■ 
1 1 

&5» 





■ ■ 



I ■ ' 






■■£»>: 






.„■«*, fc „' ■ 









^^n 










LIBRARY OF CONGRESS, 



Chap Copyright No... 

Shelf..' 

- 



UNITED STATES OF AMERICA. 



Bacteriology 



AND 



Surgical Technique 
For Nurses 



BY 

EMILY M. A. STONEY 

Superintendent of the Training School for Nurses, St. Anthony's Hospital, Rock 

Island, 111. ; Author of " Practical Points in Nursing," " Practical 

Materia Medica for Nurses," etc. 



"Every bit of knozvledge that we cannot use for the uplifting of our physical, 
intellectual, or emotional life is so much -waste of time and labor. Everything taught 
is 'worth the knowing, but not worth the putting away in the pigeon-holes of memory, 
to be recalled some day by accident." 



ILL USTRA TED 



PHILADELPHIA 
W. B. SAUNDERS & COMPANY 

1900 



4757? 



l_>br*u y of Co>Hr' 

SEP 15 1900 
stccw conr. 

OflOW OWISiON. 
OCT 9 1900 



SUJo, 







Copyright, 1900 
By W. B. SAUNDERS & COMPANY 



ELECTROTYPED BY 
WESTCOTT &. THOMSON, PHILADA. 



PRESS OF 
W. B. SAUNDERS &. COMPANY. 



TO 



DR. JOHN R. SLATTERY 

THIS VOLUME IS DEDICATED BY THE AUTHOR 

IN GRATEFUL REMEMBRANCE OF MUCH ENCOURAGE- 
MENT AND PERSONAL KINDNESS 



PREFACE. 



The following pages constitute the notes of a series 
of lectures on "Bacteriology and Surgical Tech- 
nics" which followed closely upon my lectures on 
u Materia Medica." The first part of the book is de- 
voted to Bacteriology and Antiseptics ; the second 
part to Surgical Technic, Signs of Death, Au- 
topsies. 

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

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

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

5 



6 PREFACE. 

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

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

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

EMILY M. ARMSTRONG-STONEY. 

September, 1900. 



CONTENTS. 

PART L— BACTERIOLOGY ; ANTISEPTICS. 

CHAPTER I. 

PAGE 

History of Bacteriology 9 

CHAPTER II. 
Bacteria as the Causes of Disease 20 

CHAPTER III. 
The Theory of Antitoxins 35 

CHAPTER IV. 
Antiseptics, Disinfectants, and Deodorants 42 

CHAPTER V. 
Antiseptics (continued) 55 

PART IL— SURGICAL TECHNIC 



CHAPTER VI. 

Care of Operating-room; Methods of Sterilization; Care 
of Instruments 62 

CHAPTER VII. 

Instruments Necessary in Different Operations; Keeping 
of Charts; Surgeon's Kit, etc 71 

7 



8 CONTENTS. 

CHAPTER VIII. 

PAGE 

Anesthesia 86 

CHAPTER IX. 
Antiseptic Gauzes, Tampons, Bandages, Thermocautery, Saline 
Infusions, Irrigation, etc 99 

CHAPTER X. 

Sutures and Ligatures; Sponges; Drainage; Drainage-tubes; 

Gauze Drains; Rubber Dam; Rubber and Cotton Gloves . 109 

CHAPTER XL 
Inflammation 121 

CHAPTER XII. 
Catheterization; Douches; Enemata; Washing out the 
Bladder; Lavage 123 

CHAPTER XIII. 
Operations; Preparation of the Operating-room; The Slr- 
geon and his assistants i3i 

CHAPTER XIV. 
Preparation of Patient for Operation ; Care of Patient 
during and alter operation 1 39 

CHAPTER XV. 

Sequels of Operations; Shock, Hemorrhage, Septic Peri- 
tonitis, Accidents during Operations, etc 151 

CHAPTER XVI. 
Operations in Private Practice 161 

CHAPTER XVII. 
Gynecologic Examinations and Operations 16S 

CHAPTER XVIII. 
Signs of Death; Autopsies 176 



PART I. 

BACTERIOLOGY ; ANTISEPTICS. 



CHAPTER I. 
HISTORY OF BACTERIOLOGY. 

The eye is one of the most beautiful and delicately 
contrived organs in the body, and yet its vision un- 
aided is very limited in its scope. We see so much 
that we rarely stop to think of what an enormous 
world exists in and all about us which we cannot see 
at all — a world peopled by organisms so very small 
that they can be seen and studied only by the aid of 
the most powerful magnifying lenses, and so num- 
erous that they are quite beyond any calculation. 

Bacteria exist nearly everywhere; they are almost 
universal, except that they are not found deep down 
in the ground nor high up in the air. They and their 
spores, or seeds, float in the air we breathe, swim in the 
water we drink, grow upon the food we eat, and lux- 
uriate in the soil beneath our feet. Wherever man, 
animals, and plants live, die, and decompose, bacteria 
are sure to be present. The surface of the body never 
escapes their establishment, and so deeply are some 
individuals situated beneath the epithelial cells that 
the most vigorous scrubbing and washing and the use 



IO BACTERIOLOGY. 

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

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

The existence of these bacteria has been known for 
many years, but it is only during the past few decades 
that any great advancement in our knowledge of them 
has been made. 

Over two hundred years ago a man named Athana- 
sius Kircher, a German, mistook blood-corpuscles 
and pus-corpuscles for small worms, and built up a 
new theory of the causes of disease and putrefaction 
with these worms as a basis of it. At the same time, 
Christian Lange, a professor in the medical school at 
Leipzig, expressed his opinion that the rash that 
appeared on the skin in the eruptive fevers, etc., 
was the result of putrefaction conveyed by small liv- 
ing worms in the body. Shortly after these obser- 
vations came those of Anthony van Leeuwenhoek, 
a native of Delft, in Holland, who, in his early years, 
had learned the art of polishing lenses, and who was 
able, ultimately, to produce the first really good 
microscope that had yet been constructed. He saw, 
and described with astonishing clearness, various 
forms of bacteria found in the material taken from 
the teeth of an old man who never cleaned his teeth. 
He gave an accurate description of the rod-shaped 
bacteria, motile and motionless; of the longer threads, 
now called bacilli; of the spiral threads, or spirilla; 



HISTOR Y OF BACTERIOL OG Y. 1 1 

and of rounded micro-organisms, or micrococci. 
Although he did not attempt to theorize as to the 
meaning of these organisms in the mouth at the 
time, later on, in 1713, after finding similar organ- 
isms in the greenish pellicle formed on the surface 
of the water in an aquarium, he came to the conclu- 
sion that the various forms of bacteria found in the 
material scraped from the teeth found their way into 
the mouth through the medium of the drinking-water 
that had been stored in barrels, and that some of 
these found there a nidus in which they multiplied. 

This was the real beginning of bacteriology; and 
from this origin the study advanced with considerable 
rapidity in spite of ridicule and much opposition. 
Various opinions regarding the connection of these 
germs with disease and putrefaction, w 7 ere put for- 
ward; but it was not until 1831 that any important 
advance was made in our knowledge of this connec- 
tion. Previous to that time a large mass of facts in 
regard to these little living organisms was being 
gradually accumulated, and fresh discoveries were 
constantly made by various workers; but since no 
systematic attempts to classify the newly observed 
facts were made, the scientific results were very small. 

The first real advance made in our knowledge of 
the presence of a " contagium vivum," or living con- 
tagious element in the production of disease and fer- 
mentations, was made by Frederick Miiller, of Copen- 
hagen, and was the result of a systematic attempt to 
arrange the knowledge which had been accumulated 
during all those years. From that time to the present, 
the science has made great strides; so that we have 
now an accurate knowledge of the bacteria which 



12 BACTERIOLOGY. 

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

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

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

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



HISTOR Y OF BA CTERIOL OGY. I 3 

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



14 BACTERIOLOGY. 

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

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

In 1845, Langenbeck discovered that the specific 
disease of cattle known as actinomycosis could be 
communicated to man. His observations, however, 
were not given to the world until 1878, one year 
after Bollinwr had discovered the cause of the 
disease in animals. 

In 1847, Semmelweis, on the basis of his own 
observations, formulated the precept that puerperal 
fever is the result of the introduction of organic 
ferments into the puerperal genital tract. This dis- 



HISTORY OF BACTERIOLOGY. 1 5 

covery, established by himself and confirmed by the 
observations of many others, marked an era in ob- 
stetrics. The organic ferments have since been 
identified as specific bacteria. Semmelweis, in this 
way, anticipated in practical antisepsis the discover- 
ies of Lister and Pasteur; while the late Oliver Wen- 
dell Holmes, in a paper entitled " Puerperal Fever a 
Private Pestilence," published in 1843, and repub- 
lished in 1855, in treating of its prophylaxis, an- 
ticipated the teaching of Semmelweis. Semmelweis 
was first led to recognize the source of puerperal in- 
fection by the case of Prof. Koletschka, of the 
University of Vienna, who, having received a dis- 
section-wound, became thereby fatally infected. In 
consequence of this, Semmelweis concluded that 
there was an identity between this infection and that 
of which so many hundreds of puerperal women 
died. In the school for instruction in practical ob- 
stetrics, with which he was connected, there were 
two departments, one for medical students, the other 
for mid wives; the students going as a rule directly 
to the obstetric w 7 ard from the autopsy-room. He 
first noted the much greater mortality in the stu- 
dents' ward, and in May, 1847, began to require the 
students to wash their hands in chlorin-water before 
making vaginal examinations, thereby reducing the 
puerperal mortality to a point lower than had been 
ever before reached. 

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

In 1869, the first complete study of a contagious 
affection was made by Pasteur, in two diseases affect- 



1 6 BACTERIOLOGY. 

ing silkworms — pebrine and flacherie — which he 
showed to be due to micro-organisms. 

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

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

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

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

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

In the same year Sternberg described the pneumo- 
coccus, calling it " Micrococcus Pasteuri," which he 



HISTORY OF BACTERIOLOGY, 1 7 

secured from his own saliva; and in the same year 
Pasteur also found the same organism in saliva; 
though it is to Fraenkel, Talamon, and particularly 
YVeichselbaum, that we are indebted for the dis- 
covery of the relation which the organism bears to 
pneumonia. 

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

In the same year Loeffler and Schiitz reported the 
discovery of the bacillus of glanders, an infectious 
disease almost confined to certain of the low T er ani- 
mals; although occasionally persons whose habitual 
association with and experimentation upon animals 
bring them into frequent contact with such as are 
diseased, have become accidentally infected. 

In 1884, Koch discovered the " comma-bacillus," 
the cause of cholera. 

In the same year Loeffler discovered the diphthe- 
ria-bacillus, and Nicolaier that of tetanus. 

On October 26, 1885, Pasteur made the first ap- 
plication to human medicine of his method for the 
2 



1 8 BACTERIOLOGY. 

cure of hydrophobia, nearly ten years before the time 
we began to understand the production and use of 
antitoxins. 

In 1890, Koch issued to medical men what is now 
known as tuberculin, a brownish, syrup-like fluid 
used in the diagnosis and treatment of tuberculosis. 

In 1892, Canon and Pfeiflfer discovered the bacillus 
of influenza. 

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

In 1894, Yersin and Kitasato independently iso- 
lated the bacillus causing the bubonic plague then 
prevalent at Hong-Kong, and now threatening 
Europe. 

Sanarelli, in 1896, reported the discovery of the 
micro-organism of yellow fever. His conclusions 
were based on the presence of a certain germ in 58 
per cent, of cases examined, and the production of 
symptoms and pathologic changes in the lower 
animals resemble those present in man. Sanarelli' s 
observations have been confirmed by a commission 
of the U. S. Marine-Hospital Service; but Sternberg 
and his assistants doubt the specific relation of the 
Bacillus icteroides, as it is called, to yellow fever. 

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

Malta-fever, a disease of the Mediterranean islands, 
and occasionally of the Antilles and Central and 



HISTORY OF BACTERIOLOGY. 1 9 

South America, is due to a micrococcus discovered 
by Bruce, and called Bacillus melitensis. 

Malarial fever is an infectious disease; but, unlike 
those mentioned, it is not caused by a vegetable germ, 
a bacterium, but by a microscopic animal, the Plasmo- 
dium malaricz, which is found in the blood of the 
afflicted individual. How it enters the blood is not 
definitely known, but the best authorities hold that 
its entrance is brought about by the stings of mos- 
quitoes. 

There is a widespread belief that malignant 
tumors — cancers and sarcomas — are due to infection 
with parasites. The nature of the parasite is as yet 
unknown; but the latest researches point to a tiny 
organism, a yeast-plant or blastomycete. 



CHAPTER II. 
BACTERIA AS THE CAUSES OF DISEASE. 

Diseases may be divided into two great classes — 
the constitutional, which are due to such causes as 
errors in diet, alcoholic excesses, overwork, or age; 
and the infectious or contagious, which are due to the 
introduction into the body of a living poison. We no 
longer look upon infectious and contagious diseases 
as due to an unexplainable something, whose source 
we cannot know, whose course w 7 e cannot predict, and 
whose end cannot be hastened by any efforts on our 
part. Investigation has shown that we are no longer 
fighting an unknown enemy in the dark, but that we 
have before us a definite, living thing, whose part in 
the plan of creation is as surely fixed as our own, 
whose life-history can be told, and whose growth is 
as dependent on the right amount of light, food, heat, 
and air as that of the rose in our garden. 

The word bacteria is a general name for all the 
plant micro-organisms. Of these there are many 
different classes with different names. They vary 
much in shape and size, some being round, some 
thread-like, some rod-shaped, and some of a spiral 
form. Each single organism consists of a small speck 
of protoplasm or vegetable albumin, to which maybe 
given the name of a cell; and these cells are so minute 
that they can be seen only with the aid of the best 
20 



BACTERIA AS THE CAUSES OF DISEASE. 21 

microscopes at our command. The rounded organisms, 
or micrococci, as they are called, are seldom more than 
25-J^o °f an mc ^ ^ U diameter ; the elongated cells 
average a little more perhaps, and are from x^Jou 



■1 

n ° 




p IG< x —Various forms of bacteria: i and 2, round and oval micro- 
cocci; 3, diplococci; 4, tetracocci, or tetrads; 5, streptococci; 6, bacilli; 7, 
bacilli in chains, the lower showing spore-formation; 8, bacilli showing 
spores, forming drumsticks and Clostridia; 9 and io, spirilla ; n, spirochete 
(McFarland). 

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

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

1. Moulds, or hyphomycetes. 

2. Yeasts, or blastomycetes. 
3/ Bacteria, or schizomycetes. 

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

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

2. The bacillus — rod-shaped bacterium. 
3 The spirillum — corkscrew bacterium. 



22 BA CTERIOL OGY. 

And these, which are species relatively monomorphous 
— i. c., preserve their shape — are practically the only 
ones with which we have to do. 

The cocci are named according to their arrange- 
ment with one another; if, for instance, they are in 
pairs, they are called diplococci; if in a chain, they are 

a b c d e f 







® 



© 





g h i j 

Fig. 2. — Diagram illustrating the morphology of cocci : a, coccus or 
micrococcus ; b, diplococcus ; c, d, streptococci ; e, f y tetragenococci or 
merismopedia; g t h, modes of division of cocci; i, sarcinse ; y, coccus with 
flagella ; k, staphylococci (McFarland). 

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

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

Bacteria reproduce in two ways : By direct division 
(fission) and by the development of spores or seeds 



BACTERIA AS THE CAUSES OF DISEASE. 23 

(sporulation). The most common mode is by binary 
division, one body dividing itself so as to form two 
other bodies; these two re-dividing, and so on, It 
can readily be imagined how quickly an appalling 
increase in their numbers can be thus brought about; 
but fortunately this multiplication only takes place to 
advantage under certain favorable conditions; if these 
are not present, the bacterium begins to degenerate, 
but usually does not die until it has left behind a spore. 
When the formation of a spore is about to commence, 
a small bright point appears in the protoplasm, and 
increases in size until its diameter is nearly or quite 
as great as that of the bacterium. As it nears perfec- 
tion a dark, highly refracting capsule is formed about 
it. As soon as the spore arrives at perfection the bac- 

a b c d e f 

FlG. 3. — Diagram illustrating sporulation: a, bacillus inclosing a small, 

oval spore; b, drumstick-bacillus, with terminal spore; c, Clostridium, with 

central spore ; d, free spores ; e and f t bacilli escaping from spores 

(McFarland). 

terium seems to die, as if its vitality were exhausted 
in the development of the permanent form. As soon 
as the young bacillus escapes it begins to increase in 
size, develops around its soft protoplasm a character- 
istic membrane, and having once established itself 
presently begins the propagation of its species by fission. 
In those forms of organism in which spores are not 
found the germs die very rapidly unless the conditions 
for their nutrition and multiplication remain very 
favorable. If all bacteria were of this kind, it would 
be possible to exterminate them with consider- 



24 BA CTERIOL OGY. 

able rapidity. Spores will survive a great heat, a 
heat which will kill the organism from which the 
spore came; they will also live under a treatment 
with germicidal solutions which renders the bacteria 
inactive. In other words, the spores are much more 
resistant to the effect of germicides than the bacteria 
themselves. Cold does not kill them; they live 
through it and develop whenever favorable surround- 
ings for their growth present themselves. They may 
lie dormant in the system for years, waking into 
activity only when they come into contact with some 
damaged, weakened, or diseased part which affords 
them a nest in which to develop and multiply, the 
cellular activity of the weakened part being unable to 
cope with the organisms. 

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

The majority of bacteria grow best when exposed 
to the air. Some develop better if the air is with- 
held; some will not grow at all if the least amount 
of oxygen is present. Those that grow in oxygen are 
called the aerobic bacteria, and those that will not 
grow in the presence of oxygen are the anaerobic 
bacteria. 



BACTERIA AS THE CAUSES OF DISEASE. 2$ 

A certain amount of water is always necessary for 
the growth of bacteria, though the amount required 
may be very small. If dried, no form will multiply 
and very many forms will die. 

A soil consisting of highly organized compounds is 
also necessary for their growth and multiplication, and 
slight modifications in it may prove fatal to some 
forms of bacterial life, but be highly advantageous to 
others. 

With age bacteria lose their strength and die. So 
we see that a suitable soil, and a proper amount of 
light, heat, and air are absolutely necessary for the 
growth and development of bacteria, for they carry 
on all the functions of a higher organized life; they 
breathe, eat, digest, excrete, and multiply. 

The disease-producing bacteria effect entrance into 
the interior of the body through the skin and super- 
ficial mucous membranes, wounds, alimentary canal, 
respiratory tract, and placenta. 

The entrance of bacteria into the tissues through 
the sound skin is very rare indeed, although some 
authorities claim that infection has taken place 
through the rubbing of bacteria or their spores upon 
the skin. The dangers of infection through the 
broken skin are well recognized; hence every wound, 
no matter how slight, should be protected as soon as 
possible. 

Bacteria enter the alimentary canal through the 
food and drink. Typhoid infection has taken place 
through the rectum, its occurrence being due to the 
wearing of underclothing previously worn by typhoid 
fever patients, and to the use of enema syringe tips 
which had not been sterilized after their previous use. 



26 BACTERIOLOGY. 

Bacteria enter the respiratory tract through the 
mouth and nose, as in a deep inspiration, or an act 
of coughing, sneezing, or the like. Pneumonia 
and tuberculosis are said to be the result of in- 
spiration of the specific organisms. The direct 
transmission of bacteria from a parent to the fetus 
has long been a disputed question, but is now gener- 
ally conceded. The micro-organisms pass through 
the placenta and infect the fetus. Tuberculosis of 
the ovaries, Fallopian tubes, and uterus may origi- 
nate through the blood, and infection from without 
through the vagina. Infection through the blood is 
evidenced by the general tuberculosis of all the vis- 
cera. Infection from without may result in tuber- 
culosis of the uterus, ovaries, and Fallopian tubes. 

The channels by which bacteria can enter the 
body are, then very numerous; and there is scarcely 
a moment in which some part of the body is not in 
contact with them. All the disease-producing germs 
have their favorable seat in some part of the body 
where they grow more or less luxuriantly, and in the 
secretions and excretions of which the chief source 
of their infection lies. The pneumonia-germ prefers 
the lungs; the typhoid fever germ selects the lower 
portion of the small intestine; the diphtheria-germ 
the throat; the cholera-germ the intestinal tract; 
the germ of tuberculosis prefers the lungs, but it is 
called a iC medical tramp," because it will lodge in 
any part of the body and make its home there. 
Hence we hear of tuberculous glands of the neck, 
tuberculous knee, intestinal tuberculosis, tuberculosis 
of the kidney, bladder, uterus, ovaries, Fallopian 
tubes, tuberculous peritonitis, etc. A tuberculous 



BACTERIA AS THE CAUSES OF DISEASE. 2J 

area is always a danger to the system, and may infect 
distant organs or give rise to a general tuberculosis. 
To prove that a microbe is the cause of a disease it 
must fulfil Koch's circuit. It must always be found 
associated with the disease, and it must be capable 
of forming pure cultures outside the body. These 
cultures must be capable of reproducing the disease, 
and the microbe must again be found associated with 
the morbid process thus reproduced. In other words, 
we must prove the bacteria to be always present; we 
must then isolate them, then prove that they can 
produce the disease in a healthy animal, and, finally, 
having succeeded in doing all this, we must prove 
that no other form of bacteria can produce the 
disease, and that where these bacteria cannot be 
obtained the existence of the disease is impossible. 
All these requirements have been met in many 
instances, and now there are a large number of dis- 
eases each one of which has been definitely proved to 
be caused by a germ of its own, a germ which pro- 
duces that disease and no other. Most of the germs 
need a special train of circumstances in order that they 
may be active, so that, fortunately for us all, the 
mere presence of the germ itself is not sufficient to 
produce the disease. For instance, we know that 
diphtheria is caused by a germ of its own which 
causes that disease and no other; still, exposure to 
that germ does not invariably produce diphtheria — if 
it did, we should all be infected with it. This is 
because other conditions than the mere presence of 
the germs are needed to produce the disease. The 
germs must be active, and they can act only under 
certain conditions. It will usually be found that the 



28 BACTERIOLOGY. 

attack of the disease has been preceded by a local 
inflammation of the throat, thus making a suitable 
place for the specific action of the diphtheria-germs. 
In typhoid fever the germs require a suitable condi- 
tion of the bowels before they can produce the dis- 
ease. This is also true of cholera, and explains why 
taking care of the health makes such a difference in 
the taking of this disease. The germs find their way 
into the body through the food and drink. Cases are 
reported that show how the germs enter drinking- 
water, which is sprinkled over vegetables sold in the 
streets of cholera-infected districts, how they are car- 
ried about in clothing, and taken to articles of food 
upon the table by flies which have preyed upon chol- 
era excrement. Healthy lungs are not a suitable loca- 
tion for the development and activity of the germs of 
tuberculosis. If we are not fully in good health, or 
if we inherit a tendency to this special disease, we 
may acquire it very readily, since we often inhale the 
germs of it. Should the disease take root in our 
lungs, it may be controlled to a certain extent by a 
change of climate and surroundings; by going, for 
example, from a low and damp locality to the mild 
and dry atmosphere of Colorado, the Carolina moun- 
tains, Southern California, or of the other South- 
western States, where there are few cloudy days and 
where violent atmospheric changes are rare. The 
germs there cannot be so active, for the air is stimu- 
lating, pure, and invigorating to the nervous system. 
The rarefaction of the air causes deep and strong 
involuntary respiratory movements, and there is con- 
sequently enforced a better ventilation of the lungs 
and a better oxygenation of the blood, in conse- 



BACTERIA AS THE CAUSES OE DISEASE. 29 

quence of which there follow more active tissue- 
changes throughout the body and a strengthening 
of the respiratory muscles. 

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

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

Immunity is either natural or acquired. Of 
acquired immunity w 7 e have two varieties, that which 
comes from acclimatization, and artificial immunity. 

By natural immunity is meant the natural and 
constant resistance to disease-producing germs. The 
individual is immune by Nature, and sometimes by 
racial characteristics. Acquired immunity is a 
power of resistance attained through various cir- 
cumstances. Thus, a single attack of some of the in- 



30 BACTERIOLOGY. 

fectious and contagious diseases usually confers im- 
munity against subsequent attacks. Such immunity 
generally follows an attack of typhoid fever, small- 
pox, scarlet fever, mumps, whooping-cough, measles, 
or yellow fever. Second attacks may occur ; but, as 
a rule, a patient who has had an attack of one of 
these diseases has immunity for life. Influenza, 
pneumonia, cholera, diphtheria, and erysipelas are 
among the diseases in which one attack is not 
protective. Vaccination usually insures immunity 
against small-pox; but this is ordinarily not so com- 
plete or permanent as that resulting from an attack 
of the actual disease. 

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

Racial immunity is that in which certain races are 
safe from certain diseases; for instance, negroes sel- 
dom suffer from yellow fever, but are more suscep- 
tible than whites to small-pox. It is asserted that the 
Arabs seldom or never have typhoid fever. An analo- 
gous example is afforded by the fact that white mice 
are not affected by the same diseases as the gray 
mice are, even though subjected to the same influ- 
ences in respect to climate, food, etc. 

Artificial immunity may be produced in various 
ways. It is said that an injection of the antitoxin of 
diphtheria will give protection against the disease for 
from four to eight weeks. Tetanus has been prevented 
in a similar manner. It is impossible here to enter, 
except to a slight degree, into the consideration of 
the many theories of immunity, since they are very 



BACTERIA AS THE CAUSES OF DISEASE. 3 1 

intricate, and not one has been advanced so far that 
can clearly explain it. The theory of phagocytosis 
and the theory of antitoxins are the two most im- 
portant. 

Phagocytosis is the destruction of bacteria by the 
white cells of the blood and the cells of fixed tissues. 
The cells which eat up and destroy the germs are called 
11 phagocytes.'' When the two meet a battle occurs, 
the bacteria fighting the cells with their active fer- 
ments, while the cells on their side put forth every 
effort to protect the body against the assaults of the 
disease. In a majority of the cases the bacteria win 
to the extent that the phagocytes die; but others take 
their place until the infection is overcome or the 
patient dies. The white blood-cells and tissue-cells 
having thus been educated to withstand the poison, 
their descendants inherit this capacity and are born 
insusceptible. This theory w r as suggested by Carl 
Roser in 1881. Sternberg and Koch afterward put 
forth the same view, but it is usually credited to 
Metschnikoff, who published his observations in 
1884. The theory is now known as the u Metschni- 
koff theory of phagocytosis/' and assumes an educated 
white corpuscle and body-cell. 

The other theory — the so-called antitoxic theory — 
is founded on numerous more or less convincing ex- 
periments. If an animal be injected with certain 
pathogenic bacteria or their toxins in gradually 
ascending doses, it can be immunized to doses that 
under other circumstances would prove fatal. The 
blood-serum of an animal thus immunized has the 
power, when injected into another animal, of ren- 
dering it also immune to the bacteria that have 



32 BACTERIOLOGY. 

originally been used; and in some cases the serum 
is even capable of curing the disease after it has 
developed in another animal. These properties with 
which the blood-serum has become endowed depend 
upon the presence of what are called antitoxins and 
antibacterial bodies. In man also, after recovery 
from certain infectious diseases, it is possible to 
demonstrate in the. blood-serum the presence of anti- 
toxic substances; and it is now the general belief 
that immunity, at least of the acquired form, is due 
to such antitoxins. The uses and practical prep- 
aration of antitoxins will be described in the next 
chapter. 

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

i. Staphylococcus Pyogenes Aureus . — This is the 
most common form; it is quickly killed by carbolic 
acid (i : 20), bichlorid of mercury (1 : 1000), or by a few 
moments' boiling. It is found in the mouth, alimen- 
tary canal, and under the nails; it lives in the eyes, 
nose, ears, mouth, in the superficial layers of the skin, 
and is distributed in the water, soil, and air, especially 
in the dust of houses and surgical wards where the 
proper precautions are not taken. 

2. Streptococcus pyogenes is a most important path- 
ogenic micro-organism, and is thought by many 
authorities to be identical with the streptococcus of 
erysipelas. The Streptococcus pyogenes is frequently 
associated with internal diseases, and has been found 
in the uterus in cases of infective puerperal endome- 
tritis, ulcerative endocarditis, acute septicemia, and 



BACTERIA AS THE CAUSES OF DISEASE. ^ 

other diseases. It is one of the most common causes 
of post-operative peritonitis. 

3. The Bacillus colt communis is always present in 
the intestine, and is thought to be a frequent cause 
of acute suppurative peritonitis. 

4. The Staphylococcus pyogenes albics resembles the 
aureus in form, but is less virulent. It is a common 
cause of suppuration, and although it has been found 
alone in acute abscesses, it is usually associated with 
other pyogenic cocci, chiefly the Staphylococcus pyo- 
genes aureus. 

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

6. The Staphylococcus pyogenes citreus is not quite 
so common nor so pathogenic as the other forms, and 
is less important. 

7. The Bacillus pyocyaneus exists in pus (especially 
in open wounds), and gives to it a peculiar bluish or 
greenish color. 

8. The Bacillus aerogenes capsulatus is a gas-pro- 
ducing bacillus that sometimes causes death after 
operations on the uterus; it may also enter through 
accidental wounds. 

9. The Bacillus tuberculosis is the cause of all tuber- 
culous processes. The chief cause of the spread of 
infection is found in the dried sputum, which becomes 
pulverized and is then inhaled as dust ; and since 
one patient may expectorate as many as four billion 
bacilli in twenty-four hours, his capacity for harm is 
verv considerable. The bacilli retain virulence for five 



34 BACTERIOLOGY. 

months in dried sputum, and in putrid sputum for 
forty-three days. 

10. The Micrococcus laiiceolatus, known also as 
Streptococcus lanceolatus, pneumococcus, and Diplo- 
coccus pneumoniae, is the cause of croupous pneu- 
monia and of many of the acute inflammations of the 
serous membranes of the body. It is also a pus-pro- 
ducer, and has been found in empyema and acute 
abscesses. 

ii. The bacillus of tetanus is found particularly in 
garden-soil, in the dust of halls, walks, cellars, street- 
dirt, and in the refuse of stables. It is not a pus- 
producer. Tetanus is a disease due to the absorption 
of its toxins, which poison the nervous system pre- 
cisely as would dosing with strychnin. 

12. The diphtheria-bacillus causes the dreaded dis- 
eases diphtheria and membranous croup, as well as 
inflammations of the eyes and nose; at times it also 
attacks open wounds. 



CHAPTER III. 
THE THEORY OF ANTITOXINS. 

Great progress has been made of late in the field 
of serum-therapy, though much remains open to ques- 
tion and many recorded facts cannot yet be explained. 
The field for the investigator is perhaps larger than 
ever before. For a better understanding of the sub- 
ject of antitoxins and their therapeutic application, a 
few essential facts should be borne in mind. An anti- 
toxin is not the direct result of bacterial action, but 
is properly described as an unknown body resulting 
from the resistance of the healthy organism to the 
toxins of pathogenic bacteria. According to the pre- 
vailing theory, antitoxins are the products of the 
body-cells, formed under the influence of the bacterial 
toxin. In therapeutic practice the antitoxic body 
comes to us in the blood-serum of an animal, usually 
the horse. When properly prepared and properly 
kept in aseptic containers the antitoxins are not at all 
dangerous; they are as innocuous as an equal amount 
of blood-serum or normal salt solution administered in 
the same way. Antitoxins are used both to counteract 
the effects of the toxins which are elaborated by path- 
ogenic bacteria in the body, and to render the sys- 
tem immune, so that it may resist the action of the 
bacteria should they gain access to the body. The 
antitoxins do not destroy the bacteria; in other words, 

35 



36 BACTERIOLOGY. 

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

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

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



THE THEORY OF ANTITOXINS. 37 

loss of appetite, more or less pharyngeal paralysis, 
with regurgitation of food. Sometimes deatli occurs 
from heart-paralysis. Upon recovery, which comes 
within a few days, a slightly larger dose is given. 
This treatment is continued for about one year, at the 
end of which time the horse will take from 2000 to 
3000 times the initial dose without reaction. It is 
then ready for bleeding. About 6000 cubic centi- 
meters of blood are drawn from the external jugular 
vein. This is allowed to clot, and the serum obtained 
is known commercially as antitoxin. It is customary 
to add an antiseptic, such as trikresol, to preserve the 
serum. 

In preparing the streptococcus antitoxin a culture 
is made of bacteria obtained from two sources — ery- 
sipelas and puerperal septicemia. This is done be- 
cause some eminent bacteriologists believe that the 
streptococcus of erysipelas is not identical with the 
streptococcus of puerperal fever. It is but fair to say, 
however, that others equally eminent assert the iden- 
tity of the two streptococci. To meet the possibility 
of the non-identity of the organisms, a culture ob- 
tained from the two sources is used. Its virulence is 
increased by passing it through rabbits. After pass- 
ing through about fifty rabbits a culture is planted in 
beef-tea, and the same course pursued as for diphthe- 
ria-antitoxin. Antitubercle serum is obtained by im- 
munizing horses with the original Koch's tuberculin. 

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



38 BACTERIOLOGY, 

to dispose of the bacteria. It may be that it has the 
additional property of stimulating the phagocytic and 
possibly other bactericidal functions. The following 
experiments made by Martin and Cherry in England, 
and described in the Journal of the American Medical 
Association of August 27, 1898, are of interest in this 
connection. Behring, Ehrlich, and Kanthack have 
advocated the theory that the antagonism between 
toxins and antitoxins is a chemicone, somewhat anal- 
ogous to the neutralization of an acid by an alkali; 
while Buchner, Metschnikoff, and others have main- 
tained that it is indirect and operates through the 
cells of the organism. Martin and Cherry used a 
snake-venom antitoxin. A large number of guinea- 
pigs were used. At 6o°C. the antitoxin was destroyed, 
while the venom retained its virulence. In the con- 
trol-experiment with the venom only, all the animals 
died within a few hours. A number of mixtures were 
made of 1 c.c. of antitoxin with twice the fatal dose 
of venom; others with three or four times the fatal 
dose. These mixtures were allowed to stand at the 
usual laboratory temperature (20 to 23 C.) for two, 
five, ten, fifteen, and thirty minutes respectively, then 
heated to 68° C, and afterward injected. 

As remarked above, this heat destroyed the anti- 
toxin, so that none was injected. The animals sub- 
jected to the mixture of the stronger doses of ten min- 
utes or less died or were seriously affected; all of those 
receiving the fifteen-minute mixture survived; while 
the thirty-minute mixtures produced no symptoms 
whatever. Similar results were obtained with diph- 
theria-antitoxin and toxin. These experiments seem 
to show, as far as anything can, that the neutraliza- 



THE THEORY OF ANTITOXINS. 39 

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

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

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

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



40 BA CTER10L OGY. 

and December, 1898, this department treated 219 
cases of bacteriologically proved diphtheria — all char- 
ity cases — with a death-rate of 4. 1 per cent. Some 
two and a half years ago, when antitoxin was not used, 
the death-rate from diphtheria treated by this depart- 
ment was about 35 per cent. 

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

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

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

One or two cases have been successfully treated 
with intracerebral injections of antitoxin, the theory 
being that the antitoxin should be placed where it 



THE THEORY OF ANTITOXINS. 4 1 

could neutralize the toxin which is producing the 
convulsions by means of its action on the nerve- 
centers. The value of this method of administration 
has not been proved. 

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

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

Method of Injecting Antitoxin. — The serums and 
toxins are given hypodermically, the injection being 
made into the back, thigh, side of the breast, or over 
the chest. Perfect antisepsis for the operation is 
absolutely necessary. The puncture-wound is closed 
with a collodion dressing. It is not necessary to use 
massage for the purpose of causing more rapid ab- 
sorption of the injected serum — the swelling gener- 
ally disappears in a short time of itself. Sometimes 
the site of the injection becomes very painful. In 
certain cases, pains in the joints and various skin- 
eruptions (erythema, hives) develop after the injec- 
tion. They are not of great moment, but the physi- 
cian's attention should be called to them. 

The reaction following an injection of Coley's 
mixture is sometimes severe, and may correspond 
to the symptoms beginning an attack of erysipelas — 
chill, local redness, and high temperature. 



CHAPTER IV. 

ANTISEPTICS, DISINFECTANTS, AND 
DEODORANTS. 

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

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

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

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

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

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

First. The kind of bacteria, some being easily killed 

42 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS, 43 

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

Second. The number of bacteria present. 

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

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

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

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



44 ANTISEPTICS. 

causes pain and burns if used in very strong solu- 
tions. 

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

Non-spore-forming : 

i. Streptococcus pyogenes. 

2. Staphylococcus pyogenes aureus, albus, and 
citreus. 

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

4. Diphtheria-bacillus. 

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

Among the spore-forming pathogenic organisms 
are : 

1. Bacillus of malignant edema. 

2. The tetanus-bacillus. 

3. The anthrax-bacillus. 

The germicidal or disinfecting agents at our com- 
mand are of two kinds chiefly, heat and chemic 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS, 45 

agents. The term £< disinfection n is employed for 
the action of chemic agents, and u sterilization n for 
the action of heat. 

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

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

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

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

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

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



4.6 ANTISEPTICS. 

high-tension steam (confined under a certain press- 
ure), or superheated steam (that which has been 
heated secondarily by conducting it through iron 
pipes which have been raised by flame to a tempera- 
ture of about ioo° C). 

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

Disinfection by steam is applicable to clothing, 
linen, blankets, towels, surgical dressings, instru- 
ments, curtains, carpets, brushes, mattresses, pillows 
(the two latter should be ripped open), and a number 
of delicate fabrics. It is not applicable to linen 
soiled by feces, blood, or pus, since the stains would 
become fixed by the process, nor to rubber articles. 
Under certain conditions many articles are exposed to 
the action of steam for one hour on three successive 
days, being kept during the intervals at a tempera- 
ture of 70 to 8o° C. to favor the development of 
bacteria. This is called " intermittent n or "frac- 
tional M sterilization, the object of which is to kill all 
bacteria that may have developed from spores that 
escaped the first steaming. The last sterilization is 
for the purpose of making sure. 

Hot air is inferior to both steam and hot water. 
Steam at a temperature of ioo° C. is more effectual 
than hot air at a much higher temperature. Accord- 
ing to investigations, exposure to a temperature of 
150 C. (302 P.) for one and a half hours in a hot- 
air sterilizer will kill all known bacteria and their 
spores. 

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



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 47 

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

Carbolic acid, derived from coal-tar by distillation. 
When pure, it is a solid, white, or faintly rose- 
colored, crystalline body, readily soluble in water, 
alcohol, or glycerin. On exposure to air it absorbs 5 
per cent, of moisture. A solution frequently employed 
is one of 5 per cent, strength. To make a 5 per cent, 
solution, 1 part of carbolic acid is added to 20 parts 
of very hot water and the whole shaken thoroughly. 
Any excess of carbolic acid above that strength 
falls to the bottom of the vessel as pinkish globules. 
Before using the solution care must be taken that the 
globules have been dissolved, or they will burn any 
living tissue with which they come in contact. Car- 
bolic acid is considered now to be the most reliable 
and useful of all the germicides and antiseptics. It 
has the advantage over corrosive sublimate in that it 
does not discolor instruments nor clothing; but, on 
the other hand, it irritates and benumbs the skin. 
Pure carbolic acid is a reliable disinfectant for instru- 
ments. If an instrument that is indispensable hap- 
pens to fall to the ground during an operation, it is 
laid for a few moments in pure carbolic acid, and 
then rinsed with sterile water, and is ready for use. 
Long-continued submersion in the acid will, how- 
ever, deprive knives and scissors of their temper and 
edge. Symptoms of poisoning have been produced 
by the absorption of the drug from surgical dressings 
and from the use of carbolic solutions for irrigation. 
The first evidences of poisoning are a very dark 



48 ANTISEPTICS. 

greenish or a blackish coloration of the urine, head- 
ache, giddiness, ringing or singing in the ears, and 
lassitude. The odor of carbolic acid is to a cer- 
tain extent a protective against accident; yet fatal- 
ities occasionally occur. The antidote of carbolic 
acid is milk and lime-water or flour and water. 
The strength of the solutions used varies from 
1:80 to 1:20. The acid is bought usually in the 
liquid form, having a strength of 95 per cent. To 
make a solution 1:20 (5 per cent.), 1:40 {2% per 
cent.), 1:50 (2 per cent.), 1:80 {1% per cent.), 1 
ounce of the 95 per cent, solution is added to 20, 40, 
50, or 80 ounces of water. When obtained in the 
solid form, it may readily be liquefied by placing the 
bottle in a vessel of hot water. 

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



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 49 

value for the disinfection of the excreta than car- 
bolic acid, as it hardens the albuminous material 
which covers the outside of all fecal masses, and 
thus protects the inside from the desired action. 
Tartaric acid, chlorid of sodium, or chlorid of ammo- 
nium is often added to prevent this. Compressed 
tablets, each containing tartaric acid or ammonium 
chlorid and 7*/^ grains of corrosive sublimate, or 
equal parts of chlorid of sodium and corrosive sub- 
limate, are in common use. The convenient form in 
which this drug is put up and the readiness with 
which it can be used in surgical and medical work 
have made its adoption universal. Its poisonous 
character must be kept constantly in mind. The 
first symptoms of poisoning in consequence of the 
absorption of the bichlorid are profuse salivation, 
fetid breath, a metallic taste in the mouth, sore 
teeth, spongy gums, and swollen tongue. Should 
any of these symptoms appear they should at once 
be reported to the surgeon. As the solution has no 
odor, it is occasionally swallowed in mistake. Should 
this occur, symptoms of a violent gastro-enteritis 
appear — vomiting, burning pain, bloody stools ; the 
kidneys are also affected, and an acute Bright's dis- 
ease develops. The immediate treatment of this 
acute poisoning consists in the giving of white of 
egg^ flour, or milk and lime-water, and washing out 
of the stomach. 

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

Creolin. — This is a non-irritant and practically 
non-toxic germicide. Though toxic symptoms have 
4 



50 ANTISEPTICS. 

been reported, it certainly is the least poisonous of 
the powerful germicides now in use. Its chief disad- 
vantage is that when mixed with water it forms an 
opaque emulsion; consequently it is inapplicable for 
the sterilization of instruments, since they could not 
readily be found in it. For cleansing the hands and 
for irrigation, creolin is used in strength of from 
2 to 5 per cent. To make a 2 per cent, solution, 
2 1 /} teaspoonfuls of creolin are added to 1 pint of 
water. 

Lysol is a brown, oily-looking, clear liquid, with a 
creosote-like odor, obtained from tar-oils. When 
added to ordinary hard water it forms a clear, soapy 
liquid, as it precipitates the lime-salts in the water, 
but is clear if distilled water, alcohol, or glycerin 
be mixed with it. Its antiseptic properties under 
no circumstances are impaired. On account of its 
saponaceous character it cannot be used for instru- 
ments, because it renders them slippery. It is much 
employed in surgery and gynecology, in solutions of 
from 1 to 5 per cent. To make a 1 per cent, solution, 
5 drams are added to ^ gallon of w r ater. Its chief 
advantage over other antiseptics lies in its non-irri- 
tant and much less poisonous properties. It can be 
used for the disinfection of everything in the sick- 
room. 

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

Sctprol is a dark-brown oily fluid with an odor of 
carbolic acid. When mixed with water it divides 



ANTISEPTICS, DISINFECTANTS, AND DEODORANTS. 5 I 

into oil drops, some of which fall to the bottom of 
the vessel, while others float on the top of the water, 
consequently it cannot be used for surgical purposes. 
It is a powerful disinfectant, especially valuable in 
disinfecting excreta, and possesses the property of 
diffusing evenly through the material- to which it is 
added. 

Other disinfectants outside of the coal-tar products 
are : 

Iodoform is largely used as a surgical dressing. It 
has no decided antiseptic properties. It does good by 
absorbing the liquids of the wound, thereby remov- 
ing the nidus for germ-growth. When applied to 
large moist surfaces it gives off free iodin. It prevents 
decomposition and inhibits, but does not destroy, the 
germs of putrefaction and pus-formation if they are 
present before its use. When applied to raw sur- 
faces it is occasionally absorbed into the system, 
and causes symptoms of poisoning. On account 
of this danger salol is often substituted for it, as 
is also a mixture of iodoform, 1 part to 7 parts of 
boric acid, it being both antiseptic and unirritating. 
The symptoms of absorption are headache, loss of 
appetite, rise of temperature, a rapid, feeble pulse, 
restlessness, and insomnia. These symptoms may 
pass away if the dressing is removed and discontinued. 
In grave cases there is marked anxiety, a bright- 
red eruption appears on the face and limbs, and 
there is retention of urine, with stupor, delirium, 
collapse, and death. Some patients are very sus- 
ceptible to the toxic effects of the drug. It has a 
penetrating odor, which many persons find disagree- 
able. Spirit of turpentine will at once remove the 



52 ANTISEPTICS. 

objectionable odor from the hands, instruments, and 
vessels that have been in contact with the drug. Iodo- 
form darkens upon exposure to a bright light and is 
likely to cake when it becomes moist. It is used for 
impregnating gauze-dressings, for dusting on ulcers 
and wounds, and for injections, dissolved in ether or 
olive oil, into sinuses or tuberculous abscesses. It is 
also used in the form of ointment. 

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

Formaldehyd is a gas formed by the partial oxida- 
tion of wood alcohol. Its use is greatly facilitated by 
having it combined with water and in a known def- 
inite proportion, so that the quantity used may be 
certain and definitely known. Its solution in water 
is called formol, formal, and formalin, and contains 
about 40 per cent, of formaldehyd gas. Formal- 
dehyd is non-poisonous, colorless, with a pungent, 
irritating odor, and possessing great antiseptic, disin- 
fectant, and deodorant powers. Its activity as a ger- 
micide is considered to be equal, if not superior, to 
that of bichlorid of mercury, and it is available in 
many cases in which the latter cannot be used. It 
does not corrode or tarnish metals, nor injure the 
finest fabrics either in texture or color. As a deodo- 
rant it removes immediately the odor of feces, urine, 
septic or gangrenous material. It is used externally 



ANTISEPTICS, DISINFECTANTS, AXD DEODORANTS. 53 

in the form of solution, spray, or vapor, and is some- 
times added to powders. In solution as a wash or 
irrigation in wounds, etc., it is employed in strengths 
varying from 0.5 to 20 per cent. As a dusting-pow- 
der it is used in combination with gelatin. Sheets 
of moist gelatin after exposure to formalin fumes are 
ground to a coarse powder, and are used in the dress- 
ing of wounds. A slight disadvantage is that for four 
or five hours after its use on a raw surface it produces 
more or less pain of a burning nature. In the form 
of vapor it is used for sterilizing instruments and sur- 
gical dressings, and for the fumigation of the sick- 
room and its contents. The simplified method of 
fumigating consists of diluting one pound of forma- 
lin with three times its volume of hot water, and 
boiling over a flame for half an hour. The generated 
gas is very penetrating, and having the same specific 
gravity as the air soon permeates the room in which 
it is confined, and kills all germs, not protected by 
moisture, in about three hours. Special portable 
forms of apparatus have been devised for purposes 
of room-disinfection. Spray disinfection of rooms 
with a 2 per cent, formalin solution is also very 
satisfactory. 

For the sterilization of instruments a 1 : 2000 solu- 
tion is used. Formalin is also used in the preparation 
of catgut. The catgut is wound on a glass spool, 
not too tightly, and soaked for two days in equal parts 
of ether and alcohol, after which it is rinsed in pure 
alcohol for a few moments and transferred to glass 
bottles with tightly fitting covers, and which have 
been previously sterilized, containing equal parts of 
formalin and alcohol, enough more than to cover the 



54 AXTISEPTICS. 

catgut. After one week the catgut is taken out and 
boiled for half an hour in normal saline solution, and 
is then placed in sterilized bottles containing alcohol 
•until needed. 

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

A fatal case of formalin-poisoning is reported, the 
amount taken being about 3 ounces of a 4 per cent, 
solution. Immediately after taking there were pain 
in the stomach and vomiting. The vomited matter 
was blood-stained and had the pungent odor of for- 
malin. The patient died of heart-failure thirty-two 
hours afterward. The treatment consisted in albu- 
min-water, free emesis, heart-stimulants, and normal 
saline solutions given both hypodermically and intra- 
venously. 

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



CHAPTER V. 

ANTISEPTICS (Continued). 

Peroxid of hydrogen is a popular antiseptic. It 
is an excellent agent for the destruction of pus- 
cocci. When poured or injected into a wound, 
effervescence takes place, the result of chemic reac- 
tion between the wound-secretions and the hydro- 
gen peroxid. This active frothing serves to carry 
off any shreds of tissue in the wound that cannot 
easily be reached. The peroxid is also applied to 
the throat in diphtheria to destroy and remove the 
false membrane. It readily decomposes by coming 
in contact with metals; consequently, if used as a 
spray, a glass atomizer must be employed. The per- 
oxid of hydrogen in common use is a clear, odorless 
fluid, having a bitter taste. The official solution 
contains 3 per cent, of the pure dioxid, which corre- 
sponds to about ten volumes of available oxygen, and 
it is upon its readiness to yield oxygen that its 
activity depends. The solution should be kept in a 
cool, dark place, and the cork forced tightly into the 
bottle. 

Boracic acid (boric acid) is a mild antiseptic. It is 
non-irritating and practically non-poisonous. It is 
therefore frequently used to wash out cavities, for 
injections, and in ophthalmic and aural practice. It 
is used in the form of powder, solution, ointment, and 
gauze. In solution, a saturated solution is used (a sat- 

55 



56 ANTISEPTICS. 

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

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

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

Alcohol. — Absolute alcohol is an antiseptic and dis- 
infectant used for cleansing the skin, for the prepara- 
tion of sutures and ligatures, and for the disinfec- 
tion of cutting-instruments. To sterilize the hands, 
they are scrubbed for five minutes with soap and hot 
water, then scrubbed for the same length of time in 
absolute alcohol, and finally rinsed in an antiseptic 
solution. The results obtained by the disinfection 
and cleansing of the skin with alcohol have been as- 
cribed to the solvent action of the alcohol upon the 
fatty matters on the skin, thus allowing corrosive 
sublimate and other antiseptics to come into imme- 
diate contact with the bacteria. Scrubbing the 
hands in absolute alcohol for five minutes takes up 



ANTISEPTICS. 57 

both the fatty matters of the skin and also the bac- 
teria, which are thus washed away. 

Potassium permanganate, or permanganate of 
potassium, is an antiseptic, disinfectant, and deodor- 
ant, depending for its action on its oxidizing prop- 
erties. It parts with its oxygen very readily to 
organic substances and becomes inert. Its chief dis- 
advantage is that it stains everything a brownish- 
black color. It is used in solutions varying from 
niooto 1:10. When employed for sterilizing the 
hands, it is followed by oxalic acid solution, which 
has the property of removing the stain. It is also 
used on wounds, especially those which have an 
offensive discharge, as, for example, gangenous 
ulcers, on which it acts as a deodorant as well as a 
disinfectant. It may also be employed to disinfect 
bowel-movements, to flush water-closets, etc. Its 
advantages are that it is non-poisonous in ordinary 
strengths, rapid and complete in its action, and 
shows by its change of color from reddish-purple to 
a brown whether it is acting or whether it is ex- 
hausted. The strength of the solution generally used 
is from 20 to 1 6 grains of the crystal to 1 pint of 
water. 

Oxalic acid is a powerful germicide, though it is 
not used alone, but to remove the stains of potassium 
permanganate from the skin. It is very poisonous 
and quite irritating, but the irritation can in a meas- 
ure be avoided by immersing the hands and forearms 
afterward in either plain water or lime-water. A 
series of experiments by Dr. Howard A. Kelly, to 
determine the relative part played by these two 
chemicals in the process of disinfection, led to the 



58 ANTISEPTICS. 

conclusion that both the permanganate of potassium 
and oxalic acid were germicides, but that the oxalic 
acid at a temperature of about 40 C. (104 F.) is a 
much more powerful germicide than the permangan- 
ate of potassium. Oxalic acid also removes perman- 
ganate stains from white goods, and ammonia will 
remove the stains from black goods. 

Potassium permanganate is frequently used in a 
solution called Condy* s fluid, which contains 16 
grains of permanganate of potassium crystals to 1 
ounce of water. It is a disinfectant and deodorant. 

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

Labarraqne* s solution is a solution of chlorinated 
soda, and is made from chlorinated lime and sodium 
carbonate. It is used as an antiseptic in solutions of 
1: 10, and for cleansing purposes. 

Chlorinated lime, or chlorid of lime, is one of the 
best disinfectants for drains, infected clothes, bowel- 
movements, sputum, and urine. It is also a power- 
ful deodorizer. It loses its strength if exposed to 
the air. The standard solution contains 6 ounces 
to 1 gallon of water. 

Sulphuric and hydrochloric acids are employed in 
4 per cent, solutions for the disinfection of excretions, 



ANTISEPTICS. 59 

equal parts of the solution and the substance to be 
disinfected being used. 

Ichthyolis a dark-brown thick liquid, with a highly 
disagreeable odor; it is used extensively as an antisep- 
tic, astringent, sedative, and alterative in many skin- 
diseases, various inflammatory affections, wounds, 
abscess-cavities, etc. It is employed externally in 
the form of a thick liquid and ointment. Before the 
application of ichthyol the affected parts are washed 
with warm water and soap, and gently dried. After 
painting, or after inunction, the parts are covered 
with absorbent cotton or flannel and gutta-percha 
tissue. The applications are best employed morning 
and evening. Many patients object strongly to 
it on account of its disagreeable odor. This may 
be disguised by the addition of oils of citronella 
and eucalyptus, i part of each to 50 parts of ichthyol 
— or ichthyol (9 parts) may be combined with oil of 
turpentine (1 part). Ichthyol is said to have a re- 
markably efficacious action upon recent burns in re- 
lieving the pain and facilitating healing. It is also 
used in combination with the compound stearate of 
zinc. The stains of ichthyol may be removed by 
boiling the stained articles in soap and water, or by 
washing them with potash-soap or soap-spirit. 

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

Orthoform is an antiseptic and a local anesthetic 



60 ANTISEPTICS. 

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

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

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

Sterilized vinegar is said to be equal in antiseptic 
power to a i : 2000 solution of corrosive sublimate. 
It is less irritating to the tissues than bichlorid, and 
is said to stimulate the healing process in open 
wounds instead of retarding it, as mercury some- 
times does. It is sometimes used during an oper- 
ation for irrigation, especially if there is much capil- 
lary hemorrhage, which, on account of its astringent 
action, it controls. It is also used for the disinfec- 
tion of the hands, surgical operating-rooms and wards, 
and to remove blood-stains from the hands. 

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

Resorcin is an antiseptic and deodorant, used in 



ANTISEPTICS. 6 1 

the form of solution, powder, or ointment in strengths 
varying from 2 to 20 per cent. As a powder it is 
usually mixed with boric acid, 1 : 20 or 1 : 10. It is 
not absorbed by the unbroken skin and produces 
very little irritation on the cutaneous tissues. 

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

Protargol is an albuminous compound of silver, 
containing about 8 per cent, of the metal. It 
is a powerful antiseptic, causing neither pain nor irri- 
tation when applied to raw surfaces. It is considered 
a valuable application in the treatment of wounds, 
and inflammatory surfaces discharging freely. It is 
soluble in water to the strength of about 50 per cent., 
and forms a clear light-brown fluid. 

Listerine is a proprietary antiseptic solution used 
extensively on wounds, for cleansing the mouth, 
throat, and nose, etc. 

Bicarbonate of sodium has been used with marked 
success as an antiseptic in the treatment of foul sup- 
purating wounds and ulcers in a strength of 2 per 
cent. A i-per-cent. solution has long been used in 
which to boil surgical instruments. The soda adds 
to the disinfectant power of the boiling water. 

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



PART II. 
SURGICAL TECHNIC 



CHAPTER VI. 

CARE OF OPERATING=ROOM ; METHODS OF 
STERILIZATION ; CARE OF INSTRUMENTS. 

In almost all large hospitals there are three operat- 
ing-rooms, one for general surgical, one for gyneco- 
logic, and one for septic operations. 

The operating-room for septic cases should be far 
removed from the others, and neither surgeon nor 
nurse attending this room should have anything to 
do with the others. Rooms should also be set apart 
exclusively for dressing the cases, thus extending the 
benefit of an isolation of operating-rooms and adding 
greatly to the convenience of hospital work. 

These dressing-rooms are otherwise very desirable, 
for besides having everything at hand with which to 
do a dressing properly, the nurse in charge of the 
patient has the opportunity to turn and make up the 
bed afresh during the patient's absence. Stretchers 
are used to convey patients to and from the operating- 
and dressing-rooms. The wheels generally have 
rubber tires, the top board is detachable and has four 

> J. 

handles, two at each end. At least four stretchers are 
necessary in a large hospital. 

62 



Plate i. 




STERIL IZA TION. 63 

The material used in the construction and furnish- 
ing of an operating- and dressing-room should be of 
marble, metal, porcelain, and glass, all of which can 
readily be made aseptic. The water-faucets should 
be controlled by automatic foot-valves, so as to avoid 




FIG. 4. — Wheeled stretcher. 

contamination by turning on the spigots with the 
hands after they have been rendered aseptic. 

The operating-room should be kept clean, and 
should be swept and dusted every day, and rubbed 
over with a damp cloth; in short, it should be 
in such a condition as to be ready for an operation at 
a few moments' notice. The supplies for dressings 
should not be allowed to run down, and the instru- 
ments should always be in a first-class condition. The 
emergency bundle, containing everything necessary 
for an emergency operation, should be kept in readi- 
ness. 

Sterilisation. — Sterilization mav either be drv or 



64 SURGICAL TEC ff NIC. 

moist; moist heat is preferable, because it is more 
thorough and more penetrating than dry heat. For 
dry sterilization the towels and dressings are placed 
in covered tin pans in an oven the temperature in 
which ranges from 160 to 21 2° F. For moist or 
steam sterilization, a Kellogg, a Sprague, or an Arnold 
steam sterilizer is used. The heat must be con- 
tinued for fully one hour before the operation. 

Regarding the sterilization of instruments surgeons 
differ; some prefer to have their instruments wrapped in 
a towel and put into the Schimmelbusch or Arnold 
sterilizer and allowed to boil for half an hour in a 1 
per cent, solution of carbonate of sodium to prevent 
their rusting. The water must boil before the instru- 
ments are placed in it. All edged instruments to be 
boiled in the soda solution should be wrapped in cot- 
ton and packed so firmly that they will not be tossed 
against one another bv the solution as it becomes 
agitated in boiling. This agitation seems to be the 
reason why they lose their edge. Many operators 
prefer to have their edged instruments and needles 
placed in a dish containing 95 per cent, carbolic acid 
for half an hour; then just before the operation they 
are taken out and rinsed with sterilized water. 

After sterilization the instruments are transferred 
to the instrument- table, or to shallow 7 porcelain or 
glass trays, in which they lie covered with sterilized 
towels until required. 

Instruments and dressings are now sterilized with 
formaldehyd w 7 ith excellent results, one great advan- 
tage being that neither the solution of formalin nor 
the gas injures the instruments in any way or dulls 
the edge of knives, scissors, or needles. A Schering 



Plate 2. 




STERILIZA TION. 65 

lamp is usually used either with a 40-per-cent. solu- 
tion of formaldehyd or with formalin pastils. The 
best results seem to be obtained with the pastils. One 




Fig. 5. — Apparatus for sterilization of instruments, etc. 



pastil is constantly being evaporated in the upper cup 
of the lamp; but when rapid evaporation is required 




Fig. 6. — Instrument-sterilizer 



the upper cup is removed and the pastils are placed 
in the lower part. 

During the operation, instruments which have 
5 



66 



SURGICAL TECHXIC. 



fallen to the floor and are needed for further use are 
rinsed in cold water and laid for a few moments in 
the 95 per cent, carbolic acid, then rinsed with steril- 
ized water. 

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




FlG. 7. — Sterilizer for instruments and dressings : a, for dressings ; b, for 
instruments ; c, water and solution of carbonate of sodium to prevent rust- 
ing. 



must receive special attention, since it is difficult to 
get them surgically clean. After being scrubbed the 
instruments are rinsed in hot sterilized water, wiped 
dry with a soft towel, and then laid away in the 
case. The knife-blades must be rolled in cotton. 
The important points to be remembered in cleaning 
instruments after an operation are: 



S TRRIL TZA TION. 6? 

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

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

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




FlG. 8. — Agateware tray. 

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

Every operating-room nurse should be familiar 
with the names of the instruments necessary for each 
different operation, so as to be able to lay them out 
when occasion requires. Many nurses get together 
after school-hours and "make believe" an operation 
is to take place. Each nurse has her duty assigned 



68 SURGICAL TECHXIC. 

to her, and each tries to fulfil it in a thoroughly 
professional, dignified, and quiet manner. Practice 
of this kind is never lost. 

In the operating-room should be kept two large 
ledgers, in one "of which the house-surgeons, after 
making the morning- rounds with the visiting sur- 




FlG. 9. — Hard rubber tray. 

geons, should record the number of operations to be 
performed the next day, the time, name of operator, 
etc. The operating-room nurse is thus made ac- 
quainted, by consulting the book, of the amount of 
work before her for the next day, and the character 
of the operations for which she has to prepare. 




FIG. 10. — Robb's aseptic ligature-tray ; white porcelain. 

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



STERILIZATION. 



6 9 



in which the operator wishes them. This list is given 
to the male attendant, who brings up the patients in 
succession, in such a way that while one patient is 
being operated on the next is being anesthetized. The 
head nurse in the operating-room has two or three 
sets of instruments, and during one operation an as- 
sistant nurse is sterilizing the instruments and making 
preparations for the next operation. There is then 
no waiting 011 the part of the operator, for as the 
patient operated on is wheeled out of the operating- 
room the next patient is wheeled in. The following 
chart will give an idea as to the way the book is made 
out and the order in which the operations are writ- 
ten. The emergency-operations, accidents, etc., are 
also recorded, but after the performance of the ope- 
ration. 



Date. 


Operation. 


Floor. l 


Time. 


Operator. 


Room 


Ward. 


-d 


Floor. 


Mar. 11. 


Laparotomy. 

Vaginal hysterec- 
tomy. 
Cholecystostomy. 


4th. 


8. A M. 

8.30 " 
9.00 " 

9.30 " 


Dr. Murphy. 
" Johnson. 
" Fenger. 


19 

21 
24 

16 






3d. 


« 


Appendicectomy. 


« 


lO.OO " 
IO.45 " 


" Morgan. 
" Kindig. 




R 
D 


10 
6 




« 


Amputation, breast 


« 


II.30 " 
2. P.P.I. 


" Carter. 
" Andrews. 


24 


D 


9 


4th. 


" 


Appendicectomy. 


" 


3.OO " 


" Fenger. 


21 






2d. 


" 


Cesarean section. 


" 


4.OO " 


" Eyster. 


21 






4th. 




Appendicectomy. 


3d. 


6.30 " 


" Comegys. 


29 






2d. 



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

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



7o 



SURGICAL TECHNIC. 



Date of 
Preparation. 


Prepared by 


Antiseptic 
used. 


Operator. 


Floor. 


Room. 


March 10. 


E. A. S. 


Corros. sub. 


Dr. Eyster. 


Fourth. 


No. 21. 


Date of 
Operation. 


Hour. 


Sutures 
used. 


Length of 
time prepared. 


Stitches 
removed. 


Condition. 


March n. 


4 P. M. 


Silkworm- 
gut. 


Two hours' 
boiling. 


March 19. 


Aseptic. 



A book should also be kept in each dressing-room 
showing the number of cases dressed each day, the 
dressing used, and progress since the last dressing. 
It should be kept for the convenience of the dressing- 
room nurse in making an estimate of dressings for the 
next day, and for the convenience of the surgeon in 
knowing what patients are dressed, their condition, 
and in knowing when they are to be again dressed. 
It will also recall condition of last dressing. 



Room or 
Ward. 



No. 29, 
2d floor. 



Diagnosis. Operated 



Appendicitis. March 11 



Operator. 



Dr. Come- 

gys. 



Dressed. 



March 17. 



Died or 
Discharged 



Discharged 
April 2. 



Remarks. 



CHAPTER VII. 

INSTRUMENTS NECESSARY IN DIFFERENT OPE= 
RATIONS, KEEPING OF CHARTS, SURGEON'S 
KIT, ETC. 

In many hospitals, small ones especially, where 
there are no medical students or house doctor, the 
nurse has more responsibility than in larger institu- 
tions, and becomes closely familiar with such details 
as taking the history of the patient; the arranging 
and sterilization of instruments; assisting the oper- 
ator, giving the anesthetic, and writing out the re- 
port of the operation. The following charts will be 
of use in keeping the important features of this line 
of duty in mind. When taking the patient's history 
it is a good plan to allow her to describe her con- 
dition in her own words. Any peculiarities of the 
patient's manner and other points which may be 
observed can be noted, and afterward the questions 
necessary for making out the charts may be asked. 

Family History. 

Age. Health. Disease. Cause of death if dead- 
Father. 

Mother. 

Brothers (number). 
Sisters (number). 
Wife or husband. 
Children (number). 

71 



J2 



SCRGICAL TECHNIC. 



Uncles or aunts with epilepsy, insanity, tuber- 
culosis, or consumption. 
> j. 

Personal History. 

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



(When Female.) 




Sexual History. 




I. Menstruation, 




(a) First at what age. 




(b) Regularity. No. days. 




(c) Duration. No. days. 




(d) Amount. 






r Color. 


(e) Character of discharge < 


Consist- 




ency. 




Odor. 



{/) Intermenstrual discharge. 

(g) Dysmenorrhea — when. 

TT jj • f Number. 

II. Fregnanctes \ ^ 

I Sickness or peculiarities. 

{Number. 
Sickness. 
Fever. 
IV. Labors. 

{a) Number. 



(b) Character 



Easy. 
Difficult. 
Spontaneous. 
Instrumental. 



(c) Peculiarities. 
(d) Sickness post partum, if any. 



SURGEON'S KIT. 73 

Previous Illness. 

Starting- with childhood, give different sicknesses 
and age at which same occurred, following life 
of patient to present time simply with reference 
to sickness, including appetite, bowels, urine, 
headaches, pains, coughs. 

Present Sickness. 

Date. 

Onset. Character. { Chills > P ains ' locations, se- 
I verity, etc. Peculiarities. 

Progress and changes to present time. 

Changes. Appetite. Bowels. Urine, etc. 

Examination. 

The packing of a surgeon's bag is often done by 
the operating-room nurse. Many surgeons use the 
telescope valise, or kit, as it is more commonly called; 
while others employ a regular surgeon's bag. Be- 
fore the bag is packed the nurse makes out the list of 
necessary articles, and as each article is put in it is 
checked off the list. When packed, a copy of the 
list is securely pinned upon a towel inside, where the 
surgeon can see it on first opening the bag. The kit 
is packed by first laying in two large sterilized 
towels, the ends of which hang over the edges of the 
bag. Together with the instruments, which are 
placed in a linen instrument-roll, and the dressings, 
the kit should contain three new nail-brushes, soap, 
razor, oxalic acid and permanganate of potassium 
crystals in bottles, hypodermic syringes with tablets 
of strychnin sulphate (gr. g 1 ^), atropin sulphate (gr. 
j-Jq), and morphin sulphate (gr. \\ ether and chloro- 
form (with cone and mask), tablets of corrosive sub- 



74 SURGICAL TECHXIC. 



OPERATION BLANK. 



Service of Dr. 
Date. March 10, 1899. 
Name 



I. PREPARATION OF PATIENT FOR OPERATION. 

II. ANESTHETIC. ANESTHETIST. 

Temperature. 

Before operation. 

After operation. 
Pulse. — To be taken ever} 7 five minutes. 

III. PREPARATION OF FIELD OF OPERATION. 

IV. POSITION OF PATIENT DURING OPERATION. 
V. PRIMARY MANIPULATIONS. 

VI. INCISION AND HISTORY OF OPERATION. 
VII. TREATMENT OF WOUND. 
VIII. DRAINAGE. 
IX. CLOSURE OF WOUND. 
X. DRESSING. 

XL RECOVERY FROM ANESTHETIC. 
XII. AFTER-TREATMENT. 



SUKGEON'S KIT. 



75 



limate and sodium chlorid, iodoform gauze, plain 
gauze, gauze sponges, white suits, caps and canvas 
shoes for the operator and assistants, Kelly pad, 
rubber gloves, brandy, alcohol, safety-pins, absorb- 



wmmmm 







FlG. ii. — Canton-flannel roll for instruments. 

ent cotton, twelve towels, a rubber apron, ligatures, 
sutures, and rubber and glass drainage-tubes. The 
glass-ware should be packed in the middle, to pre- 
vent breakage. When the kit is packed a third 
towel is laid over the contents, the edges of the other 




Fig. 12. — Instruments wrapped in canton-flannel roll. 

two are brought up, and all pinned together with 
safety-pins. 

The instrument-rolls are very serviceable in econo- 
mizing space and in keeping the instruments as 



y6 SURGICAL TECHNIC. 

nearly aseptic as possible. They are made of linen, 
canton flannel, or toweling, one yard long; and 
through the middle of each are adjustable loops in 
which the instruments are placed. When soiled the 
rolls may be washed and sterilized. 

LIST OF INSTRUMENTS NECESSARY IN DIFFERENT 
OPERATIONS. 

Instruments for Perineorrhaphy. 

Catheter, glass, small, i 

Catheter, glass, large, i 

Forceps, hemostatic, small, 6 pairs. 

Forceps, hemostatic, intermediate, 3 " 

Forceps, hemostatic, long, 3 " 

Forceps, hemostatic, long dressing-, 1 pair. 

Forceps, hemostatic, tissue- (rat-tooth), 2 pairs. 
Forceps, hemostatic, bullet-, 2 " 

Forceps, hemostatic, volsella, 2 " 

Scalpels, 2 " 

Uterine sound and applicator. 
Tenacula, straight, 1 pair. 

Tenacula, curved, 2 pairs. 

Tenacula, shepherd's crook, 1 pair. 

Scissors, straight, 1 " 

Scissors, right-angle, 1 " 

Scissors, left-angle, 1 " 

Sponge-holders, 6 

Needles. Sutures, silk of various sizes, 

and silkworm-gut. 
Needle-holder. Sims speculum. Retrac- 
tors. Leg-holder. Sterilized stockings. 
Glass nozzles. Irrigation dressings. 

Tenacula are used to catch and hold movable tis- 



LIST OF INSTRUMENTS. J J 

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



Instruments for Trachelor 


rhaphy. 


Catheter, glass, 




i 


Two-way catheter, 




i 


Curette, dull, 




i 


Curette, sharp, 




i 


Curette, spoon, 




i 


Dilators, different sizes. 






Forceps, hemostatic, 




8 pairs. 


Forceps, volsella, 




i pair. 


Forceps, bullet-, 




2 pairs. 


Forceps, long dressing- (Kelly), 


i pair. 


Forceps, tissue- (rat-tooth), 




2 pairs. 


Scalpels, 




2 " 


Speculum, Sims, small, 




I 


Speculum, large, 




I 


Shot-compressor and shot. 






Retractor, small, 




I 


Retractor, medium, 




I 


Scissors, straight, 




i pair. 


Scissors, curved, 




i " 


Tenacula, 




2 pairs. 


Needles, curved, various 


sizes, 


short, 


stout, straight. 






Needle-holders, 




2 



78 SURGICAL TECHNIC. 

Uterine sound and applicator. 
Sterilized stockings. Leg-holder. 
Catgut and silkworm-gut sutures. 

Instruments for Dilatation of Cervix and Curetting 
of Uterus. 

Catheter, glass, small, i 

Catheter, two-way, for irrigation, i 

Curet, sharp, I 

Curet, Martin's double blunt, I 

Curet, curved, sharp, i 

Dilators (Hank's rubber, all sizes). 
Dilator, GoodelPs, i 

Forceps, long dressing-, i pair. 

Forceps, bullet-, i " 

Uterine sound and applicator. 
Sims specula, large and small. 
Kelly perineal pad. Sterilized stockings. 

Irrigator. Glass nozzles. Dressings. 

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



Instruments for an Abdominal 


Oper 


ation. 


(Arrange for Trendelenburg Position 


f.) 


Forceps, small, hemostatic, 




6 pairs, 


Forceps, medium, 




6 " 


Forceps, pedicle-, 




4 " 


Forceps, long, 




4 ■; 


Forceps, long dressing-, 




1 pair. 


Forceps, for drainage-tube, 




1 " 


Forceps, Billroth, 




2 pairs. 


Forceps, bulldog, 




1 pair. 



LIST OF INSTRUMENTS. 79 

Forceps, rat-tooth, 2 pairs. 

Aspirator. Scalpels. Vaginal packer. 

Uterine sound. 
Paquelin's thermocautery. 
Sponge-holders. 6 

Scissors, long and small, 1 pair of each. 

Retractors, Lange's large, 1 pair. 

Volkmann's 6-prong retractors, 1 " 

Volkmann's 4-prong retractors, 1 " 

Long and small probe and director. 
Needle, aneurysm-, 1 

Needle, transfixion, right curved, 1 

Needle, transfixion, left curved, 1 

Needle, transfixion, pedicle, 1 

Needles, large, small, and intermediate, 

curved and intestinal. 
Murphy anastomosis button (sizes 1-4). 
Murphy's forceps for holding button, 1 pair. 
Murphy's forceps, intestinal clamp, 1 " 

Murphy's forceps, introducing, 1 " 

Flat dissector (Fenger). 
Drainage-tubes, glass or aluminum, as- 
sorted sizes. 
Needle-holders, 2 

Dressings, ligatures, and sutures of silk- 
worm-gut, and various sizes of silk 
and catgut. 
Laparotomy sheet. Saline solution. 
Small bolsters, made of non-absorbent 
cotton covered with gauze, six 
inches by three, to retain the intes- 
tines and to keep them from encroach- 
ing upon the site of operation. 



80 SURGICAL TECHNIC. 

Extra, for Cysts or Tumors. 
Trocars, large and small. Rubber tubing. 
Nelaton's forceps. 
Billroth' s tumor-forceps, 2 pairs. 

Extra, for Vaginal Hysterectomy. 
Sterilized stockings. Leg-holder. 
Clamp-forceps, 6 pairs. 

Uterine sound. Dissecting forceps. Long 
and short tenacula. Speculum. Curet. 

Instruments for Operations on the Brain a7id Spine. 

Forceps, hemostatic, medium, 6 pairs. 

Forceps, hemostatic, small, 6 " 

Forceps, rat-tooth (tissue-), 2 " 

Forceps, bone, three kinds; long-jaw for- 
ceps. 

Trephine — three sizes, small and medium. 

Chisels, various sizes. Hammer. 

Scalpels, 2 

Scissors, 2 pairs. 

Curets, sharp and dull. 

Needles. Sutures. Ligatures. Saline 
solution. De Vilbis forceps. 

Instruments for Amputation of a Limb. 

Esmarch bandages, 2 

Periosteotome, i 

Long amputating-knife. 

Medium amputating-knife. 

Scalpels, large and medium. 

Bone-saw. Chain-saw. 

Forceps, small hemostatic, 6 pairs. 

Forceps, medium hemostatic, 6 u 



LIST OF INSTRUMENTS, 8 1 

Forceps, bone-cutting, straight, curved, 
and angular. 

Forceps, gouging. 

Forceps, rat-tooth (tissue-), 2 pairs. 

Forceps, retractor, 1 pair. 

Scissors, large and small, 1 pair of each. 

Bone-pins. 

Four-prong retractors, 2 

Three-tailed gauze retractors, 2 

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

Instruments for the Month and Throat, 

Head-mirror. Snare of silver wire. 

Volsella forceps for tonsils. 

Uvulatome. Tonsillotome, 2 

Sponge-holders, 6 

Uvula scissors with and without claws. 

Tongue-depressor. 

A self-fastening mouth-gag". 

Trachea-dilator. 

Trachea-tubes. Intubation-tubes. 

Long forceps, 1 pair. 

Long curved forceps, 1 u 

Long straight scissors, 1 il 

Throat-mirror (laryngoscope). 

Angular forceps, 1 pair. 

Angular scissors, 1 " 

Long, slender curet. 

Gottstein knife (for adenoids). 

Gradle forceps (for adenoids). 

Bistoury. Flexible probe. 

6 



82 SURGICAL TECHNIC. 

Esophageal sound and dilator. 
Fish-bone catcher for foreign bodies. 

Instruments for the* Nose. 

Polypus-snare. Silver applicator. 

Nasal curet. 

Saw with reversible blade for cutting up 
or down. 

Nasal scissors, with and without saw- 
teeth. 

Nasal bone-scissors. 

Nasal bone-scissors, turbinated. 

Nasal polypus-forceps. 

Septum-straightening forceps, i pair. 

Nasal speculum. 

Septum-knife. 

Electrocautery for hypertrophied turbin- 
ates and for hemostasis. 

Chromic acid. Applicators. 

Iodoform-strips for packing. 

Monsell's solution for hemostasis. 

Instruments for the Ear. 

For JMastoid Opei'ations. 

Forceps, hemostatic, small, 8 pairs. 

Scalpels, small and medium, i each. 

Chisels and gouges, various sizes. 

Mastoid drills and bone-trephines, 2 

Mallet. 

Ear-speculums, various sizes. 

Diagnostic tube and otoscope. 

Ear-syringe (hard rubber). 



LIST OF INSTRUMENTS. 83 

Sponge- and cotton-holder. 

Small cnret. 

Irrigator. 

For Middle-ear Operations. 

Eustachian catheter, and Politzer's air- 
bag. 
Curets. Ear-scoop. 
Snare and wire. 
Head-mirror. 
Cotton-holder. 
Tympanum-perforators. 
Ear-aspirator for cleansing middle ear. 
Case of tuning-forks and hammer. 
Ear-scissors. 

Ear-speculum, various sizes. 
Slender polypus-forceps, 1 pair. 

Slender scalpels. 
Ear-probe. Irrigator. 

Instruments for Rectal Operations. 

Rectal speculum. 
Forceps, small hemostatic. 
Forceps, hemorrhoid. 
Scalpel. Paquelin's cautery. 
Rectal bougies. 

Sterilized stockings. Leg-holder. 
Kelly perineal pad. 

Irrigator. Dressings. Sutures. Liga- 
tures. 
Curets, sharp and dull, 1 pair of each. 

Saw and chisels for Kraske's operation. 
Metal probes for tracing fistulae. 



84 SURGICAL TECHNIC. 

Instruments for Urethral a7td Bladder Operations. 

Set of sounds, curved and straight. 

Catheters, various sizes. 

Urethral forceps, i pair. 

Artery-dilators, various sizes. 

Endoscopes with calibrators, various 
sizes. 

Urethral searcher. 

Head-mirror. Return-irrigator. 

Sounds and dilators (usually the same). 

Scalpels, artery-forceps, lithotrites. 

Stone-forceps, litholapaxy set. 

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

Necessary for Dressings after Gynecologic 
Operations. 

Sims speculum. 

Bullet-forceps, i pair. 

Long dressing-forceps (Kelly). 

Applicator. Scissors, straight, i u 

Churchill's tincture of iodin. 

Carbolic acid, 95 per cent. Ichthyol. 

Balsam of Peru and glycerin. 

Glycerin (pure). Vaselin. 

Tampons. Boric acid solution. 

Irrigator. Kelly perineal pad. 

Andrews stitch-cutter for the removal 

of silkworm-gut stitches from the 

vagina and cervix. 



LIST OF INSTRUMENTS. 85 

For Cystoscopic Examination. 

Head-mirror. 

Urethral calibrator and dilator. 
Urethral searcher. 
Vesical specula with obturators. 
Evacuator for removing urine. 
Long-mouthed toothed forceps. 
Applicator. 

Cocain solution, 10 per cent. 
Boroglycerid to lubricate the speculum 
and dilator. 

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



CHAPTER VIII. 
ANESTHESIA. 

Anesthetics are divided into two classes, local 
and general. In local anesthesia the patient does 
not lose consciousness; bat in general anesthesia 
consciousness is put in abeyance, the brain, together 
with the rest of the body, is narcotized, and there 
is profound sleep from which the patient awakens 
slowly. Both classes of anesthetics are used in sur- 
gery. 

We have practically four general anesthetics, one 
a gas, nitrous oxid, and three in liquid form: ether, 
chloroform, and ethyl bromid. The last three are 
those which are used in surgical work, while the first 
is chiefly employed in dentistry. The administration 
of the anesthetic is a duty which often falls to the 
head nurse, especially in small hospitals, in private 
practice, and in emergency cases. 

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



ANESTHESIA. 8? 

habits should be inquired into. Alcoholic patients 
pass through the exciting stage of anesthesia with 
considerable struggling; they are also more liable to 
congestions. 

An anesthetic must never be given on a full stom- 
ach, because the patient may vomit, and particles of 
food may lodge in the larynx and trachea and result 
in strangulation. The bladder and bowels must 
always be emptied, or they may act involuntarily. 
False teeth must be removed, as there is danger of 
their being swallowed. 

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



88 SURGICAL TECH NIC. 

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

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

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

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

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

In all operations in which an anesthetic is em- 



ANESTHESIA. 89 

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

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



9 o 



SUR GICA L TE CHNIC. 



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




Fig. 13. — Allis's aseptic ether-inhaler. 

strain the struggles of the patient. Ether generally 
first produces choking and coughing, followed by ex- 
citement ; that is fol- 
lowed by the muscles 
becoming rigid, the 
face may be cya- 
nosed, and the breath- 
ing stertorous or snor- 
ing ; this stage passes 
away, the muscles be- 
come relaxed, and the 
patient is in a state of 
insensibility. 

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




Fig. 14. — Method of pushing the lower 
jaw forward to prevent obstruction to 
breathing. 



ANESTHESIA, 9 1 

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



92 SURGICAL TECHNIC. 

pushed, which will generally ward it off; should she 
vomit, her head should be turned to one side, to 
allow the matter to escape more easily from the 
mouth. If the operation is about the neck or chest, 
the head must be turned to the opposite side, to pre- 
vent vomited matter from getting into the wound. 
Vomiting is usually due to incomplete anesthesia and 
the admixture of too much air with the vapor. The 
anesthetic must be persistently given until the vomit- 
ing ceases and complete relaxation occurs. 

The mucus should be constantly wiped from the 
patient's mouth. The pupils should remain con- 
tracted all through etherization, and dilate when the 
patient is returning to consciousness. Dilated pupils 
mean one of two things: either that the patient is com- 
ing out of the anesthetic influence, or that she is too 
deeply anesthetized. We can readily ascertain which 
condition the patient is in by pouring a little ether 
into the cone. If she is coming out, she will cough, 
stop breathing, and give other signs of discomfort; 
while if too deeply etherized she will breathe on 
steadily and not notice the fresh supply of ether; and 
the pupils will remain dilated until the muscles of 
the eyes regain their tone, when they contract. The 
sudden dilatation of the pupils is generally a sign of 
imminent death. It is very important for the anesthet- 
ist to watch carefully the respirations, because ether 
kills by suffocation, the heart usually beating long after 
the respirations have ceased. The anesthetist should 
speak out if the pulse is growing rapid, feeble, irreg- 
ular, or intermittent; if the respirations are becoming 
low, rapid, or gasping; if the face is becoming pale 
or blue; if the pupils are gradually dilating; or if 



ANESTHESIA. 93 

the extremities are cold and there is profuse perspira- 
tion. A very long anesthesia may lead to secondary 
prostration and collapse, and secondary shock from 
that cause alone. In other words, the prostration of 
the anesthetic is added to the effects of the oper- 
ation. 

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

In etherizing young children it is best to put them 
on the back and at once to place the ether-cone over 
the mouth and nose without temporizing. If their 
pleadings to have the cone taken away are listened 
to (and they are hard to resist), their agony will only 
be prolonged and the operation delayed. Children 
are quickly etherized, and very rapidly recover from 
the influence of the ether. 

Death from ether is slow, by paralysis of the res- 
piration, the signs of danger being a blue and 
livid skin, and low, shallow, gasping respirations. 
Ether is very inflammable; hence the can should 
never be opened near a light or fire. 

Nausea and vomiting are very common after ether, 
but are usually over at the end of eighteen hours. 
Should vomiting persist until the following day, it 
may be due to shock or to some cause other than 
ether. It may be relieved by the inhalation of hot, 
strong vinegar fumes; a cloth wet with vinegar 
placed over the mouth and nose; teaspoonful doses 
of very hot water, either plain or with four grains 
of bicarbonate of sodium added to one ounce of 
water; crushed ice; champagne and ice; small doses 



94 SURGICAL TECHNIC. 

of brandy and ice; black coffee; aromatic spirits of 
ammonia, or sometimes tea. Cocain, one-fourth 
grain every two hours for five doses, has been suc- 
cessful in severe cases; also a mustard-leaf applied 
over the stomach, and the washing out of the stomach. 
Oxygen gas is now frequently administered both to 
lessen nausea and to hasten consciousness. As a last 
res6rt, when all other treatment fails and there is 
danger that the severe retching will exhaust the 
patient, morphin, one-sixth grain, is injected over 
the epigastrium. 

Chloroform is similar in its action to ether, and is 
often to be preferred to it, because it is pleasanter to 
take, rapidly recovered from, does not produce excite- 
ment or subsequent vomiting, and the patient is 
brought more quickly under its influence. It is, 
however, more depressing to the heart than ether, 
and therefore more dangerous. The patient is not 
allowed to rise until all effects have passed off. To 
give chloroform, a few drops may be sprinkled on 
an Esmarch inhaler, a handkerchief, a towel, or a 
small wire framework covered with gauze. Where 
the operation is on the mouth, so that all available 
space and light is demanded, after the patient is fully 
anesthetized it is administered on a small gauze sponge 
clamped in forceps which are held several inches 
above the mouth. Vaselin should first be spread over 
the face, and especially around the lips and nose, to 
prevent the burning which might occur should any 
of the fluid drop. The same symptoms are to be 
watched for as in the case of ether. Death from 
chloroform is almost always sudden, from paralysis 
of the heart; the pupils become dilated, the face pale, 



ANESTHESIA. 95 

and the pulse flickering. These symptoms usually 
come on with little or no warning. 

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

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

Schleich? s anesthetic consists of one and a half 
ounces of chloroform, one-half ounce of petroleum 
ether, and six ounces of ordinary ether. It is given 
in an Esmarch inhaler, and is considered to be safer 
than chloroform. Unconsciousness is obtained usu- 
ally in one minute and a half; there is no excite- 
ment, and the reaction is rapid. There are three 
forms of this solution, the other two being weaker. 

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

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



96 SURGICAL TEC ff NIC. 

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

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

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

Eighteen grains of cocain hydrochlorate to one 
ounce of water is a 4 per cent, solution. One grain 
of boric acid added to the solution will prevent the 
development of fungi, and the solution remains 



ANESTHESIA. 97 

aseptic. The solution should be kept in a cool spot, 
for if placed in a temperature higher than 6o° P. it 
begins to lose its anesthetic properties. 

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

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

Ethyl chlorid is a local anesthetic, acting by freez- 
ing the parts. It is put up in glass tubes. The cap 
is removed from the tip of the tube and the bulb held 
in the palm of the hand, the warmth of which causes 
the liquid to escape in a vaporized stream. The tube 
is held a little distance from the part to be operated 
upon, which whitens and is ready for operation in 
about fifteen seconds. 

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

No. 



i. Strong. — 




Cocain. hydrochlor., 


i gr. 


Morph. hydrochlor., 


ig r - 


Sodium chlorid, 


i gr. 



98 SURGICAL TECHiXIC. 



o. 2. Noi'maL — 




Cocain. hydrochlor., 


ig*. 


Morph. hydrochlor., 


Jgr. 


Sodium chlorid, 


1 gr. 


o. 3. Weak. — 




Cocain. hydrochlor., 


2V g r - 


Morph. hydrochlor., 


igr. 


Sodium chlorid, 


1 gr. 



The tablets should be dissolved in distilled sterilized 
water. 

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



CHAPTER IX. 

ANTISEPTIC GAUZES, TAMPONS, BANDAGES, 
THERMOCAUTERY, SALINE INFUSIONS, IR- 
RIGATION, ETC. 

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

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

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

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

Antiseptic dressings are made by impregnating gauze 

99 

Lore. 



100 SURGICAL TECHNIC. 

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

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

Iodoform gauze may be made after the following 
formula : 



Cheese-cloth, 


5 yards* 


Alcohol, 


8 ounces. 


Iodoform, 


3 " 


Ether, 


7 " 


Glycerin, 


3 " 



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

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

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

Iodoform, 5 grams (75 grains). 

Glycerin, 100 c.c. (3I ounces). 

Mix and place in a wide-mouthed flask of thin 



SURGICAL DRESSINGS. IOI 

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

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

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

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

Bismuth gauze is made after the subjoined 
formula : 



Bismuth subiodid, 


11 drams. 


Glycerin, 


7 


Water (distilled), 


4^2 ounces. 



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

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

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



102 SURGICAL TECHXIC. 

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

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

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

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

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

Tampons are made of absorbent cotton, lambs' 
wool, or gauze, and are about seven inches long, one 



BANDAGES. 



J °3 



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

Bandages. — In addition to the well-known roller- 
bandage, special bandages find frequent employment, 





Fig. 15. — The Scultetus bandage. 



Fig. 16. — T-bandage. 



particularly after abdominal operations. The most 
important are the Scultetus and the T-bandages. 

The Scultetus bandage is used for surrounding- the 
abdomen. It is made by taking two pieces of 
flannel or of cotton, each one yard long and four 
inches w 7 ide, the two pieces being placed four inches 



104 SURGICAL TECHNIC. 

apart; across them are sewed five other pieces of the 
same length and width, each piece being overlapped 
by the one above it by one-half its breadth. This 
bandage is placed under the patient's back, the cross- 
strips are folded over the abdomen from below 
upward, and the lower ends of the vertical strips are 
brought up between the thighs and pinned to the 
front of the bandage. This keeps the bandage from 
wrinkling and retains it in position. 

~X -bandage. — The T-bandage, which is used to 
secure dressings on the anus or the perineum, is 
made of two strips of bandage, each about five inches 
wide. To the middle of one strip, which is to go 
around the waist, the end of the other strip is sew r ed, 
which forms a letter T. This latter strip is brought 
forward between the thighs and pinned to the front, 
thus securing the perineal dressing. 

Antiseptic Powders. — Reference has already 
been made to these. Those most frequently em- 
ployed are iodoform, boric acid, acetanilid, dermatol, 
and mixtures of these various kinds. Iodoform and 
boric acid are generally combined in the proportion 
of one of the former to seven of the latter. The 
powders are kept in sterilized glass salt-cellars with 
silver-tops, which are covered with gauze when not 
in use, or in sterile wide-mouth bottles over which a 
piece of gauze is stretched. As the bottle may not 
be thoroughly clean on the outside, it should be 
handed to the surgeon wrapped in a sterile towel up 
to the top. 

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



THE THERM OL 'AUTER ) ". 



I05 



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




Fig. 17.— Paquelin's thermocautery. 

order to prepare the instrument for use, a sponge 
is first placed in the bottom of the container, and 
over that is poured a small quantity of benzine or 
alcohol. Two pieces of rubber tubing, the one with 
a bulb, and another to the handle of which is screwed 
the platinum point, are connected by means of the 
stopper to the container. The tip of the platinum 
point is held in the flame of an alcohol lamp until 
it begins to glow, after which the flame is extin- 
guished, and the action of working the bulb gently 



106 SURGICAL TECHNIC. 

forces the air charged with benzine through the 
tubing to the point, where it ignites and keeps the 
point glowing. 

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

Normal saline solution is made to correspond as 
nearly as possible in specific gravity with the normal 
serum of the blood. The formula suggested by Dr. 
Locke of Boston and Dr. H. A. Hare, containing 
in one quart calcium chlorid 0.25 gm., potassium 
chlorid o. 1 gm., sodium chlorid 9 gm., is usually 
employed. It not only gives the heart a better 
fluid to work upon, but it restores to the blood that 
coagulable quality which is diminished or lost by 
hemorrhage. Tablets containing this formula have 
been devised, and are usually used. One tablet added 
to one quart of water gives the correct strength. In 
absence of the tablets one teaspoonful of table salt 
is added to one pint of water. It is absolutely neces- 
sary whatever formula is used that the solution and 
all the apparatus used be properly sterilized. If the 
water contains particles that cannot be strained out 
and there is no filter at hand, the water should stand 
until the sediment settles, when the fluid can be 
poured off, resterilized, and used. This solution is 
placed in an irrigator or a fountain-syringe which has 
been thoroughly sterilized with hot water and corro- 
sive-sublimate solution, and subsequently rinsed with 



IRRIGATION. 107 

boiled water. A long hypodermic needle, which has 
also been thoroughly sterilized, is fastened to the end 
of the rubber tube connected with the irrigator or 
fountain-syringe. The solution may be kept in a 
pitcher and poured into a glass funnel to which the 
rubber tube is attached. The temperature of the solu- 
tion should be about ioo° F. The solution is intro- 
duced under the skin of either the chest, the abdo- 
men, the thigh, the arm, or between the shoulder- 
blades. From a pint to two quarts are injected at 
one time. The part selected for the injection is to 
be sterilized thoroughly in advance. Saline infusion 
is also given by the rectum, a long rectal tube being 
used. 

In hospitals it is customary to keep on hand flasks 
of saline solution. These flasks are sterilized before 
filling; afterward they are stopped with sterile cot- 
ton-plugs and sterilized again by boiling for one 
hour on three successive days. 

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

Irrigation. — Irrigation, or flushing, is employed 
to cleanse wounds and wash out cavities, such as 
the uterus, the abdomen, etc. The solutions em- 
ployed are various. Many surgeons use sterile salt- 
solution or plain boiled water. Antiseptic solutions, 
such as bichlorid solution (1 : 10,000 to 1 : 1000), boric 
acid solution, etc., are used especially for septic 
wounds and surfaces. For purposes of irrigation a 
concial glass vessel, with a tube at the bottom to 
which a rubber tube is attached, is commonly em- 



108 SURGICAL TECH NIC. 

ployed; a fountain-syringe will also answer the pur- 
pose. The irrigating-nozzle is usually of glass. 
The solution should be warm; when it is desired to 
check hemorrhage, it is used quite hot (no°-i20° F.). 



CHAPTER X. 

SUTURES AND LIGATURES; SPONGES; DRAIN= 
AGE; DRAINAGE=TUBES; GAUZE DRAINS; 
RUBBER DAM; RUBBER AND COTTON 
GLOVES. 

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

Catgut is made from the intestine of the sheep. It 
is largely used for suture-material within the abdom- 
inal cavity or deeper layers of tissues, because it is 
absorbed by the fluids of the body, and does not 
remain after the healing of the external wound to 
constitute a foreign body. 

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

To prepare the kangaroo-tendon the following 

109 



IIO SURGICAL TECHNIC. 

method may be used: The tendon having been 
soaked in absolute ether for forty-eight hours, is 
boiled at a temperature of ioo° C. in alcohol for 
one hour. This temperature is maintained by means 
of a water-bath. It is then put in mercuric chlorid 
solution, consisting of mercuric chlorid 40 grains, 
tartaric acid 200 grains, and alcohol 12 ounces, for 
ten minutes. It is then placed with sterilized forceps 
in sterilized glass-stoppered jars containing bichlorid 
of palladium T \ grain to 1 pint of absolute alcohol. 

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

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

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



SUTURES AND LIGATURES. Ill 

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

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

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

The method used by Dr. F. W. Johnson, of Bos- 
ton, Mass., is as follows: The gut is soaked in ether 
for several days. It is then cut into the desired 
length, each length being thoroughly stretched (the 
stretching prevents kinking and twisting). The gut 
is then soaked for twenty-four hours in absolute 
alcohol, to take out as much of the water as possible. 
It is then covered with a solution of bichromate of 
potassium in absolute alcohol (fifteen grains to the 
pint), and remains in this twelve hours. Each 
length is coiled up, wrapped in waxed paper, and put 
in an envelope, which is sealed. The sealed envel- 
opes are put in a dry oven, and baked for one hour 
at a temperature of ioo° C. This removes all moist- 
ure. On the following day the sealed envelopes are 



112 



SURGICAL TECHNIC. 



baked three hours at a temperature of 140 C. The 
gut is now ready for use. The envelopes are kept in 
a glass jar. An assistant tears open one end of an 
envelope, undoes the wax paper without touching 
the catgut, and hands it to the operator. In this 
way the gut is touched by no one, and touches 
nothing until picked up by the fingers of the opera- 
tor. (For preparation of catgut by formalin, see 
Formaldehyde p. 53.) 

Silk is sterilized by being boiled for two hours 
before the operation. Five yards each of various 




Fig. 18. — All-glass ligature-box, hospital size ; six large spools. 



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



SPOXGES. 1 1 3 

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

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

The interrupted suture is made by passing catgut 
or silk through the skin from one side of the wound 
to the other; then both ends are drawn together and 
tied in a double knot. The continuous suture is the 
ordinary over-and-over stitch from one end of the 
wound to the other. The button suture is made by 
passing wire across the bottom of the wound, bring- 
ing out the ends about one inch from the edge of the 
wound, and securing each end with a button. The 
shotted suture is one in which the ends of the suture, 
after it is introduced, are passed through a perforated 
shot, which is then clamped. 

Stitch abscesses are usually produced by unclean 
suture-material. They may be caused by tying the 
stitches too tightly; but as a rule they occur when 
the sutures are not carefully sterilized. This is the 
reason why so many operators prefer their silk and 
silkworm-gut boiled immediately before using. 

Sponges. — Sponges are used to wash wound-sur- 
faces and to absorb or soak up fluids. The sponges 
most commonly employed are in the form of the 
gauze pads, the cut edges being folded over and 
loosely hemmed, and of square pieces of gauze, each 
piece being rolled loosely in the form of a ball, the 
free end being tw T isted and tucked in. The marine 
sponges are not often used at the present time. Gauze 
sponges are never employed more than once. Those 
used in operations are afterward destroyed; those not 



114 SURGICAL TEC II NIC. 

used are resterilized, placed in sterilized towels, and 
deposited in covered glass jars, which are not uncov- 
ered until called for at an operation. 

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

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

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

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

Gatl^e pads for abdominal operations are made of 
eight thicknesses of gauze about eight inches square, 



BRUSHES. I 15 

with the edges tucked in and hemmed to prevent 
fraying. 

Gau^e, now considered the most valuable of 
dressings for wounds, is cut into sections of four 
thicknesses and folded into dressings. A large num- 
ber of these are sterilized for two hours, when they 
are removed with perfectly aseptic hands and placed 
in sterilized jars. 

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

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

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

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

Brushes. — Small hand brushes having a strong 
wooden back and stiff bristles are used for scrubbing 



Il6 SURGICAL TECHNIC. 

the hands, field of operation, and the instruments. 
They should be boiled two hours before the operation, 
then placed in ajar containing- a i : iooo corrosive 
sublimate solution. A separate brush should be re- 
served for the patient, and should be so marked. A 
separate brush should also be used for the cleansing 
of the vagina or rectum. Brushes used in purulent 
wounds, cancer, etc., should be destroyed after the 
operation. The same brush should never be used 
twice by the same person without being resterilized, 
and no two persons should use the same brush. 

Drainage. — The object of drainage is to carry off 
to the surface the secretions and discharges of 
wounds and cavities. The retention and accumula- 
tion of these would interfere with healing, and, in 
the case of septic discharge, involves the danger of 
general infection. Drainage may be secured by 
means of rubber or glass tubes, or by strands of 
gauze or silk. In case of abdominal section the 
glass drainage-tube is usually preferred to gauze 
drainage, because it gives freer drainage, does not 
require a large opening in the abdominal walls, and 
is less likely to cause hernia; a sinus is more apt 
to follow T the use of gauze drainage, and without 
anesthesia its removal is painful. Gauze soils the 
dressing and edges of the wound. With the glass 
drainage-tube, if properly taken care of, the dressings 
can be kept as sweet and clean as when put on. By 
bacteriologic examination the secretions in the glass 
drainage-tube have been found on the third day free 
from pathogenic bacteria. The chief objections to 
drainage of dependent pockets in the pelvis or abdo- 
men, as formulated by Dr. J. G. Clark, of the Uni- 



DRAINAGE. 117 

versity of Pennsylvania, are, first, that the fluids are 
frequently not removed, but, on the contrary, are pent 
up by the gauze drain; and, second, instead of remov- 
ing infection, the gauze or tube may be the means 
of introducing it from the outside into the degener- 
ated fluids. To overcome the dangers of dependent 
pockets and dead spaces in the pelvis, Dr. Clark sug- 
gests the elevation of the patient's body after operation 
to a sufficient height to start the flow of fluids from the 
pelvis toward the diaphragm, and thus promote the 
rapid elimination, by the normal channels of exit 
from the peritoneal cavity, of infectious matter, and 
of vital fluids that may stagnate in these pockets and 
form a culture-medium for pyogenic organisms. 

The technic of postural drainage through the ab- 
domen, which has met with such good results, is 
very simple. After the operation proper a large 
quantity of normal saline solution is poured into the 
abdomen and allowed to remain, and the foot of the 
patient's bed is raised twenty inches for about thirty- 
six hours after the operation. The result is that the 
exudate, if infected, is greatly diluted and may all 
be absorbed by the peritoneum; if inflammatory, it is 
kept liquid, and organized exudates are avoided. The 
pressure of the viscera is removed, intestinal adhe- 
sions are avoided, peristalsis does not cause pain by 
irritation, the patient suffers less distress and discom- 
fort, and convalescence is naturally more rapid. 

Care of Drainage-tubes. — If a glass drainage-tube 
is in the abdomen, the care of it is usually left to the 
nurse. She must each time, before drainage, thor- 
oughly scrub and sterilize her hands. A svrino-e is used 
to withdraw any fluid remaining and for injecting irri- 



Il8 SURGICAL TECHNIC. 

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

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

Glass drainage-tubes are made aseptic by boiling 
for tw y o hours before the operation. 

Preparation of Rtibber Drainage-tubes. — Cut tubing 
into desired lengths, slip each piece over a glass rod, 
and scrub with a stiff brush and green soap. Rinse 



GLOVES. 



ug 



in sterile water until entirely free from soap. Boil for 
one hour in a i per cent, solution of sodium bicar- 
bonate; rinse again several times in sterile water, and 
put into sterile jars and cover with alcohol or carbolic 




Fig. 19. — Drainage-tubes : a, glass ; b, rubber. 



acid, 1 : 20. The jar is kept covered except when the 
tubes are being put in and taken out by sterilized 
forceps. 

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

Gloves. — Rubber and cotton gloves are much 
employed in surgical work, and with very good re- 
sults. They prevent infection by the surgeon's and 
assistants' hands, which even with the greatest care 
cannot be rendered completely sterile. The cotton 
gloves are sterilized by dry heat. The rubber gloves 
are sterilized by boiling one hour in a 1:20 solution 
of carbolic acid, after which they are transferred to a 
basin of sterilized water until required for use. To 
put them on, they are filled with sterile water until 
the whole glove becomes distended, after which they 
are easily slipped on. Some surgeons wear the 
gloves to protect the hands after they have been 



120 



SURGICAL TECHXIC. 



sterilized and remove them when all is ready for the 
operation. 




Fig. 20. — Finger cots. 

Green Soap. — 

Caustic potash, 
Linseed oil, 
Alcohol, 



Fig. 21. — Rubber gloves. 



13 ounces. 

(C 



40 

4 



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



CHAPTER XI. 
INFLAMMATION. 

u Inflammation is that succession of changes 
which occurs in the living tissue when it is injured, 
provided the injury is not of such a degree as at once 
to destroy the structure and vitality of the tissue n 
(Sanderson). 

The changes are, first, changes in the vessels and 
circulation; second, a passing out of fluids and solids 
from the vessels; and third, changes in the perivas- 
cular tissue— L e-., the tissues about the blood-vessels. 
These three changes produce the characteristic phe- 
nomena of inflammation — heat, redness, swelling, 
pain, and loss of function. 

The first change in an inflamed area is a dilatation 
of all the vessels — the arterioles, capillaries, and 
venules. As a result, there is an increased activity 
in the circulation and an increased flow of blood to 
the part, a condition known as active hyperemia. 
After a time the blood-current begins to slacken; 
then the white cells approach the vessel-wall and 
begin to pass through it (emigration of white cells). 
There is also a passing out of plasma or fluid from 
the blood, and in severe cases of inflammation the 
red cells may also pass out. If we now examine the 
inflamed area with a microscope, we find an enor- 
mous number of cells, chiefly white blood-cells, in 

121 



122 SURGICAL TECHXIC. 

the tissues about the vessels. Fibrin in the form of 
delicate granules and fibrils may also be present. 

Inflammation is a process which is directed to the re- 
moval of an irritant, which may be either a portion of 
an injured tissue or a foreign body or material. After 
this result has been accomplished healing or regen- 
eration takes place. If the inflammation was caused 
by bacteria, suppuration is likely to follow. In that 
case the tissues will liquefy and the cells will be 
thrown off suspended in a liquid (liquor puris), the 
whole being known as pus. In suppuration there is 
always loss of tissue, and healing, if it occurs, is 
brought about through the formation of a scar. In 
order to produce healing granulation-tissue is formed. 
Granulation-tissue consists of new cells and tiny 
capillary loops. It is sometimes called "proud flesh," 
and bleeds very easily. The scar has a marked ten- 
dency to contract and may cause great deformity. 

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



CHAPTER XII. 

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

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

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

Glass catheters are the best ; they are easily 
rendered aseptic, and show whether they are or are 
not perfectly clean. Sterilization is most important 
before using the catheter and immediately afterward. 
There is no danger of the catheter breaking, as so 

123 



124 SURGICAL TECHNIC. 

many patients fear, if it is not cracked before being 
introduced. Besides the catheter, which is taken to 
the bedside in a basin of very hot water, there are 
needed a basin of corrosive-sublimate solution 
(i : iooo), sterilized gauze or cotton, and a vessel 
to receive the urine. A lubricant of sterilized oil 
to render the entrance of the instrument as easy as 
possible is used only when a gum-elastic or rubber 
catheter is employed. A mixture of carbolic acid 
solution (i : 40) and glycerin serves for this pur- 
pose. 

Introduction of the Catheter. — The patient lies 
on her back with the knees drawn up and sepa- 
rated, the upper clothing being divided over each 
knee to guard against unnecessary exposure. The 
labia are separated with sterilized sponges and the 
parts washed with the corrosive solution. The 
catheter is inserted into the urethra, the opening 
of which is just above the vaginal entrance. If there 
is any difficulty, the catheter should be withdrawn a 
little, and gently pointed a little downward or up- 
ward, to the right or to the left. If the flow should 
cease before enough urine has been drawn, the cathe- 
ter is withdrawn a little or is inserted a little farther 
than before. Before removing" the catheter a finger 
should be placed over its end, to prevent any drops 
of urine wetting the bed. After the operation the 
parts are again washed, and the catheter boiled and 
placed in a bottle containing a solution of carbolic 
acid (1 : 20), unless the catheter is of rubber; for car- 
bolic acid ruins rubber. 

When the bladder is partially paralyzed from result 
of an operation, or otherwise, a rectal injection of 



EXAMINATION OF STOMACH-CONTENTS. I 25 

very warm water will often cause the bowel and 
bladder to empty themselves at the same time, thus 
doing- away with the necessity of using a catheter. 

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

o o 

A distended bladder must be emptied gradually, 
and as the last amount of urine is being drawn the 
flow should be slowed, to prevent any injury to the 
mucous membrane of the bladder from drawing it 
into the eye of the catheter. 

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

Examination of Stomach-contents. — Many 
times the nurse is called upon to give a test-break- 



126 SURGICAL TECHNIC. 

fast and to send the stomach-contents to the labora- 
tory for examination. 

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

Douches. — Properly given, the vaginal douche 
relieves inflammation, checks hemorrhage, acts as a 
stimulant and cleansing agent, and checks secretion. 
The amount of water used is from five to six quarts, 
of a temperature of no° F. The temperature must 
always be tested with a bath-thermometer, not with 
the hand. The Baker douche apparatus is an excel- 
lent contrivance. In its absence a fountain-syringe 
may be used. 

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

The pail or fountain-syringe must be hung about 
four feet above the bed, so that it will take about 
twenty minutes for the water to run out. Air must 
be expelled, and the water must run warm before the 



DOUCHES. 



127 



tube is inserted into the vagina. The vaginal tube 
must always be sterilized before and after using, and 
every patient should have her own tube. 

Many patients in private practice object to taking 
douches, and will neglect them 011 account of the in- 
convenience; but this they can overcome by taking 
the douches in the bath-tub. Half-way across the 
bottom of the tub a piece of board is placed, on which 
the patient can lie. The douche-board designed by 
Prof. Byron Robinson, of Chicago, has proved very' 
beneficial and convenient to patients by giving them 
a comfortable and simple method of taking a douche. 
It can be used without legs, on a bath-tub, and with 
legs (some twelve inches long) may be used in any 
room. 




FlG. 22.- — Douche-board. 



Antiseptic Douches. — Corrosive sublimate, car- 
bolic acid, creolin, and boric acid are used for anti- 
septic douches; and to prevent absorption and irrita- 
tion a plain water douche is often given after any of 
these antiseptics. 



128 SURGICAL TECHNIC. 

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

Rectal Injections (Enteroclysis) and Irriga- 
tion. — The therapeutic range of this procedure is not 
confined to the treatment of local troubles. It has 
long been used as a means of cleansing the lower 
bowel of accumulated feces. In the treatment of 
rectal ulcers and inflammations it has been employed 
both to relieve the irritation produced by fecal matter 
and to apply various medicaments to the parts. For 
the prevention of shock normal saline solution is 
injected — one or two pints. This, by filling the 
blood-vessels, enables the patient to withstand the loss 
of blood from the nerve-centers. After the operation 
shock and hemorrhage are counteracted by its use, 
and at the same time the thirst is relieved and rest- 
lessness quieted. In septic conditions, both local and 
general, by diluting the toxic materials in the circu- 
lation and promoting their excretion by the skin, 
kidneys, and bowels, saline rectal injections play an 
important part in the treatment. 

In patients whose digestive tracts are too weak to 
hold food or medicine rectal feeding or rectal medi- 
cation is employed. The rectum should be washed 
out thoroughly before the injection is given. If the 
rectum is intolerant and will not retain what is in- 
jected, it is well to turn the patient on her left side 
and raise the hips on a pillow or a folded blanket. 
A long rectal tube should be used as for a high 



RECTAL INJECTIONS. \2Q 

enema. The physician will give directions as to the 
temperature of the solution. In fever patients and 
in the hemorrhage of typhoid fever great relief and 
comfort are afforded by using very cold or iced water. 
In shock or hemorrhage a temperature of ioo° F. is 
usually preferable. In long-continued lavage for 
local trouble the patient's preference as to the tem- 
perature is generally consulted. 

A stimulating and nutrient enema, black coffee, 
or hot saline solution is given when symptoms of 
shock appear either during or after an operation ; 
it should be injected high up into the colon. The 
rectum should be thoroughly cleansed at least once 
daily with warm saline solution, which will also 
aid the absorption of the nutrient enema. When 
feeding by rectum in gynecologic cases, it should 
be remembered that tight tamponing of the vagina 
may interfere with absorption in the rectum. If the 
presence of hemorrhoids is a drawback, a 2 per cent, 
solution of cocain may be used before injecting the 
fluid. 

Stimtdating enema : 

Whiskey, 2 ounces. 

Ammonium carbonate, 15 grains. 
Beef-tea, 4 ounces. 



Or 



Brandy, 2 ounces. 

Tincture of digitalis, 20 minims. 
Milk, 4 ounces. 



130 



SURGICAL TECHN1C. 



For tympanites : 

Tincture of asafetida, 2 ounces. 

Spirits of turpentine, i ounce. 

Magnesium sulphate (Ep- 
som salt), 2 ounces. 
Warm water, i pint. 
Purgative enemata : 

i. Warm soap-suds, % pint. 

2. Common black molasses, 12 ounces. 





Warm soap-suds, 


16 " 


3- 


Molasses, black, 


4 ounces 




Glycerin, 


4 " 




Magnesium sulphate, 


1 ounce. 




Spirits of turpentine, 


1 " 




Warm soap-suds, 


8 ounces. 


4- 


Glycerin, 


4 ounces 




Turpentine, 


1 ounce. 




Magnesium sulphate (Ep- 




som salt), 


2 ounces. 


5- 


Inspissated ox-gall, 


y 2 ounce. 




Warm water, 


1 quart. 


6. 


Spirits of turpentine, 


10 drops. 




Mucilage of acacia, 


y 2 ounce. 


To be given high. 




7- 


Senna, 


y 2 ounce. 




Magnesium sulphate, 


% " 




Olive oil, 


1 " 




Boiling water, 


1 pint. 



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



CHAPTER XIII. 

OPERATIONS ; PREPARATION OF THE OPERAT- 

ING=ROOM; THE SURGEON AND HIS 

ASSISTANTS. 

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

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

Operations of expediency are those which it would be 
well to perform for the health of the patient, as, for 
instance, the removal of a malignant growth of the 
breast. If left to itself, the growth will slowly and 
gradually invade the internal organs and in a very 
few years will end life; while if removed, the patient 
will in all probability live a number of years, and 
there may be immunity for a long period before the 
disease returns. 

131 



I32 SURGICAL TECHNIC. 

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

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

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

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

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



Plate 3. 




PREPARATION OF THE OPERATING-ROOM. I 33 

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

The duties of the nurses in the operating-room are 
the same for all operations. The dress must be of 
washable material, preferably white; it should be 
fresh for the operation and as far as possible sterilized. 
A dress that has been through the wards is not 
clean; neither is one that has been worn a day or 
half a day. The dress-sleeves should be unbuttoned, 
so that they can be rolled up above the elbow, to allow 
the arms to be made as sterile as possible, and so 
that the sleeves may not come in contact with any- 
thing used in the operation itself. The finger-nails 
must be cut short. On first going to the operating- 
room the hands and forearms should be scrubbed with 
a brush and green soap and running water as hot as can 
be borne for ten minutes by the clock. The cleaning 
of the finger-nails is very important, as many of us 
would be surprised to find the large number of germs 



134 SURGICAL TECHNIC, 

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

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

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

The nail-brushes used should be absolutely sterile. 
They must be new, and need to be boiled for two 
hours on the day before the operation, and then put 
into a glass jar containing corrosive sublimate 
(i : iooo). A dirty nail-brush is the haven of myriads 
of germs and their spores, and by using such a one 
we place more germs on our hands than w 7 ere there 
before they were touched. 

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



Plate 4. 




PREPARATION OP THE OPERATING-ROOM. I 35 

tamination until the operation begins. The nurses 
next put on sterile caps and gowns. After mak- 
ing the hands aseptic it is essential that they do not 
come in contact with anything that has not been 
made aseptic before the operation is commenced, for 
such is very easy to occur unless the nurse is con- 
stantly on her guard against it. 

The surgeon and his assistants prepare for the 
operation very much the same as does the nurse. 
Many surgeons before' operating take a corrosive- 
sublimate bath (1:5000), after which they put on 
clean linen suits or long gowns and prepare their 
hands and forearms, after which they put on sterilized 
suits. The suits, which have been sterilized in bags 
or folded in a sheet, are taken from the sterilizer by 
the head nurse, and placed in the dressing-room about 
one hour before the arrival of the surgeons, so that they 
may be perfectly dry when required for use. They 
should not be hung over the back of a chair, or laid 
over a table for dust to collect upon them. We must 
bear in mind that after sterilization there is always 
the danger of contamination, and the articles must 
be carefully protected as soon as they are removed 
from the sterilizer. To avoid confusion, each suit 
and bag should be distinctly marked with the owner's 
name, as should also the white canvas shoes which 
some surgeons wear. The caps must be laid in the 
dressing-room, together with long strips of sterilized 
gauze to cover the beard and mustache. 

Spectators should remove their coats and wear long 
linen gowns. The nurses should not leave the 
operating-room unless it is absolutely necessary, and 
there should be no unnecessary opening of doors, 



136 SURGICAL TECHNIC. 

which allows cold air to enter. Constant moving 
also causes dust to become stirred up. The tem- 
perature of the operating-room should be 8o° F., and 
the air kept perfectly pure by thorough ventilation, 
which should be so arranged that draughts will be 
avoided. 

With the kind permission of Dr. F. W. Johnston, 
of Boston, I extract the following from his paper on 
u Two Years' Work with the Sprague Sterilizer in 
the Gynecologic Department at St. Elizabeth's Hos- 
pital, Boston, Mass., n which shows the great neces- 
sity of absolute cleanliness and how easily infection 
takes place from dust in the room : 

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

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

u The following is the report of E. A. Darling, 
Assistant in Bacteriology, Harvard Medical School : 

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

u The plates were exposed during the middle of 
the forenoon of December 28, 1897. 

u One dish was placed on the floor, where we sup- 
posed the dust would be kept in the most active 
motion by our feet and the nurse's dress ; one was 
placed on the stand holding the sponge-pails; one 
was placed on the patient's knees raised in the Tren- 
delenburg position; and one was placed on the table 



PREPARATION OF THE OPERATING-ROOM, I 37 

beside the instrument-tray. The dishes were un- 
covered just as the knife went through the skin. 

kW At the conclusion of the operation the dishes 
were covered, conveyed to the bacteriologic labora- 
tory, and placed in the incubator at $j° C. for several 
days. 

v% After twenty-four to seventy-two hours the plates 
were opened and the colonies counted. 

kk At the same time an attempt was made to de- 
termine the varieties of bacteria present, and par- 
ticularly to demonstrate the presence or absence of 
the pyogenic forms. 

vw Cover-glass preparations and cultures were made 
from as many different kinds of colonies as could be 
distinguished. 

" The results are, in brief, as follows : 

u Plate A. Sponge-table, exposed 1 hour 50 min- 
utes: after 24 hours show T ed 216 colonies; 72 hours, 
296 colonies. 

"Plate B. Knees of patient, exposed 1 hour 20 
minutes: after 24 hours showed 156 colonies; 72 
hours, 280 colonies. 

11 Plate C. Floor, exposed 1 hour 50 minutes: 
after 24 hours showed 296 colonies ; 72 hours, 42S 
colonies. 

"Plate D. Instrument-table, exposed 1 hour 40 
minutes: after 24 hours showed 216 colonies; 72 
hours, 256 colonies. 

u The varieties of bacteria present were studied 
minutely on Plate B (the one on the patient's knee), 
less carefully on Plate D (the one on the instrument- 
tray). Of the recognized pyogenic cocci, two varie- 
ties were found — the Staphylococcus albus (15 colo- 



I38 SURGICAL TECHNIC. 

nies on Plate B, 20 colonies on Plate D) and the 
Staphylococcus aureus (3 colonies on Plate B, 4 colo- 
nies on Plate D). 

"The remaining colonies on both plates were sar- 
cinse of several kinds, yellow, orange, and white 
moulds, and several varieties of unrecognized bacilli 
and cocci. 

u As would be expected, the plate from the floor 
showed the largest number of colonies. Plate B (the 
one on the patient's knee) most interested me. 

"The finding by Dr. Darling of fifteen colonies of 
the Staphylococcus albus and three colonies of the 
Staphylococcus aureus on this small plate within a 
few inches of the opened abdominal cavity was cer- 
tainly a grand object-lesson, and has given lots of 
food for reflection.' ' 



CHAPTER XIV. 

PREPARATION OF PATIENT FOR OPERATION; 
CARE OF PATIENT DURING AND AFTER 
OPERATION. 

The methods given here for preparing the patient 
for abdominal operations may serve as a reliable 
guide to the nurse, who is more or less responsible 
for preparatory treatment. The methods of prepara- 
tion of all kinds are subject to change in detail, 
because surgical methods are constantly advancing 
and changing, though the general principles remain. 
It should be remembered that patients rally much 
better from an operation when they have been 
properly prepared both externally and internally. 

Day Before Operation.— The patient receives a 
full bath and the hair is washed. A cathartic is 
given — castor oil, citrate of magnesium, or salts. 
The diet should be nourishing and light. Milk is not 
given before an abdominal operation, because the 
stomach may not digest it thoroughly, and its curds 
may remain in the intestines and act as an irritant. 
Gruel is nourishing and easily digested. No food is 
given after midnight. 

PREPARATION OF FIELD OF OPERATION. 

i. Scrub the parts with green soap and stiff brush. 
2. Shave from nipples to rectum. 

139 



140 SURGICAL TECHNIC. 

3. Scrub again and rinse thoroughly with sterile 
water. 

4. Rub well with alcohol, followed with ether, to 
remove fats. 

5. Wash with corrosive sublimate (1 : 1000), and put 
on an antiseptic dressing, consisting of five dressing- 
pads, one layer of common cotton, one dressing over 
that, then abdominal binder. The patient must be 
instructed not to put her fingers underneath the 
dressing nor to disturb it in any way. 

Prepare the vaginal canal by giving a warm 
douche (lysol, 1 per cent.), and cover the vulva with 
a dressing. Use perineal straps to keep the dress- 
ing and abdominal binder in position. See that the 
dressings are kept wet with the antiseptic ordered 
until the patient is taken to the operating-room. 
This preparation should be made twelve hours before 
an operation. 

Some surgeons will direct the application of a 
poultice of green soap ) which is removed early on the 
morning of the operation, the part being scrubbed 
with hot water and a brush to remove the soap, a 
warm corrosive-sublimate poultice (1 : 1000) being 
then applied. A green-soap poultice is a thin layer 
of green soap spread over a pad of gauze, absorbent 
cotton, or a towel, and covered with a dry towel and 
a bandage. The antiseptic pad, or the poultice, 
thoroughly softens the scarf-skin, which in about 
twelve hours can be scrubbed off, leaving the true 
skin. 

Biniodid of mercury is sometimes dissolved in 
the ether, making a solution of 1 : 1000, which, 
besides removing all fatty substances from the skin, is 



ARRANGING THE PATIENT. 141 

also a disinfectant. When the skin is very dirty it is 
scrubbed with turpentine, then with alcohol, and 
then with the biniodid solution. The nose and mouth 
should be thoroughly sprayed with a saturated solu- 
tion of boric acid every three hours. 

Day of Operation. — Flush out the colon and 
give a bath; take off all flannels, put on a gown open 
at the back, and cotton-flannel stockings. Cleanse 
teeth, mouth, nose, and throat with a boric-acid solu- 
tion and brush. Catheterize just before sending the 
patient to the anesthetizing-room if the operation is 
on the uterus or its appendages. Always catheterize 
in other operations if the patient is unable to urinate. 
Envelop the hair in a sterilized tow T el. 

Remove all rings and ear-rings; also false teeth, 
whether a wdiole or a partial set, as there is danger 
of their being swallowed, and put them in a tumbler 
of cold w 7 ater. Envelop feet and lower limbs in a 
w 7 arm blanket securely pinned around the hips with 
safety-pins. Besides preserving the heat, this ar- 
rangement will prevent the patient from tossing the 
limbs about while taking the anesthetic. Manv 
operators give morphin (grain ^) and atropin (y-J-^ 
of a grain), hypodermically, half an hour before 
the operation, to stimulate the heart and prevent 
vomiting. 

Arranging the Patient for the Operation. — 
The patient having been placed on the operating- 
table, the clothes are removed from the part to be 
operated upon, and sterilized blankets are tucked 
about the chest, the edges being tucked under the 
back to reduce as far as possible the loss of body- 
heat, and the bandage and pad are removed from 



142 SURGICAL TECH NIC. 

the field of operation, which is again thoroughly 
cleansed with soap and water and disinfectants. An 
assistant nurse hands the sterilized water, green soap, 
and scrubbing-brush to the assistant surgeon. The 
soap-suds are rinsed off with sterile water, after which 
the part is sponged with permanganate of potassium, 
oxalic acid, lime-water, and sterile water, or with 
ether, alcohol, and bichlorid solution. This final 
scrubbing- should be done in the anesthetizing-room 
if possible, while the patient is being anesthetized, 
to avoid delay in the operating-room. A sterilized 
sheet, having an oval opening in the center through 
which the section is made, and towels are then 
arranged around the field of operation. One towel is 
laid along the side, turned over and fastened with 
clamps to the sheet, so as to form a pocket in which 
the surgeon places the instruments he needs to have 
close at hand. The instruments are taken from the 
sterilizer and laid in trays containing sterile water or 
laid upon dry sterile towels. 

Some surgeons use the prepared sponges. These 
must be reliably counted before the operation by the 
operator and assistants, and the number written down, 
so as not to trust to memory. Sponges must be 
squeezed almost dry before they are handed to the 
surgeon, because it is only in an almost dry condition 
that they are of service. The nurse should not, 
while waiting to hand a fresh sponge, rest her hands 
or forearms on the pail. She should count the 
sponges before the surgeon begins to sew up the 
wound, and should be very sure that she has the 
exact number employed in the operation. The large 
square sponges used for covering the intestines, or 



ARRANGING THE PATIENT. 



H3 



walling off small areas, should have a long piece of 
silk attached, and to this a forceps, so that if one 
should slip out of sight it can be readily located and 
recovered without undue handling of the bowel. 
After being used, the sponges are put into a pan or 
basin, and should not be disposed of until they have 
been accounted for before the abdomen is closed. 

Whatever has been removed from the body must be 
placed in a basin and laid aside in a safe place until 
the surgeon gives his directions as to whether or not 
he wishes it to be sent to the laboratory for examina- 
tion to make sure of its character, with a view to 
clearing up some obscure point about the nature of 
the disease. 

The head nurse attends to the instruments, sutures, 
and ligatures. If the dry technic is used, a basin 
of dry gauze sponges is placed on a table within easy 
reach of the operator's assistants. 

The assistant nurses must be on the alert to change 
the hand solutions when necessary, and to wipe the 
moisture from the face of the operator and his assistant 
with a sterilized towel, to prevent drops falling 
into the wound, and this must be done at a moment 
when the surgeons are not bending over the wound. 
They must move about the room very quietly but 
quickly. If asked to do anything that they do not 
understand, they should always inform the head nurse, 
who will make the duty clear. When emergencies 
arise and the operator is dealing with exceptional 
difficulties, the nurses must be on the alert to do 
quickly anything they may be called upon to do, 
each nurse discharging- her duties without under- 
taking those belonging to another. It is absolutely 



144 SURGICAL TECHNIC. 

necessary on such occasions to exercise self-control, 
and to follow the directions given without excitement 
or confusion. 

Just before the wound is closed the soiled towels 
are removed and replaced by fresh ones. After the 
dressing has been applied the patient is raised, wiped 
perfectly dry, and a bandage put on. While the 
patient is waiting to be transferred to bed, hot- 
water bottles, well covered, should be applied to all 
parts of the body. The blankets used to cover the 
feet and chest of the patient during the operation 
should be tucked closely about the body and under- 
neath, and not merely be thrown over. 

Pneumonia and pleurisy after operation may follow 
as the result of chilling when in the operating- 
room, or exposure during the removal from the oper- 
ating-room to the patient's room. 

When the patient is replaced in bed, which has 
been thoroughly warmed during the operation, the 
nurse should be present to take charge. The pillow 
should be removed, and a towel placed for the head 
to rest upon. The foot of the bed is elevated, this 
posture being maintained for twenty-four hours, after 
which the bed is lowered. The heaters are placed 
about the patient's body, one thing being kept con- 
stantly in mind — not to burn the patient. A towel 
should be placed under the chin of the patient, and 
a small basin should be at hand to receive the vomited 
mucus, and this should be removed during quiet 
intervals. Postanesthetic retching and vomiting may 
be relieved by saturating a towel w 7 ith fresh, strong 
vinegar and holding it a few inches from the patient's 
face, laying it over the nostrils, or hanging it from 



ARRANGING THE PATIENT FOR THE OPERATION. 145 

the bedstead so that it will be near the patient's 
head. Oxygen hastens the recovery of consciousness 
and lessens the nausea. If administered with the 
anesthetic, there is almost complete absence of nau- 
sea — usually none as soon as the patient is fully con- 
scious. 

Dryness of the mouth and lips, and thirst (which 
is often a troublesome feature), may be relieved by 
placing wet cloths on the lips, by allowing the patient 
to rinse out the mouth with cool water, and by fre- 
quent bathing of the hands and face with alcohol and 
tepid water or with plain water. If thirst is extreme, 
an enema of saline solution (one pint) is given 
slowly. 

The patient should not be left alone for a single 
moment during the first thirty-six hours after an ab- 
dominal section if it can be avoided. The patient 
can do nothing for herself, and every want should be 
instantly supplied. I have known patients so eager to 
allay their thirst that they would get out of bed and 
drink water from the water-pitcher on the wash-stand 
and reach down for the hot-water bottle at the feet and 
drink part of the contents. One ward patient drank the 
water from an irrigator standing by the side of the 
next bed ; another patient while in a semiconscious con- 
dition took the drainage-tube out of the abdomen, and 
when found by the nurse after a moment's absence 
from the room was sitting up on the edge of the bed. 
Watching a patient recover from anesthesia is often 
monotonous; but if this duty is closely attended to, 
many dreadful accidents will be avoided. 

A roll should be placed under the knees, so as to 
relax the abdominal muscles and also to remove the 
10 



146 SURGICAL TECHNIC. 

strain the patient would have to make in order to 
keep up the knees. A small flat pillow placed under 
the hollow of the back will relieve the backache of 
which so many patients complain. 

Bladder and Bowels.— The catheter should be 
passed every six or eight hours if necessary, accord- 
ing to directions, the most rigid aseptic precautions 
being taken. Flatulence may be very distressing; 
consequently passage of gas by the rectum is of good 
omen, as it shows that the bowels have regained their 
normal tone and there is no obstruction. After an ab- 
dominal operation the muscular walls of the intes- 
tines share in the weakness of the patient, and are 
not strong enough to overcome the contraction of the 
sphincter muscle. The accumulation of gas distends 
the muscular fiber of the intestines, and, if not re- 
lieved, would soon result in paralysis of the intes- 
tines. To prevent this a rectal tube is inserted to 
keep the sphincter dilated and to allow the gas to 
escape when it reaches that point. Purgatives, such 
as calomel (grain 1 every hour until 10 grains have 
been taken), are usually given as soon as possible 
after the patient has recovered from the anesthetic, 
to stimulate the intestines, and keep up peristaltic 
action. 

Much fluid is not given for a certain number of 
hours after the operation, as it might cause vomit- 
ing, and also because, as we have seen, bacteria 
require heat and moisture for their development. 
If they can lie in a small pool of fluid, they will de- 
velop rapidly. We cannot deprive them of w T armth 
unless we almost freeze the patient, but we can 
deprive them of moisture. Should any bacteria 



BLADDER AND BOWELS. 1 47 

have found their way during the operation into the 
abdominal cavity, they will be rendered inert by 
the absence of moisture, and will be taken by the 
leukocytes into the lymphatic vessels and glands and 
be devoured. 

After twelve hours, if there is no vomiting, very 
hot water, or toast-water is given in teaspoonful 
doses every fifteen or twenty minutes, the quantity 
being gradually increased and the intervals length- 
ened. The familiar cup of freshly made tea is some- 
times the best drink to begin with; it is always "a 
pleasure under the circumstances to see the patient 
enjoy it, since it is not only refreshing but stimu- 
lating. If the stomach behaves well, tablespoonful 
doses of gruel or beef-essence may be given every 
half hour. Milk is not given as a rule, as the curd 
may pass along the intestines and act as an irritant. 
For the first three days, and if there is no vomiting, 
nothing but liquids is given; and after the third day 
soft and easily digestible food, which is gradually 
changed to a more solid diet. 

The external genitals should be kept perfectly 
clean, 'the body bathed, the bed and body-linen kept 
sweet and clean, the teeth brushed, and the hair 
combed. Every want of the patient should be an- 
ticipated, and she should be made as comfortable as 
possible. Sponging the palms of the hands, the 
arms, and the legs will add to the comfort of the 
patient. The luxury of a change into a fresh bed 
will often secure a good night's rest. Under no con- 
sideration should morphin be given except by the 
surgeon's directions, and every moral influence should 



148 SURGICAL TECHNIC. 

be exerted to induce the patient to endure pain rather 
than resort to the drug. 

The nurse should not ascertain whether the patient 
is comfortable by continual questioning, but by unob- 
trusive observation. Questioning may alarm a patient 
and lead her to think too much about herself. 

No visitors should be admitted without the sur- 
geon's consent. The mind of the patient is to be 
kept perfectly free from worry and excitement, and 
the whole atmosphere of the room should be bright, 
pleasant, and cheerful, no matter what trouble is 
goinor otl outside. 

A slight rise of temperature the day following oper- 
ation usually marks reaction from shock. On the 
eighth day the dressings are removed and the stitches 
taken out. The following week the patient sits up, 
and at the end of the third week she goes home. 

The following diet-list dating from the third day 
will be of assistance in varying the food. 

First Day. 
Breakfast. — Mutton-broth with bread-crumbs. 
Lunch. — Milk-punch. 

Dinner. — Raw oysters, thin bread (with crust re- 
moved) and butter, sherry wine. 
Lunch. — Cup of hot beef-tea. 
Supper. — Milk-toast, jelly. 

Second Day. 

Breakfast. — Oatmeal with sugar and cream, cup 
of cocoa. 

Lunch. — Soft custard. 

Dinner. — Small piece of tenderloin steak, chewed 
but not swallowed, baked potato. 



DIET- LIST. I49 

Lunch. — Glass of milk. 

Supper. — Buttered milk-toast (crust removed), 
jelly, cocoa. 

Third Day. 

Breakfast. — Soft-boiled egg, bread and butter, 
coffee. 

Lunch. — Milk-punch. 

Dinner. — Chicken-soup, tender sweetbreads, Ba- 
varian cream, light wine. 

Lunch. — An egg-nog. 

Supper. — Tea, raw oysters, bread and butter. 

Fourth Day. 

Breakfast. — Oatmeal with sugar and cream, a ten- 
der sweetbread, creamed potatoes, coffee, graham 
bread and butter. 

Lunch. — Glass of milk. 

Dinner. — Chicken panada, baked potato, bread, 
tapioca-cream. 

Lunch. — Cup of hot chicken-broth. 

Supper. — Buttered dry toast (crust removed), wine 
jelly, banquet crackers, tea. 

Fifth Day. 

Breakfast. — An orange, scrambled cgg ) oatmeal 
with sugar and cream, soft buttered toast, coffee. 

Lunch. — Milk-punch. 

Dinner. — Cream of celery soup, a small piece of 
tenderloin steak, baked potato, snow pudding, wine, 
bread. 

Lunch. — An egg-nog. 

Supper. — Calf's foot jelly, soft-boiled egg, bread 
and butter, cocoa. 



150 surgical technic. 

Sixth Day. 

Breakfast. — Oatmeal, poached eggs on toast, coffee. 

Lunch. — Cup of chicken-broth. 

Dinner. — Chicken-soup, small slice of tender roast 
beef, baked potato, rice-pudding, bread. 

Lunch. — Glass of milk. 

Slipper. — Baked apples, raw oysters, bread and 
butter, orange-jelly, tea. 

Seventh Day. 

Breakfast. — Orange, mush and milk, scrambled 
eggs, cream-toast, coffee. 

Lunch. — Cup of soft custard. 

Dinner. — Mutton-soup, small piece of tender beef- 
steak, creamed potatoes, sago-pudding, bread, wine. 

Lunch. — Cup of beef-tea. 

Supper. — Sponge-cake with cream, buttered dry 
toast, wine-jelly, cocoa. 

Eighth Day. 

Breakfast. — Broiled fresh fish, oatmeal, graham 
bread, coffee. 

Lunch. — Chicken-broth. 

Dinner. — Potato-soup, breast of roasted chicken, 
mashed potatoes, macaroni, blanc mange. 

Lunch. — Cup of mulled wine. 

Supper. — Cream-toast, lemon-jelly, chocolate. 

The diet for other days may be selected from pre- 
vious ones. The change of diet may cause a tem- 
porary rise in the temperature and pulse. 



CHAPTER XV. 

SEQUELAE OF OPERATIONS; SHOCK, HEMOR- 
RHAGE, SEPTIC PERITONITIS, ACCIDENTS 
DURING OPERATION, ETC. 

As a rule, the average abdominal case passes into 
convalescence, especially when the case is in skilled 
hands and the operation has been performed in a 
finished surgical way. Complications, however, are 
liable to arise in the simplest case, and throw great 
responsibility on both surgeon and nurse. It is in 
these cases that the knowledge and skill of the nurse 
mean so much, and where the greatest triumphs of 
surgery are scored. 

A nurse has no moral right to take charge of a 
surgical case unless she has at her finger-ends the 
complications liable to arise, their symptoms and the 
various means of meeting them until the arrival of 
the surgeon. 

Shock is great depression of the vital functions 
of the body brought on by injury or surgical opera- 
tion. It is produced through the agency of the ner- 
vous system. The greater the injury, the longer the 
anesthesia, the greater the shock. The anesthetic 
enables the patient to undergo the operation without 
consciousness, but it does not prevent shock coming 
on afterward from the opening of the abdomen, the 
uncovering of the viscera, the handling of the intes- 
tines, and the exposure of the delicate sympathetic 

151 



152 SURGICAL TECHNIC. 

nerves in that part to the air and to touch. If to all 
this is added a long anesthesia, then the prostration 
produced by the anesthetic is added to the effects of 
the operation. 

Different individuals are differently affected: most 
persons are more susceptible to shock after months 
of hard work, or when the system is run down after 
an illness. Invalids stand shock very well, and in- 
different persons stand it better than those who are 
despondent. The mental influence is very great: 
anything that depresses the mind aggravates shock. 
It is here that the offices of the Church have such 
an effect on some patients, in quieting apprehension 
and in adding fortitude. 

Age modifies shock. In old people shock is 
usually more severe and prolonged, especially if 
there is any organic disease. Children recover 
readily from shock if there has been very little loss 
of blood. Shock is combated to a certain extent by 
the patient's drinking a large amount of 'fluid for 
forty-eight hours before the operation, so that the 
blood-vessels of the vital organs will be w 7 ell supplied 
with fluid during the operation. Experiments have 
been made which show that when the abdomen is 
opened the abdominal veins dilate, and as a conse- 
quence a large amount of the blood in the body flows 
into them, thus leaving the heart and the vessels con- 
veying blood to the important nerve-centers at the 
base of the brain with very little fluid to work upon, 
and shock ensues. The output of the heart, as we 
know, is in proportion to the venous pressure, and 
if this is lowered the heart and the important nerve- 
centers at the base of the brain will be supplied 



shock. 153 

with a diminished amount of blood. The intra- 
venous injection of saline solution causes a rise in 
the venous pressure and an increase in the output of 
the heart. The signs of shock may be and have been 
mistaken for those of hemorrhage on account of the 
two presenting so many points of likeness ; but in 
shock the symptoms are present from the first, while 
in hemorrhage they do not come on for some hours 
after the operation. 

Two very important points to be considered in case 
of shock or of hemorrhage are the temperature and 
the condition of the patient's mind. In shock the 
temperature at first is normal or very little below nor- 
mal, and the senses are dull in proportion to the degree 
of shock present; in hemorrhage the temperature is 
subnormal, the mind is bright, keen, and alert, and 
there is an anxious expression on the face, as if the 
patient were anticipating danger. 

The symptoms of shock are a weak, rapid, and ir- 
regular pulse; sighing, rapid, irregular, and shallow 
respiration; a normal or slightly subnormal tem- 
perature ; a pale face with a pinched look ; a cold, 
clammy skin, and dulness of the mind. There 
may be involuntary movements of the bowels and 
urine as a result of loss of muscular power ; nausea 
and vomiting may also be present. 

The treatment of shock consists in lowering the 
patient's head and raising the foot of the bed, to in- 
crease the supply of blood to the vital centers ; in 
the application of heat to all parts of the body, 
particularly the sides, between the legs, and to the 
feet; in placing a mustard-plaster over the heart; 
in administering whiskey, brandy, or nitroglycerin 



154 SURGICAL TECHNIC. 

hypodermically; in giving hot black coffee by the 
rectum, or saline solution hypodermically or by 
the rectum. Strychnin is a powerful stimulant, and 
should be given in doses of 2V grain every half hour 
for four doses. Tincture of digitalis in 15-minim 
doses may be given every half hour for four doses. 
As a rule, in cases of shock there is a disposition 
on the part of nurses to do too much. Everything 
must be done in a prompt, quiet manner. For imme- 
diate stimulation in threatened collapse nitroglycerin 
is valuable. It is used for quick effect only, and 
not for prolonged stimulation of the heart's action. 
Stimulants must be given carefully, and time 
allowed to observe the effects produced, other meas- 
ures being determined accordingly. An enema of 
one-half ounce of turpentine, a well-beaten raw egg^ 
and three ounces of warm water constitutes a power- 
ful stimulant. 

It must be remembered that in severe shock the 
function of absorption by the stomach and intestines 
is almost wholly suspended, and anything given by 
the rectum must be introduced high up. When the res- 
piration of the patient is fast failing, everything de- 
pends on maintaining the heart's action. To this 
end artificial respiration must be persistently prac- 
tised. A serious danger in performing artificial res- 
piration is that in our hurry we may make the 
motions too rapidly and not give the lungs time to 
fill thoroughly nor allow the air to be expelled before 
filling the lungs again. The motions should not be 
more frequent than sixteen to eighteen in the min- 
ute, so as to imitate as nearly as possible the nat- 
ural rhythm of respiration. External heat is a most 



IIEMORRHA GE. I 5 5 

powerful heart-stimulant, and often when the heart's 
action fails it may be restored by heat over the heart 
and by hot fluids taken into the stomach. 

Recovery may be rapid or very slow; it is mani- 
fested by "reaction" — the pulse becomes more full, 
slow, and regular, the temperature rises, the body 
becomes warm, and a general improvement takes 
place. In rare cases the reaction becomes excessive 
and develops into traumatic delirium, which may be 
mild, low, and muttering, or of the wildest character. 
The skin is hot and flushed, the pulse full and regu- 
lar, and the temperature above normal. This condi- 
tion may subside and recovery take place, or it may 
be followed by collapse. 

Hemorrhage may be caused by the slipping of a 
ligature or by the displacement of clots, as the result 
of restlessness or reaction of the circulation, and 
generally occurs within the first twenty-four hours 
after the operation. The hemorrhage which comes 
from torn adhesions and bleeding surfaces is a 
free oozing, and seldom affects the pulse. When a 
drainage-tube has been used, it will usually indicate 
that there is hemorrhage by a flow of blood 
through the tube. This, however, cannot be relied 
upon, as only a moderate quantity of blood may 
flow through the tube, the abdomen being filled 
with clots. 

The symptoms of internal hemorrhage are restless- 
ness, thirst, faintness, an anxious expression, pale 
face, dilated pupils, cold skin, frequent and irregular 
or sighing respiration, subnormal temperature, and a 
weak, rapid pulse (120-140). In rare cases the pulse 
is not greatly accelerated. 



156 SURGICAL TECHNIC. 

Treatment. — The patient must be kept perfectly 
quiet 011 her back, the head being lowered and the 
foot of the bed elevated. If symptoms of shock 
supervene, heat is to be applied to all parts of the 
body by warm blankets and hot-water bottles. 
Stimulants are given only when the pulse is failing, 
as they excite the heart's action and increase the 
hemorrhage. When the hemorrhage has been exces- 
sive, infusion of saline solution is resorted to, the 
fluid that the body has lost being thus replaced. 
Bandaging the limbs from their extremities upward 
is sometimes of use in keeping the blood in the vital 
organs. When the hemorrhage comes from a slipped 
ligature with large vessels pouring blood into the 
abdominal cavity, the abdomen is reopened and the 
vessel ligated. Everything should be ready for 
operative interference when the surgeon arrives, the 
same aseptic precautions being observed as in the 
original operation. For the free oozing from torn 
adhesions the tube is emptied frequently — every ten 
minutes. The drier the pelvic cavity is kept, the 
sooner will the hemorrhage cease. 

A noted surgeon has said that if an abdominal case 
escapes shock or hemorrhage, there is still a third 
danger to which the patient is liable, that of septic 
peritonitis. This is due to the entrance of germs 
into the peritoneal cavity, either from without or 
from ruptured abscesses or wounds. It may set in 
at any time from a few hours to six days after ope- 
ration. The symptoms are pain in the abdomen and 
exquisite tenderness, distention, vomiting, constipa- 
tion, icterus, restlessness, sleeplessness. 

The temperature rises a little, rarely going for a 



HEMORRHAGE. 1 57 

few days above ioo° or ioi° F. ; but the pulse creeps 
up rapidly to 115, 120, or 130 beats per minute, and 
is weak and thready; although sometimes it is hard 
and u wiry n in the beginning. Then the temper- 
ature rises to 103 F. or above. The rectal or vag- 
inal temperature may show a much higher rise than 
that of the mouth or axilla. In one typical instance 
the temperature taken in the mouth ranged between 
101 and 102 F. , the skin was cold and clammy, 
and the patient complained of intense thirst and a 
u burning up" feeling. The vaginal temperature 
was 108 F. In some of the worst cases the writer 
has seen the temperature was below normal, but the 
prostration was severe. The abdomen is distended, 
due to distention of the transverse colon by gas. 
There are nausea and vomiting. First the contents of 
the stomach are vomited, then bile, then a dark coffee- 
colored fluid which becomes more and more fecal in 
odor; a cold perspiration appears; the patient has a 
very anxious, pinched expression, and is restless and 
talkative; the eyes are unusually bright, and there is 
a faint yellowish look about the skin and conjunc- 
tivae. As the disease continues the general system 
becomes poisoned. 

The treatment consists in ridding the system of 
the poison through the skin, bowels, and kidneys. 
High enemata of turpentine, glycerin, oil, salts, or 
molasses are usually given until the bowels are 
thoroughly moved or large quantities of gas are 
passed, because it is by putting the bowels into an 
active state that the threatened paralysis of the intes- 
tines can be overcome, and they can take up from 
the peritoneal cavity the poisonous materials that 



158 SURGICAL TECHNIC. 

are causing the disturbance. It is only when the 
intestines are so paralyzed that they cannot be moved 
that a fatal result ensues. Strychnin, being a power- 
ful heart-stimulant, is given in doses of grain ^V 
every hour until its physiologic effects are pro- 
duced. It must be stopped at the first appear- 
ance of twitching of the muscles of the face or 
of the limbs and stiffness of the neck. Vomiting 
may be relieved by washing out the stomach, by 
the application of a mustard-plaster over the region 
of the stomach, or by cocain in 3<(-grain doses for 
four doses. If improvement does not follow, the 
surface of the body becomes cold and clammy; the 
face pinched and sunken and of a dusky hue ; the 
restlessness increases, also the thirst, which becomes 
very great, and to the last the patient calls for water, 
which is vomited immediately after being taken, but 
which it is cruel to withhold. The mind usually 
remains clear to the end. 

Antistreptococcic serum has been used with fairly 
o-ood results. It comes in odass tubes, sealed her- 
metically, and is injected hypodermically with an- 
tiseptic precautions into the thigh or the side of the 
breast, where there is considerable loose subcuta- 
neous connective tissue. Another procedure of value 
is infusion of normal saline solution for the purpose 
of diluting the toxins in the blood and of removing 
them by the increased flow of urine which infusion 
brings about. 

Tympanites is often one of the earliest signs of 
septicemia, and when accompanied with a high tem- 
perature is usually a cause for anxiety, though it may 
be due to constipation, and in such cases is usually 



SINUS. 159 

without significance. The treatment consists in the 
application of turpentine stupes, the use of brisk 
purgatives or high enemata, and the insertion of the 
rectal tube for about ten inches. 

Fermentation-fever is due to the absorption of 
fibrin-ferment and the products of aseptic tissue- 
necrosis. It causes a slight rise in temperature 
which need occasion no anxiety. 

Intestinal obstruction may be due to strangula- 
tion of a knuckle of intestine beneath inflammatory 
bands, or to its enclosure between the sutures in the 
wound. There is usually distention of the abdomen. 
Note should always be made if gas is heard rumbling 
in the intestines, and also if gas is passed and how 
often ; also the result of the enemata which are ad- 
ministered to relieve the distention. 

Hernia is a sequel rather than a complication of 
abdominal operations, and is due to a failure of union 
between the cut edges of the muscles and fasciae. 
As a rule, it does not occur until some weeks after 
the patient has returned home. It is to prevent this 
accident that such stress is laid upon not allowing 
the patients to help themselves in any way without the 
surgeon's permission, so that the abdominal muscles 
may have sufficient time to become firmly united. 
This is also the reason why patients should wear an 
abdominal supporter for some months after their dis- 
charge. If hernia occurs, it is usually treated by a 
secondary operation. 

A sinus is often caused by imperfectly sterilized lig- 
atures, which may cause an abscess around the point 
of ligation. This abscess may discharge itself into 
the intestine or vagina, or into the tract occupied by 



160 SURGICAL TECHNIC. 

the drainage-tube through the abdominal wall. The 
sinus keeps open until the ligature is discharged or 
removed by another operation. 

Accidents during Operation. — Many times in dif- 
ficult abdominal or vaginal operations the walls of the 
bladder may be torn, or one of the ureters or the in- 
testine may be injured. When the ureter or bladder 
is injured, the urine sometimes passes through the 
incision to the dressing. This is called a urinary 
fistula. When the intestines are injured, fecal matter 
is discharged through the wound. This is a fecal fistula. 

Vaginal hysterectomy is the most serious of vagi- 
nal operations, but the nursing is the same as every 
operative case requires. If clamps are used, they 
usually remain attached for forty-eight hours. The 
handles are usually supported on a pad of absorbent 
cotton. In the handling of the clamps great care 
must be used, as, for instance, when the patient is 
lifted on the bed-pan one nurse should lift the clamps. 

Hysterectomy is the complete removal of the 
uterus and ovaries, either through the vagina (vagi- 
nal hysterectomy) or through the abdomen. Regard- 
ing the question of insanity which may follow a hys- 
terectomy or the removal of a large fibroid tumor, 
one must know that a large amount of blood is 
taken from the body ; that the cutting and tying of 
the large blood-vessels alter the circulation ; and that 
the operation is also more or less a shock to the 
nervous system, and may affect the brain. Insanity 
is not a complication of this operation, the recovery 
from which is usually rapid ; but when insanity does 
set in, this is commonly the cause, and the patient 
generally recovers. 



CHAPTER XVI. 

OPERATIONS IN PRIVATE PRACTICE. 

In private practice the preparation of the patient is 
just the same and should be carried out as thor- 
oughly as in a hospital. If it is not possible within 
twenty-four or thirty-six hours to make the prepa- 
ration, then we cannot say that our attempts, to 
obtain asepsis approach perfection. In emergency 
cases when there is not sufficient time to permit a 
thorough cleansing, freedom from sepsis is not so 
certain, and these cases do not cause the same anxiety 
as those that are sent to a hospital, where every effort 
to obtain complete asepsis is made. We must remem- 
ber, in making the preparations, to make as little 
bustle and noise as possible, and to carry on the 
preparations in a quiet and cheerful manner, so as not 
to frighten the patient and family. When the sur- 
geon and his assistants arrive they must be shown 
to a room in which they can change their clothing. 
The patient is not anesthetized until everything is 
in readiness. 

One difficulty which a nurse will have to encounter 
in private practice is likely to trouble her a great deal, 
inasmuch as she will find surgeons who conduct de- 
tails of cases in a way to which she is not accus- 
tomed, and which may appear to her wrong, and 
which indeed may very often be crude and unscien- 

11 161 



1 62 SURGICAL TECHNIC. 

tific. In these cases she should not be too ready to 
show her superior wisdom and instruct the surgeon, 
and inform him under whom she received her train- 
ing, because there is not the slightest likelihood that 
he will act upon her suggestions, but will naturally 
be offended. 

The directions for preparing for the operation 
will be given by the surgeon in charge. In some 
houses there may be a separate room for the opera- 
tion, while in others the nurse will have to pre- 
pare the patient's bedroom. In the latter case the 
brightest end of the room must be selected for 
the operation, to afford the surgeons plenty of light. 
A screen must be put up before the bed, so that the 
patient will not see the preparations. The nurse 
should remove from the room all movable furniture; 
lay oilcloths or newspapers covered with a damp 
sheet on the carpet, and pin them securely to it, and 
fasten a curtain across the window, so that the opera- 
tion cannot be viewed from the opposite side of the 
street. The remaining furniture and window-frames 
should be washed with carbolic-acid solution (i : 60), 
and on the morning of the operation should be 
mopped with a cloth wrung out of the solution. The 
articles necessary for the operation can be placed on 
the operating-table, covered with a sterile sheet, and 
be left outside the room until the patient is partly 
etherized,, when they may be carried in. 

If a separate room can be had, one with a northern 
light is to be preferred; and if possible it should be 
near the bath-room. Unless the nurse has twenty- 
four hours' notice in which to prepare the room 



OPERATIONS IN PRIVATE PRACTICE. 1 63 

for operation, it should not be disturbed, because 
if swept and dusted immediately before the opera- 
tion dust is stirred up and the air is so filled with 
germs that it would not be safe to open the ab- 
domen in the room. If the nurse has a few days in 
which to prepare for the operation, all unnecessary 
furniture should be removed, the hangings taken 
down, the room thoroughly swept, and the walls and 
remaining furniture washed with carbolic-acid solu- 
tion (1:60) and exposed to the action of the sun and 
air for about twelve hours, when the windows are to 
be closed, the room thoroughly dusted with a damp 
cloth and not again disturbed. The kitchen, if not 
too remote, makes the best operating-room ; it is 
warm, hot and cold water are close at hand, and 
there is no danger of soiling carpets or hangings. 

A word regarding the bed. If possible, it should 
be an iron bedstead with a fresh horsehair mattress 
and pillow. The tall wooden bedsteads which we 
so often find are perhaps heirlooms which have wit- 
nessed every illness that has visited the family, and 
also the deaths. They cannot be disinfected so 
thoroughly as can iron bedsteads. 

The operating-table should not be wider than 
twenty-five inches nor higher than thirty-seven 
inches, because if low and wide the surgeon will have 
to stoop and bend forward. A kitchen-table, or a 
dining-room table with the leaves hanging, and a 
small table at one end for the patients head, or two 
dressing-tables, one placed across the head of the 
other, will make a good narrow operating-table; or 
three chairs, with two planks, a leaf from an exten- 



164 SURGICAL TECHNIC. 

sion-table, or an ironing-board laid across them, may 
suffice. 

The table may be covered with rubber cloth, oil- 
cloth, two sheets, and a blanket. A word of caution 
here : the nurse should not use any old blanket or 
comforter to cover the operating-table, for it is likely 
to be filled with germs. 

Two wooden chairs should be at hand in case the 
Trendelenburg position is necessary, and two wooden 
boxes for the surgeons to stand upon when using this 
position. 

The evening before the operation the nurse should 
boil a washboiler full of water and then fill covered 
pitchers, the washboiler and pitchers having first been 
made thoroughly aseptic. The water is conveyed 
from the boiler to the pitchers by means of a perfectly 
clean pitcher or tin ladle. 

On the morning of the operation there should be 
sterilized in the boiler or in an oven six sheets, two 
blankets, twelve towels (not new). The heat should 
be kept up for fully one hour before the operation. 
The dry technic, by which is meant the use of dry 
sponges and gauze, is usually employed in private 
practice, especially when the water-supply is at all 
questionable. 

There will be needed several clean recently boiled 
basins for the various solutions, etc. Two tables will 
be needed — one for the instruments, the other for the 
assistant. They should be covered with freshly 
washed and ironed sheets or towels. There will also 
be needed a pail or a washtub for the soiled water, 
a tin dish or a fiat bake-pan for the instruments, 



OPERATIONS IN PRIVATE PRACTICE. 165 

brandy, a hypodermic syringe filled with the re- 
quired solution, usually strychnin sulphate (^ grain), 
a small tumbler, a Davidson or a fountain syringe, 
table-salt for salt-solution, safety-pins, two new nail- 
brushes, ready for use in a 1: 40 carbolic acid solu- 
tion, castile soap, green soap, a razor, hot-water 
bottles, two blankets, alcohol, vinegar, and matches. 
The surgeon will bring the necessary dressings with 
the instruments, which must be sterilized in the same 
way as in the hospital. 

The instruments are to be wrapped in a towel and 
allowed to boil for ten minutes in a saucepan, tin 
pail, or a fish-kettle of boiling water, to which have 
been added two teaspoonfuls of washing-soda to each 
pint of water, to prevent rusting. One end of the 
towel must be left hanging out of the kettle as a 
handle by which to lift out the instruments. The 
pail of water should be on the fire and the water 
boiling when the surgeon arrives, so that the instru- 
ments can be put in at once. 

If the nurse is asked to give the anesthetic, she 
should not attempt anything else. None but novices 
give the anesthetic and watch the operation. The 
experienced anesthetizer constantly watches the 
patient. If the nurse is asked to assist the surgeon, 
she must be neither too enthusiastic, nor too quick, 
nor too slow. When the operation is over her duties 
will have nothing peculiar about them. She must 
see the patient safely out of the anesthetic influence, 
and carry the case along as she would any other. 

Sometimes a nurse is called to an emergency oper- 
ation in a very poor family, where there are no con- 



1 66 SURGICAL TECHNIC. 

veniences. In such instances the kitchen can be 
cleaned and prepared as an operating-room in a few 
minutes. If she is called in the night and goes to 
the case with the surgeon, she should, while the sur- 
geon is making his examination of the patient, start 
a fire and put on the washboiler, to make sure of 
plenty of boiling water. She should then get six 
sheets and twelve towels, if possible. There may be 
no clean towels, and the nurse will have to wash 
some dirty ones. The sheets and towels can be soaked 
first in boiling water and afterward placed in corrosive- 
sublimate solution (i: iooo), until the surgeon is ready 
to use them. Boiling water is one of the best anti- 
septics, as it kills germs on contact. Unfortunately 
it cannot be used in rendering our hands and the field 
of operation aseptic, but it can be used in the prepa- 
ration of the sheets, towels, sponges, and instru- 
ments. 

The kitchen should be rendered as clean as pos- 
sible. The kitchen-table should be prepared for the 
operating-table, and there should be two small tables, 
one for the instrument-tray and one for the sponges. 
If small tables cannot be had, chairs covered with a 
sheet or towels wrung out of the corrosive solution 
will answer the purpose. If there is no gaslight, as 
many lamps as can be obtained should be arranged 
near the surgeon, but not too near the ether, because 
ether is inflammable. 

After the surgeon has made the examination the 
part must be shaved, washed, and a towel wrung out 
of corrosive sublimate solution applied, an enema 
given to clear the bowels, and the urine drawn. 



OPERATIONS IN PRIVATE PRACTICE. 167 

While the patient is being anesthetized the nurse 
may arrange the tables and wash a flat bake-pan 
or meat-pan for the instruments. If sponges have 
been forgotten, a clean sheet can be torn up and 
folded into flat sponges. China basins can be used 
for the antiseptics, the sponges, and the surgeon's 
hands; china pitchers for hot and cold water; a 
wash tub for the soiled water; and hot bricks, plates, 
or beer bottles for heaters. 



CHAPTER XVII. 

GYNECOLOGIC EXAMINATIONS AND 
OPERATIONS. 

PERFECT asepsis is of special importance in gyne- 
cologic examinations and operations, because in many 
instances the peritoneal cavity, which is highly suscep- 
tible to septic influences, is invaded by them. We must 
bear in mind that the whole genital tract communi- 
cates directly with the peritoneum, and infection at 
any point may cause peritoneal sepsis. Infection has 
taken place through the introduction of a dirty 
sound, and fatal peritonitis has followed perineor- 
rhaphy and trachelorrhaphy. 

The technic for major operations is usually perfect, 
but for minor operations carelessness is liable to 
creep in. We have no right to expose a patient to- 
danger no matter how small the operation to be per- 
formed; and if our technic is not as perfect as we can 
make it with the means at our command, then we 
expose the patient to the greatest of all dangers, that 
of peritoneal sepsis, which usually means death. Suc- 
cess in surgery is due to minute attention to a care- 
ful technic, and a careless nurse may be the means of 
introducing sepsis, which may result in death after a 
most brilliant and skilfully performed operation. The 
most skilful surgeon is dependent upon his assistants 
for the perfection of his technic, and only those nurses 

168 



SIMS' POSITION. 169 

who have been thoroughly instructed in the practice 
of asepsis and antisepsis should be allowed to assist at 
an operation or examination, however small. 

GYNECOLOGIC EXAMINATIONS. 

The positions which a patient may occupy when 
undergoing an examination are the knee-chest, dor- 
sal, Sims, and the upright. 

The upright, or the erect, position is rarely used 
for the purpose of making a diagnosis, but is some- 
times preferred in verifying a diagnosis, especially 
that of uterine displacement, previously made with 
the patient in another position. Around the w r aist is 
pinned a sheet, which extends to the floor, under 
which the clothing of the patient is drawn up. The 
patient stands with limbs separated, one foot resting 
on a stool or the rung of a chair. 

Dorsal Position.— The patient lies on her back 
with the knees drawn up and separated; the hips 
are brought down near the edge of the table, leaving 
sufficient room for the heels to rest together comfort- 
ably, eight or ten inches apart, without slipping from 
the table. A sheet having an oval slit in the centre 
long and wide enough to expose the parts is thrown 
over the patient. In this position there is naturally 
a certain amount of flexion of the pelvis upon the 
trunk, and almost complete relaxation of the abdomi- 
nal muscles is secured. 

Sims' Position (also called the Latero-abdominal 
Position). — In the Sims position the patient lies on 
the left side of her chest, with her head and left 
cheek resting on a low pillow, and the left arm is 



170 SURGICAL TECHNIC. 

drawn behind the body or hangs over the edge of the 
table. The hips are brought down to the left-hand 
corner of the table, so that her body lies diagonally 
across it, the head and shoulders being at the right- 
hand side, with the right hand and arm hanging over 
the table-edge. The thighs are flexed upon the abdo- 
men, the right thigh being so flexed that it lies just 
above the left knee, and the feet rest upon a board ex- 
tending from the right-hand corner of the table. This 
position is one in which there is a tendency for the 
intestines to ascend, and this causes the vagina to be 
filled with air and thus brings the uterine cervix 
within easy reach. 

The knee-chest, or genupectoral, position is much 
used for inspection of the rectum, bladder, vagina, 
and cervix of the uterus. In some cases of displace- 
ment of the uterus the patient may have to take 
this position many times daily. The patient first 
kneels on the edge of the table, then bends forward 
and rests her chest on a low pillow, her head lying 
just beyond, so that her back slopes down evenly, her 
arms clasping the sides of the table. In this position 
the abdominal organs are thrown toward the dia- 
phragm; the air enters the vagina and balloons it 
out, so to speak, so that there is an unobstructed view 
of the canal and the cervix. 

Examination of the Rectum. — The patient is 
usually placed in the knee-chest position. Either the 
rectal speculum, or in its absence a Sims speculum 
(small blade), is used. When the instrument is intro- 
duced the rectum becomes distended with air so that 
its walls are well exposed. If the patient is not in 



PRE PARA TION FOR G YNECOLOGIC EXAMINA TION. I J I 

such a position that the buttocks are in a good 
light, a head-mirror, or an electric headlight may be 
needed. It is well to have these at hand in case they 
should be called for. 

For an examination of the bladder the knee-chest 
position is sometimes used; though, as a rule, the dor- 
sal position is chosen, with the hips elevated high 
above the abdomen by means of cushions of pillows, 
which allows the intestines to gravitate toward the 
chest; and when the urethra is opened the bladder 
becomes distended with air and its interior is thus 
easily seen. Sometimes the patient is anesthetized for 
the examination, since it is usually very painful; but 
local anesthesia of the urethra is often sufficient 

Preparation for Gynecologic Examination.— 
To prepare a patient for examination the genital 
parts should be cleansed, so that there will be no 
danger of carrying septic material to the upper part 
of the genital tract; the bladder and bowels should 
be emptied. The uterus lies between the bladder and 
the rectum, and the distention of either of these 
organs will alter the position of the uterus. As a 
rule, no douche should be given before the examina- 
tion, since the surgeon may want to see the character 
of the discharge. All bands around the waist must 
be loosened, also the corsets ; a single tight band 
around the waist will crowd down the contents of the 
abdomen and displace the uterus. Around the patient 
is thrown a sheet, beneath which she can raise her 
clothing above the waist, and then step upon a chair 
and thence to the operating-table without there being 
the slightest exposure. 



172 SURGICAL TEC ff NIC. 

For examination in private practice the patient 
may lie on a small table covered with a shawl, a 
comforter, or blanket. There must be at hand a 
table, covered with a towel, on which are placed two 
bowls, one containing corrosive-sublimate solution 
(i : iooo), and the other containing warm water, 
green soap, vaselin, and towels. 

The speculum should be warmed by placing it in 
the warm sterile water. The same aseptic precau- 
tions are used during an examination as during 
an operation. The instruments should be sterilized. 
Sometimes a cleansing douche of corrosive sublimate 
(i : 2000) is administered after an examination. 

PREPARATION FOR OPERATION. 

The preparation for gynecologic operations, such 
as perineorrhaphy, etc., are the same as for an abdom- 
inal operation, excepting the difference of the field 
of operation to be prepared. In case the operation is 
a minor one upon the uterus or vagina, the prepara- 
tions may be somewhat modified according to the 
individual preference of the operator; but the general 
rules of asepsis are always the same; and they must 
be the more strictly observed in these operations be- 
cause the dangers of infection are increased by our 
inability to o-et the orenital tract thoroughly clean. 
In abdominal surgery there is not this difficulty. 

The preparation of a patient in a private house for 
a minor gynecologic operation should be as thorough as 
in a hospital. If the operation is to be performed 
with the patient in bed, there will be needed a wide 
board or an ironing-board for insertion between the 



AFTER-CARE. 1 73 

mattress and sheet, thus making a hard surface for 
the patient to lie upon. 

A piece of rubber cloth or oilcloth will serve for 
the pad. The material used is folded at the top and 
sides, covered with a towel, -and the unfolded end 
draped into a pail or wash-tub. When the patient is 
anesthetized the bed is turned toward the window to 
afford the surgeon a good light — a northern light if 
possible. A bay window should be avoided, because 
it gives cross-lights. 

The limbs are flexed, the hips brought to the 
edge of the bed, and the pad placed under them, so 
that the water used in bathing the external parts 
is conducted by the cloth into the pail or tub. 
When holding the patient's limbs the nurse should 
let the heel of one foot rest in the palm of her hand; 
the knee of the patient will then rest against the 
chest of the nurse, whose free hand is passed over 
and holds the other limb in position at the knee. 
If the nurse is asked to hold the speculum, she 
should grasp the handle from below with her right 
hand; the angle of the speculum will thus lie in the 
hollow between the thumb and forefinger, and the 
convexity of the blade will rest on the dorsum of the 
hand. The upper labia and buttocks are raised by 
the left hand. If the speculum or regular retractors 
cannot be obtained in the emergency, retractors can 
be improvised by bending the handles of four large 
spoons to the appropriate angle. Two are used to 
retract the lateral walls, the other two being applied 
to the anterior and posterior parts of the vagina. 

After-care. — After a vaginal operation, trachelor- 



174 SURGICAL TECHXIC. 

rhaphy, etc., the patient will probably be catheterized 
for a few days. We must always remember the risk 
of cystitis. Many patients have fully recovered from 
the operation proper, but convalescence has been 
delayed by this complication. 

After passing the catheter the nurse should be care- 
ful that when removing it the urine does not drop 
on the stitches; the parts are afterward sprayed with 
the ordered solution and dried. When giving 
douches the nurse must insert the tube carefully 
away from the stitches ; and after the douche is over 
she should separate the labia and wipe the vagina dry 
with sterilized cotton or or-auze held in dressing-for- 
ceps. The same care must be used when giving 
enemas, in order that the rectal and vaginal stitches 
be not broken by the tube. The patient must be in- 
structed not to strain when the bowels are moved, or 
the stitches may break. When dressings are applied, 
they may require frequent changing in order to keep 
them clean and free from discharges. Strict antisep- 
sis must be observed, the genital parts must be kept 
perfectly clean, otherwise septic material will readily 
find access and probably result in infection of the 
wound and suppuration, or a stitch-abscess. If the 
uterus is packed with gauze, the pulse and tempera- 
ture are usually taken every two hours ; and should the 
temperature rise to ioi° F. the packing is removed. 

Diet. — A liquid diet is usually ordered until after 
the third day, when the bowels will have been 
moved; after which, if all is well, the amount of food 
is increased until it attains its customary proportions. 

The patient is generally kept in bed two weeks, 



DIET. 1/5 

and the sutures removed on the ninth day in the 
order in which they were introduced. After the re- 
moval of the stitches many operators order a vaginal 
douche two or three times a day, the amount of water 
varying from four to six quarts. This treatment is 
successful only when the douches are given at the 
proper time and temperature. 



CHAPTER XVIII. 
SIGNS OF DEATH; AUTOPSIES. 

WiNSLOW, one of the professors at the University of 
Paris, and who had twice been taken for dead, was the 
first to make a scientific investigation of the signs of 
death. After Winslow came Louis, and since their 
time eminent men, especially in countries prescribing 
rapid burial, have endeavored to find certain and 
reliable signs of death before decomposition begins. 

SIGNS OF DEATH. 

Absence of respiration is not a sure sign of death, 
as it may be due to syncope or to the person being in 
a trance; nor is absence of the heart-beat, unless 
determined by means of a stethoscope in experienced 
hands. Coldness and rigidity may be due to collapse 
or catalepsy or in persons who are frozen stiff. 

In doubtful cases of apparent death which occur 
suddenly or from external violence the following 
tests are usually applied : 

i. The absence of the heart's action is carefully 
determined by a stethoscope or phonendoscope. 

2. Absence of the circulation is ascertained by 
tying a string tightly around a finger or a toe; if the 
tip becomes blue, life is not extinct, though this may 
occur in cases where there has been great loss of 

176 



SIGNS OF DEATH I J J 

blood, and in other cases where the heart is too weak 
to send the arterial blood into the capillaries of the 
fingers. 

3. Absence of respiration is determined by placing 
the surface of a mirror before the month; if the sur- 
face becomes moist, respiration has not ceased. 

4. If a subcutaneous injection of aqua ammonia is 
given a red or purple spot will form if life still exists. 

5. If a needle is inserted into the flesh of a living 
person blood will escape, but not if life is extinct ; 
still, if there has been a large loss of blood, there will 
be no escape of blood in the living. 

Rigor mortis (post-mortem rigidity or stiffness of 
death) begins in the upper part of the body, usually 
in the maxillary muscles, and spreads gradually from 
above downward. It disappears in the same order. 
It comes and goes quickly after great muscular effort 
or excitement, and when once it has been broken 
up it does not return. The time it sets in after death 
varies from ten minutes to twelve or even twenty-four 
hours. Rigor mortis is considered the most positive 
sign of death, because it indicates death of the mus- 
cle itself. 

Death of the body as a whole takes place first, and 
at intervals of an hour or even several hours death of 
one or other of the involuntary muscles follows. 

Hypostasis, or congestion of blood in the capil- 
laries, which forms in all the dependent parts of the 
body, is considered a valuable sign of death, but this 
purple color may be due to contusion, and has been 
seen in cholera patients before death. 

The body-temperature at and from one to two 
12 



178 SURGICAL TECHNIC. 

hours after death may be very high, 107 or 112 F. 

Patients dying from cholera and yellow fever have 

high temperatures for several hours after death; but, 

as a rule, the body is cold to the touch in from six to 

ten hours. 

AUTOPSIES. 

Every nurse should do all in her power to assist 
the physician or surgeon to obtain autopsies, and 
with a little tact the necessary permission can usually 
be obtained/ Every well-conducted autopsy adds 
more or less to medical knowledge. It verifies the 
diagnosis of the illness, and in many cases it explains 
or shows the cause of symptoms the explanation of 
which could not be determined before death. In 
surgical work, when a patient dies in less than 
twelve or fourteen hours after an operation, the au- 
topsy, when made by a competent bacteriologist and 
pathologist, will show whether death was due to 
sepsis or to some organic disease over which the sur- 
geon had no control. 

In a private house the autopsy should be held in 
the room giving the best light, and if possible in the 
daytime in order to obtain the correct color-interpre- 
tation; for if made in artificial light the observations 
will not be entirely trustworthy. 

At the present time an autopsy is perferably held 
almost immediately after death, and before putre- 
factive changes have taken place. The undertaker 
should always be warned not to inject the body, be- 
cause the fluids usually employed, which contain 
among other things corrosive sublimate and arsenic 
in large quantities, change the color and consistency 



AUTOPSIES. 179 

of the organs to such an extent that it is difficult to 
recognize the pathologic processes. Then, again, the 
punctures made during the embalming process may 
open an abscess or other cavity, and thus distribute 
the contained pus or exudates. Embalming-fluid 
has been poured into the mouth, and having found 
its way into the lungs and stomach, has greatly 
changed the appearance of those organs. 

The clothing on the body should be removed and 
a large sheet spread over it; or if preferred, a night- 
dress or skirt open down the middle may be put on. 

The things a nurse should provide are: 

1. Large rubber sheet, old oil-cloth, old quilts, or 
papers to put under trestle to protect the floor. • 

2. Small table for instruments, a marble-top table 
if possible, unless there is a marble-top stationary 
bowl in the room. 

3. Three washbowls: one for corrosive sublimate, 
one for dirty instruments, and one for organs re- 
moved. 

4. Two pails for dirty water. 

5. Old towels and a number of old sponges. 

6. Plenty of hot and cold water. 

7. About four quarts of fine sawdust, or oakum, 
or excelsior packing, absorbent cotton, or common 
cotton for filling up cavities, any one of which will 
prevent fluid oozing through tlfe incisions. When 
these are not obtainable, bran, cloth, or newspapers 
may be used. Fine sawdust is the best material, as 
it packs easily, does not interfere with the sewing 
by getting into the stitches, and keeps the needle 
dry. 



ISO SURGICAL TECH NIC. 

8. Six wide-mouthed bottles in which to place 
specimens from the various organs, and which can 
be securely corked. 

9. Mucilage and labels on which to write the his- 
tory of each specimen in the bottle. 

10. About three yards of fine twine or carpet- 
thread, and a large darning-needle or a large curved 
needle. 

Should the autopsy take place in a house where 
there are no conveniences, the body can be left lying 
on the undertaker's stretcher covered with a sheet, 
the clothing removed, and a large napkin put on. 
There should be several old newspapers to protect 
the floor, and on which to place the dirty instru- 
ments and organs removed; an old sheet, a pail, 
a wash-bowl, and a pitcher of warm water can always 
be obtained. 

The sheet is torn into four pieces. Two pieces are 
used, one for each side of the neck and trunk, cover- 
ing the arms, leaving the chest and abdomen free for 
the surgeon to operate; the third piece is placed be- 
neath the head; and the fourth piece is tucked in 
below the genitals, thus covering the lower extremi- 
ties. The bowl contains the large dampened sponge, 
and, together with the pail, should be placed within 
convenient reach. 

Absolute cleanliness is essential at a private autopsy. 
Blood-stains must be washed from the walls, floor, 
dishes, the rubber or oil-cloth; the papers, old 
sponges, and cloths should be burned, and the body 
must be washed perfectly clean. The room must be 
left in perfect order—just as it was before the post- 



AUTOPSIES. l8l 

mortem. Ground coffee thrown on a few live coals 
will remove all odor from the room. 

For removing the odor from the hands, turpentine 
will be found serviceable, or a solution of per- 
manganate of potassium and oxalic acid, or a dilute 
solution of formaldehyd. The result of the autopsy 
must be kept secret and revealed to no one. 



INDEX. 



Abdominal operation, instruments 

for, 78 
Abscess-stitch, 113 
Absorbent cotton, 99, 115 
Accidents during operation, 160 
Acclimatization immunity, 30 
Acquired immunity, 29 
Actinomycosis, communication of, to 

man, 14 
Adhesive plaster, rubber, 102 
After-care for gynecologic operations, 

Alcohol as an antiseptic, 56 

sterilization of hands with, 56 
Allis's aseptic ether-inhaler, 90 
Ammonia, subcutaneous injection of, 
as test in supposed death, 
177 
Amputation of limb, instruments for, 

So 
Anesthesia. S6-98 
bronchorrhea in, 19 
dilated pupils in, 92 
infiltration-, 97 

preparation for accidents in, 89 
primary, 93 

vomiting during production of, 91 
Anesthetics, administration of, 86 
chloroform, 94 
ether, administration of, 89 
ethyl bromid, 95 
general, 86 
local, 86, 95 
cocain, 95 

hydrochlorate, 96 
ethyl chlorid, 97 
eucain, 96 
ice, 96 
phenate of cocain, 97 



J Anesthetics, orthoform, 59 
hydrochlorid, 60 

Schleich's, 95 
Anthrax, discovery of bacterial na- 
ture of, 15, 16 
Antiseptic douches, 127 

dressings, 99 

powders, 104 

surgery, Lister's system, 12, 13 
Antiseptics, 42-61 

alcohol, 56 

aristol, 54 

balsam of Peru, 59 

boiling water, 45 

boracic acid, 55 

boroglycerid, 56 

carbolic acid, 47 

chlorinated lime, 58 

coal-tar derivatives, 47 

Condy's fluid, 58 

corrosive sublimate, 48 

creolin, 49 

dermatol, 61 

formaldehyd, 52 

formalin, 53 

heat, 45 
moist, 45 

hot air, 46 

hydrochloric acid, 58 

hydrogen peroxid, 55 

ichthyol, 59 

iodoform, 51 

iodol, 52 

Labarraque's solution, 58 

listerine, 61 

lysol, 50 

methyl-blue, 58 

methyl-violet, 58 

mustard, 60 

183 



1 84 



INDEX. 



Antiseptics, normal salt solution, 60 
orthoform, 59 

hydrochloric!, 60 
oxalic acid, 57 
potassium permanganate, 57 
protargol, 61 
pyoktanin, 58 
resorcin, 60 
saprol, 50 

sodium bicarbonate, 61 
sozal, 50 
steam, 45 
live, 46 
sulphuric acid, 58 
thymol iodid, 54 
vinegar, sterilized, 60 
x\ntistreptococcic serum for septic 

peritonitis, 158 
Antitoxin, administration of, followed 
by stimulation of body's ger- 
micidal powers, 39 
in therapeutic practice, 35 
method of injecting, 41 
mixture of Coley, for tumors, 40 
of diphtheria, preparation of, 36 

status of, 39 
streptococcus, 40 

preparation of, 37 
tetanus, 40 
theory of, 35 
theory of immunity, 31 
therapeutic action of, 37 
tuberculosis, 41 
preparation of, 37 
Aristol, 54 

Artificial immunity, 30 
Asepsis in gynecologic operations, 

168 
Autopsies, 178 

cleanliness in, 180 
instruments, etc., for, 179 
preparation of body for, 179 
time for, 178 

Bacillus, 21 

aerogenes capsulatus, ^ 
coli communis, ^ 
comma, discovery of, 17 
diphtherias, 34 

discovery of, 17 
icteroides, discovery of, 18 
melitensis, discovery of, 18 



Bacillus of bubonic plague, discovery 
of, 18 
of glanders, discovery of, 17 
of influenza, discovery of, 18 
of leprosy, discovery of, 16 
of Malta fever, discovery of, 18 
of measles, discovery of, 18 
of tetanus, 34 

discovery of, 17 
of yellow fever, discovery of, 18 
pyocyaneus, ]>3 
tuberculosis, ^^ 

discovery of, 17 
typhosus, discovery of, 16 
Bacteria, 20 

as causes of disease, 20 

channels of entrance into body, 

25, 26 
conditions influencing growth of, 
- 24 

disease-producing, 44 
distribution of, 9 

entrance of, through alimentary 
canal, 25 
through respiratory tract, 26 
through skin, 25 
forms of, 21 
Koch's circuit, to prove specific 

pathogenic powers of, 27 
pyogenic, 22 
reproduction of, 22 
by binary division, 23 
by fission, 22, 23 
by sporulation, 22, 23 
sizes of, 20, 21 
Bacteriology, 9 
history of, 9 
progress of, 12 
Balsam of Peru, 59 
Bandages, 103 
Scultetus, 103 
T-, 103, 104 
Bed for private operations, 163 
Bicarbonate of sodium, 61 
Bichlorid gauze, 100 
Binary division of bacteria, 23 
Bismuth gauze, 10 1 
Bladder, attention to, after opera- 
tions, 146 
irrigation of, 125 

operations on, instruments for, 84 
Boiling water as germicide, 45 



INDEX. 



l8 5 



Boric acid, 55 
Boroglycerid, 56 

Bowels, attention to, after operations, 

146 

Brain, operations on, instruments for, 

80 
Broncborrhea in anesthesia, 91 
Brushes, 115 

Bubonic plague, bacillus of, dis- 
covery of, 18 



Canton-flannel roll for instru- 
ments, 75 
Carbolic acid, 47 
Catgut, 109 

preparation of, no 
sterilization of, no 
with formalin, 53 
Catheterization, 123 
Catheters, 123 
glass, 123 
introduction of, 124 
Cautery, Paquelin, 104 
Cerebrospinal meningitis, epidemic, 
specific germ as cause of, 
18 
Cervix, dilatation of, instruments for, 

78 

Charts, keeping of, 71 

Chicken-cholera, 16 

Chlorinated lime, 58 . 

Chloroform, 94 

Cholera, chicken-, 16 

Circulation, absence of, as sign of 

death, 176 
Coal-tar derivatives, 47 
Cocain, 95 

hydrochlorate, 96 

phenate, 97 
Cocci, 21 

morphology of, 22 
Coley's antitoxin mixture for tumors, 

40 
Collodion dressing, 101 
Comma bacillus, discovery of, 17 
Condy's fluid, 58 
Continuous suture, 113 
Corrosive sublimate, 48 
swallowing of, 49 
Cotton, absorbent, 99, 115 
Creolin, 49 



Cystoscopic examination, instruments 

for, 85 
Cysts or tumors, instruments for, 78-80 

Dam, rubber, 119 
Death, signs of, 176 

absence of circulation, 176 
of heart-beat, 176 
of respiration, 176, 177 
hypostasis, 177 
insertion of needle, 177 
rigor mortis, 177 
subcutaneous injection of am- 
monia, 177 
temperature, 177 
stiffness of, 177 
Delirium, traumatic, from shock, 155 
Deodorants, 42 
Dependent pockets, 116 
Dermatol, 61 
Diet after operations, 146-150 

gynecologic, 174 
Diphtheria antitoxin, preparation of, 

36 

status of, 39 

bacillus of, 34 
discovery of, 17 
Diplococci, 22 
Diplococcus pneumoniae, 34 
Disease, bacteria as causes of, 20 

conditions necessary for causation 
of, 27 

in man, fungi connected with, 21 
Disinfectants, 42 
Disinfection, 45 

by steam, 46 
Dorsal position, 169 
Douche-board, 127 
Douches, 126 

administration of, 126 

antiseptic, 127 
Drainage, 116 

postural, 117 
Drainage-tubes, care of, 117 

glass, 116, 119 

rubber, preparation of, 118 
Dressing-rooms, 62 
Dressings, antiseptic, 99 

collodion, 101 

surgical, 99 
Dust, infection from, in operations, 
136-138 



1 86 



INDEX. 



Ear, operations on, instruments for, 

82, 83 
Emergency bundles, 115 

operations, preparations in, 165, 
166 
Emulsion of iodoform, 100 
Enema, 129, 130 
for tympanites, 1 30 
purgative, 130 
stimulating, 129 
Enteroclysis, 128 
Ether, administration of, 89 
nausea after, 93 
to children, 93 
vomiting after, 93 
death from, 93 
Ether-inhaler, Allis's, 90 
Ethyl bromid, 95 

chlorid, 97 
Eucain, 96 

Examinations, gynecologic, 168, 169. 
See also Gynecologic exami- 
nations. 
of rectum, 170 
Excretions, disinfectants for, 58 

Fermentation-fever, 159 
Finger cots, 120 
Fission, 22, 23 
Formaldehyd, 52 

as dusting-powder, 53 

inhalation of, 54 

sterilization of instruments and 
dressings with, 64 
Formalin, 53 

poisoning by, 54 

sterilization of catgut with, 53 
Fungi connected with disease in 
man, 21 

Gauze, 99, 115 

bi chlorid, 100 

bismuth, 101 

iodoform, 100 

pads, 114 

potassium permanganate, 101 

requirements of, for dressings, 99 
Genupectoral position, 170 
Germicides, 42 

Germs, incubation-period of, 29 
Glanders, bacillus of, discovery of, 
17 



Glass ligature-box, 112 
Gloves, 119 

rubber, 119, 120 
Gonococcus as cause of gonorrhea, 
16 
discovery of, 16 
Gonorrhea, gonococcus of, 16 
Green soap, 120 

Gynecologic examinations, 168, 169 
asepsis in, 168 
positions in, 169 
dorsal, 169 
genupectoral, 170 
knee-chest, 170 
latero-abdominal, 169 
Sims', 169 
upright, 169 
preparations for, 171 
operations, 168. See also Opera- 
tions, gynecologic. 
instruments for dressing after, 84 

Heart-beat, absence of, value of, 

as sign of death, 176 
Heat, germicidal powers of, 45 

moist, as germicide, 45 
Hemorrhage following operations, 

155 

symptoms, 155 
treatment, 156 
Hernia, 159 
Florsley's wax, 102 
Hot air as germicide, 46 
Hydrochloric acid as disinfectant, 58 
Hydrogen peroxid, 55 
Flydrophobia, first application of 

Pasteur's treatment, 17 
Hypostasis as sign of death, 177 
Hysterectomy, 160 
insanity after, 160 
vaginal, 160 

instruments for, 78-80 

Ice as local anesthetic, 96 
Ichthyol, 59 
Immunity, 29 

acclimatization, 30 

acquired, 29 

antitoxin theory of, 3 1 

artificial, 30 

natural, 29 

racial, 30 



INDEX. 



I8 7 



Immunity, theories of, 30-32 

phagocytosis, 31 
Incubation-period of germs, 29 
Infection from dust in operations, 

I30-I3- S 
Infiltration-anesthesia, 97 
Inflammation, 121 

causes of, 122 
Influenza, bacillus of, discovery of, 18 
Injection of antitoxin, 41 
Injections, rectal, 128 
Insanity after hysterectomy, 160 
Instruments and dressings, sterilizer 
for, 66 
canton-flannel roll for, 75 
for cystoscopic examination, S5 
for dressing after gynecologic 

operations, 84 
for operations, 76-85 
abdominal, 78 
amputation of limb, 80 
curetting of uterus, 78 
cysts or tumors, 78-80 
dilatation of cervix, 78 
on bladder, 84 
on brain, 80 
on ear, 82, 8^ 
on mouth, 81 
on nose, 82 
on rectum, 8^ 
on spine, 80 
on throat, 81 
on urethra, 84 
perineorrhaphy, 76 
trachelorrhaphy, 77 
vaginal hysterectomy, 78-80 
sterilization of, 64 
apparatus for, 65 
with formaldehyd, 64 
Instrument-trays, 67 
agateware, 67 
hard-rubber, 68 
Interrupted suture, 113 
Intestinal obstruction, 159 
Iodoform, 51 
emulsion, 100 
gauze, 100 
poisoning, 51 
lodol, 52 
Irrigation, 107 
of bladder, 125 
of rectum, 128 



Johnson's method for preparation 
of catgut, 1 1 1 

Kangaroo-tendon, 109 
Knee- chest position, 170 
Koch's circuit to prove specific path- 
ogenic powers of microbe, 27 

LabARRAQUE'S solution, 58 
Latero-abdominal position, 169 
Leprous nodules, discovery of ba- 
cilli of, 16 
Ligature, 109. See also Sutures. 
Ligature-box, glass, 112 
Ligature-tray, Robb's aseptic, 68 
Limb, amputation of, instruments 

for, 80 
Lime, chlorinated, 58 
Listerine, 61 
Listerism, 13 
Lister's system of antiseptic surgery, 

12, 13 
Lysol, 50 

Malarial fever, cause of, 19 
Malta fever, bacillus of, discovery of, 

18 
Measles, bacillus of, discovery of, 18 
Methyl-blue, 58 
Methyl-violet, 58 

Metschnikoff s theory of phagocyto- 
sis, 31 
Micrococcus lanceolatus, 34 
Pasteuri, discovery of, 16 
Mouth, dryness of, after operations, 

H5 
operation on, instruments for, 81 
Mustard as antiseptic, 60 

Natural immunity, 29 

Nausea after etherization, 93 

Needles, 115 

insertion of, as test in supposed 
death, 177 

Nodules of leprosy, discovery of ba- 
cilli of, 16 

Nose, operations on, instruments for, 
82 

Nurses, duties of, in operations, 132, 
133, 142-144 
preparations of, for operations, 133, 
134 



i88 



INDEX. 



Obstruction, intestinal. 159 

Operating-room, eare of, 62 
preparation of, 132 

Operating-table for private opera- 
tions, 163 

Operation blank, 74 

Operations, 131 

accidents during, 160 
arranging of patient for, 14 1 
attention to bladder after, 146 

to bowels after, 146 
care of patient after, 144-150 
diet after, 146-150 
dryness of mouth after, 145 
duties of nurses in, 132, 133, 142- 

144 
gynecologic, 168 
after-care, 173 
asepsis in, 168 
diet after, 174 
preparations for, 172 
hemorrhage after, 155. See also 
Honor) -Ji age following opera - 
lions. 
infection in, from dust, 136-138 
in private practice, 1 61 
bed for, 163 
furniture, instruments, etc., 

for. 164 
operating-table for. 163 
preparations for, 162 

in emergencv cases, 165, 
166 
sterilization of instruments for. 

165 

ot sheets, towels, etc.. 164 
instruments for, 76. See also In- 
struments for operations. 
of election, 132 
of emergency, 132 
of expediency, 131 
of necessity, 132 
pleurisy after, 144 
pneumonia after, 144 
preparation of field of, 139 
of vaginal canal, 140 
of nurses for, 133, 134 
of patient for, 139 

day before operation, 139 
day of operation, 141 
of surgeon and assistants for, 
135 



Operations, septic peritonitis after, 
156. See also Peritonitis, 
septic, after opera: 
sequelae of, 151 
shock after, 15 1. See also Shock 

following operations. 
thirst after, 1 45 
Orthoform, 59 

hydrochlorid, 60 
Oxalic acid, 57 

P-ADS, gauze, 114 

Paquelin cautery. 104 

Parasites as cause of malignant 

tumors, 19 
Patient, arranging of, for operations, 

141 
care of, after operations, 144-150 

preparation of. for operations, 139. 
See also Operations, prepara- 
tion of patient for. 
Perineorrhaphy, instruments for, 76 
Peritonitis, septic, after operations, 

156 

symptoms, 156 
treatment, 157 

with antistreptococcic se- 
rum, 158 
Peroxid of hydrogen, 55 
Phagocytosis theory of immunity, 

31 

Phenate of cocain, 97 

Plasmodium malaria? as cause of 

malaria, 19 
Plaster, adhesive, rubber, 102 
Pleurisy after operations, 144 
Pneumococcus. 34 

discovery of, 16 
Pneumonia after operations. 144 

croupous, bacillus of. 34 
Post-mortem rigidity, 177 
Potassium permanganate. 57 

gauze, 101 
Powders, antiseptic, 104 
Private operations, 161. See also 
Operations in private practice. 
Protargol. 61 
Puerperal fever, organic ferments as 

cause of, 14 
Pupils, dilated, in anesthesia, 92 
Purgative enemata, 130 
Pus, 122 



INDEX. 



189 



Pushing lower jaw forward to pre- 
vent obstruction to breathing, 

?° 
Pyogenic bacteria, 22 

Pyoktanin, 58 

blue, 58 

Racial immunity, 30 
Rectal injections, 128 
Rectum, examination of, 170 

irrigation of, 128 

operations on, instruments for, 83 
Resorcin, 60 

Respiration, absence of, as sign of 
death, 177 
value of, 176 

artificial, for shock following opera- 
tions, 154 
Rigor mortis, 177 
Robb's aseptic ligature-tray, 68 
Robinson's douche-board, 127 
Rubber adhesive plaster, 102 

dam, 119 

drainage-tubes, preparation of, 118 

gloves, 119, 120 

protective, 102 

SALT solution, normal, 106 

as antiseptic, 60 
Saprol, 50 
Sarcinoe, 22 

Schleich's anesthetic, 95 
Scultetus bandage, 103 
Sequelce of operations, 151 
Shock following operations, 151 

artificial respiration in, 154 

symptoms, 153 

treatment, 153 
traumatic delirium from, 155 
Shotted suture, 1 13 
Signs of death, 176. See also 

Death, signs of. 
Silk, protective, oiled, 102 

sterilization of, 1 12 
Silkworm-gut, 1 10 
Silver wire, 113 
Sims' position, 169 
Sinus, 159 

Small-pox, vaccination for, 30 
Soap, green, 120 
Sodium bicarbonate, 61 
Sozal, 50 



Spine, operations on, instruments for, 

80 
Spirillum, 21 
Splenic fever, discovery of bacterial 

nature of, 15, 16 
Sponges, 113 
gauze, 113, 114 
marine, 113, 114 
Spores, resistance of, 24, 44 
Sporulation, 22, 23 
Spotted fever, specific germ as cause 

of, 18 
Staphylococci, 22 
Staph vlococcus epidermidis albus, 

' 33 

pyogenes albus, 33 
aureus, 32 
citreus, 1,3 
Steam as germicide, 45 
disinfection by, 46 
live, as germicide, 46 
Sterilization, 45, 63 
dry, 64 
fractional, 46 
intermittent, 46 
moist, 64 

of catgut, no. See also Catgut. 
of hands with alcohol, 56 
of instruments, 64. See also In- 
struments, sterilization of. 
of sheets, towels, etc., for private 

operations, 164 
of silk, 112 
Sterilizer for instruments, 65 

and dressings, 66 
Stitch-abscesses, 113 
Stomach-contents, examination of, 

125 
Streptococci, 22 
Streptococcus antitoxin, 40 
preparation of, 37 
lanceolatus, 34 
pyogenes, 32 
Stretcher, wheeled, 63 
Sulphuric acid as disinfectant, 58 
Surgeon and assistants, preparations* 

of, 135 

Surgeon's kit, 73 

contents of, 73 

packing of, 73 
Surgery, antiseptic, Lister's system, 
12, 13 



190 



INDEX. 



Surgical dressings, 99 

technic, 62 
Sutures, 109 

button, 113 

catgut, 109. See also Catgut. 

continuous, 113 

interrupted, 113 

kangaroo-tendon, 109 

shotted, 113 

silk, 112 

silkworm -gut, no 

silver wire, 113 

Tampons, 102 
T-bandage, 103, 104 
Temperature in death, 177 
Tents, 102 
Test-breakfast, 126 
Tetanus antitoxin, 40 
bacillus of, 34 
discovery of, 17 
Tetrads, 22 

Theory of antitoxins, 35 
Thermocautery, 104 
Thiersch's solution, 56 
Thirst after operations, 145 
Throat, operations on, instruments 

for, 81 
Thymol iodid, 54 
Trachelorrhaphy, instruments for, 

Traumatic delirium from shock, 155 
Trays, instrument-, 67. See also 
Instrument-trays. 
ligature-, Robb's aseptic, 68 
Tuberculin, 18 



Tuberculosis, antitoxin of, 41 
preparation of, 37 
bacillus of, ^ 
discovery of, 17 
Tubes, drainage-, 117. See also 

Dra in age-tu bes . 
Tumors, malignant, parasites as 
cause of, 19 
treatment of, by Coley's antitoxin 
mixture, 40 
Tympanites, 158 
enema for, 130 
Typhoid fever, discovery of bacilli 
of, 16 

Upright position, 169 

Urethra, operations on, instruments 

for, 84 
Uterus, curetting of, instruments for, 



Vaccination, 30 

Vaginal canal, preparation of, for 
operation, 140 
hysterectomy, 160 

instruments for, 78-80 
Vinegar, sterilized, as antiseptic, 60 
Vomiting after etherization, 93 
during anesthetization, 91 

Wheeled stretcher, 63 

Yellow fever, bacillus of, discovery 
of, 18 



ZOOGLEA, 22 



CATALOGUE 



OF 



Books on Nursing 

AND BOOKS SPECIALLY IN- 
TERESTING FOR NURSES 



Books sent to any address, prepaid, on receipt of 
the price herein given 

PAGE 

American Pocket Medical Dictionary 2 

American Text-Book of Nursing 8 

Chapin's Compendium of Insanity 3 

Grafstrom's Mechano-Therapy 4 

Griffith's Care of the Baby 5 

Griffith's Infant's Weight Chart 5 

Hampton's Nursing 4 

Hare's Essentials of Physiology 7 

Hart's Diet in Sickness and in Health , 8 

Laine's Temperature Chart 8 

Martin's Essentials of Minor Surgery and Bandaging 7 

Meigs's Feeding in Early Infancy 5 

Morris's Essentials of Materia Medica, Therapeutics, and Prescrip- 
tion-Writing 6 

Morten's Nurses' Dictionary 8 

Nancrede's Essentials of Anatomy 7 

Pye's Elementary Bandaging and Surgical Dressing 4 

Pyle's Personal Hygiene 5 

Stevens's Manual of Materia Medica and Therapeutics . 6 

Stevens's Manual of Practice of Medicine 6 

Stoney's Materia Medica for Nurses 3 

Stoney's Practical Points in Nursing 2 



W. B. SAUNDERS & CO. 

925 WALNUT STREET PHILADELPHIA 



Practical Points in Nursing, Stama EditIon 

- M . rk • r* Thoroughly Revised. 

for Nurses in Private Practice. 

By Emily A. M. Stoney, late Superintendent of the Training- 
School for Nurses, Carney Hospital, South Boston, Mass. 456 
pages, handsomely illustrated. Cloth. Price, #1.75 net. 

In this volume the author explains the entire range of private 
nursing as distinguished from hospital nursing, and the nurse is 
instructed how best to meet the various emergencies of medical 
and surgical cases when distant from medical or surgical aid or 
when thrown on her own resources. An especially valuable feat- 
ure of the work will be found in the directions to the nurse how 
to improvise everything ordinarily needed in the sick-room. 

The Appendix contains much information that will be found 
of great value to the nurse, including Rules for Feeding the Sick ; 
Recipes for Invalid Foods and Beverages ; Tables of Weights and 
Measures ; List of Abbreviations ; Dose-List ; and a complete 
Glossary of Medical Terms and Nursing Treatment. 

" This is a well-written, eminently practical volume, which covers the entire 
range of private nursing, and instructs the nurse how to meet the various emer- 
gencies which may arise and how to prepare everything needed in the illness of 
her patient." — American Journal of Obstetrics and Diseases of Women and Children. 

The American Pocket Medical Dictionary. 

Third Edition, Revised. 

Edited by W. A. Newman Dorland, M.D., Assistant Obstet- 
rician to the Hospital of the University of Pennsylvania ; Fellow 
of the American Academy of Medicine, etc. Handsomely bound 
in flexible leather, limp, with gold edges and patent thumb index. 
Price, #1.00 net; with patent thumb index, J1.25 net. 

This is the ideal pocket lexicon. It is an absolutely new book, 
and not a revision of any old work. It gives the pronunciation 
of all the terms. It contains a complete vocabulary, defining 
all the terms of modern medicine. It makes a special feature 
of the newer words neglected by other dictionaries. It con- 
tains a wealth of anatomical tables of special value to students. 
It forms a volume indispensable to every medical man and nurse. 

" This dictionary is, beyond all doubt, the best one among pocket diction- 
aries." — St. Louis Medical and Surgical Journal. 

" This is one of the handiest little dictionaries for the pocket that we have 
ever seen. Its definitions are short, concise, and complete, so that it contains 
within a small space as many words, satisfactorily defined, as are found in some 
of the much larger volumes." — American Medico- Surgical Bulletin. 

2 



A Handbook for Nurses. just issued. 

By J. K. Watson, M.D., Edin., Assistant House-Surgeon, 
Sheffield Royal Hospital. American Edition, under the super- 
vision of A. A. Stevens, A.M., M.D., Professor of Pathology, 
Woman's Medical College, Philadelphia. i2mo, 413 pages, 73 
illustrations. Cloth, J 1.50 net. 

This work aims to supply in one volume that information which so many 
nurses at the present time are trying to extract from various medical works, and 
to present that information in a suitable form. The book represents an entirely 
new departure in nursing literature, insomuch as it contains useful information 
on medical and surgical matters hitherto only to be obtained from expensive 
works written expressly for medical men. 

Materia Medica for Nurses, 

By Emily A. M. Stoney, late Superintendent of the Training- 
School for Nurses, Carney Hospital, South Boston, Mass. Hand- 
some octavo volume of 300 pages. Cloth. Price, $1.50 net. 

The present book differs from other similar works in several 
features, all of which are intended to render it more practical and 
generally useful. The consideration of the drugs includes their 
names, their sources and composition, their various preparations, 
physiologic actions, directions for handling and administering, 
and the symptoms and treatment of poisoning. The Appendix 
contains much practical matter, such as Poison-emergencies, 
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, 
defining all the terms used in Materia Medica, and describing all 
the latest drugs and remedies, which have been generally ne- 
glected by other books of the kind. 

A Compendium of Insanity, 

By John B. Chapin, M.D., LL.D., Physician-in-Chief, Penn- 
sylvania Hospital for the Insane. i2mo, 234 pages, illustrated. 
Cloth, $1.25 net. 

The author has given, in a condensed and concise form, a 
compendium of Diseases of the Mind, for the convenient use and 
aid of physicians and students. It contains a clear, concise state- 
ment of the clinical aspects of the various abnormal mental con- 
ditions, with directions as to the most approved methods of man- 
aging and treating the insane. 

" The practical parts of Dr. Chapin's book are what constitute its distinctive 
merit. We desire especially, however, to call attention to the fact that in the 
subject of the therapeutics of insanity the work is exceedingly valuable. The 
author has made a distinct addition to the literature of his specialty." — Phila- 
delphia Medical Journal. 

3 



Nursing: Its Principles and Practice. 

Second Edition, Revised and Enlarged. 

By Isabel Adams Hampton, Graduate of the New York 
Training-School for Nurses attached to Bellevue Hospital ; Su- 
perintendent of Nurses and Principal of the Training- School for 
Nurses, Johns Hopkins Hospital, Baltimore, Md. Handsome 
i2mo volume of 512 pages, illustrated. Price, Cloth, $2.00 net. 

This original work is at once comprehensive and systematic. 
It is written in a clear and readable style, suitable alike to the 
student and the lay reader. Such a work is of especial value to the 
graduated nurse who desires to acquire a practical working knowl- 
edge of the care of the sick and the hygiene of the sick-room. 

A Text=Book of Mechanotherapy Ju8t 

(Massage and Medical Gymnastics). 



By Axel V. Grafstrom, B. Sc, M.D., late Lieutenant in the 
Royal Swedish Army ; late House Physician, City Hospital, 
Blackwell's Island, New York. i2mo, 139 pages, illustrated. 
Cloth, $1.00 net. 

This book is intended as a practical manual of the methods of 
massage and Swedish movements, so rapidly becoming popular in 
this country. It describes clearly and shows by illustration the 
various movements of the system and their mode of application 
to all parts of the body, and indicates definitely the particular 
ones applicable to the various conditions of disease. 

Elementary Bandaging and 
Surgical Dressing. 

With Directions concerning the Immediate Treatment of Cases 
of Emergency. By Walter Pve, F.R.C.S., late Surgeon to St. 
Mary's Hospital, London. Small i2ino, with over 80 illustra- 
tions. Cloth, flexible covers, 75 cents net. 

This little book is chiefly a condensation of those portions of 
Pye's " Surgical Handicraft " which deal with bandaging, splint- 
ing, etc., and of those which treat of the management in the first 
instance of cases of emergency. The directions given are thor- 
oughly practical, and the book will prove extremely useful to 
students, surgical nurses, and dressers. 

" The author writes well, the diagrams are clear, and the book itself is small 
and portable, although the paper and type are good." — British Medical Journal. 



A Manual of Personal Hygiene. Just issued. 

Proper Living upon a Physiologic Basis. By American Authors. 
Edited by Walter L. Pyle, A.M., M.D., Assistant Surgeon to 
Wills Eye Hospital, Philadelphia. Octavo, 350 pages. Pro- 
fusely illustrated. Cloth, $1.50 net. 

The object of this manual is to set forth plainly the best means of develop- 
ing and maintaining physical and mental vigor. It represents a thorough exposi- 
tion of living upon a physiologic basis. There are chapters upon the hygiene 
of the digestive apparatus, the skin and its appendages, the vocal and respiratory 
apparatus, eye, ear, brain, and nervous system, and a chapter upon exercise. 
The book is the conjoint work of several well-known American physicians and 
medical teachers, each writing upon a subject to which he has given special 
study, thus assuring for the book an originality and authority not possessed by 
any similar treatise. 

The Care of the Baby. Second Edition - 

* Revised. 

By J. P. Crozer Griffith, M.D., Clinical Professor of Dis- 
eases of Children, University of Pennsylvania ; Physician to the 
Children's Hospital, Philadelphia, etc. 404 pages, with 67 illus- 
trations in the text, and 5 plates. i2mo. Price, $1.50. net. 

A reliable guide not only for mothers, but also for medical 
students, nurses, and practitioners whose opportunities for observ- 
ing children have been limited. 

" The whole book is characterized by rare good sense, and is evidently 
written by a master hand. It can be read with benefit not only by mothers, but 
by medical students and by any practitioners who have not had large oppor- 
tunities for observing children." — American Journal of Obstetrics. 

Infant's Weight Chart. 

Designed by J. P. Crozer Griffith, M.D., Clinical Professor 
of Diseases of Children in the University of Pennsylvania. 25 
charts in each pad. Price per pad, 50 cents net. 

A convenient blank for keeping a record of the child's weight 
during the first two years of life. Printed on each chart is a 
curve representing the average weight of a healthy infant, so that 
any deviation from the normal can readily be detected. 

Feeding in Early Infancy. 

By Arthur V. Meigs, M.D. Bound in limp cloth, flush 
edges. Price, 25 cents net. 

5 



A Manual of Practice of Medicine. 

Fifth Edition, Revised and Enlarged. 

By A. A. Stevens, A.M., M.D., Instructor in Physical Diag- 
nosis in the University of Pennsylvania, and Professor of Pathol- 
ogy in the Woman's Medical College of Pennsylvania. Post 8vo, 
519 pages. Numerous illustrations and selected formulae. Price, 
bound in flexible leather, $2.00 net. 

It is well-nigh impossible for the student, with the limited 
time at his disposal, to master elaborate treatises or to cull from 
them that knowledge which is absolutely essential. From an ex- 
tended experience in teaching, the author has been enabled, by 
classification, to group allied symptoms, and to bring within a 
comparatively small compass a complete outline of the practice 
of medicine. 

Manual of Materia Medica and Therapeutics. 

Second Edition, Revised. 

By A. A. Stevens, A.M., M.D., Instructor in Physical Diag- 
nosis in the University of Pennsylvania, and Professor of Pathol- 
ogy in the Woman's Medical College of Pennsylvania. 445 
pages. Price, bound in flexible leather, $2.00 net. 

This wholly new volume, which is based on the last edition 
of the Pharmacopoeia, comprehends the following sections : Phys- 
iological Action of Drugs ; Drugs ; Remedial Measures other 
than Drugs ; Applied Therapeutics ; Incompatibility in Prescrip- 
tions ; Table of Doses ; Index of Drugs ; and Index of Diseases, 
the treatment being elucidated by more than two hundred formulae. 

" The author is to be congratulated upon having presented the medical 
student with as accurate a manual of therapeutics as it is possible to prepare." — 
Therapeutic Gazette. 

Essentials of Materia Medica, Thera= Fifth 

— ~™ —" — — ■— — — — — — — — — — — — Edition, 

peutics, and Prescription = Writing. Revised. 

By Henry Morris, M.D., late Demonstrator of Therapeutics, 
Jefferson Medical College, Philadelphia ; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. 
Cloth, $1.00; net; interleaved for notes, $1^25 net. 

" This work, already excellent in the old edition, has been largely improved 
by revision." — American Practitioner and News. 

6 



Essentials of Anatomy, 

J ' Sixth 

Including the Anatomy of the Viscera. Edition. 

By Charles B. Nancrede, M.D., Professor of Surgery and 
of Clinical Surgery in the University of Michigan, Ann Arbor. 
Crown octavo, 388 pages; 180 illustrations. With an Appendix 
containing over 60 illustrations of the osteology of the human 
body. Based upon Graf s Anatomy. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy 
gained at school, it would not be easy to speak of it in terms too favorable." — 
American Practitioner. 



Essentials of Physiology. Fourth Edition 

J ** J Revised. 

By H. A. Hare, M.D., Professor of Therapeutics and Materia 
Medica in the Jefferson Medical College of Philadelphia ; Physi- 
cian to the Jefferson Medical College Hospital. Containing a 
series of handsome illustrations from the celebrated " Icones Ner- 
vorum Capitis" of Arnold. Crown octavo, 239 pages. Cloth, 
$1.00 net; interleaved for notes, $1.25 net. 

"The best condensation of physiological knowledge we have yet seen." — 
Medical Record, New York. 

" Contains the essence of its subject. No better book has ever been pro- 
duced, and every student would do well to possess a copy." — Pacific Medical 
Journal. 



Essentials of Minor Surgery, 

™" ■"■■"^ Second 

Bandaging, and Edition, 



Venereal Diseases. 



Revised. 



By Edward Martin, A.M., M.D., Clinical Professor of 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

"A very practical and systematic study of the subjects, and shows the 
author's familiarity with the needs of students." — Therapeutic Gazette. 



The Nurse's Dictionary 

of Medical Terms and Nursing Treatment. 

By Honnor Morten, author of " How to Become a Nurse/ ' 
"Sketches of Hospital Life," etc. Containing Definitions of 
the Principal Medical and Nursing Terms, Abbreviations, and 
Physiological Names, and Descriptions of the Instruments, Drugs, 
Diseases, Accidents, Treatments, Operations, Foods, Appliances, 
etc. encountered in the ward or the sick-room. i6mo, 140 pages. 
Price, Cloth, $1.00 net. 

This little volume is intended for use merely as a small refer- 
ence-book which can be consulted at the bedside or in the ward. 
It gives sufficient explanation to the nurse to enable her to com- 
prehend a case until she has leisure to look up larger and fuller 
works on the subject. 

Diet in Sickness and in Health, 

By Mrs. Ernest Hart, late Student of the Faculty of Medi- 
cine of Paris and of the London School of Medicine for Women ; 
with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., 
London. 220 pages; illustrated. Price, Cloth, $ 1.50 net. 

Useful to those who have to nurse, feed, and prescribe for the 
sick. In each case the accepted causation of the disease and the 
reasons for the special diet prescribed are briefly described. Med- 
ical men will find the dietaries and recipes practically useful, and 
likely to save trouble in directing the dietetic treatment of patients. 

Temperature Chart. 

Prepared by D. T. Lain£, M.D. Size 8x 13^ inches. Price, 
per pad of 25 charts, 50 cents net. _ 

A conveniently arranged chart for recording Temperature, with 
columns for daily amounts of Urinary and Fecal Excretions, Food, 
Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. 



IN PREPARATION* 



An American Text=Book of Nursing. 

By American Teachers. Edited by Roberta M. West, late 
Superintendent of Nurses in the Hospital of the University of 
Pennsylvania. 

8 



9EP 15 1900 



I w$:y* £•*>