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TEXTBOOK 
 
 OF 
 
 SURGICAL NURSING 
 
THE MACMILLAN COMPANY 
 
 NEW YORK • BOSTON • CHICAGO 
 DALLAS • ATLANTA • SAN FRANCISCO 
 
 MACMILLAN & CO.. Limited 
 
 LONDON • BOMBAY ■ CALCUTTA 
 MELBOURNE 
 
 THE MACMILLAN CO. OP CANADA, Ltd. 
 
 TORONTO 
 
TEXTBOOK OF 
 SURGICAL NURSING 
 
 BY 
 RALPH COLP, A.B., M.D. 
 
 INSTRUCTOR IN SURGERY, COLUMBIA UNIVERSITY, NEW YORK ; LECTURER 
 
 IN SURGICAL NURSING, PliESBYTEKIAN HOSPITAL TRAINING SCHOOL 
 
 FOR NURSES, NEW YORK ; ADJUNCT VISITING SURGEON, 
 
 VOLUNTEER HOSPITAL, NEW YORK ; CHIEF OF SURGICAL 
 
 CLINIC, BETH ISRAEL HOSPITAL, NEW YORK; 
 
 FORMERLY LECTURER IN NURSING AND 
 
 HEALTH, TEACHERS COLLEGE, 
 
 COLUMBIA UNIVERSITY, 
 
 NEW YORK 
 
 AND 
 
 MANELVA WYLIE KELLER, B.S., R.N. 
 
 FORMERLY CHIEF OPERATING ROOM NURSE, ST. LUKE'S 
 
 HOSPITAL, NEW YORK, AND ANESTHETIST, ST. 
 
 LUKE'S HOSPITAL, NEW YORK, AND 
 
 MOBILE HOSPITAL NO. 2, 
 
 A. E. F., FRANCE 
 
 THE MACMILLAN COMPANY 
 1921 
 
 All rights reserved 
 
PRIA'TED IN THE UNITED STATES OF AMERICA 
 
 
 COPYDIGHT, 1921, 
 
 By the MACMILLAN COMPANY 
 
 Set up and electrotyped. Published June, 1921. 
 
 Press of 
 
 J. J. Little & Ives Company 
 
 New York, U. S. A. 
 
DEDICATED 
 
 IN RESPECTFUL TRIBUTE 
 
 TO THE 
 
 COURAGEOUS AND DEVOTED NURSES 
 
 WHO SACRIFICED THEIR LIVES 
 
 TO THE 
 
 CAUSE OF SUFFERING HUMANITY 
 
 IN THE GREAT WAR 
 
 .0^ 
 
PREFACE 
 
 The authors have endeavored to present as accurately and 
 as simply as possible for the pupil nurse the actual detailed 
 nursing of the various conditions related to things surgical. 
 The various procedures are based on the technic employed 
 in hospitals throughout the country, and therefore the book 
 will be found useful as a text in training schools generally 
 without regard to local conditions. It presupposes a thorough 
 knowledge of the elements of practical nursing. The funda- 
 mental treatments, as a rule, have been carefully learned in the 
 probationary periods, but a thorough understanding of the 
 underlying principles of surgery and the necessary surgical 
 nursing are often wanting. 
 
 While it is true that all orders are given by the surgeon, and 
 executed with dispatch and accuracy by the nurse, the time has 
 passed when the nurse was a mere automaton. She must know 
 the ante- and post-operative care required for all the patients 
 coming under her supervision. The complete management of 
 an operating room, as well as the conversion of a private home 
 into a suitable place for surgical procedures, should be thor- 
 oughly understood, and an operation by name, be it "glos- 
 sectomy," "thyroidectomy," or ' ' choledochotomy, " etc., 
 should immediately summon to mind the condition and the 
 technic involved. The nurse should be well acquainted with 
 the recent surgical developments of the World War, such as 
 the Carrel-Dakin method of M^ound disinfection, the ambrine 
 treatment for burns, and the suspension treatment for fractures, 
 since her aid is essential for their proper accomplishment. 
 
 The chapter dealing with Surgical Dietetics has been based, 
 in the main, on the diet lists used by the Presbyterian Hos- 
 pital, New York. We are indebted, for the photomicrographs, 
 to the Surgical Department of Columbia University, and for 
 
viii PREFACE 
 
 some of the pictures to the *' Manual of Splints and Appliances, 
 Medical Department, United States Army." 
 
 The authors -wish to express their appreciation and thanks 
 to Miss F. Evelyn Carling, Assistant Superintendent of Nurses, 
 St. Luke's Hospital, New York, for her advice and many sug- 
 gestions, and to Mrs. Ralph Colp, and Mrs. Amy P. Phillips 
 for their keen interest and invaluable assistance in the prep- 
 aration of this volume. 
 
INTRODUCTION AND HISTORY 
 
 SuRGEEY is as old as human needs. There have always been 
 bleeding wounds and broken limbs, and human ingenuity has 
 always endeavored more or less successfully to relieve the suf- 
 fering so occasioned. In ancient times, the supposedly super- 
 natural secrets of the healing art were zealously guarded from 
 the laity, and not till the Greek Hippocrates in 460 B.C. wrote 
 his surgical treatises did surgery pass from mysticism to sci- 
 ence. So keen were the observations of Hippocrates that some 
 enthusiasts claim that his two w^orks on fractures and dis- 
 locations are in many respects unsurpassed even to-day. And 
 until as recently as four centuries ago very little was added to 
 the storehouse of surgical knowledge. 
 
 During the early Christian era and the Middle Ages, sur- 
 gery was practised by many different classes of society, by 
 friars and barbers, by monks and nuns, by the famous Arabian 
 court physicians, and by ladies of noble birth. The universi- 
 ties from the very beginning prohibited research of any kind 
 and demanded that every procedure be justified by the author- 
 ity of Galen. Now and then solitary thinkers tried to find 
 out things for themselves by observation and reflection. The 
 great occupation of the majority of the people was warfare 
 and much of the little progress in surgical knowledge owed 
 its inspiration to the necessities of war. But even to aid the 
 king's armies the new truths learned by experience and ob- 
 servation were discountenanced by the faculties of the uni- 
 versities. In spite of this opposition, by the fifteenth and six- 
 teenth centuries there was a widespread awakening of the free 
 scientific spirit. It manifested itself in the forming of groups 
 to study and experiment in physics, chemistry, anatomy and 
 physiology. Tremendous progress was made in all the sci- 
 ences. Harvey discovered the circulation of the blood, the 
 
X INTRODUCTION AND HISTORY 
 
 mkroscope came into use, aud Fahrenheit invented the ther- 
 niometer, "We^-tern Europe broke out into a galaxy of names 
 that outshine the utmost scientific reputations of the best age 
 of Greece," says II. G, Wells; and of these Vesalius and Fal- 
 lopius, the anatomists, are especially honored by surgeons of 
 to-day. 
 
 By the eighteenth century, private dissecting rooms and ana- 
 tomical laboratories M'ere flourishing. However, the surgeons 
 themselves of this jieriod neither helped nor shared in this 
 great advancement of science. The barber-surgeons were an 
 untutored lot, ready to make use of a few tricks of the trade 
 for practical gain. The task remained to place the practice 
 of surgery on a high plane, and this was one of the many 
 good deeds which make the name of John Hunter shine out in 
 the history of surgery-. "More than any other man he helped 
 to make us gentlemen," a contemporary said of him. Through 
 the efforts of Dr. Hunter, the already existing companies of 
 barber-surgeons were forced to study anatomy, comparative 
 anatomy and physiology, and thus the surgical profession by 
 the right of hard and regulated study began to take rank with 
 the high order of scientists. Public museums of anatomy and 
 physiology were founded; the method of clinical teaching was 
 adopted; and in the beginning of the nineteenth century the 
 day of painless operation had come with the discovery of an- 
 esthesia. 
 
 Still the surgeon was held in disrepute. The dark ages when 
 investigation w^as forbidden were passed; all the sciences aided 
 the surgeon; he progressed with the great advance in anatomy, 
 physiology and pathology. And yet, the hospitals where he 
 operated were considered houses of certain death. An opera- 
 tion was in truth a sad affair. No matter how great the tech- 
 nical skill of the surgeon, patients, more often than not, died 
 of blood poisoning. Now and then a wound did heal wdthout 
 the formation of pus, but both spontaneous and operative 
 wounds almost invariably became infected, with death as the 
 result. So common was this, particularly in hospitals, that 
 many surgeons feared to operate at all. The term "hospi- 
 talism ' ' was coined by Sir James Y. Simpson, who collected sta- 
 
INTRODUCTION AND HISTORY xi 
 
 tistics proving that private patients were far less liable to 
 succumb from operation than those treated in hospitals. 
 
 With the advent of Lister came "a light that brightens more 
 and more as the years give us ever fuller knowledge," as Sir 
 William Osier has said. It was to the researches of Pasteur, 
 the great French scientist, that Lister owed his inspiration. 
 One of the first practical results of Pasteur's studies on fer- 
 mentation and spontaneous generation was a great transforma- 
 tion in the practice and results of surgery. It is not too much 
 to claim this as one of the greatest boons ever conferred on 
 humanity. Let us quote from Lister's paper on the subject 
 which appeared in the London Lancet, 1867. 
 
 "Turning now to the question of how the atmosphere pro- 
 duces decomposition of organic substances, we find that a flood 
 of light has been thrown upon this most important subject by 
 the researches of Pasteur, who has demonstrated by thoroughly 
 convincing evidence that it is not to its oxygen or to any of its 
 gaseous constituents that the air owes this property, but to 
 minute particles suspended in it which are the germs of various 
 low forms of life long since revealed by the microscope and re- 
 ga;rded as merely accidental concomitants of putrescence, but 
 now shown by Pasteur to be its essential cause, resolving the 
 complex organic compounds into substances of simpler chem- 
 ical constitution, just as the yeast plant converts sugar into 
 alcohol and carbonic acid." 
 
 From Lister's work modern surgery takes its rise and the 
 whole subject of wound infection, not only in relation to sur- 
 gical diseases but also to childbed or puerperal fever now forms 
 one of the most brilliant chapters in the history of Preventive 
 Medicine. So great have been the results of Lister's work that 
 it is indeed almost difficult from our fortunate position of to-day 
 to glimpse the sad position of the surgeons of his time. In 
 present-day hospitals surgical infection and puerperal fevers 
 are almost things of the past, and for these achievements alone 
 the names of Louis Pasteur and Joseph Lister will go down to 
 posterity as among the greatest benefactors of humanity. 
 
 Lister's work Avas the beginning of antiseptic surgery. Sur- 
 geons at last learned to combat with a strong antiseptic the 
 
xii IXTRODUCTION AND HISTORY 
 
 germs wiiicli exist in the air, the wound, the room, the sur- 
 geon's hands, his instruments. The blaek-robed, professorial- 
 looking surgeon of i^arlier times was sueeeeded by a surgeon 
 clothed in immaeuhite Avliite. For an operation in the true 
 Listeria!! style, tlie part to be operated on Avas first of all e!!- 
 veloped two hours before the operation i!i a towel soaked i!i 
 carbolic acid, to destroy the germs prese!it i!i the skin. In- 
 struments a!id spo!iges lay for a half hour in a flat porcelain 
 dish of carbolic acid. Towels soaked in this solutio!i covered 
 the tables and bla!ikets near the part to be operated o!!. The 
 l!a!ids of the snrgeo!is a!id !iurses were thoroughly washed i!i 
 the sa!ne solution. The operation itself was performed under 
 a cloud of carbolized vapor fro!ii a steam spray producer. 
 The!i a strip of oiled silk, coated with carbolized dextrin and 
 further washed in carbolic lotio!i, Avas placed over the wound 
 a!id over this was applied a double ply of carbolic soaked gauze, 
 covered with eight layers of dry gauze. Finally came a thin 
 mackintosh cloth, a!id this whole apparatus was covered with 
 a gauze ba!idage. The mackintosh cloth served to prevent the 
 carbolic acid from escaping and at the same time permitted 
 the discharge from the wound to spread through the gauze. 
 The vapor given off by the carbolic gauze shielded the "wound 
 and the surrou!iding parts from septic co!itamination. These 
 conditions were very strictly maintained until the wound was 
 healed. 
 
 All these cumbersome and complicated measures may seem 
 a bit unnecessary to us ; especially may we sigh Avhen we re- 
 flect that the use of carbolic acid made Lister's hands red and 
 raw. So!ne surgeons produced excellent results by methods of 
 strict cleanliness without following the Avhole Listerian tech- 
 nic. Gradually, Lister himself gave up most of these meas-i 
 ures, much to the advantage of the patient, for that same car- 
 bolic acid which so effectively destroyed pathogenic bacteria in 
 and about a wound, also invariably injured the exposed tissues. 
 The great achievement of Lister was not the spray and gauze 
 method but the conclusive proof that cleanliness is the most 
 essential factor in successful operating. 
 
 To the antiseptic surgeon of 1867 has succeeded the aseptic 
 
INTRODUCTION AND HISTORY xiii 
 
 surgeon of to-day. The aseptic surgeon uses steam and hot 
 water to sterilize all materials in the operative procedure, and 
 not only does he carefully scrub his hands, but he also renders 
 them absolutely germ-proof by wearing rubber gloves which 
 have been previously sterilized by boiling water and steam. 
 Such is the simple aseptic method which has been gradually 
 evolved from the Listerian antiseptic system. The spray pro- 
 ducer has almost passed into oblivion but the spirit of Lister's 
 teachings — scientific cleanliness — still guides the surgeon's 
 work. 
 
 In the World War aseptic surgery proved of little avail, be- 
 cause almost all wounds were contaminated and filled with pus. 
 The wound of the battlefield is not similar to the operative 
 wound of the civilian hospital. Even with the utmost effi- 
 ciency, before those wounded in modern warfare can be con- 
 veyed to the nearest surgical station much time will have 
 elapsed with ample opportunity for contamination. To deal 
 with these conditions, the antiseptic method was revived. This 
 time, however, the strong carbolic acid of Listerian fame was 
 replaced by an agent harmless to the tissues, the Carrel-Dakin 
 Solution. This solution is not merely one of historical inter- 
 est, but widely used by surgeons of to-day for a certain type of 
 wound, and it will be discussed in detail in Chapter XIX. 
 
 To-day the vision of surgery is glorious. The surgeon is 
 everywhere recognized as an indispensable worker in the com- 
 munity. The growth of a highly competent, scientifically 
 trained nursing staff has more than doubled the good results 
 of his work. Nurses have indeed existed from earliest Chris- 
 tian times ; they have either been gentle, noble-minded Sisters 
 of Mercy in the convents, or uneducated, inefficient maids in 
 hospitals. Neither of these classes was what could be called 
 trained or educated according to the present view of what 
 training and education should be for a nurse. The first train- 
 ing-school for nurses was established as recently as 1836. This 
 little school at Kaiserswerth, Germany, is the mother of the 
 present system ; within its walls Florence Nightingale acquired 
 her practical knowledge of nursing in a few months' time. 
 Miss Nightingale was a woman of genius and vision. During 
 
xiv INTRODUCTION AND HISTORY 
 
 the Crimean War the London Times roused British public opin- 
 ion by its vivid account of the terrible conditions in the mili- 
 tary hospitals of the war zone, and Miss Nightingale set out 
 for that region with a staff of trained nurses to superintend 
 the care for the sick and wounded. What she actually accom- 
 I)lished was of greater importance to humanity than nursing 
 individual soldiers stricken in the Crimea. She applied the 
 principles of hygiene to hospital administration and brought 
 light, cleanliness and order out of indescribable chaos and 
 misery. The "lady with the lamp" at Scutari showed what 
 a hospital should be and what scientific nursing should mean. 
 Although her work in the Crimea Avas done more than a score 
 of years before Lister 's revolution in surgery, Miss Nightingale 's 
 revolution in hospital building, administration and manage- 
 ment was based on the Listerian idea of scientific cleanliness. 
 And out of her work in the Crimea arose trained nursing on a 
 large scale. In 1860 the modern hospital school system was 
 inaugurated by her in Great Britain at St. Thomas's Hospital, 
 Loudon, The dignity of the nursing profession has thus been 
 raised; it has become a calling for superior women, with the 
 recognition of the need for a rigid education and training before 
 the nurse can call herself a "graduate." Just as surgeons 
 were made "gentlemen" by the work of John Hunter, so 
 nurses through the efforts of Florence Nightingale were made 
 "ladies," and their profession put on a very high plane of 
 social usefulness. 
 
 In the same decade that the Nightingale Fund School was 
 founded at St. Thomas's, Lister's great work was given to the 
 world. That is, the rise of modern surgery is contemporaneous 
 with the beginning of a careful, trained nursing body. This 
 is more than an historical coincidence, for since that time the 
 increasing demands of medical and surgical knowledge have, 
 well nigh revolutionized the nursing craft. To-day the sur- 
 geon in the operating room of the hospital, or in the private 
 home has come to rely absolutely on a highly educated and 
 trained nurse. To her he leaves the preparation of supplies, the 
 preparation of the operating room and instruments, and the 
 preparation of the patient; she even assists the surgeon in the 
 
INTRODUCTION AND HISTORY xv 
 
 operation itself in many ways. And finally, most of the after 
 care of the patient is left entirely to the nurse. It is a great 
 need that the nurse fills, a need that will grow with her capac- 
 ity to fill a greater sphere. She is the Handmaid of Surgery 
 and must live up to that high social calling by being well pre- 
 pared; she must be so educated and trained that she will not 
 be a mere automatic tool, but an intelligent, enthusiastic co- 
 worker, filled with a zeal for science, and giving her whole mind 
 and heart to the work that is before her — for only recently in 
 the history of surgery is there scientific surgical nursing. The 
 surgical nurse is a pioneer ; the trail has been blazed ; but it is 
 still a new one, and she must show what she can do. 
 
TABLE OF CONTENTS 
 
 CHAPTER PAGE 
 
 Introduction and History ix 
 
 I. Pathology 3 
 
 II. Shock and Hemorrhage 14 
 
 The treatment of shock, transfusions, the treatment of hemor- 
 rhage. 
 
 III. Post-Operative Complications 20 
 
 Nausea, vomiting, pernicious vomiting, gastric dilatation, 
 tympanites, auto-intoxication, post-operative pneumonia, 
 pulmonary embolism, urinary retention, urinary suppres- 
 sion, phlebitis, thrombosis, hemophilia. 
 
 rV. The Surgery and Surgical Nursing op the Alimentary 
 
 System 38 
 
 V. The Surgery and Surgical Nursing of the Glandular 
 
 System 72 
 
 VI. The Surgery and Surgical Nursing of the Nervous 
 
 System 80 
 
 VII. The Surgery and Surgical Nursing of the Osseous 
 
 System 87 
 
 VIII. The Surgery and Surgical Nursing of the Reproductive 
 
 System 105 
 
 IX. The Surgery and Surgical Nursing of the Respiratory 
 
 System 120 
 
 X. The Surgery and Surgical Nursing of the Skin and 
 
 Appendages 130 
 
 XI. The Surgery and Surgical Nursing of the Urinary 
 
 System 142 
 
 XII. Surgical Dietetics 151 
 
 XIII. Anesthesia 173 
 
 Preparation of the patient ; care of patient during anesthesia ; 
 after care. 
 
 XIV. Arrangement, Organization, and Equipment of the 
 
 Operating Theatre 193 
 
 The rooms and their furnishings; the personnel; supplies. 
 
 XV. Operating Room Sterilization 232 
 
 Definitions; the agents; practical methods. 
 
 XVI. The Operating Room in Action 263 
 
 Preparation of the room for che operation ; preparation and 
 sterilization of the operative field ; operative positions and 
 draping; the operation; after the operation. 
 
 xvii 
 
xviii TABLE OF CONTENTS 
 
 CHAPTER PAGE 
 
 XVII, Instrument Passing 296 
 
 Representative uiieratiuiis; drains. 
 
 XYIII. The Dressing of the Wound 313 
 
 XIX. TiJE Carrel-Dakin Treatment 321 
 
 What the system is; history; equipment; the four processes 
 of the system; the Uakin sohition, 
 
 XX. Bandaging 355 
 
 Definitions, uses of bandages, forms of bandages, materials 
 used for bandages, sizes of bandages, principles of bandag- 
 ing, modes of applying the roller bandage, the applica- 
 tion of bandages to the various parts of the body, mis- 
 cellaneous special bandages, the fastening of the bandage, 
 miscellaneous bandaging rules, the removal of roller 
 bandages. 
 
 XXI. Operations in the Home 399 
 
 The steps in the preparation and management, improvised 
 operative positions. 
 
 Appendix 415 
 
 Solutions; weights and measures; equivalent thermometer 
 scales; abbreviations and symbols. 
 
 Index ... o ....... . 437 
 
LIST OF ILLUSTRATIONS 
 
 FIG. 
 
 PAGK 
 
 1. Microscopic drawing of an incised wound twenty-four hours old 5 
 
 2. Microscopic drawing illustrating the growth of fibroblasts along 
 
 the fibrin of the blood clot 6 
 
 3. Microscopic drawing of granulation tissue 7 
 
 4. Microscopic drawing of an infected wound .... 8 and 9 
 
 5. Microscopic drawing of a deep abscess 11 
 
 6. Types of intestinal anastomoses . . . . '. • • 5* 
 
 7. Colostomy before being incised . . . . • . . 61 
 
 8. Colostomy bag 61 
 
 9. Tube "en cliemise" . . . 64 
 
 10. Methods of applying traction 95 
 
 11. Traction leg splint .96 and 97 
 
 12. Traction arm splints 99 
 
 13. Jones wrist split 100 
 
 14. Lane plate 101 
 
 15. Wyeth pins 103 
 
 16. Tracheotomy tube 123 
 
 17. Brewer empyema tube 127 
 
 18. An easy and safe method of lifting a helpless patient . . 181 
 
 19. Eestraining sheet for patients recovering from an anesthetic . 183 
 
 20. Suitable instruments for grasping the tongue .... 185 
 
 21. Mouth gags ' 186 
 
 22. Two of the more elaborate types of operating table . . .197 
 
 23. Two varieties of instrument table 199 
 
 24. Adjustable instrument table 199 
 
 25. Wheel stretcher 200 
 
 26. Carrying stretcher 200 
 
 27. Stretcher suitable for carrying patients up and down stairways 200 
 
 28. Seat for the anesthetist or surgeon 201 
 
 29. Bench for the surgeon to stand upon when the operating table 
 
 can not be adjusted suitably in height 201 
 
 30. Hand light 202 
 
 31. Dressing drum with pedal opening standard 202 
 
 32. Hot towel drum with pedal opening standard and electrically 
 
 equipped steaming device 203 
 
 33. Instrument sterilizer 203 
 
 34. Utensil sterilizer 204 
 
 xix 
 
XX LIST OF ILLUSTRATIONS 
 
 FIO. PAOH 
 
 35. Hot and cold water sterilizers 205 
 
 36. Wash basins 207 
 
 37. Two types of arm basin 208 
 
 38. Amputation retractors 214 
 
 39. Muslin apron 215 
 
 40. Operating caps 216 
 
 41. Culture tubes 217 
 
 42. Glove cover 219 
 
 43. Two types of hip or pelvic rest 220 
 
 44. Two types of irrigator stand 221 
 
 45. Face masks 222 
 
 46. Abdominal pads 224 
 
 47. Laparotomy sheet 227 
 
 48. Lithotomy towel . . . .230 
 
 49. Steam pressure dressing sterilizer 238 
 
 50. Hot air sterilizer 242 
 
 51. The Mayo soldering iron cautery 243 
 
 52. Electric cautery 243 
 
 53. The Paquelin cautery 244 
 
 54. Needle book 253 
 
 55. Method of rolling a catgut suture or ligature 255 
 
 56. Factory prepared catgut in hermetically sealed glass tube . 261 
 
 57. Dorsal position 267 
 
 58. Method of fastening the arms at the patient's side . . . 268 
 
 59. Method of fastening the arms on the chest 269 
 
 60. Laparotomy sheet in place for an abdominal operation . . 269 
 
 61. Draping for the dorsal position with two sheets and four towels 270 
 
 62. Two types of towel clamps 270 
 
 63. Trendelenburg position 271 
 
 64. Shoulder guard for keeping the patient in place in the Trendelen- 
 
 burg position 271 
 
 65. Gall bladder position (with table rest) . . . . .272 
 
 66. Gall bladder position (with broken table) 273 
 
 67. Kidney position 274 
 
 68. Prone position 275 
 
 69. Latero-prone position 276 
 
 70. Eeversed Trendelenburg position 276 
 
 71. Sims position, showing the use of one sheet for draping . . 277 
 
 72. Lithotomy position, showing the use of the table stirrups . . 277 
 
 73. Draping with a sheet and towels in the lithotomy position . . 278 
 
 74. Draping with the lithotomy towel and stockings for the 
 
 lithotomy position 279 
 
 75. Breast position 280 
 
 76. Method of draping the hand and forearm for the breast opera- 
 
 tion 281 
 
LIST OF ILLUSTRATIONS 
 
 XXI 
 
 U\) 
 
 when the 
 
 FIO. 
 
 77. Draping for lironst position 
 
 78. Detachable arm Ijofud siip])lic(l wii.li tli 
 
 79. Simple long narrow boai-d which may be fitted to any table as 
 
 an arm board 
 
 80. Use of stirrups for operations upon the leg 
 
 81. Draping for leg operations 
 
 82. Draping for a face case .... 
 
 83. Arrangement of patient in the prone position on a special hear 
 
 rest for operations upon the back of the head or neck 
 
 84. Folded towel clamped about the face to protect the operative 
 
 field from the inhaler in face, neck, or skull operations 
 
 85. The Kocher guard adjusted and draped so as to isolate the 
 
 anesthetist in operations upon the neck 
 
 86. Portable dressing stand 
 
 87. Diagram of the arrangement of the instrument stand 
 
 type shown in Fig. 24, page 199 is used . 
 
 88. Intestinal and stomach clamps .... 
 
 89. Drains . 
 
 90. Portable metal dressing box 
 
 91. Portable electric instrument sterilizer 
 
 92. Dressing carriage for use in the hospital ward 
 
 93. Adhesive plaster and tape device for holding dressings in place 
 
 and allowing their removal without the disturbance of the 
 plaster 
 
 94. Dressing forceps for use in dressing the Carrel-Dakin wound . 
 -95. The rubber delivery tubes 
 
 96. Reservoirs for the Dakin solution 
 
 97. Glass syringes for administering the Dakin solution . 
 
 98. Stopcocks for use on the supply tubing in the reservoir method 
 
 of administering the Dakin solution 
 
 99. Glass connecting and distributing tubes 
 
 100. Glass dropper tube for use oii the main supply tube in the 
 
 reservoir continuous method 
 
 101. The way to perforate the wound tube 
 
 102. The way to lay the vaseline gauze strips around the margin of 
 
 the wound 
 
 103. Four positions of wounds with the appropriate wound tubes 
 
 in them 
 
 104. Diagram of possible ways of making exits through the gauze 
 
 and cotton pad for the wound tubes so that they need not 
 lie on the skin surface, and will remain where they were 
 placed when the wound was dressed 
 
 105. Arrangement of the apparatus for the reservoir method of 
 
 instillation 
 
 106. Suggested ways of branching the main supply tube so that it 
 
 can feed the tubes of more than one wound, or widely scat- 
 tered and variously grouped tubes in the same wound . 
 
 PA OK 
 
 281 
 
 282 
 
 283 
 
 284 
 285 
 285 
 
 286 
 
 287 
 
 289 
 290 
 
 299 
 303 
 311 
 314 
 315 
 316 
 
 317 
 324 
 325 
 326 
 326 
 
 327 
 327 
 
 328 
 329 
 
 336 
 
 337 
 
 339 
 340 
 
 341 
 
xxii LIST OF ILLUSTRATIONS 
 
 FIG. PAGE 
 
 107. Arrangeinciit of the screw stopcock and the glass dropper tube 
 on the main supply tube for the reservoir continuous method 
 
 of instiilation .342 
 
 lOS. Method of connecting inaccessible wound tubes to a single 
 
 supply tube for the syringe method of instillation . . 343 
 
 109. Dr. Carrel's bacteriological chart 346 
 
 110. The roller bandage 356 
 
 111. Two methods of rolling a bandage by hand 357 
 
 112. The triangular bandage, or sling 358 
 
 113. Many-tailed bandages 359 
 
 114. Method of making plaster of Paris bandages .... 361 
 
 115. The way to grasp the roller bandage preparatory to apply- 
 
 ing it 366 
 
 116. The way to begin the application of the roller bandage . . 367 
 
 117. The circular mode of bandaging — the usual anchorage for the 
 
 applied roller bandage 367 
 
 118. The spiral mode of bandaging 368 
 
 119. The wrong mode for the part (the spiral mode for a conically- 
 
 shaped part) 369 
 
 120. The way to make a reverse 369 
 
 121. The figure-of-8 mode of bandaging 370 
 
 122. The recurrent mode of bandaging 371 
 
 123. Completed recurrent bandage 372 
 
 124. Spiral bandage of the finger anchored to the wrist with a 
 
 figure-of-8 and a circular turn 374 
 
 125. The thum.b spiea 374 
 
 126. Complete bandage for the hand and arm 375 
 
 127. Eeverse figure-of-8 bandage 375 
 
 128. Method for securing better anchorage of a bandage on a 
 
 tapering part 376 
 
 129. Heel bandage 377 
 
 130. Complete bandage for the foot and leg 378 
 
 131. The eye bandage 379 
 
 182. Double eye bandage 380 
 
 133. The ear bandage 380 
 
 134. The Barton bandage 381 
 
 135. Two methods of bandaging the cheek, temple, or chin . . 382 
 
 136. Double roller bandage for the application of the recurrent 
 
 bandage 383 
 
 137. The way to use the double roller bandage 383 
 
 138. The spica bandage of the shoulder 384 
 
 139. The shoulder spica bandage varied to cover the axillary region 385 
 
 140. The Velpeau bandage 385 
 
 141. The breast bandage 386 
 
 142. The double breast bandage 386 
 
 143. The hip spica bandage 387 
 
LIST OF ILLUSTRATIONS xxiii 
 
 FIG. PAGE 
 
 144. Various applications of the triangular bandage .... 388 
 
 145. Various applications of the many-tailed bandages .... 389 
 
 146. Methods of fastening the roller bandage 395 
 
 147. Bandage scissors 397 
 
 148. Instruments for the removal of plaster of Paris bandages . 397 
 
 149. Improvised cap and gown 401 
 
 150. Ordinary chair adapted for improvisation of the Trendelenburg 
 
 position 411 
 
 151. Lithotomy crutches, or leg holders, for supporting the legs in 
 
 the lithotomy position 412 
 
 152. Method of improvising a lithotomy crutch 412 
 
 153. Improvised Kelly pad 413 
 
TEXTBOOK 
 
 OF 
 
 SURGICAL NURSING 
 
CHAPTER I 
 
 PATHOLOGY 
 
 The surgical field may be divided into those conditions which 
 are due to inflammation, injuries, congenital deformities, and 
 new growths. Into these arbitrary four great divisions all 
 modern surgical intervention falls. And since all surgical in- 
 tervention is to a greater or lesser degree supplemented by 
 surgical nursing, a thorough and intelligent understanding of 
 the underlying pathological conditions is essential. Perhaps 
 the most common field is that of inflammation. 
 
 Inflammation. — Inflammation, according to Grawitz, may be 
 said to be the reaction of irritated damaged tissues which still 
 retain vitality. The damaging element may be one of several; 
 it may be physical, such as a cut from a knife, a bruise from 
 a stone, or a contusion from a flying timber. It may be chem- 
 ical, such as a burn with acid, such as nitric, or from caustic 
 alkali. It may be electrical, resulting from touching a "live" 
 wire; or thermal, such as a burn from fire, or a frost bite from 
 the cold; or it may be bacteriological. The last mentioned is 
 especially important for it results in wound infection. These 
 five agents then are the exciting factors of an inflammatory 
 reaction; they have in some way injured or destroyed the unit 
 structure of the body, the cell, and in order to carry ofi^ the 
 dead and dying cells, to replace them, and rebuild the damage 
 done, the process of inflammation must ensue. 
 
 What is the process of inflammation? The following, in a 
 brief way, will illustrate what happens grossly, and what oc- 
 curs if the process were to be studied underneath the mi- 
 croscope : 
 
 If a finger is cut, it bleeds. The amount of blood lost is 
 dependent upon the size of the vessel cut. In time, due to 
 clotting, the bleeding ceases and within a few hours the sur- 
 
 3 
 
4 TEXTBOOK OF SURGICAL NURSING 
 
 rounding^ skin may become red, perhaps slightly sAvollen, and 
 if it is carefully observed as to temperature, it might be some- 
 what warmer than the adjacent skin. Tlie wound is said to be 
 inflamed. If this process were examined in sections beneath 
 a microscope, a very interesting and thoroughly instructive pic- 
 ture would be seen, depending upon the time when the section 
 was taken. Within a short period after the original injury, 
 there would be along the line of the original incision a clot of 
 blood, and adjacent to it some dead cells. (Fig. 1.) Already, 
 the products of these dead cells would have stimulated a greater 
 blood flow to the part, resulting in a dilatation of blood vessels 
 and capillaries, and an infiltration of the tissues with white 
 blood cells, red blood cells, and serum. Naturally, it is this 
 that makes the part swollen, red and warm. And as these in- 
 flammatory products cause an increased pressure on the nerves 
 the wound will become painful in direct proportion to the exu- 
 dation. It has already been noted that cells have been de- 
 stroyed. Dead tissue is of no use to the organism. It must 
 be removed, and the white blood cells carry off the destroyed 
 tissue. It is a known fact that when cells are injured, some 
 which were but slightly traumatized are actually stimulated to 
 growth, and these cells (fibroblasts) immediately begin to re- 
 produce and grow into the blood clot along the fibrin strands 
 (Fig. 2) in an attempt to bridge in the gap caused by the de- 
 struction of the cells killed by the knife. In small wounds this 
 is barely visible to the naked eye, but in wounds in which a 
 definite area of tissue has been destroyed, or wounds with defi- 
 nite loss of substance, this new growth of cells together with 
 a new growth of blood vessels is known as granulation tissue. 
 (Fig. 3.) Wounds which are sutured and clean heal with the 
 minimum amount of granulation tissue and simulate small 
 cuts of the finger. This is spoken of as healing by primary in- 
 tention. Wounds in which there is a loss of tissue from one 
 cause or another heal by secondary intention, filling in the space 
 with granulation tissue. This is the process of healing which 
 takes place in every wound. It is fundamentally the same in 
 all clean wounds, whether a cut of the finger, the healing of a 
 cyst enucleation, or an incision of the abdomen as a laparotomy. 
 
PATHOLOGY 
 
 
 
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 Fig. 1. — Microscopic Drawing of Incised Wound 24 Hours Old. A, 
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 of blood vessels. Published by permission of the Department of Surgery, 
 Columbia University. 
 
TEXTBOOK OF SURGICAL NURSING 
 
 A 
 
 -B 
 
 
 
 ^'Kic 
 
 Fig. 2. — Microscopic Drawing Illustrating the Growth op Fibro- 
 blasts Along Fibrin Strands of the Blood Clot. A, fibrin strands; B, 
 fibroblasts. Published by permission of the Department of Surgery, Colum- 
 bia University. 
 
PATHOLOGY 7 
 
 The process is slightly different, however, when the wound be- 
 comes contaminated by bacteria of the pathological variety. 
 In a clean wound the minimum amount of damage is done 
 
 
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 Fig. 3. — Microscopic Drawing of Granulation Tissue. A, fibroblasts; 
 B, newly formed blood vessels. Published by permission of the Department 
 of Surgery, Columbia University. 
 
 because the only cells destroyed are those which have been 
 killed by the knife of the surgeon. But if this knife were not 
 properly sterilized and were laden with bacteria, the result 
 would be an infected wound (Fig. 4), and the outcome would 
 
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10 TEXTBOOK OF SURGICAL NURSING 
 
 be dependent upon the resistance of the individual infected, 
 and the severity of the infecting organisms. These bacteria 
 destroy cells in the same Ava}' as a knife. And, because of their 
 irritating properties, and their attempts to invade and destroy 
 the body, Nature summons the white blood cells (phagocytes) 
 (called by Metchnikoff the "policemen of the blood") to arrest 
 the onslaughts of tlie invading foes. These ■white blood cells 
 attempt to destroy bacteria. If they are successful, the bac- 
 teria remain local in position, an abscess is formed (Fig. 5) 
 and the evidences of the combat are found by the appearance of 
 pus in the wound. Pus is composed of living and dead bac- 
 teria, living and dead white blood cells. Naturally, in such a 
 process, more tissue will be destroyed than in a clean wound. 
 
 A wound in which there is pus is spoken of as a suppurating 
 wound , and the process is known as suppuration. When tissue 
 has been destroyed by the bacteria and the individual has been 
 fortunate enough to cause the process to remain localized, the 
 dead tissue will fall off from the living; the "line formed be- 
 tween the living and dead tissue is called a line of demarcation. 
 This dead tissue is spoken of as slough and very often it may 
 be seen lying in a wound as strands of yellow greenish debris. 
 In those instances where the amount of tissue, for one reason 
 or another, is as large as a toe or an entire extremity the process 
 is known as gangrene or mortification. 
 
 If the individual through some constitutional inferiority has 
 been unable to localize the bacteria, their poisons may be ab- 
 sorbed into the blood vessels directly. The patient then be- 
 comes toxic, and the condition is known as toxemia. If not only 
 the toxins of the bacteria, but the actual bacteria themselves 
 are absorbed, a sepsis, septicemia, or bacteremia results. The 
 laity call this "blood poisoning." 
 
 If the pus itself, or collections of bacteria, should localize in 
 different parts of the body and form smaller or secondary ab- 
 scesses, either in the skin or other organs, the condition is 
 known as pyemia. Sepsis and pyemia are indeed serious com- 
 plications, for they often spell death to the patient. If they 
 follow in the path of clean operations they are due to care- 
 lessness on the part of the surgeon or the nurse. They are a 
 
PATHOLOGY 
 
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12 TEXTBOOK OF SURGICAL NURSING 
 
 blot on the scalpel of aseptic surgery. It means that certain 
 bacteria entered the wound either before, during, or after op- 
 eration. The bacteria which cause wound infections are nu- 
 merous arid varied. A classification of these organisms is here- 
 with given : 
 
 Bacteria are of two classes : — saprophytes, those which live 
 on dead organic matter, and parasites, which derive their nour- 
 ishment from living bodies. The latter class produce the patlio- 
 genic or disease bacteria : these are either cocci or bacilli. The 
 various common cocci may be divided into staphylococci, strep- 
 tococci, pneumococci, meningococci, gonococci ; the bacilli, into 
 the bacillus coli communis, bacillus typhosus, bacillus para- 
 typhosus and bacillus pyoeyaneus. These are the germs which are 
 concerned in acute inflammation. There are others which cause 
 chronic inflammations, the most important of which are the 
 tubercle bacillus and the spirochaete of syphilis. Then there 
 are those rarer forms of inflammation which are due to the ba- 
 cillus of anthrax, of glanders, and those due to the fungi group, 
 such as actinomycosis. The pathological process of all of these 
 is essentially the same ; it is simply a question of degree and in- 
 tensity ; it is dependent upon the virulence of the organism caus- 
 ing the infection, and the general resistive powers of the pa- 
 tient infected. 
 
 How do bacteria enter the body? They may enter through 
 the hrohen skin giving rise to local inflammation with destruc- 
 tion of tissue and abscess formation. In addition they may 
 gain access to the lymphatics draining the infected area causing 
 lymphangitis, and often the nodes becoming tender, hard, and 
 swollen (lymphadenitis). Or the bacteria may enter the blood 
 stream directly, resulting in septicemia or pyemia. 
 
 Inhalation is the means by which the pathogenic bacteria 
 enter the trachea and lungs causing the majority of respiratory 
 diseases. By ingestion of food and drink, the germs may enter 
 the tonsils or the alimentary canal. Another portal of entry 
 in females is through the Fallopian tuhes directly into the peri- 
 toneal cavity causing peritonitis with its various complications. 
 
 If the body is in good health and properly nourished, all 
 these portals are safely guarded, but if the individual is weak- 
 
PATHOLOGY 13 
 
 ened and the various protective mechanisms are at fault, dis- 
 ease readily ensues. 
 
 Injuries. — Conditions of injury may be caused by the vari- 
 ous factors already mentioned. The extent of the injury will 
 depend upon whether the bony skeleton or the soft parts are 
 involved, whether the solid organs, such as the liver or kidney, 
 are torn, or the hollow viscera, such as the stomach and in- 
 testines, are perforated or ruptured. 
 
 Deformities. — These may be divided into two big classes : 
 those a patient is born with, and those which a patient acquires 
 during life. Among some of the congenital deformities may 
 be mentioned spina bifida, a condition in which part of the 
 bony portion of the spinal canal is missing, harelip, cleft pal- 
 ate, horseshoe kidney, six fingers, an extra arm, or the fusion 
 of two individuals as in the case of the Siamese twins. Ac- 
 quired deformities may be the results of injuries which have 
 been improperly treated, such as a poor reduction of a fracture, 
 or from paralysis of muscles due to nerve injuries which cause 
 such conditions as drop wrist or drop foot. 
 
 New Growths. — New growths, neoplasms, or tumors, may 
 be defined ''as growths, non-inflammatory in character, aris- 
 ing from pre-existing tissue but independent of the normal 
 rate or laws of growth of such tissue, subserving no physiolog- 
 ical function." They may be classified as benign and malig- 
 nant. Benign growths, as a rule, are localized; they may be 
 excised without danger of recurring, and they do not spread 
 to other parts of the organism and start new tumor formations. 
 Examples of these are fibromas, lipomas, and cysts. They 
 rarely endanger the life of the individual. Malignant growths 
 are those which are not localized, which infiltrate tissues and 
 which spread to various parts of the body (metastasize). They 
 are the cancers and the sarcomas. Surgery attempts to remove 
 these with the knife. And those cells which have escaped the 
 knife will start foci for the regeneration of new tumor tissue 
 unless they are killed by the destructive action of subsequent 
 radium and X-ray treatment. 
 
CHAPTER II 
 SHOCK AND HEMORRHAGE 
 
 Shock. — This is one of the most serious conditions with 
 which the surgeon and the nurse have to cope. It may result 
 from several circumstances. It may be associated directly with 
 severe injuries, may occur during the course of an operation, 
 or follow in its path. As to the etiology of shock there are 
 many theories, but its exact mechanism does not concern us 
 here. Shock is characterized by a rapid, thready pulse, a 
 pinched, drawn face, sweating, rapid, shallow respirations, and 
 a persistently low blood pressure. Shock may be associated 
 with hemorrhage, but there is no severe hemorrhage without 
 shock. 
 
 Prophylactic Treatment of Shock. — There are several fac- 
 tors which aid in the prophylactic treatment of shock. To 
 begin with, the patient should be kept in a happy and cheerful 
 frame of mind. He should have a good night's rest before his 
 operation and his tissues should be well supplied with water. 
 This latter can be easily accomplished by encouraging the 
 drinking of fluids in copious amounts. Of course, two hours 
 before operation no more water should be permitted. Dur- 
 ing his transport to the operating room the patient should be 
 warmly clad and when he is placed upon the table he should 
 be covered with blankets. 
 
 Of prime importance also is the technic of the operation. As 
 little as possible of the abdominal contents should be exposed, 
 and the exposed parts should be protected with moist, hot 
 saline pads. The tissues should be handled gently, the hemos- 
 tasis should be perfect, and the operation should be performed 
 with as much speed as is consistent with safety. The patient 
 should be kept under deep surgical anesthesia, the choice of 
 
 14 
 
SHOCK AND HEMORRHAGE 15 
 
 the anesthetic being dependent upon the condition of the pa- 
 tient. 
 
 After operation it is customary to administer morphine hypo- 
 dermically so that the pain which might arise will not reflexly 
 cause a general depression of the nervous system, resulting in 
 shock. 
 
 Treatment of Shock. — When a condition of shock is evident, 
 it must be treated energetically. The patient should be placed 
 flat upon the bed and covered with warm blankets; if neces- 
 sary, hot water bags and electric pads may be employed to rap- 
 idly supply additional heat. Inasmuch as the patient is un- 
 conscious it is highly important to carefully guard against 
 burns from the electric heating pad, or a too hot w^ater bag. 
 The foot of the bed is raised by means of shock blocks, so that 
 the head is at a lower level than the feet. Shock blocks come 
 in various sizes: low, medium, and high. The medium ones 
 are generally sufficient. 
 
 Stimulants. — Morphine is one of the best stimulants and 
 is administered in quarter grain doses with 1/150 atropine sul- 
 phate. Fluid is then given by infusion in the form of normal 
 saline at 105 degrees F., and to this, occasionally, is added 30 
 minims of adrenalin hydrochloride, 1-1000 solution. If the 
 shock is not so severe, fluid by hypodermoclysis or Murphy drip 
 may be sufficient. 
 
 Transfusions. — Since hemorrhage may be partially responsi- 
 ble for shock, the imperative need often is to supply the blood 
 which has been lost. Blood transfusions no longer present the 
 obstacles which they formerly did, for the long tedious sur- 
 gical methods of arteriovenous anastomosis have been prac- 
 tically replaced by the use of the syringe and its modifications. 
 
 Grouping for Transfusions. — Before any transfusion is 
 given, it is always necessary to ascertain the blood group of the 
 patient and of the "donor," because if the bloods of different 
 groups are mixed together the red blood cells are destroyed and 
 the patient is liable to suffer a very severe reaction, and derive 
 no benefit from the treatment. Human bloods are divided into 
 four groups. Of these the largest are groups two and four which 
 together constitute about eighty-three per cent, of all individuals. 
 
16 TEXTBOOK OF SURGICAL NURSING 
 
 lu selecting a "donor," it is very important that he be in good 
 physical health, and that his blood be free of syphilis as evi- 
 denced by a negative Wassermann reaction. 
 
 Transfusions may be given by one of three methods, — the 
 direct arteriovenous method ; the indirect, as represented by 
 the syringe method ; and the one in which sodium citrate is 
 used. The anastomosis of an artery of a donor to a vein of the 
 recipient is no longer done, because this rather cumbersome 
 method (which was rarely very successful) has been replaced by 
 the other two types, which are more efficient, certainly easier of 
 operation, and less trying both to patient and donor. The 
 syringe method first used by Lindenian employs glass record 
 syringes w^hich draw the blood from the vein of the donor; 
 the freshly drawn blood is then immediately injected through a 
 needle into the vein of the recipient. The great disadvantage 
 is the fact that the blood is apt to clot in the needles of the 
 syringes in spite of the fact that these instruments may be 
 flushed with saline during the procedure as is done in the Unger 
 method. To overcome this obstacle, a method frequently used 
 at the present time is the Lewisohn transfusion. It has been 
 demonstrated that chemically pure sodium citrate in solution 
 will prevent blood from clotting, and if used in a strength not 
 exceeding two-tenths per cent, will not prove injurious to the 
 patient. The usual procedure is as follows : 
 
 The donor is bled into a flask containing enough sterile 
 sodium citrate solution to prevent clotting, and as the blood 
 flows from the vein of the donor into the glass container, it is 
 slowly shaken so as to insure complete mixing with the citrate. 
 The drawn blood, now rendered uncoagulable, may be given at 
 once, or, if it is not practical, it may be kept on ice and used 
 any time wdthin twenty-four hours, provided it is warmed to 
 the body temperature before injection. As a rule, the blood 
 is given to the recipient by the "gravity method." This per- 
 mits it to flow by gravity from a container elevated about two 
 or three feet above the head of the patient into the vein of the 
 recipient through the ordinary Luer needle which has previ- 
 ously been inserted. Or, it may be given by the gravity method 
 plus a three-way stop-cock and Luer syringe. The blood flows 
 
SHOCK AND HEMORRHAGE 17 
 
 from the container into the syringe. When this is filled the 
 cock is turned and the syringe emptied of its contents by piston 
 pressure, the blood passing into the vein. Then the stop-cock 
 is turned again and the syringe refilled. This technic is elab- 
 orate but there are no real advantages over the gravity method, 
 (The apparatus used is the same as for any saline infusion; 
 it should be boiled in distilled water.) 
 
 Some surgeons prefer to give blood from which the fibrin 
 has been removed by beating fresh blood with an instrument 
 similar to an egg-beater. This procedure prevents it from clot- 
 ting, and the defibrinated blood, like the citrated, may be kept 
 for some time before its administration. The amount of blood 
 given is usually 500 c.c. and this may be repeated as often as 
 is necessary. 
 
 After Treatment. — After most transfusions there is apt to 
 be a reaction manifested by chills and fever and sometimes 
 nausea and vomiting. The nurse should always be prepared 
 for this emergency. This may occur from ten to twenty min- 
 utes after the transfusion, and the treatment is the same as for 
 any chill, — blankets, hot bottles and a little brandy, if per- 
 mitted. It is advisable to save the urine of all these cases be- 
 cause it should be examined for the presence of altered blood. 
 This will indicate whether the recently given blood has been 
 of value to the patient, or whether it has been destroyed, and 
 is being eliminated by the kidneys. 
 
 Hemorrhage. — Hemorrhage is any bleeding. It may be 
 either arterial, venous, or capillary. Arterial hemorrhage is 
 recognized by a stream of blood which is bright red and spurt- 
 ing, each spurt corresponding to a cardiac systole, or contrac- 
 tion period of the heart. Venous bleeding is a slower, steadier 
 stream of dark red blood. Capillary bleeding is evidenced 
 by simple oozing. 
 
 Symptoms. — If the bleeding is external, the hemorrhage is 
 recognized rather readily, but if it is internal bleeding, it is 
 moderately difficult to diagnose. Patients who are hemorrhag- 
 ing internally as the result of some intra-abdominal injurj^, 
 or from the rupture of blood vessels, as in a ruptured ectopic 
 pregnancy, usually show pallor, pinched face, cold clammy skin, 
 
18 TEXTBOOK OF SURGICAL NURSING 
 
 rapid thready pulse, shallow superficial respirations, and what 
 is very important — "air hunger," Air hunger is one of the 
 diagnostic signs of hemorrhage. In shock the patient is ordi- 
 narih^ quiet, somewhat depressed. In hemorrhage, the patient 
 is gasping for breath, restless, asking to have the windows open, 
 begging for more air, and feeling as if he were being smothered. 
 
 Treatment. — If a large artery has been cut, the first aid 
 treatment is simply to arrest the hemorrhage b}' applying pres- 
 sure with a tourniquet. This is a band placed around a limb, 
 and tightened until circulation through the artery is arrested. 
 It is an excellent method for the temporary arrest of hemor- 
 rhage until some medical aid can be secured and the vessel 
 clamped and tied. 
 
 Ligature. — This is the tying off of a vessel with material 
 which may be either absorbable, such as catgut, or non-absorb- 
 able, such as linen. If the vessel is moderately small and has 
 been caught in an artery clamp, sometimes by twisting the 
 arterial wall, hemostasis is secured. This method is known as 
 torsio7i. 
 
 Hemorrhage may also be controlled by means of the cautery; 
 heat is applied to the bleeding vessel so that it coagulates the 
 tissues and the bleeding stops. 
 
 Pressure. — Pressure is indeed a very important means of 
 arresting hemorrhage, and sometimes good steady pressure over 
 a bleeding surface may do much to stop the flow of blood. In 
 bleeding from bone, one of the most efficacious ways of con- 
 trolling it is to plug the hole in the bone with Horsley's wax. 
 This is composed of seven parts beeswax, one part almond oil, 
 and one part salicylic acid. 
 
 Capillary Bleeding. — There are various ways in which ooz- 
 ing can be controlled. One is by means of cold and the other 
 by heat. Cold is especially efficacious in those operations about 
 the mouth. For example, after the removal of adenoids and 
 tonsils, or operations in the nose or upon the palate, bleeding 
 is often controlled by slapping the face and neck with ice cold 
 water. It appears that the contraction of the superficial ves- 
 sels leads to a contraction of the deeper vessels, thus relieving 
 the hemorrhage. Bleeding from the capillary blood bed of the 
 
SHOCK AND HEMORRHAGE 19 
 
 uterus should not be controlled by tlic application of cold water 
 as such a procedure might result in shock. Instead, an intra- 
 uterine douche with a little acetic acid and water of from 110 
 to 115 degrees is excellent in controlling this variety of hemor- 
 rhage. Often it is necessary to supplement this with packing, 
 either with jjlain or medicated gauze. 
 
 Styptics. — Occasionally for very small pin point oozing, 
 fused silver nitrate is applied directly to the bleeding point. 
 
 After Treatment of Hemorrhage. — Inasmuch as a certain 
 amount of fluid is lost, it is very important to supply this to the 
 system either by the blood itself in the form of transfusions, or 
 by saline infusions. After the hemorrhage has been controlled, 
 necessity may demand that the patient be treated as a " shock ' ' 
 case. 
 
CHAPTER III 
 
 POST-OPERATIVE COMPLICATIONS 
 
 The operation completed, the surgeon has done the major 
 part of his work, and the patient from then on is entrusted to 
 the care of the attending nurse. It is true that all orders are 
 given by the attending surgeon, but their conscientious exe- 
 cution is dependent upon the integrity and efficiency of the 
 nurse. The surgeon may see the case but once a day ; the nurse 
 sees the patient at all times; and she, by her careful attention 
 to details and her knowledge of human nature, can do much 
 to make the patient comfortable and the post-operative course 
 smooth in spite of the many complications which might arise. 
 The immediate care of the patient after leaving the operating 
 room is discussed in Chapters XIII and XVI. It is the pur- 
 pose of this chapter to discuss the treatment of the various post- 
 operative complications. The most important of these are 
 nausea, vomiting, pernicious vomiting, gastric dilatation, tym- 
 panites, auto-intoxication, post-operative pneumonia, pulmonary 
 embolism, urinary retention, urinary suppression, phlebitis, 
 thrombosis, and hemophilia. 
 
 Nausea is quite common. It is usually present after all 
 operations for a short time. Some doctors are in the habit of 
 ordering cracked ice to relieve this distressing symptom. AVhen- 
 ever it is ordered, care must be taken lest the patient get too 
 much and in this way imbibe large quantities of cold water 
 with the result that vomiting is very apt to ensue. When the 
 feeling of nausea becomes very severe it is accompanied by 
 vomiting. If a patient vomits later than twenty-four hours 
 after operation, there probably is something in the stomach 
 which is causing a persistent irritation. Once this irritation 
 is removed, the vomiting will generally cease. It must be re- 
 membered that the patient has just been operated upon, and 
 
 20 
 
POST-OPERATIVE COMPLICATIONS 21 
 
 that the nerves are exhausted, and that conservative treatment 
 is better than radical. The most effective procedure for ridding 
 the stomach of foreign material is gastric lavage; but washing 
 the stomach is trying and tiring and should only be employed 
 when other simpler methods have proven unsuccessful. First 
 the following should be tried: — A glassful or approximately 
 eight ounces of lukewarm water with about a teaspoonful of 
 bicarbonate of soda should be administered by mouth. As a 
 rule, patients are very thirsty after operation, and avariciously 
 drink the proffered water. The result is that they are further 
 nauseated and soon vomit the ingested water, thus washing out 
 the stomach, and instant relief often ensues. Sometimes, in 
 spite of these measures, vomiting will still persist. It is due 
 then to atony, a relaxation of the muscles of the stomach wall. 
 Persistent vomiting is very weakening, and gastric lavage 
 should be given almost immediately, if the bicarbonate of soda 
 and water fail to afford relief. A post-operative lavage must be 
 of hot water, for the heat itself is the efficient agent in stimulat- 
 ing the stomach walls to contract, and therefore the water 
 should be introduced at about 108-110 degrees Fahrenheit. An- 
 other point, — as little air as possible should enter the stomach 
 tube, and when the lavage is finished, the water should be care- 
 fully siphoned off from the stomach. If the vomiting persists 
 after a good gastric lavage, it then may be due to either per- 
 nicious vomiting or possibly, gastric dilatation. 
 
 Pernicious Vomiting. — This may occur in children as well as 
 in adults, and is usually a manifestation of what is commonly 
 spoken of as "acidosis," a condition in which the normal alka- 
 linity of the blood is diminished. It is recognized by the sweet 
 and fruity odor of the breath. If this condition be suspected, 
 the urine should be examined for the presence of acetone. If 
 it be present, gastric lavage should be given, everything stopped 
 by mouth, and alkalis administered immediately either by a 
 ten per cent, sodium bicarbonate solution in a Murphy drip, or 
 intravenously in three to five per cent, solution, but never by 
 clysis. 
 
 Sodium bicarbonate is given until it is excreted by the kid- 
 neys. When the urine is alkaline it is safe to assume that suf- 
 
22 TEXTBOOK OF SURGICAL NURSING 
 
 fieieut bicarbonate has been administered to bring the blood 
 back to its normal alkaline reaction, thus reducing the acidosis 
 Avhich is the underlying cause of vomiting in these particular 
 cases. There is one point, however, -which needs emphasis in 
 the administration of sterile sodium bicarbonate solutions. 
 After the desired solution has been compounded, it must be 
 sterilized. Sterilization, by its heat, drives off carbon dioxide 
 thereb}' reducing the bicarbonate of soda to sodium carbonate. 
 This compound is not as good as the bicarbonate because it is 
 more irritating to the tissues, and is not as effective in reestab- 
 lishing the aUialinity of the blood. To counteract this, after 
 the solution has been cooled sufficiently, carbon dioxide may 
 again be added by connecting a sterile tube to a carbon dioxide 
 tank and allowing the gas to bubble through the sodium car- 
 bonate fluid for a sufficient length of time, thus making a bi- 
 carbonate compound. 
 
 Gastric Dilatation. — One of the most distressing complica- 
 tions which may arise after an operation, and one which, if 
 not treated radically, energetically, and thoroughly may result 
 in death, is acute gastric dilatation. As the name implies, in 
 this condition the stomach becomes enormously dilated, and 
 presses upward on the diaphragm. This makes respiration 
 very difficult because of the constant pressure on the diaphragm. 
 And, inasmuch as the pyloric orifice of the stomach is atonic, 
 the intestinal contents seep back into the stomach, resulting in 
 persistent vomiting of large amounts of greenish and brownish 
 colored fluids. To relieve this condition those means must be 
 employed which will cause the dilated stomach to contract and 
 approach its normal size. 
 
 Treatment. — The stomach should be lavaged with a hot soda 
 bicarbonate solution at 110 to 112 degrees Fahrenheit, and the 
 lavage continued until the return is absolutely clear. While 
 this treatment is under way, turpentine stupes should be ap- 
 plied to the upper abdomen for ten or fifteen minutes. It is 
 important to bear in mind that as these stupes must be hot to 
 be efficacious, the abdomen should be thoroughly greased with 
 vaseline before appljdng them, as great care must be taken that 
 the skin is not burned. The integrity of the skin must be pre- 
 
POST-OPERATIVE COMPLICATIONS 23 
 
 served because this procedure is to be repeated every two or 
 three hours, according to the discretion of the attending surgeon. 
 The stupe probably is the most efficient and reliable method 
 for applying external heat, although some authorities advise 
 the use of huge flaxseed poultices. Strychnine sulphate, gr. 
 1/60, may be given by hypodermic injection every four hours, 
 following the principle that the strychnine will improve muscle 
 tone. 
 
 The patient, of course, during this period, should be given 
 nothing by mouth, but measures should be taken to supply the 
 system with water. By persistent vomiting these unfortunate 
 patients have desiccated themselves of fluid, and it is necessary 
 that fluid be administered by means of a Murphy drip, or that 
 eight ounces of tap water be given by rectum every four hours. 
 If the patients show signs of shock, which they often do, a 
 hypodermoclysis of 500 to 800 c.c. of saline should be given, 
 or, in some instances, an infusion of saline. If nourishment 
 be an essential element, a solution (two to five per cent.) of glu- 
 cose may be administered intravenously. The glucose may also 
 assist in combating a beginning acidosis brought on by inanition. 
 
 After the initial period of vomiting has come to an end, 
 it is advisable to give the stomach an absolute rest for about 
 twenty-four hours, and then to start the patient on what may 
 be called a "gastric tolerance diet." The theory of this diet 
 is to partially desensitize the mucosa of the stomach and make 
 it more tolerant to fluids by the use of small doses of chloro- 
 form water. If this is retained, peptonized milk is then started 
 in small doses. The amount of peptonized milk is then gradually 
 increased, the chloroform water is omitted, and the patient, 
 after a period of absolute gastric tolerance, is gradually brought 
 over to a selected soft diet. The exact details of this diet 
 are given in Chapter XII on ''Surgical Dietetics." 
 
 Tympanites. — The distention of an abdomen following op- 
 eration is due to a gastric dilatation, a distention of the small 
 or large intestine, or a dilatation of the bladder resulting from 
 urinary retention. The word tympanites or meteorism de- 
 notes an inflation of the abdomen with gas. This gas is usually 
 intestinal; occasionally it may be free in the peritoneal cavity 
 
24 TEXTBOOK OF SURGICAL NURSING 
 
 from a perforation of the intestines. A condition of gastric 
 dilatation is recognized by distention in the upper abdomen; 
 that of the small or large intestine, by a generalized abdominal 
 distention; that of the bladder by palpation of a rounded mass 
 just above the pubes and the failure of the patient to void after 
 operation. Tympanites is certainly distressing and modern 
 surgical nursing commands many methods to alleviate and re- 
 lieve this condition, bringing much comfort to the patient. 
 
 Treatment. — The theory underljdng all treatments is to aid 
 the patient in ridding the small intestines and colon of gas. 
 The means for accomplishing this are many. One of the simplest 
 procedures and one of the most efficient is the introduction of 
 a rectal tube. 
 
 A rectal tube is a small piece of rubber tubing about three- 
 eighths of an inch in diameter, rounded at one extremity. This 
 is well lubricated with either K-Y or vaseline, and gently in- 
 troduced into the rectum beyond the internal and external 
 sphincters, and about three to four inches beyond the anus. 
 The purpose is to form an exit for gas which may have accumu- 
 lated in the colon. This simple procedure is often all that is 
 necessary. 
 
 Enemas. — Especially in emergencies when the patient has not 
 had a cathartic, or a thorough intestinal cleansing before the 
 operation, the fecal material is apt to accumulate in the colon 
 causing fermentation and often stopping the passage of gas or 
 flatus by its mechanical bulk. In these conditions it is im- 
 portant to empty the lower bowel by a cathartic enema. The 
 soapsuds enema is usually all that is required. But in those 
 cases where the soapsuds have brought very little return, and 
 the distention is still marked, and it is thought that fecal ma- 
 terial is being retained, it is advisable to give a more purga- 
 tive enema. The solutions which may be added to enemas may 
 be glycerine, one ounce, or turpentine, % ounce to the pint. 
 Milk and molasses, — four ounces of milk and four ounces of 
 molasses, — make a good irritative enema. The magnesium sul- 
 phate enema is used now quite frequently, — two ounces each 
 of water, glycerine and magnesium sulphate in saturated solu- 
 tion being employed. Some institutions use a mixture with 
 
POST-OPERATIVE COMPLICATIONS 25 
 
 oxgall in the following proi)oi'tions : — turpentine o ii, oxgall o ii, 
 magnesium sulphate § iv, glycerine § iv. 
 
 These purgative, irritative enemas, not only empty the lower 
 bowels, but also stimulate the smooth muscles to contract, 
 thus expelling the gas which has accumulated. Irritative enemas 
 for safety's sake should be small in amount. The soapsuds 
 enema, however, made from castile or ivory soap, is given in 
 amounts varying from two to four pints. After operation, it 
 is best to give the enema in the dorsal position, putting the 
 douche pan under the patient before the enema is given. The 
 returns should be watched for the presence of fecal material, 
 mucus, blood, bile, and' gas. Enemas after operation should 
 always be ordered by the attending physician, and no nurse 
 should take upon herself the responsibility of injecting fluid 
 into the rectum. As a rule, they should not be given in rectal 
 cases, perineorrhaphies, or resections of the colon unless abso- 
 lutely essential. 
 
 Colon Irrigation. — The colon irrigation performs three 
 functions: It supplies a certain amount of fluid to a system 
 which needs water; it carries off fecal material, and acts as a 
 medium for the expulsion of gas. Colon irrigations when given 
 properly should cause the patient absolutely no distress. If 
 perfectly given, there is no reason why the patient should not 
 fall asleep during the treatment. Many solutions are used 
 for the irrigations. Normal or half strength saline is quite 
 common, but it must be remembered that it increases the thirst 
 of the patient, and for this reason, provided that the rectum 
 will retain it, tap water is better. Any irrigation to be effec- 
 tive must be given hot, at a temperature varying from 110-120 
 degrees. About three gallons should be used for a single ir- 
 rigation. "While the technic of giving an irrigation is known 
 to every nurse, there are a few points which might be em- 
 phasized, and which if remembered, will cause greater com- 
 fort to the patient. They are as follows : 
 
 1. All air must be expelled from the inflow catheter before 
 it is inserted. 
 
 2. The catheter should be inserted within the outflow tube 
 so that only one tube is inserted into the rectum. 
 
26 TEXTBOOK OF SURGICAL NURSING 
 
 3. The end of the outflow tube should not be more than a 
 foot below the level of the patient. If it is, a jerky interrupted 
 flow is apt to result because too great a suction is established, 
 and the mucous membrane of the rectum is apt to be drawn 
 about the holes of the rubber tubing. 
 
 4. There should always be a return of fluid through the out- 
 flow and if for any reason it is not evident, the irrigation should 
 be stopped immediately. For the pressure of fluid through 
 the inflow tube might be so strong as to cause distention with 
 a resulting paresis of the gut ; or, what is extremely rare, there 
 might be a perforation in the colon through which fluid empties 
 itself into the peritoneal cavity. The amount of fluid which 
 the patient absorbs can easily be estimated by comparing the 
 amount given and the amount returned. 
 
 There are two ways of giving a colon irrigation: — one way 
 is to use an inflow and outflow tube ; the other, one tube to serve 
 alternately as inflow and outflow. The second method is less 
 advisable, for it is more like an intermittent enema, and is 
 certainly more uncomfortable to the patient. 
 
 Aids to Colon Irrigations. — Just as in a dilatation of the 
 stomach water is applied internally and heat externally by the 
 application of poultices, so, in giving a colon irrigation, to 
 make it more effective, and to aid in stimulating the contrac- 
 tion of the smooth muscle of the bowel, large flaxseed poultices 
 are used for their counter-irritative effects. In addition, very 
 often 1 c.c. of pituitrin is given intramuscularly during the 
 colon irrigation. It is a known fact that a substance in the 
 posterior lobe of the pituitary stimulates smooth muscles to 
 contract. Pituitary extract should not be given by mouth be- 
 cause its administration in that manner is practically ineffectual. 
 In some cases, fortunately rare, rectal tubes, enemas and colon 
 irrigations will not relieve abdominal distention. These cases 
 are spoken of as paralytic ileus. 
 
 This is a condition in which the smooth muscle of the in- 
 testine is practically paralyzed; there is no peristalsis, no pas- 
 sage of gas, the patient becomes more and more distended as 
 the fermentation becomes greater and the toxemia becomes 
 more severe. This condition is helped by immediate surgical 
 
POST-OPERATIVE COMPLICATIONS 27 
 
 interference alone. The mortality, however, is terrifically high. 
 The operation performed is an enterostomy, Chapter IV, page 
 55; an opening is made in the small intestine through which the 
 gas, fluid and solid material may escape. Thus with a diminu- 
 tion of the degree of toxemia, and the intestines relieved of 
 their burden they will have sufficient strength and recuperative 
 powers to regain their normal tone and peristaltic wave action. 
 
 Auto-intoxication. — Closely allied to meteorism is auto-in- 
 toxication. In this condition the patient absorbs certain 
 products of fermentation and decomposition from the gastro- 
 intestinal tract, resulting in a slight degree of temperature 
 usually associated with headache and general malaise. This is 
 ordinarily relieved by a movement of the bowels, procured by 
 an enema, and a cathartic. This condition is never very seri- 
 ous, and never alarming. 
 
 Post-operative Pneumonia. — This is one of the most serious 
 of post-operative complications. Often a patient reacts favor- 
 ably to an operation only to be dragged down in a day or 
 two by the toxemia of lung involvement ; and this, together 
 with the general weakness following surgical interference, 
 often results in death. While pneumonia cannot be absolutely 
 obviated as a post-operative complication, there can be a 
 marked diminution in its frequency if greater attention is paid 
 to the smaller details of ante-operative and post-operative care. 
 
 In hospital work and in private nursing the fact is often 
 forgotten that the patient in his home has been accustomed to 
 certain clothing and has been living for years under peculiar 
 hygienic conditions. Upon entering the hospital he is given 
 an abbreviated nightgown and placed in a bed with one or two 
 blankets. When he is physically examined his gown is taken 
 off, and very often there is a draught from a nearby open win- 
 dow. The deep breathing and coughing incident to the auscul- 
 tation of the lungs often cause a perspiration, and the cool air 
 on the heated skin is a poor combination. Occasionally the pa- 
 tient is. asked to get out of bed and stand up, his bare feet 
 very often resting against the cold floor; or often, when the 
 abdomen is shaved and being prepared for operation, the pa- 
 tient is unduly exposed. Then from a warm bed he is placed 
 
28 TEXTBOOK OF SURGICAL NURSING 
 
 upon a cold stretcher, wheeled through draughty, chilly halls, 
 and plunged into a superheated operating room. During the 
 operation he is apt to perspire freely, and while it is routine 
 to change a drenched gown, the patient, through neglect, is 
 often permitted to keep it, and in this condition he is sent 
 through the halls again, back into the ward. During the re- 
 covery period, he may toss around, uncovering his body, and ex- 
 posing his depressed system to more draughts, more chilling, 
 opening the way to a pneumonia. When the matter is given 
 thought, the real wonder is that pneumonia is not more fre- 
 quent. The best method of treating this serious complication 
 is by prophylaxis. Prevention is better than cure, and careful 
 and conscientious surgical nursing will greatly aid in diminish- 
 ing the incidence of this dreaded complication. 
 
 Prophylactic Treatment. — Ante-operative. — All patients be- 
 fore operation should be carefully examined for coryza, bron- 
 chitis, pharyngitis, or tonsillitis, and if any of these exist, the 
 operation should not be performed, but temporarily postponed. 
 Of course, acute cases fall into another category, and very 
 often it is advisable to do these under local anesthesia rather 
 than run the risk of ether or gas administration which is sure 
 to spread the infection into the lungs. If the nurse at any 
 time prior to operation notices that the patient sneezes exces- 
 sively, or that signs of a cold are developing, it is imperative 
 that she immediately notify the surgeon, for few will operate 
 when there is even the slightest infection of the respiratory 
 system. 
 
 When patients are being examined physically, or receiving 
 treatments, it is highly important that all windows and doors 
 in the vicinity be closed and that draughts be diminished to the 
 minimum. If a patient has to leave the bed he should be ade- 
 quately supplied with slippers, a bathrobe, and, if necessary, 
 a blanket. When he is moved to and from the operating room 
 he should be warmly covered, and in the operating room the 
 same general rules hold true. If his gown becomes wet with 
 perspiration, his body should be thoroughly dried and a new 
 gown supplied. 
 
 Operative Prophylactic Treatment. — While the patient is 
 
POST-OPERATIVE COMPLICATIONS 29 
 
 recovering from the anesthetic, the lower jaw .should be hehl 
 firmly and pressed forward, exerting pressure at both angles; 
 this will do much to prevent gagging and when the patient vomits 
 the head should be turned to one side, the jaw still being held, 
 and the vomitus eructated into a pus basin. It is highly im- 
 portant that this be always done, because if this procedure is 
 routinely and regularly followed, the danger of the vomitus 
 being aspirated into the lungs is reduced. Aspiration is not an 
 uncommon cause of pneumonia. 
 
 Post-operative Prophylactic Treatment. — When the patient 
 arrives in the ward or room he should be warmly covered, and 
 very often in order to maintain a good body heat, the bed may 
 be previously warmed either with electric pad or hot water 
 bottles. If the patient tosses about, the blankets should always 
 be readjusted. If there is a tendency to vomit the jaw should 
 be held firmly forward and the head turned to one side. These 
 instructions have been repeated because it is extremely im- 
 portant that they become deeply impressed upon the nursing 
 mind. In other words, the incidence of post-operative pneu- 
 monia may be greatly reduced if the patient before operation 
 is free of any infection of the respiratory tract, and during the 
 period of surgical attention he be fully protected against 
 draughts and unusual changes from cold to hot or hot to cold. 
 
 Treatment of Post-operative Pneumonia. — The treatment is 
 really that of any lobar pneumonia. The patient is usually 
 on a Gatch bed. The Gatch bed is one which is made in sections 
 so that the upper portion of the body may be elevated and 
 the knees flexed by adjusting these sections to any desired de- 
 gree. 
 
 The windows are opened wide and as much fresh air is 
 given as is possible. The diet is liquid including milk. Fluids 
 should be forced to about 3,000 c.c. a day, and the intake and 
 output should be accurately measured. 
 
 Abdominal distention is always looked for and treated im- 
 mediately -with rectal tube, enemas or colon irrigations. 
 
 The cough is particularly distressing and dangerous, for 
 after a surgical operation the pressure caused by straining may 
 break some of the sutures and sometimes the abdominal wound 
 
30 TEXTBOOK OF SURGICAL NURSING 
 
 is ruptured Avido opeii, and the abdominal contents eviscerated. 
 To prevent this horribk? complication a good, tight, well-placed 
 binder is exceedingly important, for it gives added support to 
 the abdominal wall. If the coughing is very severe, the nurse 
 should supi)ort the lateral areas of the abdominal wall with 
 her hands. Should evisceration take place, the intestines should 
 be covered with sterile towels, and the surgeon immediately 
 summoned. For the cough, doctors will prescribe a codeine 
 cough mixture, or leave orders for codeine to be given either 
 by mouth or hypodermic. 
 
 As soon as the diagnosis is made, it is routine to administer 
 tincture of digitalis as a cardiac stimulant, the dose being 10 
 to 15 minims three times a day. If the pulse is very rapid, 
 and the heart overacting, it is controlled by an ice bag placed 
 over the precordium. 
 
 Pleural pain, which is very distressing, yields to strapping 
 the affected side with adhesive plaster. 
 
 Pneumonia cases must always be watched carefully for 
 cardiac failure and edema of the lungs. The cardiac failure is 
 evidenced by a weak, thready pulse, cyanosis and respiratory 
 difficulty. Edema of the lungs manifests itself by bubbling 
 respirations. 
 
 Cardiac failure is treated by stimulants, such as camphor 
 in oil, caffeine or atropine. Edema of the lungs responds best 
 to good dry cupping especially applied to the posterior regions 
 of the chest. This should be done for about twenty minutes at 
 a time. Great care should always be exercised in preventing 
 the patient from being burned with the cups. The use of 
 oxygen in these cases with the present apparatus is practically 
 useless and worthless. 
 
 Pulmonary Embolism. — Closely allied to post-operative 
 pneumonia, but of different etiology, is pulmonary embolism. 
 It is not very common, and may occur after the simplest opera- 
 tions ; for example, after an appendicectomy, or an operation for 
 varicose veins ; it may be preceded by a thrombosis of the veins 
 of the lower extremity, or come as a distinct entity. As a rule, 
 it is ushered in by a sudden pain in the chest, dyspnea, bloody 
 expectoration, rapid pulse, and slight rise in temperature. If 
 
POST-OPERATIVE COMPLICATIONS 31 
 
 the chest is auscultated the doctor may sometimes note a fric- 
 tion sound, or signs of beginning pneumonia may be evident. 
 Occasionally, instant death occurs, and at best the mortality 
 is high, varying from seventy to eighty per cent. 
 
 Treatment. — Patients who develop a phlebitis or thrombosis 
 of the veins of the lower extremity, or any other region, 
 should be kept in bed until this condition absolutely sub- 
 sides, because a small piece of blood clot may break off and 
 lodge in the lung as an embolus. Patients should not be per- 
 mitted to be too active after operation even if their condition 
 is excellent. The treatment of embolism is to reassure the 
 patients, for they are apt to become greatly alarmed at the 
 sight of their bloody expectoration. To further quiet them 
 morphine is administered. If the diagnosis of its location is 
 made, it is customary to strap that side of the chest in which 
 the embolus is lodged. This will immobilize the affected lung 
 as much as possible. 
 
 The family of a patient suffering from a pulmonary embolism 
 should be apprised of the impending danger, for even though 
 the patient may recover from the shock of the embolism itself, 
 it may give rise to an embolic pneumonia and a recovery from 
 this condition is exceptionally rare although it occasionally 
 occurs. 
 
 Urinary Retention. — After operation, occasionally, a patient 
 is unable to void urine voluntarily with the result that the 
 urine collects in the bladder, the organ becoming dilated be- 
 yond its usual capacity. Pain is very apt to result from this 
 distention, and the patient is very uncomfortable. Urinary 
 retention is more prone to occur after operations about the 
 rectum, the vagina, the cervix, and the bladder itself than after 
 operations involving the upper abdomen. The reason for this 
 is that the center of micturition has been reflexly inhibited 
 by the operative procedures; or it may be due to nervousness, 
 or that conscious control has not as yet been reestablished after 
 the administration of an anesthetic. As a rule, no patient 
 should be allowed to go more than twelve to twenty hours with- 
 out voiding. However, every effort should be made to have 
 
32 TEXTBOOK OF SURGICAL NURSING 
 
 the patient void voluntarily, because all functions are better 
 performed by nature than if mechanically interfered with. 
 
 Treatment. — The treatment of urinary retention is cathe- 
 terization. A catheterization is a surgical procedure. A surgi- 
 cal procedure in clean cases is an aseptic one, and every bladder 
 Mliicli becomes infected after the introduction of the catheter 
 is a horrible reflection upon the individual Avho has done the 
 catheterization. This procedure should be done with a good 
 light. The urethral orifice is carefully exposed. The catheter, 
 be it rubber, metal, or glass, should be lubricated with a sterile 
 oil, either olive oil or K. Y. The urine which is withdrawn 
 should be saved and examined as a matter of record. While 
 catheterization every eight hours is a routine in some hospitals 
 after perineorrhaphy, it should be remembered that a patient 
 may develop a * ' catheter habit ' ' because the act of micturition or 
 urination causes slight pain, and catheterization affords instant 
 relief without pain. These cases should be treated firmly but 
 gently and various expedients should be tried to induce volun- 
 tary micturition. The drinking of large quantities of water, 
 the sound of running water from turning on a water faucet 
 within hearing distance of the patient, or pouring warm water 
 over the vulva may do much to encourage voluntary micturition. 
 
 In those cases where there is an old inflammation of the 
 bladder, it is advisable not to draw off all the urine at once, 
 but to leave about four ounces in the bladder, or if all the 
 urine is withdrawn, to introduce immediately into the bladder 
 about four ounces of a warm sterile solution of boric acid. This 
 will prevent any possibility of an infection travelling from 
 the bladder to the kidneys via the ureter. The details of 
 catheterization are not given here, as they are known to every 
 nurse, but it cannot be emphasized too strongly that this treat- 
 ment above all must be done by a nurse with a surgical con- 
 science. 
 
 Suppression of Urine. — Following some of the more exten- 
 sive major operations, especially those upon the kidney, either 
 a nephrectomy or a nephrotomj^, or prostatectomy, the kidneys 
 may shut down and secrete no urine ; the result is, that those 
 substances which should be normally excreted in the urine as 
 
POST-OPERATIVE COMPLICATIONS 33 
 
 the urea, are stored up in the blood. There is, however, a limit 
 to the amount of nitrogenous poison which the blood can con- 
 tain, and if this threshold is crossed, the patient may suffer 
 from uremic poisoning. Uremia is recognized by the urinous 
 odor of the breath, the dried parched tongue, a semicomatose 
 attitude of the patient, the urinary suppression, and an in- 
 crease in the nonprotein nitrogen of the blood. 
 
 Treatment. — The prognosis in all these cases is poor. The 
 same methods used by medical men in combating uremia re- 
 sulting from diseased kidneys are used by the surgeon. If the 
 kidneys are incapable of physiologically performing their func- 
 tion of elimination, then for the time being other organs must 
 take over that function. There are many adjuvants, — ^the sweat 
 glands of the skin and the intestinal canal are invaluable aids. 
 The reflex stimulation of the kidneys by counter-irritants, the 
 forcing of fluids so as to dilute the poison in the blood, the 
 actual removal of some blood with its poisons (phlebotomy), 
 and, finally, operation upon the kidney itself, all help in this 
 very serious complication. 
 
 The skin may be used to further aid excretion. If the pa- 
 tient will stand it, hot packs should be employed. The pur- 
 pose of a hot pack is to cause perspiration, and inasmuch as 
 urea is one of the chief elements of sweat, a partial strain is 
 taken away from the kidneys. Very often this procedure alone 
 will be sufficient to stimulate the kidneys to excrete urine. Hot 
 packs should be repeated at intervals of four to six hours. 
 While the treatment is being administered, the condition of the 
 patient must be carefully watched, for the packing often re- 
 sults in weakness and prostration. The other danger of giving 
 a pack to a surgical patient is that the body must be care- 
 fully dried after the treatment in order to prevent post-opera- 
 tive pneumonia. In addition, great care should always be 
 taken that the skin (which has already been made sensitive 
 through the application of the ante-operative painting of iodine) 
 should not be burned, and further avenues of infection opened 
 through denuded skin. 
 
 The use of the intestinal tract as an avenue of elimination 
 may be further stimulated by employment of colon irrigations. 
 
34 TEXTBOOK OF SURGICAL NURSING 
 
 The colon irrigations, as stated previously, not only carry off 
 large amounts of toxins, but tliey are a means of supplying 
 water to the tissues. 
 
 The kidneys may be stimulated reflexly by counter-irritants 
 applied to the skin of the lumbar region. This may be accom- 
 plished by the use of flaxseed poultices applied at two-hour 
 intervals, or by hot water bottles. Some surgeons employ drugs 
 in order to stimulate the kidneys directly, by the use of such 
 substances as theobromine because of its direct diuretic action. 
 Five to eight grains are given three times a day for the space 
 of three days and then the drug is stopped. There is no doubt 
 that this drug is excellent in stimulating the kidneys and cer- 
 tainly surpasses caffeine in its action. The disadvantage is that 
 it might cause a certain amount of nervousness and insomnia. 
 
 Forcing fluids either by proctoclysis or hypodermoclysis -will 
 cause enough fluid to be absorbed to dilute the blood, thus 
 resulting in a diminution in the degree of toxemia. This simple 
 method not only relieves the patient of an impending uremia, 
 but the kidneys are stimulated by the added amount of fluid. 
 
 In cases of high blood pressure with a high blood urea, the 
 actual removal of part of the blood volume will do much to re- 
 duce the nitrogen content of the blood, if only for a short period 
 of time. This is done by a phlehotoj^iy, or inserting a canula in 
 a vein in the arm, and permitting the patient to be bled of 
 250 to 700 c.c. of blood. The amount withdrawn should de- 
 pend upon the constitution and physique of the patient. Quite 
 often after this procedure, 250 to 500 c.c. of normal saline are 
 introduced intravenously, resulting in further dilution of the 
 toxins. 
 
 If, in spite of all these procedures, there is no urine ex- 
 creted, a rather heroic operative procedure may be resorted to, 
 that of decapsulating the kidneys. This is especially indicated 
 in those cases which have a chronic inflammation of the kidneys, 
 preexisting Bright 's disease. The operation is spoken of as 
 Edebohls's decapsulation. It consists of the excision of the 
 capsule from the kidney so that with this restraint removed, 
 the organ may be able to work more efficiently by establishing 
 
POST-OPERATIVE COMPLICATIONS 35 
 
 new vascular relationships with the surrounding tissues, thereby 
 obtaining better nourishment for itself. 
 
 Phlebitis. — This condition is an inflammation of the veins, 
 usually of the lower extremity. It is rather late in onset and 
 is annoying because the patient is confined to bed for a longer 
 period of time. It is manifested by cramp-like pains in the leg, 
 a rise in temperature, and a feeling of general malaise. Ex- 
 amination of the affected extremity shows that the part is 
 swollen and the skin over the veins reddened. Occasionally 
 the veins may be palpated. The treatment calls for absolute 
 rest, elevation of the affected part and immobilization, the part 
 being kept warm by a wrapping of cotton, or the additional 
 heat of an electric pad. Phlebitis may be associated with or 
 followed by thrombosis. 
 
 Thrombosis. — This may follow in the path of a phlebitis,, 
 and simply means the occlusion of the lumen of the vein with 
 a blood clot. The same condition may occur in arteries. The 
 symptoms are practically those of a phlebitis. The danger of 
 these cases lies not so much in thrombosis itself, but the fact 
 that these thrombi may give rise to small particles of blood 
 clots (emboli) which invade the blood stream and localize in 
 any part of the body. The symptoms and physical signs depend 
 on the area in which these emboli have lodged. If it should 
 localize in the brain, paralysis might ensue; if in the central 
 artery of the retina, blindness ; if within the coronary artery 
 of the heart, immediate death. A glance at these possibilities 
 is certainly proof that a thrombosis is potentially a dangerous 
 operative complication. 
 
 Treatment. — The acute condition is treated practically the 
 same as a phlebitis, with the exception that the local applica- 
 tions vary, some using ice compresses over the veins, others 
 a 20 per cent, ichthyol ointment, some the electric pad. All sur- 
 geons believe in absolute rest of the part involved. It is a 
 good practice to keep the weight of the bed clothing away 
 from the affected area, by means of a wooden or metal cradle. 
 When all the acute inflammation has subsided, the patient 
 should not be allowed up and out of bed until a good firm pres- 
 sure bandage has been applied. In a leg case, the bandage 
 
36 TEXTBOOK OF SURGICAL NURSING 
 
 is -wouud from the ankle upward to the knee. The patient 
 should be warned that even after leaving the hospital, or home, 
 that a rubber .storking jiroperly fitted should be Avorn for a 
 long period of time. 
 
 Of course when this condition involves the superficial veins 
 it is not so very serious, but it has been known to choke off 
 the femoral artery, the main channel through which the lower 
 extremity gets its supply of blood. This might result in 
 gangrene with subsequent amputation of the leg and thigh. 
 These severe post-operative complications are fortunately rather 
 rare. 
 
 Hemophilia. — As science progresses new discoveries are 
 made and some certain operative complications may be pre- 
 vented b}' prophylactic measures. A disease no longer dreaded 
 is hemophilia (a condition marked by a tendency to persistent 
 bleeding). It would never occur if routine coagulation times 
 were done on all patients before they entered the operating 
 room. Blood usually clots in seven minutes and if the period 
 of clotting is beyond eight minutes, measures should be insti- 
 tuted to insure the clotting of the blood in a shorter j)eriod. 
 There are many conditions which interfere with the normal 
 clotting of blood, but one of the most interesting of these is 
 hemophilia. It is a malady which is transmitted by the female 
 to the male, although rare instances have been reported where 
 women, too, are the sufferers. In this disease, blood does not 
 clot often until 15-20 minutes. Jaundice is another condition 
 which hinders the clotting of the blood. In hemophilia and 
 jaundice and in all cases in which the clotting time is delayed 
 methods must be taken to lower the coagulation time to within 
 normal limits. 
 
 Treatment. — Before operation those patients with a pro- 
 longed coagulation time should be given calcium lactate, gr. 15, 
 three times a day, in milk. If at the end of three days, the 
 coagulation time has not been materially reduced, they should 
 be given about from 15 to 30 c.c. of horse serum intravenously. 
 This is very valuable in lowering the coagulation time. Be- 
 fore the administration of horse serum, the patient should be 
 carefully tested by the injection of minute doses of horse serum 
 
POST-OPERATIVE COMPLICATIONS 37 
 
 into the skin to determine whether the individual is sensitive 
 to it. Patients who have recently had those diseases in which 
 horse serum is used as a curative agent, as in diphtheria anti- 
 toxin or anti-meningococcus serum, have a peculiar idiosyncrasy 
 to it, so that if this serum is given again, a condition of "an- 
 aphylaxis" may result. 
 
 Anaphylaxis has been defined as "the increased susceptibility 
 to an infection or the action of any foreign substance intro- 
 duced into the body following a primary infection." This con- 
 dition is indeed serious, manifesting itself by a sudden, labored 
 respiration, rapid pulse, cyanosis and the appearance of large 
 red cutaneous blotches, or urticaria. Death has been known 
 to occur within a few minutes. If this condition should re- 
 sult, it is best treated by the administration of atropine hypo- 
 dermically, or adrenalin, minims 15. The elimination should be 
 further promoted by colon irrigations. 
 
 Recent investigations have proved that patients with delayed 
 clotting time are often improved by ante-operative transfusions 
 of human blood. The blood of the patient should be tested 
 first for the particular group into which it falls, and then a 
 transfusion of blood from a donor whose blood group is the 
 same as that of the patient should be given. (This is described in 
 Chapter II.) 
 
CHAPTER IV 
 
 THE SURGERY AND SURGICAL NURSING OF THE 
 AlilMENTARY SYSTEM 
 
 Introduction. — In this and the following Chapters V to XI 
 of surgical conditions involving the systems of the body, the 
 various pre-operative and post-operative nursing measures which 
 are peculiar to the individual case at hand will be indicated, 
 but no standard routine courses of treatment can be reasonably 
 prescribed because every surgeon will have his own. These will 
 necessarily vary from time to time in accordance with differ- 
 ences in patients, operative procedures, general conditions, etc. 
 However, in Chapter XIII, under the subject of "Anesthesia," 
 and in Chapter XVI, under "The Operating Room," there are 
 recorded representative practices which, with what is given 
 here, will give the student the framework for surgical nursing. 
 
 Before considering the surgery of the Alimentary System, a 
 brief review of those organs which constitute it may be instruc- 
 tive. 
 
 I. Organs of the Alimentary Canal: 
 
 1. Mouth 
 
 2. Pharynx 
 
 (1) Tonsils 
 
 (2) Adenoids 
 
 3. Esophagus 
 
 4. Stomach 
 
 5. Small Intestine 
 
 (1) Duodenum 
 
 (2) Jejunum 
 
 (3) Ileum 
 
 6. Large Intestine 
 
 (1) Cecum and appendix 
 
 (2) Colon 
 
 a. ascending 
 h. transverse 
 c. descending 
 38 
 
NURSING OF THE ALIMENTARY SYSTEM 39 
 
 (3) Sigmoid Flexure 
 
 (4) Rectum 
 
 (5) Anus 
 
 II. AccKSSORY Organs op Digestion ; 
 
 1. Teeth 
 
 2. Tongue 
 
 3. Salivary Glands 
 
 (1) Parotid 
 
 (2) Submaxillary 
 
 (3) Sublingual 
 
 4. Pancreas 
 
 5. Liver and Gall Bladder 
 
 The Mouth. — The mouth is of special interest because it 
 comprises part of the operative field of the upper and lower 
 jaws, and the tongue ; it is the path through which the tonsils and 
 the adenoids are approached; and the means by which the 
 trachea and esophagus are entered. Its main importance from 
 a surgical standpoint is that it can never be rendered sterile, 
 so that all the operations on the afore-mentioned organs must 
 of necessity be contaminated. Even though the work is done 
 in a contaminated field, the same aseptic surgery should be prac- 
 tised here as is practised in other regions. 
 
 This fact should not deter the nurse from getting the mouth 
 as clean as possible for the operation. It is usual to have the 
 patient wash the buccal cavity every two hours with some 
 liquid, either warm saline, or water to which has been added 
 one of the countless pleasant-tasting antiseptics which are in 
 everyday use. This should be begun about two days prior 
 to the operation. It is imperative that mouth washing should be 
 done thoroughly. The nurse should not content herself by 
 simply informing the patient that the mouth is to be washed, 
 but she should stand by and see that it is efficiently done. 
 In addition, the teeth should be carefully brushed at least after 
 each meal. If pyorrhea exists, the teeth should be scraped and 
 the gums treated by a dentist. In this way the amount of mouth 
 contamination may be reduced to the minimum. 
 
 The inflammatory affections of the jaws, such as inflamma- 
 tion of the gums, or gingivitis, or pyorrhea alveolaris, need 
 
40 TEXTBOOK OF SURGICAL NURSING 
 
 no special meutiou licre. But the new growths of the jaws, 
 either benign or malignant, form a very important chapter in 
 surgery because they may necessitate a resection of either the 
 ni^pcr or lower maxilla}. 
 
 Tlie Jaws. — The jaw may be the seat of a varietj^ of tumor 
 formations: — (1) Cysts arising from some abnormality in the 
 development of the teeth; (2) non-malignant growths, or epulis; 
 and (3) malignant growtlis. 
 
 Treatment of New Growths of the Jaws. — If the cysts are 
 small, they are removed and the membrane wliie-li lines the 
 cavity is destroyed. If necessary, the cavity is packed and the 
 wound permitted to heal by granulation tissue. The only treat- 
 ment is to keep the mouth clean. 
 
 In the case of benign tumors, the tooth about which the tumor 
 grows is removed and with it a portion of the bone. The 
 removal is accomplished by a Gigli saw. It is always con- 
 venient to have at hand an actual cautery or Horsley's wax 
 to control the hemorrhage which may ensue from the bone. 
 
 The cases of malignant growths, either carcinomas or sarco- 
 mas, demand radical operation. In the case of the upper jaw 
 this is not so practical because, Avith the removal of the bone, 
 the eyeball loses its support and drops from its normal 
 anatomical position resulting in ' a condition of double vision 
 or diplopia ; and, by removing the hard palate, a communication 
 is made between the nose and mouth. However, in spite of these 
 two obstacles, the operation is occasionally done. 
 
 The removal of the lower jaw, however, is not so difficult; 
 it may be removed either partially or in its entirety. The 
 actual operative technic is more of interest to the surgeon than 
 the nurse and will not be discussed here. The nursing pro- 
 cedures are the same as for any radical operation on either 
 the upper or lower jaw. 
 
 Ante-operative Treatment. — As has been mentioned previ- 
 ously, the mouth should be cleansed very carefully. The opera- 
 tive field, in the male, should be prepared by shaving an hour 
 before the operation, as the beard sometimes grows very rapidly 
 and nothing is more disagreeable than to have the patient enter 
 the operating room not properly prepared. 
 
NURSING OF THE ALIMENTARY SYSTEM 41 
 
 Operation. — The anesthesia is given by intratracheal in- 
 sufflation, a method whereby the vaporized ether is forced into 
 the trachea through a catheter by means of a special apparatus. 
 With this method the anesthetist is removed far from the opera- 
 tive field and the surgeon is able to work undisturbed. The 
 head is draped as is shown in Fig. 82 (page 285). The instru- 
 ments for this operation are those used for any bone work. 
 
 Post-operative Treatment. — The packing, which is intro- 
 duced at operation into the area vacated by the maxilla, is 
 removed, as a rule, after twenty-four hours. The space left 
 by the removal of the upper jaw should be sprayed through 
 the mouth every two to three hours with some antiseptic solu- 
 tion. The patient, as soon as he is able, should wash his mouth 
 himself every two or three hours. For the first three days, it 
 is better not to give food by mouth; the nourishment is sup- 
 plied either by nutrient enemata, or by nasal gavage, the cathe- 
 ter being passed through the nostril on the sound side. As 
 soon as the wound granulates, the patient may be given a liquid 
 diet, the food always being introduced along the sound side 
 of the mouth. Great care should be taken that the mouth be 
 thoroughly cleansed after each feeding. Some surgeons re- 
 quest that the cavities be lightly packed with gauze during 
 feedings so as to prevent the liquid food from entering the 
 operative wound. This is not so important a procedure with 
 liquids as it is with soft diet, which is allowed after about 
 three weeks. It is unnecessary to confine the patient to bed any 
 longer than four days, provided that everything goes smoothly, 
 for needless confinement to bed often causes weakness. 
 
 The Tongue. — Those conditions which demand radical op- 
 erative procedure on the tongue are invariably due to malignant 
 disease, and may require that the tongue be removed in part, 
 halves or completely extirpated. Removal of the tongue (glos- 
 sectomy) is accompanied by a preliminary removal of the glands 
 of the submaxillary triangle and a ligation of the lingual artery 
 which supplies the tongue with blood. By ligating this artery 
 before a removal of the tongue is attempted, hemorrhage is very 
 markedly diminished at the time of the radical operation. 
 
 Ante-operative Preparation. — This consists of the usual 
 
42 TEXTBOOK OF SURGICAL NURSING 
 
 cleansing of the mouth as already outlmed in operations upon 
 the jaw. 
 
 Operation. — The anesthetic is administered intranasally. 
 The moiith is kept open by a self-retaining gag. A heavy silk 
 ligature should always be at hand for introduction through the 
 base of the tongue. This serves as a tractor, and even after 
 the tongue has been removed the ligature is left in place, the 
 free end being fastened either to the teeth, or identified b}'- 
 an attached pair of forceps that liang from the mouth. This 
 ligature should remain in place for at least twenty-four hours 
 after operation, for it is invaluable in controlling the base of 
 the tongue should any serious hemorrhage occur. 
 
 Post-operative Treatment. — In those conditions in which 
 either half or the entire tongue has been removed, the treat- 
 ment of the raw denuded surface of the floor of the mouth is 
 what most concerns us. The desideratum, of course, is to ren- 
 der this area aseptic. To attain this end, some operators use 
 balsam of Peru, which is applied as gently as pos.sible. The 
 dusting of iodoform powder is to be condemned, as iodine poison- 
 ing may result. Other surgeons prefer the use of mild anti- 
 septic sprays. 
 
 For about four days, the patient should be fed by enemata. 
 Each morning the bowels should be washed out with a soap- 
 suds enema followed by rectal feedings (Chapter XII) which 
 are given, as a rule, every four hours. If the patient is very 
 weak and emaciated, and demands more nourishment than can 
 be given by rectum, a small stomach tube may be passed through 
 the nostril into the stomach, and left in place. Some operators 
 prefer that the patient be fed directly by mouth; a soft rubber 
 catheter is passed along the normal side of the mouth permitting 
 the patient to swallow the liquids which are poured slowly 
 through the tube. Each feeding should be completed by the 
 administration of sterile water, and the tube withdrawn, after 
 which the mouth should be thoroughly cleansed. Soft diet may 
 be given as soon as the wound heals and swallowing without 
 difficulty is possible. The patient should be permitted to sit 
 up in bed as soon as possible, and so as to afford better drainage 
 to the secretions which collect in the mouth, the head should be 
 
NURSING OF THE ALIMENTARY SYSTEM 43 
 
 kept bent slightly forward. These cases may be allowed up from 
 bed on about the fourth day. 
 
 Treatment of Inoperable Cases. — While all patients suffering 
 from inoperable cancer are miserable, there are none who pre- 
 sent such a horrible spectacle as those with a large f ungating 
 growth of the tongue. Unable to swallow, finding difficulty in 
 breathing, suffering agonies, with an oral stench which is hardly 
 bearable for themselves or others associated with them, they 
 are entitled to all the sympathy possible. If nothing else can 
 be done for these unfortunates they may be kept absolutely 
 free from pain. The local pain is sometimes reduced by dust- 
 ing the ulcerated areas with orthoform powder. It is applied 
 before any food is taken. Morphine should be given liberally, 
 with a little atropine to prevent its depressing effects. The 
 foulness of the breath may be lessened by the continual use 
 of mouth washes and mouth irrigations. If dyspnea becomes 
 marked because of crowding of the larynx by growth, trache- 
 otomy may be necessary. If difficulty exists in swallowing, 
 rectal feeding may be given. Feeding by stomach tube or nasal 
 gavage is not practical, because the rubber tubes coming in 
 contact with the growths cause excruciating pain. Occasionally, 
 the proper use of radium and X-ray, in selected cases, will do 
 much to give relief where the knife of surgery has failed. 
 
 The Pharynx. — The pharynx is important surgically because 
 it lodges the tonsils and the posterior portion harbors the ade- 
 noids. As is known, the tonsils may be the seat of acute in- 
 flammation, and the bacteria may spread into the surrounding 
 tissues giving rise to what is popularly known as a quinsy sore 
 throat, or a peritonsillar abscess. 
 
 Treatment of a Peritonsillar Abscess. — Since this condition 
 is in reality an abscess formation, means should be taken to 
 cause a pointing of the abscess as soon as possible. With this 
 ultimate end, flaxseed poultices should be applied every two 
 hours to the side of the neck that is affected and warm throat 
 irrigations with a quart of saline at 105° should be given at 
 regular intervals. This will not only cause a localization of 
 the pus, but will be very comforting to the patient and re- 
 lieve much of the pain which accompanies this condition. The 
 
44 TEXTBOOK OF SURGICAL NURSING 
 
 abscess is opened by blunt, incision under local anesthesia and 
 the pus evacuated. The after treatment is simple, consisting 
 mainly of throat irrigations and antiseptic mouth washes to 
 relieve the oral fetoi- and promote drainage. 
 
 Tonsillectomy. — Tonsils are removed very often, both be- 
 cause of a diseased condit?3n and because of an increase in 
 size, or hypertrophy. As a rule the operation is attended with 
 very little risk and is performed nnder ether in cliildren, and 
 wdtli local anesthesia in adults. 
 
 Operative Treatment.- — Tlie patient, if a child, is placed un- 
 der ether anesthesia in the dorsal position and the mouth held 
 open by a self-retaining gag; an electric head lamp worn by 
 the surgeon supplies the light. The tonsils are removed by one 
 of several methods, either by blunt dissection with a Sinter 
 tonsillotome, or they are dissected out with scissors, and finally 
 enucleated with a snare. The hemorrhage is controlled by the 
 simple pressure of gauze sponges. If necessary, the bleeding 
 vessels may be tied, or a sponge with a piece of tape securely 
 attached may be left in the tonsillar fossa for twenty-four hours. 
 After the operation has been completed, to further stop bleed- 
 ing and cause the patient to regain consciousness as quickly 
 as possible, the neck and face are bathed with towels previously 
 soaked in ice water. 
 
 After Treatment. — ^While these cases are apt to ooze a little 
 after operation, careful watch should be kept on their pulse, 
 and if they are bleeding briskly, as evidenced by the constant 
 expectoration of bright red blood, or the vomiting of large 
 quantitiec of altered blood, the attending surgeon shoidd be 
 notified immediately, for cases of fatal hemorrhage have been 
 known to result. 
 
 The diet should be liquid, ice cream being given to children, 
 for the cold is gratifying to the throat, and the psychic effect 
 cheering to their depressed spirits, and, in addition, the cream 
 forms a protective layer to the denuded areas of the pharynx. 
 The patient is kept indoors for a day or two to prevent catch- 
 ing cold. 
 
 Adenoids. — Adenoids are removed either with a curette or 
 
NURSING OF THE ALIMENTARY SYSTEM 45 
 
 an adenotome. This operation requires no special treatment 
 beyond that already mentioned for tonsillectomy. 
 
 The Esophagus. — While the esophagus is as important as 
 any other structure of the body, its surgery is in its infancy 
 and the operations few in number. Those diseases which in- 
 terest the surgeon have very little need for a nurse, since what- 
 ever is done in the way of treatment is non-operative and per- 
 formed by the surgeon himself. 
 
 Diseases of the Esophagus. — The esophagus may be burned 
 by the passage through it of foreign substances, or injured by 
 the passage of foreign bodies. This will result in an ulceration 
 of the esophagus, with a resultant contracture and stricture, 
 making swallowing rather difficult. Of course, as in other lo- 
 cations, cancer may elect the esophagus, but since it involves 
 this organ at its lowermost portion just where it pierces the 
 diaphragm muscle, very little is done for it by active surgical 
 intervention. 
 
 Treatment. — If the esophagus has just been burned by acid, 
 then alkali must be given in the form of a solution of sodium 
 bicarbonate. If caustic alkali is the agent which has been 
 ingested, then a diluted vinegar solution is given to neutralize 
 the base. The stricture, resulting from the healing of the in- 
 jured area of esophagus is treated by the passing of esophageal 
 sounds, or bougies. These are passed at frequent intervals, 
 the diameter of the bougie being increased in size until the 
 esophagus has been dilated to normal. If the ulceration is very 
 widespread, the dilatation of the esophagus is impractical, and 
 because of its extensive nature, more radical procedures must be 
 adopted. 
 
 The patient being unable to swallow cannot be nourished 
 indefinitely by rectal enemata, so that an opening must be made 
 directly into the stomach. Through this fistula the food may 
 be introduced and the patient receive the proper nourishment 
 for his existence. This operation is known as gastrostomy 
 which is described in detail on page 46. 
 
 Foreign Bodies in the Esophagus. — The esophagus, as well 
 as the trachea and larynx, is often the resting place for swal- 
 lowed foreign bodies, such as coins, pins, etc. It is very im- 
 
46 TEXTBOOK OF SURGICAL NURSING 
 
 portaut to really asoortaiii that the patient has a foreign body, 
 aud the X-ray is a valuable aid in determining the presence 
 of many varieties. Some of these may be removed by special 
 instruments; for example, a coin-catcher, or by direct vision 
 through an esoi^hagoscope. If these bodies are of too great 
 a size to be easily dislodged and are caught fast in the cervical 
 region of the esophagus, the esophagus may be opened through 
 the neck, and the object extracted. The operation is spoken 
 of as esophagotomy. If the foreign body is close to the cardiac 
 portion of the esophagus it may be removed indirectly via the 
 stomach by a gastrostomy. 
 
 New Growths of the Esophagus. — While a resection of the 
 esophagus is sometimes performed for malignant stricture, the 
 mortality is so high and the results so uncertain that con- 
 servative rather than radical measures are invariably emploj^ed. 
 Most surgeons are content by introducing radium through an 
 esophagoscope into the esophagus and permitting the metal to 
 exert its rays upon the tumor cells and thus hinder their ex- 
 travagant multiplication. Occasionally surgeons perform a 
 gastrostomy^, so that the patient will not starve to death. 
 
 Gastrostomy. — When the esophagus is narrowed either by 
 a benign stricture, or carcinomatous tissue to such an extent 
 that feeding is practically imjDossible, a gastrostomy must be 
 performed to prevent the patient from starving. This is an op- 
 eration whereby a communication is established betv/een the 
 anterior surface of the stomach and the anterior abdominal 
 wall. Through this gastric fistula, fluid may be introduced, the 
 patient, in this fashion, being given nourishment without the 
 food actually entering the esophagus. There are different types 
 of operations done but they all are essentially the same : they 
 vary in their technic. 
 
 Ante-operative Treatment.^ — The abdomen is prepared in the 
 usual manner. Inasmuch as these patients are very emaciated 
 and weak, the operation is performed under local anesthesia, 
 preliminary^ to which morphine gr. I/4 with atropine gr. 1/150 
 is given hypodermatically. 
 
 Operation. — The abdomen is opened by a left rectus in- 
 cision, the stomach found, and packed off from the rest of the 
 
NURSING OF THE ALIMENTARY SYSTEM 47 
 
 abdominal cavity with hot saline pads. A small opening is 
 made into the stomach and a sterilized catheter is introduced 
 into its interior. The further burying of the catheter within 
 the stomach, so as to prevent regurgitation of stomach contents 
 through the fistula, is one of technical detail. The peritoneum 
 is then narrowed and a few sutures are taken approximating it 
 to the stomach, so that this organ is held firmly to the abdominal 
 wall. The catheter is brought out of the skin incision and 
 clamped. 
 
 After Treatment. — The patient is fed every four hours 
 through the catheter. A convenient way of doing this is to 
 connect it with a small funnel so that the fluids may be easily 
 poured into the stomach. The foods which may be given are 
 limited to those which can be made up into or dissolved in 
 fluids, and from six to ten ounces of liquids may be given at 
 a feeding. Their caloric value should always be estimated and 
 great care should be taken to see that the patient is given suffi- 
 cient food. Some surgeons permit their patients to chew 
 solid food for the taste and because a flow of gastric juice is 
 stimulated by the hormone *' secretin" of the saliva; but, 
 naturally, the patients are not permitted to swallow the food. 
 
 After the first few days the catheter should be removed and 
 changed daily, a fresh clean one always being ready for im- 
 mediate insertion. After the feeding the end of the tube should 
 be clamped so as to prevent leakage, and an abdominal binder 
 applied. In about two months' time the tube may be left out 
 of the stomach, and inserted at the feeding periods only. The 
 fistula in the interim may be covered with a piece of vase- 
 linated gauze, held in place by a binder. Patients should be 
 taught to insert their own tubes, the method of feeding them- 
 selves, and the foods which may be taken. 
 
 It is highly important that the skin about a gastric fistula 
 be kept scrupulously clean. Should gastric contents leak either 
 from or around the tube, the skin should be washed immedi- 
 ately and covered with some bland non-irritating ointment, 
 such as Beck's paste or vaseline. If this is not done, the gastric 
 juice will digest the skin and a painful ulcerated area about 
 the tube may result. 
 
48 TEXTBOOK OF SURGICAL NURSING 
 
 The Stomach. — The tiurgery of the stomach i'oriiLs one of 
 the most brilliant and important chapters in general abdominal 
 surgery, for each year brings new gastric operations Avith a more 
 refined teclmic. 
 
 Operations upon the stomach, or, in fact, any part of the 
 intestinal tract, introduce an element which is of great im- 
 portance from the standpoint of an operating nurse. The 
 operative field in a simple celiotomy (the opening of a peritoneal 
 cavity) is clean, and under normal conditions, free from all 
 bacteria. Yet the interior of the intestinal tract and colon, and, 
 to a slighter degree, the stomach, are swarming with bacteria. 
 Naturally, in those operations which necessitate an opening 
 into the stomach, intestines, or colon, a previously clean field 
 will be converted into a "dirty" one. However, by carefully 
 padding off the operative field from the rest of the peritoneal 
 cavity, and by later carefully discarding those instruments 
 (needles, ligatures, sponges, towels, etc.) which have come into 
 contact with the contaminated field, it is perfectly possible to 
 maintain the sterile toilet of the peritoneal cavity. This will 
 be discussed in greater detail subsequently. And it is upon the 
 nurses in the operating room that this routine and its observ- 
 ances are partially dependent. 
 
 Diseases of the Stomach. — The stomach may be subject to 
 various inflammations of the mucosa from a variety of causes. 
 These are considered under the general heading of gastritis. 
 They are of little interest surgically. The affections of the 
 stomach which demand surgical treatment are those of gastric 
 ulcer and gastric carcinoma. 
 
 Gastric Ulcer. — Gastric ulcer starts as an erosion of the 
 mucosa of the stomach, the ulceration gradually extending 
 deeper, at times eating its way through the muscular and serous 
 coats of the stomach causing a communication between the in- 
 terior of the stomach and the general peritoneal cavity. The 
 ulcer in itself is not so serious but by growing it may open a 
 blood vessel, causing a gastric hemorrhage (hematemesis). Or 
 the scar tissue which follows in the path of a healing ulcer may 
 interfere with the gastric functions by creating various de- 
 formities of the stomach. This is especially true when the ulcer 
 
NUESING OF THE ALIMENTARY SYSTEM 49 
 
 occurs in the region of the pylorus; subsequent healing of an 
 ulcer in this location may result in a narrowing or stenosis 
 of the pyloric orifice. The third danger already mentioned is 
 that of perforation, through which the gastric contents are 
 emptied into the general peritoneal cavity resulting in a 
 peritonitis. 
 
 The symptoms of gastric ulcer, in brief, are epigastric pain, 
 vomiting, and bleeding. Although the last is one of the 
 most persistent signs of gastric ulcer it may be absent. Exami- 
 nation of the stomach contents may show an increase in the 
 amount of free hydrochloric acid and the presence of blood. 
 X-ray examination with a bismuth meal may reveal an irregu- 
 larity in the outline of the stomach, indicative of ulcer. 
 
 Treatment of Gastric Ulcer. — The treatment is both medical 
 and surgical. The latter only will be discussed here. Surgical 
 treatment is employed w^hen (1) medical treatment has given 
 little relief, (2) when perforation of the ulcer has occurred, 
 (3) -when perforation has resulted in the formation of an ab- 
 scess, or (4) when the pylorus has become stenosed. 
 
 The treatment of the chronic cases is to short-circuit the food 
 contents from the stomach to the jejunum directly, instead of 
 first passing through the pyloris and duodenum. This will per- 
 mit the ulcer to heal by giving the pyloric portion of the stom- 
 ach a functional rest ; and, in those cases of pyloric constric- 
 tion, the food will now have a free exit through the new opening. 
 The establishment of a new opening in the stomach aad attach- 
 ment to it of the intestine is known as gastroenterostomy. The 
 jejunum may be attached to either the anterior or posterior 
 surface of the stomach, resulting in either an anterior or pos- 
 terior gastrojejunostomy. 
 
 Gastroenterostomy. — Ante-operative Treatment. — In chronic 
 cases of ulcer of the stomach prior to the time of operation, fluid 
 should be forced upon the patient so that there will be a re- 
 serve amount in the tissues. An hour before operation the 
 stomach is washed. Great care should be taken that the return 
 flow is absolutely clear at the completion of the treatment and 
 that none of the lavaging fluid is left within the viscus. 
 
 Operative Treatment. — The operation itself will be briefly 
 
50 TEXTBOOK OF SURGICAL NURSING 
 
 outlined demonstrating the manner in which the sterility of 
 the peritoneal cavity can be maintained although the stomach 
 and jejunum have been opened and the field contaminated. 
 After the skin incision has been made, some surgeons clamp 
 sheets to the subcutaneous tissues. The incision is then deep- 
 ened through the fascia and muscles, the peritoneum opened, and 
 the stomach and the jejunum delivered into the wound. The 
 jejunum is stripped free of its fecal content, and an intestinal 
 clamp with rubber-covered blades applied lengthwise. The 
 stomach is clamped in a similar manner. The immediate opera- 
 tive field is padded off with hot gauze pads and the surround- 
 ing sheets are further protected with additional towels. The 
 stomach and jejunum are then brought into proximity by an 
 approximating Gushing suture, using Pagenstecher linen thread 
 on a straight round needle. This suture should be sufficiently 
 long to completely encircle the stoma between the stomach and 
 intestines. The needle and thread are protected with gauze 
 for the time being. The stomach and intestine are now ready 
 to be opened. From now on until a sterile field is reestab- 
 lished everything contaminated from contact with the open gut 
 should be placed on a tray provided for dirty instruments. The 
 surgeon and his assistants must not touch anything on the 
 clean instrument table, and the sterile nurse must avoid touch- 
 ing with her gloved hands anything that has come into con- 
 tact with the contaminated operative field. After the redundant 
 mucous membrane has been trimmed, the mucous coat of the 
 stomach is ready to be united to the contiguous mucous coat 
 of the jejunum. This is accomplished with through-and-through 
 lock stitch using number or 1 chromic catgut on a round 
 straight needle for one-half the circumference of the opening, 
 a through-and-through Gushing stitch completing the closure. 
 The contaminated field is now sealed off ; clamps, soiled gauze 
 pads, instruments and towels are removed and the gloves of the 
 surgeon and his assistants are either washed in bichloride or 
 exchanged for a new pair. The suture line is cleansed with 
 saline solution and fresh pads reapplied. The suture is re- 
 enforced with Gushing suture of Pagenstecher linen thread, 
 as a continuation of the original approximative linen suture. 
 
NURSING OF THE ALIMENTARY SYSTEM 51 
 
 After the opening of the transverse mesocolon has been sutured 
 around the union between the stomach and the jejunum with 
 interrupted number 1 plain catgut on a round curved needle, 
 the gut is washed with saline solution and fresh towels placed 
 about the operative field. The hands are again washed with 
 bichloride, the gut returned into the peritoneal cavity and the 
 abdomen closed. 
 
 This will give an idea of the great care which must be 
 taken throughout the operation to maintain strict asepsis, and 
 the nurse must be ever on the alert to see that the technic is 
 rigidly followed. 
 
 After Treatment. — There is some degree of shock following 
 this type of operation, and it is necessary to administer saline 
 hypodermatically, or by rectum by Murphy drip. The drip 
 should be kept on for about four hours and off for two. This 
 will prevent irritability of the rectal mucosa, and insure the 
 proper absorption of the fluid. But as soon as the patient is 
 receiving sufficient nourishment by mouth the drip may be dis- 
 continued. 
 
 "When the patient has recovered from the anesthesia, he 
 should be placed in Fowler's position (page 59), for this posi- 
 tion favors the passage of the ingested food through the new 
 opening, the gastroenterostomy stoma. Some surgeons are in 
 the habit of allowing fluids within a few hours after the anes- 
 thetic nausea and vomiting have disappeared. Water is given 
 in dram doses every hour, and if it is tolerated, after a few 
 feedings an ounce of peptonized milk is allowed every two 
 hours, alternating with water every two hours. This may be 
 followed on about the second or third day by an ordinary Len- 
 hartz diet. In some hospitals, a special gastroenterostomy diet 
 has been arranged for these patients. Outlines of these diets 
 will be found in Chapter XII. 
 
 Complications after Gastroenterostomy. — Hemorrhage. — Oc- 
 casionally, after the operation, the pulse may mount in fre- 
 quency and the patient exhibit all the clinical symptoms of 
 hemorrhage. This is evidence of gastric bleeding. The patient 
 should immediately be placed in , an upright position in bed, 
 and cold applied over the upper epigastrium by ice bags, ice 
 
52 TEXTBOOK OF SURGICAL NURSING 
 
 coils or cold compresses. Cold may be applied internally by 
 permitting the patient to swallow small pieces of cracked lee. 
 Adrenalin liytlroclilor'ule, 1-1000 may be given in saline solu- 
 tion by moutli to control the bleeding for its local action as a 
 vasoconstrictor is well known, and at times it is a very efficient 
 hemostatic. 
 
 Vomiting. — In spite of the fact that an operation has been 
 performed upon the stomach itself, the surgeon will order a 
 gastric lavage eighteen to twenty-four hours after operation if 
 the vomiting is persistent; this may be repeated as often as is 
 necessary. 
 
 Perforated Gastric Ulcer. — Ante-Operative Treatment. — 
 Patients sutfering from a perforation of a gastric ulcer have, as 
 a rule, a beginning peritonitis, and as they are more or less 
 in a condition of shock, it is advisable that before operation ^4 
 grain of morphine be given hypodermically. This will relieve to 
 a degree some of the intense cramp-like pains and will make the 
 inductive stage of anesthesia smoother so that the struggling is 
 less. If they are in a state of severe shock, a preliminary in- 
 fusion of about 550 c.c. of saline should be given. 
 
 Operation. — The abdomen is opened, the region about the 
 stomach carefully padded off: with moist hot pads and the per- 
 foration hunted for. When found, if practical, it is enclosed 
 and inverted with a purse string suture. A thorough lavage of 
 that region of the peritoneal cavity is performed by washing out 
 the upper abdomen with warm saline, sponging out the saline 
 or using an aspirator attached to a suction machine. Some op- 
 erators are accustomed to leave 500 c.c. of saline in the abdomen 
 before closing. The question of drainage is left to the dis- 
 cretion of the individual surgeon. 
 
 Post-operative Treatment. — As soon as possible the patient 
 is placed in the Fowler position, and if greatly shocked a clysis 
 is given, of 500 to 750 c.c. of saline. Some prefer the admin- 
 istration of saline by rectum, given by Murphy drip, four hours 
 on and two hours off. Feeding is begun after eight to twenty- 
 four hours, and the patient may be placed upon a Lenhartz 
 diet. As a matter of fact, treatment for this condition is almost 
 the same as that for a gastroenterostomy. 
 
NURSING OF THE ALIMENTARY SYSTEM 53 
 
 Cancer of Stomach. — The symptoms of wliich the patient will 
 complain are determined by the area in which the growth is 
 located. If it is near the cardiac end where it does not inter- 
 fere with the functions of the stomach there may be no symptoms 
 at all. If it is in the fundus of the stomach there may be pain, 
 vomiting, loss of weight and anemia. If it is in the pyloric 
 portion, these symptoms are duplicated and there is a greater 
 tendency to vomit because of the obstruction. Examination 
 of the stomach contents in these cases may reveal a low acid 
 content, no free hydrochloric acid, and often the presence of 
 lactic acid. X-ray examination is sometimes a valuable aid to 
 diagnosis, and, occasionally, the tumor mass may be felt in 
 the upper abdomen in the position of the stomach. 
 
 Surgical Treatment of Cancer of Stomach.-^The only hope 
 in cases of gastric cancer is partial or complete excision of the 
 stomach (gastrectomy). The operation is rather shocking and 
 the mortality is high. The technic for operation and the post- 
 operative care are practically the same as that already described 
 in the treatment of gastric ulcer. 
 
 Treatment of Duodenal Ulcer. — This is practically the same 
 as the treatment for gastric ulcer. 
 
 Surgical Conditions of Intestines. — There are many diseases 
 affecting the intestines but the interesting ones from a surgi- 
 cal standpoint are those resulting in perforations and new 
 growths. The intestines may be the seat of perforation as the 
 result of typhoid, or tuberculous ulcers, or they may be torn 
 by some traumatic condition resulting from a stab or bullet 
 wound. The symptoms are those of peritonitis. The operation 
 at first is in the nature of an exploratory laparotomy. A search 
 is made for the injured intestine and when found the wound, 
 if small, is closed by a purse string suture. If the wounds are 
 multiple, it may be necessary that that part of the intestine 
 be resected, and the two open ends of the gut which have re- 
 sulted may then be joined together by what is known as an end- 
 to-end, end-to-side, or side-to-side anastomosis (Fig. 6, A, B, 
 & C). Resection is also employed in conditions of intestinal 
 growths, either benign or malignant. 
 
 If the condition of the patient is too poor to warrant the 
 
54 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 time necessary to anastomose the intestines -with suture, a Mur- 
 phj^ button may be employed (Fig. 6, D), This is a perforated 
 metal button consisting of two halves. One half is introduced 
 into one ojien end of the intestine and the intestine drawn over 
 it by suture. The other half is inserted into the other open 
 end of the gut. The two parts of the button are then locked 
 together, thus anastomosing the walls of the intestine. The 
 
 Fig. 6. — Types of Intestinal Anastomoses. A, end to end; B, side to 
 side; C, end to side; D, end to end by Murphy button. 
 
 button eventually passes along the intestine after the union 
 between the bowel segments has become firm. 
 
 Post-operative Treatment. — Operations upon the intestines 
 require the same care practically as that folloAving operations 
 upon the stomach, except that cathartics by mouth should not be 
 given too early, and, when one is given, a mild cathartic rather 
 than a severe purgative should be prescribed. While the pa- 
 tient should be kept free from pain, too much morphine should 
 not be administered, for there is always danger of intestinal 
 paresis due to overdosage of this powerful hypnotic. Should 
 
NURSING OF THE ALIMENTARY SYSTEM 55 
 
 the patient become distended, an irritative enema should be ad- 
 ministered, and after the fourth day coh)n irrigations may 
 be employed without any danger. If a Murphy button has 
 been used for anastomosis, all stools should be examined for the 
 presence of the button, and its passage should be immediately 
 reported. 
 
 Intestinal Obstruction. — This is a condition in which the 
 normal passage through the intestinal tract is interfered with, 
 either partially or completely. The symptoms naturally will 
 vary according to the locality of the obstruction. If it is high 
 up, near the duodenum, vomiting is an early symptom; if low 
 in the ileum, distention is more marked. 
 
 Treatment. — Immediately after a diagnosis of intestinal ob- 
 struction, an exploratory celiotomy is performed with the hope 
 of finding the cause of the obstruction and relieving it. 
 
 Ante-operative Treatment. — In all cases of intestinal ob- 
 struction it is very essential that the stomach be washed just 
 before giving the anesthetic. This will save a great deal of 
 annoyance later, because the danger of aspirating the foul ma- 
 terials stored in the stomach is reduced to the minimum. If 
 the patient is very weak or greatly shocked it is advisable to 
 adininister the clysis of saline either before the operation or at 
 the same time the operation is being performed. 
 
 Operation. — Inasmuch as the actual surgical conditions in 
 most cases of intestinal obstruction are not diagnosed until 
 the operation, the operating room nurse should be ready at 
 a moment's notice for anything from an enterostomy to an ex- 
 tensive resection. Since these operations demand a complete 
 exploration, there should always be on hand plenty of pads 
 and hot saline to care for the intestines as they are brought out 
 from the peritoneal cavity. If, after the obstructive element 
 has been found and removed, the distention is still great to the 
 point of paralysis of the smooth muscle of the intestine, an 
 enterostomy might be performed. This is an incision into the 
 bowel for the purpose of inserting therein an L-shaped glass 
 tube known as a Paul's tube, or a simple rubber one. The open 
 end of the glass is connected with rubber tubing which drains 
 into a bottle provided for the escape of the intestinal contents. 
 
56 TEXTBOOK OF SURGICAL NURSING 
 
 This operation practically amounts to the formation of an arti- 
 ficial anus. 
 
 Post-operative Treatment. — If an enterostomy has been 
 done, the treatment is the same as that prescribed following 
 intestinal injuries. If the tube has. been placed in a high por- 
 tion of the jejunum, peptonized milk, beaten egg and other nu- 
 tritive fluids may bo introduced through it via a catheter enter- 
 ing the descending loop of gut ; the original enterostomy tube 
 should be temporarily clamped after the feeding has been intro- 
 duced. It is very important that these cases should be given 
 plenty of fluid either hypodermically, rectally, or by infusion. 
 The skin about the enterostomy opening should be well protected 
 against the irritating influences of the intestinal contents either 
 by albolinated gauze or Beck's paste. 
 
 Intussusception. — This condition is a form of intestinal ob- 
 struction brought about by the telescoping of one portion of 
 the bowel into the other. The treatment, as a rule, is operative 
 entailing a reduction of the intussusception, or if the bowel is 
 gangrenous, a resection of the involved poi-tions. There is 
 nothing special in its nursing. 
 
 Appendicitis. — This is one of the most common operations 
 performed today, and the cases in which the nurse will be called 
 upon to assist may be divided into three great groups. 
 
 1. Interval or Chronic Appendicitis. 
 
 2. Acute Appendicitis without perforation. 
 
 3. Acute Appendicitis with perforation, 
 
 1. The Interval Appendix. — This is called an interval ap- 
 pendix because the operation is performed after an acute attack 
 has passed away and before another acute attack makes its 
 appearance. In other words, it is an acute appendix which has 
 subsided, or has become what may be termed a chronic appendix. 
 
 Symptoms. — These may vary tremendously from vague di- 
 gestive disturbances manifested by gaseous eruptions, pain and 
 flatulence, to definite pain localized in the right lower quadrant, 
 the usual anatomical position of the appendix. 
 
 Treatment. — After a definite diagnosis has been made, the 
 appendix is removed. The operation is termed appendicectomy. 
 
 Ante-operative Treatment. — The routine ante-operative 
 
NURSING OF THE ALIMENTARY SYSTEM 57 
 
 preparation which is described in Chapter XIII is given. The 
 operation is done under gas and oxygen, or gas and ether, or 
 it may be done under local anesthesia. 
 
 Operation. — The abdomen is usually opened by a "Mc- 
 Burney" or oblique incision, or a right rectus, or a vertical 
 incision. The appendix is usually delivered into the wound, 
 the mesentery is ligated with plain catgut and a purse string 
 suture of linen or Pagenstecher on a straight or curved 
 needle is introduced about the base of the appendix ; the base 
 is doubly clamped or ligated and a split pad placed about both 
 clamps. The appendix is then cut between the clamps or liga- 
 tures by means of a knife dipped in carbolic acid or by actual 
 cautery. For safety's sake, the stump is again cauterized or 
 carbolized. If the latter procedure is used, it is neutralized 
 with alcohol to prevent the carbolic from eating too deeply. All 
 the instruments coming into contact with the lumen of the 
 appendix are contaminated and should be placed in a separate 
 ''dirty " tray. The clamp is then removed ; the cauterized stump 
 is grasped with a small pair of forceps and buried by means of 
 a purse string suture. The hands are then washed in bichloride, 
 the towels changed, and a reinforcing figure-of-eight suture may 
 be taken. The abdomen is then closed in the usual manner. 
 
 Post-operative Treatment. — The patient is given a quarter 
 of a grain of morphine and 1/150 grain of atropine, if neces- 
 sary. As soon as the patient regains consciousness the gatch 
 is raised one notch. Water is allowed in sips about two hours 
 after the last vomiting, and the usual post-operative routine 
 begun. The sutures are generally removed on the seventh day, 
 and the patient alloM^ed out of bed on the ninth. The bowels are 
 moved on the second or third day by a dose of salts, followed 
 by an enema, if necessary. 
 
 Acute Appendicitis. — Rutherford Morrison states that there 
 would be no percentage of deaths from appendicitis if every 
 case commencing with acute pain and developing tenderness 
 and rigidity of the abdomen in the right lower quadrant with 
 a quickening of the pulse were operated upon within twelve 
 hours. This fact is of great importance. It is hard to impress 
 it upon the lay mind, but it is the duty of the nurse to instruct 
 
58 TEXTBOOK OF SURGICAL NURSING 
 
 the public upon this subject. Sudden pain in the right iliac 
 fossa with tenderness and slight fever accompanied by nausea 
 or vomiting point, as a rule, to acute appendicitis. 
 
 Treatment of Acute Appendicitis. — While most surgeons are 
 agreed tliat all cases of acute appendicitis should be operated 
 upon as soon as the diagnosis is made, there are some patients 
 who, in spite of all persuasion, refuse immediate operation. 
 Then again, when there is extensive pulmonary tuberculosis, 
 bad cardiovascular disease, or diabetes, the expectant treatment 
 might be followed. Of course this is dangerous. The family 
 should be warned of the consequences, and the patient carefully 
 watched. Blood counts should be taken often, and should the 
 pulse rate and the number of white blood cells increase, although 
 the temperature does not vary, an operation should be per- 
 formed, even if local anesthesia has to be resorted to. If the 
 non-operative treatment is to be pursued, the patient should be 
 put to bed, the knees flexed with a pillow underneath them and 
 ice bags applied to the abdomen. The bag should be left on for 
 two hours- and off for one. Nothing should be given by mouth 
 while there is vomiting. After the nausea has subsided, water 
 may be given in teaspoonful doses. This may be augmented 
 later by albumen water, milk and lime water, broths and meat 
 juices. Enemas should not be given promiscuously^, and if at 
 all, in small amounts and with great care. When the acute 
 symptoms have subsided a saline cathartic may be given by 
 mouth. 
 
 Ante- operative Treatment. — Fortunately, most of these cases 
 are generally operated upon as soon as the diagnosis is made. 
 Naturally no cathartic is ever given by mouth, but, if the patient 
 is in good condition, the lower bowel may be cleaned by a soap- 
 suds enema. This does much to render post-operative recovery 
 smooth and uneventful. 
 
 Operation.- -The procedure is the same as that in interval 
 appendicitis and if the appendix has not ruptured, the abdomen 
 is sewed tightly without drainage. 
 
 Post-operative Treatment. — The treatment is identical with 
 that prescribed for interval appendicitis, except that occasionally 
 eight ounces of tap water might be administered by rectum and 
 
NURSING OF THE ALIMENTARY SYSTEM 59 
 
 the patient ordered in Fowler's position if there was free fluid in 
 the pelvis. (The Fowler position is a semi-erect position obtained 
 by either elevating the head of the bed and flexing the knees 
 with a pillow or by adjusting the gatch bed.) A cathartic is 
 generally given on the third or fourth day. If everything pro- 
 gresses smoothly the patient is allowed up on the ninth day. 
 
 Acute Appendicitis with Perforation. — This is a condition of 
 acute appendicitis complicated by a perforation which either 
 forms an abscess about the appendix or results in a diffuse 
 spreading infection of the peritoneum (peritonitis). The 
 symptoms are those of acute appendicitis, only more severe. 
 
 Ante-operative Treatment. — The treatment is the same as 
 that which has been outlined for acute appendicitis. 
 
 Operative Treatment. — The appendix is removed and the 
 stump inverted whenever possible. The abscess cavity is freed 
 of its pus, and a drain is introduced into the cavity or into 
 the lower pelvis. The drainage material may be any one of 
 the substances discussed on page 310, Chapter XVII. 
 
 Post-operative Treatment. — The treatment is similar to that 
 of acute appendicitis, except that the patient is usually more 
 ■acutely ill, and occasionally shocked. The patient is placed in 
 Fowler's position and saline is given liberally by Murphy drip. 
 Dressings are generally done daily. The patient is kept in bed 
 until the drainage tube has been removed and the wound is prac- 
 tically healed. 
 
 Complications. — The complications apt to occur are those 
 which follow any abdominal operation for peritonitis. Those 
 cases in which there is a persistently high temperature and an 
 increased leukocyte count should make one suspect a secondary 
 abscess. If a mass is felt through the rectum, definite proof 
 of a secondary pelvic abscess is established. This condition 
 does not always demand operation to establish drainage of the 
 abscess, as in some cases the mass might be absorbed by efficient 
 hot colon irrigations given at four-hour intervals. 
 
 Occasionally a dressing which has been previously pussy, may 
 be covered with blood. This is evidence of a secondary hem- 
 orrhage. The attending surgeon should be called without any 
 
60 TEXTBOOK OF SURGICAL NURSING 
 
 loss of time, and tlie wound packed temporarily to control the 
 bleeding. The bleeding vessel is then sought and ligated. 
 
 Now and then, quite soon after operation, the dressing may 
 be covered Avith feces; a sign that the dreaded complication of 
 fecal fistula has occurred. All drainage tubes are removed, and 
 the wound is treated as any enterostomy or colostomy. Dressings 
 are changed at frequent intervals, and the skin is protected and 
 kept scrupulously clean. Fortunately, most of these cases heal 
 eventually, although convalescence is long and protracted. 
 
 Recentl}'^, cases of appendicular abscesses have been treated 
 by the Carrel-Dakin method. The tcchnic of its administration 
 is described in Chapter XIX. 
 
 The Colon. — AVithin recent years the surgery of the colon 
 has made tremendous strides because of the attention drawn to 
 it by the much discussed topic of colonic stasis and its relation- 
 ship to autointoxication. While many of the English surgeons 
 excise the colon in cases of obstinate and obdurate constipation, 
 complete or partial colectomy is done mainly for new growths 
 of the large intestine. In certain types of cases where an arti- 
 ficial anus has to be established as a preliminary measure, 
 colostomy is done, or the colostomy may be the only advisable 
 palliative measure for inoperable carcinoma. The surgery and 
 nursing entailed for colon cases is practically the same as that 
 for the intestinal variety both from the ante-operative and the 
 operative standpoint. The only difference is found in the post- 
 operative treatment ; all rectal medication should be omitted for 
 as great a period as is possible. 
 
 Colostomy. — A colostomy is an incision into the colon for 
 the purpose of short-circuiting the fecal contents and of estab- 
 lishing an artificial anus. The operation of colostomy is simple. 
 The desired part of the colon is brought into the wound, then a 
 glass tube is passed through the mesentery of the colon, so as 
 to prevent the colon from slipping back into the peritoneal cavity. 
 (Fig. 7.) The exposed colon is then sealed off from the peritoneal 
 cavity by suturing it to tlie parietal peritoneum. 
 
 Post-operative Treatment. — The colon is covered with vase- 
 linated gauze, and a sterile dressing applied. The patient is 
 
NURSING OF THE ALIMENTARY SYSTEM 
 
 61 
 
 ---£> 
 
 ----'/^ 
 
 \ 
 
 y 
 
 fed but little and to further constipate the patient a pill of 
 
 opium, grains 2, may be given for the first four or five days. 
 
 On about the third or fourth day the exposed loop of colon is 
 
 opened with the aid of an 
 
 actual cautery, establishing y^^-^ 
 
 the artificial anus. There are 
 
 several factors that are of 
 
 importance in caring for a 
 
 patient with a colostomy. If 
 
 possible, an attempt should 
 
 be made to regulate the move- 
 ment of the bowels and the 
 
 food given should be of a 
 
 constipating variety, so that 
 
 when the bowels move, the 
 
 movement should be hard 
 
 and formed, instead of loose 
 
 and diarrheal. The skin sur- 
 rounding the colostomy is 
 
 apt to become irritated. It 
 
 .should be protected by an 
 
 ointment of bismuth subnitrate and zinc oxide to which may be 
 
 added a little oil of eucalyptus. 
 
 If at any time, however, there is no movement from the arti- 
 ficial anus, and general distention is evident, there should be 
 no hesitancy in giving an enema through the 
 colostomy opening. It is not advisable to 
 give cathartics by mouth, espeeiall}" the saline 
 variety, for it should alw^a^'s be remembered 
 that these patients have practically no con- 
 trol of their bowel movements, and watery 
 stools cause a constant soiling of their dress- 
 ings. After a while the patient may wear 
 a colostomy bag, a rubber appliance which is 
 
 worn over the artificial anus to collect the feces. This is held 
 
 in place by straps. (Fig. 8.) 
 
 The Eectum. — Th.e important conditions from a surgical 
 
 standpoint occurring in or about the rectum are: (1) ischiorectal 
 
 Fig. 7. — Colostomy Before Being 
 Incised. A, glass rod passed through 
 mesentery of colon; B, exposed loop of 
 colon." 
 
 Fig, 8. — Colos- 
 tomy Bag. 
 
62 TEXTBOOK OF SURGICAL NURSING 
 
 abscess, (2) fistula in ano, (1^) lioiiiorrlioids, (4) caneer of 
 rectum. 
 
 Ischiorectal Abscess. — An abscess alxxit the rectum is like 
 an abscess in any other part of the body except that it niijiht 
 communicate with the rectum, and if not ti'eated properly a 
 fistula might result. Tliis is a tract connecting tlie skin and 
 rectum. For this reason it is always better to incise and drain 
 the abscess as soon as possible, packing the abscess cavity and 
 permitting it to granulate from the bottom. 
 
 Fistula in Ano. — This may be the result of a poorly treated 
 ischiorectal abscess. It is important in treating the fistula 
 that the tract be excised in its entirety by careful and complete 
 dissection. 
 
 Ante-operative Treatment. — A cathartic is given twenty- 
 four hours before operation, usually an ounce of castor oil. 
 Four hours before operation, the lower bowels should be thor- 
 oughly washed with a warm soapsuds enema. At least three 
 of these should be given. If the third return is not clear, more 
 enemata should be administered until the rectum is absolutely 
 cleansed. This rectal treatment should not be administered 
 just prior to operation, because much of the liquid material is 
 apt to be retained and the surgeon is hampered in his work by 
 the escape of rectal fluid. Some surgeons inject the fistulous 
 tract with a solution of methylene blue, a dye which colors the 
 tract making its ramifications evident. This may be done before 
 or after the anesthesia has been begun. 
 
 Operation. — Until the patient regains consciousness, the legs 
 should be tied together. In operations about the rectum, reten- 
 tion of urine is apt to result and great care should be taken lest 
 the bladder become distended. The diet should be constipating 
 and to further constipate the patient a pill containing opium is 
 given three times a day. The bowels should be moved upon 
 the fourth day, and, after the movement, the parts washed 
 with soap and warm water, and fresh packing introduced. The 
 packing must be changed each time the bowels move, if stained 
 with fecal material. The dressing of these cases is exceedingly 
 important. If the packing of the cavity is left to the nurse, she 
 should very conscientiously see that it is firmly and securely in- 
 
NURSING OF THE ALIMENTARY SYSTEM 63 
 
 trodueed into the depths of the granulating cavity. The proper 
 healing will do much to prevent a recurrence of the fistula. 
 
 Hemorrhoids. — Piles are simply dilated veins about the rec- 
 tum. They are divided into the internal variety (those situated 
 above the internal sphincter), and the external variety (beneath 
 the external sphincter). Piles may be a source of annoyance 
 by their protrusion, their bleeding, or the veins may become 
 inflamed and thrombosed. 
 
 Ante-operative Treatment. — The treatment does not differ 
 from that of an ischiorectal abscess. 
 
 Operative Treatment. — After the patient is anesthetized, the 
 sphincter ani is dilated manually as a preliminary step to the 
 operation. This gives a better exposure of the interior of the 
 rectum, and by paralyzing the sphincter, the after pain is less, 
 since the muscle about the rectum cannot contract. 
 
 The piles are removed by (1) simple excision, (2) clamp and 
 cautery, or (3) by ligating the pile-bearing area. After the op- 
 eration has been performed, some surgeons insert a rectal tube 
 around which has been wrapped two or three layers of vase- 
 linated iodoform gauze. The advantages of this are twofold: 
 it prevents hemorrhage and it enables the accumulated gas to 
 escape; but it has the great disadvantage of being rather pain- 
 ful and uncomfortable for the patient. 
 
 Post-operative Treatment. — The same measures are taken as 
 for an ischiorectal abscess, except that on the fourth day, when 
 the cathartic is given, immediately before the patient moves 
 the bowels, six ounces of warm olive oil are introduced into the 
 rectum through a tube. This softens the accumulated feces and 
 lubricates their passage. Following the movement of the bow- 
 els, the patient should be instructed to take Sitz baths, night and 
 morning. These are comforting and are very helpful in healing 
 the denuded areas about the rectum. For a period of two to 
 three weeks after operation, the patient should receive nightly 
 an ounce of licorice powder, as it is essential that the bowels 
 be kept soft and loose. The patient should be put on an anti- 
 constipation diet, a good example of which may be found in 
 Chapter XII on diets. 
 
 Complications. — The great danger in a hemorrhoid opera- 
 
64 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 tion is that of hemorrhage. If a patient begins to faint and to 
 show the signs of hemorrhage, even though no blood is visible 
 externally, -which miglit happen if a rectal tube is not inserted, 
 the attending surgeon should be immediately summoned. The 
 patient is placed under anesthesia, a tube "en chemise" is intro- 
 duced and the rectum firmly packed. A tube "en chemise" is 
 simply a rubber tube to the rectal end of which gauze is at- 
 tached. (Fig. 9.) It is inserted into the rectum and packing is 
 
 introduced between the tube 
 and gauze, thereby exerting 
 pressure on the bleeding area. 
 Sometimes the bleeding point 
 itself may be ligated. 
 
 Cancer of Rectum. — As in 
 other locations, cancer in this 
 region, provided it has not 
 progressed too far, demands 
 excision. The rectum may be 
 excised by way of several 
 routes, — by the perineal 
 route, the sacral, by the 
 vagina, through the abdomen, 
 or by a combination of these. 
 As a rule any excision of the 
 rectum is preceded by a pre- 
 liminary colostomy. The 
 technic of this has alreadj^ been described on page 60. 
 
 Excision of Rectum by Perineal Route. — The patient is 
 placed in the lithotomy position (see Fig. 72, page 277), the 
 anus is sewed up, and the rectum is dissected from the sur- 
 rounding tissues until the upper limit of the growth is reached, 
 and then it is excised. 
 
 Excision of Rectum by Sacral Route. — The patient is placed 
 in the Kraske, or reversed Trendelenburg position (see Fig. 
 70, page 276), and as a preliminary, the coccyx and a portion 
 of the sacrum are removed. This affords freer access to the 
 rectum, and the rectum is dissected freely and excised. 
 
 Excision of Rectum through the Vagina. — In this operation 
 
 .6 
 Fig. 9. — Tube "En Chemise. " A, 
 layer of gauze attached to rubber 
 tube B. 
 
NURSING OF THE ALIMENTARY SYSTEM 65 
 
 the posterior wall of the vagina is used as a means of attack 
 in delivering the rectum and excising it. 
 
 Excision of Rectum by Combined Method. — This oi)eration 
 consists of opening the abdomen and doing the operation as far 
 as possible from above, then closing the lower end of the bowel 
 temporarily and delivering the upper end of the bowel into the 
 wound to serve as a colostomy opening. The lower segment is 
 finally excised by the perineal route, or by one of its modifica- 
 tions. This entire operation may be performed at once, or in two 
 stages: a preliminary colostomy being done first, and the radi- 
 cal portion later. 
 
 None of the afore-mentioned operations call for any special 
 nursing. They are, however, attended with a great deal of 
 shock, and the nurse should be ever ready to institute those pro- 
 ceedings which she has learned to overcome this condition. 
 
 The Liver and Bile Ducts. — Certainly the most frequent af- 
 fection of the liver, and that one which most concerns the nurse 
 is that of gallstones (cholelithiasis). In this condition, the gall 
 bladder or any of the bile ducts of the liver may be the seat 
 of stones. It is true that these stones may lie in the gall bladder 
 and never cause any symptoms. But when the stone leaves the 
 gall bladder and becomes impacted or caught in some of the 
 ducts — for example, the cystic or common bile duct — symptoms 
 of gall bladder colic ensue. If the stone is impacted in a cystic 
 duct, the gall bladder may become slightly dilated with resulting 
 pain and tenderness in that region ; if the stone becomes im- 
 pacted in the common duct, inasmuch as the flow of bile is 
 impeded on its way to the intestine, there is jaundice which may 
 be very marked. As a result of the jaundice, and no passage 
 of bile into the intestine, the stools are white, clay colored, 
 and foul-smelling ; the urine is dark-brownish in color ; and the 
 skin is yellow, due to the deposition of the bile pigment in the 
 skin itself. 
 
 Medical Treatment. — During an attack of colic, the patient 
 is given large doses of morphine and placed in bed. Over the 
 region of the gall bladder it is advisable to place hot applica- 
 tions, either poultices or stupes. Following these attacks the 
 patient should have a light diet with the minimum amount of 
 
66 TEXTBOOK OF SURGICAL NURSING 
 
 fat. Intestinal elimination should be kept free by using salts, 
 especially sodium phosphate. There is a popular superstition 
 that consuming olive oil aids the free passage of gallstones. 
 This is very mucli exaggerated and without scientific foundation. 
 
 Operative Treatment. — Operative measures are employed 
 when there have been repeated attacks of colic, when the stone 
 has become impacted, or when the gall bladder is acutely in- 
 flamed or filled with pus. 
 
 Ante-operative Treatment. — The ante-operative treatment is 
 of extreme importance in jaundiced cases because jaundice is 
 one of the factors which prevents or delays the clotting of 
 blood. Naturally, pre-operative measures must be taken to 
 ensure a lowering of the coagulation time. This may be accom- 
 plished (previously mentioned in detail in Chapter III) by the 
 administration of calcium lactate, horse serum, or transfusion. 
 
 The position of the patient on the operating table is impor- 
 tant because the gall bladder and its passages lie deep within the 
 abdomen, and every effort must be made to make them as acces- 
 sible as possible. This is attained by placing the patient on the 
 table so that the gall bladder bridge may be elevated, thus forcing 
 the liver forward ; or a sandbag may be placed in the region of 
 the eleventh or twelfth ribs. Both methods yield good results. 
 (See Fig. 65, page 272.) 
 
 Operations. — The operations which may be performed upon 
 the gall bladder and its ducts are cholecystotomy, cholecystost- 
 omy, cholecystectomy, choledochotomy, and cholecystenterostomy. 
 
 Cholecystotomy. — This is an operation in which the gall 
 bladder is opened, the stones removed, and the original incision 
 in the gall bladder closed. It is not often performed because 
 the gall bladder generally requires drainage. 
 
 Cholecystostomy. — In this operation the gall bladder is not 
 removed, but it is drained; the drainage is placed into the 
 gall bladder itself by burying the tube with a purse string 
 suture. 
 
 Cholecystectomy. — This procedure is the most frequent; it 
 involves the removal of the gall bladder and the ligation of the 
 cystic duct and cystic artery. 
 
 Choledochotomy. — In those cases in which the stone lies 
 
NUESING OF THE ALIMENTARY SYSTEM 67 
 
 impacted in the common duct, the removal of the stone hy inci- 
 sion of the duct is spoken of as choledochotomy. This operation 
 entails drainage of the common bile duct. 
 
 Cholecystenter ostomy. — Sometimes the obstruction of the 
 common duct is such that it cannot be removed ; for example, 
 stricture of the duct, either benign or carcinomatous. If the 
 patient is suffering from intense jaundice, an attempt is made 
 to short-circuit the bile. This is done by establishing an 
 anastomosis between the gall bladder and the stomach or between 
 the gall bladder and the small intestines. This operation is 
 spoken of as cholegastrostomy or cholecystenterostomy. 
 
 Post-operative Treatment. — Operations in and about the gall 
 bladder are accompanied by a great deal of shock, and as most 
 operations involving the upper abdomen are attended by a 
 large percentage of pneumonias, all means must be taken to 
 insure perfect care of the patient, to prevent, him from being 
 chilled or caught in draughts. 
 
 In those cases in which the gall bladder is drained, or where 
 a cholecystotomy is performed, the end of the drainage tube 
 should be inserted into a bottle so that the bile may be col- 
 lected, its character observed, and the amount estimated. Oc- 
 casionally, bile will leak along the side of the drainage tube, 
 resulting in a general soaking and discoloration of the dressing. 
 If this discharge is very marked, the superficial layers of the 
 dressing may be removed and fresh compresses applied. 
 
 It is important that all urine should be examined closely for 
 the presence of bile, and that the stools be sent to the laboratory 
 to determine whether bile is present. While the gall bladder is 
 draining, the patient must be placed upon a diet which is poor 
 in fat, because the bile salts which aid in the saponification of 
 the fats are missing. 
 
 Surgical Conditions of the Liver. — The diseases which com- 
 monly involve the liver from a surgical standpoint are injuries 
 to the liver, abscesses of the liver and cin-hosis of the liver. 
 
 Injuries to the Liver. — The liver may be injured by direct 
 or indirect violence ; it may be torn, with an ensuing hemorrhage. 
 This must be treated by immediate laparotomy, packing the 
 tear with gauze, or by suturing the tear of the liver with mat- 
 
68 TEXTBOOK OF SURGICAL NURSING 
 
 tress sutures, employirig a round, non-cutting liver needle. The 
 suture material is usually ehromie eatgut. 
 
 Abscess of Liver. — This may be of pyogenic origin, or the 
 direct result of amebic dysentery. These abscesses may be 
 opened and drained directly through the abdomen, or if the 
 abscess is high, an operation may be performed through the 
 posterior lateral area of the chest. The parietal and visceral 
 pleura are sutured together, and after adhesions have taken 
 place, so as to seal off the pleural cavity, the liver is drained 
 through this area. In this way no pus flows through the abdomi- 
 nal or peritoneal cavity, or through the pleural cavity. This 
 operation is done in two stages: the first being a partial resec- 
 tion of the rib, with the suturing of the parietal and visceral 
 pleura ; the second is the drainage of the abscess through the 
 area of the adhesions. 
 
 Cirrhosis of Liver. — As this condition is associated with a 
 filling of the peritoneal cavity with fluid (ascites), and as it is 
 presumably due to an obstruction of the portal circulation, an 
 attempt is made to establish a collateral circulation by the Talma 
 operation ( omentopexy ) . 
 
 Twenty-four hours prior to operation, an ordinary paracente- 
 sis abdominalis is done. The patient is then operated upon, 
 and a portion of the omentum brought through the anterior 
 abdominal walls in the midline and sutured to the subcutaneous 
 tissues. In this way the omental veins will establish collateral 
 circulation with the internal mammary vein, thereby lessening 
 the strain of the portal system. 
 
 The one important factor in post-operative treatment is when 
 a patient strains, the abdomen should be firmly held so as to 
 prevent further evisceration of the abdominal contents along 
 with the omentum. 
 
 Surgical Conditions of the Pancreas. — The operations upon 
 the pancreas are very few in number. The only diseases which 
 need demand our attention are pancreatitis, either in chronic 
 or acute forms, and cancer of the head of the pancreas. In 
 inflammatory diseases of the pancreas, inasmuch as the bile is 
 supposed to be an irritating and causative factor, its flow is 
 short-circuited by draining the gall bladder (cholecystostomy). 
 
NUESING OF TI-IE ALIMENTARY SYSTEM 69 
 
 In the meanwhile the pancreas, free from the irritating effects 
 of bile, will gain a much needed rest, and the iniiammatory 
 process may subside. 
 
 Carcinoma of the head of the pancreas may encroach upon 
 the opening of the bile duct in the second portion of the duo- 
 denum causing intense jaundice. Inasmuch as new growths of 
 the pancreas cannot be excised without a terrific operative mor- 
 tality and disastrous after results, the only operation done to 
 relieve the unfortunate jaundice victims is that of drainage of 
 the gall bladder. The nursing procedures employed in these 
 cases are similar to those used in operations upon the gall 
 bladder. 
 
 Hernia. — A hernia, or rupture, may be defined as "the pro- 
 trusion of an organ or part of an organ or other structure 
 through the wall of the cavity normally containing it." The 
 rupture is named from the region in which it appears. There 
 are many locations where, because of certain mechanical weak- 
 nesses, hernia is quite common. It occurs very frequently in 
 the inguinal region. 
 
 Inguinal hernia is a form of rupture that occupies the in- 
 guinal canal either partly or entirely; if it occurs the condition 
 is spoken of as an indirect hernia. A hernia making its appear- 
 ance almost directly into the external abdominal ring is called 
 a direct hernia. 
 
 Under ordinary conditions, the contents of the hernial sac will 
 disappear into the abdominal cavity when the individual is at 
 rest, to reappear when the intra-abdominal pressure is in- 
 creased, as during coughing or arduous physical labors. A 
 hernia which disappears is known as reducible ; if because of 
 adhesions this does not occur it is irreducible. There are several 
 varieties of the irreducible group : Incarcerated, — a type of 
 obstructed hernia containing bowel in which the passage of fecal 
 material is arrested but the circulation of the intestine is unim- 
 paired. Strangulated, — a hernia in which not only the bowel 
 is obstructed but also the blood supply. If this condition is 
 not operated upon very soon after its incipiency a gangrene of 
 the obstructed loops of intestine will result. 
 
 Other varieties of hernia are femoral, which is a rupture in 
 
70 TEXTBOOK OF SURGICAL NURSING 
 
 the region of Seai"pe's triangle occurring through the femoral 
 ring; umbilical, which, is a protrusion through the abdominal 
 wall in the region of the umbilicus. Then there are hernias 
 which occur following operation, especially in those cases in 
 wliit'li tlie abdominal wall has become weakened. These are 
 known as post-operative hernias. 
 
 Occasionally, especially in children, the hernial sac may con- 
 tain the testicle ; this is known as a congenital hernia and always 
 accompanies an undescended testis. In this condition the tes- 
 ticle is not in the scrotum but within the abdomen or inguinal 
 canal. 
 
 Treatment. — Hernia may be treated conservatively with a 
 suitable apparatus or truss (an appliance made to exert pres- 
 sure over the hernial opening so as to keep the contents of the 
 sac reduced) but since the public are becoming educated to the 
 wonderful results obtained by surgeiy, it is most always treated 
 radically by operation. There are two important principles 
 underl3'ing all hernia operations : the obliteration of the hernial 
 sac, and the closure of the channel along which the hernia pro- 
 trudes. 
 
 Ante-operative Treatment. — The same ante-operative rou- 
 tine is employed as for all chronic cases (Chapter XIII). The 
 lower abdomen and genitals are shaved and a sterile dressing 
 is applied. Care must be taken that the external genitalia are 
 not painted with iodine. In the operating room', the operative 
 field is repainted with iodine, and the penis and scrotum are 
 enclosed in a sterile, wet bichloride towel. 
 
 Operation. — An incision is made over the external ring up- 
 ward along Poupart's ligament. The external ring is identified, 
 and the surgeon calls for a grooved director on which he cuts the 
 fascia of the external oblique. The sac is then identified, dis- 
 sected free, its base transfixed and ligated with catgut on a 
 curved needle. The repair of the hernia, "the closure of the 
 channel" is then performed, the suturing being done with 
 chromic catgut, kangaroo tendon, etc. A spica bandage (Fig. 
 143) in addition to adhesive plaster keeps the dressing in place. 
 A plaster spiea is often used in children where immobilization is 
 absolutely essential. If the child is very young, the spica may 
 
NURSING OF THE ALIMENTARY SYSTEM 71 
 
 be coated with shellac so as to render it impervious to urine 
 and feces. 
 
 Post-operative Treatment. — As soon as the patient reaches 
 the ward, a pillow is placed under the knees, and as soon as he 
 is conscious, a Bellevue bridge is applied across the thighs to 
 support the scrotum. 
 
 The cathartic is given on the second day and, as a rule, pa- 
 tients are kept in bed for two or more weeks. For the first 
 twenty-four hours catheterization may be necessary. 
 
 In cases of incarcerated and strangulated hernias after 
 the sac has been opened, the surgeon will cover the bowels 
 with moist warm saline towels for about ten minutes, and if 
 there is no evidence of real damage, and their color is good, 
 the intestines are reduced into the peritoneal cavity. If the 
 intestines are gangrenous, an intestinal resection will have to 
 be done. These cases are then treated like any other case of 
 intestinal resection. 
 
 In all cases of hernia it is very important to impress upon 
 the mind of the recently operated that for a few months, at 
 least, all physical exercise should be of the mildest kind, and 
 that any sudden strain must be avoided. 
 
CHAPTER V 
 
 THE SURGERY AND SURGICAL NURSING OF THE GLANDULAR 
 
 SYSTEM 
 
 In no other sj'stem -witliin recent years has the advance been 
 greater and the research more extensive than in the field of the 
 glands of internal secretion. It is true that we still know very 
 little concerning most of them. But possibly Mdthin the next 
 decade or so there will be great light shed upon the physiology 
 of those organs which either alone or in combination control 
 our physical and mental make-up. Glandular tissue has been 
 described as that tissue which has for its function the secre- 
 tion of certain substances. These may be of service to the body, 
 as the digestive juices, or they may be purely excremental in 
 nature, removing substances which are either poisonous or waste 
 in character. 
 
 Classification of Glands. — It is convenient to divide glands 
 into three groups: (1) those with ducts, (2) those without ducts 
 (the glands of internal secretion), and (3) those which are a 
 combination of (1) and (2). As examples of glands with a duct 
 there may be mentioned the liver, the largest gland in the body, 
 which secretes and excretes bile through the biliary duet; the 
 submaxillary glands, the mammary glands, the prostate, 
 sebaceous, sudoriferous, etc. Pure glands of internal secretion 
 may be represented by the pineal, the pituitary, the thyroid, the 
 parathyroid, and adrenal. Those glands which are both exter- 
 nal and internal in secretion are represented by the pancreas, the 
 ovary and the testis. 
 
 While the surgery of these glands is limited, probably those 
 deserving most of our attention are the liver and the bile ducts 
 which have been discussed under the gastrointestinal tract. 
 Chapter IV, the ovary and testis which are reviewed in Chap- 
 
 72 
 
NURSING OP THE GLANDULAR SYSTEM 73 
 
 ter VIII on the reproductive system, leaving for discussion here, 
 the pituitary and the thyroid. 
 
 Diseases of the Pituitary Gland. — The pituitary gland is 
 composed of an anterior and posterior lobe. It arises from the 
 forebrain and rests in the sella turcica of the sphenoid bone. 
 The function of the pituitary gland is probably concerned with 
 growth. Too much secretion or hyperpituitarism is a condition, 
 which, if it occurs before the ossification of the epiphyses, leads 
 to gigantism, and, when it occurs latei*, after the bones have 
 become full grown, is responsible for acromegaly. Too little 
 secretion of the pituitary body (hypopituitarism) in a growing 
 child leads to increased fat deposition in the tissues, dwarfism, 
 and poor development of the sexual organs. "When this occurs 
 in the adult it leads to adiposity and sexual retrogression. 
 
 Probably the eases which interest us most from the surgical 
 standpoint are those in which the pituitary gland is enlarged, 
 with the result that the patient complains of bitter headaches, 
 and a beginning blindness. This is often seen in the late stages 
 of acromegaly, a condition in which there is a progressive in- 
 crease in the size of the hands, feet, head, jaw, and the tissues 
 about the face. 
 
 Treatment. — Surgery endeavors to remove part of the 
 pituitary gland. This may be done either by removing part of 
 the body of the sphenoid bone via the nasal route, or by the 
 subtemporal path. There is no special nursing entailed. 
 
 Diseases of the Thyroid Gland. — The word goitre is familiar 
 to the lay mind, and even a layman distinguishes two types, — 
 the one in which there is simply an enlargement of the thyroid 
 gland, and the other in which there is enlargement complicated 
 by definite nervous symptoms. Just as in the pituitary, there 
 may be an increase or perversion of the thyroid secretion kno'\\ai 
 as hyperthyroidism, or there may be also a diminished secretion. 
 If it occurs before the age of puberty, or dates from birth, 
 cretinism results, or if it occurs in adult life, myxedema may 
 occur. 
 
 Cretinism. — These children have a diminished thyroid se- 
 cretion. As a rule they are fat and pudgy with coarse, sparse 
 hair, unable to walk, and have a subnormal temperature ; their 
 
74 TEXTBOOK OF SURGICAL NURSING 
 
 mentality is practically nil. Thyroid extract given to these 
 unfortunates often transforms them at least from an animal 
 stage to a point where they can protect themselves sufficiently 
 to exist. 
 
 Myxedema. — Very often patients in adult life begin to 
 show signs of mental sluggishness with a slow reaction time, 
 and their faces become coarse and mask-like. In other words, 
 they are somewhat like a cretin. Thyroid extract or any prep- 
 aration of the thyroid gland, given by mouth, helps these people 
 markedly. 
 
 Goitre. — Any enlargement of the thyroid gland that is 
 chronic in nature is spoken of as a goitre. There are certain 
 regions of the earth where this disease is common ; it is fre- 
 quently seen in some mountainous places of Germany, Austria, 
 France, Central Asia, Switzerland, and around the Great Lakes 
 in Michigan. It is thought to be due to some peculiar agent 
 found in the drinking water of these districts. The symptoms 
 which come from the goitre are mechanical, and result from 
 pressure of the enlarged gland upon those structures which it 
 might compress. From pressing on the wind pipe (trachea) 
 it may give rise to a cough, or it may cause difficulty in swallow- 
 ing, by pressure on the gullet (esophagus). 
 
 Treatment of Goitre. — Goitre may be treated medically or 
 surgically. Some cases respond to the internal administration 
 of potassium iodide. X-ray, when given in graduated doses, 
 sometimes reduces the size of the gland. But if the goitre is 
 large and the symptoms are aggravating and persistent, surgery 
 is practically the only measure which will afford relief. 
 
 Ante-operative Treatment. — On the morning of operation 
 the neck should be shaven, cleansed with green soap and water, 
 followed by alcohol and ether, and a sterile dressing applied. 
 
 Operation. — Gas and oxygen is the anesthetic of choice. 
 The patient is placed upon the back with a sandbag beneath 
 the shoulders so as to put the neck upon a slight stretch. (See 
 Fig. 85, page 289). In addition to the ordinary "set-up" of 
 instruments, in all operations upon the thyroid, it is essential 
 to have a tracheotomy outfit in readiness. For very often in 
 these operations, due to pressure upon the trachea, it collapses, 
 
NURSING OF THE GLANDULAR SYSTEM 75 
 
 and unless instant measures are instituted to relieve the strangu- 
 lation due to the closure of the trachea, death will readily ensue 
 because of asphyxiation. This horrible complication fortu- 
 nately is rare, but adequate preparation must always be made 
 to meet any emergency. Inasmuch as a few seconds will mean 
 the life or the death of a patient, everything should always be in 
 readiness for even this rarest of operative complications. 
 
 As there is bound to be a moderate amount of bleeding and 
 oozing from the tissues, a small cigarette drain is employed for 
 about 24 hours, and the ordinary sterile dressing is applied. 
 Since the line of incision in a goitre operation is quite visible 
 in the modern female, attempts are made to minimize the scar 
 as much as possible. To ensure perfect healing after operation 
 the neck is usually immobilized by means of starch bandages; 
 these form a very light and efficient means of restraining the 
 grosser motions of the neck. 
 
 Post-operative Care. — The patient should not be permitted 
 to talk any more than is necessary for at least a week. Atten- 
 tion should be paid to the character and tone of the voice. The 
 reason for this is obvious, when it is recalled that the nerves 
 which partially control the vocal chords lie close to the gland 
 and may have been injured or cut during the operation. 'This 
 is indeed a serious complication, because if they are cut it will 
 result in permanent alteration of the patient's voice. 
 
 It should also be remembered that occasionally patients run 
 a high temperature, rapid pulse, and may even be delirious. 
 The syndrome is often spoken of as acute thyroidism. This con- 
 dition should be treated with ice packs, but this will be dis- 
 cussed at greater length in the treatment of exophthalmic goitre. 
 
 Exophthalmic Goitre. — As a splendid example of what at- 
 tention to all details in an operation will do, nothing is more 
 striking than the reduction in the mortality of exophthalmic 
 goitre from sixteen per cent, to practically one per cent. This 
 has been made possible by the energetic researches of Dr. 
 George Crile. The factors which have caused this tremendous 
 drop have been the use of gas and oxygen as an anesthetic, 
 local anesthesia, multiple stage operation, coping with the men- 
 
76 TEXTBOOK OF SURGICAL NURSING 
 
 tal attitude, bringing the operation to the patient, and the 
 employment of the ice pack in eases of acute thyroidism. 
 
 Symptoms. — Patients with exophthalmic goitre as a rule are 
 recognized immediately by the fact that their eyes are promi- 
 nent and jirotrude, and that they are extremely nervous. Their 
 pulse rates vary from 90 to 120, and sometimes even higher. 
 In other words, they have what is called tachycardia. Their 
 skin as a rule is moist, and tliey perspire freely. A very definite 
 swelling of the thyroid gland is often visible. These symptoms 
 all point to a poisoning from either an increased amount, or a 
 perversion of the thyroid secretion. It does not take much 
 imagination to realize that, above all else, these patients need 
 peace and quiet. They are nervous to the extreme. Association 
 ■with others, incessant talking, and noises tend greatly to aggra- 
 vate them and increase their pulse rate. The keynote in the care 
 of these patients is rest under ideal surroundings and treatment 
 administered so tactfully and carefully that the shock to the 
 nervous system will be of the minimum. 
 
 Treatment. — Medical. — All cases of exophthalmic goitre 
 should, as a rule, be treated medically at first. The treatment 
 consists of rest in bed, complete isolation from society, a diet 
 of high caloric A-alue with forced feeding, and the administra- 
 tion of sodium bromide to relieve the intense nervous excitement. 
 Some physicians give iodine internally, and some use thyroid 
 extract. Detailed accounts of the medical nursing in these cases 
 may be found elsewhere. 
 
 Surgical. — It is in the surgical treatment of hyperthyroid- 
 ism that tremendous strides have been made. The patient at 
 present is not operated upon the day after she enters the hos- 
 pital. These highly nervous women are no longer subjected 
 to the terror of being ridden directly to the operating room and 
 arriving there with a pulse of 140 ; then, in their weakened 
 condition, subjected to ether anesthesia and a shocking operation, 
 with the result that having little stamina left, they usually 
 succumb within twenty-four hours after a partial thyroidectomy 
 has been attempted. 
 
 Ante-operative Treatment. — In the treatment of these cases 
 it cannot be emphasized too strongly that great tact and care 
 
NURSING OF THE GLANDULAR SYSTEM 77 
 
 should be utilized by the nurse in charge so as to gain the abso- 
 lute confidence of the patient. The room which the patient is 
 to occupy should be bright, well ventilated and airy, away from 
 all noise such as street cars, and busy corridors. The patient 
 should be kept continually in bed, not even being allowed lava- 
 tory privileges. The diet should be plentiful, an accurate ac- 
 count kept of the food ingested, and the caloric value figured 
 accurately, because it is imperative that these cases be given 
 5,000 calories or more of food a day. The patient should be 
 kept quiet on liberal dosage of bromides, even to the point of 
 bromidism. Visitors should be few, and their period of stay 
 limited. All depressing topics of conversation must be omitted. 
 Anything which would arouse the excitement of the patient, 
 such as dazzling headlines in the current newspapers, melodra- 
 matic stories, and trashy magazines, must not be permitted. 
 Since the slamming of windows and doors always causes a sudden 
 shock to the patient, great care should be taken to see that it is 
 not done. In other words, the medium in which the patient 
 lives must be calm, serene ana peaceful. 
 
 As soon as the patient has sufficiently recuperated from the 
 strangeiless of hospital surroundings, and the pulse rate has 
 fallen around 90, it is advisable to acquaint the patient with 
 the fact that she is to prepare for operation. The anesthetist 
 who is to give the anesthesia should be introduced ; he should 
 explain the operation of the gas mask, place it gently over the 
 patient's head, teach her how to breathe through it, aad just 
 what she is expected to do. He should visit her daily and re- 
 hearse the little act of psychologically anesthetizing the patient. 
 In the meanwhile the nurse should prepare the neck as if the 
 operation were really to be performed. The anesthetization of 
 the patient when possible should be done in her private room, 
 and as the patient has become accustomed to the anesthetist, 
 the mask and the preparation of the neck by the nurse, it is 
 possible that the actual day of operation may be kept secret 
 from the patient. In other words, the gland may be stolen 
 away, the patient little knowing that one of the rehearsals 
 with the anesthetist is the day on which the operation is to take 
 place. 
 
78 TEXTBOOK OF SURGICAL NURSING 
 
 Tlu' aiu'sllii'tic wliicli is used is nitrous oxide and oxygen, and, 
 in addition, tlu> line of incision is iisnally first injeeted with 
 novocain, !/:>%. The operation is usnally done in stages; that 
 is, the blood snpplj' to the thyroid is first lessened by the ligation 
 of the superior thj-roid arteries, and then the inferior thyroid 
 arteries. This may be done under local anesthesia, or under 
 gas and oxygen. The reason for the preliminary ligation is 
 to diminish the blood supply of the thyroid. This simple pro- 
 cedure is very often all that is necessary, and with it the symp- 
 toms of hyperthyroidism abate and the patient needs no further 
 surgical treatment. If, on the other hand, the symptoms are not 
 definitely improved, at least the blood supply of the gland is les- 
 sened, so that when the thyroid is removed, the hemorrhage will 
 be materially decreased, the degree of shock less, and a speedy 
 recovery of the patient assured. 
 
 Post-operative Treatment. — The patient should be kept es- 
 pecially quiet and given plenty of fluid by rectum. Very often 
 these patients are subject to a sudden rise in temperature, some- 
 times as high as 106 degrees, and an increase in pulse rate that 
 is rapid and thready. Their faces become pinched and covered 
 with perspiration; they are apt to become delirious and die 
 within a very short time. These symptoms are thought to be 
 due to an acute hyperthyroidism. It has been found that as 
 soon as these symptoms occur, they can be controlled by the use 
 of the ice pack. 
 
 Occasionally, following the operation there may be a hemor- 
 rhage from the operative wound. The bandage should be re- 
 inforced and the operating surgeon immediately summoned. 
 More rarely a condition of edema of the glottis may develop. 
 This is evidenced by difficulty in breathing, cyanosis of the 
 patient, and a bubbling respiration. This condition demands 
 immediate attention, often tracheotomy (Chapter IX, page 122), 
 and no time should be lost in summoning the medical officer 
 in charge. 
 
 Following any operation upon the thyroid, especially of 
 exophthalmic variety, the patient should be given a prolonged 
 rest in some quiet mountainous resort. The surroundings 
 should be congenial, and the patient should not be permitted 
 
NURSING OF THE GLANDULAR SYSTEM 79 
 
 to return to her usual environment until the attending physician 
 feels assured that she can stand the strain. 
 
 Tetany. — Occasionally after rather an extensive removal of 
 the thyroid gland, a peculiar condition may result, namely that 
 of tetany. This is presumably due to the fact that the parathy- 
 roid glands which are closely attached to the posterior surface 
 of the thyroid have been partially removed. 
 
 The symptoms of tetany are intermittent, bilateral spasms 
 confined to the extremities. These paroxysmal attacks may be 
 controlled by the administration of calcium lactate, about fif- 
 teen grains every three hours. 
 
CHAPTER VI 
 
 THE SURGERY AND SURGICAi NURSING OF THE NERVOUS 
 
 SYSTEM 
 
 The nervous system consists of the cerebrospinal and the 
 sympathetic or autonomic systems. The cerebrospinal division 
 is made up of the brain with the twelve pairs of cranial nerves 
 and their peripheral modifications, and the spinal cord with its 
 thirty-three pairs of spinal nerves and their peripheral modifi- 
 cations. The autonomic division comprises the sympathetic 
 ganglia and their ramifications. 
 
 Fractures of the Skull. — While these injuries should really 
 be included in the chapter on the Osseous System, they are so 
 closely related to cerebral trauma that a brief discussion here 
 might be deemed more advisable. Fractures of the skull may be 
 divided into those of the vault and those of the base. Fractures 
 of the A'ault may be simply fissures in the bone, or the bone may 
 actually be depressed and splintered into several fragments. 
 These cases are often accompanied by injuries to the blood 
 vessels of the dura or pia mater, or by actual laceration of the 
 brain substance. If it is a simple fracture, the treatment is 
 that of elevating the depressed bone with forceps, or periosteal 
 elevators, and should some of the fragments be splintered very 
 badly they may be removed with rongeurs or punch forceps. 
 Occasionally it may be necessary to trephine; this is described 
 on page 82. 
 
 Fractures of the base are more serious because of the great 
 danger of injuring the important brain structures in this loca- 
 tion. As a rule, there is bleeding from the nose, sometimes the 
 ears, and occasionally the pharynx. The treatment consists of 
 absolute rest and quiet. The head should be slightl,y elevated 
 and fixed between two pillows. If there is bleeding from the nose 
 it is advisable to irrigate the nasal fosste with warm boric solu- 
 tion to prevent the clot from becoming foul through infection. 
 
 80 
 
NURSING OF THE NERVOUS SYSTEM 81 
 
 In cases with bleeding from the ear, it is best to irrigate the 
 external auditory meatus after which the canal should be packed 
 with sterile cotton. The irrigations should be given about three 
 times a day. Qf course, the bowel movements should be free. 
 If the patient is unconscious, about two drops of croton oil are 
 placed upon the tongue to insure a thorough cleansing of the 
 alimentary canal. Retention of urine is treated by catheteri- 
 zation. Some surgeons give all these cases urotropin in doses 
 of from ten to twenty grains, three times a day, for it secretes 
 an antiseptic into the cerebrospinal fluid. If these fractures 
 are accompanied by signs of brain injury, and of intracranial 
 pressure from hemorrhage, operative interference is necessary, 
 although the mortality is extremely high. 
 
 Brain Injuries. — The brain is enclosed within a bony case, 
 the skull, and a severe injury inflicted upon the head may not 
 only injure the scalp and fracture .the skull, but also cause 
 various injuries to the brain within. The immediate effect of 
 the injury or concussion may be unconsciousness brought on by 
 shock of the nerve centers of the brain. In addition, some blood 
 vessels of the dura or pia mater may be torn with a resultant 
 intracranial hemorrhage causing compression of the brain. This 
 manifests itself by unconsciousness, irregular respirations of the 
 Cheyne-Stokes type, slow pulse, increasing of the blood pres- 
 sure, and what is called a "choked disc'' (serous inflammation of 
 the optic nerve). This may be seen with an ophthalmoscope, 
 an instrument through which the interior of the eye is inspected. 
 
 As these patients are in shock, they should first be treated for 
 this condition, but they should never be placed in the shock 
 position. In fact, the head should be elevated slightly. The 
 room must be quiet and darkened, and all visitors forbidden. 
 As a rule, an enema is given, and if the bladder is at all dis- 
 tended, a catheter is inserted, and the urine drawn off. Pa- 
 tients, after they have recovered consciousness, should be con- 
 fined to bed for at least a week and watched very carefully, 
 because very often peculiar mental symptoms may follow in the 
 wake of a concussion, and it is not safe to leave such cases alone. 
 
 Treatment cf Compression. — This presupposes a hemorrhage, 
 either extradural or subdural. The extradural hemorrhage 
 
82 TEXTBOOK OF SURGICAL NURSING 
 
 results from a rupture of one of the branches of the middle 
 meningeal arteiy. Subdural hemorrhage is due to a rupture 
 of one of the vessels of the pia mater, or a laceration of the 
 brain with its vessels. 
 
 Ante-operative Treatment. -The head is shaved completely 
 and iodinized. If the patient is unconscious, no anesthetic is 
 required; if not, a little chloroform is sufficient. The head is 
 supported on a sandbag, or small prop. (See Fig. 83.) 
 
 Operation. — A curved incision is made in the temporal re- 
 gion of the head, the temporal muscle turned down, and an 
 opening made into the skull by means of an instrument called 
 a trephine. This, by virtue of its circular serrated end, cuts 
 out a button of bone. After the bone has been removed, the 
 dura beneath is exposed. If better exposure is necessary, it 
 may be obtained by enlarging this opening, by clipping away 
 more bone with the bone-cutting forceps, or if the surgeon pre- 
 fers to keep the bone intact, he may make two more trephine 
 openings, and connect them with cuts made by a Gigli saw. 
 This will remove one large plate of bone that may afterwards be 
 replaced. The clot is then removed, and the bleeding vessels 
 are found and ligated, or special Gushing clips (small metal 
 clips) are placed upon the artery. If the bleeding is subdural, 
 the dura is incised, and the source of the hemorrhage sought 
 and controlled. The dura is then closed with interrupted su- 
 tures. The bone which had been kept in warm sterile saline 
 is replaced into the skull, as a rule, and the wound closed with 
 or without drainage. A good tight pressure bandage is applied 
 over the entire head. (Figs. 122 and 123.) 
 
 After Treatment. — Patients should be kept in bed for about 
 two wrecks. During this period they should be allowed very few 
 visitors, and absolutely no excitement. They should never be 
 left alone. If unconscious, catheterization should be performed 
 every eight hours, and the bowels moved by enema once a day, 
 unless incontinence is present. In these pitiable cases great 
 care must be taken to keep the patient exceptionally clean and 
 free from feces and urine. Unconscious patients must be turned 
 every four hours so as to prevent pressure necroses or bed 
 sores, which are always a bad reflection on the nursing care, 
 
NURSING OF THE NERVOUS SYSTEM 83 
 
 although often absolutely unavoidable. If the skin, especially 
 around the bony prominences such as the sacrum, the heels, and 
 elbows be carefully bathed with alcohol, gently massaged and 
 powdered there is very little danger of this necrosis taking place, 
 particularly if these regions are elevated for a few hours each 
 day by inflated rubber rings. During convalescence, the pa- 
 tient's mind should not be subjected to any mental strain what- 
 soever, and the surroundings should be very quiet. 
 
 Brain Abscess. — Occasionally, septic complications, or in- 
 tracranial suppuration may follow compound fractures of the 
 skull, cerebral injuries, infections of the middle ear, and disease 
 of the mastoid antrum. The diagnosis is sometimes very diffi- 
 cult, and the treatment is dependent upon the location of the 
 focus. As for abscesses in other parts of the body, the immediate 
 indication is drainage. In the brain abscess this presupposes a 
 craniotomy (already outlined) with drainage of the abscess 
 cavity. 
 
 If the abscess is due to a suppurating middle ear, the treat- 
 ment is a little more involved. To begin with, if pus is present 
 in the middle ear, it must be freely drained by incising the drum. 
 This is often done under gas, and the tympanic membrane in- 
 cised by a small, spear-like knife (myringotome). Some surgeons 
 are not in favor of syringing the ear in the beginning, but keep 
 the drainage free by wiping the meatus clean with cotton several 
 times a day. Others prefer to have the ear syringed almost 
 immediately with warm boric acid solution at least three times 
 a day. 
 
 Mastoiditis and Sinus Thrombosis. — If the pus spreads from 
 the middle ear it frequently causes an infection of -the mastoid 
 cells (mastoiditis) ; if it enters the region of the lateral sinus 
 (really a vein running in a groove of the temporal bone) a sinus 
 thrombosis may result. These conditions are treated by surgical 
 intervention. 
 
 Ante-operative Treatment. — The hair in the region of the 
 ear should be shaved for a considerable extent, and if the 
 jugular vein is to be ligated, the neck should always be ver^^ 
 carefully prepared. 
 
 Operation. — The operation consists in laying open and goug- 
 
84 TEXTIU^OK OK SURGICAL NURSING 
 
 iiig out the luastoiel t-t'lls, aiul if sinus thrombosis is present, 
 an exposure of the lateral sinus. In ease the sinus is involved 
 before it is incised, the vein into which it drains (internal jugu- 
 lar) is Uprated in the neck. The reason for this is to prevent the 
 spread of infection down the jug'ular vein into the general eir- 
 euhilion. After the vein has been ligated, the sinus is incised, 
 the clot removed by careful flushings with warm saline solu- 
 tion, and the sinus packed. 
 
 After Treatment. — Patients suffering from a sinus throm- 
 bosis are very sick. As a rule, they are septic and, like all those 
 cases, require plenty of fluid and sufficient calories to supply 
 the energy their constitutions demand to fight the bacteria in 
 the blood. Not only should they be given saline freely by rec- 
 tum, but if necessary, also glucose infusions of from five to 
 ten per cent, in strength. If patients are anemic, transfusions 
 of blood are indicated, and should be given frequently until the 
 blood cultures are negative, or the red blood cells and hemo- 
 globin have increased to within normal limits. The wounds are 
 dressed daily, cleaned carefully and packed anew; the dressings 
 are held in place by bandages. (Described in Fig. 133.) 
 
 Tumors of the Brain. — The brain may be the seat of a tumor 
 either benign or malignant in nature. As the mass within the 
 cranial cavity grows, it crowds the brain and produces signs 
 of compression with its resultant symptoms. In addition, there 
 will be other physical signs dependent upon the area of the 
 brain that is infiltrated by the new tissue, or compressed by the 
 tumor mass. If the motor area is pressed upon, there may be 
 paralysis; if the speech area is involved, there will be paralysis 
 of those muscles which they innervate or loss of function of 
 the nerves supplying the organs of special sense, as the eye, 
 ear and nose. 
 
 Treatment. — If the tumor mass is localized, an operation is 
 done similar to the one described under intracranial hemorrhage. 
 In other words, an exploratory craniotomy is performed, and 
 the trephine opening is made in that portion of the skull over- 
 lying the brain tumor area. 
 
 Occasionally, the tumor may be extirpated in toto, but if it is 
 found to be inoperable, a plate of bone is removed in the tern- 
 
NURSING OF THE NERVOUS SYSTEM 85 
 
 poral region, and the brain permitted to herniate against the 
 temporal muscle. This operation is called ' ' subtemporal decom- 
 pression." Sometimes in tumors of the cerebellum, part of the 
 occipital bone is removed, or an occipital decompression is done. 
 This procedure temporarily relieves intracranial pressure, and 
 with it, the terrible persistent headaches which torture these 
 unfortunate individuals almost to distraction. Patients are con- 
 fined to bed for three to four weeks. 
 
 Surgery of the Spinal Cord. — The surgery of the spinal cord 
 is really limited to one operation [Icmvinectomy) . Its object is 
 to expose the spinal cord for examination in those eases suffering 
 from cord pressure due either to a tumor mass or bone frag- 
 ments of some vertebral fracture. The patient is placed in po- 
 sitions illustrated in Fig. 68 or 83. The procedure consists 
 in an incision over the desired vertebras, retracting the muscles 
 attached to the vertebral column, exposing the laminae and spines 
 of the vertebrae, which are then removed with rongeurs, laminec- 
 tomy forceps, saws, and chisels, exposing the dura of the spinal 
 cord. This is then carefully incised and an exploration of the 
 cord is made. The dura is then sutured and the muscles drawn 
 over it. A moulded cast is applied over the back well into the 
 trunk, and the wound permitted to heal. 
 
 Surgery of the Spinal Nerves. — Neuritis (inflammation of 
 the nerves) is really a medical condition, but the wounds of 
 nerves are very important from a surgical standpoint. If a 
 motor nerve is cut or pressed upon so that the nerve fibers are 
 destroyed, the muscle structures supplied by it become paralyzed, 
 and the nerve below the point of incision, or pressure, atrophies, 
 although the part above, that which is connected with the nerve 
 cells, lives on. This is important because if the continuity of 
 the nerve is reestablished by suture, the nerve will regenerate 
 by growing along the path of the degenerated segment. The 
 strictest asepsis must be maintained in all these operations. If 
 the nerve is simply pressed u-pon by callus of a healing bone all 
 that is necessary is to remove the pressure; but if the nerve 
 has been recently divided, it should be immediately sutured 
 end-to-end with a very fine round needle with chromic catgut. 
 After this is done, the wound is closed, and the limb placed in 
 
86 TEXTBOOK OP SURGICAL NURSING 
 
 that position in which the tension upon the recently sutured 
 nerve will be minimum, A plaster splint is applied, and at 
 the end of one week or ten days, active and passive motions 
 are begun so as to keep up the nutrition of the muscles. Mas- 
 sage and electrical stimulation should also be begun aronud this 
 period. 
 
 The splint may be rcuioved in about six weeks to two months. 
 It should not be forgotten that nerve regeneration is a very 
 slow and tedious process, and very often as much as two years 
 will elapse before the complete, or even partial restoration of 
 function will ensue. The patient should be encouraged to mas- 
 sage the muscles involved so as to prevent atrophy and he sliould 
 be taught how the faradic and galvanic electrical currents are 
 applied, so that when attendants are no longer around, he may 
 give himself those treatments which will mean a functioning 
 extremity rather than a paralyzed one. 
 
 If the operation is done some time after the original injury 
 the process is more difficult and the various plastic nerve opera- 
 tions will have to be performed. The after care is the same as 
 that required for recent cases. 
 
CHAPTER VII 
 
 THE SURGERY AND SURGICAX, NURSING OF THE OSSEOUS 
 
 SYSTEM 
 
 FRACTURES 
 
 A FRACTURE may be described as a break in the continuity of 
 a bone. While this condition is treated in the main by the sur- 
 geon, it affords great opportunity for the nurse to exhibit her 
 skill not only in preparing the necessary things for the treatment 
 of the fracture itself, but even more by conscientiously attend- 
 ing to those details that bring comfort to the patient. A fracture 
 may be simple, that is, only involving the bone, or it may be 
 compottnd, in whiqh case the skin and deeper tissues as well as 
 the bone have been injured. Compound fractures are serious 
 and dangerous because the broken skin affords excellent oppor- 
 tunity for- the various pathogenic organisms to enter and cause 
 bone infection. For the present, however, our attention will be 
 confined to simple fractures, those in which the skin is not 
 directly injured, although it may be swollen, black and blue, and 
 very tender to the touch. 
 
 Simple Fractures. — It is obvious that as soon as any bone 
 is broken there is ordinarily some deformity about the site of 
 fracture. ' This may be due to the hemorrhage of the torn vessels 
 of the periosteum, or the deep muscles ; or it may be due to the 
 fact that the fragments of the injured bone are displaced. In 
 the normal bone, a balance exists between the muscles which are 
 attached to it. When the bone is broken, this equilibrium is 
 destroyed and the muscles attached to each fragment tend to 
 pull it in their own direction, thereby causing displacement. 
 This is not true, however, in all cases. Very often one fragment 
 is telescoped or driven directly into the other. This is spoken 
 of as an impacted fracture. 
 
 The aim in all fractures is to restore the bone fragments as 
 
 87 
 
88 TEXTBOOK OF SURGICAL NURSING 
 
 near to their anatomical condition as possible, and after this has 
 been accomplished, the next thing to do is to keep the fragments 
 in their reduced position. The first process is usually spoken of 
 as "reduction," and the second process as "immobilization." 
 
 Reduction of Fractures. — Fractures are reduced as a rule 
 under general anesthesia, either gas, gas and oxygen, or ether. 
 This is done because it is less painful, the patient is easier to 
 control and the muscles are completely relaxed instead of being 
 in a condition of spasm. Attempts at reductions are done by the 
 surgeon as soon as possible after the injur3^ 
 
 There are, however, certain fractures which do not yield to 
 manual reduction because of the following reasons: (1) Too 
 much time has elapsed between the time of fracture and the 
 period when the surgeon was called upon to treat it, (2) the 
 muscular pull between fragments is so great that manual reduc- 
 tion is impossible, (3) the fragments although reduced are not 
 able to be retained in their reduced position, (4) because of the 
 imposition of bone fragments, muscle or torn periosteum, the 
 fragments cannot be brouglit into apposition. These fractures 
 are treated either by means of apparatuses designed for the 
 gradual reduction of fractures, or by open operation. 
 
 Immobilization of Fractures. — Immobilization (the means of 
 keeping fractures at absolute rest) has for its ultimate aim the 
 healing of the divided bone ends by the growth of new tissue or 
 "callus formation." There are many methods designed to hold 
 fractures in apposition. They may be classified as follows: 
 (1) bandages, (2) strappings, (3) splints (wood, wire and 
 plaster), (4) extension and traction appliances, (5) mechanical 
 means applied through open operation. 
 
 It is a general rule in all fractures that the limb affected 
 should always be placed in a position to favor the complete relax- 
 ation of the muscles which would have a tendency to pull the 
 fragments apart, and, since the longer fragment can always be 
 more easily controlled, it should be made to follow the position 
 attained by the shorter fragment. 
 
 Bandages and Strappings. — ^While bandages are employed 
 more, in sprains and dislocations, they are occasionally used in 
 certain fractures. Fractures of the jaw are very often con- 
 
NURSING OF THE OSSEOUS SYSTEM 89 
 
 trolled by a simple four-tailed bandage (Pig. 145, page 389) ; 
 a fracture of the clavicle may be kept in position by a Velpeau 
 bandage (Fig. 140, page 385) or a Syms strapping. Both the 
 four-tailed and the Velpeau bandages are described in the chap- 
 ter on bandaging. 
 
 Strapping. — Strapping is of greatest use in sprains and a 
 few selected fractures. A sprain may be said to be '^an injury 
 to a joint with possible rupture of some of the ligaments or 
 tendons, but without dislocation or fracture." In fact, it is 
 often very difficult to differentiate between these conditions 
 without the use of the X-ray or the fluoroscope. 
 
 Treatment of Sprains. — The present day trend in the treat- 
 ment of sprains is to apply some agent which will stop further 
 effusions into the joint cavity, aid in the absorption of blood 
 which has already been poured into the joint at the time of the 
 injury, give support to the injured part, and yet permit the 
 patient to move the traumatized joint. One of the most effective 
 ways to accomplish this is by the application of adhesive strap- 
 pings. If the swelling about the joint is very severe, it is often 
 advisable to apply ice for the first twelve hours, usually in the 
 form of wet applications. This will do much to reduce the 
 swelling. The joint is then ready for strapping. This is done 
 by the surgeon. The adhesive is applied in such a manner as 
 to insure support, relieve the strain from the ruptured ligament, 
 and yet permit free movement of the affected joint. The patient 
 is then advised to walk about and to use the joint as much as 
 possible. 
 
 The strapping is left undisturbed for about a week and is 
 renewed if necessary. Very often, when the ligaments have 
 definitely ruptured, some surgeons will put the limb up in a 
 moulded splint. Baking, massage and passive movements are 
 allowed and are usually supervised by a nurse. Six weeks or 
 more may elapse before the healing of the injury is completed. 
 Strapping is used very extensively in sprains of the ankle, 
 wrist and knee. 
 
 Strapping for Fractures. — This is used most frequently when 
 one or more ribs are broken. It forms an efficient method for 
 immobilizing the chest, at the same time permitting the frac- 
 
90 TEXTBOOK OF SURGICAL NURSING 
 
 tiired ribs to heal. It should bo emphasized that the adhesive 
 plaster dressing should never be directly applied over the area 
 of fracture., with the exception of fractured ribs, because, with 
 the swelling of the limb and the pressure of the adhesive, an 
 ulceration of the skin is apt to ensue. The result is that a clean 
 fracture maj' be converted into a compound one. Another rule 
 in the application of adhesive dressings is that the part over 
 which the adhesive is to be applied should be shaven of all hair. 
 
 Splints. — "A splint is an apparatus for preventing move- 
 ment of a joint, or between the ends of a broken bone." Since 
 materials used for splints must of necessity be hard, firm and 
 unyielding they should always be padded well. There is nothing 
 more distressing than to see a patient with a simple fracture of 
 the radius just above the wrist in which the splint was not only 
 insufficiently padded but was applied too tightly. The result 
 is a forearm which has become blistered, ulcerated and paralyzed 
 from the pressure ; the function of the wrist being irretrievably 
 impaired, the stiff, smooth fingers are an ignominious monu- 
 ment to the carelessness of the surgeon and the attending nurse. 
 Let it be an unfailing, unalterable rule that all fractures in 
 splints of any description be regularly inspected so that the 
 swelling of the part never becomes so great as to impair the 
 circulation. The pulse at the wrist in fractures of the arm and 
 forearm, and the pulse at the dorsum of the foot in fractures of 
 the lower extremity should always be palpable after a splint has 
 been applied. This is simple and safe assurance that the blood 
 flow to the limb is not seriously impaired. Very often a patient 
 will complain of i)ain in an area other than that of the fracture. 
 The splint should always be carefully inspected to determine 
 the source of the discomfort. Occasionally in circular casts, it 
 is a good plan to cut a window in the plaster in the area of pain 
 so as to relieve the pressure which is invariably causing the dis- 
 tress. By doing this, the incidence of ulcers from pressure will 
 be reduced to the minimum. 
 
 Before any splint is applied it is of prime importance to 
 cleanse the injured part. The nurse, always being mindful 
 of the injury, should do this gently and carefully, causing 
 
NURSING OF THE OSSEOUS SYSTEM 91 
 
 as little pain as possible. This procedure should be completed 
 by dusting the skin of the broken limb with talcum powder. 
 
 Splint Materials. — Any material which is light and strong 
 is suitable for a splint. The following are some of the more 
 widely used materials: 
 
 Wood. — Wood has been used for centuries to support broken 
 limbs. Probably the best splints are the basswood. Basswood 
 splints usually come in sizes of 18x4x1/4 inches. When they are 
 padded carefully with cotton, they make a good temporary 
 splint, and because of the lightness of the wood, they can be cut 
 to any desired size. The one great disadvantage is that it is 
 impossible to mould them accurately. 
 
 Plaster of Paris. — This is perhaps the most widely used 
 splinting material in civilian practice, and, beyond doubt, its 
 widespread application is justifiable. It is easy to obtain, 
 strong, moderately light, and when soft lends itself to accurate 
 and easy moulding. Plaster of Paris is best handled in the form 
 of plaster of Paris bandages. The manner in which they are 
 made is given in Chapter XX. There are two ways in which 
 these bandages may be applied. They may be used as bandages 
 or '^ moulded splints." 
 
 Plaster of Paris Bandages. — These are applied as any other 
 bandage, the limb having been previously padded with non- 
 absorbent cotton. Extreme care should be taken to apply the 
 bandages smoothly, without wrinkles and rather snugly. The 
 number used is dependent upon the desired thickness of the 
 cast. After this has been obtained, the cast may be further 
 smoothed by applying an excess of plaster and polishing the same 
 with long strips of cheese cloth moistened with peroxide of 
 hydrogen. Plaster usually dries in from one to eight hours. 
 For the first thirty minutes, the limb should be held until the 
 plaster has partially dried, because the cast may become dis- 
 torted by pressure of surrounding objects. 
 
 While it is not a universal practice, a great many surgeons 
 deem it advisable to cut all circular casts in the direction of their 
 longitudinal axis, in two parallel lines, diametrically opposed. 
 The reason for this is obvious. Should the limb become swollen, 
 the danger of any untoward complications, such as pressure 
 
92 TEXTBOOK OF SURGICAL NURSING 
 
 necrosis, with a subsequent Volkmann's paralysis, is materially 
 lessened. AVlieii the cast has been cut, a bandage is applied to 
 hold the segments in place. Not only does cutting down a cast 
 insure a "safety first" policy, but it becomes very convenient 
 to do so when baking and massage are employed as the cast 
 may be quickly removed and efficiently reapplied after each 
 treatment. 
 
 If, for some reason, the surgeon sliould decide to leave the 
 cast intact, and to have it cut at a subsequent date, it must not 
 be forgotten that dried plaster is almost stone-like. The method 
 of cutting casts is given on page 397. 
 
 Moidded Plaster of Paris Splints. — As the name implies, 
 these are simply splints made up of plaster of Paris which, when 
 soft, may be moulded. They are very extensively used because 
 they are easily applied, safer than the circular cast, and save 
 the labor of cutting through plaster. They may be used for all 
 fractures of the extremities. Assume a fracture of the radius 
 just above the wrist, a so-called Colles fracture. The manner 
 of applying a moulded splint to this type of fracture is here- 
 with briefly given : The length of the splint to be used is 
 measured with a piece of gauze, in this case from the elbow to 
 the metacarpo-phalangeal joint, and, in addition, the width of 
 the arm is noted. This pattern of the splint in gauze is laid flat 
 upon some smooth surface, either glass, marble, or board. A 
 moistened plaster bandage is rolled back and forth over the gauze 
 pattern, until the desired thickness of the splint has been 
 attained. A piece of canton flannel usually lines the inner side 
 of the splint. The soft plaster, lined with flannel and a thin 
 layer of cotton, is applied to the anterior surface of the fore- 
 arm, and bandaged snugly in place. The anterior splint in this 
 way can readily be moulded to the shape of the arm. After the 
 plaster has hardened the bandage is removed, all the rough edges 
 of the splint smoothed and a muslin bandage reapplied. Some 
 surgeons in addition to an anterior splint apply a posterior one. 
 The technic is identical for all of the moulded variety. Very 
 often a splint will be made double in length and be bent upon 
 itself in the shape of a letter U, forming a joint anterior and 
 TDosterior one. This type is known as a "sugar-t9M" splint. It 
 
NURSING OF THE OSSEOUS SYSTEM 93 
 
 finds a very practical application in fractures of hotli bones of 
 the forearm. 
 
 Spicas and Jackets. — When a long bone is broken, such as 
 the femur, or the pelvis, heavier splints are required because 
 greater strength is necessary to overcome the powerful contract- 
 ing influences of the muscles of the thigh. Splints in this region 
 have but little value aside from their first aid application. If 
 the surgeon desires to use plaster for these conditions a spica 
 bandage of plaster of Paris is employed. These extend from the 
 region of the umbilicus down to the toes on the affected side. 
 
 The technic of the application of the plaster is the same, 
 but there are several factors which are a little different and 
 demand special mention. First the mechanical, for after all, 
 plaster has only a certain tensile strength. If this is exceeded, 
 the plaster is apt to crack and break, rendering the spica useless. 
 In order to prevent this, it is customary to reinforce the east, 
 especially in the lateral region, i. e., from the hip to the knee 
 and over the anterior aspect of the thigh. The reinforcing 
 naaterial may be strips of basswood, wire mesh, or sometimes 
 longitudinal strips of plaster of Paris in the form of moulded 
 splints. ■ Then, in applying the cast, inasmuch as the lower 
 abdominal region is included, sufficient space must be allowed 
 for the possible distention of the small and large intestines. 
 In other words, ample room must be left for the patient's appe- 
 tite. This is accomplished by laying two or three folded towels 
 on the abdomen, and winding the plaster so as to include them 
 temporarily, removing them after the plaster has hardened. 
 
 Since the spica winds about the genitals and anal orifice, 
 great care must be taken that there is no undue pressure against 
 these organs, and tliat the patient is able to defecate and urinate 
 without difficulty. In children whose control is apt to be lax or 
 involuntary, it is customary to coat the cast with shellac, thus 
 rendering it impervious to the urine. Spicas, as well as all other 
 complicated plaster work, are applied with great facility and 
 more efficiently if the patient is resting on a "Hawley" table. 
 
 The Hawley table, or modifications of it, is of such mechanical 
 construction that any part of the bony framework of the patient 
 may be held in any desired position for any length of time with- 
 
94 TEXTBOOK OF SURGICAL NURSING 
 
 out the aid of xeiy much assistance. Tliis, of course, is a wonder- 
 ful advance over those methods Avhich required a limb to be held 
 in a certain position by a nurse or doctor until the plaster could 
 be applied. The Ilawley table may be used not only for the 
 application of casts, spicas, and plaster jackets, but it is a con- 
 venient means to steady a limb and obtain traction if necessary, 
 during the course of an open operation upon bone. 
 
 Plaster Jackets. — These are coats or jackets made of plaster 
 tliat cover the patient from the neck well to the region of the 
 thighs. It finds its application in dislocations of fractures of 
 the vertebra? due to either accidental causes or to disease, such 
 as tuberculosis of the spine. It may be applied with the patient 
 resting either on the Hawley table, or with the patient lying 
 across some supporting straps. 
 
 Methods to Obtain Traction. — In some cases, the fragments 
 of the fracture are overriding to such a degree that were the 
 limb permitted to heal in this position great deformity and 
 shortening of the leg or arm would result. To overcome this, 
 and to correct the overlapping of bones, traction may be applied. 
 Nothing has developed the use of traction more than the Great 
 "War. For there, not only did the surgeon have to deal with 
 fractured limbs but with fractured limbs plus injuries to the soft 
 parts (compound fractures). To overcome these difficulties, 
 which are practically impossible to handle if the limb is encased 
 in plaster, an attempt is made to maintain reduction by traction 
 often combined with suspension. 
 
 Traction. — Traction is used to correct overlapping or over- 
 riding bone fragments and lateral deformities. Through its 
 agencj^, those muscles are relaxed which by their contraction 
 might have resulted in malpositions of the fracture. In 
 addition, if properly applied, it automatically secures the 
 proper alignment of the bone ends and prevents the fragments 
 from being displaced, thus avoiding injuries to muscles, blood 
 vessels, or nen-es. 
 
 In civilian practice, traction was practiced freciuently for 
 fractures of the femur either through a Buck's extension or a 
 Hodgen's splint. Briefly, the Buck's extension is made by 
 applying to the lateral aspects of the leg a piece of adhesive 
 
NURSING OF THE OSSEOUS SYSTEM 
 
 95 
 
 plaster about four inches wide, reaching from above the knee 
 to below the sole (Fig. 10, B). Between the free ends of the 
 
 K 
 
 Wood 
 
 Fig. 10. — Methods of Applying Traction. A, stocking traction; B, 
 adhesive plaster traction; C, Sinclair skate. From the Manual of Splints 
 and Appliances, Medical Department, United States Army. 
 
 adhesive a piece of wood, five by three inches, is attached. This 
 acts as a spreader, and a means by which weights may be 
 attached and traction obtained. 
 
96 TEXTBOOK OF SURGICAL NURSING 
 
 U ^ 
 
 Fig. 11\ — Traction Leg Splint. A, Thomas traction leg splint with sus- 
 pension. 
 
 The Hodgen's suspension splint (Fig. 11"), which is really 
 a forerunner of the various splints developed recently, is simply 
 two parallel iron bars bent slightly in the region of tlip knee. 
 The lower extremity is placed between these two bars, resting 
 on several cross pieces. The limb is raised from the bed by 
 cords attached to the splint and traction is obtained. Further 
 traction may be obtained by combining this with a Buck's 
 extension. 
 
 As the Buck's extension depends for its traction pull upon 
 large areas of skin being covered by adhesive, it was found 
 impractical during the war because extensive wounds of the 
 skin and deeper tissues often complicated the fractures. So 
 newer metliods of traction Avere developed, — namely, the stocking 
 traction (Fig. 10, A) and the Sinclair skate (Fig. 10, C). The 
 former emploA-s a light Aveight sock from which the toes have 
 been removed. The sock is glued to the leg, ankle and foot except 
 at its sole, and a piece of splint wood is introduced between the 
 
NURSING OF THE OSSEOUS SYSTEM 97 
 
 J31 ^ H H _ ^ 
 
 Fig. 11^ — Traction Leg Splint. 
 
 B, wooden bed frame. 
 
 For traction by weight and pulley and overhead counterweight sus- 
 pension. 
 
 Application for lower limb injuries. 
 
 Limb in anterior thigh and leg splint, Hodgen type. 
 
 Uses : — 
 
 For suspension of limb from overhead support in injuries of thigh 
 and leg. 
 
 A. Supporting slings clipped to rods of splint. 
 
 B. Cloth glued to sole of foot attached to counterweight arranged to 
 
 maintain right-angle dorsal flexion. 
 
 C. Hand grips by which patient may change his position in bed. 
 
 H. Strap iron hooks movable on upper cross-bar of frame but screwed 
 to short wood bar to maintain pulleys in proper relative position. 
 
 W. Open canvas weight bags. 
 
 This splint is used simply for a frame to sling the leg in case the nature 
 of the wounds makes the Thomas splint impossible. The traction straps 
 should be attached directly to the weight and pulley, and should not be 
 attached to the splint. 
 
 By careful adjustment of the slings the position of the bone fragments 
 can be controlled. From the Manual of Splints and Appliances, Medical 
 Department, United States Army. 
 
 sock and the sole of the foot. Traction is obtained by means 
 of a cord passed through the sock and splint. A further refine- 
 ment is the Sinclair skate; this is a piece of board attached to 
 the foot by adhesive strips or glued strips. The glue that is 
 used may be made after the following forniulte and directions 
 
98 TEXTBOOK OF SURGICAL NUESING 
 
 obtained from the "Manual of Splints and Appliances" (Med- 
 ical Department, United States Army). 
 
 SINCLAIR'S GLUE 
 
 Glue 50 parts 
 
 Water 50 " 
 
 Glycerine 2 " 
 
 Calcium chloride 1 part 
 
 Thymol 1 " 
 
 The glne is heated in a water bath to about 100° F. It is 
 painted on the skin, the last coat given is painted in a direction 
 against the growth of hair. 
 
 EESIN AND TURPENTINE GLUE 
 
 Resin 50 parts 
 
 Alcohol 50 " 
 
 Benzine (pure) ... .50 " 
 Turpentine 5 " 
 
 To the powdered resin, one-half the alcohol is added, then the 
 turpentine and benzine. The measure is washed with the 
 remaining alcohol and the contents poured into a bottle. The 
 bottle is always kept tightly corked. The glue may be removed 
 with alcohol or ether. No heat is necessary for its application 
 and it should be applied as thinly as is possible. 
 
 Suspension. — ^While traction is an important element, sus- 
 pension has enhanced its value by rendering greater comfort to 
 the patient, and making much easier the surgical dressing of the 
 wounds. The limb is usually suspended to an overhead wooden 
 or metal frame (Fig. 11-) developed from the original Balkan 
 frame. This consisted of two uprights with a cross piece at each 
 foot of the bed supporting a horizontal bar. The frame now in 
 use is a quadrilateral variety and is illustrated in Fig. 11^. 
 
 To this frame may be attached various pulleys, or these pulleys 
 may be run on trolleys as shown in Fig. 12, A, and Figs. 11^ and 
 11 ^ 
 
 There are several splints which have been recently developed, 
 and although their application and suspension is the concern 
 of the orthopedist and surgeon, the nurse should have a knowl- 
 edge sufficiently great to secure the desired appliances at the 
 
NURSING OF THE OSSEOUS SYSTEM 
 
 99 
 
 ^yn-^ 
 
 Fig. 12. — Traction Arm Splints. A, Thomas traction arm splint; 
 B, Thomas arm splint; C, Thomas traction arm splint. From the Manual 
 of Splints and Appliances, Medical Department, United States Army. 
 
100 TEXTBOOK OF SURGICAL NURSING 
 
 splint room, and in tlio event of anytliiiig oeeurring to tlieni in 
 the absence of the attending doctor, she may apply "first aid." 
 The ones most eonnuonly used are those mentioned in the 
 "Mannal of Splints and Appliances" issued by the Medical 
 Department, United States Army, and illustrated herewith. 
 
 Thomas Traction Arm Splint. — Tliis is used for fractures of 
 the shoulder joint, shaft of the humerus, elbow joint, and fore- 
 arm (Fig. 12). 
 
 Jones "Cock Up" or "Crab" Wrist Splint.— This is intended 
 for injuries to the wrist, or to maintain dorsal flexion of the 
 hand in injuries to the wrist, and in injuries to nerve and muscle 
 causing wrist drop (Fig. 13), 
 
 Fig. 13. — Jones ' ' Cock Up, " or " Crab ' ' Wrist Splint. From the Manual 
 of Splints and Appliances, Medical Department, United States Army. 
 
 Thomas Traction Leg Splint. — This is for injuries to the 
 shaft of the femur, knee joint, and leg (Fig. 11^). 
 
 Hodgen Type Splint. — This is for injuries to the thigh 
 (Fig. IP). 
 
 Open Operation for Fractures. — In these fractures, which are 
 not compound, when reduction has been impossible, it is often 
 necessary to perform an open operation, reduce the fracture 
 under the direct vision of the surgeon, and then hold the frag- 
 ments in place by some mechanical measure. The means of 
 accomplishing this are many. Some use wire, others. Lane 
 plates ; the latter are pieces of metal which bridge bones together, 
 the plate being held fast to the bones by screws (Fig. 14). 
 
 Occasionally, although the bones are in good position, union 
 by callus formation fails to take place. To stimulate bone 
 growth a piece of bone may be taken from some other part of 
 the body, as a graft from the tibia, and this is inserted into the 
 fractured bone ends. Inasmuch as infection is very much 
 
NURSING OF THE OSSEOUS SYSTEM 101 
 
 dreaded in these operations, an exaggerated technic, or Lane's 
 teehnic, is employed. This is a method whereby everything that 
 goes into or comes into contact with the wound is not touched 
 by gloved hands, but by instruments. The technic is briefly out- 
 lined in Chapter XVII. The wound, of course, is closed with- 
 out drainage, and the limb put up in some splint or fixation 
 apparatus. 
 
 Osteomyelitis. — This is an inflammation of the medulla or 
 marrow of the bone. It may be acute or chronic, and generally 
 results from a bacterial infection. All those compound fractures 
 of the war, due to shrapnel and machine gun bullets, were com- 
 plicated, as a rule, by osteomyelitis in varying degrees. 
 
 Symptoms. — The symptoms may consist of great pain re- 
 ferred to the bone affected, high fever, rapid 
 pulse, and general malaise. There may be 
 swelling, redness, and marked tenderness ,^ 
 
 on pressure over the involved area. 
 
 Treatment. — The treatment is operative. b 
 An attempt is made to give the bone free 
 drainage by incision through the skin and 
 muscles and then sufficient cortex of the bone Plate! A fractured 
 
 is removed to permit the pus in the medulla bone; B, Lane 
 . . plate; C, screws, 
 
 to dram freely. To insure free draniage the 
 
 wound is packed with gauze, and to clean up the infection 
 
 the bone and wound are Dakinized by the various methods 
 
 described in Chapter XIX. If the condition is complicated by 
 
 fracture, the limb is treated by suspension and traction, plus 
 
 the Dakin treatment. 
 
 Because of the hardness and unyielding character of bone 
 it will take a long while for the dead bone in the medulla to 
 form a line of demarcation from the living, and that is why 
 these cases of osteomyelitis linger so long before they are healed. 
 The dead bone which often comes away in spicules at a dress- 
 ing, or which is removed at some subsequent operation, is spoken 
 of as a sequestrum. 
 
 Inasmuch as the majority of these cases will suffer for some 
 time from a continual low grade toxemia, it is important to look 
 after their general condition. These patients should be given 
 
102 TEXTBOOK OF SURGICAL NURSING 
 
 as miicli fresh air as possible, kept on a high caloric diet, and 
 although confined to bed, the muscles of the affected limb should 
 be given daily massage whenever possible. This will insure 
 proper nourishment and maintain muscle tone, for it is well 
 known that muscles not in active use are apt to undergo atrophy. 
 The temperature should be carefully watched and any sudden 
 rise might be indicative either of retention of pus somewhere 
 in the wound, or the starting of a new focus in the same bone or 
 another one. 
 
 Amputations. — Fortunately, today, amputations are but 
 rarely performed, aud limbs which years ago would have been 
 sacrificed, are saved now by the newer advances of surgical 
 treatment. Amputations are mutilations. They are employed 
 as final measures and their indications are definitely defined and 
 clearly cut. 
 
 Ante-operative Treatment. — The area, through which the 
 amputation is to be done and the skin for a considerable dis- 
 tance above and below, should be shaven and cleansed very care- 
 fully. If there are any open sinuses they should be protected 
 by packing and sterile dressings, so that their discharge will not 
 contaminate the wound. 
 
 To prevent hemorrhage during amputation there are several 
 methods devised which aim to compress the blood vessels sup- 
 plying the limb in question. 
 
 Esmarch's Method.— This method attempts to squeeze all the 
 blood out of the limb by applying an elastic bandage which is 
 wound spirally from below upward, well above the region of 
 amputation. At the upper limit, an ordinary rubber tubing 
 tourniquet is applied and fastened. The elastic bandage is then 
 removed. This is not applicable in septic conditions, nor in cases 
 of tumors. 
 
 Lister's Method. — Here the limb is elevated for a few min- 
 utes and the ordinary tubing applied in a horizontal fashion as 
 a simple tourniquet. 
 
 Tourniquets. — These should always be applied well above the 
 region to be amputated, and should be sterilized. When the 
 amputation is to be done near the hip or the shoulder, strips of 
 sterile bandage should be applied around the tourniquets. These 
 
NURSING OF THE OSSEOUS SYSTEM 103 
 
 are held firmly by an assistant to prevent the tourniquet from 
 slipping. Some surgeons prefer to use Wyeth's pins, elongated 
 steel pins which are pierced through the muscles, and the tourni- 
 quet in pressing against these is prevented from sliding off 
 (Fig. 15). 
 
 Amputation Operation. — The technic of the operation is 
 variable. Some surgeons will inject all nerve trunks with novo- 
 cain before cutting them. The bone 
 stump is treated in various man- 
 ners so that a full armamentarium 
 of bone instruments should always 
 be on hand. Amputation wounds 
 are usually drained. The dressings 
 applied should be large and pres- 
 sure should be evenly exerted either 
 by adhesive strips or bandage. As a 
 
 rule the stump should be elevated. -^ -^ ,^ 
 
 Fig. 15. — Method of Ap- 
 
 Sometimes a small splint is applied plying Wyeth's Pins. A, 
 
 . ,1 , , . IT •, • Wyeth's pins; B, tourniquet, 
 
 to the stump to immobolize it m a "^ r > > ^ 
 
 more efficient manner. 
 
 After Treatment. — These patients are apt to suffer from con- 
 siderable shock so not only must this condition be watched for, 
 but also the danger of secondary hemorrhage. It should be rou- 
 tine practice to have an emergency tourniquet set very near the 
 patient's bed so that should bleeding occur no time may be lost 
 in arresting the hemorrhage. If the oozing is marked, the dress- 
 ing may be reinforced or changed in twenty-four hours, although 
 it is better to wait forty-eight hours. 
 
 Occasionally when the wound has almost healed it is often 
 necessary to apply pressure to certain flaps or skin areas to 
 relieve tension. This pressure can be obtained by thin bandaging 
 or by adhesive strappings. In bandaging, it is always to be 
 remembered that the turns which pass over the stump should be 
 begun from above downward and on the side where the longer 
 flap is. Sometimes when the flaps have been cut too short, it 
 may be necessary to apply traction to pull the muscles over the 
 stump. 
 
104 TEXTBOOK OF SURGICAL NURSING 
 
 While the stage of healing is in progress, gentle massage to 
 the muscle groups will do nuich to maintain their tone and 
 health. 
 
 If the amputation is one of the lower extremity, the patient 
 shduld be taught carefully the proper use of crutches. Crutches 
 should not press into the axilla but the weight of the body should 
 be sustained by the hand resting on the cross piece of the crutch. 
 Special instructions should be given as to how to descend and 
 ascend a flight of stairs, cautioning the patient to hold the 
 banister with one hand and using the other hand to hold the 
 supporting crutch. To prevent the crutches from slipping they 
 should always be equipped with rubber tips. 
 
Chapter viii 
 
 THE SURGERY AJSTD SURGICAL NURSING OF THE 
 REPRODUCTIVE SYSTEM 
 
 Composition. — The genital system of the female and male 
 may he divided into the external and internal organs of genera- 
 tion. The external organs in the female consist of the mons 
 veneris, the external opening of the urethra, the clitoris, the 
 labia majora, labia minora, and the hymen ; the internal organs 
 are the vagina, the uterus, the tubes and ovaries. In the male, 
 the external organs of generation are the penis, the scrotum 
 which contains the testis, the epididymis, part of the vas defer- 
 ens; the internal, the prostate, and the seminal vesicles. 
 
 Operations on Female Genital System. — The operations on 
 the female genital system resolve themselves into two classes, 
 those which are external, and those which are internal. The 
 external, mainly plastic operations, are those done for the relief 
 of a relaxed perineum or lacerated cervix, injuries which follow 
 tears incident to childbirth. A weakened pelvic floor may 
 result in a relaxation of the anterior vaginal wall with a subse- 
 quent prolapse of the bladder (cystocele). If the posterior wall 
 of the vagina is weakened, a prolapse of the rectum may occur 
 (rectocele). Surgery attempts to correct the cystocele and 
 rectocele by operations upon the vagina and a reconstruction of 
 the muscles of the perineum. The operations come under the 
 general head of perineorrhaphy. 
 
 Perineorrhaphy. — The ante-operative procedure: The vulva 
 should be shaved, scrubbed with green soap and water, then 
 with alcohol and ether. It is advisable to catheterize the bladder 
 routinely in all these cases. The patient is placed in a lithotomy 
 position (see Fig. 72, page 277) and the various operations for 
 the relief of the pathological conditions are performed. The 
 technic of the operation does not concern us here. 
 
 Post-operative Care. — Most institutions and hospitals have 
 
 105 
 
106 TEXTBOOK OF SURGICAL NURSING 
 
 standard perineorrhaphy routines. The various methods are 
 herewith outlined : 
 
 The routine which the nurse will follow in the after care of 
 a perineorrhaphy will always be prescribed by the surgeon ; it 
 will vary considerably from time to time, depending upon the 
 extent of the wound and the preferences of the particular sur- 
 geon. In any case it is extremely important to keep the wound 
 surgically clean. At best, the task is not easy, nor very satisfac- 
 tory because of the necessary, frequent exposure to the unsferile 
 excretions of the body. Fortunately, however, nature has pro- 
 vided this part of the body with unusual resistance to infection, 
 and therefore consistent and conscientious teehnic in the treat- 
 ment of a perineorrhaphy wound will be rewarded with good 
 results. Some surgeons will require that the part be kept iimno- 
 bilized for at least the first forty-eight hours. This is accom- 
 plished by means of a bandage passed about the thighs binding 
 the legs together. This will be particularly desirable in the case 
 of a restless patient. Other surgeons, however, will not pre- 
 scribe this treatment and the nurse will, of course, not administer 
 it as a routine practice because it is a rather trying ordeal for 
 some patients. When applying this bandage the nurse should 
 remember the rule forbidding the bandaging together of any 
 two surfaces of skin and should see that the thighs are comfort- 
 ably separated by means of a layer of non-absorbent cotton. 
 
 Sometimes catheterization will be prescribed to avoid contami- 
 nation of the wound by the urine. This may be for only a 
 period of forty-eight hours at stated intervals, or it may be for 
 a longer time. In some cases treatment will be directed toward 
 preventing evacuation of the bowels for a stated period, some- 
 times as long as nine days, particularly if the laceration has 
 been a complete one — that is, one which has extended into the 
 rectum. This treatment will consist of opium medication to 
 suppress peristalsis, of fluid diet without milk, or of the two 
 combined. Often, however, especially in cases of the slighter 
 wounds, catharsis, oil enemas, etc., will be given in the course of 
 a few days. Whatever the prescribed general treatment, how- 
 ever, the nurse must follow rigid aseptic teehnic throughout. 
 Catheterization, of course, is always done with the most thorough 
 
NURSING OF THE REPRODUCTIVE SYSTEM 107 
 
 asepsis, so no special lesson will be necessary here as to that, 
 except to point out that in this case the asepsis must be in the 
 interest of the wound as well as the bladder. As a rule, whether 
 or not catheterization is done, after the bladder has been 
 emptied the perineum will be douched with sterile water or some 
 mild antiseptic solution such as 2 per cent, boric acid or 1-5000 
 bichloride, which will be allowed to flow over the wound from a 
 pitcher or irrigator. The wound is then carefully patted dry 
 with sterile gauze and the prescribed dressing applied. Some- 
 times the dressing will be only the plain dry gauze ; but a dust- 
 ing powder, such as aristol, or an ointment, such as boric acid, 
 may also be applied. Keeping the wound dry is an important 
 part of the nurse's duty in this case and it will require careful 
 manipulation on her part because perineorrhaphy sutures are 
 very frequently of silkworm gut which will mean that they 
 will be likely to catch upon dressings and involve the risk of 
 tearing the wound and also of causing considerable pain to the 
 patient. The aseptic precautions will be necessary at least till 
 after the sutures have been removed, which may be any period 
 of from fi^ve to ten days. 
 
 The Uterus. — The uterus is a muscular, pear-shaped organ 
 situated in the pelvic cavity between the bladder and the rectum. 
 Its normal position is that of anteversion. The part of the 
 uterus which projects into the cavity of the vagina is known 
 as the cervix. The uterus is lined with mucous membrane ; and 
 entering the fundus or body of the uterus are the openings of 
 the Fallopian tubes. The uterus may be the seat of acute inflam- 
 mations, malpositions, or new growths, either benign or ma- 
 lignant. 
 
 Inflammations of the Uterus. — The mucous membrane of the 
 cervix of the uterus may become acutely inflamed due to a 
 variety of causes, especially from an infection by the gonococcus. 
 This condition is known as endocervicitis, and if the inflamma- 
 tion extends further and attacks the mucous lining of the uterus, 
 the process is known as endometritis. The treatment of this con- 
 dition may be either medical or surgical. 
 
 Treatment of Acute Inflammatory Conditions. — In the acute 
 infections, especially those due to a gonorrhea in which there 
 
108 TEXTBOOK OF SURGICAL NURSING 
 
 is an associated iiretliritis (inflammation of the urethra) and a 
 purulent vaginal discharge, it is of the greatest importance to 
 "warn the patient of the severe infeetiousness of the disease, and 
 the dire results which follow, if it is willfully neglected. It is 
 imperative that the hands be kept away from the eyes, because 
 a gonorrheal infection of the organs of sight may cause total 
 and permanent blindness. 
 
 The patient should be placed in bed, given a bland non-irri- 
 tating diet without condiments or spices, and all alcoholic bever- 
 ages absolutely forbidden. Fluids should be forced to the 
 utmost, and the attending nurse should give copious vaginal 
 douches everj'- four hours with any silver preparation, either 
 protargol or argyrol, in dilutions of 1-10,000. In more chronic 
 stages, these may be followed by silver nitrate irrigations. 
 
 Cervix. — The cervix, as a rule, is treated by the surgeon by 
 direct applications of 10 to 20 per cent, silver nitrate, iodine, or 
 20 per cent, argyrol. The patient is appropriately draped, placed 
 in the lithotomy position, a bivalve speculum is introduced, and 
 the applications made directly to the cervix. However, in all 
 these treatments, while the cervix itself may be benefited, it is 
 difficult to reach the endometrium or lining mucous membrane 
 of the uterus, and very often more radical surgical procedures 
 have to be resorted to. 
 
 Operative Treatment. — One of the most common procedures 
 is the operation known as dilatation of the cervix and curettage 
 of the uterus. The purpose of the dilatation is to insure suffi- 
 cient stretching of the cervical canal, so that instruments may 
 be freely passed into the uterus, and secondly to insure drainage 
 of the uterine cavity. The object of the curettage is to scrape 
 away the diseased mucous membrane of the uterus so that a new 
 and healthy lining will replace the diseased part. While this 
 operation is done for chronic inflammations, it is also performed 
 for the retained membranes of pregnancy, and for incomplete 
 abortions. It is also a diagnostic measure, for in doubtful cases 
 of cancer of the uterus, the curettings may be examined for 
 microscopic evidences of malignancy. 
 
 There are cases in which there is a definite stenosis, or narrow- 
 ing of the cervix, resulting in very painful menstruation 
 
NURSING OF THE REl^RODlUm VK SYSTEM 109 
 
 (dysmenorrhea) and often in sterility. In order to insure a 
 permanent opening of tlie cervical canal, after operative dilata- 
 tion, a stem-pessary of either glass or rubber is often sewed in 
 the cervical canal, and permitted to remain in place until the 
 appearance of the next period. While the stem-pessary is 
 within the cervix, a daily douche of disinfectant variety should 
 be administered, as the mechanical presence of the foreign body 
 generates a certain amount of disagreeable discharge. 
 
 When the cervix is badly torji, the laceration may become a 
 source of irritation. A plastic repair is often done ; the opera- 
 tion being known as trachelorrhaphy. When the tears are 
 multiple it may be necessary to amputate the cervix partially 
 or completely. 
 
 Malpositions of the Uterus. — While the normal position is 
 that of anteversion, the uterus may occupy a backward posi- 
 tion. This is spoken of as retroversion. Naturally there are 
 many women who suffer from retroversion without symptoms, 
 but if backache and other reflex symptoms are severe, the uterus 
 must be replaced. The replacement will be dependent upon the 
 movability of the uterus. The uterus may be replaced sometimes 
 by manual manipulations by the surgeon with the patient in the 
 knee-chest position. Should the procedure prove too painful, 
 because of inflammatory products binding the uterus to other 
 structures, hot vaginal douches may be ordered twice daily, 
 after which the patient is instructed to assume the knee-chest 
 position for periods of from five to ten minutes, night and morn- 
 ing. This often diminishes the inflammation to such a degree 
 that manipulations on the part of the doctor are less painful 
 and more successful. After the uterus has been replaced it may 
 be held in position by pessaries. These are appliances, usually 
 of hard rubber, of various forms, which are introduced into the 
 vagina with the object of exerting pressure so as to hold the 
 uterus in place. Pessaries must never be sterilized by boiling 
 because, if they are made of rubber, boiling alters their shape. 
 If the uterus cannot be brought back by these measures, opera- 
 tive procedures must be resorted to. 
 
 Operations for Retroversion. — The purpose of all operative 
 procedure is to bring the uterus forward and upward to its 
 
110 TEXTBOOK OF SURGICAL NURSING 
 
 normal anatomical position and to hold it securely there. In 
 the majoi'ity of operations this is accomplished hy shortening 
 the round ligaments. The operation may be performed through 
 the inguinal canals, through the abdomen, and through the 
 vagina. 
 
 The inguinal canal route : — As the round ligaments help to 
 maintain the normal position of anteversion, they may be iso- 
 lated in the inguinal canal, drawn out and sufficiently shortened 
 so as to exert tension, and thus mechanically pull tlie uterus 
 forward into place. 
 
 The abdominal route: — The uterus is lifted from its retro- 
 verted position and the fundus is sutured to the anterior abdom- 
 inal wall directly (ventral fixation). Or the round ligaments 
 are sutured to the recti muscles (the so-called Gilliam operation 
 of ventral suspension). 
 
 The vaginal route: — The patient is placed in a lithotomy 
 position, and the operation done through the vagina. The uterus 
 is brought forward by suturing either to the anterior vaginal 
 wall, or the lower part of the bladder, or it is pulled into place 
 by shortening the round ligaments. 
 
 Prolapse of the Uterus. — This condition is often called "fall- 
 ing of the womb." Prolapse of the uterus is divided into three 
 degrees. The first degree is that in which there is a relaxation 
 of the pelvic floor with a protrusion of the vaginal walls ; in the 
 second degree, the cervix is found at the vulva ; and in the third 
 degree there is a mass of the uterus protruding from the vagina 
 and lying between the thighs. 
 
 Treatment of Prolapse. — The palliative measures are the use 
 of pessaries and tampons. A large circular rubber ring in the 
 vagina is often very efficacious in maintaining the uterus in 
 position. It is highly important that these pessaries be removed 
 at least once a month and cleaned, and at the same time the 
 vaginal canal be inspected to determine whether any irritation 
 is present. 
 
 The curative measure is operation. The uterus is brought 
 forward and upward by a ventral fixation and a perineorrhaphy 
 gives support below. In some cases it is often advisable to 
 remove the uterus (hysterectomy). 
 
NURSING OF THE REPRODUCTIVE SYSTEM 111 
 
 Tumors of the Uterus. — The uterus may give origin to benign 
 and malignant growths. The most common benign tumor is a 
 fibroid. These may cause bleeding (menorrhagia), vaginal dis- 
 charge, pain, and quite often a mass may be felt within the 
 abdomen. However, there are many women who have fibroids 
 which never cause symptoms. Fibroids are treated by X-ray, 
 radium, and operation. 
 
 Operative Treatment. — If the fibroids are single and do not 
 involve the entire uterus, the tumor may be enucleated 
 (myomectomy). If the tumors are multiple and involve most 
 of the uterus, the entire organ may be removed (hysterectomy). 
 This is an operation designed to remove the uterus. It may be 
 performed through the abdomen (supravaginal hysterectomy), 
 or it may be done through the vagina (vaginal hysterectomy). 
 
 Supravaginal Hysterectomy. — After the patient is anes- 
 thetized, she is placed in an exaggerated Trendelenburg position. 
 (Fig. 63, page 271.) The abdomen is opened by a median incision 
 and the intestines are carefully padded off with warm, moist 
 saline pads. The fundus of the uterus is seized with a vulsellum. 
 The broad ligaments on each side are clamped, and, if possible, 
 one of the ovaries is left. The uterovesical fold of the peritoneum 
 is incised and dissected toward the bladder. The uterine arteries 
 are then clamped and the uterus is amputated through the 
 cervix. The cervical stump is grasped with a second vulsellum, 
 and the cervical canal is cauterized with carbolic acid or iodine. 
 The cervix is then united in interrupted sutures, and the vessels 
 usually tied with plain gut. The round ligaments are sutured to 
 the cervical stump and the pelvic peritoneum approximated to 
 the pelvic peritoneum. This, of course, leaves a little cervical 
 tissue which may cause a persistent leukorrhea. To avoid this 
 the entire cervix may be extirpated. 
 
 When the pelvic operation has been completed, the patient 
 should be returned to the horizontal position and the abdominal 
 wall closed. Occasionally vaginal drainage is required. This 
 is done before the abdomen is closed by passing a curved clamp 
 into the vagina and pressing against the posterior vaginal wall 
 behind the cervix. The surgeon incises this area and introduces 
 
112 TEXTBOOK OF SURGICAL NURSING 
 
 a, cigarette drain into the elanip. When this is withdrawn, the 
 drain is })ulled down into the vagina. 
 
 There is no special nursing required post-operatively except 
 that a careful watch should be kept for hemorrhage. Occasion- 
 ally, although fortunately rarely, a ligature slips, and an uterine 
 artery will start to bleed. This requires immediate surgical 
 interference. Patients, as a rule, are kept in bed for about 
 sixteen days. 
 
 Vaginal Hysterectomy. — This is performed through the 
 vagina without an abdominal incision. It has no advantage over 
 the other except that it does not leave a scar. 
 
 Malignant Diseases of the Uterus. — These may either affect 
 the cervix or the body of the uterus. They are usually 
 carcinomatous in character. The treatment is either complete 
 hysterectomy, or tlie application of radium. 
 
 Diseases of Fallopian Tubes. — Any inflammation of the Fal- 
 lopian tubes is spoken of as salpingitis. It may be acute or 
 chronic. 
 
 Acute Salpingitis. — This may be due to an infection occurring 
 during labor, from unclean instruments, much instrumentation, 
 or a preexisting gonorrheal infection. The history usually given 
 is that of a vaginal discharge, abdominal pain of a colicky nature 
 and, in addition, the history of a recent labor, instrumentation, 
 or gonorrhea. 
 
 Treatment. — The treatment consists of absolute rest in bed 
 in the Fowler's position (Chapter IV, page 59). Hot vaginal 
 douches are given every six to twelve hours depending upon the 
 severity of the inflammation. Applications are made to the 
 lower abdomen, either in the form, of heat or cold, and move- 
 ments of the bowels should be assured by enemas. If the pain 
 is ver}'- severe, sedatives may be given. Very often these cases 
 of tubal infection are complicated by pelvic peritonitis resulting 
 in the development of a pelvic abscess. Instead of draining this 
 through the abdomen, the abscess may often be drained through 
 the vagina by making an incision between the posterior part of 
 the cervix and the posterior wall of the vagina. This is knowr^ 
 as a colpotomy. A good sized drainage tube is introduced into 
 the abscess cavity, but because of the dependent position, the 
 
NURSING OF THE REPRODIJCTIVE SYSTEM 113 
 
 drainage tube will not stay in place without some special 
 arrangement of a cross piece, so as to make a "T" tube. Great 
 care should be taken that the vagina is kept scrupulously clean, 
 and the drainage free. To accomplish this, vaginal irrigations 
 with normal saline solution should be given twice a day. 
 
 Chronic Salpingitis. — This may be a sequel of acute salpin- 
 gitis. The tube may either be bound down with fibrous adhe- 
 sions, or it may be dilated and filled with watery material 
 (hydrosalpinx); or it may be filled with pus (pyosalpinx). 
 Occasionally it may be tuberculous. 
 
 Symptoms and Treatment. — The symptoms are backache, 
 pain in the lower abdomen, menstrual disturbances, weakness, 
 and vaginal discharge. Physical examination may reveal a mass 
 in the pelvis. If the case is adjudged favorable for operation, 
 a low laparotomy is performed with the excision of the affected 
 tube (salpingectomy). There are no special ante-operative or 
 post-operative measures other than those which have been out- 
 lined in all other abdominal operations. 
 
 Ectopic Pregnancy. — The ovum is normally fertilized in the 
 tube, and it continues its journey until it reaches the uterine 
 cavity where it becomes implanted, and proceeds to develop. 
 Occasionally, however, the fertilized ovum becomes arrested in 
 the tube tind begins its development in this location. This is 
 spoken of as an ectopic gestation. The degree to which the tube 
 may increase in diameter because of the growing ovum is limited. 
 The result is that it ruptures, causing the death of the embryo, 
 and hemorrhage from the tube. This bleeding is a source of 
 great danger to the mother because it may result in death. 
 
 Symptoms. — The history, as a rule, is that of delayed 
 menstruation. The patient is seen generally after the tubal 
 rupture. This gives rise to sharp pains localized in the lower 
 abdomen, and fainting spells due to the loss of blood. If the 
 hemorrhage is marked, the patient will exhibit all its charac- 
 teristic signs. 
 
 Treatment. — Immediate operation is indicated, for the bleed- 
 ing from the tube must be stopped by salpingectomy, and the 
 tubal branch of the ovarian artery ligated. The free blood in 
 the pelvis is removed by sponging or aspiration through suction. 
 
114 TEXTBOOK OF SURGICAL NURSING 
 
 Post-operative Care. — As these patients are suffering, as a 
 rule, from loss of tluid, saline is given intravenously, and, as 
 soon as possible, a blood transfusion. They are kept warm like 
 other shocked patients, but if it can be avoided, the shock posi- 
 tion is not used. As soon as they have recovered sufficiently tliey 
 are placed in the Prowler position. Cleans are taken, as soon 
 as practical, to increase their red blood cells by the use of 
 tonics, and the administration of iron in the form of Blaud's 
 pills. 
 
 The Ovary. — The ovary besides secreting the ovum possesses 
 an internal secretion which exercises a very important part in 
 maintaining the normal nervous mechanism of the individual. 
 Removal of both ovaries results in the complete cessation of 
 menstruation and a train of ner\'ous symptoms which make 
 these patients objects of pity. They become very excitable, 
 nervous, melancholy, and often so desperate that they have 
 ended their existence by suicide. It is now the custom, when- 
 ever possible, to leave some part of the ovarian tissue, and should 
 it be absolutely necessary to remove all of it, as in radical pan- 
 hysterectomies for cancer of the uterus, the patient may be fed 
 the ovarian extract of the animal. It is surprising what good 
 results will follow. 
 
 Diseases of the Ovary. — Ovaritis is an inflammation of the 
 ovary, rarely primarily diseased but usually secondary to tubal 
 inflammation, which results in adhesions between both structures 
 producing a condition spoken of as ''diseased adnexa" or sal- 
 pingo-oophoritis. The symptoms are similar to those of salpin- 
 gitis and the treatment employed is the same. 
 
 New Growths. — Cysts. — More than any other organ, the 
 ovary is apt to give rise to cysts and c^'stic degeneration. The 
 cysts may be of small size, or grow to enormous dimensions 
 weighing more than twenty pounds. They may be filled with a 
 clear viscid fluid or with other cellular materials. Types of the 
 last named variety are occasionally called cystadenomas. Cer- 
 tain of these tumors, if their contents are spilled over the peri- 
 toneal cavity, will cause secondary tumors acting much like 
 malignant growths. 
 
 Dermoid Cyst. — These are tumors which contain remnants 
 
NURSING OF THE REPRODUCTIVE SYSTEM 115 
 
 of the epidermis, such as hair; in addition bone is often found 
 as well as other tissues. 
 
 Carcinoma. — The ovary may be the seat of carcinomatous 
 tissue and cancers of the ovary are frequently malignant, 
 metastasizing early. 
 
 Treatment of Cysts. — In the case of simple cysts, only part 
 of the ovary affected may have to be removed, or if the entire 
 ovary is filled with many small cysts, a complete oophorectomy 
 may be performed. It is highly important that cysts of the ovary 
 be delivered intact. Every effort should be made to preserve 
 their integrity, for occasionally a cyst may be of the adenomatous 
 variety, and if accidentally ruptured, the fluid escapes into the 
 general peritoneal cavity and implantation growths take root. 
 
 In carcinoma of the ovary, the treatment, of course, is extirpa- 
 tion with subsequent X-ray or radium treatment. The general 
 outlook of patients with ovarian carcinoma is indeed poor. 
 
 The Testicle. — This is the male organ of generation and cor- 
 responds to the ovary. It consists of the testes proper which 
 manufacture the spermatozoa, and the epididymis which is 
 really a series of canals collecting the sperm from the glandular 
 substance of the testes. These tubules, or canals, unite to form 
 a single duct, the vas deferens, which carries the testicular 
 product to the seminal vesicles, small pouches situated behind 
 the prostate which open into the floor of the prostatic urethra 
 together with the openings of the prostate gland. The prostate 
 gland lies in front of the bladder surrounding the prostatic 
 urethra and secretes the fluid which nourishes the spermatozoa 
 and gives the seminal fluid its characteristic qualities. 
 
 While the great majority of these cases will be handled by 
 orderlies and trained attendants, circumstances may arise which 
 will necessitate that they be cared for by skilled nurses. 
 
 Acute Inflammation of Testicle and Epididymis. — Probably 
 the most common cause of the acute inflammation is gonorrhea 
 affecting the epididymis mainly, although it may be secondary 
 to certain, chronic diseases such as gout, or trauma from urethral 
 instrumentation. 
 
 Symptoms. — There are pain, swelling, tenderness of the epi- 
 
116 TEXTBOOK OF SURGICAL NURSING 
 
 didymis, and systemic symptoms of anorexia, fever, and general 
 malaise. 
 
 Treatment. — The patient is ordered to bed, and the testicle 
 is elevated by plaeinfi: beneath the scrotum broad strips of adiie- 
 sive plaster which are fastened to the shaven thighs. Local 
 applications to the scrotnm may be made in the form of heat or 
 cold. Probably the application bearing heat which is lightest 
 in weight is the flaxseed poultice. If ice is nsed it should not be 
 left on continuously, but on for two hours and off for one. An 
 enema should be given daily, and the patient forced to drink 
 water in large amounts. AVlien the condition is due to gonorrhea, 
 the patient should be placed upon individual precaution. After 
 the acute symptoms have subsided, the patient may be allowed 
 up, but the scrotum should be firmly supported by a suspensory 
 for some time. 
 
 Chronic Inflammation of Testicle and Epididymis. — These are 
 secondary to acute inflammations, or due to syphilis or tuber- 
 culosis. If syphilitic in nature the patient is given antisyphilitic 
 treatment in the form of mercury and salvarsan. If tuberculous, 
 the best procedure is operative. 
 
 Symptoms. — The pain is not so severe as in acute inflamma- 
 tions. In the cases of tuberculosis, there may be a sinus in the 
 scrotum discharging pus from the diseased epididymis. 
 
 Treatment of Tuberculosis. — Tuberculous epididymitis, when 
 only one side is involved, is treated by orchidectomy (excision 
 of the affected testicle). These cases require no special nursing 
 (care except that they should be placed upon individual precau- 
 tions and kept out in the open air as much as possible. 
 
 Hydrocele. — Lying in front of the testis and epididymis there 
 is a small sac called the tunica vaginalis. This may become filled 
 with fluid causing a hydrocele of the tunica vaginalis. As a rule 
 it is not painful but uncomfortable because of its mere mechan- 
 ical presence. 
 
 Palliative Treatment. — In this procedure a needle or a trocar 
 and canula are inserted into the hydrocele sac and the fluid 
 withdrawn. After most of the water has been tapped, some 
 surgeons reinject an irritathig fluid, such as a mild solution 
 
NURSING OF THE REPRODTICTTVE SYSTEM 117 
 
 of carbolic and iodine, trusting that tlie irritation will cause the 
 obliteration of the sac of the tunica vaginalis. 
 
 Operative Treatment. — The operative procedure may be done 
 under novocain. The scrotum is washed with green soap, alco- 
 hol and ether. The skin of the scrotum is anesthetized. The dis- 
 tended tunica is delivered into the wound, incised, part of it 
 cut away, and the remainder sutured behind the testicle proper, 
 destroying the sac. 
 
 Post-operative Treatment. — The scrotum is supported upon 
 a bridge and a moderate amount of pressure is applied to it to 
 prevent post-operative bleeding. 
 
 Varicocele. — Lying in the scrotum along with the spermatic 
 cord is a plexus of veins. These very often become hypertrophied 
 or increased in size and number, occasionally causing pain and 
 a dragging sensation in the scrotum. This may be remedied by 
 partially excising the veins through the scrotum, or just above 
 the external abdominal ring. The only post-operative care is 
 the support of the testicles by an adhesive bridge, and the wear- 
 ing of a suspensory bandage subsequently. 
 
 New Growths of Testicle: — The testicle, like the ovary, may 
 be a location for cysts, spermatocele, dermoids, or carcinoma. 
 In the cases of cancer, a radical excision of the testicle together 
 with the vas deferens and the lymph glands draining these 
 regions is performed but the operation is attended with very 
 much shock, and the mortality is extremely high. 
 
 Prostate. — One of the most common operations done upon 
 the male genital tract is that of prostatectomy, removal of the 
 prostate gland. This is performed for simple hypertrophy, or 
 for cancer. It is known that the prostate consists mainly of three 
 lobes, the middle coming into close relationship with the urethra 
 and the lateral lobes coming into relationship with the rectum. 
 When the prostate increases in size, it follows the path of least 
 resistance and projects into the bladder, and the increase in the 
 size of the median lobe interferes with the free passage of urine 
 because it obstructs the internal opening of the urethra. This 
 results in frequency of urination, then urinary retention which 
 must be relieved by a catheter, and from frequent catheteriza- 
 tions a condition of cystitis is very often established. The 
 
lis TEXTBOOK OF SURGICAL NURSING 
 
 suffering is quite severe, and the only measure affording perma- 
 nent relief is the removal of the obstruction (prostatectomy). 
 
 Prostatectomy. — This operation is often preceded by a period 
 of improving the patient's nutrition, and his urinary output by 
 regular catheterizations. The operation resolves itself into a 
 choice of perineal or suprapubic prostatectomy. 
 
 Perineal Prostatectomy. — The perineum is shaved and eight 
 hours before operation the usual soapsuds enema is given. 
 The patient is placed in a lithotomy position with the pelvis 
 raised by sandbags and the prostate is enucleated through the 
 perineum. 
 
 Post-operative Treatment. — The retained catheter is con- 
 nected to bottle drainage and the urine collected. The gauze 
 tampon which usually occupies the space of the removed pros- 
 tate is taken out on the fifth day; the catheter is removed on 
 the seventh, and from then on the urethra is treated with sounds 
 of various sizes. 
 
 Suprapubic Prostatectomy. — In this procedure the prostate 
 is removed through the bladder. It is done in two stages. The 
 first operation is a suprapubic cystotomy, the second the actual 
 removal of the gland through the previous bladder wound. 
 
 First Stage: — As a rule, catharsis is given forty-eight hours 
 previous to the day of operation. Before operation the bladder 
 is irrigated and often some novocain or alypin is injected. The 
 bladder is kept distended and the cystotomy is done under local 
 anesthesia. A button drainage tube is placed in the opening of 
 the bladder and the tube clamped. When the patient arrives in 
 his room the clamp should be removed from the tube and the 
 bladder drained continuously, or intermittently. The diet 
 should be very light and soft, fluids allowed in liberal amounts. 
 
 Second Stage: — While some surgeons proceed to enucleate 
 the prostate immediately after cystotomy, the majority wait 
 five or more days before completing the operation. Naturally 
 there will be rather a profuse hemorrhage following the blunt 
 dissection of the gland. This may be controlled by tampons, 
 but a better result is obtained if a bag hemostat is used. This is 
 made of rubber, is inflatable and when distended and placed 
 within the bladder exerts pressure on the bleeding areas. One 
 
NURSING OF THE REPRODUCTIVE SYSTEM 119 
 
 connection of the bag passes through the urethra, and is the 
 means by which air is introduced. This is removed in twenty- 
 four to forty-eight hours. 
 
 The suprapubic wound is freely drained, and at the end of 
 forty-eight hours a button tube is inserted, connected to the 
 bottle drainage and the patient allowed out of bed. At the 
 end of a week the patient is encouraged to void, and as soon as 
 he does so in sufficient amounts, the suprapubic tube is removed. 
 Of course, the urine will leak in small amounts, but the sinus is 
 healed in from the thirteenth to the twentieth day. 
 
 Cancer of Prostate.— In the early stages this is treated by 
 prostatectomy. In the late periods, radium is tried as a pallia- 
 tive procedure. 
 
CHAPTER IX 
 
 THE SURGERY AND SURGICAL NURSING OF THE 
 RESPIRATORY SYSTEM 
 
 The organs which constitute the respiratory system may be 
 classified as the accessory and the main groups. 
 
 rnares 
 Accessory System: 1. Nose -I septum 
 
 [sinuses 
 
 2. Mouth 
 
 f nasopharynx 
 
 3. PhaiTnx|^^^pj^^^y^ 
 
 Main System: 1. Larynx 
 
 2. Trachea 
 
 3. Bronchi 
 
 4. Lungs and Pleura 
 
 The mouth and pharynx are discussed under the Alimentary 
 System. 
 
 Nose. — The nose serves the very important function of filter- 
 ing, warming, and moistening the air. In addition to aiding 
 the sense of smell, it also gives the voice some of its qualities. 
 The diseases which affect the nose are many and well known. 
 The only pathological conditions of interest here are those 
 resulting from obstruction from a deviated septum or hyper- 
 trophy of the turbinates (bones in the nares) and infections 
 of the various sinuses. 
 
 Deviated Septum. — In this condition one or both sides of the 
 nose are occluded by a deformity of the nasal septum, and an 
 attempt is made to remove the obstructing cartilage by a sub- 
 mucous resection preserving the mucous membrane of the sep- 
 tum. After the operation has been completed, each nasal cavity 
 is packed, with strips of sterile gauze. The packing is removed 
 after twenty-four hours. 
 
 120 
 
NURSING OF THE RESPIRATORY SYSTEM 121 
 
 Hypertrophy of the Turbinates. — The turbinates are small 
 bones, three in number, found along the outer wall of each nasal 
 cavity. Occasionally these increase in size and obstruct free 
 respiration. They may be reduced by chemical irritants, cautery, 
 or partially removed by cutting them with a wire snare. Occa- 
 sionally, hemorrhage may follow the removal of part of the turbi- 
 nate bones. This may be controlled by spraying in some adrena- 
 lin solution, syringing the nose with hot water (temperature 
 about 120 degrees) or plugging the nose with cotton. Most of 
 these operations are done under novocain. 
 
 Sinusitis. — The sinuses of the nose may be frequently in- 
 volved during a cold, and very often the frontal, ethmoidal, 
 sphenoidal sinuses, or the antrum may be the seat of infection. 
 This condition is recognized by pain in the region of the sinus 
 involved, discharge, and tenderness on pressure over the sinus. 
 The treatment consists in establishing free drainage. In the 
 case of the antrum of Highmore, this is done by punctures of 
 the sinus and daily irrigations through the nose. 
 
 The Larynx. — Those conditions affecting the larynx which 
 are of interest from a surgical viewpoint may be divided into 
 the foreign bodies lodged in the larynx, and new growths. There 
 are many other conditions, such as acute and chronic inflamma- 
 tions, syphilis and tuberculosis, which require attention, but 
 they fall into the provinces of the laryngologist, and he person- 
 iilly gives most of the necessary treatments. 
 
 Foreign Bodies. — The most common way for foreign bodies 
 to lodge either in the larynx, or further down in the trachea, is 
 for the individual to swallow them. The symptoms which are 
 produced will vary according to the size of the body and its 
 location in the respiratory tract. Sometimes they are expelled 
 by coughing; at other times they may remain. Cases are not 
 rare in which the material has been of sufficient bulk to occlude 
 the larynx, with death immediately ensuing from asphyxiation. 
 
 Treatment. — Slapping the patient on the back, or inverting 
 him may dislodge the foreign body. Or, if the patient is not 
 so fortunate, it may be removed with forceps under direct vision, 
 or either a Killian or Jackson laryngoscope may be necessary. 
 These are instruments designed to enter the larynx. The 
 
122 TEXTBOOK OF SURGICAL NURSING 
 
 pharynx and larynx may be (.'ocainized, or the patient may be 
 placed under deep anestliesia. The laryngoscope is passed 
 throngh the month and jiliarynx into the larynx^ the head and 
 neck being bent baek^vard, and the foreign body removed 
 through the instrument. 
 
 Occasionally, the condition is so urgent that to relieve the 
 asphyxia, an opening must be made into the trachea below the 
 point of obstruction, so that air may enter the lungs. This 
 opening of the trachea is spoken of as tracheotomy. 
 
 Tracheotomy. — A tracheotomy is an incision into the trachea 
 in order that a tube may be introduced therein, thus pro- 
 viding for the entrance and exit of air. This may be done either 
 as an emergency measure following a thyroid operation in which 
 the trachea has collapsed, when a foreign body has become lodged 
 in the larynx so that respiration is embarrassed, in acute edema 
 of the glottis, or in obstruction asphj-xia during the adminis- 
 tration of an anesthetic. It may be employed as a preliminary 
 measure to a removal of the larynx for cancer. The operation 
 is either high or low, the high being preferable, because the 
 trachea is more accessible ; the low being done when the operator 
 has to reach a foreign body which has fallen into one of the 
 bronchi. 
 
 Operation. — The patient is placed upon the back with a 
 sandbag underneath the neck so as to make the trachea as promi- 
 nent as possible. An incision is made in the midline, the mus- 
 cles separated, the trachea exposed, incised, and a tracheotomy 
 tube introduced. These tracheotomy tubes are of various types, 
 but the one generally used is similar to Fig. 16. It is very 
 important, after the tube has been introduced, to see that it is 
 patent, and that respiration is taking place freely. As a pre- 
 caution, tape is usually threaded through the tube so that it 
 will not slip down the larynx in any disorder which might 
 ensue. Inasmuch as the outer tube comes into direct contact 
 with the skin, it is a good plan to have a fine layer of gauze 
 covered wdth boric ointment inserted between the tube and skin. 
 
 Post-operative Treatment. — The tracheotomy tube is a new 
 passage through which air is drawn into the lungs, and since 
 the air is no longer brought through the normal channels, it is 
 
NURSING OF THE RESPIRATORY SYSTEM 123 
 
 important that above all the tube should be kept patent and 
 clean. In order to ensure perfect cleanliness and free respira- 
 tion through the tube, nurses must be on duty day and night 
 ever alert to see that the patient has plenty of air. The inner 
 tube should be removed about two or three times a day, cleansed, 
 sterilized, and gently reinserted. It should never be cleaned in 
 situ, i. e., as it rests in the patient's trachea. If at any time 
 the tube should become suddenly plugged, the inner tube must 
 be withdravt^n immediately. At times the patient is apt to cough, 
 and the mucus which makes its appearance 
 at the orifice of the tube should be wiped / . 
 
 away very gently. Occasionally from .-l^r^v.-''-fl 
 
 coughing violently both the inner and outer vC^Jl 
 
 tubes may be expelled, and for this reason /S^^T" ^ 
 
 it is always important to keep a trache- X / i 
 
 otomy dilator on hand to meet this im- ft^y^ e 
 portant emergency. This instrument will ^-^ 
 keep this passage open until another tube y 
 
 may be obtained and inserted. -p^^^ 26. Tracheot- 
 
 Another important thing in these cases omt Tube. A, outer 
 . , 1 ,1 . .1 • 1 • 1 • tube; B, inner remov- 
 
 is to remember that the air which is now ^^^^q tube- C, safety 
 
 inspired no longer has the advantage of ^ard ; D, catch to hold 
 
 inner tube m place; E, 
 ' being warmed and freed from dust by the slot through which tape 
 
 nasal passages. For this reason in the -J^./yi^.^^^^fj^^^^ 
 beginning, thin layers of gauze which have 
 
 been wrung out in warm water should be placed over the trache- 
 otomy orifice and changed every half hour. Some surgeons 
 keep the patient under a croup tent so that the air may be 
 warmed by the steam and the respiratory tract have the advan- 
 tage of a warmed air. Compound tincture of benzoin may be 
 added to the croup kettles. 
 
 There are very few conditions which require more conscien- 
 tious nursing than do these patients, because their life is abso- 
 lutely dependent upon the uninterrupted inflow and outflow 
 of air through the tube. They should never be left alone, for 
 one never knows at what moment the tube may become plugged 
 and the patient become suddenly asphyxiated. Occasionally 
 mucus may collect in the trachea and not be expelled through 
 
124 TEXTBOOK OF SURGICAL NURSING 
 
 the tube. The reason for this is that the cough is insufficient in 
 strength to expt'l the iiiiicous \)\\\\x- In these eoiulitioiis a steril- 
 ized featlier might be introduced through the tube and the 
 trachea tickled, so as to incite coughing. The time for the per- 
 manent renio\al of the lubt' is i)urely at the discretion of the 
 surgeon. Very ol'icn some surgeons will remove the double silver 
 tuhe and replace it l)y a rubber one. tluMi remove the rubber one 
 when they see fit. 
 
 New Growths of the Larynx. — The larynx, like the other 
 organs in the body, may be the seat of benign or malignant 
 growths. Probabl}' the most common of the benign growths is 
 the iiapilloma. These growths may be removed in three ways: 
 through the larynx with the aid of the lar.yngeal mirror ; from 
 without by performing a thyrotomy (an incision through the 
 thyroid cartilage of the larynx), or through a Jackson or 
 Killian larjmgoscope. The instruments used for their removal 
 may be the snare, curette, forceps or galvano-cautery. 
 
 Malignant Growths, — The symptoms of a cancer infiltrating 
 the lar3'nx may be A^ery similar to those produced by the benign 
 growths. Hoarseness, later loss of voice, respiratory difficulty, 
 and pain are very common. Later when the growth extends and 
 ulceration becomes evident, cough and pain on swallowing may 
 be very evident. The only treatment is surgical. Either one- 
 half or the entire larynx may be removed. 
 
 Laryngectomy. — As the name implies the operation is one 
 in which the larynx is excised. The operation itself is preceded 
 by a tracheotomy. This may be done as a preliminary operation 
 one day, the remainder of the operation being performed at 
 another time, or the entire operation may be done at once. 
 
 Operation. — The first part of the procedure is practically the 
 same as a tracheotomy except that the trachea is blocked by the 
 use of a Hahns canula. This is done to prevent the blood from 
 the laryngectomy from leaking down the trachea into the lungs. 
 The canula is simply a tracheotomy tube which has been previ- 
 ously boiled and to which is attached and securely fastened a 
 sponge scpieezed dry and dipped in a ten per cent, ether solution 
 of iodoform. The sponge has been previously sterilized by soak- 
 ing in a 25 per cent, alcohol solution for several days. The 
 
NURSINa OF THK RI^:SIM R ATORY SYSTEM 125 
 
 tube with the sixjji^'c is introduced dry. Al'lcj- it is in llic trachea 
 from five to ten minutes there is usually enough moisture gener- 
 ated to swell the sponge and block off the larynx above. The 
 technic of the operation is unimportant. The Ilahns eanula is 
 taken out after eight hours and the tracheotomy tul)e introduced. 
 
 Post-operative Treatment. — Since the larynx has been re- 
 moved and the pharynx has just been sutured, it is highly impor- 
 tant that the patient be fed for the first few days by rectum. 
 For the next four to five days feedings should be administered 
 through the nose by catheter, and within a week as a rule, the 
 patient is able to swallow. Of course, in the beginning, only 
 soft diet should be allowed. These patients are very much 
 depressed because of the loss of voice, but they soon learn to 
 whisper and make themselves understood. 
 
 Injuries to the Thoracic Wall. — Injuries to the thoracic wall 
 may be the result of bullets, stab wounds, or compound fractures 
 of the ribs. The latter occur quite often following severe com- 
 pressions of the chest, such as occur in "run-over" accidents. 
 Wounds of the chest may be superficial, involving skin and 
 muscle, or deep, penetrating the pleural cavity. The dangers 
 of the last named variety are the complications of pneumothorax 
 (air in the pleural cavity with collapse of the lung), hemo- 
 thorax, a condition in which the pleural cavity is filled with blood 
 due to injury of the blood vessels of the lung itself; or, the 
 possibility of a superimposed infection of the pneumothorax 
 ( pyopneumothorax) . 
 
 Treatment of Injuries to the Thoracic Wall. — This is usually 
 surgical in nature. The wound is thoroughly cleansed and the 
 hemorrhage controlled. If any of the ribs have been fractured, 
 they are securely strapped and the patient kept in bed for a few 
 days. Many of these cases, especiallj^ those with deep, penetrat- 
 ing wounds, develop serious complications, such as pneumonia, 
 or infection of 'the pleural cavity (empyema). 
 
 Empyema. — One of the complications that may occur in chest 
 conditions is empyema, an infection of the pleural cavity. This 
 is usually the result of a pneumonia and rarely occurs as a 
 primary condition. 
 
 Symptoms. — The patient gives a previous history of pneu- 
 
126 TEXTBOOK OF SURGICAL NURSING 
 
 nioiiia, as a rule. After Ihc piuMiiiKniiii luis rcsdlvcd, or even 
 before this period, a siuldcii rise in Iciiipcraliire may oeciir, 
 aceompanied by fever, cliills, and tlic pl\ysieal signs of Hnid in 
 the pleural cavity. This eollection of iiuid or pus may be 
 general in nature, or localized (sacculated). As pus in olliei- 
 parts of the body usually requires drainage as soon as it is 
 formed, here also an attempt should be made to remove it. 
 
 Treatment. — "While it was customary before the war to re- 
 sect a rib and insert a drainage tube into tlie pleural cavity as 
 soon as a diagnosis of empyema was made, army experience has 
 taught that such radical procedure is not always necessary. 
 In fact, in the beginning, it is better to draw off tlie fluid which 
 has accumulated with a needle and syringe, or Potain aspirator, 
 thereby relieving the patient, and at the same time, reducing 
 certain elements which might lessen the shock at the time of the 
 future operation. It is also true that some of the patients 
 recover with this simple aspiratory procedure, although the great 
 majority must have a more radical operation performed sooner 
 or later. The more radical procedure consists in the partial 
 excision of one of the lower ribs so that better and more adequate 
 drainage maj^ be secured. 
 
 Operative Treatment. — Inasmuch as these patients are in a 
 weakened physical condition from their pneumonia, or from the 
 absorption of the poisons of the pus in the pleural cavity, it is 
 advisable not to administer a general anesthetic, but to employ 
 local anesthesia. This works with remarkable success. 
 
 Since the patients feel more comfortable when sitting almost 
 upright, the operation is performed in this position. An aspi- 
 rating needle with syringe locates the area of pus ; its location is 
 the determining factor as to which rib is to be partially resected. 
 In general empyema or suppurative pleurisj^, the incision is 
 generally made along the eighth or ninth ribs. A part of the 
 rib is removed subperiosteally, exposing the periosteum beneath 
 which is the outer surface of the pleura. The pleura is then 
 opened by incision and the pus allowed to gradually escape. 
 A drainage tube is then placed into the pleural cavity. 
 
 There are many ways of draining the thoracic cavity. Some 
 employ a Brewer tube (Fig. 17) ; others a simple rubber drain- 
 
NURSING OF THE RESPIRATORY SYSTEM 127 
 
 age tube. In empyema cases, great care should be taken that the 
 number of drainage tubes used be carefully noted and recorded. 
 The pleural cavity is a notorious hiding place for them, and 
 very often a lost tube is the reason for a persistent sinus con- 
 tinually discharging large quantities of pus. 
 
 After Treatment. — Inasmuch as the discharge from the 
 pleural cavity is moderately free, very often the drainage tubes 
 are connected with bottle drainage. Occasionally, when a 
 Brewer tube is employed, a piece of rubber 
 dam is snugly fitted around the free end of 
 the drainage tube, and the open end of the 
 dam is placed in a bottle under a water level 
 so that while the pleural fluid may escape 
 from the chest no air can enter the pleural 
 cavity. The result of this is that a negative 
 pressure is soon established, the lungs expand 
 earlier, and the patient's convalescence is 
 shortened. 
 
 The discharge is rather copious for the first 
 few days and superficial dressings must be 
 changed and reinforced whenever necessary. 
 After a few days the tubes within the chest 
 are gradually shortened, and as soon as the 
 discharge is very thin and the temperature 
 is normal, the tubes may be withdrawn alto- 
 gether. While the patients are in bed, they 
 should be encouraged to breathe as deeply as 
 possible so as to aid the expansion of the collapsed lung. With 
 this end in view, they should blow fluids from one bottle into 
 another, and children should be given those toys which encourage 
 blowing, such as horns or balloons. If the temperature suddenly 
 rises after the drainage has been removed, it simply means a 
 reaccumulation of fluid in the pleural cavity, and necessitates 
 an immediate reinsertion of the tube. 
 
 These patients should be allowed out of bed as soon as possible, 
 and wheeled into the open air. If the weather is clear, their beds 
 might even be moved into the open. The diet should be high in 
 
 , C 
 
 Fig. 17. — Brew- 
 er Empyema Tube. 
 A, Rubber Disc 
 resting tightly 
 against parietal 
 pleura; B, rubber 
 disc resting tightly 
 against skin ; C, 
 rubber tube con- 
 nected to bottle 
 drainage. 
 
128 TEXTBOOK OF SURGICAL NURSING 
 
 carbohydrates, and tonics should be given to restore their lost 
 strength. 
 
 The Lungs. — The surgery of the lungs is still in its early 
 stages of development, and the operations done upon these 
 essential organs of respiration are but few in number. This is 
 due to the mechanical difficulty of apjiroach and exposure 
 through the thoracic wall, and because of the difficulty of main- 
 taining the potential negative pressure during an operation. 
 The latter normally exists between the parietal pleura lining 
 the interior of the thoracic wall and the visceral pleura which 
 covers the lungs themselves. In the various phases of respira- 
 tion, the parietal and visceral pleurte are continually in con- 
 tact; but should, for some reason, the air from the outer world 
 enter this space, either by rupture of the lung tissue itself or 
 through the thoracic wall, the negative pressure will be destroyed 
 and the lung will collapse. A large space filled with air will thus 
 be left between the parietal and visceral pleura. If this is remem- 
 bered it will not seem strange that pleural and lung conditions 
 take such long periods of time to return to normal after opera- 
 tion, for the infection of this large rigid cavity must be sterilized, 
 the air within the chest absorbed, and the lung permitted to 
 expand with the reestablishment of the negative pressure. 
 
 Operations upon the Lungs. — There are several indications 
 in surgery for operations upon the lungs themselves. Occasion- 
 ally, it is advisable to remove a lobe of the lung because of some 
 extensive infective condition, such as an abscess. As already 
 mentioned, the normal thoracic cavity is under negative pressure, 
 and when an opening is made communicating the pleural cavity 
 with the external world, this negative pressure is destroyed, the 
 lung collapses and expansion is impossible. There are two 
 methods which aim to overcome the collapse of the lung. One 
 is to do the operation in a chamber which is under negative pres- 
 sure so that there is practically no difference between the nega- 
 tive pressure in the pleural cavity and the negative pressure in 
 the room. By the other method, the air is under increased 
 pressure and is introduced within the lung so that the lung is 
 kept expanded even though the negative pressure within the 
 thorax is destroyed. 
 
NURSING OF THE RESPIRATORY SYSTEM 129 
 
 Methods for Maintaining Negative Pressure. — This may be 
 accomplished by two main methods. The operation may be 
 performed in a special negative pressure chamber. The rooms 
 were designed by Sauerbruch, and are portable. By the other 
 method, the ordinary operating room is converted into a nega- 
 tive pressure chamber, the patient's head being passed through 
 an opening in the wall, so that it is under positive pressure, while 
 the thorax and the rest of the body within the room itself are 
 under the negative. The negative pressure used is from eight 
 to ten millimeters of mercury. 
 
 Positive Pressure Method. — This method consists in keeping 
 the lungs expanded by forcing air under pressure into them 
 through the trachea. A catheter is passed through the mouth 
 into the trachea and a stream of warm air under pressure mixed 
 with vaporized ether is forced through by means of a pump. 
 This is successful, and does not require as much time or prepara- 
 tion as the negative pressure variety of operations. 
 
 Foreign Bodies in the Lungs. — Very often foreign bodies be- 
 come lodged in the lungs, if they pass the trachea and bronchi 
 without being obstructed ; they may be localized by means of the 
 X-ray if the body is opaque, or with the bronchoscope, an instru- 
 ment for looking directly into the bronchi. Quite often they 
 may be removed through these instruments or, in very rare 
 instances, the lung may be incised to remove the foreign bodies. 
 
 Pulmonary Tuberculosis. — While this does not come under 
 the general surgical field, still the surgeon very often is called 
 upon to inject air into the pleural cavity to cause the collapse 
 of the lung. The purpose is to give the lung a rest by collapsing 
 it with the hope that the increased circulation may conquer the 
 tubercular infection. The gas, which is purified nitrogen, is 
 introduced by means of a needle. 
 
CHAPTER X 
 
 THE SURGERY AND SURGICAL NURSING OF THE SKIN AND 
 
 APPENDAGES 
 
 Surgical Conditions Involving- the Skin. — A wound may be 
 defined as a discontinuity of tissue. It may be superficial or 
 deep, clean or contaminated, accidental or intentional. For 
 purposes of classification, wounds may be divided into abra- 
 sions, contusions, punctures and lacerations. When the surface 
 layers of the epithelium are scraped away, the wound is spoken 
 of as an abrasion; when they have been destroyed by some 
 pressure, but yet not actually removed, a contusion results; a 
 punctured wound is the type left by a nail or awl ; a laceration 
 is caused by the deeper layers of the skin together with the 
 epithelium being torn. All these wounds may be clean or in- 
 fected. If they are clean they will heal in the manner de- 
 scribed in Chapter II. If they are infected by bacteria, the 
 various sequellae which have been already outlined may ensue. 
 
 Treatment. — Hemorrhage should be arrested first; then any 
 foreign material which may be present is removed, and the 
 wound sterilized and protected from any further contamination 
 by a dressing and bandage. 
 
 In most wounds, hemorrhage may be arrested by simple 
 pressure, provided that no deep blood vessels are cut. This 
 pressure should be applied directly over the bleeding surface, 
 the material used being any sterile gauze, or in emergencies, a 
 freshly laundered handkerchief. Should the bleeding still be 
 profuse the measures outlined in Chapter III may be tried. 
 After the bleeding has been controlled, the wound should be 
 cleansed by simple irrigation with sterile water or a weak 
 solution of iodine. 
 
 Antiseptics. — The application of iodine to a bleeding sur^ 
 face is of little avail, for it has been definitely proven that 
 iodine here has little or no effect. Tincture of iodine on a dry 
 
 130 
 
NURSING OP THE SKIN AND APPENDAGES 131 
 
 surface is indeed efficacious and all lacerations, even though 
 the infection be doubtful, should be thoroughly iodinized. In 
 the application of iodine to abrasions, it must be remembered 
 that if more than one coat is given, it is very apt to burn the 
 skin. Thoughtless painting and repainting of small abrasions 
 occurring in the tender skin of children or women may result 
 in a burn which is much worse than the original injury. Some 
 surgeons prefer to use peroxide of hydrogen. All wounds which 
 have come into contact with manure and dirt should be cleansed 
 first with peroxide of hydrogen and then iodinized. Of course, 
 the number of antiseptics used are many, but experience has 
 shown that while some antiseptics certainly kill bacteria, they 
 may destroy the tissues themselves, and occasionally poison the 
 individual. Because of this, bichloride of mercury and carbolic 
 acid have fallen into disrepute. They possess extremely irri- 
 tating properties and there is always danger entailed in their 
 use. The popular antiseptic at present is one which has been 
 developed during the war and w^hich has had such wonderful 
 success in the sterilization of wounds. It is the Dakin solution 
 and a complete discussion of it will be found in Chapter XIX. 
 
 After tlie bleeding has been stopped, and sterilization has 
 taken place, the wound should be protected from foreign ma- 
 terials such as dirt or bacteria. Sterile gauze is applied, either 
 dry or greased with some sterile ointment (boric acid, vaseline, 
 or liquid albolene), to prevent it from sticking to the wound. 
 The dressing may be held in place by strips of adhesive plaster 
 or a bandage, whichever suits the location of the injury the best. 
 All dressings should be made as small and inconspicuous as 
 possible both for cosmetic effect and reasons of economy. 
 
 Lacerated Wounds. — Wounds which gape considerably are 
 sutured because the period of healing and the amount of scar 
 tissue are thus lessened. The material used for the suture of 
 wounds may be horsehair, silk, silkworm gut, plain, or chromic 
 catgut described in detail in Chapter XV. For wounds of the 
 face, horsehair is the material of choice on account of its fine tex- 
 ture. For deeper wounds, material possessing a greater strength, 
 either silk or silkworm gut, is used. The needles employed are 
 full curved, or straight, small Hagedorn type. Care should al- 
 
182 TEXTBOOK OP SURGICAL NURSING 
 
 ■ways 1)0 taken flial llie eye o\' llic lu'ctllc is patent and the cutting 
 edge keen and sli;irp. Needle holders should always accompany 
 needles. , The type of holder depends upon the idiosyncrasy of 
 the surgeon. To summarize then : The arrest of hemorrhage, 
 the cleansing and sterilization of the wound and its protection 
 from infection are the essentials in the minor surgical proce- 
 dures involving the skin and deeper tissues. Nurses are always 
 expected to have those things prepared which are necessary for 
 the fulfillment of these essentials. 
 
 Infected Wounds. — If a wound is infected, the aim of the 
 surgeon is to liberate the pus, establish its free drainage, steril- 
 ize the wound and convert an infected into a clean one. To 
 obtain free drainage, an incision is made, or in a recently sutured 
 wound, a few sutures are removed, and to aid the free escape 
 of pus, a drain is inserted. In small infections the incision is 
 done under local anesthesia with a knife (scalpel). Knives 
 should always be sharp and keen as razors. Drains are the 
 handiwork of a nurse and their manufacture should be clearly 
 and thoroughly understood. The types of drains and their 
 method of preparation are described in detail on pages 310-311, 
 Chapter XVII. AVhile the drainage secures the escape of pus, its 
 freer exit is promoted by the use of wet dressings or dry heat. 
 
 Wet Dressings. — The means of keeping dressings wet are 
 many. The dressing may be wetted and then covered with oil 
 skin or rubber tissue to prevent evaporation ; or a sterile solu- 
 tion may be poured upon the wound through the dressing every 
 so often ; or the dressing may be kept continually moistened 
 by a warm saline drip or continuous immersion in a water bath. 
 Infected wounds which are treated with Dakin's solution re- 
 quire special technic (see Chapter XIX). In all wet dressings 
 the nurse should take particular care that the fluid is applied 
 to the wound and the wound only, and that the surrounding 
 skin does not become macerated or injured. 
 
 Suction Drainage. — Very often to secure better drainage, 
 gentle suction may be applied to the end of the tube, using either 
 the water siphon method or the suction machine. 
 
 Siphon Drainage. — One end of a Y-tube is attached to the 
 drainage tube and another to the moving column of water from 
 
NURSING OF THE SKIN AND APPENDAGES 133 
 
 an elevated tank or a faucet. This is arranged sa that the 
 flowing water will exert suction and carry off with it drainage. 
 The disadvantage in case a tank is employed is that water must 
 be continually supplied to keep up the siphonage. 
 
 Dry Heat. — Some surgeons, instead of using moist applica- 
 tions, prefer the use of dry heat. It should be remembered that 
 in extensive wounds the nerves are often destroyed and sensa- 
 tion is lost, so that all warm applications should be tested first 
 by the hand of the nurse before the heat is applied, for a bum in- 
 flicted on any patient is unpardonable. Heat may be applied 
 by hot water bottles, hot poultices, the electric coil or electric 
 pad. These may be applied intermittently or continuously. For 
 the continuous application the best form is the electric coil, as 
 the degree of heat may be regulated and kept fairly constant. 
 Baking a suppurating wound is also occasionally employed and 
 at times found very helpful. Probably there is nothing which 
 gives so much relief as poultices, because they are light in weight 
 and are easily adaptable to the region required. The most 
 common poulticing material is flaxseed, although there are many 
 proprietary compounds which are equally good and less trouble- 
 some. Inasmuch as poultices are very apt to lose heat rather 
 rapidly, the electric coil or a hot water bottle should be super- 
 imposed. Mustard plasters are rarely used in surgical nursing, 
 because if improperly applied, they burn the skin, and they can- 
 not be used continuously. 
 
 Packing. — When the cavity is rather large, and when heal- 
 ing must take place by granulating from the bottom, the wound 
 must be packed. Packing a wound is also an aid to drainage. 
 The materials used must be sterile, absorbent, soft and of such 
 nature that they will not shed their threads nor flood the wound 
 with foreign bodies. It is of prime importance that the nurse 
 carefully observe the packing of wounds, noting particularly 
 the number of pieces inserted into the cavity. Most packing 
 requires changing in from twenty-four to forty-eight hours be- 
 cause it becomes foul-smelling and acts as a dam rather than a 
 drain. The width of the packing is dependent upon the depth 
 and diameter of the wound; and whether it should be plain, 
 
134' TEXTBOOK OF SURGICAL NURSING 
 
 or medicated with iodoform or bismuth is a question decided by 
 the surgeon. 
 
 Treatment of Healing Wounds. — AVhen the discharge and 
 induration of an infected wound becomes less, the surgeon will 
 begin reducing or removing the drainage, and will apply medi- 
 cations to stimulate granulation tissue. Granulation tissue may 
 be stimulated chemically or physically. Weak solutions of silver 
 nitrate or the actual caustic stick are sometimes used; balsam 
 of Peru is very valuable. The size of the wound may be reduced 
 by drawing the adjacent edges together with adhesive plaster; 
 and, at times, strapping the granulating areas with sterile adhe- 
 sive plaster will stimulate the granulations and also the surface 
 epithelium to growth. 
 
 Secondary Suture. — Since the absolute sterilization of in- 
 fected wounds by the Dakin method is possible, secondary suture 
 of granulating wounds is done very often and has proven quite 
 successful (see Chapter XIX). As soon as the wound has be- 
 come filled with granulation tissue, the surface epithelium, or the 
 skin itself begins to grow. If the area to be covered by skin is 
 too great, and the resulting scar would be too big, a graft of skin 
 may be resorted to. 
 
 Skin-Grafts. — Skin-grafts are of three varieties, — Thiersch, 
 Reverdin, and Wolf. 
 
 Thiersch Graft. — The superficial layers of the epithelium are 
 shaved off with a razor and planted over the wound, the grafts 
 being rather large in size. 
 
 Reverdin Graft. — In this type small thin portions of the su- 
 perficial layer of the skin are snipped off with scissors, and 
 placed upon the granulating wound. 
 
 Wolf Graft. — In this variety, the entire thickness of the skin 
 is utilized as a graft, or it remains connected by a pedicle to 
 that part of the body from which it was taken, and after the 
 graft is firmly attached the pedicle is severed. 
 
 In all skin-grafts, the nurse must not forget to keep the part 
 quiet and warm. In removing dressings, the utmost care should 
 be observed for fear of disturbing the graft itself, and as in all 
 surgical procedures, the best aseptic technic should be main- 
 tained. 
 
NURSING OF THE SKIN AND APPENDAGES 135 
 
 Burns. — While a French surgeon originally divided burns 
 into six degrees or stages, according to the depth to which the 
 injury penetrated, it will really suffice for nursing purposes to 
 divide them into three. The agents which produce bums are 
 many. Heat in the form of solids, liquids, or steam ; chemicals, 
 such as strong acids, — for example, carbolic, acetic, hydro- 
 chloric; powerful alkalis, such as sodium hydroxide, chloride 
 of lime; special agents, such as X-ray, electrical currents and 
 radium when not properly used may all cause very severe burns. 
 Closely allied to those bums caused by heat are those due to 
 the action of cold either from exposure to low temperatures, 
 such as frostbite, or those resulting from actual contact with 
 sold substances in the form of ice, snow, or liquid air. 
 
 The pathology and clinical appearance of all burns are es- 
 sentially the same regardless of the agent inflicting the injury, 
 but the degree varies. First degree burns are recognized as 
 those in which there is redness, with some pain and swelling, 
 followed by a scaling of the skin. If the redness is of a greater 
 degree, blisters appear ; this is a second degree burn. All other 
 bums might be classified as third degree. They vary from 
 definite charred areas to those cases in which an entire limb 
 or more is involved. The symptoms which result may be classi- 
 fied as local and constitutional. 
 
 Local Symptoms. — There is a marked inflammatory reaction 
 of the' parts adjacent to the bum followed soon by sloughing 
 of the charred or injured tissues and, finally, after the wound has 
 been cleansed and the granulations are vigorous, healing ensues. 
 
 During the first and second periods, there is considerable ab- 
 sorption from the products of destroyed tissue and the patient 
 may suffer from certain constitutional complications ; these may 
 be very mild or so severe as to cause death. The causes of 
 death following burns may be shock, poisoning from the charred 
 tissues, or complications arising from infectious such as ery- 
 sipelas or sepsis. It should be remembered that extensive bums 
 rather than limited deep ones are the more serious, and that 
 children with skin burns averaging more than one-third of their 
 body are apt to die from the effects. 
 
136 TEXTBOOK OF SURGICAL NURSING 
 
 Treatment. — Tlie treatment of burns may be grouped under 
 
 two heads, — local and j^'oneral. 
 
 General Treatment. — In extensive burns there is often deep 
 shock Avliieh should be treated immediately. The patient should 
 be ]ilaced in the shock position. The body must be kept warm 
 with hot water bottles and blankets. Fluid should be given 
 either by rectum in the form of a IMurphy drip, or in very severe 
 depressed conditions, a saline infusion. If the pain is intense, 
 morphia may be riM|nired. Tt oecasionall.y liappens that, to- 
 gether with the burns, the patient suffers from poisoning of 
 carbon monoxide gas. 
 
 Carbon Monoxide Poisoning. — Tliis is recognized by the 
 great difficidty with which these patients breathe, the fact that 
 their lips are a very deep red and their skin a bluish hue. The 
 condition requires urgent interference. 
 
 Treatment. — The blood must be rid of the excess carbon 
 monoxide and its oxygen content increased. The patient may 
 be given oxygen from a commercial oxygen tank by means of 
 a funnel held directly over the nose and mouth. To prevent 
 further loss of oxj^gen, a paper cornucopia may be fastened to 
 the funnel. If the congestion of the patient is very extreme, 
 blood may be removed from a vein in the arm. This reduces 
 the actual blood content of carbon monoxide, and then the pa- 
 tient may be given an infusion of saline or a transfusion of 
 blood which will still further decrease the amount of poisonous 
 gas. 
 
 Local Treatment. — First Degree : — If there is much smarting 
 and pain, a paste of bicarbonate of soda, or cold cream, may be 
 applied, and the burned area protected from the air. 
 
 Second Degree : — When blisters or blebs are present, they 
 should be opened by puncture with a sterile needle and the serum 
 removed. After this, sterile vaseline or boric ointment may be 
 applied. 
 
 Third Degree: — If the patient has rather extensive burns, 
 and the clothes covering the skin have been destroyed by fire, to 
 prevent greater shock, it is better to give the patient anesthesia, 
 remove the clothes, cleanse the burned areas very thoroughly 
 with either copious washings of sterile saline, or bichloride in 
 
NURSING OF THE SKIN AND APPENDAGES 137 
 
 one to one thousand solution, followed by saline irrigations. 
 Wet dressings of boric acid or sublimate in one to ten thousand 
 solution may be used. These (may remain undisturbed for 
 forty-eight hours, if the patient is moderately comfortable. 
 
 Some use sterile boric acid dressings and within recent years, 
 picric acid in a saturated watery solution has gained favor. 
 After the first two days, it is advisable to dress the cases daily, 
 and as soon as the sloughs have disappeared, and granulations 
 appear, the wounds may be treated as any healing type. When 
 there has been extreme loss of epithelium the denuded areas may 
 be supplied with skin-grafts. 
 
 While some surgeons prefer wet dressings and some oint- 
 ments, still others apply nothing, leaving the burn exposed to 
 the open air. The burned area is protected from the bed linens 
 by a cradle and the part exposed to sunlight for varying periods 
 of each day. The air has a tendency to dry the part and later 
 the granulations may be stimulated by the actinic rays of the 
 sun. Then when all the sloughs have separated and the wound 
 is filled with good red granulations, it may be strapped by the 
 application of sterile adhesive over the granulations to stimu- 
 late the surface epithelium ;• or the wound may be skin-grafted. 
 After the wound has healed the later contractions of the scar 
 tissue may result in a diminution of the normal function of the 
 part ; so early passive, and later active motion with massage 
 should be given. 
 
 Paraffin Treatment of Burns. — During the Great War com- 
 batant troops were exposed to the terrors of gas attacks and the 
 chlorine and mustard gas left their marks by horrible burns 
 of a superficial and deep nature. The areas were treated by 
 paraffin or a proprietary substance called ambrine. Ambrine is 
 applied by a special apparatus which sprays the warm wax over 
 the wound in a fine layer. The method is somewhat as follows: 
 — The part is thoroughly cleansed, dried, and wrapped with a 
 sterile towel. The ambrine is melted by the heat of either an 
 alcohol lamp or Bunsen burner to a temperature of 50° C. In 
 the meantime the water bath for the actual liquefied ambrine 
 is filled with boiling water. The ambrine is poured into the 
 container, the container telescoped into the water bath and the 
 
138 TEXTBOOK OF SURGICAL NURSING 
 
 atomizing arrangement is screwed over both. Then by air pres- 
 sure the liquefied wax is sprayed over the part in a delicate, 
 thin, even, film, and tlie part covered with a fine cotton batting, 
 and a bandage applied. The advantages of this method are 
 painlessness of application, absolute sterility, formation of a 
 soft splint-like dressing over the wounded area rendering it 
 immobile and thereby diminishing pain. At the end of twenty- 
 four hours due to the exuding serum, the wax layer with the 
 thin cotton batting attached separates rather easily and pain- 
 lessly. AVhile this method requires much time and patience, 
 the end results easily compensate for the trouble involved. 
 
 It should always be remembered that the burned areas are 
 portals of entry for the various pathological bacteria. Exces- 
 sive care should therefore be taken to guard against infection. 
 The application of unsterile home remedies, such as flour and 
 water, olive oil, etc., is to be condemned. If a first aid dressing 
 must be applied and there are no sterile supplies at hand it is 
 better to cover the part with a freshly laundered, clean, dry 
 towel until the proper material may be obtained. 
 
 The Breast. — Diseases of the breast form a relatively im- 
 portant chapter in surgery. In the main they are of two great 
 varieties, — those due to inflammation and those due to new 
 growth. Inflammation may involve either the nipples or the 
 breast and may be acute or chronic. 
 
 The Nipples. — Cracked or fissured nipples, often seen dur- 
 ing lactation, are especially painful because the skin has become 
 broken. They may fonn a portal of entry for the various 
 microorganisms and thus give rise to infections of the breast 
 itself, or, when the child suckles, it may swallow some of the 
 diseased tissues about the cracked nipples. 
 
 Treatment. — All nipples after nursing should be thoroughly 
 but gentl}' washed with boric acid, then dried and powdered 
 with borated talcum. If fissures are present the child may nurse 
 through a nipple shield, and in the interval the nipples may be 
 treated with boroglyceride, touched with silver nitrate (solid) 
 or painted gently with tannic acid. These measures suffice, 
 as a rule, to bring the nipple back to its normal healthy status. 
 
 Acute Mastitis. — Acute inflammations of the breast, known 
 
NURSING OF THE SKIN AND APPENDAGES 139 
 
 as acute mastitis, usually occur in women during the close of 
 the lactating period. It is the result of improper hygiene of 
 the nipples, although this may not always be the case. 
 
 Symptoms. — The patient may complain of pain and heavy 
 feeling in the breast, and, at the same time, redness, swelling, 
 and areas of hardness may appear in certain parts of the breast. 
 There are a rise in temperature, an increase in the pulse rate, 
 loss of appetite, slight headache, and a feeling of general malaise. 
 
 Treatment. — If pus has not yet formed, the breast is ele- 
 vated with the bandage in such a way that it is firmly supported 
 upward. (See Figs. 141 and 142, page 386.) This will do much 
 to relieve the pain, but care should be taken that the binder is 
 not applied too tightly. Nursing, as a rule, is discontinued, 
 and if the breast throbs and feels distended, the milk may be 
 expressed regularly either by gentle massage, the direction of 
 the massage being a stroking motion from the circumference 
 of the breast towards tlie nipple ; or the milk may be aspirated 
 by a breast pump. During the interval, either hot applications 
 such as flaxseed poultices may be applied to the breast, or cold 
 applications in the form of a magnesium sulphate solution of 
 50 per ■ cent, strength. When pus is formed the abscess is 
 opened by the attending surgeon and freely drained. After the 
 acute suppurative process has subsided the drainage tubes are 
 shortened gradually and the granulation tissue stimulated by 
 silver nitrate. 
 
 Chronic Mastitis. — This condition is not uncommon, and pre- 
 sumably is due to a chronic inflammation of the breast. The 
 patient complains of vague and indefinite pains localized in the 
 breast itself, and, on examination, there may be found here 
 and there some very small nodules which may be tender. At 
 times the lymph glands in the axilla (arm-pit) show enlarge- 
 ment; as a matter of fact this condition is frequently difficult 
 to distinguish from cancer of the breast. 
 
 Treatment. — Sometimes a well fitting breast binder will re- 
 lieve much of the pain. If there is considerable induration or 
 hardness of the tissue, warm fomentations may bring relief. 
 Should these measures fail, most surgeons will remove that por- 
 tion of the breast which, is pathological. If at the time of opera- 
 
140 TEXTBOOK OF SURGICAL NURSING 
 
 tiou it is tliought that the condition might be cancerous, the 
 entire breast and deeper tissues are removed. 
 
 New Growths of the Breast. — As in other locations those 
 tumors Avhich invade breast tissue may be either benign or 
 maligiiant. Of benign tumors of the breast, the most common 
 are fibroadenomata ; these occur mainly in young -women ; they 
 are definitely encapsulated, freely movable, do not gi'ow beyond 
 a certain size, and cause no enlargement of the lymph glands 
 of the axilla. 
 
 Treatment. — The treatment is the excision of the growth, 
 with occasional drainage of the space left by its removal for 
 twenty-four hours. 
 
 Carcinoma. — Carcinoma of the female mammary gland is rel- 
 atively common. The rate of growth of the tumor cells will vary 
 greatly. Any mass in the breast is strongly suspicious of car- 
 cinoma if it occurs after the age of forty, and is hard, not defi- 
 nitely encapsulated, and attached to the skin or deeper muscular 
 layers. The glands in the axilla may be enlarged at a very 
 early period. If the disease has lasted for some time the patient 
 may be emaciated, pale, anemic and weak. 
 
 Treatment. — The treatment is radical excision of the en- 
 tire breast and the lymjDh glands which drain it. Inasmuch as 
 some surgeons perform a rather wide excision, the skin of the 
 patient should be prepared from beneath the angle of the jaw 
 to the umbilicus, from well beyond the midline of the affected 
 side to the region beyond the axillary border of the scapula 
 (shoulder blade). This preparation, in the main, will consist 
 of shaving the hair. Some surgeons prefer no pre-operative 
 preparation of the skin other than that of cleansing it with 
 green soap and water, leaving the iodine to be painted on in the 
 operating room ; others will have the skin cleansed with green 
 soap and water, followed by alcohol, then ether, finally applying 
 sterile dressings. 
 
 Operation. — The anesthesia may be given either by the 
 Bennet method or intranasally. A sandbag is placed beneath 
 the shoulder blade of the affected side. (See Fig. 75, page 280.) 
 The arm may be put out either at right angles to the body, 
 straight, or at right angles and bent at the elbow to an angle 
 
NURSING OP THE SKIN AND APPENDAap]^ 141 
 
 of forty-five decrees. Inasmuch as many blood vessels are to 
 be cut, there should be aji abundance of hemostatic clamps and 
 catgut ligatures. The surgeon will employ a drain, either the 
 tube, or cigarette variety. After the operation, an abundance 
 of dressing is applied, for there is apt to be a great amount 
 of oozing. The arm, forearm, and hand, as a rule, are bound 
 tightly to the chest. 
 
 Post-operative Treatment. — As soon as the patient recovers 
 consciousness she is given a backrest, so as to sit almost upright 
 in bed. As a rule, a dreissing is done at the end of twenty-four 
 to forty-eight hours, and the drainage tube removed. At this 
 dressing the arm is left free out of the bandage, and is held 
 in a sling at right angles. The arm should be given passive 
 movements carefully and gently, every two hours. The purpose 
 of this is to diminish the adhesions during healing so that the 
 scar will not limit the motion of the arm. 
 
 Patients are allowed up at the end of a week, and in about 
 six weeks after operation X-ray treatment is begun. This is 
 used to kill some of the cancer cells which may have escaped 
 the knife of the operator. Some surgeons at the time of opera- 
 tion will expose the wound to radium for a certain period of 
 time, doing the suturing later. Occasionally the arm may be 
 swollen a few weeks after operation, but it may be lessened 
 by massage and bandaging although sometimes in spite of this, 
 the arm remains large, interfering greatly with its movement. 
 
CHAPTER XI 
 
 THE SURGERY ANT> SURGICAL ITURSING OF THE URINARY 
 
 SYSTEM 
 
 Anatomy. — The urinary system is composed in a normal in- 
 dividual, of the kidnej'S, the ureters, the bladder and the urethra. 
 The kidneys, usuall.y two in number, are compound tubular 
 glands. They are situated on either side of the spinal column 
 in the region corresponding to the last two thoracic and upper 
 two lumbar vertebrae. The right kidney is at a lower level 
 than the left owing to the presence of the liver on that side. 
 As a rule they are about four inches long, two and one-half 
 inches wide, and one and one-half inches thick. Each kidney 
 is covered by a capsule. There are cases in which the kidneys 
 are fused into one, the horseshoe kidney ; or there may be only 
 one kidney present. 
 
 The ureters which connect the kidneys to the bladder vary 
 from twelve to eighteen inches in length. The bladder, which 
 is the reservoir for the urine, is situated in the pelvis behind 
 the pubis. It is in front of the vagina in the female and in 
 front of the rectum in the male. It is a muscular sac, and at 
 its neck gives origin to the urethra. The urethra is about one 
 and one-half inches long in the female, and eight to nine inches 
 in the male. It courses beneath the symphysis pubis in a down- 
 ward and forward direction; its external orifice in the female 
 is situated between the clitoris and the vaginal opening. In 
 the male it normally runs through the length of the penis. 
 
 Diseases of the Kidney. — The inflammatory affections of 
 the kidney may be either of the acute or chronic variety. The 
 acute variety may involve the pelvis of the kidney (pyelitis), 
 or there may be pus formation in the kidney itself (suppurative 
 nephritis). If the pus is retained in the pelvis with a resultant 
 dilatation, the condition is spoken of as a pyonephrosis. 
 
 142 
 
NURSING OF THE URINARY SYSTEM 143 
 
 Of the chronic inflammations, the one which interests the sur- 
 geon most is tuberculosis. 
 
 Treatment of Acute Infections. — In pyelitis, the treatment 
 is primarily medical. The patient is placed in bed ; fluids are 
 forced to about 2000 c.c. a day, and urotropin gr. 10, or more is 
 given by mouth three times a day. If it is thought that the 
 pyelitis is in some way due to a chronic constipation with a 
 dilated caput coli, colon irrigations are especially indicated. 
 Occasionally the pelvis of the kidney is irrigated directly 
 through a ureteral catheter which has been introduced into the 
 ureter by means of a cystoscope. This is an instrument designed 
 to give a view of the interior of the bladder. It has the general 
 shape of a sound, has a telescopic lens and carries an electric 
 light to illuminate the interior of the bladder which has been 
 previously distended with warm boric acid. It has several 
 modifications and attachments so that small catheters may be 
 passed into the ureteral orifices. By this means the urine from 
 both kidneys may be collected separately, and the condition and 
 functional activity of each kidney may be judged. 
 
 In pyonephrosis, the kidney is incised in the region of the 
 pelvis and the pus removed. This operation is spoken of as a 
 nephrotomy. But if the kidney shows many areas of infec- 
 tion, the so-called acute surgical kidney, it may be completely 
 removed (nephrectomy). 
 
 Operation of Nephrotomy. — The patient is placed in the kid- 
 ney position. This is described in Chapter XVI — see Fig. 67. 
 
 Post-operative Treatment of Nephrotomy. — Inasmuch as 
 urine as well as pus will escape from the kidney through the 
 wound, the dressings should be frequently removed and changed 
 to prevent maceration of the skin. The patient is placed upon 
 forced fluids, their amount carefully measured, and the urinary 
 output approximately estimated. These cases are rather pro- 
 tracted, lasting from six to eight weeks. The nutrition should 
 be particularly watched and every efi^ort taken to maintain or 
 increase the patient's weight by a liberal diet, high in car- 
 bohydrates. When they are allowed up, there is often a leakage 
 of urine through the wound, and to prevent the embarrassment 
 of a constant urinous odor, a lumbar urinal may be worn. 
 
144 TEXTBOOK OF SURGICAL NURSING 
 
 Nephrectomy. — When it is evident that the kidney has been 
 destroyed to such a degree that it is of little use to the organism, 
 it is much better to remove it completely. A nephrectomy is 
 always done for the aente septic kidney, dilt'use pyonephrosis, 
 tuberculosis, or new growths, provided the physical condition of 
 the patient will permit such an operation, and the other kidney 
 is present and not markedly diseased. If the ureter is definitely 
 pathological, it is dissected do^^^l until a healthy portion is 
 found, or if the entire length is affected, it might be totally 
 excised together with the kidney. 
 
 Post-operative Treatment. — The treatment is similar to that 
 of a nephrotomy. The drainage tubes are removed at the end of 
 three or four days, and the patient is kept in bed for three to 
 four weeks, until the wound has firmly and completely healed. 
 
 Renal Calculus. — Renal calculi or kidney stones may be 
 found in the substance of the kidney, in the pelvis, or in the 
 ureter. The stones may be single or midtiple, rough or smooth, 
 and may be present in one or both kidneys. The symptoms 
 which they cause are those of renal colic. This is a severe colicky 
 pain in the loin radiating downward to the testicle or vulva. 
 Blood is found in the urine (hematuria) and there is occa- 
 sionally frequency and urgency with burning micturition. 
 
 Treatment of Renal Calculus. — Patients who have a tendency 
 to renal colic, as evidenced by a previous history of attacks, or 
 the passage of small calculi, and whose urine contains an excess 
 of urates, should be placed upon a diet which is poor in protein. 
 Alcohol is absolutely prohibited, also tea and coffee. Alkaline 
 drinks should be administered, and the alkaline diuretics, such 
 as acetate, bicarbonate, and citrate of potassium should be 
 given freely and often. 
 
 Operative Treatment. — When there is definite evidence of a 
 stone from the clinical history augmented by positive radio- 
 graphic and cystoscopic findings, operation is indicated, for it 
 is the only measure which will insure permanent relief. The 
 operations performed for kidney stones are two in number: — 
 nephrolithotomy and nephrectomy. 
 
 Nephrolithotomy. — In this operation the procedure is similar 
 to a nephrotomy. The usual lumbar incision is made with the 
 
NURSING OF THE URINARY SYSTEM 145 
 
 patient in the kidney position (Fig. 65), the kidney exposed, 
 and the pedicle, that is, the renal artery and the renal vein, 
 are grasped by the hand of an assistant while the surgeon in- 
 cises the kidney along the convex border. Under these hemo- 
 static conditions the bleeding is very little. The calices of the 
 pelvis and kidney tissue are carefully examined and the stone 
 removed. The kidney is sutured together with mattress sutures 
 of chromic catgut on a blunt, non-cutting needle. 
 
 Post-operative Treatment. — The routine procedure in all 
 surgical kidney cases demands that fluids be forced to the 
 maximum. All the urine excreted should be accurately measured 
 and saved for the inspection of the attending surgeon. The 
 elimination must be especially watched, because after this opera- 
 tion urinary suppression is apt to result. Should this unfortu- 
 nate complication occur, those measures which are described in 
 Chapter III should be instituted immediately. For a day 
 or so the urine is apt to be bloody ; this is not particularly 
 alarming. During this period patients often complain of sj^mp- 
 toms simulating renal colic, due to clotted blood passing down 
 through the ureter. The pain is easily controlled by small 
 doses of morphine by hypodermic injections. 
 
 Operations upon the Ureter. — The ureter may be incised to 
 remove a calculus, or it may be removed for chronic diseases, 
 such as tuberculosis. The nursing is the same as for kidney 
 cases. 
 
 Urinary Bladder. — The bladder may be the site of injury, 
 acute or chronic inflammations, calculi, or new growths. 
 
 Treatment of Injuries of the Urinary Bladder. — The bladder 
 may be lacerated from external violence or in fractures of the 
 pelvis. In all suspected cases the patient is placed under gen- 
 eral anesthesia, the bladder is examined through the abdominal 
 route, and, if injured, the damage is repaired by appropriate 
 suture. As a rule, a drain in placed down to the injured area 
 of the bladder to take care of any urinary leakage which may 
 result. Some surgeons insert a permanent catheter into the 
 urethra; others prefer to catheterize the patient every eight 
 hours. In either case, great care should be taken that there be 
 no undue intravesical tension. Fluids should be administered 
 
146 TEXTBOOK OF SURGICAL NURSING 
 
 liberall}', and during the first week, urotropin gr. 10, or more 
 is given. The patient is kept in bed for at least three weeks. 
 
 Inflammations of the Urinary Bladder. — Acute Cystitis. — 
 Cj'stitis may originate in the bladder itself, or it may be sec- 
 ondary to inflammations of the kidney, urethra, or other organs. 
 The symptoms are frequency and urgency of micturition, and 
 a burning sensation when the urine is voided. 
 
 Treatment of Acute Cystitis. — Patients should be kept in 
 bed. The pressure about the bladder is relieved by elevating 
 the pelvis so that the intestines will fall away from it, and flex- 
 ing the knees so as to relax the spasm of the rectus muscles of 
 the abdomen. Hot applications applied over the bladder re- 
 gion are very agreeable, and Sitz baths given about three times 
 daily afford great relief. If the pain is very severe, morphine 
 is given. 
 
 If there is great difficulty in voiding because of excruciat- 
 ing pain, a little novocain instilled in the posterior urethra 
 affords great relief. Urine is less irritating when alkaline, and 
 an acid condition may be alkalinized by the giving of sodium bi- 
 carbonate or sodium citrate, 20 gr. three times a day. The 
 diet should be bland, non-irritating, and mainly fluid in nature. 
 Irrigations of the bladder may or may not be done according 
 to the judgment of the surgeon in charge. Irrigating solutions 
 may be of boric acid, and later, w^hen the disease becomes less 
 acute, irrigations of silver nitrate in distilled water may be 
 employed 1-5000, potassium permanganate 1-5000, or protar- 
 gol 1-10,000. They are more effective and comforting when 
 given warm. 
 
 Chronic Cystitis. — Chronic inflammations of the bladder may 
 be the result of an acute attack, or secondary to some condi- 
 tion in the bladder itself, as a papilloma or a stone. 
 
 Treatment. — The treatment is that employed in the late 
 stages of acute inflammation, namely, irrigations. These should 
 be given daily, after a diagnosis of its etiology has been made. 
 Sometimes, because of stricture of the uiethra or inflamma- 
 tion of the testes, irrigations are not practical. These cases are 
 treated by cystotomy (a suprapubic incision into the bladder 
 with the establishment of free continual drainage). 
 
NURSING OF THE URINARY SYSTEM 147 
 
 Primary tuberculosis of the urinary bladder is extremely 
 rare ; it is ordinarily infected secondary to the kidney, prostate, 
 or testis. The complaints given are usually of frequency, 
 urgency, and often bloody urine. 
 
 Treatment of Tuberculosis of Urinary Bladder. — The treat- 
 ment, of course, should be directed to the primary focus of the 
 tubercle bacillus, and, if the kidney is responsible, it should 
 be extirpated. While this is of prime importance, the patient 
 meanwhile must receive some treatment to relieve the very dis- 
 tressing symptoms of a diseased bladder. In the first place the 
 patient should be kept in good hygienic surroundings. Food 
 should be plentiful, appetizing, and highly nutritious, and every 
 measure available should be taken to insure the strengthening of 
 a weakened, debilitated constitution. The bladder should be 
 irrigated with very hot solutions of boric acid. These are al- 
 ways pleasing, and will relieve much of the pain. If the pain 
 is very severe, some novocain (but never cocaine) might be 
 instilled into the bladder. Tuberculous bladders are ulcerated, 
 and great care must be taken that too much medication is not 
 instilled, because free absorption is apt to take place and poison- 
 ing result. Rectal suppositories containing opium and extract 
 of belladonna do much to relieve pain. 
 
 Operative Treatment. — This consists in a suprapubic cys- 
 totomy and the direct treatment of the ulcerated bladder 
 mucosa, either with the actual cautery or chemical caustics. 
 The after treatment is very important. The foot of the bed 
 is raised, the bladder drained by continuous drainage, and 
 washed out daily with a bland non-irritating solution through 
 the suprapubic tube. Drainage of the bladder is kept up for 
 about six weeks. It is important to maintain all the rules of 
 strict asepsis in these cases, for nothing is more discouraging 
 than to add secondary infection. 
 
 Bladder Stone. — "When a stone is present in the bladder, 
 there are generally pain, frequency of urination, and the occa- 
 sional passage of blood at the end of micturition. The diagnosis 
 of bladder calculi is not so difficult since the use of the X-ray 
 and cystoscope, although formerly its presence was detected 
 by the metal sound stone searcher of Thompson. 
 
148 TEXTBOOK OF SURGICAL NTJRSINft 
 
 Treatment. — The stone is either removed by lithotomy or 
 
 lithohipaxy. 
 
 Litholapaxy. — The patient is placed in the lithotomy posi- 
 tion (i^'i^. 72) and the urethra locally anesthetized. Some em- 
 ploy spinal anesthesia, and others, general. In this procedure 
 an attempt is made to crush the stone ^vithin the bladder by 
 means of a lithotrite. This is an instrument introduced through 
 the urethra, and then opened when in the bladder, grasping the 
 stone between its two powerful jaws, and crushing it into 
 smaller pieces. The stony fragments are later evacuated by means 
 of a Bigelow evaeuator, which is an instrument designed to suck 
 from the bladder the stone fragments in a water current. 
 
 Post-operatively, water should be given in large amounts; 
 the urine should be kept acid, and drainage from the bladder 
 should be free, through an inlying catheter. As a rule this can 
 be removed at the end of forty-eight hours. 
 
 Suprapubic Lithotomy. — In this operation the bladder is 
 opened above the pubis ; the stone is removed, and the bladder 
 sutured. 
 
 Ante-operative Treatment and Operation. — This consists of 
 the ordinary preparation for any abdominal operation. The 
 patient is anesthetized, the bladder is distended fully wdth either 
 warm boric acid solution or air. and the patient is placed in 
 the Trendelenburg position (Fig, 63), A suprapubic median 
 incision is made, the bladder exposed, incised, and the stone 
 removed with special forceps. The bladder is sutured with a 
 double row of sutures, and the abdominal wound closed. 
 
 Post-operative Treatment. — If tlie wound is sutured tightly, 
 the patient may be permitted up in from ten to fourteen days. 
 If there is suprapubic drainage because of a concomitant 
 cystitis, the tube should be left in for about ten days, and then 
 removed; the patient- is allowed up as soon as the suprapubic 
 Avound has healed. With very old people, attempts should be 
 made to get them out of bed as soon as possible, for experience 
 has shown that a weakly healed abdominal wound is better 
 than broncho-pneumonia and death wdiich may result if these 
 cases are confined to bed. 
 
 New Growths of the Urinary Bladder. — Tumors of the blad- 
 
NURSING OF THE URINARY SYSTEM 149 
 
 der may be either benign or malignant ; the benign variety 
 may be treated through the cystoscope, or by open operation; 
 the malignant ones by open operation and radium. 
 
 Cystoscopic Treatment. — This is especially adaptable for 
 cases of small benign tumors of the papillomatous variety. These 
 growths are located with the cystoscope and fulgurated with the 
 sparks of a high frequency current under direct vision. The 
 effect is simply to burn away the tumor tissues. 
 
 Operation. — A suprapubic cystotomy is done, and an effort 
 made to extirpate the growth under direct vision by excision. 
 In cases of extensive malignant growths the bladder may be 
 excised in its entirety. The ureters may either be transplanted 
 in the rectum or brought to the skin surface through the ab- 
 dominal wall. This is an operation of considerable risk, the 
 mortality is high, and the end results extremely poor. When 
 extensive cancer exists it is much better to employ radium. 
 
 Eadium Treatment. — The solid radium, enclosed within a 
 metallic tube of platinum, is introduced into the bladder through 
 a suprapubic incision, and left in place for a certain number 
 of hours, or it may be introduced through the urethra with a 
 special cystoscopic arrangement. 
 
 These cases are often apt to hemorrhage. The bleeding is 
 effectively controlled by irrigation of the bladder with warm 
 boric acid and the introduction thereafter of a 1-1000 solu- 
 tion of adrenalin hydrochloride. 
 
 It is quite natural that such patients are nervous and ap- 
 prehensive, but every attempt should be made to reassure them, 
 rather than administer morphine, for in these chronic cases 
 the opium habit is established very easih^, and, in addition, this 
 drug has a depressive action on the kidneys. 
 
 The Urethra. — The diseases of the male urethra are usually 
 treated by the surgeon himself, and as the lesions of the female 
 urethra demand practically no operative interference, the only 
 condition which requires mention is stricture of the urethra. 
 This develops secondary to acute inflammations of the urethral 
 canal in which the mucous membrane has been partially de- 
 stroyed, and its place is taken by scar tissue. When this tis- 
 sue contracts it form§ a stricture, narrowing the lumen, result- 
 
150 TEXTBOOK OF SURGICAL NURSING ' 
 
 iiig iu difficult micturition, and often complete retention of 
 urine. To relieve this, if catheterization is impossible, a ure- 
 throtomy ,is performed. If the constriction is in the penile 
 portion an internal urethrotomy is performed; if in the deep 
 urethra, an external urethrotomy. 
 
 Internal Urethrotomy. — An internal urethrotomy consists of 
 cutting the stricture Avith an urethrotome (an instrument shaped 
 like a sound containing a hidden knife). The urethrotome 
 is introduced into the region of the stricture, the knife drawn^ 
 and the stricture cut. Sounds are then passed and the strictured 
 area dilated to the calibre desired. 
 
 External Urethrotomy. — The patient is placed in a lithotomy 
 position, a filiform bougie is passed into the penis, and an at- 
 tempt made to pass it through the strictured area. A tunnel 
 sound is threaded along the filiform bougie down to the stric- 
 tured area, the perineum is incised over the sound, and the 
 stricture, identified by means of the filiform, is cut with a spe- 
 cial urethrotomy knife. A tube is passed into the bladder 
 through the perineal incision. 
 
 Post-operatively this tube is connected with bottle drainage. 
 Fluids are forced and in about one week the tube is withdrawn 
 and the patient is encouraged to void through the urethra. 
 Sounds are passed about twice a week. 
 
 Circumcision. — This operation is performed to relieve a 
 tight prepuce (phimosis), and consists in trimming off the re- 
 dundant skin and mucous membrane of the penis. In young 
 children the nurse should change the dressing after urination. 
 
CHAPTER XII 
 
 SURGICAL DIETETICS 
 
 Diet is indeed a most important post-operative considera- 
 tion. No two patients can be nourished alike, and it is a 
 grave mistake to feed them in a routine manner as is so often 
 done. The type of operation performed, the physical condition, 
 the age, and the general post-operative behavior are all im- 
 portant factors in determining the kind of food, the amount 
 and the frequency of the feedings. Patients who have had a 
 colostomy performed certainly must be dieted differently from 
 those who have had a gastroenterostomy. A woman of sixty 
 will not be able to digest the regular hospital diet with the 
 ease of a young boy. Then again, while the diet may be per- 
 fect when under supervision of the nurse, obliging relatives 
 and kind friends may bring food and delicacies which may 
 prove detrimental to the health of the patient. It is not un- 
 usual to see gastric disturbances after visiting days, due to 
 candy and fruit which have been smuggled in by visitors. 
 This evil should be tactfully and carefully controlled. 
 
 In the discussion of surgical dietetics, to facilitate matters, 
 it will be best to first consider the diet following a simple opera- 
 tion, such as hernia, appendicectomy, ventral suspension of the 
 uterus, and simple plastic gynecological operations. 
 
 Liquid Diet. — After a patient has recovered from the anes- 
 thetic, he asks for water, and inasmuch as there is bound to 
 be nausea and vomiting following most operations, water is not 
 permitted until two hours after the last vomiting. Of course, 
 it is rather difficult to judge which is the last vomiting, but 
 this can be learned by experience. As a rule, water is given 
 in teaspoonful doses, moderately warm, although some surgeons 
 will order it ice cold. If the patient tolerates this well, more 
 may be given if desired, but he should never be allowed to drink 
 
 151 
 
152 TEXTBOOK OF SURGICAL NURSING 
 
 promiscuously and I'reel}'. It is not advisable to alluAv tiuids 
 or ' ' liquid diet ' ' until the day following operation. The liquids 
 commonly used are broths, gruels, tea, egg albumen, and lemon 
 juice. About five ounces of these are given at a time. The 
 second day after operation, milk may be added. 
 
 Milk is almost a perfect food; it is quickly delivered to the 
 stomach, is entirely absorbed, has a high caloric value and 
 provides considerable nourishment. There are some people who 
 cannot tolerate plain whole milk. This may be remedied oc- 
 casionally by adding barley water, lime water, plain water, 
 seltzer, vichy, or a little brandy. 
 
 While it is not good policy to use alcoholic beverages, such 
 as brandy or Avhisky, sudden withdrawal of these from patients 
 who have been accustomed to alcohol for j^ears might bring on 
 delirium tremens. For these chronically alcoholic individuals it 
 is sometimes advisable to give one-half to one ounce of whisky 
 three times a daj^ On the other hand, some surgeons use it 
 as a stimulant, prescribing it for weak and debilitated patients 
 the first few days after operation. 
 
 The fluids should be served at frequent intervals according 
 to the desire of the patient ; whenever possible they should be 
 served warm and always attractively. If they do not agree 
 with the patient, and cause vomiting, their administration should 
 cease. On the third day, as a rule, after the patient's bowels 
 have been moved either by a cathartic or by an enema, a se- 
 lected soft diet is allowed. 
 
 Soft Diet. — The following foods are appropriate for a soft 
 diet. It may be varied and grouped according to the taste of 
 the patient : 
 
 Cereals: — .Wlieatena, hominy, oatmeal, cornmeal, farnia, cream of 
 
 wheat. 
 Eggs : — Soft boiled. 
 
 Vegetables: — Baked, mashed, or boiled potatoes. 
 Macaroni. 
 Desserts : — Ice cream, baked custard, rice, tapioca, or cornstarch 
 
 pudding. 
 
 If this is well borne, within another day the patient may be 
 shifted to a convalescent diet. 
 
SURGICAL DIETETICS 
 
 15;^ 
 
 Convalescent Diet. For each day of the week. 
 
 Total quantity of milk allowed not ovei' 1250 e.c. (21/2 pints) daily. 
 6:00 a.m. Milk, 210 e.c. (7 ounces) if desired. 
 
 Breakfast 
 
 Coffee or tea, with milk and sugar, or milk. 
 
 One egg, or fresh fish, or plain stew. 
 
 Cereal with milk and sugar. 
 
 Toast and butter, or rolls or bread (white, graham, or brown). 
 
 Dinner 
 
 Broth or soup with barley or vegetables. 
 
 Bread and butter. Milk. 
 
 Potatoes, baked, boiled, or mashed. 
 
 Rice, macaroni, or hominy. 
 
 Beef, chicken, or fish. 
 
 Pudding, ice cream, or fruit. 
 
 Supper 
 
 Tea or milk. Toast and butter, or bread. 
 Egg. 
 
 Cooked fruit (baked or stewed apples, prunes, rhubarb, apricots, 
 pears). 
 
 At 8:00 p.m., milk, 210 e.c. (7 ounces). 
 Particular Foods for Specified Days. 
 
 Sunday 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Wheatena 
 One egg ' 
 
 Chicken 
 Baked potato 
 Orange 
 
 Monday 
 
 Egg 
 Prunes 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Hominy 
 
 Stew 
 
 Roast-beef 
 Mashed potato 
 Rice pudding , 
 
 Tuesday 
 
 Egg 
 
 Pears or apri 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Oatmeal 
 
 Egg 
 
 Fresh fish, hominy 
 Boiled potato 
 Ice cream 
 
 Egg 
 
 Stewed apples 
 
154 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 
 Wednesday 
 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 AYlieatena 
 
 Chicken, baked potato 
 
 Eg'g 
 
 Fresh fish 
 
 Macaroni 
 Tapioca pudding 
 
 Thursday 
 
 Rhubarb or prune 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Hominy 
 
 Boiled beef, rice 
 
 Egg 
 
 Egg 
 
 Mashed potato 
 Baked custard 
 
 Friday 
 
 Baked apple 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Oatmeal 
 
 Fresh fish 
 
 Eggs 
 
 Egg 
 
 Boiled potato 
 Macaroni 
 Ice cream 
 
 Saturday 
 
 Prunes 
 
 Breakfast 
 
 Dinner 
 
 Supper 
 
 Cornmeal 
 
 Chicken 
 
 Egg 
 
 Stew 
 
 Mashed potato 
 Hominy 
 Cornstarch pudding 
 
 Apricots or pears 
 
 Approximate values to be given. 
 
 Protein Carbohydrates 
 
 Men 100 gm. 300 gm. 
 
 Women 80 gm. 300 gm. 
 
 Fat Total Calories 
 90 gm. 2500 
 
 80 2m. 2200 
 
 Regular Diet. — This should be composed of the food to vrhich 
 the patient is normally accustomed, and should consist of a 
 good mixed diet. It is not necessary to outline it in detail. 
 Those foods should be selected which the patient enjoys, which 
 are easily digestible and which need not be fried in fat. An 
 example of such a diet is the following one: 
 
SURGICAL DIETETICS 155 
 
 Total quantity of milk allowed must not exceed 750 c.e. or iy2 jjints. 
 
 Breakfast 
 
 Coffee or tea with milk and sugar, or milk. 
 
 Bread and butter. 
 
 Two eggs to each patient in male wards. 
 
 One egg to each patient in female wards. 
 
 Cereal with milk and sugar. 
 
 Fresh fish. Hash. 
 
 Dinner 
 Soup 
 
 Meat or fish 
 
 Potatoes, baked, boiled, or mashed. Bread and butter. 
 Spinach, squash, boiled onions, beets, sweet potatoes, macaroni, to- 
 matoes, corn. 
 Pudding, or fruit. Milk, 180 c.c. or 6 ounces. 
 
 Supper 
 
 Tea or milk. Bread and butter. 
 
 Cooked fruit (prunes, apples, rhubarb, apricots, pears). 
 
 Cold meat. Eggs. 
 
 Cereal with milk and sugar. Milk toast. 
 
 Diet for Diabetes. — When certain diseases, such as diabetes 
 or nephritis, complicate surgical conditions, the patient often 
 undergoes a pre-operative dietetic preparation, so that the 
 best possible physical state is attained before the operation is 
 performed. It is a well-known fact that patients who suffer from 
 diabetes mellitus, a disease in which the sugar content of the 
 blood is high, and sugar appears in the urine, are extremely 
 poor operative risks. To begin with, they take their anes- 
 thetic poorly, their tissues are rather low in vitality, become 
 infected very easily, and are slow in healing. Then after opera- 
 tion, they are apt to pass into a diabetic coma, a very serious 
 complication, usually resulting in death. In-order to give these 
 patients the best post-operative chance by rendering them less 
 liable to coma, infection, and slow wound healing, every at- 
 tempt should be made to reduce their diabetes to the minimum, 
 or to render them sugar free. The following list of diets are 
 those which are usually prescribed or ordered by surgeons to ac- 
 complish these ends. 
 
156 TEXTBOOK OF SURGICAL NURSING 
 
 Standard Strict Diet. 
 
 Breakfast 
 
 2 eggs. Coffee with 45 gm. cream. 
 Hani, 90 gm. 
 
 Butter, 15 gm. on biscuit during the test period; cooked with the 
 eggs if no biscuit or bread is taken. 
 
 Luncheon 
 
 Meat, steak or chops, 120 gms. 
 
 Green vegetables (from list), 2 tablespoonfuls. 
 
 Butter, 15 gm. with green vegetable if no biscuit or bread is taken. 
 
 White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. 
 
 Afternoon tea with 15 gm. of cream. 
 
 Dinner 
 
 Clear soup. 
 
 Fish, 90 gm. 
 
 Meat, beef, mutton, turkey, or chicken, 120 gm. 
 
 Green vegetable, 2 tablespoonfuls. 
 
 Salad with 15 gm. of oil in the dressing. Cream cheese, 30 gin. 
 
 Butter, 30 gm. on fish, meat, or vegetables if no bread or biscuit 
 
 taken. 
 White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. 
 Demi-tasse. 
 
 Bedtime 
 
 Bouillon with one raw egg. 
 
 Protein, 112 gm.; nitrogen, 18 gm. ; fats, 160 gm.; calories, 2200; 
 omitting ham, protein, 94 gm.; nitrogen, 15 gm. 
 
 For convenience in determining the carbohydrate tolerance, the fol- 
 lowing biscuits may be used, as the percentage of carbohydrates 
 is practically constant : — Huntley and Palmer breakfast biscuit 
 which contains 5 gm, carbohydrate; Uneeda Biscuit, which contains 
 4.6 gm. carbohydrate. 
 
 Standard Diet with Restricted Protein. 
 
 Breakfast 
 
 2 eggs. Bacon, 15 gm. Butter, 20 gm. 
 
 Coffee with 45 gm. of cream. 
 
 Luncheon 
 
 1 eg^. Bacon, 15 gm. 
 
 Lamb chops, ham,, or beefsteak, 60 gm. Butter, 40 gm. 
 
 Salad with 15 gm. of oil in dressing. 
 
 White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. 
 
SURGICAL DIETETICS 157 
 
 Afternoon tea with 15 gm. of cream. 
 
 Dinner 
 
 Clear soup. 
 
 Butter, 30 gm. 
 
 Roast pork, beef, mutton, turkey, or lamb chops, 90 gms. 
 
 Green vegetables. 
 
 Salad with 15 gm. of oil in dressing. Cream cheese, 30 gtn. 
 
 White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. 
 
 Demi-tasse. 
 
 Bedtime , 
 
 Bouillon with one raw egg. 
 
 Protein, 62 gm. ; nitrogen, 10 gm.; fat, 180 gm.; total calories, 2500. 
 
 Omitting 30 gm. of butter and y2 ounce of bacon, calories equal 2250. 
 
 Green Days. 
 
 Breakfast 
 
 1 egg, boiled or poached. Cupful of black coffee. 
 
 Dinner 
 
 Spinach with hard boiled egg. Bacon, 15 gm. Salad with 15 gm. 
 
 of oil. 
 White wine, %^ liter, or whisky or brandy, 30 c.c. 
 
 4 :30 p. m. Cup of beef tea or chicken broth. 
 
 Supper 
 
 1 egg, scrambled with tomato and a little butter. Bacon, 15 gm. 
 Cabbage, cauliflower, sauerkraut, string beans, or asparagus. 
 White wine, or whisky or brandy, 30 c.c. 
 Sodium bicarbonate, 15 to 30 gm. in 24 hours. 
 
 Protein, 32 gm. ; nitrogen, 5 gm.; carbohydrate about 5 gm. ; fat, 
 67 gm.; calories, 575. 
 
 General Diabetic Diet List. 
 
 (May take freely.) 
 
 Soups. All meat soups and broths to which vegetables, egg 
 
 or cheese may be added. 
 
 Meats. All fresh, smoked, and cured meats except liver, 
 
 poultry and game, without sauces or gravies con- 
 taining flour. 
 
 Fish. All kinds except oysters, clams and scallops, cooked 
 
 without bread crumbs or meal; all dried, salted, 
 smoked or pickled fish. 
 
158 
 
 TEXTBOOK OF SURGICAL NURSING ' 
 
 Eggs. 
 Fats. 
 Cheese, 
 
 Salads and 
 Vegetables. 
 
 Prepared in any ■way withont flonr. 
 Bntter, lard, suet, olive oil, or other fats. 
 All kinds, especially cream, Swiss, English and pine- 
 apple. 
 Beet greens, Brussels sprouts, cabbage, cauliflower, 
 celery, chicory, cresses, cucumbers, egg-plant, en- 
 dive, kohlrabi, leeks, lettuce, okra, pumpkin, 
 radishes, rhubarb, salsify, sauerkraut, spinach, 
 string-beans, tomatoes, and vegetable marrow. 
 Pickles made from these vegetables unsweetened; 
 ripe olives. 
 Mushrooms and truffles. 
 
 Salt, pepper, cayenne, paprika, curry, cinnamon, 
 cloves, English mustard, nutmeg, caraway, capers, 
 vinegar, and piquant sauces in small quantities. 
 Jellies made from gelatin, custards and ice cream 
 made with eggs and cream ; all sweetened with sac- 
 charin and flavored with vanilla, coffee or brandy. 
 Butternuts. 
 
 Not over 90 c.c. a day. 
 
 Tea or eofl^ee, sweetened with saccharin and with 
 portion of cream allowed. Whisky, brandy, rum, 
 and other distilled liquors up to 3 oi;nces a day. 
 Light wine or Moselle wine, claret or Burgundy 
 up to 16 ounces a day. Mineral waters of all 
 kinds. Lemonade in small quantity sweetened 
 with saccharin. 
 Articles Prohibited. (Except as prescribed in the Accessory Diet.) 
 Sugars and sweets of every kind. 
 Pastry, puddings, preserves, cake and ice cream. 
 Bread, biscuits, toast, crackers, and griddle cakes. 
 Cereals such as rice, oatmeal, sago, hominy, tapioca, barley and 
 
 macaroni. 
 Vegetables such as potatoes, carrots, parsnips, beans, peas, beets, 
 
 green corn, and turnijos. 
 Fruit. Neither fresh nor dried. 
 Soups, sauces or gravies thickened with flour or meal, or made with 
 
 milk. 
 Beer, ale, porter, all sweet wines, sherry or port wine, sparkling 
 
 wines, cider and liquors. 
 Milk, chocolate or cocoa. 
 Soda water and all sweet drinks. 
 
 Fungi. 
 Condiments. 
 
 Dessert. 
 
 Nuts. 
 
 Cream. 
 
 Beverages. 
 
SURGICAL DIETETICS 159 
 
 Oatmeal Days. 
 
 Porridge made from oatmeal, 250 gm. with butter, 250 gm., salt 
 and pepper. 
 
 Black coffee, light wine ^ liter, or cognac, 60 c.c. 
 
 The whites of 6 eggs may be added to the porridge if desired. 
 
 Nitrogen gm. Carbohydrate gm. Calories 
 
 Oatmeal 6.2 170 1025 
 
 Butter 0.4 1975 
 
 6.6 or 42 gm. protein 3000 
 
 Alcohol (40 gm.) ... ■ 210 
 
 6 whites of eggs .... 3.6 90 
 
 10.2 or 63 gm. protein 3300 
 
 The entire diet consists of: — Protein, 63 gm.; nitrogen, 16.8 gm.; 
 carbohydrate, 170 gm. ; fat, 212 gm.; calories, 3300. 
 
 Diet for Patients with Nephritis. 
 
 Occasionally patients with severe nephritis have to undergo 
 operations; or, if- they are operated on in an emergency, their 
 post-operative care is partially one of diet. It is a known fact 
 that salt or sodium chloride is retained in the body in cases of 
 kidney disease, and that its retention causes edema. Occasion- 
 ally if there is a sodium chloride retention it is necessary to put 
 the patient upon a salt poor diet. These may be of three general 
 varieties. The important factor in all is that the food should be 
 prepared without any salt and that the butter and bread are to 
 be salt free and that no extra salt should be allowed. 
 
 Salt Poor Diet. 1. 
 
 Breakfast 
 
 Bread, 30 gm. or 1 oz. Sugar, 10 gm. or ^/^ oz. Farina, 60 gm. or 
 
 2 oz. 
 Butter, 30 gm. or 1 oz. ] egg or 40 gm. or l^/j oz. Coffee, 150 
 
 c.c. or 5 oz. 
 
 Total, 320 gm. or IOV3 oz. 
 
 Dinner 
 
 Bread, 30 gm. or 1 oz. Butter, 20 gm. or 2/3 oz. Sugar, 10 gm, 
 
 or ^/g oz. 
 Rice, 60 gm. or 2 oz. Farina, 100 gm. or 3^/3 oz. Tea, 150 c.c. 
 
 or 5 oz. 
 
 Total, 370 gm. or I2Y3 oz. 
 
160 TEXTBOOK OF SURGICAL NURSING 
 
 Supper 
 
 1 egg or 4U giu. or 1'/., oz. Toast, 15 gm. or i/o oz. Bread, 30 iiui 
 
 or 1 oz. 
 Butter, 15 gui. or l^/^ oz. Custard, 100 gm. or 3^/^ oz. Prunes, 
 
 60 g:ni. or 2 oz. 
 Tea, ISO c.c. or 6 oz. 
 
 Total, 440 gm. or I4-/3 oz. 
 This contains chlorides, 1 gm., protein, 35 g:m. or 1^/^ oz. Fat, 
 
 65 gm. or 2^/^ oz. Carbohydrate, 140 gm. or 4-/3 oz. Calories, 
 
 1300. 
 
 Salt Poor Diet. 2. 
 
 Breakfast 
 
 Bread, 60 gm. or 2 oz. Sugar, 40 gm. or IY3 oz. Farina, 60 gm. 
 
 or 2 oz. 
 Butter, 35 gin. or 1^/g oz. 1 egg, 40 gm. or 1^/3 oz. Coffee, 150 
 
 c.c. or 5 oz. 
 
 Total, 385 gm. or 12Vg oz. 
 
 Diuuer 
 
 One egg, 40 gm. or IY3 oz. Bread, 60 gm. or 2 oz. Butter, 30 gm. 
 
 or 1 oz. 
 Rice, 70 g-m. or 2Y3 oz. Farina, 100 gm. or 3^/3 oz. Tea, 150 
 
 c.c. or 5 oz. 
 
 Total, 450 gm. or 15 oz. 
 
 SMp2Jer 
 
 One egg or 40 gm. or 1^/3 oz. Bread, 60 gm. or 2 oz. Butter, 30 
 
 gm. or 1 oz. 
 Custard, 100 gm. or 3Y3 oz. Prunes, 60 gm. or 2 oz. Tea, 180 
 
 c.c. or 6 oz. 
 
 Total, 485 gm. or 15^/^ oz. 
 This contains chlorides, 3 gm.; protein, 50 gm, or 1^/3 oz. ; fat, 100 
 
 gm. or 31/3 oz. ; carljohydi-ate, 240 gm. or 8 oz. ; calories, 2100 
 
 Salt Poor Diet. 3. 
 
 This is the same as the convalescent diet without broths or soups. 
 The fish, meat and green vegetables must be boiled in two waters 
 to' remove most of the salt. Milk, 250 c.c. or 8 oz. only allowed. 
 
 Diet in Gastric Cases. — The diet following stomach opera- 
 tions is dependent upon what has been done surgically. If the 
 ulcer-bearing area has been removed, it is not essential to place 
 
SURGICAL DIETETICS 161 
 
 this patient upon an elaborate gastric diet. The routine in 
 these eases is as follows : 
 
 For the first twenty-four hours, the patient is given nothing 
 by mouth, water being freely administered by Murphy drip. 
 Then, water by mouth is given in dram doses every hour; 
 and, if tolerated, after two doses, it is increased to half an 
 ounce, alternating with peptonized milk, — one-half ounce every 
 two hours. Thus the patient obtains something every hour. If 
 this is well borne, after four feedings, the amount is increased 
 to one and then to two ounces. Then easily digested substances 
 are added, such as : 
 
 Farina, rice, sago, soft eggs; thin soups, consomme or bouil- 
 lon, baked or mashed potatoes; soft vegetables such as beans, 
 peas ; and buttered toast ; cocoa. 
 
 After a period of two weeks or more these articles may be 
 eaten : 
 
 Lamb or chicken in moderate amounts about two times a 
 week; fresh fish either boiled or broiled, never fried; lettuce, 
 water cress, romaine, endive, chicory with a good quantity of 
 olive oil and very little vinegar; desserts, such as ice creams 
 and custards. 
 
 It is highly important that the following foods he omitted: 
 
 Coarser vegetables such as cabbage, cucumbers, kohlrabi, 
 tomatoes, onions, celery, corn, cauliflower, sprouts, artichokes, 
 asparagus and beets. Also veal, pork, corned or smoked meats, 
 lobster, crabs, shrimps, cheese excepting Philadelphia or Neucha- 
 tel, pickles, too hot or too cold drinks, strong tea or coffee, too 
 much pastry, especially those cooked in fat, such as fritters, 
 doughnuts ; jams, cherries, cranberries and muskmelons. 
 
 Meat should be roasted or broiled; never fried. 
 
 Those cases in which the ulcerated condition of the stomach 
 still remains because the ulcer-bearing area has not been ex- 
 cised are placed upon a Von Leube or Lenhartz diet. This 
 would hold for acute perforations of the stomach and gastro- 
 enterostomies. 
 
 Von Leube Diet (Modified). — For the first three days noth- 
 ing is given by mouth, but fluid is supplied by proctoclysis 
 and a nutritive enema may be given three times daily if the 
 
162 TEXTBOOK OF SURGICAL NURSING 
 
 patient is asthenic. After a few days, peptonized milk § ii 
 alternating -with vichy 3 ii ^i^y t)6 given every two hours. 
 If this is- well borne, the milk is increased one ounce daily until 
 eight ounces are taken. If the administration of the milk is fol- 
 lowed by no pain, the amount of vichy may be increased to 
 four ounces. In about ten days, thickened soups, such as puree 
 of pea, sago, tapioca and junket are allowed. In the third week, 
 scraped raw beef, very soft boiled eggs, macaroni, puree of 
 vegetables, and zwieback may be given. The patient is gradu- 
 ally^ returned to a selected soft diet during the fourth week. 
 If pain appears a return is made to the simpler milk diet. 
 
 Lenhartz Diet. — The food of a Lenhartz diet is admin- 
 istered at hourly intervals; it must be thoroughly masticated 
 and eaten very slowly, and, during the treatment, the patient 
 must be kept in bed. For the first week, the raw eggs which are 
 used, are beaten up whole and iced ; the milk is also iced ; gran- 
 ulated sugar is added to the eggs on the third day. Boiled rice, 
 zwieback and scraped beef are prepared in the usual manner. 
 The Lenhartz diet for fourteen days is as follows: 
 
 As eggs differ in size and weight, take the total of eggs for 
 the day of diet, beat, measure, and divide into seven feedings 
 and put into medicine glasses. Keep on ice and use as directed, 
 alternating with milk. The milk is kept in a bowl of cracked 
 ice, and the eggs are beaten up raw and iced. The spoon is 
 kept in a bowl of ice. The feedings should be given very slowly 
 and the patients are never allowed to help themselves. 
 
 The patient should be given small feedings frequently and 
 fed by spoon. Salt the eggs to taste on the first and second 
 days ; sugar is started on third day. 
 
 First Day 
 
 7 a.m. 
 8 
 
 Egg 
 Milk, 
 
 20 c.c. 
 
 or -/^ oz. 
 
 9 
 10 
 
 Egg 
 Milk, 
 
 20 c.c. 
 
 or 2/.J oz. 
 
 11 
 
 12 noon 
 
 Egg 
 Milk, 
 
 15 c.c. 
 
 or 1/2 oz. 
 
 1 p.m. 
 2 
 
 Egg 
 Milk, 
 
 15 c.c. 
 
 or % oz. 
 
SURGICAL DIETETICS 163 
 
 First Day — Continued. 
 
 3 p.m. Egg 
 
 4 Milk, 15 c.c. or I/2 oz. 
 
 5 Egg 
 
 6 Milk, 15 c.c. or 1/2 oz. 
 
 7 Egg 
 
 Total, eggs (raw), 2; milk, 100 c.c. or 8^/3 oz. 
 
 Second Day 
 
 7 a.m. Egg 
 
 8 Milk, 35 c.c. or 1 oz. 
 
 9 Egg 
 
 10 Milk, 35 c.c. or 1 oz. 
 
 11 Egg 
 
 12 noon Milk, 35 c.c. or 1 oz. 
 
 1 p.m. Egg 
 
 2 Milk, 35 c.c. or 1 oz. 
 
 3 Egg 
 
 4 Milk, 35 c.c. or 1 oz, 
 
 5 Egg 
 
 6 Milk, 35 c.c. or 1 oz. 
 
 7 Egg 
 
 Total, eggs (raw), 3; milk, 200 c.c. or 6Y3 oz. 
 Third Day 
 
 7 a.m. Egg. Sugar, 2 g-m. or % oz. 
 
 8 Milk, 50 c.c. or 1-/^ oz. 
 
 9 Egg. Sugar, 3 gm. or % dr. 
 
 10 Milk, 50 c.c. or IV3 oz. 
 
 11 Egg. Sugar, 3 gm. or % dr. 
 
 12 noon Milk, 50 c.c. or IY3 oz. 
 
 1 p.m. Egg. Sugar, 3 gm. or % dr. 
 
 . 2 Milk, 50 e.c. or IV3 oz. 
 
 3 Egg. Sugar, 3 gm. or % dr. 
 
 4 Milk, 50 c.c. or IY3 oz. 
 
 5 Egg. Sugar, 3 gm. or % dr. 
 
 6 Milk, 50 c.c. or IV3 oz. 
 
 7 Egg. Sugar, 3 gm. or % dr. 
 
 Total, eggs (raw), 4; milk, 300 c.c. or 10 oz. ; sugar, 
 20 gm. or 5 dr. 
 Fourth Day 
 
 7 a.m. Egg. Sugar, 2 gm. or ^ dr. 
 
 8 Milk, 70 c.c. or 2V3 oz. 
 
 9 Egg. Sugar, 3 gm. or % dr. 
 
164 TEXTBOOK OF SURGICAL NURSING 
 
 Fourth Day — Conliiiucd. 
 
 10 a.m. Milk, 70 cc ov 12'/., oz. 
 
 11 • Kg'g". Sugar, 3 gin. or -^4 dr. 
 
 12 noon Milk, G5 e.c. or 12 oz. 
 
 1 p.m. Egg'. Sugar, 3 uui. oi- % dr. 
 
 2 Milk, 05 e.c. or 12 oz. 
 
 3 Egg. Sugar, 3 i^in. or % (Ir- 
 
 4 Milk, 65 e.c. or 2 oz. 
 
 5 Egg. Sugar, 3 gni. or % dr. 
 
 6 Milk, 65 e.c. or 2 oz. 
 
 7 Egg. Sugar, 3 gm. or % dr. 
 
 Total, eggs (raw), 5; milk, 400 e.c. or 13^^/., oz.; 
 sugar, 20 gm. or 5 dr. 
 
 Fifth Day 
 
 7 a.m. Egg. Sugar, 4 gm, or 1 dr. 
 
 8 Milk, 80 e.c. or 2^/3 oz. 
 
 9 Egg. Sugar, 4 gm. or 1 dr. 
 
 10 Milk, 80 e.c. or 2^/3 oz. 
 
 11 Egg. Sugar, 4 g-m. or 1 dr. 
 
 12 noon Milk, 80 e.c. or 2^/3 oz. 
 
 1 p.m. Egg. Sugar, 4 gm. or 1 dr. 
 
 2 Milk, 80 e.c. or 2^/3 oz. 
 
 3 Egg. Sugar, 4 gm. or 1 dr. 
 
 4 Milk, 80 e.c. or 2^/3 oz. 
 
 5 Egg. Sugar, 4 gm. or 1 dr. 
 
 6 Milk, 90 e.e. or 3 oz. 
 
 7 Egg. Sugar, 4 gm. or 1 dr. 
 
 Total, eggs (raw), 0; milk, 500 e.c. or 16^/3 oz.; 
 sugar, 30 gm. or 1 oz. 
 
 Sixth Day 
 
 7 a.m. Egg. Sugar, 4 gm. or 1 dr. 
 
 8 Milk, 100 e.c. or 31/, oz. 
 
 9 Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 
 
 3 dr. 
 
 10 Milk, 100 e.c. or 31/3 oz. 
 
 11 Egg. Sugar, 4 gm. or 1 dr. 
 
 12 noon Milk, 100 e.c. or 31/3 oz. 
 
 1 p.m. Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 
 
 3 dr. 
 
 2 Milk, 100 e.c. or 31/3 oz. 
 
 3 Egg. Sugar, 4 g-m. or 1 dr. 
 
 4 Milk, 100 e.c. or 37,, oz. 
 
SURGICAL DIETETICS 165 
 
 Sixth Day — Continued. 
 
 5 p.m. Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 
 
 3 dr. 
 
 6 Milk, 100 c.c. or 3^/.^ oz. 
 
 7 Egg. Sugar, 4 gm. or 1 dr. 
 
 Total, eggs (raw), 7; milk, (iOO c.c. or 20 oz. ; sugar, 
 30 gm. or 1 oz.; scrai:)ed beef, 36 gm. or 9 dr. 
 Seventh Day 
 
 7 a.m. One soft boiled egg. 
 
 8 Milk, 100 c.c. or 31/3 oz. 
 
 9 Egg. Sugar, 13 gm. or 3 dr. 
 
 10 Milk, 100 c.c. or 'i^/^ oz. Scraped beef, 23 gm. or 6 dr. 
 Boiled rice, 33 gm. or 1 oz. 
 
 11 One soft boiled egg. 
 
 12 noon Milk, 125 c.c. or 4 oz. 
 
 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 
 
 2 Milk, 125 c.c. or 4 oz. Seraj^ed beef, 23 gm. or 6 dr. 
 Boiled rice, 33 gm. or 1 oz. 
 
 3 . One soft boiled egg. 
 
 4 Milk, 125 c.c. or 4 oz. 
 
 5 Egg. Sugar, 14 gm. or 3Y3 oz. 
 
 6 Milk, 125 c.c. or 4 oz. Scraped beef, 23 gm. or 6 dr. 
 ■ Boiled rice, 33 gm. or 1 oz. 
 
 7 One soft boiled egg. 
 
 Total, 4 raw eggs; 4 soft boiled eggs; milk, 700 c.c. 
 or 23^/3 oz. ; sugar, 40 gm. or 1^/3 oz. ; scraped 
 beef, 70 gm. or 2'^/3 oz. ; boiled rice, 100 gm. or 
 3^/3 oz. (served with beef juice). 
 
 Eighth Day 
 
 The diet changes on this day, re(juiring only 4 raw eggs which may 
 be divided into three feedings. The other 4 eggs are to be soft boiled 
 and given as directed by diet. 
 
 7 a.m. One soft boiled egg. 
 
 8 Milk, 135 c.c. or 41/2 oz. 
 
 9 Egg. Sugar, 13 gm. or 3 dr. 
 
 10 Milk, 133 c.c. or AY2 oz. Scraped beef, 23 gm. or 6 dr. 
 Boiled rice, 33 gm. or 1 oz. 
 
 11 One soft boiled egg. Zwieback, 10 gm. or 2^/^ dr. 
 
 12 noon Milk, 133 c.c. or 41/2 oz. 
 
 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 
 
 2 Milk, 133 c.c. or 4^/2 oz. Scraped beef, 23 gm. or 6 dr. 
 Boiled rice, 33 gm. or 1 oz. 
 
166 TEXTBOOK OF SURGICAL NURSING 
 
 Eighth Day — Conti n u c d. 
 
 3 p.m. One soft boiled egg. 
 
 4 ■ Milk, 133 c.c. or 41/2 oz. 
 
 5 Egg. Sugar, 14 gm. or "dYz ^^'- Zwieback, 10 gin. or 
 
 21/2 oz. 
 
 6 Milk, 133 c.c. or 4V2 oz. Scraped beef, 24 gin. or 6 dr. 
 Boiled rice, 33 gm. or 1 oz. 
 
 7 One soft boiled egg. 
 
 Total, 4 raw eggs; 4 soft boiled eggs; milk, 800 c.c. 
 or 26-/3 '^^•5 seraj)ed -beef, 70 gm. or 2^/3 oz.; 
 boiled rice, 100 gm. or 3^/3 oz. ; zwieback, 20 gm. 
 or 5 dr. ; sugar, 40 gm. or V-/^ oz. 
 Ninth Day 
 
 7 a.m. One soft boiled egg. 
 
 8 Milk, 150 c.c. or 5 oz. 
 
 9 Egg. Sugar, 13 gm. or 3 dr. 
 
 10 Milk, 150 e.e. or 5 oz. Scraped beef, 23 g-m. or 6 dr. 
 
 Boiled rice, 66 gm. or 2 oz. 
 
 11 One soft boiled egg. Zwieback, 20 gm. or 5 dr. 
 
 12 noon Milk, 160 c.c. or 5 oz. 
 
 1 p.m. Egg. Sugar, 13 gin. or 3 dr. 
 
 2 Milk, 150 c.c. or 5 oz. Scraped beef, 23 gm. or 6 dr. 
 
 Boiled rice, 66 gm. or 2 oz. 
 
 3 One soft boiled egg. Zwieback, 20 gm. or 5 dr. 
 
 4 Milk, 150 c.c. or 5 oz. 
 
 5 Egg. Sugar, 14 gm. or 3% dr. 
 
 6 Milk, 150 c.c. or 5 oz. Scraped beef, 24 gm. or 6 dr. 
 
 Boiled rice, 66 gm. or 2 oz. 
 
 7 One soft boiled egg. 
 
 Total, 4 raw eggs; 4 cooked eggs; milk, 900 c.c. or 30 
 oz.; sugar, 40 gm. or 1^/3 oz.; scraped beef, 70 
 gm. or 2^/3 oz. ; rice, 200 gm. or 6Y3 oz. ; zwie- 
 back, 40 gm. or 1^/3 oz., or toast, 20 gm. or 5 dr. 
 Tenth Day 
 
 7 a.m. One soft boiled egg. 
 
 8 Milk, 166 c.c. or 51/2 oz. 
 
 9 Egg. Sugar, 13 gm. or 3 dr. 
 
 10 Milk, 166 c.c. or 5V2 oz. Scraped beef, 23 gm. or 6 dr. 
 
 Boiled rice, 66 gm. or 2 oz. 
 
 11 One soft boiled egg. Zwieback, 20 gm. or 5 dr. Butter, 
 
 4 gm. or 1 dr. 
 
 12 noon Cooked chopped chicken, 25 gm. or 6 dr. Milk, 166 c.c. 
 
 or 5V2 oz. 
 
SURGICAL DIETETICS 167 
 
 Tenth Day — C ontinued. 
 
 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 
 
 2 Milk, 106 e.c. or 5V2 oz. Scraped beef, 23 gm. or 6 dr. 
 
 Boiled rice, 66 gm. or 2 oz. Butter, 4 gm. or 1 dr. 
 
 3 One soft boiled egg. Zwieback, 20 gm. or 5 dr. Butter, 
 
 4 gm. or 1 dr. 
 
 4 Cooked chopped chicken, 25 gm. or 6 dr. 
 
 5 Egg. Sugar, 14 gm. or 3^/2 dr. 
 
 6 Milk, 166 c.c. or 5I/2 oz. Scraped beef, 24 gm. or 6 dr. 
 
 Boiled rice, 67 gm. or 2 oz. Butter, 4 gm. or 1 dr. 
 
 7 One soft boiled egg. 
 
 Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 
 331/g oz.; sugar, 40 gm. or 1^/3 oz.; scraped beef, 
 70 gm. or 2^/3 oz., boiled rice, 200 gm. or 6Y3 
 oz. ; zwieback, 40 gm. or 1^/3 oz.; or toast, 20 gm. 
 or 5 dr.; chicken, 50 gm. or IY3 oz.; butter, 20 
 gm. or 5 dr. 
 
 Eleventh Day 
 
 7 a.m. One soft boiled egg. Milk, 250 e.e. or 8^/3 oz. ; zwieback, 
 
 10 gm. or 21/2 dr. Butter, 4 gm. or 1 dr. 
 9 Egg. Sugar, 13 gm. or 3 dr. Scraped beef, 20 gm. or 
 
 5 dr. Boiled rice, 75 gm. or 2^^ oz. Zwieback, 10 
 gm. or 21/2 dr. Butter, 6 gm. or I14 dr. 
 
 11 One soft boiled egg. Milk, 250 c.c. or 81/3 oz. Butter, 
 
 6 gm. or 11/2 dr. Zwieback, 10 gm. or 2i/^ dr. 
 
 1 p.m. Egg. Sugar, 15 gm. or 3 dr. Cooked chopped chicken, 
 
 25 gm. or 6 dr. Boiled rice, 75 gm. or 214 oz. 
 3 One soft boiled egg. Milk, 250 e.e. or 8V3 oz. Scraped 
 
 beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 2I/2 oz. 
 Zwieback, 10 gm. or 21/2 dr. Butter, 6 gm. or II/2 dr. 
 5 Egg. Sugar, 14 gm. or 31/2 dr. Cooked chopped chicken, 
 
 25 gm. or 6 dr. Boiled rice, 75 gm. or 2I/2 oz. But- 
 ter, 6 gm. or 11/2 dr. 
 7 One soft boiled egg. Milk, 250 c.c. or 8Y3 oz. Zwie- 
 
 back, 10 gm. or 21/2 dr. Butter, 6 gm. or II/2 dr. 
 Scraped beef, 30 gm. or 1 oz. 
 
 Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 
 33 Y3 oz.;' butter, 40 gm. or IY3 oz.; sugar, 40 
 gm. or IY3 oz.; scraped beef, 70 gm. or 2Y3 oz.; 
 boiled rice, 300 gm. or 30 oz. ; zwieback, 60 gm. or 
 2 oz.; chicken, 50 gm. or IY3 oz. 
 
168 TEXTBOOK OF SURGICAL NURSING 
 
 Twelfth Day 
 
 7 a.iu. One soft boiled eg£i:. Milk, 250 e.c. or 8^/^ oz. Zwieback, 
 
 10 gin. or 2V^ dr. Butter, 4 gra. or 1 dr. 
 9 ' Egg. Sugar, 13 gm. or 3 dr. Serajjed beef, 35 gm. or 
 
 1 oz. Boiled rice, 75 gm. or 2i/2 oz. Zwieback, 10 
 gm. or 2^,2 dr. Butter, 6 gm. or IV2 ^^'• 
 11 One soft boiled egg. Milk, 250 c.c. or 8^/3 oz. Zwieback, 
 
 20 gm. or 5 dr. Butter, G gm. or lYz dr. 
 1 p.m. Egg. Sugar, 13 gm. or 3 dr. Cooked chopped chicken, 
 
 25 gm. or 6 dr. Boiled rice, 75 gm. or 2'^/2 oz. Zwie- 
 back, 10 gm. or 2V2 dr. Butter, gm. or II/2 dr. 
 3 One soft boiled egg. Milk, 250 e.c. or Sy^ oz. Scraped 
 
 beef, 35 gm. or 1 oz. Boiled rice, 50 gm. or I-/3 oz. 
 Zwieback, 10 gm. or 2V2 dr. Butter, 6 gm. or II/2 dr. 
 5 Egg. Sugar, 14 gm, or 3^ o dr. Chopped cooked chicken, 
 
 25 gm. or 6 dr. Boiled rice, 75 gin. or 2^/2 oz. Zwie- 
 back, 10 gm. or 21/2 dr. Butter, 6 gm. or IV2 dr. 
 7 . One soft boiled egg. Milk, 250 e.c. or 8^/^ oz. Zwieback, 
 
 10 gm. or 21/2 dr. 
 
 Total, 4 raw eggs; 4 cooked eggs; milk, 1000 e.c. or 
 331/3 oz. ; sugar, 40 gra. or IY3 oz. ; scraped beef, 
 70 gm. or 2^/3 oz. ; boiled rice, 300 gm. or 10 oz. ; 
 zwieback, 80 gm. or 2-/3 o^-! chicken, 50 gm. or 
 1-/3 oz. ; butter, 40 gm. or li^ oz. 
 Thirteenth Day 
 
 7 a.m. One soft boiled egg. Milk, 142 c.c. or 4-/3 oz. Zwieback, 
 
 10 gm. or 2^/2 dr. Butter, 4 gra. or 1 dr. 
 
 9 Egg. Sugar, 13 gm. or 3 dr. Milk, 142 c.c. or 42/3 oz. 
 
 Scraped beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 
 21/2 oz. Zwieback, 20 gm. or 5 dr. Butter, 6 gm. or 
 11/2 dr. 
 11 One soft boiled egg. Milk, 144 c.c. or 5 oz. Zwieback, 
 
 10 gm. or 2^ dr. Butter, 6 gm. or lYo dr. 
 
 1 p.m. Egg. Sugar, 13 gin. or 3 dr. Milk, 142 c.c. or 4-/3 oz. 
 
 Cooked chopiDed chicken, 25 gm. or 6 dr. Boiled rice, 
 75 gm. or 2I/2 oz. Zwieback, 10 gm. or 2V2 dr. But- 
 ter, 6 gm. or 1/2 dr. 
 
 3 One soft boiled egg. Milk, 144 e.c. or 5 oz. Scraped 
 
 beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 2i/2 oz. 
 Zwieback, 10 gm. or 2i^ dr. Butter, 6 gm. or II/2 dr. 
 
 5 Egg. Sugar, 14 gm. or 3i/^ dr. Milk, 142 c.c. or 4^/^ 
 
 oz. Cooked chopped chicken, 25 gm. or 6 dr. Boiled 
 rice, 75 gm. or 21/2 oz. Zwieback, 10 gm. or 2i/^ dr. 
 Butter, 6 gm. or II/2 dr. 
 
SURGICAL DIETETICS 169 
 
 Thirteenth Day — Continued. 
 
 7 p.m. One soft boiled egg. Milk, 144 c.c. or 5 oz. Zwieback, 
 10 gm. or 2V2 dr. Butter, 6 gm. or II/2 dr. 
 
 Total, 4 raw eggs ; 4 cooked eggs ; milk, 1000 c.c. or 
 33^/3 oz.; sugar, 40 gm. or l^/g oz.; scraped beef, 
 70 gm. or 2^/3 oz. ; boiled rice, 300 gm. or 10 
 oz. ; zwieback, 80 gm. or 2Y3 oz. ; chicken, 50 gm. 
 or 1-/3 oz.; butter, 40 gm. or l^/g oz. 
 Fourteenth Day 
 
 7 a.m. One soft boiled egg. Minced chop. Buttered toast. 
 
 Milk, 142 c.c. or 42/3 oz. 
 9 Boiled rice. Buttered zwieback. Custard. Milk, 142 
 
 c.c. or 4-/3 oz. 
 11 One soft boiled egg. Buttered zwieback. Junket. Milk, 
 
 142 c.c. or 4-/3 oz. 
 1 p.m. Minced chicken. Boiled rice. Buttered zwieback. Cus- 
 
 tard. Milk, 142 c.c. or 42/3 oz. 
 3 One soft boiled egg. Cooked scraped beef. Boiled rice. 
 
 Buttered toast. Milk, 144 c.c. or 5 oz. 
 5 Minced chicken. Boiled rice. Buttered zwieback. Cus- 
 
 tard. Milk, 142 c.c. or 42/3 oz. 
 7 One soft boiled egg. Buttered toast. Milk, 144 c.c. or 
 
 .5 oz. 
 
 Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 
 33^/3 oz.; sugar, 4 gm. or 1^/3 oz. ; scraped beef, 
 70 gm. or 2^/3 oz. ; boiled rice, 300 gm. or 10 oz. ; 
 zwieback, 100 gm. or S^/g oz. ; butter, 40 gm. or 
 1^/3 oz. ; chicken, 50 gm. or 1^/, oz. 
 
 Anti-Constipation Diet. — Most people after operation are 
 very constipated. Constipation has very serious sequela and 
 the importance of impressing upon the patient's mind the 
 necessity of a daily movement of the bowels cannot be over- 
 emphasized. There should be a regular time for moving the 
 bowels, which should be observed conscientiously. The best 
 time is shortly after breakfast ; the patient should remain seated 
 on the toilet for at least five or ten minutes, and then if there is 
 no desire to move the bowels, a glycerine suppository should 
 be inserted to stimulate the movement. Provided there is no 
 contraindication to any of the coarser vegetables, the patient 
 should be placed upon the anti-constipation diet. 
 
170 TEXTBOOK OF SURGICAL NURSING 
 
 Diet for Anti-Constipation. 
 
 Breakfast 
 
 Any fruit, fresh, cooked, preserved, or dried. 
 
 Shredded wheat, Thomas uncooked wheat biscuit, or oatmeal, or 
 
 toasted corn flakes with cream if possible, otherwise a small 
 
 amount of milk and sugar or molasses. 
 Bread. — Use only graham, rye, bran, whole wlieat or corn bread. 
 Butler, jam, jelly, or honey. Coffee with cream and sugar. 
 
 Liinclieon and Dinner 
 
 Soup. — Any kind except those thickened with flour, or containing 
 
 milk. 
 Fish, meat, or eggs in moderation. Eat as much of the fat as 
 
 possible. 
 Vegetables. — Fresh or canned in any quantities. Green salads with 
 
 olive oil. 
 Desserts. — Fresh fruit or fruit cooked or j^reserved is best; also 
 
 jellies prepared with coffee, wine and lemon, etc. Water ices may 
 
 be eaten freely but only small amounts of ice eream may be taken. 
 
 The undererusts of pies may not be eaten. 
 
 General Directions. — Take at least a glass of water beforG 
 breakfast, one in the middle of the day, and on 3 at niglit. In 
 addition take as much water as maj!" be decired. Tlii ; nay bo 
 plain water, vichy or any carbonated water. Evttcrmilk, .'^our 
 milk, cider, beer, and white wine are allovred. Bv.ttor in any 
 quantity is permitted. 
 
 Avoid tea, red wine, milk and whisky, white bread, noodlc.i, 
 vermicelli, macaroni, cake, rice, barlej', potatoes, and (hre.:c. 
 
 General Riiles. — Have a regular time for goin^ to the toilet. 
 Take a daily walk in the open air. Practice the setting-up 
 exercises daily. 
 
 Setting-up Exercises. — 
 
 1. Knees stiff; bend forward and try to tov.cli £ocr v.iLh 
 fingers. 
 
 2. Bend body backward from hips. 
 
 3. Bend body to the right and left from hips. 
 
 4. Rotate to the right and to the left on hips. 
 
SURGICAL DIETETICS 171 
 
 Anti-Obesity Eoutine. — Very often it is necessary to reduce 
 extremely stout individuals before any operation is undertaken. 
 Of com\.e, thi:j is difficult to accomplish and great care and 
 judgment should be exercised because the patient must not be 
 Aveakcncd unnecessarily. The general routine is as follows: 
 
 1. A hot bath on Monday, Wednesday, and Friday for ten 
 minutes before retiring. 
 
 2. Epsom salts, one tablespoonful in cold water on Tuesday 
 morning. 
 
 3. Walk at least one mile daily. 
 
 4. Setting-up exercises for ten minutes each morning before 
 breakfast. 
 
 Anti-Obesity Diet. 
 
 Breakfast Calories Proteins 
 
 One orange or one apple 70 1 
 
 Coffee with 4 tablespoonf uls milk 20 2 
 
 1 teaspoonf ul sugar 20 
 
 2 eggs or lean meat (about 5 x 3I/2 inches) 150 13 
 
 Luncheon 
 
 Cup of beef tea or clear soup 25 3 
 
 Tea with 2 tablespoonfuls milk 20 1 
 
 1 level teaspoonf ul sugar 15 
 
 2 slices of bread about 4x4x^/2 inches 146 4^/^ 
 
 1 pat of butter about 1 x 1 x V2 inches 80 
 
 1 saiieerful s^Dinach, celery, or green vegetable . 5 
 
 Lean meat about 5 x 3^/^ inches 300 24 
 
 Dr.zner 
 
 Cne cup of beef tea or clear soup 25 3 
 
 Tea vrith 2 tablespoonfuls of milk 20 1 
 
 1 te:.s^:)oonful sugar 15 2^4 
 
 1 fiicc^ of bread 70 21^ 
 
 Butter, one h:ilf pat 40 
 
 Meat about 5x3x1/2 inches 300 24 
 
 Entire potato or 2 tablespoonfuls of any starchy 
 
 vozetable without grease 90 2 
 
 ToL.l .....^ 1405 SO34 
 
172 TEXTBOOK OF SURGICAL NURSING 
 
 Additional Diet if prescribed : 
 
 One quart of butterniilk 640 60 
 
 American cheese, one inch cube 70 40 
 
 Nutrient Enemata. — As a rule these enemata are not very 
 sufcessful, but Avlien food is constantly vomited from the stom- 
 ach, or M'hen there is a stenosis of the cardia of the stomach or 
 esophagus, at least some little nourishment is received in this 
 ■vvay. Preceding it a cleansing enema of about one pint of 
 normal saline solution should be given. It is advisable to use a 
 small soft tube and to insert it about 25 cm. from the rectum, 
 for the higher it is introduced the greater is the absorption. 
 
 The food used in the enema is thoroughly mixed, then strained 
 through cheese cloth, and poured into the funnel, five ounces 
 at a time, at a temperature of 110° F. Great care should be 
 taken that no air is introduced. The patient must lie quietly 
 in bed for at least twenty minutes after the enema. Following 
 are several formulas which may be used : 
 
 1. The whites of two eggs and peptonized milk, 90 c.c. 
 
 2. One whole egg, 1 gm. of salt, 10 c.c. of brandy, 90 c.c. of 
 peptonized milk. 
 
 3. Boas's formula: — 250 c.c. milk, yolks of two eggs, 3 gm. 
 table salt, 1 tablespoonful red wine, 1 teaspoonful wheat 
 starch. 
 
 Feeding through Fistula. — This Ls employed when an open- 
 ing has been made in the stomach because of some benign or 
 malignant disease of the esophagus or cardia of the stomach. 
 The food which is passed through the fistula must be either fluid 
 or semi-solid and properly warmed. 
 
CHAPTER XIII 
 
 ANESTHESIA 
 
 PREPARATION OF THE PATIENT 
 
 The first thing to learn about the preparation of a patient 
 for an anesthetic is that it is very important in both its immedi- 
 ate and its more remote consequences. It does not need to be 
 explained, of course, that this applies to the various nursing, 
 treatments such as the regulation of diets, medications, etc., 
 but the point which is often overlooked by the inexperienced 
 is that the state of mind in which a patient approaches his 
 anesthetic will determine very materially the way in which he 
 will undergo the period of anesthesia, and that this in turn will 
 have a vital effect upon his endurance of the operation and his 
 recovery, from the effects of both the operation and the anes- 
 thetic. 
 
 The preparation, therefore, should begin with the patient's 
 mind, and at no time throughout the items of the physical 
 preparation should the nurse forget this important mental in- 
 volvement in her work. There is always a great element of 
 fear in the anticipation of taking an anesthetic, of surrender- 
 ing consciousness, and of submitting to surgery, and there is 
 perhaps no condition which the anesthetist dreads more in his 
 subject than that of nervous apprehension, for as a rule an 
 agitated or hysterical state of mind will reflect itself in the 
 physical reactions to the anesthetic and will nearly always per- 
 sist throughout the operation and the recovery from the anes- 
 thetic. The muscles of the body in such subjects will be tense 
 and this will entail shallow and irregular respirations and 
 consequently slow and irregular absorption of the anesthetic. 
 Crying will do the same and in addition will cause detrimental 
 obstruction of the air passages by tears, mucus, and conges- 
 tion. Conscious resistance by these patients will pass over into 
 
 173 
 
174 TEXTBOOK OF SURGICAL NURSING 
 
 unconscious struggling as the anesthesia develops, and Avill pro- 
 long and complicate it in numerous Avays. And finally, all tlieic 
 irregularities will use up valuable vitality and preclude tlio 
 best anesthesia and recovery. This state of alrairs the nvirse 
 can j)revent entirely in some cases and to a great degree in mo:t 
 cases by judieious word and deed as she goes about the prepara- 
 tion. This merely means that her general attitude will be re- 
 assuring and encouraging, and that she will avoid as far a^ 
 possible all reminders of the event for which tho Ij preparing. 
 Such conduct has, of course, been dinned ir.to every nurss'.i 
 ears continuously ever since she entered the ho.';;:ital an the 
 only kind which ever befits a nurse, but t-he mu.Gt practice 
 it in this case Avith the utmost degree of refinement. 
 
 With this lesson well in hand the hodily prepar2iiD:i ol the 
 patient may be taken up. There Avill be specific orders by tho 
 surgeon, and these Avill vary in detail; and there Avill also be 
 variations depending upon the anesthetic to be given and the 
 nature of the operation. Nevertheless, though Ave can cover 
 this ground in only a someAvhat general Avay we shall enumerate 
 the probable steps as f oIIoavs : 
 
 1. A cathartic will he administered twelve or more hours be- 
 fore the operation. 
 
 2. Six hours or more in advance food will he prohihitcd or 
 perhaps restricted to fluids till tAA'o or three hours before the 
 appointed time for the operation, and then nothing Avill be 
 administered by mouth. It is obligatory that several hours of 
 starA^ation immediately precede an anesthetic because anything 
 in the stomach, even water, is likely to cause A^omiting Avhen 
 the anesthetic begins to take effect, and this, besides being 
 annoying, may have serious asphj'xial results. In some cases the 
 question of harmful prostration from lack of food may override 
 the danger of its presence in the stomach, but care must be 
 exercised in this event to give foods which the stomach Avill dis- 
 pose of most rapidly such as broths, tea or coffee, etc. ; and 
 milk should be especially avoided for this reason, even :n the tea 
 and coffee. 
 
 3. The operative field may be prepared at any time, but this 
 Avill usually be determined by order and by circumstances, and 
 
ANESTHESIA 175 
 
 suggestions pertaining to specific cases have been pointed out 
 in their proper connections in Chapters IV to XI. 
 
 4, Several hours in advance one or more cleansing enemas will 
 be given. This part of the preparation must be done with con- 
 siderable caution because it must be remembered that the pa- 
 tient has probably been subjected to vigorous catharsis which 
 may have been exhausting, that the tonic effect of food has been 
 denied, and that in any case an enema is liable to be prostrating. 
 Norvou-i patients, and those in a state of reduced general vitality 
 may entirely collapse under the administration of the enema 
 at tli-ij time if care is not exercised. Plenty of time should 
 be reserved for this treatment and all suggestion of haste should 
 be avoided. 
 
 5. In cases of intestinal obstruction, other cases where the 
 Etoniaih is probably not empty, or where an operation is to 
 be pcrrormed upon the stomach a lavage may be given. This 
 U another treatment which calls for extreme calmness because 
 it is alv/ays a trying and exhausting ordeal for the patient and 
 those needing it will usually be in poor condition. 
 
 G. Immedicitely before the anesthetic is administered the 
 hladdcr miict he emptied and by catheterization if necessary. 
 
 7. The patient i-^ clad in loose, simple clothing and plenty of 
 it, acccrdir.g to the season. As a rule, a nightgown reinforced 
 over the chest with a piece of flannel, loosely-fitting stockings, 
 and a cuitablo number of blankets will comprise the wearing 
 apparel. 
 
 8. False tecih, including detachable bridgework, will be re- 
 moved and carefully laid away. 
 
 9. All jewelry is removed and safely cared for also. In cases 
 where there may be prejudice on the part of the patient against 
 removing some article of jewelry, such as a ring, it should be 
 secured against loss by anchoring in place with a piece of tape or 
 bandage. 
 
 CARE OF PATIENT DURING ANESTHESIA 
 
 The policy of calmness and reassurance which you adopted 
 before beginning the preparation must be observed with re- 
 doubled effort when the administration of the anesthetic is 
 
176 TEXTBOOK OF SURGICAL NURSING 
 
 begun, because, as pointed out above, the mental attitude of the 
 patient will determine his behavior in general throughout his 
 anesthesia. Absolute quiet in the room will be necessary for 
 the best results, and talking or Avhispering, especially after 
 the administration of the anesthetic has been begun, are par- 
 ticularly objectionable because the sense of hearing is one of the 
 last to be anesthetized 'and as it often functions capriciously 
 at this time patients may get undesirable impressions from 
 what is said. Furthermore, conversation often leads partially 
 anesthetized patients to make efforts to participate in it and 
 this will delay the anesthesia and aggravate the excitement. 
 Also, too great caution cannot be taken in deciding when the 
 sense of hearing has been entirely overcome and when it w'ill 
 be safe to indulge in professional discussion of the patient's 
 condition which it might not be wise for him to hear. 
 
 There will always be some degree of struggling, sometimes 
 voluntary and nearly always involuntary, during the induction 
 of the anesthesia, particularly in the case of ether, and the 
 nurse will usually be expected to do guard duty against this. 
 The arms and legs will be her chief concern, for though some- 
 times a strong patient will endeavor to sit up and even thrust 
 himself from the table, if the arms and legs are kept in place 
 he is helpless further. It is sometimes the custom to restrain 
 the legs by binding them to the table with a strong strap passed 
 just above the knees. With a strong, healthy patient, which is 
 the type most likely to cause trouble, this precaution may be 
 necessary, especially if there are not enough assistants available 
 to control him, for one assistant cannot manage such a subject ; 
 but this practice will be very exciting to some patients and 
 should not be adopted unless absolutely necessary. For these 
 excitable patients a good plan will be to have this strap ready 
 and to defer the adjustment of it till a degree of unconscious- 
 ness has been attained; or, some subjects will not be alarmed 
 by this restraint if it is explained that you are applying it 
 to prevent them from rolling from the narrow table after they 
 have gone to sleep. In fact, this apology for the strap, if 
 sincerely made, will sometimes comfort a nervous patient and 
 
ANESTHESIA 177 
 
 give him a sense of security, though one always runs a risk 
 when undertaking this plan. 
 
 In some institutions it is the practice to bind the arms, shoul- 
 ders, and legs to the table with a few turns of a strong bandage, 
 and the anesthetist is then able to proceed alone, but it will 
 be a rare patient who will not suffer more or less under such 
 treatment and it seems that urgent necessity is the only justifi- 
 cation for it. 
 
 Whatever plan may be adopted for guarding the legs, the 
 attendant nurse's duty will be to care for the hands. Most 
 patients are reassured by having their hands supported gently 
 by another person at this time because they realize, of course, 
 that they will soon be unconscious, and many have expressed 
 apprehension of danger befalling their hands. AVith strong 
 patients who may be expected to be exceptionally hard to con- 
 trol, it will be best to ask them to place their hands comfortably 
 upon the table at their sides and to turn the palms down- 
 ward; the nurse can place a hand gently upon each of his 
 wrists (standing with face toward the anesthetist) and thus 
 be prepared for the worst, for pressure upon the wrists can 
 prevent, the patient from turning his palms from the table 
 and unless he can turn his hand he cannot arise. This will 
 be an unnecessary precaution, however, for the average pa- 
 tient, and the nurse's rule should be to advise him to put his 
 hands where they are most comfortable and then, in a natural 
 way, to place her own hands upon his wrists or forearms in 
 such a way as to be prepared to foil any sudden attempt upon 
 his part to do the instinctive thing of grabbing the inhaler. 
 
 The nurse responsible for the hands should form the Jidbit 
 of following the pulse. Anesthetists will do this for themselves 
 but there are times when they are so entirelj^ occupied otherwise 
 that many of them will be grateful for this assistance. In per- 
 forming this service the nurse must know what variations to 
 expect under the several anesthetics, and these we shall in- 
 dicate on pages 178-180 where we discuss some of the reactions 
 of patients to the more common anesthetics. 
 
 Care should always be taken not to hold the hand of a pa- 
 tient in such a w^ay that he may grip it, for a strong one may 
 
178 TEXTBOOK OF SURGICAL NURSING 
 
 entirely overcome a nurse in this way when in the stage of 
 excitement and he may even injure her. 
 
 The foregoing comments will apply in a general way to 
 subjects of all anesthesia, but as your specific troubles and 
 duties will depend somewhat upon which of the several anes- 
 thetics is used we shall take up separately each one of the 
 four more common ones: nitrous oxide, ether, chloroform, and 
 ethyl chloride, and point out briefly the usual behavior of 
 patients under them and the corresponding nursing care. 
 
 Nitrous Oxide. — The induction period of this anesthetic is 
 very short, lasting only a few seconds and there will be little 
 or no struggling, so the nurse's duties will not extend much 
 bej'ond assisting the anesthetist in Iteeping the patient com- 
 posed so that he will breathe deeply and regularly. The gen- 
 eral precautions against excitability outlined above, however, 
 should always be taken as occasionally they will be helpful. 
 
 With nitrous oxide tlie pulse should not show much change, 
 but should be regular, full and quiet. 
 
 Ether. — This anesthetic calls for all the precautions men- 
 tioned above because its induction period is relatively long, 
 the anesthetic is comparatively disagreeable to take, there is 
 almost always a period of excitement of greater or less dura- 
 tion and severity, and there are numerous respiratory and other 
 irregularities which may arise and call for a helping hand from 
 the nurse. 
 
 The anesthetist will, of course, guide the nurse's general 
 course of action, but unless otherwise instructed she will make 
 no mistake by following the more moderate course we have 
 already advised. On the subject of restraint during the stage of 
 excitement in the induction of ether anesthesia anesthetists will 
 disagree. Some will prefer absolute resistance from the begin- 
 ning to all efforts on the part of the patient, especially with 
 his hands, and others will act upon the belief that early resist- 
 ance to these efforts only aggravates them and will therefore ad- 
 vise permitting any activity that does not displace the inhaler 
 or allow the patient to harm himself or the attendants. Per- 
 sonally, we have been entirely converted to this practice and 
 are therefore inclined to advise the nurse to adopt it where she 
 
ANESTHESIA 179 
 
 is not otherwise directed by the anesthetist, but she must )k; very 
 Gure beforehand that she is prepared to carry it out success- 
 fully, and must remember that even though the plan may suc- 
 ceed at first, some cases will later compel her to abandon it for 
 the sterner measures. 
 
 With ether one expects the pulse to increase more or less in 
 force and frequency, but extreme or sudden increase in fre- 
 quency and other abnormal developments in the pulse will be 
 matters of concern. 
 
 Chloroform. — The induction of chloroform anesthesia is 
 usually less eventful from the nurse's standpoint than that of 
 ether, that is, cases of extreme excitement will not be so numer- 
 ous; but they will occur and must therefore be kept in mind. 
 There is one important difference between the two anesthetics 
 which the nurse should note, and that is that ether is, in gen- 
 eral, stimulating to the action of the heart in the early period of 
 its administration while chloroform is depressing. For this rea- 
 son patients to whom chloroform is being administered should 
 not be allowed the extreme activity during the stage of excite- 
 ment which we have advised for those receiving ether. The 
 anesthetist will control this, but we owe it to the nurse here to 
 emphasize the fact that the method w^e recommended so highly 
 for ether patients must be confined to them. 
 
 The pulse of the chloroform patient is of comparative impor- 
 tance. We have just remarked that chloroform depresses the 
 heart, and so it does, but the nurse watching the pulse will 
 notice that in the very beginning of the administration there 
 may be a slight quickening of the pulse and a noticeable in- 
 crease in its force. Very soon, however, there will be a gradual 
 decrease of both which will probably extend below the level you 
 noticed before the anesthetic was started. Extremes in either 
 direction are, of course, danger signals. 
 
 Ethyl Chloride. — Ethyl chloride is not in general use for pro- 
 longed anesthesia, but it is popular in some communities for 
 short operations and dressings which require onlj^ a few mo- 
 ments. We mention it here since its administration will usually 
 require the attendance of a nurse throughout because entire 
 relaxation is rarely attained and restraint of hands or the part 
 
180 TEXTBOOK OF SURGICAL NURSING 
 
 operated upon will usually be necessary. Induetion, entire 
 anesthesia, and recovery will all take place within a few mo- 
 ments, and as vomiting often occurs very soon after the with- 
 drawal of the inhaler, the nurse should be prepared for this 
 from the beginning. 
 
 With ethyl chloride the pulse should not show much change, 
 as a rule, except perhaps a slight decrease of frequency and 
 force. 
 
 During the operation the anesthetist will be responsible for 
 observing the general condition of the patient, but the operat-' 
 ing room nurse also should make it a rule to remember the pa- 
 tient's condition and to be prepared to supply warm blankets, 
 hot water bottles, hypodermics, etc., at any time. The tempera- 
 ture of the room is also the nurse's responsibility, and she should 
 remember that maintenance of the standard temperature (75°- 
 76° F.) and the exclusion of draughts have a direct influence 
 in conserving the patient's well-being. 
 
 AFTER CARE 
 
 After the operation the nurse will usually be left entirely 
 responsible for the preparation of the patient for the journey to 
 his bed, and she will see that he is well wrapped in blankets. 
 During anesthesia, especially with ether, there may be con- 
 siderable perspiration, and as the outer hallways through which 
 the patient is carried will doubtless be cooler than the operat- 
 ing room and well supplied with draughts it will be very easy 
 for him to become suddenly chilled and thus to contract bron- 
 chitis or pneumonia. Also, ether patients have been given a 
 predisposition to these two complications by the irritant effect 
 of ether upon the air passages. In any other case, no mat- 
 ter what the anesthetic has been, it must be remembered that the 
 patient's vitality has been lowered by both it and the operation 
 itself and that he must be as well fortified as possible against 
 the effects of sudden change of temperature. 
 
 Special care must be taken also in handling an anesthetized 
 patient, for violent or sudden change of position may seriously 
 
ANESTHESIA 
 
 181 
 
 interfere with cardiac or respiratory action either directly by 
 overtaxation or indirectly by inducing vomiting and conse- 
 quent choking, etc. Often, when ether or chloroform anes- 
 thesia has been profound, the patient may be transferred to 
 his bed without arousing him to any degree if he is handled 
 
 Fig. 18. — An Easy and Safe Method of Lifting a Helpless Patient. 
 The two nurses at the sides of the table are grasping a piece of heavy 
 canvas, about 1 yard long and % yard wide, which lies across the table 
 under the patient's hips. 
 
 gently and quietly. A good method of lifting patients care- 
 fully and easily is illustrated in Fig. 18. 
 
 The bed should have been previously warmed with hot water 
 bottles, a warm blanket should be placed directly underneath 
 the patient and plenty of warm ones over him — that is, there 
 are no intervening sheets. His bedroom should be well heated, 
 draughts avoided, and the temperature of his body, particularly 
 
182 TEXTBOOK OF SURGICAL NURSING 
 
 the hands and feet, observed from time to time by feeling them. 
 In warm weather, or when the patient is in good general health 
 and the anesthesia has been slight or short (as in short admin- 
 istrations of nitrous oxide or ethyl chloride) the blankets and 
 some of the other precautionary measures may not be necessary, 
 but the patient should, of course, be given the benefit of any 
 doubt. 
 
 Though events of recovery will depend somewhat upon the 
 temperament and physical condition of the patient, there is 
 a general course which may be expected for each of the anes- 
 thetics and certain accidents and complications which are pe- 
 culiar to each. We shall, therefore, discuss separately the re- 
 covery to be expected from each of the four anesthetics. It 
 must be remembered, however, in all cases that the nature* 
 of the operation modifies recovery to a greater or lesser de- 
 gree, but your study of shock, hemorrhage, and other operative 
 and post-operative complications will teach you to make the 
 necessary differentiations. 
 
 Nitrous Oxide. — Patients who have had this gas will recover 
 within a very few minutes, as a rule, though the time will 
 often be prolonged by hysterical outbursts of laughing, crying, 
 etc. Nausea and vomiting sometimes occur, but they are in- 
 frequent. Oftenest a patient will shows signs of lassitude 
 and may sleep for a considerable time. Headache is not uncom- 
 mon and may sometimes be very persistent. The pulse and res- 
 pirations of these patients should always be watched closely for 
 some time, but as a rule recovery will be uneventful in these 
 respects. 
 
 Nitrous oxide subjects will usually be able to take nourish- 
 ment comparatively soon after recovery, but the surgeon 's orders 
 will determine the nurse's course in this respect, as there will 
 often be surgical reasons of which the nurse may not know 
 which will control administrations by mouth. Comments on 
 page 188 on the administration of water to ether patients will 
 apply in general to nitrous oxide subjects, and detailed in- 
 structions as to diets in all cases are given under the subject 
 of surgical diets in Chapter XII, ai^d in the discussions of the 
 various operative conditions in Chapters IV-XI. 
 
ANESTHESIA 
 
 183 
 
 Ether. — Recovery from this anesthetic calls for careful nurs- 
 ing, and patients should not be left alone for one moment until 
 consciourjness is entirely established, for whatever aid they may 
 need during this time must be given promptly. 
 
 Pro\i-ion should be made early for the restraint of violence 
 during resovery, for all the efforts incident to the stage of ex- 
 citaliJty in the induction of the anesthesia may be repeated 
 during recovery. The favorite attempt of these patients is to 
 
 Fig. 19. — Restraining Sheet for Patients Eecovering from an An- 
 esthetic. Strong safety pins may keep this in place on tlie bed frame; if 
 the bar to which it is attached is not cylindrical, friction will hold a tightly 
 drawn and well tucked in sheet; or, the sheet may be passed entirely 
 around the bed springs and the ends fastened together underneath. 
 
 get out of bed, and if there are not enough assistants to control 
 them throughout the period of this tendency a restraining 
 sheet should be fastened across the bed just over the knees (Fig. 
 19). This will be of enough assistance, as a rule, so that one 
 nurse can master the situation. 
 
 The respirations should be watched closely, for there are many 
 respiratory complications which may arise before consciousness 
 is regained. Regularly, the patient recovering from ether will 
 breathe less deeply and vigorously than normally because, 
 though ether acts as a stimulant early in its administration, 
 
18i TEXTBOOK OF SURGICAL NURSING 
 
 it eventually tends to depress the respiratory nerve center. 
 The. color of the face, particularly of the ears and lips, will be 
 a good guide as to whether or not he is inhaling sufficient oxygen 
 if it is not convenient to observe his chest motion. In this 
 connection the nurse should remember that sedatives, especially 
 morphine, if given recently, will probably have contributed to 
 the depression and she will make allowance on that basis for 
 abnormally slow or shallow respirations, but she should not be 
 too slow to be alarmed by respiratory depression after an anes- 
 thetic. In cases of extreme or sudden depression, while wait- 
 ing for help, vigorous rubbing of the lips and face with a 
 coarse towel may revive the patient somewhat, and of course the 
 nurse is always prepared to give artificial respiration in cases 
 of emergency. However, if the color and pulse are good and 
 the patient is breathing unobstructedly the best treatment is 
 to leave him alone, for many will pass unconsciously from their 
 anesthesia into a sound sleep from which they will awaken in 
 an hour or two fully recovered and more comfortable for thus 
 having passed away time which would otherwise have been 
 very unpleasant. This last remark has been inspired by obser- 
 vation of occasional instances in which concern has been felt 
 for the patient who quietly "slept off" his anesthetic, and he has 
 been aroused with no other effect than to bring him into earlier 
 consciousness of his troubles than necessary. 
 
 Other respiratory complications may arise early through 
 occlusion of the pharynx by a swollen or flabby tongue or by 
 accumulation of mucus or vomitus. This can usually be avoided 
 by keeping the patient's head turned to one side during re- 
 covery, or, if possible, by turning his entire body toward one 
 side, both of which measures allow any fluid to run out of the 
 mouth and also tend to throw the tongue and jaw forward and 
 away from the posterior wall of the pharynx. In cases of per- 
 sistent tendency of the tongue to occlude the throat the simple 
 pushing forward of the jaw may overcome the difficulty as this 
 carries the tongue forward also. This is often hard for the 
 young nurse to learn to do properly, but if she will first make 
 sure that the teeth are not locked together and will then thrust 
 the lower teeth in front of the upper ones, or as nearly so as 
 
ANESTHESIA 185 
 
 possible, she will accomplish all that she can by this measure. 
 Sometimes, however, it may be necessary to reach into the mouth 
 with a pair of tongue forceps (Fig. 20), or the fingers covered 
 with a towel or piece of gauze, and pull the tongue forward and 
 swab out the mucus with a sponge on a holder. For this it 
 will be necessary to hold the mouth open with a mouth gag of 
 some sort (Fig. 21) so as to prevent biting of the fingers, the 
 tongue, or the sponge forceps. Occasionally a spasm of the jaw 
 will accompany this condition and the patient will become very 
 
 Fig. 20. — Suitable Instruments for Grasping the Tongue. The two 
 having locks are the more useful because they answer also as sponge holders 
 for swabbing out the throat, but when used for grasping the tongue care 
 must be taken not to lock them so tightly as to crush it. 
 
 cyanotic. This calls for vigorous and quick action in prying 
 the mouth open wdth a mouth gag and relieving the obstruc- 
 tion as just described. In doing this great care must be taken, 
 of course, not to injure the teeth. 
 
 Nausea and vomiiting will occur in an average of 50 per cent, 
 of the ether cases. Some anesthetists show lower percentages 
 than this, but half the cases will be a fair number to count 
 upon. This should not persist for more than a few hours, though 
 patients naturally subject to digestive disorders may be thus 
 annoyed much longer. Special care must be exercised with the 
 patient when vomiting as there is always danger of his inhaling 
 
186 TEXTBOOK OF SURGICAL NURSING 
 
 the vomitus and becomiug asphyxiated by it ; and it is also pos- 
 sible that inhaled vomitus is responsible for some cases of 
 "ether pneumonia." Also, his eyes must be shielded from the 
 vomitus as they may be considerably irritated by it and de- 
 velop a troublesome and painful case of conjunctivitis. AVhen 
 consciousness has been recovered to some degree the coughing 
 reflex will function and the patient will be able to save himself 
 from tlie asphyxial danger by coughing, but in any case his 
 head should be held to one side while vomiting and the mouth 
 
 Fig. 21. — Mouth Gags. A, a simple wooden wedge which is very safe 
 and very serviceable for prying the teeth apart, as well as for holding the 
 mouth open temporarily for swabbing, pulling the tongue forward, etc. ; 
 B, metal gag which can be inserted only after the teeth have been well 
 parted, but which is self -retaining when well placed. 
 
 swabbed clean if necessary. The character of the vomitus 
 should always be noted. In ether cases there is likely to be 
 much mucus, as ether stimulates all secretions more than the 
 other anesthetics; and there will be indications of bile some- 
 times, and of stomach secretions. If blood is present it will be 
 a matter of special concern. However, if the operation has 
 been upon some part of the mouth, nose, throat, or stomach, it 
 must be expected that old blood ("coffee grounds") which has 
 been spilled or swallowed will be vomited. Bright red blood 
 is alarming also, but a bitten tongue or a loosened tooth may 
 be the contributing agent of this. Any case of unusual vomitus, 
 
ANESTHESIA 187 
 
 however, should be reported to the surgeon as it will usually 
 call for investigation by him. 
 
 The pulse, of course, is watched closely. That, too, will be 
 somewhat depressed, at least for a short time after the patient's 
 return to bed, but within an hour or so it should show signs 
 of recuperation. 
 
 There are several odd manifestations which may accompany 
 recovery from ether, such as tremor, hiccough, etc., but they are 
 usually transitory and are not seriously significant unless they 
 persist unduly. It is very likely that the patient who has mani- 
 fested the tremor during the induction of his anesthesia will do 
 so again when he recovers, but the nurse must not make the 
 mistake of overlooking a real chill in these patients because 
 the two conditions are easily confounded and a chill, as every 
 nurse knows, is not to be taken lightly. Likewise, persistent 
 hiccough should be regarded seriously because, aside from be- 
 ing very distressing to the patient, it may signify something 
 deeper than a mere irregularity of recovery of consciousness. 
 
 Pulmonary edema is another complication of ether anes- 
 thesia, though it is an infrequent one. The nurse has doubt- 
 less learned elsewhere the symptoms of edema of the lungs and 
 will at once recognize the unmistakable sound caused by the 
 great quantity of mucus which has accumulated in the lungs 
 and is being "washed" back and forth with respirations. A 
 collection of thick mucus in the throat will sometimes cause a 
 similar sound and even a degree of the cyanosis so prominent 
 in edema, but swabbing of the throat and observations of the 
 patient's general condition will quickly tell the nurse whether 
 or not to be alarmed. 
 
 Another complication to be feared and guarded against is 
 ''ether pneumonia." It is not frequent, but the nurse must 
 always bear it in mind. General nursing training will have 
 taught the nurse the warning signs and symptoms of pneu- 
 monia, so we shall not take space for them here. 
 
 Some authorities attribute one or two kidney disorders to 
 ether, chiefly that of albuminuria and sometimes suppression. 
 Urinalysis will show that albuminuria often does arise after 
 anesthesia; but whether it is caused by the anesthetic or by 
 
188 TEXTBOOK OF SURGICAL NURSING 
 
 something else "svill not eoneern us here as its treatment, if 
 there is any, -will be by prescription only. Suppression, of 
 course, "would be a serious condition but it is a nursing prob- 
 lem here only in so far as the nurse ^vill be responsible for 
 reporting as to whether or not evacuations of the bladder occur 
 normall}'. This subject is entered into more fully in Chapter 
 III, page 32, under post-operative complications. 
 
 The voiding of urine is always a matter of attention after 
 anesthesia and if it does not occur normally, or nearly so, it 
 must be regarded with concern. This may be due to suppres- 
 sion, which may or may not have reference to the anesthetic ; 
 but it will be very much more likely to be due to some deranging 
 effect of the anesthetic or the operation upon the nerve-control 
 of micturition which causes retention. The early training of 
 the nurse will have prepared her for overcoming mild cases of 
 retention, and the subject is discussed more fully in Chapter 
 III, page 31 ; but she should seek guidance in all cases of 
 failure to void urine within a few hours after recovery because 
 this is a verj- important avenue of elimination of the anesthetic 
 and any obstruction of it must be promptly removed. 
 ■ The nurse will be guided by the surgeon's orders as to the 
 administration of nourishment, because this will depend largely 
 upon the surgical condition of the patient as well as upon the 
 individual customs of the surgeon. Patients will be very thirsty 
 from the earliest moment of recovery and will desire large 
 quantities of Avater. Some surgeons will advise satisfying this 
 longing generously, except, of course, in stomach or other cases 
 where it will be harmful to the wound itself ; and other sur- 
 geons will prescribe extreme moderation, even to the extent 
 of allowing only small pieces of cracked ice. Every nurse 
 knows that more than the most meager quantity of water ag- 
 gravates nausea and vomiting in the vast majority of cases, but 
 it is also a fact that plenty of water and the usual prompt vomit- 
 ing of it will often have a sedative effect upon a turbulent 
 stomach by cleansing it thoroughly of the disturbing contents. 
 This treatment, however, is so heroic that the average nurse 
 shrinks from it and she should not administer it except under 
 definite order because there are many cases in which vigorous 
 
ANESTHESIA 180 
 
 vomiting would be very dangerous from the surgical standpoint, 
 to say nothing of the pain suffered by the patient. Further 
 discussion of this subject vv^ill be found in Chapter III, page 
 20, under post-operative complications. 
 
 In cases where water is forbidden the distressing parched 
 condition of the mouth may be relieved by sponging with a 
 lubricating mouth wash — one containing glycerin, for example. 
 Rectal administration of salt solution may sometimes be em- 
 ployed to relieve the extreme thirst of those patients who must 
 be denied water by mouth, but this treatment is not given 
 without definite order. 
 
 Many patients will be greatly distressed by the lingering 
 disagreeable taste of the anesthetic. The nurse may relieve 
 this with a mouth wash containing a generous amount of lemon 
 juice, tincture of myrrh, etc., according to the preference of the 
 patient. 
 
 The point at which food will be given is also a matter for 
 the surgeon to decide, but as this pertains more particularly 
 to the subject of surgical diet it is discussed under that head- 
 ing in Chapter XII, and in connection with specific operative 
 conditions in Chapters IV-XI. 
 
 Chloroform. — Recovery from chloroform requires the same 
 watchful nursing as does that from ether, but it is likely to 
 be less eventful. As a rule the patient will remain quiet and 
 pass from his anesthesia into sound sleep. 
 
 Nervous and excitable patients may have a period of excite- 
 ment which will necessitate the same precautions as to restraint 
 mentioned for ether subjects, but such cases will be compara- 
 tively rare. 
 
 Chloroform does not often produce the profuse secretion of 
 mucus nor the swollen tongue so usual in ether subjects, and 
 therefore these patients will not be so prone to the respiratory 
 obstructions which frequently complicate recovery from ether. 
 In fact, it is rare that the respirations will manifest any note- 
 worthy feature beyond the characteristic softness and quiet- 
 ness. 
 
 Nausea and vomiting will also be less frequent, though when 
 vomiting does occur it is more likely to be severe and persistent 
 
190 TEXTBOOK OF SURGICAL NURSING 
 
 thau after ether. The precautions mentioned for eases of 
 vomitin}? after ether appl.y equally to chloroform subjects, 
 with the addition of the one discussed in the following para- 
 graph. 
 
 Chloroform subjects very frequently exhibit considerable 
 pallor and this Avill usually be accompanied by marked depres- 
 sion of the pulse. These two symptoms are especially likely to 
 occur just before or during vomiting, and as their severity will 
 usually depend upon the severity of the vomiting and the excite- 
 ment accompanying it the nurse can often prevent considerable 
 exhaustion and even collapse by judicious management of such 
 cases. 
 
 The pulse is likely to be comparatively feeble throughout re- 
 covery from chloroform, and, as pointed out in the preceding 
 paragraph, is subject to periods of great depression. This makes 
 it advisable to exercise special care to keep these patients quiet. 
 though, as we have said, quiet recovery is provided by nature in 
 the great majority of chloroform subjects. 
 
 Hiccough will occur occasionally, but as in the case of ether 
 it will not often be of great consequence. 
 
 Bronchial and pulmonary complications are not frequent 
 after chloroform because the anesthetic is not so irritating to 
 these parts and does not cause the severe congestion of them 
 that ether so often does. However, they are not entirely un- 
 known and the nurse should not forget their possibility. 
 
 Though kidney complications, beyond albuminuria, are not 
 attributed to chloroform, the voiding of urine is an important 
 matter of nursing attention, as in the case of ether. 
 
 The discussion of nourishment in the case of ether wdll apply 
 in general to chloroform. 
 
 Ethyl Chloride. — Complete recovery of consciousness after 
 ethyl chloride usually takes place within a very few minutes. 
 Occasionally there will be a case of collapse, but this will usually 
 occur before the responsibility for the patient has been trans- 
 ferred from the anesthetist to the nurse. However, when col- 
 lapse does occur it is so sudden and so profound that the nurse 
 should keep its possibility in mind. 
 
ANESTHESIA 191 
 
 Headache, nausea, and vomiting occur frequently, and they 
 may be severe. 
 
 The pulse, respiratioiis, and general condition will, of course, 
 be carefully watched for some time, as in all cases of anesthesia. 
 
 Subsequent treatment as to 7iourishment, etc., will correspond 
 in general to that for nitrous oxide cases. 
 
 For lack of a more opportune moment we must mention now 
 the matter of the removal of the extra blankets with which the 
 anesthetic subject has been safeguarded. There can be no rigid 
 rule laid down as to when this should be done, as there are too 
 many varying factors to be considered. Some of the deter- 
 mining factors, excepting the self-evident one of recovery from 
 the anesthetic, are these : The particular anesthetic given ; 
 length of the anesthesia ; condition of the patient ; season of the 
 year; temperature of the room; and, of course, always the 
 subjective comfort of the patient. For the same reason that 
 the blankets were put on, care must be exercised as to their re- 
 moval; that is, there must be no chance of exposure taken. In 
 this respect error may be made in both directions, for it is as 
 much a mistake to leave these blankets on so long after recov- 
 ery that the patient becomes unduly warm as it is to take them 
 off before nature's "heating plant" is in working order. In 
 hospitals there will usually be an established routine, and else- 
 where the nurse will need to draw upon her professional good 
 judgment. Entire recovery from the anesthetic is the first 
 requisite. This will mean that nitrous oxide and ethyl chloride 
 patients, if they have blankets at all, Avill not need them as long 
 as ether and chloroform subjects. A vigorous, generally healthy 
 subject will recover all his functions much sooner after any 
 anesthetic than a weak, devitalized one. After recovery the 
 patient in poor condition may need protection further, while the 
 stronger one may not. In winter longer protection will be 
 needed than in summer. In a warm room more freedom can 
 be taken than in a cold one. In the daytime patients have 
 better resistance, on the whole, than at night. And last but 
 not least, the patient's feelings, which always have an influence 
 upon his condition, will enter into the case to some degree. 
 
192 TEXTBOOK OF SURGICAL NITRSING 
 
 Naturally, this transition is accomplished gradually, that is, 
 these special blankets are not all -svithdraAvn at one time. This 
 much having been said, common sense Avill do the rest. 
 
 All nursing care following an anesthetic must be a fusion of 
 that which pertains particularly to the anesthesia and of that 
 demanded by the surgical condition of the patient. We have 
 necessarily disregarded surgical conditions here, but their im- 
 portant nursing care is pointed out under the discussions of 
 the various operative procedures in Chapters IV to XI ; under 
 shock and hemorrhage, in Chapter II ; under post-operative com- 
 plications, in Chapter III ; and under surgical dietetics in Chap- 
 ter XII. By combining the discussions of the subject from 
 these several standpoints the nurse can formulate for herself 
 the befitting twofold course of action demanded of her for each 
 individual case. 
 
CHAPTER XIV 
 
 ARRANGEMENT, ORGANIZATION, AND EQUIPMENT OF THE 
 OPERATING THEATER 
 
 Operating room nursing is one of the advanced subjects of 
 the profession and should not be undertaken until the student 
 has had a long period of general training in bedside nursing 
 and her courses of instruction in general theory, bacteriology, 
 solutions, materia medica, etc.; for, while she will learn much 
 in the operating room that is new to her, the work there is very 
 largely a matter of piecing together and developing the frag- 
 ments of knowledge and practice of her preliminary courses. 
 
 The task of teaching operating room nursing, and particularly 
 the organization and management of it, to any great degree of 
 detail is a very difficult one because so many variations must 
 be allowed for individual preferences of surgeons, the equip- 
 ment provided by the given hospital, and the number and quali- 
 fications of the members of the staff. There is no one known 
 plan which can be called superior to all others, nor need there 
 be, for if the student masters the fundamental principles of 
 asepsis and antisepsis and has at least the average amount of 
 common sense and a logical, systematic turn of mind she can 
 adapt these principles so as to work out a good system under 
 any given set of conditions. We shall not attempt, therefore, 
 to tell you how to organize and conduct a model operating 
 room, but rather, we shall try so to instruct you in foundation 
 principles that you may equip yourself to organize and manage 
 one that will be a model for your particular limitations or ad- 
 vantages. 
 
 As we shall try to present this subject so as to make it useful 
 for all classes of readers, each one will necessarily find much 
 that will not be of value nor interest in her particular case ; but 
 the nature of the subject makes this inevitable, so we must beg 
 your indulgence for those parts which may seem too elementary 
 
 193 
 
194 TEXTHOOK OF SURGICAL NURSING 
 
 or self-evident to you, or whieh seem very foreign to your case, 
 and ask you to believe ^vith us that they -will meet the needs 
 of someone else. 
 
 Mueli that must be said here to make the discussion com- 
 plete -will be of more value if studied in combination with the 
 practical experience in the operating room itself; but the prac- 
 tice of plunging a puiiil directly into the actual work from 
 which she is expected to gather her knowledge as occasion 
 chances to present itself is to leave her education too much to 
 the mercj' of her own enthusiasm and the uncontrollable irregu- 
 larities of the work. A few preliminary classroom lessons be- 
 fore she is rushed into the confusion and excitement of the 
 operating room Mill conserve much of the pupil's nervous 
 energy, will save much valuable time for both herself and the 
 other members of the staff, and she will have a sounder edu- 
 cation for having acquired it in an orderly, logical way. 
 
 We strongly advocate the doctrine that every nurse should 
 be given a thorough course in operating room technic, not only 
 because of the countless number of additional facts she learns 
 thereby which are essential to the highest efficiency in what- 
 ever specialty she may adopt after she has graduated, but also 
 because of the general educational value of the discipline it 
 gives her in alertness, accurateness, and promptness of re- 
 sponse. However, there are relatively few nurses who should 
 aspire to become operating room "specialists," because the 
 work is a highly specialized type of nursing, and certain natural 
 as well as cultivated qualifications are necessary for more than 
 mediocre efficiency in it. We do not know any more about the 
 universally model operating room nurse than we knew a few 
 moments ago about the universally model operating room itself, 
 but a few pages hence we shall attempt to set up a few stand- 
 ards which will apply universally. 
 
 A thoroughly logical sequence in the presentation of the al- 
 most innumerable phases of this subject is very difficult to ar- 
 range, but as a nurse knows in a general way, before taking 
 up this course, what an operating room is for, she will perhaps 
 
EQUIPMENT OF THE OPERATING THEATER 105 
 
 do best by beginning here with a picture of its general arrange- 
 ment and equipment. 
 
 THE ROOMS AND THEIR FURNISHINGS 
 
 Ideally the operating theater comprises these rooms : 
 
 1. Operating room proper 
 
 2. Anesthetizing room 
 
 3. Dressing room for surgeons 
 
 4. Dressing room for nurses 
 
 5. Recovery room 
 
 6. Work room for nurses 
 
 7. Sterile supply room 
 
 8. Sterilizing room 
 
 9. Storage room 
 
 Of course, this exact number of rooms may never be available, 
 but they do represent departments, and whatever space is pro- 
 vided should be subdivided and arranged with these separate 
 features in mind. By the time you have finished this chapter 
 we shall hope to have assisted you to enough ideas to enable 
 you to make the best combination of these departments which 
 your space permits. 
 
 "When practicable the operating theater is on one of the higher 
 floors of the building because in this location it is most likely 
 to be isolated from miscellaneous traffic and undue noise and 
 dust, all of which are menaces and nuisances to an operating 
 room. 
 
 1. The Operating Room Proper. — a. Construction. — This is, 
 of course, a light room and it has a northern exposure if pos- 
 sible because of the better diffusion of light it will furnish than 
 one into which strong rays of sunlight stream in some parts, caus- 
 ing deep shadows in others ; and a skylight will be an addi- 
 tional advantage. The size of the room is best no larger than 
 is necessary for holding the equipment and allowing the mini- 
 mum space for comfort in moving about. Too large a room 
 is wasteful of time and steps, and too small an one, of course, 
 will be too congested for the easy maintenance of asepsis, be- 
 cause there are always the sterile and the unsterile equipment 
 
191) TEXTBOOK OF SURGICAL NURSING 
 
 ill more or less eloso association. Unless one has the })leasure 
 of plaimiiig the constructioii of her o\\ii operating room, how- 
 ever, she will not be able to control this feature of the matter 
 beyond exereising good judgment as to arrangement of con- 
 tents and organization of routine i)ractices. 
 
 It ought not to be necessary to remind you that the walls, 
 floors, and all other structural parts of the room should be 
 finished in the most hygienic way possible; that is, they should 
 be of some material that can be easily washed and that will not 
 catch or hold dust readily, for example, tiling, enamel paint, 
 etc. Those of you who have had the advantages of training 
 in a hospital built on modern architectural principles will have 
 observed the curve, for instance, in which the wall and the 
 floor meet instead of the old-fashioned right-angle which is 
 such a safe harbor for dust and such a good incubator for 
 germs; you will probably have noticed also that the corners 
 of the walls are fashioned similarly; also, the window ledges 
 were probablj^ slanting or curved, and all window casings, door 
 casings, and other finishings were as free as possible from nooks 
 and corners. This has all been provided for you and you have 
 taken it for granted, but you should appreciate the principles 
 involved so that if it falls to your lot at some time to control the 
 adaptation or constructioii of some room for operating pur- 
 poses you may be able to be of the best service. 
 
 On this same principle, a good technician does not provide 
 wall hooks in her operating room upon which careless persons 
 may hang various articles which lumber up the room and en- 
 courage contamination. The storage and supply rooms are the 
 proper places for all articles which are not needed for the opera- 
 tion, and between operations the storage and supply rooms are 
 the places for everything except the more non-transportable fur- 
 niture. Under some conditions of room arrangement where 
 space is limited the operating room may have to bear a part of 
 the burden of storage, but in any ease one must always follow 
 the principle of keeping all supplies protected as far as pos- 
 sible. This practice is not only refined technic but it is also 
 simple common sense in that it saves the time and labor of 
 unnecessary renovation. 
 
EQUIPMENT OF THE OPERATING THEATER 197 
 
 Good ventilation must be provided, and some way should be 
 found to do this without permitting a draught directly through 
 the room. 
 
 Heat should he generous, as the temperature of an operating 
 room should be maintained at 75° or 76° F. 
 
 Fig. 22. — Two of the More Elaborate Types of Operating Table. 
 
 h. Furniture. — The ideal material for all operating room fur- 
 niture is white-enameled metal, as it is durable and sanitary. 
 
 The first essential is the operating table. There are innumer- 
 able models on the market and the one chosen will depend upon 
 financial resources, preference of the surgeon, etc. (Fig. 22). 
 
198 TEXTBOOK OF SURGICAL NURSING 
 
 Many of the more expensive tables are very complex in their 
 mechanism, and as the average nurse is not mechanically in- 
 clined she finds it difficult to learn how to manipulate them ; 
 but as it usually falls to her lot to see that the patient is placed 
 in the proper position for the operation, she should consider it 
 her business to master the mysteries of her table, as all the at- 
 tachments and adjustments serve some helpful purpose if the 
 responsible person knows how to put them to their intended 
 use expertly. Tliis may seem a minor detail but operating 
 room work is made up of detail, and, like a delicately adjusted 
 machine, if one part functions poorly it is very likely to cause 
 embarrassment to the whole machine. For instance, in the case 
 of operations upon the kidney we have seen it necessary for the 
 surgeon, after struggling many precious minutes against the 
 handicap of an improper position of the patient, to stop operat- 
 ing, dress the wound temporarily, unsterilize his gloves and 
 gown, and adjust the patient's position himself. This is an 
 extreme illustration because of the fact that, for anatomical 
 reasons, the kidney is difficult of access in the best of positions, 
 but corresponding annoyances in many other cases may arise 
 from lack of intimate acquaintance with this very essential arti- 
 cle of equipment. 
 
 One or two instrument tables are the next essentials. If 
 there is but one operation to be done one table is enough, but 
 where there is to be a session of several cases it will be necessary 
 to have a second table for the reserve supplies. Many varieties 
 are in use (Fig. 23) and there is no importance in the design 
 of any one except w^hen one is desired which can be placed 
 across the operating table near enough to the w^ound so that 
 the surgeon can pick up the instruments from it himself. For 
 this purpose a type similar to the one illustrated in Fig. 24 
 wall be needed. This is a very serviceable table, as it is ad- 
 justable in height, is on rollers, and can thus be easily adapted 
 and moved as convenience requires. 
 
 A tahle for dressings and other miscellaneous supplies will be 
 needed in nearly every case. This should be no larger than 
 necessary. 
 
 One or more stretchers are necessary. In a large hospital 
 
EQUIPMENT OF TUB OPERATING THEATER 199 
 
 where space permits and elevators are used, the wheel stretcher 
 (Fig. 25) will be the one to provide, but in many smaller in- 
 
 FiG. 23. — Two Varieties of Instrument Table, 
 
 stitutions the carrying variety (Fig. 26) can be made to an- 
 swer all purposes; but w^here there is much carrying up and 
 
 Fig. 24. — Adjustable Ixstrujikxt Table Which May be Extended 
 Across the Operating Table in Any Location Desired. The cover shown 
 is the one described on page 216, paragraph No. 13. 
 
 'down stairs to be done the special design shown in Fig. 27 is 
 very serviceable. 
 
200 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 A tub or large basin holding () or 8 gallons will be needed in 
 large operating rooms for a 1-1000 solution of bichloride •which 
 will serve many useful purposes from time to time. 
 
 Fig. 25. — Wheel Stretcher. 
 
 Other minor articles for this room are, a seat for the anes- 
 thetist or surgeon (Fig. 28) ; possibly a small table for unsterile 
 
 Fig. 26. — Carrying Stretcher. This is, in general outline, the U. S. 
 
 Army type. 
 
 Fig. 27. — Stretcher Suitable for Carrying Patients Up and Down 
 Stairways. It is merely a bent iron tube covered with canvas slip covers. 
 Some models have a single piece of canvas shaped like the frame and 
 laced to it with a strong cord passed through eyelets in the border of the 
 canvas. 
 
 supplies such as adhesive plaster, bandages, etc. ; and a set o£ 
 loiv beiiches (Fig. 29) of differing heights for the surgeon to 
 stand upon for some operations. These should range in height 
 
EQUIPMENT OF THE OPERATING TITEATEl? 201 
 
 from 4 inches to 1 foot, and they should be about 1 foot wide and 
 2 feet long. Various kinds can be purchased from hospital 
 supply companies, but they do not furnish the useful grada- 
 tions in height, and as they are usually 
 made of metal they are not so con- 
 venient to handle as are the simple 
 wooden ones suggested in the illustra- 
 tion. 
 
 A good artificial light is of course 
 necessary, but the only general sugges- 
 tions that can be offered about this are 
 that it should be so placed that the 
 operating table need not be moved 
 when a shift is made from the daylight 
 to the artificial one ; and that it should 
 be simple in its fittings for sanitary 
 reasons. Unless one has an elaborately 
 adjustable one it should be supple- 
 mented by a simple "drop' 
 light (Fig. 30) which will be needed 
 occasionally in the case of a deep or inaccessible wound. The 
 type shown in the illustration can be draped with a sterile 
 towel when necessary. 
 
 This is enough furniture to get along with, and the guiding 
 
 or hand i'lG. 28.— Seat for the 
 Anesthetist ob Surgeon. 
 
 Fig. 29. — Bench for the Surgeon to Stand Upon When the Operat- 
 ing Table Cannot be Adjusted Suitably in Height. These may be very 
 simply made of wood, and several heights will be useful. 
 
 principle in amount of furniture should be not to encumber 
 the room with more than is reasonably necessary. 
 
 There is one other item to be mentioned in this connection 
 because, while not a necessity, it is a great convenience and a 
 
202 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 general favorite. It is the ''drum" (Fig. 31), or metal con- 
 tainer in which the dressings and other fabrics are sterilized and 
 from Avhich they are used directly while the operation is in 
 
 Fig. 30. — Hand Light. 
 
 progress. It is made with perforations which are opened to 
 admit the steam while in the sterilizer, and closed afterward, 
 making the drum very safe and dust-tight. 
 Th'e lids of these drums, when in use, are 
 opened and closed by means of a foot lever 
 on a speciall}^ fitted stand, and they thus 
 provide a very convenient storage me- 
 dium. For a complete system several 
 drums will be needed ; for example, the 
 gloves cannot be kept with the wound 
 dressings because they are covered with 
 talcum powder and this sifts from them 
 when they are handled; also, for reasons 
 which you will learn later, it is not good 
 technic to store the sterile gowns with the 
 wound dressings; and it may not be con- 
 venient to have the draping sheets and 
 towels in the same part of the room, or 
 even in the same room, with any of the 
 other supplies. Thus, you will need at 
 least four drums if you have any, and 
 when this system is used there is usually included a fifth drum 
 for hot wet towels and. pads (Fig. 32). Here we must digress 
 somewhat to say that this hot towel drum is similar to the others 
 except that it is perforated in the bottom and is fitted over a 
 
 Pig. 31. — Dress- 
 ing Drum with Ped- 
 al Opening Stand- 
 ard. 
 
EQUIPMENT OF THE OPERATING THEATER 203 
 
 small water tank which is heated electrically or otherwise, thus 
 allowing the towels to become wet and heated by the steam. Be- 
 sides the set of drums in use, as outlined, there will be needed 
 reserve ones, so this involves a considerable equipment which will 
 be too expensive in some instances ; and besides there will some- 
 times be the consideration of storage space because these stands 
 and drums require more space for a given amount of contents 
 than do the simple muslin-covered parcels which you would 
 otherwise use. 
 
 Fig. 32. — Hot Towel Drum 
 WITH Pedal Opening Standard and 
 Electrically Equipped Steaming 
 Device. 
 
 Fig. 33. 
 
 -Instrument Steril- 
 izer. 
 
 c. Sterilizers. — Where space permits the instrument sterilizer 
 (Fig. 33) should be within the operating room and as near the 
 instrument table as is practicable and safe, because frequent 
 reboiling of instruments is usually necessary during an opera- 
 tion and it saves time and handling if the person responsible 
 for the instruments has direct, easy access to this boiler. When 
 this sterilizer is heated by gas or any other open flame it must 
 be stationed a safe distance from the anesthetist because ether, 
 chloroform, and ethyl chloride are highly inflammable. Fur- 
 
204 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 thermore, extreme heat, and particularly an open flame, will 
 decompose chloroform vapor and produce phosgene and hydro- 
 chloric acid gases -which, in a small or poorly ventilated room, 
 may cause serious trouble by their irritant effect upon the eyes 
 and the respiratory tract. 
 
 In some cases one sterilizer may have to suffice for all other 
 supplies as well as the instruments; but where possible there 
 should be another large utensil sterilizer (Fig. 34) for large 
 basins, etc. This should be in the operating room also when 
 possible. 
 
 Besides the reason of convenience for having these boilers 
 
 within the room, there is the 
 technical reason that t'he steam 
 which they give off renders the 
 
 i-r— K-«-^^^^^^t^^^^^mi^ air moist and thereby keeps 
 L w^I^^^^BbII^^HB do\vn dust which might some- 
 ■m*^^^^^ (-^^HB times be a real menace in a dry 
 
 atmosphere. 
 
 Water Sterilizers (Fig. 35), 
 one for hot sterile water and one 
 for cold, and equipped with a 
 filter, will also be necessary. 
 These are perhaps best placed 
 outside of the operating room, 
 but their outlets should be ex- 
 tended into the room at some 
 easily accessible point. 
 d. Miscellaneous Equipment. — There are a great many other 
 devices which are in more or less general use and which, if 
 properly fitted into a corresponding general system, simplify 
 the work. In fact, those who have become accustomed to the 
 more elaborately outfitted operating rooms and who have never 
 been compelled to work more primitively will consider indis- 
 pensable many of these items ; but as they are more or less 
 luxuries we shall not take space here to enumerate them. 
 
 2. The Anesthetizing Room. — a. Construction. — The finish- 
 ing of the walls, floors, etc., should be similar to that described 
 for the operating room, because where there is a separate room 
 
 Fig. 34. — Utexsil Sterilizer. 
 
EQUIPMENT OF TTIE OPERATING THEATER 205 
 
 for this purpose all of the final preparation of the patient is 
 done in it and it should therefore be sanitarily fitted. It should 
 be a reasonably spacious room because a great deal of both 
 sterile and unsterile work will be done in it, and, as pointed 
 
 Fig. 35. — Hot and Cold Water Sterilizers. The small cylindrical at- 
 tachment between them contains a clay filter through which the water is 
 forced before it enters the tanks to be sterilized. This filter is removable 
 and must be cleansed often by scrubbing under running water with a very 
 stiff brush. The cold water tank has a coil of tubes running through its 
 interior through which cold water may be run for cooling the sterile water 
 after it has been boiled. These sterilizers are built to withstand high 
 steam pressure and are usually adjusted so that the water may be ster- 
 ilized under 15 pounds pressure which, as will be explained later (page 239), 
 raises its temperature about 38° F. higher than that of boiling water. 
 
 out for the operating room, there must be ample room for keep- 
 ing the sterile equipment well out of the way of the unsterile. 
 
 Ventilation and heating should correspond with that of the 
 operating room. 
 
 &. Furniture. — First of all, there must be a table or a wheel 
 
206 TEXTBOOK OF SURGICAL NURSING 
 
 stretcher for the patient. In jrenerously o(iiii[)i)ed operating 
 rooms where several operations are done in iiinuediate succes- 
 sion there will doubtless be an extra operating- table for this pur- 
 pose and the patient will be anesthetized upon the table upon 
 which the operation is to be performed. Otherwise, a wheel 
 stretcher or some other type of table will be needed. 
 
 There will also be needed a small table for the anesthetist's 
 supplies. This may be one that is fitted with wheels so that 
 it may be taken into the operating room during the operation, 
 but the articles needed by the average anesthetist after the 
 anesthesia is established are so few that it is perhaps not ad- 
 visable to have more than a simple stationary stand in the an- 
 esthetizing room. 
 
 A tahlc for miscellaneous articles will be necessary and this 
 one should be spacious because when the preparation and sterile 
 draping of the patient are done in this room expediency will 
 require that many odds and ends, such as sandbags, pillows, 
 rubber sheets, operating table attachments, etc., be within easy 
 reach. 
 
 When there is enough space to make it technically safe the 
 sterile draping supplies may be kept in this room during opera- 
 tions and for this purpose there will be needed another tahle, 
 except when the "drums" are used, in which case one packed 
 exclusively with draping sheets and towels will take the place 
 of this table. The drum is so securely closed that there can 
 never be any objection to having it in the anesthetizing room. 
 
 A chair or two may be useful in this room. 
 
 When limited space makes a separate anesthetizing room im- 
 possible, the anesthetic will be administered in the operating 
 room itself, and this will require great caution as to the sterile 
 drapings and supplies, for there is always more or less commo- 
 tion attendant upon the induction of the anesthesia and the 
 preparation of the patient in the form of struggling of the 
 patient and the necessary handling of blankets, etc. 
 
 3. Dressing Room for Surgeons. — a. Construction. — The 
 walls and floors of this room should be similar to those of the 
 operating room. 
 
 b. Furniture. — Wash basins with hot and cold running water 
 
EQUIPMENT OF THE OPERATING THEATER 207 
 
 are the important essentials of this room, and if possible pedal 
 faucets (Fig. 36) should be installed with them. The number 
 of basins will depend upon circumstances and the number of 
 surgeons operating at one time. 
 
 One or more "arm hasins" should be provided for the anti- 
 septic solution in which the hands and arms are sterilized after 
 scrubbing. Standard ones (Fig. 37), holding enough solution 
 so that the whole arm up to the elbow may be immersed are 
 best, but large ones of other design will serve. 
 
 Fig. 36. — Wash Basins Equipped with a Pedal Device fob Turning 
 THE Water On and Off, and with a ' ' Goose-Neck ' ' Faucet, Which Per- 
 mit Scrubbing of the Hands and Arms Without Contaminating Them 
 During the Process, 
 
 Where possible individual lockers should be provided in this 
 room for the surgeons. 
 
 Some provision must be made for the surgeons' sterile suits 
 or gowns. The drum answers this purpose admirably, but in 
 lieu of this a table will be needed for these sterile supplies which 
 will be packed in individual parcels or stored immediately in 
 advance on the sterilly draped table. 
 
 A few chairs will be appreciated in the dressing room. 
 
 4. Dressing Room for Nurses. — This room should be essen- 
 tially the same in equipment as the one for the surgeons, but 
 
208 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 it may not need to be as large, though this will depend upon 
 the relative number of nurses using it. 
 
 5. Recovery Room. — Where space and nurses are plentiful 
 one room may be equipped with one or more beds and with 
 paraphernalia for the resuscitation of the occasional patient 
 who may need immediate treatment. In other cases this room 
 will be CQnvenient for use in transferring the patient from 
 the operating table to the stretcher, and for the application of 
 bandages, plaster casts, splints, etc. 
 
 Fig. 37. — Two Types of Arm Basin. 
 
 6. Work Room for Nurses. — a. Construction. — This is a 
 department of the operating theater which is often neglected in 
 hospital architecture, for the fact is probably overlooked that 
 it is in this room that the nurse spends the major part of her 
 time and does the bulk of her work. For this reason the w^ork 
 room should, first of all, be well lighted both naturally and 
 artificially, and of course well ventilated and comfortably 
 heated. While it is advisable that this room should be sani- 
 tarilj' finished on the general principles of the operating room, 
 it is not so important. 
 
 h. Furniture. — Ample tvorh tables, chairs, dust-proof storage 
 
EQUIPMENT OF THE OPERATING THEATER 209 
 
 shelves and closets, a gas or other stove, and spacious washing 
 sinks cover the essential furnishings for this department. 
 
 7. Sterile Supply Room. — Where practicable this room 
 should be reserved entirely for the sterile supplies, and it 
 should, of course, be kept as free as j^ossihle from dust and 
 moisture. We would caution nurses with limited space at their 
 disposal to employ only as a last resort any part of the work 
 room for the storage of sterile supplies, as it will probably be 
 the least clean room of all. 
 
 8. Sterilizing Room. — a. Construction. — The walls and 
 floors of this room must be finished so as to be waterproof, as the 
 steam from the sterilizers will ruin anything else, and water will 
 unavoidably be spilled upon the floor from time to time. This 
 room must be well ventilated, and because of the water in the 
 sterilizers and plumbing it must be well heated to prevent freez- 
 ing in winter time. 
 
 &. Furniture. — A work table will be needed, and perhaps 
 storage shelves, but this will depend upon whether the packing 
 of the supplies for sterilization is done in this room or in the 
 nurses' work room. 
 
 The chief equipment is the steam dressing sterilizer (see Fig. 
 49, page 238). The number, size, and variety will be governed 
 by innumerable conditions, but it must be remembered that only 
 those which provide for live steam sterilization under pressure 
 in a vacuum are to be depended upon for absolute sterilization, 
 particularly of large parcels which are difficult of penetration 
 by the steam. 
 
 If a room cannot be devoted entirely to this purpose the 
 sterilizing department may have to be combined with either the 
 work room or the supply room, or even both, but strong objec- 
 tions to storing the sterile supplies in the sterilizing room are 
 that the steam keeps the room damp, and there is always danger 
 of water being spilled upon the sterile parcels which will, of 
 course, unsterilize them. 
 
 9. Storage Room. — This will be a convenient room to have 
 in which to keep infrequently used and reserve unsterile sup- 
 plies, and miscellaneous portable appliances, but in its absence 
 the nurses' work room may have to serve instead. As ad^dsed 
 
210 TEXTBOOK OF SURGICAL NURSING 
 
 above, have some corner devoted to this class of supplies and 
 form the habit of leaving nothing portable in the operating 
 room which has no useful immediate function to perform there. 
 
 THE PERSONNEL 
 
 The scene is now laid and we have a roughly furnished oper- 
 ating theater. Before we go further we shall put some people 
 into it to do the hundreds of things wliich remain to be done 
 before we are ready for our patient. 
 
 1. Personal Qualifications. — In the first place, one must be 
 very strong physically to endure the strain and severity of oper- 
 ating room work. Hours of application are likely to be longer, 
 and at all times the work is more intense than in any other type 
 of nursing, and a strong body is the only one that will hold out 
 to the bitter end. 
 
 Patience and forbearance are also more in demand, and for 
 longer periods than elsewhere. The nature of the work re- 
 quires that no time be lost and no mistakes made, and conse- 
 quently everybody is more or less under nervous tension, which 
 means that the nurse will not always receive the consideration 
 from her superior officers which she has been accustomed to 
 receiving in other lines of her work. Orders are more numer- 
 ous, and often conflicting, and if the nurse has not the maxi- 
 mum amount of the proverbial patience and self-effacement 
 which are always urged upon her profession she will often fare 
 rather uncomfortably in the operating room. 
 
 Alertness of mind, self-control, and promptness of conversion 
 of thought into action are other indispensable qualifications for 
 real efficiency. A patient is under an anesthetic and under- 
 going interference with his life mechanism, which means that 
 emergencies are always arising, and the nurse who "loses her 
 head" is not popular, to say the least, on an operating room 
 staff. 
 
 Conscientiousness, though essential and presupposed through- 
 out the professional activities, is obligatory here. "When an op- 
 erating room nurse reflects that a single chance taken under 
 pressure of orders or time may cost the health or even the life 
 
EQUIPMENT OF THE OPERATING THEATER 211 
 
 of another person she will never yield to any circumstance on 
 this point. 
 
 While all the foregoing qualifications are important, perhaps 
 the one which distinguishes the operating room "genius," so 
 to speak, from the others is the power to think, plan, and work 
 logically, consistently, and methodically. You will say that this 
 power is an asset in any walk of life, and so it is, but it is use- 
 ful here to the utmost degree, and its lack is nowhere of more 
 hindrance than in the operating room. This not only applies 
 while the operations are going on but also in the daily routine 
 of the department; for there is a multiplicity of detail in this 
 work which, if muddled by cloudy thought, can become more 
 of a squanderer of time, energy, and service than any other 
 thing we can think of. 
 
 These are all desirable qualifications. You have some of 
 them, and perhaps you are particularly fortunate and have all 
 of them; but at any rate you can acquire at least a degree of 
 each of them, and you must do so if you wish to succeed in the 
 operating room and enjoy the work there as you should. 
 
 2. Division of Duties. — This is a subject upon which it is 
 useless to say much because the number of persons on a staff 
 is determined by varying and numerous circumstances, and 
 therefore the apportionment of the work will be different in all 
 cases. However, the principle of ^'division of labor" should be 
 applied as minutely as possible, particularly in a large operat- 
 ing room where a great number of cases are done in one session. 
 By ' ' division of labor ' ' we mean, of course, the practice whereby 
 each person's w^ork is clearly defined for her so that she is held 
 responsible for the same thing at all times, and so that her activi- 
 ties do not overlap those of the others on the staff. How this 
 is done will depend upon the number of persons on the staff, 
 the arrangement of the operating theater, the number and nature 
 of the operations, etc. ; but the principle should be to aim to 
 have as many persons as are necessary to permit division of the 
 work logically up to the point where each one has only the 
 amount of work to do which she can get done with reasonable 
 ease. More work than this for each person causes confusion. 
 
212 TEXTBOOK OF SURGICAL NURSING 
 
 delay, and gvnci-al iiu't'tii'iciu'y ; and less than lliis amount is 
 extravagaiU'O. X'ariations in the qualifications and capacities 
 of the individuals for hard work, Avhether they are graduate 
 or pupil liurses, orderlies, etc., Avill also modify this division of 
 labor, but it ^vill not affect the above guiding principle. 
 
 3. Discipline. — In genei-al, tlie oi-ganization of an efficient 
 operating room staff: as to authority, system, division of duties, 
 thoroughness, attention to detail, promptness, despatch, and 
 team work may be likened to that of the Army. There must 
 be the commanding general with supreme authority, and her 
 staff must be educated to corresponding obedience. Hospital 
 discipline in general is often likened to that of the Army, and 
 the operating room organization should embody this same dis- 
 cipline in concentrated form. Emergencies involving life and 
 health are always arising, and there is usually no time for ' * rea- 
 soning why" when orders are received. If each one knows her 
 duties, has been given the proper instructions as to how to per- 
 form them, and has caught the spirit of "each for all," the 
 system will do the rest. 
 
 SUPPLIES 
 
 (For Sterilization see Chapter XV) 
 
 Our next step is to provide and prepare the various supplies 
 and odds and ends which it will be necessary to keep on hand 
 in the operating room. The nurse will have learned about and 
 used many of the things Ave shall need, but for reference pur- 
 poses we shall record here a list of standard supplies and then 
 go into detail as to those wdiich are likel}^ to be new to her when 
 she begins her operating room training. 
 
 1. Adhesive plaster 5. Basins 
 
 2. Amputation retractor 6. Blankets 
 
 3. Aprons, muslin and rubber 7. Brushes, nail 
 
 4. Bandages, Esmarch 8. Caps, surgeon's and nurse's 
 
 " flannel 9. Carrel-Dakin outfit 
 
 " gauze 10. Catheters 
 
 " muslin 11. Cautery 
 
 " plaster of Paris 12. Cotton 
 
 " starch 13. Cover for instrument stand 
 
EQUIPMENT OF THE OPERATING TPIEATER 213 
 
 14. 
 
 Culture tubes 
 
 38. 
 
 Pads, abdominal 
 
 15. 
 
 Dressings 
 
 39. 
 
 Pads, table 
 
 16. 
 
 Drugs 
 
 40. 
 
 Pillows 
 
 17. 
 
 Gauntlets 
 
 41. 
 
 Rectal tube 
 
 18. 
 
 Gauze 
 
 42. 
 
 Rubber bands 
 
 19. 
 
 Glove covers 
 
 43. 
 
 Rubber dam 
 
 20. 
 
 Gloves, rubber and cotton 
 
 44. 
 
 Rubber sheets 
 
 21. 
 
 Gowns 
 
 45. 
 
 Rubber tissue 
 
 22. 
 
 Hip rest 
 
 46. 
 
 Rubber tubing 
 
 23. 
 
 Hot water bottles 
 
 47. 
 
 Safety pins 
 
 24. 
 
 Hypodermoclysis outfit 
 
 48. 
 
 Salt solution, 10 per cent, and 
 
 25. 
 
 Infusion outfit 
 
 
 infusion 
 
 26. 
 
 Inhaler, ether 
 
 49. 
 
 Sandbags 
 
 27. 
 
 Instruments 
 
 50. 
 
 Sheets, plain and laparotomy 
 
 28. 
 
 Irrigator 
 
 51. 
 
 Splints 
 
 29. 
 
 Irrigator stand 
 
 52. 
 
 Stockings, lithotomy 
 
 30. 
 
 Kelly pad 
 
 53. 
 
 Stomach tube 
 
 31. 
 
 Masks, chloroform and ether 
 
 54. 
 
 Suits for surgeons 
 
 32. 
 
 Masks, face 
 
 55. 
 
 Suture material 
 
 33. 
 
 Mouth gag 
 
 56. 
 
 Syringes 
 
 34. 
 
 Nail cleaners 
 
 57. 
 
 Thermometers, bath and clin- 
 
 35. 
 
 Needles, hypodermic and ex- 
 
 
 ical 
 
 
 ploring 
 
 58. 
 
 Tongue forceps 
 
 36. 
 
 Needles, suture 
 
 59. 
 
 Tourniquets 
 
 37. 
 
 Packing, gauze 
 
 60. 
 
 Towels, plain and lithotomy 
 
 We shall now take up the supplies just enumerated in the 
 order and under the number they hold in the list and discuss 
 them from the operating room standpoint. 
 
 1. Adhesive Plaster. — This needs no comment. 
 
 2. Amputation Retractor. — Some such article as this will be 
 necessary in the absence of the special metal instrument for 
 the purpose, and it will be used to hold back the soft parts 
 while the bone is being sawed off in an amputation operation. 
 It is made from strong muslin and there should be two pat- 
 terns — one with two tails for use on the femur or humerus, and 
 the other with three tails for the two bones of the forearm or 
 the lower leg. For the two-tailed one cut the muslin 24 x 24 
 inches, fold double, cut half way up through the middle from 
 one edge, and stitch in all edges. (A of Fig. 38.) For the 
 three-tailed one cut the muslin 30 x 24 inches, fold double, cut 
 
214 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 in thirds half avcIv up the long way, and stiteli in all edges (B 
 of Fig. 38). 
 
 3. Aprons. — (a) Muslin. — These will be made after the 
 pattern of the ordinary "buteher's" apron, and may be used 
 over the gown or suit and changed for each operation. (Fig. 
 39.) 
 
 (?;) Fuhhcr. — These may be purchased read.y-made, or they 
 are very easily fashioned from a piece of rubber sheeting by 
 the same pattern as the muslin ones. They may not be used 
 in routine practice but there should be several on hand in every 
 
 operating room as occasions will arise 
 when the surgeon or the nurse will 
 need their protection. 
 
 4. Bandages. — This supply will 
 not differ from that which the nurse 
 wall have learned about on the wards. 
 
 5. Basins. — A good assortment of 
 white enameled basins should be on 
 hand for both sterile and unsterile 
 usage. The familiar kidney-shaped 
 one is always useful, and for a great 
 variety of purposes ; large round 
 ones holding a gallon wall be needed 
 for rinsing hands in salt solution, etc., 
 during operations ; smaller ones hold- 
 ing a pint, perhaps, will be service- 
 able for wound or dressing solutions ; long narrow, shallow ones 
 will serve for sterilizing in antiseptic solutions instruments which 
 cannot be boiled. The exact number and variety of each can- 
 not be prescribed but the supply should be generous. 
 
 Basins for use upon the floor about an operating table will 
 also be needed. Any kind Avill do but a great deal of noise wall 
 be saved if the light-weight "composition" one is used, espe- 
 cialh'' in the ease of tile or cement floor. 
 
 6. Blankets. — Plenty of blankets will be needed, and there 
 should be several warm ones in readiness in a blanket warmer, 
 the sterilizer, or upon a radiator for emergency use in shock 
 cases. 
 
 3 
 
 Fig. 38. — Amputation 
 Ketractors. a, the two- 
 tailed one for use in the 
 amputation of one bone; B, 
 the three-tailed one for use 
 in the case of two bones. 
 
EQUIPMENT OF THE OPERATINCI THEATER 215 
 
 7. Brushes, Nail. — As these will have to be boiled rex)eatedly 
 a very plain kind should be used, that is, the backs should be 
 unvarnished, and the coarse bristles will last better than fine 
 ones, 
 
 8. Caps. — (a) Surgeon's. — These are best made of muslin 
 and may be merely a skull cap (A of Fig. 40) or they may be 
 a combination of cap and face mask (C of Fig. 40), in which 
 case it is better to use a thinner material as the heavier one may 
 
 Fig. 39. — Muslin Apron. 
 
 be too warm and cumbersome. The surgeon will, as a rule, 
 make his own selection of design. (&) Nurse's. — These are 
 best made of muslin also, and any design that will cover the 
 hair well will be a good one (B of Fig. 40) and the combina- 
 tion of face mask and cap described for the surgeon (C of Fig. 
 40) may also be used by the nurse. 
 
 9. Carrel-Dakin Outfit. — The nurse will have learned all 
 about this on the wards, and Chapter XIX gives detailed in- 
 structions. The only equipment that need be kept on hand in 
 the operating room will be the wound tubes, the vaseline gauze, 
 and a small quantity of Dakin's solution. 
 
216 
 
 TEXTBOOK OF SURGICAL NUESIiNG 
 
 10. Catheters. — These will not often be used in the operat- 
 inji' room but a few of both the rublter and the glass ones used 
 on the wards should be kept on hand. 
 
 11. Cautery. — There are several kinds of cautery which 
 
 Fig, 40. — Operating Caps. A, simple skull cap for the surgeon; B, 
 nurse's cap; C, combination cap and mask suitable for either surgeon or 
 nurse (see directions for making cap C on page 222). 
 
 are described in Chapter XV, pages 242-245, under "Steriliza- 
 tion, ' ' as the cautery is, of course, a sterilizing agent. 
 
 12. Cotton. — Both the absorbent and the non-absorbent 
 cotton used on the wards should be on hand. 
 
 13. Cover for Instrument Stand.— This will be a slip cover, 
 simply a long narrow bag (see Fig. 24, page 199), which is de- 
 
EQUIPMENT OF THE OPERATING TIIEATER 217 
 
 %'';/f\ 
 
 signed to envelop the instrument stand which extends across the 
 table for operations. This bag should be made long enough to 
 reach well downward toward the base when the stand is ex- 
 tended to its highest capacity, as it will then enable the instru- 
 ment passer to adjust the height of the table sterilly at all times 
 and will furnish the simplest means of covering the unsterile 
 standard. It should be made of strong ^,^ 
 
 muslin, and the size of it will depend, of 
 course, upon the size of your particular 
 table. 
 
 14. Culture Tubes. — Cultures will fre- 
 quently be taken from wounds and a few 
 tubes should always be ready (Fig. 41). 
 Make a cotton swab on a long wooden or 
 wire applicator ; put this into a small glass 
 test tube, allowing the end to project about 
 half an inch, plug the tube loosely with 
 cotton, and then put it into a larger test 
 tube and plug this with cotton, and ster- 
 ilize. The outer tube keeps the inner one 
 sterile so that it may be handled by a ster- 
 ile person, and the inner one is for the re- 
 ception of the swab after the culture has 
 been taken. 
 
 15. Dressings. — The assortment and de- 
 signs used in the wards will probably apply 
 to the operating room. These will include 
 one or two sizes of small gauze wound 
 sponges or "wipes"; one or two sizes of 
 
 larger flat gauze wound dressings; "fluffs" or 1-yard pieces of 
 gauze folded together loosely for use on wounds from which 
 there is likely to be much drainage ; and perhaps a long narrow 
 .rolled gauze dressing which can be applied to a wound of the 
 extremities in bandage fashion. 
 
 16. Drugs. — The following list represents the drugs most 
 likely to be called for: 
 
 Fig. 41. — Culture 
 Tubes. A, tube con- 
 taining a culture me- 
 dium; B, tubes con- 
 taining swab for tak- 
 ing specimen of pus 
 from the wound. 
 
 Adrenalin 
 Albolene, liquid 
 
 Alcohol 
 Argyrol 
 
218 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 Aristol powder 
 
 Aromatic spirit of ammonia 
 
 Atropine (hypodermie) 
 
 Benzine 
 
 Bichloride of mercury 
 
 Boric acid, powder and crystals 
 
 Caffeine (hyiDoderniic) 
 
 Camphor in oil or ether 
 
 (hypodermic) 
 Carbolic acid 
 
 Carbonate of soda (washing soda) 
 Chloroform 
 Cocaine 
 
 Codeine (hypodermic) 
 Collodion 
 Dakin's solution 
 Ether 
 
 Ethyl chloride 
 Formalin 
 
 Glycerine 
 
 Green soap 
 
 Hyoscine (hypodermic) 
 
 Iodine, tincture 
 
 Lime, chloride 
 
 Lubricant (vaseline, K-Y, etc) 
 
 Morphine (hypodermic) 
 
 Nitrous oxide 
 
 Novocain 
 
 Olive oil 
 
 Oxygen 
 
 Peroxide of hydrogen 
 
 Silver nitrate, solution and 
 
 "stick" 
 Sodium chloride 
 Strychnine (hypodermic) 
 Talcum powder 
 Vaseline 
 Water, distilled 
 
 17. Gauntlets. — These will simply be loose muslin sleevelets 
 which will reach from well above the elbow to the hand. They 
 will be used Avith the short-sleeved suits and gowns in com- 
 bination with the muslin apron (Paragraph No. 3) and will be 
 kept in place either with a rubber band or a safety pin. 
 
 18. Gauze. — See "Dressings" (Paragraph No. 15). 
 
 19. Glove Covers. — Though not necessary, these covers will 
 be a great convenience and they are very simple to make. Cut 
 a piece of muslin about 12 x 31 inches, hem the ends, fold each 
 end to the middle of the piece, and stitch the sides so as to make 
 a double envelope (Fig. 42) into which the gloves may be 
 slipped separately; then fold through the middle into a com- 
 pact parcel. 
 
 20. Gloves. — (a) Rubber. — There are numerous kinds of 
 rubber gloves on the market and the one you provide will de- 
 pend upon the choice of the surgeon. They are made in many 
 sizes, so everyone can be well fitted, and it is important that 
 this be done for too tight a glove will be very uncomfortable 
 and too large a one will be a hindrance. Many gloves should 
 
EQUIPMENT OF THE OPERATING THEATER 219 
 
 be kept in reserve as they do not last long and they should not 
 be used except when in good condition. 
 
 (&) Cotton. — These are not often used but occasionally they 
 are slipped over the rubber ones when it is difficult to handle 
 
 
 1 ill 
 
 i 
 
 '. ^ : 
 
 • *: 
 
 J ■ -= 
 
 Fig. 42. — Glove Cover. 
 
 such parts as the intestines, the breast, etc., as the rubber 
 gloves are likely to slip awkwardly on these parts. Any good 
 cotton glove will answer the purpose, but relatively large ones 
 must be provided as they shrink considerably in sterilization. 
 
220 TEXTBOOK OF SURGICAL NURSING 
 
 21. Gowns. — These should be made of heavy "twilled" 
 muslin and several sizes should be provided. They must be 
 made to close in the back, and tape strings that may be tied are 
 better than buttons for closing them as they withstand the wear 
 and tear of the laundry better. They will have either long or 
 short sleeves, the long ones l)eing used when the gown is 
 changed between operations and the short ones when the gaunt- 
 lets (Paragraph No. 17) and aprons (Paragraph No. 3) are 
 used. The chief point to notice about the gowns is that the 
 long sleeves are long enough to reach well down to the hand so 
 that they may be securely tucked under the rubber gloves, and 
 
 A :b 
 
 Fig. 43. — Two Types of Hip or Pelvic Rest. A, metal design which is 
 especially suitable in the application of a plaster of Paris hip spica ; B, a 
 simple wooden block which will be better suited than A for use in applying 
 a hip spica bandage to a conscious patient, as it will be long enough to 
 reach across the patient 's body and thus to balance him comfortably, 
 whereas the metal one is narrow, is too uncomfortable for a conscious 
 patient, and usually requires an assistant to keep the patient balanced 
 upon it. 
 
 that the short ones reach well to the elbow so that they may be 
 kept securely within the gauntlet. 
 
 22. Hip Rest. — The nurse will have learned about the uses 
 of the hip rest (Fig. 43) on the ward and they will be the same 
 in the operating room, namely, for convenience in applying hip- 
 spica bandages. 
 
 23. Hot Water Bottles. — These will sometimes be needed 
 for patients in shock. 
 
 24. Hypodermoclysis Outfit. — This will be the same as the 
 one used on the ward. 
 
 25. Infusion Outfit. — This also will have been learned about 
 on the ward. 
 
 26. Inhaler. — The surgeon or the anesthetist will usually 
 decide upon the particular variety to be provided. 
 
 27. Instruments. — This subject will be best learned by the 
 
EQUIPMENT OF THE OPERATING THEATER 221 
 
 actual handling of the instruments in the operating room, 
 though we discuss the subject for the benefit of the nurse who 
 may need to prepare for instrument passing in Chapter XVII, 
 and many suggestions are included in the discussions of the 
 various operative procedures in Chapters} IV to XI. 
 
 28. Irrigator. — There are many kinds (Fig. 96, page 326) 
 and no one is necessarily bet- 
 ter suited to operating room 
 purposes than any other. The 
 glass one is very satisfactory 
 as the contents are visible, but 
 it is more troublesome to care 
 for than the enameled metal 
 one. 
 
 29. Irrigator Stand. — This 
 will be needed, as on the 
 wards, for wound irrigations, 
 infusions, etc., and the design 
 is not important (Fig. 44). 
 
 30. Kelly Pad. — The nurse 
 will have become familiar with 
 this type of pad, either under 
 this name or some other, on 
 the wards, and its use in the 
 operating room will be pointed 
 out under "Operative Posi- 
 tions and Draping" in Chap- 
 ter XVI. An improvised one 
 made from a newspaper and a rubber sheet is illustrated in Fig. 
 153, page 413. 
 
 31. Masks, Chloroform and Ether. — The special variety to 
 provide will usually be determined by the surgeon or the an- 
 esthetist. 
 
 32. Masks, Face. — There are many designs for simple 
 masks which merely cover the mouth and nose and the illus- 
 trations in Fig. 45 show representative designs for this article. 
 Designs A and B consist merely of several layers of gauze or of 
 one heavy piece with tapes sewed to the corners for tying around 
 
 Fig. 44. — Two Types of Irrigator 
 
 Stand. 
 
222 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 tlio head and neck. Design C is merely a pieee of gauze cut 30 
 inches square, folded diagonally by turning two diagonally op- 
 posite corners to the center of the piece and continuing to fold 
 in this direction till the strip is 5 or G inches in width. It is 
 
 Fig. 45. — Face Masks. Aj several layers of gauze stitched together, and 
 having tape strings attached to each corner for tying around the head and 
 neck ; B, made similarly to A ; C, piece of gauze folded as described in Para- 
 graph No. 32 ; D, made either of one layer of heavy gauze or of several 
 layers of thinner gauze, with tapes attached for tying in place as illus- 
 trated in C of Fig. 40, page 216. 
 
 adjusted by placing the middle of it over the face, twisting the 
 ends till it fits neatly, and then tying over the crown of the 
 head. Mask D of the illustration is the outline of the one which 
 is shown adjusted to the wearer in C of Fig. 40. 
 
 33. Mouth Gag. — There are many designs from which to 
 
EQUIPMENT OF THE OPERATING THEATER 223 
 
 select, and two representative types are illustrated in Fig. 21, 
 page 186. 
 
 34. Nail Cleaners. — Any kind that can be boiled will do, 
 but there is probably nothing better than the simple orange 
 stick. 
 
 35. Needles. — A plentiful supply of hypodermic and ex- 
 ploring needles will be needed, including the long, slender, hypo- 
 dermic needles which will be considerably in demand for local 
 anesthesia. 
 
 36. Needles, Sutiire. — These are properly classified as in- 
 struments and it will be assumed that the nurse has learned 
 the varieties during the course of her practical training. 
 
 37. Packing. — Plenty of gauze packing of assorted widths 
 from % inch, or even less, up to 2 inches should be in readi- 
 ness at all times. The nurse will have learned how to make this 
 on the wards. The larger sizes should be made in lengths of 5 
 yards or more, as w^hen packing of this width is used in the 
 operating room a large quantity will be needed and in most 
 cases it will be very important that it be in one uncut piece. 
 
 • 38. Pads, Abdominal. — These pads are used for blocking 
 off the operative field in abdominal operations, and several sizes 
 and shapes will be needed (Fig. 46). Pads A, B, and C of the 
 illustration are made of from 6 to 10 layers of gauze carefully 
 turned in and sewed at the edges, and with a piece of strong 
 tape firmly sewed to one corner so that they may be secured in 
 some way on the outside of the wound to prevent their being 
 lost in the abdominal cavity. In some cases it may be the cus- 
 tom to sew a heavy iron ring to the end of the tape. This ring 
 is conveniently pinned to the' draping sheet or, because of its 
 weight and the report it gives if the pad accidentally falls to 
 the floor, it is a very satisfactory means of keeping track of the 
 otherwise somewhat elusive pad. In other cases the tape will 
 be fastened to the sheet with a safety pin or clamp, or it will 
 simply be marked by the attachment of an artery clamp to it. 
 Pad D is about 1 yard long, 5 inches wide, and 8 or 10 layers 
 thick. It, also, will have a tape attached, and it should be rolled 
 into the shape of a roller bandage because it will be more con- 
 venient to handle in this form. Pad E of the illustration is 
 
224 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 especially designed for use in the removal of the appendix. It 
 will be made about 6 inches long, 4 inches wide, and 6 layers 
 thick ; it will be split half the way up from the middle of one 
 
 Fig. 46. — Abdominal Pads. A, B, and C, are made of gauze in dimen- 
 sions of 2x6 inches^ 4x10 inches, and 10 x 10 inches respectively, and 
 should be from 6 to 10 layers thick; B, is 1 yard long, 5 inches wide, and 
 10 layers thick; E, is 6 inches long, 4 inches wide, and 6 layers thick, and is 
 split into two tails at one end for use in folding about the appendix during 
 its removal. 
 
 end and will be finished about the edges like the others. This 
 pad will not need a tape because it will be used only on the sur- 
 face of the wound. 
 
 39. Pads for the Operating Table. — The table must always 
 be" covered with a soft pad. Often this will be supplied with 
 
EQUIPMENT OF THE OPERATING THEATER 225 
 
 the table by the manufacturer, but one is easily made by cover- 
 ing a folded blanket or any similar material with rubber sheet- 
 ing. The rubber sheeting should never be omitted but it should 
 be covered with a muslin sheet before a patient is placed upon it. 
 
 40. Pillows.— For all operating room purposes the hair pil- 
 low is better than any other. There will, of course, be the 
 ordinary ones for the patient's head, and uses will be pointed 
 out later for several smaller sizes — to fit under the back, the 
 knees, and the patient's head in some unusual positions. 
 
 41. Rectal Tube. — This will sometimes be needed for stimu- 
 lating enemata, etc. 
 
 42. Rubber Bands. — There should be a good assortment of 
 rubber bands as various sizes will be used occasionally for drains. 
 Also, when the muslin gauntlets are used a light-weight band 
 about the arm will be very convenient for keeping them in 
 place. 
 
 43. Rubber Dam. — This is a soft gum rubber which is made 
 in sheets of various sizes, and it is used chiefly for drains, usually 
 the ''cigarette" drain. As this will be made up after it is 
 sterilized it will be taken up again under ' ' Instrument Passing ' ' 
 in Chapter XVII, and the sterilization of it is taken up on 
 page 249. 
 
 44. Rubber Sheets. — A generous supply of these sheets 
 should be provided, and they should be used unstintingly to 
 protect both patients and operating table in cases where there 
 is likely to be fluid of any kind spilled about. A heavy gum 
 rubber sheeting is the softest kind and is more agreeable to use 
 and easier to cleanse than any other, but it is relatively ex- 
 pensive. However, it is about the only kind that should be 
 UiSed, as those which are made partially of cloth cannot be kept 
 clean enough for operating room purposes. Pieces 1 yard 
 square will be the most serviceable. 
 
 45. Rubber Tissue. — This will be purchased in thin sheets 
 of about one square yard each. It is useful for many purposes 
 such as covering dressings, for drains, etc. Its preparation for 
 use is discussed on page 250, and, under "Drains," in Chapter 
 XVII, page 310. 
 
 46. Rubber Tubing. — The operating room should possess 
 
226 TEXTBOOK OF SURGICAL NURSING 
 
 a good supply of all sizes of rubber tubing for it is used for 
 many different purposes. 
 
 47. Safety Pins. — Many of these, of course, are always 
 needed. 
 
 48. Salt Solution. — (a) Concentrated. — For purposes of ir- 
 rigation or of rinsing gloves during the operation the normal 
 salt solution {0S)%) made from ordinary salt and the filtered 
 Avater from the water sterilizer will answer. A convenient way 
 to provide this is to sterilize the salt in concentrated solution, 
 10% for instance, in flasks holding enough for one day's use. 
 The proper amount of this solution is easily added to water 
 when needed, 2y-> ounces of the 10% solution in a quart of water 
 making the normal solution nearly enough for purposes of irri- 
 gation or rinsing. (&) For Infusions. — For intravenous in- 
 fusions a more refined solution must be made because this is 
 injected directly into the blood stream where any but the ac- 
 curately normal solution can cause serious damage. Distilled 
 water may be used, but clean tap water is not objectionable; 
 chemically pure sodium chloride is advisable, though good com- 
 mon table salt will do; and the 0.9% solution must be accurately 
 mixed. 
 
 The drug market supplies salt specially prepared for the in- 
 fusion solution, and in some cases the potassium chloride and 
 the calcium chloride will be included, but the chemically pure 
 sodium chloride is extensively used alone and, as stated above, 
 common table salt answers very well. The manufacturer will 
 enclose directions for mixing his particular product, but where 
 the sodium chloride alone is used the proper proportion will be 
 124 grains of salt to one quart of solution. The nurse should 
 remember that the amount of salt is i)resci"ibed by weight and 
 she will not attempt, therefore, to measure it with a spoon or 
 any other such inexact measure, because it would be a rare case 
 indee(i in which a pharmacist could not be found to weigh it 
 for her. After the salt has been dissolved in the water the 
 solution must be filtered through fine filter paper a sufficient 
 number of times to make it perfectly clear, and then it should 
 be put into quart-size glass flasks for sterilization, the flasks 
 being very securely stopped with plugs of non-absorbent cotton 
 
EQUIPMENT OP THE OPERATING THEATER 227 
 
 covered with gauze and tied well down over the mouth of the 
 flask. The cleanest and easiest practice in making this solution 
 is to filter it directly from one flask to another each time. 
 
 49. Sandbags. — For the adjustment of the patient's posi- 
 tion upon the table it will often be necessary to have sandbags 
 of various sizes. The sand for these bags should be fine and 
 clean, sea sand being the best ; the bags should be made of heavy 
 canvas or "ticking"; and this should be covered with strong 
 rubber sheeting. Care should be taken not to fill them too 
 full, as a slightly flexible bag is more adaptable than a solid one. 
 
 50. Sheets. — (a) Plain Muslin.— A generous supply of 
 large heavy muslin sheets must be on hand for both sterile 
 
 Fig. 47. — Laparotomy Sheet. This is simply a large muslin sheet with, 
 an oblong opening cut in the center. The size of this opening should not 
 be less than 4x8 inches, and much larger openings are often preferred. 
 
 and unsterile purposes. (&) Laparotomy. — Another type of 
 sheet which is very easily made and which is a very convenient 
 article is the "laparotomy" sheet (Fig. 47). This is merely a 
 muslin sheet which is long enough to cover the entire table and 
 which has an opening about 4x8 inches or larger cut in the cen- 
 ter of it — this must, of course, be durably bound with tape. 
 This sheet will be useful for a great many operations, and we 
 shall point out its uses under "Operative Positions and Drap- 
 ing" in Chapter XVI. 
 
 51. Splints. — See suggested varieties in Chapter VII, under 
 the discussion of "Fractures." 
 
 52. Stockings, Lithotomy. — For operations in the lithotomy 
 position (Fig. 74, page 279) it is desirable to have large muslin 
 stockings which will slip over the patient's feet and the table 
 fixture loosely and extend well over the patient's abdomen and 
 
228 TEXTBOOK OF SURGICAL NURSING 
 
 down over the side of the table. Any iitirse can dcsioii a stock- 
 ing suitable for this ])urpose, as the cliief re((uisite is that it 
 be of generous size. 
 
 53. Stomach Tube. — This will be needed for an occasional 
 lavage. 
 
 54. Suits. — Hospital furnishing houses will supply these op- 
 erating suits which are made of a heavy "twilled" muslin. 
 They will have short sleeves, and the apron (Paragraph No. 3) 
 and gauntlets (Paragraph No. 17), or the gown (Paragraph 
 21) will be used Avith them. 
 
 55. Suture Material. — We shall give here only general in- 
 formation about suture materials, for it will be the exception 
 rather than the rule that the nurse will be called upon to pre- 
 pare them because factories supply them so convenient!}^ that 
 most hospitals purchase them ready for use. In Chapter XV, 
 however, under "Sterilization," Ave record various processes in 
 detail for the benefit of those who may at some time need to 
 refer to them. 
 
 Likewise, and for a corresponding reason, w^e shall speak only 
 in a general way here of the uses of suture material and leave 
 the details for the discussion of "Instrument Passing" in Chap- 
 ter XVII. 
 
 Substances used for sewing wounds are of two classes : Those 
 which are al)Sorl)able by the tissues, and those which are non- 
 ahsorhahle and which must, with a few exceptions, be removed 
 as soon as the wound is nearly enough healed to hold together 
 without them. 
 
 The absorbable suture materials are catgut and kangaroo 
 tendon. 
 
 Catgut is made from the intestines of animals, usually the 
 sheep, and consists of a strip of the submucous coat which has 
 been twisted, rope fashion, into a fairly smooth thread, and then 
 dried, cut into standard lengths, and sterilized. This is ordi- 
 narily called "plain catgut." It is usually absorbed by the 
 tissues within 5 to 10 days. To make it more resistant to ab- 
 sorption this plain catgut is treated with chromic acid which 
 hardens it, and then we get a suture that Avill hold fast as long 
 as 20 days or more, depending upon the length of time it is 
 
EQUIPMENT OF THE OPERATING THEATER 229 
 
 subjected to the hardening action of the chromic acid. This 
 suture is called "chromic" catgut. 
 
 The market usually supplies the catgut in seven sizes num- 
 bered 000, 00, 0, 1, 2, 3, and 4, the No. 000 being about the 
 weight of No. 60 sewing cotton and the No. 4 about like that of 
 the average wrapping twine used in stores. 
 
 Kangaroo tendon is made from the tendon of the kangaroo's 
 tail in a manner similar to that for catgut. It is usually some- 
 what more resistant to absorption than chromic catgut. It is 
 manufactured in several weights. 
 
 Catgut is by far the more frequently used of these materials, 
 the great majority of wounds being sewed together with it, and 
 practically all bleeding vessels tied with it. 
 
 The common non-absorbable suture materials are : Horsehair, 
 line7i thread, silk thread, silkworm gut, silver and aluminum- 
 hronze wires, and metal ^' clips." 
 
 Horsehair is simply the long hair from the horse's tail which 
 is easily cleansed and sterilized. It is usually black in color 
 when purchased ready for use, but when not naturally black 
 it is dyed to make it more clearly visible against the white drap- 
 ing towels and the patient's skin. 
 
 Silk and linen thread are familiar to every nurse. They are 
 usually dyed black for the reason given for horsehair. Silk 
 is used chiefly as a suture for the skin, and linen is employed 
 almost exclusively on the intestine and stomach. Silk is most 
 frequently used without having been treated in any way be- 
 yond sterilization, but sometimes it is saturated with paraffine 
 or albolene (see sterilization of silk thread, on page 260). Linen, 
 also, is much used plain, but perhaps the favorite form is the 
 celluloid linen, which means simply the linen thread which has 
 been saturated with a preparation of celluloid. A common 
 brand of this kind of linen thread is known as ' ' Pagenstecher. ' ' 
 The paraffine and the celluloid in these cases serve the purpose 
 of making the suture less likely to disintegrate when used in 
 parts from which it is never removed ; and the albolene serves 
 chiefly as a lubricant, particularly in the removal of the sutures. 
 These threads may be purchased in a variety of weights. 
 
 The student will recall that silk and linen were classified 
 
230 TEXTBOOK OF SURGICAL NURSING 
 
 above as non-absorbable materials, and may wonder how these 
 "foreign bodies" can sometimes be left permanentl}'^ in such 
 parts as the intestines, for instance; but it so happens that 
 nature is capable of accommodating herself to a few such in- 
 vasions b}'' either encapsulating the invader so as to shield the 
 more sensitive tissues from its irritating effect, by eventually 
 disintegrating it, or by sloughing it out. 
 
 Silkworm gut is made by draAving out into a thread the duc- 
 tile sac which the silkworm has just prepared from which to 
 spin his cocoon. This is naturally white, but it is usually dyed 
 black before it is prepared for use. Silkworm gut is a rela- 
 tively strong suture material and is therefore used as a 
 * * through-and-through " suture to hold together large abdom- 
 
 FiG. 48. — Lithotomy Tovv-el. Made of heavy muslin about 2 yards long 
 and 28 inches wide. The opening in the center is about 3 or 4 inches in 
 diameter. See use of this towel in Fig. 74, page 279. 
 
 inal wounds or any wound in which there is likely to be much 
 tension during the healing period. It is supplied in several 
 weights. 
 
 Silver and aluminimi-'bronze wire are used to suture together 
 the fragments or ends of broken bones chiefly. 
 
 Metal clips are made of silver or some other non-corroding 
 soft metal, and they are used for skin wounds and occasionally 
 for ligating blood vessels. The clip which the nurse will be 
 most likely to see in hospitals is the one called the "Michel" 
 skin clip. 
 
 56. Syringes. — There are innumerable types of syringe, and 
 the nurse will have learned on the wards the kinds Avhich are 
 in common use for hypodermics, aspirations, irrigations, etc., 
 and these three classes will cover the usual needs for the oper- 
 ating room. 
 
EQUIPMENT OP THE OPERATING THEATER 231 
 
 57. Thermometers. — The clinical thermometer will be 
 rarely used, but the bath thermometer should always be ready 
 to use for all irrigations, infusions, etc. 
 
 58. Tongue Forceps. — The surgeon or anesthetist will de- 
 cide upon the variety to be provided, but three kinds are illus- 
 trated in Fig. 20, page 185. 
 
 59. Tourniquets. — There are numerous varieties but a very 
 simple and extensively used one consists of a piece of heavy 
 rubber tubing which, is long enough to be tied about the limb, 
 or, it is often secured by means of a strong clamp. 
 
 60. Towels. — (a) Plain. — The only point to mention about 
 these towels is that they be of some soft, absorbent material 
 which launders well. Perhaps the best material is that which 
 is known commercially as "bird's-eye cotton." A linen or 
 other smooth-surface towel will be found unsatisfactory because 
 it will not stay in place well; instruments slide upon it; and 
 stains of blood, iodine, etc., are not easily removed from it. 
 (&) Lithotomy. — This is not a necessity, as a sheet or the wound 
 towels may be used instead, but it is a great convenience and 
 it is so easily made that we recommend its inclusion in the 
 equipment. It consists merely of a piece of muslin about two 
 yards long and 28 inches wide in the center of which an opening 
 3 or 4 inches in diameter is made (Fig. 48). This is used for 
 draping patients in the lithotomy position, as illustrated in 
 Fig. 74, page 279. 
 
CHAPTER XV 
 
 OPERATING ROOM STERILIZATION 
 
 The subject of bacteriolog}' is of tremendous concern in rela- 
 tion to operating- room sterilization and, as "we have said previ- 
 ously, the pupil should have studied it before taking up the op- 
 erating room course. However, those students who have not 
 yet covered the subject -will find material upon it in Chapter I, 
 and we shall review briefly here a few of the more important 
 terms which have a bearing upon the contents of this chapter. 
 
 DEFINITIONS 
 
 Septic. — When we say that a wound is septic we are using 
 a general term which means that it is under the actively de- 
 structive influence of bacteria of some kind, and the word car- 
 ries with it a special emphasis upon the decomposition caused 
 by the bacteria and its effects. The noun, sepsis, then, would 
 mean the state or condition of being septic. 
 
 Infection. — This is a term that is hard to differentiate from 
 sepsis, for when we say that a wound is infected we mean, as 
 we would if we called it septic, that it is inhabited by bacteria 
 w^hich are multiplying within it, are feeding upon it, and are, 
 therefore, destroying its health. In common parlance we use 
 the terms interchangeably, however, and there is perhaps no 
 important difference between them except, as mentioned above, 
 sepsis does bear more of a reference to the products of infection 
 and also to their effects. The term infection is also used in the 
 sense of its being the act or process by which the Avound is con- 
 taminated with bacteria, and in the sense of its being the bac- 
 teria themselves at work in the wound. The use of bacteria- 
 laden hands or instruments, for instance, in a wound would be 
 the act of infection, and the resultant growth of the bacteria 
 in the wound would be the infection itself. 
 
 232 
 
OPERATING ROOM STERILIZATION 233 
 
 Aseptic. — The term septic, then, with a-, which means not, 
 prefixed, will mean not septic, or free from sepsis; and the 
 phrase, aseptic surgery, will signify surgery done in such a 
 way as to prevent bacteria from gaining access to a wound. 
 
 Antiseptic. — This same term, with another prefix, anti-, 
 which means against, will then mean something that is opposed 
 to sepsis, and thus we call anything that tends to prevent or 
 stop sepsis or infection antiseptic. We may use it of the system 
 we employ to prevent the state of sepsis or infection from com- 
 ing about, and thus speak of antiseptic precautions and anti- 
 septic surgery; or we may apply it to the thing that actually 
 stops already existing infection or sepsis, and accordingly call 
 such things as weak solutions of bichloride, Dakin's solution, 
 etc., antiseptics. There are many other agents which will do 
 this, such as heat, strong solutions of bichloride, etc., but the 
 term antiseptic is usually applied to only those which can be 
 used upon the living body. 
 
 Disinfectant. — As the term implies, the prefix, dis-, meaning 
 to deprive of, a disinfectant is something which removes in- 
 fection. In its strictest technical meaning disinfectant is prop- 
 erly used to signify only those agents which destroy disease- 
 producing bacteria, and only such of those as cannot be used 
 upon the living body; but in everyday practice it is impossible 
 to draw any line of demarcation between our bacteria and so, 
 in everyday speech, we apply the term more broadly and in- 
 clude almost every form of bacteria-removing agent, and even 
 go so far as to call soap and water a disinfectant because, by 
 using them together, we can, though under heavy limitations, 
 remove infection. Thus, we take disinfectant out of the class 
 of destroyers and make it merely a remover, which is perhaps 
 not justice to the spirit of the word, and certainly is not con- 
 sistent with our other usages of the term when, for instance, we 
 call heat, formaldehyde gas, etc., disinfectants. However, the 
 name is unimportant so long as we know the truth. 
 
 Bactericide. — Here, again, our term defines itself. The 
 suffix -cide means destroyer, and so a bactericide is simply some- 
 thing which can kill bacteria. 
 
 Germicide. — As the term implies, a germicide is an agent 
 
234 TEXTBOOK OF SURGICAL NURSING 
 
 which can destroy germs, or bacteria. In the surgical sense 
 the terms bacteria and germs are used interchangeably, so it 
 does not materially matter which we use here. 
 
 Sterilization. — This is really our major term, for it is larger 
 than all the rest in that it signifies the absolute destruction of 
 all forms of bacteria. 
 
 Technic. — This is a word which we use a great deal and 
 which often seems to be regarded as the name of something very 
 formidable. It is the name of something Aan*y important as it 
 is applied in the operating room, but as is so often the case, 
 this very important thing is, in actuality, a very simple one, 
 Technic is nothing more nor less than the way of doing a thing, 
 and in the operating room it is merely the way in which we 
 make and keep things sterile. Even in this sense, however, 
 there is a danger of its becoming something of a bugbear and 
 of its developing into a hindrance rather than the help it is 
 designed to be and always should be. Simplicity is the key- 
 note of good technic, as it is the kejaiote of all good human 
 endeavor, and the less complex we make it the fewer will be our 
 points of contact with those things which have the power to 
 make it fail. 
 
 In the operating room, then, we have all the terms we have 
 just defined as startling watchwords, but the greatest of them 
 are septic, or infected, and sterilization; for we must treat 
 everything that is to come into contact with a wound, either di- 
 rectly or the most remotely indirectly, as though it were septic 
 or infected and must sterilize it before it is used ; and, of course, 
 it goes without saying that we must keep it so. Words and 
 their definitions are important, but they will not keep a wound 
 free from infection unless they are put into practice with an 
 intelligence and a conscience, and with a skill that can be ac- 
 quired only by diligent application. 
 
 Much will have been learned in the classroom and on the 
 wards about sterilization, antisepsis, asepsis, and all the rest, 
 and the nurse will know in a general way how to sterilize many 
 things and how to keep them sterile ; but in the operating room 
 she will find a rigidity and a minuteness of technic which at 
 first will seem to have no relation to what she has previously 
 
OPERATING ROOM STERILIZATION 235 
 
 practiced. On the wards she had to deal only with wounds 
 which were partially healed and which were not, therefore, so 
 susceptible to infection as fresh ones, and for this reason she 
 was permitted many practices which would be very dangerous 
 in the operating room where the wound is fresh and in its most 
 infectible state. Also, in the wards the supplies which she 
 handled were used only on the surface of a wound or within 
 an infected one which is very largely protected from new in- 
 fection by its own excretions, while in the operating room she 
 deals with the things that are to come into closest contact with 
 the entire area of a freshly made wound and even with the 
 blood stream itself. Her problem, therefore, is a much more 
 serious one, and her methods must be in accordance. 
 
 THE AGENTS 
 
 The subject of practical sterilization is a rather troublesome 
 one to master because of the fact that the various articles 
 needed in surgery differ so widely in composition and there- 
 fore in the amount and means of sterilization to which they 
 may be subjected without injury. By long experience and 
 practice, however, during the period of time since Lister gave 
 the world the discovery of aseptic surgery (see "Introduction 
 and History"), one or more good methods have been evolved for 
 the sterilization of every substance with which we have to deal, 
 and so our present task is simplj^ to learn, article by article, the 
 special recognized method which is adapted to each individual 
 case. The numerous and somewhat tedious methods may be 
 clarified to some degree for the student if she will learn, and 
 then remember, as she plods through the details of the follow- 
 ing pages, that, after all, each one may he classified under one 
 of two great classes, and that whatever particular process she 
 is carrying out is simply an adaptation of one of these two 
 major methods, and that the special variation is dictated by 
 some material peculiarity for which nature is responsible. 
 
 These two major classes of sterilizing agencies are : Thermal 
 and Chemical. 
 
 You will be taught one or two other classes by many authori- 
 
236 TEXTBOOK OF SURGICAL NURSING 
 
 ties. For instaiu'e, you ^vill be given the class "mechanical," 
 and the example for it will be the cleansing of the hands, etc., 
 with soap, water, and brush; but it is a fact that, in the last 
 analysis it is the soap and water w'hieh constitute the steriliz- 
 ing agency in the case, and as they are chemicals "scrubbing" 
 may very consistently be called a chemical sterilizing agent, 
 with the brush throAvn in. In fact, if the brush is given too 
 much prominence in the process it can do more harm than good 
 by scratching the skin and making harbors for infection. You 
 will also see the term "light" used for another class, and in 
 your experience you may have seen wounds treated by exposure 
 to the sunlight, and you know that sun does kill some germs 
 easily, but this may be regarded as another ease of chemical 
 action for there is considerable evidence for the belief that 
 it is the "actinic" or chemical element in the raj's of the sun 
 that does this Avork. 
 
 All of the sterilizing agents in common use, then, may be 
 classified under the two main heads which, for a little more sim- 
 plicity, maj'' be subdivided as follows: 
 
 I. THERMAL 
 
 1. Moist Heat 
 
 a. Boiling water 
 h. Steam 
 
 2. Dry Heat 
 
 a. Hot air 
 
 b. Flame 
 
 c. Actual cautery 
 
 II. CHEMICAL — All sohitions of chemicals which have the 
 power to kill germs. 
 
 I. THERMAL STERILIZATION 
 
 Of the two forms of thermal sterilization, the moist and the 
 dry, the moist form is the more effective at a given temperature 
 and period of exposure, experiment showing that the very 
 hardy anthrax spores, for example, are killed by boiling water 
 (212° F.) in about 12 minutes, whereas dry air at a tempera- 
 ture of 300° F. requires almost 3 hours. The moist form is, 
 therefore, more practical and it is fortunate that by far the 
 
OPERATING ROOM STERITJZATiON 237 
 
 greater proportion of surgical supplies may be subjected to it. 
 The reason why the moist form is the more active is a complex 
 one which it must be left to the several sciences involved to 
 explain. We have only time and space here to point out the 
 practical poM'ers of each which we make use of in our art and 
 to prescribe the particular one best suited to the sterilization of 
 each of the numerous materials and articles which we employ 
 in aseptic surgery. 
 
 1. Moist Heat. — a. Boiling Water. — This is the simplest 
 agent to use and if it did not destroy, or render unfit for use, so 
 many articles, it would make our problem of sterilization a very 
 easy one to solve, for boiling water kills most known forms of 
 disease-producing germs and their spores in a few minutes. 
 Plain water, as you know, boils at 212° Fahrenheit; and as we 
 shall point out later, in some cases we use enough carbonate of 
 soda (washing soda) in it to make a 1% solution, which raises 
 the boiling point 4° Fahrenheit and at the same time supplies 
 an additional solvent power to the water which is very service- 
 able in that it makes more certain the actual cleanliness of the 
 articles which have passed through it. In addition to this, the 
 washing soda counteracts the oxidizing or "rusting" power of 
 plain water, and this makes it especially valuable for our metal 
 supplies. 
 
 h. Steam. — Next to boiling water, steam is our best friend, 
 though the application of it necessitates special and more or 
 less complex equipment. Steam is simply water which has 
 been converted into another form, vapor, by boiling ; in its nor- 
 mal state, therefore, it is no hotter than boiling water, and of 
 no more value as a sterilizing agent. It is a physical fact, 
 however, that if we compress this steam we increase its tempera- 
 ture and its efficiency otherwise, and the more we compress it 
 the higher its temperature becomes; and so it has come about 
 that numerous instruments, "steam pressure sterilizers" (Fig. 
 49), have been invented in which we can sterilize certain sur- 
 gical supplies, which are not suitable to boiling, in this com- 
 pressed steam. 
 
 At this point w^e shall stop to study the general mechanism 
 
238 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 of the "steam pressure sterilizer" so that we shall be able to 
 understand more clearly the explanation further on as to why 
 we use it. ■ 
 
 There are many designs of steam sterilizers on the market 
 and no tAvo of them are exactly alike in detail of structure, but 
 they are alike in essential prinriplcs ami If we have a clear 
 idea of these general principles we shall have no serious diffi- 
 culty in learning to operate any particular type that we may 
 
 Fig. 49. 
 
 -Steam I'rf.sscre Dressing Sterilizer. The construction and 
 operation ot this sterilizer are explained on page 239. 
 
 encounter in practice. It is a fact that the average nurse is 
 greatl}^ puzzled by these sterilizers when she first undertakes 
 to operate them, she is afraid of them, and w^hen she does finally 
 learn to control them she performs the duty in a rather per- 
 functory way and takes little interest in her instrument beyond 
 knowing the serial order in which the valves are turned on and 
 off. Perhaps this common attitude among pupil nurses is due 
 to the fact that they are women and therefore not interested in 
 things jnechanical, but whether or not that is the reason, the 
 attitude is a bad one and an unnecessary one because a few 
 
OPERATING ROOM STERILIZATION 239 
 
 moments of study will make any one of these sterilizers very 
 intelligible and even simple to any pupil and ^vill prevent its 
 becoming the bugaboo it too often does. 
 
 In a few words, using Figure 49 as our guide, the secrets of 
 this instrument are these: The large cylindrical part is a 
 strong, hollow, steel shell which contains water, and is caUed 
 the "jacket"; underneath this is the gas burner, steam pipe 
 or other heater which boils the water and converts it into 
 steam. This "jacket" is, of course, steam-tight, and as the 
 steam increases in quantity it necessarily becomes more and 
 more compressed and correspondingly hotter. The two clock- 
 like dials on the top of the cylinder in front are '^ steam 
 gauges," which indicate in pounds the pressure of the steam; 
 one of these is connected with the "jacket'' and the other we 
 shall speak of presently. On the top of the cylinder at the 
 rear are several valves; one of these connects the "jacket" with 
 the interior of the sterilizer, the '^ chamher," into which we 
 put our supplies for sterilization. The door to the "chamber" 
 is fitted with heavy bolts which enable us to fasten it so as to 
 make the "chamber" as steam-tight as the "jacket." "When 
 we have the desired amount of steam pressure in the "jacket" 
 we then open the valve we have just mentioned and allow the 
 steam to enter the "chamber" where it permeates our supplies. 
 The water is still boiling and giving off steam to fill this new 
 space and in a few moments we have the same pressure in the 
 "chamber" as in the "jacket," as we can tell by the second 
 "steam gauge," which is connected with the "chamber." The 
 "jacket" and "chamber" are now in direct communication 
 through the steam valve and we leave them so till we have fin- 
 ished our sterilization. The standard amount of steam pressure 
 which is used in these sterilizers is 15 pounds, and at this pres- 
 sure the temperature of the steam is about 250^ Fahrenheit, 
 or 38° F. higher than boiling water. The sterilizer is fitted 
 with a "safety valve" which is regulated so as to open auto- 
 matically when more than this amount of steam accumulates 
 and allow it to escape. The details as to time of sterilization. 
 
240 TEXTBOOK OF SURGICAL NURSING 
 
 etc., will be given ^vllen T^-e describe, later on, the sterilization 
 of individual articles. 
 
 This is the A, B, C of sterilization by means of the steam 
 pressure sterilizer, but when you come to actually operate one 
 of the more complex sterilizers you will find a few more valves 
 and other attachments ; these, however, will be clearly explained 
 by the manufacturer who always supplies printed instructions, 
 and it is important that the nurse should have before her these 
 instructions at all times until she thoroughly masters the 
 mechanism of any sterilizer she may need to operate, for the 
 various designs differ in essential details. 
 
 A very important feature which will be encountered in all 
 the better ones is an arrangement for creatwg a "vacuum"; 
 and this brings us to a subject which we have not yet mentioned, 
 namely, sterilization by steam pressure in a vacuum. Those 
 of you who have studied physics will know that a vacuum is a 
 space which has nothing in it, not even air, and when we use 
 the term in connection with the sterilizer we simply mean the 
 "chamber" which has had the air sucked from it; and the 
 "vacuum valve" which you will find on your sterilizer means 
 simply a valve which is so made that it may be turned to allow 
 the steam in the "jacket" to suck all the air out of the "cham- 
 ber." This creation of the vacuum is, of course, done before 
 the steam is allowed to enter the "chamber," and so we are 
 then able to sterilize in a vacuum. 
 
 The nurse will now reasonably ask two questions : * ' Why do 
 we sterilize in a vacuum?" and more insistently, "Why, if boil- 
 ing water is hot enough to sterilize, do ive need to heat steam — 
 practically the same thing — to a so much higher degree?" The 
 answer to the first question is simply that, since by a law of 
 physics no two substances can occupy atomically the same place 
 at the same time, therefore, speaking atomically, where there is 
 air there can be no steam, and as air serves no useful purpose 
 we remove it so that the useful steam may have its place. The 
 answer to the second question is that we do not compress the 
 steam so much to raise its temperature as we do to make it 
 penetrate to the interior of the more or less compact parcels 
 
OPERATING ROOM STERILIZATION 241 
 
 of fabric which constitute almost entirely the supplies which 
 we sterilize by this means. 
 
 Finally, these sterilizers provide for the absolute drying of 
 our supplies after they are sterile, and they accomplish this by 
 sucking out the moisture just as the air was previously sucked 
 out. And here, we may now point out, is the answer to an- 
 other question which might arise, namely, "Why not simply 
 boil these supplies, since they must become as wet in the sterilizer 
 as they would in a boiler, and since they certainly become much 
 hotter?" Both of these things do happen to them, but what 
 cannot happen to them in the boiler is the thorough drying 
 which is an absolute necessity for those things which we ster- 
 ilize in this way. Another point here is that steam is free from 
 all the numerous impurities such as lime, iron, etc., which are 
 usually found in water; and so, in the steam our supplies es- 
 cape a considerable amount of soiling and staining from which 
 they would suff^er greatly in boiling. 
 
 From time to time these sterilizers must he tested because 
 there are many ways in which they may become disordered and 
 so fail to sterilize. There are a number of chemical and other 
 inventions on the market which are designed to serve this pur- 
 pose and some of them are doubtless reliable, but the safest 
 test is an actual culture of some known resistant bacteria, 
 placed in the center of the largest and most tightly packed par- 
 cel and subjected to the customary sterilization process. The 
 pathological laboratory will have to be depended upon for the 
 culture and for the bacteriological examination afterward. 
 
 2. Dry Heat.— a. Hot Air.— To sterilize by means of dry 
 air a very high temperature is necessary and it must be applied 
 for a long time, a temperature of 300°F. for one hour perhaps 
 being no more than the equivalent of boiling water (212°F.) 
 for 15 minutes. Relatively few materials will survive this de- 
 gree of heat without being injured to some extent, but there 
 may be occasions when no other means will be at hand, so we 
 must know how to make use of it. A hot air sterilizer (Fig. 
 50), in principle, is merely an ordinary baking oven, and when 
 nothing better is available the kitchen oven may be pressed into 
 
242 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 service. A thermometer is always an important attachment 
 for this sterilizer, of course. 
 
 h. Flame. — Some articles may be sterilized by passing them 
 through the flame of an alcohol lamp or a gas burner. Also, an 
 emergency means of sterilizing the inside of metal or other fire- 
 proof basins or dishes is to pour a very small amount of alcohol 
 (methyl alcohol is best) into them, light it with a match, and 
 allow it to burn out. This is a rather dangerous method, and 
 wlien it is practiced great care must be taken to use only enough 
 
 Pig. 50. — Hot Air Sterilizer. 
 
 alcohol to barely wet the surface of the article, for it burns 
 slowly and with a high degree of heat ; pains must be taken not 
 to spill the alcohol anywhere in the neighborhood ; and the bot- 
 tle must be removed to a safe distance before the match is 
 lighted. 
 
 c. Actual Cautery. — The nurse will probably never be called 
 upon actuallj^ to use this instrument herself, as its chief appli- 
 cations are for the sterilization of the appendix stump after the 
 appendix has been removed, for the removal of hemorrhoids, or 
 for the cauterization of tumors, ulcers, etc. Its care and prepara- 
 tion for use, however, will be her duty and she should become 
 familiar with it. 
 
OPERATING ROOM STERILIZATION 
 
 243 
 
 The actual cautery may be of one of these three varieties: 
 (a) A simple iron (Fig. 51) similar to the soldering iron used 
 by a plumber, and modifications of this for special uses. These 
 
 Fig. 51. — The Mayo Soldering Iron Cautery with Special Gas Burner 
 FOR Heating It. The irons are made in several shapes and sizes. 
 
 may be heated in any flame, but a special burner shown in the 
 illustration accompanies the particular type called the Mayo 
 cautery. . The only attention these irons will need to keep them 
 
 Fig. 52. — Electric Cautery. 
 
 in good condition is to scour them after use with a hard scouring 
 powder (emery, for example) or with a piece of fine sandpaper. 
 (&) The electric cautery (Fig. 52), for which also there are 
 
244 TEXTBOOK OF SURGICAL NURSING 
 
 points of a variety of sizes and designs, (c) The FaqucUn 
 cautery (Fig. 53), or one constructed on its general princijiles. 
 This is a- complex instrument Avhich requires careful JuDidJiiig 
 to keep it in working order; and as it will usually be the nurse's 
 duty to hand it to the surgeon ready for applieation every nurse 
 should make sure that slie inulcivstaiuls it and that she ean prop- 
 erly heat it. This cautery consists of a hollow platinum point 
 which is kept hot by the burning of benzine vapor pumped 
 through it from a small reservoir by means of a rubber bulb. 
 In practice this cautery is often very unsatisfactory^ because it 
 fails to become or remain hot ; but if the hollow i)latiiuim point 
 is not punctured, and if its cavity is not obstructed by a dent, 
 its failure is nearly always due to the fact that the person 
 
 Fig. 53.— The Paquelin Cautery. 
 
 manipulating it does not quite understand how it must be 
 treated. In the first place, the platinum points are very soft 
 and therefore easily bent or dented, and tliey must always be 
 handled gently and protected from accident. But gi^'en a point 
 in good condition, practically all failures with this cautery are 
 due to the fact that the proper procedure has not been followed 
 in heating it. The benzine reservoir contains a sponge, and in 
 filling it only enough benzine sliould be put into it to saturate 
 the sponge, for it is only the vapor that will serve our purpose, 
 and if there is more benzine than the sponge will absorb the 
 fluid itself will be pumped into the point and clog it. A good 
 practice is to invert the tank after filling it to allow the excess 
 to escape. The next, and perhaps the most important precau- 
 tion to be taken is that the platinum point must be heated red 
 hot (in a gas or alcoliol flame) before the benzine vapor is 
 
OPERATING ROOM STERILIZATION 245 
 
 pumped into it. The reason for this will be evident when it is 
 understood that it is the combustion of the benzine vapor within 
 the point that keeps it hot, and if the point is not hot enough to 
 burn this vapor there will simply be an accumulation of con- 
 densed vapor Avithin the point which will nearly always obstruct 
 it. The warning^ then, is to wait until the point is red-hot and 
 then begin pumping the vapor into it slowly and steadily and 
 to continue thus with the point in the flame for a few moments 
 until the circulation of the benzine vapor is well established. 
 The point can then be removed from the flame and kept red hot 
 by the steady pumping of the benzine vapor. An important 
 thing to remember is that too much must not be expected of this 
 small red-hot piece of metal, and when large amounts of tissue 
 are to be burned with it the larger points should be used; for 
 naturally, the burning is accomplished by the transference of 
 the heat from the platinum point to the tissue, and if too much 
 tissue surrounds it at any given time it is overcome by having its 
 heat used up faster than it is able to produce it. Thus it often 
 happens that the "fire" in the point goes out during a heavy 
 cauterizing operation, and as soon as this happens the pumping 
 must be stopped and the point reheated in a flame as in the 
 beginning. If the Paquelin point is always treated with the care 
 outlined here it will always respond. 
 
 II. CHEMICAL STERILIZATION 
 
 Chemical sterilization is simj^ly the soaking of articles in a 
 solution of a chemical, which has the power to kill germs, for the 
 length of time which experiment has proved each individual 
 chemical requires. It would be almost impossible to enumerate 
 the various chemicals which have been advocated from time to 
 time for this purpose, for as very few of them are entirely satis- 
 factory new ones are always coming into favor in the hope that 
 the various objections to the old ones may be avoided. There are 
 a few, however, which have stood the test of time and experience, 
 and though individual authorities will always vary in their 
 preferences of even these "tried and true" ones, we are safe in 
 saying that the following are the important chemical sterilizing 
 agents, and that they are mentioned in the order of their latitude 
 
246 TEXTBOOK OF SURGICAL NURSING 
 
 of general application in modern surgery: Bichloride of mer- 
 cury, iodine, alcohol, carbolic acid, Dakin's solution, formalin, 
 lysol, ether. 
 
 PRACTICAL METHODS 
 
 (For Initial Preparation of Supplies see Chapter XIV) 
 
 One of the first principles to be learned by the operating room 
 beginner is to reduce the handling of sterile supplies to the very 
 lowest point. Tlie methods we shall give you in the following 
 pages we believe to be perfectly safe and if you follow them 
 conscientiously we believe your supplies will be sterile, but we 
 must always remember that the human element in all our acts 
 perpetuates the possibility of mistakes and, therefore, every time 
 one avoids handling a sterile thing one escapes a possibility of 
 contaminating it. This applies particularly after the thing is 
 sterile, of course, but one must begin the application of the prin- 
 ciples with the packing of the supplies for sterilization because 
 the way in w^hich this is done will determine to no small degree 
 the amount of necessary subsequent handling. The element of 
 time saA'ing also enters here, for, on the whole, the more quickly, 
 or, rather, the more directly a sterile thing reaches the Avound 
 from the sterilizer the more certain one can be of its asepsis; 
 and so, while we are aiming to avoid frequency of handling we 
 must also aim to reduce as much as possible the duration of each 
 particular act of handling. We shall try, then, to pack our 
 supplies in the most convenient and accessible form possible; 
 and as we take up each type of supplies we shall carry it through 
 its particular process of sterilization. 
 
 There are certain supplies, such as basins, irrigators, etc., 
 which wdll be awkward to store sterilly; and there are others, 
 the instruments for example, for which there is no suitable 
 method by Avhich they may be thus stored and at the same time 
 kept in good condition. In such cases sterilization, by boiling 
 chiefly, immediately before use will have to be the practice. 
 
 Gauze and Muslin Supplies. — We shall presume first that 
 you are equipped with the drums for these supplies and that 
 you are packing for a session of two or more operations. In 
 this case you will do best to use a set of four drums, and to 
 
OPERATING ROOM STERILIZATION 247 
 
 devote one entirely to each of the following groups: (1) Gauze 
 sponges, all wound dressings, and a few towels; (2) Draping 
 sheets and towels; (3) Gowns, or aprons and gauntlets; (4) 
 Abdominal pads and towels (the hot towel drum). Such things 
 as packing, the lithotomy towel and stockings, sterile bandages, 
 cotton, etc., which are only occasionally used, are best packed 
 in individual muslin-covered parcels. Or, for the packing, a 
 convenient plan is to pack it in long glass tubes which are well 
 plugged with cotton and wrapped in a muslin cover. One doc- 
 tor's suit or gown, a cap, and a mask are best packed together 
 in a parcel for each individual according to size ; likewise, there 
 should be a similar set of cap, gown, and mask for each nurse, 
 as these articles will be needed in the dressing room, and but 
 once for a session. When the gauntlets are used a supply of 
 rubber bands or safety pins for holding them in place should 
 be packed with them. 
 
 If drums are not used about the only substitute will be the 
 muslin-covered parcels, and when preparation is made for sev- 
 eral operations to be done at one time the general plan given 
 above for the drums will work well. However, with the muslin- 
 covered parcels there will always be more handling required in 
 opening and disposing the contents upon tables, and for this 
 reason it may be better to combine them into fewer individual 
 parcels. How this is done must be left to the ingenuity of the 
 nurse who will be guided by her equipment and the nature of her 
 work; but she must always keep in mind her goal of simplicity 
 and minimum amount of handling and exposure. 
 
 In small operating rooms, where only one operation need be 
 prepared for, one drum or one parcel may be used for all these 
 supplies except, of course, the individual wearing apparel, 
 which should be arranged as in the other cases. 
 
 All of these supplies are sterilized in the steam pressure 
 sterilizer, and they should be exposed to the steam at 15 pounds 
 pressure (250° F.) for 45 minutes, and to the drying process 
 for from 20 to 30 minutes or more, according to the load. 
 
 Rubber Gloves. — The gloves should, first of all, be most 
 carefidly tested to eliminate those wath the slightest perforation 
 (see page 294). They are then poivdered well and evenly on 
 
248 TEXTBOOK OF SURGICAL NURSING 
 
 both sides with talcum powder; the culj hinicd up over the out- 
 side for about 2 inches; and phieed in the muslin covers, if these 
 have been provided, and otherwise folded in a tv)wrl. If the 
 towel is used it should be so folded about the gloves that a layer 
 of it comes between them for this will aid in permitting the 
 steam to reach all parts. It is best teehnie to provide a separate 
 glove cover or towel for each pair of gloves ; and with each pair 
 should be included a small packet of talcum poivder, as the 
 hands wdll always need to be well powdered before attempting 
 to put on the gloves. This powder is best wrapped loosely in a 
 piece of thin paper. 
 
 These parcels of one pair each are then packed together in a 
 drum or muslin cover, enough pairs being provided for accidents 
 such as tearing or unsterilizing. A few towels should be 
 included in this parcel for use in drying the hands. 
 
 It is a good practice, before sterilizing new gloves for the 
 first time, to scrub them well and hoil them for a few minutes, 
 as some brands will come out of the first sterilization covered 
 with a more or less gummy substance. The scrubbing and boil- 
 ing will prevent this, and in any case it is advisable to be sure 
 that anything one sterilizes has had the cleanest start possible. 
 
 Gloves are sterilized in the steam sterilizer at 15 pounds pres- 
 sure, and they can never be subjected to the steam for more than 
 20 minutes without greatly injuring them. If they are not 
 packed too tightly 10 minutes will be enough. Drying should 
 be accomplished inside of 20 minutes also, and if loosely packed 
 10 or 15 minutes Avill suffice. Rubber does not withstand high 
 temperatures well, and if damaged in sterilization gloves are 
 easily torn and may then be as much of a menace as when 
 imperfectly sterilized ; for it must be remembered that the hands 
 are never considered absolutely sterile. This is the "dry 
 method" of glove sterilization. 
 
 Some surgeons will prefer '^wet-sterilized" gloves, and in 
 that case the gloves are boiled for 10 minutes and then stored 
 in a basin of some antiseptic solution from which they are used 
 directly. The particular solution used will be a matter of indi- 
 vidual preference but will probably be either a 1-1000 solution 
 of bichloride of mercury, 1-60 carbolic acid, or lysol %% or 1%. 
 
OPERATING ROOM STERILIZATION 249 
 
 The advantage of gloves used in this way is that the hands 
 remain wet with the solution and are doubtless more nearly 
 sterile than they are with the dry gloves, and an accidental 
 puncture is more likely to be harmless ; but the dry ones are more 
 extensively preferred because they are more comfortable and 
 they avoid the complication of sore hands which sometimes is an 
 annoying accompaniment of the practice of using wet gloves. 
 
 As in the case of all boiling of rubber, the gloves must not 
 he put into the water until it has reached the boiling point 
 because they deteriorate somewhat at best in the hot water • also, 
 only plain water must be used, as for all rubber, and never the 
 soda solution for the two reasons that it is not necessary and 
 that it is very detrimental to rubber. 
 
 A hint which it may be well for the nurse to pick up here is 
 that old rubber which has lost its "life" may be somewhat 
 rejuvenated by boiling it for a few moments in a weak (about 
 the normal) solution of salt. 
 
 Salt Solution. — As advised above, this is a 10% solution 
 which you have prepared in glass flasks. The flasks should 
 be wrapped in a muslin cover, as it will be convenient to have 
 the outside of them sterile. They are best sterilized in the steam 
 sterilizer in the same way and for the same time as the gauze 
 and muslin supplies, and if packed carefully they may be done 
 at the same time. 
 
 The infusion salt solution should he sterilized hy the frac- 
 tional method^ which means that it must be done three times at 
 24-hour intervals, and between sterilizations it must be kept in 
 a warm (80° F.) place. The process each time will be the same 
 as for the other salt. The reason for this special treatment is 
 to encourage the development of any possible spores during the 
 interval and thus bring them into a form which will succumb to 
 the next sterilization. Special care must be taken to see that these 
 flasks are tightly plugged with non-absorbent cotton as otherwise 
 the water will evaporate considerably in the course of these three 
 sterilizations and render the solution too concentrated. 
 
 Rubber Dam. — This is used chiefly for drains, usually the 
 "cigarette" drain (see Fig. 89, page 310), which means simply 
 a piece of the rubber rolled around a strip of gauze after the 
 
250 TEXTBOOK OF SURGICAL NUKSiNG 
 
 fashion of a cigarette. It is the better practice not to make up 
 this drain till immediately before use as the length and thick- 
 ness will need to be adjusted to each individual "vvouud ; and as 
 any of the gauze you have for other purposes will do for this 
 one you will simply need to have the rubber dam in readiness 
 in a variety of sizes varying from 3 or 4 to 6 or 8 inches square. 
 The pieces should be well washed in soap and Avarm water, and 
 then sterilized hy hoiling in plain water for 10 minutes. This 
 rubber will be in better condition for use if boiled freshly at 
 the time, but when it is used frequently it is a good practice to 
 boil a supply in advance and store it in a well-covered glass jar 
 in a 1-60 carbolic solution. This solution softens the rubber in 
 time, so no more should be prepared than will be used within a 
 week or two. 
 
 Rubber Tissue. — This should be cut in sizes similar to those 
 of the rubber dam, and it too should be washed in soap and 
 water, but as hot water dissolves it care must be taken to use 
 cool water. The only method w^hich can be used for sterilization 
 of rubber tissue is the chemical one and the best solution is 
 bichloride 1-1000. Naturally, you will feel that by this method 
 you may not be able to sterilize the tissue beneath the surface 
 since it is made of rubber and is therefore impervious to any 
 solution, but when you soak it over night, or for 12 hours, you 
 may feel that your germicidal solution has reached any part of 
 it that any of the wound fluids will be able to do and that, there- 
 fore, it is fit for aseptic surgical use. Necessarily this tissue 
 must be prepared in advance, and after it has been subjected 
 to the 1-1000 solution of bichloride for 12 hours it should be 
 stored in a glass jar in a 1-5000 solution of bichloride. Do not 
 use a stronger solution than the 1-5000 for storage because the 
 tissue is used directly from this solution and a stronger one 
 wall be irritating to some wounds. Also, do not use a carbolic 
 acid solution, because rubber tissue deteriorates rapidly in it. 
 
 Rubber Tubing. — Whether or not you provide a sterile sup- 
 ply of rubber tubing will depend upon how much demand you 
 have for it. Some surgeons use it considerably for drainage, 
 and in that case it is well to have a sterile supply prepared in 
 advance. Tubes of a variety of diameters will be needed, and a 
 
OPERATING ROOM STERILIZATION 251 . 
 
 serviceable length for each piece will be about 12 or 14 inches. 
 After being well washed this rubber may be prepared for use 
 in one of several ways : It may simply be boiled for 10 minutes 
 and then stored in a jar of 1-60 carbolic solution; or, after 
 washing it may be boiled, dried, powdered, and sterilized in 
 muslin covers or long glass tubes in the steam sterilizer. The 
 reason for boiling this tubing before steam sterilization is the 
 same as that given above for rubber gloves, namely, to remove 
 the surface finish which the manufacturer has put upon it and 
 which becomes soft and somewhat sticky under the steam. The 
 powder serves the same purpose as in the case of the gloves, 
 namely, to absorb the small amount of this gum which oozes 
 to the surface during a sterilization — before use this powder 
 must be rinsed off in sterile water. Perhaps the most practical 
 plan for storing this tubing is in the long glass tubes which are 
 sold as ' ' catheter ' ' tubes. One piece in a tube will be best, and 
 a gauze-covered absorbent cotton stopper fastened well down 
 over the mouth of the tube will be necessary so as freely to 
 admit the steam to the interior. 
 
 Rubber Aprons. — These are best sterilized as advised for the 
 rubber gloves, that is, they are well powdered, wrapped in a 
 muslin cover and sterilized in the steam sterilizer as directed 
 for the gloves. 
 
 Syringes. — Many syringes are boilable and boiling is the best 
 method where permissible, but there are so many types of 
 syringe that one must make sure of the construction of each one 
 before attempting to sterilize it because the wrong method will 
 quickly put this delicate instrument out of order. An all-metal 
 one which has perhaps a leather or rubber plunger or packing, 
 a hard rubber one or one with hard rubber mountings, and 
 some of the combination glass and metal ones cannot be boiled 
 and must be sterilized by soaking in some solution. A 1-20 
 carbolic acid solution is perhaps a good all-round one for such 
 syringes, as bichloride will rust the metal parts and alcohol 
 will injure the rubber and leather parts. A plan which may 
 be applied to the all-glass one, where it wall be an advantage 
 to have it ready-sterilized, is to put it (with the plunger sepa- 
 rated) into a cotton-plugged glass tube and sterilize it in the 
 
252 TEXTBOOK OF SURGICAL NURSING 
 
 steam sterilizer. A piece of cotton will be needed in the bottom 
 of this tube to avoid breakage. 
 
 Thermometers, — The chemical method will always be neces- 
 sary for tlie sterilizati(m of thermometers and any solution will 
 answer, though bichloride should be first choice. 
 
 Needles. — As any moist method of sterilization wall soon 
 rust .syringe needles interiorly a good plan is to put each one 
 into a small glass tube plugged with cotton and sterilize in the 
 dry air sterilizer for 1 hour at 300° F. The "temper" is of 
 course somewhat altered by this process but it is not enough 
 to be seriously' noticed, and the needles will always be free from 
 rust and will last much longer. 
 
 The suture needles may he boiled with the instruments, for 
 although they come under the classification of ' ' cutting ' ' instru- 
 ments, which we shall tell you a few paragraphs hence should 
 not be boiled, the harm done to them is so little as to be negligi- 
 ble. In some large institutions where many varieties are needed 
 during a session, it is the practice to arrange a complete set in 
 a muslin or folded towel case (Fig. 54) and sterilize them in a 
 cloth cover in the hot air sterilizer for 1 hour at 300° F. This 
 high temperature and the subsequent slow cooling somewhat 
 soften them, however, but the entire avoidance of rust and the 
 couA^enience compensate for this slight objection. 
 
 Tourniquet and Esmarch Bandage. — Boil 15 minutes in nor- 
 mal salt solution. 
 
 Vaseline, Olive Oil, Glycerine. — These may all be sterilized 
 in the steam sterilizer if care is taken to put them into containers 
 that w^ill withstand the temperature. Or, a method of second 
 choice is to boil them in a water bath. 
 
 Novocain. — This will withstand a moderate amount of boil- 
 ing in a water bath. 
 
 Instruments. — All instruments except the "cutting" ones, 
 such as knives, are sterilized by boiling in the 1% washing soda 
 solution for not less than 10 minutes. The sharp-edged ones are 
 somewhat dulled by the boiling and will therefore need to be 
 sterilized chemically. Alcohol is much used for this purpose, but 
 the objection to it is that the instruments must remain in it an 
 hour or two, and in that time the water which all alcohol contains 
 
OPERATING ROOM STBRTLTZATION 
 
 253 
 
 1 
 
 K7- 
 
 It r, 
 II II 
 1. i' 
 
 ,t"l, 
 
 ''/ 1' 
 
 
 ^ 
 
 ''11'' 
 
 V) 
 
 Fig, 54.— Needle Book. Made from the ordinary draping towel or a piece 
 of muslin folded by the steps indicated. 
 
254 TEXTBOOK OF SURGICAL NURSING 
 
 rusts them more or less. Another nietlioil friMjuently praetieed is 
 to soak these instruniciits in pure carbolic acitl i'or 5 minutes, 
 rinse off the earbolie in alcohol, and then dry them. Rust is 
 avoided in this way, and -when the instruments are free from 
 intricate joints or crevices from Avliicli the earbolie mij2:ht chance 
 not to be removed thoroughly by the alcohol, there is no objection 
 to this method. Carbolic solution, 1-20, is often used also, bujt it 
 is a slow germicide and involves the complication of rust. In 
 any of the solutions, however, the disadvantage of rust may be 
 greatly reduced by the addition of a few grains of borax. 
 
 The hot air method is sometimes used for the sterilization of 
 instruments, and for the heavier and plainer ones there seems 
 to be no harmful result, but the practice will play havoc with 
 the delicately constructed and the cutting ones, as the high 
 degree of temperature necessary and the subsequent cooling 
 alter the "temper" of them and thereby their adjustment. 
 
 Suture Material. — In most cases the suture material wall be 
 purchased ready-prepared, but as the nurse may wish to know 
 the various processes for her own satisfaction, and as she may 
 sometimes be called upon to sterilize the various materials her- 
 self, we shall give here a few of the more frequently employed 
 methods. 
 
 When the nurse undertakes the sterilization of suture mate- 
 rial she must remember that she is dealing with the most serious 
 piece of sterilization which she will ever be called upon to do 
 because the sutures, especially the catgut ones, are imbedded in 
 tissues which have been more or less injured by the operation 
 and thereby made more susceptible to infection and they will 
 hold there in this very good culture medium any germs which 
 may have escaped destruction, and thus bring about the most 
 serious kind of infection. Catgut is difficult to sterilize by any 
 process because it is very easily ruined by even slight departure 
 from the tried and true methods which have been established by 
 very exact experimentation, a few degrees more of heat, for 
 instance, making it so brittle that it will crack in the process of 
 tying or tear under any slight strain; so, before attempting the 
 sterilization of catgut the nurse must make sure that she under- 
 
OPERATING ROOM STERILIZATION 
 
 255 
 
 stands and can control her sterilizer and all the other apparatus, 
 and that she has an intelligent knowledge of the formula she 
 is using, of the ends at which she is aiming in each step, and of 
 the final result she must get. A very important point which 
 she must settle before each sterilization is that she is using a 
 thermometer which is absolutely accurate, because faulty and 
 inaccurate thermometers are responsible for more failures than 
 any other defect of the process. The person who does this 
 w^ork must give her undivided attention to it throughout the 
 process or she will not escape at least one, or more, of the many 
 pitfalls which lie in her pathway. 
 
 Plain Catgut 
 
 The raw catgut is manufactured in seven and sometimes nine 
 weights and is usually sold in bundles of ten strands, each strand 
 being 10 feet in length. There are many ways advised for 
 arranging it before sterilization 
 and most of them are con- 
 venient and technically good, 
 but the one which will apply to 
 all methods is that of cutting it 
 into the proper size for use, 
 which will mean about 30 
 inches for the suture and 15 
 inches for the ligature, the 
 strand of 10 feet thus making 4 
 sutures or 8 ligatures. These 
 should then be rolled around 
 the fingers into coils of about 
 11/2 inches in diameter, the end 
 of the strand being wrapped 
 around the finished coil to pre- 
 vent its unrolling (Fig. 55). 
 The most economical way is to roll each suture or ligature sep- 
 arately, buit of course any number which is found convenient 
 may be combined into one coil. This plan involves so much less 
 handling after sterilization than those in which it is necessary 
 to cut the desired piece from a large reel, and this is perhaps the 
 
 Fig. 55. — Method of Eolling 
 A Catgut Suture or Ligature for 
 Convenient Handling in Sterili- 
 zation AND IN Dispensing at the 
 Operating Table. The ends should 
 be coiled about the roll only once 
 or twice, as more turns will per- 
 manently kink it. 
 
256 TEXTBOOK OF SURGICAL NURSING 
 
 best reason one can advance in favor of any method of steriliza- 
 tion. 
 
 There is an almost uncountable numher of formula; for the 
 preparation of catgut, and it does not seem to matter much Avhich 
 one is used for they all arrive at the same destination, namely, 
 sterile catgut. There is a little difference, however, in some 
 cases in the texture of the suture, the iodine methods, for 
 instance, having a tendency to make it a little less flexible, but 
 aside from this there seems to be no reason except individual 
 taste for preferring anj' one of the following to any other one 
 of them. 
 
 Lee Method (Modified). — 
 
 1. Line metal or glass beakers loosely with heavy filter 
 paper, so as to insulate the catgut from the walls of the beaker 
 which gets hotter during the process than the contents and will 
 burn the catgut at any point of contact. ■ 
 
 2. Throw coils of catgut into beaker loosely. 
 
 3. Place in hot air sterilizer. 
 
 4. Raise the temperature of the oven slowly to 212° F. and 
 keep it there for 40 minutes. This is to dry out the catgut, and 
 it should therefore be done on a dry day and in a room free 
 from abnormal moisture. 
 
 5. Immediately at the end of the 40 minutes barely cover 
 the catgut with liquid albolene which has been heated to about 
 120° F. 
 
 6. Raise the temperature of the sterilizer slowly and gradu- 
 ally to 300° F. and keep it at exactly this temperature for 30 
 minutes. 
 
 7. Leave the beakers in the sterilizer to cool slowly. 
 
 8. After 24 hours heat the sterilizer slowly again to 300° F. 
 and keep it there for one hour. 
 
 9. Allow to cool as before. 
 
 10. When cold drain off the albolene and store the catgut ha 
 sterile jars in a 1/16% alcoholic solution of iodine. 
 
 11. The catgut will be ready for use in 24 hours. 
 
 It will be better not to cover the beakers during the process, 
 
OPERATING ROOM STERILIZATION 257 
 
 which will be perfectly good technie since the sterilizer is not 
 disturbed during the 24 hours. It should not be necessary to 
 remind the nurse that the catgut must be transferred from the 
 beakers to the sterile storage jars with sterile forceps, 
 
 Bartlett Method. — 
 
 1. String the coils of catgut on a thread. 
 
 2. Suspend them in glass or metal beakers from a cardboard 
 or other cover so that they will not touch the beakers at any 
 point. The reason for this is that the beakers become hotter 
 in the process than their contents and the catgut will be burned 
 wherever it touches the beaker. 
 
 3. Insert the thermometer into the center of the beaker 
 through an opening in the cover. 
 
 4. Put the beakers in a sand bath and raise the temperature 
 (within the beakers) to 180° F. and keep it there for 1 hour; 
 then raise the temperature gradually to 220° F. and maintain 
 it there for 1 hour more. This ii to dry the catgut. 
 
 5. Pour on enough liquid albolene to barely cover the cat- 
 gut. 
 
 6. Heat very slowly, during a period of 1 to 2 hours to 212° 
 F. and keep it at that temperature for 12 hours. 
 
 7. At the end of 12 hours increase the heat slowly, through 
 a period of 1 hour, to 300° F. 
 
 8. When 300° F. is reached immediately turn off the heat 
 and allow the temperature to decrease to 212° F. 
 
 9. Drain off the albolene and store the catgut in sterile jars 
 in a solution composed of : 
 
 Iodine crystals 1 part 
 
 Columbian spirits 100 parts 
 
 10. The catgut is ready for use in 24 hours. 
 
 Claudius Method. — 
 
 1. Place the catgut in a jar of this solution : 
 
 Iodine crystals ...... 1 part 
 
 Potassium iodide 1 part 
 
 Distilled water 100 parts 
 
258 TEXTBOOK OF SURGICAL NURSING 
 
 2. Cover the jar tightly and h't it stand for 8 days. 
 
 3. After the eight days the catgut va.ay either be left in the 
 above solution or stored in alcoliol. 
 
 4. Rinse the eatgut in sterile water before use. 
 
 BuRMEiSTER jMethod. — Soak the catgut for one week in this 
 solution : 
 
 Chloroform 1 gram 
 
 Metallic iodine 15 c. c. 
 
 BOECKMANN METHOD. 
 
 1. Soak catgut in ether for 1 week. 
 
 2. Wrap in paraffine paper and seal in a paper envelope. 
 
 3. Sterilize in dry air sterilizer at 300° F. for 3 hours. 
 
 4. Repeat sterilization after 24 hours. 
 
 New York Hospital Method. — 
 
 1. Soak in benzine 24 hours. 
 
 2. Allow benzine to dry off. 
 
 3. Boil in alcohol for from 1 to II/2 hours, according to the 
 weight of the catgut. 
 
 4. Leave catgut in the alcohol. 
 
 5. After 24 hours boil again for % hour. 
 
 6. Store in alcohol. 
 
 Great care must be taken when boiling alcohol to do it always 
 in a double boiler or sand bath, as alcohol is easily ignited, 
 especially when an open flame is used. 
 
 Chromic Catgut 
 
 As stated above, chromic catgut is plain catgut which has 
 been hardened in a solution of chromic acid to make it resist 
 absorption in the tissues longer. 
 
 The chromicizing must he done before the catgut is sterilized 
 and before the long strands are cut. The reasons for this will 
 be found in the following facts: (a-) The chromic acid is made 
 up wdth water whieh renders the catgut spongy and which must 
 be dried out of it before anything further can be done; (6) In 
 
OPERATING ROOM STERILIZATION 259 
 
 the process of dryiny there is a certain amount of shrinkage 
 which takes place very unevenly unless tlie strands are kept 
 stretched during the process; (c) Consequently, the strands 
 must be stretched out at full length across a large frame or 
 between two wall pegs, and securely fastened at Ijoth ends under 
 moderate tension for drying; (d) It is easier and simpler to 
 handle the long strands than the short ones for this part of the 
 process. 
 
 Therefore, to chromicize the catgut we lay the rolls as they 
 come from the factory in a dish which will allow them to lie 
 loosely on the bottom without cramping, and then pour over 
 them a 1-2000 chromic acid solution, and leave them undisturbed 
 in this solution for 24 hours. At the end of this time we remove 
 one strand at a time and stretch it carefully and at an even and 
 quite moderate tension across the frame or between the pegs, 
 fastening both ends securely because there is considerable 
 shrinkage in drying and therefore a strong pull on the ends. 
 The strands may be separated without difficulty if the precaution 
 is taken before putting them to soak to examine the roll, as one 
 would a skein of yarn, to see in which direction it may be 
 unwound, and then to place it in the jar accordingly. It is 
 left on the frame until ' ' bone-dry ' ' and is then sterilized like the 
 plain catgut. 
 
 Kangaroo Tendon 
 
 This is prepared like the catgut. 
 
 Horsehair 
 
 This must be thoroughly cleansed in soap and water, and it 
 should be allowed to soak in this for a few hours in order to be 
 sure that it is perfectly clean. It is then rolled into coils like 
 the catgut, sterilized hy boiling in clear water, and is then best 
 stored in a 1-60 solution of carbolic acid. Because of the special 
 danger of tetanus and anthrax spores in the case of horsehair, 
 sterilization of fresh supplies must be very thorough, an hour 
 or more being required for safety. The horsehair will withstand 
 this amount of exposure to boiling and we therefore have no 
 excuse for giving it less. Alcohol is sometimes used instead of 
 
260 TEXTBOOK OF SURGICAL NURSING 
 
 carbolii' for storape but this is likely to make it too stiff and 
 soniewliat brittle. 
 
 Silk and Linen Thread 
 
 These must be Avound (ni small reels, i)referably glass ones, 
 and it will be more practical for future use to leave them in one 
 long- piece rather than to cut them into suture lengths. If tliey 
 are white and it is desired to dye them black any standard fast 
 dye may be used if tlie nurse first familiarizes herself Avitli the 
 correct process for doing this. 
 
 Silk and linen thread are sterilized hy boiling in plain water 
 and should not be subjected to the process for more than 30 
 minutes, as they deteriorate somewhat in boiling water. 
 
 Sometimes the silk thread may be impregnated with paraffine 
 or with liquid albolene. When paraffine is used it should either 
 be first melted and the silk then boiled in it, or a jar containing 
 the silk and enough of the paraffine to cover it when melted may- 
 be placed in the autoclave and sterilized like the gauze dressings. 
 When boiling paraffine over a flame or a stove it must be closely 
 watched as it will burn if allowed to become too hot. Albolene, 
 also, may either be boiled or sterilized in the autoclave, and it 
 will need the same care as the paraffine when boiled on a stove 
 or open flame. 
 
 Silkworm Gut 
 
 The raw silkworm gut will usually be supplied by the market 
 in bundles of 100 strands each about 14 or 15 inches long. These 
 may be wound in coils of one or more strands each like the cat- 
 gut. It is usually sold in the natural color, white, and if it is 
 preferred black it vhslj be d.yed as suggested for the silk and 
 linen. This is best done after it has been rolled into the coils. 
 It is then sterilized hy toiling in clear water, and unlike the 
 silk and linen, it does not deteriorate in boiling, so a generous 
 amount of time may be given it. It should then be stored in 
 a 1-60 carbolic acid solution. Alcohol should not be used for 
 this storage, as silkworm gut has a tendency on its own account 
 to be brittle and alcohol Mill encourage this tendency too much. 
 
OPERATING ROOM STERILIZATION 261 
 
 Some lots of raw silkworm gut will be inelined to crack and 
 splinter when rolled into the coils, and in this case it should be 
 soaked in water for an hour or tAvo, which will render it very 
 pliable. 
 
 Silver and Aluminum-Bronze Wire 
 
 These may he boiled any length of time in clear water. As 
 they are infrequently used, and as they are so easily sterilized, 
 it is not necessary to keep a sterile supply of them ahead. 
 
 Metal Clips 
 
 These are treated the same as the wire. 
 
 Factory-Prepared Suture Material in Glass Tubes 
 
 The factory-prepared suture material is usually put up in 
 hermetically sealed tubes (Fig. 56). Some of these tubes may be 
 sterilized hy hoiling, but some may not ; so, before attempting to 
 boil any of them it must be de- 
 termined whether or not it is 
 safe — the manufacturer will 
 usually caution against boiling 
 if it injures his product in any 
 way. Besides the fact that boil- 
 ing the tube sometimes ruins the 
 contents there is the danger with 
 any tube that it may explode in 
 the sterilizer. AVe have seen this 
 happen with a rather serious re- Fig. 56.— Factory-prepared 
 
 suit on an occasion when a large gUss'tube^'^''""'"^'^'^^ ^^'^'^^'' 
 number of the tubes were being- 
 boiled together and the most of them were suddenly blown out of 
 the boiler with a loud report, carrying a heavy cover before 
 them, and scattering themselves in hundreds of pieces about the 
 room. However, boiling of these tubes is a very common practice 
 and it is very convenient, but the precaution should alwaj^s be 
 taken to wrap them in a cloth cover as this will prevent the 
 
262 TEXTBOOK OF SURGICAL NURSING 
 
 probability of Iheir bring t'rai'ked by being knocked about iu 
 vigoronsly-b oiling ^\•alel^ Avliit'li is i)robably about tbe only cause 
 of tbe explosion. 
 
 A perfectly safe "way to sterilize these tubes is, of course, the 
 chemical one. It does not matter much which particular chem- 
 ical is selected as long as perfect sterilization is secured. 
 
CHAPTER XVI 
 THE OPERATING ROOM IN ACTION 
 
 PREPARATION OF THE ROOM FOR THE OPERATION 
 
 You now know in a general way how to provide what you are 
 likely to need for the average operation, and we can proceed to 
 the detailed preparation of a room. 
 
 First of all, absolute cleanliness of the room in every respect 
 must be attended to. Doors and windows must be so adjusted as 
 to prevent draughts and the entrance of dust, and the tempera- 
 ture regulated at about 75° or 76° F. 
 
 The glass and other articles which must be sterilized chem- 
 ically are ''put to soak" (the bichloride tub which we advised 
 above will serve well here) ; the various odds and ends and the 
 parcels of sterile supplies which will be needed for the particu- 
 lar case- are placed in convenient readiness; boilers are filled 
 with the articles which belong in them and are started boiling; 
 and you then proceed to the sterilization of your hands. 
 
 This, of course, you will do in the dressing room. First, you 
 will put on your cap and mask, as you cannot do it safely after 
 your hands are sterile, and no one else can do it satisfactorily 
 for you. Next, you scrul) your hands and arms by means of a 
 brush, green soap, and warm running water, scrubbing from 
 the elbows downward and continuing the process carefully and 
 painstakingly for at least 5 minutes, taking special care to clean 
 thoroughly about the nails with the nail cleaner. The brush and 
 nail file you have previously boiled and brought to the dressing 
 room in a small sterile basin of alcohol, a 1-60 carbolic solution, 
 or any other suitable solution. The scrubbing completed, you 
 will continue the sterilization of your hands by some such method 
 as these: (a) Rinse off the soap thoroughly, allowing the water 
 to run from the hands toward the elbows rather than in the oppo- 
 site direction so as to avoid the possibility of rinsing contamina- 
 
 263 
 
264 TEXTBOOK OF SURGICAL NURSING 
 
 tiou from the iimvashed upper arm dowmvard over the hands; 
 rinse in ak-oliol ; and then innnerse the arms and liands in a 
 1-1000 solution of bichloride fen- 3 minutes. When bichloride is 
 used the greatest care must alwaj^s be taken to have absolutely 
 all tlie soap removed as bichloride cannot penetrate it and there- 
 fore will never reach the skin, (h) After rinsing put a small 
 quantity of chloride of lime and the same amount of powdered 
 washing soda into the palm of j^our hand, make a lather of this 
 with a little water and rub the arms and hands witli it for a 
 minute or two ; then rinse this off in a basin of sterile water and 
 immerse the arms and hands in the bichloride for 3 minutes. 
 
 There are manj^ other methods which you may learn from time 
 to time, but these two are as thoroughgoing and as convenient 
 as any. 
 
 You now put on the sterile gown, having some unsterile person 
 fasten it for you, and you are ready to go into the operating 
 room. 
 
 All of the tables whicli are to be used for sterile supplies have 
 been '^dusted" with a towel wrung out of bichloride solution. 
 If you have an unsterile assistant she may do this for you, or 
 you may have done it previously yourself. The practice of doing 
 this after the sterile gown has been put on is not technically 
 good as there are too many chances of its being unsterilized in 
 the process. 
 
 Your next step is to drape the tables with the sterile towels, 
 and to put upon them the sterile supplies which you have boiled 
 or otherwise sterilized. In draping tables it h a good practice 
 to cover them first with towels wrung out of the bichloride solu- 
 tion, as the wet towels stay in place better than the dry ones, 
 and more than one laj^er of cover should always be used on a 
 sterile table because there may often be unnoticed holes in the 
 towels. The supplies should, of course, be kept well covered with 
 towels or a suitable sheet. 
 
 There are innumerable details in connection Avith the arrange- 
 ment of the various supplies such as suture material, instru- 
 ments, etc., but a large volume would be required to record them 
 all, and then it would be impossible to provide for all the varia- 
 tions that will be dictated from time to time by the arrangement 
 
THE OPERATING ROOM IN ACTION 265 
 
 of the room, the nature of the operation, etc. If you use the 
 drums for your supplies your task will be relatively simple, 
 but you will always need to draw upon your ingenuity in oper- 
 ating room work, and if you have given careful attention to 
 your training up to this point you should now be able to adapt 
 your methods to any given average set of conditions. 
 
 We shall now assume that you are ready for the patient. 
 
 The anesthetizing room should be in complete readiness as to 
 supplies needed there, temperature, etc., and the precaution 
 should always be taken, where possible, to have this room so 
 closed off from the operating room that the patient will not be 
 subjected to the sometimes terrifying sight of the preparation 
 you have made for him. Of course, when the operating room 
 must serve also as the anesthetizing room this cannot be 
 managed. 
 
 In the chapter on anesthesia (Chapter XIII) the care of the 
 patient has been discussed, so we shall not give that here. 
 
 After the patient has been anesthetized the next steps will 
 be to arrange him in the proper position for his operation, to 
 sterilize the operative field, and then to apply the sterile draping 
 sheets and towels. In some cases, wdien gas or gas and oxygen 
 are the anesthetics used, the patient may be entirely prepared 
 and draped before the anesthetic is administered, but this prac- 
 tice is likely to be very hard for the patient to undergo, and 
 it is usually unsatisfactory because of the fact that the position 
 and the draping are usually more or less disarranged by the 
 struggling of the patient which is always attendant upon the 
 induction of any anesthesia. 
 
 PREPARATION AND STERILIZATION OF THE OPERATIVE 
 
 FIELD 
 
 How this is done will depend upon the part to be sterilized 
 and upon the surgeon's preference of method. (For further 
 detailed discussion of the preparation of the operative field see 
 treatment of particular cases in Chapters IV-XI.) At this writ- 
 ing the prevailing practice, as far as the operating room is con- 
 cerned, is to have the part dry-shaved and then to paint it with 
 
266 TEXTBOOK OF SURGICAL NURSING 
 
 iodine, sometimes preceding the iodine with a sponging with 
 ether. As a rule the shaving will have to be done before the 
 patient comes to the operating room, and this is the better 
 technic. The point that all parts which are to be painted with 
 iodine should be perfectly dry must not be overlooked, because 
 it is a fact that the iodine does not penetrate as deeplj' into skin 
 that has been recently wet as it does into the normally dry skin, 
 and furthermore, it is believed that the presence of an abnormal 
 amount of water in the skin renders it more susceptible to the 
 somewhat irritating power of the iodine. This means that all 
 operating room shaving will be done dry, because it is perhaps 
 not overcautious to make the rule that the lather should not be 
 used within the 12 hours preceding the iodine application. 
 
 Some parts of the hody, the face for instance, as a rule are 
 not subjected to the iodine, but instead are scrubbed with green 
 soap and rinsed with alcohol and perhaps also with bichloride. 
 For children, old people, or others whose skin might be too much 
 irritated by the full-strength tincture of iodine, it is diluted to 
 half strength, and sometimes less, by the addition of alcohol. 
 
 A simple way to apply the iodine is by means of a small gauze 
 sponge held in a pair of forceps, preferably sponge forceps, but 
 care must always be taken not to use so much iodine that it will 
 trickle down under the patient's body or into the axilla or any 
 other part where it may be confined in the presence of moisture 
 and cause troublesome burns. Sometimes the iodine will be 
 sponged off with alcohol immediately after it has thoroughly 
 dried. 
 
 OPERATIVE POSITIONS AND DRAPING 
 
 It is something of an art to arrange the patient in a good and 
 stable position and to place the sterile draping so that it will 
 be unobtrusive and at the same time serviceable and durable. 
 Anyone can lay towels and sheets around an operative field, but 
 it takes study and ingenuity to do it well. Likewise, there are 
 many points about the various positions of the patient, which, 
 to be appreciated, must be studied and practiced carefully. 
 
 "We shall now take up the representative operative positions 
 and the sterile draping suitable for them. When not definitely 
 
THE OPERATING ROOM IN ACTION 
 
 267 
 
 mentioned it will, of course, be understood that the operative 
 field has heen sterilized immediately after the position has been 
 arranged and before the sterile draping is adjusted. 
 
 Also, as it will be monotonous to mention it each time, we shall 
 here lay down the rule that a rubber sheet will be thrown over 
 the patient, table, sandbag, etc., in any place where there is 
 likely to be much drainage from the operative field. 
 
 Dorsal Position. — This is the most frequently employed po- 
 sition (Fig. 57), and it will be used for most operations upon the 
 intestines, stomach, pancreas, spleen, and bladder. In some 
 
 Fig. 57. — Dorsal Position. The pillows under the back and thighs are 
 for the greater comfort of the patient and for the relaxation, of the ab- 
 dominal muscles. 
 
 cases the patient is simply placed flat upon the back, but in 
 others there will be a small pillow under the ''small" of the 
 back and a larger one or a small sandbag under the thighs as 
 shown in the illustration. The pillow under the back will be 
 especially desirable for women, whose backs naturally curve 
 more than men's, and it will serve the purpose of preventing 
 the severe backache which so frequently complicates convales- 
 cence from a long abdominal operation, because it keeps the 
 muscles of the back in their natural position and prevents the 
 abnormal strain which would otherwise occur. The pillow under 
 the knees causes relaxation of the abdominal muscles which 
 results in much less strain upon them and thus enables the sur- 
 
268 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 geon to retract tliem out of his way more easily and with less 
 injury to them when doing an abdominal operation. The arms 
 may be arranged in various ways but these two will answer all 
 purposes for this position: («) They may be fastened at the 
 patient's side by means of a folded towel (Fig. 58), w^hieh is 
 passed across the table under the joatient's back and an end 
 pinned about each forearm, or an end turned over each arm and 
 then lucked under the patient's body. (&) They maj' be laid 
 against the chest Avith the hands well outward on the shoulders 
 
 Fig. ^8. — AIe'ihuu of J-'astexing the Arms at the Patient's Side. 
 The towel is passed under the patient 's body crosswise of the table, and the 
 end is carried around the wrist and then tucked under the body. 
 
 (Fig. 59), the sleeve pinned to the shoulder of the gown, and 
 the tail of the gown tucked about them to hold them in place. 
 The arms are less obtrusive, as a rule, when hnng at the patient's 
 side, but there are many operations in which this practice is 
 technically quite unrefined, for instance, abdominal or other 
 trunk cases in which pus, irrigating solutions, etc., may run 
 down over the arms and hands thus placed. 
 
 The sterile draping for this position is relatively simple and 
 is done in one of two ways: (a) The laparotomy sheet described 
 on page 227 is laid over the patient very carefully (Fig. 60), 
 two people being almost necessary for this act in order not to 
 
THE OPERATING ROOM IN ACTION 
 
 269 
 
 run the risk of dragging the sheet over the patient and thus 
 unsterilizing it underneath in parts which may later be drawn 
 up into the operative field. There are several fancy ways in 
 
 Fig. 59. — Method of Fastening the Arm>s ox tiik Chest. The sleeve 
 of the gown is pinned well outward on the shoulder, and the tail of the gown 
 is then brought up over the arms and securely tucked under the patient's 
 body. 
 
 Fig. 60. — Laparotomy Sheet in Place for an Abdominal Operation. 
 If the opening in the sheet is larger than necessary for the particular ease 
 this sheet may be supplemented with towels as shown in Fig. 61. 
 
 which this sheet is sometimes folded before sterilization so that 
 one person can apply it, but they require a great deal of time, 
 and as there is always more than one person sterile for any 
 
270 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 Fig. 61.— Draping for the Dorsal Position with Two Sheets and 
 Pour Towels. One sheet is laid across the lower part of the table and the 
 edge brought up to the lower border of the operative field, and the other 
 over the chest similarly. The towels are then disposed over these as illus- 
 trated, the crosswise towels lying on top of the lengthwise ones for greater 
 security. One of the towel clamps shown in Fig. 82 binds these towels and 
 the underlying sheets securely together at each corner of the operative field. 
 
 Pjq_ 62. — Two Types of Towel Clamps, Used foe Holding the Drap- 
 ing Sheets and Towels Together. The sharp-pointed clamp is usually 
 passed through the patient's skiii as well as the draping. 
 
THE OPERATING ROOM IN ACTION 
 
 271 
 
 Fig. 63. — Trendelenburg Position. The pillows under the patient's 
 back and thighs serve the same purpose as in the dorsal position (Fig. 57). 
 The shoulder guard, shown more clearly in Fig. 64, keeps the patient from 
 sliding. 
 
 Fig. 64. — Shoulder Guard for Keeping the Patient in Place in 
 THE Trendelenburg Position. The guard is made entirely of metal, and 
 as it sometimes injures the patient 's shoulder it is advisable to wrap it 
 with cotton and a bandage as has been done to this one. 
 
272 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 operation Avliere this sheet will be appropriate an assistant can 
 always be found ; or, if carefully done there can be no objection 
 to an unsterile person handling the end which is placed under 
 the patient's chin because this is unsterilized immediately in 
 any case. (6) Tioo sheets and i towels may be arranged as in 
 Fig. 61. It should be noticed that the towels which run length- 
 wise of the patient are put on first and the crosswise ones laid 
 over them, because this is the much more secure way and it 
 brings the towel edges into positions where they will be less 
 
 Fig. 65. — Gall Bladder Position. This table has a crosswise rest which 
 may be screwed up under the gall bladder region so as to throw it well 
 upward. In lieu of this a small sandbag will serve the purpose. See also 
 Fig. 66. 
 
 likely to cause annoyance by catching upon instruments or by 
 being brushed out of place by the arms of the surgeon and assist- 
 ants. The two crosswise towels will keep the draping in place 
 much better if they are wet, but if the operative field has been 
 painted with iodine there may be objections raised to the use 
 of wet towels here. A towel clamp (Fig. 62) or some substitute, 
 such as an ordinary artery clamp, will be needed at each of the 
 four corners of the field to keep the draping in place. 
 
 Trendelenburg Position. — For this position (Fig, 63), the 
 patient is first placed in the dorsal position, the foot section of 
 the table is dropped, and the whole table top is then inclined, 
 
THE OPERATING ROOM IN ACTION 
 
 273 
 
 with the foot upward, at an angle of 45° or less, care having 
 been taken to have the patient's knees exactly opposite the 
 hinge of the footpiece. It will be necessary to have the patient 
 braced in some way at the shoulders so as to prevent his slipping 
 downward. All the better tables will have shoulder guards 
 (Fig. 64) for this purpose, but in their absence sandbags will 
 serve well. 
 
 The pillows under the back and knees will serve the same 
 purpose here as in the dorsal position. The hands and arms will 
 be arranged as for the dorsal position. 
 
 Fig. 66. — Gall Bladder Position. This particular table can be broken 
 under the gall bladder region so as to accomplish the purpose of the rest 
 shown in Fig. 65. 
 
 This position will be used in gynecological or other pelvic 
 operations as it causes the intestines to gravitate out of the way 
 and also brings the pelvic contents up from the bony cavity in 
 which they would otherwise be more or less inaccessible. 
 
 The draping is the same as for the dorsal position. 
 
 On page 411 is illustrated a method for improvising this posi- 
 tion when without the convenience of the special table. 
 
 Gall Bladder Position. — In some cases the dorsal position will 
 answer for operations upon the gall bladder, but oftener the 
 region will have to be thrown upward (Fig. 65) so as to bring 
 
274 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 the organ out from under the ribs. If your table is not supplied 
 with the ' ' rest ' ' shown in the illustration a pillow or small sand- 
 
 FiG. 67. — Kidney Position. A, rear view showing the disposal of the 
 one arm and the elevation of the patient's waist line to about the level of 
 the hips; B, front view showing where the other arm rests and how the 
 sandbags are best placed for stabilizing the patient in the proper position, 
 which is slightly forward of the true lateral position. 
 
 bag will answer the purpose; or, you may have a table which 
 
 can be broken in the middle directly under the gall bladder 
 
 region (Fig. 66) which will accomplish the same purpose. 
 
THE OPERATING ROOM IN ACTION 275 
 
 The draping will be the same -as for the dorsal position. 
 
 Kidney Position. — The patient is turned on his side (Fig. 
 67) with the lower arm at his back, the other up toward his face, 
 the uppermost knee and hip joints flexed so as to bring the knee 
 down upon the table in the capacity of a brace to keep the body 
 from falling forM^ard, the chest is braced anteriorly with a large 
 sandbag, and sometimes the pelvis also will need the support 
 anteriorly of a heavy sandbag. The crosswise rest is now 
 screwed upward directly under the location of the kidney so 
 
 Fig. 68. — Prone Position. The patient lies flat upon his face except 
 for one shoulder which is elevated slightly upon a small sandbag so as 
 to turn his face away from the table sufficiently for the administration of 
 the anesthetic. Some tables may be broken at the head so as to accomplish 
 this purpose without the sandbag, or, the arrangement shown in Fig. 83 
 may be used. 
 
 as to throw the organ as well outward and upward as necessary 
 from under the ribs. Foresight should be used in seeing that 
 the patient is properly placed in relation to this rest before any 
 of the preceding adjustments are made so that the raising of it 
 will not disarrange the position. When properly arranged the 
 patient will incline very slightly toward his face from the true 
 lateral position. 
 
 This is the most difficult position to arrange and a great deal 
 of practice should be devoted to it by the beginner. 
 
 The draping corresponds to that for the dorsal position. 
 
 Prone Position. — The patient lies flat upon the table with the 
 face downward and the arms above the head (Fig. 68). Spe- 
 
276 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 cial care of the head must be taken in an-aiiyin«j; this position; 
 some tables will be so constructed that a section at the liead may 
 be lowered somewhat to allow the patient's head the required 
 
 ^^Sim 
 
 Fig. 69. — LATEKo-i'KnXK I'dsiTiox. The patient is inclined about half 
 way between the lateral and the prone positions, and tlie sandbags under 
 the chest and the hips, and his flexed knees, stabilize him. 
 
 Fig. 70. — Eeversed Tkendelenburg Position. 
 
 room, but in place of this a small pillow or sandbag may be 
 placed under one shoulder. 
 
 This position will be used for operations upon the spine or 
 other parts of the back. 
 
 The dorsal draping may be adapted to this position. 
 
THE OPERATING ROOM IN ACTION 
 
 277 
 
 Fig. 71. — Sims Position, Showing the Use op One Sheet for Draping. 
 The patient inclines slightly forward from the lateral position, has his 
 knees drawn upward, and if he is under an anesthetic he will need a sandbag 
 against his hips and chest to stabilize him. 
 
 Fig. 72. — Lithotomy Position, Sho^nj.xu the Use of the Table Stirrups. 
 
278 TEXTBOOK OF SURGICAL NURSING 
 
 Latero-Prone Position. — This Avill be used for operations 
 upon the chest (Fig. 69). The body is turned about half way 
 between the lateral and the prone positions, and the chest and 
 hips rest against sandbags, the lower arm lying at the back 
 and the other upward toward the face. 
 
 The elorsal elreipiug is adaptable to this position. 
 
 Reversed Trendelenburg. — In this position the patient is 
 
 Fig. 7.3. — Draping avith a Sheet and Towels in the Lithotomy Posi- 
 tion. The blunt towel clamp shown in Fig. 62 will be needed to keep the 
 sheet in place at each heel and to bind the sheet and towels together about 
 the stirrups. 
 
 placed upon the table face downward with the hip joints di- 
 rectly over the line at which the foot section of the table breaks, 
 with the arms over the head. Screw the table upw^ard as in 
 the Trendelenburg position, allowing the foot to drop at the 
 same time (Fig. 70). The patient will be so well balanced in 
 this position as a rule that the shoulder guards will not be 
 needed. 
 
THE OPERATING ROOM IN ACTION 
 
 279 
 
 This position will be used for some operations upon the rectum. 
 
 The principles of the dorsal draping will apply here. 
 
 Sims Position. — This will be used occasionally for examina- 
 tions of the rectum. There is no essential difference in the ar- 
 ranr-ement of the patient's body between this position and the 
 
 Fig. 74. — Dkapixg with the Lithotomy Towel and Stockings for 
 THE Lithotomy Position. A blunt towel clamp will be needed at either 
 edge of the towel near the top to keep it in place. If this towel is wet 
 it will stay in place better. 
 
 latero-prone one, except that the patient will lie on the left 
 side. 
 
 As the draping will rarely ever need to be sterile the way in 
 which it is done is not important, but Fig. 71 will show how it 
 may be done with one sheet. 
 
 Lithotomy Position. — ^For this position (Fig. 72) some kind 
 of leg supports will be needed. Metal ones called stirrups 
 (see illustration) will doubtless be supplied with your table, 
 but if not, one of the devices which we describe iu Chapter XXI, 
 
280 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 page 412, under improvised positions for operations in the 
 home may be used. The stirrups are put into place, the foot 
 of the" table is dropped, the patient's feet being held meantime, 
 the i)atient is drawn down so that the buttocks project slightly 
 over the end of tlic table, and the legs are then fastened up- 
 ward and backward so as to throw the knees well backward 
 toward the abdomen. Sometimes a sandbag may be placed 
 under the buttocks to adjust the position of the pelvic organs, 
 
 Fig. 75. — Breast Position. A small sandbag- will be necessary under 
 the shoulder, if the axilla is involved, to throw the part away from the table. 
 Note the wire arch, the Kocher guard, which extends across the table in the 
 plane of the patient's shoulders. A di'aping sheet thrown across this iso- 
 lates the anesthetist from the operative field. (See Fig. 77.) 
 
 or, for the same reason, the foot of the table may be slightly 
 elevated as in the Trendelenburg position. A Kelly pad or a 
 rubber sheet must always be used over the end of the table. In 
 this position the arms will have to be arranged at the chest. 
 
 The lithotomy position will be used for some gynecological^ 
 gemtourinary and rectal operations. 
 
 The draping may be done with a sheet and towels (Fig. 73), 
 or, better, with the lithotomy stockings and towel (Fig. 74) 
 described on page 231. 
 
 Breast Position. — For operations upon the breast the patient 
 will lie upon her back. If the disease is malignant the axillary 
 
THE OPERATING ROOM IN ACTION 
 
 281 
 
 Fig. 76. — Method of Draping the Hand and Forearm for the Breast 
 Operation. A towel folded once crosswise is thrown over the hand and 
 is then bound about the wrist with a towel folded lengthwise into a narrow 
 strip and applied like a bandage. The remainder of the forearm is cov- 
 ered in this fashion, two or more towels being needed to make the draping 
 secure, and a towel clamp serving to bind the end. (See Fig. 77.) 
 
 Fig. 77. — Draping for Breast Position. 
 
282 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 glands will be removed as well as the breast, and in this ease the 
 arm on the affected side must be free. Usually a small pillow 
 or sandba<g will be placed under the shoulder on this side to 
 throw the axilla well up from the table (Fig. 75). fhe unin- 
 volved arm may be placed either at the side or on the chest. 
 
 For a simple breast, operation the dorsal draping will apply. 
 When the axilla is involved, however, the draping is more com- 
 plex and may be done as follows : After the operative field has 
 been sterilized the patient's head and shoulders are liftud, a 
 
 Fig. 78. — DF.TAciiAin.E Arm Eoard Supplied with the Table. 
 
 rubber sheet is spread under the shoulders and over the side of 
 the table by an assistant, and a sterile sheet is then passed 
 under the shoulders so that the table is well covered in the re- 
 gion of the axilla ; the hand and forearm, which have been held 
 by an unsterile assistant, are then covered with sterile towels, 
 beginning at the hand with one which is folded once cross- 
 wise, making a nearly square cover which is allowed to fall in 
 folds about the wrist, and continuing from the w^rist to the oper- 
 ative field with towels folded lengthwise, bandage fashion (Fig. 
 76), Wet towels are better for this purpose as they stay in 
 place better. The general principles of the dorsal draping may 
 
THE OPERATING ROOM IN ACTION 
 
 283 
 
 then be applied, the arm and the axilla being, of course, a part 
 of the operative field (Fig. 77). 
 
 There is an attachment supplied with the more complete 
 tables which will be very useful in the breast case — it is the 
 Kocher guard, and it is simply a semicircular piece of soft 
 metal which is fitted vertically across the table in about the 
 plane of the patient's chin (see Figs. 75, 76 and 77), and serves 
 the purpose of holding the upper sterile sheet well up between 
 the operative field and the anesthetist. This is a very service- 
 
 FiG. 79. — Simple Long, Narrow Board which IMay Be Fitted to Ant 
 Table as an Arm Board. 
 
 able attachment, and if not supplied with the table may be 
 very easily improvised. There are other devices designed to 
 serve the same purpose but the Kocher guard is adaptable to 
 a greater variety of positions as it is made of soft metal and can 
 be bent into any desired shape (see adaptation of it for neck 
 cases in Fig. 85, page 289). 
 
 Arm Position. — Many hand and arm operations can be done 
 with the part simply laid upon the patient's body, but often a 
 small table will be needed, an arm board which is supplied with 
 some" tables may be attached (Fig, 78), or a simple long, narrow 
 board may be used as illustrated in Fig. 79. 
 
 The laparotomy sheet will serve well in some cases for draping, 
 
284 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 the arm being simply slipped through the opening and un- 
 sterile parts of the arm wrapped with towels as described for 
 the breast, case (Fig. 76), or two sheets may be arranged as for 
 the leg (see Fig. 80), any uninvolved part of the arm or hand 
 being wrapped with towels, as just described. 
 
 Leg Positions. — A great variety of positions will be em- 
 ployed from time to time for operations upon the various parts 
 of the feet and legs, depending upon whether the anterior or 
 the posterior aspect or both must be accessible. The simple 
 
 Fig. 80. — Use of Stirrups for Operations upon the Leg. 
 
 dorsal position with a sandbag under the heel will answer for 
 the anterior aspect of the leg and for the foot except when the 
 heel is involved, in which case it may be necessary to turn the 
 patient either upon his side or his face, and in this latter posi- 
 tion, of course, the posterior aspects of the legs are also ac- 
 cessible. 
 
 Another plan which gives access to all parts of the feet and 
 legs is to suspend them from the tahle stirrups which are used 
 for the lithotomy position (Fig. 80). This position applies 
 especially well in the case of operations for the removal of 
 numerous and scattered varicose veins. 
 
THE OPERATING ROOM IN ACTION 
 
 285 
 
 The draping for leg cases is difficult, but two large sheets and 
 a few towels will answer all needs. The parts are, of course, 
 first sterilized and the necessary sandbags and rubber sheets 
 put into place, and then, while a sterile assistant holds the 
 
 HRBBPB'^HH 
 
 HP 
 
 HHP^ 
 
 1 
 
 ^ Ti?^W 
 
 
 A 
 
 m. 
 
 
 ' _c^-' 
 
 .. \ A 
 
 ' \ 
 
 
 V 
 
 
 
 Fig. 81. — Draping for Leg Operations. One sheet is used under the 
 legs and one thrown over the patient 's trunk and allowed to meet this, and 
 the two clamped together. Considerable slack should be allowed in the 
 lower sheet as otherwise the draping will be disarranged when the legs are 
 moved about during the operation. 
 
 Draping for a Face Case. 
 
 legs, a sterile sheet is passed underneath them over the entire 
 foot of the table and well upward to the border of the operative 
 field; another sheet is thrown over the patient's trunk and down- 
 ward to meet the other one, and the edges of the two are then 
 clamped together both between the legs and on the outside (Fig. 
 
286 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 81). Extra towels may, of course, be placed upon the sheet 
 underneath the parts if thought necessary for safety. 
 
 When the feet are not included in the operative field they 
 must be well wrapped in towels after the fashion advised for 
 the hand (Fig. 76), or, a very convenient plan is to use a heavy 
 white cotton sock or stocking which can be securely clamped 
 at the edge the same as the towel. Any uninvolved part of 
 the leg should also be covered. When only one leg is involved 
 
 J^'iG. «;i — Arrangement of Patient in the Prone Position on a Spe- 
 cial Head Eest for Operations Upon the Back of the Head or Neck. 
 Some such method is necessary when it is essential to the surgeon that the 
 head be not turned as it would need to be were it lying upon the table. 
 
 the only variation will be that the other will simply be covered 
 with the lower sheet. 
 
 When the stirrups are used they may te sterilized ly 'boiling 
 if a sterilizer large enough for them is available, and otherwise 
 they may be wrapped in sterile towels. 
 
 Head Positions. — In practically all head cases a small sand- 
 bag will be needed under the head, because otherwise it will not 
 be stable. This will simply be so adjusted as to make the oper- 
 ative field most accessible. 
 
 For the face and mouth (tonsils, etc.) and the front and top 
 
THE OPERATING ROOM IN ACTION 
 
 287 
 
 of the skull the patient's body will be in the 'dorsal position and 
 the head turned as necessary. 
 
 For operations upon the face the draping will be done as 
 follows: The patient's head and shoulders are held up and a 
 sheet with a wet towel laid upon it is passed underneath so 
 that the sheet will extend well up under the shoulders and the 
 towel will come into position directly under the head which is 
 
 Fig. 84. — Folded Towel Clamped About the Face to Protect the 
 Operative Field from the Inhaler in Face, Neck, or Skull Qperations. 
 
 now laid upon the towel. This wet towel is then wrapped and 
 clamped securely around the head and hair (Fig. 82), a sheet 
 is thrown over the patient's body and clamped about the neck 
 to the lower sheet. 
 
 In all operations about the head it is advisable that the anes- 
 thetist be supplied with a sterile ether mask, sterile gloves, and 
 a sterile cover for his ether can, unless, of course, the vapor 
 method of administering the anesthetic is used, in which case 
 the unsterile apparatus may be carried out of the way by means 
 of its rubber tubing. 
 
 For the hack of the head the position just described may an- 
 swer, the simple prone position may be used, or the patient may 
 
288 TEXTBOOK OF SURGICAL NURSING 
 
 have to be placed in the prone position and some such device 
 as is shown in Fig. 83 added for the convenience of the anes- 
 thetist. This last position, of course, involves the special equip- 
 ment of the head rest, but a small table or some other article 
 of furniture may be adapted. 
 
 For all head cases the arms should he arranged at the pa- 
 tient 's side. This is a somewhat strained position for them when 
 the prone position is used but they will be too much in the way 
 over the head. 
 
 The draping for an operation upon the skull when the patient 
 lies upon his back or in the simple prone position will be done 
 thus: The usual sandbag and rubber sheet are first adjusted, 
 the patient's head is held from the table and sterilized, a sterile 
 sheet is passed well under it, and the head may then be laid 
 upon this, after w-hich the top sheet is applied and a folded 
 towel clamped about the face as shown in Fig. 84 to isolate the 
 anesthetist. When the special head rest is used one sheet thrown 
 over the patient and clamped about the neck and the folded 
 towel about the face wall be about all the draping necessary. 
 
 One or two metal face guards are made specially for sepa- 
 rating the operative field and the inhaler in such cases, but 
 draping with them wall be easy if one can do it as just de- 
 scribed. 
 
 For nose and throat operations done under local anesthesia, 
 with the patient sitting in a chair, a towel about the head and 
 one sheet thrown about the patient and clamped together at the 
 back of the neck will usually suffice. 
 
 Neck Positions. — The sandbag and the rubber sheet will al- 
 ways be used as for the head cases, but the head will usually 
 be thrown further back, particularly w^hen the operation is for 
 goiter; and, of course, well to one side for cervical gland cases. 
 
 As in all operations about the head, the problem of isolating 
 the anesthetist is an aw^kward one to solve, but where the Kocher 
 guard is available it may be so bent and draped as to make a 
 technically perfect arrangement and a reasonably convenient 
 one for all concerned (Fig. 85). In this case, after the neck has 
 been sterilized a sterile sheet is passed under it and the shoul- 
 ders; another sheet is then thrown over the patient's body and 
 
THE OPERATING ROOM IN ACTION 289 
 
 Fig. 85. — The Kocher Guard Adjusted and Draped so as to Isolate 
 THE Anesthetist in Operations upon the Neck. 
 
290 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 the edge passed about the neck and clamped at the back, A 
 third sheet is then thrown over the Koeher guard and clamped 
 about the .neck also. This latter clamp is best adjusted by an 
 unsterile person on the anesthetist's side of the guard. There 
 are other designs of guard Avhieh are very suitable for this pur- 
 pose of isohiting the anesthetist, but it is not necessary to enu- 
 merate them, for if one can adjust the 
 Koeher guard satisfactorily the others 
 will not be puzzling. 
 
 When a guard is not used the pro- 
 cedure should be in general as de- 
 scribed for face cases, including care- 
 ful isolation of the anesthetist. 
 
 When there is a separate anesthetiz- 
 ing room the preparation and draping 
 are best done there and the table rolled 
 into the operating room fully prepared 
 for the surgeon. It will thus be seen 
 that convenience will require that the 
 sterile preparation and draping sup- 
 plies be stationed in the anesthetizing 
 room. AA^ith the drum system this 
 will be easy, but otherwise it will be necessary to have a sterilly 
 draped table for the purpose ; or, if conditions do not make this 
 possible or safe a small stand (Fig. 86), which is easily carried 
 may be prepared for each individual case and carried into the 
 preparation room each time. 
 
 Fig. 86. — Portable Dress 
 ING Stand. 
 
 THE OPERATION 
 
 It "will not be possible to do more than barely outline the 
 procedure of the nursing staff during an operation, because 
 there are so many minor details which will differentiate almost 
 every operation from every other. 
 
 In general, however, especially where a number of opera- 
 tions are done in immediate succession, there should be a rec- 
 ognized head nurse who will be responsible for the general 
 
THE OPERATING ROOM TN ACTION 291 
 
 management of the nurses' end of the work, and for the dis- 
 pensation of the sterile supplies as needed. As the sterile sup- 
 ply drums or tables must serve for all the cases it is evident 
 that no person but an absolutely sterile one can draw supplies 
 from them, and this makes it obligatory that one nurse, prefer- 
 ably the head nurse, do nothing but serve as the connecting link 
 between these supplies and those who use them. This means 
 that she never touches anything that has been in contact with 
 any case, because, of course, no matter how "clean" a given 
 operation may be it is not considered clean in relation to any 
 other, and this nurse must serve as the guardian of every pa- 
 tient's right to the benefit of every doubt. This may seem 
 like overdoing the matter, and if every nurse on the staff were 
 highly experienced perhaps it would be, but it must be remem- 
 bered that the operating room, like the wards and every other 
 nursing department of the hospital, is a training school, that 
 inexperience is rampant, and that, therefore, many sacrifices 
 must he made to the cause of education, and many otherwise un- 
 necessary precautions taken against the dangers of inexperience. 
 
 We have already pointed out, but it needs repetition, that 
 handling of sterile supplies must &e kept at the absolute mini- 
 mum; and furthermore, nothing that can be handled with for- 
 ceps should be touched with the gloves, for the very good reason 
 that an instrument can be made sterile and kept so with much 
 greater certainty than a pair of gloves on the two hands of any 
 given, and very busy, human being. 
 
 The numler of assistant sterile nurses will be determined by 
 circumstances, but as a rule, in large institutions especially, one 
 or two others may be present to help about the wound in the 
 way of holding retractors, etc. An unsterile nurse to do er- 
 rands will be useful; and this is logically the lesson with which 
 a beginner should be initiated into the mysteries of the operat- 
 ing room in action. 
 
 One or more orderlies will be necessary about an operating 
 room to do the heavy lifting and other heavy work which nurses 
 cannot do. Other duties for orderlies will vary with local 
 conditions. 
 
 Management hetween operations should be well thought out, 
 
292 TEXTBOOK OF SURGICAL NURSING 
 
 and the ease and despatch Avith which the Avork of this period 
 is done will depend almost entirely upon the number of as- 
 sistants. It may not be possible for the head nurse to remain 
 sterile at this time because it is likely that her staff will be di- 
 vided between the patient just finished and the one to follow 
 and she will, therefore, need to do some of the unsterile work 
 between operations. 
 
 Too much haste must he avoided during the period of re- 
 sterilization between operations, and special precautions must 
 be taken, of course, after an infected case. Everything that has 
 been used or subjected to contamination in any way must be 
 rehoiled or discarded, all soiled linen removed, the floor basins 
 emptied, and the floor mopped. Where possible the patient 
 should have been taken to another room (the recovery room), 
 or at least a distant corner of the operating room, before blankets 
 are applied or other preparations made for the transference of 
 the patient to his bed, as a great deal of dust may be raised in 
 this process and other unsterile things scattered about. Gown, 
 or apron, and gloves are of course changed, and before the fresh 
 ones are put on the hands should be rinsed in the bichloride or 
 other solution again, because it is rarely possible that one has 
 avoided contact with the soiled gloves or goAvn in the act of 
 their removal. 
 
 Attention should be called here to an item which is often 
 overlooked, namely, that if the operating table has been sub- 
 jected to contamination in an operation it must not be used 
 again till it has been thoroughly cleansed. In cases of known 
 infection it may be protected in advance by putting rubber 
 sheets in strategic places, but contaminating drainage cannot 
 always be foreseen, and the operating table, because of its many 
 corners and crevices, may become through such cases a very 
 active carrier of infection. 
 
 AFTER THE OPERATION 
 
 It will be the practice to operate upon the patients of any 
 given group in such order that the cleanest one is done first 
 and the least clean one last, and so, at the end of a session the 
 operating room will be in more need of resterilization than at 
 
THE OPERATING ROOM IN ACTION 293 
 
 any time during the session. It must, therefore, have the most 
 thorough renovation at this time. 
 
 In most hospitals the laundry will be equipped and the help 
 trained to dispose of the soiled linen properly, bu.t in any case 
 the operating room nurse must see that no linen which is viru- 
 lently contaminated is carried about until it has been rendered 
 innocuous. Perhaps the best method of doing this is to soak 
 the linen for several hours in a 1% or 2% solution of formalin. 
 This disinfectant is a very active one, and it does not injure 
 the linen, but gloves should be worn for wringing it from the 
 linen after sterilization for it is highly irritating to the skin. 
 
 The floor must receive special attention, especially if infec- 
 tious material has been scattered about. In cases of known 
 serious contamination of the floor it must be flushed for a time 
 with some antiseptic solution before a maid is asked to subject 
 her hands and knees or the mop to it. Formalin will answer 
 well for this purpose, but it should not be forgotten that for- 
 malin, giving off its pungent fumes from a large floor surface, 
 will quickly make a room uninhabitable if the doors and win- 
 dows have not been previously opened. 
 
 Walls 'and all furniture, including the operating table, which 
 may have been subjected to blood stains or other contamination, 
 must be well washed ; and of course the dressing and anesthet- 
 izing rooms will be thorouglily renovated. 
 
 The instruments are washed in warm water and soap, hot 
 water being avoided as it will coagulate any blood present and 
 make it very difficult to dislodge. For the same reason clamps 
 and other jointed instruments must be taken apart for the 
 washing so as to insure thorough cleansing before boiling. They 
 should then be boiled for 10 or 15 minutes. After they are 
 boiled about all they will need to put them into good condition 
 will be thorough drying, each one being taken apart as much as 
 possible for this. If they are wiped directly from a hot water 
 bath the heat which they retain will appreciably aid in com- 
 pletely freeing inaccessible parts from moisture and thus pre- 
 vent rust. Rusted parts should be scoured gently with a fine 
 polish, such as ''bon ami," but scouring should be done spar- 
 ingly for, while it may give an instrument case a brighter ap- 
 
294 TEXTBOOK OF SURGICAL NURSING 
 
 pearance, it materially shortens the span of life of the nickel 
 plating. Delicately-jointed instruments should be oiled imme- 
 diately, and all should be provided -with a dry storage place. 
 
 The gloves are well scrubbed on both sides with soap and 
 warm water, hot Avater being precluded for the same reason as 
 for the instruments. It is even more important that blood 
 should be thoroughh' removed from gloves as the sterilization 
 will render absolutely irremovable any that may have been left 
 upon them. Before further handling they should then be 
 boiled for about 5 minutes, not being put into the water, of 
 course, till it has reached the boiling point ; and then they are 
 dried and tested for holes. The test for defects is an important 
 one, and a great deal of practice will be necessary to learn to 
 do it without oversights. It must be remembered that the 
 smallest pinhole may allow the passage of infection to the 
 wound from the hand, and that all tests must be made with 
 these in mind. A good method is to hold the cuff open, the 
 fingers of the glove being downward, in which position they 
 will be well inflated with air; then quickly grasp the edges of 
 the cuff together, confining the air which, under a little pres- 
 sure, can be felt by the cheek, for instance, escaping from the 
 smallest perforation. If the glove is in good condition gener- 
 ally, the holes should be patched, as nurses and junior staff as- 
 sistants can wear patched gloves without inconvenience. Too 
 great economy must not be exercised, however, in the salvaging 
 of torn gloves because when a glove becomes so old and life- 
 less that it tears easily it is a menace and should be thrown 
 away. Cuffs and other strong parts of badly torn gloves can 
 be utilized for the patches which should not be cut any larger 
 than is necessary to make a durable repair. 
 
 Patching is something of an art, too, but if done skillfully 
 a patch will usually outlast the remainder of the glove. It is 
 done thus: Turn the glove wrong side out — this is important 
 because the wrong side of the rubber is usually rougher than 
 the right side and the cement will therefore adhere better; 
 locate the hole accurately; cut a patch to fit; sponge both the 
 patch and the region of the hole rather vigorously with benzine 
 — this will cleanse the surfaces and at the same time somewhat 
 
THE OPERATING ROOM IN ACTION 295 
 
 roughen them ; apply a thin coat of rubber cement to the patch, 
 quickly put the patch into place, and press firmly for a few 
 moments until the cement has dried well. Note that the ce- 
 ment is better applied to the patch than to the glove, because 
 it will not be possible to estimate the exact space required on the 
 glove. A light sponging with benzine over the region will com- 
 plete the process neatly. Do not sterilize these gloves until the 
 cement has had several hours in which to dry completely. 
 
 All unused sterile supplies which have been opened must 
 be resterilized, including all drums. This may seem like an- 
 other case of overprecaution, when little has been used from 
 a parcel, but if this were not made the rule such a parcel 
 might remain in reserve too long; for it ought to be the prac- 
 tice to resterilize all supplies at least as often as once a week. 
 For this reason it is not good technic to keep more than one 
 week's stock sterilized ahead, and some system ought to be in 
 operation whereby the parcel longest in reserve should always 
 be used first. In a large establishment where it is hard to fol- 
 low every detail regularly, it is wise to mark each parcel with 
 the date of sterilization so that too old ones may be detected. 
 
 All the miscellaneous utensils used must, of course, be re- 
 sterilized before they are stored away, 
 
 CONCLUDING SUGGESTIONS 
 
 Aim to have only standard equipment, and no more of that 
 than you use. 
 
 Try to keep your methods and your entire system as simple 
 as possible. The natural tendency of operating room technic 
 is to become complex and involved and constant good manage- 
 ment is required to prevent nonessentials from superseding 
 and supplanting essentials. 
 
 Do not overstock in sterile supplies, and keep what you have 
 in circulation. 
 
 If your operating room is a training ground for pupil nurses 
 do not forget the educational phase of the work in the press of 
 routine requirements. The two can prosper hand in hand but 
 all concerned must recognize them both and someone must study 
 the system and guide it wisely. 
 
CHAPTER XVII 
 
 INSTRUMENT PASSING 
 
 As a rule there will not be time enough during the routine 
 course of training in the operating room for the nurse to gain 
 an intimate knowledge of the uses of instruments and suture 
 materials, but as she will very often be called upon after grad- 
 uation to assume the responsibility for providing the .proper 
 ohes and for officiating at the operating table as "instrument 
 passer," we shall record here a few principles which should 
 guide her in this duty, and as many details as it will seem 
 worth while for her to learn in the abstract. 
 
 The subject is a very difficult one to present on paper in any 
 other than a general way because in practice there will re- 
 peatedly arise, through preferences of surgeons and the di- 
 versities and irregularities of cases, variations in detail of both 
 instruments and technic which cannot possibly be foreseen. 
 Moreover, we have not the space here to cover, even in a gen- 
 eral way, every one of the hundreds of operations that may 
 be performed upon the human body; but we advise every 
 prospective instrument passer who wishes to work intelligently 
 and resourcefully to secure access to one of the good hooks 
 which surgeons have written on operative surgery and familiar- 
 ize herself, with the probabilities, at least, in any given case, 
 and thus endeavor to make of herself an intelligent and co- 
 operative assistant rather than a mere mechanical adjunct 
 which she Avill otherwise be, at least until she has had the op- 
 portunities of a long period of observation. 
 
 However, though by actual count the number of recognized 
 surgical operations would run well up into the hundreds, the 
 instrument nurse will find in her study of them that, after all, 
 from her standpoint they differ in relatively few important re- 
 spects. Her chief problem, therefore, will be to master her 
 
 296 
 
INSTRUMENT PASSING 297 
 
 general equipment and to establish her technic as the founda- 
 tion upon which she can then build very easily her superstruc- 
 ture of detail. 
 
 Accordingly, we shall take as the nucleus of our lesson a 
 representative operation which we shall study in detail as in- 
 strument passers, and when we have finished that and learned 
 it well we can, with comparative ease, proceed to the necessary 
 variations for other cases. In doing this we shall assume that 
 the nurse has been taught, in her regular course of operating 
 room training (as she should have been), to recognize all of 
 the more common instruments, needles and suture materials. 
 
 Let us assume, then, that you are to be "instrument passer" 
 for an appendicectomy. The instruments you will provide are : 
 
 4 towel clamps 
 
 1 scalpel 
 
 4 pairs plain anatomical forceps (1 very fine-pointed) 
 
 2 pairs toothed anatomical forceps 
 
 3 pairs scissors (1 straight, 2 curved) 
 
 1 dozen artery forceps 
 ^ dozen Kocher clamps 
 
 2 pairs blunt retractors (2 sizes) 
 
 1 pair "crushing" forceps (if one of the various special designs is 
 
 not available, a strong, straight pair of hemostatic forceps may 
 answer) 
 
 3 pairs sponge forceps 
 
 2 small aneurism needles 
 1 probe 
 
 1 grooved director 
 
 2 needle holders 
 
 1 pair dressing forceps 
 
 2 straight "round" needles (intestinal) 
 2 curved "round" needles (intestinal) 
 
 2 curved "round" needles (heavy) • ' 
 
 4 curved "surgeon's" needles (2 sizes) 
 
 2 straight "skin" needles (except where skin "clips" are used) 
 
 The suture material will be: 
 
 Plain catgut, Nos. 0, 1 and 2 
 
 Chromic eatg-ut, Nos. and 2 
 
 Linen thread (or celluloid linen — ^Pagensteeher) 
 
 Silkworm gut 
 
298 TEXTBOOK OF SURGICAL NURSING 
 
 Silk thread, horsehair, or skin ''clii)s" and the special forceps for ap- 
 plying them 
 
 Everythiug- being sterile and conveniently placed, you may 
 now arrange the instrument stand (Fig. 24, page 199) in some 
 such orderl}' waj^ as that suggested in Fig. 87, laying aside the 
 pair of straight scissors and one pair of the plain anatomical 
 forceps for your own use in handling the sutures. 
 
 Next it will be wise to make a "suture look" from a towel 
 folded as shown for the needle book in Fig. 54, page 253, namely, 
 by these steps: (1) Lengthwise, bringing each edge to the mid- 
 dle j (2) Crosswise, bringing each end to the middle; (3) Cross- 
 wise, through the middle again, bringing the ends together; 
 (4) Crosswise, through the middle again. This will give you, 
 as shown in the illustration, a compact, book-like arrange- 
 ment of the towel in which you have two separate compart- 
 ments in which to store your sutures and needles conveniently. 
 This is, of course, not a necessity but one of those conveniences 
 which will never be discarded when once tested out, for if 
 one assigns a place to each kind of suture material a great deal 
 of time and trouble wdll be saved in finding what one w^ants 
 when pressed for time. 
 
 Now, arrange in this hook the suture material and accom- 
 panying needles. You will probably first be asked for a liga- 
 ture for the vessels about the base of the appendix. This will 
 be the No. 1 or 2 plain catgut in the aneurism needle, or one 
 of the heavy round needles in the needle holder, and you may 
 need several of them. Next will be the linen suture, the ' ' purse 
 string," for the appendix, on a straight intestinal needle. The 
 next will be the second purse string — the No. plain or chromic 
 catgut, also on a straight intestinal needle. Next wdll prob- 
 ably be the ligatures, which should be of No. 1 plain catgut — 
 these you can lay out straight within one of the folds of the 
 suture book with the ends projecting so that you can easily 
 grasp them. Then you will probably be asked for the sutures 
 for closing the wound, Avhich will come in the following order: 
 No. 1 plain catgut on either a surgeon's needle, or the heavier 
 curved round one, for the peritoneum; No. 2 plain catgut for 
 
INSTRUMENT PASSING 
 
 299 
 
 «^ 
 
 ^ 
 
 2; 
 
 h 
 
 
 CO 
 
300 TEXTBOOK OF SURGICAL NURSING 
 
 the muscle; the same, or the No. 2 chromic for the fascia; next 
 you may need the No. 2 plain catgut for the fat layer, or per- 
 haps some fine silkworm gut on a larger sharp needle for the 
 fat and skin layers together; then will follow the skin suture 
 — the silk or horsehair — on a sharp straight needle, or perhaps 
 the skin clips. The suture material is now in convenient order 
 and you are ready for the operation to begin. 
 
 The first instrument used will be the knife, W'hich you will 
 have within easy reach, as j^ou will also have the forceps, scis- 
 sors, clamps, etc., w^hich will be used next. You will watch 
 all steps of the operation closely, replacing artery clamps on 
 the stand as they are used, and endeavoring to keep one step 
 ahead of the surgeon in your preparation. When the appen- 
 dix has been drawn up into the wound you will have the 
 aneurism needle, or the heavy round needle threaded with the 
 mesoappendix ligature ready to hand to the surgeon, and keep 
 yourself in readiness to hand him another until this part of 
 the operation is finished. Then will come the linen purse string 
 on the straight and fine round needle. At this point you will 
 probably be asked for the "crushing" clamp. The appendix 
 will then be cut away and the stump sterilized, probably with 
 the cautery. Then the fine-pointed pair of thumb forceps will 
 be used for inverting the appendix stump. 
 
 At this point the instrument nurse must learn a special lesson 
 in technic: The appendix stump exposes the interior of the 
 intestine which, of course, is not sterile, and although it has 
 been cauterized, the crushing forceps, the inversion forceps, 
 and the knife or scissors which were used for cutting it away 
 are not considered clean, and it is the instrument nurse's duty 
 to see that these instruments are discarded — a small basin or 
 a folded towel may be used to receive both these and the ap- 
 pendix and immediately handed to an unsterile attendant. This 
 lesson should be w^ell learned and the technic of carrying it out 
 well planned because it will apply in most operations where 
 a part is removed, and in others where an unclean step in- 
 tervenes. 
 
 After the appendix stump has been inverted the second purse 
 
INSTRUMENT PASSING 301 
 
 string suture — the No. plain or chromic; catgut on the straight 
 round needle — will be used. 
 
 Then you will provide the wound-closing sutures in this or- 
 der: No. 1 plain catgut on a surgeon's or the heavy round 
 needle in the needle holder for the peritoneum; the No. 2 plain 
 catgut similarly for the muscle ; the No. 2 plain or chromic cat- 
 gut on a surgeon's needle for the fascia; the No. 2 plain catgut 
 on the same needle for the fat layer, or the silkworm gut on a 
 larger surgeon's needle for the fat layer and the skin com- 
 bined; the silk or horsehair on the straight sharp needle for 
 the skin, or the clips and their special forceps. 
 
 In some cases, usually where there is infection, the wound will 
 be closed by means of " through-and-through" sutures, that is, 
 the entire abdominal wall will be treated as one layer and heavy 
 sutures, such as silkworm gut, will be used on large, strong, 
 sharp needles. 
 
 All through the operation you have endeavored to see one 
 step ahead and to have ready in advance whatever will be 
 needed so as to save confusion and waiting. This you can only 
 do by watching the operation very closely. Meantime, you have 
 kept your instrument table clean and in order, with wipes, 
 clamps, etc., always within easy reach of the surgeon, and un- 
 needed instruments out of the way. 
 
 You have now passed instruments for an operation which in- 
 volves many of the fundamental principles of your art. You 
 will need all the types of instruments (except the appendix 
 crusher) for practically every operation, with special additional 
 ones which we shall point out later ; the arrangement of the in- 
 strument table and the supply of suture materials are standard ; 
 and your general course of procedure will apply always. We 
 can then proceed to supplement this wdth the special instructions 
 for particular operations, but it must be remembered that this 
 is a subject on which w^e can speak only in generalities and 
 probabilities and that you will have to learn your particulars in 
 actual practice from day to day from your surgeon and from 
 your ever-varying cases. 
 
 Before taking up the discussion of individual operations, 
 however, let us repeat that the general set of instruments which 
 
302 TEXTBOOK OF SURGICAL NURSING 
 
 you provided for tlie appendix operation Mill be assumed 
 for all otiiers, and lliat the sets mentioned under the following 
 individual headings will merelj^ be additions. The suture mate- 
 rial supply, on the other hand, -was perhaps as complex and 
 elaborate as it "will be in any other case, and mucli more so than 
 in most of tliem. Ligatures, however, a])i)ly universally, and 
 they will be assumed in addition to the suture material w^e shall 
 mention. 
 
 It will also be taken for granted that the nurse is familiar 
 Avitli the special designs of instruments suitable for different 
 structures and parts of the body and wdll know the difference, 
 for instance, between the "bone-cutting forceps" meant in the 
 list for skull operations and the one meant for operations upon 
 the extremities. The easiest road to this specific knowledge will 
 be a few hours devoted to the study of some complete illustrated 
 instrument catalog. This may seem like learning the English 
 language by studying the International Dictionary, but a trial 
 of the suggestion will prove its worth. 
 
 REPRESENTATIVE OPERATIONS 
 
 We shall aim to discuss one or more operations from each 
 anatomical group, and as we shall select the more complex ones 
 the nurse will have no difficulty in deducting from them what- 
 ever help she may need for the other simpler ones of the group 
 which "\ve do not mention. 
 
 In Chapters IV to XI operations have teen presented in essen- 
 tial details and in the same anatomical order which will be fol- 
 lowed here, and since many special instruments have teen 
 pointed out there the student should study the corresponding 
 subject in those chapters at the same time that she takes them 
 up here. 
 
 Intestines. — For operations upon the intestines these special 
 instruments should be provided : 2 pairs of intestinal clamps 
 with rubber tubing covers for the blades (A and B or C of 
 Fig. 88), large abdominal retractors, 6 pairs of fine tenacula 
 (Allis's, for example), 1 or 2 extra pairs of scissors and thumb 
 forceps, and sometimes a Murphy button. 
 
INSTRUMENT PASSING 
 
 303 
 
 The suture material will usually be linen thread or the Pagen- 
 stecher, and No. 00 or chromic catgut ; and the needle will be 
 the fine, straight, round intestinal one usually, though occa- 
 sionally a curved one will be called for instead. 
 
 When the interior of the intestine is exposed during the opera- 
 tion the instrument nurse must apply the special technic 
 described in the case of the removal of the appendix (page 300), 
 
 Fig. 88. — Intestinal and Stomach Clamps. A, plain, flexible intes- 
 tinal clamp; B, the same clamp with the rubber tubing covers which must 
 always be used and which should be slightly smaller in diameter than the 
 clamp so that they will fit snugly; C, larger double intestinal or stomach, 
 clamp with the rubber tubes in place. 
 
 As in the case of the appendix, a special towel or basin should 
 be provided for the reception of all the instruments used during 
 the unclean stage of the operation, and the instrument passer 
 can then manage to avoid contaminating either her own gloves 
 or her instrument table — the special forceps and scissors advised 
 above were for use at this stage so as to avoid the trouble o'f 
 resterilization for the remainder of the operation. 
 
 When the Murphy button is used the two sections should be 
 screwed apart and each clamped in an artery clamp for conven- 
 ience in handling. Purse strings of heavy linen or silk thread 
 
304 TEXTBOOK OF SURGICAL NURSING 
 
 on an intestinal needle will be used for fastening them in 
 place. 
 
 The closure of the ahdominol ivall -will correspond to that of 
 the appendix Avound. 
 
 Hernia. — There are no special instruments required for any 
 of the operations for the repair of a hernia, except in those 
 cases which involve strangulation of the intestine. Then, of 
 course, you will need to provide for an operation upon the intes- 
 tines as described above. 
 
 The sutures for hernia repair will be in general as follows: 
 No. 1 or 2 plain catgut on the heavier round needle for the 
 ''sac"; No. 2 chromic catgut, kangaroo tendon, or sometimes 
 silkworm gut on the same needle for the muscle ; the chromic or 
 No. 2 plain catgut for the fascia; and for the fat and skin the 
 same as for the appendix case. 
 
 Gall Bladder. — The two more common operations involving 
 the gall bladder are the excision of the part and the removal of 
 stones from it. The instrument passer should always provide 
 for both, and the only special instruments will be : gallstone 
 forceps, gallstone scoops, bile duct probe, and perhaps a small 
 trocar with rubber tube attached. 
 
 If the gall bladder is removed a strong ligature of No. 2 plain 
 or chromic catgut on the heavier round needle should be prepared. 
 When it is not removed you may need to supply a medium- 
 sized rubber drainage tube, an ordinary rubber catheter some- 
 times being used; and for closing the gall bladder around this 
 you may need a No. 1 chromic suture on a small round needle. 
 
 There may sometimes be an anastomosis performed between 
 the intestine and the gall bladder or gall duct. In this case the 
 preparation described for intestinal operations Avill apply in 
 general. 
 
 There will probably be no new feature about the closure of 
 the wound. 
 
 Tonsils and Adenoids. — For the removal of tonsils there are 
 many methods, but you will always provide a mouth gag, a 
 tongue depressor, a tonsil-seizing forceps, an eneucleator or 
 dissector, a tonsil punch, a pair of long scissors, and either a 
 snare or one of the many designs of tonsillotomes. 
 
INSTRUMENT PASSING 305 
 
 Removal of adenoids usually accompanies the tonsillectomy, 
 and for this you will simply need some kind of adenoid curette. 
 
 Rectum. — For excision of the rectum, if done through an 
 abdominal incision, the preparation for intestinal work will, of 
 course, apply. Sometimes, however, the operation may be done 
 through an incision hy ivay of the sacrum, which means that 
 you will need a supply of bone instruments also. As this opera- 
 tion is rare, and to save space here, we refer you to page 307, 
 under "Bones," for the list of bone instruments. 
 
 For dilatation of a stricture of the rectum there are various 
 metal dilators, and bougies of several materials including metal, 
 hard rubber, soft rubber, etc. 
 
 Removal of hemorrhoids is usually done by the clamp and 
 cautery method. For this you will need a rectal speculum, a 
 pile-seizing forceps, a pile clamp, and the cautery. Ordinarily 
 you will not need to provide a rectal dilator for a hemorrhoids 
 operation. 
 
 Where a suturing operation is done No. 2 plain or chromic 
 catgut on a round needle should be provided ; and for a ligation 
 operation strong silk will probably be used. 
 
 Stomach. — For operations upon the stomach, such as a gastro- 
 enterostomy or removal of a part of the organ, the intestinal 
 preparation and technic will apply, except that the larger special 
 stomach clamps will be needed instead of the smaller intestinal 
 ones. One variety of stomach clamp is shown in C of Fig. 88. 
 
 Blood Vessels. — Suturing of blood vessels will not often 
 trouble the general instrument passer, but the material used 
 is usually extremely fine silk on an extremely slender round nee- 
 dle. Special very fine clamps and forceps are designed for this 
 purpose also. 
 
 For the removal of varicose veins one of several designs of 
 special "strippers" may be used, though often nothing but the 
 usual dissecting instruments will be needed. 
 
 Lymph Glands. — About the only special instrument for this 
 operation will be a pair of suitable grasping forceps — a tenacu- 
 lum. Plenty of artery clamps and ligatures will be a wise pre- 
 caution in these cases. Plain catgut No. 1 or 2 for suturing 
 
306 TEXTBOOK OF SURGICAL NURSING 
 
 the deeper stnu'tiires, and horsehair or silk for the skin will be 
 the likely suture mufcrial. 
 
 Spleen^ — Operations iipon the spleen will be infrequent. 
 Fur removal of the organ your chief concern Avill be to provide 
 plenty of large hemostatic forceps and strong ligatures. 
 Suturijifj of the spleen will probably be done with plain catgut 
 on a round needle. 
 
 Thyroid Gland. — For the removal of the gland the special 
 thyroid grasping forceps or a suitable tenaculum will be the 
 only special preparation, aside from plenty of artery clamps and 
 ligatures. Plain catgut No, 1 or 2 for the deeper structures and 
 horsehair or silk for the skin will be the likely suture meiterial. 
 
 Tendons. — Your only special concern will be in cases of 
 suture of the tendon, when you will probably need chromic cat- 
 gut or silk sutures on a round needle. 
 
 Brain. — Naturally, the special instruments needed for reach- 
 ing the brain will belong to the "bone instrument" group, and 
 they will be these: 
 
 Periosteal elevator Bone-ciitting forceps 
 
 Bone drill, or trepbine Bone-gouging forceps 
 
 Chisels Bone curettes 
 
 Gouges Small sharp retractors (toothed) 
 
 Mallet Special brain retractors 
 
 When the dura is to he sutured fine catgut on a small round 
 needle will* probably be used. The scalp will usually be closed 
 with silkworm gut on a surgeon's needle. 
 
 Nerves. — For the suture of nerves fine chromic catgut or 
 silk should be provided on a fine round needle. 
 
 Spine. — For operations upon the spine, which Avill be as- 
 sumed to include the spinal cord, you should provide the special 
 bone-cutting forceps designed for the purpose, and in addition 
 to that, chisels, gouges, mallet, periosteal elevator, exsection saw, 
 and a small blunt hook. 
 
 , For closing the ivound you will need fine catgut on a round 
 needle for the dura, No. 2 plain catgut for the deep structures, 
 and perhaps silkworm gut for the skin. 
 
 Bones. — For all bone work, such as the open repair of frac- 
 
INSTRUMENT PASSING 307 
 
 tures, the removal of the whole or parts of bones, etc., you should 
 be equipped with general hone instruments as follows: 
 
 Periosteal elevators Bone curettes 
 
 Chisels Bone-holding forceps (serinestrnin 
 
 Gouges forceps) 
 
 Mallet Saws (Gigli's, and other suitable 
 
 Bone-cutting forceps ones) 
 
 Bone-gouging forceps Bone drill 
 
 In the case of fracture the silver or aluminum-bronze wire 
 may be used for suturing the tone fragments ; sometimes, as in 
 the case of the patella, chromic catgut may be needed ; or, you 
 may need to provide bone plates, such as the "Lane" plates 
 (Fig. 14, page 101), and then you will also need screws, screw 
 driver, and screw-holding forceps. 
 
 When the "Lane" plating is done you may be expected to 
 carry out the special Lane technic for the operation, which means 
 a method by which the hands are never put into the wound, 
 everything being done with instruments, and all supplies han- 
 dled entirely with forceps. Considerable practice will be neces- 
 sary before one can carry out this technic well and without great 
 fatigue from the close application it will require. Its principle 
 is so excellent, however, that you will do well to acquire the 
 habit of applying it as far as you can in all your instrument and 
 suture work, and with practice you will find that many of the 
 things you usually fumbled with your fingers — needles, for 
 example — can be handled much more easily and quickly with 
 forceps. 
 
 For the closure of fracture wounds No. 2 plain catgut and 
 silkworm gut will be your likely suture material. 
 
 Reproductive Organs. — For the various operations upon the 
 pelvic organs through an ahdominal incision you should provide 
 these special instruments : Deep abdominal retractors, 2 large 
 aneurism needles, plenty of large hemostatic (hysterectomy) 
 forceps, sponge forceps, one or two tenacula or "elevating" 
 forceps. 
 
 In the case of hysterectomy you will need ligatures of No. 3 
 or 4 plain catgut on the aneurism needle, or on the heavy round 
 
308 TEXTBOOK OF SURGICAL NURSING 
 
 needle in the needle holder. These lip,'atures should be lono; — 
 the full suture length — as it "will not be convenient to tie 
 shorter ones in tlie depths of the pelvic cavity. After the uterus 
 is removed you will need the No. 3 or 4 plain catgut and some- 
 times also the No. 2 on a heavy shav]i needle for sewing over 
 the stump. 
 
 Salpingectomy and oophorectomy will require no further 
 preparation. 
 
 In the case of removal of a large ovarian cyst you should pro- 
 vide a large trocar with a long rubber tube attached. 
 
 For suspension of the uterus there are a number of possibili- 
 ties in the way of sutures,- but you will probably guess well if 
 you provide plenty of No. 2 chromic catgut on a medium-sized 
 surgeon's needle. 
 
 Occasionall}' some of these operations may be done through a 
 vaginal incision instead of the abdominal one. This will not 
 modify your preparation materially except that you will need 
 vaginal retractors instead of abdominal ones. 
 
 For a curettage these instruments will be needed : Vaginal 
 speculum, tenaculum, cervical dilator, several sizes of uterine 
 curettes, uterine sound, uterine dressing forceps, and an intra- 
 uterine irrigating tip. 
 
 For operations upon the cervix the special instruments will 
 be a vaginal speculum and a tenaculum. The sutures will prob- 
 ably be No. 2 chromic catgut or silkworm gut on a heavy sharp 
 needle. 
 
 This same preparation will apply for the several plastic 
 operations that may be done upon the vaginal wall. 
 
 For suturing the perineum you will probably need No. 2 plain 
 or chromic catgut on a medium-sized round needle, and silk- 
 worm gut on a heavy surgeon's needle. 
 
 Breast. — For the removal of the breast the instrument pass- 
 er's chief concern will be to provide plenty of artery forceps and 
 ligatures. The sutures will usually include No, 2 plain catgut 
 on a surgeon 's needle for the deeper parts, and silkworm gut on 
 a large surgeon's needle for the skin, and sometimes silk or 
 horsehair also. 
 
INSTRUMENT PASSING 309 
 
 Lungs.— The most frequent operation will be for drainage of 
 an empyema. For this you will need a periosteal elevator and 
 a pair of rib-cutting forceps. You should also provide a drain- 
 age tube which may be one of the specially-designed empyema 
 drainage tubes (Fig. 17, page 127) or a plain rubber tube with 
 one or two holes cut into the side of it (Fig. 89), and a safety 
 pin attached to keep it in place. Sometimes the wound may be 
 partially closed with silkworm gut sutures on a strong needle. 
 
 Mastoid Bone. — The bone instruments should, of course, be 
 relatively small in this case and should include periosteal ele- 
 vators, chisels, gouges, mallet, bone-gouging forceps, and bone 
 curettes. Small sharp retractors will be better than blunt ones. 
 
 Skin. — Skin-grafting operations will require the provision 
 of a special skin-grafting razor or knife, and it must be in per- 
 fect condition. It will perhaps be the instrument nurse's duty 
 to arrange the grafts after they are cut for convenient applica- 
 tion. A good way to do this is to spread them out on rubber 
 tissue by means of which they are easily picked up and put into 
 place. 
 
 Kidney. — When the kidney is to be removed the special 
 instruments will be a few long hemostatic forceps and a tenacu- 
 lum; and heavy catgut (No. 4) ligatures on a ligature carrier 
 or a round needle for the pedicle will probably be the suture 
 material. 
 
 When a stone is to he removed from the kidney a special 
 "lithotomy" forceps or scoop should be provided. The incision 
 in the kidney itself will probably be closed with fine (No. or 1) 
 chromic catgut which should be threaded on a fine round needle. 
 
 For fixation of the kidney silkworm gut or chromic catgut will 
 be the probable suture material. 
 
 The closure of this wound will present no new problems. 
 
 Bladder. — For suprapubic operation upon the bladder there 
 will probably be no special requirements in instruments. 
 Sutures for the bladder wall will usually be of fine chromic 
 catgut on a round needle. 
 
 Amputations. — The instruments you will provide are : A saw 
 suitable in size and design for the part, a knife of appropriate 
 size, periosteal elevator, bone curette, bone-cutting and gouging 
 
310 TEXTBOOK OF SURGICAL NURSING 
 
 forceps, and an amputation retractor. Ligatures -will, of course, 
 correspond in \voiulit to tiie size of the stump. Sutures "svill 
 probably, be of No. 2 plain catgut and silkworm gut. 
 
 DRAINS 
 
 We have said notliing as Ave have gone along about the prepa- 
 ration of drains because the question of where they will be used, 
 and Avhat kind, if any at all, will depend entirely upon circum- 
 stances. However, as it "will be the instrument passer's duty, 
 as a rule, to provide and fashion the drain we shall append a 
 few comments here about the various kinds, (Fig. 89.) A spe- 
 cial drainage tube for empyema cases has been illustrated in 
 Fig. 17, page 127, and the student will find information about 
 it there. 
 
 A. Cigarette Brain. — For this a piece of rubber dam or rub- 
 ber tissue of suitable size will be used, and within it will be 
 rolled, lengthwise, cigarette fashion, a piece of gauze of a size to 
 fit the wound, the ends of the gauze being allowed to project 
 slightly beyond the rubber (A of Fig. 89). 
 
 B. Mikulicz Drain. — A square piece of gauze or rubber dam 
 large enough to line the entire Avound is folded as indicated in 
 B^ of Fig. 89 — that is, diagonally several times. "With a pair 
 of sharp, curved scissors small notches are cut in this folded 
 piece of material as shown in B- of the illustration. For inser- 
 tion the drain will be unfolded, and after it has been perforated 
 it should appear as shown in B^ of the illustration. When this 
 is in place in the wound it will be packed full of gauze packing. 
 
 C. Rubber Tissue and Rubber Dam. — Pieces of either of 
 these materials may be folded flat or rolled into tubes of suit- 
 able size (C of Fig. 89). 
 
 D. Rubber Tubing. — Pieces of rubber tubing may be fash- 
 ioned in various ways (D of Fig. 89). The gauze packing may 
 or may not be used in these drains. The large drain of group D 
 has the rubber tube inside of the gauze, and the whole is encased 
 within a few layers of rubber dam. 
 
 E. Horsehair and Silkworm Gut. — A strand may be rolled 
 into a suitable shape for small wounds (E of Fig. 89). 
 
INSTRUMENT PASSING 
 
 311 
 
 F. Rubber Bands, — For small drains an ordinary rubber 
 band, either whole or in part, may be used (F of Fig. 89). 
 
 G. Gauze Packing. — This will need no special preparation. 
 A safety pin should accompany every drain, either to pin it 
 
 T 
 
 Fig. 89. — Drains. A, cigarette drain made of gauze rolled within a piece 
 of rubber tissue or rubber dam; B'^, B^, B^, three stages in the evolution of 
 the Mikulicz drain which is made from a piece of gauze or rubber dam; C, 
 rubber tissue or rubber dam drains made by folding the piece flat or by 
 rolling it into a tube; D, various designs of rubber tubing drains; E, horse- 
 hair or silkworm gut drain; F, ordinary rubber band. 
 
 fast to the dressing or to serve as a guard against its slipping 
 into the wound and becoming lost. 
 
 A pair of dressing forceps is, of course, always among the 
 general instruments, and this should always be in readiness for 
 the insertion of the drain. 
 
312 TEXTBOOK OF SURGICAL NURSING 
 
 As we have warned all the way aloug, what we have given 
 here is only the probable and the possible. It Mill now be the 
 instrument passer's dut}' to learn the special methods of her 
 surgeon and to familiarize herself as widely as possible with 
 surgical procedures, and then she will be equipped to supple- 
 ment knowledge with the good guessing which every instrument 
 passer should always know how to practice. 
 
CHAPTER XVIII 
 
 THE DBESSING OF THE WOUND 
 
 The actual dressing of the wound will either be done by the 
 surgeon himself or the specific method for doing it will be pre- 
 scribed by him if the nurse is to do the work. HoAvever, the 
 nurse has important responsibilities in relation to all wound 
 dressings and upon her technic and general efficiency will 
 depend to no small degree the simplification of the treatment, 
 the comfort of the patient during the ordeal, and the actual 
 progress of the wound toward recovery. 
 
 Good technic is, of course, the most important thing to learn 
 about a dressing, and the nurse's first concern should be so to 
 arrange her supplies and equipment that asepsis will be more 
 or less automatic. 
 
 A wound which has been sutured and has had a day or more, 
 as most of them will have had, in which to heal somewhat, will 
 not be as susceptible to infection as the fresh and open one in 
 the operating room; the time of exposure for the dressing is 
 much shorter than for the operation ; and actual contact with 
 the wound is relatively slight. The extreme precautions, there- 
 fore, of the operating room as to sterile clothing and elaborate 
 draping are not called for in the dressing, but with these two 
 exceptions there should not he, and there need not he, any relaxa- 
 tion of rigid aseptic technic. 
 
 Circumstances and equipment will determine one's general 
 plan for the preparation of dressing supplies. If it is a case 
 of a single dressing the best method is to prepare in a parcel 
 just enough supplies for one dressing. This will be safest and 
 it will also be convenient. However, in hospitals where numer- 
 ous dressings must be done in immediate succession there must 
 be a common source of supply. This can be managed by steril- 
 izing the supplies in muslin-covered parcels and then transfer- 
 ring them to glass or enamel jars which have been sterilized 
 
 313 
 
314 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 separately and whii'li have dust-tiglit covers. The best technic, 
 however, is to use the supplies directly from the container in 
 which they were sterilized provided it can be safely opened and 
 closed repeatedly. This will save much time and work and, of 
 course, is better technic in tliat it eliminates the exposure inci- 
 dent to the transferral from one container to the other. 
 
 There is a special meted dressing hox or drum (Fig. 90) which 
 is ideal both as to convenience and as to safety. It is made with 
 
 a catch which serves to prop 
 the lid open during steriliza- 
 tion and to close it securely 
 afterward. A simple mechan- 
 ism on the top of this box 
 answers the double purpose of 
 a handle for carrying it and 
 of a lever for opening the lid 
 easily and safely. This consti- 
 tutes a very compact and thor- 
 oughly satisfactory container 
 in which can be stored all the 
 gauze and cotton supplies, in- 
 cluding the draping towels, 
 and when it can be procured 
 it should be used in preference 
 to any other device. 
 
 Fig. 90. — Portable Metal 
 Dressing Box. The bar across the 
 top serves as a handle for carrying 
 and also as a lever for opening the 
 lid, and it is so attached that it 
 may be turned down over the side 
 of the box out of the way. 
 
 While this dressing box is very safe and can be kept cleaner 
 than any other container, it must be remembered that no con- 
 tainer which is opened and closed frequently can be considered 
 sterile indefinitely. When a number of dressings are to be done 
 at a time, those believed to be "clean" should, of course, be 
 done first and the infected ones last ; and the dressing box thus 
 frequently exposed during a considerable period of time would 
 not be safe to use further until resterilizecl. The plan advised 
 for the operating room dressing supplies in Chapter XVI, page 
 295, will apply here also, especially where inexperienced nurses 
 are concerned; that is, do not hold over from one session to 
 another a used dressing box, even though you are reasonably 
 certain of its sterility. 
 
THE DRESSING OF THE WOUND 
 
 315 
 
 The dressing ifistruments will, of course, be boiled freshly for 
 each dressing. The practice, sometimes seen, of boiling them in 
 advance, drying them with a sterile towel, and wrapping them 
 in a sterile muslin cover for the next day 's use, is one that should 
 not be adopted except in those instances where one has not easy 
 and prompt access to a boiler. As in the case of the operating 
 room, it is well to have the instrument boiler near at hand when 
 doing dressings, especially when several are to be done in close 
 succession. There are many portable electric instrument steril- 
 izers on the market (Fig. 91), and if one of these can be pro- 
 cured and the suitable connection for it provided near the 
 patient it makes an admirable dressing equipment. Most of 
 these sterilizers have an attachment which automatically dis- 
 
 FiG. 91, — Portable Electric Instrument Sterilizer. 
 
 connects the current in case they boil dry, and some of the more 
 recent designs have a thermostatic mechanism which assumes 
 entire responsibility for keeping the water at the boiling point 
 and of turning off the current if the water supply becomes 
 exhausted. 
 
 The other supplies and equipment for a dressing need not be 
 taken up here because that phase of the subject belongs more 
 particularly to general practical nursing and the pupil will have 
 learned it in her practical course. 
 
 To have all these necessities conveniently at hand, especially 
 when more than one dressing is to be done at a time, will call 
 for some means of compact and easy portability. There is 
 always the tray, of course, which can be very conveniently 
 arranged and stocked, but when a variety of dressings are to be 
 
316 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 clone the items it must accommodate Avill be so numerous and 
 so heavy that it will be cumbersome and not very satisfactory 
 generally, In spacious hospital wards the most convenient and 
 technically the best device for storing and transporting supplies 
 from one patient to another is one of the dressing carriages 
 (Fig. !)2) Avhu-h are made in many designs and sizes. These 
 carriages have several shelves, are mounted on rubber-tired 
 wheels, sometimes have an attachment for elevating an irrigator 
 
 Fig. 92. — Dressing Carriage for Use in the Hospital Ward. 
 
 which is useful in Carrel-Dakin dressings and other irrigations, 
 and are very simple to Avheel about from bed to bed. If one has 
 the electric instrument sterilizer and accessible wall outlets for 
 its attachment it may be kept on this carriage also and will thus 
 furnish an ideal means of keeping the instruments perfectly 
 clean and ready for instant use. If wisely stocked with supplies 
 and kept in good order this dressing carriage will save many 
 precious steps and wdll enable one nurse to do all the assisting 
 for a series of dressings without the expenditure of the valuable 
 time of a second errand nurse. 
 
 As remarked above, most of the other nursing details of dress- 
 
THE DRESSING OF THE WOUND 
 
 317 
 
 ings belong more particularly to general praeti(;al nursing, 
 but there are several points which will l)ear emphasis from the 
 strictly surgical standpoint. 
 
 Exposure of the patient, particularly one in poor condition, 
 should be as little as possible because it may have considerable 
 to do with both his general and his 
 local recovery, especially if the room 
 is not warm. 
 
 The removal of adhesive plaster, 
 especially from extensive surfaces 
 which have been painted with iodine, 
 calls for consideration on the part of 
 the surgical nurse, because the skin 
 underneath it is liable to have be- 
 come tender and will therefore be 
 painful as the adhesive is torn from 
 it; and sometimes the surface may 
 even be found denuded where the 
 plaster has been. This will mean 
 
 another wound to care for, and if the 
 
 . . , , . . n X 1 xi • Fig. 93. — Adhesive 
 
 original wound is an infected one this plaster and Tape Device 
 
 new one may become troublesome, for Holding Dressings in 
 
 Place and Allowing Their 
 Also, if the skin has been broken removal Without the Dis- 
 adhesive plaster cannot be applied ---- o. thk Piaster. 
 
 again, and this in itself will be at strip to which the tape is 
 
 1 , • • T attached has been turned 
 
 least an inconvenience. In cases J^^^^. ^.^^ ^ ^j^^^^ ^^.^^^^^^^ 
 
 where the skin shows a tendency to which makes this part 
 , -ITT stronger and also prevents 
 
 become sore, or is already so ; where ^^ f roj^ adhering to the skin, 
 
 a patient is particularly disturbed by thus permitting of its being 
 
 turned back out or the way 
 the removal of the adhesive ; or where while the wound is being 
 
 the dressing needs to be changed fre- ^iressed. 
 quently, some such method as that illustrated in Fig. 93 may 
 be used for keeping the dressing in place. This consists merely 
 of pairs of adhesive straps, one on either side of the dressing, 
 connected by tapes which are tied across the dressing. These 
 straps will remain in place for a long time and will answer 
 all the purposes of a continuous adhesive strap, except that of 
 great tension. There are various good ways of softeiiing ad- 
 hesive plaster before attempting to remove it. They all take 
 
318 TEXTBOOK OF SURGICAL NURSING 
 
 more time than the (lircct method of pulling it off, but in cases 
 of sensitive, nervous, or very ill patients, and often with children, 
 it Avill be necessary to adopt one of these gentler methods. Any 
 oil — albolene, or olive oil, for examples — -will soften the plaster 
 in a few minutes and Avill have no unpleasant effect ui)()n even 
 a broken skin. Benzine will dissolve the plaster more quickly 
 but it Avill be painful if the skin is broken. 
 
 The general principles of handling sterile sui)plies for dress- 
 ings will have been taught the nurse in her practical course of 
 instruction and if she has had her operating room training she 
 will know them well, but the important lyriuciple of arranging 
 equipment and general technic so as to reduce the amount of 
 handling necessary cannot be urged too often. This point is 
 not only imi)ortant in the interest of asepsis, but it also saves 
 much time, labor, and confusion. A good standard practice is 
 to keep a pair of long sterile forceps and a pair of scissors for 
 use in handling the sterile supplies in a tall jar containing a 
 solution of 1-40 or 1-60 carbolic acid to which a few grains of 
 borax have been added for the purpose of preventing rust. 
 These can be kept on the dressing tray or carriage at all times, 
 and as long as they are used for nothing but the perfectly sterile 
 dressings they need not be reboiled oftener than once a day. 
 The point that these forceps and scissors should be long ones is 
 emphasized because their length will enable the nurse to keep 
 her unsterile hand well out of the region of the opening of the 
 sterile container and tlius avoid the possibility of unsterile dust 
 dropping from it onto the sterile supplies. 
 
 In this connection it should be urged upon the nurse who 
 dispenses the sterile supplies to kee23 her hands as free from 
 coniamination as possible. It will not be necessary for her to 
 sterilize them but she should avoid, as far as she can, the removal 
 of dressings, and the application of adhesive plaster, bandages, 
 etc., after the dressing is done, especially in an infected case, 
 if she is obliged to go directly to another wound. If an assistant 
 is available this part of the dressing should be left entirely to 
 her. In any case the soiled dressings should always be removed 
 and otherwise handled Avith forceps. These forceps need not be 
 sterile but it will be just as well to keep them in a jar of the weak 
 
TUB DRESSING OF THE WOUND 319 
 
 carbolic solution on the dressing tray or carriage. The precau- 
 tion should be taken to use for this purpose a different kind of 
 forceps and jar from those provided for the sterile work. 
 
 In this connection the nurse usually needs to be cautioned 
 about her technic as it pertains to the ubiquitous handage scis- 
 sors. The usual abiding place of these indispensable instru- 
 ments, when they are not in use, is the nurse's apron belt or 
 pocket, and it becomes automatic for her always to put them 
 back there after use. In the ordinary everyday work this is 
 a perfectly legitimate practice, but in the case of cutting off 
 infected dressings the nurse should remember that her bandage 
 scissors and her apron belt or pocket are entitled to the same 
 technical attention as her hands or anything else she uses, and 
 she will, therefore, sterilize her bandage scissors whenever she 
 has been obliged to contaminate them. 
 
 Another point which is often overlooked is that solutions used 
 for washing or irrigating wounds should not he thrown into the 
 receptacle containing the gauze dressings. These two articles 
 are eventually disposed of by entirely different means, the dress- 
 ings by way of the furnace and the solutions by way of the sewer. 
 Thus, if thrown together they must be separated later, which 
 entails avoidable labor and very bad technic in that much wider 
 contamination than is necessary is caused by this solution. Two 
 waste dressing receptacles (preferably pails with handles) are 
 necessary if solutions are used for a dressing. 
 
 As remarked in the beginning of this chapter, if the nurse 
 dresses the wound herself she will have the guidance of the 
 surgeon as to specific treatment, but she will need to exercise 
 her best knowledge of asepsis and general surgical technic on 
 her own account. 
 
 The person who does a dressing must, of course, have sterile 
 hands. The bare hands may be sterilized as directed in Chapter 
 XVI, page 263, or if sterile rubber gloves are available they 
 should be used instead. If sterile gloves are used it will not be 
 necessary to put' the hands through the rigid sterilizing process 
 required in the operating room but, of course, they should be 
 very thoroughly cleansed. 
 
 All sponging of the wound, the handling of drains, dressings, 
 
320 TEXTBOOK OF SURGICAL NURSING 
 
 etc., should he done icith forceps, and to do this it will be neces- 
 sary to provide two pairs of dressing or anatomical forceps — 
 one for each hand. With a little practice one can thus keep her 
 gloves entirelj' clean throughout a dressing, and can do a number 
 of dressings without changing gloves. However, as a safeguard 
 against unconscious error, the gloves sJwuld he given a thorough 
 rinsing after each case in some antiseptic solution, such as 1-1000 
 bichloride. 
 
 Some of the foregoing advice may seem a little overdrawn, but 
 when a nurse has become a finished technician she knows that 
 good technic is as easy as had technic, and where life and health 
 are dependent upon us w^e have no right to do less than our best. 
 
CHAPTER XIX 
 
 THE OARREL-DAKIN TREATMENT 
 
 The Carrel-Dakin system of treating infected wounds is now 
 so generally used that a nurse's surgical education is not com- 
 plete unless she has an intelligent conception of its scientific 
 principles and a thorough working knowledge of its detailed 
 practical application, for there is perhaps no other treatment 
 in which so much of the ultimate success depends upon the 
 intelligence, thoroughness and conscientiousness of the nurse 
 as in this cg-se. Furthermore, while regularly the dressing and 
 certain other parts of the preparation for the treatment are 
 done by the surgeon, there will be occasions when the nurse will 
 be called upon to do the dressing herself ; and so, there is this 
 reason in addition to the general educational one for her acquir- 
 ing as complete a knowledge as possible of this important 
 subject. 
 
 WHAT THE SYSTEM IS 
 
 The Carrel-Dakin treatment may be defined very simply as 
 a method of killing the germs in an infected wound. You have 
 become very familiar with many antiseptics and have sterilized 
 many different kinds of material with the several ones, and at 
 first thought you may not see why bichloride, for example, 
 might not simply be applied to a wound, as you apply it to your 
 hands, and thus kill its germs. The tissues of a wound, however, 
 give us a very different proposition from that of the healthy 
 surface of your hands. 
 
 In the first place, yaw always wash your hands very thor- 
 oughly with soap and water to remove everything but the 
 healthy, clean surface of them before you expect bichloride to 
 serve you ; and since soap and w^ater constitute a very good 
 disinfectant on their own account, you have thus greatly reduced 
 the task for the bichloride. 
 
 321 
 
322 TEXTBOOK OF SURGICAL NURSING 
 
 Secondly, the tissues of a wound arc a literal culture medium 
 for the germs, and this means that there is present in the wound, 
 besides the germs themselves, the dead tissue wliich they have 
 destroyed in the process of their feeding upon it, and all the 
 other waste, "\\hirli you have learned about in Chapter I, that 
 accompanies inflammation and infection. 
 
 Furthermore, a great deal of this material is not on the sur- 
 face of the ivound but permeates its walls to a greater or lesser 
 depth. Thus, you see, even though we were able, as we sometimes 
 are, to wash the wounds as j^ou do your hands, we could not 
 reach the "soiled" parts that are within the tissues themselves, 
 and could not, therefore, expect our bichloride to accomplish 
 much in these parts. 
 
 More than this, bichloride, as is true of all the other powerful 
 antiseptics which you have used, is very irritating to the tissues 
 and while it was destroying the germs it would also destroy, or 
 at least devitalize, the good tissue which it reached. You have 
 doubtless learned this in the case of your own hands which have 
 become sore or have developed a rash Avhen you have had to 
 use it frequently. Bichloride has been used only as an example 
 and you would find that carbolic acid, formalin, or any other 
 known antiseptic that is at all powerful would act similarly. 
 Also, your hands have been only an example with which can 
 be compared all the various articles which you are in the habit 
 of sterilizing with an antiseptic solution. 
 
 Another more complex and abstruse problem which enters 
 into this subject is that of actually getting a solution of any 
 kind into the tissues themselves, even "clean" ones. Those of 
 you who have studied physics and chemistry will know from 
 what you have learned about "osmotic pressure" that there is 
 a great difference among the powers of solutions to permeate any 
 given material. This may be demonstrated by taking a jar with 
 a partition of some permeable membrane, parchment paper, for 
 instance, through the middle of it, and pouring into one side a 
 colored solution of salt in water and into the other side plain 
 water, and then watching them mix. Each solution permeates 
 through the membrane into the other compartment, and in this 
 case the water permeates more rapidly than the colored salt 
 
THE CARREL-DAKIN TREATMENT 323 
 
 solution because the water is the less dense; solution, or, as we 
 say, has less "osmotic pressure." If we put the same solution 
 into the two compartments they will mix equally because, of 
 course, their "osmotic pressures" are equal. Similarly, if we 
 put two different solutions having the same density into the 
 two compartments they, too, would mix equally because they 
 had the same "osmotic pressure." In the study of physiology 
 the blood serum is taken as the standard fluid for all compari- 
 sons of this kind and any fluid which has the same "osmotic 
 pressure" as the blood serum is said to be ^'isotonic" with the 
 blood. This term ' ' isotonic ' ' is one which nurses often hear and 
 they should know its meaning, especially if they wish to under- 
 stand one of the great hidden secrets of the efficacy of the Dakin 
 solution. 
 
 The fact, then, which we have just tried to prepare you to 
 understand is that another great reason why bichloride, car- 
 bolic acid, formalin, etc., will not sterilize an infected wound 
 is because they are not ' ' isotonic ' ' with the blood serum and will 
 not, therefore, mix well with it through the permeable "mem- 
 brane" we have in the case of wounds — the body tissues. 
 
 Consequently, in order to sterilize an infected wound we have 
 to devise some means, first, of "washing" it as best we can, and 
 then of applying to it a solution which has the power of killing 
 its germs whether they are on its surface or more or less 
 entrenched within its tissues. This Drs. Carrel and Dakin 
 have done for us in great detail in the Carrel-Dakin system of 
 wound disinfection. 
 
 HISTORY 
 
 The method, as a whole, is the invention of Dr. Alexis Carrel, 
 the distinguished American biologist who, since his emigration 
 to this country in 1905 from his native land, France, has 
 repeatedly commanded the attention and admiration of scientists 
 the world over by his brilliant and serviceable experiments and 
 discoveries in the art of surgery, carried on, for the most part, 
 at The Rockefeller Institute for Medical Research, in New York. 
 
 The Carrel-Dakin treatment was introduced, however, on the 
 battlefield, in the beginning of the European war, by Dr. Carrel 
 
324 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 at his Frencli Ann\- liospilal, t'oiiiulcd by llic Rockefeller Insti- 
 tute at Corapiepnr, Kfjiiicc. In tliis woi-k he had llie eollabora- 
 tiori of Dr. Dakin who did inueh of tlu' laboratory experimenta- 
 tion necessary to perfect the remarkable solution Avliich Dr. 
 Dakin had <>iven to the profession some time previously and 
 which bore his name. In time the treatment was adopted by 
 several other French Armj' surgeons and became an established 
 treatment in their war hospitals. Because of its exacting and 
 somewhat tedious technic, however, and through hesitancy to 
 institute radical changes in procedure, the method was rather 
 slow of adoption by surgeons in general, but its beneficence has 
 become such an established fact that it is now in fairly general 
 use. 
 
 Before taking up the study of the system as a whole we shall 
 take time to gather together and learn about the tools we shall 
 need, for when we have all this in mind the remainder of the 
 
 Fig. 94. — ^Dressing Forceps for Use in Dressing the Carrel-Dakin 
 
 Wound. 
 
 text will be more intelligible ; and as this is the part of the 
 Carrel-Dakin method with which the nurse is most concerned 
 in practice, special emphasis put upon these details before think- 
 ing of anything further will be a good initial investment. 
 
 EQUIPMENT 
 
 For the administration of this treatment a considerable num- 
 ber of articles are needed, and experience will teach that none 
 of them can be omitted without serious handicap following. 
 
 The necessary items are these : 
 
 1. Instruments: 4 pairs of long dressing forceps (Fig. 94) 
 and 2 pairs of long scissors ; all sterile, of course. 
 
THE CARREL-DAKIN TREATMENT 
 
 325 
 
 2. A small sterile basin of Dakin's solution. 
 
 3. A jar of sterile vaseline-gauze strips. 
 
 4. Sterile rubber delivery tubes (Fig. 95). 
 
 5. Small sterile gauze dressings. 
 
 
 
 
 • . • . • . • . •>3 
 
 A' 
 
 
 
 
 ■ . ■ . • .'.--i 
 
 A- 
 
 
 
 • 
 
 V^ \ \ ] \ \ \\) 
 
 ,B 
 
 
 
 
 c^ <■ ^ 
 
 :p 
 
 Fig. 95.— The Rubber Delivery Tubes. A\ closed at the end by tying; 
 A^, closed at the end by stitching ; B, made the same as A"^ or A^ and after- 
 ward wrapped with gauze or Turkish toweling; C, the end cut at an angle 
 and a large opening cut in one side near this end; D, a longer tube per- 
 forated in the middle, and connected at the ends to a glass Y-tube. 
 
326 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 6. Large sterile gauze dressings. 
 
 7. Sterile cotton pads. 
 
 8. Sterile safety pins. 
 
 ^ 
 
 3 
 
 Fig. 96. — Eeservoirs for the Dakin Solution. A, a glass graduated 
 one which may be securely stopped with a cork; B, a flat-bottomed one 
 made of enameled metal. 
 
 Fig. 97. — Glass Syringes for Administering the Dakin Solution. 
 A, rubber bulb type which may be operated with one hand— the most con- 
 venient one for the purpose; B, the more common plunger type. 
 
 9. Bandages. 
 
 10. Irrigator stand (Fig. 44, page 221). 
 
 11. Reservoir for Dakin 's solution (Fig. 96). 
 
 12. Glass syringe (1-ounce size) (Fig. 97), 
 
THE CARREL-DAKIN TREATMENT 
 
 327 
 
 13. Rubber tubing — enough to reach generously from the 
 reservoir to the wound, 
 
 14. Stopcock (spring or screw) (Fig. 98). 
 
 A B 
 
 Fig. 98. — Stopcocks for Use on the Supply Tubing in the Eeservoir 
 Method of Administering the Dakin Solution. A, metal spring va- 
 riety, suitable for the intermittent method, as it always entirely closes off 
 the tube; B, screw variety, suitable for the continuous method of instil- 
 lation, as the rate of flow of the solution can be very exactly controlled 
 with it. 
 
 CC 
 
 X::^ CX 
 
 OC 
 
 cc 
 
 im' 
 
 Fig. 99. — Glass Connecting and Distributing Tubes. A, ordinary 
 straight splicing tube; B, suitable for connecting rubber tubes of dif- 
 ferent calibers, as in the case of uniting one of the small wound tubes 
 directly to the main supply tube. This tube also answers as a dropper 
 tube in place of the special one illustrated in Fig. 100; C, Y-tube for 
 making various bifurcations in the main supply tube; D, E, and F, 2-, 3-, 
 and 4-way tubes for connecting the wound tubes with the supply tube. 
 
 15. Glass connecting and distributing tubes (straight, Y- 
 shaped, 2-, 3-, and 4-way) (Fig. 99). 
 
 16. Glass dropper tube (Fig. 100). 
 
328 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 1. Instruments. — For the drossinor the forceps and scissors 
 should be long ones so as to make it possible to keep the hands 
 -well aAvav from tlie ^vol^nd and dressings. The best type of 
 dressing foreeps is the one illustrated in Fig. 94. Four pairs 
 are provided, as both the person -who dresses the wound and the 
 assistant -will use a pair in each hand. 
 
 2. Solution Basin. — This may be of any 
 material that is easily steriliza'bJe, but as Da- 
 kin's solution deteriorates upon exposure to 
 light it is advisable to select a dish made of 
 an opaque material and one having a cover. 
 An enamel-ware covered dish which holds a 
 pint will be a good one for the average pur- 
 pose. This should be sterilized by boiling. 
 
 3. Vaseline Gauze. — Probably the best 
 gauze for this purpose is bandage gauze, as the 
 material used must have more body than the 
 average dressing gauze has. The size of the 
 pieces will doubtless be prescribed by the in- 
 dividual surgeon, as preferences vary, but an 
 
 Fig. 100.— Glass average suggestion would be to cut a 2-inch 
 
 Dropper Tube for bandage into 6-inch lengths. Turn back one 
 
 Use on the Main ° ^ 
 
 Supply Tube in end of each strip a half inch or more ; the 
 
 Continuous Meth- reason for this is that it can be picked up more 
 
 The solution g^sily after it has been impregnated ■with the 
 
 not pass '' 1 o 
 
 Lay these in a neat rank, the piece 
 ck lying on top each time, 
 this dish may be of any 
 
 OD. 
 
 can 
 
 througli this tube vaseline. 
 
 faster than drop , , t i i i • , i .• 
 
 by drop, and the yo^^' have turned back lymg on top each time, 
 
 rate at which it is j^ ^ shallow dish 
 
 dropping can be 
 
 readily observed at material that will withstand the steam pressure 
 
 of the autoclave, it must have a cover, and it 
 
 will be found more satisfactory to have it of a length and 
 
 breadth only slightly larger than the gauze strips. Melt the 
 
 vaseline (preferably the white vaseline) and pour it over the 
 
 gauze, using only enough to cover it. It might be mentioned 
 
 that the dish containing the gauze should be warm when the 
 
 melted vaseline is poured into it so that a good permeation of 
 
 the gauze will take place then, when the proper amount needed 
 
 must be judged. This is then sterilized in the autoclave for the 
 
THE CARREL-DAKTN TREATMENT 329 
 
 maximum time used for the other dressings. We would em- 
 phasize the superiority of this method of prei)aring the gauze 
 over several other methods in practice, as it eliminates all han- 
 dling after sterilization. If, for any reason, this technic cannot 
 be carried out, however, the three items may be sterilized separ- 
 ately by the best available method and combined after- 
 ward. 
 
 4. Delivery Tubes. — Select for these tubes a soft rubber 
 tubing of about the No. 14 or 15 French-scale size. This tubing 
 must not be too stiff to adjust easily in the wound, nor so soft 
 
 Fig. 101. — The Way to Perforate the Wound Tube. This particular 
 punch is made for the purpose, but any similar one which makes a hole about 
 % millimeter in diameter will do. Two holes are made at a time in this 
 way at directly opposite points on the walls of the tube. The next two 
 will be made at a distance of about half an inch from these, and in a line 
 at right angles to theirs. 
 
 as to be easily compressed by dressings, angles of the wound, 
 etc. Cut the tubing into lengths ranging from 12 to 16 inches 
 (the length will be governed by the character and location of 
 the wound), and then fashion these pieces into whichever of the 
 following varieties you need for your particular case : 
 
 Tube A. Close one end, either by tying (A^ of Fig. 95) as 
 near as possible to the end with a strong thread (linen, prefer- 
 ably), or by taking two short stitches (A^ of Fig. 95) at right 
 angles over the end. With a sharp punch, about % millimeter in 
 diameter, perforate the tubes (Fig. 101) for distances varying 
 from 2 to 8 inches (depending upon the extent of the wound) 
 from the tied end, taking care to distribute the perforations as 
 
330 TEXTBOOK OF SURGICAL NURSING 
 
 evenly as possible over the surface of the tube, and making 
 about 4 holes to each iiu-h ol" tul)ino'. Do not attempt to make 
 these holes with a hot needle, as this may leave loose pieces of 
 burnt rubber in the tube whieli would later become foreign 
 bodies in the wound. There is no substitute for the punch 
 which removes entirely a small piece of the rubber. This tube 
 is used as you now see it, but for some purposes it needs a fur- 
 ther modification thus : 
 
 Tube B. Over the perforatitms of the tube described above 
 wind, bandage fashion (B of Fig. 95) a strip of soft gauze, or, 
 as Dr. Carrel originally prescribed, a piece of Turkish toweling. 
 The toweling is not always at hand, and soft gauze makes a 
 good substitute. Tlie amount applied will necessarily vary with 
 the wound, but a good average amount would be 6 or 8 layers. 
 It will be a wise precaution to .stitch this gauze at one end to 
 the tube to prevent its being lost in the wound. This tube will 
 be used in cases where the solution has to be carried uphill, the 
 gauze serving the purpose of holding the solution in contact 
 with the wound surface. 
 
 Tuhe C. Leave both ends open, cut one end at an angle, and 
 about Yq inch from this end cut a small hole (C of Fig. 95) 
 with a pair of scissors, making the tube resemble an open-end 
 rectal tube. This tube will be used in deep, narrow wounds 
 where all one needs to do is to fill the cavity with the solution. 
 Or, if the continuous method of administration is used, this 
 will be the most serviceable tube. 
 
 Tube D. This tube should be about twice as long as the 
 others, and it is perforated in the middle (D of Fig. 95) instead 
 of at one end. The solution is carried into this tube at both ends 
 by means of a glass Y-tube (C of Fig. 99) and the loop thus 
 formed is used for surface wounds. 
 
 These tubes are best sterilized in clear boiling water, and 15 
 minutes is enough time to give them, for every nurse knows that 
 rubber articles deteriorate soon under anj^ method of steriliza- 
 tion. 
 
 5. Small Gauze Dressings. — For this dressing the small 
 gauze sponge or "wipe" which is provided for general sponging 
 
THE CARREL-DAKIN TREATMENT 331 
 
 will serve. This will be used as Dakin packing in many wounds 
 in cooperation with the tubes. 
 
 6. Large Gauze Dressings. — These will simply be large 
 folded gauze dressings of a size a^d shape to generously cover 
 the wound. 
 
 7. Cotton Pads. — These pads are very important adjuncts 
 and should be made with care and foresight as to size, shape, and 
 thickness. There should be a generous layer of absorbent cotton, 
 a thinner one of non-absorbent cotton, and these should be 
 securely covered with a layer of gauze. Their size and proi^or- 
 tions will vary with the size, nature, and location of the wound, 
 but they should always be large enough to extend well beyond 
 the gauze dressings on all sides, and if the wound is so situated 
 that there may be drainage downward, as in the case of the 
 extremities, this pad should be large enough to envelop the part 
 entirely. 
 
 All gauze and cotton dressings will, of course, be sterilized 
 in the steam autoclave. 
 
 8. Safety Pins. — It is important that these should be steril- 
 ized either by dry heat, or by boiling immediately before use 
 so as to be sure that they are free from rust. 
 
 9. Bandages. — There should be a supply of sterile bandages 
 on hand, as in some cases it is necessary to use them where 
 sterility is obligatory. 
 
 10. Irrigator Stand. — In the hospital the provision of a suit- 
 able stand presents no problem (see Fig. 44, page 221), but in 
 the home and other places one can always find a costumer, a 
 chandelier, a bed post, chiffonier, or any number of other sup- 
 ports which can be utilized for raising the solution the required 
 height above the patient. 
 
 11. Reservoir for Solution. — ^IVIany authorities advise a glass 
 irrigating jar (A of Fig. 96) for this purpose, and if it is small 
 and graduated in ounces or cubic centimeters it is a good one; 
 but if it is large it seems a little inconsistent, inasmuch as the 
 Dakin solution is known to deteriorate when exposed to light, 
 and if one puts as much as a quart in this jar it is evident that 
 the last portions of this quantity used will have been exposed 
 for many hours. Another objection to the glass containers is 
 
332 TEXTBOOK OF SURGICAL NURSING 
 
 that most of tlieni are not fiat-bottomed and eannot, therefore, 
 be elevated by any means but suspension whieh might not always 
 be convenient. Tlie graduated glass jar, however, is an advan- 
 tage in that it enables one to see the amount of the solution that 
 is being injected at each instillation; but in the average case 
 perhaps the article most easily obtained will be the simple 
 enameled metal irrigator with a flat bottom and an outlet in the 
 form of a tube projecting from the side (B of Fig. 96). This 
 is easily sterilized by hoilivg, and if not provided with a ready- 
 made cover a heavy cloth cover can be fitted. Tlie most service- 
 able size in this type of irrigator will be one that holds a quart. 
 This irrigator, as well as the glass ones, may, of course, be 
 sterilized hy steam, or hy soaking in some antiseptic solution, 
 such as bichloride. 
 
 We would caution the nurse against the temptation which may 
 come to her in a private house to use a rubber douche bag lor 
 the reservoir. All concerned, including the bag, would come 
 to grief within a very short time as the Dal<;in solution finds 
 weak places in rubber sooner than any other solution. 
 
 12. Glass Syringe. — This will be needed only when the solu- 
 tion is administered by the syringe method instead of by reser- 
 voir. It is, of course, necessary to provide an individual syringe 
 for each wound. The capacity should be from 1 to 2 ounces; 
 a smaller one is too trifling, and a larger one may be too force- 
 ful (Fig. 97). Of these two syringes A of the illustration is 
 the better model because it can be manipulated with one hand, 
 which will always be a great advantage as the other hand will 
 be free to control and steady the wound tube. These are steril- 
 ized by boiling. 
 
 13. Rubber Tubing. — The red rubber tubing seems to be 
 the best quality for this purpose. One piece, long enough to allow 
 considerable slack between the reservoir and the delivery tubes, 
 should be provided, and there should also be on hand several 
 shorter pieces. This rubber should be in perfect condition, as, 
 at its best, it does not withstand the Dakin solution well, and a 
 small defect will soon play havoc with the patient's comfort, 
 the bed, and the nurse 's time. The caliber of this supply tubing 
 should be a few sizes larger than that of the wound tubes, or, a 
 
THE CARREL-DAKIN TREATMENT 333 
 
 No. 18 or 20, Frencli-scale. Sterilize this by boiling for 10 
 minutes in clear water. Of course, if the solution is to be 
 administered by syringe this tubing may not be needed. 
 
 14. Stopcock. — This must be in perfect condition, and many 
 should be in reserve as the solution rusts them quickly. When 
 the treatment is given intermittently these stopcocks should be 
 of the metal spring variety (A of Fig. 98), but when the con- 
 tinuous method is used the screw variety (B of Fig. 98) is best, 
 as it permits of better control of the flow. 
 
 15. Glass Connecting' and Distributing Tubes. — There 
 should be a generous supply of all the varieties illustrated in Fig. 
 99. Special attention is called to the tube with the one fine, taper- 
 ing end, B of the illustration, which should be used on the main 
 supply tube when the drop method is used and a special dropper 
 tube (Fig. 100) is not available. It is not advisable to use a 
 distributing tube of more than 4 divisions, as a greater number 
 of the rubber delivery tubes in one group is clumsy and difficult 
 to adjust. 
 
 These tubes can all be 'boiled, but they should be well wrapped 
 in a towel or some similar material to avoid breakage, and they 
 should be put into the water before it is heated to avoid the 
 same calamity. 
 
 16. Glass Dropper Tube. — This is a great convenience 
 (Fig. 100) in the continuous method but not a necessity, as any 
 nurse who has administered the Murphy drip must have discov- 
 ered when she has had to proceed with the treatment after she has 
 broken the only tube she had, or it has refused to function for 
 some unknown reason. 
 
 The nurse has now prepared, sterilized, and assembled ready 
 for use all the necessary equipment for the treatment, and we 
 can proceed with the study of the system. 
 
 THE FOUR PROCESSES OF THE SYSTEM 
 
 It must be learned in the beginning of this subject that the 
 complete Carrel-Dakin system embraces more than the mere 
 application of an antiseptic to a wound. This is an exceedingly 
 
334 TEXTBOOK OF SURGICAL NURSING 
 
 inipoi-tant part oF the teclmic, l)ut it t-ould not siu'cood out of 
 cooperation witli the three other procedures \vhi('li go ^vitll it 
 to make the Avhole. The four processes, then, Avhicli make up 
 the complete system are : 
 
 I. Dchridement. IT. Administration of the Dakin Solution 
 to the Infected Wound. III. The Periodical Bacteriological 
 Examination of the ^Xound. IV. The Suturing of the Wound 
 When Sterile. 
 
 I. DEBEIDEMENT 
 
 As outlined above, the Carrel-Dakin teelniic proper begins 
 ■with the surgical operation called " dehridement," which is a 
 French word meaning, in the words of the International Dic- 
 tionary, "Operation of removing by an incision any part which 
 causes obstruction or prevents escape of pus." This operation, 
 however, as applied here by Dr. Carrel, involves a little more 
 than the above definition implies, for by ''debridement" Dr. 
 Carrel means a very thorough, delicate, and rigidly aseptic 
 removal from the wound at the very earliest possible moment 
 of all foreign material, infected tissue, injured tissue which 
 might easily become infected, and also as much good tissue as 
 might stand in the way of the thorough application of the 
 Dakin solution to absolutely every part of the wound. In other 
 words, when the surgeon "debrides" a wound he operates as 
 soon as he can, uses and exacts the most rigid aseptic technic 
 possible, and under these conditions lays the wound widely open, 
 takes out all foreign bodies, dirt, etc., and then cuts away all 
 dead and injured tissue and whatever good tissue may be neces- 
 sary to give him reasonably good access to everj' remote part of 
 the wound, using great care throughout not to cause any more 
 injury to the good tissue than is absolutely necessary to gain 
 his end; and when he is through he has a wound that contains 
 nothing but living, and, so far as the eye can see, healthy tissue. 
 
 The first step in the treatment has now been taken — the wound 
 has been "debrided" and as much of the infection has been 
 removed as is possible by means of pure surgery. 
 
THE CARREL-DAKIN TREATMENT 335 
 
 11. ADMINISTRATION OF THE DAKIN SOLUTION 
 
 This subdivision of the method involves a group of procedures 
 which we shall classify as follows: 
 
 1. Dressing of the Wound. — a. Vaseline Gauze, h. The De- 
 livery Tuhes. c. The Gauze and Cotton Dressings. 
 
 2. Adjustment of Instillation Appliances. — a. For the Res- 
 ervoir Intermittent Method, b. For the Reservoir Continuous 
 Method, c. For the Syringe Method. 
 
 3. Instillation of the Dakin Solution. — a. The Reservoir In- 
 termittent 3Iethod. 1). The Reservoir Continuous Method. 
 c. The Syringe Method. 
 
 1. Dressing of the Wound.— It may seem to you, after 
 learning of the thoroughness with which the debridement was 
 done, that the wound should now be free from germs and that 
 healing would take place in the natural course of events. Or, if 
 you accepted doubt on this point you might hold that we could 
 determine whether or not there still remained infection by taking 
 a culture of this clean and healthy-looking wound. This conten- 
 tion would not be quite sound, however, because of the fact that 
 infection does not develop and become active for a day or two, 
 and so, in order to play safe, the stage is set immediately for 
 the instillation of the antiseptic solution. 
 
 a. The Vaseline Gauze. — The first step is to apply the vase- 
 line gauze strips to the skin immediately surrounding the wound. 
 The skin becomes irritated in a short time if subjected to a 
 constant bath of the combination of Dakin 's solution and the 
 wound excretions, and for this reason all parts likely to be 
 exposed to drainage must be carefully covered with the vaseline 
 gauze which is impervious to it (Fig. 102). 
 
 The assistant, a pair of dressing forceps in each hand, picks 
 up the end of the vaseline gauze strip which she turned back 
 when she packed it, pulls the piece loose from the others and 
 immediately grasps the other end with the pair of forceps in 
 the other hand. She passes it thus to the person dressing the 
 wound; he, also, has a pair of dressing forceps in each hand. 
 
336 TEXTBOOK OF SURGICAL NURSING 
 
 These strips are then i)r(>ssed smoothly and closely upon the 
 needful parts as pointed out above. 
 
 h. The Delivery Tubes. — Next, the rubber Avound tubes are 
 put into place. The size, shape, location, and general character 
 of the wound will determine Avhieh of the four kinds of delivery 
 tubes you have provided will be used (Fig. 103). In some cases 
 you may be called upon for more than one kind for the same 
 wound. 
 
 Tuhe A (Fig. 95) is the most frequently used one because it 
 can be adapted to the greatest variety of wounds and can be 
 best fitted into the more shapeless ones (see A of Fig. 103). 
 
 Fig. 102. — The Wat to Lay the Vaseline Gauze Strips Around the 
 Margin of the Wound. 
 
 HoAvever, if the wound is in such a position that it will not hold 
 the solution until it is absorbed — -in other words, if it is not 
 right-side-up, as one on the lower part of the leg or arm, or on 
 the back — tube B (Fig. 95) will have to be used (see B of Fig. 
 103), and the gauze which you have wrapped around it will serve 
 as a storehouse which will supply the solution to the tissues as 
 fast as they can absorb it. Some of the small gauze dressings 
 which you have provided may also be used in this case to fill 
 in the wound or to keep the tubes in place. It should be remem- 
 bered that when this gauze is used it should be saturated with 
 the Dakin solution before it is inserted. Also, when tube B is 
 used the gauze-wound end should be dipped into the solution 
 before insertion. The solution basin mentioned above is, of 
 course, used for this purpose. 
 
 If the wound is a relatively smooth-walled one, and will hold 
 
TPIE CARREL-DAKIN TREATMENT 
 
 337 
 
 g 2 bc' 
 
338 TEXTBOOK OF SURGICAL NURSING 
 
 the solution, tube C (Fig. 95) is used (see C of Fig. 103), and 
 some of the small gauze dressings may be tucked around it to 
 keep muscles or other structures from closing in upon it and 
 obstructing it, though when this is done the gauze should be 
 so placed that it does not come Ix'iween the tube openings and 
 the wound surface, as it is likely to become clogged with wound 
 excretions and will then be impervious to the solution. 
 
 In the case of a shallow ivound on the surface, especially if it 
 is extensive, one or more of tube D (Fig. 95) will be used (see 
 D of Fig. 103), a thin layer of gauze being first spread over 
 the wound to prevent the tube from adhering to it. Not more 
 than one or two thicknesses of gauze should be used because it 
 will become clogged with the wound excretions and prevent the 
 solution from reaching the wound. A number of tube A may 
 also be used on this type of wound. 
 
 In all eases tubes must be selected in which the perforations 
 will not extend beyond the edges of the ivound. 
 
 When tube D is used the glass Y-connecting tube must be 
 affixed before it is put into place, but with the others it will be 
 found more satisfactory, and just as good technic, to adjust 
 their connecting tubes after the patient has been put to bed. 
 
 c. The Gauze and Cotton Dressings. — The sterile gauze dress- 
 ings are next applied, and over them the cotton pad, non- 
 absorbent side outward, of course. In nearly all cases these 
 pads will have to be split so as to allow the rubber delivery tubes 
 to pass outward through them (Fig. 104) rather than under 
 them, one reason for this being that by this means the tubes 
 can be kept in place better, and another being that the patient 
 is thus protected from any leakage from the ends of the tubes 
 and also from the unpleasantness of contact with rubber. The 
 safety pins you have provided will come into service at this 
 point. 
 
 The cotton pads must never be omitted because they serve 
 two important purposes: They protect the bed and the patient's 
 clothing, and the non-absorbent layer of cotton prevents undue 
 evaporation of the solution. In this connection it may be well 
 
THE CARREL-DAKIN TREATMENT 
 
 339 
 
 to warn the nurse against covering any part of a Carrel-Dakm 
 dressing with rubber sheeting of any kind, as a certain amount 
 of evaporation is inevitable and the re-condensation that would 
 take place under the rubber sheet would be as unwholesome 
 and uncomfortablct in this case as every nurse knows it is in 
 all others. 
 
340 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 The dressings arc llicii, of coui'sc, sccinrd l)y bandages, or 
 in some cases l)y tape or Avebbing- straps Avliicli can be tied in 
 place. Dressings for Carrel-Dakhi cases should not be fastened 
 quite so tightly as is permissible with most other dressings, 
 because they Avill administer the solution better -when loose, and 
 furthermore, the bandages sometimes shrink a little when they 
 become wet. 
 
 2. Adjustment of Instillation Appliances. — Before the ar- 
 rangement of the instillation outfit is carried further, which- 
 ever method of administration is to be used, the patient must he 
 made comfortable and the bedding adjusted as far as possible. 
 
 Fig. 105. — Arrangement of the Apparatus for the Reservoir Method 
 
 OF Instillation. 
 
 The chief object to keep in mind at this point is to arrange the 
 patient and bedding, in relation to the wound, in such a way as 
 to make possible the administration of the Dakin solution with- 
 out any disturbance or discomfort to the patient. 
 
 Your next step will depend upon which of the several methods 
 
THE CARREL-DAKIN TREATMENT 341 
 
 of instillation you will adopt. The details of these methods are 
 as follows : 
 
 a. For the Reservoir Intermittent Method. — This is the most 
 frequently used method, and after it is installed, and as long as 
 all appliances are in good condition, it is the most convenient 
 one (Fig. 105). 
 
 The solution reservoir has been elevated above the level of the 
 wound about 18 inches if the large irrigator is used, and about 
 3 feet for the small one ; the long rubber tube has been securely 
 
 Fig. 106. — Suggested Ways of Bkanching the Main Supply Tube So 
 That It Can Feed the Tubes of More Than One Wound, or Widely 
 Scattered and Variously Grouped Tubes in the Same Wound. 
 
 attached to it; the metal spring stopcock (A of Fig. 98) has 
 been put into place on this tube ; the reservoir has been filled 
 with fresh Dakin solution and securely covered; and now the 
 connection will be made to the wound tubes. 
 
 The number and grouping of the tubes in the wound will 
 determine which of the glass distributing tubes will be selected, 
 and the important thing to remember here is to make all con- 
 nections so that the tubes will be allowed to remain without 
 tension in the position they were given when the dressing was 
 done. The variety of glass connecting and distributing tubes 
 enables one to make an unlimited number of combinations, so 
 that any number of ;wound tubes can be supplied with the solu- 
 
342 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 tion from the same source (Fig. 106). A 
 study of this ilhistration will furnish 
 enough suggestions to cover any case, 
 
 h. For the Reservoir Continuous 
 Method. — When this method is adopted 
 cMivcry tuhe C (Fig. 95) is used in 
 the wound. Instead of the spring stop- 
 cock on the main supply tuhe the screw 
 one (B of Fig. 98) should be used, and 
 just bclow^ this the tube should be cut 
 and the dropper tuhe (Fig. 100) in- 
 serted, as indicated in Fig. 107. Other- 
 wise the adjustment is the same as that 
 described above for the reservoir inter- 
 mittent method. 
 
 c. For the Syringe Method. — If the 
 wound tubes are easily accessible no 
 further adjustment is necessary, for the 
 solution can be injected into each indi- 
 vidual tube directly from the syringe. 
 If the wound is so situated, however, 
 that this is inconvenient, the glass con- 
 necting and distributing tubes and 
 some of the short pieces of supply tub- 
 ing you have provided can be arranged 
 as for the reservoir method so as to be 
 able to feed the solution from one main 
 tube (Fig. 108). 
 
 3. Instillation of the Solution.— 
 
 The standard practice is to administer 
 the solution every tivo hours, day and 
 night. This frequency is determined 
 oJ'the''s7rew 'i^oP^K by the fact that Dakin's solution is very 
 AND THE Glass Dropper unstable and loses its sterilizing power 
 Tube on the Main Supply , , -, r. i • • t ^^^ i 
 
 Tube for the eeservoir by the end of this period. The mechan- 
 
 CoNTiNuous Method of ^^^ ^g g^ adjusted, as you are now pre- 
 
 InSTILLATION. o : ■ ^ 
 
THE CARREL-DAKIN TREATMENT 343 
 
 pared to concede, that, with average care, the treatment can be 
 given without any disturbance or discomfort to the patient, and 
 so, it is just as easily carried out during the night as in the day- 
 time. This is a very merciful feature of the method because 
 this is one treatment which is never interrupted. The impor- 
 tance of regularity and punctuality in the instillation is one of 
 the most urgent points for the beginner to learn. Another 
 important point to be learned early is to pay close attention to 
 the amount, as nearly as possible, of the solution which is 
 required to fully bathe each individual wound and then reli- 
 giously give just that amount, and no more and no less. If too 
 little is given the germs in the parts of the wound unbathed 
 
 Fig. 108. — Method of Connecting Inaccessible Wound Tubes to a 
 Single Supply Tube for the Syringe Method of Instillation. 
 
 flourish unhindered and indefinitely ; if too much is given it may 
 not all be absorbed before the next instillation and the old, use- 
 less solution blocks the way for the new. Another menace of 
 too great a quantity is the discomfort, and even injury, to the 
 patient which results from the solution being spilled over healthy 
 surroundings of the wound or onto the bedding and causing 
 irritation of the patient's skin. In some instances the surgeon 
 will, when he has finished the debridement, estimate, or even 
 measure, the correct dosage for that particular wound and 
 prescribe this exact amount for each instillation. As you can 
 readily see, in order to carry out this provision it will be neces- 
 sary that either the syringe method of administration be used, 
 or else, that you be equipped with the graduated glass irrigator. 
 Otherwise, one or two instillations will be enough to teach one 
 
344 TEXTBOOK OF SURGICAL NURSING 
 
 the proper quantity for a given "wound, but if there must be 
 doubt at any time it is better to err on the side of too much than 
 on that of too little. Of course, as the wound heals a smaller 
 dosag-e of the solution will be necessary, but this variation will 
 be determined from time to time when the wound is dressed. 
 
 Details of the actual instillation for the several methods are 
 as follows: 
 
 a. The Reservoir Intermittent Method. — All the nurse has 
 to do to make the instillation by this means is to open the stop- 
 cock for the time necessary for the passage of the amount of the 
 solution prescribed or estimated. 
 
 The two great errors that are most easily committed by this 
 method are to allow the solution to ilow too suddenly and too 
 forcefull,y, and to give too large a dose. Sudden and forceful 
 instillations are painful to the patient, especially if the solution 
 is cold. The objections to overdosage have been mentioned 
 above. 
 
 Another difficulty is to determine whether or not all the 
 deli very tubes are functioning. It is possible, however, to get 
 this information by the closest scrutiny of the glass distributing 
 tube while the solution is flowing. When one does become 
 blocked it may sometimes be opened by disconnecting it at tlie 
 glass distributing tube and gently forcing some of the Dakin's 
 solution into it with a syringe. This should be done with great 
 care, however. 
 
 h. The Reservoir Continuous Method. — The screw stopcock 
 is so adjusted that the solution drops through the glass dropper 
 to the wound at the proper rate to keep the dressings at an even 
 degree of moisture. The actual rate will depend, of course, 
 upon the area supplied by the tube, but it will probably be 
 somewhere between 5 and 10 drops per minute. 
 
 This was the method originally recommended by Dr. Carrel, 
 but it has now been rather laid aside in favor of the others. 
 
 c. The Syringe Method. — It need hardly be said that this 
 method consists merely of injecting the Dakin solution into the 
 
THE CARREL-DAKIN TREATMENT 345 
 
 tubes by means of a syringe. This should be done slowly and 
 gently, and, as remarked before, the syringe should not be too 
 large, as it will be too difficult to control. 
 
 Two features of the syringe method make it a close competitor 
 of method (a) for first place. The first is the fact that the 
 dosage can he more easily controlled; and the second is that one 
 can be sure that each individual delivery tiihe is always free 
 and functioning. Experience with the syringe system has dem- 
 onstrated that the tubes do become clogged frequently and that 
 considerable effort is required to free them. 
 
 A difficulty which arises when the tubes do not stand upright, 
 or nearly so, in the wound, is that the solution flows out again 
 as soon as the syringe is withdrawn. In such cases the rubber 
 delivery tubes are best connected up to one supply tube, as 
 described for the reservoir system, and this tube clamped shut 
 immediately after the instillation with one of the spring clamps. 
 Or, in some cases, if the delivery tubes are long enough, this 
 leakage can be prevented by bringing the mouth of the tube up 
 over the dressing and pinning so that it is higher than the 
 wound. 
 
 III. THE BACTERIOLOGICAL EXAMINATION OF THE 
 
 WOUND 
 
 After the lapse of a day or two, during which time the treat- 
 ment has been going on, of course, a system of microscopical 
 examinations of the wound excretions is instituted. 
 
 A platinum wire loop of standard size is used to take up the 
 excretion from the various parts of the wound w^hich are believed 
 to be most infected; this material is then spread upon a slide 
 and put through the usual technical process for preparing 
 microscopical slides. Under the microscope a count is made of 
 the numher of hacteria in a given field and the result is recorded 
 on a tracing chart similar to those on which nurses trace tem- 
 peratures (Fig. 109). This test is repeated periodically, usually 
 every second day, until there have been three successive exami- 
 nations in which no germs were seen, when the wound is con- 
 sidered sterile and ready for nature to heal. 
 
346 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 The first smear or two may not show much decrease in the 
 number of germs, but after that there should be a gradual 
 decrease, and the zero mark on the chart is reached in from a 
 few days to several weeks, depending upon the severity of the 
 injury and upon the type of tissue involved; that is, whether 
 it is the soft parts of the body, bone, etc. 
 
 If the expected downward course of the count does not take 
 place promptly all possible causes should he investigated, and 
 
 MONTH 
 
 1 
 
 OAY9 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Q 
 
 -I 
 U 
 L. 
 
 > 
 
 a 
 u 
 
 
 
 < 
 
 bl 
 
 > 
 < 
 
 O-O 
 
 60 
 40 
 20 
 10 
 
 5 
 
 1- 
 
 1/2 
 1/5 
 l/io 
 1/20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 ^ 
 
 Ml 
 
 ^ 
 
 
 ^ 
 
 ^ 
 
 
 
 J 
 
 _ 
 
 
 
 
 
 -i 
 
 
 
 ^ 
 
 ^ 
 
 _ 
 
 
 
 _ 
 
 _ 
 
 _ 
 
 
 
 
 
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 ^ 
 
 
 Fig. 109. — Dr. Carrel's Bacteriological Chart for a Traced Kecord 
 OF THE Microscopical Count op the Bacteria in the Smears Taken 
 from the Wound During the Course of the Carrel-Dakin Treatment. 
 
 the trouble will usually be traced to one or more of the following 
 causes : 
 
 1. Incomplete debridement. 
 
 2. Incorrectly placed delivery tubes. 
 
 3. Insufficient number of delivery tubes. 
 
 4. Insufficient amount of instillation. 
 
 5. Faulty adjustment of dressings. 
 
 6. Flaw in technic somewhere along the line from dehride- 
 ment to instillation. 
 
 The surgeon or the pathologist will do this bacteriological 
 
THE CARREL-DAKIN TREATMENT 347 
 
 part of the technic, though there may be cases in which the 
 nurse will be called upon to take the smear from the wound. 
 It should not be necessary to remind the nurse that the strictest 
 aseptic technic must be observed in this act, and that the slide 
 must be carefully protected from contamination until delivered 
 to the pathologist. 
 
 The smears should be taken at the same hour each day; not 
 sooner than two hours after an instillation; and the various 
 operations from the taking of the smear to the counting of the 
 germs should be clone by the same person or persons throughout 
 the course for a given case, so as to eliminate all variations due 
 to causes outside of the wound itself. 
 
 IV. SUTURING OF THE WOUND 
 
 When three successive smears have shown no germs the sur- 
 geon then sutures the wound, which should heal uneventfully. 
 It must not be forgotten, however, that this sterilized wound is 
 not yet safe, but that it may be reinfected unless the rigid 
 asepsis is maintained until healing is complete. 
 
 One case has now been carried through the entire course of 
 the Carrel-Dakin treatment and we shall proceed to learn how 
 to treat the tubes for the next one. 
 
 DISPOSAL OF USED DELIVERY TUBES 
 
 If in good condition these tubes may be used again, but the 
 greatest care must be exercised in the re-preparation of them. 
 
 Immediately upon removal from the wound the tubes should 
 be stored in some antiseptic solution. If this is not possible 
 immediately they should at least be put into a basin of saline 
 solution or even plain water, because if they are allowed to 
 become dry before washing it will often be very difficult to get 
 them clean. Any antiseptic solution which will not injure rub- 
 ber will do, such as lysol or carbolic. Dakin's solution may be 
 used, of course, but unless one's supply is very abundant this 
 is more extravagant than necessary. 
 
348 TEXTBOOK OF SURGICAL NURSING 
 
 In any case, the tubes should he allowed to soak for several 
 hours in the antiseptic solution before anyone is asked to handle 
 them for- washing. It is probably true, however, that these tubes 
 are not greatly infected, particularly on the inside, because of 
 the fact that they liave constantly been in contact with the Dakiu 
 solution wliih^ in the wound. 
 
 Nevertheless, rubber gloves sJiould be worn ivhen washing 
 them, and care should be taken not to splash the wash water 
 into the eyes, mouth, etc. This point may seem an unnecessary 
 one to remind nurses of, for they learn early in their work to 
 beware of such accidents, but this is a peculiar case because of 
 the fact that, in order to get the tubes clean on the inside, it is 
 necessary (for they are tied shut at one end) to struggle con- 
 siderably with them while holding them stretched out enough to 
 enlarge the perforations sufficiently to allow what is inside to 
 be washed out. They will inevitably snap out of one's fingers 
 repeatedly and should not be able to splash anything about which 
 is not reasonably clean. Clear running water should be used 
 first in the washing, and then soap and water. The use of a 
 forceful syringe is an advantage at this stage. After a thorough 
 rinsing the tubes are ready for the final boiling. 
 
 THE DAKIN SOLUTION 
 
 What It Is Made From. — Dakin's solution is usually made 
 from three well-known chemical substances, namely, chloride of 
 lime, carbonate of soda (washing soda), and bicarbonate of soda. 
 This sounds as though it should be a very simple chemical and a 
 very easily prepared one, but as we shall see later, when we get 
 down to the study of its chemistry, it is really far from simple. 
 
 AVhen we come to the instructions for making the solution we 
 shall give a process in which the chloride of lime is not used, 
 but since this other method only uses another means of obtain- 
 ing the all-important chemical, chlorine, it involves no vital 
 difference. 
 
 What It Is. — ^In simple terms Dakin's solution is a 0.45 to 
 0.50 per cent, solution of sodium hypochlorite. Chlorine, as you 
 may know, is one of the most active of the chemical elements, 
 
THE CARREL-DAKIN TREATMENT 349 
 
 especially where animal and vegetable matter are involved, and 
 so, while this makes it a powerful antiseptic, it must also be re- 
 membered that it v/ill destroy, in time, many other materials with 
 which it might come into contact while you are using it — your 
 personal clothing, the bedding, etc., for examples. You are all 
 familiar with Javelle water, or bleaching solution, and if you will 
 learn that Dakin's solution, by virtue of its chlorine, is a close 
 relative of bleaching solution you will know something of its 
 action in this respect. 
 
 You learned in the beginning of this chapter what "isotonic" 
 means, so, now we can reveal to you the very important fact that 
 Dakin's solution is "isotonic" with the Uood serum, and that is 
 why it can sterilize wounds as no other solution can. 
 
 Before this time you may have advanced so far in your expe- 
 rience as to have learned about Dichloramine-T and one or two 
 other recent rivals of Dakin's solution, and will challenge the 
 above claim of uniqueness for the Dakin solution; but these 
 more recent antiseptics have merely borrowed the Dakin solu- 
 tion secret, the chlorine, and used it in another form, so the 
 claim is still justified. 
 
 In the exact per cent, of strength given above Dakin's solution 
 is at the same time very active antiseptically and only very 
 slightly irritating. 
 
 As you have already learned, it is an unstaMe chemical, 
 especially when exposed to the chemical action of light, and for 
 this reason care should always be taken to keep it well corked, 
 away from the light, and to use none but a freshly prepared 
 solution. In well-regulated hospitals only enough for one day's 
 use is made at a time, though it will keep well for perhaps a 
 week or two if very carefully protected. 
 
 What It Does. — First of all, Dakin's solution is an active 
 germicide. By virtue of the same power with which it kills 
 germs so effectively Dakin's solution also acts upon all other 
 organic substances, and so we find it dissolving Mood clots, pus, 
 tissue waste, etc., in the wounds. This is a very important fact 
 to know because the solution of a Mood clot -may entail a hemor- 
 rhage, as may also the solution of waste tissue. This should 
 
350 TEXTBOOK OF SURGICAL NURSING 
 
 bo kept ill mind at all times wlieii atliuinislering the treat- 
 ment. 
 
 Dakin's solution is also a deodorant. Perhaps one of the 
 first points that a nurse will note about her first "Dakinized" 
 wound is, that Avhere otherwise there would be an offensive 
 odor of pus there is only the fresh, clean odor of the chlorine. 
 
 Another graceful service which this highly accomi)lished solu- 
 tion gives is to Icautify the ivound into a healthful-appearing, 
 rich, red color. 
 
 How It Is Made. — The accurate compoimding of the Dakin 
 solution is a very exact and technical chemical process, and 
 should be done by an experienced chemist ; but as a matter of 
 knowledge and reference we give here the early crude process 
 and the later more elaborate one. 
 
 Dakin's Early Process 
 
 Ordinary "water 10 litres 
 
 Anhj'drous carbonate of soda 140 g-rams 
 
 or, CrystalUzed salt 400 grams 
 
 Chloride of lime 200 grams 
 
 Shake the mixture well. After half an hour siphon off the 
 clear liquid and filter through cotton. Add to this solution: 
 
 Boric acid 40 grams 
 
 Daufresne's Technic 
 
 This is Dr. Carrel's own description of the process as pub- 
 lished in the Journal of the American Medical Association, De- 
 cember 9, 1916. 
 
 Dakin's solution is a solution of sodium hypochlorite for sur- 
 gical use, the characteristics of which, established after numer- 
 ous tests and a long practical experience, are as follows: 
 
 (a) Complete Absence of Caustic Alkali. — The absolute 
 necessity for employing in the treatment of wounds a solution 
 free from alkali hydroxide excludes the commercial Javelle 
 water, Labarraque's solution and all the solutions prepared by 
 any other procedure than the following : 
 
THE CARREL-DAKIN TREATMENT 351 
 
 (b) Concentration. — The concentration of sodium hypo- 
 cMorite must be exactly between 0.45 and 0.50 per cent. Below 
 0.45 per cent, of hypochlorite the solution is not sufficiently ac- 
 tive; above 0.50 per cent, it becomes irritating. 
 
 (c) Chemicals Required for the Preparation. — Three chem- 
 ical substances are indispensable to Dakin 's solution : Chlori- 
 nated lime, anhydrous sodium carbonate, and sodium bicar- 
 bonate. Among these three products the latter two are of a 
 practically adequate constancy, but this is not the case with the 
 first. Its content in active chlorine (decoloring chlorine) varies 
 within wide limits, and it is absolutely indispensable to titrate 
 it before using it. 
 
 Titration of the Chlorinated Lime. — There must be on hand 
 for this special purpose : 
 
 A 25 c.c. buret graduated in 0.1 c.c. 
 A pipet gauged for 10 c.c. 
 
 A decinormal solution of sodium thiosulphite (hypo- 
 sulphite). 
 
 This decinormal solution of sodium thiosulphite can be ob- 
 tained in the market; it can also be prepared by dissolving 25 
 grams of pure crystalline sodium thiosulphite in 1 litre of dis- 
 tilled water and verifying by the decoloration of an equal vol- 
 ume of the decinormal solution of iodine by this solution. The 
 iodine is prepared by dissolving 1.27 grams iodine and 5 grams 
 potassium iodide in 100 c.c. of water. 
 
 The material for the dosage thus provided, a sample of the 
 provision of chlorinated lime on hand is taken up either with 
 a special sound or in small quantities from the mass Avhich then 
 are carefully mixed. 
 
 Weigh out 20 grams of this average sample, mix it as com- 
 pletely as possible with 1 litre of ordinary w^ater, and leave it 
 in contact a few hours, agitating it from time to time. Filter. 
 
 Measure exactly with a gauged pipet 10 c.c. of the clear 
 fluid ; add to it 20 c.c. of a 1 :10 solution of potassium iodide 
 and 2 c.c. of acetic or hydrochloric acid. Drop, a drop at a 
 time, into this mixture a decinormal solution of sodium thio- 
 sulphite until decoloration is complete. 
 
 The number of cubic centimetres of the hypochlorite solution 
 
352 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 required for complete decoloration, multiplied by 1.775 gives 
 the freight of the active chlorine contained in 100 grams of 
 the chlorinated lime. 
 
 This figure being known, it is applied to the accompanying 
 table, which will give the quantities of chlorinated lime, of 
 sodium carbonate, and of sodium bicarbonate which are to be 
 employed to prepare 10 litres of Dakin's solution. 
 
 Quantities of Ingredients for Ten Litres of Daliin's Solution 
 
 Titer of 
 
 Chlorinated 
 
 Anhydrous Sodiimi 
 
 Sodium Bicar- 
 
 Chlorinated 
 
 Lime 
 
 Carbonate 
 
 bonate 
 
 Lime 
 
 Gm. 
 
 Gm. 
 
 Gm. 
 
 20 
 
 230 
 
 115 
 
 96 
 
 21 
 
 220 
 
 110 
 
 92 
 
 22 
 
 210 
 
 105 
 
 88 
 
 23 
 
 200 
 
 100 
 
 84 
 
 24 
 
 192 
 
 96 
 
 80 
 
 25 
 
 184 
 
 92 
 
 76 
 
 26 
 
 177 
 
 89 
 
 72 
 
 27 
 
 170 
 
 85 
 
 70 
 
 28 
 
 164 
 
 82 
 
 68 
 
 29 
 
 159 
 
 80 
 
 66 
 
 30 
 
 154 
 
 77 
 
 64 
 
 31 
 
 148 
 
 74 
 
 62 
 
 32 
 
 144 
 
 72 
 
 60 
 
 33 
 
 140 
 
 70 
 
 59 
 
 34 
 
 135 
 
 68 
 
 57 
 
 35 
 
 132 
 
 66 
 
 55 
 
 36 
 
 128 
 
 64 
 
 53 
 
 37 
 
 124 
 1 
 
 62 
 
 52 
 
 Example. — If it required 16.6 c.c. of the decinormal solution 
 of the sodium thiosulphite for complete decoloration, the titer 
 of the chlorinated lime in active chlorine is: 
 16.6 X 1.775 = 29.7 percent. 
 
 The quantities to be employed to prepare 10 litres of the solu- 
 tion will be in this case : 
 
 Chlorinated lime 154 grams 
 
 Dry sodium carbonate 77 grams 
 
 Sodium bicarbonate 62 fframs 
 
THE CARREL-DAKIN TREATMENT 353 
 
 If crystalline sodium carbonate is being used, then instead 
 of the 80 grams of dry carbonate it must be replaced by : 
 
 Crystalline sodium carbonate 220 grams 
 
 Preparation of Dakin's Solution. — To prepare ten litres of 
 the solution : 
 
 1. Weigh exactly the quantities of chlorinated lime, sodium 
 carbonate, and sodium bicarbonate which have been determined 
 in the course of the preceding trial. 
 
 2. Place in a 12-litre jar the chlorinated lime, and 5 litres 
 of ordinary water, agitate vigorously for a few minutes, and 
 leave in contact for from 6 to 12 hours, over night, for instance. 
 
 3. At the same time dissolve, cold, in the five other litres 
 of water, the sodium carbonate and the bicarbonate. 
 
 4. Pour all at once the solution of the sodium salts into 
 the jar containing the maceration of the chlorinated lime, agi- 
 tate vigorously for a few moments, and leave it quiet to permit 
 the calcium carbonate to settle as it forms. At the end of half 
 an hour siphon the liquid and filter it through double paper to 
 obtain an entirely limpid product, which must be protected 
 from light. 
 
 Light, in fact, alters quite rapidly solutions of hypochlorite, 
 and it is indispensable to protect from its action the solutions 
 which are to be preserved. The best way to realize these con- 
 ditions is to keep the finished fluid in large wicker-covered demi- 
 johns of black glass. 
 
 Titration of Dakin's Solution. — It is a wise precaution to 
 verify, from time to time, the titer of the solution. This titra- 
 tion utilizes the same material and the same chemical substances 
 as are used to determine the active chlorine in the chlorinated 
 lime: 
 
 Measure out 10 c.c. of the solution, add 20 c.c. of the 1 :10 
 solution of potassium iodide and 2 c.c. of acetic or hydrochloric 
 acid. Drop, a drop at a time, into this mixture a decinormal 
 solution of sodium thiosulphite until decoloration is complete. 
 
 The number of cubic centimetres employed multiplied by 
 0.03725 will give the weight of the sodium hypochlorite con- 
 tained in 100 c.c. of the solution. 
 
 A solution is correct when, under the conditions given above. 
 
354 TEXTBOOK OF SURGICAL Nx^trsING 
 
 from 12 to 13 c.c. of (kH-inornial tliiosulpliitc are reciuired to 
 complete the decoloration : 
 
 13 X 0.03725 = 0.485 per eont. of XaOCl 
 
 The Test for the Alkalinity of Dakin's Solution. — It is easy 
 to differentiate the solution obtained by tliis procedure from 
 the commercial hypochlorites aiid from Labarraque's solution: 
 
 Pour into a glass about 20 c.c. of the fluid, and drop on the 
 surface a few centigrams of phenolphthalein in powdered form. 
 Dakin's solution, correctly prepared, gives absolutely no change 
 in tint, while in the same conditions Javelle water and La- 
 barraque's fluid give an intense red coloration which indicates 
 in the latter two solutions the presence of free caustic sodium. 
 
 Another method which simplifies the manufacture of the 
 Dakin solution if the requisite apparatus can be secured is sim- 
 ply to dissolve the sodium carbonate in the proper amount of 
 water and then pass the chlorine gas directly into this solution 
 from cylinders of the compressed gas. A meter is used to 
 measure the gas as it flows, but the tests used in the above 
 process for the finished product must be made in this case also. 
 
CHAPTER XX 
 
 BANDAGING 
 
 The subject of bandaging is one which can be disposed of 
 with a few arbitrary demonstrations, and some pupils can be 
 trained thus into dextrous bandagers ; but on the whole, time 
 can be saved and more intelligent skill attained if demonstra- 
 tion and practice are reserved till a general survey of the field 
 has been made from the more purely theoretical standpoint. 
 It may be true that the art of bandaging is not a major sub- 
 ject, speaking theoretically, but there are certain real principles 
 involved which must be observed in all bandaging that is 
 worthy of the name, and though they are few they are impor- 
 tant enough to be dignified by serious classification and study 
 as a foundation for practice. Before we take up the actual prac- 
 tice of the art of bandaging, therefore, let us prepare ourselves 
 to do it as intelligently as we can. 
 
 DEFINITIONS 
 
 A handage may be defined as a piece of flexible material 
 suitably fashioned for application about something as a cover- 
 ing, a reinforcement, or a compressor. 
 
 The term bandaging will then mean the art of applying the 
 bandage for any of these purposes. 
 
 USES OF BANDAGES 
 
 The purposes for which bandages are used may be summed 
 up under these headings : 
 
 1. To hold dressings, splints, and other appliances in place. 
 
 2. For support, as in the case of a sprained joint, etc. 
 
 3. For pressure, as in the ease of a bleeding vessel, etc, 
 
 355 
 
356 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 The specific uses are too numei-ous to mention here, and they 
 will be readily gathered in the following pages. 
 
 FORMS OF BANDAGES 
 
 Under the general definition the bandage may be of a great 
 number of forms, but those in more common and standard use 
 are: (a) The Roller Bandage, (b) The Triangula)' Bandage, 
 (c) The Many-Tailed Bandage. 
 
 Fig. 110. — The Eoller Bandage, 
 
 (a) The Roller Bandage (Fig. 110) is merely the bandage 
 material ^vhieh has been cut into a long, narrow strip and 
 rolled up, from one end to the other, into a compact cylinder 
 so that it may be more easily and quickly handled and used. 
 
 The market supplies these bandages in all materials and sizes 
 ready for use, but there will be occasions when these will not be 
 available and every student should learn the several methods 
 for preparing them. There are numerous hand machines for 
 
BANDAGING 
 
 357 
 
 
 Fig. 111. — Two Methods of Eolling a Bandage by Hand. 
 
358 TEXTBOOK OF SURGICAL NURSING 
 
 rolling bandages, and tlie nurse Avill liave access to these in 
 most hospitals, but as a preparation against the times when she 
 ■will be out of reach of machines she should practice one or 
 both of the Junid methods illustrated in Fig. 111. This is 
 really a simple thing to do and the only points to bear in mind 
 about it are that a solidly rolled bandage is nuicli more satis- 
 factorily applied than a softly rolled one, and that to secure 
 a solidly rolled one it must be very compactly rolled from the 
 very beginning because the whole will have no more body in 
 the end than its core. 
 
 The roller bandage is by far the more commonly used one, 
 and the one which is adaptable to the greatest variety of pur- 
 poses. 
 
 (b) The Triangular 
 Bandage (Fig. 112) is 
 simply a three-cornered 
 piece of material the shape 
 of the half of a square 
 which has been cut from one 
 
 Pig. 112. — The Triangular Bandage, corner to the diagonally op- 
 OR Sling. ., i • i i t_ 
 
 posite one, or which has been 
 
 folded double along this line. Aside from one or two uses which 
 will be encountered later, this bandage will be employed only as 
 a substitute for the roller bandage in emergency cases, as it is 
 more easily and quickly improvised than the roller one. 
 
 (c) The Many-Tailed Bandage (Fig. 113) is made in a 
 number of slightly varying designs but consists essentially 
 either of a single oblong piece of material which has been 
 split at each end into two or more tails (A and B of the illus- 
 tration), or of a combination of two or more strips whose edges 
 have been overlapped and stitched together in the middle, leav- 
 ing the ends free (C of the illustration). The particular type 
 C is commonly known as the Scultetus bandage or binder. The 
 many-tailed bandage serves few purposes for which the roller 
 bandage will not be preferred, but it has wide application and 
 constitutes a very serviceable emergency form because it is 
 simple to make and easy to apply. 
 
BANDAGING 359 
 
 A 
 
 Fig. 113. — Many-tailed Bandages. A and B, the simple design made 
 by splitting the ends of an oblong piece of material; C, the Scultetus 
 bandage or binder made from strips of material lapped one upon the 
 other and stitched together for a short distance in the middle. 
 
 MATERIALS USED FOR BANDAGES 
 
 It would be impossible to give an exhaustive list of the ma- 
 terials from which bandages are made because there is scarcely 
 any limiting requisite except that of flexibility. However, the 
 more or less standard ones for the three forms of bandages are 
 as follows: 
 
 (a) Boiler Bandage 
 Gauze 
 Muslin 
 
 Canton flannel 
 Woolen flannel 
 
360 TEXTBOOK OF SURGICAL NURSING 
 
 "Elastic" webbing (-woven cotton bandage) 
 
 Rubber 
 
 Crinoline impregnated witli stare-h — the "starch bandage" 
 
 Crinoline impregnated with plaster of Paris — the ''plaster 
 
 of Paris bandage" 
 Crepe paper 
 Gauze is the most frequently used material. Its advantages 
 are that it is light in weight, cool, and so flexible that it is easily- 
 fitted to all parts. It cannot be washed or used a second time 
 Avith satisfaction and is therefore a relatively expensive ma- 
 terial. 
 
 Muslin is very suitable where greater strength is needed, as 
 in the application of the larger splints, in the arrest of hemor- 
 rhage, and in other cases Avhere more pressure is required than 
 gauze will supply. It withstands washing and repeated usage. 
 Canton flannel, because of its combined softness to the touch 
 and its strength, is often used where pressure is necessary over 
 a sensitive part. It is also useful as padding underneath a 
 plaster or starch bandage. 
 
 Woolen flannel is used chiefly for its softness of texture. It, 
 too, is washable and can be used repeatedly. 
 
 '^Elastic" wehhing is a specially woven cotton material which 
 furnishes the advantages of the adaptability and a large part 
 of the lightness of the gauze, a measure of the strength of the 
 muslin, the softness of the flannel, and the elasticity of the 
 rubber. As a substitute for the rubber this bandage has the 
 very desirable superiority of being highly porous, but its 
 strength is considerably less. 
 
 The ruhher bandage, commonly known as the ''Esmarch," is 
 made of gum rubber. It is used as a pressure or constricting 
 bandage for the arrest of hemorrhage, or for special treatment 
 (see page 390). 
 
 The starch bandage is merely crinoline which lias been satu- 
 rated with a boiled solution of starch, and rolled loosely after 
 it has become dry. It is softened again in warm water for the 
 application, and when it has dried in place it constitutes a 
 fairly rigid and relatively light cast or splint. It will be used 
 for the immobilization of fractured or otherwise injured parts. 
 
BANDAGING 361 
 
 Plaster of Paris bandages are made of crinoline into which has 
 been rubbed as much plaster of Paris as it will hold. They are 
 applied wet and in numerous layers, and when they have dried 
 they make a very rigid, strong, and heavy encasement or splint. 
 They are used where complete immobilization of a part is 
 needed, particularly for fractures. 
 
 The nurse may need to make plaster of Paris bandages occa- 
 sionally, and to do so she will proceed thus : Tear the crinoline 
 the desired size (see under "Sizes of Bandages," page 362), and 
 remove all ravelings; pour a large quantity of the plaster in 
 a heap upon a smooth table ; lay one end of the bandage upon 
 this, brush a handful of plaster over it, rub firmly and smoothly 
 
 Fig. 1 1 1.--.Mk-i-i[()d op jMaking Plaster ob' Parts Bandages. Note the 
 large quantity of plaster in use, which is necessary for best results. 
 
 with the hand two or three times and then roll the finished por- 
 tion carefully and loosely (Fig. 114). Proceed thus, rolling 
 up each section of a few inches as fast as it is ready and han- 
 dling very carefully so as not to undo what has been done. Sub- 
 stitutes for the hand, such as a wooden spatula, have been tried 
 for rubbing in the plaster, but the hand is the best instrument 
 in that it causes less friction and jarring and therefore pro- 
 duces a more smoothly and evenly impregnated bandage. Use 
 plenty of plaster under your hand as you rub, brushing off 
 the excess immediately before rolling the finished part. Wrap 
 each bandage securely in paper as soon as finished. 
 
 Crepe paper makes a very light bandage, and as it does not 
 possess much strength it will be useful only where very slight 
 protection for dressings is needed. 
 
362 TEXTBOOK OP SURGICAL NURSING 
 
 (b) TriaiKjiihir Bandage 
 
 Muslin is the usual material for this bandage, but anj' similar 
 material ■will, of course, serve as well. 
 
 (c) Many-Tailed Bandage 
 
 Muslin and Canton flannel will be used for this bandage, 
 the choice depending upon the purpose it is to serve and the 
 part to which it is applied. 
 
 SIZES OF BANDAGES 
 (a) The Roller Bandage 
 
 The length of the factory-rolled gauze bandage is usually 10 
 yards, and that of the muslin and flannel ones 5 yards. These 
 have proved to be the most serviceable lengths on the whole, for 
 these materials, the greater length being needed in the gauze 
 because of its lighter weight and inferior strength which neces- 
 sitate the use of more layers of it. The crinoline for the starch 
 and plaster of Paris bandages may be of any length, but it is 
 wise to vary the length with the width — that is, the narrower 
 ones need not be as long as the wider ones. 
 
 The width of the roller bandage will depend upon the part 
 to which it is applied and will vary roughly as follows: 
 
 Finger % to 1 inch 
 
 Hand and arm li^ to 21/0 inches 
 
 Foot and leg IM2 to 3 inches 
 
 Hip 3 to 4 inches 
 
 Body (chest and abdomen) 3 to 5 inches 
 
 (b) The Triangular Bandage 
 
 This bandage will vary in size with the part upon which it 
 is used and will be in general as follows: 
 
 Arm (the sling) the half of 1 square yard 
 
 Hand the quarter of the sling 
 
 Foot the half of the sling 
 
 Head the half of the sling 
 
 Shoulder the half of 1 square yard 
 
 Hip the half of 1 square yard 
 
BANDAGING 363 
 
 (c) The Many -Tailed Bandage 
 
 It will not be very helpful to prescribe dimensions for this 
 bandage as it will need to be fitted to each patient, and the il- 
 lustrations in Fig. 145, page 389, will guide the student as to 
 the proper measurements to make. 
 
 PRINCIPLES OF BANDAGING 
 
 Before we undertake to apply a bandage we should adopt 
 as our fixed, guiding influences these three principles of the 
 art: 
 
 1. Evenness of Pressure 
 
 2. Durahility 
 
 3. Neatness 
 
 These principles are stated in the order of their importance, 
 and in the order in which they should be put into effect by the 
 beginner, but one may not call herself a finished practitioner 
 until she is able to observe the three simultaneously. They 
 scarcely need elucidation, but a few important details pertain- 
 ing to each of them which the student should be reminded of 
 are as follows : 
 
 1. Evenness of Pressure. — Every bandage necessarily ex- 
 erts a certain amount of pressure depending upon the part to 
 which it is applied and the purpose which it is to serve. A bony 
 part, such as the skull, for instance, will need and endure, in 
 general, more pressure than a yielding part, such as the hand; 
 and a bandage applied to compress a bleeding vessel must, of 
 course, exert more pressure than one which serves the mere 
 purpose of keeping a dressing in place. Much practice is the 
 only means of acquiring good judgment as to the suitable 
 amount of pressure for any given case, and this must always 
 be guided by an intelligent comprehension of the object of 
 the treatment and the condition of the part bandag'ed, and by 
 due consideration for the patient's immediate and future com- 
 fort. 
 
 "Whatever the tension of the bandage, however, the impor- 
 tant point, from all standpoints, is that it should be equal 
 
364 TEXTBOOK OF SURGICAL NURSING 
 
 throughout, because very serious results may follow otherwise. 
 In the first plaee, a bandage whieh constricts in lines here 
 and there is \tn-y uncomfortahle. This objection -svill often take 
 care of itself, however, through the complaint of the patient ; 
 but the really serious damage is done in those cases where the 
 part Avas j)reviously so painful throughout or so subnormally 
 sensitive for some reason that the patient does not accuse the 
 bandage. In these instances the unevenly-applied bandage may 
 so constrict blood vessels and compress nerves as to cause gan- 
 grene or parahjais in the part. 
 
 Of course, a bandaged pai-t is always kept under observation, 
 but the best precaution against accidents from unevenness of 
 pressure is plenty of diligent practice -with the bandage. 
 
 2. Durability. — The importance of durability in an applied 
 bandage is so self-evident as to need no comment, except, per- 
 haps, the reminder that an unstable bandage is usually a very 
 uncomfortahle thing to wear. 
 
 When one has learned the first principle well she has pro- 
 gressed a long way toward the secret of this second one. That 
 is, a bandage which is evenly applied, within the limitations of 
 reasonably good pressure, is more likelj^ to stay in place than 
 the uneven one. However, the problem of durability involves 
 much more than this and it is perhaps not an exaggeration to 
 say that excellence is harder to attain under this principle than 
 under either of the other two. 
 
 Much may be accomiDlished as to durability by placing the 
 part in its customary position or in the desired permanent one 
 before applying the bandage, because muscular motion under- 
 neath a bandage will surely disarrange it more or less. 
 
 Finall}^, faithfulness to the method customary for the part or 
 purpose will be of great importance because experience is re- 
 sponsible for the particular method and it will be rare that the 
 best results will follow any considerable departure from the 
 advice of long experience. These various methods will be taken 
 up a few pages hence and the student wall do well when she 
 reaches them to accord them a special mark of respect for the 
 sake of this ])rineipl(' of dural)ility. 
 
 3. Neatness. — This last principle is very unproverbial in 
 
BANDAGING 365 
 
 that it is also the least. However, though they do not rank high 
 as objects of beauty, most of the standard applied bandages do 
 admit of some artistic merit and every student should aim to 
 do them all the justice possible in this respect. Neatness 
 should be kept in mind with the other two important principles 
 from the very beginning, because with practice they will oper- 
 ate very well in unison, and if careless habits are once formed, 
 it will be hard to inject a new element into them. 
 
 MODES OF APPLYING THE ROLLER BANDAGE 
 
 There are these five recognized modes of applying the roller 
 bandage to the several parts of the body : 
 
 1. Circular 
 
 2. Spiral 
 
 3. Reverse 
 
 4. Figure-of-8 
 
 5. Recurrent 
 
 Each one of these modes has its reason for existence in some 
 peculiar adaptability to a part, in a special suitability for some 
 purpose,' or in a combination of the two. Very few applied 
 bandages, how^ever, are pure examples of one mode, for the 
 complexity of design in the human framework calls for a com- 
 pound of tw^o or more of them in the great majority of cases. 
 It will be helpful for the student, nevertheless, to study each 
 of these five elementary designs individually because she will 
 acquire thereby both synthetical and analytical power in the 
 work which will make it at the same time more intelligible and 
 more interesting to her. Accordingly, w^e shall pause here to 
 present each of the five modes in a simple detailed example, 
 and if the student will take this discussion seriously she wdll 
 save herself much floundering when she comes, a few pages 
 hence, to the necessarily more unorganized presentation of band- 
 aging as applied in the average everyday practice. 
 
 First of all, the part to be bandaged is arranged in the posi- 
 tion which is to be permanent for it ; the bandager takes a posi- 
 tion in front of the patient, as a rule (exceptions will be dis- 
 covered later) ; and the bandage is then disposed in the hands 
 
366 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 as illustrated in Fig. 115 — that is, oiu' hand proiiaros to place 
 and keep the free end where it belongs and the other to control 
 the unwinding of the bandage as it is applied. We then study 
 the five different modes thus: 
 
 - 1. Circular Mode. — The head is one of the subjects for this 
 type of bandage, and so with both liands we lay the bandage 
 against the forehead (Fig. 116), a small portion having been 
 unrolled for ease in properly locating it. The free end is held 
 against the temple with the one hand while with the other the 
 bandage is rolled around the circumference of the head Avitli 
 
 Fig. 115. — The Way to Grasp the Roller bandage preparatory to Ap- 
 plying It. 
 
 even and firm tension till it reaches the free end when it is con- 
 tinued over this and around the head again in exactly the 
 same track. After the end has been secured the hand which 
 held it will be released, of course, to assist the other one by 
 carrying the roll around on its side of the head. AVhen the 
 roll reaches the location of the free end the second time we 
 have a circle of two layers of bandage around the head (Fig. 
 117), and have thus secured by friction and stress, or, in other 
 words, have "anchored/' our bandage; and at the same time 
 we have applied the amount of bandage which may be taken 
 as a standard foundation — that is, two layers. This will rarely 
 ever constitute a complete piece of bandaging, but it does enter 
 
BANDAGING 
 
 367 
 
 Fig. 116. The Way to Begin the Application of the Eolleb Bandage. 
 
 Fig. 117.— The Circular Mode op Bandaging — the usual anchorage for 
 the applied roller bandage. 
 
 into nearly every bandage as the means of both anchoring it 
 in the beginning and of securing it at the end. 
 
 2. Spiral Mode. — For this demonstration we shall select 
 
368 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 the upper onn. Grasp the bandage as before, lay it upon the 
 arm near the elbow, and apply a eireular bandage — that is, 
 two layers, one directly upon the other, entirely around the 
 arm. Then begin to travel upward with slow spiral turns of 
 the bandage (Fig. 118), allowing each turn to cover at least 
 one-third of the width of the previously-applied one. Keep in 
 mind, as you do tliis, your three principles, maintaining the 
 same tension on your bandage throughout, rolling the layers on 
 smoothly and at a stable angle (that is, not so great an angle 
 that they will have a tendency to creep back), and make it as 
 
 neat as you can by keeping the edges 
 of every two layers parallel and by 
 covering the same fraction of the 
 width of the previous layer every 
 time. Finished with two or more of 
 the circular turns, this will make a 
 complete design which is applicable 
 only to such comparatively parallel- 
 sided parts as some upper arms, the 
 fingers, etc., or to similarly-shaped 
 
 splints. 
 
 3. Reverse Mode. — The forearm 
 is a suitable part upon which to 
 demonstrate this mode because of its 
 cone-like outline. It will be a good 
 plan for the beginner to apply, first 
 of all, a few turns of the spiral bandage to this part in order 
 to learn at once why it will not answer (Fig. 119). She will see 
 that it embodies an infraction of every one of the three principles 
 of bandaging — that is, the two edges of the bandage exert 
 unequal degrees of pressure, which is very clear from the fact 
 that one of them is entirely free of tension in a part of every 
 turn; it will not stay in place, as its appearance very clearly 
 indicates and as a slight pull would demonstrate; and it cer- 
 tainly does not look neat. AVe can correct all these evils very 
 easily, however, in this way: 
 
 Start just above the wrist with the now familiar circular 
 bandage; then begin one of the spiral turns, but just as the 
 
 Fig. 118. — The Spiral 
 Mode of Bandaging. 
 
BANDAGING 369 
 
 lower edge of the bandage shows the objectionable slack, which 
 is due to its having a shorter distance to cover than the other, 
 turn the roller upside down (Fig. 120), thus making a twist in 
 
 Fig. 119. — The Wrong Mode for the Part. Note the loose edge of each 
 turn. The Spiral Mode will fit only a parallel-sided part. 
 
 the bandage which uses up this slack and allows the bandage 
 to lie flat for the remainder of the turn, when the same prob- 
 lem will arise and it will be solved in the same way for each 
 
 Fig. 120. — The Way to Make a Reverse. The roller is now right side 
 up because one reverse has already been made. After the next reverse it 
 will be upside down again. 
 
 turn until the part is covered. In the act of twisting, or '^ re- 
 versing," the bandage, special care is required to avoid stretch- 
 ing it so tightly that it will be drawn into wrinkles instead of 
 
370 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 into one flat fold. This is done by holding the applied bandage 
 down Avith one hand just at the site of the reverse while the 
 free part is allowed to slacken slightly for the moment of the 
 reversal, after wliieh the usual tension is resumed for the next 
 turn. This bandage AA'ill be secured at the end with the usual 
 circular bandage. 
 
 A great deal of practice will be required before one can apply 
 the bandage well by this mode, and if it cannot be done well 
 
 A ^ 
 
 Fig. 121. — The Figure-of-8 Mode op Bandaging. A, the first turns; B, the 
 completed bandage of the ankle. 
 
 some other mode should be used instead for there are too many 
 loopholes in it for offenses against all of the three principles of 
 bandaging. It is a very suitable method, however, for tapering 
 parts, such as the arm and leg, and if one wishes to become a 
 versatile bandager she must learn it. 
 
 4. Figure-of-8 Mode. — The ankle furnishes us with a good 
 subject for this mode of bandaging. Start, as usual, with the 
 circular bandage as your anchorage, placing it around the foot 
 just at the base of the arch ; then pass the bandage in figure- 
 of-8 style thus: Diagonally across the instep toward the base 
 of the heel, around the back of the heel, and across the instep 
 
BANDAGING 
 
 371 
 
 again in the other diagonal to the original (drcular bandage 
 on the side opposite the starting point of the first diagonal (A 
 of Fig. 121). This completes one figure-of-8 turn, and the 
 bandage is continued simply by repeating this maneuver till the 
 part is covered, lapping each turn over one-third or one-half of 
 the width of the preceding one. If this is to constitute a com- 
 
 FiG. 122. — The Recurrent Mode of Bandaging. The patient is hold- 
 ing the reverses in place at the back of the head. On a smaller part, such 
 as the stump of a limb, the bandager can control the entire operation 
 himself. 
 
 plete dressing it will be secured by the circular bandage around 
 the ankle (B of Fig. 121). 
 
 Though the design of this bandage is not the simplest one 
 to learn, aside from that it is one of the easiest modes with 
 which to secure good results under all of the three principles. 
 Durability is an especially prominent feature of the figure-of-8 
 bandage, and its appearance can be made to compete yery fa- 
 vorably with that of any of the other modes. 
 
 The figure-of-8 design has a very wide application, being 
 almost the only suitable one for the joints of the iocly, particu- 
 larly the larger ones, such as the ankle, knee, hip, wrist, elbow, 
 
372 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 and shoulder; and it is also applicable, in coiiibliidtiou with the 
 reverse mode, in various other parts Avliich will be indicated 
 later. 
 
 5. Recurrent Mode.— This is pei-hai)s tlie most difiicult mode 
 to learji and it is also rather awkward to ai)i)ly. in that it re- 
 quires the assistance of a third hand wlien api)lied to the h(>ad, 
 which is the most common subject for it. Often the patient 
 himself will be able to lend this helping hand but if he can- 
 not do this an assistant must be pro- 
 vided. As it Avill probably be the 
 only available part for practice, we 
 shall select the head for our subject. 
 Pass a circular bandage around the 
 head, as described in ]\Iode 1, stop- 
 ping at the middle of the forehead ; 
 then reverse the bandage by the 
 same maneuver as you used for the 
 reverse Mode (Fig. 120, page 369), 
 and pass the roller backward across 
 the middle of the head and down 
 over the circular turn at the back, 
 holding the fold of the reverse firm- 
 ly in place with the thumb of the 
 other hand meanwhile, and now ask- 
 ing the patient or the assistant to 
 place his hand upon the intersection 
 of the layers on the other side (Fig. 
 122). Repeat this process, back and 
 forth, till the whole head is covered, working from the middle 
 toward the sides alternately, and covering one-half of the pre- 
 vious layer each time (Fig. 123). In stationing the reverses it 
 will be found possible and easiest to group them closely together 
 (each immediately on top of the previous one) in the middle of 
 either side rather than to distribute them along the circular 
 bandage, as they can be more easily held in place this way and 
 they will usually fit the part better thus. AVhen the head has 
 been entirely covered the bandage is again reversed to the direc- 
 tion of the original circular bandage and two more circular 
 
 Fig. 123. — Completed Ee- 
 CURRENT Bandage. Note that 
 the turns all lie flat, and that 
 they converge toward the mid- 
 dle of the forehead, wliieh 
 means that the reverses are 
 lying directly over one an- 
 other, as they should do. 
 
BANDAGING 373 
 
 turns are passed around the head to secure the ends wliich you 
 and your assistant have been holding. 
 
 This makes a comph^te bandage which will often be used for 
 the stump of a limb, the end of a finger, etc., as well as for the 
 head. 
 
 As stated above, these are elementary designs which will be 
 found in combinations of two or more oftener than alone, but 
 we shall assume that the student has practiced them as advised, 
 and in the following section shall build up the numerous com- 
 plex designs very largely in terms of these modes without again 
 going into the details of their structure. 
 
 THE APPLICATION OF BANDAGES TO THE VARIOUS PARTS 
 
 OF THE BODY 
 
 (a) The Roller Bandage 
 Hand and Arm 
 
 It will be an unusual case in which a bandage will be applied 
 to the fingers, the hand, and the entire arm at the same time; 
 but the student's best plan is to combine these parts in one les- 
 son and it will then be an easy matter for her to make the 
 subtractions appropriate for any given case. 
 
 Either the spiral or the combination of the figure-of-8 and 
 reverse modes will be found suitable for the fingers, with the 
 introduction of the recurrent mode if the ends of the fingers are 
 to be covered. As a rule, however, a finger bandage will not 
 be durable unless it is connected with the wrist by means of a 
 figure-of-8 and a circular bandage (Fig. 124), introduced after 
 every second or third spiral turn. Each finger may, of course, 
 be bandaged in this way separately, but in everyday practice 
 it will be found that w^hen two or more fingers need bandag- 
 ing they will usually be combined in one dressing and bandaged 
 together, in wdiich case the method for a single finger will apply. 
 In cases where all the fingers are involved they will usually be 
 combined in a single large dressing and the suitable mode of 
 bandaging them will then be the recurrent one (see Fig. 122, 
 
374 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 page 371). The finger bandage may be anchored either around 
 the wrist or tlie end of the finger. 
 
 The thumb presents a somewhat different ease from the fin- 
 gers in that it is nearly always bandaged with what is termed 
 the "spica" bandage (Fig. 125). This spica involves nothing 
 
 Fig. 124. — Spiral Bandage of the Finger Anchored to the Wrist with 
 a flgure-of-8 and a circular turn. 
 
 new as to mode, for it is a pure figure-of-8, but it so happens 
 that in the complete design the layers present the appearance of 
 the spikes in a head of barley, and therefore the bandage has 
 been given the distinctive name ' ' spica. ' ' Though the , term 
 has its origin in the mere appearance of the completed bandage, 
 
 Fig. 125. — The Thumb Spica. 
 
 "spica" always carries with it the meaning of a joint bandage 
 because the figure-of-8 takes on this appearance in all cases of 
 its application to a joint ^vhich connects an appendage to its 
 trunk. The application of a thumb spica will present no new 
 problem to the student, and we have emphasized it here only 
 for the sake of introducing the term which wall arise in several 
 other cases later. 
 
 Whether or not the fingers and the thumb are involved, our 
 
BANDAGING 
 
 375 
 
 method of procedure for the hand and arm will be this (Fig. 
 126) : Begin about the palm with the circular bandage, then 
 a spiral or two if necessary, and proceed with the figure-of-8 
 over the back of the hand and the wrist, around the wrist with 
 
 Fig. 126. — Complete Bandage for the Hand and Arm. 
 
 Fig. 127. — Reverse Figure-of-8 Bandage. A, front view showing the figure- 
 of-8 turn; B, rear view showing the reverse turn. 
 
 the circular, upward over the cylindrical part of the forearm 
 with the spiral, and thence with the reverse over the conical 
 part to the elbow. The elbow (in a slightly flexed position) is 
 then covered, directly over the joint, with two or three circular 
 
376 TEXTBOOK OF SURGICAL NURSING 
 
 turns, several figure-of-8 turns (enough to cover it securely) 
 are passed over this and about the joint, -working upward and 
 downward from the joint alternately. The upper arm is then 
 covered with either th(> spiral or the reverse, depending upon 
 whether it is of a general eylindrieal shape or a conical one. 
 
 On the shafts of the arm a combination of the figure-of-8 and 
 the reverse modes are very suitable, the figure-of-8 being used 
 as the theme and the reverse being introduced only when needed 
 to keep the bandage lying fiat and to equalize the tension of 
 the edges, which will usually be every second turn (Fig. 127). 
 In this ease the cross of the figure-of-8 turn is made on the top 
 
 Fig. 128. — Method foe Securing Better Anchorage of a Bandage 
 ON A Tapering Part. The long spii'al turns provide friction for the re- 
 mainder of the bandage and also stabilize the wrist portion. 
 
 of the arm (A of Fig. 127) and the reverse on the back (B of 
 Fig. 127). This bandage is very much preferred to any other 
 by some persons because of its superior durahility. 
 
 Another variation sometimes employed for securing durabil- 
 ity in a bandage of a forearm which is extremely conical in 
 shape is to run a lo]ig spiral turn (just after completing the 
 wrist section) from the wrist to the elbow, one or two circular 
 turns around the arm just below the elbow, and then the long 
 spiral back again (Fig. 128). This gives the forearm bandage 
 the advantage of a little more friction for keeping it in place 
 on the sloping part, as it will not tend to slip so much on these 
 turns of gauze as it would on the bare skin ; and these layers 
 have been made very secure by the turns at the elbow. 
 
 Foot and Leg 
 
 The toes may be bandaged separately, like the fingers ; and 
 when the figure-of-8 extension is necessary to keep it in place 
 
BANDAGING 377 
 
 the ball of the foot will usually answer as the wrist does for 
 the fingers. Also, as in the case of the fingers, when several 
 or all of the toes are involved they will usually be dressed to- 
 gether and the bandage will be the recurrent one. 
 
 Under Mode 4, page 370, the ankle bandage has been pre- 
 sented but the heel was not included as it involves one or two 
 special considerations, and in practice it is not covered in a 
 foot bandage unless there is a particular reason for doing so. 
 When the heel is involved the principles of the elbow bandage 
 may be applied to it — that is, after the circular turns have been 
 applied around the arch of the foot a long spiral turn of the 
 
 A 
 
 Fig. 129. — Heel Bandage. A, regular circular and figure-of-8 method; B, 
 variation necessary for a prominent heel — an interlocked figure-of-8. 
 
 bandage will carry it smoothly to the heel, a circular bandage is 
 applied around the heel and the instep, and the figure-of-8 
 ankle bandage is then applied as in the case of the elbow (A 
 of Fig. 129). 
 
 In cases where the heel is unusually prominent it will be im- 
 possible to cover it smoothly with the figure-of-8 bandage. This 
 difficulty may be overcome by modifying the design for several 
 turns as illustrated in B of Fig. 129. An analysis of these 
 turns will show that they constitute merely an interlocked 
 figure-of-8 passing crosswise of the ankle. 
 
 In general principles the foot and leg handage, as a whole, 
 is exactly like that for the hand and arm. Disregarding the 
 toes, we start around the arch of the foot with the circular 
 
378 TEXTBOOK OF SURGICAL NURSING 
 
 turns, and one or two spirals if needed. Then cover the heel 
 as described in the preceding paragraphs. This will entail the 
 fignre-of-8 of tlie ankle which was described under Mode 4, 
 page 370. The details for the remainder of the leg will then 
 
 Fig. 130. — Complete Bandage for the Foot and Leg. 
 
 correspond exactly wdth those given for the arm, including the 
 several variations pointed out there (Fig. 130). 
 
 The knee-joint bandage, of course, wall be upside down from 
 the standpoint of the bandager as compared with the elbow, 
 but this will not cause any noteworthy confusion. 
 
 The Eye 
 
 The eye bandage becomes a very simple one if we conceive of 
 it as being constructed, as it really is, entirely from the ele- 
 mentary circular bandage. Accordingly, let us imagine our 
 standard circular bandage to be rigid, like a barrel hoop, and 
 fit it thus into the several positions of the layers in the eye 
 
BANDAGING 
 
 379 
 
 bandage. First of all, we place it around the top of the head 
 as we did the circular bandage in the demonstration of Mode 
 No. 1 ; this is our foundation, or anchorage. Then we imagine 
 this circle on a pivot near the base of the nose and swing it 
 down over the eye we are to bandage till it reaches the neck just 
 below the ear on that side, and meanwhile, on the opposite side 
 just over the other ear, it will have risen somewhat above our 
 foundation circle. The two circles will now cross each other 
 
 Fig. 131. — The Eye Bandage. A, the first two circular turns in place; B, 
 the completed bandage for one eye. 
 
 on the forehead and on the back of the head (A of Fig. 131). 
 Then we swing our circle again but only far enough this time 
 to cover one-half or one-third of the width of the parts of the 
 other layers which lie below the one ear and above the other. 
 In other words, this layer lies the width of the lap nearer each 
 ear than the preceding one and crosses it on the forehead and 
 on the back of the head at the sites of its intersections with the 
 horizontal turn. This maneuver is repeated until we have 
 enough angling layers (usually two or three) to cover the eye 
 well, and then we swing our circle back again into the first 
 
380 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 Fig. 132. — Double Eye Bandage. 
 
 position and apply ono or two 
 of the horizontal tnrns to an- 
 chor the Avhole (B of Pig. 
 1-'51). On some heads it may 
 l)c necessary to anchor each 
 angling- circle willi the hori- 
 zontal one, bnt this will mean 
 merely swinging the circle al- 
 ternately from one position to 
 the other. 
 
 The flexible bandage will 
 not i^erform with all the me- 
 chanical exactitude of the 
 rigid hoop, of course, and the 
 changes in plane will have to 
 be made with gradual sweeps, 
 but these will be easily man- 
 aged if the student has her 
 picture of the hoop structure 
 clearly in mind. 
 
 To handage hoth eyes all 
 one needs to do is to alternate 
 the angling turns between the 
 two eyes, and as a rule one 
 anchoring turn should be ap- 
 plied for each pair of angling 
 ones. The whole is, of course, 
 anchored finally with one or 
 two of the horizontal turns 
 (Fig. 132). 
 
 Fig. 133. — The Ear Bandage. 
 Note that it is merely tlie eye bandage The Ear 
 
 design slipped about one-quarter of 
 the way around the head, and that 
 
 more turns are required for the ear rp^^^ g^^, bandage, for either 
 
 region than were needed for the eye. . 
 
 one or both ears, will corre- 
 spond to that for the eyes in all detail except that more turns 
 will be necessary as a rule (Fig. 133). In bandaging one ear it 
 is sometimes difficult to avoid covering the opposite one also, but 
 
BANDAGING 
 
 381 
 
 by careful planniiif? this (lifficulty can practically always be 
 overcome. 
 
 The Face and Jaw 
 
 The Barton bandage of the jaw will be used in case of frac- 
 ture where immobilization is desired. When analyzed this may 
 be called a compound figure-of-8 bandage, for it is composed 
 of two figure-of-8 's which have one loop in common — that is, 
 the loop which envelops the crown of the head makes a figure- 
 
 FiG. 134. — The Barton Bandage. A, method of anchoring; B, the 
 complete design. As this is usually a pressure bandage two or more layers 
 will usually lie necessary. The fastening of this bandage is not shown as 
 it will be best placed on the head or face turn on the other side. 
 
 of-8 with either one of the two adjoining ones. To apply this 
 bandage, begin by laying the end of the bandage diagonally 
 across the top of the head, pass downward across one cheek, un- 
 derneath the chin, upward over the other cheek, across the 
 head in the other diagonal (A of Fig. 134), downward and 
 around the back of the head, forward around the front of the 
 chin, thence to the back of the head, and then upward to the 
 starting point at the top of the head. This is the complete de- 
 sign of the bandage (B of Fig. 134), but as it is usually applied 
 for pressure upon the jaw one or two layers more will be added. 
 
382 TEXTBOOK OF SURGICAL NURSING 
 
 This bandage "will usually be applied under ronsidevable tension. 
 
 The illustrations (Fig. 135) show hru «v///.s- of applying a 
 
 haudage to the cheek, temple, or chin. They need no special 
 
 explanation except that they are started like the Barton band- 
 
 3 
 
 Fig. 135. — Two Methods of Bandaging the Cheek, Temple, or Chin. 
 A, a simple figure-of-8 which will fit a head with a prominent crown; B, 
 method necessary when the crown of the head is flatter, the 'turns about 
 the forehead alternating with the others and binding them iu place. Band- 
 age A is fastened on the other side of the head. 
 
 age. Since heads vary so much in shape a trial must always 
 be made of the first turn of these bandages to make sure that 
 it is stably stationed. A variation forward or backward, on 
 the top of the head, of the starting point, will always enable 
 one to find the proper balance. 
 
 The Head 
 
 The appropriate bandage for the head is the recurrent one 
 which we described under Mode No. 5 (Figs. 122 and 123, 
 pages 371 and 372). 
 
 A more convenient way to apply the head bandage, however, 
 is with tivo roller handages, the ends of which have been care- 
 fully pinned or sewed together (Fig. 136). For this we pro- 
 ceed thus: Lay the bandages against the middle of the fore- 
 head, and then hold one stationary while you apply the an- 
 
BANDAGING 
 
 383 
 
 choring circular bandage about the head with the other. Then 
 pass the bandage which has been idle across the top of the 
 head to the circular turn at the back, roll the other bandage 
 across this (Fig. 137), and then continue carrying the one 
 
 'K 
 
 Fig. 136. — Double Eolleb Bandage for the Application of the Recur- 
 rent Bandage. 
 
 bandage back and forth over the top of the head and binding 
 it down at each end by the circular turns of the other. 
 
 The whole head may, of course, need to be covered thus, but 
 the student should form the habit (which does not seem nat- 
 
 FiG. 137. — The Way to Use the Double Roller Bandage. 
 
 ural for beginners) of putting on only as much of the head 
 bandage as is necessary to keep the dressing in place, as it is 
 very easily discontinued at any point. 
 
 This recurrent bandage, especially when applied to the head, 
 is usually designated as the " capeline" bandage, because of its 
 
384 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 likeness to an iroji skull cap which was worn by soldiers in the 
 Middle Ages. 
 
 The Shoulder and Axilla 
 
 The '^spica" is the bandage most frecinently used for the 
 shoulder (Fig. 138). Like the thumb spiea, of course, it is 
 merely a figure-of-8 design, and needs no comment except, per- 
 haps, to point out that the application of it is begun about the 
 arm, and that a few spiral or reverse turns should be made 
 around the arm for secure anchorage before beginning the 
 spica proper. 
 
 AVhen there is a dressing in the axilla to be covered the shoul- 
 
 FiG. 138. — The Spica Bandage of the Shoulder. 
 
 der spica may be varied by alternating turns around the chest 
 with the figure-of-8 turns (Fig. 139). 
 
 The Velpeau bandage will be used to immobilize the shoulder 
 in such cases as fracture of the clavicle or scapula or disloca- 
 tion of the shoulder. Place the arm of the injured side across 
 the chest so that the hand lies Avell up toward the other shoulder. 
 Start the bandage by placing the end over the scapula of the 
 sound side, carry the roller forward over tlie injured shoulder, 
 angling doAvnward and underneath the humerus, and thence 
 forward over the anterior chest and around to the starting 
 point (A of Fig. 140). Repeat thi^ turn once for security and 
 
BANDAGING 385 
 
 strength, then make a circular turn around the chest and over 
 the arm just at the elbow, and then complete the bandage by 
 alternating these two turns till the whole arm has been cov- 
 ered (B of Fig. 140). 
 
 Fig. 139. — The Shoulder Spica Bandage Varied to Cover the Axillary 
 
 Eegion. 
 
 Fig. 140. — The Velpeau BANDAGE.r A, the first turns, two or more 
 layers being necessary, as a rule, in the turn about the humerus; B, the 
 completed Velpeau. 
 
 The Breast 
 
 This bandage is another figure-of-8, one loop of the figure 
 passing horizontally about the chest and the other diagonally 
 
386 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 between the affected side and the opposite slionlder (A of Fig. 
 141). 
 
 Start underneath the arm of the affected side and anchor the 
 bandage with two circular turns about the chest just beneath 
 
 A 3 
 
 Fig. 141. — The Breast Bandage. A, the way to start the bandage; B, the 
 
 complete design. 
 
 the breast, passing the roller across the anterior chest first and 
 then around the back — that is, when the right breast is to be 
 bandaged the end of the bandage is placed under the right arm 
 
 and the roller is carried across 
 the anterior chest to the left 
 arm ; and for the left breast the 
 direction is reversed. The an- 
 chorage completed, the first 
 diagonal turn is started directly 
 underneath the breast, and is 
 carried well over on the oppo- 
 site shoulder, thence angling 
 downward across the back and 
 around to the starting point. 
 These alternate horizontal and 
 diagonal turns are then re- 
 peated till the whole breast is covered (B of Fig. 141). 
 
 To bandage lioth hreasts at the same time, start as for one. 
 Apply the first diagonal turn, start the next horizontal turn but 
 carry it only as far as the opposite side and then instead of 
 completing it carry it diagonally upward across the back to the 
 
 Fig 
 
 142. — The Double Bkeast 
 Bandage. 
 
BANDAGING 
 
 387 
 
 other shoulder, and tlunice diagonally downward across the an- 
 terior chest and underneath the otliei- breast. Tlicii apply a 
 complete circular turn and extend it around to the starting 
 point under the first breast. Continue the bandage by alter- 
 nating the diagonal maneuvers with the horizontal one till the 
 breasts are covered (Fig. 142). 
 
 Hip Spica 
 
 There is no essential difference between this bandage and the 
 spica of the thumb. The hip spica is sometimes applied with- 
 out the circular turns about the waist (A of Fig. 143), but the 
 alternation of the circular turn with each figure-of-8 (B of 
 
 A 3 c 
 
 Fig. 143. — The Hip Spica Bandage. A, without the circular turn about 
 the waist; B, with the circular turn alternating with each figure-of-8; C, 
 the double spica applied with a single bandage. 
 
 Fig. 143) makes a more durable bandage and one which will 
 be more comfortable for most patients. Any part of the hip 
 region may be covered with this bandage by simply placing 
 the spica directly over the wound. This bandage may be 
 started around either the waist or the leg. 
 
388 
 
 TEXTBOOK OP SURGICAL NURSING 
 
 A double liip s\nri\ is very rcadilx xipplicd with diic biindajxe 
 by simply altcni.-it in<_;- tiic liuurc-dl'-S's hclwccu the sides and 
 inserting circular liiriis ahoiil Hie waisl, between them eaeh 
 time (C of Fig. 14:5). Tlus bandage may be started around 
 either the waist oi- one leg. 
 
 For the apiilieation of these bandages it will be necessary to 
 elevate the patient's hips on some such rest as that shown in 
 B of Fig. 43, page 220. 
 
 (b) The Triangular Bandage 
 
 As remarked previously, the triangular form of bandage, 
 with one or two exceptions (chiefly the sling), is an emergency 
 
 Fig. 144. — Various Applications of the Triangular Bandage. 
 
 one and will be used only in the absence of the roller bandage. 
 Emergencies, however, are very important and the nurse should, 
 therefore, not consider her bandaging education complete till 
 she has become adept with the triangular bandage. Parts to 
 
BANDAGING 
 
 389 
 
 which this bandage may be applied are the arm (sling), hand, 
 head, foot, shoulder, hip, etc., and the illustrations (Fig. 144) 
 will give the student all the suggestions she will need for the 
 several cases. 
 
 The three principles of bandaging are, of course, as ap- 
 plicable to this form of bandage as to the roller one. 
 
 (c) The Many -Tailed Bandages 
 
 The student's first concern as to these bandages is to make 
 them of the proper size because they must fit well if they are 
 
 Fig. 145. — Various Applications of the Many-tailed Bandages. 
 
 to be faithful to our three bandaging principles. Parts to 
 which the several types are applicable are the head, chin, breast, 
 abdomen, arm, leg, etc., and the illustrations (Fig. 145) will 
 show the variations suitable to these different parts. 
 
390 TEXTBOOK OF SURGICAL NURSING 
 
 MISCELLANEOUS SPECIAL BANDAGES 
 
 The plaster of Paris handagc is a roller bandage, but as it is 
 applied wet and eviMitnally liecomes very rigid its application 
 involves a few iioints wliicli dift'erentiate it from the average 
 roller bandage. First of all, the plaster is never placed directly 
 upon the skin, a substantial ]iadding of cotton, Canton flannel, 
 or stockinet, etc., always being used underneath it. Tlie nurse 
 ^\ill rarely ever apply this bandage herself but she will assist 
 with it and her part will doubtless be the soaking of it. This 
 she will do by standing it on end in a basin of sufficient warm 
 water or weak salt solution to cover it. A very few moments 
 wall suffice for saturating it, the cessation of the bubbling Avhich 
 always follows immersion indicating that it is ready for use. 
 Since you have probably made the bandage yourself you will 
 know how insecure the plaster is wdthin it and will therefore 
 be very cautious about the removal of it from the water. It 
 must be squeezed just enough so that the water will no longer 
 drip from it — no more and no less — for if too wet the dripping 
 water will carry the plaster away with it and will unnecessarily 
 wet the padding, and if too dry it will become hard before it 
 can be applied. Your method, therefore, wall be to encircle 
 the bandage very cautiously with a hand at either end, com- 
 press the ends gently at the same time, lift it out of the water, 
 and simultaneously extend your pressure over the remaining 
 surface just sufficiently to stop the dripping — but do not twist 
 it. Practice is required to do this well and without wastage 
 of the bandages, for it must be done quickly as well as care- 
 fully. As light w^ood splints are sometimes used to reinforce 
 this bandage they will be part of the nurse's preparation, as 
 wdll also a small amount of dry plaster which is sometimes used 
 for finishing the surface of it. 
 
 For the application of the starch bandage the nurse's prepara- 
 tion will be similar to that for the plaster, but the bandages 
 will not require the extreme care in handling and they may 
 be more nearly freed of the water. 
 
 The Esmarch bandage is sometimes applied for the purpose 
 of reducing the venous circulation of a congested part and 
 
BANDAGING 391 
 
 thereby increasing its arterial supply and the accompanying 
 local nourishment. This constitutes a special treatment known 
 as the "Bier's" treatment. It will, therefore, never be admin- 
 istered except by special order, but it belongs to the subject of 
 bandaging and there are several points about it which the nurse 
 should learn. 
 
 The treatment is usually administered to some inflamed part 
 of the extremities, and the general rule of applying the bandage 
 from, below upward will hold in this case. The mode of appli- 
 cation will be the spiral one ; the bandage will be applied above 
 the inflamed part ; and as the object of the bandage will be to 
 restrict the venous circulation and not the arterial, it must not 
 be applied too tightly. The frequency and duration of this 
 treatment will be prescribed, and while it is in operation the 
 nursing attention must be faithful. The parts below the band- 
 age should retain their normal temperature; there should be 
 no accompanying pain; the pulse in the part should not be al- 
 tered; but a moderate amount of swelling and edema, and a 
 bluish-red color, should be expected. As a rule, the part will be 
 elevated after the bandage has been removed to hasten the 
 reduction of the edema, but the nurse will be guided by in- 
 structions from the surgeon as to this. 
 
 Varicose veins of the leg are sometimes treated with a pres- 
 sure handage. The material to be used for this bandage will 
 usually be prescribed, and it may be any one of those we have 
 already discussed. The elastic materials, however, will prob- 
 ably be given preference, though where elasticity is desired it 
 may be secured in some degree with an inelastic bandage by 
 first covering the part with a thin layer of non-absorbent cot- 
 ton. The importance of this bandage from our present stand- 
 point lies in the requirements that it be very smoothly and 
 evenly applied, that its tension be sufficient to support the en- 
 larged veins without obliterating them, and that it be applied 
 as follows : Elevate the foot somewhat before applying the 
 bandage so that the veins will not be unnecessarily engorged ; 
 start the bandage near the toes ; and use the spiral form as much 
 as possible throughout, departing from it only sufficiently to 
 secure even pressure over the more irregularly-shaped parts. 
 
392 TEXTBOOK OF SFKOTCAL NURSING 
 
 A pressure bandage is sometimes applied to the extremities, 
 particularly the legs, in ease of shock to reduce the circulation 
 in them to some degree and therebj^ to conserve the heart's 
 energy somewhat. A generous layer of non-absorbent cotton 
 should ahvays be used under this bandage because, while it fur- 
 nishes the usually desired elasticity it also conserves the body 
 heat whieh is vitallj^ important in such cases. 
 
 Many of the bandages described in the practical discussion 
 above might properly be classified here also as "special" band- 
 ages — for examples, the ankle bandage in a case of sprain, the 
 Velpeau, the Barton, some of the spicas, and sometimes the 
 breast bandage — ^but as they are tluis distinguished merely by 
 their greater tension tliey merit only mention in this connection. 
 
 THE FASTENING OF THE BANDAGE 
 
 (a) The Boiler Bandage 
 
 First of all, the site selected for the securing of the end of 
 the bandage should be remote enough from the wound to avoid 
 causing pain to the patient by the manipulation necessary. If 
 not inconsistent with this point, an accessible place should be 
 chosen for evident reasons. And of not the least importance 
 is the point that all fastenings that protrude, such as knots and 
 safety pins, should be so placed that the patient will not have 
 the discomfort of resting upon them. 
 
 There are only about four good methods for fastening the 
 bandage and they have their special adaptations and limitations 
 as follows : 
 
 1. Safety Pin.— This fastener (A of Fig. 146) will apply 
 to most bandages and it is a very satisfactory one because it 
 can be passed through all the underlying layers and so bind 
 them all securely together. It may sometimes be objection- 
 able, however, for children in places where they can reach it 
 and open it, or where they might injure themselves upon it. 
 Likewise, irrational patients are liable to interfere with this 
 fastener. 
 
 2. Adhesive Plaster. — This is an unobtrusive and neat 
 fastener (B of Fig. 146) but it is not as secure as the safety 
 
BANDAGING 
 
 393 
 
 Fig. 146. — Methods of Fastening the Eoller Bandage. A, the cor- 
 ners of the end have been turned under so as to make a stronger and neater 
 finish, and a safety pin has been passed through it and as many of the 
 underlying layers as possible; B, the corners of the end have been neatly 
 turned under and a strip of adhesive plaster binds it to the layer under- 
 neath; C, the end of the bandage has been split lengthwise far enough to 
 make two tails long enough to be tied around the part, a knot being tied 
 at the bottom of the slit to prevent further tearing; D, the corners of the 
 end are turned under and a few stitches of thread taken between it and the 
 immediately underlying layer. 
 
 pin and will not, therefore, answer for some pressure bandages. 
 Also, it cannot be used for a bandage over a wet dressing nor 
 in any other case where the bandage is likely to become wet, 
 as in the instanee of the Carrel-Dakin treatment. 
 
394 TEXTBOOK OF SURGICAL NURSING 
 
 3. Tying. — This is a rough-and-ready method (C of Fig. 
 146) whit'h can always be resorted to in the absence of other 
 means. To fasten the bandage by this method, tear or cut it 
 down tlie middle of the end, tie a knot at the bottom of the 
 slit to prevent further tearing, and then tie these strips around 
 the part. The student should learn this method but she should 
 immediately store it away for emergency use only, as it is al- 
 most never comfortable to the patient because of the fact that 
 if it is tight enough to hold the bandage in place it will cause 
 a line of stricture. 
 
 The Esmarch 'bandage is an exception to this case in that 
 tying is about the only suitable method for it. The rubber 
 ■will not, of course, be split to make the strings, for tapes are 
 usually cemented to one end for the purpose. If these are 
 lacking, however, a few turns of a gauze bandage, a piece of 
 tape, or anything similar may be fastened about the terminus 
 of the Esmarch. The above-mentioned objection to tying does 
 not enter into this case because the rubber is rigid enough to 
 dissipate the objectionable pressure of the string. 
 
 4. Sewing. — This method (D of Fig. 146) is applicable 
 W'here greater strength is needed, or in the case of children or 
 irrational patients. It goes without saying, of course, that 
 great caution is necessary in sewing a bandage on a patient. 
 
 (b) The Triangular Bandage 
 
 The safety pin, tying of the corners, or both (see Fig. 144, 
 page 388), will cover all cases for this bandage. 
 
 (c) The Many -Tailed Bandages 
 
 Tying of the ends or safety pins will answer for the head and 
 chin bandages, but for the other parts safety pins are all but 
 indispensable (see Fig. 145, page 389). 
 
 MISCELLANEOUS BANDAGING RULES 
 
 1. Never bandage two surfaces of shin together — separate 
 them with gauze or cotton, preferably non-absorbent cotton. 
 There is always a certain amount of moisture present on the 
 
BANDAGING 395 
 
 surface of the skin and if this is confined it will accumulate, 
 and in addition to being uncomfortable it may seriously chafe 
 the parts in time. The non-absorbent cotton keeps these sur- 
 faces apart and allows evaporation of the moisture, whereas 
 absorbent cotton or gauze absorbs and retains it. This applies 
 particularly to the fingers, toes, axilla, and the arm and (;hest 
 in the case of the Velpeau bandage. 
 
 2. In all cases where surgical necessity does not contravene, 
 parts should he handaged in their accustomed position. This 
 applies with special emphasis to the ears, which should always 
 have sufficient padding behind them to prevent their being 
 held more closely to the head than is natural for them. Band- 
 ages of the neck, axilla, the hand and fingers, and the toes, 
 also call for special consideration in this respect. 
 
 3. In bandaging the hand and foot leave the fingers and toes 
 exposed if possible so that they may be watched as guides to 
 the condition of the circulation of the limb. Coldness, blue- 
 ness, and swelling of the fingers or toes, or of any part below 
 a bandage, are signs that it is too tight at some point. This 
 accident is very largely precluded by attention to pressure in 
 the application of the bandage, but it must not be forgotten 
 that parts under even the most expertly applied bandage may 
 swell later from causes entirely unrelated to the bandage itself. 
 In the cases of the arm or leg the pulse, if accessible, at the 
 radius or the dorsum of the foot will, of course, be a valuable 
 guide to the state of the arterial circulation. 
 
 4. Do not apply a wet landage because it will probably 
 shrink in drying and become too tight. The plaster of Paris 
 and starch bandages are, of course, exceptions, but they are 
 always applied with this in mind, and a thick padding of 
 stockinet, cotton, or Canton flannel is usually provided under- 
 neath them to guard against this danger. 
 
 5. When applying a bandage over a wet dressing, or over a 
 Carrel-Dakin dressing which will eventually become wet, re- 
 member this probability of shrinkage and apply it correspond- 
 ingly loosely. 
 
 6. If necessary to bandage a dressing under a splint, remem- 
 ber to do it loosely because, even though you may be able to note 
 
396 TEXTIU)()K OF SlKiiK'AL Xl'KSIXO 
 
 the condition of the part, it Avill be very ineonvenient to correct 
 undue tightness in this case, and durability is not important 
 here since the splint and its bandage Mill give the additional 
 security ■ needed. 
 
 7. In placing the reverses of the reverse bandage, see that 
 they are not over bony or prominent parts, such as the shin 
 or radius, for they may become very jiainful because of the 
 inicvcn surface they i-reate. The line of these reverses is best 
 l)lacc(l on ihc (iii1>i(lc of the leg and arm. 
 
 8. Always apply the roller handage from below upward, 
 particularly when exerting special pressure, because when put 
 on in the opposite dir(H'tioii it allows the veins, which are even- 
 tually' to be underneath it, to become engorged with blood which 
 is thus imprisoned and may later be the cause of much dis- 
 comfort and even more far-reaching trouble. Likewise, the 
 Seultetus bandage should be fastened from below^ upward. 
 
 9. Make it a rule in applying the roller bandage to the ex- 
 tremities to start hy rolling it outward rather than inward — 
 that is, to bandage a right arm or leg (assuming that you are 
 face-to-face with your patient), hold the roller in your left 
 hand and start by rolling it toward your left side ; to bandage 
 a left arm or leg, then, you will hold the bandage in your right 
 hand and start it toAvard your right. A test application will 
 show you that observance of this rule will give you greater free- 
 dom and ease in the adjustment of the reverses and the fig- 
 ure-of-8 's. 
 
 THE REMOVAL OF ROLLER BANDAGES 
 
 Gauze and paper bandages are rarely ever used more than once 
 and they are therefore usually cut away. If one is equipped 
 with the special bandage scissors (Fig. 147), the operation is 
 very simple as the blunt point can be passed underneath the 
 bandage with perfect safety, provided, of course, that the 
 region of the Avound is entirely avoided, as it should be in any 
 case. 
 
 The washable and rubber bandages will simply be uuAvound, 
 and a little practice will enable one to roll them together loosely 
 
BANDAGING 
 
 397 
 
 as fast as they ai-e uiiwouiid. DcxtcrJIy in this is really a 
 valuable acquisition because it saves much time and avoids an- 
 noyance to the patient and confusion to the bandager. 
 
 For tile removal of plaster of Paris 'bandages one needs a 
 
 Fig. 147. — Bandage Scissors. The one longer point is blunt and smooth 
 and is designed to be passed underneath a bandage immediately on the 
 surface of the patient's body without danger of injury during the process 
 of cutting off the bandage — a procedure which is never safe with an ordi- 
 nary pair of scissors. 
 
 strong knife or saw and a pair of strong bandage scissors. 
 There are special instruments (Fig. 148) made for this pur- 
 pose and they will usually be provided in hospitals. The oper- 
 ation consists merely in cutting directly through the entire 
 
 Fig. 148. 
 
 -Instruments for the Eemoval of Plaster of Paris Bandages 
 — Saw, Knife, and Heavy Bandage Scissors. 
 
 length of the shell in a sufficient number of places to enable 
 one to lift the cast away with as little disturbance as pos- 
 sible to the patient. The lines chosen must be accessible, of 
 course; if possible they should be remote from the wound (if 
 
398 TEXTBOOK OF SURGICAL NURSING 
 
 there is one) ; and to save labor one should selert the shortest 
 lines thai will answer the jMirpose. Some labor may be saved 
 in the sawiuy- proeess by Avetting the plaster immediately ahead 
 of the instrument with a few drops of hydrogen peroxide, 
 acetic acid, or bichloride solution. These solutions have a 
 slightly solvent power over the plaster, but a little plain water 
 answers the purpose very well also. Care should be taken not 
 to use enough of these solutions to wet bandages or dressings 
 underneath, and it should also be remembered that the bichloride 
 will be very unkind to the metal instruments if exposed to 
 them too long. The precaution should always be taken of dis- 
 carding the knife or saw in favor of the scissors before this 
 bandage is entirely severed to escape the danger of cutting 
 the patient. Sometimes this labor will be obviated by the sur- 
 geon who Avill cut the plaster just after applying it and while 
 it is still soft. In this case the cast will be bound together by 
 a strong bandage and its removal will then be a simple matter. 
 Starch bandages can usually be cut with strong bandage scis; 
 sors, though if they are thick the plaster knife or saw may be 
 needed. 
 
 Finally, practice is your great highway to success in the art 
 of bandaging. We may seem to have led you through more, 
 devious byways than necessary to bring you to it, but we be- 
 lieve this is a case of the longest way around being the short- 
 est way home. 
 
CHAPTER XXI 
 OPERATIONS IN THE HOME 
 
 There is perhaps no greater bugbear to the young nurse than 
 the prospect of having to prepare for an operation in the home. 
 No matter how excellent her course of training may have been 
 in general, she very rarely has learned the solutions of the 
 many practical problems which will arise when she is out of 
 reach of the elaborate equipment and the ready-to-use supplies 
 which made life comparatively simple for her in the hospital 
 operating room. However, the nurse who has learned her hos- 
 pital lessons best will, of course, succeed best in the home be- 
 cause operations in the home, while they do not call for new 
 principles, they do call with a vengeance for special combina- 
 tions and adaptations of the old ones. This is really a hard- 
 task until one has had a little experience, and even with ex- 
 perience each home will make some new demand upon one's in- 
 genuity and technical elasticity. System and good technic are 
 easy in the hospital operating room where practice has stand- 
 ardized everything in such a way as to make them almost auto- 
 matic, but in the home natural conditions are often quite ad- 
 verse. One can always succeed, however, by virtue of the very 
 fact which often hinders system in the hospital, namely, that 
 there are so many roadways to Rome. 
 
 "We shall now assume that you have had a good course of 
 training in the hospital operating room, that you have studied 
 Chapters XIV to XVII thoroughly, and that you have in 
 mind clearly the things you will need and your general course 
 of action, and with this for your armament we shall take you 
 into the home and endeavor to guide you there in the prepara- 
 tion for an operation. 
 
 If you have been nursing the patient a day or so before the 
 operation you may have had some warning and will therefore 
 • 399 
 
400 TEXTBOOK OF SURGICAL NURSING 
 
 have the advantaiio of doing some ])reliiuiiiary ])rc'paration 
 leisurely. If you are ealk'd on sliorl notice, however, you must 
 know hoAv to make the most of your time, beeause shortness of 
 time is not ahvays a good excuse for poor vork. In general, 
 then, -vve shall say that when you are called to jirepare for an 
 operation in the home you should proceed in tliis order: 
 
 First Step. — See to the supply of sterile gauze dressings, 
 towels, sheets, caps, gowns, masks, and gloves. Often the sur- 
 geon vill have these in readiness in his office and you vill not 
 need to supply them. In other cases you may be so situated 
 that you can buy CA^erything you will need from some supply 
 house. But often you will need to collect the best supply you 
 can find about the house or elsewhere and sterilize it by any 
 means you can devise. 
 
 There is scarcely any substitute for gauze in an operation, 
 but either it or its first cousin, cheesecloth, will be available 
 in the most remote place. How you make up your dressings 
 will depend chiefly upon the time you have, but be as simple as 
 possible. If the operation is to be an abdominal one you should 
 provide, if you. can, something to answer the purpose of the 
 abdomiinal tail pads described on page 224. The other gauze 
 supplies besides the wipes and wound dressings will depend 
 entirely upon the case. 
 
 Gowns will not be found in the home, and if the surgeon does 
 not supply them you will need to substitute something else. 
 About the onlj' thing you can use is a large muslin sheet, and 
 this can be made to work very well indeed by draping it about 
 the body in some such fashion as that illustrated in Fig. 149. 
 
 Improvisation of the cap will be very simple for any nurse 
 with a piece of muslin or gauze (Fig. 149). 
 
 Likewise, the face mask can be very quickly made from gauze 
 or muslin (see mask C, Fig. 45, page 222). 
 
 Sheets and towels must be what you can get, but always use 
 the muslin ones rather than the linen if you have a choice, as 
 they are more satisfactory in every respect. 
 
 It will rarely ever be advisable to undertake to pi^jvide a 
 supply of dry sterile gloves because there will be no suitable 
 
OPERATIONS IN THE HOME 
 
 401 
 
 home method of sterilizing them thus, and their preparation 
 will be suggested later on. 
 
 Perhaps the best type of improvised sterilizer is made from 
 a wash boiler which has a well-fitting lid. Fill the boiler about 
 one-fourth (or less) full of water. Suspend the parcels to be 
 
 Fig. 149. — Improvised Cap and Gowisr. For the cap a piece of gauze 
 about 1 yard long and a half yard wide has been used. Muslin or any 
 similar material will do as well. The gown consists simply of an ordinary 
 bed sheet, one edge of it being laid across the chest, the two upper corners 
 crossed in the back, brought up over the shoulders, and pinned to the 
 edge in front. 
 
 sterilized over the water, and just clear of its surface, by one 
 of the following methods: (a) Fasten a piece of muslin across, 
 hammock fashion, by tying the ends to the handles of the boiler ; 
 (&) Make a platform by laying narrow strips of wood upon 
 pillars of bricks, stones, or some similar heavy household article 
 laid in the bottom of the boiler; (c) Lay in the bottom of the 
 boiler anything you can find which will hold the supplies to be 
 sterilized above the surface of the water in such a way as to 
 
402 TEXTBOOK OF SURGICAL NURSING 
 
 allow free circulation of the steam through them, particularly 
 from the bottom upward — a kitchen colander, sieve, or a wire 
 dish-draining tray may be Avell adapted to this purpose. Cover 
 the hoilrr tightly. After the water has reached the boiling 
 ])oiiit tlie lieat siipi)ly should be so regulated as to keep it barely 
 boiling because the steam is all you need for your purpose and 
 you gain nothing by the vigorous boiling except unnecessary 
 splashing of the water over the supplies. If the cover fits well 
 tlie weight of it Avill compress the steam slightly and thereby 
 raise its temperature someAvhat. Do not make the mistake, 
 however, of trj-ing to secure the lid of an ordinary wash boiler 
 sufficiently to make it steam tight as this may result very dis- 
 astrously. 
 
 Continue the steaming for at least one hour. 
 
 The parcels must then he dried, of course, and this may be 
 done in the kitchen oven, on the radiator, in the sunshine, or if 
 there is a little time to spare, an electric fan will answer. Care 
 must be taken when using the kitchen oven not to have it so 
 hot that it will scorch the supplies. 
 
 The haking oven also furnishes another means of steriliza- 
 tion. If one has a thermometer, the oven can be made to serve 
 quite satisfactorily, as the gauze and muslin materials are 
 safe from scorching below 300°F. and a much lower tempera- 
 ture than that wall not sterilize unless maintained for an im- 
 practicably long time. However, in the absence of a thermome- 
 ter one can regulate the temperature fairly accurately around 
 the scorching point by testing it with a loose piece of gauze 
 or muslin or a piece of newspaper and regulating the supply of 
 heat so as to keep the temperature just below this point. This 
 is a rather unrefined method but it is better than none. As 
 the parts of the supplies which come in contact with the metal 
 of the oven will burn sooner than the free parts, it is advisable 
 to put several layers of newspaper under the parcels, as this 
 will serve as an insulator and will also show when the oven is 
 too hot before the damage spreads to the supplies. When there 
 is a shelf in the oven it is better to use this than the floor of it 
 because the shelf will allow better distribution of the heat. 
 
OPERATIONS TN TTTK TiOME 403 
 
 An hour should be aUowed for tliis inciliod ol" sterilization 
 also. 
 
 Parcels to be sterilized by such improvised methods must 
 not be made too large nor too compact because the lack of 
 pressure and exact regulation of temperature make thorough 
 penetration rather uncertain. 
 
 In a very rare case you may be so isolated from supplies and 
 so short of time that you cannot apply any of the above meth- 
 ods of sterilization. In such an emergency it would, of course, 
 be possible to get along by boiling towels and sheets, and even 
 dressings, and using them wet, but such an exigency is so im- 
 probable as scarcely to be worthy of mention. 
 
 Second Step. — Select the most suitaMe room. First, deter- 
 mine the transportability of the patient, and if there is no limi- 
 tation on that ground you may proceed thus : If the operation 
 is to be done in the daytime the best lighted room possible is 
 the one to choose. If it is done at night, or if there is not good 
 daylight available, consideration must be given to the artificial 
 light equipment before the room is decided upon. 
 
 If it is large enough and has the necessary light, the bathroom 
 is perhaps the best one because it can be most easily cleansed 
 both before and after the operation. The kitchen is perhaps 
 the last choice because it will disturb the household routine 
 more than that of any other, and the sanitary objections from 
 the standpoint of both the kitchen and the operation are very 
 strong. Of the remaining rooms the choice will depend, first 
 of all, upon the light, and secondly upon the amount of work 
 and confusion necessary to adapt them for the purpose. 
 
 Cases in which you are obliged to use an otherwise unde- 
 sirable room because the patient cannot be moved will be rare, 
 and you will have to make the best of the situation; but, after 
 all, lack of light would be about the only serious obstacle which 
 would ever arise in such a case. 
 
 When the patient's bedroom itself must be used the prepara- 
 tion must be made as brief and simple as possible because it will 
 be an exceptional patient who will not be considerably unnerved 
 by having his misfortune thus emphasized for him. Screens 
 will, of course, help in most cases to shield the patient some- 
 
404 TEXTl'.OOK OF SFRCJITAL NURSING 
 
 ■what, l)iit all rcan-aiiucnit'iit of the room wliirli is not abso- 
 lutely necessary should be avoided^ and everyt]iin<;' possible of 
 a surgical appearance should be kept outside till the anesthesia 
 has been started. 
 
 Third Step. — Renovate the room ficlected. This step can be 
 overdone as av(>11 as underdone. The room must, of course, be 
 thoroughly clean, but if little time is to intervene between the 
 renovation and the operation the removal of carpets, pictures, 
 etc., Avill do more harm than good by raising dust which will 
 not have time to settle sufficiently. When there is a day's warn- 
 ing, for instance, Ave should remove the carpet in the interest 
 of both itself and the operation, but it is d()ul)tful that it is ever 
 necessary to go to the extreme of removing w^all hangings be- 
 cause these articles can usually be made as sanitary as the walls 
 themselves by careful moist dusting. Also, the removal of fur- 
 niture can be carried to an extreme, because such articles as 
 tables, dressers, etc., can be reasonably cleaned and used as 
 convenient pieces of operating room furniture. One must use 
 a great deal of common sense in adapting a room for operations, 
 and in doing so the time provided will take first place in mak- 
 ing decisions, confusion of the household second place, and tech- 
 nical convenience last place. By technical convenience we do 
 not mean technical safety, because safety can be secured under 
 almost any conditions by skilled management after the stage 
 is set. 
 
 When carpets arc left in place they must he carefully covered 
 both for their own protection and for the confinement in tliciu 
 of any dust which might otherwise be raised. This is easily 
 done by spreading several layers of newspaper upon them, and 
 if the lower layer is moistened with Avater we may feel that the 
 room is very well insulated from the dust of the carpet. Sheets 
 may be tacked down over the newspapers if desired, but the 
 newspapers themselves probably make a better floor surface for 
 the purpose than the sheets. A large rubber sheet immediately 
 under the operating table is, of course, ideal, but unless it is 
 known that there will be considerable drainage from the wound 
 an extra amount of newspaper will serve as well. The practice 
 of covering pictures, furniture, etc., Avith sheets is a doubtful 
 
OPERATIONS IN THE HOME 405 
 
 precaution because such articles can nearly always be made as 
 free from objectionable features as the sheets themselves by judi- 
 cious dusting. 
 
 Windows which offer a view to the neighborhood may be 
 very easily "frosted" by rubbing a little wet "bon ami" or a 
 thick lather of soap over them. Sapolio and other scouring 
 powders will answer but nothing is so easily applied and re- 
 moved as the "bon ami." 
 
 Fourth Step. — Boil some water and set it aside to cool for 
 the cold sterile water you may need. This can be done in any 
 large vessel you can find, and the quantity will have to be 
 judged from the nature of the operation and the amount your 
 method of hand sterilization will call for. 
 
 If you have not been able to secure sterile salt in any other 
 form, it will be wise at this time to provide a pint or more of 
 10% salt solution. This can be made in a small basin or kitchen 
 pitcher from tap water and table salt, and boiled. 
 
 Fifth Step. — Provide the necessary tables, etc. Some surgeons 
 will bring with them a portable folding operating table, but in 
 the absence of this convenience you will need to look about the 
 home for a good substitute. In doing this it must be kept in 
 mind that this table must not be too wide. A long, narrow 
 kitchen or library table will often be suitable ; two shorter tables 
 may be placed end-to-end; a strong ironing table may answer 
 very w^ell, with the addition of a small stand at the foot if it is 
 not long enough ; a narrow door may be taken down and sup- 
 ported upon small tables, boxes, etc., or extension boards from 
 a dining room table, or any other boards, may be utilized simi- 
 larly. The height of any of these tables can be increased if 
 necessary with magazines, books, etc. A pad of blankets or 
 something similar must, of course, be provided for the table. 
 
 A small stand that may be drawn up to the operating table 
 will be suitable for the instruments, and any other table, dresser 
 top, etc., which can be draped sterilly will answer for the re- 
 serve sterile supplies. 
 
 If a folding ironing board is available it can be made to serve 
 admirably as an instrument table which may be drawn across 
 the operating table. 
 
406 TEXTHOOK OF SURGICAL NURSING 
 
 For fhe anesthetist's seat a small, low stand may answer, books 
 or a box may be placed upon a chair, or any one of a dozen 
 substitutes may be devised. 
 
 Make sure that there will he the proper kind of light. There 
 will usually be an extension light of some kind in the home 
 which may be appropriated if the ordinary light of the room 
 is not sufficient or is inconveniently located. 
 
 Sixth Step. — Collcet those other things ivhich will need to 
 he sterilized, sueh as solution basins, pitcher, irrigator, hand 
 brushes, etc. Recall the articles we have listed in Chapter XIV 
 on pages 212-213, decide upon which you will need, and then se- 
 lect the best substitute available. Hand basins and the other 
 smaller basins can usually be found among the kitchen equip- 
 ment ; a i)itrher will alwaj^s be at hand; a rubber douche bag, 
 or a kitchen funnel and rubber tube will take the place of the 
 irrigating can for irrigations, infusions, etc. ; and hand brushes 
 may be found in every household. 
 
 The simplest way to sterilize these things is to boil them in the 
 Avash boiler or some large kettle on the kitchen stove. If you 
 cannot find anything large enough in which to do this you may 
 have to boil the larger basins directly on the stove with the 
 smaller things inside of them. Basins sterilized in this way will 
 be sterile on the outside as Avell as the inside, but after standing 
 over a gas flame or a stove of any kind it must be remembered 
 that they will not be clean enough on the outside to associate with 
 the other supplies, and must be kept away from them. Some- 
 times you may need to resort to the method of sterilizing the 
 interiors of some of these things by means of the alcohol flame 
 as described in Chapter XV on page 242, or one of the chemical 
 solutions may have to serve. With careful management the 
 unsterile outsides of these articles will not do any harm. 
 
 In sterilizing these household articles great consideration must 
 be accorded them, and nothing should be used in any way that 
 may be injurious to it unless the family is w^illing to have it sacri- 
 ficed. As a rule the family will place anything in the house at 
 your service at this time, but you have so much latitude in the 
 way of substitutes that you need not make any inroads upon 
 family valuables. 
 
OPERATIONS IN THE HOME 407 
 
 At this time boil another teakettleful of water and keep it hot 
 for the hot sterile water supply. 
 
 Seventh Step. — Collect such unsterile articles as you are 
 likely to need. Blankets and hot water bottles are always easily 
 secured ; one or two kitchen pails of any sort will answer for floor 
 basins; a pillow for the patient's head and several others for 
 adjustment of the patient's position should be ready; one or 
 two extra unsterile sheets, and a few towels will be needed; 
 adhesive plaster, bandages, and safety pins are, of course, ele- 
 mentary provisions for all operations. 
 
 You should, of course, think of the possibility of a hypodermic 
 of some stimulant or sedative and make a rule of having your 
 own syringe in readiness, though the surgeon or anesthetist will 
 doubtless see to this also. 
 
 Provision for the preparation of the operative field should also 
 be made and you should have at hand whatever of the probable 
 things you can secure. Soap and alcohol will nearly always he 
 available, and in the modern household you will be very likely 
 to find iodine. This is another responsibility of which the sur- 
 geon will probably relieve you. 
 
 Eighth Step. — If the ruhher gloves have not ieen otherwise 
 prepared you will now hoil them for about 5 minutes with the 
 basins and other things which have been boiling and then store 
 them in one of the basins in some antiseptic solution. It is 
 always a good plan when boiling a number of gloves to put them 
 into a bag for the process. This makes handling easier and 
 safer, and the parcel itself can simply be placed in the solution 
 basin and the gloves used directly from it without any previous 
 handling. 
 
 You may or may not need to concern yourself about the instru- 
 ments as the surgeon may bring them with him at the last 
 moment ready for use. However, unless you know that this will 
 be the case you should have boiling soda water ready for them 
 in a suitable basin ; or, if you have them in advance, now is the 
 time to see that they are boiled. If you have the advantage of 
 an electric or gas boiler or a portable stove of any kind which 
 may be heated in the operating room, that will be ideal, as it is 
 
408 TEXTBOOK OF SURGICAL NURSING 
 
 always a comfort to have the instrument boiler reasonably near 
 the operating: table. 
 
 Great care must always be taken, however, with an open fire 
 of any -kind in the operating room to keep it a safe distance 
 from the ether, cldoroform, or ethyl chloride, as these anesthetics 
 are highly inflammable. Also, intense heat, and particularly an 
 open flame, decomposes chloroform vapor and forms phosgene 
 and hydrochloric acid gases which, if released in a poorly venti- 
 lated or small room, may seriously irritate the eyes and the 
 respiratory tract of the occupants. 
 
 Ninth Step. — All unsterile supplies being in place, and the 
 sterile ones either ready or almost so, about one-half hour before 
 the appointed time for the operation you should begin the sterile 
 preparation of the room. 
 
 You have, of course, provided a place and the supplies for 
 Ste7'ilizati\0)i of the hands. The bathroom basin will probably 
 answer this purpose whether you are using the room for the 
 operation or not. Any running water available should be 
 utilized, but in cases where there is none you will need to provide 
 hand basins and plenty of both unsterile and sterile water in 
 pails or pitchers. The method of hand sterilization you prepare 
 for will depend upon Avhat antiseptics you can get, but in most 
 eases you can follow one of those suggested on page 263. 
 
 The general technic for '' setting up" the room can be the 
 same as in the hospital. Your sterile basins, instruments, etc., 
 are in the kitchen or wherever you may have boiled them, and 
 if they cannot be transported sterilly by an unsterile assistant 
 you may have to bring them yourself after you are sterile. If 
 you have used a wash boiler the probability is that everything 
 is in it (with the exception of the instruments which you may 
 have boiled separately) and unsterile assistants can carry this 
 to the operating room when you are ready for it. 
 
 Dispose all the sterile supplies as accessibly as possible, for 
 assistants will usually be fewer in the home than in the hospital 
 and you will have to perform more than the usual duties assigned 
 to one person there. Also, plan well ahead for the unsterile 
 work, because you may have to depend upon untrained persons 
 for this. 
 
OPERATIONS IN THE HOME 409 
 
 The first one or two operations with which you assist in the 
 home, especially if you have finished your hospital training 
 recently, will seem somewhat confused technically; but if you 
 have kept everything sterile and have avoided wastage of time 
 for your patient you have succeeded well and have doubtless 
 broadened your education to the extent of learning that there 
 is more than one good way to do everything. You must never 
 expect to graduate in this branch of work, however, for no two 
 homes wall present the same problems, and you will always need 
 to be prepared to rise to new occasions. 
 
 The general directions for draping given in Chapter XVI on 
 pages 266 to 290 may be followed in the home operation, though 
 greater economy in sheets and towels will often be obligatory. 
 Some of the draping accompaniments, such as sandbags, rubber 
 sheets, towel clamps, etc., will doubtless be missing, but pillows, 
 rolls of newspaper or magazines, etc., well bound together will 
 take the place of sandbags; newspaper or oilcloth will nearly 
 always answer for a rubber sheet; and safety pins will make 
 good towel clamps if artery forceps cannot be spared. 
 
 As cautioned above, have all sterile supplies within as easy 
 reach from the operating table as possible because your duties 
 will probably be manifold during the operation, and you may 
 need to hold a retractor, for instance, with one hand while you 
 perform the instrument passer's duties or the general assistant 
 nurse's duties with the other. As in all operating room manage- 
 ment, time spent in preliminary planning and the exercise of 
 good common sense will be your best investments. 
 
 Your duties after the operation w'ill depend upon circum- 
 stances, but in any case you will make sure that all the household 
 articles which were used for the operation are put into proper 
 condition again for home use. This applies in a special way to 
 the household linens. All blood-stained pieces should be rinsed 
 clear of blood, and infected ones should be soaked in some anti- 
 septic solution such as 1-40 carbolic or 1% formalin; for it 
 should be remembered that servants and members of the family 
 naturally shrink from these things, and that outside of hospitals 
 laundries are probably not prepared to treat them properly. 
 
410 TEXTBOOK OF SURGICAL NURSING 
 
 Likewise, you are the person to see that all soiled gauze is safely 
 disposed of, and that the other articles which have been used 
 are thoroughly cleansed and resterilized. Also, if the floor, 
 walls, or other parts of the room have been contaminated in any 
 way the responsibility is yours of seeing that they are restored 
 for family use. In other words, you do as a well-trained nurse 
 always does, namely, leave things as you found them. AVhere 
 servants are plentiful you will doubtless be relieved of most of 
 the reorganization of the room, but sterilization is a professional 
 responsibility and you should not delegate any part of it to 
 untrained persons. 
 
 What you do in the home with instruments or other things 
 which you or the surgeon may have brought in will depend upon 
 whether you remain to nurse the patient or are free. If you 
 can cleanse and resterilize these things without disturbance to 
 the patient it will be better practice to do this before carrying 
 them about, but your chief concern should always be to restore 
 the normal conditions of the home as soon and as unobtrusively 
 as possible under existing circumstances. 
 
 IMPROVISED OPERATIVE POSITIONS 
 
 The arrangement of special positions will be rather difficult 
 in cases where the surgeon does not provide the portable oper- 
 ating table, and even then some of the more elaborate attach- 
 ments will doubtless be missing. The portable tables usually 
 provide for the lithotomy and Trendelenburg positions, but for 
 gall bladder and kidney positions you will need a substitute for 
 the elevating attachment, and for arm cases you may need an 
 arm board substitute. The following suggestions will provide 
 ways out of these difficulties: 
 
 Trendelenburg Position. — Sometimes it may be possible to 
 incline the entire improvised table enough to answer the pur- 
 pose, but a plan which can always be used in the home is to 
 arrange a small chair on the table as illustrated in Fig. 150. 
 To overcome the tendency of the patient to slide on this the 
 shoulders may be lashed to the table by means of a strong band- 
 age or a small sheet. Pillows and blankets must be freely used 
 with this contrivance to pad or supplement it. 
 
OPERATIONS IN THE HOME 
 
 411 
 
 Gall Bladder Position. — All you will need for this is a suit- 
 able pillow to take the place of the usual table rest shown in 
 Fig. 65, page 272. 
 
 Kidney Position. — A large pillow will be needed in this ease 
 to take the place of the table rest (Fig. 67, page 274). Other 
 pillows will make good substitutes for the sandbags, but compact 
 bundles of old magazines or any other suitable articles, such as 
 sheets, blankets, etc., may be fitted to the purpose. 
 
 "Fig. 1.50. — Ordinary Chair Adapted for Improvisation of the Tren- 
 delenburg Position. The bandage is first wound very tightly from leg to 
 leg and afterward, to keep it from slipping downward, it is lashed to each 
 leg by tying a short piece of bandage tightly around it and over the end 
 of the leg. It will be necessary to use plenty of pillows or folded blankets 
 over the bandage and the back of the chair, both for the protection of 
 the patient and for the adjustment of his position. 
 
 Lithotomy Position. — Some means of supporting the legs 
 will be your first concern for this position. There are several 
 designs of "lithotomy crutches" (Fig. 151) on the market to 
 which you may have access. Otherwise, a large sheet may be 
 used as illustrated in Fig. 152. This sheet has been folded 
 diagonally into a neat strap before application because it is 
 more compact and stronger this way. Note that the sheet is 
 passed on the outside of the thigh rather than the inside before 
 it is tied or pinned below the knee, because otherwise the feet 
 
412 
 
 TEXTBOOK OF SURGICAL NURSING 
 
 ^vill tend to turn inward ^\■lu'ro they will be in the way of the 
 surgeon. If the knees tend to fall so far outward as to cause 
 too "much strain u|)i)n the hip joints the banda<i'e shown in the 
 
 A ^ 
 
 Fig. 151. — Lithotomy Crutches, or Leg Holders, for Supporting the 
 Legs in the Lithotomy Position. A, of the illustration, shows the essen- 
 tial principles of the Clover crutch, which is adjustable in all parts. The 
 leg straps are fastened around the thighs ; the horizontal portion is made 
 of metal and holds the legs from swaying sidewise; and the long strap 
 passes underneath the back. B represents the Eobb leg holder. This, also, 
 is anchored under the patient's back. 
 
 illustration connecting the knees should be used, but this will 
 not always be necessary. A strong bandage or any other strap- 
 like contrivance maj'- be used instead of the sheet. In some cases 
 
 Fig. 152. — Method of Improvising a Lithotomy Crutch from an Ordi- 
 nary Sheet Folded into a Strap, with the Addition of a Few Turns 
 OP A Bandage About the Thighs if Necessary. 
 
 where the operation is to be short and there are assistants avail- 
 able two persons may hold the legs in position. 
 
 Some substitute for the Kelly pad will he necessary. For 
 this you wall require a w'aterproof sheet of some sort about a 
 yard square. In the absence of a rubber sheet d> piece of oil- 
 
OPERATIONS IN THE HOME 413 
 
 cloth can usually Ik' found. Make a solid roll of n('ws})a])f'r 
 2 or 3 inches in diameter and 3 or 4 feet in length ; bend this 
 into a semicircle, lay it across one end of the rubber sheet and 
 then roll the rubber sheet around this and turn them inward 
 together until they are securely combined and are the desired 
 size and shape. You should then have a pad like the one illus- 
 trated in Fig. 153. 
 
 If you know that there will not be an irrigation during the 
 operation or that there will not be drainage of any kind from 
 the wound this pad will not be needed. 
 
 Fig. 153. — Improvised Kelly Pad. A rubber sheet or a piece of oilcloth, 
 and a few newspapers rolled together and bent into a semicircle, combined 
 as indicated, are all that one needs for this contrivance. 
 
 A pillow or old magazines will make the substitute for the 
 sandbag which you may or may not need under the hips. 
 
 Arm Position. — When an extra rest is needed for an arm 
 case a small side table may be used ; or, a small board of any 
 kind may be slipped under the jDatient's \)0&y (underneath the 
 table pad) and allowed to project as desired (Fig. 79, page 
 283). As a rule the weight of the patient wall be all the an- 
 chorage necessary for this board, especially if it is long enough 
 to extend well across the table. 
 
 You will find it helpful in all these problems of improvisation 
 to take as your guiding star the result you wish to secure rather 
 than the passing detail of making or finding an exact copy of 
 some convenience you have learned to use in the hospital, 
 because in emergency work getting the operation done is of 
 
414 TEXTBOOK OF SURGICAL NURSING 
 
 more import am-o tJiau elegance of equipineiit. This is not meant 
 as an indorsement of neglect to do the best you can in any 
 respect, but merelj' to nrge emi)hasis upon essentials. In this, 
 as in all human activities, experience will be the best teacher. 
 
APPENDIX 
 
 SOLUTIONS 
 
 A solution is a liquid which has dissolved within it some solid, gas, 
 or other liquid substance. 
 
 Liquids differ greatly as to the amount of any given substance they 
 can hold in solution, each one varies with its temperature, and also 
 there are wide differences among the various substances as to the 
 amounts of them Avhich any given liquid is capable of dissolving. The 
 differences pertaining to the various liquids themselves are not of prac- 
 tical interest to the nurse because water is about the only solvent she 
 uses, so the folloAving remarks about solutions will refer to those made 
 with water, and the substances considered will be only the more com- 
 mon ones which the nurse Avill encounter in everyday practice. 
 
 Two extreme instances of the limitations Avhieh substances impose 
 upon the solvent power of water are those of silver nitrate and boric 
 acid. We can dissolve in 1 ounce of water at a certain temperature 
 more than 2 ounces of silver nitrate but only about 25 grains of boric 
 acid, and if we put any greater proportion of one of these substances 
 into the water the excess will merely remain undissolved either in the 
 bottom of the container or in suspension in the water, and the solution 
 itself will be what is called a saturated one. Likewise, there is a defi- 
 nite saturation point for every other substance. 
 
 A saturated solution of any given substance, then, is one in which 
 the liquid is holding in solution all of the substance which it is capable 
 of dissolving. 
 
 The poiver of water to dissolve any substance, however, varies with 
 the temperature, the rule being that the higher the temperature the 
 more it can hold in solution. Therefore, the term ''saturated solution" 
 is only a relative one. In the following table of a few substances 
 frequently used by the nurse are given the amounts of water in which 
 1 gram of the substance makes a saturated solution. The figures are 
 those given in the United States Pharmacopoeia, and they apply only 
 when the water is at the temperature of 25° Centigrade (77° Fahren- 
 heit), which is the temperature adopted in the Pharmacopoeia as tbe 
 standard normal one. The milliliter is used in the table as the unit 
 of volume instead of the cubic centimeter, but although the two units 
 are not quite identical they are given the same apothecary equivalent 
 (16.23 minims) and it does not matter, for present purposes, which 
 term is applied. 
 
 415 
 
416 APPENDIX 
 
 Table of Amounts of Water in Which 1 G-ram Makes a Saturated 
 
 Solution 
 
 Alum 7.2 mils 
 
 Bichloride of niercuiT lo.") " 
 
 Boric acid IS.O " 
 
 Carbolic acid lo.O " 
 
 Magnesimii sulpliate 1.0 mil 
 
 Potassium perinanoanate 13.5 mils 
 
 Silver nitrate 0.4 mil 
 
 Sodium bicarbonate 10.0 mils 
 
 Sodium chloride 2.8 " 
 
 With a table of figures at hand for reference a saturated solution 
 is easy to make, but this strength of any substance is not often used 
 and the nurse's chief concern will be about the weaker stjhilions which 
 she will have to make either from the undissolved substance, the satu- 
 rated solution, or from a solution of some other streugtli. 
 
 The strengths of solutions are indicated either by the per cent method, 
 as a 5% solution, or by the arithmetical ratio metiiod, as a 1 in 20 
 solution, both terms showing the ratio which the weight of the dis- 
 solved solid substance bears to the corresponding measure of the whole 
 amount of solution. That is, they Avill stand for grains in minims, 
 ounces in ounces, grams in cubic centimeters or mils, etc. For large 
 quantities, of course, multiples of these units are substituted in prac- 
 tice, and for smaller quantities fractions will enter into the compu- 
 tation. 
 
 T]ie per cent method of reckoning solutions is often very puzzling 
 to beginners, but it is in reality comparatively easy because it involves 
 only the simple rudiments of percentage. The term per cent means 
 merely, by the hundred, and the symbol, '^'/c , is only an abbreviated 
 form of y-J-Q- . The 57f solution, tlien, could be designated as a y| ^^ 
 (five one-hundredths) solution, or a 5 in 100 solution, which means 
 that there is the proportion of 5 grains in every 100 minims. This 
 is the same as a 1 in 20 solution, since, if there are 5 parts in every 
 100 parts there must be 1 part in every one-fifth of 100, or 1 in every 
 20 (usually written 1-20). Similarly, the process of division may be 
 carried into fractions, for if there is 1 in 20, there must be ^2 iii 10> 
 and ^ in 5. The minim, of course, is not divisible in practice, but 
 the grain may be fractioned indefinitely, as will be shown later on. 
 Also, instead of dividing both these numbers they may be multiplied, 
 which will be convenient in case large quantities of solutions are to 
 be made, and thus the 1-20 solution could be considered a 10 in 200 
 or a 50 in 1000 solution, and so on indefinitely, though the practical 
 
APPENDIX 417 
 
 Ijlan in this case is to use a larger unit, such as the dram (fiO grains 
 or minims), the ounce (4cS0 i^rains or minims), etc., instead of the 
 single grain or minim. Similarly, a 25% solution may be designated 
 as a ^^^^, 25 in 100, 1 in 4, or a 1/4 in 1 solution, and so on for any 
 per cent of strength. 
 
 As stated above, a minim can not be divided in practice and there- 
 fore it will occur in some per cents of strength that the grains and 
 minims are not in such ratio that 1 grain will correspond to an exact 
 whole number of minims. In an 8% solution, for example, there are 
 8 grains in 100, 4 in 50, and 2 in 25, beyond which the comparison 
 can not be carried because the next division would be 1 grain in 121/2 
 minims, and since I2V2 minims can not be measured it can not be 
 used in these computations. A way around this obstacle, however, is 
 provided later on. 
 
 Fractions of 1% are a little different problem, but they present no 
 difficulties if they are regarded as merely fractions of y-J-g-- For in- 
 stance, a -|- % solution is a ^ of y^t? ^ f^o'' ^i" ^ 1-500 solution. 
 
 In actual practice frequently, when large quantities of a solution 
 are to be made, it will not be practicable to measure the solutions in 
 minims, and the apothecary dram (60 minims) and the ounce (480 
 minims) will be rather aAvkward to reconcile with the per cent (1-100) 
 system of reckoning. A universal rule which covers these cases is 
 given later on, but occasionally one can use as convenient landmarks 
 such multiples of these measures as 5 drams, for instance, which eon- 
 tain 300 roinims, 5 ounces, which contain 2400 minims, and so on. 
 
 We can now make a solution such, for instance, .as a 2% or a 2-100 
 one of boric acid, for all we need to do is to take 2 ounces of boric 
 acid and add enough water to it to make 100 ounces in all. The stu- 
 dent should learn, before she goes further, that it would be wrong to 
 make this solution by adding 2 ounces of boric acid to 100 ounces of 
 water because the finished solution would contain more than 100 
 ounces and we should then have 2 in more than 100. Neither would 
 we always have 102 ounces of solution in such a case because the 
 ounces of the solid substance are determined by apothecaries' weight 
 and those of water by apothecaries' measure, and they are not, there- 
 fore, to be reckoned as equal. If we start out to make 100 ounces and 
 make all calculations for that amount we must see that we have ex- 
 actly 100 ounces when we have finished. 
 
 The real problem of solution making, however, arises when we have 
 to make a limited quantity of some particular strength, and the be- 
 ginner may be puzzled to know hoAv she can make a solution of 1 
 grain in 1000 minims of water, when she is expected to make only 
 1 ounce (480 minims). But a second thought will show that the 
 1-1000 is only a statement of a ratio and not a prescription of a whole 
 grain and an actual 1000 minims. For instance, if there is 1 grain 
 
418 APPENDIX 
 
 of bichloride in 1000 minims, there must be j'q of a grain in 100 
 minims andyJ-Q-of a grain in 10 minims, and the strength of the 1-1000 
 sohition could be written -^^q -100, -jJ^-lO, and so on. 
 
 In the following jirobleius, the per cent and the ratio designations 
 of solution strengths will be intermingled, and the student should make 
 it a point to be able to translate from one to the other at sight. 
 
 Tableis and powders, as our source of supply, will not entail any 
 difficulties except those which arise also with the various stock solutions, 
 so we shall use stock solutions chiefly and the tablet and powder 
 problems will take care of themselves at the same time. 
 
 Problem. — Make 5 ounces of 2% silver nitrate solution from a 25% 
 stock solution. 
 
 In quantities no larger than this it will be best to reduce the ounces 
 to minims, first of all. 
 Then, 5x480 = 2400 
 
 The total number of minims desired, therefore, is 2400; and as 2%, 
 or j|-^ of this amount is eventually to be silver nitrate, 
 then, 2% of 2400 
 
 or, y|-j5- X 2400 = 48, the number of grains needed. 
 
 The next step is to get this 48 grains from the 25% stock solution; 
 and this solution may be analyzed thus : 
 
 25 grains = 100 minims 
 5 " = 20 " 
 1 grain = 4 " 
 
 To get the 48 grains, then, we take from the stock bottle 48 times 
 the quantity which contains 1 grain, or, 
 
 48 X 4 ^ 192, the number of minims to take, 
 = 3 drams, 12 minims. 
 
 In making the solution, remember that this 3 drams and 12 minims 
 must constitute a part of the total 5 ounces prescribed instead of being 
 an addition to it. This will be clear to the pupil because when she 
 started out she desired 5 ounces, not 5 ounces plus 3 drams and 32 
 minims, and made all her calculations for the even 5 ounces. The 
 practical way of securing this amount, if a large enough measuie is 
 at hand, will be to put the 3 drams and 12 minims into it first and 
 then add water up to the 5-ounce mark. If a smaller measure nuist 
 be used, the only way will be to reckon the difference between 5 
 ounces and the 3 drams and 12 minims and measure out only that 
 amount of water. 
 
 Students who are familiar with the subject of algebraic proportions 
 will find it very applicable in a ease like that of the above problem, 
 for we can reason thus: The quantity of 25% solution which we mr..st 
 use will bear the same relation to our final quantity of 2% solution that 
 2% bears to 25%' ; and with 
 
APPENDIX 419 
 
 x' = quantity of stock solution we nnist use 
 a = quantity of dilute solution we are making 
 & = strength of dilute solution we are making 
 c = strength of stock solution 
 we can state our problem thus: 
 
 x: a^^ h : c 
 In other words, when we take a small amount of 25% solution and 
 convert it into a larger amount of 2% solution we merely accept the 
 ratio which the strengths of the two solutions dictate and then, by the 
 use of a certain quantity of water, relate such portions of the solutions 
 as have the inverse of their strength ratio. Then, we can solve our 
 problem thus : 
 
 Let X =^ the number of minims of the 25% solution we shall have to use- 
 Then, :r: 2400 = 2%: 25% 
 Solving for x, 25a; = 2 x 2400 
 
 = 4800 
 a; = 192 
 Remember, that if we let x equal the number of minims we must eon- 
 vert our 5 ounces to minims, and that if we prefer to use 5 ounces or 
 40 drams we must let x equal the number of ounces or drams. 
 
 We can solve any form of solution problem with this formula by 
 merely using x for the unknown term. Apply it, then, to the same 
 solution under the following various conditions : 
 Problem. — How much of a 1-4 solution of silver nitrate will be needed 
 
 to make 5 ounces of a 2% solution f 
 Let X = the number of minims of the 1-4 solution needed, 
 and 1-4 = 25%. 
 
 Then, a;: 2400 = 2% : 25% 
 
 2bx = 4800 
 « = 192 
 Or, let x = the number of minims of the 1-4 solution needed, 
 
 and 2% = 1-50. 
 Then, x : 2400 = 1-50 : 1-4 
 
 = 4:50 
 50:r = 9600 
 x = 192 
 
 Problem. — How many grains of silver nitrate will he needed to make 5 
 
 ounces of a 2% solution? 
 Let a; = the number of grains needed, 
 
 and 2% = 1-50.' 
 Then, a;: 2400 = 1:50 
 
 50a; = 2400 
 a; = 48 
 
420 APPENDIX 
 
 Problem. — 117/rt/ /n Ihe slremjlh of a silrcr nil rate sohiliijn in which 
 
 ihere are -iS grains of silver ))iiralc lo every 5 ounces? 
 Let , X =^ the jier cent of strength 
 
 then, a;-100 = the rnlio of strength 
 Hence, x : 100 = 48 : 2400 
 
 2400a; = 4800 
 x = 2 
 and a:-100 = 2-100 
 
 = 1-50 
 
 Problem. — Make 5 ounces of 1-50 silver nitraie solution from a 25% 
 
 solution. 
 Let .i' = the nninl)ei' of minims of the 25% solution needed, 
 
 and 1-50 = 2% 
 Then, :r: 2400 = 2% : 25%> 
 
 25a; = 4800 
 X = 192 
 
 Problem. — Hoiv much 2% solution can he made from 4S grains of silver 
 
 nitrate? 
 Let X =^ the number of minims tlial can be made, 
 
 and 2% = 1-50. 
 Then, 48 : a; = 1 : 50 
 
 or, a; : 48 = 50 : 1 
 
 X = 2400 
 
 The above method works perfectly until we have a problem that re- 
 quires us to use a stock solution which will not yield the grains or 
 fractions of a grain we need in whole minims. For instance, apply 
 it to this 
 
 Problem. — Make 1 ounce of I- % silver nitrate solution from a 5% 
 
 solution. 
 Let a; = the number of minims of the 5%^ solution needed, 
 
 and 1 ounce =^ 480 minims. 
 Then, x : 480 = i % : 5% 
 
 5x =4 A 
 a; = 13f 
 Thus, we need 13# minims. But Ave can not measure >- of a 
 
 ' 7 ' 
 
 minim. Li many cases | of a minim would be so unimportant that 
 it could be dropped ; but if we were dealing with morphine, for in- 
 stance, it would not be unimportant and we must, therefore, know some 
 way out of such a difficulty. 
 
 We shall now formulate a rule ivhich icill cover the most involved 
 fractions, and it will be worth while for the ]iupil to work this out, for 
 when she has done so she will be equal to the most intricate i^roblems 
 and will understand the short cuts of the simple ones all the better. 
 
APPENDIX 421 
 
 In the following process we shall deal only with fractions of a 
 grain because usually any whole grains that may be needed with them 
 could be taken from the stock solution separately, and if not, the whole 
 number and the fraction could be reckoned as an improper fraction. 
 
 Taking the above problem then, we can analyze it thus : 
 (1.) What fraction of a grain will be needed? 
 
 1 ounce = 480 minims 
 
 J % or -J_r of 4Sfl = 4 8 =: 2 4 
 
 Therefore, the amount of silver nitrate needed is -|-| of a grain. 
 
 If preferred, this question may be answered by the proportion for- 
 mula thus : 
 Let X = the fraction of a grain needed, 
 
 and 1 % = 1-700. 
 Then, ' «: 480 = 1:700 
 
 700j; = 480 
 
 -r.=:24 
 
 (2.) What is the smallest number of minims that may be taken from 
 the stock solution which will yield |^|- of a grain? 
 Analyze the 5% stock solution thus : 
 
 5%= 5-100 
 = 4-80 
 = 3- 60 
 = 2- 40 
 = 1- 20 
 = 3/4-15 
 = 1/2- 10 
 = 1/4- 5 
 An inspection of these numerous possibilities shows that 15 minims, 
 containing % of a grain, is the smallest one Avhieh Avill yield the neces- 
 sary 11^ of a grain. Therefore, we measure out 15 minims of the stock 
 solution. 
 
 (3.) How can Y-k of a grain be divided so that exactly |-|- of a grain 
 could be separated from it? 
 
 If the 3^ of a grain were made up of thirty-fifths, like the ||- of a 
 grain we need, it Avould be easy to take away from it the desired 24 
 pai'ts. But the quarters of any whole thing can never contain an in- 
 tegral number of its thirty-fifths. We can, however, find a small frac- 
 tion of a grain which both the % and the f-i will contain exactly in 
 their respective proportions. In other words, we can find a common 
 denominator for these two fractions. 
 Then, % and |-|. = iff and J^^ 
 
 In the 15 minims, then, there are 105 parts of the grain of the same 
 size ( y|^ of a grain) as the 96 parts which we wish to get from it. 
 
422 APPENDIX 
 
 (4.) How can 15 minims of icater he divided into 105 parts? 
 
 The addition of water to the 15 minims of silver nitrate solution will 
 not change the amount of silver nitrate in the whole quantity, but it 
 will change the amount in each minim. We can, therefore, add enongii 
 minims to the 15 so that each of its 105 parts of a grain will have a 
 certain number of whole minims to itself. 
 Thus, 15 + 90 = 105 ^= 1 minim for each y]^ of a grain, 
 
 and 15 + 195 = 210 = 2 minims " " " "" " 
 
 and so on indefinitely. 
 
 With a different stock solution it might have happened that the |2§" 
 of a grain were in more than 105 minims of water in the beginning. 
 For instance, from a V2% stock solution, 150 minims would have to 
 be taken to get -] 5| of ^ grain. 
 Then, 150 + 60 = 210 := 2 minims for each -j ] ^ of a grain, 
 
 and 150 + 165 = 315 = 3 minims '' " " • " " " 
 and so on indefinitely. 
 
 Thus, we could add as much water as we pleased as long as our total 
 number of minims could be distributed equally among the 105 parts of 
 a grain which we know they hold in solution. In other words, Ave 
 must add to our portion of stock solution the number of minims of 
 water that will make the total number exactly divisible by the number 
 of parts of a grain which are in it. 
 
 (5.) How, then, do we determine the actual number of minims which 
 we must take from this new solution in order to get exactly the 
 ■f^ ''** Tl% ^f ^ gfo-ii^ '?t'e need? 
 Since jl^ = 1 minim 
 
 then -i\% = 96 X 1 
 
 =^ 96 minims 
 
 Therefore, 96 minims will be the amount of this diluted stock solution 
 to use to get -^-^ or |-^ of a grain. 
 
 Likewise, if y|-^ = 2 minims 
 
 then -^^ = 96 X 2 
 
 = 192 minims, 
 and 192 minims would be the portion to use. 
 
 Then, we can summarize the process for solving fractional solution 
 problems thus: 
 
 (1.) Determine the fraction of a grain needed. 
 
 (2.) Take from the stock solution the number of minims which con- 
 tain the fraction of a grain nearest this {at least as large, of 
 course). 
 
 (3.) B educe these two fractions to a common denominator. 
 
 (4.) Add enough water {if any is necessary) to the portion of stock 
 solution so that the total number of minims will be divisible by 
 
APPENDIX 423 
 
 the number of parts of a (jrain which it contains {the numera- 
 tor of the larger fraction) ; and note the number of minims pro- 
 vided for each of these parts. 
 (5.) Multiply this number of minims by the number of parts of the 
 grain needed {the numerator of the smaller fraction). This 
 will be the number of minims to use. 
 
 To become familiar with the rule, apply it step by step to several 
 more problems : 
 Problem.' — Malte 1 ounce of \% solution of boric acid from a 4% 
 
 stock solution. 
 (1.) ^% or -^-^ of 480= 11^, the needed fraction of a grain. 
 (2.) 4% =4-100 
 
 = 1-25 
 
 Since |^ is very little less than 1 grain, a whole grain, or 25 minims, 
 will have to be taken from the 4% stock solution. 
 
 (3.) 1 = 11 
 
 Thus, the two fractions we have to deal with already have a common 
 denominator. 
 
 (4.) Our portion of stock solution is 25 minims, a number which 
 is divisible by the number of parts of a grain in it, so no water need 
 be added in this case; and we have 1 minim for each -^-^ of a grain. 
 
 (5.) . 24x1 = 24, 
 
 and 24 is therefore the number of minims to use to get -|| of a grain 
 of boric acid. 
 
 The experienced student will be able to solve this problem by mere 
 inspection, for it happens that steps (3), (4), and (5) solved them- 
 selves in the nature of the case and were evident at a glance. 
 
 In a case like. this it would be just as simple to put the whole grain 
 into 500 minims of water and discard the 20 minims containing the 
 unwanted -gV of a grain, since the wastage is the same in the two 
 cases and they require about the same work to carry out. Sometimes, 
 hovp^ever, wastage will not be so negligible, and it will not always be 
 necessary under the rule. 
 Problem. — Make 4 ounces of 1-7000 potassium permanganate solution 
 
 from a 1% stock solution. 
 (1.) 1-7000 = ^0% 
 
 ■^ % of 4 ounces 
 
 or, -if^^ of 1920 = ytjSg., the fraction of a grain needed. 
 (2.) 1% = 1-100 
 
 = 1/2-50 
 =1-40 
 = 1^-30 
 
424 APPF.NDTX 
 
 The ^ of a gTain is the nearest to wiiat we need, so 30 minims is 
 
 our quantity. 
 
 (^ ) =^. anrl -^ s^ r= LO o. 3,,^ -^K^^. 
 
 (•^•J. 10 ''"'^' 170 35 **"•* ^Bff* 
 
 (4.) . 30 + 75 = 105 
 
 =^ 1 minim for each ^^ y of a grain. 
 (5.) 96 X 1 = 9G, 
 
 and 96 is therefore the number of minims we need to use to get .^^q, 
 or .•♦.*V of a grain. 
 Problem, — Make 100 minims of^% cocaine sohdiuu from a J'/o stock 
 
 solution. 
 (1.) ^% of 100 ^^g-, the fraction of a grain we need. 
 
 (2.) 1% = 1-100 
 
 = 1-50 
 = -40 
 Therefore, use the | of a grain in 40 minims. 
 
 (3.) I- and -1=36^ and t\ 
 
 (4.) 40 + 2 = 42 
 
 = 7 minims to each j^g- of a grain. 
 (5.) 5x7^=35, 
 
 and therefore 35 minims is the amount tO' use to get j^^, or ^ of a grain. 
 Problem. — Make IY2. ounces of 1-1000 bichloride solution from a 1-16 
 stock solution. 
 
 (1.) 1% ounces = 720 minims 
 
 1-1000 = ^0% 
 •Jy-% of 720 minims ^= jVcfo' 
 
 ^ J-l, the fraction of a grain needed. 
 
 2 5' = 
 
 (2.) Stock solution = 1-16 
 
 = 1/2-8 
 
 = 1/4-4 
 
 = 34-12 
 The 12 minims containing % of a grain Avill jaeld the amount we 
 Avish. 
 
 (3.) I and ^f = -^Vo and -j^q. 
 
 (4.) 12 + 63 = 75 = 1 minim to each -^ -J-^ of a grain. 
 
 72 X 1 = 72, the number of minims to use. 
 
 All but a few solutions are more easily and quickly made with warm 
 water than with cold, and as they are nearly always warmed for use 
 it will be the best practice to warm the water first. In making a 
 saturated solution, however, the element of temperature, already 
 pointed out, must be remembered. 
 
 The temperatures of water understood by the tei'ms "cold," "warm," 
 etc., as ado])ted in the IT. S. P., are as follows: 
 
APPENDIX 425 
 
 Cold water 15°-25° Centigrade 
 
 Lukewarm water 35°-40° " 
 
 Warm water 60°-70° " 
 
 Hot water 85°-95° " 
 
 The practice, often reconunended to nurses, of making a saturated 
 solution by merely putting into the water a little more of the substance 
 than it will hold, is not a refined one, for the excess is always in the 
 container and if it is not in suspension it is in the bottom of the con- 
 tainer and becomes mixed in solid form with the solution every time 
 it is agitated. The nurse's best coarse in making all solutions will be 
 to measure all ingredients accurately and she will then know exactly 
 what she is dealing with. 
 
 In measuring minims of any solution the student must remember 
 that the drop is not a permissible substitute for the minim. The 
 minim is an invariable and standard unit of measure, while the size 
 of the drop varies with many conditions, chiefly the size and shape of 
 the dropper, the temperature of the liquid, and the nature of the 
 liquid. Under standard conditions a drop of distilled water will equal 
 a minim, and the same will be true of a few other liquids, but among 
 the great majority of liquids there are striking differences in the size 
 of the drop. To get a picture of the inequality of drops and minims 
 the student will do well to study the following table which shows the 
 number of drops in a dram of a few familiar liquids under standard 
 conditions. The fluid dram, of course, is a standard measure con- 
 taining 60 minims. 
 
 Table of Drops in a Fluid Dram 
 
 Water 60 
 
 Dilute hydrochloric acid 60 
 
 Glycerine 67 
 
 Castor oil 77 
 
 Balsam of Peru 101 
 
 Tincture of digitalis 128 
 
 Tincture of unx vomica 140 
 
 Aromatic spirit of ammonia 142 
 
 Alcohol 146 
 
 Tincture of iodine 148 
 
 Ether 176 
 
 Chloroform 250 
 
 The nurse will usually have a prescription to guide her as to the 
 strength of any solution she is to use, but a reference list of the usual 
 strengths of the more common ones is given below : 
 
426 
 
 APPENDIX 
 
 Usual Strengths cf Solutions 
 
 Alum 5% 
 
 Argyrol 1-1000 to 25% 
 
 Bichloride of moiruiy 1-1000 In 1-10,000 
 
 Boric acid '2'.'< to T)'^ 
 
 Carbolic acid 1 -20 to 1-60 
 
 Creolin Vs'/r to 2% 
 
 Fornmliii 1/2% to 1% 
 
 Iclilliyol 3'/' to 50% 
 
 Lysul 1/2% to 2%' 
 
 Potassium pennanoaiuite 1-1000 to 1-10,000 
 
 Silver nitrate . . . „ 0.1% to 5% 
 
 Sodium bicarbonate 1''/^ to 10% 
 
 Sodium chloride 0.6' ^ to 0.9% 
 
 WEIGHTS AND MEASURES 
 Apothecaries' Weight 
 
 •ound 
 
 Ounces 
 
 Drams Scruples 
 
 Grains 
 
 lb. 
 
 E 
 
 3 i. 
 
 
 gr. 
 
 1 = 
 
 12 
 
 = 96 = 288 
 
 = 
 
 5760 
 
 
 1 
 
 8 = 24 
 
 = 
 
 480 
 
 
 
 1 = 3 
 
 = 
 
 60 
 
 
 
 1 
 
 = 
 
 20 
 
 
 
 Avoirdupois Weight 
 
 
 
 Pound 
 
 Ounces Drams 
 
 Grains 
 
 
 lb. 
 
 oz. 
 
 dr. 
 
 gr. 
 
 
 1 
 
 = 16 
 
 = 256 = 
 
 7000.0 
 
 
 
 1 
 
 = 16 = 
 
 437.5 
 
 
 
 
 1 = 
 
 27.34375 
 
 
 
 Metric Weight 
 
 
 
 s 
 
 10 
 
 milligrams ^ 1 centigram 
 
 
 
 
 10 
 
 centigrams =1 decigram 
 
 
 
 
 10 
 
 decigrams = 1 gram 
 
 
 
 
 10 
 
 grams = 1 decagram 
 
 
 
 
 10 
 
 decagrams ^ 1 hectogram 
 
 
 
 
 10 
 
 hectograms ^ 1 kilogram ■ 
 
 
 
 
 10 
 
 kilograms = 1 myriagram 
 
 
 
 
 10 
 
 myriagranis = 1 quintal 
 
 
 
 
 10 
 
 quintals = 1 tonneau 
 
 
 
APPENDIX 
 
 427 
 
 
 a . . 
 
 N» 
 
 - 
 
 - 
 
 - 
 
 
 O o CO 
 
 CO 
 
 tH 
 
 CO 
 
 o 
 
 
 O T-H CO 
 
 CO 
 (M 
 
 1—1 
 
 CO 
 
 CO 
 
 o 
 
 o 
 o 
 
 i-H 
 
 
 CO 
 
 
 
 
 ^ 
 
 ■O 
 
 lO 
 
 O 
 
 LO 
 
 o 
 
 t^ 
 
 o 
 
 iH 
 
 o 
 
 CO 
 
 (./) 
 
 
 
 ^ 
 
 -* 
 
 
 
 II 
 
 II 
 
 
 
 f^ 
 
 ^ 
 
 
 
 •73 
 
 lO 
 
 
 
 O 
 
 lO 
 
 
 
 1X5 
 
 t^ 
 
 I-H 
 
 CO 
 O lO 
 
 
 O 
 
 -^ 
 
 CO 
 
428 APPENDIX 
 
 Apothecaries' or Wine Measure 
 
 Gallon 
 
 Pints 
 
 Fl 
 
 iiidoiinces 
 
 Fluidrams 
 
 
 Minimi 
 
 C. 
 
 0. 
 
 
 n 
 
 
 f3 
 
 
 m 
 
 1 
 
 8 
 
 = 
 
 128 
 
 = 
 
 1024 
 
 = 
 
 61,440 
 
 
 1 
 
 = 
 
 16 
 
 = 
 
 128 
 
 ^ 
 
 7,680 
 
 
 
 
 1 
 
 = 
 
 8 
 1 
 
 — 
 
 480 
 60 
 
 Metric Dry and Liquid Measure 
 
 10 milliliters 
 
 = 1 centiliter 
 
 10 centiliters 
 
 = 1 deciliter 
 
 10 deciliters 
 
 = 1 liter 
 
 10 liters 
 
 = 1 decaliter 
 
 10 decaliters 
 
 = 1 hectoliter 
 
 10 hectoliters 
 
 = 1 kiloliter 
 
 10 kiloliters 
 
 = 1 myrialitei 
 
APPENDIX 
 
 429 
 
 ^ - a 
 
 CO ci 
 
 CO O 
 I- o 
 
 -* O 
 
 o o 
 
 o o o o 
 
 O O CO o 
 
 O CO cq CCl 
 
 '^il CO o 
 
 > 
 
 to i: ^ ^ 
 
 o o <c> o 
 T-i CO 1-' CO 
 
 CM (M 
 
 -^ 
 
 CO _ 
 
 O CO O CO o 
 
 1-5 CO 1^ CO CO 
 
 1— I CO CM 
 
 O - i: 
 
 O ,-H O 
 
 i-i ci CO 
 
 O 
 
430 APPENDIX 
 
 EQUIVALENT TEMPEKATl'HE SCALES 
 
 Ealirciiheit Ceiitii;i-ade 
 Degrees Degrees 
 
 Boiling point of water 212 100 
 
 200 });u 
 
 li)() S7.S 
 
 180 H2.2 
 
 170 7U.7 
 
 KiO 71.1 
 
 150 C5.6 
 
 140 60 
 
 130 54.4 
 
 120 48.9 
 
 110 43.3 
 
 Normal bodj' temperature 98.6 37 
 
 90 32.2 
 
 80 26.7 
 
 70 21.1 
 
 60 15.6 
 
 50 10 
 
 40 -. ... 4.4 
 
 Freezing point of water 32 
 
 20. —6.7 
 
 10 —12.2 
 
 —17.8 
 
 The Fahrenheit scale is used chiefly in the English-speaking coun- 
 tries. The Centigrade scale is used in Europe and Latin-America 
 chiefly, but it is considerably used also in most of the other countries. 
 
 Tlie conversion of any given reading of one scale into its equivalent 
 in the other is very easy. If 32 (the number of degrees below the 
 freezing point in the Fahrenheit scale) is subtracted from 212 (the 
 boiling point on the Fahrenheit scale) the remainder will be 180, which 
 is the actual number of degrees on the Fahrenheit scale between freez- 
 ing and boiling. On the Centigrade scale the corresponding number 
 is 100. Then, any given number of degrees on the Fahrenheit scale 
 (after 32 has been subtracted) is to the corresponding one on the 
 Centigrade scale as 180 is to 100, or, reduced to lowest terms, as 9 is 
 to 5. In other words, the Centigrade reading will be five-ninths (|) 
 of the Fahrenheit one. 
 
 Example. — Convert 98.6° Fahrenheit into Centigrade. 
 98.6 — 32 = 66.6 
 
 66.6 X ;] = 37, the corresponding reading on the Centi- 
 grade thermometer. 
 
APPENDIX 431 
 
 To work the problem backward, and convert Cenligrade degrees into 
 Fahrenheit ones, the fraction will sini])ly be inverted; that is, the 
 Centigrade degrees will be multiplied by nine-fifths (5). It must be 
 remembered, however, that the resulting figure will represent only the 
 number of degrees above the freezing point on the Fahrenheit scale, 
 and 32 must be added in this case to get the true Fahrenheit reading. 
 Example.- — Convert 37° Centigrade into Fahrenheit. 
 
 37 x-| =66.0 
 
 66.6 + 32^=98.6, the true corresponding reading on the 
 Fahrenheit thermometer. 
 
 ABBREVIATIONS AND SYMBOLS 
 
 aa, ana, equal parts of each. 
 
 A.c, ante cihum, before meals. 
 
 Ad, to, up to. 
 
 A.D., auris dexter^ right ear. 
 
 Ad 2 vie, ad duas vices, for two doses. 
 
 Add., adde, add to it. 
 
 Ad lib., ad libitum, whenever desired. 
 
 Ag argentum, silver. 
 
 Al aluminum. 
 
 Al. dieb., alterius diebus, every other day. 
 
 Alt. hor., alterius horis, every other hour. 
 
 Alt. noc, alterna node, every other night. 
 
 Aq., aqua^ water. 
 
 Aq. astr., aqua astricta, ice. 
 
 Aq. bull., aqua bulliens, boiling water. 
 
 Aq. com., aqua communis, common water. 
 
 Aq. dest., aqua destillata, distilled water. 
 
 Aq. ferv., aqua fervens, hot water. 
 
 Aq. pur., aqua pura, pure water. 
 
 As, arsenic. 
 
 A. S., auris sinister, left ear. 
 At. wt., atomic weight. 
 
 An, aurum, gold. 
 Av., avoirdupois. 
 Bi, bismuth. 
 Bib., bibe, drink. 
 
 B. i. d., bis in die, twice a day. 
 Bis, twice. 
 
 Bis hor., bis horis, every two hours. 
 
 Br, bromine. 
 
 Bull., bulliat, let it boil. 
 
432 APPENDIX 
 
 c., cum, with. 
 
 C, carbon, oentiorade. 
 
 C, or Cong'., congius, a gallon. 
 
 Ca, calcium.- 
 
 Calef., calefactus, warm, let it be made warm. 
 
 Cap., capiat, let him take. 
 
 C.c, cubic cc'iitinieter. 
 
 Ce, cerium. 
 
 Cent., centigrade. 
 
 Cg., centigram. 
 
 Cib., cibus, food. 
 
 CI, chlorine. 
 
 Cm., centimeter. 
 
 C. m., eras mane, tomorrow morning. 
 
 C. m. s., eras mane sumendus, to be taken tomorrow morning. 
 
 C. n., eras node, tomorrow night. 
 
 Cochl., cochleare, spoonful. 
 
 Cochleat., cochleatim, by spoonfuls. 
 
 Coehl. ampl., cochleare amplum, a tablespoonful. 
 
 Cochl. infant., cochleare infantis, a teasi)oonful. 
 
 Coehl. mag-., cochleare magnum, a tablespoonful. 
 
 Coehl. med., cochleare meclum, a dessertspoonful. 
 
 Cochl. para v., cochleare parvum, a teaspoonful. 
 
 Col., cola, strain. 
 
 Colet., eoletur, let it be strained. 
 
 Collut., collutorium, a mouth wash. 
 
 Collyr., collyrium, a mouth wash. 
 
 Comp., compositus, compound. 
 
 Cong., congius, gallon. 
 
 Cons., eonserva, keep. 
 
 Contim., eontimetur, let it be continued. 
 
 Cont. rem., eontimetur remedia, let the medicine be continued. 
 
 Coq., coque, boil. 
 
 Coq. in s. a., coque in sufficienle aqua, boil in sufficient water. 
 
 C. P., chemically pure. 
 
 Crast., erastinus, for tomorrow. 
 
 Cu, cuprum-, copper. 
 
 C. v., eras vespere, tomorrow evening. 
 
 Cwt., a hundredweight. 
 
 Cyath., cyathus, a glassful. 
 
 Cyath. vin., cyathus vinarius, a wine glass. 
 
 Decoct, hord., decoctum hordei, barley water. 
 
 Deeub., decubitus, lying down. 
 
 De d. in d., de die in diem, from day to day. 
 
 Deg., degree. 
 
APPENDIX 433 
 
 Deglut., deylutiatur, let it be swallowed. 
 
 Dep., depuratus, purified. 
 
 Destil., destilla, distil. 
 
 Det., detur, let it be given. 
 
 Det. in dup., det. in 2plo, detur in duplo, let twice as much be given. 
 
 Dieb. alt., diebus alterius, on alternate days. 
 
 Dieb. tert., diebus teriius^ every third day. 
 
 Dil., dilue, let it be dissolved. 
 
 Dil., dilutus, dilute. , 
 
 Dim., dimidius, one-half. 
 
 D. in p., divide in partes aequales, divide into equal parts. 
 
 Div., divide. 
 
 Donee, alv. sol. fuerit., donee alvus soluta fuerit, until the bowels are 
 
 opened. 
 Dr., dram. 
 
 Dur. dolor., durante dolore, while the pain lasts. 
 Ejusd., ejusdem, of the same. 
 Elix., elixir. 
 
 Emp., emplastrum, a plaster. 
 Emp. vesic, emplastrum vesicatorum, a blister. 
 Enem., enema. 
 
 Exhib., exhibeatur, let it be given. 
 Ext., extract, external. 
 F., fac, make. 
 Fahr., Fahrenheit. 
 Fe, ferrum, iron. 
 
 Feb. dur., febre duranti, while the fever lasts. 
 Fid., fluid. 
 
 F. mist., f,at mistura, make a mixture. 
 Fot., fotus, a fomentation. 
 F. pil., fiat pilula, make a pill. 
 Fract. dos., fracta dosi, in divided doses. 
 Freq., frequenter, frequently. 
 Ft., flat, let it be made. 
 F3, fltiicl dram. 
 F3, fluid ounce. 
 Garg., gargarisma, a gargle. 
 Gm., gram. 
 Gr., grain. 
 Gtt., guttae, drops. 
 Guttat., guttatim, by drops. 
 H, hydrogen. 
 
 Hd., hora decubitus, at bedtime. 
 Hg, hydrargyrum, mercury. 
 Hor. deeub., liora decubitus, at bedtime. 
 
434 APPENDIX 
 
 H. s.. hora .suiniii, at bedtime. 
 
 r, iodine. 
 
 Id., ideui, (lie irianie. 
 
 In a(|., in aqua, in water. 
 
 In d., in die, daily. 
 
 Inf., infusum, an int'nsion. 
 
 Inject., injectis, an injection. 
 
 K, kaliiim, pota.ssium. 
 
 Kji'., kilogram. 
 
 L., liter. 
 
 Lat. dol., lateri dolenti, to the painfid side. 
 
 Lb., libra, a jionnd. 
 
 Li, lithium. 
 
 Lin., linimenHiWy liniment. 
 
 Liq., liquor. 
 
 Loe. dol., loco dolenti^ to the painful spot. 
 
 Lot., lolio, a lotion. 
 
 M., misce, mix. 
 
 Mae., macera, macerate. 
 
 IMan., manii)., marnpidus, a handful. 
 
 Man. pr., inane primo, early in tlie morning. 
 
 Mass. pil., massa pilularum, pill-mass. 
 
 Matut., matutinus, in the mornino-. 
 
 M. et N., mane et node, morning and night. 
 
 M. ft., let a mixture be made. 
 
 Mg, mag-nesium. 
 
 Mist., mistura, a mixture. 
 
 Mn, manganese. 
 
 Mor. diet., more dido, in the manner directed. 
 
 Mor. sol., more solito, in the usual way. 
 
 N, nitrogen. 
 
 Na, sodium. 
 
 Ne rep., ne repetatur, not to be repeated. 
 
 Noct., node, at night. 
 
 Noct. maneq., node maneque, at night and in the morning. 
 
 Non repetat., non repetatur, do not repeat. 
 
 0, oxygen. 
 
 0., odarius, a pint. 
 
 0-, both eyes. 
 
 0. d., omne die, every day. 
 
 0. D., ocidus dexter, right eye. 
 01., oleum, oil. 
 
 01. oliv., oleum olivae, olive oil. 
 O. m., omni mane, every morning. 
 Omn. bih., omni bihora, every two hours. 
 
APPENDIX 435 
 
 Omn. hoi., omni hora, every hour. 
 
 Omii. noct., omni node, every night. 
 
 O.-n., omni node, every night. 
 
 0. S., oculus sinister, left eye. 
 
 0. U., oculus uterque, either eye. 
 
 Ov., ovum, an egg. 
 
 Oz., ounce. 
 
 P, phosphorus. 
 
 P. or pug., pugillus, a pinch. 
 
 Part, aeq., partes aequales, equal parts. 
 
 Part, vie, partihus vicibus, in divided dose.s. 
 
 Pb., plumbum, lead. 
 
 P. c, post cibum, after meals. , 
 
 Pil., pilula, a pill. 
 
 Pond., pondere, by weight. 
 
 P. rat. aetat., pro rata aetatis, in proiDortion to the age. 
 
 P. r. n., pro re nata, according to need. 
 
 Pro, for. 
 
 Pt., pint. 
 
 Pulv., pulvis, powder. 
 
 Q. d., quarter in die, four times a day. 
 
 Q. h., quaque hora, every hour. 
 
 Q. i. d., quarter in die, four times a day. 
 
 Q. 1., quantum libet, as much as you choose. 
 
 Q. p., quantum placeat, at will. 
 
 Q. q. h., quaque quarta hora, every fourth hour. 
 
 Q. s., quantum sufficit, as much as is necessary. 
 
 Qt., quart. 
 
 Quotid., quotidie, daily. 
 
 Q. v., quantum vis, as much as you wish. 
 
 Ra, radium. 
 
 Rad., radix, root. 
 
 Rect., rectificatus, rectified. 
 
 Rep., repetatur, let it be repeated. 
 
 S., sine, without. 
 
 S. or sig., signa, write. 
 
 Sat., saturated. 
 
 Sb, stibium, antimony. 
 
 Semih., semihora, half an hour. 
 
 Sig., signetur, let it be labeled. 
 
 Sig., signa, write. 
 
 Simul, together. 
 
 Sing., singulorum, of each. 
 
 Sol., solution. 
 
 Solv., solve, dissolve. 
 
436 APPENDIX 
 
 S. 0. s., si opus sit, if necessary. 
 
 Sp., spiritus, spirit. 
 
 Sp. gr., specific gravity. 
 
 Spir., spiritus, spirit. 
 
 Spt., spiriHis, spirit. 
 
 St., stet, let it stand. 
 
 Stat., stall m, at once. 
 
 Ss., semissis, a half. 
 
 Sii., sumet, lot liiin lake. 
 
 Sum., sumendus, to be taken. 
 
 S. v., S2)iritiis vini, alcoholic si)irit. 
 
 S. V. r., spiritus vini rectificatus, rectified S]»irit of wine. 
 
 S. V. t., spiritus vini tenuis, dilute alcohol, proof spirit. 
 
 Syr., syrup. 
 
 T., temperature. 
 
 T., ter, three times. , 
 
 T. i. d., ter in die, three times a day. 
 
 Tinct., tincture. 
 
 Tr., tincture. 
 
 Ult. praes., ultimum prcEscriptus , last prescribed. 
 
 Ung., unguentum, ointment. 
 
 U. S. P., United States Pharmacopoeia. 
 
 Ut diet., ut dictum, as directed. 
 
 Vitel., xitellus, yolk. 
 
 Vitel. ovi, vitellus ovi, yolk of egg. 
 
 Viz., videlicet, namely. 
 
 Wt., weight. 
 
 Zn, zinc. 
 
 5, dram. 
 
 B, ounce. 
 
 3, scruple. 
 
 B, recipe, take. 
 
 iTi, minim. 
 
INDEX 
 
 Abbreviations and symbols, 431 
 Abdomen, bandage for, 389 
 
 distention of, 23 
 
 pads for, 213, 223, 247 
 
 paracentesis of, 68 
 Abrasion, 130 
 Abscess, 10 
 
 in appendicitis, 59 
 
 ischiorectal, 61 
 
 of brain, 83 
 
 of liver, 68 
 
 peritonsillar, 43 
 
 secondary, 59 
 Acidosis, 21 
 Acromegaly, 73 
 Actual cautery, 236, 242 
 Adenoids, instruments for, 44, 305 
 
 surgery of, 44 
 Adhesive plaster, and tape device, 
 317 
 
 removal of, 317 
 After care of anesthesia patients, 
 
 180 
 Agents, sterilizing, 235 
 Air, hot, sterilization by, 236, 241, 
 252, 254, 258, 257, 258, 402 
 
 sterilizer for, 241 
 Albolene silk thread, 229, 260 
 Albuminuria, 187, 190 
 Alcohol, 74, 105, 117, 140, 242, 246, 
 252, 258, 266, 406, 407 
 
 flame sterilization, 242, 406 
 Algebraic proportions, 418 
 Alimentary system, 38-71 
 Alkalinity, Dakin's test for, 354 
 Aluminum-bronze wire, 229, 230, 261, 
 
 307 
 Ambrine, 137 
 Amputations, 102-104 
 
 instruments and sutures for, 103, 
 309 
 
 retractors for, 212, 213 
 Anaphylaxis, 37 
 Anastomosis, intestinal, 53, 67 
 Anchorage of roller bandage, 366 
 Anesthesia, 173-192 
 
 care of patient in, 175, 180 
 
 chloroform, 179, 189 
 
 complications after, 180, 182, 184, 
 186, 187, 188, 189, 190, 191 
 
 ether, 178, 183 
 
 Anesthesia, ethyl chloride, 179, 190 
 
 intratracheal, 41 
 
 nitrous oxide, 178, 182 
 
 preparation of patient for, 1 73 
 
 pulse in, 177, 178, 179, 180, 182, 
 187, 190, 191 
 
 respirations in, 182, 183, 189, 
 191 
 Anesthetist, isolation of from opera- 
 tive field, 287, 288 
 Anesthetizing room, 195, 204, 265 
 Ankle bandage, 370, 377 
 Anthrax spores, 259 
 Anti-constipation diet, 169 
 Anti-obesity diet, 171 
 Antiseptic, definition of, 233 
 
 solutions, 130, 245 
 
 surgery, history of, ix-xv 
 Antrum of Highmore, 121 
 Anus, artificial, 56 
 Apothecaries', measure, 428 
 
 weight, 426 
 Appendicectomy, 57-60 
 
 instrument passing for, 297 
 Appendicitis, 56-60 
 Applying the roller bandage, modes 
 
 of, 365 
 Aprons, muslin, 212, 214, 247 
 
 rubber, 212, 214, 251 
 Arms, arrangement of for opera- 
 tions, 177, 268, 273, 275, 278, 
 280, 282, 288 
 
 bandage for, 368, 373, 375, 388, 
 389 
 
 basins for, 207 
 
 board for, 283, 413 
 
 draping of, 282, 283 
 
 operative position for, 283, 413 
 
 Thomas traction splint for, 100 
 Arrangement of operating theater, 
 
 193 
 Arteries, instruments and sutures 
 
 for, 305 
 Artificial anus, 56 
 Aseptic, definition of, 233 
 
 surgery, history of, ix-xv 
 Asphyxia, 184 
 Autointoxication, 27" 
 Autonomic system, 80 
 Avoirdupois weight, 426 
 Axilla, bandage for, 384 
 
 437 
 
438 
 
 INDEX 
 
 Back, operative position and draping 
 
 for, 276 
 Bactereniia, 10 
 Bacteria, classification of, 12 
 
 count- of in Carrel-Dakin treat- 
 ment, 345 
 
 ]>ortals of entry for, 12 
 Bactericide, definition of, 233 
 Bap, colostomy, 61 
 Bakinjr, 89, 92 
 Balkan frame, 98 
 Bandage, abdominal, 389 
 
 anchorage of, 366 
 
 ankle, 370, 377 
 
 application of to various parts of 
 the body, 373 
 
 arm, 368, 373, 375, 388, 389 
 
 axilla, 384 
 
 Barton, 381 
 
 Bier's, 391 
 
 breast, 385, 389 
 
 Canton flannel, 359, 360 
 
 capeline, 383 
 
 chest, 388, 389 
 
 chin, 381, 382, 389 
 
 circular, 366 
 
 crepe paper, 360, 361 
 
 definition of, 355 
 
 double roller, 382 
 
 durability of, 363, 364 
 
 ear, 380 
 
 elastic webbing, 360 
 
 elbow, 375 
 
 Esmareh, 102, 212, 252, 360, 390 
 
 evenness of pressure of, 363 
 
 eye, 378 
 
 face, 381 
 
 fastening of, 392 
 
 figure-of-8, 370 
 
 finger, 373 
 
 flannel, 212, 360 
 
 foot, 376, 377, 388 
 
 for fractures, 88 
 
 for pressure, 391, 392 
 
 forms of, 356 
 
 gauze, 212, 359, 360 
 
 hand, 373, 375, 388 
 
 head, 366, 372, 382, 388, 389 
 
 heel, 377 
 
 hip, 387, 388 
 
 jaw, 381, 382, 389 
 
 knee, 378 
 
 leg, 376, 377, 378, 389 
 
 many-tailed, 358, 362, 363, 389 
 
 materials used for, 359 
 
 muslin, 212, 360 
 
 neatness of, 363, 364 
 
 plaster of Paris, 91, 212, 361, 390, 
 397 
 
 pressure of, 363 
 
 Bandage, recurrent, 372 
 
 removal of, 396 
 
 reverse, 368 
 
 roller, 356, 359, 362, 365, 373, 382 
 
 rcdliiig of, 356 
 
 rubber, 102, 212, 252, 360, 390 
 
 scissors for, 319, 396, 397 
 
 Scultetus, 358, 389 
 
 shoulder, 384, 388 
 
 sizes of, 362 
 
 spica, 93, 374, 384, 387 
 
 spiral, 367 
 
 starfli, 212, 360, 390 
 
 tension of, 363 
 
 thumb, 374 
 
 toe, 376 
 
 triangular, 362, 388 
 
 uses of, 355 
 
 A'elpcau, 384 
 Bandages, 212, 214, 247, 326, 331 
 Bandaging, 355-398 
 
 definition of, 355 
 
 principles of, 363 ' 
 
 rules for, 394 
 Bands, rubber, 213, 225, 247, 311 
 Bartlett method of catgut steriliza- 
 tion, 257 
 Barton bandage, 381 
 Basins, arm, 207 
 
 floor, 214 
 
 solution, 200, 212, 214, 246, 325, 
 328, 406 
 
 wash, 206 
 Bath, Sitz, 63 
 Bathroom, as home operating room, 
 
 403 
 Beck's paste, 56 
 
 Bed, for anesthesia patient. 29, 181, 
 191 
 
 Gatch, 29 
 Bedroom, as home operating room, 
 
 403 
 Bellevue bridge, 71 
 Benches, floor, 200 
 Benign growths, 13 
 Bichloride of mercury, 246, 248, 250, 
 263, 264, 266, 320, 321, 322, 
 332 
 Bier 's bandage, 391 
 Bigelow evacuator, 148 
 Bile ducts, 65 
 Bladder, urinary, 145-149 
 
 in anesthesia, 175, 188, 190 
 
 instruments and sutures for, 148, 
 309 
 
 operative position and dra[)ing for, 
 267 
 Blankets, 29, 175, 180, 181, 191, 212, 
 
 214 
 Bleeding, capillary, 17, 18 
 
INDEX 
 
 439 
 
 Blood, clot of, 4, 35 
 clotting time of, 36 
 defibrinated, 17 
 grouping of, 15 
 "poisoning" of, 10 
 red cells of, 4 
 serum of, 4 
 transfusions of, 15 
 vessels, instruments and sutures 
 
 for, 305 
 white cells of, 4, 10 
 Board arm, 283, 413 
 Boeckman method of catgut sterili- 
 zation, 258 
 Boiling, sterilization by, 236, 237, 
 246, 248, 250, 251, 252, 258, 259, 
 260, 261, 286, 315, 330, 332, 333, 
 348, 403_, 406, 407 
 Bones, grafting of, 100 
 
 instruments and sutures for, 40, 
 
 80, 82, 85, 100, 103, 306 
 Lane plates for, 100, 307 
 surgery of, 87-104 
 Book, needle, 252 
 
 suture, 298 
 Bottles, hot water, 213, 220 
 Box, dressing, 202, 314 
 Brain, instruments and sutures for, 
 80, 82, 306 
 surgery of, 80-85 
 Breast, bandage for, 385, 389 
 draping of, 282 
 instruments- and sutures for, 141, 
 
 308 
 operative position for, 140, 280 
 surgery of, 138-141 
 Brewer tube, 126 
 Bronze wire, 229, 230, 261, 307 
 Brushes, nail, 212, 215, 236, 263 
 Buck's extension, 94 
 Burmeister method of catgut ster- 
 ilization, 258 
 "Burns, 135-138 
 Button, Murphy, 54, 302, '303 
 
 Calcium lactate, 36, 79 
 Calculus, of bladder, 145 
 
 renal, 144 
 Callus formation, 88 
 Canton flannel bandage, 359, 360 
 Canula, Hahn's, 124 
 Capeline bandage, 383 
 Capillary bleeding, 17, 18 
 Caps, operating room, 212 215 247, 
 
 400 
 Carbolic acid, 57, 111, 246, 248, 251, 
 
 254, 409 
 Carbon monoxide poisoning, 136 
 Carcinoma, of breast, 140 
 pf esophagus, 45 
 
 Carcinoma, of jaw, 40 
 
 of larynx, 124 
 
 of ovary, 115 
 
 of pancreas, 68 
 
 of prostate, 119 
 
 of rectum, 64 
 
 of stomach, 53 
 
 of uterus, 112 
 Care of patient, in anesthesia, 175, 
 
 180 
 Carpets, in home operations, 404 
 Carrel, Dr. Alexis, 323 
 Carrel-Dakin treatment, 321-354 
 
 adjustment of appliances for, 340 
 
 bacteriological examination of 
 wound in, 345 
 
 continuous method of, 342, 344 
 
 debridement in, 334 
 
 definition of, 321 
 
 dressing of wound in, 335 
 
 dressings for, 326, 330, 331, 338 
 
 equipment for, 215, 324 
 
 history of, 323 
 
 instillation of solution in, 342 
 
 instruments for, 324, 328 
 
 intermittent method of, 341, 344 
 
 reservoir method of, 341, 342, 344 
 
 suturing of wound in, 347 
 
 syringe method of, 342, 344 
 
 tubes for, 325, 329, 336, 347 
 Carriage, dressing, 316 
 Casts, plaster of Paris, 91, 93, 390, 
 
 397 
 Catgut, chromic, 228, 258 
 
 method of rolling, 255 
 
 plain, 228, 254-258 
 
 sterilization of, 254-259 
 Cathartic, before operation, 58, 62, 
 
 174 
 Catheterization, 82, 105, 106, 175 
 Catheters, 212, 216 
 Cautery, 212, 216, 236, 242, 243, 244 
 
 uses of, 18, 57, 63, 242, 300 
 Celiotomy, 48, 55 
 Cells, red blood, 4 
 
 white blood, 4, 10 
 Celluloid linen thread, 229 
 Centigrade thermometer scale, 430 
 Cerebrospinal system, 80 
 Cervix, instruments and sutures for, 
 308 
 
 surgery of, 108 
 Chair, use of for Trendelenburg po- 
 sition, 410 
 Chamber, Sauerbruch, 129 
 Chemical sterilization, 235, 236, 245, 
 
 see also alcohol, bichloride of 
 mercury, carbolic acid, Dakin's 
 solution, ether, formalin, iodine, 
 lysol 
 
440 
 
 INDEX 
 
 Chest, bandage for, 388, 389 
 
 instruments for, 309 
 
 operative position and draping for, 
 27S 
 Cheyne-Stokcs respirations, 81 
 Chiil, 187 
 
 Chin bandage, 381, 382, 389 
 Chlorinated lime, titration of, 351 
 Chkiroforni, anesthesia, care of pa- 
 tient in, 179, 189 
 
 decomposition of, 204, 408 
 Choked itise, 81 
 Chok^cystectomy, 66 
 Cholecystenterostomy, 67 
 Cholecystostomy, (56 
 Chok'cystotomy, 66 
 Clioledochotomy, 66 
 Chok^gastrostomy, 67 
 Chok^lithiasis, 65-67 
 Chromic catgut, 228, 258 
 Cigarette drain, 310 
 Circular mode of bandaging, 366 
 Circumcision, 150 
 Cirrhosis of liver, 68 
 Citrate of sodium, 16 
 Clamp, crushing, 297, 300 
 
 intestinal, 302 
 
 stomach, 50, 305 
 
 tongue, 185, 213, 231 
 
 towel, 270, 272, 278, 279, 281, 
 285, 287, 288, 290 
 Clamp and cautery operation, 63 
 Claudius method of catgut steriliza- 
 tion, 257 
 Cleaning, of Carrel-Dakin tubes, 347 
 
 of gloves, 294 
 
 of home operating room, 404 
 
 of instruments, 293 
 
 of operating table, 292 
 Clips, Gushing, 82 
 
 metal skin, 229, 230, 261 
 Clot, blood, 4, 35 
 Clothing for anesthesia, 28, 175 
 Clotting time of blood, 36 
 Clover crutch, 412 
 ' ' Cock-up ' ' wrist splint, 100 
 Colectomy, 60 
 Collapse," 190 
 Colon, irrigation of, 25 
 
 surgery of, 60 
 Colostomy, 60 
 
 bag for, 61 
 Colpotomy, 112 
 
 Complications, after anesthesia, 180, 
 182, 184, 186, 187, 188, 189, 190, 
 191 
 
 post-operative, 20-37, 51, 59, 63, 
 67, 75, 78, 79, 103, 114 
 Compound fracture, 87 
 Compression of brain, 81 
 
 Concussion of brain, 81 
 Congenital, deformities, 13 
 
 hei'uia, 7(1 
 Connecting tubes, 327, 333 
 Construction, of anesthetizing room, 
 204 
 
 of dressing rooms, 206 
 
 of operating room, 195 
 
 of sterilizing room, 209 
 
 of work room, 208 
 Continuous method of Carrel-Dakin 
 
 treatment, 342, 344 
 Contracture of esophagus, 45 
 Contusion, 130 
 Cord, spinal, 85 
 Cotton, 212, 216, 247 
 
 gloves, 213, 219 
 
 pads, 326, 331, 338 
 Count, bacteriological, 345 
 Cover, glove, 213, 218 
 
 instrument stand, 212, 216 
 
 muslin, for parcels, 203, 247, 313 
 "Crab" wrist splint, 100 
 Craniotomy, 80, 82, 83, 84 
 Crepe paper bandage, 360, 361 
 Cretinism, 73 
 Crile, Dr. George W., 75 
 Crutches, 104 
 
 lithotomy, 411 
 Culture tubes, 213, 217 
 Cultures, of Carrel-Dakin wound, 345 
 Curettage of uterus, 108 
 
 instruments for, 308 
 Gushing, clips, 82 
 
 suture, 50 
 Cutting down of plaster cast, 397 
 Cyst, 40, 114 
 
 ovarian, instruments for, 308 
 Cystadenoma of ovary, 114 
 Cystitis, 146 
 Cystocele, 105 
 Cystoscope, 143, 149 
 
 Dakin, Dr., 324 
 
 Dakin solution, 215, 246, 324, 325, 
 328, 331, 332, 347, 348-354 
 
 action of, 349 
 
 composition of, 348, 351 
 
 Daufresne's technic for, 350 
 
 definition of, 348, 350 
 
 dosage of, 343 
 
 instillation of, 342 
 
 making of, 350-354 
 
 table of quantities of ingredients 
 of, 352 
 
 titration of, 353 
 Dam, rubber, 213, 225, 249 
 
 drains of, 310 
 Dauf resne 's technic, 350 
 Debridement, 334 
 
INDEX 
 
 441 
 
 Decapsulation, Edebohl's, 34 
 Decompression of brain, 85 
 Defibrinated blood, 17 
 Deformities, 13 
 
 Delivery tubes, Carrel-Dakin, clean- 
 ing of, 347 
 
 making of, 329 
 
 rubber for, 325, 329 
 
 uses of, 336 
 Demarcation, line of, 10 
 Depression, of pulse, 179, 187, 190 
 
 respiratory, 184 
 Dermoid cyst of ovary, 114 
 Deviated septum, 120 
 Diabetic diet, 155 
 Dichloramine-T, 349 
 Diet, after anesthesia, 152, 182, 188, 
 190, 191 
 
 anti-constipation, 169 
 
 anti-obesity, 171 
 
 before anesthesia, 174 
 
 diabetic, 155 
 
 gastric, 160 
 
 general rules for, 170 
 
 Lenhartz, 162 
 
 liquid, 151 
 
 nephritic, 159 
 
 regular, 154 
 
 salt-poor, 159 
 
 soft, 152 
 
 standard strict, 156 
 
 Von Leube, 161 
 Dietetics, surgical, 151-172 
 Dilatation, of cervix, 108, 308 
 
 of esophagus, 45 
 
 of sphincter ani, 63 
 instruments for, 305 
 
 of stomach, 22 
 Direct hernia, 69 
 Discipline of operating room staff, 
 
 194, 212 
 Disinfectant, definition of, 233 
 Disinfection, of floor, 293 
 
 of linen, 293 
 Distention, abdominal, 23 
 Distributing tubes, Carrel-Dakin, 
 
 327, 333 
 Dorsal position, 267 
 Double roller bandage, 382 
 Douche bag as irrigator, 332, 406 
 Drainage of wounds, siphon and 
 
 suction, 132 
 Drains, 55, 113, 126, 249, 250, 310 
 Dram, fluid, table of drops in, 425 
 Draping, arm position, 282, 283 
 
 breast position, 282 
 
 dorsal position, 268 
 
 face position, 287 
 
 foot position, 285, 286 
 
 for home operations, 409 
 
 Draping, gall bladder position, 275 
 
 hand position, 282, 284 
 
 head position, 287, 288, 290 
 
 kidney position, 275 
 
 latero-prone position, 278 
 
 leg position, 285 
 
 lithotomy position, 280 
 
 neck position, 288 
 
 nose position, 288 
 
 of tables, 264 
 
 prone position, 276 
 
 reversed Trendelenburg position, 
 279 
 
 Sims position, 279 
 
 skull position, 288 
 
 throat position, 288 
 
 Trendelenburg position, 273 
 Dresser, as supply table, 404 
 Dressing of the vpound, 313-320 
 
 Carrel-Dakin method of, 335 
 
 dressing box for, 314 
 
 dressing carriage for, 316 
 
 instruments for, 315, 318, 324, 328, 
 335 
 
 preparation of supplies for, 313 
 
 sterilizer, instrument, for, 315 
 Dressing room, 195, 206, 207 
 Dressings, wound, 213, 217, 247, 330, 
 331, 338, 400 
 
 carriage for, 316 
 
 drums for, 202, 206, 207, 246, 314 
 
 handling of, 246, 291, 314, 318, 
 319, 335 
 
 instruments for, 297, 311, 315, 318, 
 324, 328, 335 
 
 packing of, 246, 313 
 
 portable stand for, 290 
 
 sterilizers for, 209, 237-241, 401 
 
 strapping device for, 317 
 
 wet, 132 
 Drop, relation, of to minim, 425 
 Dropper tube, 327, 333, 342 
 Drugs, list of, 217 
 Drums, dressing, 202, 206, 207, 246, 
 
 314 
 Dry heat, as wound treatment, 133 
 
 sterilization by, 236, 241, 252, 254, 
 256, 257, 258, 402 
 Drying of sterilized supplies, 241, 
 
 402 
 Ducts, bile, 65 
 Duodena 1 ulcer, 53 
 Durability of bandages, 363, 364 
 Dwarfism, 73 
 
 Dyeing of suture materials, 260 
 Dysmenorrhea, 109' 
 
 Ear bandage, 380 
 Ectopic pregnancy, 113 
 Edebohl's decapsulation, 34 
 
442 
 
 INDEX 
 
 Edema, of glottis, 78 
 pulnionarv, 80, 187 
 Elastic bandages, 252, 360, 390 
 Elbow bandage, 375 
 Electric, cautery, 243 
 
 ]iortal)le iiistnuuent sterilizer, 315 
 Embolism, pulmonary, 30 
 Embolus, 31 
 Empyema, 125 
 
 Brewer drainage tube for, 126 
 instruments for, 309 
 Enemas, 24, 58, 62, 172, 175 
 Enterostomy, 55 
 Epididymis, 115 
 Epulis, 40 
 
 Equipment, for Carrel-Dakin treat- 
 ment, 215, 324 
 of operating theater, 193-231 
 Equivalent, measures, 429 
 temperature scales, 430 
 weights, 427 
 Esmareh bandage, 102, 212, 252, 360, 
 
 390 
 Esophagotomy, 46 
 Esophagus, surgery of, 45 
 Ether, anesthesia, care of patient in, 
 178, 183 
 
 pneumonia after, 27, 186, 187 
 as antiseptic, 74, 105, 117, 140, 
 
 246, 258, 266 
 inhaler for, 213, 220 
 Ethyl chloride anesthesia, care of 
 
 patient in, 179, 190 
 Evacuator, Bigelow, 148 
 Evenness of pressure in bandages, 
 
 363 
 Evisceration, 30 
 
 Examination, bacteriological, of Car- 
 rel-Dakin wound, 345 
 Excitement, control of in anesthesia, 
 176, 177, 178, 179, 183, 189, 190 
 Exercises, setting-up, 170 
 Exophthalmic goiter, 75 
 Exploratory laparotomy, 53 
 Exploring needles, 213, 223 
 Extension, Buck's, 94 
 Eyes, bandage for, 378 
 
 protection of in vomfting, 186 
 
 Face, bandage for, 381 
 draping for, 287 
 guards for, 283, 288, 290 
 masks for, 213, 221, 247, 400 
 operative positions for, 286 
 Fahrenheit thermometer, x, 430 
 Fallopian tubes, surgery of, 112 
 Fallopius, X 
 
 Fascia, sutures for, 300, 301 
 Fastening of bandages, 392 
 I'at layer, sutures for, 300, 301 
 
 Fecal fistula, 60 
 Feeding through fistula, 172 
 Femoral hernia, 70 
 Fibrin strands, 4 
 Fibroadenoma of breast, 140 
 I'^ibroblasts, 4 
 Fibroids of uterus, 111 
 Field, operative, preparation of, 70, 
 74, 82, 83, 102, 105, 117, 140, 
 174, 265, 407 
 
 surgical, 8 
 Figure-of-8 mode of bandaging, 370 
 Finger bandage, 373 
 Fistula, fecal, 60 
 
 feeding through, 172 
 
 gastric, 46 
 
 in ano, 62 
 Fixation of uterus, 110 
 
 sutures for, 308 
 Flame, sterilization by, 236, 242, 
 
 406 
 Flannel bandage, 212, 360 
 Floor, basins for, 214 
 
 benches, 200 
 
 construction of in operating room, 
 196, 204, 209 
 
 disinfection of, 293 
 Florence Nightingale, xiii 
 "Fluffs,"' 217 
 
 Food, after anesthesia, 152, 182, 188, 
 190, 191 
 
 before anesthesia, 174 
 Foot, bandage for, 376, 377, 388 
 
 draping of, 285, 286 
 
 operative positions for, 284 
 Forceps, dressing, 297, 311, 324, 328, 
 335 
 
 tongue, 185, 213, 231 
 
 towel, 270, 272, 278, 279, 281, 285, 
 287, 288, 290 
 Foreign bodies, in esophagus, 45 
 
 in larynx, 121 
 
 in lungs, 129 
 
 in trachea, 45 
 Formalin, 246, 293, 409 
 Forms of bandages, 356 
 Formula3 for preparation of catgut, 
 
 256-259 
 Fowler's position, 59 
 Fractional sterilization, 249 
 Fractions, reckoning of solutions in, 
 
 420 
 Fractures, 80, 87-102 
 
 compound, 87 
 
 definition of, 87 
 
 immobilization of, 88 
 
 impacted, 87 
 
 of the skull, 80 
 
 open operations for, 100 
 
 reduction of, 88, 100 
 
INDEX 
 
 443 
 
 Fractures, simple, 87 
 
 traction treatment of, 94-100 
 Frame, Balkan, 98 
 Furniture, for anesthetizing room, 
 205 
 
 for dressing room, 206 
 
 for operating room, 197 
 
 for sterilizing room, 209 
 
 for work room, 208 
 
 Gags, mouth, 185, 213, 222 
 
 Galen, ix 
 
 Gall bladder, draping for, 275 
 
 instruments and sutures for, 304 
 
 operative positions for, 273, 411 
 
 surgery of, 65-67 
 Gallstones, 65 
 Gases, from decomposed chloroform, 
 
 204, 408 
 Gastrectomy, 53 
 Gastric, diet, 160 
 
 dilatation, 22 
 
 fistula, 46 
 
 ulcer, 48, 52 
 Gastroenterostomy, 49 
 Gastrojejunostomy, 49 
 Gastrostomy, 46 
 Gatch bed, 29 
 Gauntlets, 213, 218, 247 
 Gauze, 213, 218, 246 
 
 bandages, 212, 359, 360 
 
 packing, 213, 223, 247, 311 
 
 vaselinated, 325, 328, 335 
 Generation, organs of, 105 
 Germicide, definition of, 233 
 Gigantism, 73 
 Gilliam operation, 110 
 Gland, or glands, classification of, 
 72 
 
 instruments and sutures for, 305, 
 306 
 
 of internal secretion, 72 
 
 parathyroid, 79 
 
 pituitary, 73 
 
 prostate, 117 
 
 thyroid, surgery of, 73-79 
 Glandular system, 72-79 
 Glassware,, sterilization of, 263 
 Glossectomy, 41 
 Glottis, edema of, 78 
 Glove cover, 213, 218 
 Gloves, cotton, 213, 219 
 
 rubber, 213, 218 
 cleaning of, 294 
 patching of, 294 
 preparation of for sterilization, 
 
 247 
 sterilization of, 248, 400, 407 
 Glue, resin and turpentine, 98 
 
 Sinclair's, 98 
 
 Glycerin, 252 
 
 Goiter, exophthalmic, 75 
 
 instruments and sutures for, 74, 
 
 306 
 operative position and draping 
 
 for, 288 
 surgery of, 74-79 
 Gowns, operating room, 213, 220, 
 
 247, 400 
 Grafts, bone, 100 
 skin, 134 
 
 instruments for, 134, 309 
 Granulation tissue, 4, 134 
 Grouping of blood for transfusion, 
 
 15 
 Growths, new, 13, 40, 41, 46, 114, 
 
 117, 124, 140, 148 
 Guards, face, 283, 288, 290 
 Kocher, 283, 288 
 shoulder, 271, 273 
 
 Hahn 's canula, 124 
 Handling, of anesthetized patient, 
 180 
 of sterile supplies, 246, 291, 314, 
 318, 319, 335 
 Hands, bandages for, 373, 375, 388 
 draping for, 282, 284 
 methods of fastening in operative 
 positions, 177, 268, 273, 275, 278, 
 280, 282, 288 
 operative position for, 283 
 sterilization of, 263, 319, 408 
 Harvey, ix 
 Hawley table, 93 
 
 Head, bandages for, 366, 372, 382, 
 388, 389 
 control of in anesthesia, 29, 184, 
 
 186 
 draping of, 287, 288, 290 
 operative positions for, 276, 286, 
 
 287, 288 
 rest for, 288 
 Headache, 182, 191 
 Healing of wounds, 4, 134 
 Heat, dry, as wound treatment, 133 
 sterilization- by, 236, 241, 252, 
 254, 256, 257, 258, 402 
 moist, 236, 237 
 Heating of operating theater, 197, 
 
 205, 208, 209 
 Heel bandage, 377 
 Heniatemesis, 48 
 Hemophilia, 36 
 Hemorrhage, 17-19, 59, 103 
 
 and shock, 14-19 
 Hemorrhoids, 63 
 
 Hernia, instruments and sutures for, 
 70, 304 
 surgery of, 69-71 
 
444 
 
 INDEX 
 
 Hiccough, after anesthesia, 187, 190 
 Highnune, aLtrum of, 121 
 Uilipofiates, ix 
 Hips, bandages for, 387, 388 
 
 rests for, 213, 220, 3S8 
 History, of Carrel-Dakin treatment, 
 323 
 
 of surgery, ix-xv 
 Hodgen's splint, 94, 96, 100 
 Home, operations in, 399-414 
 Horsehair, 229, 259 
 
 drains of, 310 
 Horse serum, 36 
 Horsley's wax, 18 
 Hot air, sterilization by, 236, 241, 
 252, 254, 256, 257, 258, 402 
 
 sterilizer, 241 
 Hot towel drum and heater, 202 
 Hot water bottles, 213, 220 
 Hunter, Dr. John, x 
 Hydrocele, 116 
 
 Hydrochloric acid gas, 204, 408 
 Hydrosalpinx, 113 
 Hyperpituitarism, 73 
 Hyper thy roidisir., 73 
 Hypertrophy, of tonsils, 44 
 
 of turbinates, 121 
 Hypodermic needles, 213, 223, 252 
 Hypodermoclysis, indications for, 15 
 
 outfit for, 213, 220 
 H;j7)opituitarism, 73 
 Hypothyroidism, 73 
 Hysterectomy, 110, 111, 112 
 
 instruments and sutures for, 111, 
 307, 308 
 
 Ice pack, 75, 78 
 Ileus, paralytic, 26 
 Immobilization of fractures, 88 
 Impacted fractures, 87 
 Improvised operative position, for 
 arm, 413 
 
 for gall bladder, 411 
 
 for- kidney, 411 
 
 lithotomy, 411 
 
 Trendelenburg, 410 
 Incarcerated hernia, 69, 71 
 Indirect hernia, 69 
 Infected wounds, 7, 132 
 Infection, definition of, 232 
 
 of wound, 3, 7, 132 
 Inflammation, 3 
 Infusion, indications for, 15 
 
 outfit for, 213, 220 
 
 salt solution for, 213, 226, 249 
 Inguinal hernia, 69 
 Inhaler, ether, 213, 220 
 Injuries, 3, 13 
 
 of brain, 81 
 
 of liver, 67 
 
 Injuries, tif thoracic wall, 125 
 
 of urinary bladder, 145 
 Instillation of Dakin's solution, 335, 
 342 
 adjustment of appliances for, 340 
 Instrument stand cover, 212, 216 
 Instruments, 213, 220 
 
 arrangement of on stand, 298 
 
 cleaning of, 293 
 
 for Carrel-Dakin dressings, 324, 
 
 328 
 for dressings, 297, 311, 315, 318, 
 
 324, 328, 335 
 for operations, 40, 44, 45, 46, 50, 
 54, 57, 63, 70, 74, 80, 82, 85, 
 103, 111, 122, 124, 134, 141, 
 145, 148, 150, 297-310 
 passing of, 296-312 
 sterilization of, 246, 252 
 sterilizers for, 203, 315 
 tables for, 198, 405 
 Intention, primary and secondary, 
 
 healing by, 4 
 Intermittent method for Carrel- 
 Dakin treatment, 341, 344 
 Internal secretion, glands of, 72 
 Intestines, anastomosis of, 53 
 clamp for, 302 
 instruments and sutures for, 54, 
 
 57, 302 
 obstruction of, 55 
 operative position and draping for, 
 
 267 
 perforation of, 53, 59 
 resection of, 53, 55, 71 
 surgery of, 53-60 
 Intratracheal anesthesia, 41 
 Intussusception, 56 
 Iodine, 70, 82, 111, 246, 257, 258, 
 
 266, 407 
 Ironing board, as instrument table, 
 
 405 
 Irreducible hernia, 69 
 Irrigation of colon, 25 
 Irrigators, 213, 221, 246, 326, 331, 
 341 
 douche bag as, 332, 406 
 stands for, 213, 221, 326, 331 
 Ischiorectal abscess, 61 
 Isotonic, as property of Dakin's so- 
 lution, 349 
 definition of, 323 
 
 Jacket, plaster of Paris, 93 
 Jackson laryngoscope, 121 
 Jaundice, 36, 65, 66 
 Jaw, bandage of, 381, 382, 389 
 
 holding of in anesthesia, 29, 184 
 
 surgery of, 40, 41 
 Jones 's ' ' Crab ' ' wrist splint, 100 
 
INDEX 
 
 445 
 
 Kangaroo tendon, 228, 229, 259 
 Kelly pad, 213, 221 
 
 improvised, 412 
 
 uses of, 280 
 Kidney, decapsulation of, 34 
 
 disorders of after anesthesia, 187, 
 190 
 
 draping for, 275 
 
 instruments and sutures for, 145, 
 309 
 
 operative position for, 275j 411 
 
 surgery of, 142-145 
 Killian laryngoscope, 121 
 Kitchen, as home operating room, 
 
 403 
 Knee bandage, 378 
 Kocher guard, 283, 288 
 Kraske operation, 64 
 
 Lacerated wounds, 131 
 Lacerations, 130 
 Laminectomy, 85 
 Lane, bone plates, 100 
 
 instruments for applying, 307 
 
 technic, 100, 307 
 Laparotomy, exploratory, 53 
 
 sheet, 213, 227 
 
 draping with, 268, 283 
 Laryngectomy, 124 
 Laryngoscope, 121 
 Larynx, surgery of, 121-125 
 Latero-prone position, 278 
 Lee method of catgut sterilization, 
 
 256 
 Legs, bandages for, 376, 377, 378, 
 389 
 
 draping for, 285 
 
 operative positions for, 284 
 
 restraint of in anesthesia, 177, 
 183 
 
 supports for, 279, 284, 286, 411 
 
 Thomas splint for, 100 
 Lenhartz diet, 162 
 Lewisohn transfusion, 16 
 Lifting of anesthetized patient, 180 
 Ligation, 18 
 Ligatures, 298, 302 
 Light, as sterilizing agent, 236 
 
 for operating room, 195, 201, 403, 
 406 
 Lime, chloride of, titration of, 351 
 Lindeman transfusion, 16 
 Line of demarcation, 10 
 Linen, disinfection of, 293 
 
 thread, 229, 260 
 Liquid diet, 151 
 Lister, xi-xiv, 235 
 
 tourniquet of, 102 
 Litholapaxy, 148 
 
 Lithotomy, crutches, 411 
 
 position, 279, 411 
 draping for, 280 
 
 stirrups, 279, 284, 286, 411 
 
 stockings, 213, 227, 247 
 draping with, 280 
 
 suprapubic, 148 
 
 towel, 213, 231, 247 
 draping with, 280 
 Liver, bile ducts and, 65 
 
 surgery of, 65-68 
 Location of operating room, 195 
 Lockers, dressing room, 207 
 Lungs, edema of, 30, 187 
 
 embolism of, 30 
 
 instruments and sutures for, 309 
 
 surgery of, 128-129 
 
 tuberculosis of, 129 
 Lymph glands, instruments and su- 
 tures for, 305 
 Lymphadenitis, 12 
 Lymphangitis, 12 
 Lysol, 246, 248 
 
 Malignant growths, 13 
 Malpositions of uterus, 109 
 Management, nursing, between oper- 
 ations, 291 
 
 of operations, 290 
 Many-tailed bandages, 358, 362, 363, 
 
 389 
 Masks, chloroform and ether, 213, 
 221 
 
 face, 213, 221, 247, 400 
 Massage, 86, 89, 92, 102 
 Mastitis, 138 
 
 Mastoid bone, instruments for, 309 
 Mastoiditis, 83 
 
 Materials used for bandages, 359 
 Mayo cautery, 243 
 Measures, equivalent, 429 
 
 tables of, 428 
 
 weights and, 426 
 Mending of gloves, 294 
 Mental preparation of patient for 
 
 operation, 76, 173 
 Metal clips, 229, 230, 261 
 Meteorism, 23 
 Metric, measure, 428 
 
 weight, 426 
 Michel clips, 230 
 Mikulicz drain, 310 
 Minim, relation of to drop, 425 
 Modes of applying the roller band- 
 age, 365 
 Moist heat, 236, 237 
 Mortification, 10 
 Moulded plaster splints, 92 
 Mouth, care of, 39, 41, 42, 186, 189 
 
 gags for, 185, 213, 222 
 
446 
 
 INDEX 
 
 Mouth, operative position am] diap- 
 inj? for, 286 
 
 surgery of, 39 
 
 wash for, 39, 189 
 Movements, passive, 89 
 Murphv button, 54, 302, 303 
 Muscle, sutures for, 298, 301 
 Muslin, apron, 212, 214, 247 
 
 bandage, 212, 360 
 
 covers for parcels, 203, 247, 313 
 
 sheets, 213, 227, 247 
 
 sterilization of, 246 
 ^Myomectomy, 111 
 Myringotomy, 83 
 Myxedema, 74 
 
 Nail, brushes, 212, 215, 236, 263 
 
 cleaners, 213, 223 
 Nausea, 20, 182, 185, 188, 189, 191 
 Neatness of bandages, 363, 364 
 Neck, operative positions and drap- 
 ing for, 288 
 Needle book, 252 
 Needles, exploring, 213, 223 
 hypodermic, 213, 223 
 sterilization of, 252 
 suture, 213, 223 
 
 kinds for operations, 297, 298, 
 300, 301, 303, 304, 305, 306, 
 307, 308, 309 
 Negative pressure, 129 
 Nephrectomy, 144 
 Nephritic diet, 159 
 Nephrolithotomy, 144 
 Nephrotomy, 143 
 
 Nerves, instruments and sutures for, 
 306 
 spinal, surgery of, 85 
 Nervous system, 80-86 
 Neuritis, 85 
 
 New growths, classification of, 13 
 of bladder, 148 
 of breast, 140 
 of esophagus, 46 
 of jaw, 40 
 of larynx, 124 
 of ovarv, 114 
 of testicle, 117 
 of tongue, 41 
 New York Hospital method of cat- 
 gut sterilization, 258 
 Newspapers, in home operating 
 
 room, 402, 404, 409, 413 
 Nightingale, Florence, xiii 
 Nitrous oxide anesthesia, care of 
 
 patient in, 178_, 182 
 Nose, operative position and draping 
 for, 288 
 surgery of, 120 
 
 Nourishment, after anesthesia, 152, 
 182, 188, 190, 191 
 before anesthesia, 174 
 
 Novocain, sterilization of, 252 
 
 Nurses, division of duties of, 211 
 operating room duties of, 290, 291 
 operating room staff of, 210, 291 
 qualifications of, 394, 2j0, 212 
 training of, 194, 212 
 
 Nursing, of alimentary system, 38-71 
 of glandular sj'stom, 72-79 
 of nervous system, 80-86 
 of osseous system, 87-104 
 of reproductive system, 105-119 
 of respiratory system, 120-129 
 of skin and appendages, 130-141 
 of urinary system, 142-150 
 
 Nutrient enema, 172 
 
 Obstruction, intestinal, 55 
 
 respiratory, 181, 184, 189 
 Olive oil, sterilization of, 252 
 Omentopexy, 68 
 Oophorectomy, 115, 308 
 Open operations for fractures, 100 
 Operating room, arrangement of, 193 
 
 bathroom as, 403 
 
 bedroom as, 403 
 
 construction of, 195 
 
 equipment of, 193 
 
 floors of, 196 
 
 furniture for, 197 
 
 in action, 263-295 
 
 kitchen as, 403 
 
 light for, 195, 201, 403, 406 
 
 location of, 195 
 
 nurses of, 194, 210, 211, 212, 290, 
 291 
 
 organization of, 193 
 
 personnel of, 194, 210, 212, 291 
 
 preparation of for operations, 263, 
 408 
 
 renovation of in home, 404 
 
 selection of in the home, 403 
 
 size of, 195 
 
 sterilization in, 232-262, 292, 295, 
 409 
 
 supplies for, 212 
 
 temperature of, 197, 263 
 
 walls of, 196, 204 
 Operating tables, 197, 405 
 
 cleaning of, 292 
 Operating theater, 193-231 
 Operations, complications after, see 
 complications. 
 
 draping for, 266 
 
 dressings for, 217, 400 
 
 in the home, 399-414 
 
 instruments for, see instruments 
 
 nurses' duties during, 290 
 
INDEX 
 
 447 
 
 Operations, nurses' management be- 
 tween, 291 
 positions for, 266, 410 
 preparation, of operative field for, 
 see preparation. 
 of patient for, see preparation 
 of room for, 263, 408 
 representative, for instrument 
 
 passing, 297-310 
 sutures for, see sutures 
 Operative, field, preparation of, see 
 preparation 
 positions and draping, 266-290 
 improvised, 410-413 
 Ophthalmoscope, 81 
 Orderlies, operating room, 291 
 Organization of operating theater, 
 
 193 
 Osmotic pressure, 322 
 Osseous system, 87-104 
 Osteomyelitis, 101 
 Ovaries, cyst of, 114 
 • instruments for, 308 
 surgery of, 114-115 
 Oven, as sterilizer, 241, 402 
 
 Pack, ice, 75, 78 
 
 Packing, gauze, 213, 223, 247, 311 
 
 of supplies, 246, 313 
 
 of the wound, 133 
 Pad, or pads, abdominal, 213, 223, 
 247 
 
 Carrel-Dakin dressing, 326, 331, 
 338. 
 
 Kelly, 213, 221 
 improvised, 412 
 uses of, 280 
 
 operating table, 213, 224, 405 
 Pagenstecher linen thread, 50, 57, 
 
 229 
 Pallor, in chloroform anesthesia, 190 
 Pancreas, operative position and 
 draping for, 267 
 
 surgery of, 68 
 Paper bandage, crepe, 360, 361 
 Paquelin cautery, 244 
 Paracentesis, abdominal, 68 
 Paraffine, for burns, 137 
 
 for silk thread, 229, 260 
 Paralytic ileus, 26 
 Parasites, 12 
 Parathyroid gland, 79 
 Passing of instruments, 296-312 
 Passive movements, 89 
 Paste, Beck's, 56 
 Pasteur, Louis, xi 
 Patching of gloves, 294 
 Pathology, 3-13 
 Paul's tube, 55 
 Pelvic rest, 213, 220, 388 
 
 Per cent of solutions, 416 
 I'erforated gastric ulcer, 49, 52 
 Perforation, in appendicitis, 59 
 
 intestinal, 53 
 Perineorrhaphy, 105, 110 
 
 nursing care of, 106 
 Perineum, instruments and sutures 
 for, 308 
 
 surgery of, 105 
 Peritoneum, sutures for, 298, 301 
 Peritonitis, 59 
 Peritonsillar abscess, 43 
 Pernicious vomiting, 21 
 Personnel of the operating room, 
 
 194, 210, 212, 291 
 Pessary, 109, 110 
 Phagocytes, 10 
 Pharynx, surgery of, 43 
 Phimosis, 150 
 Phlebitis, 35 
 Phlebotomy, 34 
 Phosgene gas, 204, 408 
 Piles, 63 
 Pillows, 213, 225 
 
 uses of, 267, 273, 274, 276, 282, 
 407, 410, 411, 413 
 Pins, Wyeth's, 103 
 Pituitary gland, 73 
 Plaster of Paris bandages, applica- 
 tion of, 91, 93, 390 
 
 jacket of, 93 
 
 making of, 361 
 
 molded splints of, 92 
 
 removal of, 397 
 
 spica of, 93 
 Plates, Lane bone, 100 
 
 instruments for applying, 307 
 Pneumonia, "ether," 186, 187 
 
 post-operative, 27 
 Poisoning, blood, 10 
 
 carbon monoxide, 136 
 Portable, dressing box, 314 
 
 dressing stand, 290 
 
 electric sterilizer, 315 
 Portals of entry for bacteria, 12 
 Position, or positions, arm, 283, 413 
 
 breast, 280 
 
 dorsal, 267 
 
 face, 286 
 
 foot, 284 
 
 for genito-urinary operations, 280 
 
 for gynecological operations, 273, 
 280 
 
 Fowler's, 59 
 
 gall bladder, 273, 411 
 
 hand, 283 
 
 head, 276, 286, 288 
 
 improvised operative, 410-413 
 
 kidney, 275, 411 
 
 Kraske, 64 
 
448 
 
 INDEX 
 
 Position, latero-prone, 278 
 
 leg, 284 
 
 lithotomy, 279, 411 
 
 neck, 288 
 
 operative, and draping, 266-290 
 
 prone, 275 
 
 reversed Trendelenburg, 278 
 
 Sims, 279 
 
 skull, 288 
 
 throat, 288 
 
 Trendelenburg, 272, 410 
 Positive pressure, 129 
 Post-oi)crative, complications, see 
 complications 
 
 hernia, 70 
 
 pneumonia, 27 
 Pregnancy, ectopic, 113 
 Preparation, of catgut, 254-259 
 
 ot" operating room, 263, 408 
 
 of operative field, 70, 74, 82, 83, 
 102, 105, 117, 140, 174, 265, 
 407 
 
 of patient for operation, 39, 55, 
 58, 62, 66, 70, 74, 76, 118, 173 
 Pressure, bandage for, 391, 392 
 
 evenness of in bandaging, 363 
 
 negative and positive, 129 
 
 osmotic, 322 
 
 steam, for sterilization, 205, 237, 
 239, 247, 248, 249, 251, 252, 328, 
 331 332 
 
 sterilizers, 205, 209, 237-241 
 Primary intention, 4 
 Principles of bandaging, 363 
 Problems, solution, 418-424 
 
 rules for solving, 418, 420 
 Prolapse of uterus, 110 
 Prone position, 275 
 Proportions, algebraic, 418 
 Prostate gland, surgery of, 117-119 
 Prostatectomy, 118 
 Pulmonary, complications after op- 
 eration, 27-31, 187, 190 
 
 edema, 30, 187 
 
 embolism, 30 
 
 tuberculosis, 129 
 Pulse, in anesthesia, 177, 178, 179, 
 
 180, 182, 187, 190, 191 
 Punctured wound, 130 
 Purse string, 52, 53, 57, 66, 298, 300. 
 Pus, 10 
 
 Pyelitis, 142, 143 
 Pyemia, 10 
 
 Pyonephrosis, 142, 143 
 Pyosalpinx, 113 
 
 Qualifications, personal, of operating 
 
 room nurses, 194, 210, 212 
 Quinsy sore throat, 43 
 
 Radium treatment, 43, 46, 111, 112, 
 
 115, 119, 149 
 Recovery room, 195, 208 
 Rectal tube, 24, 213, 225 
 Ixectocele, 105 
 
 Eeetum, instruments and sutures for, 
 63, 305 
 operative positions and draping 
 
 for, 279, 280 
 surgery of, 61-65 
 Eeeurrent mode of bandaging, 372 
 Eed blood cells, 4 
 Reducible hernia, 69 
 Reduction of fractures, 88, 100 
 Regular diet, 154 
 Removal, of adhesive plaster, 317 
 
 of bandages, 396 
 Renal calculus, 144 
 Renovation of home operating room, 
 
 404 
 Representative operations for in- 
 strument passing, 297-310 
 Reproductive sj'stem, 105-119 
 
 instruments and sutures for, 307 
 Resection, intestinal, 53, 55, 71 
 rib, 126 
 
 instruments for, 309 
 Reservoir method of Carrel-Dakin 
 
 treatment, 341, 342, 344 
 Reservoirs for solutions, 326, 331, 
 
 341 
 Resin and turpentine glue, 98 
 Respirations, after anesthesia, 182, 
 183, 189, 191 
 Cheyne-Stokes, 81 
 depression of, 184 
 Respiratory system, 120-129 
 Rest, arm, 283, 413 
 head, 288 
 
 hip, or pelvic, 213, 220, 388 
 operating table, 274, 275 
 Resterilization of operating room, 
 
 292, 295, 409 
 Restraint of patient in anesthesia, 
 176, 177, 178, 179, 183, 189, 
 190 
 Retention of urine, 31, 188 
 Retractor, amputation, 212, 213 
 Retroversion of uterus, 109 
 Reverdin skin-grafts, 134 
 Reverse mode of bandaging, 368 
 Reversed Trendelenburg position, 
 
 278 
 Rib resection, 126 
 
 instruments for, 309 
 Robb leg holder, 412 
 Roller bandage, 356, 359, 362, 365, 
 373, 382 
 modes of applying, 365 
 Rolling of bandages, 356 
 
INDEX 
 
 449 
 
 Room, operating, arrangement of, 
 
 193 
 construction of, 195 
 equipment of, 193 
 furniture for, 197 
 location of, 195 
 organization of, 193 
 preparation of for operation, 263, 
 
 408 
 renovation of in the home, 404 
 selection of in the home, 403 
 sterilization in, 232-262, 292, 295, 
 
 409 
 Eubber, apron, 212, 214, 251 
 
 bandage, Esmarch, 102, 212, 252, 
 
 360, 390 
 bands, 213, 225, 247, 311 
 
 as drains, 311 
 
 as sleeve holders, 225, 247 
 dam, 213, 225 
 
 drains of, 310 
 
 sterilization of, 249 
 gloves, 213, 218, 247, 248, 294, 400, 
 
 407 
 sheets, 213, 225 
 
 uses of, 267, 280, 282, 288, 412 
 tissue, 213, 225 
 
 drains of, 310 
 
 sterilization of, 250 
 tubing, 213, 225 
 
 for Carrel-Dakin outfit, 327, 329, 
 332 
 
 for drains, 310 
 
 sterilization of, 250 
 Rules, bandaging, 394 
 for diet, 170 
 for solving solution problems, 418, 
 
 420 
 
 Salpingectomy, 113 
 
 instruments and sutures for, 308 
 Salpingitis, 112, 113 
 Salt solution, 213, 226 
 
 preparation of, 226, 405 
 
 sterilization of, 249, 405 
 Salt-poor diet, 159 
 Sandbags, 213, 227 
 
 uses of, 267, 274, 275, 276, 278, 
 280, 282, 284, 286, 288, 409, 
 413 
 Saprophytes, 12 
 Sarcoma of jaw, 40 
 Saturated solution, definition of, 415 
 
 making of, 425 
 Sauerbrueh chamber, 129 
 Scales, equivalent temperature, 430 
 Scissors, bandage, 319, 396, 397 
 
 dressing, 318, 324, 328 
 Scrubbing of hands, 263, 319, 408 
 Scultetus bandage, 358, 389 
 
 Seat, for anesthetist or surgeon, 200, 
 
 406 
 ^Secondary, abscess, 59 
 
 hemorrhage, 59, 103 
 
 intention, 4 
 
 suture, 134 
 Secretions, internal, 72 
 Selection of home operating room, 
 
 403 
 Sepsis, 10, 232 
 Septic, definition of, 232 
 Septicemia, 10 
 Septum, deviated, 120 
 Serum, blood, 4 
 
 horse, 36 
 Setting-up exercises, 170 
 Shaving of operative field, 40, 70, 74, 
 
 82, 83, 102, 105, 140, 265 
 Sheet, or sheets, for home opera- 
 tions, 400 
 
 laparotomy, 213, 227 
 draping with, 268, 283 
 
 plain muslin, 213, 227, 247 
 
 draping with, 272, 279, 280, 282, 
 284, 285, 287, 288, 290 
 
 rubber, 213, 225 
 
 uses of, 267, 280, 282, 288, 412 
 Shock, 81 
 
 and hemorrhage, 14-19 
 Shoulder, bandages for, 384, 388 
 
 guards for, 271, 273 
 
 spica bandage for, 384 
 Silk thread, 229 
 
 sterilization of, 260 
 Silkworm gut, 229, 230 
 
 drains of, 310 
 
 sterilization of, 260 
 Silver wire, 229, 230, 261, 307 
 Sims position, 279 
 Sinclair's, glue, 98 
 
 skate, 96, 97 
 Sinus thrombosis, 83 
 Sinusitis, 121 
 Siphon drainage, 132 
 Sitz bath, 63 
 Size, or sizes, of bandages, 362 
 
 of operating room, 195 
 Skate, Sinclair 's, 96, 97 
 Skin, and appendanges, 130-141 
 
 clips for, 229, 230, 261 
 
 grafts of, 134 
 
 instruments for, 134, 309 
 
 sutures for, 300, 301 
 Skull, draping of, 288 
 
 fractures of, 80 
 
 instruments and sutures for 80, 
 82, 306 
 
 operative position for, 2S6 
 Skylight in operating room, 195 
 Sling, 388 
 
450 
 
 INDEX 
 
 Slough, 10 
 
 Smears, in Carrel-Pakin treatmoiit, 
 
 345, 347 
 Soda, carbonate of as sterilizing 
 agent, 237, 252 
 citrate of" in transfusions, 16 
 Soft diet, 152 
 
 Soldering iron cautery, Mayo, 243 
 Solution, Dakin's, 215, 246, 324, 325, 
 328, 331, 332, 347, 348-354. 
 action of, 332, 343, 349 
 composition of, 348, 351 
 Dauf rcsne 's technic for, 350 
 definition of, 348, 350 
 dosage of, 343 
 instillation of, 342 
 making of, 350-354 
 table of quantities of ingredients 
 
 of, 352 
 titration of, 353 
 Solutions, 415-426 
 
 algebraic jiroportiou method of 
 
 reckoning, 418 
 antiseptic, 130, 245 
 basins for, 200, 212, 214, 246, 325, 
 
 328, 406 
 definition of, 415 
 fractional, reckoning of, 420 
 indication of strengths of, 416 
 per cent method of reckoning, 
 
 416 
 problems of, 418-424 
 
 rules for solving, 418, 420 
 salt, 213, 226, 249, 405 
 saturated, 415, 425 
 usual strengths of, 426 
 Solvent power of water, 415 
 Sphincter ani, dilatation of, 63^ 305 
 Spica bandage, 93, 374, 384, 387 
 Spinal cord, surgery of, 85 
 Spine, instruments and sutures for, 
 85, 306 
 operative position and draping 
 for, 276 
 Spiral mode of bandaging, 367 
 Spleen, instruments and sutures for, 
 306 
 operative position and draping for, 
 267 
 Splint, or splints, 213, 227 
 Hodgen 's, 94, 96, 100 
 Jones's "Crab" or "Cock-up" 
 
 wrist, 100 
 materials for, 91 
 plaster of Paris, molded, 92 
 sugar-tong, 92 
 Thomas traction, 100 
 Sponges, crauze, 217, 247, 330 
 Spores, killing of, 237, 249, 259 
 Sprains, 89 
 
 Staff, operating room nursing, 194, 
 
 210, 212 
 Stand, dressing, portable, 290 
 instrument, 198, 405 
 
 arrangement of instruments on, 
 298 
 irrigator, 213, 221, 326, 331 
 Standard strict diet, 156 
 Starch bandage, 212, 360, 390 
 Stasis of colon, 60 
 Steam, in operating room, 204 
 pressure sterilizer, 205, 209, 237- 
 
 241 
 sterilization by, 205, 236, 237, 247, 
 
 248, 249, 251, 252, 328, 331, 
 332, 401 
 
 Stenosis, cervical, 108 
 Sterile supplies, handling of, 246, 
 291, 314, 318, 319, 335 
 
 room for, 195, 209 
 Sterilization, after operations, 292, 
 295, 409 
 
 agents of, 235 
 
 between operations, 292 
 
 by actual cautery, 57, 242, 300 
 
 by boiling, 236, 237, 246, 248, 250, 
 251, 252, 258, 259, 260, 261, 
 286, 315, 330, 332, 333, 348, 403, 
 406, 407 
 
 by chemicals, 235, 236, 245, see 
 also alcohol, bichloritle of mer- 
 cury, carbolic acid, Dakin's so- 
 lution, ether, formalin, iodine, 
 lysol 
 
 by dry heat, 236, 241, 252, 254, 
 256, 257, 258, 402 
 
 by flame, 242, 406 
 
 by steam, 205, 236, 237, 247, 248, 
 
 249, 251, 252, 328, 331, 332, 
 401 
 
 definition of, 234 
 
 fractional, 249 
 
 in the home, 400, 401, 402, 403, 
 
 405, 406, 407, 408, 409, 410 
 methods of, 246 
 of catgut, 254-259 
 of gauze and muslin, 247 
 of gloves, 248, 400, 407 
 of hands, 263, 319, 408 
 of instruments, 246, 252 
 of operative field, 70, 74, 82, 174, 
 
 265, 407 
 of rubber tissue, 250 
 of suture materials, 254-262 
 operating room, 232-262 
 temperatures for, 236, 237, 239, 
 
 241, 247, 248, 252, 256, 257, 258, 
 
 402 
 thermal, 235, 236 
 vacuum method of, 240 
 
INDEX 
 
 451 
 
 Sterilizer, hot air, 241 
 
 improvised, for home, 401 
 
 instrument, 203, 315 
 
 oven as, 241, 402 
 
 steam pressure, 205, 209, 237-241 
 
 test for, 241 
 
 utensil, 204 
 
 vacuum, 240 
 
 water, 204 
 Sterilizing room, 195, 209 
 Stirrups, 279, 284, 286, 411 
 Stockings, for traction, 96 
 
 lithotomy, 213, 227, 247 
 draping with, 280 
 
 ordinary, for draping, 286 
 Stomach, clamp for, 50, 305 
 
 dilatation of, 22 
 
 fistula of, 46 
 
 instruments and sutures for, 50, 
 305 
 
 operative position and draping 
 for, 267 
 
 surgery of, 48-53 
 
 tube for, 213, 228 
 Stone, of gall bladder, 65 
 
 of kidney, 144 
 
 of urinary bladder, 147 
 Stopcocks, 327, 333, 341, 342 
 Storage room, 195, 209 
 Strands, fibrin, 4 
 Strangulated hernia, 69, 71 
 Strapping, device for dressings, 317 
 
 for fractures and sprains, 88, 89 
 Strengths of solutions, indication of, 
 416 
 
 table of, 426 
 Stretchers, 198 
 Stricture of esophagus, 45 
 Struggling, control of in anesthesia, 
 176, 177, 178, 179, 183, 189, 190 
 Styptics, 19 
 Suction drainage, 132 
 Sugar-tong splint, 92 
 Suits, operating room, 213, 228, 247 
 Sunlight, as sterilizing agent, 236 
 Supplies, for Carrel-Dakin treatment, 
 215, 324 
 
 for dressings, 313 
 
 for operating room, 212 
 
 handling of sterile, 246, 291, 314, 
 318, 319 
 Supply room, sterile, 195, 209 
 Suppression of urine, 32, 187, 188 
 Suppuration, 10 
 Suprapubic lithotomy, 148 
 Supravaginal hysterectomy. 111 
 Surgery, history of, ix-xv 
 
 of alimentary system, 38-71 
 
 of glandular system, 72-79 
 
 of nervous system, 80-86 
 
 Surgery, of osseous system, 87-104 
 of reproductive system, 105-119 
 of respiratory system, 120-129 
 of skin and appendages, 130-141 
 of urinary system, 142-150 
 
 Surgical field, 3 
 
 Suspension, of fractures, 98 
 of uterus, 110 
 
 instruments and sutures for, 308 
 
 Suture, or sutures, book for, 298 
 Gushing, 50 
 
 for operations, 42, 50, 57, 100, 297, 
 298, 300, 301, 302, 303, 304, 305, 
 
 306, 307, 308, 309, 310 
 materials for, 213, 228 
 
 needles for, 213, 223, 297, 298, 
 300, 301, 303, 304, 305, 306, 
 
 307, 308, 309 
 secondary, 134 
 sterilization of, 254-262 
 through-and-through, 230, 301 
 
 Suturing of Carrel-Dakin wound, 347 
 Symbols, abbreviations and, 431 
 Syringe method for Carrel-Dakin 
 
 treatment, 342, 344 
 Syringes, 213, 230 
 
 for Carrel-Dakin treatment, 326, 
 332 
 
 sterilization of, 251 
 System, alimentary, 38-71 
 
 glandular, 72-79 
 
 nervous, 80-86 
 
 osseous, 87-104 
 
 reproductive, 105-119 
 
 respiratory, 120-129 
 
 skin and appendages, 130-141 
 
 urinary, 142-150 
 
 Table, or tables, anesthetist's, 206 
 draping of, 264 
 Hawley, 93 
 instrument, 198, 405 
 
 arrangement of for operations, 
 298 
 operating, 197, 405 
 supply, 198, 200, 206, 207, 404, 405 
 Talma operation, 68 
 Teaching of nurses, 193, 194 
 Technic, definition of, 234 
 Lane, 100, 307 
 of dressing the wound, 313-320, 
 
 335 
 of handling sterile supplies, 246, 
 
 291, 314, 318, 319, 335 
 of unsterile stage in operations, 50, 
 57, 300, 303 
 Temperature, equivalent scales of, 
 430 
 operating room, 197, 263 
 standard, of water, 425 
 
452 
 
 INDEX 
 
 Temperature, sterilizing, 236, 237, 
 239, 241, 247, 248, 252, 256, 
 257, 258, 402 
 Tendons, instruments and sutures 
 
 for, 306 
 Tension of bandages, 363 
 Test, for alkalinity of Dakin's solu- 
 tion, 354 
 
 for sterilizer, 241 
 Testicle, surgery of, 115 
 Tetanus spores, 259 
 Tetany, 79 
 
 Tlieater, operating, 193-231 
 Thermal sterilization, 235, 236 
 Thermo-eautcry, 236, 242 
 Thermometers, 213, 231, 242, 255 
 
 equivalent scales of, 430 
 
 sterilization of, 252 
 Thiersch skin-grafts, 134 
 Thirst, after anesthesia, 20, 188, 189 
 Thomas traction splints, 100 
 Thoracic wall, surgery of, 125 
 Thread, silk ind linen, 229, 260 
 Throat, operative position and drap- 
 ing for, 288 
 Thrombosis, 35 
 
 sinus, 83 
 Througli-and-through suture, 230, 
 
 30 1 
 Thumb, spica bandage of, 374 
 Thyroid gland, instruments and su- 
 tures for, 306 
 
 surgery of, 73-79 
 Thyroidism, 75 
 Tissue, granulation, 4, 134 
 
 rubber, 213, 225 
 drains of, 310 
 sterilization of, 250 
 Titration, of chloride of lime, 351 
 
 of Dakin 's solution, 353 
 Toe bandage, 376 
 Tongue, control of in anesthesia, 184 
 
 forceps for, 185, 213, 231 
 
 surgery of, 41-43 
 Tonsillectomy, 44 
 
 instruments for, 44, 304 
 
 operative position and draping for, 
 286 
 Tonsils, surgery of, 44 
 Torsion, 18 
 
 Tourniquets, 18, 102, 213, 231, 252 
 Towels, 213, 231, 247 
 
 clamps for, uses of, 270, 272, 278, 
 279, 281, 285, 287, 288, 290 
 
 drum for, 202 
 
 for home operations, 400 
 
 lithotomy, 213, 231, 247 
 draping with, 280 
 Toxemia, 10 
 Trachelorrhaphy, 109 
 
 Tracheotomy, 74, 122 
 
 Traction treatment of fractures, 94- 
 
 100 
 Training of nurses, 193, 194 
 Transfusions, 15-17 
 Treatment, Carrel-Dakin, 321-354 
 Tremor, after anesthesia, 187 
 Trendelenburg position, 272, 410 
 Trephine, 80, 82 
 Triangular bandage, 362, 388 
 Truss, 70 
 T-tube, 113 
 
 Tub, for operating room, 200 
 Tube, or tubes. Brewer, 126 
 
 Carrel-Dakin, 325, 336 
 cleaning of, 347 
 making of, 329 
 rubber for, 325, 329 
 uses of, 336 
 
 catgut, 261 
 
 connecting, 327, 333 
 
 culture, 213, 217 
 
 delivery, for Carrel-Dakin treat- 
 ment, 325, 329, 336, 347 
 
 distributing, Carrel-Dakin, 327, 
 333 
 
 drainage, 310 
 
 dropper, 327, 333, 342 
 
 ' ' en chemise, ' ' 64 
 
 Fallopian, surgery of, 112 
 
 Paul's, 55 
 
 rectal, 24, 213, 225 
 
 stomach, 213, 228 
 
 T-, 113 
 Tuberculosis, of epididymis, 116 
 
 of intestines, 53 
 
 of urinary bladder, 147 
 
 pulmonary, 129 
 Tubing, rubber, 213, 225 
 
 drains of, 310 
 
 for Carrel-Dakin outfit, 327, 329, 
 332 
 
 sterilization of, 250 
 Tumors, 13 
 
 of brain, 84 
 
 of breast, 140 
 
 of jaw, 40 
 
 of uterus, 111 
 Tunica vaginalis, 116 
 Turbinates, hypertrophy of, 121 
 Tympanites, 23, 24 
 
 Ulcer, duodenal, 53 
 
 esophageal, 45 
 
 gastric, 48, 52 
 
 intestinal, 53 
 Umbilical hernia, 70 
 Unger transfusion, 16 
 Uremia, 33 
 Ureters, 145 
 
INDEX 
 
 453 
 
 Urethra, 149 
 
 Urethrotomy, 150 
 
 Urinary, bladder, surgery of, 145-149 
 system, 142-150 
 
 Urine, albumen in, 187, 190 
 retention of, 31, 188 
 suppression of, 32, 187, 188 
 voiding of, 31, 32, 188, 190 
 
 Uses of bandages, 355 
 
 Usual strengths of solutions, 426 
 
 Utensil sterilizer, 204 
 
 Uterus, instruments and sutures for, 
 111, 307, 308 
 operative positions and draping 
 
 for, 273 
 surgery of, 107-112. 
 
 Vacuum, sterilization in, 240 
 Vagina, instruments and sutures for, 
 308 
 operative position and draping 
 
 for, 280 
 surgery of, 105, 112 
 Varicocele, 117 
 
 Varicose veins, bandage for, 391 
 instruments for, 305 
 operative positions and draping 
 for, 284 
 Vaselinated gauze, 325, 328, c25 
 Vaseline, sterilization of, 252 
 Veins, instruments for, 305 
 Velpeau bandage, 384 
 Ventilation of operating theater, 197, 
 
 205, 208, 209 
 Ventral, fixation of uterus, 110. 
 
 suspension of uterus, 110 
 Vesalius, x 
 
 Voiding of urine, 31, 32, 188, 190 
 Vomiting, 20, 21, 29, 52, 180, 181, 
 
 182, 185, 188, 189, 191 
 Von Leube diet, 161 
 
 Walls, operating theater, 196, 204 
 Wash, basins, 206 
 
 mouth, 39, 189 
 Washing, of Carrel-Dakin tubes, 347 
 
 of gloves, 294 
 
 of instruments, 293 
 
 Washing, of operating table, 292 
 
 soda, as sterilizing agent, 237, 252 
 Water, boiling, 236, 237 
 
 for anesthesia patients, 20, 151, 
 
 188, 189 
 solvent power of, 415 
 sterilization of in the home, 405 
 sterilizers for, 204 
 table of standard temperatures 
 for, 425 
 Wax, Horsley's, 18 
 Weights, and measures, tables of, 
 426 
 equivalent, table of, 427 
 Wet dressings, 132 
 White blood cells, 4, 10 
 Windows, "frosting" of, 405 
 Wine measure, 428 
 Wipes, gauze, 217, 247, 330 
 Wire, for suturing, 100, 229, 230, 
 
 261, 307 
 Woie skin-graft, 134 
 Wood splints, 91 
 Work room for nurses, 195, 208 
 Wounds, Carrel-Dakin, bacteriologi- 
 cal examination of, 345 
 dressing of, 335 
 suturing of, 34V 
 tubes for, 325, 329, 336, 337 
 types of, 337 
 classification and definition of, 
 
 130 
 dressing of, 313-320, 335 
 dressings for, 213, 217, 247, 330, 
 
 331, 338, 400 
 healing of, 4, 134 
 infected, 7, 132 
 infection of, 3 
 lacerated, 131 
 packing of, 133 
 punctured, 130 
 suppurating, 10 
 Wrist, Jones 's ' ' Crab " or " Cock- 
 up" splint for, 100 
 Wyeth's pins, 103 
 
 X-iaj treatment, 43, 74^ 111, 115, 
 141 
 
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