If' ^^^tAJiA jr^af rJ. HX00019348 LECTURES GYNECOLOGICAL NURSING DELIVERED BY EDWARD J. ILL, M.D„ NURSES OF ST. BARNABAS HOSPITAL NEWARK, NEW JERSEY. REPORTED BY MISS ELLEN F. CONNINGTON. NEWARK, N. J.: John C. SciiErxER, Hook Binder and Printer. LECTURES GYNECOLOGICAL NURSING DELIVERED BY EDWARD J. ILL, M.D., NURSES OF ST. BARNABAS HOSPITAL NEWARK, NEW JERSEY. REPORTED BY MISS ELLEN F. CONNINGTON. NEWARK, N. J. : John C. Schei.ler, Ijook Binbek and Printer. PRKKACK. The contents of this pamphlet represents very well the lectures delivered by the undersigned to the nurses of St. Barnabas Hospital during the winter of 1900-1901. I am sure these ''Notes" will be of use to those for whom they are intended. I have purposely refrained from any theoretical talk. Our lectures to nurses should be of the simplest and most practical character. The nurse should not be encumbered with things that she cannot understand, or which are useless to her in the practical work of her calling. Miss Connington deserves much praise for the spirit with which she has collected these notes and published them. EDWARD J. ILL. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/lecturesongynecoOOille LECTUEE I. We expect that a nurse who listens to a lecture on gyne- cological nursing should have had some experience and some knowledge as to general nursing, dietetics, baths, etc. These things Avill, therefore, not be touched upon in these lectures. By gynecology we mean a study of the diseases peculiar to women. I will incjude in my lectures to you the nursing of diseases of the rectum, breast and the bladder of the female. The anatomy of the female pe,lvis and its contents inter- est the nurse only so far as it is necessary for her to under- stand such manipulations as she will be called upon to per- form. For that reason I will not detain you by a long and minute detail of the structures. We shall study the anatomy under five headings: First — The anatomy of the bony pelvis. Second — The external genitals. Third — The internal genitals. Fourth — The rectum. Fifth — The bladder and urethra. The bony pelvis consists of four bones, the two innominata and the sacrum with its elongation, called the coccyx. The innominate bone is divided into three distinct portions, the i,lium, the ischium and the pubes, which remain separated from each other up to and even beyond the period of puberty, but later unite into one strong bone. The pelvic bones are connected one to the other by strong ligaments. Between the pubic bones in front and the sacrum and the ilium in the back there is a heavy layer of fibro-carti- lage which permits a slight motion of these parts. The pelvis forms a structure which is intended to protect from injury, through external violence, the many important organs it con- tains, while it forms, at the same time, a support for the other intra-abdominal organs. In its shape, in the woman it is shal- lower and wider than in the man. This is for the purpose of permitting the passage of the child. By the external genitals we mean those parts which can be seen by an inspection from outside on separating those two folds of skin called the labia majora. In the normal condition, with the thighs slightly abducted and flexed on the abdomen, these two large folds of skin should cover the more delicate structures of the vulva. When the female ha.s arrived at puberty the outei' and upper portion of the labia majora are covered with short crisj) hair. Within the large lips there arises just below the upper portion tlie labia minora, runninji^ a downward and outward course. They lose themselves just above and to the outer side of the opening into the vagina. These folds, like those of the labia majora, are formed of skin. As the labia minora are separated we see within its upper borders a triangular space called the vestibule, which is cov- ered by a pale pink mucous membrane. In the lower portion of this, that is in the base of the triangle, we see a small tri- angular slit, which is the opening into urethra, and is called the meatus urinarius. This triangular orifice appears in this shape normally in the virgin; in the married woman and in the woman who has borne children the urethral opening is no longer of a triangular shape, but becomes roundish. Within the labia minora we also find an opening of various shapes. In the virgin it is either round, semi-lunar or divided into several openings by strips of mucous membrane usually running in an anterior and posterior direction. This opening is called the ostium of the vagina, or the opening to the vagina, and is formed by a duplicature of mucous membrane. In the married woman and in the woman who has had chil- dren this delicate membrane is dilated and torn, so that it wi,ll often appear in the shape of small bits of mucous membrane fringing the opening to the vagina. Below the ostium vaginae we have that space running as far as the anus, which is called the perineum. As we look into the ostium vaginae we can observe a canal lined by mucous membrane, running in a curved direction up- ward and backward, with a slight concavity forward. It has many folds. It is from two and one-half inches in its anterior wall to three and one-half inches in its posterior wal,l in length. This canal is formed by various muscular layers and lined on its inner surface by a mucous membrane. It forms the connecting link between the internal genitals and the ex- ternal genitals, and is called The vagina. Under normal con- ditions the wajls fall together, assuming the form of the let- ter X This brings us to a discussion of the internal genitals and will not detain us long, as they are of very little practical value to the nurse in the exercise of her duties. Where the vagina terminates it surrounds the lower por- tion of a strong muscular organ, called the uterus. That por- tion which projects into the vagina is knoAvn as the vaginal portion of the uterus. This is but a portion of the neck of the uterus, so called for it extends upward for a little over an inch in the unmarried woman and forms about one-half of the whole length of this organ. From the internal opening of the uterus, upward, we have the body of the organ. The length of the whole uterus is about two and one-half inches in the nulli- parous woman and from two and three-quarters to three inches in the multiparous woman; its cavity is lined by a mucous membrane and starts as a small opening in the vaginal portion, extending upward in a fusiform shape unti,l it reaches the internal opening, where there is a decided contraction. Above this the cavity takes on a triangular shape. The upper lateral portion of the cavity being continuous with the cavity of the oviducts or Fallopian tubes. It is in this large tri- angular cavity that the egg finds its lodgment and the child grows to full term. It is also this portion of the uterus that develops so wonderfully during pregnancy. Its strong mus- cular wa,lls assist to a marked degree in expelling the child into the outer world. The uterus is situated in the upper portion of the lesser cavity of the pelvis between the bladder in front and the rec- tum behind. It is a very movable organ. The uterus is held in its position in the pelvis by duplicatures of peritoneum covering cellular tissue of great elasticity and considerable strength. Within the folds of this peritoneum can also be found some muscular tissue, vessels, nerves and the lymphat- ics. These duplicatures are called ligaments, of which there i«re three important ones on each side: The utera-sacral, pos- ter! orily the lateral or broad ligaments on either side, and the round ligaments in front. Besides the vessels, nerves and lymphatics in the broad ligaments we find the ovary and the Fallopian tube. The Fallopian tubes are lined with mucous membrane, and they originate in both upper and lateral portions of the uterus, extending outward for about four and one-half inches and ending in a trumpet-shaped expansion. It has various diame- ters, is of a cord like shape near the uterine end and extends outward toward its fimbriated end. At times it is very tortu- ous. Just behind and below, covered like a dome by the tube, is the ovary. The ovary is an elongated organ, situated to the side and behind the uterus, fastened to what is known as the broad ligament; its longest diameter is one and one-half inch, its greatest breadth is three-quarters of an inch, and its thickness is one-half inch. The ovaries are the most important organs in the female generative system. It is here that the egg ripens, which is destined to become the new individual. As the ovary casts oil' the ripe egg it finds its way into the Fallopian tube, where it is carried along until it becomes fructified and finds its lodgment in the cavity of the bodj^ of the uterus. When we follow up the urethral orifice we find that it enters a canal about one and one-half inches long. It is di- rec ted upward and backward, opening into the bladder above. This canal is lined with mucous membrane and is somewhat dilatable. The bladder is the receptacle for urine as it is excreated from the kidneys. When it is fu,lly distended its lateral diameter is greater than its sagital diameter. It is a muscular organ and lined with a mucous membrane. It is very dila- table, and under normal conditions will easily hold one-half to one pint of urine, and when it is abnormally distended may contain two quarts or more. The rectum, which is the lower portion of the intestinal tract and ends in the anus below, is a muscu,lar organ and is lined by mucous membrane. It is situated in the hollow of the sacrum, behind the uterus. As the patient stands upright the direction is at first straight upward, then upward and backward and to the left. Nature has intended this as a re- ceptacle for the fecal discharges until such time when at the convenience of the individual it can be expelled. Nature guards this canal by a circular voluntary muscle at its lowest end. This is a wise provision, as it enables the individual to retain the bowel contents. I cannot impress upon you too much the importance of knowing the relative location and direction of these various canals and organs which I have described to you. During my lectures I will have occasion to return again and again to this important subject. LECTURE 11. THE USE OF THE CATHETER. The vesical catheter is an instrument used for the purpose of emptying the urinary bladder when, for one reason or an- other, the patient is unable to void her urine or when we wish to obtain a specimen free from contamination for an exami- nation. There are two kinds of catheters, for the most part, used in the female. The short glass catheter with a slightly turned up anterior portion and openings on one or both sides, and the soft rubber catheter. The latter should be used only excep- tionally, and in such cases where the neck of the bladder has been drawn up above the pubis. The glass catheter is the ideal instrument for all ordinary purposes. It is easily cleansed; boiling water and chemicals do not affect it. The eye can detect any impurities on its inner surface. In the use of the catheter it is important not to have 9 either too large or too small an instrument. A number thir- teen of the American scale will fit the Tast majority of cases. It should be aseptically clean and kept so during its introduc- tion. The patient should be protected from any unnecessary ex- posure. The vulva only should be in view, a light blanket or a sheet should be placed lengthwise covering each leg sep- arately. The nurse should raise the knees to avoid any strain on the part of the patient. The greatest gentleness is to be exercised as the instru- ment is pushed along through the urethra into the bladder, and a lubricator is seldom necessary. As the direction of the urethra is at first slightly backward and then upward, the catheter should carefully follow this direction. The vestibule must be thoroughly cleaned with a little sterile cotton and water. Before the catheter is introduced it is best to separate the labia minora with index and middle finger of the left hand, using the right hand for the manipulations necessary for the operation. After catheterization immediately clean the in- strument and sterilize it so that it will be ready for the next introduction. After cleansing it, it can be kept in an anti- septic solution, a corrosive sublimate solution for instance, which, however, should be carefully washed off with sterile water before reintroducing the instrument. When an inflammation of the bladder is produced by the catheter it is caused by a septic germ carried into the viscus. A dirty catheter is, therefore, responsible for this condition. As a clean catheter cannot be passed into the bladder except by sight, the nurse should never hesitate to expose the patient and use such light as is necessary to reach the desired end. If you will explain to the patient why this is done she will never object. It is important that the upper part of the body be somewhat elevated to get a free flow of urine. You should never attempt to catheterize the bladder with the foot of the bed raised, as you will be sure to have air aspirated into the organ. The nurse will sometimes be called upon to wash out the bladder. In doing this she should carefully follow the direc- tions given by the surgeon, using the greatest gentleness and never overdistend the bladder. The liquid to be used for ir- rigation shou,ld be of the body temperature as the viscus is very sensitive to heat or cold. The position of the patient may be two-fold; she may be asked to lie flat on her back with her knees raised, or she may be placed in the knee-elbow or even the knee-chest position. In the latter position the danger of introducing air into the bladder should be carefully guarded against. 10 By INCONTINENCE of urine we refer to a condition where the patient is unable to retain urine in the bladder; as a result there is a constant dribbling. There is a condition of apparent incontinence which is really a RETENTION of urine. It means that the bladder is so full that it overflows, and this condition should always be borne in mind when we have an incontinence or a frequent passage of very small quantities of urine. By SUPPRESSION of urine we mean that condition where the patient's kidneys fail to excrete. It is important that, you should be familiar with these terms and their exact meaning. THE VAGINAL DOUCHE. In administering the vaginal douche we must remember that the direction of the vagina is upward and backward, and that the instrument or nozzle must follow this direction. The instruments used for this purpose are a table, a Kelly pad, or when the douche is given with the patient in bed, a large douche pan and a douche bag with its proper fitting nozzle. (Among the rubber douche bags the so-called King's Fountain Syringe, with a thermometer attached, is the most serviceable.) For hospital purposes the metal or granite irrigators are the most serviceable. They are the only ones that bear boiling. The object of the hot vaginal douche is first cleansing, and secondly to get a contracting action on the blood vessels. For the latter purpose water of a temperature from 105 to 120 de- grees is used. It may be aj)plied in the sitting or squatting posture, but is of little or no use in this position unless the vulva is tightly closed over the nozz,le, thus preventing the overflow of the liquid. The douche may be used with the patient lying flat on her back; here the table and Kelly pad are of the greatest value. The hips should always be raised above the plane of the back, and a very small pillow allowed for the head on,ly. When the patient is in bed too much care cannot be exercised in this direction, as the value of the hot douche is very much enhanced by the proper care as to this posture. At times it is important that the douche be given while the patient is on her knees and elbows or even on the knees and chest. The bathtub is the most favorite place for such manipulations, and great care should be taken to see that the thighs are PERPENDICULAR. When it is desired that the patient should do this in her own room, the knee-elbow posture onlj^ can be used, and a narrow baking pan should then be placed between the knees to catch the water. 1 1 * Since we know from the anatomy of the vagina that this canal is but three inches long, it is only necessary to introduce the tube but a short distance. This is especially the case when we have been careful to pjace the patient in the posture I have just explained to you. When the douche is used for cleansing it should consist of soapsuds in water at about the body temperature, and should not consist of less than two quarts (2 liters), allowing the liquid to flow freely. This will occasion a loss of from three to five degrees temperature from the time that the fluid leaves the receptacle until it reaches the patient. Tt should be fol- lowed by clean water or an antiseptic solution as may be directed. The quantity of water used in a douche depends entirely on its object and may be from a pint to several gallons (8 liters or more.) The time consumed is an important factor. The slower the flow of water the greater wil,l be its value when a hot douche is ordered. The temperature also is of importance as a very hot douche will not cleanse the parts, but simply produce a powerful contraction of the muscular coat and blood vessels of the vagina. You will, therefore, when you prepare a patient for exami- nation or operation not use a very hot douche, but one at a temperature of from 95 to 100 degrees. You will often be called upon to give medicated douches. Be sure never to mix the medicine with the water in the irri- gator. I have again and again seen nurses prepare a car- bolized douche by fiilling the irrigator with the water and then pouring the carbolic acid into the water. The first part of the douche is x>ure carbolic acid and the result is a frightfully burned patient and a summarily discharged nurse. LECTUEE III. RECTAL INJECTIONS. By a rectal injection, enema, or clyster, we mean an opera- tion by which fluid is carried through the anus into the rectum and colon. We divide the enema into low and high enemas. By a low enema we mean the introduction of fluid by means of a small nozzle into the lower part of the rectum. By a high enema we mean the introduction of the fluid high up into the bowel, either by a long rubber tube called a rectal catheter or by such posture as will be s])()k('n of later on. 12 The original purpose of the rectal enema was to cleanse the rectum of its contents by either simpl}' washing the bow(4 out with a large quantity of water or else the introduction of such fluids as would excite the expulsion of its contents. It is important to know that one enema is rarely enough for a thorough cleansing of the bowel. A second enema of a large quantity of y»urm water, a quart or more shou,ld immediately follow the expulsion of the first. When this is done for the purpose of preparing a i)atient for an examination or opera- tion the last enema should be given AT LEAST THREE HOUES before the time set for the operation, otherwise the operator may be seriously annoyed by having the patient's bowels move during the operation. The patient's life may be- come endangered hj an infection of the wound from these de- jections. Whenever such annoyance occurs the nurse is to blame in the majority of cases, and is by no means a recom- mendation as to her ability. The temperature for an enema should be about 100 degrees. It will be of value to you to know that the rectum does not bear antiseptics well. Besides the irritating effect of the anti- septic there is a chance for rapid absorption producing a fatal result. A second purpose of the rectal enema is for the introduc- tion of medicines into the system. Medicines are used in this way, when the patient is unable to swallow or when the stom- ach will not retain the drug, or when for any reason we wish to give the stomach a rest. The quantity injected for this purpose should not exceed sixty C. C. (2 ounces), nor should it be administered oftener than once in two hours. The third purpose of the rectal enema is for the introduc- tion of food into the bowel. Various mixtures will be advised to you for this purpose. Few patients will tolerate more than 200 c. c. m. (6 or vS ounces) once in six hours. It should be given very slow,ly. The time for the introduction should be from five to fifteen minutes. Milk, peptonized milk, eggs, normal salt solution and stimulants are most frequently given. Brandies and whiskies can be given only in vpry small quantities, as they soon irritate the rectum. Once in twenty-four hours the bowel should be flushed with a normal salt solution. A fourth use for the rectal enema is the introduction of fluid into the circulation after hemorrhage and shock following op erations or accidents. For this purpose the enema should consist of what is known as a normal salt solution. It is made up of six parts of common salt in one thousand parts of water, (one dram to the pint of sterile water). During the admin- istration of the normal salt solution, the patient, lying on her back, should have her feet elevated, and too much stress cannot be laid upon the slow and steady stream vv^hich is re- quired for this manipulation. The temperature shoujd be about that of the body, from 05 to 100 degrees. The position in which an enema can be administered may be either the left or the right lateral ; flat on the back with the knees raised; flat on the back with the bed inclined to- ward the head; in the knee-elbow posture, and in the knee- chest posture. For ordinary purposes the left lateral position is the most convenient. When it is desired that the fluid should go high up into the bowel, i. e., the colon, the right lateral position has in my experience given me the best re- sults, as I have been able to trace the fluid into the transverse and descending colon. Of course, when the patient is able to go on her knees and chest, that will be the most favorable po- sition for a. high enema. Sometimes it is desirable to simply flush the bowel and then the patient is allowed to remain flat on her back with her knees raised. After properly protecting the bed with a rubber sheet, etc., the patient is placed direct.ly on a bed pan. Protect the patient's back by placing a folded towel upon that portion of the bed pan upon which the patient rests. You should also see that the bed pan is not cold. A large rubber rectal catheter is then introduced, and the patient is directed not to make any attempt to retain the fluid as it passes into the organ. This would lead us to speak of the great difficulty often experienced in moving the bowels of a woman confined to her bed. This difficulty is experienced from the fact that she must have her bowels moved while in an unaccustomed position for that function, also that she likely has been placed upon a liquid or light diet, and from the lack of ajl muscular ex- ercise. A few things are to be noticed, especially in regard to the movements. While a patient may have an apparent diarrhoea she may be suffering from a large collection of fecal matter in the rectum, usually called an impaction of feces. This can only occur when the nurse has not observed the quantity of the alvine discharges. It is remedied by large injections of sweet oil, from 200 C. C. M. to 500 C. C. M. (Six ounces to one pint), followed by a copious enema of warm soapsuds. If this does not soften and bring away the masses they must be broken up with the finger, and by repeated warm water injections the broken up masses should be brought away. H GENERAL OBSERVATIONS. It is important for the nurse that she should make some general observations about the person of her patient. She should report to the doctor any soreness, swelling, pro- tuberance, discharges, cough, expectoration and the character and quantity of urine excreted; also shape, form, consistency and odor of the recta] discharges. In the gynecological cases observe especially anything that may appear wrong about the private parts of the patient. The character, odor and quantity of discharge from the vagina. Report to the doctor any peculiar and bad habits vou may notice about your patient. Of the latter it willl be wise not to speak of to the patient herself. Of the character of the vaginal discharge you should note especially whether it is bloody or foul smelling; if it is bloody, whether it is bright red or dirty brown, whether it is thin or thick, or clotted. At times there wijl be a j'ellow-white or glary discharge of ropy, thick or thin fluid. MENSTRUATION. Among the vaginal discharges which occur normally we bave the discharge of menstruation. By menstruation is un- derstood a flow of blood from the uterus recurring at certain intervals and connected with the ripening or discharge of an ovule from the ovary. While this discharge of the ovule from the ovary may not always happen at the exact time of menstruation it usually occurs near it. At all events the ovary is the exciting cause of menstruatioUj^ It is called a normal and a physiological menstruation when a woman be- tween the age of puberty, usually from twelve to fourteen years, until the time of the climacteric, from forty-five to fifty years of age, has a periodical flow of blood. Normally this occurs once in twenty-eight days. It usually lasts from four to six days, and it is accompanied by some slight general malaise and uneasiness. The quantit}^ of the bloody discharge is not always easy to ascertain. The usual way is to inquire as to the number of nai3kins a patient soils. Two napkins a day should be considered about normal. The habits of the patient during her former ,life in this regard should be taken into consideration. For what might be a normal quantity for one woman v/ould prove an excessive quantity for another one. That loss which proves a source of exhaustion to any woman is certainly a pathological quantity. 15 The largest amount of flow usually occurs on the first and second days. The character of the flow is commonly of a dirty reddish-brown character, and is often preceded or fol- lowed by a slight glairy discharge. Menstruation becomes pathological when the period of flow is shorter or longer than twenty-eight days; when the time of the flow is but one or two days or more than a week, when the quantity is excessively large or very small, and when the character is bright red, clotted or foul-smelling. Men- struation also becomes pathological when accompanied by excessive pain. Terms used by the laity for this flow is the monthly sick- ness, the monthly period, the regular flow, the unwell period, etc. Always report the appearance, the expectancj^ or the cessation of menstruation as it is often necessary to discon- tinue medicines, local applications, douches, etc., and may call for other suggestions as to treatment. LECTURE IV. PREGNANCY AND ABORTION. It is wise both for the doctor and the nurse always to sus- pect pregnancy. Great worry, humiliation and chagrin may be spared to them, and great danger and sorrow to the pa- tient. Our attention should be directed to a possible pregnancy as soon as the patient has gone over the usual time of men- struation. The cessation of menstruation is then usually one of the first symptoms of pregnancy. This is the more so if the woman has heretofore been regular. This sign is really of great practical value. Of course, there are circumstances under which suppression occurs, due to morbid conditions or a pregnancy may occur in the absence of menstruation. Women do become pregnant during an amenorrhea, and this should be remembered. The next symptom, which is most frequent, is the nausea and sickness upon rising after the night's sleep. It is usually termed the morning sickness. Among the objective signs the earliest is a darkening and widening of the areolar around the nipple. The symptoms just enumerated refer to the signs of preg- nancy of the early months only. The signs of pregnancy of the ,latter months has been taught you by the obstetrician of the institution. i6 When after such a cessation of menstruation and morning sickness a patient has abdominal pains, bloody discharge or a hemorrhage, we may expect an abortion. By abortion we mean an expulsion of the ovum before the fourth month, i. e., at a time when the chorion has not yet changed into the placenta. Such a patient should be put to bed immediately and appropriate medical advice sought. The dangers of abortion are: First, hemorrhage, which may be very excessive, but rarely dangerous to life. Second, sepsis, as shown by chill, fever, foul discharge and general illness of the patient. This is a dangerous condition and early surgical treatment is advisab.le. The nurse may be called upon in the absence of the medical adviser to treat a case of abortion. Her assistance should be of the most temporary kind, and she should never take upon herself the serious re- sponsibility which accompanies such an accident. When the hemorrhage is free she should immediately raise the foot of the bed, but not less than twenty inches. She should remove all of the pillows and bolsters from under the patient's head and shoulders, iit such times the patient should not have hot drinks as they tend to re.lax the muscular sphincters. When the patient becomes faint she may be given Hoffman's Anodyne in small doses to be repeated every fifteen or thirty minutes. Plenty of fresh air and very little bed clothing. In extreme cases, and when no medical assistance can be summoned, it will be proper to tampon the vagina. For this purpose she should be as clean as circumstances will permit. In the absence of sterile gauze, cotton or an antisep- tic gauze, she may use clean, recently ironed handkerchiefs wrung out of boiling water. In place of a speculum a metal shoe horn may be of value. The treatment by the nurse for sepsis should rather be preventative than otherwise She should keep the vulva and its surroundings clean and dry. The discharge should be caught up in sterile or antiseptic gauze. If the gauze is sterile it should be changed more frequently than an antiseptic gauze. Great care should be exercised during defecation, so that no fecal discharge will enter the genital tract. When sepsis has once set in the nurse should not fol.low any routine except the greatest care and cleanliness, but should most strictly obey the attending physician's orders. 17 PREPAEATION OF THE PATIENT FOR GYNECO- LOGICAL EXAMINATIONS AND VAGINAL APPLICATIONS. The table for gynecological examinations should be short, not over 75 centimeters (30 inches) in height, 60 centimeters (24 inches) in width, and 100 centimeters (40 inches) in length. A wider or a longer table will prove a great inconvenience; a chair should be placed at the lower end of the table not over 45 centimeters (18 inches) in height, so that the patient's feet will rest on the chair while she is lying flat on her back. The nurse should be prepared with the necessary basin, soap and towel for the doctor's use. If a lubricant is de- manded it should be sterile vaseline or a 20 per cent, borated vaseline. The latter can never be used again when the soiled finger has touched it. The table should be of sufficient strength to hold the patient and should be covered with a clean blanket and sheet, which is best pinned down so as to remain in place. A small pillow for the head finishes the preparation of the table. The patient is prepared by a thorough enema unless the bowels have moved spontaneously shortly before. The nurse should inspect the vulva before the arrival of the doctor and see that it is c,lean. Want of cleanliness reflects upon the ability of the nurse to discharge her duties in a proper manner. All of the clothing about the waist, abdomen and breast should be loose. This is an important consideration in a well- conducted examination. The patient is examined in the following positions: First — Dorsal. Second — Left lateral, position of Sim's. Third — Knee-elbow position. Fourth — Knee-chest position. By the dorsal position we mean that the patient lies flat on her back, with the head and shoulder s,lightly elevated; the lower limbs are extended or flexed, as the operator may desire. This is the posture used for an abdominal examination. When the examination becomes vaginal the knees should be flexed and raised so that the patient's feet will rest on each side of the table. The knees are then widely separated so as to expose to view the external genitals. That this may be done prop- erly it will have been necessary to raise the ijatient's skirts behind her before she sits down upon the table. The patient should also have been covered with a sheet under which the front part of the clothing has been pushed up beyond the hips. When the examination is to be abdominal the clothing should be pushed well up under the arms. With nervous women it will often be necessary for the nurse to keep the knees separated hx holding them apart. This should be done with gentleness and firmness, which will soon tire out the adductor muscles of the thighs. Now and then you will be asked to get the patient in such a position that the pelvis and thighs are raised above the chest and head; to do this it is necessary to flex the thighs upon the abdomen, which will ejevate the hips and sacrum. This po- sition is often called the lithothomy posture by surgeons generally, and is a modified dorsal position. For an examination in the left semi-prone position of Sim's it is important that you should follow the directions which I now give you, otherwise you will fail in your endeavors. The patient's skirts having been raised behind her, she is asked to sit down at the right-hand lower edge of the table upon the left half of the buttock. She is then told to lie upon her left side and as she goes down her left arm is drawn behind her while the right shoulder is pushed toward the surface of the table. The face is brought over to the left side of the table and the right arm is allowed to hang over the left side of the table. Both knees are placed upon the table in such a way that the thigh of the left (lower) limb extends at right angles from the body, while the right knee is placed above the left one. It should not be forgotten that to do this properly there should be no pillow under the patient's face, but she should lie upon a perfectly fiat table. If it is found that the upper portion of her trunk has not rotated sufQciently forward, a slight pressure upon the right shoulder in that direction wi,ll accomplish the desired end. The nurse then takes a position at the lower right-hand end of the table, pushing all the clothing up above the hips under the sheet, which she has already spread over the patient. This sheet is raised suf- ficiently to uncover the left buttocks and the genitals, while a fold of it is tucked in between the thighs. The nurse is now prepared for any assistance she may be asked to give. The Sim's speculum must be held in position by the nurse. To do this she must stand to the right and back of the patient, facing the surgeon. It is also important that the nurse stands firmly and quietly on both feet. If she so desires she may rest her right arm on her hip while she holds the speculum; this leaves the left hand free so that she may raise the right buttock of the patient or separate the labia if so desired. The knee-elbow posture is accomplished in the following way: The patient is asked to stand upon the chair at the lower end of the table, facing the table. The skirts are raised in front of her and she is then directed to kneel upon the table. She now bends her body down forward and rests her trunk upon her elbows. It is very important that the thighs should be perfectly perpendicular as this raises the hips to the greatest possible height in relation to the rest of the body. The patient is now covered with a sheet and her clothes raised over her back under it. The knees are then separated for six or eight inches and the patient is j"^ady for ex- amination. When the knee-chest position is desired you will simply have to get the patient from the knee-elbow posture into the former by asking her to rest her face and as much as possible of her chest upon the table with the arms lying above the head, always remembering that the thighs should remain PERFECTLY PEEPENDICULAR. The instruments to be used during the examination should be placed upon a clean towej or in a basin of warm water, to the right hand of the operator. It is well to have some clean cotton ready to be used as wipes and a basin into which soiled instruments, cotton and dressings may be thrown. When you are asked to prepare cotton or oakum tampons, make them of medium size with a clean string tied around the middle so that the tampon will take the form of a dumb- bell. The oakum tampon should always be covered with a thin layer of cotton. Always remind your patient that the tampon must be removed and tell her when. At times it will be necessary that the patient be supplied with a vulva pad. You will sometimes be called upon to clean pessaries that have remained in the vagina for a long time. They should be brushed first with Sapolio and warm water. If there is any calcareous concretions on the pessary which is so common with those that have remained in the vagina for a long time, it should be removed by washing or dipping the instrument into a dilute solution of muriatic acid, and washed off with plain water. Vaginal suppositories are frequently ordered. They come in various shapes and sizes. When they are made of butter of cocoa they need no lubricant, otherwise a little moist soap will answer very we,ll. The nurse should proceed in the following way in their introduction: Standing on the right side of the patient, with the patient on her back, she separates the knees widely and with the left hand parts the labia majora, while with the right hand she introduces the suppository into the vaginal orifice, pushing it along with the finger until it is arrested in the posterior cul-de-sac of the vagina. The Ijatient is then directed to remain in the dorsal position f(jr an hour or more. 20 When you are called upon to make a vaginal application it will be done most readily by the instrument known as Thomas's Cupping Cup. The piston of this instrument is withdrawn half-way, a tampon with a string attached pushed into it until it has been arrested. This is then filled with the lit|uid prescribed for the application and the piston drawn down the other half of the instrument. The result of this is that the liquid is drawn into the cotton. The instrument is now introduced into the vagina as high as it can be pushed and the cotton and liquid forced out. The string, which has been allowed to hang down from the instrument, will now hang from the vagina. LECTURE V. SURGICAL CLEANLINESS. You have heard me speak in my past lectures about clean- liness, about sterile instruments and sterile dressings. It will be my duty to tell you what we mean by surgical clean- liness in relation to gynecological nursing. By surgical cleanliness we mean that everything that may come in contact with a wound or its surrounding should be free from dirt and living organism, and a well-trained and conscientious nurse will consider it a disgrace to make a break in those details which insure such cleanliness. It will pre- vent serious illness to the patient and its importance in operative gj^necological work cannot be overestimated. When a patient gets sick after an operation, with fever and other symptoms of blood poisoning, we may truly ask ourselves : Who was dirty? It is not uncommon, I am Borrj to say, to meet unclean doctors, and it will be your duty to prepare things in such a way that the least amount of harm will result from his work, but it wi,ll be the duty of the clean doctor to ask for a clean nurse when an incompetent one presents herself. The part of the body which the gynecologist is asked to treat is the most difficult to keep clean. Its closeness to the end of the alimentary canal with its discharges, the moisture and discharges from the genito-urinary tract and the warmth of that part of the body are all factors which favor decompo- sition and growth of living organisms. The greatest care should be exercised in keeping all of these discharges from recent wounds. They are all poisons in a greater or less de- gree. Your hands should be cjean from such poisons when you are called upon to perform manipulations in other cases. 21 We eau prevent wound poisoning by first avoiding to carry the poison to the patient. Second, by avoiding to give wound poison a chance to grow and multiply, and Third, by carrying poison from one patient to another. The first is done by allowing only clean things to come in contact with the patient. The second is accomplished by promptly remoying all discharges from the wound and its neighborhood, thus taking away the medium in which the germ will grow. The last is reached by the nurse who wil,l consider it her duty to abstain from handling a clean patient when she has been in attendance upon one suffering with a suppurating or infectious diseases. Such poisoning is called sepsis and means the result of putrefactive changes in the body. All wound poisoning is produced by germs. We often hear the term SEPTIC. This means a thing that will cause sepsis; for this reason a septic body is a substance that under favorable circumstances promotes and produces putrefaction. Surgical sepsis arises from the invasion of a wound by pathogenic or disease producing micro-organisms which find in the tissues suitable conditions for their de- velopment and growth. ASEPSIS means freedom from germs. An antiseptic is a body not only free from germs but one that will kill them. The term disinfectants is applied to agents used for destroying septic material. You will do well not to use this term in your examinations, but rather express yourself in fitting language how such an end is reached. There are certain things that are especially dangerous as sources o-f infection, because they form good media for germ growth, like blood, mucus, urine, fecal discharges, etc. Thus also are all of the discharges from wounds; the dis- charges from the womb after child birth and miscarriages. A dangerous source of infection is found in scarjet fever, erysipelas, diphtheria and the poisons of dead bodies. For her own sake the nurse should be careful never to touch septic matter with sore fingers. It is best not to touch it at all, but use instruments for all manipulations. A nurse whose ward work brings her into direct contact with abscesses, sloughing carcinomata, suppurating wounds, etc., must be debarred from helping at operations or making dressings for c1g9.i1 C3.SGS THE BEST NURSE IS THE ASEPTIC NURSE. I look with great suspicion upon the antiseptic nurse and doctor. They succeed more frequently in killing their patient with the antiseptics than in killing the germs. 22 Personal ejeanliness must be observed by frequent bath- ing, elianges of underclotliing and linen. A nurse wlio is dirty in her general habits is unfit to be a nurse at all. While this is especially so in surgical work, she is a dangerous nurse at all times. The obligation to keep clean begins long before entering the operating room for the purpose of ''WASHING UP." It is a duty devolving upon nurses to avoid direct contact with septic material at all times. It is possible to do so, and to scrub the hands thoroughly after any such con- tact. The nurse should educate herself to a feeling of aver- sion to touching anything unclean. There is nothing heroic in puddling in dirt. All instruments should be made aseptic by the use of Sapolio, soap and brush, and then boiling them. Boiling in a 1 per cent soda solution also has the great advantage of pre- venting rust. This you will find to be much better than using strong antiseptic solutions, for if the instruments have any grease upon them the antiseptic wi,ll not penetrate. Besides they spoil the instruments. All of the trays and basins are safe only when they have been boiled. All glass instruments, such as catheters and tubes, douche nozzles, etc., should be sterilized by boiling, and kept so, ready for use in a saturated solution of boric acid or a corrosive sublimate solution 1-2000. When a strong anti- septic, such as corrosive sublimate is used, the instrument should always be washed off with sterile water before touch- ing the patient. Aseptic vaseline should be used as a lubricant for all instruments. It is prepared by heating vaseline in the oven for one-half hour. Vaseline can be rendered aseptic in a very few minutes in a spoon held over a gas flame until it begins, to boil. LECTURE VI. GENERAL REMARKS ON THE PREPARATION OF PA- TIENTS FOR ABDOMINAL AND GYNE- COLOGICAL OPERATIONS. For all of these operations which come under the head of abdominal and gynecological operations we have gradually learned that the patient does better and has an easier conva- lescence, if she undergoes such preparatory treatment as will cleanse the skin, will empty the bowels and keep them so. For that reason the patient should have a hot soap bath and a good rubbing with a coarse towel. A laxative and a rectal injection are necessary to carry away the fecal dis- charges which you know so often accumu,late in the bowels of some people. In order that the bowels may remain empty the diet should be of such a character as will leave little residue in the alimentary tract. Such a diet should consist of milk, broths and gruels. Especially is this the case on the day previous to the operation. We should especially avoid such food as wil,l produce gas in the intestines. The skin about the location of the operation should be thoroughly cleansed by lathering with soap and shaving. While you are in the hospital, at least, never forget to send to the house surgeon a specimen of urine which should have been drawn with a catheter. When you send a specimen of urine to the doctor's office it is wise to send it in such a way that decomposition can take place only very slowly. In fact, with great care one can draw a specimen of urine which will keep very we,ll for several days. The method by which this is done is the following: A small rubber tube is fastened to the end of a catheter and this, with the bottle into which the urine is to be drawn and the cork with which to close the bottle, are all boiled for ten minutes. When the urine is drawn (of course, with the precautions already spoken of), the rubber tube is allowed to hang into the bottle and as soon as the bottle is quite ful,l it is tightly corked with the sterile cork. The whole neck of the bottle is then cov- ered with sterile cotton and gauze. The patient is prepared by thoroughly shaving and scrub- bing the location to be operated upon. A bi-chloride towel is then placed over the parts. As the patient goes upon the oper- ating table she should have her trunk and lower limbs cov- ered with flannels, artificial teeth removed and all tight bands loosened. The patient should always be catheterized before an abdominaloperation, i. e., after she is well under the anesthetic. The nurse should be clean herself. She should refrain from nursing a surgical case if she has lately been in at- tendance on a septic case. A hot bath and a change of washable clothing are an important requirement for every operation. When the operation is over the patient shou,ld be speedily made dry and placed in a warm bed. Nurses are often at a loss to know how to prepare for a change of dressing in a private house. They have been ac- customed to receive everything sterile and now they are left without it. They will succeed fairly well if they follow these directions: Cotton pledgets of the size of hickory nuts are 24 placed in a clean fruit jar until the jar is full. The nurse then supplies the jar with a rubber washer and cap. A similar jar is then filled with rolls of absorbent cotton, which when unrolled will be six by eight inches in size. These jars, tightlv closed, are then wrapped in a towel so that they will get wet all over. They are now boiled for three hours. Gauze pledgets and dressings are steri.lized in the same way. Sterile towels are made in this way, or else in the following: A clean sheet is spread over an ironing board and sprinkled thoroughly with clean water and ironed with a very hot smoothing iron. A clean towel is then spread upon this sheet and sprinkled with clean water. She now irons this towel until it is thoroughly dry with the \erj hot iron; this is then laid aside on the sheet just spoken of, and another towel is then ironed and fo.lded. Each towel is thus thoroughly ironed and nicely folded and placed on the side of the ironing board that is covered with the sheet. In this way she irons and folds four towels, eventually wrapping them in the first towel spoken of. This is continued until she has a sufficient number of dressing towels ironed for each dressing. In sterilizing the towels the nurse should have her hands thoroughly clean. The following precautions should be taken when you are not pressed for time : You can steri,lize your cotton and towels by rolling them up and placing them in a quart fruit jar, tight.ly closed and boiled for three hours. Of course, the bottles must be hermetically sealed and removed from the boiling water while the water is still hot. If the bottles are allowed to remain in the water until it cools the suction will force water into the jars. I have NO USE for a nurse who SCORCHES and DE- STROYS the linen of a household, nor will I recommend one who does so. Nurses should never sterilize towels by putting them in the oven and scorching them, as this is the common practice. No family likes to have two or three dozen towels destroyed on them in this way. Nor are they thoroughly sterile unless scorched. The nurse should have supplied at the bedside a pair of scissors and dressing forceps, a small glass syringe and a small brandy glass, all sterilized and placed in a sterilized basin containing sterile water; she should supply dressings as ordered. A basin for soiled dressings will be of great use. When the nurse is ca,lled on to do the dressing she should avoid using her fingers. She should at all times use dressing- forceps whenever possible. In the emergency cases when the time for preparation is very short the nurse will have to use all of her wits to prepare the patient as best her training has taught her. She should ♦ 25 never forget to supply or to think of the best light for night work. In these cases we must take risks in regard to asepsis which cannot be permitted with ordinary cases. As a rule the doctor will order how the patient should be prepared; when he fails to do so you will not go amiss by following such directions as are given to you in such an in- stitution as this, and which is my pleasure to tell you. In the hospital you will have no voice in the selection of the operating or sick room. These are already furnished. It is different in the private house. When the doctor is present consult him as to the choice of room; when not, be sure to select such a room as will have plenty of light and air, but avoid the direct sunlight for the operation. When there is no choice, and there is direct sunlight, cover the windows with a sheet during the operation. A north light is best for al,l operations. Kemove all useless furniture, but do not upset the whole house; cover the large pieces with sheets, and if there has been no time to remove the carpet cover it with newspapers and sheets. Avoid stirring up the dust. Wipe all of the furniture and woodwork with a damp towel. The temperature should be about 80 degrees F. You should clean and disinfect all closets, basins and bathtubs near the operating room; this is best done by pouring a strong hot solution of potash lye into these utensils. For our purpose an operating table," such as has been de- scribed under the head of gynecological examinations, will do very well. An ordinary kitchen table is always handy; let it be thoroughly scrubbed and cleaned. Two smaller tables for instruments and sponges or wipes, two buckets for waste water, two basins, preferably agate or tinware, and one porcelain basin, besides a soap dish for the patient to vomit into; nail brushes shou,ld also be procured. The por- celain basin can be used for towels, steeped in a hot bichloride solution. The two basins of tin or agateware should have been boiled in a wash boiler for ten minutes, and one can be used by the operator to wash his hands in during the operation, while the other is for sterile warm water for the purpose of washing up the patient. This will supply all of the utensils that may be wanted in this direction. T^or the larger operations two dozen towels, two sheets and a clean small blanket, all recentlj^ sterilized. Sterilized hot and cold water will have to be supplied and should be prepared in this Avay. See that your pitchers are thoroughly clean, then ,boil them in a wash boiler for one-half hour. Fill a tea kettle and let the water that is in it boil for ten minutes, then pour it into your boiled pitchers. They should now be 26 covered with a sterile towel and set in a safe place to cool. Two large toilet pitchers full of water will be sufficient for most operations. The nurse should have her glass catheter boiled ready for use. Pr-jtect the floor beneath the operating table by spreading oilcloth or newspapers over it, and over this lay the sheets. In the room adjoining the operating room you should have basins of water, soap, brushes and towels for the surgeon's use. AVliatever antiseptics he may want to use will be or- dered by him. Thus also will he order the dressings. If none is ordered the nurse should have sterile gauze, iodoform gauze, sterile cotton, and a many tailed or plain flannel bandage ready. She should be provided with safety pins and a good pair of scissors. When the surgeon has no gown you may use a large towel recently ironed and pin it to his suspenders. If you are responsible for the sponges, count them and re- count them most carefully. Sea sponges are rarely used in these days. When napkins are used they should be care- fully counted, and each one accounted for before the wound is closed. A napkin or sponge left in the abdomen is likely to kill the patient. In this hospital every napkin is known by a letter and a number; the letter is changed on every set of thirty naj)kins in such a way that no two nai)kins in the house have the same number and letter on it. For instance, there is but one napkin known as 0. 17. Every nurse should supply herself with shaving appliances and a hypodermic syringe. She should see that alcohol and brandy or whiskey is furnished. The room and bed for the patient after the operation should be properly prepared for her reception after the oper- ation. It is well to leave the patient in the room that she has been operated in. The bed should have been made v/arm by the use of hot water bottles, but never pack hot water bottles around your patient, as severe burns have been caused by such Dractices. If the room selected is a cheerful and quiet one so much the better. Ask your doctor for instructions about diet and the use of the catheter. PEEPAKATION OF THE PATIENT FOR SPECIAL OPERATIONS. 1.— PREPARATION OF THE PATIENT FOR EXAMINA- TION UNDER AN ANESTHETIC. The patient's bowels should have been moved thoroughly with fifteen grammes of potassii et sodii tartras, to be given 27 « on the Dioi'uing preceding the examination, one-half hour before breakfast and liquid diet on that day. On the evening of that day she should have a hot soap bath, including a sham- poo of the head and clean linen. On the morning of the exami- nation she should have two large warm water rectal enemas, the first of which should be of soapsuds followed by plain water. The last of these should be given three hours before the examination. After the bowels have been thorough,ly emptied a large warm vaginal douche of soapsuds should be given. She must have no breakfast whatever, and no milk for twelve hours previous to the anesthesia. If the anesthesia is to take place in the afternoon she can have a little black coffee and later some beef broth. 2.— PREPARATION OF PATIENT FOR RECTAL OPERATIONS. The anus and vulva shou,ld be shaved, and a thorough bath, shampoo, etc., and clean linen put on. The bowels should be thoroughly emptied. I prefer a calomel purge, which is given on the morning of the day before the operation and followed by a seidlitz powder two hours after the last dose of calomel. The following is the formula I order for the calome.I powders: R. Calomel 0.6 Sodae Bicarb 0.3 Sacch. Alb 2.0 M. Div. in doses No. 3. Sig. One powder every two hours. On the morning of the operation two large rectal enemas, the first of which should be soapsuds and the last plain water, and a vaginal douche are administered as has been noted under the foregoing order. The patient should have had a liquid diet on the day she took tlu.' calomel powders and no breakfast on the day of the operation. 3.— PREPxVRATION OF THE PATIENT FOR DILATATION OF THE CERVIX UTERI AND CURETTAGE. Are the same as number one, except that the patient should be shaved about the vujva and pubes, and the calomel powders given as in number two. 28 4.-- -PREPARATION OF THE PATIENT FOR OPERATION ON THE CERVIX UTERI, THE BLADDER, VAGINA AND PERINEUM. Should be the same as under number three, except that the patient should have a strictly liquid diet on the day pre- vious to the operation. 5.— FOR THE PREPARATION OF THE PATIENT FOR ABDOMINAL SECTION AND ALL VAGINAL OPER- ATIONS IMPLICATING THE PERITONEUM. All patients prepared for vaginal operations implicating the peritoneum should also have the abdomen ttrepared for an abdominal section. She should be in the hospital or under preparation for forty-eight hours previous to the operation. On the first day she should be given calomel and seidlitz powders as under number two. She should have two soapsud douches and a hot soapsud bath, hair shampoo, clean body linen and clean bed linen in the evening. She should have another seidlitz powder or fifteen grammes of potassii et sodii tartras on the morning of the second day. In the evening another hot soap bath and clean linen. After this she is put into a clean bed and a soap poultice placed over the whole abdomen for two hours. The abdomen is then thoroughly shaved and scrubbed, especial care being given to the navel. The same can be said of the vulva. The abdomen is then Avashed with ether and alcoho,l. All is covered with sterile gauze, which is kept in position by a well-fitting abdominal and T binder. On the morning of the operation the patient receives an enema of warm soap water, followed by one of plain water, the last of which should be administered at least three hours before the time set for the operation. If the second one con- tains fecal matter, a third or fourth may be necesssary. A vaginal douche of corrosive sublimate 1-5000 follows. A large piece of gauze or a towel dipped into a corrosive sublimate solution of 1-2000 is placed over the abdomen and vulva and should be kept in place for tvv o hours, that is to the time of the operation, and kept in position by a well-fitting abdominal and T binder. The patient is then dressed in flannel clothes. During the first day of the preparation the patient should have only such food as is easily digested and will produce but little gas or residue. A patient's idiosyncrasy must be taken into consideration. As a rule she will do well with a broiled 29 chop or steak, wheat porridge, milk, tea, coffee, beef broths, chicken broths and cooked rice. Avoid all vegetables, fruits and sweets. On the day previous to the operation liquids only are ad- missable. On the day of the operation she should have noth- ing if the operation is done early in the morning, otherwise she may have a cup of beef or mutton broth with barley. The urine should always be drawn on the first day for examination. 6.— PREPAEATION OF PATIENT FOR AMPUTATION OF THE BREAST. The nurse should begin preparations twenty-four hours before the time set for the operation. The patient should have a calomel purge and a seid,litz powder as in number two. A liquid diet and a hot bath, shampoo and clean linen on the evening preceding the operation. A soap poultice should be placed upon the breast, shoulder, upper part of the arm and axilla for two hours after the bath, when it is removed and the breast, axilla and arm are thoroughly scrubbed and shaved. All is then washed off well with ether and alcohol and covered with sterile gauze, which is kept in position by a breast binder and shoulder straps. On the morning, two hours before the operation, a cor- rosive sublimate poultice 1-2000 is placed over the breast, shoulder, upper part of the arm and axilla. She is to have no breakfast, if the operation is done in the morning, other- wise she may have beef or mutton broth with barley. THE AFTER-TREATMENT OF THE PATIENT. The care which the nurse gives to her patient should, among other things, consist of keeping a careful record of everything going on about her. A record of the temperature, pulse and respiration, at intervals of three hours; the quantity of food given, amount of urine passed or drawn, the escape of flatus, the hours of sleep or restlessness, medicine given, condition of the skin, mouth, change of dressings, baths, etc., are all very important. She should also note the total amount of food that has been given in the twenty-four hours, and the quantity of urine passed or drawn in the same time. 30 It is wise to record the amount of urine passed for at least three times twenty-four hours after the operation, unless spe- cial orders for its continuance is given. The patient may pass her urine if she can. Anything worth while recording should be recorded at the moment it occurs and the memory never trusted. In all rectal operations a well-fitting T binder, with a suitable dressing and compress over the anus, is desirable. The dressings and compress should be renewed, the parts cleaned after each catheterization or defecation. It is wise when a cathartic has been ordered to inject from 150 c. c. m. to 200 c. c. m. of sweet oil into the rectum, as it assists ma- terially in the painlessness and ease with which the movement passes over the raw surfaces. It is wise to inject this with a soft rubber catheter of medium size, to which is attached a funnel or syringe. The temperature of the oil should be from 95 to 100 degrees; this can be heated to the desired temperature by placing the vessel containing the oil into another vessel con- taining hot water. As soon as the bowels have moved the parts should be thoroughly cleansed with pledgets of sterile cotton and sterile water; if necessary, soap may be added. It is not easy in the rectal cases to take the temperature in the bowej. It is therefore best to take a mouth temperature or a temperature by the vagina. In operations about the vagina or the perineum the ex- ternal genital should be kept scrupulously dry and clean. Douches should not be given unless ordered. In the perineal operations small pieces of gauze should be placed on both sides of the vulva and sutures. These should be frequently changed, certainly often enough to keep the parts dry. The movements of the bowels, after perineal operations, whether they have been complete or incomplete tears, should be urged after forty-eight hours; in both cases from 130 to 200 c. c. of oil should be injected into the rectum. This is most necessary in the after-treatment after the operation for complete laceration of the perineum. In this operation the patient's bowels should be moved while she lies on her left side, the nurse taking care of her in the following way: The patient should be placed on her left side with a sma,ll pillow under her head and a pus basin pushed well under the left buttock after both knees have been well flexed and the bed protected. When the inclination comes the nurse supports the perineum with her left hand by pressing the flesh of the right buttock just above the gluteal fold to the left side, while the right hand raises the flesh of the right side above the anus outward. This opens the anus without putting any pressure on the perineal wound. If the move- 31 ment is an easy one it is not necessary to repeat this manipu- ilation, and the second movement may be had on the bed pan. A movement should be secured once in two days. When the urine is drawn the thighs should be raised at right angles to the body. The meatus urinarius will become quite apparent. When the patient passes urine voluntarily the parts should be rinsed with sterile water and wiped dry with pledgets of sterile absorbent cotton or gauze, using a sterile dressing forcep to handle the pledgets instead of the fingers. Take the temperature by the rectum. In all of the cases thus far spoken of the patient should be placed on a .liquid diet for two days, except in the rectal cases, when it will be wise to give a liquid diet for five days. In the abdominal sections we usually give our patients no drinks until vomiting ceases. One can, as a rule, say that all vomiting ceases after six or eight hours; we then give a tea- spoonful of hot water, as hot as the patient can take it, every ten minutes for tw^elve hours. Hot barley water (three table- spoonfuls of washed bar,ley in a quart of water, boiled for three hours and kept at a quart), and hot water alternately every ten minutes may be given for the next twelve hours. If during this time the patient complains of great thirst a warm normal salt solution (6 parts of salt to 1000 parts of water), may be slowly injected into the rectum in quantities of 200 c. c. m. once in three hours. When the barley water and the hot water has agreed with the patient, hot milk is added to the diet in tablespoonful doses alternately with the barley water every twenty minutes. As soon as the patient has passed gas per rectum she takes one-half teacupful doses of the food as she desires, but not less frequently than every hour. When she sleeps she should not be disturbed for anything. Beef and chicken broth with barley, rice or oatmeal can be added to this diet on the fourth day. The urine should be drawn once in six or eight hours unless the patient can pass it herself. While there is no serious ob- jection to having the bowels move earlier than the fifth day, 1. e., four times twenty-four hours after the operation, it has been my custom to do so for many years. I usually order a teaspoonful of Kochelle salts every hour in a table-spoonful of water until the bowels move. When the patient is nauseated, or when she vomits, I stop the Rochelle salts by mouth and order two tablespoonfuls of Rochelle salts in 500 c. c. m. of water to be given by enema. From the time that her bowels move until the end of the week the patient takes a liquid diet ; after that she may take solids. The bowels are moved every second day, and the patient may be allowed to sit up on the eighteenth day. 32 In exceptional cases you will be asked to manage the drainage tube. The drainage tube is placed in the lower end of the wound down into Douglas's Cul-de-sac. After the wound is closed and covered by such dressing as suits the surgeon, a piece of rub- ber dam is slipped over the flanged end of the tube, then a small piece of gauze is placed over the tube and the rubber dam folded over this; the nurse now will be directed to empty this tube at various intervals, and it is done in the foljowing way: Sterile dressing towels are placed around the rubber dam and the latter carefully unfolded. A small-size rubber tube about 14 inches in length to which has been attached a glass syringe, all thoroughly sterile, is carefuljy introduced into the bottom of the glass drainage tube. By withdrawing the piston of the syringe the fluid in the drainage tube is withdrawn into the syringe. The rubber tube is now with- drawn and the fluid emptied out of the syringe. This maneuver is repeated until the drainage tube is thoroughly emptied. A piece of iodoform or corrosive sublimate gauze is placed over the drainage tube and the rubber dam carefully folded over this. The whole apparatus is held in position by a towel or napkin pinned over it. This emptying of the tube is done once an hour for the first twenty-four hours and less frequently during the next. Once in six hours the tube is given a slow twist so as to free the openings in the lower end.