&^^*&&&&^ --jggaftn 11 NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine The New V By ZHL. & of Medicine 19 •BBifiaSaSi With the Compliments of the Publishers WITHDRAWN MAY 0 7 2009 THE NEW YORK ACA06MY OFMEOICWEUBRARY W. B. Saunders Company West Washington Square Philadelphia '.'■>,•! <■-■_' Nursing in Diseases OF THE Eye, Ear, Nose and Throat BY HARMON SMITH, M. D. Surgeon in Throat Department (Editor) JOHN R. SHANNON, M. D. WENDELL PHILLIPS, M. D. Surgeon in Eye Department Surgeon in Ear Department JOHN E. MACKENTY, M. D. Surgeon in Throat Department ASSISTED BY DAVID H. WEBSTER, M. D. JOHN R. PAGE. M. D. Assistant Surgeon in Eye Department Assistant Surgeon in Ear Department FRANCIS W. WHITE, M. D. Junior Surgeon in Throat Department WITH CHAPTERS BY HERBERT B. WILCOX, M. D. HELENA M. TOOTHAKER, R. N. Attending Physician to the Hospital . -, « 7 Superintendent j6f NuMesy i; OF MEDICINE f . THIRD EDITION, THOR<^J(G^LY M$$fo t PHILADELPHIA'ATfC LONDON W. B. SAUNDERS COMPANY 1922 Copyright, 1910, by W. B. Saunders Company. Reprinted September, 1911. Revised, reprinted, and recopyrighted September, 1915. Reprinted August, 1917, April, 1919, February, 1920, and March, 1921. Revised, reprinted, and recopyrighted September, 1922 Copyright, 1922, by W. B. Saunders Company (jvJLM) MADE IN U. 8. A. PRESS OF W. B. 8AUNDEH8 COMPANY PHILADELPHIA PREFACE TO THE THIRD EDITION For this, the third edition, the text has been thor- oughly gone over, new matter added, and obsolete matter omitted where deemed necessary. Several sub- jects have been added, namely: The preparation and postoperative treatment of Laryngectomy, Cleft Palate, and Thyroidectomy. The chapters on treatment of eye diseases have been thoroughly revised. It is hoped that the additions will increase the useful- ness of this new edition. New York City, September, 1922. 3 PREFACE In looking about for a book on Nursing which would serve as a text-book for the nurses in the Training-school of the Manhattan Eye, Ear, and Throat Hospital, we were unable to find one which seemed exactly adapted to our purpose. A practical difficulty in the preparation of such a book arises from the fact that the preliminary education of nurses varies so greatly. For this reason, certain things which are too advanced for some are elementary for others. For example, an account of the action of antiseptics involves some knowledge of chemistry, and those nurses who have not had a course in chemistry are necessarily at a disadvantage. Some may feel that the anatomic descriptions have no place in a book on nursing. "We believe, however, that a nurse may be expected to know at least as much of anatomy as is usually taught in the text-books of the public schools and academies. We have attempted to present this part of the subject in a popular style. We have tried to keep in mind that the book is in- tended for nurses and not for physicians, and have en- deavored not to go beyond the capacity of the best educated nurses. 5 6 PREFACE Our thanks are especially due to Dr. Edwin G. Zabris- kie, Pathologist to the Hospital, for many photographs which he has taken for use in illustrating this book. We also thank those of the Hospital Staff who have kindly read the manuscript, proof, or who have offered suggestions. The modern spelling of scientific terms lias been adopted, in accordance with the usage of the majority of writers on scientific subjects. New York City. CONTENTS I. GENERAL PART CHAPTER I PAGE Germ Theory of Disease................................ 11 CHAPTER II Antiseptics.............................................. 21 Oxidizing Agents, 27—Reducing Agents, 29. CHAPTER III Disinfection of Rooms and Clothing.................... 30 CHAPTER IV Sterilization............................................ 34 Sterilization of the Hands, 34—Sterilization of Dressings and Bandages, 36—Sterilization of Instruments, 3S. CHAPTER V Preparation of Surgical Dressings...................... 40 Various Packings Used in Nose and Throat Work, 41 CHAPTER VI Operating Room Technic................................ 43 CHAPTER VII The Nurse's Duties at Operations...................... 50 CHAPTER VIII The Nurse's Duties .in' Emergencies..................... 56 Hemorrhage, 56—Vomiting, 60—Mental Disturbances, 61— Rise of Temperature, 62—Shock, 63—Erysipelas, 64— Drug Poisoning, 65. CHAPTER IX Management of Troublesome Children.................. 67 CHAPTER X The Ideal Nurse and Her Conduct in the Sick Room ... 74 7 8 CONTENTS CHAPTER XI page The Feeding and Care of Infants....................... 79 Infant Feeding, 84—Sleep, 97—Temperature, 97—Con- vulsions, 98—Fresh Air, 98—The Bath, 99—Infant's Diseases, 99. __________ II. THE EYE CHAPTER XII The Anatomy and Physiology of the Eye............... 102 CHAPTER XIII Common Remedies Used in the Treatment of the Eye . 116 Antiseptics, 117—Astringents or Styptics, 120—Irritants, 124—Counterirritants, 126—Caustics, 126—Anesthetics and Anodynes, 128—Mydriatics and Myotics, 132— Refraction, 135. CHAPTER XIV Common Remedies (Continued)........................... 136 Emergencies which May Arise and Require Prompt Attent- ion of the Nurse, 142. CHAPTER XV Eversiox of Lids; Retractors; Drops, Solutions, Oint- ments, and Salves................................ 143 CHAPTER XVI Contagious Eye Diseases............................... 150 Eye Operative Technic, 153—Anesthetics, 158—Important Operations, 159. CHAPTER XVII Eye Ixstruments and Appliances........................ 162 III. THE EAR CHAPTER XVIII Outline of the Anatomy and Physiology of the Ear .. . 176 CHAPTER XIX Examination of the Ear: General Method and Instru- ments Commonly Employed........................ 186 Tests for Hearing, 192—Functional Tests of the Static Labyrinth, 194. CONTENTS 9 CHAPTER XX PAGE Diseases of the Auricle and External Auditory Canal. . 198 CHAPTER XXI Diseases of the Middle Ear............................ 203 Preparation for Operation on the Mastoid, 215—Other Operations, 222. CHAPTER XXII Diseases of the Internal Ear.......................... 231 IV. THE NOSE CHAPTER XXIII Anatomic Description of the Nose and Accessory Sinuses . 234 CHAPTER XXIV Diseases of the Nose................................. 240 V. THE PHARYNX AND LARYNX CHAPTER XXV Anatomic Description of the Pharynx.................. 251 CHAPTER XXVI Diseases of the Pharynx............................... 253 Pharyngitis, 254—Tonsillitis, 256—Adenoids, 258. CHAPTER XXVII The Larynx............................................ 266 Anatomic Description, 266—Examination of the Larynx, 268—Edema of the Larynx, 269—Benign and Malignant Tumors, 269—Laryngeal Tuberculosis, 270—Syphilis, 271—Foreign Bodies, 271—Douches, 272—Irrigation, 276—Sprays, 277—Gargles, 278—Inhalations, 278— Tracheotomy, 279—Laryngectomy, 282—Cleft-palate and Harelip, 297—Thyroidectomy. 303. Index 311 EYE, EAR, NOSE, AND THROAT NURSING I. General Part chapter I GERM THEORY OF DISEASE From the earliest times it was known that those who were exposed to certain diseases were liable to contract them. It was known that small-pox, measles, and scarlet fever were extremely contagious, while other maladies were less so. It was known that epidemics of various diseases, such as "plague," small-pox, cholera, yellow fever, typhus fever, typhoid fever, and many others, were liable to break out at irregular intervals in various parts of the world and very likely would destroy a large percentage of the population of the cities or vil- lages affected. It was known that the cities were in more danger than the rural regions from these attacks, but even the villages were not exempt. For example, in the year 1721 Boston had an epidemic of small-pox, and out of a population of about 11,000 there were 5989 cases, with nearly 1000 deaths. About the year 1730 an epidemic of what was called "throat distemper" swept over New England, and in one village of about 140 in- habitants, 31, or more than one-fifth of the entire popu- 12 EYE, EAR, NOSE, AND THROAT NURSING iation, died of the disease. Other villages had a similar mortality. The cause of such epidemics was absolutely unknown, but was generally thought to be a "miasma" or poisonous exhalation of the atmosphere. As an illus- tration of this, the word "influenza," the name of an epidemic catarrhal disease, means "influence," and was applied to the disease because it was supposed to be due to an occult atmospheric influence. The name "mal- aria" means " bad air." The discovery of vaccination accomplished much in bringing small-pox under control, but even as late as 1869-73 a terrible epidemic of small-pox spread over Europe. Other diseases, such as cholera, typhus fever, and yellow fever, were held in check by the quarantine laws. The belief was quite general that there was very little hope of accomplishing much more than this in the control of epidemics until about thirty years ago, when it was discovered that certain germs were always associ- ated with certain diseases; that the germs of one disease differed from those of other diseases; that if the germs of a given disease were injected into a guinea-pig or other animal, the disease would appear in the animal. Since this discovery was made there has been a remark- able advance in the science of medicine. Not only has the association of germs with various diseases been es- tablished, but also the manner of transmission of the germs has been discovered in many cases. It has been learned that the germs of certain diseases are conveyed by insects, so that a mosquito that has drawn the blood of a person ill with malarial fever or yellow fever may carry the disease to others. Typhoid fever and cholera are conveyed by germs contained in the food and GERM THEORY OF DISEASE 13 drink. Here, too, insects, particularly the house fly frequently convey the germs, but in many cases the spread of these diseases is due to pollution of the water- supply. The germs of the bubonic plague are conveyed by rats. A disease known as "sleeping sickness" has destroyed a large percentage of the population of certain parts of Africa. In the British protectorate of Uganda it is said that 200,000 people, or two-thirds of the popula- tion, have died of this disease since 1901. It has been discovered that in this disease there is always a parasite present in the blood, and that this parasite is carried to the victim by the tsetse fly. The germs of many diseases are blown about in the air, so that it is impossible to know when one is in danger of contracting disease. It is found, however, that some are more liable to contract disease than others, and in most cases the disease does not follow, even though the germs are present. If this were not so we should all soon die of tuberculosis or other germ disease. We all have the power of resisting disease to a greater or less degree. Some have more resistance than others, and every in- dividual has greater power of resistance at some times than at others. A physician or nurse may be exposed to a germ disease many times without taking the disease, but finally may succumb if exposed when fatigued by overexertion or loss of sleep. Anything which lowers the vitality, as, for example, the habitual use of alcoholic drinks, diminishes the resistance to disease. The mental state also has a great influence. It is an old belief, and undoubtedly well founded, that one who is afraid of a disease is much more liable to take it than one who is fearless. 14 EYE, EAR, NOSE, AND THROAT NL USING The white corpuscles of the blood are believed to have the power of destroying disease germs which enter the body provided that the vitality of the body is kept up. These white corpuscles are, therefore, called "phago- cytes," the meaning of which is "eating cells" or "de- vouring cells." In recent years it has been discovered that resistance to germs of tuberculosis is greatly increased by keeping the patient all the time in the open air. It will undoubtedly be found that many other discvases may be cured or prevented by the fresh-air treatment, simply because by this treatment the resisting power is increased. Physicians are no longer afraid of such epidemics as formerly visited our large cities. Inspection of the water-supply and milk-supply has done much toward reducing deaths from typhoid fever. At Albany, New York, a system of filtration of the drinking-water was introduced about the year 1899. A comparison of the five-year period, 1894-98, with the five-year period, 1900-04, shows that the number of deaths per 100,000 from typhoid fever was, before filtration, 104; after fil- tration, 26. From diarrheal diseases, before filtration, 125; after filtration, 53. Of children under five years of age, before filtration, 606; after filtration, 309.l Dur- ing the same two periods, at Troy, New York, only a few miles away, where, the filtration system was not intro- duced, the death-rate remained practically unchanged. In Massachusetts the death-rate from tuberculosis is only about one-half as great now as it was in 1875. Probably there has been a similar reduction in the death- 1 These statistics are taken from "Human Body and Health," Davison, published by American Book Co. GERM THEORY OF DISEASE 15 rate from tuberculosis in many other older States. In Havana, Cuba, where yellow fever had been present almost constantly from the earliest times, there has been no yellow fever, except isolated cases, for several years. In the Panama Canal Zone, where formerly, on account of tropical fevers, it was frequently fatal even to cross from ocean to ocean, the conditions have been changed by sanitary engineers, so that now the death-rate is very low. This has been accomplished by means of sewerage of towns, drainage of swamps, screening of the houses to keep out mosquitoes, and by other sanitary measures, all having for their object the destruction of the disease germs or making the conditions unfavorable for the de- velopment and transmission of the germs. Contagious and Infectious Diseases.—Diseases which are transmitted by actual contact with a person affected with the disease, or by the use of the same articles, or by exposure to the breath or exhalations of the body, or to the effete matter given off in certain diseases, such as the membrane formed in diphtheria or the scales which fall from the skin after scarlet fever, are called contagious diseases. Infectious diseases, on the other hand, are those which are not conveyed directly from one person to another, as a rule, but are due to germs conveyed through the air, food, or water. Thus, many people may be ill at one time from typhoid fever because of pollution of their water-supply or milk-supply. It is possible to associate very closely with one who is affected with an infectious disease without any danger of contracting the disease. One may even sleep in the same bed and inhale the breath of a patient suffering with typhoid fever or malarial fever without taking these 16 EYE, EAR, NOSE, AND THROAT NURSING diseases. Such diseases, therefore, cannot be called contagious diseases, although they are germ diseases. Some diseases are both contagious and infectious. Thus, tuberculosis may be taken by associating closely with a tuberculous person. Tuberculosis is, therefore, a contagious disease. It is, however, more commonly conveyed by means of germs blown about in the air; in milk from tuberculous cows; or in the meat from animals affected with tuberculosis. The disease is, therefore, according to our definition, also an infectious disease. Epidemics.—Any disease which affects a large number of people in one locality at one time is called an epidemic. Epidemics may be either of contagious or infectious dis- eases. Epidemics disappear when the cause is removed or when all those who are susceptible have been attacked. Endemic diseases, on the other hand, are those which are constantly present in certain localities on account of peculiar local conditions. The term "zymotic" is a general term applied to all germ diseases. It is derived from a Greek word meaning "a ferment." In surgery, too, the discovery of the germ theory of disease has caused a remarkable change in the methods used at operations; in the preparation of the operating rooms and of the patients; in the preparation of the sur- geon and nurses, and of the instruments and dressings. It has rendered possible and safe many operations which, before this era, were regarded as dangerous or impossible. Previous to 1880 it is said that there were certain wards in Bellevue Hospital where operations of any kind were certain to be followed by erysipelas. Before the intro- duction of antiseptic methods, a wound in the knee-joint GERM THEORY OF DISEASE 17 was almost certain to be followed by infection, so that it would be necessary to amputate the leg. No surgeon was bold enough to do an abdominal operation except in an emergency, and then the results were frequently fatal. Operations on the eyes were frequently followed by severe inflammation and suppuration. Now all these operations are done with great safety, because it is found that the infection which formerly followed was due to germs, and that if the germs are kept out of the wound there will be no infection. Formerly the germs were frequently carried from one patient to another on the instruments. Now the instruments are carefully sterilized; that is, they are treated in a way which will destroy any germs which may be present. Other pre- cautions which will be described later are taken to pre- vent the entrance of germs into the wound. Previous to the discovery of the germ theory of disease epidemics were regarded as a great mystery, and all sorts of fantastic explana- tions were given to account for their occurrence. In the early days there was much superstition in the minds of the people concern- ing epidemics. The appearance of comets or meteors, the aurora borealis, or eclipses of the sun or moon were regarded as portents or warnings of coming disaster—perhaps epidemics; perhaps war. The position of the planets, and especially the conjunction of two planets, or of a planet with the moon, was believed to determine the time when and place where the epidemic would occur. As science advanced it was hoped that chemic analysis would reveal something in the atmosphere which would account for the occurrence of epidemics. Careful chemic examinations were made of the air over malarial swamps, but nothing was found which was not present in the air everywhere. The last hypothesis which was advanced previous to the announce- ment of the germ theory was that the occurrence of epidemics was governed by variation in the sun-spots. This explanation appears to have been satisfactory to many people. In 1876 M. Louis Pasteur proved that the germs of the disease 2 18 EYE, EAR, NOSE, AND THROAT NURSING of cattle, called anthrax, could be taken from an animal affected with the disease and cultivated outside the body of the animal, and then, if injected into another animal, the same disease would be produced. The full significance of this discovery was not realized at once. For years afterward many continued to hold the old belief that diseases were generated anew from atmospheric causes without any contact with those affected with the same disease and without the presence of disease germs. The following quotations from " Quain's Dictionary of Medicine," edition of 1884, will show the state of knowledge at that time: Under the heading "Germs of Disease," p. 533, we read: "We must be on our guard against ascribing too general an influence to 'germs of disease.' In certain cases these may have been, in the first place, non-existent, as when such a disease has been 'auto- genetic,' and in no sense a derivative of antecedent disease of the same kind. This caution is especially applicable in regard to such an affection as erysipelas, which, although certainly contagious, is also on very good grounds judged to be 'generable,' especially during certain states of lowered health induced by renal disease and some other visceral affections. Though not so certainly known, it is by many deemed probable that a similar caution may be neces- sary in regard to more general contagious affections, such as diph- theria, typhoid, typhus fever, and cholera, which though certainly contagious, may also be autogenetic. On this subject, however, much doubt and uncertainty still prevail." Under the heading of "Periodicity in Diseases," in the same work, on page 1130, we read: "In these phenomena we have evidence of secular pathologic changes to which a clue is sought in studying their relation with secular meteorologic and telluric changes. In the epidemics of short recurring periods—the lesser epidemics, so to speak—it is becoming possible to construct a theory of recurrence, founded on the relationship of man to his physical and social sur- roundings, and the periodic changes which he and they undergo in common and in subordination to the periodic changes observed in Nature at large, and when the disease is communicable in relation to the number of susceptible people in a community. In the epi- demics of long recurring periods—the greater epidemics—the same conditions obtain; but it would appear as if there were, in addition, some slowly developed cumulative influences at work, which mani- fest themselves only after long intervals of time. So far as these influences may consist in meteorologic changes, we look principally to India, where these changes are more uniform in their occurrence, GERM THEORY OF DISEASE 19 for the earliest clear light on the subject. There, for example, cholera is constantly present—now as a disease endemic to a partic- ular region, now as a widespread epidemic within the limits of the peninsula, but ever and anon breaking its bounds and spreading pandemically throughout the world. James L. Bryden, M. D., has shown that the different developments of cholera within the boundaries of India have very definite relations to particular meteorologic phenomena; and it seems not unreasonable to sup- pose that, following the line of research inaugurated by him, in progress of time it will be possible to discriminate between the me- teorologic changes which determine or concur with epidemic prev- alence of the disease within India and those which determine or concur with wider extension of the malady, such as affected Europe in 1829-37, 1847-50, 1852-56, 1865-67, and 1869-73. Blandford's meteorologic researches promise much help in this direction, inas- much as they are tending to show a close relation between the greater cycles of meteorologic change in India and cycles of me- teorologic change in the sun's atmosphere, particularly as observed in the sun-spot period." Again, under the head of "Epidemic," page 441, we read: "Much of the speculation as to epidemics which passes current for science at the present day is, in reality, an unsuspected continuation of the mystic teachings of earlier medicine, magnetism or electricity, for example, taking the place of Saturn or Mercury in the scheme of causation. The terminology is modernized, but the underlying conception remains the same. Again, the so-called 'precursors' of epidemics which still find a place in treatises on medicine are the relics of the doctrine of portents of the middle ages. They rest on the assumption of an epidemic being determined by some common extramundane or intramundane cause, of which it is but one of sev- eral effects. . . . For example, the earlier epidemics of malignant cholera which visited Europe were believed to have been heralded by an unusual prevalence of 'fevers' and of diarrheal affections. . . . In view of the extreme looseness with which the word epidemic is used in medicine, sometimes simply as a descriptive term, some- times as a technical or quasi-technical term involving various hypothetic and theoretic conceptions inconsistent with each other, and sometimes as implying an occult influence, it would be well if it could be discarded from medical literature and language." When it is borne in mind that this edition was published only thirty years ago and that the writers were men of the highest 20 EYE, EAR, NOSK, AND THROAT NURSING medical authority of that time, we can realize how recent is the knowledge of the germ theory of disease. In " Appleton's American Cyclopedia," edition of 18S3, under the heading of "Malaria," we read : "Malaria (Ital., mala aria, 'bad air') or marsh miasm, an emanation which produces in mankind intermit- ting and remitting diseases. This poison is not cognizable by the senses nor can it be detected by chemical tests; it is known only by its effects. The concurrence of vegetable matter susceptible of decay, of moisture either on the surface or a short distance below it, and of a certain elevation of temperature, is necessary for its evolu- tion; of these, long-continued heat has the greatest influence in in- creasing the intensity of the poison." The presence of the plasmodium malar iw in the blood of patients suffering with malarial fever had been announced by Crudeli and Klebs previous to that time, but the importance of the discovery was evidently not appreciated. The effect of the germ theory was felt in surgical practice some- whatearlier than in medical practice, for the reason that the researches and experiments of Sir Joseph Lister, begun as early as 1865, proved that micro-organisms are always present in fermentation, decompo- sition, and putrefaction, and that these processes could be prevented or stopped by any means which would prevent the production of germs. He was the first to apply this knowledge to the treatment of surgical cases and to perform surgical operations under conditions of asepsis. He was also the first to demonstrate the value of carbolic acid as a germ destroyer. The results which he obtained in his operations were so much better than those obtained under the old methods that within a few years surgeons generally were convinced of their value, but so late as 1885 or even later there were some who were unconvinced and who scoffed at antiseptic precautions. CHAPTER II ANTISEPTICS The word "antiseptic" is defined in the Century Dic- tionary as ''anything which destroys the micro-organisms of disease, putrefaction, or fermentation, or which re- stricts their growth and multiplication." The word antiseptic is also used as an adjective, as, for example, we speak of an antiseptic application or an antiseptic wash. The noun, "antisepsis," means the exclusion, especially from a wound, of the germs which, if allowed to enter, would produce septic infection or blood-poisoning. Thus we may say " a great revolution in the management of wound infection has been brought about by antisepsis." Asepsis, on the other hand, means freedom from harm- ful germs. It must always be borne in mind that there are many more harmless germs than harmful ones. The harmful germs are the germs of disease, of suppuration, of putrefaction, and sometimes of fermentation. A wound is said to be "aseptic" when such precautions have been taken that it is believed that no germs of suppuration are present. It is possible that a wound may be aseptic even when no such precautions have been taken. The word " sepsis " is from a Greek verb which means " to make putrid." In this chapter it is not the intention to make a list 21 22 EYE, EAR, NOSE, AND THROAT NURSING of antiseptics, but to describe a few of them and explain the principles upon which their action depends. Heat.—Up to a certain point the development of germs is favored by heat. At the freezing-point of water germs remain dormant, but as the temperature rises the development is more rapid until the temperature of about 100° F. is reached. Above this point, as the temperature rises, the growth becomes less rapid, and at 155° F. most germs are destroyed. For this rea- son milk which has been kept at a temperature of 155° F. for thirty minutes will keep for days without souring. Milk thus treated is said to be " Pasteurized." At the temperature of boiling water (212° F. or 100° C.) all fully developed germs are destroyed. The spores from which the germs develop, however, are not destroyed by a short exposure to this temperature. To make certain, therefore, that all spores are destroyed, it is customary to keep a solution which is to be sterilized at a temperature of 212° F. for twenty minutes. This will destroy all germs, but not the spores from which the germs develop. After allowing the spores to develop for twenty-four hours the solution is again heated to 212° F. for twenty minutes, and sometimes the same is repeated after another interval of twenty-four hours. Heat, therefore, in the cases where it can be applied is one of the most effective antiseptics which we have. Heat is available for sterilizing instruments, bandages, and dressings. Bedclothing and wearing apparel may also be sterilized by heat, and thus the spread of conta- gious diseases may be prevented. The heat may be either dry or moist. The articles to be sterilized may be put in boiling water, in steam, or in an oven or room heated ANTISEPTICS 23 above 212° F. The effect upon the germs will be the same in any case, except that with dry heat a higher temperature is required. In many cases, however, it is obvious that heat sufficient to destroy germs cannot be used without doing serious damage. The highest temperature at which an applica- tion may be made to the body without danger of scalding is not much above 120° F., and this temperature, as be- fore stated, is very favorable for the multiplication of germs. Cold is an antiseptic, not in the sense that it will destroy germ life, because most germs may be actually frozen in a solid block of ice, but when the ice is melted and the temperature raised to the proper point it will be found that the vitality of the germs has not been impaired in the least. Still, as stated in the previous section, a low temperature is unfavorable to the multiplication of germs and, therefore, cold applications are very useful in the early stages of such diseases as purulent inflamma- tions of the eyes or in other parts of the body where there is inflammation with threatened formation of pus. Antiseptic Solutions and Chemic Antiseptics.— There are many solutions which are used for the destruc- tion of germs or to retard their multiplication. These differ much in strength and efficiency. Some knowledge of the properties of the various antiseptics is necessary in order to select the one best adapted to a given case. An antiseptic which is most effective for destroying germs may not be suitable for sterilizing instruments, because it would dull the edge or destroy the polish of the surface, and so cause the instrument to rust. Some antiseptics are unsuitable for sterilizing clothing because 24 EYE, EAR, NOSE, AND THROAT NURSING they would injure the fabric or destroy the color. Many very efficient antiseptics must be used with great caution on the human body for fear of poisonous effects or of local damage. Many antiseptics may be used on the surface of the body which could not be used in the eye, the throat, or an open wound. It is necessary, therefore, to consider not only whether an antiseptic is an efficient germ destroyer, but whether it can be safely applied for the purpose desired. The following are some of the commonest antiseptics: ' Bichlorid of Mercury.—This is a powerful antiseptic. Germs cannot live long in a solution containing 1 part of bichlorid of mercury in 10,000 parts of water. Stronger solutions act more quickly in destroying germs, but have the disadvantage of being irritating to the skin in proportion to the strength. For this reason bandages sterilized with bichlorid of mercury cannot be used on patients who are susceptible to this irritation. Knives cannot be sterilized with it because they will be dulled and rusted. The albumin in the tissue is coagulated by it, so that it acts only on the surface, and germs in- closed in the albumin may escape unharmed. More- over, the drug is a deadly poison and must be kept out of the way of children or of anyone who might swallow it by mistake. To avoid accidents of this kind the drug is frequently made up into tablets which arc colored, so they may not be mistaken for anything else. The solu- tion made from these tablets takes the same color. Carbolic Acid or Phenol.—The pure carbolic acid is in crystalline form at the ordinary temperature of the air. The crystals may be liquefied by heating, but will immediately become solid crystals again when cooled. ANTISEPTICS 25 On adding a small quantity of glycerin or water they are liquefied and remain so at the ordinary temperature of the air. A solution of 1 part of carbolic acid in 40 parts of water (i. e., a 2i per cent, solution) will destroy all germ life in a very short time. It should be remem- bered that in using antiseptics, the stronger the solu- tion the more quickly will germs be destroyed, but in many cases it is practically better to use weaker solutions and allow a longer time, especially when the antiseptics are to come in contact with the body. Carbolic acid in solution of 1 part in 20 is sometimes used for steriliz- ing instruments, but the instruments must not be allowed • to remain more than a few minutes in the solution, and then should be clipped in boiling water or they will soon rust. Carbolic acid acts as a local anesthetic. If the hands are held in a weak solution for a short time a numbness will be noticed. A strong solution of carbolic acid acts as a caustic. It will be noticed, therefore, that the same chemic substance may act in several dif- ferent ways, depending upon the strength of the solution. Thus, carbolic acid is an antiseptic in any strength, but it may also be a local anesthetic, an irritant, or a caustic. Carbolic acid has an advantage over bichlorid of mercury in that it does not coagulate the albumin of the tissue, and, therefore, penetrates more deeply. Chlorin.—The action of chlorin is quite different from that of carbolic acid or of bichlorid of mercury. It is, like them, poisonous to germs, but it has also a chemic action upon the tissues and especially upon diseased or dead tissues. Most of the tissues of the body are very complex in their chemic composition. The complex molecules are very readily broken up under the action 26 EYE, EAR, NOSE, AND THROAT NURSING of chemic agents. As a rule, the more complex the mole- cule, the more readily it is broken up. The molecules of albuminoids or proteids, which form the chief part of the solid constituents of the blood, muscles, nerves, brain, and many other organs of the body and also the entire substance of all forms of germs, are exceedingly complex. The molecule contains carbon, hydrogen, oxygen, nitrogen, and sulphur, and each molecule con- tains altogether perhaps more than 200 atoms of these various elements. If any one of the atoms is removed the molecule is immediately destroyed, and in case it was contained in living tissue the part of the tissue affected is destroyed. It is found that chlorin has a * very strong affinity for hydrogen, and as soon as chlorin comes in contact with hydrogen the two unite to form hydrochloric acid. When chlorin comes in contact with one of the complex molecules of proteid substances it has no difficulty in abstracting the hy- drogen and thus destroying the molecule. Decom- posing organic matter generally has a foul odor, and this odor is destroyed by the action of chlorin because the chlorin breaks up the molecules which produce the bad odor. The effect of chlorin in bleaching fabrics is due to a similar action. The coloring-matter contains hydrogen. This is removed by the chlorin and the color disappears. If cloth remain long in contact with chlorin not only is the coloring-matter attacked, but also the hydrogen is drawn from the molecules of the fabric itself and the fabric is weakened. The union of the chlorin with the hydrogen taken from the tissues forms hydro- chloric acid, which itself is a powerful antiseptic. A second way in which chlorin acts is that the chlorin or ANTISEPTICS 27 a part of it may unite with and become a part of the molecule with which it is brought into contact. A third way in which chlorin acts will be described under the heading Oxidizing Agents. Preparations Containing Chlorin.—The officinal preparation of chlorin-water contains T\ of 1 per cent, of chlorin. This is a powerful antiseptic, but must be freshly prepared, as the chlorin soon unites with the hydrogen of the water, forming hydrochloric acid. Chlorid of Lime.—"A compound resulting from the action of chlorin upon hydrate of calcium and containing at least 25 per cent, of available chlorin" (United States Dispensatory). Chlorinated Soda (Liquor Sodse Chlorate or Labar- raque's Solution of Chlorinated Soda).—This is a "clear pale-greenish liquid of a faint odor of chlorin, a disagree- able alkaline taste, and an alkaline reaction. The strength corresponds to at least 2 per cent, of available chlorin" (United States Dispensatory). Bromin.—"Bromin is a volatile liquid of a dark red color when viewed in masses; hyacinth red, in thin layers. Its taste is very caustic and its smell strong and dis- agreeable, having some resemblance to that of chlorin" (United States Dispensatory). Bromin as an antiseptic acts in a precisely similar manner to chlorin, but not so powerfully. Oxidizing Agents Hydrogen Peroxid.—In this we have an example of still another class of antiseptics. It is a law of chemistry that when oxygen is set free from any combination it is very active and ready to enter a new combination with 28 EYE, EAR, NOSE, AND THROAT NURSING another element. In this state it is spoken of as " nascent oxygen." Hydrogen of peroxid consists of two atoms of hydrogen united with two atoms of oxygen. This is represented by the symbol H202. This very readily breaks up into water (H20) and oxygen (0). The oxygen thus set free attacks anything with which it can unite. When brought into contact with complex or- ganic molecules this free oxygen may unite with the hydrogen or with the carbon in the molecule. In either case the molecule is broken up and destroyed. Thus; when hydrogen peroxid is brought into contact with pus, the pus-cells are attacked by the nascent oxygen and are destroyed with a great bubbling, due to the escape of gases as the cells are broken up. The union of oxygen with another element is called oxidation. Anything which sets oxygen free so that it can so unite is called an oxidizing agent. Chlorin also acts sometimes as an oxidizing agent. Instead of taking hydrogen from an organic molecule, as described in a previous section, it may attack the hydro- gen in wrater and form hydrochloric acid and set free the oxygen of the water, which will act in the same way as the oxygen set free from hydrogen peroxid, attacking and destroying the molecules of organic matter, espe- cially of dead organic matter. Bromin and iodin, which are very closely related to chlorin in chemic behavior, also act in the same way as oxidizing agents. Permanganate of potash is a very powerful oxidizing agent. When brought into contact with organic sub- stances it readily gives up its oxygen, which attacks the organic matter in the way previously described. ANTISEPTICS 29 Reducing Agents These act in a manner opposite to that of the oxidiz- ing agents. Instead of setting free oxygen, which may attack an organic molecule and unite with its hydrogen or carbon, a reducing agent extracts oxygen from sub- stances with which it comes in contact. The result, however, is the same as far as the destruction of the or- ganic matter is concerned. For example, when hydro- gen peroxid comes in contact with coloring-matter, the oxygen in the hydrogen peroxid unites with the hydrogen in the coloring-matter and the coloring-matter is de- stroyed. On the other hand, when sulphurous acid comes in contact with the coloring-matter the coloring-matter is destroyed just as effectively, but instead of taking out the hydrogen it takes out the oxygen. In either case the molecule is broken up and destroyed. The chemic reactions which occur when sulphur is burned in the presence of oxygen or air are very com- plex, but, in brief, it is sufficient to say that in burning, the sulphur unites with the oxygen of the air, forming sulphurous oxid (S02). This then unites with the water in the air, forming sulphurous acid (S02 + H20 = H2S03). When the sulphurous acid comes in contact with or- ganic matter it extracts oxygen, forming sulphuric acid (H2S03 + O = H2S04). It is this last change which causes the bleaching which is seen when colored articles are exposed to the fumes of burning sulphur. CHAPTER III DISINFECTION OF ROOMS AND CLOTHING The nurse need scarcely be told that disinfection of rooms occupied by persons suffering from a contagious disease is one of the chief means by which the spread of such a disease is combatted. It may be remarked here that the matter is simplified very materially if, previous to its occupancy by such a patient, the room has been prepared in a proper manner. Thus, all ornaments, pictures, and unnecessary furniture should be removed, all closets should be emptied. Such furniture as re- mains should be simple, free from upholstery, and easily cleaned. The carpet should be removed, although a small rug may be allowed to remain on the floor; hangings should be taken down, and the woodwork, closets, walls, and ceiling thoroughly scrubbed with soap, washing soda, and water, special attention being given to joints, corners, and crevices. During the patient's occupancy of the room care must be taken, above all else, to secure free ventilation into the open air, in order not only that the patient may have pure air to breathe but also that the pathogenic organ- isms created by the disease may not be confined in the room. In diseases in which these organisms are given off in large quantities in the sputum, urine, or feces, these discharges must be disinfected promptly by a germ- 30 DISINFECTION OF ROOMS AND CLOTHING 31 destroying solution placed in their receptacles. For this purpose chlorinated lime possesses many advantages over any other germicide. Carbolic acid and formaldehyd may also be used. The clothing of the patient and the bedclothing must be frequently changed, and that which is removed should be immersed in a 5 per cent, solution of carbolic acid for two or three hours; boiled for half an hour, and then washed thoroughly with soap and warm water. In addition, the room itself must be kept scru- pulously clean. When the patient has recovered from his disease, and it is desired to make use of the room occupied by him for its customary purposes, it must undergo disinfection. This applies also to the furniture, bed-linen, and clothing which it may have contained. If the precaution has been taken to properly prepare the apartment before- hand, as suggested above, this cleansing becomes a very easy matter. The first thing to be accomplished is the destruction of the germs of the disease, after which the room and its contents must be cleaned. In the case of the bedding, clothing, etc., disinfection should be by steam heat, if possible, the materials being left in the chamber of the steam sterilizer for half an hour or more. When such an apparatus is not available, the articles should be immersed in a 2 per cent, solution of carbolic acid for two hours, then boiled for thirty minutes, and sub- sequently washed. Fine fabrics, mattresses, or other articles which cannot be treated in this manner, may be hung upon a line in the room about to be disin- fected; or, in cases of severe infection, they should be burned. The use of formaldehyd, either in a watery solution 32 EYE, EAR, NOSH, AND THROAT NURSING or vaporized, has almost entirely superseded sulphur for disinfecting purposes, as it is the most reliable germ- icide known. It does not affect either the color or struc- ture of clothing, and its vapor mixes readily with the air, penetrating loose materials much more deeply than any other germicide. Its effect is more potent if the air of the apartment is moist and warm. If the formaldehyd is to be applied in watery solution, an atomizer is em- ployed, and a 20 per cent, solution of the drug is sprayed upon all the surfaces in the room, which is then closed for twenty-four hours. In the case of rooms not absolutely bare, those containing bedding, clothing, furnishings, etc., the vapor of formaldehyd must be used. Appli- ances for generating this vapor may be had at establish- ments dealing in hospital supplies. Windows, doors, chimneys, ventilators, and other openings should be tightly closed—either by packing the openings with cot- ton, sealing them with gummed paper, or strips of news- paper pasted with ordinary flour paste—closet doors and bureau drawers should be opened, and the air of the apartment made to contain at least 1 per cent, of for- maldehyd gas. When this is accomplished, the room must be closed for twenty-four hours, after which it is opened, ventilated, and thoroughly scrubbed with soap, water, and washing soda. Where sulphur is used the same precautions as to tightly closing every crevice in the room must be observed and sulphur candles, which burn for two hours, giving off dense fumes of sulphurous acid, may be employed. The room must be kept closed for eight hours, and when re- opened all woodwork should be washed with a 1: 1000 solution of bichlorid of mercury, the wall paper should DISINFECTION OF ROOMS AND CLOTHING 33 be removed, and the plastered surfaces freshly kalsomined. As before remarked, sulphur is not as efficient as for- uialdehyd, and, moreover, it possesses the disadvantage of discoloring metals unless oiled, and acts injuriously upon clothing and organic material generally. CHAPTER IV STERILIZATION STERILIZATION OF THE HANDS Of the various acts in the preparation for an operation, none is more important, as far as the nurse is concerned, than the sterilizing of her hands and arms, and in order that this may be as uniformly thorough as possible some established method should be rigidly followed at all times. Nothing can excuse a nurse for the omission of any part of this routine. The surgeon may be, and unfortunately, sometimes is, careless about such mat- ters—or, at least, seemingly so—but his is the repon- sibility; the nurse cannot assume any such responsibil- ity, but must observe to the smallest detail the method laid down for her guidance. It may be pointed out also that in operations upon the eyeball the surgeon prac- tically never touches the part operated upon, while in operations upon the ear, nose, or throat he frequently wears gloves. The nurse, on the other hand, may be called upon to handle dressings, sponges, etc., with or without gloves, and, consequently, must always have her hands in an absolutely sterile condition. More- over, it cannot be too often repeated that if, during the course of an operation, or at any time after she has once gone through the process of "scrubbing up," the nurse's hands or arms should become contaminated through com- 34 STERILIZATION 35 ing in contact with an article of furniture, clothing, or other unsterile object, she must again wash them in an antiseptic solution and rinse them off thoroughly after- ward. Contamination with actually infectious material, such as vomited matter, secretion from the patient's mouth, etc., demands the repetition of the entire dis- infecting process before the nurse may again essay her role as an assistant at the operation. There have been a great variety of methods of ster- ilizing the hands and arms put forward by surgeons from time to time, a few of which may be regarded as standard methods and will be mentioned. In all, the first step consists in thoroughly scrubbing the hands and forearms with warm water and Castile or tincture of green soap for five minutes. Special attention must be paid to the finger-nails, which should be kept short with the edges filed, the nail-brush being used vigorously. The soapy solution is then removed by thoroughly rinsing the hands and arms in warm water or alcohol. So far, all methods agree. With regard to the subsequent procedure, that most commonly followed is to immerse the hands and arms in a solution of the bichlorid of mercury, 1 part to 1000 parts of water. This substance is one of the most powerful germicides known, and solutions containing it are easily prepared, but it possesses the disadvantage of being very irritating to the skin of many individuals, who, consequently, favor some other antiseptic solution. Bichlorid of mercury is also readily precipitated by soap; hence the necessity for thorough rinsing of the arms and hands before immersing them in the bichlorid solution. This immersion should last for at least three minutes, after which a second rinsing should follow in sterile 36 EYE, EAR, NOSE, AM) THROAT NURSING water, the hands and arms being then dried on a sterile towel. As a substitute for bichlorid of mercury for cleansing the hands and arms, lysol, in a 2 per cent, solution, is sometimes used. It possesses a slightly soapy character, does not irritate the skin, and is a powerful germicide thus making an excellent hand solution. Disinfection by lime and soda is also frequently em- ployed. This method consists in covering the hands and forearms with a thin paste made of chlorid of lime and carbonate of soda, and after a few minutes wash- ing it off in sterile water or weak bichlorid solution. The potassium permanganate and oxalic acid method may also be mentioned, although it has fallen into dis- use of late years. After the preliminaries mentioned above, the hands and arms are immersed in a saturated solution of potassium permanganate until they are stained a mahogany brown; they are then put into a saturated solution of oxalic acid until all the color has vanished. Finally, they are rinsed in sterile water or weak bichlorid solution. STERILIZATION OF DRESSINGS AND BANDAGES Operation wounds may be contaminated or rendered "septic" through the instruments, the hands of the operator or assistant, or the dressings. The necessity for absolute "surgical cleanliness" of the hands and arms has been emphasized. No less thorough must be the preparation of the dressings and instruments which are to come in contact with the wound or its immediate sur- roundings. All towels, gowns, dressings, bandages, sponges, cotton pledgets, suture material, ligatures, STERILIZATION 37 nail-brushes, etc., arc to be sterilized by being subjected to the influence of hot steam in closed chambers. There are many varieties of apparatus for sterilizing with steam, of which the one shown in Fig. 1 may serve as an ex- ample. Fig. 1.—High-pressure steam sterilizer for dressings (Ashton). After having been saturated with superheated steam for half an hour the dressings should be kept in closed metallic receptacles until about to be used. They are then removed with sterile forceps or clean hands as required. Dry heat, which was formerly used for sterilization purposes, has been almost entirely aban- 38 EYE, EAR, NOSE, AND THROAT NURSING doned, as it requires very much longer to do the work by that method, and also because the penetrating power of dry heat is much inferior to that of steam, and, conse- quently, as a germicide it is distinctly less efficient. When a steam sterilizer is not available, reliance must be placed upon boiling the articles to be used for thirty minutes, which will render them aseptic. STERILIZATION OF INSTRUMENTS There remains to be considered the preparation of the instruments for an operation. Modern practice demands that all surgical instruments shall be of the simplest possible description, unnecessary angles being avoided, and instead of screws to join different parts of scissors and such instruments, a simple locking arrangement is used. This facilitates cleaning and decreases the like- lihood of the formation of rust. The handles are of aluminum or other metal, nickeled and polished. Fine cutting instruments are kept in racks, which secure the handle and leave the points and cutting edges free. The nurse must learn to handle the more delicate in- struments, such as cataract knives, keratomes, etc., with extreme care, as their keenness must be preserved, and, moreover, they are expensive. Consequently, they must not be dropped carelessly into a sterilizer, but first placed in a rack, such as is referred to above, and then immersed in the sterilizing solution. This is usually a 1 per cent, solution of sodium carbonate, which prevents rusting. Some surgeons advocate dipping the instruments then into alcohol (95 per cent.), but many content themselves with boiling the instruments, after which they are removed with sterile forceps to a suitable STERILIZATION 39 tray covered with a sterile towel. Prolonged boiling has the effect of dulling the keen edge of very fine knives, which, therefore, may be dipped several times into the boiling solution and subsequently into alcohol, and gently dried with sterile gauze, care being taken that no filaments of the cotton remain adherent to the knife- blade. Finally, should an instrument become contam- inated previous to or during an operation by coming in contact with any object not sterilized, as, for example, the hair or beard of the patient, it must, of course, be at once resterilized by the nurse before being again em- ployed. CHAPTER V PREPARATION OF SURGICAL DRESSINGS Method of preparing adenoid and tonsil sponges, goiter and cervical gland dressings, submucous resection dressings, wooden applicators. Various kinds of packing. Sterilization of rubber gloves, rubber tissue, and nasal splints. The following methods are employed in the prepara- tion of the various dressings used in the nursing of nose and throat work. In preparing dressings for goiter cases use: (1) Three 1-yard squares of gauze made into fluffed pads. (2) One roll of gauze, 1 yard long, 6 inches wide. (3) One 9-inch square of absorbent cotton. (4) One bandage, 6 inches wide. To make an adenoid and tonsil sponge the desired size, cut gauze in a 9-inch square, folding all the raw edges in, making a flat sponge 1* inches square. Sponges used in submucous resection of the nasal sep- tum should be made from gauze cut 4 inches square pull- ing from the center, making a pointed sponge. This shape is valuable because of the size of the nasal passages. Bronchoscopy Sponges.—The sponge is minute in con- struction because of the small field it is useful in, and should be made very carefully of a 1-inch bandage folded with both edges turned in, making a sponge \ inch in length and \ inch in width. 40 PREPARATION OF SURGICAL DRESSINGS 41 Postnasal Plugs.—These may be constructed out of cotton, gauze, or a Simpson Bernay sponge, using a No. 14 heavy black silk, tied in the center of the sponge for anchorage. Wooden Applicators for Submucous Work.—Wooden applicators should be wound with small pieces of absorb- ent cotton, by turning the wooden applicator within the center of the cotton and twisting the applicator until firm. It is essential that too much cotton be not used, because the action of heat expands the cotton fibers and loosens it from the applicator. Although we have metal applicators, the wooden ones are preferable because they can be sterilized in packages in advance of the operation. The Care of Rubber Gloves.—In the care of rubber gloves, a nurse must first ascertain whether the gloves are in perfect condition. This may be accomplished by filling the gloves with water, and if there are any holes the water will soon leak out. The following method may be used for dry sterilization. The gloves should be thor- oughly washed and boiled for five minutes. Dried, placed in pairs, according to sizes. The wrists should be turned half-way down, the gloves powdered on both sides, and an envelope made of gauze filled with powder and placed between each pair of gloves. This envelope of gauze acts as a powder-puff for the hands. Place the gloves in strong muslin covers, mark with the size, and sterilize at 15-pound pressure of steam for ten minutes. Various Packings Used in Nose and Throat Work Vaselin Packing.—Take a 1-inch packing bandage, melt white vaselin, and soak the strips of packing in this. When thoroughly saturated, place in glass test-tubes, 42 EYE, EAR, NOSE, AND THROAT NURSING plug the end with cotton, and sterilize at full steam pres- sure for forty-five minutes. Iodoform Packing.—To 1 square yard of gauze use: (1) Iodoform powder, 1 dram. (2) Glycerin, 1 ounce. (3) Alcohol, 2 ounces. Cut the gauze in strips, 1 inch wide, fold the edges in, making ^-inch packing. Soak in the iodoform solution twenty-four hours. Then place in test-tubes, plug with the cotton, sterilize in the autoclave ten minutes at a 15-pound pressure. Balsam of Peru Packing.—The same method is em- ployed in the preparation of the gauze as in the other packings, using a balsam of Peru solution. Rubber Tissue.—As rubber tissue is employed a great deal in nasal operations, it is necessary that precautions should be taken in preparing it for use. The following method is one which may be employed: Scrub the tissue with green soap, wash off with sterile water, cut into squares the desired size, soak in a bichlorid of mercury solution (1: 500) for twenty-four hours. At the end of this period wash thoroughly with sterile water, place in a sterile jar containing a normal salt solution. Nasal Splints.—There are various kinds of nasal splints, but those made of hard rubber with perforations are more generally used, and should be carefully scrubbed, washed in cold water, and boiled five minutes for usage. CHAPTER VI OPERATING ROOM TECHNIC In a private dwelling the room selected for an opera- tion should be the largest one situated at a convenient distance from the patient's bedroom. The facilities for ventilating the room and the available source or sources of light should be carefully studied. Elec- tricity is the best artificial light, on account of the ease with which it may be brought close to the patient and directed upon the field of operation by means of a shade or reflector, or made use of in the form of a head-light with mirror to be worn by the surgeon. Where elec- tricity is not available, however, the lights from ordinary illuminating gas (the burners being provided with incan- descent mantles, if possible, and a reflector), or, failing this, from a kerosene lamp, or, finally, from the acetylene flame of an ordinary bicycle lamp, may be utilized. In many eye operations a good light from a window is entirely satisfactory, especially if the window is so situ- ated that the light will fall upon the side of the patient's face. In others, however, a thoroughly concentrated light is needed, and in these cases reliance should be placed upon an artificial illuminant. It may be said that in all nose, throat, and ear operations artificial light is necessary; one of the favorite means of providing it being the head-light worn by the surgeon and obtain- ing its electricity from the street current or from a 44 EYE. EAR, NOSK. AND THROAT NURSING storage-battery. Should it be found necessary to rely upon the unprotected flame of some form of gas or kero- sene lamp, strict attention must be paid to the ventila- tion of the room. If ether is to be used as an anesthetic, it is exceedingly dangerous to allow the ether vapor to come in contact with an uncovered flame, as the vapor is highly inflammable. Cases of serious injury from neglect of proper precautions in this matter have been reported. Should chloroform be the anesthetic chosen, and no elec- tricity be available for lighting purposes, arrangements must be made for free direct ventilation into the open air, as a burning flame in a room into which chloroform vapor is being liberated produces fumes which are exceedingly irritating and even dangerous to those who must breathe them. Briefly, it may be said that the matter of the source of light, the anesthetic, and the means of venti- lating the room should always be discussed with the attending surgeon beforehand, so that there may be no confusion at the time of operation. The nurse should be fully informed upon this matter, and may quite prop- erly call the attention of the attending surgeon or his assistant to the subject if she has not already been in- structed. Having selected a room, the question of its prepara- tion for the operation will depend upon the length of time elapsing before the operation is to be performed. Thus, if the time be an interval of a day or two, it is best to remove all hangings and such articles of movable fur- niture as are not to be used, and to thoroughly scrub the walls and floors. Should, however, but a few hours remain before the room is to be made use of, it is safer to disturb nothing—not even sweeping the floor. In- OPERATING ROOM TECH NIC 45 stead, all pictures, hangings, and large furniture should be covered with sheets wrung out of boiling water or a solu- tion of bichlorid of mercury (1:1000). The floor should be similarly covered, and under the sheets about the operating table should be spread newspapers or heavy paper to prevent damage by blood or irrigating fluids. Sheets should be pinned or tacked to the side walls to a height of 5 or 6 feet from the floor. A long, narrow, strong table (usually the kitchen table or ironing table) may be used as an operating table. This should be covered with a folded blanket over which a rubber sheet and a clean linen or cotton sheet should be spread. A folded blanket and sheet should be placed at the foot of this table in readiness for covering the patient. At the head, a firm head-rest should be provided. This can be made by rolling a bath towel to form a pad and pinning it firmly, or by rolling a sheet and pinning it in a towel. Two small tables should be provided: one for instru- ments, the other for sponges, dressings, solutions, etc The size of these tables will be determined by the char- acter of the operation. Eye operations require very small space for instruments and dressings as compared, for instance, with mastoid operations, in which ample space is needed for a large array of instruments, dressings, solutions, etc. A small table accommodates the instru- ments and sponges necessary in a tonsil and adenoid operation, while a large space is necessary for those re- quired in operations on the accessory sinuses. In addition, a small table and a low chair or piano-stool should be provided for the anesthetist. All of these tables should be covered with sheets or large towels, over which sterile 41) EYE, EAR, NOSE, AND THROAT NURSING towels should be spread, as the instruments and dressings are laid out. In operations requiring a general anesthetic there should be provided an emergency table for hypodermo- clysis, intravenous infusion, and hypodermic injection. This table should contain, according to the nature and situation of the operation to be performed, a selection of Fig. 2.—Emergency table. the following articles and solutions: A saline or stimu- lating enema, solutions of hydrogen peroxid, adrena- lin, tannic acid, and gallic acid; a croup tent, tonsil clamp; tracheotomy set; ampoules for inhalations; an oxygen tank < Fig. 2). That no time may be lost when haste is essential, the solutions for hypodermic use should be in large- necked bottles, covered with sterile rubber and sterile OPERATING ROOM TECHNIC 47 needles in the rubber. For intravenous infusion, in- struments should be sterilized and ready, and suture material and dressings in sterile packages laid out on the table. If carefully done up, these will not need to be frequently sterilized. In an adjoining bath-room, if possible, at any rate where running hot and cold water are available, prepa- ration should be made for the surgeon and assistants to sterilize their hands. For this procedure the following articles are essential: Several cheap nail-brushes and wooden nail-picks (orange sticks) which have been sterilized by boiling twenty minutes; 8 ounces of tinc- ture of green soap; a small basin or bowl containing 95 per cent, alcohol; two large basins or bowls, one con- taining 1:1000 solution of bichlorid of mercury, the other, sterilized water. Other solutions, such as lysol and car- bolic acid, may be required by the surgeon, but need not be provided unless requested. The surgeon usually brings his own sterile gowns, rubber gloves, towels, dressings, instruments, suture material, etc. It is advisable, however, for the nurse to inquire if she is expected to provide any of these articles, particularly in large towns where they are so easily pro- curable. The nurse should also inquire if the instruments are to be sterilized at the patient's home, in which case a suitable vessel for boiling them and a quantity of bicar- bonate of soda should be at hand. In all operations cer- tain solutions will be required and three or four small glass vessels should be in readiness to receive them. These should be sterilized by boiling for twenty minutes or immersion for twenty minutes or more in 1:1000 bi- chlorid in a large vessel or the bath-tub. The large por- 48 EYE, EAR, NOSE, AND THROAT NURSING celain vessels and pitchers for irrigating solutions should be similarly sterilized. In all ear operations the following should be at hand: Alcohol, 95 per cent.; hydrogen peroxid; solution of adrenalin chlorid 1: 1000; normal salt solutions (hot and cold in large quantities for irrigation of wound and possible rectal injection or intravenous infusion). The same are likely to be needed in any major nose and throat operation. In operations for tonsils and adenoids the nurse should be provided with a dish of sterile water into which the fragments of adenoids may be shaken out. Many surgeons like to have towels in ice-water to be dashed into the patient's face to stop hemorrhage or to hasten recovery from the anesthetic. In operations upon the eye sterilized solutions of cocain (4 and 8 per cent.); atropin (1 per cent.); adrenalin chlorid (1:1000); bowls of solutions of boric acid, normal salt, and distilled water are to be provided; also plenty of pledgets of absorbent cotton or gauze wrung out of boric acid solution. To summarize. The following list of what is mainly needed for an operation in a private house may be ap- pended : f 1) Operating table. (2) Two smaller tables: one for instruments and one for dressings and solutions. (3) Stool for anesthetist. (4) A small table for anesthetist's outfit. (5) A flat dish of alcohol for knives. (»>) A bowl of sterile water on instrument table for rinsing. (7) A small pitcher for irrigating solution. OPERATING ROOM TECHNIC 49 (8) A pus basin or some substitute for catching the irrigating fluid. (9) Small glasses or bottles for adrenalin, cocain, atropin, hydrogen peroxid, etc. (10) Several large porcelain or granite ware pitchers for hot and cold normal salt solution. (11) A foot-tub or large pail on the floor by the operat- ing table for soiled sponges. After the vessels, except the foot-tub, have been thoroughly sterilized, they should be placed on a sterile table and then filled and covered with sterile covers made of towels or several thicknesses of gauze wrung out in 1: 2000 solution of bichlorid of mercury. (12) Three basins for the hand solutions (alcohol, sterile water, and bichlorid of mercury 1:1000) should be first sterilized and then filled. (13) 8-ounce bottle of tincture of green soap (14) Sterile nail-brushes and nail-picks. CHAPTER VII THE NURSE'S DUTIES AT OPERATIONS The nurse who assists at the operation must rendei her hands aseptic and be ready to sponge, hand instru- ments, thread needles, hold retractors, and apply dress- ings, as the requirements arise. Hand solutions, sponges, sterile sheets, and towels arc to be previously prepared and placed within easy access of the assistant. In nearly all operations upon the nose and throat, except cervical adenitis of the left side, the operator stands at the right of the patient, and within his reach on the same side should be placed the required instruments. The table for dressings, sponges, astringents, and sterile towels should be on the left side of the patient, accessible to the assistant; while the table for the anes- thetist should be at the head of the patient and to his right and supplied with a few large gauze sponges, a few small towels, and a hypodermic syringe loaded with totj gr. of nitroglycerin and -fa gr. of strychnin, unless otherwise ordered. A nurse is not called upon to note the general condition of the patient, as "facies," res- piration, pulse, or the color of the blood unless requested to do so by the doctor; but should the attention of the operator and the anesthetist be diverted by some unusual circumstance, and the nurse apprehends danger from her own observation, it will not be deemed officious should she call their attention to the symptoms noted. 50 THE NURSE'S DUTIES AT OPERATIONS 51 A nurse should never leave an operation to attend the telephone, door bell, anxious member of the family, or any other summons unless permitted to do so by the operator. After the nurse's hands have been surgically cleansed, any article not sterile should be handled with a sterile towel or piece of gauze, so that the necessity for rester- ilizing the hands may be obviated. If the floor has been properly protected by old sheets over newspapers, the necessity for throwing soiled sponges and dressings in a proper receptacle is not so imperative, but when the patient is coming out from under the anes- thetic a proper receptacle must be at hand in case of vomiting. A pus basin is the best, but a small bowl or even a soap dish will answer in an emergency. These provisions are a part of the nurse's duties at private houses; in hospitals such provisions are a part of the regular equipment. During an operation the operator is frequently intent upon a certain part of the procedure to the mental exclusion of other parts, and he will fre- quently want certain instruments, sponges, dressings, or sutures, while unable at the moment to call them by name; if the assistant or nurse recognizes such want and supplies it it is called " anticipating" the want of the operator, and such a quality in a nurse greatly enhances her value at an operation. Patient's Bed.—The nurse should invariably see that the patient's bed is properly prepared before she gives her attention to the operation; such preparation con- sists in removing the pillow and placing a folded sheet or bath towel where the head will rest, and if a rubber sheet is convenient it should be placed beneath the 52 EYE, EAR, NOSE. AND THROAT NURSING towel to protect the bedclothes. The bed should be warmed by hot-water bottles which should not come in contact with the patient, as frequently bad burns have resulted therefrom. This rule should be followed in summer as well as in winter, for the patient's resistance is always lowered by the anesthetic, and cold, pneumonia, and shock may be often avoided by proper after-care of the patient. A nurse should never address the operator upon ir- relevant subjects while the operation is in progress. The Nurse's Duties After Operation.—The anes- thetist ordinarily returns the patient to the bed, but should he need the nurse to steady either head or foot, it is her duty to render such assistance. Should the anesthetist remain for a while with the pa- tient, the nurse can remove the floor coverings, sponges, table sheets, etc., and clear away, as much as her time will permit, all evidences of the operation. It is unwise to permit either the family or any of the domestics to remove the bloody evidences of an operation. The ordinary individual retains an unpleasant memory of the sight of an operating room after the performance, and it is the nurse's duty to lessen this unpleasantness as much as possible. Should the anesthetist have to depart immediately after the operation, as is frequently the case where a special anesthetist is employed, it becomes the duty of the nurse to attend the patient until after the tendency to vomiting is over or until the drowsiness following the anesthesia gives her a few minutes in which to wrap up the soiled linen and sponges. The next attention of the nurse is the comfort of the patient. If possible, without offending the family, keep THE NURSE'S DUTIES AT OPERATIONS 53 them all out of the room, and if nothing is wanted and the patient is in no danger, send them for a walk or drive. Their presence only complicates the nurse's duties and is of no avail to the patient. The doctor ordinarily leaves instructions for the care of the patient; should this be omitted, it is not advis- able to give any nourishment within two or three hours after the operation. Then a small quantity of pulverized ice may be tried or sips of hot water. Should the opera- tion be for the removal of tonsils and adenoids, the hot water is contraindicated, as it might induce bleeding. Great difficult}' is experienced in getting the first liquids to remain on the stomach, and in this condition the good judgment of the nurse plays an important part. Ice- cream for postoperative throat cases is quite acceptable. but some children are never allowed ice-cream when well, and should, therefore, not be permitted to have it under these circumstances. Frequently a little gum-arabic- water with a few drops of lemon-juice in it, or the white of an egg beaten up with a little lemon or sherry wine, will be retained by the stomach. Some operators claim that dry food is far better than liquid in cases of protracted vomiting, and recommend toast, zwieback, and crackers. Not for several hours after an operation should any attempt be made to give the patient food in any quantity, and the character of the food should be determined by the doctor. In most operations on the nose and throat a certain quantity of blood has been swallowed, which offers the most fertile medium for infection by the numerous bacteria of the intestines, and if not quickly removed results in undesirable intestinal disturbance. In such 54 EYE, EAR, XOSK, AND THROAT NUKSIN'G cases the administration of a cathartic on the following morning is almost a necessity. In other operations upon the head the necessity for a cathartic is not so impera- tive, though equally advisable. Should the doctor omit mentioning the character of the cathartic, it is advisable to give such as is ordinarily used by the family, or, if possible, consult with the doctor concerning it. By no means substitute one of your own selection unless re- quested to do so by the relatives of the patient, and in that case castor oil is by far the safest and least irrita- ting. It may be given in sarsaparilla without the least detection of the oil; 2 ounces for an adult is by no means too much, and greater pain from griping is produced by too little than by too much. After certain operations upon the eye, and especially after cataract operation, it is dangerous to administer a cathartic, and, therefore, the nurse should never give a cathartic after an opera- tion on the eye without an order from the surgeon. The nurse should always take the temperature, pulse, and respiration of the patient before and shortly after the operation, and record it. If the patient's mouth and tongue become sticky and disagreeable it is her duty to swab out the mouth and clean the tongue and gums with some camphorated solution, such as listerin and water or any mouth-wash the patient may fancy. Too much attention to the comfort of the patient cannot be given, and such attentions determine the acceptableness of the nurse to patient and doctor. Conversation with the patient after operation should be avoided, and when al- lowed, it is always expedient to let the patient determine the subject of conversation. Interference with the domes- tic arrangements of the household is to be avoided as much THE NURSE'S DUTIES AT OPERATIONS 55 as possible consistent with giving the patient the neces- sary attention. Many domestics resent the presence of a nurse, and will frequently attempt to thwart her en- deavors in behalf of the patient; such attempts should not influence the nurse in the persuance of what she considers her duty. She should endeavor to disturb as little as possible any of the established routine of the household and not demand too much attendance from the domestics. If the case is one requiring the services of only one nurse, she is entitled- to two hours each day for recreation. Sufficient time for sleep must always be considered. Should the case require the care of two nurses for day and night duty, then it is not expected that the nurse will take two hours out of either of these periods for herself. Sponge-bathing followed by an alcohol rub is an es- tablished procedure in all cases, unless otherwise ordered by the doctor. CHAPTER VIII THE NURSE'S DUTIES IN EMERGENCIES HEMORRHAGE The degree of hemorrhage should determine largely what course the nurse should pursue. In nose and throat cases a certain amount of hemorrhage is expected, and to control moderate hemorrhage certain styptics have been left with the nurse to meet this contingency. Mild hemorrhage from the nose may often be controlled by injecting therein a medicine-dropper full of hydrogen peroxid diluted with one-third water. Iced cloths placed over the nose or slapped on the face, so that a certain shock is produced thereby, exercising a moderate ner- vous influence upon the vasomotor system, will frequently control the bleeding. Adrenalin solution in full strength run into the nostrils with a small bulb syringe, or a solution of tannic and gallic acid, consisting of 1 dram gallic and 2 drams tannic acid added to 1 ounce of water, also acetotartrate of aluminum (1 part in 8 parts of water), used in the same way, will often overcome the hem- orrhage if it is not too severe. Pressure on the bleeding side with the ball of the thumb and continued for ten minutes is often effective. If, however, the flow is continuous and assumes in the mind of the nurse the importance of a real hemorrhage, she had best tele- phone for the operator, and, failing in this, get some sur- geon near at hand. 56 THE NURSE'S DUTIES IN EMERGENCIES 57 It would not be advisable for the nurse to attempt pack- ing the nose under ordinary circumstances, as the supply of necessary instruments and packing would not be at hand, but should these be left by the physician and the hemorrhage become alarming, it would be good judg- ment for her to pack the nose until the doctor arrived, having first wet the gauze in pure adrenalin or alum solution. This may be accomplished by running a loop of gauze far back into the nostril with the two ends held outside the nose, into which loop is packed other strips of gauze until no more can be introduced. This packing is best accomplished by the use of a cotton applicator wound with only sufficient cotton to protect the point and then wet with water. This moistened tip will engage the gauze and facilitate packing while not endangering the nasal mucous membrane. Pledgets of cotton the size of the little finger wrapped loosely upon the applicator may also be packed in the nostril and left there by dis- engaging the applicator. It is well to moisten these pledgets in adrenalin or alum solution before introducing, and also to record the number of pledgets introduced. Hemorrhage following the re- moval of adenoids is controlled by injecting hydrogen per- oxid in full strength through the nostrils and with suffi- cient force to come against the back wall of the pharynx, from which location the adenoid has been removed. The same solution of tannic and gallic acid and ad- renalin solution may likewise be injected through the nose. In cases of emergency, when these styptics have not been left for the use of the nurse and time appears an 58 EYE, EAR, NOSE, AND THROAT NURSING element in the consideration of the patient, vinegar, lemon-juice, or alum solution may be employed through the nose in a similar manner. It is absolutely impracticable for a nurse to apply a postnasal tampon, though she should be able to make one and have it ready at all operations for the removal of adenoids or in operations upon the sinuses. A post- nasal tampon is made by rolling a piece of gauze tightly to the size of the thumb, which is tied with a heavy silk thread in the middle, leaving two ends attached about 18 inches long. The ends of he gauze roll are now trimmed off until it is about 1 \ inches long. In the application of the tampon one of the strings is pulled through the nose by means of a Bellocq's canula and the gauze plug pulled into the nasopharynx with the aid of the index-finger of the surgeon. The string that is pulled through the nose is tightly tied to another roll of gauze, which holds it in place at the vestibule of the nostril. The other string is left extending out of the mouth, to aid in dislodging the plug when it is necessary to remove it. Xo plug should remain in place over twenty-four hours, owing to the danger of ear infection. Tonsillar Hemorrhage.—Hemorrhage after tonsillec- tomy is much less frequent than formerly, and is con- trolled so easily that temporizing measures should not be resorted to under ordinary circumstances. After every tonsillectomy the nurse must be on the alert to recognize any or all signs and symptoms of hemorrhage —as increased pulse rate, becoming small and thready; pallor, restlessness, shallow respirations, and excessive thirst. Free blood may not be seen, as frequently the THE NURSE'S DUTIES IN EMERGENCIES 59 patient swallows instead of expectorating the blood, therefore the patient should be induced to expectorate at intervals, but hawking should be prohibited, as any action of the pharyngeal muscles tends to loosen the clots in the severed vessels. Frequent swallowing or gargling should be interdicted. If the occasion arises and the nurse must depend upon her own initiative until the surgeon arrives, several procedures may be carried out with the double purpose of arresting the hemorrhage and solacing the patient. The control of postoperative hemorrhage should be outlined as follows: A. Preventive.—1. Blood-clotting time tested, and any case with more than twelve minutes' time should be rejected until treatment has reduced it to eight minutes. 2. Lactate of lime, gr. xx t. i. d., given for three days before the operation. 3. Iron preparations by mouth if anemia is present, preferably syrupus ferri iodidi. 4. General building up of body strength. 5. Ice-collar after operation. 6. Morphin, without atropin, hypodermically before or after operation to reduce the reflex action of swallowing and quiet the muscular action generally. 7. Position of patient: Lying on either side, face down; thigh of opposite side flexed, thus allowing mucus and blood to escape from the mouth. 8. Inspection of the pharynx if practicable, as a large clot may form in a tonsillar fossa, which extends down the lateral pharyngeal wall and acts as a drain or wick, carrying the blood directly into the esophagus. 60 EYE, EAR, NOSE, AND THROAT NURSING B. Immediate.—1. Notify the surgeon. 2. Solutions to be held in the mouth at frequent intervals and allowed to bathe the bleeding parts, as a teaspoonful of the mixture of tannic and gallic acid, equal parts, in a wineglass of water; peroxid, 25 per cent.; alum, vinegar, gelatin, or lemon juice. Adrenalin is to be condemned. The following are to be given directly under the doctor's orders: 3. Coagulose—ten minims hypodermically. 4. Thromboplastin, of which there are two kinds, one for local application and the other for hypodermic use. 5. Horse-serum—10 c.c. hypodermically—after test for anaphylaxis. 6. Mechanical contrivances. It is highly inadvisable for the nurse to attempt the use of any of these instru- ments. It may, however, become necessary for the nurse to remove one of them from the throat of a patient, so she should be thoroughly familiar with the method of their application and removal, also the method of re- moval of a sponge or sponges left purposely in the tonsillar fossa or fossa}. Vomiting Moderate vomiting is to be expected in cases of general anesthesia, and requires attention only to prevent the inhalation of food products or blood-clots. Should foreign matter be drawn into the larynx, a sharp blow on the back will ordinarily dislodge it by the sudden expulsion of the residual air held in the lungs. Should this fail, the introduction of the finger into the larynx and pulling out any foreign substance therein is advis- able. THE NURSE'S DUTIES IN EMERGENCIES 61 Should the choking continue, the patient can be in- verted if a child, or the head and shoulders lowered over the side of the bed if an adult, and the back pounded at frequent intervals. However, if the matter is not dislodged in the first instance, get the nearest physician at hand to attend the patient and telephone for the surgeon who has operated. Vomiting sometimes becomes persistent, and taxes alike operator and nurse to overcome it. Absolute rest of the stomach for a period of six hours will frequently prove the best course, but the anxiety of relatives to have the patient take "something" will frequently overcome one's better judgment. Champagne or brandy well iced, gum-arabic-water, beaten white of egg, small quantities of dry food, milk and lime-water, large doses of bismuth (gr. xx) every two hours, small doses of wine of ipecac, drop doses of Fowler's solution of ar- senic, yo-gr. doses of calomel every half-hour, spraying the throat with ether externally, etc., are all remedies employed for persistent vomiting. In general surgical cases washing out the stomach be- fore the patient leaves the operating table has lessened postoperative vomiting. It has not been employed to any extent in operations upon the head. Mental Disturbances Mental disturbances after operations on the eye, especially in elderly patients, and more particularly when both eyes are bandaged—are of fairly frequent occurrence, and may vary from a mild aberration to active delirium and even maniacal outbursts. The nurse will take note 62 EYE, EAR, NOSE, AND THROAT NURSING of the earliest symptoms of such a complication and will see that the patient is constantly under observation and is prevented from doing damage to himself, and especially to his eye, and will immediately notify the surgeon in charge, who will institute appropriate measures for the relief of the condition. These, it may be added, usually include: letting the patient out of bed, if thus confined; removal of the bandage from one or both eyes, and the exhibition of quieting remedies, such as the bromids, codein, etc. Rise of Temperature Even in minor surgical cases, a slight rise of tempera- ture just after the operation is to be expected, except in the evacuation of pus, when the temperature ordinarily falls. A sudden rise of temperature in any operative case, after it has been running a regular course, is sufficient cause for notifying the doctor. Should the temperature fall to subnormal in any operative ear case, notify the operator at once. Either rising or falling temperature, after a period of continuous fever, is an index to the condition of the patient and must be communicated to the doctor. Should there be a rise of temperature, to 104° F., and it is impossible to confer with the physician in charge, an alcohol sponge should be given. Frequently the cause of a rise of temperature, both in simple and complicated cases, is due to intestinal fermentation, and calomel fol- lowed by castor oil or a dose of magnesium sulphate will remove the cause and lower the temperature. Some physicians grant permission to the nurse to give cath- THE NURSE'S DUTIES IN EMERGENCIES 63 artics under such circumstances in uncomplicated cases, but it is far more expedient to notify the physician and gain his consent to give any medication. AY hen gastro-intestinal disturbance is not the cause of the rise of temperature, it is usually due either to toxic absorption from the wound or to invasion of some other area by the infective micro-organism present in the first instance, and only the physician is qualified to deal with the condition. Erysipelas and iodoform-poisoning must also be borne in mind as possible causes. Shock The possibility of surgical shock should be constantly borne in mind by the nurse, and no condition coming under her supervision calls for quicker action or calmer judgment. Her recognition of shock is made entirely by the symp- toms present, which are pallor, with cold and clammy skin, dilated pupils, reacting slowly to light; irregular, weak, thready, and frequently imperceptible pulse; ir- regular, sometimes sighing respiration; loss of voluntary muscle movement; occasional nausea or actual vomiting. The temperature is usually subnormal and there is great thirst and restlesness. There may be mental inactivity and loss of control of bowels or bladder, and, lastly, coma. Do not give strong liquors by mouth at this time, as they are likely to enter the larynx and create irritation, nor strong inhalations of ammonia, etc. As shock is probably due as much to cerebral anemia as to any other cause, lower the patient's head, so that blood may flow thereto, and bandage the lower extremities. 04 EYE, EAR, NOSE, AND THROAT NURSING If the face becomes cyanotic, the head should be raised and the bandages removed. Stimulating drinks, if the patient can swallow, should be given diluted with hot water. External heat should be applied, but carefully, as burns are not infrequent under these circumstances. An enema of hot black coffee with an ounce or two of brandy added is of great value. The doctor should be summoned at once, when he will give strychnin, brandy, digitalis, and other heart tonics in large doses. If the shock is due to loss of blood, saline infusion should be given, or a hot saline enema with brandy, until the doctor arrives. ERYSIPELAS Erysipelas is an infection of the skin, and may follow any operation upon the head. It is probably more fre- quent in mastoid operations than in any of the others of the head. A dermatitis of a roseate color beginning adjacent to the operative area, accompanied with pain and a rise of temperature, should be the first warning to the nurse. The beginning is frequently associated with gastric dis- turbance that is inexplicable. Pain in the joints sim- ulating rheumatism is often present. Immediate attention of the doctor should be called to the condition, as it is frequently a serious complication and may be readily transmitted to other surgical cases. Should the doctor not be in ready communication with the nurse, it is justifiable for her to put on a 25 per cent. ichthvol in glycerin poultice and give dram doses of the tincture of chlorid of iron in water every three hours until she can consult the physician. the nurse's duties in emergencies 65 Drug Poisoning Iodoform.—Some people are peculiarly susceptible to iodoform-poisoning, and even death is known to have resulted in certain surgical cases from dressings of iodo- form gauze. The symptoms are rise of temperature, reaching 104° F. or higher; headache, loss of appetite, rapid pulse, with low tension, even running as high as 180; general depression, restlessness, and sometimes collapse. The treatment consists in withdrawing the dressings and giv- ing small doses of opium, and in the judicious use of stim- ulants. The nurse should remove the dressings, if the surgeon is not within reach, and substitute plain sterile gauze. The rest of the procedure should be left to the physician. Not infrequently a rash appears upon the body, and is particularly noticeable adjacent to the wound. Carbolic Acid.—There exists an idiosyncrasy to this drug in many people, and in these cases even the dress- ings of carbolized gauze will produce loss of appetite, nausea, feverishness, headache, vertigo, and depression, which may ultimately develop into coma. The most accurate diagnosis is in the chemic examina- tion of the urine and also by its smell and smoky ap- pearance. Lime-water, Glauber's salt, and gum-arabic-water should be freely given internally, wmile alcohol will neutralize the local effects. In cases of attempted sui- cide by carbolic acid, alcohol given immediately will, in many instances, overcome the effects. Atropin hypo- dermically is also given. 5 66 EYE, EAR, NOSE, AND THROAT NURSING Bichlorid of Mercury.—If taken internally by mis- take or otherwise, the antidotes are white of egg, mag- nesia, milk, lime-water, and gluten. Cocain.—Cocainism is manifested by the pulse be- coming first quick and forcible; later becoming small, rapid, and intermitting. Respiration is slow and shal- low and the patient complains of a tightness about the chest. The skin becomes cold and clammy, and the sub- ject is impressed with the belief that death is impend- ing. The pupils dilate and the mouth becomes dry, the patient complaining of an inability to swallow. Ammo- nia may be given the patient to inhale, and 1 ounce of whisky in water may be given by mouth. Opium and chloral are given by mouth, while the in- halation of chloroform or ether will shorten the existence of the symptoms. CHAPTER IX MANAGEMENT OF TROUBLESOME CHILDREN The care of children presents some of the most difficult phases of nursing, but it is a very important branch of service, and no training for general work is complete without actual experience in the children's ward, nor can any nurse be regarded as fully qualified for a general practice of her profession who has not proved herself competent in this branch. The possession of an inborn love for children is undoubtedly an invaluable factor and not to be underrated, but, in almost every candidate, compensation for its absence can be secured in a highly practical degree through thorough self-con- trol and the exercise of tact, of quiet, unruffled patience, and of kindly, but not demonstrative sympathy. The child presents an entirely new problem as com- pared with the adult patient. The latter's reasoning power is, at least, comparatively well developed, and he is correspondingly governed by his own appreciation of necessity and fitness; but the child, in direct proportion to its youth, is only an uncomprehending subject of the will of those about it. Its own more or less unconscious will is exercised only in resistance to what disturbs or alarms it, and the degree and character of such disturb- ance and alarm are due, outside of actual physical suffer- ing, to two conditions—its previous training and its present treatment. 67 68 eye, ear, nose, and throat NURSING Unfortunately, not only is the nurse necessarily ig- norant of the previous training, but in the great majority of cases this training is not of a character to induce1 ready submission to the requirements of proper care, and she it- compelled to overcome the child's resistance through either tactfulness or force. The latter should never be resorted to until all reasonable efforts in the former have failed. This course is not only humanitarian, but scien- tific. The mental condition of every patient is of prime importance, and a child that is violently rebellious, or even morose, grieved or alarmed, is necessarily at a cor- responding disadvantage in its physical condition. The gaining of the patient's confidence, however young the patient may be, must be an ever-present purpose from the outset. This is often no easy task, and first impressions are all important, but, this confidence once gained, the nurse is well started in her work. Not only her every movement, but her manner, attitude, features, voice, touch, should be expressive of promptness with- out haste, kindly interest, gentleness, and sympathy without indulgence, firmness without harshness, and, above all, of absolute truthfulness. Facts may advan- tageously be presented in their brightest and most hope- ful aspects and without prominence of their unpleasant features, but never contrary to truth; and no promise should ever be made without punctilious performance. A child's faith in its elders assumes infallibility and, this assumption once shattered, confidence and its benign consequences are lost forever. Furthermore, children are imitators, and example is more effective than pre- cept. The patient's peculiarities should be carefully studied MANAGEMENT OF TROUBLESOME CHILDREN 69 and availed of in all possible ways for its care and control, and every unnecessary cause for alarm studiously avoided. Unreasoning fear, occasioned by carelessness or thought- lessness in the performance of some simple duty, will remain inseparably associated with the act in the pa- tient's mind and render future performance of the duty a constant and perhaps serious source of disturbance; or the fear may associate itself with the nurse herself and render her future service or even presence imprac- ticable. Fear of or aversion to strangers or strange surroundings may for a time place the nurse at a disad- vantage, but a kind word or a toy at the right moment may distract the attention and dispel the fear. Regu- larity is essential. Young children especially very soon establish habits, and a child that is cared for regularly will not be sleepless and fretful at night without physical cause. The nurse who carefully and conscientiously studies the full import of the foregoing suggestions and faithfully applies them, will generally encounter no serious diffi- culties in the care of children, but occasionally a patient will be found that obstinately refuses to take the medicine or submit to the treatment prescribed. Arguments, en- treaties, and promises (that can be fulfilled) may be employed to advantage, but never, under any circum- stances, menaces or threats of any kind. If, notwithstanding all reasonable efforts, the patient still persists in refusal, no further time should be lost in coaxing that will probably have to be repeated day after day or perhaps several times a day. In case of dressing, everything that is to be needed having first been got in readiness, the nurse should promptly wrap a sheet closely 70 EYE, EAR, NOSE, AND THROAT NURSING about the child's body, arms, and legs, to prevent strug- gling and prepare it for the doctor (Fig. 3). In case of re- fusal to take medicine, the child should be swathed in the same manner and its nostrils held closed till it opens the mouth to breathe, when a spoon with the medicine should be inserted as far as possible, emptied, and withdrawn. When it is not necessary or convenient to swathe a child, the following methods may be used: Restraint for an Eye Examination.—The nurse, seated in front of the surgeon, nearlv facing him, takes the child on her lap on its back and places its head be- Fig. 3.—Swathed child, method of restraint. tween the surgeon's knees. Then with one hand she holds the child's wrists and with the other she supports the child's back or neck or assists the surgeon by draw- ing down the lower lids (Fig. 4). Usually the surgeon does not need assistance in holding down the lower lids, and the nurse's second hand can be used for supporting the back of the neck or head. Restraint for an Ear Examination or Dressing.— The child's head is covered with a towel which has been moistened to prevent slipping. For this purpose it is well to use an antiseptic solution. The nurse, seated MANAGEMENT OF TROUBLESOME CHILDREN 71 before the surgeon, takes the child on her lap and throws one of her legs over the child's legs and at the same time over her own other leg. With one hand she grasps the child's wrists and with the other she keeps the head firmly held against her own chest with the affected ear toward the surgeon (Fig. 5). Fig. 4.—Method of restraining child in eye examination. Restraint for a Throat Examination.—The nurse, seated before the surgeon, takes the child between her knees, confining its legs by firmly crossing her own around them; then passing her arms under the child's, she places her hands on its forehead, holding the back of its head against her own chest (Fig. 6). This may seem harsh treatment, but it should all be done gently, firmly, and deliberately, without haste, excitement, or anger. It will soon be accepted by the 72 EYE, EAR, NOSE, AND THROAT NURSING patient as inevitable, and will probably result in gradual decrease of resistance and final submission without fur- ther repetition of the procedure being necessary. Shouk I the child struggle so hard that the consequent exhaus- tion seems liable to counteract the benefit, the physician Fig. 5.—Method of restraining Fig. 6.—Method of restraining child for an ear examination or child for a throat examination. dressing. should be promptly informed of the conditions, so that he may take the responsibility of determining whether or not the procedure shall be continued. Close observance of the patient for the purpose of promptly noting and reporting all new evidences or MANAGEMENT OF TROUBLESOME CHILDREN 73 phases of disease is, of course, one of a nurse's chief cares, but especially is this incumbent upon her in chil- dren's cases, where the patients are incapable of supple- menting her efforts in that direction. The mother or other friends of the patient may at times be of assistance to the nurse in gaining the confi- dence and willing control of children who are old enough to understand, but with infants, and generally with older children, the nurse will succeed better in their absence. CHAPTER X THE IDEAL NURSE AND HER CONDUCT IN THE SICK ROOM The qualities of the ideal nurse are so diverse as to be found but rarely in one person—the best woman physically, mentally, and morally. She must have health and the power of endurance that comes from a sound body, for there is only too much truth in the com- mon saying that nursing demands all, not part. Many a pupil nurse, at the close of her term of training, enters upon the practice of her profession a skilled nurse cer- tainly, but already, upon the threshold of her career, handicapped by impaired physical condition. Coupled with sound health there must be physical aptitude and a certain degree of manual dexterity. Her touch should be firm but gentle, light but steady. There is no room in the field of trained nursing for the clumsy, the weak, or the nervous. The ideal nurse must have mental as well as physical power and aptitude. She must have broad intelligence, sound common sense, acute perception, and the ability of correct observation, of just appreciation of the rela- tive importance of what she observes, and of accurate statement. She must be dignified, quiet, neat, tactful, patient, systematic, and capable of unremitting vigil- ance; firm and unyielding, that the orders given may be 74 IDEAL NURSE AND HER CONDUCT IN SICK ROOM 75 strictly executed, but gentle in manner, that she may accomplish her duty without antagonism; soothing, not irritating by her presence, and winning the confi- dence of patients and friends. And to be all this, and to do all that the being it implies, a nurse must have manners, which, as Emerson says, "are the happy ways of doing things." To care for the sick intelligently and to be able prop- erly to utilize this admirable physical and mental equip- ment, the nurse must be trained, not by lectures only, but by having every phase and detail of the work under close actual observation. The regularity and strict discipline of hospital training are of great benefit in assisting a nurse to become punctual trustworthy, patient, obedient, and courteous. How- ever irksome rules and restrictions may sometimes appear, they are indispensable to success, or to any degree of order and comfort where many persons are working together; and especially is this true, when, as is so fre- quently necessarily the case with pupil nurses, many of the workers are quite inexperienced. Hence all nurses who take their profession seriously—and whoever does not so take it has no right in it—should give cheerful obedience to the rules established for their guidance, and should be faithful and punctual in every duty. Perhaps in no disease will good nursing be brought out more than in typhoid fever. Here, it is not a ques- tion of a few days of giving nourishment and treatment regularly, but of many days or weeks of constant and patient care. The nurse's ability to comprehend the doctor's orders and the patient's necessities means every- thing. If she has trained herself to thoughtful observa- 76 EYE, EAR, NOSE, AND THROAT NURSING tion of her patient and to anticipate his needs, it will be of great advantage. He may be, and probably is, only semiconscious, but she can usually succeed in giving the nourishment that is so important. It may take time and patience, but if she fails in one way, she will try another. If the pa- tient is poorly nourished, every effort must be made to prevent pressure sores. With neglect of twelve or twenty-four hours, the work of days may count for nothing. Good nursing also demands that the nurse recognize and be ready for emergencies which may occur in either medical or surgical cases. No time must be lost. The proper thing must be done at once, and her readiness and presence of mind must inspire patient, friends, and attendants with confidence. The surgeon frequently judges the nurse's ability by her promptness and fore- sight in having everything in readiness, and by her capacity to remember his methods and his favorite dress- ings. It is trying to both patient and doctor, and under some conditions disastrous, to have to wait for what should have been prepared in advance. In contagious cases the nurse's knowledge must be sufficient to supplement the physician's efforts for pre- venting spread of the disease. Many of the details are necessarily left to her, and she is responsible for such intelligent execution of the orders given as will make sure that the necessary precautions are taken. In addition to the direct personal care of the patient, good nursing includes perfect ventilation, which must be accomplished without draughts and, with some diseases, without change of temperature. The air should be pure, IDEAL NURSE AND HER CONDUCT IN SICK ROOM 77 wholesome, and cool—68° to 70° F., unless some special temperature is ordered—and sunlight must not be ne- glected. In private as well as hospital work the nurse must be in correct uniform, no rustling skirts, no perfumery, no jewelry; the first duty of the nurse upon going to the house is to find out where everything that is to be needed is kept. Her time belongs to the family employing her, but she has full control of the patient and of the sick room. She should, however, bo as little trouble in the household as possible, remembering that the family is under very great expense, and improvising all she can. She must be gentle, not only of hand, but of voice and of foot; must avoid whispering, using a low quiet tone, and in moving about the house, especially in the night time, make no noise, so that neither the patient nor the family may be disturbed. The patient may be saved many unpleasant experi- • ences by having placed at the foot of the bed a stand, to keep visitors from leaning against it. The nurse must not sit on the edge of the bed; she must avoid defacing furniture with heat or solutions, and must be especially careful in using alcohol, protecting chairs, tables, or other furniture in use. During a dangerous illness the members of the family may feel that this is a matter of no consequence, but afterward it will appear in quite a different light, and many sighs will be caused by needless defacement. The trained nurse should be able to adapt herself readily to the disposition of the patient and to the vari- ous conditions existing in the household. If she is capable and well trained she will at once take charge of 78 EYE, EAR, NOSE, AND THROAT NURSING the sick room and of the patient's diet, and will inspire in the minds of the anxious friends and of the attending physician a feeling of relief that no words can express. Nurses are often considered an expensive luxury; not only, however, does their presence bring with it a great relief of responsibility, but the doctor will have to make many less visits if he has a reliable nurse. As the patient becomes convalescent the duties of the nurse change. The diet is more varied, and more time is required for the dainty dishes or the more nourishing foods, all of which should be prepared and served by the nurse. The patient must not find the convalescent period tedious. Books and magazines are to be read, letters answered, and flowers acknowledged. Indeed, a nurse should be able to fit in anywhere. An excellent hospital nurse may succeed poorly in private work, for the executive ability that means so much in the hospital counts for little in caring for a single patient. The duties of the nurse are many, but the friends of the patient have their duties toward the nurse. If good nursing is desired, the nurse must have proper consider- ation. During the trying nights and days of illness she loses many hours of sleep, many hours of sunshine. Who else works or, if not actively at work, is confined at her post ready for any duty for twenty-four consecutive hours? The care of every case should be so arranged as to allow the nurse a number of hours daily for sleep and recreation. A good motto for patient, friends, and nurse is Charles Reade's "Put Yourself in His Place." CHAPTER XI THE FEEDING AND CARE OF INFANTS In the care of infants and young children there is need on the part of the nurse of keener observation and more accurate interpretation of surface conditions, evidencing welfare or distress, than exists in the nursing of adults, who are able to make known their every want or com- plaint. This is particularly true because of the vast import- ance of the nutritive conditions, data for the estimation of which a nurse must supply the physician from obser- vation alone in many instances. In hospital work it will frequently devolve upon the nurse to furnish the physician with sufficient previous history to enable him to intelligently undertake the care of the child. She should, therefore, know what points are of importance as relating to the nutritive condition and how to elicit these from the mother. Whatever may be the disease which brings the child to the hospital, there can be nothing as important as the proper provision of nourishment for the patient and the correction of digestive disturbances, if they exist. The following points should be inquired into: Is the child nursing? If so, how often by day and by night? How long is the child at the breast? If the child is not nursing, how long was maternal feeding continued and with what success? The reason for stopping this 79 80 EYE, EAR, NOSE, AND THROAT NURSING form of nourishment may bring to light important points in the mother's condition or the general family history. If the child has never nursed or if for a short time only, the exact diet which he has had from birth should be learned. Here a list of the foods given is valueless unless ac- companied by an exact description of how each has been made up; how long it was continued and what success accompanied the various forms of nourishment used. The present digestive condition should be care- fully analyzed, inquiries being made as to: The Appetite.—Did the child take the breast well or poorly? or, if on the bottle, was it taken well or not? If other food besides milk has been given, how was this taken? In case of breast feeding it should be asked whether the child took the breast well, continued to nurse strongly until satisfied, or whether, on taking the breast, he fretted, stopped, and refused further nursing, thus indicating his failure to obtain any nourishment, or, again, whether he nursed strongly for a short time and, evidently becoming overfilled, regurgitated his food. The Gastric Condition.—Has the child vomited? If so, at what times with relation to the ingestion of food, whether immediately following nursing or at irregu- lar intervals between feedings? Vomiting immediately following the taking of the breast or bottle would indi- cate too rapid feeding or too large amounts of food. Vomiting at irregular intervals between feedings would indicate some defect in quality rather than quantity of the food. The vomiting of large amounts forcibly, especially if associated with constipation, should turn THE FEEDING AND CARE OF INFANTS 81 the attention to the possible existence1 of some obstruc- tion at the outlet of the stomach. The vomiting of sour material shortly after feeding would indicate that the meals were too frequent; that is, that remnants of the previous meal still remained in the stomach at the time of the succeeding feeding. Intestinal Condition.—The number of stools daily should be ascertained: their color, their consistency, the presence or absence of mucus; whether there be much gas expelled or much colic from its retention. The normal child should have one, two, or three stools daily. The color will vary with the kind of food taken, being golden yellow in the case of good breast-milk, lighter yellow if cows' milk is given, and darker where cereal decoctions are used. Loose green stools indicate an irri- tation or inflammation of the intestinal tract. They are green because they have been hurried through the body before the normal change from green to yellow has had time to occur. They are loose because their fluid part has not been absorbed by the body. They may be foul because the digestive processes are poor and products of decomposition are present in abnormal amounts. Mucus indicates a congested mucous mem- brane. It is to be remembered that after the use of castor oil mucus is always present in the stool; that is, the oil's action on the intestinal mucosa is to stimulate its secretion of mucus. Stools.—The proper description of a stool should embrace the following points: Size.—A stool is very large, medium, small, or consists in merely a stain upon the napkin. Consistency.—It may be homogeneous or curdled, 82 EYE, EAR, NOSE, AND THROAT NURSING smooth or lumpy, dry, hard and crumbly or loosej thin, and watery. Color.—This may be a golden yellow, white, light yel- low, brown, green, black, or any combination of these. Odor.—A stool may have the normal odor, may be merely offensive, or have the foulness of decompo- sition. Curds.—They may be present or absent, large or small, white or yellow. Mucus may appear in shreds, masses, or casts. Frothiness in a stool should always be reported. Having familiarized herself with the patient's previous condition, the nurse should learn to recognize and intel- ligently interpret certain surface indications which mark the varying types of children which may come under her care. The child may be large, normal, or small for his age; he may be premature. He is well nourished, thin, or emaciated, or he may present some local acute disease which is lowering his general bodily resistance. If the child be premature, weak foods and extra pre- cautions against exposure are indicated; if the child is well nourished and has had nothing but breast feeding, the change now to artificial food should remind one that a weaker mixture is necessary than the age and size of the child would otherwise demand. If the baby has been badly started on inadequate breast milk, later supple- mented by poor milk mixtures or general table food, the digestive tract will again be unable to take a food cal- culated to nourish one of his age. The child otherwise normal, who is suffering from an acute illness, also must be given food and mixtures weaker than would otherwise THE FEEDING AND CARE OF INFANTS 83 be provided. The age of a child does not alone deter- mine the strength of food suitable for him, but careful consideration must be given to the above-mentioned factors. The Normal Child.—In order to appreciate the ab- normal, one must possess a certain knowledge of the normal, child. A full-term child weighs at birth from 7 to 1\ pounds. The head is 1 inch larger than the chest. He is 20 inches long. The average gain in weight is 5 to 8 ounces weekly the first three months, less for the second three, and still less for the latter half-year. At three months he should weigh 12| pounds; at six months, 15| pounds; at one year, 20 pounds. It is important that the relation of the head and chest during the first two years should be borne in mind. At birth the head and chest are nearly equal. The head is greater in circumference until the second year, from which time on the chest should be the larger. This is significant in two ways: a small head in early life points to some arrest of the brain's development; later, a relatively small chest is an important sign of nutritive disorders, a common example being rickets. At one year the normal child has six teeth; at one and one-half years, twelve teeth; at two years, sixteen teeth. The condition of the fontanel is frequently an aid to the determination of the general physical condition. It should be closed at eighteen months. Delay in its closing points either to retarded bone formation or in- tracranial pressure. A sunken fontanel accompanies low vitality and malnutrition, while a tense bulging fon- tanel is almost invariably found with meningitis and is frequently present in febrile conditions. The normal 84 EYE, EAR, NOSE, AND THROAT NURSING child should support the head strongly at four months and be able to sit alone at eight months. He usually walks freely at about the fifteenth month. Objects are recognized at about the fifth month. Hearing is well established during the first week. Single words may be said at the end of twelve months, short sentences toward the end of the second year. Infant Feeding The question of infant feeding is one that cannot well be condensed to meet the limited scope of this volume. The outward signs of good and bad feeding should, how- ever, be quickly recognized upon intelligent observa- tion of the action of the stomach and intestines. There are three classes of food stuffs which enter into the mate- rial used in nourishing children, and as there are three classes of foods, so there are three distinct classes of indigestion, each induced by its own particular cause. The first of these three' classes to be considered is the fats. These are contained in the cream of milk, are necessary as heat producers, but do not provide directly for the building up of body tissue. They are somewhat laxative and are, more often .than the other two types of food, the cause of indigestion. The first evidence of overfeeding with cream or fat is gastric irritability. This shows itself early by the regurgitation of small quantities of food. Later there may be loose, frequent stools, sometimes light colored, other times green, usu- ally offensive, or if the condition has gone on to a marked extent, constipation may result. The second class of food stuffs is the carbohydrates, including starches and sugars. The function of sugar THE FEEDING AND CARE OF INFANTS 85 and starch in nutrition is similar to that of fats, but they are, to a certain extent, tissue builders. If given in too great quantities their action is chiefly to produce intes- tinal fermentation with foul, acid, slimy stools. Most of the proprietary foods rely upon carbohydrates for their nutritional value. The third class of food stuffs is represented by the proteids, which are commonly spoken of as making up the curd of the milk. These are the source of the material which the body uses in making up its substance. The evidence of indigestion from them is usually intestinal; that is, we get our warning from the condition of the stools, which are frequently loose, green, and containing much mucus. Colic is frequently present. Breast Feeding.—Much can be done to regulate the composition of the secretion of the human breast. Since the first or so-called "foremilk" is poorer in fats than the latter part or "strippings," the other elements being fairly constant, it is possible to reduce the amount of food given by allowing the child to nurse from both breasts rather than thoroughly emptying one side alone. The diet of the mother has a direct bearing upon the condition of the milk. It should consist in three regular meals made up of simple nourishing foods, and avoiding pastry, rich desserts, sour fruits, and salads. In general, poor nourishment on the part of the mother means poor milk; too liberal a diet, a milk erratic in its composition or too rich for infant digestion. Regular exercise is very important in sustaining a proper milk secretion. Care should be taken to provide the mother with uninter- rupted rest at night, for upon her nervous condition, 86 EYE, EAR, NOSE, AND THROAT NURSING more than upon anything else;, depends her success as a wet nurse. The mother's bowels should be regulated and kept open by the use of cooked fruits, massage, exercise, ene- mata, and, lastly, drugs. If the milk be scanty and poor, partial bottle feeding should be instituted, the mother given a diet rich in meats, cream, and milk. If the milk be scanty but rich, the fluids given the mother should be increased and the child given a bottle after nursing containing a weak formula. If the milk be abundant, but poor, less fluids are needed by the mother and a diet rich in meats and cream. The breast should be emptied of part of its contents before the child nurses, in order that he may have the richer late milk. If the milk be abundant and rich, the mother's diet should be somewhat restricted, exercise insisted upon, and the child given before each nursing a small amount of barley- water, lime-water, or a very weak milk mixture to dilute the milk which he will later get from the breast. If the secretion from the breast varies greatly in quality and quantity, an early loss of the milk may be expected. For the first two or three days after birth there is little milk secreted, but a laxative fluid (colostrum) is present, whose purpose is to clear out the intestinal tract of the child and prepare it for the reception of its future nourishment by mouth. During these first three days the child should be put to the breast every four hours to stimulate the milk secretion, and should have warm boiled water in dram doses at two-hour intervals. From birth to the eighth month the feedings should be given every three hours from 6 a. m. to 10 p. m., with one feeding during the night. From the eighth month on the feeding should THE FEEDING AND CARE OF INFANTS 87 be every four hours from 6 in the morning until 10 at night. The midnight feeding should be stopped by the eighth month, or as much before this as the baby's appe- tite and condition will allow. As the child develops, the capacity of the stomach increases correspondingly. The aim should be to give such quantities as will fit it at each feeding, and arrange such intervals as will allow its complete emptying before the time for the next meal. The amount that the child gets from the breast is, of course, controlled by the length of time that he is allov/ed to nurse; the kind of food that he gets is controlled by (a) giving him the alternating breasts, (b) the "fore" or later milk from each breast at each feeding, (c) the modification of the mother's diet, (d) lengthening of the feeding intervals, and (e) dilution of the milk by giving barley- or lime-water before nursing. Weaning may be accomplished suddenly or gradually. The latter is preferable if possible. Sudden weaning is necessary in case of illness on the part of the mother or when the baby persistently refuses the bottle so long as any breast feeding is allowed. Gradual weaning may become necessary because of the too great strain on the mother or because of her inability to furnish the proper food. Temporary weaning may be advisable for pur- poses of diagnosis or to tide over a period during which the mother's milk may be temporarily unfit for use. When a baby is taking part breast and part bottle feed- ing it is difficult to determine, in case of digestive dis- turbance, which form of food may be the cause. In such a case it is advisable to stop nursing entirely for from twenty-four to forty-eight hours, giving the bottle alone during this time. If the symptoms of indigestion are 88 EYE, EAR, NOSE, AND THROAT NURSING improved, it is fair to suppose that the breast feeding has been at fault and permanent weaning may then be recom- mended. If, on the other hand, no improvement is seen, the cause of the disturbance must be sought for in the character of the bottle feeding. During this time the flow of milk should be stimulated and the mother's com- fort provided for by the use of the breast-pump, at such times as the baby would have otherwise been nursed. Temporary weaning may be necessary for a few days preceding and during the menstrual period. This is not common, but it sometimes happens that serious injury is done to the child at these times. The symptoms giving warning of this necessity are severe vomiting, numerous stools with much mucus, and colic. The treatment aside from weaning is free purgation with castor oil and fre- quent bowel irrigations. In gradual weaning there should be introduced one or more bottles a day in place of breast feeding, or the breast feeding may be preceded or supplemented by bottle feeding. If weaning is done before the ninth month, the child should be put upon the bottle; if after the ninth month, it is easier to wean directly to the cup. If the child refuses the bottle, it is always best to let hunger do what argument, coaxing, or force1 will never accomplish. The child should not see; the mother at or near meal time, the bottle or cup should be presented to the child and he shoulel be allowed to take it or refuse it as he wishes. Nothing, however, should be given until the time for his next feeding has arrived. A child will quickly learn from experience that the meal hour is the only time when food is to be had and will accommodate himself to the necessities of life. THE FEEDING AND CARE OF INFANTS 89 Breast feeding should not be continued longer than to the ninth or tenth month. Bottle feeding should cease at the twelfth to the fourteenth month. If delayed later than this the difficulties will greatly increase, as a child who has become inseparably wedded to the bottle will often refuse milk offered in any other way throughout the rest of his childhood. Maternal nursing is to be conserveel and protracted to the greatest possible extent. Weaning, however, should be accomplished where neces- sary, before1 the mother is worn out and the child under- nourished. Artificial, Substitute, or Bottle Feeding.—There is only one substitute for nature's food; that is, milk; and the milk most available for use is that of the cow. Milk is rich or poor according to the percentage of its constituent parts. Porevntage feeding means artificial nourishment on mixtuivs prepared to provide certain percentages of fat, carbohydrates, anel proteids, which are made to vary according to the needs of the individual to be fed. This is accomplished by the use of the lower or higher levels from the quart bottle or by different mix- tures of plain milk anel cream. Fats, sugar, and proteids occur in breast milk in varying proportions or percentages, accoreling to the duration of lactation; that is, the age of the child which it is nourish- ing; low percentages or weak food, early; high percent- ages or stronger food, later. The fats are at first usually about 1 per cent, and increase with the age to 3.5 to 4.5 per cent. The sugar varies less; it is at first high, 6 to 7 per cent.; slowly dropping to 4.5 to 6 per cent. The proteids range from 0.3 per cent, in the early days to 3 per cent, in late lactation. In cows' milk the fats are about 90 EYE, EAR, NOSE, AND THROAT NURSING 4 per cent.; sugars, 4.5 per cent.; proteids, 3.5 per cent.; these percentages varying greatly, not with the age of the milk, as in the case of the human see-ret ion, but according to the breed and care of the cows pro- ducing it. The foregoing figures will represent the percentage's of a good mixed or herd milk. Jersey milk gives us a much higher fat, the percentage here being 5 to 6 per cent. This difference of 1 to 3 per cent, between an ordinary herd milk and Jersey seems small, but that it is of great importance to know the kind of milk which is being used is shown by a comparison of a mixed and pure Jersey milks, the latter being about twice1 as rich as the former. Wliile the difference to the adult would be simply a little more satisfaction in drinking a glass of the latter, the changing of a baby from a mixture made up of one to the same modification of the other would mean a sudden doubling of the total amount of food taken in a day? and would result almost inevitably in a serious digestive upset. One should, then, know something of the source of the milk which is in use in order that it may be modi- fied much or little, according to its percentage of fats and proteids; but more than this, it should be known that this milk has been taken from he'althy cows by clean milkers, into sterile pails, and that it has been quickly cooled and kept cool to keep down the bacterial content. This bacterial content in milk makes one of the greatest elifferences between it and mother's milk, the latter being a perfectly sterile fluid. Milk is spoken of as 4, 7, 10, 16 per cent., according to the amount of fat which it contains, and in making up mixtures for percentage feeding use is made of some THE FEEDING AND CARE OF INFANTS 91 one of these, according to the desired relation between the fats and proteids. With a quart bottle of average milk it is possible to obtain by using various levels any of the above-mentioned strengths of milk. The top 10 ounces removed from the quart contain 10 per cent, of fat; the fat-content is three times as great as the proteid. The top 16 ounces contain 7 per cent, of fat, the fats here being twice the proteids. In the whole mixture from the bottle, fats and proteids are about equal. It is not possible to set elown fixed formulas for each period of the first twelve months. The following table is intendeel to serve only as a general guide in making up anel increasing the milk mixtures: Ingredients. Resulting Percentages. . •6 c S "5 SJ! Age. M 2 « S3 1 oz. 16 oz. l. o2 ■S a 6. '3 o a « 1st week . 3oz., -,c;v. 1 oz. .5 1 to 2oz. 3hrs. 2d week . 6 oz., 1% 1 oz. 1 oz. 13 oz. 2. 6. 1. 2 to 3 oz. 3hrs. 1 month . 7 oz., 7%. 1 oz. 8 oz., 4%. 1 oz. 1 oz, 12 oz. 2.50 6. 1.25 l3to4oz. 3 hrs. 3 months. 1 oz. 11 oz. 1.60 6. 1.40 5 to 6 oz. 3 hrs. 5 months. 10 oz., 4%. loz. 1 oz. 9 oz. 2. 6. 1.75 6 to 7 oz. 3 hrs. 8 months. 13 oz., 4%. 1 oz. 1 oz. 6 oz. 2.60 6. 2.40 7 to8oz. 4 hrs. 9 months. 15 oz., i%.\ 1 oz. | 1 oz. 4 oz. 3. 6. 2.80 |8to9oz. 4 hrs. 12 months. 16 oz., i%.\ 1 oz. 1 oz. 3oz. 3.2 6. 3. IHolOoz. 4 hrs. If in place of any of the above, skim-milk be used, and the formula be left otherwise the same, mixtures contain- ing very low fat percentages are obtained. Formulas made from the top third of the quart are seldom advisable. The high fats such as these formulas provide are dangerous, especially in hot weather and to children suffering either from digestive or general dis- eases. The formulas made from the top half of a quart bottle 92 EYE, EAR, NOSE, AND THROAT NURSING of milk containing 7 per cent, of fat may be1 safely given infants under three months, but, in general, whole milk mixtures are to be preferred. Children older than this do better upon milk mixtures made from plain or mixed milk. It is to be remembered that the object in utilizing these milks of varying composition and in employing formulas representing different modifications is to over- come in part divergences between human and cows' milk, and also to meet the digestive idiosyncrasies of the individual case. Lime-water, 1 oune-e to ('very 20 ounces of food mix- ture, or sodium bicarbonate, 1 grain to the ounce, are added te> the formulas to provide for the proper alkalinity which is lacking in cows' milk. Sugar, 1 ounce to 20 ounces of total food, is added to raise the carbohydrate content of the cows' milk to the neeeled point. The appended table indicates the amounts of milk suitable for use1 at various ages. The amount of the fooel should be in the early months from 1 ounce eluring the first week to 4 ounces at the1 end of the1 third month. A chilel of six months should take 5 to 6 ounces at each feeding; at eight months, 7 to the light, as the silver is soon changed to the black oxid of silver. It should be kept in dark brown or blue bottles. Alum (Sulphate of Aluminum and Potassium).—This is found in the volcanic regions of Southern Italy, ready formed in the earth. It has to be dissolved out and purified and then allowed to crystallize by the evapora- tion of the water containing it in solution. It is also manufactured from minerals found in the same regions, which contain the constituents of alum, and, therefore, are called alum ores. Alum is now manufactured by the direct combination of its constituents, which may be obtained from different sources. Alum is a very powerful astringent when applied to the mucous membrane of the eye or elsewhere. It coagulates blood rapidly and is used as a styptic in nose- bleed or other bleeding from mucous surfaces. It is frequently applied to the conjunctiva in the form of the solid crystal, which is cut in a convenient form, and for convenience in applying may be set in a handle. Zinc sulphate and copper sulphate in very weak solu- tions act as astringents. In stronger solutions they are irritants. Tannin or Tannic Acid.—This is an acid extracted from nutgalls. The nutgalls are vegetable excrescences in the leaves or bark of certain plants, especially oaks. These excrescences are produced by the deposit of an egg of an insect. Galls are generally nearly spheric in shape and of a size varying from the size of a pea to that of a hazelnut. Nutgalls are sometimes called oak- apples. The nutgalls are ground to fine powder and treated with ether, which extracts the tannin. Tannin is COMMON REMEDIES USED IN TREATMENT OF EYE 123 easily dissolved in water or glycerin. It is a powerful astringent when applied to mucous surfaces, such as the conjunctiva, the gums, or the uvula. Tannin coagulates albumin very effectively. In the eye, tannin is generally used in solution in glycerin. This solution is sometimes made as strong as 25 per cent. Generally, however, it is used in the strength of 2 to 10 per cent. Acetic Acid, Dilute (Acidum Aceticum Dilutum).— Three strengths of acetic acid are given in the United States Pharmacopoeia. These are the glacial acid oi concentrated acetic acid, containing nearly 99 per cent. of pure acetic acid. The commercial acetic acid is considerably weaker, as it contains only 36 per cent, of absolute acetic acid and 64 per cent, of water. The third preparation is the dilute acetic acid, which contains only 6 per cent, of pure acetic acid. It is, therefore, important for the nurse to know which of these three preparations is being dealt with. The glacial acid is caustic and is employed for removing warts. Even the commercial acid is a mild caustic. The dilute acid is hardly stronger than vinegar, which consists essentially of acetic acid and water, and may be substituted for dilute acetic acid in those cases where acetic acid is indicated. Subacetate of lead, in the solution known as liquor plumbi subacetatis, is astringent, but is used only as an external application. It was formerly much used, largely diluted (1 or 2 per cent.), as an eye-wash, but it was dis- covered that in case of ulcer or abrasion of the cornea there was danger that the lead would form a white opacity, and so its use has been given up. Adrenalin and suprarenalin are preparations made 124 EYE, EAR, NOSE, AND THROAT NURSINC from the1 suprarenal glands of cattle and sheep. They act as astringents without the irritating properties of most of the astringents. The usual preparation is the adrenalin chlorid or the suprarenalin chlorid, and this is put up in solution of the strength of 1: 1000. A drop of the preparation dropped into an inflamed eye will cause a blanching of the eye in a minute or two. This blanching is due to the contraction of the small blood- vessels, anel the effect lasts for an hour or two and is not often followed by a reaction. If an eye which is to be operated upon under eocain is inflamed, the eocain will act more effectively if the congestion is first removed by instilling adrenalin or suprarenalin chlorid. The bleeding during an operation may be greatly diminished or wholly avoided by the use of these solutions. IRRITANTS The term " irritant," when applied to remedies used in the eye, refers to those which when applied locally to the conjunctiva cause more or less inflammation. The object of such applications is to cause an increased flow of blood, anel by this means absorption is increased. When an ulcer becomes indolent, with no tendency to heal, the application of an irritant may at once start the healing process. In the case of granular lids the repeated application of irritants may cause the1 granu- lation to be absorbed graelually. The term irritant is also applied to certain drugs taken internally, as an "irritant poison." Following are some of the irritants useel in the eye: Yellow Oxid of Mercury Ointment.—The official oint- ment contains 10 per cent, of the yellow oxid. In the COMMON REMEDIES USED IN TREATMENT OF EYE 125 eye, however, it cannot be used in this strength. The strength for the eye varies from 1 to 3 per cent. The yellow oxiel of mercury is a very fine powder, and shows no crystalline particles even when examined under the microscope. The yellow oxid of mercury differs from the red oxid in being in a much finer state of division. The yellow oxid has nearly displaced the red oxid in eye treatment, because the red oxid fre- quently causes more irritation than can be borne. This is perhaps due to the fact that no matter how finely the red oxid is divided it still shows crystalline particles. The yellow oxid of mercury ointment is used in cases of ulcer of the cornea and in blepharitis marginalis (inflammation of the eyelids). Calomel or mild chlorid of mercury is also used as an irritant to stimulate the healing of ulcers of the cornea. Sulphate of Copper or "Bluestone."—This occurs in nature in the water which flows through copper mines. When this water is evaporated the sulphate of copper is deposited in the form of crystals. It may also be obtained by heating together copper and sulphuric acid. The product obtained by heating these together is dis- solved in hot water and the crystals of sulphate of copper form when the water is evaporated and cooled. For use in the eye the crystals are cut to a convenient form and mounted generally on wooden handles. In cases of trachoma or granulated lie Is the crystals of bluestone are applied directly to the conjunctiva. This application is exceedingly irritating, but results in the gradual disappearance of the granulations. The granulations are not burned away, as some suppose, but the irritation of the bluestone causes a gradual absorption. 126 EYE, EAR, NOSE, AND THROAT NURS1NC Sulphate of zinc acts similarly to sulphate of e-opper, but is less irritating. COUNTERIRRITANTS "In medicine, a substance or an appliance employed to produce an irritation in one part of the body in oreler to counteract or remove a morbid conelition existing in another part. The term is more specifically applied to such irritating substances as when applieel to the skin redden or blister it or produce pustules, purulent tissue's, etc." (Century Dictionary.) The use of counterirritants in eye diseases is very limited. In certain deep-seated and painful inflamma- tions they are occasionally used. The point of applica- tion is usually the temple or sometimes back of the ear in the mastoiel region. The commonest counterirritants are mustard, can- tharides or Spanish flies, turpentine, croton oil, tartar emetic, tincture of iodin, and the actual cautery. Setons, which were formerly used, have been given up. Caustics "In medicine, any substance which burns, corrodes, or disorganizes the tissues of animal structures. An escharotic." (Century Dictionary.) The word "caustic" is derived from a Greek word which means "to burn." Nitrate of Silver or Silver Nitrate.—This is very fre- quently used either in strong solution, or in the form of the solid crystals, or mixed with potassium nitrate. This last is sometimes cast into a stick, which goes under the name of the "mitigated silver nitrate." Silver COMMON REMEDIES USED IN TREATMENT OF EYE 127 nitrate in solid form was formerly called by surgeons "lunar caustic." A convenient method of using silver nitrate as a caustic is to heat an applicator made of iron or other metal and fuse a crystal of silver nitrate upon the end. The bead of silver nitrate formed in this way may be as small as desired, and has the advantage that it is not as brittle as the crystals. Caustic potash or potassium hydrate is a hard white brittle substance which is easily dissolved in water. When exposed to the air it soon absorbs moisture from it and deliquesces or "melts." It must, therefore, be kept in a bottle tightly corked, so as to exclude the air. If caustic potash is applied to the skin the skin is elcstroyed (cauterized) at the point of application. In case of entropion (turning in) of the lower lid the con- dition can sometimes be remedie'd by applying caustic potash to the skin below the lid, in a line parallel to the edge of the lid and a few millimeters from the edge. The scar formed in healing draws down the edge of the lid so that the defect is remedied. If the effect is not sufficient at the first application, a second may be made. Caustic soda or sodium hydrate has an action similar to that of caustic potash. Carbolic Acid.—In the treatment of corneal ulcer carbolic acid is frequently used as a caustic. For this purpose the carbolic acid is used in full strength. Tincture of iodin acts as a much milder caustic in treatment of ulcer of the cornea. Bichlorid of mercury in strong solution is a caustic, but its action is limited for fear of poisonous effects. The Actual Cautery.—This consists in burning or cauterizing the tissues by the application of heat. For 128 EYE, EAR, NOSE, AND THROAT NURSING the eye a e-onvenient method is to heat a probe red hot in the1 flame of an alcohol lamp. It is best to use1 a probe made of platinum, as this may be heated again anel again without being corroeleel. Another method of applying the actual cautery is by nutans of a platinum tip heated to a red or white heat by the passage1 of a current of electricity. This is called the "galvanocau- tery." A third method is by means of a tip heated by burning naphtha vapor. The apparatus most fivquontly used fortius is the co-called "Paemelin cautery." This form of cautery is more useful in other parts of the body where the surface to be cauterized is more extensive. Anesthetics and Anodynes The word " anesthetic " is derived from a Greek worel meaning "without sensation," anel the word " anodyne'' from another Greek word meaning "freeing from pain." Both worels are use>d either as adjectives or nouns. Thus, we speak of an anodyne poultice or the anesthetic effect of ether. As a noun, we1 say: " Hot water is an anodyne*; ether is an anesthetic." Anesthetics not only take away sensation, but fre- quently relieve pain at the same time. Anodynes may relieve pain without taking away sensation. They are not given unless pain is present. Anesthetics are frequently given when there' is no pain in oreler that the patient may undergo an operation without suffering. According to this definition, anesthetics are anodynes, but anodynes are not anesthetics, except that in the case of sonie anodynes, as opium and its preparations, a sufficient amount may be given to cause anesthesia— i. e., freedom from sensation as well as freedom from pain. COMMON REMEDIES USED IN TREATMENT OF EYE 129 Local Anesthetics.—Anesthetics may be divided into two classes—local and general. Local anesthetics are those which produce a loss of sensation only in the part to which they are applied. On a mucous surface they may be applieel with a dropper, as is generally done in the eye, or with a bit of cotton wounel on a probe or applicator anel saturated with the solution, as is gen- erally elone in the nose anel throat. In other situations the local anesthetic may be injected under the skin with a hypodermic syringe, as the local anesthetics have little effect upon a surface covered with skin. When injected into the flesh in this way the solution is soon taken up by the blood and distributed through the system. It is, therefore, necessary to work rapidly before the anes- thetic effect is lost, and, moreover, care must be taken not to inject a quantity sufficient to do harm consti- tutionally. The local anesthetic which is most frequently useel in the eye is eocain. This is an alkaloid derive1* 1 from the plant coca erythroxylon found in South America. There are three very different plants which are often confused on account of the similarity of names. That on which the cocoanut grows is a tall palm tree, called cocoa-palm. The second is a smaller evergreen tree, called the cocoa tree. This is the tree which produces the cacao or cocoa from which chocolate is made. The third is the coca erythoxylon. This is a bush or shrub anel the alkaloid eocain is extracted from the loaves. The preparation generally used is the hydrochlorate of eocain, which is in the form of white crystals. For use in the eye these crystals are dissolved in water. The strength of the solution of eocain for use in the eye 9 130 EYE, EAR, NOSE, AND THROAT NURSING is generally from 2 to 4 per cent. In some cases an S per cent, solution is used. The solution is dropped into the eye at intervals of five minutes for fifteen minute's to a half-hour. The effect of the eocain is to whiten the conjunctiva by contracting the small blood-vessels and forcing out the blood. The pupil is also dilated and the eyelids are drawn wide open, so that the eye sometimes has a staring appearance. The anesthetic effect of the eocain passes away generally within half an hour, al- though the pupil may remain dilated for some hours. The dilation of the pupil is not associated with loss of the power of accommodation or, at the most, the loss of accommodation is very slight. In case the eye is inflamed, adrenalin or suprarenalin solution may be first dropped into the eye to drive' out the blood, anel then the eocain will act more effectively. Sometimes cocain-poisoning is encountered, but this happens very rarely in eye practice, because the amount used is so very small. The symptoms of cocain-poison- ing are given uneler the heading Nurse's Duties in Emer- gencies, on p. 66. Holocain hydrochlorate and eucain hydrochlorate are synthetic compounels used in a similar manner and hav- ing an effect similar to eocain hydrochlorate. Freezing.—The rapid evaporation of ether and other volatile liquids produces intense cold, and local anes- thesia is produced by directing a spray of ether upon the surface to be anesthetized. The effect of the cold is to benumb the nerves of sensation over the part to which the spray is applied. This method of producing anes- thesia cannot be applied to operations upon the eye. General Anesthetics.—These differ from local anes- COMMON REMEDIES USED IN TREATMENT OF EYE 131 thetics in that they not only produce a loss of sensation but also a loss of consciousness. In certain operations on the eye this is a serious disadvantage, especially in operations upon the muscles of the eyes. When these operations are done under eocain the patient retains consciousness and the muscles are under the control of the will. Under a general anesthetic the eyes wander about without control, and in operations upon the muscles the operator cannot judge accurately as to the effect ob- tained. The nausea and vomiting which frequently follow the administration of ether may cause a hemorrhage, or loss of vitreous after such an operation as cataract, and so ether is never used for such an operation unless the patient is uncontrollable. Nitrous oxid gas is used for certain operations requir- ing only a short time. It is also used to anesthetize the patient before the administration of ether. As soon as the patient is unconscious from the nitrous oxid gas, the ether is applied and the time of ether anesthesia is thereby shortened. Chloroform is preferred by some surgeons to ether in cases where there is no evidence of disease of the heart. Anodynes.—In medicine, the word "anodyne" is applied to any drug or application used to relieve pain. In certain painful conditions of the eye the local anes- thetics may also act as anodynes by relieving the pain. Heat and cold are often used for the relief of pain— i. e., as anodynes. Action: Numbing nerve terminals and reducing congestion. Tincture of opium was formerly used as a local ano- dyne, but now is rarely so used. Opium and its prepara- tions are, however, used internally for the relief of certain 132 EYE, EAR, NOSE, AND THROAT NURSING painful conditions. Morphin sulphate, an alkale)iel e>f opium, is sometimes administered hypodermie'ally when the local anodynes fail. Poultices are anodyne in their action, but are not now used, as in many cases eyes have' been destroyed by their use. Mydriatics and Myotics The word "mydriatic" is derived from a Greek word meaning "enlargement of the pupil." The term is applied to those drugs which have1 the effect of producing elilatation of the pupil. When used in the treatment of the eye they arc usenl in solution and dropped into the eye with a medicine-dropper. Atropin Sulphate.—This is the alkaloiel of the drug belladonna. This word belladonna is from two Italian words meaning "beautiful lady," because the drug has been useel for the purpose of enlarging the pupil to give brilliancy to the eyes. The1 botanic name of the plant is Atropa belladonna, anel from these two are de- rived the names of the drug, belladonna anel its alkaloid atropin. Atropin sulphate1 is used in the strength of 1 per cent. for adults, and \ ro \ of 1 per cent, for children. As the drug is extremely poisonous it must be used with great care and kept where it cannot be accidentally swallowed. The drug is so powerful that in a very susceptible1 patient yfor gr. may produce dryness of the throat anel ^ gr. may produce symptoms of poisoning. When used in the eye local poisoning sometimes follows. Even a single drop of a ^ per cent, solution will sometimes cause local poisoning. The symptoms of local poisoning from atropin are a redness and thickening of the lids espe* COMMON REMEDIES USED IN TREATMENT OF EYE 133 cially the lower lid. The appearance resembles that of ivy-poisoning or of eczema. When this occurs it is necessary to give up the use of the drug, for the poison- ing will recur every time the drug is used. The applica- tion of carbolizeel vaselin is perhaps the best treatment for this local poisoning (United States Dispensatory). When general poisoning occurs the symptoms are: Dryness of the mouth and throat, flushing of the face, burning in throat and stomach, great thirst, difficulty in swallowing, nausea anel rete-hing, loss of vision, diz- ziness, anel delirium; sometimes violent gestures anel fits of laughter, followed by coma, a feeble pulse1, cold hands and feet, twitching of muscles, deep coma, and some- times convulsions followed by death. Several other mydriatics are used at times insteael of atropin, but they need only be mentioned here. Atropin, hyoscin, hyoscyamin, and duboisin all have the same chemic formula, but there are some slight differ- ences in certain characters, and especially in their effects as mydriatics, some acting more quickly than others and the effect passing off more quickly with some than with others. These are all derived from plants, Atropa belladonna, Datura stramonium, Hyoscy- amus niger, and Duboisia myoporoides. Euphthalmin and homatropin are synthetic prepa- rations which dilate the pupils quickly, and the effect passes off within twenty-four hours. Cocain hydrochlorate also acts as a mydriatic, but does not, like the other mydriatics, paralyze the ac- commodation. Myotics.—These are remedies which are used to con- tract the pupils. The most important one is eserin, used 134 EYE, EAR, NOSE, AND THROAT NURSING in acute glaucoma, which is generally used in the strength of 1 to 2 gr. in 1 ounce of water. The other myotic which is commonly used is pilocarpin hydrochlorate, used in chronic glaucoma, which is much less active in its effects than eserin. Other Remedies.—Zinc Oxid.—For the eczema which accompanies phlyctenular keratitis an ointment contain- ing salicylic acid with zinc oxid is very satisfactory. The following is commonly used: Acid, salicyl............................... gr. x; Zinc oxid \..............................M 3ij; Pulv. amylj Petrol alba................................. 3j—M. Zinc sulphate, 1 per cent., is a mild antiseptic used in chronic forms of conjunctivitis, particularly angular con- junctivitis. It may either be freely instilled every three hours or used in an eye cup. When the latter method is used h of 1 per cent, has proved satisfactory. Ethylhydrocuprein (optochin), 2 or 4 per cent., is a very effective germicide in conjunctivitis or keratitis due to the pneumococcus. Mercurocrome, 2 per cent., is a valuable aid in clearing up obstinate attacks of conjunctivitis. Leeches.—In certain cases of inflammation, especially of painful inflammation of the eye, great relief is obtained by applying a leech to the temple and drawing away blood from the inflamed tissues. To force the leech to bite at the point desired it may be placed in a test-tube, the open mouth of which may be held against the temple, and withdrawn when the leech has taken hold. Another method is to wrap the leech in a towel, leaving only its COMMON REMEDIES USED IN TREATMENT OF EYE 135 head free. In case the leech does not bite readily, the skin may be scarified at the point where it is to be applied. REFRACTION In the chapter on Anatomy you learned that those whose eyes are perfectly formed usually by the time they reach forty-five years of age require glasses for reading to compensate for the loss of elasticity of the crystalline lens. In those whose eyes are abnormal glasses are re- quired either to improve the sight or relieve headache and eye-strain. The near-sighted (myopic) individual, whose eyeball is so long that the rays of light cross before they reach the retina, usually discovers the condition by noticing that others see distant objects which to him are but a blur. The short eye (hyperopic), or eye with un- equal curvature of the cornea (astigmatic), may cause headache and eye-strain which may even disturb the general nervous system and the sufferer never suspect the source of the trouble, because the sight is perfect. The most satisfactory method of determining the amount of refractive error is by the use of a cycloplegic, such as atropin or homatropin, to suspend the action of accommo- dation. A retinoscopy is then done, followed by the trial case. CHAPTER XIV COMMON REMEDIES (CONTINUED) Heat and Cold.—These are very effective remedies in various conditions of the eye. Their use1 as antiseptics has been described in Chapter II under the heading Antiseptics, and as Anodynes in the1 preceding chapter. Heat.—In addition to the uses referred to as antiseptic and anoelyne, heat is also used to reeluce inflammation, and to bring about the absorption of the products of inflammation anel of blood which has exuded into the tissues. Heat may be applieel either moist or dry. Dry Heat.—Some of the methods of applying dry heat which are used in other parts of the body are not avail- able for the eye on account of their weight. Even the hot-water bag has a very limited use on this account. In some cases a small bag may be used. Instead of the hot-water bag a coil of rubber tubing is sometimes used, through which a stream of hot water of any desired temperature is kept' flowing. Cloths folded several thicknesses or cotton wool may be heated in the oven and laid on the eyes. These, of course, must be changed as often as necessary to keep up the proper temperature. Where the electric current is available heat may be applied by electric heating pads, which can be attached by means of a cord to any electric-lamp socket. The degree of heat may be modified by placing as many 136 COMMON RE.MEDIES USED IN TREATMENT OF EYE 137 layers of cloth as may be necessary over the eye, so that the skin may not be burned. Moist Heat.—This may be applied by dipping cloth, gauze, or pledgets of cotton in water at the temperature of about 120° F. and laying them over the eye. The Fig. 20.—Use of the electric heater in keeping at the proper temperature the water for heating the pads in applying moist heat. excess of water should be wrung out before applying to the eye. The water may be kept at a nearly uniform temperature by placing an alcohol lamp under a basin containing the water. The basin may be placed upon any support to holel it at the proper distance above the lamp, and the size of the lamp flame may be regulated 138 EYE, EAR, NOSE, AND THROAT NURSING by raising or lowering the wick so as to increase; or di- minish the heat. A bath thermometer shoulel be at hand, so that the temperature of the water may be kept at the proper point. Fig. 20 represents the use1 of the electric heater in kevping the water at the proper tem- perature and the manner of applying the pads, which in this case were of absorbent cotton, and the nurse is represented as squeezing out between her hands the excess of water. There should be sufficient thickness to the cloths or cotton to retain the heat for a reasonable time. These should be changeel on the eye every thirty to sixty sec- onds, and the application, as a rule, should not be kept up more than ten or fifteen minutes at a time, and not more than once an hour, for fear of blistering the skin. This danger may be lessened by applying vaselin to the lids before using the hot water. A piece of oiled silk may be laid over the eye as an additional pre- caution. Cold.—The use of cold as an anodyne has already been referred to. Following are the me'thods generally used in applying cold to the eye. Dry Cold.—The best mode of application of elry cold is by means of the rubber coil, through which ice-water or water of any desireel temperature may be allowed to flow. A metallic coil, called the Leiter coil, made of proper size and form to place over the eye, may be used in place of the rubber coil. In using the metallic coil a piece of gauze should be placed over the lids, so that the metal shall not come in direct contact with the skin. Sometimes cracked ice is placed in a small rubber bag and laid upon the eye, but the plan is objectionable on COMMON REMEDIES USED IN TREATMENT OF EYE 139 account of the weight, and also the degree of cold may be too severe. Moist cold is best applied by means of cloths, gauze, or cotton, which have been first moistened anel then cooled by placing them on a cake of ice. The best material for these pads is surgeon's lint, which is best prepared by cutting into circles about 2 inches in diameter. These are then folded once with the rough siele inward and moistened and placed upon the block Fig. 21.—Cold eye-pads. of ice. If surgeon's lint is not available, soft cotton cloth may be used. This may be cut into squares 4 inches each way and then folded twice, so that when folded they will form squares made up of four thicknesses of cloth and measuring 2 inches in each direction. If two corners are now trimmed off with the scissors so as to make the shape approximately semicircular, the pad will fit better over the eye (Fig. 21). Absorbent cotton, which is sometimes recommended for this purpose, soon 140 EYE, EAR, NOSE, AND THROAT NURSING mats together in a wad if ham He'd when moist, and, therefore, does not serve the purpose as well as either surgeon's lint or soft muslin. Gauze may be' useel, but there should be six or eight layers to make a pad of suffi- cient thickness. If one eye is to be treated with the iceel cloths there shoulel be at least six paels at one time placed upon the block of ice, and these are to be picked up in regular order and placeel on the eye. After the first pael has rested on the eye for perhaps fifteen seconds, it is te> be1 placeel back upon the ice anel the second pad placeel e>n the eye1. The more frequently the cloths are1 changed the greater will be the effect of the cold. From fifteen sec- onds to half a minute1 is the usual interval for changing the pads. If the pads are taken in regular ordeT, the pael which is useel will always be the one which has the been the longest on the ice and, therefore, the coldest. When the end of the row is reached, start back at No. 1 again. If both eyes are affected, the pads may be ar ranged on the ice in two rows and picked up a pair at a time and conveyed to the eyes. Cold should be applied continuously for several hours. The paels shoulel be moist, but not wet enough so that water will run down over the face. A towel should be placed by the1 side of the patient's face to catch any water which may run down. If the colel applica- tions are to be continued for a long time, it is well to anoint the lids with vaselin before applying the iced cloths. Inunctions.—Medicines, as a rule, are not absorbed through the unbroken skin. There is, however, one way by which they can be introduced through the skin, and that is by combining the medicine with some form of COMMON REMEDIES USED IN TREATMENT OF EYE 141 fat, such as larel, tallow, or vaselin. By means of rub- bing, the fat may be forced through the skin, and with it the medicine which is combined with it. Certain disease's of the eye are dependent upon a con- dition of the blood which requires inunctions of a mer- curial ointment. It is, therefore, important that a nurse should know how to use the inunction. In order to be effective it is necessary that the ointment be thoroughly rubbed in. Of course, the physician will prescribe the amount to be used. The rubbing must be continued until the surface is dry. This may require from twenty minutes to half an hour. The inunction must be ap- plied on a different spot each time. If applied to the same spot twice in succession or too near together the skin will be made sore. It is best to choose a spot on the surface where the skin is as tender as possible, as, for example, on the inner rather than the outer surface of the arm, leg, or thigh. The inunction may be applienl to the upper arm on one day and to the forearm the next day. On the third day the other upper arm may be taken, and so on, using a new spot each time. The physician should see the patient often, as it is necessary to stop the inunction at the first evidences of salivation. The nurse's hand must be protected by means of a rubber glove while applying the inunction, otherwise the nurse may absorb as much of the drug as the patient receives. The patient may, however, be instructed to use the inunction upon himself, and in that case, of course, it is not necessary to protect the patient's hand. A Modified Hot Pack.—Hot packs are used in con- junction with the internal and hypodermic injection of pilocarpin hydrochlorate to aid diaphoresis in certain 142 EYE, EAR, NOSE, AND THRe)AT NURSING abnormal conditions of the eye, especially those relat- ing to the fundus. Cover the bed with a hot dry blanket, remove the patient's nightgown, fold the blanket around the pa- tient, tucking it in around the shoulders and feet. Pro- tect the hot-water bags with covers; place one at the feet and two or three on each siele. Have several extra blankets over the patient, an ice-cap or ie-e1- compress on the head. Give the patient hot drinks. Pulse (at the temporal artery) must be carefully wate-heel for any depressant effect. Leave the patient in the pack from one-half hour to two hours. At the end of that time give1 the patient an alcohol rub, remove the ice-cap and blanket around the body, and all but one hot-water bag; put on a warm nightgown and gradually remove the extra blankets. Emergencies Which May Arise and Require Prompt Attention of the Nurse Lime Burns.—No water. Remove as much lime as possible by everting lid; instill oil, sweet oil, castor oil, lard, or simple syrup. Ammonia.—Use vinegar or lime-juice, followed by cold applications. Mineral Acids.—Use alkaline wash—bicarbonate of soda. Carbolic Acid.—Use alcohol—1 part water to 3 parts alcohol. Burns.—Apply vaselin to prevent adhesions. CHAPTER XV EVERSION OF LIDS; RETRACTORS; DROPS, SOLUTIONS, OINTMENTS, AND SALVES Eversion of the Eyelids.—The eversion of the lower lid is a very simple matter. Place a finger Or thumb upon the lower lid, just-below the lashes, and direct the patient to look upward and at the same time press down- Fig. 22.—Eversion of the upper lid. ward with a finger, and the edge of the lid will roll out- ward, exposing the conjunctival surface. Eversion of the upper lid requires some practice, but a nurse who is to attend eye cases should learn the art 143 144 EYE, EAR, NOSE, AND THROAT Nl'KSING as soon as opportunity offers. First direct the' patient to look downward without inclining the head forward, and at the same time grasp the lashes of the upper lid between the thumb and forefinger of one hand, anel with the other hand place a small pencil, penholder, or ap- plicator horizontally along the upper part of the lid Fig. 23.—Eversion of the upper lid. (Fig. 22). Then draw the lid downward and forward and at the same time press the pencil or applicator downward with the other hand. After practising until it is easy to turn the lid by this method, a finger may be substituted for the pencil (Fig. 23), and, perhaps, after a time sufficient skill may be' acquired so that the lid TREATMENT OF EYES 145 may be turned with one hand alone without the assist- ance of the other hand. The nurse may stand either behind the patient or in front, as shown in the illus- trations. The majority of patients when told to look downward will incline the head forward without relatively chang- ing the position of the eyes. It is, therefore, necessary to impress upon the patient that he must turn the eyes downward without moving the head, and, moreover, he must continue to look elownward as long as it may be necessary to keep the lid everted, because if the patient looks upward sudelenly, even after the lid has been suc- cessfully turned, the lid will be immediately turned back to its natural position. The reason for this will be seen from what we have learned under the anatomy of the eye, that the conjunctiva which lines the lid is continuous with that which covers the front of the eye- ball, and, therefore, when the eye is turned upward the conjunctiva of the upper lid is also drawn upward, and the tension on the conjunctiva causes the lid to turn inward. Sometimes the eyelids are devoid of lashes and the conjunctival surface is contracted on account of scars from old trachoma or perhaps from a lime burn. Some- times the entire lid is thickened, especially in cases of acute purulent disease. Such lids are very difficult and sometimes almost impossible to turn. Lid Retractor.—When an eye with tight or swollen lids is to be cleansed it is necessary to raise the lids from the eyes with an instrument called a lid retractor. The retractor must be carefully introduced under the upper lid in such a way as not to injure the cornea. A 10 146 EYE, EAR, NOSE, AND THROAT NURSINO finger or thumb of the other hand is used to press down the lower lid at the same time that the retractor draws the upper lid upward. In this way the eye may be in- spected to see if there are corneal ulcers or abrasions and irrigating solutions may be used to cleanse the eye. When the lid is raised by the ordinary form of retractor any secretion present may be washed out by means of a bulb syringe with a soft-rubber tip, or by means of ab- sorbent cotton saturated with the solution which has been chosen for the purpose. This is best accomplished when the patient is lying on a bed or couch or in a redlin- ing chair with the head thrown well back. In treating children who object to the treatment it may be necessary to hold the child's head between the knees. This will be more fully treated under the heading Management of Troublesome Children. In applying drops to the eyes the best method is to draw down the lower lid with the finger of the left hand, directing the patient to look upward, as describee! under the heading Eversion of the Lower Lid. Then, with the dropper in the right hand, allow a drop to fall upon the inner surface of the lid. The drop will enter the eye1 just as effectively in this way as if it were alloweel to fall directly upon the surface of the eyeball. This method is much more agreeable to the patient, as it is startling and sometimes painful to have a drop fall directly upon the sensitive cornea. On account of the susceptibility of some individuals to the toxic properties of certain drugs, i. e., atropin, homatropin, and scopola- min, the following precaution should be taken to prevent the solution from being drawn down into the nose by the lacrimal sac. After each instillation make firm contin- TREATMENT OF EYES 147 uous pressure for about two minutes over the lacrimal canaliculi and sac, either with your own finger or have the patient do it. The further precaution of keeping the lids closed during and following the instillation of eocain is imperative to prevent the loss of the corneal epithelium. The act of winking is reflex. Thus when the nerve terminals have lost their sensitivity the eye remains open and the surface of the cornea soon becomes white. Moreover, eocain softens the surface epithelium, thus enhancing the destructive action of the air. In instilling drops into the eyes the point of the drop- per should never be allowed to come in contact with the lids or eye, as some of the secretion from the eye might adhere to the dropper and so carry contagion to another patient. It is best in every case to draw up into the dropper only so much of the solution as is to be used, and then to rinse out the dropper by drawing sterile water in and out before replacing the dropper in the bottle. The bottles containing the solutions to be dropped into the eyes are generally made for hospital use in such a way that the dropper itself forms the stopper of the bottle. For this reason the dropper need never be laid down where it may be contaminated by germs, and there is no danger that a dropper which has been used for one kind of solution should be used for another kind. The abbreviations 0. D. (optic dextra), right eye; 0. S. (optic sinistra), left eye, and C. S. C. (coup sur coup) are frequently used by surgeons in writing orders. C. S. C. literally means "blow on blow," and is used where a rapid and complete action of a drug is desired, and indicates 148 EYE, EAR, NOSE, AND THROAT NO USING that one drop is to be instilled every five minutes for six times. Care of Bottles and Solutions.—Bottle's and droppers are cleansed by washing in soapsuds, and if there is any eleposit in the bottles or pipets, use hydrochloric acid 1:3 or 1:6, being careful to rinse thoroughly. The1 rubbers must, of course, be removed from the droppers Sterilize by boiling or by soaking in bichlorid of mer- cury (1: 500) over night or at least for one or two hours Some find a eleposit after boiling, which they claim is not present if soakeel in the bichlorid solution. Boiling is better for operating room purposes. Solutions are made up from distilled water; bottles are filled and sealeel for operating room use and are not usee! a second time. For ward use' it is we'll for each patient to have his own tray with solutions, and only changed if not perfectly elear. Some solutions may be filtered and boiled or sterilized. Others, like' atropin and eocain, are changed by heat. Some of the solutions are changed by the action of light. Eserin solution is e-hange'd to a pink tint, but is not damaged, and eocain solution to a blue tinge, and then it is not suitable for use in the eye. Droppers should never be inverted so that the' solutions will come in contact with the rubber, as rubber cannot be perfectly sterilized and there may also be a chemic change. Solutions of nitrate- of silver soon undergo a chemic change on exposure to the light, and should be kept away from the light and in bottles of dark glass. For the sake of economy only small quantities of solu- tions should be prepared at one time. In applying ointments to the eyes, if it is desired to TREATMENT OF EYES 149 have the ointment reach the eyeball itself, the lids are held slightly apart by the fingers of one hand, and the ointment, as much as has been directed by the physician, is to be placed between the lids by a finger of the other hand or by a small spatula. Some prefer to wind a bit of cotton tightly upon a probe or wooden toothpick and, taking the salve on this, wiping it off between the lids. In any case, after the salve is placed between the lids, a gentle massage of the lids should be employed to spread the salve over the surface of the eyeball. If the salve1 is to be applied only to the edge of the lids, the lids should be first thoroughly eleansed and all scales and crusts removed. The salve is then spread over the edge of the lid with the finger. For cleansing the lids as a preparation for the application of the salve a solution of borax (about h teaspoonful to 1 cupful of hot water) is generally used. CHAPTER XVI CONTAGIOUS EYE DISEASES. THE NURSE'S DUTIES AT OPERATIONS Attention has been called elsewhere to the definition of the terms "contagion" and "infection;" hence, it is not necessary to repeat what contagious or infectious diseases are. We may add, however, that contagion is spoken of as "direct" when, for example, the discharge from an inflamed eye is ejected into the eye of one who may be examining it; or "indirect," as when an eye becomes affected by poisonous material carrieel into it by means of a towel, sponge, or other agent. For all practical purposes it is sufficient that a nurse should regard every eiisease of the eye which is accom- panie'd by a discharge as contagious, and when called upon to attend such a case should take every precau- tion against the carrying of the contagious material to fresh soil. Some diseases of the eye are more conta- gious than others. Of these may be mentioned gonorrheal ophthalmia and ophthalmia neonatorum, which arc analogous diseases and are intensely contagious, reemir- ing the most extreme care in their handling. The proper management of one of these cases calls, first of all, for isolation, and a separate chamber should be provided and properly prepared for the patient (see Chapter III). Should the circumstances of the family be such that this is impossible, the case should be removed 150 NURSE'S DUTIES IN CONTAGIOUS EYE DISEASES 151 to an ophthalmic hospital possessing accommodations for contagious diseases; and if such an institution is not available, the nurse must devise the best means in her power to ensure the safety of those whose presence in the vicinity of the patient is unavoidable. Having arranged these preliminaries, the nurse will proceed to carry out the instructions of the physician in charge; putting on a gown sufficiently voluminous to cover her costume entirely, and wearing goggles to protect her own eyes. It is safe to say that the first, and one of the most important, of the physician's orders will be to cleanse the eyes frequently, by which is meant to keep the external portions of the eye and the conjunctival sac as free from secretion as possible. The nurse should know how to do this in case no specific instructions are given her, and the following method is recommended: In the case of adults, the bedclothing, pillows, etc., are protected with towels, and a basin is placed in posi- tion against the side of the head to catch the excess of solution used to cleanse the eye. A bowl of warm boric acid lotion, or whatever other cleansing agent has been ordered, is placed near at hand, and the liquid is conveyed to the eye either by means of pads of absorb- ent cotton or gauze or in a rubber bulb irrigator. With the fingers and thumb of the left hand the eyelids are separated as gently as possible while a stream of solution is allowed to run into the conjunctival sac and out into the receiving basin with just sufficient force to dislodge the particles of secretion. For irrigating purposes a number of devices have been recommended and used, the irrigator mentioned above being one of the simplest and best. It consists of a hollow rubber bulb fitted to a 152 EYE, EAR, NOSE, AND THROAT NURSING short glass canula smootheel and rouneled at the tip. This may be moved about with ease until all parts of the conjunctival cul-de-sae' have been reached. Moist- ened pledgets of absorbent cotton are used to wipe1 away small particles of adherent discharge. The nurse1 will have been instructed, it need scarcely be1 saiel, in the simple procedure of everting the lids, and when this can be done with sufficient ease to avoid injuring the corneal epithelium it will form the preliminary step in the cleansing process. But not seldom the lids will be found so greatly swollen (chemosis), or so stiffened by the character of the inflammatory process, that recourse must be had to a lid retractor in oreler that the field of operation may be disclosed. The liel retractor is an in- strument designed to effect the raising of the upper liel. It must only be employed by those who have had in- struction in its use, anel then with extreme care, as by clumsy handling very serious injury may be done to the cornea. In cases where only one eye is inflamed, the other must be protected from infectiein by a Buffer's shield. This little appliance will be found illustrated in the chapter on Instruments, with instructions as to its ad- justment. When the patient is a small child, it may be necessary to wrap it about with a sheet in order that its hands may not come in contact with the eyes, and also that the proc- ess of cleansing the eyes and applying remedies may be carried out effectually. An illustration is given else- where in this volume showing a child thus arranged. Otherwise the procedure is the same as for an adult. NURSE'S DUTIES AT OPERATIONS 153 In addition to cleansing the eyes, it will be the duty of the nurse to instil drops or carry out any other line of treatment ordered; then, having performed these offices, she must again render herself surgically clean before undertaking any service for another patient or coming in contact with anyone. Thus, the protective gown must be removed and sent for resterilization, the goggles discarded, and the hands and arms subjected to that thorough disinfection which has been described else- where. Finally, it is well that the nurse should be prepared for such an emerge'ncy as the accidental introduction of a drop of discharge from an inflamed eye into one of her own or into the eye of some one standing near by, possibly assisting. No surgeon may be near and prompt- ness is of supreme importance when this accident hap- pens. The upper lid should be everted and the conjunc- tival sac thoroughly irrigated with a solution of bichlorid of mercury (1: 5000), after which a few drops of a 2 per cent, solution of nitrate of silver should be instilled into the eye, followed for two hours by applications of iced cloths. These measures will usually be successful in averting any serious consequence from the accident. Nevertheless, it is advisable that until such favorable termination is reasonably certain the other eye should be protected carefully. Eye Operative Technic The nurse's duties preparatory to and during opera- tions on the eye are important, and should be carried out to the letter. Antisepsis—or the methods em- ployed in the production of that condition called "asep- sis"—is of value only in so far as it is complete. "A 154 KVE, EAR, NeiSE, AND THROAT NURSING chain is no stronger than its we'akest link," therefore it is obvious that if we would assure', as far as in our power lies, the success of an operative proceelure, we must ne>t neglect the smallest matter in the eletail of our prepara- tion for each separate operation. Of course the prime1 responsibility must rest upon the surgeon, but only less important are the duties which devolve upon the nurse1 in charge. With reference to the patient, it is assumed that if it is a hospital case, he has been bathed thoroughly and clothed in garments suitable for remaining in be»d. Except in old people the intestinal tract should be cleared effectively by a brisk cathartic given the elay before the operation; should this have been neglected, and should the operation be timeel for the afternoon, a saline cathartic may be given on the morning of that day; wThile in cases where there remains insufficient time for even this, an enema may be given shortly be- fore the operation. In the case of patients of advanced years, surgeons sometimes hesitate to give a cathartic for fear of setting up a troublesome diarrhea, which might prove ruinous to an eye after a delicate operation, such as a cataract extraction; hence the nurse must not assume this responsibility unless under the surgeon's orders. Preparatory to an operation the urine should be voided, and if there are artificial teeth, these should be removed. In the case of women patients, the hair should be combed well up on the top of the head and plaited loosely, so that the bandage (when one is re- quired) may be properly applied, as well as for the comfort of the patient. When the patient is on the table (the arrangement NURSE'S DUTIES AT OPERATIONS 155 anel preparation of which is elescribeel elsewhere) the upper part of the body, the hair, anel sieles of the1 face must be covered with sterilized sheet and towels. The face must then be washed with warm water anel Castile or other pure semp, special attention being paiel to the eyebrows and eyelashes. The conjunctival sac is then irrigated with a warm saturated solution of boric acid. A convenient instrument for this purpose is an ordinary glass pipet with the edges surrounding the tip rounded so as not to injure the mucous membrane, and having a soft-rubber bulb attached. This bulb is of such a size as to fit comfortably into the palm of the hand; and with a little care every portion of the conjunctival cul-de-sac can be readily reached and cleansed. The eye is then closed and a pad of gauze or cotton wrung out of a solu- tion of bichlorid of mercury (1:5000) is placed lightly over the closed lids. The eye which is not to be operated upon is usually shut and a small oval patch of cotton, covered on both sides with a single thickness of gauze (Knapp's dressing), secureei over it with adhesive plaster. In restless patients, or those who experience difficulty in controlling the movements of the eye, the unaffected eye is left open frequently, the surgeon thus securing the co-operation of the patient in rendering the opera- tive measures smooth and uncomplicated. A rubber cap should be drawn over the patient's hair and the head surrounded with sterilized towels, one being laid lightly over the chin and mouth. Some surgeons do not consider their preparation complete until the eye- lashes have been clipped close to the lid margin, but the majority content themselves with a careful cleansing of the lashes and eyebrows. 156 EYE, EAR, NOSE, AND THROAT NURSING For operations taking place1 in private houses, a north light should be secured, if possible, anel the1 operating table or bed placed as near the window as is convenient. Occasionally, instead of using a table the surgeon may elect to operate while the patient remains in beel. This has the advantage of avoiding the necessity of moving the patient at the conclusion of the operation, but, on the other hand, unless the bed is unusually high, it compels the operator to stoop considerably anel as- sume an uncomfortable' attitude, when he should be at perfect ease1. Unless the patient is very feeble, however, it is bettei to make use of an operating table; but should the patient be operated on in bed, the mattress should first be cov- ered with a rubber sheet, over which is drawn a sterilized sheet. The room, moreover, should be prepared in accordance with the instructions already given in the preparatory chapter of this volume. Should good day- light be not obtainable, or as an adjunct to it, an elec- tric elroplight, fitted with a reflector, will prove valuable in houses wired for electricity. Where gas only is used as an illuminant, a lamp fitted with an incanelescent mantle, such as the Welsbach, may be used: or recourse had to a portable electric lamp, such as most surgeons now possess. The furniture should be removed from the room and sufficient space secured for the operating table and for the smaller tables for the instruments and dressings. A stool must be provided for the anesthetist, with a smaller table for his outfit. There should also be ample room for the surgeon and his assistant and one or two nurses, without crowding. Usually, in opera- tions about the eye or its surroundings, there is little NURSE'S DUTIES AT OPERATIONS 157 necessity to provide for much bleeding; occasionally, however, this contingency must .be considered, when the walls of the room should be protected with sheets to a height of 5 feet or more, and the carpet covered with newspapers spread over with sheets. The tables upon which the instruments, dressings, etc., are to rest should be covered with clean sheets or towels. The nurse should have ready an 8-ounce bottle of tincture of green soap, with a sterile nail-brush and an orange-wooeI nail cleaner for each surgeon, a basin of alcohol and one of bichlorid of mercury (1:1000) or whatever other disinfectant the surgeon may select for his hanels. There should also be provided a large basin of sterile water, one of normal salt solution, and one of a mild antiseptic solution, usually boric acid. Besides these1, the surgeon will doubtless have instructed her to have conveniently at hanel sterilized bottles of solutions of eocain (one 4 and one 8 or 10 per cent.), eserin (1 per cent.), atropin (1 per cent.), argyrol (15 to 25 per cent.), anel adrenalin (1: 1000). The sterilization of instruments and the preparation of the arms and hands have been gone into elsewhere. It is, perhaps, unnecessary to add that the nurse's uni- form should be covered with a sterilized gown and her hair confined within a sterilized cap. Finally, she should see that the dressings, solutions, and prepared pads of cotton for sponging, etc., are not only abundant but also conveniently placed, and she should be careful to move about her duties quietly and rapidly, speaking only when necessary and in a moderate tone of voice, showing every consideration for the feelings of the patient or of friends who may be near. 158 EYE, EAR, NOSE, AND THROAT NURSING ANESTHETICS Local anesthetics are useel largely in eye practise, and they differ from general anesthetie-s in affecting only the part to which they are applied. There have been a number of drugs useel to produce local anesthesia from time to time, the most important being eocain, eucain, and holocain. Of these1, eocain is by far the most gonor- ally useel and its value is inestimable. For example1, in the operation for the removal of cataract, where it is desirable that the conscious effort of the patient should be at the command of the surgeon, and where the nausea and vomiting accompanying general anesthesia might work serious damage, eocain acts perfectly. Its value as a local anesthetic was discovered by Dr. Roller, now of this city, in 1884, and since that time it has been used widely in all small operations; 2, 4, and 8 per cent. solutions are ordinarily employed, and the drug is dropped into the conjunctival sac or upon the cornea at intervals of five minutes for thirty minutes before the operation. Care must be exercised to have the solutions and dropper sterilized, and the surface of the cornea should be occa- sionally moistened during operation, as the epithelium is apt to become roughened from exposure and may be in- jured after eocain has been used. In lid operations and in orbital explorations, etc., eocain is frequently used hypo- dermically, the point of the needle being carefully moved about from place to place while buried under the skin, in order that as large an area as possible may be reached. The anesthetic effect of eocain, as a rule, passes off in about half an hour. Some surgeons prefer to use eucain, which is less toxic NURSE'S DUTIES AT OPERATIONS 159 than eocain, and, moreovei-, does not dilate the pupil or increase the intra-ocular tension; and holocain, in 1 per cent, solution, is also a favorite with many. It is bac- tericidal as well as anesthetic. Nevertheless, eocain remains much the most widely used of all the local anesthetics. Important Operations Often a surgeon has to operate without an assistant, under which circumstance he relies upon the nurse to hand him his instruments and, if need arise, assist him. It is well that she be familiar with the steps of the most important operations. Cataract Extraction.—There are many modifications in the procedure and each surgeon may have some par- ticular instrument, such as Fischer's hooks, capsulotomy knife, or Kalt's suture, or method, such as intracapsular, Homer, Smith, or Kalt, but the majority follow the von Graefe technic: 1. Speculum to hold lids apart. 2. Incision with cataract knife. 3. Iridectomy with iris scissors and iris forceps. 4. Cystotomy with cystotome. 5. Expression of lens with Daviel's spoon at upper margin of wound and horn spoon below. 6. Replacing iris pillars with repositor, smoothing out conjunctiva flap. 7. Removal of speculum. 8. Atropin, argyrol, and bandage. 9. Rings mark. In addition to the above-mentioned instruments the tray should always contain a fenestrated wire loup, a rubber bulb with a fine glass pipet for irrigating the 160 EYE, EAR, NOSE, AND THROAT NURSING anterior chamber, boric acid solution and normal saline solution, and cotton balls, 1 per cent, solution of atropin, 1 : 1000 adrenalin, and 25 per cent, argyrol. Double Advancement for Strabismus.—The tray shoulel contain: Right and left speculum. 2 pairs mouse-tooth forceps. 1 pair smooth forceps. 1 pair tenotomy scissors (Stevens). 1 pair straight scissors. 2 strabismus hooks. 1 Stevens needle-holder. 6 double armed sutures. 1 scleral forceps. 1 irrigator, for it is necessary frequently to moisten t he1 cornea. Heisrath Kuhnt for Trachoma.—The tray should con- tain: 1 hypodermic set. 2 Heisrath forceps, or one Erhadt clamp. 1 lid spatula. 2 mouse-tooth forceps. 1 scalpel. 2 small artery clamps. 1 pair curved scissors. 1 needle-holder. 6 double armed sutures. 1 fixation forceps. The operation may be done under either local or general. The surgeon first injects the upper cul de sac, under conjunctiva, next everting lid, makes incision along line of demarkation between healthy and diseased NURSE'S DUTIES AT OPERATIONS 161 conjunctiva, inserts three sutures in healthy conjunctiva, and then separates it toward cul de sac. Incision is then made through conjunctiva and tarsus 3 mm. from margin of lid and parallel to it. The conjunctiva and tarsus in the included area.is then removed and the healthy conjunctiva sutured to the margin of the cut tarsus, the sutures being tied on the skin over a roll of cotton, atropin in oil instilled. If done under general, eyes are bandaged until patient comes out of anesthetic. If reaction is marked the nurse should apply iced cloths. Enucleation and Evisceration.—There are so many modifications of these two procedures which are resorted to where it is necessary to remove an eye that only the principles involved can be mentioned. The surgeon in enucleation removes the entire eye- ball, while in evisceration only the contents, leaving sclera and muscles in situ. In either case he may suture the conjunctiva or sclera together, or insert a glass ball or pad of fat and firmly suture it in place. 11 CHAPTER XVII EYE INSTRUMENTS AND APPLIANCES There are' a large number of instruments and appli- ances used in the examination and treatment of eye1 conditions, as well as in carrying out the numerous opera- tions upon that organ. It is not the1 intention to give a description of all of these here, but a general ielca of the instruments employed in the principal operations will be attempted by means of illustrations, and a brief account of a number of appliances found convenient in manipulations about the eye or treatment of its diseases. Beginning with the latter, we may, first e>f all, speak of smoked glasses. These are provider! by the optie-ian in a variety of shades, one of the1 most generally useful being that designated as "No. 2 London Smoke." When the object aimed at is to temper the intensity of the rays of light entering the eye, this shaelc is com- monly employed, anel answers the purpose well. Latterly, scientifically prepared protective glasses, such as Euphos, which is yellowish green in color, and Crookes' glass, which is very slightly tinted, have become popular. They are said to exclude the ultraviolet rays of the spec- trum, which are very irritating to sensitive eyes. The Buller Shield (Fig. 24).—This is an ingenious device, designed by the late Dr. Buller, of Montreal, for protecting the sound eye when its fellow has been attacked by a purulent inflammation. It consists of 162 EYE INSTRUMENTS AND APPLIANCES 163 a watch glass placed between two squares of adhesive plaster. That which is attached to the outer or convex surface of the watch glass is somewhat the larger, and the center of each is cut out so as to allow the glass to be seen through, as shown in the illustration (Fig. 24). The shield is placed over the eye to be protected and the exposed adhesive surface fastened carefully to the skin of the nose, brow, and cheek, an opening being left for the ventilation of the eye at the lower and outer angle. This device, it can readily be seen, enables the patient to use his well eye freely, while at the same time it is protecteel from the introduction of infective material from the inflamed eye. Fig. 24.—Buller's shield. The Knapp dressing (Fig. 25) is a very favorite one for covering an eye which has been operated upon. It consists of two oval pieces of gauze, between wmich is placed a layer of absorbent cotton about { inch thick. These pads are prepared in quantity and arranged in pairs for the two eyes in separate packets. In use they 164 EYE, EAR, NOSE, AND THROAT NURSING are placed lightly over the eloseel lids and kept in place by strips of adhesive plaster. Shades, designed to protect the eye from excess of light, are frequently prescribed in preference to smoked glasses. They are made of different materials anel to cover one or both ewes. The most commonly used are made of limp cardboard, covoird with black silk, and with tapes or rubber band attached; while others are made with a lining of green material. Objec- tion has been made to the use of cloth-covered shaeles on the ground that they are apt to be kept about the ■ft ^^L !■■■*■''' ^JUL ' ■fej?- Fig. 25. —The Knapp dressing. house after being used and brought into requisition again should occasion arise, thus tending to spread con- tagion. To avoid this danger, some ophthalmologists favor paper shades, which are destroyed after being used once. EYE INSTRUMENTS AND APPLIANCES 165 The Ring mask (Fig. 26), which was devised by the late Dr. Frank Ring, of the Manhattan, is an excellent protector for eyes which have been operated upon, and which it is particularly necessary to preserve from ex- ternal violence. It is used very extensively after the operation for the removal of cataract, and serves its purpose in these cases admirably. It consists of a broad piece of papier mache, which has been molded to the shape of the forehead and cheek, with a slight indenta- Fig. 26.—Ring mask. tion over the bridge of the nose and bulging protuber- ances over the orbital spaces. Being quite firm and of light weight and possessing tapes which attach it snugly to the head, the mask is a decidedly satisfactory article in the surgeon's equipment. 166 EYE, EAR, NOSE, AND THROAT NURSINC The Priestly-Smith Lamp (Fig. 27).—This is a lamp for use at the1 bedside, and is an extreme'ly handy device in cases where a bright diffused light in the1 sick room is not elesireel and ye't where a proper illuminating ap- paratus for inspection, changing dressings, or applying medicines to an eye may be1 necessary. It consists of a polisheel metal cylindric tube with a cross-piece, at each end of which is a condensing lens. A candle1 is placed within the tube1, the flame being kept at the lewol of the lenses by means of a spring. This lamp is most convenient, being easily managed with one hanel. Fig. 27. —The Priestly-Smith lamp in use. Artificial (or Glass) Eyes.—Artificial eyes are used, as is well known, when for any reason the eyeball has been removed. They should not be worn until all signs of irritation resulting from the operation have disappeared. The nurse shoulel know the1 proper method EYE INSTRUMENTS .AND APPLIANCES 167 of putting in and taking out these delicate shells, and for that purpose the following instructions arc appended: To Insert the Eye.—Place the left hanel flat upon the forehead, and with the tips of the two middle fingers raise1 the upper eyelid. With the right hand push the edge of the artificial eye beneath the upper lid, which may now be released by the1 fingers and allowed to drop upon the eye. The latter must then be supported by the fingers of the left hand, while with the right hand the lower lid is drawn forward and made to secure the lower edge of the shell, thus holding it firmly in place. To Remove the Eye.—Draw down the lower lid with the middle finger of the left hand. Then, with the right hand, place the enel of a small blunt instrument under the edge of the artificial eye, which is made to slip for- warel oveT the lower lid, when it will readily elrop out. This maneuver must be carried out with care, as the eye can very easily be destroyed by dropping on a hard sur- face. Of late years an artificial eye designed by Snellen has come into very general use1. It is constructed with a disk-shaped plate to fill in the concavity of the shell. This avoids the irritation from the slightly worn e>dges which is an objectionable feature of the old-fashioned oyo, and prevents the collection of mucus and tears be- tween the stump and the shell. Bandaging the Eyes.—The subject of bandaging the ewes is an important one, and it is well that the nurse should learn at once that an eye must never be bandaged without direct instructions to that effect from the sur- geon. She1 will soon discover that inflamed eyes are very rarely bandaged, since banelaging renders the eye 168 EYE, EAR, NOSE, AND THROAT NURSING hot and retains the discharges in the conjunctival sac. Bandages are used in ophthalmology mainly for pro- tection and occasionally for support. The latter is the case, for example, in some forms of ulceration of the cornea, where perforation of that structure is feared, and the former is the case after operative procedures of all kinds. There are some special forms of bandage recommended for eye work and quite extensively used by their ad- mirers. Of these may be mentioned the u Moorfields" bandage, made of a double fold of linen, 7 or 8 inches long by 3 inches broad, with a notch cut for the nose and tapes at evae-h corner for securing it to the head. Another is Liebreich's bandage, made of wove>n material and fitted with ingeniously arranged tapes, which make it very easy to apply and remove. There; is also Stev- enson's "dumb-bell" bandage—called so from its peculiar shape. Most surgeons, however, prefer to use the ordi- nary roller bandage, 2 inches wide, made of unbleached muslin or gauze. This is best applied by standing in front of the patient. If the right eye is to be covered, place the external surface of the free1 end of the bandage in the center of the forehead above the eyebrows. Holding the1 bandage in the right hand, and securing the end in place with the fingers of the left hand, carry the bandage to the right around the head in such a man- ner as to give it a firm holel upon the occiput. Reaching the forehead, it overlaps and fixes the free end, anel is continued once more around the middle of the back of the head. It is then passed below the right ear and up over the right cheek and eye to the location of the orig- inal turns, where it is secured with adhesive tape. This arrangement makes it possible to inspect the eye without EYE INSTRUMENTS AND APPLIANCES 169 raising the patient's head from the pillow. The left eye may be bandaged in the same way by merely re- versing the instructions given above. A very popular method of bandaging the eyes is by means of what is called the "figure-of-eight" bandage. Instructions for applying this bandage, which may be used for one or both eyes, resemble those above given for the single-tour roller, except that the turns are in- creased in number alternately around the head and diagonally up over cheek and eye, each turn overlapping the preceding one evenly and neatly. When it is used for both eyes, as it commonly is, the first diagonal turn is brought up from below the ear over the eye which has been operated upon, then around the head and down over the cheek and eye on the sound side, and so on, as many times as the surgeon may desire. If the patient is restless, the bandage must be frequently inspected by the nurse, as the movements of the head upon the pillow have a tendency to dislodge the turns which pass around the occiput. Dressing Tray for Cataract Operations.—For the dress- ing of cataract cases a tray is prepared containing bowls of warm boric acid and saline solutions, absorbent cot- ton balls for cleansing purposes, Knapp's dressing, band- ages, a condensing lens, solutions of eocain, atropin, eserin, and, frequently, argyrol, anel a receptacle for used sponges and bandages. An illustration is given of such a tray (Fig. 28). Some surgeons, instead of using the Knapp dressing, fill the hollows of the orbital spaces with small pieces of moist cotton, carefully placed, and cover the whole with a mass of gauze, securing this with a bandage. 170 EYE, EAR, NOSE, AND THROAT NURSING Instruments for Eye Operations.—The instruments most commonly employ e'e I in the operation for the ex- Fig. 28.—Dressing tray for cataract operations. traction of cataract are shown in Fig. 29 arranged upon a tray. Fig. 29.—Instruments for cataract extraction. Following are illustrations of many of the instruments used in eye operations (Figs. 30-34) EYE INSTRUMENTS AND APPLIANCES 171 Lid speculum. Lid retractor. Paracentesis knife. m Cataract knife. Entropion forceps. Foreign- Foreign- body needle, body spud. Fig. 30.—Principal instruments used in eye operations. 172 EYE, EAR, NOSE, AND THROAT NURSING Keratome. Weber's knife. Graefe's cystotomy. Ill) Knife needle. Scalpel. Lens Tattooing needles. Spatula. spoon. Chalazion curet. Wire loop. Needle holder. Trachoma forceps. Fig. 31.—Principal instruments used in eye operations (continued). EYE INSTRUMENTS AND APPLIANCES 173 Advancement forceps. Tendon forceps. Strabismus forceps. Iris forceps. Lacrimal dilators. Lacrimal probe. Fig. 32. —Principal instruments used in eye operations (continued) 8925�2 371373 89992 80 174 EYE, EAR, NOSE, AND THROAT NURSING Enucleation scissors. Tenotomy scissors. Iris scissors. Straight scissors. Fig. 33.—Principal instruments used in eye operations (continued). EYE INSTRUMENTS AND APPLIANCES 175 Irrigator. Lacrimal syringe. ig. 34. —Principal instruments used in eye operations (continued). Other instruments commonly employed are: Beer's knife. Fixation forceps. Pterygium knife. Dissecting forceps. Cilia forceps. Snellen's clamp. III. The Ear CHAPTER XVIII OUTLINE OF THE ANATOMY AND PHYSIOLOGY OF THE EAR1 The organ of hearing is best divideel for study into three divisions: (1) The external car and auditory canal; (2) the middle ear or tympanum; (3) the internal ear or labyrinth. Functionally, the first two divisions are classed to- gether anel called the sound-conducting apparatus, and the third is called the sound-perreivinq apparatus. The external ear, pinna, or auricle, as it is called, consists of a plate of yellow elastic cartilage, folded and bent on itself to form the ridges and expressions known as the helix, anthelix, concha, etc., shown in Fig. 35, and is covered with a thin and firmly attached skin. The1 lower portion of the auricle or lobe of the ear is devoid of cartilage and consists chiefly of connective tissue and fat. The cartilage of the external ear is pro- longed inward in the shape of a tube from the concha to form the outer two-fifths of the external auditory canal. In adults this external auditory canal is about \\ inches long anel is narrowest at its middle, which is also the- highest point of its floor, for as it runs inwarel it is directed 1 The author is indebted to Dr. P. B. Barringer's useful "Ab- stract of Physiology" for a large part of this chapter. 176 OUTLINE OF ANATOMY AND PHYSIOLOGY OF EAR 177 first upward anel forward anel then downward anel for- ward to the elruni membrane. Therefore1, in oreler to straighten the canal to examine or irrigate it the auricle should be drawn upward and backward. In infants at birth and for some months following, the upper and lower walls of the external canal are in contact, owing to lack of development of the bony canal. Consequently, Helix Tragus Antitragus Fig. 35.—Right auricle: Nomenclature after Spalteholz (Barnhill and Wales). up to two years of age the canal is best straightened for examination or irrigation by pulling the auricle elown- ward anel backward. As the development of the canal takes place in older children it is straightened by pulling backward and then backward and upward, as in adults. At its entrance or meatus the canal expands a little in its vertical diameter ((|)), and at its inner end it 12 178 EYE, EAR, NOSE, AND THROAT NU USING expands horizontally (-©■), in vienv e)f which most e*ar specula are made with oval tube's. The1 inner end is closed by the drum membrane, which extern Is obliquely across it, making the anterior wall and floor of the canal longer than the roof and posterior wall. The nerve- supply of the canal, from Arnold's branch of the pneunio- gastric nerve anel from a branch of the fifth nerve1, is Fig. MJ. —Diagrammatic section through the right ear: G, External auditory meatus; T, tympanic membrane; P, tympanic cavity; (), oval window; r, round window; B, semicircular canal; S, cochlea; Vt, scala vestibuli; Pt, scala tympani (Czermak). interesting because of the reflex coughs and neuralgia caused by hardened wax or foreign bodies in the canal. The skin of the outer half of the canal contains hair- follicles and ceruminous or wax-glands. The hairs protect it from insects, dust, and extraneous matter, and the cerumen keeps the skin soft. The muscles that move the ear are in man almost OUTLINE OF ANATOMY AND PHYSIOLOGY OF EAR 179 functionless and serve only as attachments for it to the side of the head. The middle ear or tympanum is an irregular cavity about the size anel shape of a grain of Indian corn placed on edge with the point forward. The external wall of the tympanum consists mainly of the drum membrane set in its bony ring, the annulus tympanicus, which is incomplete at the top and at which point the membrane sags, and is called the membrana flaccida or ShrapneWs membrane. The chorda tympani nerve, supplying the anterior two-thirds of the tongue with taste, crosses on the inner side of the drum mem- brane, and when a myringotomy (incision of the drum) is performed it is sometimes severeel, causing a temporary numbness anel loss of taste on that side of the tongue. The inner wall of the tympanum has twe> openings through it communicating with the internal ear. These are called the fenestra oralis (or oval window) anel the fenestra rotunda (or round window). Arching back- ward from over the oval window and then elownward in the posterior wall runs the facial nerve, lying in its bony canal the aquaeductus Fallopii. The anterior wall has in it near the bottom an open- ing for the Eustachian tube, which runs from the middle ear to the throat. Its trumpet-shaped opening into the throat dilates during the act of swallowing and admits air to the middle ear, thus keeping the pressure equal on both sides of the drum membrane. Into the mouth of this tube the catheter is placed when direct inflation of the middle ear is practised. The posterior wall of the tympanum has near its top an opening into the mastoid antrum called the aditus. 180 EYE, EAR, NOSE, AND THROAT NURSING Through this opening inflammation may extenel from the middle oar to the mastoid cells, causing mastoiditis. The superior wall is a thin plate of bone separating the middle ear from the brain. The1 inferior wall is called the floor. The tympanum is lined with mucous membrane, which is continuous with that lining the aditus and mastoid antrum. Fig. 37. —The drum-mombrane and ossicles from within, showing at- tachment of malleus handle to drum-head (Pyle's Personal Hygiene). The upper part of the tympanum behind Shrapnell's membrane, level with the aditus, is called the attic. This region contains the bones of the middle ear (Fig. 37). The ossicles, or bones of the middle ear, are three in number and are called respectively the malleus, incus, and stapes or hammer, anvil, and stirrup. The malleus, the most external bone, has its hanelle woven into the middle of the tympanic membrane. When sound- OUTLINE OF ANATOMY AND PHYSIOLOGY OF EAR 181 waves strike1 the ear drum the motion is imparted to the malleus, and by an interlocking union is transmitted to the incus, thence to the stapes, and by its foot-plate, which is woven into the1 membrane closing the oval window, te> the fluid of the internal ear. The muscles of the ossicles are two—the tensor tympani and the Body of incus Handle of malleus \ Facial nerve i> V Utjfk* i—?—■--------— >— .'■■ v > _ Pneumatic mastoid cells Large tip cell Fig. 38.—Right temporal bone. Vertical section through middle ear, viewed from within (Barnhill and Wales) stapedius. These, with the ligaments, particularly those between the malleus and incus, are interesting but complicating, and had better be described in an anatomy than in a book on nursing (Fig. 38). The mastoid portion of the temporal bone lies just behind the ear. Its outer surface is rough and subcu- taneous, and ends below in a nipple-like tip, called the mastoid process. Its inner surface has a deep groove for the lateral sinus. This is the large vein lying be- 182 EYE, EAR, XOSF, AND THROAT NUUSING tween two layers of the elura, the1 bladder-like cowring of the brain, which becomes the jugular vein in the neck after passing acrejss the mastoid process like a letter S, in close contact with its inner surface, as described above. The importance of this vein in connee'tion with mastoiditis will be seen later on. Between the external and internal surfaces or plates of the bone lie the mastoid cells and mastoid antrum. The latter is separateel from the brain above by a thin plate of bone called the tegmen antri (Fig. 38). Horizontal semi circular canal Posterior semi- circular canal Ampulla Superior semicircular canal Ampulla Fen extra ovalis Bony cochlea Vestibule Fenestra rotunda Fig. 39.—Right bony labyrinth, viewed from outer side: This figure represents the appearance produced by removing the petrous portion of the temporal bone down to the denser layer immediately surrounding the labyrinth (from (Juain, after Sdmmering) The internal ear or labyrinth lies just internal to the tympanic cavity and consists of a central cavity or vestibule, a posterior portion formed by the semicircular canals, and an anterior portion by the cochlea. The cochlea is the auditory part of the ear. The canals are chiefly concerned in equilibration. The vestibule is curi- ously concerned in both. The bony labyrinth has within it a membranous imitation of its form which is filled OUTLINE OF ANATOMY AND PHYSIOLOGY OF EAR 183 with a fluid called endolymph. Around this mem- branous labyrinth, between it and the bony wall, is a space filled with fluid called perilymph. The vestibule has somewhat the same general shape as the tympanum. In its outer wall it has the foramen ovale filled in by the foot-plate of the stapes; behind are the openings of the semicircular canals; and in front, the cochlea. The semicircular canals are three in number and are located above and behind the vestibule. Each canal describes a little more than a half-circle, and one end of this semicircle is dilated and called its ampulla. They are called the superior, the horizontal, and the posterior semicircular canals, and they lie in such a way that each one is at right angles to the other two. The superior canal lies parallel to the posterior canal of the op- posite side, and has its ampullated end free in the upper part of the vestibule, but its other end is in common with the posterior canal. The posterior canal has its ampullated end opening into the lower part of the vestibule and the other joins the superior canal. The hori- zontal canal is the smallest of the three and has two distinct openings into the vestibule. Its hard, white appearance is an important landmark in the mastoid operation, to show the proximity of the facial nerve The membranous labyrinth consists of a membranous tube loosely filling each canal, but dilated and closely adherent to the bone of the ampulla. At each end these membranous canals are joined to a membranous sac called the utricle, which lies in the posterior end of the vestibule. This utricle is connected by a Y-shaped tube to a smaller membranous sac in the vestibule called the saccule, and the united end of the Y tube passes througli the internal wall of the vestibule in a canal called the aquteductus vestibuli to a subdural space. A small tube now unites the saccule with the scala media of the cochlea. These membranous tubes and sacs are held in place by little fibrous processes which run from them to the surrounding bony wall. The vestibular branch of the auditory nerve has little hair-like endings which extend into the cavity of each ampulla, 184 EYE, EAR, NOSE, AND THROAT NURSING somewhat similar ones appear in the utricle and saccule, the function of which seems to be as follows: The endolymph is free to move in the canals, so that when any movement is made of the head in the plane of any canal the endolymph of the canal, by reason of its inertia, seems to flow against the movement. This causes a stream- ing of endolymph through the hair-cells, which, of course, move with the head as they are attached to the side of the ampulla, and a stimulus is given to the nerve-ending through the hair-cells. When a movement in a given plane is long continued the endolymph of that canal is finally set in motion, and this motion continues after the body stops. This causes a sense of vertigo, as seen in children who turn around until they "get drunk." By the movement imparted I to the fluid in the'se canals and its influence on certain nerve1 terminals in it we are able to tell "with our eyes shut" our plane of movement in any act. The cochlea lies in front of the vestibule and is a cavity in the bone formed like a small snail-shell, coileel two and one-half times around a central axis. It contains the end organ of hearing and receives the sounel im- pressions, which are carried to the brain and there per- ceived or interpreted. The method of tone perception is more elaborately explained in fine print, anel may be interesting to read, although not necessarily learned. The tube as it winds around is divided into two parts by a septum, partly bony and partly membranous, which extends from its base almost to the apex of the coil. The inner half of the septum next the central axis is bony, and the outer half is a thin fibrous membrane attached to the outer wall of the tube. The membranous part is called the membrana basilaris and supports the famous organ of Corti. This septum, as stated, extends from the base of the coil almost to the top and divides the tube into two canals, an. upper, or scala vestibuli, and a lower, or scala tympani, which communicates at the apex, the helicotrema. The lower end of the scala vestibuli, as its name suggests, opens directly into the vestibule, and the lower end of the scala tympani OUTLINE OF ANATOMY AND PHYSIOLOGY OF EAR 185 ends against the interna tympanic membrane which closes the round window and separates this canal from the middle ear. In the scala vestibuli is a membrane which rises from the junction of the bony part of the septum with the membrana basilaris, to the outer wall of the tube, and divides it from top to bottom. The triangular space between it and the membrana basilaris is called the scala media, is filled with endolymph through the canalis revniens, and contains the organ of Corti, while the scala vestibuli and scala tym- pani contain perilymph. The organ of Corti lies on the membrana basilaris and contains the tunnel of Corti. This tunnel is formed of inner and outer rod- shaped cells which rest upon the basilar membrane and lean against each other at the top like the rafters of a house, leaving a triangular tunnel below; on either side of this column of rod-shaped cells which form the tunnel there is a line of hair-cells, the inner row being single and the outer triple, while both have the slant of Corti rods. The hair-cells have little hair-like processes extending from their upper surface, and these project through little openings in a mem- brane which overlies them. Above this is a heavier membrane which just touches the tips of the hair-like processes and seems to act as a damper to excessive vibration. The cochlear branch of the auditory nerve runs in the modiolus or central axis of the cochlea, and sends out branches from base to apex through the bony parts of the septum (lamina spiralis) to re- ceive the impulses of the hair-cells in the organ of Corti. To explain briefly the function of what has been described above it is best to follow a sound-wave as it passes through the external canal and strikes the drum membrane, where vibrations are con- veyed by the chain of ossicles to the oval window. The foot- plate of the stapes then starts in wave motion the perilymph in the scala vestibuli, and these waves pass over to the scala tympani through the helicotrema at the apex of the cochlea and end against the membrane covering the round window. By these waves the membrana basilaris is thrown into motion, and the motion of the membrane is greatest at a certain point that corresponds to the size of the wave. The vibration at this point is recorded by the hair- cells of the organ of Corti and the impulse carried away to the brain by the nerve that receives it at this point, and the impulse is "per- ceived" as "sound" and the memory of it stored in some center in the brain that receives it. The above theory, although not ap- proved by all authorities, is the one that has been most generally accepted up to the present time. CHAPTER XIX EXAMINATION OF THE EAR: GENERAL METHOD AND INSTRUMENTS COMMONLY EMPLOYED When the first aural examination is made, the canal, in a large number of case's, may be obstructed by ceru- men, epithelial plugs, or some foreign material introduced Fig. 40.—Syringing an ear. by the patient to relieve pain. This obstruction must necessarily be removed before the drum-membrane can be seen, and the removal may best be accomplished 186 . EXAMINATION OF THE EAR 187 with least discomfort to the patient by means of a Pomeroy syringe and a warm 10 per cent, solution of bicarbonate of soda. In case the obstruction is froni an impacted mass of cerumen, inspissated pus, or epithelium, the plug should be loosened and disintegrated by filling the canal with warm hydrogen peroxid for a few minutes before the injection (Fig. 40). In using the Pomeroy syringe the auricle should be held between the index and middle fingers of the left hand; the thumb is then free to act as a rest for the tip, and the auricle can be drawn upward and backward to straighten the canal (see Anatomy). This method may seem awkward at first, but it has the advantage of holding the tip steady and preventing a jerky con- tact with a sensitive meatus. The tip should be long and narrow, not bulbous, and when placed just within and against the wall of the meatus should have ample room around it for the return flow. Where the ob- 188 EYE, EAR, NOSE, AND THROAT NURSING struction does not come away roadily the stream shoulel be alternately directed forwarel, backward, upward, anel downward. Persistence anel patience and a large quan- tity of soda solution will almost invariably remove1 the plug. The equipment of an aural examining tray (Fig. 41) should include. (1) Head mirror. (2) Full set of ear specula. (3) Cotton applicators. (4) Sterile cotton. (5) Hydrogen peroxid. (C) Attic probe. (7) Ring curet. (8) Tongue depressor. (9) Nasal speculum. (10) Pair of ear forceps. (11) PonuToy syringe anel pus basin. (12) Jar of bicarbonate of soela anel bowl for irrigating solution. Bear in mind that this equipment is only for cleans- ing and inspee-ting the canal anel ear drum, anel includes no instruments for testing or treatment. The nasal speculum and tongue depressor are necessary to eleter- mine the presence or absence of adenoids or enlargeel tonsils, the removal of which is one of paramount im- portance in certain diseases of the middle ear. The attic probe is a very fine silver probe about 6 inches long, which tapers to the size of a pin, but has on it a small probe point. It can be bent in any direc- tion and is most useful in examining the middle ear through perforations in the drum, and in judging dis- EXAMINATION OF THE EAR 189 Pomeroy ear syringe. heme conduction in normal individuals. When this is the case, Rinne's test may be described as positive. When it is hearel longer on contae-t over the mastoid than through the air at the meatus, it is not normal anel Rhine is negative. (3) Weber's Test.—When a strongly sounding tuning- fork is held against the forehead or on the top of the1 head in the middle line, and when one ear is firmly close'd by the tip of the finger, the sound seems reinforced or strengthened and is referred to the closed side. The result of Weber's test may be described as, Weber re- ferred to left or right ear. In typical middle-ear diseases or any impairment of the sound-conducting apparatus Schwabach's test would show bone conduction increased, Rinne's would approach or be negative (bone conduction better than air conduction), and Weber would be referred to the poorer side. In typical nerve deafness or disease of the sound-perceiving apparatus the bone conduction would be diminished, Rinne positive, and Weber referred to the least affected side. There would be a failure to hear high tones, whereas in middle-ear disease there is a deafness for low tones. Functional Tests of the Static Labyrinth The following tests, with the exception of the galvanic, are all based on the discovery by Ewald that a movement of endolymph in a semicircular canal is accompanied by a corresponding movement of the eyes in the same direction and in the same plane as that of the canal in which the endolymph moves, and that the snap-back or nystagmus is in the opposite direction. Knowledge of this relation- EXAMINATION OF THE EAR 195 ship between the eyes and the endolymph has resulted in the development of the tests for labyrinthine disease, now in general use. In cases of chronic suppurative otitis media a fistula in the horizontal semicircular canal can sometimes be diagnosed by compressing air in the middle ear, which causes, through the fistula, a move- ment of the endolymph and a corresponding movement of the eyes. This is known as the fistula test. The fistula test is performed by compressing the air in the auditory canal, either by means of a Siegel otoscope or by some other device for closing the meatus and pro- ducing pressure or suction on the air in the canal. Where a fistula exists in the horizontal canal, pressure or suc- tion may disturb the fluid in this canal and produce a corresponding slow movement and nystagmus in the eyes. A positive fistula ear test then denotes a weakness in the labyrinthine wall, so when it has once been demon- strated it should be repeated only with caution and not oftener than necessary. Barany's observation of the disturbance produced by the use of heat or cold in the ear led to his development of the caloric test, which consists in irrigating the ear with either hot or cold water. When cold water is used in a normal ear with the head erect, a movement of endo- lymph is produced in the anterior vertical canal down- ward and toward the ear irrigated, and there is a corre- sponding nystagmus or quick movement of the eyes to the opposite side; if the irrigation is prolonged, dizziness, nausea, and vomiting with profound prostration develop. The same symptoms appear when hot water is used, except that the nystagmus is toward the side irrigated. When the water reaches the drum membrane for five 196 EYE, EAR, NOSE, AND THROAT NURSING minutes or more without the occurrence of any reaction, the labyrinth may be considered functionless. The re- action occurs much quicker when the drum-membrane is perforated or absent, and for this reason it is advisable for people with perforated ear-drums to protect their ears before going in swimming. The effect of cold water on the labyrinth in these cases is sometimes vctv rapid, and the dizziness and loss of equilibrium producer! might easily render one helpless in deep water. This may be the reason why strong swimmers, occasionally without warning, suddenly utter a cry for help and go down before rescue is possible. Caloric Test.—The nurse in getting things ready for t his test shoulel have a large irrigator or fountain-syringe, with a small tip, filled with either hot or cold water, as required by the surgeon. Cold water should be not warmer than 70° F., and in some cases ice is required. When hot water is used the temperature in the irrigator should not be below 110°. After the irrigator is filled, an addi- tional supply of water (at the proper temperature) should be on hand in a large pitcher. The patient is then pro- tect eel with towels and the ear is irrigated, the return flow being carried away either in a special device that is placed below the ear, or in a basin of some kind. In the use of the latter care should be taken to hold it well below the auricle on the side of the neck, where the patient can- not by wincing or shrugging his shoulder press the vessel up and close his canal. The rotation tests are used to determine the compara- tive activity of the two labyrinths. The necessary articles to perform this test are a pivot chair, especially con- structed, and a stop watch. The horizontal semicircular EXAMINATION OF THE EAR 197 canals of the two systems are the ones usually compared, and it has been found that in these canals after rotation the canal in which the endolymph moves toward the am- pulla causes a greater motion of the eyes than does the canal in which the flow of the endolymph is away from the ampulla, consequently in rotating the patient to the right ten times with a sudden stop, a flow of endolymph is placeel toward the ampulla in the left horizontal semi- circular canal, and the after-nastagmus which results is chiefly caused by the left ear and is directed to that side. The reverse is true when the patient is rotated to the left. Now, when there is recent disease of one side and com- pensation for the lack of function on that side has not had time to take place, there will be a marked difference in the duration of the after-nystagmus, which results from the patient being rotated to the right and then to the left, but if both static labyrinths are normal, there is a difference of only a few seconds in the duration of the nystagmus after rotating in both directions. The Galvanic Test.—The action of the galvanic current in this test is not definitely known; but it has been found by experiment that when one electrode is held in the patient's hand and the cathode or negative electrode is placed on his mastoid that a current of about 4 milli- amperes will produce a rotatory nystagmus toward that side or toward the ear tested. The nystagmus is to the opposite side when the positive pole is placed on the mastoid and the negative in the hand. When it requires more than a current of 4 milliamperes to produce the nystagmus, the labyrinth on that side is considered to be less irritable than normal. The nystagmus in this case is supposed not to be caused by disturbance of the laby- rinthine fluid, but to stimulations of the vestibular nerve. CHAPTER XX DISEASES OF THE AURICLE AND EXTERNAL AUDI- TORY CANAL Eczema.—The kind that most frequently requires the care of a nurse is the acute form which occurs in children, and is usually associated with a discharge from the middle ear. This discharge, from neglect anel want of proper treatment, causes an excoriation anel infection of the skin of the canal anel sometimes of the whole scalp. In young babies and in weakly strumous children an- other form sometimes occurs in the fold behind the ear and spreads to the skin over the mastoid and superior surface of the auricle when there is no middle-ear dis- charge. Treatment consists of particular attention to the mid- dle-ear discharge, when it is present, as describeel under chronic purulent middle-ear disease (0. M. P. C), and the local application of zinc oxid ointment after the careful removal of the crusts and cleansing of the affecteel area. After the first general cleansing, watery solutions or hydrogen peroxid shoulel not be used on the affected surface, but it should be kept protected and well coated with ointment and covered with sterile gauze. If the scalp is involved, it should be shaved, the crusts soaked off with oil, and a mixture of zinc oxid ointment and ammoniated mercurial ointment applied. Bland oint- ments, such as zinc oxid, are better than those with salicylic acid and other irritating substances in them, 198 DISEASES OF AURICLE AND AUDITORY CANAL 199 except in rare instances. Proper constitutional treat- ment, diet, and hygienic surroundings are most important in these cases. The chronic dry eczema of the external auditory canal causes intense itching and fills the canal with epithelial scales (dandruff) and plugs. Treatment is to remove scales and plugs and keep the canal packed with pledgets of cotton or gauze satu- rated with ointment or oil. If the plugs cannot be re- moved easily, hydrogen peroxid may be used to soften and dissolve them; they should then be syringed with a solution of bicarbonate of soda and water. After this is done the canal must be carefully dried and filled with gauze saturated with zinc oxid ointment or equal parts of zinc oxid anel white precipitate ointment. Solutions of bichlorid of mercury should not be used, nor should boric acid or iodoform, as they sometimes cause dermatitis. Salicylic acid with zinc ointment for the first dressings is often found useful in these cases in removing crusts. In some cases the daily application of a saturated solution of potassium permanganate has been found to relieve the itching and effect a cure. Iodoform dermatitis occasionally occurs afteT opera- tions on the ear, owing to the use of iodoform dressings. At times this may give rise to alarming symptoms, par- ticularly in children. Treatment consists in constant application of cotton or gauze soaked in ice-cold water, to which a teaspoonful of the following mixture has been added: Aluminii sulphat...................... 8 gm. Liquor plumbi subacetatis ............ 4 cc. Aquse............................... 100 cc.—M. Sig.—1 dram to 6 ounces of ice-water; apply externally. 200 EYK, FAR, NOSK, AND THROAT NURSIXei Perichondritis (inflammation of the1 cartilage of the ear) may be troatotl in its first stage for the first twelve or twenty-four hours similarly. It lvemhvs the most constant attention, however, and the nurse1 shoulel report the slightest advancement of the1 inflammation to the surgeon, in order that more radical treatment may be instituted before it is too late. The ugliest deformity of the ear is the shriveled auricle or "pugilist's" ear resulting from a severe perichondritis. Cerumen (ear wax) and epithelial plugs (dandruff) should be softened anel syringed out in the manner ele- scribeel, and under no circumstance's should the nurse attempt their removal with any kind of instrument. Cerumen drops, composed of bicarbonate of soela, gr. xxv; glycerin, 5j; aqua, 3j, arc often prescribes 1 to be1 instilleel into the ear for several hours or even elays before attempting the removal of the plug by syringing, but in the majority of cases such plugs may be removed without this delay by instilling warm hydrogen pcroxiel, allowing it to remain five or ten minutes with the patient lying down, and then syringing with warm solution of bicarbonate of soda (2 drams to 1 quart of water), using a Pomeroy syringe in the manner described on p. 187. Otomycosis, a disease which fills the canal like an epithelial plug, is due to a fungous growth called asper- gillus. It may be removed by syringing, anel shoulel then be treated by instillations of antiseptic solutions to kill the growth. Frost-bite.—The margin of the helix or rim of the auricle is the part first affected. The ear becomes yel- lowish white and, if badly frozen, may become brittle. DISEASES OF AURICLE AND AUDITORY CANAL 201 The most important thing to remember is to exclude the patient from a warm room until the circulation of the ear is restored. Apply gentle friction with snow or cracked ice at first, then bathe the ear with ice-water, and keep it cooi. Foreign bodies in the canal can in nearly every case be removed by syringing, and no one but an experienced otologist should ever attempt their removal in any other way, no matter how easy it may seem to do so with a pair of forceps or a hook. The attempt to remove them with instruments often results in their being either pushed through the drum or in producing so much swelling of the canal that an anesthetic and incision behind the ear is necessitated. Peas, beans, and bodies that are liable to swell if kept moistened, should be syringed with alcohol if the first attempt or two with water fails to remove them. This is important, as the alcohol takes up the water and pre- vents the swelling. Many other ways are advised, but the nurse should not assume the responsibility of attempting them, but should call in an otologist. Furuncles of the Canal.—Boils occur in the external auditory canal frequently as a result of infection from a purulent middle ear. Often, where there is no apparent cause, the infection may be traceel to the use of ear spoons, hairpins, or other implements which have caused slight abrasions. Anemic and diabetic subjects are frequent sufferers. The canal becomes swollen and very painful, and is usually occluded by debris and swelling. Treatment is both local and constitutional. The quick- 202 EYE, EAR, NOSE, AND THROAT NURSING est relief from pain is usually afforded by incision of the furuncle under an anesthetic (gas) followed by a wet dressing of some antiseptic astringent solution, such as aluminum acetate, boric acid, or some other non-irritating antiseptic. However, it is useless to incise1 until the abscess points sufficiently to indicate its presence very near the surface. A stock or autogenous furuncle vaccine may be administered every four or five days te> increase the patient's resistance and prevent, if possible, recur- rence of the boils. Where it is not found advisable or necessary to incise the furuncles they are frequently treated by the introduction of antiseptic solutions, or oils, on gauze wicks in the canal. Cresatin, ichthyol, boroglycerid (50 per cent.), etc., are useel in this way in conjunction with vaccine treatment. As long as the dis- charge of pus continues from the furuncle, a wick of gauze should be kept in the canal to absorb it and prevent its acting as a source of infection to other follicles in the skin of the canal. Diffuse inflammation often spreads from the canal to the external ear, and sometimes can be treated without incision by first cleansing away all the debris and using a cold astringent wet dressing of aluminum acetate. Packing the canal with pledgets soaked in 50 per cent. boroglycerid is often used. Hot-water bags are some- times used to relieve pain, but heat as it was formerly used, in poultices of flaxseed, etc., is no longer used to any extent in these antiseptic and aseptic times, and it has been observed that hot applications seem more apt to cause swelling of the auricle itself and extension of the inflammation from the canal to the concha than does the cold treatment. (See Treatment of Perichondritis.) CHAPTER XXI DISEASES OF THE MIDDLE EAR Acute middle-ear catarrh (0. M. C. A.1) is an acute catarrhal affection of the middle ear in which the mucous lining of the cavity becomes inflamed. The drum is somewhat reddened and may be retracted, de- pendent on whether the middle-ear cavity itself is more or less filled with mucus or serous fluid. It is accom- panied by a feeling of fulness or stuffiness in the ear, sometimes amounting to pain, and is caused by conges- tion and swelling of the Eustachian tube and its lining membrane, as well as that of the tympanum. This con- dition is usually associated with cold in the head, inflamed nasopharynx, or adenoids and enlarged tonsils, and occurs most frequently in children. Treatment is directed toward the swollen nasophar- ynx by removing adenoids and enlarged tonsils if present. Gentle inflation of the middle ear with a Eustachian catheter is practised in cases where there is retraction of the drum with little fluid present. If there is red- ness and bulging of the drum-membrane, showing the presence of fluid behind it, an incision should be made and the fluid evacuated. Hot oil, laudanum, and other well-known "grand- mother's remedies" should not be employed, for, be- 1 Otitis media catarrhalis acuta. 203 204 EYE, EAR, NOSE, AND THROAT NURSING sides being useless, they are1 dirty, sticky, anel difficult to remove1. WIhtc something must be1 elone1 to cone-iliate the patient before the surgeon's arrival, a few drops of warm salt and water or a warm se>lutiem of adrenalin chlorid (1: 1000) may be instilled into the canal, anel a hot-water bag applied, with some relief and no damage to the ear. Acute purulent otitis (0. M. P. A.1) is a step further ad- vanced in midelle-ear inflammation than the 0. M. C. A., anel elovolops where that conelition has become infecteel with a pus-forming germ, giving rise to an abscess in the mielelle ear and causing the e'arae-hevs so frequently met with. These1 e'arae'hes are predispe)s(id by adenoids anel enlarged tonsils, anel usually follow head colels or some1 disease1 which has caused an inflammation of the1 nasetpharvnx. The inflammation extends up the Eus- tachian tube1 to the mielelle1 ear anel cause's an exuelate in that cavity, whiedi becomes infected by some pus- forming germ from the nose or throat. Violent blenving of the nose, forcing mue-us up through the tube, the improper use1 of nasal elenie-he's, and sniffing of water up the ikjso shoulel be avoided, on account of the danger of producing such an infee:tion. No earache1 shoulel be treateel as a trivial matter, nor shoulel the elischarge be neglected if it continues after the earache has coase'd, owing to the1 e-ase1 with which serious complications elevelop. Mastoid antrum tender- ness is piesent in nearly every case of acute earache anel the possibility of extension to the mastoid cells is always imminent. As soon as the diagnosis of (). M. P. A. is made, the patient should be put to beel and preparations 1 Otitis media purulenta acuta. DISEASES OF THE MIDDLE EAR 205 made for myringotomy (incision in the drum), which is usually performed now instead of a paracentesis (punc- turing of the drum), which was formerly the treatment in these cases. Occasionally after spontaneous rupture of the drum, myringotomy will not be necessary, but this is very rarely the case, because the rupture is usually insufficient for drainage, both on account of its size and its location in the drum. When convenient a general anesthetic is advised; nitrous oxid gas for adults and older children, a few whiffs of chloroform or ether for infants. When- ever necessary it is quite admissible to operate without anesthesia or by the employment of local anesthetic of the following formula: ]$. Cocain crystals Carbolic acid crystals\...................^ 3] M Menthol crystals J When mixed this formula deliquesces, and 10 drops or more of the solution should be introduced into the external auditor)' canal by means of a dropper, the patient's head resting on a table or sofa with the affected ear upward. A pledget of cotton about the size of the canal should then be • dipped into the same solution and pressed into the canal with considerable force. By leaving this solution in the canal twenty minutes the anesthesia becomes prac- tically complete in the majority of cases. Whenever this local anesthesia is employed the canal should be wiped out either before or after the myringotomy and alcohol applied to counteract the local effect of the carbolic acid. In every instance a paracentesis should be preceded by 206 EYE, EAR, NOSE, AND THROAT NURSING careful sterilization of the external auditory canal. This is accomplished by wiping the surface of the canal with tincture of iodin followed by similar application of alcohol. The nurse should have ready at the bedside sterile towels, cotton, and cotton applicators, or sterile toothpick swabs (preferably both), culture tubes, and a few glass slides for smears, hydrogen peroxid, tincture of iodin, alcohol, a Pomeroy ear syringe and pus basin, and an irrigating solution of boric acid or 1 : 5000 bichlorid of mercury for cleansing the canal (Fig. 46). Fig. 46.—Myringotomy tray, If the patient is at a hospital the instruments needed, except the knife, will be found on the examining tray and should be freshly sterilized. The knife (myringo- tome) should be placeel in 95 per cent, alcohol and the blade should never be wrapped in cotton, but should be treated with the same care as a cataract knife. If the operation is to be at the patient's house, the surgeon may be relied upon te> bring his own instruments. Immediately after the operation the canal should be cleansed by syringing with moderate force to prevent DISEASES OF THE MIDDLE EAR 207 the blood-clot from blocking the incision. Occasionally, particularly in children, a moist gauze drain is intro- duced into the canal down to the drum, and the discharge is absorbed into a loose dressing over the auricle. The usual treatment, however, is irrigation of the canal every two or three hours, according to the amount of discharge, with boric acid (saturated) or normal salt solution. In the interval, sterile cotton should be kept in the meatus to prevent the discharge from running over the auricle and excoriating the skin. This should be changed fre- Fig. 47.—Babies ear-cap. quently to prevent it from acting as a plug. Children should wear tight-fitting caps of thin material (Fig. 47) to prevent them from removing the cotton and spread- ing the discharge with their fingers. In acute cases boric acid or sterile salt solution is prefer- able to bichlorid solution for irrigation, as it is less liable to cause sloughing of the edges of the incision, which might produce a permanent perforation in the drum. Boric acid crystals will be found more convenient than 208 EYE, EAR, NOSE, AND THROAT NURSINei the powder for making the solution, as they are1 more soluble, and do not, like the powder, float on the surface. It is also important that the irrigation be at a tem- perature grateful to the patient (106° to 110° F.), as the ear is sometimes so sensitive1 that a cold solution will Fig. 48. —Irrigating an ear. cause it to ache for hours and a sleepless night will follow. The best apparatus for irrigating the ear at the bed- side is either a fountain syringe or an irrigator. This should be hung at a height of 2 or 3 feet above the level of the patient's head. The flow is steady and gentle, can be easily controlled, and has not the painful features of bulb syringes, which squirt large air bubbles into DISEASES OF THE MIDDLE EAR 209 the canal, and cause loud explosions, which are most disagreeable to the patient (Fig. 48). An old syringe that has been used for other purposes should never be employed when a new one can be pro- cured. Both the tube with the small tip and the bag shoulel be thoroughly cleaned and boiled before using. Fig. 49. —Fowler's irrigator. After each irrigation the apparatus should be taken down and dried, wrapped in a clean towel, and set aside for the next irrigation. Fowler's "bell glass irrigator" (Fig. 49), which not only cleanses by the flow of water through it, but has a suction effect as well, and keeps the solution from wet- ting the patient, has recently come into favor with many 14 210 EYE, EAR, NOSE, AND THROAT NURSINei surgeons as a useful apparatus for use1 with the irrigator. Lucae's glass return-flow irrigating tip (Fig. 50) is another satisfactory device which has been in use for ),eiars. They are made in different sizes and can be obtained at almost any pharmacy. When the ordinary tip is used it should be long anel narrow, consielerably smaller than the meatus, so as to allow ample room for the return flow. When the tip is placed in position, barely w'ithin the meatus, which should be straightened in the same manner as when the ear is syringed, the stream should be directed, not against Fig. 50. —Lucae's glass siphon douche. the drum, but against the side of the canal far back. If the discharge is very thick and tenacious the irrigator may be raise1*I. In certain cases some surgeons direct the nurse to fill the canal with warm hydrogen peroxid, allowing it to remain for a few minutes before irrigat- ing. Others have considered this a dangerous practice1, claiming that the effervescing of the peroxid might carry the discharge from the middle ear into the antrum. Those who make use of it contend that it has been dem- onstrated that in every case of 0. M. P. A. of a few days' duration pus has already invaded the antrum, and that DISEASES OF THE MIDDLE EAR 211 from its relation to the aditus and middle ear it could not well be otherwise. As the discharge diminishes the irrigations are made at longer intervals, being discon- tinued when the discharge has entirely ceased. Ice-bags and ice-coils should not be applied to the mastoid except by special order of the surgeon. Cold local applications eliminish the tenderness and relieve the pain without stopping the progress of the disease and mask the symptoms to a dangerous degree. Morphin, codein, acetanilid, phenacetin, or aspirin should not be given, for the same reason. In nervous, restless patients sodium bromid, adalin,- and trional, drugs which induce sleep without so much interference with temperature or local condition, may be used for the first night or two. The temperature should be taken by the rectum, every three hours, night and day, and a careful watch kept for any sign of chill or sudden rise of temperature. The bowels should be kept open and the patient restricted to a liquid diet until all untoward symptoms pointing to- ward mastoid involvement have subsided. Careful watch should be kept night and day, and should any one of the following symptoms arise the surgeon in charge must be notified at once: chill, sudden rise of tempera- ture, intense headache or pain, dizziness, or vomiting, nystagmus, continued drowsiness or stupor, stiffness of neck or retraction of head, delirium, or coma. The severe earache and mastoid tenderness, and the more or less high temperature which is present in the first stages of acute middle-ear infection, are relieved promptly, as a general rule, by myringotomy, and where this is per- formed early, before the infection has become established in the middle ear and mastoid, the discharge usually 212 EYE, EAR, NOSE, AND THROAT NURSING ceases and the patient recovers in from two days to two weeks. Where these symptoms are not relieved by the myringotomy and the pain continues severe, temperature1 high, and the tenderness marked, operation on the mastoid may become necessary. In the smouldering type the acute symptoms are re- lieved by the myringotomy, but the infection in the bone progresses slowly with little or no pain. Prolonged dis- charge, swelling, or sagging of the superior canal wall, associated with considerable deafness, is sufficient indie'.u- tion in most cases for operative interference, even where there is no tenderness over the mastoid and no appre- ciable rise of temperature. No definite symptoms of mastoiditis and its many com- plications can be set down here for the very good reason that in no two cases are the symptoms wholly alike, and in trying to apply "cardinal signs" to all cases the nurse may be led astray and not appreciate the seriousness of her patient's case because, let us say, he has no mastoid tenderness, no temperature, and no edema or redness over his mastoid. It is better, therefore, to' state, as we have done, the dangerous symptoms she should report and to explain their significance. For example: A chill followed by a sudden rise of temperature in a case of mastoiditis that has existed for several days, or has been operated on, would strongly indicate septic absorption, very probably through the lateral sinus, and if other causes of sepsis were not obvious the possibility of a sinus thrombosis would naturally be thought of. In such cases the patient often feels quite comfortable despite the fluctuations in his temperature, and the inex- DISEASES OF THE MIDDLE EAR 213 perienced are misled by this euphoria (sense of well- being) . Dizziness accompanied by vomiting and nystagmus, associated with inflammation of the middle ear or mastoid, would indicate marked irritation of the labyrinth and, in all probability, spreading of the infection from the middle ear to the labyrinth or internal ear to be limited there with marked impairment of hearing as a result of it, or, as not infrequently happens, extension of the infection through the internal ear to the meninges. The latter causes at first great restlessness and headache, with more or less delirium, and later more marked signs of meningitis, such as retraction of the head and coma. An abnormally slow pulse associated with occasional vomiting and intense headache is suggestive of brain abscess. It may be caused, however, by a temporary congestion of the brain or increased intracranial pres- sure from other causes. Chronic purulent otitis media (O. M. P. C.1) follows 0. M. P. A. frequently as a result of its neglect or improper treatment. It often occurs after scarlet fever, measles, and other acute infectious diseases, where the ears have been neglected in the general treatment of the illness, the child being too sick to call attention to the acute otitis, which is allowed to become chronic through lack of treatment. To prevent this in such cases aural examinations should be made every few days. The foul discharge in these cases can be markedly dimin- ished and rendered free from odor by the following treatment: 1 Otitis media purulenta chronica. 214 EYE, EAR, NOSE, AND THROAT NURSINO Have the" patient lie de>wn with the1 a fleeted ear up, fill the ear with warm hyelrogen peroxid anel work it well down to the midelle ear by now and the'ii drawing the auricle upward and backward, wipe away the foam; put in fresh solution and keep the treatment up for five1 minutes; then syringe the ear clean with boric aciel solu- tion or 1:5000 bichlorid, anel after elrving the canal drop in a half teaspoonful of 80 per cent, alcohol, anel fill the meatus with cotton, to be changed frequently. The alcohol will in most cases smart cemsiderably the1 first few times it is used, but the ear soon becomes ac- customed to its use. If there is any dermatitis of the canal or auricle, use normal salt solution instead of bi- chlorid, and apply zinc oxid ointment or Lassar's paste to the irritated area. For the first few days this procedure may have to be followed every three hours, but when the discharge diminishes it can be done less frequently. It is very necessary when adenoids and enlarged tonsils are present to have them removed, as they are most frequently the exciting cause of the disease. Cotton should be kept in the ears anel changed frequently to prevent the discharge from flowing over the auricle anel che'ek anel producing a derma- titis which not infrequently involves the whole side of the face and scalp. In the treatment of children the tight-fitting caps before spoken of will be found useful. When the above treatment fails after a fair trial, an ossiculectomy or the radical operation, depending on the extent of the disease, shoulel be considered to effect a cure. DISEASES OF THE MIDDLE EAR 215 Chronic catarrhal otitis (0. M. C. C.1), or dry catarrh of the middle ear, is frequently the cause of deafness, but persons afflicted with the disease rarely need the care of a trained nurse1 in the treatme-nt of it. From having to record tests of hearing before and after treatment the office nurse will appreciate the benefit to be derived from treatment commenced early in the course of the disease and the hopelessness of benefiting those of long staneling. The ronien'al of adenoids anel enlarged tonsils when they exist in cases of beginning deafness will often pro- mote the return of normal hearing. In such cases oc- casional inflation of the middle ear with the Eustachian catheter and proper care of the nasopharynx will prevent the return of the deafness. Preparation for Operation on the Mastoid The "simple mastoid" operation does not extend be- yond the mastoid process of the temporal bones. It consists in the removal of all the cellular structure of the mastoid process without invasion of the middle ear or external auditory canal. The commonly called "radical" is performed only when the middle ear is so eliseaseel that its drum and ossicles have to be removed. The posterior bony canal wall is then cut down and the cavity of the middle ear is cleaned out and joined to that of the mastoid antrum, making one large cavity. The remaining cells of the mastoid process may or may not be removed, depending 1 Otitis media catarrhalis chronica. 216 EYE, EAR, NOSE, AND THROAT NURSINO on their conelition. In either case, a new meatus has to be made by cutting the auricle. The walls of the- canal are foleled back to prevent its atresia (closing up) and te> increase the space for subsequent elressings. In Fig. 51. —Area shaved on a woman. The hair is braided tightly to the opposite side of the head and a lock of hair is left in front of the ear. many cases the incision over the mastoid bone can be sutured and the cavity dressed through the new meatus. In preparation of the patient for a simple mastoid or radical operation, as in any other operation where ether or chloroform is required, a specimen of urine should be obtained before and after the operation, and the usual directions for enema and catharsis carried out. In private practice, particularly in women, the nurse should enquire of the attending surgeon exactly how much hair he wishes her to remove with the razor and thereby avoid a respon- Fig. 52. -Area shaved for mastoid operation. diseases of the middle ear 217 sibilify which is sometimes to the patient the greatest in connection with the operation. She should also inquire whether or not the patient is to have a shampoo. If this is not contra indicated, it adds greatly to the comfort of the patient in the weeks following the operation when the head is bandaged. Usually a shaved area extending 2 inches from the meatus in the required direction is sufficient, and most women appreciate the saving of a large lock of hair just in front of and above the auricle. This can be combed forward and upward and that part next the field of operation held down with collodion (Fig. 51). Where the skin is to be sterilized at the time of operation by the application of tincture of iodin, this is as far as the prepa- ration need be carried, except to cleanse the canal of dis- charge and place in it a piece of gauze. After the anes- thetic has been administered and the patient properly placed on the table a bottle of iodin and a plentiful supply of alcohol must be at hand. The usual 7 per cent, tinc- ture of iodin, particularly in blond patients, occasionally blisters if it is not promptly removed with alcohol, so a tincture diluted with alcohol to a 3 or 4 per cent, strength is now more commonly used. The following preparation is the one that has been in use at many institutions for many years past, and it still is satisfactory when properly followed. Before preparing the skin thoroughly cleanse the canal, first with hydrogen peroxid, then with bichlorid solu- tion (1:5000), and fill it with gauze moistened with the solution. The auricle and field of operation, the cheek and the neck, should next be thoroughly scrubbed 21S EYE, EAR, NOSE, AND THROAT NURSING with green soap and water, alcohol and ether, anel washed off with 1:5000 bichlorid solution. A large moist dressing of 1:8000 bichloriel solution should then be applied, care being taken that the crevices in the auricle are well filled with small strips of gauze, and that the dressing extends well forward on the cheek and down the siele of the neck. Great care in the1 preparation of the auricle itself is particularly necessary before the "radical" operation, because of the incision made in the concha for the new meatus. It is not unusual to see a patient come into the operating room with a dressing which barely covers the auricle, leav- ing part of the field of operation entirely expe)seid. The elressing shoulel come well down on the neck, even if it be somewhat cumbersome and difficult to keep in position. To recapitulate: The nurse should first enquire of the surgeon how much hair is to be removed and whether or not he wishes to use iodin for preparation of the skin. She should then— Obtain a specimen of urine. Shave an area l\ to 2 inches around the ear, measured from the meatus. Douche the ear with bichlorid of mercury, 1: 5000. Place a strip of gauze and collodion, not adhesive plaster, over the margin of hair. Put a strip of gauze in the canal, and apply a dry elmss- ing if iodin is to be used later; if not, the preparation must be continued as described above. When skin-grafting is to be employed in a "radical," the left thigh (without reference to the ear that is to be operated on) should be chosen, and its anterior and inner aspect prepared; because experience has shown that it DISEASES OF THE MIDDLE EAR 219 is easier to cut the skin from above downward than it is from below upward. If the surgeon cuts grafts with his left hand, the right thigh should be prepared. For preparation of an operating room, refer to Chap- ter I. After the patient has been anesthetized, the bandage should be cut and the dressing removed without the field Fig. 53. —Arrangement of towels around mastoid region before opera- tion. of operation being touched by the nurse whose hands are not sterile. The patient's body should be covered with a sterile sheet, and the head, face, anel neck with towels properly arranged and pinned in place around the mas- toid by the nurse whose hands are sterile. Careful towel- ing, without the annoyance of excessive "sailcloth," for the protection of the wound from the skin, and, for what is more important in mastoid surgery than elsewhere, the protection of the freshly opened skin from contact with the scrapings and pus from the virulently infected mastoid is necessary. A device, sometimes called an ether bridge, that rests 220 EYE, EAR, NOSE, AND THROAT NURSING on the cheek of the patient in front of the auriede over which a towel is placed is of considerable convenience1 in that it gives the anesthetist an unobstructed view of the patient's face, but keeps him out of the way of the operator. Folded iodoform gauze strips \ inch wide shoulel be close at hand from the beginning of the operation in case they are needed for a rent in the sinus or dura, and bone- wax to control any bleeding from the bone. Skin-grafting.—When skin-grafting is necessary, a sepa- rate table with the instruments and solutions on it should be1 made ready and covered with a sterile cover, so that after the cavity has been prepared the grafts may be cut and placed with clean instruments and fresh solutions, without fear of contamination from the soiled table and instruments. Together with the razor and special grafting instru- ments, the nurse should have on the table three glass slides; a pair of sharp-pointed scissors; a pair of heavier se-issors; one small spoon curet; one medium-size spoon curet; two pairs of bayonet forceps; a number of appli- cators; sterile cotton, toothpick swabs, a bowl of warm salt solution, gauze sponges; a tube of |-inch plain gauze packing to be used for pledgets. Some surgeons use cotton pledgets with aristol on them to hold the grafts in place, so it is well lor the nurse te> inquire what the surgeon is in the habit of using. Often little attention is paid to the abrasion on the thigh, and frequently patients complain of the pain it give's them. A elressing of silver leaf applied thickly and bandaged firmly to pre- vent any oozing of blood under it will be found most satis- factory. If properly applied the dressing need not be1 removed for ten days, when the surface will be healed. DISEASES OF THE MIDDLE EAR 221 Emergencies That May Arise.—One of the most fre- quent complications that arise in mastoid surgery is hemorrhage from the lateral sinus, the large vein lying in the covering of the brain, due to its accidental or intentional opening by the surgeon. This can be con- trolled immediately if the nurse has right before her the folded iodoform gauze strips already mentioned. These must be at hand from the very beginning of the opera- tion, as the sinus is sometimes injured at the first stroke of the chisel. When the sinus is found unexpectedly clotted and it is necessary to tie off, or take out the internal jugular vein, its continuation in the neck, the nurse has only to supply a sand-bag or some folded towels to put under the patient's shoulders. A rectal tube and plenty of hot sterile salt solution should be ready in case it is needed for treatment of any shock that may arise during the operation. If intraveiums infusion is necessary it is the part of the surgeon to attenel to it, and the nurse has only to supply the salt solution. When the1 jugular vein is to be1 excised there is at first a hasty preparation of the skin of the neck usually with iodin, sometimes with soap, water, alcohol, and bichlorid, or some anti- septic solution, but nothing outsiele of the things ,enu- merated under Preparation of an Operating Room will be needed. When a brain abscess is encountereel the surgeon may require other instruments, but the nurse1 cannot be expected to have them ready unless notified in time. If she has the things before mentioned she will be pre- pared for any emergency. 222 eye, ear, nose, and throat nursing Other Operations Myringotomy.—See page 205. Ossiculectomy is the operation for removing the os- sie'les from the middle ear, that is, the malleus and incus, the stapes being left in its place. This is usually deme under eocain anesthesia, but is probably done with greater satisfaction to the patient under a general anos- thetie. The preparation for this operation consists of cleansing the1 ear thoroughly with hydrogen peroxid anel 1: 5000 bichloriel of mercury solution, and packing the canal anel crevice's of the auricle with gauze saturated with 1: 8000 bichlorid of mercury solution, which shoulel remain in the ear until the time for the operation. The usual hand solutions should be gotten ready anel a table prepared havingonit a full set of oar specula, se-issors, applicators, toothpick swabs, gauze packing, adrenalin, anel an ear dressing. The surgeon may ho expected to select the ossiculectomy instruments, and after he has removed the ossicle's, a sterile ear syringe (Pomeroy's) should be1 reaely for syringing out the blood before pack- ing the1 canal with iodoform or plain gauze. Incisions of Furuncles in the Aural Canal.—A general anesthetic is usually employed, and the patient shoulel be prepared accordingly. The auricle is usually too sensitive to admit of much cleansing before the patient is anesthetized, and it nee;d only be wiped off and pro- tectee I with gauze saturated in an antiseptic solution before this is done. The instruments needed are a set of ear specula, furuncle knife, bayonet force'ps, small spoon curet, scissors, probe, director, and applicators; the solutions: alcohol, hydrogen peroxid, carbolic aciel (95 per cent.), and a bowl of 1 per cent, carbolic acid DISEASES OF THE MIDDLE EAR 223 solution, unless some other antiseptic solution is preferred by the surgeon. A Pomeroy syringe and pus basin, sterile towels, a tube of plain gauze packing, and an ear dressing will complete the list of things necessary. (See Treatment of Furuncles, p. 201.) Dressing and Bandaging.—The technic of dressing "mastoids" anel "raelicals" varies greatly with differ- ent surgeons, but in the main they use the same1 instru- ments and make use of the same dressings and solutions. Some surgeons dress their cases without touching the wound or any of the dressings with their fingers. They hold the auricle between their fingers with thin squares of cotton an inch or more in size moistened in an antiseptic solution, and with smaller pieces held in forceps wipe out the wound with whatever solution they see fit, and use sterile toothpick swabs to avoid twisting cotton on applicators with their unsterile fingers. The rest of the dressing, except the outside cotton and ban- dage, is applied with the same precaution. Other surgeons use gloves; handle the packing and gauze freely, and twist cotton on applicators without fear of infection. Others do not use the gloves, but follow this last technic, considering that they have ster- ilized their hanels by immersion in an antiseptic solution. This is the most unsafe method of the three, as most men are in too great a hurry to properly sterilize their hands. During the past five years new antiseptics have been dis- covered which, in solutions of proper strength, are harmless to the tissues and yet of considerable bactericidal value. In consequence of this, antiseptics are now more generally used in infected wounds than they were a few years ago. 224 EYE, EAR, NOSE, AND THROAT NURSING The ideal antiseptic is one that cleanses thoroughly without injury to the tissues, that dissolves blood-clots and sloughing tissue and exposes bacteria in such place's to its germicidal action. Such an antiseptic is, at the present time, more nearly met with in the solution of sodium hypochlorite, known as Dakin's solution, than in any other. Dakin's solution is an aqueous solution whie-h contains not less than .45 per cent, nor more than .50 per e-ent. of sodium hypochlorite, and which is not alkaline to phenol- phthalein. If the percentage of sodium hypochlorite is below .45 per cent, the antiseptic power of the sejlution is too low. If greater than .50 per cent, the solution is irritating. If the solution is alkaline to phenolphthalein it is also irritating. If it is not just what it should be it is not Dakin's solution and it should not be used as such. The following points must be remembered in its use: it shoulel be freshly prepared every day and kept in dark bottles away from the light. If a bowl of the solution is exposeel to the direct sunlight even for a minute it will lose strength, and if exposed to the subdued light of a ward away from the bright light it may be useless in half an hour. So it is necessary to keep it in dark bottle's away from bright light until ready for use. Bowls for its use must not be wet with other solutions, but rinsed only with plain water. A drop or two of Burow's solution (aluminum acetate) or an ordinary antiseptic tabled of bichlorid of mercury and ammonium e-hlorid will turn a bowl of Dakin's solution white and render it unfit for use. Its value as a cleansing agent for infected wounds is DISEASES OF THE MIDDLE EAR 225 due to its action as a solvent for dead animal matter, blood- clots, pus, and necrotic tissue. Consequently, in wounds where secondary hemorrhage might be expected it should be used with caution because its faculty for dissolving blood-clots might act to promote hemorrhage. It will also in time dissolve silk, catgut, etc. (dead animal tissue), so its prolonged use may render this material unreliable. As the strength of the solution is not neutralized by the dry skin as it is by the secretions of the wound, the skin around the wound must be protected with vaselin to prevent its becoming inflamed. The point to be remembered about this valuable solu- tion is that unless every precaution, as described above, is observed it had best not be used, and if quick beneficial results are not obtained by its use in dirty wounds it means that the fault is with the user, not with Dakin's solution. The solution is no longer "Dakin's" if it has been allowed to deteriorate. Solutions of chloramin, sometimes also called Dakin's solution, have the advantage of being more stable and of being easily made from tablets, but they are lacking in either the solvent or the penetrating power of the Carrel- Dakin solution. The same can be said of the solutions of dichloramin-T in chlorcosane; they have1 high anti- septic value, but not the solvent properties of the hypo- chlorite solution. A dressing tray for mastoid and radical cases should hold the following instruments in a small tray carefully protected with a sterile cover of either cloth, metal, or glass: Bayonet-shaped or straight forceps; Hartmam; I'oireps, scissors, straight and curved, full set of eai specula; applicators, silver probe, attic probe, ring curet, 15 226 EYE, EAR, NOSE, AND THROAT NURSING two spoon curets, medium and small. A head-mirror and a pair of banelage se'issors are also necessary, but, of course, these should not be placed on the sterile tray (Fig. 54). There shoulel be a receptacle for the soiled instruments and, in addition, a finger-bowl filled with whatever sec- tion the surgeon desires—Dakin's, bichlorid, boric acid, carbolic, or salt solution. In a separate part of the1 tray away from the sterile instruments a silver nitrate1 stick Fig. 54.—Dressing-tray for mastoid and radical cases. and the small solution bottles containing nitrate of silver solution (50 per cent.), sterile eocain (10 per cent.), collodion, balsam of Peru, 2 and 5 per cent. dichloramin-T, and an}r other solutions especially required, should be placed. Larger bottles of peroxid and alcohol, with two medicine-glasses in which to pour them, should also be supplied. The gauze packing, both iodoform and plain, and balsam of Peru, should be of the softest, most absorbent DISEASES OF THE MIDDLE EAR 227 gauze with infolded edges \ inch wide, kept in tubes 6 inches long. Larger tubes than these are unnecessary for most dressings, and gauze left in a tube should not be used at a future time without being resterilizeel. This is important, as old tubes of gauze, left with their cotton stoppers pushed down in them and their necks entirely exposed to contamination, is a most common and flag- Fig. 55.—Method of applying bandage to mastoid dressing. rant example of faulty technic. Two jars of absorbent cotton wipes, moistened in an antiseptic solution, are necessary for those who dress their cases without touch- ing the wound or dressings with their fingers; one of large, 1 inch or more square, for holding the auricle, and the other of those \ inch square, to be used with the forceps for wiping the wound. Toothpick swabs and sterile cotton or cotton balls should be kept in small packages 228 EYE, EAR, NOSE, AND THROAT NURSING rather than in jars, as they arc then less liable to con- tamination. The dressings should be in individual packages, wrapped in muslin and sterilizeel. Each package should contain the usual thickness of absorbent cotton 6 inches square; two or more large handkerchiefs of shaken gauze, and a semilunar patch of folded gauze Fig. 56.—Finished mastoid dressing. to place behind the auricle over the wound. Enough plain gauze packing for the mastoid can be rolled in a coil and conveniently placed in the dressing if it is desir- able to dispense with the tube. In dressing a mastoid particular attention should be paid to the cleansing of the canal at each dressing, and this should be kept well filled with plain gauze packing, both to absorb the secretion and to prevent its closure. Particular attention also should be paid to the skin DISEASES OF THE MIDDLE EAR 229 around the wound, which becomes easily irritated. This should be kept covered with zinc oxid ointment or Lassar's paste. In bandaging, the ear should always be banelaged back ware I against the heael. When applieel in the op- posite direction the tendency is to carry the auricle forwarel and close the meatus, anel in children, occasion- ally, to folel the auricle on itself and cause a lop ear (Figs. 55 and 56). _____ Fig. 57.—Black silk ear patch. To recapitulate the articles needed for a dressing tray: (1) The instruments named, which are not many and take up very little space. (2) Head-mirror and bandage scissors—the last the nurse should have in her belt. (3) Receptacle for soiled instruments. (4) Two jars of bichlorid wipes—large and small. 230 EYE, EAR, NOSE, AND THROAT NURSING (5) Package of sterile towels. (6) Bowl of solution (Dakin's). (7) Peroxid, alcohol, and two medicine-glasses. (8) Silver nitrate stick and jar of Lassar's paste. (9) Bottles of silver nitrate (50 per cent.), collodion (with brush in cork), 10 per cent, eocain, and any other solution especially required. Fig. 58.—Cotton and collodion dressing. (10) 6-inch tubes of folded gauze—ioeloform, plain, and balsam of Peru. (11) Small package of toothpick swabs anel cotton for applicators. (12) Individual dressings and bandages. CHAPTER XXII DISEASES OF THE INTERNAL EAR Internal ear affections may be classed as suppura- tive and nonsuppurative. Suppurative labyrinthitis may be acute or chronic, in either case it is usually caused by extension of suppura- tive elisease from the middle ear. The panotitis, which frequently makes deaf mutes of children, is usually assex'iated with scarlet fever, and is due to suppurative involvement of both the middle and internal ear. The acute form sometimes follows operation on the middle ear when the labyrinth has been entered and infected or, in rare instances, it may develop in a case of acute otitis (O. M. P. A.) before myringotomy has been performed, the infection passing through the internal wall of the middle ear. or through the oval or round window. It may also develop suddenly from an old suppurative con- dition of the middle ear (0. M. P. C). The patient first becomes dizzy and nauseated, and shows marked nystag- mus (a jerky movement of the eyeballs) in the beginning when looking to the side of the diseased ear. He com- plains of tinnitus (head noises), of headache, deafness, and later may show signs of meningitis. At the first appearance of any of the above symptoms the patient should be put to bed and the surgeon notified. Early operation for drainage of the labyrinth is advo- cated by some surgeons; others consider operative inter- ference unwise, and prefer to rely on the protective bar- 231 232 EYE, EAR, NOSE, AND THROAT NURSINe; riers erected by nature and the administration of seda- tives. Chronic suppurative labyrinthitis may follow the acute1 form or gradually develop from an 0. M. P. C. of long standing. The hearing is usually entirely lost in the affected ear and the caloric test' on that side is negative1. Pus discharges either through a fistula into the middle ear or antrum, or through the1 oval or round wine low. These cases may continue quiescent for years or they may suddenly give rise to meningitis, brain absevss, or thrombosis of the lateral sinus. The treatment is the same as that given for O. M. P. C, anel when this fails the radical operation, with removal of the semicircular canals anel drainage of the ce>chlea and vestibule1, should be1 considered. Non-suppurative Labyrinthitis.—Sudden loss of hear- ing in both ears where no suppuration or apparent disease exists is not uncommon. The cause is usually acute congestion, hemorrhage, or exudate in the laby- rinth. The patient, deaf to outside noises, complains of roaring or bell-like tinnitus, dizziness, nausea, anel staggering gait. He may lose consciousness suddenly and die. This group of symptoms was called Meniere's disease and the cause was said to be hemorrhage into the labyrinth. It is now known that other causes than hemorrhage produce the same symptoms, among which are acute congestion and the formation of exudate or anything that causes a profound disturbance of the; labyrinth. Cerebrospinal meningitis sometimes leaves a case stone deaf without any apparent involvement of the ear. Syphilis, either hereditary or acquired, lSeep. 195. DISEASES OF THE INTERNAL EAR 233 is a common cause of this kind of deafness. Other causes are poisonous doses of drugs that cause congestion of the labyrinth, such as quinin and sodium salicylate, caisson disease, and arteriosclerosis. The treatment is, first of all, rest in bed until the vertigo anel nausea have disappeared, then large doses of potassium iodid and pilo- carpin sweats are usually given to hasten the absorption of the hemorrhage or exudate. In the syphilitic cases salvarsan is used in a series of injections, with mercury and potassium iodid administered, as usual, in the interval between the injections. Chronic labyrinthine deafness, like chronic middle-ear deafness, rarely comes under the care of a trained nurse. It is called "nerve eleafness" and practically nothing can be done for the relief of it. (See Test, p. 193.) It is sometimes hereditary anel may come on gradually, the labyrinthine capsule becoming more and more involved in a spongification, or the acute symptoms of Meniere's elisease may subside, leaving the nerve partially or totally destroyed and the patient corresponelingly deaf. The same may be true after suppurative labyrinthitis has healed and ceaseel to elischarge. The deafness of old age is usually a nerve deafness, in which the hearing for low tones remains good, but that for high tones is lost. In deaf mutes the labyrinths have usually been de- stroyed in babyhood by scarlet fever, meningitis, heredi- tary syphilis, measles, or some other acute infectious disease IV. The Nose chapter XXIII ANATOMIC DESCRIPTION OF THE NOSE AND ACCES- SORY SINUSES Externally the nose is elividetl into— Root, where the two nasal bone's articulate with the frontal bone. Dorsum, the top surface from the; root to the tip, formed by the two nasal bones anel lateral cartilages. Tip, the extremity made up of separate cartilages. Internally the ne)sei is separateel into a right and left nasal cavity by the septum. The anterior opening of each chamber is called the vestibule, around the inner part of which thick hairs grow, caller I vibrissa1. The posterior openings are called the choana! or posterior nares. Each nasal cavity has a floor, which forms the supe- rior surface of the harel and soft palate; a mof, which is formed by the cribriform plate of the ethmoid bone; an inner wall, which is the septum; anel an outer wall, which is maele1 up of the turbinated bodies which sepa- rate each chamber into three meati by their curvatures. The turbinated bodies or turbinates are six fragile scroll-like bones covered with mucous membrane, three on each side, and arranged one above the other, with a 234 DESCRIPTION OF NOSE AND ACCESSORY SINUSES 235 meatus between, so that they are called, according to their position, superior, middle, and inferior turbinates. The inferior, as its name implies, is nearest to the floor of the nose, and is ordinarily the largest. The middle n Fig. 59. —The lateral wall of the left nasal cavity. Almost the entire middle turbinated bone has been excised in order to expose the structures and orifices situated beneath it. A piece has been removed from the anterior portion of the inferior turbinated bone. The original borders of the turbinated bones are indicated by dotted lines. The superior turbinated bone is intact. The orifices of the left sphenoidal arid frontal sinuses are shown by arrows. a, Ostium of sphenoid sinus; b, left sphenoid sinus; c, fossa of Rosenmiiller; d, orifice of Eustachian tube; e, left frontal sinus; /, infundibulum; g, attach, middle turbinated bone; h, hiatus semilunaris (Schultze and Stewart). is intermediate and the superior is placed highest in the nostril. Above the superior there may be additional turbinates, but they are of no surgical importance. 236 EYE, EAR, Ne)SE, AND THROAT NURSING The turbinates are arrangeel in such a manner that the greatest amount of heating anel moistening surface is presented to the incoming air in the least possible space. Their function is to warm, moisten, anel filter the inspireel air befere1 its reception into the lungs. Beneath the inferior turbinate is the inferior meatus of the nose, the lower boundary of which is on a plane1 with, and unite\s in forming, the floor of the nose1. Into this meatus empties the tear duct. An inflammation of the inferior turbinate may occlude this duct by pressure1 or by aelhe'sie^ns to the aeljacent mucems membrane, in which case1 there is an overflow of the lacrimal socivtiem upon the lower ewevliel. The upper third of the septum anel upper third of the outer wall of the nasal chamber are supplied by the olfactory nerve, and it is only upon this area of the nose that the se'iise1 of smell is perceived. The remaining two-thirds are devoted to the act of ivs- piration. Beneath the mielelle turbinate and above the inferior is the middle meatus. Into this there empties the frontal sinus, the anterior ethmoidal cells, and the antrum of Highmore or maxillary sinus, in a common groove. The frontal sinus drains through the nasofrontal duct into a curved groove called the hiatus semilunaris; while the maxillary sinus opens into this meatus through the ostium maxillare. These openings are both under the mid- dle turbinate and are difficult to locate with the probe. Above the middle turbinate is the superior meatus, into which the posterior ethmoidal cells and the sphe- noidal sinus empty. It is exceedingly difficult to probe the sphenoidal sinus through its ostium before the re- moval of the middle turbinate. DESCRIPTION OF NOSE AND ACCESSORY SINUSES 237 Nasal Septum.—The septum should divide the internal nose into two equal compartments, but, owing to various accidents and faulty development, there are few noses in which this is the case. The septum is made up of the perpenelicular plate of the ethmoid, the1 vomer, and the Fig. 60.—Osseous and cartilaginous septum of the nose: 1, Triangular cartilage of the septum; 2, columnar cartilage, cartilage of the aperture; 3, cartilage of Jacobson; 4, supra vomerine cartilage, sometimes present: 5, vomer; 6, perpendicular plate of ethmoid; 7, ethmovomerine suture; 8, sphenoidal sinus; 9, nasal bone; 10, palate bone (Arnold). cartilage of the septum, which is the triangular or quad- rilateral cartilage. The vomer projects from the sphenoid bone behind and extends forward under the cartilage nearly to the anterior extremity, and receives its name from its fancied resemblance to a plough-share. The entire inner sur- face of the nose is covered with mucous membrane. 238 EYE, EAR, NOSE, AND THROAT NURSING That part supplied by the1 olfactory nerve1 is known as the Schneiderian membrane. Functions of the Nose.—It is the organ of smell. It warms, moistens, and filters the air before1 it tuitors the lungs. It aids in phonation and in the pe'rce'ption of taste. It gives expression to the face and is a racial characteristic. The sinuses aeljacent to and emptying into the nose are important from thear surgical consideration. The Maxillary Sinus or Antrum of Highmore.—There1 is one on either siele of the ne.>se, situated in the superior maxillary bone, anel emptying into the middle meatus. This sinus varies in size from a pea to a walnut and is sometimes absent. The floor of the sinus is frequently on a level with the floor of the ne>se, but it may be above or behnv this plane. The floor is formed by the alveolar process of the superior maxilla, anel the roof is the floe>r of the orbit. The inner wall convsponels with the outer wall of the nasal chamber. These are the facings of this e-avity of greatest importance from an operative stanelpoint. Frontal Sinuses.—They are two in number, situated between the two tables of the frontal bone, and are locate'd internally and superiorly to the upper rim of the orbit of either side. They vary in size from a pea to a chest- nut and are sometimes absent on one or both sides. They drain through the hiatus semilunaris into the middle meatus of the nose. They are important surgically because they are frequently infecteel by bacteria being forced from the nasal chamber into the cavitie's during the act of blowing the nose. Also, they may be infected by direct extension of the pyogenic organisms existing DESCRIPTION OF NOSE AND ACCESSORY SINUSES 239 in the nose1. Probably the most frequent infecting micro-organism is the grip bacillus. By means of the x-ray the presence or absence of the sinus may be deter- mined, also its extent, and if it is filled with pus. Ethmoid Cells.—Between the frontal sinus anteriorly and the sphenoidal sinus posteriorly are situated a mass of bone-cells, which lie above and to the side of the superior meatus. These cells are divided into anterior and posterior cells. The anterior empty into the middle meatus anel the posterior into the superior meatus. They are frequently infected by the various bacteria in the nostrils, and it is from these infected cells that most polypi spring when the pyogenic condition has been long neglected. Sphenoidal Sinus.—There are ordinarily in the sphenoid bone two sinuses divieleel by a thin lamina of bone, called the septum* They are situated in the body of the sphe- noid bone and vary in size from a pea to a pecan nut. They have an outlet known as the ostium, which opens into the superior meatus. This sinus, like the others, is frequently infected, and when filled with serum or pus sufficiently to create pressure, gives pain behind the eyes and a dull headache. Growths, both malignant and benign, originate in this sinus, and when they assume large proportions cause the eye of that side to bulge outwarel. This condition is known as exophthalmos. To enter this sinus it is necessary first to remove the middle turbinate in order to obtain a perfect view of the operative field. CHAPTER XXIV DISEASES OF THE NOSE Examination of Patient.—For the examination of the nose or thre>at the1 patient's lu^ael should be on a level Fig. 61.—Position for examination of the nose. with or a little below the head of the examiner. The light should be on the right side of the patient on a level with his ear, and may be either gas or electricity with a proper condenser (Fig. 61). The instruments for ■>A0 DISEASES OF THE NOSE 241 examination, as nasal speculum, tongue1 depressor, etc., should be on a table to the left of the examiner, while the instruments for the operation should be on a table at his right. For the examination of infants the nurse should wrap the baby completely in a blanket or sheet with the head protruding. She should hold the baby with its head resting against her left shoulder and her left hand sup- porting it in front. The most effective method of holding a fractious e'hild is for the nurse to take him in her lap, confine his knees and legs between her own, place her arms under his and her hands pressed against each side of his head (see Fig. 6, p. 72). This necessitates a forced extension of his arms and hands outward, and should he endeavor to interfere with the examination, his hands can be kept away by the extension of the nurse1's elbows. Rhinitis.—This may be acute, which is the ordinary cold; chronic; hypertrophic; atrophic; mucopurulent; membranous, or caseous. Acute Rhinitis.—The ordinary cold is being treated with more1 consideration daily, as it precedes so many of the1 infe'ctious fevers anel other constitutional diseases. Its symptoms are manifest and the diagnosis easily made by all. Treatment. — Prophylactic. — This includes clothing adapted to the season of year and climate in which the patient lives. As a general rule when persons spend the greater part of their time indoors, especially the modern superheated buildings, they should depend upon the change of outer garments rather than changes of inner garments to meet the sudden and at times extreme variations in the atmospheric temperature and barometric 16 242 EYE, EAR, NOSE, AND THROAT NURSING conditions. Proper attention shoulel be paiel to the1 elimination of wet footwear. Diet is very important — overeating is prone to cause gastro-intestinal disturbance, the absorbtion of toxins, and consequently a lowered resistance. Cold sponges and cold plunges or showers are very efficacious, but should be employed only by those of the sthenic type, and unless a glow to the skin and a feehng of stimulation and warmth ensues the "cold water" treatment should be interdicted. As far as pos- sible the dissemination of particles by sneezing and cough- ing should be limited by the use of handkerchiefs, which should be sterilized immediately after limited use1, either by means of immersion in a 5 per cent, solution of formalin or by boiling. Local and Constitutional.—The same principle is to induce depletive reactions—to get rid of exudates, anel not to lock them in—therefore suprarenal extracts anel eocain are contraindicated in the early stages. Heat locally, either dry or moist, as by means of the elee'tric light box (Brunnings and Killian), the croup kettle en- some modification of it is indicated. Hot drinks, mustard foot-bath, Dover's powder, and mild catharsis are also useful. When the nasal discharge becomes thick, post- nasal irrigations with some mild alkaline solution, as Dobell's 25 per cent., normal saline, or Seder's, may be used twice daily. Also the administration of stimulating expectorants by mouth, as ammonium chlorid. Acute Rhinitis in Children.—There is no essential difference in the symptomatology as compared to the c-emdition in adults, except the more common presener of adenoids, and if uncomplicated terminating quicker. Prophylaxis is very important. The diet is most impor- DISEASES OF THE NOSE 243 tant of all, then proper care in dressing and bathing—the avoidance of draughts, keeping away from steam radiators ' or other heating device the heat from which causes a sudden taking-up of moisture and a consequent sudden chilling of the surface of the infant's body. Cool spong- ing should follow the warm bath if proper reaction is obtained. Bundling the infant up in clothing is to be decidedly condemned. Local and Constitutional.—A small piece of absorbent cotton is rolled into a wick, moistened with warm milk to which sodium chlorid or boric acid has been added in the proportion of 3 gr. to the ounce, and then intro- duced into the nostril and worked back and forth until as much mucus as possible has been removed. Argyrol, lper cent., is then allowed to flow into the nostril from a medicine-dropper. The treatment is carried out in both sides twice daily for three or four days. Two to five drops of the solution of ammonium acetate a couple of times a day may be given. Opium in any form is not well borne by infants and its use should be avoided. Chronic Rhinitis.—This may be accomplished by caustics, as silver nitrate, fused on a metal applicator or fused chromic acid. Nitric acid may also be applied. Atrophic Rhinitis and Ozena.—The former may precede the latter and is characterized by an excessive dryness of the nasal mucous membrane, the formation of scabs or crusts which are firmly adherent to the walls and septum Decomposition takes place, giving rise to an offensive odor. When the atrophy is very marked and the odor is exceedingly offensive the term "ozena" is applied. One peculiar symptom is that though the nasal cavities are much larger than normal due to the 244 EYE, EAR, NOSE, AND THROAT NURSING shrinking of the mue-ous membranes, the patient fre- quently complains of inability to breathe through the nose, even when it is free from erusts. In no other part of the human body is there a condition comparable te> this form of atrophy—it is essentially a elisease of the nose. The cause is primarily malnutrition, and is practie'ally a elisease of the poor, although it does occur in theise1 in good financial circumstances. Nasal accessory sinusitis may be a dominant causative factor. The condition may exist on one siele erf the nose only and be due en- tirely to a deflected septum, and manifest itself only on the side of the concavity. The e'ondition is most often observed between the fourteenth and twentieth years of age. The treatment has for its object the re- moving of the crusts by means of mild warm alkaline irrigations two or three times a day, followeel by stimulat- ing solutions e)f iodin, argyrol, or ichthyol. The iodin preparatiem is known as Mandle's solution: Potass, iodid................................ 3 ij 5 Iodin....................................... 3ss; Glycerin.................................... 3 v-—M The strength of the above may be incivaseel, adding to the same amount of glycerin potass, iodid 3iv and iodin 3j. When sinusitis is the underlying cause eradication of this condition is indicated, especially the radical opera- tion upon the maxillary antrum, when involved. In- herited syphilis is also citeel as a predisposing, if not an active, cause. Hypertrophic Rhinitis.—As the name implies, there DISEASES OF THE NOSE 245 is an increase in the amount of tissue in the nose, but not any physiologic increase. The condition gives rise to annoying symptoms, such as nasal obstruction with marked remissions of obstruction for short periods, the special senses, as taste and smell, may be affected and ringing in the ears, with possibly some hardness of hearing. Treatment.—The medical treatment of this condition is unsatisfactory. Keeping the membrane free from dis- charge by means of alkaline solutions as mentioned under acute rhinitis helps to ameliorate some of the symp- toms, but surgical interference must sooner or later be resorted to in order to give any degree of permanent relief. Many procedures have been devised, but the main object is to remove as little tissue as possible, but as much as is necessary to give unobstructed passage to the respired air. Purulent rhinitis occurs usually in children from infec- tion ordinarily transmitted from other parts of the body by the fingers. Treatment should be directed to keep- ing the nose clean and to the protection of the eyes. Membranous Rhinitis.—Here a fibrous exudate is found on the mucous membrane resembling diphtheria. A culture often, though not always, determines the diag- nosis. Caseous Rhinitis.—The sense of smell is lost and a cheesy material is found in the nasal passages which emits a most disagreeable odor, usually due to a foreign body. Epistaxis.—Nosebleed may be due to injury, rupture of a blood-vessel, ulceration, adenoids, fevers, or sup- pressed or vicarious menses. In people over fifty it may denote arterial change, also Bright's disease or heart lesion. Considerable blood may be lost in this 246 EYE, EAR, NOSE, AND THROAT NURSING way before serious damage oeviirs. Patients are liable to attach importance1 to this condition when it is of trivial character. Treatment should be dire'ctenl to the cause, but when in ignorance of the cause, efforts shoulel be made to stop the existing hemorrhage, except in eases of high arterial tension. Cold to the nape of the neck; pressure with the thumb or finger against the bleeding side; light packing with pledgets of cotton, wdiich may be soaked in adrenalin, hyelrogen peroxid, alumnol, tannic acid solution, or any mild astringent except the iron preparations may be resorted to. Fused silver nitrate on a metal probe, balsam of Peru and castor oil on a gauze packing, or submucous elevation of the bleeding area have given good results when the other methods have failed. Whenever any one of the last three is resorted to the part or parts involved must be cocainized previous to such treatment. Hay-fever.—Predisposing causes are an inherited neurotic temperament. The exciting causes are plant, animal, and vegetable odors, or possibly the pollen of plants. It usually begins in young adult life1 anel appears with regular periodicity. When the attack occurs in June it is known as June cold or rose1 cold; hay-fever, when coming on later in the year. Symptoms.—Stuffy sensation in the nose with copious discharge of clear serum. The eyes are red and the lids swollen. The roof of the mouth itches and burns; and the patient sneezes continually. Treatment.—Removal to a high dry place like the White Mountains will often overcome the yearly attacks, but some cases improve more at the seashore or on a sea voyage. Nearly every drug has been tried for the DISEASES OF THE NOSE 247 relief of this condition, but none have proved of any great value for any length of time. Internally, benzo- ate of soda has proved efficacious, also some of the cin- chona preparations, as cinchonidia and blennostasin. Locally, solutions of adrenalin (1:10,000), followed by mild antiseptic douches, have given temporary relief. Serum prepared from injections of ragweed was used for a while with good results, but it has now fallen into dis- favor. • The pollen test has revolutionized the treatment of hay-fever, as in many instances the specific or offending pollen or pollens may be determined and treatment instituted whereby the susceptibility may be overcome and the patient freed from the distressing symptoms. Lupus. Tuberculosis. Syphilis.—These diseases are treated in accordance with the diagnosis made. Follow- ing any of these conditions there may be a destruction of tissue. If the nasal septum is destroyed the dorsum of the nose frequently falls in and causes what is known as "saddleback" nose. If there is any support at all for the tissues, paraffin may be injected subcutaneously to overcome the deformity. The injection should be made only in selected cases and with every precaution exercised to prevent disastrous consequences. A more recent treatment for saddleback nose, when no active causative factor is still present, is the transplanta- tion of tissue from some part of the same individual, as rib, sternum, crest of the tibia, or even a part of the middle turbinated bone. At times the latter under special conditions has been apparently successfully transplanted from another individual than the one seeking relief. Deviations of the Septum.—This condition may result 248 EYE, EAR, NOSE, AND THROAT NURSING from injury, faulty development, or e-ongenital malfor- mation. The deviation may involve either bone, carti- lage, or both. Symptoms.—Obstructed nasal breathing, dry, scabby secretions over the deflecteel portion; postnasal catarrh, tinnitus in one or both ears, mouth-breathing, ete. Treatment.—Surgical: The most approved method of overcoming this septal deformity is known as the sub- mucous resection. The instruments required are nasal speculum, small scalpel, sharp and blunt mucous membrane elevators, a swivel knife, bone-cutting forceps, bivalve speculum, ample number of cotton applicators properly wrapped, and a pair of flat-jawed forceps. • Semic operators prefer to wash out the nasal fossae before operating with a mild alkaline solution, such as normal saline. The head and e'hest of the patient are protected by aseptic towels. The patient may be in a sitting or recumbent position and a local or a general anesthetic may be used. One of the suprarenal gland preparations is applied locally to combat bloeeling. Dressings.—Rubber tissue; strips of vaselined gauze, and Bernay sponges. Postoperative Care — Kest in bed with iced cloths placed over the nose. Some sedative should be given to allay the nervousness occasioned by the eocain. Liquid diet and a brisk e-athartic. Children under fourteen should not be operated upon, owing to the danger of the nose falling in from lack of support. Fractures.—By fracture is ordinarily meant the break- ing of one or both nasal bones. The bones themselves may be broken or they may have broken away at their DISEASES OF THE NOSE 249 articulation with the frontal bone. A fractured nose should be immediately cared for, as the parts can then be placed in almost complete apposition and held there until union takes place. Hemorrhage is first controlled by packing. After this the inside of the nose is supported by hollow splints or Bernay sponges, or, while pressure is exerted externally by small roller bandages or by means of the bridge splint which not only supports the nasal bones from below but also keeps them pressed toward the middle line, and is worn for about ten days. Abscess of the septum or of the dorsum of the nose frequently follows a fracture, particularly if there has been a protrusion of the bone through the nose externally or mucous membrane internally. The nostril should be irrigated with antiseptic solutions to prevent infection. Sinusitis.—This may be acute or chronic. Sinuses involved are the maxillary, frontal, ethmoidal, and sphenoidal. Symptoms.—The same symptoms apply in a measure to involvement of all of the sinuses, viz.: headache; local tenderness over the sinus or, in the case of the sphenoid, dull steady pain behind the eyes; chilly sen- sations; low temperature; peculiar non-re\sonating tone to voice, perceptible alike to patient and listener; general malaise; loss of appetite, etc. Treatment.—Palliative anel surgical. Palliative treat- ment consists in spraying the nostril with some slightly astringent solution, such as adrenalin (1 to 8 parts water), followed by copious douching wdth some hot antiseptic solution with a temperature of 110° F. It is unim- portant what antiseptic is employed, provided the water 250 EYE, EAR, NOSE, AND THROAT NURSING has been rendered alkaline by 5j of bicarbodate of se>ela and 5j of sodium chlorid to 1 pint of water. The astrin- gent shrinks the tissues around the sinus's outlet and the copious flow of hot water tends to draw the pus out of the sinus. This may be greatly facihtateel by means of the vacuum or suction apparatus of various forms, some of which are so arranged that solutions or nebula) may be suddenly forced into the vacuumized cavities of the nose. The pus may also be removed from the nasal passages by means of the Douglass doue'hc. Operative.—Internal and external. The external is ordinarily employed after the internal has failed to ac- complish the desired end. The internal operation has for its object the removal of obstructing tissues and establishing free drainage of the sinus. Irrigation of the sinus is then easy of accomplishment and in the majority of cases affects a cure. The external operation consists in entering the sinus by the nearest route con- sistent with the anatomy involved, and likewise aims to lessen, as far as possible, subsequent deformity. V. The Pharynx and Larynx CHAPTER XXV ANATOMIC DESCRIPTION OF THE PHARYNX The pharynx extends from the posterior limit of the nose to the esophagus, which is to a point opposite1 the cricoiel cartilage, and measures about 5 inches. It is divided into the nasopharynx, which is that part hidden by the soft palate when looking into the mouth; the oropharynx, which is the part of the throat seen when looking into the mouth with the tongue we;ll de- pressed ; anel the laryngopharynx, which is the remain- ing portion extending to the esophagus. In the nasopharynx are seen the posterior openings of the nares; the openings or entrance into the Eustachian tubes; the fossa? just behind the Eustachian promi- nences, known as the fossae of Rosenmuller, and high up in the vault the adenoids, or Luschka's tonsil. In the oropharynx are the faucial tonsils, situated between the anterior and posterior fold on either side of the throat; the posterior pharyngeal wall, where re'tropharyngeal abscess is most frequently observed; the lingual tonsil, which is at the base of the tongue between the epiglottis anel the tongue, and the epi- glottis. At the base of the tongue there may be a venous plexus which sometimes dilates to the point of rupture, 251 252 EYE, EAR, NOSE, AND THROAT M KSINei causing a hemorrhage1, which may be1 mistaken as coming from the lungs. The laryngopharynx is the narrowest part of the pharynx, and here foreign boelie's frequently loelge1. Pain is often referred to this location by the patient, although the lesion may be in the1 larynx proper. The pharyngeal constrictors surrounel this area and aiel in swallowing. CHAPTER XXVI DISEASES OF THE PHARYNX Examination of the Pharynx and Larynx.—A head- mirror, postnasal anel laryngeal mirrors, tongue depres- sor, probe, cotton applicator, absorbent cotton (Fig. 62), in addition to source of light, are the essentials for the examination. The patient should be sitting with the light at the level of his ear and to his right. Fig. 62.—Apparatus for the examination of the pharynx and larynx. Elongated Uvula.—This may result from an acute or chronic inflammation of the pharynx or it may be con- genital. This condition frequently produces cough of a distressing nature and simulates consumption, bron- chitis, and asthma. These symptoms may be relieved 253 2f)l EYE, EAR, NOSE, AND THROAT NURSING by removing the cause. Astringents may prove effective, but surgical removal is most reliable. Pharyngitis Acute Pharyngitis.—The nasopharynx anel the1 oro- pharynx with their containing structures are1 wry apt to be involved in inflammation after taking colel, if not immediately, a fe^v days lateT. Digestive elisturbance's, rheumatism, and gout are predispe)sing facteirs, while cold and grip infection are the exciting cause's. Symptoms.—Dryness of the throat, pain on swalletw- ing, frequent desire to clear the throat, slight itching sensation around the Eustae-hian tube's, with a fulness in the ears and huskiness of the voice. The glands of the neck may be swollen anel tender, and there is usually slight fever, quickening of the pulse, accompanied by chilliness anel pain in the back. Treatment.—Revst in bed, internal medication, sprays. gargles, as, fy Tr. ferric chlor....................... 5J! (ilyc..........................q.s. ad. giij.—M. Sig.—One dram to 1 ounce in hot water every three hours as a gargle. Or, 1$. Tr. guaiac.......................... 3 j to 5ij. Sig.—3«> in hot water every three hours as a gargle. postnasal irrigation (5 per cent, argyrol), medicated steam inhalations, I*. 01. pini pumil.) ._ g. Tr. benzoian. J Milk magnesia................q.s. ad. 5iv.—M. Sig.—One dram to 1 pint of boiling water as inhalation. and local astringents by means of applicators. DISEASES OF THE PHARYNX 255 Chronic Pharyngitis follows acute pharyngitis, and is most frequently the result of numerous acute attacks. It is found in rheumatic, gouty, or alcoholic patients. This condition may become granular or dry. The treat- ment is constitutional, with local stimulation with nitrate of silver (10-20 per cent, solution), etc. Pharyngeal Ulcers.—They may be simple, follicular, syphilitic, tubercular, lupoid, or membranous. The diagnosis depends upon the appearance of the ulcer, the history of the case, and the microscopic findings. The treatment varies according to the etiology and pathology of the ulcer. In a general way all ulcers should be kept clean with an antiseptic douche or gargle; the cleansed area dusted with some powder, preferably orthoform, which relieves pain and is also antiseptic. The part involved should be kept as quiet as possible, which in some cases necessitates rectal alimentation. Retropharyngeal Abscess.—This occurs most frequently in children. Causes.—The result of infection following acute fevers, erysipelas, pharyngeal infections, as infected adenoids, and tuberculous cervical vertebrae. Symptoms.—Difficult breathing and swallowing. Rest- lessness, emaciation, fever, and the inability of infants to nurse. Occasionally this condition is mistaken for adenoids. Treatment.—Incision and evacuation of the pus. This procedure is dangerous, owing to the possibility of the pus getting into the lungs and resulting in pneumonia. The safest way to open the abscess is to have the child lie on the table with the face downward or held by the 256 EYE, EAR, NOSE, AND THROAT NURSINO nurse with its head downward. However, if the nurse or assistant holding the1 child is sufficiently (mick, the child may be immediately invertcel after the surgeon has opened the abscess, in which case the child should be wrapped completely in a sheet or blanket with the head only protruding. The position is then the' same' as for the examinatiem of e-hildrcn or infants for adenoids. Never empW a general anesthesia owing te> dangeT of inspiration pneumonia. After opening the abscess the patient should be placed in bed with the head lowered. Frequent irrigation of the abscess-cavity is essential to insure proper healing. Iron and other constitutional medication should be given to build up the child. Tonsillitis Acute Tonsillitis.—This condition is ordinarily diag- nosed by the patient, owing to the sensations of pain and fulness in the throat and the difficulty in swallowing. Many constitutional diseases are ushered in by acute tonsillitis, as typhoid fe'vea-, syphilis, acute rheumatism, scark't fever, and diphtheria. Predisposing Causes.— Rheumatic diathesis, bael venti- lation, eligestive1 disturbane'es, sewer gas, and low vital- ity. Exciting ('auses.—Exposure to colel anel draughts. Whether acute tonsillitis is infectious is not definitely determined, but in view of its epielemic tendencies it is well to treat it as infectious. Symptoms.—High fever, occasionally reaching 105° F. Pain in the neck, back, and limbs, chilly sensations up and down the spine, sore throat, difficult swalleming, DISEASES OF THE PHARYNX 257 headache, and possibly vomiting, due perhaps to the irritation of the pharynx by the enlarged tonsil. Inspection.—Pharynx, palate, uvula, and tonsils are red and puffy. I'pon the tonsils may be seen small white patches which can be easily removed, leaving a reddened surface beneath, but not a raw bleeding one, as in diphtheria. When these patches coalesce they form a membrane resembling a diphtheritic or a Yin- cent's angina membrane. The cervical glands are swollen and the tonsil is easily palpable from the outside. Treatment.—Re\d in bed, preferably between light blankets, owing to the1 rheumatic tendency of these cases; good ventilation and proper isolation. Laxatives, salicylates, and iron, depending upon the individual requirements of the case1. Sprays, swabs, douches, gargles, and inhalations are all indicated. They are effective proportionately to the way in which they are given. Locally, nitrate of silver, iodin preparations, and guaiacol may be applied directly to the tonsil; while the ice-bag or coil externally is of undoubted value. The diet should be light, preferably liquid. Chronic tonsillitis results in enlargement of the tonsils. Here the tonsils may be large and protruding or large and buried. They may be1 also small and protruding or small with deep crypts, anel partially concealed by the faucial pillars. The size of the tonsil should not be the controlling factor in the determination of its removal. Symptoms.—Frequent colds, impaired digestion, foul breath, difficult deglutition, faulty respiration, enlargeel cervical glands, and neuritis. Complications.—Peritonsillar abscess; repeated attacks of acute tonsillitis; tuberculous glands, and rheumatism. 17 258 EYE, EAR, NOSE, AND THROAT NURSING Treatment.—Tonsilloe'temiy, if conditions warrant it, or frequent irrigations of the crypts and silver nitrate locally. The use of the x-ray and radium have been advocated recently. Adenoids They are sometimes present at birth or may appear shortly after. In infants their presence may be deter- mined by mouth-breathing, snuffles, and inability to nurse without frequent interruptions to breathe through the mouth. Symptoms in children vary in intensity, and in certain cases their presence creates no apparent disturbance. The adenoid tissue lessens as age increases, but if any of the following symptoms persist, it is decidedly unwise to await their reduction by age. Symptoms in Children.—Mouth-breathing, snoring, running nose, frequent colds, earache, nosebleed, slow development, narrow chest, bad digestion, restless nights, persistent hacking cough, mental dulness, and adenoid facies. In certain cases where the adenoid only gives evidence of its presence when the child has a cold or some digestive disturbance, local and constitutional treatment will prove effective. When the adenoid continues to give the symptoms mentioned, surgical removal is necessary. Anesthesia is always advisable. In infants a whiff of chloroform is all that is necessary. From two to eight years old, ether can be used satisfactorily, and after this, gas followed by ether. It is inadvisable to give young children gas. Tonsillectomy and Adenectomy.—A. In Children.— Operations upon both are usually performed at the same DISEASES OF THE PHARYNX 259 time and under the same anesthetic. The positions of the patient for operation are: Flat on the back (Fig. 63) on the right or left side, and in the upright position (Fig. 64), either on the operating table or in a chair. The position favored by most operators is prone on the back under general anesthesia. Anesthetics.—In children under ten ether alone is safest and most generally employed. Chloroform alone Fig. 63.—Recumbent position of patient for removal of tonsils. is inadvisable, though special anesthetists sometimes start the anesthetic with a little chloroform followed by ether. The more chloroform employed, the less the hemorrhage. In children over ten the ether may advantageously be preceded by gas. Gas alone is usually considered of too short duration for a successful operation upon tonsils and adenoids, though it can be used with advantage for removal of adenoids alone. 260 EYE, EAR, NOSE, AND THROAT NUHSINe; The instruments and accessories to be employed depend entirely upon the choice of the operator. The essential instruments are: a tonsillectome or snare; a thin-blaeled knife; scissors; tonsil separatees; grasping forceps; tonsil pillar retractor; long handled artery clamps; tongue1 depressor; one or more adenotomes of varying size; Fig. 64.—Sitting position of patient for removal of tonsils. sponge holders; mouth gag; suction tip for the suction apparatus, and towels immersed in ice-water. Tannic and gallic acid paste or Monsel vaselin and sutured ade- noid sponges should be readily available. Operation.—With general anesthesia, the patient flat on the back (Fig. 63), the mouth gag is introduced far back between the molar teeth on the left side, and the DISEASES OF THE PHARYNX 261 jaws then separated as far as possible. The throat is then freed of mucus by means of the suction tip and the operator proceeds to remove the tonsil according to the methoel of his choice. The throat and operative field are ke;pt free from blood or mucus by means of the suc- tion tip in the hands of the nurse. After one tonsil has been renmveel the operator makes certain there are no ae-tively bleeding points before beginning the removal of the1 otheT tonsil, after which the adenoid is reme)ved. The patient's face is now gently slapped with a towel from which ice-water has been wrung which lessens oozing by vasomotor stimulation. A complete inspection is made of both tonsillar fossae to ascertain if oozing or active bleeding is overe'ome before removal of the patient from the operating room. If not corrected, active meas- ures should be1 instituted immediately for its control as follows: 1. Placing a dry adenoid sponge or one soaked in tannic and gallic acid solution or anointed with Monsel vaselin in the tonsillar fossa?. 2. Grasping the bleeding point by means of an artery forceps, anel crushing the vessel sufficiently to prevent further he'niorrhage, or leaving the instrument in place for a few minutes, or if necessary ligating the spurting artery. 3. The employment of metal sutures which are first threaded on a string to prevent inhaling or swallowing if detached by vomiting or gagging. 4. Suturing the pillars over a piece of gauze. 5. The application of one of the mechanical tonsil hemostats as the Mikuliez-Stocrk (Fig. 65), which should never be too firm nor left on for over six hours. 262 EYE, EAR, NOSE, AND THROAT NURSING B. In Adults.—1. Under general anesthesia the technic is exactly the same as for children, except that more attention is paid to diet and elimination by means of the gastro-intestinal tract. The employment of morphin hypodermically, gr. \, one hour before the time set for the operation, greatly lessens the preoperative agitation of the patient, lessens the amount of anesthetic required, anel prevents postoperative pain and restlessness to a marked degree. 2. Under local anesthesia the patient may or may not ,be prepared by the use of sedatives, bromiels, etc., for a Fig. 65.—Mikulicz-Stoerk tonsil hcmostat. few elays previous to the clay of operation and an hour before by the administration of morphin as above. Die1! and elimination receive proper attention. The throat is eleared of all mucus by means of alkaline douches or a 50 per cent. Dobell solution. The tonsils and pillars are then gently swabbed with 10 or 20 per cent, ewuin solution, after which a \ of 1 pen- cent, solution of novo- cain or other synthetic anesthetic, or as some prefer weak eocain solution, is injected by means of a syringe with a special curved tip into the1 tonsillar fossa? and peri- tonsillar tissues. Usually three separate1 injections are1 made into each side, one into the upper petle1 and into DISEASES OF THE PHARYNX 263 the lower, and one midway between these two points. The amount used depends upon the individual operator's judgment for each case. The addition of a few drops of suprarenal extract to the anesthetic solution is advo- cated by some operators. Usually within five or six minutes anesthesia is complete. The patient is draped in a sterile sheet or, preferably, sterile gown and cap, or towel used as such. The patient may sit upright in a chair or be semirecumbent upon an operating table. If sitting the patient may require to have the head steadied. The operative procedure is as follows: The surgeon seizes one tonsil with a grasping forceps and gently but firmly draws the tonsil toward the middle line of the throat. This puts the'anterior pillar of the tonsil on the stretch, and while in this position a tonsil separator is inserted between the anterior pillar and the tonsil, the former then being separated from the tonsil, from and including the upper pole to the lower. The wire of the snare is now threaded over the free end of the grasping forceps, anel by gentle manipulation the wire loop is made to encompass as much as possible the base of the tonsil, and either by means of the operator's hand or by mechanical means the wire is drawn into the stylet of the snare and the tonsil severed from its remaining attachments. Careful inspection of the tonsillar fossa is carried out and if no bleeding occurs the same procedure is gone through with the other tonsil. If an adenoid is present and no complications arise it may be removed by any of the adenotomes after the posterior pharyngeal wall has been anesthetized in the region of the adenoid by means of a 20 or 10 per cent, solution of eocain. The 2(11 EYE, EAR, NOSK, AND THROAT Nl'HSlNO after-care is practically the same as when general anes- thesia is administered. After-treatment.—The patient is placeel in bed anel kept perfectly quiet. Children are placed on the siele1, Fig. 66.—Elevation of foot of crib in the after-treatment of tonsillectomy. anel the1 foot of the crib is elevated (Fig. 66). Some npe'raten-s caution the nurse explicitly in regarel to keeping the patient on the right side during the time of recovery from the anesthetic. This posture prevents, in a measure, the blood, saliva, and vomited material from entering either the lungs or the stomach. The right side1 is preferable, as it does not impede heart action. Care, however, must be taken that the face does not become imbedded in the mattress, as this has been known to almost cause suffocation. If the right arm is drawn under the head it will keep the face suffi- ciently away from the bed-clothes. These rules should apply for twenty-four hours. No food is given for sev- eral hours, when a little cracked ice or cold milk is given. Ice-cream may be give>n four or five hours after the1 operation, other things being favorable. DISEASES OF THE PHARYNX 265 The patient is kept in bed for twenty-four hours at least, and quiet is advisable for three to four days in order to help prevent secondary hemorrhage and to lessen the dangers resulting from exposure. The bowels should be moveel at the end of twenty-four to thirty-six hours, castor oil being most serviceable for this purpose. The diet for the first two or three days subsequent to the operation should consist of cool or cold liquids, and such locally non-irritating soft diet as eggs, custard, milk-toast, boiled rice, etc. CHAPTER XXVII THE LARYNX Anatomic Description The framework of the larynx is made up of the thy- roid, cricoiel, anel the arytenoiei cartilages, held together by a dense membrane and numerous muscles (Fig. 67). Above the upper entrance to the larynx is situated the Fig. 67. —The larynx as seen in the laryngoseopic mirror. The illustration shows the parts larger than normal in order to bring out the details (Fowler). epiglottis, which remains almost vertical during respira- tion, but is forced downward upon the top of the larynx during deglutition, thereby preventing food or fluid from entering the larynx. 266 THE LARYNX 267 On looking into the larynx from above, one sees two folds of mucous membrane projecting from either side, which are the ventricular bands or false vocal cords. Just below these are two sulci or ventricles, which are the ventricles of the larynx, and below the ventricles are Epiglottis Cartilago triticea Internal laryngeal branch of superior laryngeal nerve Superior laryngeal artery Superior cornu of thyroid cartilage----*. Ala of thyroid cartilage Oblique line of thyroid carti- lage Inferior border of thyroid cartilage Inferior cornu of thyroid cartilage Cricoid cartilage Recurrent laryngeal nerve Greater cornu of hyoid bone Thyrohyoid ligament Lesser cornu of hyoid bone Body of hyoid bone Lateral portion of thyrohyoid membrane Central portion of thyrohyoid membrane Superior border of thyroid cartilage Incisura thyroidea Angle of thyroid cartilage Lateral portion of cricothy •J membrane ral portion of cricothy- Capsular ligament of crico- thyroid articulation Fig. 68. —Anterior view of larynx, including cricothyroid membrane. (From Deaver's Surgical Anatomy.) two dense bands of elastic fibrous tissue, pearly white, which are the true vocal cords. These cords are attached anteriorly to the thyroid cartilage and posteriorly to the arytenoid cartilages. Below the larynx and continuous with it is the trachea. Looking at the larynx from in front, with its muscles 268 EYE, EAR, NOSE, AND THROAT NURSING cut away, erne sees first the' hyetiel bone1, the body of which marks the entrance' to the esophagus behinel. Then a membrane between the hyoid bone1 anel the thyroid cartilage, the thyrohyoid membrane. Next are seen the two large1 plates of the1 thyroid cartilage uniting at an acute1 angle in front; this is known as Adam's apple anel is more prominent in men. Then another membrane, cricothyroid, anel, lastly, the smalleT portion of the cricoid e'artilage (Fig. 68). Speaking and Singing Voice.—The air from (he lungs is forced against the ve>cal cords, which are set in vibra- tion, anel the initial sound from them is transmitted te> the bones of the1 head, which act as resonators, anel these emit certain tones which are governed in intensity by the1 force of the air-current anel the number of vibrations of the vocal cords. Examination of the Larynx This may be accomplished by means of reflected light on a laryngeal mirror or directly by passing a tube into the larynx. Under ordinary ciie-umstances the laryn- goscopy mirror is used, but in refractory children and when a foreign body is suspected, the Killian, Jackson, or Bruning laryngoscopic or bronchoscopic tubes are used. These tubes may be used upon the adult under eocain anesthesia, but in children no anesthetic, or a general anesthetic, preferably chloroform, is necessary. When these tubes are to be used, the nurse should always have ready ample small gauze sponges on long holders, with all fibers removed, adrenalin solution in full strength, and a 10 per cent, solution of eocain. THE larynx 269 Edema of the Larynx Edema of the larynx may occur as a complication of or in the course of any of the infectious diseases, as typhoid, scarlet fever, diphtheria, etc. It may also occur as the result of direct infection in erysipelas, phthisis, or from abscess of the tonsil, base of the tongue, or retropharynx. Symptoms.—Dyspnea, voice husky at first and sub- sequently lost. Pain may not be present, but a distinct sense of discomfort is experienced. The face gives evi- dence of anxiety and the skin is clammy. Treatment.—Ice externally and internally; adrenalin spray and inhalations of medicated steam. It is fre- quently necessary for the physician to scarify the larynx or to perform tracheotomy. In eveTy case vigorous purgatives should be administered, as by this means serum is drawn away from the tissues involved. Benign and Malignant Tumors If malignant, they may be confused with syphilis or tuberculosis, and microscopic examination of a specimen may be necessary to determine the diagnosis. Whether henign or malignant, surgical intervention is necessary. Papilloma in Children.—This condition is not as preva- lent as formerly, possibly due to early care the naso- pharynx receives in the child, especially the removal of adenoid tissue. In a child of talking age hoarseness, or a croupy cry in an infant is sufficient to make a careful observer think of the possibility of papilloma of the larynx. As the disease is usually slowly progressive and many growths present, dyspnea or cyanosis may easily be induced by 270 EYE, EAR, NOSE, AND THROAT NURSING undue or even slight excitement. Other conditions to be thought of arc laryngeal diphtheria, false or pseudo- croup, foreign bodies, laryngeal stenosis, lvtnjpharyngeal abscess, subglottic tumefaction and abscess at the base of the tongue. Treatment.—Removal by direct laryngoscopy and fulguration have been tried, but not always successfully. In fact, the surest way of overcoming the difficulty is by performing a tracheotomy and let the rest of the larynx and the physiologic changes bound to occur effect the cure. Radium in papilloma of the larynx in children has not been the success it has in the single papilloma in adults. Laryngeal Tuberculosis This condition is ordinarily secondary to tuberculosis else'where in the body. Predisposing Causes.—Exhaustion or long-continued fatigue, mental anel physical. Lowered vitality, bad ventilation, poor fooel, colds, frequent inflammation of the upper air-tract. Exciting Cause.—The tubercle bacillus. Symptoms.—Severe pain, particularly on swallowing, cough, usually of an irritating, hacking nature. Loss of weight, night-sweats, hoarseness or loss of voice, short- ness of breath, and even difficult respiration upon exer- tion. The diagnosis is maele by the history of the case, the appearance of the larynx, and from the microscopic findings. Treatment.—If seen early, removal to a high dry climate will in some instances arrest the progress of the disease. Rest of the larynx, neither talking nor whisper- THE LARYNX 271 ing. Soothing inhalations, as the mixture of oil of pine, menthol, and milk of magnesia. For the pain, ortho- form powders, eocain, and iodoform emulsion, applied locally. Syphilis It is frequently difficult to determine if a lesion in the larynx is syphilitic, tuberculous, or cancerous. The main points of difference are that in syphilis pain is frequently absent, the ulceration is deeper, the infiltra- tion is greater in extent, and the surrounding tissues are not so anemic. The constitutional symptoms are less pronounced; there is less loss of weight, less cough, a different history, and the microscopic picture may be entirely different. Treatment.—This has been revolutionized by the in- troduction of salvarsan and similar products. As soon as a diagnosis has been made treatment should be in- stituted and carried out actively as above supplemented by mercury and the iodid of potassium. Great care, however, must be exercised in the administration of the latter if marked stenosis of the larynx exists, as a sudden edema in the larynx may occur and prove fatal. Before administering potassium iodid the patient should be ad- mitted to a hospital and a tracheotomy set kept in prox- imity for use in case of emergency. Keeping the pharynx and larynx cleaned by means of irrigations, warm normal salt or Dobell's solutions, followed by the application of silver nitrate aids in healing the ulcers. Foreign Bodies Coins, whistles, pins of various kinds, false teeth, and an infinite number of other articles may become lodged in 272 EYE, FAR, NOSE, AND THROAT NURSING the pharynx, larynx, trachea., or bronchi. The presemce of one of these artie-les may or may ne)t proeluce1 alarm- ing symptoms or simply mild symptoms not at all lve-og- nized by the patient as arising from its presence. Al times the history aids in the diagnosis, but there are only two absolute methods of proving the1 presene-e of such a body, namely, the ar-ray, or visual, by indirect or direct means with the laryngeal mirror or brone'he)se'e>pe. The removal of a foreign ImhIv is done with or without the patient being under either local or general anesthesia. This is a matter for the individual operator to eleM-ide. If an rr-ray plate is made mue-h time and effort will be saved, as the1 operator is not called upon to make a diligent search for the lost object, but can proceed with the instru- ment of his selection, as the Jackson or Killian broncho- scope, or with one of the forms of suspension apparatus. In either case as soon as the object of the search has been definitely located its extraction with suitable forceps is undertaken. If done under local anesthesia the patient usually is in the sitting position on a low stool, the nurse gently but firmly holding the head. If, however, the operation is done under a general anesthesia the anes- thetist steadies the head, and the patient is recumbent. All instruments, towels, sheets, or other accessories coming in direct contact with the patient should be sterile. Douches The solutions and their strength are determineel by the doctor. Douches shoulel be copious, as a large1 flow does less damage to mucous surface's than a small one1. The Douglass syringe should be used, with the patient seated and the head well flexed on the chest and slightly THE LARYNX 273 turned toward the side where the tip is introduced. The patient opens his mouth and continues to breathe, while the flow takes place from one nostril to the other Fig. 69.—Nasal douching with fountain syringe. around the septum. The pressure should be gentle and uniform, thus lessening, as far as possible, the danger of forcing the liquid or other matter into the Eustachian 18 274 RYF, EAR, NOSE, AND THROAT NURSINei tubes. It is also better to introdue'e1 the syringe into the opposite side from the operation first, as the discharge and clots are then forced out without endangering the Eustachian tubes or the healthy side. A sufficient num- Fig. 70.—Nasal douching with fountain syringe with patient reclining. ber of irrigations should be employed to perfectly cleanse the nose, and the water should be hot (110° F.) unless otherwise ordered. This syringe is effective in post1 operative work—infected sinuses and atrophic rhinitis. THE LARYNX 275 A douche bag may be employed in like manner if a blunt nasal tip is used in the end of the tube and the nos- tril held firmly around the tip while irrigating. Should the nurse be requested to irrigate only one nostril, then Fig. 71.—Nasal douching with Douglass syringe. the tip may be omitted and the solution allowed to flow from a straight tip or from the tube itself. The bag should be placed about 2 feet above the patient's head unless otherwise ordered. 276 eye, ear, nose, and throat nursing Irrigation This term ordinarily applies to washing out some cavity or sinus. For diagnostic purposes or in acute suppurative processes of the antrum, for instance, irriga- Fig. 72.—Irrigating maxillary sinus. tion may be carried out by puncturing below the inferior turbinate of the side to be investigated or treated, by means of an antrum trocar, attached to a syringe by rubber tubing and a saline, boric or antiseptic solution forced through. In chronic cases, when a permanent THE LARYNX 277 opening is present, the patient himself may perform the irrigation. Most frequently, however, the surgeon carries out this procedure. If, however, it is applied to simple irrigation of the nasal passages, as by means of the Douglass douche or ordinary irrigating can or bag, great care must be exercised not to force the irrigating solution into one or both middle-ear cavities. This is prevented by (1) Absolute shrinking of the turbinates of both sides, especially of the inferior turbinates. (2) The position of the patient's head, tilted a little to the opposite side to the passage being irrigated, and well flexed on the chest. (3) A minimum of force to the flow of irrigating solu- tion, regular respiration by the patient through the mouth, and avoidance on the part of the patient of any effort to swallow or to blow through the nose. Sprays Those most commonly employed are hand sprays, which are easily manipulated. In spraying the nose, insert the tip just within the vestibule and hold up the nostril gently on the end of the spray nozzle. In this way easier entrance is obtained for the solution. A very forceful spray is injurious to the nasal mucous membrane and should not be used. The throat can be more vigor- ously sprayed. It is difficult to spray the larynx with- out proper instruments. However, some of the solution will ultimately reach the larynx and a nurse is often requested to perform this function for the patient. The spray nozzle should be turned downward and the patient should hold his tongue forward while the tip of 278 EYE, EAR, NOSE. AND THROAT NURSlNei the spray is placed far back, but not touching the phar- ynx, and the patient instructed to take- three or four deep inhalations or to say "ah," at which time the spray is worked rather vigorously. Gargles These are manifold anel are either hot or cold. The nurse should encourage the1 patient to prevent the liquid being swallowed or inhaleel by continuous exhalation. The gargles shoulel not be1 too hot. Inhalations Medicates! ste\ini inhalation is a most effective way of allaying inflammation of the mucous membranes, particularly of the larynx. An improvised wray of giving an inhalation is to plae-e1 in a narrow-necked pitcher a pint of boiling water into which is poured the1 medicated solution. Over the mouth of the pitcluT is placeel a cornucopia made of pasteboard or oiled paper, with the smaller end turneel toward the mouth of the patient, and from which exudes the vape>r. A more effective way is to use an earthenware inhaler (Maws), which has the advantage of holding the heat longer, or another simpler, cheapeT inhaler, known as the benzoinal inhale1!", which is made1 of tin and can be1 placed ewr an alcohol lamp or on the gas stove, anel the solution brought to the boiling-point. The latest imprnvement in this line is the vacuum inhaler, eemstruete'd after the manner of the Thermos Bottle, which retains its heat for a long period. This is especially sea-viewable1 in traveling or for use at night, where hot water is not easily obtained. There1 are many forms of solutions useel in hot water. Benzoin, THE LARYNX 279 turpentine, eucalyptol, etc., all have their advocates, but are sometimes irritating to delicate mucous mem- branes. The following mixture is very soothing in croup. laryngitis, tracheotemiy cases, and acute colds: Oleum pini pumilionis.................... 3j Menthol................................ gr. v Milk of magnesia........................ oij One dram of the mixture to a pint of boiling water. This same mixture may be useel in a croup kettle and should be renewed every three hours. Tracheotomy The trachea may have to be opened in an emergency or as a more deliberate procedure. Frequently the condition is so critical that the trachea must be opened without consideration of asepsis or antisepsis and with any instrument at hand. Entrance by means of a pocket knife has saved many lives. In such cases the incision is made through the skin and other tissues directly into the trachea and below the cricoid cartilage. The incision should be made with the long axis of the trachea, but even a transverse incision is preferable to none. Even in emergencies, if time permits, the neck should be put in extension; a loaf of bread, a brick, or a folded sheet may be used for this purpose. The chin should be kept in line with the episternal notch. When tracheotomy is performed without the necessity for haste, more care is exercised. The entire area between the top of the larynx and the sternum should be surgi- cally clean and a bichlorid dressing applied. Chloro- form anesthesia is ordinarily employed in these cases, as the secretion is far less excessive than when ether is 280 EYE, EAR, NOSE, AND THROAT NURSlNti used. The patient is placed on the back with a sand- bag beneath the shoulelers, so that the head is partially extended. Local anesthesia is frequently emple>ve'd in adults, and the same position on the operating table is assumed. Instruments.—Scalpels (both sharp and probe pointed); scissors (curved and straight, blunt and sharp pointed); artery clamps; forceps; dhvctors; tenacula; small re- tractors; trachea dilator; catheter; curved needle; strong silk and catgut sutures; tongue forceps; mouth-gag; sponges; and seweral sizes of long silver tracheotomy tubes fitted with tape. The silver tubes create1 less irritation than those made of aluminum or hard rubber. Tracheotomy is performed for any obstruction to respiration which cannot be over- come by other nutans, whether due to the presence1 of a tumor, foreign body, or inflammatory pre>cess. When it is performed for diphtheria, special care should be exer- cised by the operator te> preveait his becoming infected, for which he should wear a face1 mask. After-care.—A piece of gauze we>t with 1:5000 bi- chlorid solution should be kept over the mouth of the tube. The patient should be placed under a tent where a croup kettle is kept boiling with some of the1 balsams addeel to the water, preferably the oil of pine mixture (Fig. 73). The tent should permit of no draught, but offer ample ventilation, and should not be kept so warm that both patient and nurse get a steam bath. The head of the patient should be lowered slightly to pre- vent the inhalation of blood or mucus. The inner tube should be kept as clean as possible, which in many instances necessitates removal eveay fifteen minutes or THE LARYNX 281 oftener. The nurse should not remove the outer tube nor attempt cleaning the inner tube with cotton on a probe when it is in situ, as there is danger of having the cotton slip off and be drawn into the trachea. It is far safer to remove the inner tube for cleansing. The mucus may be swabbed away with gauze, and even strips of gauze may be inserted into the inner and outer tubes Fig. 73.—Croup tent arranged for tracheotomy case. to relieve them of mucus; but when this is done one end of the strip should be firmly held in one hand. The nurse's attention shoulel be directed te> the position of the tube, to hemorrhage around the tube, to the patient's breathing, pulse-rate, and temperature. The dangers are pneumonia, shock, displacement of the tube, hemor- rhage, and infection of the wound. Should the tube be displaced, the nurse1 should attempt immediately to 282 EYE, EAR, NOSE, AND THROAT NURSING replace it, but should this prove difficult, no time should be lost in the endeavor to force the tube into its former place, as this only creates trauma and makes it harder to reinsert subsequently, but she should immediately hold the opening in the trachea apart with forceps, trachea dilator, or any instrument at hand, so that the patient may breathe until the doctor arrives. Laryngectomy Laryngectomy is the complete removal of the larynx. This includes the thyroid and cricoid cartilages. The procedure opens the hypopharynx above, exposes the mouth of and about 2 inches of esophagus behind, and leaves the cut end of the trachea below projecting from the neck just above the sternum. It destroys loud speech and prevents mouth and nasal breathing. It is a formid- able operation justified only by the terrible nature of the disease for which it is done, namely, cancer. When cancer is incipient and confined to the laryngeal box (intrinsic) the operation is life-saving and gives a high percentage of cures. But when the disease has extended beyond the confines of the laryngeal cartilages (extrinsic) it is useless and unjustifiable. Laryngectomy may be done in one or two stages. Many operators prefer to do a preliminary tracheotomy from ten days to two weeks before the major operation of removing the larynx. A few surgeons in this country and most of the continental surgeons prefer the one- stage operation, which means that at one time the larynx is removed, the hypopharynx closed, and the stump of the trachea carefully attached to the skin at the supra- sternal notch. This is, in my opinion, the operation of THE LARYNX 283 choice and is indicated in the early cases before obstruc- tion to breathing occurs. When the breath way is partially closed, as often occurs in the more advanced cases, we have to adopt the two- stage method. Laryngeal obstruction of sufficient extent to prevent free aeration requires tracheotomy and a period of rest and recuperation preceding the laryn- gectomy. Preparation of Patient.—It is well, if possible, to have the patient under observation and treatment in the hospital for a few days prior to the operation. During this period the following procedures should be carried out: 1. Careful attention should be given to the cleansing of the mouth by removing carious teeth and tartar, and to the treatment of infected gums. 2. Diseased crypts in the tonsils should be cleaned up and treated with iodin; mouth-wash and tooth brush should be used after each feeding. If any chronic infec- tion exists in the nasal cavities a nasal douche should be given twice a day of a normal salt solution slightly alkalinized with soda. 3. It was discovered some years ago that patients with a high blood-sugar stood this severe operation badly. Excessive blood-sugar is a contraindication to the operation. The true diabetic almost invariably succumbs. 4. The colon should be cleansed by a laxative and a high enema of pure carbonate of soda (5j to 2 quarts). This is followed by a colon irrigation of salt solution through a large colon tube. Two or three gallons of solu- tion is required to thoroughly cleanse the colon. Every other day up to the time of operation the patient should 284 EYE, EAR, NOSE, AND THROAT NURSING have a modified irrigation using about a gallon of salt solution. ;">. Bicarbonate of soda (5iij in twenty-four hours) should be given by mouth between meals for three days preceding the operation. 6. The diet should be nutritious, with low protein con- tent. Eggs, milk, and beef are contraindicated if sufficient food of other kinds can be taken. The diet should be about as follows: Well-cooked cereals with cream, chicken and thick soups, spaghetti, rice, all the bi-eaelstuffs and butter, all vegetables, green and cooked, e-ookeel fruit, and orange juice. Simple desserts. 7. If there is a disturbed balance of circulation the patient should be digitalized. This, too little used expe- dient, is a powerful aid in making the operative crossing safer. 8. Prolonged starvation before the operation is a mis- take. As the hour approaches for the ordeal the eliet should be made more concentrated and nutritious. A period of twelve hours' starvation is the limit. During this twelve-hour period water should be given ad libitum up to within three hours before the operation. 9. A few hours before the operation the chin, up to the lip, the neck well back, and the upper part of the chest should be shaved. This applies to both sexes. The shaved area is gently scrubbed with green soap using a large pledget of cotton (not a brush). The scrub- bing e-overs a period of six to eight minutes during which the water is frequently changed. Alcohol is then applied. No dressing is required. 10. The surgeon may or may not advise morphin, gr. j, atropin 1 :300 given from one to one and a half THE LARYNX 285 hours prior to the beginning of the operation. This, if given, is injected into the muscle. The patient must in all cases come to the. operating room on a stretcher so as not to interfere with the somnolent effect of the drug. 11. The bladder should be emptied at the last momenl before1 leaving the ward or room. 12. To face this operation involving e-onsiderable risk to life1 and the gloomy prospect of loss of speee-h, to say nothing of the possibility of a recurrence, requires supreme courage on the1 part of the patient. This attitude of mind can be greatly strengthened by tact and cheerful- ness on the part of the nurse. Every means must be used to strengthen the patient's confidence in the skill of his surgeon and in the prospect of ultimate cure. Remember that fear is the most baleful influence in life and even by itself may cause death. Preparation of Operating Room.—The comfort of the patient on the operating table, especially in a long opera- tion, is seldom considered. In the yeaing this is of less importance than in the old, in whom, King for hours on a hard table in a strained posture, may not only materially increase the shock of the operation, but leave lasting effects in the joints and ligaments. As the sub- ject under discussion applies mostly to the middle aged and to the old, greater care in placing the patient on the table should be observed. If a soft hair mattress or a water-bed made to fit the table is not available (and it is only in the few up-to-date operating rooms that they are found) two or three large pillows laid lengthwise serve fairly well for the purpose. The knees should lie slightly flexed and a pillow or roll placed beneath them. 286 EYE, EAR, Ne)SE, AND THROAT NURSINCJ The patient is then asked if he is e'omfortable. If not, he is told to arrange the pillows to suit himself. The hands must never be placed under the patient's hips. Prolonged pressure on them in this position has many times resulted in a very annoying neuritis. A half-opened sheet is laid under the patient and its ends brought up and fastened so as to hold the arms parallel to and in contact with the body. In laryngectomy and other neck operations a small soft pad (not a sand-bag as is ofteai listed) or a foleled sheet is placed crosswise between the shoulders se> that the head may be extended. A folded she'et is placeel behind the occiput. Here again e-are: must be exercised to prevent overextending of the head. In old age and often in middle age the neck bee'eanc^s more or less fixed. Overextensions may cause consider- able and prolonged postoperative pain and soreness. The patient must again be consulted as to his comfort. Nothing is so confusing to a smooth technic on the nurse's as well as the surgeon's part as a crowded instru- ment table. Four tables, two of good size, should be placed as follows: One small table stands at the head of the operating table for the suction outfit. On a second table to the left of the operating table is placed the anesthetist's apparatus—mouth-gag, tongue depressor, forceps, tongue ligatures of heavy silk or linen on large curved needles, sterile gloves for the anesthetist, sterile chloroform and ether masks, sterile suction tube, large soft catheter, long curved metallic suction tip, sponge forceps and sponges, chloroform and ether in sterile bag or covering, two glass connecting tubes, and one curved metal anesthesia tube and a hand pump. THE LARYNX 287 On two large tables arranged on the right of the operat- ing table are placed the operating instruments, ligature, sponges, etc. On the larger of these tables the operative instruments are arranged. They are as follows: Two very sharp knives, three dozen artery clamps, two pairs of mouse-tooth forceps, curved and straight scissors, two pairs of long curved dressing forceps, Brophy's cleft palate forceps, one pair heavy curved on the edge bone- cutting forceps or scissors, two large hypodermic syringes with long and short needles, i ounce of sterilized 1 per cent, novocain solution to which 3 or 4 drops of adrenalin (1 : 1000) have been added, a Richardson or other blunt dissector, one aneurysm blunt needle, blunt and sharp retractors, two large tenacula grasping forceps. On the smaller table are placed the dressings, sponges, and ligature materials—small folded sponges, fluffed sponges, folded dressings (2| and 3 inch), bandages. Straight skin needles, medium and small curved needles, two needle holders, \ dozen tubes of No. 0 and No. 1 plain gut, fine silver wire, silkworm gut, coarse horse hair, fine and coarse silk and perforated shot and small lead disks. Heavy rubber-dam, large tracheal cannula, two small glasses, two small bowls, 10 and 20 per cent. solution eocain, warm normal saline solution, one feeding tube, cigarette drins, sterile adhesive, 3-inch wide folded bismuth paste gauze, folded iodoform packing 1 to 2 per cent., graded sizes of rubber tubing from \ to f inch in diameter. The length of each piece of tubing should be about 8 inches. A table tray should be dressed and in readiness. On this the surgeon places what he needs immediately in 288 EYE, EAR, NOSE, AND THROAT NURSING the operation: a knife, artery clamps, retractors and scissors, mouse-tooth forceps, hypodermic syringes, novo- cain solution. For the preparation of the operative field a tray shoulel be ready and contain the following: Three glasses, one for iodin, 3| per cent., one for alcohol for the skin, and one for a 2 per cent, freshly prepared solution of mercuro- chrome for the mouth and pharynx, two applicators, two small sponge-holders, towel clips, safety-pins, sponges, absorbent cotton. The skin anel the mouth preparation may be1 done by the chief operating nurse or by the1 surgical assistant, and the1 draping e>f the patient by the sterile table nurse1. Iodin is applied to the lenver part of the fae-e1 from the chin up to the lip, te> the neck three-quarters of the way around, anel to the chest as low as the nipple1 line. The1 mouth is held open with a gag and the1 memirochrome solution is applied te> the teeth anel arounel the1 tee'th, te> the whole buccal cavity, te> the pharynx, tonsils, and as far down in the1 hypopharynx as can be reae-he'd. The iodin shoulel always be removed from the1 face and, if desireel, from the neck and chest with alceihol. Two sterile nurses should be in attenelanev, one to pass instruments and the other to pass sutures. The patient is draped as follows: A long sheet extend- ing from the chin to the feet, a tent she^t fastene'el by drawing string under the chin and thrown over the1 hoop which is attached to the table. Four storilo towels fastened with towel clamps surround the operative field. The disadvantage of the tent sheet is that the patient's face cannot be kept under observation by the surgeon, and the anesthetist is seldom competent to judge the patient's THE LARYNX 289 condition. Hence, some surgeons dispense with the tent and cover the patient's chin up to the mouth with a folded wet towel fastened by a tape behind the head, the tape passing above the ears. Moreover, it is an ad- vantage to do the first part of the operation under local anesthesia, in which it is imperative1 to keep the counte- nance of the1 patient under observation in order to note any expression of pain. The operating-room nurse should have everything in readiness for an emergency. The suction outfit should be tested and oiled before the operation starts. An intravenous set, saline, lung motor, hypodermic syringe, and stimulants should be within immediate reach. Postoperative Treatment.—The bed should be warmed, but all hot-water bottles must be removed before the patient is put into it. This point cannot be stressed too strongly. Some terrible burns have occurred from its neglect. The1 night-gown is e-hanged if soiled or wet. Beside the bed a suction pump is permanently installed and must be kept there all through the1 convalescence. Its purpose is to keep the trachea and tube clear of the tenacious secretions (which are often a troublesome feature of this period), and to cleanse the wound if infec- tion takes place. Instructions in its use must be care- fully given by the surgeon. The method is as follows: Several medium-sized soft-rubber catheters are kept in a bowl of sterile boric acid solution. After the catheter is used it is washed, sterilized, and replaced in the bowl. Care must be exercised so that its use does not injure the delicate mucous membrane of the trachea, especially at its bifurcation. It is to be kept in mind that this division of the trachea takes place opposite a 19 290 EYE, EAR, NOSE, AND THROAT NURSING line drawn across the sternum between the points of junction of the second ribs with the sternum. This in the adult is not more than 4 inches from the mouth of the tracheal cannula. The catheter is grasped about 6 inches from its end and quickly but gently passeel into the trachea. As it is passed and withdrawn it is rotated between the thumb and first finger, se) that the mouth of the catheter may be brought in contae-t with the entire tracheal wall. This procedure is repeat eel until the secretion is cleared away. The frequency of its use depends entirely upon the amount of secretiem. In some cases it is not ne^elenl at all, and in others it is used every fifteen or twenty minutes. It is te> be avoided if possible, since it annoys the patient and may irritate the trachea. On the1 other hand, it is a life-saving device when indicated. Before its use the laryngectomized cases with excessive1 tracheal secretion could easily drown in their own secretions. It is essential for the comfort of the patient to carry out the manipulation as quie-kly as possible so as not to pro- long unnecessarily the1 spasmodic cough which it ineluces. After laryngectomy the tracheal cannula is so placed in the trachea that it cannot slip out, but after tracheotomy especially if below the thy mid bridge (low tracheotomy), and in thick fat necks, the tube ma)' become displaced and fatal asphyxia occur. To obviate this ace-ident it is a safeguard for the surgeon to transfix the trachea on either side of the slit in its wall with a strong silk thread. These threads project on either side of the cannula. If asphyxia occurs and the nurse suspects that the tube has become displaced she removes the tube entirely and pulls laterally on the two loops which hang THE LARYNX 291 out on either side of the wound in the neck. This imme- diately opens the slit in the trachea and presses away the tissues of the neck in its vicinity, allowing free access of air to the lungs. The secretions which lodge in the inner tube of the cannula are desiccated by the constant passage of the current of air and dry on the tube walls. This gradually encroaches upon the lumen of the tube and shuts off the breathway. Hence it is imperative' that the inner tube be frequently removed and cleansed. This cleaning must be thoroughly done, using soap and warm water and a swab. After careful inspection shows that every par- ticle of dried secretion has been removed, leaving the lumen clean and bright, the tube is sterilized and replaced. The outer tube must not be disturbed by the nurse during the days immediately following the operation. Its removal and dressing should be the duty of the surgeon. Later, when healing begins and the nurse has learned the technic of this dressing it may be left in her hands. A fluffed piece of gauze kept moistened with boric acid solution is laid over the mouth of the tube. It drys rapidly and must be frequently changed. This supplies to some extent the lack in the inspired air of moisture normally supplied by the nasal cavities. The croup tent is almost universally used. In the cold seasons of the year when comfortable room ventila- tion can be secured the tent may be useful in carrying a moist warm air to the patient's lungs. But in the summer, especially when hot, the croup tent is a horror. Its discomfort to the patient quite overweighs its benefit. Even in the cold seasons it should not be used if the patient objects. 292 EYE, EAR, NOSE, AND THROAT NURSING Allowing the patient te> be in one position for hours should be avoided. He should be encouraged to turn from side to side anel should occasionally be proppe'el well up on a bed-rest. Especially must this rule be1 observed in the old, who have a tendency to pulmonary hypostasis. Saliva forms in the1 mouth and gravitates te> the pharynx and hype>pharynx, where1 it lodges in a pool jusl above the line of stitches closing the hypopharynx. Some patients arc able to swallow this; others have1 difficulty. Once every few hours the1 patient is turner 1 well ovea- on his side, and a large catheter attacheel to the suction apparatus is passe>el back into the mouth and throat and the saliva is removed. Once a day the surgeem or nurse under instruction paints the mouth, teeth, and pharynx with a 2 per cent. mercurochromc solution. An antiseptic mouth-wash is used eveay few hours, but no atteanpt should be1 made to gargle, sinev this act is evidently impossible. The heael of the patient should at the1 beginning be kept slightly flexed. The pillows shoulel be so arranged as to promote; this position. This takes the strain off the sutures closing the neck wound. The dressing covering the wound above the tracheal tube should be changed by the nurse as often as it be- comes soiled. This should be done aseptie-ally, using gloves or applying and removing the dressings with sterile forceps. The dressing of the wound above the tracheal cannula is a simple procedure unless infection occurs. The seao- sanguineous discharge from the wicks and tubes requires a change of dressing twice or three times in twentv-femr THE LARYNX 293 hours. If five days pass with no evidence of infection the treatment is that of any other aseptic wound. In laryngectomy the hypopharynx is opened, exposing the neck wound to the many and sometimes virulent bacterial flora of the mouth. Since clean mouths, healthy teeth and gums are rarely found in the middle aged and in the old, the problem of avoiding infection is a most difficult one. When it occurs the case becomes very complicated and arduous for the nurses as well as for the surgeon. It is here that an intelligent, indus- trious, and conscientious nurse contributes enormously toward the saving of the patient's life. Three con- tingencies must be kept constantly in mind, namely: the spreading of the infection along the muscular planes of the neck to the mediasternum; the occurrence of a general sepsis; and the gravitation of the virulent wound discharge into the lung through the open trachea. The surgeon must anticipate the first and second of these by opening wide the field of operation. The third danger is largely in the nurse's hands. Neck wounds con- taminated by the bacteria of the mouth frequently take on a gangrenous aspect. As the inner line of sutures give way saliva pours through in great quantity and seems to act as a digestant on the infected area, thus making constant attention to the wound imperative. If the surgeon is competent and realizes the gravity of the situation he will open the wound wide, place small drainage-tubes in the extension pockets, and fill the whole area with gauze over which a loose wet dressing is placed. The tubes must project through the dressing. The nurse is instructed to apply suction to these tubes every half- hour and to instill through the tubes a little Dakin's 294 EYE, EAR, NOSE, AND THROAT NURSING solution. Experienced nurses may even do the com- plete dressing, which in bad cases should be done ox cry three to six hours. It is only by constantly cleansing the wound by suction, Dakin's solution, and frequent change of dressings that we may hope to escape a lethal result. Watchful waiting and twenty-four-hour dressings have no place here. Such casual care has buried hundreds of these cases in the past and is, I regret to say, still actively working in the hit (Test of the undertaker. As the case progresses the sloughs separate, the tissues as- sume a healthy appearance, the wound contracts, some- times leaving a large or small fistula through which saliva pours. If this does not close, a plastic operation may later be indicated. A properly arranged tube projecting through the dress- ing and frequently attached to the suction apparatus does much toward keeping the dressing clean and reduc- ing the nurse's work. Feeding.—The feeding tube which projects a few inches from one or other nostril should be curved and attached to the face with a small piece of adhesive plaster. If it has a tendency to slip out or in, a small safety-pin may be made to transfix the tube wall (avoiding the1 lumen) at the point where it emerges from the nostril. To this is fastened two short pieces of tape. These are attached to the face by small strips of adhesive plaster. The curve of the tube should be so arranged as not to impinge too forcibly on the ala of the nose. Much soreness and dis- comfort may occur from such prolonged pressure. The nostril around the tube should be kept clean and occa- sionally painted with a 2 per cent, mercurochrome solu- tion or anointed with zinc ointment. THE LARYNX 295 Regurgitation through the tube after feeding occurs in some cases. It may be induced by too rapid feeding. It may be obviated by a cork in the end of the tube and slow feeding, with the patient in the semirecumbent posture. The prime importance of nourishment was sadly over- looked by the earlier operators in this field, which resulted in disaster to the patient. Then the surgical mortality was rarely below 30 per cent. In experienced hands, especially if the cases are carefully selected, this toll has dwindled to 3 per cent. Some of the causes con- tributing to this change may be set down as follows: a more exact and less traumatic operative technic; the exclusion of blood from the lungs during operation; the partial substitution of local for general anesthesia; the use of intratracheal suction and wound suction (in infected cases); laying wide open the operative field on the earliest suspicion of infection, and thorough, pains- taking attention to drainage; the co-operation of nurses trained in this work; feeding through a tube permanently established in the esophagus. Without intelligent and conscientious co-operation on the part of the nurses in charge our best efforts must fail. Therefore, it is the duty of the surgeon to see that his nurses are thoroughly instructed not by the written or spoken word, but by repeated demonstrations. The feeding tube is placed in position at the time of the operation. It extends into the esophagus about 4 or 5 inches, its end lying about midway down the sternum. Its displacement must be carefully guarded against, since it is difficult and sometimes impossible to replace1 it. The point of its exit from the nostril should be marked by the surgeon for the nurse's instruction. 29(i EYE, EAR, NOSE, AND THROAT NURSING The food formulas are constructed on the1 calory re- quirements for an individual of average weight. Three- heavy and three light feedings are given in twenty-four hours. These are alternated and given at four-hour intervals. The exact formulas must, of necessity, be1 governed by the judgment of the surgeon in charge. The following are suggested: (1) Whole egg. Milk-sugar. Butter. Oatmeal jelly. Milk. (2) Milk-sugar. Butter. Oatmeal jelly. Milk. Soups and fruit juices and, later, ground vegetables may be added. This thick mixture is poured into or" drawn into a large piston syringe. The patient is raised as far as may be possible into the semirecumbent posture and the food is slowly forced into the feeding tube. Each feeding must be followed by 3 or 4 ounces of water similarly forced through the tube. This cleanses the tube and adds the required fluid content. Gravitation, by using a funnel, may be employed instead of the syringe. Careful record must be kept of the number of fluidounces re- ceived and retained by the patient. If this falls below (34 ounces and if the stomach refuses te) retain the full amount, the difference in water between the amount taken and the amount required must be given by rectum by the drip method. THE LARYNX 297 Rectal feeding is absolutely useless in any condition. Only the water holding the food in suspension is absorbed, the food remaining in the bowel to ferment and cause irritation. Therefore only water is given by rectum. For example, if the patient can retain only 30 ounces of food per day, 34 ounces of water must be given by rectum. The tube is retained until the neck wound has closed. This may be days or weeks. The esophagus fortunately tolerates the tube very well. The colon must be kept empty by an occasional laxative and colon irrigation. The irrigation may be required every third or fourth day. The patient is gotten out of bed as soon as possible. If the temperature comes down to normal in a week, which it usually does, the patient may be set up in a reclining chair. While the temperature remains up bed is the best place. The convalescence may be completed in ten days or may extend over six weeks, depending on the degree and severity of the infection, which is common after all opera- tions in which the mouth or pharynx is opened into the neck. Cleft-palate and Harelip Since practically all plastic work for harelip and cleft- palate is done in the early years of life skill in caring for children is required on the part of the nurse. In order that the child may be more amenable a few days under the nurse's care should be spent in the hospital and away from the family. There are exceptions, how- ever, to this statement. Some children do better in their home environment 298 EYE, EAR, NOSE, AND THROAT NURSING with their mother assisting in their care. Where the child has been sanely trained and the mother does not let her maternal instinct overlap her judgment, home may be the most fitting place to operate. Bet tea- asepsis is often secured at home than in a hospital operating room, in which often no care has been taken to exe-lude septic operations. In no field of surgery is careful asepsis more essential. Unfortunately, there is a tendency on the part of nurses specializing in the care of nose, throat, and oar work to become lax in their aseptic technic ,and this letting down, it is sad to state, is but the reflection of the too frequent careless and indolent methods of our spee'ial surgeons. With some justification they feel that the nose, throat, and mouth cannot be made aseptic, hence why take the trouble. This seemingly logical e'emclusion is based upon a false knowledge of the subject. The bacteria infecting the mouth and throat, even though they show under culture a virulent nature, may be to the individual quite harmless due to an immunity acquired by long contact. The introduction of a new strain of the same bacteria may prove disastrous. Hence the urging of every aseptic care possible. In order to make the operative field as clean as possible attention should be given to the following points: 1. Diseased tonsils and adenoids should be removed. 2. Diseased teeth and gums should be taken care; e>f by a competent dentist. In cleft-palate1 and harelip there is also present deformity of the alveolar process with irregular eruption of the teeth and the eruption of deformed and partially developed teeth. Frequently the gums around these teeth are septic and the teeth THE LARYNX 299 decayed. Extraction or filling and treatment of the gums should be thoroughly done. 3. If sinus disease is present every effort, even opera- tive, should be invoked to get rid of the nasal discharge. Where the sinus disease is incurable success in the opera- tion for palatal deformity is greatly jeopardized. This does not, however, apply to the lip deformity, which on account of the great vascularity of the parts may be healed in the presence of infection. 4. The general condition of the patient is of paramount importance. It should be brought to the highest possible standard. A long sojourn in the country is its best mode of attainment. Hence the best time in the year for these operations is in the fall after the summer vacation. The winter and spring months are notoriously bad for these operations. When the above requirements have been fulfilled and the mouth and throat are healed and healthy the immediate preparation for the operation may be taken up. In the case of young children no change in the diet to which the child is accustomed should be made. If in the hospital, it is advisable to have the food prepared at home by the mother or the child's nurse and brought in daily. In older children a fluid or almost fluid diet is indicated during the eight or ten days of healing. This should be nutritious and properly balanced and varied as much as possible under the circumstances. (Milk, raw egg, thick soups, thin cereal gruels, ovaltine, and malted milk with cream, fruit juices, ice-cream, etc.). The usual nursing bottle may be used providing the MacKenty technic is employed in the operation. If the tongue pressure obturator is omitted as in other 300 EYE, EAR, NOSE, AND THROAT NURSING technics, the use of a nursing bottle wemlel endanger the fine of union. Spoon feeding is then imperative1. This method is irksome to the child and may result in under- feeding. A full diet is given from the beginning in young babies. In older children more time is allowed afteT the anesthetic before a full diet is reached. Children under one year suffer little from a properly given anes- thetic, and their digestion seems to assume its normal trend almost at once. Food up to the full digestive capacity is extremely essential to combat the ever-present danger of wound infection. The starvation employed in fairly recent times in these cases accounted for many failures. In babies one feeding only is eanitted before the time set for operation. Two or three hours after operation feeding is resumed. The bowels should be emptied by a laxative and an enema given several hours before the operation. The operating-room technic is that employed in any aseptic operation. Nurses, assistants, and anesthetist wear gle>ves. The anesthesia containers are plae-eMl in sterilized covers. Iodin is used over the faev anel lips, the strength being ge>verneel by the age1 of the patient. In infants a 1^ per e-ent. is all the delicate skin will stand. In older e-hildren the usual 3| per cent, is indie-atenl. Iodin is a poor memth disinfee-tanl as it e-auses a supeT- fieial e'xfe>liation of the epithe'lium, thus lowering the1 surface resistane-e1 te> bacterial invasion. A 2 pea- evnt. freshly prepareel mereairochrome solution is ideal for this purpose. It is e-aiefully applied to the entire surface of the mouth, pharynx, nasopharynx, and nasal cavities. The operating-room technic so far as it appears te> the assisting nurses must be as varied as the idiosyncrasies THE LARYNX 301 of the various operators. I can but set down here that which is used by the writer in the MacKenty cleft-palate operation: The patient is placed on a table well padded especially over the upper end. The head is drawn slightly over the end of the table and extended, the occiput and neck resting on the padded edge of the table. The head is bound in a sterile towel, the e-ars and eyes being included. The operator sits on a stool at the head of the table. The anesthetist sits on the left. The assistant stands on the right. The suction apparatus is between the anes- thetist and the foot of the table. The sterile tube from it is secured to the dressings over the patient's chest by a special clamp or safety-pin. A plain sterile sheet covers the patient. Over this is placed a split sheet whie-h is brought up and fastened to the patient's head dressing by a elamp. Safety-pins should not be used unless care be exercised in avoiding the piercing of the sterile coverings to the infected areas beneath. A tray table is placed across the patient's chest for the instruments immediately in use. On the right of the operating table are placexl two tables. On one the following articles are arranged: Folded sponges, fluffed sponges; 6 fine silkworm-gut strands threaded at both ends on a medium-sized curved Lane cleft-palate needle; 6 similar strands with medium-sized straight Lane needles. A single knot holds the needle secured to the thread. Six medium-sized Lane cleft-palate curved needles threaded at one end only on either heavy horse hair or fine strong silk (the best is known as Equisetene fine); 2 needle-holders (long, slim—Mayo's or Lane's), one tube of No. 0 or 00 plain catgut which is seldom used. 302 EYE, EAR, NOSE, AND THROAT NURSING On a second table placed at the operators right elbow the following instruments are plae-cd: A Mae-Kent y or other angular cleft-palate knife, 4 Brophy cleft-palate elevators, 1 small straight periosteal elevator, 1 ordinary scalpel, 1 sharp-pointed knife (both with razor-like edges), 1 pair of Brophy long-curved tissue forceps, 1 slim-pointed mouse-tooth forceps, 1 ordinary dressing forceps, 1 dozen clamps, 1 pair of slim curved scissors, 1 mouth-gag, 1 tongue suture, 1 Yankauer suction tip; a MacKenty obturator with dental wrench, 2 MacKenty prepared lead ribbons, a strand of heavy linen or silk thread, 1 large half-curvcel needle. As intimateel above, all ne'eelles must be threaded before the operation begins, since they are so fine that threading them during the operation is a potent cause of delay. The Postoperative Treatment.—After each feeding the mouth is irrigated with plain sterile water, care being taken te) get all particles of food away from the wound and from beneath the obturator. After cleansing a few drops of a 2 per cent, solution of mercurochrome is applied with a dropper along the stitch line in the mouth and 3 or 4 drops instilled in each nostril. This cleansing is much easier if a liquid or semiliquid diet is given. Too much importance cannot be attached to its thorough- ness. Its neglect spells failure. Some sedative is frequently indicated to promote sleep and allay crying during the first twenty-four hours. Paragoric in young children and codein in older ones may be given on the surgeon's order. On the ninth or tenth day the obturator, lead ribbons, and stitches are removed and the child may return to its normal diet. THE LARYNX 303 The obturator effectively prevents contact of the patient's fingers with the wound and obviates the bar- barous practice of tying the arms. If no obturator is used in young children the arms are secured so as to allow limited arm movements. The arms and hands should never be tightly secured. A laxative should be given on the day following the operation to rid the intestines of blood swallowed during the operation. This may be assisteel by a saline cleansing enema. The child is allowed freedom of action in bed from the start and every effort made to prevent crying and fretting. Thyroidectomy Thyroidectomy means the surgical removal of the thyroid gland. The name is misleading, since the entire gland should never be removed. Enough must be left to maintain its normal function. From one-half to seven- eighths may be excised, depending on the degree of eejn- stitutional toxemia and upon the original size of the gland. Preparation of the Patient.—A rest in bed of several days prior to operation under medical observation and in the care of a nurse congenial to the patient is an essential part of the preparation for operation for the removal of the thyroid gland. Every means should be used to allay fear of the ordeal and to build up the broken re- sistance present to greater or lesser degree in all of these cases. This refers particularly to the toxic type known as Graves' disease or toxic goiter or exophthalmic goiter. Ordinary goiter, struma, non-toxic goiter is, surgically speaking, a simple enlargement of the thyroid gland and 304 EYE, EAR, NOSE, AND THROAT NURSING needs only the preparation given to any ordinary surgical case. Toxic cases vary in degree. Some are so broken by the disease that weeks of treatment must precede1 any surgical effort in their behalf. And eweai then the e>pera- tion may be1 only the more simple one1 e>f tying one or twe) superior poles of the gland. Others are1 at emee in a condition to fae-e the ordeal with slight danger of disastea\ All toxic cases have1 periods of ewae-erbation anel remission in their symptoms. It is the part of wisdom to operate1 during a perioel of remission. This period should be eletermined by a pro- longed observation in each case in which tests on the basic metabolism and the blood chemistry are made. In all cases, slight or severe1, a rest in bed as stated above eloes mue'h to sle>w down the excessive oxidation rate anel the corresponding incivased pulse-rate so characteristic of this disease. Since te>xic goiter is a disease in which the body tissues are oxidized at a rate from 10 to 75 per cent, above normal it is logical that forced feeding to supply fuel and rest to delay its burning up go hand in hand in the days or weeks of preparation. The diet should be1 carefully laid down by the surgeon or physician and food given to the limit of te)lerance. The colon should be1 kept ck'ar of accumulation so apt to occur in resting patients on a full diet. Mild laxatives are indicated, but more important than these1 are colon irrigations given e>very second or third day by one experienced in the method. The irrigation should be preceded by an enema con- taining 1 even teaspoonful of pure carbonate1 of soda to 2 quarts. The irrigation of normal salt solution follows THE LARYNX 305 the expulsion of the enema. The temperature of both should be 105° to 110° F. If the operation is done in the forenoon, the breakfast is omitted. If in the afternoon, a light breakfast should be given. The use of morphin before operation rests with the surgeon. If permitted it should be given hypo- dermically one and a half hours prior to the beginning of the anesthesia; this allows the period of excitation to pass, and brings the patient to the operating room in the sejporifie stage of the elrug. Several hours before the operation the neck, three- quarters around, the chin and e-hest are shaved anel cleansed with soap and water, then with pure alcohol and covered with a sterile dressing bandaged on around the neck and armpits. The patient is taken to the operating room in the recumbent posture. Operating-room Technic.—The strictest asepsis must be observed. The gift and skill for its faultless applica- tion is not given to many. Asepsis is more than a science, it is a religion. In no operation is its observance to the last degree more essential than in thyroidectomy. These cases are in a most receptive state for infection and in the worst possible condition to bear it. Even in slight degree it mayr determine the issue and throw the balance against the patient. Only nurses thoroughly trained in operating-room technic and acutely conscientious should be allowed to assist at this operation. Two nurses are required—one for the ligature and sponge table, and the other for the instrument table. On the first of these are placed: 1 dozen tubes of plain catgut No. 0, and 2 tubes each of No. 1 and No. 2 plain 20 306 EYE, EAR, NOSE, AND THROAT NURSING catgut (No. 0 is used for all vessels excepting the supermr thyroids which are held with No. 1 or No. 2), 2 tubes of fine silk, 2 tubes of fine silkworm gut, 2 small cigarette drains, a foot of small soft-rubber tubing, 2 ligature carriers, 2 Mayo needle-holders, folded sponges, fluffed sponges, folded dressings, and 2 3-inch bandages, various sized curved needles, and 2 or more straight skin needles, 3| per cent, solution of iodin, head and body draperies. On the second table the following instruments are laid out: 2 very sharp medium sized knives, 3 dozen artery clamps, 6 small pedicle clamps, 2 pairs of tissue forceps, 2 or more tissue retractors, 1 blunt dissector, 2 large tissue tenacula, curved and straight scissors, 6 tenvel and skin holders or tenacula. Somewhere conveniently placed in the operating room a complete tracheotomy set should be in readiness, and an intravenous not with sterile salt solution kept at the proper temperature. The neck, jaw, chin, and chest are iodized with a 3| per cent, iodin and wiped with alcohol. The head is dressed in the usual way with towels. The body is covered with a plain sheet, over which is spread a sheet with a draw-string for the neck. This latter is attached to the neck and thrown over a half-circle arm attacheel to the table. The ether is given beneath this canopy. A third split sheet is spread over the body and its ends brought up And attached to the head dressing with a clamp. An adjustable table is placed over the abdomen and on it placed clamps, knife, sponges, and tissue forceps. The surgeon should be consulted as to how he wishes the needles threaded, and this should be done before the: operation begins. THE LARYNX 307 The nurse at the ligature and sponge table keeps her ligatures and sponges in order and anticipates the sur- geon's need in this regard. The instrument nurse keeps the instruments clean and arranged in order and must see that they are not piled up and in confusion. Two assistants besides the surgeon are required for a rapid and smooth technic. In the absence of one assistant one of the nurses may be called to hold retractors. It is better that the instrument table nurse be used. Postoperative Treatment.—The nurse must be cogni- zant of the complications which may follow immediately upon the operation. These are as follows: Surgical shock; rapid, weak pullse; palor; a sunken, expressionless face; restlessness; irregular or sighing respiration, and sweating are some of the more evident expressions of shock. A mild degree of shock is frequently present in nearly all of these cases. The immediate treatment which may be administered while waiting for the surgeon are: Heat to the body and limbs, bandaging of limbs, the Murphy drip, elevation of the foot of the bed. It is unsafe for the nurse to take it upon herself to administer drugs such as stimulants and opiates without the advice of the surgeon. Stimulants may make the condition more profound by overtaxing a tired brain center and an exhausted heart muscle. The surgeon may order intravenous saline, morphin, strychnin, caffein, digitalis, or adrenalin. These should be in immediate readiness. All instruments for the ad- ministration of an intravenous should be sterilized and laid out with the saline at the proper temperature and iodin Z\ per cent, to sterilize the arm. Acute Thyroidemia.—This is one of the most dangerous 308 EYE, EAR, NOSE, AND THROAT NURSING and most frequent complications of thyroidectomy. In character it is much like shock. The pulse may go above 200. The patient looks bronzed and sunken. The restlessness is extreme and a violent delirium is not uncommon. The causes which lead up to it are1: An unduh- prolonged operation, loss of blood, rough handling of the gland during the operation, thus expressing an overdose of the gland see'ietion into the cimilation, and the. thyroid secretion from the cut eaids of the gland lying in the wound and not being properly drained off. The best treatment for this condition is not to provoke its occurrence, since, facing it, we are often quite helpless. All the water possible should be gotten into the circula- tion by intravenous, by ree'tum, and mouth. Morphin is always indicated. If the wound has been drained by double tube, the cavity from which the gland was re- moved may, with advantage, be frequently flushed with a saline solution. This proe-edure has saved some desperate cases. The rest of the treatment is essentially the1 same as that used for shock. Hemorrhage.—The nurse must be on guard for the first evidence of secondary hemorrhage. As the dressing applied in these cases is large much loss of blood may occur before it is noticed. The recumbent position of the patient makes the blood gravitate backward. It is, therefore, at the posterior edges of the dressing that the early evidence of bleeding may be looked for. Help should be summoned and everything needed made ready to reopen the wound without moving the patient from the sick room. If desperate, the nurse is justified in removing the dressing in order to apply pressure with the gloved hands THE LARYNX 309 directly to the wound. The bleeding generally comes from one or other superior thyroid artery. Their cut ends are situated at the superior external part of the field of operation. Pressure may here be made with the thumbs directed inward and backward. Stimulants should not be used in hemorrhage until the flow of blood is checked. The reason for this is obvious. Asphyxia.—This is a rare complication. It is due to a kinking of the trachea softened by the long pressure of an enlarged thyroid. If to this flaccid condition of the breathing tube is added an overtight dressing or an im- properly placed drainage-tube asphyxia may occur.' To relieve it the bandages should be immediately cut. The nurse, then standing at the head of the bed, takes a secure hold under the lower jaw on both sides and, throwing the head back, she at the same time makes traction toward her so as to extend the head. This position is held until the surgeon arrives. A long rest in bed is indicated after thyroidectomy since recovery is generally slow. INDEX Abscess of nose after fracture, 249 retropharyngeal, 255 Accessory sinuses of nose, anat- omy, 234 Acetic acid, dilute, in diseases of eye, 123 Acid, acetic, dilute, in diseases of eye, 123 boric, in diseases of eye, 117 ointment of, in diseases of eye, 117 carbolic, as antiseptic, 24 in diseases of eye, 118, 127 in eye, treatment, 142 oxalic, sterilization of hands with, 36 tannic, in diseases of eye, 122 Acids, mineral, in eye, treatment, 142 Acidum aceticum dilutum in diseases of eye, 123 Acoumeter test for hearing, 202 Adam's apple, 267 Adenectomy, after-treatment, 204 hemorrhage after, treatment, 57, 261 in adults, 262 anesthesia, 262 in children, 258 anesthesia, 259 instruments for, 260 Adenoid sponge, 40 Adenoids, 251, 258 hemorrhage after removal of, treatment, 57 removal of. See Adenectomy. symptoms of, in children, 25S Aditus, 179, 180 Adrenalin in diseases of eye, 123 Advancement, double, for stra- bismus, 160 forceps. 173 Air, fresh, for infant, 98 germs in, 13 Alum in diseases of eye, 122 Aluminum, sulphate of, in dis- eases of eye, 122 Ammonia in eye, treatment, 142 Ampulla, 183 Anesthesia, 128 in tonsillectomy and adenec- tomy in adults, 262 in children, 259 Anesthetics, 128 for operations on eye, 158 general, 130 local, 129 for operations on eye, 158 Anodynes in diseases of eye, 128, 131 Anterior chamber of eye, 111 Antisepsis, 21 Antiseptic solutions, 23 Antiseptics, 21 bichlorid of mercury, 24 bromin, 27 311 DEX 312 INI Antiseptics, carbolic acid, 21 chemic, 23 chlorid of lime, 27 chlorin, 25 chlorinated soda, 27 cold, 23 heat, 22 in diseases of eye, 117 Labarraque's solution of chlor- inated soda. 27 liquor sodae chloratae, 27 phenol, 24 Antrum, mastoid, 1S2 of Highmore, anatomy of, 238 Anvil bone of ear. 182 Appetite of child, SO Applicator, cotton, ISO wooden, 41 Aquseductus Fallopii, 179 Aqueous humor, 111, 112 Argyrol in diseases of eye, 120 Argyrosis, 121 Artery, ophthalmic, 103 Artificial eye, 166 method of inserting, 167 of removing, 167 Snellen's, 167 infant feeding, 89 Arytenoid cartilage, 265 Asepsis, 21 Asphyxia after thyroidectomy, 309 Astringents in diseases of eye, 120 Atrophic rhinitis, 243 Atropin as mydriatic, 133 sulphate as mydriatic, 132 poisoning from, 185 Attic, 180 probe, 189 Auditory canal, 17(5 external, dandruff in, 200 diseases of, 198 Auditory canal, external, eczema of, acute, 19S chronic dry, 199 epithelial plugs in, soften- ing of, 200 foreign bodies in, 201 furuncles of, 201, 222 inflammation of, 202 iodoform dermatitis of, 199 Auricle, anatomy and physiol- ogy, 176 diseases of, 198 eczema of, acute, 198 chronic dry, 199 frost-bite of, 200 inflammation of, diffuse, 202 iodoform dermatitis of, 199 preparation of, in mastoid operation, 217 Babies' ear-cap, 207 Bacteria in milk, 94 Balsam of Peru packing, 42 Bandage, dumb-bell, of Steven- son, 168 eye, 167 figure-of-eight, of eye, 169 Liebreich's, 168 mastoid, 227 Moorfield's, 168 of ear after mastoid operation, 229 roller, of eye, 168 sterilization of, 36 Bandaging eyes, 167 in mastoid operation, 223 Bathing infant, 99 Bed, patient's, preparation of, before operation, 51 Beef-juice in infant feeding, 96 Beer's knife, 175 ind: Belladonna as mydriatic, 132 Benzoinal inhaler, 278 Bichlorid of mercury as anti- septic, 24 for sterilizing hands, 35 in diseases of eye, 118, 127 ointment in discuses of eye, 119 poisoning, 66 Biniodid of mercury in diseases of eye, 119 Bleeding from nose, 236 Blood, swallowing of, preven- tion, 59 Blood-corpuscles, white, ability of, to destroy germs, 14 Bluestone in diseases of eye, 125 Body, vitreous, 109 Boiling of milk, 94 Bones of middle ear, 180 Borax in diseases of eye, 118 Boric acid in diseases of eye, 117 ointment in diseases of eye, 117 Bottle-feeding in infants, 88, 89 length of time to continue, 89 Bottles, care of, 148 Thermos, 278 Boucheron's ear speculum, 1S9 Bowels, mother's, regulation of, 86 training of, in child, 97 Breast feeding of infants, 85 care of mother's bowels in. 86 diet of mother in, 85 length of time to continue, 89 Bridge, ether, 219 Bromin as antiseptic, 27 as oxidizing agent, 28 ex 313 Bronchi, foreign bodies in, 271 Bronchitis in children, 100 Bronchoscopy sponges, 40 Buller's shield, 152, 162 Burns, lime, of eye, treatment, 142 of eye, treatment, 142 Calomel in diseases of eve, 125 Caloric test for static labyrinth, 195, 196 Canal, auditory, 176 external. See Auditory canal, external. horizontal, of ear, 183 posterior, of ear, 183 superior, of ear, 183 Canaliculus, lacrimal, 106 Canalis reuniens, 185 Canals, lacrimal, 105 semicircular, of labyrinth, 182, 183 Cannula, tracheal, after tracheot- omy, 290 Carbohydrates in infant feeding, 84 Carbolic acid as antiseptic, 24 in diseases of eye, 118, 127 in eye, treatment, 142 poisoning, 65 Care of children, 79 of infants, 79 Carrel-Dakin solution, 225 Cartilage, arytenoid, 265 cricoid, 205 of ear, inflammation, 200 of external ear, 176 tarsal, 104, 106 thyroid, 265 Caruncle, lacrimal, 106 Caseous rhinitis, 245 314 INDEX Cataract extraction, 159 knife, 171 operations, dressing tray for, 169 instruments for, 170 Catarrh of middle ear, acute, 203 chronic, 215 Caustic in diseases of eye, 126 lunar, in diseases of eye, 126 potash in diseases of eye, 127 soda in diseases of eye, 127 Cautery in diseases of eye, 127 I'aquelin, in diseases of eye, 128 Cells, devouring, 14 eating, 14 ethmoid, anatomy of, 249 goblet, 105 mastoid, 182 Cereals in infant feeding, 96 Cerumen drops, 200 softening of, 200 Chalazion curet, 172 Cheek bone, 102 Chemic antiseptics, 23 Chemosis, 152 Child, acute rhinitis in, 242 adenectomy in, 258 anesthesia, 259 appetite of, 80 bathing of, 99 bowels of, training of, 97 bronchitis in, 100 care of, 79 contagious diseases of eyes in, care of, 152 convulsions in, 98 croup in, 99 diseases of, 99 examination of nose and throat in, 241 feeding, 84. See also Infant feeding. Child, fresh air for, 98 gastric condition of, so intestinal condition in, Si measles in, 99 normal, 83 papilloma of larynx in, 269 rickets in, 101 scarlet fever in, 99 scurvy in, 101 sleep of, 97 stools of, 81 color, 82 consistency, 81 curds, 82 frothiness, 82 mucus, 82 odor, 82 size, 81 temperature of, 97 tonsillectomy in, 258 anesthesia, 259 troublesome, management of, 67 restraint for ear examina- tion or dressing in, 70 for eye examination in, 70 for throat examination in, 71 vomiting of, 80 Chloramin for infected wounds, 225 Chlorid of lime as antiseptic, 27 of mercury in diseases of eye, 125 Chlorin as antiseptic, 25 as oxidizing agent, 28 preparation containing, 27 Chlorinated soda as antiseptic, 27 Chlorin-water in diseases of eye, 120 Chloroform as antiseptic, 131 Chorda tympani nerve, 179 index 315 Choroid coat of eyeball, 107 Cilia forceps, 175 Ciliary muscle, 110 Clamp, Snellen's, 175 Cleft-palate, 297 instruments for operation, 302 operating-room technic in op- erations for, 300 postoperative treatment, 302 Clothing, disinfection of, 30 Coat, choroid, of eyeball, 107 sclerotic, of eyeball, 107 Cocain as local anesthetic, 129 as mydriatic, 133 in operations on eye, 158 poisoning, 66 Cochlea, 182, 184 Coil, Leiter, in diseases of eye, 138 Cold as antiseptic, 23 eye-pads, 139 in diseases of eye, 131, 138 Collodion and cotton dressing, 230 Color of child's stool, 82 of eye, 111 Colostrum, 86 Conjunctiva, 104, 105 Contagious diseases, 15 of eyes, 150 cleansing in, 151 in children, care of, 152 nurse's duties in, 150 Convulsions in child, 98 Copper sulphate in diseases of eye, 122, 125 Cornea, 107, 111, 112 diameter of, 107 Corpuscles, white, ability of, to destroy germs, 14 Corrosive sublimate in diseases of eye, 118 Corti's organ, 184, 185 Cotton and collodion dressing, 230 applicator, 189 styptic, 121 Counterirritants in diseases of eye, 126 Coup sur coup, 147 Cricoid cartilage, 265 Cricothyroid membrane, 267 Crookes' glasses, 162 Croup in children, 99 tent, 281 after laryngectomy, 291 Crystalline lens, 109 suspensory ligament of, 109 Curds in child's stool, 82 Curet, chalazion, 172 ring. 189 Cystotome, Graefe's, 172 Dakin's solution, 224, 225 Dandruff in external auditory canal, 200 Deafness, labyrinthine, chronic, 233 nerve, 233 tests for, 192. See also Hear- ing, tests for. Depressor, tongue, 190 Dermatitis, iodoform, of auricle and external auditory canal, 199 Deviations of nasal septum, 247 treatment, 248 Devouring cells, 14 Dichloramin-T in chlorcosane for infected wounds, 225 Diet of mother, effect, on milk, 85 Dilators, lacrimal, 173 Diplopia, 114 Disease, germ theory of, 11 316 INDEX Disinfection of clothing, 30 of room, 30 Dissecting forceps, 175 Double advancement for strabis- mus, 160 vision, 114 Douche, Lucae's, 210 Douches, 272 Douching, nasal, with Douglass syringe, 275 with fountain syringe, 273, 274 Douglass syringe, nasal douch- ing with, 275 Dressing, cotton and collodion, 230 ear, restraint for, in trouble- some children, 70 in mastoid operation, 223 Knapp's, 155, 163 sterilization of, 36 Dressings after laryngectomy, 292 Dressing-tray for cataract opera- tions, 169 for mastoid operation, 226 Dried milk preparations, 93 Droppers, care of, 148 Drops, applying of. to eyes, 146 Drug poisoning, 65 Drum membrane, 17s Dry cold in diseases of eye, 138 heat in diseases of eye, 136 Duboisin as mydriatic, 133 Duct, nasal, 100, 105, 106 tear-, 106 Dumb-bell bandage of Steven- son, 168 Ear, 176 anatomy of, 176 anvil bone of, 180 Ear, bandage of, after mastoid operation, 229 cartilage of, inflammation, 200 dressiujj, restraint for, in trou- blesome children, 70 examination of, 186 instruments for, 188, 190 position of patient and nurse for, 191 restraint for, in troublesome children, 70 tray in, 188 external, 176 anatomy and physiology, 176 cartilage of, 176 forceps, angular, 190 frost-bite of, 200 hammer bone of, 180 horizontal canal of, 183 internal, 176 anatomy and physiology, 182 diseases of, 231 semicircular canals of, 182, 183 vestibule of, 182, 183 irrigation of, method of, 208 middle, 176 anatomy and physiology, 179 bones of, 180 catarrh of, acute, 203 chronic, 215 diseases of, 203 muscles of, 178 ossicles of, 180 muscles of, 181 patch, 229 perichondritis of, 200 physiology of, 170 posterior canal of, 183 INDEX 317 Ear, pugilist's, 200 speculum, Boucheron's, 189 Gruber's, 189 stirrup bone of, 180 superior canal of, 183 syringe, Pomeroy, 189 syringing, 186 wax, softening of, 200 Earache, 204 Ear-cap, babies', 207 Eating cells, 14 Eczema of auricle, acute, 198 chronic dry, 199 of external auditory canal, acute, 198 chronic dry, 199 Edema of larynx, 269 Eggs in infant feeding, 96 Electric heater, 137 Elongated uvula, 253 Emergencies, nurse's duties in, 56 Emergency table, 46 Endemic diseases, 16 Endolymph, 183, 185 Entropion forceps, 171 Enucleation of eye, 161 scissors, 173 Epidemics of disease, 11, 16 superstition regarding, 17 Epiglottis, 251, 265 Epistaxis, 245 Epithelial plugs in external audi- tor}' canal, softening of, 200 Erysipelas, t>4 Ether as anesthetic, 131 bridge, 219 Ethmoid bone, 102 cells, anatomy, 239 Ethylhydrocuprein as germicide in conjunctivitis or keratitis, 134 Eucain hydrochlorate as local anesthetic, 130 in operations on eye, l.'iS Euphos glasses, 162 Euphthalmin as mydriatic, 133 Eustachian tube, 179 Eversion of eyelids, 143 of lower eyelid, 143 of upper eyelid, 143 Evisceration of eye, 161 Examination of ear, restraint for, in troublesome children, 70 of eye, restraint for, in trouble- some children, 70 of throat, restraint for, in troublesome children, 71 Exophthalmic goiter, 303 Exophthalmos, 239 External ear, 176 anatomy and physiology, 176 cartilage of, 176 Eye, 102 ammonia in, treatment, 142 anatomy of, 102 anterior chamber of, 111 applying drops to, 146 ointments to, 148 salve to, 149 artificial, 166 method of inserting, 167 of removing, 167 Snellen's, 167 bandaging of, 167 burns of, treatment, 142 carbolic acid in, treatment, 142 contagious diseases of, 150 care of, in children, 152 cleansing in, 151 duties of nurse in, 150 diseases of, adrenalin in, 123 alum in, 122 318 INDEX Eye, diseases of, anodynes in, K} 128, 131 antiseptics in, 117 argyrol in, 120 astringents in, 120 bichlorid of mercury in, 118, 127 ointment in, 119 biniodid of mercury in, 119 bluestone in, 125 borax in, 118 boric acid in, 117 ointment in, 117 calomel in, 125 carbolic acid in, 118, 127 caustic potash in, 127 soda in, 127 caustics in, 126 cautery in, 127 chlorid of mercury in, 125 chlorin-water in, 120 cold in, 131, 138 contagious, 150 cleansing in, 151 duties of nurse in, 150 copper sulphate in, 122, 125 corrosive sublimate in, 118 counterirritants in, 12(3 dilute acetic acid in, 123 dry cold in, 138 galvanocautery in, 12s heat in, 131, 136 hot-pack in, 141 hydrogen peroxid in, 120 inunctions in, 140 iodin in, 119 iodoform in, 119 ointment in, 119 irritants in, 124 lead subacetate in, 123 leeches in, 134 Leiter coil in, 138 e, diseases of, liquor phimbi subacetatis in, 123 lunar caustic in, 12(5 mercurial ointment in, 141 mercury in, 118 metallic coil in, 138 mitigated silver nitrate in, 126 moist cold in, 139 heat in, 137 morphin sulphate in, 132 oxycyanid of mercury in, 119 Panas' biniodid of mercury solution in, 119 solution of biniodid of mercury in, 119 Paquelin cautery in, 128 permanganate of potash in, 120 phenol in, 118 potassium hydrate in, 127 poultices in, 132 remeelies in, 116 silver nitrate in, 121, 126 sodium biborate in, 118 hydrate in, 127 styptics in, 120 sulphate of aluminum in, 122 of potassium in, 122 suprarenalin in, 123 tannic acid in, 122 tannin in, 122 tincture of iodin in, 127 of opium in, 131 yellow oxid of mercury oint- ment in, 124 zinc sulphate in, 122, 126 enucleation of, 161 evisceration of, 161 examination, restraint for, in troublesome children, 70 figure-of-eight bandage of, 169 INDEX 319 Eye, foreign bodies in, needle for removing, 171 spud for removing, 171 glass, 166 method of inserting, 167 of removing, 167 Snellen's, 167 instruments, 162 lime burns, treatment, 142 mineral acids in, treatment, 142 muscles of, 114 operations on, anesthetics for, 158 eocain in, 158 eucain in, 158 general anesthetics for, 130 holocain in, 158 instruments for, 170, 175 local anesthetics for, 129 nurse's duties in, 153 preparation of room, 156 operative technic, 153 physiology of, 102 posterior chamber of, 111 pupil of, 110 size of, 110 recti muscles of, 113, 114 refractive media of, 112 roller bandage of, 168 shades, 164 superior and inferior oblique muscles of, 113, 114 Eyeball, 106 choroid coat of, 107 sclerotic coat of, 107 structures of, 109 Eye-ground, normal, 108 Eyelashes, 104 Eyelids, 103 eversion of, 143 lower, eversion of, 143 Eyelids, retractor for, 145, 172 spatula for, 172 speculum for, 172 upper, eversion of, 143 Eye-pads, cold, 139 Facial nerve, 179 False vocal cord, 266 Fat, orbital, 103 Fats in cows' milk, 89 in infant feeding, 84 Faucial tonsils, 251 Feeding after laryngectomy, 295 infant, 84. See also Infant feeding. tube after laryngectomy, 295 Fenestra ovalis, 179 rotunda, 179 Figure-of-eight bandage of eye, 169 P'istula test for static labyrinth, 195 Fixation forceps, 175 Foramen, optic, 103 Forceps, advancement, 173 cilia, 175 dissecting, 175 ear, angular, 190 entropion, 171 fixation, 175 Hartmann's. 190 iris, 173 Lucae's, 189 pterygium, 175 strabismus, 173 tendon, 173 trachoma, 172 Foreign bodies in bronchi, 271 in external auditory canal, 201 in eye, needle to remove, 171 spud for removing, 171 320 INDEX Foreign bodies in larynx, 271 in pharynx, 271 in trachea, 271 Foremilk, 85 Formaldehyd for disinfecting rooms, 31, 32 Fossa, Rosenmiiller's, 251 Fountain syringe, nasal douching with, 273, 274 Fovea centralis, 109 Fowler's irrigator, 209 Fracture of nose, 248 Freezing as local anesthetic, 131 Fresh air for children, 98 Frontal bone, 102 sinus, anatomy of, 238 Frost-bite of auricle, 200 Frothiness in child's stool, 82 Frozen milk, 93 Furuncles of external auditory canal, 201 incisions of, 222 Galvanic test for static laby- rinth, 1*>7 Galvanocautery in diseases of eye, 128 Gargles, 278 Gas, nitrous oxid, as anesthetic, 131 Gastric condition of child, 80 Germ theory of disease, 11 Germs, ability of white cor- puscles to destroy, 14 in air, 13 Gland, lacrimal, 104 Glands, Meibomian, 104 Glass eye, 166 method of inserting, 161 of removing, 167 Snellen's, 167 Glasses, Crookes', 162 Euphos, 162 smoked, 162 Goblet cells, 105 Goiter, exophthalmic, 303 toxic. 303 Graefe's cystotome, 172 Grafting, skin-, in mastoid opera- tion, 218 (Jraves' disease, 303 Gruber's ear speculum, 1*9 IIammkk bone of ear, 180 Hands, sterilization of, 34 oxalic acid method, 30 potassium permanganate method, 3(5 with bichlorid of mercury, 35 with lime and soda, 36 with lysol, 36 Harelip, 297 instruments for operation, 302 operating-room technic, 300 postoperative treatment, 302 Hartmann's forceps, 190 Hay-fever, 240 pollen test in, 247 treatment, 246 Hearing, tests for, 192 acoumeter, 192 high tones, 192 instruments for, 193 localization, 193 low tones, 192 Rinne's, 193, 194 Schwabach's, 193 tuning-forks for, 193 voice, 192 watch, 192 Weber's, 194 whisper, 192 INDEX 321 Heat as antiseptic, 22 dry, in diseases of eye, 136 in diseases of eye, 131, 136 moist, in diseases of eye, 137 Heater, electric, 137 Helicotrema, 184 Hemorrhage after removal of adenoids, treatment, 57, 261 after thyroidectomy, 308 after tonsillectomy, treatment of, 58, 201 from nose, 245 packing nose to control, 57 treatment, 56 postoperative, control of, 59, 60 tonsillar, control of, 58 Hemostat, Mikulicz-Stoerk, 262 Hiatus semilunaris, 236 Highmore, antrum of, anatomy, 238 Holder, needle, 172 Holocain hydrochlorate as local anesthetic, 130 in operations on eye, 159 Homatropin as mydriatic, 133 Hook, iris, 171 strabismus, 171 Horizontal canal of ear, 183 Hot pack in diseases of eye, 141 Humor, aqueous, 111, 112 Hyaloid membrane, 109 Hydrogen peroxid as oxidizing agent, 27 in diseases of eye, 120 Hyoid bone, 267 Hyoscin as mydriatic, 133 Hyoscyamin as mydriatic, 133 Hypertrophic rhinitis, 244 treatment, 245 Ideal nurse, conduct of, in sick room, 74 qualities of, 74 Image on retina, 112 Incisions of furuncles in aural canal, 222 Incus, 180 Infant, appetite of, 80 bathing of, 99 bowels of, training of, 97 bronchitis in, 100 care of, 79 convulsions in, 98 croup in, 99 diseases of, 99 feeding, 84 artificial, 89 beef juice in, 96 bottle, 88, 89 length of time to con- tinue, 89 breast, 85 care of mother's bowels in, 86 diet of mother in, 85 length of time to continue, 89 carbohydrates in, 84 cereals in, 96 eggs in, 96 fats in, 84 milk, 89 percentage, 89 proteids in, 85 regularity of, 96 substitute, 89 weaning, 88 fresh air for, 98 gastric condition of, 80 intestinal condition in, 81 measles in, 99 rickets in, 101 21 DEX 322 ini Infant, scarlet fever in, 99 scurvy in, 101 sleep of, 97 stools of, 81 color, 82 consistency, 81 curds, 82 frothiness, 82 mucus, 82 odor, 82 size, 81 temperature of, 97 vomiting of, 80 Infected wounds, chloramin for, 225 Dakin's solution for, 224, 225 dichloramin-T in chlorcosane for, 225 Infection after laryngectomy, 293, 294 Infectious diseases, 15 Inflammation, diffuse, of auricle, 202 of cartilage of ear, 200 of external auditory canal, 202 Influenza, definition of word, 12 Inhalations, 278 of steam, 278 Inhaler, benzoinal, 278 Instruments, eye, 162 for adenectomy, 260 for cataract extraction, 170 for cleft-palate and harelip op- erations, 302 for ear examination, 188, 190 for examination of pharynx and larynx, 253 for eye operations, 170-175 for laryngectomy, 286, 287 for testing hearing, 193 for thyroidectomy, 305, 306 Instruments for tonsillectomy, 260 for tracheotomy, 280 sterilization of, 38 Internal ear, 176 anatomy and physiology, 182 diseases of, 231 semicircular canals of, 182, 183 vestibule of, 182, 183 tympanic membrane, 185 Intestinal condition in children, 81 Inunctions in diseases of eye, 140 Iodin as oxidizing agent, 28 in diseases of eye, 119 tincture of, in diseases of eye, 127 Iodoform dermatitis of auricle and external auditory canal, 199 in diseases of eye, 119 ointment in diseases of eye, 119 packing, 42 poisoning, 65 Iris, 110 color of, 111 forceps, 173 hook, 171 pigment of, 111 scissors, 174 Irrigation, 276 of ear, method of, 208 of maxillary sinus, 276 Irrigator, eye, 175 Fowler's, 209 Irritants in diseases of eye, 124 Jersey milk, 90 Jugular vein, 182 INDEX 323 Keratome, 172 Knapp's dressing, 155, 163 Knife, Beer's, 175 cataract, 171 grattage, 175 needle, 172 paracentesis, 171 Weber's, 172 Kuhnt's operation for trachoma, 160 Labarraqcte's solution of chlor- inated soda as antiseptic, 27 Labyrinth, 176 anatomy and physiology, 182 membranous, 183 semicircular canals of, 182, 183 static, functional tests of, 194 caloric, 195, 196 fistula, 195 galvanic, 197 rotation, 196 vestibule of, 182, 183 Labyrinthine deafness, chronic, 233 Labyrinthitis, non-suppurative, 232 suppurative, acute, 231 chronic, 232 Lacrimal apparatus, 104 bone, 102 canaliculus, 106 canals, 105 caruncle, 106 dilators, 173 gland, 104 point, 105 probes, 173 punctum, 105, 106 syringe, 175 Lamina spiralis, 185 Lamp, Priestly-Smith, 166 Laryngectomy, 282 croup tent after, 291 dressings after, 292 feeding after, 295 tube in, 295 infection after, 293, 294 instruments for, 286, 287 postoperative treatment, 289 preparation of operating room, 285 of patient, 283 tracheal cannula after, 290 tray in, 287, 288 use of suction pump after, 289 Laryngopharynx, 252 Larynx, 251, 265 anatomy of, 265 edema of, 269 examination of, 253, 267 instruments for, 253 foreign bodies in, 271 papilloma of, in children, 269 spraying of, 277 steam inhalation of, 278 syphilis of, 271 tuberculosis of, 270 treatment, 270 tumors of, benign, 269 malignant, 269 ventricular bands, 266 Layers of retina, 108 nervous, 108 pigmentary, 108 Lead subacetate in diseases of eye, 123 Leeches in diseases of eye, 134 Leiter coil in diseases of eye, 138 Lens, crystalline, 109 suspensory ligament of, 109 spoon, 172 Liebreich's bandage, 168 324 INDEX Ligament, suspensory, of crystal- line lens, 109 Lime and soda for disinfecting hands, 36 burns of eye, treatment, 142 chlorid of, as antiseptic, 27 Lime-water in milk, 92 Lingual tonsil, 251 Liquor chloratse as antiseptic, 27 plumbi subacetatis in diseases of eye, 123 Localization tests of hearing, 193 Loop, wire, 172 Lucae's bayonet forceps, 189 siphon douche, 210 Lunar caustic in diseases of eye, 126 Lupus, destruction of nose after, 247 Luschka's tonsil, 251 Lysol for sterilizing hands, 36 Macula lutea, 109 Malar bone, 102 Malaria, definition of word, 12 Malignant tumors of larynx, 269 Malleus, 180 Mask, ring, 165 Mastoid antrum, 182 bandage, 227 cells, 182 operation, bandage of ear after, 229 dressing and bandaging in, 223 dressing-tray for, 226 emergencies arising in, 221 preparation for, 215 of auricle in, 218 of skin in, 216 radical, preparation for, 215, 218 Mastoid operation, simple, prep- aration for, 215, 218 skin-grafting in, 218 portion of temporal bone, LSI process, 1^1 Maxillary bone, superior, 102 sinus, anatomy, 238 irrigation of, 276 Measles in children, 99 Meibomian glands, 102 Membrana basilaris, 184 flaccida, 179 Membrane, cricothyroid, 267 drum, 178 hyaloid, 109 internal tympanic, 185 Sehneiderian, 238 Shrapnell's, 179, 180 thyrohyoid, 267 Membranous labyrinth, 183 rhinitis, 245 Meniere's disease, 232 Mental disturbances after opera- tion, 61 state, influence of, in disease susceptibility, 13 Mercurial ointment in diseases of eye, 141 Mercurocrome in conjunctivitis, 134 Mercury, bichlorid of, in diseases of eye, 118, 127 ointment of, in diseases of eye, 119 biniodid of, in diseases of eye, 119 chlorid of, in diseases of eye, 125 in diseases of eye, 118 ointment, yellow oxid of, in diseases of eye, 124 INDEX 32£ Mercury, oxycyanid of, in dis- eases of eye, 119 Metallic coil in diseases of eye, 138 Miasma, 12 Middle ear, 176 anatomy and physiology, 179 bones of, 180 catarrh of, acute, 203 chronic, 215 diseases of, 203 myringotomy for, 211 Mikulicz-Stoerk tonsil hemostat. 262 Milk, bacteria in, 94 boiling of. 94 effect of diet of mother on, 85 fats in, 89 formulas in first twelve months, 91 frozen, 93 in infant feeding, 89 Jersey, 90 lime-water in, 92 pasteurisation of, 22, 94 peptonization of, 95 complete, 95 partial, 95 percentage of, 90 preparations, dried, 93 proteids in, 90 sterilization of, 94 sugar in, 89 Milk-supply, inspection of, 14 Mineral acids in eye, treatment, 142 Mitigated silver nitrate in dis- eases of eye, 127 Modiolus, 185 Moist cold in diseases of eye, 139 heat in diseases of eye, 137 Moorfield's bandage, 168 Morphin sulphate in diseases of eye, 132 Mother, diet of, effect on milk, 85 Mucus in child's stool, 82 Mules' sphere introducer, 171 spheres, 171 Muscles, ciliary, 110 ocular, 114 of ear, 178 of ossicles of ear, 181 recti, of eye, 114 superior and inferior oblique, of eye, 114 Mydriatics, 132 Myotics, 133 Myringotomy, 205 for acute purulent otitis media, 205 for middle-ear infections, 211 tray, 206 Nasal bones, 103 douching with Douglass syr- inge, 275 with fountain syringe, 273, 274 duct, 105, 106 septum, anatomy of, 237 deviations of, 247 treatment, 248 sinusitis, 249 specula, 190 splints, 42 vibrissa?, 234 Nascent oxygen, 28 Nasopharynx, anatomy of, 251 Needle for removing foreign bodies from eye, 171 holder, 172 knife, 172 tattooing, 172 326 INDEX Xerve, chorda tympani, 179 deafness, 233 facial, 179 olfactory, 236 optic, 103, 113 Nervous layer of retina, 108 Nitrate of silver in diseases of eye, 121, 12(5 mitigated, in diseases of eye, 126 Nitrous oxid gas as anesthetic, 131 Non-suppurative labyrinthitis, 232 Normal child, 83 Nose, 234 abscess of, after fracture, 249 accessory sinuses of, anatomy, 234 anatomy of, 234 destruction of, after lupus, 247 after syphilis, 247 after tuberculosis, 247 diseases of, 240 examination of, 240 in infants, 241 fracture of, 248 functions of, 238 hemorrhage from, packing nose to control, 57 treatment, 56 packing of, to control hemor- rhage, 57 saddleback, 247 spraying of, 277 vestibule of, 234 Nosebleed, 245 Nurse, duties of, at operations, 50 before operation, 52 in contagious eye diseases, 150 Nurse, duties of, in emergencies, 50 in operations on eye, 153 ideal, conduct of, in sick-room, 74 qualities of, 74 Nutgalls, 122 Oak-apples, 122 Ocular muscles, 114 Odor of child's stool, 82 Ointment, applying of, to eye, 148 bichlorid of mercury, in dis- eases of eye, 119 boric acid, in diseases of eye, 117 iodoform, in diseases of eye, 119 mercurial, in diseases of eye, 141 yellow oxid of mercury, in dis- eases of eye, 124 Old-sight, 110 Olfactory nerve, 236 Operating room, preparation of, for laryngectomy, 285 in private dwelling, 43 technic, 43 in cleft-palate and harelip operations, 300 in thyroidectomy, 305 table in private dwelling, 45 Operations, cataract, dressing tray for, 169 instruments for, 170 important, 159 * in private dwelling, list of what needed, 48 Kuhnt's, for trachoma, 160 mastoid, bandage of ear after, 229 INDEX 32< Operations, mastoid, dressing and bandaging in, 223 dressing-tray for, 226 emergencies arising in, 221 preparation for, 215 of auricle in, 217 of skin in, 216 radical, preparation for, 215 simple, preparation for, 215 skin-grafting in, 218 mental disturbances after, 61 nurse's duties at, 50 before, 52 on eye, anesthetics for, 158 eocain in, 158 eucain in, 158 general anesthetics for, 130 holocain in, 159 instruments for, 170-175 local anesthetics for, 129 nurse's duties in, 153 preparation of room, 156 Operative technic, eye, 153 Ophthalmic artery, 103 Opium, tincture of, in diseases of eye, 131 Optic chiasm, 113 commissure, 113 dextra, 147 foramen, 103 nerve, 103, 113 sinistra, 147 Optochin as germicide in con- junctivitis or keratitis, 134 Orbit, 102 front view, 102 side view, 103 supra-orbital ridge, 102 walls of, 102 Orbital fat, 103 Organ of Corti, 184, 185 Oropharynx, anatomy of, 251 Ossicles of ear, 180 muscles of, 181 Ossiculectomy, 222 Otitis media, acute purulent, 204 catarrhalis acuta, 203 chronica, 215 chronic purulent, 213 purulenta acuta, 204 myringotomy in, 205 chronica, 204 Otomycosis, 200 Oval window, 179 Oxahc acid method of sterilizing hands, 36 Oxidizing agents, 27 bromin, 28 chlorin, 28 hydrogen peroxid, 27 iodin, 28 permanganate of potash, 28 Oxycyanid of mercury in dis- eases of eye, 119 Oxygen, nascent, 28 Ozena, 243 Packing, balsam of Peru, 42 iodoform, 42 nose to control hemorrhage, 57 vaselin, 41 Palate, 102 cleft-, 297 Panas' solution of biniodid of mercury in diseases of eye, 119 Papilloma of larynx in children, 269 Paquelin cautery in diseases of eye, 128 Paracentesis knife, 171 Pasteurization of milk, 22, 94 Patient's bed, preparation of, before operation, 51 DKX 32S ini Peptonization of milk, 95 complete, 95 partial, 95 Percentage infant feeding, 89 of milk, 91 Perichondritis of ear, 200 Perilymph, 183 Permanganate of potash as ox- idizing agent, 28 in diseases of eye, 120 Phagocytes, 14 Pharyngitis, 254 acute, 254 chronic, 255 Pharynx, 251 anatomy of, 251 diseases of, 253 examination of, 253 instruments for, 253 foreign bodies in, 271 ulcers of, 255 Phenol as antiseptic, 24 in diseas(>s of eye, 118 Pigment of iris, 110 Pigmentary layer of retina. 108 Pinna, anatomy and physiology, 176 Plasmodium malaria?, 20 Plica semilunaris, 106 Plugs, postnasal, 41 Point, lacrimal, 105 Poisoning, bichlorid of mercury, 66 carbolic acid, 65 eocain, 66 drug, 54 from atropin sulphate, 132 iodoform, 65 Pollen test in hay-fever, 247 Pomeroy ear syringe, 189 Posterior canal of ear, 183 chamber of eye, 111 Postnasal plugs, 41 Postoperative hemorrhage, con- trol of, 59, 60 treatment in thyroidectomy, 307 Potash, caustic, in diseases of eye, 127 permanganate of, in diseases of eye, 120 Potassium hydrate in diseases of eye, 127 permanganate1 method of ster- ilizing hands, 30 sulphate in diseases of eye, 122 Poultices in diseases of eye, 132 Presbyopia, 110 Priestly-Smith lamp, 166 Probe, attic, 189 lacrimal, 173 Proteids in infant feeding, 85 in milk, 90 Pterygium forceps, 175 Pugilist's ear, 200 Pump, suction, use of, after laryngectomy, 289 Punctum lacrimale, 105, 106 Pupil of eye, 110 size of, 110 Purulent otitis media, acute, 204 chronic, 213 rhinitis, 245 Radical mastoid operation, preparation for, 215 Recti muscles of eye, 114 Reducing agents, 29 Refraction, 135 Refractive media of eye, 112 Remedies in diseases of eye. 116 Restraining child in ear exam- ination, 70 INDEX 329 Restraining child in eye exam- ination, 70 in throat examination, 71 Retina, 108 image on, 112 layers of, 108 nervous layer of, 108 pigmentary layer of, 108 yellow spot of, 109 Retractor, eyelid, 171 lid, 145 Retropharyngeal abscess, 244 Rhinitis, 241 acute, 241 in children, 242 atrophic, 243 caseous, 245 chronic, 243 hypertrophic, 244 treatment, 245 membranous, 245 purulent, 245 Rickets, 101 Ring curet, 189 mask, 165 Rinne's test for hearing, 193, 194 Roller bandage of eye, 168 Room, disinfection of, 30 operative, preparation of, in private dwelling, 43 preparation of, for operations on eye, 156 Rosenmiiller's fossa, 251 Rotation tests for static laby- rinth, 196 Round window, 179 Rubber gloves, care of, 41 tissue, 42 Saccule, vestibular, 183 Saddleback nose, 247 Salve, applying of, to eyes, 149 Scala media, 185 tympani, 184 vestibuli, 184 Scalpel, 172 Scarlet fever in children, 99 Schneiderian membrane, 238 Schwabach's test for hearing, 193 Scissors, enucleation, 174 iris, 174 straight, 174 tenotomy, 174 Sclerotic coat of eyeball, 107 Scurvy in children, 101 Semicircular canals of labyrinth, 182, 183 Sepsis, 21 Septum, nasal, anatomy of, 237 deviations of, 247 treatment, 248 Shades, eye, 164 Shield, Buller's, 152, 162 Shock, 63 Sharpnell's membrane, 179, 180 Silver nitrate in diseases of eye, 122, 126 mitigated, in diseases of eye, 126 Singing voice, 267 Sinus, frontal, anatomy of, 238 maxillary, anatomy of, 238 irrigation of, 276 sphenoidal, anatomy of, 239 Sinuses, accessory; of nose, anat- omy of, 234 Sinusitis, nasal, 249 Siphon douche, Lucae's, 210 Skin, preparation of, in mastoid operation, 216 Skin-grafting in mastoid opera- tion, 220 Sleep of child, 97 330 INDEX Sleeping sickness, 13 Smith-Priestly lamp, 166 Smoked glasses, 162 Snellen's artificial eye, 167 clamp, 175 Soda, caustic, in diseases of eye, 127 chlorinated, as antiseptic, 27 Sodium biborate in diseases of eye. 118 hydrate in diseases of eye, 127 hypochlorite, 224 Solutions, antiseptic, 23 care of, 148 Sound-conducting apparatus, 176 Sound-perceiving apparatus, 176 Spatula, 172 eyelid, 171 Speaking voice, 267 Speculum, Boucheron's, 189 eyelid, 171 Gruber's, 189 nasal, 190 Sphenoid bone, 102 Sphenoidal sinus, anatomy of, 239 Sphere introducer, Mules', 171 Spheres, Mules', 171 Splints, nasal, 42 Sponges, adenoid, 40 bronchoscopy, 40 in submucous resection, 40 tonsil, 40 Spoon, lens, 172 Spot, yellow, of retina, 109 Spraying larynx, 277 nose, 277 throat, 277 Sprays, 277 Spud for removing foreign bodies from eye, 171 Stapes, 180 Steam inhalation, 278 sterilizer, 37 Sterilization, 34 of bandages, 36 of dressings, 36 of hands, 34 oxalic acid method, 36 potassium permanganate method, 36 with bichlorid of mercury, 35 with lime and soda, 36 with lysol, 36 of instruments, 38 of milk, 94 Sterilizer, steam, 37 Stevenson's dumb-bell bandage, 168 Stirrup of bone of ear, 180 Stools of children, 81 color, 82 consistency, 81 curds, 82 frothiness, 82 mucous, 82 odor, 82 size, 81 Strabismus, double advancement for, 160 forceps, 173 hook, 171 Straight scissors, 174 Strippings, 85 Styptic cotton, 121 Styptics in diseases of eye, 120 Subacetate of lead in diseases of eye, 123 Substitute infant feeding, 89 Suction pump, use of, after laryngectomy, 289 Sugar in milk, 89 INDEX 331 Sulphate of aluminum in diseases of eye, 122 of copper in diseases of eye, 122, 125 of potassium in diseases of eye, 122 of zinc in diseases of eye, 122, 126 Sulphur for disinfecting rooms, 32 Superior canal of ear, 183 Suppurative labyrinthitis, acute, 231 chronic, 232 Suprarenalin in diseases of eye, 123 Surgeon, preparation of, in opera- tions in private dwellings, 47 Surgical dressings, preparation of, 40 Susceptibility to disease, 13 Suspensory ligament of crystal- line lens, 109 Swallowing of blood, prevention, 59 Swathed child, method of re- straint, 70 Syphilis, destruction of nose after, 247 of larynx, 271 Syringe, Douglass, nasal douch- ing with, 275 lacrimal, 175 nasal douching with, 273, 274 Pomeroy, 189 Syringing ear, 186 Table, emergency, 43 operating, in private dwelling, 42 Tannic acid in diseases of eye, 122 Tannin in diseases of eye, 122 Tarsal cartilages, 104, 106 Tattooing needles, 172 Tear-duct, 106 Tears, 104 Tegmen antri, 182 Temperature of child, 97 rise of, 62 Temporal bone, mastoid portion of, 181 Tendon forceps, 173 Tenotomy scissors, 174 Tent, croup, 281 after laryngectomy, 291 Tests for hearing, 192. See also Hearing, tests for. Thermos bottle, 278 Throat distemper, epidemic of, 11 examination of, 240 in children, 241 restraint for, in troublesome children, 71 spraying of, 277 Thyrohyoid membrane, 267 Thyroid cartilage, 265 gland, surgical removal, 303 Thyroidectomy, 303 acute thyroidemia after, 307 asphyxia after, 309 hemorrhage after, 308 instruments for, 305, 306 operating-room technic in, 305 postoperative treatment, 307 preparation of patient, 303 Thyroidemia, acute, after thy- roidectomy, 307 Tincture of iodin in diseases of eye, 127 of opium in diseases of eve, 131 Tissue, rubber, 42 332 ini Tone perception, 184 Tongue depressor, 190 Tonsil, faucial, 251 hemostat, Mikulicz-Stoerk, 262 lingual, 251 Luschka's, 251 removal of, 264. See also Tonsillectomy. sponge, 40 Tonsillar hemorrhage, control of, 58 Tonsillectomy, after-treatment, 264 hemorrhage after, treatment, 261 in adults, 262 anesthesia, 262 in children, 258 anesthesia, 259 instruments for, 260 position of patient in, 259, 260 Tonsillitis, 256 acute, 256 treatment of, 257 chronic, 257 treatment of, 258 Toxic goiter, 303 Trachea, 266 foreign bodies in, 271 Tracheal cannula after trache- otomy, 290 Tracheotomy, 279 after-care, 280 croup tent for, 280 instruments for, 280 Trachoma forceps, 172 Kuhnt's operation for, 160 Tray, dressing, for cataract oper- ations, 169 for mastoid operation, 226 in ear examination, 188 Tray in laryngectomy, 287, 288 myringotomy, 206 Troublesome children, manage- ment, 07 restraint for ear examina- tion or dressing in, 70 for eye examination in, 70 for throat examination in, 71 Tuberculosis, destruction of nose after, 247 of larynx, 270 treatment, 270 Tumors of larynx, benign, 269 malignant, 269 Tuning-forks for testing hearing, 193 Turbinates, 234 inferior, 235 middle, 235 superior, 235 tympanic membrane, internal, 185 Tympanum, 176 anatomy and physiology, 179 Typhoid fever, prevention of, 14 Ulcers, pharyngeal, 255 Utricle, 183 Uvula, elongated, 253 Vaselin packing, 41 Vein, jugular, 182 Ventricular bands of larynx, 267 Vestibular saccule, 183 Vestibule of internal ear, 182, 183 of nose, 234 Vibrissa?, nasal, 234 Vision, double, 114 INDEX 333 Vitreous body, 109 Vocal cords, false, 266 true, 2(Hi Voice, singing, 267 speaking, 267 test for hearing, 192 Vomer, 237 Vomiting, 60 in children, 80 Watch test for hearing, 192 Water-supply, inspection of, 14 Wax, ear, softening of, 200 Weaning. 87 gradually, 88 sudden, 87 temporary, 87 Weber's knife, 172 test for hearing, 194 Whisper test for hearing, 192 White corpuscles, abihty of, to destroy germs, 14 Window, oval, 179 round, 179 Wire loop, 172 Wooden applicators, 41 Wounds, infected, chloramin for, 225 Dakin's solution for, 224, 225 dichloramin-T in chlorco- sane for, 225 Yellow fever, prevention of, 15 oxid of mercury ointment in diseases of eye, 124 spot of retina, 109 Zinc oxid for eczema accompa- nying phlyctenular keratitis, 134 sulphate in chronic forms of conjunctivitis, 134 in diseases of eye, 122, 126 Zymotic diseases, 16 WITHDRAWN MAY 072009 f'AV, .-wvv*e Kfl&feitju 4K>tiu!