forceps, 123 trephine, 124 Hydrocyanic acid poisoning, 230 Hydrogen dioxid as disinfectant, 61 for, 25 Hygiene for nurses, 311 Hyperemia, active, 198 Bier’s, 223 Hyphomycetes, 29 Hypodermic injection, 215 method of, 215 Hypodermoclysis, 222 apparatus for, 225 Hyoscyamus poisoning, 231 Hypostasis, 307 Hysterectomy, vaginal, 275 IcE-BAG, 198 Ichthyol, 194 Illuminating gas poisoning, 231 Immunity, 38 acclimatization, 39 acquired, 39 artificial, 40 natural, 39 phagocytosis theory of, 40, 41 racial, 39 Imperial drink, 300 Incision, deep, 227 of abscess for drainage, 227 Infant, care of, 235 clothing for, 236 feeding of, 236 artificial, 237 nursing of, 236 Infiltration anesthesia, 160 Inflammation, causes of, 199 definition of, 197 function of, 198 phenomena of, 197 Influenza bacillus, discovery of, 26 Infusion, intravenous, 221 saline, 224 Inhalation anesthesia, intrapharyn- geal, 160 Inhaler, chloroform, Griffith’s, 155 Injection, hypodermic, 215 rectal, 209 Insanity, postoperative, 275 Instruments, cabinet for, 102 Cate Of, 102 for dressing tray, 122 for operations, abdominal, 131 bone-plating, 139 336 INDEX Instruments for operations, cir- | Iris forceps, 130 cumcision, 143 curetment of uterus, 135 cystoscopy, 143 dilation of cervix, 135 glands of neck, removal of, 129 laminectomy, 124 ligation of carotid arteries, 129 on chest, 131 on ear, 125 on extremities, 135 on eyes, 129 on gall-bladder, 131 on goiter, 129 on head, 122 on hemorrhoids, 143 on hernia, 131 on intestines, 131 on kidney, 135 on liver, 131 on male genital organs, 139 on nose, 125 on stomach, 131 on throat, 125 on uterus, 135 osteoplastic grafting, 139 perineorrhaphy, 135 removal of tongue, 129 repair of cervix, 135 resection of rectum, 143 submucous resection, 128 list of, 122 required for operations, 116 roll, 119 sterilization of, 106 trays for, 110 Insufflation anesthesia, cheal, 161 apparatus for, 162-164 technic of, 165 Interrupted suture, 216 Intestinal obstruction after opera- tion, 274 operations, instruments for, 131 Intradermic injection, 215 Intravenous infusion, 221 Todin catgut, 191 poisoning, 232 tincture of, as germicide, 57 Todoform as germicide, 62 gauze, 181 ‘poisoning from, 62 intratra- knife, 130 SCISSOTS, 130 spatula, 130 Irrigation of bladder, 202 of wounds, apparatus for, 225 rectal, 209 Irrigator, 253 Hoffman’s uterine, 139 Invalid’s soup, 304 Jacxson’s laryngoscope, 165 Jelly, tapioca, 302° Joints, adhesive plaster strapping of, 95 KANGAROO tendon, 192 Kelly’s curved round needles, 134 retractor, 137 Kidney, instruments for operation on, 135 Kirchner’s theory of disease, 18 Kit, surgeon’s, 116 contents of, 118 packing of, 118 Knee bandage, figure-of-8, 87, 95 Knee-chest position, 292 Knife, iris, 130 : Koch’s circuit to prove specific pathogenic powers of microbe, 3 > discovery of tubercle bacillus, 25 tuberculin, 26 Koumiss, 300 LABARRAQUE’S solution, 64 Labor, diet after, 235 nurses’ duties after, 233 before, 233 Laborde’s method of artificial res- piration, 260 Laminectomy, instruments for, 124 Lange’s theory of disease, 18 Langenbeck’s periosteal elevator, 126 Laryngoscope, Jackson’s, 165 Latero-abdominal position, 291 Lavage, gastric, 207 : Lead salts, poisoning by, 232 INDEX Ledger, dressing-room, 114 operating-room, 112-115 Leeching, 220 Leg, bandage of, figure-of-8, 88 lower, spiral reverse of, 88 ulcers, adhesive plaster strapping of, 95 Lemonade, 300 effervescing, 300 egg, 300 Lentz’s cranial chain tourniquet, 123 - Leprosy, discovery of bacterial origin of, 24 Liebreich’s eye bandage, 72 Ligatures, 190 Lime-water, 299 Liniments, 219 Linnartz’s stomach clamp forceps, 136 Lister’s antiseptic surgery, 20 Liston’s amputating knives, 132 Lithotomy position, 283, 292 Lithotrite, 142 Liver, instruments for operations On; 131 Live steam, sterilization with, 55 Lobelia poisoning, 232 Local anesthesia, 168 alypin, 171 akoin, 171 eucain, 171 novocain, 170 phenol, 171 Schleich’s solutions for, 170 tropacocain, 171 with cracked ice and salt, 168 Lombard nasal tube for ether anes- thesia, 151 Luer’s hypodermic syringe, 146 trachea cannula, 127 Lysol as germicide, 60 MACEWEN’sS bone-cutting instru- - - ments, 141 Malaria, cause of, 27 Male genital organs, instruments for operations on, 139 Malta fever, cause of, 26 Marine sponges, 179 Massage, 227 22 oF Mayo’s operating scissors, 133 scalpel, 132 Mayo-Simpson’s self-retaining re- tractor, 136 Medical chart, 121 Medicated gauze, 180 Membrane, cargile, 188 Membranous croup, bacillus of, 44 Meningitis, cerebrospinal, cause of, 26 ; Mercury bichlorid as germicide, 56 poisoning from, 57 Metchnikofl’s theory of phagocyto- sIS, 41 Metric system, 64 Michel’s clamps, 194 Micrococcus lanceolatus, 43 Milk and cinnamon, 301 diet, 300 mixtures, 237, 238 toast, 303 Mineral acids, poisoning by, 230 Miter box for cutting bandages, 67 Molds, 29 Moleskin adhesive plaster, 93 Montgomery straps, 98 Morphin poisoning, 232 Mosetig-Moorhof wax, 105 Mosquito transmission of malaria, PG : of yellow fever, 26 Murphy breast-binder, 236 button, 136 drop method of rectal irrigation, 210 Mustard foot-bath, 217 plaster, 217 Mutton-broth, 305 NEcK, figure-of-8 bandage of, 74 operations on, 277 Needles, 122 insertion of, as sign of death, 307 Kelly’s curved round, 134 Needle-holder, Noble’s improved Reiner’s, 134 Nitrous oxid anesthesia, 156 administration of, 157 apparatus for, 156 ether anesthesia, 158 338 INDEX Noble’s improved Reiner’s needle- | Operations in private practice, holder, 134 Nose, instruments for operations on, 125 Novocain anesthesia, 170 Nozzle, vaginal douche, 209 Nurses’ conduct in sick-room, 314 feet, care of, 312 hygiene for, 311 life, personal conduct of, 311 periods for relaxation, 314 personal appearance, 314 conduct of, 310 preparation of, for operation, 241 | rewards, success of, 278 | Nursing of infant, 235 obstetric, 233 Nux vomica, poisoning from, 232 OBSTETRIC nursing, 233 Occipitofrontal bandage, 71 Oil-ether colonic anesthesia, 166 Ointments, 219 Operating gown, 244 Operating-room, 245 care of, 102 duties of nurse in, 241 equipment of, 105 ledger, 112-115 preparation of, 239, 240 spectator’s dress for, 246 Operating-table, 274 Operations, 239 accidents during, 275 arranging patient for, 253 blank, 120 care of bladder and bowels after, 258 patient after, 256 diet-list after, 260-262 dress for, 242 duties of assistant nurses at, 256 of head nurse at, 255 emergency, preparations for, 286 | fermentation fever after, 273 } articles required for, 284, 285 giving anesthetic in, 286 operating-table for, 281, 282 preparations for, 280 instruments for 116, 122-143. See also Instruments for opera- tions. intestinal obstruction after, 274 of election, 240 of emergency, 240 of expediency, 239 of necessity, 239 on head, 276 on neck, 277 peritonitis after, 272 preparation of field of, 251 patient for, 250 day before, 250 on day of, 252 sequele of, 263 shock after, 263 sinus after, 275 special, 276 tympanites after, 273 _ varieties of, 239 visitors after, 260 Opium poisoning, 232 Orangeade, 300 Osteoplastic grafting, instruments for, 139 Oxalic acid as germicide, 62 poisoning, 232 PACKING, gauze, 183 Pads, gauze, 179 Pagenstecher sutures, 193 Palmer bandage, demigauntlet, 84 Panado, 303 Paquelin cautery, 220 Paralysis, infantile, Flexner’s serum in, 51 Paralyses, postoperative anesthetic, 167 gynecologic, 289. See also Gyne-| Paste, Unna’s, 105 cologic operations. hemorrhage after, 269. See also Hemorrhage after operations. infections of abdomen after, 257 in private practice, 278 Pasteur’s germ theory of disease, 20 treatment of hydrophobia, 25 Patient, arranging of, for operation, 253 care of, after operation, 256 INDEX Patient, hospital clothing for, 250 preparation of, for operation, 250 day before, 250 on day of, 252 taking history of, 116 transportation of, 249 Pathogenic bacteria, 29 - Pelvic binder, adhesive plaster, 95 Perineorrhaphy, instruments for, 135 Perineural anesthesia, 169 Peritonitis after operation, 272 antistreptococcic serum for, 273 treatment of, 272 Personal conduct of nurse’s life, 311 Petri dish, 247 Phagocytes, 40 Phagocytosis, 40 Phenol anesthesia, 171 Phosphorus poisoning, 232 Pile-clamp, Gant’s, 143 Pébrine, 24 Plasmodium malariz, 27 Plaster, 227 adhesive, 93 Plaster-of-Paris bandage, 98 application of, 98 removal of, 98 splints, roo Pneumococcus, 43 discovery of, 25 Pneumonia, bacillus of, 43 mode of infection in, 35 Poached eggs, 302 Poisoning from carbolic acid, 59 cocain, treatment of, 170 from corrosive sublimate, 57 from iodoform, 62 from mercury bichlorid, 57 Poisons and antidotes, 230-232 Postoperative hernia, 274 insanity, 275 Postural drainage, 186 Potain’s aspirator, 137 Potash poisoning, 232 Potassium permanganate as germi- cide, 59 Private practice, operations in, 278 Proctoclysis, continuous, apparatus fOr, 20 method of, 212 Joe Proud flesh, 199 Pudding, tapioca, 304 Puerperal fever, Semmelweis’ the- ory of, 23 Pulmotor, Draeger, 260 Punch, Hartmann’s round tonsil, 126 Puncturation, 226 Puncture, deep, 227 Purgative enemata, 214 Pus, 199 basin, 112 Putrefaction, cause of, 29 Pyogenic cocci, 30 REACTION. See Test. Recipes, diet, 299 Rectal anesthesia, 166 injections, 209 irrigation, 209 Rectum, examination of, 293 instruments for resection of, 143 Reiner’s needle-holder, Noble’s im- proved, 134 ; Rennet, 303 Resin plaster, 93 Respiration, absence of, as sign of death, 307 artificial, 267 Respiratory tract, entrance of bac- teria into, 35 Retractor, Buck’s mastoid, 126 Collins’, 137 Desmarre’s lid, 130 Kelly’s, 137 Mayo-Simpson’s 136 Volkmann, 137 Rice, boiled, 303 plain, 303 Richard’s _ tonsil-holding 128 Rigor mortis, 307 Rochester sterilizer, 108 Rongeur forceps, Hudson’s cranial, 123 Rubber adhesive plaster, 93 dam, 184 : sterilization of, 188 drainage-tubes, preparation of, 187 self-retaining, forceps, 340 INDEX Rubber-glove solution, 189 Sinexon’s nasal dilator, 127 mesh, 184 Sleep, twilight, 166 tissue, 184 Slings, 92 Rubber gloves, 188 Snare, tonsil, 127 Soap, green, 196 Soda salts, poisoning by, 232 SALINE infusion, intravenous, 224 | Solutions, antiseptic, 64 solution, normal, 224 . Sound, Simpson’s uterine, 140 Saprol, 59 Soup, invalid’s, 304 3 Saprophytes, 29 tapioca, 302 Sarcine, 30 toast, 301 Saw, Gigli wire, 123 Sozal, 59 Sayre’s dressing, 03 Spatula, iris, 130 Scalpel, Mayo’s, 132 Speculum, Auvard’s self-retaining, Scarification, 226 138 Schizomycetes, 29 Fox’s eye, 130 Schleich’s solutions for local anes-| Sims’, 138 thesia, 169, 170 Spice-plasters, 218 Scissors, curbed, 133 Spinal anesthesia, 172 Emmett’s angular bent, 133 apparatus for, 172 iris, 130 Babcock’s solution for,-177 Mayo’s operating, 133 contra-indications to, 177 Scopolamin-morphin anesthesia, peints for injection in, 173 166 postoperative treatment, 177 Scrambled eggs, 303 steps of, 175, 176 Scultetus bandage, 92 technic of, 174 Segord’s volsella forceps, 134 Spinlhli, 29 Semmelweis’ theory of puerperal | Spirocheta pallida, 44 fever, 23 discovery of, 27 Sequel of operations, 263 Splenic fever, discovery of bacterial Serum therapy, 44, 45 nature of, 23 Sheets, 184 Splints, o9 Shirred eggs, 303 coaptation, 100 Shock, surgical, age factor in, 264| plaster-of-Paris, 100 artificial respiration in, 266 Sponges, gauze, 178 mental condition in, 265 keeping count of, 254 susceptibility to, 264 marine, 179 d symptoms of, 265 Spores, effect of heat on, 33 ‘temperature in, 265 formation of, 32 treatment of, 265 resistance of, 33 Shotted suture, 216 . Sporulation, 32 Shoulder, spica bandage of, 77 Spotted fever, cause of, 26 descending, 79 Stacke’s guard for facial nerve, 126 — Signs of death, 306. See also} Staphylococci, 30 : Death, signs of. demonstration of, 31 | Silk ligatures, 192 Staphylococcus epidermidis albus, Silkkworm-gut, 193 aE Silver nitrate poisoning, 232 pyogenes albus, 42 Sims’ position, 291 aureus, 30, 42 sharp curet, 138 citreus, 43 speculum, 138 Steam, disinfection by, 55 Sinus after operation, 275 Stegomyia fasciata, 26 INDEX Sterilization, 54, 105 by. heat, 55 fractional, 55 intermittent, 55 methods of, 102 of catgut, 190 of instruments, 106 of.rubber dam, 188 with boiling water, 55 Sterilizer, 104 bed-pan, I1I Rochester, 108 Sterilizing outfit, 109 room, 107, IIo Stethoscope, 306 Griffith’s anesthetizing, 148 Stomach-contents, examination of, 205 instruments for operations on, 131 tube, 206 method of passing, 205 Stone’s tissue forceps, 133 Stone-searcher, Thompson’s, 142 Stramonium poisoning, 230 Straps, catheter, 98 Montgomery, 98 Streptococci, 30 Gram method of staining, 31 antitoxin preparation of, 47 Streptococcus lanceolatus, 43 pyogenes, 42 Stretcher, house, 103 wheeled, 103 Strychnin poisoning, 232 Stump, recurrent bandage of, 87 Stupe, turpentine, 217 Sublimate gauze, 180 Submucous resection, instruments for, 128 Sunlight, effect of, on bacteria, 33 Superheated steam, sterilization with, 55 Surgeon’s kit, 116 contents of, 118 packing of, 118 Surgery, antiseptic, 20 objects of, 239 Surgical applications, 194 procedures, minor, 215 technic, 65 Suspensory bandage of breast, 74 341 Sutures, 190 button, 216 continuous, 216 glovers’, 216 horsehair, 193 - interrupted, 216 Pagenstecher, 192 shotted, 216 varieties of, 216 wire, 193 Suturing clamps, 216 Sylvester’s method of artificial res- piration, 267, 268 Syphilis, organism producing, 27, 44 Syringe cup, 277 fountain, 285 household bulb, 285 Luer’s hypodermic, 146 nasal and ear, 277 Tarr’s hemostat forceps, 134 Tamarind water, 300 Tampons, vaginal, 181, 182 Tapioca jelly, 302 pudding, 304 soup, 302 Tea, flaxseed, 301 Technic, surgical, 65 Temperature as sign of death, 308 in surgical shock, 265 Tendon, kangaroo, 192 Test, tuberculin, 52 Von Pirquet, 52 Wassermann, 51 Widal, 52 Test-breakfast, 205 Tetanus antitoxin, 50 bacillus of, 43 Tetrads, 30 Thermocautery, 229 Thermometer, bath, 208 clinical, 228. Toast, milk, 303 soup, 301 water, 301 Thomas’ dull curet, 138 Thompson’s stone-searcher, 142 Throat, instruments for operations in. 125 Thumb, bandage of, spica, 84 342 Thymol-iodid as germicide, 63 Tincture of green soap, 196 Tobacco poisoning, 232 Tongue, instruments for, removal of, 129 Tonsil snare, 127 Tonsillotome, Ermold’s, 128 Tourniquet, Esmarch’s,.270 Lentz’s cranial chain, 123 Towels, 184 Transportation of patient, 249 Traumatic delirium, 266 Trays, glass, 112 instrument, I10 Trendelenburg position, 283, 296 Trephine, Hudson’s cranial, 124 Treponema pallidum, discovery of, 27 Tropacocain anesthesia, 171 Tuberculin, Koch’s, 26 Lest, 52 Tuberculosis antitoxin, preparation ol, 47 bacillus of, 43 discovery of, 25 climatic control of, 37 mode of infection in, 35 sites of infection in, 36 tests for presence of, 52 Turpentine stupe, 217 Twilight sleep, 166 Tympanites after operation, 273 enema for, 214 Typhoid bacillus, discovery of, 24 mode of infection in, 35 Unna’s paste, 195 Upright position, 290 Uninary fistula, 275 Uterus, instruments for operations on, 135 INDEX VACCINATION, 219 Vaccine, antityphoid, 50 Vaginal douche, 207 antiseptic, 208 apparatus for, 209 nozzle, 209 hysterectomy, 275 tampons, 181, 182 Vapor apparatus for anesthesia,151 method of ether anesthesia, 152 Velpeau’s bandage, 78 Venesection, 221 Visitors after operation, 260 Volkmann retractor, 137 Volsella forceps, Segond’s, 134 Von Pirquet test, 52 Vulva, virginal, 201 WALCHER position, 203 Wassermann test, 51 Water, 209 albumin, 299 apple, 299 barley, 299 coil, 198 lime-, 209 tamarind, 300 ‘toast, 301 Wax, Horsley’s, 196 Mosetig-Moorhof, 195 Wecker’s iris scissors, 130 Wet cups, 220 Widal test, 52 Wire sutures, 193 YEASTS, 29 Yellow fever, method of transmis- sion, 26 ZINC oxid adhesive plaster, 93 salts, poisoning by, 232 Zodglea, 30 Books for Nurses PUBLISHED BY W. B. SAUNDERS COMPANY West Washington Square Philadelphia London: 9, Henrietta Street, Covent Garden Sanders’ Nursing A NEW WORK Miss Sanders’ new book is undoubtedly the most complete and most practical work on nursing ever published. Hverything about every subject with which the nurse should be familiar is detailed in a clean cut, definite way. ‘There is no other nursing book so full of good, practical informa- tion—information you need. Modern Methods in Nursing. By GEORGIANA J. SANDERS, formerly Superintendent of Nurses at Massachusetts Gen- eral Hospital. 12mo of 881 pages, with 227 illustrations. Cloth, $2.50 net. Dunton’s Occupation Therapy JUST ISSUED Dr. Dunton gives those forms likely to be of most service to the nurse in private practice. You get chapters on puzzles, reading, physical exercises, card games, string, paper, wood, plastic and metal work, weaving, picture puzzles, basketry, chair caning, bookbinding, gardening, nature study, drawing, painting, pyrography, needle- work, photography, and music. Occupation Therapy for Nurses. By WILLIAM RUSH DunTON, Jr., M. D., Assistant Physician at Sheppard and Enoch Pratt Hospitals, Towson, Md. s12mo of 240 pages, illustrated. Cloth, $1.50 net. Stoney’s Nursing NEW (4th) EDITION Of this work the American Journal of Nursing says: ‘‘It is the fullest and most complete and may well be recommended as being of great general usefulness. The best chapter is the one on observation of symptoms which is very thorough.’’ ‘There are directions how to zmprvovise everything. Practical Points in Nursing. By EmiLy M. A. STONEY, formerly Super- intendent of the Training School for Nurses in the Carney Hospital, South Boston, Mass. 12mo, 495 pages, illustrated. Cloth, $1.75 net. Stoney’s Materia Medica new Ga comon Stoney’s Materia Medica was written by a head nurse who knows just what the nurse needs. American Medicine says it contains ‘‘all the information in regards to drugs that a nurse should possess.”’ Materia Medica for Nurses. By EMILY M. A. STONEY, formerly Super- intendent of the Training School for Nurses in the Carney Hospital, South Boston, Mass. 1z2mo volume of 300 pages. Cloth, $1.50 net. Stoney’s Surgical Technic NEW (3d) EDITION The first part of the book is dovoted to Bacteriology and Antiseptics; the second part to Surgical Technic, SigHe of Death, Bandaging, Care of Infants, etc. Bacteriology and Surgical Technic for Nurses. By EMILY M. A. STONEY. Revised by FREDERIC R. GRIFFITH, M. D., New York. t2mo volume of 311 pages, fully illustrated. Cloth, Sz.so net. Goodnow’s First-Year Nursing 2 vito Miss Goodnow’s work deals entirely with the practical side of first-year nursing work. It is the application of text-book knowledge. It tells the nurse ow to do those things she is called upon to do in her first year in the training school—the actual ward work. First-Year Nursing. By MINNIE GOODNOvW, R. N., formerly Super- inteadent of the Women’s Hospital, Denver. i2mv Of 354 pages, illustrated. Cloth, $1.50 net. Aikens’ Hospital Management This is just the work for hospital superintendents, training- school principals, physicians, and all who are actively inter- ested in hospital administration. The Medical Record says: ‘“‘Tells in concise form exactly what a hospital should do and how it should be run, from the scrubwoman up to its financing.’’ Hosnital Management. Arranged and edited by CHARLOTTE A. AIKENS, formerly Director 0‘ Sibley Memorial Hospital, Washing- ton, D.C. sz2mo of 488 pages, illustrated. Cloth, $3.00 net Aikens’ Primary Studies NEW (3d) EDITION Trained Nurse and Hospital Review says: ‘‘It is safe to say that any pupil who has mastered even the major portion of this work would be one of the best prepared first year pupils who ever stood for examination.’’ Primary Studies for Nurses. By CHARLOTTE A. AIKENS, formerly Director of Sibley Memoria! Hospital, Washington, D. C. 1r2mo of 471 pages, illustrated. Cloth, $1.75 net. Aikens’ Training-School Methods and the Head Nurse This work not only tells how to teach, but also what should be taught the nurse and how much. ‘The Medical Record says: ‘‘This book is original, breezy and healthy.’’ Hospital Training-School Methods and the Head Nurse. By CHAR- LOTTE A. AIKENS, formerly Director of Sibley Memorial Hospital, Washington, D. C. 12mc of 267 pages. Cloth, $1.50 net. °1, 3 - - Pikes oclitical, OtUGies ~~ ew on euimon This work for second and third year students is written on the same lines as the author’s successful work for primary stu- dents. Dietetic and Hygienic Gazette says there ‘‘is a large amount of practical information in this book.’’ Clinical Studies for Nurses. By CHARLOTTE A. AIKENS, formerly Director of Sibley Memorial Hospital, Washington, D. C, xz2mo of 569 pages, illustrated Cloth, $2.00 net Bolduan and Grund’s Bacteriology The authors have laid particular emphasis on the immediate application of bacteriology to the art of nursing. It is an applied bacteriology in the truest sense. A study of all the ordinary modes of transmission of infection are included. Applied Bacteriology for Nurses. By CHARLES F. BOLDUAN, M.D., Assistant to the General Medical Officer, and MARIE GRUND, M.D., Bacteriologist, Research Laboratory, Department of Health, City of New York. xz2mo of 166 pages, illustrated. Cloth, $1.25 net. Fiske’s The Body A NEW IDEA Trained Nurse and Flospital Review says “‘it is concise, well- written and well illustrated, and should meet with favor in schools for nurses and with the graduate nurse.”’ Structure and Functions of the Body. By ANNETTE FISKE, A. M., Graduate of the Waltham Training School for Nurses, Massa- chusetts. 12mo of 227 pages, illustrated. Cloth, $z.25 net Beck’s Reference Handbook | sew ¢sz) evition This book contains all the information that a nurse requires to carry out any directions given by the physician. The Montreal Medical Journal says it is ‘‘ cleverly systematized anc shows close observation of the sickroom and hospital regime.”’ A Reference Handbook for Nurses. By AMANDA K. BECK, Grad- uate of the Illincis Training School for Nurses, Chicago, Ill, 32mo volume of 244 pages. Bound in flexible leather, $1.25 net. Roberts’ Bacteriology & Pathology This new work is practical in the strictest sense. Written specially for nurses, it confines itself to information that the nurse should know. All unessential matter is excluded. The style is concise and to the point, yet clear and plain. The text is illustrated throughout. Bacteriology and Pathology for Nurses. By JAY G. ROBERTS, Ph. G., M. D., Oskaloosa, lowa. 12mo of 206 pages, illustrated. $1.25 net. DeLee’s Obstetrics for Nurses our Dr. DeLee’s book really considers two subjects—obstetrics for nurses and actual obstetricnursing. Zvained Nurse and Flospital Review says the ‘‘book abounds with practical suggestions, and they are given with such clearness that they cannot fail to leave their impress.” Obstetrics for Nurses. By JOSEPH B. DELEE, M. D., Professor of Obstetrics at the Northwestern University Medical School, Chicago. t2mo volume of 508 pages, fully illustrated. Cloth, $2.50 net. Davis’ Obstetric & Gynecologic Nursing NEW (4th) EDITION The Trained Nurse and Hospital Review says: ‘‘ This is one of the most practical and useful books ever presented to the nursing profession.’’ The text is illustrated. Obstetric and Gynecologic Nursing. By EDWARD P. DAvis, M. D., Professor of Obstetrics. in the Jefferson Medical College, Philadel- phia. zzmo volume of 480 pages, illustrated. Buckram, $1.75 net. Macfarlane’s Gynecology for Nurses NEW (2d) EDITION Dr. A. M. Seabrook, Woman’s Hospital of Philadelphia, says: ‘‘It is a most admirable little book, covering in a concise but attractive way the subject from the nurse’s standpoint.’’ A Reference Handbook of Gynecology for Nurses. By CATHARINE MACFARLANE, M. D., Gynecologist to the Woman’s Hospital of Phila- delphia. 32mo of 156 pages, with 7o illustrations. Flexible leather, $1.25 net. Asher’s Chemistry and Toxicology Dr. Asher’s one aim was to emphasize throughout his book the application of chemical and toxicologic knowledge in the study and practice of nursing. He has admirably succeeded. t2mo of 190 pages. By PHILIP ASHER, PH. G., M. D., Dean and Pro- fessor of Chemistry, New Orleans College of Pharmacy. Cloth, $1.25 net. Aikens’ Home Nurse’s Handbook The point about this work is this: It tells you, and shows you just how to do those little things entirely omitted from other nursing books, or at best only incidentally treated. The chapters on ‘‘Home Treatments’’ and ‘‘Every-Day Care of the Baby,’’ stand out as particularly practical. Home Nurse’s Handbook. By CHARLOTTE A. AIKENS, formerly Di- rector of the Sibley Memorial Hospital, Washington, D. C. 12mo of 276 pages, illustrated. Cloth. $1.50 net Eye, Ear, Nose, and Throat Nursing This book is written from beginning to end for the nurse. You get antiseptics, sterilization, nurse’s duties, etc. You get an- atomy and physiology, common remedies, how to invert the lids, administer drops, solutions, salves, anesthetics, the various diseases and their management. New (2d) Edition. Nursing in Diseases of the Eye, Ear, Nose and Throat. By the Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. 12m0 of 291 pages, illustrated. Cloth, $1.50 net Paul’s Materia Medica tw Gh tee In this work you get definitions—what an alkaloid is, an in- fusion, a mixture, an ointment, a solution, a tincture, etc. Then a classification of drugs according to their physiologic action, when to administer drugs, how to administer them, and how much to give. A Text-Book of Materia Medica for Nurses. By GEORGE P. PAUL,M.D., Samaritan Hospital, Troy, N. Y. 12mo of 282 pages. Cloth, $1.50 net Paul’s Fever Nursing NEW (3d) EDITION In the first part you get chapters on fever in general, hygiene, diet, methods for reducing the fever, complications. In the second part each infection is taken up zz detail. In the third part you get antitoxins and vaccines, bacteria, warnings of the full dose of drugs, poison antidotes, enemata, etc. Nursing in the Acute Infectious Fevers. By GEORGE P. PAUL, M. D. 12mo of 275 pages, illustrated. Cloth, $1.00 net McCombs’ Diseases of Children for Nurses NEW (2d) EDITION Dr. McCombs’ experience in lecturing to nurses has enabled him to emphasize just those points that nurses most need to know. National Hospital Record says: ‘‘We have needed a good book on children’s diseases and this volume admirably fills the want.’’ The nurse’s side has been written by head nurses, very valuable being the work of Miss Jennie Manly. Diseases of Children for Nurses. By ROBERT S. McCComss, M.D., Instructor of Nurses at the Children’s Hospital of Philadelphia. 1r2mo of 470 pages, illustrated. Cloth, $2.00 net Wilson’s Obstetric Nursing sew ea evition In Dr. Wilson’s work the entire subject is covered from the beginning of pregnancy, its course, signs, labor, its actual accomplishment, the puerperium and care of the infant. American Journal of Obstetrics says: ‘‘ Every page empasizes the nurse’s relation to the case.’’ A Reference Handbook of Obstetric Nursing. By W. REYNOLDS WILSON, M.D., Visiting Physician te the Philadelphia Lying-in Char- ity. 32mo of 355 pages, illustrated. Flexible leather, 51.25 net, American Pocket Dictionary NEW (9th) EDITION The Zvrained Nurse and Hospital Review says: ‘‘We have had many occasions to refer to this dictionary, and in every instance we have found the desired information.’’ American Pocket Medical Dictionary. Edited by W. A. NEWMAN DORLAND, A. M., M.D., Loyola University, Chicago. Flexible leather, gold edges, S1.0co net; with patent thumb index, $1.25 net, Lewis’ Anatomy and Physiology ( ssinéx Nurses Joarnai of Pacific Coast says ‘‘it is not in any sense rudimentary, but comprehensive in its treatment of the sub- jects.”’ The low price makes this book particularly attractive. Anatomy and Physiology for Nurses. By LEROY Lewis, M.D., Lec- turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay City, Mich. 12mo of 326 pages, 150 illustrations. Cloth, $1.75 net Z Bohm & Painter’s Massage The methods described are those employed in Hoffa’s Clinic —methods that give results. Every step is illustrated, showing you the exact direction of the strokings. The pictures are large. You get the technic used in Professor Hoffa’s Clinic. Octavo of 91 pages, with 97 illustrations. By MAX BOHM, M. D., Berlin, Germany. Edited by CHARLES F. PAINTER, M. D., Professor or Orthopedic Surgery, Tufts College Medical School, Boston. Cloth, $1.75 net SECOND Grafstrom’s Mechano-therapy EDITION Dr. Grafstrom gives you here the Swedish system of mechan- otherapy. You are given the effects of certain movements, gymnastic postures, medical gymnastics, general massage treatment, massage for the various conditions. The illustra- tions are full-page line drawings. Mechanotherapy (Massage and Medical Gymnastics). By AXEL V. GRAFSTROM, B. Sc., M. D., Attending Physician Gustavus Adolphus Orphanage, Jamestown, New York. 16mo of 200 pages. Cloth, $z.25 net Friedenwald and Ruhrah’s Dietetics for Nurses NEW (3d) EDITION This work has been prepared to meet the needs of the nurse, both in training school and after graduation. American Jour- nal of Nursing says it ‘‘is exactly the book for which nurses and others have long and vainly sought.”’ Dietetics for Nurses. By JULIUS FRIEDENWALD, M. D., Professor of Diseases of the Stomach, and JOHN RUHRAH, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. 12mo volume of 431 pages. Cloth, $1.50 net Friedenwald & Ruhrah on Diet — Esimon This work is a fuller treatment of the subject of diet, pre- sented along the same lines as the smaller work. Everything concerning diets, their preparation and use, coloric values, rectal feeding, etc., is here given in the light of the most re- cent researches. Diet in Health and Disease. By JULIUS FRIEDENWALD, M.D., and JOHN RUHRAH, M.D. Octavo volume of 857 pages. Cloth, $4.00 net RO TE TE 8 a i i i i i i ll —— Pyle’s Personal Hygiene NEW (is) EDITION Dr. Pyle’s work discusses the care of the teeth, skin, com- plexion and hair, bathing, clothing, mouth breathing, catch- ing cold; singing, care of the eyes, schoo! hygiene, body posture, ventilation, heating, water supply, house-cleaning, home gymnastics, first-aid measures, etc. A Manual of Personal Hygiene. Edited by WALTER L. PYLE, M. D., Wills Eye Hospital, Philadelphia. 12mo, 543 pages of illus. $1.50 net Galbraith’s Personal Hygiene and Physical Training for Women ILLUSTRATED Dr. Galbraith’s book tells you how to train the physical pow- ers to their highest degree of efficiency by means of fresh air, tonic baths, proper food and clothing, gymnastic and outdoor exercise. There are chapters on the skin, hair, development of the form, carriage, dancing, walking, running, swimming, rowing, and other outdoor sports. Personal Hygiene and Physical Training for Women. By ANNA M. GALBRAITH, M.D., Fellow New York Academy of Medicine. 12mo of 371 pages, illustrated. Cloth, $2.00 net Galbraith’s Four Epochs of Woman’s Life This book covers each epoch fully, in a clean, instructive way, taking up puberty, menstruation, marriage, sexual instinct, sterility, pregnancy, confinement, nursing, the menopause. The Four Epochs of Woman’s Life. By ANNA M. GALBRAITH, M. D. With an Introductory Note by JOHN H. MUSSER, M.D., University of Pennsylvania. 12mo of 247 pages. Cloth, $1.50 net Griffith’s Care of the Baby NEW (6th) EDITION Here is a book that tells in simple, straightforward language exactly how to care for the baby in health and disease; how to keep it well and strong; and should it fall sick, how to carry out the physician’s instructions and nurse it back to health again. The Care of the Baby. By J. P. CROZER GRIFFITH, M.D., Univers- ity of Pennsylvania. 12mo of 458 pages, illustrated. Cloth, $1.50 net Aikens’ Ethics for Nurses ‘JUST READY This book emphasizes the importance of ethical training. It is a most excellent text-book, particularly well adapted for classroom work. The illustrations and practical problems — used in the book are drawn from life. Studies in Ethics for Nurses. By CHARLOTTE A. AIKENS, formerly Superintendent of Columbia Hospitai, Pittsburg. 12mo of 318 pages, Cloth, $1.75 net. Goodnow’s History of Nursing seavy soon Miss Goodnow’s work gives the main facts of nursing history from the beginning to the present time. It is suited for class- room work or postgraduate reading. Sufficient details and personalities have been added to give color and interest, and to present a picture of the times described. History of Nursing. By MINNIE GOODNOw, R.N., formerly Super- intendent of the Women’s Hospital, Denver. 12mo of 300 pages, illustrated. READY Berry’s Orthopedics for Nurses SOON The object of Dr. Berry‘s book is to supply the nurse with a work that discusses clearly and simply the diagnosis, prog- nosis and treatment of the more common and important ortho- pedic deformities. Many illustrations are included. ‘The work is very practical. ! Or:honedic Surgery for Nurses. By JOHN MCWILLIAMS BERRY, M.D., Clinical Professor of Orthopedics and Rontgenology, Albany Medical College, 12mo of 100 pages, illustrated. Whiting’s Bandaging This new work takes up each bandage in detail, telling you— and showing you by original illustrations—just how each bandage should be applied, each turn made. “ Dr. Whiting’s teaching experience has enabled him to devise means for over- coming common errors in applying bandages. Bandaging. By A. D. WHITING, M.D, Instructor in Surgery at the University of Pennsylvania. 12mo of 151 pages, with 117 illustra- tions. Cloth, $1.25 net. ST RR SE YT A FC 10 Hoxie & Laptad’s Medicine for Nurses Medicine for Nurses and Housemothers. By GEORGE HowarpD Hoxiz, M. D., University of Kansas; and PEARL L. LApTaD. 12mo of 351 pages, illustrated. Cloth, $1.50 net. New (2d) Edition. This book gives you information that will help you to carry out the directions of the physician and care for the sick in emergencies. It teaches you how to recognize any signs and changes that may occur be- tween visits of the physician, and, if necessary, to meet conditions until the physician’s arrival. Boyd’s State Registration for Nurses State Registration for Nurses. By Lourz CRoFT BovD, R. N., Graduate Colorado Training School for Nurses. Octovo of 149 pages. Cloth, $1.25 net. New (2d) Edition. Morrow’s Immediate Care of Injured Immediate Care of the Injured. By ALBERT S. Mor- Row, M. D., New York City Home for Aged and In- firm. Octavo of 354 pages, with 242 illustrations. Cloth, $2.50 net. New (2d) Edition. deNancrede’s Anatomy NEW (7th) EDITION Essentials of Anatomy. By CHARLES B. G. DENAN- CREDE, M. D., University of Michigan. 12mo of 400 pages, 180 illustrations. Cloth, $1.00 net. Morris’ Materia Medica NEW (7th) EDITION Essentials of Materia Medica, Therapeutics, and Pre- scription Writing. By HENRY Morris, M.D. Re- vised by W. A. BastTEDO, M. D., Columbia University, New York. 12mo of 300 pages, illustrated. Cloth, $1.00 net. Register’s Fever Nursing A Text Book on Practical Fever Nursing. By EpwarD C. REGISTER, M. D., North Carolina Medical College. Octavo of 350 pages, illustrated. Cloth, $2.50 net. 11 : : ¥ 7 - = : se ‘ A = . nike ace ; : ney - a es ) - % 09 2 Ls mm ‘tao re ae » DOBBS BROS. INC. > a wroturerecs 4 ‘ 4