Part 9

A strong screw must be fastened in the wall near the window at the height of about seven feet to support the fountain syringe, which will be filled with whatever solution the surgeon requires for irrigating the wound.

One slop-jar stands at the side or end of the large table, the other beside the table that holds the basin of sponges.

The bureau (covered with a sheet) or the mantle-shelf will serve to hold the dressings and rubber gloves. A small stand or table will be needed by the doctor who gives the anesthetic for his hypodermic, clean towels, and ether or chloroform.

All the basins, towels, and pitchers to be used during the operation must be thoroughly washed in warm soap suds and then boiled for an hour, or—when that is not possible—allowed to stand all morning in a 1: 1000 bichlorid solution, and then rinsed off with sterilized water before using. Two of the basins are filled with sterilized water or salt solution for washing the sponges, another basin holds the wet sterilized towels, and the fourth the solution for the surgeon’s hands.

A small bowl is needed for the soft soap to wash off the part of the body to be operated on, also a small pitcher of 1: 2000 bichlorid and some alcohol.

In the bath-room arrange plenty of clean towels, a bowl of 1: 2000 bichlorid, and one containing alcohol, synol, or green soap, and a sterilized nail-brush for the surgeon’s hands. The surgeon will send instruments, sutures, and anesthetic.

You cannot err in having ready a good supply of sterilized water, as an emergency may arise in which a double quantity would be required. Clean the wash-boiler thoroughly, fill it almost to the top, and boil for half an hour. One boilerful must be prepared in time for the water to grow cold before the operation; it is then poured into pitchers that have been washed in warm soap suds, and rinsed off with the sterilized water. Cover the pitchers with sterilized towels or napkins.

It is of the utmost importance that everything should be in perfect readiness when the surgeon arrives. The nurse will do well to go over the list carefully, so that nothing may be missing.

TO PREPARE A ROOM FOR AN OPERATION.

BY JESSIE MCCALLUM,

Graduate Johns Hopkins School for Nurses.

_From the American Journal of Nursing._

1. The room selected for the operation should be near the bath-room, as a porcelain tub filled with bichlorid solution of the strength of 1: 1000 makes an excellent arrangement for disinfecting the washbowls, pitchers, platters, plates, etc., which are to be used during the operation for the solutions, instruments, needles, and ligatures.

2. If the carpet cannot be removed, it may be protected with oilcloth, rubber sheeting, or newspapers, over which sheets can be pinned.

3. The windows can be frosted by rubbing sapolio on the inner surface, thus preventing any possible observation from the outside.

4. Two small tables placed together to form one of the required size, old blankets being used to make the tables of uniform height and also to furnish a comfortable surface for the patient, can be used for an operating-table, care being taken to cover the blankets with a bed-rubber or table oilcloth and a sheet, securely folded under, and tied to the table with muslin bandages.

5. A Kelly pad can be improvised by tightly rolling a blanket and covering it with a rubber sheet, two ends of which are to be pinned together and used to conduct the solutions into the foot-tub below.

6. An ironing-board or the leaf of an extension table, supported by two chairs, makes a good table for instruments or solution basins.

7. An ordinary clothes-boiler, one-third filled with water, can be used as a sterilizer, the instruments rolled in gauze, and the brushes and orange sticks (for the doctor’s hands) being immersed therein. The necessary dressings, towels, sheets, fountain syringe, etc., are sterilized by hanging them in a hammock or sling hung from the handles of the boiler. A kitchen fork, lengthened by securely fastening to it an iron spoon, makes a convenient utensil with which to remove the articles from the boiler.

8. An ordinary sheet folded over at the top makes an excellent gown for the operator, if the ends be carefully taken up under the arms, crossed in the back, and used as sleeves for the shoulders and upper part of the arm, the middle of the upper hem of the sheet being pinned to the collar in front.

9. Water boiled in the clothes-boiler or tea-kettles can be quickly cooled by placing pitchers of it, covered with sterile towels or cloths, in a dish-pan or foot-tub of cracked ice.

10. A kettle of water kept boiling during the operation is a great convenience.

11. Salt solution filtered into household preserving jars can be sterilized in the wash-boiler with the other articles.

12. A stretcher can be improvised by slipping two window-poles or broom-handles into the folds of a sheet folded the proper size and securely fastened with safety-pins.

13. The Trendelenburg position can be secured by using an ordinary kitchen chair comfortably padded with a rubber-covered pillow and sheet, the back of the chair being placed under the patient.

14. The patient can be put in the lithotomy position by placing under the knees a padded walking-stick, to the ends of which is fastened a sheet folded diagonally, and passed under the shoulders.

AN EMERGENCY STEAM STERILIZER.

Take an ordinary wash-boiler. Make a crate of three light boards and a few slats to fit the interior. Boards should be about six inches high, to escape the water. The slats laid across will support all goods necessary for an operation. Pack parcels lengthwise to permit the full circulation of steam. Sterilize under full pressure of steam for one hour. Then take out and place on a table to dry.

TO STERILIZE AN OBSTETRIC SET OR SMALL PACKAGES.

Use a boiler or small kettle which has two handles. Make a hammock of strong muslin, tie corners to the handles and place packages in the sling suspended an inch or two above the boiling water. Cutting the muslin in a square and folding it on the bias gives more room, as the goods will stretch.

INSTRUMENTS TO USE FOR OPERATIVE CASES.

CURETMENT SET.

1 pair scissors. 1 uterine probe, long. 2 forceps, 8-inch. 4 “ curets, sharp and dull. 2 tissue forceps, long. 6 hemostats, 6-inch. 1 placenta forceps, Barrett’s. 2 tenacula. 1 uterine dressing forceps. 2 volsella. 3 “ sounds. 1 Sims’ speculum. 1 “ dilator. 1 retractor, deep and broad. 1 “ douche point.

HERNIA SET.

2 pairs scissors. 6 hemostats, 4-inch. 2 scalpels. 18 “ 6- “ 2 pairs tissue forceps. 3 “ 8- “ 1 grooved director. 1 needle-holder. 1 Kocher “ 2 perineum needles. 1 Fenger “ Suturing material and needles. 1 probe. 2 pairs retractors, sharp and dull.

AMPUTATION SET.

2 pairs scissors. 6 hemostats, 4-inch. 1 scalpel. 18 “ 6- “ 2 pairs tissue forceps. 2 “ 8- “ 1 bone saw. 2 curets. 1 cutting forceps. 2 periosteotomes, long and short. 1 holding “ 1 bone elevator. 2 bone-holding forceps. 2 probes. 1 lion jaw. 1 hammer. 1 rongeur. 2 chisels. 1 grooved director. 1 needle-holder. 1 Kocher “ Needles and suturing material. 2 pairs retractors, sharp and dull.

LAPAROTOMY SET.

1 pair scissors, curved. 2 pairs retractors, broad. 1 “ “ straight. 2 “ “ narrow. 2 scalpels. 6 hemostats, 4-inch. 2 pairs tissue forceps. 18 “ 6- “ 1 grooved director. 3 “ 8- “ 1 Kocher “ 2 “ curved, 8-in. 1 Fenger “ 2 tenacula. 1 probe. 2 volsella. 2 pairs retractors, superficial. 2 perineum needles. 2 “ “ sharp. 1 needle-holder. 2 “ “ dull. Needles and suturing material. 2 “ “ deep.

GALL-STONE SET.

1 laparotomy set. 2 gall-stone scoops. 1 lithotomy forceps. Aspirating syringe and needle. 1 long probe. 2 bone curets.

SKIN-GRAFT SET.

1 scalpel. 2 curets. 1 pair scissors. 3 hemostats, 8-inch. 1 tissue forceps, plain. 6 “ 6- “ 1 “ “ rat-tooth. 2 razors. 1 Fenger director.

SKULL FRACTURE SET.

1 pair scissors, straight. 18 hemostats, 6-inch. 1 “ “ curved. 6 “ 4- “ 2 scalpels. 4 “ 8- “ 1 bone-holding forceps. 3 bone curets. 1 bone-cutting “ 2 gouges. 1 probe, long. 2 periosteotomes. 1 “ short. 1 rongeur. 1 Fenger grooved director. 1 lion jaw. 1 Kocher grooved director. 2 trephines. 2 retractors, superficial, sharp. 1 deVilbiss. 2 retractors, superficial, dull. 1 hammer. 2 chisels. 2 aneurism needles. 1 aspirating syringe. 1 bone elevator. 1 “ needle. 2 pair tissue forceps. Needle-holder and needles. 1 ether mask.

HEMORRHOID SET.

2 pair scissors. 1 grooved director. 2 knives. 6 hemostats, 6-inch. 1 clamp. 2 “ 8- “ 2 retractors. 2 “ “T.“ 2 tooth tissue forceps. 1 bone curet. 1 plain “ “ 1 rectal dilator. 1 probe. Cautery.

PROSTATECTOMY SET.

1 laparotomy set, suprapubic. 1 hernia set, perineal.

Add to either set:

6 sounds, graduated sizes. 6 filiform bougies. 2 metal catheters. 1 rubber catheter, size 16. 2 grooved staves. 1 “ “ “ 18.

SURGICAL SETS FOR STRANGULATED HERNIA, GASTRO-ENTEROSTOMY, GUNSHOTS, ETC.

1 laparotomy set. 4 intestinal clamps. 2 Murphy buttons.

TUBERCULOUS GLAND AND GOITER SETS.

1 hernia set 2 aneurism needles.. 6 hemostats, 6-inch. 1 ether mask.

WIRING OF BONE.

1 amputation set. 4 drills. 2 drill-holders. Wire or plates and screws.

SURGICAL SETS FOR VARICOSE VEINS, VARICOCELE, HYDROCELE.

1 hernia set.

SURGICAL POSTURES.

OPHTHALMIA.

PURULENT OPHTHALMIA (SUPPURATIVE INFLAMMATION OF THE CONJUNCTIVA).

BY CASSIUS D. WESCOTT, M. D.,

Assistant Professor of Ophthalmology at Rush Medical College, Chicago, Ill.

Purulent ophthalmia is caused by a specific germ, and is very contagious.

_Local Treatment._—Irrigate with warm boric-acid solution or normal salt solution every hour. Anoint the edges of the lids with sterile vaselin to permit free drainage. Castor oil and glycerin, of each, equal parts; or borated vaselin may be used for the same purpose. Astringents and caustics, silver nitrate, etc., are usually applied by the doctor.

_For an anodyne_, atropin is principally employed, also cold or hot compresses; in the use of the latter care must be taken to prevent irritation of the skin that will show itself in a permanent livid hue.

In case of excessive swelling a leech may be applied, or the doctor may resort to scarification.

_Medicines_ consist of cathartics, diuretics, diaphoretics, opiates, tonics.

_General Treatment._—Frequent baths, plenty of fresh air. Temperature of the room should be uniform. Moderate and subdued light.

_Diet_ should consist of nutritious food, liquid or soft, according to the condition of the patient.

The gravity of each case depends largely upon the extent to which the cornea is involved.

Treatment must, of course, be modified according to the virulence of the inflammation.

_To Apply a Leech._—Leeches are applied to relieve congestion. Put one in a small vial with a mouth large enough for the leech to crawl through. Cleanse the patient’s temple, and with a sterile needle scratch the skin until the blood shows. Directly over this place the mouth of the vial. The leech will bite almost instantly, and will drop off when it is gorged. If the occasion requires the leech to be taken off before it is gorged, sprinkle a little salt on its head. Hemorrhage should not be checked unless profuse, in which case a piece of ice or alum applied to the spot will arrest the flow. _If possible, the patient should be kept in ignorance of the application._

OPHTHALMIA NEONATORUM.

When the disease develops it will be manifested, as a rule, from three to five days after birth by redness of the eye and a slight discharge. It is the duty of the nurse, as well as of the accoucheur, to examine the eyes of the new-born babe each day during the lying-in period, and at the first sign of trouble, if discovered by the nurse, the attention of the physician should be directed to the matter. During the first two or three days after the disease begins there is usually little or no pus present, and comparatively little swelling of the lids, except in the most violent cases. During this so-called first stage the treatment should be that of an ordinary acute catarrhal conjunctivitis—viz.: iced compresses applied for an hour twice a day if the baby is well and strong; gentle flushing of the conjunctival sac with a warm saturated solution of boric acid. As soon as pus begins to form, the eyes must be cleansed more frequently—every hour during the day and every two hours during the night—and the edges of the lids should be kept constantly anointed with sterile vaselin to prevent their agglutination and the retention of the discharge. Drainage is indicated whenever there is suppuration, and if we can prevent the sticking together of the lids in this way, we allow free drainage and reduce the irritation which invariably results from retention of the discharges in these cases.

In all cases it will be noticed that after the discharge has been washed away from the everted lids there are strings or shreds of mucus in the folds of the conjunctiva. The nurse should endeavor at each cleansing to wash them out by continuous flushing and gentle manipulation of the lids. If she does not succeed in keeping the eyes free from these shreds the physician will remove them at least once a day.

If the conjunctiva of the globe becomes swollen and edematous and rolls up over the edge of the cornea, the nutrition of this precious membrane becomes threatened, and inflammation of the cornea, with ulceration or sloughing, is the cause of the blindness which follows this disease. At the slightest indication of haziness of its surface the iced compresses should be discontinued and hot fomentations resorted to. They may be applied every three hours for fifteen minutes each time. Great care and judgment are necessary in order that the heat be sufficient to be effective without burning the delicate skin of the lids and that it be continuous. The compresses should be changed at least every sixty seconds during their application. When the cornea becomes ulcerated great care must be used in the manipulation of the lids not to make pressure upon the eye-ball for fear of causing perforation. If the lids are slippery from the presence of vaselin or discharge, a single thickness of gauze or a little cotton held between the finger and the lid will be found a great help in opening the eye.

As the discharge of pus begins to diminish, which may not be for several weeks in bad cases, we may somewhat modify our treatment; the strong applications need not be quite so strong, and the cleansing need not be quite so frequent; but the most important item in the treatment of all these cases is the frequent thorough cleansing of the eyes, and if the cleansing is thoroughly done as above described each hour and the lids kept constantly anointed, in order to prevent accumulation of the irritating discharge, more frequent cleansing will not be necessary. Great care must also be exercised to prevent much crying by these little patients. They must be kept warm, regularly nursed or fed, and the slightest derangement of the alimentary canal must be attended to. If the cause of the crying cannot be ascertained and removed, it is wiser to soothe the baby with a simple anodyne than to permit the crying to go on.

It should not be necessary to point out the danger which lies in all things which come in contact with the discharge from these eyes.

Blennorrhea neonatorum is responsible for at least 25 per cent. of all the blindness in the world, and yet not one case in a hundred should result disastrously if skilfully and patiently managed.

EMERGENCIES.

HEMORRHAGES.

Hemorrhage from the arteries may be recognized by its bright red color and by the spurting jets by which the blood leaves the wound. Venous (from the veins) hemorrhages flow in a steady stream and are darker in color. Arterial hemorrhage may be checked by firm pressure over the side nearest the heart or above the wound. Venous hemorrhages may be checked by firm pressure on the side distant from the heart or below the wound. Large veins like the jugular should be compressed both above and below the wound because the vein may bleed from both ends. If possible, digital pressure should be made directly over the bleeding point.

Hemorrhage from the _leg_ may be checked by firm pressure upon the femoral artery, in the middle of the groin at the top of the thigh.

Hemorrhage from the _forearm_ by compression under the inner edge of the biceps against the humerus.

Hemorrhage from the _upper arm_ by compression of the axillary artery against the humerus in the axilla.

Hemorrhage from the _cheek_ by compression on the facial artery against the lower jaw just in front of the masseter muscle.

Flexing the limbs at the joints with a pad between them to make the compression secure and then binding the part may prove a successful method of arresting the flow of blood. A constrictor of rubber tubing twisted firmly around the limb is a ready appliance and a most successful way of checking a flow of blood from an injured limb. But it should not remain on longer than absolutely necessary or gangrene may result from complete stoppage of the circulation.

Wounds should be packed fully and evenly with some absorbent material. Applications of heat and cold are common methods of checking hemorrhages, heat being at all times preferable. Hot water poured on open wounds will encourage coagulation. Bleeding from an ulcer of the leg, which often results from varicose veins, should be stopped by firm pressure over the wound.

_Hemorrhage from the Lungs._—A teaspoonful of salt taken internally may stop it. Place an ice-bag over the chest. Morphin, gr. ⅛-¼, may be given under the instructions of a physician. In all cases put patient in bed and enjoin complete rest until medical aid arrives.

_Nose-bleed (Epistaxis)._—First of all, position and rest should be attended to. The patient should not lie down unless very weak. The higher the head the better. Loosen clothing about the neck and thorax. Caution patient against coughing or sneezing. Holding the nostril tightly closed, with cold applications to the back of the neck, is sometimes successful. Insufflation of ice- or alum-water, or of tannic acid solution may induce coagulation. Profuse bleeding will require packing of the nostrils.

FRACTURES.

_Compound Open Fracture._—The bone is broken and the wound extends from the seat of the fracture to the outside. Such wound may be caused by the injury itself, or may occur secondarily from the protrusion of pieces of bone through the skin.

_A comminuted fracture_ is one in which the bone is broken into a number of fragments.

_An Impacted Fracture._—The broken ends have been forcibly driven into one another, and are thus fixed.

_Multiple Fracture._—The bone is fractured at different points, or when different adjoining bones are broken.

_A complicated fracture_ is one associated with a serious injury to some important adjacent part—_e.g._, a large vessel.

_A green stick or incomplete fracture_ occurs where the bone is soft and bends, and is only partially fractured; it is most frequent in children.

=Symptoms= of fractures are usually pain, loss of function, deformity (seen or felt by passing the fingers over the seat of pain), crepitus or the grating sound produced and felt on rubbing the broken ends against each other, abnormal mobility in the course of the bone, swelling, and discoloration.

The principal point is to keep the part immovable and in a position to give as little pain as possible. Support the limb with something stiff and padded with cotton or remnants of yielding material. Bandages can be made of handkerchiefs, strips of linen, ribbon, etc., to keep the splint firm.

For the _forearm_ padded splints long enough to take in the hand from above the elbow should be applied. Tie firmly with bandages and suspend in a sling.

If the _upper_ arm be fractured, bind it tightly to the side. For the _thigh_, the splints should extend from under the arm to the ankle and should be bound to the body and leg with long towels or sheets torn into strips. A splint made of blankets, rolled up tightly from both sides on broomsticks, allowing space for the limb to rest between the supports, is a good and ready appliance. Always make extension to prevent contractions of the muscles, as this would result in shortening the leg.

For a broken _clavicle_ (collar-bone) bind the arm to the chest. Put the patient on the flat of his back with a small pad between the shoulder-blades. This will keep the broken ends in a normal position.

N. B.—In every case elevate and support the injured member on a pillow, keep in position and give complete rest until medical aid arrives.

DISLOCATIONS.

Dislocation is a displacement of the joint. It may occur with a break of the limb, but usually results from a fall or strain.

There may be deformity and inability to move the injured part. Sometimes an abnormal projection is the first sign. If inflammation arises, apply cold applications. The only treatment a nurse may give is to keep the patient quiet and await skilled help.

SPRAINS.

There may be extreme pain, swelling, inflammation, discoloration, and inability to use the joint. Support and elevation of the limb is of the greatest importance. Use hot or cold applications to allay the inflammation and pain. Cover with a thin soft pad, and bandage evenly and firmly. A sprain should not be neglected, as it may cause future disease of the injured part.

For recent bruises cold applications are best. Give the patient complete rest, support and elevate the injured limb, apply cold or hot applications, and await skilled help.

BURNS AND SCALDS.