\son Columbia ZBmbersftK-v v lull ttttttuirial ftmo Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/surgicalassistan1907bric THE SURGICAL ASSISTANT The Surgical Assistant A Manual for Students, Practitioners, Hospital Internes and Nurses BY WALTER M. BRICKNER, B. S., M. D. CHIEF OF SURGICAL DEPARTMENT, MOUNT SINAI HOSPITAL DISPENSARY, SURGEON TO THE ROCKAWAV PARK SANITARIUM FOR CHILDREN, ETC., NEW YORK CITY WITH 123 ORIGINAL ILLUSTRATIONS SECOND EDITION The International Journal of Surgery Co. MEDICAL PUBLISHERS IOO WILLIAM STREET, NEW YORK I907 COPVRtGTIT, iqos, tgo?, BY THE INTERNATIONAL JOURNAL OF SURGERY CO. TO HOWARD LILIENTHAL, M. D. AS A TOKEN OF PERSONAL REGARD, AND AS A TRIBUTE TO HIS SURGICAL SKILL, THIS BOOK IS DEDICATED PREFACE. Surgical text-books, even those that deal most minutely with operative technics, make but scant reference to the duties of the surgeon's assistants. And yet the skill of the assistants is scarcely less important than the skill of the sur- geon himself. In an operation the surgeon must depend, not only upon the experience and the caution of the anesthetist, but also upon the familiarity with aseptic details, the fore- sight and adaptability, and the coolness in emergency of those who aid him in the mechanical procedure itself. If we except a brochure by Dr. Carl Lauenstein— " Der Assistenzarzt " — which in neither scope nor execution has anything in common with this book, nothing known to the author has been written upon this important subject. The volume he presents is then, a pioneer, and as such, no doubt, has its shortcomings. In spite of these he believes it will be found a helpful guide — to the student preparing for hospital examinations or substituting in hospital or dispensary work ; to the hos- pital interne who, early in his service, unfamiliar as yet with surgical technics or even with the names and forms of many surgical appliances, is, for a time, embarrassed by the awkwardness of his untutored hands and the slowness of his untrained eye ; to the graduate nurse who, trained in the hospital operating-room only in the handing of sponges and towels, finds herself confronted in private practice with the necessity of preparing a room for an operation and very often of assisting actively in the operation itself; and to the general practitioner, as a volume of reference to aid him in maintaining a large share in the treatment of those of his patients who otherwise would pass from his entirely into other hands. If, in emergency, it occasionally becomes 7 8 Preface. imperative for one not thoroughly trained in surgery to per- form a major operation, how much more often will it be necessary for him to render assistance to the consultant whom he has called to an urgent case! Moreover, the possession of ability to help well would go far to settle satisfactorily the questions of fees ; for, sharing in the labor of an operation, and conducting some or all of the after- dressings, are rendering to both patient and surgeon definite and valuable services, well worthy of recognition. Essentially a technical manual, this work aims to be thor- oughly practical, its object being to present clearly and concisely the many important details of method, the valua- ble little " wrinkles," which, familiar enough to the surgeon and to the trained assistant, have not before been gathered together in print. The latter part of the book is devoted to the description, from the assistant's standpoint, of various operations, step by step. For this purpose there are selected for consider- ation only those operations that are commonly performed, those that typify certain groups of operations, those that constitute important emergencies, and those that require special description. Manifestly the assistant's manipulations must depend, in large part at least, upon the operator's methods; but since the essential and the commonly adopted technics are de- scribed it ought not to be difficult to modify them to suit the needs of individual cases. It will be noted that most of the descriptions are given as though but one assistant (in addition to the anesthetist) were present, and the reader may sometimes think the author has forgotten that an assistant has but two hands. In fact, however, there are few operations that cannot be conducted with but one assistant, and, in emergency, only one may be available. In such cases the assistant must often make his two hands do the work of three or four. When, however, a full quota of assistants is present the proper distribution of their duties may be derived from a reference to the earlier chapters. Preface. 9 Especial care has been taken to make the index useful. It is hoped that the appendix containing the formulary for the preparation of ligature material, surgical dressings, etc., will also prove useful. While illustrations of the instru- ments in constant use are quite essential to a hand-book of this character, it has been thought best to print them together in a second appendix. The electrotypes for most of these pictures have been kindly furnished by Messrs. George Tiemann & Co. All the other illustrations in the book are the work of Dr. Erwin Reissman, to whom the author expresses his appreciation. He would also thank here Drs. Arpad G. Gerster, Howard Lilienthal, and Paul J. Rosenheim for suggestions, and Dr. Joseph MacDonald, jr., for his uniform courtesy and interest in the publication of the work. W. M. B. 30 West Ninety-second Street, New York, April 15, 1905. CONTENTS. PART I. Chapter I. PAGE THE CONDUCT OF THE ASSISTANT AND HIS RELATIONS WITH THE SURGEON AND THE PATIENT . . 27 Chapter II. THE HOSPITAL INTERNE. Relations with Superior and Subordinate Officers, Nurses, Patients — The House Surgeon — Rounds — Dressings — Examinations — Observation of Symptoms — Care of Histories 32 Chapter III. ASSISTANCE IN EXAMINATIONS AND DRESSINGS. Examinations — Fractures and Dislocations — Change of Dressings 37 Chapter IV. PREPARATIONS FOR AN OPERATION— THE ROOM. General Considerations — System — Preparations in Detail . 53 Chapter V. PREPARATIONS FOR AN OPERATION— THE PATIENT. THE ASSISTANT HIMSELF ; TECHNICS OF ASEPSIS. Carrying the Patient — Aseptic Preparations in Detail — Aseptic " Don'ts" .68 11 12 Contents. Chapter VI. THE ANESTHETIST. PAGE Effects of Chloroform, of -Ether, of their Mixtures; Indica- tions and Contra-indications for Each — Technics of An- esthetizing — Symptoms to be Observed; their Indica- tions; Treatment — Emergencies — Individual Methods of Administering the Various Anesthetics; Chloroform; Ether; Gas and Ether; Chloroform-Ether Mixtures; Nitrous Oxid; Nitrous Oxid and Oxygen; Ethyl Chlo- rid; Ethyl Bromid — Obstetric Narcosis . . .81 Chapter VII. PREPARATION AND PRESERVATION OF SURGICAL INSTRUMENTS AND ACCESSORIES. Sterilization of the Various Instruments, etc. — Cleansing and Preservation 102 Chapter VIII. •• HANDING INSTRUMENTS." 114 Chapter IX. ASSISTANCE AT THE WOUND. General Considerations — Use of the Hands — The Incision — Sponging — Retracting — Dissection — Hemostasis; Ma- nipulation of Ligatures — Suturing — Removing Sutures — Irrigating 13° Chapter X. IMMEDIATE POST-OPERATIVE CARE OF THE PATIENT. Clothing— Removal from Table— The Room— The Bed- Arrangement of the Patient in Bed— Pain and Restless- ness — Tightness of the Dressing — Vomiting — Feeding — Singultus — Urination— Shock and Concealed Hemor- rhage; Differential Diagnosis — Treatment of Shock — Treatment of Hemorrhage; External Hemorrhage; Bleedingfrom Wounds in General; Anterior Naris; Pos- terior Naris; Tonsil; Intercostal Vessels; Intra-abdom- Contents. 13 inal Bleeding; Kidney; Renal Vessels; Bladder; Peri- neum; Rectum; Uterus (post-partum); Cervix Uteri — After-Treatment of Severe Hemorrhage — Pulmonary Edema; Use of Cups; Phlebotomy — Uremic Convul- sions — Poisoning by the Absorption of Antiseptics; Carbolic Acid; Bichlorid of Mercury; Iodoform . . 147 PART II. Chapter XI. OPERATIONS UPON THE HEAD. The Cranium; Trephining — Mastoid Operations . . . 163 Chapter XII. OPERATIONS UPON THE HEAD (Continued). Ophthalmic Operations — Extraction of Cataract — Iridec- tomy — Strabismus — Enucleation — Eye Dressings — Re- moval of the Upper Jaw . . . . . .171 Chapter XIII. OPERATIONS UPON THE THROAT, THE NECK AND THE CHEST. Removal of Pharyngeal Adenoids — Retropharyngeal Ab- scess — External Esophagotomy; Thyroidectomy; Re- moval of Glands and New Growths; Operations upon Vessels and Nerves — Tracheotomy — Breast Amputa- tion — Empyema Thoracis 177 Chapter XIV. ABDOMINAL OPERATIONS. Preparation of the Field — Armamentarium — Dissection of the Abdominal Wall — Opening the Peritoneal Cavity — Exposing the Viscera — Pads and Packings — Suturing the Abdominal Wall— The Dressing . . 184 14 Contents. Chapter XV. ABDOMINAL OPERATIONS {Continued). PAGE Exploratory Laparotomy — Appendicitis — General Peritoni- tis — Lavage of the Stomach 196 Chapter XVI. ABDOMINAL OPERATIONS {Continued). Operations upon the Gall-bladder and Gall Ducts — Chole- cystostomy ; Cholecystotomy — Choledochotomy — Chole- cystectomy — Cyst of the Liver — Abscess of the Liver — Subphrenic Abscess — Resection of the Liver (new growth) 202 Chapter XVII. ABDOMINAL OPERATIONS (Continued). Operations upon the Stomach and Intestines — Gastrostomy — Internal Esophagotomy — Gastrorrhaphy; Enteror- rhaphy — Gastro-enterostomy; Gastrectomy; Pyloro- plasty; Pylorectomy — Colostomy — Intestinal Resection — Intestinal Anastomosis 207 Chapter XVIII. ABDOMINAL OPERATIONS (Continued). Operations upon the Female Pelvic Organs, Abdominal Route — Ovariotomy ; Salpingectomy — Cysts — Abscess — Ectopic Gestation — Hysterectomy — Cesarean Section 218 Chapter XIX. ALEXANDER'S OPERATION OF SHORTENING THE UTERINE ROUND LIGAMENTS. HERNIOTOMY. Alexander's Operation— Ventral Herniotomy— Inguinal Herniotomy — Femoral Herniotomy .... 225 Chapter XX. OPERATIONS UPON THE KIDNEY AND URETER. Lumbar Route — Position — Nephrotomy — Nephrectomy — Nephropexy — Abdominal Route — Operations upon the Ureter 235 Contents. 15 Chapter XXI. OPERATIONS UPON THE BLADDER AND URETHRA. PAGE Cystoscopy in the Male — Endoscopy — Cystoscopy in the Female — Suprapubic Cystotomy; Lithotomy; Prosta- tectomy; Neoplasm; Ulcer — Drainage — Internal Ure- throtomy — External Urethrotomy; Perineal Section — Manipulation of Steel Sounds 241 Chapter XXII. OPERATIONS IN AND ABOUT THE VAGINA. Position — Preparation — Curettage — Trachelorrhaphy — Hysterectomy — Drainage of Pelvic Abscess, etc. — Plas- tic Operations — Anterior Colporrhaphy — Posterior Col- porrhaphy; Perineorrhaphy 257 Chapter XXIII. RECTAL OPERATIONS. Position — Preparation— Dressing — Radical Operations for Hemorrhoids — Stricture — Fistulo in Ano . . . 277 Chapter XXIV. OPERATIONS UPON THE EXTREMITIES. Amputations — Osteotomy 286 Chapter XXV. SKIN-GRAFTING. INTRAVENEOUS INFUSION. SUBCUTANEOUS INFUSION 299 APPENDICES. Appendix I. THE PRELIMINARY PREPARATION AND ROUTINE AFTER-TREATMENT OF OPERATIVE CASES . 311 16 Contents. THE PREPARATION OF SURGICAL MATERIALS; FORMULARY. PAGE Sutures and Ligatures — Sea-Sponges — Rubber Tissue; Guttapercha Solutions, etc. — Bone Chips — Paraffin Mix- tures — Bone Wax — Bandages — Dressings — Towels and Gowns — Surgical Solutions — Battery Fluids — Enemata 314 Appendix II. ILLUSTRATIONS OF SURGICAL INSTRUMENTS 337 INDEX. 355 LIST OF ILLUSTRATIONS. FIGURE i. Manner of holding a child firmly in the sitting pos ture 2. 3- 4- 5- 6. 7- 8. 9- io. ir. 12. 13- 14. 15- 16. 17. 18. 19. 20. 23- 24. 25- 26. 27. 28. 20- on of well Manner of holding a child upon a table Proper manner of holding foot during applicati bandage Maintaining reduction of forearm fracture . Triangular cardboard axillary pad Padded straight splint Plaster dressing — arrangement for making soft cuff Freeing bandage of frayed edges Handing plaster bandage .... Plaster dressing — smooth cuff formed . Arrangement for dressing wound of neck . Scheme of operating room arranged in private d ing Improvised Trendelenburg table . Table arranged for operation in lithotomy positi Arrangement for anesthetist Arrangement of accessories on mantel-shelf Arrangement of instrument table Arrangement of table for second assistant (nurse) Lifting and carrying a patient Transportation of a patient by two men Arrangement of sterilized towels for laparotomy The assistant " scrubbed up " and ready for opera tion Administration of chloroform — holding jaw forward etc. Sponging mucus from the pharynx Administration of gas and ether .... Testing iridectome on " drum " Repairing aspirating syringe with leather packing Surgical catgut — scale of sizes .... Squeezing end of catgut for insertion in eye of needle 17 37 38 39 4i 42 43 45 46 47 49 5i 59 60 61 63 64 66 67 69 70 7i 73 90 98 107 no 117 118 18 List of Illustrations. FIGURE PAGE 30. Twisting silkworm-gut suture ..... 119 31. " Button suture " ........ 120 32. Handing gauze packing 121 33. Handing " cigarette " drain ...... 122 34. Preparation of drainage tube ..... 123 35. Fenestrated drainage tube 123 36. Handing drainage tube on probe 124 37. The clove hitch 125 38. Incorrect manner of handing chisel and mallet to operator .125 39. Correct manner of handing chisel and mallet . .126 40. Handing suture and forceps .... . . . 127 41. Cotton sponges ........ 128 42. Incorrect manner of holding retractors . . . 131 43. Proper disposition of hands and arms in holding re- tractors . . . . . . . . .131 44. Stretching the skin to facilitate primary incision . 132 45. Retractor exposing to view a large surface through a small opening ........ 134 46. Dissection between mouse-tooth forceps . . . 136 47. Manipulation of hemostat and scissors in application of a ligature 138 48. Surgeon's knot; flat knot; granny knot . . . 139 49. Application of " chain ligature " to omentum . . 141 50. Coaptation of edges by traction with tenacula . . 142 51. Coaptation of edges by traction with two forceps . 142 52. Assistant's manipulations during introduction of con- tinuous suture ........ 143 53. Lifting skin edges with one forceps for introduction of suture 144 54. Eversion of wound edges during suturing . . . 145 55. Tying button sutures -. 145 56. Elevation of foot of bed with chair ; arrangement of bed . . 152 57. Position of head for operation on lower jaw or neck ; for mastoid operation ...... 167 58. Gauze shaped for mastoid dressing .... 169 59. Mastoid dressing held with starch bandage . . 170 60. Manner of passing instruments and illuminating for cataract operation ....... 172 61. Eye pads in a shallow basin of boracic acid solution . 173 List of Illustrations. 19 FIGURE PAGE 62. Dressing and bandage of one eye . . . .174 63. Application of dressing after breast operation . . 181 64. Position of patient for empyema operation — rib drawn up with hook 182 65. " Trap-door incision " — rectus abdominis exposed . 185 66. "Trap-door incision" — posterior rectus sheath ex- posed . . . . . . . . . . 186 67. " Trap-door incision" — posterior rectus sheath divided between two forceps 187 68. Enlarging peritoneal opening — protecting underlying viscera ......... 188 69. Lifting up with retractors to expose a large visceral surface . ... 189 70. Tying laparotomy straps ... . . . . 194 71. A method of applying adhesive straps over abdom- inal dressing ........ 195 72. Gauze packing inserted and cecum drawn into wound 197 73. Assistant lifting up appendix while operator inserts double ligature . . . . . . . . 198 74. Amputation of appendix ..... 75. Assistant holding patient on his side — draining gall bladder into pus basin 76. Inguinal colostomy — rod in place; anchorage 77. Manner of handing half of Murphy button . 78 Bassini's operation — retraction of divided external ob lique, exposing sac; opening sac between forceps 79. Bassini's operation — separation of sac from cord 80. Bassini's operation — introduction of deep sutures 81. Bassini's operation — second suture layer, restoring external oblique ....... 82. Turns of bandage after inguinal herniotomy 83. Perineal turns of bandage after inguinal herniotomy 84. Assistant pushing up kidney by pressure on abdomen cushion under lower loin . . . 85. Suprapubic cystotomy ...... 86. Arrangement of syphon for suprapubic drainage of bladder 249 87. Manner of holding penis, scrotum, and urethral sound in external urethrotomy . 252 88. Arrangement of table, towels, and chairs for perineal operation 258 199 203 210 216 228 229 230 231 232 233 237 246 20 List of Illustrations. FIGURE PAGE 89. Manner of applying Clover's crutch . . . . . 259 90. Disposition of operator and assistant in vaginal and perineal operations ....... 260 91. Disposition of surgeon, assistant, and anesthetist in trachelorrhaphy 263 92. Trachelorrhaphy — assistant sponging wound and clamping sutures ....... 264 93. Drainage of pelvic abscess — retracting vaginal walls; drainage tube inserted in dressing forceps . . 267 94. Dissection of cystocele flap . . . . . 269 95. Holding loops of suture in anterior colporrhaphy . 271 96. Dissection of rectocele flap 272 97. Dissection of rectocele flap — assistant manipulates both forceps; surgeon's finger in rectum . .273 98. Posterior colporrhaphy — catching up loops of suture 274 99. Insertion of perineal sutures ' 276 100. Sims' position — rectal examination .... 277 101. Manner of stretching sphincter ani .... 278 102. Tampon canula 279 103. Rectal dressing 280 104. Clamp and cautery operation — clamping . . . 281 105. Clamp and cautery operation — cauterizing . . . 282 106. " Canule a chemise " 285 107. Two-tailed cloth retractor for amputation . . . 287 108. Three-tailed cloth retractor for amputation . . 287 109. Driving blood from the limb with rubber bandage . 289 no. Martin's rubber bandage applied to arm . . . 290 in. Application of constrictor to thigh .... 291 112. Position of lower extremities in amputation of the thigh 292 113. Bone exposed for sawing 293 114. Stump supported and bloodvessels exposed . . 294 115. Preparation of a finger for amputation . . . 296 116. Osteomyelitis — removing bits of bone and sponging pus, etc ' 297 117. Skin-grafting — stretching skin with McBurney's hooks 300 118. Skin-grafting — stretching skin with the hands . . 300 119. Intravenous infusion — arrangement of arm and of ac- cessories 303 120. Intravenous infusion — opening the vein . . . 305 121. Intravenous infusion — introducing the canula . . 306 122. Subcutaneous saline infusion . . . . 308 List of Illustrations. 21 APPENDIX. i. Yankauer's chloroform mask 2. Allis' ether inhaler 3. Bennett's apparatus 4. Ware's ethyl chlorid mask 5. Denhard's mouth-gag 6.- Paquelin's cautery . 7. Gerster's iodoform duster 8. Dieulafoy's aspirator 9. Trocar and canula . 10. Volkmann's spoon . 11. Scalpels 12. Bistouries .... 13. Tenotome . . . 14. Flexible probes 15. Fluhrer's aluminum probe 16. Grooved director 17. Amputating knife . 18. Catlin (interosseous knife) 19. Curved scissors 20. Angular scissors 21. Heavy bandage shears . 22. One-pronged retractor . 23. Two-pronged retractor . 24. Small blunt retractor 25. Large (abdominal) blunt retractor 26. Four-pronged retractor . 27. Forms of surgical needles 28. Peaslee needle 29. Aneurism needle 30. Ligature carrier 31. Dieffenbach's needle holder . 32. Wyeth's needle holder . 33. Hagedorn's needle holder 34. Anatomical (" thumb ") forceps 35. Tissue forceps 36. Dressing forceps 37. Slender (vaginal) dressing forceps 38. Bullet forceps 39. Sponge forceps 40. Gerster's artery forceps . 337 337 337 337 337 338 338 338 338 338 339 339 339 339 339 339 339 339 340 340 340 340 340 340 340 340 341 341 341 341 341 341 341 342 342 342 342 342 342 342 22 List of Illustrations. FIGURE 41. Esmarch's bulldog artery forceps 42. Pean's artery forceps 43. Serrefins 44. Spencer Wells' straight clamp 45. Skene's curved clamp 46. Spencer Wells' T-shaped clamp 47. Angiotribe .... 48. Murphy's button 49. Tracheal canula 50. Nasal speculum 51. Polypus snare .... 52. Bosworth's nasal saw 53. Snellen's entropion forceps . 54. Rack for ophthalmic instruments 55. Knapp's trachoma forceps 56. Gottstein's adenoid curette . 57. Bowman's lachrymal probes . 58. Wire eye speculum 59. Iris scissors 60. Beer's keratome 61. Graefe's linear cataract knife 62. Knapp's cystotome 63. Levi's fenestrated lens spoon 64. Wilde's tubular aural specula 65. Angular ear forceps 66. Mastoid mallet 67. Mastoid chisels 68. Mastoid gouge 69. Keyhole saw . 70. Flat bone saw . 71. Ferguson's lion-jaw bone-holding forceps 72. Markoe's sequestrum forceps 73. Liston's bone-cutting forceps 74. Costotome 75. MacEwen's osteotome . 76. Hamilton's bone drills . ■ . 77. Sharp bone spoon; periosteal elevator. 78. French and English urethral scales 79. Olive-tipped catheter . . • . 80. Olivary bougie . 81. Woven catheter . . . . List of Illustrations. 23 FIGURE PAGE 82. Bougie a boule 347 83. Phimosis clamp 347 84. Filiform bougies ........ 348 85. Filiform bougies . . . . . . . 348 86. Ultzmann urethral syringe 348 87. Otis' urethrometer 348 88. Thompson's stone searcher 348 89. Thompson's lithotrite 348 90. Olive-tipped catheter 348 91. Otis' urethrotome ........ 348 92. Maissoneuve's urethrotome 348 93. Endoscope ......... 349 94. Wheelhouse's staff . 349 95. Teale's probe-gorget (urethral director) . . . 349 96. Stone forceps 349 97. Clover's crutch (Peter's) 349 98. Tenaculum 350 99. Volsellum ......... 350 100. Sims' wire adjuster 350 101. Uterine sound 350 102. Sharp uterine curette ....... 350 103. Dull uterine curette ....... 350 104. Palmer's cervix dilator 350 105. Goodell's cervix dilator ....... 350 106. Recurrent uterine douche nozzle 351 107. Sims' vaginal depressor 351 108. Garrigues' weighted speculum 351 109. Vaginal spatula 351 no. Ferguson's cylindrical vaginal speculum . . .351 in. Sims' vaginal speculum 351 112. Brewer's bivalve vaginal speculum .... 352 113. Bivalve rectal speculum 352 114. Ashton's fenestrated rectal speculum .... 352 115. Smith's pile clamp 352 116. English rectal bougies 352 PART I. THE SURGICAL ASSISTANT. PART ONE. CHAPTER I. THE CONDUCT OF THE ASSISTANT AND HIS RELA- TIONS WITH THE SURGEON AND THE PATIENT. Since many minor procedures and almost all major ones are impossible to the surgeon without help, and since upon the skill and care with which that help is rendered depend in no small degree the comfort and the safety of the patient, the surgical assistant may come at once to a realization of his importance to both surgeon and patient and to an appre- ciation of his proper relation to each of them. Primarily for the purpose of serving another's needs, his greatest use- fulness will lie in forestalling them. However simple or mechanical his duty may be on any occasion, he will always find it is best performed by observing closely conditions as they are developed and requirements as they appear. Manu- ally, he must help in the procedure ; mentally, he must him- self undertake it ; he should be not a pair of hands alone but a brain as well. His usefulness thus developed, he is often in a position to make a suggestion that may help the solution of a knotty problem. This is especially true when, as should often be the case, the patient's physician is, for the nonce, the surgeon's helper, for he continues as medical adviser even while his patient is upon the operating table ; and while technically he is assisting the surgeon, in a broader sense the surgeon is merely assisting him. 27 28 The Surgical Assistant. If, in the light of his greater experience, the surgeon deems unworthy of adoption any suggestion, however sensi- ble, that should seldom be a cause for offense. During oper- ations especially, the assistant will do well to keep his mouth closed and his eyes open. If he observe this rule, both as a matter of decorum and as an aseptic principle, an occasional suggestion, introduced deferentially, will be regarded with respect, — otherwise it will be as unwelcome as it is apt to be unwise. It is scarcely appropriate to dwell here upon the necessity of being prepared to inform the consultant surgeon of every detail of a case that may be of importance to him in forming his opinion. This information is all the more valuable when it is a carefully written record. It is not less important to save for his own observation stools, vomits, uterine or other discharges, etc., even if they are of only negative value. The lack of a thorough urinary report may embarrass the consult- ant very seriously. It will in many instances prove embar- rassing to him, too, if there are not also prepared for him such paraphernalia as may be necessary for his examination. Thus, if he may desire to aspirate a doubtful swelling, there should be ready: soap and water, a brush, alcohol or ether (or both), and sublimate solution, for disinfecting the area to be punctured, and similar materials for sterilizing his hands; a sterile needle and syringe (which should be proven to be in working order by actual test) ; a porcelain or white enamelled dish to receive the contents of the syringe when they are expelled for examination, or, lacking this, a glass dish beneath which may be fastened a disc of white paper; a small dressing, a few towels, and some absorbent cotton. All these things should be near at hand but, until needed, they should not be within the patient's sight. The require- ments for other manipulations will be considered later. A preparation of the patient's body for examination is seldom necessary and often inadvisable, for it is best for the surgeon to see things in their actual condition. It would, for example, be unwise to administer a douche before a vagi- nal inspection. On the other hand, an examination of the The' Conduct of the Assistant. 29 abdomen may be difficult because of tympanites that might have been relieved by a preliminary purgative. Often the assistant will be called upon to prepare for an examination or for some minor procedure hastily, and after the surgeon has arrived. Here he must use nice judgment to secure the greatest convenience to the surgeon with the least confusion in the household. By improvising, and by adapting things at hand to his needs, he may avoid a scurry- ing about that is sure to distress the patient and to annoy his relatives. On the other hand, it is better to send to the kitchen for a table or a chair than to put bottles or basins upon polished or upholstered furniture. Stains and scratches are unpardonable, and they are lasting and unpleasant reminders of a visit that under any circumstances was antici- pated with fear and, often, is recalled with distress. In most instances, too, it is better to trouble the family for a stone or china dish, rather than spoil even a cheap unenam- elled metal one with a mercurial solution. It is the assistant's business to see that the patient's body, clothing and bed- covers are properly protected against soiling by blood, pus, or other fluid. Apiece of oilcloth will suffice if rubber sheet- ing is unavailable or, lacking both, several towels should be used to protect the part most apt to be soiled. A round basin held against the body almost invariably fails to catch discharges. If a kidney-shaped receptacle (pus basin) is not at hand, absorbent cotton or towels should be used to receive a discharge not too profuse. Blood-stained, soiled towels, etc., should be dropped into a paper bag or a basin, which may be pushed out of sight or covered with a cloth and carried from the room. When using plaster of Paris, no protection of the patient and his surroundings from the spattering drops can be too careful. Plaster of Paris is no more desired on the carpet or furniture than are stains of blood or pus, and however much the patient may politely insist that " it doesn't matter a bit," he is not apt to mean it. Even if it " doesn't matter " to him, it should to the physi- cian, for carelessness in these particulars is as much bad tech- nics as is awkwardness in operative manipulations. It is not 30 The Surgical Assistant. hard to believe, too, that despite his protestations the patient will conclude to employ in the future a surgeon whose repu- tation for skill may be less, but whose tidiness is more in evidence, and whoever may be at fault, he is not apt to think kindly of either the surgeon or his assistant, if they leave him wet, soiled and dishevelled. The assistant should observe the utmost gentleness. This secures the patient's confidence and prepares him to bear with equanimity such pain as is unavoidable. It will prob- ably be distressing to pass an instrument before the patient's eyes, and it is certainly awkward to reach across his body for something that could just as well have been placed else- where. A speculum that is cold, or too hot, or dripping wet, or too freely smeared with vaselin is sure to cause dis- comfort. When it is necessary to wear a rubber apron it is always best to cover this with a white gown, for rolled shirtsleeves look ungenteel and the apron appears too formidable, while a white gown gives the impression that it is worn as much for the patient's sake as for the protection of the surgeon's clothing. In this connection it must be remembered that the average layman has a very fair idea of the principles of asepsis, and decided and proper notions of surgical cleanli- ness. However simple the procedure at hand may be, it very properly produces the best impression to have everything used conform with these quite correct notions. A small amount of blood will produce a large stain, and a small instrument may provoke considerable fear ; it is, there- fore, always best to keep both implements and soiled dress- ings out of sight as much as possible and to remove all of them as soon as this can be done. However hasty an assistant's preparations, they should never be ostentatious. He appears most dignified when his bearing is most modest. Let him secure what he wants quietly, making his requests in an undertone and beyond the patient's hearing. His preparations, too, can be com- pleted with no disturbance to the surgeon. There is seldom need of asking him for instructions; certainly no need of The Conduct of the Assistant. 31 asking him aloud. He should make ready what will be needed, and what may be needed. If a nurse be present, her position should not be made an opportunity to exhibit authority. Orders ought to be given to her in a low voice and carried out as quietly as the assist- ant himself is working. She should be given the same opportunity to forestall the assistant's wishes as the assistant himself likes to enjoy in anticipating the surgeon's needs. If the assistant observes something of importance that the surgeon may have overlooked, it is his duty to impart his discovery to the surgeon, and it is also his duty to impart it without attracting the patient's notice. It is in bad taste for an assistant to seek recognition of his acumen. The credit belongs to the surgeon; just as the assistant is responsible to the surgeon and the surgeon is responsible for his assist- ant. If the patient learns through another that the assistant has made a shrewd and useful observation, he will think the more of it because it was not immodestly proclaimed. In any event, it is bad to discuss the patient's condition in his presence, and bad to indulge in loud talking, peremptory orders, or unnecessary questions. A patient often seizes an opportunity to learn from the assistant some facts concerning his condition that the sur- geon or the family physician may'not have imparted. At such a time if the assistant hesitates or stammers, he confirms, perhaps, a fear that no mere statements can remove. He may answer, often truthfully : " I have been too busy helping Dr. to observe all the conditions," or " I am not suffi- ciently familiar with all the facts to form any opinion, but you may rely on what the doctor has told you." It is obvious from these general remarks that an assistant's conduct may do much to mar, and not a little to preserve, the surgeon's reputation as well as his own, and that if he endeavors to conserve the one he will go far towards increas- ing the other. It is but a corollary to this that mere manual dexterity is of little value in an assistant without tact and dis- cretion, and that lacking these qualities he is not apt to find his services in great demand. CHAPTER II. THE HOSPITAL INTERNE. The young surgeon's resident hospital service is the most instructive, ought to be the most pleasant, and often proves the most important, period in his professional career. His bearing and his accomplishments during this term of " ap- prenticeship " profoundly influence and may quite deter- mine his entire future. The chief attractions in medicine are its intense human interest and the extent to which it draws upon all the arts and sciences ; and no time is better adapted than his hospital service for a physician to develop both sides of his profes- sion — the philanthropic and the scientific. Zeal, thorough- ness and sincerity ; cheerfulness, willingness and punctuality ; forethought, breadth and direction ; courage, caution and kindness — all these, and more, are expected of the members of a hospital staff. A due appreciation of these considerations at the outset will properly direct the interne's work and govern his deal- ings with his colleagues, superior officers, subordinates and patients. In all large hospitals there must be among the medical and nursing corps strict discipline in the division of authority and responsibility. The junior internes owe prompt and cheerful obedience to the resident surgeon (house surgeon), who in turn is directly subordinate to the visiting surgeon. Upon the house surgeon falls the responsibility for the details of treatment and nursing of the patients, the complete records of all cases, the proper conduct of the wards and operating rooms, the economical use of hospital supplies and the division of duties among the members of his staff. The esprit de corps of his assistants will depend chiefly upon 32 The Resident Staff. 33 himself; on the other hand, to the extent that the junior internes and nurses are loyal to the house surgeon will he, in turn, be inclined to shield them from criticism. The relations between the juniors and the visiting surgeon are indirect. The house surgeon is the intermediary ; and, during rounds and operations especially, all reports and, in a whisper, all questions and suggestions should be addressed to him. It is to the best interest of the patients that the bear- ing of the house-staff in the wards should at all times indicate respect for the surgeon in charge. Even among themselves it is, to say the least, in bad taste for young hospital men to ridicule the judgment of their seniors, from whom those young men have learned whatever they may know. Mistakes are made by all ; and an experienced man often has better reasons for being wrong than an inexperienced one may have for being right. Aside from the strictly surgical manipulations the per- formance of most of the details of treatment devolves upon the nurses. Among their corps the same division of author- ity obtains as among the medical attendants. The head nurse in each ward is directly responsible for the work of her assistants to the house surgeon, and all his directions for nursing should be given to her. A woman, occupying, while on duty, a subordinate position, — it is only fair to her that the interne should exercise considerate regard for her physical limitations and her natural sensibility, both in the character of his orders and in the manner in which he delivers them. A nurse's education in medicine is very elementary and much that the physician does is more or less mystifying to her. If the interne will explain to her the rationale of his procedures, he will at the same time arouse her interest in the results and engage her more intelligent co-operation in securing them. Moreover, pupil nurses are in the hospital for the same pur- pose as are the internes, — to acquire at the bedside what cannot be learned from text-books and lectures. Naturally, therefore, the nurses look to the resident staff for instruction. Indeed, however it may be conducted, every hospital is a school of medicine for all concerned in the care and observa- 34 The Surgical Assistant. tion of its patients, from the surgeon-in-chief down to the probationary nurses, — and, indirectly, for the medical and nursing world at large. Even an ignorant patient under- stands this, and he thinks the more of the interne who exhibits a scientific zeal in the study of his ailment. But the interne has deservedly lost all the patient's regard when he allows the scientific to absorb or obscure the human side of his work — when, in other words, he loses sight of the patient in the case! The patient should be made to feel, that above all other interests in him, the doctors are most concerned in his comfort and his recovery. Certainly it is a breach of professional relations and, no less, of all sympathetic regard, to declare in a patient's hearing that, for example, the dis- tressing pulsations of a large aneurism are " very pretty." But more than that, sick men try to read their fate in the countenances and gestures of their medical attendants and a shrug of the shoulders on the part of one of them may blast some poor fellow's hopes of recovery. The hospital accepts a sacred trust from every sufferer it receives, and in this trust each interne has a share. He owes to the humblest charity patient no less than to the occu- pant of the best private room, unceasing watchfulness and attention, gentleness and sympathy. Not even the rush and hurry of an active surgical service excuse prolonged or repeated examinations when a patient is sleepy or in pain, nor dressings during the meal hour. A change of dressings may be either a trying ordeal or a source of much relief to the patient, and in either event it should be conducted at a suitable time, gently, thoroughly and with all surgical clean- liness. Healing is hastened and comfort is secured by keep- ing the neighborhood of the wound free of germ-harboring crusts, epithelial scales and dried blood. History-taking is to be conducted with the same thorough- ness and consideration. A time should be selected, if possi- ble, when the patient is not in great pain nor drowsy. A sleepy or suffering patient does not furnish a very satisfac- tory anamnesis nor does a patient who becomes restless or ill-humored under prolonged questioning. Often an event History Taking. 35 or a symptom which the patient deems too insignificant to relate is of the utmost importance. The house surgeon should therefore select for history-taking those internes who have served sufficiently long to be skilful in questioning and experienced in etiology and symptomatology. The histories of patients too ill to question should be secured as soon as possible from an intelligent near relative. Following a record of the patient's name, age, sex and birthplace is entered on the first bedside sheet the family history. This consists in a statement of hereditary family tendencies and similar relevant data. Then follows the previous history which should include [the manner of birth], diseases of childhood, subsequent ailments and injuries, resi- dence in tropical countries, etc., venereal infections, alcohol and tobacco habits, etc. The present history is ordinarily started with the observation of the first symptom directly related to the patient's ailment. Both the previous and pres- ent histories are very important and it requires much careful questioning to elicit all the facts and much patience to secure a record of symptoms in their proper order. The present history is to be summarized with a brief statement of the patient's chief complaints at the time. Following these, there is entered the status praesens — a physical examination of the patient as dictated by the house surgeon or visiting surgeon on rounds. The habit of making complete examinations in all cases — even of patients with no other ailment than hemorrhoids or a hernia, will prove a vastly instructive one. The subsequent history consists of a careful record of observations, which should be entered at the time they are made. Many observations not important to the individual case are still noteworthy in that they may form the basis of important statistical studies in other directions. The reports of all laboratory examinations should be duly copied in, or otherwise incorporated with, the history, and photographs or skiagraphs are mounted on cardboard of the same size as the bedside sheets, to be bound with them. Operations are to be described in the record within a few hours after they 36 The Surgical Assistant. are performed. Details are important — thus a statement of the number, character and location of non-absorbable sutures should always be made. A sketch may greatly illuminate the description. The record of the narcosis is to be included. As each patient is discharged, or dies, his history is to be turned over to the interne in charge of it. The final notes are then entered, e. g., a reference to, or copy of, the autopsy report, and the record is indexed by the patient's name and cross-indexed by diseases and filed away for binding. The interne should make a point of accompanying the house surgeon upon the rounds of the visiting surgeon, fo r it affords him an opportunity to learn methods of diag- nosis. For these rounds the patients' records and various reports should be ready for presentation by the house sur- geon. By gestures or whispers the junior may correct mis- statements of the house surgeon but, obviously, he should never contradict him aloud. Fresh dressings and sterile instruments are also to be ready for the visiting surgeon, and one, at least, of the internes should also be " washed up " to assist him. The house-staff rounds are likewise important to the junior for they allow him to observe symptoms that have been noted by his colleagues, and to discuss diagnosis and methods. Less restrained than the rounds of the visiting surgeon, they are none the less serious, and they should never be allowed to degenerate by inattention, flirtations or frivolity. CHAPTER III. ASSISTANCE IN EXAMINATIONS AND DRESSINGS. The proper disposition of the assistant's hands and body, so essential to good technics during operations — in connec- tion with which subject it can be discussed more at length FIG. 1. Manner of holding a child firmly in the sitting posture. — is not less important during the conduct of examinations and dressings. It is, indeed, more difficult to handle the conscious than the anesthetized subject, since in the former 37 38 The Surgical Assistant. case the patient's comfort must be conserved as well as the surgeon's convenience. For restraining struggling children, the illustrations here given afford suggestions. Figure I illustrates a very useful method and indicates the general principles involved. The position is intended chiefly for manipulations about the face, throat and neck. To restrain the child's arms a sheet wound tightly about its body may be substituted for one of the assistant's hands, which is then left free for holding: a mouth- FlG. 2. Manner of holding a child upon a table. gag or for other service. Figure 2 suggests the manner of restraining children upon a table. Here the assistant stands opposite the surgeon ; his arm and forearm on the side next to the table are thrown over the child's lower extremities and the corresponding hand grasps the hands of the patient; with the other hand the forehead is held firmly and the child's head is turned in the direction required. Assistance in Examinations. 39 When it is necessary to hold a child high, as for examina- tion of the throat by the light from a chandelier, it will often be found useful for the assistant (or parent) to turn the FIG. 3. Proper manner of holding foot during application of bandage. patient so that its head faces over his left shoulder. The assistant's left forearm then supports the child's buttocks and, with the corresponding hand, encircles its wrists and thighs, while the right hand grasps the occiput. If the child is unruly it would be well to further restrain the lower extremities by wrapping them in a sheet or towel. For many manipulations about the head, e. g., galvano-puncture of nevi, the surgeon is often required to grip it between his thighs. The assistant, seated opposite, then holds the child's lower extremities in a similar manner in his own lap, seizing the child's wrists with one hand, and, with the other, manipulat- ing the sponge electrode. During the application of dressings, especially immobi- lizing dressings, it is important to maintain the part in the 40 The Surgical Assistant. proper position with the least obstruction by the assistant's hands. A single illustration will suggest the proper methods. During the application of a dressing to the leg, one or two fingers under the heel will amply support the extremity ; the other hand grasping the toes, steadies the limb and main- tains the proper flexion of the foot, and the assistant's arms and body are disposed so as to offer the least interference with the surgeon's movements. Unless otherwise indicated the foot should be flexed to, or beyond, a right angle, and if the dressing applied is of plaster, starch or other firm material, the foot should also be held inverted until the application is dry. When the assistant cannot spare a hand to maintain flexion of the foot this can be accomplished by the patient himself drawing upon each end of a long strip of bandage passed about the toes or beneath the ball of the foot. FRACTURES AND DISLOCATIONS. The assistant's work in the treatment of fractures and dislocations consists in counter-traction during the manipula- tions of reduction ; and in the maintaining of the reduction, or in application of the dressing while the surgeon holds the joint surfaces or the bone fragments in the desired position. Of the method of exerting counter-traction little need be said here, since in each case it must be suggested and gov- erned by the manner and direction of the traction. It is important, however, that the assistant should so dispose his hands and body, that while he does not impede, by either, the movements of the surgeon, he is able to grasp firmly and to exert a steady pull without slipping of the fingers and with- out cramping of the muscles of his arms or hands. Gripping between the fingers and the palm is often firmer and less tiring than gripping between the thumb and fingers. Fig. 4 illustrates the application of these principles in exerting trac- tion and counter-traction for reduction of a forearm fracture. When the surgeon, often after tedious manipulation, has secured the proper reduction of the fragments of a fractured bone and has assured himself, so far as he can, that he has freed the ends of fragments of soft tissue, he may deem it Assistance in Fracture Dressings. 41 unwise to remove his fingers until the reduction has been secured by a dressing, the application of which will then fall to the assistant. Therefore, while the dressing of fractures belongs rather to a work on surgery, a few words about the materials used and their method of application will not be out of place here. Fig. 4. Maintaining reduction of forearm fracture, assistant's fingers, arms and body. Note position of Padding. — Padding used for the prevention of pressure sores is most often of common or absorbent cotton. When needed, it should be applied freely over all projecting points, e. g., the iliac spines, the malleoli, the heels (as in using Buck's extension apparatus). For padding the axillae and the mammae in the use of any dressing that is to remain longer than a few days soft gauze, smoothly applied, is preferable to cotton, for the latter soon becomes matted and stiff by absorption of a sour-smelling, acrid secretion, and thus favors the production of the dermatitis it is intended to prevent. Before applying protective padding in the axillae or under the breasts, the parts should be washed with soap and water 42 The Surgical Assistant. and then with alcohol, then dried carefully and dusted over evenly and freely, but not too thickly, with starch or talcum powder. Pads that are intended to exert, rather than to prevent, pressure should be made of gauze, folded into a sufficient thickness and trimmed to the exact size required. They may be fastened to the skin or to the splint by strips of adhesive plaster, or allowed to hold their proper position by the pressure of the dressing alone. FIG. 5. Triangular cardboard axillary pad. Triangular axillary pads, such as are needed in the dress- ing of fractures of the humerus, may be quickly fashioned from heavy manilla cardboard. This is cut the width of the axilla, and bent into triangular shape, the ends being secured by strips of adhesive plaster. The pad is covered smoothly with gauze and held in place with adhesive strips passing Preparation of Splints. 43 over the opposite shoulder. Triangular pads may be simi- larly fashioned for the popliteal space or the elbow. Splints. — Two kinds of wood lend themselves most readily to the fashioning of flat splints — thin pine, and cigar-box wood. Of the latter, two or more thicknesses are usually needed. Such splints should be cut to appropriate length and breadth, and should, ordinarily, have rounded ends. Cigar-box wood is very readily trimmed to proper size and shape with a pocket-knife or with bandage scissors, and, although it splits easily, there is but little difficulty in cutting it to fit rounded parts, e. g., the thenar eminence. Gauze, Fig. 6. Padded straight splint. folded smoothly in several thicknesses, is the best padding. It should be long enough to prevent contact between the skin and the edges of the splint, and may be fastened to the latter with a bandage or, more elegantly, with adhesive strips. Cigar-box wood may be readily molded to a curved "sur- face (e. g., the arm) in the following manner. The splint is laid upon the face of a piece of adhesive plaster of the same size. Then, with a knife, parallel slits are cut longitudinally through the wood and down to, but not into, the adhesive plaster. In this way, a firm, transversely flexible form is made, hinged upon the plaster and capable of being molded to the extremity. The greater the curve of the surface to which such a splint is to be applied the narrower should be made the strips into which the splint is divided. Basswood veneering is a most useful material for rein- forcing immobilizing dressings and, with starch dressings especially, affords an elegant, light, but strong and durable splinting. It is readily torn into strips and being very flex- ible, can be applied lengthwise, spirally or circumferentially. Its flexibility may be increased by soaking it a few minutes 44 The Surgical Assistant. in warm water. In applying a starch dressing over the leg and foot the veneer strip run anteriorly may be split into several pieces over the dorsum pedis and there spread out like a fan. When used for immobilizing the knee or ankle in a dressing not absolutely rigid, it must be remembered that thin strips of veneering will be apt to crack in the popliteal space or in front of the ankle. At such levels, therefore, they should be made to pass to the sides of the joints or should be reinforced by some heavier material. Reinforcing strips are most useful when incorporated in the bandage, rather than under it. Thus veneering strips may be introduced during the application of the starch band- ages — a turn or more of the bandage between the strips. Tin Strips are very useful for reinforcing plaster dress- ings. When not too heavy they may be curved about flexed joints, but the assistant must be very careful to see that the surface, and not the edge of the strip, is at all points flat against the dressing. Perforating the strips with an awl makes them less liable to slip in the plaster. The holes should be punched at frequent intervals and alternately inward and outward, so that the rough-edged awl-hole can afford a better " grip " for the plaster. It must be borne in mind that metal strips, unless very narrow and used sparingly, greatly interfere with the x-ray examination of the parts so important after dressing a fracture. Heavy cardboard splints, used in immobilizing the elbow, etc., should be fashioned by tearing, not by cutting, for torn edges are thin and readily molded to a curved surface. At the angle corresponding to the joint the molding is facilitated by one or two incomplete transverse tears. Moistening the splints in water adds to their flexibility. Starch (Dextrin) Crinolin Bandages are to be softened in warm water, squeezed out, and freed of loose strands, before applying. They shrink markedly in width when moistened and therefore even for finger dressings the assist- ant should not select one narrower than one and a half or even two inches. Starch bandages applied too thickly will be found to dry .only in the outer layers, the deeper ones Assistance in Immobilizing Dressings. 45 remaining moist for many days. They should not be applied next to the skin, nor directly over absorbent cotton. In addition to their use for immobilizing, a few turns of a starch bandage serve admirably to prevent an ordinary dressing from slipping, as from the finger or the head. The stiff starch bandage may easily be removed by cutting it through with a pocket knife or by moistening and unrolling it. Plaster of Paris. — Ample protection to the patient's cloth- ing, furniture and floor should be secured by means of linen or rubber sheets. The assistant will do well to cover also his own shoes and clothing. After cleansing the patient's skin and dusting it with tal- cum powder, flannel bandages should be applied smoothly FIG. 7. Plaster dressing— arrangement for making soft cuff. over the part, extending two or more inches beyond what are to be the edges of the plaster dressing. Over the flannel is 46 The Surgical Assistant. smoothly laid absorbent or, better, non-absorbent cotton, — over projecting parts or on the entire surface or in a ring at the ends of the dressing. The cotton extends only to within about two inches from the ends of the flannel, but a little be- yond the levels where the plaster dressing will stop. On many parts of the body, e. g., the lower extremity, hip and chest, a white stocking or circular stockinet or a section of balbriggan underwear, may be applied smoothly next to the skin, instead of the flannel bandages. To prevent the plaster from adhering to his hands the assistant may now anoint them with vaselin (especially about the finger nails) or, better, cover them with rubber gloves, or with Murphy's gutta-percha solution (page Jj). 7 \ Fig. 8. Freeing bandage of frayed edges. Plaster of Paris bandages should be very loosely rolled and the powdered plaster should be evenly and smoothly distrib- uted in the meshes of the crinolin. They must be kept in Plaster of Paris. 47 air-tight containers, e. g., tin canisters sealed with adhesive plaster. One by one, as needed, the bandages are submerged in a basin of lukewarm water and held there until they cease to give off bubbles. It is essential to cover the entire bandage at once with the water, and it is best to use a basin deep enough to submerge the bandage end up. A little salt added to the water hastens the setting process, but tends to make the finished dressing less firm. It is unnecessary, since good plaster sets quickly. When the bubbling has ceased, the assistant lifts the bandage from the water and, still holding it over the basin, gently squeezes it. Each edge is to be quickly freed of all loose threads. The beginning of the bandage is then found and opened out a few inches. With Fig. 9. Handing plaster bandage. this part held in his right hand and the body of the roller, facing upward, in his left, the assistant places the bandage in the hands of the operator in such a manner that it can, thus, 48 The Surgical Assistant. be applied to the dressing. If the operator is left-handed the assistant reverses the position of the bandage, keeping the roller upward. If the assistant is called upon to apply the bandage himself he must be careful to exercise no pressure, but to allow the roller to pass about the part with scarcely greater tension than its own weight.* During their application both operator and assistant should continuously smooth out the plaster bandages with the fingers and the palms of the hands. This is to be done rapidly and always in the same direction (that in which the turns are made) to keep the edges of the bandages flat. If the bandages are " thin " this smoothing process, may be used to incorporate a little extra plaster paste, scooped from the bottom of the basin in which the bandages are wet, or made in the palm of the hand from dry plaster powder and water. If it is found that a bandage has begun to set before all of the roller is applied, the assistant should cut off" the unused part and prepare a fresh bandage. Between turns of the dressing reinforcing splints of tin, wood, etc., may be incorporated. The plaster bandages themselves may be used to reinforce special parts, e. g., the ankle, sole of the foot, groin, etc., by passing them back- wards and forwards several times over these points. Before the last bandages are applied near the edges, the projecting flannel is turned down over the cotton and the plaster, and is then held in place with a few turns of the plaster bandage. Thus are formed neat, soft, even cuffs. A plaster, starch, or other dressing applied over the groins of children or feeble adults may be protected from soiling with urine, by incorporating in it a large piece of rubber tissue turned over the edge and covered by the last turns of the dressing. The smoothing process should be continued for several minutes after all the bandages have been put on, until the dressing is even and of graceful contour, and the edges and meshes of the bandages are lost to view. Plaster * There is some discussion as to whether or not plaster contracts in setting. Be that as it may, if the bandage is applied more tightly than above described the cast will be too tight. Plaster of Paris. 49 is heavy at best, and the assistant should therefore make the dressing no thicker than it has to be. The final smoothing requires but a very thin paste or no paste at all. The assistant should see that the patient maintains the proper position from the beginning of the dressing until the plaster is dry. Applied to the leg only, the heel may be supported upon a high cushion or a chair. Applied as a hip-spica, or about the trunk, a hip-rest must be used if the patient is recumbent. Applied to the leg and foot, it is essen- FiG. 10. Plaster dressing— smooth cuff formed. Dotted rectangular line about genitals indicates sheet of gutta-percha. tial that the latter should, in most cases, be held inverted and at right angles. If no assistant can be spared to grasp the toes for this purpose, the position may be secured, as described before, by passing a gauze bandage under the ball of the foot and placing its ends like a pair of reins, into the hands of the patient. Finally, before the assistant leaves 50 The Surgical Assistant. the patient he should make sure that the dressing is not tight enough to impede the circulation in the part. In dis- pensary and hospital practice it is convenient to mark upon fracture dressings, in ink, the date of their application. As soon as possible all open but unused cans of plaster or plaster bandages should be tightly closed and sealed with a strip of adhesive plaster over the overlapping edge of the cover. The preliminary cleansing of the hands of plaster should not be performed in a plumbed basin, but in a portable one for otherwise the drain or trap may be occluded. Rubbing with granulated sugar aids somewhat in removing plaster from the hands, as does also the addition of a tablespoonful of sodium carbonate to the water in which they are washed. The removal of a plaster dressing requires as much patience as skill. An excellent tool for the purpose is a car- penter's miter saw. Also useful, but less satisfactory, is a well pointed pruning knife. The track through which the knife is to pass may be softened by means of strong acetic acid applied from time to time with a brush or a dropper. Heavy plaster shears are of use only when the dressing is of little thickness. As in the application of plaster, so before its removal the patient and the floor should be protected from soiling. CHANGE OF DRESSINGS. The dressing of a recent aseptic wound requires the same preparations on a small scale that operations do on a large one. For use in the dressing of granulating or suppurating wounds, however, freshly laundried towels may be con- sidered surgically clean. They may, moreover, be rendered sterile by soaking in a strong solution of bichlorid of mer- cury (^ per cent.) or of carbolic acid (5 per cent.) Forceps, probes and scissors may be rapidly and effectually sterilized for a small dressing by passing them through an alcohol or Bunsen flame. Jeweller's aluminum tweezers and aluminum probes may be repeatedly sterilized in this way, but expensive Assistance in Change of Dressings. 51 instruments should be " boiled." " Wipes " made of dry sterile gauze, or smooth balls of absorbent cotton soaked in a sterile solution, make satisfactory sponges. A sufficient number of them should be prepared in advance and, indeed, " packings," pads, lunar caustic, irrigating solutions at proper temperature and all else that will be needed should be made ready before the dressing is begun, in order to avoid unnec- essary delay. The patient should first be placed in a comfortable position and protected by a rubber sheet, if necessary, against soiling of his body or bedding. A towel is slipped under the part, pins are removed from the dressing and placed conveniently Fig. 11. Arrangement for dressing wound of the neck. Note hair gath- ered up under towel and head supported by assistant (nurse). at hand, e. g., in the assistant's coat or apron, and the bandage is cut through from below upward and in a line not over the wound. The superficial dressings should be re- moved gently, if necessary moistening them with a sterile solution squeezed from a sponge, if the hands are clean, or dripped from a syringe. The deep dressing should be left in place until sterile towels are placed under the part and around it. Soiled dress- ings should be removed with forceps and dropped at once 52 The Surgical Assistant. * into a basin or, better yet, into a grocer's paper bag. This is an excellent receptacle for discarded dressings, soiled sponges, etc. If its bottom is spread out, it will stand open even on a bed, and a tear in its mouth will facilitate the intro- duction of gauze and bandages. The deep dressing should be removed with clean forceps or, if it is aseptic, with disin- fected hands. If adherent to the skin this dressing should first be moistened. Upon withdrawing a packing, the assist- ant should be prepared with a towel or a pus basin to receive a small or large amount of pus or other discharge that some- times escapes from a wound. The removal of adhesive strips is facilitated by pressing under them a bit of absorbent cotton dipped in benzin. Ether is also excellent for this purpose, but it is irritating to the wound and frequently nauseates the patient. Oftentimes the assistant must support the part as well as assist with the dressing itself. Figure 1 1 illustrates how this may be accomplished. Whatever position the assistant is called upon to assume he must above all be careful not to embarrass the movements of the surgeon nor to obstruct the passage of light to the wound. CHAPTER IV. PREPARATIONS FOR AN OPERATION. THE ROOM. The preparation of a room for operation naturally falls to an assistant, either a physician or a nurse. If left to the latter it is still the duty of the assistant surgeon to overlook the work done and to see that all details have been provided for before the operation is begun. It is necessary, therefore, that he should have an orderly system of prepara- tion and a knowledge of what may be needed, otherwise he will add confusion to a family's distress and, by the omis- sion of something important, invite delay or disaster in the operation. The comfort of the family, and especially of the patient, is therefore to be considered in the choice of the room for operation, as well as are its size, the arrangement of the light, the proximity of running water, and the heating and venti- lating facilities, etc. The room selected should be large, if possible. A nursery has the advantages that its preparation usually requires but little removal of furniture, and that it can be sacrificed by the family for a few hours without much inconvenience. The dining-room is well adapted to the purpose, for it is often uncarpeted, is usually well-lighted, and being near the kitchen, is convenient for washing, sterilizing, the selec- tion and carrying of basins, and the speedy removal of soiled articles when the operation is concluded. The operating room should be near to, and, if possible, on the same floor as the patient's bedroom. The latter may itself be used for the operation — the patient retiring to another room during the preparations. This arrangement is convenient when the patient is too heavy to be carried far, and it saves him the 53 54 The Surgical Assistant. exposure of transportation through a sometimes cold hall- way. On the other hand, it has the serious drawbacks that the sickroom, which from the first should be fresh and well- ventilated is, instead, filled with fumes of chloroform or ether, and littered with paraphernalia that cannot easily be removed without disturbing the invalid. The room selected, the assistant should next see that there are provided those supplies — most of them obtainable at a drugstore— that will be needed. They are : 1. Three cheap, unvarnished hand-brushes. 2. Green soap, \ ii; or " marble soap " ;* or " synol " or other antiseptic soap. 3. One or two orange sticks or new meat skewers, or other nail cleaners. 4. One pint of alcohol, 95 per cent. 5. Two or more five-yard jars of plain sterilized gauze. 6. One one-pound, or two half-pound cartons of steri- lized absorbent cotton. 7. Bichlorid of mercury tablets. 8. Purified chloroform, 3 iii ss (original bottle). 9. Two or more cans of purified ether, 1 iii ss each. 10. Tablets for hypodermatic use,— strychnin, nitro- glycerin, morphin, atropin. 11. Whiskey. 12. Washing soda. 13. Safety pins. 14. Vaselin or albolene for the anesthetist. 15. Razor; shaving brush. 16. Pure carbolic acid, 3 i- 3 ii. 17. Chlorid of lime ; carbonate of soda. 18. One demijohn of distilled water. 19. One two-quart fountain syringe. * A mixture of soap and marble-dust for removing scales of epi- dermis. Preparation of an Operating Room. 55 20. One yard or less of surgeon's gutta-percha (" rubber tissue "). 21. One roll of adhesive plaster of suitable width. 22. One five-yard jar of iodoformized gauze, 5 per cent." 2$. Gauze or muslin bandages. 24. Cheese-cloth for a binder.* 25. Rubber tubing for drainage tubes. 26. Oilcloth or rubber sheeting for the table. 27. Oilcloth or tar-paper for the floor. Of these supplies some may be provided by the surgeon, several may be found in the house, and some or all of items 14 to 2J may be unnecessary. Again, the tastes of the operator or the needs of the case may make it necessary to secure other articles, for example : crystals of potassium permanganate and of oxalic acid ; plaster of Paris bandages ; flannel bandages ; non-absorbent cotton ; collodion ; sterile adhesive strips ; hydrogen dioxid ; lysol ; creolin ; boracic acid; adrenalin; cocain, chloretone, eucain, or other local anesthetic ; chemically pure sodium chlorid or " infusion tab- lets ; " formaldehyd solution, etc. Gauze commercially sterilized should be in jars, tubes or tin cans, rather than in pasteboard cartons. If it is neces- sary to economize there may be ordered one jar for pack- ings, sponges, and the inside dressing, and one or more cartons for the outside dressing. It is desirable then to select cartons in which the gauze is packed in layers rather than those in which it is packed in a roll, all of which latter must be lifted out in order to cut off a small piece. Before arranging the room itself, the assistant should direct the sterilization of a sufficient number of towels. Dry sterilization in the kitchen oven is objectionable, in the * A towel serves admirably for children and slender adults ; for Stout subjects towels may be stitched end to end. 56 The Surgical Assistant. writer's opinion, because without a suitable thermometer there is no assurance that the temperature is sufficiently high unless, as is often the case, the towels are actually burned. Soaking in sublimate solution, 1-500, is better, but sterilization by steam or by boiling water is best of all. A large kettle should be filled with water and placed upon the fire in the kitchen or, more conveniently, upon a gas-stove in or near the operating room. A capacious wash- boiler, if at hand, is preferable to the kettle for it will accom- modate towels, sheets, basins, hand-brushes, fountain syringe (which, if new, should first be rinsed out with running water), orange sticks and a pitcher, and it will afford, in addition, a large stock of hot, sterilized water. From the fund of towels that can be spared for the opera- tion, six to twelve should be laid aside to use dry. One to two dozen, preferably without fringes and free from holes, should be wrapped up in one or two packages, enclosed in a towel or a sheet and dropped into the wash-boiler or sus- pended in its steam. If the supply of towels is small, clean dish-cloths or dis- carded napkins may be substituted ; or one bed sheet may be used to take the place of many towels. Strips of bandage may be tied by one end to a handle of the clothes-boiler, and by the other end to the towel packages and other articles being sterilized, thus affording a ready means of lifting out all of these from the hot water. If there is at hand no receptacle large enough to hold the basins for boiling, or for their immersion (for fifteen minutes) in T V per cent, sublimate solution,' the assistant, while busying himself -with other details, can direct the sterilization of the basins in the following manner : Each one is thoroughly scrubbed with water and soap, then scalded with boiling water. Into one is then poured two or more ounces of pure carbolic acid which is made to circulate over the surface. Most of this is then poured into the next basin and the process repeated, the excess of carbolic acid being poured into the third basin, and so on. To the carbolic acid remaining in each receptacle is then added enough hot water to make a carbolic acid Preparation of an Operating Room. 57 solution of about 3 per cent, to 5 per cent, strength. This is flowed several times over the interior and the edges, and after standing a few minutes is poured out. The basins are then rinsed out with boiled water. Once sterilized none of them should be handled by the rim and, it need hardly be added, dishes not sterilized by boiling should not be piled upon one another. Enamelled basins are, of course, the most suitable, but there is no need to purchase them, cheap though they be. Even a poorly furnished kitchen will usually contain all the basins needed for any operation. Kitchen bowls, dishes used for mixing dough, and soup tureens answer admirably for sponge-, and hand-basins, and soup plates will serve for ligature dishes, etc. If instrument trays are needed and are not supplied by the surgeon, clean baking pans and plat- ters may be pressed into service, but it will serve as well to spread the instruments out on sterilized towels. The follow- ing list includes all the basins, trays, etc., that will be needed : Three hand basins for sublimate solution. One hand basin for alcohol. Two large sponge basins if sea-sponges are used. One basin to contain strong sublimate solution for liga- ture bottles and tubes, and gutta-percha. One small basin for sponge to cleanse instruments. One or two dishes for ligatures and sutures. One or two pans for instruments. One dish for soap and water to cleanse field of operation. One slop-jar. To which may be added : A basin for hot pads. A bowl to receive pus or other discharge. A cup or saucer to serve as a specimen dish. Two basins for solutions of potassium permanganate and oxalic acid, respectively. A dish for salt solution. 58 The Surgical Assistant. A shaving mug, and For the Anesthetist : A basin, and a tumbler for boiled water. Having inaugurated the sterilization of the towels, dishes, etc., the assistant can now give his attention to the arrange- ment of the room itself. Enough furniture should be moved aside to provide ample space. It is unnecessary to clear the room, however, and unless the preparations are made the day preceding the operation, dusting, sweeping, and the mov- ing of pictures should be avoided. Sheets may be spread over furniture, mantel-shelf, and ornaments, but this is not necessary. Where the operating table is to stand the floor should be protected with a piece of linoleum, or lacking this, with old rugs, newspapers, tar-paper, or sheets, tacked down. For the operating table the kitchen again can usually be drafted upon. Library tables, too, are often suitable, and if necessary two tables may be lashed together, end to end, inequalities in their height being evened by means of a folded blanket or a pillow. The weaker table, if two are joined, should be used for the patient's head — unless that is the part to be operated upon. Obviously, the operating table, if possible, should be placed near the window, when operating by daylight ; but it is more important that the light should fall into the wound than that the superficial field of operation should receive the greatest amount of light. Thus, for a vaginal hysterectomy the patient's head should be furthest from the window, but for an abdominal hysterectomy the position should be reversed. Over the table is spread a folded blanket, upon this the rubber sheet, and over both a fresh linen sheet. At the foot of the table is laid a folded blanket or sheet, or both, to cover the patient. At the head is placed a pillow, prefer- ably flat and of hair, and nearby a folded towel. For an operation upon the kidney (q. v.) a firm cylindrical cushion or sandbag, or a pillow rolled into a cylinder, is to be laid across the middle of the table. Preparation of an Operating Room. 59 Beyond the head of the table is placed a chair for the anes- thetist and to one side of this a small table or another chair, covered with a towel, for the anesthetist's armamentarium. "pr* '- a fp_ .:, h\£^ E Fl rZZ ail :C0 % " © m (3) m amltf cjcdV / \ « l£J h i w ©g Fig. 12. General scheme of operating room arranged in private dwelling. *, n, window panes (soaped) ; b, oilcloth ; c, operating table ; d, pillow; e, slop- jar ; f, anesthetist's chair ; g; anesthetist's table ; h, operator ; z", assistant ; /, nurse ; k, instrument table ; /, nurse's table ; m, m, hand basins ; n, mantel- shelf with unsterilized accessories; o, wash-basin; fi, basin of alcohol; q, basin of sublimate solution ; r, boiler of hot water ; s t demijohn of distilled (cold) water ; t, irrigating bag. On each side of the operating table and at a convenient dis- tance from it is placed a chair, stool, or large wooden box (which may also be covered with a towel) for a hand basin. 60 The Surgical Assistant. A slop-pail is then placed on one side of, and partly under, the table. It is best located on the side where is to stand the assistant who sponges the wound. On the opposite side is sometimes needed a footstool for the operator. The Tren- delenburg position may be secured by the familiar method shown in the illustration, the table coverings being continued over the back of the chair and the pillow moved to the center of the table. Fig. 13. Improvised Trendelenburg table. For operations about the perineum, the table is arranged as shown in figure 14. For a Kelly pad may be substituted the rubber sheet. The upper end is tucked about a twisted sheet arranged in a horseshoe ; the lower end drains over the end of the table into the slop-pail. The drainage is better maintained by pinning together in front the two lower cor- ners of the sheeting, thus forming a funnel. (The same device may be employed laterally upon the table for other operations. Used for drainage, it will be found economical to purchase sheeting coated with rubber on both sides and therefore easy to free of blood-stains.) At the foot of the table are placed two chairs — one for the operator on the left, the other for the assistant on the right. The hand basins and instrument table are placed nearby. A twisted sheet laid on the operating table in the manner illustrated, to be passed Preparation of an Operating Room. 61 from behind the patient, over one of the shoulders and tied at the knees, makes an excellent leg-holder. It may be sup- plemented by a piece of broomstick, two feet long, padded, to be bandaged at each end to the legs to maintain their separation. Fig. 14. Table arranged for operation in lithotomy position. One large table or bureau may be used for instruments, dressings, sponge basins, etc., but it is better, if a nurse or second assistant is at hand, to place one (or two) tables for the instruments and sterilized dressings on the side at which the assistant is to stand, and another table for sponge basins, towels, etc., on the side of the operator. The nurse detailed to the care of the sponges is then able to relieve the operator in the manipulation of retractors, etc. If the assistant is not fairly familiar with the technics of the opera- tion or those of the individual surgeon, it may be well to place the instrument table where the operator can help him- self to what he wants. For this purpose an invalid's feed- ing table projecting over the patient's body is very con- venient for holding the instruments in immediate use. These 62 The Surgical Assistant. tables should be covered with sterilized sheets or with towels and, if their tops are polished, with some waterproof material also. Window-curtains should be drawn aside and pinned or tied back. If it is possible for curious neighbors to see into the room through the window panes, these should be soaped. This is accomplished by passing over them a wetted cake of soap or the palm of the hand smeared with lather. The more irregularly the streaks of soap are applied the more the rays of light will be diffracted. The assistant now lays out in systematic order upon a bookcase, mantel-shelf or table, the supplies that have been purchased, the operating aprons, gowns and caps, etc. Of these, one or two jars of gauze and the jar of sea-sponges are placed upon the table for sterilized dressings, or at the back of the instrument table. The sterilized fountain syringe, if one is to be used, may be suspended from the chandelier or, by means of a piece of twine or bandage, from a picture-molding or curtain-pole, thus to avoid driving a nail into the wall. The irrigating solution should not be poured in until just before the opera- tion is begun, and it should be prepared in a pitcher — not mixed in the bag. The anesthetist's table is now supplied with : Chloroform and ether, chloroform and ether masks, mouth-gag (appendix, figure 5), screw-gag, tongue-forceps, sponge holder {e.g., a clamp) and sponge, vaselin or albo- lene, a basin to receive vomitus, a few towels, a safety- pin or bandage for fastening a towel about the head, a tumbler of boiled water, a sterilized hypodermatic syringe and needle, laid across the tumbler and filled with strychnin sulphate, gr. 1-30 dissolved in whiskey. If a chloroform dropper is not supplied, there should be cut two V-shaped gutters in opposite sides of the cork of the chloroform bottle, — one groove for the entrance of air, the other for the egress of the anesthetic (see page 94). A mask for the administration of chloroform may be im- provised by drawing a corner of a towel through a safety- Preparation of an Operating Room. 63 pin. An ether mask may be quickly fashioned by folding a newspaper twice across its width, and laying this lengthwise in a towel. The edges of the towel are turned in, and the paper and towel are then folded over into a hollow, flat- tened cylinder of appropriate size. The loose end is pinned down and one of the open ends is also closed with pins. Into the apex of the cone thus formed is stuffed absorbent cotton or gauze. The use of a gas-ether apparatus renders many of these articles unnecessary. or G^J FIG. 15. Arrangement for anesthetist, a, chloroform mask ; b, ether mask ; c, screw-gag- ; d, mouth-gag ; e, sponge on holder ; /, towels ; g, pus basin; h, tumbler of sterile water and hypodermatic syringe (loaded); z', chloroform bottle ; /, ether can ; k, vaselin or albolene. The basins and dishes should now be distributed. On the wash-sink are placed two hand basins. In one is poured alcohol, 50 to 95 per cent. The other is to be filled with sub- limate solution, 1-1000, and in it are placed a hand-brush and an orange stick. In the sink, which should be scrubbed and scalded out, are placed another hand-brush and nail cleaner. The pot, tube, or bottle of soap is placed alongside ; as are also basins containing a saturated solution of perman- ganate of potash and an 8 to 10 per cent, solution of oxalic acid, respectively, and the box of chlorid of lime and the crystals of sodium carbonate — if either of these methods of disinfection is to be used. On each side of the operating 64 The Surgical Assistant. table is placed another hand basin, and in it is to be made a sublimate solution, 1-2000. On the nurse's table are placed, if needed, two basins for rinsing sea-sponges, to be filled with boiled water or sublimate solution, 1-2000. Upon the instrument table are placed one or two shallow dishes, to contain alcohol for ligatures and sutures; one deep dish to contain sublimate solution, 1-500, for immersing ligature bottles or tubes, a sponge, and a piece of gutta-percha (which latter should previously be washed in cold soapsuds and rinsed in alcohol) ; one dish to contain sterile water or weak carbolic acid solution for cleansing instruments ; the speci- men dish ; a tumbler or butter-dish to contain a little pure carbolic acid, if needed for cauterizing an appendix-stump ; and trays to be filled with sterile water or carbolic acid solu- tion, 1 per cent., if the surgeon prefers them to spreading the instruments out upon sterile towels. Lastly, a shallow dish FIG. 16. Arrangement, In order, of accessories on mantel-shelf or other piece of furniture, a, razor ; b, basin with brush and water for scrubbing- patient ; c, soap ; d, two dry towels ; e, alcohol bottle ; f, absorbent cotton ; g, bandages ; /z, adhesive plaster ; z', safety-pins ; /, binder ; k, k, k, bottles of bichlorid tablets, carbolic acid, etc. is filled with hot water for cleansing the field of operation. Upon the edge of the dish is placed some green soap, and in the water are laid a hand-brush or a mop of absorbent cotton, and a shaving brush. This dish is placed with the unsterilized supplies and alongside of it are arranged a razor, two dry towels and the unused alcohol — as shown in dia- gram 16. Here, too, may be placed a wide-mouthed specimen bottle, or jar, containing 2 per cent, formaldehyd solution. The packages of towels, now thoroughly sterilized, are Preparation of an Operating Room. 65 lifted from the boiler and placed upon a clean dish or in weak sublimate solution to cool. The boiler is lifted from the range and placed in a corner of the room, where it can be drawn upon to make and replenish the solutions. The pitcher, lifted out and placed upon a sterilized towel, is used to dip out the hot water. The demijohn of distilled water* is placed nearby. Its cork is replaced by a plug of absorbent cotton, after wiping the neck and mouth of the demijohn with a sponge moistened in some antiseptic solu- tion. In filling the basins it is to be remembered that neither unenamelled metal dishes nor water containing washing soda should be used in making sublimate solutions. The instruments should now be " boiled " in water to which has been added a handful of washing soda. A fish- boiler makes an excellent sterilizer. While this is on the fire the assistant should uncover the gauze and sponge jars, and place the ligature tubes and the strip of rubber tissue in the basin of strong sublimate solution. Then he puts on his apron, cap, and mouth-cover, thoroughly sterilizes his hands and forearms, and dons his sterile gown. The instruments are lifted out of the sterilizer and freed of soda by dumping them in the instrument trays or by pouring boiled water over them. If no instrument trays are used — and when the hands have been in oxalic acid the in- struments will be found very slippery unless used dry — ster- ilized towels are lifted out of the package and spread out (handling them by their borders) for the instruments. Wet towels soak up infectious materials through their meshes, so they should be spread in sufficient thickness. The instruments are now arranged neatly and systemati- cally according to the order in which they will be needed. With a pair of forceps, sponges are lifted from their jar. One is dropped into the dish of sublimate solution, 1-500; another into the instrument-cleaning dish, and several into * Even if this water, commercially prepared, is not absolutely sterile it certainly is sufficiently so for the preparation of antiseptic solutions, and its employment saves much time in preparing cold sterile water— time that in urgent cases cannot be spared. 66 The Surgical Assistant. the first sponge basin. Gauze sponges previously prepared, or cut now from the sterilized gauze, are laid upon a sterile towel on the nurse's table together with sponge handles. The latter should never be allowed to remain in the sponge basin if it contains sublimate solution, nor to touch the rim of the basin unless the latter has been boiled or is covered with a sterilized towel or strip of gauze. Packings, pads, Fig. 17. Instrument table, a, sterilized towels ; b,b, gauze jars ; c, sterile adhesive strips ; d, sterile absorbent cotton ; e, dish of alcohol for prepared sutures and ligatures ; f\ dish of sublimate solution, one-fifth per cent., for ligatures in bottles and gutta-percha ; ff, basin with sponge for cleansing in- struments ; /i, packings ; i, sterilized safety-pins ; j, needles ; k, aspirating syringe ; /, the other instruments arranged in the order in which they will be needed ; m, pads ; », drainage tubes. and drainage strips of appropriate size and number are cut and laid out on the instrument table. Some or all of the liga- ture- and suture-tubes are emptied into the shallow dish of alcohol. A supply of ligature strands is cut and arranged in the dish in little rolls. Two each of all the kinds of sutures that will be needed are threaded and placed neatly in the same dish. With this arrangement of the instrument table, to be dis- cussed again in detail, the assistant has completed his prepa- rations. Preparation of an Operating Room. 67 Proceeding with dispatch and with such a system as is here outlined, and directing systematically those who may be at hand to help him, an assistant can in one or two hours Fig. 18. Arrangement of table for second assistant (nurse's table), a, a, first and second sponge basins ; d, sponges in sponge holders ; c, sterilized towels; d, sterilized gauze, sponges and pads. transform the parlor of a mansion or the kitchen of a tene- ment into an operating room equipped and ready for major aseptic surgery. CHAPTER V. PREPARATIONS FOR AN OPERATION. THE PATIENT. The preparation of a patient's digestive tract and the pre- liminary preparation of the field of operation concern the surgeon rather than the assistant, in private practice at least, and these details, important though they are, cannot logi- cally be discussed here (see appendix I). Of those prepara- tions immediately preceding an operation, however, a few words should be said. Carrying a patient from bed to table requires considerable knack. Unless the individual is quite heavy he may often be more conveniently carried by one man than by two or more. Figure 19 illustrates how this is accomplished. The patient's body is rolled upon the assistant's forearms (held in the manner shown), and against his chest which, thrown somewhat backwards, supports the weight without, as a rule, any great strain. If the patient is narcotized the head should be held low. The arms must not be allowed to hang down even for the short space of time elapsing before the table is reached. Figure 20 illustrates the conveyance of a person by two men. Obviously the assistants should arrange themselves, in lifting the body, with reference to the side of the table or, after the operation, the side of the bed, to which the patient is to be restored. It is well to place the patient at once in the position upon the table which he is to occupy, for shifting afterwards is awkward. The arms should be so disposed that they are not subjected to any pressure or stretching (see page 86). 68 Preparation of a Patient for Operation. 69 If the operation is one that requires a preliminary lavage of the stomach that has not already been performed, the assist- ant should next give his attention to this (page 200). It will save much trouble and discomfort if, before the field of operation is disinfected, the patient's clothing is rolled up far enough to prevent soiling and wetting. Thus, the night shirt and undershirt should be drawn well up to the shoulders posteriorly if a laparotomy is to be performed. FIG. 19. Lifting and carrying a patient. A blanket or sheet is then spread over the parts of the body not to be exposed for the operation, but the movements of the chest must not be impeded by heavy covering. A rub- ber sheet turned over the edge of the blanket will preserve it from soiling. The field of operation must then be cleansed over a wide area. Even if the parts are not " hairy " they should be 70 The Surgical Assistant. shaved. Cleansing with green soap and hot water by means of a stiff brush or a soft cotton mop, as the operator may prefer, must be thorough in either case and per- formed with clean hands. Abundant lather is necessary, but not more important than a sufficiency of water, which it is well to apply from time to time during the scrubbing. Folds and crevices of the skin and especially the umbilicus (in abdominal operations) must be cleansed deliberately and Fig. 20. Transportation of a patient. thoroughly. For operations upon the foot the interphalan- geal spaces should be vigorously rubbed with a strip of gauze or the edge of a towel dipped in soapsuds, and the nails should be trimmed and scrubbed carefully. The parts are then wiped with one end of a dry towel, and with the other end (wrapped about the hand, barber fashion) alcohol is applied over the entire surface. This Preparation of a Patient for Operation. 71 may be followed by a wiping with ether. Iodoform-ether may be poured into the umbilicus and other crevices, where it forms a protecting film. The final cleansing of the field with -§- per cent, sublimate solution or other antiseptic, should be left until after the assistant has again disinfected his own hands and the sterilized towels are spread. Disin- fection of the patient's skin by chlorid of lime and carbonate of soda is as described below for the assistant's hands. With the exercise of a little judgment the towels may be disposed about the field of operation economically and yet in sufficient number. They should be handled only by their edges. One is laid above, and another below the field and, without touching anything else in the manipulation, FIG. 21. Arrangement of sterilized towels for laparotomy. folded over the edge of the blanket underneath. It is well next to apply towels at each side, then transversely laid towels which, crossing over these, hold them from slip- ping off the table (Fig. 21.) Sterilized safety-pins may be used to catch them more securely, if necessary, but it must be remembered as a matter of aseptic accuracy, that 72 The Surgical Assistant. the points of these pins as they emerge from the under sur- faces of the deepest towels are no longer sterile, and they should not be touched when the pin is closed. Enough towels should be spread (transversely) to cover most of the body and the table, leaving exposed for the operation a much smaller field than has been disinfected. Two layers of towels should be used in the immediate neighborhood of this field, and during the operation wet and bloody ones should be replaced or covered. A sterilized sheet, with an opening through which to operate, may be spread over the body in place of, or in addition to, the towels. THE ASSISTANT HIMSELF; TECHNICS OF ASEPSIS. In the familiarity with aseptic detail on the part of those who help, the surgeon must enjoy absolute confidence. An assistant who needlessly handles sponges, instruments, or dressings " because they are sterilized," or puts one unnec- essary finger into the wound, or rests his hands upon his hips, " because his gown has been disinfected," has not yet learned that the essence of asepsis consists in avoiding, as far as possible, contact with everything, sterilised and un- sterilized. Nor will he be thoroughly versed in aseptic prin- ciples until, to him, their every application becomes instinc- tive, their practise automatic ! Surgeons are often timid of allowing the family physician to assist in an operation solely because he may lack a famili- arity with asepsis, for which a merely theoretical under- standing cannot be substituted. To the acquirement of this practical experience even the occasional assistant should give his most conscientious attention. Thorough preliminary disinfection is only a part, but a vital part, of aseptic technics. Before the " scrubbing up " is begun the assistant should don a rubber apron for the protection of himself, and a mouth-mask and cap for the protection of the patient. These latter can be fashioned from a piece of gauze stretched over the scalp, the ends being crossed beneath the occipital protuberance, brought forward Preparation of the Assistant. 73 and spread over the nose, mouth (and beard) and tied at one side. The shirt-sleeves should be rolled up well above the elbows ; and the scrubbing should also be beyond this level. It must be deliberate, vigorous and painstaking. Hot, run- ning water is desirable and a rather stiff hand-brush, suita- ble soap, and a nail cleaner are essential. After a brief scrub- bing of the nails these should be trimmed rather short and then receive a preliminary treatment with the orange stick FlG. 22. The assistant "scrubbed up " and ready for the operation. or other cleaner — under their edges and in the skin-fold about their borders. After a second, more prolonged, scrub- bing, the nails should have a second cleaning with the stick. Then follows a vigorous, systematic scrubbing from finger- tips to elbows — first one arm and then the other, finger by finger, area by area. Such a scrubbing requires scarcely 74 The Surgical Assistant. less than five minutes for each extremity. Since the mouths of the sudoriferous and sebaceous glands, which are thrown into activity by the labor of an operation, contain many micro-organisms, Maylard suggests the following rational procedure : " The hands are submerged for from five to ten minutes in water as hot as can be conveniently borne. The effect of this is to dilate all the capillary vessels, as indicated by the redness of the skin, and thus excite into active secretion the two sets of glands. The sodden surface epithelium together with the secretions are finally removed by first massaging the hands under water, by making one rub the other, and then using some ordinary soap." * After the scrubbing, the soap is washed from the skin with running water, and the hands and forearms are bathed for one minute in alcohol, 50 per cent.f to 95 per cent. Then follows their scrubbing for three minutes in a solution of bichlorid of mercury, 1-1000 to 1-2000, carbolic acid, 1-40, or lysol, 1-100. By pressing the pulps of the finger-ends for- wards against the bottom of the basins, as advised by Weir, the spaces under the edges of the nails are opened to the entrance of the disinfecting solution. For additional disin- fection, desirable if the assistant has recently been in contact with pus or other infectious material, the hands, after wash- ing in alcohol and before washing in sublimate solution, may be immersed in a saturated solution of potassium per- manganate. They are then rinsed in water (after allowing the excess of the solution on the skin to drip back into the dish), and the brown stain is removed by immersion in a strong solution of oxalic acid (8 to 10 per cent.) For the bichlorid of mercury method there may be sub- stituted disinfection by " chlorid of lime " and carbonate of soda. After the scrubbing with soap and water about a tablespoonful of the lime and one or two crystals of the soda are mixed in the palms with enough water to form a paste ; and this paste is rubbed for five minutes into the nails and the skin of the hands and forearms, which are thus brought in * Annals of Surgery, Vol. XXXV., No. 1. f The weaker solution is the more penetrating. Preparation of the Assistant. 75 contact with the free chlorin gas liberated by the mixture. The paste is then washed off with sterile water. " The ob- jectionable odor which this leaves upon the hands for several hours may be removed by washing them in water contain- ing about 10 per cent, of aqua ammonia, the chlorin uniting with the ammonia to form ammonium chlorid." * Other modifications of the system of disinfection need no description in a work of this character. All methods need considerable time, and with none may the process be hur- ried. Often the surgeon, who has made his own preparations while the assistant has been cleansing the field of operation, is impatient to begin before the assistant himself has com- pleted the disinfection of his hands. This should not cause him to shorten his toilet nor, indeed, should anything else be allowed to hasten him unduly — except, perhaps, the con- dition of the patient. While an unsterilized gown (for which in emergency a clean sheet, properly draped about the body, may be substi- tuted) may, of course, be worn during the disinfecting proc- ess, it is not until that process is completed that a sterile gown should be put on. In donning it the assistant should be careful that neither his hands nor his forearms touch any part of the gown that may have brushed against his body. Nor, if it buttons in the back, should he attempt to fasten the gown himself. In any event it is advised as a matter of rou- tine that he dip his hands and forearms once more into the sublimate solution after the gown is on. Sleeves, separate or attached to the gown, are sometimes worn to prevent wound contamination by secretions from the forearms. The employment of rubber gloves is the only method we possess of securing for the animate, the same aseptic condi- tion as for the metal surgical tools. They constitute the next and final item in the assistant's personal preparation. If sterile talcum powder is not provided for drawing on the gloves in the proper way described below they may be slipped on under water, which balloons out the fingers, or in * Palmer's " Surgical Asepsis," 1903. 76 The Surgical Assistant. a weak lysol solution, which is lubricating. That method is not to be recommended, however, for the imprisoned water macerates, and lysol irritates, the skin, and fluid dripping out of the glove at the wrist may carry with it into the wound sodden epithelium. Application of the gloves dry is the ideal method, and the technic is as follows : A salt- or sugar-" sifter " or perforated powder duster, filled with pulverized talcum or starch, is wrapped in a towel, and sub- mitted to live steam for twenty minutes in a sterilizer, after which time the steam is turned off and the powder dried in the heat of the apparatus. The gloves are laid fiat in a towel, which is then folded over them in a maner to both cover and separate them. This package is then enclosed in another towel and also sterilized by steam for twenty minutes. It is said that the rubber is less apt to adhere or tear if dried in the air rather than in the sterilizer. The above is the only method of rapidly preparing dry sterile dusting powder, but the gloves may be prepared at the time of the operation by " boiling " them. If this is done in the instrument sterilizer they should be dropped in last and care should be taken that they are not placed in contact with sharp metal points. Two long dressing forceps are also to be sterilized. With these the gloves are to be lifted out by their fingers (to drain the water from them) and laid upon a double thickness of sterile towels. Their surfaces are patted dry with the upper towel, and dusted on each side with the talcum or starch powder. Then the gloves are turned inside out. To accomplish this, each one in turn is seized by the cuff with one of the forceps while the other forceps is passed into the glove and made to grasp and pull upon the " web " between two of the fingers.* The body of the glove is thus reversed, but not the fingers. If now the glove is seized with both the forceps at its cuff and rapidly twirled about its long diameter it will by its twisting seal up air within it, and pressure upon it (exerted through the towel) will cause the air to open out the " fingers " with a " pop." The now outer surface of the glove is patted dry. All this * Collins, New York Medical News, August 20, 1904. Preparation of the Assistant. 77 is accomplished without touching to the gloves anything but the forceps and the towel — both sterilized by heat. Disinfected and dried by either of these methods, and lying on a towel, the gloves are thus to be drawn on : — The assistant dusts the talcum powder upon his dry hands, then, grasping the wrist margin of a glove in a sterile towel or piece of gauze, he slips it over the corresponding hand. The other hand is similarly clothed, lifting up the second glove with a fresh piece of gauze to pull it on. If the fingers need adjusting, this is done after both gloves are on or, at least, with still another piece of gauze over the opposite hand — never with the naked hand. Seizing or adjusting a glove with bare fingers defeats the very purpose of " the boiled hand " ! This is self-evident ; and yet the very frequent violation of the proper technic, even by those who are care- ful in other details, makes necessary the minute instructions upon the application of rubber gloves, just given. Cotton gloves, if used at all, must be changed as often during the operation as they become wet. Gloves of either material should be of proper size, for if the fingers are too short, or especially, if they are too long the wearer's manipu- lations will be much hampered. The Murphy rubber dam used on the patient's skin serves a purpose similar to the rubber gloves. As a substitute Murphy has recently em- ployed a solution of formalin-sterilized gutta-percha (4 to 8 per cent, in benzin or acetone) which covers the hands and the patient's skin with an impervious coating. It does not impair the sense of touch and is easily removed with benzin. For the patient, he recommends the acetone solution and for the surgeon the benzin. " The method of application to the [dried] hands and forearms is that of simple washing as with alcohol, care being taken to fill in around and beneath the nails. The hands must then be kept exposed to the air with the fingers separated until thor- oughly dry. They may then be washed in alcohol, bichlorid, or any of the antiseptic solutions without interfering with the coating or affecting the skin. It wears off on the tips of the fingers if the operations be many or prolonged, when 78 The Surgical Assistant. another application may be made [to them] between oper- ations ...."* Were it not for its frequent breach by the untrained it would be unnecessary to state so obvious and elementary a rule as that, once disinfected, neither the forearms nor the hands should be allowed to come in contact with anything not sterilized ; and that, if such an accident occur, immediate re-disinfection should be performed. But more than this, it is important not to handle even the sterilized articles un- necessarily. The gloved hand may become contaminated during an operation by contact with secretions from the patient's or the operator's skin, while the naked hand is always a possible source of contamination by its own secre- tions. Hence, in the course of an operation the hands should be frequently washed in the antiseptic solution placed by the table. Although it contains a contradiction, it is a safe principle for the assistant to follow to have confidence in his aseptic methods; and yet to regard the hands, and every article that has once been touched, as possible sources of error. In the constant application of such a rule he will develop the best technics of asepsis. Thus it will at once restrain him from touching his instruments needlessly, from lifting them except by their handles. It will remind him that instruments that were sterile when he handed them to the surgeon may not be so after they have been in the wound; and that therefore neither his fingers, nor forceps that have been used elsewise, should be introduced into the jars of ligatures and packings. He will not allow instru- ments or sponges to pass through too many hands. (Indeed an advantage of gauze sponges, quite as important as their adaptability to steam sterilization, lies in the fact that they are used but once and but one hand is needed to use them.) Similarly, he will hold packings taut above the patient's skin while they are being introduced. These are but a few of the details of asepsis, to be ac- * J. B. Murphy, Journal American Medical Association, March 19, 1904. Second communication, September 17, 1904. Technics of Asepsis. 79 quired by training and by the application of sound princi- ples. The others are far too numerous to mention. There may be stated, however, for the assistant to take to heart, a few "aseptic dont's:" Don't " scrub up " hastily — either the patient or yourself. Don't forget to rinse your hands frequently during an operation. Don't fail to re-disinfect after contact with unsterilized articles, by immersing in an antiseptic solution or by scrub- bing again, if necessary. Don't let your arms touch your gown, even though it be sterilized. Don't touch anything needlessly. Don't pass instruments or sponges through too many hands. Don't put your finger in the wound if an instrument will do as well. Don't put either in the wound without reason. Don't expose too large a " field of operation." Don't neglect to keep the .area about the wound (and in the wound) clean and dry. Don't sponge into'the wound. Don't allow sutures, gauze or instruments to drag over uncovered skin. Don't rest your hands on the patient's skin. Don't allow your head to come close to the wound. Don't allow your head to rub against the operator's. Don't spread your arms over the patient's body. 80 The Surgical Assistant Don't allow your elbows, or the operator's elbows, to touch instruments on the patient's body. Don't fail to watch constantly for errors in aseptic tech- nic ; don't hesitate to call attention to them at once. Don't talk! CHAPTER VI. THE ANESTHETIST. The assistant who administers the anesthetic shares with the surgeon, to a far greater degree than does any other of those who help at an operation, the responsibility for the welfare of the patient; he occupies towards the surgeon a peculiar relationship — a relationship which in the conduct of their work should be mutually recognized. Only a grave emergency justifies the administration of a general narcotic by one who has not had tuition, and at least reasonable experience. For this reason and because detailed instruction can be found elsewhere, it is intended here to deal, for the most part, with some practical points not always emphasized in text-books. The choice of the anesthetic is usually made by the oper- ator. Nevertheless, since it is of the greatest importance for the narcotizer to appreciate, so we may logically review, the effects upon the various organs of ether and of chloroform, and the chief indications and contra-indications in the use of each. Chloroform is a cardiac depressant, ether a cardiac stimulant. Ether is therefore, generally speaking, safer and except for those who are expert, it is the anesthetic of choice when no contra-indication to its administration is present. Although, in the author's experience, respiratory paralysis is far more frequent during chloroformization than is cardiac failure, still in those cases that eventuate fatally the deter- mining phenomena are usually cardiac. However, while chloroform is therefore inadmissible in the presence of an active heart lesion, nevertheless an old endocarditis, well compensated and without marked circulatory disturbances, does not interfere with the administration of that anesthetic when, for other reasons, ether is ineligible. It must be re- 81 82 The Surgical Assistant. membered too that cardiac failures during chloroformization, being more striking (and more tragic), are more often re- ported than fatalities from pneumonia or suppression of urine subsequent to ether narcoses. Ether is a pulmonary irritant and congestant ; and the weight of evidence seems to be in favor of its being also a renal irritant. For opera- tions upon the lungs or kidneys, or in the presence of disease of these organs, chloroform, therefore, should ordinarily be selected. While, with skill, ether can be administered to very young subjects by the " open " or " drop " method without inordinate irritation of their sensitive air-passages, chloroform is generally preferable for infants and small chil- dren ; as it is also for patients of advanced years, because of the greater danger of pneumonia and, if arteriosclerosis be present, of cerebral trouble from the use of ether. If ad- vanced arteriosclerosis exists, both ether and chloroform are dangerous drugs, and either must be employed with great caution. Ether causes cerebral congestion and is not to be preferred for intracranial operations. For the same reason, and also because it can be administered with less interference to the operator's manipulations than can ether, chloroform is to be selected for operations upon the mouth and throat. An important exception to this rule exists in anesthetization for the removal of adenoid growths and en- larged tonsils. In these cases, ether is probably safer; but accumulating evidence indicates that in the presence of the status lymphaticus, of which adenoid growths are sometimes only an expression, ether, as well as chloroform, is distinctly dangerous. When it is important to minimize the vomiting after opera- tion, chloroform is ordinarily to be preferred. As the malaise after the employment of ether is usually more last- ing, so its initial effects (unless these be eliminated by em- ploying the gas-ether sequence) are more disagreeable, than those of chloroform, which induces unconsciousness more speedily as well as more pleasantly. This is important in selecting an anesthetic for a patient who is timid or sensitive, and it is even more important if he be alcoholic. Choice of Anesthetic. 83 Anesthesia mixtures (the A. C. E. and C. E. mixtures* so popular in England, Billroth's mixture,"}" the Schleich mix- tures $ exploited seven years ago, "Anesthol," f f etc.,) oc- cupy in a general way, in regard to safety and to effects, a position between those of chloroform and of ether, but they may, of course, produce the ill-effects of either. Used by some surgeons more or less as a routine, these mixtures are by others employed in preference to chloroform in those cases in which there is an objection to pure ether, e. g., the great age or youth of the subject, the presence of a bron- chial, pulmonary or renal affection, etc. The mixtures are sometimes useful as an introduction to chloroform or ether (" anesthesia sequence "), and it cannot be denied that occa- sionally there is met a subject who cannot be satisfactorily narcotized by either chloroform or ether, but who reacts well to the skilful administration of one of their mixtures. All the foregoing considerations impress the value to the anesthetist of personally studying the heart and the pulse, of inquiring into the condition of the lungs, the kidneys and, in suspicious cases, the lympathic system, of learning the patient's temperament (and of removing false teeth or other loose objects from the mouth), before the narcosis is started. Nor should it be begun until he has provided himself with one or two towels and the instruments referred to in a pre- vious chapter — screw-gag or hardwood wedge for forcing * A. C. E., alcohol, i part ; chloroform, 2 parts ; ether, 3 parts. C. E., chloroform, 2 parts ; ether, 3 parts. For a description of the uses of these mixtures, and as an excellent text-book upon the entire subject, the reader is referred to Frederick Hewitt's " Anesthetics and Their Administration." f Alcohol, 1 part ; chloroform, 3 parts ; ether, 1 part. \ Three separate combinations of chloroform, ether, and petrolic ether (benzin). ft A chemical combination of ethyl chlorid with a " molecular solution " of ether and chloroform, the liquid having a boiling point closely approximating the temperature of the body: ethyl chlorid, 17$; chloroform, 36$; ether, 47$, by volume. — Willy Meyer, Journal American Medical Association, February 28, 1903. Manufactured by Chas. Cooper & Co., New York. 84 The Surgical Assistant. open the mouth; Denhard or other mouth-gag; tongue-for- ceps; one or more throat swabs; and a syringe loaded for hypodermatic stimulation — all of which should be within easy reach, but out of the patient's sight. In those cases in which an emergency demands the admin- istration of a general anesthetic without previous prepara- tion of the patient a preliminary gastric lavage may be de- sirable. It is conducive to cleanliness to confine the patient's hair in a thin rubber cap or in a towel. One of the long edges of the towel encircles the head, passing just below the occipital protuberance, just above the ears, and across the forehead, where the overlapping ends are caught with a safety pin. The body of the towel is brought forward over the scalp, and the two loose ends folded together and secured at the forehead with the same pin. A few turns of a bandage may be used, instead, to hold the cap. A preliminary hypodermatic injection of morphin (gr. 1-6 — gr. 1-5 of the sulphate) may be made when the opera- tion is apt to be prolonged, or when the quantity of the nar- cotic required should for any reason be minimized. Chlo- retone, gr. x-xv, by mouth, has also been recommended. It is usually desirable, and sometimes quite imperative, to ad- minister morphin (gr. 1-6 — gr. 1-4) to alcoholic patients. It diminishes the intensity and duration of the " excitement " they usually exhibit, and simplifies a narcosis that, at best, is apt to be difficult and trying. An injection of atropin sulphate, gr. 1-100, prevents excessive mucus secretion from ether narcosis. When morphin or atropin is thus used, its effect upon the pupils must be taken into account in watch- ing the eye signs. Both pupils should be inspected before the narcosis and during its induction, so that the anesthetist may learn the effects upon them, in the individual case, of increasing and decreasing the doses. It is important to secure the confidence of the patient from the outset, to inform him of the sensations he will ex- perience, and to instruct him to take deep breaths — all before any narcotic vapors are approached to his face. The mask The Stages of Narcosis. 85 should at first be held several inches away and then brought gradually closer to the nose. A brief cessation of respira- tion in the first stage, more common during etherization than in chloroform narcosis, does not demand a removal of the mask, as it does when occurring during profound anes- thesia but, on the contrary, it requires that the mask should be held in position so that the patient will receive with the first returning inspiration, which is usually deep, a needed dose of the vapor. The stage of excitement is frequently absent (objectively, at least), often brief, and only occasionally troublesome; and slight restless movements should not be restrained. Al- coholics become pugnacious, however, and large, plethoric individuals may be difficult to handle. To restrain the patient then requires one or more assistants to hold the wrists and knees firmly against the table, while the anesthetist grips the head between his forearms. Pressure upon the chest must be avoided. An injection of morphin at this stage is very helpful. If ether is being administered the mask should be freely saturated and held firmly against the face, all air being excluded. Chloroform, too, may be " pushed " some- what but, unlike ether, should never be " crowded." Though the patient be struggling violently it is important that some- one should watch the pulse, for even in this stage of incom- plete narcosis dangerous collapse may occur — just as occa- sionally it occurs when operative procedures are undertaken during insufficient anesthesia. After several deep inspira- tions the subsidence of the violent tremors, glottic spasms and cyanosis marks the termination of the stage of excite- ment ; but the administration of the anesthetic should not be remitted until the second stage* is safely inaugurated. The appearance of stertor (if it has not already been present in these individuals) also marks the advent of deepening nar- cosis. At this stage it is important to keep the air passages freely open, for which purpose it is well to remove the pillow and to extend the head — whether it be held sideways or in the * " Third stage " of Snow, Hewitt, and other authors. 86 The Surgical Assistant. median line. The position of the arms also must 'be care- fully attended to. When the site of the operation does not interfere, it is best to place the arms alongside the chest, with the forearms folded lightly across the lower thorax where they may be held by rolling the bottom of the patient's shirt over them. A paralysis of one of these members after general anesthesia is usually attributable to its having been allowed to lie in a vicious position. Such paralysis is very distressing, for it is always of long duration and is sometimes incurable. For its occurrence the anesthetist must hold himself solely re- sponsible ; for its prevention, therefore, he should afford his constant watchfulness . Discussing the anatomical factors in the production of narcosis paralyses, in connection with the report of a bilateral brachial palsy occurring in a patient upon whom the author operated for appendicitis, he deduced these practical rules : * " i. The care of the arms is as important a part of the anesthetist's duty as is the administration of the narcotic. They should never be allowed to hang over the edge of the table. This position threatens the musculo-spiral nerve by pressure, and the entire plexus by stretching. " 2. Rotation and superextension of the head should be exercised only while emergency requires it. " 3. Prolonged pressure of any kind should be avoided, be it that of an assistant's hand or body, or that of a harness. When used, the shoulder-strap of a leg-holder should pass over the tip of the shoulder, or over a large pad of cotton wool on the neck; or, best of all, should be held by an as- sistant (the anesthetist can usually spare a hand to pull the strap up from the body from time to time). It should be remembered that this apparatus has occasionally caused para- lysis in a leg, as in one of Garrigues' cases. " 4. The common practice of drawing the arms alongside the head, however much it may contribute to the conveni- ence of the anesthetist and the comfort of the operator, is a bad one and should not be tolerated. Remembering that in * New York Medical Journal, April 27, 1901. Signs to be Watched. 87 some of the cases reported the arms were lying alongside the body during the operation, the safest rule to follow is to avoid allowing either arm to remain more than a few minutes in any one position, however innocent that position may appear to be." Paralysis of a leg is less apt to come from the pressure of a strap itself than from the pressure of an assistant's body upon the flexed extremity. While the anesthetist is not re- sponsible for such a fault he is in a position to call attention to it. Nor should his watchfulness cease when the patient is removed from the operating table. He should see that none of the extremities lies in a constrained position when the pa- tient is returned to his bed. (That someone of experience should remain at the bedside until the patient is " out " of the narcosis needs here no more than the passing mention.) In addition to the arms, the anesthetist should take con- stant note of the patient's color, pulse, respiration, and re- flexes. The Color of the lips, of the lobes of the ears, of the escap- ing blood, is an index to the extent of the oxygenation in the lungs. Slight cyanosis, especially during etherization, does not call for treatment if present from the beginning. Deeper cyanosis is an indication for freeing the air passages if they are obstructed by mucus or by the falling back of the tongue, for the allowance of more air, or (more particularly in the presence of other signs) for the withdrawal of the anesthetic. The Pulse should be watched constantly and by the anes- thetist himself. This may be conveniently done at or just below the point where the facial artery passes over the horizontal ramus of the lower jaw (at the anterior border of the masseter muscle), where the temporal artery crosses the zygoma, at some point along the course of the internal carotid, or by holding the upper lip between finger and thumb (superior coronary branch of the facial artery). Frequent reference to the radial artery is helpful, too, and, indeed, the radial pulse may be watched throughout — and without drag- ging the arm alongside the head to accomplish it. 88 The Surgical Assistant. Acceleration of the pulse-rate is frequently to be noted during the first stage, but in the second stage — of chloroform narcosis more especially — the pulse usually resumes about its normal rate. Enfeeblement of the pulse is a matter of concern, but not necessarily of alarm. It may have no other significance than an individual reaction to the narcotic, disappearing when the patient is allowed to " come out " ; and a skilful anesthetist often carries a patient safely through a pro- longed, deep narcosis, with a pulse that is throughout of poor quality. A pulse that is both rapid and feeble, how- ever, more especially if the symptom is a progressive one, requires treatment. It must be decided whether it is the re- sult of shock, loss of blood, insufficient aeration of the blood, or the cumulative effect of the anesthetic. Accordingly it will call for haste in the operation, stimulation, more air, change of anesthetic, or withdrawal of anesthetic — or a combination of these. Rapidity and enfeeblement of the pulse often appearing rather abruptly, may, however, have a significance quite diffierent from these, viz., that the patient is " coming out," or (and) that he is about to vomit. Nice judgment is there- fore needed to determine which of two opposite things is required — more anesthetic or less anesthetic. If the nar- cotizer informs the surgeon that the patient's condition is bad — which he should always do when such is the case, he may disconcert the operator unnecessarily — which he should never do, and may find, to his embarrassment, that the patient reacts vigorously the next moment. If he assumes that the patient is coming out and pushes the narcosis, he may administer a lethal dose to an already poisoned heart. If the condition of the reflexes does not help him in deciding which course to pursue, he should withdraw the mask and await further developments. At no time should an anes- thetist administer a single dose of the vapor without having an accurate appreciation of how far the patient is " under," and in what condition he is. Haphazard anesthetization is bad anesthetization ; and guesswork is never excusable, The Respiration. 89 The Respiration, which may be jerky and irregular or rapid, in the first stage, should be regular and slow in the second stage of narcosis, when it is usually more or less stertorous. Blowing of the cheeks is in most cases a sign of deep narcosis. Flapping of the soft palate gives a stridu- lent or sonorous character to the stertor, which latter, being due in part, at least, to falling back of the tongue, can usu- ally be overcome by lifting the jaw forward. This is accom- plished by pressure of the middle finger against the angle of the inferior maxilla, — the forefinger is thus left free to feel the facial pulse, and the thumb to test the eye reflexes. Fig. 23. Administration of chloroform. The jaw is being held forward by- pressure of the middle finger of one hand ; the index finger is on the facial artery and the thumb is testing the conjunctival reflex. Note also the towel about the head, which is extended on a flat pillow ; and the unconstrained position of the arms and hands. Supporting the jaw on one side only will usually suffice, and it is advisable to change occasionally from one side to the other to obviate the soreness which otherwise often results from continuous pressure upon one spot. The jaw may also be held forward by catching the lower incisor teeth in front of the upper ones (if they be large and strong), and it can be maintained in this position by light support with one finger under the chin. If extension of the jaw does not 90 The Surgical Assistant. entirely overcome the stertor, nothing further need be done, provided neither cyanosis nor other sign indicates inefficient respiration ; and it must, of course, be remembered that during etherization engorgement of, and increased secre- tion by, the pharynx are themselves causative of stertor. If, however, it is evident that the base of the tongue is still seriously obstructing the air passage in spite of the jaw ex- FiG. 24. Sponging mucus from the pharynx. Mouth-gag in position. tension, then a screw- or wedge-gag should be pried into the mouth, between the upper and lower molar teeth, and the tongue drawn forward by means of forceps. For pro- longed traction on the organ this bruising instrument should be replaced by a stout guy-suture passed transversely through the tongue near its middle. The pharynx must be kept free of mucous accumulations. To reach the cavity a metal mouth-gag is introduced between the jaws, after they are forced open with the screw or wedge, and the handles of the instrument approached. A sponge firmly secured in a carrier is then passed well down in the pharynx, the walls of which are cleansed from below up- wards by imparting a spiral movement to the sponge. This Respiratory Failure. 91 is repeated until the throat is clear. Accumulations in the pharynx of mucus, blood or vomitus, when the operation is concluded and the patient is reacting, should not be wiped out, both because the returning pharyngeal reflexes will in- duce their expulsion and because the irritation of the sponge is apt to provoke vomiting. Sudden stoppage of the respiration, like enfeeblement of the pulse, is not necessarily ominous for, like the pulse sign, it may merely presage reaction. Often extension of the jaw, strong pressure upon the thorax or slapping the chest with a wet towel may be all that is necessary to restore respira- tion. If no other serious sign is present the anesthetist may safely wait a brief period for the breathing to return. If it does not, however, then no further time should be wasted with tentative measures, but artificial respiration (Sylves- ter's) should be inaugurated at once. It should be vigorous, systematic and slow (synchronous with the manipulator's respirations). The upward movement of the arms should be a steady one ; the downward movement should be fol- lowed by strong pressure upon the sides of the chest. Atro- pin may arouse the medullary centre, and since the heart action will soon flag if breathing be not restored, stimulants should not be long withheld. When the heart begins to fail, strong thumb pressure or percussion over its apex should be practiced, and repeated about eighty times a minute. La- borde's tongue traction may be performed synchronously with the artificial inspiratory movement. Dilatation of the anal sphincter is sometimes very useful. Elevation of the foot of the table and the application of hot blankets are help- ful adjuvants. Finally, faradaization of the phrenic nerve and insufflation of the lungs may be tried if the apparatus are at hand. None of these methods, however, is as reli- able as the artificial respiration, which should be persisted in for hours if necessary — until rhythmic breathing is restored, or until the faintest heart flutter has long since ceased to be heard and other signs of death are unmis- takably present. The Eyes. Although the conjunctival reflex is most active 92 The Surgical Assistant. over the cornea (corneal reflex), that part of the eye should not be touched since this risks the production of an ulcera- tion. The sclera may be touched frequently without injury but to elicit the conjunctival reflex it usually suffices to lightly and quickly lift the edge of the upper lid — which move- ment at the same time exposes the pupil for inspection. The liveliness of the conjunctival reflex is less important than the variations in its activity. While generally a feeble contrac- tion in the orbicularis when the conjunctiva is touched, in- dicates a relatively deep narcosis, and a vigorous contraction indicates a relatively light narcosis, the response is not the same in all individuals. Thus it is sometimes to be noted that a patient is quite relaxed and anesthetic even though the conjunctival reflex is fairly active; and, per contra, an- other patient may unexpectedly react when this reflex is absent, and ocasionally when, also, the respiration is ster- torous, and the cheeks " blowing." Changes in the reactibil- ity of the lid are, however, very useful as indices to fluctua- tions in the depth of the narcosis. The same remarks apply to the size of the pupil. Although it is usually moderately contracted during the second stage of the narcosis (more especially of chloroform narcosis), it is often dilated or of medium size. By studying the pupil for a few moments, however, the anesthetist learns its in- dividual reactions, and by the changes it undergoes he may be able, unless much morphin has been injected, to gauge very accurately the depth of the narcosis and^o conduct its administration accordingly. Thus an alteration from mod- erate dilatation to contraction frequently means deepening of the narcosis, and vice versa. If extreme dilatation of the pupil occurs suddenly during deep narcosis, it tells the anesthetist that he has allowed his patient to approach too near the danger line ! In light narcosis the pupils may dilate reflexly from operative manipulation. Disappearance of the pupillary reaction to light indicates a dangerously profound narcosis and calls for withdrawal of the anesthetic until the reflex is re-established. By thus studying the color of the skin, the pulse, the re- Stimulation. 93 spiration, and the eye reflexes the anesthetist is enabled to secure and maintain a degree of narcosis required by special cases. Conditions present before operation, or arising during anesthesia, may make it necessary to give the patient but little of the narcotic, viz., to secure unconsciousness without complete relaxation, or relaxation without profound narcosis. During a herniotomy it may occasionally be helpful to allow a patient to " come out " sufficiently to strain into view a sac that has slipped back into the abdominal cavity. Operations upon the anus require deep anesthesia, — stretching of the sphincter ani or the cervix uteri may elicit a loud snort or a vigorous movement of the legs, even when the other re- flexes are abolished. Stimulation. For bolstering a flagging heart strychnin or (and) whiskey (or brandy) may be injected hypoder- matically in doses, for adults, of gr. 1-30 and 30 minims, respectively, which may be repeated. Digitalis (TTLx of the tincture) is very serviceable, as are caffein (e. g., the sali- cylate or benzoate of caffein and sodium, gr. ii), adrenalin and nitroglycerin. Small doses of morphin (gr. 1-8 — gr. 1-6) possess the double advantage of stimulating and steady- ing the heart and of reducing the quantity of anesthetic necessary to maintain narcosis. To combat shock occurring during operation the assistant may order the introduction, by means of a piston syringe, beyond the internal sphincter ani, of Tinct. digitalis TT\, xx Whiskey |i Salt 3 ss — 3 i Water (at no° F to 120 F) § viii— Oi In the event of collapse, large doses of strychnin (gr. 1-20 — gr. 1-10) and of whiskey, are indicated. Ether, 3 ss, in which may be dissolved a grain of camphor, may be injected for rapid, though transitory, effect. Finally intravenous in- fusion may be required. - Vomiting. Threatened vomiting may usually be avoided by " pushing " the anesthetic. But vomiting that is inevitable 94 The Surgical Assistant. or actual demands that the mask should be removed, the head turned strongly to one side (away from the field of operation, preferably), and the jaw pushed well forward. Steady pressure upon the left phrenic nerve in the space between the two heads of the sterno-mastoid muscle may be tried as a means of controlling emesis. Not until the vomiting has ceased and the mouth and pharynx are cleansed, should the anesthesia be resumed. Individual Methods of Administering the Various Anesthetics. Chloroform. In emergency an ordinary handkerchief, or the corner of a towel passed through a safety pin (as sug- gested by Lister) may be used as a mask, or better than these, as a makeshift, a piece of gauze stitched over a large tea- strainer. Ordinarily there is employed an inhaler, such as that of Esmarch or Laplace, or the very excellent one re- cently devised by Yankauer* (appendix, fig I.) Upon these is stretched a piece of balbriggan or unbleached muslin, or a double thickness of surgical gauze. Lacking a regular " drop bottle," one may be devised as described on page 62 or, prob- ably better, " a simple drop bottle is made by cutting two V's in a cork in opposite sides. A piece of absorbent cotton long enough to reach the bottom of the bottle is placed in one V, and allowed to protrude about an inch ; the other V serves for an air vent. The rapidity of the drops may be regulated by inclining the bottle, though it should never be tipped enough to allow the anesthetic to run from the opening in the cork. The size of the drops may be regulated by twisting the cotton wick fine or coarse. Another method which works equally well and does not spoil the cork is to place a match in the neck of the bottle beside the cork, so that it will not fit too tight, and then place in the cotton wick." f * New York Medical Journal and Philadelphia Medical JournaJ, June 4, 1904. f B. F. Stevens, American Medicine, August 13, 1904. Administration of Chloroform. 9U When chloroform is administered where gas or a grate-fire is burning, it is especially important that the room be kept ventilated, for otherwise it becomes filled with phosgen (car- bon oxychlorid), a very irritating gas produced by the de- composition of the chloroform vapor. The patient's eyelids, nose, cheeks, lips and chin should be anointed with a thin layer of vaselin or albolene (or even butter) to prevent burning — a precaution that is unnecessary when the Yankauer mask is used. Should chloroform drop on the unprotected parts of the face, however, it will do no damage if immediately wiped off. If chloroform (or ether) fall into the eye, the conjunctival sac should be promptly ir- rigated with a little warm water. The chances of such an accident are minimized by protecting the eyes with cotton pads or a folded towel. Ideal chloroformization consists in allowing the drug to fall, drop by drop, upon the mask, at such regular intervals throughout as will just maintain, unfluctuating, the desired narcosis ; and in ceasing the administration at such time as will allow reaction as soon as, but no sooner than, anesthesia is no longer needed. Practically, however, this method is approached, but seldom actually carried out. Variation will usually be found necessary, both in the rate of administration and in the quantity administered from time to time ; and thus, too, the drug will be withdrawn altogether, now and again, for long or short periods, as the profundity of the narcosis indicates. With the exercise of skill and patience, children may be chloroformed while sleeping. When awake they invariably cry when they smell the vapor ; as the crying subsides it is wise to withdraw the mask for a short time, for it is just at this stage that children may otherwise inhale an overdose. For operations upon the head or neck, the* anesthetist should disinfect his hands, use a sterilized mask, and sur- round the chloroform bottle with sterilized gauze. He should see to it, here, that no instrument is allowed to lie on the exposed (or unexposed) cornea. For operations about the mouth the mask may be replaced by a long, curved, metal 06 The Surgical Assistant. tube, one end of which is introduced into the faucial opening and the other end connected by rubber tubing with the exit pipe of an atomizer. By means of the hand bulb air is bubbled through chloroform in the flask, and the vapor of the narcotic is carried into the patient's air passages. The same device may be used for administering chloroform through a tracheal wound or, less elegantly, a thin pad of gauze held in a sponge carrier in front of the tracheal opening may be used to carry the drug. Ether. There is no need to protect the face with vaselin, for the skin does not burn from contact with ether. Ether vapor is heavier than air and highly inflammable, for which reasons no lamp, gas jet or fire should be allowed to burn in the room except above the level of the operating table Open (" Drop ") Method. This is conducted much as is chloroform administration, an open inhaler being used. Since ether evaporates very rapidly, however, several thicknesses of gauze should be stretched over the mask, and it is also advisable to use an inhaler like that of Laplace, in which much of the gauze is covered with a metal cap, or to stitch over the gauze a piece of oiled silk, leaving exposed a space in the center about the size of a silver dollar. The ether is applied more freely than is chloroform, i. e., the drops are made to follow one another more closely. The open method of etherization may be used for adults, but is especially applicable to children. Closed Method. The towel cone described on page 63 answers all practical purposes. Half an ounce of ether, more or less, is poured on the cotton, gauze or sea-sponge in the apex, and renewed as it evaporates. The Allis inhaler (ap- pendix, fig. 2) permits the introduction of the ether from above when the anesthetist does not wish to lift the mask from the face. Through the same opening air is drawn with each inspiration, unless the rubber sides are folded over the top. The " ex- citement " of the first stage of ether narcosis is usu- ally more marked and more prolonged than in chloroformiza- tion. Towards the end of this stage a general tremor is oc- Administration of Ether. 97 casionally noticed. Occasionally, too, a vivid roseola makes its appearance about the face, neck and chest. It comes early in the narcosis, and lasts but a few minutes. While in chloro- formization free admixture with air is imperative at all times, during etherization air is usually needed (in relatively smaller amounts) only from time to time. And so here, too, remissions in the administration are called for as cyanosis, stertor, or the profundity of the narcosis may indicate. If ether is used during an operation upon the head, its adminis- tration may be conducted under the covering of a sterilized towel. Hewitt describes the use of the Allis inhaler and the towel cone as constituting the " Semi-Open " Method of etheriza- tion, and limits the Closed Method to the employment of Clover's, Ormsby's, Bennett's or other apparatus that includes a rubber bag from which the patient breathes his own ex- halations mixed with fresh ether vapor. The modus oper- andi of these excellent apparatus is simple, and needs no special description here. Anesthesia by ether may be induced more quickly and more pleasantly than by chloroform, if preceded by the ad- ministration of nitrous oxid gas. For this purpose a Gas and Ether apparatus, such as Bennett's (appendix, figure 3), is desirable. By an arrangement of graduated stops, ether vapor is slowly introduced into the face-piece as the patient " goes under " the gas, which latter is gradually withdrawn, the gas reservoir being replaced by an empty rubber bag for collecting and returning the expired gases. Traps are provided for the admission of air in regulated volume. Chloroform and Ether mixtures. These are always to be administered upon an open mask, preferably one arranged as described for the drop method of etherization. It must not be supposed that any of these mixtures eliminates en- tirely the dangers of either of their chief components, and " the claim that the administration of [these] mixtures re- quires less care and less watchfulness than the use of chloro- form or ether is, to say the least, vicious in purpose and re- 98 The Surgical Assistant. suit."* It was the author's experience with the Schleich mixtures that the eye signs during narcosis are not very re- liable guides. Fig. 25. Administration of gas and ether by means of a Bennett apparatus. Head turned to one side. Jaw extended. Forearms at sides of chest. Anes- thetist's forefinger notes facial pulse. Nitrous Oxid narcosis, as, indeed, the administration of all general anesthetics, should be preceded by an examination of the heart and the mouth. Unlike chloroform or ether it may be " pushed " from the start, the face-piece of the apparatus being crowded down snugly and all air excluded, after a preliminary whiff or two of mixed gas and air. If the patient be instructed to hold one arm up, the ar- rival of analgesia, if not of anesthesia, will be marked by the falling of the extremity. Relaxation is not a purpose of this narcotic, and marked rigidity often ac- companies complete unconsciousness. The occurrence of violent coarse tremors or spasms, however, is an indication for the prompt allowance of air. Cyanosis is the * Mt. Sinai Hospital Reports, Vol. i, 1898 Ethyl Chlorid Narcosis. 99 rule, but it should not be allowed to pass beyond the point of duskiness, and certainly should not be long maintained at deep blueness, of the features. When the narcosis is pro- longed, or the cyanosis becomes deep, the administration should be remitted, and the patient allowed to breathe air for a brief period. That asphyxia is not essential to the produc- tion of anesthesia by laughing gas is shown by the fact that, by means of Gas and Oxygen, admitted to the face-piece of an appar- atus in regulated proportions, from separate cylinders, a sufficiently deep narcosis may be maintained, for an hour if necessary, without the appearance of any cyanosis. Ethyl Chlorid general narcosis has such wide usefulness in minor surgery and, by reason of the greater portability of the apparatus, possesses so obvious an advantage over laughing gas that the simple technics of its induction are well worth learning. Like nitrous oxid it does not usually secure muscu- lar relaxation. In spite of this the writer has, without much difficulty, performed complete stretching of the sphincter ani and clamping and cauterization of internal hemorrhoids, upon a slender adult anesthetized by ethyl chlorid. Various masks have been devised for its administration. That of Breuer has an inspiratory and an expiratory valve, the for- mer of which opens from a receptacle for gauze or absorbent cotton, upon which the ethyl chlorid is poured. A very simple mask is that of Ware (appendix, figure 4). It con- sists in a short tube, about one inch in diameter, one end of which is covered with two or more layers of gauze and thrust into the opening of the simpler, valveless form of face- piece sold by the S. S. White Dental Co. for nitrous oxid ap- paratus. This mask may be improvised from a funnel, or a cone of heavy cardboard which, however, must be fashioned to fit the face closely. The ethyl chlorid is sprayed into the mask from a glass tube sold originally for local anesthesia ("kelene "). For economy and convenience of administra- tion there should be selected only those tubes that have auto- matic, spring releases ; and the patency of the fine opening in- to the tube should be tested when the purchase is made. By 100 The Surgical Assistant. pressure on the spring the ethyl chlorid is sprayed through the tube and on the gauze intermittently, viz., with each in- spiration. The expired air soon freezes upon the gauze ; but the frost should not be allowed, by reason of too rapid admin- istration of the drug, to close entirely the opening into the face-piece. Flushing of the face, muscular spasms and a brief dila- tation of the pupils are followed, when narcosis appears, by diminution of the contractions of the muscles, decrease in the size of the pupil, and somewhat stertorous breathing. The pulse rate is xcelerated. The pupillary signs are, in general, like those in chloroform narcosis, but are less constant. If the anesthesia is prolonged the administration of the drug may be remitted from time to time. These remissions must be for very brief periods only, however, for the patient " comes out " as quickly as from laughing gas, and with as little after-effect. (Vomiting occurs sometimes; nausea is a more frequent sequel, but usually does not last long.) Ethyl Bromid. This anesthetic is less satisfactory than ethyl chlorid, and probably less safe. It is very important with the bromid, and indeed with the chlorid, of ethyl, to secure a pure preparation. A towel-cone or Ormsby inhaler may be used, about a teaspoonful of the drug being poured on the sponge. The mask is applied firmly to the face until the patient has inhaled a few times, after which some air is ad- mitted. Ethyl bromid does not seem suited for intermittent administration, nor for any operation that is not quite brief, e. g. } those that can be accomplished during, or just after, the administration of a single " dose." It induces rapidly a narcosis that is as quickly recovered from. There is usually no struggling. Respiration is free, sometimes slightly snor- ing. The pulse rate is accelerated, as a rule. The conjunc- tival reflex may become lost or may remain quite active ; the pupil usually dilates. Unless the administration is very brief, it is followed by severe headache and vomiting. For Obstetric Narcosis chloroform is most generally useful, although ether is not ineligible for many operations. Obstetric Narcosis. 101 The manner of administration in normal labors depends upon whether the purpose is to alleviate pain, to retard ex- pulsion, or both. In the second stage of delivery, before the head is at the outlet, a " whiff " of chloroform may be administered to " take the edge off " a pain. For this purpose the liquid is poured rather freely upon a mask or handkerchief, with the advent of a pain, and withdrawn as the pain passes off. When the head is stretching the vulvar outlet the pains be- come more and more frequent and severe, and so the ad- ministration of the chloroform is made more continuous and the patient is brought moderately " under." Thus the peri- neum is allowed to distend gradually, and the head is de- livered by the accoucheur, slowly and without injury to the maternal soft parts. When the head is born the chloroform should not be withdrawn, for the sudden onrush of the shoulders that would follow may rupture a perineum that has been carefully guarded ; and even the infant hips occa- sionally do damage in passing. When the child's body has been delivered, however, the mask should be removed, for excess of chloroform favors uterine inertia and, therefore, retention of the secundines and hemorrhage. For forceps deliveries chloroform should be used, as a rule, when the blades are inserted, and continued or not according as the operator desires to deliver without or with the aid of maternal effort. For versions and other intra-uterine manipulations moder- ate narcosis should be induced. For breech extractions the chloroform is needed when the hand is introduced to seize a foot, but unless the delivery is to be hastened, the anesthetLt should thereafter remove the mask, and may assist by exert- ing pressure upon the fundus uteri. The narcotic is resumed if the infant's hands must be brought down; and the final extraction is best accomplished under narcosis since, to avoid asphyxia, the manipulations must be rapid. CHAPTER VII. THE PREPARATION AND PRESERVATION OF SURGICAL INSTRUMENTS AND ACCESSORIES. STERILIZATION. Most surgical instruments are to be sterilized by "boiling" for ten minutes in water, to which has been added sodium carbonate (washing soda) to prevent rusting. A one per cent, solution is sufficiently strong for the purpose, but it is a convenient practice to drop about a handful of the salt into the water. Delicate instruments should be laid on top of the others in the sterilizer. After boiling, the instruments should be rinsed free of soda crystals in sterile water or in a weak carbolic acid solution. Excess of either of these fluids should be allowed to drain from the instruments, if they are to be spread out on towels, although carbolic acid solution is not apt to rust the metal during the course of an operation. For hasty preparation in minor work, instruments may be sterilized by passing them rapidly through an alcohol or a Bunsen flame — a procedure that is not to be recommended for finely tempered tools. Aluminum instruments are ruined by boiling in soda solu- tion. They should be sterilized by boiling in plain water, or by passage through a flame. Scalpels, amputating knives, urethral blades and delicate scissors should not be submitted to prolonged boiling. They may be sterilized by washing with soap and water, rinsing in alcohol and prolonged immersion in carbolic acid solution, 5 per cent., or in pure lysol. Boiling for half a minute may be substituted for the carbolic immersion, without much injury to the cutting edges. Needles may be boiled with the coarse instruments, being 102 Sterilization of Surgical Instruments. 103 laid in the sterilizer in a small dish or fastened on a strip of bandage. Immersion in pure lysol may be substituted for the boiling. Needles are apt to be ruined by sterilization in a flame, but they may be disinfected hastily by dipping in carbolic acid. Another hasty method, not altogether to be commended, consists in igniting a thin layer of alcohol poured over the needles spread out in a dish. Ophthalmic instruments, after boiling and rinsing, should be carefully dried with squares of soft, sterilized linen. Cataract knives and iridectomes may be disinfected like scal- pels or by immersions in benzin, three per cent, formaldhyd solution and alcohol successively. Male cystoscopes, laryngeal mirrors, etc., cannot be sub- mitted to boiling, at least not in their entire'ty. The non- metallic parts should be disinfected by thoroughly cleansing in soap and water, and bathing in 5 per cent, carbolic acid or 3 per cent, formaldehyd solution ; or washed in soapsuds, dried and exposed to formalin vapor, produced by gently heating formalin powder or tablets in a closed chamber. Wooden handles split and become swollen by repeated boiling; but since they are, for the most part, cheaply re- placed, this is not a serious matter. Rawhide mallets cannot be boiled without serious injury. They are, therefore, undesirable. If used at all, they are to be disinfected in formalin gas. Aspirating syringes, entirely of metal or glass, or with asbestos or rubber packings, should be boiled. Those with leather packings are to be sterilized as follows : Draw up boil- ing soda solution into the barrel ; dip the entire instrument into the sterilizer for a few seconds ; eject the fluid ; wash out several times with carbolic acid solution. Injection Syringes are sterilized in the same manner, greater care being necessary, however, to secure asepsis of the barrel and the packing. With those that cannot be boiled, therefore, the washing out with carbolic acid should be done repeatedly and followed by washing with sterile water. Syringe needles are to be boiled with the wires in place, 104 The Surgical Assistant. and these should not be removed until the instrument is needed. Rubber materials. Instruments with well made vulcan- ized rubber handles may be boiled freely, although it occa- sionally happens that rubber scalpel handles are warped and decolorized somewhat by the heat. Razor handles are quickly warped, if boiled. Hard rubber pessaries, tongue depressors, etc., also lose their proper form in boiling water, and should, therefore, be sterilized in carbolic acid or other antiseptic solution. Hard rubber hand syringes are to be similarly dis- infected, after cleansing the individual parts if necessary. " Fountain " and Davidson syringes may be boiled, as may also tubing, inhalers, dam and bandages of rubber. It is well not to boil any of these articles (unless they be of red rubber) with the metal instruments, for the latter are sometimes dis- colored thereby. Rubber gloves and finger cots of good quality may be boiled freely. They should be sterilized separately or floated above the instruments in the sterilizer, to avoid tearing by contact with sharp metal. Rubber catheters and bougies (appendix, figures 79-85, 90) may be boiled, but after being thus treated several times they become very soft and must be discarded. Catheters and bougies with shellac surfaces should not be submitted to hot water, even for a moment. They may be disinfected by thorough cleansing in soap tincture, or antiseptic soap, and immersion in car- bolic acid solution. After this they may be dropped into a tube of formaldehyd-glycerin (three per cent.) in which, indeed, they may be kept between operations. Exposure of catheters, dry, in a cabinet, to formalin vaporized in a gen- erator can be relied upon as an efficient means of disinfec- tion. Krotoszyner and Willard* recommend the following methods of sterilization as proven by them to be safe as well a simple : " Soft-rubber catheters are rendered sterile by being boiled five minutes, preferably in sodium chlorid solution, care being taken that the solution fills the lumen of the * New York Medical News, August 27, 1904. Sterilization of Surgical Accessories. 105 catheter. As a matter of precaution the catheter should be washed with soap-spirits and running water after use. " Hard-rubber and silk- and cotton-woven catheters should be boiled five minutes in a saturated solution of sulphate of ammonia. Each instrument should be wrapped separately in gauze or a towel, or if several catheters are to be sterilized, in such a manner that their surface shall not come in contact with the sides of the vessel or other catheters. " Urether-catheters can be folded and wrapped in a towel so that their surfaces are kept apart, and boiled for five minutes in a saturated solution of ammonium sulphate." " Instruments can be kept aseptic if they are snugly wrapped' in a piece of gauze or towel wet with soap-spirits." They " lay stress on the fact that soap-spirits, after the for- mula of the German pharmacopoeia, is to be used for soaking the gauze or towel, as soap-spirits prepared in other ways do not form the essential impermeable covering." Esophageal probangs should be cleaned with soap and water. The sterilization of gutta-percha tissue has been de- scribed before, — wash in cold soapsuds ; rinse in alcohol ; im- merse in cold sublimate solution until needed. Suture Materials. Catgut and kangaroo tendon must of necessity be brought to the operation ready for use (see ap- pendix i). Silk, silkworm-gut, horsehair and silver wire may be sterilized, if necessary, at the time of the operation. Silk and silver wire may be boiled with the instruments. Horsehair, silk and silkworm-gut are to be boiled for thirty minutes in plain waier, or in 5 per cent, carbolic acid solu- tion. Boiling in soda solution renders silkworm-gut soft and friable. In emergency, household spool linen thread, cotton and silk may be boiled for surgical use ; they make accept- able sutures. Dressing gauze and absorbent cotton are likewise usually employed commercially prepared, or sterilized in the sur- geon's laboratory. However, they may be sterilized in the patient's home by boiling or by steaming in a large kettle, and drying in an oven. If surgical gauze is not accessible, dress- ing materials may be secured in an emergency, by boiling 106 The Surgical Assistant. strips of muslin or linen, which can be quickly dried by press- ing with a hot clean laundry iron. Gauze sponges are also sterilized in live steam. Sea- sponges are prepared for surgical use by a lengthy process, described in appendix i. Wax, for plugging bleeding bone surfaces, should be boiled and then poured into a sterile, shallow dish in which it is to be kept (covered) until needed (see appendix i). Splints. As a refinement of asepsis, splints to be incor- porated in a sterile dressing may be boiled, if of metal, or soaked in sublimate solution, if of wood. Hypodermatic injection solutions should be sterilized by boiling if they undergo no chemical deterioration in the process. Nirvanin and beta-eucain may be thus boiled, but cocain solutions should not be. (These should be made with sterile water, and kept in well stoppered bottles that have also been sterilized. A few crystals of boracic, or salicylic acid, added to cocain solutions preserve them for a consider- able time.) Before filling a syringe with a solution for hypodermatic use, it is well to rinse it out with a little sterile water or with some of the solution itself. Cocain solutions, notably, become turbid in a syringe that contains even a small quantity of soda solution ; the syringe needle itself should be washe"d free of this fluid before the injec- tion is made. The following procedure insures against " hypo " infec- tions, if the skin is clean: The needle (with the wire in situ) is boiled in water in a tablespoon and then thrown out on a clean towel. The spoon is again half filled with water, which is boiled and sucked up into the syringe three or four times to disinfect the barrel. A few minims more of water than it is intended to inject are then returned from the syringe to the spoon (the rest of the water being thrown away) and again brought to a boil. Then the hypodermatic tablet is dropped into the spoon and allowed to dissolve with- out further boiling. The solution is drawn into the syringe ; the needle, handled only by its butt, is freed from the wire and screwed on ; and all air is then expelled from the syringe, Cleansing of Instruments. 107 held point upwards, by gentle pressure on the piston. A solid metal piston, unless it fits the syringe very exactly, has a tendency to slide by its own weight. An instrument with such a piston must therefore be held horizontally until the in- jection is introduced. CLEANSING AND PRESERVATION. Promptly at the conclusion of an operation, jars containing sterile materials should be re-covered, and as soon thereafter as is expedient, the instruments should be cleaned and dried. If they have been in contact with infected tissues it is desir- able to re-sterilize them also. The scalpels should receive attention first. They are to be washed off in cold or tepid water (hot water would coagulate any blood or other secretion that may be upon them), and carefully dried. The blades should then be wrapped in absorbent cotton. A hand-brush should not be used on knife- blades. Scalpels may be honed and stropped in the same Fig. 26. Testing iridectome on •' drum. manner as razors and, as with the latter, the evenness and the sharpness of the edge can be tested by gently drawing it across the end of the thumb-nail and of the thumb, respec- tively. Cataract and Von Graefe knives may be tested on a piece of thin, soft kid (from a lady's glove) or of goldbeater's skin, stretched over a napkin ring. If the point does not enter smoothly but, instead, makes a crackling sound as it pierces the membrane, it is not perfect. 108 The Surgical Assistant. The edges of the blades of scissors, if " catchy," may be smoothed to a surprising extent by pressure between the thumb and forefinger, carried several times from lock to tip. Scissors employed in the operation itself should not ordi- narily be used also for cutting gauze. Each variety and size of scissors has its own capacity, and an attempt to use it for substances or thicknesses beyond that capacity is apt to result in " springing " the instrument. Thus, ophthalmic scissors must not be used in ordinary dissections, tissue scissors are not intended to cut bandages, nor bandage shears to cut plaster of Paris. Needles should be dipped in alcohol and thoroughly dried. The drying process may be completed by shaking the needles about in lycopodium, in a box of which they may be left until needed again. Otherwise, they may be kept in a strip of gauze, through which their bodies are thrust, or laid away in a needle-box or in carbonate of soda solution. The coarser instruments are placed gently in a basin of water. From this they are lifted, one by one, taken apart, scrubbed with a hand-brush, rinsed, dried and re-assembled. It is recommended that the assistant familiarize himself with the names and mechanisms of the various surgical tools. Although many manufacturers stamp the corresponding blades of clamps and artery forceps with a certain number, it is best to clean these instruments one by one, to facilitate their proper re-adjustment. Locks and screws should be cleaned and dried with especial care. Holes and depressions are dried out with wisps of absorbent cotton. The drying of instruments that have inseparable joints may be made more thorough by dipping them in alcohol or, better, by warming them in an oven or over a flame. The lumina of cystoscopes and other hollow instruments are washed out with soapsuds, then with plain water, and dried by means of absorbent cotton wound on a probe or an applicator. Ether may be used, if necessary, to remove dried blood. A brush such as is used for tobacco pipes is useful for cleaning the channel for ureter catheters. The lumina of infusion canulse, es- pecially, must be made absolutely clean and dry. Steel Care of Instruments. 109 sounds must be scrupulously dried and polished. They are to be handled with some care to prevent denting or roughen- ing by striking other instruments or by falling upon a hard surface. Probes are easily straightened by rolling them un- der the foot. Wire and chain saws, and the teeth of flat saws, are washed in soapsuds, patted dry, wet in alcohol and again dried. Moisture still adhering in the chain links or between the teeth may be driven off by passing the saw over an alcohol flame. Rouge or crocus powder used oc- casionally on instruments as a polish helps to remove and to prevent rust accumulations. Oxidation of the surface of silver instruments is easily treated by an application of putz- pomade, which is also useful for rust and similar stains. Fine emery is often needed for old rust spots, but it must be used very cautiously on nickel-plated instruments, as, in- deed, must all the coarse household polishing powders. Fin- ger marks and grease are removed by polishing or by the application of benzin or ether. Iodin, nitrate of silver, or mercurial solutions dropping on an instrument should be wiped away at once.* Instruments should not be laid away in contact with soft rubber, or with bottles containing any corroding substance. Saws, especially wire- and chain-saws, should be anointed with vaselin or " anti-rust " before they are returned to the instrument cabinet, which latter should be dry and reasonably dust-proof. The efficiency of a hand syringe ought to be tested after, as well as before, an operation : The finger is pressed firmly against the point of the syringe, and the piston rod is drawn out and held for a moment to allow the entrance of air through possible leaks. On releasing it the piston should re- turn to the bottom of the instrument. (The pistons of syringes made entirely of glass should not be released sud- denly, lest their impact fracture the bottom of the barrel.) Then air is drawn into the syringe, the tip is again closed * Stains of silver nitrate may be removed from the hands with a strong solution of potassium iodid; stains of iodin, with ammonia water; and stains of methylene blue or other anilin dyes, with strong hydrochloric acid. 110 The Surgical Assistant. with a finger, and pressure is made on the piston rod. If it yields, the syringe is defective. The tests may be repeated, using water instead of air. If on attempting to empty the syringe against the compressing finger, water escapes at the bottom, the parts of the frame should be screwed more tightly together. If this fails to prevent the leakage, the in- side washer is defective or out of position, and should be re- placed or re-arranged. If the fluid in a syringe escapes above the piston, when pressure is exerted against the occluding finger, the piston is too small. A syringe that cannot be boiled, once used in aspirating in- infected tissues, should not be employed for injections — at FIG. 27. Repairing aspirating syringe with leather packing. least not until all its parts have been thoroughly disinfected. Syringes but little used can be kept in good order by occa- sionally moistening the washers and packings to prevent Care of Instruments. Ill shrinkage. To cleanse or repair a glass and metal syringe with leather or rubber packings, the top should be unscrewed and the piston removed. The framework and barrel are cleaned with soap and water or with benzin and then boiled, after taking out the washers. In most syringes, the piston packing can be regulated in size by means of the nut attached to it. If it be of leather and is much shrunken it should be soaked in water, but only long enough to restore it to the proper size. It may be sterilized by immersion in 2 per cent, formaldehyd solution. The piston should be re-introduced sidewise at first, and with a rotary motion. Rubber pack- ings require lubrication with water or, if this is insufficient, with a little tincture of green soap or lysol. If the piston is of leather a little olive oil should be dropped in the cell between the two packings usually present, just as the second packing is about to be pushed into the barrel. If the small (outside) washer at the needle end of a syringe is lost or injured during an operation a substitute can be extem- porized by winding about the screw-thread a little absorb- ent cotton. The moisture in syringe needles after use should be blown out. This procedure may be supplemented by warming the needle several inches above a flame. The wire should then be dried and passed through the needle. If the lumen of the needle is found occluded by a plug that cannot be displaced with the wire or by the pressure of fluid from the syringe, the following device may be employed : Attached to a syringe filled with water, the needle is held in an alcohol flame, while pressure is exerted on the piston. When the needle be- comes very hot, steam and water will suddenly escape through it. This procedure should be used as a last resort, however, for it injures the needle. Fountain syringes are to be washed out and suspended, bottom up, until dry, after which their mouths may be plugged with absorbent cotton to exclude dust. Potassium permanganate adhering to glass or rubber irrigating reser- voirs is easily decolorized by oxalic acid solution. Catheters and bougies should be cleaned as described 112 The Surgical Assistant. on page 104. They are then sealed in a tube of formalin- glycerin, or are dried and either dusted with talcum pow- der and placed in a box, or hung in a catheter jar con- taining a formalin pastil. This last method probably does not in itself reliably asepticize catheters, and when employed for long periods it allows woven instruments to deteri- orate. Rubber bandages ( Martin's) should be dusted with talcum and rolled up, the tape end innermost. They should be wrapped in paper or gutta-percha, and enclosed in a tin box made air-tight by means of a strip of adhesive plaster, in the same way that a plaster of Paris bandage is preserved. Con- strictors are to be similarly treated. These precautions save the rubber from drying and cracking. Rubber gloves are dried with a towel and dusted with tal- cum or corn-starch, then turned inside out and dried on the other surface. The glove fingers may be easily reversed by closing the opening of the glove at the wrist with a few turns of the rubber and by pressing the air thus sealed in the body of the glove toward the fingers. Punctures and small tears are patched (all on the same side) with pieces from an old glove, by means of india-rubber cement thinned out, if neces- sary, with a little benzin. Larger rents in the fingers may be covered with a finger cot when the glove is worn. Rubber gloves, like rubber bandages, should be kept well protected from the air. Bandage knives cut best when they have a " saw edge." This is secured by sharpening them on a rough stone, such as a window sill. The mechanisms of electric appliances ought to be studied and tested in advance of an operation. The poles of a gal- vanic battery should be lifted from the cells while the battery is out of use. It need hardly be emphasized that care must be exercised not to spill the fluid. With dry cell batteries the only caution necessary is to see that the circuit is open before the box is put away. Wet electrodes should be wrapped in rubber tissue if left in the box. Paquelin- and galvano-cauteries should also be tested before an operation is Care of Instruments. 113 begun. The tip of a Paquelin instrument (appendix, figure 6) should be removed while it is still hot, and before the cur- rent of benzin vapor has been turned off, for incomplete com- bustion of the vapor appears to favor clogging of the sponge platinum. CHAPTER VIII. HANDING INSTRUMENTS. No duty that an assistant can assume is as apt to tax his forethought, skill and patience as that of " handing instru- ments." He must, at the same time, deliver what is needed at the moment, cleanse and replace appliances that have been used, and be ready with what may be required next. If he is not to help at the wound, in addition, he should stand as near to it as possible, that he may watch every step in the operation. He must observe closely and act promptly. If the surgeon n'orks rapidly the instrument hander must think more rapidly. His duty is to anticipate the operator's needs and to adapt his armamentarium to conditions as they are developed. That assistant is useful who can, at each step, place the appropriate appliance in the hands of the operator, just one instant before the latter realizes that he needs it. Often deeply engrossed in the study of the condition present, the surgeon will be grateful for the suggestion, when there is handed to him at the right moment the right thing with which to meet that condition. The instrument hander should therefore think out in ad- vance the various steps of the operation and the complications that may arise at each, and he should prepare his materials accordingly. They ought to be arranged conveniently and systematically on his table. Powder sifters (appendix, fig. 7), cautery handles, and other unsterilized articles should be wrapped in pieces of gauze (which may be held in place with a bit of catgut or a safety-pin), or handled with towels, and jars and basins that are placed near the instruments should be surrounded with towels to prevent infection of tools or fingers by accidental 114 Arrangement of Instruments. 115 contact. The instruments themselves should be laid out, as nearly as possible, in the order in which they will be needed, e. g., for a laparotomy, — scalpels, hemostatic forceps, mouse-tooth forceps, scissors (straight and curved), retrac- tors (sharp and blunt), etc.; for an osteotomy, — scalpels, hemostats (if no tourniquet is used), retractors, periosteal elevators, raspatories, chisels and mallet, sharp spoons, etc. ; for a curettage of the uterus, — speculum, volsellum, uterine sound, dilators, curettes, intra-uterine irrigating tip, dress- FlG. 17. Instrument table, a, sterilized towels; b, b, gauze jars; c, sterile adhesive strips ; d, sterile absorbent cotton ; e, dish of alcohol for prepared sutures and ligatures; f, dish of sublimate solution, one-fifth per cent., for ligatures in bottles and gutta-percha ; g, basin with sponge for cleansing in- struments; h, packings; i, sterilized safety-pins; j\ needles; k, aspirating syringe ; /, the other instruments arranged in the order in which they will be needed ; m, pads ; », drainage tubes. ing forceps. It will be convenient for the instrument hander to lay aside for his own use in preparing sutures, packings and the like, a pair of straight scissors, a pair of curved scissors, a pair of thumb forceps and, if the sterilizer is kept at hand, a pair of dressing forceps to lift instruments out of it. Syringes are to be tested, as previously described, and the adjustment of complicated implements carefully in- spected. The needles are spread out (dry, or in a dish of alcohol), 116 The Surgical Assistant. according to their shapes and sizes, so that at any moment an appropriate needle may be quickly selected. Operators have individual fancies in the use of needles but, in a general way, it may be stated that the ordinary curved surgical needle is most generally useful, that needles curved in a half circle are well adapted for deep suturing in narrow spaces and for passing a mass ligature, and that small straight needles are of great service in intestinal work. The Hagedorn needle, which is flat and sharp ( fashioned at the point somewhat like a half-spear-head) and has a large eye, is given the prefer- ence by many surgeons. It is used with a Hagedorn needle- holder, or passed with the fingers alone. The instrument hander should select a needle strong enough for the tissues which it is to traverse, but otherwise no larger than is neces- sary to carry the suture. See appendix, figure 27. If suture materials are brought to the operation in bottles or sealed tubes, these may be sterilized in sublimate solution, or opened in a towel (the tubes are to be broken) and the contents dropped into a dish of alcohol. Spools that are mounted in wide-mouthed jars are, of course, not to be re- moved. With these the free end of the silk or gut should be drawn up with forceps, and as much as is needed for a suture or a ligature cut off about an inch from the reel, care being taken to keep the material, the instruments and the fingers from contact with the edge of the jar. A supply of ligatures eight to nine inches in length should be prepared in advance. They are coiled up, ring-like, by wrapping them about two fingers of the left hand(not about the nails), and then laid back in the alcohol. If the free end of the ligature thus coiled is twisted once around a segment of the ring, it will prevent the ligature from straightening out again in the dish. Catgut of the size numbered 2 in figure 28* is most generally useful for ligatures, but number 1 may be used in delicate plastic work, as on the face, while heavier material (number 4 to * The scales of numbers employed by different manufacturers are not identical. The ligature numbers referred to through the text are intended to indicate sizes that correspond to those numbers in figure 28. Ligatures. 117 number 6) is needed for large pedicles (as of the renal ves- sels) and similar " mass ligatures." Fig. 28. Surgical catgut— scale of sizes. Two, at least, of each kind of suture that will be needed should be threaded in advance, rolled up with the needle, and placed in the ligature dish. Sutures of the size correspond- 118 The Surgical Assistant. ing to number i in the scale here given will be most often needed. For ophthalmic operations and other delicate work, sutures numbered o and oo will be useful, while the indica- tions for heavier material are obvious. Twisted silk is most convenient in the smaller sizes, braided silk in the larger ones. In general, sutures should be about twelve inches long, depending upon the length of the wound to be united and the manner in which the stitches are to be placed. It is a less serious fault to cut a suture rather too short than to hand one too long, for long threads are apt to drag over the skin, and are awkward to manipulate. In threading, the suture should be held close to its end be- tween the right thumb and forefinger, the needle, correspond- ingly held in the left hand, being passed over it. If the Fig. 29. Squeezing end of catgut for insertion in eye of needle. needle-eye rebels against the passage through it of a piece of catgut or kangaroo tendon, the difficulty can usually be overcome by cutting the end of the suture obliquely and flattening it by pressure between the handles of the scis- sors. Silk, however, should be cut squarely across, lest its strands unravel on attempting to pass it through the eye. Small sutures are apt to slip out of the needle unless fastened to it with a single knot. Silkworm-gut is secured by twist- ing it several times, or more correctly, by twisting the needle on its long axis while holding the loop of silkworm-gut steady. Silver wire is prevented from slipping out of the Sutures. 119 needle by flattening the short and long end together and, if necessary, by twisting them slightly on each other. " Button sutures," used after breast amputations or laparo- tomies, when there is great tension to be overcome, are to be prepared by mounting on stout silk, or on one or two strands of silkworm-gut, a piece of block tin about a half inch square, and a large lead shot, both perforated. The corners of the tin are trimmed to protect the skin, for which account the sharp edges of the button should also be turned up Fig. 30. Twisting silkworm-gut suture. (towards the shot). After the button the shot is slipped on the suture, and clamped about a quarter of an inch from the end by compression with a needle-holder or other heavy in- strument. Instead of the tin and shot, an ordinary bone or china button may be used, two strands of silk or silkworm-gut being passed through its holes and tied together on its con- cave surface. Buttons of all kinds are apt to cause pressure 120 The Surgical Assistant. necrosis of the skin ; for them may be substituted small rolls of gauze or pieces of rubber tubing, over which the suture ends are tied (quilled sutures). When handing a suture to the operator the needle should be grasped near its eye in the holder, the point of the needle should be to the operator's left and its concavity towards him. When a reversed suture is to be passed the position of the needle in the holder is to be reversed, as it is to be, also, for 9 Fig. 31. Button suture." left-handed operators. If the needle-holder has a tapering end, only flat needles should be grasped near its extremity, for curved ones are apt to be broken by the narrow tip. With the suture should be handed a mouse-tooth forceps, and a pair of curved scissors. With " button sutures " should also be handed a hemostat, to secure the free end of the suture after it has passed through the tissues, until the operator is Drains and Packings. 121 ready to fix it permanently with a second button and shot. These the assistant should hold to him in the palm of his hand, and should pass after them an instrument for com- pressing the shot. Especial care should be exercised that suture ends touch nothing" but the assistant's hand in transit from instrument table to operator. Some at least of the gauze drains and packings that will be needed should be prepared in advance. It is well, too, to pre- pare the dressing and lay it aside, covered with a towel. For mastoid operations slender strips of gauze will sometimes be Fig. 32. Handing gauze packing. more useful than sponges for cleaning narrow recesses. For laparotomies, several packings of various widths and appro- priate thicknesses should be cut and kept in readiness on the instrument table. If the intestines are apt to be much ex- posed, hot towels and pads should also be at hand. These are 122 The Surgical Assistant. made ready when needed, by folding them in the center of a towel, which is to be dipped into a basin of water kept hot over a small flame. The towel is then wrung by its dry ends, and the pad is lifted out. Laparotomy pads should be handed with that corner up- permost to which is usually sewed a strand of stout silk for the attachment of an artery clamp to be left hanging outside the belly. With pads or abdominal packings should be handed, for their introduction, a pair of blunt scissors curved on the flat, or a similarly shaped instrument. (Figure 32.) Split compresses are made by dividing folded pieces of gauze half way through their middle. They are useful for surrounding an appendix to prevent soiling of the other tissues when it is amputated, for dressing about the project- ing end of a drainage tube, etc. FIG. 33. Handing "cigarette" drain. The Mikulicz bag consists in a few layers of gauze which are laid flat into a wound (e. g., after nephrotomy) and tucked into all its recesses. The edges of the " bag " project beyond the skin. Packings are laid in the wound thus lined with gauze, and renewed at intervals, the bag itself being left Drains and Packings. 123 in place for several days (usually until it is loosened by wound secretions). Gauze drains should be trimmed evenly, and freed of ravelled strands. The cigarette (or Morris) drain consists in a wick or roll of gauze of appropriate size, wrapped in gutta-percha tissue. The free edge of the rubber may be fastened down by slightly moistening it with chloroform. The gauze must project beyond the rubber at each end. This drain combines the advantages of gauze capillarity with the ease of removal of rubber tubing. It is introduced with dressing forceps or with the fingers. Drainage tubes should be cut obliquely at the deep end, and the edge of this cut bevelled with curved scissors. Fenes- tras may be cut along the tube, of size and number determined by the nature and quantity of the discharge to be drained. Fig. 34. Preparation of drainage tube. Two medium-sized tubes drain better than one large one, more especially since they afford the means of recurrent irri- gation. A safety-pin is usually fastened through the project- FIG. 35. Fenestrated drainage tube. ing end of the tube. For introduction through a narrow or an irregular tract, the tube may be stretched tightly over a large probe, the tip of which impinges against the inside of 124 The Surgical Assistant. the rubber near the end. Traction threads, for pulling tub- ing through a sinus, or attaching tampons, are best fastened by a clove hitch (the manner of making which is shown in figure 37), which is secure but easily removable. The preparation of the tampon camda and of the " camde Fig. 36. Handing drainage tube on probe. en chemise " will be more appropriately described in discuss- ing assistance at rectal operations. In the manner of passing an instrument, there is an art. Every appliance or dressing should be placed in the grasp of the operator in the direction and position in which he is to apply it in the wound. This relieves him of the necessity of Handing Instruments. 125 lifting his eyes from the operating field to the appliance, and of turning the latter about in his hand. FIG. 37. The clove hitch, a, formation; b, application. Beginning with the scalpel, the blade should point approxi- FlG. Incorrect manner of handing chisel and mallet to operator. mately in the direction of the wound to be made, when it leaves the assistant's hand. Several artery forceps should. 126 The Surgical Assistant. be laid near-by while the incision is in progress, and the han- dles should point towards the operator — or, better, some should point towards the operator, and some towards his assistant at the wound. (If the scalpel used for the skin in- cision is now replaced by a second one, the chances of con- veying infection into the wound from the skin are thereby diminished.) The sharp retractors that may next be needed should be held by the instrument hander by their shanks, and the handles should be pointing away from the wound and at FlG. 39. Correct manner of handing chisel and mallet, suited to the posi- tion of the operator and the direction of the wound. right angles to its axis. So, too, with the mouse-tooth for- ceps next required. One should be held within easy grasp of the operator, the other in the position in which his assistant will apply it. So, too, with sutures, the instrument passer should place the needle holder with his left hand into the right hand of the operator and the forceps with his right hand into the surgeon's left. And so 3 too, with all the instru- Handing Instruments. m merits and all the dressings, even down to so small an article as a safety-pin. During the course of an operation, only those few instru- ments in immediate use should be left on the patient's body, or on the " invalid table " over his body, and these should be cleaned whenever blood accumulates upon them. Others that have been used should be cleansed and replaced on the instrument table or, if they have been soiled by infectious Fig. 40. Handing suture and forceps. material, laid apart from the instruments that are still sterile. The assistant should see to it that instruments lying on the patient's body are not brought in contact with the elbows of the operator, that the sharp points of tools are tarned down- wards, and that the towel on which the instruments are al- lowed to lie is replaced when it is blood-soaked or otherwise soiled. 128 The Surgical Assistant The assistant who hands sponges should observe the same system. She must watch the operation closely to adapt the sizes of the sponges to the needs developed. If gauze " wipes " are used, several may be placed near the wound, — by means of a pair of forceps to avoid undue handling. If sea-sponges are being employed she ought to have a clean one always in her hand, ready when needed. This sponge she passes from her fingers to the wound-assistant's palm, taking the soiled sponge from his fingers into her palm. The soiled sea-sponge must be passed through two basins of cleansing solution, then squeezed thoroughly. ,When the sponging is active it is well to have one or two sponges lying near the field of operation, for nothing is more annoying than to have to wait for a fresh sponge — except, perhaps, to be obliged to wipe a wound with a sponge already soaked with blood. Cotton sponges, little used except in minor surgery and for ophthalmic work and wound-dressings, may be neatly made from squares of absorbent cotton. The edges of these / f ) X Fig. 41. Cotton sponges. may be twisted together, thus making a loose ball. A better method, but one requiring a little more dexterity, is the fol- lowing : The left hand is made into a loose fist, and the square of cotton is laid on the thumb and fore-finger. In the centre Handing Instruments. 129 of the square is placed a smaller bit of cotton to make the sponge more solid. With the index finger of the other hand, the edges of the cotton are turned in ; then this finger is held in the centre of the sponge, which is rotated about it with the left hand to make the ball compact. Sponge holders and applicators, like other instruments, should be passed in the proper direction. Thus, for spong- ing in the depth of the abdomen the sponge-holder is handed vertical, the sponge downward ; for sponging in the vagina, the holder is handed horizontal, the sponge forward. It is important that sponges should be fastened compactly and firmly in their holders, and that cotton should be firm on ap- plicators. Applicators with square ends are better than those with corrugated or spiral ones, for they hold the cotton securely yet allow of its easy deliberate removal. The wind- ing of cotton about an applicator should begin furthest from the tip, and here the cotton, small in amount, must be pressed firmly between thumb and finger. As the tip is brought down through the fingers the pressure is lessened, making the cotton here less firm but thicker and more ab- sorbent. Nitrate of silver may be attached to a probe or applicator in full strength, for use in the middle ear, etc., by heating the tip of the instrument in a flame and pressing it into the solid caustic. This melts a little of the salt, which on cooling forms a bead on the probe. For use in more accessible situa- tions the nitrate of silver cone may be conveniently mounted in a discarded thermometer case by means of a little paraffin or of a strip of adhesive plaster. CHAPTER IX. ASSISTANCE AT THE WOUND. In the immediate assistance in an operation, close attention and manual gracefulness are far more to be cultivated than the display of mere brilliancy of technic. Only by strict attention can the assistant supply the needs of the moment and foresee the requirements that will next develop. He should be always ready to do his share, undirected ; he should not try to do more than his share. At each step of an opera- tion he should be close at hand, yet never in the way — " al- ways there," but never " too much there." How many of the manipulative details he may undertake himself must de- pend upon his own technical experience and upon his famil- iarity with the surgeon's methods. An ill-considered act may spoil an hour's work ; on the other hand, a quick move- ment — likewise unsolicited — may save a patient's life. What- ever the assistant does, he should do quietly, without disturb- ing the operator and, if possible, without waiting for him to give orders. If all the assistants are thus quick, and suf- ficiently familiar with the technics of the procedure at hand, and with those of the individual surgeon, a long and compli- cated operation can be, and should be, conducted from beginning to end without a word being spoken. The surgical assistant must work unobtrusively, and a primary principle of his art is, that his every move must be directed by a consideration of the convenience of the surgeon. He will hardly allow himself to interfere with the operator's line of vision or to obstruct his light if he bear in mind that the dispatch with which an operation can be carried out de- pends much upon the manner in which the assistant disposes his body, as well as that in which he employs his hands. Dexterity in the proper use of the hands implies also the use of the proper hand. Nothing can contribute more to 130 The Incision. 131 the graceful conduct of an operation and to the serenity of the operator, than careful regard to this apparently small Fig. 42. Incorrect manner of holding retractors; assistant's left forearm interferes with operator's movements. matter. In manipulations through the vagina especially, where the field is relatively small and the number of instru- ments in use is apt to be large, awkwardness in the position of the assistant's arm or in the assignment of his work to one or the other hand, is often the cause of annoyance and of de- lay. Fig. 43. Proper disposition of hands and arms in manipulating retractors. The Incision may be facilitated by aiding the operator in stretching the skin. This is done with the left hands and in 132 The Surgical Assistant. a direction at right angles to the proposed line of incision, the assistant's right hand holding a sponge in readiness to dry the wound. A long incision through a loose fold of skin, as of the scrotum, may be accomplished by a short downward sweep of the knife, if the tissue is pinched up on each side with the thumb and forefinger. Sponging is perhaps more than any other one thing dur- ing an operation, what most requires the employment of a Fig. 44. Stretching the skin to facilitate primary incision. diligent assistant. The wound must be kept dry at all times. To accomplish the best result with the least interference to the operator the sponge should be used frequently, in the short intervals between the operator's manipulations, with a quick, wiping movement, and quickly withdrawn from the line of vision. To remove fluids from the abdominal or other cavity, a rotary motion should be imparted to the sponge — Sponging; Retracting. 133 especially useful if the fluid is thick and viscid. To prevent soiling of the abdominal contents with pus or feces escaping from a small opening, bits of sea-sponge should be used, either prepared on artery forceps or lifted from a dish, one by one, with thumb forceps. The manner of passing and cleansing sea-sponges has been described. Sponges soaked with pus or other infectious material should be discarded at once, not cleansed. Obscuration of a wound by the oozing of blood from one angle may often be quickly obviated by pressing a sponge or a bit of gauze into that angle. A few rules are worth remembering : Hold the sponging hand near the wound ; not over the wound. Keep the wound dry ; sponge quickly and often. Use dry sponges ; have fresh sponges within reach. Wipe; don't dip. Don't sponge against the operator's knife or needle-point. Sponge from the wound towards the skin: never from the skin into the wound. Never use in a clean wound a sponge that has been on the skin or in contact with infectious material ; discard it at once. Retracting. Next to assiduous sponging, the intelligent use of retractors is most helpful in the facilitation of an oper- ation. Their purposes are two-fold — to expose and to pro- tect. They should be so placed as to best display the tissues under immediate manipulation — usually in a direction at right angles to the wound, or in the angles of the wound. They should be inserted carefully and deliberately, never blindly or hastily, lest they cause laceration or mangling, or push from view structures that ought to be exposed. In re- tracting an abdominal wound, especially, great care should be exercised to avoid including the intestine in the grip of the instrument. Traction force should be exerted gently and steadily — enough to satisfactorily open the wound, but not enough to bruise the tissues. When using sharp retractors all the prongs should be sufficiently buried to prevent slipping and to avoid injury to the surgeon's fingers ; but if the super- ficial tissues are being retracted, the assistant should see that 134 The Surgical Assistant. the prongs are not forced through the skin from beneath. As the dissection or other manipulation proceeds deeper and deeper or from one place to another, so the retractors should be shifted — a process that again should be conducted with due regard to the operator's fingers. Whenever expedient, it is best to insert a second retractor in the new site before removing the first retractor from the abandoned position. When a retractor is no longer serving a useful purpose it should be removed; but if the assistant is in doubt as to its continued utility he had better leave it in position until directed otherwise. In any case, a sharp instrument should not be withdrawn from beneath the operator's hand or fore- arm. Fig. 45. Use of retractors to expose to view a large visceral surface through a relatively small opening. The assistant should early learn the value of lifting up with the retractors. During laparotomies, especially, this Dissection. 135 simple procedure is of invaluable aid, in separating and dis- playing the various layers of the abdominal wall and their bloodvessels and nerves, in drawing the parietal peritoneum from the viscera beneath, and in exposing the abdominal con- tents to visual exploration through a relatively small opening. All other things being equal, blunt retractors should be given the preference for use in the neighborhood of large blood- vessels and of intestinal or other delicate structures. Well- curved blunt hooks and blunt retractors should be chosen for distracting a nerve or bloodvessel or a tense muscle (e. g., the rectus abdominis). Obviously, a retractor should be Selected with reference to the size and depth of the wound, for its purpose is to create space, not to obstruct it. Blunt curved scissors are useful for temporary retraction. The assistant's fingers may be similarly called into requisi- tion, but they should be thus employed only when no instru- ment at hand will equally serve the purpose. An assistant whose sole duty may be to hold a retractor for even an hour or more, should not allow himself to become listless and to loll 'over the table or to bear his weight upon the instrument, for aside from the fact that this is inelegant and indecorous, prolonged pressure upon the patient's skin by the shank of a retractor is apt to cause troublesome necrosis. Dissection. The character of the assistance required in this procedure is indicated by the manipulations of the opera- tor. Dissection conducted layer by layer between two mouse- tooth forceps requires of the assistant to seize the same tis- sue as does the operator, near to, and directly opposite, the point where he attaches his forceps. The structure grasped is then drawn up, allowing the passage of scalpel or scissors between the two instruments. Only the tissue to be divided should be seized — obviously a very important consideration in incising the parietal peritoneum. The assistant should not, as a general rule, relinquish his grasp until the operator has removed his forceps to another position, when the as- sistant follows him thereto. For seizing a bloodvessel, to dissect it from its bed, anatomical forceps should replace 136 The Surgical Assistant. toothed instruments. Either hand may be used for the for- ceps, the other one holding a retractor or a sponge. Fig. 46. Dissection between mouse-tooth forceps. Hemostasis. We have said that the most useful service an assistant at the wound can perform is assiduous and in- telligent sponging. When divided vessels are to be clamped it is especially important that he sponge the bleeding surface in order that the exact location of the hemorrhage may be seen. A stream of blood from a single large vessel should be stopped at once by the assistant's ringer, until the surgeon has properly exposed the vessel for clamping. If there is simultaneous bleeding from several points, as there usually is after a long incision, the assistant may take part in the application of hemostats. This he should do de- liberately, however quickly, taking care to secure in the grasp of the instrument as little as possible of the tissue surround- ing the mouth of the bleeding vessel. ( When there has been exposed a vessel that must be " ligated in continuity, " while Hemostasis. 137 the surgeon clamps it at one end the assistant clamps it at the other ; and here, too, he must be careful to catch in the forceps no nerve or other structure that it is desirable to pre- serve. When securing a vein in continuity it is well to grasp it proximally first, lest otherwise it collapse and become lost to view. An inadvertent nick in the side of a large vein is to be closed with a small " bite " of the hemostat, thus allow- ing the application of a " side ligature." When the number of hemostats applied to the wound is large enough to obstruct manipulations, or when the supply of these instruments is nearly, but not entirely exhausted, some or all of them may be removed. Small vessels, e. g., many of those in the skin, are usually definitively closed by the mere pressure of the forceps for several minutes, and slightly larger vessels may be closed by twisting the forceps a few turns before removing them; but vessels of any con- siderable size are to be tied before the hemostats are with- drawn. Several ligatures may be applied in a short space, of time if the assistant affords intelligent aid. He should lift up each hemostat in turn in order that the ligature may be passed behind it, so holding the forceps that the tissues to which it is applied are not twisted or distorted. After the ligature is passed behind it the handle of the forceps is dropped or depressed, in order to lift up the point of the in- strument beyond the ligating loop. If, however, the forceps' beak is too deeply buried in the tissues to accomplish this, the assistant should draw gently upward on the hemostat while a single knot is formed loosely about it. The loop of catgut can then usually be helped to slide over the beak if the hemostat is rotated slightly from side to side. Sometimes, however, the surgeon or the assistant will be obliged to push the loop down with a finger or with an instrument. If it has not been thus necessary to hold the forceps up while the first knot is tied, the assistant should seize it again immediately thereafter, in order to remove it when the knot is complete. Occasionally it is useful, when working in a small space, to remove the clamp after the first knot is secured. While the assistant's left hand is thus occupied with the manipulation 138 The Surgical Assistant. of the hemostat, his right should hold in readiness a pair of scissors to cut the ligature ends. Blunt-end scissors, curved on the flat, are best adapted to this purpose. They should be held, with the concavity of the curve uppermost, by the ter- minal phalanx of the thumb and the middle phalanx of the fourth (or third) finger. Downward pressure with the thumb and upward pressure with the fourth finger secure close contact of the edges when cutting, while counter-pres- sure of the index finger over the lock steadies the instrument. Fig. 47. ligature. Manipulation of hemostat and scissors in the application of a The fifth finger may be rested on the patient's body to bal- ance the hand. The scissors are held slightly open while the ligature is being tied, and when the surgeon lifts its free ends, the blades are made to surround them. With a quick movement at the wrist the blades are to be carried down along the strands and closed about a quarter of an inch from the knot. These manipulations, longer in the description than in the performance, secure speed as well as precision. The assistant is often called upon to apply ligatures him- self. The " square, " " flat, " or " reef " knot is formed by passing one end of the ligature, e. g., that in the right hand, in front of and around the other end into the left hand, and tightening the first knot ; then passing the same ligature end back from the left hand in front of and around the other end, as before, into the right hand, and tightening the second knot. Hemostasis. 139 If the second loop is made by passing the ligature end in a manner different from that in which it was passed in the first loop (i. e., behind, instead of in front, of the other strand), there is formed a " granny knot. " Such a knot is ass aS*^** 8 ** **»» Fig. 48. Surgeon's Knot. Flat Knot. Granny Knot. more likely to slip than a square knot, but while its inadvert- ent application is a surgical inelegance it need ordinarily cause the assistant no worry, when only a small vessel is concerned, provided that it has been drawn tightly. The " surgeon's knot " differs from the square knot, in that the first loop is made by carrying one end of the ligature twice around the other end. This loop, when tightened, is less apt to slip during the formation of the second one than is the first loop of the square knot, which latter is quite sufficient, however, for most of the bloodvessels to be tied. A third loop may be added when in doubt as to the security of the second one. 140 The Surgical Assistant. " Mass ligatures " are applied in the same manner, but it must be remembered that it is unsafe to tie many vessels in one mass. If the surgeon employs a " Staffordshire knot " to secure a pedicle, (usually an ovarian pedicle), the assistant should grasp the loop of silk after it has been thrust through, and draw it over the ovary or other mass and over one of the two free ends of the ligature, which are then tied together after drawing them tightly to constrict the pedicle with the loop. Rubber ligatures, as applied to the renal vessels in nephrectomy, are secured by tying a strand of stout silk firmly about a single knot of the rubber, tightly drawn. Pedicle ligatures should not be cut shorter than half an inch from the knot. Whatever the size of the mass to be secured, it is worse than foolish to tighten any ligature by seizing its ends in the whole hands and pulling these far apart, for such a procedure will cut through almost any ligature (to say little of the assistant's hands themselves). It is far better to seize the ligature ends between the thumb and forefinger of each hand, and bringing the tips of these close to the knot and to each other, thumb nail to thumb nail or finger nail to finger nail, to exert a steady traction or a series of tractions. Assistance in applying the " chain ligature, " as used, for example, upon the omentum, is rendered in the following way: The tissue is lifted up and spread out evenly in an assistant's hands. When the operator thrusts through the omentum at a point near its edge (determined by the number and position of the bloodvessels) a pair of dressing-, or ana- tomical-, forceps, the assistant inserts in its beak the ends of two stout (catgut) ligatures, which are drawn through, and the corresponding ends of one of these (easily determined by a seesaw motion on the strands) are tied tightly around the free edge of the omentum. Then when the operator again transfixes the tissue the assistant places in the forceps a third ligature and " his end " of the second one. After the second strand is tied and the omentum again pierced, the sur- geon receives from the assistant a fourth ligature and the other end of the third one, and so on. When the ligatures are all tied they are to be lifted up in a row, to indicate the Suturing. 141 line of amputation, after the performance of which their free ends are to be cut. Fig. 49. Application of '•' chain ligature " to omentum. Suturing. The assistance to be rendered during sutur- ing consists in exposing the edges to be united and in secur- ing their accurate coaptation. When it is convenient to do so, it is helpful to lift up the two edges, and, if they be of the skin or muscular aponeuroses, to put them more or less upon the stretch. This is not always possible with deep-seated structures, e. g., the peritoneum, and when it is not the assist- ant must content himself with lifting with his forceps the exact bit of tissue through which the needle is to pass, or exposing it so that the operator can lift it up. When, how- ever, the edges can be stretched this may be done by inserting a small hook in each angle of the wound, or by pinching up both edges at the angles with mouse-tooth forceps. After the first knot of an interrupted or continuous suture has been secured at one end of the wound the end of the suture be- yond the knot may be drawn up as a guy-thread, and the hook or forceps abandoned. When interrupted sutures are being inserted in tissues under tension the margins to be 142 The Surgical Assistant. united should be held together with forceps by the assistant as each knot is being tied. After tying, the suture may be cut FIG. 50. Coaptation of edges by traction with tenacula. short, or one or both ends " cut long," and drawn up with the Fig. 51. Coaptation of edges by traction with two forceps. first one in an assistant's hand until all the sutures of that row are in place. The adaptation of edges during the intro- Suturing. 143 • duction of a continuous suture is maintained by the assistant by holding taut the proximal (loose) end of the thread near its emergence from the tissues, — releasing it, to secure a new hold, as the next suture is drawn down upon the line of union (Fig. 52). The final knot of a continuous suture is made by leaving the last loop only partly drawn through and tying to it the emergent end of the suture, still attached to the needle ; or, by drawing the final loop tightly but double, the free end on one side being then tied to the double (needle) Fig. 52. Assistant's manipulations during introduction of continuous suture. end on the other. When the suture has been secured the ends should be cut short and the needle replaced upon the instru- ment table or left elsewhere within plain view. Skin edges may frequently be sufficiently adapted during suturing, with a single pair of forceps (Fig. 53), and looser folds of skin may be pinched together by the assistant's fingers, at each end of the wound, a continuous suture holding well enough in place when there is no tension. To prevent inversion and overlapping, skin edges should be carefully coaptated by the assistant. This is to be done by means of mouse-tooth forceps, everting the edges of the wound as they are brought together (Fig. 54). It should be remembered by the assistant, when he applies sutures him- self, that the further from the edges they are inserted the more the latter are inverted ; and that by shifting the inser- 144 The Surgical Assistant. tion to the skin edge itself, or far from the edge, he can over- come a tendency to inversion or eversion, respectively. Sutures that he applies in fascia should not be close together nor very tightly drawn, lest they cause necrosis. FIG. 53. Lifting skin edges with one forceps for introduction of suture. The special assistance needed in the application of button, shot and quilled sutures has already been described (page 119). Removing Sutures. The suture is lifted up with forceps on one side at, or near, the knot, in a manner to drag out of the skin on that side a short segment of the loop that was buried in it. With scissors this freshly exposed segment is divided close to the skin itself. By this manipulation, when the suture is lifted out, its track is not infected by pulling through it any of the unburied portion of the loop. Irrigating. Even though the tubing of the fountain syringe or irrigating jar is sterilized before the operation, it Irrigating. 145 is difficult to keep it so for any length of time and, therefore, Fig. 54. Eversion of wound edges during suturing. Fig. 55. Tying button sutures. if the assistant himself will be called upon to irrigate, he 146 The Surgical Assistant. should have ready a separate irrigating tip and short seg- ment of rubber tubing. This he attaches to the longer tubing whenever he needs it, and removes it immediately after. The fluid to be prepared will depend upon the needs of the case. Thus, it may be water, saline solution, strong or weak sublimate solution, etc. The manner of irrigating also must be varied. If its purpose is simply to keep the operating field clear, as in plastic operations upon the perineum, the tip is held just above, but close to the wound, and a short stream, under slight pressure, is intermittently discharged. When a cavity is to be washed out, however, the irrigation should be continuous and more or less forcible, but so directed that it produces no splashing. The force of the stream is regulated by the height of the reservoir, and may be further varied by pressing upon the rubber tube with the fingers or with a pinch-cock. To irrigate the abdominal cavity, the saline solution should be poured from a pitcher. CHAPTER X IMMEDIATE POST-OPERATIVE CARE OF THE PATIENT. As soon as an operation is concluded and the dressing is applied, the patient's shirt should be drawn down and a blan- ket wrapped about him. If, in spite of the precautions noted on page 69, the shirt has been much wet during the opera- tion, it should be replaced by a fresh one on the table, to avoid chilling of the patient and soiling of the bedclothes. To put a nightshirt on an unconscious subject is facilitated by employing a little system. After the soiled shirt is drawn over the head and the skin is thoroughly dried, one of the patient's arms is pulled through a sleeve of the clean shirt, the body of the garment, rolled up, is drawn over his head, the other sleeve is adjusted, and then the shirt is pulled down over the trunk. If the patient is very heavy, it may be neces- sary to split the shirt through the back and put it on in the manner in which the surgeon dons his gown. When the patient's condition forbids the delay and exposure incident to a change of garments, he should simply be wrapped in a blanket, and thus carried to bed. The transportation from table to bed is conducted on a stretcher — for which an ironing-board may be made to serve — or in the manner, and with the precautions, described on page 68. Often the operating table can be rolled alongside the bed and the patient lifted off, or slid off by tipping the table. A nurse, if not a physician, should remain with the patient at least until he is well " out " of the narcosis. Sometimes the surgeon will deem it necessary for the assistant himself to watch the patient for several hours after an operation. It is therefore important to consider here some items that may require his attention, 147 148 The Surgical Assistant. The Room should be well ventilated, but not cooled below a temperature of 68° to 70 F. The light is to be subdued, but not so much excluded that the patient's features cannot easily be watched. Quiet is to be maintained and, as a rule, the family is to be excluded. The Bed must be prepared in advance. The upper sheet is removed so that, for the first few hours, the patient lies be- neath, or even between, blankets. The lower sheet is smoothly drawn, and across the middle of it is evenly laid a piece of rubber sheeting or oilcloth about a yard wide. Over this, and of the same width, is tightly pinned a " draw sheet," consisting of unbleached muslin or of an ordinary sheet doubled over. In order that the patient's head shall be low, the pillows are removed entirely, or a single flat pillow is allowed. Over it are spread towels, and a basin is laid near- by — these to provide for vomiting. The bed is to be made warm by the use of several bags or bottles of hot water ; but these should be removed before the patient arrives, or at least it should be determined that the bags are not hot enough to produce a burn, or that they are very well covered with towels or flannnel. The Patient must be laid in an unconstrained position, i. e., one that does not threaten pressure-paralysis of an extremity. If one of the limbs has been operated upon, it is placed on a pillow, to which it may be secured with pins or bandages. Pressure of the bedclothes upon it is avoided by placing over it a regular " cage," or one devised from barrel-hoops or a box, or by such other means as will suggest themselves. The patient's temperature should be noted soon after the operation, and at two- to four-hourly intervals thereafter. The pulse should be studied as frequently as the patient's condition may require. Pain and Restlessness usually come with returning con- sciousness, and frequently call for the hypodermatic injection of morphin, with or without atropin. Tightness of the Dressing is often an early complaint of the patient. If inspection prove it to be indeed constrictive, the pressure must, of course, be relieved — by nicking the Post-Operative Vomiting; Feeding. 149 bandage or by reapplying it. When plaster of Paris has been employed, the extremity is to be watched for evidences of compression. Swelling or cyanosis of the parts beyond the cast is an indication that it is too tight. Slight congestion of the digits is not necessarily an indication of undue interfer- ence with the circulation, however. If the anemic spot under the nail, produced by pinching with the fingers, is quickly restored to its original color when the fingers are withdrawn, the circulation in the part is not much interfered with. When the edge of a cast is found to be pressing into the flesh, it must be cut away or lifted up with a little cotton wool. Vomiting is the usual sequel of narcosis by ether or chlo- roform, but it is not constant in its duration or severity. Oc- curring before the patient is " out," the head is to be turned well to one side, and the jaw extended; and, afterwards, the buccal cavity is to be wiped out. Occurring after the re- flexes have returned, the patient need only be encouraged to " spit out " whatever vomitus remains in the throat. The vomiting tendency can sometimes be much relieved by hold- ing over the nose an inhaler or handkerchief wet with vin- egar. When the emesis is unduly persistent, tincture of iodin given in one-drop doses in a little water at half-hourly intervals may prove quite useful. Morphin, too, often re- lieves, but also often aggravates, vomiting. Feeding. After the administration of ether or chloroform, no nourishment should be given by mouth for a period of six hours (more or less, depending upon the condition of the patient and the nature of the operation), and then only if the vomiting has ceased and nausea has largely disappeared. Frequently a little water may be allowed after four hours ; and with children feeding can usually be resumed sooner than with adults. During the interval of abstinence, dryness of the mouth may be relieved by wetting the lips with water ; and pellets of ice may be administered from time to time after the first hour or two if the vomiting has stopped or much diminished. For dryness, also, chewing-gum is frequently allowable to stimu- late salivary secretion. Hot tea for adults, and milk and 150 The Surgical Assistant. lime-water for children, given by the teaspoonful, are, as a general rule, the best articles with which to inaugurate feed- ing. Singultus occasionally occurs during the first hours after an operation. In mild cases it usually responds to such measures as " holding the breath," or the application of a mustard paste to the epigastrium, or the administration of hot water or of carminatives (aromatic spirits of ammonia, compound spirits of ether, compound tincture of cardamom, etc.) When more severe it frequently yields to morphin, while in still more persistent cases belladonna (the tincture by mouth, or atropin hypodermatically) usually proves the most effectual single remedy. Rhythmic tongue traction is also of help. Faradaization of the phrenic nerve and other measures recommended for long-continued hiccough scarcely need consideration in the treatment of immediately post- operative singultus. Urination. The patient should be instructed to empty his bladder just before the operation. For a longer or shorter period after an operation, especially one involving the perineal region (the anus and urethra, in particular), the patient often finds himself unable to urinate. Ordinarily, a period of nine hours may be allowed to elapse. If during that time micturi- tion has not taken place, it can frequently be brought about by the injection of a half pint of warm water into the rectum, the application of a hot-water bag to the hypogastrium or [and] the administration of sweet spirits of nitre in tea- spoonful doses at half hourly intervals. In those instances where there is no objection to the patient sitting up in bed, the assumption of this posture may be found all that is neces- sary to accomplish evacuation of the bladder. The sound of running water acts as an active stimulant to urination ; and it must be remembered, too, that the presence of another person in the room is often a decided inhibitory factor, especially with nervous and sensitive patients. If these various methods fail to accomplish urination, catheterization must be performed (pages 244 and 255). After plastic operations upon the vagina or perineum, the Shock vs. Concealed Hemorrhage. 151 bladder is to be emptied with the catheter at regular intervals of six hours or, at least, to prevent infection of the wound, it is to be washed off with some antiseptic solution after each urination (and defecation). Shock and Hemorrhage. These two conditions have cer- tain symptoms in common, and while an external hemorrhage is readily discovered, the tragic error of mistaking for mere shock a concealed hemorrhage can easily be made by the un- wary. Progressiveness of the symptoms, while it may be present in shock, should in itself arouse strong suspicions of the existence of a continued hemorrhage. But the other means of differentiation are not few if the evidences are carefully studied. The better to contrast these evidences, they are presented in parallel columns : — Shock. Often regressive Absent Symptoms in general Local symptoms Concealed Hemorrhage. Always progressive! Mentality Restlessness Pallor Sweating Respiration Pulse Effect of intravenous infusion Effect of other stimu- lants Temperature Dull; stuporous Slight Moderate Frequently present Rapid Rapid and weak More or less lasting Variable; may be sub- normal Often present, e.g.., cough ; localized pain or ten- derness; abdominal dis- tention; vomiting; hema- temesis; hematuria; etc. Active Often great Very marked— especially of mucous membranes; pro- gressive Usually absent Marked and increasing " air-hunger " More and more rapid and weak Transitory [Specific gravity the blood of Increased* Often markedly mal Decreased] subnor- Treatment of Shock. The pillow is removed from beneath the patient's head, and the foot of the bed is elevated by means of bricks, boxes, etc., or upon a chair in the manner illustrated in figure 56. The patient is wrapped in blankets warmed in an oven, and surrounded with hot water bottles. Friction may be applied to the extremities. To raise the * Vale — Medical Record, August 27, 1904. 152 The Surgical Assistant. general blood-pressure, the limbs may be bandaged tightly, beginning at the digits; and this compression may also be applied . to the abdomen, taking care, however, not to em- barrass respiration. FIG. 56. Elevating the foot of a bed with a chair. Note flat pillow, towel, draw-sheet. The judicious employment of stimulants cannot be taught in a text-book but must be learned at the bedside. The in- experienced assistant is apt to use them too freely, which, however, is a less serious fault than using them too little. Strychnin (gr. 1-30 injected hypodermatically, and re- peated in an hour, if need be), may be all that is necessary. Other remedies may be required, however, and of these the most serviceable are whiskey (Tl\xxx hypodermatically, and repeated at intervals of fifteen minutes to three hours), digi- talis (Tl\x of the tincture, TTLiii of the fluid extract, or gr. 1-60 of digitalin*), adrenalin (Tl\x of T VP er cent, solution ad- renalin chlorid every two hours), cafrein (gr. ii of the sodio- salicylate or the sodio-benzoate), ether (TTLxxx) and camphor (gr. i dissolved in olive oil or oil of sweet almonds, or in ether). A "stimulating enema" (page 93) is a powerful restorative also, in those cases especially where the shock is * There are several preparations of digitalin, and the dose is not the same for all of them. Secondary Hemorrhage. 153 in large part clue to loss of blood at the operation. In cases of severe shock not yielding to the above agencies, an intra- venous infusion (page 301) may prove a life-saving measure. Treatment of Hemorrhage. Here stimulants serve to augment the bleeding, and their use should therefore be reserved until after it is checked. This is stated only as a general rule, however, for in the presence of severe hem- orrhage stimulation may be quite necessary to maintain heart action during the time that must elapse before the bleeding vessel can be secured. Intravenous saline infusion (page 301), strychnin, digitalis and adrenalin are the most useful stimulating remedies. A small dose of morphin may be in- dicated primarily as a sedative and incidentally as a stimu- lant. Ergot (ergotole or aseptic ergot, hypodermatically) is only an adjuvant in the treatment of hemorrhage, and is of no avail when the bleeding is from a large vessel. External hemorrhage is often controllable by means of compression, as by a tight bandage, adhesive straps or sand- bags. To check bleeding from a wound in one of the extrem- ities, the assistant should apply a tourniquet (page 289) ; while in other instances manual compression of large blood- vessels, e. g. the abdominal aorta, may serve to hold the hemorrhage in check until the surgeon himself arrives. When such means as above described are not available, and the surgeon in charge is not within immediate call, the assis- tant himself must promptly attack the bleeding vessel or sur- face, wheresoever it may be ; Bleeding from Wounds in General. Retract widely and sponge free of blood-clots. Tie individual bleeding vessels, if accessible. Treat general oozing by tight packing with gauze (dry, iodoformized, is considerably more hemostatic than plain gauze), and a compressive bandage. From the Anterior Naris. Plug with gauze strips or with cotton, and apply ice compresses to the nose. The application to the mucous membrane of adrenalin solution (1-2,000 to 1-5,000 suprarenal extract) or powdered antipyrin is of great assistance. Cocain, too, is astringent as well as anesthetic. It must be borne in mind, however, that the reaction after the 154 The Surgical Assistant. effect of these drugs passes off may be very severe, and the tamponade must therefore be none the less careful when they are used. From the Posterior Naris. Pass a catheter or probang through the nostril to the pharynx and draw its tip out through the mouth. To this tip fasten with a clove-hitch one end of a string six or eight inches long, to the other end of which is secured a plug of gauze. By pulling upon the catheter the string is drawn forward through the nose, and the plug is brought up to the posterior naris. From the Tonsil. Treat by the following measures, in order, and according to the severity and persistence of the bleeding: upright position with avoidance of hawking and coughing ; ice in the throat and ice bag externally ; application of adrenalin by swab or spray ; pressure upon the tonsil with a gauze pad which may be coated with suprarenal extract or other hemotastic ; digital compression of the tonsil and of the common carotid artery, or, better, compression of the gland, internally and externally, with a special tonsil clamp ; clamp- ing and ligation of accessible spurting vessels ; transfixion- or purse-string-suture of the tonsil ; ligation of the common carotid artery. From Intercostal Vessels. Expose the wound and press between, and well beyond, the ribs the centre of a " handker- chief " of gauze. Into the bottom of this pocket pack a strip of gauze. Then pull on the " handkerchief " in order to wedge the vessels tightly between the rib and the wad of gauze. If this fail, pass a hemostatic suture, by means of a half-curved needle, close to the edge of the rib above and around the intercostal tissues. Intra-abdominal Hemorrhage. Prepare hastily, i.e., with- out unduly sacrificing the important element of time to the now secondary consideration, asepsis — towels, sponges, gauze pads, ligatures and sutures, a large pitcherful of hot .9 per cent, saline solution, mouse-tooth forceps, scissors, [scalpel], sharp and blunt retractors, needles and needle- holder, ligature-carrier, clamps, artery forceps and sponge- carriers. Place the patient upon a stretcher or table, and Secondary Hemorrhage. 155 open, or re-open, the abdomen. Sponge out obstructing blood clots and seek the bleeding vessel or vessels, the prob- able location of which is indicated by the nature of the primary operation. Clamp firmly and apply ligatures or hemostatic sutures. Pour the saline solution, at a tempera- ture of about 105 Fahr., into the abdominal cavity to wash out the remaining blood, and leave about a quart of the solution within the peritoneal sac. Close the wound by " through and through " sutures of silk or silkworm-gut. If the hemorrhage be from a vessel in the gall ducts, the assistant will do best to simply apply a strong but narrow clamp, and insert gauze packings about it, leaving both the instrument and all the gauze strips protruding from the wound. Bleeding from the liver itself is difficult to control. Clamps and sutures often tear through, and the actual cau- tery may also avail nothing. In such instances apply gauze packings and a firm, compressive dressing. Cholemia, often present in conditions requiring operation upon the biliary tract, is a pronounced hemorrhagic factor, and so packing and even ligating may not in themselves suffice to control the bleeding. When it is thus persistent, strong and con- tinuous manual pressure directly over the dressing must be maintained for many hours. From the Kidney (after nephrotomy). Retract the wound and have the nurse or other helper push the organ into it by pressure from in front (figure 84). Sponge out the wound in the kidney and pack it with gauze ; pack also around the kidney. If this fail to check the bleeding, which is unlikely, pass heavy catgut sutures through the substance of the organ. From the Renal Pedicle (after nephrectomy). Search with a finger in the opened wound for the renal artery, and seize the vessels in a clamp directed along the finger. Leave the instrument in the wound and pack gauze around it. If the pedicle cannot be reached, open the abdomen promptly and ligate or compress the renal vessels transperitoneally. From the Bladder. Place the patient in the Trendelen- burg position in such a manner as to direct a good light into 156 The Surgical Assistant. the bladder. If necessary, insert gauze above the fundus to protect the peritoneal cavity against soiling. Open or re- open the bladder and retract the wound with guy threads or forceps. Sponge out blood clots and pack the viscus syste- matically and tightly with gauze strips. Individual vessels may be secured by hemostatic sutures, while light touches of the actual cautery are of aid in stopping the hemorrhage from a larger or smaller surface. Gauze packing may fail to stop the bleeding from large vessels at the base of the bladder. In such a case employ the following device : Transfix several small superimposed squares of gauze with a double strand of heavy silk, or of twine, about six inches long. Carry the silk directly through the perineum, either by means of a heavy needle or with for- ceps, and pull upon it so as to bring the gauze tightly against the bleeding surface. Fasten the silk to the external dress- ing or to the thigh. From the Perineum (after prostratectomy, urethrotomy, cystotomy, etc.). Retract the wound, tie individual vessels, secure the drainage tube in position, pack gauze strips about it and apply a compressive dressing. From the Rectum. If the hemorrhage is moderate, insert a large " tampon-canula " (page 279). If the loss of blood be large or continue in spite of the tampon, introduce a speculum, clamp and tie bleeding vessels and then insert the tampon-canula. In some instances, as in bleeding after the division of a stricture, a " canule a chemise" will prove more effective than the tampon-canula. The use of a tube, instead of packing the rectum with gauze alone, has the advantages of making continued hemorrhage manifest by the escape of blood into the dressing, and of permitting the passage of flatus. From the Uterus (post-partum). Administer by means of a Chamberlain tube or other uterine irrigation tip, a copious hot ( 1 1 5 Fahr.) douche of .9 per cent, saline, or 1-10,000 sublimate solution, or of plain water to which may with advantage be added half an ounce of acetic acid to each quart. Stimulate contraction of the uterus by pressure on, Pulmonary Edema. 157 and manipulation of, the fundus, and by the administration of ergot. If these measures fail, pack the organ systemati- cally with long strips of gauze. Continue pressure upon the fundus for one hour. From the Cervix Uteri. If hot douches and gauze pack- ings are insufficient, pass a hemostatic suture. The after treatment of severe hemorrhage is that of shock due to any cause, described above. The use of saline infu- sions is especially indicated. Pulmonary Edema manifests itself by increasing dyspnea and cyanosis, by moist rales that become louder and louder and more diffused over the chest, and by the appearance, a little later, of a profuse cold sweat. The treatment must be prompt, vigorous and persistent. Nitroglycerin and atro- pin, administered hypodermatically in large doses (gr. 1-50 of each) and repeated to the physiological limit, are the most important remedies. Stimulants, notably strychnia, are also indicated to assist the heart in overcoming the pulmonary stasis. A small dose of morphin (gr. \ ) may be of much service. Oxygen is often of real use and, at any rate, should be sent for early lest the assistant otherwise subject himself to the unfriendly criticism of the patient's family. The gas should be allowed to escape from the tank only in sufficient volume to bubble at a moderately rapid rate through the bottle of water. The tip of the tube attached to the bottle is held in the patient's nostril. All the mechanical methods of abstracting and diverting blood from the lungs must be brought into play. The head of the bed is to be raised. Cups should be applied freely to the chest both anteriorly and posteriorly. Lacking the regular cupping glasses, medicine- and wine-tumblers make very acceptable substitutes. The method of using them that minimizes the dangers of burning the patient and of igniting the bedclothes, is the following : A torch is made by winding a little cotton about the end of an opened hairpin or of a probe. This is dipped in alcohol and lighted, then rubbed rapidly about the interior of the cup, which is to be promptly clapped on the chest. " Bleeding the patient into himself " is 158 The Surgical Assistant. accomplished by applying constrictors to the limbs near their roots, one or two extremities at a time, and for periods of not over half an hour each, the constriction being only tight enough to compress the veins without obstructing the arterial supply. When the tourniquet is properly applied, the super- ficial veins dilate visibly, and the extremity becomes cyanosed and swollen. Hot applications are to be made to the limbs not at the time being constricted. Actual blood-letting (phlebotomy) is indicated only in plethoric individuals. The arm is prepared and bandaged, as described for intravenous infusion, and the vein is ex- posed in the same manner. There are these differences, however, that the distal ligature is not tied in advance (the proximal ligature may be) and that the bandage is not cut through until after the operation is completed. The vein is opened with a scalpel or with scissors. A towel or basin held above the wound when the vein is opened prevents soiling of the bedclothes. If the exposed vein segment is compressed digitally above and below until after it is opened, and a canula is inserted (towards the patient's fingers), spat- tering is avoided and the blood may be directed neatly into a glass graduate. Six to twelve, or even sixteen ounces, may be withdrawn. When sufficient blood has been sacri- ficed, the vein is again compressed with a finger, the ligatures are tied and the vessel is divided between them, the bandage is cut through, and the wound is rapidly dressed with a bit of gauze. Uremic (Eclamptic) Convulsions. A wedge or gag is to be slipped between the teeth to prevent injury to the tongue. A handkerchief or mask well wet with chloroform is held over the face so that the patient inhales the vapor as soon as the respiratory spasm subsides. With the chloroform the convulsions are controlled, either by keeping the patient in a state of mild narcosis, or by applying the mask the instant a recurrence of twitching appears. The rest of the imme- diate treatment consists in reducing the arterial tension and in securing activity of the emunctories. Hot packs, consist- ing in wrapping the patient in blankets wrung out in very Poisoning by Antiseptics. 159 hot water, are to be used freely. Vasculo-dilators, e. g., nitroglycerin, are also to be employed. If a reliable prepara- tion of veratrum viride is obtainable, a hypodermatic injec- tion of TTtiii of the fluid extract or TTLv of the tincture may be administered, and this the assistant may repeat in two or three hours if the first dose has not effected softening, en- feeblement, or irregularity of the pulse, or reduction of its rate below ninety. Phlebotomy (vide supra), followed by intravenous or rectal saline infusion, is indicated if the patient is not anemic or has not already lost much blood. Poisoning by the Absorption of Antiseptics seldom gives symptoms within the first few hours after operation, and will, therefore, be but briefly considered. Carbolic acid absorption produces pallor, labored respira- tion, drowsiness deepening into coma, and collapse ; pupils normal or contracted ; urine olive-green. Treat by changing the dressing and irrigating the wound and by administer- ing stimulants and diuretic agencies. Poisoning by bichlorid of mercury produces salivation, diarrhea, vomiting, rapid and feeble pulse, sometimes sup- pression of urine. Change the dressing, wash the wound, administer water and purgatives. Iodoform poisoning. In mild cases there are produced a vivid rash about the wound, mental excitation and the iodin reaction in the urine. In severe cases the cerebral symptoms are marked — delirium or mania, but sometimes coma — and the scarlatiniform rash spreads over other parts of the body ; pyrexia develops, the pupils become contracted and the pulse is rapid and feeble; collapse may supervene. Remove all iodoform from the wound, and employ symptomatic treat- ment. Carbonate of potash is said to be an antidote to iodo- form, and may be used both locally and internally. PART II. PART II. CHAPTER XI. OPERATIONS UPON THE HEAD. THE CRANIUM. Trephining. The anesthetist, as for all aseptic operations upon the head and neck, should wear a sterilized gown and a cap, and should disinfect his hands. All of his tools should be steril- ized or covered with aseptic gauze. In addition, it is wise for him to so place a sterilized towel that it will safeguard against contact between the operators' hands and his own. The narcotizer should stand or sit at the side of the table opposite to the operator. He will usually be least in the way if he seats himself opposite the patient's chest. It is worth repeating here that he should guard the patient's eyes from any inadvertent pressure. The instrument hander arranges his tools in about the fol- lowing order : scalpels, mouse-tooth forceps, anatomical for- ceps, hemostats, scissors, retractors, periosteal elevator, raspa- tory, trephines (the adjustment of the central pins of which is to be inspected), bone-seizing forceps, De Vilbiss or other bone-cutting forceps, [Gigli wire saw], rongeurs, sharp spoons, chisels, gouges, mallet, probes, [bullet searcher], [as- pirating syringe], needle holder. In the dishes he arranges a number of fine and medium-sized catgut ligatures, and sutures appropriate for the meninges (fine catgut) and for the scalp (silk or catgut). From a dish of sterilized Hors- ley's wax a few plugs are removed with a spoon and placed within ready reach ; and in addition the assistant places on his 163 164 The Surgical Assistant. table some gauze packings and a piece of rubber tissue pre- pared as previously described. If an electric or other motor is to be used for driving tre- phines or burrs, as much of the apparatus as may come within the field of operation should be covered with gauze (wound about it). Similarly, the instrument hander should cover the rheophores of an electric battery that may be used on the brain and, it need hardly be said, he should sterilize the platinum electrodes. The patient is placed with his head well supported on a towel-covered, flat or wedge-shaped, pillow at one end of the operating table, so disposed as to secure the best light in the" wound. Below should be a slop-pail. If the scalp has not been already prepared, it should now be shaved, either com- pletely or, at least, over a wide area. The skin is then to be disinfected, as described in chapter V. It is well to include the face in this toilet in order to minimize the contamination of the anesthetist's hands. A fresh towel is next spread over the pillow, removing the first one if it is wet (as it is apt to be). If a Martin's constrictor is to be employed, it should be applied at this juncture, being passed circularly about the head, just above the auricles and the eyebrows and just below the occipital protuberance, and secured at the point of cross- ing with a piece of bandage. Towels are now spread freely about the field of operation, and the head is turned so that this site is uppermost. After passing scalpel and mouse-tooth forceps, the instru- ment hander should be ready with hemostats. He should select the Hartley T-shaped or Spencer Wells pedicle clamps, if they are provided, for the scalp bleeds all along the cut sur- face and, besides, ordinary hemostats are not here easily re- tained. Although the T-clamps, gripping as they do the entire thickness of the scalp, may be used as retractors, it is perhaps better for the assistant to insert the usual instru- ments for drawing aside the skin-flap. What will next be re- quired of him will depend upon the nature of the operation. If it is for depressed fracture there should next be passed a probe and a periosteal elevator. After these no other instru- Trephining. 165 merits may be needed than bone forceps [and scissors] for removing" fragments, rongeurs for smoothing off projecting bone edges, sutures for the external wound, and a " cigar- ette " or other drain. Utmost gentleness and caution must be exercised when sponging over a fractured cranial bone. If the trephine is used, the assistant should support the head and, as opportunity offers, sponge away the bone dust. As the operator removes the trephine from time to time, there should be placed in his hand a fine probe, with which he may test the depth of his cut. If the button of bone does not happen to come away with the final removal of the trephine, an elevator is given to the surgeon to pry it out, after which a probe is again handed to explore the epidural space. When, in operating for any cerebral or meningeal lesion, or in excision of the Gasserian ganglion, a bone-flap is to be raised, the assistant should hand a trephine for making two or more apertures, and then instruments for connecting these openings, — De Vilbiss or other bone-cutting forceps, Gigli wire saw and director upon which to pass it, Van Arsdale saw, bone drill, or gouge and mallet, according to the oper- ator's preference. After the [skin- and] bone-flap has been raised, it is to be retracted, preferably in a piece of gauze, by the -assistant, who must exercise care not to strip the bone from its periosteal covering. Bleeding from a vessel in the bone calls for the use of a tiny plug of wood or of wax, which the instrument hander passes in the palm of his hand or in a saucer, or for the introduction into the bony channel of a heated wire (e. g., one from an aspirating needle). The lift- ing of a bone-flap may cause severe hemorrhage from a men- ingeal vessel torn at a point inaccessible to forceps or suture. At its appearance the assistant should, therefore, be ready with a gauze packing. Before dividing the meninges the operator may desire to secure some of their bloodvessels, and for this purpose he should be given a fine catgut suture on a small round needle. For the incision into the dura there are to be handed two small mouse-tooth forceps, and a pair of small blunt-pointed straight scissors or a delicate scalpel. To secure bleeding 166 The Surgical Assistant. points in the brain itself, serrefines (appendix, figure 43) should be passed, if they are provided, for, being light, they are less apt to tear out than ordinary hemostats. If the latter are used therefore, they should be supported in position by the assistant's hand until the ligatures are applied. When the wound is to be closed the assistant gently sponges off the bone-flap and removes the T-clamps from the scalp. Vessels that then bleed, unless of large size, will be secured by the scalp sutures. These are usually inter- rupted and of catgut, and should be threaded on stout needles. A gauze drain may be desired. The dressing should be retained by an evenly compressing recurrent bandage, and this, in turn, may well be secured with a starch-crinolin roller. The assistant should support the head while the patient is being lifted from the table and into his bed. MASTOID OPERATIONS. The assistant places the patient's head on a firm, flat, wedge-shaped or cylindrical pillow, the diseased area upper- most. The hair is to be shaved from the region about the mastoid process, the rest of the scalp being covered by a towel (page 84) or a rubber cap. The locks of hair that straggle from under the cap, if the patient is a female, may be pasted back with collodion. The external auditory canal is then irrigated with a boracic acid or other antiseptic solu- tion, and then the cheek, auricle, mastoid region and neck are to be scrubbed and disinfected. After this the towels are spread, and a bit of absorbent cotton or a narrow strip of gauze may be lightly packed into the auditory meatus. The instruments should be arranged much as for trephin- ing, the coarser bone tools used in that operation being re- placed here by the smaller mastoid burrs, gouges, chisels and curettes (appendix, figs. 66-68). These are spread out systematically, according to their sizes and shapes. An aural hand-syringe and a basin of irrigating solution, a pus basin (sterilized or covered with a sterile towel), one or two small Mastoid Operations. 167 saucers and a supply of bone wax should be at hand. But few ligatures need be prepared. A few sutures of silk, cat- gut or horsehair should be mounted on stout, full curved (" mastoid ") needles. If the operation be extended into the FIG. 57. Position of the head for operation upon the lower jaw or neck. For a mastoid operation the rubber cap should not be drawn quite so far down. neck, e. g., to explore the jugular vein, one or two sutures are to be threaded on ordinary surgicat needles ; and if a complete Stacke operation is found necessary, the assistant prepares silk sutures on small round needles for fastening the incised concha in its new position. A generous supply of bits of sea-sponge should be torn. These should be placed in a dish, together with a pair of thumb forceps, or, better yet, several of them are securely mounted on artery forceps and their loose edges trimmed with scissors. The sizes of these sponges should be altered to suit the varying depth and width of the cavity in which the opera- 168 The Surgical Assistant. tor is working. Larger pieces may be rinsed, squeezed dry, and used repeatedly, but very small bits of sponge should be discarded after using once. Sea-sponge, unless quite compact, tears on rough bone and it is well, therefore, for the assistant to prepare strips of gauze about an inch wide and six inches long and free of raveled edges. When needed for " sponging " several of these, strips are placed near the wound and with them a probe for their manipulation. A longer piece of gauze of the same width and double thickness, is to be laid aside on the instrument table for plug- ging the lateral sinus should it be inadvertently opened. When the primary incision has been made hemostats are passed and after them ligatures, to be tied at once since the forceps are apt to be dislodged or to obstruct manipulations if left in situ. The insertion of retractors will stop the bleed- ing from most of the vessels running through the soft parts over the mastoid process. Care should be taken not to bruise the auricle with the retractor. When the bone is reached the operator is relieved of the scalpel and given an elevator for the periosteum (un- less this tissue is destroyed by the disease process). In turn this is to be replaced by an instrument for attacking the bone itself, which the assistant should select according to the pref- erences of the surgeon and the conditions present. Some mastoid operators depend chiefly upon chisels and gouges, while others prefer burrs. If the bone surface is normal or sclerosed a mallet is handed with the gouge; if it is eroded the gouge alone may be required ; while if the bone surface is much destroyed, especially if the patient is a young child, a sharp spoon will suffice. The instrument hander should closely follow the development of the operation, so that he may forestall the surgeon's request for a larger or a smaller curette and will at the proper time hand him, unasked, a rongeur to remove a ledge of bone, etc. Aside from holding retractors, the assistance at the wound consists chiefly in sponging and in removing bone fragments. Mastoid Operations. 169 The sponging must be assiduous, but none the less judicious. It would be unwise, for example, to too hastily wipe away a drop of pus that may appear, for with it may be removed Fig. 58. Gauze to be laid over the mastoid wound, trimmed to fit against the auricle. the early clue to a new site of operative attack. Again, if an area of brain tissue or of the sigmoid sinus is exposed, an infectious bone fragment may be thrust into it by spong- ing that is more vigorous than cautious. The removal of bone fragments is better accomplished with dressing- than with anatomical-forceps. Two warnings should be given here, viz. : to avoid injury by the forceps to the facial nerve, if the Fallopian aqueduct has been opened ; and to refrain from pulling upon any bone particles not altogether freed from the periosteum, without first complet- ing the detachment with a snip of the scissors. The last is a small detail in technic, but an important one, — the tearing away of a still adherent bit of bone at the mastoid apex may bring with it a few fibres of the sterno-mastoid muscle, and thus open a channel of infection in the neck, 170 The Surgical Assistant. After the bone cavity has been cleansed and packed the retractors should be withdrawn, and any bleeding vessels secured. The dressing is then to be applied. In order that the auricle shall not be distorted the deeper layers of gauze may be trimmed to fit the posterior surface of the concha. A plug of absorbent cotton is then to be placed lightly in the auditory canal, and the auricle evenly covered with a smooth pad of gauze or cotton wool. If there is little oozing of blood and the dressing is soon to be changed, the outer layers of FIG. 59. Mastoid dressing firmly retained and reduced in bulk by the ap- plication of a starch bandage. gauze may be wet in a solution of salt, aluminum acetate (liquor Burowii), bichlorid of mercury, etc., and covered with gutta-percha tissue, oiled silk or wax paper. Over this is laid a thin layer of cotton wool. The bandage, two inches wide, is applied in oblique turns over the scalp and figure-of- eight turns about the forehead and neck. If a starch band- age be applied over this the neck turns may be omitted — which will save the patient much discomfort. CHAPTER XII. OPERATIONS UPON THE HEAD.— Continued. OPHTHALMIC OPERATIONS. Extraction of Cataract. This operation should be per- formed in the patient's bed, and the assistant should see that the pillows are so arranged that the head will have to be moved little, or not at all, when the operation is concluded. The necessity for changing the shirt or pillow-covers is, therefore, to be avoided by protecting these with rubber sheeting. After irrigating the conjunctival sac with warm boracic acid solution (saturated) from a sterile "undine" or small pitcher, and instilling cocain or other solutions, the eyelids, forehead and cheek should be gently cleansed with water and castile soap, by means of an absorbent cotton mop. This may be followed by an application of a weak sublimate solu- tion, and a second boracic acid irrigation of the conjunctiva. The patient's head is now placed in proper position on the pillow, viz. : well extended and facing directly upwards. The sound eye is covered with a pad of absorbent cotton, and sterile towels are laid over the brow and scalp (this towel should be pinned to the pillow, or otherwise fastened), over the face and on the pillow. If the eye is to be illuminated by artificial light condensed by a refracting lens, the assistant to whom this instrument is entrusted should assume a position which he can maintain, unvaryingly, throughout the operation, for if the lens be shifted at a critical moment a human eye may be sacrificed in consequence. The entire cornea, if not the entire eyeball, is to be steadily illuminated. The preparation of the instruments has already been de- 171 172 The Surgical Assistant. scribed (pages 103 and 107). The operator should not be obliged to turn his eyes even for a moment from the operat- ing field. It is important, therefore, that the instrument passer should place in his hand the proper instrument, promptly and in the exact direction in which the operator is to apply it. Similarly, after an instrument has been used, the assistant should be ready to take it promptly from Fig. 60. Manner of passing instruments and " illuminating " for a cataract extraction. the surgeon's hand. The handles only of the tools are to be touched, and the points should come in contact with nothing between the sterile basin and the eye, the eye and the basin again. If an instrument that is bloody is needed a second time, however, it may be dipped into boiled water and dried with a bit of sterilized linen, several pieces of which should be at hand. The following is the order in which the instruments are passed: spring wire speculum ("right-sided" or "left- sided " as the case may be) ; fixation forceps ; cataract knife ; Cataract; Strabismus. 173 iris forceps ; iris scissors, de Wecker or other iridectome, if iridectomy is required; cystotome for dividing the lens capsule; spoon for expressing the cataract; iris repositor. (Appendix, figures 58-63.) « In addition to illuminating and instrument handing, such other assistance as may be needed will consist in holding the fixation forceps for a moment, and in sponging. There is usually but little blood that needs to be wiped away. The sponging is to be by pledgets of moist absorbent cotton, free of projecting fibres, and it should carefully avoid pressure on the eyeball or contact with the wound itself. If the latter requires cleansing by sponging or irrigation, this is per- formed by the operator himself. FlG. 61. Eye pads in a shallow basin of boracic acid solution. Iridectomy requires the same assistant's technics as de- scribed above, the cystotome and spoon, however, not being needed. It is not necessary to perform this operation in the patient's bed. Strabismus. The assistant passes the instruments in the following order : speculum, fixation forceps ; conjunctiva for- ceps and scissors ; strabismus hook ; tendon scissors ; tendon sutures (unless simple tenotomy is performed) ; conjunc- tival sutures. The sutures, not longer than eight inches, are usually of iron-dyed silk and mounted on small curved needles, It is best for the assistant to have half a dozen 174 The Surgical Assistant. sutures prepared in advance, for in some strabismus opera- tions they are inserted into the tendons before the latter are divided. Enucleation requires the following instruments, in order: speculum; fixation forceps; conjunctiva scissors; strabismus hook ; tendon scissors, and either the same or a stronger pair of scissors to divide the optic nerve ; gauze pad for pressure until the hemorrhage ceases; conjunctival suture. Fig. 62. Dressing and bandage of one eye. The eye dressings to be handed to the operator, or applied by the assistant, are ordinarily, first, one or more flat circular pads of absorbent cotton about two and a half inches in diam- eter (several of which pads should be prepared in advance, either dry or, preferably, kept in a shallow dish of boracic acid solution — fig. 61), over this, loose pads of dry cotton to fill in evenly the orbito-nasal hollow, and then a two-inch Removal of the Upper Jaw. 175 roller. Beginning- at the centre of the forehead, the bandage is applied, smoothly and without exerting pressure, in cir- cular and oblique (" figure of eight ") turns. If the patient wears a braid, the circular turns pass above it, the oblique turns below it, thus adding to the security of the dressing and to the comfort of the patient. After a cataract operation both eyes should be bandaged ("double figure of eight"). REMOVAL OF THE UPPER JAW. The following are needed : scalpels, mouse-tooth and anatomical forceps, dressing forceps, straight and curved scissors, medium-sized sharp retractors, artery forceps and slender clamps, a stout probe, periosteal elevator, " keyhole " or other narrow saw, [a teaspoon bent at right angles at the junction of the bowl with the handle], mouth-gag, upper incisor dental forceps, osteotome, lion-jaw bone forceps, ron- geurs, chisel, mallet, Volkmann sharp spoon, needles, needle holder, ligatures, sutures, several sponges on long handles, a few squares of gauze and several long, narrow strips of plain and of iodoformized gauze. According to the desire of the operator, the assistant ar- ranges the patient with the head in Rose's position, (i. '. e., towards the urethra and towards the coccyx. It is wise, therefore, for the assistant to stretch only later- ally, i. e., to draw his thumbs towards the tubera ischii. The rectum is then swabbed out with soap and water by means of a sponge or cotton mop fastened in a sponge carrier. With the anus held open, the soapsuds are next Rectal Operations. 279 washed out of the bowel by an irrigation with warm subli- mate solution, 1-5000. Only a small amount of the solution should be used, for if any be retained in the gut it may be expelled later during the operation, to the annoyance of the operator. To prevent any such expulsion of retained fluid or of feces, and also for use as a tractor to expose internal hemorrhoids, there may be introduced into the rectum — either by the assistant after he has completed the preparation of the field by disinfecting the perineum, or by the surgeon at the beginning of the operation — a " sponge on a string." This is made by attaching a double strand of heavy silk or catgut to the center of a gauze- or sea-sponge, either by transfixion or, better, by means of a double knot or of a clove- hitch (see figure 37). After cleansing the field, the assistant disinfects his hands and slips a gown over his rubber apron, then spreads towels over the end of the table and on the patient's thighs, and taking his seat on the operator's right, lays a towel across the surgeon's lap and another upon his own. The Rectal Dressing. After the operation for hemor- rhoids, polypus, prolapus, etc., some surgeons dust the Fig. 102. "Tampon canula." wound with iodoform and introduce simply an anodyne sup- pository, others employ a simple strip of gauze, while still others pass into the bowel a " tampon canula." This latter has the advantages of preventing oozing of blood by gentle pressure against the wound, of allowing any considerable hemorrhage to show itself in the outer dressings, and of 280 The Surgical Assistant. making painless the escape of flatus and the introduction of enemata. It should be prepared in advance by the assistant, and may be made of any size, but is ordinarily about three inches long. A piece of stiff rubber tubing of that length is smeared with vaselin and wrapped about with several layers of iodoformized gauze of the same width. Vaselin is rubbed in over each turn of the gauze. One end of the tampon is then trimmed in the form of a truncated cone, as shown in Fig. 103. Rectal dressings — tampon canula, split compress, gauze pad, T binder. the illustration, the surface is smoothed with a final applica- tion of vaselin, and the distal end is transfixed with a large safety-pin to prevent the canula from slipping entirely into the bowel. The external dressing consists of a split compress when the " tampon canula " is employed, of one or more pads of gauze and a T binder, as indicated in figure 103. The gauze Hemorrhoids. 281 may be pinned to the binder to prevent slipping of the dressing. RADICAL OPERATION FOR HEMORRHOIDS^^" ^ ~~ There should be ready: rectal speculum {e.g., Sims' bi- ^ valve), pile clamp (appendix, fig. 115), Paquelin cautery, two mouse-tooth forceps, a few artery forceps, [dressing FIG. 104. Clamp and cautery operation. A, assistant's right hand ; B, as- sistant's left hand ; C, surgeon's left hand ; D, surgeon's right hand. forceps], scissors curved on the flat, [a scalpel], needles and needle holder for suturing operations, sponges, a few sponge handles, No. 2 catgut ligatures, other ligature and suture material as described below, " sponge on a string," iodoform duster, tampon canula, split compress, gauze pads and binder. If there is no second assistant, these articles may all be arranged on a low table within easy reach. Clamp and Cautery Operation. (Smith's.) The " sponge on a string " having been inserted into the rectum, the assist- ant places in the operator's lap the pile clamp, curved scis- 282 The S'URGIcal Assistant. sors, and a pair of mouse-tooth forceps, and a pair of forceps in his own lap. By gentle traction upon the string, if this be necessary, or by everting the mucous membrane with his fingers on each side of the anus, the assistant exposes the hemorrhoids. The surgeon having lifted a pile at one point, the assistant seizes it near the further extremity in such a manner that the clamp can be properly applied beneath the forceps and in the direction of the axis of the rectum (figure 104). The blades of the clamp closed, the assistant relin- FlG. 105. Clamp and cautery operation. A, assistant's right hand ; B, sur- geon's right hand ; C, surgeon's left hand. quishes his forceps and screws tight the fixation nut of the clamp. Then he wipes the pile dry with a mounted sponge, and rests the latter just beyond the end of the clamp to pre- vent damage by slipping of the cautery. If the surgeon does not remove the hemorrhoid with scissors (and then sear the stump) a towel is placed over his right hand in which to receive at once the handle of the Paquelin cautery. The Hemorrhoids. 283 platinum should be kept at a cherry red heat only — i. c, not " white hot,'' yet hot enough to thoroughly sear the pile stump without sticking in its passage across it. The cauterization completed, the assistant sponges charred bits from the surface of the clamp and unscrews the nut to release it. When the other piles have been similarly treated, he gently withdraws the sponge tampon from the rectum and again gently everts the mucous membrane that it may receive a dusting of iodoform crystals. After the iodoform box there should be handed the tampon canula [or gauze drain and a probe], split compress, gauze pads and T binder, in the order named. Clamp and Suture Operation. (Thelwell Thomas.) After each hemorrhoid is clamped and cut off, the assistant hands to the surgeon a twelve-inch strand of No. 2 catgut, on each end of which is a straight needle, and with his left hand relieves the operator of the clamp while the sutures are passed from side to side and knotted. Hemostats and ligatures are occasionally needed also. Crushing Operation. The assistant observes the same technic as in the previous methods, the " screw-crusher " being used instead of the clamp. No cautery is necessary, the pile being amputated with scissors or scalpel just before the crusher is released. Ligature Operation. (Allingham.) As in the other meth- ods, the assistant aids in elevating each pile with mouse- tooth, hemostatic or volsellum forceps, while the mucosa near the base is circumcised with curved scissors [or scalpel]. The assistant then hands a No. 3 catgut or stout silk liga- ture, and drags upon the pile with both the forceps while the surgeon ties the hemorrhoid and cuts it off. If it is large enough to need ligating in segments, a ligature of double length is to be threaded on a large surgical needle, or passed through a Peaslee needle, with either of which the centre of the pile is transfixed. Excision of the Pile-Bearing Area (Whitehead's Opera- tion.) If after stretching the sphincter there is not suffi- cient prolapse, with the spread fingers of the left hand the 284 Thb Surgical Assistant. assistant, by pressure on each side of the anus, causes the hemorrhoidal area to protrude. With forceps in the right hand he aids the surgeon in picking up the mucous mem- brane near the skin border, in order that it may be separated here with blunt scissors and dissected up. The assistant's technics are much the same as in assisting at vaginal plastic operations. Spurting vessels must be clamped, and tied or twisted. After each portion of the dissected cuff of mucous membrane is cut away, a silk suture will be needed to attach the corresponding cut edge of mucosa to the skin, the assist- ant helping in the adaptation with his mouse-tooth forceps. The dressing is the same as in the other methods of operat- ing. INTERNAL DIVISION OF STRICTURE OF THE RECTUM. Here are needed : speculum ; [straight steel sound] ; scal- pel ; stout, long-bladed, probe-pointed bistoury ; long curved and straight scissors ; long dressing forceps ; slender clamps ; sponges in carriers ; ligatures ; an assortment of Wales' rec- tal bougies (appendix, fig. 116) ; drainage tubing; and gauze. The diseased area should be kept well exposed, well lighted and sponged dry. After the stricture is divided, suc- cessively larger bougies are needed. The internal dressing consists of a large tampon canula. If, however, there is much hemorrhage from vessels that cannot be ligated, there should be quickly prepared, instead, a " petticoated tube " (canule a chemise). This is made by stitching an end of a piece of stout rubber tubing in an opening made in the center of a large square of gauze. After it is passed, like a closed umbrella, into the rectum, long strips of gauze are handed to the surgeon with which to pack tight the space between the tube and the square of gauze, as in the manner of filling a " Mikulicz bag." FISTULA IN ANO. The instruments required are : speculum ; slender, flexible probe ; stout probe ; grooved director ; narrow scalpel ; straight and curved scissors ; mouse-tooth forceps ; sharp re- Stricture of the Rectum. Fistula. 285 tractors ; Volkmann spoons ; sponge carriers ; hemostats ; [needles; needle holder; and sutures]. Peroxid of hydro- gen or a colored solution (e. g., of methylene blue) is some- times used, as an injection, to aid in demonstrating all branching sinuses. The assistant's duty is to keep the Fig. 106. " Canule a chemise." (Petticoated tube.) wound well retracted and dry, and from time to time to hold a probe or director in the fistulous tract. The dressing con- sists, usually, in a gauze packing and compress, with or without a tampon canula. CHAPTER XXIV. OPERATIONS UPON THE EXTREMITIES. AMPUTATIONS. For Major Amputations the assistant should have ready: one or two large scalpels ; straight and curved scissors ; two mouse-tooth forceps ; four sharp-pronged retractors ; one dozen artery forceps ; a stout probe ; dressing forceps ; full- curved and half-curved needles ; needle holder ; amputating knife; double-edged interosseous knife* ("catlin") for am- putations through the forearm or leg ; raspatory ; periosteal elevator ; large flat saw ; Gigli wire saw ; [metacarpal saw] ; [lion- jaw bone forceps] ; Liston's or other bone-cutting for- ceps ; [rongeur] ; anatomical forceps ; tourniquet ; [Horsley's bone wax] ; " cloth retractor " ; ligatures and sutures ; irri- gating salt solution ; drainage tubing ; sterile rubber tissue ; six or eight sea-sponges in a basin of hot sublimate solution ; an abundance of sterile gauze ; absorbent cotton ; several four-inch bandages ; [starch bandages] ; splints ; and the usual supply of towels, sheets and other accessories. The paraphernalia for intravenous infusion should also be at hand as for any operation that may entail great shock or loss of blood. The catlin is not essential, and may be replaced by the amputating knife itself, if of narrow blade, or by a scalpel ; the saw may be omitted for disarticulations ; while the special transfixion pins must be included with the other instruments in preparing for an amputation at the hip or shoulder by Wyeth's method. The Tourniquet. While Petit's apparatus, — consisting of a stout strap with pad and buckle and two plates to be separ- * See Appendix 2, pages 339 and 346. 286 Amputations. 287 ated by a screw, — and other older forms are still occasionally used, bandages, tubing or bands of rubber are most employed for constricting the limb. They are to be sterilized in boiling water, after the assistant has assured himself that they are strong and sound. This last is important, since rubber often submitted to heat, or not kept in air-tight containers between operations, is apt to prove rotten at the critical moment. For the shoulder or the upper part of the thigh there should be Fig. 107. Two-tailed cloth retractor. Fig. 108. Three-tailed cloth retractor. ready Esmarch's constrictor, — consisting of a flat rubber band with a hook at one end and a chain at the other, — or a piece of stout, soft (black) rubber tubing two feet long; while for constriction at other points, except the digits, the Martin rubber bandage should be prepared. The Cloth Retractor is designed to hold the soft parts out of the way while the bone is being sawn. It consists of a 288 The Surgical Assistant. sterile towel, or of a piece of unbleached muslin or of several thicknesses of gauze, about two feet long and one foot wide, torn lengthwise half way into two or three tails. The two- tailed retractor is to be prepared for an amputation through the arm or thigh ; while for an amputation through the fore- arm or leg a three-tailed retractor will be needed, the middle (narrow) tail passing through the interosseous space. After the retractor is split it should be rolled up until wanted. Position of the Patient. When the amputation is through the upper extremity, the limb should be supported by a nurse or assistant at right angles to the body, — the axilla or the upper portion of the arm, according as the amputation is in the arm or forearm, being at the edge of the table. For amputations below the wrist, as for other operations on the hand, the assistant may support the extremity upon a board placed at right angles to the table and held in position by the weight of the patient's chest upon it. For an amputation through the thigh or leg, the patient should be brought to the foot of the table so that more or less of the extremity, as the line of division indicates, pro- jects beyond, — the opposite limb being supported upon a chair and covered with a sheet, as shown in figure 112. Preparation of the Field. If the tissues to be removed are infected, they should be freely covered with gauze or towels, secured by a bandage, before any cleansing of the skin is attempted. In any case towels should be bandaged about the distal portion of the extremity up to a point six inches below the line of amputation. While the hand or foot is supported, the skin is then thoroughly disinfected. The assistant, hav- ing again disinfected his own hands, bandages fresh towels over the distal portion, and gives the extremity into the hands of a nurse who is " washed up," to hold for a few minutes in a vertical position in order to partially empty it of blood. This process may be much aided by " milking " the limb from the digits towards the trunk. When it is important to save to the patient as much blood as possible, the assistant should apply a rubber bandage firmly to the elevated limb from the digits up as far as de- Amputations. 289 sired (figure 109). The turns of this bandage should not reverse, nor scarcely overlap. The last few turns are made one directly over the other, and under the last turn the body of the bandage is slipped. The rest of the bandage is then unwound from the limb. While the extremity is still elevated, the constrictor is next to be applied, either by the surgeon or by the assistant himself. If a rubber bandage has. been used as above de- scribed, an Esmarch band is carried twice about the limb close above it and well on the stretch, and is secured by slip- Fig. 109. Driving blood from the limb with rubber bandage. ping the hook into a link of the chain ; after which the band- age is removed. When a rubber bandage is used as the con- strictor, several turns are made one directly over the other, and with the rubber well stretched ; the body of the bandage is slipped under the last turn, the assistant taking care to re- member whether it is inserted from below or from above, in order that it may easily be removed afterwards. In con- stricting the upper extremity, it is important that the band- 290 The Surgical Assistant. age should not be wound about the centre of the arm, for at that level it may cause paralysis of the musculo-spiral nerve by pressure against the humerus. Tubing used upon the thigh or upper arm, in the same manner as the Esmarch tourniquet, is wound about twice, and its ends are held tightly on the stretch and somewhat away from the body, while an assistant secures them by tying a piece of bandage around the crossing. The application of the older tour- niquets needs no further description here than to say that they are intended to press directly and especially upon the main bloodvessels of the extremity. The constrictor in Fig. 110. Martin's rubber bandage applied to arm. place, the limb is lowered gently to the horizontal, and towels are spread about the upper end. The Operation. If there are two other helpers present, the assistant places himself opposite to the operator, who usually elects to stand so that his left side is towards the patient's trunk. If only a nurse is present to steady the distal portion of the extremity, the assistant manages the proximal portion, standing on the outer side of the thigh for an ampu- tation of the lower extremity, on the side of the arm opposite to the operator for an amputation of the upper extremity. If no nurse be at hand the assistant must steady the limb alone by its distal or proximal portion, according as the amputation is above or below the mid joint. For amputations Amputations. 291 at or below the wrist or ankle, the nurse manages the limb, while the assistant faces the operator. Grasped firmly by the assistant above and by the nurse below, the limb is abducted sufficiently to allow the surgeon ample space, and is steadied at first horizontally, and later is depressed or elevated according as the tissues anterior, or those posterior, to the bone are being divided. For a circular amputation, or an amputation with flaps cut by transfixion, the amputating knife is first provided ; but in FlG. 111. Application of constrictor to thigh, and method of securing it with strip of bandage. other cases the surgeon may desire to mark out the skin flaps with a scalpel before using the amputating knife. Ac- cording as he has one or^two hands to spare, the assistant now provides himself with one or two sharp-pronged retract- ors with which to lift up the skin- or skin and muscle-flaps to expose the tissues beneath, first at one place and then at another. This is especially necessary when the skin cuff is to be dissected up in circular amputations. Where, by reason 292 The Surgical Assistant. of the absence of a second helper (to hold the extremity), the assistant can spare but one hand for retracting, a retrac- tor should also be given to the surgeon himself. The muscles divided down to the bone, the surgeon is now relieved of the amputating knife and provided with the catlin for severing the interosseous tissues (amputation through the leg or forearm), and then a scalpel to circumcise the periosteum and [a raspatory and] an elevator with which to push that tissue back. The two-tailed or three-tailed retractor being next applied, the assistant holds it drawn tightly over the proximal seg- FlG. 112. Position of lower extremities in amputation of the thigh. Con- strictor tied. ment of the extremity in order to expose the bone to the saw (figure 113). The assistant at one end, and the nurse at the other, must be careful during the sawing to hold the limb very steady, for uneven pressure upward may fracture the bone before it is entirely cut through, while pressure downward will make it bind upon the saw. In order that the sawing may be easy, the assistant should drip water from an irrigator or a sponge upon the bone until Amputations. 293 it is completely divided. Occasionally, when the Gigli wire saw is used, the operator requests the assistant to take one of the handles. In that case he need only bear in mind that the saw must not be bent acutely over the bone, but Fig. 113. Bone exposed for sawing. Two-tailed cloth retractor drawn tightly on tissues above. should be kept almost straight, for otherwise it is apt to bind or even break. If any fragment of bone" project beyond the sawn surface, the bone forceps will be needed for its removal. [When the amputation is by the osteoplastic method of Bier there will be needed a metacarpal or scroll saw, or Gigli wire saw in a scroll saw frame, with which to cut out the bone flap, and a few catgut stitches to secure its periosteal covering in place.] The cloth retractors are now to be removed and the stump elevated so that the operator can seek the severed blood- vessels, to facilitate which over-hanging skin or muscle should be drawn away with sharp retractors. The larger vessels having been clamped with hemostats, the assistant 294 The Surgical Assistant. squeezes the stump so that the trickling of blood from the smaller vessels may indicate their location. Until these are secured blood should not be sponged from the cut surface. After the bloodvessels have been tied, forceps and scissors are handed to the operator to draw out and cut short the large nerve trunks. The constrictor is now to be removed, by either the as- FiG. 114. Stump supported and bloodvessels exposed for clamping'. sistant or the nurse, as expediency may dictate. If the rub- ber tube constrictor has been used it is released by drawing tightly upon its free ends and cutting through the bandage Amputations. 295 knot carefully with a knife. The pressure on the limb is diminished only gradually at first, so that any now bleeding large vessel can be secured, and then the tourniquet is re- moved altogether. After handling the constrictor the as- sistant should " wash up " before again helping at the wound. When all visible vessels have been tied, a handful of sponges, wrung out of hot solution, should be laid upon the cut surface to check capillary oozing; while for bleeding from the bone itself a bit of Horsley's wax may be needed. If the operator elects to stitch the muscles together over the bone there should be handed him a continuous suture of chromicized gut and a small drain Consisting of a narrow wick of rubber tissue. Where, however, the skin only is to be united a fenestrated rubber drain should be provided, its projecting end to be transfixed with a safety pin. To unite the skin there will be needed plain or button sutures of silk or of silkworm-gut or strips of sterile adhesive plaster. The Dressing consists of [a strip of gutta-percha over the wound, and on this] a compress of gauze, split to surround the tube, over which is arranged an abundance of loose gauze. A few gauze compresses are spread evenly over the loose pieces, and all are held in place by ample bandag- ing. If the leg or forearm has been amputated, the limb should be supported upon a well-padded splint in order to keep the knee or elbow, respectively, in extension. Bony prominences, e. g., the knee, shoulder, iliac spines, etc., must be protected with cotton wool before bandaging over them. The stump should be held up while the patient is being carried to bed, and is then to be kept elevated by sup- porting it upon a pillow to which it may be pinned or band- aged. Amputation of a Digit. Here are needed, for an " am- putation in contiguity" (disarticulation): scalpel; mouse- tooth forceps ; straight and curved scissors ; two small sharp retractors; probe; [sharp spoon]; [bone-seizing ("lion jaw") forceps] ; two hemostats; and suturing implements: while for an " amputation in continuity " (through a pha- 296 The Surgical Assistant, lanx) there are also needed a metacarpal or scroll saw and bone-cutting forceps. If the amputation is at or close to the metacarpophalan- geal or metatarso-phalangeal articulation a Martin rubber bandage should be applied to the forearm or leg, respec- tively. For an amputation beyond that point a piece of nar- row soft rubber tubing or solid rubber may be used as a Fig. 115. Preparation of a finger for amputation. constrictor about the base of the digit, being secured at its point of crossing with an artery forceps. To isolate the field of operation the digit may be thrust through a small opening in a towel or compress of gauze. If the segment to be ablated is gangrenous or infected it should be wrapped in, or held in, a piece of gauze. OSTEOTOMY FOR OSTEOMYELITIS. The instruments needed are : scalpels ; mouse-tooth and anatomical forceps ; straight and curved scissors ; probe ; sharp retractors; periosteal elevator (appendix, fig. 77); Osteotomy for Osteomyelitis. 297 raspatory ; dressing forceps ; " sequestrum forceps " ; hem- ostats; small sponge carriers; chisels and gouges; mallet; rongeurs; Volkmann bone curettes (sharp spoons, appendix, fig. 10) ; [bone drill (appendix, fig. 76)]; suturing imple- ments ; catgut sutures ; a few ligatures. Bits of sea-sponge ; a constrictor; an irrigator; and splints should also be ready. The constrictor is applied, as for an amputation. Instru- ments are handed in the following order: scalpel, mouse- tooth forceps, sharp retractors, periosteal elevator or raspa- tory, chisel and mallet (see figures 38 and 39) and then, as Fig. 116. Removing chips of bone and sponging pus, etc., in operation for osteomyelitis. the case requires, gouges, curettes, sequestrum forceps, ron- geurs or bone drill. The assistant's further duties consist chiefly in exposing the bone by retraction of the divided soft parts and, later, in keeping the bone cavity clear. For the latter purpose he should hold in one hand a dressing forceps to separate and remove each bone fragment as it is cut with the chisel, while with the other hand he mops out the cavity with small or large pieces of sponge, as described for mas- 298 The Surgical Assistant. toid operations. When the osteotomy is completed the bone is washed out with sublimate solution, i-iooo. If the wound is left open the assistant provides gauze packings and an abundant absorbent dressing, [splint] and bandages. If a bone flap has been made (osteoplastic method), a gauze drain is needed, and sutures [for the periosteum and] for the skin ; while if the cavity is allowed to fill up with blood, to be organized into bone (Schede method), no drain is used, but sutures are needed for the skin and a piece of rubber tissue is to be laid over the wound. Gauze compresses are then applied smoothly from the digits up, to be held by an even bandage. A starch bandage in which are incorporated strips of basswood veneer may be applied over all in place of using a posterior splint. The neighboring joints are to be immobilized in the dressing. The constrictor is not removed until the dressing is com- pleted. CHAPTER XXV. SKIN-GRAFTING. SALINE INFUSIONS. SKIN-GRAFTING (THIERSCH METHOD). The following are needed: sharp (Volkmann) spoon; [McBurney skin-graft retractors] ; skin-graft razor (for which an ordinary broad razor or microtome blade may be substituted) ; two small probes; straight scissors; [scalpel]; anatomical forceps; rubber tissue; strips of rubber tissue, ^ to | inch wide, cut from the sheet after it has been dis- infected and thoroughly rinsed in 0.9 per cent.* salt solution ; three basins of " physiologic salt solution," for the rubber strips, the sponges and dressing, and the surgeons' hands, respectively; flat gauze compresses of appropriate size; gauze-, cotton- or sea-sponges ; absorbent cotton ; and band- ages. For the success of the graft it is important that strict asep- sis should be employed, and yet that no antiseptic should come in contact with the wound or the surface from which the epithelium is taken, after their preliminary cleansing. It is therefore necessary that the operating fields, the sur- geon's and assistant's hands, the basins, gutta-percha strips and the sea-sponges (if these are used) should all be washed with " physiologic salt solution." This is to be made by adding sixty-nine grains (very roughly a scant teaspoon- ful *) of table salt or, preferably, of chemically pure sodium chlorid, to each pint needed of tepid sterilized water. The solution should be made in a pitcher or basin that has been disinfected and then washed out with sterile water. After " boiling " all the instruments, except the razor, they should be rinsed in water and wiped dry. The razor should be washed with antiseptic soap, then with alcohol, dipped for a few seconds in the boiling soda solution, rinsed * See foot-note under " Intravenous Infusion." 299 300 The Surgical Assistant. in sterile water and dried. " Boiling " is too apt to dull the edge of such an instrument and, moreover, it would warp the handle of an ordinary razor, if that be used. The wound to be treated, and the surface of the thigh or other part from which the grafts are to be taken, usually disinfected and dressed the day before, are to be uncovered and washed off with salt solution. The thigh is then covered with a towel wet in the solution, while the wound is being FIG. 117. Skin-grafting. Stretching the skin with McBurney's hooks. prepared to receive the grafts. For this there is handed first the spoon with which to curette the exuberant granula- tions usually present. The scalpel is also needed sometimes to pare unhealthy wound edges. The assistant then washes the bleeding surface with salt solution and applies a dry compress to check oozing while the grafts are being shaved. Fig. 118. Skin-grafting. Stretching the skin with the hands. The skin-furnishing surface is now uncovered again and the surgeon is provided with the razor and a probe. The skin is put upon the stretch in a longitudinal direction. This is done by using the McBurney retractors as shown in fig- ure 117, or by the pressure of two sticks of wood, or by the hands alone applied as shown in figure 118. Skin-grafting. Intravenous Infusion. 301 The stretching may be done by the assistant alone, or by the surgeon below and the assistant above. A strip of skin about two inches wide is thus kept evenly and tightly stretched and, by the proper application of the retractors or the hands, somewhat elevated above the skin on each side of it. As the razor is moved along the assistant should drip salt solution upon it from a sponge, enough to flood the surface of the blade without, however, washing off the epi- thelial strip gathering upon it. Usually the surgeon trans- fers each strip to the wound as soon as it is cut. The as- sistant removes the compress, gently dries the surface and then, with a second probe, assists the operator in spreading the grafts evenly on the wound. When all are in place the pieces of rubber tissue are needed. These the assistant lifts from their basin with thumb forceps, cuts them of appro- priate length (usually the width of the wound) and hands them one by one in the forceps. The grafts covered with the gutta-percha, there are supplied compresses of gauze moist- ened in salt solution, then rubber tissue again, or oiled silk, [absorbent cotton], and a bandage. Gutta-percha strips and moist compresses are similarly prepared to dress the surface from which the grafts were shaved. Instead of these rubber tissue strips, Cargile membrane — sterilized " gold-beater's skin," sold dry in sterile envelopes — is sometimes used in the same way, and silver foil has also been suggested. Since all of these macerate the underlying epithelium some surgeons apply a dry dressing directly over the grafts ; for this the assistant hands first a single layer of gauze, and then gauze compresses and a bandage. intravenous infusion. The assistant may be called upon to administer an intra- venous saline infusion himself, while an operation is in pro- gress, and the technic will, therefore, be described in detail. In hospitals, where emergencies are frequent and shock or severe hemorrhage has often to be dealt with, the arma- mentarium for this procedure should be always at hand and ready for use, A box, divided into one large and three 302 The Surgical Assistant. small compartments, may be employed for the purpose* : In the large compartment are kept, all sterilized and rolled in sterile gauze within a sterile towel : one sharp scalpel wrapped in cotton ; one pair of straight scissors ; one pair of curved scissors ; bandage scissors ; one anatomical forceps ; one mouse-tooth forceps; one pair of small sharp retractors; two artery forceps ; one metal infusion canula, with rubber tube and glass attachment tip; one needle holder; two sur- gical needles. The three small compartments hold, re- spectively : a small jar containing, in alcohol, a reel of med- ium sized (No. 2) catgut; a jar containing several pads of iodoformized gauze ; a sterilized two-inch bandage, wrapped in sterile gauze. Pasted inside the cover of the box should be a list of the above-mentioned contents with directions to the nurse for their resterilization, replacement and replenish- ment. In each ward should be kept, strictly for this pur- pose, a graduated five-pint infusion (irrigating) bottle and attached tubing; a glass funnel; [a glass graduate] ; and a bath thermometer — all covered, and not only aseptic but scrupulously clean ; and, if hot sterile water is not on tap, a demijohn of distilled water and a special kettle in which to heat it. The other articles needed are : the packages or tablets of sodium chlorid (c. p.) ; a piece of rubber sheeting; a few sterilized towels ; several cotton sponges ; sublimate solution; and soap, brush, water, and ether. Not all of the items just listed are essential and, indeed, in the emergencies of private practice an intravenous infu- sion may be safely administered with no other paraphernalia than a torn handkerchief tourniquet ; a pair of scissors ; a strand of spool cotton ; a fountain syringe ; a glass irrigating tip or stout aspirating needle to serve as a canula ; filtered, boiled tap water ; table salt ; a teaspoon ; and a clean hand- kerchief to bind upon the wound. The fountain syringe and tubing should be washed out and then boiled for as many of fifteen minutes as the urgency of the case will allow. The glass infusion bottle possesses the advantages over the rub- ber bag that it allows one to note the rate of flow of the * Brickner, Mt. Sinai Hospital Reports — Vol. I. Intravenous Infusion. 303 solution and to determine, also, that no shred of cotton or other foreign substance be floating in it. This last, of course, is very important and, too, it is important that the lumen of the tubing and of the canula should harbor no particles of rust or other embolus-making accumulation. Lacking both bottle and fountain syringe the solution may be introduced, through a funnel and tubing, from a pitcher, the funnel be- ing kept continuously full to prevent the admission of air into the vein. The solution is made by filtering into the bag or bottle, Fig. 119. Intravenous infusion. through several thicknesses of sterilized gauze, plain water boiled and cooled to about no° F., or cold sterile water heated to that temperature, in which after the boiling or heating there has been dissolved sodium chlorid (sterilized by baking in an oven, or by boiling in a few ounces of water) 304 The Surgical Assistant. in the proportion of nine grammes to each liter (69 grains to each pint.*) The reservoir should be hung about two feet above the level of the patient. While the solution is being thus prepared the operator dis- infects the skin with soap and water, ether, and sublimate * This yields a 0.9 per cent, solution (" normal," or better called " physiologic " saline solution). The most recent physiologic teach- ing is that the proportion of sodium chlorid in the -blood is not, as formerly held, 0.6 per cent., but 0.84 per cent. A 0.9 per cent, solu- tion of sodium chlorid has the same freezing point as blood, and therefore the same osmotic pressure. " The difference between .84 and .9 per cent, probably represents the amount contributed to the osmotic effect by the many other compounds of the plasma." (Mathews — Annals of Surgery, August, 1904.) A scant teaspoonful of table salt is, roughly speaking, the quan- tity for each pint of solution. Such a means of measuring, however, is inaccurate and is therefore justified only in an emergency. Prop- erly, the solution should be made from a concentrated stock solution or from chemically pure sodium chlorid sterilized in packages of exact weight (69 grains, 138 grains, etc.). Infusion salt tablets, manufactured for this purpose, are very convenient, but it must be remembered that often the directions given with them are for a 0.6 per cent, solution. A tablet of 30 grains (2 grams) yields a solution of approximately 0.9 per cent, strength when dissolved in § vii (210 c.c.) Although sodium chlorid, the most abundant of the inorganic salts of the blood, is the only one absolutely essential to the solution, Mathews and others have pointed out that it is not a matter of in- difference whether or not the other blood salts are represented, especially in cases of toxemia, etc., where the infusion is repeated at intervals. Mathews gives, as the formula for a "balanced" physiologic solution: sodium chlorid, .9 ; potassium chlorid, .03; cal- cium chlorid, .02; water, 100. Tablets containing various combina- tions of the blood salts are made by manufacturing chemists, in addition to the plain sodium chlorid tablet, e. g.. Sharp & Dohme infusion tablet No. 2: sodium chlorid, 2.25 grams; potassium chlorid, 0.075 gram; calcium chlorid, 0.025 gram; JohnWyeth & Co. infusion tablet No. 3: sodium chlorid, 2.0 grams; sodium carbonate, 0.3 gram (for *' alkaline " infusion); Parke, Davis & Co. tablet: sodium chlo- rid, 9.0 grams; calcium chlorid, 0.25 gram; potassium chlorid, 0.1 gram. Intravenous Infusion. 305 solution, a piece of rubber sheeting or oilcloth being placed under the extremity to protect the bed or table. The veins Fig. 120. Intravenous infusion. Opening the vein. in the cubital fossa accommodate themselves best to the oper- ation and the median basilic vein is usually chosen, but any superficial vein, e. g., one of the sapheni, may be used. After disinfecting his hands the operator makes three or four turns of the bandage about the upper arm, sufficiently 306 The Surgical Assistant. tight to constrict the veins. Towels are then spread about the field. An incision about an inch long is made along and directly over the most prominent vein in the cubital fossa, and with scalpel and forceps the vessel is freed from the connective tissue on each side. The handle of the scalpel is thrust under it to separate it from its bed along the extent of the wound. With forceps or ligature carrier a loop of FIG. 121. Intravenous infusion. Introducing the canula. catgut is then drawn beneath the vein and cut in two. One strand of gut is tied tightly about the distal end of the exposed vein segment and the other strand is loosely placed in a single knot about the proximal end. The upper sur- face of the vein is next lifted with anatomical forceps, and with curved scissors an oblique opening is cut half way across the vein. The dissection and opening of the vein are Intravenous Infusion. 307 ordinarily easy, but if the vessel is collapsed or very small they may require much delicacy. Where the vessel is lost to view or mutilated in an effort to incise it, it will usually save time to abandon it and seek an entrance through some neighboring vein. The canula is now attached to the tubing leading from the reservoir, and a little of the fluid is allowed to run on the operator's hand ; this is both to drive all air out of the tube and to determine that the solution has not cooled below a proper temperature.* The solution still run- ning, the little flap formed in the vein is raised and the canula is thrust well in. The single knot of the loose ligature is drawn about the vein and canula and, at the same time, the constricting bandage is cut through. The level of the fluid in the jar is now noted in order to observe the rate of flow, which should not be very rapid, and the quantity used. Under no circumstances should the level of the solution in the reservoir be allowed to sink as far as the level of the outlet. In cases of shock, suppression of urine, etc., one to one and one-half pints, occasionally two pints, of salt solution are employed for an adult of average weight. Larger amounts are apt to cause great congestion of the viscera. When the infusion is injected to supply loss of blood, however, the quantity may be regulated in a measure by the severity of the hemorrhage. The effect upon the pulse at the opposite wrist should be watched. As the canula is being withdrawn the proximal ligature is tied firmly about the vein, which is then divided between the two ligatures. The little wound, left open or closed with a few stitches, is dressed with a simple compress of gauze. In hospital practice the preparation for, and performance of, an intravenous infusion can be accomplished within fif- teen minutes, and even in the home it ought not to take much longer. Occasionally a chill and an evanescent rise of tem- perature (even as high as 106 F.) follow the infusion, but * Intravenous infusions are employed at various temperatures up to 120° F. It is open to question whether there is any advantage in having them above the body temperature (98°.6-ioo° F.). 308 The Surgical Assistant. usually they are of no evil significance. (It has been sug- gested that they are the result of a destruction of red blood cells by an infusion not physiologically balanced.) SUBCUTANEOUS SALINE INFUSION. (HYPODERMOCLYSIS.) The solution is prepared in the same manner as for intra- venous infusion. The reservoir is hung about three feet above the patient. Attached to the tubing is a stout aspi- rating needle which, while the solution is flowing, is thrust Fig. 122. Subcutaneous saline infusion. almost horizontally into the subcutaneous tissue of the back (loin) or the buttock or under the female breast. The punc- ture wound must be covered with a bit of sterile gauze or with collodion. The latter will not adhere to the skin if the puncture hole is wet or bleeding. To obviate the difficulty the skin about the tiny wound is pinched up tightly and wiped dry, the collodion dabbed on, and the compression continued for a minute or two thereafter. APPENDIX I. APPENDIX I. THE PRELIMINARY PREPARATION AND ROUTINE AFTER-TREATMENT OF OPERATIVE CASES. FOR AN OPERATION UNDER GENERAL NARCOSIS TO BE PERFORMED IN THE EARLY AFTERNOON. The patient is allowed a light supper (e. g., coffee, toast and one egg) the evening before. The morning of the oper- ation a cup of tea or coffee is allowed for breakfast, but noth- ing thereafter. In many cases, however, water may be al- lowed until about an hour preceding the operation. About three or four o'clock of the preceding afternoon there is administered an active purge, e. g., pulv. glycyrr- hizse comp. % ss, or magnesium sulphate § ss, or a mixture of pulv. glyc. co. and magn. sulphat. aa 3 ii, or oleum ricini 5 ss, or hydrarg. chlorid. mit. (e. g., a series of six one-half grain doses of calomel given at ten-minute intervals). About ten o'clock of the same evening a high soapsuds enema is administered, and this is repeated about six o'clock the next morning. At ten o'clock (four or five hours after the second high injection) a low enema is given. Just before the purgative is administered [the patient is given a warm bath and] the field of operation is carefully shaved, scrubbed with soap and water and covered with a " soap poultice." This consists in an abundance of loose gauze, wrung out in a lather of green soap, covered with rubber tissue or oiled silk, and held in place with a bandage. When the second high enema is given, the soap poultice is removed, the skin washed with alcohol and ether, and gauze wet in sublimate solution, 1-3,000, applied. This dressing is not removed until the operation. After operation— Morphin is frequently needed. Cath- 311 312 The Surgical Assistant. eterization at eight-hourly intervals may be necessary. All nourishment by mouth is withheld for four to six hours or until vomiting ceases. Fluid diet is maintained until the bowels are moved. This is ordinarily done on the second day after the operation by means of a high soapsuds [and peppermint water] enema in the morning, and a cathartic (pil. cathartic, vegetabile or pil. cathartic, comp. or cascara sagrada, etc.) the same evening. rectal operations (e.g., hemorrhoids). The bowels are moved as above -but, in addition, low enemata are repeated until the fluid returns clear, and a rectal tube is inserted for half an hour two hours before the operation. The perineum is shaved and prepared as above. After operation, — For two days fluid diet is maintained, and the bowels are confined by the administration of tinct. opii deod. Tti x b.i.d. On the morning of the third day there is administered Epsom salt § ss, followed in two hours by an injection of olive oil (through the tampon canula) and an hour later by a low soapsuds enema. Thereafter solid or semi-solid diet is allowed. ABDOMINAL OPERATIONS. In emptying the bowels it is best to employ the additional procedures described for rectal operations. For an opera- tion upon the female pelvic organs the vagina is also pre- pared (vide infra). Stomach operations. — For 36-48 hours preceding the operation the diet should be only of sterilized fluids, and the mouth is to be kept clean by the free use of a tooth-brush and of an antiseptic mouth-wash (e. g., equal parts of peroxid of hydrogen and of sublimate solution, 1-10,000). An hour before the operation gastric lavage is performed, preferably with sterile water or saline solution and a sterile s-tomach tube. After operation, — The time and manner of moving the bowels depend, to a great extent, upon the nature of the operation and the condition of the patient. In the presence Routine of Operative Cases. 313 of peritonitis, the bowels are moved in twenty-four hours. For tympanites, an enema of peppermint water, to which may be added 3 i-ii of oil of turpentine, may be indicated. In cases in which gauze drainage through the vagina is employed, voluntary urination is not to be permitted until the gauze is removed. OPERATIONS UPON THE NOSE. An antiseptic spray or douche is to be used freely before- hand. operations upon the mouth or throat. Tooth-brush and mouth-wash are to be used as for gastric operations. bladder operations. In addition to the other preparations, urinary disinfect- ants (e.g., urotropin, gr. vii t.i.d.), the free drinking of water, [and bladder irrigations] are employed. Preparatory to a cystoscopic examination without general narcosis, an enema is administered in the morning if the bowels have not moved, and half an hour before the exami- nation an opium suppository is inserted. After the passage of instruments through the urethra, the administration of quinin (gr. x) is often desirable as a pre- ventive of " urethral chill." vaginal operations. Douches of bichlorid of mercury, 1-5,000, are adminis- tered morning and evening before the operation, and after the last enema on the day of the operation. The external genitals are shaved (except sometimes for curettage, drain- age of pelvic abscess, etc.) and prepared by soap poultice and sublimate dressing as are other fields of operation. After operation. Curettage, trachelorrhaphy. The vaginal gauze is re- moved after twenty- four hours; the uterine gauze after 314 The Surgical Assistant. forty-eight. The bowels are moved on the second day, and sublimate douches, 1-5,000 are administered daily after all gauze is out. Plastic operations (colporrhaphy, perineorrhaphy). Un- til the morning of the fourth day, the thighs are bound together, fluid diet is maintained, tinct. opii deod. TTLx are administered b.i.d., and catheterization is performed every five hours. On the fourth morning Epsom salt § ss is given, followed in one hour by an enema of olive oil 3 iv, and after another hour by a low soapsuds enema. Thereafter semi- solid diet is begun, a douche and an enema are administered each morning, and voluntary urination is permitted. Until the wound heals, however, it is to be washed off and a fresh gauze pad is to be applied, after each urination and defeca- tion. Vaginal hysterectomy and other operations in which a communication is made between the vagina and the abdom- inal cavity. Catheterization is to be performed at regular in- tervals until the drainage gauze is removed. EMERGENCY CASES. To patients requiring operation before the bowels can be regularly prepared a low enema may be administered. In the presence of an intra-abdominal abscess (appendicitis, etc.), a high enema is contra-indicated, and the preparation of the skin must be conducted with great gentleness. THE PREPARATION OF SURGICAL MATERIALS; FORMULARY. CATGUT. Of the commercial gut only strands that are clean, strong, rough and yellow should be selected. Bichlorid Method, (v. Bergmann.) (a). 1. Wind in rings or on spools. 2. Remove all fat by immersion in commercial (sul- phuric) ether for twenty-four hours or longer, Preparation of Catgut. 315 changing the ether if necessary [or by soaking in benzin for a whole month]. 3. Remove from ether and place upon a towel to dry. 4. Place in hydrarg. chlorid. corrosiv I alcohol 95 per cent 500 small sizes (00 and o) for nine days, larger sizes for fourteen days. 5. Transfer to alcohol 95 per cent. Preferably keep in alcohol two weeks before using. (Mt. Sinai Hospital, N. Y.) There are various modifications of this method. Thus : (b). 1, 2. Select and wind gut and remove fat as in (a). 3. Pour off ether and cover gut with hydrarg. chlorid. corrosiv 20 distilled water 400 alcohol 2000 Renew this solution three times at intervals of twenty-four hours. 4. Soak for twenty-four hours in absolute alcohol. 5. Preserve in fresh alcohol. (Philadelphia German Hospital.) (c). 1, 2. As in (a). 3. Place in hydrarg. chlorid corrosiv gr. xx acid, tartaric gr. c alcohol 95 per cent ^ vi smaller sizes five to seven minutes, medium sizes ten to fifteen minutes, largest sizes twenty to thirty minutes. 4. Preserve in alcohol 95 per cent., to each eight ounces of which is added one drop of a solu- tion of palladium chlorid. (gr. xv to 1 1). (Johnston's quick method, employed at Jefferson Hospital, Philadelphia.) Claudius' Method* The raw gut, without any fat-removing preparation, is * Deutsche Zeitschrift f. Chirurgie, Vol. 64, p. 489. 316 The Surgical Assistant. simply wound in single layers on glass spools and dropped into a solution of iodin ( pulverized ) I . potassium iodid I . distilled water ioo ■ in a well stoppered jar, and left there eight days. Before using, the iodin may be washed off by rinsing the spool in an aseptic solution, but if the gut is used directly from the solution, it will be more distinctly antiseptic (iodin). Un- used portions of gut are re-sterilized by returning them to the same (or, better, another) jar of the solution for from half an hour to eight days, according to the contamination to which they have been exposed. Catgut prepared by this cheap and simple method is strong, smooth, not swollen, pliable, knots easily, does not curl up as does gut kept in alcohol, and is absorbed in about the same time as catgut prepared by other methods. If it be left in the solution more than three or four months, however, it is apt to become too brittle. Elsb erg's Method* i. Free the raw gut of fat by immersing it for twenty-four to forty-eight hours in ether or in chloroform, or in a mixture of chloroform I ether 2 2. Wind tightly, in a single layer, on large glass spools having a hole in each flange, in which the ends of the gut can be tied. 3. Boil for ten to thirty minutes in a saturated solution of ammonium sulphate in water, or for three to ten minutes in a saturated solution of ammonium sulphate in aqueous carbolic acid solution, 1 per cent, to 2 per cent. 4. Remove the spools with sterile forceps, and rinse them for half to one minute in warm sterile water, carbolic acid, or sublimate solution. 5. Use at once or preserve in strong alcohol. * International Clinics, Vol. 1., nth Series. Preparation of Catgut. 317 Catgut can be re-sterilized (from three to six times) by boiling again. The solution can be used repeatedly by simply adding water to replace that which has evaporated; the ammonium sulphate crystallizes out unchanged. Cumol Method (Kronig). i. Remove all fat with ether, chloroform or benzin. 2. Suspend it, rolled in rings or in figure-of-eight forms, in a glass beaker or large test-tube. 3. Heat in an oven or over a sand-bath at 8o° C. for two hours. 4. Still suspended in the beaker, pour in cumol at ioo° C. and heat to or nearly to 165 C, maintaining that tem- perature one hour. (Cumol boils at a little above 165° C.) 5. Pour off cumol and dry in an oven or over a sand-bath at ioo° C. for two hours. 6. With sterile forceps transfer to alcohol. This method is complicated, difficult and not without danger, and is not suitable for office preparation. Boiling in Alcohol. Alcohol boils at 174 F., which temperature is not suffi- ciently high to sterilize catgut. The alcohol must, there- fore, be boiled under pressure, to accomplish which special apparatus is required. (a). In an apparatus the fat-freed gut is boiled fifteen minutes in a mixture of liquified phenol 5 distilled water 10 ethyl alcohol 85 (Saul's Method.) (b). Fat-freed catgut is wound on a glass spool and placed in a glass tube. This tube is nearly filled with alco- hol, its end is hermetically sealed, and it is then subjected in an autoclave to live steam at 248 F. for an hour. When needed, the glass tube is broken and the catgut dropped into sterile water to soften it. 318 The Surgical Assistant. Formalin Method. (a), i. Remove fat from gut by ether, chloroform or benzin. 2. Wind on glass plates in not more than one or two layers. 3. Soak for twelve to forty-eight hours in 2 per cent. to 4 per cent, aqueous formaldehyd solution (1-2 parts of commercial formalin. in twenty parts of distilled water). 4. Remove formalin by soaking twenty-four hours in running water. 5. Boil the formalin-hardened gut in distilled water fifteen to thirty minutes. 6. Preserve in acid carbolic 4 or hydrarg. chiorid. corrosiv 1 glycerin 5 alcohol 96 per cent 100 (Hofmeister's technic.) or cut the catgut in pieces, tie them in bundles and preserve in a glass-stoppered jar containing pulverized iodoform 100 glycerin 5° absolute alcohol 950 Shake the mixture every few days. (Senn's modification of Hofmeister's technic.) (b). 1. Cut the raw gut into required lengths. 2. Wrap each piece separately in filter-paper that has been soaked for twenty-four hours in a 2 per cent, solution of formaldehyd. Leave thus for twenty-four hours. 3. Dry in the paper at a temperature of 140 F. 4. Preserve dry until needed ; then soak a few minutes in a sterile solution. (Vollmer-Kossman technic.) Preparation of Catgut. 319 ( c ) . (Formol-iodin) . i. Submerge raw commercial catgut in 4 per cent, aqueous formalin solution thirty-six to forty- eight hours. 2. Wash in running water twelve hours. 3. Submerge in Claudius' iodin solution (vide supra) eight days. (Stone's modification of Claudius' method, to in- crease tensile strength of gut.*) Dry Heat Method of Boeckmann. 1. Soak in ether one week to remove fat. 2. Wrap in strands in fine tissue- or paraffin-paper, and seal in paper envelopes. 3. Place envelopes in sterilizer and subject them for three hours to a dry heat of 284 F., and for four hours to 290 F. ; or to 300 F. for three hours on two successive days. 4. When needed, cut off end of envelope, remove inner package with sterile forceps, and dip gut in sterile water to make it pliable. Chromicising Catgut. (a). 1. Roll catgut on spools. 2. Alcohol 95 per cent, for twenty-four hours. 3. Dry on a towel. 4. Place in potass, bichromat gr. lxxv aqueous solution carbolic acid, 5$... 5 pints small sizes for forty-eight hours, large sizes for fifty-two hours. 5. Alcohol 95 per cent., small sizes for five days, large sizes for three to four weeks, (b). 1. Place 200 parts by weight of catgut for twenty- four to forty-eight hours in carbolic acid 200 water 2000 chromic acid 1 * Medical Record, November 12, 1904. 320 The Surgical Assistant. 2. Preserve in alcohol. (Am. Text-Book of Surgery.) (c). i. Remove fat with ether. 2. Place for twenty-four hours in a 4 per cent, aque- ous solution of chromic acid. 3. Dry in a hot-air sterilizer. 4. Sterilize by one of the above methods. (d). Elsberg's- Method. Boil spools of catgut in 1-1000 aqueous chromic acid solution saturated with ammonium sulphate. Other steps as for Elsberg's method of plain sterilization. The resistance of the catgut to absorption in the tissues varies with the strength of, and duration of exposure to, the chromicizing solution. KANGAROO TENDON.. Kangaroo tendon is prepared in much the same manner as chromicized catgut. It should always be chromicized. Marcy's Method. 1. Soak the dried tendon in sublimate solution, 1-1,000. 2. Separate the individual strands. 3. Dry each strand in a sterile towel. 4. Chromicize (vide supra). 5. Keep in carbolic acid 5 boiled linseed oil 100 6. When needed, wipe the oil off of each strand with a sterile towel and immerse for half an hour in 1-1,000 aqueous solution of bichlorid of mercury. (This does not swell and soften the tendon as it would catgut.) Traax' Method. 1, 2, 3. As in Marcy's technic. 4. Immerse in aqueous solution formaldehyd, 2 per cent, to 4 per cent, for forty-eight hours. 5. Wash in running water twelve to twenty- four hours. Preparation of Suture Materials. 321 6. Immerse tendons until " dark golden brown " in a fresh solution of chromic acid I carbolic acid 200 water 4000 7. Dry between sterile towels and preserve in 10 per cent. carbolized oil. 8. When needed, wipe off each strand with a towel satu- rated with sublimate solution, 1-1000. CRANE AND HERON TENDON.* May be sterilized by the method of Claudius (vide supra). HORSEHAIR. 1. Wash with water and potash soap. 2. Boil ten to fifteen minutes in 4 per cent, carbonate of sodium solution. 3. Preserve in sublimated alcohol, 1-1000. SILK. Wind on glass spools and boil vigorously, small sizes for fifteen minutes, larger sizes for half an hour, in 5 per cent, carbolic acid solution or 1 per cent, carbonate of sodium solution. Preserve in 5 per cent, carbolic acid solution or in sublimated alcohol, 1-1000. CELLULOID THREAD. English gray linen thread is boiled in 1 per cent, solution of carbonate of sodium, then wrapped in a sterile towel, dried in hot air or steam and, finally, is dipped in a solution of celluloid heated in a hot-air sterilizer, and is placed in a sterile container. * The leg tendons, 11-16 inches long, of grallatorial birds are rec- ommended by Kieffer (Journal Am. Med. Assoc, November 19, 1904), as being readily procured, clean, easily sterilized, strong, tying well, and resistant to absorption for about six weeks. The Surgical Assistant. SILKWORM-GUT. (a). I. Cut off the rough ends of the commercial silkworm fibers. 2. Boil in 5 per cent, carbolic acid solution, or in plain water for half an hour (never in sodium carbo- nate solution). 3. Preserve in plain or sublimated alcohol, in carbolic acid solution 1 per cent, to 5 per cent., or in lysol solution | per cent. (b). 1. As in (a) 2. Place in ether for forty-eight hours. 3. Corrosive sublimate solution, 1-1000, for one hour. 4. Preserve as in (a). (c). 1. As in (a). 2. Soak fifteen minutes in 5 per cent, carbolic acid solution. 3. Sterilize by live steam. 4. As in (a). Silkworm-gut is easily dyed, and incidentally impregnated with an antiseptic, by immersing it for twenty-four hours in a 1 per cent, solution of methyl violet, before it is boiled. SEA-SPONGES. (a), i. Select firm, well-beaten sponges. 2. Place for twelve hours in commercial muriatic acid 1 water 3 3. Wash and squeeze out repeatedly in running water. 4. Soak three to four days in 5 per cent, green soap in water, stir, wash and squeeze out. 5. Wash until clean in running water. 6. Place in 5 per cent, carbolic acid solution at least twenty-four hours. Preserve in carbolic acid solution. (Mt. Sinai Hospital, N. Y.) Preparation of Surgical Materials. 323 (b). i. Beat out dust. 2. Place for forty-eight hours in 15 per cent, solution muriatic acid. 3. Wash with water. 4. Place for one hour in a solution of potassium permanganate-. 3 in water 5 pints 5. Soak four hours in a solution of sodium hyposulphite 3 x hydrochloric acid 3 v water 3 pints 6. Wash with running water for six hours. 7. Preserve in sublimate solution, 1-1000. (From Da Costa's "Modern Surgery.") WAX OR PARAFFIN PAPER. (a). Melt the wax or paraffin. While pouring it on thin [tissue] paper, iron evenly with a hot flatiron. (b). Dip the paper in melted wax or paraffin, then pass it through a laundry mangle. rubber tissue (gutta-percha). Sterilize by: 1. Washing and soaking in green soap and cold water. 2. Rinsing in plain water. 3. Immersing for twenty-four hours in sublimate solution, I-IOOO. 4. Preserve in sterile water or salt solution, or in a sterile towel. rubber tubing. 1. Cut in lengths. 2. Blow out dust. 3. Boil in plain water ten minutes. 4. Dry on sterile towel. 5. Keep in 5 per cent, carbolic acid solution. rubber gloves; catheters. (See Chapters V. and VII.) 324 The Surgical Assistant. murphy's gutta-percha solutions. Benzin solution, 4 per cent, for surgeon's hands ; acetone solution, 4 per cent, for field of operation. 1. Cut the gutta-percha chips in small pieces. 2. Wash in formalin, full strength, and dry. 3. Macerate the chips in benzin or acetone for three days, then filter through cotton that has been in formalin vapor for forty-eight hours. Repeat filtering twice, and solution is ready for use. The benzin is sterilized by boiling it in a water-bath in a strong, well-corked bottle. The gutta-percha solution itself loses its adhe- siveness if boiled, and it is not miscible with formalin. (Method of E. von Hermann, chemist.*) TRAUMATACIN. A saturated solution of gutta-percha in chloroform. senn's decalcified bone chips. 1. Saw the shaft of the femur or the tibia of a recently killed ox into sections two inches in length. 2. Remove periosteum and marrow, and place the remain- ing segments for two to four weeks into 15 per cent, solution of hydrochloric acid, changing the solution daily. 3. Wash decalcified segments in distilled water. 4. Immerse a few minutes in dilute potash solution to neu- tralize the remaining acid. 5. Immerse in distilled water for twenty-four hours. 6. Cut each, in direction of its long axis, into strips three- quarters of an inch wide ; slice strips into chips one millimeter thick. 7. Preserve chips in sublimated alcohol, 1-500. 1. Mix VON MOSETIG-MOERHOF BONE-FILLING. iodoform • 60 spermaceti 40 oleum sesami 40 * Murphy, Journal A. M. A., September 17, 1904. Preparation of Surgical Materials. 325 2. Heat slowly to ioo° C. in a flask on a water bath ; keep at that temperature fifteen minutes. 3. Allow to cool and solidify while shaking constantly. 4. When needed, melt and heat to 50 C. in a thermostat. horsley's bone wax. 1. Mix salicylic acid 1 almond oil , 1 beeswax 7 2. Boil ten minutes. 3. Pour in shallow dish to cool ; cover. paraffin for subcutaneous injection, etc. Mix commercial paraffin with sufficient petroleum jelly to reduce melting point to desired degree, e.g., no F., as determined accurately with thermometer. Proportions cannot be stated, for blocks of commercial paraffin are not of the same melting point throughout. When needed, boil the mixture in a flask or tin receptacle placed in the water in a sterilizer; cool in the flask to about 120 F. ; draw into ster- ile syringe ; evacuate air bubbles from syringe and place it in sterile water at 8o° F. to allow paraffin to cool in it uniformly to semi-solid state. Before injecting, warm the attached syringe needle in hot water. (Harmon Smith's technic.) plaster bandages. The best dental plaster, kept in air-tight containers, should be used. Gauze or crinolin, cut in strips about five yards long and of the desired width, is laid upon a table and the plaster is smoothly and evenly rubbed into its meshes. In order that the plaster will not be spilled out of the strip, it should be rolled up little by little as the powder is incor- porated in it. The bandage, very loosely rolled, is wrapped up in waxed paper or gutta-percha, and placed in a tin box, the cover of which is sealed around the edge with a strip of adhesive plaster. 326 The Surgical Assistant. starch bandages. Cheese-cloth impregnated with starch and dried is cut into strips of desired width and rolled up. WATER GLASS (SOLUBLE GLASS ) DRESSING. The wound is dressed and bandaged in the ordinary way. Into and upon the bandage is applied with a brush liquor sodii silicatis (U. S. P.) or liquor potassii silicatis, or a mix- ture of two parts of the latter with one part of the former. (The combination is said to set more quickly and firmly than either solution used alone.) Instead of painting on the soluble glass, the bandages may be dipped into it and then applied. TOWELS, CAPS AND GOWNS. 1. Remove blood, pus, etc., by soaking several hours in cold water, to which may be added some ammonia. 2. Rinse in several changes of cold water. 3. Boil in soap and soda for about an hour. 4. Rinse in plain water. 5. Dip in bluing. 6. Wring out. 7. Dry. 8. Iron and fold ; wrap in a package in a sheet or bag or place in a sterilizing drum. 9. Steam-sterilize and dry in autoclave. ( New towels should be boiled before using, to prevent stiffening.) ABSORBENT AND NON-ABSORBENT COTTON. Cotton, in rolls, pads or " sponges " may be steam-steril- ized and dried in an autoclave. BORATED COTTON. Immerse sterilized absorbent cotton in a saturated aqueous solution of boracic acid ; wring out and allow to dry slowly. Preparation of Surgical Gauze. 32? plain gauze; gauze pads and sponges. If ordinary cheese-cloth is used, it is boiled in soft soap or soda to remove the grease and make it absorbent. After the boiling it is rinsed and dried, folded in a package and sterilized in a towel, a jar or a canister, in an autoclave (250 F., fifteen pounds pressure, at least fifteen minutes). Sponges and pads are made of several folds of gauze, the edges of which are turned in and hemmed to avoid loose threads. Abdominal pads should have a narrow tape strongly sewed to one of the corners. Pads, -ponges and "packings" (the edges of which are similarly folded in) are sterilized in packages like the dressing gauze. BICHLORID GAUZE. Wring out sterile gauze in : hydrarg. chlorid. corrosiv gr. x sodium chlorid 3 ss acid citric 3 i glycerin O ss aq. destillat O ii (Enough for sixty yards.) Keep moist or dry in sterile jars, well stoppered. The citric acid and sodium chlorid are added to the solution to prevent decomposition of the mercurial salt. (Formula from Senn's " Nurse's Guide.") carbolized gauze. Wring out sterile gauze in : acid carbolic § iii glycerin 3 xviv aq. destillat O ii (Enough for sixty yards.) Preserve the same as sublimate gauze. (Formula from Senn's " Nurse's Guide.") 328 The Surgical Assistant. IODOFORMIZED GAUZE. (a), i. With disinfected hands, wring out pieces of gauze in aqueous sublimate solution, 1-500. 2. Shake pieces out loose and mix them thoroughly, one by one, and then altogether in powdered iodoform § i glycerin § i aq. sublimate solution, 1-1000. ... 3 xxxii (This quantity is enough for sixteen yards. The mixture makes a 3 per cent, gauze). 3. Fold in packages; sterilize in towel or jar in the autoclave. (Mt. Sinai Hospital, N. Y.) (b). 1. Soak gauze uniformly in a mixture of iodoform 20 parts glycerin 20 parts alcohol 70 parts, by weight (5 per cent, mixture.) 2. Wring out as dry as possible. 3. Fold in packages or rolls; place in aseptic jars and seal hermetically. (c). 1. Place sterile gauze in 20 per cent, ethereal solution of iodoform for ten minutes. 2. Wring out and place in basin covered with sterile towel to allow ether to evaporate. (Gauze now greenish-blue.) 3. Soak twelve hours in aqueous sublimate solution, 1-4000. (Gauze restored to yellow color and anti- septic.) 4. Wring dry as possible. 5. Fold ; place in sterile jars. (Pryor's Method.) To improve the Color of Iodoformized Gauze, — For each thirty yards add to the mixture about a dram of tincture of curcuma, prepared thus : Mix, powdered curcuma ^ iv proof spirit 1 pint Formulary. 329 Let stand until clear ; pour off clear liquid ; add spirit until all color is extracted. (From Senn's " Nurse's Guide.") IODOFORM EMULSION. Use iodoform, I part; glycerin, 9 parts (by volume or weight). Boil the glycerin, pour it into sterile bottle, allow it to cool, add iodoform, cork with sterile stopper, shake. IODOFORM-ETHER. A saturated solution of iodoform in sulphuric ether. IODOFORM-COLLODION. Iodoform, gr. xlviii; collodion, § i. STRONGER IODIN TINCTURE. Iodin crystals 2 parts alcohol , aa s parts ether j 3 F Keep in glass-stoppered bottle. This is twice the strength of the officinal tincture. (Elsberg.) BALSAM OF PERU AND CASTOR OIL (OILY DRESSING). Mix Peruvian balsam, 1 part, and castor oil, 10 parts ; pour into clean bottle ; plug neck with cotton ; sterilize in auto- clave. This is poured on the gauze when needed. LIQUOR ALUMENI ACETATIS (BUROW'S SOLUTION FOR WET DRESSINGS). Plumbi acetate 3.50 alumen 9.0 aq. ad 100.0 Mix and filter. Dilute for use with five to eight times as much water. Maceration and whitening of the skin, especi- ally of the hand and foot, by the application of gauze mois- tened in this solution, may be prevented by adding to the solution about one-sixth its bulk of glycerin or alcohol. 330 The Surgical Assistant. Thiersch's solution (for wet dressings and irrigation). Salicylic acid 3 ss ( i part) boracic acid 3 iii (6 parts) water O ii ( 500 parts) PLAIN BORACIC ACID SOLUTION. Boracic acid 4 parts water 100 parts (Saturated solution.) Boracic acid crystals dis- solve more readily than the powder. SALINE SOLUTION. Physiologic Salt Solution : Sodium chlorid 138 grains ; 9 grams water 1 quart ; 1 liter "Balanced" Physiologic Salt Solution: Sodium chlorid 0.90 potassium chlorid 0.03 calcium chlorid 0.02 water 100.00 SUBLIMATE SOLUTIONS. 1:10,000 1:1,000 bichlorid of mercury, gr. 1 x / 2 ; o. 1 15 grains; 1 gram water ... 1 quart; 1 liter 1 quart; 1 liter. 1:500 25$ stock solution bichlorid of mercury, gr. xxx; 2.0 8 ounces; 250 grams water 1 quart; 1 liter 1 quart; 1 liter 1:1000 1:500 25^ stock solution, 3 i; 4 c.c. 3 ii; 8 c.c. water 1 quart; 1 liter 1 quart; 1 liter Commercially prepared tablets containing 7^ grains of the mercurial salt (and citric or tartaric acid) yield a 1-1000 solution in a pint of water. Formulary. 331 CARBOLIC ACID SOLUTIONS. Phenol crystals are liquified by setting the bottle in which they are sold in hot water ; to hasten the process a teaspoon- ful of hot water may be poured into the neck of the bottle. i per cent. 2 per cent. 5 per cent. (saturated solution) pure carbolic acid, 3 iiss; 10 c.c. 3v; 20 c.c. 3 xiiss; 50 c.c. water 1 quart; 1 liter 1 quart; 1 liter 1 quart; 1 liter CREOLIN AND LYSOL SOLUTIONS. 1 per cent. 2 per cent, creolin; lysol, 3 iiss; 10 c.c. 3 v; 20 c.c. water 1 quart; 1 liter. 1 quart; 1 liter. FORMALDEHYD SOLUTIONS. 1 per cent. 3 per cent, formalin-glycerin, com'c'l formalin, 3 v\%\ 25 c.c. com'c'l formalin, 3 ivss; 18 c.c. water 1 quart; 1 liter. glycerin § viii; 250 c.c. PICRIC ACID SOLUTION FOR BURNS. Picric acid gr. xxxviii ; 2.5 grams alcohol 1 i ; 30.0 c.c. water O i ; 250.0 c.c. NITRATE OF SILVER SOLUTIONS. 1 per cent. 5 per cent. argent, nitrate, gr. v; 0.3 grams. gr. xxv; 1.5 grams, aq. destillat § 1 ; 30 c.c. § 1 ; 30.0 c.c. It is important that the solution should be made with dis- tilled water and preserved in dark, glass-stoppered bottles that have been rinsed out with distilled water. COCAIN SOLUTIONS. ]/z per cent. 2 per cent, cocain hydrochlorate. . . gr. iiss; 0.15 gr. x; 0.6 grams sterile distilled water. . . . § 1; 30.0 c c. § 7; 30.0 c.c. To preserve the solution, a few grains of boracic or sali- cylic acid should be added. 332 The Surgical Assistant. schleich's solutions for infiltration anesthesia. No. i (Strong) No. 2 (Normal) No. 3 (Weak) Cocain hydrochlorate morphin hydrochlorate sodium chlorid, c. p. sterile water (about § ii) gr. 11 gr- X gr. 11 •m iooo gr. i gr. X gr. n •pi IOOO gr- A gr- % gr. " JT1 IOO ° SOLUTIONS FOR ELECTRIC BATTERIES. Carbon-zinc Galvanic " Dip " Battery. Sulphuric acid 4 ounces potassium bichromate, enough to saturate. water i quart Have the cells half full. Leclanche Battery. Copper pole tightly packed in a porous receptacle with a mixture of manganese dioxid and gas carbon covered with pitch; zinc pole dipping in solution of sal ammoniac. To replenish, wash glass cell clean, put in fresh zinc rod if needed, and fill jar one-third its depth with a strong solution of sal ammoniac (ammonium chlorid) — about six ounces to the quart of water. Gravity ("Crowfoot") Battery for charging storage cells. Copper pole in copper sulphate solution at the bottom ; zinc pole near the top of the solution. Blue vitriol (copper sulphate) is placed in generous quan- tity at the bottom of the cell, and enough water is poured in to nearly fill the jar. A little common salt or sulphuric acid is added to the zinc to start the action of the battery. ENEMATA. Cathartic Enema. This consists ordinarily of plain warm water or water in which a lather is made with (Castile) soap. To it, es- pecially when administered " high," various elements may be added according to the indication, e. g., olive- or cotton-seed Formulary. 333 oil, six to eight ounces ; magnesium sulphate, one ounce ; inspissated ox-gall, a tablespoonful ; and, to relieve tympan- ites : peppermint water ; spirits of turpentine, one or two tea- spoonfuls ; tincture of asafcetida, one-half to one ounce, etc. Stimulating Enema. Tinct. digitalis lUxx whiskey \ i table salt 3 ss- 3 i water § viii-0 i (tinct. opium TTlxx) Nutritive Enema. A combination such as that of some, or all, of the follow- ing:- egg - • i peptonized milk 3 iv-vi beef extract, peptonoids or somatose . . . § i-ii whiskey § i salt solution variable (tinct. opium TTtx-xx) APPENDIX II. Surgical Instruments. 337 Fig. 3. — Bennett's apparatus for the administration of gas and ether. A, Air-trap> in face-piece; B, ether chamber; D, chamber containing valved tubes for transmit- ting nitrous oxid gas; E, air-trap; F, stop-cock for introducing gas into balloon. c m Fig. 4. — Ware's ethyl chlorid mask, a, face-piece; i, metal tube; c, section showing insertion of gauze. 338 The Surgical Assistant. Fig. 6. — Paquelin cautery. Fig. 7. — Gerster's iodoform duster. Fig. 8. — Dieulafoy's aspirator. Fig. 9. — Trocar and canula. Fig. jo. — Volkmann's spoon. Surgical Instruments. 339 Fig. 14. — Flexible probes. &.TIEMAWI&C0.I1Y, Fig. 11. — Scalpels. Fig. 12.— Bistouries. Fig. 13. — Tenotome. Fig. 17.— Amputating knife. .Fig. 18.— Cat! in (Interosseous knife.) 340 The Surgical Assistant. Fig. 22. — Fig. 23. — Fig. 24 — One-pronged Two-pronged Small blunt retractor. retractor retractor. Fig. 25.— Large (abdom- inal) blunt retractor. Fig. 26. — Four-pronged retractor. Surgical Instruments. 341 Mastoid Hemostatic Hagedora pattern Haoedora Fig. 2". — Forms of surgical needles. Fig. 30. ~ Ligature carrier.' Fig. 33. — Hagedorn s needle holder, 342 The Surgical Assistant. Fig. 43.— sjerrefins. Fid. 42— Pean's artery forceps. Surgical Instrument?. 343 Fig. 44. — Spencer Wells' straight clamp. Fig. 45. — Skene's curved clamp. Fig. 46.— Spencer Wells' T-shaped clamp. Female half. Male half. Partly closed. Fig. 48.— Murphy's button. Fig 49. — Tracheal canula Fig. 47.— Angiotribe. Fig. 50^-Nasal speculum. 344 The Surgical Assistant. Fig. 53. — Snellen's entropion forceps. ill,, — — -A — aT G TIEMANN&.CO. Fig. 56.— (iott- stein's adenoid curette. Fig. 55. — Knapp's Fig. 54.— Racjc for ophthalmic instruments. trachoma forceps C.TIEMAIItJ 4 CO. "Fic. 57. — Bowman's lachrymal probes.' Surgical Instruments. 345 Fig.~"59. — Iris scissors. Fig. 60. — Beer's keratome. Fig. 6i. — Graefe's cataract knife. G.1IEMAMN S. CO Fig. 62. — Knapp's cystotome. 03*NNVW3U. 3 Fic. 63. — Levi's fenestrated lens spoon. Fig. 66. —Mastoid mallet. flilMiWIWItilltimitil imtotTHm' - - ^^ac*&*>*!V ACq QMMMMMmmmm l^T f ' If *r - Fig. 67. — Mastoid chisels. Fig. 64.— Wilde's tubular a'-fral specula. E