WY 161 C741t 1921 54630830R NLM D52flA7ET t> NATIONAL LIBRARY OF MEDICINE SURGEON GENERAL'S OFFICE 1IBRARY. Section No. 113, W.D.S. G.O. No .Z.MJ.&J-3 NLM052887296 TEXTBOOK OF SURGICAL NURSING THE MACMILLAN COMPANY NEW YORK • BOSTON • CHICAGO DALLAS • ATLANTA • SAN FRANCISCO MACMILLAN & CO.. Limited LONDON • BOMBAY • CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, Ltd. TORONTO TEXTBOOK OF SURGICAL NURSING BY RALPH COLP, A.B., M.D. INSTRUCTOR IN SURGERY, COLUMBIA UNIVERSITY, NEW YORK; LECTURER IN SURGICAL NURSING, PRESBYTERIAN HOSPITAL TRAINING SCHOOL FOR NURSES, NEW YORK ; ADJUNCT VISITING SURGEON, VOLUNTEER HOSPITAL, NEW YORK | CHIEF OF SURGICAL CLINIC, BETH ISRAEL HOSPITAL, NEW YORK \ FORMERLY LECTURER IN NURSING AND HEALTH, TEACHERS COLLEGE, . COLUMBIA UNIVERSITY, NEW YORK / AND MANELVA WYLIE KELLER, B.S., R.N. FORMERLY CHIEF OPERATING ROOM NURSE, ST. LUKE'S HOSPITAL, NEW YORK, AND ANESTHETIST, ST. LUKE'S HOSPITAL, NEW YORK, AND MOBILE HOSPITAL NO. 2, A. E. F., FRANCE LIBRARY jfteto gorfe THE MACMILLAN COMPANY 1921 All rights reserved PRINTED IN THE UNITED STATES OF AMERICA w lol CT1I "y9 f Copyright, 1921, By THE MACMILLAN COMPANY Set up and electrotyped. Published June, 1921. AUG 17 1921 <] Press of J. J. Little & Ives Company New York, U. S. A. ©CLA622430- -Vio rY DEDICATED IN RESPECTFUL TRIBUTE TO THE COURAGEOUS AND DEVOTED NURSES WHO SACRIFICED THEIR LIVES TO THE CAUSE OF SUFFERING HUMANITY IN THE GREAT WAR PREFACE The authors have endeavored to present as accurately and as simply as possible for the pupil nurse the actual detailed nursing of the various conditions related to things surgical. The various procedures are based on the technic employed in hospitals throughout the country, and therefore the book will be found useful as a text in training schools generally without regard to local conditions. It presupposes a thorough knowledge of the elements of practical nursing. The funda- mental treatments, as a rule, have been carefully learned in the probationary periods, but a thorough understanding of the underlying principles of surgery and the necessary surgical nursing are often wanting. While it is true that all orders are given by the surgeon, and executed with dispatch and accuracy by the nurse, the time has passed when the nurse was a mere automaton. She must know the ante- and post-operative care required for all the patients coming under her supervision. The complete management of an operating room, as well as the conversion of a private home into a suitable place for surgical procedures, should be thor- oughly understood, and an operation by name, be it "glos- sectomy," "thyroidectomy," or " choledochotomy," etc., should immediately summon to mind the condition and the technic involved. The nurse should be well acquainted with the recent surgical developments of the World War, such as the Carrel-Dakin method of wound disinfection, the ambrine treatment for burns, and the suspension treatment for fractures, since her aid is essential for their proper accomplishment. The chapter dealing with Surgical Dietetics has been based, in the main, on the diet lists used by the Presbyterian Hos- pital, New York. We are indebted, for the photomicrographs, to the Surgical Department of Columbia University, and for vii viii PREFACE some of the pictures to the '' Manual of Splints and Appliances, Medical Department, United States Army." The authors wish to express their appreciation and thanks to Miss F. Evelyn Carling, Assistant Superintendent of Nurses, St. Luke's Hospital, New York, for her advice and many sug- gestions, and to Mrs. Ralph Colp, and Mrs. Amy P. Phillips for their keen interest and invaluable assistance in the prep- aration of this volume. INTRODUCTION AND HISTORY Surgery is as old as human needs. There have always been bleeding wounds and broken limbs, and human ingenuity has always endeavored more or less successfully to relieve the suf- fering so occasioned. In ancient times, the supposedly super- natural secrets of the healing art were zealously guarded from the laity, and not till the Greek Hippocrates in 460 B.C. wrote his surgical treatises did surgery pass from mysticism to sci- ence. So keen were the observations of Hippocrates that some enthusiasts claim that his two works on fractures and dis- locations are in many respects unsurpassed even to-day. And until as recently as four centuries ago very little was added to the storehouse of surgical knowledge. During the early Christian era and the Middle Ages, sur- gery was practised by many different classes of society, by friars and barbers, by monks and nuns, by the famous Arabian court physicians, and by ladies of noble birth. The universi- ties from the very beginning prohibited research of any kind and demanded that every procedure be justified by the author- ity of Galen. Now and then solitary thinkers tried to find out things for themselves by observation and reflection. The great occupation of the majority of the people was warfare and much of the little progress in surgical knowledge owed its inspiration to the necessities of war. But even to aid the king's armies the new truths learned by experience and ob- servation were discountenanced by the faculties of the uni- versities. In spite of this opposition, by the fifteenth and six- teenth centuries there was a widespread awakening of the free scientific spirit. It manifested itself in the forming of groups to study and experiment in physics, chemistry, anatomy and physiology. Tremendous progress was made in all the sci- ences. Harvey discovered the circulation of the blood, the ix x INTRODUCTION AND HISTORY microscope came into use, and Fahrenheit invented the ther- mometer. "Western Europe broke out into a galaxy of names that outshine the utmost scientific reputations of the best age of Greece," says II. G. Wells; and of these Vesalius and Fal- lopius, the anatomists, are especially honored by surgeons of to-day. By the eighteenth century, private dissecting rooms and ana- tomical laboratories were flourishing. However, the surgeons themselves of this period neither helped nor shared in this great advancement of science. The barber-surgeons were an untutored lot, ready to make use of a few tricks of the trade for practical gain. The task remained to place the practice of surgery on a high plane, and this was one of the many good deeds which make the name of John Hunter shine out in the history of surgery. "More than any other man he helped to make us gentlemen," a contemporary said of him. Through the efforts of Dr. Hunter, the already existing companies of barber-surgeons were forced to study anatomy, comparative anatomy and physiology, and thus the surgical profession by the right of hard and regulated study began to take rank with the high order of scientists. Public museums of anatomy and physiology were founded; the method of clinical teaching was adopted; and in the beginning of the nineteenth century the day of painless operation had come with the discovery of an- esthesia. Still the surgeon was held in disrepute. The dark ages when investigation was forbidden were passed; all the sciences aided the surgeon; he progressed with the great advance in anatomy, physiology and pathology. And yet, the hospitals where he operated were considered houses of certain death. An opera- tion was in truth a sad affair. No matter how great the tech- nical skill of the surgeon, patients, more often than not, died of blood poisoning. Now and then a wound did heal without the formation of pus, but both spontaneous and operative wounds almost invariably became infected, with death as the result. So common was this, particularly in hospitals, that many surgeons feared to operate at all. The term "hospi- talism" was coined by Sir James Y. Simpson, who collected sta- INTRODUCTION AND HISTORY tistics proving that private patients were far less liable to succumb from operation than those treated in hospitals. With the advent of Lister came "a light that brightens more and more as the years give us ever fuller knowledge," as Sir William Osier has said. It was to the researches of Pasteur, the great French scientist, that Lister owed his inspiration. One of the first practical results of Pasteur's studies on fer- mentation and spontaneous generation was a great transforma- tion in the practice and results of surgery. It is not too much to claim this as one of the greatest boons ever conferred on humanity. Let us quote from Lister's paper on the subject which appeared in the London Lancet, 1867. "Turning now to the question of how the atmosphere pro- duces decomposition of organic substances, we find that a flood of light has been thrown upon this most important subject by the researches of Pasteur, who has demonstrated by thoroughly convincing evidence that it is not to its oxygen or to any of its gaseous constituents that the air owes this property, but to minute particles suspended in it which are the germs of various low forms of life long since revealed by the microscope and re- garded as merely accidental concomitants of putrescence, but now shown by Pasteur to be its essential cause, resolving the complex organic compounds into substances of simpler chem- ical constitution, just as the yeast plant converts sugar into alcohol and carbonic acid." From Lister's work modern surgery takes its rise and the whole subject of wound infection, not only in relation to sur- gical diseases but also to childbed or puerperal fever now forms one of the most brilliant chapters in the history of Preventive Medicine. So great have been the results of Lister's work that it is indeed almost difficult from our fortunate position of to-day to glimpse the sad position of the surgeons of his time. In present-day hospitals surgical infection and puerperal fevers are almost things of the past, and for these achievements alone the names of Louis Pasteur and Joseph Lister will go down to posterity as among the greatest benefactors of humanity. Lister's work was the beginning of antiseptic surgery. Sur- geons at last learned to combat with a strong antiseptic the Xll INTRODUCTION AND HISTORY germs Avhich exist in the air, the wound, the room, the sur- geon's hands, his instruments. The black-robed, professorial- looking surgeon of earlier times was succeeded by a surgeon clothed in immaculate white. For an operation in the true Listerian style, the part to be operated on was first of all en- veloped two hours before the operation in a towel soaked in carbolic acid, to destroy the germs present in the skin. In- struments and sponges lay for a half hour in a flat porcelain dish of carbolic acid. Towels soaked in this solution covered the tables and blankets near the part to be operated on. The hands of the surgeons and nurses were thoroughly washed in the same solution. The operation itself was performed under a cloud of carbolized vapor from a steam spray producer. Then a strip of oiled silk, coated with carbolized dextrin and further washed in carbolic lotion, was placed over the wound and over this was applied a double ply of carbolic soaked gauze, covered with eight layers of dry gauze. Finally came a thin mackintosh cloth, and this whole apparatus was covered with a gauze bandage. The mackintosh cloth served to prevent the carbolic acid from escaping and at the same time permitted the discharge from the wound to spread through the gauze. The vapor given off by the carbolic gauze shielded the wound and the surrounding parts from septic contamination. These conditions were very strictly maintained until the wound was healed. All these cumbersome and complicated measures may seem a bit unnecessary to us; especially may we sigh when we re- flect that the use of carbolic acid made Lister's hands red and raw. Some surgeons produced excellent results by methods of strict cleanliness without following the whole Listerian tech- nic. Gradually, Lister himself gave up most of these meas-i ures, much to the advantage of the patient, for that same car- bolic acid which so effectively destroyed pathogenic bacteria in and about a wound, also invariably injured the exposed tissues. The great achievement of Lister was not the spray and gauze method but the conclusive proof that cleanliness is the most essential factor in successful operating. To the antiseptic surgeon of 1867 has succeeded the aseptic INTRODUCTION AND HISTORY surgeon of to-day. The aseptic surgeon uses steam and hot water to sterilize all materials in the operative procedure, and not only does he carefully scrub his hands, but he also renders them absolutely germ-proof by wearing rubber gloves which have been previously sterilized by boiling water and steam. Such is the simple aseptic method which has been gradually evolved from the Listerian antiseptic system. The spray pro- ducer has almost passed into oblivion but the spirit of Lister's teachings—scientific cleanliness—still guides the surgeon's work. In the World War aseptic surgery proved of little avail, be- cause almost all wounds were contaminated and filled with pus. The wound of the battlefield is not similar to the operative wound of the civilian hospital. Even with the utmost effi- ciency, before those wounded in modern warfare can be con- veyed to the nearest surgical station much time will have elapsed with ample opportunity for contamination. To deal with these conditions, the antiseptic method was revived. This time, however, the strong carbolic acid of Listerian fame was replaced by an agent harmless to the tissues, the Carrel-Dakin Solution. This solution is not merely one of historical inter- est, but widely used by surgeons of to-day for a certain type of wound, and it will be discussed in detail in Chapter XIX. To-day the vision of surgery is glorious. The surgeon is everywhere recognized as an indispensable worker in the com- munity. The growth of a highly competent, scientifically trained nursing staff has more than doubled the good results of his work. Nurses have indeed existed from earliest Chris- tian times; they have either been gentle, noble-minded Sisters of Mercy in the convents, or uneducated, inefficient maids in hospitals. Neither of these classes was what could be called trained or educated according to the present view of what training and education should be for a nurse. The first train- ing-school for nurses was established as recently as 1836. This little school at Kaiserswerth, Germany, is the mother of the present system; within its walls Florence Nightingale acquired her practical knowledge of nursing in a few months' time. Miss Nightingale was a woman of genius and vision. During XIV INTRODUCTION AND HISTORY the Crimean War the London Times roused British public opin- ion by its vivid account of the terrible conditions in the mili- tary hospitals of the war zone, and Miss Nightingale set out for that region with a staff of trained nurses to superintend the care for the sick and wounded. What she actually accom- plished was of greater importance to humanity than nursing individual soldiers stricken in the Crimea. She applied the principles of hygiene to hospital administration and brought light, cleanliness and order out of indescribable chaos and misery. The "lady with the lamp" at Scutari showed what a hospital should be and what scientific nursing should mean. Although her work in the Crimea was done more than a score of years before Lister's revolution in surgery, Miss Nightingale's revolution in hospital building, administration and manage- ment was based on the Listerian idea of scientific cleanliness. And out of her work in the Crimea arose trained nursing on a large scale. In 1860 the modern hospital school system was inaugurated by her in Great Britain at St. Thomas's Hospital, London. The dignity of the nursing profession has thus been raised; it has become a calling for superior women, with the recognition of the need for a rigid education and training before the nurse can call herself a "graduate." Just as surgeons were made "gentlemen" by the work of John Hunter, so nurses through the efforts of Florence Nightingale were made "ladies," and their profession put on a very high plane of social usefulness. In the same decade that the Nightingale Fund School was founded at St. Thomas's, Lister's great work was given to the world. That is, the rise of modern surgery is contemporaneous with the beginning of a careful, trained nursing body. This is more than an historical coincidence, for since that time the increasing demands of medical and surgical knowledge have well nigh revolutionized the nursing craft. To-day the sur- geon in the operating room of the hospital, or in the private home has come to rely absolutely on a highly educated and trained nurse. To her he leaves the preparation of supplies, the preparation of the operating room and instruments, and the preparation of the patient; she even assists the surgeon in the INTRODUCTION AND HISTORY xv operation itself in many ways. And finally, most of the after care of the patient is left entirely to the nurse. It is a great need that the nurse fills, a need that will grow with her capac- ity to fill a greater sphere. She is the Handmaid of Surgery and must live up to that high social calling by being well pre- pared; she must be so educated and trained that she will not be a mere automatic tool, but an intelligent, enthusiastic co- worker, filled with a zeal for science, and giving her whole mind and heart to the work that is before her—for only recently in the history of surgery is there scientific surgical nursing. The surgical nurse is a pioneer; the trail has been blazed; but it is still a new one, and she must show what she can do. TABLE OF CONTENTS CHAPTER PAGE Introduction and History........ix I. Pathology............3 II. Shock and Hemorrhage.........14 The treatment of shock, transfusions, the treatment of hemor- rhage. III. Post-Operative Complications.......20 Nausea, vomiting, pernicious vomiting, gastric dilatation, tympanites, auto-intoxication, post-operative pneumonia, pulmonary embolism, urinary retention, urinary suppres- sion, phlebitis, thrombosis, hemophilia. IV. The Surgery and Surgical Nursing of the Alimentary System............38 V. The Surgery and Surgical Nursing of the Glandular System............™ VI. The Surgery and Surgical Nursing of the Nervous System........... . 80 VII. The Surgery and Surgical Nursing of the Osseous System............' VIII. The Surgery and Surgical Nursing of the Eeproductive System............^ IX. The Surgery and Surgical Nurstng of the Respiratory System............120 X. The Surgery and Surgical Nursing of the Skin and Appendages...........130 XI. The Surgery and Surgical Nursing of the Urinary System............ XII. Surgical Dietetics..........151 I 73 XIII. Anesthesia...........J-'° Preparation of the patient; care of patient during anesthesia; after care. XIV. Arrangement, Organization, and Equipment of the Operating Theatre .........193 The rooms and their furnishings; the personnel; supplies. XV. Operating Room Sterilization 232 Definitions; the agents; practical methods. XVI. The Operating Room in Action.......263 Preparation of the room for the operation; preparation and sterilization of the operative field; operative positions and draping; the operation; after the operation. xvii XV111 TABLE OF CONTENTS CHAPTER PAGE XVII. Instrument Passing.........296 Representative operations; drains. XVIII. The Dressing of the Wound.......313 XIX. The Carrel-Dakin Treatment.......321 What the system is; history; equipment; the four processes of the system; the Dakin solution. XX. Bandaging ...........355 Definitions, uses of bandages, forms of bandages, materials used for bandages, sizes of bandages, principles of bandag- ing, modes of applying the roller bandage, the applica- tion of bandages to the various parts of the body, mis- cellaneous special bandages, the fastening of the bandage, miscellaneous bandaging rules, the removal of roller bandages. XXI. Operations in the Home........399 The steps in the preparation and management, improvised operative positions. Appendix...........415 Solutions; weights and measures; equivalent thermometer scales; abbreviations and symbols. Index............437 LIST OF ILLUSTRATIONS FIG. . PAGR 1. Microscopic drawing of an incised wound twenty-four hours old 5 2. Microscopic drawing illustrating the growth of fibroblasts along the fibrin of the blood clot........6 3. Microscopic drawing of granulation tissue.....7 4. Microscopic drawing of an infected wound .... 8 and 9 5. Microscopic drawing of a deep abscess......11 6. Types of intestinal anastomoses.......54 7. Colostomy before being incised.......61 8. Colostomy bag...........61 9. Tube "en chemise"..........64 10. Methods of applying traction........9o 11. Traction leg splint.........96 and 97 12. Traction arm splints..........99 13. Jones wrist split...........100 14. Lane plate............101 15. Wyeth pins............103 16. Tracheotomy tube..........123 17. Brewer empyema tube.........127 18. An easy and safe method of lifting a helpless patient . . 181 19. Restraining sheet for patients recovering from an anesthetic . 183 20. Suitable instruments for grasping the tongue .... 185 21. Mouth gags............186 22. Two of the more elaborate types of operating table . . . 197 23. Two varieties of instrument table.......199 24. Adjustable instrument table........199 25. Wheel stretcher...........200 26. Carrying stretcher........ . . 200 27. Stretcher suitable for carrying patients up and down stairways 200 28. Seat for the anesthetist or surgeon.......201 29. Bench for the surgeon to stand upon when the operating table can not be adjusted suitably in height.....201 30. Hand light............202 31. Dressing drum with pedal opening standard.....202 32. Hot towel drum with pedal opening standard and electrically equipped steaming device........203 33. Instrument sterilizer..........203 34. Utensil sterilizer...........204 xix XX LIST OF ILLUSTRATIONS FIG. PAGE 35. Hot and cold water sterilizers . 205 36. 207 37. 208 38. 214 39. 215 40. 216 41. 217 42. 219 43. Two types of hip or pelvic rest 220 44. Two types of irrigator stand 901 45. 222 46. 224 47. 907 48. 230 49. Steam pressure dressing sterilizer 238 50. 242 51. The Mayo soldering iron cautery 243 52. 243 53. 244 54. 253 55. Method of rolling a catgut suture oi ■ ligature . 255 56. Factory prepared catgut in hermetically sealed glass tube 261 57. 267 58. Method of fastening the arms at the patient's side . 268 59. Method of fastening the arms on the chest . 269 60. Laparotomy sheet in place for an abdominal o peration 269 61. Draping for the dorsal position with two sheets and four towels 270 62. 270 63. 271 64. Shoulder guard for keeping the patient in place in the Trendelen- 271 65. Gall bladder position (with table rest) 272 66. Gall bladder position (with broken table) 273 67. 274 68. 275 69. 276 70. Reversed Trendelenburg position 276 71. Sims position, showing the use of one sheet for draping . 277 72. Lithotomy position, showing the use of the table stirrups . 277 73. Draping with a sheet and towels in 1 lie lithotomy position . 278 74. Draping with the lithotomy towel and stockings for the 279 75. 280 76. Method of draping the hand and forearm for the breast opera- 281 LIST OF ILLUSTRATIONS xxi FIO. PAGE 77. Draping for breast position........281 78. Detachable arm board supplied with the table .... 282 79. Simple long narrow board which may be fitted to any table as an arm board...........283 80. Use of stirrups for operations upon the leg.....284 81. Draping for leg operations . . . . . . . . 2H5 82. Draping for a face case.........285 83. Arrangement of patient in the prone position on a special head rest for operations upon the back of the head or neck . . 286 84. Folded towel clamped about the face to protect the operative field from the inhaler in face, neck, or skull operations . . 287 85. The Kocher guard adjusted and draped so as to isolate the anesthetist in operations upon the neck.....289 86. Portable dressing stand.........290 87. Diagram of the arrangement of the instrument stand when the type shown in Fig. 24, page 199 is used.....299 88. Intestinal and stomach clamps.......303 89. Drains.............311 90. Portable metal dressing box........314 91. Portable electric instrument sterilizer......315 92. Dressing carriage for use in the hospital ward . . . .316 93. Adhesive plaster and tape device for holding dressings in place and allowing their removal without the disturbance of the plaster............317 94. Dressing forceps for use in dressing the Carrel-Dakin wound . 324 95. The rubber delivery tubes.........325 96. Reservoirs for the Dakin solution.......326 97. Glass syringes for administering the Dakin solution . . . 326 98. Stopcocks for use on the supply tubing in the reservoir method of administering the Dakin solution......327 99. Glass connecting and distributing tubes......327 100. Glass dropper tube for use oh the main supply tube in the reservoir continuous method.......328 101. The way to perforate the wound tube......329 102. The way to lay the vaseline gauze strips around the margin of the wound............336 103. Four positions of wounds with the appropriate wound tubes in them............337 104. Diagram of possible ways of making exits through the gauze and cotton pad for the wound tubes so that they need not lie on the skin surface, and will remain where they were placed when the wound was dressed......339 105. Arrangement of the apparatus for the reservoir method of instillation...........340 106. Suggested ways of branching the main supply tube so that it can feed the tubes of more than one wound, or widely scat- tered and variously grouped tubes in the same wound . . 341 xxii LIST OF ILLUSTRATIONS FIG. PAGE 107. Arrangement of the screw stopcock and the glass dropper tube on the main supply tube for the reservoir continuous method of instillation...........342 108. Method of connecting inaccessible wound tubes to a single supply tube for the syringe method of instillation . . 343 109. Dr. Carrel's bacteriological chart.......346 110. The roller bandage..........356 111. Two methods of rolling a bandage by hand.....357 112. The triangular bandage, or sling.......358 113. Many-tailed bandages..........359 114. Method of making plaster of Paris bandages .... 361 115. The way to grasp the roller bandage preparatory to apply- ing it .............366 116. The way to begin the application of the roller bandage . . 367 117. The circular mode of bandaging—the usual anchorage for the applied roller bandage.........367 118. The spiral mode of bandaging........368 119. The wrong mode for the part (the spiral mode for a conically- shaped part)...........369 120. The way to make a reverse........369 121. The figure-of-8 mode of bandaging.......370 122. The recurrent mode of bandaging.......371 123. Completed recurrent bandage........372 124. Spiral bandage of the finger anchored to the wrist with a figure-of-8 and a circular turn.......374 125. The thumb spica...........374 126. Complete bandage for the hand and arm.....375 127. Reverse figure-of-8 bandage........375 128. Method for securing better anchorage of a bandage on a tapering part...........376 129. Heel bandage...........377 130. Complete bandage for the' foot and leg......378 131. The eye bandage...........379 132. Double eye bandage..........380 133. The ear bandage...........380 134. The Barton bandage..........381 135. Two methods of bandaging the cheek, temple, or chin . . 382 136. Double roller bandage for the application of the recurrent bandage............333 137. The way to use the double roller bandage.....383 138. The spica bandage of the shoulder...... 384 139. The shoulder spica bandage varied to cover the axillary region 385 140. The Velpeau bandage........ 335 141. The breast bandage......... 38g 142. The double breast bandage....... 38g 143. The hip spica bandage....... 337 LIST OF ILLUSTRATIONS xxiii PAGE FIG. 144. Various applications of the triangular bandage . . . . 388 145. Various applications of the many-tailed bandages .... 389 146. Methods of fastening the roller bandage.....395 147. Bandage scissors...........397 148. Instruments for the removal of plaster of Paris bandages . 397 149. Improvised cap and gown.........401 150. Ordinary chair adapted for improvisation of the Trendelenburg position............41 151. Lithotomy crutches, or leg holders, for supporting the legs in the lithotomy position.........412 152. Method of improvising a lithotomy crutch.....412 153. Improvised Kelly pad.........413 TEXTBOOK OF SURGICAL NURSING CHAPTER I PATHOLOGY The surgical field may be divided into those conditions which are due to inflammation, injuries, congenital deformities, and new growths. Into these arbitrary four great divisions all modern surgical intervention falls. And since all surgical in- tervention is to a greater or lesser degree supplemented by surgical nursing, a thorough and intelligent understanding of the underlying pathological conditions is essential. Perhaps the most common field is that of inflammation. Inflammation.—Inflammation, according to Grawitz, may be said to be the reaction of irritated damaged tissues which still retain vitality. The damaging element may be one of several; it may be physical, such as a cut from a knife, a bruise from a stone, or a contusion from a flying timber. It may be chem- ical, such as a burn with acid, such as nitric, or from caustic alkali. It may be electrical, resulting from touching a "live" wire; or thermal, such as a burn from fire, or a frost bite from the cold; or it may be bacteriological. The last mentioned is especially important for it results in wound infection. These five agents then are the exciting factors of an inflammatory reaction; they have in some way injured or destroyed the unit structure of the body, the cell, and in order to carry off the dead and dying cells, to replace them, and rebuild the damage done, the process of inflammation must ensue. What is the process of inflammation? The following, in a brief way, will illustrate what happens grossly, and what oc- curs if the process were to be studied underneath the mi- croscope : If a finger is cut, it bleeds. The amount of blood lost is dependent upon the size of the vessel cut. In time, due to clotting, the bleeding ceases and within a few hours the sur- 3 4 TEXTBOOK OF SURGICAL NURSING rounding skin may become red, perhaps slightly swollen, and if it is carefully observed as to temperature, it might be some- what warmer than the adjacent skin. The wound is said to be inflamed. If this process were examined in sections beneath a microscope, a very interesting and thoroughly instructive pic- ture would be seen, depending upon the time when the section was taken. Within a short period after the original injury, there would be along the line of the original incision a clot of blood, and adjacent to it some dead cells. (Fig. 1.) Already, the products of these dead cells would have stimulated a greater blood flow to the part, resulting in a dilatation of blood vessels and capillaries, and an infiltration of the tissues with white blood cells, red blood cells, and serum. Naturally, it is this that makes the part swollen, red and warm. And as these in- flammatory products cause an increased pressure on the nerves the wound will become painful in direct proportion to the exu- dation. It has already been noted that cells have been de- stroyed. Dead tissue is of no use to the organism. It must be removed, and the white blood cells carry off the destroyed tissue. It is a known fact that when cells are injured, some which were but slightly traumatized are actually stimulated to growth, and these cells (fibroblasts) immediately begin to re- produce and grow into the blood clot along the fibrin strands (Fig. 2) in an attempt to bridge in the gap caused by the de- struction of the cells killed by the knife. In small wounds this is barely visible to the naked eye, but in wounds in which a definite area of tissue has been destroyed, or wounds with defi- nite loss of substance, this new growth of cells together with a new growth of blood vessels is known as granulation tissue. (Fig. 3.) Wounds which are sutured and clean heal with the minimum amount of granulation tissue and simulate small cuts of the finger. This is spoken of as healing by primary in- tention. Wounds in which there is a loss of tissue from one cause or another heal by secondary intention, filling in the space with granulation tissue. This is the process of healing which takes place in every wound. It is fundamentally the same in all clean wounds, whether a cut of the finger, the healing of a cyst enucleation, or an incision of the abdomen as a laparotomy. PATHOLOGY 5 •''*?Cv"'i v.;; ;«gj , •;- .\;.,5- I--------------B ^;'^$ '% ,*J v. ..• - .' •,.,«??;;•.•'••.■".' ... ~~ •.■^X' - , * n-... C ■A ___r--^ d Fig. 1.—Microscopic Drawing of Incised Wound 24 Hours Old. .4, line of incision; B, blood clot; C, cellular infiltration; D, relative dilatation of blood vessels. Published by permission of the Department of Surgery, Columbia University. 6 TEXTBOOK OP SURGICAL NURSING ----A B Fig. 2.—Microscopic Drawing Illustrating the Growth of Fibro- blasts Along Fibrin Strands of the Blood Clot. A, fibrin strands- B fibroblasts. Published by permission of the Department of Surgery, Colum- bia University. PATHOLOGY 7 The process is slightly different, however, when the wound be- comes contaminated by bacteria of the pathological variety. In a clean wound the minimum amount of damage is done Fig. 3.—Microscopic Drawing of Granulation Tissue. A, fibroblasts; B, newly formed blood vessels. Published by permission of the Department of Surgery, Columbia University. because the only cells destroyed are those which have been* killed by the knife of the surgeon. But if this knife were not properly sterilized and were laden with bacteria, the result would be an infected wound (Fig. 4), and the outcome would r- a --- - -A 8 TEXTBOOK OF SURGICAL NURSING < 1 1 oQ i 1 '^^ .■;<■'■• •• 'V';".' . •' ■ ■■>■■.■•■■-;■. • ,; ' ." !.■--,;.-■•■ *.- •»1;.';-"; , . . - . ... . \.. v *.m«PV '-*\ ... *>•>«/»*• . -. ..•-. .• •. :. •»* . ^ ' -* <.'**■'*> . t"*'*" ■ f*%> *i>..i •»•*' •<\ >.'N ,• v , ^ — - C ^-D Fig. 42.—Microscopic Detail Drawing of B of Fig. 41; C, bacteria in the wound and pus; D, granu- lation tissue. Published by permission of the Department of Surgery, Columbia University. > X o 6 Q r;r.:r>'<>*^-'" _-----B S#------A Fig. 5.—Microscopic Drawing of a Deep Abscess. A, abscess cavity; B, pus. Pub- lished by permission of the Department of Surgery, Columbia University. > w o t-1 o O 12 TEXTBOOK OF SURGICAL NURSING blot on the scalpel of aseptic surgery. It means that certain bacteria entered the wound either before, during, or after op- eration. The bacteria which cause wound infections are nu- merous and varied. A classification of these organisms is here- with given: Bacteria are of two classes:—saprophytes, those which live on dead organic matter, and parasites, which derive their nour- ishment from living bodies. The latter class produce the patho- genic or disease bacteria: these are either cocci or bacilli. The various common cocci may be divided into staphylococci, strep- tococci, pneumococci, meningococci, gonococci; the bacilli, into the bacillus coli communis, bacillus typhosus, bacillus para- typhosus and bacillus pyocyaneus. These are the germs which are concerned in acute inflammation. There are others which cause chronic inflammations, the most important of which are the tubercle bacillus and the spirochaete of syphilis. Then there are those rarer forms of inflammation which are due to the ba- cillus of anthrax, of glanders, and those due to the fungi group, such as actinomycosis. The pathological process of all of these is essentially the same; it is simply a question of degree and in- tensity ; it is dependent upon the virulence of the organism caus- ing the infection, and the general resistive powers of the pa- tient infected. How do bacteria enter the body? They may enter through the oroken skin giving rise to local inflammation with destruc- tion of tissue and abscess formation. In addition they may gain access to the lymphatics draining the infected area causing lymphangitis, and often the nodes becoming tender, hard, and swollen (lymphadenitis). Or the bacteria may enter the blood stream directly, resulting in septicemia or pyemia. Inhalation is the means by which the pathogenic bacteria enter the trachea and lungs causing the majority of respiratory diseases. By ingestion of food and drink, the germs may enter the tonsils or the alimentary canal. Another portal of entry in females is through the Fallopian tubes directly into the peri- toneal cavity causing peritonitis with its various complications. If the body is in good health and properly nourished, all these portals are safely guarded, but if the individual is weak- PATHOLOGY 13 ened and the various protective mechanisms are at fault, dis- ease readily ensues. Injuries.—Conditions of injury may be caused by the vari- ous factors already mentioned. The extent of the injury will depend upon whether the bony skeleton or the soft parts are involved, whether the solid organs, such as the liver or kidney, are torn, or the hollow viscera, such as the stomach and in- testines, are perforated or ruptured. Deformities.—These may be divided into two big classes: those a patient is born with, and those which a patient acquires during life. Among some of the congenital deformities may be mentioned spina bifida, a condition in which part of the bony portion of the spinal canal is missing, harelip, cleft pal- ate, horseshoe kidney, six fingers, an extra arm, or the fusion of two individuals as in the case of the Siamese twins. Ac- quired deformities may be the results of injuries which have been improperly treated, such as a poor reduction of a fracture, or from paralysis of muscles due to nerve injuries which cause such conditions as drop wrist or drop foot. New Growths.—New growths, neoplasms, or tumors, may be defined "as growths, non-inflammatory in character, aris- ing from pre-existing tissue but independent of the normal rate or laws of growth of such tissue, subserving no physiolog- ical function." They may be classified as benign and malig- nant. Benign growths, as a rule, are localized; they may be excised without danger of recurring, and they do not spread to other parts of the organism and start new tumor formations. Examples of these are fibromas, lipomas, and cysts. They rarely endanger the life of the individual. Malignant growths are those which arc not localized, which infiltrate tissues and which spread to various parts of the body (metastasize). They are the cancers and the sarcomas. Surgery attempts to remove these with the knife. And those cells which have escaped the knife will start foci for the regeneration of new tumor tissue unless they are killed by the destructive action of subsequent radium and X-ray treatment. CHAPTER TI SHOCK AND HEMORRHAGE Shock.—This is one of the most serious conditions with which the surgeon and the nurse have to cope. It may result from several circumstances. It may be associated directly with severe injuries, may occur during the course of an operation, or follow in its path. As to the etiology of shock there are many theories, but its exact mechanism does not concern us here. Shock is characterized by a rapid, thready pulse, a pinched, drawn face, sweating, rapid, shallow respirations, and a persistently low blood pressure. Shock may be associated with hemorrhage, but there is no severe hemorrhage without shock. Prophylactic Treatment of Shock.—There are several fac- tors which aid in the prophylactic treatment of shock. To begin with, the patient should be kept in a happy and cheerful frame of mind. He should have a good night's rest before his operation and his tissues should be well supplied with water. This latter can be easily accomplished by encouraging the drinking of fluids in copious amounts. Of course, two hours before operation no more water should be permitted. Dur- ing his transport to the operating room the patient should be warmly clad and when he is placed upon the table he should be covered with blankets. Of prime importance also is the technic of the operation. As little as possible of the abdominal contents should be exposed, and the exposed parts should be protected with moist, hot saline pads. The tissues should be handled gently, the hemos- tasis should be perfect, and the operation should be performed with as much speed as is consistent with safety. The patient should be kept under deep surgical anesthesia, the choice of 14 SHOCK AND HEMORRHAGE 15 the anesthetic being dependent upon the condition of the pa- tient. After operation it is customary to administer morphine hypo- dermically so that the pain which might arise will not reflexly cause a general depression of the nervous system, resulting in shock. Treatment of Shock.—When a condition of shock is evident, it must be treated energetically. The patient should be placed flat upon the bed and covered with warm blankets; if neces- sary, hot water bags and electric pads may be employed to rap- idly supply additional heat. Inasmuch as the patient is un- conscious it is highly important to carefully guard against burns from the electric heating pad, or a too hot water bag. The foot of the bed is raised by means of shock blocks, so that the head is at a lower level than the feet. Shock blocks come in various sizes: low, medium, and high. The medium ones are generally sufficient. Stimulants.—Morphine is one of the best stimulants and is administered in quarter grain doses with 1/150 atropine sul- phate. Fluid is then given by infusion in the form of normal saline at 105 degrees F., and to this, occasionally, is added 30 minims of adrenalin hydrochloride, 1-1000 solution. If the shock is not so severe, fluid by hypodermoclysis or Murphy drip may be sufficient. Transfusions.—Since hemorrhage may be partially responsi- ble for shock, the imperative need often is to supply the blood which has been lost. Blood transfusions no longer present the obstacles which they formerly did, for the long tedious sur- gical methods of arteriovenous anastomosis have been prac- tically replaced by the use of the syringe and its modifications. Grouping for Transfusions.—Before any transfusion is given, it is always necessary to ascertain the blood group of the patient and of the "donor," because if the bloods of different groups are mixed together the red blood cells are destroyed and the patient is liable to suffer a very severe reaction, and derive no benefit from the treatment. Human bloods are divided into four groups. Of these the largest are groups two and four which together constitute about eighty-three per cent, of all individuals. 16 TEXTBOOK OF SURGICAL NURSING In selecting a "donor," it is very important that he be in good physical health, and that his blood be free of syphilis as evi- denced by a negative Wassermann reaction. Transfusions may be given by one of three methods,—the direct arteriovenous method; the indirect, as represented by the syringe method; and the one in which sodium citrate is used. The anastomosis of an artery of a donor to a vein of the recipient is no longer done, because this rather cumbersome method (which was rarely very successful) has been replaced by the other two types, which are more efficient, certainly easier of operation, and less trying both to patient and donor. The syringe method first used by Lindeman employs glass record syringes which draw the blood from the vein of the donor; the freshly drawn blood is then immediately injected through a needle into the vein of the recipient. The great disadvantage is the fact that the blood is apt to clot in the needles of the syringes in spite of the fact that these instruments may be flushed with saline during the procedure as is done in the Unger method. To overcome this obstacle, a method frequently used at the present time is the Lewisohn transfusion. It has been demonstrated that chemically pure sodium citrate in solution will prevent blood from clotting, and if used in a strength not exceeding two-tenths per cent, will not prove injurious to the patient. The usual procedure is as follows: The donor is bled into a flask containing enough sterile sodium citrate solution to prevent clotting, and as the blood flows from the vein of the donor into the glass container, it is slowly shaken so as to insure complete mixing with the citrate. The drawn blood, now rendered uncoagulable, may be given at once, or, if it is not practical, it may be kept on ice and used any time within twenty-four hours, provided it is warmed to the body temperature before injection. As a rule, the blood is given to the recipient by the "gravity method." This per- mits it to flow by gravity from a container elevated about two or three feet above the head of the patient into the vein of the recipient through the ordinary Luer needle which has previ- ously been inserted. Or, it may be given by the gravity method plus a three-way stop-cock and Luer syringe. The blood flows SHOCK AND HEMORRHAGE 17 from the container into the syringe. When this is filled the cock is turned and the syringe emptied of its contents by piston pressure, the blood passing into the vein. Then the stop-cock is turned again and the syringe refilled. This technic is elab- orate but there are no real advantages over the gravity method. (The apparatus used is the same as for any saline infusion; it should be boiled in distilled water.) Some surgeons prefer to give blood from which the fibrin has been removed by beating fresh blood with an instrument similar to an egg-beater. This procedure prevents it from clot- ting, and the defibrinated blood, like the citrated, may be kept for some time before its administration. The amount of blood given is usually 500 c.c. and this may be repeated as often as is necessary. After Treatment.—After most transfusions there is apt to be a reaction manifested by chills and fever and sometimes nausea and vomiting. The nurse should always be prepared for this emergency. This may occur from ten to twenty min- utes after the transfusion, and the treatment is the same as for any chill,—blankets, hot bottles and a little brandy, if per- mitted. It is advisable to save the urine of all these cases be- cause it should be examined for the presence of altered blood. This will indicate whether the recently given blood has been of value to the patient, or whether it has been destroyed, and is being eliminated by the kidneys. Hemorrhage.—Hemorrhage is any bleeding. It may be either arterial, venous, or capillary. Arterial hemorrhage is recognized by a stream of blood which is bright red and spurt- ing, each spurt corresponding to a cardiac systole, or contrac- tion period of the heart. Venous bleeding is a slower, steadier stream of dark red blood. Capillary bleeding is evidenced by simple oozing. Symptoms.—If the bleeding is external, the hemorrhage is recognized rather readily, but if it is internal bleeding, it is moderately difficult to diagnose. Patients who are hemorrhag- ing internally as the result of some intra-abdominal injury, or from the rupture of blood vessels, as in a ruptured ectopic pregnancy, usually show pallor, pinched face, cold clammy skin, 18 TEXTBOOK OF SURGICAL NURSING rapid thready pulse, shallow superficial respirations, and what is very important—"air hunger." Air hunger is one of the diagnostic signs of hemorrhage. In shock the patient is ordi- narily quiet, somewhat depressed. In hemorrhage, the patient is gasping for breath, restless, asking to have the windows open, begging for more air, and feeling as if he were being smothered. Treatment.—If a large artery has been cut, the first aid treatment is simply to arrest the hemorrhage by applying pres- sure with a tourniquet. This is a band placed around a limb, and tightened until circulation through the artery is arrested. It is an excellent method for the temporary arrest of hemor- rhage until some medical aid can be secured and the vessel clamped and tied. Ligature.—This is the tying off of a vessel with material which may be either absorbable, such as. catgut, or nonabsorb- able, such as linen. If the vessel is moderately small and has been caught in an artery clamp, sometimes by twisting the arterial wall, hemostasis is secured. This method is known as torsion. Hemorrhage may also be controlled by means of the cautery; heat is applied to the bleeding vessel so that it coagulates the tissues and the bleeding stops. Pressure.—Pressure is indeed a very important means of arresting hemorrhage, and sometimes good steady pressure over a bleeding surface may do much to stop the flow of blood. In bleeding from bone, one of the most efficacious ways of con- trolling it is to plug the hole in the bone with Horsley's wax. This is composed of seven parts beeswax, one part almond oil, and one part salicylic acid. Capillary Bleeding.—There are various ways in which ooz- ing can be controlled. One is by means of cold and the other by heat. Cold is especially efficacious in those operations about the mouth. For example, after the removal of adenoids and tonsils, or operations in the nose or upon the palate, bleeding is often controlled by slapping the face and neck with ice cold water. It appears that the contraction of the superficial ves- sels leads to a contraction of the deeper vessels, thus relieving the hemorrhage. Bleeding from the capillary blood bed of the SHOCK AND HEMORRHAGE 19 uterus should not be controlled by the application of cold water as such a procedure might result in shock. Instead, an intra- uterine douche with a little acetic acid and water of from 110 to 115 degrees is excellent in controlling this variety of hemor- rhage. Often it is necessary to supplement this with packing, either with plain or medicated gauze. Styptics.—Occasionally for very small pin point oozing, fused silver nitrate is applied directly to the bleeding point. After Treatment of Hemorrhage.—Inasmuch as a certain amount of fluid is lost, it is very important to supply this to the system either by the blood itself in the form of transfusions, or by saline infusions. After the hemorrhage has been controlled, necessity may demand that the patient be treated as a " shock'' case. CHAPTER III POST-OPERATIVE COMPLICATIONS The operation completed, the surgeon has done the major part of his work, and the patient from then on is entrusted to the care of the attending nurse. It is true that all orders are given by the attending surgeon, but their conscientious exe- cution is dependent upon the integrity and efficiency of the nurse. The surgeon may see the case but once a day; the nurse sees the patient at all times; and she, by her careful attention to details and her knowledge of human nature, can do much to make the patient comfortable and the post-operative course smooth in spite of the many complications which might arise. The immediate care of the patient after leaving the operating room is discussed in Chapters XIII and XVI. It is the pur- pose of this chapter to discuss the treatment of the various post- operative complications. The most important of these are nausea, vomiting, pernicious vomiting, gastric dilatation, tym- panites, auto-intoxication, post-operative pneumonia, pulmonary embolism, urinary retention, urinary suppression, phlebitis, thrombosis, and hemophilia. Nausea is quite common. It is usually present after all operations for a short time. Some doctors are in the habit of ordering cracked ice to relieve this distressing symptom. When- ever it is ordered, care must be taken lest the patient get too much and in this way imbibe large quantities of cold water with the result that vomiting is very apt to ensue. When the feeling of nausea becomes very severe it is accompanied by vomiting. If a patient vomits later, than twenty-four hours after operation, there probably is something in the stomach which is causing a persistent irritation. Once this irritation is removed, the vomiting will generally cease. It must be re- membered that the patient has just been operated upon, and 20 POST-OPERATIVE COMPLICATIONS 21 that the nerves are exhausted, and that conservative treatment is better than radical. The most effective procedure for ridding the stomach of foreign material is gastric lavage; but washing the stomach is trying and tiring and should only be employed when other simpler methods have proven unsuccessful. First the following should be tried:—A glassful or approximately eight ounces of lukewarm water with about a teaspoonful of bicarbonate of soda should be administered by mouth. As a rule, patients are very thirsty after operation, and avariciously drink the proffered water. The result is that they are further nauseated and soon vomit the ingested water, thus washing out the stomach, and instant relief often ensues. Sometimes, in spite of these measures, vomiting will still persist. It is due then to atony, a relaxation of the muscles of the stomach wall. Persistent vomiting is very weakening, and gastric lavage should be given almost immediately, if the bicarbonate of soda and water fail to afford relief. A post-operative lavage must be of hot water, for the heat itself is the efficient agent in stimulat- ing the stomach walls to contract, and therefore the water should be introduced at about 108-110 degrees Fahrenheit. An- other point,—as little air as possible should enter the stomach tube, and when the lavage is finished, the water should be care- fully siphoned off from the stomach. If the vomiting persists after a good gastric lavage, it then may be due to either per- nicious vomiting or possibly, gastric dilatation. Pernicious Vomiting.—This may occur in children as well as in adults, and is usually a manifestation of what is commonly spoken of as "acidosis," a condition in which the normal alka- linity of the blood is diminished. It is recognized by the sweet and fruity odor of the breath. If this condition be suspected, the urine should be examined for the presence of acetone. If it be present, gastric lavage should be given, everything stopped by mouth, and alkalis administered immediately either by a ten per cent, sodium bicarbonate solution in a Murphy drip, or intravenously in three to five per cent, solution, but never by clysis. Sodium bicarbonate is given until it is excreted by the kid- neys. When the urine is alkaline it is safe to assume that suf- 22 TEXTBOOK OF SURGICAL NURSING ficient bicarbonate has been administered to bring the blood back to its normal alkaline reaction, thus reducing the acidosis which is the underlying cause- of vomiting in these particular cases. There is one point, however, which needs emphasis in the administration of sterile sodium bicarbonate solutions. After the desired solution has been compounded, it must be sterilized. Sterilization, by its heat, drives off carbon dioxide thereby reducing the bicarbonate of soda to sodium carbonate. This compound is not as good as the bicarbonate because it is more irritating to the tissues, and is not as effective in reestab- lishing the alkalinity of the blood. To counteract this, after the solution has been cooled sufficiently, carbon dioxide may again be added by connecting a sterile tube to a carbon dioxide tank and allowing the gas to bubble through the sodium car- bonate fluid for a sufficient length of time, thus making a bi- carbonate compound. Gastric Dilatation.—One of the most distressing complica- tions which may arise after an operation, and one which, if not treated radically, energetically, and thoroughly may result in death, is acute gastric dilatation. As the name implies, in this condition the stomach becomes enormously dilated, and presses upward on the diaphragm. This makes respiration very difficult because of the constant pressure on the diaphragm. And, inasmuch as the pyloric orifice of the stomach is atonic, the intestinal contents seep back into the stomach, resulting in persistent vomiting of large amounts of greenish and brownish colored fluids. To relieve this condition those means must be employed which will cause the dilated stomach to contract and approach its normal size. Treatment.—The stomach should be lavaged with a hot soda bicarbonate solution at 110 to 112 degrees Fahrenheit, and the lavage continued until the return is absolutely clear. While this treatment is under way, turpentine stupes should be ap- plied to the upper abdomen for ten or fifteen minutes. It is important to bear in mind that as these stupes must be hot to be efficacious, the abdomen should be thoroughly greased with vaseline before applying them, as great care must be taken that the skin is not burned, The integrity of the skin must be pre- POST-OPERATIVE COMPLICATIONS 23 served because this procedure is to be repeated every two or three hours, according to the discretion of the attending surgeon. The stupe probably is the most efficient and reliable method for applying external heat, although some authorities advise the use of huge flaxseed poultices. Strychnine sulphate, gr. 1/60, may be given by hypodermic injection every four hours, following the principle that the strychnine will improve muscle tone. The patient, of course, during this period, should be given nothing by mouth, but measures should be taken to supply the system with water. By persistent vomiting these unfortunate patients have desiccated themselves of fluid, and it is necessary that fluid be administered by means of a Murphy drip, or that eight ounces of tap water be given by rectum every four hours. If the patients show signs of shock, which they often do, a hypodermoclysis of 500 to 800 c.c. of saline should be given, or, in some instances, an infusion of saline. If nourishment be an essential element, a solution (two to five per cent.) of glu- cose may be administered intravenously. The glucose may also assist in combating a beginning acidosis brought on by inanition. After the initial period of vomiting has come to an end, it is advisable to give the stomach an absolute rest for about twenty-four hours, and then to start the patient on what may be called a "gastric tolerance diet." The theory of this diet is to partially desensitize the mucosa of the stomach and make it more tolerant to fluids by the use of small doses of chloro- form water. If this is retained, peptonized milk is then started in small doses. The amount of peptonized milk is then gradually increased, the chloroform water is omitted, and the patient, after a period of absolute gastric tolerance, is gradually brought over to a selected soft diet. The exact details of this diet are given in Chapter XII on "Surgical Dietetics." Tympanites.—The distention of an abdomen following op- eration is due to a gastric dilatation, a distention of the small or large intestine, or a dilatation of the bladder resulting from urinary retention. The word tympanites or meteorism de- notes an inflation of the abdomen with gas. This gas is usually intestinal; occasionally it may be free in the peritoneal cavity 24 TEXTBOOK OF SURGICAL NURSING from a perforation of the intestines. A condition of gastric dilatation is recognized by distention in the upper abdomen; that of the small or large intestine, by a generalized abdominal distention; that of the bladder by palpation of a rounded mass just above the pubes and the failure of the patient to void after operation. Tympanites is certainly distressing and modern surgical nursing commands many methods to alleviate and re- lieve this condition, bringing much comfort to the patient. Treatment.—The theory underlying all treatments is to aid the patient in ridding the small intestines and colon of gas. The means for accomplishing this are many. One of the simplest procedures and one of the most efficient is the introduction of a rectal tube. A rectal tube is a small piece of rubber tubing about three- eighths of an inch in diameter, rounded at one extremity. This is well lubricated with either K-Y or vaseline, and gently in- troduced into the rectum beyond the internal and external sphincters, and about three to four inches beyond the anus. The purpose is to form an exit for gas which may have accumu- lated in the colon. This simple procedure is often all that is necessary. Enemas.— Especially in emergencies when the patient has not had a cathartic, or a thorough intestinal cleansing before the operation, the fecal material is apt to accumulate in the colon causing fermentation and often stopping the passage of gas or flatus by its mechanical bulk. In these conditions it is im- portant to empty the lower bowel by a cathartic enema. The soapsuds enema is usually all that is required. But in those cases where the soapsuds have brought very little return, and the distention is still marked, and it is thought that fecal ma- terial is being retained, it is advisable to give a more purga- tive enema. The solutions which may be added to enemas may be glycerine, one ounce, or turpentine, y2 ounce to the pint. Milk and molasses,—four ounces of milk and four ounces of molasses,—make a good irritative enema. The magnesium sul- phate enema is used now quite frequently,—two ounces each of water, glycerine and magnesium sulphate in saturated solu- tion being employed. Some institutions use a mixture with POST-OPERATIVE COMPLICATIONS 25 oxgall in the following proportions:—turpentine 3 ii, oxgall 5 ii, magnesium sulphate § iv, glycerine § iv. These purgative, irritative enemas, not only empty the lower bowels, but also stimulate the smooth muscles to contract, thus expelling the gas which has accumulated. Irritative enemas for safety's sake should be small in amount. The soapsuds enema, however, made from castile or ivory soap, is given in amounts varying from two to four pints. After operation, it is best to give the enema in the dorsal position, putting the douche pan under the patient before the enema is given. The returns should be wTatched for the presence of fecal material, mucus, blood, bile, and gas. Enemas after operation should always be ordered by the attending physician, and no nurse should take upon herself the responsibility of injecting fluid into the rectum. As a rule, they should not be given in rectal cases, perineorrhaphies, or resections of the colon unless abso- lutely essential. Colon Irrigation.—The colon irrigation performs three functions: It supplies a certain amount of fluid to a system which needs water; it carries off fecal material, and acts as a medium for the expulsion of gas. Colon irrigations when given properly should cause the patient absolutely no distress. If perfectly given, there is no reason why the patient should not fall asleep during the treatment. Many solutions are used for the irrigations. Normal or half strength saline is quite common, but it must be remembered that it increases the thirst of the patient, and for this reason, provided that the rectum will retain it, tap water is better. Any irrigation to be effec- tive must be given hot, at a temperature varying from 110-120 degrees. About three gallons should be used for a single ir- rigation. While the technic of giving an irrigation is known to every nurse, there are a few points which might be em- phasized, and which if remembered, will cause greater com- fort to the patient. They are as follows: 1. All air must be expelled from the inflow catheter before it is inserted. 2. The catheter should be inserted within the outflow tube so that only one tube is inserted into the rectum. 26 TEXTBOOK OF SURGICAL NURSING 3. The end of the outflow tube should not be more than a foot below the level of the patient. If it is, a jerky interrupted flow is apt to result because too great a suction is established, and the mucous membrane of the rectum is apt to be drawn about the holes of the rubber tubing. 4. There should always be a return of fluid through the out- flow and if for any reason it is not evident, the irrigation should be stopped immediately. For the pressure of fluid through the inflow tube might be so strong as to cause distention with a resulting paresis of the gut; or, what is extremely rare, there might be a perforation in the colon through which fluid empties itself, into the peritoneal cavity. The amount of fluid which the patient absorbs can easily be estimated by comparing the amount given and the amount returned. There are two ways of giving a colon irrigation:—one way is to use an inflow and outflow tube; the other, one tube to serve alternately as inflow and outflow. The second method is less advisable, for it is more like an intermittent enema, and is certainly more uncomfortable to the patient. Aids to Colon Irrigations.—Just as in a dilatation of the stomach water is applied internally and heat externally by the application of poultices, so, in giving a colon irrigation, to make it more effective, and to aid in stimulating the contrac- tion of the smooth muscle of the bowel, large flaxseed poultices are used for their counter-irritative effects. In addition, very often 1 c.c. of pituitrin is given intramuscularly during the colon irrigation. It is a known fact that a substance in the posterior lobe of the pituitary stimulates smooth muscles to contract. Pituitary extract should not be given by mouth be- cause its administration in that manner is practically ineffectual. In some cases, fortunately rare, rectal tubes, enemas and colon irrigations will not relieve abdominal distention. These cases are spoken of as paralytic ileus. This is a condition in which the smooth muscle of the in- testine is practically paralyzed; there is no peristalsis, no pas- sage of gas, the patient becomes more and more distended as the fermentation becomes greater and the toxemia becomes more severe. This condition is helped by immediate surgical POST-OPERATIVE COMPLICATIONS 27 interference alone. The mortality, however, is terrifically high. The operation performed is an enterostomy, Chapter IV, page 55; an opening is made in the small intestine through which the gas, fluid and solid material may escape. Thus with a diminu- tion of the degree of toxemia, and the intestines relieved of their burden they will have sufficient strength and recuperative powrers to regain their normal tone and peristaltic wave action. Auto-intoxication.—Closely allied to meteorism is auto-in- toxication. In this condition the patient absorbs certain products of fermentation and decomposition from the gastro- intestinal tract, resulting in a slight degree of temperature usually associated with headache and general malaise. This is ordinarily relieved by a movement of the bowels, procured by an enema, and a cathartic. This condition is never very seri- ous, and never alarming. Post-operative Pneumonia.—This is one of the most serious of post-operative complications. Often a patient reacts favor- ably to an operation only to be dragged down in a day or two by the toxemia of lung involvement; and this, together with the general weakness following surgical interference, often results in death. While pneumonia cannot be absolutely obviated as a post-operative complication, there can be a marked diminution in its frequency if greater attention is paid to the smaller details of ante-operative and post-operative care. In hospital work and in private nursing the fact is often forgotten that the patient in his home has been accustomed to certain clothing and has been living for years under peculiar hygienic conditions. Upon entering the hospital he is given an abbreviated nightgown and placed in a bed with one or two blankets. When he is physically examined his gown is taken off, and very often there is a draught from a nearby open win- dow. The deep breathing and coughing incident to the auscul- tation of the lungs often cause a perspiration, and the cool air on the heated skin is a poor combination. Occasionally the pa- tient is asked to get out of bed and stand up, his bare feet very often resting against the cold floor; or often, when the abdomen is shaved and being prepared for operation, the pa- tient is unduly exposed. Then from a warm bed he is placed 28 TEXTBOOK OF SURGICAL NURSING upon a cold stretcher, wheeled through draughty, chilly halls, and plunged into a superheated operating room. During the operation he is apt to perspire freely, and while it is routine to change a drenched gown, the patient, through neglect, is often permitted to keep it, and in this condition he is sent through the halls again, back into the ward. During the re- covery period, he may toss around, uncovering his body, and ex- posing his depressed system to more draughts, more chilling, opening the way to a pneumonia. When the matter is given thought, the real wonder is that pneumonia is not more fre- quent. The best method of treating this serious complication is by prophylaxis. Prevention is better than cure, and careful and conscientious surgical nursing will greatly aid in diminish- ing the incidence of this dreaded complication. Prophylactic Treatment.—Ante-operative.—All patients be- fore operation should be carefully examined for coryza, bron- chitis, pharyngitis, or tonsillitis, and if any of these exist, the operation should not be performed, but temporarily postponed. Of course, acute cases fall into another category, and very often it is advisable to do these under local anesthesia rather than run the risk of ether or gas administration which is sure to spread the infection into the lungs. If the nurse at any time prior to operation notices that the patient sneezes exces- sively, or that signs of a cold are developing, it is imperative that she immediately notify the surgeon, for few will operate when there is even the slightest infection of the respiratory system. When patients are being examined physically, or receiving treatments, it is highly important that all windows and doors in the vicinity be closed and that draughts be diminished to the minimum. If a patient has to leave the bed he should be ade- quately supplied with slippers, a bathrobe, and, if necessary, a blanket. When he is moved to and from the operating room he should be warmly covered, and in the operating room the same general rules hold true. If his gown becomes wet with perspiration, his body should be thoroughly dried and a new gown supplied. Operative Prophylactic Treatment.—While the patient is POST-OPERATIVE COMPLICATIONS 29 recovering from the anesthetic, the lower jaw should be held firmly and pressed forward, exerting pressure at both angles; this will do much to prevent gagging and when the patient vomits the head should be turned to one side, the jaw still being held, and the vomitus eructated into a pus basin. It is highly im- portant that this be always done, because if this procedure is routinely and regularly followed, the danger of the vomitus being aspirated into the lungs is reduced. Aspiration is not an uncommon cause of pneumonia. Post-operative Prophylactic Treatment.—When the patient arrives in the ward or room he should be warmly covered, and very often in order to maintain a good body heat, the bed may be previously warmed either with electric pad or hot water bottles. If the patient tosses about, the blankets should always be readjusted. If there is a tendency to vomit the jaw should be held firmly forward and the head turned to one side. These instructions have been repeated because it is extremely im- portant that they become deeply impressed upon the nursing mind. In other words, the incidence of post-operative pneu- monia may be greatly reduced if the patient before operation is free of any infection of the respiratory tract, and during the period of surgical attention he be fully protected against draughts and unusual changes from cold to hot or hot to cold. Treatment of Post-operative Pneumonia.—The treatment is really that of any lobar pneumonia. The patient is usually on a Gatch bed. The Gatch bed is one which is made in sections so that the upper portion of the body may be elevated and the knees flexed by adjusting these sections to any desired de- gree. The windows are opened wide and as much fresh air is given as is possible. The diet is liquid including milk. Fluids should be forced to about 3,000 c.c. a day, and the intake and output should be accurately measured. Abdominal distention is always looked for and treated im- mediately with rectal tube, enemas or colon irrigations. The cough is particularly distressing and dangerous, for after a surgical operation the pressure caused by straining may break some of the sutures and sometimes the abdominal wound 30 TEXTBOOK OF SURGICAL NURSING is ruptured wide open, and the abdominal contents eviscerated. To prevent this horrible complication a good, tight, well-placed binder is exceedingly important, for it gives added support to the abdominal wall. If the coughing is very severe, the nurse should support the lateral areas of the abdominal wall with her hands. Should evisceration take place, the intestines should be covered with sterile towels, and the surgeon immediately summoned. For the cough, doctors will prescribe a codeine cough mixture, or leave orders for codeine to be given either by mouth or hypodermic. As soon as the diagnosis is made, it is routine to administer tincture of digitalis as a cardiac stimulant, the dose being 10 to 15 minims three times a day. If the pulse is very rapid, and the heart overacting, it is controlled by an ice bag placed over the precordium. Pleural pain, which is very distressing, yields to strapping the affected side with adhesive plaster. Pneumonia cases must always be watched carefully for cardiac failure and edema of the lungs. The cardiac failure is evidenced by a weak, thready pulse, cyanosis and respiratory difficulty. Edema of the lungs manifests itself by bubbling respirations. Cardiac failure is treated by stimulants, such as camphor in oil, caffeine or atropine. Edema of the lungs responds best to good dry cupping especially applied to the posterior regions of the chest. This should be done for about twenty minutes at a time. Great care should always be exercised in preventing the patient from being burned with the cups. The use of oxygen in these cases with the present apparatus is practically useless and worthless. Pulmonary Embolism.—Closely allied to post-operative pneumonia, but of different etiology, is pulmonary embolism. It is not very common, and may occur after the simplest opera- tions ; for example, after an ap'pendicectomy, or an operation for varicose veins; it may be preceded by a thrombosis of the veins of the lower extremity, or come as a distinct entity. As a rule, it is ushered in by a sudden pain in the chest, dyspnea, bloody expectoration, rapid pulse, and slight rise in temperature. If POST-OPERATIVE COMPLICATIONS 31 the chest is auscultated the doctor may sometimes note a fric- tion sound, or signs of beginning pneumonia may be evident. Occasionally, instant death occurs, and at best the mortality is high, varying from seventy to eighty per cent. Treatment.—Patients who develop a phlebitis or thrombosis of the veins of the lower extremity, or any other region, should be kept in bed until this condition absolutely sub- sides, because a small piece of blood clot may break off and lodge in the lung as an embolus. Patients should not be per- mitted to be too active after operation even if their condition is excellent. The treatment of embolism is to reassure the patients, for they are apt to become greatly alarmed at the sight of their bloody expectoration. To further quiet them morphine is administered. If the diagnosis of its location is made, it is customary to strap that side of the chest in which the embolus is lodged. This will immobilize the affected lung as much as possible. The family of a patient suffering from a pulmonary embolism should be apprised of the impending danger, for even though the patient may recover from the shock of the embolism itself, it may give rise to an embolic pneumonia and a recovery from this condition is exceptionally rare although it occasionally occurs. Urinary Retention.—After operation, occasionally, a patient is unable to void urine voluntarily with the result that the urine collects in the bladder, the organ becoming dilated be- yond its usual capacity. Pain is very apt to result from this distention, and the patient is very uncomfortable. Urinary retention is more prone to occur after operations about the rectum, the vagina, the cervix, and the bladder itself than after operations involving the upper abdomen. The reason for this is that the center of micturition has been reflexly inhibited by the operative procedures; or it may be due to nervousness, or that conscious control has not as yet been reestablished after the administration of an anesthetic. As a rule, no patient should be allowed to go more than twelve to twenty hours with- out voiding. However, every effort should be made to have 32 TEXTBOOK OF SURGICAL NURSING the patient void voluntarily, because all functions are better performed by nature than if mechanically interfered with. Treatment.—The treatment of urinary retention is cathe- terization. A catheterization is a surgical procedure. A surgi- cal procedure in clean cases is an aseptic one, and every bladder which becomes infected after the introduction of the catheter is a horrible reflection upon the individual who has done the catheterization. This procedure should be done with a good light. The urethral orifice is carefully exposed. The catheter, be it rubber, metal, or glass, should be lubricated with a sterile oil, either olive oil or K. Y. The urine which is withdrawn should be saved and examined as a matter of record. While catheterization every eight hours is a routine in some hospitals after perineorrhaphy, it should be remembered that a patient may develop a '' catheter habit'' because the act of micturition or urination causes slight pain, and catheterization affords instant relief without pain. These cases should be treated firmly but gently and various expedients should be tried to induce volun- tary micturition. The drinking of large quantities of water, the sound of running water from turning on a water faucet within hearing distance of the patient, or pouring warm water over the vulva may do much to encourage voluntary micturition. In those cases where there is an old inflammation of the bladder, it is advisable not to draw off all the urine at once, but to leave about four ounces in the bladder, or if all the urine is withdrawn, to introduce immediately into the bladder about four ounces of a warm sterile solution of boric acid. This will prevent any possibility of an infection travelling from the bladder to the kidneys via the ureter. The details of catheterization are not given here, as they are known to every nurse, but it cannot be emphasized too strongly that this treat- ment above all must be done by a nurse with a surgical con- science. Suppression of Urine.—Following some of the more exten- sive major operations, especially those upon the kidney, either a nephrectomy or a nephrotomy, or prostatectomy, the kidneys may shut down and secrete no urine; the result is, that those substances which should be normally excreted in the urine as POST-OPERATIVE COMPLICATIONS 33 the urea, are stored up in the blood. There is, however, a limit to the amount of nitrogenous poison which the blood can con- tain, and if this threshold is crossed, the patient may suffer from uremic poisoning. Uremia is recognized by the urinous odor of the breath, the dried parched tongue, a semicomatose attitude of the patient, the urinary suppression, and an in- crease in the nonprotein nitrogen of the blood. Treatment.—The prognosis in all these cases is poor. The same methods used by medical men in combating uremia re- sulting from diseased kidneys are used by the surgeon. If the kidneys are incapable of physiologically performing their func- tion of elimination, then for the time being other organs must take over that function. There are many adjuvants,—the sweat glands of the skin and the intestinal canal are invaluable aids. The reflex stimulation of the kidneys by counter-irritants, the forcing of fluids so as to dilute the poison in the blood, the actual removal of some blood with its poisons (phlebotomy), and, finally, operation upon the kidney itself, all help in this very serious complication. The skin may be used to further aid excretion. If the pa- tient will stand it, hot packs should be employed. The pur- pose of a.hot pack is to cause perspiration, and inasmuch as urea is one of the chief elements of sweat, a partial strain is taken away from the kidneys. Very often this procedure alone will be sufficient to stimulate the kidneys to excrete urine. Hot packs should be repeated at intervals of four to six hours. While the treatment is being administered, the condition of the patient must be carefully watched, for the packing often re- sults in weakness and prostration. The other danger of giving a pack to a surgical patient is that the body must be care- fully dried after the treatment in order to prevent post-opera- tive pneumonia. In addition, great care should always be taken that the skin (which has already been made sensitive through the application of the ante-operative painting of iodine) should not be burned, and further avenues of infection opened through denuded skin. The use of the intestinal tract as an avenue of elimination may be further stimulated by employment of colon irrigations. 34 TEXTBOOK OF SURGICAL NURSING The colon irrigations, as stated previously, not only carry off large amounts of toxins, but they are a means of supplying water to the tissues. The kidneys may be stimulated reflexly by counter-irritants applied to the skin of the lumbar region. This may be accom- plished by the use of flaxseed poultices applied at two-hour intervals, or by hot water bottles. Some surgeons employ drugs in order to stimulate the kidneys directly, by the use of such substances as theobromine because of its direct diuretic action. Five to eight grains are given three times a day for the space of three days and then the drug is stopped. There is no doubt that this drug is excellent in stimulating the kidneys and cer- tainly surpasses caffeine in its action. The disadvantage is that it might cause a certain amount of nervousness and insomnia. Forcing fluids either by proctoclysis or hypodermoclysis will cause enough fluid to be absorbed to dilute the blood, thus resulting in a diminution in the degree of toxemia. This simple method not only relieves the patient of an impending uremia, but the kidneys are stimulated by the added amount of fluid. In cases of high blood pressure with a high blood urea, the actual removal of part of the blood volume will do much to re- duce the nitrogen content of the blood, if only for a short period of time. This is done by a phlebotomy, or inserting a canula in a vein in the arm, and permitting the patient to be bled of 250 to 700 c.c. of blood. The amount withdrawn should de- pend upon the constitution and physique of the patient. Quite often after this procedure, 250 to 500 c.c. of normal saline are introduced intravenously, resulting in further dilution of the toxins. If, in spite of all these procedures, there is no urine ex- creted, a rather heroic operative procedure may be resorted to, that of decapsulating the kidneys. This is especially indicated in those cases which have a chronic inflammation of the kidneys, preexisting Bright's disease. The operation is spoken of as Edebohls's decapsulation. It consists of the excision of the capsule from the kidney so that with this restraint removed, the organ may be able to work more efficiently by establishing POST-OPERATIVE COMPLICATIONS 35 new vascular relationships with the surrounding tissues, thereby obtaining better nourishment for itself. Phlebitis.—This condition is an inflammation of the veins, usually of the lower extremity. It is rather late in onset and is annoying because the patient is confined to bed for a longer period of time. It is manifested by cramp-like pains in the leg, a rise in temperature, and a feeling of general malaise. Ex- amination of the affected extremity shows that the part is swollen and the skin over the veins reddened. Occasionally the veins may be palpated. The treatment calls for absolute rest, elevation of the affected part and immobilization, the part being kept warm by a wrapping of cotton, or the additional heat of an electric pad. Phlebitis may be associated with or followed by thrombosis. Thrombosis.—This may follow in the path of a phlebitis, and simply means the occlusion of the lumen of the vein with a blood clot. The same condition may occur in arteries. The symptoms are practically those of a phlebitis. The danger of these cases lies not so much in thrombosis itself, but the fact that these thrombi may give rise to small particles of blood clots (emboli) which invade the blood stream and localize in any part of the body. The symptoms and physical signs depend on the area in which these emboli have lodged. If it should localize in the brain, paralysis might ensue; if in the central artery of the retina, blindness; if within the coronary artery of the heart, immediate death. A glance at these possibilities is certainly proof that a thrombosis is potentially a dangerous operative complication. Treatment.—The acute condition is treated practically the same as a phlebitis, with the exception that the local applica- tions vary, some using ice compresses over the veins, others a 20 per cent, ichthyol ointment, some the electric pad. All sur- geons believe in absolute rest of the part involved. It is a good practice to keep the weight of the bed clothing away from the affected area, by means of a wooden or metal cradle. When all the acute inflammation has subsided, the patient should not be allowed up and out of bed until a good firm pres- sure bandage has been applied. In a leg case, the bandage 36 TEXTBOOK OF SURGICAL NURSING is wound from the ankle upward to the knee. The patient should be warned that even after leaving the hospital, or home, that a rubber stocking properly fitted should be worn for a long period of time. Of course when this condition involves the superficial veins it is not so very serious, but it has been known to choke off the femoral artery, the main channel through which the lower extremity gets its supply of blood. This might result in gangrene with subsequent amputation of the leg and thigh. These severe post-operative complications are fortunately rather rare. Hemophilia.—As science progresses new discoveries are made and some certain operative complications may be pre- vented by prophylactic measures. A disease no longer dreaded is hemophilia (a condition marked by a tendency to persistent bleeding). It would never occur if routine coagulation times were done on all patients before they entered the operating room. Blood usually clots in seven minutes and if the period of clotting is beyond eight minutes, measures should be insti- tuted to insure the clotting of the blood in a shorter period. There are many conditions which interfere with the normal clotting of blood, but one of the most interesting of these is hemophilia. It is a malady which is transmitted by the female to the male, although rare instances have been reported wThere women, too, are the sufferers. In this disease, blood does not clot often until 15-20 minutes. Jaundice is another condition which hinders the clotting of the blood. In hemophilia and jaundice and in all cases in which the clotting time is delayed methods must be taken to lower the coagulation time to within normal limits. Treatment.—Before operation those patients with a pro- longed coagulation time should be given calcium lactate, gr. 15, three times a day, in milk. If at the end of three days, the coagulation time has not been materially reduced, they should be given about from 15 to 30 c.c. of horse serum intravenously. This is very valuable in lowering the coagulation time. Be- fore the administration of horse serum, the patient should be carefully tested by the injection of minute doses of horse serum POST-OPERATIVE COMPLICATIONS 37 into the skin to determine whether the individual is sensitive to it. Patients who have recently had those diseases in which horse serum is used as a curative agent, as in diphtheria anti- toxin or anti-meningococcus serum, have a peculiar idiosyncrasy to it, so that if this serum is given again, a condition of "an- aphylaxis" may result. Anaphylaxis has been defined as "the increased susceptibility to an infection or the action of any foreign substance intro- duced into the body following a primary infection." This con- dition is indeed serious, manifesting itself by a sudden, labored respiration, rapid pulse, cyanosis and the appearance of large red cutaneous blotches, or urticaria. Death has been known to occur within a few minutes. If this condition should re- sult, it is best treated by the administration of atropine hypo- dermically, or adrenalin, minims 15. The elimination should be further promoted by colon irrigations. Recent investigations have proved that patients with delayed clotting time are often improved by ante-operative transfusions of human blood. The blood of the patient should be tested first for the particular group into which it falls, and then a transfusion of blood from a donor whose blood group is the same as that of the patient should be given. (This is described in Chapter II.) CHAPTER IV THE SURGERY AND SURGICAL NURSING OF THE ALIMENTARY SYSTEM Introduction.—In this and the following Chapters V to XI of surgical conditions involving the systems of the body, the various pre-operative and post-operative nursing measures which are peculiar to the individual case at hand will be indicated, but no standard routine courses of treatment can be reasonably prescribed because every surgeon will have his own. These will necessarily vary from time to time in accordance with differ- ences in patients, operative procedures, general conditions, etc. However, in Chapter XIII, under the subject of "Anesthesia," and in Chapter XVI, under "The Operating Room," there are recorded representative practices which, with what is given here, will give the student the framework for surgical nursing. Before considering the surgery of the Alimentary System, a brief review of those organs which constitute it may be instruc- tive. I. Organs of the Alimentary Canal: 1. Mouth 2. Pharynx (1) Tonsils (2) Adenoids 3. Esophagus 4. Stomach 5. Small Intestine (1) Duodenum (2) Jejunum (3) Ileum 6. Large Intestine (1) Cecum and appendix (2) Colon o. ascending b. transverse c. descending 38 NURSING OF THE ALIMENTARY SYSTEM 39 (3) Sigmoid Flexure (4) Rectum (5) Anus II. Accessory Organs op Digestion : 1. Teeth 2. Tongue 3. Salivary Glands (1) Parotid (2) Submaxillary (3) Sublingual 4. Pancreas 5. Liver and Gall Bladder The Mouth.—The mouth is of special interest because it comprises part of the operative field of the upper and lower jaws, and the tongue; it is the path through which the tonsils and the adenoids are approached; and the means by which the trachea and esophagus are entered. Its main importance from a surgical standpoint is that it can never be rendered sterile, so that all the operations on the afore-mentioned organs must of necessity be contaminated. Even though the work is done in a contaminated field, the same aseptic surgery should be prac- tised here as is practised in other regions. This fact should not deter the nurse from getting the mouth as clean as possible for the operation. It is usual to have the patient wash the buccal cavity every two hours with some liquid, either warm saline, or water to which has been added one of the countless pleasant-tasting antiseptics which are in everyday use. This should be begun about two days prior to the operation. It is imperative that mouth washing should be done thoroughly. The nurse should not content herself by simply informing the patient that the mouth is to be washed, but she should stand by and see that it is efficiently done. In addition, the teeth should be carefully brushed at least after each meal. If pyorrhea exists, the teeth should be scraped and the gums treated by a dentist. In this way the amount of mouth contamination may be reduced to the minimum. The inflammatory affections of the jaws, such as inflamma- tion of the gums, or gingivitis, or pyorrhea alveolaris, need 40 TEXTBOOK OF SURGICAL NURSING no special mention here. But the new growths of the jaws, either benign or malignant, form a very important chapter in surgery because they may necessitate a resection of either the upper or lower maxillae. The Jaws.—The jaw may be the seat of a variety of tumor formations:—(1) Cysts arising from some abnormality in the development of the teeth; (2) non-malignant growths, or epulis; and (3) malignant growths. Treatment of New Growths of the Jaws.—If the cysts are small, they are removed and the membrane which lines the cavity is destroyed. If necessary, the cavity is packed and the wound permitted to heal by granulation tissue. The only treat- ment is to keep the mouth clean. In the case of benign tumors, the tooth about which the tumor grows is removed and with it a portion of the bone. The removal is accomplished by a Gigli saw. It is always con- venient to have at hand an actual cautery or Horsley's wax to control the hemorrhage which may ensue from the bone. The cases of malignant growths, either carcinomas or sarco- mas, demand radical operation. In the case of the upper jaw this is not so practical because, with the removal of the bone, the eyeball loses its support and drops from its normal anatomical position resulting in a condition of double vision or diplopia; and, by removing the hard palate, a communication is made between the nose and mouth. However, in spite of these two obstacles, the operation is occasionally done. The removal of the lower jaw, however, is not so difficult; it may be removed either partially or in its entirety. The actual operative technic is more of interest to the surgeon than the nurse and will not be discussed here. The nursing pro- cedures are the same as for any radical operation on either the upper or lower jaw. Ante-operative Treatment.—As has been mentioned previ- ously, the mouth should be cleansed very carefully. The opera- tive field, in the male, should be prepared by shaving an hour before the operation, as the beard sometimes grows very rapidly and nothing is more disagreeable than to have the patient enter the operating room not properly prepared. NURSING OF THE ALIMENTARY SYSTEM 41 Operation.—The anesthesia is given by intratracheal in- sufflation, a method whereby the vaporized ether is forced into the trachea through a catheter by means of a special apparatus. With this method the anesthetist is removed far from the opera- tive field and the surgeon is able to work undisturbed. The head is draped as is shown in Fig. 82 (page 285). The instru- ments for this operation are those used for any bone work. Post-operative Treatment.—The packing, which is intro- duced at operation into the area vacated by the maxilla, is removed, as a rule, after twenty-four hours. The space left by the removal of the upper jaw should be sprayed through the mouth every two to three hours with some antiseptic solu- tion. The patient, as soon as he is able, should wash his mouth himself every two or three hours. For the first three days, it is better not to give food by mouth; the nourishment is sup- plied either by nutrient enemata, or by nasal gavage, the cathe- ter being passed through the nostril on the sound side. As soon as the wound granulates, the patient may be given a liquid diet, the food always being introduced along the sound side of the mouth. Great care should be taken that the mouth be thoroughly cleansed after each feeding. Some surgeons re- quest that the cavities be lightly packed with gauze during feedings so as to prevent the liquid food from entering the operative wound. This is not so important a procedure with liquids as it is with soft diet, which is allowed after about three weeks. It is unnecessary to confine the patient to bed any longer than four days, provided that everything goes smoothly, for needless confinement to bed often causes weakness. The Tongue.—Those conditions which demand radical op- erative procedure on the tongue are invariably due to malignant disease, and may require that the tongue be removed in part, halves or completely extirpated. Removal of the tongue (glos- sectomy) is accompanied by a preliminary removal of the glands of the submaxillary triangle and a ligation of the lingual artery which supplies the tongue with blood. By ligating this artery before a removal of the tongue is attempted, hemorrhage is very markedly diminished at the time of the radical operation. Ante-operative Preparation.—This consists of the usual 42 TEXTBOOK OF SURGICAL NURSING cleansing of the mouth as already outlined in operations upon the jaw. Operation.—The anesthetic is administered intranasally. The mouth is kept open by a self-retaining gag. A heavy silk ligature should always be at hand for introduction through the base of the tongue. This serves as a tractor, and even after the tongue has been removed the ligature is left in place, the free end being fastened either to the teeth, or identified by an attached pair of forceps that'hang from the mouth. This ligature should remain in place for at least twenty-four hours after operation, for it is invaluable in controlling the base of the tongue should any serious hemorrhage occur. Post-operative Treatment.—In those conditions in which either half or the entire tongue has been removed, the treat- ment of the raw denuded surface of the floor of the mouth is what most concerns us. The desideratum, of course, is to ren- der this area aseptic. To attain this end, some operators use balsam of Peru, which is applied as gently as possible. The dusting of iodoform powder is to be condemned, as iodine poison- ing may result. Other surgeons prefer the use of mild anti- septic sprays. For about four days, the patient should be fed by enemata. Each morning the bowels should be washed out with a soap- suds enema followed by rectal feedings (Chapter XII) which are given, as a rule, every four hours. If the patient is very weak and emaciated, and demands more nourishment than can be given by rectum, a small stomach tube may be passed through the nostril into the stomach, and left in place. Some operators prefer that the patient be fed directly by mouth; a soft rubber catheter is passed along the normal side of the mouth permitting the patient to swallow the liquids which are poured slowly through the tube. Each feeding should be completed by the administration of sterile water, and the tube withdrawn, after which the mouth should be thoroughly cleansed. Soft diet may be given as soon as the wound heals and swallowing without difficulty is possible. The patient should be permitted to sit up in bed as soon as possible, and so as to afford better drainage to the secretions which collect in the mouth, the head should be NURSING OF THE ALIMENTARY SYSTEM 43 kept bent slightly forward. These cases may be allowed up from bed on about the fourth day. Treatment of Inoperable Cases.—While all patients suffering from inoperable cancer are miserable, there are none who pre- sent such a horrible spectacle as those with a large fungating growth of the tongue. Unable to swallow, finding difficulty in breathing, suffering agonies, with an oral stench which is hardly bearable for themselves or others associated with them, they are entitled to all the sympathy possible. If nothing else can be done for these unfortunates they may be kept absolutely free from pain. The local pain is sometimes reduced by dust- ing the ulcerated areas with orthoform powder. It is applied before any food is taken. Morphine should be given liberally, with a little atropine to prevent its depressing effects. The foulness of the breath may be lessened by the continual use of mouth washes and mouth irrigations. If dyspnea becomes marked because of crowding of the larynx by growth, trache- otomy may be necessary. If difficulty exists in swallowing, rectal feeding may be given. Feeding by stomach tube or nasal gavage is not practical, because the rubber tubes coming in contact with the growths cause excruciating pain. Occasionally, the proper use of radium and X-ray, in selected cases, will do much to give relief where the knife of surgery has failed. The Pharynx.—The pharynx is important surgically because it lodges the tonsils and the posterior portion harbors the ade- noids. As is known, the tonsils may be the seat of acute in- flammation, and the bacteria may spread into the surrounding tissues giving rise to what is popularly known as a quinsy sore throat, or a peritonsillar abscess. Treatment of a Peritonsillar Abscess.—Since this condition is in reality an abscess formation, means should be taken to cause a pointing of the abscess as soon as possible. With this ultimate end, flaxseed poultices should be applied every two hours to the side of the neck that is affected and warm throat irrigations with a quart of saline at 105° should be given at regular intervals. This will not only cause a localization of the pus, but will be very comforting to the patient and re- lieve much of the pain which accompanies this condition. The 44 TEXTBOOK OF SURGICAL NURSING abscess is opened by blunt incision under local anesthesia and the pus evacuated. The after treatment is simple, consisting mainly of throat irrigations and antiseptic mouth washes to relieve the oral fetor and promote drainage. Tonsillectomy.—Tonsils are removed very often, both be- cause of a diseased condition and because of an increase in size, or hypertrophy. As a rule the operation is attended with very little risk and is performed under ether in children, and with local anesthesia in adults. Operative Treatment.—The patient, if a child, is placed un- der ether anesthesia in the dorsal position and the mouth held open by a self-retaining gag; an electric head lamp worn by the surgeon supplies the light. The tonsils are removed by one of several methods, either by blunt dissection with a Sluter tonsillotome, or they are dissected out with scissors, and finally enucleated with a snare. The hemorrhage is controlled by the simple pressure of gauze sponges. If necessary, the bleeding vessels may be tied, or a sponge with a piece of tape securely attached may be left in the tonsillar fossa for twenty-four hours. After the operation has been completed, to further stop bleed- ing and cause the patient to regain consciousness as quickly as possible, the neck and face are bathed with towels previously soaked in ice water. After Treatment.—While these cases are apt to ooze a little after operation, careful watch should be kept on their pulse, and if they are bleeding briskly, as evidenced by the constant expectoration of bright red blood, or the vomiting of large quantities of altered blood, the attending surgeon should be notified immediately, for cases of fatal hemorrhage have been known to result. The diet should be liquid, ice cream being given to children, for the cold is gratifying to the throat, and the psychic effect cheering to their depressed spirits, and, in addition, the cream forms a protective layer to the denuded areas of the pharynx. The patient is kept indoors for a day or two to prevent catch- ing cold. Adenoids.—Adenoids are removed either with a curette or NURSING OF THE ALIMENTARY SYSTEM 45 an adenotome. This operation requires no special treatment beyond that already mentioned for tonsillectomy. The Esophagus.—While the esophagus is as important as any other structure of the body, its surgery is in its infancy and the operations few in number. Those diseases which in- terest the surgeon have very little need for a nurse, since what- ever is done in the way of treatment is non-operative and per- formed by the surgeon himself. Diseases of the Esophagus.—The esophagus may be burned by the passage through it of foreign substances, or injured by the passage of foreign bodies. This will result in an ulceration of the esophagus, with a resultant contracture and stricture, making swallowing rather difficult. Of course, as in other lo- cations, cancer may elect the esophagus, but since it involves this organ at its lowermost portion just where it pierces the diaphragm muscle, very little is done for it by active surgical intervention. Treatment.—If the esophagus has just been burned by acid, then alkali must be given in the form of a solution of sodium bicarbonate. If caustic alkali is the agent which has been ingested, then a diluted vinegar solution is given to neutralize the base. The stricture, resulting from the healing of the in- jured area of esophagus is treated by the passing of esophageal sounds, or bougies. These are passed at frequent intervals, the diameter of the bougie being increased in size until the esophagus has been dilated to normal. If the ulceration is very widespread, the dilatation of the esophagus is impractical, and because of its extensive nature, more radical procedures must be adopted. The patient being unable to swallow cannot be nourished indefinitely by rectal enemata, so that an opening must be made directly into the stomach. Through this fistula the food may be introduced and the patient receive the proper nourishment for his existence. This operation is known as gastrostomy which is described in detail on page 46. Foreign Bodies in the Esophagus.—The esophagus, as well as the trachea and larynx, is often the resting place for swal- lowed foreign bodies, such as coins, pins, etc. It is very im- 46 TEXTBOOK OF SURGICAL NURSING portant to really ascertain that the patient has a foreign body, and the X-ray is a valuable aid in determining the presence of many varieties. Some of these may be removed by special instruments; for example, a coin-catcher, or by direct vision through an esophagoscope. If these bodies are of too great a size to be easily dislodged and are caught fast in the cervical region of the esophagus, the esophagus may be opened through the neck, and the object extracted. The operation is spoken of as esophagotomy. If the foreign body is close to the cardiac portion of the esophagus it may be removed indirectly via the stomach by a gastrostomy. New Growths of the Esophagus.—While a resection of the esophagus is sometimes performed for malignant stricture, the mortality is so high and the results so uncertain that con- servative rather than radical measures are invariably employed. Most surgeons are content by introducing radium through an esophagoscope into the esophagus and permitting the metal to exert its rays upon the tumor cells and thus hinder their ex- travagant multiplication. Occasionally surgeons perform a gastrostomy, so that the patient will not starve to death. Gastrostomy.—When the esophagus is narrowed either by a benign stricture, or carcinomatous tissue to such an extent that feeding is practically impossible, a gastrostomy must be performed to prevent the patient from starving. This is an op- eration whereby a communication is established between the anterior surface of the stomach and the anterior abdominal wall. Through this gastric fistula, fluid may be introduced, the patient, in this fashion, being given nourishment without the food actually entering the esophagus. There are different types of operations done but they all are essentially the same: they vary in their technic. Ante-operative Treatment.—The abdomen is prepared in the usual manner. Inasmuch as these patients are very emaciated and weak, the operation is performed under local anesthesia, preliminary to which morphine gr. 14 with atropine gr. 1/150 is given hypodermatically. Operation.—The abdomen is opened by a left rectus in- cision, the stomach found, and packed off from the rest of the NURSING OF THE ALIMENTARY SYSTEM 47 abdominal cavity with hot saline pads. A small opening is made into the stomach and a sterilized catheter is introduced into its interior. The further burying of the catheter within the stomach, so as to prevent regurgitation of stomach contents through the fistula, is one of technical detail. The peritoneum is then narrowed and a few sutures are taken approximating it to the stomach, so that this organ is held firmly to the abdominal wall. The catheter is brought out of the skin incision and clamped. After Treatment.—The patient is fed every four hours through the catheter. A convenient way of doing this is to connect it with a small funnel so that the fluids may be easily poured into the stomach. The foods which may be given are limited to those which can be made up into or dissolved in fluids, and from six to ten ounces of liquids may be given at a feeding. Their caloric value should always be estimated and great care should be taken to see that the patient is given suffi- cient food. Some surgeons permit their patients to chew solid food for the taste and because a flow of gastric juice is stimulated by the hormone "secretin" of the saliva; but, naturally, the patients are not permitted to swallow the food. After the first few days the catheter should be removed and changed daily, a fresh clean one always being ready for im- mediate insertion. After the feeding the end of the tube should be clamped so as to prevent leakage, and an abdominal binder applied. In about two months' time the tube may be left out of the stomach, and inserted at the feeding periods only. The fistula in the interim may be covered with a piece of vase- linated gauze, held in place by a binder. Patients should be taught to insert their own tubes, the method of feeding them- selves, and the foods which may be taken. It is highly important that the skin about a gastric fistula be kept scrupulously clean. Should gastric contents leak either from or around the tube, the skin should be washed immedi- ately and covered with some bland non-irritating ointment, such as Beck's paste or vaseline. If this is not done, the gastric juice will digest the skin and a painful ulcerated area about the tube may result. 48 TEXTBOOK OF SURGICAL NURSING The Stomach.—The surgery of the stomach forms one of the most brilliant and important chapters in general abdominal surgery, for each year brings new gastric operations with a more refined technic. Operations upon the stomach, or, in fact, any part of the intestinal tract, introduce an element which is of great im- portance from the standpoint of an operating nurse. The operative field in a simple celiotomy (the opening of a peritoneal cavity) is clean, and under normal conditions, free from all bacteria. Yet the interior of the intestinal tract and colon, and, to a slighter degree, the stomach, are swarming with bacteria. Naturally, in those operations which necessitate an opening into the stomach, intestines, or colon, a previously clean field will be converted into a "dirty" one. However, by carefully padding off the operative field from the rest of the peritoneal cavity, and by later carefully discarding those instruments (needles, ligatures, sponges, towels, etc.) which have come into contact with the contaminated field, it is perfectly possible to maintain the sterile toilet of the peritoneal cavity. This will be discussed in greater detail subsequently. And it is upon the nurses in the operating room that this routine and its observ- ances are partially dependent. Diseases of the Stomach.—The stomach may be subject to various inflammations of the mucosa from a variety of causes. These are considered under the general heading of gastritis. They are of little interest surgically. The affections of the stomach which demand surgical treatment are those of gastric ulcer and gastric carcinoma. Gastric Ulcer.—Gastric ulcer starts as an erosion of the mucosa of the stomach, the ulceration gradually extending deeper, at times eating its way through the muscular and serous coats of the stomach causing a communication between the in- terior of the stomach and the general peritoneal cavity. The ulcer in itself is not so serious but by growing it may open a blood vessel, causing a gastric hemorrhage (hematemesis). Or the scar tissue which follows in the path of a healing ulcer may interfere with the gastric functions by creating various de- formities of the stomach. This is especially true when the ulcer NURSING OF THE ALIMENTARY SYSTEM 49 occurs in the region of the pylorus; subsequent healing of an ulcer in this location may result in a narrowing or stenosis of the pyloric orifice. The third danger already mentioned is that of perforation, through which the gastric contents are emptied into the general peritoneal cavity resulting in a peritonitis. The symptoms of gastric ulcer, in brief, are epigastric pain, vomiting, and bleeding. Although the last is one of the most persistent signs of gastric ulcer it may be absent. Exami- nation of the stomach contents may show an increase in the amount of free hydrochloric acid and the presence of blood. X-ray examination with a bismuth meal may reveal an irregu- larity in the outline of the stomach, indicative of ulcer. Treatment of Gastric Ulcer.—The treatment is both medical and surgical. The latter only will be discussed here. Surgical treatment is employed when (1) medical treatment has given little relief, (2) when perforation of the ulcer has occurred, (3) when perforation has resulted in the formation of an ab- scess, or (4) when the pylorus has become stenosed. The treatment of the chronic cases is to short-circuit the food contents from the stomach to the jejunum directly, instead of first passing through the pyloris and duodenum. This will per- mit the ulcer to heal by giving the pyloric portion of the stom- ach a functional rest; and, in those cases of pyloric constric- tion, the food will now have a free exit through the new opening. The establishment of a new opening in the stomach and attach- ment to it of the intestine is known as gastroenterostomy. The jejunum may be attached to either the anterior or posterior surface of the stomach, resulting in either an anterior or pos- terior gastrojejunostomy. Gastroenterostomy.—Ante-operative Treatment.—In chronic cases of ulcer of the stomach prior to the time of operation, fluid should be forced upon the patient so that there will be a re- serve amount in the tissues. An hour before operation the stomach is washed. Great care should be taken that the return flow is absolutely clear at the completion of the treatment and that none of the lavaging fluid is left within the viscus. Operative Treatment.—The operation itself will be briefly 50 TEXTBOOK OF SURGICAL NURSING outlined demonstrating the manner in which the sterility of the peritoneal cavity can be maintained although the stomach and jejunum have been opened and the field contaminated. After the skin incision has been made, some surgeons clamp sheets to the subcutaneous tissues. The incision is then deep- ened through the fascia and muscles, the peritoneum opened, and the stomach and the jejunum delivered into the wound. The jejunum is stripped free of its fecal content, and an intestinal clamp with rubber-covered blades applied lengthwise. The stomach is clamped in a similar manner. The immediate opera- tive field is padded off with hot gauze pads and the surround- ing sheets are further protected with additional towels. The stomach and jejunum are then brought into proximity by an approximating Cushing suture, using Pagenstecher linen thread on a straight round needle. This suture should be sufficiently long to completely encircle the stoma between the stomach and intestines. The needle and thread are protected with gauze for the time being. The stomach and intestine are now ready to be opened. From now on until a sterile field is reestab- lished everything contaminated from contact with the open gut should be placed on a tray provided for dirty instruments. The surgeon and his assistants must not touch anything on the clean instrument table, and the sterile nurse must avoid touch- ing with her gloved hands anything that has come into con- tact with the contaminated operative field. After the redundant mucous membrane has been trimmed, the mucous coat of the stomach is ready to be united to the contiguous mucous coat of the jejunum. This is accomplished with through-and-through lock stitch using number 0 or 1 chromic catgut on a round straight needle for one-half the circumference of the opening, a through-and-through Cushing stitch completing the closure. The contaminated field is now sealeel off; clamps, soiled gauze pads, instruments and towels are removed and the gloves of the surgeon and his assistants are either washed in bichloride or exchanged for a new pair. The suture line is cleansed with saline solution and fresh pads reapplied. The suture is re- enforced with Cushing suture of Pagenstecher linen thread, as a continuation of the original approximative linen suture. NURSING OF THE ALIMENTARY SYSTEM 51 After the opening of the transverse mesocolon has been sutured around the union between the stomach and the jejunum with interrupted number 1 plain catgut on a round curved needle, the gut is washed with saline solution and fresh towels placed about the operative field. The hands are again washed with bichloride, the gut returned into the peritoneal cavity and the abdomen closed. This will give an idea of the great care which must be taken throughout the operation to maintain strict asepsis, and the nurse must be ever on the alert to see that the technic is rigidly followed. After Treatment.—There is some degree of shock following this type of operation, and it is necessary to administer saline hypodermatically, or by rectum by Murphy drip. The drip should be kept on for about four hours and off for two. This will prevent irritability of the rectal mucosa, and insure the proper absorption of the fluid. But as soon as the patient is receiving sufficient nourishment by mouth the drip may be dis- continued. "When the patient has recovered from the anesthesia, he should be placed in Fowler's position (page 59), for this posi- tion favors the passage of the ingested food through the new opening, the gastroenterostomy stoma. Some surgeons are in the habit of allowing fluids within a few hours after the anes- thetic nausea and vomiting have disappeared. Water is given in dram doses every hour, and if it is tolerated, after a few feedings an ounce of peptonized milk is allowed every two hours, alternating with water every two hours. This may be followed on about the second or third day by an ordinary Len- hartz diet. In some hospitals, a special gastroenterostomy diet has been arranged for these patients. Outlines of these diets will be found in Chapter XII. Complications after Gastroenterostomy.—Hemorrhage.—Oc- casionally, after the operation, the pulse may mount in fre- quency and the patient exhibit all the clinical symptoms of hemorrhage. This is evidence of gastric bleeding. The patient should immediately be placed in an upright position in bed, and cold applied over the upper epigastrium by ice bags, ice 52 TEXTBOOK OF SURGICAL NURSING coils or cold compresses. Cold may be applied internally by permitting the patient to swallow small pieces of cracked ice. Adrenalin hydrochloride, 1-1000 may be given in saline solu- tion by mouth to control the bleeding for its local action as a vasoconstrictor is well known, and at times it is a very efficient hemostatic. Vomiting.—In spite of the fact that an operation has been performed upon the stomach itself, the surgeon will order a gastric lavage eighteen to twenty-four hours after operation if the vomiting is persistent; this may be repeated as often as is necessary. Perforated Gastric Ulcer.—Ante-Operative Treatment.— Patients suffering from a perforation of a gastric ulcer have, as a rule, a beginning peritonitis, and as they are more or less in a condition of shock, it is advisable that before operation *4 grain of morphine be given hypodermically. This will relieve to a degree some of the intense cramp-like pains and will make the inductive stage of anesthesia smoother so that the struggling is less. If they are in a state of severe shock, a preliminary in- fusion of about 550 c.c. of saline should be given. Operation.—The abdomen is opened, the region about the stomach carefully padded off with moist hot pads and the per- foration hunted for. When found, if practical, it is enclosed and inverted with a purse string suture. A thorough lavage of that region of the peritoneal cavity is performed by washing out the upper abdomen with warm saline, sponging out the saline or using an aspirator attached to a suction machine. Some op- erators are accustomed to leave 500 c.c. of saline in the abdomen before closing. The question of drainage is left to the dis- cretion of the individual surgeon. Post-operative Treatment.—As soon as possible the patient is placed in the Fowler position, and if greatly shocked a clysis is given, of 500 to 750 c.c. of saline. Some prefer the admin- istration of saline by rectum, given by Murphy drip, four hours on and two hours off. Feeding is begun after eight to twenty- four hours, and the patient may be placed upon a Lenhartz diet. As a matter of fact, treatment for this condition is almost the same as that for a gastroenterostomy. NURSING OF THE ALIMENTARY SYSTEM 53 Cancer of Stomach.—The symptoms of which the patient will complain are determined by the area in which the growth is located. If it is near the cardiac end where it does not inter- fere with the functions of the stomach there may be no symptoms at all. If it is in the fundus of the stomach there may be pain, vomiting, loss of weight and anemia. If it is in the pyloric portion, these symptoms are duplicated and there is a greater tendency to vomit because of the obstruction. Examination of the stomach contents in these cases may reveal a low acid content, no free hydrochloric acid, and often the presence of lactic acid. X-ray examination is sometimes a valuable aid to diagnosis, and, occasionally, the tumor mass may be felt in the upper abdomen in the position of the stomach. Surgical Treatment of Cancer of Stomach.—The only hope in cases of gastric cancer is partial or complete excision of the stomach (gastrectomy). The operation is rather shocking and the mortality is high. The technic for operation and the post- operative care are practically the same as that already described in the treatment of gastric ulcer. Treatment of Duodenal Ulcer.—This is practically the same as the treatment for gastric ulcer. Surgical Conditions of Intestines.—There are many diseases affecting the intestines but the interesting ones from a surgi- cal standpoint are those resulting in perforations and new growths. The intestines may be the seat of perforation as the result of typhoid, or tuberculous ulcers, or they may be torn by some traumatic condition resulting from a stab or bullet wound. The symptoms are those of peritonitis. The operation at first is in the nature of an exploratory laparotomy. A search is made for the injured intestine and when found the wound, if small, is closed by a purse string suture. If the wounds are multiple, it may be necessary that that part of the intestine be resected, and the two open ends of the gut which have re- sulted may then be joined together by what is known as an end- to-end, end-to-side, or side-to-side anastomosis (Fig. 6, A, B, & C). Resection is also employed in conditions of intestinal growths, either benign or malignant. If the condition of the patient is too poor to warrant the 54 TEXTBOOK OF SURGICAL NURSING time necessary to anastomose the intestines with suture, a Mur- phy button may be employed (Fig. 6, D). This is a perforated metal button consisting of two halves. One half is introduced into one open end of the intestine and the intestine drawn over it by suture. The other half is inserted into the other open end of the gut. The two parts of the button are then locked together, thus anastomosing the walls of the intestine. The Fig. 6.—Types of Intestinal Anastomoses. A, end to end; B, side to side; C, end to side; 1), end to end by Murphy button. button eventually passes along the intestine after the union between the bowel segments has become firm. Post-operative Treatment.—Operations upon the intestines require the same care practically as that following operations upon the stomach, except that cathartics by mouth should not be given too early, and, when one is given, a mild cathartic rather than a severe purgative should be prescribed. While the pa- tient should be kept free from pain, too much morphine should not be administered, for there is always danger of intestinal paresis due to overdosage of this powerful hypnotic. Should NURSING OF THE ALIMENTARY SYSTEM 55 the patient become distended, an irritative enema should be ad- ministered, and after the fourth day colon irrigations may be employed without any danger. If a Murphy button has been used for anastomosis, all stools should be examined for the presence of the button, and its passage should be immediately reported. Intestinal Obstruction.—This is a condition in which the normal passage through the intestinal tract is interfered with, either partially or completely. The symptoms naturally will vary according to the locality of the obstruction. If it is high up, near the duodenum, vomiting is an early symptom; if low in the ileum, distention is more marked. Treatment.—Immediately after a diagnosis of intestinal ob- struction, an exploratory celiotomy is performed with the hope of finding the cause of the obstruction and relieving it. Ante-operative Treatment.—In all cases of intestinal ob- struction it is very essential that the stomach be washed just before giving the anesthetic. This will save a great deal of annoyance later, because the danger of aspirating the foul ma- terials stored in the stomach is reduced to the minimum. If the patient is very weak or greatly shocked it is advisable to administer the clysis of saline either before the operation or at the same time the operation is being performed. Operation.—Inasmuch as the actual surgical conditions in most cases of intestinal obstruction are not diagnosed until the operation, the operating room nurse should be ready at a moment's notice for anything from an enterostomy to an ex- tensive resection. Since these operations demand a complete exploration, there should always be on hand plenty of pads and hot saline to care for the intestines as they are brought out from the peritoneal cavity. If, after the obstructive element has been found and removed, the distention is still great to the. point of paralysis of the smooth muscle of the intestine, an enterostomy might be performed. This is an incision into the bowel for the purpose of inserting therein an L-shaped glass tube known as a Paul's tube, or a simple rubber one. The open end of the glass is connected with rubber tubing which drains into a bottle provided for the escape of the intestinal contents. 56 TEXTBOOK OF SURGICAL NURSING This operation practically amounts to the formation of an arti- ficial anus. Post-operative Treatment.—If an enterostomy has been done, the treatment is the same as that prescribed following intestinal injuries. If the tube has. been placed in a high por- tion of the jejunum, peptonized milk, beaten egg and other nu- tritive fluids may be introduced through it via a catheter enter- ing the descending loop of gut; the original enterostomy tube should be temporarily clamped after the feeding has been intro- duced. It is very important that these cases should be given plenty of fluid either hypodermically, rectally, or by infusion. The skin about the enterostomy opening should be well protected against the irritating influences of the intestinal contents either by albolinated gauze or Beck's paste. Intussusception.—This condition is a form of intestinal ob- struction brought about by the telescoping of one portion of the bowel into the other. The treatment, as a rule, is operative entailing a reduction of the intussusception, or if the bowel is gangrenous, a resection of the involved portions. There is nothing special in its nursing. Appendicitis.—This is one of the most common operations performed today, and the cases in which the nurse will be called upon to assist may be divided into three great groups. 1. Interval or Chronic Appendicitis. 2. Acute Appendicitis without perforation. 3. Acute Appendicitis with perforation. 1. The Interval Appendix.—This is called an interval ap- pendix because the operation is performed after an acute attack has passed away and before another acute attack makes its appearance. In other words, it is an acute appendix which has subsided, or has become what may be termed a chronic appendix. Symptoms.—These may vary tremendously from vague di- gestive disturbances manifested by gaseous eruptions, pain and flatulence, to definite pain localized in the right lower quadrant, the usual anatomical position of the appendix. Treatment.—After a definite diagnosis has been made, the appendix is removed. The operation is termed appendicectomy. Ante-operative Treatment.—The routine ante-operative NURSING OF THE ALIMENTARY SYSTEM 57 preparation which is described in Chapter XIII is given. The operation is done under gas and oxygen, or gas and ether, or it may be done under local anesthesia. Operation.—The abdomen is usually opened by a "Mc- Burney" or oblique incision, or a right rectus, or a vertical incision. The appendix is usually delivered into the wound, the mesentery is ligated with plain catgut and a purse string suture of linen or Pagenstecher on a straight or curved needle is introduced about the base of the appendix; the base is doubly clamped or ligated and a split pad placed about both clamps. The appendix is then cut between the clamps or liga- tures by means of a knife dipped in carbolic acid or by actual cautery. For safety's sake, the stump is again cauterized or carbolized. If the latter procedure is used, it is neutralized with alcohol to prevent the carbolic from eating too deeply. All the instruments coming into contact with the lumen of the appendix are contaminated and should be placed in a separate "dirty" tray. The clamp is then removed; the cauterized stump is grasped with a small pair of forceps and buried by means of a purse string suture. The hands are then washed in bichloride, the towels changed, and a reinforcing figure-of-eight suture may be taken. The abdomen is then closed in the usual manner. Post-operative Treatment.—The patient is given a quarter of a grain of morphine and 1/150 grain of atropine, if neces- sary. As soon as the patient regains consciousness the gatch is raised one notch. Water is allowed in sips about two hours after the last vomiting, and the usual post-operative routine begun. The sutures are generally removed on the seventh day, and the patient allowed out of bed on the ninth. The bowels are moved on the second or third day by a dose of salts, followed by an enema, if necessary. Acute Appendicitis.—Rutherford Morrison states that there would be no percentage of deaths from appendicitis if every case commencing with acute pain and developing tenderness and rigidity of the abdomen in the right lower quadrant with a quickening of the pulse were operated upon within twelve hours. This fact is of great importance. It is hard to impress it upon the lay mind, but it is the duty of the nurse to instruct 58 TEXTBOOK OF SURGICAL NURSING the public upon this subject. Sudden pain in the right iliac fossa with tenderness and slight fever accompanied by nausea or vomiting point, as a rule, to acute appendicitis. Treatment of Acute Appendicitis.—While most surgeons are agreed that all cases of acute appendicitis should be operated upon as soon as the diagnosis is made, there are some patients who, in spite of all persuasion, refuse immediate operation. Then again, when there is extensive pulmonary tuberculosis, bad cardiovascular disease, or diabetes, the expectant treatment might be followed. Of course this is dangerous. The family should be warned of the consequences, and the patient carefully watched. Blood counts should be taken often, and should the pulse rate and the number of white blood cells increase, although the temperature does not vary, an operation should be per- formed, even if local anesthesia has to be resorted to. If the non-operative treatment is to be pursued, the patient should be put to bed, the knees flexed with a pillow underneath them and ice bags applied to the abdomen. The bag should be left on for two hours and off for one. Nothing should be given by mouth while there is vomiting. After the nausea has subsided, water may be given in teaspoonful doses. This may be augmented later by albumen water, milk and lime water, broths and meat juices. Enemas should not be given promiscuously, and if at all, in small amounts and with great care. AVhen the acute symptoms have subsided a saline cathartic may be given by mouth. Ante-operative Treatment.—Fortunately, most of these cases are generally operated upon as soon as the diagnosis is made. Naturally no cathartic is ever given by mouth, but, if the patient is in good condition, the lower bowel may be cleaned by a soap- suds enema. This does much to render post-operative recovery smooth and uneventful. Operation.- -The procedure is the same as that in interval appendicitis and if the appendix has not ruptured, the abdomen is sewed tightly without drainage. Post-operative Treatment.—The treatment is identical with that prescribed for interval appendicitis, except that occasionally eight ounces of tap water might be administered by rectum and NURSING OF THE ALIMENTARY SYSTEM 59 the patient ordered in Fowler's position if there was free fluid in the pelvis. (The Fowler position is a semi-erect position obtained by either elevating the head of the bed and flexing the knees with a pillow or by adjusting the gatch bed.) A cathartic is generally given on the third or fourth day. If everything pro- gresses smoothly the patient is allowed up on the ninth day. Acute Appendicitis with Perforation.—This is a condition of acute appendicitis complicated by a perforation which either forms an abscess about the appendix or results in a diffuse spreading infection of the peritoneum (peritonitis). The symptoms are those of acute appendicitis, only more severe. Ante-operative Treatment.—The treatment is the same as that which has been outlined for acute appendicitis. Operative Treatment.—The appendix is removed and the stump inverted whenever possible. The abscess cavity is freed of its pus, and a drain is introduced into the cavity or into the lower pelvis. The drainage material may be any one of the substances discussed on page 310, Chapter XVII. Post-operative Treatment.—The treatment is similar to that of acute appendicitis, except that the patient is usually more acutely ill, and occasionally shocked. The patient is placed in Fowler's position and saline is given liberally by Murphy drip. Dressings are generally done daily. The patient is kept in bed until the drainage tube has been removed and the wound is prac- tically healed. Complications.—The complications apt to occur are those which follow any abdominal operation for peritonitis. Those cases in which there is a persistently high temperature and an increased leukocyte count should make one suspect a secondary abscess. If a mass is felt through the rectum, definite proof of a secondary pelvic abscess is established. This condition does not always demand operation to establish drainage of the abscess, as in some cases the mass might be absorbed by efficient hot colon irrigations given at four-hour intervals. Occasionally a dressing which has been previously pussy, may be covered with blood. This is evidence of a secondary hem- orrhage. The attending surgeon should be called without any 60 TEXTBOOK OF SURGICAL NURSING loss of time, and the wound packed temporarily to control the bleeding. The bleeding vessel is then sought and ligated. Now and then, quite soon after operation, the dressing may be covered with feces; a sign that the dreaded complication of fecal fistula has occurred. All drainage tubes are removed, and the wound is treated as any enterostomy or colostomy. Dressings are changed at frequent intervals, and the skin is protected and kept scrupulously clean. Fortunately, most of these cases heal eventually, although convalescence is long and protracted. Recently, cases of appendicular abscesses have been treated by the Carrel-Dakin method. The technic of its administration is described in Chapter XIX. The Colon.—Within recent years the surgery of the colon has made tremendous strides because of the attention drawn to it by the much discussed topic of colonic stasis and its relation- ship to autointoxication. While many of the English surgeons excise the colon in cases of obstinate and obdurate constipation, complete or partial colectomy is done mainly for new growths of the large intestine. In certain types of cases where an arti- ficial anus has to be established as a preliminary measure, colostomy is done, or the colostomy may be the only advisable palliative measure for inoperable carcinoma. The surgery and nursing entailed for colon cases is practically the same as that for the intestinal variety both from the ante-operative and the operative standpoint. The only difference is found in the post- operative treatment; all rectal medication should be omitted for as great a period as is possible. Colostomy.—A colostomy is an incision into the colon for the purpose of short-circuiting the fecal contents and of estab- lishing an artificial anus. The operation of colostomy is simple. The desired part of the colon is brought into the wound, then a glass tube is passed through the mesentery of the colon, so as to prevent the colon from slipping back into the peritoneal cavity. (Fig. 7.) The exposed colon is then sealed off from the peritoneal cavity by suturing it to the parietal peritoneum. Post-operative Treatment.—The colon is covered with vase- linated gauze, and a sterile dressing applied. The patient is NURSING OF THE ALIMENTARY SYSTEM 61 fed but little and to further constipate the patient a pill of opium, grains 2, may be given for the first four or five days. On about the third or fourth day the exposed loop of colon is opened with the aid of an V \ / Fig. 7.—Colostomy Before Being Incised. A, glass rod passed through mesentery of colon; B, exposed loop of colon. actual cautery, establishing S^S^ the artificial anus. There are several factors that are of importance in caring for a patient with a colostomy. If possible, an attempt should be made to regulate the move- ment of the bowels and the food given should be of a constipating variety, so that when the bowels move, the movement should be hard and formed, instead of loose and diarrheal. The skin sur- rounding the colostomy is apt to become irritated. It should be protected by an ointment of bismuth subnitrate and zinc oxjde to which may be added a little oil of eucalyptus. If at any time, however, there is no movement from the arti- ficial anus, and general distention is evident, there should be no hesitancy in giving an enema through the colostomy opening. It is not advisable to give cathartics by mouth, especially the saline variety, for it should always be remembered that these patients have practically no con- trol of their bowel movements, and watery stools cause a constant soiling of their dress- ings. After a while the patient may wear a colostomy bag, a rubber appliance which is worn over the artificial anus to collect the feces. This is held in place by straps. (Fig. 8.) The Rectum.—The important conditions from a surgical standpoint occurring in or about the rectum are: (1) ischiorectal Fig. 8.—Colos- tomy Bag. 62 TEXTBOOK OF SURGICAL NURSING abscess, (2) fistula in ano, (3) hemorrhoids, (4) cancer of rectum. Ischiorectal Abscess.—An abscess about the rectum is like an abscess in any other part of the body except that it might communicate with the rectum, and if not treated properly a fistula might result. This is a tract connecting the skin and rectum. For this reason it is always better to incise and drain the abscess as soon as possible, packing the abscess cavity and permitting it to granulate from the bottom. Fistula in Ano.—This may be the result of a poorly treated ischiorectal abscess/ It is important in treating the fistula that the tract be excised in its entirety by careful and complete dissection. Ante-operative Treatment.—A cathartic is given twenty- four hours before operation, usually an ounce of castor oil. Four hours before operation, the lower bowels should be thor- oughly washed with a warm soapsuds enema. At least three of these should be given. If the third return is not clear, more enemata should be administered until the rectum is absolutely cleansed. This rectal treatment should not be administered just prior to operation, because much of the liquid material is apt to be retained and the surgeon is hampered in his work by the escape of rectal fluid. Some surgeons inject the fistulous tract with a solution of methylene blue, a dye which colors the tract making'its ramifications evident. This may be done before or after the anesthesia has been begun. Operation.—Until the patient regains consciousness, the legs should be tied together. In operations about the rectum, reten- tion of urine is apt to result and great care should be taken lest the bladder become distended. The diet should be constipating and to further constipate the patient a pill containing opium is given three times a day. The bowels should be moved upon the fourth day, and, after the movement, the parts washed with soap and warm water, and fresh packing introduced. The packing must be changed each time the bowels move, if stained with fecal material. The dressing of these cases is exceedingly important. If the packing of the cavity is left to the nurse, she should very conscientiously see that it is firmly and securely in- NURSING OF THE ALIMENTARY SYSTEM 63 troduced into the depths of the granulating cavity. The proper healing will do much to prevent a recurrence of the fistula. Hemorrhoids.—Piles are simply dilated veins about the rec- tum. They are divided into the internal variety (those situated above the internal sphincter), and the external variety (beneath the external sphincter). Piles may be a source of annoyance by their protrusion, their bleeding, or the veins may become inflamed and thrombosed. Ante-operative Treatment.—The treatment does not differ from that of an ischiorectal abscess. Operative Treatment.—After the patient is anesthetized, the sphincter ani is dilated manually as a preliminary step to the operation. This gives a better exposure of the interior of the rectum, and by paralyzing the sphincter, the after pain is less, since the muscle about the rectum cannot contract. The piles are removed by (1) simple excision, (2) clamp and cautery, or (3) by ligating the pile-bearing area. After the op- eration has been performed, some surgeons insert a rectal tube around which has been wrapped two or three layers of vase- linated iodoform gauze. The advantages of this are twofold: it prevents hemorrhage and it enables the accumulated gas to escape; but it has the great disadvantage of being rather pain- ful and uncomfortable for the patient. Post-operative Treatment.—The same measures are taken as for an ischiorectal abscess, except that on the fourth day, when the cathartic is given, immediately before the patient moves the bowels, six ounces of warm olive oil are introduced into the rectum through a tube. This softens the accumulated feces and lubricates their passage. Following the movement of the bow- els, the patient should be instructed to take Sitz baths, night and morning. These are comforting and are very helpful in healing the denuded areas about the rectum. For a period of two to three weeks after operation, the patient should receive nightly an ounce of licorice powder, as it is essential that the bowels be kept soft and loose. The patient should be put on an anti- constipation diet, a good example of which may be found in Chapter XII on diets. Complications.—The great danger in a hemorrhoid opera- 64 TEXTBOOK OF SURGICAL NURSING tion is that of hemorrhage. If a patient begins to faint and to show the signs of hemorrhage, even though no blood is visible externally, which might happen if a rectal tube is not inserted, the attending surgeon should be immediately summoned. The patient is placed under anesthesia, a tube "en chemise" is intro- duced and the rectum firmly packed. A tube "en chemise" is simply a rubber tube to the rectal end of which gauze is at- tached. (Fig. 9.) It is inserted into the rectum and packing is introduced between the tube and gauze, thereby exerting pressure on the bleeding area. Sometimes the bleeding point itself may be ligated. Cancer of Rectum.—As in other locations, cancer in this region, provided it has not progressed too far, demands excision. The rectum may be excised by way of several routes, -— by the perineal route, the sacral, by the vagina, through the abdomen, or by a combination of these. Fig. 9.—Tube "En Chem7se." A, As a rule any excision of the layer of gauze attached to rubber rectum is preceded by a pre- tube B- ,..,„,, limmary colostomy. The technic of this has already been described on page 60. Excision of Rectum by Perineal Route.—The patient is placed in the lithotomy position (see Fig. 72, page 277), the anus is sewed up, and the rectum is dissected from the sur- rounding tissues until the upper limit of the growth is reached, and then it is excised. Excision of Rectum by Sacral Route.—The patient is placed in the Kraske, or reversed Trendelenburg position (see Fig. 70, page 276), and as a preliminary, the coccyx and a portion of the sacrum are removed. This affords freer access to the rectum, and the rectum is dissected freely and excised. Excision of Rectum through the Vagina.—Tn this operation NTRSING OF THE ALIMENTARY SYSTEM 65 the posterior wall of the vagina is used as a means of attack in delivering the rectum and excising it. Excision of Rectum by Combined Method.—This operation consists of opening the abdomen and doing the operation as far as possible from above, then closing the lower end of the bowel temporarily and delivering the upper end of the bowel into the wound to serve as a colostomy opening. The lower segment is finally excised by the perineal route, or by one of its modifica- tions. This entire operation may be performed at once, or in two stages: a preliminary colostomy being done first, and the radi- cal portion later. None of the afore-mentioned operations call for any special nursing. They are, however, attended with a great deal of shock, and the nurse should be ever ready to institute those pro- ceedings which she has learned to overcome this condition. The Liver and Bile Ducts.—Certainly the most frequent af- fection of the liver, and that one which most concerns the nurse is that of gallstones (cholelithiasis). In this condition, the gall bladder or any of the bile ducts of the liver may be the seat of stones. It is true that these stones may lie in the gall bladder and never cause any symptoms. But when the stone leaves the gall bladder and becomes impacted or caught in some of the ducts—for example, the cystic or common bile duct—symptoms of gall bladder colic ensue. If the stone is impacted in a cystic duct, the gall bladder may become slightly dilated with resulting pain and tenderness in that region; if the stone becomes im- pacted in the common duct, inasmuch as the flow of bile is impeded on its way to the intestine, there is jaundice which may be very marked. As a result of the jaundice, and no passage of bile into the intestine, the stools are white, clay colored, and foul-smelling; the urine is dark-brownish in color; and the skin is yellow, due to the deposition of the bile pigment in the skin itself. Medical Treatment.—During an attack of colic, the patient is given large doses of morphine and placed in bed. Over the region of the gall bladder it is advisable to place hot applica- tions, either poultices or stupes. Following these attacks the patient should have a light diet with the minimum amount of 66 TEXTBOOK OF SURGICAL NURSING fat. Intestinal elimination should be kept free by using salts, especially sodium phosphate. There is a popular superstition that consuming olive oil aids the free passage of gallstones. This is very much exaggerated and without scientific foundation. Operative Treatment.—Operative measures are employed when there have been repeated attacks of colic, when the stone has become impacted, or when the gall bladder is acutely in- flamed or filled with pus. Ante-operative Treatment.—The ante-operative treatment is of extreme importance in jaundiced cases because jaundice is one of the factors which prevents or delays the clotting of blood. Naturally, pre-operative measures must be taken to ensure a lowering of the coagulation time. This may be accom- plished (previously mentioned in detail in Chapter III) by the administration of calcium lactate, horse serum, or transfusion. The position of the patient on the operating table is impor- tant because the gall bladder and its passages lie deep within the abdomen, and every effort must be made to make them as acces- sible as possible. This is attained by placing the patient on the table so that the gall bladder bridge may be elevated, thus forcing the liver forward; or a sandbag may be placed in the region of the eleventh or twelfth ribs. Both methods yield good results. (See Fig. 65, page 272.) Operations.—The operations which may be performed upon the gall bladder and its ducts are cholecystotomy, cholecystost- omy, cholecystectomy, choledochotomy, and cholecystenterostomy. Cholecystotomy.—This is an operation in which the gall bladder is opened, the stones removed, and the original incision in the gall bladder closed. It is not often performed because the gall bladder generally requires drainage. Cholecystostomy.—In this operation the gall bladder is not removed, but it is drained; the drainage is placed into the gall bladder itself by burying the tube Avith a purse string suture. Cholecystectomy.—This procedure is the most frequent; it involves the removal of the gall bladder and the ligation of the cystic duct and cystic artery. Choledochotomy.—In those cases in which the stone lies NURSING OF THE ALIMENTARY SYSTEM 67 impacted in the common duct, the removal of the stone by inci- sion of the duct is spoken of as choledochotomy. This operation entails drainage of the common bile duct. Cholecystenterostomy.—Sometimes the obstruction of the common duct is such that it cannot be removed; for example, stricture of the duct, either benign or carcinomatous. If the patient is suffering from intense jaundice, an attempt is made to short-circuit the bile. This is done by establishing an anastomosis between the gall bladder and the stomach or between the gall bladder and the small intestines. This operation is spoken of as cholegastrostomy or cholecystenterostomy. Post-operative Treatment.—Operations in and about the gall bladder are accompanied by a great deal of shock, and as most operations involving the upper abdomen are attended by a large percentage of pneumonias, all means must be taken to insure perfect care of the patient, to prevent him from being chilled or caught in draughts. In those cases in which the gall bladder is drained, or where a cholecystotomy is performed, the end of the drainage tube should be inserted into a bottle so that the bile may be col- lected, its character observed, and the amount estimated. Oc- casionally, bile will leak along the side of the drainage tube, resulting in a general soaking and discoloration of the dressing. If this discharge is very marked, the superficial layers of the dressing may be removed and fresh compresses applied. It is important that all urine should be examined closely for the presence of bile, and that the stools be sent to the laboratory to determine whether bile is present. While the gall bladder is draining, the patient must be placed upon a diet which is poor in fat, because the bile salts which aid in the saponification of the fats are missing. Surgical Conditions of the Liver.—The diseases which com- monly involve the liver from a surgical standpoint are injuries to the liver, abscesses of the liver and cirrhosis of the liver. Injuries to the Liver.—The liver may be injured by direct or indirect violence; it may be torn, with an ensuing hemorrhage. This must be treated by immediate laparotomy, packing the tear with gauze, or by suturing the tear of the liver with mat- 68 TEXTBOOK OF SURGICAL NURSING tress sutures, employing a round, non-cutting liver needle. The suture material is usually chromic catgut. Abscess of Liver.—This may be of pyogenic origin, or the direct result of amebic dysentery. These abscesses may be opened and drained directly through the abdomen, or if the abscess is high, an operation may be performed through the posterior lateral area of the chest. The parietal and visceral pleura are sutured together, and after adhesions have taken place, so as to seal off the pleural cavity, the liver is drained through this area. In this way no pus flows through the abdomi- nal or peritoneal cavity, or through the pleural cavity. This operation is done in two stages: the first being a partial resec- tion of the rib, with the suturing of the parietal and visceral pleura; the second is the drainage of the abscess through the area of the adhesions. Cirrhosis of Liver.—As this condition is associated with a filling of the peritoneal cavity with fluid (ascites), and as it is presumably due to an obstruction of the portal circulation, an attempt is made to establish a collateral circulation by the Talma operation (omentopexy). Twenty-four hours prior to operation, an ordinary paracente- sis abdominalis is done. The patient is then operated upon, and a portion of the omentum brought through the anterior abdominal walls in the midline and sutured to the subcutaneous tissues. In this way the omental veins will establish collateral circulation with the internal mammary vein, thereby lessening the strain of the portal system. The one important factor in post-operative treatment is when a patient strains, the abdomen should be firmly held so as to prevent further evisceration of the abdominal contents along with the omentum. Surgical Conditions of the Pancreas.—The operations upon the pancreas are very few in number. The only diseases which need demand our attention are pancreatitis, either in chronic or acute forms, and cancer of the head of the pancreas. In inflammatory diseases of the pancreas, inasmuch as the bile is supposed to be an irritating and causative factor, its flow is short-circuited by draining the gall bladder (cholecystostomy). NURSING OF THE ALIMENTARY SYSTEM 69 In the meanwhile the pancreas, free from the irritating effects of bile, will gain a much needed rest, and the inflammatory process may subside. Carcinoma of the head of tiie pancreas may encroach upon the opening of the bile duct in the second portion of the duo- denum causing intense jaundice. Inasmuch as new growths of the pancreas cannot be excised without a terrific operative mor- tality and disastrous after results, the only operation done to relieve the unfortunate jaundice victims is that of drainage of the gall bladder. The nursing procedures employed in these cases are similar to those used in operations upon the gall bladder. Hernia.—A hernia, or rupture, may be defined as "the pro- trusion of an organ or part of an organ or other structure through the wall of the cavity normally containing it." The rupture is named from the region in which it appears. There are many locations where, because of certain mechanical weak- nesses, hernia is quite common. It occurs very frequently in the inguinal region. Inguinal hernia is a form of rupture that occupies the in- guinal canal either partly or entirely; if it occurs the condition is spoken of as an indirect hernia. A hernia making its appear- ance almost directly into the external abdominal ring is called a direct hernia. Under ordinary conditions, the contents of the hernial sac will disappear into the abdominal cavity when the individual is at rest, to reappear when the intra-abdominal pressure is in- creased, as during coughing or arduous physical labors. A hernia which disappears is known as reducible; if because of adhesions this does not occur it is irreducible. There are several varieties of the irreducible group: Incarcerated,—a type of obstructed hernia containing bowel in which the passage of fecal material is arrested but the circulation of the intestine is unim- paired. Strangulated,—a hernia in which not only the bowel is obstructed but also the blood supply. If this condition is not operated upon very soon after its incipiency a gangrene of the obstructed loops of intestine will result. Other varieties of hernia are femoral, which is a rupture in 70 TEXTBOOK OF SURGICAL NURSING the region of Scarpe's triangle occurring through the femoral ring; umbilical, which is a protrusion through the abdominal wall in the region of the umbilicus. Then there are hernias which occur following operation, especially in those cases in which the abdominal wall has become weakened. These are known as post-operative hernias. Occasionally, especially in children, the hernial sac may con- tain the testicle; this is known as a congenital hernia and always accompanies an undescended testis. In this condition the tes- ticle is not in the scrotum but within the abdomen or inguinal canal. Treatment.—Hernia may be treated conservatively with a suitable apparatus or truss (an appliance made to exert pres- sure over the hernial opening so as to keep the contents of the sac reduced) but since the public are becoming educated to the wonderful results obtained by surgery, it is most always treated radically by operation. There are two important principles underlying all hernia operations: the obliteration of the hernial sac, and the closure of the channel along which the hernia pro- trudes. Ante-operative Treatment.—The same ante-operative rou- tine is employed as for all chronic cases (Chapter XIII). The lower abdomen and genitals are shaved and a sterile dressing is applied. Care must be taken that the external genitalia are not painted with iodine. In the operating room, the operative field is repainted with iodine, and the penis and scrotum are enclosed in a sterile, wet bichloride towel. Operation.—An incision is made over the external ring up- ward along Poupart 's ligament. The external ring is identified, and the surgeon calls for a grooved director on which he cuts the fascia of the external oblique. The sac is then identified, dis- sected free, its base transfixed and ligated with catgut on a curved needle. The repair of the hernia, "the closure of the channel" is then performed, the suturing being done with chromic catgut, kangaroo tendon, etc. A spica bandage (Fig. 143) in addition to adhesive plaster keeps the dressing in place. A plaster spica is often used in children where immobilization is absolutely essential. If the child is very young, the spica may NURSING OF THE ALIMENTARY SYSTEM 71 be coated with shellac so as to render it impervious to urine and feces. Post-operative Treatment.—As soon as the patient reaches the ward, a pillow is placed under the knees, and as soon as he is conscious, a Bellevue bridge is applied across the thighs to support the scrotum. The cathartic is given on the second day and, as a rule, pa- tients are kept in bed for two or more weeks. For the first twenty-four hours catheterization may be necessary. In cases of incarcerated and strangulated hernias after the sac has been opened, the surgeon will cover the bowels with moist warm saline towels for about ten minutes, and if there is no evidence of real damage, and their color is good, the intestines are reduced into the peritoneal cavity. If the intestines are gangrenous, an intestinal resection will have to be done. These cases are then treated like any other case of intestinal resection. In all cases of hernia it is very important to impress upon the mind of the recently operated that for a few months, at least, all physical exercise should be of the mildest kind, and that any sudden strain must be avoided. CHAPTER V THE SURGERY AND SURGICAL NURSING OF THE GLANDULAR SYSTEM In no other system within recent years has the advance been greater and the research more extensive than in the field of the glands of internal secretion. It is true that we still know very little concerning most of them. But possibly within the next decade or so there will be great light shed upon the physiology of those organs which either alone or in combination control our physical and mental make-up. Glandular tissue has been described as that tissue which has for its function the secre- tion of certain substances. These may be of service to the body, as the digestive juices, or they may be purely excremental in nature, removing substances which are either poisonous or waste in character. Classification of Glands.—It is convenient to divide glands into three groups: (1) those with ducts, (2) those without ducts (the glands of internal secretion), and (3) those which are a combination of (1) and (2). As examples of glands with a duct there may be mentioned the liver, the largest gland in the body, which secretes and excretes bile through the biliary duct; the submaxillary glands, the mammary glands, the prostate, sebaceous, sudoriferous, etc. Pure glands of internal secretion may be represented by the pineal, the pituitary, the thyroid, the parathyroid, and adrenal. Those glands which are both exter- nal and internal in secretion are represented by the pancreas, the ovary and the testis. While the surgery of these glands is limited, probably those deserving most of our attention are the liver and the bile ducts which have been discussed under the gastrointestinal tract Chapter IV, the ovary and testis which are reviewed in Chap- 72 NURSING OF THE GLANDULAR SYSTEM 73 ter VIII on the reproductive system, leaving for discussion here, the pituitary and the thyroid. Diseases of the Pituitary Gland.—The pituitary gland is composed of an anterior and posterior lobe. It arises from the forebrain and rests in the sella turcica of the sphenoid bone. The function of the pituitary gland is probably concerned with growth. Too much secretion or hyperpituitarism is a condition, which, if it occurs before the ossification of the epiphyses, leads to gigantism, and, when it occurs later, after the bones have become full grown, is responsible for acromegaly. Too little secretion of the pituitary body (hypopituitarism) in a growing child leads to increased fat deposition in the tissues, dwarfism, and poor development of the sexual organs. When this occurs in the adult it leads to adiposity and sexual retrogression. Probably the cases which interest us most from the surgical standpoint are those in which the pituitary gland is enlarged, with the result that the patient complains of bitter headaches, and a beginning blindness. This is often seen in the late stages of acromegaly, a condition in which there is a progressive in- crease in the size of the hands, feet, head, jaw, and the tissues about the face. Treatment.—Surgery endeavors to remove part of the pituitary gland. This may be done either by removing part of the body of the sphenoid bone via the nasal route, or by the subtemporal path. There is no special nursing entailed. Diseases of the Thyroid Gland.—The word goitre is familiar to the lay mind, and even a layman distinguishes two types,— the one in which there is simply an enlargement of the thyroid gland, and the other in which there is enlargement complicated by definite nervous symptoms. Just as in the pituitary, there may be an increase or perversion of the thyroid secretion known as hyperthyroidism, or there may be also a diminished secretion. If it occurs before the age of puberty, or dates from birth, cretinism results, or if it occurs in adult life, myxedema may occur. Cretinism.—These children have a diminished thyroid se- cretion. As a rule they are fat and pudgy with coarse, sparse hair, unable to walk, and have a subnormal temperature; their 74 TEXTBOOK OF SURGICAL NURSING mentality is practically nil. Thyroid extract given to these unfortunates often transforms them at least from an animal stage to a point where they can protect themselves sufficiently to exist. Myxedema,.—Very often patients in adult life begin to show signs of mental sluggishness with a slow reaction time, and their faces become coarse and mask-like. In other words, they are somewhat like a cretin. Thyroid extract or any prep- aration of the thyroid gland, given by mouth, helps these people markedly. Goitre.—Any enlargement of the thyroid gland that is chronic in nature is spoken of as a goitre. There are certain regions of the earth where this disease is common; it is fre- quently seen in some mountainous places of Germany, Austria, France, Central Asia, Switzerland, and around the Great Lakes in Michigan. It is thought to be due to some peculiar agent found in the drinking water of these districts. The symptoms which come from the goitre are mechanical, and result from pressure of the enlarged gland upon those structures which it might compress. From pressing on the wind pipe (trachea) it may give rise to a cough, or it may cause difficulty in swallow- ing, by pressure on the gullet (esophagus). Treatment of Goitre.—Goitre may be treated medically or surgically. Some cases respond to the internal administration of potassium iodide. X-ray, when given in graduated doses, sometimes reduces the size of the gland. But if the goitre is large and the symptoms are aggravating and persistent, surgery is practically the only measure which will afford relief. Ante-operative Treatment.—On the morning of operation the neck should be shaven, cleansed with green soap and water, followed by alcohol and ether, and a sterile dressing applied. Operation.—Gas and oxygen is the anesthetic of choice. The patient is placed upon the back with a sandbag beneath the shoulders so as to put the neck upon a slight stretch. (See Fig. 85, page 289). In addition to the ordinary "set-up" of instruments, in all operations upon the thyroid, it is essential to have a tracheotomy outfit in readiness. For very often in these operations, due to pressure upon the trachea, it collapses, NURSING OF THE GLANDULAR SYSTEM 75 and unless instant measures are instituted to relieve the strangu- lation due to the closure of the trachea, death will readily ensue because of asphyxiation. This horrible complication fortu- nately is rare, but adequate preparation must always be made to meet any emergency. Inasmuch as a few seconds will mean the life or the death of a patient, everything should always be in readiness for even this rarest of operative complications. As there is bound to be a moderate amount of bleeding and oozing from the tissues, a small cigarette drain is employed for about 24 hours, and the ordinary sterile dressing is applied. Since the line of incision in a goitre operation is quite visible in the modern female, attempts are made to minimize the scar as much as possible. To ensure perfect healing after operation the neck is usually immobilized by means of starch bandages; these form a very light and efficient means of restraining the grosser motions of the neck. Post-operative Care.—The patient should not be permitted to talk any more than is necessary for at least a week. Atten- tion should be paid to the character and tone of the voice. The reason for this is obvious, when it is recalled that the nerves which partially control the vocal chords lie close to the gland and may have been injured or cut during the operation. This is indeed a serious complication, because if they are cut it will result in permanent alteration of the patient's voice. It should also be remembered that occasionally patients run a high temperature, rapid pulse, and may even be delirious. The syndrome is often spoken of as acute thyroidism. This con- dition should be treated with ice packs, but this will be dis- cussed at greater length in the treatment of exophthalmic goitre. Exophthalmic Goitre.—As a splendid example of what at- tention to all details in an operation will do, nothing is more striking than the reduction in the mortality of exophthalmic goitre from sixteen per cent, to practically one per cent. This has been made possible by the energetic researches of Dr. George Crile. The factors which have caused this tremendous drop have been the use of gas and oxygen as an anesthetic, local anesthesia, multiple stage operation, coping with the men- 76 TEXTBOOK OF SURGICAL NURSING tal attitude, bringing the operation to the patient, and the employment of the ice pack in cases of acute thyroidism. Symptoms.—Patients with exophthalmic goitre as a rule are recognized immediately by the fact that their eyes are promi- nent and protrude, and that they are extremely nervous. Their pulse rates vary from 90 to 120, and sometimes even higher. In other words, they have what is called tachycardia. Their skin as a rule is moist, and they perspire freely. A very definite swelling of the thyroid gland is often visible. These symptoms all point to a poisoning from either an increased amount, or a perversion of the thyroid secretion. It does not take much imagination to realize that, above all else, these patients need peace and quiet. They are nervous to the extreme. Association with others, incessant talking, and noises tend greatly to aggra- vate them and increase their pulse rate. The keynote in the care of these patients is rest under ideal surroundings and treatment administered so tactfully and carefully that the shock to the nervous system will be of the minimum. Treatment.—Medical.—All cases of exophthalmic goitre should, as a rule, be treated medically at first. The treatment consists of rest in bed, complete isolation from society, a diet of high caloric value with forced feeding, and the administra- tion of sodium bromide to relieve the intense nervous excitement. Some physicians give iodine internally, and some use thyroid extract. Detailed accounts of the medical nursing in these cases may be found elsewhere. Surgical.—It is in the surgical treatment of hyperthyroid- ism that tremendous strides have been made. The patient at present is not operated upon the day after she enters the hos- pital. These highly nervous women are no longer subjected to the terror of being ridden directly to the operating room and arriving there with a pulse of 140; then, in their weakened condition, subjected to ether anesthesia and a shocking operation, with the result that having little stamina left, they usually succumb within twenty-four hours after a partial thyroidectomy has been attempted. Ante-operative Treatment.—In the treatment of these cases it cannot be emphasized too strongly that great tact and care NURSING OF THE GLANDULAR SYSTEM 77 should be utilized by the nurse in charge so as to gain the abso- lute confidence of the patient. The room which the patient is to occupy should be bright, well ventilated and airy, away from all noise such as street cars, and busy corridors. The patient should be kept continually in bed, not even being allowed lava- tory privileges. The diet should be plentiful, an accurate ac- count kept of the food ingested, and the caloric value figured accurately, because it is imperative that these cases be given 5,000 calories or more of food a day. The patient should be kept quiet on liberal dosage of bromides, even to the point of bromidism. Visitors should be few, and their period of stay limited. All depressing topics of conversation must be omitted. Anything which would arouse the excitement of the patient, such as dazzling headlines in the current newspapers, melodra- matic stories, and trashy magazines, must not be permitted. Since the slamming of windows and doors alwa}Ts causes a sudden shock to the patient, great care should be taken to see that it is not done. In other words, the medium in which the patient lives must be calm, serene ana peaceful. As soon as the patient has sufficiently recuperated from the strangeness of hospital surroundings, and the pulse rate has fallen around 90, it is advisable to acquaint the patient with the fact that she is to prepare for operation. The anesthetist who is to give the anesthesia should be introduced; he should explain the operation of the gas mask, place it gently over the patient's head, teach her how to breathe through it, and just what she is expected to do. He should visit her daily and re- hearse the little act of psychologically anesthetizing the patient. In the meanwhile the nurse should prepare the neck as if the operation were really to be performed. The anesthetization of the patient when possible should be done in her private room, and as the patient has become accustomed to the anesthetist, the mask and the preparation of the neck by the nurse, it is possible that the actual day of operation may be kept secret from the patient. In other words, the gland may be stolen away, the patient little knowing that one of the rehearsals with the anesthetist is the day on which the operation is to take place. 78 TEXTBOOK OF SURGICAL NURSING The anesthetic which is used is nitrous oxide and oxygen, and, in addition, the line of incision is usually first injected with novocain, V2%. The operation is usually done in stages; that is, the blood supply to the thyroid is first lessened by the ligation of the superior thyroid arteries, and then the inferior thyroid arteries. This may be done under local anesthesia, or under gas and oxygen. The reason for the preliminary ligation is to diminish the blood supply of the thyroid. This simple pro- cedure is very often all that is necessary, and with it the symp- toms of hyperthyroidism abate and the patient needs no further surgical treatment. If, on the other hand, the symptoms are not definitely improved, at least the blood supply of the gland is les- sened, so that when the thyroid is removed, the hemorrhage will be materially decreased, the degree of shock less, and a speedy recovery of the patient assured. Post-operative Treatment.—The patient should be kept es- pecially quiet and given plenty of fluid by rectum. Very often these patients are subject to a sudden rise in temperature, some- times as high as 106 degrees, and an increase in pulse rate that is rapid and thready. Their faces become pinched and covered with perspiration; they are apt to become delirious and die within a very short time. These symptoms are thought to be due to an acute hyperthyroidism. It has been found that as soon as these symptoms occur, they can be controlled by the use of the ice pack. Occasionally, following the operation there may be a hemor- rhage from the operative wound. The bandage should be re- inforced and the operating surgeon immediately summoned. More rarely a condition of edema of the glottis may develop. This is evidenced by difficulty in breathing, cyanosis of the patient, and a bubbling respiration. This condition demands immediate attention, often tracheotomy (Chapter IX, page 122) and no time should be lost in summoning the medical officer in charge. Following any operation upon the thyroid, especially of exophthalmic variety, the patient should be given a prolonged rest in some quiet mountainous resort. The surroundings should be congenial, and the patient should not be permitted NURSING OF THE GLANDULAR SYSTEM 79 to return to her usual environment until the attending physician feels assured that she can stand the strain. Tetany.—Occasionally after rather an extensive removal of the thyroid gland, a peculiar condition may result, namely that of tetany. This is presumably due to the fact that the parathy- roid glands which are closely attached to the posterior surface of the thyroid have been partially removed. The symptoms of tetany are intermittent, bilateral spasms confined to the extremities. These paroxysmal attacks may be controlled by the administration of calcium lactate, about fif- teen grains every three hours. CHAPTER VI THE SURGERY AND SURGICAL NURSING OF THE NERVOUS SYSTEM The nervous system consists of the cerebrospinal and the sympathetic or autonomic systems. The cerebrospinal division is made up of the brain with the twelve pairs of cranial nerves and their peripheral modifications, and the spinal cord with its thirty-three pairs of spinal nerves and their peripheral modifi- cations. The autonomic division comprises the sympathetic ganglia and their ramifications. Fractures of the Skull.—While these injuries should really be included in the chapter on the Osseous System, they are so closely related to cerebral trauma that a brief discussion here might be deemed more advisable. Fractures of the skull may be divided into those of the vault and those of the base. Fractures of the vault may be simply fissures in the bone, or the bone may actually be depressed and splintered into several fragments. These cases are often accompanied by injuries to the blood vessels of the dura or pia mater, or by actual laceration of the brain substance. If it is a simple fracture, the treatment is that of elevating the depressed bone with forceps, or periosteal elevators, and should some of the fragments be splintered very badly they may be removed with rongeurs or punch forceps. Occasionally it may be necessary to trephine; this is described on page 82. Fractures of the base are more serious because of the great danger of injuring the important brain structures in this loca- tion. As a rule, there is bleeding from the nose, sometimes the ears, and occasionally the pharynx. The treatment consists of absolute rest and quiet. The head should be slightly elevated and fixed between two pillows. If there is bleeding from the nose it is advisable to irrigate the nasal fossaa with warm boric solu- tion to prevent the clot from becoming foul through infection. 80 NURSING OF THE NERVOUS SYSTEM 81 In cases with bleeding from the ear, it is best to irrigate the external auditory meatus after which the canal should be packed with sterile cotton. The irrigations should be given about three times a day. Of course, the bowel movements should be free. If the patient is unconscious, about two drops of croton oil are placed upon the tongue to insure a thorough cleansing of the alimentary canal. Retention of urine is treated by catheteri- zation. Some surgeons give all these cases urotropin in doses of from ten to twenty grains, three times a day, for it secretes an antiseptic into the cerebrospinal fluid. If these fractures are accompanied by signs of brain injury, and of intracranial pressure from hemorrhage, operative interference is necessary, although the mortality is extremely high. Brain Injuries.—The brain is enclosed within a bony case, the skull, and a severe injury inflicted upon the head may not only injure the scalp and fracture the skull, but also cause various injuries to the brain within. The immediate effect of the injury or concussion may be unconsciousness brought on by shock of the nerve centers of the brain. In addition, some blood vessels of the dura or pia mater may be torn with a resultant intracranial hemorrhage causing compression of the brain. This manifests itself by unconsciousness, irregular respirations of the Cheyne-Stokes type, slow pulse, increasing of the blood pres- sure, and what is called a "choked disc"' (serous inflammation of the optic nerve). This may be seen with an ophthalmoscope, an instrument through which the interior of the eye is inspected. As these patients are in shock, they should first be treated for this condition, but they should never be placed in the shock position. In fact, the head should be elevated slightly. The room must be quiet and darkened, and all visitors forbidden. As a rule, an enema is given, and if the bladder is at all dis- tended, a catheter is inserted, and the urine drawn off. Pa- tients, after they have recovered consciousness, should be con- fined to bed for at least a week and watched very carefully, because very often peculiar mental symptoms may follow in the wake of a concussion, and it is not safe to leave such cases alone. Treatment cf Compression.—This presupposes a hemorrhage, either extradural or subdural. The extradural hemorrhage 82 TEXTBOOK OF SURGICAL NURSING results from a rupture of one of the branches of the middle meningeal artery. Subdural hemorrhage is due to a rupture of one of the vessels of the pia mater, or a laceration of the brain with its vessels. Ante-operative Treatment.-The head is shaved completely and iodinized. If the patient is unconscious, no anesthetic is required; if not, a little chloroform is sufficient. The head is supported on a sandbag, or small prop. (See Fig. 83.) Operation.—A curved incision is made in the temporal re- gion of the head, the temporal muscle turned down, and an opening made into the skull by means of an instrument called a trephine. This, by virtue of its circular serrated end, cuts out a button of bone. After the bone has been removed, the dura beneath is exposed. If better exposure is necessary, it may be obtained by enlarging this opening, by clipping away more bone with the bone-cutting forceps, or if the surgeon pre- fers to keep the bone intact, he may make two more trephine openings, and connect them with cuts made by a Gigli saw. This will remove one large plate of bone that may afterwards be replaced. The clot is then removed, and the bleeding vessels are found and ligated, or special Cushing clips (small metal clips) are placed upon the artery. If the bleeding is subdural, the dura is incised, and the source of the hemorrhage sought and controlled. The dura is then closed with interrupted su- tures. The bone which had been kept in warm sterile saline is replaced into the skull, as a rule, and the wound closed with or without drainage. A good tight pressure bandage is applied over the entire head. (Figs. 122 and 123.) After Treatment.—Patients should be kept in bed for about two weeks. During this period they should be allowed very few visitors, and absolutely no excitement. They should never be left alone. If unconscious, catheterization should be performed every eight hours, and the bowels moved by enema once a day, unless incontinence is present. In these pitiable cases great care must be taken to keep the patient exceptionally clean and free from feces and urine. Unconscious patients must be turned every four hours so as to prevent pressure necroses or bed sores, which are always a bad reflection on the nursing care, NURSING OF THE NERVOUS SYSTEM 83 although often absolutely unavoidable. If the skin, especially around the bony prominences such as the sacrum, the heels, and elbows be carefully bathed with alcohol, gently massaged and powdered there is very little danger of this necrosis taking place, particularly if these regions are elevated for a few hours each day by inflated rubber rings. During convalescence, the pa- tient's mind should not be subjected to any mental strain what- soever, and the surroundings should be very quiet. Brain Abscess.—Occasionally, septic complications, or in- tracranial suppuration may follow compound fractures of the skull, cerebral injuries, infections of the middle ear, and disease of the mastoid antrum. The diagnosis is sometimes very diffi- cult, and the treatment is dependent upon the location of the focus. As for abscesses in other parts of the body, the immediate indication is drainage. In the brain abscess this presupposes a craniotomy (already outlined) with drainage of the abscess cavity. If the abscess is due to a suppurating middle ear, the treat- ment is a little more involved. To begin with, if pus is present in the middle ear, it must be freely drained by incising the drum. This is often done under gas, and the tympanic membrane in- cised by a small, spear-like knife (myringotome). Some surgeons are not in favor of syringing the ear in the beginning, but keep the drainage free by wiping the meatus clean with cotton several times a day. Others prefer to have the ear syringed almost immediately with warm boric acid solution at least three times a day. Mastoiditis and Sinus Thrombosis.—If the pus spreads from the middle ear it frequently causes an infection of the mastoid cells (mastoiditis) ; if it enters the region of the lateral sinus (really a vein running in a groove of the temporal bone) a sinus thrombosis may result. These conditions are treated by surgical intervention. Ante-operative Treatment.—The hair in the region of the ear should be shaved for a considerable extent, and if the jugular vein is to be ligated, the neck should always be very carefully prepared. Operation.—The operation consists in laying open and goug- 84 TEXTBOOK OF SURGICAL NURSING ing out the mastoid cells, and if sinus thrombosis is present, an exposure of the lateral sinus. In case the sinus is involved before it is incised, the vein into which it drains (internal jugu- lar) is ligated in the neck. The reason for this is to prevent the spread of infection down the jugular vein into the general cir- culation. After the vein has been ligated, the sinus is incised, the clot removed by careful flushings with warm saline solu- tion, and the sinus packed. After Treatment.—Patients suffering from a sinus throm- bosis are very sick. As a rule, they are septic and, like all those cases, require plenty of fluid and sufficient calories to supply the energy their constitutions demand to fight the bacteria in the blood. Not only should they be given saline freely by rec- tum, but if necessary, also glucose infusions of from five to ten per cent, in strength. If patients are anemic, transfusions of blood are indicated, and should be given frequently until the blood cultures are negative, or the red blood cells and hemo- globin have increased to within normal limits. The wounds are dressed daily, cleaned carefully and packed anew; the dressings are held in place by bandages. (Described in Fig. 133.) Tumors of the Brain.—The brain may be the seat of a tumor either benign or malignant in nature. As the mass within the cranial cavity grows, it crowds the brain and produces signs of compression with its resultant symptoms. In addition, there will be other physical signs dependent upon the area of the brain that is infiltrated by the new tissue, or compressed by the tumor mass. If the motor area is pressed upon, there may be paralysis; if the speech area is involved, there will be paralysis of those muscles which they innervate or loss of function of the nerves supplying the organs of special sense, as the eye, ear and nose. Treatment.—If the tumor mass is localized, an operation is done similar to the one described under intracranial hemorrhage. In other words, an exploratory craniotomy is performed, and the trephine opening is made in that portion of the skull over- lying the brain tumor area. Occasionally, the tumor may be extirpated in toto, but if it is found to be inoperable, a plate of bone is removed in the tern- NURSING OF THE NERVOUS SYSTEM 85 poral region, and the brain permitted to herniate against the temporal muscle. This operation is called '' subtemporal decom- pression." Sometimes in tumors of the cerebellum, part of the occipital bone is removed, or an occipital decompression is done. This procedure temporarily relieves intracranial pressure, and with it, the terrible persistent headaches which torture these unfortunate individuals almost to distraction. Patients are con- fined to bed for three to four weeks. Surgery of the Spinal Cord.—The surgery of the spinal cord is really limited to one operation (laminectomy). Its object is to expose the spinal cord for examination in those cases suffering from cord pressure due either to a tumor mass or bone frag- ments of some vertebral fracture. The patient is placed in po- sitions illustrated in Fig. 68 or 83. The procedure consists in an incision over the desired vertebras, retracting the muscles attached to the vertebral column, exposing the laminae and spines of the vertebras, which are then removed with rongeurs, laminec- tomy forceps, saws, and chisels, exposing the dura of the spinal cord. This is then carefully incised and an exploration of the cord is made. The dura is then sutured and the muscles drawn over it. A moulded cast is applied over the back well into the trunk, and the wound permitted to heal. Surgery of the Spinal Nerves.—Neuritis (inflammation of the nerves) is really a medical condition, but the wounds of nerves are very important from a surgical standpoint. If a motor nerve is cut or pressed upon so that the nerve fibers are destroyed, the muscle structures supplied by it become paralyzed, and the nerve below the point of incision, or pressure, atrophies, although the part above, that which is connected with the nerve cells, lives on. This is important because if the continuity of the nerve is reestablished by suture, the nerve will regenerate by growing along the path of the degenerated segment. The strictest asepsis must be maintained in all these operations. If the nerve is simply pressed upon by callus of a healing bone all that is necessary is to remove the pressure; but if the nerve has been recently divided, it should be immediately sutured end-to-end with a very fine round needle with chromic catgut. After this is done, the wound is closed, and the limb placed in 86 TEXTBOOK OF SURGICAL NURSING that position in which the tension upon the recently sutured nerve will be minimum. A plaster splint is applied, and at the end of one week or ten days, active and passive motions are begun so as to keep up the nutrition of the muscles. Mas- sage and electrical stimulation should also be begun around this period. The splint may be removed in about six weeks to two months. It should not be forgotten that nerve regeneration is a very slow and tedious process, and very often as much as two years will elapse before the complete, or even partial restoration of function will ensue. The patient should be encouraged to mas- sage the muscles involved so as to prevent atrophy and he should be taught how the faradic and galvanic electrical currents are applied, so that when attendants are no longer around, he may give himself those treatments which will mean a functioning extremity rather than a paralyzed one. If the operation is done some time after the original injury the process is more difficult and the various plastic nerve opera- tions will have to be performed. The after care is the same as that required for recent cases. CHAPTER VII THE SURGERY AND SURGICAL NURSING OF THE OSSEOUS SYSTEM FRACTURES A fracture may be described as a break in the continuity of a bone. While this condition is treated in the main by the sur- geon, it affords great opportunity for the nurse to exhibit her skill not only in preparing the necessary things for the treatment of the fracture itself, but even more by conscientiously attend- ing to those details that bring comfort to the patient. A fracture may be simple, that is, only involving the bone, or it may be compound, in which case the skin and deeper tissues as well as the bone have been injured. Compound fractures are serious and dangerous because the broken skin affords excellent oppor- tunity for the various pathogenic organisms to enter and cause bone infection. For the present, however, our attention will be confined to simple fractures, those in which the skin is not directly injured, although it may be swollen, black and blue, and very tender to the touch. Simple Fractures.—It is obvious that as soon as any bone is broken there is ordinarily some deformity about the site of fracture.' This may be due to the hemorrhage of the torn vessels of the periosteum, or the deep muscles; or it may be due to the fact that the fragments of the injured bone are displaced. In the normal bone, a balance exists between the muscles which are attached to it. When the bone is broken, this equilibrium is destroyed and the muscles attached to each fragment tend to pull it in their own direction, thereby causing displacement. This is not true, however, in all cases. Very often one fragment is telescoped or driven directly into the other. This is spoken of as an impacted fracture. The aim in all fractures is to restore the bone fragments as 87 88 TEXTBOOK OF SURGICAL NURSING near to their anatomical condition as possible, and after this has been accomplished, the next thing to do is to keep the fragments in their reduced position. The first process is usually spoken of as "reduction," and the second process as "immobilization." Reduction of Fractures.—Fractures are reduced as a rule under general anesthesia, either gas, gas and oxygen, or ether. This is done because it is less painful, the patient is easier to control and the muscles are completely relaxed instead of being in a condition of spasm. Attempts at reductions are done by the surgeon as soon as possible after the injury. There are, however, certain fractures which do not yield to manual reduction because of the following reasons: (1) Too much time has elapsed between the time of fracture and the period when the surgeon was called upon to treat it, (2) the muscular pull between fragments is so great that manual reduc- tion is impossible, (3) the fragments although reduced are not able to be retained in their reduced position, (4) because of the imposition of bone fragments, muscle or torn periosteum, the fragments cannot be brought into apposition. These fractures are treated either by means of apparatuses designed for the gradual reduction of fractures, or by open operation. Immobilization of Fractures.—Immobilization (the means of keeping fractures at absolute rest) has for its ultimate aim the healing of the divided bone ends by the growth of new tissue or "callus formation." There are many methods designed to hold fractures in apposition. They may be classified as follows: (1) bandages, (2) strappings, (3) splints (wood, wire and plaster), (4) extension and traction appliances, (5) mechanical means applied through open operation. It is a general rule in all fractures that the limb affected should always be placed in a position to favor the complete relax- ation of the muscles which would have a tendency to pull the fragments apart, and, since the longer fragment can always be more easily controlled, it should be made to follow the position attained by the shorter fragment. Bandages and Strappings.—While bandages are employed more in sprains and dislocations, they are occasionally used in certain fractures. Fractures of the jaw are very often con- NURSING OF THE OSSEOUS SYSTEM 89 trolled by a simple four-tailed bandage (Fig. 145, page 389) ; a fracture of the clavicle may be kept in position by a Velpeau bandage (Fig. 140, page 385) or a Syms strapping. Both the four-tailed and the Velpeau bandages are described in the chap- ter on bandaging. Strapping.—Strapping is of greatest use in sprains and a few selected fractures. A sprain may be said to be 'ran injury to a joint with possible rupture of some of the ligaments or tendons, but without dislocation or fracture." In fact, it is often very difficult to differentiate between these conditions without the use of the X-ray or the fluoroscope. Treatment of Sprains.—The present day trend in the treat- ment of sprains is to apply some agent which will stop further effusions into the joint cavity, aid in the absorption of blood which has already been poured into the joint at the time of the injury, give support to the injured part, and yet permit the patient to move the traumatized joint. One of the most effective ways to accomplish this is by the application of adhesive strap- pings. If the swelling about the joint is very severe, it is often advisable to apply ice for the first twelve hours, usually in the form of wet applications. This will do much to reduce the swelling. The joint is then ready for strapping. This is done by the surgeon. The adhesive is applied in such a manner as to insure support, relieve the strain from the ruptured ligament, and yet permit free movement of the affected joint. The patient is then advised to walk about and to use the joint as much as possible. The strapping is left undisturbed for about a week and is renewed if necessary. Very often, when the ligaments have definitely ruptured, some surgeons will put the limb up in a moulded splint. Baking, massage and passive movements are allowed and are usually supervised by a nurse. Six weeks or more may elapse before the healing of the injury is completed. Strapping is used very extensively in sprains of the ankle, wrist and knee. Strapping for Fractures.—This is used most frequently when one or more ribs are broken. It forms an efficient method for immobilizing the chest, at the same time permitting the frac- 90 TEXTBOOK OF SURGICAL NURSING tured ribs to heal. It should be emphasized that the adhesive plaster dressing should never be directly applied over the area of fracture, with the exception of fractured ribs, because, with the swelling of the limb and the pressure of the adhesive, an ulceration of the skin is apt to ensue. The result is that a clean fracture may be converted into a compound one. Another rule in the application of adhesive dressings is that the part over which the adhesive is to be applied should be shaven of all hair. Splints.—"A splint is an apparatus for preventing move- ment of a joint, or between the ends of a broken bone." Since materials used for splints must of necessity be hard, firm and unyielding they should always be padded well. There is nothing more distressing than to see a patient with a simple fracture of the radius just above the wrist in which the splint was not only insufficiently padded but was applied too tightly. The result is a forearm which has become blistered, ulcerated and paralyzed from the pressure; the function of the wrist being irretrievably impaired, the stiff, smooth fingers are an ignominious monu- ment to the carelessness of the surgeon and the attending nurse. Let it be an unfailing, unalterable rule that all fractures in splints of any description be regularly inspected so that the swelling of the part never becomes so great as to impair the circulation. The pulse at the wrist in fractures of the arm-and forearm, and the pulse at the dorsum of the foot in fractures of the lower extremity should always be palpable after a splint has been applied. This is simple and safe assurance that the blood flow to the limb is not seriously impaired. Very often a patient will complain of pain in an area other than that of the fracture. The splint should always be carefully inspected to determine the source of the discomfort. Occasionally in circular casts, it is a good plan to cut a window in the plaster in the area of pain so as to relieve the pressure which is invariably causing the dis- tress. By doing this, the incidence of ulcers from pressure will be reduced to the minimum. Before any splint is applied it is of prime importance to cleanse the injured part. The nurse, always being mindful of the injury, should do this gently and carefully, causing NURSING OF THE OSSEOUS SYSTEM 91 as little pain as possible. This procedure should be completed by dusting the skin of the broken limb with talcum powder. Splint Materials.—Any material which is light and strong is suitable for a splint. The following are some of the more widely used materials: Wood.—Wood has been used for centuries to support broken limbs. Probably the best splints are the basswood. Basswood splints usually come in sizes of 18x4x14 inches. When they are padded carefully with cotton, they make a good temporary splint, and because of the lightness of the wood, they can be cut to any desired size. The one great disadvantage is that it is impossible to mould them accurately. Plaster of Paris.—This is perhaps the most widely used splinting material in civilian practice, and, beyond doubt, its widespread application is justifiable. It is easy to obtain, strong, moderately light, and when soft lends itself to accurate and easy moulding. Plaster of Paris is best handled in the form of plaster of Paris bandages. The manner in which they are made is given in Chapter XX. There are two ways in which these bandages may be applied. They may be used as bandages or "moulded splints." Plaster of Paris Bandages.—These are applied as any other bandage, the limb having been previously padded with non- absorbent cotton. Extreme care should be taken to apply the bandages smoothly, without wrinkles and rather snugly. The number used is dependent upon the desired thickness of the cast. After this has been obtained, the cast may be further smoothed by applying an excess of plaster and polishing the same with long strips of cheese cloth moistened with peroxide of hydrogen. Plaster usually dries in from one to eight hours. For the first thirty minutes, the limb should be held until the plaster has partially dried, because the cast may become dis- torted by pressure of surrounding objects. While it is not a universal practice, a great many surgeons deem it advisable to cut all circular casts in the direction of their longitudinal axis, in two parallel lines, diametrically opposed. The reason for this is obvious. Should the limb become swollen, the danger of any untoward complications, such as pressure 92 TEXTBOOK OF SURGICAL NURSING necrosis, with a subsequent Volkmann's paralysis, is materially lessened. When the cast has been cut, a bandage is applied to hold the segments in place. Not only does cutting down a cast insure a "safety first" policy, but it becomes very convenient to do so when baking and massage are employed as the cast may be quickly removed and efficiently reapplied after each treatment. If, for some reason, the surgeon should decide to leave the cast intact, and to have it cut at a subsequent date, it must not be forgotten that dried plaster is almost stone-like. The method of cutting casts is given on page 397. Moulded Plaster of Paris Splints.—As the mime implies, these are simply splints made up of plaster of Paris which, when soft, may be moulded. They are very extensively used because they are easily applied, safer than the circular cast, and save the labor of cutting through plaster. They may be used for all fractures of the extremities. Assume a fracture of the radius just above the wrist, a so-called Colles fracture. The manner of applying a moulded splint to this type of fracture is here- with briefly given: The length of the splint to be used is measured with a piece of gauze, in this case from the elbow to the metacarpo-phalangeal joint, and, in addition, the width of the arm is noted. This pattern of the splint in gauze is laid flat upon some smooth surface, either glass, marble, or board. A moistened plaster bandage is rolled back and forth over the gauze pattern, until the desired thickness of the splint has been attained. A piece of canton flannel usually lines the inner side of the splint. The soft plaster, lined with flannel and a thin layer of cotton, is applied to the anterior surface of the fore- arm, and bandaged snugly in place. The anterior splint in this way can readily be moulded to the shape of the arm. After the plaster has hardened the bandage is removed, all the rough edges of the splint smoothed and a muslin bandage reapplied. Some surgeons in addition to an anterior splint apply a posterior one. The technic is identical for all of the moulded variety. Very often a splint will be made double in length and be bent upon itself in the shape of a letter U, forming a joint anterior and posterior one. This type j.s known as a "sugar-tong" splint. It NURSING OF THE OSSEOUS SYSTEM 93 finds a very practical application in fractures of both bones of the forearm. Spicas and Jackets.—When a long bone is broken, such as the femur, or the pelvis, heavier splints are required because greater strength is necessary to overcome the powerful contract- ing influences of the muscles of the thigh. Splints in this region have but little value aside from their first aid application. If the surgeon desires to use plaster for these conditions a spica bandage of plaster of Paris is employed. These extend from the region of the umbilicus down to the toes on the affected side. The technic of the application of the plaster is the same, but there are several factors which are a little different and demand special mention. First the mechanical, for after all, plaster has only a certain tensile strength. If this is exceeded, the plaster is apt to crack and break, rendering the spica useless. In order to prevent this, it is customary to reinforce the cast, especially in the lateral region, i. e., from the hip to the knee and over the anterior aspect of the thigh. The reinforcing material may be strips of basswood, wire mesh, or sometimes longitudinal strips of plaster of Paris in the form of moulded splints. Then, in applying the cast, inasmuch as the lower abdominal region is included, sufficient space must be allowed for the possible distention of the small and large intestines. In other words, ample room must be left for the patient's appe- tite. This is accomplished by laying two or three folded towels on the abdomen, and winding the plaster so as to include them temporarily, removing them after 1he plaster has hardened. Since the spica winds about the genitals and anal orifice, great care must be taken that there is no undue pressure against these organs, and that the patient is able to defecate and urinate without difficulty. In children whose control is apt to be lax or involuntary, it is customary to coat the cast with shellac, thus rendering it impervious to the urine. Spicas, as well as all other complicated plaster work, are applied with great facility and more efficiently if the patient is resting on a "Hawley" table. The Hawley table, or modifications of it, is of such mechanical construction that any part of the bony framework of the patient may be held in any desired position for any length of time with- 94 TEXTBOOK OF SURGICAL NURSING out the aid of very much assistance. This, of course, is a wonder- ful advance over those methods which required a limb to be held in a certain position by a nurse or doctor until the plaster could be applied. The Hawley table may be used not only for the application of casts, spicas, and plaster jackets, but it is a con- venient means to steady a limb and obtain traction if necessary, during the course of an open operation upon bone. Plaster Jackets.—These are coats or jackets made of plaster that cover the patient from the neck well to the region of the thighs. It finds its application in dislocations of fractures of the vertebras due to either accidental causes or to disease, such as tuberculosis of the spine. It may be applied with the patient resting either on the Hawley table, or with the patient lying across some supporting straps. Methods to Obtain Traction.—In some cases, the fragments of the fracture are overriding to such.a degree that were the limb permitted to heal in this position great deformity and shortening of the leg or arm would result. To overcome this, and to correct the overlapping of bones, traction may be applied. Nothing has developed the use of traction more than the Great AVar. For there, not only did the surgeon have to deal with fractured limbs but with fractured limbs plus injuries to the soft parts (compound fractures). To overcome these difficulties, which are practically impossible to handle if the limb is encased in plaster, an attempt is made to maintain reduction by traction often combined with suspension. Traction.—Traction is used to correct overlapping or over- riding bone fragments and lateral deformities. Through its agency, those muscles are relaxed which by their contraction might have resulted in malpositions of the fracture. In addition, if properly applied, it automatically secures the proper alignment of the bone ends and prevents the fragments from being displaced, thus avoiding injuries to muscles, blood vessels, or nerves. In civilian practice, traction was practiced frequently for fractures of the femur either through a Buck's extension or a Hodgen's splint. Briefly, the Buck's extension is made by applying to the lateral aspects of the leg a piece of adhesive NURSING OF THE OSSEOUS SYSTEM 95 plaster about four inches wide, reaching from above the knee to below the sole (Fig. 10, B). Between the free ends of the Fig. 10.—Methods of Applying Traction. A, stocking traction; B, adhesive plaster traction; C, Sinclair skate. From the Manual of Splints and Appliances, Medical Department, United States Army. adhesive a piece of wood, five by three inches, is attached. This acts as a spreader, and a means by which weights may be attached and traction obtained. 96 TEXTBOOK OF SURGICAL NURSING Fig. II1.—Traction Leg Splint. A, Thomas traction leg splint with sus- pension. The Hodgen's suspension splint (Fig. II2), which is really a forerunner of the various splints developed recently, is simply two parallel iron bars bent slightly in the region of the knee. The lower extremity is placed between these two bars, resting on several cross pieces. The limb is raised from the bed by cords attached to the splint and traction is obtained. Further traction may be obtained by combining this with a Buck's extension. As the Buck's extension depends for its traction pull upon large areas of skin being covered by adhesive, it was found impractical during the war because extensive wounds of the skin and deeper tissues often complicated the fractures. So newer methods of traction were developed,—namely, the stocking traction (Fig. 10, A) and the Sinclair skate (Fig. 10, C). The former employs a light weight sock from which the toes have been removed. The sock is glued to the leg, ankle and foot except at its sole, and a piece of splint wood is introduced between the NURSING OF THE OSSEOUS SYSTEM 97 Fig. II2.—Traction Leg Splint. B, wooden bed frame. For traction by weight and pulley and overhead counterweight sus- pension. Application for lower limb injuries. Limb in anterior thigh and leg splint, Hodgen type. Uses:— For suspension of limb from overhead support in injuries of thigh and leg. A. Supporting slings clipped to rods of splint. B. Cloth glued to sole of foot attached to counterweight arranged to maintain right-angle dorsal flexion. C. Hand grips by which patient may change his position in bed. H. Strap iron hooks movable on upper cross-bar of frame but screwed to short wood bar to maintain pulleys in proper relative position. W. Open canvas weight bags. This splint is used simply for a frame to sling the leg in case the nature of the wounds makes the Thomas splint impossible. The traction straps should be attached directly to the weight and pulley, and should not be attached to the splint. By careful adjustment of the slings the position of the bone fragments can be controlled. From the Manual of Splints and Appliances, Medical Department, United States Army. sock and the sole of the foot. Traction is obtained by means of a cord passed through the sock and splint. A further refine- ment is the Sinclair skate; this is a piece of board attached to the foot by adhesive strips or glued strips. The glue that is used may be made after the following formulae and directions 98 TEXTBOOK OF SURGICAL NURSING obtained from the "Manual of Splints and Appliances" (Med- ical Department, United States Army). SINCLAIR'S GLUE Glue ...............50 parts Water..............50 " Glycerine .......... 2 " Calcium chloride..... 1 part Thymol ............ 1 " The glue is heated in a water bath to about 100° F. It is painted on the skin, the last coat given is painted in a direction against the growth of hair. RESIN AND TURPENTINE GLUE Resin ..............50 parts Alcohol ............50 " Benzine (pure) ... .50 " Turpentine ......... 5 " To the powdered resin, one-half the alcohol is added, then the turpentine and benzine. The measure is washed with the remaining alcohol and the contents poured into a bottle. The bottle is always kept tightly corked. The glue may be removed with alcohol or ether. No heat is necessary for its application and it should be applied as thinly as is possible. Suspension.—While traction is an important element, sus- pension has enhanced its value by rendering greater comfort to the patient, and making much easier the surgical dressing of the wounds. The limb is usually suspended to an overhead wooden or metal frame (Fig. II2) developed from the original Balkan frame. This consisted of two uprights with a cross piece at each foot of the bed supporting a horizontal bar. The frame now in use is a quadrilateral variety and is illustrated in Fig. II2. To this frame may be attached various pulleys, or these pulleys may be run on trolleys as shown in Fig. 12, A, and Figs. II1 and ll2. There are several splints which have been recently developed, and although their application and suspension is the concern of the orthopedist and surgeon, the nurse should have a knowl- edge sufficiently great to secure the desired appliances at the NURSING OF THE OSSEOUS SYSTEM @== Fig. 12.—Traction Arm Splints. A, Thomas traction arm splint; B, Thomas arm splint; C, Thomas traction arm splint. From the Manual of Splints and Appliances, Medical Department, United States Army. 100 TEXTBOOK OF SURGICAL NURSING splint room, and in the event of anything occurring to thein in the absence of the attending doctor, she may apply "first aid." The ones most commonly used are those mentioned in the "Manual of Splints and Appliances" issued by the Medical Department, United States Army, and illustrated herewith. Thomas Traction Arm Splint.—This is used for fractures of the shoulder joint, shaft of the humerus, elbow joint, and fore- arm (Fig. 12). Jones "Cock Up" or "Crab" Wrist Splint.—This is intended for injuries to the wrist, or to maintain dorsal flexion of the hand in injuries to the wrist, and in injuries to nerve and muscle causing wrist drop (Fig. 13). fiG. 13.—Jones '' Cock Up, " or " Crab '' Wrist Splint. From the Manual ,; of Splinfs, and Appliances, Medical Department, United States Army. « Thomas Traction Leg Splint.—This is for injuries to the shaft of the femur, knee joint, and leg (Fig. 111). Hodgen Type Splint.—This is for injuries to the thigh (Fig. IP). Open Operation for Fractures.—In these fractures, which are not compound, when reduction has been impossible, it is often necessary to perform an open operation, reduce the fracture under the direct vision of the surgeon, and then hold the frag- ments in place by some mechanical measure. The means of accomplishing this are many. Some use wire, others, Lane plates; the latter are pieces of metal which bridge bones together, the plate being held fast to the bones by screws (Fig. .11). Occasionally, although the bones are in good position, union by callus formation fails to take place. To stimulate bone growth a piece of bone may be taken from some other part of the body, as a graft from the tibia, and this is inserted into the fractured bone ends. Inasmuch as infection is very much NURSING OF THE OSSEOUS SYSTEM 101 dreaded in these operations, an exaggerated technic, or Lane's technic, is employed. This is a method whereby everything that goes into or comes into contact with the wound is not touched by gloved hands, but by instruments. The technic is briefly out- lined in Chapter XVII. The wound, of course, is closed with- out drainage, and the limb put up in some splint or fixation apparatus. Osteomyelitis.—This is an inflammation of the medulla or marrow of the bone. It may be acute or chronic, and generally results from a bacterial infection. All those compound fractures of the war, due to shrapnel and machine gun bullets, were com- plicated, as a rule, by osteomyelitis in varying degrees. Symptoms.—The symptoms may consist of great pain re- ferred to the bone affected, high fever, rapid pulse, and general malaise. There may be swelling, redness, and marked tenderness on pressure over the involved area. Treatment.—The treatment is operative. B-'' An attempt is made to give the bone free drainage by incision through the skin and muscles and then sufficient cortex of the bone pLAte.' ^Tractured is removed to permit the pus in the medulla bone; B, Lane + a • -p 1 rn • » -, • .-, Plate; c> screws. to dram treely. To insure free drainage the wound is packed with gauze, and to clean up the infection the bone and wound are Daklnized by the various methods described in Chapter XIX. If the condition is complicated by fracture, the limb is treated by suspension and traction, plus the Dakin treatment. Because of the hardness and unyielding character of bone it will take a long while for the dead bone in the medulla to form a line of demarcation from the living, and that is why these cases of osteomyelitis linger so long before they are healed. The dead bone which often comes away in spicules at a dress- ing, or which is removed at some subsequent operation, is spoken of as a sequestrum. Inasmuch as the majority of these cases will suffer for some time from a continual low grade toxemia, it is important to look after their general condition. These patients should be given \VA 102 TEXTBOOK OF SURGICAL NURSING as much fresh air as possible, kept on a high caloric diet, and although confined to bed, the muscles of the affected limb should be given daily massage whenever possible. This will insure proper nourishment and maintain muscle tone, for it is well known that muscles not in active use are apt to undergo atrophy. The temperature should be carefully watched and any sudden rise might be indicative either of retention of pus somewhere in the wound, or the starting of a new focus in the same bone or another one. Amputations-.—Fortunately, today, amputations are but rarely performed, and limbs which years ago would have been sacrificed, are saved now by the newer advances of surgical treatment, Amputations are mutilations. They are employed as final measures and their indications are definitely defined and clearly cut. Ante-operative Treatment.—The area, through which the amputation is to be done and the skin for a considerable dis- tance above and below, should be shaven and cleansed very care- fully. If there are any open sinuses they should be protected by packing and sterile dressings, so that their discharge will not contaminate the wound. To prevent hemorrhage during amputation there are several methods devised which aim to compress the blood vessels sup- plying the limb in question. Esmarch's Method.—This method attempts to squeeze all the blood out of the limb by applying an elastic bandage which is wound spirally from below upward, well above the region of amputation. At the upper limit, an ordinary rubber tubing tourniquet is applied and fastened. The elastic bandage is then removed. This is not applicable in septic conditions, nor in cases of tumors. Lister's Method.—Here the limb is elevated for a few min- utes and the ordinary tubing applied in a horizontal fashion as a simple tourniquet. Tourniquets.—These should always be applied well above the region to be amputated, and should be sterilized. When the amputation is to be done near the hip or the shoulder, strips of sterile bandage should be applied around the tourniquets. These NURSING OF THE OSSEOUS SYSTEM 103 are held firmly by an assistant to prevent the tourniquet from slipping. Some surgeons prefer to use Wyeth's pins, elongated steel pins which are pierced through the muscles, and the tourni- quet in pressing against these is prevented from sliding off (Fig. 15). Amputation Operation.—The technic of the operation is variable. Some surgeons will inject all nerve trunks with novo- cain before cutting them. The bone stump is treated in various man- ners so that a full armamentarium of bone instruments should always be on hand. Amputation wounds are usually drained. The dressings applied should be large and pres- sure should be evenly exerted either by adhesive strips or bandage. As a rule the stump should be elevated. . Fig. 15.—Method op Ap- Sometimes a small splint is applied plying Wyeth's Pins. A, to the stump to immobolize it in a Wyeth's pins; B' tourni(luet- more efficient manner. After Treatment.—These patients are apt to suffer from con- siderable shock so not only must this condition be watched for, but also the danger of secondary hemorrhage. It should be rou- tine practice to have an emergency tourniquet set very near the patient's bed so that should bleeding occur no time may be lost in arresting the hemorrhage. If the oozing is marked, the dress- ing may be reinforced or changed in twenty-four hours, although it is better to wait forty-eight hours. Occasionally when the wound has almost healed it is often necessary to apply pressure to certain flaps or skin areas to relieve tension. This pressure can be obtained by thin bandaging or by adhesive strappings. In bandaging, it is always to be remembered that the turns which pass over the stump should be begun from above downward and on the side where the longer flap is. Sometimes when the flaps have been cut too short, it may be necessary to apply traction to pull the muscles over the stump. 104 TEXTBOOK OF SURGICAL NURSING While the stage of healing is in progress, gentle massage to the muscle groups will do much to maintain their tone and health. If the amputation is one of the lower extremity, the patient should be taught carefully the proper use of crutches. Crutches should not press into the axilla but the weight of the body should be sustained by the hand resting on the cross piece of the crutch. Special instructions should be given as to how to descend and ascend a flight of stairs, cautioning the patient to hold the banister with one hand and using the other hand to hold the supporting crutch. To prevent the crutches from slipping they should always be equipped with rubber tips. CHAPTER VIII THE SURGERY AND SURGICAL NURSING OF THE REPRODUCTIVE SYSTEM Composition.—The genital system of the female and male may be divided into the external and internal organs of genera- tion. The external organs in the female consist of the mons veneris, the external opening of the urethra, the clitoris, the labia majora, labia minora, and the hymen; the internal organs are the vagina, the uterus, the tubes and ovaries. In the male, the external organs of generation are the penis, the scrotum which contains the testis, the epididymis, part of the vas defer- ens; the internal, the prostate, and the seminal vesicles. Operations on Female Genital System.—The operations on the female genital system resolve themselves into two classes, those which are external, and those which are internal. The external, mainly plastic operations, are those done for the relief of a relaxed perineum or lacerated cervix, injuries which follow tears incident to childbirth. A weakened pelvic floor may result in a relaxation of the anterior vaginal wall with a subse- quent prolapse of the bladder (cystocele). If the posterior wall of the vagina is weakened, a prolapse of the rectum may occur (rectocele). Surgery attempts to correct the cystocele and rectocele by operations upon the vagina and a reconstruction of the muscles of the perineum. The operations come under the general head of perineorrhaphy. Perineorrhaphy.—The ante-operative procedure : The vulva should be shaved, scrubbed with green soap and water, then with alcohol and ether. It is advisable to catheterize the bladder routinely in all these cases. The patient is placed in a lithotomy position (see Fig. 72, page 277) and the various operations for the relief of the pathological conditions are performed. The technic of the operation does not concern us here. Post-operative Care.—Most institutions and hospitals have 105 106 TEXTBOOK OF SURGICAL NURSING standard perineorrhaphy routines. The various methods are herewith outlined: The routine which the nurse will follow in the after care of a perineorrhaphy will always be prescribed by the surgeon; it will vary considerably from time to time, depending upon the extent of the wound and the preferences of the particular sur- geon. In any case it is extremely important to keep the wound surgically clean. At best, the task is not easy, nor very satisfac- tory because of the necessary, frequent exposure to the unsterile excretions of the body. Fortunately, however, nature has pro- vided this part of the body with unusual resistance to infection, and therefore consistent and conscientious technic in the treat- ment of a perineorrhaphy wound will be rewarded with good results. Some surgeons will require that the part be kept immo- bilized for at least the first forty-eight hours. This is accom- plished by means of a bandage passed about the thighs binding the legs together. This will be particularly desirable in the case of a restless patient. Other surgeons, however, will not pre- scribe this treatment and the nurse will, of course, not administer it as a routine practice because it is a rather trying ordeal for some patients. When applying this bandage the nurse should remember the rule forbidding the bandaging together of any two surfaces of skin and should see that the thighs are comfort- ably separated by means of a layer of non-absorbent cotton. Sometimes catheterization will be prescribed to avoid contami- nation of the wound by the urine. This may be for only a period of forty-eight hours at stated intervals, or it may be for a longer time. In some cases treatment will be directed toward preventing evacuation of the bowels for a stated period, some- times as long as nine days, particularly if the laceration has been a complete one—that is, one which has extended into the rectum. This treatment will consist of opium medication to suppress peristalsis, of fluid diet without milk, or of the two combined. Often, however, especially in eases of the slighter wounds, catharsis, oil enemas, etc., will be given in the course of a few days. Whatever the prescribed general treatment, how- ever, the nurse must follow rigid aseptic technic throughout. Catheterization, of course, is always done with the most thorough NURSING OF THE REPRODUCTIVE SYSTEM 107 asepsis, so no special lesson will be necessary here as to that, except to point out that in this case the asepsis must be in the interest of the wound as well as the bladder. As a rule, whether or not catheterization is done, after the bladder has been emptied the perineum will be douched with sterile water or some mild antiseptic solution such as 2 per cent, boric acid or 1-5000 bichloride, which will be allowed to flow over the wound from a pitcher or irrigator. The wound is then carefully patted dry with sterile gauze and the prescribed dressing applied. Some- times the dressing will be only the plain dry gauze; but a dust- ing powder, such as aristol, or an ointment, such as boric acid, may also be applied. Keeping the wound dry is an important part of the nurse's duty in this case and it will require careful manipulation on her part because perineorrhaphy sutures are very frequently of silkworm gut which will mean that they will be likely to catch upon dressings and involve the risk of tearing the wound and also of causing considerable pain to the patient. The aseptic precautions will be necessary at least till after the sutures have been removed, which may be any period of from five to ten days. The Uterus.—The uterus is a muscular, pear-shaped organ situated in the pelvic cavity between the bladder and the rectum. Its normal position is that of anteversion. The part of the uterus which projects into the cavity of the vagina is known as the cervix. The uterus is lined with mucous membrane; and entering the fundus or body of the uterus are the openings of the Fallopian tubes. The uterus may be the seat of acute inflam- mations, malpositions, or new growths, either benign or ma- lignant. Inflammations of the Uterus.—The mucous membrane of the cervix of the uterus may become acutely inflamed due to a variety of causes, especially from an infection by the gonococcus. This condition is known as endocervicitis, and if the inflamma- tion extends further and attacks the mucous lining of the uterus, the process is known as endometritis. The treatment of this con- dition may be either medical or surgical. Treatment of Acute Inflammatory Conditions.—In the acute infections, especially those due to a gonorrhea in which there 108 TEXTBOOK OF SURGICAL NURSING is an associated urethritis (inflammation of the urethra) and a purulent vaginal discharge, it is of the greatest importance to warn the patient of the severe infectiousness of the disease, and the dire results which follow, if it is willfully neglected. It is imperative that the hands be kept away from the eyes, because a gonorrheal infection of the organs of sight may cause total and permanent blindness. The patient should be placed in bed, given a bland non-irri- tating diet without'condiments or spices, and all alcoholic bever- ages absolutely forbidden. Fluids should be forced to the utmost, and the attending nurse should give copious vaginal douches every four hours with any silver preparation, either protargol or argyrol, in dilutions of 1-10,0(10. In more chronic stages, these may be followed by silver nitrate irrigations. Cervix.—The cervix, as a rule, is treated by the surgeon by direct applications of* 10 to 20 per cent, silver nitrate, iodine, or 20 per cent, argyrol. The patient is appropriately draped, placed in the lithotomy position, a bivalve speculum is introduced, and the applications made directly to the cervix. However, in all these treatments, while the cervix itself may be benefited, it is difficult to reach the endometrium or lining mucous membrane of the uterus, and very often more radical surgical procedures have to be resorted to. Operative Treatment.—One of the most common procedures is the operation known as dilatation of the cervix and curettage of the uterus. The purpose of the dilatation is to insure suffi- cient stretching of the cervical canal, so that instruments may be freely passed into the uterus, and secondly to insure drainage of the uterine cavity. The object of the curettage is to scrape away the diseased mucous membrane of the uterus so that a new and healthy lining will replace the diseased part. While this operation is done for chronic inflammations, it is also performed for the retained membranes of pregnancy, and for incomplete abortions. It is also a diagnostic measure, for in doubtful cases of cancer of the uterus, the curettings may be examined for microscopic evidences of malignancy. There are cases in which there is a definite stenosis, or narrow- ing of the cervix, resulting in very painful menstruation NURSING OF THE REPRODUCTIVE SYSTEM 109 (dysmenorrhea) and often in sterility. In order to insure a permanent opening of the cervical canal, after operative dilata- tion, a stem-pessary of either glass or rubber is often sewed in the cervical canal, and permitted to remain in place until the appearance of the next period. While the stem-pessary is within the cervix, a daily douche of disinfectant variety should be administered, as the mechanical presence of the foreign body generates a certain amount of disagreeable discharge. When the cervix is badly torn, the laceration may become a source of irritation. A plastic repair is often done; the opera- tion being known as trachelorrhaphy. When the tears are multiple it may be necessary to amputate the cervix partially or completely. Malpositions of the Uterus.—While the normal position is that of anteversion, the uterus may occupy a backward posi- tion. This is spoken of as retroversion. Naturally there are many women who suffer from retroversion without symptoms, but if backache and other reflex symptoms are severe, the uterus must be replaced. The replacement will be dependent upon the movability of the uterus. The uterus may be replaced sometimes by manual manipulations by the surgeon with the patient in the knee-chest position. Should the procedure prove too painful, because of inflammatory products binding the uterus to other structures, hot vaginal douches may be ordered twice daily, after which the patient is instructed to assume the knee-chest position for periods of from five to ten minutes, night and morn- ing. This often diminishes the inflammation to such a degree that manipulations on the part of the doctor are less painful and more successful. After the uterus has been replaced it may be held in position by pessaries. These are appliances, usually of hard rubber, of various forms, which are introduced into the vagina with the object of exerting pressure so as to hold the uterus in place. Pessaries must never be sterilized by boiling because, if they are made of rubber, boiling alters their shape. If the uterus cannot be brought back by these measures, opera- tive procedures must be resorted to. Operations for Retroversion.—The purpose of all operative procedure is to bring the uterus forward and upward to its 110 TEXTBOOK OF SURGICAL NURSING normal anatomical position and to hold it securely there. In the majovity of operations this is accomplished by shortening the round ligaments. The operation may be performed through the inguinal canals, through the abdomen, and through the vagina. The inguinal canal route:—As the round ligaments help to maintain the normal position of anteversion, they may be iso- lated in the inguinal canal, drawn out and sufficiently shortened so as to exert tension, and thus mechanically pull the uterus forward into place. The abdominal route:—The uterus is lifted from its retro- verted position and the fundus is sutured to the anterior abdom- inal wall directly (ventral fixation). Or the round ligaments are sutured to the recti muscles (the so-called Gilliam operation of ventral suspension). The vaginal route:—The patient is placed in a lithotomy position, and the operation done through the vagina. The uterus is brought forward by suturing either to the anterior vaginal wall, or the lower part of the bladder, or it is pulled into place by shortening the round ligaments. Prolapse of the Uterus.—This condition is often called "fall- ing of the womb." Prolapse of the uterus is divided into three degrees. The first degree is that in which there is a relaxation of the pelvic floor with a protrusion of the vaginal walls; in the second degree, the cervix is found at the vulva; and in the third degree there is a mass of the uterus protruding from the vagina and lying between the thighs. Treatment of Prolapse.—The palliative measures are the use of pessaries and tampons. A large circular rubber ring in the vagina is often very efficacious in maintaining the uterus in position. It is highly important that these pessaries be removed at least once a month and cleaned, and at the same time the vaginal canal be inspected to determine whether any irritation is present. The curative measure is operation. The uterus is brought forward and upward by a ventral fixation and a perineorrhaphy gives support below. In some cases it is often advisable to remove the uterus (hysterectomy). NURSING OF THE REPRODUCTIVE SYSTEM 111 Tumors of the Uterus.—The uterus may give origin to benign and malignant growths. The most common benign tumor is a fibroid. These may cause bleeding (menorrhagia), vaginal dis- charge, pain, and quite often a mass may be felt within the abdomen. However, there are many women who have fibroids which never cause symptoms. Fibroids are treated by X-ray, radium, and operation. Operative Treatment.—If the fibroids are single and do not involve the entire uterus, the tumor may be enucleated (myomectomy). If the tumors are multiple and involve most of the uterus, the entire organ may be removed (hysterectomy). This is an operation designed to remove the uterus. It may be performed through the abdomen (supravaginal hysterectomy), or it may be done through the vagina (vaginal hysterectomy). Supravaginal Hysterectomy.—After the patient is anes- thetized, she is placed in an exaggerated Trendelenburg position. (Fig. 63, page 271.) The abdomen is opened by a median incision and the intestines are carefully padded off with warm, moist saline pads. The fundus of the uterus is seized with a vulsellum. The broad ligaments on each side are clamped, and, if possible, one of the ovaries is left. The uterovesical fold of the peritoneum is incised and dissected toward the bladder. The uterine arteries are then clamped and the uterus is amputated through the cervix. The cervical stump is grasped with a second vulsellum, and the cervical canal is cauterized with carbolic acid or iodine. The cervix is then united in interrupted sutures, and the vessels usually tied with plain gut. The round ligaments are sutured to the cervical stump and the pelvic peritoneum approximated to the pelvic peritoneum. This, of course, leaves a little cervical tissue which may cause a persistent leukorrhea. To avoid this the entire cervix may be extirpated. When the pelvic operation has been completed, the patient should be returned to the horizontal position and the abdominal wall closed. Occasionally vaginal drainage is required. This is done before the abdomen is closed by passing a curved clamp into the vagina and pressing against the posterior vaginal wall behind the cervix. The surgeon incises this area and introduces 112 TEXTBOOK OF SURGICAL NURSING a cigarette drain into the clamp. When this is withdrawn, the drain is pulled down into the vagina. There is no special nursing required post-operatively except that a careful watch should be kept for hemorrhage. Occasion- ally, although fortunately rarely, a ligature slips, and an uterine artery will start to bleed. This requires immediate surgical interference. Patients, as a rule, are kept in bed for about sixteen days. Vaginal Hysterectomy.—This is performed through the vagina without an abdominal incision. It has no advantage over the other except that it does not leave a scar. Malignant Diseases of the Uterus.—These may either affect the cervix or the body of the uterus. They are usually carcinomatous in character. The treatment is either complete hysterectomy, or the application of radium. Diseases of Fallopian Tubes.—Any inflammation of the Fal- lopian tubes is spoken of as salpingitis. It may be acute or chronic. Acute Salpingitis.—This may be due to an infection occurring during labor, from unclean instruments, much instrumentation, or a preexisting gonorrheal infection. The history usually given is that of a vaginal discharge, abdominal pain of a colicky nature and, in addition, the history of a recent labor, instrumentation, or gonorrhea. , Treatment.—The treatment consists of absolute rest in bed in the Fowler's position (Chapter IV, page 59). Hot vaginal douches are given every six to twelve hours depending upon the severity of the intiammation. Applications are made to the lower abdomen, either in the form, of heat or cold, and move- ments of the bowels should be assured by enemas. If the pain is very severe, sedatives may be given. Very often these cases of tubal infection are complicated by pelvic peritonitis resulting in the development of a pelvic abscess. Instead of draining this through the abdomen, the abscess may often be drained through the vagina by making an incision between the posterior part of the cervix and the posterior wall of the vagina. This is known as a colpotomy. A good sized drainage tube is introduced into the abscess cavity, but because of the dependent position, the NURSING OF THE REPRODUCTIVE SYSTEM 113 drainage tube will not stay in place without some special arrangement of a cross piece, so as to make a "T" tube. Great care should be taken that the vagina is kept scrupulously clean, and the drainage free. To accomplish this, vaginal irrigations with normal saline solution should be given twice a day. Chronic Salpingitis.—This may be a sequel of acute salpin- gitis. The tube may either be bound down with fibrous adhe- sions, or it may be dilated and filled with watery material (hydrosalpinx); or it may be filled with pus (pyosalpinx). Occasionally it may be tuberculous. Symptoms and Treatment.—The symptoms are backache, pain in the lower abdomen, menstrual disturbances, weakness, and vaginal discharge. Physical examination may reveal a mass in the pelvis. If the case is adjudged favorable for operation, a low laparotomy is performed with the excision of the affected tube (salpingectomy). There are no special ante-operative or post-operative measures other than those which have been out- lined in all other abdominal operations. Ectopic Pregnancy.—The ovum is normally fertilized in the tube, and it continues its journey until it reaches the uterine cavity where it becomes implanted, and proceeds to develop. Occasionally, however, the fertilized ovum becomes arrested in the tube end begins its development in this location. This is spoken of as an ectopic gestation. The degree to which the tube may increase in diameter because of the growing ovum is limited. The result is that it ruptures, causing the death of the embryo, and hemorrhage from the tube. This bleeding is a source of great danger to the mother because it may result in death. Symptoms.—The history, as a rule, is that of delayed menstruation. The patient is seen generally after the tubal rupture. This gives rise to sharp pains localized in the lower abdomen, and fainting spells due to the loss of blood. If the hemorrhage is marked, the patient will exhibit all its charac- teristic signs. Treatment.—Immediate operation is indicated, for the bleed- ing from the tube must be stopped by salpingectomy, and the tubal branch of the ovarian artery ligated. The free blood in the pelvis is removed by sponging or aspiration through suction. Ill TEXTBOOK OF SURGICAL NURSING Post-operative Care.—As these patients are suffering, as a rule, from loss of fluid, saline is given intravenously, and, as soon as possible, a blood transfusion. They are kept warm like other shocked patients, but if it can be avoided, the shock posi- tion is not used. As soon as they have recovered sufficiently they are placed in the Fowler position. Means are taken, as soon as practical, to increase their red blood cells by the use of tonics, and the administration of iron in the form of Blaud's pills. The Ovary.—The ovary besides secreting the ovum possesses an internal secretion which exercises a very important part in maintaining the normal nervous mechanism of the individual. Removal of both ovaries results in the complete cessation of menstruation and a train of nervous symptoms which make these patients objects of pity. They become very excitable, nervous, melancholy, and often so desperate that they have ended their existence by suicide. It is now the custom, when- ever possible, to leave some part of the ovarian tissue, and should it be absolutely necessary to remove all of it, as in radical pan- hysterectomies for cancer of the uterus, the patient may be fed the ovarian extract of the animal. It is surprising what good results will follow. Diseases of the Ovary.—Ovaritis is an inflammation of the ovary, rarely primarily diseased but usually secondary to tubal inflammation, which results in adhesions between both structures producing a condition spoken of as "diseased adnexa" or sal- pingo-oophoritis. The symptoms are similar to those of salpin- gitis and the treatment employed is the same. New Growths.—Cysts.—More than any other organ, the ovary is apt to give rise to cysts and cystic degeneration. The cysts may be of small size, or grow to enormous dimensions weighing more than twenty pounds. They may be filled with a clear viscid fluid or with other cellular materials. Types of the last named variety are occasionally called cystadenomas. Cer- tain of these tumors, if their contents are spilled over the peri- toneal cavity, will cause secondary tumors acting much like malignant growths. Dermoid Cyst.—These are tumors which contain remnants NURSING OF THE REPRODUCTIVE SYSTEM 115 of the epidermis, such as hair; in addition bone is often found as well as other tissues. Carcinoma.—The ovary may be the seat of carcinomatous tissue and cancers of the ovary are frequently malignant, metastasizing early. Treatment of Cysts.—In the case of simple cysts, only part of the ovary affected may have to be removed, or if the entire ovary is filled with many small cysts, a complete oophorectomy may be performed. It is highly important that cysts of the ovary be delivered intact. Every effort should be made to preserve their integrity, for occasionally a cyst may be of the adenomatous variety, and if accidentally ruptured, the fluid escapes into the general peritoneal cavity and implantation growths take root. In carcinoma of the ovary, the treatment, of course, is extirpa- tion with subsequent X-ray or radium treatment. The general outlook of patients with ovarian carcinoma is indeed poor. The Testicle.—This is the male organ of generation and cor- responds to the ovary. It consists of the testes proper which manufacture the spermatozoa, and the epididymis which is really a series of canals collecting the sperm from the glandular substance of the testes. These tubules, or canals, unite to form a single duct, the vas deferens, which carries the testicular product to the seminal vesicles, small pouches situated behind the prostate which open into the floor of the prostatic urethra together with the openings of the prostate gland. The prostate gland lies in front of the bladder surrounding the prostatic urethra and secretes the fluid which nourishes the spermatozoa and gives the seminal fluid its characteristic qualities. While the great majority of these cases will be handled by orderlies and trained attendants, circumstances may arise which will necessitate that they be cared for by skilled nurses. Acute Inflammation of Testicle and Epididymis.—Probably the most common cause of the acute inflammation is gonorrhea affecting the epididymis mainly, although it may be secondary to certain chronic diseases such as gout, or trauma from urethral instrumentation. Symptoms.—There are pain, swelling, tenderness of the epi- 116 TEXTBOOK OF SURGICAL NURSING didymis, and systemic symptoms of anorexia, fever, and general malaise. Treatment.—The patient is ordered to bed, and the testicle is elevated by placing beneath the scrotum broad strips of adhe- sive plaster which are fastened to the shaven thighs. Local applications to the scrotum may be made in the form of heat or cold. Probably the application bearing heat which is lightest in weight is the flaxseed poultice. If ice is used it should not be left on continuously, but on for two hours and off for one. An enema should be given daily, and the patient forced to drink water in large amounts. When the condition is due to gonorrhea, the patient should be placed upon individual precaution. After the acute symptoms have subsided, the patient may be allowed up, but the scrotum should be firmly supported by a suspensory for some time. Chronic Inflammation of Testicle and Epididymis.—These are secondary to acute inflammations, or due to syphilis or tuber- culosis. If syphilitic in nature the patient is given antisyphilitic treatment in the form of mercury and salvarsan. If tuberculous, the best procedure is operative. Symptoms.—The pain is not so severe as in acute inflamma- tions. In the cases of tuberculosis, there may be a sinus in the scrotum discharging pus from the diseased epididymis. Treatment of Tuberculosis.—Tuberculous epididymitis, when only one side is involved, is treated by orchidectomy (excision of the affected testicle). These cases require no special nursing (care except that they should be placed upon individual precau- tions and kept out in the open air as much as possible. Hydrocele.—Lying in front of the testis and epididymis there is a small sac called the tunica vaginalis. This may become filled with fluid causing a hydrocele of the tunica vaginalis. As a rule it is not painful but uncomfortable because of its mere mechan- ical presence. Palliative Treatment.—In this procedure a needle or a trocar and canula are inserted into the hydrocele sac and the fluid withdrawn. After most of the water has been tapped, some surgeons reinject an irritating fluid, such as a mild solution NURSING OF THE REPRODUCTIVE SYSTEM 117 of carbolic and iodine, trusting that the irritation will cause the obliteration of the sac of the tunica vaginalis. Operative Treatment.—The operative procedure may be done under novocain. The scrotum is washed with green soap, alco- hol and ether. The skin of the scrotum is anesthetized. The dis- tended tunica is delivered into the wound, incised, part of it cut away, and the remainder sutured behind the testicle proper, destroying the sac. Post-operative Treatment.—The scrotum is supported upon a bridge and a moderate amount of pressure is applied to it to prevent post-operative bleeding. Varicocele.—Lying in the scrotum along with the spermatic cord is a plexus of veins. These very often become hypertrophied or increased in size and number, occasionally causing pain and a dragging sensation in the scrotum. This may be remedied by partially excising the veins through the scrotum, or just above the external abdominal ring. The only post-operative care is the support of the testicles by an adhesive bridge, and the wear- ing of a suspensory bandage subsequently. New Growths of Testicle:—The testicle, like the ovary, may be a location for cysts, spermatocele, dermoids, or carcinoma. In the cases of cancer, a radical excision of the testicle together with the vas deferens and the lymph glands draining these regions is performed but the operation is attended with very much shock, and the mortality is extremely high. Prostate.—One of the most common operations done upon the male genital tract is that of prostatectomy, removal of the prostate gland. This is performed for simple hypertrophy, or for cancer. It is known that the prostate consists mainly of three lobes, the middle coming into close relationship with the urethra and the lateral lobes coming into relationship with the rectum. When the prostate increases in size, it follows the path of least resistance and projects into the bladder, and the increase in the size of the median lobe interferes with the free passage of urine because it obstructs the internal opening of the urethra. This results in frequency of urination, then urinary retention which must be relieved by a catheter, and from frequent catheteriza- tions a condition of cystitis is very often established. The 118 TEXTBOOK OF SURGICAL NURSING suffering is quite severe, and the only measure affording perma- nent relief is the removal of the obstruction (prostatectomy). Prostatectomy.—This operation is often preceded by a period of improving the patient's nutrition, and his urinary output by regular catheterizations. The operation resolves itself into a choice of perineal or suprapubic prostatectomy. Perineal Prostatectomy.—The perineum is shaved and eight hours before operation the usual soapsuds enema is given. The patient is placed in a lithotomy position with the pelvis raised by sandbags and the prostate is enucleated through the perineum. Post-operative Treatment.—The retained catheter is con- nected to bottle drainage and the urine collected. The gauze tampon which usually occupies the space of the removed pros- tate is taken out on the fifth day; the catheter is removed on the seventh, and from then on the urethra is treated with sounds of various sizes. Suprapubic Prostatectomy.—In this procedure the prostate is removed through the bladder. It is done in two stages. The first operation is a suprapubic cystotomy, the second the actual removal of the gland through the previous bladder wound. First Stage:—As a rule, catharsis is given forty-eight hours previous to the day of operation. Before operation the bladder is irrigated and often some novocain or alypin is injected. The bladder is kept distended and the cystotomy is done under local anesthesia. A button drainage tube is placed in the opening of the bladder and the tube clamped. When the patient arrives in his room the clamp should be removed from the tube and the bladder drained continuously, or intermittently. The diet should be very light and soft, fluids allowed in liberal amounts. Second Stage:—While some surgeons proceed to enucleate the prostate immediately after cystotomy, the majority wait five or more days before completing the operation. Naturally there will be rather a profuse hemorrhage following the blunt dissection of the gland. This may be controlled by tampons, but a better result is obtained if a bag hemostat is used. This is made of rubber, is inflatable and when distended and placed within the bladder exerts pressure on the bleeding areas. One NURSING OF THE REPRODUCTIVE SYSTEM 119 connection of the bag passes through the urethra, and is the means by which air is introduced. This is removed in twenty- four to forty-eight hours. The suprapubic wound is freely drained, and at the end of forty-eight hours a button tube is inserted, connected to the bottle drainage and the patient allowed out of bed. At the end of a week the patient is encouraged to void, and as soon as he does so in sufficient amounts, the suprapubic tube is removed. Of course, the urine will leak in small amounts, but the sinus is healed in from the thirteenth to the twentieth day. Cancer of Prostate.—In the early stages this is treated by prostatectomy. In the late periods, radium is tried as a pallia- tive procedure. CHAPTER IX THE SURGERY AND SURGICAL NURSING OF THE RESPIRATORY SYSTEM The organs which constitute the respiratory system may be classified as the accessory and the main groups. rnares Accessory System: 1. Nose4 septum ^sinuses 2. Mouth Cnasopharynx 3. Pharynx|oropharynx Main System: 1. Larynx 2. Trachea 3. Bronchi 4. Lungs and Pleura The mouth and pharynx are discussed under the Alimentary System. Nose.—The nose serves the very important function of filter- ing, warming, and moistening the air. In addition to aiding the sense of smell, it also gives the voice some of its qualities. The diseases which affect the nose are many and well known. The only pathological conditions of interest here are those resulting from obstruction from a deviated septum or hyper- trophy of the turbinates (bones in the nares) and infections of the various sinuses. Deviated Septum.—In this condition one or both sides of the nose are occluded by a deformity of the nasal septum, and an attempt is made to remove the obstructing cartilage by a sub- mucous resection preserving the mucous membrane of the sep- tum. After the operation has been completed, each nasal cavity is packed with strips of sterile gauze. The packing is removed after twenty-four hours. 120 NURSING OF THE RESPIRATORY SYSTEM 12l Hypertrophy of the Turbinates.—The turbinates are small bones, three in number, found along the outer wall of each nasal cavity. Occasionally these increase in size and obstruct free respiration. They may be reduced by chemical irritants, cautery, or partially removed by cutting them with a wire snare. Occa- sionally, hemorrhage may follow the removal of part of the turbi- nate bones. This may be controlled by spraying in some adrena- lin solution, syringing the nose with hot water (temperature about 120 degrees) or plugging the nose with cotton. Most of these operations are done under novocain. Sinusitis.—The sinuses of the nose may be frequently in- volved during a cold, and very often the frontal, ethmoidal, sphenoidal sinuses, or the antrum may be the seat of infection. This condition is recognized by pain in the region of the sinus involved, discharge, and tenderness on pressure over the sinus. The treatment consists in establishing free drainage. In the case of the antrum of Highmore, this is done by punctures of the sinus and daily irrigations through the nose. The Larynx.—Those conditions affecting the larynx which are of interest from a surgical viewpoint may be divided into the foreign bodies lodged in the larynx, and new growths. There are many other conditions, such as acute and chronic inflamma- tions, syphilis and tuberculosis, which require attention, but they fall into the provinces of the laryngologist, and he person- ally gives most of the necessary treatments. Foreign Bodies.—The most common way for foreign bodies to lodge either in the larynx, or further down in the trachea, is for the individual to swallow them. The symptoms which are produced will vary according to the size of the body and its location in the respiratory tract. Sometimes they are expelled by coughing; at other times they may remain. Cases are not rare in which the material has been of sufficient bulk to occlude the larynx, with death immediately ensuing from asphyxiation. Treatment.—Slapping the patient on the back, or inverting him may dislodge the foreign body. Or, if the patient is not so fortunate, it may be removed with forceps under direct vision, or either a Killian or Jackson laryngoscope may be necessary. These are instruments designed to enter the larynx. The 122 TEXTBOOK OF SURGICAL NURSING pharynx and larynx may be cocainized, or the patient may be placed under deep anesthesia. The laryngoscope is passed through the mouth and pharynx into the larynx, the head and neck being bent backward, and the foreign body removed through the instrument. Occasionally, the condition is so urgent that to relieve the asphyxia, an opening must be made into the trachea below the point of obstruction, so that air may enter the lungs. This opening of the trachea is spoken of as tracheotomy. Tracheotomy.—A tracheotomy is an incision into the trachea in order that a tube may be introduced therein, thus pro- viding for the entrance and exit of air. This may be done either as an emergency measure following a thyroid operation in which the trachea has collapsed, when a foreign body has become lodged in the larynx so that respiration is embarrassed, in acute edema of the glottis, or in obstruction asphyxia during the adminis- tration of an anesthetic. It may be employed as a preliminary measure to a removal of the larynx for cancer. The operation is either high or low, the high being preferable, because the trachea is more accessible; the low being done when the operator has to reach a foreign body which has fallen into one of the bronchi. Operation.—The patient is placed upon the back with a sandbag underneath the neck so as to make the trachea as promi- nent as possible. An incision is made in the midline, the mus- cles separated, the trachea exposed, incised, and a tracheotomy tube introduced. These tracheotomy tubes are of various types, but the one generally used is similar to Fig. 16. It is very important, after the tube has been introduced, to see that it is patent, and that respiration is taking place freely. As a pre- caution, tape is usually threaded through the tube so that it will not slip down the larynx in any disorder which might ensue. Inasmuch as the outer tube comes into direct contact with the skin, it is a good plan to have a fine layer of gauze covered with boric ointment inserted between the tube and skin. Post-operative Treatment.—The tracheotomy tube is a new passage through which air is drawn into the lungs, and since the air is no longer brought through the normal channels, it is NURSING OF THE RESPIRATORY SYSTEM 123 important that above all the tube should be kept patent and clean. In order to ensure perfect cleanliness and free respira- tion through the tube, nurses must be on duty day and night ever alert to see that the patient has plenty of air. The inner tube should be removed about two or three times a day, cleansed, sterilized, and gently reinserted. It should never be cleaned in situ, i. e., as it rests in the patient's trachea. If at any time the tube should become suddenly plugged, the inner tube must be withdrawn immediately. At times the patient is apt to cough, and the mucus which makes its appearance at the orifice of the tube should be wiped .'E away very gently. Occasionally from i!flr^s. — ft coughing violently both the inner and outer VVvS Jl tubes may be expelled, and for this reason /V^j— c it is always important to keep a trache- / /* otomy dilator on hand to meet this im- ^S / ' portant emergency. This instrument will \^K keep this passage open until another tube \ may be obtained and inserted. FlG 16._Tracheot. Another important thing in these cases omy Tube. A, outer is to remember that the air which is now $&'• t*be!nn£ "SfeJ inspired no longer has the advantage of guard; D, catch to hold u • t t n t n -, inner tube in place; E, being warmed and freed from dust by the slot through which tape nasal passages. For this reason in the m*y. be tie/ .t0 ,hold . safety guard in place. beginning, thin layers of gauze which have been wrung out in warm water should be placed over the trache- otomy orifice and changed every half hour. Some surgeons keep the patient under a croup tent so that the air may be warmed by the steam and the respiratory tract have the advan- tage of a warmed air. Compound tincture of benzoin may be added to the croup kettles. There are very few conditions which require more conscien- tious nursing than do these patients, because their life is abso- lutely dependent upon the uninterrupted inflow and outflow of air through the tube. They should never be left alone, for one never knows at what moment the tube may become plugged and the patient become suddenly asphyxiated. Occasionally mucus may collect in the trachea and not be expelled through 121 TEXTBOOK OF SURGICAL NURSING the tube. The reason for this is that the cough is insufficient in strength to expel the mucous plug. In these conditions a steril- ized feather might be introduced through the tube and the trachea tickled, so as to incite coughing. The time for the per- manent removal of the tube is purely at the discretion of the surgeon. Very often some surgeons will remove the double silver tube and replace it by a rubber one, then remove the rubber one when they see fit. New Growths of the Larynx.—The larynx, like the other organs in the body, may be the seat of benign or malignant growths. Probably the most common of the benign growths is the papilloma. These growths may be removed in three ways: through the larynx with the aid of the laryngeal mirror; from without by performing a thyrotomy (an incision through the thyroid cartilage of the larynx), or through a Jackson or Killian laryngoscope. The instruments used for their removal may be the snare, curette, forceps or galvano-cautery. Malignant Growths.—The symptoms of a cancer infiltrating the larynx may be very similar to those produced by the benign growths. Hoarseness, later loss of voice, respiratory difficulty, and pain are very common. Later when the growth extends and ulceration becomes evident, cough and pain on swallowing may be very evident. The only treatment is surgical. Either one- half or the entire larynx may be removed. Laryngectomy.—As the name implies the operation is one in which the larynx is excised. The operation itself is preceded by a tracheotomy. This may be done as a preliminary operation one day, the remainder of the operation being performed at another time, or the entire operation may be done at once. Operation.—The first part of the procedure is practically the same as a tracheotomy except that the trachea is blocked by the use of a Halms canula. This is done to prevent the blood from the laryngectomy from leaking down the trachea into the lungs. The canula is simply a tracheotomy tube which has been previ- ously boiled and to which is attached and securely fastened a sponge squeezed dry and dipped in a ten per cent, ether solution of iodoform. The sponge has been previously sterilized by soak- ing in a 25 per cent, alcohol solution for several days. The NURSING OF THE RESPIRATORY SYSTEM 12,1 tube with the sponge is introduced dry. After it is in the trachea from five to ten minutes there is usually enough moisture gener- ated to swell the sponge and block off the larynx above. The technic of the operation is unimportant. The Halms canula is taken out after eight hours and the tracheotomy tube introduced. Post-operative Treatment,—Since the larynx has been re- moved and the pharynx has just been sutured, it is highly impor- tant that the patient be fed for the first few days by rectum. For the next four to five days feedings should be administered through the nose by catheter, and within a week as a rule, the patient is able to swallow. Of course, in the beginning, only soft diet should be allowed. These patients are very much depressed because of the loss of voice, but they soon learn to whisper and make themselves understood. Injuries to the Thoracic Wall.—Injuries to the thoracic wall may be the result of bullets, stab wounds, or compound fractures of the ribs. The latter occur quite often following severe com- pressions of the chest, such as occur in "run-over" accidents. ^Vounds of the chest may be superficial, involving skin and muscle, or deep, penetrating the pleural cavity. The dangers of the last named variety are the complications of pneumothorax (air in the pleural cavity with collapse of the lung), hemo- thorax, a condition in which the pleural cavity is filled with blood due to injury of the blood vessels of the lung itself; or, the possibility of a superimposed infection of the pneumothorax (pyopneumothorax). Treatment of Injuries to the Thoracic Wall.—This is usually surgical in nature. The wound is thoroughly cleansed and the hemorrhage controlled. If any of the ribs have been fractured, they are securely strapped and the patient kept in bed for a few days. Many of these cases, especially those with deep, penetrat- ing wounds, develop serious complications, such as pneumonia, or infection of'the pleural cavity (empyema). Empyema.—One of the complications that may occur in chest conditions is empyema, an infection of the pleural cavity. This is usually the result of a pneumonia and rarely occurs as a primary condition. Symptoms.—The patient gives a previous history of pneu- 126 TEXTBOOK OF SURGICAL NURSING monia, as a rule. After the pneumonia has resolved, or even before this period, a sudden rise in temperature may occur, accompanied by fever, chills, and the physical signs of fluid in the pleural cavity. This collection of fluid or pus may be general in nature, or localized (sacculated). As pus in other parts of the body usually requires drainage as soon as it is formed, here also an attempt should be made to remove it. Treatment.—While it was customary before the war to re- sect a rib and insert a drainage tube into the pleural cavity as soon as a diagnosis of empyema was made, army experience has taught that such radical procedure is not always necessary. In fact, in the beginning, it is better to draw off the fluid which has accumulated with a needle and syringe, or Potain aspirator, thereby relieving the patient, and at the same time, reducing certain elements which might lessen the shock at the time of the future operation. It is also true that some of the patients recover with this simple aspiratory procedure, although the great majority must have a more radical operation performed sooner or later. The more radical procedure consists in the partial excision of one of the lower ribs so that better and more adequate drainage may be secured. Operative Treatment.—Inasmuch as these patients are in a weakened physical condition from their pneumonia, or from the absorption of the poisons of the pus in the pleural cavity, it is advisable not to administer a general anesthetic, but to employ local anesthesia. This works with remarkable success. Since the patients feel more comfortable when sitting almost upright, the operation is performed in this position. An aspi- rating needle with syringe locates the area of pus; its location is the determining factor as to which rib is to be partially resected. In general empyema or suppurative pleurisy, the incision is generally made along the eighth or ninth ribs. A part of the rib is removed subperiosteal^, exposing the periosteum beneath which is the outer surface of the pleura. The pleura is then opened by incision and the pus allowed to gradually escape. A drainage tube is then placed into the pleural cavity. There are many ways of draining the thoracic cavity. Some employ a Brewer tube (Fig. 17) ; others a simple rubber drain- NURSING OF THE RESPIRATORY SYSTEM 127 age tube. In empyema cases, great care should be taken that the number of drainage tubes used be carefully noted and recorded. The pleural cavity is a notorious hiding place for them, and very often a lost tube is the reason for a persistent sinus con- tinually discharging large quantities of pus. After Treatment.—Inasmuch as the discharge from the pleural cavity is moderately free, very often the drainage tubes are connected with bottle drainage. Occasionally, when a Brewer tube is employed, a piece of rubber dam is snugly fitted around the free end of the drainage tube, and the open end of the dam is placed in a bottle under a water level so that while the pleural fluid may escape from the chest no air can enter the pleural cavity. The result of this is that a negative pressure is soon established, the lungs expand earlier, and the patient's convalescence is shortened. The discharge is rather copious for the first few days and superficial dressings must be changed and reinforced whenever necessary. After a few days the tubes within the chest are gradually shortened, and as soon as the discharge is very thin and the temperature is normal, the tubes may be withdrawn alto- gether. "While the patients are in bed, they should be encouraged to breathe as deeply as possible so as to aid the expansion of the collapsed lung. With this end in view, they should blow fluids from one bottle into another, and children should be given those toys which encourage blowing, such as horns or balloons. If the temperature suddenly rises after the drainage has been removed, it simply means a reaccumulation of fluid in the pleural cavity, and necessitates an immediate reinsertion of the tube. These patients should be allowed out of bed as soon as possible, and wheeled into the open air. If the weather is clear, their beds might even be moved into the open. The diet should be high in Fig. 17.—Brew- er Empyema Tube. A, Kubber Disc resting tightly against parietal pleura; B, rubber disc resting tightly against skin; C, rubber tube con- nected to bottle drainage. 128 TEXTBOOK OF SURGICAL NURSING carbohydrates, and tonics should be given to restore their lost strength. The Lungs.—The surgery of the lungs is still in its early stages of development, and the operations done upon these essential organs of respiration are but few in number. This is due to the mechanical difficulty of approach and exposure through the thoracic wall, and because of the difficulty of main- taining the potential negative pressure during an operation. The latter normally exists between the parietal pleura lining the interior of the thoracic wall and the visceral pleura which covers the lungs themselves. In the various phases of respira- tion, the parietal and visceral pleurae are continually in con- tact ; but should, for some reason, the air from the outer world enter this space, either by rupture of the lung tissue itself or through the thoracic wall, the negative pressure will be destroyed and the lung will collapse. A large space filled with air will thus be left between the parietal and visceral pleura. If this is remem- bered it will not seem strange that pleural and lung conditions take such long periods of time to return to normal after opera- tion, for the infection of this large rigid cavity must be sterilized, the air within the chest absorbed, and the lung permitted to expand with the reestablishment of the negative pressure. Operations upon the Lungs.—There are several indications in surgery for operations upon the lungs themselves. Occasion- ally, it is advisable to remove a lobe of the lung because of some extensive infective condition, such as an abscess. As already mentioned, the normal thoracic cavity is under negative pressure, and when an opening is made communicating the pleural cavity with the external world, this negative pressure is destroyed, the lung collapses and expansion is impossible. There are two methods which aim to overcome the collapse of the lung. One is to do the operation in a chamber which is under negative pres- sure so that there is practically no difference between the nega- tive pressure in the pleural cavity and the negative pressure in the room. By the other method, the air is under increased pressure and is introduced within the lung so that the lung is kept expanded even though the negative pressure within the thorax is destroyed. NURSING OF THE RESPIRATORY SYSTEM 129 Methods for Maintaining Negative Pressure.—This may be accomplished by two main methods. The operation may be performed in a special negative pressure chamber. The rooms were designed by Sauerbruch, and are portable. By the other method, the ordinary operating room is converted into a nega- tive pressure chamber, the patient's head being passed through an opening in the wall, so that it is under positive pressure, while the thorax and the rest of the body within the room itself are under the negative. The negative pressure used is from eight to ten millimeters of mercury. Positive Pressure Method.—This method consists in keeping the lungs expanded by forcing air under pressure into them through the trachea. A catheter is passed through the mouth into the trachea and a stream of warm air under pressure mixed with vaporized ether is forced through by means of a pump. This is successful, and does not require as much time or prepara- tion as the negative pressure variety of operations. Foreign Bodies in the Lungs.—Very often foreign bodies be- come lodged in the lungs, if they pass the trachea and bronchi without being obstructed; they may be localized by means of the X-ray if the body is opaque, or with the bronchoscope, an instru- ment for looking directly into the bronchi. Quite often they may be removed through these instruments or, in very rare instances, the lung may be incised to remove the foreign bodies. Pulmonary Tuberculosis.—While this does not come under the general surgical field, still the surgeon very often is called upon to inject air into the pleural cavity to cause the collapse of the lung. The purpose is to give the lung a rest by collapsing it with the hope that the increased circulation may conquer the tubercular infection. The gas, which is purified nitrogen, is introduced by means of a needle. CHAPTER X THE SURGERY AND SURGICAL NURSING OF THE SKIN AND APPENDAGES Surgical Conditions Involving the Skin.—A wound may be defined as a discontinuity of tissue. It may be superficial or deep, clean or contaminated, accidental or intentional. For purposes of classification, wounds may be divided into abra- sions, contusions, punctures and lacerations. When the surface layers of the epithelium are scraped away, the wound is spoken of as an abrasion; when they have been destroyed by some pressure, but yet not actually removed, a contusion results; a punctur'ed wound is the type left by a nail or awl; a laceration is caused by the deeper layers of the skin together with the epithelium being torn. All these wounds may be clean or in- fected. If they are clean they will heal in the manner de- scribed in Chapter II. If they are infected by bacteria, the various sequellae which have been already outlined may ensue. Treatment.—Hemorrhage should be arrested first; then any foreign material which may be present is removed, and the wound sterilized and protected from any further contamination by a dressing and bandage. In most wounds, hemorrhage may be arrested by simple pressure, provided that no deep blood vessels are cut. This pressure should be applied directly over the bleeding surface, the material used being any sterile gauze, or in emergencies, a freshly laundered handkerchief. Should the bleeding still be profuse the measures outlined in Chapter III may be tried. After the bleeding has been controlled, the wound should be cleansed by simple irrigation with sterile water or a weak solution of iodine. Antiseptics.—The application of iodine to a bleeding sur- face is of little avail, for it has been definitely proven that iodine here has little or no effect. Tincture of iodine on a dry 130 NURSING OF THE SKIN AND APPENDAGES 131 surface is indeed efficacious and all lacerations, even though the infection be doubtful, should be thoroughly iodinized. In the application of iodine to abrasions, it must be remembered that if more than one coat is given, it is very apt to burn the skin. Thoughtless painting and repainting of small abrasions occurring in the tender skin of children or women may result in a burn which is much worse than the original injury. Some surgeons prefer to use peroxide of hydrogen. All wounds which have come into contact with manure and dirt should be cleansed first with peroxide of hydrogen and then iodinized. Of course, the number of antiseptics used are many, but experience has shown that while some antiseptics certainly kill bacteria, they may destroy the tissues themselves, and occasionally poison the individual. Because of this, bichloride of mercury and carbolic acid have fallen into disrepute. They possess extremely irri- tating properties and there is always danger entailed in their use. The popular antiseptic at present is one which has been developed during the war and which has had such wonderful success in the sterilization of wounds. It is the Dakin solution and a complete discussion of it will be found in Chapter XIX. After the bleeding has been stopped, and sterilization has taken place, the wound should be protected from foreign ma- terials such as dirt or bacteria. Sterile gauze is applied, either dry or greased with some sterile ointment (boric acid, vaseline, or liquid albolene), to prevent it from sticking to the wound. The dressing may be held in place by strips of adhesive plaster or a bandage, whichever suits the location of the injury the best. All dressings should be made as small and inconspicuous as possible both for cosmetic effect and reasons of economy. Lacerated Wounds.—Wounds which gape considerably are sutured because the period of healing and the amount of scar tissue are thus lessened. The material used for the suture of wounds may be horsehair, silk, silkworm gut, plain, or chromic catgut described in detail in Chapter XV. For wounds of the face, horsehair is the material of choice on account of its fine tex- ture. For deeper wounds, material possessing a greater strength, either silk or silkworm gut, is used. The needles employed are full curved, or straight, small Hagedorn type. Care should al- 132 TEXTBOOK OF SURGICAL NURSING ways be taken that the eye of the needle is patent and the cutting edge keen and sharp. Needle holders should always accompany needles. The type of holder depends upon the idiosyncrasy of the surgeon. To summarize then: The arrest of hemorrhage, the cleansing and sterilization of the wound and its protection from infection are the essentials in the minor surgical proce- dures involving the skin and deeper tissues. Nurses are always expected to have those things prepared which are necessary for the fulfillment of these essentials. Infected Wounds.—If a wound is infected, the aim of the surgeon is to liberate the pus, establish its free drainage, steril- ize the wound and convert an infected into a clean one. To obtain free drainage, an incision is made, or in a recently sutured wound, a few sutures are removed, and to aid the free escape of pus, a drain is inserted. In small infections the incision is done under local anesthesia with a knife (scalpel). Knives should always be sharp and keen as razors. Drains are the handiwork of a nurse and their manufacture should be clearly and thoroughly understood. The types of drains and their method of preparation are described in detail on pages 310-311, Chapter XVII. AVhile the drainage secures the escape of pus, its freer exit is promoted by the use of wet dressings or dry heat. Wet Dressings.—The means of keeping dressings wet are many. The dressing may be wetted and then covered with oil skin or rubber tissue to prevent evaporation; or a sterile solu- tion may be poured upon the wound through the dressing every so often; or the dressing may be kept continually moistened by a warm saline drip or continuous immersion in a water bath. Infected wounds which are treated with Dakin's solution re- quire special technic (see Chapter XIX). In all wet dressings the nurse should take particular care that the fluid is applied to the wound and the wound only, and that the surrounding skin does not become macerated or injured. Suction Drainage.—Very often to secure better drainage, gentle suction may be applied to the end of the tube, using either the water siphon method or the suction machine. Siphon Drainage.—One end of a Y-tube is attached to the drainage tube and another to the moving column of water from NURSING OF THE SKIN AND APPENDAGES 133 an elevated tank or a faucet. This is arranged so that the flowing water will exert suction and carry off with it drainage. The disadvantage in case a tank is employed is that water must be continually supplied to keep up the siphonage. Dry Heat.—Some surgeons, instead of using moist applica- tions, prefer the use of dry heat. It should be remembered that in extensive wounds the nerves are often destroyed and sensa- tion is lost, so that all warm applications should be tested first by the hand of the nurse before the heat is applied, for a burn in- flicted on any patient is unpardonable. Heat may be applied by hot water bottles, hot poultices, the electric coil or electric pad. These may be applied intermittently or continuously. For the continuous application the best form is the electric coil, as the degree of heat may be regulated and kept fairly constant. Baking a suppurating wound is also occasionally employed and at times found very helpful. Probably there is nothing which gives so much relief as poultices, because they are light in weight and are easily adaptable to the region required. The most common poulticing material is flaxseed, although there are many proprietary compounds which are equally good and less trouble- some. Inasmuch as poultices are very apt to lose heat rather rapidly, the electric coil or a hot water bottle should be super- imposed. Mustard plasters are rarely used in surgical nursing, because if improperly applied, they burn the skin, and they can- not be used continuously. Packing.—When the cavity is rather large, and when heal- ing must take place by granulating from the bottom, the wound must be packed. Packing a wound is also an aid to drainage. The materials used must be sterile, absorbent, soft and of such nature that they will not shed their threads nor flood the wound with foreign bodies. It is of prime importance that the nurse carefully observe the packing of wounds, noting particularly the number of pieces inserted into the cavity. Most packing requires changing in from twenty-four to forty-eight hours be- cause it becomes foul-smelling and acts as a dam rather than a drain. The width of the packing is dependent upon the depth and diameter of the wound; and whether it should be plain, 134 TEXTBOOK OF SURGICAL NURSING or medicated with iodoform or bismuth is a question decided by the surgeon. Treatment of Healing Wounds.—When the discharge and induration of an infected wound becomes less, the surgeon will begin reducing or removing the drainage, and will apply medi- cations to stimulate granulation tissue. Granulation tissue may be stimulated chemically or physically. Weak solutions of silver nitrate or the actual caustic stick are sometimes used; balsam of Peru is very valuable. The size of the wound may be reduced by drawing the adjacent edges together with adhesive plaster; and, at times, strapping the granulating areas with sterile adhe- sive plaster will stimulate the granulations and also the surface epithelium to growth. Secondary Suture.—Since the absolute sterilization of in- fected wounds by the Dakin method is possible, secondary suture of granulating wounds is done very often and has proven quite successful (see Chapter XIX). As soon as the wound has be- come filled with granulation tissue, the surface epithelium, or the skin itself begins to grow. If the area to be covered by skin is too great, and the resulting scar would be too big, a graft of skin may be resorted to. Skin-Grafts.—Skin-grafts are of three varieties,—Thiersch, Reverdin, and Wolf. Thiersch Graft.—The superficial layers of the epithelium are shaved off with a razor and planted over the wound, the grafts being rather large in size. Reverdin Graft.—In this type small thin portions of the su- perficial layer of the skin are snipped off with scissors, and placed upon the granulating wound. Wolf Graft.—In this variety, the entire thickness of the skin is utilized as a graft, or it remains connected by a pedicle to that part of the body from which it was taken, and after the graft is firmly attached the pedicle is severed. In all skin-grafts, the nurse must not forget to keep the part quiet and warm. In removing dressings, the utmost care should be observed for fear of disturbing the graft itself, and as in all surgical procedures, the best aseptic technic should be main- tained. NURSING OF THE SKIN AND APPENDAGES 135 Burns.—While a French surgeon originally divided burns into six degrees or stages, according to the depth to which the injury penetrated, it will really suffice for nursing purposes to divide them into three. The agents which produce burns are many. Heat in the form of solids, liquids, or steam; chemicals, such as strong acids,—for example, carbolic, acetic, hydro- chloric ; powerful alkalis, such as sodium hydroxide, chloride of lime; special agents, such as X-ray, electrical currents and radium when not properly used may all cause very severe burns. Closely allied to those burns caused by heat are those due to the action of cold either from exposure to low temperatures, such as frostbite, or those resulting from actual contact with 3old substances in the form of ice, snow, or liquid air. The pathology and clinical appearance of all burns are es- sentially the same regardless of the agent inflicting the injury, but the degree varies. First degree burns are recognized as those in which there is redness, with some pain and swelling, followed by a scaling of the skin. If the redness is of a greater degree, blisters appear; this is a second degree burn. All other burns might be classified as third degree. They vary from definite charred areas to those cases in which an entire limb or more is involved. The symptoms which result may be classi- fied as local and constitutional. Local Symptoms.—There is a marked inflammatory reaction of the parts adjacent to the burn followed soon by sloughing of the charred or injured tissues and, finally, after the wound has been cleansed and the granulations are vigorous, healing ensues. During the first and second periods, there is considerable ab- sorption from the products of destroyed tissue and the patient may suffer from certain constitutional complications; these may be very mild or so severe as to cause death. The causes of death following burns may be shock, poisoning from the charred tissues, or complications arising from infections such as ery- sipelas or sepsis. It should be remembered that extensive burns rather than limited deep ones are the more serious, and that children with skin burns averaging more than one-third of their body are apt to die from the effects. 136 TEXTBOOK OF SURGICAL NURSING Treatment.—The treatment of burns may be grouped under two heads,—local and general. General Treatment.—In extensive burns there is often deep shock which should be treated immediately. The patient should be placed in the shock position. The body must be kept warm with hot water bottles and blankets. Fluid should be given either by rectum in the form of a Murphy drip, or in very severe depressed conditions, a saline infusion. If the pain is intense, morphia may be required. It occasionally happens that, to- gether with the burns, the patient suffers from poisoning of carbon monoxide gas. Carbon Monoxide Poisoning.—This is recognized by the great difficulty with which these patients breathe, the fact that their lips are a very deep red and their skin a bluish hue. The condition requires urgent interference. Treatment.—The blood must be rid of the excess carbon monoxide and its oxygen content increased. The patient may be given oxygen from a commercial oxygen tank by means of a funnel held directly over the nose and mouth. To prevent further loss of oxygen, a paper cornucopia may be fastened to the funnel. If the congestion of the patient is very extreme, blood may be removed from a vein in the arm. This reduces the actual blood content of carbon monoxide, and then the pa- tient may be given an infusion of saline or a transfusion of blood which will still further decrease the amount of poisonous gas, Local Treatment.—First Degree :—If there is much smarting and pain, a paste of bicarbonate of soda, or cold cream, may be applied, and the burned area protected from the air. Second Degree:—When blisters or blebs are present, they should be opened by puncture with a sterile needle and the serum removed. After this, sterile vaseline or boric ointment may be applied. Third Degree:—If the patient has rather extensive burns, and the clothes covering the skin have been destroyed by fire, to prevent greater shock, it is better to give the patient anesthesia, remove the clothes, cleanse the burned areas very thoroughly with either copious washings of sterile saline, or bichloride in NURSING OF THE SKIN AND APPENDAGES 137 one to one thousand solution, followed by saline irrigations. Wet dressings of boric acid or sublimate in one to ten thousand solution may be used. These tmay remain undisturbed for forty-eight hours, if the patient is moderately comfortable. Some use sterile boric acid dressings and within recent years, picric acid in a saturated watery solution has gained favor. After the first two days, it is advisable to dress the cases daily, and as soon as the sloughs have disappeared, and granulations appear, the wounds may be treated as any healing type. When there has been extreme loss of epithelium the denuded areas may be supplied with skin-grafts. While some surgeons prefer wet dressings and some oint- ments, still others apply nothing, leaving the burn exposed to the open air. The burned area is protected from the bed linens by a cradle and the part exposed to sunlight for varying periods of each day. The air has a tendency to dry the part and later the granulations may be stimulated by the actinic rays of the sun. Then when all the sloughs have separated and the wound is filled with good red granulations, it may be strapped by the application of sterile adhesive over the granulations to stimu- late the surface epithelium; or the wound may be skin-grafted. After the wound has healed the later contractions of the scar tissue may result in a diminution of the normal function of the part; so early passive, and later active motion with massage should be given. Paraffin Treatment of Burns.—During the Great War com- batant troops were exposed to the terrors of gas attacks and the chlorine and mustard gas left their marks by horrible burns of a superficial and deep nature. The areas were treated by paraffin or a proprietary substance called ambrine. Ambrine is applied by a special apparatus which sprays the warm wax over the wound in a fine layer. The method is somewhat as follows: —The part is thoroughly cleansed, dried, and wrapped with a sterile towel. The ambrine is melted by the heat of either an alcohol lamp or Bunsen burner to a temperature of 50° C. In the meantime the water bath for the actual liquefied ambrine is filled with boiling water. The ambrine is poured into the container, the container telescoped into the water bath and the 138 TEXTBOOK OF SURGICAL NURSING atomizing arrangement is screwed over both. Then by air pres- sure the liquefied wax is sprayed over the part in a delicate, thin, even film, and the part covered with a fine cotton batting, and a bandage applied. The advantages of this method are painlessness of application, absolute sterility, formation of a soft splint-like dressing over the wounded area rendering it immobile and thereby diminishing pain. At the end of twenty- four hours due to the exuding serum, the wax layer with the thin cotton batting attached separates rather easily and pain- lessly. While this method requires much time and patience, the end results easily compensate for the trouble involved. It should always be remembered that the burned areas are portals of entry for the various pathological bacteria. Exces- sive care should therefore be taken to guard against infection. The application of unsterile home remedies, such as flour and water, olive oil, etc., is to be condemned. If a first aid dressing must be applied and there are no sterile supplies at hand it is better to cover the part with a freshly laundered, clean, dry towel until the proper material may be obtained. The Breast.—Diseases of the breast form a relatively im- portant chapter in surgery. In the main they are of two great varieties,—those due to inflammation and those due to new growth. Inflammation may involve either the nipples or the breast and may be acute or chronic. The Nipples.—Cracked or fissured nipples, often seen dur- ing lactation, are especially painful because the skin has become broken. They may form a portal of entry for the various microorganisms and thus give rise to infections of the breast itself, or, when the child suckles, it may swallow some of the diseased tissues about the cracked nipples. Treatment.—All nipples after nursing should be thoroughly but gently washed with boric acid, then dried and powdered with borated talcum. If fissures are present the child may nurse through a nipple shield, and in the interval the nipples may be treated with boroglyceride, touched with silver nitrate (solid) or painted gently with tannic acid. These measures suffice, as a rule, to bring the nipple back to its normal healthy status. Acute Mastitis.—Acute inflammations of the breast, known NURSING OF THE SKIN AND APPENDAGES 139 as acute mastitis, usually occur in women during the close of the lactating period. It is the result of improper hygiene of the nipples, although this may not always be the case. Symptoms.—The patient may complain of pain and heavy feeling in the breast, and, at the same time, redness, swelling, and areas of hardness may appear in certain parts of the breast. There are a rise in temperature, an increase in the pulse rate, loss of appetite, slight headache, and a feeling of general malaise. Treatment.—If pus has not yet formed, the breast is ele- vated with the bandage in such a way that it is firmly supported upward. (See Figs. Ill and 112, page 386.) This will do much to relieve the pain, but care should be taken that the binder is not applied too tightly. Nursing, as a rule, is discontinued, and if the breast throbs and feels distended, the milk may be expressed regularly either by gentle massage, the direction of the massage being a stroking motion from the circumference of the breast towards the nipple; or the milk may be aspirated by a breast pump. During the interval, either hot applications such as flaxseed poultices may be applied to the breast, or cold applications in the form of a magnesium sulphate solution of 50 per cent, strength. When pus is formed the abscess is opened by the attending surgeon and freely drained. After the acute suppurative process has subsided the drainage tubes are shortened gradually and the granulation tissue stimulated by silver nitrate. Chronic Mastitis.—This condition is not uncommon, and pre- sumably is due to a chronic inflammation of the breast. The patient complains of vague and indefinite pains localized in the breast itself, and, on examination, there may be found here and there some very small nodules which may be tender. At times the lymph glands in the axilla (arm-pit) show enlarge- ment; as a matter of fact this condition is frequently difficult to distinguish from cancer of the breast. Treatment.—Sometimes a well fitting breast binder will re- lieve much of the pain. If there is considerable induration or hardness of the tissue, warm fomentations may bring relief. Should these measures fail, most surgeons will remove that por- tion of the breast which is pathological. If at the time of opera- 110 TEXTBOOK OF SURGICAL NURSING tion it is thought that the condition might be cancerous, the entire breast and deeper tissues are removed. New Growths of the Breast.—As in other locations those tumors which invade breast tissue may be either benign or malignant. Of benign tumors of the breast, the most common are fibroadenomata; these occur mainly in young women; they are definitely encapsulated, freely movable, do not grow beyond a certain size, and cause no enlargement of the lymph glands of the axilla. Treatment.—The treatment is the excision of the growth, with occasional drainage of the space left by its removal for twenty-four hours. Carcinoma.—Carcinoma of the female mammary gland is rel- atively common. The rate of growth of the tumor cells will vary greatly. Any mass in the breast is strongly suspicious of car- cinoma if it occurs after the age of forty, and is hard, not defi- nitely encapsulated, and attached to the skin or deeper muscular layers. The glands in the axilla may be enlarged at a very early period. If the disease has lasted for some time the patient may be emaciated, pale, anemic and weak. Treatment.—The treatment is radical excision of the en- tire breast and the lymph glands which drain it. Inasmuch as some surgeons perform a rather wide excision, the skin of the patient should be prepared from beneath the angle of the jaw to the umbilicus, from well beyond the midline of the affected side to the region beyond the axillary border of the scapula (shoulder blade). This preparation, in the main, will consist of shaving the hair. Some surgeons prefer no pre-operative preparation of the skin other than that of cleansing it with green soap and water, leaving the iodine to be painted on in the operating room; others will have the skin cleansed with green soap and water, followed by alcohol, then ether, finally applying sterile dressings. Operation.—The anesthesia may be given either by the Bennet metliod or intranasally. A sandbag is placed beneath the shoulder blade of the affected side. (See Fig. 75, page 280.) The arm may be put out either at right angles to the body, straight, or at right angles and bent at the elbow to an angle NURSING OF THE SKIN AND APPENDAGES 141 of forty-five degrees. Inasmuch as many blood vessels are to be cut, there should be an abundance of hemostatic clamps and catgut ligatures. The surgeon will employ a drain, either the tube, or cigarette variety. After the operation, an abundance of dressing is applied, for there is apt to be a great amount of oozing. The arm, forearm, and hand, as a rule, are bound tightly to the chest. Post-operative Treatment.—As soon as the patient recovers consciousness she is given a backrest, so as to sit almost upright in bed. As a rule, a dressing is done at the end of twenty-four to forty-eight hours, and the drainage tube removed. At this dressing the arm is left free out of the bandage, and is held in a sling at right angles. The arm should be given passive movements carefully and gently, every two hours. The purpose of this is to diminish the adhesions during healing so that the scar will not limit the motion of the arm. Patients are allowed up at the end of a week, and in about six weeks after operation X-ray treatment is begun. This is used to kill some of the cancer cells which may have escaped the knife of the operator. Some surgeons at the time of opera- tion will expose the wound to radium for a certain period of time, doing the suturing later. Occasionally the arm may be swollen a few weeks after operation, but it may be lessened by massage and bandaging although sometimes in spite of this, the arm remains large, interfering greatly with its movement. CHAPTER XI THE SURGERY AND SURGICAL NURSING OF THE URINARY SYSTEM Anatomy.—The urinary system is composed in a normal in- dividual, of the kidneys, the ureters, the bladder and the urethra. The kidneys, usually two in number, are compound tubular glands. They are situated on either side of the spinal column in the region corresponding to the last two thoracic and upper two lumbar vertebra. The right kidney is at a lower level than the left owing to the presence of the liver on that side. As a rule they are about four inches long, two and one-half inches wide, and one and one-half inches thick. Each kidney is covered by a capsule. There are cases in which the kidneys are fused into one, the horseshoe kidney; or there may be only one kidney present. The ureters which connect the kidneys to the bladder vary from twelve to eighteen inches in length. The bladder, which is the reservoir for the urine, is situated in the pelvis behind the pubis. It is in front of the vagina in the female and in front of the rectum in the male. It is a muscular sac, and at its neck gives origin to the urethra. The urethra is about one and one-half inches long in the female, and eight to nine inches in the male. It courses beneath the symphysis pubis in a down- ward and forward direction; its external orifice in the female is situated between the clitoris and the vaginal opening. In the male it normally runs through the length of the penis. Diseases of the Kidney.—The inflammatory affections of the kidney may be either of the acute or chronic variety. The acute variety may involve the pelvis of the kidney (pyelitis), or there may be pus formation in the kidney itself (suppurative nephritis). If the pus is retained in the pelvis with a resultant dilatation, the condition is spoken of as a pyonephrosis. 142 NURSING OF THE URINARY SYSTEM 143 Of the chronic inflammations, the one which interests the sur- geon most is tuberculosis. Treatment of Acute Infections.—In pyelitis, the treatment is primarily medical. The patient is placed in bed; fluids are forced to about 2000 c.c. a day, and urotropin gr. 10, or more is given by mouth three times a day. If it is thought that the pyelitis is in some way due to a chronic constipation with a dilated caput coli, colon irrigations are especially indicated. Occasionally the pelvis of the kidney is irrigated directly through a ureteral catheter which has been introduced into the ureter by means of a cystoscope. This is an instrument designed to give a view of the interior of the bladder. It has the general shape of a sound, has a telescopic lens and carries an electric light to illuminate the interior of the bladder which has been previously distended with warm boric acid. It has several modifications and attachments so that small catheters may be passed into the ureteral orifices. By this means the urine from both kidneys may be collected separately, and the condition and functional activity of each kidney may be judged. In pyonephrosis, the kidney is incised in the region of the pelvis and the pus removed. This operation is spoken of as a nephrotomy. But if the kidney shows many areas of infec- tion, the so-called acute surgical kidney, it may be completely removed (nephrectomy). Operation of Nephrotomy.—The patient is placed in the kid- ney position. This is described in Chapter XVI—see Fig. 67. Post-operative Treatment of Nephrotomy.—Inasmuch as urine as well as pus will escape from the kidney through the wound, the dressings should be frequently removed and changed to prevent maceration of the skin. The patient is placed upon forced fluids, their amount carefully measured, and the urinary output approximately estimated. These cases are rather pro- tracted, lasting from six to eight weeks. The nutrition should be particularly watched and every effort taken to maintain or increase the patient's weight by a liberal diet, high in car- bohydrates. When they are allowed up, there is often a leakage of urine through the wound, and to prevent the embarrassment of a constant urinous odor, a lumbar urinal may be worn. 114 TEXTBOOK OF SURGICAL NURSING Nephrectomy.—When it is evident that the kidney has been destroyed to such a degree that it is of little use to the organism, it is much better to remove it completely. A nephrectomy is always done for the acute septic kidney, diffuse pyonephrosis, tuberculosis, or new growths, provided the physical condition of the patient will permit such an operation, and the other kidney is present and not markedly diseased. If the ureter is definitely pathological, it is dissected down until a healthy portion is found, or if the entire length is affected, it might be totally excised together with the kidney. Post-operative Treatment.—The treatment is similar to that of a nephrotomy. The drainage tubes are removed at the end of three or four days, and the patient is kept in bed for three to four weeks, until the wound has firmly and completely healed. Renal Calculus.—Renal calculi or kidney stones may be found in the substance of the kidney, in the pelvis, or in the ureter. The stones may be single or multiple, rough or smooth, and may be present in one or both kidneys. The symptoms which they cause are those of renal colic. This is a severe colicky pain in the loin radiating downward to the testicle or vulva. Blood is found in the urine (hematuria) and there is occa- sionally frequency and urgency with burning micturition. Treatment of Renal Calculus.—Patients who have a tendency to renal colic, as evidenced by a previous history of attacks, or the passage of small calculi, and whose urine contains an excess of urates, should be placed upon a diet which is poor in protein. Alcohol is absolutely prohibited, also tea and coffee. Alkaline drinks should be administered, and the alkaline diuretics, such as acetate, bicarbonate, and citrate of potassium should be given freely and often. Operative Treatment.—AVhen there is definite evidence of a stone from the clinical history augmented by positive radio- graphic and cystoscopic findings, operation is indicated, for it is the only measure which will insure permanent relief. The operations performed for kidney stones are two in number:— nephrolithotomy and nephrectomy. Nephrolithotomy.—In this operation the procedure is similar to a nephrotomy. The usual lumbar incision is made with the NURSING OF THE URINARY SYSTEM 115 patient in the kidney position (Fig. 65), the kidney exposed, and the pedicle, that is, the renal artery and the renal vein, are grasped by the hand of an assistant while the surgeon in- cises the kidney along the convex border. Under these hemo- static conditions the bleeding is very little. The calices of the pelvis and kidney tissue are carefully examined and the stone removed. The kidney is sutured together with mattress sutures of chromic catgut on a blunt, non-cutting needle. Post-operative Treatment.—The routine procedure in all surgical kidney cases demands that fluids be forced to the maximum. All the urine excreted should be accurately measured and saved for the inspection of the attending surgeon. The elimination must be especially watched, because after this opera- tion urinary suppression is apt to result. Should this unfortu- nate complication occur, those measures which are described in Chapter III should be instituted immediately. For a day or so the urine is apt to be bloody; this is not particularly alarming. During this period patients often complain of symp- toms simulating renal colic, due to clotted blood passing down through the ureter. The pain is easily controlled by small doses of morphine by hypodermic injections. Operations upon the Ureter.—The ureter may be incised to remove a calculus, or it may be removed for chronic diseases, such as tuberculosis. The nursing is the same as for kidney cases. Urinary Bladder.—The bladder may be the site of injury, acute or chronic inflammations, calculi, or new growths. Treatment of Injuries of the Urinary Bladder.—The bladder may be lacerated from external violence or in fractures of the pelvis. In all suspected cases the patient is placed under gen- eral anesthesia, the bladder is examined through the abdominal route, and, if injured, the damage is repaired by appropriate suture. As a rule, a drain in placed down to the injured area of the bladder to take care of any urinary leakage which may result. Some surgeons insert a permanent catheter into the urethra; others prefer to catheterize the patient every eight hours. In either case, great care should be taken that there be no undue intravesical tension. Fluids should be administered 146 TEXTBOOK OF SURGICAL NURSING liberally, and during the first week, urotropin gr. 10, or more is given. The patient is kept in bed for at least three weeks. Inflammations of the Urinary Bladder.—Acute Cystitis.— Cystitis may originate in the bladder itself, or it may be sec- ondary to inflammations of the kidney, urethra, or other organs. The symptoms are frequency and urgency of micturition, and a burning sensation when the urine is voided. Treatment of Acute Cystitis.—Patients should be kept in bed. The pressure about the bladder is relieved by elevating the pelvis so that the intestines will fall away from it, and flex- ing the knees so as to relax the spasm of the rectus muscles of the abdomen. Hot applications applied over the bladder re- gion are very agreeable, and Sitz baths given about three times daily afford great relief. If the pain is very severe, morphine is given. If there is great difficulty in voiding because of excruciat- ing pain, a little novocain instilled in the posterior urethra affords great relief. Urine is less irritating when alkaline, and an acid condition may be alkalinized by the giving of sodium bi- carbonate or sodium citrate, 20 gr. three times a day. The diet should be bland, non-irritating, and mainly fluid in nature. Irrigations of the bladder may or may not be done according to the judgment of the surgeon in charge. Irrigating solutions may be of boric acid, and later, when the disease becomes less acute, irrigations of silver nitrate in distilled wrater may be employed 1-5000, potassium permanganate 1-5000, or protar- gol 1-10,000. They are more effective and comforting when given warm. Chronic Cystitis.—Chronic inflammations of the bladder may be the result of an acute attack, or secondary to some condi- tion in the bladder itself, as a papilloma or a stone. Treatment.—The treatment is that employed in the late stages of acute inflammation, namely, irrigations. These should be given daily, after a diagnosis of its etiology has been made. Sometimes, because of stricture of the urethra or inflamma- tion of the testes, irrigations are not practical. These cases are treated by cystotomy (a suprapubic incision into the bladder with the establishment of free continual drainage). NURSING OF THE URINARY SYSTEM 147 Primary tuberculosis of the urinary bladder is extremely rare; it is ordinarily infected secondary to the kidney, prostate, or testis. The complaints given are usually of frequency, urgency, and often bloody urine. Treatment of Tuberculosis of Urinary Bladder.—The treat- ment, of course, should be directed to the primary focus of the tubercle bacillus, and, if the kidney is responsible, it should be extirpated. While this is of prime importance, the patient meanwhile must receive some treatment to relieve the very dis- tressing symptoms of a diseased bladder. In the first place the patient should be kept in good hygienic surroundings. Food should be plentiful, appetizing, and highly nutritious, and every measure available should be taken to insure the strengthening of a weakened, debilitated constitution. The bladder should be irrigated with very hot solutions of boric acid. These are al- ways pleasing, and will relieve much of the pain. If the pain is very severe, some novocain (but never cocaine) might be instilled into the bladder. Tuberculous bladders are ulcerated, and great care must be taken that too much medication is not instilled, because free absorption is apt to take place and poison- ing result. Rectal suppositories containing opium and extract of belladonna do much to relieve pain. Operative Treatment.—This consists in a suprapubic cys- totomy and the direct treatment of the ulcerated bladder mucosa, either with the actual cautery or chemical caustics. The after treatment is very important. The foot of the bed is raised, the bladder drained by continuous drainage, and washed out daily with a bland non-irritating solution through the suprapubic tube. Drainage of the bladder is kept up for about six weeks. It is important to maintain all the rules of strict asepsis in these cases, for nothing is more discouraging than to add secondary infection. Bladder Stone.—When a stone is present in the bladder, there are generally pain, frequency of urination, and the occa- sional passage of blood at the end of micturition. The diagnosis of bladder calculi is not so difficult since the use of the X-ray and cystoscope, although formerly its presence was detected by the metal sound stone searcher of Thompson. 148 TEXTBOOK OF SURGICAL NURSING Treatment.—The stone is either removed by lithotomy or litholapaxy. Litholapaxy.—The patient is placed in the lithotomy posi- tion (Fig. 72) and the urethra locally anesthetized. Some em- ploy spinal anesthesia, and others, general. In this procedure an attempt is made to crush the stone within the bladder by means of a lithotrite. This is an instrument introduced through the urethra, and then opened when in the bladder, grasping the stone between its two powerful jaws, and crushing it into smaller pieces. The stony fragments are later evacuated by means of a Bigelow evacuator, which is an instrument designed to suck from the bladder the stone fragments in a water current. Post-operatively, water should be given in large amounts; the urine should be kept acid, and drainage from the bladder should be free, through an inlying catheter. As a rule this can be removed at the end of forty-eight hours. Suprapubic Lithotomy.—In this operation the bladder is opened above the pubis; the stone is removed, and the bladder sutured. Ante-operative Treatment and Operation.—This consists of the ordinary preparation for any abdominal operation. The patient is anesthetized, the bladder is distended fully with either warm boric acid solution or air, and the patient is placed in the Trendelenburg position (Fig. 63). A suprapubic median incision is made, the bladder exposed, incised, and the stone removed with special forceps. The bladder is sutured with a double row of sutures, and the abdominal wound closed. ' Post-operative Treatment.—If the wound is sutured tightly, the patient may be permitted up in from ten to fourteen days. If there is suprapubic drainage because of a concomitant cystitis, the tube should be left in for about ten days, and then removed; the patient is allowed up as soon as the suprapubic wound has healed. With very old people, attempts should be made to get them out of bed as soon as possible, for experience has shown that a weakly healed abdominal wound is better than broncho-pneumonia and death which may result if these cases are confined to bed. New Growths of the Urinary Bladder.—Tumors of the blad- NURSING OF THE URINARY SYSTEM 149 der may be either benign or malignant; the benign variety may be treated through the cystoscope, or by open operation; the malignant ones by open operation and radium. Cystoscopic Treatment.—This is especially adaptable for cases of small benign tumors of the papillomatous variety. These growths are located with the cystoscope and fulgurated with the sparks of a high frequency current under direct vision. The effect is simply to burn away the tumor tissues. Operation.—A suprapubic cystotomy is done, and an effort made to extirpate the growth under direct vision by excision. In cases of extensive malignant growths the bladder may be excised in its entirety. The ureters may either be transplanted in the rectum or brought to the skin surface through the ab- dominal wall. This is an operation of considerable risk, the mortality is high, and the end results extremely poor. When extensive cancer exists it is much better to employ radium. Radium Treatment.—The solid radium, enclosed within a metallic tube of platinum, is introduced into the bladder through a suprapubic incision, and left in place for a certain number of hours, or it may be introduced through the urethra with a special cystoscopic arrangement. These cases are often apt to hemorrhage. The bleeding is effectively controlled by irrigation of the bladder with warm boric acid and the introduction thereafter of a 1-1000 solu- tion of adrenalin hydrochloride. It is quite natural that such patients are nervous and ap- prehensive, but every attempt should be made to reassure them, rather than administer morphine, for in these chronic cases the opium habit is established very easily, and, in addition, this drug has a depressive action on the kidneys. The Urethra.—The diseases of the male urethra are usually treated by the surgeon himself, and as the lesions of the female urethra demand practically no operative interference, the only condition which requires mention is stricture of the urethra. This develops secondary to acute inflammations of the urethral canal in Avhich the mucous membrane has been partially de- stroyed, and its place is taken by scar tissue. When this tis- sue contracts it forms a stricture, narrowing the lumen, result- 150 TEXTBOOK OF SURGICAL NURSING ing in difficult micturition, and often complete retention of urine. To relieve this, if catheterization is impossible, a ure- throtomy is performed. If the constriction is in the penile portion an internal urethrotomy is performed; if in the deep urethra, an external urethrotomy. Internal Urethrotomy.—An internal urethrotomy consists of cutting the stricture with an urethrotome (an instrument shaped like a sound containing a hidden knife). The urethrotome is introduced into the region of the stricture, the knife drawn, and the stricture cut. Sounds are then passed and the strictured area dilated to the calibre desired. External Urethrotomy.—The patient is placed in a lithotomy position, a filiform bougie is passed into the penis, and an at- tempt made to pass it through the strictured area. A tunnel sound is threaded along the filiform bougie down to the stric- tured area, the perineum is incised over the sound, and the stricture, identified by means of the filiform, is cut with a spe- cial urethrotomy knife. A tube is passed into the bladder through the perineal incision. Post-operatively this tube is connected with bottle drainage. Fluids are forced and in about one week the tube is withdrawn and the patient is encouraged to void through the urethra. Sounds are passed about twice a week. Circumcision.—This operation is performed to relieve a tight prepuce (phimosis), and consists in trimming off the re- dundant skin and mucous membrane of the penis. In young children the nurse should change the dressing after urination. CHAPTER XII SURGICAL DIETETICS Diet is indeed a most important post-operative considera- tion. No two patients can be nourished alike, and it is a grave mistake to feed them in a routine manner as is so often done. The type of operation performed, the physical condition, the age, and the general post-operative behavior are all im- portant factors in determining the kind of food, the amount and the frequency of the feedings. Patients who have had a colostomy performed certainly must be dieted differently from those who have had a gastroenterostomy. A woman of sixty will not be able to digest the regular hospital diet with the ease of a young boy. Then again, while the diet may be per- fect when under supervision of the nurse, obliging relatives and kind friends may bring food and delicacies which may prove detrimental to the health of the patient. It is not un- usual to see gastric disturbances after visiting days, due to candy and fruit which have been smuggled in by visitors. This evil should be tactfully and carefully controlled. In the discussion of surgical dietetics, to facilitate matters, it will be best to first consider the diet following a simple opera- tion, such as hernia, appendicectomy, ventral suspension of the uterus, and simple plastic gynecological operations. Liquid Diet.—After a patient has recovered from the anes- thetic, he asks for water, and inasmuch as there is bound to be nausea and vomiting following most operations, water is not permitted until two hours after the last vomiting. Of course, it is rather difficult to judge which is the last vomiting, but this can be learned by experience. As a rule, water is given in teaspoonful doses, moderately warm, although some surgeons will order it ice cold. If the patient tolerates this well, more may be given if desired, but he should never be allowed to drink 151 152 TEXTBOOK OF SURGICAL NURSING promiscuously and freely. It is not advisable to allow fluids or "liquid diet" until the day following operation. The liquids commonly used are broths, gruels, tea, egg albumen, and lemon juice. About five ounces of these are given at a time. The second day after operation, milk may be added. Milk is almost a perfect food; it is quickly delivered to the stomach, is entirely absorbed, has a high caloric value and provides considerable nourishment. There are some people who cannot tolerate plain whole milk. This may be remedied oc- casionally by adding barley water, lime water, plain water, seltzer, vichy, or a little brandy. While it is not good policy to use alcoholic beverages, such as brandy or whisky, sudden withdrawal of these from patients who have been accustomed to alcohol for years might bring on delirium tremens. For these chronically alcoholic individuals it is sometimes advisable to give one-half to one ounce of whisky three times a day. On the other hand, some surgeons use it as a stimulant, prescribing it for weak and debilitated patients the first few days after operation. The fluids should be served at frequent intervals according to the desire of the patient; whenever possible they should be served warm and always attractively. If they do not agree with the patient, and cause vomiting, their administration should cease. On the third day, as a rule, after the patient's bowels have been moved either by a cathartic or by an enema, a se- lected soft diet is allowed. Soft Diet.—The following foods are appropriate for a soft diet. It may be varied and grouped according to the taste of the patient: Cereals:—Wheatena, hominy, oatmeal, cornmeal, farnia, cream of wheat. Eggs:—Soft boiled. Vegetables:—Baked, mashed, or boiled potatoes. Macaroni. Desserts:—lee cream, baked custard, rice, tapioca, or cornstarch pudding. If this is well borne, within another day the patient may be shifted to a convalescent diet. SURGICAL DIETETICS 153 Convalescent Diet. For each day of the week. Total quantity of milk allowed not over 12,10 c.c. (2^2 pints) d 6:00 a.m. Milk, 210 c.c. (7 ounces) if desired. Breakfast Coffee or tea, with milk and sugar, or milk. One egg, or fresh fish, or plain stew. Cereal with milk and sugar. Toast and butter, or rolls or bread (white, graham, or brown). Dinner Broth or soup with barley or vegetables. Bread and butter. Milk. Potatoes, baked, boiled, or mashed. Rice, macaroni, or hominy. Beef, chicken, or fish. Pudding, ice cream, or fruit. Supper Tea or milk. Toast and butter, or bread. Egg. Cooked fruit (baked or stewed apples, primes, rhubarb, aprii pears). At S:00 p.m., milk, 210 c.c. (7 ounces). Particular Foods for Specified Days. Sunday Breakfast Dinner Supper Wheatena Chicken Egg One egg • Baked potato Prunes Orange Monday Breakfast Dinner Hominy Roast-beef Stew Mashed potato Rice pudding, Breakfast Oatmeal Egg Tuesday Dinner Fresh fish, hominy Boiled potato Ice cream Supper Egg Pears or apricots Supper Egg Stewed apples 154 TEXTBOOK OF SURGICAL NURSING Breakfast Wheatena Fresh fish Breakfast Hominy Egg Wednesday Dinner Supper Chicken, baked potato Egg Macaroni Rhubarb or prunes Tapioca pudding Thursday Dinner Boiled beef, rice Mashed potato Baked custard Supper Egg Baked apple Breakfast Oatmeal Egg Breakfast Cornmeal Stew Friday Dinner Fresh fish Boiled potato Macaroni Ice cream Saturday Dinner Chicken Mashed potato Hominy Cornstarch pudding Approximate values to be given. Protein Carbohydrates Men ........100 gm. 300 gm. Women .....80 gm. 300 gm. Supper Eggs Prunes Supper Egg Apricots or pears Fat Total Calories 90 gm. 2500 80 gm. 2200 Regular Diet.—This should be composed of the food to which the patient is normally accustomed, and should consist of a good mixed diet. It is not necessary to outline it in detail. Those foods should be selected which the patient enjoys, which are easily digestible and which need not be fried in fat. An example of such a diet is the following one: SURGICAL DIETETICS 155 Total quantity of milk allowed must not exceed 750 c.c. or l1/^ pints. Breakfast Coffee or tea with milk and sugar, or milk. Bread and butter. Two eggs to each patient in male wards. One egg to each patient in female wards. Cereal with milk and sugar. Fresh fish. Hash. Dinner Soup Meat or fish Potatoes, baked, boiled, or mashed. Bread and butter. Spinach, squash, boiled onions, beets, sweet potatoes, macaroni, to- matoes, corn. Pudding, or fruit. Milk, 180 c.c. or 6 ounces. Supper Tea or milk. Bread and butter. Cooked fruit (prunes, apples, rhubarb, apricots, pears). Cold meat. Eggs. Cereal with milk and sugar. Milk toast. Diet for Diabetes.—When certain diseases, such as diabetes or nephritis, complicate surgical conditions, the patient often undergoes a pre-operative dietetic preparation, so that the best possible physical state is attained before the operation is performed. It is a well-known fact that patients who suffer from diabetes mellitus, a disease in which the sugar content of the blood is high, and sugar appears in the urine, are extremely poor operative risks. To begin with, they take their anes- thetic poorly, their tissues are rather low in vitality, become infected very easily, and are slow in healing. Then after opera- tion, they are apt to pass into a diabetic coma, a very serious complication, usually resulting in death. In order to give these patients the best post-operative chan'ce by rendering them less liable to coma, infection, and slow wound healing, every at- tempt should be made to reduce their diabetes to the minimum, or to render them sugar free. The following list of diets are those which are usually prescribed or ordered by surgeons to ac- complish these ends. 156 TEXTBOOK OF SURGICAL NURSING Standard Strict Diet. Breakfast 2 eggs. Coffee with 45 gm. cream. Ham, 90 gm. Butter, 15 gm. on biscuit during the test period; cooked with the eggs if no biscuit or bread is taken. Luncheon Meat, steak or chops, 120 gms. Green vegetables (from list), 2 tablespoonfuls. Butter, 15 gm. with green vegetable if no biscuit or bread is taken. White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. Afternoon tea with 15 gm. of cream. Dinner Clear soup. Fish, 90 gm. Meat, beef, mutton, turkey, or chicken, 120 gm. Green vegetable, 2 tablespoonfuls. Salad with 15 gm. of oil in the dressing. Cream cheese, 30 gm. Butter, 30 gm. on fish, meat, or vegetables if no bread or biscuit taken. White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. Demi-tasse. Bedtime Bouillon with one raw egg. Protein, 112 gm.; nitrogen, IS gm.; fats, 160 gm.; calories, 2200; omitting ham, protein, 94 gm.; nitrogen, 15 gm. For convenience in determining the carbohydrate tolerance, the fol- lowing biscuits may be used, as the percentage of carbohydrates is practically constant:—Huntley and Palmer breakfast biscuit which contains 5 gm. carbohydrate; Uneeda Biscuit, which contains 4.6 gm. carbohydrate. Standard Diet with Restricted Protein. Breakfast 2 eggs. Bacon, 15 gin. Butter, 20 gm. Coffee with 45 gm. of cream. Luncheon 1 egg. Bacon, 15 gm. Lamb chops, ham, or beefsteak, 60 gm. Butter, 40 gm. Salad with 15 gm. of oil in dressing. White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. SURGICAL DIETETICS 157 Afternoon tea with 15 gm. of cream. Dinner Clear soup. Butter, 30 gm. Roast pork, beef, mutton, turkey, or lamb chops, 90 gms. Green vegetables. Salad with 15 gin. of oil in dressing. Cream cheese, 30 gm. White wine, 2 claret glasses, or whisky or brandy, 2 tablespoonfuls. Demi-tasse. Bedtime Bouillon with one raw egg. Protein, 62 gm.; nitrogen, 10 gm.; fat, 180 gm.; total calories, 2500. Omitting 30 gm. of butter and x/2 ounce of bacon, calories equal 2250. Green Days. Breakfast 1 egg, boiled or poached. Cupful of black coffee. Dinner Spinach with hard boiled egg. Bacon, 15 gm. Salad with 15 gm. of oil. White wine, % liter, or whisky or brandy, 30 c.c. 4:30 p. m. Cup of beef tea or chicken broth. Supper 1 egg, scrambled with tomato and a little butter. Bacon, 15 gm. Cabbage, cauliflower, sauerkraut, string beans, or asparagus. White wine, or whisky or brandy, 30 c.c. Sodium bicarbonate, 15 to 30 gm. in 24 hours. Protein, 32 gm.; nitrogen, 5 gm.; carbohydrate about 5 gm.; fat, 67 gm.; calories, 575. General Diabetic Diet List. (May take freely.) Soups. All meat soups and broths to which vegetables, egg or cheese may be added. Meats. All fresh, smoked, and cured meats except liver, poultry and game, without sauces or gravies con- taining flour. Fish. All kinds except oysters, clams and scallops, cooked without bread crumbs or meal; all dried, salted, smoked or pickled fish. 158 TEXTBOOK OF SURGICAL NURSING Eggs. Fats. Cheese. Salads and Vegetables. Prepared in any way without flour. Butter, lard, suet, olive oil, or other fats. All kinds, especially cream, Swiss, English and pine- apple. Beet greens, Brussels sprouts, cabbage, cauliflower, celery, chicory, cresses, cucumbers, egg-plant, en- dive, kohlrabi, leeks, lettuce, okra, pumpkin, radishes, rhubarb, salsify, sauerkraut, spinach, string-beans, tomatoes, and vegetable marrow. Pickles made from these vegetables unsweetened; ripe olives. Mushrooms and truffles Salt, pepper, cayenne, paprika, curry, cinnamon, cloves, English mustard, nutmeg, caraway, capers, vinegar, and piquant sauces in small quantities. Jellies made from gelatin, custards and ice cream made with eggs and cream; all sweetened with sac- charin and flavored with vanilla, coffee or brandy. Butternuts. Not over 90 c.c. a day. Tea or coffee, sweetened with saccharin and with portion of cream allowed. Whisky, brandy, rum, and other distilled liquors up to 3 ounces a day. Light wine or Moselle wine, claret or Burgundy up to 16 ounces a day. Mineral waters of all kinds. Lemonade in small quantity sweetened with saccharin. Articles Prohibited. (Except as prescribed in the Accessory Diet.) Sugars and sweets of every kind. Pastry, puddings, preserves, cake and ice cream. Bread, biscuits, toast, crackers, and griddle cakes. Cereals such as rice, oatmeal, sago, hominy, tapioca, barley and macaroni. Vegetables such as potatoes, carrots, parsnips, beans, peas, beets, green corn, and turnips. Fruit. Neither fresh nor dried. Soups, sauces or gravies thickened with flour or meal, or made with milk. Beer, ale, porter, all sweet wines, sherry or port wine, sparkling wines, cider and liquors. Milk, chocolate or cocoa. Soda water and all sweet drinks. Fungi. Condiments. Dessert. Nuts. Cream. Beverages. SURGICAL DIETETICS 159 Oatmeal Days. Porridge made from oatmeal, 250 gm. with butter, 250 gm., salt and pepper. Black coffee, light wine *4 liter, or cognac, 60 c.c. The whites of 6 eggs may be added to the porridge if desired. Nitrogen gm. Carbohydrate gm. Calories Oatmeal............6.2 170 1025 Butter .............0.4 1975 6.6 or 42 gm. protein 3000 Alcohol (40 gm.) ... 210 6 whites of eggs .... 3.6 90 10.2 or 63 gm. protein 3300 The entire diet consists of:—Protein, 63 gm.; nitrogen, 16.8 gm.; carbohydrate, 170 gm.; fat, 212 gm.; calories, 3300. Diet for Patients with Nephritis. Occasionally patients with severe nephritis have to undergo operations; or, if they are operated on in an emergency, their post-operative care is partially one of diet. It is a known fact that salt or sodium chloride is retained in the body in cases of kidney disease, and that its retention causes edema. Occasion- ally if there is a sodium chloride retention it is necessary to put the patient upon a salt poor diet. These may be of three general varieties. The important factor in all is that the food should be prepared without any salt and that the butter and bread are to be salt free and that no extra salt should be allowed. Salt Poor Diet. 1. Breakfast Bread, 30 gm. or 1 oz. Sugar, 10 gm. or 1/3 oz. Farina, 60 gm. or 2 oz. Butter, 30 gm. or 1 oz. 1 egg or 40 gm. or lr/3 oz. Coffee, 150 c.c. or 5 oz. Total, 320 gm. or 102/3 oz. Dinner Bread, 30 gm. or 1 oz. Butter, 20 gm. or 2/3 oz. Sugar, 10 gm. or 1/3 oz. Rice, 60 gm. or 2 oz. Farina, 100 gm. or 31/3 oz. Tea, 150 c.c. or 5 oz. Total, 370 gm. or 12V3 oz. 160 TEXTBOOK OF SURGICAL NURSING Supper 1 egg or 40 gm. or l1/3 oz. Toast, 15 gm. or y2 oz. Bread, 30 gm. or 1 oz. Butter, 15 gm. or D/2 oz. Custard, 100 gm. or 31/3 oz. Prunes 60 gm. or 2 oz. Tea, ISO c.c. or 6 oz. Total, 440 gm. or 142/3 oz. This contains chlorides, 1 gm., protein, 35 gm. or U/g oz. Fat, 65 gm. or 21/6 oz. Carbohydrate, 140 gm. or 42/3 oz. Calories, 1300. Salt Poor Diet. 2. Breakfast Bread, 60 gm. or 2 oz. Sugar, 40 gm. or lx/3 oz. Farina, 60 gm. or 2 oz. Butter, 35 gm. or iy6 oz. 1 egg, 40 gm. or l1/3 oz. Coffee, 150 c.c. or 5 oz. Total, 385 gm. or 125/6 oz. Dinner One egg, 40 gm. or V-/3 oz. Bread, 60 gm. or 2 oz. Butter, 30 gm. or 1 oz. Rice, 70 gm. or 2l/3 oz. Farina, 100 gm. or 3y3 oz. Tea, 150 c.c. or 5 oz. Total, 450 gm. or 15 oz. Supper One egg or 40 gm. or l1/3 oz. Bread, 60 gin. or 2 oz. Butter, 30 gm. or 1 oz. Custard, 100 gm. or 31/3 oz. Prunes, 60 gm. or 2 oz. Tea, 180 c.c. or 6 oz. Total, 4S5 gm. or 155/6 oz. This contains chlorides, 3 gm.; protein, 50 gm. or l2/3 oz.; fat, 100 gm. or 3V3 oz.; carbohydrate, 240 gm. or 8 oz.; caiories, 2100 Salt Poor Diet. 3. This is the same as the convalescent diet without broths or soups. The fish, meat and green vegetables must be boiled in two waters to remove most of the salt. Milk, 250 c.c. or 8 oz. only allowed. Diet in Gastric Cases.—The diet following stomach opera- tions is dependent upon what has been done surgically. If the ulcer-bearing area has been removed, it is not essential to place SCRGICAL DIETETICS 161 this patient upon an elaborate gastric diet. The routine in these cases is as follows: For the first twenty-four hours, the patient is given nothing by mouth, water being freely administered by Murphy drip. Then, water by mouth is given in dram doses every hour; and, if tolerated, after two doses, it is increased to half an ounce, alternating with peptonized milk,—one-half ounce every two hours. Thus the patient obtains something every hour. If this is well borne, after four feedings, the amount is increased to one and then to two ounces. Then easily digested substances are added, such as: Farina, rice, sago, soft eggs; thin soups, consomme or bouil- lon, baked or mashed potatoes; soft vegetables such as beans, peas; and buttered toast; cocoa. After a period of two weeks or more these articles may be eaten: Lamb or chicken in moderate amounts about two times a week; fresh fish either boiled or broiled, never fried; lettuce, water cress, romaine, endive, chicory with a good quantity of olive oil and very little vinegar; desserts, such as ice creams and custards. It is highly important that the following foods be omitted: Coarser vegetables such as cabbage, cucumbers, kohlrabi, tomatoes, onions, celery, corn, cauliflower, sprouts, artichokes, asparagus and beets. Also veal, pork, corned or smoked meats, lobster, crabs, shrimps, cheese excepting Philadelphia or Neucha- tel, pickles, too hot or too cold drinks, strong tea or coffee, too much pastry, especially those cooked in fat, such as fritters, doughnuts; jams, cherries, cranberries and muskmelons. Meat should be roasted or broiled; never fried. Those cases in which the ulcerated condition of the stomach still remains because the ulcer-bearing area has not been ex- cised are placed upon a Von Leube or Lenhartz diet. This would hold for acute perforations of the stomach and gastro- enterostomies. Von Leube Diet (Modified).—For the first three days noth- ing is given by mouth, but fluid is supplied by proctoclysis and a nutritive enema may be given three times daily if the 162 TEXTBOOK OF SURGICAL NURSING patient is asthenic. After a few days, peptonized milk § ii alternating with vichy * ii may be given every two hours. If this is well borne, the milk is increased one ounce daily until eight ounces are taken. If the administration of the milk is fol- lowed by no pain, the amount of vichy may be increased to four ounces. In about ten days, thickened soups, such as puree of pea, sago, tapioca and junket are allowed. In the third week, scraped raw beef, very soft boiled eggs, macaroni, puree of vegetables, and zwieback may be given. The patient is gradu- ally returned to a selected soft diet during the fourth week. If pain appears a return is made to the simpler milk diet. Lenhartz Diet.—The food of a Lenhartz diet is admin- istered at hourly intervals; it must be thoroughly masticated and eaten very slowly, and, during the treatment, the patient must be kept in bed. For the first week, the raw eggs which are used, are beaten up whole and iced; the milk is also iced; gran- ulated sugar is added to the eggs on the third day. Boiled rice, zwieback and scraped beef are prepared in the usual manner. The Lenhartz diet for fourteen days is as follows: As eggs differ in size and weight, take the total of eggs for the day of diet, beat, measure, and divide into seven feedings and put into medicine glasses. Keep on ice and use as directed, alternating with milk. The milk is kept in a bowl of cracked ice, and the eggs are beaten up raw and iced. The spoon is kept in a bowl of ice. The feedings should be given very slowly and the patients are never allowed to help themselves. The patient should be given small feedings frequently and fed by spoon. Salt the eggs to taste on the first and second days; sugar is started on third day. First Day 7 a.m. Egg 8 Milk, 20 c.c. or 2/3 oz. 9 Egg 10 Milk, 20 c.c. or 2/3 oz. 11 Egg 12 noon Milk, 15 c.c. or y2 oz. 1 p.m. Egg 2 Milk, 15 c.c. or i/2 oz. SURGICAL DIETETICS 163 First Day—Continued. 3 p.m. Egg 4 Milk, 15 c.c. or i/2 oz. 5 Egg 6 Milk, 15 c.c. or y2 oz. 7 Egg Total, eggs (raw), 2; milk, 100 c.c. or 3x/3 oz. Second Day 7 a.m. Egg 8 Milk, 35 c.c. or 1 oz. 9 Egg 10 Milk, 35 c.c. or 1 oz. 11 Egg 12 noon Milk, 35 c.c. or 1 oz. 1 p.m. Egg 2 Milk, 35 c.c. or 1 oz. 3 Egg 4 Milk, 35 c.c. or 1 oz. 5 Egg 6 Milk, 35 c.c. or 1 oz. 7 Egg Total, eggs (raw), 3; milk, 200 c.c. or 62/3 oz. Third Day 7 a.m. Egg. Sugar, 2 gm. or y2 oz. 8 Milk, 50 c.c. or l2/3 oz. 9 Egg. Sugar, 3 gm. or % dr. 10 Milk, 50 c.c. or l2/3 oz. 11 Egg. Sugar, 3 gm. or % dr. 12 noon Milk, 50 c.c. or l2/3 oz. 1 p.m. Egg. Sugar, 3 gm. or % dr. 2 Milk, 50 c.c. or l2/3 oz. 3 Egg. Sugar, 3 gm. or % dr. 4 Milk, 50 c.c. or l-/3 oz. 5 Egg. Sugar, 3 gm. or % dr. 6 Milk, 50 c.c. or l2/3 oz. 7 Egg. Sugar, 3 gm. or % dr. Total, eggs (raw), 4; milk, 300 c.c. or 10 oz.; sugar, 20 gm. or 5 dr. Fourth Day 7 a.m. Egg. Sugar, 2 gm. or y2 dr. 8 Milk, 70 c.c. or 2y3 oz. 9 Egg. Sugar, 3 gm. or % dr. 164 TEXTBOOK OF SURGICAL NURSING Fourth Day—Continued. 10 a.m. Milk, 70 c.c. or 2ya oz. 11 Egg. Sugar, 3 gm. or % dr. 12 noon Milk, (55 c.c. or 2 oz. 1 p.m. Egg. Sugar, 3 gm. or % dr. 2 Milk, 05 c.c. or 2 oz. 3 Egg. Sugar, 3 gm. or % dr. 4 Milk, 65 c.c. or 2 oz. 5 .Egg. Sugar, 3 gm. or % dr. 6 Milk, 65 c.c. or 2 oz. 7 Egg. Sugar, 3 gm. or % dr. Total, eggs (raw), 5; milk, 400 c.c. or 131/, oz.; sugar, 20 gm. or 5 dr. Fifth Day 7 a.m. Egg. Sugar, 4 gm. or 1 dr. 8 Milk, 80 c.c. or 2-/3 oz. 9 Egg. Sugar, 4 gm. or 1 dr. 10 Milk, 80 c.c. or 22/3 oz. 11 Egg. Sugar, 4 gm. or 1 dr. 12 noon Milk, SO c.c. or 22/3 oz. 1 p.m. Egg. Sugar, 4 gm. or 1 dr. 2 Milk, SO c.c. or 22/3 oz. 3 Egg. Sugar, 4 gm. or 1 dr. 4 Milk, 80 c.c. or 22/3 oz. 5 Egg. Sugar, 4 gm. or 1 dr. 6 Milk, 90 c.c. or 3 oz. 7 Egg. Sugar, 4 gm. or 1 dr. Total, eggs (raw), 6; milk, 500 c.c. or 162/3 oz.; sugar, 30 gin. or 1 oz. Sixth Day 7 a.m. Egg. Sugar, 4 gin. or 1 dr. 8 Milk, 100 c.c. or 31/, oz. 9 Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 3 dr. 10 Milk, 100 c.c. or 31/3 oz. 11 Egg. Sugar, 4 gm. or 1 dr. 12 noon Milk, 100 c.c. or 31/3 oz. 1 p.m. Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 3 dr. 2 Milk, 100 c.c. or 3x/3 oz. 3 Egg. Sugar, 4 gm. or 1 dr. 4 Milk, 100 c.c. or 3ya oz. SURGICAL DIETETICS 165 Sixth Day—Continued. 5 p.m. Egg. Sugar, 4 gm. or 1 dr. Scraped beef, 12 gm. or 3 dr. 6 Milk, 100 c.c. or 3y3 oz. 7 Egg. Sugar, 4 gin. or 1 dr. Total, eggs (raw), 7; milk, (i()0 c.c. or 20 oz.; sugar, 30 gm. or 1 oz.; scraped beef, 36 gm. or 9 dr. Seventh Day 7 a.m. One soft boiled egg. 8 Milk, 100 c.c. or 3y3 oz. 9 Egg. Sugar, 13 gm. or '3 dr. 10 Milk, 100 c.c. or 3y3 oz.. Scraped beef, 23 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 11 One soft boiled egg. 12 noon Milk, 125 c.c. or 4 oz. 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 2 Milk, 125 c.c. or 4 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 3 One soft boiled egg. 4 Milk, 125 c.c. or 4 oz. 5 Egg. Sugar, 14 gm. or 31/3 oz. 6 Milk, 125 c.c. or 4 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 7 One soft boiled egg. Total, 4 raw eggs; 4 soft boiled eggs; milk, 700 c.c. or 231/3 oz.; sugar, 40 gm. or l1/., oz.; scraped beef, 70 gm. or 21/., oz.; boiled rice, 100 gm. or 3x/3 oz. (served with beef juice). Eighth Day The diet changes on this day, requiring only 4 raw eggs which may be divided into three feedings. The other 4 eggs are to be soft boiled and given as directed by diet. 7 a.m. One soil boiled egg. 8 Milk, 135 c.c. or 4y2 oz. 9 Egg. Sugar, 13 gm. or 3 dr. 10 Milk, 133 c.c. or 4*/2 oz- Scraped beef, 23 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 11 One soft boiled egg. Zwieback, 10 gm. or 2y2 dr. 12 noon Milk, 133 c.c. or 4y2 oz. 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 2 Milk, 133 c.c. or 4y2 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 166 TEXTBOOK OF SURGICAL NURSING Eighth Day—Continued. 3 p.m. One soft boiled egg. 4 Milk, 133 c.c. or 4y2 oz. 5 Egg. Sugar, 14 gm. or 3y2 dr. Zwieback, 10 gm. or 2i/2 oz. 6 Milk, 133 c.c. or 4*4 oz. Scraped beef, 24 gm. or 6 dr. Boiled rice, 33 gm. or 1 oz. 7 One soft boiled egg. Total, 4 raw eggs; 4 soft boiled eggs; milk, 800 c.c. or 262/3 oz.; scraped beef, 70 gm. or 2y3 oz.; boiled rice, 100 gm. or 3y3 oz.; zwieback, 20 gm. or 5 dr.; sugar, 40 gm. or l1/3 oz. Ninth Day 7 a.m. One soft boiled egg. 8 Milk, 150 c.c. or 5 oz. 9 Egg. Sugar, 13 gm. or 3 dr. 10 Milk, 150 c.c. or 5 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 66 gm. or 2 oz. 11 One soft boiled egg. Zwieback, 20 gm. or 5 dr. 12 noon Milk, 150 c.c. or 5 oz. 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 2 Milk, 150 c.c. or 5 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 66 gm. or 2 oz. 3 One soft boiled egg. Zwieback, 20 gm. or 5 dr. 4 Milk, 150 c.c. or 5 oz. 5 Egg. Sugar, 14 gm. or 3y2 dr. 6 Milk, 150 c.c. or 5 oz. Scraped beef, 24 gm. or 6 dr. Boiled rice, 66 gm. or 2 oz. 7 One soft boiled egg. Total, 4 raw eggs; 4 cooked eggs; milk, 900 c.c. or 30 oz.; sugar, 40 gm. or l1/3 oz.; scraped beef, 70 gm. or 2y3 oz.; rice, 200 gm. or 62/3 oz.; zwie- back, 40 gm. or l1/3 oz., or toast, 20 gm. or 5 dr. Tenth Day 7 a.m. One soft boiled egg. 8 Milk, 166 c.c. or 5V2 oz. 9 Egg. Sugar, 13 gm. or 3 dr. 10 Milk, 166 c.c. or 5V2 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 66 gm. or 2 oz. 11 One soft boiled egg. Zwieback, 20 gm. or 5 dr. Butter, 4 gm. or 1 dr. 12 noon Cooked chopped chicken, 25 gm. or 6 dr. Milk, 166 c.c. or 5^2 oz. SURGICAL DIETETICS 167 Tenth Day—Continued. 1 p.m. Egg. Sugar, 13 gm. or 3 dr. 2 Milk, 166 c.c. or 5*4 oz. Scraped beef, 23 gm. or 6 dr. Boiled rice, 66 gm. or 2 oz. Butter, 4 gm. or 1 dr. 3 One soft boiled egg. Zwieback, 20 gm. or 5 dr. Butter, 4 gm. or 1 dr. 4 Cooked chopped chicken, 25 gm. or 6 dr. 5 Egg. Sugar, 14 gm. or 3y2 dr. 6 Milk, 166 c.c. or 5y2 oz. Scraped beef, 24 gm. or 6 dr. Boiled rice, 67 gm. or 2 oz. Butter, 4 gm. or 1 dr. 7 One soft boiled egg. Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 33x/3 oz.; sugar, 40 gm. or iy3 oz.; scraped beef, 70 gm. or 2y3 oz., boiled rice, 200 gm. or 62/3 oz.; zwieback, 40 gm. or l1/3 oz.; or toast, 20 gm. or 5 dr.; chicken, 50 gm. or l2/3 oz.; butter, 20 gm. or 5 dr. Eleventh Day 7 a.m. One soft boiled egg. Milk, 250 c.c. or 8ya oz.; zwieback, 10 gm. or 21/2 dr. Butter, 4 gm. or 1 dr. 9 Egg. Sugar, 13 gm. or 3 dr. Scraped beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 2y2 oz. Zwieback, 10 gm. or iy2 dr. Butter, 6 gm. or V-/2 dr. 11 One soft boiled egg. Milk, 250 c.c. or 8y3 oz. Butter, 6 gm. or V/2 dr. Zwieback, 10 gm. or 2y2 dr. 1 p.m. Egg. Sugar, 15 gm. or 3 dr. Cooked chopped chicken, 25 gm. or 6 dr. Boiled, rice, 75 gm. or 2y2 oz. 3 One soft boiled egg. Milk, 250 c.c. or 8ya oz. Scraped beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 2y2 oz. Zwieback, 10 gm. or 2y2 dr. Butter, 6 gm. or \y2 dr. 5 Egg. Sugar, 14 gm. or 3V2 dr. Cooked chopped chicken, 25 gm. or 6 dr. Boiled rice, 75 gm. or 2x/2 oz. But- ter, 6 gm. or iy2 dr. 7 One soft boiled egg. Milk, 250 c.c. or 8ya oz. Zwie- back, 10 gm. or 2V2 dr. Butter, 6 gm. or iy2 dr. Scraped beef, 30 gm. or 1 oz. Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 33y3 oz.; butter, 40 gm. or lx/3 oz.; sugar, 40 gm. or iy3 oz.; scraped beef, 70 gm. or 21/, oz.; boiled rice, 300 gm. or 30 oz.; zwieback, 60 gm. or 2 oz.; chicken, 50 gm. or l2/3 oz. 168 TEXTBOOK OF SURGICAL NURSING Twelfth Day 7 a.m. One soft boiled egg. Milk, 250 c.c. or 8x/3 oz. Zwieback, 10 gm. or 2V2 dr. Butter, 4 gm. or 1 dr. 9 Egg. Sugar, 13 gm. or 3 dr. Scraped beef, 35 gm. or 1 oz. Boiled rice, 75 gm. or 2x/2 oz. Zwieback, 10 gm. or 2V2 dr. Butter. 6 gm. or ll/2 dr. 11 One soft boiled egg. Milk, 250 c.c. or S'/3 oz. Zwieback, 20 gm. or 5 dr. Butter, 6 gm. or IV2 dr. 1 p.m. Egg. Sugar, 13 gm. or 3 dr. Cooked chopped chicken, 25 gm. or 6 dr. Boiled rice, 75 gm. or 2V2 oz. Zwie- back, 10 gm. or 2\2 dr. Butter, 6 gm. or iy2 dr. 3 One soft boiled egg. Milk, 250 c.c. or S'/3 oz. Scraped beef, 35 gm. or 1 oz. Boiled rice, 50 gm. or l2/3 oz. Zwieback, 10 gm. or 21,2 dr. Butter, 6 gm. or iy2 dr. 5 Egg. Sugar, 14 gm. or 3\'2 dr. Chojoped cooked chicken, 25 gm. or 6 dr. Boiled rice, 75 gm. or 2\'2 oz. Zwie- back, 10 gm. or 2y2 dr. Butter, 6 gin. or U/2 dr. 7 One soft boiled egg. Milk, 250 c.c. or Sy3 oz. Zwieback, 10 gm. or 21/2 dr. Total, 4 raw eggs; 4 cooked eggs; milk. 1000 c.c. or 33y3 oz.; sugar, 40 gm. or l1/3 oz.; scraped beef, 70 gm. or 2'/3 oz.; boiled rice, 300 gm. or 10 oz.; zwieback, 80 gm. or 22/3 oz.; chicken, 50 gm. or l2/3 oz.; butter, 40 gm. or \y2 oz. Thirteenth Day 7 a.m. One soft boiled egg. Milk, 142 c.c. or 4-/3 oz. Zwieback, 10 gm. or 2x/2 dr. Butter, 4 gm. or 1 dr. 9 Egg. Sugar, 13 gm. or 3 dr. Milk, 142 c.c. or 4-/3 oz. Scraped beef, 20 gin. or 5 dr. Boiled rice, 75 gm. or 2\2 oz. Zwieback, 20 gm. or 5 dr. Butter, (i gm. or iy2 dr. 11 One soft boiled egg. Milk, 144 c.c. or 5 oz. Zwieback, 10 gm. or 21/2 dr. Butter, 6 gm. or iy2 dr. 1 p.m. Egg. Sugar, 13 gm. or 3 or. Milk, 142 c.c. or 4-/3 oz. Cooked chopped chicken, 25 gm. or 6 dr. Boiled rice, 75 gm. or 2V2 oz. ZAvieback, 10 gm. or 2H dr. But- ter, 6 gm. or y2 dr. 3 One soft boiled egg. Milk, 144 c.c. or 5 oz. Scraped beef, 20 gm. or 5 dr. Boiled rice, 75 gm. or 21 2 oz. Zwieback, 10 gm. or 2y2 dr. Butter, 6 gm. or iy2 dr. 5 Egg. Sugar, 14 gm. or 314 dr. Milk, 142 c.c. or 4-/3 oz. Cooked chopped chicken, 25 gm. or 6 dr. Boiled rice, 75 gm. or 2y2 oz. Zwieback, 10 gm. or 2y2 dr. Butter, 6 gm. or iy2 dr. SURGICAL DIETETICS 169 Thirteenth Day—Con tinued. 7 p.m. One soft boiled egg. Milk, 144 c.c. or 5 oz. Zwieback, 10 gm. or 2x/2 dr. Butter, 6 gm. or \y2 dr. Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 33y3 oz.; sugar, 40 gm. or iy3 oz.; scraped beef, 70 gm. or 21/3 oz.; boiled rice, 300 gm. or 10 oz.; zwieback, 80 gm. or 22/3 oz.; chicken, 50 gm. or l'-/3 oz.; butter, 40 gm. or iya oz. Fourteenth Day 7 a.m. One soft boiled egg. Minced chop. Buttered toast. Milk, 142 c.c. or 4-/3 oz. 9 Boiled rice. Buttered zwieback. Custard. Milk, 142 c.c. or 42/3 oz. 11 One soft boiled egg. Buttered zwieback. Junket. Milk, 142 c.c. or 42/3 oz. 1 p.m. Minced chicken. Boiled rice. Buttered zwieback. Cus- tard. Milk, 142 c.c. or 42/3 oz. 3 One soft boiled egg. Cooked scraped beef. Boiled rice. Buttered toast. Milk, 144 c.c. or 5 oz. 5 Minced chicken. Boiled rice. Buttered zwieback. Cus- tard. Milk, 142 c.c. or 42/3 oz. 7 One soft boiled egg. Buttered toast. Milk, 144 c.c. or 5 oz. Total, 4 raw eggs; 4 cooked eggs; milk, 1000 c.c. or 33y3 oz.; sugar, 4 gm. or iy3 oz.; scraped beef, 70 gm. or 21/3 oz.; boiled rice, 300 gm. or 10 oz.; zwieback, 100 gm. or 31/3 oz.; butter, 40 gm. or iy3 oz.; chicken, 50 gm. or l2/3 oz. Anti-Constipation Diet.—Most people after operation are very constipated. Constipation has very serious sequelae and the importance of impressing upon the patient's mind the necessity of a daily movement of the bowels cannot be over- emphasized. There should be a regular time for moving the bowels, which should be observed conscientiously. The best time is shortly after breakfast; the patient should remain seated on the toilet for at least five or ten minutes, and then if there is no desire to move the bowels, a glycerine suppository should be inserted to stimulate the movement. Provided there is no contraindication to any of the coarser vegetables, the patient should be placed upon the anti-constipation diet. 170 TEXTBOOK OF SURGICAL NURSING Diet for Anti-Constipation. Breakfast Any fruit, fresh, cooked, preserved, or dried. Shredded wheat, Thomas uncooked wheat biscuit, or oatmeal, or toasted corn flakes with cream if possible, otherwise a small amount of milk and sugar or molasses. Bread.—Use only graham, rye, bran, whole wheat or corn bread. Butter, jam, jelly, or honey. Coffee with cream and sugar. Luncheon and Dinner Soup.—Any kind except those thickened with flour, or containing milk. Fish, meat, or eggs in moderation. Eat as much of the fat as possible. Vegetables.—Fresh or canned in any quantities. Green salads with olive oil. Desserts.—Fresh fruit or fruit cooked or preserved is best; also jellies prepared with coffee, wine and lemon, etc. AVater ices may be eaten freely but only small amounts of ice cream may be taken. The undercrusts of pies may not be eaten. General Directions.—Take at least a glass of water before breakfast, one in the middle of the day, and one at night. In addition take as much water as may be desired. This may be plain water, vichy or any carbonated water. Buttermilk, sour milk, cider, beer, and white wine are allowed. Butter in any quantity is permitted. Avoid tea, red wine, milk and whisky, white bread, noodles, vermicelli, macaroni, cake, rice, barley, potatoes, and cheese. General Rules.—Have a regular time for going to the toilet. Take a daily walk in the open air. Practice the setting-up exercises daily. Setting-up Exercises.— 1. Knees stiff; bend forward and try to touch floor with fingers. 2. Bend body backward from hips. 3. Bend body to the right and left from hips. 4. Rotate to the right and to the left on hips. SURGICAL DIETETICS 171 Anti-Obesity Routine.—Very often it is necessary to reduce extremely stout individuals before any operation is undertaken. Of course, this is difficult to accomplish and great care and judgment should be exercised because the patient must not be weakened unnecessarily. The general routine is as follows: 1. A hot bath on Monday, Wednesday, and Friday for ten minutes before retiring. 2. Epsom salts, one tablespoonful in cold water on Tuesday morning. 3. Walk at least one mile daily. 4. Setting-up exercises for ten minutes each morning before breakfast. Anti-Obesity Diet. Breakfast Calories Proteins One orange or one apple..................... 70 1 Coffee with 4 tablespoonfuls milk ............ 20 2 1 teaspoonful sugar ......................... 20 0 2 eggs or lean meat (about 5 x 3V2 inches) ...... 150 13 Luncheon Cup of beef tea or clear soup................. 25 3 Tea with 2 tablespoonfuls milk ............... 20 1 1 level teaspoonful sugar .................... 15 0 2 slices of bread about 4 x 4 x y2 inches........ 146 41/2 1 pat of butter about 1 x 1 x y2 inches ...... 80 1 saueerful spinach, celery, or green vegetable . 5 Lean meat about 5 x 3y2 inches .............. 300 24 Dinner One cup of beef tea or clear soup.............. 25 3 Tea with 2 tablespoonfuls of milk.............. 20 1 1 teaspoonful sugar ......................... 15 2^4 1 slice of bread ............................. 70 2% Butter, one-half pat.......................... 40 Meat about 5 x 3 x y2 inches.................. 300 24 Entire potato or 2 tablespoonfuls of any starchy vegetable without grease ................... 90 2 Total................................. 1405 803/4 172 TEXTBOOK OF SURGICAL NURSING Additional Diet if prescribed: One quart of buttermilk ..................... 640 60 American cheese, one inch cube ............... 70 40 Nutrient Enemata.—As a rule these enemata are not very successful, but when food is constantly vomited from the stom- ach, or when there is a stenosis of the cardia of the stomach or esophagus, at least some little nourishment is received in this way. Preceding it a cleansing enema of about one pint of normal saline solution should be given. It is advisable to use a small soft tube and to insert it about 25 cm. from the rectum, for the higher it is introduced the greater is the absorption. The food used in the enema is thoroughly mixed, then strained through cheese cloth, and poured into the funnel, five ounces at a time, at a temperature of 110° F. Great care should be taken that no air is introduced. The patient must lie quietly in bed for at least twenty minutes after the enema. Following are several formula? which may be used: 1. The whites of two eggs and peptonized milk, 90 c.c. 2. One whole egg, 1 gm. of salt, 10 c.c. of brandy, 90 c.c. of peptonized milk. 3. Boas's formula:—250 c.c. milk, yolks of two eggs, 3 gm. table salt, 1 tablespoonful red wine, 1 teaspoonful wheat starch. Feeding through Fistula.—This is employed when an open- ing has been made in the stomach because of some benign or malignant disease of the esophagus or cardia of the stomach. The food which is passed through the fistula must be either fluid or semi-solid and properly warmed. CHAPTER XIII ANESTHESIA PREPARATION OF THE PATIENT The first thing to learn about the preparation of a patient for an anesthetic is that it is very important in both its immedi- ate and its more remote consequences. It does not need to be explained, of course, that this applies to the various nursing treatments such as the regulation of diets, medications, etc., but the point which is often overlooked by the inexperienced is that the state of mind in which a patient approaches his anesthetic will determine very materially the way in which he will undergo the period of anesthesia, and that this in turn will have a vital effect upon his endurance of the operation and his recovery from the effects of both the operation and the anes- thetic. The preparation, therefore, should begin with the patient's mind, and at no time throughout the items of the physical preparation should the nurse forget this important mental in- volvement in her work. There is always a great element of fear in the anticipation of taking an anesthetic, of surrender- ing consciousness, and of submitting to surgery, and there is perhaps no condition which the anesthetist dreads more in his subject than that of nervous apprehension, for as a rule an agitated or hysterical state of mind will reflect itself in the physical reactions to the anesthetic and will nearly always per- sist throughout the operation and the recovery from the anes- thetic. The muscles of the body in such subjects will be tense and this will entail shallow and irregular respirations and consequently slow and irregular absorption of the anesthetic. Crying will do the same and in addition will cause detrimental obstruction of the air passages by tears, mucus, and conges- tion. Conscious resistance by these patients will pass over into 173 174 TEXTBOOK OF SURGICAL NURSING unconscious struggling as the anesthesia develops, and will pro- long and complicate it in numerous ways. And finally, all these irregularities will use up valuable vitality and preclude the best anesthesia and recovery. This state of affairs the nurse can prevent entirely in some cases and to a great degree in most cases by judicious word and deed as she goes about the prepara- tion. This merely means that her general attitude will be re- assuring and encouraging, and that she will avoid as far as possible all reminders of the event for which she is preparing. Such conduct has, of course, been dinned into every nurse's ears continuously ever since she entered the hospital as the only kind which ever befits a nurse, but she must practice it in this case with the utmost degree of refinement. With this lesson well in hand the bodily preparation of the patient may be taken up. There will be specific orders by the surgeon, and these will vary in detail; and there will also be variations depending upon the anesthetic to be given and the nature of the operation. Nevertheless, though we can cover this ground in only a somewhat general way we shall enumerate the probable steps as follows: 1. A cathartic will be administered twelve or more hours be- fore the operation. 2. Six hours or more in advance food will be prohibited or perhaps restricted to fluids till two or three hours before the appointed time for the operation, and then nothing will be administered by mouth. It is obligatory that several hours of starvation immediately precede an anesthetic because anything in the stomach, even water, is likely to cause vomiting when the anesthetic begins to take effect, and this, besides being annoying, may have serious asphyxial results. In some cases the question of harmful prostration from lack of food may override the danger of its presence in the stomach, but care must be exercised in this event to give foods which the stomach will dis- pose of most rapidly such as broths, tea or coffee, etc.; and milk should be especially avoided for this reason, even in the tea and coffee. 3. The operative field may be prepared at any time, but this will usually be determined by order and by circumstances, and ANESTHESIA 175 suggestions pertaining to specific cases have been pointed out in their proper connections in Chapters IV to XI. 4. Several hours in advance one or more cleansing enemas will be given. This part of the preparation must be done with con- siderable caution because it must be remembered that the pa- tient has probably been subjected to vigorous catharsis which may have been exhausting, that the tonic effect of food has been denied, and that in any case an enema is liable to be prostrating. Nervous patients, and those in a state of reduced general vitality may entirely collapse under the administration of the enema at this time if care is not exercised. Plenty of time should be reserved for this treatment and all suggestion of haste should be avoided. 5. In cases of intestinal obstruction, other cases where the stomach is probably not empty, or where an operation is to be performed upon the stomach a lavage may be given. This is another treatment which calls for extreme calmness because it is always a trying and exhausting ordeal for the patient and those needing it will usually be in poor condition. 6. Immediately before the anesthetic is administered the bladder must be emptied and by catheterization if necessary. 7. The patient is clad in loose, simple clothing and plenty of it, according to the season. As a rule, a nightgown reinforced over the chest with a piece of flannel, loosely-fitting stockings, and a suitable number of blankets will comprise the wearing apparel. 8. False teeth, including detachable bridgework, will be re- moved and carefully laid away. 9. All jewelry is removed and safely cared for also. In cases where there may be prejudice on the part of the patient against removing some article of jewelry, such as a ring, it should be secured against loss by anchoring in place with a piece of tape or bandage. CARE OF PATIENT DURING ANESTHESIA The policy of calmness and reassurance which you adopted before beginning the preparation must be observed with re- doubled effort when the administration of the anesthetic is 176 TEXTBOOK OF SURGICAL NURSING begun, because, as pointed out above, the mental attitude of the patient will determine his behavior in general throughout his anesthesia. Absolute quiet in the room will be necessary for the best results, and talking or whispering, especially after the administration of the anesthetic has been begun, are par- ticularly objectionable because the sense of hearing is one of the last to be anesthetized and as it often functions capriciously at this time patients may get undesirable impressions from what is said. Furthermore, conversation often leads partially anesthetized patients to make efforts to participate in it and this will delay the anesthesia and aggravate the excitement. Also, too great caution cannot be taken in deciding when the sense of hearing has been entirely overcome and when it will be safe to indulge in professional discussion of the patient's condition which it might not be wise for him to hear. There will always be some degree of struggling, sometimes voluntary and nearly always involuntary, during the induction of the anesthesia, particularly in the case of ether, and the nurse will usually be expected to do guard duty against this. The arms and legs will be her chief concern, for though some- times a strong patient will endeavor to sit up and even thrust himself from the table, if the arms and legs are kept in place he is helpless further. It is sometimes the custom to restrain the legs by binding them to the table with a strong strap passed just above the knees. With a strong, healthy patient, which is the type most likely to cause trouble, this precaution may be necessary, especially if there are not enough assistants available to control him, for one assistant cannot manage such a subject; but this practice will be very exciting to some patients and should not be adopted unless absolutely necessary. For these excitable patients a good plan will be to have this strap ready and to defer the adjustment of it till a degree of unconscious- ness has been attained; or, some subjects will not be alarmed by this restraint if it is explained that you are applying it to prevent them from rolling from the narrow table after they have gone to sleep. In fact, this apology for the strap, if sincerely made, will sometimes comfort a nervous patient and ANESTHESIA 177 give him a sense of security, though one always runs a risk when undertaking this plan. In some institutions it is the practice to bind the arms, shoul- ders, and legs to the table with a few turns of a strong bandage, and the anesthetist is then able to proceed alone, but it will be a rare patient who will not suffer more or less under such treatment and it seems that urgent necessity is the only justifi- cation for it. Whatever plan may be adopted for guarding the legs, the attendant nurse's duty will be to care for the hands. Most patients are reassured by having their hands supported gently by another person at this time because they realize, of course, that they will soon be unconscious, and many have expressed apprehension of danger befalling their hands. With strong patients who may be expected to be exceptionally hard to con- trol, it will be best to ask them to place their hands comfortably upon the table at their sides and to turn the palms down- ward ; the nurse can place a hand gently upon each of his wrists (standing with face toward the anesthetist) and thus be prepared for the worst, for pressure upon the wrists can prevent the patient from turning his palms from the table and unless he can turn his hand he cannot arise. This will be an unnecessary precaution, however, for the average pa- tient, and the nurse's rule should be to advise him to put his hands where they are most comfortable and then, in a natural way, to place her own hands upon his wrists or forearms in such a way as to be prepared to foil any sudden attempt upon his part to do the instinctive thing of grabbing the inhaler. The nurse responsible for the hands should form the habit of following the pulse. Anesthetists will do this for themselves but there are times when they are so entirely occupied otherwise that many of them will be grateful for this assistance. In per- forming this service the nurse must know what variations to expect under the several anesthetics, and these we shall in- dicate on pages 178-180 where we discuss some of the reactions of patients to the more common anesthetics. Care should always be taken not to hold the hand of a pa- tient in such a way that he may grip it, for a strong one may 178 TEXTBOOK OF SURGICAL NURSING entirely overcome a nurse in this way when in the stage of excitement and he may even injure her. The foregoing comments will apply in a general way to subjects of all anesthesia, but as your specific troubles and duties will depend somewhat upon which of the several anes- thetics is used we shall take up separately each one of the four more common ones: nitrous oxide, ether, chloroform, and ethyl chloride, and point out briefly the usual behavior of patients under them and the corresponding nursing care. Nitrous Oxide.—The induction period of this anesthetic is very short, lasting only a few seconds and there will be little or no struggling, so the nurse's duties will not extend much beyond assisting the anesthetist in keeping the patient com- posed so that he will breathe deeply and regularly. The gen- eral precautions against excitability outlined above, however, should always be taken as occasionally they will be helpful. With nitrous oxide the pulse should not show much change, but should be regular, full and quiet. Ether.—This anesthetic calls for all the precautions men- tioned above because its induction period is relatively long, the anesthetic is comparatively disagreeable to take, there is almost always a period of excitement of greater or less dura- tion and severity, and there are numerous respiratory and other irregularities which may arise and call for a helping hand from the nurse. The anesthetist will, of course, guide the nurse's general course of action, but unless otherwise instructed she will make no mistake by following the more moderate course we have already advised. On the subject of restraint during the stage of excitement in the induction of ether anesthesia anesthetists will disagree. Some will prefer absolute resistance from the begin- ning to all efforts on the part of the patient, especially with his hands, and others will act upon the belief that early resist- ance to these efforts only aggravates them and will therefore ad- vise permitting any activity that does not displace the inhaler or allow the patient to harm himself or the attendants. Per- sonally, Ave have been entirely converted to this practice and are therefore inclined to advise the nurse to adopt it where she ANESTHESIA 179 is not otherwise directed by the anesthetist, but she must be very sure beforehand that she is prepared to carry it out success- fully, and must remember that even though the plan may suc- ceed at first, some cases will later compel her to abandon it for the sterner measures. With ether one expects the pulse to increase more or less in force and frequency, but extreme or sudden increase in fre- quency and other abnormal developments in the pulse will be matters of concern. Chloroform.—The induction of chloroform anesthesia is usually less eventful from the nurse's standpoint than that of ether, that is, cases of extreme excitement will not be so numer- ous; but they will occur and must therefore be kept in mind. There is one important difference between the two anesthetics which the nurse should note, and that is that ether is, in gen- eral, stimulating to the action of the heart in the early period of its administration Avhile chloroform is depressing. For this rea- son patients to Avhom chloroform is being administered should not be allowed the extreme activity during the stage of excite- ment which we have advised for those receiving ether. The anesthetist will control this, but we owe it to the nurse here to emphasize the fact that the method we recommended so highly for ether patients must be confined to them. The pulse of the chloroform patient is of comparative impor- tance. We haAre just remarked that chloroform depresses the heart, and so it does, but the nurse Avatching the pulse will notice that in the very beginning of the administration there may be a slight quickening of the pulse and a noticeable in- crease in its force. Very soon, however, there will be a gradual decrease of both which will probably extend below the level you noticed before the anesthetic Avas started. Extremes in either direction are, of course, danger signals. Ethyl Chloride.—Ethyl chloride is not in general use for pro- longed anesthesia, but it is popular in some communities for short operations and dressings which require only a few mo- ments. We mention it here since its administration Avill usually require the attendance of a nurse throughout because entire relaxation is rarely attained and restraint of hands or the part 180 TEXTBOOK OF SURGICAL NURSING operated upon will usually be necessary. Induction, entire anesthesia, and recovery will all take place Avithin a few mo- ments, and as vomiting often occurs very soon after the Avith- draAval of the inhaler, the nurse should be prepared for this from the beginning. With ethyl chloride the pulse should not show much change, as a rule, except perhaps a slight decrease of frequency and force. During the operation the anesthetist will be responsible for observing the general condition of the patient, but the operat- ing room nurse also should make it a rule to remember the pa- tient's condition and to be prepared to supply warm blankets, hot Avater bottles, hypodermics, etc., at any time. The tempera- ture of the room is also the nurse's responsibility, and she should remember that maintenance of the standard temperature (75°- 76° F.) and the exclusion of draughts have a direct influence in conserving the patient's well-being. AFTER CARE After the operation the nurse Avill usually be left entirely responsible for the preparation of the patient for the journey to his bed, and she will see that he is well wrapped in blankets. During anesthesia, especially with ether, there may be con- siderable perspiration, and as the outer halhvays through Avhich the patient is carried Avill doubtless be cooler than the operat- ing room and well supplied Avith draughts it will be very easy for him to become suddenly chilled and thus to contract bron- chitis or pneumonia. Also, ether patients have been given a predisposition to these two complications by the irritant effect of ether upon the air passages. In any other case, no mat- ter what the anesthetic has been, it must be remembered that the patient's vitality has been loAvered by both it and the operation itself and that he must be as well fortified as possible against the effects of sudden change of temperature. Special care must be taken also in handling an anesthetized patient, for violent or sudden change of position may seriously ANESTHESIA 181 interfere with cardiac or respiratory action either directly by overtaxation or indirectly by inducing vomiting and conse- quent choking, etc. Often, when ether or chloroform anes- thesia has been profound, the patient may be transferred to his bed without arousing him to any degree if he is handled Fig. 18.—An Easy and Safe Method of Lifting a Helpless Patient. The two nurses at the sides of the table are grasping a piece of heavy canvas, about 1 yard long and ^ yard wide, which lies across the table under the patient's hips. gently and quietly. A good method of lifting patients care- fully and easily is illustrated in Fig. 18. The bed should have been previously warmed with hot water bottles, a warm blanket should be placed directly underneath the patient and plenty of warm ones over him—that is, there are no intervening sheets. His bedroom should be well heated, draughts avoided, and the temperature of his body, particularly 182 TEXTBOOK OF SURGICAL NURSING the hands and feet, observed from time to time by feeling them. In warm weather, or when the patient is in good general health and the anesthesia has been slight or short (as in short admin- istrations of nitrous oxide or ethyl chloride) the blankets and some of the other precautionary measures may not be necessary, but the patient should, of course, be given the benefit of any doubt. Though events of recovery will depend somewhat upon the temperament and physical condition of the patient, there is a general course which may be expected for each of the anes- thetics and certain accidents and complications which are pe- culiar to each. We shall, therefore, discuss separately the re- covery to be expected from each of the four anesthetics. It must be remembered, however, in all cases that the nature of the operation modifies recovery to a greater or lesser de- gree, but your study of shock, hemorrhage, and other operative and post-operative complications will teach you to make the necessary differentiations. Nitrous Oxide.—Patients who have had this gas will recover within a very few minutes, as a rule, though the time will often be prolonged by hysterical outbursts of laughing, crying, etc. Nausea and vomiting sometimes occur, but they are in- frequent. Oftenest a patient will shows signs of lassitude and may sleep for a considerable time. Headache is not uncom- mon and may sometimes be very persistent. The pulse and res- pirations of these patients should ahvays be watched closely for some time, but as a rule recovery will be uneventful in these respects. Nitrous oxide subjects will usually be able to take nourish- ment comparatively soon after recovery, but the surgeon's orders will determine the nurse's course in this respect, as there Avill often be surgical reasons of Avhich the nurse may not know Avhich Avill control administrations by mouth. Comments on page 188 on the administration of water to ether patients will apply in general to nitrous oxide subjects, and detailed in- structions as to diets in all cases are given under the subject of surgical diets in Chapter XII, and in the discussions of the various operative conditions in Chapters IV-XI. ANESTHESIA 183 Ether.—Recovery from this anesthetic calls for careful nurs- ing, and patients should not be left alone for one moment until consciousness is entirely established, for whatever aid they may need during this time must be given promptly. Provision should be made early for the restraint of violence during recovery, for all the efforts incident to the stage of ex- citability in the induction of the anesthesia may be repeated during recovery. The favorite attempt of these patients is to Fig. 19.—Restraining Sheet for Patients Becoveking from an An- esthetic. Strong safety pins may keep this in place on the bed frame; if the bar to which it is attached is not cylindrical, friction will hold a tightly drawn and well tucked in sheet; or, the sheet may be passed entirely around the bed springs and the ends fastened together underneath. get out of bed, and if there are not enough assistants to control them throughout the period of this tendency a restraining sheet should be fastened across the bed just over the knees (Fig. 19). This will be of enough assistance, as a rule, so that one nurse can master the situation. The respirations should be watched closely, for there are many respiratory complications Avhich may arise before consciousness is regained. Regularly, the patient recovering from ether will breathe less deeply and vigorously than normally because, though ether acts as a stimulant early in its administration, 184 TEXTBOOK OF SURGICAL NURSING it eventually tends to depress the respiratory nerve center. The color of the face, particularly of the ears and lips, will be a good guide as to whether or not he is inhaling sufficient oxygen if it is not convenient to observe his chest motion. In this connection the nurse should remember that sedatives, especially morphine, if given recently, Avill probably have contributed to the depression and she will make allowance on that basis for abnormally slow or shallow respirations, but she should not be too slow to be alarmed by respiratory depression after an anes- thetic. In cases of extreme or sudden depression, while wait- ing for help, vigorous rubbing of the lips and face with a coarse towel may revive the patient somewhat, and of course the nurse is always prepared to give artificial respiration in cases of emergency. However, if the color and pulse are good and the patient is breathing unobstructedly .the best treatment is to leave him alone, for many will pass unconsciously from their anesthesia into a sound sleep from which they will awaken in an hour or two fully recovered and more comfortable for thus having passed away time which would otherwise have been very unpleasant. This last remark has been inspired by obser- vation of occasional instances in which concern has been felt for the patient who quietly "slept off" his anesthetic, and he has been aroused with no other effect than to bring him into earlier consciousness of his troubles than necessary. Other respiratory complications may arise early through occlusion of the pharynx by a swollen or flabby tongue or by accumulation of mucus or vomitus. This can usually be avoided by keeping the patient's head turned to one side during re- covery, or, if possible, by turning his entire body toward one side, both of which measures allow any fluid to run out of the mouth and also tend to throw the tongue and jaw forward and aAvay from the posterior wall of the pharynx. In cases of per- sistent tendency of the tongue to occlude the throat the simple pushing forAvard of the jaw may overcome the difficulty as this carries the tongue forward also. This is often hard for the young nurse to learn to do properly, but if she will first make sure that the teeth are not locked together and will then thrust the lower teeth in front of the upper ones, or as nearly so as ANESTHESIA 185 possible, she will accomplish all that she can by this measure. Sometimes, however, it may be necessary to reach into the mouth with a pair of tongue forceps (Fig. 20), or the fingers covered with a towel or piece of gauze, and pull the tongue forward and swab out the mucus with a sponge on a holder. For this it will be necessary to hold the mouth open with a mouth gag of some sort (Fig. 21) so as to prevent biting of the fingers, the tongue, or the sponge forceps. Occasionally a spasm of the jaw will accompany this condition and the patient will become very Fig. 20.—Suitable Instruments for Grasping the Tongue. The two having locks are the more useful because they answer also as sponge holders for swabbing out the throat, but when used for grasping the tongue care must be taken not to lock them so tightly as to crush it. . cyanotic. This calls for vigorous and quick action in prying the mouth open with a mouth gag and relieving the obstruc- tion as just described. In doing this great care must be taken, of course, not to injure the teeth. Nausea and vomiting will occur in an average of 50 per cent. of the ether cases. Some anesthetists show lower percentages than this, but half the cases will be a fair number to count upon. This should not persist for more than a few hours, though patients naturally subject to digestive disorders may be thus annoyed much longer. Special care must be exercised with the patient when vomiting as there is always danger of his inhaling 186 TEXTBOOK OF SURGICAL NURSING the vomitus and becoming asphyxiated by it; and it is also pos- sible that inhaled vomitus is responsible for some cases of "ether pneumonia." Also, his eyes must be shielded from the vomitus as they may be considerably irritated by it and de- velop a troublesome and painful case of conjunctivitis. When consciousness has been recovered to some degree the coughing reflex will function and the patient will be able to save himself from the asphyxial danger by coughing, but in any case his head should be held to one side while vomiting and the mouth Fig. 21.—Mouth Gags. A, a simple wooden wedge which is very safe and very serviceable for prying the teeth apart, as well as for holding the mouth open temporarily for swabbing, pulling the tongue forward, etc.; B, metal gag which can be inserted only after the teeth have been well parted, but which is self-retaining when well placed. swabbed clean if necessary. The character of the vomitus should always be noted. In ether cases there is likely to be much mucus, as ether stimulates all secretions more than the other anesthetics; and there Avill be indications of bile some- times, and of stomach secretions. If blood is present it will be a matter of special concern. HoAvever, if the operation has been upon some part of the mouth, nose, throat, or stomach, it must be expected that old blood ("coffee grounds") which has been spilled or swalloAved Avill be vomited. Bright red blood is alarming also, but a bitten tongue or a loosened tooth may be the contributing agent of this. Any case of unusual vomitus, ANESTHESIA 187 however, should be reported to the surgeon as it will usually call for investigation by him. The pulse, of course, is Avatched closely. That, too, will be somewhat depressed, at least for a short time after the patient's return to bed, but Avithin an hour or so it should shoAV signs of recuperation. There are several odd manifestations which may accompany recovery from ether, such as tremor, hiccough, etc., but they are usually transitory and are not seriously significant unless they persist unduly. It is very likely that the patient Avho has mani- fested the tremor during the induction of his anesthesia will do so again when he recovers, but the nurse must not make the mistake of overlooking a real chill in these patients because the two conditions are easily confounded and a chill, as every nurse knoAvs, is not to be taken lightly. LikeAvise, persistent hiccough should be regarded seriously because, aside from be- ing very distressing to the patient, it may signify something deeper than a mere irregularity of recovery of consciousness. Pulmonary edema is another complication of ether anes- thesia, though it is an infrequent one. The nurse has doubt- less learned elseAvhere the symptoms of edema of the lungs and will at once recognize the unmistakable sound caused by the great quantity of mucus Avhich has accumulated in the lungs and is being "Avashed" back and forth with respirations. A collection of thick mucus in the throat will sometimes cause a similar sound and even a degree of the cyanosis so prominent in edema, but SAvabbing of the throat and observations of the patient's general condition will quickly tell the nurse whether or not to be alarmed. Another complication to be feared and guarded against is "ether pneumonia." It is not frequent, but the nurse must always bear it in mind. General nursing training will have taught the nurse the warning signs and symptoms of pneu- monia, so Ave shall not take space for them here. Some authorities attribute one or tAVO kidney disorders to ether, chiefly that of albuminuria and sometimes suppression. Urinalysis will show that albuminuria often does arise after anesthesia; but whether it is caused by the anesthetic or by 188 TEXTBOOK OF SURGICAL NURSING something else will not concern us here as its treatment, if there is any, will be by prescription only. Suppression, of course, Avould be a serious condition but it is a nursing prob- lem here only in so far as the nurse will be responsible for reporting as to whether or not evacuations of the bladder occur normally. This subject is entered into more fully in Chapter III, page 32, under post-operative complications. The voiding of urine is always a matter of attention after anesthesia and if it does not occur normally, or nearly so, it must be regarded with concern. This may be due to suppres- sion, Avhich may or may not have reference to the anesthetic; but it Avill be very much more likely to be due to some deranging effect of the anesthetic or the operation upon the nerve-control of micturition Avhich causes retention. The early training of the nurse will have prepared her for overcoming mild cases of retention, and the subject is discussed more fully in Chapter III, page 31; but she should seek guidance in all cases of failure to void urine Avithin a few hours after recovery because this is a very important avenue of elimination of the anesthetic and any obstruction of it must be promptly removed. The nurse will be guided by the surgeon's orders as to the administration of nourishment, because this will depend largely upon the surgical condition of the patient as well as upon the individual customs of the surgeon. Patients will be very thirsty from the earliest moment of recovery and will desire large quantities of water. Some surgeons will advise satisfying this longing generously, except, of course, in stomach or other cases where it will be harmful to the wound itself; and other sur- geons will prescribe extreme moderation, even to the extent of allowing only small pieces of cracked ice. Every nurse knows that more than the most meager quantity of water ag- gravates nausea and vomiting in the vast majority of cases, but it is also a fact that plenty of water and the usual prompt vomit- ing of it will often have a sedative effect upon a turbulent stomach by cleansing it thoroughly of the disturbing contents. This treatment, however, is so heroic that the average nurse shrinks from it and she should not administer it except under definite order because there are many cases in which vigorous ANESTHESIA 189 vomiting would be very dangerous from the surgical standpoint, to say nothing of the pain suffered by the patient. Further discussion of this subject will be found in Chapter III, page 20, under post-operative complications. In cases where Avater is forbidden the distressing parched condition of the mouth may be relieved by sponging with a lubricating mouth Avash—one containing glycerin, for example. Rectal administration of salt solution may sometimes be em- ployed to relieve the extreme thirst of those patients who must be denied Avater by mouth, but this treatment is not given Avithout definite order. Many patients will be greatly distressed by the lingering disagreeable taste of the anesthetic. The nurse may relieve this Avith a mouth wash containing a generous amount of lemon juice, tincture of myrrh, etc., according to the preference of the patient. The point at Avhich food will be given is also a matter for the surgeon to decide, but as this pertains more particularly to the subject of surgical diet it is discussed under that head- ing in Chapter XII, and in connection Avith specific operative conditions in Chapters IV-XL Chloroform.—Recovery from chloroform requires the same watchful nursing as does that from ether, but it is likely to be less eventful. As a rule the patient will remain quiet and pass from his anesthesia into sound sleep. Nervous and excitable patients may have a period of excite- ment which will necessitate the same precautions as to restraint mentioned for ether subjects, but such cases will be compara- tively rare. Chloroform does not often produce the profuse secretion of mucus nor the swollen tongue so usual in ether subjects, and therefore these patients will not be so prone to the respiratory obstructions which frequently complicate recovery from ether. In fact, it is rare that the respirations Avill manifest any note- Avorthy feature beyond the characteristic softness and quiet- ness. Nausea and vomiting will also be less frequent, though when vomiting does occur it is more likely to be severe and persistent 190 TEXTBOOK OF SURGICAL NURSTNG than after ether. The precautions mentioned for cases of vomiting after ether apply equally to chloroform subjects, with the addition of the one discussed in the following para- graph. Chloroform subjects very frequently exhibit considerable pallor and this will usually be accompanied by marked depres- sion of the pulse. These two symptoms are especially likely to occur just before or during Aromiting, and as their severity will usually depend upon the severity of the vomiting and the excite- ment accompanying it the nurse can often prevent considerable exhaustion and even collapse by judicious management of such cases. The pulse is likely to be comparatively feeble throughout re- covery from chloroform, and, as pointed out in the preceding paragraph, is subject to periods of great depression. This makes it advisable to exercise special care to keep these patients quiet. though, as Ave have said, quiet reco\Tery is provided by nature in the great majority of chloroform subjects. Hiccough Avill occur occasionally, but as in the case of ether it will not often be of great consequence. Bronchial and pulmonary complications are not frequent after chloroform because the anesthetic is not so irritating to these parts and does not cause the severe congestion of them that ether so often does. However, they are not entirely un- knoAAm and the nurse should not forget their possibility. Though kidney complications, beyond albuminuria, are not attributed to chloroform, the voieling of urine is an important matter of nursing attention, as in the case of ether. The discussion of nourishment in the case of ether will apply in general to chloroform. Ethyl Chloride.—Complete recovery of consciousness after ethyl chloride usually takes place Avithin a very few minutes. Occasionally there will be a case of collapse, but this will usually occur before the responsibility for the patient has been trans- ferred from the anesthetist to the nurse. HoAvever, when col- lapse does occur it is so sudden and so profound that the nurse should keep its possibility in mind. ANESTHESIA 191 Headache, nausea, and vomiting occur frequently, and they may be severe. The pulse, respirations, and general condition will, of course, be carefully Avatched for some time, as in all cases of anesthesia. Subsequent treatment as to nourishment, etc., will correspond in general to that for nitrous oxide cases. For lack of a more opportune moment Ave must mention now the matter of the removal of the extra blankets Avith which the anesthetic subject has been safeguarded. There can be no rigid rule laid doA\m as to Avhen this should be done, as there are too many varying factors to be considered. Some of the deter- mining factors, excepting the self-evident one of recovery from the anesthetic, are these.: The particular anesthetic given; length of the anesthesia; condition of the patient; season of the year; temperature of the room; and, of course, ahvays the subjective comfort of the patient. For the same reason that the blankets A\7ere put on, care must be exercised as to their re- moval; that is, there must be no chance of exposure taken. In this respect error may be made in both directions, for it is as much a mistake to leave these blankets on so long after recov- ery that the patient becomes unduly warm as it is to take them off before nature's "heating plant" is in Avorking order. In hospitals there Avill usually be an established routine, and else- where the nurse Avill need to draw upon her professional good judgment. Entire recovery from the anesthetic is the first requisite. This Avill mean that nitrous oxide and ethyl chloride patients, if they have blankets at all, will not need them as long as ether and chloroform subjects. A vigorous, generally healthy subject Avill recover all his functions much sooner after any anesthetic than a weak, devitalized one. After recovery the patient in poor condition may need protection further, Avhile the stronger one may not. In winter longer protection will be needed than in summer. In a Avarm room more freedom can be taken than in a cold one. In the daytime patients have better resistance, on the whole, than at night. And last but not least, the patient's feelings, Avhich ahvays have an influence upon his condition, will enter into the case to some degree. 192 TEXTBOOK OF SURGICAL NURSING Naturally, this transition is accomplished gradually, that is, these special blankets are not all AvithdraAvn at one time. This much having been said, common sense will do the rest. All nursing care folloAving an anesthetic must be a fusion of that which pertains particularly to the anesthesia and of that demanded by the surgical condition of the patient. We have necessarily disregarded surgical conditions here, but their im- portant nursing care is pointed out under the discussions of the various operative procedures in Chapters IV to XI; under shock and hemorrhage, in Chapter II; under post-operative com- plications, in Chapter III; and under surgical dietetics in Chap- ter XII. By combining the discussions of the subject from these several standpoints the nurse can formulate for herself the befitting twofold course of action demanded of her for each individual case. CHAPTER XIV ARRANGEMENT, ORGANIZATION, AND EQUIPMENT OF THE OPERATING THEATER Operating room nursing is one of the advanced subjects of the profession and should not be undertaken until the student has had a long period of general training in bedside nursing and her courses of instruction in general theory, bacteriology, solutions, materia medica, etc.; for, while she will learn much in the operating room that is neAV to her, the work there is very largely a matter of piecing together and developing the frag- ments of knoAAdedge and practice of her preliminary courses. The task of teaching operating room nursing, and particularly the organization and management of it, to any great degree of detail is a very difficult one because so many variations must be allowed for individual preferences of surgeons, the equip- ment provided by the given hospital, and the number and quali- fications of the members of the staff. There is no one known plan which can be called superior to all others, nor need there be, for if the student masters the fundamental principles of asepsis and antisepsis and has at least the average amount of common sense and a logical, systematic turn of mind she can adapt these principles so as to work out a good system under any given set of conditions. We shall not attempt, therefore, to tell you how to organize and conduct a model operating room, but rather, we shall try so to instruct you in foundation principles that you may equip yourself to organize and manage one that will be a model for your particular limitations or ad- vantages. As Ave shall try to present this subject so as to make it useful for all classes of readers, each one will necessarily find much that will not be of value nor interest in her particular case; but the nature of the subject makes this inevitable, so we must beg your indulgence for those parts Avhich may seem too elementary 193 191 TEXTBOOK OF SURGICAL NURSING or self-evident to you, or which seem very foreign to your case, and ask you to believe with us that they will meet the needs of someone else. Much that must be said here to make the discussion com- plete Avill be of more value if studied in combination Avith the practical experience in the operating room itself; but the prac- tice of plunging a pupil directly into the actual Avork from Avhich she is expected to gather her knoAvledge as occasion chances to present itself is to leave her education too much to the mercy of her own enthusiasm and the uncontrollable irregu- larities of the work. A few preliminary classroom lessons be- fore she is rushed into the confusion and excitement of the operating room Avill conserve much of the pupil's nervous energy, Avill save much valuable time for both herself and the other members of the staff, and she will have a sounder edu- cation for having acquired it in an orderly, logical way. We strongly advocate the doctrine that every nurse should be given a thorough course in operating room technic, not only because of the countless number of additional facts she learns thereby which are essential to the highest efficiency in what- ever specialty she may adopt after she has graduated, but also because of the general educational value of the discipline it gives her in alertness, accurateness, and promptness of re- sponse. However, there are relatively feAv nurses who should aspire to become operating room "specialists," because the Avork is a highly specialized type of nursing, and certain natural as well as cultivated qualifications are necessary for more than mediocre efficiency in it. We do not knoAv any more about the universally model operating room nurse than Ave knew a few moments ago about the universally model operating room itself, but a few pages hence we shall attempt to set up a few stand- ards Avhich will apply universally. A thoroughly logical sequence in the presentation of the al- most innumerable phases of this subject is very difficult to ar- range, but as a nurse knoAvs in a general way, before taking up this course, what an operating room is for, she will perhaps EQUIPMENT OF THE OPERATING THEATER 195 do best by beginning here with a picture of its general arrange- ment and equipment. THE ROOMS AND THEIR FURNISHINGS Ideally the operating theater comprises these rooms: 1. Operating room proper 2. Anesthetizing room 3. Dressing room for surgeons 4. Dressing room for nurses 5. Recovery room 6. Work room for nurses 7. Sterile supply room 8. Sterilizing room 9. Storage room Of course, this exact number of rooms may never be available, but they do represent departments, and Avhatever space is pro- vided should be subdivided and arranged Avith these separate features in mind. By the time you have finished this chapter we shall hope to have assisted you to enough ideas to enable you to make the best combination of these departments which your space permits. When practicable the operating theater is on one of the higher floors of the building because in this location it is most likely to be isolated from miscellaneous traffic and undue noise and dust, all of which are menaces and nuisances to an operating room. 1. The Operating Room Proper.—a. Construction.—This is, of course, a light room and it has a northern exposure if pos- sible because of the better diffusion of light it Avill furnish than one into which strong rays of sunlight stream in some parts, caus- ing deep shadows in others; and a skylight Avill be an addi- tional advantage. The size of the room is best no larger than is necessary for holding the equipment and alloAving the mini- mum space for comfort in moving about. Too large a room is Avasteful of time and steps, and too small an one, of course, will be too congested for the easy maintenance of asepsis, be- cause there are always the sterile and the unsterile equipment 196 TEXTBOOK OF SURGICAL NURSING in more or less close association. Unless one has the pleasure of planning the construction of her oavii operating room, Iioav- ever, she will not be able to control this feature of the matter beyond exercising good judgment as to arrangement of con- tents and organization of routine practices. It ought not to be necessary to remind you that the walls, floors, and all other structural parts of the room should be finished in the most hygienic way possible; that is, they should be of some material that can be easily Avashed and that Avill not catch or hold dust readily, for example, tiling, enamel paint, etc. Those of you Avho have had the advantages of training in a hospital built on modern architectural principles will have observed the curve, for instance, in which the wall and the floor meet instead of the old-fashioned right-angle which is such a safe harbor for dust and such a good incubator for germs; you will probably have noticed also that the corners of the Avails are fashioned similarly; also, the Avindow ledges Avere probably slanting or curved, and all AvindoAv casings, door casings, and other finishings Avere as free as possible from nooks and corners. This has all been provided for you and you have taken it for granted, but you should appreciate the principles involved so that if it falls to your lot at some time to control the adaptation or construction of some room for operating pur- poses you may be able to be of the best service. On this same principle, a good technician does not provide wall hooks in her operating room upon Avhich careless persons may hang various articles Avhich lumber up the room and en- courage contamination. The storage and supply rooms are the proper places for all articles which are not needed for the opera- tion, and between operations the storage and supply rooms are the places for everything except the more non-transportable fur- niture. Under some conditions of room arrangement where space is limited the operating room may have to bear a part of the burden of storage, but in any case one must ahvays follow the principle of keeping all supplies protected as far as pos- sible. This practice is not only refined technic but it is also simple common sense in that it saves the time and labor of unnecessary renovation. EQUIPMENT OF THE OPERATING THEATER 197 Good ventilation must be provided, and some way should be found to do this without permitting a draught directly through the room. Heat shoidd be generous, as the temperature of an operating room should be maintained at 75° or 76° F. Fig. 22.—Two of the More Elaborate Types of Operating Table. b. Furniture.—The ideal material for all operating room fur- niture is white-enameled metal, as it is durable and sanitary. The first essential is the operating table. There are innumer- able models on the market and the one chosen will depend upon financial resources, preference of the surgeon, etc (Fig. 22). 198 TEXTBOOK OF SURGICAL NURSING Many of the more expensive tables are very complex in their mechanism, and as the average nurse is not mechanically in- clined she finds it difficult to learn how to manipulate them; but as it usually falls to her lot to see that the patient is placed in the proper position for the operation, she should consider it her business to master the mysteries of her table, as all the at- tachments and adjustments serve some helpful purpose if the responsible person knoAvs hoAv to put them to their intended use expertly. This may seem a minor detail but operating room work is made up of detail, and, like a delicately adjusted machine, if one part functions poorly it is very likely to cause embarrassment to the Avhole machine. For instance, in the case of operations upon the kidney Ave have seen it necessary for the surgeon, after struggling many precious minutes against the handicap of an improper position of the patient, to stop operat- ing, dress the wound temporarily, unsterilize his gloves and gOAvn, and adjust the patient's position himself. This is an extreme illustration because of the fact that, for anatomical reasons, the kidney is difficult of access in the best of positions, but corresponding annoyances in many other cases may arise from lack of intimate acquaintance with this very essential arti- cle of equipment. One or tAvo instrument tables are the next essentials. If there is but one operation to be done one table is enough, but Avhere there is to be a session of several cases it will be necessary to have a second table for the reserve supplies. Many varieties are in use (Fig. 23) and there is no importance in the design of any one except Avhen one is desired which can be placed across the operating table near enough to the Avound so that the surgeon can pick up the instruments from it himself. For this purpose a type similar to the one illustrated in Fig. 21 Avill be needed. This is a very serviceable table, as it is ad- justable in height, is on rollers, and can thus be easily adapted and moved as convenience requires. A table for dressings and other miscellaneous supplies will be needed in nearly every case. This should be no larger than necessary. One or more stretchers are necessary. In a large hospital EQUIPMENT OF THE OPERATING THEATER 199 where space permits and elevators are used, the wheel stretcher (Fig. 25) will be the one to provide, but in many smaller in- Fig. 23.—Two Varieties of Instrument Table. stitutions the carrying variety (Fig. 26) can be made to an- swer all purposes; but where there is much carrying up and Fig. 24.—Adjustable Instrument Table Which May be Extended Across the Operating Table in Any Location Desired. The cover shown is the one described on page 216, paragraph No. 13. down stairs to be done the special design shown in Fig. 27 is very serviceable. 200 TEXTBOOK OF SURGICAL NURSING A tub or large basin holding 6 or 8 gallons will be needed in large operating rooms for a 1-1000 solution of bichloride which will serve many useful purposes from time to time. Fig. 25.—Wheel Stretcher. Other minor articles for this room are, a seat for the anes- thetist or surgeon (Fig. 28) ; possibly a small table for unsterile u u Fig. 26.—Carrying Stretcher. This is, in general outline, the U. S. Army type. Fig. 27.—Stretcher Suitable for Carrying Patients Up and Down Stairways. It is merely a bent iron tube covered with canvas slip covers. Some models have a single piece of canvas shaped like the frame and laced to it with a strong cord passed through eyelets in the border of the canvas. supplies such as adhesive plaster, bandages, etc.; and a set of low benches (Fig. 29) of differing heights for the surgeon to stand upon for some operations. These should range in height EQUIPMENT OF THE OPERATING THEATER 201 from 4 inches to 1 foot, and they should be about 1 foot wide and 2 feet long. Various kinds can be purchased from hospital supply companies, but they do not furnish the useful grada- tions in height, and as they are usually made of metal they are not so con- venient to handle as are the simple wooden ones suggested in the illustra- tion. A good artificial light is of course necessary, but the only general sugges- tions that can be offered about this are that it should be so placed that the operating table need not be moved when a shift is made from the daylight to the artificial one; and that it should be simple in its fittings for sanitary reasons. Unless one has an elaborately adjustable one it should be supple- mented by a simple "drop" or hand Fig. 28.—Seat for the light (Fig. 30) which will be needed Anesthetist or Surgeon. occasionally in the case of a deep or inaccessible wound. The type shown in the illustration can be draped with a sterile towel when necessary. This is enough furniture to get along with, and the guiding Fig. 29.—Bench for the Surgeon to Stand Upon When the Operat- ing Table Cannot be Adjusted Suitably in Height. These may be very simply made of wood, and several heights will be useful. principle in amount of furniture should be not to encumber the room with more than is reasonably necessary. There is one other item to be mentioned in this connection because, while not a necessity, it is a great convenience and a 202 TEXTBOOK OF SURGICAL NURSING general favorite. It is the "drum" (Fig. 31), or metal con- tainer in which the dressings and other fabrics are sterilized and from which they are used directly while the operation is in — ■ 1 ^ii0e^m " ^SK^^^XMMI^^ ■■MMBjgWpMjjB ^^*" Fig. 30.—Hand Light. progress. It is made Avith perforations which are opened to admit the steam while in the sterilizer, and closed afterward, making the drum very safe and dust-tight. The lids of these drums, when in use, are opened and closed by means of a foot lever on a specially fitted stand, and they thus provide a very convenient storage me- dium. For a complete system several drums will be needed; for example, the gloves cannot be kept with the wound dressings because they are covered with talcum powder and this sifts from them when they are handled; also, for reasons which you will learn later, it is not good technic to store the sterile goAvns with the wound dressings; and it may not be con- venient to have the draping sheets and towels in the same part of the room, or even in the same room, with any of the other supplies. Thus, you will need at least four drums if you have any, and when this system is used there is usually included a fifth drum for hot wet towels and pads (Fig. 32). Here we must digress somewhat to say that this hot towel drum is similar to the others except that it is perforated in the bottom and is fitted over a Fig. 31. — Dress ing Drum with Ped al Opening Stand ARD. EQUIPMENT OF THE OPERATING THEATER 203 small water tank which is heated electrically or otherwise, thus alloAving the towels to become wet and heated by the steam. Be- sides the set of drums in use, as outlined, there will be needed reserve ones, so this involves a considerable equipment which will be too expensive in some instances; and besides there will some- times be the consideration of storage space because these stands and drums require more space for a given amount of contents than do the simple muslin-covered parcels which you would otherwise use. Fig. 32.—Hot Towel Drum Fig. 33.—Instrument Steril- with Pedal Opening Standard and izer. Electrically Equipped Steaming Device. c. Sterilizers.—Where space permits the instrument sterilizer (Fig. 33) should be within the operating room and as near the instrument table as is practicable and safe, because frequent reboiling of instruments is usually necessary during an opera- tion and it saves time and handling if the person responsible for the instruments has direct, easy access to this boiler. When this sterilizer is heated by gas or any other open flame it must be stationed a safe distance from the anesthetist because ether, chloroform, and ethyl chloride are highly inflammable. Fur- 204 TEXTBOOK OF SURGICAL NURSING thermore, extreme heat, and particularly an open flame, will decompose chloroform vapor and produce phosgene and hydro- chloric acid gases which, in a small or poorly ventilated room, may cause serious trouble by their irritant effect upon the eyes and the respiratory tract. In some cases one sterilizer may have to suffice for all other supplies as well as the instruments; but where possible there should be another large utensil sterilizer (Fig. 34) for large basins, etc. This should be in the operating room also when possible. Besides the reason of convenience for having these boilers within the room, there is the technical reason that the steam which they give off renders the air moist and thereby keeps down dust which might some- times be a real menace in a dry atmosphere. Water Sterilizers (Fig. 35), one for hot sterile water and one for cold, and equipped with a filter, will also be necessary. These are perhaps best placed outside of the operating room, but their outlets should be ex- Fig. 34.—Utensil Sterilizer. tended into the room at some easily accessible point. d. Miscellaneous Equipment.—There are a great many other devices which are in more or less general use and which, if properly fitted into a corresponding general system, simplify the work. In fact, those who have become accustomed to the more elaborately outfitted operating rooms and who have never been compelled to work more primitively will consider indis- pensable many of these items; but as they are more or less luxuries we shall not take space here to enumerate them. 2. The Anesthetizing Room.—a. Construction.—The finish- ing of the walls, floors, etc., should be similar to that described for the operating room, because where there is a separate room EQUIPMENT OF THE OPERATING THEATER 205 for this purpose all of the final preparation of the patient is done in it and it should therefore be sanitarily fitted. It should be a reasonably spacious room because a great deal of both sterile and unsterile work Avill be done in it, and, as pointed Fig. 35.—Hot and Cold Water Sterilizers. The small cylindrical at- tachment between them contains a clay filter through which the water is forced before it enters the tanks to be sterilized. This filter is removable and must be cleansed often by scrubbing under running water with a very stiff brush. The cold water tank has a coil of tubes running through its interior through which cold water may be run for cooling the sterile water after it has been boiled. These sterilizers are built to withstand high steam pressure and are usually adjusted so that the water may be ster- ilized under 15 pounds pressure which, as will be explained later (page 239), raises its temperature about 38° F. higher than that of boiling water. out for the operating room, there must be ample room for keep- ing the sterile equipment well out of the way of the unsterile. Ventilation and heating should correspond with that of the operating room. b. Furniture.—First of all, there must be a table or a wheel 206 TEXTBOOK OF SURGICAL NURSING stretcher for the patient. In generously equipped operating rooms where several operations are done in immediate succes- sion there Avill doubtless be an extra operating table for this pur- pose and the patient will be anesthetized upon the table upon which the operation is to be performed. OtherAvise, a wheel stretcher or some other type of table Avill be needed. There Avill also be needed a small table for the anesthetist's supplies. This may be one that is fitted with wheels so that it may be taken into the operating room during the operation, but the articles needed by the average anesthetist after the anesthesia is established are so few that it is perhaps not ad- visable to have more than a simple stationary stand in the an- esthetizing room. A table for miscellaneous articles will be necessary and this one should be spacious because Avhen the preparation and sterile draping of the patient are done in this room expediency will require that many odds and ends, such as sandbags, pilloAvs, rubber sheets, operating table attachments, etc., be Avithin easy reach. When there is enough space to make it technically safe the sterile draping supplies may be kept in this room during opera- tions and for this purpose there Avill be needed another table, except Avhen the "drums" are used, in Avhich case one packed exclusiArely Avith draping sheets and towels Avill take the place of this table. The drum is so securely closed that there can never be any objection to having it in the anesthetizing room. A chair or two may be useful in this room. When limited space makes a separate anesthetizing room im- possible, the anesthetic Avill be administered in the operating room itself, and this will require great caution as to the sterile drapings and supplies, for there is ahvays more or less commo- tion attendant upon the induction of the anesthesia and the preparation of the patient in the form of struggling of the patient and the necessary handling of blankets, etc. 3. Dressing Room for Surgeons.—a. Construction.—The walls and floors of this room should be similar to those of the operating room. b. Furniture.—Wash basins with hot and cold running water EQUIPMENT OF THE OPERATING THEATER 207 are the important essentials of this room, and if possible pedal faucets (Fig. 36) should be installed with them. The number of basins will depend upon circumstances and the number of surgeons operating at one time. One or more "arm basins" should be provided for the anti- septic solution in which the hands and arms are sterilized after scrubbing. Standard ones (Fig. 37), holding enough solution so that the Avhole arm up to the elboAv may be immersed are best, but large ones of other design will serve. Fig. 36.—Wash Basins Equipped with a Pedal Device for Turning the Water On and Off, and with a "Goose-Neck" Faucet, Which Per- mit Scrubbing of the Hands and Arms Without Contaminating Them During the Process. Where possible individual lockers should be provided in this room for the surgeons. Some provision must be made for the surgeons' sterile suits or gowns. The drum answers this purpose admirably, but in lieu of this a table will be needed for these sterile supplies which will be packed in individual parcels or stored immediately in advance on the sterilly draped table. A few chairs will be appreciated in the dressing room. 4. Dressing Room for Nurses.—This room should be essen- tially the same in equipment as the one for the surgeons, but 208 TEXTBOOK OF SURGICAL NURSING it may not need to be as large, though this will depend upon the relative number of nurses using it. 5. Recovery Room.—Where space and nurses are plentiful one room may be equipped with one or more beds and with paraphernalia for the resuscitation of the occasional patient who may need immediate treatment. In other cases this room will be convenient for use in transferring the patient from the operating table to the stretcher, and for the application of bandages, plaster casts, splints, etc. Fig. 37.—Two Types of Arm Basin. 6. Work Room for Nurses.—a. Construction.—This is a department of the operating theater which is often neglected in hospital architecture, for the fact is probably overlooked that it is in this room that the nurse spends the major part of her time and does the bulk of her work. For this reason the work room should, first of all, be well lighted both naturally and artificially, and of course well ventilated and comfortably heated. While it is advisable that this room should be sani- tarily finished on the general principles of the operating room, it is not so important. b. Furniture.—Ample work tables, chairs, dust-proof storage EQUIPMENT OF THE OPERATING THEATER 209 shelves and closets, a gas or other stove, and spacious washing sinks cover the essential furnishings for this department. 7. Sterile Supply Room.—Where practicable this room should be reserved entirely for the sterile supplies, and it should, of course, be kept as free as possible from dust and moisture. We Avould caution nurses Avith limited space at their disposal to employ only as a last resort any part of the work room for the storage of sterile supplies, as it will probably be the least clean room of all. 8. Sterilizing Room.—a. Construction.—The walls and floors of this room must be finished so as to be waterproof, as the steam from the sterilizers Avill ruin anything else, and water will unavoidably be spilled upon the floor from time to time. This room must be well ventilated, and because of the water in the sterilizers and plumbing it must be avcII heated to prevent freez- ing in winter time. b. Furniture.—A work table will be needed, and perhaps storage shelves, but this will depend upon Avhether the packing of the supplies for sterilization is done in this room or in the nurses' work room. The chief equipment is the steam dressing sterilizer (see Fig. 49, page 238). The number, size, and variety will be governed by innumerable conditions, but it must be remembered that only those which provide for live steam sterilization under pressure in a vacuum are to be depended upon for absolute sterilization, particularly of large parcels Avhich are difficult of penetration by the steam. If a room cannot be devoted entirely to this purpose the sterilizing department may have to be combined Avith either the work room or the supply room, or even both, but strong objec- tions to storing the sterile supplies in the sterilizing room are that the steam keeps the room damp, and there is always danger of water being spilled upon the sterile parcels which will, of course, unsterilize them. 9. Storage Room.—This will be a convenient room to have in which to keep infrequently used and reserve unsterile sup- plies, and miscellaneous portable appliances, but in its absence the nurses' work room may have to serve instead. As advised 210 TEXTBOOK OF SURGICAL NURSING above, have some corner devoted to this class of supplies and form the habit of leaving nothing portable in the operating room which has no useful immediate function to perform there. THE PERSONNEL The scene is now laid and Ave have a roughly furnished oper- ating theater. Before Ave go further Ave shall put some people into it to do the hundreds of things which remain to be done before Ave are ready for our patient. 1. Personal Qualifications.—In the first place, one must be very strong physically to endure the strain and severity of oper- ating room Avork. Hours of application are likely to be longer, and at all times the Avork is more intense than in any other type of nursing, and a strong body is the only one that Avill hold out to the bitter end. Patience and forbearance are also more in demand, and for longer periods than elsewhere. The nature of the Avork re- quires that no time be lost and no mistakes made, and conse- quently everybody is more or less under nervous tension, which means that the nurse will not ahvays receive the consideration from her superior officers Avhich she has been accustomed to receiving in other lines of her Avork. Orders are more numer- ous, and often conflicting, and if the nurse has not the maxi- mum amount of the proverbial patience and self-effacement Avhich are ahvays urged upon her profession she will often fare rather uncomfortably in the operating room. Alertness of mind, self-control, and promptness of conversion of thought into action are other indispensable qualifications for real efficiency. A patient is under an anesthetic and under- going interference Avith his life mechanism, Avhich means that emergencies are always arising, and the nurse avIio "loses her head" is not popular, to say the least, on an operating room staff. Conscientiousness, though essential and presupposed through- out the professional activities, is obligatory here. When an op- erating room nurse reflects that a single chance taken under pressure of orders or time may cost the health or even the life EQUIPMENT OF THE OPERATING THEATER 211 of another person she Avill never yield to any circumstance on this point. While all the foregoing qualifications are important, perhaps the one which distinguishes the operating room "genius," so to speak, from the others is the power to think, plan, and work logically, consistently, and methodically. You Avill say that this poAver is an asset in any Avalk of life, and so it is, but it is use- ful here to the utmost degree, and its lack is nowhere of more hindrance than in the operating room. This not only applies while the operations are going on but also in the daily routine of the department; for there is a multiplicity of detail in this work which, if muddled by cloudy thought, can become more of a squanderer of time, energy, and service than any other thing Ave can think of. These are all desirable qualifications. You have some of them, and perhaps you are particularly fortunate and have all of them; but at any rate you can acquire at least a degree of each of them, and you must do so if you wish to succeed in the operating room and enjoy the work there as you should. 2. Division of Duties.—This is a subject upon Avhich it is useless to say much because the number of persons on a staff is determined by varying and numerous circumstances, and therefore the apportionment of the work will be different in all cases. However, the principle of "division of labor" should be applied as minutely as possible, particularly in a large operat- ing room Avhere a great number of cases are done in one session. By "division of labor" we mean, of course, the practice whereby each person's work is clearly defined for her so that she is held responsible for the same thing at all times, and so that her activi- ties do not overlap those of the others on the staff. Hoav this is done will depend upon the number of persons on the staff, the arrangement of the operating theater, the number and nature of the operations, etc; but the principle should be to aim to have as many persons as are necessary to permit division of the Avork logically up to the point where each one has only the amount of work to do which she can get done with reasonable ease. More work than this for each person causes confusion, 212 TEXTBOOK OF SURGTCAL NURSING delay, and general inefficiency; and less than this amount is extravagance. Variations in the qualifications and capacities of the individuals for hard Avork, whether they are graduate or pupil nurses, orderlies, etc., will also modify this division of labor, but it Avill not affect the above guiding principle. 3. Discipline.—In general, the organization of an efficient operating room staff as to authority, sj'stem, division of duties, thoroughness, attention to detail, promptness, despatch, and team work may be likened to that of the Army. There must be the commanding general Avith supreme authority, and her staff must be educated to corresponding obedience. Hospital discipline in general is often likened to that of the Army, and the operating room organization should embody this same dis- cipline in concentrated form. Emergencies involving life and health are always arising, and there is usually no time for '' rea- soning AArhy" Avhen orders are received. If each one knows her duties, has been given the proper instructions as to how to per- form them, and has caught the spirit of "each for all," the system will do the rest. SUPPLIES (For Sterilization see Chapter XV) Our next step is to provide and prepare the various supplies and odds and ends Avhich it Avill be necessary to keep on hand in the operating room. The nurse Avill have learned about and used many of the things avc shall need, but for reference pur- poses Ave shall record here a list of standard supplies and then go into detail as to those which are likely to be new to her when she begins her operating room training. 1. Adhesive plaster 5. Basins 2. Amputation retractor 6. Blankets 3. Aprons, muslin and rubber 7. Brushes, nail 4. Bandages, Esmarch 8. Caps, surgeon's and nurse's flannel 9. Carrel-Dakin outfit gauze 10. Catheters " muslin 11. Cautery " plaster of Paris 12. Cotton starch 13. Cover for instrument stand EQUIPMENT OF THE OPERATING THEATER 213 14. Culture tubes 38. Pads, abdominal 15. Dressings 39. Pads, table 16. Drugs 40. Pillows 17. Gauntlets 41. Rectal tube 18. Gauze 42. Rubber bands 19. Glove covers 43. Rubber dam 20. Gloves, rubber and cotton 44. Rubber sheets 21. Gowns 45. Rubber tissue 22. Hip rest 46. Rubber tubing 23. Hot Avater bottles 47. Safety pins 24. Hypodermoclysis outfit 48. Salt solution, 10 per cent, and 25. Infusion outfit infusion 26. Inhaler, ether 4!). Sandbags 27. Instruments 50. Sheets, plain and laparotomy 28. Irrigator 51. Splints 29. Irrigator stand 52. Stockings, lithotomy 30. Kelly pad 53. Stomach tube 31. Masks, chloroform and ether 54. Suits for surgeons 32. Masks, face 55. Suture material 33. Mouth gag 56. Syringes 34. Nail cleaners 57. Thermometers, bath and clin- 35. Needles, hypodermic and ex- ical ploring 58. Tongue forceps 36. Needles, suture 59. Tourniquets 37. Packing, gauze 60. ToAvels, plain and lithotomy We shall now take up the supplies just enumerated in the order and under the number they hold in the list and discuss them from the operating room standpoint. 1. Adhesive Plaster.—This needs no comment. 2. Amputation Retractor.—Some such article as this will be necessary in the absence of the special metal instrument for the purpose, and it Avill be used to hold back the soft parts while the bone is being saAved off in an amputation operation. It is made from strong muslin and there should be two pat- terns—one with tAvo tails for use on the femur or humerus, and the other Avith three tails for the tAvo bones of the forearm or the lower leg. For the two-tailed one cut the muslin 24 x 24 inches, fold double, cut half Avay up through the middle from one edge, and stitch in all edges. (A of Fig. 38.) For the three-tailed one cut the muslin 30 x 24 inches, fold double, cut 214 TEXTBOOK OF SURGICAL NURSING in thirds half way up the long Avay, and stitch in all edges (B of Fig. 38). 3. Aprons.—(a) Muslin.—These Avill be made after the pattern of the ordinary "butcher's" apron, and may lie used over the gown or suit and changed for each operation. (Fig. 39.) (6) Rubber.—These may be purchased ready-made, or they are very easily fashioned from a piece of rubber sheeting by the same pattern as the muslin ones. They may not be used in routine practice but there should be several on hand in every operating room as occasions will arise Avhen the surgeon or the nurse will need their protection. 4. Bandages. — This supply will not differ from that which the nurse Avill have learned about on the wards. 5. Basins.—A good assortment of Avhite enameled basins should be on hand for both sterile and unsterile usage. The familiar kidney-shaped one is always useful, and for a great variety of purposes; large round ones holding a gallon will be needed for rinsing hands in salt solution, etc., during operations; smaller ones hold- ing a pint, perhaps, will be service- able for wound or dressing solutions; long narroAV, shallow ones will serve for sterilizing in antiseptic solutions instruments which cannot be boiled. The exact number and variety of each can- not be prescribed but the supply should be generous. Basins for use upon the floor about an operating table will also be needed. Any kind will do but a great deal of noise will be saved if the light-Aveight "composition" one is used, espe- cially in the case of tile or cement floor. 6. Blankets.—Plenty of blankets will be needed, and there should be several warm ones in readiness in a blanket warmer, the sterilizer, or upon a radiator for emergency use in shock cases. Fig. 38. — Amputation Retractors. A, the two- tailed one for use in the amputation of one bone; B, the three-tailed one for use in the case of two bones. EQUIPMENT OF THE OPERATING THEATER 215 7. Brushes, Nail.—As these will have to be boiled repeatedly a very plain kind should be used, that is, the backs should be unvarnished, and the coarse bristles will last better than fine ones. 8. Caps.— (a) Surgeon's.—These are best made of muslin and may be merely a skull cap (A of Fig. 40) or they may be a combination of cap and face mask (C of Fig. 40), in which case it is better to use a thinner material as the heavier one may Fig. 39.—Muslin Apron. be too warm and cumbersome. The surgeon will, as a rule, make his own selection of design, (b) Nurse's.—These are best made of muslin also, and any design that will cover the hair well will be a good one (B of Fig. 40) and the combina- tion of face mask and cap described for the surgeon (C of Fig. 40) may also be used by the nurse. 9. Carrel-Dakin Outfit.—The nurse will have learned all about this on the wards, and Chapter XIX gives detailed in- structions. The only equipment that need be kept on hand in the operating room Avill be the wound tubes, the vaseline gauze, and a small quantity of Dakin's solution. 216 TEXTBOOK OF SURGICAL NURSING 10. Catheters.—These will not often be used in the operat- ing room but a few of both the rubber and the glass ones used on the wards should be kept on hand. 11. Cautery.—There are several kinds of cautery which Fig. 40.—Operating Caps. A, simple skull cap for the surgeon; B, nurse's cap; C, combination cap and mask suitable for either surgeon or nurse (see directions for making cap C on page 222). are described in Chapter XV, pages 242-245, under "Steriliza- tion," as the cautery is, of course, a sterilizing agent. 12. Cotton.—Both the absorbent and the non-absorbent cotton used on the wards should be on hand. 13. Cover for Instrument Stand.—This will be a slip cover, simply a long narrow bag (see Fig. 24, page 199), which is de- EQUIPMENT OF THE OPERATING THEATER 217 m & nil signed to envelop the instrument stand Avhich extends across the table for operations. This bag should be made long enough to reach Avell dowmvard toward the base when the stand is ex- tended to its highest capacity, as it Avill then enable the instru- ment passer to adjust the height of the table sterilly at all times and Avill furnish the simplest means of covering the unsterile standard. It should be made of strong muslin, and the size of it will depend, of course, upon the size of your particular table. 14. Culture Tubes.—Cultures will fre- quently be taken from Avounds and a few tubes should ahvays be ready (Fig. 41). Make a cotton SAvab on a long Avooden or Avire applicator; put this into a small glass test tube, alloAving the end to project about half an inch, plug the tube loosely with cotton, and then put it into a larger test tube and plug this with cotton, and ster- ilize. The outer tube keeps the inner one sterile so that it may be handled by a ster- ile person, and the inner one is for the re- ception of the swab after the culture has been taken. 15. Dressings.—The assortment and de- signs used in the wards will probably apply to the operating room. These will include one or two sizes of small gauze wound sponges or "Avipes"; one or tAvo sizes of larger flat gauze wound dressings; "fluffs" or 1-yard pieces of gauze folded together loosely for use on wounds from Avhich there is likely to be much drainage; and perhaps a long narrow rolled gauze dressing which can be applied to a Avound of the extremities in bandage fashion. 16. Drugs.—The following list represents the drugs most likely to be called for: Adrenalin Alcohol Albolene, liquid Argyrol if 3 Fig. 41.—Culture Tubes. A, tube con- taining a culture me- dium; B, tubes con- taining swab for tak- ing specimen of pus from the wound. 218 TEXTBOOK OF SURGICAL NURSING Aristol powder Glycerine Aromatic spirit of ammonia Green soap Atropine (hypodermic) Hyoscine (hypodermic) Benzine Iodine, tincture Bichloride of mercury Lime, chloride Boric acid, poAvder and crystals Lubricant (vaseline, K-Y, etc.) Caffeine (hypodermic) Morphine (hypodermic) Camphor in oil or ether Nitrous oxide (hypodermic) Novocain Carbolic acid OliA'e oil Carbonate of soda (washing soda) Oxygen Chloroform Peroxide of hydrogen Cocaine Silver nitrate, solution and Codeine (hypodermic) "stick" Collodion Sodium chloride Dakin's solution Strychnine (hypodermic) Ether Talcum poAvder Ethyl chloride Vaseline Formalin Water, distilled 17. Gauntlets.—These will simply be loose muslin sleevelets Avhich Avill reach from Avell above the elbow to the hand. They will be used with the short-sleeved suits and goAvns in com- bination Avith the muslin apron (Paragraph No. 3) and Avill he kept in place either Avith a rubber band or a safety pin. 18. Gauze.—See "Dressings" (Paragraph No. 15). 19. Glove Covers.—Though not necessary, these covers will be a great convenience and they are very simple to make. Cut a piece of muslin about 12 x 31 inches, hem the ends, fold each end to the middle of the piece, and stitch the sides so as to make a double envelope (Fig. 42) into Avhich the gloves may be slipped separately; then fold through the middle into a com- pact parcel. 20. Gloves.— (a) Rubber.—There are numerous kinds of rubber gloves on the market and the one you provide will de- pend upon the choice of the surgeon. They are made in many sizes, so everyone can be well fitted, and it is important that this be done for too tight a glove will be very uncomfortable and too large a one will be a hindrance. Many gloves should EQUIPMENT OF THE OPERATING THEATER 219 be kept in reserve as they do not last long and they should not be used except Avhen in good condition. (b) Cotton.—These are not often used but occasionally they are slipped over the rubber ones when it is difficult to handle • ; J • c/c or 1%. OPERATING ROOM STERILIZATION 249 The advantage of gloves used in this Avay is that the hands remain wet Avith the solution and are doubtless more nearly sterile than they are Avith the dry gloves, and an accidental puncture is more likely to be harmless; but the dry ones are more extensively preferred because they are more comfortable and they avoid the complication of sore hands Avhich sometimes is an annoying accompaniment of the practice of using Avet gloves. As in the case of all boiling of rubber, the gloves must not be put into the water until it has reached the boiling point because they deteriorate someAvhat at best in the hot Avater; also, only plain water must be used, as for all rubber, and never the soda solution for the tAvo reasons that it is not necessary and that it is very detrimental to rubber. A hint Avhich it may be well for the nurse to pick up here is that old rubber Avhich has lost its "life" may be someAvhat rejuvenated by boiling it for a few moments in a weak (about the normal) solution of salt. Salt Solution.—As advised above, this is a 10% solution which you have prepared in glass flasks. The flasks should be Avrapped in a muslin coArer, as it Avill be convenient to have the outside of them sterile. They are best sterilized in the steam sterilizer in the same Avay and for the same time as the gauze and muslin supplies, and if packed carefully they may be done at the same time. The infusion salt solution should be sterilized by the frac- tional method, which means that it must be done three times at 24-hour intervals, and betAveen sterilizations it must be kept in a AArarm (80° F.) place. The process each time \vill be the same as for the other salt. The reason for this special treatment is to encourage the development of any possible spores during the interval and thus bring them into a form Avhich will succumb to the next sterilization. Special care must be taken to see that these flasks are tightly plugged with non-absorbent cotton as otherwise the water will evaporate considerably in the course of these three sterilizations and render the solution too concentrated. Rubber Dam.—This is used chiefly for drains, usually the "cigarette" drain (see Fig. 89, page 310), which means simply a piece of the rubber rolled around a strip of gauze after the 250 TEXTBOOK OF SURGICAL NURSING fashion of a cigarette. It is the better practice not to make up this drain till immediately before use as the length and thick- ness will need to be adjusted to each individual wound; and as any of the gauze you have for other purposes will do for this one you will simply need to have the rubber dam in readiness in a variety of sizes varying from 3 or 4 to 6 or 8 inches square. The pieces should be well washed in soap and warm Avater, and then sterilized by boiling in plain water for 10 minutes. This rubber will be in better condition for use if boiled freshly at the time, but when it is used frequently it is a good practice to boil a supply in advance and store it in a well-covered glass jar in a 1-60 carbolic solution. This solution softens the rubber in time, so no more should be prepared than will be used within a week or two. Rubber Tissue.—This should be cut in sizes similar to those of the rubber dam, and it too should be washed in soap and water, but as hot water dissolves it care must be taken to use cool water. The only method which can be used for sterilization of rubber tissue is the chemical one and the best solution is bichloride 1-1000. Naturally, you will feel that by this method you may not be able to sterilize the tissue beneath the surface since it is made of rubber and is therefore impervious to any solution, but when you soak it over night, or for 12 hours, you may feel that your germicidal solution has reached any part of it that any of the wound fluids will be able to do and that, there- fore, it is fit for aseptic surgical use. Necessarily this tissue must be prepared in advance, and after it has been subjected to the 1-1000 solution of bichloride for 12 hours it should be stored in a glass jar in a 1-5000 solution of bichloride. Do not use a stronger solution than the 1-5000 for storage because the tissue is used directly from this solution and a stronger one will be irritating to some wounds. Also, do not use a carbolic acid solution, because rubber tissue deteriorates rapidly in it. Rubber Tubing.—Whether or not you provide a sterile sup- ply of rubber tubing will depend upon how much demand you have for it. Some surgeons use it considerably for drainage, and in that case it is well to have a sterile supply prepared in advance. Tubes of a variety of diameters will be needed, and a OPERATING ROOM STERILIZATION 251 serviceable length for each piece will be about 12 or 14 inches. After being well Avashed this rubber may be prepared for use in one of several Avays: It may simply be boiled for 10 minutes and then stored in a jar of 1-60 carbolic solution; or, after Avashing it may be boiled, dried, powdered, and sterilized in muslin covers or long glass tubes in the steam sterilizer. The reason for boiling this tubing before steam sterilization is the same as that given above for rubber gloves, namely, to remove the surface finish which the manufacturer has put upon it and which becomes soft and someAvhat sticky under the steam. The poAvder serves the same purpose as in the case of the gloves, namely, to absorb the small amount of this gum Avhich oozes to the surface during a sterilization—before use this powder must be rinsed off in sterile water. Perhaps the most practical plan for storing this tubing is in the long glass tubes which are sold as '' catheter'' tubes. One piece in a tube will be best, and a gauze-covered absorbent cotton stopper fastened Avell down over the mouth of the tube will be necessary so as freely to admit the steam to the interior. Rubber Aprons.—These are best sterilized as advised for the rubber gloves, that is, they are well powdered, wrapped in a muslin cover and sterilized in the steam sterilizer as directed for the gloves. Syringes.—Many syringes are boilable and boiling is the best method where permissible, but there are so many types of syringe that one must make sure of the construction of each one before attempting to sterilize it because the Avrong method will quickly put this delicate instrument out of order. An all-metal one which has perhaps a leather or rubber plunger or packing, a hard rubber one or one with hard rubber mountings, and some of the combination glass and metal ones cannot be boiled and must be sterilized by soaking in some solution. A 1-20 carbolic acid solution is perhaps a good all-round one for such syringes, as bichloride Avill rust the metal parts and alcohol will injure the rubber and leather parts. A plan which may be applied to the all-glass one, Avhere it will be an advantage to have it ready-sterilized, is to put it (with the plunger sepa- rated) into a cotton-plugged glass tube and sterilize it in the 252 TEXTBOOK OF SURGICAL NURSING steam sterilizer. A piece of cotton will be needed in the bottom of this tube to avoid breakage. Thermometers.—The chemical method will always be neces- sary for the sterilization of thermometers and any solution Avill answer, though bichloride should be first choice. Needles.—As any moist method of sterilization Avill soon rust syringe needles interiorly a good plan is to put each one into a small glass tube plugged with cotton and sterilize in the dry air sterilizer for 1 hour at 300° F. The "temper" is of course someAvhat altered by this process but it is not enough to be seriously noticed, and the needles Avill ahvays be free from rust and Avill last mucli longer. The suture needles may be boiled with the instruments, for although they come under the classification of "cutting" instru- ments, AAdiich Ave shall tell you a few paragraphs hence should not be boiled, the harm done to them is so little as to be negligi- ble. In some large institutions where many varieties are needed during a session, it is the practice to arrange a complete set in a muslin or folded towel case (Fig. 54) and sterilize them in a cloth cover in the hot air sterilizer for 1 hour at 300° F. This high temperature and the subsequent sIoav cooling someAvhat soften them, however, but the entire avoidance of rust and the convenience compensate for this slight objection. Tourniquet and Esmarch Bandage.—Boil 15 minutes in nor- mal salt solution. Vaseline, Olive Oil, Glycerine.—These may all be sterilized in the steam sterilizer if care is taken to put them into containers that Avill withstand the temperature. Or, a method of second choice is to boil them in a Avater bath. Novocain.—This will withstand a moderate amount of boil- ing in a wrater bath. Instruments.—All instruments except the "cutting" ones, such as knives, are sterilized by boiling in the 1% washing soda solution for not less than 10 minutes. The sharp-edged ones are someAAThat dulled by the boiling and will therefore need to be sterilized chemically. Alcohol is much used for this purpose, but the objection to it is that the instruments must remain in it an hour or two, and in that time the water which all alcohol contains OPERATING ROOM STERILIZATION 253 It 't II II .I'll, ''ll' Fig. 62.—Tavo Types of Toavel Clamps, Used for Holding the Drap- ing Sheets and Towels Together. The sharp-pointed clamp is usually passed through the patient's skin as well as the draping. THE OPERATING ROOM IN ACTION 271 Fig. 63.—Trendelenburg Position. The pillows under the patient's back and thighs serve the same purpose as in the dorsal position (Fig. 57). The shoulder guard, shown more clearly in Fig. 64, keeps the patient from sliding. iViG. 64.—Shoulder Guard for Keeping the Patient in Place in the Trendelenburg Position. The guard is made entirely of metal, and as it sometimes injures tlie patient's shoulder it is advisable to wrap it with cotton and a bandage as lias been done to this one. 272 TEXTBOOK OF SURGICAL NURSING operation Avhere this sheet will be appropriate an assistant can ahvays be found; or, if carefully done there can be no objection to an unsterile person handling the end Avhich is placed under the patient's chin because this is unsterilized immediately in any case, (b) Two sheets and 4 towels may be arranged as in Fig. 61. It should be noticed that the toAvels Avhich run length- wise of the patient are put on first and the crosswise ones laid over them, because this is the much more secure Avay and it brings the towel edges into positions where they will be less Fig. 65.—Gall Bladder Position. This table has a crosswise rest which may be screwed up under the gall bladder region so as to throw it well upward. In lieu of this a small sandbag will serve the purpose. See also Fig. 66. likely to cause annoyance by catching upon instruments or by being brushed out of place by the arms of the surgeon and assist- ants. The two crosswise towels Avill keep the draping in place much better if they are wet, but if the operative field has been painted Avith iodine there may be objections raised to the use of Avet toAvels here. A towel clamp (Fig. 62) or some substitute, such as an ordinary artery clamp, Avill be needed at each of the four corners of the field to keep the draping in place. Trendelenburg Position.—For this position (Fig. 63), the patient is first placed in the dorsal position, the foot section of the table is dropped, and the whole table top is then inclined, THE OPERATING ROOM IN ACTION 273 with the foot upAvard, at an angle of 45° or less, care having been taken to have the patient's knees exactly opposite the hinge of the footpiece. It Avill be necessary to have the patient braced in some Avav at the shoulders so as to prevent his slipping doAvnAvard. All the better tables Avill have shoulder guards (Fig. 64) for this purpose, but in their absence sandbags will serve well. The pilloAvs under the back and knees Avill serve the same purpose here as in the dorsal position. The hands and arms will be arranged as for the dorsal position. Fig. 66.—Gall Bladder Position. This particular table can be broken under the gall bladder region so as to accomplish the purpose of the rest shown in Fig. 65. This position will be used in gynecological or other pelvic operations as it causes the intestines to gravitate out of the way and also brings the pelvic contents up from the bony cavity in Avhich they would otherAvise be more or less inaccessible. The draping is the same as for the dorsal position. On page 411 is illustrated a method for improvising this posi- tion Avhen Avithout the convenience of the special table. Gall Bladder Position.—In some cases the dorsal position will ansAver for operations upon the gall bladder, but oftener the region will have to be thrown upward (Fig. 65) so as to bring 274 TEXTBOOK OF SURGICAL NURSING the organ out from under the ribs. If your table is not supplied with the '' rest'' shoAvn in the illustration a pillow or small sand- B Fig. 67.—Kidney Position. A, rear view showing the disposal of the one arm and the elevation of the patient's waist line to about the level of the hips; B, front view showing where the other arm rests and how the sandbags are best placed for stabilizing the patient in the proper position, which is slightly forward of the true lateral position. bag will ansAver the purpose; or, you may have a table which can be broken in the middle directly under the gall bladder region (Fig. 66) which Avill accomplish the same purpose. THE OPERATING ROOM IN ACTION 275 The draping Avill be the same as for the dorsal position. Kidney Position.—The patient is turned on his side (Fig. 67) Avith the loAver arm at his back, the other up toAvard his face, the uppermost knee and hip joints flexed so as to bring the knee down upon the table in the capacity of a brace to keep the body from falling forAvard, the chest is braced anteriorly Avith a large sandbag, and sometimes the pelvis also Avill need the support anteriorly of a heavy sandbag. The crossAvise rest is noAV screwed upAvard directly under the location of the kidney so Fig. 68.—Prone Position. The patient lies flat upon his face except for one shoulder which is elevated slightly upon a small sandbag so as to turn his face away from the table sufficiently for the administration of the anesthetic. Some tables may be broken at the head so as to accomplish this purpose without the sandbag, or, the arrangement shown in Fig. 83 may be used. as to throAv the organ as Avell outAvard and upward as necessary from under the ribs. Foresight should be used in seeing that the patient is properly placed in relation to this rest before any of the preceding adjustments are made so that the raising of it Avill not disarrange the position. When properly arranged the patient will incline very slightly toward his face from the true lateral position. This is the most difficult position to arrange and a great deal of practice should be de\roted to it by the beginner. The draping corresponds to that for the dorsal position. Prone Position.—The patient lies flat upon the table Avith the face downward and the arms above the head (Fig. 68). Spe- 276 TEXTBOOK OF SURGICAL NURSING cial care of the head must be taken in arranging this position; some tables will be so constructed that a section at the head may be loAvered someAvhat to alloAv the patient's head the required Fig. 69.—Latero-prone Position. The patient is inclined about half way between the lateral and the prone positions, and the sandbags under the chest and the hips, and his flexed knees, stabilize him. Fig. 70.—Eeversed Trendelenburg Position. room, but in place of this a small pillow or sandbag may be placed under one shoulder. This position will be used for operations upon the spine or other parts of the back. The dorsal draping may be adapted to this position. THE OPERATING ROOM IN ACTION 277 Fig. 71.—Sims Position, Shoaving the Use of One Sheet for Draping. The patient inclines slightly forward from the lateral position, has his knees drawn upward, and if he is under an anesthetic he will need a sandbag against his hips and chest to stabilize him. Fig. 72.—Lithotomy Position, Showing the Use of the Table Stirrups. 278 TEXTBOOK OF SURGICAL NURSING Latero-Prone Position.—This will be used for operations upon the chest (Fig. 69). The body is turned about half way between the lateral and the prone positions, and the chest and hips rest against sandbags, the loAver arm lying at the back and tlie other upAvard toward the face. The dorsal draping is adaptable to this position. Reversed Trendelenburg.—In this position the patient is Fig. 73.—Draping avith a Sheet and Toavels in the Lithotomy Posi- tion. The blunt towel clamp shown in Fig. 62 will be needed to keep the sheet in place at each heel and to bind the sheet and towels together about the stirrups. placed upon the table face downward Avith the hip joints di- rectly over the line at which the foot section of the table breaks, Avith the arms over the head. ScreAv the table upward as in the Trendelenburg position, alloAving the foot to drop at the same time (Fig. 70). The patient Avill be so Avell balanced in this position as a rule that the shoulder guards will not be needed. THE OPERATING ROOM IN ACTION 279 This position will be used for some operations upon the rectum. The principles of the dorsal draping Avill apply here. Sims Position.—This will be used occasionally for cxetmina- tions of the rectum. There is no essential difference in the ar- rangement of the patient's body betAveen this position and the Fig. 74.—Draping with the Lithotomy Toavel and Stockings for the Lithotomy Position. A blunt towel clamp will be needed at either edge of the towel near the top to keep it in place. If this towel is wet it will stay in place better. latero-prone one, except that the patient will lie on the left side. As the draping will rarely ever need to be sterile the way in which it is done is not important, but Fig. 71 Avill show hoAV it may be done with one sheet. Lithotomy Position.—For this position (Fig. 72) some kind of leg supports will be needed. Metal ones called stirrups (see illustration) will doubtless be supplied Avith your table, but if not, one of the devices which we describe in Chapter XXI, 280 TEXTBOOK OF SURGICAL NURSING page 412, under improvised positions for operations in the home may be used. The stirrups are put into place, the foot of the table is dropped, the patient's feet being held meantime, the patient is drawn down so that the buttocks project slightly over the end of the table, and the legs are then fastened up- Avard and backAvard so as to throw the knees well backAvard toward the abdomen. Sometimes a sandbag may be placed under the buttocks to adjust the position of the pelvic organs, Fig. 75.—Breast Position. A small sandbag will be necessary under the shoulder, if the axilla is involved, to throw the part away from the table. Note the wire arch, the Kocher guard, which extends across the table in the plane of the patient's shoulders. A draping sheet thrown across this iso- lates the anesthetist from the operative field. (See Fig. 77.) or, for the same reason, the foot of the table may be slightly elevated as in the Trendelenburg position. A Kelly pad or a rubber sheet must ahvays be used over the end of the table. In this position the arms will have to be arranged at the chest. The lithotomy position will be used for some gynecological, genitourinary and rectal operations. The draping may be done Avith a sheet and towels (Fig. 73), or, better, Avith the lithotomy stockings and toAvel (Fig. 74) described on page 231. Breast Position.—For operations upon the breast the patient will lie upon her back. If the disease is malignant the axillary THE OPERATING ROOM IN ACTION 281 Fig. 76.—Method of Draping the Hand and Forearm for the Breast Operation. A towel folded once crosswise is thrown over the hand and is then bound about the wrist with a towel folded lengthwise into a narrow strip and applied like a bandage. The remainder of the forearm is cov- ered in this fashion, two or more towels being needed to make the draping secure, and a towel clamp serving to bind the end. (See Fig. 77.) Fig. 77.—Draping for Breast Position. 282 TEXTBOOK OF SURGICAL NURSING glands will be removed as Avell as the breast, and in this case the arm on the affected side must be free. Usually a small pillow or sandbag will be placed under the shoulder on this side to throw the axilla well up from the table (Fig. 75). The unin- volved arm may be placed either at the side or on the chest. For a simple breast operation the dorsal draping Avill apply. When the axilla is involved, however, the draping is more com- plex and may be done as follows: After the operative field has been sterilized the patient's head and shoulders are lifted, a Fig. 78.—Detachable Arm Board Supplied with the Table. rubber sheet is spread under the shoulders and over the side of the table by an assistant, and a sterile sheet is then passed under the shoulders so that the table is well covered in the re- gion of the axilla; the hand and forearm, which have been held by an unsterile assistant, are then covered with sterile towels, beginning at the hand with one which is folded once cross- wise, making a nearly square cover which is allowed to fall in folds about the wrist, and continuing from the wrist to the oper- ative field with towels folded lengthwise, bandage fashion (Fig. 76). Wet towels are better for this purpose as they stay in place better. The general principles of the dorsal draping may THE OPERATING ROOM IN ACTION 283 then be applied, the arm and the axilla being, of course, a part of the operative field (Fig. 77). There is an attachment supplied with the more complete tables Avhich will be very useful in the breast case—it is the Kocher guard, and it is simply a semicircular piece of soft metal which is fitted vertically across the table in about the plane of the patient's chin (see Figs. 75, 76 and 77), and serves the purpose of holding the upper sterile sheet well up between the operative field and the anesthetist. This is a very service- Fig. 79.—Simple Long, Narrow Board which May Be Fitted to Any Table as an Arm Board. able attachment, and if not supplied with the table may be very easily improvised. There are other devices designed to serve the same purpose but the Kocher guard is adaptable to a greater variety of positions as it is made of soft metal and can be bent into any desired shape (see adaptation of it for neck cases in Fig. 85, page 289). Arm Position.—Many hand and arm operations can be done with the part simply laid upon the patient's body, but often a small table will be needed, an arm board which is supplied with some tables may be attached (Fig. 78), or a simple long, narrow board may be used as illustrated in Fig. 79. The laparotomy sheet will serve well in some cases for draping, 284 TEXTBOOK OF SURGICAL NURSING the arm being simply slipped through the opening and un- sterile parts of the arm wrapped with towels as described for the breast case (Fig. 76), or tAvo sheets may be arranged as for the leg (see Fig. 80), any uninvolved part of the arm or hand being wrapped with towels, as just described. Leg Positions.—A great variety of positions will be em- ployed from time to time for operations upon the various parts of the feet and legs, depending upon whether the anterior or the posterior aspect or both must be accessible. The simple Fig. 80.—Use of Stirrups for Operations upon the Leg. dorsal position with a sandbag under the heel will answer for the anterior aspect of the leg and for the foot except when the heel is involved, in Avhich case it may be necessary to turn the patient either upon his side or his face, and in this latter posi- tion, of course, the posterior aspects of the legs are also ac- cessible. Another plan which gives access to all parts of the feet and legs is to suspend them from the table stirrups which are used for the lithotomy position (Fig. 80). This position applies especially well in the case of operations for the removal of numerous and scattered varicose veins. THE OPERATING ROOM IN ACTION 285 The draping for leg cases is difficult, but two large sheets and a few towels will ansAver all needs. The parts are, of course, first sterilized and the necessary sandbags and rubber sheets put into place, and then, while a sterile assistant holds the Fig. 81.—Draping for Leg Operations. One sheet is used under the legs and one thrown over the patient's trunk and allowed to meet this, and the two clamped together. Considerable slack should be allowed in the lower sheet as otherwise the draping will be disarranged when the legs are moved about during the operation. Fig. 82.—Draping for a Face Case. legs, a sterile sheet is passed underneath them over the entire foot of the table and well upward to the border of the operative field; another sheet is thrown over the patient's trunk and doAvn- ward to meet the other one, and the edges of the two are then clamped together both between the legs and on the outside (Fig. 286 TEXTBOOK OF SURGICAL NURSING 81). Extra towels may, of course, be placed upon the sheet underneath the parts if thought necessary for safety. When the feet are not included in the operative field they must be well wrapped in towels after the fashion advised for the hand (Fig. 76), or, a very convenient plan is to use a heavy Avhite cotton sock or stocking which can be securely clamped at the edge the same as the towel. Any uninvolved part of the leg should also be covered. When only one leg is involved Fig. 83.—Arrangement of Patient in the Prone Position on a Spe- cial Head Rest for Operations Upon the Back of the Head or Neck. Some such method is necessary when it is essential to the surgeon that the head be not turned as it would need to be were it lying upon the table. the only variation will be that the other will simply be covered with the lower sheet. When the stirrups are used they may be sterilized by boiling if a sterilizer large enough for them is available, and otherwise they may be wrapped in sterile towels. Head Positions.—In practically all.head cases a small sand- bag will be needed under the head, because otherwise it will not be stable. This will simply be so adjusted as to make the oper- ative field most accessible. For the face and mouth (tonsils, etc.) and the front and top THE OPERATING ROOM IN ACTION 287 of the skull the patient's body will be in the dorsal position and the head turned as necessary. For operations upon the face the draping will be done as follows: The patient's head and shoulders are held up and a sheet with a Avet towel laid upon it is passed underneath so that the sheet will extend well up under the shoulders and the towel will come into position directly under the head which is Fig. 84.—Folded Towel Clamped About the Face to Protect the Operative Field from the Inhaler in Face, Neck, or Skull Operations. now laid upon the towel. This wet towel is then wrapped and clamped securely around the head and hair (Fig. 82), a sheet is thrown over the patient's body and clamped about the neck to the lower sheet. In all operations about the head it is advisable that the anes- thetist be supplied Avith a sterile ether mask, sterile gloves, and a sterile cover for his ether can, unless, of course, the vapor method of administering the anesthetic is used, in which case the unsterile apparatus may be carried out of the way by means of its rubber tubing. For the back of the head the position just described may an- swer, the simple prone position may be used, or the patient may 288 TEXTBOOK OF SURGICAL NURSING have to be placed in the prone position and some such device as is shown in Fig. 83 added for the convenience of the anes- thetist. This last position, of course, involves the special equip- ment of the head rest, but a small table or some other article of furniture may be adapted. For all head cases the arms should be arranged at the pa- tient's side. This is a somewhat strained position for them when the prone position is used but they will be too much in the way over the head. The draping for an operation upon the skull when the patient lies upon his back or in the simple prone position Avill be done thus: The usual sandbag and rubber sheet are first adjusted, the patient's head is held from the table and sterilized, a sterile sheet is passed well under it, and the head may then be laid upon this, after Avhich the top sheet is applied and a folded towel clamped about the face as shown in Fig. 84 to isolate the anesthetist. When the special head rest is used one sheet thrown over the patient and clamped about the neck and the folded towel about the face will be about all the draping necessary. One or two metal face guards are made specially for sepa- rating the operative field and the inhaler in such cases, but draping with them will be easy if one can do it as just de- scribed. For nose and throat operations done under local anesthesia, with the patient sitting in a chair, a towel about the head and one sheet thrown about the patient and clamped together at the back of the neck will usually suffice. Neck Positions.—The sandbag and the rubber sheet will al- ways be used as for the head cases, but the head will usually be thrown further back, particularly when the operation is for goiter; and, of course, Avell to one side for cervical gland cases. As in all operations about the head, the problem of isolating the anesthetist is an awkward one to solve, but where the Kocher guard is available it may be so bent and draped as to make a technically perfect arrangement and a reasonably convenient one for all concerned (Fig. 85). In this case, after the neck has been sterilized a sterile sheet is passed under it and the shoul- ders; another sheet is then thrown over the patient's body and THE OPERATING ROOM IN ACTION 289 Fig. 85.—The Kocher Guard Adjusted and Draped so as to Isolate the Anesthetist in Operations upon the Neck. 290 TEXTBOOK OF SURGICAL NURSING the edge passed about the neck and clamped at the back. A third sheet is then thrown over the Kocher guard and clamped about the neck also. This latter clamp is best adjusted by an unsterile person on the anesthetist's side of the guard. There are other designs of guard Avhich are very suitable for this pur- pose of isolating the anesthetist, but it is not necessary to enu- merate them, for if one can adjust the Kocher guard satisfactorily the others will not be puzzling. When a guard is not used the pro- cedure should be in general as de- scribed for face cases, including care- ful isolation of the anesthetist. When there is a separate anesthetiz- ing room the preparation and draping are best done there and the table rolled into the operating room fully prepared for the surgeon. It will thus be seen that convenience will require that the sterile preparation and draping sup- plies be stationed in the anesthetizing room. With the drum system this will be easy, but otherwise it will be necessary to have a sterilly draped table for the purpose; or, if conditions do not make this possible or safe a small stand (Fig. 86), which is easily carried may be prepared for each individual case and carried into the preparation room each time. Fig. 86.—Portable Dress- ing Stand. THE OPERATION It will not be possible to do more than barely outline the procedure of the nursing staff during an operation, because there are so many minor details Avhich Avill differentiate almost every operation from every other. In general, however, especially where a number of opera- tions are done in immediate succession, there should be a rec- ognized head nurse who will be responsible for the general THE OPERATING ROOM IN ACTION 291 management of the nurses' end of the work, and for the dis- pensation of the sterile supplies as needed. As the sterile sup- ply drums or tables must serve for all the cases it is evident that no person but an absolutely sterile one can draAv supplies from them, and this makes it obligatory that one nurse, prefer- ably the head nurse, do nothing but serve as the connecting link betAveen these supplies and those avIio use them. This means that she never touches anything that has been in contact Avith any case, because, of course, no matter how "clean" a given operation may be it is not considered clean in relation to any other, and this nurse must serve as the guardian of every pa- tient's right to the benefit of every doubt. This may seem like overdoing the matter, and if every nurse on the staff Avere highly experienced perhaps it Avould be, but it must be remem- bered that the operating room, like the Avards and every other nursing department of the hospital, is a training school, that inexperience is rampant, and that, therefore, many sacrifices must be made to the cause of education, and many otherwise un- necessary precautions taken against the dangers of inexperience. We have already pointed out, but it needs repetition, that handling of sterile supplies must be kept at the absolute mini- mum; and furthermore, nothing that can be handled Avith for- ceps should be touched Avith the gloves, for the very good reason that an instrument can be made sterile and kept so with much greater certainty than a pair of gloves on the two hands of any given, and very busy, human being. The number of assistant sterile nurses will be determined by circumstances, but as a rule, in large institutions especially, one or two others may be present to help about the wound in the \\7ay of holding retractors, etc. An unsterile nurse to do er- rands will be useful; and this is logically the lesson Avith Avhich a beginner should be initiated into the mysteries of the operat- ing room in action. One or more orderlies Avill be necessary about an operating room to do the heavy lifting and other heavy work Avhich nurses cannot do. Other duties for orderlies will vary with local conditions. Management between operations should be well thought out, 292 TEXTBOOK OF SURGICAL NURSING and the ease and despatch Avith Avhich the Avork of this period is done will depend almost entirely upon the number of as- sistants. It may not be possible for the head nurse to remain sterile at this time because it is likely that her staff will be di- vided between the patient just finished and the one to follow and she will, therefore, need to do some of the unsterile work between operations. Too much haste must be avoided during the period of re- sterilization betAveen operations, and special precautions must be taken, of course, after an infected case. Everything that has been used or subjected to contamination in any Avay must be reboiled or discarded, all soiled linen removed, the floor basins emptied, and the floor mopped. Where possible the patient should have been taken to another room (the recovery room), or at least a distant corner of the operating room, before blankets are applied or other preparations made for the transference of the patient to his bed, as a great deal of dust may be raised in this process and other unsterile things scattered about. Gown, or apron, and gloves are of course changed, and before the fresh ones are put on the hands should be rinsed in the bichloride or other solution again, because it is rarely possible that one has avoided contact with the soiled gloves or gown in the act of their removal. Attention should be called here to an item Avhich is often overlooked, namely, that if the operating table has been sub- jected to contamination in an operation it must not be used again till it has been thoroughly cleansed. In cases of known infection it may be protected in advance by putting rubber sheets in strategic places, but contaminating drainage cannot ahvays be foreseen, and the operating table, because of its many corners and crevices, may become through such cases a very active carrier of infection. AFTER THE OPERATION It will be the practice to operate upon the patients of any given group in such order that the cleanest one is done first and the least clean one last, and so, at the end of a session the operating room will be in more need of resterilization than at THE OPERATING ROOM IN ACTION 293 any time during the session. It must, therefore, have the most thorough renovation at this time. In most hospitals the laundry will be equipped and the help trained to dispose of the soiled linen properly, but in any case the operating room nurse must see that no linen which is viru- lently contaminated is carried about until it has been rendered innocuous. Perhaps the best method of doing this is to soak the linen for several hours in a 1% or 2% solution of formalin. This disinfectant is a very active one, and it does not injure the linen, but gloves should be Avorn for wringing it from the linen after sterilization for it is highly irritating to the skin. The floor must receive special attention, especially if infec- tious material has been scattered about. In cases of known serious contamination of the floor it must be flushed for a time Avith some antiseptic solution before a maid is asked to subject her hands and knees or the mop to it. Formalin Avill ansAver well for this purpose, but it should not be forgotten that for- malin, giving off its pungent fumes from a large floor surface, will quickly make a room uninhabitable if the doors and win- dows have not been pre\7iously opened. Walls and all furniture, including the operating table, which may have been subjected to blood stains or other contamination, must be Avell washed; and of course the dressing and anesthet- izing rooms will be thoroughly renovated. The instruments are Avashed in Avarm water and soap, hot water being avoided as it Avill coagulate any blood present and make it very difficult to dislodge. For the same reason clamps and other jointed instruments must be taken apart for the washing so as to insure thorough cleansing before boiling. They should then be boiled for 10 or 15 minutes. After they are boiled about all they will need to put them into good condition will be thorough drying, each one being taken apart as much as possible for this. If they are wiped directly from a hot water bath the heat which they retain will appreciably aid in com- pletely freeing inaccessible parts from moisture and thus pre- vent rust. Rusted parts should be scoured gently with a fine polish, such as "bon ami," but scouring should be done spar- ingly for, while it may give an instrument case a brighter ap- 294 TEXTBOOK OF SURGICAL NURSING pearance, it materially shortens the span of life of the nickel plating. Delicately-jointed instruments should be oiled imme- diately, and all should be provided Avith a dry storage place. The gloves are well scrubbed on both sides with soap and Avarm Avater, hot Avater being precluded for the same reason as for the instruments. It is even more important that blood should be thoroughly removed from gloves as the sterilization will render absolutely irremovable any that may have been left upon them. Before further handling they should then be boiled for about 5 minutes, not being put into the water, of course, till it has reached the boiling point; and then they are dried and tested for holes. The test for defects is an important one, and a great deal of practice will be necessary to learn to do it Avithout oversights. It must be remembered that the smallest pinhole may allow the passage of infection to the Avound from the hand, and that all tests must be made with these in mind. A good method is to hold the cuff open, the fingers of the glove being downward, in which position they Avill be Avell inflated Avith air; then quickly grasp the edges of the cuff together, confining the air Avhich, under a little pres- sure, can be felt by the cheek, for instance, escaping from the smallest perforation. If the glove is in good condition gener- ally, the holes should be patched, as nurses and junior staff as- sistants can Avear patched gloves without inconvenience. Too great economy must not be exercised, however, in the salvaging of torn glo\res because when a glove becomes so old and life- less that it tears easily it is a menace and should be thrown aAvay. Cuffs and other strong parts of badly torn gloves can be utilized for the patches which should not be cut any larger than is necessary to make a durable repair. Patching is something of an art, too, but if done skillfully a patch will usually outlast the remainder of the glove. It is done thus: Turn the glove wrong side out—this is important because the Avrong side of the rubber is usually rougher than the right side and the cement will therefore adhere better; locate the hole accurately; cut a patch to fit; sponge both the patch and the region of the hole rather vigorously with benzine —this will cleanse the surfaces and at the same time somewhat THE OPERATING ROOM IN ACTION 295 roughen them; apply a thin coat of rubber cement to the patch, quickly put the patch into place, and press firmly for a few moments until the cement has dried avcII. Note that the ce- ment is better applied to the patch than to the glove, because it will not be possible to estimate the exact space required on the glove. A light sponging Avith benzine over the region will com- plete the process neatly. Do not sterilize these gloves until the cement has had several hours in which to dry completely. All unused sterile supplies Avhich have been opened must be resterilized, including all drums. This may seem like an- other case of overprecaution, Avhen little has been used from a parcel, but if this Avere not made the rule such a parcel might remain in reserve too long; for it ought to be the prac- tice to resterilize all supplies at least as often as once a week. For this reason it is not good technic to keep more than one week's stock sterilized ahead, and some system ought to be in operation whereby the parcel longest in reserve should ahvays be used first. In a large establishment where it is hard to fol- low every detail regularly, it is wise to mark each parcel with the date of sterilization so that too old ones may be detected. All the miscellaneous utensils used must, of course, be re- sterilized before they are stored away. CONCLUDING SUGGESTIONS Aim to have only standard equipment, and no more of that than you use. Try to keep your methods and your entire system as simple as possible. The natural tendency of operating room technic is to become complex and involved and constant good manage- ment is required to prevent nonessentials from superseding and supplanting essentials. Do not overstock in sterile supplies, and keep Avhat you have in circulation. If your operating room is a training ground for pupil nurses do not forget the educational phase of the work in the press of routine requirements. The two can prosper hand in hand but all concerned must recognize them both and someone must study the system and guide it wisely. CHAPTER XVII INSTRUMENT PASSING As a rule there will not be time enough during the routine course of training in the operating room for the nurse to gain an intimate knowledge of the uses of instruments and suture materials, but as she will very often be called upon after grad- uation to assume the responsibility for providing the proper ones and for officiating at the operating table as "instrument passer," we shall record here a few principles which should guide her in this duty, and as many details as it will seem worth Avhile for her to learn in the abstract. The subject is a very difficult one to present on paper in any other than a general way because in practice there will re- peatedly arise, through preferences of surgeons and the di- versities and irregularities of cases, variations in detail of both instruments and technic which cannot possibly be foreseen. Moreover, we have not the space here to cover, even in a gen- eral way, every one of the hundreds of operations that may be performed upon the human body; but Ave advise every prospective instrument passer who wishes to work intelligently and resourcefully to secure access to one of the good books which surgeons have written on operative surgery and familiar- ize herself with the probabilities, at least, in any given case, and thus endeavor to make of herself an intelligent and co- operative assistant rather than a mere mechanical adjunct which she Avill otherAvise be, at least until she has had the op- portunities of a long period of observation. HoAvever, though by actual count the number of recognized surgical operations Avould run Avell up into the hundreds, the instrument nurse Avill find in her study of them that, after all, from her standpoint they differ in relatively few important re- spects. Her chief problem, therefore, will be to master her 296 INSTRUMENT PASSING 297 general equipment and to establish her technic as the founda- tion upon which she can then build very easily her superstruc- ture of detail. Accordingly, we shall take as the nucleus of our lesson a representative operation Avhich we shall study in detail as in- strument passers, and when Ave have finished that and learned it well Ave can, with comparative ease, proceed to the necessary variations for other cases. In doing this we shall assume that the nurse has been taught, in her regular course of operating room training (as she should have been), to recognize all of the more common instruments, needles and suture materials. Let us assume, then, that you are to be "instrument passer" for an appendicectomy. The instruments you will provide are: 4 towel clamps 1 scalpel 4 pairs plain anatomical forceps (1 very fine-pointed) 2 pairs toothed anatomical forceps 3 pairs scissors (1 straight, 2 curved) 1 dozen artery forceps y2 dozen Kocher clamps 2 pairs blunt retractors (2 sizes) 1 pair "crushing" forceps (if one of the various special designs is not available, a strong, straight pair of hemostatic forceps may answer) 3 pairs sponge forceps 2 small aneurism needles 1 probe 1 grooved director 2 needle holders 1 pair dressing forceps 2 straight "round" needles (intestinal) 2 curved "round" needles (intestinal) 2 curved "round" needles (heavy) 4 curved "surgeon's" needles (2 sizes) 2 straight "skin" needles (except where skin "clips" are used) The suture material will be: Plain catgut, Nos. 0, 1 and 2 Chromic catgut, Nos. 0 and 2 Linen thread (or celluloid linen—Pagenstecher) Silkworm gut 298 TEXTBOOK OF SURGICAL NURSTNG Silk thread, horsehair, or skin "clips" and the special forceps for ap- plying them Everything being sterile and conveniently placed, you may now arrange the instrument stand (Fig. 24, page 199) in some such orderly way as that suggested in Fig. 87, laying aside the pair of straight scissors and one pair of the plain anatomical forceps for your own use in handling the sutures. Next it will be wise to make a "suture book" from a towel folded as shown for the needle book in Fig. 54, page 253, namely, by these steps: (1) Lengtlrwise, bringing each edge to the mid- dle; (2) CrossAvise, bringing each end to the middle; (3) Cross- Avise, through the middle again, bringing the ends together; (4) Crosswise, through the middle again. This will give you, as shoAvn in the illustration, a compact, book-like arrange- ment of the toAvel in Avhich you have tAvo separate compart- ments in which to store your sutures and needles conveniently. This is, of course, not a necessity but one of those conveniences Avhich Avill never be discarded when once tested out, for if one assigns a place to each kind of suture material a great deal of time and trouble will be saved in finding Avhat one wants Avhen pressed for time. Noav, arrange in this book the suture material and accom- panying needles. You will probably first be asked for a liga- ture for the vessels about the base of the appendix. This will be the No. 1 or 2 plain catgut in the aneurism needle, or one of the heavy round needles in the needle holder, and you may need several of them. Next will be the linen suture, the '' purse string," for the appendix, on a straight intestinal needle. The next Avill be the second purse string—the No. 0 plain or chromic catgut, also on a straight intestinal needle. Next will prob- ably be the ligatures, which should be of No. 1 plain catgut— these you can lay out straight Avithin one of the folds of the suture book Avith the ends projecting so that you can easily grasp them. Then you Avill probably be asked for the sutures for closing the wound, Avhich will come in the folloAving order: No. 1 plain catgut on either a surgeon's needle, or the heavier curved round one, for the peritoneum; No. 2 plain catgut for \J 3 " C db do Y do do : (TO Jk 1 *~ < oxsd 0 Fig. 87.—Diagram of the Arrangement of the Instrument Stand when the Type Shoavn in Fig. 24, Page 199, Is Used. to CO CO 300 TEXTBOOK OF SURGICAL NURSING the muscle; the same, or the No. 2 chromic for the fascia; next you may need the No. 2 plain catgut for the fat layer, or per- haps some fine silkworm gut on a larger sharp needle for the fat and skin layers together; then Avill follow the skin suture —the silk or horsehair—on a sharp straight needle, or perhaps the skin clips. The suture material is now in convenient order and you are ready for the operation to begin. The first instrument used Avill be the knife, which you Avill have Avithin easy reach, as you Avill also have the forceps, scis- sors, clamps, etc., Avhich Avill be used next. You will watch all steps of the operation closely, replacing artery clamps on the stand as they are used, and endeavoring to keep one step ahead of the surgeon in your preparation. When the appen- dix has been draAvn up into the wound you will have the aneurism needle, or the heavy round needle threaded with the mesoappendix ligature ready to hand to the surgeon, and keep yourself in readiness to hand him another until this part of the operation is finished. Then will come the linen purse string on the straight and fine round needle. At this point you will probably be asked for the "crushing" clamp. The appendix Avill then be cut aAvay and the stump sterilized, probably with the cautery. Then the fine-pointed pair of thumb forceps will be used for inverting the appendix stump. At this point the instrument nurse must learn a special lesson in technic: The appendix stump exposes the interior of the intestine AA'hich, of course, is not sterile, and although it has been cauterized, the crushing forceps, the inversion forceps, and the knife or scissors Avhich were used for cutting it aAvay are not considered clean, and it is the instrument nurse's duty to see that these instruments are discarded—a small basin or a folded towel may be used to receive both these and the ap- pendix and immediately handed to an unsterile attendant. This lesson should be well learned and the technic of carrying it out well planned because it will apply in most operations where a part is removed, and in others AAdiere an unclean step in- tervenes. After the appendix stump has been inverted the second purse INSTRUMENT PASSING 301 string suture—the No. 0 plain or chromic catgut on the straight round needle—will be used. Then you will provide the wound-closing sutures in this or- der: No. 1 plain catgut on a surgeon's or the .heavy round needle in the needle holder for the peritoneum; the No. 2 plain catgut similarly for the muscle; the No. 2 plain or chromic cat- gut on a surgeon's needle for the fascia; the No. 2 plain catgut on the same needle for the fat layer, or the silkworm gut on a larger surgeon's needle for the fat layer and the skin com- bined ; the silk or horsehair on the straight sharp needle for the skin, or the clips and their special forceps. In some cases, usually Avhere there is infection, the wound will be closed by means of "through-and-through" sutures, that is, the entire abdominal Avail will be treated as one layer and heavy sutures, such as silkworm gut, will be used on large, strong, sharp needles. All through the operation you have endeavored to see one step ahead and to have ready in advance whatever will be needed so as to save confusion and waiting. This you can only do by watching the operation very closely. Meantime, you have kept your instrument table clean and in order, with wipes, clamps, etc., ahvays Avithin easy reach of the surgeon, and un- needed instruments out of the way. You have now passed instruments for an operation which in- volves many of the fundamental principles of your art. You will need all the types of instruments (except the appendix crusher) for practically every operation, Avith special additional ones Avhich Ave shall point out later; the arrangement of the in- strument table and the supply of suture materials are standard; and your general course of procedure will apply ahvays. We can then proceed to supplement this Avith the special instructions for particular operations, but it must be remembered that this is a subject on which we can speak only in generalities and probabilities and that you will have to learn your particulars in actual practice from day to day from your surgeon and from your ever-varying cases. Before taking up the discussion of individual operations, hoAvever, let us repeat that the general set of instruments which 302 TEXTBOOK OF SURGICAL NURSING you provided for the appendix operation will be assumed for all others, and that the sets mentioned under the folloAving individual headings will merely be additions. The suture mate- rial supply, on the other hand, was perhaps as complex and elaborate as it Avill be in any other case, and much more so than in most of them. Ligatures, however, apply universally, and they Avill be assumed in addition to the suture material we shall mention. It will also be taken for granted that the nurse is familiar Avith the special designs of instruments suitable for different structures and parts of the body and Avill knoAV the difference, for instance, betAveen the "bone-cutting forceps" meant in the list for skull operations and the one meant for operations upon the extremities. The easiest road to this specific knoAvledge will be a feAv hours deA-oted to the study of some complete illustrated instrument catalog. This may seem like learning the English language by studying the International Dictionary, but a trial of the suggestion will prove its worth. REPRESENTATIVE OPERATIONS We shall aim to discuss one or more operations from each anatomical group, and as Ave shall select the more complex ones the nurse will have no difficulty in deducting from them what- ever help she may need for the other simpler ones of the group which Ave do not mention. In Chapters IV to XI operations have been presented in essen- tial details and in the same anatomical order which will be fol- loAved here, and since many special instruments have been pointed out there the student should study the corresponding subject in those chapters at the same time that she takes them up here. Intestines.—For operations upon the intestines these special instruments should be provided: 2 pairs of intestinal clamps with rubber tubing covers for the blades (A and B or C of Fig. 88), large abdominal retractors, 6 pairs of fine tenacula (Allis's, for examine), 1 or 2 extra pairs of scissors and thumb forceps, and sometimes a Murphy button. INSTRUMENT PASSING 303 The suture material Avill usually be linen thread or the Pagen- stecher, and No. 00 or 0 chromic catgut; and the needle will be the fine, straight, round intestinal one usually, though occa- sionally a curved one Avill be called for instead. When the interior of the intestine is exposed during the opera- tion the instrument nurse must apply the special technic described in the case of the removal of the appendix (page 300). Fig. 88.—Intestinal and Stomach Clamps. A, plain, flexible intes- tinal clamp; B, the same clamp with the rubber tubing covers which must always be used and which should be slightly smaller in diameter than the clamp so that they will fit snugly; C, larger double intestinal or stomach clamp with the rubber tubes in place. As in the case of the appendix, a special towel or basin should be provided for the reception of all the instruments used during the unclean stage of the operation, and the instrument passer can then manage to avoid contaminating either her oavii gloves or her instrument table—the special forceps and scissors advised above Avere for use at this stage so as to avoid the trouble o'f resterilization for the remainder of the operation. When the Murphy button is used the tAvo sections should be screwed apart and each clamped in an artery clamp for conven- ience in handling. Purse strings of heavy linen or silk thread 304 TEXTBOOK OF SURGICAL NURSING on an intestinal needle will be used for fastening them in place. The closure of the abdominal wall will correspond to that of the appendix Avound. Hernia.—There are no special instruments required for any of the operations for the repair of a hernia, except in those cases Avhich involve strangulation of- the intestine. Then, of course, you will need to provide for an operation upon the intes- tines as described above. The sutures for hernia repair Avill be in general as follows: No. 1 or 2 plain catgut on the heavier round needle for the "sac"; No. 2 chromic catgut, kangaroo tendon, or sometimes silkworm gut on the same needle for the muscle; the chromic or No. 2 plain catgut for the fascia; and for the fat and skin the same as for the appendix case. Gall Bladder.—The tAvo more common operations involving the gall bladder are the excision of the part and the removal of stones from it. The instrument passer should ahvays provide for both, and the only special instruments will be: gallstone forceps, gallstone scoops, bile duct probe, and perhaps a small trocar Avith rubber tube attached. If the gall bladder is removed a strong ligature of No. 2 plain or chromic catgut on the heavier round needle should be prepared. When it is not removed you may need to supply a medium- sized rubber drainage tube, an ordinary rubber catheter some- times being used; and for closing the gall bladder around this you may need a No. 1 chromic suture on a small round needle. There may sometimes be an anastomosis performed betAveen the intestine and the gall bladder or gall duct. In this case the preparation described for intestinal operations will apply in general. There will probably be no new feature about the closure of the wound. Tonsils and Adenoids.—For the removal of tonsils there are many methods, but you will ahvays provide a mouth gag, a tongue depressor, a tonsil-seizing forceps, an eneucleator or dissector, a tonsil punch, a pair of long scissors, and either a snare or one of the many designs of tonsillotomes. INSTRUMENT PASSING 305 Removal of adenoids usually accompanies the tonsillectomy, and for this you Avill simply need some kind of adenoid curette. Rectum.—For excision of the rectum, if done through an abdominal incision, the preparation for intestinal Avork Avill, of course, apply. Sometimes, hoAvever, the operation may be done through an incision by way of the sacrum, which means that you Avill need a supply of bone instruments also. As this opera- tion is rare, and to save space here, Ave refer you to page 307, under "Bones," for the list of bone instruments. For dilatation of a stricture of the rectum there are various metal dilators, and bougies of several materials including metal, hard rubber, soft rubber, etc. Removal of hemorrhoids is usually done by the clamp and cautery method. For this you will need a rectal speculum, a pile-seizing forceps, a pile clamp, and the cautery. Ordinarily you Avill not need to provide a rectal dilator for a hemorrhoids operation. Where a suturing operation is done No. 2 plain or chromic catgut on a round needle should be provided; and for a ligation operation strong silk Avill probably be used. Stomach.—For operations upon the stomach, such as a gastro- enterostomy or removal of a part of the organ, the intestinal preparation and technic will apply, except that the larger special stomach clamps Avill be needed instead of the smaller intestinal ones. One variety of stomach clamp is shoAvn in 0 of Fig. 88. Blood Vessels.—Suturing of blood vessels will not often trouble the general instrument passer, but the material used is usually extremely fine silk on an extremely slender round nee- dle. Special very fine clamps and forceps are designed for this purpose also. For the removal of varicose veins one of several designs of special "strippers" may be used, though often nothing but the usual dissecting instruments will be needed. Lymph Glands.—About the only special instrument for this operation will be a pair of suitable grasping forceps—a tenacu- lum. Plenty of artery clamps and ligatures will be a wise pre- caution in these cases. Plain catgut No. 1 or 2 for suturing 306 TEXTBOOK OF SURGICAL NURSING the deeper structures, and horsehair or silk" for the skin Avill be the likely suture material. Spleen.—Operations upon the spleen will be infrequent. For removal of the organ your chief concern Avill be to provide plenty of large hemostatic forceps and strong ligatures. Suturing of the spleen wall probably be done Avith plain catgut on a round needle. Thyroid Gland.— For the removal of the gland the special thyroid grasping forceps or a suitable tenaculum Avill be the only special preparation, aside from plenty of artery clamps and ligatures. Plain catgut No. 1 or 2 for the deeper structures and horsehair or silk for the skin Avill be the likely suture material. Tendons.—Your only special concern Avill be in cases of suture of the tendon, Avhen you Avill probably need chromic cat- gut or silk sutures on a round needle. Brain.—Naturally, the special instruments needed for reach- ing the brain will belong to the "bone instrument" group, and they will be these: Periosteal elevator Bone drill, or trephine Chisels Gouges Mallet When the dura is to be sutured fine catgut on a small round needle Avill probably be used. The scalp will usually be closed with silkworm gut on a surgeon's needle. Nerves.—For the suture of nerves fine chromic catgut or silk should be provided on a fine round needle. Spine.—For operations upon the spine, which will be as- sumed to include the spinal cord, you should provide the special bone-cutting forceps designed for the purpose, and in addition to that, chisels, gouges, mallet, periosteal elevator, exsection saAv, and a small blunt hook. For closing the wound you Avill need fine catgut on a round needle for the dura, No. 2 plain catgut for the deep structures, and perhaps silkAvorm gut for the skin. Bones.—For all bone work, such as the open repair of frac- Bone-cutting forceps Bone-gouging forceps Bone curettes Small sharp retractors (toothed) Special brain retractors INSTRUMENT PASSING 307 tures, tlie removal of the whole or parts of bones, etc., you should be equipped with general bone instruments as MIoavs: Bone curettes Bone-holding forceps (sequestrum forceps) Saws (Gigli's, and other suitable ones) Bone drill In the case of fracture the silver or aluminum-bronze Avire may be used for suturing the bone fragments; sometimes, as in the case of the patella, chromic catgut may be needed; or, you may need to provide bone plates, such as the "Lane" plates (Fig. 14, page 101), and then you will also need screws, screw driver, and screAAT-holding forceps. When the "Lane" plating is done you may be expected to carry out the special Lane technic for the operation, which means a method by which the hands are never put into the wound, everytli ing being done Avith instruments, and all supplies han- dled entirely Avith forceps. Considerable practice Avill be neces- sary before one can carry out this technic Avell and Avithout great fatigue from the close application it will require. Its principle is so excellent, hoAvever, that you will do Avell to acquire the habit of applying it as far as you can in all your instrument and suture work, and with practice you will find that many of the things you usually fumbled Avith your fingers—needles, for example—can be handled much more easily and quickly with forceps. For the closure of fracture wounds No. 2 plain catgut and silkAvorm gut will be your likely suture material. Reproductive Organs.—For the various operations upon the pelvic organs through an eibdominal incision you should provide these special instruments: Deep abdominal retractors, 2 large aneurism needles, plenty of large hemostatic (hysterectomy) forceps, sponge forceps, one or tAvo tenacula or "elevating" forceps. In the case of hysterectomy you will need ligatures of No. 3 or 4 plain catgut on the aneurism needle, or on the heavy round Periosteal elevators Chisels Gouges Mallet Bone-cutting forceps Bone-gouging forceps 308 TEXTBOOK OF SURGICAL NURSING needle in the needle holder. These ligatures should be long— the full suture length—as it will not be convenient to tie shorter ones in the depths of the pelvic cavity. After the uterus is removed you will need the No. 3 or 4 plain catgut and some- times also the No. 2 on a heavy sharp needle for seAving over the stump. Salpingectomy and oophorectomy will require no further preparation. In the case of removal of a large ovarian cyst you should pro- vide a large trocar with a long rubber tube attached. For suspension of the uterus there are a number of possibili- ties in the Avay of sutures, but you Avill probably guess well if you provide plenty of No. 2 chromic catgut on a medium-sized surgeon's needle. Occasionally some of these operations may be done through a vaginal incision instead of the abdominal one. This Avill not modify your preparation materially except that you will need vaginal retractors instead of abdominal ones. For a curettage these instruments will be needed: Vaginal speculum, tenaculum, cervical dilator, several sizes of uterine curettes, uterine sound, uterine dressing forceps, and an intra- uterine irrigating tip. For operations upon the cervix the special instruments Avill be a Anginal speculum and a tenaculum. The sutures Avill prob- ably be No. 2 chromic catgut or silkAvorm gut on a heavy sharp needle. This same preparation Avill apply for the several plastic operations that may be done upon the vaginal wall. For suturing the perineum you will probably need No. 2 plain or chromic catgut on a medium-sized round needle, and silk- worm gut on a heavy surgeon's needle. Breast.—For the removal of the breast the instrument pass- er's chief concern will be to provide plenty of artery forceps and ligatures. The sutures will usually include No. 2 plain catgut on a surgeon's needle for the deeper parts, and silkAvorm gut on a large surgeon's needle for the skin, and sometimes silk or horsehair also. INSTRUMENT PASSING 309 Lungs.—The most frequent operation will be for drainage of an empyema. For this you will need a periosteal elevator and a pair of rib-cutting forceps. You should also proAdde a drain- age tube Avhich may be one of the specially-designed empyema drainage tubes (Fig. 17, page 127) or a plain rubber tube with one or two holes cut into the side of it (Fig. 89), and a safety pin attached to keep it in place. Sometimes the wound may be partially closed Avith silkworm gut sutures on a strong needle. Mastoid Bone.—The bone instruments should, of course, be relatively s)n