The Operating Room INSTRUCTIONS FOR NURSES AND ASSISTANTS ST. MARY’S HOSPITAL ROCHESTER ) MINNESOTA V WITH 144 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1924 Copyright, 1924, by W. B. Saunders Company MADE IN U. S. A. PRESS OF W. B- SAUNOERS COMPANY PHILADELPHIA PREFACE This manual is a development of “Notes for Operating Room Nurses, St. Mary’s Hospital, Rochester, Minnesota,” first printed in 1920 for use in St. Mary’s Training School for Nurses. In the present volume the subject matter has been revised and extended. The original purpose, however, has been kept in view, to provide the students of St. Mary’s Training School with a practical guide in operating room technic as used in St. Mary’s Hospital. The methods described are those actually in use, most of them having been tested by long and successful experience. New inventions and discoveries that afford real improvement in surgical technic are readily adopted at St. Mary’s Hospital as in other progressive hospitals, hence the details of the technic change, and no manual can be a stereotyped guide in all particulars for any great length of tune. St. Mary’s Hospital, Rochester, Minnesota April, 1924 13 CONTENTS PAGE Introduction 17 Equipment of Operating Room 23 Procedures Preliminary to Operation 25 During the Operation 32 After the Operation 33 Preparation of Patient for Abdominal Operation 34 Preparation of Patient for Kraske Operation 57 Preparation .of Patient for Operation on the Kidney 60 Lithotomy Position 63 Preparation of Patient for Operations on the Thorax 67 Preparation of Patient for Breast Operation 71 Preparation of Patient for Operations on the Neck 74 Craniotomy with Osteoplastic Flap 79 Laminectomy 85 Bone Operations 86 Other Miscellaneous Operations 98 Technic of Blood Transfusion 102 Anesthesia 104 Miscellaneous 107 Solutions 114 Drains 118 Sutures 120 Intern’s Dressing Basket 121 Trays 123 Sets of Sterile Linen 126 To Operate Autoclave 127 Index of Illustrations 128 Index 157 IS Instructions for Nurses and Assistants in the Operating Room INTRODUCTION While the general principles of operating room procedures are the same in all hospitals, there is much variance in minor details of method and technic. Many hospitals have perfected methods which yield splendid results to themselves, although they are entirely unsuited to other hospitals doing a different class of work, differently managed, or differently situated. Each institution must, to a certain extent, develop methods suited to its special requirements, but it may gain much by studying the methods successfully followed in other institutions. Even in the various operating rooms of St. Mary’s Hospital, the technic varies slightly according to the preference of the surgeon, or the character of the work. The methods employed at St. Mary’s Hospital are presented merely as methods that are being successfully used in a hospital doing a large amount of surgical work. They have the merit of simplicity, which, in turn, implies economy in supplies, econ- omy in time, and economy in the number of employees. “The greate rthe surgeon, the fewer the fads and instruments,” is more than half true. The central thought at St. Mary’s Hos- pital is to get the patient well with as little loss of time as pos- sible; whatever contributes to this end is adopted; whatever does not, is eliminated. Good technic is not measured by the number of assistants and nurses in the operating room, any more than is asepsis by the pile of soiled linen. The only persons in the operating room arena during an operation at St. Mary’s Hospital are the patient, 17 18 INSTRUCTIONS FOR THE OPERATING ROOM the surgeon, one first and two second surgical assistants, the operating room supervisor, the anesthetist, the sterile and the non-sterile nurse. The clinic, wearing white cover-alls, occupies the gallery. It is both unwise and unnecessary to surround the operating room with such an air of mystery that the patient is led to think it is a horrible sight and that he cannot be taken there until after Fig. 1.—Surgical pavilion, St. Mary’s Hospital. he is asleep. The modern operating room is interesting and at- tractive, and a view of it will be an encouragement to the patient, especially if he expresses a wish to see it. At St. Mary’s Hospital the anesthetic is administered in the operating room and the preparation of the operative field goes on at the same time. This saves from twenty to thirty minutes on each operation. The operating rooms in St. Mary’s Hospital are located on INTRODUCTION 19 the fifth floor of the surgical pavilion. Ten rooms, similar in all respects, are grouped in pairs with a wash-up and sterilizing room for each pair. Each operating room is two stories high, the arena •Nomlngl&tukl Of- Room? • •V." -Visitors Waiting .Loom. •?.U- -Soile.0 LiNtn •T. ■ Toilit •stu/ -Sistlh.? Looml Loom S.' -STtNOQLAPlILt^ •C>' -aLoetT •A.U Assistants Locknl Looms CL, Consultatign Loom. ■b.‘ -bAtSSINO LOOMS 'Mm -blue Loom •h.S: -bAC.T STE.LILIZINO LOOM * btM* -b[.MONSTA,ATION LoOM 'b.L. -bt-D LOOMS •T • -Flugloscopio Loom ■FL' -Fan Loom. .•U.a -House, Otostl 'IbL' -InTW.HE.5 btDILQOMS. *I.L.* -iNTtuts Loonxl Loom. •ILL: -UiTtANLS Living Loom. •kj. -Litohe-n. *L: -Lanoa-atoA;/ •G.U -GE.N5A.AL. tibOLATOL/.. •L.L. -Loclll Loom' •M.o- -Main Offi.ce,. ■n.l: -Nuasls Lgclll Loom. •N.W" -Nurses WgLl Loom •O' -Gffi&e,. •0.L. -OPLAAT1NG LOOM . •RM.' -Patients Waiting Rooms-Meh •FW.' -Fatit-NTS Waiting Looms-Women ■Fq.' -Private, Gffiol •F* -FnoT©Giunit,A.s Looms. •L' -bAbiGOLAPmo Loom. •S.L StlLuZing Loom 'l ie -Instilumliit Loom ■TIL! -TILtATMLHI LOOM •ML -Macniml Loom Fig. 2.—Fifth floor plan. is 30 feet square; the floor is of gray flint tile in 2 inch units, wainscots, of tile, are 7 feet high; the seat banks and floor of gallery are of terrazzo, leaning rails are of polished white metal; INSTRUCTIONS FOR THE OPERATING ROOM 20 the gallery accommodates 100 persons; the visitors’ entrance is on the sixth floor (Fig. 2). NOMtNGLATUML Of F\OOM? E"-lNTLCNES bttCOOMS IT - iNTECNtS ToiLLT ILE"-Intlmls Living Eoom L. -LlDEtCY M. - Museum ML" - Mens Lgccec Exxim ' MLO"-Muslum And Lidmcy OrricL TRj -EexTAMIION EcjCiM S" -Studios SC -Stocl E^oom Sil -SyLIGHT SL" -Soiled Linen I" -.JoiLET UOC'-llrrLC Her Or Oplmting E.oom lb -Visiting Doctors Waiting Edom WbW.'-tontN Doctors Waiting Coom w L* - Womens Locelc Loom Fig. 3.—Sixth floor plan. All the operating rooms have zenith light, and all but three have north light. The windows are double, the outside one is of plate glass and the inner, of polished pyramid glass. They INTRODUCTION 21 are equipped with motor driven light-proof shades with switch Fig. 4.—Amphitheater. control in the arena. Small casement windows give access to an area 2 feet wide between the sashes, where the heating coils, are 22 INSTRUCTIONS TOR THE OPERATING ROOM located, and to the cleaning balconies outside. Each room has silent signal connection with the bulletin board in the visiting doctors’ waiting room and with the corridors of the sixth floor, to indicate the operation in progress (Fig. 3). The amphitheater occupies the center of the north wing. It is lighted from the north by a glass area of 225 square feet. The gallery seats 300, the farthest seat being 26 feet from the oper- ating table; the visiting doctors’ entrance is on the sixth floor. The amphitheater is equipped with a motion picture and stere- opticon booth for clinic use. The sterilizing room is to the right and the instrument room to the left of the arena (Fig. 4). EQUIPMENT OF OPERATING ROOM Balfour operating table Sink, with pedal valves and aspirator connections Stools Low square blocks Fig. 5.—Operating room. Sterile table Basin stand Roentgen-ray plate History rack Irrigator 23 24 INSTRUCTIONS FOR THE OPERATING ROOM Circular lights Electric cautery with hairpin point and cutting point Basket for soiled linen Pail for sponges Glass shelf with alcohol, Harrington’s solution, hand lotion, and finger files Fig. 6.—A sterilizing room. Equipment: autoclave, two sterile water tanks, two small boilers, large boiler, gas plate, table, instrument case, and hopper. Towel racks Drum for gowns Drum for instruments, towels, and sleeves for cautery (these drums are especially made by the Scanlan-Morris Company of Chicago). PROCEDURES PRELIMINARY TO OPERATION The surgeons begin their work at 8:30 a.m. and continue until the schedule of operations for the day is completed. Emer- gencies, of course, have the right of way at all hours. The sched- ule for the day is sent to the hospital the preceding afternoon so that preparations can be made accurately in respect to the kind and amount of material required. In the evening the autoclave and boilers are prepared for the next day’s work. In the large boiler are placed: Pan and tray used on sterile table to receive instruments Two basins to hold square packs Four or more packages of square packs One long pack or more. In the small boiler are placed: Basin for holding instruments Safety pins and Jones clips Pan containing lifting forceps. Water is run into the boilers the following morning. Basins are wrapped separately in cloth (remnants of worn out sheets and gowns will do for this purpose) and sterilized in the autoclave for one hour. When basins are taken out, surgeons’ gowns for five cases are put in the drum and sterilized for one hour. The drum is then removed to the operating room, and the gowns are taken out next morning as needed. After the drum is removed the following are placed in the autoclave: Laparotomy sets Breast sets Goiter sets Dressings Sponges Towels 25 26 INSTRUCTIONS FOR THE OPERATING ROOM Large and small specimen pans Alcohol bowls Iodin bowls Square pan containing gauze for iodin and cotton for pledgets Covers for screen Sleeves for cautery Large curtain for operating table Small sheet for table Covers for faucet. These are sterilized for one hour and unpacked the next morning as required. Extra laparotomy sets, breast sets, goiter sets, towels, dress- ings, and specimen pans are kept sterilized. If not used within a certain time, they are resterilized. Gloves Gloves are all tested, and if necessary, mended. They are then boiled right side out for fifteen minutes, hung up to dry, turned, powdered on the wrong side, and turned right side out. Next they are sorted as first, second, third, and fourth class; the first class, for surgeons, are unmarked; the cuffs of the second class are turned back two folds to mark them for the first assistant; the cuffs of the third are turned back one fold to mark them for the second assistant; the remainder are marked for the nurses by inserting the cuff of one glove in the cuff of another. Gloves are put together in packages of six pairs and are boiled fifteen minutes as needed. Setting up a room At 6:30 a.m. a large boiler is filled with water, and steam turned on, so that square packs may boil for one hour, or auto- claved, which may be a better plan. In the small boiler are placed 3 gallons of water, and 3 ounces of Wyandotte soda, for sterilizing instruments. At 7 a.m. the pan containing the lifting forceps is taken from PROCEDURES PRELIMINARY TO OPERATION 27 the small boiler and placed on the table in the sterilizing room. With these forceps towels are taken from the drum and the table covered. On the table are placed pins, clips, and basins, which have been sterilized in the instrument boiler. In the boiler are placed Straight forceps Short and long curved forceps Backhaus clips Retractors Long tissue forceps Fibroid hooks Tenacula, and a pan containing Scissors Pointed forceps Stomach clippers Needle holders Appendix invertors Tissue forceps Discarded forceps, marked, to be used in handling gauze for painting with iodin Pair of gloves for the sterile nurse. All are to be boiled fifteen minutes. All cutting instruments, knives excepted, are boiled ten minutes; other instruments may boil from twenty to thirty minutes. As many knives as the day’s work will require are placed in carbolic acid solution for at least one-half hour, then placed in a 75 per cent alcohol solution, or they may be placed in a sterile pan lined with sterile gauze or cotton to protect the edges of the knives, and boiled three minutes, brought to the table and placed in the 75 per cent alcohol solution. Basin stand On the upper shelf of basin stand are placed Basin with water for gloves Basin with 1 : 5,000 bichlorid for washing hands during operation 28 INSTRUCTIONS FOR THE OPERATING ROOM Square dish containing sponges, cotton pledgets, and forceps for handling iodinized gauze Alcohol Iodin. On the lower shelf of basin stand are placed Ether Scissors Razor Fig. 7.—Operating table in readiness for patient. Bottle of alcohol Bottle of iodin Adhesive Safety pins Sponges for benzin. On supply table are placed Emesis towels Hand towels PROCEDURES PRELIMINARY TO OPERATION 29 Pillow slips Anesthetists’ gauze Table covers Jackets Leggings .Sheets. Fig. 8.—Prepared sterile table. Sterile table (Fig. 8) The sterile table is draped with a sterile sheet and towels. A large curtain is attached to the rod of the sterile table with sterile safety pins; a pin is placed in the center and one at each 30 INSTRUCTIONS FOR THE OPERATING ROOM end of the upper part of the rod; Jones clips are placed on lower part of rod, one in the center, and one at each end. The non-sterile nurse brings from the large boiler the instru- ment pan and tray and two basins to receive the instruments and sterile packs; then gloves are boiled for fifteen minutes. The sterile nurse drapes the basin stand with sterile towels and places on it the pan containing sponges, cotton pledgets, forceps for handling iodinized gauze, bowl for alcohol, and bowl for iodin. With lifting forceps the non-sterile nurse brings the instru- ments from the smaller boiler and places them in a tray on the sterile table; the sterile nurse arranges and covers them with a sterile towel. The non-sterile nurse places in the small boiler Extra instruments Tubing for drains Safety pins Needles Syringes Jones clips and then places on the basin stand a sterile basin containing plain water, and another containing 1 : 5,000 bichlorid solution. In cups on table are placed Catgut taken from 5 per cent carbolic solution Silkworm taken from 4 per cent iodin solution Silk taken from 70 per cent alcohol solution. Knives are taken from the carbolic solution and placed in 70 per cent alcohol in a sterile pan until needed. The two outer wrappers are removed from the dermal, which is boiled two minutes. Extra instruments and dermal are placed in drum. Scrubbing hands Hands and arms are scrubbed with soap and water for at least ten minutes. Surgeon’s Jumbo, ivory, or green soap is used with taps of running cold and hot sterile water. An ample quantity of soap, worked into a lather, is rubbed into hands and PROCEDURES PRELIMINARY TO OPERATION 3i arms, nails are cleaned with a file, hands and arms are rinsed, resoaped, and the palms of the hands and around finger nails are scrubbed with brush or gauze; they are then rinsed thoroughly in water as hot as can be borne, carefully removing every trace of soap. Hands and arms are rinsed in 70 per cent alcohol, and the tips of the fingers dipped in 5 per cent iodin, or Harrington’s solution. Operating room schedule At 7:45 a.m. the first surgical assistant and the anesthetist come to the operating room. The first assistant scrubs for ten minutes. The anesthetist prepares ether, masks, cotton, and any other supplies she may need. The orderly telephones for patient and the nurse brings him to the waiting room. At 8:15 the surgeon arrives, and the second assistant informs the operating room staff. The first assistant brings the patient from the waiting room and introduces him to the anesthetist and nurses. The patient is assisted to the table; the anesthetist takes his bathrobe and slippers, and places them on the cart in the hall. The non-sterile nurse cleanses the operative field with 1 : 1000 iodinized benzin, and then with ether. Soap and water are used for hemorrhoid and fistula cases; for vaginal cases iodin is applied after the vagina has been cleansed with alcohol. The first assistant applies to the operative field two coats of iodin. The first coat is allowed to dry before the second is applied. (See page 35.) The assistant puts on sterile gown and applies a third coat of iodin to the operative field. The sterile nurse puts on sterile gown and gloves. The sterile nurse and first assistant drape the patient (p. 35). When the surgeon is ready to operate, the second nurse switches signal light on bulletin boards, and the clinic files into the gallery. The second assistant reads the history of the case. DURING THE OPERATION Instructions to the sterile nurse: Keep your attention fixed on the surgeon’s work. Anticipate his needs so that he will not have to ask for any- thing. Place instruments in the position most convenient to his hand. Have specimen pans ready. Have sponges open when necessary. Keep one piece of catgut on the table; when it is used, supply another if it will be needed. When the surgeon lays down the needle, put it in the holder and have it ready for him if he needs it again. Cleanse your gloves after handling anything that has been used in the operation, and after emptying the pan of soiled instruments. Use forceps in handling articles. Change sterile table after each operation. Remember that the conscientiousness of the nurse regarding asepsis is as important in saving the patient's life as is the skill of the surgeon. Instructions to the non-sterile nurse: Be accurate in whatever you do. Safety first; gain speed by repetition. Be alert to render assistance to the sterile nurse. Resterilize every instrument every time it is used. Cleanse them, boil them for ten minutes, and return them to the table.. Wash and boil every instrument inadvertently dropped. Keep perspiration wiped from the brow of the surgeon and assistants. Wash soiled square packs after each operation. Attend to boiler and keep it from boiling over. . Keep everything picked up. 32 AFTER THE OPERATION 33 Count the square packs after an operation; in laparotomies this must be done. Avoid unnecessary hurry; do not give observers the impres- sion that you are trying to attract attention. Be as quiet as possible; the mle of silence applies to your movements as well as to your voice. Use forceps in handling anything that has been sterilized. When you carry a sterilized article, hold it a safe distance from you. Do not set it down, but wait for the sterile nurse to take it from you. When a surgeon has finished his work at the operating table, unfasten his gown and press the button for the stenographer. When the assistants have finished their work, unfasten their gowns. Replenish the iodin and alcohol bowls. Replenish the supply of adhesive. Mend the gloves if any have been punctured, sort them, pair them, and put them in to boil. AFTER THE OPERATION When the surgeon has finished his work, the clinic files out. The surgeon has two second assistants who alternate at the oper- ating table. The orderly brings in the carriage for the patient and places it beside the operating table. To lift the patient, the anesthetist supports his head; the two second assistants take position opposite each other, one beside the carriage, the other beside the operating table, put their arms under the patient’s shoulders and buttocks, grasp each other’s hands, and move him easily and gently on to the carriage. One assistant accompanies the orderly taking the patient to his room, examines whether the patient’s bed has been properly warmed, sees that the patient is all right, puts him in charge of a nurse, and writes the orders for him. Meantime the other assistant and the anesthetist dress the table, prepare towels, jacket, sheet, and blanket for the next patient, and have his history at hand. The routine proceeds for the next case. PREPARATION OF PATIENT FOR ABDOMINAL OPERATION A body jacket is put on the patient over the nightgown or nightshirt. A towel is placed over the pubic region and the nightgown or nightshirt tucked under the jacket. A strap is fastened over the thighs. The patient’s wrists are strapped Fig. 9.—In readiness for a laparotomy. at his sides, pillows are placed under his elbows, and his feet and ankles are covered with a blanket; this is covered with a sheet, and the instrument tray is placed just distal to the operative field (Fig. 9). 34 PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 35 The Trendelenburg position is used in operations on the uterus and adnexa, bladder and ureters, sigmoid and cecum. The patient is placed and draped as for other abdominal oper- ations, except that the ankles are strapped at the foot of the table. No strap is used over the thighs, and the instrument tray is fastened in the special holder for the Trendelenburg position. GENERAL DIRECTIONS The skin is cleaned with benzin and ether and one coat of 4 per cent tincture of iodin applied. Four sterile towels are placed around the site of the incision, one above, one below, and one on either side, and a laparotomy sheet with an opening to work through, is placed over the patient. A small sheet is placed above the operative field, passing over the screen and attached to it with two Jones clamps. Another coat of iodin is applied and the towels and laparotomy sheet are held in place by four Backhaus clamps, one clamp being placed at each corner of the exposed area of skin, the teeth of the clamps passing through the towels, the laparotomy sheet, and skin. The incision is carried down through the muscle and the surgeon ties off the bleeding points. While he is doing this the second assistant washes the knife in sterile water. The surgeon rinses his gloves in sterile water and the two assistants put on the wound towels, using three Backhaus clamps on each side. The incision is carried through the peritoneum, and a salt sponge is placed on each side of the incision. The operative field is packed off with salt sponges. In performing hysterec- tomy, or resection of the sigmoid, a long pack is used to pack off the intestines. Throughout the operation every effort is made to prevent soiling. The bowel and stomach are cut across between clamps, and when the stomach or intestines are opened, if pos- sible, rubber guarded clamps are applied to prevent the escape of contents. If the sponges become soiled, they are removed and clean ones substituted. When the operation is completed the salt sponges and wound towels are removed and four clamps are placed on the edges of the peritoneum, one at the lower angle, one at the upper angle, 36 INSTRUCTIONS FOR THE OPERATING ROOM and one at the middle of each side. A sponge is placed over the omentum and intestines just under the incision. A double strand of No. 1 chromic catgut on a catgut needle is used in closing. First the peritoneum and fascia posterior to the muscle are approximated by one row of continuous sutures; the same suture is continued, approximating the fascia anterior to the muscle. Silkworm tension sutures are inserted, and tied, and the skin edges approximated with dermal sutures. The dressing is held in place by adhesive plaster. Fifteen straight forceps (Ochsner) (Fig. 33) Five curved forceps (Carmalt) (Fig. 34) One tissue forceps (Kelly) (Fig. 35) Two dissecting scissors (Mayo) (Fig. 36) Two heavy scissors (Ferguson) (Fig. 37) One tissue forceps (Kelly) (Fig. 49) One scalpel Six Backhaus forceps (Fig. 38) Two wound towels ' Square packs (Fig. 27) Abdominal retractor (Fritsch) (Fig. 39) Ordinary abdominal sutures are: No. 1 chromic double catgut thread on large Mayo needles (Fig. 40), with Hegar needle-holder (Fig. 41) Five or six silkworm sutures on Mayo trocar needle (Fig. 42), with needle-holder Dermal sutures on Keith needles (Fig. 43) All abdominal operations require a gauze dressing; all drain- age operations require a cotton dressing Ordinary Instruments Instruments and sutures Appendectomy Ordinary instruments Invertor (Mayo) (Fig. 44) Pointed forceps (Kelly) (Fig. 45) PREPARATION OF PATIENT EOR ABDOMINAL OPERATION 37 Small scissors for cutting off appendix (Fig. 46) Abdominal retractor (Fritsch) (Fig. 39) No. 1 plain catgut, for ligating where appendix is removed from mesentery Sixteen-inch silk suture on No. 7, straight calix-eyecl intes- tinal needle (Fig. 47) Small specimen pan Ordinary abdominal closure Cholecystectomy Instruments and sutures Ordinary instruments Abdominal retractor (Fritsch) (Fig. 39) Four large curved forceps (Fenger) (Fig. 48) Tissue forceps (Kelly) (Fig. 49) One-third strand No. 1 plain catgut for ligating cystic duct No. 0 plain double on small Mayo needle (Fig. 40) and Hegar needle-holder (Fig. 41), for sewing where the gallbladder is removed from the liver More catgut and drains are used in more difficult cases If the case is dry no drain is used Ordinary abdominal closure Put safety pin in each drain Note: Drains are put up after specimen is removed Cholecystostomy Instruments and sutures Ordinary instruments Gallbladder trocar (Ochsner) (Fig. 50) Gallbladder scoop (Mayo) (Fig. 51) Large bile spoon (Moore) (Fig. 52) Gauze packer (Kelly) (Fig. 53) Dressed tube (about 10 inches long and inch in diameter) covered with two thicknesses of 1-inch iodoform gauze wrapped in gutta percha 38 INSTRUCTIONS FOR THE OPERATING ROOM One-half strand of No. 0 plain catgut in intestinal needle on needle-holder for sewing in tube Bring dressing, connector, and bottle to table after ordinary abdominal closure Choledochotomy Instruments and sutures Ordinary instruments Common duct probes (Mayo) (Fig. 54) Common duct scoop (Mayo) (Fig. 55) Gallbladder scoop (Mayo) (Fig. 51) Three stomach clippers (Ochsner) (Fig. 56) Tissue forceps (Kelly) (Fig. 49) Catheter or Robson drain (catheter sizes 8, 10, and 12) No. 0 plain catgut for sewing in the catheter (one-third strand on curved intestinal needle with holder) (Murphy) (Fig. 41) Ordinary abdominal closure Reconstruction of Ducts Instruments and sutures Ordinary instruments Four stomach clippers (Ochsner) (Fig. 56) Catheters, sizes 8, 10, and 12 Common duct probe (Mayo) (Fig. 54) Tissue forceps (Kelly) (Fig. 49) T-tube No. 1 plain catgut for tying First suture: Silk on curved intestinal needle with holder (Murphy) (Fig. 41) Second suture: No. 0 chromic catgut on intestinal needle with holder (Murphy) (Fig. 41) Third suture: Silk on curved intestinal needle with holder (Murphy) (Fig. 41) Put up change Ordinary abdominal closure PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 39 Cholecystogastrostomy Instruments and sutures Ordinary instruments Gallbladder trocar (Ochsner) (Fig. 50) Large bile spoon (Moore) (Fig. 52) Four stomach clippers (Ochsner) (Fig. 56) Two straight rubber clamps (Scudder) (Fig. 57) First suture: 18 inches of silk on straight intestinal needle (Fig. 47). (Wrap remaining silk in square pack, Fig. 27.) Small knife. Straight Mayo dissecting scissors (Fig. 58) Second suture: No. 0 chromic catgut on straight intestinal needle (Fig. 47). Put up change of ordinary instruments. Use silk which remained after suturing gallbladder and stomach for further suturing Ordinary abdominal closure Operation for Pancreatic Cyst Instruments and sutures Ordinary instruments Abdominal retractor (Fritsch) (Fig. 39) Tubing with suction bottle (Fig. 59) Great quantity of square packs (Fig. 27) Large tube stitched into cyst sac with No. 1 plain catgut on catgut needle No. 1 or 2 catgut for ligating vessels Connector for tube Ordinary abdominal closure Splenectomy Instruments and sutures Large curved forceps (Fenger) (Fig. 48) Abdominal retractor (Fritsch) (Fig. 39) Two long packs (Fig. 28), only one usually required No. 1 plain catgut for ligating (Fig. 40) 40 INSTRUCTIONS FOR THE OPERATING ROOM One single strand plain catgut on Mayo needle (Figs. 40 and 41) Ordinary abdominal closure Gastroenterostomy Instruments and sutures Ordinary instruments Four stomach clippers (Ochsner) (Fig. 56) Pointed forceps (Kelly) (Fig. 45) Two straight rubber-covered clamps (Scudder) (Fig. 57) Two small wet sponges opened and rolled together. Six or seven square packs (Fig. 27) No. 0 chromic catgut on straight needle for first row Wrap catgut which remains after the first row in a square pack (Fig. 27) Put up small knife, blunt straight Mayo scissors (Fig. 58) No. 0 chromic catgut on straight needle for second row No. 0 plain catgut for ligating Put up change with two square packs (Fig. 27) Change consists of the following: Six straight forceps (Ochsner) (Fig. 33) Two curved forceps (Carmalt) (Fig. 34) Two pairs scissors: one Ferguson (Fig. 37) and one Mayo dissecting (Fig. 36) Pointed forceps (Kelly) (Fig. 45) Sponges (Fig. 26) Use catgut wrapped in square pack (Fig. 27) after change Ordinary abdominal closure Excision of Duodenal Ulcer Instruments and sutures Ordinary instruments Four or six stomach clippers (Ochsner) (Fig. 56) Small knife Pointed forceps (Kelly) (Fig. 45) First suture: No. 0 chromic catgut on straight needle PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 41 No. 0 plain catgut for ligating Square packs for cleansing operative field (Fig. 27) Second suture: 18 inches of silk on straight intestinal needle (Fig. 47) Put up change, consisting of ordinary instruments Ordinary abdominal closure Note: Have cautery and No. 0 chromic catgut on curved needle with holder ready in case a second ulcer is found after first ulcer has been excised Excision of Gastric Ulcer Instruments and sutures Ordinary instruments Six stomach clippers (Ochsner) (Fig. 56) Pointed forceps (Kelly) (Fig. 45) Small knife Cautery, if desired (Balfour method) First suture: No. 0 chromic catgut on straight needle Second suture: 18 inches of silk on small curved intestinal needle Put up change as for gastro-enterostomy Gastro-enterostomy Ordinary abdominal closure Excision of Gastrojejunal Ulcer Instruments and sutures Ordinary instruments Four stomach clippers (Ochsner) (Fig. 56) Pointed forceps (Kelly) (Fig. 45) Two straight rubber-covered clamps (Scudder) (Fig. 57) Opening in stomach closed first with No. 0 chromic catgut on a straight needle, second with silk on a straight needle (Fig. 47) _ Opening in jejunum closed in similar manner One-half strand No. 1 plain catgut on catgut needle (Figs. 40 and 41) for closing mesentery 42 INSTRUCTIONS FOR THE OPERATING ROOM New gastro-enterostomy or excision of duodenal ulcer some- times necessary (see gastro-enterostomy or technic for duodenal ulcer) Put up change, consisting of instruments and sutures for ordinary abdominal closure Gastrostomy Instruments and sutures Ordinary instruments Four stomach clippers (Ochsner) (Fig. 56) Small knife Have ready rubber-covered clamp (Scudder) (Fig. 57) Pezzar catheter (retention catheter) Silk on curved intestinal needle for holding catheter in place Ordinary abdominal closure Resection or Stomach: Polya Operation Instruments and sutures Ordinary instruments Tissue forceps (Kelly) (Fig. 49) Two Payr clamps (small and medium) (Fig. 66) Two straight rubber-covered clamps (Scudder) (Fig. 57) No. 1 plain catgut for ligating Electric cautery (Fig. 144), used after clamps are applied to stomach and stomach cut off One-third strand of chromic catgut No. 1 on catgut needle used for closing duodenum when through ligating (Figs. 40 and 41) Catgut used first and then gone over with about 15 inches of silk on small curved intestinal needle (Murphy) Two straight clamps (Scudder) (Fig. 57) Four clippers (Ochsner) (Fig. 56) One pointed forceps (Kelly) (Fig. 45) Eighteen inches of silk on curved intestinal needle (Murphy) with holder (Fig. 41) used to suture stomach to intestine; wrap remaining silk in square pack (Fig. 27) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 43 Put up small blunt dissecting scissors (Fig. 58) Small knife No. 0 chromic catgut on straight needle Put up change, using silk which was wrapped in square pack (Fig- 2.7) Add straight needle (Fig. 47) and clean needle-holder (Fig. 41) Sometimes more silk is required Put up clean tissue forceps (Fig. 49) Ordinary abdominal closure Sleeve Resection Instruments and sutures Ordinary instruments Four stomach clippers (Ochsner) (Fig. 56) Tissue forceps (Kelly) (Fig. 49) Two Payr clamps (medium) (Fig. 66) Two straight rubber-covered clamps (Scudder) (Fig. 57) Cautery used to cut off stomach after clamps are applied (Fig. 144) No. 1 catgut for ligating Eighteen inches of silk on curved intestinal needle (Murphy) with holder to suture the two ends of stomach together, wrapping the remaining silk in a square pack (Fig. 27) No. 0 chromic catgut on straight needle Put up change and clean square packs, using silk which was wrapped in square pack, have straight needle, needle- holder and tissue forceps in change Ordinary abdominal closure Billroth No. 2 Instruments and sutures Ordinary instruments No. 1 catgut for ligating Tissue forceps (Kelly) (Fig. 49) Two Payr clamps (small and medium) (Fig. 66) One straight rubber-covered clamp (Scudder) (Fig. 57) 44 INSTRUCTIONS FOR THE OPERATING ROOM Electric cautery for cutting off stomach (Fig. 144) No. 1 chromic catgut on catgut needle with holder for closing duodenum, then covered with a row of silk on curved intestinal needle (Murphy) No. 0 chromic catgut on straight needle for closing opening in stomach, then covered with silk on straight needle Gastro-enterectomy is made using gastro-enterostomy technic Resection of Cecum, Ileum, and Transverse Colon Instruments and sutures Ordinary instruments Abdominal retractors (Fritsch) (Fig. 39) No. 1 catgut for ligating Two straight rubber-covered clamps (Scudder) (Fig. 57) . Four stomach clippers (Ochsner) (Fig. 56) Electric cautery (Fig. 144) Put up one-half strand No. 1 plain catgut on catgut needle (Figs. 40 and 41) for suturing the mesentery after specimen has been removed Anastomosis first made with silk on a straight intestinal needle, and second with No. 0 chromic catgut on straight intestinal needle (Fig. 47) Put up ordinary change Enterostomy One straight rubber-covered clamp (Fig. 57) Two stomach clippers (Fig. 56) Small knife Put up catheter (6, English) and silk on a curved needle (Murphy) with needle-holder (Fig. 41) Ordinary abdominal closure Brown’s Operation for Colitis Instruments and sutures Ordinary instruments Abdominal retractors (Fritsch) (Fig. 39) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 45 Four stomach clippers (Fig. 56) Straight rubber-covered clamps (Fig. 57) Electric cautery (Fig. 144) Gauze packer (Kelly) (Fig. 53) Smithies tube (about 12 inches) containing a cotton pledget in one end Two one-half strands No. 1 chromic catgut on catgut needle (Figs. 40 and 41) Vaselin dressing Ordinary abdominal closure Ileocolostomy Instruments and sutures Ordinary instruments Abdominal retractors (Fritsch) (Fig. 39) Two straight rubber-covered clamps (Fig. 57) Four stomach clippers (Ochsner) (Fig. 56) Small knife Straight Mayo dissecting scissors (Fig. 58) No. 1 plain catgut for ligating Anastomosis made with silk on straight needle (Fig. 47) Chromic catgut No. 0 on straight needle Put up change Ordinary abdominal closure Extraperitoneal Shortening oe the Round Ligaments Instruments and sutures Ordinary instruments Two-prong retractors (Collins) (Fig. 71) No. 1 plain catgut for ligating One-half strand No. 2 chromic catgut (Figs. 40 and 41) for ligaments One-half strand No. 1 plain catgut (Figs. 40 and 41) Dermal sutures on Keith needle (Fig. 43) 46 INSTRUCTIONS FOR THE OPERATING ROOM Inguinal Hernia Instruments and sutures Ordinary instruments Two-prong retractors (Collins) (Fig. 71) Large four-prong retractors for large hernia (Israel) (Fig. 70) One-third strand No. 1 plain catgift on catgut needle for ligating sac Put up large curved silkworm suture needle (Bonney) (Fig. 80) for “kocherizing” sac One-half strand No. 1 chromic catgut on catgut needle for closing hernia (Figs. 40 and 41) No. 1 plain catgut for ligating No. 1 plain catgut on catgut needle (Figs. 40 and 41) Dermal suture on Keith needle (Fig. 43) Femoral Hernia Instruments and sutures Ordinary instruments Two-prong retractors (Collins) (Fig. 71) No. 1 chromic catgut on catgut needle (Figs. 40 and 41) No. 1 plain catgut on catgut needle (Figs. 40 and 41) No. 1 plain catgut for ligating Dermal suture on Keith needle (Fig. 43) Ventral Hernia Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Four-prong retractor (Israel) (Fig. 80) No. 1 chromic double catgut on catgut needle (Figs.' 40 and 41) Five silkworm sutures on Mayo trocar needle (Fig. 42) Dermal suture on Keith needle (Fig. 43) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 47 Umbilical Hernia Instruments and sutures Same as for ventral hernia Operation for Scrotal Hernia Instruments and sutures Same as for inguinal hernia Operation for Hydrocele Instruments and sutures Ordinary instruments Two-prong retractors (Collins) (Fig. 71) Gallbladder trocar (Fig. 50) Small basin for fluid No. 1 plain catgut for ligating No. 1 plain catgut on catgut needle (Figs. 40 and 41) Dermal suture on Keith needle (Fig. 43) If castration is done in either hydrocele or inguinal hernia, more catgut is used on needle and for ligating Instruments and sutures Operation for Spermatocele and Varicocele Same as for hydrocele except for trocar Operation for Drainage of Abscess Instruments and sutures Small sharp knife Tissue forceps (Fig. 35) Bone curets (large and small) (Fig. 98) Small pointed forceps (Kelly) (Fig. 45) Catgut for ligating Iodoform gauze for packing 48 INSTRUCTIONS EOR THE OPERATING ROOM Fig. 10.—Trendelenburg position, Abdominal Hysterectomy Instruments and sutures Ordinary instruments Balfour abdominal retractor (Fig. 60) Long pack (Fig. 28) Tissue forceps (Kelly) (Fig. 49) Two tenaculums or Henrotin vulsellum forceps (Fig. 61) Fibroid hooks (Fig. 62) The remaining portion of cervix is swabbed with iodin after specimen is removed in a subtotal hysterectomy In a total hysterectomy, 8 inches of iodoform gauze on a Murphy forceps is dipped in iodin and inserted into the vagina One-third strand No. 2 plain catgut on small cervix needle with Hegar needle-holder (Figs. 40 and 41) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 49 After the surgeon has used the catgut on needle, put the needle, needle-holder, and tissue forceps in pan and re- move from the table Two-thirds strand of No. 1 catgut for ligating Place on table: Tissue forceps (Fig. 35), No. 2 plain double catgut on catgut needle with Hegar needle-holder (Figs. 40 and 41). Bring clean square pack after long pack and retractor are removed. Bring up change consisting of: Wound towels Straight forceps (Fig. 33) Curved forceps (Fig. 34) Tissue forceps (Fig. 35) Cutting scissors (Fig. 37) Sponges (Fig. 26) Ordinary abdominal closure Myomectomy Instruments and sutures Ordinary instruments Balfour retractor (Fig. 60) and long pack (Fig. 28) Tissue forceps (Kelly) (Fig. 49) No. 1 plain catgut for ligating First suture: One-half strand No. 1 plain catgut on catgut needle (Figs. 40 and 41) Second suture: One-half strand No. 1 chromic catgut on catgut needle (Figs. 40 and 41) More catgut may be required Ordinary abdominal closure Oophorectomy and Salpingectomy Instruments and sutures Ordinary instruments Balfour retractor (Fig. 60) Tissue forceps (Fig. 49) 5° INSTRUCTIONS FOR THE OPERATING ROOM Long pack (Fig. 28) No. 1 catgut for ligating One-half strand No. 1 catgut on catgut needle for sewing after removal of tube or ovary (Figs. 40 and 41) Ordinary abdominal closure Hysterotomy Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) Long pack (Fig. 28) Tissue forceps (Kelly) (Fig. 49) Sims uterine curet, sharp (Fig. 64) No. 1 plain catgut for ligating First suture: One-half strand No. 1 plain catgut on catgut needle (Mayo) (Figs. 40 and 41) Second suture: One-half strand No. 1 or 2 chromic catgut on catgut needle (Mayo) (Figs. 40 and 41) Ordinary abdominal closure Intraperitoneal Shortening of Round Ligaments Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) and long pack (Fig. 28), seldom used Two stomach clippers (Ochsner) (Fig. 56) for catching liga- ments One-half strand No. 1 chromic catgut on catgut needle (Figs. 40 and 41) Ordinary abdominal closure Cesarean Section Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 51 Long pack (Fig. 28) No. 1 chromic double in small catgut needle with holder (2 strands) Ordinary abdominal closure Have ready for infant: Sterile towel Large basin containing sterile hot water Large basin containing sterile cold water Catheters, sizes 12 and 14 (French) Tape for ligating cord Scissors Two forceps Small sponges Sterile receiver Resection of Sigmoid Instruments and sutures Ordinary instruments No. 1 catgut for ligating Two tissue forceps (Fig. 49) Balfour retractors (Fig. 60) Long pack (Fig. 28) Four large Carmalt curved forceps (Fig. 100) Two Brunner step forceps or right-angle clamp (Fig. 84) Four stomach clippers (Ochsner) (Fig. 56) Electric cautery for cutting off bowel (Fig. 144) One-half strand No. 1 plain catgut on a curved catgut needle with holder * One-half strand No. 1 chromic catgut in curved catgut needle with holder Covered with silk in curved intestinal needle (Murphy) with holder Three Penrose drains Ordinary abdominal closure 52 INSTRUCTIONS FOR THE OPERATING ROOM Tube Resection Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) and long pack (Fig. 28) Tissue forceps (Kelly) (Fig. 49) No. 1 catgut for ligating Four stomach clippers (Ochsner) (Fig. 56) Two straight rubber-covered clamps (Scudder) (Fig. 57) or Brunner step forceps (Fig. 84) or right-angle clamp Electric cautery (Fig. 144) Put up one-half strand No. 1 plain catgut on catgut needle (Figs. 40 and 41) for suturing opening made in mesentery after specimen has been removed Put up tube (Smithies) Eighteen inches of silk on curved intestinal needle (Murphy) with holder (Fig. 41). Remaining silk wrapped in square pack (Fig. 27) No. 0 chromic catgut on curved needle (Fig. 40) with holder (Fig. 41) Put up change Remaining silk then used; more silk sometimes required Ordinary abdominal closure One silkworm suture for sewing tube in rectum Closure oe Colostomy Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Tissue forceps (Kelly) (Fig. 49) Four stomach clippers (Fig. 56) No. 0 chromic catgut on straight needle No. 1 chromic catgut single in catgut needle with holder Four silkworm gut sutures Dermal on Keith needle PREPARATION OF PATIENT FOR ABDOMINAL OPERATION S3 Mikulicz Operation Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) Long pack (Fig. 28) Tissue forceps (Kelly) (Fig. 49) No. 1 catgut for ligating Two one-half strands No. 1 plain catgut on catgut needle (Figs. 40 and 41) Six silkworms on Mayo trocar needle (Fig. 42) Dermal sutures on Keith needle (Fig. 43) Dressing with quantity of vaselin Piece of gutta percha for covering bowel Ureterolithotomy Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) Deaver retractors (Fig. 73) Stomach clippers (Ochsner) (Fig. 56) About 6 inches of tape to hold ureter Long knife (Mayo) (Fig. 101) Gallbladder scoop (Fig. 51) Stone forceps (Mayo) (Fig. 72) One-half strand No. 00 plain catgut on intestinal needle (Murphy) with needle-holder (Fig. 72) Rubber tissue or two or three one-half rubber tubes for drains Ordinary abdominal closure Ureterectomy Instruments and sutures Ordinary instruments Knife Two-prong retractors (Collins) (Fig. 71) 54 INSTRUCTIONS FOR THE OPERATING ROOM No. 1 catgut for ligating No. 1 catgut on catgut needle (Figs. 40 and 41) Dermal suture on Keith needle (Fig. 43) Transplantation of Ureter Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) Two tissue forceps (Kelly) (Fig. 49) Four stomach clippers (Ochsner) (Fig. 56) About 6 inches of tape for ureter Curved rubber-covered clamp Deaver retractors (Fig. 73) Small knife First suture: No. 0 chromic catgut on needle (Murphy), holder (Hegar) (Fig. 41), for putting ureter into bowel Second suture: Silk on curved intestinal needle (Murphy) with needle-holder (Fig. 41) Ordinary abdominal closure Dilatation of Urethra (Retrograde) Instruments and sutures Ordinary instruments Sounds (sizes 10, 12, 14, and 16, English) (Van Buren) (Figs. 88 and 89) Bladder retractors (Judd-Masson) (Fig. 74) Blunt retractors (Green) (Fig. 75) Tissue forceps (Kelly) (Fig. 49) Deaver retractors (Fig. 73) Large catheter for bladder (size 20, English) No. 1 or 2 plain catgut on catgut needle with needle-holder for sewing tube in bladder (Figs. 40 and 41) Five or six silkworm sutures on Mayo trocar (Fig. 42) PREPARATION OF PATIENT FOR ABDOMINAL OPERATION 55 Diverticulum of Bladder Instruments and sutures Same as for resection of bladder Catheter is left in urethra if bladder is closed tight Catheters (sizes 8 and 10, English) Resection of Bladder Instruments and sutures Ordinary instruments Balfour retractors (Fig. 60) Oviatt forceps (Fig. 76) Deaver retractors (Fig. 78) Two tissue forceps (Kelly) (Fig. 49) Deep retractors (Pynchon) (Fig. 77) Two blunt retractors (Green) (Fig. 75) Bladder retractors (Judd-Masson) (Fig. 74) Bladder retractors (Rankin) (Fig. 107) Three curved forceps (Fenger) (Fig. 48) Square packs (Fig. 27) One-half strand No. 1 plain catgut on catgut needle (Figs 40 and 41) One-half strand No. 2 plain catgut on catgut needle (Figs 40 and 41) No. 1 catgut for ligating Drains, split tube, large catheter (size 20) for bladder Electric cautery (Fig. 144) Ordinary abdominal closure Prostatectomy Instruments and sutures Ordinary instruments Two tissue forceps (Kelly) (Fig. 49) Deaver retractors (Fig. 73) Bladder retractors (Judd-Masson) (Fig. 74) Two blunt retractors (Green) (Fig. 75) 56 INSTRUCTIONS FOR THE OPERATING ROOM Bladder retractor (Rankin) (Fig. 107) Oviatt prostate forceps (Fig. 76) Large catheter (about size 20, English) One and one-half yards Kephlin gauze (3 inches wide) Put up one square pack (Fig. 27) One-half tube in space of Retzius One-half strand No. 1 plain catgut (Figs. 40 and 41) for sutur- ing capsule One-half strand No. 1 plain catgut for sewing tube into bladder Five silkworm sutures (Mayo trocar) (Fig. 42) Put up wire spreader after removing bladder retractor Catheters (sizes 8 and 10) with some K Y for catheterizing patient before operation Instruments and sutures Cystotomy Ordinary instruments Two blunt retractors (Green) (Fig. 75) Deaver retractors (Fig. 73) Bladder retractors (Judd-Masson) (Fig. 74) Bladder retractor (Rankin) (Fig. 107) Tissue forceps (Kelly) (Fig. 49) Stone forceps, curved and straight (Little lithotomy forceps) (Figs. 78 and 79) Trocar and cannula Large catheter (size 20, English) Square packs (Fig. 27) One-half strand No. 1 plain catgut (Figs. 40 and 41) for sew- ing tube in bladder Five silkworm sutures (Fig. 42) Catheters for catheterizing patient before operation, with a little K Y on sponge for lubricating catheters (sizes 8 and 10, English) PREPARATION OF PATIENT FOR KRASKE OPERATION The patient lies on his abdomen, with the kidney rack, without the wings, under him at the suprapubic region. This rack is raised about one foot above the table. His ankles are strapped at the foot of the table and his arms are supported by a board passing under the pad on the table at the level of the shoulders. Feet and ankles are covered with a blanket; a sheet Fig. 11.—Kraske position undraped. is spread over the legs, and the instrument tray is placed about a foot distal to the operative field. The operative field is cleansed with benzin and ether, and the first coat of iodin applied. Four sterile towels are placed around the operative field, and a damp sterile towel distal to the anus. A laparotomy sheet is spread over the patient and the second coat of iodin applied to the op- erative field. Towels and laparotomy sheet are fixed in position 57 58 INSTRUCTIONS FOR THE OPERATING ROOM with Backhaus clips. The head of the table is lowered slightly before the operation is begun (Figs. 11 and 12). Fig. 12.—Kraske position draped. Kraske (Posterior Excision) Instruments and sutures Ordinary instruments Tissue forceps (Kelly) (Fig. 49) Eight large curved forceps (Fenger) (Fig. 48) Wide chisel (Alexander) (Fig. 67) Bone mallet (Fig. 68) Kraske 6-prong retractors (Fig. 69) Electric cautery (Fig. 144) No. 1 plain catgut for ligating Catgut on needle (Figs. 40 and 41) One-half strand No. 1 chromic catgut on needle (Figs. 40 and 41) One-half strand No. 1 plain catgut on needle Five silkworm sutures on Mayo trocar (Fig. 42) Dermal sutures on Keith needle PREPARATION OF PATIENT FOR KRASKE OPERATION 59 Strip of iodoform gauze pack if there is considerable bleeding Split tube Dressing with quantity of vaselin Postanal Dermoid Instruments and sutures Same as for removal of coccyx Removal oe Coccyx Instruments and sutures Ordinary instruments No. 1 plain catgut for ligating Two sharp retractors Chisel (Fig. 67) Mallet (Fig. 68) No. 1 catgut in catgut needle with holder Silkworm Dermal PREPARATION OF PATIENT FOR OPERATION ON THE KIDNEY The patient lies on his side and is held in position by the wings of the kidney rack, for the posterolateral incision. If the left kidney is to be operated on, the rack is placed so that the handle is on the right side of the table. The patient is on his right side with the right kidney region in the space between the wings of the kidney rack. His arms are extended in front of Fig. 13.—Kidney position undraped. him and supported on a board passing under the pad on the table. His ankles are strapped to the foot of the table, the left ankle about twelve inches posterior to the right. A rubber pillow is placed between his knees and a strip of gauze is passed around the left knee and tied to the right side of the table. Feet and ankles are covered with a blanket. A sheet is placed 6o PREPARATION OF PATIENT FOR OPERATION ON THE KIDNEY 61 over the legs and the instrument tray placed a few inches distal to the operative field. The skin is cleansed with benzin and ether; one coat of iodin is applied and four sterile towels are placed around the site of the incision. A laparotomy sheet is spread over the patient; the towels and edges of the opening in sheet are fixed in position by Backhaus clips. Before starting the operation the kidney Fig. 14.—Kidney position draped. rack is raised a few inches; it is let down again before the wound is closed (Figs. 13 and 14). Pelviolithotomy Instruments and sutures Ordinary instruments Four-prong retractors (Israel) (Fig. 70) Tissue forceps (Kelly) (Fig. 49) Two stomach clippers (Ochsner) (Fig. 56) Stone forceps (Mayo) (Fig. 72) Large gallbladder scoop (Mayo) (Fig. 51) 62 INSTRUCTIONS FOR THE OPERATING ROOM Small knife One-half strand No. 0 plain catgut on intestinal needle (Murphy) with needle-holder (Fig. 41) Two or three one-half rubber tubes or Penrose tube Ordinary abdominal closure Instruments and sutures Nephrectomy for Hydronephrosis Ordinary instruments Four-prong retractors (Israel) (Fig. 70) Large curved forceps (Fenger) (Fig. 48) Square packs (Fig. 27) Electric cautery (Fig. 144) Two-thirds strand No. 1 plain double catgut for ligating Strip ‘ of iodoform gauze if forceps are left on pedicle and vessels Ordinary closure Nephrectomy for Tuberculous Kidney Instruments and sutures Ordinary instruments Four-prong retractors (Israel) (Fig. 70) Tissue forceps (Kelly) (Fig. 49) Three or four curved forceps (Fenger) (Fig. 48) Square packs (Fig. 27) Electric cautery (Fig. 144) Two-thirds strand No. 1 plain double catgut for ligating Put up one-half strand No. 1 plain catgut for ligating ureter One-fourth inch rubber tube (8 inches long) through which a Murphy forceps (Fig. 63) is inserted and the catgut ligating the ureter is caught and brought through tube Put up catgut needle and tube sutured to abdominal wound with catgut (Figs. 40 and 41) Strip of iodoform gauze if forceps are left on pedicle and vessels Ordinary abdominal closure LITHOTOMY POSITION Leggings are put on the patient for operations on the vagina, perineum, vulva, and rectum. She lies on her back; after she is anesthetized, her hands are clasped across her chest and her feet are placed in stirrups about one and one-half feet above the operating table. She is placed toward the foot of the table so that buttocks are well over the edge. If the operation is to correct urinary leakage, only alcohol is used to prepare the operative field. If the operation is on the anus or rectum, the anus is dilated and the anal canal and rectum are cleansed with soapy water. In other operations the skin and vagina are cleansed with alcohol and then with iodin; a wad of cotton soaked in iodin held on a clamp, is placed in the vagina. A sterile towel is placed over the pubic region, and another towel over the anus, and held in position by two Backhaus clips in the perineum. The patient is covered with a perineal sheet, and the instrument tray is placed distal to the operative field. Vaginal Hysterectomy Instruments and sutures Weighted vaginal speculum (Auvard) (Fig. 82) Two tenaculums (Fig. 61) Ferguson retractors (Fig. 83) Sharp retractors (Murphy) (Fig. 81) Four large curved forceps (Fenger) (Fig. 48) Gallbladder roll Ordinary instruments Two strands No. 1 double chromic catgut on catgut needle (Figs. 40 and 41) If clamps are left on, no catgut is used, but a long strip of iodoform gauze, and linen for tying forceps 63 64 INSTRUCTIONS FOR THE OPERATING ROOM If forceps are removed, perineorrhaphy is performed If clamps are left on, retention catheter is left in Sims uterine sound used to insert catheter; K Y for lubricating Vaginal pad and T-binder Amputation of Cervix Instruments and sutures Heavy weight retractors (Auvard) (Fig. 82) Ordinary instruments Side retractors (Fig. 83) Tenaculums (Fig. 61) Two one-half strands No. 1 chromic catgut on small cervix needle Vaginal pad and T-binder Curettage Instruments and sutures Heavy weight retractors (Auvard) (Fig. 82) Two tenaculums (Fig. 81) Dilator (Wylie) (Fig. 85) Two curets, dull and sharp (Sims) (Fig. 64) (Thomas) (Fig. 86). Douche point (Bozeman) (Fig. 87) Sterile water in irrigating can Sometimes Sims vaginal retractor is used (Fig. 99) Strip gauze soaked with iodin and gauze packer (Fig. 53) Operation for Vesicovaginal Fistula Instruments and sutures Ordinary instruments Six stomach clippers (Ochsner) (Fig. 56) Heavy weight retractors (Auvard) (Fig. 82) Side retractors (Fig. 83) Uterine sound (Sims) LITHOTOMY POSITION 65 Retention catheter Glass syringe (1 ounce) Graduate with sterile water No. 1 plain catgut on catgut needle (Figs. 40 and 41) No. 1 chromic catgut on catgut needle (Figs. 40 and 41) Perineorrhaphy Instruments and sutures Ordinary instruments Small, sharp, pointed scissors Six or eight stomach clippers (Ochsner) (Fig. 46) One-half strand No. 1 chromic catgut on catgut needle (Figs. 40 and 41) Put up graduate containing sterile water and sponge for running over sutures Bovee Operation Instruments and sutures Ordinary instruments Heavy weight retractors (Auvard) (Fig. 82) Side retractors (Fig. 83) Tenaculums (Fig. 61) Six or eight stomach clippers (Ochsner) (Fig. 56) Sharp pointed-scissors (Fig. 46) One-half strand No. 1 chromic catgut on catgut needle (Figs. 40 and 41) If perineorrhaphy is done, use perineorrhaphy technic Vaginal pad and T-binder Hemorrhoids Instruments and sutures Hemorrhoidal clamp (Kelsey) Small pointed knife Four curved forceps (Carmalt) (Fig. 34) Asbestos paper and soldering irons 66 INSTRUCTIONS TOR THE OPERATING ROOM Internal hemorrhoids: one-half strand of No. 1 catgut on needle (Figs. 40 and 41) Dressing: Vaselin and vaginal pad Rectal Fistula Instruments and sutures Two small probes (Fig. 97) Five stomach clippers (Ochsner) (Fig. 56) Straight forceps (Fig. 33) Sharp dissecting scissors (Mayo) (Fig. 46) Cutting scissors (Fig. 37) Tissue forceps (Fig. 35) Retractors (Pynchon, Deaver) (Figs. 77 and 95) Plain catgut for ligating No. 1 plain catgut for sewing (Figs. 40 and 41) Iodin or methylene blue to be injected Sometimes silk on catgut needle (Murphy) with needle- holder (Fig. 41) Dressing: Vaselin and vaginal pad Vesiculectomy Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Deaver retractors (Fig. 73) Tongue depressor (Fig. 74) Fork retractor Sounds (sizes 10, 12, 14, 16, and 18, English), Ferguson-Otis- van Buren (Figs. 88 and 89) K Y for lubricating No. .1 catgut on catgut needle with holder (Figs. 40 and 41) Six or eight silkworm sutures on finger needle (Fig. 80) Strip iodoform gauze Catheters (sizes 8 and 10, English) for urethra. PREPARATION OF PATIENT FOR OPERATIONS ON THE THORAX If the chest is to be approached anteriorly, the patient is draped and placed on the table as for laparotomy. It is important to have sufficient exposure. A foot rest is used on the table. For the approach to the posterior chest, or through axillary lines, the patient is placed on his side between two supports, usually long pillows, these being drawn together by means of a bandage at each end. The body may be moved, and the chest fixed in any position desired by means of the supports. The upper arm is tied with a bandage, pulled forward back of pa- tient’s neck, and tied by the anesthetist. The other arm is extended and tied on a board. The leg, resting on the table, is extended. The other leg is brought down on the table almost at a right angle, and placed against the other leg at the bend of the knee. A firm hitch is taken on the ankle of the leg with a goiter roll, and fixed to the table. The roll is carried under the table to the opposite side, then the bandage is fixed again, carried over and attached to the extended leg, just above the ankle, and then carried across the table to the starting point. A strap is placed across at the knees. The patient is draped. The table is well away from operative field, and usually the upper end rests over the symphysis. Plastic Operation for Chronic Empyema Instruments and sutures Drapery (eight towels, eight clips, laparotomy sheet) Ordinary instruments (knife, scissors, hemostats, tissue for- ceps, probe, and so forth) Sharp retractors (Fig. 81) Dull retractors (Fig. 75) Self-retaining retractors (Fig. 106) Four-pronged retractors (Fig. 70) Two record syringes '67 68 INSTRUCTIONS FOR THE OPERATING ROOM 0.5 per cent novocain solution Assorted needles Periosteal elevators (Figs. 102 and 103) Rib shears (Fig. 104) No. 1 plain catgut, double, on cervix needle Iodoform gauze packs Open Drainage of Empyema Cavity Instruments and sutures Drapery as for chronic empyema Ordinary instruments Sharp retractors (Fig. 81) Self-retaining retractors (Fig. 106) Two record syringes 0.5 per cent novocain solution Assorted needles Periosteal elevators (Figs. 102 and 103) Rib shears, two types (Figs. 104 and 105) No. 1 plain catgut on catgut needle Long drainage tubes Large catheters, 20 to 30 French Strip of 2-inch iodoform gauze Insertion of Catheter for Closed Drainage of Empyema Instruments and sutures Drapery as for chronic empyema Ordinary instruments Fine-bladed knife Record syringes 0.5 per cent novocain solution Assorted needles Trocar Cannula 22 French catheter tube clamp 1 oz. glass syringe Basin saline solution PREPARATION OF PATIENT FOR OPERATIONS ON THE THORAX 69 Drainage of Lung Abscess Instruments and sutures, first stage of operation Drapery (eight towels, eight clips, laparotomy sheet) Ordinary instruments Sharp retractors (Fig. 81) Dull retractors (Fig. 75) Two record syringes 0.5 per cent novocain solution Assorted needles Periosteal elevators (Figs. 102 and 103) Rib shears, two types (Figs. 104 and 105) Self-retaining retractor (Fig. 106) No. 0 chromic catgut, double, on full curved fine catgut needle 2-inch iodoform gauze pack No. 1 plain catgut, double, on catgut needle Four or five silkworm sutures Dermal suture Instruments and sutures, second stage of operation Drapery as for first stage Ordinary instruments Two record syringes 0.5 per cent novocain solution Assorted needles Sharp retractors (Fig. 81) Dull retractor (Fig. 75) Record syringes with large needles Electric cautery (Fig. 144) Split tube Iodoform pack Resection of Tumor of Chest Wall Instruments and sutures Same as for first stage, lung abscess 7° INSTRUCTIONS FOR THE OPERATING ROOM Extrapleural Thoracoplasty Instruments and sutures Drapery (eight towels, eight clips, laparotomy sheet) Ordinary instruments Sharp retractors (Fig. 81) Two record syringes 0.5 per cent novocain solution Assorted needles Self-retaining retractor (Fig. 106) Periosteal elevator (Figs. 102 and 103) Blunt goiter retractors (Fig. 75) Rib shears, two types (Figs. 104 and 105) Saline to wash wound Absolute alcohol in syringe with fine needle Syringe with water No. 1 plain double catgut Dermal suture PREPARATION OF PATIENT FOR BREAST OPERATION Practically all the patients are placed on the table and draped so that a radical amputation may be performed without change of position or draping. The patient lies well toward the foot of the table and toward the edge opposite the breast to be oper- Fig. 15.—Breast position undraped. ated on. Assuming that the right breast is to be removed, the patient lies well toward the left edge and the foot of the table. The right arm is extended laterally and slightly upward so that an angle of about 120 degrees is formed in the axilla by the arm and the body. The arm rests on a board extending under the pad 7i 72 INSTRUCTIONS FOR THE OPERATING ROOM on the operating table, and is held in position by a gauze bandage passed around the wrist and the board. A strap is passed over the thighs and the left wrist is strapped in the usual position. A blanket is wrapped around the feet and ankles. A stirrup holder is placed on the left edge of the table as far toward the head as possible. The lower part of the body is covered with a sheet, and the instrument tray is placed just distal to the um- bilicus. Fig. 16.—Breast position draped. After the usual treatment with benzin, ether, and the first coat of iodin, four sterile towels are placed around the breast to be operated on. The instrument tray is covered by a small sheet placed across the patient just distal to the operative field. Above the operative field is placed another small sheet, one end of which covers the board supporting the right arm, and the PEEPARATION OP PATIENT FOR BREAST OPERATION 73 other end passing over the top of the stirrup holder forms a screen for the anesthetist. A wet towel is placed along the posterior axillary field. Towels and sheets are held in place by Backhaus clips (Figs. 15 and 16). Amputation of Breast Instruments and sutures Large scissors (Fig. 37) Four scalpels Dissecting scissors (Fig. 36) Tissue forceps (Fig. 35) Large number of straight forceps (Fig. 33) Two curved forceps (Fig. 34) Two sharp retractors (Murphy) (Fig. 81) Two-prong retractors (Collins) (Fig. 71) No. 1 plain catgut for ligating From eight to ten silkworm sutures on finger needle (Bonney) (Fig. 80) Dermal sutures on Keith needle (Fig. 43) Spiral tube if drain is used Quantity of hot packs (put in boiling water and wrung dry, Fig. 27) One-half strand No. 1 plain catgut on small Mayo trocar if small tumor is removed from breast (Fig. 42) Curved needle (Fig. 92) to close subcuticular fascia About three silkworm sutures used for Warren operation Finger needle (Bonney) (Fig. 80) and dermal suture on Keith needle (Fig. 43) PREPARATION OF PATIENT FOR OPERATIONS ON THE NECK The patient’s gown is replaced by a surgical jacket, and he is moved on the table so that his shoulders are just over the break between the body of the table and the head piece. The foot rest is brought up snugly against the soles of his feet. A strap is fastened across the thighs, and the wrists are strapped Fig. 17.—Neck position. to the sides of the table. Pillows are placed under the elbows, and the feet and ankles are covered with a blanket. A sheet is spread over the patient up to the shoulders, and the instru- ment tray is placed distal to the operative field. The foot piece of the table is lowered until it forms an angle of about 30 de- grees with the horizontal. The head of the table is elevated 74 PREPARATION OF PATIENT FOR OPERATIONS ON THE NECK 75 until the entire table is in line with the foot piece, so that the patient lies at an angle of about 30 degrees with the horizontal. The neck is cleansed with benzin and ether, and the first coat of iodin is applied. In exophthalmic goiter 1.75 per cent tincture, and in other cases, 4 per cent tincture is used. Two sterile towels are opened and laid one above the other under the patient’s neck and head. The sides of the upper towel are brought up over the patient’s ears and hair, and fastened over the forehead. Another sterile towel is placed on each side of the oper- ative field. The tray is covered by a small sheet distal to the operative field. Another small sheet is placed above the operative field, and passed over the screen, and at the angle of the man- dible on each side is fastened with a curved clamp to the towel covering the head, and with two Jones clips, to the top of the screen. A wet sterile towel is placed on each side of the operative field and another coat of iodin is applied. The head is lowered just before starting the operation, and raised again before start- ing to sew up (Fig. 17). Goiter (Ligation) Instruments and sutures Two small blunt retractors (Crile) (Fig. 90) Two small sharp retractors (Sands) (Fig. 91) Straight forceps (Fig. 33) Tissue forceps (Fig. 35) Dissecting scissors (Fig. 36) Cutting scissors (Fig. 37) Scalpel One ounce 0.5 per cent novocain injected One-half strand No. 1 plain catgut for ligating One-half strand No. 00 plain catgut on catgut needle (Figs. 40 and 41) Put up small curved horsehair needle (Fig. 92) Dressing consists of three small sponges (Fig. 26) Twenty cubic centimeter record syringe with needle to inject novocain 76 INSTRUCTIONS FOR THE OPERATING ROOM Thyroidectomy Instruments and sutures Sterile gauze for ether cone Large number of straight forceps (Fig. 33) Tissue forceps (Fig. 35) Dissecting scissors (Fig. 36) Cutting scissors (Fig. 37) Scalpel Large number of sponges (Fig. 26) Sharp retractors (Murphy) (Fig. 81) Blunt retractors (Green) (Fig. 75) Quantity of catgut used depends on size of goiter (No. 1 plain catgut for ligating) One-half strand No. 1 plain catgut on catgut needle for sew- ing where gland was removed (Figs. 40 and 41), sometimes goiter needle (Fig. 93) One-half strand No. 1 plain catgut for sewing muscle Plain No. 00 catgut on Keith needle Tube drain, safety pin Operations for Glands of Neck Instruments and sutures Large number of straight forceps (Fig. 33) One pair large scissors (Fig. 37) One pair dissecting scissors (Fig. 36) Tissue forceps (Fig. 35) Scalpel Two sharp retractors (Murphy) (Fig. 81) One round gland retractor (Parker) (Fig. 94) Two-prong retractors for block or complete dissection (Fig. 71) _ Large quantity No. 1 plain catgut One-half strand No. 1 plain catgut (Figs. 40 and 41) Dermal sutures on Keith needle (Fig. 43) Two spiral tubes for drainage Two safety pins PREPARATION OF PATIENT FOR OPERATIONS ON THE NECK 77 Thyrotomy Instruments and sutures Ordinary goiter instruments Sharp retractors (Murphy) (Fig. 41) Blunt retractors (Green) (Fig. 75) Fibroid hooks (Fig. 62) Bone cutter (Fig. 96) Stomach clippers (Ochsner) (Fig. 56) No. 1 chromic catgut on catgut needle (Figs. 40 and 41) No. 1 plain catgut for ligating Luer tracheotomy tubes (sizes 3, 5, and 7) If the growth is small, sew up tight; do not use tube Tracheotomy Instruments and sutures Straight forceps (Fig. 43) Dissecting scissors (Fig. 36) Small scalpel Tissue forceps (Fig. 35) Two stomach clippers (Ochsner) (Fig. 56) Two sharp hooks Luer tracheotomy tubes (sizes 3, 5, and 7) No. 1 catgut for ligating No. 1 catgut on catgut needle (Figs. 40 and 41) Silkworm sutures on finger needle (Bonney) (Fig. 80) Small piece iodoform gauze Instruments and sutures Laryngectomy Ordinary instruments Two sharp retractors (Murphy) (Fig. 81) Blunt retractors (Fig. 75) Fibroid hooks (Fig. 62) Stomach clippers (Fig. 56) Bone cutter (Fig. 96) 78 INSTRUCTIONS TOR THE OPERATING ROOM Luer tracheotomy tubes (sizes 3, 5, and 7) Swab trachea with 10 per cent cocain No. 1 chromic catgut on catgut needle (Figs. 40 and 41) No. 1 plain catgut for ligating No. 1 plain catgut on needle (Figs. 40 and 41) Dermal sutures on Keith needle (Fig. 43) Operation for Diverticulum of Esophagus Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Blunt goiter retractors (Green) (Fig. 75) Gland retractors (Parker) (Fig. 94) Small retractors (Deaver) (Fig. 95) No. 1 plain catgut for ligating No. 0 chromic catgut on small curved intestinal needle (Murphy) (Fig. 41) No. 1 plain catgut on catgut needle with holder for muscle Skin closed with dermal sutures (Fig. 43) CRANIOTOMY WITH OSTEOPLASTIC FLAP A large number of pointed, or Kelly forceps, are supplied. The incision is made at the base of the flap in front and back, Fig. 18.—Instruments for operation on the brain: a. DeVilbiss bone biters b. Hudson drill c. Straight bone biters d. Special curved bone biters e. Large curved bone biters f. Straight double-jointed bone biters g. Dural guide h. Pedicle clamp i and j. Illuminated pituitary retrac- tors k. Illuminated ganglion retractors l. Brain retractors m, n, and o. Pituitary forceps p. Bayonet forceps q, r, and s. Periosteal elevator t. Laminectomy periosteal elevator u. Dural hook v. Aneurysm needle w. Knot tier x. Blunt hook y. Right-angled knife z. Brain trocar and cannula a'. Dural forceps b'. Ganglion scissors 79 8o INSTRUCTIONS FOR THE OPERATING ROOM then a periosteal elevator (Fig. 18 s) is inserted under the flap, and the pedicle clamp (Fig. 18 h) is applied. Following this the scalp incision is completed around the flap. The forceps are bunched together with rubber bands, and three wet wound towels are applied to the edge of the wound. The trephine open- ings are made with a Hudson drill (Fig. 18 b), then the dural guide (Fig. 18 g) is inserted under the bone, followed by the Gigli saw (Figs. 19 and 20) and the bone sawed out between the trephine openings. The DeVilbiss bone biter (Fig. 18 a) is used to bite away the bone at the lower margin of the bone flap and the flap is turned back. The dural vessels are ligated Fig. 19.—Gigli saw. Fig. 20.—Gigli handle with silk on small dural needles, and large flat pads of wet cotton are applied around the margin of the wound. The dura is opened with a dural hook (Fig. 18 u) and a scalpel. Usually a brain trocar and cannula (Fig. 18 z) is employed to make several punctures at this stage; to open the dura, a special straight scissors and dural forceps are used. At this stage a grooved director and brain retractor (Fig. 18 1) are usually necessary. For bleeders on the cortex of the brain, Cushing’s clips (Fig. 21) instead of ligatures are employed; these should always be ready. Instead of sponging the cortex, it is irrigated (Fig. 22); if spong- ing is necessary, it is done with balls of fluffy cotton wet with CRANIOTOMY WITH OSTEOPLASTIC FLAP 8i Fig. 21.—A. Cushing clip forceps; B. Cushing clip holder. Fig. 22.—Hospital asepto syringe. Fig. 23.—Jansen mastoid retractor. 82 INSTRUCTIONS FOR THE OPERATING ROOM sodium chlorid solution, using the bayonet forceps (Fig. 18 p). At the completion of the operation, bone biters (Fig. 18 f) are employed to bite out the bone for decompression, and the flap is replaced. For suturing the flap, trocar-pointed scalp needles are used (Ferguson No. 4). It is preferable to supply two or three dozen of these threaded with No. 1 silk, cut to convenient length for tying. Craniotomy with Osteoplastic Flap Instruments and sutures Pedicle clamp (Fig. 18 h) Bone biter (DeVilbiss) (Fig. 18 a) Drill (Hudson) (Fig. 18 b) Dural guide (Fig. 18 g) Bone biters (Stille) Large curved bone biters (Fig. 18 e) Straight bone biters (Fig. 18 f) Dural forceps Brain trocar and cannula (Fig. 18 z) Dural hook (Fig. 18 u) Periosteal elevators (Fig. 18 q, r, s) Bayonet forceps (Fig. 18 p) Brain retractors (Fig. 18 1) Saw and handle (Gigli) (Figs. 19 and 20) Dural needles threaded Scalp needles (trocar point) Special irrigating syringe (Fig. 22) Cushing’s clips (Fig. 21) Pituitary Operations Instruments and sutures Same as for craniotomy Pituitary forceps (Fig. 18 m, n, o) Illuminated retractor (Fig. 18 i, j) Gallbladder scoops Strips of rubber tissue for shingling brain 83 CRANIOTOMY WITH OSTEOPLASTIC FLAP Gasserian Ganglion Operation The patient is placed with the head rest in the proper position and the incision is made in front of the ear. Ordinary straight forceps are supplied to catch the bleeders. Plain catgut on a catgut needle is used to retract the fascia and a mastoid re- tractor (Fig. 23) is inserted. A trephine opening is made and enlarged with bone biters (Fig. 18 c). The dura is elevated with a periosteal elevator (Fig. 18 q) and a brain retractor, the surgeon using a headlight. Illuminated ganglion retractors are inserted and the dissection carried out with bayonet forceps (Fig. 18 p) and four sizes of dental rolls. The middle meningeal artery is dissected loose with a right-angled hook (Fig. 18 x), the aneurysm needle (Fig. 18 v) threaded with silk is passed around the middle meningeal, and the loop caught with a dural hook. The knot is tied with a special knot tier (Fig. 18 w), and the silk and the middle meningeal are cut with special ganglion scissors (Fig. 18 b')- The dissection is continued until the root is exposed, and two blunt hooks are used, followed by a right-angled knife (Fig. 18 y) to cut the root. A gauze drain is inserted, and the wound sutured as in the operation for crani- otomy. Instruments and sutures Drill (Hudson) (Fig. 18 b) Bone biters, straight (Fig. 18 c) Bone biters, special curved (Fig. 18 d) Bone biters (Stille) Bone biters, straight double-jointed (Fig. 18 f) Periosteal elevators (Fig. 18 q, r, s) Bayonet forceps (Fig. 18 p) Brain retractor (Fig. 18 1) Illuminated retractors (Fig. 18 k) Dural hook (Fig. 18 u) Aneurysm needle (Fig. 18 v) Knot tier (Fig. 18 w) Blunt hook (Fig. 18 x) 84 INSTRUCTIONS FOR THE OPERATING ROOM Right-angled knife (Fig. 18 y) Ganglion scissors (Fig. 18 b') Container for cotton pledgets Mastoid retractor (Fig. 23) Craniotomy for Cerebellar Operation The patient is placed on the cerebellar head rest. A Heiden- heim hemostatic stitch is inserted, using a cervix needle threaded with double chromic catgut. An ordinary cat’s paw retractor and periosteal elevator (Fig. 18 s) are used for turning the flap. Trephine openings are made and the bone removed with bone biters (Fig. 18 e, f), bone wax being used to stop bleeding. A trephine and incision are made to tap the lateral ventricle, and a trocar inserted into the lateral ventricle. The dura is opened as in the operation for craniotomy. Illuminated retractors are usually used to examine the cerebellar pontile angles on each side. Closure is made with needles and silk as in the operation for craniotomy. Instruments and sutures Drill (Hudson) (Fig. 18 b) Bone biters, straight (Fig. 18 c) Bone biters, large curved (Fig. 18 e) Bone biters, double-join ted (Stilie) Pituitary forceps (Fig. 18 m, n, o) Bayonet forceps (Fig. 18 p) Periosteal elevators (Fig. 18 q, r, s) Dural hook (Fig. 18 u) Brain trocar and cannula (Fig. 18 z) Dural forceps (Fig. 18 a') Illuminated retractor (Fig. 18 k) Brain retractor (Fig. 18 1) Cushing’s clips (Fig. 21) Dural needles threaded with silk LAMINECTOMY The incision is made. Straight forceps are supplied. The muscle attachment to the lamina is removed by a special peri- osteal elevator (Fig. 18 t) to a self-retaining goiter retractor, two wet towels are applied and the spinous process and laminie removed with bone-biting forceps (Fig. 18 c, e, f); bone wax is used to stop bone bleeding. Retraction sutures of silk in dural needles are inserted into the dura, and the dura is opened. Fluffy cotton balls on bayonet needles are used for sponging at this stage. Blunt hooks (Fig. 18 x) are used for lifting the cord, and Cushing’s clips (Fig. 21) to control bleeding. The dura is closed with continuous silk on dural needles; the wound is closed with chromic catgut on large catgut needles and continuous dermal sutures in the skin. Instruments and sutures Bone biters, straight (Fig. 18 c) Bone biters, large curved (Fig. 18 e) Bone biters, double-jointed (Stille) (Fig. 18 f) Bone biters (Elsberg special) Bayonet forceps (Fig. 18 p) Periosteal elevators (Fig. 18 t) Dural hook (Fig. 18 u) Blunt hook (Fig. 18 x) Dural forceps (Fig. 18 a') Dural needle threaded 85 BONE OPERATIONS Ordinary instruments Hemostats Tissue forceps Scalpel Dissecting scissors (Fig. 36) Suture scissors (Fig. 37) Sponges • Wound towels Six Backhaus clips (Fig. 38) Warm square packs One-half strand No. 1 plain catgut for ligating' One-half strand No. 1 plain catgut on small catgut needle with needle-holder Silkworm sutures on finger needles (Bonney) Dermal on Keith needles (small finger needles are used for incisions on concave surfaces) Warm square packs are necessary to prevent drying of tis- sues, especially if bone or fascia are being transplanted. Instruments Bone Transplant for Fractured Femur Ordinary instruments Fracture table (Fig. 24) Bone clamp (large and small) (Collins) Beef-bone screws Taps (Fig. 112) Bone screw-driver (Fig. 135) Electric saw and drill (Geiger) (Fig. 126) Periosteal elevators (large and small) (Figs. 102 and 103) Hand saws (Fig. 124) Lane bone holders (Fig. 118) 86 BONE OPERATIONS 87 Lion jaw forceps (Fig. 121) Rongeur bone forceps (large and small) (Figs. 122 and 123) Stille-Liston bone-cutting forceps (Fig. 105) Retractors, sharp (Murphy) (Fig. 81) Two-prong retractors (Collins) (Fig. 71) Fig. 24.—Fracture table, Four-prong retractors (Israel) (Fig. 70) Chisels (Fig. 138 c) Gouges (Fig. 138 b) Meyerding mallet (Fig. 129) Three sterile cotton dressings 88 INSTRUCTIONS FOR THE OPERATING ROOM Sterile 5-yard gauze roll If bone plate is used the same instruments are needed as for bone transplant except the electric saw Application of Metal Plate on Femur Instruments Lane steel plate (six holes) (Fig. 134) Lane steel plate (eight holes) (Fig. 133) No. 7 Lane steel screws in five lengths Simplex screw-holder and driver combined (Fig. 136) Lane screw-driver (Fig. 135) Dressing (gauze and cotton) Materials for plaster-of-Paris cast Meyerding sacral rest (Fig. 141) Arthroplasty of the Hip Instruments and sutures Ordinary instruments Bone drill Periosteal elevators (large and small) (Figs. 103 and 130) Hand saws (Fig. 124) Lane bone holders (Fig. 118) Rongeur bone forceps (Figs. 122 and 123) Bone-cutting forceps (Fig. 120) Meyerding mallet (Fig. 129) Chisels (four sizes) (Fig. 138 c) Sharp retractors (Murphy) (Fig. 81) Four-prong retractors (Israel) (Fig. 70) Murphy reamer and end mill brace with medulla (Figs. 115 and 117) Reamers (four sizes) (Fig. 116) No. 1 chromic catgut on catgut needle with holder Ordinary sutures Dressing Material for plaster-of-Paris cast, or Thomas splint Meyerding sacral rest (Fig. 141) BONE OPERATIONS 89 Arthroplasty of Elbow Instruments and sutures Ordinary instruments Periosteal elevators (large and small) (Figs. 103 and 130) Hand saws (Fig. 124) Lane bone holders (Fig. 118) Rongeur bone forceps (Figs. 122 and 123) Bone-cutting forceps (Fig. 120) Meyerding mallet (Fig. 129) Chisels (four sizes) (Fig. 138 c) Sharp retractors (Murphy) (Fig. 81) Four-prong retractors (Israel) (Fig. 70) Files (three sizes) Bone screws Yankee hand drill (Fig. 139) No. 1 chromic catgut on catgut needle with holder Ordinary sutures Material for plaster-of-Paris cast, or special splint Arthroplasty of Knee Instruments and sutures Ordinary instruments Yankee hand drill (Fig. 139) Periosteal elevators (large and small) (Figs. 103 and 130) Hand saws (Fig. 124) Lane bone holders (Fig. 118) Rongeur bone forceps (Figs. 122 and 123) Bone-cutting forceps (Fig. 120) Meyerding mallet (Fig. 129) Chisels (four sizes) (Fig. 138 c) Sharp retractors (Murphy) (Fig. 81) Four-prong retractors (Israel) (Fig. 70) Reamers (four sizes) (Fig. 116) Putti chisels No. 1 chromic catgut on catgut needle with holder 90 INSTRUCTIONS FOR THE OPERATING ROOM Ordinary sutures Tourniquet Material for plaster-of-Paris cast, or special splint Albee Bone Graft to Spine Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Two-prong retractors (Fig. 71) Periosteal elevators (Figs. 103 and 130) Murphy chisels (Fig. 127) Meyerding mallet (Fig. 129) Bone-cutting forceps (Fig. 120) Long flexible metal probe (Fig. 128) No. 2 chromic catgut on Mayo catgut needle Electric drill (Geiger) (Figs. 125 and 126) Bone screws Tap and bone screw-driver (Figs. 108, 109, 110, 111, 112, and 113) Instruments and sutures for leg Ordinary instruments Electric saw and bone drill (Geiger) (Figs. 125 and 126) Thin chisel for removing bone graft (Fig. 138 c) Meyerding mallet (Fig. 129) Saline to cool electric saw Three large sterile cotton dressings Sterile 5-yard gauze roll Bradford frame Hibbs’ Spinal Fusion Operation Instruments and sutures Ordinary instruments Sharp retractors (Murphy) (Fig. 81) Two-prong retractors (Fig. 71) BONE OPERATIONS 9i Periosteal elevators (Figs. 103 and 130) Murphy chisels (Fig. 127) Meyerding mallet (Fig. 129) Bone-cutting forceps (Fig. 120) Long flexible metal probe (Fig. 128) Two self-retaining retractors (Fig. 106) Small sharp periosteal elevators (Fig. 131) Hibbs’ bone biters (Fig. 119) Small hand saw (Fig. 138 a) No. 2 chromic catgut on Mayo catgut needle Salt packs for bone chips Operation for Foreign Body In the Knee Instruments and sutures Ordinary instruments Sharp retractors (Fig. 81) Two-prong retractors (Fig. 71) Parker saw (Fig. 123) Second knife Tissue forceps (Fig. 35) Small gallbladder scoop (Fig. 51) Three sterile cotton dressings Large padded gutter splint Resection of the Knee Instruments and sutures Ordinary instruments Sharp retractors (Fig. 81) Hand saw (Fig. 124) Rongeur bone forceps (Figs. 122 and 123) Bone-cutting forceps (Fig. 120) Two long wire nails Hammer (Fig. 68) Chisels (Fig. 138 c) Mallet (Fig. 129) 92 INSTRUCTIONS FOR THE OPERATING ROOM Three large cotton dressings Material for plaster-of-Paris cast Tourniquet Amputation of Leg Instruments and sutures Ordinary instruments Tourniquet Sterile leg rest (Fig. 140) Sharp retractors (Fig. 81) Two-prong retractors (Fig. 71) Amputation retractor (Fig. 142) Angular bone-cutting forceps (Fig. 143) Parker saw (Fig. 124) Two rubber tissue drains (for infected cases only) No. 2 chromic catgut for ligating large vessels Alcohol (95 per cent) in record syringe Two large cotton dressings Posterior splint for amputations below the knee Operation for Bunion Instruments and sutures Ordinary instruments Kelly straight forceps (Fig. 45) Mayo angular bone-cutting forceps (Fig. 143) Rongeur bone-cutting forceps (small) (Fig. 123) Bone-cutting forceps (Fig. 120) Chiropodist’s cutting forceps Sharp retractors (Fig. 81) Ligation retractors (Fig. 91) Thin chisel (Fig. 138 c) Mallet (Fig. 129) Three stomach clippers (Fig. 56) Alcohol dressing Sterile tongue depressors BONE OPERATIONS 93 Soutter or Campbell Operation for Contraction of Hip Instruments and sutures Ordinary instruments Chisels (Fig. 138 c) Material for plaster-of-Paris cast Osteomyelitis of Tibia Instruments and sutures Ordinary instruments Periosteal elevators (Figs. 103 and 131) Bone gouges (Fig. 138 b) Bone chisels (Fig. 138 c) Meyerding mallet (Fig. 129) Bone curet (Fig. 132) Rongeur bone-cutting forceps (Figs. 122 and 123) Yankee hand drill (Fig. 139) Electric motor with drills and twin saws (for radical oper- ation) (Figs. 125 and 126) Iodoform gauze packing Dakin tubes and manifold Dakin gauze packing Vaselin gauze Safety pins Bone Plate for Fractured Radius or Ulna Instruments and sutures Ordinary instruments Periosteal elevators (Figs. 103 and 131) Parker hand saw (Fig. 124) Small hand saw (Fig. 138 a) Rongeur bone-cutting forceps (Figs. 122 and 123) Bone-cutting forceps (Fig. 120) Chisels (Fig. 138 c) Mallet (Fig. 129) Bone plates (Fig. 114) Bone screws (6 by 32, 10 by 24) 94 INSTRUCTIONS FOR THE OPERATING ROOM Electric motor (Geiger) (Fig. 125) Drills (Fig. 126) Taps (Figs. 108, 110, 111, 112, and 113) Bone screw-drivers (Fig. 109) Hand drill (Fig. 139) Lane bone holders (Fig. 118) Bone clamp (large and small) (Collins) Lion-jaw forceps (Fig. 121) Dressings Material for plaster-of-Paris cast Transplantation of Tendon Instruments and sutures Ordinary instruments Tourniquet No. 0 chromic catgut on brain needle Silk on brain needle Narrow chisel (Fig. 138 c) Meyerding mallet (Fig. 129) Hand drill (Fig. 139) Stomach clippers (Fig. 35) Square saline packs Sterile dressings Material for plaster-of-Paris cast Instruments and sutures Ghant Osteotomy of Femur Ordinary instruments Sharp retractors (Fig. 81) Four-prong retractors (Fig. 70) Two-prong retractors (Fig. 71) Chisels (Fig. 138 c) Osteotomes (Fig. 138 c) Mallet (Fig. 129) Extra large bone-screw with brace and small reamer (Figs. 115 and 116) BONE OPERATIONS 95 Hand drill (Fig. 139) Dressings Material for plaster-of-Paris cast Arthrodesis of Ankle Instruments and sutures Ordinary instruments. Sharp retractors (Fig. 81) Chisels (Fig. 138 c) Gouges (Fig. 138 b) Mallet (Fig. 129) Rongeur bone-cutting forceps (Figs. 122 and 123) Tourniquet Silkworm and dermal on curved needles Dressings Material for plaster-of-Paris cast Astragalectomy Instruments and sutures Ordinary instruments Chisels (Fig. 138 c) Mallet (Fig. 129) Rongeur bone-cutting forceps (small) (Figs. 122 and 123) Lion-jaw forceps Tourniquet Sutures on curved needles Dressings Material for plaster-of-Paris cast Fractured Patella Instruments and sutures Ordinary instruments Bone screws Taps (Figs. 108, 110, 111, 112, and 113) Bone screw-drivers (large and small) (Fig. 109) 96 INSTRUCTIONS FOR THE OPERATING ROOM Electric motor (Geiger) (Fig. 125) Drills (Fig. 126) Sharp retractors (four) (Fig. 81) Tourniquet Chromic catgut No. 1 on curved catgut needle Silver wire Dressings Material for plaster-of-Paris cast The Method of Making Plaster-of-Paris Bandages The material for plaster-of-Paris bandages is starched crin- oline and quick-setting dental plaster. The mesh of the crinoline is 30 by 32 strands to the square inch; a coarser mesh allows the plaster to drop out, and the bandages are not satisfactory. The plaster is the so-called “clover-leaf brand,” and is designated as “quick-setting xx dental plaster.” The bandages are made as follows: The crinoline, 18 inches wide and about 5f yards long, is spread on a long frame table, the plaster of Paris is rubbed into the meshes of the cloth, and the crinoline rolled on a special roller device until the roll is about 2.5 inches in diameter. By weight there are ounces of crinoline to 21T9o ounces of plaster; about three parts of plaster to one part of crinoline. The plaster bandage roll is placed in a cutting device, and the bandages cut into either 4- or 8-inch widths. In the ordinary plaster boxes as supplied to the hospitals there are seventy-two 4-inch rolls of plaster, or thirty-six 8-inch rolls of plaster. The method of applying an ordinary cast The extremity on which the cast is to be applied is covered with (1) stockinet of suitable width, (2) a layer of table felting, (3) a cotton sheet, and (4) a layer of paper bandage. Plaster bandages are soaked in cold water until the water stops bubbling in a pail equipped with a coarse wire drain to which is attached a suitable handle. When the water stops bubbling the wire screen is lifted by its handle, and the bandages allowed to drain BONE OPERATIONS 97 for a minute or two, after which they are wound about the part or member being treated. Each turn of the bandage is rubbed so as to make a smooth, well-fitting cast. If a leg or arm which has been operated on is being covered and there is a chance that swelling may occur, canvas suspension straps are incorporated in the cast so that the limb may be suspended by means of an Fig. 25.—Plaster-of-Paris cart. over-head Balkan frame. This technic prevents, to a great extent, swelling and the necessity of splitting the cast. Figure 25 is a cart for the convenient handling of plaster-of- Paris bandages. It contains all material necessary for making the bandages, including stockinet, table felt, and silence cloth. A compartment is also provided for knives, and so forth, for re- moving the casts. OTHER MISCELLANEOUS OPERATIONS Operation For Spina Bifida Instruments and sutures Usual preparation Dissecting instruments No. 0 or No. 1 chromic catgut on Crile needle Plain catgut on catgut needle Dermal Sterile cotton and tincture of benzoin Lumbar Puncture Instruments and sutures Needle and trocar Receptacle for fluid Sponges to wash parts Iodin swab Dressing Skin Grafting Instruments and sutures Skin grafting retractors (Quin) One or two razors (sharp) One or two tissue forceps (fine) Pointed scissors (Mayo) Two or three forceps (Allis) One or two appendix invertors (Mayo) Salt solution Wire gauze Vaselin dressing where the skin was taken 98 other miscellaneous operations 99 Operation For Varicose Veins Instruments and sutures Rochester cutting scissors Dissecting scissors (Mayo) Vein strippers (Mayo) Sharp retractors (Murphy) Tissue forceps (Sands) Forceps (straight) (Ochsner) Forceps (Murphy) Forceps (curved) (Kelly) Catgut for tying Silkworms on large surgical needle Dermal on small surgical or Keith needle Dressing and sterile bandage Operation For Peripheral Nerves Instruments and sutures Usual preparation Dissecting instruments Dural forceps Twelve forceps (Halsted) Sharp scalpels Crile needles (non-cutting) Instruments and sutures Circumcision Sharp pointed scissors (Mayo) Rochester cutting scissors Scalpel (fine) Six or eight anastomosis forceps (Allis) Eight or ten mosquito forceps (Halsted) No. 0 chromic catgut on intestinal or small surgical needle Sterile vaselin dressing No. 1 plain catgut Fine silk IOO INSTRUCTIONS FOR THE OPERATING ROOM V-shaped Excision of Lip Instruments and sutures Rochester cutting scissors Trachelorrhaphy scissors (Hanks) Scalpel Tissue forceps (Sands) Six to ten hemostats (Ochsner-Mayo) Two stomach clippers No. 1 chromic catgut on Mayo catgut needle Three or four silkworm sutures on surgical needles Dermal on small surgical needles Iodin Instruments and sutures Operation For Harelip Tiny scalpel Eight mosquito forceps (Halsted) Six or eight forceps (Allis) Tissue forceps (Sands) Four artery clamps (Langenbeck) Periosteal elevators (Richardson) Silkworm sutures on tiny Crile needles Dermal on tiny surgical needles Operation For Cleft Palate Instruments and sutures Mouth gags (Denhardt) Small sharp pointed scissors (Mayo) Rochester small cutting scissors Eight or ten mosquito forceps (Halsted) Two fine and large tissue forceps (Sands) Small tongue depressor (Pynchon) Periosteal elevators (Richardson) Periosteal elevators, two sizes (Allis) Eight anastomosis stomach clickers (Allis) Silkworm, tiny Crile needles OTHER MISCELLANEOUS OPERATIONS IOI Tonsillectomy and Adenoidectomy Instruments and sutures Mouth gag (Whitehead) Small tongue depressor (Pynchon) Small dissecting scissors (Mayo) Four or five vulsellum forceps (Henrotin) Tissue forceps (Sands) Adenoid curet (Gottstein’s) TECHNIC OF BLOOD TRANSFUSION After the blood has been grouped in order to determine the compatibility of the blood of the prospective donor with that of the recipient, the technic of the blood citrate method involves: (1) The preparation of instruments and reagents; (2) the sur- gical preparation of the arm of the donor and of the recipient; (3) the withdrawal of blood from the vein of the donor; (4) the infusion of the withdrawn blood into the vein of the recipient. Instruments required Glass graduate (500 c.c.) Stirring rod Rubber delivery tubes, 6 to 8 inches long, with needle (large, 13 to 15 gauge), sharp, polished on the inside, and pref- erably fitted with trocar Glass salvarsan tube (500 c.c.) with 3 or 4 feet of rubber tubing having adapter attachment to the recipient’s needle, and with one or more needles, is used for running the blood into the vein of the patient Cambric needles (sizes 10, 12, or 14) for transfixing veins when necessary Hypodermic syringe of novocain The needles are boiled or, preferably, carbolized. All other utensils are boiled or sterilized, and all glassware and rubber tubing used in contact with the blood, are rinsed, and then boiled in distilled or soda water. The reagent sodium citrate should be the purest obtainable crystalline salt, and may be obtained in 5 c.c. ampules containing 18 grains of the salt in solution in distilled water, enough to prevent coagulation in one pint of blood. In order that it may better mix with the blood, the citrate is dissolved in about 55 c.c. of 0.6 per cent saline made up with freshly redistilled water. 102 TECHNIC OF BLOOD TRANSFUSION 103 An extra portion of citrate solution is used for rinsing all glass- ware and tubing immediately before contact with the blood. All new rubber tubing is thoroughly cleansed with a small buret brush and soaked for three days in 5 per cent sodium hydroxid and irrigated with tap water for a week or more. The arm of the donor and the arm of the recipient are washed with benzin, painted with 3 per cent ticture of iodin, and draped with sterile towels so that the veins of the cubital fossa are ex- posed. The veins are made prominent by tightening the tourni- quet above the elbow while the patient opens and closes his fist. The needle is inserted into the donor’s vein, through an intra- dermal novocain wheal, pointing toward the hand. The nurse holds the delivery tube leading from the donor’s needle so that the stream of blood, without splashing or dripping, is directed into the citrate solution, which is stirred slowly and continuously with the glass rod until the desired amount of blood has been withdrawn. The tourniquet is kept only tight enough to block the venous flow above the elbow, while the donor slowly opens and closes his fist in order to maintain a steady stream of blood throughout the procedure. Fifty cubic centimeters of saline solution is then poured into the salvarsan tube, and the air is removed from the long rubber delivery tube attached, which is then left pinched or clamped off while the needle is inserted into the recipient’s vein in the direction of the venous blood flow. The delivery tube is attached to the needle while blood is flowing from the patient and saline from the tubing so that no air may enter. Then the citrated blood is added. The first 100 c.c. of blood is allowed to run in slowdy during five minutes or more, while the patient is watched and also instructed to report any unusual symptoms. The remainder of the blood is allowed to run in within from ten to fifteen minutes. If any questionable symptoms arise, the procedure is stopped and is not continued unless the changes noted are quite insignificant and transitory. ANESTHESIA Ether is administered by the drop method on a chloroform mask covered with stockinet. When the anesthetist desires to obtain a more concentrated vapor, surgeons’ gauze is folded over the stockinet, and the ether is dropped on the gauze. As a precaution against cross infection, the anesthetist ster- ilizes her hands after each operation, resterilizes the mask, puts on a fresh piece of sterile stockinet, and uses fresh sterile gauze for making folds. At the end of the day’s work, the pieces of stockinet and gauze are washed and sterilized to be used again. Ether Anesthesia Nitrous Oxid and Oxygen Anesthesia Nitrous oxid and oxygen, commonly spoken of as gas oxygen anesthesia, is given by the closed method. The face mask is placed over nose and mouth with precaution that both are free; it is held in place by a towel and clamp and the sides are packed with cotton to prevent gas from escaping, and to exclude the air which would add nitrogen to the gas. The exhaling valve on the top of the mask may be used. The anesthetist has on hand an ample supply of oxygen. Cyanosis is not permitted even for a moment. Ether or local anesthesia is combined with nitrous oxid and oxygen to produce the deeper anesthesia. If the face mask, breathing tube, and bag have been used in an infectious case, they are soaked in a solution of carbolic, 1:40, for two hours; otherwise it is washed with soap and water and im- mersed in a carbolic solution. Regional Anesthesia In the induction of regional anesthesia, procain (Metz) solutions are used. Injections are made with the Labat special syringe and needles for regional anesthesia. 104 ANESTHESIA 105 Preparation of the solution Half physiologic salt solution (0.45 per cent) is prepared, boiled for ten minutes, let cool, and put in sterile bottles. This is called a sterile salt solution. Twenty-five to 50 c.c. of sterile salt solution is heated to boiling point, and 2.5 gm. (the contents of one paper) of novocain powder is added. This gives a novocain solution. It is stirred for two minutes, and removed from the fire. Seventy-five c.c. of salt solution is poured into a graduated glass, the novocain solution added, then completed with saline up to 250 c.c. for 1 per cent solution, or to 500 c.c. for 0.5 per cent solution. Larger amounts may be made up at a single boiling by using more papers of novocain and keeping in mind the amount of saline necessary to dilute to the required percentage of strength. Ten drops of adrenalin solution to 100 c.c. of novocain is added just before use and after the novocain solution is cold. One-half of 1 per cent solution (0.5 per cent) is used in in- filtration and field block work, and 1 per cent solution for most nerve block procedures. Apparatus Used in Regional Anesthetic Procedures The syringe and hypodermic needle are used in all local anesthetic work. Field block Two 8 cm. needles Two 10 cm. needles Caudal anesthesia Two spinal puncture needles Transsacral anesthesia Two spinal puncture needles Two 5 cm. needles Two 8 cm. needles Two 10 cm. needles 106 INSTRUCTIONS FOR THE OPERATING ROOM Paravertebral nerve block Two 8 cm. needles Two 10 cm. needles Splanchnic and parasacral anesthesia 12 cm. needles 15 cm. needles Sterilization of Syringe MISCELLANEOUS The syringe is kept in a basin of 70 per cent alcohol. When needed for use the disconnected parts are passed through 10 per cent formalin solution, then rinsed twice in sterile distilled water. The syringe may also be sterilized by boiling; the plunger is always first disconnected from the barrel. The plunger is not forced into the barrel until both are cool. Care of Needles The needles are sterilized by boiling five minutes immediately before they are used. Stylets or sheaths are not removed. After needles, stylets, and sheaths have been used, they are wiped dry with sponges. If they are tarnished, they are polished with a very fine emery cloth. Needles are washed with ether. Sheaths are dried by swabbing the inside with cotton appli- cators. A small amount of “ three-in-one” oil is injected into the lumen of each needle and the exterior is anointed with oil. Stylets are inserted into the needles, and each needle is placed into its corresponding sheath. Cotton Dressings The bolt of gauze or the amount required is unrolled and spread on a table. The rolls of cotton are cut in two, unrolled, and placed in the middle of the strip of gauze. The edges are folded over, and the dressings cut in about 10-inch lengths. They are folded over twice and put in packages of six in a cloth wrapper. Gauze is cut in 4-inch squares, and placed in about a 2-inch pile in a cotton wrapper. Raw-edged Sponges St. Mary’s Hospital Sponge (Fig. 26) Gauze in bolts of 100 yards is used. The bolt is cut, taking about 20 folds at a time (Fig. 26 a), leaving about 15 yards on io7 108 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 26.—St. Mary’s Hospital sponge. MISCELLANEOUS 109 the bolt; the folded edge is cut (Fig. 26 b); this is cut oblong in two pieces about 9 by 18 inches (Fig. 26 c); the corners and then the lower raw edge are brought to the middle (Figs. 26 d, e, f); the upper edge is turned in | inch (Fig. 26 g); this is folded over so that the upper edge covers the lower edge (Fig. 26 h); it is then folded in three parts (Fig. 26 i), making approximately a 25-inch square (Fig. 26 j), or in two parts. After these sponges have been used, they are laundered, stretched on a board in which nails have been driven about \\ inches apart, then folded. They are afterward used for hot dressings or for cleansing patients with benzin. St. Mary’s Hospital Square Pack With Marker (Fig. 27) The bolt of gauze is cut as in making St. Mary’s sponge. About 60 folds of the gauze gives material for 30 square packs. Fig. 27.—St. Mary’s Hospital square pack. Two folds are doubled, making the pack eight thicknesses (Fig. 27 a); this is stitched around the edge except for about 3 inches at one end (Fig. 27 b); through this opening the pack is turned inside out; a piece of black tape 8 inches long with a metal ring no INSTRUCTIONS FOR THE OPERATING ROOM Fig. 28.—St. Mary’s Hospital long pack. MISCELLANEOUS Ill at the end is prepared (Fig. 27 c), and inserted in corner of pack (Fig. 27 d), and the pack is stitched all around, and the ring is stitched in place to keep it stationary in the corner (Fig. 27 e). To make tape for the packs the best quality of black sateen is torn in strips 1 to 1| inches wide. Both edges are turned so that the width of the strip is about \ inch; this is sewed and cut in 8-inch lengths. St. Mary’s Hospital Long Pack (Fig. 28) Gauze 8 yards long and 18 inches wide is used. The edges are stitched, but it is not necessary to turn the gauze. A piece of tape is stitched in the right upper corner. Goiter Rolls Five-yard lengths are cut from a bolt of gauze. Raw edges are turned under at each end, folded lengthwise, making material 9 inches wide, and rolled. Iodin Swabs Iodin swabs are made by folding gauze four times; this gives thicknesses of gauze 4 inches wide, which are cut in 3-inch lengths, and are put up in packages of twenty-five. Caps and Masks (Fig. 29) Straight nose and mouth mask (Fig. 29 a) Voile, double Length, 8 inches; width, 9 inches Two 26-inch tapes are drawn through hem at sides Cap with band and circular top (Fig. 29 b) Double muslin for band, soft India linen for top Band, 3| inches wide, 24 inches long Top, circle 12 inches in diameter 11 2 INSTRUCTIONS FOR THE OPERATING ROOM a, Straight nose and mouth mask b Cap with band and circular -top c Gathered nose and mouth mask, d Nose and mouth mask with wire e Head mask Fig. 29.—Caps and masks for operating room, Gathered nose and mouth mask (Fig. 29 c) Voile, double Length, 7| inches; width, 8 inches Width is shirred to a 3-inch length; the mask is bound with tape, and a 12-inch length of tape for tying sewed at each corner MISCELLANEOUS IX3 Nose and mouth mask with wire (Fig. 29 d) India linen or voile Length, 12 inches; width, 14 inches Doubled piece in center, 5| inches long, 6 inches wide Tape for tying is sewed on both sides, 4| inches from the top. A fuse wire 22 inches long is run through hem at the top, to go over the nose and back of the ears Head mask (Fig. 29 e) India linen or voile Width, 18 inches; length, 21 inches Opening for eyes, 6 inches from lower edge; length, inches; width, 3 inches Doubled piece for mouth and nose, length 4J inches; width, 5| inches; shirred at tapering top to fit over nose Two 9-inch tapes for tying are sewed at the lower end of mask, and two 14-inch tapes are sewed at each side of the opening Sterilization of Dressings and Vaselin The dressings already wrapped are placed in the autoclave for one hour at 15 pounds pressure. The vaselin is put in jars of convenient size, and placed in the autoclave for the same length of time under the same pressure. Preparation of Sets of Gloves A package is made containing One small towel for each glove or pair of gloves Two large towels Newspapers Gown Powder which is sterilized. Gloves are boiled fifteen minutes. Hands and arms are scrubbed for ten minutes; nurse puts on gown, spreads the papers, and then the towels. Gloves are wiped and powdered, and wrapped in small towels, either singly or in pairs. SOLUTIONS Dichloramin-T 25 gr. of powdered dichloramin-T 1 oz. of fluid chlorcosane Mix the powder with some of the fluid chlorcosane to make a smooth paste. Heat remaining fluid to 80° C. and combine with the mixture Tincture of iodin (7 per cent) Apothecaries’ weight 4 oz. 3 drs. of iodin crystals 3 oz. 1 dr. of potassium iodid 2 qts. of 90 per cent alcohol Metric weight 140 gm. of iodin crystals 100 gm. of potassium iodid 2 liters of 90 per cent alcohol Ochsner’s (500 c.c.) 100 c.c. distilled water 100 c.c. alcohol 300 c.c. boric acid 30 c.c. carbolic (making approximately a 5 per cent solution) Balsam Peru in castor oil (5 per cent solution) 4000 c.c. castor oil 200 c.c. balsam Peru Warm castor oil to 80° C.; add balsam Peru Chinisol (2 per cent solution) 16 oz. distilled water 154 gm. chinisol powder H4 SOLUTIONS IIS 66 gm. sodium chlorid Mix well, shake vigorously, strain through piece of sterile gauze; handle with sterile forceps Chlorid of lime 10 pounds of chlorid of lime 20 pounds of soda (Wyandotte) Ten pounds of chlorid of lime are placed in jar and 20 pounds of soda (Wyandotte) in tube, a pail of cold water is poured on the lime, and it is left to dissolve. Cold water is poured on the soda; this is poured into the lime, and stirred quickly or the lime will burn (the lime is not poured on the soda). This makes 40 gallons of chlorid of lime Glucose (10 per cent) This is prepared in the laboratory and given the same as a blood transfusion Calcium preparation In sterile towel are placed Two 10 c.c. syringes (Luer) Needles Sponges Alcohol for cleansing Pair of forceps 5 c.c. 10 per cent calcium chlorid in ampule Tourniquet Preparation of materials used in subcutaneous injection of salt solution 95 per cent alcohol 5 per cent carbolic Sterile water Sandpaper Fig. 30.—Salt solution ready for subcutaneous injection. Fig. 31.—Giving a patient the subcutaneous injection of salt solution. ii6 SOLUTIONS 117 Sterile gloves are worn. The needles are sandpapered, wired, and placed in alcohol. The bottle is uncorked, and bottle with tubing is immersed in 5 per cent carbolic acid, rinsed with 5 per cent alcohol and with sterile water; filled with sterile sodium chlorid solution (18 gm. salt to 2000 c.c. water), and corked. The needle, attached to the tubing, is placed in a sterile towel, and the tubing wrapped around the neck of the bottle. Two strips of adhesive are attached to the bottle. Small package of sponges, swab, and iodin are required for the preparation of the patient for the injection (Figs. 30 and 31). DRAINS Gutta percha The gutta percha is washed with soap and water, cut into desired lengths, each piece rolled in gauze and placed in 1:1000 solution bichlorid of mercury. Rubber tubing New tubing is boiled for one hour before using it the first time. Thereafter it is boiled with the instruments when it is needed. Penrose tubing Boiled fifteen minutes and placed in a sterile jar. Vaselin gauze Into a porcelain pan with cover is placed a layer of 1-inch, 2-inch, or 3-inch gauze, then a layer of vaselin, and so on alternately until the pan is filled; it is then sterilized in autoclave for one hour. Vaselin-iodoform gauze Sterile iodoform gauze is dipped into melted sterile vaselin. Iodoform gauze (2.5 per cent) A solution is made of 500 c.c. soapsuds (green soap) 25 c.c. iodoform powder This is about enough for seven bandages. After mixing thoroughly, bandages are unrolled, placed in the solution, and wrung dry; they are then rolled, wrapped separately in gauze, and boiled for fifteen minutes. Sterile gloves are worn to wring the bandages dry. A number of sterile towels are wrapped around the bandages, and they are hung in a warm place, or placed in a warm autoclave for about two days. When dry, they are placed in a dark sterile jar. xx8 DRAINS ng Iodoform gauze A solution is made of 180 c.c. soapsuds (green soap) 25 c.c. iodoform powder 10 c.c. glycerin The glycerin and iodoform powder are mixed and then ster- ilized in the autoclave for one-half hour at 15 pounds pressure. The sterile salt solution is added, and the sterile bandages are placed in the solution, wrung dry, and rolled. They are kept in a dark, covered jar. Dermal SUTURES The outer two paper covers are removed, and the dermal with the third cover on is boiled for two minutes Silkworm This is boiled from ten to fifteen minutes and placed in 4 per cent iodin for five days before using to render more pliable Silk This is boiled for fifteen minutes and placed in 70 per cent alcohol Chinese twist and silk Irish linen This is boiled from ten to twelve minutes and preserved in 75 per cent alcohol or 1:1000 bichlorid Catgut tubes These are scrubbed with soap and water, washed in running water, and placed in 5 per cent carbolic for forty-eight hours. The tubes are covered with double layer of gauze. Before using, tubes are washed in sterile water 120 INTERN’S DRESSING BASKET (Fig. 32) Instrument cup for sterile instruments Instrument cup for used instruments Half-cup 3 per cent carbolic containing Eight curved forceps Eight tissue forceps Eight scissors Fig. 32.—Intern’s dressing basket. Bottle of 3 per cent iodin Bottle of 50 per cent alcohol Bottle of sterile vaselin Papers to receive soiled dressings Three-inch and 4-inch roller bandages Two packages of large dressings 121 122 INSTRUCTIONS FOR THE OPERATING ROOM Two packages of small dressings Package of raw-edged sponges Three rolls of adhesive Adhesive roller Iodin swabs TRAYS Tracheotomy set Tracheotomy tube Scalpel Retractors (6 straight, 2 curved) Catgut Needle and holder Tissue forceps Scissors Dressings Sterile gloves Eye Package of sterile sponges Small bottles containing Boric acid solution Argyrol (10 per cent) Albolin Eye shield Adhesive Uterine hemorrhage Two pairs sterile gloves Uterine packer Vaginal pack Sterile towels Tissue forceps (Kelly) (Fig. 17) Gauze Tube of iodoform gauze Abdominal hemorrhage Two pairs sterile gloves Six straight forceps 123 124 INSTRUCTIONS FOR THE OPERATING ROOM Two curved forceps Tissue forceps (Kelly) (Fig. 17) Scalpel Needles and holder Catgut Tube of iodoform gauze Dressings Scissors Adhesive Sterile towels Aspiration Small dish containing Scalpel Syringe and aspirating needles Sterile culture tube Aspiration tube Adhesive Catgut Needles and holder Scissors Tissue forceps Dressings (small and large) Intravenous Five sterile towels Two curved hemostats Tourniquet Knife for incision Small knife Tissue forceps Fine tissue forceps Scissors Small sharp pointed scissors Four small pointed forceps Cannulas (2 sizes) TRAYS 125 Salvarsan tube (500 c.c.) Two yards rubber tubing Graduate (500 c.c.) One Lewisohn needle, 15 gauge No. 0 catgut for tying One-half strand dermal on dermal needle Laparotomy SETS OF STERILE LINEN Laparotomy sheets Seven towels Three wound towels Dressings Fifty sponges used as wipes, and not counted Sheet for anesthetist’s screen Goiter Eight towels Two sheets Fifty sponges Gauze for the cone Lithotomy Three towels One wound towel Fifty sponges Lithotomy sheet Kraske Laparotomy sheet Seven towels Fifty sponges Kidney Same as for Kraske Breast Two small sheets Eight towels 100 sponges 126 TO OPERATE AUTOCLAVE Open safety valve on top of autoclave Open steam chamber and vacuum Open waste pipe before filling autoclave with water Open steam supply Close steam chamber Lower safety valve when it sputters Get steam up to 15 pounds pressure Then open steam chamber until there are 5 inches of vacuum Close vacuum valve When right and left gauge register 15, begin to count Sterilize for one hour Close steam chamber Open vacuum valve until it drops to 5, then open steam chamber until there are 5 inches of vacuum Close steam chamber Close vacuum valve, being sure to have steam chamber closed first Turn off steam supply Open door 127 INDEX OF ILLUSTRATIONS Alexander bone chisel, Fig. 67 Amphitheater, Fig. 4 Angular bone-cutting forceps, Fig. 143 Auvard weighted vaginal speculum, Fig. 82 Backhaus towel forceps, Fig. 38 Balfour abdominal retractor, Fig. 60 Beef-bone plates (Brougham and Ecke), Fig. 114 Bone mallet, Fig. 68 Bonney cutting needle, Fig. 80 Bozeman uterine douche, Fig. 87 Brain instruments, Fig. 18 Breast position undraped, Fig. 15 Breast position draped, Fig. 16 Brunner step forceps or right-angle clamp, Fig. 84 Caps and masks, Fig. 29 Carmalt curved forceps, Fig. 34 Carmalt hysterectomy clamp, Fig. 100 Charriere’s bone-cutting forceps, Fig. 120 Cheyne dry dissector, Fig. 131 Chisels, Fig. 138 c Collins suturing forceps, Fig. 65 Collins two-prong retractor, Fig. 71 Crile double retractor, Fig. 90 Cushing clip forceps and holder, Fig. 21 Deaver abdominal retractor, Fig. 73 Deaver small retractor, Fig. 95 Electric cautery, Fig. 144 Esmarch rongeur, Fig. 122 128 INDEX OF ILLUSTRATIONS 129 Fenger curved forceps, Fig. 48 Ferguson angle on flat scissors, Fig. 37 Ferguson bone-holding forceps, Fig. 121 Ferguson double-end retractor, Fig. 83 Ferguson grooved sound, Fig. 88 Fibroid hook, Fig. 62 Fifth floor plan, Fig. 2 Fracture table, Fig. 24 Fritsch abdominal retractor, Fig. 39 Geiger drills and saws, Fig. 126 Geiger electric motor, Fig. 125 Gigli handle, Fig. 20 Gigli saw, Fig. 19 Gouge, Fig. 138 b Green retractor, Fig. 75 Grooved director probe, Fig. 97 Hand saw, Fig. 138 a Hedblom periosteal elevator, Fig. 103 Hegar needle-holder, Fig. 41 Henderson beef-bone brace, Fig. 110 Henderson beef-bone screw-driver, Fig. 109 Henderson brace, Fig. Ill Henderson tap, Fig. 112 Henrotin vulsellum forceps, Fig. 61 Herzel periosteal elevator, Fig. 102 Hibbs cutting forceps, Fig. 119 Hospital asepto syringe, Fig. 22 Hudson sternum shears, Fig. 104 Intern’s dressing basket, Fig. 32 Israel retractor, Fig. 70 Jansen mastoid retractor, Fig. 23 Judd-Masson retractor, Fig. 74 130 INSTRUCTIONS FOR THE OPERATING ROOM Keith straight needle, Fig. 43 Kelly tissue forceps, one tooth, Fig. 35 Kelly straight forceps, Fig. 45 Kelly 9-inch tissue forceps, Fig. 49 Kelly gauze packer, Fig. 53 Kidney position undraped, Fig. 13 Kidney position draped, Fig. 14 Kraske position undraped, Fig. 11 Kraske position draped, Fig. 12 Kraske six-prong retractor, Fig. 69 Lane bone-holding forceps, Fig. 118 Lane screw-driver, Fig. 135 Lane steel plate, eight-hole, Fig. 133 Lane steel plate, six-hole, Fig. 134 Laparotomy, ready for, Fig. 9 Leg rest, Fig. 140 Liston bone-cutting forceps, Fig. 96 Little curved lithotomy forceps, Fig. 78 Little straight lithotomy forceps Fig. 79 Luer curved rongeur, Fig. 123 Mayo appendix invertor, Fig. 44 Mayo catgut needle, Fig. 40 Mayo common-duct probe, Fig. 54 Mayo common-duct scoop, Fig. 55 Mayo curved dissecting scissors, small, Fig. 36 Mayo cystic-duct scoop, Fig. 51 Mayo stone forceps, Fig. 72 Mayo straight dissecting scissors, Fig. 58 Mayo trocar needle, Fig. 42 Mayo ureter knife, Fig. 101 Meyerding mallet, Fig. 129 Meyerding sacral rest, Fig. 141 Moore bile spoon, Fig. 52 Murphy artist chisels, Fig. 127 Murphy brace handle, Fig. 115 INDEX OF ILLUSTRATIONS 131 Murphy forceps, Fig. 63 Murphy medulla reamers, Fig. 116 Murphy reamers, Fig. 117 Murphy sharp retractor, Fig. 81 Neck position, Fig. 17 Needle, calix-eyed intestinal, Fig. 47 Needle, No. 6, cutting, Fig. 92 Ochsner gallbladder trocar, Fig. 50 Ochsner stomach clippers, Fig. 56 Ochsner straight forceps, Fig. 33 Operating room, Fig. 5 Operating table, Fig. 7 Osteotome, Fig. 138 c Otis-van Buren sound, Fig. 89 Oviatt prostate forceps, Fig. 76 Owen double-end bone curet, Fig. 98 Parham-Martin holder and band, Fig. 137 Parker amputating saw, Fig. 124 Parker double-end retractor, Fig. 94 Payr gastrectomy clamp, Fig. 66 Plain periosteal raspatory, Fig. 130 Plaster-of-Paris cart, Fig. 25 Probe, 12-inch silver, with eye, Fig. 128 Pynchon tongue retractor, Fig. 77 Rankin bladder retractor, Fig. 107 Salt solution, Fig. 30 Sands double retractor, Fig. 91 Schroeder goiter needle, No. 1, Fig. 93 Scissors, curved, Fig. 46 Screw and tap holder, Fig. 108 Scudder stomach clamp, short and long, Fig. 57 Self-retaining retractor, Fig. 106 132 INSTRUCTIONS FOR THE OPERATING ROOM Simplex screw-driver, Fig. 136 Sims uterine curet, Fig. 64 Sims vaginal retractor, Fig. 99 Sixth floor plan, Fig. 3 Sponge, square pack and long pack, Figs. 26, 27, and 28 Sterile table, Fig. 8 Sterilizing room, Fig. 6 Stille-Liston cutting forceps, Fig. 105 Subcutaneous injection, Fig. 31 Surgical pavilion, Fig. 1 Sweet amputating retractor, Fig. 142 Thomas uterine curet, Fig. 86 Trendelenburg position, Fig. 10 Tube, suction, Fig. 59 Twist drill, Fig. 113 Volkmann bone curet, Fig. 132 Wylie dilator, Fig. 85 Yankee hand drill, Fig. 139 INDEX OF ILLUSTRATIONS 133 Fig. 33.—Ochsner straight forceps. 6 %¥,V\W CYv\C.M»^. Fig. 37.—Ferguson angle on flat scissors. Fig. 35.—Kelly tissue forceps, one tooth. Fig. 36.—Mayo curved dissecting scissors, small. Fig. 38.—Backhaus tovv-i forceps. Fig. 34.—Carmalt curved forceps. 134 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 39.—Fritsch abdominal retractor, Fig. 43.—Keith straight needle Fig. 41.—Hegar needle holder Fig. 44.—Mayo appendix invertor. Fig. 42.—Mayo trocar needle. Fig. 40.—Mayo catgut needle. 5HABPB5MITH SHARP 6 5M1TH INDEX OF ILLUSTRATIONS i35 Fig. 45.—Kelly straight forceps. Fig. 47.—Calix-eyed intestinal needle. SHARP a SMITH Fig. 48.—Fenger curved forceps. Fig. 46.—Curved scissors. 136 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 49.—Kelly 9-inch tissue forceps. Fig. 55.—Mayo common-duct scoop. Fig. 52.—Moore bile spoon. Fig. 53.—Kelly gauze packer. Fig. 54.—Mayo common-duct probe. Fig. 51.—Mayo cystic-duct scoop. Fig. 50.—Ochsner gallbladder trocar. INDEX OF ILLUSTRATIONS 137 Fig. 58.—Mayo straight dissecting scissors. Fig. 56.—Ochsner stomach clippers. Fig. 57.—Scudder stomach clamp. Fig. 59.—Suction tube. SANDS 138 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 60.—Balfour abdominal retractor. Fig. 61.—Henrotin vulsellum forceps or tenaculum. Fig. 64.—Sims uterine curet. Fig. 63.—Murphy forceps. Fig. 62.—Fibroid hook. SHARP a SMITH INDEX OF ILLUSTRATIONS 139 Fig. 68.—Bone mallet. 2474 Fig. 70.—Israel retractor. Fig. 65.—Collins suturing forceps. Fig. 67.—Alexander bone chisel. Fig. 66.—Payr gastrectomy clamp. Fig. 69.—Kraske six-prong retractor. Fig. 71.—Collins two-prong retractor. SHARP lit SMITH 140 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 73.—Deaver abdominal retractors. Fig. 72.—Mayo stone forceps. Fig. 75.—Green retractor. Fig. 74.—Judd-Masson retractor SandS INDEX OF ILLUSTRATIONS I4I Fig. 80.—Bonney cutting needle. Fig. 78.—Little curved lithotomy forceps. Fig. 76.—Oviatt prostate forceps. SHARP B5MITH Fig. 81.—Murphy sharp retractor. Fig. 79.—Little straight lithotomy forceps. Fig. 77.—Pynchon tongue retractor. 142 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 82.—Auvard weighted vaginal speculum. Fig. 86.—Thomas uterine curet Fig. 84.—Brunner step forceps or right-angle clamp. Fig. 83.—Ferguson double-end retractor. Fig. 85.—Wylie dilator. INDEX OF ILLUSTRATIONS 143 Fig. 90.—Crile double retractor. Fig. 91.—Sands double-end retractor. Fig. 87.—Bozeman uterine douche. Fig. 89.—Otis-van Buren sound. Fig. 88.—Ferguson grooved sound. Fig. 92.—No. 6 cutting needle. SHARP S SMITH 144 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 93.—No. 1 Schroeder goiter needle. Fig. 95.—Deaver small retractor. SHfiRP a SMITH Fig. 98.—Owen double-end bone curet. Fig. 97.—Grooved director probe. SANDS SHARP Q SMITH Fig. 96.—Liston bone-cutting forceps. Fig. 94.—Parker double-end retractor. Fig. 99.—Sims vaginal retractor. SANDS INDEX OF ILLUSTRATIONS 145 Fig. 100.—Carmalt hysterectomy clamp. Fig. 102.—Hedblom periosteal elevator. Fig. 103.—Herzcl periosteal elevator. Fig. 101.—Mayo ureter knife. 146 INSTRUCTIONS TOR THE OPERATING ROOM Fig. 104.—Hudson sternum shears. Fig. 105.—Stille-Liston cutting forceps. Fig. 106.—Self-retaining retractor. INDEX OF ILLUSTRATIONS 147 Fig. 109.—Henderson beef-bone screw-driver. Fig. 107.—Rankin’s bladder retractor. Fig. 111.—Henderson brace. Fig. 110.—Henderson beef-bone screw-brace. SHARP&SMITH Fig. 108.—Screw and tap holder. Fig. 113.—Twist drill. Fig. 112.—Henderson tap. 148 INSTRUCTIONS TOR THE OPERATING ROOM Fig. 114.—Brougham and Ecke beef-bone plates. Fig. 115.—Murphy brace handle. Fig. 116.—Murphy medulla reamers. INDEX OF ILLUSTRATIONS 149 Fig. 117.—Murphy reamers. Fig. 120.—Charriere bone cutting forceps. Fig. 118.—Lane bone-holding forceps. Fig. 119.—Hibbs cutting forceps. i5° INSTRUCTIONS FOR THE OPERATING ROOM Fig. 122.—Esmarch rongeur. Fig. 121.—Ferguson bone-holding forceps. Fig. 124.—Parker amputating saw. Fig. 123.—Luer curved rongeur. INDEX OF ILLUSTRATIONS i5i Fig. 125.—Geiger electric motor. Fig. 128.—Twelve-inch silver probe with eye Fig. 126.—a, Geiger twist drill; b, Geiger twin and single saw; c, Geiger twist drill. Fig. 127.—Murphy artist chisels. 152 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 131.—Cheyne dry dissector. Fig. 129.—Meyerding mallet. Fig. 133.—Lane steel plate (eight-hole). Fig. 130.—Plain periosteal raspatory, Fig. 134.—Lane steel plate (six-hole). Fig. 132.—Volkmannbone curet. FULL SIZE INDEX OF ILLUSTRATIONS 153 Fig. 135.—Lane screw driver. Fig. 136.—Simplex screw-driver. Fig. 137.—Parham-Martin holder and band. J54 INSTRUCTIONS POR THE OPERATING ROOM Fig. 138.—a, Hand saw; b, gouge; c, chisel osteotomes. Fig. 139.—Yankee hand drill. INDEX OF ILLUSTRATIONS i55 Fig. 140.—Leg rest. Fig. 141.—Meyerding sacral rest. Fig. 143.—Angular bone-cutting forceps. Fig. 142.—Sweet amputating retractor. *56 INSTRUCTIONS FOR THE OPERATING ROOM Fig. 144.—Electric cautery. INDEX Abdominal hemorrhage tray, 123 hysterectomy, instruments and su- tures for, 48 hysterotomy, instruments and su- tures for, 50 myomectomy, instruments and su- tures for, 49 operations, 34 preparation of patient for, 34 Abscess, drainage of, instruments and sutures for, 47 of lung, drainage of, instruments and sutures for, 69 Adenoidectomy, instruments and su- tures for, 101 Albee bone graft to spine, instruments and sutures for, 90 Amputation of breast, instruments and sutures for, 73 of cervix, instruments and sutures for, 64 of leg, instruments and sutures for, 92 Anesthesia, ether, 104 nitrous oxid and oxygen, 104 regional, 104 preparation of solution, 105 Anesthetic procedures, apparatus used in, 105 caudal, 105 field block, 105 paravertebral nerve block, 106 splanchnic and parasacral, 106 transsacral nerve block, 105 Ankle, arthrodesis of, instruments and sutures for, 95 Appendectomy, instruments and su- tures for, 36 Application of metal plate on femur, instruments for, 88 Arthrodesis of ankle, instruments and sutures for, 95 Arthroplasty of elbow, instruments and sutures for, 89 of hip, instruments and sutures for, 88 of knee, instruments and sutures for, 89 Aspiration tray, 124 Astragalectomy, instruments and su- tures for, 95 Autoclave, to operate, 127 Balsam Peru in castor oil, solution, 114 Bandages, plaster-of-Paris, method of making, 96 Basin stand, 27 Billroth No. 2, instruments and su- tures for, 43 Bladder, diverticulum of, instruments and sutures for, 55 resection of, 55 Blood transfusion, instruments re- quired, 102 technic of, 102 Bone graft to spine, Albee, instru- ments and sutures for, 90 operations, ordinary instruments, 86 157 158 INDEX Bone plate for fractured radius or ulna, instruments and sutures for, 93 transplant for fractured femur, in- struments and sutures for, 86 Bovee operation, instruments and su- tures for, 65 Breast, amputation of, instruments and sutures for, 73 position, 71 preparation of patient for operation on, 71 set of sterile linen for, 126 Brown’s operation for colitis, instru- ments and sutures for, 44 Bunion, operation for, instruments and sutures used, 92 Calcium, preparation of, 115 Campbell or Soutter operation for contraction of hip, instruments and sutures for, 93 Cap, with band and circular top, tech- nic of making, 111 Care of needles, 107 Casts, plaster-of-Paris, technic of applying, 96 Catgut tubes, sutures, 120 Catheter for closed drainage of em- pyema, instruments and sutures used, 68 Caudal anesthesia, instruments used, 105 Cavity, open drainage of empyema, instruments and sutures used, 68 Cecum, resection of, instruments and sutures for, 44 Cerebellar flap, craniotomy with, in- struments and sutures for, 84 operation, craniotomy for, 84 Cervix, amputation of, instruments and sutures for, 64 Cesarean section, instruments and su- tures for, 50 Chest wall, resection of tumor, in- struments and sutures for, 69 Chinese twist and silk Irish linen su- tures, 120 Chinisol, solution, 114 Chlorid of lime, solution, 115 Cholecystectomy, instruments and sutures for, 37 Cholecystogastrostomy, instruments and sutures for, 39 Cholecystostomy, instruments and sutures for, 37 Choledochotomy, instruments and sutures for, 38 Chronic empyema, plastic operation, instruments and sutures for, 67 Circumcision, instruments and suture for, 99 Cleft palate, instruments and sutures for operation on, 100 Closed drainage of empyema for in- sertion of catheter, instruments and sutures used, 68 Closure of colostomy, instruments and sutures for, 52 Coccyx, removal of, instruments and sutures for, 59 Colitis, Brown’s operation, instru- ments and sutures for, 44 Colon, transverse, resection of, in- struments and sutures for, 44 Colostomy, closure of, instruments and sutures for, 52 Contraction of hip, Soutter or Camp- bell operation for, instruments and sutures for, 93 Cotton dressings, 107 Craniotomy with cerebellar flap, in- struments and sutures for, 84 technic of, 84 osteoplastic flap, instruments and sutures for, 82 technic of, 79 Curettage, instruments for, 64 Cyst, pancreatic, instruments and su- tures for operation for, 39 INDEX T59 Cystotomy, instruments and sutures for, 56 Dermal suture, 120 Dermoid, postanal, instruments and sutures for operation on, 59 Dichloramin-T, solution, 114 Dilatation of urethra, instruments and sutures for, 54 Diverticulum of bladder, instruments and sutures for, 55 of esophagus, instruments and su- tures for, 78 Drainage of abscess, instruments and sutures for, 47 of lung, instruments and sutures for, 69 of empyema cavity, open, instru- ments and sutures for, 68 closed, insertion of catheter, 68 Drains, 118 gutta-percha, 118 iodoform gauze, 118 Penrose tubing, 118 rubber tubing, 118 vaselin gauze, 118 iodoform gauze, 118 Dressing basket, intern’s, 121 Dressings, 107 and vaselin, sterilization of, 113 cotton, 107 Ducts, reconstruction of, instruments and sutures for, 38 Duodenal ulcer, excision of, instru- ments and sutures for, 40 Elbow, arthroplasty of, instruments and sutures for, 89 Empyema, insertion of catheter for closed drainage, instruments and sutures used, 68 open drainage of cavity, instru- ments and sutures for, 68 plastic operation for chronic, in- struments and sutures for, 67 Equipment of operating rooms, 23 Esophagus, diverticulum of, instru- ments and sutures for, 78 Ether anesthesia, 104 Excision of duodenal ulcer, instru- ments and sutures for, 40 of gastric ulcer, 41 of gastrojejunal ulcer, 41 posterior Kraske, 58 V-shaped, of lip, 100 Extraperitoneal shortening of round ligaments, instruments and sutures for, 45 Extrapleural thoracoplasty, instru- ments and sutures for, 70 Eye tray, 123 Femoral hernia, instruments and fu- tures for operation on, 46 Femur, application of metal plate, in- struments and sutures for, 88 fractured, bone transplant for, in- struments and sutures for, 86 Ghant osteotomy of, instruments and sutures for, 94 Field block anesthesia, instruments used in, 105 Fistula, rectal, instruments and su- tures for, 66 vesicovaginal, instruments and su- tures for, 64 Flap, cerebellar, craniotomy with, in- struments and sutures for, 84 osteoplastic, craniotomy with, in- struments and sutures for, 82 Foreign body in knee, instruments and sutures for operation for, 91 Fractured femur, bone transplant for, instruments and sutures for, 86 patella, instruments and sutures for, 95 radius or ulna, bone plate for, in- struments and sutures for, 93 Fusion operation, Hibbs’ spinal, in- struments and sutures for, 90 160 INDEX Gasserian ganglion operation, in- struments and sutures for, 83 Gastric ulcer, excision of, instruments and sutures for, 41 Gastro-enterostomy, instruments and sutures for, 40 Gastro jejunal ulcer, excision of, in- struments and sutures for, 41 Gastrostomy, instruments and su- tures for, 42 Gathered mask for nose and mouth, technic of making, 112 Ghant osteotomy of femur, instru- ments and sutures for, 94 Giving a patient a subcutaneous in- jection, 116 Glands of neck, instruments and su- tures for operations on, 76 Gloves, dry sterilized, 113 preparation of sets of, 113 Glucose, solution, 115 Goiter, ligation for, instruments and sutures for, 75 rolls, technic of making, 111 set of sterile linen for, 126 Grafting, skin, instruments and su- tures for, 98 Gutta-percha drain, 118 Hands, scrubbing of, 30 Harelip, instruments and sutures for operation for, 100 Head mask, technic of making, 113 Hemorrhoids, instruments and su- tures for, 65 Hernia, femoral, instruments and su- tures for, 46 inguinal, 46 scrotal, 47 umbilical, 47 ventral, 46 Hibbs’ spinal fusion operation, in- struments and sutures for, 90 Hip, arthroplasty of, instruments and sutures for, 88 Hip, contraction of, Soutter or Camp- bell operations for, instruments and sutures used, 93 Hydrocele, instruments and sutures for operation for, 47 Hydronephrosis, nephrectomy for, in- struments and sutures for, 62 Hysterectomy, abdominal, instru- ments and sutures for, 48 vaginal, instruments and sutures for, 63 Hysterotomy, instruments and su- tures for, 50 Ileocolostomy, instruments and su- tures for, 45 Ileum, resection of, instruments and sutures for, 44 Illustrations, index of, 128 Inguinal hernia, instruments and su- tures for, 46 Instructions to non-sterile nurse, 32 to sterile nurse, 32 Instruments used for abdominal op- erations, 36 for blood transfusion, 102 for bone operations, 86 for cerebellar operations, 84 for craniotomy, 82, 84 for ganglion operations, 83 for laminectomy, 85 for pituitary operations, 82 Intraperitoneal shortening of the round ligaments, instruments and sutures for, 50 Intravenous tray, 124 Intern’s dressing basket, 121 Iodin, tincture of, 114 swabs, technic of making, 111 Iodoform gauze, 118, 119 Kidney, preparation of patient for operation on, 60 set of sterile linen for, 126 INDEX 161 Kidney, tuberculous, nephrectomy for, instruments and sutures for, 62 Knee, arthroplasty of, instruments and sutures for, 89 foreign body in, instruments and sutures for, 91 resection of, instruments and su- tures for, 91 Kraske operation, posterior excision, instruments and sutures for, 58 preparation of patient for, 57 set of sterile linen for, 126 Laminectomy, instruments and su- tures for, 85 Laparotomy, set of sterile linen for, 126 Laryngectomy, instruments and su- tures for, 77 Leg, amputation of, instruments and sutures for, 92 Ligaments, round, extraperitoneal shortening of, instruments and sutures for, 45 intraperitoneal shortening of, 50 Ligation, goiter, instruments and su- tures for, 75 Lip, V-shaped excision of, instru- ments and sutures for, 100 Lithotomy, pelvic, instruments and sutures for, 61 position, 63 set of sterile linen for, 126 uretero, instruments and sutures for, 53 Local anesthesia, 104 Lumbar puncture, instruments and sutures for, 98 Lung abscess, drainage of, instru- ments and sutures for, 69 Mask, head, 113 nose and mouth, gathered, technic of making, 112 straight, technic of making, 111 Mask, nose and mouth, with wire, technic of making, 113 Metal plate on femur, instruments for application of, 88 Mikulicz operation, instruments and sutures for, 53 Myomectomy, instruments and su- tures for, 49 Neck, glands of, instruments and su- tures for operation on, 76 preparation of patients for opera- tion on, 74 Needles, care of, 107 Nephrectomy for hydronephrosis, in- struments and sutures for, 62 for tuberculous kidney, instruments and sutures for, 62 Nerves, peripheral, instruments and sutures for operation on, 99 Nitrous oxid and oxygen anesthesia, 104 Non-sterile surgical nurse, instruc- tions to, 32 Normal saline solution, 117 Nose and mouth mask, gathered, technic of making, 112 straight, technic of making, 111 with wire, technic of making, 113 Nurse, non-sterile, instructions to, 32 sterile, instructions to, 32 Ochsnek’s solution, 114 Oophorectomy and salpingectomy, in- struments and sutures for, 49 Open drainage for empyema cavity, instruments and sutures for, 68 Operating room, equipment of, 23 schedule, 31 Operation on breast, preparation of patient for, 71 on kidney, preparation of patient for, 60 162 INDEX Operation on neck, preparation of patient for, 74 on thorax, preparation of patient for, 67 preliminary procedures to, 25 Operations, abdominal, preparation of patient for, 34 Albee, instruments and sutures for, 90 Bovee, instruments and sutures for, 65 Brown’s, for colitis, instruments and sutures for, 44 Mikulicz, instruments and sutures for, 53 Ordinary instruments for abdominal operations, 36 for bone operations, 86 Osteomyelitis of tibia, instruments and sutures for, 93 Osteoplastic flap, craniotomy with, instruments and sutures for, 82 Osteotomy of femur, Ghant, instru- ments and sutures for, 94 Pack, long, technic ot making, 111 square, with marker, 109 Palate, cleft, instruments and sutures for operation on, 100 Pancreatic cyst, instruments and su- tures for operation for, 39 Parasacral and splanchnic anesthesia, instruments used in, 106 Paravertebral nerve block, instru- ments used in, 106 Patella, fractured, instruments and sutures for, 95 Pelviolithotomy, instruments and su- tures for, 61 Penrose tubing, 118 Peripheral nerves, instruments and sutures for operation on, 99 Perineorrhaphy, instruments and su- tures for, 65 Pituitary operations, instruments and sutures for, 82 Plaster-of-Paris bandages, method of making and technic of application, 96 Plastic operation for chronic empy- ema, instruments and sutures for, 67 Plate on femur, metal, instruments for application of, 88 Polya operation, instruments and su- tures for, 42 Position for lithotomy, 63 Trendelenburg, 48 Postanal dermoid, instruments and sutures for operation for, 59 Preparation of patient for abdominal operations, 34 for breast operation, 71 for Kraske operation, 57 for operation on kidney, 60 on neck, 74 on thorax, 67 of subcutaneous injection of salt, material used in, 115 Preparing gloves, 26 Procedures preliminary to operation, 25 Prostatectomy, instruments and su- tures for, 55 Radius or ulna, fractured, bone plate for, instruments and sutures for, 93 Raw-edged sponges, 107 Reconstruction of ducts, instruments and sutures for, 38 Rectal fistula, instruments and su- tures for, 66 Regional anesthesia, 104 preparation of solution for, 105 Removal of coccyx, instruments and sutures for, 59 Resection of bladder, instruments and sutures for, 55 INDEX 163 Resection of cecum, instruments and sutures for, 44 of ileum, instruments and sutures for, 44 of knee, instruments and sutures for, 91 of sigmoid, instruments and sutures for, 51 of stomach, Billroth No. 2, instru- ments and sutures for, 43 Polya, instruments and sutures for, 42 sleeve, instruments and sutures, 43 of transverse colon, instruments and sutures for, 44 of tube, instruments and sutures for, 52 of tumor of chest wall, instruments and sutures for, 69 Rolls, goiter, technic of making, 111 Round ligaments, extraperitoneal shortening of, instruments and sutures for, 45 intraperitoneal shortening of, 50 Rubber tubing, 118 Salpingectomy and oophorectomy, instruments and sutures for, 49 Schedule of operating room, 31 Scrotal hernia, instruments and su- tures for, 47 Scrubbing hands, 30 Section, cesarean, instruments and su- tures for, 50 Sets of gloves, preparation of, 113 Setting up a room, 26 Shortening of round ligaments, extra- peritoneal, instruments and sutures for, 45 intraperitoneal, 50 Sigmoid, resection of, instruments and sutures for, 51 Silk sutures, 120 Silk sutures, Irish linen, 120 Silkworm sutures, 120 Skin grafting, instruments and su- tures for, 98 Sleeve resection, instruments and su- tures for, 43 Solutions, 114 Soutter or Campbell operation for contraction of hip, instruments and sutures for, 93 Spermatocele and varicocele, instru- ments and sutures for, 47 Spinal bifida, instruments and sutures for operation for, 98 Spinal fusion operation, Hibbs’, in- struments and sutures for, 90 Spine, Albee bone graft to, instru- ments and sutures for, 90 Splanchnic and parasacral anesthesia, instruments used in, 106 Splenectomy, instruments and su- tures for, 39 Sponges, raw-edged, 107 St. Mary’s Hospital, technic of making, 107 Square pack, St. Mary’s Hospital, technic of making, 109 Sterile linen sets for breast, 126 for goiter, 126 for kidney, 126 for Kraske, 126 for laparotomy, 126 for lithotomy, 126 nurse, instructions to, 32 table, 29 Sterilization of dressings and vaselin, 113 of syringe, 107 Stomach, resection of, Polya, instru- ments and sutures for, 42 sleeve, instruments and sutures for, 43 Subcutaneous injection of salt, prep- aration of materials for, 115 Supply table, 29 164 INDEX Sutures, 120 used in abdominal operations, 36 in bone operations, 86 in cerebellar operations, 84 in craniotomy, 82 in ganglion operations, 83 in laminectomy, 85 in pituitary operations, 82 Swabs, iodin, technic of making, 111 Syringe, sterilization of, 107 Technic of blood transfusion, 102 Tendon, transplantation of, instru- ments and sutures for, 94 Thoracoplasty, extrapleural, instru- ments and sutures for, 70 Thorax, preparation of patient for operation on, 67 Thyroidectomy, instruments and su- tures for, 76 Thyrotomy, instruments and sutures for, 77 Tibia, osteomyelitis of, instruments and sutures for, 93 Tincture of iodin, 114 Tonsillectomy, instruments and su- tures for, 101 Tracheotomy, instruments and su- tures for, 77 tray, 123 Transfusion of blood, instruments re- quired for, 102 technic of, 102 Transplantation of bone for fractured femur, instruments and sutures for, 86 of tendon, instruments and sutures for, 94 of ureter, instruments and sutures for, 54 Transsacral anesthesia, instruments used in, 105 Transverse colon, resection of, instru- ments and sutures for, 44 Tray, abdominal hemorrhage, 123 Tray, aspiration, 124 eye, 123 intern’s dressing, 121 intravenous, 124 tracheotomy, 123 uterine hemorrhage, 123 Trendelenburg position, 48 Tube resection, instruments and su- tures for, 52 Tuberculous kidney, nephrectomy for, instruments and sutures for, 62 Tumor of chest wall, resection of, in- struments and sutures for, 69 Ulcer, duodenal, excision of, instru- ments and sutures for, 40 gastric, excision of, instruments and sutures for, 41 gastrojejunal, excision of, instru- ments and sutures for, 41 Ulna or radius, fractured, bone plate for, instruments and sutures for, 93 Umbilical hernia, instruments and sutures for, 47 Ureter, transplantation of, instru- ments and sutures, for, 54 Ureterectomy, instruments and su- tures for, 53 Ureterolithotomy, instruments and sutures for, 53 Urethra, dilatation of (retrograde), in- struments and sutures for, 54 Uterine hemorrhage tray, 123 Vaginal hysterectomy, instruments and sutures for, 63 Varicocele and spermatocele, instru- ments and sutures for operation on, 47 Varicose veins, instruments and su- tures for operation on, 99 Vaselin and dressing, sterilization of, 113 INDEX 165 Vaselin gauze, 118 iodoform gauze, 118 Veins, varicose, instruments and su- tures for operation on, 99 Ventral hernia, instruments and su- tures for operation for, 46 Vesicovaginal fistula, instruments and sutures for operation on, 64 Vesiculectomy, instruments and su- tures for, 66 V-shaped excision of lip, instruments and sutures for, 100 jfl 0 f f y ■»