■m**?- m W4&-- WY 162 S881b 1916 54720940R NLM DSEflTlST 3 NATIONAL LIBRARY OF MEDICINE nrc~"2 - iq?& SURGEON GENERALS OFFICE LIBRARY. Section No. 113, w. n.s. g.o. No. 2JAjU> s 3—513 NLM052891593 BOOKS BY EMILY A. M. STONEY Practical Points in Nursing i2mo of 511 pages, illustrated. Revised by LUCY CORNELIA CATLIN, R. N. Cloth, $1.75 net. Fifth Edition Materia Medica for Nurses i2mo of 306 pages. Cloth, #1.50 net. Third Edition Bacteriology and Surgical Technic for Nurses i2mo of 342 pages, illustrated. Cloth. Fourth Edition BACTERIOLOGY AND SURGICAL TECHNIC FOR NURSES BY EMILY A. M. STONEY •a Formerly Superintendent of the Training School for Nurses, Carney Hospital, South Boston, Mass.; Author of "Practical Points in Nursing," " Practical Materia Medica for Nurses" FOURTH EDITION ENLARGED AND RESET "Every bit of knowleige that we cannot use for the uplifting of our phys- ical, intellectual, or emotional life is so much waste of lime and labor. Everything taught is worth the knowing, but not worth the putting away in the pigeon-holes of memory to be recalled seme day by accident' PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1916 Copyright, 1900, by W. B. Saunders and Company. Set up, electrotyped, printed, and copyrighted September, 1900. Reprinted September, 1902. Revised, reprinted, and recopyrighted January, 1905. Reprinted March, 1906, November, 1907,, Feb- _ ruary, 1909, and August, 1909. Revised, reprinted, and recopyrighted Sep- tember, 1910. Reprinted July, 1912, and January, 1914. Reprinted September, 1915, and December, 1915. Revised, entirely reset, ... reprinted, and recopyrighted September, 1916 Copyright, 1916, by W. B. Saunders Company S OCT -5 1916 J PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO DR. JOHN R. SLATTERY THIS VOLUME IS DEDICATED BY THE AUTHOR IN GRATEFUL REMEMBRANCE OF MUCH ENCOURAGE- MENT AND PERSONAL KINDNESS PREFACE TO THE FOURTH EDITION To bring this new edition dowTn to date the text and illustrations have been gone over in a thorough manner. While the general plan of the book remains the same, the addition of new matter and the elimination of obso- lete material have necessitated the entire resetting of the work. The chapters requiring the most revision were those on Antiseptics, Disinfectants, and Deodorants; Gauze Sponges, etc.; Minor Surgical Procedures, and Sequels of Operation. So extensive were the changes in the chapters on Bandages and Dressings, Instruments, and Anesthesia that they had to be entirely rewritten. Some of the more important additions are the follow- ing: Antityphoid Vaccine; Antitoxin in Cerebrospinal Meningitis; Flexner's Serum in Infantile Paralysis; Serum Reactions; Method of Passing Stomach-tube; Murphy's Method of Continuous Proctoclysis. It is hoped that the present edition will serve as useful a purpose as its predecessor. September, 1916. 9 PREFACE The following pages constitute the notes of a series of lectures on "Bacteriology and Surgical Tech- nic " which followed closely upon my lectures on " Materia Medica." The first part of the book is de- voted to Bacteriology and Antiseptics ; the second part to Surgical Technic, Signs of Death, Au- topsies. No attempt has been made to write a complete treatise on bacteriology, but merely to outline and simplify that branch for nurses. It was deemed advisable to add the chapter on "Signs of Death and Autopsies," as many nurses are unacquainted with the preparations for an autopsy in private practice. So many changes have taken place in surgery since the lectures were delivered that it has been necessary to rewrite many of the chapters. In this I was assisted by Dr. A. S. Allen and by Professors J. B. Murphy, Christian Fenger, and Joseph L. Miller, of the Northwestern University Medical College. I am glad of this opportunity to thank them for their assistance. 11 12 PREFACE Free use has been made of the works on bac- teriology by McFarland, Crookshank, and Woodhead; of "Aseptic Surgical Technique," by Dr. Hunter Robb; "Operative Gynecology," by Dr. Howard A. Kelly; and "Aseptic Treatment of Wounds," by Dr. C. Schimmelbusch. I am unable to express my indebtedness to Dr. Joseph P. Comegys for his valuable assistance with the manuscript and its preparation for the press. I wish also to thank Drs. George L. Eyster and Charles C. Carter for their friendly help and interest in the work. EMILY A. M. STONEY. CONTENTS PART L—BACTERIOLOGY; ANTISEPTICS CHAPTER I page History of Bacteriology........................- *......... 17 CHAPTER II Bacteria as the Causes of Disease......................... 28 CHAPTER III The Theory of Antitoxins.................................. 45 CHAPTER IV Antiseptics, Disinfectants, and Deodorants................ 53 PART IL—SURGICAL TECHNIC CHAPTER V Bandaging and Dressings................................... 65 CHAPTER VI Care of Operating-room; Methods of Sterilization; Care of Instruments..................,............... ...... 102 13 14 CONTENTS CHAPTER MI PAGE Instrtments Necessary in Different Operations, Keeping of Charts, Surgeon's Kit, etc........................ 116 CHAPTER VIII Anesthesia.................................................. I44 CHAPTER IX Gauze Sponges; Pads; Dressings; Tampons; Dressing-room Outfit; Drainage, Care of Drainage-tubes; Gloves; Sutures and Ligatures; Surgical Applications..... -- 178 CHAPTER X Inflammation............................................... *97 CHAPTER XI Catheterization; Douches; E\emata; Washing out the Bladder; Lavage........................................ 200 CHAPTER Xn Minor Surgical Procedures................................ 215 CHAPTER XIII Obstetric Nursing; Care of Infants, etc................... 233 CHAPTER XIV Operations; Preparation of the Operating room; the Sur- geon and His Assistants................................ 239 CHAPTER XV Transportation; Preparation of Patient for Operation; Care of Patient During and After Operation.......... 249 CHAPTER XVI Sequelae of Operations; Shock, Hemorrhage, Septic Peri- tonitis, Accidents During Operation, etc................ 263 CONTENTS 15 CHAPTER XVII page Special Operations.......................................... 276 CHAPTER XVIII Operations in Private Practice............................. 278 CHAPTER XIX Gynecologic Examinations and Operations.................. 288 CHAPTER XX Diet Recipes............................................... 299 CHAPTER XXI Signs of Death; Autopsies.................................. 3°6 CHAPTER XXII Hygiene; Personal Conduct of a Nurse's Life; of the Re- wards; Success......................................... 3" Glossary................................................... 3*7 Index...................................................... 3 29 PART I BACTERIOLOGY; ANTISEPTICS CHAPTER I HISTORY OF BACTERIOLOGY The eye is one of the most beautiful and delicately contrived organs in the body, and yet its vision un- aided is very limited in its scope. We see so much that we rarely stop to think of what an enormous world exists in and all about us which we cannot see at all— a world peopled by organisms so very small that they can be seen and studied only by the aid of the most powerful magnifying lenses, and so numerous that they are quite beyond any calculation. Bacteria exist nearly everywhere; they are almost universal, except that they are not found deep down in the ground nor high up in the air. They and their spores, or seeds, float in the air we breathe, swim in the water we drink, grow upon the food we eat, and lux- uriate in the soil beneath our feet. Wherever man, animals, and plants live, die, and decompose, bacteria are sure to be present. They are always on the surface of the body, and so deeply are some bacteria situated beneath the epithelial cells that the most vigorous scrub- 2 17 18 BACTERIOLOGY bing and washing and the use of powerful disinfectants are necessary to remove them from the surgeon's hands. The mouth is said to be always replete with them; and, since many are swallowed, the digestive tract always contains them. The germ of pneumonia, for instance, is said to be habitually present in the mouth of almost every healthy person; consequently, its en- trance into the lungs is only a matter of accident. The existence of these bacteria has been known for many years, but it is only during the past few decades that any great advancement in our knowledge of them has been made. Over two hundred years ago a man named Athana- sius Kircher, a German, mistook blood-corpuscles and pus-corpuscles (leukocytes) for small worms, and built up a new theory of the causes of disease and putrefaction upon this basis. At the same time Christian Lange, a professor in the medical school at Leipzig, expressed his opinion that the rash that ap- peared on the skin in the eruptive fevers, etc., was the result of putrefaction conveyed by small living worms in the body. Shortly after these observa- tions came those of Anthony van Leeuwenhoek, a native of Delft, in Holland, who, in his early years, had learned the art of polishing lenses, and who was able, ultimately, to produce the first really good micro- scope that had yet been constructed. He saw, and described with astonishing clearness, various forms of bacteria found in the material taken from the mouth of an old man who never cleaned his teeth. He gave an accurate description of the rod-shaped bacteria, motile and motionless, now called bacilli; of the spiral threads, HISTORY OF BACTERIOLOGY 19 or spirilla; and of rounded micro-organisms, or micro- cocci. Although he did not attempt to theorize as to the meaning of these organisms at the time, later on, in 1713, after finding similar organisms in the greenish pellicle formed on the surface of the water in an aquarium, he came to the conclusion that the various forms of bacteria found in the material scraped from the teeth found their way into the mouth through the medium of the drinking-water that had been stored in barrels, and that some of these found there a nidus in which they multiplied. This was the real beginning of bacteriology; and from this origin the study advanced with considerable rapidity in spite of ridicule and much opposition, Various opinions regarding the connection of these germs with disease and putrefaction were put for- ward, but it was not until 1831 that any important advance was made in our knowledge of this connec- tion. Previous to that time a large mass of facts in regard to these little living organisms was being gradu- ally accumulated, and fresh discoveries were constantly made by various workers; but since no systematic at- tempts to classify the newly observed facts were made, the scientific results were very small. The first real advance made in our knowledge of the presence of a living contagious element in the production of disease and fermentations was made by Frederick Miiller, of Copenhagen, and was the result of a systematic attempt to arrange the knowl- edge which had been accumulated during all those years. From that time to the present the science has made great strides; so that we have now an accu- 20 BACTERIOLOGY rate knowledge of the bacteria which cause a number of different diseases. The knowledge of methods and details of work is now so general that the science of bac- teriology is rapidly growing, and has already revolution- ized very many branches of medicine. In 1840 Henle was led to believe that the cause of miasmatic, infective, and contagious diseases must be looked for in living fungi or other minute living or- ganisms. Unfortunately, at that time the methods of study employed prevented him from demonstrating the accuracy of his belief. It was left for Pasteur and Koch to complete the work. Davaine, in 1848, was the first to see and to recognize disease-producing bacteria—he saw anthrax bacilli in the blood of sheep dead of splenic fever. Pasteur then took up the work; and in 1857 his faultless demonstration of the germ theory of disease was brought out as a result of his experiments on fer- mentation and putrefaction, and on the bacteria of wine and those of the silkworm. He showed that the acetic fermentation, viscosity, bitterness, and turning flat of wines are due to the action of certain organized ferments, and demonstrated a causal relation between certain lowly organized parasitic organisms and spe- cial diseases in animals and insects. Upon Pasteur's observations Lord Lister based his successful system of the treatment of wounds, known as "antiseptic sur- gery." We all know of the wonderful success which now marks the operations of major surgery, and of the daring boldness of operators who attempt what was utterly impossible as long as antiseptic surgery was HISTORY OF BACTERIOLOGY 21 unknown. Lister, accepting the truth of Pasteur's statement—that germs are the producers of fermenta- tions—concluded that germs entering wounds from the outside might be the cause of suppuration; and since germs are always and everywhere floating in the air, suspended in water, and attached to the surgical in- struments, dressings, and sponges used in operations, he judged correctly that it was highly advantageous to employ an antiseptic agent in order to kill any of the suspended or adherent organisms before any materials could be allowed to come in contact with wounded tissues; consequently, the hands of the operator and his assistants, the surgical instruments, sponges, dress- ings, sutures and ligatures were kept constantly satu- rated with a solution of carbolic acid (i :4o), and the operation was performed under a spray of carbolic acid (i :2o). Carbolized dressings were used; and if the discharge was profuse, the dressings were changed once in twenty-four hours under a constant use of the spray. The researches of a later date have shown, how- ever, not only that the atmosphere cannot be disin- fected, but also that the air of ordinarily quiet rooms, while containing the spores of numerous saprophytic organisms, rarely contains many pathogenic bacteria. We also know that a direct stream of air, such as is generated by an atomizer, causes more bacteria to be conveyed into a wound than ordinarily would fall upon it, thereby increasing instead of lessening the danger of infection. Lister, we must remember, was not the discoverer of carbolic acid nor of the fact that it would kill bacteria; but, convinced that inflamma- tion and suppuration were caused by the entrance of 22 BACTERIOLOGY germs from the air, instruments, sponges, and dress- ings into wounds, he suggested the antisepsis which would result from the use of sterile instruments, clean hands, dressings, towels, and the like; and made ap- plications intended to keep the surface of the wound moistened with a germicidal solution in order to kill such germs as might accidentally enter. He also introduced the practice of concluding operations by the application of a protective dressing, such as would tend to preclude the entrance of germs at a subse- quent period. This procedure defeats its purpose for usefulness by reason of the moisture retained acting as a direct growth medium for those bacteria already upon or in the skin. Listerism has spread slowly but surely to all the departments of surgery and obstetrics. Since Lister's treatment was first inaugurated, many details of its application have been variously modified and great additions to our knowledge have been made. In bacteriology much important work has been done, and great advances are being constantly made. There are a number of diseases, each one of which has been definitely proved to be caused by a germ of its own, a germ which causes no other disease. There is also a list of diseases in which the proof is not yet conclusive, but for which the probability is that a specific germ will be found. The following data have been gathered chiefly from the works of McFarland and Woodhead: In 1845 Langenbeck discovered that the specific disease of cattle known as actinomycosis could be com- municated to man. His observations, however, were not given to the world until 1878, one year after Bollinger had discovered the cause of the disease in animals. HISTORY OF BACTERIOLOGY 23 In 1847 Semmelweis, on the basis of his own ob- servations, formulated the precept that puerperal fever is the result of the introduction of organic ferments into the puerperal genital tract. This discovery, established by himself and confirmed by the observations of many others, marked an era in obstetrics. The organic fer- ments have since been identified as specific bacteria. Semmelweis in this way anticipated in practical anti- sepsis the discoveries of Lister and Pasteur; while the late Oliver Wendell Holmes, in a paper entitled "Puer- peral Fever a Private Pestilence," published in 1843 and republished in 1855, in treating of its prophylaxis, an- ticipated the teaching of Semmelweis. Semmelweis was first led to recognize the source of puerperal in- fection by the case of Prof. Koletschka, of the Univer- sity of Vienna, who, having received a dissection wound, became thereby fatally infected. In consequence of this Semmelweis concluded that there was an identity between this infection and that of which so many hundreds of puerperal women died. In the school for instruction in practical obstetrics with which he was connected there were two departments, one for medical students, the other for midwives, the students going, as a rule, directly to the obstetric ward from the autopsy room. He first noted the much greater mortality in the stu- dent's ward, and in May, 1847, began to require the students to wash their hands in chlorin-water before making vaginal examinations, thereby reducing the puerperal mortality to a point lower than had been ever before reached. In 1863 Davaine established by experiments the bac- terial nature of splenic fever, or anthrax. 24 BACTERIOLOGY In 1869 the first complete study of a contagious affection was made by Pasteur, in two diseases affect- ing silkworms—pebrine and flacherie—which he showed to be due to micro-organisms. In 1875 Koch described more fully the anthrax bacillus, gave a description of its spores and the prop- erties of the same, and was enabled to cultivate the germ on artificial media; and, to complete the chain of evidence, Pasteur and his pupils supplied the last link by reproducing the same disease in animals by artificial inoculation from pure cultures. The study of the bac- terial nature of anthrax has been the basis of our knowl- edge of all contagious maladies; and most advances in technic have been made first through the study of the bacillus of that disease. In 1879 Hansen announced the discovery of bacilli in the cells of leprous nodules. They were subse- quently clearly described by Neisser. From the nature of the symptoms and from the course of the disease, leprosy up to this time was long considered to be a disease similar to tuberculosis, and the discovery of the bacillus paved the way for the reception of Koch's discovery of the tubercle bacillus. In the same year Neisser discovered the gonococcus to be the specific cause of gonorrhea. In 1880 the bacillus of typhoid fever was first observed by Eberth, and independently by Koch. In 1880 Pasteur published his work upon Chicken- cholera, an epidemic disease which affects turkeys, pigeons, chickens, ducks, and geese, and which causes al- most as much destruction among them as the occasional epidemics of cholera and small-pox produce among men. HISTORY OF BACTERIOLOGY 25 In the same year Sternberg described the pneumo- coccus, calling it "Micrococcus Pasteuri," which he secured from his own saliva; and in the same year Pasteur also found the same organism in saliva; though it is to Frankel, Talamon, and particularly Weichsel- baum that we are indebted for the discovery of the relation which the organism bears to pneumonia. In 1882 Robert Koch made himself immortal by the discovery of and work upon the bacillus of tuber- culosis, one of the most dreadful and, unfortunately, most common diseases of mankind. While great men of the earlier days of pathology clearly saw that the time must come when the parasitic nature of this disease would be proved, and some, as Klebs, Ville- min, and Cohnheim, were "within an ace" of the dis- covery, it remained for Koch to succeed in demonstrating and isolating the specific bacillus, and to write so accu- rate a description of the organism and the lesions it produces as to render the discovery one of the most complete ever made in the history of medical science. In the same year Loffler and Schiitz reported the discovery of the bacillus of glanders, an infectious disease almost confined to certain of the lower ani- mals; although occasionally persons whose habitual association with and experimentation upon animals bring them into frequent contact with such as are diseased, have become accidentally infected. In 1884 Koch discovered the "comma-bacillus," the cause of cholera. In the same year Loffler discovered the diphtheria bacillus, and Nicolaier that of tetanus. On October 26, 1885, Pasteur made the first applica- 26 BACTERIOLOGY tion of his method for the treatment of hydrophobia, nearly ten years before the time we began to understand the production and use of antitoxins in human medicine. In 1890 Koch issued to medical men what is known as tuberculin, a brownish, syrup-like fluid used in the diagnosis and treatment of tuberculosis. In 1892 Canon and Pfeiffer discovered the bacillus of influenza. In 1894 Yersin and Kitasato independently isolated the bacillus causing the bubonic plague then prevalent at Hong-Kong. The bacterial cause of yellow fever has not been deter- mined, but its method of transmission is known to be through the bite of the mosquito Stegomyia fasciata. This mosquito, to become infected, must bite the patient during the first three days of the disease, and then the mosquito is harmless until the lapse of at least twelve days. After being bitten by the mosquito the period of incubation is from six to ten days. Dr. Chas. Finlay, of Havana, was the first to pronounce clearly a mosquito theory of the transmission of yellow fever, and it was later proved conclusively by a Commission of the United States Army composed of Reed, Carroll, Agra- monte, and Lazear. Two of the above, Reed and Lazear, died from allowing themselves to be bitten by infected mosquitoes to prove conclusively that the mosquito, and the mosquito alone, transmitted the disease. Epidemic cerebrospinal meningitis or spotted fever is caused by Diplococcus intracellularis meningitidis. Malta fever, a disease of the Mediterranean islands, and occasionally of the Antilles and Central and South HISTORY OF BACTERIOLOGY 27 America, is due to a micrococcus discovered by Bruce, and called Bacillus melitensis. Malarial fever is an infectious disease; but, unlike those mentioned, it is not caused by a vegetable germ, a bacterium, but by a microscopic animal, the Plasmo- dium malaria, which is found in the blood of the afflicted individual. Malaria is carried solely by a species of mosquito, the Anopheles. There is some grounds for a belief that malignant tumors—cancers and sarcomas—are due to micro- organisms. The nature of the parasite is as yet un- known. Spirochseta pallida or Treponema pallidum, discov- ered by Schaudinn and Hoffmann in 1905, is now generally accepted as the exciting cause of syphilis. The organism is from 6 to 15 ^ in length and presents from six to fourteen spiral turns. It is found constantly in primary and secondary and with difficulty in tertiary lesions. Its presence in a suspected lesion is regarded as diagnostic, while its absence does not exclude syphilis. CHAPTER II BACTERIA AS THE CAUSES OF DISEASE Diseases may be divided into two great classes— the constitutional, which are due to such causes as errors in diet, alcoholic excesses, overwork, or age; and the infectious or contagious, which are due to the introduction into the body of a living poison. We no longer look upon infectious and contagious diseases as due to an unexplainable something, whose source we cannot know, whose course we cannot predict, and whose end cannot be hastened by any efforts on our part. Investigation has shown that we are no longer fighting an unknown enemy in the dark, but that we have before us a definite, living thing, whose part in the plan of creation is as surely fixed as our own, whose life-history can be told, and whose growth is as de- pendent on the right amount of light, food, heat, and air as that of the rose in our garden. The word bacteria is a general name for all the plant micro-organisms. Of these there are many different classes with different names. They vary much in shape and size, some being round, some thread-like, some rod shaped, and some of a spiral form. Each single organ- ism consists of a small speck of protoplasm or vegetable albumin, to which may be given the name of a cell; and these cells are so minute that they can be seen only with the aid of the best microscopes at our command. The 28 bacteria as the causes of disease rounded organisms, or micrococci, as they are called, are seldom more than -rshm inch in diameter; the elongated cells average a little more perhaps, and are from Tiin to 6~oVo mcn m length. Different forms natu- rally vary from this standard of size; but these figures will give a good idea as to the actual size of the forms under consideration (Fig. i). The fungi connected with disease in man are divided into three classes: i. Molds, or hyphomycetes. 2. Yeasts, or blastomycetes. 3. Bacteria, or schizomycetes. 1 2 3 4 5 6 ? V 9 '10 11 Fig. 1.—Various forms of bacteria: 1 and 2, Round and oval micro- cocci; 3, diplococci; 4, tetracocci, or tetrads; 5, streptococci; 6, bacilli; 7, bacilli in chains, the lower showing spore formation; 8, bacilli showing spores, forming drumsticks and Clostridia; 9 and 10, spirilla; 11, spiro- chete (McFarland). Some bacteria, or schizomycetes, induce the various fermentations; while others are productive of putre- faction, and are called saprophytes. Others, again, known as the pathogenic bacteria, are the cause of various diseases; while those which do not ordinarily cause disease are known as the non-pathogenic bac- teria. The chief forms of bacteria are: 1. The coccus—berry-shaped or spheric bacterium. 2. The bacillus—rod-shaped bacterium. 3. The spirillum—corkscrew bacterium. And these, which are species relatively monomorphous 3o BACTERIOLOGY —i. e., preserve their shape—are practically the only ones with which we have to do. The cocci are named according to their arrange- ment with one another; if, for instance, they are in pairs, they are called diplococci; if in a chain, they are called streptococci; if in a cluster, like a bunch of grapes, they are called staphylococci; and if in an irregular mass, stuck together by a thick substance, they consti- tute a zooglea. Those developing in fours are called tetrads; in eights, sarcinae. *0 03O33 o?Jr Qe^ ** T*33f ©s *i g h i j k Fig 2.—Diagram illustrating the morphology of cocci: a, Coccus or micrococcus; b, diplococcus; c, d, streptococci; e, f, tetragenococci or merismopedia; g, h, modes of division of cocci; i, sarcinae; j, coccus with flagella; k, staphylococci (McFarland). The cocci are also named according to their func- tions, as, for instance, "pyogenic," or pus-forming; the specific name also describing the form, arrangement, color, and function; for example, Staphylococcus pyogenes aureus signifies a spheric colorless micro-organism form- ing a yellow pigment, arranging itself with its fellows into the form of a bunch of grapes, and producing pus. As the surgical nurse carries on a daily warfare for the destruction of pus micro-organisms and prevention BACTERIA AS THE CAUSES OF DISEASE 31 of their growth, she cannot be too familiar with every aspect of these germs. The two most constant pus formers are: (i) the staphylococcus (Fig. 2, k), which, when present in a wound, may cause a free flow of pus; still it generally manifests a milder disease con- dition than the virulent (2) streptococcus germ (see Fig. 1, No. 5; Fig. 2, c, d). Staphylococci may be observed under the microscope by placing a drop of the pus upon a cover-glass, after- ward spreading the specimen by applying another cover-glass; dry over an alcohol lamp and stain with a solution of methylene-blue. Wash away the excess and place the specimen face down upon a glass slide. Streptococci are best stained by the so-called Gram method. To a dried and spread drop of pus upon a cover-glass apply an excess quantity of the following: Anilin, 4 parts. Saturated alcoholic solution of basic anilin dye, 11 " Water, ioo " Stain in this for fifteen minutes; transfer to Gram's solution: Iodin, 4 parts. Potassium iodid, 2 Water, 300 " Stain for four minutes; remove and wash the specimen in 95 per cent, alcohol; finally stain in the following for half a minute: Bismarck brown, 3 parts. Water, 70 " 32 BACTERIOLOGY Wash in 95 per cent, alcohol; clear the specimen by adding a few drops of carbolxylol; place upon a glass slide for observation. Anyone capable of developing an ordinary kodak film will find but little difficulty in learning this apparently deeply mysterious technic of the bacteriologic laboratory. Bacteria reproduce in two ways: By direct division (fission) and by the development of spores of seeds (sporulation). The most common mode is by binary division, one body dividing itself so as to form two other bodies; these two re-dividing, and so on. It can readily be imagined how quickly an appalling in- CeD c. q) o o O CS=3 gzD a b c d c f Fig. 3.—Diagram illustrating sporulation: a, Bacillus inclosing a small oval spore; b, drumstick bacillus, with terminal spore; c, Clostridium, with central spore; d, free spores; e and /, bacilli escaping from spores (McFarland). crease in their numbers can be thus brought about; but, fortunately, this multiplication only takes place to advantage under certain favorable conditions; if these are not present the bacterium begins to degenerate, but usually does not die until it has left behind a spore. When the formation of a spore is about to commence, a small bright point appears in the protoplasm, and increases in size until its diameter is nearly or quite as great as that of the bacterium. As it nears perfec- tion a dark, highly refracting capsule is formed about it. As soon as the spore arrives at perfection the bac- terium seems to die, as if its vitality were exhausted BACTERIA AS THE CAUSES OF DISEASE 33 in the development of the permanent form. As soon as the young bacillus escapes it begins to increase in size, develops around its soft protoplasm a character- istic membrane, and, having once established itself, presently begins the propagation of its species by fission. In those forms of organism in which spores are not found the germs die very rapidly unless the conditions for their nutrition and multiplication remain very favor- able. If all bacteria were of this kind, it would be possible to exterminate them with considerable rapid- ity. Spores will survive a great heat, a heat which will kill the organism from which the spore came; they will also live under a treatment with germicidal solu- tions which renders the bacteria inactive. In other words, the spores are much more resistant to the effect of germicides than the bacteria themselves. Cold does not kill them; they live through it and develop whenever favorable surroundings for their growth pre- sent themselves. They may lie dormant in the system for years, waking into activity only when they come into contact with some damaged, weakened, or diseased part which affords them a nest in which to develop and multiply, the cellular activity of the weakened part being unable to cope with the organisms. The conditions which influence the growth of bacteria are, first, a temperature ranging from 850 to 1040 F., some forms requiring a higher and some a lower tem- perature. Some forms of bacteria are not influenced in their growth by the presence or absence of light. To some, sunlight is destructive. A few hours' exposure to the sun is fatal to the anthrax bacillus and to cultures of the Bacillus tuberculosis. The rays of the sun, how- 3 34 BACTERIOLOGY ever, must come into contact with the germs and are usu- ally active only on the surface of cultures. The majority of bacteria grow best when exposed to the air. Some develop better if the air is with- held; some will not grow at all if the least amount of oxygen is present. Those that grow in oxygen are called the aerobic bacteria, and those that will not grow in the presence of oxygen are the anaerobic bac- teria. A certain amount of water is always necessary for the growth of bacteria, though the amount required may be very small. If dried, no form will multiply and very many forms will die. A soil consisting of highly organized compounds is also necessary for their growth and multiplication, and slight modifications in it may prove fatal to some forms of bacterial life, but be highly advantageous to others. With age bacteria lose their strength and die. So we see that a suitable soil and a proper amount of light, heat, and air are absolutely necessary for the growth and development of bacteria, for they carry on all the functions of a higher organized life; they breathe, eat, digest, excrete, and multiply. The disease-producing bacteria effect entrance into the interior of the body through the skin and super- ficial mucous membranes, wounds, alimentary canal, respiratory tract, and placenta. The entrance of bacteria into the tissues through the sound skin is very rare indeed, although some authorities claim that infection has taken place through the rubbing of bacteria or their spores upon the skin. The dangers of infection through the broken skin are BACTERIA AS THE CAUSES OF DISEASE 35 well recognized; hence every wound, no matter how slight, should be protected as soon as possible. Bacteria enter the alimentary canal through the food and drink. Typhoid infection has taken place through the rectum, its occurrence being due to the wearing of underclothing previously worn by typhoid fever patients, and to the use of enema syringe tips which had not been sterilized after their previous use. Bacteria enter the respiratory tract through the mouth and nose, as in a deep inspiration, or an act of coughing, sneezing, or the like. Pneumonia and tuberculosis.are said to be the result of inspiration of the specific organisms. The direct transmission of bacteria from a parent to the fetus has long been a disputed question, but is now generally conceded. The micro-organisms pass through the placenta and infect the fetus. Tuberculosis of the ovaries, Fallopian tubes, and uterus may originate through the blood or from with- out through the vagina. Infection through the blood is evidenced by the general tuberculosis of all the viscera. The channels by which bacteria can enter the body are, then, very numerous; and there is scarcely a moment in which some part of the body is not in contact with them. All the disease-producing germs have their favorable seat in some part of the body where they grow more or less luxuriantly, and in the secretions and ex- cretions of which the chief source of their infection lies. The pneumonia germ prefers the lungs; the typhoid fever germ selects the lower portion of the small intestine; the diphtheria germ, the throat; the cholera germ, the intestinal tract; the germ of tuberculosis prefers the lungs, but it is called a "medical tramp," because it will 36 BACTERIOLOGY lodge in any part of the body and make its home there. Hence we hear of tuberculous glands of the neck, tuber- culous knee, intestinal tuberculosis, tuberculosis of the kidney, bladder, uterus, ovaries, Fallopian tubes, tuber- culous peritonitis, etc. A tuberculous area is always a danger to the system, and may infect distant organs or give rise to a general tuberculosis. To prove that a microbe is the cause of a disease it must fulfil Koch's circuit. It must always be found associated with the disease, and it must be capable of forming pure cultures outside the body. These cultures must be capable of reproducing the disease, and the microbe must again be found associated with the morbid process thus reproduced. In other words, we must prove the bacteria to be always present; we must then isolate them, then prove that they can pro- duce the disease in a healthy animal, and, finally, having succeeded in doing all this, we must prove that no other form of bacteria can produce the disease, and that where these bacteria cannot be obtained the existence of the disease is impossible. All these re- quirements have been met in many instances, and now there are a large number of diseases each one of which has been definitely proved to be caused by a germ of its own, a germ which produces that disease and no other. Most of the germs need a special train of circumstances in order that they may be active, so that, fortunately for us all, the mere presence of the germ itself is not sufficient to produce the disease. For instance, we know that diphtheria is caused by a germ of its own which causes that disease and no other; still, exposure to that germ does not invariably produce BACTERIA AS THE CAUSES OF DISEASE 37 diphtheria—if it did, we should all be infected with it. This is because other conditions than the mere presence of the germs are needed to produce the disease. The germs must be active, and they can act only under cer- tain conditions. It will usually be found that the attack of the disease has been preceded by a local inflammation of the throat, thus making a suitable place for 'the specific action of the diphtheria germs. In typhoid fever the germs require a suitable condi- tion of the bowels before they can produce the dis- ease. This is also true of cholera, and explains why taking care of the health makes such a difference in the taking of this disease. The germs find their way into the body through the food and drink. Cases are reported that show how the germs enter drinking- water which is sprinkled over vegetables sold in the streets of cholera-infected districts, how they are car- ried about in clothing, and taken to articles of food upon the table by flies which have preyed upon chol- era excrement. Healthy lungs are not a suitable loca- tion for the development and activity of the germs of tuberculosis. If we are not fully in good health, or if we inherit a tendency to this special disease, we may acquire it very readily, since we often inhale the germs of it. Should the disease take root in our lungs, it may be controlled to a certain extent by a change of climate and surroundings; by going, for example, from a low and damp locality to the mild and dry atmosphere of Colorado, the Carolina mountains, Southern Cali- fornia, or of the other Southwestern States, where there are few cloudy days and where violent atmospheric changes are rare. The germs there cannot be so active, 38 BACTERIOLOGY for the air is stimulating, pure, and sunlight has an inhibitory action upon the tubercle bacillus. The rare- faction of the air causes deep and strong involuntary respiratory movements, and there is consequently en- forced a better ventilation of the lungs and a better oxygenation of the blood, in consequence of which there follow more active tissue changes throughout the body and a strengthening of the respiratory muscles. On finding favorable conditions it takes germs some days to develop and produce the disease; this time is known as the period of incubation. The question is often asked, Why, when we are so constantly in contact with disease germs, do we not contract the diseases? All bacteria leave the body through the skin, lungs, kidneys, or bowels; and by a faithful use of disinfectants and antiseptics the germs may be kept confined to their original position. After their escape from the body they are difficult to control. The scales of skin or dandruff from a case of scarlet fever, measles, or small-pox, or the dust that arises from the dried sputum of a pneumonia or tuberculous patient, or the poisonous material which may enter our drinking- water from too close proximity of the well and the sewer into which typhoid discharges have been emptied, may readily be the means of propagating disease. These sources of infection should be scrupulously avoided. Another protective factor is the natural or acquired power of resistance to disease-producing germs. Immunity is either natural or acquired. Of ac- quired immunity we have two varieties, that which comes from having had the disease and artificial im- munity produced by injecting special antitoxins. BACTERIA AS THE CAUSES OF DISEASE 39 By natural immunity is meant the natural and con- stant resistance to disease-producing germs. The indi- vidual is immune by Nature and sometimes by racial characteristics. Acquired immunity is a power of resistance attained through various circumstances. Thus, a single attack of some of the infectious and contagious diseases usually confers immunity against subsequent attacks. Such immunity generally follows an attack of typhoid fever, small-pox, scarlet fever, mumps, whooping-cough, measles, or yellow fever. Second attacks may occur; but, as a rule, a patient who has had an attack of one of these diseases has immunity for life. Influenza, pneumonia, cholera, diphtheria, and erysipelas are among the diseases in which one attack is not protective. Vaccination usually insures immunity against small-pox; but this is ordinarily not so complete or permanent as that resulting from an attack of the actual disease. Acclimatization immunity is exemplified by various diseases which do not trouble natives or those long resident, but which may affect strangers not inured to the climate. Racial immunity is that in which certain races are safe from certain diseases; for instance, negroes seldom suffer from yellow fever, but are more susceptible than whites to small-pox. It is asserted that the Arabs sel- dom or never have typhoid fever. An analogous exam- ple is afforded by the fact that white mice are not affected by the same diseases as the gray mice are, even though subjected to the same influences in respect to climate, food, and surroundings. 40 BACTERIOLOGY Artificial immunity may be produced in various ways. It is said that an injection of the antitoxin of diphtheria will give protection against the disease for from four to eight weeks. Tetanus has been prevented in a similar manner. It is impossible here to enter, except in a slight degree, into the consideration of the many theories of immunity, since they are very intricate, and not one has been advanced so far that can clearly explain it. The theory of phagocytosis Fig. 4.—Phagocyte destroying a bacillus (Landerer). and the theory of antitoxins are the two most impor- tant. Phagocytosis is the destruction of bacteria by the white cells of the blood and the cells of fixed tissues. The cells which eat up and destroy the germs are called "phagocytes." When the two meet a battle occurs, the bacteria fighting the cells with their active fer- ments, while the cells on their side put forth every effort to protect the body against the assaults of the disease. In a majority of the cases the bacteria win to the extent that the phagocytes die; but others take their place until the infection is overcome or the patient dies. The white blood-cells and tissue-cells having BACTERIA AS THE CAUSES OF DISEASE 41 thus been educated to withstand the poison, their de- scendants inherit this capacity and are born insusceptible. This theory was suggested by Carl Roser in 1881. Sternberg and Koch afterward put forth the same view, but it is usually credited to Metschnikoff, who published his observations in 1884. The other theory—the so-called antitoxic theory— is founded on numerous more or less convincing ex- periments. If an animal be injected with certain pathogenic bacteria or their toxins in gradually as- cending doses, it can be immunized to doses that under other circumstances would prove fatal. The blood- serum of an animal thus immunized has the power, when injected into another animal, of rendering it also immune to the bacteria that have originally been used; and in some cases the serum is even capable of curing the disease after it has developed in another animal. These properties with which the blood-serum has become endowed depend upon the presence of what are called antitoxins and antibacterial bodies. In man also, after recovery from certain infectious diseases, it is possible to demonstrate in the blood-serum the presence of antitoxic substances; and it is now the general be- lief that immunity, at least of the acquired form, is due to such antitoxins. The uses and practical pre- paration of antitoxins will be described in the next chapter. The most important of the special surgical micro- organisms—i. e., those most frequently met with in surgical work—are the following, the majority being pus producers: 42 BACTERIOLOGY I. Staphylococcus Pyogenes Aureus.—This is the most common form; it is quickly killed by carbolic acid (i : 20), bichlorid of mercury (1 : 1000), or by a few moments' boiling. It is found in the mouth, alimentary canal, and under the nails; it lives in the eyes, nose, ears, mouth, in the superficial layers of the skin, and is distributed in the water, soil, and air, especially in the dust of houses and surgical wards where the proper precautions are not taken. 2. Streptococcus pyogenes is a most important patho- genic micro-organism, and is thought by many authori- ties to be identical with the streptococcus of erysipelas. The Streptococcus pyogenes is frequently associated with internal diseases, and has been found in the uterus in cases of infective puerperal endometritis, ulcerative endocarditis, acute septicemia, and other diseases. It is one of the most common causes of postoperative peritonitis. 3. The Bacillus coli communis is always present in the intestines, and, while ordinarily active in the proc- esses of digestion, it is thought to be a frequent cause of acute suppurative peritonitis. 4. The Staphylococcus pyogenes albus resembles the aureus in form, but is less virulent. It is a common cause of suppuration, and although it has been found alone in acute abscesses, it is usually associated with other pyogenic cocci, chiefly the Staphylococcus pyog- enes aureus. 5. The Staphylococcus epidermidis albus is a micro- coccus which is almost always present upon the skin, not only upon the surface, but also in the outer layers. BACTERIA AS THE CAUSES OF DISEASE 43 6. The Staphylococcus pyogenes citreus is not quite so common nor so pathogenic as the other forms, and is less important. 7. The Bacillus pyocyaneus exists in pus (especially in open wounds), and gives to it a peculiar bluish or greenish color. 8. The Bacillus aerogenes capsulatus is a gas-pro- ducing bacillus that sometimes causes death after operations on the uterus; it may also enter through accidental wounds. 9. The Bacillus tuberculosis is the cause of all tuber- culous processes. The chief cause of the spread of infection is found in the dried sputum, which becomes pulverized and is then inhaled as dust; and since one patient may expectorate as many as four billion bacilli in twenty-four hours, his capacity for harm is very considerable. The bacilli retain virulence for five months in dried sputum, and in putrid sputum for forty-three days. 10. The Micrococcus lanceolatus, known also as Streptococcus lanceolatus, pneumococcus, and Diplo- coccus pneumoniae, is the cause of croupous pneu- monia and of many of the acute inflammations of the serous membranes of the body. It is also a pus pro- ducer, and has been found in empyema and acute ab- scesses. n. The bacillus of tetanus is found particularly in garden-soil, in the dust of halls, walks, cellars, street- dirt, and in the refuse of stables. It is not a pus producer. Tetanus is a disease due to the absorption of its toxins, which poison the nervous system pre- cisely as would dosing with strychnin. 44 BACTERIOLOGY 12. The diphtheria bacillus causes the dreaded dis- eases diphtheria and membranous croup, as well as inflammations of the eyes and nose; at times it also attacks open wounds. The Spirochata pallida is the cause of syphilis and it is transmitted usually by direct inoculation from one infected with the disease, the primary and secondary lesions being most infectious. CHAPTER III THE THEORY OF ANTITOXINS Great progress has been made of late in the field of serum-therapy, though much remains open to ques- tion and many recorded facts cannot yet be explained. The field for the investigator is perhaps larger than ever before. For a better understanding of the sub- ject of antitoxins and their therapeutic application, a few essential facts should be borne in mind. An anti- toxin is not the direct result of bacterial action, but is properly described as an unknown body resulting from the resistance of the healthy organism to the toxins of pathogenic bacteria. According to the pre- vailing theory, antitoxins are the products of the body cells, formed under the influence of the bacterial toxin. In therapeutic practice the antitoxic body comes to us in the blood-serum of an animal, usually the horse. When properly prepared and kept in aseptic con- tainers the antitoxins are not at all dangerous; they are as innocuous as an equal amount of blood-serum administered in the same way. Antitoxins are used both to counteract the effects of the toxins which are elabor- ated by pathogenic bacteria in the body, and to render the system immune, so that it may resist the action of the bacteria should they gain access to the body. The antitoxins do not destroy the bacteria; in other words, they are not germicides. In fact, the antitoxic serums 45 46 BACTERIOLOGY are themselves good culture-media. One theory of their action is that they neutralize the toxin, thus giving the natural bactericidal powers of the body an oppor- tunity to exercise their function. The following is a brief description of the process employed in the laboratory of Parke, Davis & Co. for the preparation of diphtheria antitoxin: Young horses in perfect condition are selected and kept under careful observation by an expert veterina- rian for three or four weeks. During this time they are carefully tested with tuberculin for the possible existence of unsuspected and undeveloped tubercu- losis, and with mallein for glanders. When a horse is found to be perfectly healthy it receives its first dose of diphtheria poison or, more properly, a solution of the toxin of the diphtheria bacillus. This is pre- pared in the following manner: A culture is obtained from the throat of a patient suffering from a virulent at- tack of diphtheria. The diphtheria bacillus is isolated from this culture and planted in a flask of bouillon or beef-tea, which is then kept in an incubator from three to four weeks. At the end of this time it has attained its maximum toxicity and the bacteria begin to die of their own poison. The toxin which they have elaborated in the course of their existence is held in solution in the beef-tea. This bouillon solution of toxin is then filtered through porcelain to remove the bacterial cells and any other extraneous matter. It is then ready for injection into the horse. About TVy of I c.c. is injected intravenously. The horse responds with all the consti- tutional symptoms of diphtheria, such as a chill, fever, loss of appetite, more or less pharyngeal paralysis, THE THEORY OF ANTITOXINS 47 with regurgitation of food. Sometimes death occurs from heart paralysis. Upon recovery, which comes within a few days, a slightly larger dose is given. This treatment is continued for about one year, at the end of which time the horse will take from 2000 to 3000 times the initial dose without reaction. It is then ready for bleeding. About 6000 c.c. of blood are drawn from the external jugular vein. This is allowed to clot, and the serum obtained is known commercially as antitoxin. It is customary to add an antiseptic, such as trikresol, to preserve the serum. In preparing the streptococcus antitoxin a culture is made of bacteria obtained from two sources—ery- sipelas and puerperal septicemia. This is done because some eminent bacteriologists believe that the strepto- coccus of erysipelas is not identical with the streptococcus of puerperal fever. It is but fair to say, however, that others equally eminent assert the identity of the two streptococci. To meet the possibility of the non-iden- tity of the organisms a culture obtained from the two sources is used. Its virulence is increased by passing it through rabbits. After passing through about fifty rabbits a culture is planted in beef-tea, and the same course pursued as for diphtheria antitoxin. Antitubercle serum is obtained by immunizing horses with the original Koch's tuberculin. As to the therapeutic action of antitoxin, little or nothing is known positively. It seems reasonable to conclude from experimental evidence that the anti- toxin neutralizes the toxin in the body and thereby gives the natural germicidal powers an opportunity to dispose of the bacteria. It may be that it has the 48 BACTERIOLOGY additional property of stimulating the phagocytic and possibly other bactericidal functions. The following experiments made by Martin and Cherry, of Mel- bourne, Australia, and described in the Jour. Amer. Med. Assoc, of August 27, 1898, are of interest in this connection. Behring, Ehrlich, and Kanthack have advocated the theory that the antagonism between toxins and antitoxins is a chemical one, somewhat anal- ogous to the neutralization of an acid by an alkali; while Buchner, Metschnikoff, and others have main- tained that it is indirect and operates through the cells of the organism. Martin and Cherry used a snake-venom antitoxin. A large number of guinea- pigs were used. At 6o° C. the antitoxin was destroyed, while the venom retained its virulence. In the con- trol-experiment with the venom only all the animals died within a few hours. A number of mixtures were made of 1 c.c. of antitoxin with twice the fatal dose of venom; others with three or four times the fatal dose. These mixtures were allowed to stand at the usual laboratory temperature (200 to 230 C.) for two, five, ten, fifteen, and thirty minutes respectively, then heated to 68° C, and afterward injected. As remarked above, this heat destroyed the anti- toxin, so that none was injected. The animals sub- jected to the mixture of the stronger doses of ten min- utes or less died or were seriously affected; all of those receiving the fifteen-minute mixture survived; while the thirty-minute mixtures produced no symptoms whatever. Similar results were obtained with diph- theria antitoxin and toxin. These experiments seem to show, as far as anything can, that the neutraliza- THE THEORY OF ANTITOXINS 49 tion of toxins may occur in the test-tube, and that the vital processes in the organism and the body cells are not essential. These gentlemen made further exper- iments by passing a mixture of toxins and antitoxins through a Pasteur-Chamberland filter. This was po- rous for toxin, but not for antitoxin, owing to the dif- ference in the size of their molecules. The toxin which passed through the filter, after having been mixed with antitoxin, was neutral. The unavoidable conclusion from this experiment is that the toxin was neutralized before filtration. Experiments have been tried in order to prove the theory that toxins are albumoses and antitoxins globu- lins; but these experiments do not appear to be con- clusive as to this point. The supposition that the administration of antitoxin is followed by a stimulation of the germicidal powers of the body seems to be reasonable, at least in the case of the antistreptococcic serum, since the strepto- cocci disappear with the passing away of the signs and symptoms. On the other hand, the Klebs-Loff- ler bacillus is found in the throat for weeks and even months after the disappearance of all symptoms of diphtheria in cases treated with the antitoxin. The present status of diphtheria antitoxin may be presented in a few words: It has established itself as a specific in the treatment of this disease. During the past few years the use of larger doses has become more general, and it seems certain that better results were obtained. The administrators of the Chicago Depart- ment of Health give 2000 units in all cases of suspected diphtheria, and employ iooo units as an immunizing 4 50 BACTERIOLOGY dose. During the months of November and December, 1898, this department treated 219 cases of bacteriologic- ally proved diphtheria—all charity cases—with a death- rate of 4.1 per cent. Some years ago, when antitoxin was not used, the death-rate from diphtheria treated by this department was about 35 per cent. Antistreptococcic serum gives promise of being second only to the diphtheria antitoxin in point of therapeutic value. It has been most successful in erysipelas and puerperal septicemia. Cases of scarlet fever are reported in which it has been useful in short- ening the duration of the disease and in preventing unfortunate complications and sequelae, such as otitis media and other suppurative processes due to strepto- cocci. A mixture of the toxin of the streptococcus of ery- sipelas and the products of a harmless germ, the Bacillus prodigiosus, is used by Coley and others as an injec- tion in malignant tumors that are past the stage of operation or are so situated that an operation is im- possible. Tetanus antitoxin is valuable as a prophylactic treat- ment, and if used in large doses in the early stages it is the best known method for the treatment of tetanus. The antitoxin may be introduced subcutaneously, intra- venously, and intraduraliy. Small doses are practically valueless, but large and repeated doses are very successful. Antityphoid vaccine has now practically prevented typhoid fever, but it is useless as a therapeutic agent. Antitoxin in cerebrospinal meningitis is given intra- durally and is moderately successful, especially if given early. THE THEORY OF ANTITOXINS 51 Flexner's serum in infantile palsy is at present being tried. It is apparently very successful if given early. The antitubercle serum has not shown itself to have more value than a great number of other remedies vaunted as specifics in tuberculosis. Method of Injecting Antitoxin.—The serums and toxins are given hypodermically, the injection being made into the back, thigh, side of the breast, or over the chest. Perfect antisepsis for the operation is absolutely necessary. The puncture wound is closed with a collodion dressing. It is not necessary to use massage for the purpose of causing more rapid ab- sorption of the injected serum—the swelling gener- ally disappears in a short time of itself. Sometimes the site of the injection becomes very painful. In certain cases pains in the joints and various skin eruptions (erythema, hives) develop after the injec- tion. They are not of great moment, but the physi- cian's attention should be called to them. The reaction following an injection of Coley's mixture is sometimes severe, and may correspond to the symp- toms beginning an attack of erysipelas—chill, local redness, and high temperature. Within the last few years certain serum reactions have developed. By the use of these methods the presence or the absence of a disease is detected. For example, syphilis, the presence or absence of it may be deter- mined by a complicated serologic reaction called the Wassermann test. To obtain blood for this test the finger is stuck with a blood sticker and the blood pressed into a test tube until it is three-quarters full. A test for gonorrhea is used, but it is not entirely satisfactory. 52 BACTERIOLOGY For detecting the presence or absence of tuberculosis, we have three tests: (i) Tuberculin test, which is made by scarifying the skin and rubbing in tuberculin. This gives a cutaneous reaction in forty-eight hours if the disease is present. (2) Tuberculin is injected subcu- taneously, and the temperature is taken every hour for forty-eight hours. If tuberculosis is present there will be a marked rise in the temperature. (3) Von Pirquet test: This method consists in dropping tuberculin into the conjunctiva. If the test is positive the conjunctiva becomes reddened. The Widal test consists in mixing a small amount of the blood-serum of the patient with a pure culture of typhoid bacilli. If typhoid fever exists there will be clumping or agglutination of the bacilli. CHAPTER IV ANTISEPTICS, DISINFECTANTS, AND DEODORANTS Articles and wounds which are entirely free from bacteria and their spores are termed aseptic or sterile. An antiseptic is a substance which kills or retards the growth of bacteria. A disinfectant or germicide is a chemical or physical agent which destroys the vitality of bacteria. Excessive heat, dry or moist, is a disinfectant because it kills bacteria; while cold retards growth, but does not kill bacteria. A deodorant is a substance which destroys offensive odors. Occasionally a substance possesses all three qualities, as carbolic acid. In strong solution (5 per cent.) it is a germicide; in 1 or 2 per cent, it is an antiseptic. Its natural odor makes it a good deodorant. The power of a chemical agent to destroy bacteria depends on: (1) The kind of bacteria; some being easily killed by an agent which is harmless to others. Spore-forming bacteria are very resistant, and the spores are much more resistant than the bacteria. (2) The number of bacteria present. (3) The temperature of the disinfecting agent. The higher the temperature, the more powerful the agent. 53 54 ANTISEPTICS (4) The strength of the solution, no matter of what substance. The stronger the solution, the more powerful the agent. (5) The nature and character and quality of the as- sociated material. If they are contained in a large amount of organic material, such as sputum or fecal matter, the chemical agent may combine with these and may thus be converted into an ineffective material before it has had an opportunity to act on the bacteria. The agents capable of destroying bacteria are chem- icals, physical and mechanical. The chemical agents are numberless; but there are many which cannot be em- ployed because they are too weak or act too slow, are too poisonous, are too destructive to objects with which they come in contact, or are too expensive for general use; for example, corrosive sublimate or mercuric bichlorid cannot be used for sterilizing instruments because it cor- rodes and blackens them. Potassium permanganate stains everything it comes in contact with. Some forms of physical agents cannot be used in certain instances; for example, boiling water, steam, or hot air could not be used to sterilize a surgeon's hands. For practical purposes the term "disinfection" is used for the action of chemical agents, and the term "steriliza- tion" for physical agents such as heat. Among all agents, both chemical and physical, heat is entitled to the first place, and fire, though seldom practi- cal, is superior to all others. Fire should always be used to destroy old clothing, books, and playthings that have been in contact with patients suffering from infectious diseases. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 55 Heat is used in the form of hot air, steam, and boiling water. Boiling water kills most germs on contact, and the more resistant types are killed by it in one or two minutes; for example, spores of anthrax. Steam is the next most powerful agent. It is more penetrating than hot air, but the air must be saturated with it for it to exert its full influence. Steam is used in four forms: Simple Steam.—Quiescent. Live Steam.—Circulating. High-tension Steam.—Under pressure. Superheated Steam.—That which has been secondarily heated to ioo° C. Live steam destroys anthrax spores in from five to fifteen minutes. Disinfection by steam is applicable to clothing, linen, blankets, towels, surgical dressings, instruments, cur- tains, carpets, brushes, mattresses, pillows (the two latter should be ripped open), and a number of delicate fabrics. It is not applicable to linen soiled by feces, blood, or pus, since the stains would become fixed by the process (soak first in plain cold water), nor to rubber articles. Under certain conditions many articles are exposed to the action of steam for one hour on three successive days, being kept during the intervals at a temperature of 700 to 8o° C. to favor the development of bacteria. This is called "inter- mittent" or "fractional" sterilization, the object of which is to kill all bacteria that may have developed from spores that escaped the first steaming. The last steril- ization is for the purpose of making sure. Hot air is inferior to both steam and hot water. 56 ANTISEPTICS Steam at a temperature of ioo° C. is more effectual than hot air at a much higher temperature. Accord- ing to investigations, exposure to a temperature of 1500 C. (3020 F.) for one and a half hours in a hot-air sterilizer will kill all known bacteria and their spores. The most prominent chemical germicides in use now are: 1. Bichlorid of mercury. 2. Tincture of iodin. 3. Carbolic acid. 4. Potassium permanganate. 5. Alcohol. 6. Creolin. 7. Lysol. 8. Harrington's solution. 9. Argyrol. 10. Hydrogen dioxid. 11. Chlorid of lime. (1) Corrosive sublimate or bichlorid of mercury has, like carbolic acid, the advantage of being both effica- cious and cheap. It has the disadvantages that it is decomposed by alkalies, that it is precipitated by albumin, and that it corrodes metals. It is used in strengths of from 1 : 10,000 to 1 : 500. The solution should be made as it is needed, because in old solu- tions most of the soluble corrosive sublimate has been converted into insoluble calomel, and the solution is not germicidal. By using the compressed tablets now on the market fresh solutions are readily made. A tablet usually contains the requisite amount of corrosive sublimate to make when added to 1 pint of water a 1 : 1000 solution, and by increasing or diminishing the ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 57 amount of water the strength of the solution may be altered at pleasure. The tablets are very convenient, and almost compel accuracy in the preparation. Cor- rosive sublimate is of less value for the disinfection of the excreta than carbolic acid, as it hardens the albuminous material which covers the outside of all fecal masses, and thus protects the inside from the desired action. Tar- taric acid, chlorid of sodium, or chlorid of ammonium is often added to prevent this. Compressed tablets, each containing tartaric acid or ammonium chlorid and y\ grains of corrosive sublimate, or equal parts of chlorid of sodium and corrosive sublimate, are in common use. The convenient form in which this drug is put up and the readiness with which it can be used in surgical and medical work have made its adoption universal. Its poisonous character must be kept constantly in mind. The first symptoms of poisoning in consequence of the absorption of the bichlorid are profuse salivation, fetid breath, a metallic taste in the mouth, sore teeth, spongy gums, and swollen tongue. Should any of these symp- toms appear they should at once be reported to the sur- geon. As the solution has no odor, it is occasionally swallowed in mistake. Should this occur, symptoms of a violent gastro-enteritis appear—vomiting, burning pain, bloody stools; the kidneys are also affected and an acute Bright's disease develops. The immediate treat- ment of this acute poisoning consists in the giving of white of egg, flour or milk and lime-water, and washing out of the stomach. (2) Tincture of iodin is made by dissolving iodin crys- tals in 95 per cent, alcohol, the amount of the latter used indicating the strength of the solution: 7 per cent, tine- 58 ANTISEPTICS ture is the standard and is the strength most commonly used; i, 3, and 5 per cent, solutions are also used for various conditions. This antiseptic is the most common in use for prepar- ing the field of operation, disinfecting wounds, and as a dressing solution in weaker strength. Nearly every surgeon will agree that every lacerated, incised, punc- tured, or stab wound occurring accidentally should be swabbed out with tincture of iodin. So, should you be present and called on to treat any such accident in the absence of a physician, use tincture of iodin before apply- ing a dressing. (3) Carbolic acid is a coal-tar product derived by dis- tillation. When pure it is a solid white or faintly rose- colored, crystalline body, soluble in water, alcohol, or glycerin. On exposure to air it absorbs 5 per cent, of moisture. In making a solution of carbolic acid it is dissolved in hot water and shaken thoroughly. In solution it is used more to disinfect instruments and floors of operating rooms than for dressings or treatment, except in the dressings of furuncles immediately after incision; pure carbolic acid is used here to disinfect the tissues after incision. It has the advantage over corrosive sublimate in that it does not discolor instruments or clothing. Dilute carbolic acid is a reliable disinfectant for instru- ments. If an instrument that is indispensable hap- pens to fall to the floor during an operation, it may be laid for a moment in pure carbolic acid, then rinsed with sterile water, and it is ready for use. Long- continued submersion in the acid will, however, de- prive knives and scissors of their temper and edge. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 59 It is not used to any great extent in general dressings because it irritates and causes a numbness of the skin. Symptoms of poisoning have been produced by the absorption of the drug from surgical dressings and from the use of carbolic solutions for irrigation. The first evidences of poisoning are a very dark greenish or a blackish coloration of the urine, headache, giddi- ness, ringing or singing in the ears, and lassitude. The odor of carbolic acid is, to a certain extent, a protect- ive against accident; yet fatalities occasionally oc- cur. The antidotes of carbolic acid are alcohol, milk, and lime-water, or flour and water. The strength of the solutions used varies from 1 : 80 to 1 : 20. The acid is bought usually in the liquid form, having a strength of 95 per cent. To make a solution 1 : 20 (5 per cent.), 1 : 40 (2\ per cent.), 1 : 50 (2 per cent.), 1 : 80 (\\ per cent.), 1 ounce of the 95 per cent, solution is added to 20, 40, 50, or 80 ounces of water. When obtained in the solid form, it may readily be liquefied by placing the bottle in a vessel of hot water. Other coal-tar derivatives which are akin to carbolic acid, but less powerful as disinfectants and less poisonous are: creolin, lysol, sozal, and saprol, the two latter being very rarely used. (4) Potassium Permanganate.—This drug is an anti- septic, disinfectant, and deodorant. It depends for its action on its oxidizing properties. In contact with or- ganic substances it parts with its oxygen very readily and becomes inert. Its chief disadvantage is that it stains everything a brownish-black color. It is used usually in strengths of I : 100 to 1 : 10. It was formerly used quite extensively to sterilize the hands. The stain it leaves on 6o ANTISEPTICS the hands may be removed by oxalic acid solution. It is used in treating wounds, especially those which have an offensive odor, acting as a deodorant as well as an anti- septic. It is also used to disinfect bowel movements and to flush water-closets. It shows by its changing from a reddish purple to brown whether it is acting or whether it is exhausted. (5) Alcohol.—Absolute alcohol is an antiseptic and disinfectant used for cleansing and sterilizing the skin, for preparation of sutures and ligatures, and for steril- izing instruments. Alcohol is used by some surgeons in the preparation of the patient for operation, and it makes an excellent dressing medium for fresh wounds which have been sutured. (6) Creolin and (7) Lysol axe both coal-tar deriva- tives. They are used chiefly by obstetricians and gyne- cologists. When mixed with water they make a soapy, oily solution very suitable for vaginal douches because they do not irritate the canal. Lysol ordinarily is used in from 1 to 3 per cent, solutions, but when repeated vaginal douches are ordered 0.50 per cent. (^ per cent.) solution is the maximum that the average patient will tolerate. Creolin is less irritant and probably less germicidal. (8) Harrington s Solution.—This solution, designed by Harrington, of Boston, is becoming more commonly used. It is an excellent disinfectant for the field of operation and for hand sterilization. Its capacity for destroying bacteria is twenty times greater than any known germicide and it is no more irritating than any other drug of this class. Hands washed in this solution for one minute become sterile, so that no bacterial growths can be obtained from the scrapings made from such hands. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 6l The following is the formula Bichlorid of mercury........... Hydrochloric acid............. Aqua destillata............... Alcohol...................... (9) Argyrol is a definite chemical compound of silver containing 30 per cent, of that metal. The various com- binations of silver possess more or less antiseptic qualities and are irritating to the tissues to a greater or less extent. But the preparation is very efficient as an antiseptic and practically non-irritating. It is not precipitated by al- bumin or sodium chlorid. It is used chiefly in infections of the mucous membranes in solutions varying from 2 to 50 per cent. Solutions should be made fresh, as it deteriorates rapidly. The stains are best removed by washing the materials in a solution of bichlorid of mercury. (10) Hydrogen dioxid is useless when employed as an antiseptic or disinfectant because it has no such prop- erties. The sphere of its usefulness lies in the fact that it eliminates its oxygen freely when in contact with or- ganic matter. It is therefore used to remove blood-clots, necrosed tissue, and other debris in wounds and ulcers. It possesses some hemostatic qualities and may be used in minor venous oozing. (11) Chlorid of lime, when mixed with carbonate of soda and moistened with water to form a paste, elim- inates chlorin gas, which possesses antiseptic qualities. Some surgeons use this combination for hand sterilizing. Other less prominent antiseptics are: (1) Formaldehyd.—It is a gas formed from the partial oxidation of wood alcohol. It is more commonly gr. xlviij; o viij; Oiiss; Oiiss. 62 ANTISEPTICS used as a disinfectant than for treatment purposes. It is very commonly used by health officers in gas form to fumigate rooms after infectious diseases. In solution, which is made by dissolving the gas in water, it is used for disinfecting floors and walls, especially of operating rooms. Its disadvantages are: after using the solution on the skin the latter begins to smart and burn. Its vapors are irritat- ing to the lungs, eyes, and nostrils. It is a very power- ful germicide, being superior to bichlorid of mercury. (2) Iodoform, a yellow powder with a penetrating odor, derives its antiseptic properties from the fact that it eliminates iodin. On clean wounds which exude serum it does good by absorbing the serum, thus removing good culture-media for bacterial growth. It prevents decom- position, and inhibits the growth of but does not de- stroy pus-producing bacteria. By absorption from a large wound surface it sometimes produces poisoning, as evidenced by headache, loss of appetite, elevation of temperature and pulse, restlessness, and insomnia. In severe cases a fine macular eruption appears on the face Fig. 5.—Formaldehyd generator. ANTISEPTICS, DISINFECTANTS, AND DEODORANTS 63 and limbs. Some patients are very susceptible to it. It is used in the form of iodoform gauze for dressings, iodo- form ointment, as a dusting-powder, and dissolved in ether or sterile oil for injecting sinuses and tuberculous abscesses. (3) Aristol (thymol-iodid) is a dusting-powder with action similar to iodoform, but without the disagreeable odor. (4) Boric Acid.—As a powder and in solution it is a mild antiseptic very commonly used. Its most impor- tant seat of usefulness is in eye work and for irrigations of the bladder. It is a non-poisonous, white, odorless powder, and for this reason is preferred to other dusting-powders. To get the best effect it must be in a saturated solution. (5) Oxalic acid is a powerful germicide, but is not com- monly used now except to remove the stains left by potas- sium permanganate. At a temperature of 400 C. it is a very powerful germicide. It irritates the skin, but this can in a measure be avoided by immersing the hands and forearms in cold water or lime-water. Abuses of Antiseptics and Germicides.—This class of drugs has been more abused than any other in the ante- and postoperative treatment and management of sur- gical cases. They are useful and necessary in their place, but their place is limited. The cleaner a surgeon or nurse is surgically, the less they will use antiseptics. In in- fected wounds and other cavities the greater the infection, the milder the solution and the greater the quantity should be used; cleanse the wound by removing all ne- crotic and foreign material before applying your anti- septic. Contrarily, strong solutions should be used for the surgeon's hands and for the field of operation. 64 ANTISEPTICS ANTISEPTIC SOLUTIONS Approximate Ways of Making Antiseptic Solutions by Apothe- caries' Measure To make— i oz. of a i : 500 solution use ipt iqt iqt iqt 1 qt 1 qt 1 qt 1 qt 1 : 500 1 : 500 1 :1000 1 : 2000 1 : 3000 1 : 4000 1 : 5000 1 : 10,000 1 gr. of the drug IS g^ " " 3° gr. " " 15 gr- " " l\ gr. " " 5 gr- " " 3fgr. " " 3 gr. a n 12 gr. " " Percentage Solutions (Approximately) To make— 1 dram of a 1 per cent, solut: 1 dram 1 dram 1 oz. 1 oz. 1 oz. on use % gr. + of the drug. " 15 gr. " 2igr. " 5 gr. + " " Qlgr. " 19 gr- Metric System Solids. Approximate equivalent. Liquids Approximate equivalent. 1 grain........ 0.065 gram. 1 ounce....... 30.000 grams. 1 pound....... 500.000 grams. 1 minim. . . 0.06 c.c. 1 ounce. . . 30.00 c.c. 1 pint..... 500.00 c.c. 1 quart... . 1000.00 c.c. or 1 liter. Examples To make— 1000 c.c. (1 liter) of a 1 : 500 solution use 2 grams of the drug. 1000 c.c. " " 1 : 1000 " " 1 gram " " 1000 c.c. " " 1 : 2000 " " \ gram " " Labarraque's solution is a solution of chlorinated soda, and is made from chlorinated lime and sodium carbonate. It is used as an antiseptic in solutions of 1 : 10, and for cleansing purposes. PART II SURGICAL TECHNIC CHAPTER V BANDAGING AND DRESSINGS BANDAGING A nurse will be frequently judged by her ability to ap- ply a bandage properly. Materials.—They may be of unbleached muslin, gauze, black or white, flannel; crinoline, or gauze for plaster-of- Paris; or rubber. Muslin purchased in large rolls is cut in lengths of from 6 to 8 yards. The end of the muslin is cut in the desired widths for bandages and torn in strips. Rolling by Hand.—One end of the bandage is folded upon itself several times and rolled between the thumb and first finger of the left hand until it becomes firm enough to hold between the fingers. The folded por- tion is held between the thumb and index finger of the left hand and rotated by the thumb and second finger of the right hand. The bandage machine consists of an upright and octagonal shaft mounted upon a metallic base which may be screwed to a table. The shaft is turned by hand 5 65 66 SURGICAL technic or foot, depending upon the type of machine used. The width of the space on the shaft is regulated by a movable upright. The bandage is fed to the roller by the left hand. It should be rolled tense, and when the bandage is finished the crank is reversed automatically, releasing the bandage from the shaft, allowing it to be pulled out (Fig. 6). It is now considered cheaper to buy bandages already rolled in yard lengths and cut as needed (Fig. 7). Fig. 6.—Hand roller-bandage machine. (Fowler's Surgery.) Application of Bandage.—Bandages are used to hold splints and dressings in place, to give support as in frac- tures. They should be applied moderately tight. If support is the motive, a number of turns will secure this much better than a few tight ones. It is much better to apply a bandage too loosely than too tightly. In applying wet dressings, always remember to allow for shrinkage. A bandage is started by placing the outer surface of the initial extremity upon the starting-point and holding it with index-finger of the left hand. With BANDAGING AND DRESSINGS 67 the roller held in the right hand, two turns are made in the direction which the bandage is to take. To overlap is to make a second turn cover a certain portion of the preceding turn. This is the procedure in all spiral bandages. To recur is to catch a turn at some point and turn it in such a way so that it either exactly retraces its course or turns off slightly in another direction. Fig. 7.—Mitre box and Christy knife for cutting bandages. (Fowler's Operating Room and the Patient.) To Reverse.—The bandage is turned laterally upon itself, so that the part that was external is now internal. This is performed by holding the bandage in place with the thumb of the left hand, slightly relaxing the roller while pronating the right hand (Fig. 8). The thumb is now removed and the bandage tightened and continued around the part until the second reverse is reached, where the same procedure takes place. It is very necessary to have the turns in alignment. This may be made in the opposite direction, i. e., descending or ascending. The 68 SURGICAL TECHNIC object of reversing a bandage is to adapt it to the change in diameter of the part. To Secure.—The end of the bandage is split into two tails. These are passed in opposite directions around the part and tied in place. The end of the bandage may also be pinned, but great care should be used so that the pins do not penetrate the bandage and stick into the part. Fig. 8.—Making the reverse. (Fowler's Surgery.) Removal.—Each turn should be taken off reversely from the way it was put on. There are three general types of bandage, of which all others are modifications: circular, spiral reversed, and figure-of-8. Barton's Bandage (2 inches by 6 yards).—The initial end of the roller is placed on the head under the mastoid process and the bandage is carried upward and in front of the parietal eminence, across the vertex of the skull, BANDAGING AND DRESSINGS 69 downward in front of the ear, under the chin, upward in front of the opposite ear, over the top of the head, where it crosses the first- turn and back to the starting-point. The bandage is then continued forward below the right ear, in front of the chin, and back to the starting-point. These turns should be continued until the end of the bandage is reached. Fig. 9.—Barton's bandage. (Fowler's Surgery.) Secure with adhesive plaster or pins introduced where the bandage crosses. In applying this bandage great care should be taken to see that each turn overlaps the preceding turn and that the bandage crosses in the me- dian line of the skull (Fig. 9). Uses.—To retain dressings on face, fractures and dis- locations of lower jaw. Gibson's Bandage (2 inches by 5 yards).—This ban- dage consists of three turns from the occiput to the fore- head and back again. On the final turn the bandage is reversed as it reaches the front of the ear. It is then 7o SURGICAL TECHNIC carried downward under the chin, thence up on the op- posite side, and back to the reversing point. This turn is repeated three times and the occipitofrontalis portion of the bandage is repeated three times. It is secured by pins placed at the reversing and inter- secting points (Fig. 10). Uses.—Same as Barton's bandage. Fig. 10.—Gibson's bandage. (Fowler's Surgery.) Recurrent Bandage (2 inches by 4 yards).—Fix the roller by a circular turn from the occiput to the fore- head and back again. Continue for two turns. Upon reaching the occiput at the end of the second turn the bandage is reversed, carried forward, across the top of the head to the frontal region, where it is held in place by an assistant and reversed backward and forward, first on one side and then on the other, overlapping the pre- vious turn by f inch until the entire head is covered. The bandage is then again reversed and the free ends held in place by circular turns around the occipitofrontal BANDAGING AND DRESSINGS 71 region and secured by pins at the reversing points (Fig. 11). Uses.—To retain dressings to the head and scalp and to make compression. Double Head Recurrent (2 inches by 4 yards).—Two bandages. The ends of the bandages are sewed together. Place the portion between the two rollers on the forehead and carry the rollers backward until they meet opposite Fig. 11.—Recurrent bandage of the head. (Fowler's Surgery.) the occipital protuberance. At this point the bandages are reversed, one going circularly around the head, the other backward and forward over the scalp, each turn being caught by the circular bandage, and so on until the head is entirely covered. The bandages are then continued as circular turns until the bandage is finished. Uses.—To retain dressings to the scalp. Occipitofrontal Bandage (2 inches by 4 yards).—The end of the bandage is placed upon the forehead. To fix 72 SURGICAL TECHNIC it, a circular turn is made around the forehead and the occiput. A circular turn is then made so that it reaches down as far as possible posteriorly and as far up on the forehead as possible. The next turn is made so that the posterior portion is above the occiput and the anterior portion above the eyebrow. These turns may be re- peated as many times as desired (Fig. 12). Uses.—To secure dressings on anterior and posterior portions of scalp. Fig. 12.—Occipitofrontal bandage. Liebreich's Eye Bandage.—Strip of flannel, white or black, 2\ inches by 8 to 10 inches, fitted with tapes at the extremities. Apply to one eye obliquely, reverse the tapes by crossing at the occiput with a circular turn, and tying. Apply to both eyes transversely with circular turn of the tapes and tie (Fig. 13). Crossed Bandage of Eye (2 inches by 6 yards).—The bandage is fixed by a circular turn from the occiput to the forehead. The bandage is then carried from the BANDAGING AND DRESSINGS 73 occiput below the right ear, up over the outer portion of the cheek to the base of the nose, and continued to the occiput, passing below the left parietal eminence. These Fig. 13.—Modified Liebreich's eye bandage. turns are alternated, the one passing below the ear over- laps the former turns two-thirds. Continue until the de- Fig. 14.—Figure-of-8 of one eye. sired result is obtained. Flannel bandage is more com- fortable (Fig. 14). Uses.—To retain dressings to the eye. 74 SURGICAL TECHNIC Double Crossed Bandage of Both Eyes (2 inches by 6 yards).—The bandage is fixed by two occipitofrontal circular turns. The bandage is then carried forward below the ear, crossing the cheek to the root of the nose, and back to the occiput. A circular occipitofrontal turn is then made, and the bandage carried below the right parietal eminence to the root of the nose; downward across the cheek under the left ear, to the occiput. These turns are repeated as described above until the desired result is obtained (Fig. 15). Use.—To hold dressings on both eyes. Fig. 15.—Figure-of-8 of both eyes. Figure-of-8 of Head and Neck (2 inches by 3 yards).— Fix the bandage by two circular turns around the neck, starting just below the occiput. Then carry the bandage upward above the right ear over the forehead above the left ear and back to the starting-point. Alternate these turns until the bandage is finished. Uses.—To retain dressings to the throat and back of the neck. Suspensory and Compressor Bandages of the Breast (2\ inches by 7 yards).—Place the end of the bandage BANDAGING AND DRESSINGS 75 upon scapula of the injured side. Secure by two oblique turns carried over the opposite shoulder and conducted downward under the breast and carried to the axilla of the same side. Then carry the end of the bandage trans- versely around the chest, covering in the lower portion of the injured or affected breast. Repeat these turns, the oblique turn from the axilla over the shoulder alternating with the transverse turns around the chest until the Fig. 16— Bandage for the breast. (Fowler's Surgery.) breast is covered in. Each series of turns in ascend- ing should obscure two-thirds of the foregoing turn (Fig. 16). jjsei—This bandage is used to hold dressings to the breast and make compression on the breast at the same time. Double Breast Bandage.—The roller is started from the scapula of the affected side, and carried over the shoulder of the opposite side to the front of the chest, thence under the affected breast and obliquely along the 76 SURGICAL TECHNIC lateral and back of chest to its starting-point. This turn is repeated in order to secure the end of the bandage. The second turn is a circular one around the chest just below the breasts. The third turn is started at the point of the initial extremity, and the bandage is carried around the chest wall to the under surface of the second breast. From here it is carried over the front of the chest, thence over the opposite shoulder, and back over the chest to the starting-point. First, second, and third turns respec- Fig. 17.—Double breast bandage. (Fowler's Surgery.) tively are now repeated, each turn covering in two-thirds of the foregoing turn, and in this way both breasts are securely and neatly covered (Fig. 17). Use.—Support and pressure of breast. Figure-of-8 of Back and Chest (2% inches by 7 yards).— Place the initial end of the bandage on the back between the scapulae. Carry the bandage upward over the right shoulder, down under the axilla, and back to the starting- point. Continue over the left shoulder to the axilla and BANDAGING AND DRESSINGS 77 back to the starting-point. Continue these turns until the bandage is finished (Figs. 18, 19). Uses.—To retain dressings on upper part of back and to pull shoulders back. Fig. 18.—Posterior figure-of-8 Fig. 19.—Anterior figure-of-8 bandage of the chest. (Fowler's bandage of the chest. (Fowler's Surgery.) Surgery.) Spica Bandage of the Shoulder (2^ inches by 7 yards). —Fix the bandage by circular turns at the insertion of the deltoid. Then carry the bandage across the arm, over the anterior portion of the chest to the axilla, and across the back to the starting-point, then under the arm and repeat as described above, each turn overlapping the previous turn two-thirds. Continue thus until the shoulder is covered. This bandage may be put on in a similar way for the left shoulder, providing one uses the left hand (Fig. 20). Use.—To retain dressings on shoulder. SURGICAL TECHNIC Fig. 20.—Ascending spica of the shoulder. (Fowler's Surgery.) Velpeau's Bandage.—Two to three rollers, 2\ inches by 7 yards each. The hand of the injured side is placed Fig. 21.—Velpeau's bandage— Fig. 22.—Velpeau's bandage— first turn. (Fowler's Surgery.) second turn. (Fowler's Surgery.) so that the tips of the fingers touch the sound clavicle. The initial end of the bandage is placed over the sound BANDAGING AND DRESSINGS 79 scapula and the bandage carried over the point of the affected shoulder, then backward over the outer surface of the arm, behind the elbow, across the chest to the sound axilla, and under it to the starting-point. Repeat this turn, thence making a circular turn around the chest over the top of the injured elbow and back to the starting-point. The first turn is repeated, overlapping three-quarters of the first turn toward the middle line of the body, then a circular turn, then a shoulder turn until the tip of the Fig. 23/—Velpeau's bandage completed. (Fowler's Surgery.) elbow is reached by the shoulder turns, after which only circular turns are made until the arm is encased in the bandage. In applying this bandage, as in any other bandage where skin surfaces come together, a layer of lint or a towel should be placed between the surfaces to prevent excoriation (Figs. 21, 22, 23). Use.—Fracture of clavicle. Descending Spica of Shoulder (2\ inches by 7 yards).— The initial end of the roller is placed over the sound scap- 8o SURGICAL TECHNIC ula and the bandage carried upward over the injured shoulder, downward to the anterior fold, through the axilla, then upward and forward over the shoulder, across the chest, under the opposite axilla to the starting-point, each turn overlapping the preceding turn two-thirds. Repeat these turns until the shoulder is covered. Use.—To retain dressings on shoulder. Desault Bandage (2 inches by 7 yards).—Three to five rollers. Oval pad for axilla. First Roller.—The arm is elevated with the oval pad placed in the axilla. The free end of the bandage is Fig. 24.—Desault's bandage, first Fig. 25.—Desault's bandage, roller. second roller. placed over the pad and held in place by two or three circular turns around the chest. Each turn should over- lap the preceding one two-thirds of its width. It is then brought across the front of the chest, over shoulder, under the axilla, and back to the starting-point. Second Roller.—The arm is brought down to the side of the body with the elbow flexed at a right angle and held in place by circular turns around the chest and arm until the arm is covered, each turn overlapping the pre- BANDAGING AND DRESSINGS 81 ceding turn two-thirds. This may be started from above downward or the reverse. Third Roller.—The free end of the bandage is placed in the sound axilla and the bandage carried obliquely across the front of the chest, over the injured shoulder, down the back of the arm to the elbow, thence upward over the forearm to the starting-point. Then upward across the back of the chest, over the injured shoulder, down the front of the arm, around the elbow obliquely, upward across the back to the starting-point. These turns should Fig. 26.—Desault's bandage, third roller. be alternated, each turn overlapping the preceding turn until three sets have been completed (Figs. 24, 25, 26). Uses.—Fracture of clavicle and dislocation of shoulder. Jones' Position for Fracture of the Elbow.—This con- sists in flexing the forearm upon the arm and by holding it in place by a strip of adhesive plaster wound several times around the arm and forearm, and the arm supported by tying the wrist to the neck by means of a bandage. Figure-of-8 Bandage of the Elbow (2 inches by 4 yards). —The bandage should be applied with the elbow flexed. The end of the bandage is applied a few inches below the 6 82 SURGICAL TECHNIC elbow-joint. A few circular turns fixes the bandage. The end of the bandage is then carried across the flexure of the joint and a circular turn is made a few inches above the joint. The bandage is then carried obliquely to the start- ing-point and a circular turn is here made. Alternate the circular turns below the joint with those above the joint, each time obliquely crossing the flexure of the elbow. The turns gradually approach the tip of the olecranon Fig. 27.—Figure-of-8 bandage of the elbow. (Fowler's Surgery.) from both directions and the bandage is completed by a circular turn (Fig. 27). Uses.— To retain dressings and as part of the spiral reversed of the upper extremity. Spiral Reversed of the Forearm (2\ inches by 7 yards). —The end of the bandage is fixed by one or two circular turns around the wrist. It is then carried upward by two or three spiral turns until the increased circumference BANDAGING AND DRESSINGS 83 makes reversed turns necessary. These turns are made by holding the bandage in place with the thumb of the left hand, slightly relaxing the roller held in the right hand, and at the same time pronating the right hand. The bandage is now continued around the forearm, where another reverse is made, and so on until the elbow is reached, where the bandage is ended by circular turns. Use.—To retain dressings on forearm. Spiral Bandage of the Finger (1 inch by i\ yards).— The bandage is secured by circular turns around the Fig. 28.—Spiral bandage of the finger. (Fowler's Surgery.) middle phalanx, and carried over the tip of the finger by oblique turns. It is then continued, gradually ascending the finger by circular turns, each turn overlapping the preceding one by two-thirds until the base of the finger is reached. It is then passed obliquely across the back of the hand to the wrist, where one or two circular turns are made. It is then carried to the base of the finger, where it is pinned or tied in place (Fig. 28). Use.—To retain dressings to fingers. 84 SURGICAL TECHNIC Spiral Reverse of Finger (i inch by i^ yards).—The end of the bandage is secured by one or two turns of the bandage around the phalangeal joint, and the bandage carried upward by spiral reversed turns until the base of the finger is reached. Finish by circular turns. Use.—To hold dressings on fingers. Spica Bandage of Thumb (i inch by i| yards).—The bandage is fixed by circular turns around the wrist. The bandage is then continued over the back of the hand to the tip of the thumb, across the tip of the thumb, over the back of thumb to the wrist, where a circular turn is Fig. 29.—Spica of the thumb. (Fowler's Surgery.) made. These turns are repeated, each turn overlapping the preceding turn by two-thirds, until the thumb is covered (Fig. 29). Use.—To retain dressings to the thumb. Demigauntlet Dorsal Bandage (1 inch by 4 yards).— The bandage is fixed by circular turns at the wrist. It is then carried across the back of the hand to the base of the first finger, where a circular turn is made and the ban- dage is returned to the wrist. Each finger is encircled in turn and the bandage is finished by a few figure-of-8 turns around the wrist and hand (Fig. 30). Use.—To hold dressing on back of hand. BANDAGING AND DRESSINGS 85 Demigauntlet Palmar Bandage.—The application is the same as the demigauntlet bandage of the dorsal sur- face of the hand, with the exception that the turns are made across the palmar instead of the dorsal surface of the hand. Use.—To retain dressings to palmar surface of hand. Fig. 30.—Demigauntlet bandage. (Fowler's Surgery.) Single Spica of Groin, Ascending (2\ inches by 7 yards). —This bandage should be applied with the right hand for the right side and with the left hand for the left side. The bandage is fixed by circular turns around the abdo- men. I'pon reaching the anterior superior spine, the bandage descends across the groin around the thigh, up to the anterior superior spine, where a circular turn is made around the abdomen. These turns should be alternated, each turn overlapping the preceding turn by two-thirds. The bandage is completed by a circular turn around the abdomen (Fig. 31). Use.—To retain dressings in groin. 86 SURGICAL TECHNIC Fig. 31.—Ascending spica of the groin. (Fowler's Surgery.) Descending Spica of the Groin (2! inches by 7 yards). —The descending spica of the groin is applied in the same manner as the ascending, with the exception that the Fig. 32.—Descending spica of the groin. (Fowler's Surgery.) turns descend instead of ascend. It is necessary to have the first turn, then, as high as possible (Fig. 32). Use.—To retain dressings to the groin. BANDAGING AND DRESSINGS 87 Double Spica Bandage of Groin.—Instead of using the complicated double bandage, it is advisable to apply a right and left single spica. Figure-of-8 of the Knee (2\ inches by 2 yards).—The bandage is fixed by circular turns around the upper portion of the leg. It is then carried across the popliteal space and a circular turn made around the thigh, descend- ing across the popliteal space, and by circular turns car- ried around the leg. These turns are repeated, each turn Fig. 11.—Figure-of-8 of the knee. (Fowler's Surgery.) overlapping the preceding turn two-thirds until the popliteal space is covered in. The bandage is completed by a few circular turns around the thigh (Fig. 33). Use.—To retain dressings to popliteal space. Recurrent Bandage for a Stump (2\ inches by 6 yards). —Fix by circular turns near the lower end of the stump. Continue by recurrent turns covering in the end of the stump. Complete by ascending oblique spiral or spiral reversed turns, each turn overlapping two-thirds of the preceding turn (Fig. 34). 88 SURGICAL TECHNIC Figure-of-8 Bandage of Leg.—The end of the bandage is fixed by one or two circular turns around the ankle. The bandage is then carried upward by spiral turns until the diameter of the leg increases, necessitating oblique turns. The bandage is then carried up across the leg to just belowr the. knee, where a circular turn is made, then downward across the anterior surface of the leg. These turns are repeated, each turn overlapping the previous Fig- 34-—Recurrent bandage of the stump. (Fowler's Surgery.) turn two-thirds of its width until the whole leg is neatly covered. The bandage is completed by one or two circular turns just below the knee. Use.—Retaining dressing to leg. Spiral Reverse of Lower Extremity (2\ inches by 7 yards).—The bandage is fixed by circular turns around the ankle, and then carried upward by spiral turns until they no longer lie flat upon the leg. Then, by spiral BANDAGING AND DRESSINGS 89 reversed turns, the bandage is continued up to the knee, around the knee by figure-of-8 turns, and continued up Fig. 35.—-Spiral reverse of the lower extremity. (Fowler's Surgery.) the thigh by spiral reversed turns. The reversed turns are made as in the arm by drawing the bandage taut, holding it in place with the left hand, slightly relaxing the Fig. 36.—Figure-of-8 of the Fig. 37.—Spica of the foot. foot and ankle. (Fowler's Sur- (Fowler's Surgery.) gery.) bandage, pronating the hand so that the part of the ban- dage that was against the skin is now away from it. The 9o SURGICAL TECHNIC bandage is continued around the leg until you reach the line of the reverse, where a reverse is again made (Fig. 35). Use.—To retain dressings on the lower extremity. Spica Bandage of Foot (2 inches by 3 yards).—The bandage is fixed by a circular turn around the ankle and is then carried across the anterior surface of the foot to the base of the toes, thence across the sole of the foot, over the anterior surface of the foot, around back to the heel. These turns are repeated, each turn overlapping the preceding turn by two-thirds until the ankle is covered in (Fig. 37). Use.—To retain dressings to foot. Fig. 38.—Method of covering the Fig. 39.—Figure-of-8 bandage of heel. the instep. To Cover the Heel (American Method) (Fig. 38).— Circular turns (3) about the ankle (to fix); descend by oblique turn across the back of the foot; circular turn at the base of the toes. Continue by covering the foot with ascending spiral reversed turns until the instep is reached. Cover the heel by circular turns from the instep to the heel, alternating with figure-of-8 turns about the sides of the heel. Complete by circular turns, as- cending the ankle. BANDAGING AND DRESSINGS 91 Bandage of the Foot Not Covering the Heel (French) (Fig- 39)-—Circular turns at the ankle (to fix). Ob- lique turn across the back of the foot, descending to the base of the toes, where a circular turn is made. Cover in the foot to the instep with spiral reversed turns (ascend- ing). Complete by circular turns about the ankle and lower leg. Complete Bandage of the Lower Extremity (see Fig. 35). —This bandage is used for applying compression to the leg to retain dressings. Circular turns at the ankle (to fix); oblique turn, descending across the dorsum of the Fig. 40.—T-bandage. foot, with a circular turn at the base of the toes. Con- tinue by covering in the foot and heel. Ascend the leg by circular, oblique, spiral, or reversed spiral, covering in the calf. Continue by figure-of-8 turns at the knee. Complete by ascending spiral or reversed spiral of the thigh. T-Bandages, Slings, and T-Binders.—Materials.— These are best made from heavy unbleached muslin or flannel. A T-binder should consist of two pieces of material about 4 to 6 inches in width. The horizontal portion 92 SURGICAL TECHNIC should be sufficiently long to surround the part to be bandaged and the vertical length should be about 18 inches. The second piece is sewed to the middle of the first (Fig. 40). Slings are most frequently used to support the fore- arm and are usually designated as the handkerchief and roller. The handkerchief sling consists of a piece of material approximately 1 yard square folded diagon- ally. It is preferable to the roller sling. Fig. 41.—The Scultetus bandage. A roller sling consists of a 3-inch roller bandage which is carried around the neck, then under the wrist, and the two ends drawn sufficiently tight to give the desired sup- port and tied. Scultetus Bandage.—It is most frequently applied to the abdomen and is made of a piece of muslin or gauze about 16 inches in width and about one and one-half times the circumference of the part. In both free ends slits are made about 2 inches apart and 6 inches deep. It is used to retain dressings that require frequent changing. The opposite ends are tied in a bow-knot. BANDAGING AND DRESSINGS 93 ADHESIVE PLASTER Adhesive plaster dressings are usually used to fix joints, secure splints in fractures, and in strapping ulcers. Rubber Adhesive Plaster.—It is a manufactured prod- uct consisting of a linen material covered by a composite material with caoutchouc as a base. It has the property of adhering to whatever material it comes in contact with. Zinc Oxid Adhesive Plaster.—This plaster is prepared by incorporating rubber adhesive plaster with oxid of zinc. It is equally as adhesive as the rubber plaster, and possesses the advantage that it is not apt to produce irri- tation of the skin. This plaster has largely supplanted both the resin and rubber adhesive plaster in surgical dressings. Resin plaster is made of resin, lead, and wax spread on linen material, and when it comes from the manufacturer is covered by a thin tissue paper. It should always be kept in a cool place, otherwise it deteriorates. For application it is necessary to remove the tissue paper and gently heat. Moleskin adhesive plaster consists of spreading a zinc oxid material on moleskin or a heavy flannel. It is es- pecially useful in abdominal dressings where support is necessary, such as a Rose binder. Sayre's dressing for fracture of the clavicle requires two strips of zinc oxid adhesive plaster 3 inches wide and sufficiently long to encircle the chest one and one-half times. A piece of linen encircles the injured arm, then one end of the strip is circled round the arm with the adhesive side toward the chest. The arm is pulled back- ward and the adhesive plaster carried across the posterior 94 SURGICAL TECHNIC chest under the sound arm and then back to the front part of the chest. Now draw the hand of the injured side forward until it touches the sound clavicle. The remaining strip is placed on the back over the injured arm and carried downward over the tip of the elbow of the injured side, up over the back of the hand, over the sound shoulder to the starting-point. It is well to cut a hole in the center of the adhesive where it crosses the elbow (Figs. 42, 43). Fig. 42.—Sayre's dressing-—pos- Fig. 43.—Sayre's dressing—ante- terior view. (Keen's Surgery.) rior view. (Keen's Surgery.) Chest Strapping.—This consists of strips which are cut in widths of 2\ inches and sufficiently long to reach from 1 inch beyond the spine of the vertebra to I inch beyond the sternum. With the patient sitting, the arm of the injured side is held up and the patient is told to exhale, at which time the straps are applied one after the other from below upward, each strip overlapping the other one-third (Fig. 44). BANDAGING AND DRESSINGS 95 Pelvic Binder.—This consists of a strip of moleskin adhesive plaster sufficiently long to pass one and one- half times around the hips. One end of the adhesive is placed just above the trochanter of the injured side, car- ried across the back over the crests of the ilium and back to the starting-point, and continued in this line until all the strip is in place. Fig. 44.—Strapping the ribs (after A. S. Morrow). Figure-of-8 of the Knee.—This is well illustrated in the accompanying diagram. Strips should be 1 inch wide and 11 to 15 inches long (see Fig. 33). Strapping of Ulcers of the Leg.—Ulcer of the leg may be strapped in the circular or oblique method as is shown in the diagram (Fig. 45). Strapping of the Joints.—This requires strips of zinc oxid adhesive plaster 2 inches wide and sufficiently long to extend two-thirds around the joint. The first strap is applied a few inches below the joint and the strapping 96 SURGICAL TECHNIC continued until the joint is covered. Each strap should overlap the preceding strap by twTo-thirds. This dressing will be found to be satisfactory in the treatment of sprains of joints, etc. Strapping of the Ankle-joint.—Straps of zinc oxid adhesive, i^ by 18 inches, are required. The first strap is started at a point midway between the knee and the Fig. 45.—Strapping an ulcer of the leg. (Keen's Surgery.) ankle, applied to the edge of the tendo achilles, carried across the sole of the foot and up the opposite side of the leg. A strap is next placed so that its middle crosses the point of the heel, the ends being carried forward on the inner and outer surface of the foot. These straps should be alternated until the ankle-joint is covered in. One should avoid having these straps meet in the front of the foot or make circular constriction (Fig. 46), BANDAGING AND DRESSINGS 97 Buck's extension is a method of obtaining traction upon the leg and thigh. The attachment is made by Fig. 46.—Strapping the ankle-joint. (Keen's Surgery.) adhesive plaster and consists of straps 4! inches wide and long enough to reach from well above the knee to Fig. 47.—Fracture of the thigh. Completed apparatus and, in addi- tion, a long outside T-splint, straps, and swathe. Weights applied. (Scudder.) loosely around the sole of the foot and up the opposite side of the leg to a point opposite the starting-point. A piece of wrood, 5 by 3 inches, is then placed in the center 7 98 SURGICAL TECHNIC of the strap. A hole is cut in the center of the board through which a rope is passed. The adhesive surfaces of the plaster are placed on either side of the leg and thigh and are held in place by figure-of-8 turns of adhesive fol- lowed by a muslin bandage. The extension may be obtained by elevating the foot of the bed and tying the rope thereto, or by passing the rope over a pulley and attaching weights (Fig. 47). Montgomery Straps.—They consist of a strip of zinc oxid adhesive from 1 to 2 inches in width and from 3 to 6 inches in length. The corners of one end of the adhesive are turned in and this end punctured. A strip of tape is sewed or tied to this. These are placed to either side of the wound and tied over the dressing. Use.—To hold dressings in place. Catheter straps are similar to the above, but are nar- rower and shorter. PLASTER-OF-PARIS Plaster-of-Paris bandages, like all other bandages, are made in various lengths and widths. This bandage consists of unwashed crinoline or gauze with the mesh filled with the best dental plaster-of-Paris. The material may be cut in the desired width or length, or the whole width of the material may be rolled at once. If not used at once, they should be kept in covered metal boxes to keep out the dampness. Plaster bandages can be purchased at any good apoth- ecary shop. Application of Plaster-of-Paris Bandage.—The part should first be covered by a flannel roller or a bandage made of raw cotton and held in place by a gauze bandage. BANDAGING AND DRESSINGS 99 In applying body casts, a union suit of heavy material is advisable. The plaster bandage should be immersed in water until the bubbles cease to escape, the excess water squeezed out, and the bandage applied by circular turns. Reverses in the bandage are allowable, but not advisable. After the application of each bandage, plaster of the consist- ency of thick cream should be rubbed in, as in this way less bandage will be required. In applying casts to the leg three to five bandages are usually sufficient. Strips of tin, zinc, or binder's board may be placed between the layers of the bandage to increase the tensile strength. Plaster bandages set better on dry days. Heavy rubber gloves are desirable to keep the hands of the operator free from plaster, or if they are not used, sugar and glycerin will assist in removing the plaster. After the bandages are applied, great care should be used so that none of the plaster gets into the plumbing, as it will close the drain. Removal of Cast.—This is best done with a heavy knife, cutting obliquely to the plaster. Vinegar, peroxid of hydrogen, etc., are useful to soften the plaster and assist in its removal. Windows or fenestrations may be cut in the cast. After the cast is dry it is well to confine the free ends in adhesive to prevent rubbing. SPLINTS Splints, padded with cotton-batting, oakum, wool, or hair, may be constructed from white pine, poplar, or willow wood, | to \ inch (3-12 mm.) in thickness, cut to measured length and width; they may be of IOO SURGICAL TECHNIC pasteboard or binder's board, molded to shape by soaking in boiling water, or of rawhide similarly worked; of felt; plaster-of-Paris; starch (dissolved in cold water, after which boiling water is added until the proper con- sistence is secured) requires from twelve to forty-eight hours to dry thoroughly (Fig. 48); gum and chalk (equal parts of gum arabic and precipitated chalk, add sufficient boiling water, stirring to obtain a proper consistence of solution) applied upon bandages; hatter's felt or binder's ri 4------- //^J ] 1\ ( Fig. 48.—Splint made from plaster-of-Paris bandage. Complete by molding to the part; trim after setting has taken place. board may be softened in hot water and molded to the injured parts. The coaptation splint consists of thin and narrow board strips (of bass wood or pine) placed in position (side by side, with a slight interval) upon a sheet of adhesive plaster, or they may be quilted between two pieces of sheeting. The splint is held in position by bandaging or by adhesive straps, and may be employed in emergency or to reinforce the ordinary board or bracket splint. Fracture-box consists of a stout board 6 to 8 inches (15-20 cm.) wide by 18 to 30 inches (45-75 cm.) BANDAGING AND DRESSINGS 101 long, with hinged sides, a foot-board, upright, firmly attached at right angles to the bottom board, padded with a pillow, cotton-batting, or bran; may be used in treat- ing fractures of the lower leg and knee. Bags made from stout muslin or light duck canvas cut 14 inches (35 cm.) wide by 3 feet (90 cm.) to 5 feet (1.5 m.) long, doubled, sewed, and inverted before filling with sand or bran, closed with a draw-string or by stitching, are employed in fractures of the leg and thigh. Compresses to prevent displacement may be made of cotton, lint (folded), oakum, and held in place by adhesive straps, bandage, or placed upon splints when padding. Prevent infection of the soft parts from maceration of the skin surfaces after fracture by a thorough cleans- ing of the parts before applying the first permanent dressing and by "alcohol rubs" at each subsequent dress- ing. Neuralgic pain in the region after fracture is due to organized blood-clot or exudate. Treat by massage. Swelling, loosening, infection, malposition of the parts will demand an examination or change of dressings and correction by the surgeon. CHAPTER VI CARE OF OPERATING-ROOM; METHODS OF STERILIZATION; CARE OF INSTRUMENTS In almost all large hospitals there are three operat- ing-rooms, one for general surgical, one for gynecologic, and one for septic operations. This is ideal, but unneces- sary if correct methods of sterilization are employed. Fig. 49.—Kny-Scheerer instrument cabinet, having adjustable shelves and a plate-glass partition in the center, which practically divides it into two closets. Dressing-rooms on each floor are very desirable, for besides having everything at hand with which to 102 CARE OF OPERATING-ROOM 103 Fig. 50.—Wheeled stretcher. Fig. 51.—House stretcher. do a dressing properly, the nurse in charge of the patient has the opportunity to return and make up the bed afresh during the patient's absence. Stretchers are 104 SURGICAL TECHNIC Fig. 5 2.—Improved model sterilizer. used to convey patients to and from the operating- and dressing-rooms. The wheels generally have rubber tires, the top-board is detachable and has four handles, CARE OF OPERATING-ROOM 105 two at each end. At least two stretchers are necessary on each floor. The material used in the construction and furnish- ing of an operating- and dressing-room should be of marble, metal, porcelain, and glass, all of which can readily be made aseptic. The water-faucets should be controlled by automatic foot- or elbow-valves, so as to avoid contamination by turning on the spigots with the hands after they have been rendered aseptic. The operating-room should be kept clean, and should be damp-swept and wiped every day; in short, it should be in such a condition as to be ready for an operation Fig. 53.—Sterilizing tube for edged instruments. at a few moments' notice. The supplies for dressings should not be allowed to run down, and the instruments should always be in a first-class condition. An emer- gency bundle, containing everything necessary for an emergency operation, should be kept in readiness. Sterilization may be either dry or moist; moist heat is preferable, because it is more thorough and more penetrating than dry heat. For dry sterilization the towels and dressings may be placed in covered tin pans in an oven the temperature in which ranges from 1600 to 212° F. This method is only used in an emergency. For moist or steam sterilization a Kellogg, a Sprague, or an Arnold steam sterilizer is io6 SURGICAL TECHNIC used. The heat must be continued for fully one hour before the operation. Regarding the sterilization of instruments surgeons differ; some prefer to have their instruments wrapped in a towel and put into the sterilizer and allowed to boil for fifteen minutes in a I per cent, solution of carbonate of sodium to prevent their rusting. All edged instru- ments to be boiled in the soda solution should be wrapped Fig. 54.—Arnold sterilizer. Fig. 55.—Formalin lamp. in cotton and packed so firmly that they will not be tossed against one another by the solution as it becomes agitated in boiling. This agitation seems to be one of the reasons why they lose their edge. In a private house a tray or basin deep enough to allow the instruments being covered by the water are placed on a stove and boiled for fifteen minutes. Many operators prefer to have their edged instruments and needles placed in a dish contain- ing 95 per cent, alcohol for half an hour; then just before CARE OF OPERATING-ROOM IO7 the operation they are taken out and rinsed with sterilized water. Usually the knives are placed in the last three minutes of the boiling time. io8 SURGICAL TECHNIC After sterilization the instruments are transferred t the instrument-table or to shallow porcelain trays, 1 Fig. 57.—The Rochester sterilizer for instruments and dressings. (De Lee.) which they lie covered with sterilized towels until re- quired. Fig. 58.—The Rochester sterilizer open. (De Lee.) After the operation the instruments should be taken apart, washed in cold water to remove all blood, pus, and tissue particles, and then thoroughly scrubbed with CARE OF OPERATING-ROOM I09 green soap. Instruments with permanent joints, which fortunately are seldom seen now, must receive special attention, since it is difficult to get them surgically clean. After being scrubbed the instruments are rinsed in hot sterilized water, wiped dry with a soft towel, locks oiled, and then laid away in the case. The knife-blades must be rolled in cotton. The .important points to be re- Fig. 59.—Latest form of complete sterilizing outfit for dressings, water, in- struments, sheets, towels and operating gowns, basins and trays. membered in cleaning instruments after the operation are: First, all instruments that can be so dealt with must be taken apart and the rough catches thoroughly cleansed in cold water. Second, they must be dried carefully in order to prevent rusting; for instruments once rusted seem always to have a tendency to return to that condition. no SURGICAL TECHNIC Instrument trays are made of porcelain or agate-ware. Instrument trays, pitchers, etc., are best sterilized in large steam sterilizer built especially for this purpose. CARE OF OPERATING-ROOM III They should be allowed to remain in the sterilizer until used. Special sterilizers come for the disinfecting of bed-pans, douche-pans, etc. They are placed in a sterilizer containing the soiled contents with the lid of the sterilizer dropped in place and are then sterilized by steam. Later, by turning a spigot, the contents are Fig. 61.—Sterilizer for the disinfecting of bed-pans, douche-pans, etc. (Courtesy of Bernstein Manufacturing Co.) drained off and the receptacles are ready for use. All hospitals should be equipped with this apparatus. Every operating-room nurse should be familiar with the names of the instruments necessary for each different operation, so as to be able to lay them out when occasion requires. Many nurses get together after school hours and "make believe" an operation is to take place. Each nurse has her duty assigned to her, and each tries 112 SURGICAL TECHNIC to fulfil it in a thoroughly professional, dignified, and quiet manner. Practice of this kind is never lost. In the operating-room should be kept two large ledgers, Fig. 62.—Glass tray. in one of which the house-surgeons, after making the morning rounds with the visiting surgeons, should record Fig. 63.—Pus basin. the number of operations to be performed the next day, the time, name of operator, etc. The operating-room nurse is thus made acquainted, by consulting the book, Fig. 64.—Glass trays. of the amount of work before her for the next day, and the character of the operations for which she has to prepare. On the morning of the operations she makes out a list of the floor and number of private room or letter of ward and number of bed from which the patients are to be brought to the operating-room, and the order CARE OF OPERATING-ROOM H3 in which the operator wishes them. This list is given to the male attendant, who brings up the patients in succession, in such a way that while one patient is being operated on the next is being anesthetized. The head nurse in the operating-room has two or three sets of instruments, and during one operation an as- sistant nurse is sterilizing the instruments and making Fig. 65.—Metal tray. preparations for the next operation. There is then no waiting on the part of the operator, for as the patient operated on is wheeled out of the operating-room the next patient is wheeled in. The following chart will give an idea as to the way the book is made out and the order in which the operations are written. The emer- gency operations, accidents, etc., are also recorded, but after the performance of the operation. Operation. Floor.1 I Time. Mar 11. Laparotomy. 4th Vaginal hysterec- tomy. Cholecystostomy. Appendicectomy. Amputation, breast. Appendicectomy. Cesarean section. Appendicectomy. 3H 8 A.M. E r. Murphy. 10 8.30 ■' • 21 9.00 " Johnson. 24 9-3° " Fenger. ib 10.00 " Morgan. 10.4S " ' Kindig. 11.30 " ' ' Carter. 2 P.M. ' ' Andrews. 24 3.00 " ' Fenger. 21 4.OO '" ' Eyster. 21 1 6.3O " ' ' Comegys. 29 Ward. -6 a H 10 D 6 D 0 3d 4th 2d 1th 2d 1 Clean operating-room, fourth floor; septic, third floor. 8 ii4 SURGICAL TECHNIC The second book gives the date on which the patient was prepared for operation, by whom prepared, etc., as, for example— Date of prepared by Preparation. r Antiseptic used. Operator. Dr. Eyster. Floor. Fourth. Room. March 10. E. A. S. Corros. sub. No. 21. Date of Operation. TI Sutures Hour- used. Length of time prepared. Stitches removed. March 19. Condition. March n. 4 P. M. Silkworm-gut. Two hours' boiling. Aseptic. A book should also be kept in each dressing-room showing the number of cases dressed each day, the dressing used, and progress since the last dressing. It should be kept for the convenience of the dressing- room nurse in making an estimate of dressings for the next day, and for the convenience of the surgeon in knowing what patients are dressed, their condition, and in knowing when they are to be again dressed. It will also recall condition of last dressing. CARE OF OPERATING-ROOM 115 Rw,I^°r Diagnosis, i Operated. Ward. No. 29, Appendicitis. March 11. 2d floor. Operator. Dressed. Di?charged. Remarks" Dr. Come- March 17.1 Discharged gys. April 2. CHAPTER VII INSTRUMENTS NECESSARY IN DIFFERENT OPERATIONS, KEEPING OF CHARTS, SUR- GEON'S KIT, ETC. In many hospitals, small ones especially, where there are no medical students or house doctor, the nurse has more responsibility than in larger institutions, and becomes closely familiar with such details as taking the history of the patient; the arranging and sterilization of instruments; assisting the operator, giving the anes- thetic, and writing out the report of the operation. The following charts will be of use in keeping the important features of this line of duty in mind. When taking the patient's history it is a good plan to allow her to describe her condition in her own words. Any peculiarities of the patient's manner and other points which may be observed can be noted, and afterward the questions necessary for making out the charts may be asked. Family History. Age. Health. Disease. Cause of death if dead. Father. Mother. Brothers (number). Sisters (number). Wife or husband. Children (number). Uncles or aunts with epilepsy, insanity, tuber- culosis, or cancer. 116 INSTRUMENTS 117 Personal History. When born. Where lived. Peculiarities of cli- mate. Occupations. Habits (as to eating, drinking, sleeping, etc.). Appetite. Condition of bowels. Nervousness. (When Female.) Sexual History. I. Menstruation: (a) First at what age. (b) Regularity. No. days. (c) Duration. No. days. (d) Amount. Color. (e) Character of discharge edition Of this work the American Journal of Nursing says: "It is the fullest and most complete and may well be recommended as being of great general usefulness. The best chapter is the one on observation of symptoms which is very thorough." There are directions how to improvise everything. Practical Points in Nursing. By Emily M. A. Stoney, formerly Super- intendent of the Training School for Nurses in the Carney Hospital, South Boston, Mass. 12010, 495 pages, illustrated. Cloth, $1.75 net Stoney's Materia Medica NEw (3d) edition Stoney's Materia Medica was written by a head nurse who knows just what the nurse needs. American Medicine says it contains "all the information in regards to drugs that a nurse should possess." Materia Medica for Nurses. By Emily M. A. Stoney, formerly Super- intendent of the Training School for Nurses in the Carney Hospital, South Boston, Mass» i2mo volume of 300 pages. Cloth, $1.50 net. Stoney's Surgical Technic NEw (3d) edition The first part of the book is dovoted to Bacteriology and Antiseptics; the second part to Surgical Technic, Signs of Death, Bandaging, Care of Infants, etc. Bacteriology and Surgical Technic for Nurses. By Emily M. A. Stoney. Revised by Frederic R. Griffith, M. D., New York. i2mo volume of 311 pages, fully illustrated. Cloth, $1.50 net Goodnow's First-Year Nursing 2d edition Miss Goodnow's work deals entirely with the practical side of first-year nursing work. It is the application of text-book knowledge. It tells the nurse how to do those things she is called upon to do in her first year in the training school—the actual ward work. First-Year Nursing. By Minnie Goodnow, R. N., formerly Super- intendent of the Women's Hospital, Denver. i2moof 354 pages, illustrated. Cloth, $1.50 net. Aikens' Hospital Management This is just the work for hospital superintendents, training- school principals, physicians, and all who are actively inter- ested in hospital administration. The Medical Record says: "Tells in concise form exactly what a hospital should do and how it should be run, from the scrubwoman up to its financing." Hospital Management. Arranged and edited by Charlotte A. Aikens, formerly Director o" Sibley Memorial Hospital, Washing- ton, D. C. i2mo of 488 pages, illustrated. Cloth, $3.00 net Aikens' Primary Studies new (3d) edition Trained Nurse and Hospital Review says: "It is safe to say that any pupil who has mastered even the major portion of this work would be one of the best prepared first year pupils who ever stood for examination." Primary Studies for Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. i2mo of 471 pages, illustrated. Cloth, $1.75 net. Aikens' Training-School Methods and the Head Nurse This work not only tells how to teach, but also what should be taught the nurse and how much. The Medical Record says' "This book is original, breezy and healthy." Hospital Training-School Methods and the Head Nurse. By Char- lotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. 121110 of 267 pages. Cloth, $1.50 net Aikens' Clinical Studies NEW (2d) EDITIOn This work for second and third year students is written on the same lines as the author's successful work for primary stu- dents. Dietetic and Hygienic Gazette says there " is a large amount of practical information in this book." Clinical Studies for Nurses. By Charlotte A. Aikens, formerly Director of Sibley Memorial Hospital, Washington, D. C. umo of 56g pages, illustrated Cloth, $2.00 net 3 Bolduan and Grund's Bacteriology The authors have laid particular emphasis on the immediate application of bacteriology to the art of nursing. It is an applied bacteriology in the truest sense. A study of all the ordinary modes of transmission of infection are included. Applied Bacteriology for Nurses. By Charles F. Bolduan, M.D., Assistant to the General Medical Officer, and Marie Grund, M.D., Bacteriologist, Research Laboratory, Department of Health, City of New York. i2mo of 166 pages, illustrated. Cloth, $1.25 net. Fiske's The Body anew idea Trained Nurse and Hospital Review says "it is concise, well- written and well illustrated, and should meet with favor in schools for nurses and with the graduate nurse." Structure and Functions of the Body. By Annette Fiske, A. M., Graduate of the Waltham Training School for Nurses, Massa- chusetts. i2mo of 221 pages, illustrated. Cloth, $1.25 net Beck's Reference Handbook new (3d) edition This book contains all the information that a nurse requires to carry out any directions given by the physician. The Montreal Medical Journal says it is " cleverly systematized and shows close observation of the sickroom and hospital regime." A Reference Handbook for Nurses. By Amanda K. Beck, Grad* uate of the Illinois Training School for Nurses, Chicago, III. 32mo volume of 244 pages. Bound in flexible leather, $1.25 net. Roberts' Bacteriology & Pathology This new work is practical in the strictest sense. Written specially for nurses, it confines itself to information that the nurse should know. All unessential matter is excluded. The style is concise and to the point, yet clear and plain. The text is illustrated throughout. Bacteriology and Pathology for Nurses. By Jay G. Roberts, Ph. G., M. D., Oskaloosa, Iowa. 121110 of 206 pages, illustrated. $1.25 net. DeLee's Obstetrics for Nurses Dr. DeLee's book really considers two subjects—obstetrics for nurses and actual obstetric nursing. Trained Nurse and Hospital Review says the "book abounds with practical suggestions, and they are given with such clearness that they cannot fail to leave their impress." Obstetrics for Nurses. By Joseph B. DeLee, M. D., Professor of * Obstetrics at the Northwestern University Medical School, Chicago. 121110 volume of 508 pages, fully illustrated. Cloth, $2.50 net. Davis' Obstetric & Gynecologic Nursing NEW (4th) EDITION The Trained Nurse and Hospital Review says: " This is one of the most practical and useful books ever presented to the nursing profession." The text is illustrated. Obstetric and Gynecologic Nursing. By EDWARD P. Davis, M. D., Professor of Obstetrics in the Jefferson Medical College, Philadel- phia, iamo volume of 480 pages, illustrated. Buckram, $1.75 net Macfarlane's Gynecology for Nurses NEW (2d) EDITION Dr. A. M. Seabrook, Woman's Hospital of Philadelphia, says: " It is a most admirable little book, covering in a concise but attractive way the subject from the nurse's standpoint." A Reference Handbook of Gynecology for Nurses. By Catharine Macfarlane, M. D., Gynecologist to the Woman's Hospital of Phila- delphia. 32mo of 156 pages, with 70 illustrations. Flexible leather, $1.25 net. Asher's Chemistry and Toxicology Dr. Asher's one aim was to emphasize throughout his book the application of chemical and toxicologic knowledge in the study and practice of nursing. He has admirably succeeded. i2mo of 190 pages. By Philip Asher, Ph. G., M. D., Dean and Pro- fessor of Chemistry, New Orleans College of Pharmacy. Cloth, $1.25 net. »_^^_—•>^""^™>™■■■ 5 Aikens' Home Nurse's Handbook The point about this work is this: It tells you, and shows you just how to do those little things entirely omitted from other nursing books, or at best only incidentally treated. The chapters on "Home Treatments" and "Every-Day Care of the Baby," stand out as particularly practical. Home Nurse's Handbook. By Charlotte A. Aikens, formerly Di- rector of the Sibley Memorial Hospital, Washington, D. C. nmo of 276 pages, illustrated. Cloth. $1.50 net Eye, Ear, Nose, and Throat Nursing This book is written from beginning to end. for the mirse. You get antiseptics, sterilization, nurse's duties, etc. You get an- atomy and physiology, common remedies, how to invert the lids, administer drops, solutions, salves, anesthetics, the various diseases and their management. New (2d) Edition. Nursing in Diseases of the Eye, Ear, Nose and Throat. By the Committee on Nurses of the Manhattan Eye, Ear and Throat Hospital. i2mo of 291 pages, illustrated. Cloth, $1.50 net Paul's Materia Medica new (2d) edition In this work you get definitions—what an alkaloid is, an in- fusion, a mixture, an ointment, a solution, a tincture, etc. Then a classification of drugs according to their physiologic action, when to administer drugs, how to administer them, and how much to give. A Text-Book of Materia Medica for Nurses. By George P. Paul.M.D., Samaritan Hospital, Troy, N. Y. i2mo of 282 pages. Cloth, $1.50 net Paul's Fever Nursing NEW»« ed.t.on In the first part you get chapters on fever in general, hygiene, diet, methods for reducing the fever, complications. In the second part each infection is taken up in detail. In the third part you get antitoxins and vaccines, bacteria, warnings of the full dose of drugs, poison antidotes, enemata, etc. Nursing in the Acute Infectious Fevers. By George P. Paul, M. D. i2moof 275 pages, illustrated. Cloth, $1.00 net 6 McCombs' Diseases of Children for Nurses NEW (2d) EDITION Dr. McCombs' experience in lecturing to nurses has enabled him to emphasize^?/ those points that nurses most need to know. National Hospital Record says: "We have needed a good book on children's diseases and this volume admirably fills the want." The nurse's side has been written by head nurses, very valuable being the work of Miss Jennie Manly. Diseases of Children for Nurses. By Robert S. McCombs, M. D., Instructor of Nurses at the Children's Hospital of Philadelphia. i2mo of 470 pages, illustrated. Cloth, $2.00 net Wilson's Obstetric Nursing new m edition In Dr. Wilson's work the entire subject is covered from the beginning of pregnancy, its course, signs, labor, its actual accomplishment, the puerperium and care of the infant. America?i Journal of Obstetrics says: " Every page empasizes the nurse's relation to the case." A Reference Handbook of Obstetric Nursing. By W. Reynolds Wilson, M.D., Visiting Physician to the Philadelphia Lying-in Char- ity. 32010 of 355 pages, illustrated. Flexible leather, $1.25 net American Pocket Dictionary new <*« edition The Trained Nurse and Hospital Review says: "We have had many occasions to refer to this dictionary, and in every instance we have found the desired information." American Pocket Medical Dictionary. Edited by W. A. Newman Dorland, A. M., M. D., Loyola University, Chicago. Flexible leather, gold edges, $1.00 net; with patent thumb index, $1.25 net Lewis' Anatomy and Physiology EDT,?,oS Nurses Joarnalof Pacific Coast says "it is not in any sense rudimentary, but comprehensive in its treatment of the sub- jects." The low price makes this book particularly attractive. Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., Lec- turer on Anatomy and Physiology for Nurses, Lewis Hospital, Bay City, Mich. i2mo of -126 pages, 150 illustrations. Cloth, $1.75 net SECOND EDITION Bohm & Painter's Massage The methods described are those employed in Hoffa's Clinic —methods that give results. Every step is illustrated, showing you the exact direction of the strokings. The pictures are large. You get the technic used in Professor Hoffa's Clinic. Octavo of gi pages, with 97 illustrations. By Max Bohm, M. D., Berlin, Germany. Edited by Charles F. Painter, M. D., Professor or Orthopedic Surgery, Tufts College Medical School, Boston. Cloth, $1.75 net Grafstrom's Mechano-therapy Dr. Grafstrom gives you here the Swedish system of mechan- otherapy. You are given the effects of certain movements, gymnastic postures, medical gymnastics, general massage treatment, massage for the various conditions. The illustra- tions are full-page line drawings. Mechanotherapy (Massage and Medical Gymnastics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician Gustavus Adolphus Orphanage, Jamestown, New York. i6mo of 200 pages. Cloth, $1.25 net Friedenwald and Ruhrah's Dietetics for r\ urses new od) edition This work has been prepared to meet the needs of the nurse, both in training school and after graduation. American four- nal of Nursing says it "is exactly the book for which nurses and others have long and vainly sought." Dietetics for Nurses. By Julius Friedenwald, M. D., Professor of Diseases of the Stomach, and John Ruhrah, M.D., Professor of Diseases of Children, College of Physicians and Surgeons, Baltimore. i2mo volume of 431 pages. Cloth, $1.50 net FOURTH EDITION Friedenwald & Ruhrah on Diet This work is a fuller treatment of the subject of diet, pre- sented along the same lines as the smaller work. Everything concerning diets, their preparation and use, coloric values, rectal feeding, etc., is here given in the light of the most re- cent researches. Diet in Health and Disease. By Julius Friedenwald, M.D., and John Ruhrah, M.D. Octavo volume of 857 pages. Cloth, $4.00 net Pyle's Personal Hygiene new^ edition Dr. Pyle's work discusses the care of the teeth, skin, com- plexion and hair, bathing, clothing, mouth breathing, catch- ing cold; singing, care of the eyes, school hygiene, body posture, ventilation, heating, water supply, house-cleaning, home gymnastics, first-aid measures, etc. A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Wills Eye Hospital, Philadelphia. i2mo, 543 pages of illus. $1.50 net Galbraith's Personal Hygiene and Physical Training for Women illustrated Dr. Galbraith's book tells you how to train the physical pow- ers to their highest degree of efficiency by means of fresh air, tonic baths, proper food and clothing, gymnastic and outdoor exercise. There are chapters on the skin, hair, development of the form, carriage, dancing, walking, running, swimming, rowing, and other outdoor sports. Personal Hygiene and Physical Training for Women. By Anna M. Galbraith, M.D., Fellow New York Academy of Medicine. i2mo of 371 pages, illustrated. Cloth, $2.00 net Galbraith's Four Epochs of Woman's Life This book covers each epoch fully, in a clean, instructive way, taking up puberty, menstruation, marriage, sexual instinct, sterility, pregnancy, confinement, nursing, the menopause. The Four Epochs of Woman's Life. By Anna M. Galbraith, M. D. With an Introductory Note by John H. Musser, M. D., University of Pennsylvania. 121110 of 247 pages. Cloth, $1.50 net Griffith's Care of the Baby NEw <6«h) edition Here is a book that tells in simple, straightforward language exactly how to care for the baby in health and disease; how to keep it well and strong; and should it fall sick, how to carry out the physician's instructions and nurse it back to health again. The Care of the Baby. By J. P. Crozer Griffith, M.D., Univers- ity of Pennsylvania. i2mo of 458 pages, illustrated. Cloth, $1.50 net Aikens' Ethics for Nurses JUST READY This book emphasizes the importance of ethical training. It is a most excellent text-book, particularly well adapted for classroom work. The illustrations and practical problems used in the book are drawn from life. Studies in Ethics for Nurses. By Charlotte A. Aikens, formerly Superintendent of Columbia Hospital, Pittsburg. i2mo of 318 pages. Cloth, $1.75 net. Goodnow's History of Nursing REAdysoon Miss Goodnow's work gives the main facts of nursing history from the beginning to the present time. It is suited for class- room work or postgraduate reading. Sufficient details and personalities have been added to give color and interest, and to present a picture of the times described. History of Nursing. By MINNIE Goodnow, R.N., formerly Super- intendent of the Women's Hospital, Denver. i2mo of 300 pages, illustrated. READY SOON Berry's Orthopedics for Nurses The object of Dr. Berry's book is to supply the nurse with a work that discusses clearly and simply the diagnosis, prog- nosis and treatment of the more common and important ortho- pedic deformities. Many illustrations are included. The work is very practical. Or;hopedic Surgery for Nurses. By John McWilliams Berry, M.D., Clinical Professor of Orthopedics and Rontgenology, Albany Medical College, umoof 100 pages, illustrated. Whiting's Bandaging This new work takes up each bandage in detail, telling you__ and showing you by original illustrations—just how each bandage should be applied, each turn made. Dr. Whiting's teaching experience has enabled him to devise means for over- coming common errors in applying bandages. Bandaging. By A. D. Whiting, M.D., Instructor in Surgery at the University of Pennsylvania. 1211,0 of 151 pages, with 117 illustra- tions. Cloth, $1.25 net. 10 Hoxie & Laptad's Medicine for Nurses Medicine for Nurses and Housemothers. By George Howard Hoxie, M. D., University of Kansas; and Pearl L. LapTad. 12mo of 351 pages, illustrated. Cloth, $1.50 net. New {2d) Edition. This book gives you information that will help you to carry out the directions of the physician and care for the sick in emergencies. It teaches you how to recognize any signs and changes that may occur be- tween visits of the physician, and, if necessary, to meet conditions until the physician's arrival. Boyd's State Registration for Nurses State Registration for Nurses. By Louie Croft Boyd, R. N., Graduate Colorado Training School for Nurses. Octovo of 149 pages. Cloth, $1.25 net. New {2d) Edition. Morrow's Immediate Care of Injured Immediate Care of the Injured. By Albert S. Mor- row, M. D., New York City Home for Aged and In- firm. Octavo of 354 pages, with 242 illustrations. Cloth, $2.50 net. New (2d) Edition. deNancrede's Anatomy NEw am edition Essentials of Anatomy. By Charles B. G. deNan- crede, M. D., University of Michigan. 12mo of 400 pages, 180 illustrations. Cloth, $1.00 net. Morris' Materia Medica NEw (7.h> edition Essentials of Materia Medica, Therapeutics, and Pre- scription Writing. By Henry Morris, M. D. Re- vised by W. A. Bastedo, M. D., Columbia University, New York. 12mo of 300 pages, illustrated. Cloth, $1.00 net. Register's Fever Nursing A Text Book on Practical Fever Nursing. By Edward C. Register, M. D., North Carolina Medical College. Octavo of 350 pages, illustrated. Cloth. $2.50 net. f / 7 ■91 A*