The operating room and the patient

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Preface To The Second Edition

This edition is much enlarged, having had added to it several chapters on ** General Considerations in the After-treatment.'' I am indebted to Miss Kurtz, Supervisor of Nurses at the German Hospital, for help in revising the chapters on the Instrument and Supply Room and to Dr. Carl Fulda, Clinical Assistant at the German Hospital, for translations from the German and aid in many ways. It is hoped that the new chapters dealing with wound complications and treatment will prove of value to the general practitioner, who is at times called upon to carry out the after-treatment of surgical cases.

Preface

I WISH to thank Miss Kurtz, Supervisor of Nurses at the German Hospital, for many kind suggestions in the chapters upon supplies ; Mr. Francis A. Deck for his admirable illustrating; and last, but not least, the W. B. Saunders Company for the excellent manner in which they have brought out this little book.

Chapter I. — The Operating Room and its Pes

General considerations, i 7 — Arrangement during operation, 19 — Preparation of table iq — Sinks 10 — Scrub-up tray, ao— Disinfection of operating room table; nickel; brass; glass, 20 — Personnel, 2 i— Costumes nurses, anesthetist, orderly, operator and assistants \isitors, ji — Operating room nurse, 23— Senior operating room nurse, 34 — Junior operating room nurse, 25 — Anesthetic nurse, 27 — Preliminary training for nurses. 27^-Operating room orderly, aS.

Chapter II. — The Insthlment and Supply Room

General considerations, ag — Care of instruments, 31^ Brushes, 31 — Soap, 3a — Nail cleaners, nail files, and nail scissors, 3a— Chlorinated lime and sodium carbonate, 3a — Hand lotions, 32 — <;aps, 33 — Masks, 33 — Rubber aprons, 33 — Gowns, 34 — Rubber gloves, 34 — Finger cots, 35— Protectors, 35 — Laparotomy sheets, 35^ — Perineal sheets, 35— Anus protectors, 36 — Towels, 36^Blankets, 36 — Screen covers, 36 — Rubber sheeting, 36 — Kelly pads, 37^Pad covers, 37 — Bottle bags, 37 — Hand and leg bags, 37^ Powders, 37 — Iodoform, 37 — ^Zinc oxid, 37— Saline powders, 37 — Potassium permanganate. 37 — Oxalic acid. 37 — Thiersch powders, 3S — Boric acid, 38 — Salicylic acid, 38 — Bichlorid of mercury, 3S— Carbonate of soda, 38 — Bicarbonate of soda, 38 — Sodium chlorid, 38 — Magnesia sulphate. 38 — Bichromate of potash, 38 — Cocain hydrochlorate, 38 — Solutions, 38 — Bichlorid of mercury, 38 — Acid bichlorid, 35 — Carbolic acid, 39 — Boric acid. 39 — Thiersch, 39^ Normal saline, 39— Bichlorid permanganate, 39 — Permanganate of potassium, 40 — Oxalic add. 40 — Ammonia, 40 — Lime water, 40— Iodoform emulsion, 40 — Chlorid of zinc, 40 — Bichromate of potash. 40 — Woelfler's, 40 — Tincture of iodin, 40 — Benzin, 41 — Alcohol, 41^ — Sterile water, 41^ Hydrogen peroxid. 4i^Sodiiim bicarbonate, 41 — Commercial ether, 41— Glycerin. 41 — Balsam of Peru, 4i^Ichthyol, 41 — Vaselin, 41 — Olive oil, 41— Whale oil and iodoform —Paraffin, 41— Cocain, 41.

12 CONTENTS

PAGE

Chapter III. — ^The Instrument and Supply Room (continued) 42 Gauzes, 42 — Iodoform, 42 — Zinc oxid, 44 — Boric acid, 44 — Bichlorid of mercury, 44 — ^Thiersch, 45 — Balsam of Peru, 45 — Carbolized, 45 — Gauze drains, 45 — Wicking drain, 45 — Silk protective drains, 45 — Rubber tissue drains, 46 — Mikulicz drain, 47 — Cotton, 47 — Lamb's wool, 47 — Sponges: hand, stick, laparotomy, 47, 48 — Compresses, 48 — Laparotomy pads, 49 — Laparotomy dressing, 49 — Paper dressing, 49 — Cleansing of gauze, 49 — Bandages, 49 — Bandage box, 50 — Retractor bandages, 50 — ^T-bandages, 50 — Triangular bandages, 51 — Slings, 51 — Breast binder, 51 — Abdominal binder, 51 — Adhesive plaster, 51 — Waxed or paraffined paper, 52 — Rubber goods, 53 — Drainage tubes, 53 — Rubber dam, 53 — Green silk protective. 53 — Filiform bougies, 53 — Tourniquet and rubber bandages, 53 — Rubber bolsters, 54 — Glass goods, 54 — Suture and ligature material, 54 — Plain catgut, 54 — Chromic catgut, 56 — Formalin catgut, 56 — AntivSeptic catgut, 56 — lodin catgut, 57 — Braided catgut, 57 — Kangaroo tendon, 57 — Silk, 57 — Linen thread, 57 — Paraffin silk, 57 — Silkworm-gut, 57 — Horsehair, 58 — Silver wire, 58 — Percentage table, 58 — Thermocautery, 58 — Sand-bags, 59 — Splints, 60.

Chapter IV. — Anesthesia 61

Anesthetic room, 61 — Anesthetic cart, 61 — ^Oxygen apparatus, 61 — Anesthetic tray, 6t — Restoratives, 61 — Ether inhaler, 63 — The Anesthetist, 64 — Selection of the anesthetic, 65 — Ether anesthesia, 66 — Chloroform anesthesia, 70 — Ethyl bromid, 72 — Nitrous oxid and oxygen anesthesia, 73 — Nitrous oxid and ether anesthesia, 73 — Junker's apparatus, 74 — Trendelenburg cannula, 75 — Anesthol, 75 — Spinal analgesia, 77 — Cocain anesthesia, 81.

Chapter V. — The Patient 84

General preparation, 84 — The blood, heart, lungs, and kidneys, 84, 85 — The skin, 85 — The bowels, 86 — Diet, 86 — Local preparation: General directions, 86 — Head, 87 — Mouth, 87 — Neck, 88 — Thorax, 88 — Abdomen, 88 — Genitals, 88 — Rectum and anus, 88 — Extremities, 89 — Nose and pharynx, 89 — Esophagus and stomach, 89 — Small and large intestine, 89 — Urinary system, 89 — Preparation just previous to anesthetization, 91 — Position of the patient, 92 — Dependent head position, 93 — Extended neck position, 93 — Position for amputation of breast, 93 — Position for thoracotomy, 94 — Position for operations upon

CONTENTS 13

PAGE

the upper abdomen, 94 — Dorsal position, 94 — ^Trendelenburg position, 94 — Reversed Trendelenburg position, 96 — Lithotomy position, 96 — Exaggerated lithotomy position. 97 — Sims* position, 98 — Kidney position, 99 — Ventral position, 99 — Knee-chest position, 100 — Final preparation of the field of operation, 100 — Hand disinfection, 105 — Application of dressings, 108.

Chapter VI. — General Considerations in the After-treatment ■ 1 10

General considerations, no — Recovery from anesthesia, 112 — Anesthetic vomiting, 113 — General appearance of patient, 115 — Parotitis, 116 — Pain, 117 — Thirst, 118 — Nutrition, 118 — Digestion, 119 — Dilatation of the stomach and duodenum, 120 — General hygiene, 123 — Urine, 123 — Albuminuria, 124 — Cystitis, 124 — Anuria, 124 — Retention of Urine, 124 — Catheterization in the female, 125 — Postoperative pneumonia, 126 — Causes of sudden death following operation, 127 — Temperature, 127 — Pulse, 129 — Respiration, 130.

•Chapter VII. — Course op Aseptic Wounds. Infection 13

Revision of dressings, 131 — Quiet, 131 — Percentage of sterile wounds, 131 — Normal course of wound healing per primam, 131 — Primary wound dressing, 123 — Removal of skin sutures, 134 — Second dressing, 135 — Removal of deep sutures, 135 — Drainage in aseptic wounds, 136 — Aseptic wounds healing per secundum, 137 — Disturbances in the course of an aseptic wound; infection, 138 — Stitch abscess, 144 — Retention of secretion, 144 — Retention of secretion with tension, 145 — Phlegmon: subcutaneous, 146 — Intermuscular, 146 — Tendinous, 147 — Diffuse cellular infiltration, 148 — Infection in loose cellular tissue, 148.

Chapter VIII. — Complications of Wound Infection 150

Lymphangitis, 150 — Lymphadenitis, 151 — Septicemia, 152 — Pyemia, 153 — Erysipelas, 155 — Hospital gangrene, 157 — Malignarrt edema, 158 — Infectious emphysema, 158 — Bacillus pyocyaneus infection, 159 — Tetanus, 159.

-Chapter IX. — ^Aseptic Wounds in Infected Tissues 163

Thermo-cautery wounds, 164 — Blockage of the drain, 164 — Disturbances of granulation, 165 — Sinus, 166 — Hemorrhage, 167 — Primary oozing, 168 — Secondary hemorrhage, 168 — Intravenous saline infusion, 174 — Hypodermoclysis, 176 — Autoinfusion, 176 — Secondary suturing, 176 — Skin

14 CONTENTS

PAGE

grafting, 177 — Wound disturbances the result of antiseptics, 178 — Carbolic acid, 181 — Bichlorid of mercury, 184 — Iodoform poisoning, 184.

Chapter X. — Wound Disturbances the Result of Pressure 187 Post-operative paralysis, 187 — Paralysis due to operative traumatism, 187 — Paralysis of an entire extremity, 188 — Constriction paralysis, 188 — Postural paralysis, i8g — Ischemic muscular paralysis, 191 — Decubitus, 192 — Disturbances of circulation, 194 — Prevention of venous return, 194 — Thrombosis of the femoral vein, 194 — Phlebitis of the internal saphenous vein, 196 — Air embolism, 196 — General complications of operations, 197— -Shock, 197 — Delirium tremens, 198 — Toxemia, 199.

Chapter XI. — Wounds of Special Tissues 201

Skin and subcutaneous tissues, 201 — Plastic operations, 203 — Complications occurrinj; in scar tissue, 206 — Tendon and muscle, 208 — Vascular system, 212 — Lymphatic system, 215 — Thoracic duct, 216 — Xervous system, 216 — Osseous system, 218 — Amputations and disarticulations,

Chapter XII. — Lists of Instruments and Dressings Commonly Employed 227

Index 269

LIST OF ILLUSTRATIONS nC. PAGE

Relation of operating room and adjoining rooms, Frontispiece

1 . Operating room i8

2. Nurse's costume 22

3. Assistant's costume 22

4. Instrument and supply room. First view 30

5. Nail cleaner ^^

6. Instrument and supply room. Second view 43

7. The sterilizing room 46

8. Dowd's condenser 55

10. Author's modification of G. R. Fowler's ether inhaler 63

1 1 . Junker's apparatus 74

,12. Trendelenburg cannula 75

13. Dorsal position; operation suit 90

14. Dependent head position 91

15. Extended neck position 91

16. Position for breast amputation 92

1 7. Thoracotomy position 93

18. Position for operations upon the upper abdomen 94

19. Dorsal position 95

20. Trendelenburg position 96

21. Reversed Trendelenburg position 97

22. Lithotomy position, with sling sheet 98

23. Lithotomy position 99

24. Exaggerated lithotomy position 100

25. Sims' position loi

26. Single kidney position 10 1

27. Ventral position 102

28. Knee-chest position 102

29. Dorsal position; arms fastened 103

30. Dorsal position; ready for operation 105

31. Dorsal position; abdominal dressing applied 107

32. Dorsal position; abdominal binder applied 108

^^. Bed ready to receive patient iii

IS

The Operating Room

AND

The Patient.

Chapter I. The Operatihg Room And Its Personnel

I Genera! considerations. Arrangement during operations. Preparai of table. Sinks. Scrub-up tray. Disinfection of operating n: table; nickel; brass; glass. Personnel. Costianes; nurses; [ anesthetist; orderly; operator and assistants; visitors. Operating nurse. Senior operating room nurse. Junior operating room Anesthetic nurse. Preliminary training for nurses, Oper- 1 ating room orderly.

General Considerations. — The operating room should f be on the top floor, should have a large floor space and [ lofty ceiling. The central skylight should be double, I air-tight, and made of ribbed glass. The east side of the I room should have large double windows. The floor, I walls, and ceiling should be tiled. There should be no I comers. Heating should be by hot water or steam. ' The relation of the operating room to the adjoining rooms ' is shown in the frontispiece.

General Operating Room Rules. — There should be no

I confusion in the operating room. Each person should

be thoroughly acquainted not only with his or her duties,

I but also with the duties of others employed in the operat-

I ing room. There should be no unnecessary talking. Each l8 OPERATING ROOM AND THE PATIENT.

movement should be executed quickly and ■ and without coming in contact with other persons.

The operating room furniture consists of two or more operating tables, an instrument table, a sponge table.

I a ligature and dressing table, an anesthetic table, three stools, two irrigation stands, a stand for the large bichlorid bath, six basins and stands for solutions, two screens, a table for the scrubbing outfit, four sinks with hot and

OPERATING ROOM AND ITS PERSONNEL.

cold water taps, a waste sink, pails and receptacles for soiled gauze, gowns, etc., a stand or inclosure for visitors.

During an operation the arrangement is somewhat as follows: The table is so placed as to afford the best possible view o'f the field of operation; the anesthetist seated at the head, behind him and to his right the table containing the anesthetic outfit and the oxygen apparatus; the operator to one side of the field of operation; his adjunct opposite; the house-surgeon to the right of the operator; the senior assistant to the left of the adjunct ; the instrument table behind the adjunct-surgeon ; the operating room nurse midway between the instrument table and the adjunct; the sponge table behind the senior assistant; the senior operating room nurse midway between the sponge table and the senior assistant ; at the operator's right stands a basin for hand solution ; also one at the adjunct's left; to either side of the table is a pail for soiled sponges ; on one side of the room stand the sinks with soap, brushes, etc., in place on the scrub-up table; nearby in line are the stands containing the bichlorid bath, alcohol, permanganate, ttxalic acid, and ammonia or aqua calcis; the visitors' stand or inclosure is so placed as to be readily accessible from the operating room entrance ; the large receptacles for soiled dressings, gowns, etc.. are at the farther side of the operating room.

Preparation of Operating Table. — On the table is placed the Trend elenburj; crutch, with small rubber pads attached (t{> protect the patient's shoulders), a long rubber hot-water pad (covered with a sheet), a small rubber pillow (covered with a towel). The lithotomy posts and stirrups should be near at hand ; also the attachment for operations upon the hand and forearm.

Preparation of the Sinks. — Nail scissors, nail files, wire nail brushes, a jar containing hand brushes, a jar of green soap, a bottle of alcohol, a jar of chlorid of lime, a jar of carbonate of soda, and a bottle of hand lotion should be on a small table near the sinks. Bottles which are to be handled should have bichlorid towels pinned around them or should be covered with bottle bags with drawstrings to fasten around the neck of the bottle. This prevents slipping.

The scrub-up tray is placed on a small, movable table in a convenient part of the room. It contains a large flask of sterile water with aseptic cotton plug, a large flask of acid-bichlorid, sterile brushes in lo per cent, bichromate of potash solution, liquid green soap, tincture of iodin, Woelfler's solution, alcohol, turpentine, ether, razor, safety-pins, bandages, and scissors.

Disinfection of the Operating Room. — The walls of the operating room should be washed down at least once a month with soap and water. The furniture should be scrubbed with soap and water and wiped off with bichlorid (i :iooo) or carbolic (i :2o) after every operation, when practicable, and certainly after every series of operations. This must also be done after every septic case. The room should be dusted daily and should always be ready for use. Dusting or cleaning should not be done just before an operation. The air of the room should be moist. All windows must be kept closed and drafts avoided. In summer those windows which are to be kept open in rooms adjoining the opemting room should be provided with screens. The temperature of the room shoidd be between 75° and 85° F. All ventilators are covered with nonabsorbent cotton filters. After each series of operations the floor is flushed and scrubbed with bichlorid solution, i :iooo. Once each month the operating room is disinfected by the formalin process. This method is also used after cases of streptococcic infections. Steaming of the operating room should be done daily in order to keep the air moist and prevent dust.

Hand basins, pitchers, pus basins, and dre&sing pails are scrubbed with soap and water and sterilized by boiling for ten minutes in a utensil sterilizer. Tables are scrubbed with soap and water, then rinsed with bichlorid, 1 :iQoo. Nickel work is cleansed daily with "bon ami" and polished with chamois-skin.

Brass work is cleansed daily with "bon ami" and polished with a dry, soft cloth.

Glassware is cleansed by scrubbing with soap and water, rinsed, then sterilized by boiling for ten minutes in a utensil sterilizer, allowed to cool, and polished with gauze wet with alcohol.

Personnel of the Operating Room. — The operating room staff proper consists of an operating room nurse, a senior operating room nurse, and two junior operating room nurses. The position of operating room nurse is a pennanent one. The senior and junior nurses serve in each position for at least one month, during which time they are excused from duty elsewhere in the hospital. There is an operating room orderly; also an anesthetic nurse who remains with the patient until anesthesia is estabhshed and later accompanies the patient to the bed, remaining until the patient has recovered from the anesthetic.

The operating staff consists of the operator, his adjunct, the house-surgeon, the senior assistant, and the anesthetist. The resident pathologist attends operations in which cultures or frozen sections are desired.

Operating Room CoBtiunes. — Nurses employed in the operating room shall wear over their regular nurse's costume (sleeves and cuffs detached) a plain linen gown with sleeves reaching below the elbow. These gowns fasten in the back, are snug fitting, and of sufficient length to entirely cover the dress.- A gauze mask is worn which covers the nose and mouth. A cap, linen or gauze, is so arranged as to entirely cover and confine the hair. The operating and sponge nurses wear rubber gloves. Gowns are changed after each case unless the operator otherwise orders. Rubbers or rubber-soled shoes should be worn to prevent slipping.

Fig. 3. — Assistant's costume.

The anesthetist is provided with a long-sleeved gown having a breast pocket. He wears a mask and cap. The operating room orderly wears a long-sleeved gown and cap and mask. Operator's and assistant's gowns are long sleeved. Rubber gloves are used at the discretion of the operator.

Visitors are provided with freshly laundered, longsieeved, loosely fitting linen gowns. Each gown is rolled up in a compact package and is not unrolled until needed. They are put on by the visitors before entering the operatingroom. The number of visitors is limited to the capacity of the visitors' stand.

Operating Room Nurse. — The operating room nurse is responsible for the care of the operating room, the anesthetic room, the instrument room, and all the furniture and apparatus pertaining thereto. She is responsible for the preparation of all instruments, dressings, ligatures, sutures, and appliances necessary for each operation; also for the preparation of all dressings and bandages used in the hospital. She should keep a record of all dressings and appliances issued to the different wards of the hospital, with the date and amount of each issue, and make a monthly statement of the same. She issues to each ward the necessary dressing sets, inspects these instruments frequently, and instructs the ward nurse in the care of such instruments. She stands at the instrument table during operations and passes such instruments to the surgeon as he may require. She should endeavor in every way to anticipate his wants. She watches closely the nurses who assist her in the operating room and who are under her direction, and sees that they properly perform their duties. She must not leave her post at the instrument table except at the re* quest of the operating surgeon. She personally prepares all ligature and suture material. She allows no instrument, apparatus, or dressing to leave the operating room without a written requisition. She delivers such messages as are reported to her to the person for whom such message is intended.

^^^ She keeps the key to the operating room, instrument room, and anesthetic room. These rooms are kept locked when nut in use. The operating room nurse also sees that all specimens are sent to the pathologic laboratory, properly labeled with the name of the patient and the hospital number. She also sees that all stains are removed from the gowns, sheets, etc., before these are sent to the laundry.

Senior Operating Room Nurse. — The senior operating room nurse should have four weeks' experience as junior operating room nurse before becoming senior. Under the direction of the operating room nurse she has charge of all the sterilizing and preparation of material, except the ligature and suture material. Assisted by her junior she prepares all the supplies used in the operating room and also those sent to the wards. On operating days she lays out the requisite number of towels, protectors, caps, masks, rubber aprons, gowns, etc. (everything except the suture and ligature material), necessary for the operations to be performed that day.

During the operation, her post is at the sponge table, and she shall not leave her post except at the request of the operating room nurse. She places bichlorid towels or protectors around the edges of the hand basins. She hands the operator and his assistants their gowns. She

• passes all sponges, towels, and protectors, anticipating the needs of the operator as much as possible, and is responsible for the correct counting of all sponges.

After operations she cleans all instruments and returns them to their places. She also washes out blood-stained gauze, gowns, etc. She sees that the surgeon's dressing

I room is provided with sterilized gowns for visitors and that the surgeon's operating clothes are properly prepared. At operations in which but one sterile nurse is required the sponge table is taken care of by the operating

OPERATING ROOM AND ITS PERSONNEL.

room nurse. The senior's term of service should be at least one montli.

Junior Operating Room Nurse. — The junior operating room nurse should serve for at least four weeks before becoming senior. She is responsible for the dusting of the instrument and supply room, the cases and drawers of which should be cleaned at least once each week. The room itself is dusted each night before she goes off duty. She prepares the ward packages of towels for sterilization by the senior nurse. She cuts and folds all the compresses, and assists the senior nurse in making bandages, sponges, etc. She is responsible for the cleanliness of all the operating room and anesthetic room furniture. Before going off duty, she shall see that the operating room, instrument room, and anesthetic room are in order, that the sinks and basins are clean, that the soap, brushes, etc., are in their respective places.

On operating days she arranges the operating room furniture, prepares the basins, solutions, anesthetic room, and the anesthetic table. When the patient is wheeled into the operating room, the junior nurse assists in placing the patient on the table. She fastens the patient's arms above the head in operations upon the upper abdomen or thorax, across the chest, in other abdominal and pelvic operations. She assists in placing the patient in the kidney, lithotomy, or Sims' position as required. The blankets are smoothly arranged so as to completely expose the parts to be operated on, but no portion of the body is to be left unnecessarily imcovered. She removes the bandages and bichlorid towels from the site of operation, taking care not to bring her hand in contact with the patient's skin. She then assists the assistant house surgeon in preparing the field of operation, pouring for him liquid green soap and warm water, alcohol, ether, alcohol-bichlorid , acid-bichlorid, or iddin-

OPERATING ROOM AND THE PATIENT.

bichlorid as required. In abdominal cases she brings Woelfler's solution for the umbilicus.

She then fastens the gowns of the operator and his assistants ; places hand basins on either side of the table, changes the hand solutions as they become discolored ; sees that the anesthetist is supplied with anesthetic; picks up all sponges and towels which drop to the floor and places them in their proper receptacles; picks up fallen instruments, cleanses them, and, if so ordered, sterilizes them; collects the used hand brushes and sterilizes them; places freshly sterilized brushes in the brush jar for each case; keeps the instrument sterilizer three-quarters full of soda solution and boiling during the operation; prepares and gives hypodermic injections as ordered; operates the thermocautery; collects, counts, and places in a pail near the sponge nurse all soiled sponges used in a laparotomy, and reports the number to the senior nurse and to the operating room nui^e. She must be ready at all times to give the sponge count ; sees that the saline solution is kept at the proper temperature; takes all messages coming to the operating Toom and reports them to the operating room nurse.

Between operations she washes the frame of the chloroform mask or ether cone, changes the covers, and replaces the soiled hair bag of the latter with a fresh one. She brings a dry, warm blanket for the patient and assists the ward nurse to prepare the patient to leave the operating room (dry shirt, stockings, etc.); flushes the operating room floor with bichlorid solution after each case ; removes the protectors from the hand basins, flushes the basins with sterile water and refills them with bichlorid ; cleans and prepares the operating table for the next case; collects soiled gowns, towels, sponges, etc., and places them in their respective receptacles.

On the completion of an operation or series of operations she rinses out the stains in the operating room clothing k

OPERATING ROOM AND ITS PERSONNEL.

and towels, and prepares them for the laundry. She cleanses the rubber aprons with soap and water and wipes them off with carbolic solution ; cleans all the operating room furniture, anesthetic table, etc. ; sees that the solutions are all in order, reporting any deficiency to the operating room nurse; renews all solutions; and cleanses all glassware, basins, blood-stained gauze, etc.

She must watch the operating room nurse, the senior nurse, and the anesthetist and anticipate their needs as much as possible. She must not leave the room unless ordered to do so by the operating room nurse. She sees that each visitor is provided with a gown, cap, and mask.

The second junior nurse should be familiar with the duties of the first, so that when two operations are proceeding simultaneously she may help. At other times she is employed in preparing dressings and material.

The Anesthetic Nurse accompanies the patient from the ward to the anesthetic room and remains there until the patient is taken to the operating room. She marks on the anesthetic slip her name, the name of the patient, the variety of anesthetic, the time begun, and the time established; also the patient's pulse when the anesthesia is established. She watches the pulse carefully, noting its quality and counting it frequently, and reporting its rate to the anesthetist. She assists in controlling any struggling of the patient. She gives hypodermic injections when ordered to do so by the anesthetist. She must be famihar with the use of the oxygen tank. She sees, just previous to the patient's being taken to the operating room, that the patient's cap is on properly and that the blankets are smoothly arranged.

Course Preliminary to Entering Operating Room Training. — The super\'isor of nurses should arrange a list of nurses for operating room training. These attend operations and by observation and study ; quaint themselves with their future duties.

z8

OPERATING ROOM AND THE PATIENT.

Operating Room Orderly. — The operating room orderly remains with the patient while in the .anesthetic room, controls any struggling on the part of the patient, wheels the patient into the operating room, assists the anesthetist in placing the patient on the table, and sees that the pad of the anesthetic cart and the pillow remain on the cart. He removes the "hfter" (small stretcher) from under the patient and then removes the cart to the anesthetic room, Shoidd the cover of the pad or pillow be soiled, he removes the cover, places it in the soiled clothes receptacle, wipes off the soiled rubber coverings with bichlorid, i : looo, and puts on fresh linen covers. He brings the tray containing the anesthetic outfit from the anesthetic room and places it upon a table placed at the right and behind the anesthetist. Should the operation be one involving the male genitalia, the orderly should remain. He places screens around the operating table, brings to the assistant house surgeon the soap and water, alcohol, ether, and bichlorid or acid -bichlorid solution as required, and performs such duties ordinarily performed by the junior operating room nurse as shall be assigned to him. In cases in which he is not needed in the operating room he remains in the anesthetic room and holds himself in readiness to receive orders from the operating room nurse. Such messages are delivered to him through the medium of the junior nurse.

Chapter II. The Instrument And Supply Room

General Considerations. — The instrument and supplyroom should communicate directly with the operating room. It should be a large room fitted with numerous drawers and shelves capable of containing all the supplies needed for use in the operating room. The furniture consists of three enamel chairs ; one, long, narrow enamel table for preparing supplies ; bandage roller ; an apparatus for preparing plaster-of- Paris bandages; and a dust-proof instrument case. Glass bowls, mortar and pestle, glass graduates, and mixing rods should be kept on a shelf above the supply table. A shelf should be reserved for books relating to aseptic technic, surgical bacteriology, operative surgery, and instruments.

Instruments should be kept in their proper places in the instrument case when not in use. Knives should be kept in racks to prevent dulling. Needles should be kept in needle trays. So far as practicable, instruments should be kept in sets representing the operations for which they are commonly used. Instruments in part made of soft rubber should be kept in a separate drawer. No rubber goods should be kept in the instnmient cabinet. Sets of instruments the propertv of individual operators should be kept separate from the hospital instruments. Duplicate sets of instruments may be con\-eniently kept in linen holders.