' '"".SRJl £*.♦■ ;i|.'ii;:ii ''■!':i."«JiMf»':V'''-"''*i '! isiniHi^:; llfi.^ .....- NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine £ A. SURGICAL AND WAR NURSING SURGICAL AM) WAR NURSING / .- / ,' BY A. II. T5ARKLUY, M.D. (Hon.), M.C.. F.A.C.S. Lecturer at Good Samaritan Hospital Training School for Nurses; Consulting Surgeon, Good Samaritan Hospital, Lexington, Ky. 11727/ 79 ILLUSTRATIONS r y, ACADl^ OF MEDICINE SEP 2 3 191^ IJ 11 LIBRARY ST. LOUIS ('. Y. MOSBY COMPANY 3918 Copyright, 1918, By C. V. Mosby Company <~JlJ Press of C. V. Mosby Company 1918 PREFACE The author has not attempted, in this small volume, to cover the Avhole subject of nursing, but only such phases of the subject as would be of practical value in the average surgical case. The primary intention is that this book will take an intermediate position between a reference and a text book, and that it will find favor with the student of nursing as well as with the graduate. The fact that nurses are not doctors has not been lost sight of in its preparation, hence much of the matter may seem ele- mentary. The author has drawn largely from his lectures de- livered to the nurses at the Good Samaritan Hospital Training School for much of the material used. In the preparation of the chapters on War Nursing, he has been guided by his personal experience as a United States Army Surgeon during the Spanish-American War, and by intimate acquaintance with eminent sur- geons recently returned from the European battle fields. The subject of nursing is so closely allied to that of medicine that at times it is hard to separate them, therefore much will be presented Avhich the nurse should know, but less which she will be called upon to practice. The illustrations of the instruments of appliances have been supplied by The Max Wocher & Son Co., Cincin- nati, Ohio. A. II. B. / CONTENTS CHAPTER I Xurswg as a Profession..... CHAPTER II The Surgical Nurse...... CHAPTER III Bandages and Instruments .... CHAPTER IV Sterilization.......... CHAPTER V CHAPTER VI Solutions, Medicines, Weights, Measures, Abbreviations . 5(3 CHAPTER VII Temperature—Pulse—Respiration—Blood I'kessuke . . . o\j CHAPTER VIII Enemas, Douches, and Catheterization....... "4 CHAPTER IX Urixe AND B'LOOD................ CHAPTER X Applications to the Body............s' CHAPTER XI Preparation op Patient for Examination......W 9 10 CONTENTS CHAPTER XII Preparation of Patient for Operation.......100 CHAPTER XIII Operating Room and Xurse's Duties........1,IS CHAPTER XIV Operations in Private Homes, and How to Prepare the Room.................l-n CHAPTER XV Postoperative Care of Patients..........1-2 CHAPTER XVI Xursixg ix" Special Cases............E>,:1 CHAPTER XVII Postoperative Complications...........ETS CHAPTER XVIII Anesthetics axd Anesthesia........... 14:; CHAPTER XIX Ixjuries ix which a Xurse May be Called to Render First Aid..................153 CHAPTER XX War Xursixg.................15.S CHAPTER XXI War Xursixg (Cont'd) .............16(5 CHAPTER XXII War Xursixg (Cont'd) .............17S CHAPTER XXIII War Xursixg ("Cont'd) .............1S4. (IEOSSARY Glossary...................198 ILLUSTRATIONS FIG. PAGE 1. A nurse's complete outfit for visiting nurses.....23 2. Thumb bandage. Ascending, spiral bandage.....25 3. Ascending reverse bandage...........25 I. Bandage to protect eye.............2(3 5. Velpeau bandage...............2o 6. Skull cap bandage. Spica bandage for shoulder .... 26 7. Box and knife for cutting gauze rolls into bandages of desired length. Bandage roller........27 S. Electric bandage roller.............27 9. Plaster of Paris bandage machine. Spreads plaster on bandage which is then rolled by turning crank ... 27 10-A. Lightweight abdominal supporter with stays for cor- pulency or hernia.............-s 10--B. Elastic abdominal supporter with stays for corpulency . 28 PLC. Elastic abdominal supporter without stays for pregnancy 28 10-/?. Abdominal belt with uterine supporter for prolapse of uterus .................-° 11. Minor operating scalpel.............29 12. Series of minor operating scalpels, bistouries, abscess and hernia knives...............-•' 13-.4. Straight surgical scissors...........30 13-/>. Surgical scissors curved on the flat........30 14. Gauze and bandage scissors...........30 15. Mathcw needle holder for legular surgical needles ... 31 16. Universal needle holder for regular as well as Hagedorn needles.................31 17. Tissue forceps................31 18. Self-retaining abdominal retractor.........32 1!). Abdominal retractor..............32 20. Abdominal retractor..............32 2.1. Kelly's curved artery forceps..........33 22. Kelly's straight artery forceps..........33 23. Pean's artery forceps.............33 24. Curved artery forceps mouse tooth.........33 11 V2 ILLUSTRATIONS FIG. ''AGE 25. Pedicle clamp................31 2(i. Intestinal clamp...............3 1 27. Gastroenterostomy clamp............34 2v Dressing forceps................,;) 29. Vulsellum forceps...............■"••» 30. Uterine sound................•">.) 31. Intrauterine douche..............•">.) 32. Sims' speculuni................3(i 33. Bivalve speculum...............36 34. Trocar and cannula.....»........36 3>5. Silver probe.................36 36. Fountain syringe...............•"■(! 37. Glass hypodermic syringe............37 38. Gum male catheters..............37 39. Perfection porcelain enameled bed pun.......37 40•/>. Male white enamel urinal...........37 40-/?. Male white enamel urinal...........37 41-/?. Female rubber urinal to be worn by patient suffering from incontinence of urine..........38 41-/)'. Male rubber urinal to be worn by patient suffering from incontinence of urine............38 42. Kelly pad for douching or operating........38 43. Electric gauze cutter for pads, etc.........3!l 44. Electric plaster of Paris bandage cutler.......3!) 45. Straight surgical needles............40 46. Half curved surgical needles...........40 47. Full curved surgical needles with large eye for catgut . . 40 4s. Full curved surgical needles...........40 49. Trephine for skull operations...........41 50. Bone forceps.................41 51. Periosteal elevator ..............41 52. Uterine dilator................42 53. Uterine curette................42 54. Spoon currette................42 55. Complete sterilizer equipment...........15 56. Small practical dressing, instrument, and water sterilizer for office or small hospital...........46 57. Proper way to remove sterile instrument with 1 ray from sterilizer.................47 ILLUSTRATIONS 13 FIG. PAGE 58. Sterile gowns, sheets, sponges, cotton and dressings wrapped in containers, also flask sterile normal saline solution 48 50. Regular hospital bed.............51 60. Hospital bed with back rest, fracture extension apparatus. and elevating rubber wheels..........51 61. Invalid lifter frame to roll over any 36-inch bed ... 52 (52. The Smith fracture bed or for handling heavy patients. . 52 63. Wire cradle used to protect weight of cover from limbs . 53 64. Bed in Fowler position on bed elevator.......54 1)5. Foot of bed elevated on blocks for patient who is in shock and who has lost considerable blood......54 06. Tycos blood pressure instrument.........71 67. Improved Murphy drip outfit with white enameled can, used to administer normal salt solution.....75 68. Porcelain enameled douche pan.........."9 60. Tray for catheterization of patient........80 70. Things necessary in making urinalysis.......84 71. Glass tubes used in counting red and white blood cells, also needle used to prick finger.........8.; 72. Leggings to be worn by patient during operation . . . 106 73. Surgeon's scrub room.............HO 74. Rubber drains, small sponge, large abdominal pack on for- ceps—sponge held in sponge forceps......HI 75. Correct position of first assistant nurse—scrub nurse—also arrangement of table with instruments and dressing 111 76. Patient in position for operation on perineum or rectum . 112 77. Proper way to hand needle holder to surgeon .... 113 78. Making gauze sponge—gauze folded lengthwise .... Ho 79. Making gauze sponge—ends folded so as to meet in middle 115 SO. Gauze sponge completed............Hfi SI. Proper way to hold glove for surgeon.......116 82. Proper way to thread needle..........H' 83,. Proper way to hand knife to surgeon.......118 84. Bed properly prepared to receive patient after operation . 123 85. Rubber hot water bottle............123 86. Stomach tube................l-° 87.' Pus basin.................1-C> 88. Rubber rectal tube..............129 89. Bed arranged for tub bath...........130 14 ILLUSTRATIONS FIG. 1>UiK 90. Bed arranged for continuous (water either poured or sprayed) bath..............13° 91. Method of changing draw sheet on bed without exposing patient.................1 92. Tastily served diet tray............131 93. Ice cap..................VA[ 94. Rubber air cushion.............134 95. Dressing wound. Soiled dressings removed—wound cleansed. (Note paper bag folded to receive soiled dressings.) ...............I-"' 96. Dressing wound. Sterile dressings over wound held in place with adhesive straps..........130 07. Dressing wound. Dressing completed.......137 OS. Method of giving hypodermoclysis........1-41 99. Anesthetic room...............117 100. Anesthetic room with carriage, table, and oxygen tank . 147 101. Anesthetist table..............1 [H 102. Mouth gag.................l4i) id.".. Lungmotor. (Note mouthpieces—one for child and one for adult.)...............119 104. Dakin instrument employed in applying Dakin solution to wounds.................1^-' 105. Aeroplane splint used in treatment of compound or in- cisional fracture of arm and forearm......174 106. Hubert Jones' modification of Thomas' splint for thigh and leg, also used to fix limb while transporting patient.................1"! 107. Robert Jones' leg splint for fractures of lower portion of leg.................174 108. Walker's splint for wrist and forearm.......174 109. Railway splint...............175 110. Blake's modification of Wallace's extension splint for gradual extension.............175 111. Robert Jones' elbow splint for immobilization of joint . 176 112. Robert Jones' humerus extension splint for fractures of middle and lower shaft..........176 113. Caldwell's paraffin sprayer...........194 114. Hamilton's hot-air douche used for drying the burned surface preparatory to receiving the paraffin . . . 19 1 SURGICAL AND WAR NURSING SURGICAL AM) WAR M RSIXG CHAPTER I XURSIXC AS A PROFESSION Xursing was formerly done by the inexperienced, and, in many instances, by those of questionable char- acter. Their lack of ability to care for the sick was only exceeded by their ignorance of what constituted a re- spectable knowledge of their profession. This condi- tion existed prior to and for a long time after the advent into the world of Christianity, and was practiced mostly in prisons and alms houses ; however, as time went on, this condition gradually grew better until only a few years since the trained nurse came upon the stage of action, equipped with a more accurate knowledge of how to nurse those entrusted to her care. Xursing is, indeed, an exalted calling; and, like other professions, is not attained without much labor, thought, and self-sacrifice. The saying, "There is no excellence without great labor," is certainly true as re- gards nursing. I know of no work whose duties are more exacting and at the same time requiring a greater patience than that of nursing. Xursing has taken its place alongside other profes- sions, and as years go by we see its scope widening and the nurse becoming more efficient until now she has become well nigh indispensable. The public has gradually become acquainted Avith the 17 18 SURGICAL AND WAR NURSING possibilities of the professional nurse, and has come to respect the noble profession which she represents. Today we have the large hospitals and their training schools where thousands of young women are fitted for their life's work to go forth into the world, many of whom reflect great credit on their Alma Mater. Other professions have their national and state as- sociations, and so have the nurses. They are alive to the great benefit to be derived from reading papers and exchanging views. They have their State Board of Examiners, and in many states have succeeded in get- ting laws passed which undoubtedly redound to the good of the profession. The word profession is used instead of occupation or vocation for the reason that nursing is truly a profes- sion. The many duties which a nurse is called upon to perforin are so closely allied to the many scientific and intricate problems of the human body that nursing is no longer largely a matter of guess work, but one in which skill, judgment, and the greatest care must be exercised. Those practicing nursing occupied a peculiar position in the early days of professional nursing, as it was hard for a family in which she nursed to be sure of the professional's social status; but time has remedied this, and the professional is now considered the equal of those whom she serves. Many women from the best and most influential families have made professional nursing their life work. It may be said before closing this short chapter on nursing as a profession, that the practice of surgery as carried on at the present time would be an extremely laborious task were the preoperative arrangements left to the surgeon. Nursing therefore is not only a boon NURSING AS A PROFESSION 19 to the sick but a very valuable adjunct to the surgeon. Xursing has attracted many women. Some are prompted to take it up from a monetary consideration, others from a pure love of service to others. The latter class ahvays excel, as nursing is like medicine and surgery. They go hand in hand, spurred on by one great impetus; that is, to save. This is beautifully ex- pressed by Holmes in a poem which was read at a meet- ing of the Massachusetts Medical Society in 1855, the sentiment applying equally well to the nursing profes- sion : As Life's unending column pours, Two marshalled hosts are seen, Two armies on the trampled shores That death flows black between. One marches to the drum beat's roll, The wide-mouthed clarion's bray, And bears upon a crimson scroll, "Our glory is to slay." One moves in silence by the stream, With sad, yet watchful eyes, Calm as the patient planet's gleam That walks the clouded skies. Along its front no sabers shine, No blood-red pennons wave, Its banner bears the single line, "Our duty is to save." CHAPTER II THE SCRCICAL \TRSE The surgical nurse should be a woman whose very presence would inspire confidence. Jler health should he excellent, as nothing so handicaps a nurse as to be always complaining or not well. Xo woman should undertake nursing whose personal and family history is loaded with disease. She should give scrupulous at- tention to her teeth. Nothing so detracts as bad teeth, and sometimes a very small cavity will cause a foul breath which is very offensive and abominable to pa- tients whose stomachs are none too strong. The nose and throat should receive' careful attention, as well as the stomach and bowels, and the latter should always lie regular, as no single factor, probably, causes more dis- comfort than constipation. These conditions should be watched, and if need be, the nurse should see, regularly, a dentist or a specialist. She should give great care to her feet. She is likely to be required to be on her feet continuously for a long period of time. Properly fitting shoes with nightly bathing will usually insure her against trouble. The hair should be thoroughly cleansed before enter- ing upon a case, to guard against carrying a disease from one patient to another. The nails should be given constant attention to prevent scratching the patient while handling. Cutting the nails closely and regularly, together with plenty of soap, warm water and a brush, with thorough drying will usually suffice to keep them in good condition. 20 THE SUHGICAL NURSE 21 The clothes worn by a nurse should be of such material as will stand frequent boiling and washing, as frequent changes are required while nursing a case. Under no circumstances should she wear the same uniform in two consecutive cases Avithout subjecting it to a thorough washing. The uniforms should be of pleasant color, not loud, preferably white, and the laundress should be instructed not to place too much starch in them, as the noise from a stiff uniform worn by a nurse while moving about in a sick room may cause undue discomfort to the patient. In nursing a case in which there is pus, there is always a possibility of contamination, in which event the clothing should be immersed for three or four hours in a solution of zinc sulphate four ounces, sodium chloride two ounces, to one gallon of water; or, they may be left for one or two hours in a solution of 1:20 carbolic acid, or 1:10,000 bichloride, after which they are wrung as dry as possible and sent to the laundry. The manner and temperament of a nurse at all times should be pleasing and gentle, voice never loud, move- ments easy: she should be willing to accommodate the patient so far as is consistent with his or her welfare. Nurses who arc moody are usually short lived in the profession, as their shortcomings become known early and are calculated to make few friends either in or out of the profession. Patience, sympathy, and kindness are all necessary, but should at all times be subservient and under the control of a well-balanced mind. The surgical nurse should be a person of keen perceptions, and thoroughly alert at all times to the condition of the patient. The five senses with which she has been endowed should in no wise be impaired, as the slightest deviation 22 SURGICAL AND AVAR NURSING in one of these from the normal would place her beyond the pale of usefulness. The time off duty should be spent if possible in the open where fresh air and exercise may be taken. Exer- cise, while very necessary, should never be taken to excess. Every nurse should be off duty a portion of each day, and it is well to so arrange her time that she may be on duty during the visit of the surgeon in charge. From two to five o'clock in the afternoon seem to be the popular hours, but she should consult the convenience and wishes of the surgeon, and pos- sibly also of the family when the case is in a private home. The nurse should bear in mind that she owes the pa- tient the best service which she is capable of rendering, and her undivided attention; and nothing should dis- tract her or cause her in any way to give, either by word or deed, the slightest semblance of neglect on her part toward the patient. She should be absolutely loyal to the surgeon in charge, recording conscientiously and carefully all that may transpire between his visits, so that the chart will not be a jumbled lot of notes without much significance, but an intelligent and methodical record. All ex- planations to the surgeon should be made outside the sick room if possible, and not before the patient, who is usually on the alert to know of his condition. The habit some nurses have of talking to the patient, family or friends about one surgeon or another, is a pernicious practice and should be studiously avoided. AY hen two nurses are employed on a given case, their duties to each other are plain. The nurse first employed should be in charge, and the second nurse should act in the capacity of assistant. Their relations at no time THE SURGICAL NURSE 23 should be strained, as this will at once defeat their efforts and the patient may suffer as the result. The code of ethics that nurses now work under is no doubt familiar to all, and if carefully observed it will prevent many misunderstandings between nurses, that might otherwise arise. The public is at all times critical and ever ready to Fig. 1.—A nurse's complete outfit for visitng nurses. say things that are not pleasant to hear. The nurse is not exempt from these criticisms, and being cognizant of this fact, she should at all times and under all cir- cumstances so conduct herself as to dispel all doubt as to her sincerity of purpose and to command the highest respect. CHAPTER III BANDACES AND INSTRUMENTS Bandages Bandages are made of a variety of material, such as cotton, flannel, crinoline, rubber, etc. Bandages are used to exert pressure, to hold dressings or splints in apposition to the surface of the body or limbs, as the case may be, and to give support to certain parts of the body; as, for instance, in the use of abdominal sup- ports. AYhile much may be gained by reading textbooks on bandaging, to become expert one should have consider- able practice, and should study the condition for Avhich a bandage is applied, the particular kind of bandage to use, and also the parts to be bandaged should be taken into consideration. The mere fact of making a bandage fit like a kid glove is not all there is to bandaging. Broadly speaking, a bandage should be placed on smoothly and the pressure exerted should be equally distributed. Cotton, flannel, linen, or gauze bandages a.re most commonly used in the form of a roller of various widths, depending on the part of the body to be bandaged. The length of the average roller is cither twelve or fifteen feet. Plaster of Paris, crinoline, and silicate of sodium are usually employed to fix a limb or the spine, as in the use of the plaster jacket, and extensively used as splints in broken bones to insure their immobility. 24 BANDAGES AND INSTRUMENTS Fig. 2.—Thumb bandage. Ascending spiral bandage. IB ***" ipr ■», ^>. r-\" 1 fi^L^ Fig. 3.—Ascending reverse bandage. 26 SURGICAL AND WAR NURSING Fig. 5.—Velpeau bandage. Fig. 6.—Skull cap bandage. Spica bandage for shoulder which may be ex- tended down arm. BANDAGES AND INSTRUMENTS Fig. 7.—Box and knife for cutting gauze rolls into bandages of desired length. Bandage roller. Fig. 9.—Plaster of Paris bandage machine. Spreads plaster on bandage which is then rolled by turning crank. 2S SURGICAL AND AVAR NUKSIMi AYhei'e a dressing is to be placed on a particular part of the body, and Avhere for good and sufficient reasons none of the above named articles used for bandaging is deemed expedient, adhesive plaster in various widths and lengths is sometim.es ir:cd. Fig. 10-A.*—Lightweight abdomi- Fig. 10-B.—Elastic abdominal sup- nal supporter with stays for cor- porter with stays for corpulency. pulency or hernia. Fig. 10-C.—IClastic abdominal sup- Fig. 10-D.—Abdominal belt w'lh porter without stays for pregnancy. uterine supporter for prolapse of uterus. Flannel bandaues arc used Avhcn it is desired to re- duce swelling, and its frequent site of application is the extremities. The abdominal bandage is used extensively by some 'The illustrations of instruments and appliances throughout the book have been supplied through the courtesy of the makers, The Max Wocher \ Son Co., Cincinnati, Ohio, from whom they can be secured. BANDAGES AND INSTRUMENTS 29 surgeons after abdominal operations, and Avhile in many cases (and especially in those cases of pendulous ab- domens) they are of undoubted service, at the same time they can be worn too tight and too long, so that F':g. 11.—Alinor operating scalpel. the normal muscular tone in many cases is to a cer- tain extent impaired. These bandages are made of drilling Avith eyelets to lace either in the front or back, or the many-tail cotton bandage is frequently used to support the abdo- men. They are also often made of silk or of silk and 12.__Series of minor operating scalpels, bistouries, abscess and hernia knives. rubber. All abdominal bandages should fit snugly and exert even backward and slightly upward pressure, and by all means should be provided with straps to prevent the bandage from riding upwards. 30 SURGICAL AND WAR NURSING Instruments The instruments used in operative work will depend upon the surgeon and what he is accustomed to use in Fig. 13-A.—Straight surgical scissors. Fig. 13-B.—Surgical scissors curved on the flat. B Fig. 14.—Gauze and bandage scii- BANDAGES AND INSTRUMENTS 31 this or that particular operation. Some surgeons use many more instruments in performing an amputation of the leg than others; and Avhile it is necessary to have a sufficient number of the right kind of instruments, it must not be construed that the large array used by some operators is by any means indicative of their skill. The cutting instruments are the knives and scissors. Fig. IS.—Mathew needle holder for regular surgical needles. Fig. 16.—Universal needle holder for regular as well as Hagedorn needles. Fig. 17.—Tissue forceps. The knives are the scalpel, tenotome, long amputating knife, and the bistoury either sharp and curved or straight and blunt pointed. The scissors commonly used are straight and either sharp or blunt pointed, curved, and those used in perineal work, which are so made as to work on either right or left side. The needle holders are of various designs; however the simpler their construction the more serviceable, as 32 SURGICAL AND AVAR NURSING a rule. They are used to hold Ilagedorns, round, full curved and flat needles. Tissue forceps, sometimes called by surgeons "thumb forceps," are made with and without teeth. H=/ MAX WOCHER & SON. CIN.. o. Fig. 19.—Abdominal retractor. Fig. 20.—Abdominal retractor Retractors are used to hold the edges of the wound apart, and thereby to give better access to the parts involved. The larue retractors are used in abdominal BANDAGES AND INSTRUMENTS 33 !1.—Kelly's curved artery forceps. -Kelly's straight artery forceps. F.'g. 23.—Pean's artery forceps. Fig. 24. -Curved artery forceps mouse tooth. 34 SURGICAL AND AVAR NURSING F;g. 25.—Pedicle clamp. Fig. 26.—Intestinal clamp. Fig. 27.—Gastroenterostomy clamp. BANDAGES AND INSTRUMENTS 35 Fig. 31. -Intrauterine douche. ( Fig. 30.—Uterine sound. work, and the small retractors are used in smaller wounds and in holding open the eyelids during an op- eration upon the eyeball. Forceps are of a variety of patterns: Hemostatic for- 36 SURGICAL AND AVAR NURSING ceps are used in controlling bleeding. The long flat or curved clamps are used not only to prevent hemor- Fig. 34.—Trocar and cannula. Fig. 35.—Silver probe. Fig. 36.—Fountain syringe. rhage, but to grasp a mass of tissue such as the broad ligament, etc. The special clamp or forceps such as BANDAGES AND INSTRUMENTS 37 Fig. 37.—Glass hypodermic syringe. Fig. 38.—Gum male catheters. Fig. 39. —Perfection porcelain enameled bed pan. Fig. 40-A —Female white enamel urinal. Fig. 40-B.—Male white enamel urinal. are used in gastroenterostomy and intestinal Avork, have long slender blades that are usually covered with rub- ber tubing to prevent injuring the bowel. Sponge forceps are long forceps with long handles 38 SURGICAL AND AVAR NURSING and arc used in mopping out the pelvic and other cavi- ties. Speculums are used in making vaginal examinations Fig. 41-A.—Female rubber urinal to be worn by patient suffering from incontinence of urine. Fig. 41-S.—Male rubber urinal to be worn by patient suffering from incontinence of urine. Fig. 42.— Ki-lly pad for douching or operating. Avhereby a better view may be had of the cervix and vaginal A'ault, and in operative work on the cervix and vagina. The types generally employed are the bivalve BANDAGES AND INSTRUMENTS 39 and the Sims; the cylindrical speculum made usually of hard rubber or glass is used in making applications to the vaginal Avail and cervix. The specialist uses a small ear speculum for examination and treatment of the ear. Fig. 44.—Flectric plaster of Paris bandage cutter. Dressing forceps are long, curved forceps, used mostly in vaginal and uterine Avork. Uterine sound is a long, slender, graduated instru- ment employed in measuring the length of the uterus. The intrauterine douche is an instrument used to irri- gate the uterine caA'ity. 40 SURGICAL AND WAR NURSING Volsellum forceps are curved or straight forceps which have teeth, and are used to grasp and hold tissue. Trocar and cannula are used in drawing water from the abdomen, tapping large cysts and distended gall Fig. 45.—Straight surgical needles. Fig. 46.—Half curved surgical needles. Fig. 47.—Full curved surgical needles with large eye for catgut. Fig. 48.—Full curved surgical needles. bladder. It consists of a metal tube (cannula) through which is passed a sharp-pointed instrument (trocar) and, thrust into a cavity to be drained, the trocar is re- moved, leaving the cannula in situ. BANDAGES AND INSTRUMENTS 41 (Irooved directors and small silver probes are instru- ments which are frequently required in folloAving ap Fig. 49.—Trephine for skull operations. Fig. 50.—Bone forceps. Fig. 51.—Periosteal elevator. and cutting fistulous tracts and for diagnostic purposes. Syringes are of several kinds. The fountain and the Davidson syringes are used in irrigating and douching. 42 SURGICAL AND AVAR NURSING Fig. 52.—Uterine Fig. 53.—Uterine Fig. 54.—Spoon dilator. curette. curette. The small rubber bulb syringe is used in Avashing small cavities such as the ear and small abscesses. The hypodermic syringe is used to administer medi- BANDAGES AND INSTRUMENTS 43 cine subcutaneously, and is also used to inject into and around the field of operation such drugs as act as a local anesthetic, such as novocaine, quinine, and urea hydrochloride, and cocaine. Catheters are both male and female, and are made of soft rubber, glass, and metal. Some catheters are so constructed that the bladder may be Avashed out after the urine has been AvithdraAvn. Bed pans, urinals, and Kelly's pad are all acces- sories Avhich should be on hand. Male urethral sounds are made of steel and are used to dilate the urethra. They are graduated in size in the English, French, and American scale. Needles and Suture Material. The needles used are straight, full and half curved, round, flat, and cutting. Sutures and ligatures are made of catgut, silk, linen, and silkAVorm gut of various sizes. The catgut is of tAvo varieties, plain and chromic, the latter being so treated in the course of its preparation as to prevent its absorption until ten, twenty, or thirty days, and ranges in size from 0 to No. 3. Tourniquet. This is a piece of flat rubber about thirty inches long, used to prevent hemorrhage by winding it tightly around the limb. It is employed chiefly in operative Avork on the extremities. Ligature carriers, used to carry a ligature through a mass of tissue, are of several varieties, the Cleveland ligature carrier being most frequently employed. CHAPTER IV STERILIZATION It Avould be impossible to review in one short chapter the entire subject of sterilization; therefore, only such phases of this important subject will be discussed as the Avell-tra.ined nurse should know, and Avhich she will be called upon daily to put into practice. As bacteriology is closely linked to sterilization, the nurse is respectfully referred to the standard textbooks on that subject, of Avhich there is a plentiful supply. Sterilization may be accomplished in two ways: first, by heat, either moist or dry; and second, by the use of chemicals. If heat is to be used, the article to be sterilized should be placed in an oven or dry sterilizer in which the tem- perature is raised to not less than 110° to 230° C, and maintained for one to three hours. Should moist heat be used, it may be applied in the form of steam raised to a temperature of 250° C, or better to 270° C. for twenty minutes; or by placing the articles in boiling water for a considerable length of time. In case boil- ing is used, it frequently happens that certain chemicals are added to render the process more complete. The sterilization of all small instruments is best ac- complished by thoroughly Avashing with brush, soap and hot water, and then boiling for one-half hour in a one per cent solution of sodium carbonate, which pre- vents the rusting that is noticed after boiling in plain water to which the soda has not been added. 44 p-„ 55—Complete sterilizer equipment comprising 1 dressing sterilizer, 1 pair'water sterilizers, 1 utensil sterilizer, and 1 instrument sterilizer, sup- plied for gas, steam, or electric heating. 4(> SURGICAL AND AVAR NURSING It has been said that all instruments Avith a culling cdi^e are dulled by boiling, and many surgeons prefer 1o have them scrubbed with brush, soap and hot water, and then placed for some time in 1 :20 carbolic acid solu- tion. "While this is very effective, it does not compare to boiling, especially Avhen one considers that some germs withstand the action of chemicals for a much longer period than Avhen subjected to the boiling pro- cess. Fig. 56.—Small practical dressing, instrument and water sterilizer for office or small hospital. Some instruments, as avcII as some articles used in the operating room Avill not admit of sterilization either by moist or dry heat Avithout risk of damaging them, as, for instance, those made of rubber, leather, A\bale- bone, bougies, etc. Rubber instruments can be boiled, but care should be taken to see that the rubber is not burned; and if the boiling is repeated too often, the instrument Avill lose its efficiency by reason of the fact STERILIZATION 47 that it becomes flabby and loses its elasticity. It is better to clean such instruments Avith soap and water and to immerse them in either a 1 :20 carbolic acid solu- tion, or in a solution of bichloride of mercury 1:1000. Dishes, trays, cups and basins that are made of enameled Avare may be cleansed Avith hot Avater and soap and placed in a sterilizer and either boiled or sub- Fig. 57.__Proper way to remove sterile instrument with tray from steri Pitchers, bowls, trays, etc., in autoclave ready to be sterilized. jected to a high degree of heat under pressure, or after they have been thoroughly cleaned may be placed in a strong solution of bichloride of mercury or 1:20 car- bolic acid solution for one or two hours before using. All towels, sheets, and other linens used about a sur- gical patient should first be soaked in 1:3000 solution of bichloride of mercury for two or three hours, then wrung dry and laundered, after which they should be 48 SURGICAL AND WAR NURSING carefully wrapped, and placed in the steam sterilizer in which they remain for three hours; or, they may be sub- jected to steam for three successive days, sterilization for one hour the first day and one-half hour on each suc- ceeding day. Carize sponges, packs, cotton and dressings to be used should be carefully prepared so as to avoid contamina- tion, then Avrapped in packages of one dozen small sponges and one half dozen packs Avith tapes, and placed in the steam sterilizer. Fig. 58.—Sterile gowns, sheets, sponges, cotton and dressings wrapped in containers, also flask sterile normal saline solution. The cotton should be made into swabs of convenient size, and the dressings should be so arranged in pack- ages as to suit the case, be it abdominal, perineal, or mastoid; these swabs should be subjected to the same process of sterilization as that used Avith the gauze, sponges, pads, etc. All safety pins should be sterilized before using. All soiled dressings removed from the patient, cot- tons, SAvabs, and gauze sponges used in cleansing the wound, should be placed in a paper bag and consigned to the furnace. STERILIZATION 49 The excreta should receive careful attention upon the part of the nurse. All urinals and bed pans should be rinsed Avith 1:20 carbolic acid solution, and then thoroughly irrigated Avith Avarm Avater before using. These articles, as soon as used, should be removed from the room, emptied, and carefully cleaned as de- scribed above, so as to be ready for use next time. Chlorinated lime, Avhen fresh, is one of the best agents to use in these receptacles, as free chlorine is liberated and this is highly inimical to living organisms. Disinfection of a room that has been A^acated by a pa- tient should always take place, and should not be oc- cupied by another until the process is complete. This may be done by closing the room tight and burning sul- phur candles; this ansAvers very Avell Avhen other meth- ods can not be employed. The best method, and one used in many hospitals and by some boards of health, is to carefully Avipe all AvoodAvork Avith a damp cloth, and the floor Avith a carbolic acid solution 1:20, or Avith bichloride solution 1:1000, using a mop for this pur- pose ; then, plug every opening tightly with cotton and alloAV a formaldehyde generator to operate for a feAv hours. The room should be kept closed for several hours afterAvards, then it should be thoroughly aired before using. • This latter process Avill usually insure against infec- tion of the next patient Avho uses the room. CHAPTER Y BEDS The regulation bed hoav in use in most hospitals is single and made of iron, and is six feet six inches long, Avith a double Avire spring. The height should be care- fully noted in selecting a bed Avhich a patient will occupy. Hospital beds should not be too low or too high.—usually about twenty-six inches. The constant stooping and lifting Avhich necessarily devolves upon the nurse is exceedingly trying Avhen the bed is too Ioav. The weight should not be exces- sive, as light beds are easier handled and are just as durable as the cumbersome ones sometimes seen in use. All beds should be provided Avith casters that can easily be removed should the occasion arise. The trained nurse should be well versed in bed making, as a Avell- made bed is conducive to the patient's comfort. A Avell-made bed consists of a covering over die springs, then a mattress, preferably hair, and over this it is sometimes advisable to place a light pad. A rub- ber sheet is placed over the mattress if the case is one Avhere the bedding is likely to be soiled by discharges; but if this is not likely to happen, it is best to leave off the rubber sheet as it is very Avarm, and especially so in the hot months. A cotton sheet is next spread and Avell tucked in at the sides, head, and foot. The patient is covered Avith another sheet, and a light blanket is throAvn across the foot of the bed to be used if needed. In cases Avhere the patient has sustained considerable 50 BEDS 51 iil -J Fig. 59.—Regular hospital bed. Fig. 60.—Hospital bed with back rest, fracture extension apparatus, and elevating rubber wheels. shock, it is advisable to place him between blankets for a short time until he reacts, when the blankets can be removed, as heat is conducive to a hurried reaction. SI SURGICAL AND WAR NURSING The bed may be warmed Avith hot water bottles, care fully protecting the patient from being burned. i! ift 4 r m\ am —I(£ U9 B grain. The lat- ter dose is large, and should be given only in extreme cases, and its effect should lie carefully Avatched. The usual dose required Avill rarely exceed I/4 grain. Codeine is also an opiate, being someAvhat Aveaker than morphine, and given in Vi grain to \ 2 grain doses. The phosphate or sulphate is chiefly used; it is said that codeine is less likely to produce nausea than mor- phine. Heroine is also a derivative of opium, and is ad- ministered in doses of %0 to % grain; usually yv2 grain will answer in the majority of cases Avhere it is required. 60 SURGICAL AND AVAR NURSING The free use of all opiates is to be discouraged, since not only their toxic effect is dangerous, but the likeli- hood of patients becoming addicted to their use should not be lost sight of. The United States government has passed a laAv, known as the Harrison Anti-narcotic LaAV, which forbids persons, unless they be properly registered Avith the internal revenue collector in the district in which they reside, from dispensing any form of opiate. The bromides are used to quiet, and are administered by either the mouth or the rectum. Potassium and sodium bromide are used in doses ranging from 10 to 20 grains by the mouth, from 20 to 40 grains by the rectum. Aspirin is much used at present to relieve pain. It is made in tablet form of 5 grains each, or may be given in powder form. A combination that is frequently found effective in relieving pain and promoting sleep is 5 grains each of aspirin and veronal; if the suffering is severe and it is not desirable to resort to an opiate, 2 or :> grains of phenacctin may be added to the veronal and aspirin. Drugs that stimulate the heart arc always to be given with caution. Digitalis is prepared in a number of Avays and some of the pharmaceutical houses make very relia- ble preparations from the crude drug. The tincture is, as a rule, the one preparation that is usually at hand and given in doses from 5 to 15 minims. All prepara- tions of digitalis are at times likely to disagree Avith the stomach. Strychnia sulphate and strychnia nitrate are usually given hypodermically in doses from %0 grain to }(.,, grain, depending on the urgency of the case. Black coffee is a most excellent heart stimulant and is administered in doses of from 'A to 6 ounces. Atropine sulphate is made from belladonna and is SOLUTIONS, MEDICINES, AVEIGHTS, ETC. 61 used to check too free perspiration and excessive floAV of mucus, often noticed after operation, and also as a respiratory stimulant. It is given in doses ofs1/^,,,, grain 10 V200 grain, usually %.-)0 grain being the customary dose. Cocaine muriate is used in solution mostly for local anesthetic purposes and in 1 per cent to 10 per cent strength, the solution usually employed being 4 per cent. This drug at times produces toxic symptoms and should be carefully Avatehed. Novocaine is a much better preparation as it is ju ;t as efficacious and much less poisonous. It is used in i/2 to 4 per cent solution. Its principal use is in local anesthesia. Both before and after every operation the nurse will be instructed to see that the patient's bowels are evac- uated. When evacuant enemas are not desired, the sur- geon may order any one of the folloAving drugs: Calomel is a Avhite, tasteless powder made from mer- cury and may be given in Achat is spoken of as broken doses; that is ]{0 to 14 grain every 20 or 30 minutes until one or tAvo grains have been taken, or the patient may take 5 grains at one dose. It is customary to combine an equal amount of soda bicarbonate with the calomel. Calomel is given much oftener in the South than in the North, and in all cases should be folloAved by a saline cathartic. Saline cathartics are oftener used and are quicker in their action than calomel. They are magnesium sulphate (Epsom salts) given in one-half ounce doses dissolved in one-half glass water. Rochelle salts may be given in the same size doses for the same purpose. Castor oil is given in one-half to one ounce doses. This can be given in orange or lemon juice or strong 62 SURGICAL AND AVAR NURSING coffee. Squibb's castor oil is to be preferred, as it is a refined product and less nauseating. It should bo given on an empty stomach. A convenient Avay to administer castor oil is to squeeze the juice of half an orange in a glass, pour in the oil, and squeeze the juice from the other half of the orange over it; some add Avater and stir, but this makes a bulky mixture Avhich is not de- sirable. Many drugs that move the boAvels are uoav put up in palatable form, such as cascara sagrada. This drug is given in doses of from fifteen minims to one dram. Medicine may be administered not only by the mouth, which is the usual method, but also by hypodermic in- jection. .For this purpose, small soluble tablets are used by dissolving in Avarm sterile Avater. The effect produced is much quicker than by the mouth or rectum. When the stomach is irritable and it is deemed expe- dient to rest it, medicine can be given by the rectum. This method can not be tolerated by some patients for any length of time, as the boAvel becomes quite irritable and likely to expel Avhate\er is placed in it. The dose per rectum is much larger than that given hypodermi- cally or by the mouth. Medicine to be given per rectum may be dissolved in warm saline or sterile Avater or may be placed in suppositories and, after being greased, in- serted into the boAvel. The suppositories are so made that they dissolve at the temperature of the body. They are also used in the vagina, and Avhen so administered usually exert only a local effect. It should be stated, before leaving the subject of drugs, that Avhen a nurse is ordered to give a dose of medicine before meals as a rule it should be taken one- half hour before the meal is served and that under no circumstances should she attempt the administration of SOLUTIONS, MEDICINES, AVEIGHTS, ETC. 63 any medicine by the mouth Avhen the patient is un- conscious. The nurse Avill have handed her, perhaps on more than one occasion Avhile nursing a case, a prescription on Avhich, besides the names of the ingredients there "will be certain symbols and abbreviations Avith which she should be thoroughly familiar. The folloAving are some of the abbreviations used, as Avell as the Aveights and symbols: Apothecary Measure GO minims — 1 fluid dram (3 i) 2 fluid drams = 1 dessertspoonful 4 fluid drams =• 1 tablespoonful or one-half ounce (5 ss) S fluid drams =1 fluid ounce (5 i) 16 ounces — 1 pint (oj) 2 pints = 1 quart 4 quarts — 1 gallon Apothecary Weku-it 20 grains =1 scruple (3) H scruples — 1 dram (3 i) S drams =1 ounce(§ i) Abbreviations Ha — of each. ad lib = as much as desired. Aq. (or aqua) — water. Aq. pur = distilled water. Bis iud = twice daily. <'.c. = cubic centimeter. Cm. = centimeter. Cum. = with. Dil. = dilute. Dccub. = lying down position- Ft. (or fiat) = let there be made. Fl. = fluid. SURGICAL AND AVAR NURSING Gtt. = drop. Gr. = grain. M. — mix. Mist. — mixture. I\(\ = after meals. P.r.n. =:as occasion arises. Q.s. — sufficient quantity. R; = recipe. Stat. = immediately. Sig. = sign or give directions. T.i.d. = three times daily. Tr. — tincture. (TIAPTER VII T KM PERATURE—PULSE—RESPIRATION- 15FOOD PRESSURE That a nurse should be of real service Avhile nursing a surgical case, it is of the utmost importance that she should understand the meanings of the variations in temperature, pulse, and respiration. The average normal temperature is 9825° F., or 37° C ; hoAvever this may vary in perfectly healthy indi- viduals from 97% to 99% F. Any temperature either aboA'e or beloAv these figures is indicative of trouble Avhich should be reported to the surgeon in charge. The clinical thermometer iioav in general use has either Fahrenheit or centigrade scale, the former being the more popular and ranging from 94° to 110°. These in- struments are so made that it is necessary to leaA-e them in the mouth from one to three minutes in order that the registration may be complete. Before being placed in the patient's mouth, the thermometer should be care- fully Avashed off Avith a solution of 1:1000 bichloride mercury, and after the registration is noted it should be placed in either the above solution or some other equally effective antiseptic solution when it Avill be ready for use next time. A thermometer should neA^er be placed in warm Avater, for fear of breakage. There are several ways of taking the temperature: by the mouth, by the rectum, by axilla, and by the sense of touch, though this last method is by no means re- liable. It should be stated that when taken by the rec- 65 66 SURCICAL AND AVAR NURSING turn it may register one-half degree higher than Avhen taken by the mouth; it is usually about one-half degree loAver by axilla or groin than by the mouth. These slight variations should be remembered and in recording the temperature it should be stated Avhether by mouth, rectum, or axilla. The thermometer should al- Avays be shaken doAvn to or beloAV 95° before using. Temperature taken at irregular intervals, Avhile bet- ter than not taking it at all, conveys but little informa- tion, and in all cases strict periodicity should be ob- served. It is a very good rule to take temperature at 8 a.m. and noon, 4 p.m. and 8 p.m. These hours cover sufficient time to catch any abnormal temperature that might arise in the average surgical case. Temperature may come on suddenly or gradually, and may disappear either by crises, as in pneumonia, or more gradually (lysis). The latter is the usual ending in surgical cases, as fe\rers rarely drop suddenly to normal and remain there. A patient's temperature may be disturbed from many causes, as in cases after operation Avhere there is no pus it is not uncommon to have a temperature of one or tAvo degrees Avhich usually subsides in a feAV days. This temperature is sometimes spoken of as an "asep- tic" temperature, and is thought to, and very probably does, result from the absorption of decomposed products of liberated blood. In children and young people Avho undergo operations on the bones or anus, it is not uncommon to find them a short Avhile after operation Avith a temperature of 102°, 103°; a stitch abscess will cause a rise in the tempera- ture, in an otherAvise normal case. This comes on about the fifth day following the operation and as a rule is readily discoverable. It Avill sometimes be noticed that patients Avill have TEMPERATURE, PULSE, RESPIRATION 67 a subnormal temperature. This condition is usually produced by shock or hemorrhage, and Avhen so pro- duced the subnormal temperature is accompanied by a fall in the blood pressure, all of Avhich indicates im- minent danger. In patients after operation Avhere there is a falling in the temperature and rise in the pulse rate, this discrepancy should be reported at once as it means that shock is pending if not already present, and proba- bly death will ensue. In all septic cases there is usually a rise in the tem- perature ; hoAvever the patient may be so exhausted and his poAver of resistance so reduced that he sIioavs lit- tle if any fever. In cases Avith pus it may be noticed that immediately after evacuation there will be a con- siderable rise in the temperature; this, however, usu- ally subsides gradually in a fcAV days. In considering temperature, it is Avell to state that once in a while there Avill be found patients Avhose ob- ject is to mislead both the surgeon and the nurse; as, for instance, such practices as holding ice or cold water in the mouth Avhich of course gives a Ioav reading, or they may use hot Avater, in Avhich case the reverse will be found to be true. Fortunately, cases of this kind are infrequently met Avith although they are encountered occasionally, and the nurse should be on her guard. In the convalescent period folloAving an operation, certain complications may develop Avhich will at once cause a rise in the temperature and therefore cause considerable anxiety on the part of the surgeon and nurse. They are tympanitis, menstruation, tonsillitis, erysipelas, pneumonia, or any of the acute exanthemata; also, any of the following may cause a rise in tempera- ture after convalescence has been established, though 68 SURGICAL AND AVAR NURSING not so common as those enumerated above: la grippe, malaria, phlebitis and thrombosis. A Avord regarding charting may not be out of place here. Almost every hospital has a dilferent form of chart, though all contain certain spaces for registering the temperature, pulse, respiration, medicine, and diet. The chart should be kept clean and all writing should be in a legible hand and all figures should be distinctly formed. The temperature, pulse, and respiration should be taken at the same hours each day so that the same hour of one day can be compared Avith the correspond- ing hour of each preceding day, should this be neces- sary. The pulse is one of the best indexes to a patient's condition. In health, the pulse may vary from 70 to 80 beats per minute, 72 being normal in the vast ma- jority of cases. The counting of a pulse correctly is by no means easy in some cases, as the pulse may be very small or small and very soft. The nurse should, in each case she is called to, if the time permits, be- fore operation familiarize herself Avith the character of pulse and note anything abnormal about it. This puts her in possession of valuable information Avhich comes in nicely in judging the same pulse after operation. There are several things regarding the pulse Avhich the nurse should note carefully, its frequency, size or any anomaly of the vessels, Avhether or not it is regular and the tension. As stated above, the frequency may vary considerably. As to the size of the vessels, it may be said that the arteries in some patients are quite small; also in some patients Ave find abnormal branching of the arteries, Avith irregular distribution making the vessel hard to locate. TEMPERATURE, PULSE, RESPIRATION 69 The pulse may be irregular and skip beats, as in hem- orrhage, shock, intense toxemia, or in patients who have chronic endocarditis. The tension may be Ioav or high; in all conditions that depress the vitality of the patient, such as shock, hem- orrhage, extensive traumatism or prolonged surgical operations, the pulse Avill be found Ioav. A high ten- sion pulse is noticed after exercise, excitement and stimulants; hoAvever, if there is no pathologic condition present, it usually subsides. It should not be forgot- ten by the nurse that the pulse rate and tension is some- what increased after a meal, Avhile certain medicines Avill produce the same result. Preceding the operation, and during the administra- tion of an anesthetic, a rise of from 10 to 30 beats may be noted. If the anesthetic has been properly given and no loss of blood occurs together Avith little handling of the parts and a short operation, this rise is, as a rule, only temporary. If the operation is prolonged and there has been some loss of blood together Avith more or less trauma, the pulse may reach 120 to 140 beats per minute. After an abdominal operation where there has been no complication, the pulse rate will be increased from 20 to 30 beats. This, however, will finally subside, and the normal rate Avill be reached in from three to five days. After hemorrhage it Avill be noticed that the pulse is increased in frequency, but that its volume is not as good as before. This is because the heart is exerting it- self to overcome the lessened peripheral resistance. In- tense pain will cause an acceleration of the pulse, and in very nervous patients the same can be noticed. Dis- tention Avith gas folloAving an operation will cause an increase of from 10 to 40 beats, depending on the amount 70 Sl'ROlCAL AND AVAR NURSING of distention and the temperament of the patient. In brain abscess, tumor or hemorrhage, the pulse Avill usu- ally be found to be sIoav and full. In connection Avith the pulse, a few remarks on blood pressure may not be out of place. The nurse may never be called upon to take and record blood pressure; how- ever, a general knoAvledge of how it is taken and its significance Avill do her no harm. The taking of blood pressure by any one of the iioav avcII recognized instruments Avill be found good prac- tice for the nurse, as it imparts A'aluable information as to a patient's condition Avhen the indicator shows a hy- pertension or a hypotension. There are a number of instruments iioav in use; proba- bly the simplest one is that called "Tycos." It con- sists of a pneumatic armpiece Avith two rubber tubes to Avhich are inserted the recording instrument and to the other tube a rubber bulb Avhich so distends the air pad with air that Avhen properly Avrapped around the arm Avill compress it so the radial pulse can not be felt. The finger is placed over the pulse and at the moment it begins to beat, the hand on the recording instrument Avill point to the figure Avhich indicates the blood pres- sure. The normal blood pressure in healthy people may be stated as foIIoavs : in children over two years of age, from 85 to 110 mm.; in adults, it ranges from 105 to 145 mm. In females the pressure is usually 10 mm. less than in males. Blood pressure may give valuable information to the surgeon before operation, in estimating the efficiency of the heart. During the administration of an anesthetic TEMPERATURE, PULSE, RESPIRATION 71 it serves as one of the most reliable sources of informa- tion regarding the heart. Early warning of impending shock is obtained by this method, so that proper meas- ures may be instituted to revive the patient, In chloroform anesthesia, all but 10 per cent of the cases shoAV a fall in blood pressure from 10 to 40 mm. Ether causes, usually, a rise in the blood pressure up to the point of saturation of the patient, then a fall will be noticed. During an operation, the blood pressure Fig. 66.—Tycos blood pressure instrument. should be taken every 10 minutes. This gives the sur- geon and anesthetist ample time to use any measure that may be deemed advisable. The surgical significance of blood pressure may be stated in a very general Avay; as, for instance, opera- tions on the scalp, face, or mouth cause very little ir- regularity in the blood pressure; on the other hand, operations on the skull, dura or brain are usually fol- lowed by a considerable fall; this, however, depends 72 SURGICAL AND AVAR NURS1N0 largely on the length of the operation and also on the amount of manipulation of the brain. In amputations of the breast, a slight fall may be observed, and in empyema a decided and rapid fall occurs. In all abdominal operations there is a tendency to- wards a decline. This, also, depends upon the time consumed and the traumatism inflicted. Operations on the extremities may sIioav no marked change, unless accompanied by extensive trauma. The folloAving are a feAv conditions that usually cause the blood pressure to rise: Arteriosclerosis Chronic nephritis Cerebral hemorrhage Emphysema Eclampsia Pregnancy Toxemia The following are a feAv Avhich sIioav a variable pres- sure : Cerebral tumor Exophthalmic Goiter Jaundice Menopause The folloAving usually cause a low pressure: Anemia Diabetes Exhaustion Hemorrhage Shock and Collapse TEMPERATURE, PULSE, RESPIRATION 73 Respiration Much may be learned regarding a patient's condition by systematicadly recording his respiration. This should be done at the same time the temperature and pulse are taken. The average adult in good health will breathe about 16 or 18 times per minute, Avhile in children a respiratory rate of 20 to 26 is not incompatible with a healthy condition. Certain causes, such as exercise or excitement, AA-hile not associated Avith a diseased con- dition, may cause an acceleration of the respiratory act. In hemorrhage the respiration may be hurried and sighing, while in pulmonary embolism it may be rapid, shallow, and gasping in character. In peritonitis, the respirations are nearly ahvays increased and may run to 40 or more per minute. The abdomen is tense, and acts as a splint to the inflamed area therein, and if the case gets progressively avotsc the respirations be- come entirely thoracic in character. In case the abdomen becomes distended, due to an excessive accumulation of gas in the intestines, the respirations are increased. They, hoAveArer, subside and become normal again after the cause has been removed. A careful respiratory record in a case that has been operated upon may warn the surgeon of an impending pneumonia, a not infrequent postoperative complica- tion. The nurse should observe whether or not the res- pirations are regular, their frequency, and their char- acter—such as, deep or shalloAV, or noisy. All of these are invaluable and it is the nurse's duty to so record them. CHAPTER VIII ENEMAS, DOUCUFS, AXD CATHETERIZATION Enemas are used to supply water to the system ; to administer medicine, either for sedative, stimulating, or astringent purposes; for evacuating the boAvels; and for nutrition. The several kinds of syringes used for this purpose are the fountains, Davidson, hard rubber, and the bulb syringe. The fountain or Davidson syringes will be found best suited in the majority of cases; however, when an oily substance is to be injected in small quanti- ties, the hard rubber syringe Avill be found useful. The bulb syringe holding 2 to 4 ounces is especially adapted for very young children. As to the administration of enemas, the nurse should keep in mind the purpose for Avhich it is given. The solution should be placed in the fountain syringe, if this type is to be used, after it has been previously pre- pared in a pitcher, the temperature of the solution in- jected depending on the purpose for Avhich it is used. The patient is placed on her left side, with her hips elevated Avith one pillow; the knees should be flexed, or she should lie on her back Avith her limbs drawn up; or, if for any reason it is desired to let the fluid ascend high in the colon, the patient may be placed in the knee- chest position. The anus is greased Avith A'aseline as Avell as the nozzle of the syringe. The air is permitted to escape from the tube before inserting the nozzle, so as not to cause pain and possibly expulsion of the 74 ENEMAS, DOUCHES, AND CATHETERIZATION 75 enema before the desired time. The fluid should be per- mitted to flow slowly, and after all has been given a toAvel folded should be pressed firmly against the boAvel, thus helping the patient to retain the enema. In in- serting the nozzle, the nurse should be gentle, never forcing it, as the mucous membrane of the rectum is easily damaged. The amount injected in adults will vary from one pint to four pints, and in children from 76 SURGICAL AND AVAR NURSING one-half pint to one and one-half pints. In infants and very young children, from one to four ounces will be found sufficient. When it is desired to supply water to the system, it may be given in quantities from one-half pint to one and one-half pints of warm water, usually one pint being sufficient, as often as directed by the surgeon. In cases of shock, when it is necessary to fill up the blood vessels due to loss of blood and also to increase the action of the kidneys, it is customary to give normal salt solution by the rectum (proctoclysis). It can be given by the continuous drop method or six ounces every three or four hours can be administered over a long period of time. AVhen the enema is used to evacuate the bowels, any one of the folloAving may be used: Soapsuds enema, or an enema of turpentine. Sotipsoads, 1 pint or Glycerine, Epsom salts, Aft % ii Warm water, 1 pint or Glycerine, Salts, aa g ii Turpentine, 3 i Warm water, l1/2 pints or Glycerine, 3 ii Warm water, 1 pint In using turpentine in an enema, the solution should be thoroughly shaken before using. ENEMAS, DOUCHES, CATHETERIZATION 77 When medicines are ordered to be given by the bowel, they are usually Avritten down and definite quantities of the particular drugs are stated; if the medicine happens to be an oily substance in small quantity, say four ounces, it may be injected by means of a hard rubber syringe; if, however, it is desired to control hemorrhage as an astringent, it Avill be found best to use either the Davidson or fountain syringe. Drugs such as the bromides, chloral and stimulating enemas can best be given Avith the latter syringes. In nutrient enemas in adults, the rectal tube should be used and in children either the infant rectal tube or soft rubber catheter will ansAver. In this connection it may be stated that it is not necessary to pass a tube farther than 6 or 8 inches, as it is likely to coil upon itself. In giving a nutrient enema, it is necessary that the bowel be empty and also that the hips be elevated as much as is consistent Avith the comfort of the patient, since the higher up the bowel the more rapidly will the enema be absorbed. While every surgeon has his own formula for nutrient enemas Avhich he is accustomed to use, a few will be given below that have found favor among many surgeons: These Avere taken from Crandon's Surgical After-treat- ment, page 126, and may be A^aried to suit the indi- vidual case. 3 eggs beaten in Peptonized milk, 3 iii Salt, 2 or 3 pinches Milk, 3 iii Eggs, 2 or 3 Salt, 2 or 3 pinches Red wine, 1 tablespoonful 78 SURGICAL AND AVAR NURSING Dry peptone, Sugar of milk, aa 3 ' Alcohol, 3 i Tr. opium, git x. Water, q.s. 3 ix P>y doucliinfj is meant the directing of a stream of Avater against some part of the body. It is usually spoken of in connection Avith the vagina, ear, or nose. For the ear, a small rubber bulb syringe called an "ear syringe" is usually employed; however, if this is not at hand, the fountain syringe can be used, cau- tion being taken not to use too much force, this being controlled by the height to which the syringe is ele- vated. In the use of the nasal douche, either the "nasal douche" is used, or the solution is sprayed through a specially constructed syringe by means of compressed air. In both nasal and ear douches, their employment is for cleansing, relieving congestion, relieving inflam- mation, and either stimulating, astringent or soothing as the case may be. When a douche is used in the vagina or uterus, the fountain syringe or irrigating can had best be used. It may be intended for cleanliness, to relieve congestion or to check hemorrhage, astringent, and to remove de- bris. The nurse Avill often be called upon to give douches, except perhaps the uterine Avhich is given by the surgeon, or his assistant. In giving the douche, the nurse should give strict attention to the same rules as to gentleness and cleanliness as she observes in her other Avork. To give a vaginal douche, the patient is placed on her back and a douche pan is placed under her hips; the noz- zle is inserted gently into the vagina, Avhen the solu- ENEMAS, DOUCHES, CATHETERIZATION 79 tion with which the syringe is rilled is permitted to flow. In ear and nose douching, either normal salt solu- tion, boric acid solution, or sterile water are commonly used. In vaginal and uterine douches, very hot sterile water at 116° F. is used to control hemorrhage as well as astringent solutions such as tannic acid or alum. As an antiseptic vaginal or uterine douche, carbolic acid solution 1:80 or bichloride of mercury 1:5000 to 1:10,000 strength may be used. Catheterization is the process of drawing the urine from the bladder. Fig. 68.—Porcelain enameled douche pan. It not infrequently happens that after an operation the patient can not empty the bladder. This causes great discomfort and the duty devolves on the nurse to re- lieve the distress by catheterization. In some cases the nurse may have to practice this only once or twice, then again it may be necessary for some time. Operations upon the rectum or pelvic organs sometimes cause re- tention, then again some drugs will cause it, as, for in- stance, morphine. The position in bed causes reten- tion in some cases, as voiding urine Avhile lying on the back is at times quite difficult, Patients should be en- couraged to pass the urine if it is at all possible. Much care should be taken by the nurse to cleanse so SURGICAL AND AVAR NURSING her hands as she would for an abdominal operation as chances for infection are at all times great. She should have the patient lying on the back Avith the knees drawn up and limbs separated, and in a good light. The vulva is washed with warm sterile Avater and green soap; after this, the parts should be washed with an an- tiseptic solution 1:10,000 bichloride of mercury, care- fully cleansing around the meatus. The boiled glass catheter is taken Avith the gloved hand of the nurse and Pg. 69.—Tray for catheterization of patient. gently inserted into the meatus and bladder. The blad- der emptied, the parts are sponged Avith cotton dipped in the antiseptic solution and all catheters are scrubbed and then boiled and kept in 1:5,000 bichloride solution until used next time. Catheters are made of glass, silver, soft rubber, and elastic. Of these the glass and soft rubber will be found best, as the silver catheter can not be properly sterilized and the elastic ones do not stand boiling Avell; ENEMAS, DOUCHES, CATHETERIZATION 81 hoAvever, the glass and soft rubber ones have none of these disadvantages. The chances for infection are, as stated above, very great, and scrupulous cleanliness of patient, instruments, and nurse must be observed. Cystitis arises from in- fection, Avhich may extend up the ureters to the kidneys, causing a pyelitis or pyelonephritis and possibly sup- pression or death. In nervous individuals, the passage of a catheter may cause a certain amount of shock which usually passes off in a short Avhile, or if infection takes place, to the shock is added fever and chill. Catheteri- zation should, in the average case, be done every eight to ten hours. The nurse should be exceedingly gentle, and especially if any plastic Avork has been done on the vagina, in order that she may not produce an undue amount of pain or alloAv the urine to infect the stitches, or the secretion from the Avound to infect the bladder. A Avell-trained nurse should be able to pass a male catheter Avith the same ease and dexterity that she does a female. In catheterizing a male patient, the same rules as to cleanliness of the nurse, instruments, and patient are to be observed. The catheters are either steel, silver, or soft rubber. The soft rubber catheter should, if pos- sible, be used, as it is less harsh to the mucous mem- brane of the urethra and more certainly sterilized. In the passage of the catheter in the male, it may meet Avith some resistance at the neck of the bladder. This is in all probability due to a spasm of the sphincter and may be overcome by gentle and steady pressure. In cases Avhere a knoAvn obstruction exists, as in prostate cases, the surgeon should instruct the nurse hoAv to pass the instrument, as Avell as to the particular kind of in- strument to use. CHAPTER TX URINE AND BLOOO In considering the urine and blood, only such facts will be set forth as will be of practical value to the nurse. While the examination of either is usually done by those especially trained and in a well-equipped lab- oratory, the knowledge of certain facts regarding the urine and blood of a surgical patient Avill enable the nurse to form more accurate observations and conclu- sions as to the condition of the patient. The amount of urine passed by a healthy individual in tAventy-four hours is about three pints. This is in- fluenced to a certain extent by the amount of Avater taken into the system, the amount of perspiration, and of Avater given off through the lungs. Besides the phys- iologic variations many diseases ha\re a decided in- fluence on the quantity of urine excreted; thus, in dis- eases of the circulatory system, the quantity is usually diminished, also in acute and sometimes chronic nephri- tis, acute fevers and toxic conditions. Certain drugs known as diuretics also increase the output of urine, as citrate of potash—diuretine, or SAveet spirits of nitre. The color is usually straw or amber color, though this may depend upon the degree of concentration. Certain drugs, such as carbolic acid, Avill produce a dark green or black color; salicylic acid a green, and rhubarb a broAvn or red color. Also, some of the analine dyes, used as medicines, such as methylene blue, Avill impart this color to the urine. 82 URINE AND BLOOD 8:1 In certain diseased conditions of the kidneys, ureter, bladder or urethra, blood may be found in the urine, Avhich imparts a reddish tinge. Bile may be present from jaundice or other diseased condition of the biliary tract, in which case the urine Avill have a yelloAV or greenish hue. The consistency of normal urine is ahvays aqueous, but not infrequently in diseases of the genitourinary tract it may be thick and ropy. This may be noticed in cases of cystitis, pyelitis, etc., and is due to the presence of an excessive amount of mucus or pus or both. Thus it Avill be noted that the urine has certain char- acteristics which are discernible to the eye, and it is the duty of the nurse to Avatch each specimen voided, if possible, and to note on the chart any marked changes from the normal. If urine is examined both chemically and micro- scopically, certain substances may be found Avhich usu- ally indicate diseased kidneys. In this chapter, men- tion Avill be made of only the more important things found with the microscope, and only the tests commonly used for albumin, sugar and the method of taking spe- cific graA'ity Avill be given. With the microscope, casts are found, also blood cells, crystals of various shapes, sizes and kinds, bacteria, and extraneous matter. To discover these and to differen- tiate one cast, cell, bacteria or crystal from another re- quires more time, knowledge, and experience than the average surgical nurse has been able to spare from her Avork. The specific gravity of normal urine may be put doAvn at 1.018 for an average amount of 48 ounces in 24 hours. But as this quantity is by no means fixed, Avhile that of the solid remains about the same, the specific gravity St SURGICAL AND AVAR NURSING must vary accordingly, as when the skin is not secret- ing actively and when plenty of water has been imbibed the specific gravity may be lowered to 1.00.); while on the other hand where there is an active secretion of the skin along with Avatery evacuations from the bowels, the urine becomes more concentrated and the specific gravity may reach as high as 1.030. The instrument used in testing the specific gravity is called a "urinometer." It has a graduated scale langing from 10 to 60. A large test tube is filled -•- full of urine and the urinometer is placed in it. The Fig. 70.—Things necessary in mak'ng urinalysis. Microscope, chemical reagents, graduate, urinometer, and funnel for filtering urine. exact place on the scale to Avhich the urinometer rises Avill indicate the specific gravity. The test for albumin in the urine is made as folloAVs: Place about 2 or 3 inches of urine in a test tube and heat gently. Should the urine become turbid it is due to either albumin or earthy phosphates; if the latter are present, a feAv drops of acetic acid Avill cause the urine to clear up; if albumin is present, the turbidity will re- main after the acid has been added. The nitric acid test is made by placing in a test tube a small quantity of nitric acid then overlay the acid Avith urine by alloAving it to Aoav very sloAvly (Ioavii URINE AND BLOOD So the side of the test tube. At the junction of the urine and niti'ic acid, if albumin is present, Avill be formed a Avhite ring. The test commonly employed for sugar is Fehling's. Fehling's solution consists of a mixture of cupric sul- phate, Rochelle salt and caustic alkali. As it is likely to decompose, the solution is put into separate bottles, in one the cupric sulphate, and in the other the Rochelle salt and alkali. To make the test for sugar, pour into a test tube an equal amount from the Iavo bottles, then dilute by adding Avater enough to double the quan- Fig 71.—Glass tubes used in counting red and white blood cells, also needle used to prick finger—drop of blood is placed in center of glass slide which is put under microscope and then counted. tity. Boil thoroughly and add a little of the suspected urine. If sugar is present, it "will give a yelloAV color and a red precipitate of copper Avill be found in the bot- tom of the test tube. Acetone is found in the urine in many cases, and often accounts for obstinate vomiting Avhich may, in some cases, be erroneously attributed to the anesthetic. Soda bicarbonate per rectum, if it can not be retained by the mouth, Avill usually effect a cure. After nursing many surgical cases and Avatching re- peated examinations, the nurse will come to understand 86 SURGICAL AND AVAR NURSING their significance; thus, those patients avIio show bad condition of the kidneys are generally bad surgical risks, and especially so if a general anesthetic is to be gwen. Much that is of invaluable service to the surgeon has been learned, of late years, from the examination of the blood. In the consideration of the blood picture, there are four things to be considered in a systematic ex- amination: First, hemoglobin; second, red blood cells; third, the Avhite blood cells; and fourth, the differential count. The hemoglobin is the coloring constituent of the blood and one of the indices of health. Normally, it is about 00 to 95 per cent. The red cells are the oxygen-carrying elements; normally, the number per cubic millimeter is 5,000,000 in men and 4,500,000 for Avomen. A deficiency in the red blood cells Avith a decrease in the hemoglobin is knoAvn as "anemia" and an increase in these is called "polycythemia." The causes of the former are numer- ous, among Avhich are hemorrhage, malnutrition, chronic diseases, syphilis, tuberculosis, malignancy, and septic conditions. Nothing is as yet definitely knoAvn as to the cause of polycythemia. The white blood cells constitute the army of defense which the body possesses against an invasion of patho- genic bacteria. Normally, the number of Avhite blood cells may vary betAveen 6,500 to 10,000, and an increase above that number is called a leucocytosis, and any de- crease is called a "leucemia." If in a patient the blood examination sIioavs a leucocytosis, it generally means either a collection of pus or an acute infection such as appendicitis, cholecystitis, pneumonia or other toxic con- ditions. CHAPTER X APPLICATIONS TO THE BODY ( Cold—Heat—Bier 's Hyperemia—Lotions— 0 o u n terirrit an ts ) In considering applications made to the body, it must be understood that in this chapter only those usually used externally Avill be discussed. The practice of ap- plying different things to the body of a patient is an exceedingly old practice, dating far back into the his- tory of medicine and surgery. The applications used by the ancients, and it may be said in more recent years, Avere at times exceedingly painful and disagreeable, if not in some instances positively dangerous. Applications are used either hot or cold. Hot ap- plications are used in debilitated and old people to raise the body temperature also to produce sleep as by the relaxing effect of a hot bath. In cases where the kidneys are inactive, either hot baths or hot packs Avill be found serviceable by producing profuse perspiration, thereby relieving the system of effete material that Avould otherAvise be detrimental to the health of the pa- tient. Heat in some form, usually fomentations, is employed to relieve congested and inflamed parts. When thus used, the soothing effect of hot moist heat is due to the fact that more blood is draAvn into the part in- volved, thereby relieving some of the tension. When the inflamed part has reached the stage Avhere the SAvelling and redness is intense, the peripheral ves- sels may be so impaired that suppuration is inevitable, 87 88 SURGICAL AND WAR NURSING in which case the free use of moist heat will hasten the latter process. Heat is used to equalize blood pressure, also in some skin affections. In these conditions, the bath should be the method of choice. In combating shock and col- lapse, heat is a most valuable remedy, and should always be resorted to; either hot blankets or hot bottles Avill be found best for this purpose. Heat may be applied either moist or dry, and in the folloAving manner: Hot Avater Hot fomentations Hot compresses Hot poultices Hot Avater bottle Hot bricks Hot salt or sand Hot cloths Hot air Hot Avater may be applied by pouring over the part affected hot Avater from a pitcher or other receptacle, or by submersion in hot Avater. Hot fomentations are used extensively, as this is not only very effective, but a cleanly manner in Avhich heat can be applied. A large, heavy cloth or bath toAvel is best to use by soaking in boiling Avater from Avhich it is removed and placed in a Avringer especially con- structed for this purpose, and Avrung dry. The part of the body to Avhich it is to be applied is exposed, the toAvel or cloth is taken from the wringer quickly, and placed over the part, this in turn being covered by a large, thick, dry cloth, and the Avhole is enveloped in APPLICATIONS TO THE BODY 89 either a large piece of rubber or oil silk. This causes the retention of the heat for a longer time. These should be applied every tAventy minutes to be effective, and under no circumstances should the nurse permit them to get cold. Where smaller areas are involved and Avhere the fo- mentations can not be conveniently used, compresses made of cotton or thick flannel Avill be found quite ade- quate ; these, however, require frequent changing. Two should be used, so as to haA^e one ahvays ready for ap- plication the moment the other gets cool. Poultices are much used Avhen moist heat is desired, and are made usually of flaxseed, bread, or meal. Poul- tices have no advantage over either hot fomentations or compresses except that they retain the heat longer. When a poultice becomes cold it should be remoAred and a fresh one applied. All poultices should be made fresh each time, not using the same one tAvice. To make a poultice, place the flaxseed in a cup, pour in enough boil- ing Avater to make a paste, then heat and stir for a short Avhile and spread thick betAveen layers of cheese cloth or light cotton. Sometimes a few drops of carbolic acid are added; also, several drops of laudanum may be added for its soothing effect. However, as the virtue of the poultice lies in its heat, it is questionable if the addition of the latter adds anything to its efficacy. In the application of dry heat, the use of thick tOAvels or flannel Avill be found of service, as they are easy to apply and are of considerable benefit in joint affections. Hot Avater bottles are convenient and do not require changing so often; they are made of rubber Avhich is the best to use, or of tin, Avhich is in use in many hos- pitals, as they are cheaper and last longer. Glass bot- tles are also frequently used; hoAvever, these are not so 90 SURGICAL AND AVAR. NURSING good as either rubber or tin, as they are more likely 1o break and cut the patient. In the use of the rubber, tin or glass hot Avater bottle, care should be taken by the nurse to sec that it is not too full and that it is tightly corked for fear of leakage. Hot bricks, salt, and sand are used for practically the same conditions that the hot Avater bottle is used, and have no advantage over the latter and should be used only Avhen a hot Avater bottle can not be procured. In the application of hot air, the nurse Avill seldom be called upon, as this is used by the surgeon and is ap- plied by means of an especially constructed apparatus. The limb, or part of the body to be treated, is placed in an oven or hot air chamber Avhere the temperature is raised to a desired degree. The hot air treatment of joints either from trauma or disease is now well rec- ognized. The application of cold to the surface of the body produces a someAvhat different effect, as might be ex- pected. While heat relaxes, cold contracts. It is used to reduce the temperature, as in cases of sun stroke or fevers; in either case, the submersion in a cold bath, or ice applied to the head, or if the case be extreme, the patient may be placed in an ice pack. In the early stages of congested or inflamed surfaces, cold, Avhen applied, may check the process, thereby avoiding the possibility of suppuration. Cold may be applied to the body by means of the ice cap, ice coil, or ice cloths. If the ice cap is to be used, it should not be too full, the air should be expelled as far as possible, and the cap should fit perfectly so as not to leak. The ice coils consist of a number of coils so wound on a rubber cap as to fit the head and through which con- stantly floAvs a stream of cold or ice Avater; this is not APPLICATIONS TO THE BODY 91 so pi'acticable or convenient, in many cases, as the ice cap and is less frequently used. Ice cloths may be applied to any part of the body, the size to be used depending on the part of the body af- fected. They should be applied often. In the application of cold to the body, especially Avhen an ice cap is used, it should not be allowed to stay on for an extended period of time, and should ahvays have a thin toAvel between the cap and skin. A practice re- garding ice caps in many hospitals is to apply for Iavo or three hours, and then remove it for one hour. Lotions, sometimes called by the less dignified name of Avashes, are medicated solutions in varying strength and are applied to the surface of the body or limbs, mostly for their soothing effect. They may be applied either hot or cold, on a piece of lint or gauze, Avhich is spread over the area involved. Counterirritants are such medicines as tr. iodine, musterole, ammonia, cantharides, turpentine, ether, chloroform, and the Paquelin cautery. The object in using a counterirritant is to relieve deep-seated in- flammation by attracting the blood to the more super- ficial layers. Tr. iodine and ammonia, Avhen applied without enveloping the part in a bandage causes little more than a redness of the skin; hoAvever, Avhen applied in full strength, and the air is excluded, they may! readily blister. Mustard, either in the form of a plaster Avhich is made by mixing one part to five parts flour to which may be added enough Avarm Avater to make a thick paste, is spread betAveen two layers of linen or some thin material and applied, or, the ready made mustard leaves found in all drug stores -will blister if left on long enough. The same is true of cantharides. When either of these is used, its action should be 92 SURGICAL AND AVAR NURSING carefully watched by the nurse, as some skins blister very easily. Other counterirritants, such as turpentine, ether, chloroform, and croton oil are seldom used for this purpose; hoAvever, their action on sensitive skins is prompt, often producing severe blisters. The actual cautery may be used either in the form of cautery irons heated to red heat, or the Paquelin cau- tery, which consists of the cautery proper with a plat- inum point and a rubber bulb and tube. Benzine is placed in the cautery and lighted, after which the heat is kept going by the intermittent pressure on the rubber bulb. The cautery is more stimulating and its action is more prompt than that of other counterirritants. The cautery is useful around diseased and inflamed joints, especially those with a small amount of effusion into the joint cavity; in muscular conditions such as lum- bago, and in spinal affections it will be found service- able. Bier's hyperemic treatment, as it is called, is designed to produce a local, artificial hyperemia. This is clone either by a rubber band around the affected part and proximal to the wound, or by the use of cupping glasses or by means of hot air. Bier's treatment is based on the principle that a con- gested and inflamed area is not necessarily a diseased condition, but an effort on Nature's part to assist the body in repelling the invading organisms. When the rubber band is employed, it is placed just tight enough not to stop circulation, as this is the most important point to be watched in the carrying out of this treatment. The cupping glass is placed over the inflamed part and the air is removed by means of a small suction pump or syringe, thus causing a vacuum. APPLICATIONS TO THE BODY 93 The hot air is applied by placing the body or limb in an OA'en made for the purpose. This treatment is of greatest value Avhen the condi- tion is recognized and treatment instituted at once. In cases Avhere pus has formed, it should be evacuated and the treatment then applied will necessarily cut short the disease. In general it may be said that acute infectious proc- esses require a much longer application of the hypere- mic treatment each day than in chronic cases. The nurse is referred to Bier's book on this subject, which she may read Avith profit as its application is not hard; especially is this true after she has been shoAvn a feAv times. HoAvever, it is all important that she should grasp the principles underlying the treatment. CHAPTER XI PREPARATION OF PATIENT FOR ENAMINATTON The preparation of a patient for examination is a most important procedure Avhen properly carried out, The importance of the nurse during any examination should not be underestimated, as much, if not all, the responsibility of a patient's being properly prepared rests upon her. She should knoAV in advance Avhat por- tion of the body is to be examined and if possible the object to be attained by the surgeon from such an examination. In office practice, the patients Avill usually be able to Avalk and to assist themselves to a certain extent. The patient is placed upon an examining table, the clothing being either removed (in which case the patient is cov- ered Avith a sheet kept for that purpose) or loosened sufficiently to permit of easy access to the part, of the body to be examined. If in the hospital or in their homes, a bed is used instead of the table. The bed should be made firm by placing two Avide boards under the springs to prevent sagging. If the pelvic organs or the rectum are to be examined, the patient can be brought either to the side of the bed or the hips to the edge. If the chest is to be examined, the patient should be stripped to the Avaist, and allowed to either sit, stand, or lie doAvn, according to the desire of the surgeon. The remainder of the body is protected from exposure by a light blanket or sheet. 94 PREPARATION OP PATIENT FOR EXAMINATION 95 If the field to be examined is the abdomen, it should be thoroughly exposed, the rest of the body being pro- tected by tAvo sheets, one over the chest and the other spread from the pubis doAvn, covering the entire lower extremities. If one of the limbs is to be examined, the clothing is removed, and the remainder of the body is so draped with a sheet as to prevent unnecessary exposure. In the examination of all patients, the preparation should be carried out in a quiet and orderly way, at no time alloAving the patient to become nervous, as ex- aminations of patients in a highly nervous state are, as a rule, not satisfactory. The history of the patient is taken by the surgeon who may request the nurse to do the writing for him, or he may haATe regular forms or history sheets which he keeps on file in his office for future reference. The form given here is one which embraces all the important Date ad. Dsc. Name Age Color A\T-P> Residence Married Single Occupation Children Family History Personal History Present Illness Phys- Exam. URINE—Color Sp'g Sed Albu Sugar Micro Ex. Diagnosis Treatment Advised Operation 96 SURGICAL AND AVAR NURSING points in a patient's history and has been found con- venient. The urine should be examined in all cases both chemi- cally and, Avhen possible, microscopically; also, the amount of urine voided in twenty-four hours should be known. This information is important in estimating the kidney function, as the exact condition ol the avenues of elimination should be knoAvn in anticipation of- any operation or treatment undertaken. The blood should be examined, as avcII as the blood pressure taken. If there is a suspicion of pus or gen- eral infection, a blood count should be made. The feces should also be observed by the nurse, its color, con- sistency, Avorms, blood, or anything abnormal or un- usual should be placed on the chart. The foregoing applies in a general Avay to all ex- aminations. However, as the nurse will be called upon to attend women and as a majority of their troubles are pelvic, it Avill be most proper to speak here, at some length, of gynecologic examinations, their aim, and some of the conditions commonly met Avith. A gynecologic examination has for its purpose the acquiring of certain facts regarding the female gener- ative organs, that the surgeon may be able to make a diagnosis of the trouble. The patient should receive a Avarm tub bath, if able to leaA'e the bed; if not, a sponge bath, all soap being re- moved and the skin thoroughly dried. The boAvels should be thoroughly evacuated by giving a cathartic the night before, or an enema of soap suds several hours before the time for the examination. Should the patient retain a portion of the enema, it should be AvithdraAvn by means of a rectal tube. The bladder should be emptied a short Avhile before PREPARATION OF PATIENT FOR EXAMINATION 97 the examination, and if for any reason the patient can not void, she should be catheterized, using all precau- tions against infection. Should catheterization be nec- essary, it Avill be Avell for the nurse to have at hand a four ounce sterile bottle and cork, in order that a speci- men direct from the bladder may be had should the surgeon ask for one. After the bladder has been evacuated, a douche should be given, noting carefully before its administration any discharge and its char- acter. The douche used may be 1:10,000 bichloride of mercury, carbolic acid solution 1:80, or normal saline solution. The nurse should find out from the surgeon Avhat position he Avants the patient in, Avhether standing, dorsal, dorsal elevated, Sims, knee-chest, lithotomy, Trendelenburg, or horizontal—these are called the gynecologic positions. The patient is, of course, pro- tected by a sheet, and should Avear leggings that come Avell past the knees. If the standing position is used, the patient is told to stand, placing the right foot on a low stool or chair steadying herself by holding to the back of the cnair. The skirts are rolled up and pinned, a sheet being dropped from around the Avaist to the floor in such a manner as to leave an opening at the side for the inser- tion of the examining hand. This position is sometimes used to determine the amount of prolapse or displace- ment of the pelvic organs. In the dorsal position, the patient is placed on her back Avith her hips at the edge of the table or bed, her feet resting upon foot rests if a table is used, and on a chair or supported by the nurse if she is in bed;- her thighs and legs are flexed upon the abdomen. The dorsal elevated position is the same as the dorsal position, except a hard pilloAV is inserted under her head 98 SURGICAL AND AVAR NURSING and shoulders. In either position a sheet is folded around both limbs and across her abdomen in such a manner as to expose only the vulva. In the Sims position the patient lies on her left side with the left hip at the edge of the table or bed, Avith her left arm behind her, both knees drawn up with the right slightly in advance of the left. Drape a sheet over the limbs and abdomen, and separate the edges of it to expose the vaginal outlet. In the knee-chest position, the patient rests on her knees, which are draAvn Avell toAvard her chest and sep- arated slightly, the chest being in contact with the bed Avhile her face is turned to one side. Place a sheet over the hips, and separate it in order to expose the gluteal cleft. The lithotomy position is used only in operative Avork, and is that position in Avhich the patient lies on the table in the same position as the dorsal except the feet rest in stirrups fastened at the end of the table. The Trendelenburg position is that in which the pa- tient lies on a table so arranged that it breaks at the knees, permitting them to hang over, Avhile the table is tilted so that the knees are at the highest point. This position is useful in operative Avork in the pelvis, as it permits the intestines to fall aAvay from the field of operation. The horizontal position is Avhere the patient lies flat in the bed upon her back Avith her head on a pilloAv, her arms placed by her side. The preparation of the patient for examination, and the different positions having been described, it is well that the nurse should know Avhat instruments and solu- tions would be needed, and how to arrange them so that they will be convenient to the surgeon. A small table, over which have been spread sterile PREPARATION OF PATIENT FOR EXAMINATION 99 toAvels, is placed on either the right or left side of the surgeon. On this should be placed one pair dressing forceps, one pair volsellum forceps, one bivalve specu- lum, one Sims speculum, one uterine sound, one sound for the bladder, one glass catheter, one pair rubber gloves, and tAvo or three applicators, all these having been previously sterilized by boiling, and a small jar in Avhich are sterile cotton balls, and a small jar of sterile vaseline. The solutions chiefly used in a gynecologic examination are 1:10,000 bichloride of mercury or sterile Avater and a basin of hot water Avith soap and brush. This last the surgeon uses to cleanse his hands, after Avhich he immerses them for a short Avhile in the bichlor- ide solution and then puts on the gloves. The patient lies on her back Avith her hips at the edge of the table or bed, Her body and limbs are draped Avith the sheet so as to expose only the vulva, the surgeon sits on a chair or stool facing her. Should the examination be conducted after night or in a room Avith a poor light, an electric light with a long cord should be at hand. In cases Avhere an examination is to be made upon a patient in great pain, shock, or Avhere the patient's con- dition is such as not. to permit of much handling, under these conditions the nurse will find that the routine preparation is not advisable and only such sponging as Avill insure reasonable cleansing of the parts to be ex- amined should be undertaken. Where patients are brought into the hospital or their homes suffering from a crushed, lacerated, or broken limb, the nurse should, after the patient has been placed in bed, cut the clothing Avith a pair of scissors so as to furnish ready inspection of the part. She should have a basin of warm solution of bichloride 1:5000, cotton swabs, one pair sterile tissue forceps, and one pair sterile rubber gloves for the surgeon. CHAPTER XII PREPARATION OF PATIENT FOR OPERATION The preparation of the patient for operation, it mat- ters not Avhat the character of the operation will be, has a very considerable influence on the patient's condi- tion subsequent to the operation. Particularly is this true in goiter and prostatic cases, and Avhere there is anemia due to hemorrhage from fibroids, gastric or duodenal ulcer. It will no doubt be recalled by the nurse, if she has had the opportunity to observe many surgeons' Avork, that the manner in Avhich the patient may be prepared for operation varies considerably. Some surgeons Avill prescribe a long, preparatory treatment, Avhile others equally good require a very short and simple course; the nurse Avill also recall cases operated upon Avith little if any preparation Avho do nicely. There are certain dangers in either extremes; as, for instance, in those cases that have been subjected 10 a long and severe preparatory treatment, there is danger of impairment of the strength by confinement to the bed, Aveakened by excessive purgation, and last but not least, they become nervous and impatient by the long Avait before the expected day of operation. Or, in cases that have been given very meager preparation, there is danger not only in infection, but the condition of the excretory function is in all probability not knoAvn. No case except the worst emergencies should be operated upon without some attempt at preparatory treatment, and these, of course, receive some preparation on the operating table. In all cases Avhere time Avill permit, 100 PREPARATION OF PATIENT FOR OPERATION 101 they should be subjected to a simple and sane prepara- tory treatment before an operation. The preparation of patients by the older surgeons was indeed severe, as in those days starvation, vomiting, and free purgation was the routine practice, and in the majority of instances Avhere the patients Avere robust enough to survive this ordeal, they had little fear but that they Avould stand the operation. This treatment today Ave knoAv to be irrational because a patient who has been starved and to whom emetics and purgatives have been administered must of necessity be weakened by the excessive loss of Avater, and can not possibly be in as good condition for operation as one avIio has received a less rigorous treatment. The practice of administering stimulants some days before an operation in anticipation of a Aveak heart, to patients Avhose heart action is normal, is only mentioned to be condemned. These should be held in reserve and given only in those cases Avhere conditions arise that demand their use. The nurse in charge of a patient who is to be operated upon, should give special attention to the diet. As stated above, starving a patient does more harm than good. The patient should partake of a sufficient quantity of nourishing food to keep his strength, but never to the point of overloading his stomach. The diet for some days before the date set for operation should consist of such articles of food as Avill leave as little residue in the bowels as possible; such as eggs, soups, concentrated broths, toast and coffee (if they are accustomed to it, for breakfast). If the operation is to be performed in the morning, the preceding evening meal should be very light, and only a cup of black coffee or a small cup of strong beef broth should constitute the breakfast. By 102 SURGICAL AND AVAR NURSING the time the hour arrives for operation, it Avill be found that the patient's stomach Avill be practically empty. The nurse should insist that the patient drink plenty of water for some time prior to the operation, as it not only flushes the kidneys but supplies the body with suf- ficient fluid so that the intolerable thirst often noticed after operation is avoided. The boAvels and urine should be given careful atten- tion. A cathartic such as comp. liquorice powder oil, or castor oil .>i in orange juice, or Seidlitz powder, or citrate magnesia should be given the day before the op- eration to insure thorough evacuation and early on the morning of the operation the rectum should be flushed with either a soap suds enema or normal saline solution, care being taken to see that all is expelled before the patient is brought into the anesthetizing room. In cases Avhere time "will not permit of the use of cathartics by the mouth, an enema usually of warm soap suds will ansAver. It might be Avell to state that patients suffering from conditions such as acute abdominal troubles or acute ap- pendicitis Avith possible abscess, ruptured gall bladder, possible rupture of gastric or duodenal ulcer, a partial or total obstruction of the bowels, any one of these conditions should preclude active purgation, even Ioav enemas when ordered should be gwen with the greatest care. The nurse should save a night and morning specimen of urine for examination. She should carefully measure the total quantity passed in tAventy-four hours. The skin should next receive the attention of the nurse. The preparation of a patient should always, Avhen possible, begin with a warm tub bath both Avith soap and brush. This should be given the day before PREPARATION OF PATIENT FOR OPERATION 103 the opei'ation, after Avhich a clean night dress is put on and the patient is put back to bed Avhich has been pre- Adously changed and aired. The activity of the skin adds much to the elimination after the operation, and relieves the kidneys of much Avork at a time Avhen it is most needed. If for any reason the condition of the pa- tient is such that she can not be placed in a tub, a sponge bath may be given in the bed. In conjunction Avith the bath, a douche should be given except in the case of young girls. The skin is exceedingly hard to get "surgically clean" as the staphylococcus and other germs are present, and it requires considerable effort to dislodge and destroy them. Many methods have been devised, nearly every operator having his OAAai ideas regarding the steriliza- tion of the skin; hoAvever, the folloAving will serve as an example. It has been folloAved at the Good Samaritan Hospital in my Avork for a number of years and the re- sults are all that could be asked of any skin prepara- tion. The skin is shaved, if there is any hair, care being taken not to cut the skin; it is then scrubbed Avith a gauze sponge and tr. green soap; the skin is dried and a moist dressing soaked in 1:10,000 bichloride solu- tion is alloAved to stay on overnight. This is removed early on the morning of the operation, AArhen the skin is again scrubbed Avith tr. green soap and gauze sponge; this is f olloAved by an application of ether to remove any fatty substance, and this by absolute alcohol, after Avhich a sterile dressing is placed over the part and not re- moved until the patient is on the operating table, when the skin is painted Avith one-half strength tr. of iodine. Another method practiced by some surgeons is as fol- Ioavs: The skin is scrubbed Avith soap and Avarm Ava- 101 SURGICAL AND AVAR NURSING ter and permitted to dry; it is then painted with tr. of iodine after Avhich a sterile dressing is applied and not removed until the patient is anesthetized, after Avliich the skin receives another coat of iodine Avhich soon dries, and the patient is ready for the operation. That there is no absolutely certain method of skin sterilization is attested by the fact that of the numerous Avays that have been devised and adA^ocated by various surgeons, none have stood the test of time, and serious objections may be raised against all; for instance, after the most painstaking method of skin preparation, germs may lie found, thus proving conclusively that Avith any of the accepted methods the skin is not germ free. The method of applying tr. iodine, Avhich is at pres- ent much in vogue, is of questionable value as a germi- cide, as recent experiments have proved that it probably inhibits the groAvth of bacteria but does not destroy the spores. It should be remembered, in applying tr. of iodine, that the skin should be perfectly dry, as Avhen applied to a moist skin it does not penetrate to the deeper layers. A method is suggested by Tinker, of cleansing the skin with soap and Avater, then applying Harrington's solu- tion and rubbing the skin vigorously for tAvo or three minutes, then sponging off Avith alcohol. Harrington's solution is as folloAvs: Corrosive sublimate, O.N gm. Commercial alcohol (!>4%), 640.0 c.c. Hydrochloric acid, 60.0 c.c. Water, 300.0 c.c. The preparation of special areas such as those cov- ered Avith hair, the mouth, vagina and cervix, hands and feet, bladder and rectum, need special attention. The site of any operation that is covered with hair should be shaved, or the hair removed with depilatories. PREPARATION OF PATIENT FOR OPERATION 10-") On such places as the scalp, eyebroAvs, pubis and vulva, or in the axilla, if the razor is used, the shaving should be done carefully, the surface should be left smooth and the skin free from small cuts. After the hair has been removed, the surface is cleansed Avith soap and Avarm water, which is folloAved by the application of some antiseptic. Some surgeons prefer the use of depilatories to re- move the hair, as it is easy of application, quick in its action, and possesses some germicidal properties. Mor- ris of NeAv York says, "When the depilatory has been Aviped aAvay from the skin after about five minutes' ap- plication, the melted hair and superficial loose epithe- lium conies away, together Avith any dirt that lies Avithin the area acted upon. The skin is then as sterile, ap- parently, as it Avould have been after the labor and pro- longed methods of preparation, and Ave have entirely avoided the disturbance caused by shaving. "In removing hair from the vulva, for instance, the mucous membranes of the labia are sometimes irri- tated by the depilatories unless avc first brush the 'mucous membrane Avith a little sterile oil for protection from plastering the Avhole vuhra Avith the paste." Crandon, in his book on Surgical After-Treat mad recommends Boudet's depilatory Avhich is composed of calcii caustici pulveri (fresh unslaked lime) 10.0; sodii sulphid (crystals) 3.0; and amyli (pulverized starch) 10.0. He says, "These ingredients are separately pul- verized, mixed, and kept in a bottle dry. When needed for use, enough water is added to form a thin paste. This is spread on the part to be denuded about % inch thick by means of a wood or glass spatula. At the end of five minutes, the paste is Avashed off Avith sterile Ava- ter,' after which the usual preparation proceeds." 106 SURGICAL AND AVAR NURSING When such parts as the hands or the soles of the feet are to be operated upon, they should receive repeated and prolonged soaking in hot Avater in Avhich there is plenty of soap, in order to soften the thick, horny skin Avhich can then be scraped off. If the operation is to be on the mouth, the teeth should be carefully examined, all cavities and rough places Fig. Leggings to be worn by patient during operation. should be attended to by the dentist, a mouth Avash should be liberally used, such as phenoglycerite of 1an- nin either full strength or diluted one-half Avith water, or saturated solution of either boric acid or sodium bicarbonate ansAvers quite as well as a mouth Avash. PREPARATION OF PATIENT FOR OPERATION 107 The preparation of the bladder by the nurse, for op- eration, consists of the external cleansing, but also of the administration of urinary antiseptics such as uro- tropin gr. x every four hours Avith water until Irom eight to twelve doses have been taken, or salol gr. v, every four hours for several doses; but in some cases irrigation of the bladder Avith some antiseptic ordered by the surgeon Avill be required. The rectum, like the mouth, can not be rendered sterile but much can be done by thoroughly emptying the rectum by enemas of soap suds which are folloAved by copious use of normal saline or weak antiseptic ene- mas such as boric acid solution. The vagina and cervix are both hard to cleanse, and like the rectum they can not be made germ free; hoAV- ever, the free use of hot Avater and soap in the vagina, together with the removal, if present, of mucus from the cervix, after Avhich the cervical canal is SAvabbed with 25 per cent tr. iodine solution, will prove beneficial. This is followed by thoroughly douching the vagina with either 1:80 carbolic solution, or 1:5000 bichloride solu- tion. After the final preparation the nurse should see that the patient has on clean clothing. These consist of leggings AAdiich come Avell upon the thighs, and a plain but clean gown. The hair should be plaited, and the head tied up in a sterile towel or cap made for the purpose. The teeth, if false, should be removed and placed by the nurse in a cup of water. All jeAvelry must be removed and either given to the family if pres- ent, or cared for by the nurse. CHAPTER XIII OPERATING ROOM AXD NURSU'S DUTIES The majority of hospitals in this country have the operating room located on the top floor. This is done for three reasons: First, it is out of the Avay; second, it is less likely to accumulate dust than if located on the first floor; and third, the best light is usually to be had on the top floor. The old operating room had Avood floors, Avhitewashed ceilings, and no provision Avas made during its construc- tion for any of the modern conveniences now to be found in a modern operating room. The modern operat- ing room should have a northern exposure, plenty of AvindoAvs, and a large sloping skylight, the latter being protected on the outside by Avire netting. The room should be large, the floor of tile, in the center of Avhich is a drain pipe properly protected. The Avails around the room, for a distance of five feet from the floor, are covered Avith either tile or marble, the remaining side Avails, doors, Avindow sash and ceiling should be painted with Avhite enamel paint. The doors usually are so placed that one door leads from operating room to the anesthetizing room, another door leads from op- erating room to sterilizing room, and the third door leads into the doctors' Avash room. The doors are hung so they Avill open either Avay, the AvindoAvs should fit perfectly and be properly screened. The room should be heated by steam and be provided Avith a hot and cold Avater spigot direct from the sterilizer, Avhich are op- erated by the foot. The room should have a large elec- 108 OPERATING ROOM AND NURSE's DUTIES 109 trie light and gas fixture over the operating table, and also have tAvo or more sockets conveniently placed for portable electric light. Adjacent to the operating room and connected by doors, is the sterilizing room in which all instruments, suture material, dressings, and utensils are sterilized; and the anesthetizing room into Avhich the patient is brought on a carriage. In this room there should be a glass-topped table on Avhich are placed tAvo cans ether, 1 ether drop bottle, 1 bottle chloroform, 1 chloroform drop bottle, 1 tongue forceps, 1 mouth gag, 1 sponge forceps, 1 tube sterile vaseline, 1 jar small sponges, 1 pair scissors, 1 large pus basin, 1 dozen safety pins, C2 dozen soft toAvels, 1 goAvn for the anesthetist, 1 hypodermic syringe with tablets of morphine gr. '-%, 1 strychnia sulphate gr. %,-„ amyl nitrate pearls, 1 pul- motor, and 1 oxygen tank. The doctors' Avash room should have lockers for clothing, shoAver bath, 4 Avash basins provided Avith hot and cold Avater Avhich are op- erated by a foot pedal, tr. green soap, brushes, nail files, one boAvl each full of slaked lime and soda, one large boAvl of 1:5000 bichloride and another boAvl of al- cohol. The reco\rery room should contain a comfortable bed, and have AvindoAvs so arranged that plenty of fresh air can be had without the patient being in a draft. The things needed in the operating room are, besides a modern operating table, three glass top tables, six large porcelain basins, one glass arm basin, one irri- gator, one Avhite enamel stool for the anesthetist, and a chair for the surgeon should he need one, three small porcelain cups, one tray for suture material and needles, one specimen basin, one porcelain bucket, and one Kelly pad. The three glass top tables should be arranged at con- venient distance from the operating table; on one table no SURGICAL AND AVAR NURSING should be placed, after it has been covered Avith a sterile sheet, one sterile laparotomy sheet, two sterile sheets, one dozen sterile toAvels, tAvo packages sterile sponges one dozen in package, one-half dozen sterile abdominal packs Avith tapes, each one yard long, ab- dominal dressings, small sterile cotton compresses, one boAvl filled Avith hot sterile Avater or normal salt solution for moistening the abdominal packs, one glass tube in Fig. 73.—Surgeon's scrub room. Avhich there is Avide packing gauze, one glass tube Avith narroAc packing, tAvo cigarette drains, three small porce- lain cups (one for iodine, one for alcohol, and one for carbolic acid), three or four small cotton applicators, one clamp to hold the gauze sponge saturated Avith iodine, and one dozen sterile safety pins. On the second table may be placed all instruments used in the operation; they should be laid out sys- tematically, all scissors in one place, all forceps placed OPERATING ROOM AND NURSE'S DUTIES 111 Fig. 74.—Rubber drains, small sponge, large abdominal pack on forceps- sponge held in sponge forceps. Fig. 75.—Correct position of first assistant nurse—scrub nurse—also arrange- ment of table with instruments and dressing. 112 SURGICAL AND AVAR NURSING together, and so on. The suture material and needles are placed in a small tray. On the third table are to be found one flask of alcohol, one flask of tr. green soap, one flask tr. iodine, one flask tr. iodine one-half strength, one flask of carbolic acid, and a flask containing one quart of sterile normal salt solution. The six large porcelain basins should be used as Fig. 76.—Patient in position for operation on perineum or rectum, folloAvs: Tavo basins, one filled with 1:5000 bichlo- ride solution and one filled Avith sterile water, are for the surgeon's use; tAvo basins Avith same solutions are for the assistants; and two for the nurses' use. The gloves of the surgeon and assistants and nurses should be placed in their respective basins. The irrigator should have two boAvls Avhich are filled with quite warm sterile water and 1:10,000 bichloride V OPERATING ROOM AND NURSE'S DUTIES 113 solution. It should be seen beforehand that the irriga- tor is in good shape. Before the patient is brought into the operating room, the operating table should be padded with a piece of felt cut the shape of the table, over which is placed a rubber sheet, and over this is spread a sterile cotton sheet. The padding of the table protects the bony prominences from pressure directly against the metal top. Fig. 77.—Proper way to hand needle holder to surgeon. After the patient has been anesthetized and placed on the table, the nurse should remove all clothing doAvn to the sterile dressing Avhich covers the site of the opera- tion, the chest should be covered Avith a small blanket, the loAver limbs should be completely covered Avith a blanket over Avhich is placed sterile sheets. The sterile dressing is iioav removed and the skin is given another coat of tr. iodine. This is alloAved to dry, after which 114 SURGICAL AND AVAR NURSING the laparotomy sheet is spread over the entire body. In every operation, no more of the body should be exposed than is essential for tAAro reasons: first, undue exposure is unnecessary and inelegant, and second, the body heat should be so conserved as to lose as little as is absolutely necessary. If the upper extremities are not to be oper- ated upon, they should be laid straight out alongside the body, or they may be folded upon the chest, care being taken that they do not rest on the edge of the table for fear of musculospiral paralysis. In the performance of the average operation, the sur- geon has three assistants: one Avho stands opposite him and lends first assistance; the duties of the second as- sistant are to render any help that may be needed by the surgeon and first assistant, and to take the first as- sistant's place in his absence; the third assistant ad- ministers the anesthetic, and his duties rank next in importance to that of the surgeon. Three nurses should be on duty in the operating room during a major operation. The head nurse or surgical supervisor, the first assistant nurse, and second assistant nurse. The duties of each are as follows: The head nurse is in full charge of the operating room and is responsible for the cleanliness, preparation of the room, sterilization of all articles used during an op- eration, and the conduct and technic of all nurses under her supervision. She instructs the nurses in the prepara- tion of various solutions to be used, such as normal salt solution, carbolic acid solution, bichloride solution, and in the making of all dressings, sponges, and bandages. The first assistant nurse's duties are to prepare the operating room for all operations, lay out the necessary basins, pitchers, solutions, and dressings; to see that the room is at the proper temperature, and to sterilize her Operating room and nurse's duties 115 Fig. 7S.—Making g&uze sponge—gauze folded lengthwise. Fig. 79.—Making gauze sponge—ends folded so as to meet in middle. hands and put on sterile gown and gloves and assist at the operation. She is also expected to cleanse the room after each operation, and if the case operated upon has pus, she should seal and thoroughly disinfect the room. 116 SURGICAL AND AVAR NURSING Fig. 80.—Gauze sponge completed. Fig. 31.—Proper way to hold glove for surgeon. OPERATING ROOM AND NURSE S DUTIES 117 This should be done once every tAvo Aveeks Avhen there have been only clean cases. She should understand hoAV Fig. 82.—Proper way to thread needle. to operate the sterilizers for both water and dressings and keep them clean and brightly polished. The duties of the second assistant nurse are to assist 118 SURGICAL AND AVAR NT USING the first assistant nurse in preparing the room for op- eration, keeping things clean in the interval between Fig. 83.—Proper way to hand knife to surgeon. operations, assist in making and sterilizing the dress- ings. She is expected to render any help the anesthetist OPERATING ROOM AND NURSE's DUTIES 119 may need. She removes the instruments in the wire basket from the sterilizer Avithout touching them, and brings them into the operating room to the first as- sistant nurse, A\rho arranges them on a sterile table. The duties of each nurse should be thoroughly un- derstood that Avhen the operation is once begun it should be carried to completion Avithout the slightest hitch on the nurse's part. No one thing adds so much to the value of a nurse as the power of concentration and ob- servation. She should have her mind at all times on her duties and should be able to anticipate the Avants of the the surgeon Avithout his having to ask each time for this or that thing. She should have things so arranged that she can put her hand on any article wanted without haA'ing to look for it. All of these points should be observed if the nurse Avould become proficient, as it means the saving of much time Avhile the patient is under the anesthetic. CHAPTER XIV OPERATIONS IN PRIVATE HOMES, AND HOW TO PREPARE THE ROOM Operations in private homes are ahvays surrounded Avith many difficulties, Avhile the surgeon in charge and the nurse on duty suffer many inconveniences. The pos- sibility of rendering a room in a private residence as sterile as the operating room in a well regulated hospital is Avell nigh impossible. However, many serious opera- tions are performed in private homes, and brilliant re- sults are often obtained. It is ahvays difficult to prepare a room for operation in a private home, and this is much harder to do in some homes than in others owing to the circumstances of the people, surroundings and environments, as the average home of the well-to-do class of people is usually clean, Avhile among the poorer classes the surroundings are sometimes very undesirable and their ability to pur- chase certain things needed is necessarily limited. When an operation is to be performed in a private home, the nurse should be sent to the home the day before the operation is to take place, and should have instructions if possible as to the choice of the room and its preparation. If she is not so instructed, she Avill have to rely on her oAvn judgment as to details. She must select a well lighted room and in close proximity to the one the patient is to occupy. All furniture should be removed, as well as all pictures, curtains, and the car- pet. The Avails, AvindoAvs, and doors should be Aviped (town with a cloth wet Avith 1:1000 bichloilde solution, and the floor should be scrubbed. This should all be done 120 OPERATIONS IN PRIVATE HOMES 121 the day previous to the operation, and under no cir- cumstances should the dust be raised by SAveeping. The nurse should give her attention to the preparation of the table, solutions, and dressings. The table may be a portable operating table sent to the house by the sur- geon, or a kitchen table properly cleaned and padded may ansAver every purpose. She should have plenty of boiled Avater, both hot and cold, in sterilized pitchers, three sterile sheets, one blanket, and one dozen sterile toAvels besides the sterile dressings, tAvo small tables covered Avith sterile cloths, one for instruments and the other for dressings and solutions. The instruments can be sterilized by boiling on the kitchen stove, and basins for the surgeons to use in Avashing, together with one filled Avith bichloride solution 1:5000 and another Avith Avarm sterile Avater into Avhich the sterile gloves may be placed. A good hypodermic syringe with the neces- sary heart and respiratory stimulant, together Avith an oxygen tank should be at hand and ready for use should the occasion arise. A Kelly pad, sterile fountain syringe and a large foot tub are also articles AA'hich the nurse should not overlook. The nurse should see the patient has been bathed and properly dressed for the operation, as Avell as that the skin has been properly prepared. Be- fore the patient is taken from the operating room, her room should be Avell aired and the bed changed and hot-Avater bottles so placed as not to come in contact Avith the patient's skin. If the patient is to occupy the same room as that in Avhich the operation has been per- formed, the preparation should be carried out in a quiet, orderly manner, so as not to get the patient nervous; and immediately after the completion of the operation and before the patient recovers consciousness, all tables, chairs, soiled sheets, toAvels, sponges and instruments should be removed and the room put in order. CHAPTER XV POSTOPERATIVE (/ARE OF PATIHXTS The postoperative care of patients by the nurse begins Avhen the operation has been completed and the patient removed to her room and placed in bed. Much depends at this time upon the nurse, as she is left after the op- eration with the patient; and nothing so adds to the reputation of the nurse both in the estimation of the patient and that of the surgeon, as careful and pains- taking after care. The patient's Avelfare and comfort should be her first thought; her duties should be exe- cuted Avith care and forethought, and her every act Avhile on duty should be performed in such a manner as to not excite the patient's suspicion, but on the con- trary should inspire the greatest confidence in her. Once the nurse gets the confidence of a patient, the nursing becomes much easier. Before the patient has been brought to her room, the nurse Avill have prepared the same for the patient's re- ception by having it at the proper temperature, usally about 72 P., Avith light someAvhat subdued, and ven- tilation amply provided for. The bed should be avcII aired, and clean sheets, pilloAV slips, and blankets should be had. The bed should be made up and covers turned doAvn, hot-Avater bottles should be placed in the bed to get it warm. However, after the patient has been placed in bed, these should be placed at a convenient distance and separated from the patient by a blanket to keep from burning. After the patient sIioavs signs of reaction, that is, warm skin, perspiration, better pulse, and pa- 122 POSTOPERATIVE CARE OF PATIENTS 123 Fig. 84.—Bed properly prepared to receive patient after operation. Fig. 85.—Rubber hot water bottle. tient becoming noisy and throAving herself around in bed, the hot Avater bottles may be removed and possibly one of the blankets. These should not be removed too 121 SURGICAL AND WAR NURSING rapidly, as the patient might get chilled and bad results folloAV. The patient should not be left alone for an instant until she has fully regained consciousness, as patients in recovering from the narcosis of an anesthetic often throw themselves around in the bed and not infrequently get their hands under the dressing and either tear off the dressing or infect the wound. It is ahvays well to place the hands outside the sheet but under the blanket. In most hospitals, the orders given the nurse by the surgeon are written in a book kept for the purpose, which is called an "Order Book;" all orders should be Avritten, as the nurse is likely to forget something. It is good practice in nursing in private homes for the nurse to either have a book in which all orders are Avritten or she should take them down herself as given by the surgeon. It is my custom to write all orders; for an average case Avhere there is reason to feel that no complications will arise, the following orders usually suffice: First.—When the patient begins to come out and get noisy, administer morphine sulphate gr. 1/4, and if the patient continues to suffer in three hours the nurse may give either codeine phosphate gr. x/-i or heroin gr. Vi2- This Avill usually be found sufficient to control the ma- jority of cases. It should be stated that it is best to give as little opiate as possible, since it has a tendency to constipate the patient and prevent the expulsion of gas. Second.—Water as soon as possible and in small quan- tities and frequently repeated, or cracked ice may be given in place of Avater. Should nausea or vomiting persist, the patient should be given one or two glasses full of Avater in Avhich has been placed gr. 30 of bicar- POSTOPERATIVE CARE OF PATIENTS 125 bonate of soda in each glass. Should the patient vomit or retain this, Avithhold all liquids for three or four hours, when small quantities of Avater can be tried. Third.—Pass the tube for gas, if necessary. Fourth.—Catheterize, if the patient can not void in eight or ten hours from the time she last passed urine. Fifth.—Should the pulse become weak, give strych- nia sulphate gr. %0 or 15 HI of tincture of digitalis and report patient's condition to the surgeon at once. The nausea after an operation is quite annoying to some patients; however, this usually subsides during the first tAventy-four hours. It may persist for a longer period, and in some cases is only relieved after the stomach has been thoroughly emptied. The nurse should see that the patient lies flat on the back and keeps absolutely quiet. The vomiting is some cases, after an anesthetic has been taken, is not severe and ceases after the stomach has been emptied. This may persist for tAvo or three days in seA^ere cases and not only Aveakens the patient, but causes intense pain after abdominal operation. For the relief of this distressing symptom, the nurse should frequently sponge the face and hands in cold water, rinse the mouth Avith cold water, or the following may be gh^en: Oxalate cereum, gr. v Bismuth subnitrate, gr. x Muriate cocaine, gr. Vt Give the above in one poAvder, or cracked ice. This may be repeated in two or three hours if not relieved. Probably of all remedies for postoperative vomiting, none is quite so effective as Avashing out the stomach. This may be accomplished in tAvo Avays: First, the stom- ach tube may be swalloAved and the stomach Avashed 12() SURGICAL AND AVAR NURSING thoroughly with a quantity of either Avarm water or Avarm normal saline; second, the patient may be in- structed to drink several glasses of Avarm Avater into Avhich have been placed thirty to forty grains of sodium bicarbonate; after the stomach has been filled in this F'g. 86.—Stomach tube. manner, it Avill be quite easy to vomit the entire con- tents. Much has been Avritten of late years about ace- tone, and it has been found that in many of these cases of persistent vomiting acetone is present in the urine, Fig. 87.-—Pus basin. and the administration of bicarbonate of soda in dram doses by the rectum will cause the vomiting to ease. It might be stated that in some cases, after the em- ployment of all recognized remedies, the vomiting con- tinues and finally ceases of its oavii accord; these are I'OSTOPERATIVK CARE OF PATIENTS 127 supposed by some surgeons to be of a nervous origin. Some patients suffer more pain after operation than others, usually nervous patients suffering most. This condition is best controlled for the first 36 hours Avith morphine, codeine or heroin in proper doses and at proper intervals, depending upon the severity of the pain. The administration of opiates causes constipation, and sometimes nausea, and in some cases the retention of urine folloAvs its use. The use of such drugs should be made with the greatest possible caution, as patients are quick to learn their virtue in relieving pain and may become addicted to their use. The nurse should, under no circumstances, tell a patient Avhat she is giv- ing. Some patients do not suffer so much from pain in or near the incision as they do Avith their back. This is due in all probability to the fact that the muscles sup- porting the spine are relaxed by the anesthetic, and the shape of the average operating table is such as to alloAv sagging of the back. This may be overcome by placing a small sand bag or pilloAV under the small of the back. The catheterization of patients after operation is one of the duties the nurse is frequently called upon to per- form. She should be scrupulously clean in order that infection of the bladder may not follow, an error Avtiich ahvays reflects great discredit on a nurse. Some pa- tients can not pass their urine for some days after being operated upon. Whether this is due to nervousness or to the position in bed is hard to say; nevertheless it is true that operations in and around the bladder, sucfi as rectal and pelvic operations, may cause retention. The nurse should try Avarm applications if possible over the bladder," and place the patient on her side or turn a faucet or pour water from one pitcher to another; the patient hearing the sound of the water may thus void 12S SURGICAL AND AVAR NURSING urine. Should the simple expedients fail to accomplish the desired result, she should resort to the use of the catheter. As to hoAV often the catheter should be used depends upon several conditions; as, in a case in Avhich there has been considerable loss of blood, exccssh-e pur- gation before the operation, or Avhere there is profuse perspiration and the quantity of Avater taken by the patient is small, the interval between catheterizations is much longer than Avhere the loss of Avater from the system is small and the intake of water is large. It may be stated that in a majority of cases the catheterization of a patient every eight or ten hours Avill usually be found sufficient, and under no circumstances should the catheter be used after the patient is able to void urine except to obtain a specimen of urine direct from the bladder for the purpose of examination. The nurse should learn early in her nursing career the difference betAveen retention of urine and suppres- sion of urine. In the former, the kidneys are secreting the urine, which passes into the bladder, but the pa- tient can not pass it out; in the latter, the kidneys do not secrete any urine, therefore Avhen the catheter is passed into the bladder it fails to bring any urine—a very grave condition and one that should be reported to the surgeon at once. Some patients suffer considerably from the accumula- tion of gas in the stomach and intestines; the severity of the pain caused by gas sometimes far outweighs that caused by the operation. The accumulation of gas in the stomach is relieved usually by vomiting, but more promptly by inserting a stomach tube and Avashing out the stomach. When the gas is in the boAvel, a dose of castor oil if the patient can stand it, or enemas which contain glycerine, salts, and turpentine may relieve the POSTOPERATIVE CARE OF PATIENTS 129 patient, or the passage of a rectal tube may bring prompt relief. After an operation, the boAvels should move on the third day; and if the patient is uncomfortable, a lax- ative enema may be used on the second day; however, the patient's boAvels should be moved by a cathartic on the morning of the third day, and one passage daily should be had thereafter. The nurse should carefully record the temperature, pulse, and respiration every four hours except Avhen the patient is asleep, the convenient hours being at 8 a.m., Fig. 88.—Rubber rectal tube. noon, 4 p.m., and 8 p.m. The nurse should see that the patient has had no cold or hot water in the mouth for some time before taking the temperature, and she should count the pulse while the patient is quiet and not after the patient's bath or after the bed has been changed, as these disturb the patient to a certain extent and may cause an increase in the beat for a short Avhile. The drinking of water and the diet after operation will depend upon the condition of the patient and the character of the operation; as in stomach and intestinal surgery, the diet is either liquids or nothing at all is given for 36 to 48 hours. In the average case, the liberal use of Avater is not only beneficial to the patient, but 130 SURGICAL AND AVAR NURSING Fig. 89.—Bed arranged for tub bath. Fig. 90.—Bed arranged for continuous (water either poured or sprayed) bath. POSTOPERATIVE CARE OF PATIENTS 131 F:g. 91.—Method of changing draw sheet on bed without exposing patient. Fig. 92.—Tastily served diet tray. exceedingly grateful. Liquids are usually given for the first three or four days, or until the boAvels have been moved well, then soft solids such as eggs, milk-toast, 132 SURGICAL AND AVAR NURSING soups, etc., may be given for a short Avhile, Avhen the patient is gradually placed back on regular diet. The morning bath, Avhen patients are not too sick to take it, is very refreshing and helpful. The nurse should give the patient a warm bath daily, care being taken not to expose the patient unduly and to be sure that all soap has been removed from the skin. The bathing should be followed by a light massage of the limbs, both upper and lower, and the back with the liberal use of alcohol. After the patient has been bathed, a change of cloth- ing should be at hand and placed on the patient, after which the bed linen should all be changed, when the patient's toilet is complete for the day. The nurse should also see that the mouth and teeth are kept clean with cotton swabs and some antiseptic mouth wash; later, when the patient is able she should be given her toothbrush. When should a patient sit up? Some surgeons be- lieve in getting them up on the second or third day. This, I think, is rushing things too much. Some keep them in bed for three Aveeks; this, in the average case where union is had by first intention, is too long. The average case will be in bed for ten days, then permitted to sit up for a short while each day, and go home on the fourteenth day. The time when they should sit up de- pends on each individual case. CHAPTER XVI XUIISING IN SPECIAL CASES While there is a certain general routine in nursing the average surgical case, there are a number of patients avIio require certain operations that demand an extra amount of attention by the nurse. In lacerated perineum Avhich is caused by childbirth, the operation knoAvn as perineorrhaphy is performed. The perineum may be torn dOAvn to but not through the sphincter; this is called an incomplete tear; or, it may extend through the sphincter into the bowel, and is called a complete tear. In all operations upon the peri- neum, it is of the utmost importance to keep the parts clean, and to this end the nurse should frequently in- spect the site of the operation, and if necessary bathe the parts and place fresh dressings over them. On the fourth or the fifth day, the boAvels should be moved by a laxative; this may be preceded by an enema of a feAV ounces of olive oil in order to soften the fecal matter in the rectum. This is especially desirable in those cases Avhere the tear has extended into the boAvel, as the stitches may be put on a tension or tear out as the result of large, hard fecal masses passing over them, if the matter has not been previously softened. After each boAvel moArement and after each urination, the parts should be cleansed by placing the patient on a bed pan and pouring a pitcher of Avarm antiseptic solution over them. Some surgeons require the nurse to catheterize the patient for the first tAvo or three days to prevent the urine from infecting the Avound. In all operations upon 133 134 SURGICAL AND AVAR NUKS1N0 the vagina, the same rules should be observed as stated aboAre. In operations upon the rectum, the same dili- gence should be exercised by the nurse in keeping the parts clean. Frequent sponging and change of pads will insure sufficient cleanliness for prompt healing of the wound. Fig. 93.—Ice cap. In cases of empyema, that is, pus in the pleural cavity, the operation is one where either a portion of one or more ribs is removed, pus evacuated, and tubes for Fig. 94.—Rubber air cushion. drainage are inserted. In a case of this kind, the nurse should be extremely cautious in removing the dressings, not to remove the tubes and to see that they are securely fastened to prevent the escape into the pleural cavity, as has frequently happened. It may be that the Aoav of postoperative care of patients 13.1 pus Avill be so great as to require numerous dressings, and some of these Avill naturally fall on the nurse in the absence of the surgeon or his assistants, and she will do avcII to remember that the displacement of the tubes will cause considerable incoiwenience to the patient and anxiety to the surgeon. In cases of fracture which the nurse is called upon to attend, her principal duties will be to make the patient Fr'g 95.—Dressing wound. Soiled dressings removed—wound cleansed. (Note paper bag folded to receive soiled dressings.) comfortable, prevent bed sores by keeping the sheets and clothing smooth, sponging the back, and by the use of air cushions. When the boAvels move, the bed pan should be used, placing it under the patient in such a manner as not to disturb the fracture; in fact, all hand- ling' of the patient, such as bathing, changing of clothes and bedding, should be done in a gentle and careful manner. 136 surgical and war nursing In cases Avhere drainage of the gall bladder is neces- sary, the nurse should see that the receptacle for catch- ing the bile is emptied; the skin should be kept clean, and all bile stained dressings, clothes, and bedding should be changed. In an operation such as colotomy, Avhere there is Fig. 96.—Dressing wound. Sterile dressings over wound held in place with adhesive straps. likely to be much soiling of the skin by fecal discharges, the nurse should frequently change the dressings, bathe the skin, and apply zinc ointment should the skin be- come irritated. All dressings should be changed fre- quently, not only for the sake of cleanliness, but to keep the odor down as much as possible. In vaginal hysterotomy, some surgeons prefer to clamp all Aressels and leave the clamps protruding from the vagina. In such cases, the nurse should exercise the greatest caution lest the clamps become detached, POSTOPERATIVE CARE OF PATIENTS 137 or undue tension be placed on them in changing the patient's position. In all cases Avhere there is pus, the nurse should nave a paper bag ready at each dressing to receive all soiled dressings, sponges, etc., and the Avhole contents should be burned. All instruments used in dressing should be boiled before and after their use. The nurse should wear rubber gloAres and these should be boiled after each dressing and placed in a porcelain pan in Avhich there is 1:5,000 bichloride solution. When for any reason the surgeon leaves a catheter in the urinary bladder the duty of removing, cleansing and replacing same Avill most likely fall on the nurse. She should observe the rules of surgical cleanliness re- garding her hands, the catheter may be cleansed by boiling, or a neAv catheter may be used Avhich of course should be thoroughly sterilized before its introduction. CHAPTER XVII POSTOPERATIVE COMPLIOATK >NS After any surgical operation, certain complications may arise; and Avhile the duty of the attending nurse is not to treat them, she should be on the alert and notify the surgeon Avhen there is the slightest deviation from the normal course. Some complications such as hemor- rhage, shock, and respiratory failure come on so quickly that she may have to act promptly in the absence of the surgeon. The nurse should use judgment in all such cases, and be equal to any emergency that may arise, never for a moment permitting herself to become ex- cited, as much depends upon her calmness, which not only allays all fear that the patient may have but pre- vents the family or friends from becoming excited. Hemorrhage is one of the most dangerous complica- tions that can arise folloAving an operation. The bleed- ing may be an ooze from the capillaries. This form of hemorrhage is easily controlled by pressure, elevation of the part, the application of adrenalin solution 1:1000, Monsel's solution of iron, tannic acid, sodium chloride (common salt), pulverized alum, very hot applications, or ice. Any one of these may be sufficient to stop mod- erate capillary bleeding. In cases Avhere the hemorrhage is venous, that is, Avhere the blood Aoavs from a vein, there is a steady flow of dark red blood. Pressure Avill usually control venous bleeding. Should the bleeding come from a large artery, a fatal termination may speedily ensue if it is not promptly checked. If the hemorrhage is from an artery 138 POSTOPERATIVE COMPLICATIONS 139 in a limb, the nurse should place a rubber bandage or an extemporized tourniquet until the surgeon can arrive. In other parts of the body Avhere a tourniquet can not be used, firm and direct pressure may check the floAV of blood until other measures can be used, such as grasp- ing the artery with a pair of hemostatic forceps and tying the vessel or a deep suture placed by means of a curved needle will often be all that is required. In postpartum hemorrhage the nurse should cleanse her hands, put on a pair of sterile gloves, and insert one hand if possible and remove all clots in the uterus, then give the very hot (120°) douche of sterile water. A sponge saturated with vinegar and placed in the uterus will often check the bleeding. A hypodermic of ergotole 20 minims, or pituitary extract given hypodermically Avill cause prompt contractions. In cases where bleeding is internal, there is little the nurse can do except to sustain the patient until the surgeon can be summoned. In severe hemorrhage, the foot of the bed should be elevated and a pint or quart of normal salt solution should either be injected under the skin or given intra- venously. It is well for the nurse to remember that when the bleeding is internal, the use of powerful stimu- lants will cause an increase in blood pressure and con- tinue the bleeding. In these cases a dose of morphine gr. 1/4 is frequently given with good results. The nurse should not lose sight of the fact that some patients are "bleeders;" that is, their blood will not clot, in which case the use of lactate of calcium in 10 to 20 grain doses, or horse serum, may be of great service. The symptoms of hemorrhage are fairly constant, de- pending upon the amount of blood lost. There is also a certain amount of shock in every case where much 140 SURGICAL AND WAR NURSING blood is lost, due to the heart pumping against a lessened peripheral resistance. In severe hemorrhage, there is restlessness, increase in pulse rate, the patient will call for Avater and de- mands air, breathing becomes rapid and labored, pallor of face, pupils dilated, extremities become cold, surface of body and face bathed in perspiration, and if the hemorrhage continues the symptoms become more pro- nounced, the pulse is thready and irregular, respiration becoming Aveaker all the time until death ends the scene. Respiratory failure is most often met with during the performance of an operation, and is less frequently met with postoperative, than other complications. The symptoms are shalloAV breathing, cyanosis, and finally complete failure to breathe. When this occurs during an operation, the anesthetic is promptly removed, arti- ficial respiration, oxygen, inversion of the patient, rhythmical traction on the tongue, and hypodermics of atropine and strychnia may be given. Shock may be immediate—that is, Avhile the operation is in progress—or it may be delayed and come on either a feAv hours or days following the surgical procedure. When shock comes on gradually, there is noticed an in- creased pulse rate and a decrease in the volume and tension. The respiration becomes faster and the lips and face pallid, temperature drops if the condition of shock persists, all symptoms become more pronounced toward the end. Many patients become maniacal and throAV themselves around until they are completely ex- hausted and die. The causes of shock are many; hoAveArer, it may be stated that prolonged operations, too much anesthetic, rough and undue handling of the viscera, together Avith improper preparation of the patient for operation may POSTOPERATIVE COMPLICATIONS 141 all be contributing factors and in many instances actu- ally cause profound shock. Fig. 98.—Method cf giving hypodermoclysis. The treatment of shock may best be by such measures as will prevent its occurrence, such as through emptying 142 SURGICAL AND AVAR NURSING of the bowels but not excessive purgation, the admin- istration of atropine ^r. 1/150 with morphine ^v. \\ before the operation. The operation should be per- formed quickly and in such a manner as Avill not pro- duce any undue trauma to the parts and the minimum loss of blood. The patient should be Avrapped in warm blankets following the operation, to prevent the loss of body heat. When the patient is in shock, the administration of adrenalin 5 to 15 minims of a 1:1000 solution should be given either hypodermically or intravenously in salt solution. Digitalis hyperdomically, or sodium benzoate of caffeine in 5 grain doses may be employed Avith good effect. A good stimulating enema may be given, such as : Black coffee, I 6 Brandy § 1 Digitalis n\ 2(1 Laudanum \\ li] Perhaps the most effective remedy is the injection of a quart of normal salt solution under the skin, or in- travenously. The use of any of the above mentioned remedies should be employed only by directions given by the surgeon. Pneumonia, suppression of urine, tetanus, sepsis, peri- tonitis, and erysipelas are such postoperative compli- cations as will be detected and treated by the surgeon. In all these, the nurse should record his orders carefully and she will not be spending her time in vain if in her leisure moments she reads from some standard textbook their cause, symptoms, and treatment. CHAPTER XVIII ANESTHETICS AND ANESTHESIA The subject of anesthesia is one that is full of interest to the nurse as well as to the physician. The nurse may never be called upon to administer an anesthetic; never- theless, a knowledge of the different kinds of anesthet- ics and the different methods of administration will do no harm. Not infrequently a nurse is called upon to give an anesthetic in the absence of sufficient surgical help, and her duties and responsibilities on such an occasion may be equal to, if not greater than those of the surgeon. Formerly, nurses were only called upon in emergencies to give anesthetics; but iioav in some of the largest hos- pitals Ave see the nurse in the role of regular anesthetist to the institution. To become expert, she should receive special training, though she can acquire a reasonable degree of skill by watching its administration by the doctors while in the discharge of her duties in the operation room. Before considering its administration, it is interesting to note that no branch of medicine or surgery has more history attached than that of anesthesia. It has been said that the first anesthesia ever produced was that by the Divine Providence when He caused Adam to sleep and from his side removed a rib. Be this as it may, Ave know that from almost the dawn of man, anesthesia in some form or other has been practiced. The ancient Assyrians employed the method of digi- tal compression of arteries to produce numbness. An- 143 144 SURGICAL AND AVAR NURSING cient Egyptians used Indian hemp to become drowsy. Passages in the Talmud refer to easing pain of torture and death by giving draughts of spiced wine to the ATictim. The Greeks Avere Avell versed for their time in the use of anesthetics, as at the siege of Troy the Greek surgeons used astringent and anodyne poultices to re- lieve pain. They were the first to use mandragora, around Avhich much superstition centered; as, for instance, in the gathering of this drug they would go at the dead of night Avith a dog that Avas tied to a leash, so when he struggled to loose himself he Avould scratch up the roots of the mandragora Avhich let out shrieks that killed the clog. If these phenomena did not take place and the dog was not killed, the plant Avas of no value as it had lost its strength. The roots and bark Avere boiled in Avine, and a small glass full Avas given to produce sleep and relieve pain. The Greeks used another plant called "morion" for anesthetic purposes. This is supposed to be closely al- lied to mandragora. The Romans practiced surgical anesthesia Avith much the same drugs as did the Greeks. The Hindu surgeons not only produced complete an- esthesia, but Avent one step further than their predeces- sors in that, after the operation was completed, they gave another drug called "sanjivini" to quickly restore consciousness. The Chinese in 220 A.D. used probably Indian hemp, and some native surgeons in the rural districts of China to this day have never used any of the modern anesthet- ics, but rely upon some drug or combination of drugs Avhich has been handed doAvn for generations, to pro- duce anesthesia. ANESTHETICS AND ANESTHESIA 145 Later on in the middle ages, Ave are told that the Irish surgeons used the volatile principles of drugs to pro- duce sleep. Thus avc see up to this time numbness and sleep were produced either by drinking a decoction of the sleep-producing drug or it Avas applied externally in the form of a poultice. It remained for Priestly, in 1767, to discover Avhat he termed "vital air" or oxygen, Avhich gave impetus to others a\4io were trying to discoArer an ideal anesthetic. In 1776, he made a further discovery: nitrous oxide, Avhich Avas first used for anesthetic purposes in 1799. Horace Wells was the first to use it in this country. Ether Avas used first in Boston as an anesthetic in Oc- tober, 1846, and has since held first place among the long list of anesthetics. Chloroform Avas first used in Edinburgh by Simpson in November, 1847, and has since been used extensh'ely. From the foregoing, it can be seen that anesthesia has a long history; and Avhile the Ancients employed anes- thetics in a crude Avay, they must have afforded relief to some degree. Operations performed before the days of ether and chloroform meant agonizing pain, and those Avith stout hearts often quailed at the thought of having to undergo the terrible ordeal. Thus it is said of Lord Nelson that he was so painfully affected by the coldness of the operator's knife when his right arm Avas ampu- tated at Teneriffe, that at the Battle of the Nile he gave orders to his surgeons to have hot water kept ready so that at the worst he might be operated upon Avith a warm knife. Anesthetics are iioav spoken of as either general or local. Of the general anesthetics, ether, chloroform, and nitrous oxide gas are the ones usually employed. Ether and chloroform are used for prolonged operations, Avhile 146 SURGICAL AND AVAR NURSING nitrous oxide is useful for short operations. General anesthetics are used to relieve pain during operations, childbirth, to produce muscular relaxation so as to re- duce hernias, dislocations and fractures, to make diag- nosis, and in convulsions. Patients that are to undergo surgical operation should receive some preparation Avhen possible. The nurse should see that the boAvels have been thoroughly emptied by either enemas or cathartics, de- pending upon Avhich the surgeon orders. The amount of urine passed during the tAventy-four hours preced- ing the operation should be carefully measured and re- corded. A specimen should be examined, and the re- sults Avritten on the chart. The pulse and respiration should be counted some hours before the operation Avhen the patient is quiet. The diet should be light and nu- tritious, preferably broths and gruels, and the patient should be encouraged to partake freely of Avater, as this supplies the system Avith plenty of fluid, flushes the kid- neys, and allays to some extent the unquenchable thirst following operations. The day of the operation, the pa- tient may be given, three or four hours prior to the operation, a cup of coffee or broth. The nurse should con- sult the surgeon regarding the amount and character of food and drink given the patients. All loose teeth should be removed. The administration of anesthetics to pa- tients Avho only a short time before have taken food is almost certain to produce vomiting. This is as annoying to the surgeon as it is unnecessary, as it sometimes delays the operation and there is danger of drawing particles of food into the larynx or bronchi, thereby producing dis- agreeable symptoms. After the anesthetic has been started and the patient begins to vomit, it is best to turn the head to one side and hold the jaAV up slightly and let the stomach be avcII emptied, Avhen the anesthetic may be pushed. Later during the operation, should there ANESTHETICS AND ANESTHESIA 147 Fig 99.—Anesthetic room. F'g. 100.—Anesthetic room with carriage, table, and oxygen tank. be a tendency to vomit, it will only be necessary to give a little more of the drug to check the vomiting. 148 SURGICAL AND WAR NURSING The nurse should have ready, in each case where a general anesthetic is to be given, the following: two Fig. 101.—Anesthetist table. small porcelain basins, half dozen towels, tube of sterile vaseline to grease the patient's face and lips, as ether ANESTHETICS AND ANESTHESIA 149 and chloroform are often quite irritating to the skin; two ether cones made of paper and toAvel or an Allis Fig. 102.—Mouth gag. Fig. 103.—Lungmotor. (Note mouthpieces—one for child and one for adult.) ether inhaler, the former being better as they are quickly made and a fresh cone can be had for each case; a good hypodermic syringe, strychnia, digalen, atropine, mor- 150 SURGICAL AND AVAR NURSING phia, benzoate caffeine, oxygen tank, pulniotor, tongue forceps, and mouth gag. Patients vary very much in their behavior when tak- ing anesthetic, as some go under its influence quietly while others are boisterous and require holding. It is Avell after the patient is on the table or ward carriage to strap the limbs and arms before the anesthetic is started, as they are held more securely and much com- motion is often avoided. When ether is given, all unnecessary noise and talk- ing should be avoided, the cone should be held a little distance from the face, for a feAv moments, as this often allays the fear patients frequently have that they Avill suffocate. After the irritation from the first fcAV Avhiffs has passed, the cone may be placed OA7er the nose and mouth, at the same time, encouraging the patient to take deep breaths. The patient may struggle and cry out, the face is flushed and the respiration and pulse quick- ened. The ether is given all the Avhile, Avhen the patient finally quiets doAvn and becomes relaxed. At this stage, the patient may come out quickly if the ether is Avith- held for any length of time. As the anesthetic is con- tinued, the muscular system is relaxed, the patient is in- sensible to pain, and the reflexes are abolished except the pupil reacts to light. During the administration of ether, care should be taken that no light or fire, such as cautery, comes too near to the vapor, as ether is highly inflammable. Patients sometimes cease to breathe Avhen taking ether. This may be only for a moment, as Avhen fresh ether is added to the cone. "When, hoAvever, this occurs and the face becomes cyanotic, the cone should be removed at once, the jaw held avcII foiAvard Avhile pressure is made by an assistant on the sides of the chest. If these are of no avail and the state of anesthesia seems to be deep- ANESTHETICS AND ANESTHESIA 151 ening, the resort to artificial breathing, stimulants, loAver- ing the head of the table, oxygen and pulmotor may suffice to restore the patient. Should there be a ten- dency for the tongue to fall backward and interfere Avith breathing, it must be held forward with forceps or a ligature on needle placed through the tongue. This lat- ter, Avhile resorted to sometimes, is undesirable, as the tongue is left very sore aftei'Avards. The use of chloroform as an anesthetic is preferred by some surgeons, though on the Avhole ether is more fre- quently used as it is considered less dangerous; though chloroform, Avhen given by an experienced anesthetist, has many qualities to recommend it, as it is less irritat- ing, patients get under its effect quicker, and the period of recovery is much shorter than when ether is given. The nurse should not attempt the administration of chloroform unless she has previously had some experi- ence with it. as its action on the heart is sometimes sud- den, producing fatal syncope before stimulants can be given. Ether is not so rapid in its effect and spends its force on the respiratory centers. Chloroform is exten- sively used in obstetrics, young children and old people, and is to be preferred to ether when there is any kidney lesion present. The preparation by the nurse of patients who are to take chloroform is the same as that when taking ether. The nurse may seldom be called to administer a local anesthetic, as this is usually done by the surgeon or one of his assistants. There are many local anesthetics; however, those Avhich the nurse will see most commonly used are cocaine, novo- eaine, ethyl chloride, ice and salt. Cocaine has been used as a local anesthetic since 1884, and while possessing some toxic properties, its effect is most complete when properly used. It can be applied 152 SURGICAL AND AVAR NURSING on pledgets of cotton to open Avounds and to the mucous membranes, and for the latter reason it is used ex- tensively in nose and throat operations. When an opera- tion such as opening a felon or abscess is to be performed, it is injected Avith an ordinary sterile hypodermic or a syringe made especially for the purpose. It is used in from one-half per cent to ten per cent strength, four per cent being most commonly used. The layers of the tissue to be incised are infiltrated by inserting the needle slantingly into the skin and depositing the solution in drops in a line through Avhich the incision is to be made. Novocaine is used extensively and is less toxic than cocaine, hence it is much more desirable as a local anes- thetic. Ethyl chloride is a convenient local anesthetic and is free from the possible toxic effect, as it is sprayed on the area to be operated until the tissues are blanched, Avhen incision may be made Avithout pain. Ice and salt, when mixed and applied to the surface, renders it numb and slight operations may be performed Avhile the an- esthetic effect lasts, Avhich, hoAvever, is of short dura- tion. CHAPTER XIX INJURIES IN WHICH A NURSE MAY BH CALLED TO RENDER FIRST AID During the course of every professional nurse's career she may be called upon to render first aid to persons Avho are injured. While a nurse is not expected to cither practice medicine or surgery, or assume the responsibil- ities of treatment Avhich naturally fall upon the surgeon, she may be and frequently is called upon to render the first seiwices until a surgeon can be called to take charge of a case; hence, a knoAvlcdge of the common injuries and how to treat them may be helpful to her. Sprains are quite common injuries which are pro- duced by violent twisting or straining of the soft parts surrounding the joints. Sprains may be slight, mod- erate, or severe, depending upon the violence of the ac- cident. Sprains may be so severe as to detach a small portion of the bone, in which case they are spoken of as sprain-fractures. When a sprain occurs, the affected portion should be at once put at rest, the limb should be elevated and either very cold cloths or hot applications, whichever is most acceptable to the patient, should be applied con- tinuously, or a tight fitting bandage should be applied should it be impossible to use the hot or cold cloths. Fractures are injuries that are frequently met with, and this class of injuries should receive as prompt at- tention as possible because the longer the interval be- tween the receipt of the injury and the treatment, the more difficult will the management become. 153 154 SURGICAL AND AVAR NURSING When a person sustains a fracture, he should lie down; and should much deformity result, the nurse should take the limb and gently pull it into a straight position if pos- sible, and place it on either a pilloAV or a padded board and then apply cold cloths until the surgeon arrives. Should the fracture be compound, that is, where either the bones protrude through the skin or Avhere there is an open wound leading to the site of the break, the wound should be cleaned as thoroughly as possible and a piece of sterile gauze be placed over it. In removing all dirt and extraneous material, the nurse should be gentle and under no circumstances should the avouiuI be probed, as further infection may take place. If no physician or surgeon can be had for some time, she should administer, in those cases of compound fracture that have been con- taminated by the dirt from the street, a dose of 1,500 units of antitetanic scrum if she can procure it. Should the patient have to be transported, she can splint the limb by laying it on pillows and tying a string or tape around the limb and pillows, just tight enough to cause the pilloAvs to hug the limb snugly. A very useful splint may be made by folding a blanket in such a Avay that the ends form two long rolls between Avhich the broken limb is placed. The blanket is held apposed to the limb by either a bandage or tapes placed at convenient dis- tance from each other. Dislocations are the displacement of either one or both bones of a joint. When such an accident occurs, the limb should be placed in a position Avhich will relax so far as possible the structures involved, and the liberal use of cold applications may suffice to give some relief and at the same time limit the swelling Avhich usually folloAvs. Contusion or bruise may result from the impact of a blunt instrument against the body surface or it may INJURIES REQUIRING FIRST AID 155 result from a fall. Contusions are more or less painful and are usually accompanied by some SAvelling. The treatment should consist of keeping the part quiet; this is best done by placing the limb, if it is one of the ex- tremities, on a splint. Should the pain and swelling be severe, cold application or some soothing lotion, such as lead and opium, may be applied. Cuts and punctures. In this class of injuries the treatment will vary, depending upon their severity, as in deep cuts with gaping edges, the resort to sutures may be necessary in order to close the Avound. In deep punc- tures by infected instruments, free incision may be needed in order to facilitate drainage. In the average case the duties of the nurse will be to disinfect the wound so far as possible. This may be done by bathing with boiled water to Avhich has been added some antiseptic, or thoroughly coating the Avound with tincture of iodine should she have this at hand. After the Avound has been rendered aseptic so far as possible, it should be care- fully enveloped in sterile gauze, and a light bandage employed. Fainting is the temporary loss of consciousness pro- duced by various causes; for instance, the sight of blood or an accident. Some people faint when in a crowd in a poorly ventilated room. This condition is sometimes more or less influenced by the condition of the stomach and also the general health of the individual, as those in a poor state of health are more likely to faint than the robust and strong, although it occurs in both. When a person faints, he should be laid on the floor or on a bed or taken into the open if proper ventilation can not be had, as fresh air is all that in most cases will be needed. The clothes should be loosened about the neck and body, the face should be bathed in cold water, and a bottle of camphor or smelling salts should be held 156 SURGICAL AND AVAR NURSING close to the nose in order that the patient may inhale the odor, as both are somcAvhat stimulating. In the aged and Avcak, a small dose of brandy or Avhiskcy may be given. The patient should remain quiet for a Avhile, until the effect of fainting has passed off. Snake bite is more frequently encountered in some countries than others, and in southern climates than in northern. In this country, the bite of the copperhead, water moccasin, and rattlesnake are the most poisonous. The symptoms are pain, Avhich later becomes intense; swelling, Avhich in some cases increases very rapidly; ex- travasation of blood. The patient may become drowsy, or may lose consciousness. If the poison is injected into a vein of any size, the result may be rapidly fatal, de- pending on the amount of poison injected, When a person is bitten, a tight bandage or tourniquet should be applied proximal to the bite and the patient instructed to suck the blood from the Avound; or better, after the circulation has been limited by the tourniquet, the site of the bite should be thoroughly incised and cauterized by carbolic acid or a hot iron. Stimulation with Avhiskcy may be needed, but caution should be ex- ercised in its administration, as some victims have died from the toxic effects of the liquor Avho Avould have in all probability survived the snake poison. The in- jection Avith a hypodermic syringe of a 1 per cent po- tassium permanganate solution is recommended as very effective and at present the use of a serum is said to act nicely, though this latter remedy has not been on trial long enough to prove its value. Frostbite is the effect produced by cold. It usually involves the exposed parts of the body, such as the nose, ears, feet and hands. A numbness or sense of Aveight is experienced by some Avhich is increased Avhen the pa- tient comes near the fire. The treatment consists in rub- INJURIES REQUIRING FIRST AID 157 bing the parts Avith either suoav or cold water, then a cloth saturated Avith alcohol Avhich is folloAved by brisk rubbing Avith the bare hands and if the extremities arc involved, they should be enveloped in a warm blanket. Under no circumstances should the patient sit near a hot fire or use hot Avater, as the circulation in the affected part should be induced to return sloAvly. Fourth of July accidents have become so common that in some states the prohibition of fireworks Avas necessary. The toy pistol, fire crackers, and sky rockets all con- tributed their quota of injuries on this national holiday. In some cases poAvder grains are driven into the skin, while in others the wad from the blank cartridge is deeply imbedded. When an accident of this kind occurs. the wound should be cleansed of all powder, wads, and extraneous material, thorough irrigation Avith solution of bichloride of mercury 1:1000, and if possible 1500 units of antitetanic serum should be given as soon as possible. CHAPTER XX WAR NURSING The Trained Nurse in War While much has been said regarding the services of the trained nurse in hospital Avork, social settlement, mis- sion nursing, and the services she has rendered in con- nection Avith health boards throughout the country, little if anything has been written about the Avonderful self- sacrifice and untiring work of the professional nurse on the battle field. At the present time the nursing profes- sion is singularly conspicuous for valuable services being rendered on the battle fields of Europe. In this respect it may not be out of place to say that the heroism of the Army and Navy is a legacy from brave sires, and equal to it is the splendid Avork rendered by the nursing pro- fession of Avhose Avomen the daring of hardships and dan- gers in their tender Avorks of mercy Avas inspired with the spirit of the pioneer mothers Avhose splendid devotion made possible the subjugation of savages and turning a Avilderness into the homesteads of a mighty nation. In every Avar in Avhich the country has been engaged, some representatives of the nursing profession have stood out in bold relief for services which they have rendered, and with the first call to arms, simultaneously came the prof- fered services of the Avomen. The Red Cross Society, on Avhose roster some of the most eminent names in the nursing profession are en- rolled, in all its different branches and several organiza- tions has done untold good and its work has been recog- 158 WAR NURSING 150 nized not only by the President of the United States but by the rulers of other countries. The Senate of the United States passed a resolution, without a single dissenting voice, tendering Miss Clara Barton and the Red Cross Society the thanks of Congress for services rendered in the Spanish-American War, Avhich services could have been rendered only by women trained in the art of nursing. The draft on the nursing profession in America at the present time is exceedingly heavy, as this country is engaged in Avar Avith the most formidable foe Avithin its history; and Avhile victory will be ours, it Avill not come Avithout long and continued fighting, Avith the result that the casualty list Avill be long and the Avork for the nurse avill be multiplied tenfold. The nurse is working in this Avar under circumstances totally different from anything the Avorld has heretofore known as regards the manner in Avhich the Avarfare it- self is conducted. This is a Avar that is being fought out scientifically, as neAV methods of destruction are con- stantly being invented by fertile brains on both sides. Demands Upon the Nurse From what, is known at present of the demands made upon the nurse at the front, it is quite evident that she should be thoroughly prepared and as much time as possible should be spent in intensive training and pre- paratory Avork, as her duties will be varied and the hours long. Especially is this true after a severe engagement, as it not infrequently happens that a hospital that has a staff of doctors and a corps of nurses sufficient to care for three or four hundred patients may suddenly be called upon to care for six to nine hundred Avounded men. The duties of the nurse then are twofold : first, the discharge 160 SURGICAL AND AVAR NURSING of her own duties, and second, directing or instructing those under her Avho may not have been so fortunate as she as regards a professional education, as many Avomen are employed aat1io hold no degree in nursing, but avIiosc patriotism prompted them to offer their services, Avhich in the absence of the more skilled and trained Avere ac- cepted. The nurse before entering the service should be sure she is physically all right, as the tremendous strain and long hours on duty may speedily render her unfit for the Avork, hence she becomes a charge instead of a help. The nurse should provide herself Avith a few things before she goes to the front, such as rubber gloves, a pocket case, and a good hypodermic syringe. These arti- cles arc furnished but in a Avar of the magnitude of this one, it is at times hard to get supplies quickly; and Avhile she may have only a fcAV occasions to use these of her own purchase, there may be times Avhen she will need them badly. The gloves should be Avorn as much for her oavii protection as that of the patient, as in this Avar as in no other has infection been so rampant. This War Differs From Other Wars This Avar differs from other Avars in the great number of men engaged, the very great A'aricty of destructive methods employed, such as bullet, shrapnel, high explo- sive shells from heavy artillery, bombs, gases of various kinds but all with deadly effect, hand grenades, etc., the soil over Avhich the two armies are fighting and the means of transporting the Avounded. The nurse should understand that in all Avounds, Avhether in civil life or in battle, there is a certain de- gree of inflammation. This does not necessarily mean infection; hoAvever, in the present A\rar nearly all Avounds AVAR NURSING 161 are infected. Some Avho are fortunate to receive prompt and thorough treatment recover quite rapidly, Avhile those who are less fortunate and Avho may be compelled to lie out in "No Man's Land" for twenty-four to forty- eight hours, notwithstanding the first aid that they are themselves able to apply, are nearly ahvays infected. The soil conditions of France and Belgium are conducive to this widespread infection, as for centuries the soil of these countries has been cultivated and manured and the earth is teeming with bacteria of all kinds, especially those derived from fecal matter and the pus-producing kind. The Avounds are of such a nature as to encourage their groAvth, as they are of such a destructive character with much devitalized tissue that falls an easy prey to aerobic and anaerobic bacteria Avith their resulting con- sequences. In the South African War, and in the Russo-Japanese War infection Avas present, but not to the extent of that seen in the present Avar. In the South African and Russo- Japanese Wars, the fighting took place over ground that had received little if any manure, and most of the fight- ing Avas done in the open. And again, many of the new devices for destroying human beings were not in vogue then as now, hence the widespread infection with its in- creasing mortality. Most of the fighting so far has been trench fighting, so far as the infantry is concerned, the men standing for hours and sometimes for several days in a trench from seven to nine feet deep, the bottom of Avhich is often full of water. The clothing as avcII as the body is often covered Avith mud, and the poor facilities, under such conditions, for the soldier to keep himself clean, ren- der him more liable to infection Avhen he is Avounded than he would otherwise be. 162 SURGICAL AND AVAR NURSING Bacteria The bacteria commonly met Avith in this Avar may he divided into tAvo general classes, as follows: Firstj those kiiOAvn as aerobic, that require oxygen for their existence. 'They are: Streptococcus Staphylococcus Bacillus- Pyocyaneus Colon bacillus. Second, those known as anaerobic that can not live in the presence of oxygen. They are: Bacillus of Tetanus Bacillus of Malignant Edema Gas bacillus (or bacillus Capsulatus of Welsh). A Avound may be infected Avith one or more of the above, some being more virulent than others; for in- stance, the gas bacillus or bacillus of either tetanus or malignant edema are far more deadly than those of the staphylococcic variety; however, any of these may en- danger if not destroy life when permitted to multiply unchecked. Fortunately, there is developed Avithin our bodies a substance that may for convenience be called "antitoxine," Avhich resists the poison caused by the pres- ence of bacteria. In some persons the poAver of resist- ance to pyogenic bacteria is quite marked Avhile others offer little or no resistance; the former Ave speak of as being more or less immune, Avhile in the latter class little if any immunity exists. Immunity may be natural in some persons, meaning that they possess within their bodies a substance that AVAR NURSING 163 naturally inhibits the growth of, or destroys entirely, the bacteria that may have gained entrance; on the other hand, immunity may be acquired, as Avhen a soldier is vaccinated or given a dose of antitctanic scrum or anti- typhoid serum, he is thus rendered immune against small- pox, tetanus, or typhoid fever. Immunity thus acquired lasts for a variable length of time, usually two or three years; hoAvever, Avhen exposure is great, it is Avell to give immunizing doses at closer intervals. In the present Avar, every recruit is required to be vaccinated and to take the antityphoid serum before he proceeds further with his training. The result is that both smallpox and typhoid fever have been practically eliminated from the troops. The Transportation of the Wounded In the present Avar the different methods for quick transportation of the Avounded soldiers have been per- fected to such an extent that it frequently happens that Avithin a few hours after an engagement, the Avounded begin to arrive at the hospitals located close to the first line trenches. The stretcher bearers bring the wounded to the first aid or dressing station, and from here they are sent farther back by other means of transportation. The automobile has been of inestimable value in mov- ing Avounded men as great numbers can be cared for in a short Avhile. Keene states that the American Field Ambulance in France alone has four hundred ambulances and has transported three hundred thousand wounded men. The majority of ambulances are fitted with stand- ard size stretchers so that when the wounded are brought from the front to the dressing stations or hospitals, they leave the wounded man on the stretcher and in return receive an empty stretcher Avith blankets, and return to the front for another load, thus saving time in trans- 164 SURGICAL AND AVAR NURSING ferring the Avounded man, avIio is left on the original stretcher until final disposition is made of him. This not only saves time and enables the ambulances to make more trips but saves the soldier much pain and incon- venience by not changing him from one stretcher to another, and in many cases the question of life depends on the least amount of handling. Sir A. A. BoAvlby in the British Medical Journal describes the light raihvay ambulance trolley used in transporting the Avounded; also the overhead trolley in the trenches used for quick transportation. Both of these have been the means of saving many a life by get- ting the wounded quickly to a place Avhere they can re- ceive prompt attention. Hospital trains Avhich operate between evacuation hos- pitals and base hospitals are equipped with every pos- sible convenience, such as a modern operating room, an x-ray laboratory, and a diet kitchen, together Avith a full complement of nurses and surgeons who are in charge. It may be said that it is a modern hospital on Avheels. Attention to the Wounded After a severe engagement, there is usually a sudden influx of Avounded to the dressing stations and farther back to the evacuation hospitals, and still farther when their condition will permit them to be moved to the base hospitals. The nurse should at all times keep her wits about her and at no time allow the large number of soldiers suffering from wounds varying from slight to those of a most horrible and repulsive character to dis- concert her. She should carefully examine every man entrusted to her care so far as possible to see that he is made as comfortable as possible. She should find out the exact nature of his wounds AVAR NURSING 165 and their location, Avhether he is suffering from wounds caused by shell fire, burns, bullet or stab wounds, to see if a tourniquet has been applied or tight bandaging, pos- sibly to control bleeding, if so see if they are too tight, which not only causes pain but may interfere with the circulation of the blood in the parts involved. If a fracture, Avhether simple or compound, she should see that the splints are in place and are not producing undue pressure. If the Avound is not of the stomach and abdominal viscera, food and drink may be given, for it must be remembered that they may have been Avithout either for a considerable period of time. The clothing should be changed and a bath green provided the patient's con- dition and Avound Avill permit, as nothing so revives a soldier Avho has stood for days in Avater and mud as these little comforts. The nurse should keep a careful lookout for those suf- fering from shock and render Avhatever services may seem indicated, such as the elevation of the foot of the bed. The application of heat, and the administration of stim- ulants, the subcutaneous or intravenous injection of nor- mal saline will usually be done by the surgeon, Iioav- ever. she should have everything ready for such an emergency. CHAPTER XN1 WAP NURSING (Cont'd) Character of Wounds In civic life, Avounds seen are usually inflicted with pistol, gun or knife. They are generally single and most of them are sterile; Avhile some are infected, those that are infected are usually Avith the pyogenic bacteria such as staphylococcus and streptococcus, Avhile the wounds in- flicted on the battle field are almost Avithout exception infected not only Avith pyogenic organisms but in the present Avar a very large percentage are infected with the gas bacillus or the bacillus of tetanus and sometimes both. Wounds received in battle are usually produced by bullet, shrapnel, shell fire from high explosives, and stab Avounds, as those inflicted Avith the bayonet. The shrapnel and shell Avounds are murderous in char- acter and the most frequent type seen. Bursting shell Avounds are proportionately more dangerous because of the fact the fragments frequently carry into the Avound clothing, dirt, and other foreign material; and again be- cause of the devitalization of not only the tissues in the immediate tract of the missile, but all subjacent tis- sue is deAdtalized to such an extent that tissue necrosis speedily folloAvs. It is in these cases that tetanus and gas infections are most commonly seen. The severity of a bullet Avound is proportionate to the distance; thus the maximum amount of destructivencss of a bullet fired from the modern rifle is attained at about 166 AVAR NURSING 167 five hundred meters, as at this distance a large hole will be torn in the soft parts Avhile a bone Avill be completely shattered. The stab Avounds produced by the bayonet are usually of the punctured or jagged variety, and are usually fatal Avhen the Avound involves the abdomen or the chest. Those from shrapnel or shell fire produce frightful muti- lation of a bursting character. Those from the rifle arc more or less round at the point of entrance and some- what larger at the point of exit; hoAvever, Avhen a soft nose bullet or the dum dum bullets are used, their Avounds may rival those produced by shell fire. It has been noticed that in order of their destructive- ness to life, Avounds of the head stand first; then those of the chest and upper extremities; and next to these are Avounds of the abdomen. Treatment of Wound Infection In the treatment of Avound infection in the present Avar, much has been learned that has been of inestimable benefit to the Avounded soldier. In the early months of the Avar, much suffering Avas occasioned by wounds being infected and in many instances lh^es Avere lost to say nothing of the Avholesale amputations that took place, all because no adequate means had at that time been de- vised to successfully cope Avith the rampant infection then seen. Things have changed—thanks to the efforts of Carrel and Dakin, Avho set about finding some method of rendering wounds sterile, Avhich they succeeded in doing. Dakin, after much experimentation, found that hy- pochlorite of soda solution of a certain strength, coupled with its method of application as suggested by Carrel, was the best method of rendering Avounds sterile. The Carrel-Dakin method may be divided into the 168 SURGICAL AND AVAR NURSING mechanical cleansing of the Avound and the chemical sterilization or application of the hypochlorite solution to the whole surface of the Avound. The Mechanical Cleansing- of Wounds When patients after an engagement are brought to the hospitals, if they are in shock they are treated for this condition; if not, and their Avounds and condition per- mit, they are given nourishment, made Avarm, and are bathed. The character of the wound is noted and whether or not important organs have been invaded by the missile. If the Avounds be of the extremities, care- ful attention is given to the blood vessels and the nerve supply. The x-ray is used to locate fragments of shell, bullet and other foreign bodies, this in conjunction with the electromagnetic vibrator of Professor Bergonie, the tele- phone probe, the Hirtz compass localizer, and other de- vices for the exact localization of foreign bodies have all aided materially in the treatment of Avounds in the pres- ent Avar. After the above preliminaries have been thoroughly accomplished, the patient is given a general anesthetic; in some eases Avhen deemed advisable, spinal or local anesthesia may be used. The skin is sterilized with tr. iodine; the edges of the Avound are trimmed, the Avound is then laid open so as to thoroughly expose all pockets, the incision is ahvays made Avhen possible parallel to the long axis of the limb, all foreign bodies, blood clots, bruised and damaged tissue and loose fragments of bone are removed. Counteropenings for drainage are seldom if ever made and when clone are frequently plugged so as to keep the solution in the Avound, as the success of the Carrel-Dakin treatment depends on the solution coming in contact Avith the Avhole interior of the wound surface. AVAR NURSING 169 Wiping the wound out Avith gauze sponges does not suf- fice, as the tract of the missile and all tissue that is in any Avay damaged must be cut out smooth Avith a sharp Fig 104—Dakin's instrument employed in applying Dakm's solution to wounds. It consists of 5 glass distributing tubes for using single or large number of rubber conducting tubes, the flask is used for mixing the solution and the syringe with rubber bulb is used in testing the permeability of the conducting tubes. cutting instrument, as in this way and no other will the wound be entirely freed from extraneous matter and tissue of questionable vitality. It is important to have complete hemostasis, as blood 170 SURGICAL AND AVAR NURSING clots in the wound form a fine nidus for bacteria and prevent the solution from having complete effect. The Avounds arc left open and are never closed at the beginning for fear of subsequent development of infec- tion; later, after the complete sterilization of the wound is assured, the wound is closed. Chemical Sterilization of the Wound There are tAvo Avays of applying the hypochlorite so- lution to a wound: One is by the instillation method, and the other is the continuous drip method. The latter is not so satisfactory and much less used than the former. The apparatus used in applying Dakin's solution is a glass flask holding one quart, a long rubber tube known as the irrigating tube, one end of which is connected to the glass flask containing the solution, the other is con- nected to the distributing tube. The distributing tube is a glass tube from which several tubes are drawn at a right angle to the main tube, the number of these tubes varying from one to six, depending on the number of conducting tubes (Carrel) to be used in the Avound. The conducting tubes arc small rubber tubes usually from ten to sixteen inches in length, and the sides for a distance of several inches are pierced by small holes through Avhich the solution flows into the Avound. Some of the conducting tubes are covered for an inch to three inches Avith bath toweling securely sewed to the tube so as not to come loose in the wound. This is intended to give more even distribution to the fluid. The reservoir containing the fluid is placed between twenty and forty inches above the wound, and after the wound has been dressed and conducting tubes are in place, the nurse is instructed to release the jmiehcock on the irrigating tube for a feAv seconds every two hours, thus permitting the fluid to Aoav into the Avound. AVAR NURSING 171 It is not the object in this treatment to flush the Avound, as is commonly done in civil practice Avith other anti- septic fluids, but just enough of the solution should Aoav in to "puddle" the Avound. This part of the treatment is entrusted to the nurse and she should thoroughly grasp the idea of "puddling" the Avound and not flush- ing it too much, as success or failure may depend on how avcII the nurse discharges her duty in this respect. Another method of instillation is by means of a syringe, but this method is not much used as it requires much time and the services of several nurses, Avhere many such treatments are to be given. It should be stated that the use of the various con- ducting tubes, and as to Avhether one or more are em- ployed in a given case will depend on the character of the Avound. The nurse will also be instructed hoAV to find out whether or not the conducting tubes are plugged and if the solution is being thoroughly distributed over the surface of the wound, and thereafter this important duty will devolve upon her and any suspicion that things are not right should be brought to the attention of the sur- geon immediately. The permeability of the conducting tubes is tested Avith a glass syringe on the end of Avhich is a rubber bulb. Dressing the Wound The conducting tubes are inserted into the Avound and kept in place by gauze placed in the wound opening, the skin is protected from the irritating effect of the solution by means of strips of gauze that have been sterilized in vaseline. These strips are laid around the margin of the wound and extending on to the skin for a distance of from three to six inches, depending on the size and lo- cation of the wound. Over all this is laid a pad made 172 SURGICAL AND AVAR NURSING of one layer of nonabsorbent cotton and one of absorbent cotton, around the Avhole of Avhich is placed sterile gauze. The side of the pad that contains the absorbent cotton is placed next the Avound. Care should be ex- ercised in placing pads over the wound, that the tubes are in no Avay pressed upon. A pad is placed posteriorly so that the edges of the pads meet on the sides of the limb. The pads are now pinned Avith safety pins, thus dispensing Avith bandages. The tubes are fastened to the dressing Avith either safety pins or adhesive tape. Bacterial Examination of Wounds In conjunction Avith this method of treating Avounds, the bacterial examination of the wound is of great as- sistance as it indicates the progress toward sterilization the Avound is making. The accuracy of these examina- tions, Avhile not exact, imparts sufficiently accurate in- formation to enable the surgeon to state with a reason- able degree of certainty on what day the wound may be closed. In many hospitals at the front, the nurse is in- structed to do this Avork, as it is simple and easily understood. A sterile platinum loop is placed into the Avound Avhere there is a likelihood of there being bacteria. On the loop of platinum v\ ill be some secretion from the wound. This is placed on a sterile glass slide and allowed to dry. The nurse then stains the smear on the slide with a drop of carbolized thionin. After a feAv seconds this is Avashed off Avith water and the slide is again dried. The slide is now ready to be counted. A drop of cedar oil is now placed on the slide which is examined with a microscope, using a No. 1 eyepiece and a 1/12 oil im- mersion lens. The bacteria are now counted in the mi- croscopic field; as Carrel states, Avhen the number in a WAR NURSING 173 field exceeds fifty or one hundred, it is useless to count them more precisely. The examinations are made at the time of dressing the Avound or oftener if need be, and the count one day is compared with that of the preceding day so as to note any decrease in bacteria, which means sterilization is progressing nicely, or any increase in the number of bacteria which indicates that infection is progressing. There are some objections to hypochlorite solution: First, it is very irritating to the skin; second, the exact strength must be maintained, as when below 0.45 per cent, the germicidal action is too Aveak, when above 0.5 per cent it is too irritating; third, the solution becomes inert after it loses its chlorine and must be replenished at stated intervals, usually two hours. In order to overcome these difficulties, Dakin has pro- posed the use of another synthetic chloramine called "Dichloramine-T." This is nonirritating and is dis- solved in eucalyptol and paraffine. The solution is used in strengths of 5 per cent or 10 per cent and its ger- micidal properties last for twenty-four hours. Dichlor- amine-T may be applied on gauze or sprayed or the Avound may be filled with it. Other Antiseptics Many of the antiseptics commonly employed in civil life are also used, such as bichloride of mercury, boric acid, iodine, carbolic acid, and potassium permanganate. Besides these, many new antiseptics are being used, such as acriflavine, proflavine, and brilliant green. As to the merits of these new antiseptics, continued use in the hands of competent and impartial surgeons will tell. Hypertonic saline solution advocated so strongly by Sir Almroth Wright, is used by some surgeons at the 171 SURGICAL AND WAR NURSING Fig. 105.—Aeroplane splint used in treatment of compound or iilcisional fracture of arm and forearm. Fig. 106.—Robert Jones' modification of Thomas' splint for thigh and leg, also used.to fix limb while transporting patient. It*. 107.—Robert Jones' leg splint for fractures of lower portion of leg. Fig. 108.—Walker's splint for wrist and forearm. AVAR NURSING 175 front; however, the results of wound treatment by this method in the hands of many competent surgeons have not been as good as that attained by the use of Dakin's solution. Fig. 109.—Railway splint. An aerial suspension splint for the treatment of fractures of the femur and tibia Fractures The type of fractures seen in Avar hospitals differs a cry much from those seen in civil life, because nearly lfior no.—Blake's modification of AVallace's extension splint for gradual extension. cverv compound fracture received on the battle field is infected and there is extensive shattering of the bone. The shattering, whether of the long, short, or flat bones is due to the high explosive effect of the projectile. 176 SURGICAL AND AVAR NURSING In the treatment of fractures, the nurse Avill be called upon to render no small amount of service. Should the fracture be compound, after it has been dressed the nurse should be exceedingly careful in handling the limb so as in no Avay to disturb the position of the bones; she should see that bandages do not bind the limb unduly, thereby producing discomfort. Also, she should be con- stantly on the alert for signs and symptoms of infection, such as any discharge from the wound, rise of tempera- Fig. 111.—Robert Jones' elbow Fig. 112.—Robert Jones' humerus splint for immobilization of joint. extension splint for fractures of middle and lower shaft. ture and-pulse, chilly sensation, or increase in bacterial count. The surgeon's attention should be called to any of these symptoms at once. Compound fractures are treated as other infected wounds in so far as irrigation is concerned, as nearly all compound fractures are treated Avith Dakin's solu- tion, which the nurse Avill see is carried out correctly. The treatment of simple fractures after they have once been properly reduced and immobilized usually amounts to very little unless some complication arises that ncces- WAR NURSING 177 sitates redressing. There have been a number of devices introduced for holding fractured bones in position Avhile some of the older appliances are still used with success; such as Buck's extension, the Balkan frame, plaster of Paris and starch and bandages. In compound fractures Avhere the Avound requires dressing, splints have been so devised that dressing is easily accomplished Avithout any disturbance of the po- sition of the bones. CHAPTER XXII WAR NURSINU (Cont'd) Head Injuries Wounds of the head are frequently seen, notwithstand- ing the universal use of the steel helmet. Wounds in- volving the face, neck, and lacerated wounds of the scalp are dressed close behind the lines at first aid dress- ing stations; however, those cases requiring more ex- tensive operation, and especially those wounds of the head in which the brain is involved, are sent farther back to base hospitals Avhere all conveniences possible can be had, as it has been clearly shown that in cases A\here there is brain involvement the patient has a bet- ter chance to recover when sent to a base hospital where everything can be done for him, than to operate upon his arrival at the first line dressing stations, as in the latter his chances for infection are great, The nursing of head injuries in Avhich the wounds are slight will be comparatively easy; but in those grave cases Avhere the projectile has done much damage to the skull and brain, the nurse will be expected to ex- ercise the greatest judgment and skill as so much de- pends on skillful nursing in these cases. She should ac- quaint herself Avith certain symptoms of brain injury so as to be of the greatest assistance to both the patient and surgeon. She should note carefully the character of the pulse which is usually sIoav, any unusual headache, irregular pupils, tAvitching muscles, stupor, unconscious- ness or paralysis. Any one of these symptoms may be a signal of impending trouble. 178 WAR NURSING 179 In the treatment of head injuries, the nurse will be particularly struck by the amount of damage the brain can stand and the patient recover. Upon the arrival of a soldier Avith brain injury at the base hospital, the head is shaved, an x-ray plate is taken, the Avound is freely opened and devitalized, and infected brain tissue together Avith all spicules of bone and for- eign bodies removed. The use of the electromagnet is extensively employed in removing the missile from the brain. The operation is concluded with closing the Avound cither Avith or Avithout drainage, rubber tubes being used in preference to gauze for this purpose on account of the tendency of gauze to become entangled in brain tissue, Avhich makes its removal difficult. Hemorrhage is thoroughly checked by means of liga- ture or muscle implantation or bone Avax. After operation, the patient is placed in bed Avith head elevated. The nurse should see that the patient is made comfortable in this position. Nourishing diet, pleasant and quiet surroundings, all contribute much to the comfort and speedy convalescence of these patients. Wounds of the face seen in this Avar are often fright- ful, as the Avhole upper or lower jaAV or nose or other portion of the face may be shot aAvay. The development of plastic surgery together Avith the Avonderful services rendered by the dental units have in many instances re- stored the face to near normal, thus avoiding the horrible disfigurement which the patient would otherwise be com- pelled to carry through life. Chest Wounds Chest Avounds Avill form a very interesting chapter in surgical works written after the Avar, as much has been learned as to their management. 180 SURGICAL AND AVAR NURSING In considering Avounds of the chest it is necessary to remember that Avithin its bony Avails many organs arc located that are necessary to life. Injuries may be inflicted Avith bullet, shrapnel, or bay- onet. The damage done depends on the character of wound, as a ball going through the chest Avail and lung, provided no large vessels are severed, "will cause no great destruction of the parts traversed, Avhile those from shrapnel usually produce considerable damage and not infrequently pieces of the projectile remain in either the pleural cavity or the lung. Those wounds produced by the bayonet are as a rule quite dangerous, as the Aveapon is usually driven with considerable force and at close range and quite often penetrates the mediastinum or severs some of the large blood vessels. The mortality in chest Avounds differs at various dressing stations and base hospitals. It has been stated that, taking a large number of chest Avounds, the mortality will average 20 per cent. Death is due, as a rule, to hemorrhage, sepsis, or pneu- monia. Many Avounded die in a few hours from hem- orrhage and many who escape this die from sepsis later, Avhile quite a number die as the result of pneumonia. It has been proved that the opposite lung will be dam- aged to considerable extent. This is usually hemorrhagic in character. In the treatment of wounds of the chest, rest in bed for a considerable period of time is of the utmost im- portance, as it minimizes the chances for hemorrhage. Strapping Avith adhesive so as to thoroughly immobi- lize the chest on the affected side is of prime importance. In the absence of hemorrhage, rest and immobilization are the principal points to be remembered in treating injuries to the chest and its contents. In those cases Avhere blood has accumulated in suffi- WAR NURSING 181 cient quantity, aspiration will have to be resorted to; and in cases where infection has occurred, and pus formed in the pleural cavity, thorough drainage by means of rib resection Avith the insertion of tubes will be found necessary. In infected cases, the use of Carrel-Dakin method is of great assistance, as convalescence is materially short- ened. Hemorrhage may be controlled by packing the cavity or by suture of the lung tissue. Patients should be kept in a pure atmosphere and ab- stain from undue exercise during convalescence. In those cases that require drainage, the nurse will see that the drainage tubes do not become blocked and she should use extra care during the dressing of a case to preArent the tubes from being draAvn into the pleural cavity, thus necessitating another operation for their removal. Abdominal Wounds In the Spanish-American War, many Avounds of the abdomen Avere seen that recovered completely without operation. This Avas due to the small steel ball then in use. In the present Avar, wounds of the abdomen are not only from bullets but from shrapnel shell and its contents, bombs, grenades, etc. The Avounds are fre- quently multiple and involve one or more of the intra- abdominal organs; then again, wounds seen in the pres- ent Avar are almost Avithout exception infected. In previous Avars, the tendency has been to defer operation ; but in the present Avar, all patients Avith ab- dominal Avounds are operated upon as early as possible, there being tAvo conditions only Avhich should cause post- ponement: the first are those cases in Avhich there is unmistakable evidence that the peritoneal cavity has not been invaded; and the second arc those cases in 182 SURGICAL AND AVAR NURSING Avhich the patient is profoundly shocked, in Avhich case proper treatment promptly instituted for the latter con- dition may safely tide the Avounded man over into a safely operable state. The nurse Avill see, after an engagement, many who are suffering from both penetrating and nonpenetrating Avounds of the abdomen, as LockAvood and his associates state in the British Medical Journal of March 10, 1917 that in one night between nine and tAvelve o'clock, ninety-six operative cases Avere brought in, of Avhich thirty-six Avere abdominal; and of this number thirty- tAvo Avere operated upon. In general, the treatment of all penetrating Avounds of the abdomen consists in locating and removing all foreign bodies, suture Avhen possible, of all organs that tuwe been punctured unless in the kidney, Avhen the vessels and the parenchyma have been destroyed, Avhere nothing short of removal Avill suffice, or in the intestines Avhere resection offers the best chance for recovery. bisection of the intestine carries greater risk than simply suturing the punctures, and is resorted to only Avhen the latter procedure Avill not suffice. Drainage is not as a rule employed; however, in some cases it may be deemed advisable, in which case pelvic drainage or drainage posteriorly may be instituted. In the latter it is done in those cases of Avounds of the colon to prevent retrocolie infection. After operation the patient is placed in the PoavIci- position to facilitate drainage aAvay from the upper abdomen and diaphragm. No enemas or food should be given for several days, only Avater in half ounce quantities at regular intervals, and should nausea set in, this should be Avithheld. In cases that are in profound shock, water may be adniinisfered WAR NURSING 183 intravenously, as in this state little if any absorption takes place Avhen given subcutaneously. Much depends upon the attention given these patients by the nurse after operation, as many cases have been nursed to a successful issue that in the beginning looked hopeless, thus proving that the service of the nurse stands second to none, in such cases. CHAPTER XXIII WAR XTRSIXO (Cont'd) Gas Infection and Gas Gangrene Probably of all infections seen at the hospitals on the battle field, that the nurse Avill be called upon to attend, that produced by the gas bacillus is not only the most frequently encountered but the most virulent, destroy- ing life sometimes Avithin a remarkably short time. Has infection and gas gangrene are produced by the gas bacillus of Welsh, Avhich is anaerobic, (las gangrene folloAvs gas infection in those cases Avhere there is ex- tensive devitalization of the tissues and where the bacilli have been carried to great depths. Judd (Surgery, Cynecology and Obstetrics) says the soil over Avhich the armies are fighting, the Aveather, the clothing, the skin, projectiles, and character of the wounds all are conducive to the growth and formation of the gas bacillus. The Aveather is damp, cloudy, and much humidity exists in France and Belgium at certain seasons. The clothing is usually soiled and not infrequently covered for days Avith mud. The chances for keeping the skin clean are none too good, and especially is this true Avhen an important engagement is to take place. The char- acter of projectiles used, such as pieces of shell, hand grenades, bombs, and shrapnel, produce wounds the character of Avhich render them peculiarly susceptible to infection, as they are often multiple, extensively lac- erated, and quite often the missile does not go through 13-1 WAR NURSING 185 the tissues but remains in the body Avith clothing and dirt, until removed. The symptoms of gas infection may come on suddenly or may not shoAV up for several days. There is usually pain, swelling, rise of temperature, accelerated pulse, and a fine crackling sound is produced Avhen pressure is made over the infected area. This last symptom is called "crepitation," and is caused by the formation of gas in the tissues. The limb changes in color, usually from normal to a livid, thence to a dark hue, the discharge may be broAvnish in color, and has an offensive odor. The gas may invade the muscular planes and cellular tissue OA-er the entire limb and extend over the body. When the infection has been deep and extensive, gas gangrene usually folloAvs. This latter condition is ex- ceedingly grave, and unless it can be arrested promptly, death speedily ensues. Gas infection is very rarely seen in the head and neck, not often in the thorax, and most often in the lower ex- tremities : This is explained by the fact that the gas bacillus is anaerobic and that the head, neck, and thorax are so Avell supplied Avith blood, Avhich supplies the necessary oxygen. The prognosis in gas affection and gas gangrene de- pends on hoAV quickly the man receives treatment, and on hoAV thoroughly the Avound is sterilized. The treatment of gas infection and gas gangrene is as follows: The wound is laid open thoroughly, all mis- siles, dirt, clothing, and foreign material removed, the Avound is sterilized, Avith either Dakin solution, salt Avater, hydrogen peroxide, iodine solution, carbolic acid, Chlumsky's solution, or Merciere solution. Xot infre- quently deep incisions four to six inches long are made parallel to the long axis of the limb and over a con- 1S6 SURGICAL AND AVAR NURSING siderable area of the infected part. In case gangrene is threatened or present, amputation well above the af- fected portion is the only treatment that offers much hope of relief. The limb should not be bandaged as all encouragement should be given the gas and discharge to escape. It has been stated that a serum may yet be produced that will successfully check the ravages of this dreadful infection. Tetanus Those nurses avIio saw service in the early months of the present Avar saw many cases of tetanus; however, the free use of antitetanic serum as iioav practiced at the front has reduced so appreciably the number of cases and the mortality that it may be said that it is rare now to see a Avounded man die from tetanus if he has received early enough, the proper treatment. The same condition of the soil, clothing, skin, and the character of Avounds, referred to under "Gas Infection" holds good for tetanus, the tetanus germ being essen- tially anaerobic in character. The nurse will be expected to call the attention of the surgeon to any symptoms such as hardness or rigidity of the adjacent muscles, sensitiveness to sound or light, increased reflexes as the nerves in the Avound are at- tacked by the tetanic germs, Avhich in turn transmit their impulses to the cord or central nervous system and thence to the brain. The infection does not travel by the blood current. To make a diagnosis of tetanus after Avell defined symptoms of lockjaAv are present, is to alloAv the patient to pass from a safe period to one in Avhich there is little hope of saving life. It is on this AVAR NURSING 187 account that the nurse should keep a constant vigil over every case of Avound infection. The treatment of tetanus may be said to depend al- most entirely on the administration of the serum. The practice of giving to every man Avounded a dose of anti- tetanic serum either on the field or upon his arrival at the first dressing station has prevented much suffering from this terrible disease. It is customary to give an initial dose, 500 units, as soon after the injury as pos- sible, and as the effect lasts only about ten days, it is necessary to administer a second dose seven days after the first; and should conditions demand it, a third dose may be given. Tetanus has been knoAvn to develop quite a number of days after the patient's Avound had healed, and in a number of cases Avhere it became necessary to perform a secondary operation, tetanus has very unex- pectedly developed. Hence, in all cases Avhere any oper- ative procedure is contemplated, it is Avise to give the serum tAvo or three days before. These late cases of tetanus are spoken of as delayed tetanus, for the symptoms of which the nurse should be constantly on the lookout. It might be well to state that the administration of serum is in most hospitals entrusted to the nurse, and it behooves her to have at hand a supply of serum so there Avill be no delay in its administration. The injection of a solution of magnesium sulphate in the muscles near the wound has some effect in lessening the spasm. Its use by some surgeons is questionable Avhile others claim much for it. The free incision and liberal use of Dakin solution, potassium permanganate or iodine should not be neg- lected. The use of morphine in y± grain doses frequently re- 1S8 SURGICAL AND AVAR NURSING peated is probably the most effective remedy in relieving pain. The patient's general condition should be im- proved so far as possible. Burns Burns are, without doubt, the most frequent injury met Avith in civil life, and the liability of late years seems to have increased in direct proportion to the invention of machinery and progress of civilization and science. Since almost the beginning of the war abroad, avc have heard from time to time about the frightful burns caused by modern high explosives. There is no injury that causes more agonizing pain and protracted suffering and so often condemns the un- fortunate victim to a lifelong mutilation of the most dis- tressing and repulsive character. The severity of a burn depends on the character and degree of heat, the length of time it is applied, and the thickness of the cutaneous structure. Thus molten lead or caustic acids Avill produce more destruction in the same length of time over the same area than hot Avater or steam, and it requires a longer application of dry than moist heat. The degree to Avhich a patient is burned is more or less influenced by the character of fabric covering the skin, as Avhen the surface is covered Avith silk or cotton, the damage is considerably less than when covered Avith avooI. Again, burns are more severe Avith tight fitting garments than Avhen loose ones are Avorn, because the heat is more directly applied in the one than in the other. As burns are usually on the surface of the body and may involve one or more layers of the skin, it is Avell to WAR NURSING 189 pause for a moment and take a hasty resume of the physiology of this important covering. It may be roughly stated that the skin performs from one fortieth to one fifteenth of the entire respiratory function. The absorptive poAver of the skin (unbroken) is a debated question, though Aveight of opinion is that it has power to absorb, though in small amount. Thus it Avill be noted from the foregoing that an area of skin large enough to cover the body of an average person plays a most important part in the excretory function; for example, a person five feet eight and one-half inches high, Aveighing one hundred and fifty pounds, should have approximately 2,325 square inches of skin, or over sixteen square feet of evaporating surface. It can be readily seen hoAV burns, involving considerable area and depth, Avould affect the health of the individual. The prognosis of burns may be considered from two vieAvpoints: First, as to life. Second, as to the usefulness of a member, and the cosmetic effect. With reference to the latter, the terrible deformity resulting from injuries of this character, sometimes renders the patient unfit to earn a livelihood, and in the treatment all possible care should be taken to avoid such complications. Burns about the extremities are the ones, as a rule, that incapacitate patients most, and those about the face and neck are often followed by extensive cicatrization, which produces the most hor- rible disfigurement, Several things must be considered in the prognosis as to life in cases of extensive burns. First, the age of the patient. 190 SURGICAL AND AVAR NURSING Second, condition of patient's health at the time of the injury. Third, area and depth of the burned surface. Fourth, location of the burn. Cifth, resulting complications. Age of Patient.—It is a well-known fact that young children do not stand burns Avell, as they are particularly liable to the numerous secondary visceral complications Avhich are frequent sequela of burns, and are especially ill calculated to resist them. Thoracic and cerebral complications in children are out of all proportion, even in slight burns, to that of grown people. The aged are likewise affected and resist these injuries poorly, hence the prognosis in both is grave. Health of the Patient.—Those patients who have been burned and Avho are suffering from tuberculosis, syphilis, gout, nephritis, or any constitutional disease Avhich tends to lower their resisting power, Avill stand injuries badly, as any of the above mentioned complications may materially affect the outcome of a case. Alcoholics are prone to succumb after burns, as their poAvers of resistance are lessened, and are more liable to visceral complications than nonalcoholics. Area and Depth of Burned Surface.—It has been said that if one third of the body area Avas burned, the chance of recovery is slight. The author had a man burned over considerably more than half of his body, Avho made a complete recovery. It sometimes happens that small areas are folloAved by death due to shock and other complications; and when large areas of the body surface have a burn of the first degree, the shock and pain, together Avith the kidney complications, which are apt to folloAV, render the prognosis doubtful. WAR NURSING 191 Location of Burn.—Burns of the chest are of all burns the most fatal. Particularly is this true Avith children and old people. Burns of the neck may be folloAved by laryngeal inflammation and edema of the glottis, and those of the face and head by erysipelas and cerebral involvement. When located on the limbs and back, where the skin and muscles are thick, they serve to pro- tect the adjacent viscera and are less fatal. Resulting- Complications.—Many of the complications folloAving burns have been referred to in the foregoing; hoAvever, such complications as cerebral, visceral, sepsis, and kidney lesions are probably the most important, and in a case Avhere any of these arise, the prognosis should be extremely guarded. Treatment.—It can be readily appreciated that pa- tients suffering from extensive burns require the most sedulous attention on the part of the attending surgeon to procure healing of large areas and to prevent if pos- sible any deformity, to support the patient's strength, and to meet Avith intelligent treatment any threatened complication that may arise. Many remedies have been suggested, some of Avhich possess real virtue, Avhile others are of no value Avhatever. Ficric acid, used extensively by the French surgeons in strengths of 1:50 to 1:100 by moistening a piece of gauze and placing it over the site of the burn has given good results; this, hoAvever, in the hands of many sur- geons has given no better results than other less objec- tionable remedies, as it imparts a yelloAV stain Avhich is hard to remove and it has been knoAvn to produce car- boluria. A solution of Epsom salts applied on gauze and Kept moist, is most useful, as it relieves pain, reduces in- flammation, is nontoxic, is cleanly, and is easily obtained. 192 SURGICAL AND AVAR NURSING The continuous bath of either normal saline or sodium bicarbonate has been especially useful, this method be- ing both simple and efficacious. Alcohol placed on a fresh burn of the first degree Avill relieve pain and inflammation in a remarkably short time. Within the last three years, there has been introduced to the profession a method Avhich is as unique as it is useful. It is the method of applying fresh amniotic membrane to the burned area. All cases in Avhich this treatment has been used Avere burns of the second and third degree, and under the usually accepted methods of treatment, by skin grafts, etc., Avould have entailed more suffering, Avould have been more difficult to dress, and last but not least Avould have necessitated a much longer stay in the hospital. The method is as foIIoavs : The amniotic membrane from a healthy placenta is procured, the membrane cut in strips of sufficient size to cover the burned area, the inner side of the membrane is applied to the denuded surface, the Avhole surface is then covered Avith a mixture of paraffine, beesAvax, and castor oil. The paraffine and beeswax are melted, and enough castor oil is added to make it fluid ; this is applied with cotton applicators or pledgets of cotton on tooth- picks, using a fresh one each time. The dressing is changed on the second or third day Avhen a similar one is applied. Those Avho have not used this method will be surprised Iioav quickly a large surface can be covered Avith healthy skin. It might be stated that after the dressing has been removed, the surface should be gently irrigated Avith normal saline solution, care being taken to not disturb the islands of epithelium. Before using, the membrane should be thoroughly cleansed of all blood and serum, WAR NURSING 193 and it should be positively knoAvn that the woman from Avhom it is obtained is free from disease. The applica- tion of the Avax dressing should be smooth so as to ex- clude all air. Perhaps of all that has come to us from abroad, the treatment of burns seems to be one of the best things so far. The burns in this Avar haA^e been so numerous and extensive, from the nature of the explosives used, that some expedient had to be devised that would hasten the healing of large areas. They claim for the paraffine method the folloAving: That it is easy of application. That it relieves pain promptly. That it heals large surfaces denuded of skin in an incredibly short time. That it produces a soft and pliable skin. The method consists in spraying a mixture of resin and paraffine, AAThich has been melted, over the raAv sur- face and covering this with a thin layer of sterile absorbent cotton over AAdiich the mixture is applied again. This is peeled off each day and a neAV dressing of the same mixture is applied until the Avound is healed. When the wounds are ready for this treatment they are dried by means of an electric hair drier. This method was first used by a French surgeon (Dr. Barthe de Sandfort) Avho lays great stress on the particular kind of paraffine and the method of its preparation. Most surgeons are of the opinion that the paraffine and resin possess no curative value, but the merits lie in the proper application. It should be melted and maintained at 70° (\ Avhile being applied. It is sprayed on the surface by means of an atomizer, care being taken not to let it get on the sound skin, as it produces, at this temperature, some pain. It can not be applied successfully with a 194 SURGICAL AND WAR NURSING brush, as this seems to produce pain, and the surface can not be evenly coated. Fig. 113.—Caldwell's paraffin sprayer. Fig. 114.—Hamilton's hot-air douche used for drying the burned surface preparatory to receiving the paraffin. There have been quite a number of variations in the manufacture of the paraffine dressing and also in its AVAR NURSING 195 method of application. All have agreed that the most satisfactory Avay to apply it is with some form of spray or atomizer, as the surface is not only unevenly coated but some pain is produced Avhen the application is made Avith a brush or cotton sAvabs. Stanolind Surgical Wax made by the Standard Oil Company has given good results. It is applied by means of a sprayer after the Avound has been thoroughly cleansed and dried. Shell Shock This peculiar condition is produced by the bursting of high explosive shells close to the soldier, causing a rare- faction of the air in his immediate vicinity. The con- dition is one that the nurse will quite often see, and if she is skillful in handling nervous and hysterical pa- tients, she should succeed admirably Avith patients suf- fering from shell shock. In many cases, there is no evidence of the patient's having been Avounded, as no mark on his body exists, still he is severely shocked. This condition is seen mostly in those who have an unsteady nervous system, probably from heredity. Shell shock may vary in intensity from being slightly dazed to a condition of profound unconsciousness. The man may Avalk to the nearest dressing station in a dazed condition. He nearly ahvays has some disturbance of the special senses; as, his vision is usually blurred and photophobia is present in many cases, his taste and smell are both affected, he can not articulate well, and deafness is frequent in patients suffering from shell shock. The treatment of these cases is usually passed up to the neurologist, though the surgeon sees many such cases. The patient should be put to bed for several Aveeks; he 196 SURGICAL AND WAR NURSING should be assured he will recover; the nurse should be tactful in conversation with him, and at all times im- press upon him that both the surgeon and herself thoroughly understand his ease, that many others in a similar condition have recovered, and so will he. The use of electricity, nourishing food, and removal so far behind the lines that he will be completely out of sound Of the guns—all these measures tend to bring the soldier back to normal. In cases where there is any cardiovascular disturbance, the proper treatment will of course be prescribed by the surgeon in charge. The nurse should exhibit the greatest amount of pa- tience, as the convalescence in these cases is, as a rule, long. Trench Diseases Trench foot is a condition caused by standing in trenches that contain water for a considerable length of time. It is thought to be parasitic in origin. There is usually swelling, redness, and a prickly sensation. The treatment consists in placing the patient in bed, mild antiseptic lotions should be applied; it has been found in some of the German hospitals that a solution of sul- phate of copper has been very efficacious. Trench frostbite is also produced by long exposure in the trenches in Avhich there is Avater. The condition resembles, to a certain extent, the frostbite seen in civil life. The treatment is practically the same as that of frostbite. Gas Asphyxiation Perhaps of all the diabolical things invented by the Germans to destroy life since the Avar began, the asphyx- iating gases used first by them are the most insidious as well as the most deadly. AVAR NURSING 197 Asphyxiating gas Avas first used by the Germans dur- ing the second battle of Ypres in 1915. Then, the gas used could be more quickly detected than that used at the present time, and Avhen the alarm Avas sounded, the men usually had time to put on their gas masks, and take all necessary precautions against it. At present, the gas is contained in a shell from which it is liberated.. The "mustard gas" as it is called, has a pungent odor, and so irritant is it that soldiers passing over ground that has been moistened Avith the liquid contents of the shell AAThich in turn generates the gas, have been burned' by it. The exposed parts are affected most, such as the face, hands and arms. The soldier may not know for some hours that he has been gassed unless he has in- haled quite a quantity, in which case the effect is im- mediate and profound. The milder cases suffer only from a slight burn of the skin over the exposed parts, lacrimation, conjunctivitis, laryngitis, and bronchitis; these cases, Avith proper care, recover quickly; hoAvever, those of the more severe type not only have those symptoms enumerated above, but usually haATe bronchopneumonia with bloody or puru- lent expectoration, and in some pulmonary edema. In all cases, there is more or less pain in the region of the stomach and difficulty in breathing. The treatment of gas poisoning Avill, of course, be directed by the physician in charge; and A\Thile nothing of a specific nature can be done, they can be relieved by the use of opiates such as heroin or codein. These drugs not only relieve the severe pain, but allay to a con- siderable extent the cough Avhich is ever present. The patient should be in dry quarters, and inhalation of oxygen given. The complications should be treated accordingly, should any arise. GLOSSARY Names of Operations and Diseases Commonly Met with in Surgical Nursing" Appendectomy. The removal of the appendix vermiformis. Appendicitis. Inflammation of the appendix. It may be acutely inflamed and subside, or may get progressively worse and become gangrenous and rupture, or it may be chronic, in which case the patient has usually had more than one attack and there are always present adhesions. Carcinoma. Commonly called cancer; carcinoma is a malignant growth. Cervicitis. Inflammation of the membrane lining the cervical canal. Cholecystectomy. Excision of the gall bladder. Cholecystotomy. Opening of the gall bladder by means of an in- cision through the abdominal wall. Cholecystitis. Inflammation of the gall bladder; may be acute or chronic, and is frequently associated with gallstones. Colostomy. This is an operation by which an artificial anus is made by making a large opening into the colon. Cystitis. Inflammation of the bladder. Embolus. An embolus is the detached portion of a clot of blood; and while an embolus may lodge in any vein, it is commonly found in the femoral or the pulmonary vein. Empyema. This is an accumulation of pus in the pleural cavity, which is removed either by aspiration or the resection of a portion of one or more ribs. Endometritis. Inflammation of the membrane which lines the uterine cavity. It may be acute or chronic in character. Enterorrhagia. The discharge of blood from the bowel. Epistaxis. Xose-bleed. 198 WAR NURSING 199 Extrauterine Pregnancy. In this condition, the pregnancy takes place outside the uterine cavity, commonly in the tube or in the tube-ovarian; that is, between the tube and the ovary. Tibroid. This is a tumor made up of fibrous tissue and is not primarily malignant, though it may ultimately become so. Eloating Kidney. This is a condition where the attachment of the kidney to the back has become elongated; it may be uni- lateral or it may be bilateral. Fracture. Fracture is the breaking of a bone; it may be a simple bending and is then known as a green stick fracture; or it may be a break, and is then called a simple fracture; or it may be comminuted—that is, where the bone is broken into several pieces; or it may be a compound fracture where the bones protrude through the skin or where there is an open wound leading to the site of fracture. Gastroenterostomy. Operation of making an opening between the stomach and intestines. Hematemesis. The vomiting of blood. Hematuria. The passing of blood with the urine; the blood may be from the kidneys, ureter, bladder, prostate, or urethra. Hemorrhoids. Hemorrhoids or piles are enlarged veins in the lower portion of the rectum; they may be external and pro- trude from the anus, or located above the sphincter muscle, in which case they are called internal piles or hemorrhoids. Herniotomy. An operation for the cure or closure of a rupture. Hysterectomy. Removal of the uterus; when done by opening the abdomen, it is called abdominal hysterectomy; and when re- moved through the vagina, it is called vaginal hysterectomy. Ilio-sigmoidostomy. This is an operation intended to short circuit the fecal current by making an anastomosis between the ilium and sigmoid. Laparotomy. An operation on any of the organs within the ab- dominal cavity by an incision through the abdominal wall. Laryngectomy. An operation for the removal of the larynx. Laryngotomy. An operation for opening the larynx by means of an incision. Lipoma. A tumor composed of fat. 200 SURGICAL AND AVAR NURSING Lithotomy. The operation for the removal of stone in the blad- der by cutting. This was done by the older surgeons almost exclusively through the perineum. Lithotrity. The crushing of a stone in the bladder by means of an instrument called a lithotrite which is inserted through the urethral canal. Metritis. An inflammation of the parenchyma of the uterus. Myomectomy. An operation for removal of the myoma, usually from the uterus. Nephrectomy. Excision of the kidney. Nephrolithotomy. Operation for the removal of a stone in the kidney. Ovariotomy. The removal of one or both ovaries. Perineorrhaphy. The repair by suture of the perineum after lac- eration caused by the passage of the child during childbirth. Periostitis. Inflammation of the periosteum covering the bone. Peritonitis. This is an inflammation of a portion of the perito- neum and is called local peritonitis, usually found in the pelvis, or it may involve the whole of the peritoneum, in which case it is spoken of as general peritonitis. The char- acter of peritonitis may be simple, acute, or septic. Prolapse of the Rectum. A downward displacement of the rectum. Prolapse of the Uterus. This is a downward displacement of the uterus and its appendages. Rectal Fistula. This is an opening from the lumen of the bowel into the tissues, called a blind fistula; or, it may extend from the lumen of the bowel through the tissues and open on the outside, this being known as a complete fistula. Rectovaginal Fistula. This is an opening through the rectum and vagina. Salpingitis. Inflammation of the Fallopian tube. Three varieties are commonly met with; namely, hydrosalpinx, haematosal- pinx, and pyosalpinx. In hydrosalpinx there is dropsy of the tube; haematosalpinx is an accumulation of blood or hemor- rhage into the tube; pyosalpinx or pus tube is, as the name indicates, a collection of pus in the Fallopian tube. Salpingo-oophorectomy. This is the operation for excision and removal of the Fallopian tube and ovary. WAR NURSING 201 Sarcoma. Sarcoma is a destructive malignant growth. Suprapubic Cystotomy. The removal of stone or tumor in the bladder by cutting through abdominal wall above the pubie bone. Trachelorrhaphy. The closure by sutures of a laceration of the uterine cervix. Tracheotomy. Cutting into the trachea for the purpose of admit- ting air into the lungs. Trephining. An operation for the removal of a circular piece of bone from the skull. Vaginitis. Inflammation of the vagina; it may be catarrhal, gon- orrheal, ulcerative, or diphtheritio in character. Vesicovaginal Fistula. An opening through the bladder and vagina. INDEX A Abbreviations, 63-64 Abdomen, preparation for ex- amination of, 95 wounds of, 181 Abdominal supporters, 28 Acetone, 85 treatment for, 126 Accidents, Fourth of Julv, 157 Acriflavine, 17.1 Adhesive plaster, use of, 28 Aluminum acetate, 58 Alcohol, 5S Albumen, test for, 84-8.1 Amniotic membrane, in treat- ment of burns, 192- 193 Anemia, 86 Anesthesia, general considera- tion of, 143 history of, 143-145 local, with cocaine, 151, 152 preparation of patient by nurse for, 146 with chloroform, 151 with ether, 150-151 Anesthetic, administration of, 146-147 ethvl chloride as a local, 152 novocaine as a local, 152 things needed during its ad- ministration, 148-150 Anesthetics, general or local, 145-146 Antiseptics, 173 Applications to body, 87 Asphyxiation, by gas, 196 Aspirin, 60 Atropine, 60 B Back rest, use of while patient is in bed, 55 Macteria, 162 I'acterial examination of wounds, 172-173 Balkan frame, 177 Bandages: abdominal, 28-29 cotton, flannel, linen, or gauze, 24 materials used in making, 24 plaster of Paris, crinolin, silicate; of sodium, 24 uses of, 24 Velpeau, 26 Bath, of patient, 132 Bayonet wounds, 166 Bed, Fowler position of, 55 fracture, 53 making, 50 pan, 37 position of, for patient in shock, 55 Beds, 50 Bergonie, telephone of, 168 Bier's hyperemic treatment, 92 method of, 92-93 Bichloride of mercury, 56 Bladder, preparation for ex- amination of, 107 Blood examination: general consideration of, 86 hemoglobin in, 86 red cells in, 86 white cells in, 86 Blood pressure, conditions that cause a low, 72 INDEX 203 Blood pressure—Cont'd. conditions that cause a rise of, 72 conditions that cause a var- iable, 72 during operation, 70 in healthy persons, 70 method of taking, 70 surgical significance of, 71 Boric acid, 59 Book, order, 124 Bondet, depilatory of, 105 Bowels, movement of, follow- ing operation, 129 Bone wax, use of, 179 Brilliant green, 173 Bromides, 60 Buck's extension. 177 Bullet wound, 166-167 Burns, 188 prognosis of, 189 treatment of, 191-195 C Calomel, 61 Carbolic acid, 57 Carrel-Dakin, 167-168 treatment, object of, 171 Castor oil, method of adminis- tration, 62 Catgut. 43 Cathartics, before operation, 102 saline, 61 Catheter, care of bv nurse, 137 kinds of, 80 male. 37-43 Catheterization, chances for infection dur- ing, 81 following operations, 127- 128 general consideration of, 79 of male patient, 81 preparation of nurse's hands, SO preparation of patient for, 80 resistance sometimes encoun- tered in male during, 81 tray for, 80 Cautery, actual, 92 Cauterv, Paquelin, 91-92 Chest:' preparation for examination of, 94 wounds in, cause of death, ISO wounds of, 179 Chloroform anesthesia, 151 Uhlumskv's solution, 185 Cocaine,'61, 151-152 Codeine, 59 Cold applications, 90 length of time, 91 Colotomy, nursing after oper- ation for, 136 Complications, postoperative, 138 Contusions, 154-155 Counterirritants, 91-92 Cradle wire, 53-55 Creolin, 58 Criticism of nurse bv public, 23 Cuts, 155 D Dakin solution, application of, 170-171 Depilatories, use of, 104-105 Depilatory, Bondet's, 105 Dichloramine-T, 173 Diet, before operation, 101- 102 postoperative, 130-132 Dislocations, 154 Dorsal position for examina- tion, 97 Douche, porcelain enameled pan for, 79 Douching, method of giving vaginal, 78-79 of ear, 78 of nose, 78 of vagina, 78 Dressing of wounds, 171-172 Dressings, sterilization of, 48 204 IX DEX Drugs, 59 administration per rectum, 62 aspirin, 60 atropine, 60 bromides, 60 calomel, 61 castor oil, 61 cocaine, 61 codeine, 59 digitalis, 60 heroin, 59 morphine sulphate, 59 novocaine, 61 salts, 61 strychnia, 60 time of administration, 62 Duties of nurse, 22 E Empvema, nursing cases of, 134-135 Enema, general consideration of, 74 method of giving, 74-75 nutrient, 77-78 things needed in giving, 74 used to evacuate bowels, 76 Erysipelas, 142 Ether, administration of, 150- 151 Ethyl chloride, 152 Examination: of abdomen, preparation of patient by nurse for, 95 of blood, 96 of chest preparation of pa- tient by nurse for, 94 of patient at office, 94 of urine, 96 preparation of patient for, 94 preparation of patient for gynecologic, 96-97 preparation of patient for, in shock, 99 F Fainting, 155-156 Feet, preparation for oper- ation, 106 Fehling's test for sugar, S5 First aid, rendered by nurse, 153 Fracture, nursing care of, 135' Fractures, 153-154 nurse's duties in trealment, 176 treatment of compound, 176- 177 treatment of simple, 176-177' types of, 1 75 Frost bite, 156-157 G Gall bladder, nursing case af- ter operation on, 136 Gas asphvxiation, treatment of, 197 gangrene, 184 infection, 184 symptoms of, 185 treatment of, 185-186 pains, treatment- of post op- erative, 128 Gvnecologic, examinations, 96 positions, 97-98 H Hands, preparation for oper- ation, 106 Harrington, solution of, 104 Head, injuries of, 178 Heat: application of dry, 89-90 employed to combat shock,. 88 in form of poultices, 89 method of application, 88 Hemoglobin, 86 Hemorrhage, postoperative, 138- 139 symptoms of, 139-140 treatment of, 139 Heroin, 59 INDEX 205 Hirtz, compass localizer of, 168 History sheet, 95 Holmes' poem, 19 Horizontal position for exam- ination, 98 Hot air, method of application of, 90 Hot fomentations, 87-S9 Hypochlorite of soda, 167 Hypochlorite solution, objec- tion to, 173 I Ice cap, 90 cloths, 91 coils, 90 Immunity, 162-163 Injuries of head, 177 treatment of, 179 Instruments, 30 artery forceps, 33-35 bone forceps, 41 cutting, 29-31 dressing forceps, 35-39 grooved director, 41 intrauterine douche, 35-39 ligature carriers, 43 needed for gynecologic ex- amination, 98-99 needle holder, 31 needles, 40-43 periosteal elevator, 41 retractors, abdominal, 32 silver probe, 36 special clamps, 34-36 speculums, .".6-38 spoon curette, 42 sponge forceps, 37 tissue forceps, 31-32 trephine, 41 trocar and cannular, 36-40 uterine curette, 42 uterine dilator, 42 uterine sound, 35-39 vulsellum forceps, 35-40 Iodine, tr. of, 58 K Kelly pad, 38 Knee-chest position for exami- nation, 98 L Lavage, of stomach for post- operative nausea, 125 Leggings, for patient during operations, 107 Leucocytosis, 86 Lithotomy position for exami- nation, 98 Lotions, 91 Lugol 's solution, 58 Lvsol, 58 M Measure, apothecary, 63 Mereiere, solution of, 185 Morphine sulphate, 59 Mouth, preparation of for op- eration, 106 Murphy drip outfit, 75 Mustard, 91 Mustard gas, 197 N Nausea, postoperative, 124-125 Novocaine, 61, 152 Nurse: attention to wounded by, 164- 165 clothes of, 21 debt to patient, 22 debt to surgeon, 22 demands on, 159-160 duties of. in head injuries, 178 duties of, in treatment of shell shock, 196 duty of first assistant, 114, 115, 117 duty of head, 114 duty of second assistant, 117, 118, 119 health of, 20 hours off duty, 22 manner and temperament of, 21 206 INDEX Xurse—Cent 'd. postoperative orders to, 124- 125 social status, 1S the duties when two are nursing a case, 22 the five senses of, 21 the surgical, 20 toilet of, 20 Nurses, duty during operation, 113, 114 Xursing, as a profession, 17 in special cases, 133 after colotomv operation, 136 after operation on gall bladder, 136 after vaginal hvsterotomv, 136 empyema, 134, 135 fracture, 135 lacerated perineum, 133 where there is pus, 137 0 Operation, cathartics before, 102 diet before, 101, 102 preparation of pa tient for, 100, 101 skin prepared before, 102- 104 Operations, preparation for in private homes, 120 Opiates, use of, 60 postoperative, 127 Orders, postoperative, to nurse, 124, 125 Pad, Kelly's, 39 Pain, due to gas following op- eration, 128 use of opiates for postopera- tive, 127 Paquelin cautery, 91-92 Paraffine in treatment of burns, 1S5, 193-194 Patient, care of, while in bed, 53 sitting up after operation, 132 Perineal laceration, nursing cases of, 133 Peritonitis. 142 Plaster of Paris, 24 Pneumonia, 142 Polycythemia, S6 Postoperative, care of patient, 122-124 complications, 13S regarding temperature, 129 shock, 140 Position, dorsal, 97 dorsal elevated, 97 horizontal, 98 knee-chest, 98 lithotomy, 98 Sims', 98 standing, 97 Trendelenburg, 98 Positions, gynecologic, 97-98 Potassium permanganate, 58 Poultices, 89 Preparation of patient for op- eration, 100, 101 Proctoclysis, 76 Proflavine, 173 Puddling of wound, 171 Pulse, character after hemor- rhage, 69 character and size of, 68-69 counting of, 68 during and after operation, 69 Punctures, 155 Pus cases, nursing of, 137 R Rectum, preparation for opera- tion, 107 Red Cross Society, 158-159 Respiration, following abdomi- nal distention, 73 following hemorrhage, 73 general consideration of, 73 record of, following opera- tion, 73 INDEX 207 Respiratory failure, treatment of, 140 Room: anesthetizing, 147 doctor's wash, 109 location of operating, 108 modern operating, 108-109 of patient, preparation for private homes, 120, 121 preparation for operation in private homes, 120. 121 preparation for patient af- ter operation, 122 recovery, 109 sterilizing, 109 things needed in operating, 109, 110, 112 S Saline solution, Sir Almroth Wright's, 173-175 Shell shock, 195 treatment of, 195-196 Shell Avound, 166 Shock, causes of, 140 examination of pi tient in, 99 postoperative, 140 treatment of, 141, 142 Shrapnel wound, 166 Sims' position for examin- ation, 98 Skin, preparation for opera- tion, 102-103-104 Snake bite, 156 Solution, 56 alcohol, 58 aluminum acetate, 58 application of Dakin, 170- 171 bichloride of mercury, 56 boric acid, 59 carbolic acid, 57 Chlumsky's, 185 creolin, 58 dichloramine-T, 173 Harrington's, 104 hypochlorite, 167 iodine, Tr. of, 58 Lugol's, 58 lysol, 58 Merciere, 185 normal salt, 59 potassium permanganate, 58 strychnia, 60 Sounds, male urethral, 43 Sprains, 153 Stanolind surgical wax, 195 Standing position for exami- nation, 97 Sterilization, 44 chemical of wound, 170-171 of dressings, cotton, etc., 48 of enamelware, 47 of rubber instruments, 46 of small instruments, 44-46 of towels, sheets, etc., 47 of urinals, bed pan, and room, 49 methods of, 44 Sugar, test for, 85 Suture material, 43 Syringe, fountain, 36-41 hypodermic, 37-42 small rubber, 42 T Table, preparation of operat- ing, 113 Temperature, 65 after operation, 66 after shock or hemorrhage, 67 charting of, 68 during convalescent period, 67 in septic cases, 67 methods of taking, 65 recording of postoperative, 129 variation of, 66 Tetanus, 142 nurse's duties in case of, 186 treatment of, 186-187 208 INDKX Tinker's method of prepara- tion of skin, 104 Treatment, Bier's hyperemic, 92 Carrel-Dakin method of wound, 168-171 of abdominal wounds, 1S2- 183 of chest Avounds, 180-1S1 of fractures, nurse's duty, 176 of head injuries, 179 Trench foot, 196 frostbite, 196 Trendelenburg position, 98 Tourniquet, 43 U Urinal: female, rubber, to be worn, 3S female, white enamel, 37 male, rubber, to be worn, 38 male, white enamel, 37 Urine: acetone in, 85 albumin, test for, sl-85 Fehling 's sugar test for, 85 general consideration of, 82- 83 instruments used in testing, 84 passage of, following oper- ation, 127-128 retention of, 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