Bacteriology and surgical technic for nurses

’
a
*

reat sts lh nites genet hal elt mies of fore) A

j STAUB) F ' cc
He tick aoa
4 if Niseistiee
, " I fl W. y
J ; ”

a

~ghe

ii rated hete Nisan mi ewibtatetivns veal Riots eatin nae neapnns een tasaiiger enamels anernew anal nee
IP : ited

Copymigit Ne

COPYRIGHT DEPOSIT:

Ni gen
ila

BOOKS BY EMILY A, MoSTONEW

Practical Points in Nutsing

12mo of 500 pages, illustrated. Cloth,
$1.75 net. fourth Edition

Materia Medica for Nurses

I2mo of 306 pages. Cloth, $1.50 net.
Third Edition

Bacteriology and Surgical Technic for Nurses

12mo of 277 pages, illustrated. Cloth,
$1.50 net. Second Edition

BACTERIOLOGY

AND

SURGICAL TECHNIC

FoR NURSES

BY

EMILY Mo A. STONEY

Superintendent of the Training School for Nurses, St. Anthony’s Hospital, Rock
Island, Ill.; Author of ‘‘ Practical Points in Nursing,”’ ‘‘ Practical
Materia Medica for Nurses,’ etc.

Third Edition, Thoroughly Revised and Enlarged

BY

FREDERIC RICHARDSON GRIFFITH, M.D. (Univ. of Penn.)

oF New York

Surgeon, Fellow of the New York Academy of Medicine

“Every bit of knowledge that we cannot use for the uplifting of our physical,
intellectual, or emotional life ts so much waste of time and labor. Everything taught
is worth the knowing, but not worth the putting away in the pigeon-holes of memory,

to be recalled some day by accidené.”’

TEL OUSTRA ie DP

PHILADELPHIA AND LONDON —

W. B. SAUNDERS COMPANY
$910

Copyright, 1900, by W. B. Saunders and Company. Set up, electrotyped, printed,
and copyrighted September, 1900, Reprinted September, 1g02. Revised,
reprinted, and recopyrighted January, 1905. Reprinted March,

1906, November, 1907, February, 1909, and August, 1909. Re-
vised, reprinted, and recopyrighted September, 1910.

Copyright, 1910, by W. B, Saunders Company.

PRINTED IN AMERICA

PRESS OF
W. B. SAUNDERS COMPANY
PHILADELPHIA

© a2738

TO

Dk JOHN AR. - SLATTERY

THIS VOLUME IS DEDICATED BY THE AUTHOR

IN GRATEFUL REMEMBRANCE OF MUCH ENCOURAGE-
MENT AND PERSONAL KINDNESS

meeeAce TO THE THIRD EDITION.

THE chief concern in producing the present edi-
tion has been to use plain and simple language to
teach the surgical nurse to be clean, reliable, suc-
cessful in her work.

Some well-tried diet recipes have been added, and
special operations have been considered a little more
fully; and meanings of all the hard words used in
Bilemtext, it 1S believed, have been explained in the

Glossary.
FREDERIC RICHARDSON GRIFFITH.
NEw YORK, September, 1910.

PREEA CE.

THE following pages constitute the notes of a series
of lectures on ‘‘ Bacteriology and Surgical Tech-
nic’? which followed closely upon my lectures on
‘‘ Materia Medica.’’ he first part of the book is de-
voted to Bacteriology and Antiseptics; the second
part to Surgical Technic, Signs of Death, Au-
topsies.

No attempt has been made to write a complete
treatise on bacteriology, but merely to outline and
simplify that branch for nurses.

It was deemed advisable to add the chapter on
‘‘Signs of Death and Autopsies,’’ as many nurses
are unacquainted with the preparations for an autopsy
in private practice.

So many changes have taken place in surgery since
the lectures were delivered that it has been necessary
to rewrite many of the chapters. In this I was
assisted by Dr. A. S. Allen and by Professors J. B.
Murphy, Christian Fenger, and Joseph L. Miller, of
the Northwestern University Medical College. I am
glad of this opportunity to thank them for their
assistance.

4 PREFACE.

Free use has been made of the works on bac-
teriology by McFarland, Crookshank, and Woodhead;
of ‘‘ Aseptic Surgical: Technique,’’ by Dr. Hunter
Robb; ‘‘Operative Gynecology,’’ by Dr. Howard A.
Kelly; and ‘‘ Aseptic Treatment of Wounds,’’ by
Dr. C. Schimmelbusch.

I am unable to express my indebtedness to Dr.
Joseph P. Comegys for his valuable assistance with
the manuscript and its preparation for the press.

I wish also to thank Drs. George L. Eyster and
Charles C. Carter for their friendly help and interest
in the work.

EMILY M. ARMSTRONG-STONEY.

CONTENTS.

PART IL—BACTERIOLOGY; ANTISEPTICS.

CHAPTER I.

PAGE

ENIGROKWGON SACTERIOLOGY © 585048 Sa cs 8S eee es 9
CHAPTER II.

BACGUURIARAS RHE CAUSES OF IDISEASE .°. s 3 3 6 606 ol. 6s 21

CHAPTER IL.

MEMOHEORY, OF sANTITOXINS ©). oss oe 5 el LS eames RG

CHAPTER Tv.

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS ........ 44

CHAPIER we

PANGISHETICS) (CONTINUED) 1-3 S22) es ee wee et 8 58

PART IL—SURGICAL TECHNIC.

ChyNRAIERS Wale

IBANDAGINGEAND = ORESSINGS®:, = “slo. o6 iue e e Je cee ees 66

6 CONTENTS.

CHAPTER VII.

CARE OF OPERATING-ROOM ; METHODS OF STERIL'ZATION; CARE
OF INSTRUMENTS. .

CHAPTER VIII.

PAGE

86

INSTRUMENTS NECESSARY IN DIFFERENT OPERATIONS; KEEPING

OF CHARTS; SURGEON’S KIT, ETC. . .

CHAPTER IX. .

ANESTHESIA .

CHAPTER X.

ANTISEPTIC GAUZES, TAMPONS, THERMOCAUTERY, SALINE INFU-
SIONS, IRRIGATION, ETC.

CHAPTER XI.

SUTURES AND LIGATURES; SPONGES; DRAINAGE; DRAINAGE-
TUBES ; GAUZE DRAINS; RUBBER DAM; RUBBER AND COTTON
GLOVES .

CHAPTER XII.

INFLAMMATION

CHAPTERS chit

CATHETERIZATION; DOUCHES; ENEMATA; WASHING OUT THE
BLADDER ; LAVAGE

CRAP Re xalVe

MINOR SURGICAL PROCEDURES

CLAPALD RY Seve

OBSTETRICAL NURSING; CARE OF INFANTS, ETC.

CHAPTER XVI.

OPERATIONS; PREPARATION OF THE OPERATING-ROOM ; THE SUR-
GEON AND His ASSISTANTS

97

- 130

147

157

173

176

186

197

203

CONTENTS. 7

CHARTER XOVir

PAGE
TRANSPORTATION; PREPARATION OF PATIENT FOR OPERATION ;
CARE OF PATIENT DURING AND AFTER OPERATION .... 212
CLONE Re Ovals
SEQUEL OF OPERATIONS ; SHOCK, HEMORRHAGE, SEPTIC PERI-
HONLHISSONCCIDENTS DURING OPERATIONS, ERG) 2. =). =) 1227
CEU EAE Re GX
SE GI MemOBERAUIONS 1656) hcii eee ee ee GS ete tc kira) 23Q
CEVA PANE RONG
CEERAMONSEEN PRIVAGE: PRACTICE 22. 2). 6 2 2 jos 6. 243
(CSUR TU BIR 30-08
GYNECOLOGIC EXAMINATIONS AND OPERATIONS ....... . 254
CHARTER XOX:
JOVIIBTE IR IBIGIVENSSS, (5 Now ae eae aN cg ans Ce Pa ie a 265
CIlSVAUHIN WR XO-QUNE
SLENSRON MS DEATH ee NU MOPSIES( (4 Sika toe ie sl OS ey lees oh eee 272
CHAPTER XXIV.
HYGIENE ; PERSONAL CONDUCT OF A NuRSE’S LIFE; OF THE RE-
PAD She SUCCESS Meme vn el ae EE Be ee a ee, a 27S
\CTLOSSAIRY 3 1/55 Sopra Sabena: Nera gic ten lore ers at aera rier mee The SER ee omer 1

NENG) Dem Eg Mise ets esti, ats Loh Volrry ) tan ke ae Se se wa ae oe BOG

PART 1.
BACTERIOLOGY; ANTISEPTICS.

CHAP Pra R 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 num-
erous 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 upin 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 sute tobe present. The surface of the body never
escapes their establishment, and so deeply are some
individuals situated beneath the epithelial cells that
the most vigorous scrubbing and washing and the use

9

10 BACTERIOLOGY. ©

of powerful disinfectants are necessary to remove them
from the surgeon’s hands.

The mouth is said to be always replete with them;
and, since many are swallowed, the digestive tract
always contains them. ‘The germ of pneumonia, for
instance, is said to be habitually present in the mouth
of almost every healthy person; consequently, its
entrance into the lungs is only a matter of accident.

The existence of these bacteria has been known for
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 nan named Athana-
sius Kircher, a German, mistook blood-corpuscles
aud 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
appeared on the skin in the eruptive fevers, etc.,
was the result of putrefaction conveyed by small liv-
ing worms in the body. Shortly after these obser-
vations came those of Anthony van Leeuwenhoek,
a native of Delft, in Holland, who, in his early years,
had learned the art of polishing lenses, and who was
able, ultimately, to produce the first really good
microscope that had yet been constructed. He saw,
and described with astonishing clearness, various
forms of bacteria found in the material taken from
the 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, or spirilla; and of

HISTORY OF BACTERIOLOGY. If

rounded micro-organisms, or micrococci. 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
gradually accumulated, and fresh discoveries were
constantly made by various workers; but since no
systematic attempts to classify the newly observed
facts were made, the scientific results were very small.

The first real advance made in our knowledge of
the presence of a living contagious element in the
production of disease and fermentations was made
by Frederick Muller, 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
accurate knowledge of the bacteria which cause a

12 BACTERIOLOGY.

number of different diseases. The knowledge of
methods and details of work is now so general that
the science of bacteriology is rapidly growing, and
has revolutionized already very many branches of
medicine.

In 1840, Henle was led to believe that the cause of
mlasmatic, infective, and contagious diseases must be
looked for in living fungi, or other minute living
organisms. Unfortunately, at that time the methods
of study employed prevented him from demonstrating
the accuracy of his belief. Itwasleft for Pasteur and
Koch to complete the work. Davaine, in 1848, was
the first to see and to recognize disease-producing
bacteria—he saw anthrax-bacilli in the blood of sheep
dead of splenic fever. |

Pasteur then took up the work; and in 1857 his
faultless demonstration of the germ-theory of disease
was brought out as a result of his experiments on fer-
mentation and putrefaction, and on the bacteria of
wine and those of the silkworm. He showed that the
acetic fermentation, viscosity, bitterness, and turning
flat of wines are due to the action of certain organized
ferments, and demonstrated a causal relation between
certain lowly-organized parasitic organisms and spe-
cial diseases in animals and insects. Upon Pasteur’s
observations Lord Lister based his successful system
of the treatment of wounds, known as ‘‘antiseptic
surgery.’?

We all know of the wonderful success which now
marks the operations of major surgery, and of the
daring boldness of operators who attempt what was
utterly impossible as long as antiseptic surgery was
unknown. Lister, accepting the truth of Pasteur’s

HISTORY OF BACTERIOLOGY. 13

statement—that germs are the producers of fermenta-
tions—concluded that germs entering wounds from the
outside might be the cause of suppuration; and since
germs are always and everywhere floating in the air,
suspended in water, and attached to the surgical in-
struments, dressings, and sponges used in operations,
he judged correctly that it was highly advantageous
to employ an antiseptic agent in order to kill any of the.
suspended or adherent organisms before any materials
could be allowed to come in contact with wounded
tissues; consequently, the hands of the operator and
his assistants, the surgical instruments, sponges, dress-
ings, sutures and ligatures, were kept constantly satu-
rated with a solution of carbolic acid (1 : 40), and the
operation was performed under a spray of carbolic acid
(1:20). Carbolized dressings were used; and if the
discharge was profuse, the dressings were changed
once in twenty-four hours under a constant use of the
spray. The researches of a later date have shown, how-
ever, not only that the atmosphere cannot be disin-
fected, but also that the air of ordinarily quiet rooms,
while containing the spores of numerous saprophytic
organisms, rarely contains many pathogenic bacteria.
We also know that a direct stream of air, such as is
generated by an atomizer, causes more bacteria to be
_ conveyed into a wound than ordinarily would fail
upon it, thereby increasing instead of lessening the
danger of infection. Lister, we must remember, was
not the discoverer of carbolic acid nor of the fact that
it would kill bacteria; but, convinced that inflamma-
tion and suppuration were caused by the entrance of
germs from the air, instruments, sponges, and dress-
ings, into wounds, he suggested the antisepsis which

14 BACTERIOLOGY.

would result from the use of sterile instruments, clean
hands, dressings, towels, and the like; and made ap-
plications intended to keep the surface of the wound
moistened with a germicidal solution in order to kill
such germs as might accidentally enter. He also
introduced the practice of concluding operations by
the application of a protective dressing, such as would
tend to preclude the entrance of germs at a sub-
Sequent period. 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. Ljsterism has spread slowly but
surely to all the departments of surgery and obstetrics.

Since Lister’s treatment was first inaugurated,
many details of its application have been variously
modified and great additions to our knowledge have
been made. In bacteriology much important work
has been done, and great advances are being con-
stantly made. ‘There are a number of diseases, each
one of which has been definitely proved to be caused
by a germ of its own, a germ which causes no other
disease. ‘There is also a list of diseases in which the
proof is not yet conclusive, but for which the proba-
bility is that a specific germ will be found!) The
following data have been gathered chiefly from the
works of McFarland and Woodhead.

In 1845, Langenbeck discovered that the specific
disease of cattle known as actinomycosis could be
communicated 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.

In 1847, Semmelweis, on the basis of his own

HISTORY: OF BACTERIOLOG V, 15

observations, formulated the precept that puerperal
fever is the result of the introduction of organic
ferments into the puerperal genital tract. This dis-
covery, established by himself and confirmed by the
observations of many others, marked an era in ob-
stetrics. [he organic ferments have since been
identified as specific bacteria. Semmelweis, in this
way, anticipated in practical antisepsis the discover-
ies of Lister and Pasteur; while the late Oliver Wen-
dell Holmes, in a paper entitled ‘‘ Puerperal Fever a
Private Pestilence,’’ published in 1843, and repub-
lished in 1855, in treating of its prophylaxis, an-
ticipated the teaching of Semmelweis. Semmelweis
was first led to recognize the source of puerperal in-
fection by the case of Prof. Koletschka, of the
University of Vienna, who, having received a dis-
section-wound, became thereby fatally infected. In
consequence of this, Semmelweis concluded that
there was an identity between this infection and that
of which so many hundreds of puerperal women
died. In the school for instruction in practical ob-
stetrics, with which he was connected, there were
two departments, one for medical students, the other
for midwives; the students going as a rule directly
to the obstetric ward from the autopsy-room. He
first noted the much greater mortality in the stu-
dents’ ward, and in May, 1847, began to require the
students to wash their hands in chlorin-water before
making vaginal examinations, thereby reducing the
puerperal mortality to a point lower than had been
ever before reached.

In 1863, Davaine established by experiments the
bacterial nature of splenic fever, or anthrax.

16 BACTERIOLOGY.

In 1869, the first complete study of a contagious
affection was made by Pasteur, in two diseases affect-
ing silkworms—pébrine and flachérie—which he
showed to be due to micro-organisms.

In 1875, Koch described more fully the anthrax-
bacillus, gave a description of its spores and the
properties of the same, and was enabled to cultivate
the germ on artificial media; and, to complete the
chain of evidence, Pasteur and his pupils supplied
the last link by reproducing the same disease in
animals by artificial inoculation from pure cultures.
The study of the bacterial nature of anthrax has been
the basis of our knowledge of all contagious mala-
dies; and most advances in technic have been made
first through the study of the bacillus of that disease.

In 1879, Hansen announced the discovery of bacilli
in the cells of leprous nodules. ‘They were subse-
quently clearly described by Neisser. From the
nature of the symptoms and from the course of the
disease, leprosy up to this time was long considered
to be a disease similar to tuberculosis, and the dis-
covery of the bacillus paved the way for the recep-
tion of Koch’s discovery of the tubercle-bacillus.

In the same year Neisser discovered the gonococ-
cus to be the specific cause of gonorrhea.

In 1880, the bacillus of typhoid fever was first
observed by Eberth, and independently by Koch.

In 1880, Pasteur published his work upon
‘*chicken-cholera,’’? an epidemic disease which affects
turkeys, pigeons, chickens, ducks, and geese, and
which causes almost as much destruction among
them as the occasional epidemics of cholera and
small-pox produce among man.

TIESTO VOM MBACLTER ILOILO Ga 17

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 Fraenkel, Talamon, and particularly
Weichselbaum, that we are indebted for the dis-
covery of the relation which the organism bears to
pneumonia.

In 1882, Robert Koch made himself immortal by
the discovery of and work upon the bacillus of tuber-
culosis, one of the most dreadful, and unfortunately
most common, diseases of mankind. While great
men of the earlier days of pathology clearly saw that
the time must come when the parasitic nature of this
disease would be proved, and some, as Klebs, Ville-
mineand Cohmhemm, were within an ace’ of the
discovery, it remained for Koch to succeed in dem-
onstrating and isolating the specific bacillus, and to
write so accurate a description of the organism and
the lesions it produces as to render the discovery one
of the most complete ever made in the history of
medical science.

In the same year Loeffler and Schutz 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 Loeffler discovered the diphthe

tia-bacillus, and Nicolaier that of tetanus.
2

18 BACTERIOLOGY.

On October 26, 1885, Pasteur made the first ap-
plication of his method for the treatment of hydro-
phobia, 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 experimentally in the diagnosis of tubercu-
losis. See
In 1892, Canon and Pfeiffer discovered the bacillus
of influenza.

In the same year Canon and Pielicke first found a
bacillus now thought to be the specific cause of
measles.

In z894, Yersin and Kitasato independently iso-
lated the bacillus causing the bubonic plague then
prevalent at Hong-Kong, and now threatening
Europe.

sanarelli, in 1896, reported the discovery of the
micro-organism of yellow fever. His conclusions
were based on the presence of a certain germ (Bacil-
lus icteroides) in 58 per cent. of cases examined, and
the production of symptoms and pathologic changes
in the lower animals resemble those present in
man. Sanarelli’s observations have been confirmed
by a commission of the U. S. Marine-Hospital Ser-
vice. Some doubt has lately been thrown upon this
germ being the specific cause of yellow fever. How-
ever, the mode of transfer of the disease from sick to
well persons has been proved. Mosquitoes, it is now
known, act as the disseminators of yellow fever. The
females of the species called Stegomyia fasciata, twelve
days after biting an individual sick of yellow fever, act

FHSTORY OF BACTERIOLOGY: 19

the réle of carrier for several months’ time thereafter.
This mosquito is prone to inhabit thickly populated
districts rather than the open country, its presence and
multiplication depending upon the continuance of
stagnant water. It is most active between the hours
of 4 Pp. M. and midnight, and ceases to bite when the
temperature falls below 62° F. ‘This last fact bearing
out the long-known observation that the first frost
killed the fever, no new cases developing afterward
in a given district liable to extremes of temperature.
Preventive measures call for the destruction of all the
mosquitoes in the house of a patient taken with the
disease, best accomplished by closing up and screen-
ing all the doors and windows of the premises and
burning sulphur (1 pound of roll sulphur to every
1000 cubic feet of room space). Screening of the
patient, sick or dead, must be carried out for the com-
mon protection. Spirits of camphor, oil of penny-
royal, or 5 per cent. menthol ointment applied fre-
quently to exposed parts of the body—neck, face,
wrists, and ankles—may be employed to keep off the
mosquitoes in the non-immune.

Epidemic cerebrospinal meningitis, or spotted
fever, is now known to be caused by a specific germ
present in the cerebrospinal fluid of patients suffer-
ing from this disease. The route of infection is not
fully determined, but it is probably through the nose.

Malta-fever, a disease of the Mediterranean islands,
and occasionally of the Antilles and Central and
South America, is due to a micrococcus discovered
by Bruce, and called Bacillus melitensis.

Malarial fever is an infectious disease; but, unlike
those mentioned, it is not caused by a vegetable germ,

20 BACT RLOLOG

a bacterium, but by a microscopic animal, the Plasmo-
dium malari@, which is found in the blood of the
afflicted individual, its entrance being brought about
by the stings of mosquitoes (females of certain
varieties). 3
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; but the latest researches point to a tiny
organism, a yeast-plant or blastomycete.

C EAE AER? LI:
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. Weno
longer look upon infectious and contagious diseases
as due to an unexplainable something, whose source
we cannot know, whose course we cannot predict, and
whose end cannot be hastened by any efforts on our
part. Investigation has shown that we are no longer ~
fighting an unknown enemy in the dark, but that we
have before us a definite, living thing, whose part in
the plan of creation is as surely fixed as our own,
whose life-history can be told, and whose growth 1s
as dependent on the right amount of light, food, heat,
and air as that of the rose in our garden.

The word dacterza is a general name for all the
plant micro-organisms. Of these there are many
different classes with different names. They vary
much in shape and size, some being round, some
thread-like, some rod-shaped, and some of a spiral
form. Each single organism consists of a small speck
of protoplasm or vegetable albumin, to which may be
given the name of a cell; and these cells are so minute

that they can be seen only with the aid of the best
21

22 BACTERIOLOGY.

microscopesatourcommand. Therounded organisms,
or micrococci, as they are called, are seldom more than
sstyo Of an inch in diameter; the elongated cells
average a little more perhaps, and are from zgipa

9 oo SI 9 8 eS 07 ) SUS Y h nan
of SB o oe ol oa UN or
£4 Oo 035 04 5 7 8 9 10 «13

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, spirochetse
(McFarland).

to ggg Of an inch in length. Different forms nat-
urally vary from this standard of size; but these fig-
ures will give a good idea as to the actual size of
the forms under consideration.

The fungi connected with disease in man are divided
into three classes :

1. Moulds, or hyphomycetes.

2. Yeasts, or blastomycetes.

3. Bacteria, or schizomycetes.

Some bacteria, or schizomycetes, induce the various
fermentations; while others are productive of putre-
faction, and are called saprophytes. Others, again,
known as the pathogenic bacteria, are the cause of
various diseases; while those which do not ordinarily
cause disease are known as the non-pathogenic bac-
teria. The chief forms of bacteria are:

1. The coccus—berry-shaped or spherical bacte-
rium.

2. The bacillus—rod-shaped bacterium.

3. The spirillum—corkscrew bacterium.

BACTERIA AS THE CAUSES OF DISEASE. 23

And these, which are species relatively monomorphous
—1. €., 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 ina chain, they are

a b c G T
) ae) 69399 $2
@ +)

& A z ij

Fic. 2.—Diagram illustrating the morphology of cocci: a, coccus or
micrococcus; 4, diplococcus; c¢, d, streptococci; e, f, tetragenococci or
merismopedia; g, 2, modes of division of cocci; 2, sarcinz; 7, coccus with
flagella; 2, staphylococci (McFarland).

called streptococci; if in a cluster, like a bunch of
grapes, they are called staphylococci; and if in an
irregular mass, stuck together by a thick substance,
they constitute a zodglea. Those developing in fours
are called tetrads; in eights, sarcine.

The cocci are also named according to their func-
tions, as, for instance, ‘* pyogenic,’’ or pus-forming;
the specific name also describing the form, arrange-
ment, color, and function; for example, Staphylo-
coccus pyogenes aureus signifies a spherical colorless
micro-organism forming a yellow pigment, arranging
itself with its fellows into the form of a bunch of
grapes, and producing pus.

As the surgical nurse carries on a daily warfare for
the destruction of pus micro-organisms and prevention
of their growth, she cannot be too familiar with everv

24 BACTERIOLOGY.

aspect of these germs. The two most constant pus
formers are :.(1) the Staphylococcus (Fig. 2, £), 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 (Fig.
i; IN@: §))

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’s
method. Toa 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, Oe faite
Water, LOO en

Stain in this for fifteen minutes; transfer to Grain’s
solution :

Todin, 4 parts.
Potassium iodid, Qe
Water, 200) 1)

Stain for four minutes ; remove and wash the speci-
men in 95 per cent. alcohol ; finally stain in the fol-
lowing for half a minute : 3

Bismarck brown, 3 parts.
66

Water. 7O

Wash in 95 per cent. alcohol; clear the specimen by

BACTERIA AS THE CAUSES OF DISEASE. 25

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
increase in their numbers can be thus brought about;
but fortunately this multiplication only takes place to
advantage under certain favorable conditions; if these
are not present, the bacterium begins to degenerate,
but usually does not die until it has left behind a spore.
When the formation of a spore is about to commence,
a small bright point appears in the protoplasm, and
increases in size until its diameter is nearly or quite
as great as that of the bacterium. As it nears perfec-
tion a dark, highly refracting capsule is formed about
it. As soon as the spore arrives at perfection the bac-

CSD esa 0) @-o (45> e>
a b c a é va
Fic. 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/f, bacilli escaping from spores
(McFarland).

terium seems to die, as if its vitality were exhausted
in the development of the permanent form. As soon
as the young bacillus escapes it begins to increase in
size, develops around its soft protoplasm a character-

26 BACTERIOLOGY.

istic membrane, and having once established itself
presently begins the propagation of its species by fission.
In those forms of organism in which spores are not
found the germs die very rapidly unless the conditions
for their nutrition and multiplication remain very
favorable. If all bacteria were of this kind, it would
be possible to exterminate them with consider-
able rapidity. Spores will survive a great heat, a
heat which will kill the organism from which the
spore caine; they will also live under a treatment
with germicidal solutions which renders the bacteria
inactive. In other words, the spores are much more
resistant to the effect of germicides than the bacteria
themselves. Cold does not kill them; they live
through it and develop whenever favorable surround-
ings for their growth present themselves. ‘They may
lie dormant in the system for years, waking into
activity only when they come into contact with some
damaged, weakened, or diseased part which affords
them a nest in which to develop and multiply, the
cellular activity of the weakened part being unable to
cope with the organisms.

The conditions which influence the growth of bac-
teria are, first, a temperature ranging from 85° to 104°
F., some forms requiring a higher and some a lower
temperature. Some forms of bacteria are not influ-
enced in their growth by the presence or absence of
light. To some, sunlight is destructive: (Avie
hours’ exposure to the sun is fatal to the anthrax-
bacillus and to cultures of the Bacillus tuberculosis.
The rays of the sun, however, must come into contact
with the germs and are usually active only on the
surface of cultures.

ACM nehA WAS he CAUSES OF IDISHASE. 27,

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 allif 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
bacteria.

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 1s
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 well recognized; hence every wound,
no matter how slight, should be protected as soon as
possible.

28 BACTERIOLOGY.

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 hke. Pneumonia
and tuberculosis are said to be the result of in-
spiration of the specific organisms. The direct
transmission of bacteria from a parent to the fetus
has long been a disputed question, but is now gener-
ally conceded. ‘The micro-organisms pass through
the placenta and infect the fetus. Tuberculosis of
the ovaries, Fallopian tubes, and uterus may origi-
nate through the blood, and infection from without
through the vagina. Infection through the blood is
evidenced by the general tuberculosis of all the vis-
cera. Infection from without may result in tuber-
culosis of the uterus, ovaries, and Fallopian tubes.

The channels by which bacteria can enter the
body are, then very numerous; and there is scarcely
a moment in which some part of the body is not in
contact with them. All the disease-producing germs
have their favorable seat in some part of the body
where they grow more or less luxuriantly, and in the
secretions and excretions of which the chief source
of their infection lies. ‘The pneumonia-germ prefers
the lungs; the typhoid fever germ selects the lower
portion of the small intestine; the diphtheria-germ
the throat; the cholera-cerm the intestimalpjiner
the germ of tuberculosis prefers the lungs, but it is

BACTERIA AS THE CAUSES OF DISEASE. 29

called a ‘‘medical tramp,’’ because it will lodge in
any part of the body and make its home there.
Hence we hear of tuberculous glands of the neck,
tuberculous knee, intestinal tuberculosis, tuberculosis
of the kidney, bladder, uterus, ovaries, Fallopian
tubes, tuberculous peritonitis, etc. A tuberculous
area is always a danger to the system, and may infect
distant organs or give rise to a general tuberculosis.

To prove that a microbe is the cause of a disease it
must fulfil Koch’s circuit. It must always be found
associated with the disease, and it must be capable
of forming pure cultures outside the body. ‘These
cultures must be capable of reproducing the disease,
and the microbe must again be found associated with
the morbid process thus reproduced. In other words,
we must prove the bacteria to be always present; we
must then isolate them, then prove that they can
produce the disease in a healthy animal, and, finally,
having succeeded in doing all this, we must prove
that no other form of bacteria can produce the
disease, and that where these bacteria cannot be
obtained the existence of the disease is impossible.
All these requirements have been met in many
instances, and now there are a large number of dis-
eases each one of which has been definitely proved to
be caused by a germ of its own, a germ which pro-
duces that disease and no other. Most of the germs
need a special train of circumstances in order that they
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

30 BACTERIOLOGY.

that germ does not invariably produce diphtheria—if
it did, we should all be infected with it. ‘This is
because other conditions than the mere presence of
the germs are needed to produce the disease. ‘The
germs must be active, and they can act only under
certain 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 imour
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 moun-
tains, Southern California, or of the other South-
western States, where there are few cloudy days and
where violent atmospheric changes are rare. ‘The

BACTERIA AS THE. CAUSES Of DISEASE, 31

germs there cannot be so active, for the air is stimu-
lating, pure, and invigorating to the nervous system.
The rarefaction of the air causes deep and strong
involuntary respiratory movements, and there is con-
sequently enforced a better ventilation of the lungs
and a better oxygenation of the blood, in conse-
quence of which there follow more active tissue-
changes throughout the body and a strengthening
of the respiratory muscles.

On finding favorable conditions it takes germs some
days to develop and produce the disease; this time is
known as the period of incubation.

The question is often asked, Why, when we are so
constantly in contact with disease-germs, do we not
contract the diseases? All bacteria leave the body
through the skin, lungs, kidneys, or bowels; and
by a faithful use of disinfectants and antiseptics
the germs may be kept confined to their original
position. After their escape from the body they are
dificult to control. The scales of skin or dandruff
from a case of scarlet fever, measles, or small-pox, or
the dust that arises from the dried sputum of a
pneumonia or tuberculosis patient, or the poisonous
material which may enter our drinking-water from
too close proximity of the well and the sewer into
which typhoid discharges have been emptied, may
readily be the means of propagating disease. These
sources of infection should be scrupulously avoided.
Another protective factor is the natural or acquired
power of resistance to disease-producing germs.

inmimiinitve Is either iatural or acquired. ~Of
acquired immunity we have two varieties, that which
comes from acclimatization, and artificial immunity.

a8 BACTERIOLOGY.

By natural immunity is meant the natural and
constant resistance to disease-producing germs. The
individual is immune by Nature, and sometimes by
racial characteristics. Acquired immunity is a
power of resistance attained through various cir-
cumstances. Thus, a single attack of some of the in-
fectious and contagious diseases usually confers im-
munity against subsequent attacks. Such immunity
generally follows an attack of typhoid fever, small-
pox, scarlet fever, mumps, whooping-cough, measles,
or yellow fever. Second attacks may occur; but, as
a tule, a patient who has had an attack of one of
these diseases has immunity for life. Influenza,
pneumonia, cholera, diphtheria, and erysipelas are
among the diseases in which one attack is not
protective. Vaccination usually insures immunity
against small-pox; but this is ordinarily not so com-
plete or permanent as that resulting from an attack
of the actual disease. |

Acclimatization immunity 1s exemplified by vari-
ous diseases which do not trouble natives or those
long resident, but which may affect strangers not im-
mured to the climate.

Racial immunity is that in which certain races are
safe from certain diseases; for instance, negroes sel-
dom suffer from yellow fever, but are more suscep-
tible than whites to small-pox. In the former case
doubtless due to the sweat odor of this race proving
repellant to mosquitoes, the recognized medium of
transfer of this disease germ. It is asserted that the
Arabs seldom or never have typhoid fever. An analo-
gous example is afforded by the fact that white mice
are not affected by the same diseases as the gray mice

BACTERIA AS THE CAUSES OF DISEASE.” 33

are, even though subjected to the same influences in
respect to climate, food, and surroundings.

Artificial immunity may be produced in various
ways. It is said that an injection of the antitoxin of
diphtheria will give protection against the disease for
from four to eight weeks. Tetanus has been prevented
in asimilar manner. It is impossible here to enter,
excepu in) a slicht deoree, into the consideration of
the many theories of immunity, since they are very
_ intricate, and not one has been advanced so far that
can clearly explain it. The theory of phagocytosis
and the theory of antitoxins are the two most im-
portant. |

Phagocytosis is the destruction of bacteria by the
white cells of the blood and the cells of fixed tissues.
The cells which eat up and destroy the germs are called
‘‘ phagocytes.’’ When the two meet a battle occurs,
the bacteria fighting the cells with their active fer-

Fic. 4.—Phagocyte destroying a bacillus (Landerer).

ments, while the cells on their side put forth every
effort to protect the body against the assaults of the
disease. Ina majority of the cases the bacteria win
to the extent that the phagocytes die; but others take
their place until the infection is overcome or the
patient dies. The white blood-cells and tissue-cells

having thus been educated to withstand the poison,
3

34 BACTERIOLOGY.

their descendants inherit this capacity and are born
insusceptible. ‘This theory was suggested by Carl
Roser in 1881. Sternberg and Koch afterward put
forth the same view, but it is usually credited to
Metschnikoff, who published his observations in
1884.

The 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 toxius in gradually
ascending doses, it can be immunized to doses that
under other circumstances would prove fatal. The
blood-serum of an animal thus immunized has the
power, when injected into another animal, of ren-
dering it also immune to the bacteria that have
originally been used; and in some cases the serum
is even capable of curing the disease after it has
developed in another animal. These properties with
which the blood-serum has become endowed depend
upon the presence of what are called antitoxins and
antibacterial bodies. In man also, after recovery
from certain infectious diseases, it is possible to
demonstrate in the blood-serum the presence of anti-
toxic substances; and it is now the general belief
that immunity, at least of the acquired form, is due
to such antitoxins. The uses and practical prep-
aration of antitoxins will be described in the next
chapter.

The most important of the special surgical micro-
organisms—z. ¢., those most frequently met with in
surgical work—are the following, the majority being
pus-producers :

1. Staphylococcus Pyogenes Aureus.—This is the

ACHE TA AS” THE (CAUSHS OF DISEASE. 35

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, alimen-
tary 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 1s a most important path-
ogenic micro-organism, and is thought by many
authorities to be identical with the streptococcus of
erysipelas. The Streptococcus pyogenes 1s frequently
associated with internal diseases, and has been found
in the uterus in cases of infective puerperal endome-
tritis, ulcerative endocarditis, acute septicemia, and
other diseases. It is one of the most common causes
of post-operative peritonitis.

3. The Bacillus colt communts is always present in
the intestine, 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 pyo-
genes aureus.

5. The Staphylococcus eprdermutidts albus is a micro-
coccus which is almost always present upon the skin,
not only upon the surface, but also in the outer layers.

6. The Staphylococcus pyogenes citreus is wot quite
so common nor so pathogenic as the other forms, and
is less important.

36 BACTERIOLOGY.

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 tuberculosts 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
abscesses. :

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 1s) wotlaypee-
producer. ‘Tetanus is a disease due to the absorption
of its toxins, which poison the nervous system pre-
cisely as would dosing with strychnin.

12. The adtphtherta-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.

SCIBUE IE IM DI ROE
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 bornein mind. An anti-
toxin is not the direct result of bacterial action, but
is properly described as an unknown body resulting
from the resistance of the healthy organism’ to the
toxins of pathogenic bacteria. According to the pre-
vailing theory, antitoxins are the products of the ©
body-cells, formed under the influence of the bacterial
toxin. In therapeutic practice the antitoxic body
comes to us in the blood-serum of an animal, usually
_the horse. When properly prepared and properly
kept in aseptic containers the antitoxins are not at all
dangerous; they are as innocuous as an equal amount
of blood-serum or normal salt solution administered in
the same way. Antitoxins are used both to counteract
the effects of the toxins which are elaborated by path-
ogenic bacteria in the body, and to render the sys-
tem immune, so that it may resist the action of the
bacteria should they gain access to the body. The

antitoxins do not destroy the bacteria; in other words,
37

38 BACTERIOLOGY.

they are not germicides. In fact, the antitoxic serums
are themselves good culture-media. One theory of
their action is that they neutralize the toxin, thus
giving the natural bactericidal powers of the body an
opportunity to exercise their function. |

The following is a brief description of the process
employed in the laboratory of Parke, Davis & Co.,
for the preparation of diphtheria-antitoxin :

Young horses in perfect condition are selected and
kept under careful observation by an expert veterina-
rian for three or four weeks. During this time they
are carefully tested with tuberculin for the possible
existence of unsuspected and undeveloped tubercu-
losis, and with mallein for glanders. When a horse
is found to be perfectly healthy it receives its first.
dose of diphtheria-poison, or more properly a solution
of the toxin of the diphtheria-bacillus. This is pre-
pared in the following manner: A culture is obtained
from the throat ofa patient suffering from a virulent at-
tack of diphtheria. The diphtheria-bacillus is isolated
from this culture and planted in a flask of bouillon
or beef-tea, which is then kept in an incubator from
three to four weeks. At the end of this time it has
attained its maximum toxicity and the bacteria begin
to die of their own poison. The toxin which they
have elaborated in the course of their existence is held
in solution in the beef-tea. This bouillon solution
of toxin is then filtered through porcelain to remove
the bacterial cells and any other extraneous matter.
It is then ready for injection into the horse. About
one-tenth of one cubic centimeter is injected intra-
venously. ‘The horse responds with all the constitu-
tional symptoms of diphtheria, such as a chill, fever,

THE THEORY OF ANTITOXINS. 39

loss of appetite, more or less pharyngeal paralysis,
with regurgitation of food. Sometimes death occurs
from heart-paralysis. Upon recovery, which comes
within a few days, a slightly larger dose is given.
This treatment is continued for about one year, at the
end of which time the horse will take from 2000 to
3000 times the initial dose without reaction. It is
then ready for bleeding. About 6000 cubic centi-
meters of blood are drawn from the externai 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 be-
cause some eminent bacteriologists believe that the
streptococcus of erysipelas is not identical with the
streptococcus of puerperal fever. It is but fair to say,
however, that others equally eminent assert the iden-
tity of the two streptococci. To meet the possibility
of the non-identity of the organisms, a culture ob-
tained from the two sources is used. Its virulence is
increased by passing it through rabbits. After pass-
ing through about fifty rabbits a culture is planted in
beef-tea, and the same course pursued as for diphthe-
tia-antitoxin. Antitubercle serum is obtained by im-
munizing horses with the original Koch’s tuberculin.

As to the therapeutic action of antitoxin, little or
nothing is known positively. It seems reasonable to
conclude from experimental evidence that the anti-
toxin neutralizes the toxin in the body and thereby
gives the natural germicidal powers an opportunity

40 BACTERIOLOGY.

to dispose of the bacteria. It may be that it has the
additional property of stimulating the phagocytic and
possibly other bactericidal functions. The following
experiments made by Martin and Cherry, of Mel-
bourne, Australia, and described in the /Jour. of the
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 chemic one, somewhat anal-
ogous to the neutralization of an acid by an alkali;
while Buchner, Metschnikoff, and others have main-
tained that it is indirect and operates through the
cells of the organism. Martin and Cherry used a
snake-venom antitoxin. A large number of guinea-
pigs wereused. At 60°C. the antitoxin was destroyed,
while the venom retained its virulence. In the con-—
trol-experiment with the venom only, all the animals
died within a 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. 4!

tion of toxins may occur in the test-tube, and that the
vital processes in the organism and the body-cells are
not essential. These gentlemen made further exper-
iments by passing a mixture of toxins and antitoxins
through a Pasteur-Chamberland filter. This was po-
rous for toxin, but not for antitoxin, owing to the
difference in the size of their molecules. The toxin
which passed through the filter, after having been
mixed with antitoxin, was neutral. The unavoidable
conclusion from this experiment is that the toxin was
neutralized before filtration.

Experiments have been tried in order to prove the
theory that toxins are albumoses and antitoxins globu-
lins; but these experiments do not appear to be con-
clusive as to this point. |

The supposition that the administration of antitoxin
is followed by a stimulation of the germicidal powers
of the body seems to be reasonable, at least in the
case of the antistreptococcic serum, since the strepto-
cocci disappear with the passing away of the signs
and symptoms. On the other hand, the Klebs-Loeff-
ler bacillus is found in the throat for weeks and even
months after the disappearance of all symptoms of
diphtheria in cases treated with the antitoxin.

The present status of diphtheria-antitoxin may be
presented in a few words. It has established itself as
a specific in the treatment of this disease. During
the past year the use of larger doses has become more
general, and it seems certain that better results were
obtained. The administrators of the Chicago Depart-
ment of Health give 2000 units in all cases of sus-
pected diphtheria, and employ 1000 units as an im-
munizing dose. During the months of November

42 BACTERIOLOG V.--

and December, 1898, this department treated 219
cases of bacteriologically proved diphtheria—all char-
ity cases—with a death-rate of 4.1 per cent. Some
two and a half years ago, when antitoxin was not used,
the death-rate from diphtheria treated by this depart-
ment was about 35 per cent.

Antistreptococcic serum gives promise of being
second only to the diphtheria-antitoxin in point of
therapeutic value. It has been most successful in
erysipelas and puerperal septicemia. Cases of scarlet
fever are reported in which it has been useful in
shortening the duration of the disease and in pre-
venting unfortunate complications and sequelee, such
as otitis media and other suppurative processes due to
streptococci.

A mixture of the toxin of the streptococcus of

erysipelas and the products of a harmless germ, the
Bacillus prodigiosus, is used by Coley and others as an
injection in malignant tumors that are past the stage
of operation or are so situated that an operation is im-
possible.

It is to be regretted that tetanus-antitoxin does not
in clinical use do all that it will do in the laboratory.
It has been used in a considerable number of cases,
but in nearly every instance without any result that
would justify us regarding it as a great curative
agent. Nevertheless, it should be used early in
every case of tetanus, the patient thereby having a
somewhat better chance of recovery.

One or two cases have been successfully treated
with intracerebral injections of antitoxin, the theory
being that the antitoxin should be :placed where it
could neutralize the toxin which is producing the

=

TEE SHHORV OF ANTITOXINS 43

convulsions by means of its action on the nerve-
centers. ‘The value of this method of administration
has not been proved.

As a preventive measure the use of tetanus-anti-
toxin is strongly commended.

An antityphoid fever serum has lately been devel-
oped which, if proved successful, must become of
the greatest value in the prevention and cure of this
insidious disease.

The antitubercle serum has not shown itself to
have more value than a great number of other
remedies vaunted as specifics in tuberculosis.

Method of Injecting Antitoxin.—The serums and
toxins are given hypodermically, the injection being
made into the back, thigh, side of the breast, or over
the chest. Perfect antisepsis for the operation is
absolutely necessary. ‘The puncture-wound is closed
with a collodion dressing. It 1s not necessary to use
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 symptoms beginning an attack of erysipelas—
chill, local redness, and high temperature.

MCIEUE edb as ION,

ANTISEPTICS, DISINFECTANTS, AND
DEODORANTS.

SUBSTANCES which retard or check the growth of
bacteria amid otherwise suitable surroundings are
called antiseptics.

Articles and wounds which are entirely free from
bacteria and their spores are termed aseptic or sterile.

Disinfectants or germicides entirely destroy the
vitality of bacteria. Excessive heat, dry or moist, is
a true disinfectant, because it entirely destroys bac-
teria, while cold is an antiseptic; it does not kill bac-
teria, but retards their development.

A chemic agent which will cause the death of bac-
teria is called a germicide.

A deodorant is an agent that destroys bad odors.
A disinfectant is an antiseptic, and may be a deodo-
rant; but because a substance has the power to de-
stroy bad odors it does not follow that it has the power
to destroy the bacteria which are the cause of the
odor. Carbolic acid, for instance, is a disinfectant
and deodorant; while Platt’s chlorides is a prompt
deodorant, but has almost no disinfectant power.

The power of a chemic agent to destroy bacteria
depends on several conditions :

First. The kind of bacteria, some being easily killed
7

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 45

by an agent which is entirely harmless to others.
Spores are much more resistant than the bacteria from
which they are derived.

Second. The number of bacteria present.

Third. The temperature at which the exposure to
the disinfecting agent is made; the higher the tem-
perature the greater the effect.

Fourth. The strength of the solution; a small quan-
tity of a strong solution of corrosive sublimate is
much more efficient than a large amount of a weak
solution.

Fifth. The nature and quality of the associated
material. If the bacteria are associated with a large
amount of organic matter, the chemical agent used
may combine with the latter and may thus be con-
verted into an ineffective material before it has an op-
portunity to act upon the bacteria. This result must
be especially guarded against in the disinfection of
sputum and fecal matter.

The agents capable of destroying bacteria are nuim-
berless; but there are many which cannot be employed
in practice because they are too weak or act too slowly,
or are too poisonous, or too expensive for general use
in the required quantity, or are too destructive to the
objects with which they come in contact. Water at
a high temperature cannot be used for the disinfec-
tion of the hands of the surgeon or of the field of oper-
ation, or of organic substances in general. Corrosive
sublimate cannot be employed in the sterilization of
instruments, since it corrodes and blackens them; it
also discolors clothing and furniture when used in
strong solutions. Potassium permanganate stains
everything with which it comes in contact.

46 ANTISEPTICS.

By long-continued action in concentrated solution
some of the agents which arrest the growth will finally
lead to the death of those bacteria which have been
subjected to them. Many agents, however, which
arrest the growth of bacteria, are not capable of de-
stroying them, and particularly their spores. Cold,
for example, will arrest the development of bacteria
but has no power to destroy anthrax-spores even when
applied with the most extreme intensity. The resist-
ance of spores is one of the strangest phenomena in
nature; some can be boiled and some can be subjected
to the intensely cold action of liquid air without per-
ishing. ‘The chief disease-producing bacteria which
form spores and those which do not are:

Non-spore-forming :

I. Streptococcus pyogenes.

2. Staphylococcus pyogenes aureus, albus, and
citreus.

3. Streptococcus of erysipelas (believed to be iden-
tical with the Streptococcus pyogenes).

4. Diphtheria-bacillus.

5. It is doubtful whether the tubercle-bacillus 1s
spore-forming. The weight of opinion favors the
absence of spores in this organism.

Among the spore-forming pathogenic organisms
are :

1. Bacillus of malignant edema.

2. ‘The tetanus-bacillus.

3. ‘The anthrax-bacillus.

The germicidal or disinfecting agents at our com-
mand are of two kinds chiefly, heat and chemic
agents. ‘The term ‘‘disinfection’’ is employed for

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 47

the action of chemic agents, and ‘‘sterilization’’ for
the action of heat.

Among all germicidal or disinfecting agents heat is
entitled to the first place, and fire, for its thorough-
ness, is superior to all others. All infected articles
of little value, books, playthings, etc., that can be
burned should be thus destroyed, as should also spu-
tum and bowel-movements. ‘The very best way to
treat the latter is to mix them with sawdust and then
to burn them.

In surgical work, for the perfect sterilization of
articles capable of withstanding it, fire is preferable
because of its certain action. Edged instruments and
forceps may be exposed for a very short time to the
direct flame; but if continued too long the temper of
the steel is affected.

We must remember that after sterilization there is
always the danger of contamination, and the articles
must, therefore, be carefully protected immediately
after sterilization. If they are left uncovered for dust
to collect upon them, the object of sterilization is
defeated.

Light, especially sunlight, acts as a germ destroyer.

Heat may be applied in the form of hot air, moist
air (steam), or boiling water.

Bowling water kills germs on contact, and de-
stroys anthrax-spores, as a rule, in from two to four
minutes.

Moist heat (steam) is the next most powerful agent.
It is more thorough and more penetrating than hot air.
Steam exerts its full influence only when the air is
saturated with it. Saturated steam may be simple
steam (quiescent), live steam (circulating steam),

48 ANN PUSE PLCS:

high-tension steam (confined under a certain pressure),
or superheated steam (that which has been heated
secondarily to a temperature above 100° C.).

Live steam destroys anthrax spores in from five to
fifteen minutes, according to their degree of resistance.

Disinfection by steam is applicable to clothing,
linen, blankets, towels, surgical dressings, instru-
ments, curtains, carpets, brushes, mattresses, pillows
(the two latter should be ripped open), and a number
of delicate fabrics. It is not applicable to linen soiled
by feces, blood, or pus, since the stains would become
fixed by the process (soak first in plain cold water),
nor to rubber articles. Under certain conditions many
articles are exposed to the action of steam for one hour
on three successive days, being kept during the inter-
vals ata temperture of 70° to 80°" C@ tomaveritme
development of bacteria. Thus is called Simtewan =
tent’’ or “fractional” sterilization, the object of
which is to kill all bacteria that may have developed
from spores that escaped the first steaming. ‘The last
sterilization is for the purpose of making sure.

fiot atr is inferior to both steam and hot water.
steam at a temperature of 100° C. is more effectual
than hot air at a much higher temperature. Accord-
ing to investigations, exposure to a temperature of
150° C. (302° F:) for one and achalf hours ameashor
air sterilizer will kill all known bacteria and their
spores. |

Ozone, formed by electric discharges in water,
may be used to improve its quality for drinking pur-
poses.

The list of chemic substances used as germicides
is constantly changing, and those which are now

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 49

- considered the most valuable may in a little while be
considered not so effectual as newer ones. Among
the recognized antiseptics and disinfectants now in
use are:

Chlorin, in the free gaseous form or in watery solu-
tion, is used for general disinfecting.

Sulphur dioxid, best used in the presence of moist-
ure, is produced by burning roll sulphur (flowers of
sulphur) in a closed receptacle.

Corrosive sublimate, or bichlorid of mercury, has,
like carbolic acid, the advantage of being both effica-
cious and cheap. It has the disadvantages that it
is decomposed by alkalies, that it is precipitated by
albumin, and that it corrodes metals. It is used in
strengths of from 1:10,000 to 1:500. ‘The solution
should be made as it is needed, because in old solu-
tions most of the soluble corrosive sublimate has
been converted into insoluble calomel, and the solu-
tion is not germicidal. By using the compressed
tablets now on the market fresh solutions are readily
made. A tablet usually contains the requisite amount
of corrosive sublimate to make when added to one
pint of water a 1: 1000 solution, and by increasing or
diminishing the amount of water the strength of the
solution may be altered at pleasure. The tablets
are very convenient, and almost compel accuracy
in the preparation. Corrosive sublimate is of less
value for the disinfection of the excreta than car-
bolic acid, as it hardens the albuminous material
which covers the outside of all fecal masses, and
thus protects the inside from the desired action.
Tartaric acid, chlorid of sodium, or chlorid of ammo-

nium is often added to prevent this. Compressed
4

50 ANTISEPTICS,

tablets, each containing tartaric acid or ammonium
chlorid and 7% grains of corrosive sublimate, or
equal. parts of chlorid of sodium and corrosive sub-
limate, are in common use. ‘The convenient form in
which this drug is put up and the readiness with
which it can be used in surgical and medical work
have made its adoption universal. Its poisonous
character must be kept constantly in mind. ‘The
first symptoms of poisoning in consequence of: the
absorption of the bichlorid are profuse salivation,
fetid breath, a metallic taste in the mouth, sore
teeth, spongy gums, and swollen tongue. Should
any of these symptoms appear they should at once
be reported to the surgeon. As the solution has no
odor, it is occasionally swallowed in mistake. Should.
this occur, symptoms of a violent gastro-enteritis
appear—vomiting, burning pain, bloody stools; the
kidneys are also affected, and an acute Bright’s dis-
ease develops. The immediate treatment of this
acute poisoning consists in the giving of white of
egg, flour, or milk and lime-water, and washing out
of the stomach.

Carbolic acid, derived from coal-tar by distillation.
When pure, it is a solid, white, or faintly rose-
colored, crystalline body, readily soluble in water,
alcohol, or glycerin. On exposure to air it absorbs 5
per cent. of moisture. A solution frequently employed
is one of 5 per cent. strength. To make a 5 per cent.
solution, 1 part of carbolic acid is added to 20 parts
of very hot water and the whole shaken thoroughly.
Any excess of carbolic acid above that strength
falls to the bottom of the vessel as pinkish globules.
Before using the solution care must be taken that the

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 51

globules have been dissolved, or they will burn any
living tissue with which they come in contact. Car-
bolic acid is considered now to be the most reliable
and useful of all the germicides and antiseptics. It
has the advantage over corrosive sublimate in that it
does not discolor instruments nor clothing; but, on
the other hand, it irritates and benumbs the skin.
Pure carbolic acid is a reliable disinfectant for instru-
ments. If an instrument that is indispensable hap-
pens to fall to the floor during an operation, it may be
laid for a moment in pure carbolic acid, then rinsed
with sterile water, and it is ready for use. Long-
continued submersion in the acid will, however, de-
ptive knives and scissors of their temper and edge.
Symptoms of poisoning have been produced by the
absorption of the drug from surgical dressings and
from the use of carbolic solutions for irrigation. The
first evidences of poisoning are a very dark greenish
or a blackish coloration of the urine, headache, giddi-
ness, fringing or singing in the ears, and lassitude.
The odor of carbolic acid is, to a certain extent, a pro-
tective against accident; yet fatalities occasionally
occur. The antidotes of carbolic acid are alcohol, milk,
and lime-water, or flour and water. The strength of
BHemsoliitons mised! varies from 1:50 to 1:20, Lhe
acid is bought usually in the liquid form, having a
strength of 95 per cent. To make a solution I : 20 (5
pemReent.), 140125 per cent.), 12502 per cent.), 1:80
(11 per cent.), 1 ounce of the 95 per cent. solution is
added to 20, 40, 50, or 80 ounces of water. When
obtained in the solid form, it may readily be liquefied
by placing the bottle in a vessel of hot water.

Crude carbolic acid mixed with strong sulphuric

.
'
|
|

52 ANTTSEPALCS:

acid makes a powerful disinfectant where possible to
employ it.

There are other products of coal-tar distillation akin
to, but not so poisonous as, carbolic acid. Among
them are the following :

Creolin.—This is a non-irritant and practically
non-toxic germicide. Though toxic symptoms have
been reported, it certainly is the least poisonous of
the powerful germicides now in use. Its chief disad-
vantage is that when mixed with water it forms an
opaque emulsion ; consequently it is inapplicable for
the sterilization of instruments, since they could not
readily be found init. For cleansing the hands and
for irrigation, creolin is used in strengths of from
2to5 percent. The antiseptic value of creolin would
seem to be discounted, as this reviser recalls several
deaths from tetanus in puerperal women where tap-
water—later proved to contain tetanus germs—was
employed in making up creolin solutions for irriga-
tions. To make a 2 per cent. solution, 24 teaspoon-
fuls of creolin are added to 1 pint of water.

Lysol is a brown, oily-looking, clear liquid, with a
creosote-like odor, obtained from tar-oils. When
added to ordinary hard water it forms a clear, soapy
liquid, as it precipitates the lime-salts in the water,
but is clear if distilled water, alcohol, or glycerin
be mixed with it. Its antiseptic properties under
no circumstances are impaired. On account of its
saponaceous character it cannot be used for instru-
ments, because it renders them slippery. It is much
employed in surgery and gynecology, in solutions of
from 1 to 5 percent. To makeat per cent. solution,
5 drams are added to % gallon of water. Its chief

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 53

advantage over other antiseptics lies in its non-irri-
tant and much less poisonous properties. It can be
used for the disinfection of everything in the sick-
room.

Sozal is an antiseptic obtained in small crystals
which have an odor of coal-tar. It is said to possess
the same advantages as corrosive sublimate without
its toxic properties. The crystals are readily soluble
in water, glycerin, or spirit.

Saprol is a dark-brown oily fluid with an odor of
carbolic acid. When mixed with water it divides
into oil drops, some of which fall to the bottom of
the vessel, while others float on the top of the water,
consequently it cannot be used for surgical purposes.
It is a powerful disinfectant, especially valuable in
disinfecting excreta, and possesses the property of
diffusing evenly through the material to which it is
added.

Other disinfectants outside of the coal-tar products
are :

Lodoform has been largely used as a surgical dressing.
It has no decided antiseptic properties. It does good
by absorbing the liquids of the wound, thereby re-
moving one of the factors for germ growth. When
applied to large moist surfaces it gives off free iodin.
It prevents decomposition and inhibits, but does not
destroy, the germs of putrefaction and pus formation
if they are present before its use. When applied to
raw surfaces it is occasionally absorbed into the sys-
tem, and causes symptoms of poisoning. On account
of this danger salol is often substituted for it, as
is also a mixture of iodoform, I part to 7 parts of
boric acid, it being both antiseptic and unirritating.

54 ANTISEPTICS.

The symptoms of absorption are headache, loss of
appetite, rise of temperature, a rapid, feeble pulse,
restlessness, and insomnia. ‘These symptoms may
pass away if the dressing is removed and discontinued.
In grave cases there is marked anxiety, a bright-
red eruption appears on the face and limbs, and
there is retention of urine, with stupor, delirium,
collapse, and death. Some patients are very sus-
ceptible to the toxic effects of (the ‘dirite- lias
penetrating odor, which many persons find disagree-
able. Spirit of turpentine will at once remove the
objectionable odor from the hands, instruments, and
vessels that have been in contact with thedrug. Iodo-
form darkens upon exposure to a bright light and is
likely to cake when it becomes moist. It is used for
impregnating gauze-dressings, for dusting on ulcers
and wounds, and for injections, dissolved in ether or
olive oil, into sinuses or tuberculous abscesses. It is
also used in the form of ointment.

lodol is a pale yellow crystalline powder, almost
insoluble in water, but readily soluble in ether and
alcohol, less so in glycerin or oils. It is often used
as a substitute for iodoform, having the samme proper-
ties. Like iodoform, it darkens if exposed to a bright
light. It is used in the form of powder, solution, and
ointment, and has the advantage of not being so pot-
sonous as iodoform.

Formaldehyd is a gas formed by the partial oxida-
tion of wood alcohol; it may be produced by burning
wood spirit in an ordinary alcohol lamp. Its use is
greatly facilitated by having it combined with water
in a definite proportion, so that the quantity used may
be certain and positively known. Its solution in

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 55

water is called formol, formal, and formalin, and con-
tains about 40 per cent. of formaldehyd gas. Formal-
dehyd is non-poisonous, colorless, with a pungent,
irritating odor, and possessing great antiseptic, disin-
fectant, and deodorant powers. Its activity as a ger-
micide is considered to be equal, if not superior, to
that of bichlorid of mercury, and it is available in
many cases in which the latter cannot be used. It
does not corrode or tarnish metals, nor injure the finest
flpkics eitwer im texture or color. As a deodorant it
removes immediately the odor of feces, urine, septic,
or gangrenous material. It may be used externally in
the form of solution, spray or vapor, and is sometimes
added to powders. In solution as a wash or irrigation
in wounds, it is employed in strengths varying from
0.5 to 20 per cent. Asa dusting-powder it is used in
combination with gelatin. Sheets of moist gelatin,
after exposure to formalin fumes, are ground to a
coarse powder, used in the dressing of wounds. A
slight disadvantage is that for four or five hours after
its use on a raw surface it produces more or less pain
of a burning nature. In the form of vapor it is used
for sterilizing instruments and surgical dressings, and
for the fumigation of the sick-room and its contents.
The simplified method of fumigating consists of di-
luting one pound of formalin with three times its vol-
ume of hot water, and boiling over a flame for half an
hour. The generated gas is very penetrating, and
_ having the same specific gravity as the air, soon per-
meates the room in which it is confined, and kills all
germs, not protected by moisture, in about three
hours. Special portable forms of apparatus have been
devised for purposes of room-disinfection. Spray dis-

56 ANTISEPTICS.

infection of rooms with a 2 per cent. formalin solution
is also very satisfactory.

For the sterilization of instruments a I : 2000 solu-
tion is used.

fine

FIG. 5.—Formaldehyd generator.

Formaldehyd vapor when inhaled irritates the lungs.
It also irritates the eyes and nostrils, causing them to
smart.

A fatal case of formalin-poisoning is reported, the

ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 57

amount taken being about 3 ounces of a 4 per cent.
solution. Immediately after taking there was pain in
the stomach and vomiting. The vomited matter was
blood-stained and had the pungent odor of formalin.
The patient died of heart-failure thirty-two hours
afterward. ‘he treatment consisted in albumin-water,
free emesis, heart-stimulants, and normal saline solu-
tions given both hypodermically and intravenously.

Aristol (thymol iodid) is a reddish-brown powder
containing about 45 per cent. of iodin. It is used as
a substitute for iodoform. It has not the disagreeable
odor of iodoform, and its use is attended with less
danger of poisoning. It is used in the form of fine
powder or ointment, the strength of the latter varying
from $ to 1 dram to the ounce of pure lard.

eee sa

SISO BIE INIT IR | Wh

ANTISEPTICS (Continued).

Hydrogen dioxtd or peroxtd of hydrogen is a popular
antiseptic. It isan excellent agent for the destruction
of pus-cocci. When poured or injected into a wound,
effervescence takes place, the result of chemic reac-
tion between the wound-secretions and the hydro-
gen peroxid, causing coagulation of albumin and the
setting free of gas. ‘This active frothing serves to
carry off any shreds of tissue in the wound that cannot
easily be reached. It may likewise do harm by bur-
rowing the cellular tissues. The peroxid is also
applied to the throat in diphtheria to destroy and
remove the false membrane. It readily decomposes
by coming in contact with metals; consequently, if
used as a spray, a glass atomizer must be employed.
The hydrogen peroxid in common use is a clear, odor-
fess fluid, having a bitter taste. Ihe omeral¥colie
tion contains 3 per cent. of the pure dioxid, which
corresponds to about ten volumes of available oxygen,
and it is upon its readiness to yield oxygen that its
activity depends. ‘The solution should be kept in a
cool, dark place, and the cork forced tightly into the
bottle; when removing the stopper always point the
bottle away from the face. 3

Boracic acid (boric acid) is a mild antiseptic. It is
non-itritating and practically non-poisonous. It 1s

therefore frequently used to wash out cavities, for in-
58

ANTISEPTICS. 59

jections, and in ophthalmic and aural practice. Itis
used in the form of powder, solution, ointment, and
gauze. In solution, a saturated solution is used (a sat-
urated solution is one in which the water dissolves as
much as it will of the drug; the remainder lying at the
bottom of the vessel as an indication that the solution
is sufficiently strong). It is easily made by placing
one-half pound of boric acid in a half-gallon bottle
filled with boiled water and shaking thoroughly until
saturated. It is impossible to use a solution which
is too strong, because the water cannot take up any
more than I in 30 (about 4 per cent.), which is the
usual strength used. In rare cases it acts as an irri-
tant to the skin and produces an eczematous condi-
tion. 7

Boroglycerid 1s a non-poisonous antiseptic solution
made from boric acid and glycerin, and is used as a
wash, an irrigation, and for saturating tampons.

Thtersch’s solution is an antiseptic of moderate
power, unirritating and non-poisonous; it contains
salieyine acid, 2 parts; boric’ acid, 12 parts; hot
water, 1000 parts.

Alcohol.—Absolute alcohol is an antiseptic and dis-
infectant used for cleansing the skin, for the prepara-
tion of sutures and ligatures, and for the disinfec-
tion of cutting-instruments. ‘To sterilize the hands,
they are scrubbed for five minutes with soap and hot
water, then scrubbed for the samme length of time in
absolute alcohol, and finally rinsed in an antiseptic
solution. ‘Ihe results obtained by the disinfection
and cleansing of the skin with alcohol have been as-
cribed to the solvent action of the alcohol upon the
fatty matters on the skin, thus allowing corrosive

60 ANTISEPTICS.

sublimate and other antiseptics to come into imme-
diate contact with the bacteria. Scerubbime (ie
hands in absolute alcohol for five minutes takes up
both the fatty matters of the skin and also the bac-
teria, which are thus washed away.

Potasstum permanganate, or permanganate of
potassium, is an antiseptic, disinfectant, and deodor-
ant, depending for its action on its oxidizing prop-
erties. It parts with its oxygen Very readilyete
organic substances and becomes inert. Its chief dis-
advantage is that it stains everything a brownish-
black color. It is used in solutions varying from
I:100 to 1:10. When employed for sterilizing the
hands, it is followed by oxalic acid solution, which
has the property of removing the stain. It is also
used on wounds, especially those which have an
offensive discharge, as, for example, gangenous
ulcers, on which it acts as a deodorant as well as a
disinfectant. It may also be employed to disinfect
bowel-movements, to flush water-closets, etc. Its
advantages are that it 1s non-poisonous in ordinary
strengths, rapid and complete in its action, and
shows by its change of color from reddish-purple to
a brown whether it is acting or whether it is ex-
hausted. The strength of the solution generally used
is from 20 to 16 grains of the crystal to 1 pint of
water.

Oxalc acid is a powerful germicide, though it is
not used alone, but to remove the stains of potassium
permanganate from the skin. It is very poisonous
and quite irritating, but the irritation can in a meas-
ure be avoided by immersing the hands and forearms
afterward in either plain water or lime-water. A

ANTISEPTICS. 61

Semes) Ol experiments by Dr. Howard A. Kelly, to
determine the relative part played by these two
chemicals in the process of disinfection, led to the
conclusion that both the permanganate of potassium
and oxalic acid were germicides, but that the oxalic
acid at a temperature of about 40° C. (104° F.)isa
much more powerful germicide than the permangan-
ate of potassium. Oxalic acid also removes perman-
ganate stains from white goods, and ammonia will
remove the stains from black goods.

Potassium permanganate is frequently used in a
solution called Condy’s fluzd, which consists of a
strong solution of the impure drug, and may be em-
ployed to disinfect and deodorize urinals and closets,
but cannot be employed to disinfect rooms. It must
be mixed with the discharges it is intended to neu-
tralize.

Pyoktanin (methyl-violet, methyl-blue, blue pyok-
tanin), an aniline derivative, is a disinfectant and
antiseptic. It occurs in two colors, blue and yellow,
the yellow variety being used in ophthalmic practice
only. Its great disadvantage is that it stains every-
thing with which it comes in contact. The stains,
however, may be removed with alcohol or Labar-
raque’s solution. It is used in the form of powder,
ointment, and in solutions of the strength of 1: 500
and 1: 1000.

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
1:10, and for cleansing purposes.

Chlorinated lime, or chlorid of lime, is one of the
best disinfectants for drains, infected clothes, bowel-

62 ANTISEPTICS.

movements, sputum, and urine. It is also a power-
ful deodorizer. It loses its strength if exposed to
the air. Lhe standard solution contains 6) ommecs
to 1 gallon of water.

Milk of lime is made by slaking lime in water.
The freshly made solution is used to disinfect typhoid
stools or urine, but must be thoroughly mixed with the
infected material to be effective. ‘The disadvantage
of this solution is its liability to clog the drain-pipes.

Sulphuric and hydrochloric acids are employed in 4
per cent. solutions for the disinfection of excretions,
equal parts of the solution and the substance to be dis-
infected being used.

Zinc chlorid has some value in solution as a de-
odorizet.

Ichthyol, derived from fish scales, is a dark brown
thick liquid, with a highly disagreeable odor ; it is
used extensively as an antiseptic, astringent, sedative,
and alterative in many skin diseases, various inflam-
matory affections, wounds, and abscess-cavities. It is
employed externally in the form of a thick liquid and
ointment. Before the application of ichthyol the
affected parts are washed with warm water and soap,
and gently dried. After painting, or after inunction,
the parts are covered with absorbent cotton or flannel
and gutta-percha tissue. The applications are best
employed morning and evening. Many patients object
strongly to its use on account of the disagreeable odor.
This may be disguised by the addition of oils of citron-
ella and eucalyptus, 1 part of each to 50 parts of ich-
thyol—or ichthyol (9 parts) may be combined with oil
of turpentine (1 part). Ichthyol is said to have a re-
markably efficacious action upon recent burns in re-

ANTISEPTICS. 63

lieving the pain and facilitating healing. It is also
used in combination with the compound stearate of
zinc. ‘The stains of ichthyol may be removed by
boiling the stained articles in soap and water, or by
washing them with potash-soap or soap-spirit.

Balsam of Peru is used as an external application
to wounds, 10 to 20 per cent. in castor oil, it having
both an antiseptic and a stimulant action. Glycerin
is sometimes used as a menstruum for ichthyol and
balsam of Peru because of its dehydrating effect
upon the granulation-tissues of a wound, whereby
they are held more in check and do not form so
rapidly.

Orthoform is an antiseptic and a local anesthetic
having a decided action when applied to raw sur-
faces or exposed nerve-endings. It owes its anti-
septic action to benzoic acid. It is a white, crystal-
line powder, without odor or taste, entirely non-poi-
sonous, is slowly absorbed, and is used in the form
of powder or ointment. In rare cases it causes severe
inflammation and even sloughing of the skin.

Orthoform hydrochlorid is a combination of ortho-
form and hydrochloric acid, and is also an anes-
thetic. :

Mustard, vinegar, and normal salt solution are also
antiseptic.

Sterilized vinegar is said to be equal in antiseptic
power to a 1: 2000 solution of corrosive sublimate.
It is less irritating to the tissues than bichlorid, and
is said to stimulate the healing process in open
wounds instead of retarding it, as mercury some-
times does. It is sometimes used during an oper-
ation for irrigation, especially if there is much capil-

64 ANTISEPTICS.

lary hemorrhage, which, on account of its astringent
action, it controls. It is also used for the disinfec-
tion of the hands, surgical operating-rooms and wards,
and to remove blood-stains from the hands.

Mustard is used for the disinfection of the hands
and arms of the surgeon and his assistants, and of
the field of operation. After scrubbing the hands and
arms with a stiff brush and green soap, the water
used being as hot as can be borne, one teaspoonful of
mustard is rubbed in very thoroughly for about three
minutes, after which it is washed off with hot steril-
ized water. ‘The field of operation is prepared in the
same way.

Resorcin 1s an antiseptic and deodorant, used in
the form of solution, powder, or ointment in strengths
varying from 2 to 20 per cent. As a powder it is
usually mixed with boric acid, 1 : 20 or 1 310) willbe
not absorbed by the unbroken skin and produces very
little irritation on the cutaneous tissues.

Dermatol, also called bismuth subgallate, is used
as a substitute for iodoform in the dressing of wounds.
It is an antiseptic, sedative, and astringent.

Protargol is an albuminous compound of silver,
containing about 8 per cent. of the metal. It is solu-
ble in water to the strength of about 50 per cent.,
and forms a clear light-brown fluid.

Listeriné 1S a proprietary antiseptic solution used
extensively on wounds, for cleansing the mouth,
throat, and nose. 7

Bicarbonate of sodium has been used with marked
success as an antiseptic in the treatment of foul sup-
purating wounds and ulcers in a strength of 2 per
cent. A I-per-cent. solution has long been used in

ANTISEPTICS. 65

which to boil surgical instruments. It is customary
ordinarily to simply add sufficient soda to impart a
greasy feeling to the fingers. The soda adds to the
disinfectant power of the boiling water.

Soaps have some action as weak disinfectants.

There are numerous other antiseptics of proprietary
nature, but it is hardly necessary to refer to them.
Chemists are constantly adding new preparations to
the long list already in use.

~

9)

PART UE
SURGICAL TECHNIC.

CHET ER ava
BANDAGING AND DRESSINGS.

BELIEVING that nurses will be far more likely to
practise and to understand the application of the
various bandages if the directions are set down in a
terse manner than when wordy descriptions are em-
ployed, the following section upon bandaging is in-
tended to be read off while the nurse is actually
engaged in applying the bandage described. With
the bandage of proper size in hand she is to begin its
active application while another directs her move-
ments by reading from the text (a glance at the illus-
tration before beginning will aid in securing a well-
proportioned dressing). It is to be recalled when
applying the complex bandages that but one edge is
to show, the rest being covered up by subsequent
turns. Fears that the bandage is not being correctly
and neatly applied, because of wrinkles appearing,
may be discarded if the upper or lower edge (as the
case may be) is applied sufficiently taut. It may be
added, too, that frequent turns, each applied moder-
ately firm, will secure the patient’s comfort better
than a few turns tightly set.

Secure the initial end of a bandage when apply-

66

BANDAGING AND DRESSINGS. 67

ing by making three circular (overlapping) turns
about the limb or part which 1s to be covered. Fasten
the extremity by means of another bandage, safety
pins, by tearing up the end in two, reversing and
tying about the part, narrow adhesive strap, or by
stitching at the crossing points of the bandage.

Head.—For head bandaging use a roller 2 inches
wide, 6 yards long.

Circular Turns.—This bandage may be used to
cover the forehead, temporal regions, or the sides and
base of the scalp.

NY y

Fic. 6.—Figure-of-eight of one eye. FIG. 7. Figure-of-eight of both eyes.

Circular with Oblique Turns (Figs. 6, 7).—Begin
this bandage by laying the initial end beyond the site
of the injury or upon the opposite side of the head.
May be used to cover one or both eyes ; scalp.

Circular with Recurrent. — Begin with circular
turns, then apply the recurrent or refolding turns
back and forth over the top of the head. Another
hand is needed to hold the bandage until the final
circular fixing turnsare made. Is used to cover whole
of scalp (Fig. 8).

Circular of the Forehead.—This bandage is used to
cover the occiput, neck, or base of the skull.

68 SORGIGAL, LECHNIC

Circular of the Occiput and Forehead (Fig. 9).—
This bandage is applied by making a reverse over the
temporal region from the crown to the under jaw
after passing the first turns. It covers the lower jaw
and the parotid region.

Fic. 8.—Recurrent bandage of FIG. 9.—Crossed bandage of the
the head. angle of the jaw.

Circular.—From the occiput to the forehead, re-
versed over the temporal region; then circular and
oblique turns from the crown to the under jaw. It
covers the cheek and side of the face.

FIG. 1o.—Barton’s bandage, or figure- FIG, 11.—Gibson’s bandage.
of-eight, of the jaw.

Barton’s (Fig. 10).—This is used for fracture and
dislocation of the jaw. It is made with figure-of-
eight turns, beginning just behind the mastoid proc-

BANDAGING AND DRESSINGS. 69

ess with alternating circular turns from the occiput
to the chin.

Modified Barton’s is used to obtain greater security.
Add circular turns from the occiput to the forehead.

Gibson’ s (Fig. 11) is used for fracture or dislocation
Omer lower jaw. Lhree circular turns are made
from the crown (vertex) to the lower jaw; reverse
and make three circular turns over the temporal re-
gion, from the occiput to the forehead, then three
circular turns from the occiput to the chin; reverse
and make a last turn from the occiput to the forehead.

FIG. 12.—Four-tailed bandage for FIG. 13.—Griffith’s head bandage.
the jaw.

Handkerchief or Four-tailed Bandage (Fig. 12).—
This is used for fracture or dislocation of the lower
jaw, to retain dressings.

Griffith's Head Bandage (Fig. 13).—A simple re-
taining bandage for dressings about the angles of the
jaw and adjacent neck region may be made from a
yard length of a three- or four-inch roller. The
bandage is applied by laying it against the dressing

JO SURGICAL TECHNIC.

in place. The ends are then drawn up upon each
side of the patient’s head. A two-tailed end is made
from each by tearing down the middle until the level
of the lobe of the ear is reached. ‘The four tails are
then to be drawn taut, crossed, and tied over the vertex.

Neck.—For this bandage use a roller 2 inches
wide, 5 yards long.

Circular.— Circular with oblique turns. Circular
with jigure-of-erght turns about the arzla (Fig. 14).

FIG. 14.—Figure-of-eight bandage of neck and axilla. —

They are used to retain dressings to the neck or
axilla.

Chest.—Roller 3 inches wide, 10 yards long.

Spiral Bandage of the Chest.—This bandage is
used to secure dressings to the chest, temporary dress-
ing for fracture of the ribs. It is made by applying
circular turns with oblique (spiral) turns until the
chest is covered ; a final turn is made for support over
the shoulder and down the front of the chest.

Anterior Figure-of-eight Turns.—This is used to
cover the front and upper parts of thorax; igs
formed by circular turns from the axilla across the
chest (to fix the bandage); figure-of-eight turns from
behind the shoulder up and over, crossing anteriorly
to the other side of the body.

a

BANDAGING AND DRESSINGS. Wes

Postertor Figure-of-erght Turns.—Used for fracture
of the clavicle or dislocation. To hold dressings to
back of the chest. Oblique turns from one shoulder,
across the back to the opposite axilla, thence anterior
up and over the shoulder with figure-of-eight turns to
the other side of the body.

Bandage for Support and Compression of the Breast
(Fig. 15).—Circular turns (oblique) from the scapula
of the sound side, across the back, to axilla, beneath
the breast, over the shoulder to point of starting.
Alternate with circular turns about the thorax. By
repeating the turns for the other side both breasts may
be supported.

Fic. 15.—Figure-of-eight bandage of Fic. 16.—Gauntlet bandage.
the breast.

Upper Extremity.—For these bandages use a
roller 24 inches wide, 7 yards long.

Roller 2 inches wide, 6 yards long, for hands,
wrist, and elbow.

Fingers.—Roller 1 inch wide, 3 yards long for
fingers.

Circular with Oblique (Spiral) Turns.—Used to
retain dressings or splints. For additional support
apply one or two circular turns to the wrist.

Gauntlet Bandage of the Hand (Fig. 16).—It is

[2 SORGICAL TH OHINIG.

used to cover back of hand and all of the fingers. It
is made by circular turns to the wrist (fixes), oblique
turn across the back of the hand to the little finger ;
cover in by circular, oblique (spiral), and recurrent
(refolding) turns ; when necessary to cover up the ends
of the fingers, return to the wrist by an oblique and
circular turn ; cover remaining fingers and the thumb.
Complete by a circular turn to the wrist. 7
Back of Hand (Demt-gauntlet) (Fig. 17).—Used to
secure dressings to either the back or palmar (by re-
versing) surfaces of the hand. Fix by circular turns
about the wrist. Continue with an oblique turn

FIG. 17.—Demi-gauntlet bandage. FIG. 18.—Spica of the thumb.

across the back of the hand to the base of the little
finger, circle the finger, return to the wrist. Com-
plete by similar turns to the remaining fingers and
thumb with a final circular turn of the wrist. |
Speca of Thum (Fig. 18).—Used to retain dressings
or splints to this part. Circular turns of the wrist to
fix. Continue by an oblique turn to the uprotthe
thumb, circular with an oblique turn to the wrist.
Continue by repeating until the thumb is entirely
covered. Complete by a circular turn aroumd@ihne
wrist. Cover the end of the thumb by recurrent (re-
folding) turns when necessary. | 3

BANDAGING AND DRESSINGS. eae aw hs

;

Spiral Reversed of the Upper Extremity (Fig. 19).
—Used to cover the arm, forearm, and hand. Fix
by circular turns at the wrist. Cover the hand by
circular and oblique turns (spiral or spiral reversed) ;
with figure-of-eight turns about the base of the thumb
and the wrist. Cover the arm by ascending circular
with oblique (spiral reversed and spiral) turns to the
elbow which is covered in by figure-of-eight turns.
Complete by circular (oblique, spiral, and spiral re-
versed) turns to the axilla.

FIG. 19.—Spiral reversed bandage of FIG. 20.—Figure-of-eight bandage
the upper extremity. of the elbow.

fFigure-of-erght of Elbow (Fig. 20).—Used for dress-
ings about the elbow. Allows motion without de-
tangement of the dressing. Fix by circular turns
just below the elbow. Continue by an oblique turn
across the front of the joint to the upper arm. Coim-
plete by circular turn with a return across the joint
to the starting-point. Continue, overlaying two-
thirds of the previous turn laid down, until the parts
are entirely covered.

Steca of the Shoulder (Descending ).—Used to retain
splints and dressings about the shoulder. Circular
turns about the arm at the level of the axilla (to fix) ;
oblique turn across the shoulder, base of the neck,
about the opposite axilla to the back. Complete the
turn by crossing the first turn at the base of the neck.

en oe ae

74 SURGICAL TECHNIC.

Continue until the parts are covered (each turn over-
lapping two-thirds of the previous one).

Spica of the Shoulder (Ascending) (Fig. 21).—This
bandage is made by circular turns around the arm at
the level of the axilla (to fix). Continue by an oblique
turn across the chest to the opposite axilla, return
across the back to starting-point. Continue by re-
peating these turns (ascending by overlapping pre-
ceding turns two-thirds).

Fic. 21.—Ascending spica of the shoulder. FIG. 22.—Velpeau’s bandage,

Velpeau Bandage (Fig. 22).—This is used for fract-
ure of the clavicle and scapula and for dislocation of
the humerus. Place the fingers of the affected side
upon the sound shoulder (prevent the skin surfaces
coming in contact by means of gauze, towel, dusting-
powder). Commence the application of the bandage
from the scapula of sound side, continue with a turn
over the shoulder of the affected side, anteriorly down
the arm, behind the elbow; across the front of the
ehest to the sound axilla; thence to the {pomeron
starting. Repeat (to fix) After the second turn
carry the bandage transversely around the chest, over
the flexed arm, near the elbow. Continue by alter-
nating circular turns (ascendiyg spirally) with turns
similar to the fixation turns.

BANDAGING AND DRESSINGS. 75

Desault Bandage.—Used in fracture of the clavicle.

First roller (Fig. 23): Elevate slightly the arm of
the affected side; place a pad in the axilla, secured
by circular turns (spiral) with figure-of-eight about
the opposite shoulder (to fix). Complete by covering
in the chest with circular oblique turns.

eT
(/ \ 2
FIG. 23.—Desault’s bandage, FIG. 24.—Desault’s bandage,
first roller. second roller.

Second roller (Fig. 24): Lower the arm of the
affected side; flex the forearm (to a right angle) across
the front of the chest. Bind the arm to the chest by
circular turns (spiral) from the shoulder to the elbow.

FIG. 25.—Desault’s bandage, third roller.

Third roller (Fig. 25): Forms two triangles if cor-
rectly applied (an anterior and a posterior). Oblique

76 SURGICAL TECHNIC.

turns beginning in the axilla of the sound side, thence
across the chest to the shoulder, around the shoulder
to beneath the elbow. Return to starting-point. Re-
peat, alternating in front and behind. Complete the
dressing by applying a sling.

Abdomen.—For abdominal bandages use a roller
4 inches wide, 9 yards long.

Circular with Spiral Turns.—Binder ; many-tailed
binder (9 to 18 inches wide, 1 to 2 yards long). Used
to secure dressings, and for support of the parts.

Lower Extremity.—Use a roller 3 inches wide, 9
yards long.

Spica of the Groin (Ascending).—Used to secure
dressings to the groin, upper portion of the thigh.
Circular turns around the.thigh (to fix). Continue
by oblique circular turn just below the crest of the
ileum of the sound side. Return to the starting-
point. Repeat, ascending and covering two-thirds of
the previous turn.

Sprca of the Groin (Descending).—Made by circular
turns about the thigh, high up (to fix). Continue by
a circular oblique turn to the crest of the opposite
ileum. Complete by returning to the affected side,
crossing the first turn in the middle of the thigh.
Repeat by circular oblique turns, descending by over-
lapping two-thirds of the previous turn.

Figure-of-eight Bandage of the Groin (Fig. 26).—
An emergency or provisional bandage may be quickly
applied to the groin by passing the end of a three-
inch roller bandage about the body above the hips.
Cross the ends over the center of the groin and re-
verse them, one passing above the thigh, the other
behind to be tied upon the outer aspect of the limb.

BANDAGING AND DRESSINGS. Teh

Double Spica of the Groins (Fig. 27).—Made by
circular turns about the abdomen above the crests of
the iliac bones. Continue by an oblique circular turn
to and around the left thigh, across to the back of the
abdomen, anterior with an oblique turn to the inner

Vdd dddddddddqQqGdaggés7,

\

FIG. 26.—The Pryor inguinal bandage. FIG. 27.—Double spica of the groins.

side of the right thigh, circular turn ; mount obliquely
to the opposite side of the abdomen. Repeat until
both groins are covered, overlapping two-thirds of
previous turn at the crossing line in the middle of
the thighs.

Knee.—Roller 24 inches wide, 5 yards long.

figure-of-eight Bandage of the Knee.—Used for re-
taining dressings about the knee. Circular turns (3)
about the leg below the knee (to fix). Continue by
an anterior oblique turn across the front of the knee,
mounting to the thigh ; circular turn about the thigh ;
return by recrossing the knee, descending with an ob-
lique turn. Repeat, overlapping previous turns two-

78 SURGICAL LE CHIC.

thirds at the midline. Complete by covering in the
parts entirely, finishing with circular turns.

Figure-of-erght Bandage of Both Knees.—Used as
a temporary dressing for fracture or dislocation of the
thighs.

Circular turns about the legs at the level of the tops
of the calves (to fix). Continue by rising obliquely
across the front of the knees to the thighs; finish
with a circular turn; return to the starting-point by
a descending oblique turn across the front of the
knees. Repeat, covering in two-thirds of the pre-
vious turns until the parts are entirely covered. Com-
plete by right-angled turns about the bandage, by
passing between the legs and thighs.

Foot.—Use a roller 24 inches wide, 6 yards long.

Spica of the Foot (Fig. 28).—This bandage is used
for sprains, and as a dressing to the foot. Circular

FIG. 28.—Spica of the FIG. 29.—Method of FIG.30.—Figure-of-eight
instep. covering the heel. bandage of the instep.

turns (3) about the ankle (to fix) ; descend by an ob-
lique turn across the back of the foot to the base of
the toes, circular turn; cover the foot by ascending,
oblique, spiral reversed turns until the instep is
reached. Continue by oblique turns, covering in the

BANDAGING AND DRESSINGS. 79

heel. Complete by ascending, oblique, circular turns
above the ankle.

To Cover the Feel (American Method) (Fig. 29).—
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-
eight turns about the sides of the heel. Complete by
circular turns, ascending the ankle.

Bandage of the Foot Not Covering the Heel (French)
(Fig. 30).—Circular turns (3) at the ankle (to fix).
Oblique 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 (ascending). Complete by circular turns about
the ankle and lower leg.

Complete Bandage of the Lower Extremity (Fig.
31).—This bandage is used for applying compression
to the leg to retain dressings. Circular turns (3) at
the ankle (to fix) ; oblique turn, descending across the
dorsum of the foot, with a circular turn at the base
of the toes. Continue 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-eight turns at the knee. Complete by as-
cending spiral or reversed spiral of the thigh.

Figure-of-eight of the Leg.—This bandage is usea
to secure compression; it is not easily disarranged.
Circular turns (3) about the ankle (to fix). It is made
by oblique turn across the dorsum of the foot; circu-
lar turn at the base of the toes. Continue by cover-

80 SURGICAL TECHNIC,

“ing in the foot. Ascend the foot to the ankle with
oblique, spiral reversed turns. Ascend the leg to the
top of the calf by an oblique turn across the front of
the shin. Continue with a circular turn just below
the knee; return to the ankle, crossing the previous
turn on the line of the shin.. Complete by repeating
the oblique turns, covering two-thirds of the previous
turn as you mount the leg. Finish with a circular
turn just below the knee.

FIG. 31.—Spiral reversed bandage FIG. 32.—Recurrent bandage
of the lower extremity. for a stump.

Recurrent Bandage for a Stump (Fig. 32).—Roller
24 inches wide, 6 yards long. Circular turns near
the lower end of the stump (to fix). Ascend with
oblique circular turns. Continue by recurrent (refold-
ing) turns, covering the end of the stump. Complete
by ascending oblique, spiral, or spiral reversed turns,
overlapping two-thirds of the previous turn.

Spiral Reversed Bandage of the Pents.—Roller 1
inch wide, 1 yard long. Circular turns at the peno-
scrotal junction (to fix). Continue by an oblique turn
to the glans; circular turns. Ascend the body of the

BANDAGING AND DRESSINGS. SI

penis by oblique, circular, or reversed spiral turns.
Complete by circular and figure-of-eight turns about
the base of the penis and scrotum.

Bandage for Securing the Lithotomy Fosition.—
Roller 23 inches wide, 4 yards long. Bring the
patient’s hand down to the side of his foot. Circular
turns (3) around the wrist and ankle (to fix). Con-
tinue by alternating circular turns about the wrist
and ankle. Repeat with the hand and foot of the
opposite side. A rolled sheet twisted from opposite

FIG. 33.—Perineal binder.

corners, passing under one shoulder, over the other,
and beneath the patient’s knees, drawn up to his
chest and tied, will answer the same purpose.

Perineal Binder for Retaining Dressings to Pert-
neum (Figs. 33, 34).—Roller 8 inches wide, 4 feet
long.

Liebretch’s Eye Bandage (Fig. 35).—Strip of flan-
nel, white or black, 24 inches wide, 8 to 10 inches

long, fitted with tapes at the extremities. Apply to
6

82 SURGICAL TECHNIC.

one eye obliquely, reverse the tapes by crossing at the
occiput, circular turn, and tying. Apply to both
eyes transversely with circular turn of the tapes and
Ce;

FIG. 34.—Perineal binder in position. FIG. 35.—Modified Liebreich’s
eye bandage.

In addition to the well-known roller-bandage, spe-
cial bandages find frequent employment, particularly
after abdominal operations. ‘The most important are
the Scultetus and the T-bandages.

The Scu/tetus, or many-tailed, bandage is used for
surrounding the abdomen. It is made of two pieces
of flannel or of cotton, each 1 yard long and 4 inches
wide, the two pieces being placed 4 inches apart ; across
them are sewed five other pieces of the same length and
width, each piece being overlapped by the one above
it by one-half its breadth. This bandage is placed
under the patient’s back, the cross-strips are folded
over the abdomen from below upward, and the lower
ends of the vertical strips are brought up between

BANDAGING AND DRESSINGS. 83

the thighs and pinned to the front of the bandage.
This keeps the bandage from wrinkling and retains it
in position. Greater security will be obtained in
male patients if the tail be torn half way down its
middle, the two strips being then brought up over
each groin space. A simple form of this bandage
may be made from a width of flannel 1 yard long.
Placed smoothly beneath the patient’s back, its ends
are torn nearly through in strips or tails, each 6 or 8
inches wide. It is applied by overlapping and alter-
nating the tails, which are to be then snugly fastened
with safety pins or adhesive straps.

FIG. 36.—The Scultetus bandage. FIG. 37.._I -bandage.

T-bandage.—The T-bandage, which is used to se-
cute dressings on the anus or the perineum, is made
up of two strips of bandage, each about 5 inches
wide. ‘To the middle of one strip, which is to go
around the waist, the end of the other strip is sewed,
which forms a letter T. This latter strip is brought
forward between the thighs and pinned to the front,
thus securing the perineal dressing.

Splints, padded with cotton-batting, oakum, wool,

84 SURGICAL TECHNIC.

or hair, may be constructed from white pine, poplar,
or willow wood, +4 to $ inch (3-12 mm.) in thickness,
cut to measured length and width; they may be of
pasteboard or binder’s board, molded to shape by
soaking in boiling water, or of raw-hide similarly
worked ; of felt; plaster of Paris; starch (dissolved in
cold water, after which boiling water is added until the
proper consistence is secured) requires from twelve to
forty-eight hours to dry thoroughly (Fig. 38); gum
and chalk (equal parts of gum arabic and precipitated

FIG. 38.—Splint made from plaster-of-Paris bandage. Complete by mold-
ing to the part; trim after setting has taken place.

chalk, add sufficient boiling water, stirring to obtain
a proper consistence of solution), applied upon band-
ages; hatter’s felt or binder’s 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 adhe-
sive 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 em-

BANDAGING AND DRESSINGS. 85

ployed in emergency or to reinforce the ordinary
board or bracket splint. Fvracture-box consists of a
stout board 6 to 8 inches (15-20 cm.) wide by 18 to 30
inches (45-75 cm.) 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 treating 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 pre-
vent 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
cleansing of the parts before applying the first per-
manent dressing and by ‘‘alcohol rubs’’ at each sub-
sequent dressing. 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.

CHeAGE dL Ray ui

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 gyneco-
logic, and one for septic operations.

1 —= =
SSS

TTT tie SS>> eal
HO Ii on 5
= DT
mn =

FIG. 39.—Kny-Scheerer instrument cabinet, having adjustable shelves
and a plate-glass partition in the center, which practically, divides it into two
closets.

The operating-room for septic cases should be far
removed from the others, and neither surgeon nor

nurse attending this room should have anything to
86

STERILIZATION. 87

do with the others. Rooms should also be set apart
exclusively for dressing the cases, thus extending the
benefit of an isolation of operating-rooms and adding
greatly to the convenience of hospital work.

Fic. 40.—Griffith’s hook for use in glass-shelved instrument cases.

These ‘dressing-rooms are otherwise very desirable,
for besides having everything at hand with which to
do a dressing properly, the nurse in charge of the

FIG. 41.—Wheeled stretcher.

patient has the opportunity to turn and make up the
bed afresh during the patient’s absence. Stretchers
are used to convey patients to and from the operating-
and dressing-rooms. The wheels generally have

88 SURGICAL TECHNIC

rubber-tires, the top-board is detachable and has four
handles, two at each end. At least four stretchers
are necessary in a large hospital.

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 -

FIG. 42.—House-stretcher.

should be damp-swept and wiped every day ; in short,
it should be in such a condition as to be ready for an
operation at afew moments’ notice. The supplies for
dressings should not be allowed to run down, and the
instruments should always be in a first-class condition.
An emergency bundle, containing everything neces-
sary for an emergency operation, should be kept in
readiness.

STERILIZATION. 89

FIG. 43—Improved model sterilizer.

Sterilization.—Sterilization may be either dry or
moist ; moist heat is preferable, because it is more
thorough and inore penetrating than dry heat. For

90 SURGICAL TECHNIC.

dry sterilization the towels and dressings are placed
in covered tin pans in an oven the temperature in
which ranges from 160° to 212° F. For moist or

FIG. 44.—Sterilizing tube for edged instruments.

steam sterilization, a Kellogg, a Sprague, or an Arnold

steam sterilizer is used. ‘The heat must be continued

for fully one hour before the operation. |
Regarding the sterilization of instruments surgeons

Fic. 45.—Arnold sterilizer. Fic. 46.—Formalin lamp.

differ; some prefer to have their instruments wrapped
in a towel and put into the Schimmelbusch or Arnold
sterilizer and allowed to boil for half an hour ina 1
per cent. solution of carbonate of sodium to prevent

RVEATEN I:

Sterilizing Room, Medico-Chirurgical Hospital, Philadelphia.

STERILIZATION. gi

their rusting. The water must boil before the instru-
ments are placedin it. All edged instruments to be
boiled in the soda solution should be wrapped in cot-
ton and packed so firmly that they will not be tossed
against one another by the solution as it becomes
agitated in boiling. This agitation seems to be the
reason why they lose their edge. Many operators
prefer to have their edged instruments and needles
placed in a dish containing 95 per cent. carbolic acid
for half an hour; then just before the operation they
are taken out and rinsed with sterilized water.

FIG. 47.—Sterilizer for instruments and dressings,

After sterilization the instruments are transferred
to the instrument-table, or to shallow porcelain or
glass trays, in which they lie covered with sterilized
towels until required.

Instruments and dressings are now sterilized with
formaldehyd with excellent results, one great advan-
tage being that neither the solution of formalin nor
the gas injures the instruments in any way or dulls

Q2 SORGIGAL TH CHNWIC,

the edge of knives, scissors, or needles. A Schering
lamp is usually used either with a 4o-per-cent. solu-
tion of formaldehyd or with formalin pastils. The
best results seemed to be obtained with the pastils.
One pastil is constantly being evaporated in the upper
cup of the lamp; but when rapid evaporation is re-
quired the upper cup is removed and the pastils are
placed in the lower part.

Fic. 48.—Latest form of complete sterilizing outfit for dressings, water, in-
struments, sheets, towels and operating gowns, basins, and trays.

After the operation the instruments should be
taken apart, washed in cold water to remove all
blood, pus, and tissue-particles, and then thoroughly
scrubbed with green soap. Instruments with perma-
nent joints, which fortunately are seldom seen now,
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

Ep a Gen a) POO

Pe REY fetes Paster ya Be nN

| a
eA

BEARE 2:

Sterilizing Room, Medico-Chirurgical

Hospital, Philadelphia.

Si RILIZA TON: 93

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 remembered in
cleaning instruments after an operation are:

First, all instruments that can be so dealt with
must be taken apart and the rough catches thoroughly
cleansed. .

Second, they must be dried carefully in order to
prevent rusting; for instruments once rusted seem
always to have a tendency to return to that condi-
tion.

Instrument-trays are made of glass, porcelain, agate-
ware, or hard rubber; and are rendered aseptic by
being first scrubbed with green soap and warm water,
after which they are filled to the brim with 1: 500 cor-
rosive sublimate, which is allowed to remain in them
for half an hour. When needed they are rinsed with
salt solution or sterile water. Many surgeons prefer
the trays filled with enough sterile water to cover the
instruments, while others again prefer the instru-

FIG. 49.—Glass instrument tray.

ments to be laid dry on the glass table, which has
been previously covered with a sterilized sheet or
towels.

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 to-

94 SORGICAL TECHNIC.

gether after school-hours and ‘‘make believe’’ an
operation is to take place. Each nurse has her duty
assigned to her, and each tries to fulfil it in a thor-
oughly professional, dignified, and quiet manner.
Practice of this kind is never lost.

FIG. 50.—Glass hand bowl. FIG. 51.—Pus basin.

In the operating-room should be kept two large
ledgers, in one of which the house-surgeons, after
making the morning rounds with the visiting sur-
geons, should record the number of operations to be
performed the next day, the time, name of operator,
etc. The operating-room nurse is thus made ac-
quainted, by consulting the book, of the amount of
work before her for the next day, and the character
of the operations for which she has to prepare.

FIG. 52.—Robb’s aseptic ligature-tray ; white porcelain.

On the morning of the operations she makes out a
list of the floor and number of private room or letter
of ward and number of bed, from which the patients
are to be brought to the operating-room, and the order

SHERILIZA TION. 95

in which the operator wishes them. This list is given
to the male attendant, who brings up the patients in
succession, in such a way that while one patient is
being operated on the next is being anesthetized. The
head nurse in the operating-room has two or three
sets of instruments, and during one operation an as-
sistant nurse is sterilizing the instruments and making
preparations for the next operation. ‘There is then
no waiting on the part of the operator, for as the
patient operated on is wheeled out of the operating-
room the next patient is wheeled in. The following
chart will give an idea as to the way the book is made
out and the order in which the operations are writ-
ten. The emergency-operations, accidents, etc., are
also recorded, but after the performance of the ope-
ration.

Date. Operation. Floor.1 | Time. Operator. |Room| Ward. 3 Floor.

Mar. 11.) Laparotomy. 4th. | 8. Am.| Dr. Murphy. | 19 3d.
ce ee 6e 8.30 ce ce ce 21 ce
«« | Vaginal hysterec- ae 9:00)-¢) |) <> Johnson: ||) 24 <

tomy.

«* | Cholecystostomy. oa 9.30 <* | “* Henger: 16 <e
«« | Appendicectomy. Sc | KOLOons ican Mlorgzane 133) Il hi)
«Ss s See | LOCA Tea acre eK Gi ge D 6
« |Amputation, breast Cs |resreeyoy |) OF Gurauare D 9
oa a Ss se 2. P.M.| ‘© Andrews.| 24 4th.
«* | Appendicectomy. aS 3.00) °° |) “Benger: 21 2d.
«« | Cesarean section. sf 4.00 ** | ‘© Eyster. 21 4th.
«« | Appendicectomy. Bae 6.30 “| ** Comegys.| 29 ed.

The second book gives the date on which the
patient was prepared for operation, by whom pre-
pared, etc., as, for example—

1 Clean operating-room, fourth floor; septic, third floor.

96 SURGICAL TECHNIC.

-

- Date of Antiseptic
Preparation. Prepared by eh Operator. Floor. Room.
March to. E. A. 'S. Corros. sub, | Dr. Eyster. Fourth. No. 21.

Date of Sutures Length of Stitches ae
Operation. LOE used. time prepared.| removed. Condition.
March 11. 4P.M. Silkworm- Two hours’ | March a9. 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.

Died or
ischarged.

Room or

WErEL. Diagnosis. | Operated. Operator. Dressed. D Remarks.

No. 29,| Appendicitis. | March 11. | Dr, Come- | March 17.| Discharged
2d floor. gys. April 2.

(Cis AICI IN Wie

INSTRUMENTS NECESSARY IN DIFFERENT OPE-
RATIONS, KEEPING OF CHARTS, SURGEON’S
KIT, ETC.

InN many hospitals, small ones especially, where
there are no medical students or house doctor, the
nurse has more responsibility than in larger institu-
tions, and becomes closely familiar with such details
as taking the history of the patient; the arranging
and sterilization of instruments; assisting the oper-
ator, giving the anesthetic, and writing out the re-
port 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 con-
dition 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 consumption.
7 97

98 SURGICAL TECHNIC.

Personal History.

When born. Where lived. Peculiarities of cli-
mate. Occupations. Habits (as to eating,
drinking, sleeping, etc.). Appetite. Condi-
tion of bowels. Nervousness. Culture.

(When Female.)
Sexual History.
I. Menstruation.
(a) First at what age.
(6) Regularity. No. days.
(c) Duration. No. days.

(2) Amount.
Color.
(e) Character of discharge Consist-
ency.
Odor.

(/) Intermenstrual discharge.
(2) Dysmenorrhea—when.

Il. Pregnancies oe

Sickness or peculiarities.
Number.
Ill. Mescarriages | Sickness.
Fever.
IV. Ladors.
(a) Number.
Easy.
Difficult.

Spontaneous.
Instrumental.

(c) Peculiarities.

(2) Sickness post partum, if any.

(2) Character |

Previous Illness.
Starting with childhood, give different sicknesses

s. \ ,
se ee a es ee eee =

SURGEON’S KIT. 99

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.

Oreo Character. | Chills, pains, locations, se-
Wenltyeietc. ecultaritics:

Progress and changes to present time.
Changes. Appetite. Bowels. Urine, etc.
Examination.

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. Be-
fore the bag is packed the nurse makes out the list of
necessary articles, and as each article is put in it 1s
enecked 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 laying in two large sterilized
towels, the ends of which hang over the edges of the
bag. Together with the instruments, which are
placedin a linen instrument-roll, and the dressings,
the kit should contain three new nail-brushes, soap,
razor, oxalic acid and permanganate of potassium
crystals in bottles, hypodermic syringes with tablets
of strychnin sulphate (gr. 3), atropin sulphate (gr.
iso), and morphin sulphate (gr. 4), cocain hydro-
chlorate (gr. 4), ether and chloroform (with cone and
mask), tablets of corrosive sublimate and sodium
chlorid, iodoform gauze, plain gauze, gauze sponges,
white suits, caps and canvas shoes for the operator

100 SOR GICAL, LE CHING,

and assistants, Kelly pad, rubber gloves, brandy,
alcohol, 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, to prevent breakage. When the kit 1s

| i)
an

Mae uy. W/% Whe 4 Atv
!

Wal YY MW Wee the Wh Mp eA EEE
fn) '
‘

(
li

—— = 5 é Sp ae
masse. {UM = Le

——>

i

Ui @ \ ie Wik I
as ay hee ; unt i iy "
VV TER Ve WAY
ARERR RRR
OAM EE

Fic. 53.—Canton-flannel roll for instruments.

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.

= Hy Y ij
Uf iy Z re Y
RE aN
Wil,

Fic. 54.—Instruments wrapped in canton-flannel roll,

They are made of linen, canton flannel, or toweling,
one 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.

TS Ee ET eT eer

OPERATION BLANK. IOI

OPERATION BLANK.

IS CIUE CE! Ol) 122 taaine) Wav cct deat mnie) ay ast ow, 28
Date. March 10, 1899.

I. PREPARATION OF PATIENT FOR OPERATION.

Me ANESTHETIC. ANESTHETIST.
Temperature.
Before operation.
After operation.
Pulse and Respirations.—To be taken continuously
during operation.
Ill. PREPARATION OF FIELD OF OPERATION.
ME EOSEIO@N OF PATIENT DURING OPRBRATION.
V. PRIMARY MANIPULATIONS.
VI. INCISION AND HISTORY OF OPERATION.
VII. TREATMENT OF WOUND.
VIII. DRAINAGE.
IX. CLOSURE OF WOUND.
X. DRESSING.
XI. RECOVERY FROM ANESTHETIC.

XII. AFTER-TREATMENT.

| ae)

ad a a ae ee ee
Beta ae ee ee ee |

DPS ear bee ale oe
Bie Pee ees. |

ee ee ee

eee eee
@
a

roo Y& A A D
OOO FO eo Oem So sey o
ae aca A xf A A Ff

fi

|

Day of
Disease —

102

Time, pulse, respiration, temperature, food, sleep, bowel movements, urination, and

Fic. 55.—Modern medical chart.

remarks are all set down.

LIST OF INSTRUMENTS. 103

LIST OF INSTRUMENTS NECESSARY IN DIFFERENT
OPERATIONS.

Instruments for General Anesthesta.
Inhalers for gas, ether, chloroform.
Wooden mouth-wedge and gag.

Tongue forceps.

Hypodermic syringe and needle.
Anesthetizing stethoscope.
Throat swabs.

Instruments for Local Anesthesia.
Two glass hypodermic syringes.
Two medicine glasses, one to hold cocain solution,
the other for weak, sterile soda solution.
Extra needles and cleaning wires.

Instruments for Perineorrhaphy.

Catheter, glass, small, I
Catheter, glass, large, I
Forceps, hemostatic, small, 6 pairs.
Forceps, hemostatic, intermediate, Baca
Forceps, hemostatic, long, oak
Forceps, hemostatic, long dressing-, I pair.
Forceps, hemostatic, tissue- (rat-tooth), 2 pairs.
Forceps, hemostatic, bullet-, Deve
Forceps, hemostatic, volsella, as
Scalpels, 2
Uterine sound and applicator.

Tenacula, straight, pap ebhe
Tenacula, curved, 2 pairs.
Tenacula, shepherd’s crook, I pair.
Scissors, straight, Rice:
Scissors, right-angle, Peeps

Scissors, left-angle, 1 ae

104 SORGICAL TECHNIC:

Sponge-holders, 6 pairs.
Needles. Sutures, silk of various sizes,

and silkworm-egut.
Needle-holder. Sims’ speculum. Retrac-

tors. Leg-holder. Sterilized stockings.

Glass nozzles. Irrigation dressings.

Tenacula are used to catch and hold movable tis-
sues which are being sutured, to hold the cervix
uteri, etc. There are two kinds, the curved and the
straight; and of the curved there are three varieties:
the shepherd’s crook, the siinple curved, and the cor-
rugated. The shepherd’s crook is much used in
vaginal operations, and has the advantage over the
others that when once it is put in place it can be
dropped without losing its hold on the tissues.

Instruments for Trachelorrhaphy.

Catheter, glass, I
Two-way catheter, I
Curette, dull I
Curette, sharp, I
Curette, spoon, I
Dilators, different sizes.

Forceps, hemostatic, 8 pairs.
Forceps, volsella, I pair.
Forceps, bullet-, 2 pairs.
Forceps, long dressing- (Kelly), I pair.
Forceps, tissue- (rat-tooth), 2 pairs.
Scalpels, 2
Speculum, Sims’, small, I
Speculum, large, I

Shot-compressor and shot.
Retractor, small,
Retractor, medium,

as
:
=4
é
s
%,
4
e
7
Pe
i
;
om
ia
&
i
is
ba

LIST OF INSTRUMENTS. 105

FIG. 57.—Volsella.

106 SORGIGAL- TECHNIC.

FIG. 60.—Snare. FIG. 61.—Spoon curet.

LIST OF INSTRUMENTS. 107

Fic. 62.—Curved scissors for performing trachelorrhaphy.

FIG. 67.—Reiner’s needle-holder.

108 SURGICAL TECHNIC.

Scissors, straight, I pair.
Scissors, curved, Eee tee
Tenacula, 2 pairs.

Needles, curved, various sizes, short,
stout, straight.

Needle-holders, 2

Uterine sound and applicator.

Sterilized stockings. Leg-holder.

Catgut and silkworm-gut sutures.

Instruments for Dilatation of Cervix and Curetting.
of Uterus.

Catheter, glass, small,
Catheter, two-way, for irrigation,
Curet, sharp,
Curet, Martin’s double blunt,
Curet, curved, sharp,
Dilators (Hank’s rubber, all sizes). :
Dilator, Goodell’s, I é
Forceps, long dressing-, 1 ypatiite 3
Forceps, bullet-, Be
Uterine sound and applicator.
Sims’specula, large and small.
Kelly perineal pad. Sterilized stockings.
_ Irrigator. Glass nozzles. Dressings.

Small sponges. Cotton pledgets.
Churchill’s tincture of iodin.
Carbolic acid, 95 per cent. Leg-holder.

a = SH A A

Instruments for an Abdominal Operation.

Arrange for Trendelenburg position. Secure this
by special table; elevation of one end of an ordi-
nary table by means of blocks or upon two kitchen
chairs or by placing a flat-backed chair upside down

LIST OF INSTRUMENTS. 109

Fic. 70.—Varieties of hemostatic forceps.

IIo SURGICAL TECHNIC,

under the operating mattress ; secure the patient in
position by tying with bandage, sheet, or towel.

Forceps, small, hemostatic, 6 pairs.
Forceps, medium, OF os
Forceps, pedicle-, 4 pairs.
Forceps, long, A
Forceps, long dressings, I pair.
Forceps, for drainage-tube, Te
Forceps, Billroth, 2 pairs..
Forceps, bulldog, I pair.
Forceps, rat-tooth, 2 pairs.

Aspirator. Scalpels. Vaginal packer.
Uterine sound.
Paquelin’s thermocautery.

Sponge-holders. 6
Scissors, long and small, I pair of each.
Retractors, Lange’s large, I pair.
Volkmann’s 6-prong retractors, ry
Volkmann’s 4-prong retractors, Pode

Long and small probe and director.

Needle, aneurysin-,

Needle, transfixion, right curved,

Needle, transfixion, left curved,

Needle, transfixion, pedicle,

Needles, large, small, and intermediate,

- curved and intestinal.

Murphy anastomosis button (sizes 1-4).

Murphy’s forceps for holding button, I pair.

Murphy’s forceps, intestinal clamp, 1 “

Murphy’s forceps, introducing, I

Flat dissector (Fenger).

Drainage-tubes, glass or aluminum, as-
sorted sizes.

Needle-holders, bee”)

= = A &

é¢

EIST, OF INSTROMENTS. i031

FIG. 71.—Murphy anastomosing FIG. 72.—Griffith’s antiseptic irri-
button: 4, open; B, closed. gator tip holder.

Fic. 74.—Angiotribe of Tuffier,

112 SURGICAL TECHNIC.

FIG. 77,—Eusta- F1G.78.—Perios- FIG. 79.—Perios-
chian catheter. teum knife. teal elevator.

FIG. 76.—Cotton
applicators for nose

and ear work. FIG. 80,—Politzer’s inflating bag.

LIST OF INSTRUMENTS.

FIG. 85.—Gigli’s chain saw.

I14 SOKRGICALE ela CLUNUC:

Dressings, ligatures, and sutures of silk-
worin-gut, and various sizes of silk
and catgut.

Laparotomy sheet. Saline solution.

Small bolsters, made of non-absorbent
cotton covered with gauze, six
inches by three, to retain the intes-
tines and to keep them from encroach-
ing upon the site of operation.

Extra, for Cysts or Tumors.

Trocars, large and small. Rubber tubing.
Nélaton’s forceps.
Billroth’s tumor-forceps, 2 pairs.
Angiotribe or tumor-pedicle crushing for-

ceps.

Extra, for Vaginal Hysterectomy.

Sterilized stockings. Leg-holder.
Clam p-forceps, 6 pairs.
Uterine sound. Dissecting forceps. Long

and short tenacula. Speculum. Curet.

Instruments for Operations on the Brain and Spine.

Forceps, hemostatic, medium, 6 pairs.
Forceps, hemostatic, sinall, Orie
Forceps, rat-tooth (tissue-), oe

Forceps, bone, three kinds; long-jaw forceps.

Trephine—three sizes, small and medium.

Chisels, various sizes. Hammer.

Scalpels, ; 2

Scissors, 2 pairs.

Curets, sharp and dull.

Needles. Sutures. lLigatures. Saline
solution. De Vilbiss forceps. |

115

LIST OF INSTRUMENTS.

—Catlin, knife, and saws for amputation.

FIG. 86

Fic. 87.—Simpson’s forceps.

Fic. 88.—Breast-pump.

shield.

9go.—Nipple

FIG

.—Modern combination of Baude-
locque’s and Osiander’s pelvimeter.

FIG. 89

16) SURGICAL TECHNIC.

Instruments for Amputation of a Limb.

Esmarch bandages, 2
Periosteotome, E
Long amputating-knife.
Medium amputating-knife.
Scalpels, large and medium.
Bone-saw. Chain-saw.
Forceps, small hemostatic, 6 pairs.
Forceps, medium hemostatic, Git
Forceps, bone-cutting, straight, curved,

and angular.
Forceps, gouging.

Forceps, rat-tooth (tissue-), 2 pairs.
Forceps, retractor, I pair.
Scissors, large and small, I pair of each.
Bone-pins.

Four-prong retractors, 2
Three-tailed gauze retractors, 2

Dressings. Sutures. Ligatures of silk,
catgut (various sizes), and silkworm-
gut.

Obstetrical Instruments and Applances.

Bed-pan.

Fountain syringe.

Glass catheter.

Glass catheter, two-way, for irrigation.
Scissors.

Cranioclast.

Perforator.

Breast-pump.

Nipple shield.

Incubator, for premature-born children.

LIST OP ANSTROMENTES. DE,

Instruments for the Mouth and Throat.

Head-mirror. Snare of silver wire.
Volsella forceps for tonsils.

Uvulatome. Tonsillotome, 2
Sponge-holders, 6
Uvula scissors with and without claws.
Tongue-depressor.,

A self-fastening mouth-gag.
Trachea-dilator.

Trachea-tubes. IJIntubation-tubes.

Long forceps, I pair.
Long curved forceps, ae
Long straight scissors, ery
Throat-mirror (laryngoscope).

Angular forceps, I pair.
Angular scissors, es

Long, slender curet.

Gottstein knife (for adenoids).
Gradle forceps (for adenoids).
Bistoury. Flexible probe.
Esophageal sound and dilator.
Fish-bone catcher for foreign bodies.

Instruments for the Nose.

Polypus-snare. Silver applicator.

Nasal curet.

Saw with reversible blade for cutting up
or down.

Nasal scissors, with and without saw-
eet:

Nasal bone-scissors.

Nasal bone-scissors, turbinated.

118 SURGICAL TECHNIC,

Nasal polypus-forceps.
Septum-straightening forceps, I pair.
Nasal speculum.
Septum-knife.
Electrocautery for hypertrophied turbin-
ates and for hemostasis.
Chromic acid. Applicators.
Iodoform-strips for packing.
Monsell’s solution for hemostasis.

Instruments for the Eye.
Lens (double convex).
Ophthalmoscope.
Speculum.
Cataract knife.
Strabismus hook.
Probes.
Iris forceps.
Fixation forceps.
Keratome.
Cystotome.
Horn or metal spoon.
Wire loop.

Instruments for the Ear.
for Mastoid Operations.

Forceps, hemostatic, small, 8 pairs.
Scalpels, small and medium, I each.
Chisels and gouges, various sizes.

Mastoid drills and bone-trephines, = 2
Mallet. |

Ear-speculums, various sizes.
Diagnostic tube and otoscope.
Kar-syringe (hard rubber).

LIST OF INSTRUMENTS. 119

————
SSS ~

FIG. 93.—Nasal splint.

Tihs

=
tA

A
B

5
BS
&
$
tn
~»>
x

F1G. 92.—Probang FIG. 94.—Ridal speculum.
for removing foreign
bodies from the
throat.

FIG. 91.—Septum com-
pression forceps.

120 SOR GICAL PIL CHINTC.

— —————

FIG. 97.—Eyelid speculum.

4

FIG. 95.—Sharp-
PIG netieldyre-
tractor.

FIG. 99.—Tonsillotome.

LIST-OP INSTROMENTS 121

. FIG. 1o1.—Tracheotomy
forceps.

FIG. 103.—Steel-eyed curet.

122 SURGICAL TECHNIC.

FIG. 104.—Adenoid forceps.

FIG. 105.—Mouth-gag.

FIG. 107.—Phimosis forceps.

LIST OF INSTRUMENTS. 123

i]
i
JAS
ae)
i i}
i i
Hi |
Wi] i
i} ik
i i }

FIG. 108.—Cata- FIG, 109.—Cysto- FIG.110.—Cap- FIG. 111.—Metal
ract knife. tome. sule forceps. spoon.

FIG. 112.— Wire loop for extraction of lens.

FIG. 113.—-Loring’s ophthalmoscope.

124 SURGICAL TECHNIC.

SS

SS=>

SS=
SS=a==z

FIG.115.—Rectal speculum, FIG. 116.—Rectal speculum,
large size. small size.

SS oe SSS

FIG. 117.—Probes.

Fic, 118.—De Vilbiss trephine. FIG. 119.—Gruber’s ear specula.

LIST. OF INSTROMENTS. 125°

Sponge- and cotton-holder.
Small curet.
Irrigator.

for Middle-ear Operations.

Eustachian catheter, and Politzer’s air-
bag.
Curets. Ear-scoop.
Snare and wire.
Head-mirror.
- Cotton-holder.
.Tympanum-perforators.
Ear-aspirator for cleansing aide ear.
Case of tuning-forks and hammer.
Ear-scissors.
Ear-speculum, various sizes.
Slender polypus-forceps, I pair.
Slender scalpels.
Ear-probe. Irrigator.

Instruments for Rectal Operations.

Rectal speculum.

Forceps, small hemostatic.

Forceps, hemorrhoid.

Scalpel. — Paquelin’s cautery.

Rectal bougies.

Sterilized stockings. Leg-holder. .

Kelly perineal pad. 3

Irrigator. Dressings. Sutures. Liga-. -
tures. | he

Curets, sharp and dull, I pair of each.

Saw and chisels for Kraske’s operation.

Metal probes for tracing fistulee.

126 SURGICAL TECHNIC.

Instruments for Urethral and Bladder Operations.

Set of sounds, curved and straight.

Catheters, various sizes.

Urethral forceps, I pair.

Artery-dilators, various sizes.

Endoscopes with calibrators, various
s1zes.

Urethral searcher.

Head-mirror. Return-irrigator.

Sounds and dilators (usually the same).

Scalpels, artery-forceps, lithotrites.

Stone-forceps, litholapaxy set.

Curets, etc., for suprapubic or perineal
lithotomy, or for litholapaxy, opera-
tions on tumors, ete.

Necessary for Dressings after Gynecologic

Operations.
Sims speculum.
Bullet-forceps, I pair.
Long dressing-forceps (Kelly).
Applicator. Scissors, straight, aS ome

Churchill’s tincture of iodin.

Carbolic acid, 95 per cent. Ichthyol.

Balsam of Peru and glycerin.

Glycerin (pure). Vaselin.

Tampons. Boric acid solution.

Irrigator. Kelly perineal pad.

Andrews stitch-cutter for the removal
of silkworm-gut stitches from the
vagina and cervix.

LIST OF INSTRUMENTS. 127

Fic. 121.—Griffith’s director,
eyed (to enter deep-seated pus
collections by being passed down,
FIG. 120.—Canton-flannel the aspirating needle used as a

legging (Hirst). guide).

FIG.123.—Gouley’s tunnelled catheter threaded on a filiform bougie.

128 SURGICAL TECHNIC.

FIG, 126.—Bigelow’s evacuator.

LIST OF INSTRUMENTS. 129

For Cystoscopic Examination.

Head-mirror.

Urethral calibrator and dilator.

Urethral searcher.

Vesical specula with obturators.

Evacuator for removing urine.

Long-mouthed toothed forceps.

Applicator.

Cocain solution, Io per cent.

-Boroglycerid to lubricate the speculum

and dilator.

In private practice a head-mirror or reflector can
be improvised with a lamp or candle and a mirror.

9

CE ACE RG

ANESTHESIA.

ANESTHETICS are divided into two classes, local
and general. In local anesthesia the patient does
not lose consciousness; but in general anesthesia
consciousness is lost, the brain, together with
the rest of the body, is narcotized, and there is pro-
found sleep from which the patient awakens slowly.
Both classes of anesthetics are used in surgery.

We have practically four general anesthetics, one
a gas, nitrous oxid, and three in liquid form: ether,
chloroform, and ethyl bromid. The first is em-
ployed in dentistry and as a preliminary anesthetic,
while the last three are used in general surgical
work. The administration of the anesthetic is a
duty which may unavoidably fall to the nurse in
emergency cases.

The anesthetic should be administered in a room
apart from the operating-room, so that the patient
may be spared the sight of the preparations for the
operation and the necessary display of instruments.
Before giving the anesthetic the urine, heart, lungs,
and mouth are examined, the mouth because patients
are apt to deny the presence of false teeth, and male
patients have been known to go to the anesthetizin
room with tobacco in their mouths. ‘The patient’s
habits should be known. Alcoholic patients pass
through the exciting stage of anesthesia with con-

130

ANESTHESIA. 131

FIG. 128.—Luer’s hypodermic syringe.

FIG. 129.—Hard-rubber FIG. 130.—Griffith’s wooden mouth-wedge
oral screw. and gag.

132 SURGICAL TEL CHNIC

siderable struggling; they are also more liable to
congestions.

An anesthetic must never be given on a full stom-
ach, because the patient may vomit, and particles of
food may lodge in the larynx and trachea and result
in strangulation. An interval of four to six hours
should be allowed for, or in emergency the patient’s
stomach may require to be washed by use of stomach-
tube and warm water siphonage. ‘The bladder and
bowels must always be emptied, or they may act in-
voluntarily. False teeth must be removed, as there is
danger of their being swallowed.

Absolute silence must be maintained while the
anesthetic is being administered, as anything said
may be heard by the patient and be repeated. What-
ever is said by the patient during the anesthetic state,
or while going into or coming out of it, must be kept
absolutely secret. Family secrets and other things
may be told which might make great trouble if they
were repeated. So a religious silence must be ob-
served by every one with regard to any statement
that the patient may make while intoxicated. Care
must also be taken that the operation is not dis-
cussed. Many paticnts have been made very un-
happy through carelessness on this point; for they
can often hear everything that is said by the doctors,
students, and nurse, but are totally unable to make
any sign by which a bystander may know that they
can hear. ‘These are about the first lessons that
should be impressed upon a nurse when she be-
gins her operating-room service. Oliver Wendell
Holmes, in his A/edical Essays, says: ‘It 1s a ter-
rible thing to take away hope, even earthly hope,
from a fellow-creature. Be very careful what names

ANESTHESIA. — 133

you let fall before your patient. He knows what it
means when you tell him he has tubercles, or Bright’s
disease; and if he hears the word carcinoma, he will
certainly look it out in a medical dictionary, if he
does not interpret its dread significance on the
instant.”’

It is not always best that the patient should know
that she has carcinoma; if she hears that word, she
will feel that it is a sentence of death sooner or later,
and her life will be made miserable, whereas, if she
is not informed as to the nature of her condition, her
life can often be made more comfortable.

The giving of the anesthetic is by no means a sub-
ordinate duty. It requires a very skilled and trust-
worthy assistant, one who is competent to act in case
of emergency, because the life of the patient is as
much in the hands of the anesthetist as in those
of the operator. The anesthetist’s whole attention
must be given to the administration of the drug.
Consequently, he cannot also watch the operator.

The majority of patients are opposed to giving up
consciousness, and often it costs a great struggle. It
is here that a nurse should inspire her patient with
confidence. Although we see many operations in
the hospital in a single day, yet to the patient it is
the one great event in his or her life.

Some patients have an idea that an operation is
mere butchery; while others who have any control
over themselves can be shown the operating-room in
readiness for work. A few cheering words convey-
ing the right meaning are all that is needed, but we
should remember that these are needed.

In all operations in which an anesthetic is em-

134 SURGICAL TECHNIC.

ployed, even in those of a minor character, it is well
to be prepared for accidents, such as heart-failure,
arrest of respiration, or hemorrhage. ‘There should
be a hypodermic tray, with bottles containing solu-
tions of strychnin sulphate, atropin sulphate, digit-
alis, whiskey, nitroglycerin, morphin sulphate, and
camphorated oil. Two hypodermic syringes in good
order should be in readiness. An oxygen-inhaling
apparatus is a valuable adjunct to an operating-room,
and may prove useful in respiratory failure. It is
also advisable to have a small faradic battery near
at hand. A quantity of normal saline solution
should always be in readiness for injection under
the skin.

The Allis inhaler is generally used, and in its
absence a cone is to be preferred to a sponge, since a
cone is always fresh and clean. An ether cone is
made by folding a newspaper; or a straw cuff may be
shaped to fit over the nose and mouth, a stiff towel
being folded around and secured with safety-pins, and
a clean handkerchief or piece of cotton placed inside.
Ether should be given slowly; the cone should not
be filled with ether and put over the face, entirely
smothering the patient. The patient should be in-
structed how to inhale it, slowly and deeply, and also
to close the eyes, or cover them with a folded towel,
because ether is an irritant to them. About two
tablespoonfuls of ether are poured into the cone,
which should be held a little distance from the
patient’s face, and as he becomes accustomed to the
vapor and comes under its influence the cone may be
brought nearer; the strangling sensation, of which
so many patients complain, is then in a measure
avoided. A little patience exercised at the beginning

ANESTHESIA. 135

obtains more satisfactory results and less shock than
when the drug is crowded, and force is used to re-

\N \ Yj X
\ / f aly).
\ i i DG
\\\\\ \\ us NC : Lp, Ss
\\\t \ ® =
\ \ \\ KS R&kts YA
SQA yy eee EN
AN SG ——
SS ——
=
———-

FIG. 131.—Allis’s aseptic ether-inhaler.

strain the struggles of the patient. Ether generally
first produces choking and coughing, followed by ex-

Fic. 132.—Method of pushing the lower
jaw forward to prevent obstruction to
breathing.

citement ; that is fol-
lowed by the muscles
becoming rigid, the
face? may © be eya-
nosed, and the breath-
ing stertorous or snor-
ing ; this stage passes
away, the muscles be-
come relaxed, and the
patient is in a state of
insensibility.

The lower jaw must

be kept forward by placing the thumbs behind the
angles of the jaw. Gentle pushing of the jaw for-
ward and upward, which brings the upper behind the

136 SURGICAL TECHNIC.

under teeth, keeps the tongue from slipping back and
obstructing the larynx, and gives free access of air to
the lungs. Should the tongue slip back, it may be
pulled forward with the fingers or with a pair of for-
ceps. Holding the tongue forward by means of pass-
ing a suture through the tongue with a needle is rarely
required ; neither should too much pressure be put
on the tongue-forceps, for that will cause the tongue
to become sore and swollen, and after the patient recov-
ers from the anesthetic, about the first thing of which
she complains is the soreness of tongue and jaws. Fre-
quent inspirations of fresh airshould be given. When
completely etherized only a small quantity of the
drug is needed to keep the patient under its influence.
The eyeball should not be touched in order to ascer-
tain if the patient is completely narcotized ; it is
liable to cause conjunctivitis. Press down the upper
eyelid on the eyeball ; 1f the patient makes no move-
ment, and is perfectly relaxed, then insensibility is
complete. Bronchorrhea (excessive mucus formation)
usually occurs during the earlier stages of anesthesia ;
but if proper care is taken not to crowd the ether at
the start, the mucus secreted will not be of sufficient
amount to cause any distressing symptom. When it
does occur, the head should be turned to the side and
‘the mouth wiped with a gauze sponge in a sponge-
holder. Bronchorrhea may prove to be a distressing
complication to the administration of the anesthetic,
inasmuch as the free secretion in the bronchi and
bronchioles may interfere with thoroughly anesthet-
izing the patient, and the patient is more prone to
nausea from swallowing the mucus, which is probably

ANESTHESIA. 137

soaked with ether. If the patient seems inclined to
vomit, the ether should be pushed, which will gener-
ally ward it off; should she vomit, her head should be
turned to one side, to allow the matter to escape more
easily from the mouth. If the operation is about the
neck or chest, the head must be turned to the opposite
side, to prevent vomited matter from getting into the

FIG. 133.—Griffith’s single-eared anesthetizing stethoscope, which will
enable the anesthetist to have constant knowledge of the patient's heart and
respiratory action while allowing the hands to be free.

wound. Vomiting is usually due to incomplete anes-
thesia and the admixture of too much air with the
vapor. The anesthetic must be persistently given
until the vomiting ceases and complete relaxation
occurs.

The mucus should be constantly wiped from the
patient’s mouth. The pupils should remain con-
tracted all through etherization, and dilate when the
patient is returning to consciousness. Dilated pupils
mean one of two things: either that the patient is com-
ing out of the anesthetic influence, or that she is too
deeply anesthetized. We can readily ascertain which
condition the patient is in by pouring a little ether
into the cone. If she is coming out, she will cough,
stop breathing, and give other signs of discomfort;

138 SURGICAL TECHNIC.

while if too deeply etherized she will breathe on
steadily and not notice the fresh supply of ether; and
the pupils will remain dilated until the muscles of
the eyes regain their tone, when they contract. The
sudden dilatation of the pupils is generally a sign of
imminent death. It is very important for the anesthet-
ist to watch carefully the respirations, because ether
kills by suffocation, the heart usually beating long after
the respirations have ceased. The anesthetist should
speak out if the pulse is growing rapid, feeble, irreg-
ular, or intermittent; if the respirations are becoming
low, rapid, or gasping; if the face is becoming pale
or blue; if the pupils are gradually dilating; or if
the extremities are cold and there is profuse perspira-
tion. In every case of continued doubt it is best to
let the patient revive slightly. A very long anesthesia
may lead to secondary prostration and collapse, and
secondary shock from that cause alone. In other
words, the prostration of the anesthetic is added to
the effects of the operation.

Primary anesthesia is that moment of temporary
unconsciousness which comes on after the patient has
taken a few inhalations, before the stage of excite-
ment.

In etherizing very young children it is best to put
them on the back and at once to place the ether-cone
over the mouth and nose without temporizing. If
their pleadings to have the cone taken away are list-
ened to (and they are hard to resist), their agony will
only be prolonged and the operation delayed. Older
children, once their confidence is won, may be grad-
ually anesthetized as in the case of adults. Children
are quickly etherized, and very rapidly recover from
the influence of the ether. i

ANESTHESIA. 139

Death from ether is slow, by paralysis of the respi-
ration, the signs of danger being a blue and livid skin,
and low, shallow, gasping respirations. It sometimes
kills quickly by action upon the heart direct. Ether
is very inflammable; hence the can should never be
opened near a light or fire.

Nausea and vomiting are very common after ether,
but are usually over at the end of eighteen hours.
The smell of the anesthetic, due to saturation of the
patient’s hair with the vapor, in a woman may be pre-
vented by protecting the individual’s head by means
of a towel held in place by use of safety-pins before
going into the operating room. Postoperative vomit-
ing may sometimes be overcome by applying an ab-
dominal binder wrung out in cold water—the so-called
Neptune girdle. Should vomiting persist until the
following day, it may be due to shock or to some
cause other than ether. It may be relieved by the
inhalation of hot, strong vinegar fumes; a cloth wet
with vinegar placed over the mouth and nose; tea-
spoonful doses of very hot water, either plain or with
four grains of bicarbonate of sodium added to one
ounce of water; crushed ice; champagne and ice;
small doses of brandy and ice; black coffee ; aromatic
spirits of ammonia, or sometimes tea. Cocain, one-
fourth grain every two hours for five doses, has been
successful in severe cases ; also a mustard-leaf applied
over the stomach, and the washing out of the stomach.
Oxygen gas is now frequently administered both to
lessen nausea and to hasten consciousness. Asa last
resort, when all other treatment fails and there is
danger that the severe retching will exhaust the
patient, morphin, one-sixth grain, is injected over
the epigastrium.

140 , SURGICAL TECHNIC.

Chloroform is similar in its action to ether, and is
often to be preferred to it, because it is pleasanter to

FIG. 134.—Griffith’s wire-frame
chloroform inhaler.

FIG. 135.—Griffith’s chloroform in-
haler covered with square of double-
thickness gauze.

take, rapidly recovered from, does not produce excite-
ment or subsequent vomiting, and the patient is

F1G, 136.—Mask and tube for ethyl chlorid (Hirst).

brought more quickly under its) milwencesy mingac.
however, more depressing to the heart than Verner

ANESTHE STA. IAI

and therefore more dangerous. The patient is not
allowed to rise until all effects have passed off. To
give chloroform, a few drops may be sprinkled on
an Hsmarch inhaler, a handkerchief, a towel, or a
small wire framework covered with gauze. Where
the operation is on the mouth, so that all available
_ space and light is demanded, after the patient is fully
anesthetized it is administered on a small gauze sponge
clamped in forceps which are held several inches
above the mouth. Vaselin should first be spread over
the face, and especially around the lips and nose, to
prevent the burning which might occur should any
of the fluid drop. Acrid vomit sometimes causes
superficial skin burns. Preventive treatment consists
in cleansing with a wetted towel or one wrung out in
weak soda solution. ‘The same symptoms are to be
watched for as in the case of ether. Death from
chloroform is almost always sudden, from paralysis
of the heart; the pupils become dilated, the face pale,
and the pulse flickering. These symptoms usually
come on with little or no warning.

Ethyl bromid is often used asa substitute for chloro-
form, which it resembles in its action, except that it
is more prompt. It is employed in minor operations
and gynecologic examinations. About half a dram
is poured on a folded towel, or chloroform-inhaler,
and held close to the mouth and nose. The same
amount is added at intervals until the patient is com-
pletely narcotized. The stage of excitement is short,
and its elimination is rapid. It leaves a disagreeable
odor of garlic on the breath, which may last several
days; but, on the other hand, the patient recovers
rapidly, and may be able in a very little while to
resume work.

142 SURGICAL TECHNIC.

Ethyl bromid is also used as a local anesthetic in
the form of a spray.

Schletch’s anesthetic consists of one and a half
ounces of chloroform, one-half ounce of petroleum
ether, and six ounces of ordinary ether. It is given
in an Hsmarch inhaler, and is considered to be safer
than chloroform. Unconsciousness is obtained usu-
ally in one minute and a half; there 1s mevexeite-
ment, and the reaction is rapid. )iherevarestinee
forms of this solution, the other two being weaker.

Local anesthetics are those which abolish the
sensibility of the peripheral nerves of a particular
area (Brunton).

Cocain is the best one that we have at present; the
others are ethyl chlorid, eucain, menthol-chloral,
otthoform, freezing with ice and salt, carbolic acid,
alcohol, ether, the so-called infiltration-anesthesia.

Ice.—The disadvantage of using ice is that it is
always followed by a reaction, the blood-vessels
becoming filled with blood; and the patient suffers
the pain and tingling sensation which follow intense
cold. It is used in the following way: To a little,
finely-chopped ice is added about a quarter the
amount of salt; this mixture is placed in a piece of
gauze and laid over the part, which in about ten
minutes becomes white and numb.

Eucain is much used as a local anesthetic in sur-
gery of the nose, throat, and ear in strengths of 2,
5, and 8 per cent. In the onset its action 1s slightly
slower than that of cocain, from five to ten minutes
elapsing before the patient is ready for operation,
but when established the anesthesia is fully equal to
that of cocain. ‘The duration of the anesthesia is

ANESTHE STA. 143

from ten to twenty minutes, fifteen minutes being
the most usual time.

Cocain hydrochlorate is a very good anesthetic. It
is ordinarily employed in a 7; of 1 per cent. toa 4 per
cent. solution, and is principally applied to the mu-
cous membranes, such as the eye, the mouth, the nose,
the urethra. It is not so effective when applied
to the sound skin; in order to produce anesthesia
there it must be injected subcutaneously, when it
gives rise to a rapid edema of the tissues. It has the
power of shrinking up the blood-vessels and tempo-
ratily driving the blood out of the parts, which is
quite an advantage in minor operations.

One-half grain of cocain hydrochlorate dissolved
in an ounce of water forms a ;5 per cent. solution:
eighteen grains of cocain hydrochlorate to one
ounce of water is a 4 per cent. solution. One grain
of boric acid added to the solution will prevent the
development of fungi, and the solution remains
aseptic. ‘The solution should be kept in a cool spot,
for if placed ina temperature higher than 60° F. it
begins to lose its anesthetic properties.

The use of the cocain discoids enables the nurse to
prepare a desired amount of a fresh solution at a mo-
ment’s notice. ‘They are convenient and safe, and
contain accurately weighed quantities of pure cocain.

The phenate of cocain is a local anesthetic, used in
from 5 to 10 per cent. solutions. It takes longer to
act than the hydrochlorate; it also coagulates the
tissues and lessens absorption.

Ethyl chlortd is a local anesthetic, acting by freez-
ing the parts. It is put up in glass tubes. The cap
is removed from the tip of the tube and the bulb held

144 SURGICAL TECHNIC.

in the palm of the hand, the warmth of which causes
the liquid to escape in a vaporized stream. (‘The tube
is held a little distance from the part to be operated
upon, which whitens and is ready for operation in
about fifteen seconds.

The method of zxfltration-anesthesta (local anes-
thesia by injection of solutions in the skin) was in-
troduced by Schleich, who claims that a weak solu-
tion of cocain hydrochlorate, with common salt, and
a small amount of morphin, will produce a thorough
and prolonged anesthesia. There are three prepara-
tions, each of which is put up in tablet-form, contain-
ing the proper proportions :

No. 1. Strong.—
Cocain. hydrochlor., I or.
Morph. hydrochlor., 4 or,
Sodium chlorid, I or.
No. 2. Normal.—
Cocain. hydrochlor., Z or,
Morph. hydrochlor., Seok.
Sodium chlorid, I ef.
No. 3. Weak.—
Cocain. hydrochlor., sp QT.
Morph. hydrochlor., SSAC.
Sodium chlorid, 1G ese:

The tablets should be dissolved in distilled sterilized
water.

Alcohol and ether are local anesthetics, as is also
any agent which evaporates rapidly and produces
cold.

Cocain anesthesia has become an important factor

ANESTHESIA. 145

in modern surgical procedures. While generally con-
fined to use in so-called minor operations, such as the
laying open of abscesses and finger amputations, some
surgeons have not hesitated to employ it success-
fully in operations for appendicitis, hernia, and gland-
ular tumors of the neck. It has been determined
that a 75 per cent. solution of the hydrochlorate of
cocain will anesthetize the skin for a period of from
forty-five minutes to one hour and a half.

Fic. 137.—Griffith’s combined inhaler for gas and liquid anesthetics.

Spinal cocainization produced by injecting a solu-
tion of hydrochlorate of cocain (mixed up with spinal
fluid to form 1 to 4 per cent.) directly into the spinal
canal has been employed. ‘This procedure must be
carried out with absolutely sterile implements. From
its manifest dangers it is now believed to have a very
limited usefulness.

Cocain poisoning may be avoided by never employ-

10

146 SURGICAL TECHNIC.

ing more than the amount of solution equalling one-
third of a grain of cocain hydrochlorate. The symp-
toms of overdose are dryness of the mouth and throat,
mental excitement, delirium, dilated pupils, with
increased heart and respiratory action, convulsions.
Treatment of oncoming symptoms consists in hypo-
dermic injections of full doses of morphin sulphate. °
General anesthesia is now secured with greater de-
spatch and with more comfort to the patient by means
of the mixed gases of oxygen and nitrous oxid, the
ill effects of the latter gas, whose action is that of
mechanical suffocation, being overcome by the oxygen,
or by the employment of nitrous oxid gas alone as a
preliminary to ether. Owing to the imore pactiye
properties of chloroform it is not generally employed
in the combination anesthesia.

(CISA IP SE IIR Oe

ANTISEPTIC GAUZES, TAMPONS, THERMOCAU=-
TERY, SALINE INFUSIONS, IRRIGATION, ETC.

Surgical Dressings.—Gauze and absorbent cot-
ton are now almost universally used as wound-dress-
ings. A dressing may be aseptic or autiseptic. An
antiseptic dressing absorbs from the wound all dis-
charges, prevents the access of germs to the wound
from the outside, and also destroys all germs that may
come in contact with it. An aseptic dressing has the
same properties, with the exception that it cannot
destroy germs.

In selecting gauze for dressings, that which pos-
sesses the greatest absorbent power should be secured.
It should be soft, A/zadle, and free from irritating and
gritty materials.

When applied to a wound, it should be unfolded
and laid on loosely (fluffed) ; it thus forms a softer
dressing and more readily absorbs the discharges.

Absorbent cotton is ordinary cotton deprived of its
oil, in order to render it absorbent. Laid over gauze,
it acts as a sieve through which germs cannot pass ;
also as a springy protective, by means of which the
wound is protected from undue pressure.

Antiseptic dressings are made by impregnating gauze
147

148 SURGICAL TECHNIC.

with an antiseptic, such as bichlorid of mercury,
iodoform.

To make dzchlorid gauze, the gauze after the initial
boiling is immersed in a 1 : 1000 bichlorid solution for
twenty-four hours, after which it is dried, cut into
dressings, and packed in glass sterilized jars.

lodoform gauze may be made after the following ©

formula :
Cheese-cloth, 5 yards.
Alcohol, 8 ounces.
Iodoform, Ey.
Ether, i eas
Glycerin, 2)

Shake the alcohol and iodoform together in a sterile

bottle for fifteen minutes, then add the glycerin, and-

lastly the ether. Put all into a sterilized stone jar ;
then rub the mixture into the gauze thoroughly, and
cut the latter into strips two inches wide. Each strip
is rolled up separately, and several strips are placed
in a sterilized jar. When required for use a strip is
taken out with sterile forceps.

In some cases an emulsion of iodoform is rubbed
into the gauze. This emulsion, according to Wharton,
is made by adding three drams of iodoform to six
ounces of Castile soap-suds. ‘This suffices to impreg-
nate eighteen ounces of moist gauze.

The iodoform glycerin or oil which is used for
injections into wounds is prepared by taking

Iodoform, 5 grams (75 grains).
Glycerin, Too v.c. (34 ounces).

Mix and place in a wide-mouthed flask of thin

SURGICAL DRESSINGS. 149

glass, and sterilize for one hour, plugging the flask
afterward with sterilized cotton.

Potassium-permanganate Gauze.—The formula for
this is as follows:

Potassium permanganate, 160 grains.
Hot water (distilled), 33 ounces.

The gauze is cut and rolled as for iodoform gauze,
and saturated thoroughly in the above solution. It
should be preserved in colored glass jars.

Bismuth gauze is made after the subjoined
formula :

Bismuth subiodid, rr drams.
Glycerin, i)
Water (distilled), 4% ounces.

Mix and rub thoroughly into the meshes of gauze,
cut, and preserve the same as iodoform gauze.

In emergency cases old sheets and clean linen may
_be cut to the desired size and sterilized in an oven.

Collodion Dressing.—Collodion is a preparation of
pyroxylin in alcohol and ether. On evaporation of
the alcohol and ether a thin, impervious film of col-
lodion is left. The collodion is either painted over
the surface of the wound by means of a clean stick of
wood or an applicator with sterile cotton fixed to the
end, or thin layers of absorbent cotton are saturated
with it, laid on the wound, and allowed to dry. Col-
lodion is used only when the wound is aseptic. Vari-
ous antiseptic agents, such as iodoform, boric acid,
etc., may be dissolved or suspended in the collodion.
The surface of the wound must be perfectly dry, or
the collodion will not adhere. An ordinary dry

I50 SOK GICAL. Lie CEENTG:

dressing may be applied over the collodion as a further
protective.

Florsley’s wax is made of seven parts of beeswax
to one part each of almond oil and salicylic acid.

Rubber adhesive plaster is at times used in the later
stages of wound-healing, for the purpose of drawing
the edges together. ‘The chief objection to its use is
that it cannot be thoroughly sterilized. A protective
dressing may be applied over it in the usual way.
Rubber plaster is also used to take the place of band-
ages where these are inconvenient or difficult of
application.

FIG. 138.—Vaginal tampon, sterilized and placed ina gelatin capsule ready
for use (Hirst).

Oiled stlk or rubber protective is used when it is
desirable to prevent sticking of the dressings to the
wound, as in ulcers, and skin-grafting. The mate-
rial is applied in narrow strips which overlap each
other like shingles. The strips are sterilized by wash-
ing in cold soap-suds and soaking them in a1: 250
solution of corrosive sublimate. ‘They are then rinsed
in sterile water or saline solution, in which they are
allowed to float until needed by the surgeon.

%

ANTISEPTIC POWDERS. I51

Tents are small strips of rolled gauze used to
keep a wound open for the escape of pus. They
are rarely employed at present, having been replaced
by the drainage-tube. The term tent more fre-
quently designates a conical or cylindrical pencil of
sponge, sea-tangle, and other substance, employed for
dilating a narrow channel, such, for instance, as the
Ecimyieaiacanal. When imtroduced, the tent) expands
from the absorption of moisture, and this dilates the
part.

Tampons are made of absorbent cotton, lambs’
wool, or gauze, and are about seven inches long, one
and one-half inches wide, and one-half an inch thick.
They are folded and tied in the middle with a strong
white thread or fine twine, leaving long ends by
which to remove the tampon. ‘The so-called kite-tail
tampon is made by fastening several of these pieces
of cotton toa thread about two inches apart. ‘The
tampons may after sterilization be kept in a dry,
sterile jar, or they may be thoroughly soaked in water
and then kept in glycerin. ‘Tampons are principally
used for introduction into the vagina. Previous to
introduction they may be dipped into various special
solutions. ‘They are generally removed from the
vagina on the day after the application.

Antiseptic Powders. — Reference has already
been made to these. ‘Those most frequently em-
ployed are iodoform, boric acid, acetanilid, dermatol,
and mixtures of these various kinds. JIodoform and
boric acid are generally combined in the proportion
Of One Of tie former to seven of the latter. The
powders are kept in sterilized glass salt-cellars with
silver-tops, which are covered with gauze when not

152 SURGICAL TECHNIC.

in use, or in sterile wide-mouth bottles over which a
piece of gauze is stretched. As the bottle may not
be thoroughly clean on the outside, it should be
handed to the surgeon wrapped in a sterile towel up
to the top.

The thermocautery, known also as the Paquelin
cautery, because of its invention by Paquelin, of
Paris, is frequently employed in surgery to control

FIG. 139.—Paquelin’s thermocautery : Connect point or tip (d, d) to the
container at (¢) after pouring a teaspoonful of benzine into the reservoir (a).
Connect bulbs to the bottom of the reservoir at (/). Attach the blowpipe (c).
Open stopcocks (e and /), press the bulb and apply a lighted match at @.
Remove blowpipe (c) and continue incandescence after platinum has begun
to glow by gently working the bulb.

bleeding, and also to produce counter-irritation.
The efficacy of this instrument depends on the fact
that when the vapor of some highly combustible car-
bon compound is driven over heated platinum its
rapid incandescence is sufficient to maintain the heat
of the inetal. Platinum points of various shapes and
sizes are attached to a rubber tube, which is con-
nected with a metal container half full of benzine
or alcohol, the vapor of which is pumped through

ee Pe. ae ee

ee ee

ees oe ~

NORMAL SALINE SOLUTION. 153

the tubing and holder into the platinum point. In
Order to prepare’ the amstrument for tse benzin
(above 65° Baume) is the best combustible, but wood-
alcohol, naphtha, benzol, gasolene, ammonia-water,
or ether may be used.

FIG, 140.—Intravenous saline infusion. Manner of incising vein and
inserting glass tube (Senn).

After using, the container should be completely
closed, and the points while hot must be removed
from the handle and laid away to cool; they must
not be put into water, but wiped perfectly clean.
The handle when cool must be removed from the
tubing, and each part must be carefully laid in its
own compartment in the case.

Normal saline solution is made to correspond as
nearly as possible in specific gravity with the normal
serum of the blood. The formula suggested by Dr.

154 SORGICAL LECHNIC,

Locke of Boston and Dr. H. A. Hare, containing
in one quart calcium chlorid 0.25 gm., potassium
chlorid 0.1 gm., sodium chlorid 9 gm., is usually
employed. 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. Tablets con-
taining this formula have
been devised, and are
usually used. One tablet
added to one quart of water
gives the correct strength.
In absence of the tablets
one teaspoonful of table
salt is added to one pint
of water. It is absolutely
necessary whatever for-
mula is used that the solu-
tion and all the apparatus
used be properly sterilized.
If the water contains par-
ticles that cannot be strain-
ed out and there is no filter
at hand, the water should
FIG. 141.—Apparatus forhypodermo- stand until the sediment

elysis\(Eiitsy). settles, when the fluid can
be poured off, resterilized, and used. ‘This solution is
placed in an irrigator or a fountain-syringe which has
been thoroughly sterilized with hot water and corro-—
sive-sublimate solution, and subsequently rinsed with

NORMAL SALINE SOLUTION. 155

boiled water. A long hypodermic needle, which has
also been thoroughly sterilized, is fastened to the end
of the rubber tube connected with the irrigator or
_fountain-syringe. The fluid may be kept in a pitcher
and poured into a glass funnel to which the rubber
tube is attached. The temperature of the solution
should be about 100° F. ‘The solution is intro-
duced under the skin of either the chest, the abdo-

FIG. 142.—Apparatus for douching the abdominal cavity (Hirst).

men, the thigh, the arm, or between the shoulder-
blades. From a pint to two quarts are injected at
one time. The part selected for the injection is to
be sterilized thoroughly in advance. Saline infusion
is also given by the rectum, a long rectal tube being
used.

In hospitals it is customary to keep on hand flasks
of saline solution. These flasks are sterilized before

156 SURGICAL TECHNIC,

filling ; afterward they are stopped with sterile cot-
ton-plugs and sterilized again by boiling for one
hour on three successive days.

Normal salt solution is used for
irrigation and for injections in cases
of shock, in acute diabetic and
uremic coma, hemorrhage, puer-
peral infection and eclampsia.

Irrigation.—Irrigation, or flush-
ing, is employed to cleanse wounds
and wash out cavities, such as the
uterus, the abdomen. ‘The solu-
tions employed are various. Many
“surgeons use sterile salt-solution or
plain boiled water. Antiseptic solu-
tions, such as bichlorid solution
(1 ? 10,000’ to’ 1: 1000); bore vaera
solution, are used especially for
septic wounds and surfaces. For
purposes of irrigation a conical glass
vessel, with a tube at the bottom to
anon a rubber tube is attached, is
Fic. Sate commonly employed; a oe:
apparatus for the irri- syringe will also answer the purpose.
ens a wound ‘The irrigating-nozzle is usually of

glass. The solution should be warm;

when it is desired to check hemorrhage, it is used
quite hot (r10°-120° F.).

Cre AR Ea ER oc le

SUTURES AND LIGATURES; SPONGES; DRAIN-

AGE; DRAINAGE-TUBES ;

GAUZE DRAINS;

RUBBER DAM; RUBBER AND _ COTTON

GLOVES.

Sutures, which are used to
bring together the edges of a
wound, may be of silver wire,
silkworm-gut, twisted Chinese
silk, kangaroo-tendon, catgut,
and horse-hair. Of these, silk-
worm-gut, cateut, and silk are
most commonly tfsed.

Caigut is made from the in-
testine of thesheep. Itis largely
used for suture-material within
the abdominal cavity or deeper
layers of tissues, because it is
absorbed by the fluids of the
body, and does not remain after
EiemMicalina vol wthe external
wound to constitute a foreign
body.

Kangaroo-tendon is prepared
from the split sinews of the tail
of that animal, and was intro-

tube, on glass reels; the tubeis
stoppered with cotton (Hirst).

157

158 SURGICAL TECHNIC.

duced by Dr. H. O. Marcy of Boston. It is obtainable
in any size, and comes in pieces of about twenty inches
in length. Its advantage over catgut consists in its
greater strength. It is more easily sterilized, and
does not lose its strength during perfect sterilization.
It is particularly of value in buried sutures and liga-
tures and continuous sutures at the surface.

To prepare the kangaroo-tendon the following
method may be used: The tendon “having speen
soaked in absolute ether for forty-eight hours, is
heated to a temperature of 100° C. in alcohol under
pressure in a closed receptacle for one hour. This
temperature is maintained by means of a water-bath.
It is then put in mercuric chlorid solution, consisting
of mercuric chlorid 4o grains, tartaric acid 200 grains,
and alcohol 12 ounces, for ten minutes; lt ms memerm
placed with sterilized forceps in sterilized glass-stop-
pered jars containing bichlorid of palladium ;4 grain
to 1 pint of absolute alcohol.

Silkworm-gut 1s prepared for use by soaking for
forty-eight hours in ether and one hour ini: 1000
corrosive sublimate; it is then kept in a long tube of
alcohol, though many surgeons prefer it made asep-
tic by boiling two hours before the operation. It is
seldom used as a buried suture, but chiefly in closing
wounds with interrupted sutures.

Catgut.—There are various methods of sterilizing
catgut, among them the methods of Leavens and Fow-
ler, by which catgut is kept in alcohol in sealed tubes,
the preparation by formalin recently proposed by Senn,
cumol catgut, all equally effective if judiciously car-
tied out. The gut used should be of the vem, best
quality. The following are the most popular methods
of preparation : ;

SUTURES AND LIGATURES. 159

1. Six strands of catgut, each fourteen inches long,
are wound on glassreels and soaked in ether for twenty-
four hours to remove all fatty substances. The spools
are then removed with sterilized forceps and dropped
into covered glass jars, containing 95 per cent.
alcohol, care being taken that the catgut is com-
pletely submerged and that allowance is made for
evaporation. The mouth of the jar is covered with

FIG. 145.—Sterile catgut in glass tubes ready for use.

absorbent cotton and the jar placed on a water-bath,
the water of which is gradually heated until the
alcohol boils, when the jar is removed. ‘This opera-
tion is repeated on two successive days. On the third
day of sterilization the absorbent cotton is removed,
and a glass cover, fitted with a rubber protective to
prevent evaporation, 1s screwed on.

2. The catgut is soaked for twelve hours in a corro-
sive sublimate solution (1 : 1000), and afterward from
twenty-four to forty-eight hours in oil of juniper.
The spools are then transferred to covered glass jars,
containing sufficient absolute alcohol to cover the cat-
gut completely. The alcohol is changed every two
weeks.

160 SURGICAL TECHNIC.

3. Strands of catgut are soaked for twenty-four
hours in oil of juniper, after which they are wound
upon glass reels, and placed in covered glass jars con-
taining absolute alcohol.

lodized Catgut.—Ordinary catgut placed for eight
days in the following solution:

Todin, I part.
Potassium iodin, ite
Water, 100 parts.

Tensile strength not affected up to six months.

When used externally irritation to the skin may ©
result (due to the action of iodin).

Bichlorid Catgut (said to keep indefinitely).—Place
the gut strings in ether for twenty-four hours (dis-
solves out fat), then in a solution of:

Bichlorid of mercury, 1 pats
Alcohol (95 per cent.), 500 parts.
Ordinary sized gut strings are sterile after eight
days; large sizes, after fourteen days.
The method used by Dr. F. W. Johnson, of Bos-
ton, Mass., is as follows: he gut is soaked in ether
for several days. It is then cut into the desired
length, each length being thoroughly stretched (the
stretching prevents kinking and twisting). The gut
is then soaked for twenty-four hours in absolute
alcohol, to take out as much of the water as possible.
It is then covered with a solution of bichromate of
potassium in absolute alcohol (fifteen grains to the
pint), and remains in this twelve hours. Each
length is coiled up, wrapped in waxed paper, and put
in an envelope, which is sealed. ‘The sealed envel-

SUTURES AND. LIGATURES, 161

opes are put in a dry oven, and baked for one hour
at a temperature of 100° C. ‘This removes all moist-
ure. On the following day the sealed envelopes are
bpakedithree hours at a temperature of r40- €. The
gut is now ready for use. The envelopes are kept in
a glass jar. An assistant tears open one end of an
envelope, undoes the wax paper without touching
the catgut, and hands it to the operator. In this way
the gut is touched by no one, and touches nothing
until picked up by the fingers of the operator.

Formalin Preparation.—Formalin is also used in
the preparation of catgut. The catgut is wound
on a glass spool, not too tightly, and soaked for
two days in equal parts of ether and alcohol, after
which it is rinsed in pure alcohol for a few moments
and transferred to glass bottles with tightly fitting
covers, and which have been previously sterilized,
containing equal parts of formalin and alcohol,
more than enough to cover the catgut. After one
week the catgut is taken out and boiled for half
an hour in normal saline solution, and is then
placed in sterilized bottles containing alcohol until
needed.

Silk is sterilized by being boiled for two hours
before the operation. Five yards each of various
sizes of twisted Chinese and pedicle silk are wound
on glass spools and allowed to boil for two hours
before the operation. When called for by the oper-
ator the pan containing the silk is handed to him,
and he takes out the required size with sterilized
forceps. In this way the sutures and ligatures are
touched by no one but the surgeon himself. It is

always a good plan to sterilize fresh silk for each
11

162 SORGICAL LECHNIC

major operation. By so doing we are sure of it being
perfectly aseptic.

To sterilize horsehair, first wash thoroughly in
ereen soapsuds; rinse several times; soak in ether
for twenty-four hours, Boil in sterile watermamon
twenty minutes. Preserve in alcohol, 95 per cent.

Silver wire is sterilized by means of dry heat or by
boiling in a I per cent. soda solution with the instru-
ments. Usually the latter is preferred.

The zxterrupted suture is made by passing catgut
or silk through the skin from one side of the wound

FIG. 146.—Interrupted suture FIG. 147.—Continued or Glover's
(Bernard and Huette), suture (Bernard and Huette).

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 other. The duzton suture is made by
passing wire across the bottom of the wound, bring-
ing out the ends about one inch from the edge of the

FIG. 148.—Button suture (Bryant). FIG. 149.—Metal suturing clamps.

wound, and securing each end with a button. ‘The
shotted suture 1s one in which the ends of the suture,

SPONGES. 163

after it is introduced, are passed through a perforated
shot, which is then clamped.

Metal Suturing Clamps. — Modified serrefines,
made of block tin, they have been successfully em-
ployed as sutures, being readily applied or detached
by dissecting forceps. Infection through the skin or
stitch-hole abscess does not occur from their use, as
the retaining spur does not deeply puncture. Scar-
ring is decreased by their employment, and claims for
value in intestine sewing have been made.

Stitch abscesses are usually produced by unclean
suture-material. They may be caused by tying the
stitches too tightly; but, as a rule, they occur when
the sutures are not carefully sterilized. This is the
reason why so many operators prefer their silk and
silkworm-gut boiled immediately before using. It
cannot be denied that a sterile suture may become in-
fected when passing through the deeper layers of the
epidermis, and so give rise toa stitch-hole abscess.

Sponges.—Sponges are used to wash wound-sur-
faces and to absorb or soak up fluids. The sponges
most commonly employed are in the form of the
gauze pads, the cut edges being folded over and
loosely hemmed, and of square pieces of gauze, each
piece being rolled loosely in the form of a ball, the
free end being twisted and tucked in. ‘The marine
sponges are not often used at the present time. Gauze
sponges are never employed more than once. ‘Those
used in operations are afterward destroyed; those not
used are resterilized, placed in sterilized towels, and
deposited in covered glass jars, which are not uncov-
ered until called for at an operation.

- The great advantage of gauze over a marine sponge
is that it can be thoroughly sterilized.

164); SURGICAL TECHNIC.

If marine sponges are required for an operation, the
dark-colored ones should be bought. They do not look
so attractive, but they are the finest sponges; they are
‘uncut?’ and ‘‘unbleached,’’ and give more service
than the clearer-looking ones, which are partly or
wholly bleached. The bleached and cheaper sponges
have been made by cutting one large sponge into
several small ones; or by cutting off portions that
were torn in taking the sponges from the ocean.

Marine sponges should be prepared as follows: 1.
Lay them in a stout cloth and pound sufficiently to
break up grit and lime. 2. Rinse with warm water
until it remains clear. 3. Immerse in hydrochloric
acid solution (two drams to one quart of water) for
twenty-four hours. 4. Immerse in saturated solution of
permanganate of potassium, followed with oxalic acid,
then pass them through lime-water to take out all
the oxalic acid, and rinse well in plain sterile water;
after which they are immersed for twenty-four hours
in a I:1000 corrosive sublimate solution. They are
preserved until used in a 3 per cent. carbolic acid
solution.

When wanted for use the sponges are lifted out of
the jar with long dressing-forceps and rinsed in plain
sterile water.

Gauze pads for abdominal operations are made of
eight thicknesses of gauze about eight inches square,
with the edges tucked in and hemmed to prevent
fraying. |

Pads are usually made in sets of five, seven, or nine
for purposes of identification. As a further precau-
tion to prevent a pad being left within the abdominal
cavity the first pad should have a stout threaded cord

NEEDLES. 165,

attached to it. Additional pads may now be threaded
upon the cord, all being removed without fear from
miscount. A weighted or gravity pad made by quilt-
_ ing flat bits of lead within the layers of gauze may
be useful at times to act asa retractor of the intes-
tines.

Gauze, now considered the most valuable of

dressings for wounds, is cut into sections of four
_ thicknesses and folded into dressings. A large num- —
ber of these are sterilized for two hours, when they
are removed with perfectly aseptic hands and placed
in sterilized jars.

Absorbent cotton used in dressing cases is pre-
pared in the same way.

Some hospitals find it expedient to sort, wash, re-
sterilize, and use over soiled bandages and gauze.
Cotton waste, after being boiled, sterilized, and dried,
is used in place of absorbent cotton and gauze for the
filling of pads.

To sterilize oils or glycerin, place in a water-bath
and boil for two hours.

Needles of various shapes and sizes required for
an operation are sterilized with the instruments.
Many operators prefer the needles to be threaded,
then attached to a towel, which is folded, enveloped
in another towel, and securely fastened. These bun-
dles are sterilized and are not opened until called
for by the operator or his assistants. After the opera-
tion is completed the sutures and ligaments which
have not been used are carefully dried and resterilized.
In choosing the needles care must be taken that only
sharp needles and strong sutures and ligatures are
selected for use.

166 SURGICAL, TACHINIG

_ Sheets, gowns, and towels used in operations are all
made into convenient bundles and sterilized for two
hours prior to an operation. Bundles once opened
are not used again for other operations until they are
resterilized.

Emergency bundles containing everything neces-
sary for an emergency operation are stored in cases
provided for them; but if not used for forty-eight
hours, are again sterilized before being used.

Brushes.—Small hand brushes having a strong
wooden back and stiff bristles are used for scrubbing
the hands, field of operation, and the instruments.
They should be boiled two hours before the operation,
~then placed in ajar containing a I : 1000 corrosive
sublimate solution. A separate brush should be re-
served for the patient, and should beso marked. A
separate brush should also be used for the cleansing
of the vagina or rectum. Brushes used in purulent
wounds and cancer should be destroyed after the
operation. ‘The same brush should never be used
twice by the same person without being resterilized,
and no two persons should use the same brush.

Drainage.—The object of drainage is to carry off
to the surface the secretions and discharges of
wounds and cavities. The retention and accumula-
tion of these would interfere with healing, and, in
the case of septic discharge, involves the danger of
general infection. Drainage may be secured by
means of rubber or glass tubes, or by strands of
gauze, catgut, silkworm-gut, horse-hair, or silk. In
case of abdominal section the glass drainage-tube is
usually preferred to gauze drainage, because it gives
freer drainage, does not require a large opening in the

h
7
>

DRAINAGE. 167

abdominal walls, and is less likely to cause hernia;
a sinus is more apt to follow the use of gauze drain-

FIG. 150.—Drainage-tubes and syringe for sucking them out (Hirst).

age, and without anesthesia its removal is painful.
Gauze soils the dressings and edges of the wound.
With the glass drainage-tube, if properly taken care
of, the dressings can be kept as sweet and clean as
when put on. By bacteriologic examination the se-
cretions in the glass drainage-tube have been found —
on the third day free from pathogenic bacteria. The
‘‘cigarette drain’’ is made by rolling a loose twist of
gauze in rubber tissue. The chief objections to
drainage of dependent pockets in the pelvis or abdo-
Mem, asi iormulated by Dr J. G. Clark, of the Uni-
versity of Pennsylvania, are, first, that the fluids are
frequently not removed, but, on the contrary, are pent
up by the gauze drain; and, second, instead of remov-
ing infection, the gauze or tube may be the means
of introducing it from the outside into the degener-
ated fluids. ‘To overcome the dangers of dependent
pockets and dead spaces in the pelvis, Dr. Clark sug-
gests the elevation of the patient’s body after operation
to a sufficient height to start the flow of fluids from the

168 GSIACIOME, ILE CELINE,

pelvis toward the diaphragm, and thus promote the
rapid elimination, by the normal channels of exit
from the peritoneal cavity, of infectious matter, and
of vital fluids that may stagnate in these pockets and
form a culture-medium for pyogenic organisms.

The technic of postural drainage through the ab-
domen, which has met with such good results, is
very simple. Aiter the operation proper a daree
quantity of normal saline solution is poured into the
abdomen and allowed to remain, and the foot of the
patient’s bed is raised twenty inches for about thirty-
six hours after the operation. The result is that the
exudate, if infected, is greatly diluted and may all
be absorbed by the peritoneum; if inflammatory, it is
kept liquid, and organized exudates are avoided. ‘The
pressure of the viscera is removed, intestinal adhe-
sions are avoided, peristalsis does not cause pain by
irritation, the patient suffers less distress and discom-
fort, and convalescence is naturally more rapid; Fow-
ler’s position seeks, by elevating the head of the
patient’s bed and slinging the individual from the
shoulders, to prevent the spreading of a local peri-
toneal infection upward toward the vital organs.

Closure of the abdomen without drainage after
thoroughly drying out the cavity is the rule of some
operators, who believe that so-called drains for the
most part act as foreign bodies.

Care of Drainage-tubes.—lf a glass drainage-tube
is in the abdomen, the care of it is usually left to the
nurse. She must, each time before drainage, thor-
oughly scrub and sterilize her hands. A syringe is used
to withdraw any fluid remaining and for injecting irri-
gating solutions. The syringe must be washed first

DRAINAGE. 169

with boiling water, the water being passed through
it several times, then with corrosive-sublimate solu-
tion (1: 1000), followed with boiling water; the
syringe is then to be laid in the corrosive solution
until the nurse has washed her hands a second time
and unpinned the dressing covering the tube. The
rubber tube attached to the syringe is passed down
the center of the drainage-tube to the bottom, then
withdrawn a little, so that only the fluid will be
drawn up, and not the tissue of the pelvis. The
syringe-piston is to be slowly and steadily drawn up.
When removing the syringe the nurse should be
careful that blood does not drop on the dressing.
The mouth of the tube is to be covered while the
syringe is being emptied, and the corrosive and hot
water are to be passed through the syringe before
again putting it down the tube.

Some surgeons place a piece of twisted gauze into
the tube, which sucks up the fluid. This gauze is
changed at stated intervals, and the tube is cleaned
with a small piece of sterilized cotton or gauze fast-
ened on the end of a pair of long forceps; then a
fresh twist of gauze is inserted. The amount of
fluid drawn and its character must always be reported
by the nurse. When the drainage-tube is to be
removed, the nurse should observe the same precau-
tions as she would for a dressing.

Glass drainage-tubes are made aseptic by boiling
for two hours before the operation.

Preparation of Rubber Drainage-tubes.—Cut tubing
into desired lengths, slip each piece over a glass rod,
and scrub with a stiff brush and green soap. Rinse
in sterile water until entirely free from soap. Boil for

7) SURGICAL TE CHNIC-

one hour in a 1 per cent. solution of sodium bicar-
bonate (enough to impart a greasy feel to the water);
rinse again several times in sterile water, and put into

FIG. 151.—Drainage-tubes: a, glass; 0, rubber.

sterile jars and cover with alcohol or carbolic acid,
1:20, “Ihe jar is kept covered) except wiemueaae
tubes are being put in and taken out by sterilized
forceps.

Rubber Dam.—Rubber dam is sterilized by boil-
ing in 1 per cent. soda solution, and is afterward
transferred to a glass jar containing 1: 20 carbolic
acid solution.

Cargile membrane, tissue made from the perito-
neum of the ox, is used as a protective against adhe-
sion formation, particularly in operations upon the
bowels.

Several years ago the reviser discovered a similar
material to be very cheaply and easily obtained from
sharks.

Gloves.—Rubber and cotton gloves are much
employed in surgical work, and with very good re-
sults. ‘hey prevent infection by the surgeon’s and
assistants’ hands, which even with the greatest care
cannot be rendered completely sterile. The cotton
gloves are sterilized by dry heat. The rubber gloves

GLOVES. 171

are sterilized by boiling one hour in a 1:20 solution
of carbolic acid, after which they are transferred to a
basin of sterilized water until required for use. To
put them on, they are filled with sterile water until
the whole glove becomes distended, after which they
are easily slipped on. Some surgeons wear the
gloves to protect the hands after they have been

Zi

Y }

WY
Wi )

FIG. 152.—Finger cots. FIG. 153.—Rubber glove.

sterilized and remove them when all is ready for the
operation. ‘The disadvantage of rubber gloves lies in
their causing the wearer’s hands to perspire, thereby
increasing the danger of infecting the wound in cases
of accidental puncture of the glove by knife or needle
during operation. ‘The same care must be used in
scrubbing hands when rubber gloves are used as
when they are not. Careless regard of this rule will
end up sooner or later in infection from a punctured
glove.

Rubber-glove Solution.—Murphy suggests an asep-
tic film covering sufficiently tenacious to last during
several hours’ work, to be made by dipping the hands
and arms into a 4 per cent. solution of pure gutta-
percha chips dissolved in sterile benzine or acetone

172 SCOR CICAL It) CHINIC.

(use chloroform or carbon tetrachlorid in place of these,
owing to inflammability). The solution must not be
boiled. Apply by immersion, allowing excess to drip
from the fingers; the acetone solution dries in a few
seconds, that of benzin requires two or three minutes.
Remove from the skin, which is left pliant, by wash-
ing in benzin.
Green Soap.—

Caustic potash, 12 ounces.
Linseed oi], now
Alcohol, Are

Heat the oil in a vessel to 140° F. or till it is too hot
for the fingers. Dissolve the potash in 67 ounces of
hot water. Add the alcohol and let it cool. Then add
the heated oil, stirring constantly until mixed. Let
the mixture stand twelve hours and add alcohol.

To make a tincture of green soap:

Green soap, 3 parts.
Alcohol o5) per centa. 2a
Ether, I part.

To prepare cold, mix and stir for a few minutes
every hour until a clear solution is formed; or the
soap may be melted first over a slow fire. Remove to
a safe cool place, stir occasionally, and just before
complete hardening recurs, add the alcohol and ether.

CHUAGP dee xO I:
INFLAMMATION.

INFLAMMATION is the reaction of a part to an
irritant.

The first changes are in the vessels and circulation;
second, a passing out of fluids and solids from the
vessels; and third, changes in the perivascular tissue
—z. €., the tissues about the blood-vessels. These

FIG. 154.—Normal vessels and FIG. 155.—Dilatation of the vessels
blood-stream. in inflammation.
(American Text-Book of Surgery.)

three changes produce the characteristic phenomena
of inflammation—heat, redness, swelling, pain, and
loss of function.

The first change in an inflamed area is a dilatation
of all the vessels—the arterioles, capillaries, and
venules. As a result, there is an increased activity

in the circulation and an increased flow of blood to
173

174 SORGICAL LECHNIG

the part, a condition known as active hyperemia.
After a time the blood-current begins to slacken;
then the white cells approach the vessel-wall and

J

li Th Wy
aie,
w\\ W

cs

ow
—— —

SS or:
SSE

FIG. 156.—Ice-bag (Ashton). FIG. 157.—Water coil.

begin to pass through it (emigration of white cells).
There is also a passing out of plasma or fluid from
the blood, and in severe cases of inflammation the
red cells may also pass out. If we now examine the
inflamed area with a microscope, we find an enor-
mous number of cells, chiefly white blood-cells, in
the tissues about the vessels. Fibrin in the form of
delicate granules and fibrils may also be present.
Inflammation is a process which is directed to the re-
moval of an irritant, which may be either a portion of
an injured tissue or a foreign body or material. After
this result has been accomplished healing or regen-
eration takes place. If the inflammation was caused
by bacteria, suppuration is likely to follow. In that
case the tissues will liquefy and the cells will be
thrown off suspended in a liquid (liquor puris), the
whole being known as fus. In suppuration there is
always loss of tissue, and healing, if it occurs, is

INFLAMMATION. 175

brought about through the formation of a scar. In
order to produce healing granulation-tissue is formed.

FIG. 158.—Bier’s vacuum treatment apparatus for boils.

Granulation-tissue consists of new cells and tiny capil-
lary loops. It is sometimes called ‘‘ proud flesh,’ and
bleeds very easily. ‘The scar has a marked tendency
to contract and may cause great deformity.

FIG. 159.—Bier’s air suction apparatus for treating stiff knee.

Among the causes of inflammation are injuries,
chemical irritants, heat and cold, and bacteria.

CHARTER ie

CATHETERIZATION; DOUCHES; ENEMATA;
WASHING OUT THE BLADDER; LAVAGE.

THE use of the catheter is ordinarily very simple,
and yet it may truthfully be said that there is no oper-
ation which is performed with so little regard for asepsis.
Asepsis and antisepsis are as important here as they
would be in preparing for an abdominal operation.

Cystitis is often caused by the introduction of germs
into the bladder by means of a dirty catheter, or by
not cleansing the external genitals, vestibule, and
meatus before the operation. Normal urine is to be
considered sterile unless there is some disease of the
kidneys or bladder; and when infection occurs we
may assume that the germs have gained entrance
from without. The catheter may be of glass. When
a glass catheter is not at hand, a silver or rubber
one may be used. When of glass or silver or rubber it
should be boiled twenty minutes before being used.

Glass catheters are the best; they are easily
rendered aseptic, and show whether they are or are
not perfectly clean. Sterilization is most important
before using the catheter and immediately afterward.
There is no danger of the catheter breaking, as so
many patients fear, if it is not cracked before being
introduced. Besides the catheter, which is taken to

the bedside in a basin of very hot water, there are
176 3

Bs:
.

LNTTRODOCTION TOT: THE CATTLE LET.:. E77

needed a basin of corrosive sublimate solution
(1000) sterilized” eauze or cotton, and a vessel
to receive the urine. A lubricant of sterilized oil

FIG. 160.—Virginal vulva: 1, Labia majora ; 2, fourchet; 3, labia.minora ;
4, glans clitoridis; 5, meatus urinarius; 6, vestibule ; 7, entrance to the vagina;
8, hymen; 9, orifice of Bartholini’s gland; Io, anterior commissure of labia
majora; II, anus; 12, blind recess; 13, fossa navicularis ; 14, body of clitoris.
(Modified from Tarnier.)

to render the entrance of the instrument as easy as
possible is used only when a gum-elastic or rubber
catheter 1s employed. A mixture of ecarbolic acid
solution (I : 40) and glycerin serves for this purpose.
Introduction of the Catheter.—The patient lies
on her back with the knees drawn up and _ sepa-
rated, the upper clothing being divided over each

knee to guard against unnecessary exposure. ‘The
12

178 SURGICAL TECHNIC.

labia are separated with sterilized sponges and the
parts washed with the corrosive solution. The
catheter is inserted into the urethra, the opening
of which is just above the vaginal entrance. If there
is any difficulty, the catheter should be withdrawn a
little, and gently pointed a little downward or up-
ward, to the right or to the left. If the flow should
cease before enough urine has been drawn, the cathe-
ter is withdrawn a little or is inserted a little farther
than before. Before removing the catheter a yaneer
should be placed over its end, to prevent any drops
of urine wetting the bed. After the operation the
parts are again washed, and the catheter boiled and
placed in a bottle containing a solution of carbolic
acid (1 : 20), unless the catheter is of rubber; for car-
bolic acid ruins rubber.

When the bladder is partially paralyzed from result
of an operation, or otherwise, a rectal injection of
very warm water will often cause the bowel and
bladder to empty themselves at the same time, thus
doing away with the necessity of using a catheter.

The urine for examination by the physician is best
drawn with the catheter, to prevent contamination
from vaginal discharges.

A distended bladder must be emptied gradually;
several sittings, at intervals of four or six hours, may
be necessary 1n some cases; and as the last amount of
urine is being drawn the flow should be slowed, to
prevent any injury to the mucous membrane of the
bladder from drawing it into the eye of the catheter.

Irrigation of the Bladder.—T'o irrigate the
bladder a fountain-syringe, cleansed with boiling
water and a disinfectant, is needed; also a glass
catheter, which is sterilized in the same way as for

;
:
!

hae ay * "
eee ee ee

EXAMINATION OF STOMACH-CONTENTS. 179

catheterizing. The parts, of course, are cleansed in
the manner described. The patient is first catheter-
ized; the catheter is then rinsed with boiling water
and attached to the rubber tubing of the syringe
which contains the irrigation solution (boric acid or
salt solution), the temperature of the latter being
about 100° F. The solution must run warm before
the catheter is inserted. The rapidity of the flow is
regulated by raising or lowering the irrigator. The
quantity of solution introduced is governed by the
feelings of the patient ; usually 200 c.c. 1s all that
can be tolerated, after which the tube is disconnected
and the fluid is drawn off. If a double catheter is
used, the tubing is not removed. ‘The irrigation is
repeated until the washings come away perfectly clear
and clean.

Examination of Stomach-contents. — Many
times the nurse is called upon to give a test-break-
fast and to send the stomach-contents to the labora-
tory for examination.

A test-breakfast usually consists of a cup of tea
without milk or sugar, and two soda-crackers; or in-
stead of the crackers a small piece of rare steak or
small piece of bread without butter is given. One
hour after, the stomach-contents are obtained by pass-
ing the stomach-tube. As soon as the tube comes in
contact with the walls of the stomach they contract
and force out the contents. If vomiting does not
occur, it may be excited by pouring down the tube
about two drams of lukewarm water. The contents
are measured, and placed in a clean bottle labelled
with the patient’s name, the date, quantity, and hour
that the breakfast was given and contents secured;
the bottle is then sent immediately to the laboratory.

180

SURGICAL TECHNIC.

In cases where revulsion does not occur, pour a
measured quantity of warm water (one pint) into the
stomach, remove it, and secure the test meal by
siphonage (lower the mouth of the stomach-tube
below the level of the patient’s stomach, when gravi-
tation will cause the fluid to flow).

Douches.—Properly given, the vaginal douche
relieves inflammation, checks hemorrhage, acts as a
stimulant and cleansing agent, and checks secretion.
The amount of water used is from five to six quarts,
of a temperature of 110° F. The temperature must

FIG. 161.—Bath-
thermometer.

always be tested with a bath-thermometer
(Fig, 161)) mot with) the) ianelsedeme
Baker douche apparatus (Fig. 162) is an
excellent conttivance, = im fitce=albsemec
a fountain-syringe may be used.

-When taking a douche the patient
should le on her back, with the thighs
flexed om the abdomen and the legs
flexed on the thighs. In this position
the water comes in contact with the
whole vagina.

The pail or fountain-syringe must be
hung about four feet above the bed, so
that it will take about twenty minutes
for the water to run out, “Aur miitstie
expelled, and the water must run warm
before the tube is inserted into the vagina.
The vaginal tube must always be steril-
ized before and after using, and every
patient should have her own tube.

Many patients in private practice object

to taking douches, and will neglect them on account
of the inconvenience; but this they can overcome by

DOUCHES. I8I

taking the douches in the bath-tub. Half-way across
the bottom of the tub a piece of board is placed, on
which the patient can lie. The douche-board designed

SS
ise) SSS
SS "5N\ mi,
Sa
fe) = |
oO : ; \
Le i i
oO aad

by Prof. Byron Robinson, of Chicago, has proved very
beneficial and convenient to patients by giving them
a comfortable and simple method of taking a douche.

= —

|

Hl: Hat he bi
Se

i

ml

It can be used without legs, on a bath-tub, and with
legs (some twelve inches long) may be used in any
room.

Antiseptic Douches.—Corrosive sublimate, carbolic
acid, creolin, and boric acid are used for antiseptic

182 SORGICAL TECHNIC.

douches; and to prevent absorption and irritation
a plain water douche is often given after any of
these antiseptics.

FIG. 164.—Douche-board.

After any intra-uterine douche too forcibly given
uterine colic with dangerous collapse may occur.

A patient shouid le quietly for one hour after tak-
ing a douche; if only one is used a day, it is best to
give it at night, because then the uterus is most con-
gested and needs the hot water most, and the tempo-
rary weak feeling which follows a douche will be gone
before morning.

Rectal Injections (Enteroclysis) and Irriga-
tion.—The therapeutic range of this procedure is not
confined to the treatment of local troubles. It has
long been used as a means of cleansing the lower
bowel of accumulated feces. In the treatment of
rectal ulcers and inflammations it has been employed
both to relieve the irritation produced by fecal matter
and to apply various medicaments to the parts. For
the prevention of shock normal saline solution is

RECTAL INJECTIONS. 183

injected—one or two pints. This, by filling the
blood-vessels, enables the patient to withstand the loss
of blood from the nerve-centers. After the operation
shock and hemorrhage are counteracted by its use,
and at the same time the thirst is relieved and rest-
lessness quieted. In septic conditions, both local and
general, by diluting the toxic materials in the circu-
lation and promoting their excretion by the skin,
kidneys, and bowels, saline rectal injections play an
important part in the treatment.

In patients whose digestive tracts are too weak to
hold food or medicine rectal feeding or rectal medi-
cation is employed. ‘The rectum should be washed
out thoroughly before the injection is given. If the
rectum is intolerant and will not retain what is in-
jected, it is well to turn the patient on her left side
and raise the hips on a pillow or a folded blanket.
A long rectal tube should be used as for a high
enema. ‘The physician will give directions as to the
temperature of the solution. In fever patients and
in the hemorrhage of typhoid fever great relief and
comfort are afforded by using very cold or iced water.
In shock or hemorrhage a temperature of 100° F. is
usually preferable. In long-continued lavage for
local trouble the patient’s preference as to the tem-
perature is generally consulted.

A stimulating and nutrient enema, black coffee,
or hot saline solution is given when symptoms of
shock appear either during or after an operation ;
it should be injected high up into the colon. The
rectum should be thoroughly cleansed at least once
daily with warm saline solution, which will also
aid the absorption of the nutrient enema. When

184 SURGICAL TECHNIC.

feeding by rectum in gynecologic cases, it should
be remembered that tight tamponing of the vagina
may interfere with absorption in the rectum. lf the
presence of hemorrhoids is a drawback, a 2 per cent.
solution of cocain may be used before injecting the
fluid.

Stimulating exema :

Whiskey, 2 ounces.

Ammonium carbonate, I5 grains.

Beef-tea, 4 ounces.
Or :

Brandy, 2 ounces.

Tincture of digitalis, 20 minims.

Milk, 4 ounces.
For tympanttes :

di imetine onasaicrida, 2 ounces.
Spirits of turpentine, I outice.
Magnesium sulphate (Ep-

som salt), | 2 ounces.
Warm water, I pint.

Purgative enemata-:

1. Warm soap-suds, yy pint.

2. Common black molasses, 12 ounces.
Wari soap-suds, LO.

3. Molasses, black, 4 ounces.
Glycerin, Ae ie
Magnesium sulphate, I ounce.
Spirits of turpentine, 1 os

Warm soap-suds, 8 ounces.

RECTAL ANJECTIONS, 185

4. Glycerin, 4 ounces.
Turpentine, I ounce.
Magnesium sulphate (Ep-

som salt), 2 outices.

5. Inspissated ox-gall, Y% ounce.

Warm water, I quart.

6. Spirits of turpentine, 10 drops.
Mucilage of acacia, Y% ounce.
To be given high.

7. senna, yy ounce.
Magnesium sulphate, % “
Olive oil, neater
Boiling water, I pint.

Infuse the senna in the water. ‘Then dissolve
the magnesia, add the oil, and thoroughly mix
by stirring.

CHA 2 Ie RI XG Ve
MINOR SURGICAL PROCEDURES.

Hypodermic Injection.—This procedure is em-
ployed to secure rapid medication or in obtaining
local anesthesia by the injection method. When
used in the latter capacity it is called interdermic
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

FIG. 165.—Method of reducing primary puncture pain in cocainization or
hypodermic injection.

puncture use first soap and water. Apply ether,
alcohol, or tincture of iodin to render the site sterile.

Insert the needle-point at the summit of a pinched-
up fold of the sterilized skin (Fig. 165). For hypo-
dermic medication the skin of the arm, forearm, or
the thigh may be selected, fleshy parts favoring rapid
absorption. Avoid superficial veins and deeper ves-
sels, as direct entry of the drug into the blood-current
might give rise to a too rapid effect.

186

MINOR SURGICAL PROCEDURES. 187

Counter-irritation.-—Counter-irritation or revul-
sion is a method of producing 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 area or
through the nervous system, and may be used in
cases of localized inflammation or congestion to
overcome neuralgic pain and in conditions of gen-
eral depression or shock.

The methods employed may be mild or severe in
their effects. Of the milder means used for the pur-
pose the mustard foot-bath is one of the best. It
consists in soaking the feet and legs of the patient
in a bucket two-thirds full of water at a temperature
of from 110° to 140° F., to which has been added
one to two tablespoonfuls of ground mustard. ‘The
patient’s body should be protected by blanketing
during the bath, which may continue 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.

Mustara-plaster, made by mixing up one part of
ground black mustard to five parts of wheat flour or
flaxseed in a little water, and applied upon a cloth
or folded newspaper 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.

188 SURGICAL TECHNIC.

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 much pain or irritation.
Spice-plasters or bags are often ordered in the treat-
ment of children. The mixture consists of equal
parts of ground ginger, cloves, cinnamon, allspice,
to which add and thoroughly mix one-fourth part
of Cayenne pepper; wet with hot water, alcohol, or
whiskey before applying. ‘The so-called warming
plaster consists of Burgundy pitch 12 parts, canthar-
ides cerate 1 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: (@) Heat may be used as
a pyretic in shock, collapse, insanity ; (2) cold as an
antipyretic in acute fever, sunstroke.

Application.—(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
(Fig. 166), hot blankets); (4) Mozsz, poultice (flaxseed,
oatmeal, or hops, mixed with water, is sterilized by
boiling); hot bath ; hot pack ; hot douche ; hot fomen-
tation (gauze, flannel, or towel wrung out in hot water,
hot antiseptic solution; change when cooled). A ready
method of producing diaphoresis (sweating) is by pour-
ing water upon hot bricks wrapped in flannel.

a Sia an)
Mawes
2 tere =

MINOR SURGICAL PROCEDURES. 189

(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) ; (0) Mozst¢ (irrigation, ice-water compresses, cold
pack—wringing sheet out in ice water and wrapping
it around the patient. Keep it wet by sprinkling);

FIG. 166,—Hot-air oven.

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.—Vaccination is the inoculation of
an individual with the virus of cow-pox.

Fic. 167.—Mareschal’s individual vaccination stylet.

dine intplements: needed] are a ueedle, lancet, or
ivory point (Fig. 167); fresh virus (bovine or human-
ized).

Vaccination is performed as follows: (a) Render
skin surface aseptic (select by choice upper and outer
third of arm, inner side of thigh) ; (4) abrade the skin

I9gO SORGICAL “TECHNIC,

until serum exudes; (c) carefully work in the moist-
ened virus; (a) 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: (2) Ammonia;
(4) chloroform ; (c) camphor; (@) 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); (4) ichthyol; (c) bella-
donna; (@) boric acid; (e) resorcin; (/) iodin. Do
not use 1odin locally where there will be a possibility
of a future cutting operation, because the skin be-
comes like leather and heals badly.

FIG. 168.—Dry cup.

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 (Fig. 168). The operation is performed

ii ESS oy co aa

MINOR SURGICAL PROCEDURES. IgI

by means of special 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; (2) scarify with a bistoury or by means of a
spring scarificator upon the cupped sites; (c) reapply
the cups to the incised areas; (@) treat the scarifica-
tion wounds antiseptically.

Cupping is employed to produce local depletion ;
wet cups are better in serous inflammations.

Leeching.—(a) American leech (draws about a
teaspoonful—4 c.c.—of blood).

(6) Swedish leech (draws three or four—12-16 c.c.—
teaspoonfuls).

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 re-
place in a jar of water having a perforated cork. Dress
the wound antiseptically; apply a compress, nitrate of
silver torsion (acupressure), for continuous bleeding.

Leeching is employed to secure local depletion.

Scarification.—This consists in the making of
small linear incisions through the skin and subcu-
taneous or mucous tissues for the purpose of securing
local depletion to relieve tension.

I92 S\OKIGM CALE AOFM NC:

Puncturation is the operation of making punc-
tures with a sharp-pointed bistoury through the skin
or mucous tissues. It is performed to secure local
depletion or to relieve pressure.

Deep puncture and incision with a sharp-pointed
bistoury is sometimes performed—(qa@) To relieve ten-
sion ; (4) 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) ; (4) mercury (used for
its resolvent effect upon indurated glands, chronic
arthritis); (c) adhesive, ‘‘ American surgeon’s adhe-
sive plaster’’ (contains rubber, and adheres without
heating) ; (¢) resin plaster (requires heating to adhere).

Collodion and cotton are used to support and
seal external flaps and wounds.

Massage.—Massage consists of manual manipu-
lations 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
(stroking movements, gentle at first, afterward of
increasing 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 (ele-
vation, flexion, and contraction of the parts produced
by the operator).

Clinical Thermometer.—May be of Fahrenheit
(common form) or Centigrade scale. ‘To reduce read-

;
{
a
=
4
:
4
4
F

© on: = Daa e ie

MINOR SURGICAL PROCEDURES. 193

ings—(1) Fahrenheit to Centigrade: Subtract 32 from
the number of Fahrenheit degrees and multiply the

FIG. 169.—Clinical thermometer.

remainder by 3; (2) Centigrade to Fahrenheit: Multi-
ply the number of Centigrade degrees by ? and add 22.

Thermometers may be—(a) straight, self-register-
ing (90° to 110° F.—33.3° to 44.4° C.); (8) surface,
coiled or bulb (80° to 110° F.—26.6° to 44.4° C.).

Temperature may be taken in—(a) Mouth; (0)
axilla; (¢) rectum ; (@) vagina. Most exact in vagina
and rectum. Mouth-temperature is higher than that
ey guae axilla and less than that of the rectum.
Axilla-temperature is somewhat less than a degree
below the rectal.

Electricity is used—(a) As a muscle tonic; (0) for
nerve-sedative action employ that form of electricity

; CoM TTT,

which gives the best contractions with the least
amount of pain and discomfort to the patient; for

FIG. 171.—Electrolysis needles.

implements required see Figs. 170, 171; (c) electrolysis
(used in the treatment of aneurysm, tumors, for the
13

194 SOKRGICA LE EE CENCE.

removal of superfluous hair); (7) cautery, ecraseur
(is followed by least hemorrhage when used at a dull
pred lneab):

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; emol-
lient drinks; fixed oils (sweet oil, olive oil, cod-liver
oil). 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 ; whiskey 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
of the leg.

Aconite.—Give emetics; stimulants (external and
internal); keep up the body-heat; patient is to be
placed flat on his back.

Antimony Tartrate.—Give vegetable acids—tannic
acid (gr. v-xv—o.333-I gm.), catechu (13j-1j—4-8
Ce):

Arsenic.—Give freshly precipitated hydrated ses-
quioxid of iron (made By adding magnesia to any
iron solution).

Atropin, Belladonna, Stramontum.—Emetics (mus-
tard flour in water); apply cold to the head; give
physostigma (gr. 7j;-}—0.006-0.013 gm.) or pilo-
carpin (gr. }—o.008 gm.).

Cantharides.—Give emetics; emollient drinks;
opium (gr. ++—0.016-0.033 gm.) by mouth and

ee ee ee ee

POISONS AND ANTIDOTES. 195

rectum; large draughts of water to flush the kid-
neys.

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 in leg; hypodermic piece (15 min.—I c.c.)
of tincture of digitalis; gr. <4 (0.001 gm.) of atropin.

Colchicum.—Give netics) followed by demulcent
drinks; keep up external heat. If coina is present,
brandy, ammonia, coffee. Opium in large dose.

Contum.—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 Ovl.—Give emetics ; wash out the stomach ;
mucilaginous fluids containing opium.

Digitalts.—Give emetics; recumbent position;
tincture of aconite (1-5 drops—o.066-0. 333 c.c.);
opium (gr. 14+—o0. 16-0.033 gm.).

Elatertum.—Give demulcent drinks; enemata of
opium; external heat.

Flyoscyamus.—Stomach-pump ; give emetics ; stim-
ulants (external and internal); physostigma (gr. ~- ~
0.006 gm.); pilocarpin (gr. +—o.008 gm.).

Illuminating-gas.—Hypodermic injection (I min.
=O OOO) C.C,) Ol) Mitroglycerin eatry (oil artiticial
respiration.

196 SURGICAL TECHNIC.

lIodin.—Give emetics; demulcent drinks (starch
or flour in water); opium (gr. 14—0.016-0.033
gin.); external heat.

Lead Salts.—Give any soluble sulphate (magnesia
or soda). Follow with emetics, opium (gr. j-}—
0.016-0.033 gin.), and milk.

Lobelta. External and internal stimulation. |

Morphin; Opium.—Atropin (gr. zyp—0.006 gin.)
hypodermically 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; per-
manganate of potassium; cocain (gr. 4+-1—o.016-
O1022) Sil. |) Tepedta im Mecessany.

Oxalc Actd.—Give lime (plaster, lime-water, milk.

of lime).

Phosphorus.—Sulphate of copper in emetic dose as
a chemic antidote; emetics; purgatives. No oils.

Potash and Soda Salts.—Dilute acetic acid; citric
acid; lemon-juice; vinegar: txed oils) demumlcems
drinks.

Selver Nitrate.—Solution of common salt; demul-
cent drinks; emetics. :

Strychnin; Nux Vomica.—Give 30 grains (2 gm.)
of chloral and 60 grains (4 gm.) of bromid of potas-
siuin ; nitrate of amyl.

Tobacco.—Emetics ; stimulants (external and inter-
nal); strychnin (gr. 34-7,—0.0022-0.0044 gm.).

Zinc Salts.—Carbonate of soda; emetics; warm
demulcent drinks.

Potsonous Fish.—Emetics to wash out the stomach ;
purgatives; stimulants. ©

a _ 4 > * " - —
ee ee es ee eee

ee.

CHAS Ral Re xe:
OBSTETRICAL NURSING, CARE OF INFANTS, ETC.

PROFESSOR Hirst has employed printed slips con-
taining the following directions to the nurse:

BEFORE LABOR.

leave ready towels; ether, 4 lib. + brandy, 2 oz. >
vinegar, 4 oz.; hot water; a bottle of antiseptic tab-
lets; 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.

Ill. No vaginal injection to be given unless
ordered.

IV. Take the temperature three times a day—
morning, noon, and evening.

Weeblace larse pad wader 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
solution, I: 2000. Use absorbent cotton.

VII. If, at the end of twelve hours, the bladder
197

198 SURGICAL . TECHNIC.

cannot be emptied naturally, use a catheter. After-
ward, if necessary, catheterize patient three times a
day.

FIG. 172.—Bed arranged tor 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 sublimate
solution, I: 2000, in which are many large pledgets of cotton; a small tin
cup on an alcohol lamp to boil 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).

VIII. The patient is to lie on her back ;shemnay,
be moved from one side of the bed to the other sev-
eral times a day; her limbs may be rubbed with alco-
hol and water or bathing whiskey once a day.

OBSTETRICAL NURSING, CARE OF INFANTS. 199

IX. The nurse’s hands are to be washed with nail-
brush, soap and water, and rinsed in a I: 3000 sub-
limate solution before catheterizing the patient,
cleansing the genitals or breasts.

Diet.—first 48 Hours.—Milk, 1%-2 pints a day,
gruel, soup, one cup of tea a day, toast and butter.

Second 48 Hours.—Milk-toast, poached eggs, por-
ridge, soup, corn starch, tapioca, wine jelly, small
raw oysters, one cup of coffee or tea a day.

Third 48 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 thermometer, or else the water will often be
too hot.

II. The cord is to be dressed with salicylated cot-
ton. Observe carefully for bleeding.

III. It should be bathed daily, about mid-day, 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 talcum powder, lycopodium, zine oxid, or
rice flour. In case 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

200 SOK GICAL. LE CHNIGC,

food is to be givenit. After the second day it should
be nursed every two hours, from 7 A.M. to 9 P.M.,
and. twice during the night (1 A.M. and 5 A.M.).
After every nursing the nipples are to be carefully
washed with a piece of absorbent cotton, warm water,
and Castile soap, and then smeared with a little sweet
oil.

|-——- a =n "=== === --- 4

Fic. 173.—The Murphy breast-binder.

Clothing.—lf born during the winter season a
baby should be clothed as follows: A binder of flan-
nel or knit wool twice around abdomen, a knit shirt,
diaper, knit woollen shoes, and two skirts, the first
flannel (in midsummer, linen), and finally its dress.
The skirts should 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 one ounce, and it increases one ounce
per month up to six months. A child should never
be nursed while it lies in its crib, but be taken up in

. _ 2 » =e me =a ii iy ara mal
ae ee el a el - Hh a

OBSTETRICAL NURSING, CARE OF INFANTS. 201

the arms. Young mothers experience great pleasure
in suckling a child, and may put it to the breast every
fifteen or thirty minutes, giving rise to derangement
of the infant’s bowels which may become serious.

FIG. 174.—Schultze’s method of artificial respiration: A, Inspiration;
£8, expiration (Hirst).

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 prepared foods are injurious according to the
amount of starch contained.

Milk Mixtures.—(a) For first twelve or fourteen days
take:

Condensed milk, 1 teaspoonful.
Boiled water, 3 tablespoonfuls.
Cream, 1 teaspoonful.
Lime water, I z

Stir.

202 MOG HOAUE SSE CIZONME.

(6) After fourteenth day up to third month the
following may be used:

Milk, 1 tablespoonful.
Boiled water, 5 teaspoonfuls.
Cream, I teaspoonful.
Lime-water, a 4
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
teaspoonfuls.

(c) A mixture for general use may be made accord-
ing to the following formula:

Milk, 1 ounce, 2 tablespoonfuls.
Boiled water, I ounce, 2 M
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
KeSuLe:

Clete e IIE IR Ok Vi tp

OPERATIONS ; PREPARATION OF THE OPERAT.
ING-ROOM; THE SURGEON AND HIS
ASSISTANTS.

SURGERY has two objects, to prolong life and to
relieve suffering. If it accomplishes either of these
objects it succeeds. ‘To prolong life or to relieve suf-
fering divides operations into several classes, because
they occur with more or less urgency according to
the condition the patient is in.

We often hear it said of an operation that it is one
of necessity; of another, that it 1s one of emergency;
and of another, that it is one of expediency. For
convenience, operations are divided into two classes.
First, operations of necessity; second, operations of
expediency; and the first class may be subdivided
into emergency and elective operations.

Operations of 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.
203

204. SURGICAL LECLHINIC:

Operations of mecesszty are performed to save the
life of the patient, as, forexample, in cases of intes-
tinal obstruction, in hemorrhage from rupture of an
extra-uterine pregnancy, etc.

Emergency operations are those which must be
performed immediately, without any choice, such .
as tracheotomy.

An elective operation is at the choice of the patient;
if done at all, it is only as a last chance and forlorn
hope.

Preparation of the Operating-room.—The op-
erating-room should be made as aseptic as possible;
the walls and floor should be washed with corrosive-
sublimate solution (1:2000). The operating-table,
stands, chairs, and other furniture, which are usually
of glass and iron, should be washed with the subli-
mate solution. ‘The sterilizer, which has been packed
with the dressings, blankets (2), sheets (2), towels,
caps, suits, and gowns for the operator, assistants,
and nurses, should be started two hours before the
operation. ‘The instruments should boil half an hour
before the operation in a 1 per cent. soda solution.
Everything that will be needed for the operation and
for possible accidents must be in the operating-room,
and within easy reach. The solutions used should be
quite warm, both for the surgeons and patient. We
often come across a nurse who when she has filled
the basins will put in her dirty hand, to see if the
water is too hot or too cold. We can readily tell
from the outside of the basin if the water is of the
proper temiperatune:

At all major operations four nurses are necessary—
the head nurse, who has charge of the instruments;

PREPARATION OF THE OPERATING-ROOM. 205

a second nurse, to take charge of the sponges; a third
nurse, to keep ready for the operator a basin of ster-
ile water to enable him at any time to quickly rinse
his hands to remove septic fluid or to free his fingers
from blood and clots, and attend to the irrigation,
Eves 1ourth murse, to handle; unsterilized. articles.
Each nurse should have a clear idea of her duties,
and discharge them without undertaking the duties
belonging to another. If the dry technic is used, the
head nurse can hand the sponges as well as the in-
struments, and this givesa nurse to wait on her exclu-
sively. Under no consideration should the head
nurse be left alone for a single moment, as the
operator might call for something which she, being
‘surgically clean,’’ could not touch, and so cause a
probable delay in the operation.

The duties of the nurses in the operating-room are
the same for all operations. The dress must be of
washable material, preferably white; it should be
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 aday. The dress-sleeves should be unbuttoned,
so that they can be rolled up above the elbow, to allow
the arms to be made as sterile as possible, and so
that the sleeves may not come in contact with any-
thing used in the operation itself. The finger-nails
must be cut short. On first going to the operating-
room the hands and forearms should be scrubbed with
a brush and green soap and running water as hot as can
be borne for ten minutes by the clock. The cleaning
of the finger-nails is very important, as many of us
would be surprised to find the large number of germs

206 SORCGICAL GLECHNIC.

taken from under the finger-nails as the result of one
cleansing.

The hands and forearms are then rendered absolutely
sterile by putting them first into a saturated solution of
permanganate of potassium until they are of a deep-
brown color from the tips of the fingers to the elbow,
then into a hot saturated solution of oxalic acid until
all the permanganate stain has been removed; they are
then washed in sterilized hot water, and finally are
soaked for three minutes in a solution of corrosive
sublimate (1 : 1000). The solutions reach those corners
and crevices in the finger-nails that cannot be reached
by the brusn.

Some surgeons prefer ether and alcohol for cleans-
ing the skin. After the hands have been scrubbed
thoroughly in hot soap-suds and the finger-nails
cleaned, the hands are washed in ether, which re-
moves from the skin all oily and fatty substances;
they are next washed in pure alcohol for one minute,
and finally soaked for three minutes in a solution of
corrosive sublimate (1: 1000). The field of operation
is cleansed in the same manner with ether, alcohol,
and the sublimate solution.

The nail-brushes used should be absolutely sterile.
They must be new, and need to be boiled for two
hours on the day before the operation, and then put
into a glass jar containing corrosive sublimate
(x :1000). A dirty nail-brush is the haven of myriads
of germs and their spores, and by using such a one
we place more germs on our hands than were there
before they were touched.

In some hospitals it is the custom to put on ster-
ilized rubber gloves, to protect the hands from con-

Clinical Amphitheater, Medico-Chirurgical Hospital, Philadelphia.

PREPARATION OF THE OPERATING-ROOM. 207

tamination until the operation begins. The nurses
next put on sterile caps and gowns. 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 operation is commenced, for such
is very easy to occur unless the nurse is constantly
on her guard against it.

Wl lp, 7

SSS

FIG. 175.—a, Long-sleeved gown; 4, the same, showing glove with gauntlet
turned up over wristband of gown (Hirst).

The surgeon and his assistants prepare for the
operation very much the same as does the nurse.
Many surgeons before operating take a corrosive-
sublimate bath (1: 500), after which they put on

208 SORGICALE LE CHINIGE

clean linen suits or long gowns and prepare their
hands and forearms, after which they put on sterilized
suits. The suits, which have been sterilized in bags
or folded in a sheet, are taken from the sterilizer by
the head nurse, and placed in the dressing-room about
one hour before the arrival of the surgeons, so that they
may be perfectly dry when required for use. They
should not be hung over the back of a chair, or laid
over a table for dust to collect upon them. We must
bear in mind that after sterilization there is always
the danger of contamination, and the articles must
be carefully protected as soon as they are removed
from the sterilizer. To avoid confusion, each suit
and bag should be distinctly marked with the owner’s
name, as should also the white canvas shoes which
some surgeons wear. ‘The caps must be laid in the
dressing-room, together with long strips of sterilized
gauze to cover the beard and mustache.

Spectators should remove their coats and wear long
linen gowns. The nurses should not leave the
operating-room unless it is absolutely necessary, and
there should be no unnecessary opening of doors,
which allows cold air to enter. Constant moving
also causes. dust to become stirred up. The tem-
perature of the operating-room should be 80° F., and
the air kept perfectly pure by thorough ventilation,
which should be so arranged that draughts will be
avoided. .

With the kind permission of Dr. F. W. Johnston,
of Boston, I extract the following from his paper on
‘““T'wo Years’ Work with the Sprague Sterilizer in
the Gynecologic Department at St. Elizabeth’s Hos-
pital, Boston, Mass.,’’ which shows the great neces-

“erydaperiyg ‘peydsozy peorsinsyy-oorpay ‘utooy suyerodg [eorsins

PLATE 4.

ane

mad

PREPARATION OF THE OPERATING-ROOM. 209

sity of absolute cleanliness and how easily infection
takes place from dust in the room: ‘

‘‘T was especially anxious to ascertain if any pus-
producing organisms should be found in the dust.

‘“’The operating-room is kept as clean as soap and
water and corrosive sublimate can effect the cleanli-
ness of its floor and walls.

iveltollowing 1s the reportet B.A: Darling,
Assistant in Bacteriology, Harvard Medical School :

FIG. 176.—Petri dish with colonies (Warren).

‘‘Four Petri double dishes containing films of
sterilized and coagulated blood-serum were exposed
in various parts of the operating-room during a cel-
iotomy, the period of exposure varying from one hour
and twenty minutes to one hour and fifty minutes.

‘“The plates were exposed during the middle of
the forenoon of December 28, 1897.

‘One dish was placed on the floor, where we sup-
posed the dust would be kept in the most active
motion by our feet and the nurse’s dress; one was

placed on the stand holding the sponge-pails; one
14

210 SORGICAL, HECHNIE,

was placed on the patient’s knees raised in the Tren-
delenburg position ; and one was placed on the table
beside the instrument-tray. The dishes were un-
covered just as the knife went through the skin.

‘“At the conclusion of the operation the dishes
were covered, conveyed to the bacteriologic labora-
tory, and placed in the incubator at 37° C. for several
days.

‘‘After twenty-four to seventy-two hours the plates
were opened and the colonies counted. .

‘At the same time an attempt was made to de-
termine the varieties of bacteria present, and par-
ticularly to demonstrate the presence or absence of
the pyogenic forms.

‘“Cover-glass preparations and cultures were made
from as many different kinds of colonies as could be
distinguished.

‘* The results are, in brief, as follows:

‘‘Plate A. Sponge-table, exposed 1 hour 50 min-
utes: after 24 hours showed 216 colonies; 72 hours,
296 colonies.

‘Plate B. <Kwees of patient, exposed 1 hour 20
minutes: after 24 hours showed 156 colonies; 72
hours, 280 colonies.

‘Plate C. Floor, exposed 1 hour 50 minutes:
after 24 hours showed 296 colonies; 72 hours, 428
colonies.

“Plate D. Jnstrument-table, exposed 1 hour 40
minutes: after 24 hours showed 216 colonies; 72
hours, 256 colonies.

“The varieties of bacteria present were studied
minutely on Plate B (the one on the patient’s knee),
less carefully on Plate D (the one on the instrument-

PitaPAkATTON, OF THE OPERATING ROOM. “201

tray). Of the recognized pyogenic cocci, two varie-
ties were found—the Staphylococcus albus (15 colo-
nies on Plate B, 20 colonies on Plate D) and the
Staphylococcus aureus (3 colonies on Plate B, 4 colo-
nies on Plate D).

‘“The remaining colonies on both plates were sar-
cinze of several kinds, yellow, orange, and white
moulds, and several varieties of unrecognized bacilli
and cocci.

‘“As would be expected, the plate from 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
Staphylococcus aureus on this small plate within a
few inches of the opened abdominal cavity was cer-
tainly a grand object-lesson, and has given lots of
food for reflection.’’

CHAP AD FoR xe ine.

TRANSPORTATION ; PREPARATION OF PATIENT
FOR OPERATION ; CARE OF PATIENT DURING
AND AFTER OPERATION.

Transpottation.—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 am-
bulance 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
requireinents 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 pos-
sible 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 in-
sisting on a perfect toilet; an ample supply of cover-
ing is the chief necessity. The nurse should accom-
pany the patient in the ambulance, to give any —

212

PREPARATION OF FIELD OF OPERATION. . 213

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.

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 prepara-
tion of all kinds are subject to change in detail,
because surgical methods are constantly advancing
and changing, though the general principles remain.
It should be remembered that patients rally much
better from an operation when they have been
properly prepared both externally and internally.

Day Before Operation.—The patient receives a
full bath and the hair is washed. A cathartic is
given—castor oil, citrate of magnesium, or salts.
The diet should be nourishing and light. 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. |

I. 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.

214 SCT GH CAL al OLTN NG,

3. Serub again and rinse thoroughly with sterile
water.

4. Rub well with alcohol, followed with ether, to
remove fats.

5. Wash with corrosive sublimate (1 : 1000), and put —
on an antiseptic dressing, consisting of five dressing-
pads, one layer of common cotton, one dressing over
that, then abdominal binder. ‘The patient must be
instructed not to put her fingers underneath. the
dressing nor to disturb it in any way.

Prepare the vaginal canal by giving a warm
douche (lysol, 1 per cent.), and cover the vulva with
a dressing. Use perineal straps to keep the dress-
ing and abdominal binder in position. See that the
dressings are kept wet with the antiseptic ordered
until the patient is taken to the operating-room.
This preparation should be made twelve hours before
an operation.

Some surgeons will direct the application of a
poultice of green soap, which is removed early on the
morning of the operation, the part being scrubbed
with hot water and a brush to remove the soap, a
warm corrosive-sublimate poultice (1 :1000) being
then applied. A green-soap poultice is a thin layer
of green soap spread over a pad of gauze, absorbent
cotton, or a towel, and covered with a dry towel and
a bandage. “Ihe antiseptic pad, or the pouliicee
thoroughly softens the scarf-skin, which in about
twelve hours can be scrubbed off, leaving the true
skin.

Pn PAICAILON OL ALE ED WOR OPERATTON, 205

Biniodid of mercury is sometimes dissolved in
the ether, making a solution of 1: 1000, which, be-
sides removing all fatty substances from the skin, is
also a disinfectant. When the skin is very dirty it is
scrubbed with turpentine, then with GS
alcohol, and then with the biniodid 1)
solution. The nose and mouth should il
be thoroughly sprayed with a satu-
rated solution of boric acid every three
hours.

me

FIG. 177.—Solution basins stand. FIG. 178.—Irrigator.

Day of Operation.—Flush out the colon and
give a bath; take off all flannels, put on a gown open
at the back, and cotton-flannel stockings. Cleanse
teeth, mouth, nose, and throat with a boric-acid solu-
tion and brush. Catheterize just before sending the
patient to the anesthetizing-room if the operation is

ay ee

216 SURGICAL. TACHNIC

on the uterus or its appendages. Always catheterize
in other operations if the patient 1s 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, and put them in a tumbler
of cold water. Envelop feet and lower limbs in a
warin blanket securely pinned around the hips with
safety-pins. Besides preserving the heat, this ar-
rangement will prevent the patient from tossing the
limbs about while taking the anesthetic. Many
operators give morphin (grain +) and atropin (71,
of a grain), hypodermically, half an hour before
the operation, to stimulate the heart and prevent
vomiting.

Atranging the Patient for the Operation.—
The patient having been placed on the operating-
table, the clothes are removed from the part to be
operated upon, and sterilized blankets are tucked
about the chest, the edges being tucked under the
back to reduce as far as possible the loss of body-
heat, and the bandage and pad are removed from
the field of operation, which is again thoroughly
cleansed with soap and water and disinfectants. An
assistant nurse hands the sterilized water, green soap,
and scrubbing-brush to the assistant surgeon. ‘The
soap-suds are rinsed off with sterile water, after which
the part is sponged with permanganate of potassium,
oxalic acid, lime-water, and sterile water, or with
ether, alcohol, and bichlorid solution. This final
scrubbing should be done in the anesthetizing-room
if possible, while the patient is being anesthetized,
to avoid delay in the operating-room. A sterilized

—ae

ARRANGING THE PATIENT. 217

sheet, having an oval opening in the center through
which the section is made, and towels are then
arranged around the field of operation. One towel is
laid along the side, turned over and fastened with

FIG. 179.—Towels pinned over rubber-dam, leaving no skin surface exposed
(Hirst).

clamps to the sheet, so as to form a pocket in which
the surgeon places the instruments he needs to have
close at hand. The instruments are taken from the
sterilizer and laid in trays containing sterile water or
laid upon dry sterile towels.

Some surgeons use the prepared sponges. These
must be reliably counted before the operation by the
operator and assistants, and the number written down,
so as not to trust to memory. Sponges must be
squeezed almost dry before they are handed to the
surgeon, because 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

218 SURGICAL TECHNIC

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

FIG. 180.—Dressing table.

Square sponges used for covering the intestines, or
walling off small areas, should have a long piece of
silk attached, and to this a forceps, so that if one
should slip out of sight it can be readily located and
recovered without undue handling of the bowel.
After being used, the sponges are put into a pan or
basin, and should not be disposed of until they have
been accounted for before the abdomen is closed.

Whatever has been removed from the body must be
placed in a basin and laid aside in a safe place until
the surgeon gives his directions as to whether or not
he wishes it to be sent to the laboratory for examina-
tion to make sure of its character, with a view to
clearing up some obscure point about the nature of
the disease. |

ARRANGING THE PATIENT. 219

The head-nurse attends to the instruments, sutures,
and ligatures. If the dry technic is used, a basin
of dry gauze sponges is placed on a table within easy
reach of the operator’s assistants.

The assistant nurses must be on the alert to change
the hand solutions when necessary, and to wipe the
moisture from the face of the operator and his assistant
with a sterilized towel, to prevent drops falling
into the wound, and this must be done at a moment
when the surgeons are not bending over the wound.
They must move about the room very quietly but
quickly. If asked to do anything that they do not
understand, they should always inform the head nurse,
who will make the duty clear. When emergencies
arise and the operator is dealing with exceptional
difficulties, the nurses must be on the alert to do
quickly anything they may be called upon to do,
each nurse discharging her duties without under-
taking those belonging to another. It is absolutely
necessary on such occasions to exercise self-control,
and to follow the directions given without excitement
or confusion.

Just before the wound is closed the soiled towels
are removed and replaced by fresh ones. After the
dressing has been applied the patient is raised, wiped
perfectly dry, and a bandage put on. While the
patient is waiting to be transferred to bed, hot-
water bottles, well covered, should be applied to all
parts of the body. The blankets used to cover the
feet and chest of the patient during the operation
should be tucked closely about the body and under-
neath, and not merely be thrown over.

Pneumonia and pleurisy after operation may follow
as the result of chilling when in the operating-

220 SURGICAL Mis GENIC:

room, or exposure during the removal from the oper-
ating-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. ‘The foot of the bed is elevated, this
posture being maintained for twenty-four hours, after
which the bed is lowered. ‘The heaters are placed
about the patient’s body, one thing being kept con-
stantly in mind—not to burn the patient. A towel
should be placed under the chin of the patient, and
a small basin should be at hand to receive the vomited
mucus, and this should be removed during quiet
intervals. Nausea and vomiting may be relieved
by saturating a towel with fresh, strong vinegar
and holding ita few inches from “the paremrus
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
anesthetic, there is almost complete absence of nau-
sea—usually none as soon as the patient is fully con-
SC10US. :

Dryness of the mouth and lips, and thirst (which
is often a troublesome feature), may be relieved by
placing wet cloths on the lips, by allowing the patient
to rinse out the mouth with cool water, and by fre-
quent bathing of the hands and face with alcohol and
tepid water or with plain water. If thirst is extreme,
an enema of saline solution (one pint) is given
slowly.

The patient should not be left alone for a single

BLADDER AND BOWELS. PAGAN

moment during the first thirty-six hours after an ab-
dominal section if it can be avoided. ‘The paticnt
can do nothing for herself, and every want should be
instantly supplied. I have known patients so eager to
allay their thirst that they would get out of bed and
drink water from the water-pitcher on the wash-stand
and reach down for the hot-water bottle at the feet and
drink part of the contents. One ward patient drank the
water from an irrigator standing by the side of the
next bed; another patient while in a semiconscious con-
dition took the drainage-tube out of the abdomen, and
when found by the nurse after a moment’s absence
from the room was sitting up on the edge of the bed.
Watching a patient recover from anesthesia is often
monotonous; but if this duty is closely attended to,
many dreadful accidents will be avoided.

A roll should be placed under the knees, so as to
relax the abdominal muscles and also 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 patients complain.

Bladder and Bowels.—The catheter should be
passed every six or eight hours if necessary, accord-
ing to directions, the most rigid aseptic precautions
being taken. Flatulence may be very distressing;
consequently passage of gas by the rectum is of good
omen, as it shows that the bowels have regained their
normal tone and there is no obstruction. After an ab-
dominal operation the muscular walls of the intes-
tines share in the weakness of the patient, and are
not strong enough to overcome the contraction of the
sphincter muscle. ‘The accumulation of gas distends

222 SOKRGICAL “LECTINIG,

the muscular fiber of the intestines, and, if not re-
lieved, would soon result in paralysis of the intes-
tines. To prevent this a rectal tube is inserted to
keep the sphincter dilated and to allow the gas to
escape when it reaches that point. Purgatives, such
as calomel (grain 1 every hour until ro grains have
been taken), are usually given as soon as possible
after the patient has recovered from the anesthetic,
to stimulate the intestines, and keep up peristaltic
action. :

Much fluid is not given for a certain number of
hours after the operation, as it might cause vomit-
ing, and also because, as we have seen, bacteria
require heat and moisture for their development.
If they can lie in a small pool of fluid, they will de-
velop rapidly. We cannot deprive them of warmth
unless we almost freeze the patient, “but we ean
deprive them of moisture. Should any bacteria
have found their way during the operation into the
abdominal cavity, they will be rendered inert by
the absence of moisture, and will be taken by the
leukocytes into the lymphatic vessels and glands and
be devoured.

After twelve hours, if there is no vomiting, very
hot water, or toast-water is given in teaspoonful
doses every fifteen or twenty minutes, the quantity
being gradually increased and the intervals length-
ened. ‘The familiar cup of freshly made tea is some-
times the best drink to begin with; it is always a
pleasure under the circumstances to see the patient
enjoy it, since it is not only refreshing but stimu-
lating. If the stomach behaves well, tablespoonful
doses of gruel or beef-essence may be given every

be bes i a aca
ee ee ee eer Pee ee ee Pe ane eee ea 2 are

BLADDER AND BOWELS. 223

half hour. Milk is not given asa rule, as the curd
may pass along the intestines and act as an irritant.
For the first three days, and if there is no vomiting,
nothing but liquids is given; and after the third day
soft and easily digestible food, which is gradually
changed to a more solid diet.

The external genitals should be kept perfectly
clean, the body bathed, the bed and body-linen kept
ewecesand clean, the teeth prushed) and. the lair
combed. Every want of the patient should be an-
ticipated, and she should be made as comfortable as
possible. Sponging the palms of the hands, the
arms, and the legs will add to the comfort of the
pauene the luxury of a change mto a iresh bed
will often secure a good night’s rest. Under no con-
sideration should morphin be given except by the
surgeon’s directions, and every moral influence should
be exerted to induce the patient to endure pain rather
than resort to the drug.

The nurse should not ascertain whether the patient
is comfortable by continual questioning, but by unob-
trusive observation. Questioning may alarm a patient
and lead her to think too much about herself.

No visitors should be admitted without the sur-
geon’s consent. The mind of the patient is to be
kept perfectly free from worry and excitement, and
the whole atmosphere of the room should be bright,
pleasant, and cheerful, no matter what trouble is
going on outside.

A slight rise of temperature the day following oper-
ation usually marks reaction from shock. On the
eighth day the dressings are removed and the stitches
taken out. The following week the patient sits up,
and at the end of the third week she goes home.

224 SURGICAL LECHNIC,

The following diet-list, dating from the third day,.
will be of assistance in varying the food.

First Day.

Breakfast.—Mutton-broth with bread-crumbs.

Lunch.—Milk-punch.

Dinner.—Raw oysters, thin bread (with crust re-
moved) and butter, sherry wine.

Lunch.—Cup of hot beef-tea.

Supper.—Milk-toast, jelly.

SECOND DAY.

Breakfast.—Oatmeal with sugar and cream, cup
of cocoa.

LUNG) SO Custanaeay

Dinner.—Small piece of tenderloin steak, chewed
but not swallowed, baked potato.

Lunch.—Glass of milk.

Supper.—Buttered miulk-toast (crust removed),
jelly,).cocea:

THIRD Day.

Breakfast.—Soft-boiled egg, bread and butter,
coffee.

Lunch.—Milk-puich.

Dinner.—Chicken-soup, *tender sweetbreads, Ba-
varian cream, light wine.

Lunch.— An egg-nog.

Supper.—Tea, raw oysters, bread and butter.

FouRTH DAY.

Breakfast.—Oatmeal with sugar and cream, a ten-
der sweetbread, creamed potatoes, coffee, graham
bread and butter.

Lunch.—Glass of milk.

DTT LE UST 225

Dinner.—Chicken panada, baked potato, bread,
tapioca-cream.

Lunch.—Cup of hot chicken-broth.

Supper.—Buttered dry toast (crust removed), wine
jelly, banquet crackers, tea.

Ernie DAY.

Breakfast.—An orange, scrambled egg, oatmeal
with sugar and cream, soft buttered toast, coffee.

Lunch.—Milk-punch.

Dinner.—Cream of celery soup, a small piece of
tenderloin steak, baked potato, snow pudding, wine,
bread.

Lunch.—An egg-nog.

Supper.—Calf’s foot jelly, soft-boiled egg, bread
and butter, cocoa.

SixTH DAy.

Breakfast.—Oatmeal, poached eggs on toast, coffee.

Lunch.—Cup of chicken-broth.

Dinner.—Chicken-soup, small slice of tender roast
beef, baked potato, rice-pudding, bread.

Lunch.—Glass of milk.

Supper.—Baked apples, raw oysters, bread and
butter, orange-jelly, tea.

SEVENTH DAY.

Breakfast.—Orange, mush and milk, scrambled
eggs, cream-toast, coffee.

_Lunch.—Cup of soft custard.

Dinner.—Mutton-soup, small piece of tender beef-

steak, creamed potatoes, sago-pudding, bread, wine.
15

226 SURGICAL TECHNIC.

Lunch.—Cup of beef-tea.
Supper.—Sponge-cake with cream, buttered dry
toast, wine-jelly, cocoa.

FIGHTH DAv.

Breakfast.—Broiled fresh fish, oatmeal, graham
bread, coffee.

Lunch.—Chicken-broth.

Dinner.—Potato-soup, breast of roasted chicken,
mashed potatoes, macaroni, blanc mange.

Lunch.—Cup of mulled wine.

Supper.—Cream-toast, lemon-jelly, chocolate.

FIG. 181.—Griffith’s bed-grapple for patient’s comfort during convalescence.

The diet for other days may be selected from pre-
vious ones. ‘The change of diet may cause a tem-
porary rise in the temperature and pulse.

CsA IP BUI DC WOVE

SEQUEL4E OF OPERATIONS; SHOCK, HEMOR.
RHAGE, SEPTIC PERITONITIS, ACCIDENTS
DURING OPERATION, ETC.

AS a tule, the average abdominal case passes into
convalescence, especially when the case is in skilled
hands and the operation has been performed in a
finished surgical way. Complications, however, are
liable to arise in the simplest case, and throw great
responsibility on both surgeon and nurse. It is in
these cases that the knowledge and skill of the nurse
mean so much, and where the greatest triumphs of
surgery are scored.

A nurse has no moral right to take charge of a
surgical case unless she has at her 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 opera-
tion. It is produced through the agency of the ner-
vous system. ‘The greater the injury, the longer the
anesthesia, the greater the shock. The anesthetic
enables the patient to undergo the operation without
consciousness, but it does not prevent shock coming
on afterward from the opening of the abdomen, the
uncovering of the viscera, the handling of the intes-
tines, and the exposure of the delicate sympathetic

227

228 SORGICALE IAACEAMNG:

werves in that part to the air and to touch. If to all
this is added a long anesthesia, then the prostration
produced by the anesthetic is added to the effects of
the operation.

Different individuals are differently affected: most
persons are more susceptible to shock after months
of hard work, or when the system is run down after
an illness. Invalids stand shock very well, and in-
different persons stand it better than those who are
despondent. The mental influence is very great;
anything that depresses the mind aggravates shock.
It 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 1s
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 combated to a certain extent by
the patient’s drinking a large amount of fluid. for
forty-eight hours before the operation, so that the
blood-vessels of the vital organs will be well supphed
with fluid during the operation. Experiments have
been made which show that when the abdomen is
opened the abdominal veins dilate, and as a conse-
quence a large amount of the blood in the body flows
into them, thus leaving the heart and the vessels con-
veying blood to the important nerve-centers at the
base of the brain with very little fluid to work upon,
and shock ensues. ‘The output of the heart, as we
know, is in proportion to the venous pressure, and
if this is lowered the heart and the important nerve-
centers at the base of the brain will be supplied

SHOCK. 229

with a diminished amount of blood. ‘The intra-
venous injection of saline solution causes a rise in
the venous pressure and an increase in the output of
the heart. Thesigns of shock may be and have been
mistaken for those of hemorrhage on account of the
two presenting so many points of likeness; but in
shock the symptoms are present from the first, while
in hemorrhage they do not come on for some hours
after the operation.

Two very important points to be considered in case
of shock or of hemorrhage are the temperature and
the condition of the patient’s mind. In shock the
temperature at first is normal or very little below nor-
mal, and the senses are dull in proportion to the degree
of shock present; in hemorrhage the temperature is
subnormal, the mind is bright, keen, and alert, and
there is an anxious expression on the face, as if the
patient were anticipating danger.

The symptoms of shock are a weak, rapid, and ir-
regular pulse; sighing, rapid, irregular, and shallow
respiration; a normal or slightly subnormal tem-
perature; a pale face with a pinched look; a cold,
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 in-
crease the supply of blood te the vital centers; in
the application of heat to all parts of the body,
particularly the sides, between the legs, and to the
feet; in placing a mustard-plaster over the heart;
in administering whiskey, brandy, or nitroglycerin

230 SUR GICAL TECHNIC.

hypodermically; in giving hot black coffee by the
rectum, or saline solution hypodermically or by
the rectum. Strychnin is a powerful stimulant, and
should be given in doses of =)5 grain every half hour
for four doses. ‘Tincture of digitalis in 15-minim
doses may be given every half hour for four doses.
As a rule, in cases of shock there is a disposition
on the part of nurses to do too much. Everything
must be done ina prompt, quiet manner. For imme-
diate stimulation in threatened collapse nitroglycerin
is valuable: It is used for quick efiect onlye and
not for prolonged stimulation of the heart’s action.
Stimulants must be given carefully, and time
allowed to observe the effects produced, other meas-
ures being determined accordingly. An enema of
one-half ounce of turpentine, a well-beaten raw egg,
and three ounces of warm water constitutes a power-
ful stimulant.

It must be remembered that in severe shock the
function of absorption by the stomach and intestines
is almost wholly suspended, and anything given by
the rectum must be introduced high up. When the res-
piration of the patient is fast failing, everything de-
pends on maintaining the heart’s action. ‘To this
end artificial respiration must be persistently prac-
tised. A serious danger in performing artificial res-
pitation is that im our hurry we may Mmakesule
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 min-
ute, so as to imitate as nearly as possible the nat-
ural rhythm of respiration. External heat is a most

SHOCK. 231

powerful heart-stimulant, and often when the heart’s
action fails it may be restored by heat over the heart
and by hot fluids taken into the stomach.

FIG. 182.—Sylvester’s method of performing artificial respiration (inspiration)

Recovery may be rapid or very slow; it is mani-
fested by ‘‘reaction’’—the pulse becomes more full,

FIG. 183.—Sylvester’s method of performing artificial respiration (expiration).

slow, and regular, the temperature rises, the body
becomes wari, and a general improvement takes

232 SORGICAL = LECTINIC,

place. In rare cases the reaction becomes excessive
and develops into ¢raumatic delirium, which may be
mild, low, and muttering, or of the wildest character.
The skin is hot and flushed, the pulse full and regu-
lar, and the temperature above normal. This condi-
tion may subside and recovery take place, or it may
be followed by collapse.

Hemorrhage may be caused by the slipping of a
ligature or by the displacement of clots, as the result
of restlessness or reaction of the circulation, and
generally occurs within the first twenty-four hours

FIG. 184.—Esmarch's tourniquet, consisting of 9 feet of elastic webbing
2% inches wide, 3 feet tubular strap with chain.

after the operation. ‘The hemorrhage which comes
from torn adhesions and bleeding surfaces is a
free oozing, and seldom affects the pulse. When a_
drainage-tube has been used, it will usually indicate
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.

HEMORRHAGE. 233

The symptoms of internal hemorrhage are restless-
ness, thirst, faintness, an anxious expression, pale
face, dilated pupils, cold skin, frequent and irregular

FIG. 185.—Bellocq’s canula, 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.

or sighing respiration, subnormal temperature, and a
weak, rapid pulse (120-140). 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
foot of the bed elevated. If symptoms of shock
supervene, heat is to be applied to all parts of the
body by warm blankets and _ hot-water bottles.
Stimulants are given only when the pulse is failing,
as they excite the heart’s action and increase the
hemorrhage. When the hemorrhage has been exces-
sive, infusion of saline solution is resorted to, the
fluid that the body has lost being thus replaced.
Bandaging the limbs from their extremities upward
is sometimes of use in keeping the blood in the vital
organs. When the hemorrhage comes from a slipped
ligature with large vessels pouring blood into the
abdominal cavity, the abdomen is reopened and the
vessel ligated. Everything should be ready for
operative interference when the surgeon arrives, the
same aseptic precautions being observed as in the
Original operation. For the free oozing from torn

234 SURGICAL TECHNIC.

adhesions the tube is emptied frequently—every ten
minutes. The drier the pelvic cavity 1s) kept, cme
sooner will the hemorrhage cease.

A noted surgeon has said that if an abdominal case
escapes shock or hemorrhage, there is still a third
danger to which the patient is liable, that of septic
peritonitis. This is due to the entrance of germs
into the peritoneal cavity, either from without or
from ruptured abscesses or wounds. It may set in
at any time from a few hours to six days after ope-
ration. ‘The symptoms are pain in the abdomen and
exqtisite tenderness, distention, vomiting, constipa-
tion, icterus, restlessness, sleeplessness.

The temperature rises a little, rarely going for a
few days above 100° or 101° 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”? im the besinning.- Then themtemiperm
ature rises to 102° F. or above. The rectalvor aes
inal temperature may show a much higher rise than
that of the mouth or axilla. In one typical instance
the temperature taken in the mouth ranged between
1o1° and 102° F., the skin was cold and clammy;
and the patient complained of intense thirst and a
‘“burning up’’ feeling. The vaginal \temiperacune
was 108° F. In some of the worst cases the writer
has seen the temperature was below normal, but the
prostration was severe. ‘The abdomen is distended,
due to distention of the transverse colon by gas.
There are nausea and vomiting. First the contents of
the stomach are vomited, then bile, then a dark coffee-
colored fluid which becomes more and more fecal in
odor; a cold perspiration appears; the patient has a

HEMORRHAGE. 22%

very anxious, pinched expression, and is restless and
talkative; the eyes are unusually bright, and there is
a faint yellowish look about the skin and conjunc-
tivee. As the disease continues the general system
becomes poisoned.

_ The treatment consists in ridding the system of
the poison through the skin, bowels, and kidneys.
High enemata of turpentine, glycerin, oil, salts, or
molasses are usually given until the bowels are
thoroughly moved or large quantities of gas are
passed, because it is by putting the bowels into an
active state that the threatened paralysis of the intes-
tines can be overcome, and they can take up from
the peritoneal cavity the poisonous materials that
are causing the disturbance. It is only when the
intestines are so paralyzed that they cannot be moved
that a fatal result ensues. Strychnin, being a power-
ful heart-stimulant, is given in doses of grain gz
every hour until its physiologic effects are pro-
duced. It must be stopped at the first appear-
ance of twitching of the muscles of the face or
of the limbs and stiffness of the neck. Vomiting
may be relieved by washing out the stomach, by
the application of a mustard-plaster over the region
of the stomach, or by cocain in 4%-grain doses for
four doses. If improvement does not follow, the
surface of the body becomes cold and clammy; the
face pinched and sunken and of a dusky hue; the
restlessness increases, also the thirst, which becomes
very great, and to the last the patient calls for water,
which is vomited immediately after being taken, but
which it is cruel to withhold. The mind usually
remains clear to the end.

220 SURGICAL TECHNIC.

Antistreptococcic serum has been used with fairly
good results. It comes in glass tubes, sealed her-
metically, and is injected hypodermically with an-
tiseptic precautions into the thigh or the side of the
breast, where there is considerable loose subcuta-
neous connective tissue. Another procedure of value
is infusion of normal saline solution for the purpose
of diluting the toxins in the blood and of removing
them by the increased flow of urine which infusion
brings about.

Tympanites is often one of the earliest signs of
septicemia, and when accompanied with a high tem-
perature is usually a cause for anxiety, though it may
be due to constipation, and in such cases is usually
without significance. The treatment consists in the
application of turpentine stupes, the use of brisk
purgatives or high enemata, and the insertion of the
rectal tube for about ten inches.

Fermentation-fever is due to the absorption of
fibrin-ferment and the products of aseptic tissue-
necrosis. It causes a slight rise im temperature
which need occasion no anxiety.

Intestinal obstruction may be due to strangula-
tion of a knuckle of intestine beneath inflammatory
bands, or to its enclosure between the sutures in the
wound. ‘There is usually distention of the abdomen.
Note should always be made if gas is heard rumbling
in the intestines, and also if gas is passed and how
often; also the result of the enemata which are ad-
ministered to relieve the distention.

Hernia is a sequel rather than a complication of
abdominal operations, and is due to a failure of union
between the cut edges of the muscles and fascie.

SINUS. 237

As a tule, it does not occur until some weeks after
the patient has returned home. It is to prevent this
accident that such stress is laid upon not allowing
the patients to help themselves in any
way without the surgeon’s permission,
so that the abdominal muscles may have
sufficient time to become firmly united.
This is also the reason why patients

FIG. 186.—General operating table.

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, 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 abdominal wall. The
sinus keeps open until the ligature is discharged or
removed by another operation.

238 SURGICAL TECHNIC.

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
intestine may be injured. When the ureter or blad-
der is injured, the urine sometimes passes through the
incision to the dressing. ‘This is called a urinary
fistula. When the intestines are injured, fecal matter
isdischargedthroughthe wound. Thisisa fecal fistula.

Vaginal hysterectomy is the most serious of vagi-
nal operations, but the nursing is the same as every
operative case requires. If clamps are used, they
usually remain attached for forty-eight hours. The
handles are usually supported on a pad of absorbent
cotton. In the handling of the clamps great care
must be used, as, for instance, when the patient is
lifted on the bed-pan one nurse should lift the clamps.

Hysterectomy is the complete removal of the
uterus and ovaries, either through the vagina (vagi-
nal hysterectomy) or through the abdomen. Regard-
ing the question of insanity which may follow a hys-
terectomy or the removal of a large fibroid tumor,
one must know that a large amount of blood is
taken from the body ; that the cutting and tying of
the large blood-vessels alter the circulation ; and that
the operation is also more or less a shock to the
nervous system, and may affect the brain. Insanity
is zot a complication of this operation, the recovery
from which is usually rapid ; but when insanity does
set in, this is commonly the cause, and the patient
generally recovers.

(Cal VIP IN IB IR, “OIL
SPECIAL OPERATIONS.

Operations Upon the Head.—Nursing after opera-
tions upon the brain calls for special diligence in
watching the patient during the first hours subse-
quently. Unlooked for symptoms may arise, and a
change for better or worse in those accompanying the
condition for which operation was performed; delir-
ium, 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
subsequent further complication of the case from a bad
body burn. Asa general rule, it is safest to never put
a bag directly against the patient’s body, but to place
it outside the blanket.

Lye, ear, nose, and throat cases, besides the general
care and watchfulness necessary, require to be ob-
served for shock or hemorrhage, where, as in the case

239

240 SURGICAL TEGHNIC.

of the eye, serious functional injury might be done;
or special symptoms complained of relating to the
particular sense-organ operated upon.

FIG. 187.—Soft-rubber nasal and FIG. 188.—Syringe cup to
ear syringe. hang upon patient’s ear to
catch the drip when irriga-

ting the aural canal.

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 dis-
placed, coughed out, or clogged by exudate or false
membrane shreds. Rapid cyanosis or a blowing-
bellows action sounding through the tracheal slit are
the signs calling for immediate correction of the diffi-
culty, to avoid an immediate fatal terminatiou of the
case from total closure of wound or tube. If the case
is one of tracheotomy with a displaced tube, the nurse

SPECIAL OPERATIONS. 241

should make no attempt at readjustment, but quickly
loosening or cutting the tapes, must, after withdrawing
the tube, insert and set the tracheal forceps, which in-
strument must be ever at hand at the patient’s bed-
side for such emergency use. Afterward the surgeon
may be sought, who will replace the tube; but there
will not be time to send for the physician to perform
the former vital office.

Operations upon the thorax include those open-
ing the chest for draining the pleural cavity and the
mediastinum, suturing the heart, as after a stab or
gunshot wound, removal of tumors within or upon the
chest-walls. Shock and hemorrhage must be particu-
larly watched for. Besides, in operations involving
the pleura, collapse of the lung from disturbance of the
internal chest, vacuum may occur, calling fora prompt
treatment of the associated rapid sinking and cyanotic
state generally accompanying it, depending upon the
physical state of the organ. Efforts tending to a re-
establishment of the normal state of vacuum carried
out by the surgeon includes the attempt at production
of artificial vacuum by means of an air-pump or by
use of the Bier apparatus, consisting of a pump and
having a bell-glass connection. The nurse’s efforts
in face of such complication would include the careful
but rapid withdrawal of the drainage-tube, if there be
any, and the sealing of the opening in the chest-wall
by means of rubber tissue and adhesive-plaster strips,
or by use of a plug of sterile cotton, held in place by
adhesive straps.

Abdominal operations must also be observed for
the first signs of a developing general peritonitis.

In the extremities, after operation for pus infec-

16

242 SURGICAL TECHNIC.

tion, elevation of the parts so affected goes far to pre-
vent the lymph stasis or blocking up of the lymph
spaces, with consequent squeezing, too, of the arterial
and venous capillaries, thus aiding pus development;
whereas, if free circulation is permitted, even at the
cost of increasing pressure from elevation, recovery is
aided. Further benefit in this connection is obtain-
able by the frequent applications of water as hot as
can be borne. Finally, where the nurse applies the
gauze and bandages, she must remember and use the
minimum amount, else, in thus putting germs to bed
in her bulky dressings, she assists in retaining heat at
the surface wound of a temperature at which they de-
velop quickest.

Fractures, whether the patient be confined to bed
or not, always require the most careful attention from
the nurse in charge. A slight displacement following
a misstep in going about the wards, if unreported and
not looked after, may decide the future functional value
of a fractured arm. But if the danger isso great, why
not keep all fracture cases in bed? For the reason
that most patients, even fractures of the thigh, when
a proper sustaining splint can be applied, improve
more rapidly when they are up and about, a bed being
oftentimes too sedative in effect for the patient’s best
interest.

CISA IE JE Da IR GG
OPERATIONS IN PRIVATE PRACTICE.

IN private practice the preparation of the patient is
just the same and should be carried out as thor-
oughly asin a hospital. If it is not possible within
twenty-four or thirty-six hours to make the prepa-
ration, then we cannot say that our attempts to
obtain asepsis approach perfection. In emergency
cases when there is not sufficient time to permit a
thorough cleansing, freedom from sepsis is not so
certain, and these cases do not cause the same anxiety
as those that are sent to a hospital, where every effort
to obtain complete asepsis is made. We must remem-
ber, in making the preparations, to make as little
bustle and noise as possible, and to carry on the
preparations in a quiet and cheerful manner, so as not
to frighten the patient and family. When the sur-
geon and his assistants arrive they must be shown
to a room in which they can change their clothing.
The patient is not anesthetized until everything is
in readiness.

One difficulty which a nurse will have to encounter
in private practice is likely to trouble her a great deal,
inasmuch as she will find surgeons who conduct de-
tails of cases in a way to which she is not accus-
tomed, and which may appear to her wrong, and

which indeed may very often be crude and unscien-
243

244 SURGICAL TECHNIC.

tific. In these cases she should not be too ready to
show her superior wisdom and instruct the surgeon,
and inform him under whom she received her train-
ing, because there is not the slightest likelihood that
he will act upon her suggestions, but will naturally
be offended.

—— a

—
Te

ii
hi

SSS SS TTS
ro Vi
| a SS |

j
= V4 5 A Ve TV, i = =
7/7 Wh =
Z \
V4 Va Y

FIG. 189.—-Portable operating-table set up for a vaginal operation (Hirst).

The directions for preparing for the operation
will be given by the surgeon in charge. Have the
temperature at about 75° FP. In’ some @iomse:
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 bright-

OPERATIONS IN PRIVATE PRACTICE. 245

est end of the room must be selected for the
operation, to afford the surgeons plenty of hght. A
screen must be put up before the bed, so that the
patient will not see the preparations. The nurse
should remove from the room all movable furniture;
sheet any large piece, as piano; lay oilcloths or news-
papers 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 nec-
essary 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 pos-
sible. 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 washing pitchers, plates, wash-
bowls. Unless the nurse has twenty-four hours’
notice in which to prepare the room for operation, it
should not be disturbed, because if swept and dusted
immediately before de 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 re-

246 SURGICAL TECHNIC.

moved, the hangings taken down, the room thot-
oughly swept, and the walls and remaining furniture
washed with carbolic-acid solution (1:60) and ex-
posed to the action of the sun and air for about
twelve hours, when the windows are to be closed,

FIG. 190.—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).

the room thoroughly dusted with a damp cloth, and
not again disturbed. ‘The £z¢chen, if not too remote,
makes the best operating-room; it 1s warm, hot and
cold water are close at hand, and there is no danger
of soiling carpets or hangings. Plug the drain-pipe
openings with gauze or towel-pads soaked with bi-
chlorid solution 1 : 1000.

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

OPERATHONS WIN “PRIVATE PRACTICE, ZA7,

be an iron bedstead with a fresh horsehair mattress
and pillow. The tall wooden bedsteads which we
so often find are perhaps heirlooms which have wit-

FIG. 191.—Kitchen table prepared for gynecologic operation, showing Kelly
draining-pad and leg supports (Hirst).

nessed every illness that has visited the family, and
also the deaths. They cannot be disinfected so
thoroughly as can iron bedsteads.

248 SURGICAL TECHNIC.

The operating-table should not be wider than
twenty-five inches nor higher than thirty-seven
inches. because if low and wide the surgeon will
have to stoop and bend forward. A kitchen-table, or
a dining-room table with the leaves hanging, and a
small table at one end for the patient’s head, or two
dressing-tables, one placed across the head of the
other, will make a good narrow operating-table; or
three chairs, with two planks; a leaf from an exten-

:

aie rate
Nees : ees
RNY 4 i ‘ ; aA
AN ES eee eee ee oe oS pee as SS

F1G. 192.—The Trendelenburg posture in bed, using a chair to elevate
the pelvis (De Lee).

sion-table, or an ironing-board laid across them, may
suffice.

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’ eermc yin
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

OPERATIONS IN PRIVATE PRACTICE. 249

in case the T'rendelenburg position is necessary, and
two wooden boxes for the surgeons to stand upon
when using this posture.

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 dress-
ings by using a wash-boiler fitted with a light wood
inside crate to hold the dressings above the water.
Sterilize 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 washboiler full of water and then fill covered
pitchers, the washboiler and pitchers having first been
made thoroughly aseptic. The water is conveyed
from the boiler tothe pitchers by means of a perfectly
clean pitcher or tin ladle.

On the morning of the operation there should be
sterilized in the boiler or 1n an oven six sheets, two
blankets, twelve towels (not new). The heat should
be kept up for fully one hour before the operation.
The dry technic, by which is meant the use of dry
sponges and gauze, is usually employed in private
practice, especially when the water-supply is at all
questionable.

There will be needed several clean recently boiled
basins for the various solutions, etc. Two tables
will 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

250 SURGICAL TECHNIC.

be needed a pail or a washtub for the soiled water,
a tin dish or a flat bake-pan for the instruments,
brandy, a hypodermic syringe filled with the re-
quired solution, usually strychnin sulphate (= grain),
a small tumbler, a Davidson or a fountain-syringe,

Sot set geese See ee aS eee fee
a ——— SSS,

3.—Household bulb-syringe (

table-salt for salt-solution, safety-pins, two new nail-
brushes, ready for use in a 1:40 carbolic acid soiu-

tion, castile soap, green soap, a razor, hot-water
bottles, two blankets, alcohol, vinegar, and matches.

Fic. 194.—Fountain-syringe.

The surgeon will bring the necessary dressings with
the instruments, which must be sterilized in the same
way as in the hospital.

The instruments are to be wrapped in a towel and

OPE RATMONS VN GPILVATTE TRA CTAC Fe. 251

allowed to boil for ten minutes in a saucepan, tin
pail, or a fish-kettle of boiling water, to which have
been added two teaspoonfuls of washing-soda to each
pint of water, to prevent rusting. One end of the
towel must be left hanging out of the kettle as a
handle by which to lift out the instruments. The
pail of water should be on the fire and the water
boiling when the surgeon arrives, so that the instru-
ments can be put in at once.

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
experienced anesthetizer constantly watches the
patient. If the nurse is asked to assist the surgeon,
she must be neither too enthusiastic, nor too quick,
nor too slow. When the operation is over her duties
will have nothing peculiar about them. She must
see the patient safely out of the anesthetic influence,
and carry the case along as she would any other.

Sometimes a nurse is called to an emergency oper-
ation in a very poor family, where there are no con-
wemences. In stich instances the kitchen can be
cleaned and prepared as an operating-room ina few
minutes. If she is called in the night and goes to
the case with the surgeon, she should, while the sur-
geon is making his examination of the patient, start
a fire and put on the washboiler, to make sure of
plenty of boiling water. She should then get six
sheets and twelve towels, 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 boiling water and afterward placed in corrosive-
sublimate solution (1: 1000), until the surgeon is ready

252 SURGICAL TECHNIC.

to use them. Boiling water is one of the best antt-
septics, as it kills germs on contact. Unfortunately
it cannot be used in rendering our hands and the field
of operation aseptic, but it can be used in the prepa-
ration of the sheets, towels, sponges, and instru-
ments.

The kitchen should be rendered as clean as pos-
sible. The kitchen-table should be prepared for the
operating-table, and there should be twosmall tables,
one for the instrument-tray and one for the sponges.
If small tables cannot be had, chairs covered with a
sheet or towels wrung out of the corrosive solution
will answer the purpose. If there is no gaslight, as
many lamps as can be obtained should be arranged
near the surgeon, but not too near the ether, because
ether is inflammable.

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, and a towel wrung out
of corrosive sublimate solution applied, an enema
given to clear the bowels, and the urine drawn.
While the patient is being anesthetized the nurse
may arrange the tables and wash a flat bake-pan
or meat-pan for the instruments. If sponges have
been forgotten, a clean sheet can be torn up and

OPERATIONS -IN PRIVATE PRACTICE. 253

folded into flat sponges. China basins can be used
for the antiseptics, the sponges, and the surgeon’s
hands; china pitchers for hot and cold water; a
washtub for the soiled water; and hot bricks, plates,
stove-lids, 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.

CH Al Pian i Re xo

GYNECOLOGIC EXAMINATIONS AND
OPERATIONS.

PERFECT asepsis 1s 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. Wemust
bear in mind that the whole genital tract communt-
cates directly with the peritoneum, and infection at
any point may cause peritoneal sepsis. Infection has
taken place through the introduction of a dirty
sound, and fatal peritonitis has followed perineor-
thaphy and trachelorrhaphy.

The technic for major operations is usually perfect,
but for minor operations carelessness is liable to
creep in. We have no right to expose a patient to
danger no matter how small the operation to be per-
formed; and if our technic is not as perfect as we can
make it with the means at our command, then we
expose the patient to the greatest of all dangers, that
of peritoneal sepsis, which usually means death. Suc-
cess in surgery is due to minute attention to a care-
ful technic, and a careless nurse may be the means of
introducing sepsis, which may result in death after a
most brilliant and skilfully performed operation. ‘The
most skilful surgeon is dependent upon his assistants
for the perfection of his technic, and only those nurses

204

GYNECOLOGIC EXAMINATIONS. 255

who have been thoroughly instructed in the practice
of asepsis and antisepsis should be allowed to assist at
an operation or examination, however small.

GYNECOLOGIC EXAMINATIONS.

The positions which a patient may occupy when
undergoing an examination are the knee-chest, dor-
sal, Sims, and the upright.

FIG. 195.—Examination in the erect posture (Hirst).

The upright, or the erect, position is rarely used
for the purpose of making a diagnosis, but is some-

256 SURGICAL TECHNIC.

times preferred in verifying a diagnosis, especially
that of uterine displacement, previously made with
the patient in another position. Around the waist is
pinned a sheet, which extends to the floor, under
which the clothing of the patient is drawn up. The
patient stands with limbs separated, one foot resting
on a stool or the rung of a chair.

Dorsal Position.—The patient lies on her back
with the knees drawn up and separated ; the hips
are brought down near the
edge of the table, leaving
sufficient room for the heels
to rest together comfortably,
eight or ten inches apart,
without slipping from the
table. A sheet having an

S$

H
} |
| ie
| ' :
|

FIG. 196.—Dorsal recumbent posture. FIG. 197.—Edebohl’s dorsal posture.

oval slit in the center long 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 relaxa-
tion of the abdominal muscles is secured. 7
Sims’ Position (also called the Latero-abdominal
Posttion).—In the Sims position the patient les on
the left side of her chest, with her head and left

KNEE-CHEST POSITION. 257

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 being at the right-
hand side, with the right hand and arm hanging over
the table-edge. The thighs are flexed upon the abdo-
men, the right thigh being so flexed that it lies just
above the left knee, and the feet rest upon a board ex-
tending from the right-hand corner of the table. This

FIG. 198.—Sims’ posture, anterior view.

position is one in which there is a tendency for the
intestines to ascend, and this causes the vagina to be
filled with air and thus brings the uterine cervix
within easy reach.

The lithotomy position is used when operating
upon the rectum and in some conditions of the blad-
der. The position is obtained by placing the patient
upon his back, knees and thighs flexed and sepa-
tated, the hands being drawn down and attached by
bandaging to the patient’s feet and ankles.

The knee-chest, or genupectoral, position is much
used for inspection of the rectum, bladder, vagina,
and cervix of the uterus. In some cases of displace-

ment of the uterus the patient may have to take
17

258

SURGICAL TECHNIC.

this position many times daily. The patient first
kneels on the edge of the table, then bends forward
and rests her chest on a low pillow, her head lying

Paes iWZ=_=
PP SS uy WO

—=

‘4a

!

I

i

an er

FIG. 199.—Knee-chest, or genupectoral, posture.

just beyond, so that her back slopes down evenly, her

arms clasping the sides of the table.

In this position

the abdominal organs are thrown toward the dia-

S

km
“4 a a

cc

My

FIG. 200.—Walcher posture.

phragm; the air enters the
vagina and balloons it out,
so to speak, so that there
is an unobstructed view of
the canal and the cervix.
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.
Examination ofthe Rec-
tum.—The patient is usually
placed in the knee-chest
position. Hither the rectal
speculum, or in its absence

a Sims speculum (small blade), is used. When the
instrument is introduced the rectum becomes distended

GYNECOLOGIC EXAMINATION, 259

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 head-
light may be needed. It is well to have these at hand
in case they should be called for.

For an examination of the bladder the knee-chest
position is sometimes used; though, asa rule, the dor-
sal position is chosen, with the hips elevated high
above the abdomen by means of cushions or pillows,
which allows the intestines to gravitate toward the
chest; and when the urethra is opened the bladder
becomes distended with air and its interior is thus
easily seen. Sometimes the patient is anesthetized for
the examination, since it is usually very painful; but
iocal anesthesia of the urethra is often sufficient.

Preparation for Gynecologic Examination.—
To prepare a patient for examination the genital
parts should be cleansed, so that there will be no
danger of carrying septic material to the upper part
of the genital tract; the bladder and bowels should
be emptied. ‘The uterus lies between the bladder and
the rectum, and the distention of either of these
organs will alter the position of the uterus. Asa
tule, no douche should be given before the examina-
tion, 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
clothing above the waist, and then step upon a chair
and thence to the operating-table without there ane
the slightest exposure.

260 SURGICAL TECHNIC.

For examination in private practice the patient
may lie on a small table covered with a shawl, a
comforter,;or blanket: There must be vaee mendes
table, covered with a towel, on which are placed two
bowls, one containing corrosive-sublimate solution
(1: 1000), and the other containing warm water,
green soap, vaselin, and towels.

The speculum should be warmed by placing it in
the warm sterile water. The same aseptic precau-
tions are used during an examination as during
an operation. The instruments should be sterilized.
Sometimes a cleansing dauche of corrosive sublimate
(1 : 2000) is administered after an examination.

PREPARATION FOR OPERATION.

The preparation for gynecologic operations, such
as perineorrhaphy, etc., are the same as for an abdom-
inal operation, excepting the difference of the field
of operation to be prepared. In case the operation is
a minor one upon the uterus or vagina, the prepara-
tions may be somewhat modified according to the
individual preference of the operator; but the general
rules of asepsis are always the same; and they must
be the more strictly observed in these operations be-
cause the dangers of infection are increased by our
inability to get the genital tract thoroughly clean.
In abdominal surgery there is not this difficulty.

The preparation of a patient in a private house for
a minor gynecologic operation should be as thorough as
in a hospital. If the operation is to be performed
with the patient in bed, there will be needed a wide
board or an ironing-board for insertion between the

PREPARATION. FOR OPERATION, 261

mattress and sheet, thus making a hard surface for
the patient to lie upon.

Griffith’s Operating Table-bed.—Elevation is
secured by means of blocks each four inches square

HH

UE Se eee

Fic. 201.—Griffith’s operating table-bed.

by fourteen inches in length and having a hole two
inches square and six inches long cut in one end.

Trendelenburg’s position is secured by removing
the extensions from the head legs after applying a
broad binder or shoulder straps to the patient. Fow-
ler’s position for securing gravity drainage of the
peritoneal cavity is obtained by removing the foot
pieces after slinging the patient by means of shoulder
straps.

A piece of rubber cloth or oilcloth will serve for
the pad. The material used is folded at the top and

262 SURGIGAE. RECHATIGC

sides, covered with a towel, and the unfolded end
draped into a pail or wash-tub. When the patient is

FIG. 202.—Trendelenburg posture.

anesthetized the bed is turned toward the window to
afford the surgeon a good light—a northern light if
possible. A bay window should be avoided, because
it gives cross-lights.

The limbs are flexed, the hips brought to the
edge of the bed, and the pad placed under them, so
that the water used in bathing the external parts
is conducted by the cloth into the pail vor tus
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 he in the

PREPARATION FOR OPERATION. 263

hollow between the thumb and forefinger, and the
convexity of the blade will rest on the dorsum of the
hand. ‘The upper labia and buttocks are raised by
the left hand. If the speculum or regular retractors
cannot be obtained in the emergency, retractors can
be improvised by bending the handles of four large
spoons to the appropriate angle. ‘Two are used to
retract the lateral walls, the other two being applied
to the anterior and posterior parts of the vagina.

After-care.—After a vaginal operation, trachelor-
thaphy, 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-for-
ceps. 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 in-
structed not to strain when the bowels are moved, or
the stitches may break. When dressings are applied,
they may require frequent changing in order to keep
them clean and free from discharges. Strict antisep-
sis 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

264 SURGICAL MBOHNIGC,

wound and suppuration, or a stitch-abscess. If the
uterus 1s packed with gauze, the pulse and tempera-
ture are usually taken every two hours ; and should the
temperature rise to 101° F. the packing is removed.

Diet.—A liquid diet is usually ordered until after
the third day, when the bowels will have been
moved; after which, if all is well, the amount of food
is increased until it attains its customary proportions.

The patient is generally kept in bed two weeks,
and the sutures removed on the ninth day in the
order in which they were introduced. After the re-
moval of the stitches many operators order a vaginal
douche two or three times a day, the amount of water
varying from four to six quarts. ‘This treatment is
successful only when the douches are given at the
proper time and temperature.

Cisse Ig Re OOO
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 sur-
prise for her patient:

Water.—Boiled water is the saftest and best for
the sick. Reacrated 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
very light; strain through a cloth; add a glass of
water. Stir in a teaspoonful 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.

Time Water.—Take a lump of unslaked lime the
size of an egg, and place it in a half-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.

265

266 SURGICAL TECHNIC.

Barley Water.—Stir two ounces of pearl barley in
a pint and a half of cold water; boil for half an hour
over a slow fire in a 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 ina heaping dessertspoonful
of sugar. Fill up the glass with water; stir in more
sugar if necessary.

Effervescing Lemonade.—Add half a teaspoonful
of bicarbonate of soda to the above; or may use
Vichy water to make:

Egg Temonade.—Shake up the white of one egg
in a cup of water, to which add two teaspoonfuls of
leinon juice and sugar; shake. Serve at once.

Imperial Drink.—Add a teaspoonful of cream of
tartar to a 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 pre-
served 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
boiling 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 tea-
spoonful of lemon juice may be added to vary the taste.

Milk Diet.—This consists of two or three quarts of
milk daily.

DIET RECIPES. 267

Koumyss.—Dissolve a third of a cake of com-
pressed yeast in a little lukewarm water; add this to
a quart of 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 till 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; add a couple of pieces of orange peel or
lemon. Pour over alla pint of boiling water; cover
with a napkin; let cool; strain for use. Must be
made fresh.

Toast Soup.—YToast a thin slice of stale bread.
While hot, spread butter over it, having no excess.
Break into fragments and place in a pitcher; add
three-quarters of a pint of boiling water; add a pinch
of salt and pepper. Serve hot.

Flaxseed Tea.—Add one-half cup of flaxseed to
one 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 mix-
ture, allowing half an ounce of the bark to a pint of
liquid.

Milk and Cinnamon.—T half a pint of new milk
add enough broken cinnamon sticks to flavor; add to
this a teaspoonful of sugar; strain. Serve cold or hot.

Atrrowroot Gruel.—Stir up half a tablespoonful
of arrowroot flour with a little cold water; add a cup-
ful of water, stirring in half a dessertspoonful of sugar

268 SURGICAL ALE CHINIC

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 been mixed half 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 tablepoonsfuls of grated cracker in
a little water and add to the heated water. Boil for
five minutes; add a cupful of 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 mak-
ing 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 dessert-
spoonful of sugar; the rind and juice of one lemon; a
pinch of salt anda pint of water; heat, stirring the
mixture until boiling; turn into a mold and set out to
cool before serving.

Tapioca Soup.—Boil a pint of meat broth; stir in
an 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.

DIET: RECEIPES. 269

Poached Eggs.—Bring water to a boil in a sauce-
pan; 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 askimmer and serve
ona thin piece of buttered toast; sprinkle a little salt
and 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 frying pan, buttered; 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
cinnamon over the whole; add a 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 acup anda half of milk to the boiling point;
add a pinch of salt and a small bit of butter; thicken
the milk by adding one-half teaspoonful of corn-
starch; stir well and boil for five minutes. Pour the
milk mixture over the toast in a closed dish. Serve
hot. :

Rennet.—One pint of milk warmed, 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

270 SCKRGICAL T3CEHNIGC.

every grain is softened without dissolving into a
shapeless mass.

Plain Rice.—T wo tablespoonfuls of rice are to be
washed and placed in a shallow baking dish; add two
tablespoonfuls of sugar; flavor with lemon peel or
vanilia; add one quart of milk. Bake for three hours
in a moderate oven, stirring every twenty minutes.
Cool for an hour before using. Serve cold.

Tapioca Pudding.—Soak one-half cup of tapioca
over night in cold water; put it over the fire and heat
to clearness. Mix up one pint of milk and two eggs
to form a custard 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 half a pint of milk; boil for five minutes, stir-
ring all the time; add a pinch of salt; sweeten to taste,
and add a flavoring extract. Serve cold.

Beef Essence.—Cut up one pound of fresh lean
beef from the neck 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 one pint of beef essence made

JOYEBIE SIE OIE. 271

quite hot add half a pint of cream, likewise hot, to
which the yolk of a fresh egg has been stirred up.
Mix carefully together in a lined saucepan; season
and serve.

Beef Broth.—Take a pound of beef (neck or shoul-
der) and slice it up; place in a pan and salt, then
pour on a quart of cold water; place on the fire and
bring toa simmer; keep so over a slow fire an hour
and a half; set back on the range for half an hour;
strain; serve.

Mutton Broth.—Cut up a pound of good mutton
into small pieces and sprinkle with salt; allow to sim-
mer over a slow fire, after adding one quart of cold
water, for an hour and a half; boil for half an hour;
strain; serve.

Beef Juice.—Take half a 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 meet presser or lemon squeezer; adda 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 well as every-
thing adhering to the side-bones and back; cut up the
halves in thin slices; place them in a pan and sprinkle
with salt, then adda quart of cold water; bring toa
simmer over a slow fire; allow to remain for an hour
qideashal “hens temove irom 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.

CEWAGE sISE NR. xe Gt iele
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 trance: mor is absence of the heart-beatymmless
determined by means of a stethoscope in experienced
hands. Coldness and rigidity may be due to collapse
or catalepsy or in persons who are frozen stiff.

In doubtful cases of apparent death which occur
suddenly or from external violence the following
tests are usually applied :

1. The absence of the heart’s action is carefully
determined by a stethoscope or phonendoscope.

2. Absence of the circulation is ascertained by
tying a string tightly around a finger or a toe; if the
tip becomes blue, life is not extinct, though this may
occur in cases where there has been great loss of

PH (3

SIGNS OF DEATH. 273

blood, and in other cases where the heart is too weak

to send the arterial blood into the capillaries of the
fingers.

FIG. 203.—Stethoscope. FIG. 204.—Bazzi-Bianchi’s phonendoscope.
3. Absence of respiration is determined by placing
the surface of a mirror before the mouth ; if the sur-
face 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.
18

274. SURGICAL THCHNIC.

5. If a needle is inserted into the flesh of a living
person blood will escape, but not if life is extinct ;
still, if there has been a large loss of blood, there will
be no escape of blood in the living.

Rigor mortis (post-mortem rigidity or stiffness of
death) begins in the upper part of the body, usually
in the maxillary muscles, and spreads gradually from
above downward. It disappears in the same order.
It comes and goes quickly after-great muscular effort
or excitement, and when once it has been broken
up it does notreturn. 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, because it indicates death of the mus-
cle itself.

Death of the body as a whole takes place first, and
at intervals of an hour or even several hours death of
one or other of the involuntary muscles follows.

Hypostasis, cadaveric lividity, or congestion of
blood in the capillaries, which forms in all the de-
pendent parts of the body, is considered a valuable
sign of death, but this purple color may be due to
contusion, and has been seen in cholera patients
before death.

The body-temperature at and from one to two
hours after death may be very high, 107° or 112° F.
Patients dying from cholera and yellow fever have
high temperatures for several hours after death; but,
as a rule, the body 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

AUTOPSIES. 275

with a little tact the necessary permission can usually
be obtained. Every well-conducted autopsy adds
more or less to medical knowledge. It verifies the
diagnosis of the illness, and in many cases it explains
or shows the cause of symptoms the explanation of
which could not be determined before death. In
surgical work, when a patient dies in less than
twelve or fourteen hours after an operation, the au-
topsy, when made by a competent bacteriologist and
pathologist, will show whether death was due to
sepsis or to some organic disease over which the sur-
geon had no control.

In a private house the autopsy should be held in
the room giving the best light, and if possible in the
daytime in order to obtain the correct color-interpre-
tation; for if made in artificial light the observations
will not be entirely trustworthy.

At the present time an autopsy is perferably held
almost immediately after death, and before putre-
factive changes have taken place. The undertaker
should always be warned not to inject the body, be-
cause the fluids usually employed, which contain
among other things corrosive sublimate and arsenic
in large quantities, change the color and consistency
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

276 SURGICAL TECHNIC.

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, a marble-top table
if possible, unless there is a marble-top stationary
bowl in the room.

3. Three washbowls: one for corrosive sublimate,
one for dirty instruments, and one for organs re-
moved.

4. Two pails for dirty water.

5. Old towels and a number of old sponges.

6. Plenty of hot and cold water.

7. About four quarts of fine sawdust, or oakum,
or excelsior packing, absorbent cotton, or common
cotton for filling up cavities, any one of which will
prevent fluid oozing through the incisions. When
these are not obtainable, bran, cloth, or newspapers
may be used. Fine sawdust is the best material, as
it packs easily, does not interfere with the sewing
by getting into the stitches, and keeps the needle
dry.

8. Six wide-mouthed bottles in which to place
specimens from the various organs, and which can
be securely corked. 7

9. Mucilage and labels on which to write the his-
tory of each specimen in the bottle.

10. About three yards of fine twine or carpet-

AUTOPSIES. : 277

thread, and a large darning-needle or a large curved
needle.

Should the autopsy take place in a house where
there are no conveniences, the body can be left lying
on the undertaker’s stretcher covered with a sheet,
the clothing removed, and a large napkin put on.
There should be several old newspapers to protect
the floor, and on which to place the dirty instru-
ments and organs removed; an old sheet, a pail,
a wash-bowl, and a pitcher of warm water can always
be obtained.

The sheet is torn into four pieces. Two pieces are
used, one for each side of the neck and trunk, cover-
ing the arms, leaving the chest and abdomen free for
the surgeon to operate; the third piece is placed be-
neath the head; and the fourth piece is tucked in
below the genitals, thus covering the lower extrem1-
ties. The bowl contains the large dampened sponge,
and, together with the pail, should be placed within
convenient reach.

Absolute cleanliness is essential at a private autopsy.
Blood-stains must be washed from the walls, floor,
dishes, the rubber or 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 post-
mortem. Ground coffee thrown on a few live coals
will remove all odor from the room.

For removing the odor froin the hands, turpentine
will be found serviceable, or a solution of per-
manganate 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.

CHASE ER oan

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) xeoulamiiyasm
conducting her mode of life are the chiefest factors
for securing a continuation of the sound health con-
ditions 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 never-
theless essential for a good nurse to learn how to
save up energy during ordinary times that she may
have sufficient vital capital force to meet the emer-
gency demands.

Sufficient sleep and a regular time for eating is as
important 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 is for the most part made a matter
of convenience rather than considered as most im-

278

PERSONAL CONDUCT OF A NURSE’S LIFE. 279

portant 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-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 com-
fort, there is seldom allowed time enough for suff-
cient body bathing.

A nurse who spends a day a month in bed during
the beginning of her monthly sicknesses will often
be considered selfish, and she may now and then lose
a position temporarily by following such a course,
but her increased value to herself and to the profes-
sion she serves during the rest of the month will far
outweigh the apparent disadvantage.

site: presence of, decayed teeth) corms, bumious,
varicose veins in the legs, and hemorrhoids are all
common affections 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 appearance of the handicapping condi-
tions 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 affec-
tions which arise from ill-fitting shoes, nurses are
particularly liable to the condition called ‘‘ footsore,”’
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 com-
fort and health not by wearing her oldest, run-down

280 SURGICAL TECHNIC.

shoes, but always during working hours a well-fit-
ting, ample sized shoe which allows her toes to lie
uncramped. ‘The other essential for comfort is to
keep the feet dry. Perspiration quickly softens the
skin of the feet, and allows swelling in the soft cel-
lular tissue beneath to take place. While a perspir-
ing foot is by no means unhealthy, the relaxation
which accompanies it calls for treatment. To over-
come 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 ; stimu-
lating foot baths, alternating hot and cold water,
accompanied by rubbing with a coarse towel and
massage; alcohol bath and rub; painting the soles
of the feet with a ro to 20 per cent. formalin solu-
tion once or twice a week ; talcum powder, rice flour,
fuller’s earth dusted in the shoes; paper insoles, made
from newspaper after folding several leaves, and cut to
the size of the stockinged foot, will be found invalu-
able in keeping the feet both dry and warm. A daily
change may be. made at the time of “dressmesgelan
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 omseme
feet, manifested by a continuous ache upon standing,
may be overcome by massage, strapping and bandag-
ing, or supported 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 discomfort, if not to well-marked skin disease.
Drying up of the normal oil of the skin is the earliest

PERSONAL CONDUCT OF A_NURSE’S LIFE, 28%

direct cause of roughness, cracking, and scaling skin.
A peculiar sensitiveness of certain individuals’ skins
for such drug solutions as carbolic acid, bichlorid
of mercury, and oxalic acid, which act toward them
as special irritants, and which is known by the term
idiosyncrasy, is not considered. In general, to keep
the hands pliant by massage and the free use of cold
cream, lanolin, or some such bland ointment, will
suffice. In cases which fail of relief, rubber gloves
must be worn.

The importance of cultivating her powers of obser-
vation 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 ob-
serving faculty by evolving opinions.

A good nurse makes no noise herself, and acts as a
perpetual noise preventer in and around the sick-
room. 3

The stricter a nurse holds herself to the prescribed
uniform of her school the better, thus fancy collars,
and neckwear, jewelry, and hair ornaments, finger-
rings, detract her personality from the rdle 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
physician call for but the ordiuary dignity which be-
comes 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 con-
tinually tax herself with the requirements of her art.

282 SORGICAL “LEGCHINIC

Proper amusements have their place, and will the
better equip her for the serious work hours.

Nurses will do well to study surgical supply cata-
logues, 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 con-
duct 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 ‘‘ travelling
case,’’? by connecting herself with work in some dis-
tant 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 correspondence depart-
ment to provide for this ‘‘exchange’’ system in prac-
tice over the country. Besides rest in change of en-
vironment the results will be better, because broader,
educated nurses. Of the rewards for conscientious
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 be-
tween ‘‘ cases,’’ is to be overcome by a mutual division
of expenses, 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 communica-
tion 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

eS OWA Te CONDUCT= OF Ay NORSE SS LILLE, 283

physician and tells him what she can do and the scale
of her prices for her work has made an impression,
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
vocation, must be the sum-up of her whole life’s
work. If at the commencement of her career she
learns to know herself 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.

GEOSSAR

A.

Abdominal binder. A wide band-
age dressing used to support the walls
of the abdomen after open operations

or the womb after childbirth. Musiin, |
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.

A circumscribed collec-

One active in on-

set, energetic in course, and of short |

duration.
Aérobic.
of oxygen for development.

Requiring the presence |

| 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.

285

286

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 septic
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.

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
glycerin.

Bouillon. Strained beef soup; a
culture-medium. :

Bronchi. ‘The first division of the
windpipe.

Bronchioles.
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.

Yeast-forming

The finest divisions

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. To draw off the
urine, —

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. Soda 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 |

287

Complication. A disease appear-
ing during the course of another,
which may modify the termination.

Contagious. Capable of 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 period of
uninterrupted recovery from __ ill-
ness.

Convulsion. A nervous condi-
tion giving rise to violent, continued,
or intermittent muscular contrac-
tions.

Corrosive sublimate. _Bichlorid

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
its cavity.

Cyanosis. The symptoms arising
when the supply of oxygen is greatly
lessened, as in strangulation.

Cyst. A circumscribed membran-
ous cavity occurring abnormally and
containing fluid, semifluid, or solid
contents.

clear as

Substances upon
experimentally

288

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. Act of decaying;
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. The act of heating
a solid or liquid in an apparatus, so
that the vapors given off may be
collected.

Douche. A more or less forcible
flushing of a cavity or part of the body
for purposes of cleansing and stimula-
tion.

E.

Eclampsia. Convulsions during
the childbearing period caused by
kidney disease.

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; pro-
duced :

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

GLOSSAR Y.

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. Two trumpet-
shaped pipes, each about four inches
long, connecting the womb with the
abdominal cavity, through which ova
pass.

Fascia.
sheaths separating muscles.

Feces. Body and food waste from
the bowels.

19

Strong, glistening fibrous

289

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.
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.

A contagious disease

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

290 GLOSSARY.
gonorrhea; consists of a double, I
dumbbell coccus. ;
Gonorrhea. A_ sexual _ disease Icterus. Bile-stained; jaundiced.

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. Relating to
sexual organs of a woman.

the

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

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
fluid 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. 261

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

| 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. Medicines.

Menstruum. A fluid carrier or
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. Any form of
germ life.

Minim. A fluid drop.

Monomorphous. Having but one
form.

Germs having a

292

N.

Narcotized. Poisoned by the action
of a narcotic, as opium.

Natural rhythm of respiration.
Normal breathing.

Nerve-center. One of the count-
less impulse generators or reflectors
in the body.

Neutralization.
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 fluid dis-
charge made solid by the formation
of fibrin.

Otitis media. Inflammation of
the chambers of the middle ear.

Ova. Eggs.

Ovaries. The two _ egg-bearing
organs in the female.

Oxidation. Burning up.

Oxygenation of the blood. Re-
freshing of the blood by the action of
the red cells in taking up oxygen.

1

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. An
apparatus for sterilizing and filtering
by the action of superheated steam,
varied in pressure by means of an air-

pump.

|

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 in calculating the
size of a woman’s pelvis.

Pelvis. The bony framework at
the base of the spinal column sup-
porting the trunk and affording at-
tachment for the thighs.

Perforator. A sharp, spear-headed
instrument used by obstetricians to
pierce the skull (to facilitate delivery)
of a dead infant or one whose life
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
which propels the contents of the
bowels.

Peritoneal cavity. The space oc-
cupied by the abdominal organs.

Peritoneum, The lining mem-

brane of the belly cavity and cover-

GLOSSAR Y. 293
Puerperal. Relating to child-
birth.

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 of
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.

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.

Revulsion. A rejection; counter-
irritation.

Rigor. Sense of coldness accom-
panied by a superficial convulsive
seizure.

204
S.

Salicylated. Containing a given
amount of salicylic acid.

Saliva. Spittle.

Saprophytic organisms. Those
living in or on decaying organic mat-
berg

Sarcoma. A form of cancer of
rapid growth and occurring most
often in the young.

Saturated. Fully filled; soaked.

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

or pus-germ infection.

Septic discharge.
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.

Sequelez.
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.

Purulent; con-

After-effects of dis-

GLO SSATON.

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.
action; urging.
Subcutaneous injection.
made beneath the skin.
Subnormal temperature.
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.

Arousing to greater
One

Degree

GLOSSARY. 205

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.

abe

Tampon. A gauze or cotton plug;
may have a string or tape attathed
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.

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.

296

Urination.
water.

Uterine appendages. The ovaries,
Fallopian tubes, broad and other at-
taching ligaments 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.

The act of passing

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.

ABDOMINAL bandage, 76
cavity, apparatus for douch-
ing, 155
operations, 241
instruments for, 108
Abscess, stitch-, 163
Absorbent cotton, 147, 165
Accidents during operation, 238
Acclimatization immunity, 32
Acid, carbolic, treatment after |
poisoning by, 194
hydrocyanic, treatment after |
poisoning by, 194
Acids, mineral, treatment after
poisoning by, 194
Aconite poisoning, 194
Acquired immunity, 32
Actinomycosis, communication
of, to man, I4
Adenoid forceps, 122
Adhesive plaster, rubber, 150
After-care for gynecologic opera-
tions, 263
Albumin water, 265
Alcohol as an antiseptic, 59
sterilization of hands with, 59
Allis’s aseptic ether-inhaler, 135
Ambulance, transportation by,
212
Ammonia, subcutaneous injec-
tion of, as test in supposed
death, 273
Amputation of
ments for, 116
Anastomosis button of Murphy,
Tiel
Anesthesia, 130-146
bronchorrhea in, 136
dilated pupils in, 138
general, instruments for, 103

limb, instru-

Anesthesia, infiltration, 144
instruments for, 103
local, instruments for, 103
preparation for accidents in,
134
primary, 138
vomiting during production of,

137
Anesthetics, administration of,
130
chloroform, 140
cocain, 144
ether, administration of, 134
ethyl bromid, 141
general, 130
local, 130, 142
cocain, 142
hydrochlorate, 143
ethyl chlorid, 143
eucain, 142
1Ce Ae :
phenate of cocain, 143
orthoform, 63
hydrochlorid, 63
Schleich’s, 142
Anesthetizing stethoscope
Griffith, 137
Aneurysm needle, 113
Angiotribe of Tuffier, 111
Anthrax, discovery of bacterial
nature of, 15, 16
Antidotes, 194-196
Antimony tartrate poisoning, 194
Antiseptic douches, 181
dressings, 147
powders, 151
surgery, Lister’s system, 12, 13
Antiseptics, 44-64
alcohol, 59
aristol, 57

of

297

298

Antiseptics, balsam of Peru, 63
boiling water, 47
boric acid, 58
boroglycerid, 59
carbolic acid, 50
chlorin, 49
chlorinated lime, 61
coal-tar derivatives, 50
Condy’s fluid, 61
corrosive sublimate, 49
creolin, 52
crude carbolic acid, 51
dermatol, 64
formaldehyd, 54
heat, 47
moist, 47
hot air, 48
hydrochloric acid, 62
hydrogen peroxid, 58
ichthyol, 62
iodoform, 53
iodol, 54
Labarraque’s solution, 61
listerine, 64
lysol, 52
methyl-blue, 61
methyl-violet, 61
milk of lime, 62
mustard, 64
normal salt solution, 63
orthoform, 63
hydrochlorid, 63
oxalic acid, 60
ozone, 48
potassium permanganate, 60
protargol, 64
pyoktanin, 61
resorcin, 64
saprol, 53
soaps, 65
sodium bicarbonate, 64
sozal, 53
steam, 47
live, 48
sulphur dioxid, 49
sulphuric acid, 62
thymol iodid, 57
vinegar, sterilized, 63
zine chlorid, 62
Antistreptococcie serum for sep-
tic peritonitis, 236

INDEX.

Antitoxin, administration of, fol-
lowed by stimulation of
body’s germicidal powers, 41

in therapeutic practice, 37
method of injecting, 43
mixture of Coley for tumors,

42
of diphtheria, preparation of,
38
status of, 41
streptococcus, 42
preparation of, 39
tetanus, 42
theory of, 37
of immunity, 34
therapeutic action of, 39
tuberculosis, 43
preparation of, 39
Antityphoid fever serum, 43
Apple water, 265
Aristol, 57
Arnold sterilizer, 90
Arrowroot gruel, 267
Arsenic poisoning, 194
Artificial immunity, 33
respiration, 230
Schultze’s method, 201
Sylvester’s method, 231
Asepsis in gynecologic opera-
tions, 254
Atropin poisoning, 194
Autopsies, 274
cleanliness in, 277
instruments, etc., for, 276
preparation of body for, 275
time for, 275

BACILLUS, 21
aérogenes capsulatus, 36
coli communis, 35
comma, discovery of, 17
diphtheriz, 36
discovery of, 17
effect of light on, 47
icteroides, discovery of, 18
melitensis, discovery of, 19
of bubonic plague, discovery
of, 18
of glanders, discovery of, 17
of influenza, discovery of, 18

INDEX.

Bacillus of leprosy, discovery of,
16
of Malta fever, discovery of, 19
of measles, discovery of, 18
of tetanus, 36
discovery of, 17
of yellow fever, discovery of,
18
pyocyaneus, 36
tuberculosis, 36
discovery of, 17
typhosus, discovery of, 16
Bacteria, 20
as causes of disease, 20
channels of entrance into body,
27 28
conditions influencing growth
of, 26
disease-producing, 46
distribution of, 9
entrance of, through alimen-
tary canal, 28
through respiratory tract, 28
through skin, 27
forms of, 21
Koch’s circuit to prove spe-
cific pathogenic powers of,
29
pyogenic, 23
reproduction of, 25
by binary division, 25
by fission, 25
by sporulation, 25
sizes of, 20, 21
Bacteriology, 9
history of, 9
progress of, 11
Balsam of Peru, 63
Bandage, abdominal, 76
Barton’s, 68
breast, 71
chest, 70
Desault, 75
elbow, 73
eye, 81
fingers, 71, 72
foot, 78
for securing
tion, 81
four-tailed, of jaw, 69
Gibson’s, 69

lithotomy posi-

299

Bandage, Griffith’s, of head, 69
groin, 76, 77
hand, 71
handkerchief, 69
head, 67
knee, 77, 78
leg; 79
lower extremity, 76
neck, 70
penis, 80
perineal binder, 81
PEYOR 77
recurrent, of stump, 80
Scultetus, 82
shoulder, 74
T-, 83
thumb, 72
upper extremity, 71
Velpeau, 74
Bandaging, 66
Barley gruel, 268
water, 266
Barton’s bandage, 68
Basin, pus, 94
Bath thermometer, 180
Baudelocque-Osiander pelvime-
tery TES
Bazzi-Bianchi’s phonendoscope,
273
Bed for private operations, 246
Bed-grapple of Griffith, 226
Beef broth, 271
essence, 270
Belladonna, treatment after poi-
soning by, 194
Bellocq’s canula, 233
Bicarbonate of sodium, 64
Bichlorid gauze, 148
Bier’s air-suction apparatus for
stiff knee, 175
vacuum treatment apparatus
for boils, 175
Bigelow’s evacuator, 128
Binary division of bacteria, 25
Bismuth gauze, 149
Bladder, attention to, after oper-
ations, 221
irrigation of, 178
operations on, instruments for,
126
Boiled rice, 269

300

Boiling water as germicide, 47
Boils, Bier’s vacuum treatment,
apparatus for, 175
Bone-cutting forceps, 112
of DeVilbiss, 113
Boric acid, 58
Boroglycerid, 59
Bowels, attention to, after opera-
tions, 221
Brain, operations on,
TMCHIES Ope
Braun’s cranioclast, 113
Breast, bandage of, 71
Breast-binder, Murphy’s, 200
Breast-pump, 115
Bremer’s ureter-cystoscope, 122
Bronchorrhea in anesthesia, 136
Broth, beef, 271
chicken, 271 -
juice, 271
mutton, 271
Brush, electric, 193
Brushes, 166
Buboniec plague, bacillus of, dis-
covery of, 18
Bulb-syringe, 250
Button, Murphy’s, 111
Button-suture, 162

instru-

CADAVERIC lividity, 274
Cantharides poisoning, 194
Canton-flannel legging, 127

roll for instruments, 100
Canula, Bellocq’s, 233
Capsule forceps, 123
Carbolic acid, crude, 51
Cargile membrane, 170
Cataract knife, 123
Catgut, 158

bichlorid, 160

iodized, 160

preparation of, 158

sterilization of, 158

with formalin, 161

Catheter, Eustachian, 112

Gouley’s, 127

Skene’s, 105
Catheterization, 176
Catheters, 176

glass, 176

INDEX.

Catheters, introduction of, 177
Catlin, 115
Cautery, Paquelin, 152
Cerebrospinal meningitis, epi-
demic, specific germ as cause
of, 19
Cervix, dilatation of,
ments for, 108
Chain-saw of Gigli, 113
Charts, keeping of, 97
medical, 102
Chest, bandage of, 70
Chicken broth, 271
Chicken-cholera, 16
Chlorinated lime, 61
Chlorin, 49
Chlorin-water poisoning, 195
Chloroform, 140
inhaler, Griffith’s, 140
poisoning, 195
Cholera, chicken, 16
Cigarette drain, 167
Circulation, absence of, as sign of
death, 272
Coal-tar derivatives, 50
Coaptation splint, 84
Cocain, 142
anesthesia, 144
hydrochlorate, 143
phenate, 143
poisoning, 145
Cocainization, spinal, 145
Coccin 21
morphology of, 23
Colchicum poisoning, 195
Cold, application of, 189
dry, application of, 189
moist, application of, 189
use of, 188
Coley’s antitoxin mixture for
tumors, 42
Collodion dressing, 149, 192
Comma bacillus, discovery of, 17
Compresses,, 85
Condy’s fluid, 61
Conium poisoning, 195
Continuous suture, 162
Copper sulphate poisoning, 195
Cornstarch, 270
Corrosive sublimate, 49
poisoning, 195

instru-

INDEX.

Corrosive sublimate, swallowing |

of, 50
Cotton, 192
absorbent, 147, 165
applicators, 112
Counterirritation, 187
Cracker gruel, 268
Cranioclast, Braun’s, 113
Creolin, 52
Croton-oil poisoning, 195
Cupping, dry, 190
wet, IQI
Curet, sharp, 107
spoon, 106
steel-eyed, 121
Currant juice, 266
Cystoscopic examination, instru-
ments for, 129
Cystotome, 123
Cysts or tumors, instruments for,

114

Dam, rubber, 170
Death, signs of, 272
absence of circulation, 272
of heart beat, 272
of respiration, 272, 273
hypostasis, 274
insertion of needle, 274
rigor mortis, 274
subcutaneous injection of
ammonia, 273
temperature, 274
stiffness of, 274
Delirium, traumatic, from shock,
232
Deodorants, 44
Dependent pockets, 167
Dermatol, 64
Desault bandage, 75
DeVilbiss bone-cutting forceps,
113
trephine, 124
Diet after operations, 222, 226
gynecologic, 264
milk, 266
of labor, 199
recipes, 265
Digitalis poisoning, 195
Diphtheria antitoxin, prepara-
tion of, 38

301

Diphtheria antitoxin, status of,

AI
bacillus of, 36
discovery of, 17
Diplococci, 23
Diplococcus pneumonie, 36
Director, Griffith’s, 127
Disease, bacteria as causes of, 20
conditions necessary for causa-
tion of, 29
in man, fungi connected with,
21
Disinfectants, 44
Disinfection, 46
by steam, 48 /
Dorsal position, 256
Douche-board, 182
Douche-pan, 181
Douches, 180
administration of, 180
antiseptic, 181
vaginal, apparatus for, 181
Douching abdominal cavity, ap-
paratus for, 155
Drain, cigarette, 167
Drainage, 166
postural, 168
Drainage-tubes, care of, 168
glass, 166, 169
rubber, preparation of, 169
Dressing-rooms, 87
Dressing-table, 218
Dressings, 66
antiseptic, 147
collodion, 149, 192
surgical, 147
Dust, infection from, in opera-
tions, 209-211

EAR, Operations on, 239
instruments for, 118
specula, 124
syringe, 240
Edebohl’s dorsal posture, 256
Effervescing lemonade, 266
Egg lemonade, 266
Eggs, 268
poached, 269
scrambled, 269
shirred, 269

302

Elaterium, poisoning by, 195
Elbow, bandage of, 73
Electric brush, 193
Electricity, 193
Electrolysis, 193
needles, 193
Elevator, periosteal, 112
Emergency bundles, 166
operations, preparations
251, 252
Emulsion of iodoform, 148
Enema, 183, 184
for tympanites, 184
purgative, 184
stimulating, 184
Enteroclysis, 182
Esmarch’s tourniquet, 232
Ether, administration of, 134
nausea after, 139
to children, 138
vomiting after, 139
death from, 139
Ether-inhaler, Allis’s, 135
Ethyl bromid, 141
chlorid, 143
mask and tube for, 140
Eucain, 142
Eustachian catheter, 112
Evacuator, Bigelow’s, 128
Examinations, gynecologic, 254,
255. See also Gynecologic
examinations.
of rectum, 258
Excretions, disinfectants for, 62
Extremities, operations on, 241
Eye, bandage of, 81
operations on, 239
instruments for, 118
Eyelid speculum, 120

in,

FERMENTATION-FEVER, 236

Finger cots, 171

Fingers, bandage of, 71, 72

Fish poisoning, 196

Fission, 25, 26

Flaxseed tea, 267

Flour ball, 268

Foot, bandage of, 78

Forceps, adenoid, 122
bone-cutting, 112

INDEX.

Forceps, bone-cutting, of DeVil-
biss, 113
capsule, 123
hemostatic, varieties of, 109
phimosis, 122
septum, 119
tracheotomy, 121
Formaldehyd, 54
as dusting-powder, 55
generator, 56
inhaiation of, 56
sterilization of instruments and
dressings with, 91
Formalin lamp, 90
poisoning, 56
sterilization of catgut with,
161
Fountain-syringe, 250
Four-tailed bandage, 69
Fowler’s position in peritonitis,
168
Fracture-box, 85
Fractures, 242
Fungi connected with disease in
man, 21

GANT’s pile-clamp, 128
Gas and liquid anesthesia, inhaler
Ore, TAU
nitrous-oxid, portable appara-
tus for, 131
Gauze, 147, 165
bichlorid, 148
bismuth, 149
iodoform, 148
packer, 107
pads, 164
potassium permanganate, 149
requirements of, for dressings,
147
Genupectoral position, 257
Germicides, 44
Germs, incubation-period of, 31
Gibson’s bandage for jaw, 69
Gigli’s chain-saw, 113
Girdle, Neptune, 139
Glanders, bacillus of, discovery
Of oie
Glass hand bowl, 94
instrument tray, 93

INDEX.

Glover’s suture, 162
Gloves, 170
rubber, 170
solution for, 171
Glycerin, sterilization of, 165
Gonococcus as cause of gonor-
rhea, 16
discovery of, 16
Gonorrhea, gonococcus of, 16
Gouley’s tunneled catheter, 127
Gram’s method of staining strep-
tococcus, 24
Green soap, 172
Griffith’s antiseptic irrigator tip
holder, 111
bed-grapple, 226
combined inhaler for gas and
liquid anesthesia, 145
Giector,.127
head bandage, 69
hook for use in glass-shelved
instrument cases, 87
membrane, 170
one-piece wooden mallet, 124
operating table-bed, 261
single-eared anesthetizing
stethoscope, 137
wire-frame chloroform inhaler,
140
wooden mouth-wedge and gag,
131 .
Groin, bandage of, 76, 77
Gruber’s ear specula, 124
Gruel, arrowroot, 267
barley, 268
cracker, 268
Gynecologic examinations, 254,
aU
asepsis in, 254
positions in, 255
dorsal, 256
Edebohl’s, 256
genupectoral, 257
knee-chest, 257
latero-abdominal, 256
lithotomy, 257
Sims’, 256
Trendelenburg, 261
upright, 255
Walcher, 258
preparations for, 259

393

Gynecologic operations, 254. See
also Operations, gyneco-
logic.

instruments
after, 126

for dressing

HAnp, bandage of, 71, 72
bowl, glass, 94
Handkerchief bandage, 69
Hard-rubber oral screw, 131
Head, bandage of, 67
operations on, 239
Heart-beat, absence of, value of,
as sign of death, 272
Heat, application of, 188
dry, application of, 188
germicidal powers of, 47
moist, application of, 188
as germicide, 47
use of, 188
Hemorrhage following opera-
tions, 232
symptoms, 233
treatment, 222
Hemostatic forceps, 109
Hernia, 236
Horsehair suture material, 162
Horsley’s wax, 150
Hot air as germicide, 48
Hot-air oven, 189
House-stretcher, 88
Hydrochloric acid as disinfect-
ant, 62
Hydrocyanic acid, poisoning by,
194
Hydrogen peroxid, 58
Hydrophobia, first application of
Pasteur’s treatment, 18
Hygiene of nurse, 278
Hyoscyamus poisoning, 195
Hypodermic injection, 186
syringe, Luer’s, 131
Hypodermoclysis, apparatus for,
154
Hypostasis as sign of death, 274
Hysterectomy, 238
insanity after, 238
vaginal, 238
instruments for, 114

304

Ick as local anesthetic, 142
Ice-bag, 174
Ichthyol, 62
Illuminating gas, poisoning by,
195
Immunity, 31
acclimatization, 32
acquired, 32
antitoxin theory of, 34
artificial, 33
natural, 32
facialy a2
theories of, 32-34
phagocytosis, 33
Imperial drink, 266
Incision, deep, 192
Incubation-period of germs, 31
Infant, new-born, 199. See also
New-born infant.
Infants, care of, 197
Infection from dust in operations,
209-211
of sutures, 163
Infiltration-anesthesia, 144
Inflammation, 173
causes of, 175
Influenza, bacillus of, discovery
Ofe1s
Inhaler, Griffith’s, for gas and
liquid anesthesia, 145
wire-frame chloroform, 140
Injection of antitoxin, 43
Injections, rectal, 182
Insanity after hysterectomy, 238
Instruments and dressings, steril-
izer for, 91
cabinet for, 86
canton-flannel roll for, 100
for anesthesia, 103
general, 103
local, 103
for cystoscopic examination,
129
for dressing after gynecologic
operations, 126
for operations, 103-129
abdominal, 108
amputation of limb, 116
curetting of uterus, 108
cysts or tumors, 114
dilatation of cervix, 108

INDEX.

Instruments for operations on
bladder, 126
on brain, 114
on ear, 118
on eye, 118
on mouth, 117
on nose, 117
on rectum, 125
on spine, 114
on throat, 117
on urethra, 126
perineorrhaphy, 103
trachelorrhaphy, 104
vaginal hysterectomy, 114
obstetrical, 116
sterilization of, 89
apparatus for, 9i
with formaldehyd, 91
sterilizing tube for, 90
Instrument-trays, 93
glass, 93
Interrupted suture, 162
Intestinal obstruction, 236
Iodin poisoning, 196
Iodoform, 53
emulsion, 148
gauze, 148
poisoning, 53
Todol, 54
Irrigation, 156
of bladder, 178
of rectum, 182
of wound, apparatus ior, 156
Irrigator, 215

JoHNSON’s method for prepara-
tion of catgut, 160

KANGAROO-TENDON, 157
Kelly’s leg-holder, 105
pad, improvised, 248
Keye’s stone-searcher, 127
Knee, bandage of, 77, 78
stiff, Bier’s air suction appara-
CUS HOT ICs
Knee-chest position, 257
Knife, cataract, 123
for amputation, 115
periosteum, I12

INDEX.

Kny-Scheerer instrument cab- | Malta fever,

inet, 86
Koch’s circuit to prove specific
pathogenic powers of microbe,

29
Koumyss, 267

LABARRAQUE’S solution, 61 ©
Labor, diet of, 199
nurse’s duties after, 197
before, 197
Lamp, formalin, 90
Lange’s retractor, 111
Latero-abdominal position, 256
Lead salts, poisoning by, 196
Leeching, 191
Leg, bandage of, 79
holder, 105
Lemonade, 266
effervescing, 266
egg, 266
Lens, wire loop for extraction of,
0238
Leprous nodules,
bacilli of, 16
Liebreich’s eye bandage, 81
Wigatine, 157. ) cee also, Sutures:
Ligature-tray, Robb’s aseptic, 94
Light, effect of, on bacteria, 47
Limb, amputation of, instru-
ments for, 116
Lime, chlorinated, 61
milk of, 62
water, 265
Liniments, 190
Listerine, 64
Listerism, 13
Lister’s system of antiseptic sur-
Lithotomy position, 249, 257
bandage for securing, 81
Lithotrite, 128
Lobelia poisoning, 196
Loring’s ophthalmoscope, 123
Luer’s hypodermic syringe, 131
Lysol, 52

discovery of

MALARIAL fever, cause of, 19
Mallet, Griffith’s, 124
rawhide, 120

20

305

bacillus of, dis-
covery of, 19

ees S vaccination stylet,

Mane and tube for ethyl entra)
140
Massage, 192
Measles, bacillus of, discovery of,
18
Membrane, cargile, 170
shark, 170
Metal spoon, 123
suturing clamps, 162
Methyl-blue, 61
Methyl-violet, 61
Metschnikoff’s theory of phago-
cytosis, 34
Micrococcus lanceolatus, 36
Pasteuri, discovery of, 17
Milk and cinnamon, 267
diet, 266
of lime, 62
toast, 269
Mineral acids, poisoning by, 194
Minor surgery, 186
Morphin poisoning, 196
Mosquitoes as disseminators of
yellow fever, 18
Mouth, dryness of, after opera-
tions, 220
operation on, instruments for,
117
Mouth-gag, 122
Mouth-wedge and gag, Griffith’s,
131
Murphy’s anastomosing button,
Tee
breast-binder, 200
rubber-glove solution, 171
Mustard as antiseptic, 64
Mustard-plaster, 187
Mutton broth, 271

NASAL splint, 119
syringe, 240
Natural immunity, 32
Nausea after etherization, 139
Neck, bandage of, 70
operations on, 240
Needle, aneurysm, 113

300

Needle-holder, Reiner’s, 107
Needles, 165
electrolysis, 193
insertion of, as test in sup-
posed death, 274
Neptune girdle, 139
New-born infant, care of, 199
clothing of, 200
feeding of, 200
nursing of, 199
Nipple-shield, 115
Nitrous-oxid gas, portable ap-
paratus for, 131
Nodules of leprosy, discovery of
bacilli of, 16
Nose, operations on, 239
instruments for, 117
Nurses, duties of, after labor, 197
before labor, 197
in operations, 204, 205, 216—
220, 239-242
hygiene of, 278
personal conduct of, 278
preparations of, for operations,
205, 206
rewards, success of, 278
Nursing, obstetrical, 197
Nux vomica poisoning, 196

OBSTETRICAL instruments and
appliances, 116
nursing, 197
Obstruction, intestinal, 236
Oils, sterilization of, 165
Ointments, 190
Operating table-bed, 261
Operating-room, care of, 86
preparation of, 204
Operating-table, 237
for private operations, 248
portable, 244
Operation blank, 1o1
Operations, 203
accidents during, 238
arranging of patient for, 216
attention to bladder after, 221
to bowels after, 221
care of patient after, 219-226
diet after, 222-226
dryness of mouth after, 220

INDEX.

Operations, duties of nurses in,
204, 205, 9 20-220 eae —
242

gynecologic, 254

after-care, 263
asepsis in, 254
diet after, 264
preparations for, 260

hemorrhage after, 232. See
also Hemorrhage following
operations.
infection in, from dust, 209-
AINCM
in private practice, 243
bed for, 246
furniture, instruments,
ete;, for) 2409

operating-table for, 248
preparations for, 244
in emergency cases, 250,
251
sterilization of instru-
ments for, 250
of sheets, towels, etc.,
250
instruments for, 103-129. See
also Instruments for opera-
tions.
of election, 204 ©
of emergency, 204
of expediency, 203
of necessity, 204
on abdomen, 241
on ear, 239
on extremities, 241
on eye, 239
on head, 239
on neck, 240
on nose, 239
on thorax, 241
on throat, 239
pleurisy after, 219
pneumonia after, 219
preparation of field of, 213
of vaginal canal, 214
of nurses for, 205, 206
of patient for, 212
day before operation, 213
day of operation, 215
of surgeon and assistants for,
207

INDEX.

Operations, septic peritonitis
after, 234. See also Pern-
tonitis, septic, after opera-
tions. .

sequelee of, 227

shock after, 227. See also
Shock following operations.

special, 239

thirst after, 220

Ophthalmoscope, Loring’s, 123

Opium poisoning, 196

Oral screw, hard-rubber, 131

Orangeade, 266

Orthoform, 63

hydrochlorid, 63

Oven, hot-air, 189

Oxalic acid, 60
poisoning, 196

Ozone, 48

PADS, gauze, 164
Panado, 269
Paquelin cautery, 152
Parasites as cause of malignant
tumors, 20
Patient, arranging of, for opera-
tions, 216
care of, after operations, 219-
226
preparation of, for operations,
212. See also Operations,
preparation of patient for.
transportation of, 212
Pelvimeter, Baudelocque-Osian-
der, 115
Penis, bandage of, 80
Perforator, Smellie’s, 113
Perineal binder for retaining
dressings to perineum, 81
Perineorrhaphy, instruments for,
103
Perineum bandage, 81
Periosteal elevator, 112
Periosteum knife, 112
Peritonitis, Fowler’s position in,
168
septic, after operations, 234
symptoms, 234
treatment, 235
with antistreptococcic
serum, 236

307

Peroxid of hydrogen, 58

Personal conduct of nurse, 278

Phagocytosis theory of immun-
Ly, 33

Phenate of cocain, 143

Phimosis forceps, 122

Phonendoscope, Bazzi-Bianchi,
273

Phosphorus poisoning, 196

Pile-clamp, Gant’s, 128

Plasmodium malariz as cause of
malaria, 20

Plaster, adhesive, rubber, 150

Plasters, 192

Pleurisy after operations, 219

Pneumococcus, 36
discovery of, 17

Pneumonia after operations, 219
croupous, bacillus of, 36

Poached eggs, 269

Poisons and antidotes, 194

Politzer’s inflating bag, 112

Portable apparatus for nitrous-

oxid gas, 131

operating-table, 244

Post-mortem rigidity, 274

Potash salts, poisoning by, 196

Potassium permanganate, 60

gauze, 149

Powder, antiseptic, 151

Powder-blower, 121

Private operations, 243. See
also Operations in private prac-
tice.

Probang, 119

Probes, 124

Protargol, 64

Pryor inguinal bandage, 77

Puerperal fever, organic ferments
as cause of, 14

Pump, breast-, 115

Puncturation, 192
deep, 192

Pupils, dilated,
138

Purgative enemata, 184

Pus, 174
basin, 94

Pushing lower jaw forward to
prevent obstruction to breath-

ing, 135

in anesthesia,

308

Pyogenic bacteria, 23
Pyoktanin, 61
blue, 61

RACIAL immunity, 32

Rawhide mallet, 120

Recipes, diet, 265

Rectal injections, 182
speculums, 124

Rectum, examination of, 258
irrigation of, 182
operations on, instruments for,

125
Reiner’s needle-holder, 107
Rennet, 269
Resorcin, 64
Respiration, absence of, as sign
of death, 272
value of, 272
artificial, for shock following
operations, 230
Sylvester's method
a, Barn
Schultze’s method, 201
Retractor, Lange’s, 111
sharp-pointed, 120
Schroeder’s, 109
Rice, boiled, 269
plain, 270
Ridal speculum, 119
Rigor mortis, 274
Robb’s aseptic ligature-tray, 94
Robinson’s douche-board, 181
Rubber adhesive plaster, 150
dam, 170
drainage-tubes, preparation of,
169
gloves, 170
solution for, 171
heels, 280
protective, 150

SALT solution, normal, 153
as antiseptic, 63

Saprol, 53

Sarcine, 23

Saw, chain-, of Gigli, 113

Saws for amputation, 115

Scarification, 191

INDEX.

Schleich’s anesthetic, 142
Schroeder’s vaginal retractor, 109
Schultze’s method of artificial
respiration, 201
Scissors, curved sharp-pointed,
120
Scrambled eggs, 269
Screw, oral, 131
Scultetus bandage, 83
septum forceps, 119
sequelz of operations, 227
Serum, antityphoid fever, 43
Shark membrane, 170
Shirred eggs, 269
Shock following operations, 227
artificial respiration in,
230
symptoms, 229
treatment, 229
traumatic delirium from, 232
Shotted suture, 162
Shoulder, bandage of, 73, 74
Signs of death, 274. See also
Death, signs of.
Silk, protective, oiled, 150
sterilization of, 161
Ssilkworm-gut, 158
Silver nitrate poisoning, 196
wire, 162
Simpson’s forceps, 115
sound, 107
Sims’ position, 256
speculum, 109
Sinus, 237
Skene’s reflux catheter, 105
Small-pox, vaccination for, 32
Smellie’s perforator, 113
Snare, 106
soap, green, 172
Soaps, 65
Soda salts, poisoning by, 196
Sodium bicarbonate, 64
Solutions basin stand, 215
Sound, Simpson’s, 107
Soup, invalid’s, 270
tapioca, 268
toast, 267
Sozal, 53
Speculum, ear, 124
eyelid, 120
rectal, 124

INDEX.

Speculum, Ridal, 119
Sims’, 109
Spinal cocainization, 145
Spine, operations on,
ments for, 114
Spirillum, 21
Splenic fever, discovery of bac-
terial nature of, 15, 16
Splints, 83
coaptation, 84
nasal, 119
Sponges, 163
gauze, 163
Marine, 163, 164
Spoon curet, 106
metal, 123
Spores, resistance of, 26, 46
Sporulation, 25
Spotted fever, specific germ as
cause of, 19
Staining streptococcus, Gram’s
method, 24
Staphylococci, 23, 24
Staphylococcus epidermidis al-
bus, 35
pyogenes albus, 35
aureus, 34
citreus, 35
Steam as germicide, 47
disinfection by, 48
live, as germicide, 48
Stegomyia fasciata, 18
Sterilization, 47, 89
dry, 89
fractional, 48
intermittent, 48
moist, 89
of catgut, 158.
gut.
of glycerin, 165
of hands with alcohol, 59
of horsehair, 162
of instruments, 90. See also
Instruments, sterilization of.
of oils, 165
of sheets, towels, etc.,
private operations, 249
of silk, 161
Sterilizer for
dressings, 91
improvised, 249

instru-

See also Cat-

for

instruments and

309

Sterilizing outfit, 92
tube for instruments, 90
Stethoscope, 273
Griffith’s anesthetizing, 137
Stitch-abscess, 163
Stomach-contents,
of, 179
Stone-searcher, Keye’s, 127
Stramonium, poisoning by, 194
Streptococci, 23, 24
Streptococcus antitoxin, 42
preparation of, 39
lanceolatus, 36
pyogenes, 35
staining of, Gram’s method, 24
Stretcher, house-, 88
improvised, 252
wheeled, 87
Strychnin poisoning, 196
Stump, recurrent bandage of, 80
Stupe, turpentine, 188
Sulphur dioxid, 49
Sulphuric acid as disinfectant, 62
Surgeon and assistants, prepara-
tions of, 207
Surgeon’s kit, 99
contents of, 99
packing of, 99
Surgery, antiseptic, Lister’s sys-
ESO | eA 168)
Surgical dressings, 147
technic, 66
Sutures, 157
button, 162
catgut, 157. See also Catgut.
continuous, 162
horsehair, 162
infection of, 163
interrupted, 162
kangaroo-tendon, 157
shotted, 162
silk, 161
silkworm-gut, 158
silver wire, 162
Suturing clamps, metal, 162
Sweating, method of producing,
188
Sylvester’s method of artificial
respiration, 231
Syringe, bulb-, 250
cup, 240

examination

310

Syringe, ear, 240
fountain-, 250
Luer’s hypodermic, 131
nasal, 240

TABLE-BED, Operating, 261
Tamarind water, 266
Tampons, 151
vaginal, 150
Tapioca jelly, 268
pudding, 270
soup, 268
T-bandage, 83
Tea, flaxseed, 267
Temperature, 193
in death, 274
Tenaculum, curved, 105
Tents, 151
Test-breakfast, 179
Tetanus antitoxin, 42
bacillus of, 36
discovery of, 17
Tetrads, 23
Theory of antitoxins, 37
Thermocautery, Paquelin’s, 152
Thermometer, bath-, 180
clinical, 192
Thiersch’s solution, 59
Thirst after operations, 220
Thorax, operations on, 241
Throat, operations on, 239
instruments for, 117
Thumb, bandage of, 72
Thymol iodid, 57
Toast, milk, 269
soup, 267
water, 267
Tobacco poisoning, 196
Tonsillotome, 120
Tourniquet, Esmarch’s, 232
Tracheal tube, 121
Trachelorrhaphy,
sors for, 107
instruments for, 104
Tracheotomy forceps, 121
Transportation of patient, 212
Traumatic delirium from shock,
232
Trays, instrument, 93.
Instrument trays.

curved — scis-

See also

INDEX.

Trays, ligature-, Robb’s aseptic,

94
Trendelenburg’s position, 261
in bed, 248
Trephine, DeVilbiss, 124
Tuberculin, 18
Tuberculosis, antitoxin of, 43
preparation of, 39
bacillus of, 36
discovery of, 17
Tubes, drainage-, 168.
Drainage-tubes.
Tuffier’s angiotribe, 111
Tumors, malignant, parasites as
cause of, 20
or cysts, instruments for, 114
treatment of, by Coley’s anti-
toxin mixture, 42
Turpentine stupe, 188
Tympanites, 236
enema for, 184
Typhoid fever, discovery of ba-
cilli of, 16

See also

UPRIGHT position, 255

Ureter-cystoscope, Bremer’s, 122

Urethra, operations on, instru-
ments for, 126

Uterus, curetting of, instruments
for, 108

VACCINATION, 32, 189
stylet, Mareschal’s, 189
Vacuum treatment apparatus,
Bier’s, for boils, 175
Vaginal canal, preparation of, for
operation, 214
douche, apparatus for, 181
hysterectomy, 238
instruments for, 114
retractor, Schroeder’s, 109
tampon, 150
Velpeau bandage, 74
Vinegar, sterilized, as antiseptic,
63
Volsella, 105
Vomiting after etherization, 139
during anesthetization, 137

WALCHER posture, 258
Water, 265
albumin, 265
apple, 265
barley, 266
coil, 174
lime, 265
tamarind, 266
toast, 267
Wheeled stretcher, 87

INDEX. | 311

Wound, irrigation of, apparatus
for, 156

YELLOW fever, bacillus of, dis-
covery of, 18
mosquitoes as disseminators
of, 18

Zinc chlorid, 62

Wire loop for extraction of lens, salts, poisoning by, 196

123

Zoodglea, 23

eo oc

SAUNDERS’ BOOKS

for

NURSES

maicens clinical Studies for Nurses ;. .:... . .
Aikens’ Primary Studies for Nurses. .

Aikens’ Training School Methods and the Bead Taree:
Beck’s Reference Handbook for Nurses ae
Davis’ Obstetric and Gynecologic Nursing. ....
DeLee’s Obstctrics for Nurses . nee
Dorland’s American Illustrated wiediveal Deconary <
Dorland’s American Pocket Medical Dictionary .....
Howlers Operating Room and Patient. ........
cdenwald and’ Rubralt om. Diet. ..- .. 6... = «
Grafstrom’s Mechanotherapy Cee ASS eee omar her nc
Griffth’s Care of the Baby.

Hoxie’s Medicine for Nurses . see
Lewis’ Anatomy and Physiology for Nases! aa tes
Macfarlane’s Gynecology for Nurses. ......
Manhattan Hospital Eye, Ear, Nose and Throat Nicene
McCombs’ Diseases of Children for Nurses .

Morris’ Essentials of Materia Medica
Morrow’s Immediate Care of the Injured .
Nancrede’s Essentials of Anatomy .
Paul’s Materia Medica for Nurses are
Paul’s Nursing in the Acute Infectious revere
Pyle’s Personal Hygiene .

Register’s Fever Nursing . . ee
Stoney’s Bacteriology and Sauectionil een :
Stoney’s Materia Medica for Nurses

Stoney’s Nursing . : :
Wilson’s Reference Tandibook of lapstemic Nursing.

W. B. SAUNDERS COMPANY
925 Walnut Street Philadelphia

London: 9, Henrietta Street, Covent Garden

uU
>
Q)
mM

IONONMO NM OOUNUAHRPDWOYANAUNUMOBHBWYADARAGMUNUNPHPW WW

Stoney’s Nursing NEW (3d) EDITION

In this excellent volume the author explains the entire range
of private nursing as distinguished from osfital nursing ;
and the nurse is given definite directions how best to meet the
various emergencies. Zhe American Journal of Nursing says
it ‘‘is the fullest and most complete’’ and ‘‘may well be rec-
ommended 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 zmprovise everything
ordinarily needed in the sick room.

Practical Points in Nursing. By EMILY M. A. STONEY, Superin-
tendent of the Training School for Nurses in the Carney Hospital,
South Boston, Mass. sz2mo, 466 pages, illustrated. Cloth, $1.75 net.

Stoney’s Materia Medica NEW (3d) EDITION

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. * * * ‘The treatment of poisoning
is stated in a manner that will permit of its being carried out
thoroughly and intelligently.’’

Materia Medica for Nurses. By EMILY M. A. STONEY, Superin-
tendent of the Training School for Nurses in the Carney Hospital,
South Boston, Mass. 12mo volume of 300 pages. Cloth, $1.50 net.

SECOND EDITION

Stoney’s Surgical Technic

The first part of the book is devoted to Bacteriology and
Antiseptics; the second part to Surgical Technic, Signs of
Death, Autopsies, Bandaging and Dressings, Obstetric Nurs-
ing, Care of Infants, etc., Hygiene and Personal Conduct of
the Nurse, etc. The New York Medical Record says it “‘isa
very practical book which presents the subjects stated in its
title in a concise manner.’’

Bacteriology and Surgical Technic for Nurses. By EMILY M. A,
STONEY. Revised by FREDERIC R. GRIFFITH, M. D., New York
1z2mo volume of 300 pages, fully illustrated. Cloth, $1.50 net

BR TE EE EY EL

Hoxie’s Medicine for Nurses

This work is truly a practice of medicine for the nurse, en-
abling her to recognize and, if necessary, to combat any signs
and changes that may occur between visits of the physician.
The Trained Nurse and Hospital Review says: ‘‘ This book
has our unqualified approval.’’

Practice of Medicine for Nurses. By GEORGE HOWARD HOXxIE, M.D.,
Professor of Internal Medicine, University of Kansas. Witha chap-
ter on Technic of Nursing by PEARL L. LAPTAD. 12mo of 284 pages,
illustrated. Cloth, Sr.s0 net.

Aikens’ Primary Studies for Nurses

ILLUSTRATED

Trained Nurse and Flospital 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 Memorial Hospital, Washington, D. C. 12mo of
435 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. 12mo of 267 pages. Cloth, $1.50 net.
Aikens’ Clinical Studies for Nurses
ILLUSTRATED

This new work is written on the same lines as the author’s
successful work for primary students, taking up the studies
the nurse must pursue during the second and third years.

Clinical Studies for Nurses. By CHARLOTTE A. AIKENS, formerly
Director of Sibley Memorial Hospital, Washington, D.C. 12mo of
512 pages, illustrated. Cloth, 52.00 net.

Fowler’s Operating Room <cv Dae

Dr. Fowler’s work contains all information of a surgical
nature that a nurse must know in order to attain the highest
efficiency. Canadian Journal of Medicine and Surgery says:
‘‘We find compactly and clearly stated just those thousand
and one things which when required are so hard to locate.’’

The Operating Room and the Patient. By RUSSELL S. FOWLER,
M. D., Professor of Surgery, Brooklyn Postgraduate Medical School.
Octavo of 284 pages, with original illust tions. Cloth, $2.00 net.

Nancrede’s Anatomy NEW (7th) EDITION

The American Journal of Medical Sciences says this work ‘‘is
one of the best of all the question compends and will no doubt
continue to enjoy its deserved success.”’

Essentials of Anatomy. CHARLES B. G. DENANCREDE, M. D., Pro-
fessor of Surgery and Clinical Surgery in the University of Michi-
gan, Ann Arbor. 12mo, 400 pages, 180 illustrations. Cloth, $1.00 net.

Beck’s Reference Handbook NEW (2d) EDITION

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 and
shows close observation of the sickroom and hospital regime.’’

A Reference Handbook for Nurses. By AMANDA K. BECK, Grads
uate of the Illinois Training School for Nurses, Chicago, Il,
32mo volume of 200 pages. Bound in flexible leather, Sz.25 net.

Paul’s Materia Medica

The physiologic actions Dr. Paul arranges according to the
action of the drug and not the organ ‘acted upon. Vurses
Journal of the Pacific Coast says: ‘‘ The arrangement is most
admirable. One of the features is the text on pretoxic signs.”’

A Text-Book of Materia Medica for Nurses. By GEORGE P. PAUL,
M. D., Assistant Visiting Physician and Adjunct Radiographer to the
Samaritan Hospital, Troy, N. Y. 12mo of 240 pages. Cloth, $1:50 net.

DeLee’s Obstetrics for Nurses = enmicn

Dr. DelLee’s book really considers two subjects—obstetrics
for nurses and actual obstetricnursing. TZ vained 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.
zz2mo volume of 512 pages, fully illustrated. Cloth, $2.50 net.

Davis’ Obstetric & Gynecologic Nursing

THE NEW (3d) 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. remo volume of 436 pages, illustrated. Buckram, $1.75 net.

Macfarlane’s Gynecology for Nurses

ILLUSTRATED

Dr. A. M. Seabrook, \Voman’s Hospital of Philadelphia, says:
*‘Tt is a most admirable little book, covering in a concise but
attractive way the subject from the nurse’s standpoint. You
certainly keep up to date in all these matters, and are to be
complimented upon your progress and enterprise.’’

A Reference Handbook of Gynecology for Nurses. By CATHARINE
MACFARLANE, M. D., Gynecologist to the Woman’s Hospital of Phil-

adelphia. 32mo of 150 pages, with 70 illustrations. Flexible leather,
$1.25 net.

Paul’s Fever Nursing

Nursing in the Acute Infectious Fevers. By GErOROE
P. Paut, M. D., Assistant Visiting Physician and
Adjunct Radiographer to the Samaritan Hospital, Troy.
12mo of 200 pages. Cloth, $1.00 net.

5

Manhattan Hospital Eye, Ear, Nose,
and Throat Nursing JUST READY

This is a practical book, prepared by surgeons who, from their
experience in the operating amphitheatre and at the bedside,
have realized the shortcomings of present nursing books in

regard to eye, ear, nose, and throat nursing.

Nursing in Diseases of the Eye, Ear, Nose and Throat. By the
Committee on Nurses of the Manhattan Eye, Ear, and Throat Hospital: -
J. EDWARD GILES, M. D., Surgeon in Eye Department; ARTHUR B.
DUEL, M. D., (chairman), Surgeon in Ear Department; HARMON
SMITH, M. D., Surgeon in Throat Department. Assisted by JOHN R.
SHANNON, M.D., Assistant Surgeon in Eye Department; and JOHN
R. PAGE, M. D., Assistant Surgeon in Ear Department. With chap-
ters by HERBERT B. WILCOX, M. D., Attending Physician to the Hos-
pital; and Miss EUGENIA D. AYERS, Superintendent of Nurses. 12mo
of 300 pages, illustrated.

Friedenwald and Ruhrah’s Dietetics
for Nurses NEW (2d) 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 395 pages. Cloth, $z.50 net

American Pocket Dictionary new cm eninion

The Trained 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.’’

Dorland’s Pocket Medical Dictionary. Edited by W. A. NEWMAN

DORLAND, M.D., of the University of Pennsylvania. Flexible leather,
with gold edges, $1.00 net; with patent thumb index, $1.25 net.

SECOND

Grafstrom’s Mechano-therapy EDITION

Mechano-therapy (Massage and Medical Gymnastics). By AXEL V.
GRAFSTROM, B. Sc., M. D., Attending Physician, Gustavus Adolphus
Orphanage, Jamestown, N. Y. 12mo, 200 pages. Cloth, $Sr.25 net.

Friedenwald & Ruhrah on Diet THIRD EDITION

Diet in Health and Disease. By JULIUS FRIEDENWALD, M. D., and
JOHN RUHRAH, M. D. Octavo volume of 764 pages. Cloth, 54.00 net.

6

McCombs’ Diseases of Children for Nurses

Dr. McCombs’ experience in lecturing to nurses has enabled
him to emphasize just those points that nurses most need to know.
National Flospital 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. MCCOMBS, M. D.,
Instructor of Nurses at the Children’s Hospital of Philadelphia. 1z2mo
of 431 pages, illustrated. Cloth, 52.00 net

Wilson’s Obstetric Nursing

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 to the Philadelphia Lying-in Char-
ity. 3z2mo of 355 pages, illustrated. Flexible leather, 51.25 net.

Morris’ Materia Medica NEW (7th) EDITION

The Trained Nurse and Flospital Review says: ‘The work is
thoroughly up to date, well arranged, compact, and yet con-
tains a very large amount of matter.’’

BEN Mon oeMi DERevicciby Wa. Lasion, A Re

Instructor in Materia Medica and Pharmacology at the Colum-
bia University, New York. s12mo of 300 pages. Cloth; $1.00 net,

Griffith’s Care of the Baby | sew um evimion

The New York Medical Journal says: ‘‘ We are confident if
this little work could find its way into the hands of every
trained nurse, infant mortality would be lessened by at least

fifty per cent.’’
The Care of the Baby. By J. P. CROZER GRIFFITH, M. D., Clinical
Professor of Diseases of Children, University of Pennsylvania.
12mo Of 455 pages, illustrated, including 5 plates. Cloth, $1.50 net.

q

Lewis’ Anatomy and Physiology

RECENTLY ISSUED—THE NEW (2d) EDITION

Nurses Journal of Pacific Coast says ‘‘it is not in any sense rud-
imentary, but comprehensive in its treatment of the subjects.’’

Anatomy and Physiology for Nurses. By LEROY LEWIS, M.D., Lec-
turer on Anatomy and Physiology tor Nurses, Lewis Hospital, Bay
City, Mich. 12mo of 375 pages, 156 illustrations. Cloth, $1.75 net.

Dorland’s Illustrated Dictionary
THE NEW (5th) EDITION—2000 NEW TERMS
This edition contains over 2000 new terms. Dr. Howard A.
Kelly says: ‘‘ Dr. Dorland’s Dictionary is admirable. It is so
well gotten up and of such convenient size. No errors have
been found in my use of it.”’
ferns aged In Medicine; Surgery, Dentisity. Pharmacy. Chemisty,
and kindred branches; with roo new and elaborate tables. By W.

A. N. DORLAND, M. D. Large octavo of 876 pages, 2093 illustrations,
11g in colors. Flexible leather, $4.50 net: thumb index, $5.00 net

Morrow’s Immediate Care of Injured

The Trained Nurse and Flospital Review says: ““ We are most
pleased with the work. ‘The illustrations are clear and prac-
tical; the wording plain and reasonably concise.’’ It is an
invaluable work for the nurse—practical in the extreme.

Immediate Care of the Injured. By ALBERT S. MorROw, M. D.,
Attending Surgeon to the New York City Home for the Aged and
Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, $2.50 net.

Register’s Fever Nursing

A Text-Book on Practical Fever Nursing. By Epwarp
C. REGISTER, M.D., Professor of the Practice of Medi-
cine in the North Carolina Medical College. Octavo
of 350 pages, illustrated. Cloth, $2.50 net.

Pyle’s Personal Hygiene NEW (3d) EDITION

A Manual of Personal Hygiene. Edited by WaLrEeR
lL. PYLE, M.D., Wills Eye Hospital, Philadelphia.
Octavo, 451 pages, Illustrated. , $1.50 net.

8

SS
om
a
e
= 28
2 =
ai
og =
Sega
o 6
®
Sj
ro)

RESS

NAUMAN
0 021 062

3/5 9