Surgical and gynæcological nursing

Front matter

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Preface

The task of preparing a text-book on surgical and gynaecological nursing has been approached with considerable hesitation and, it is believed, with a full appreciation of the difficulties to be encountered and the obstacles to be, if possible, surmounted. The responsibility of deciding as to the relative importance to the nurse of theory as opposed to practice and the proportion of such a book that should be devoted to each has proved no light one. Nor has the desire to present all theory from the viewpoint of its practical application seemed easy of fulfilment.

The effort, throughout the preparation of this volume, has been to present to the student and graduate nurse an essentially practical statement of those procedures in her professional work that fall within the realms of general surgery and gynaecology. While fully realizing the importance of a clear understanding of the theory governing the practice of these branches of nursing, it has not appeared either necessary or desirable to attempt the incorporation of the theories of the sister branches as presented to the student of medicine. As a consequence, such consideration as may be given to surgical bacteriology, pathology, symptomatology or treatment has been with the sole idea of emphasizing the importance of certain nursing duties — as the sterilization of instruments and dressings, the accurate noticing and recording of signs and symptoms, or the preparation of materials necessary for the proper surgical treatment of specified conditions.

The unusual amount of space (both textual and illustrative) given to the subject of surgical instruments was planned with the hope that it would give a chance to the nurse for preparation before she is thrown into the thick of the operating-room fray. Even a general idea of the names, appearances, and uses of the instruments she is to handle, together with some knowledge of their routine application and order of use, should spare the novice at least some part of the discouragement and confusion to which she is subject under the operating-room systems of many hospitals.

In addition to those portions of the book that are strictly surgical in their application, there has, necessarily, been some vi PREFACE

consideration of border-line subjects. Under this classification might come such chapters as the one on the use of fractional doses in hypodermic medication and the one upon weights, measures, solutions and formulae. The excuse for the presence of these particular chapters must be based upon the existence of an apparent necessity for the consideration of these subjects — particularly in their connection with surgical nursing.

Throughout, the desire has been constant to prepare a text-book that would supply those needs that were most apparent to the lecturer and the operator, without neglecting that part of the field that had already been fully and successfully covered. It only remains to be hoped that the completed volume will, to some extent, fulfil this wish.

Many thanks are due to Captain Christie, Medical Corps, U. S. A., and to Sergeant Cahill, of the Army Hospital Corps, for assistance with the illustrations of instruments; to Lenz & Lossau for the loan of surgical instruments ; to the Superintendent of Nurses at Providence Hospital for valuable suggestions and aid ; to Mr. William Kearny Carr for the privilege of using some of his beautiful microphotographs of bacteria; and to Dr. R. M. Le Comte for the loan of a number of examples of the work of that past-master of microphotography, the late Dr. William M. Gray. Undoubtedly our greatest single obligation is to Miss Isabel M. Stewart, of Teachers' College, Columbia University, who has reviewed the entire manuscript, and whose criticisms and suggestions have pointed the way to a rather thorough revision both of the subject matter and arrangement of the book to its very great advantage. Our thanks are particularly due also to Dr. George W. Crile for his kindness in reading and criticising the chapter on anoci-association. Finally we desire to express our grateful appreciation to the J. B. Lippincott Company for their constant courtesy and forbearance throughout a somewhat tedious siege.

Edward M. Parker,

December, 1915.

Part I Infection Hapter Page

I. The Cells of the Body and the Invading Cells 3

Historical Introduction. The Cell: Form and Structure; Activities; Vital Requirements — Moisture, Food, Temperature; Qualities of the Cell — Irritability, Adaptability, Specialization, Constant Change, Continuity of Life, Stability. Single-celled Organisms. Many-celled Organisms. Health and Disease. Infection. Single-celled Organisms Concerned in Infection: Bacteria; Protozoa; Yeasts and Moulds; Filterable Viruses, Unknown Invaders.

II. The Sources and Modes of Infection 25

Number of Species Concerned. Distribution: In Air; in Water; in the Soil; in Food; in the Human Body. Relation of Parasite to Host. Carriers of Disease Organisms. Modes of Transmission.

III. Infection in Wounds 34

Definitions. Operative Wounds. Normal Healing. Infected Wounds. Healing in Infected Wounds. Sources and Modes of Septic Wound Infection. Bacteria Concerned in Wound Infection: Staphylococcus Pyogenes Aureus; Streptococcus Pyogenes; Colon Bacillus; Bacillus Pyocyaneus. Other Infections of Importance in Surgery: Tetanus; Gas Bacillus; Tubercle Bacillus; Organism of Syphilis; Gonococcus.

Part II The Field Of Surgery

IV. Surgical Pathology 55

Definitions: Affection; Disease; Etiology; Lesion; Symptom; Physical Signs; Signs; Diagnosis; Treatment; Pathology. Meaning of Pathological Changes. Causes of Disease: Mechanical; Physical; Chemical. Changes in Cell Activities: Adaptive Changes — Examples of Adaptive Changes, Compensatory Changes, Primary Adaptive Changes Which Occur in Accidental and Operative Wounds, Inflammation, The Healing Process, Healing by Granulation, Defences of the Body Against Infection; Perverted Cell Activities. Tissue Changes: Constructive — Repair, Hypertrophy, Tumor Formation; Destructive Tissue Changes — Atrophy, Necrosis; Cell Degenerations. Disturbances of General Function.

vii viii CONTENTS

V. Surgical and Gynecological Nomenclature 83

General Derivation; Method of Construction; Root-words; Prefixes; Suffixes; Abbreviations.

VI. The Surgical Field 89

Outline of the Surgical Field: Affections Not Caused by Disease — Anatomical Defects, Mechanical Derangements, Foreign Bodies, Trauma; Diseases and Affections Arising from Disease — Infections, New-growths, Other Organic Diseases, Functional Diseases. Surgical Specialism: Ophthalmology; Otology; Laryngology and Rhinology; Gynaecology; 'Genito-urinary Surgery; Orthopaedic Surgery; Surgery of the Nervous System; General Surger} r . Operative Surgery: Nomenclature; Operative Hazards; Mortality; Morbidity; The Surgical Obligation.

Part III

VII. Postures 101

The Horizontal Recumbent Position; Trendelenburg Position; Reversed Trendelenburg Position; Dorsal Position; Dorsal Elevated Position; Dorsosacral (Lithotomy) Position; Elevated Dorsosacral Position; Right and Left Lateral-prone Position; Knee-chest Position; Erect Position. Variations from the Usual Arrangement and Equipment in Operations: Trendelenburg; Lithotomy; Knee-chest Position.

VIII. Bandaging 109

Principles of Bandaging: Those That Concern Efficiency; Those That Concern Neatness. Forms and Uses of Bandages. Materials and Preparation. Application of the Roller Bandage. Bandaging for the Fixation of Dressings. Bandaging for Pressure. The "Turns" Used in Bandaging. Regional Bandaging: The Head, the Neck, the Thorax, the Abdomen, the Extremities. Plaster- of-Paris Bandages and Casts.

IX. Preparation for the Treatment of Fractures 134

Treatment of Fractures; Fracture Bed; Splints; Padding Splints; Materials for Fastening Splints; Apparatus for Extension; Temporary Fixation of Fractures; Permanent Fixation of Fractures; Observation after the Dressing of Fractures.

X. Remedial Measures 142

Measures Requiring Simple Cleanliness: The Enema; Rectal Irrigation; Continuous Proctoclysis; Active and Passive Congestion; Continuous Irrigation; Fowler Position; Special Forms of Dressings. Routine Measures Requiring Aseptic Technic: Hypo-

CONTENTS ix

dermic Medication; Catheterization; Bladder Irrigation; Vaginal Douche; Changing of Perineal Dressings. Aseptic Ward Measures in Which the Nurse Prepares and Assists: The Dressing Room; the Dressing Cart; Dressing of Abdominal Wounds; Hypodermoclysis; Intravenous Infusion of Physiological Salt Solution; Uterine and Vaginal Packing.

XI. Fkactional Doses in Hypodermic Medication 161

Method of Obtaining Fractional Doses from a Stock Tablet. Table of Fractional Doses from Stock Tablets. General Rules. Standard Stock Tablets. Examples.

XII. Weights, Measures, Solutions and Formula 169

Weights and Measures: Linear Measure; Measures of Volume; Measures of Weight; Transposition of Tables. Solutions. Formulae: For Local Anaesthetics; for Antiseptic Solutions; for Enemata; for Saline Solutions; for Ointments and Pastes; for Vaginal Douches; for Depilatory Powder. Making Solutions from Pure Drugs. Making Solutions from Stock Solutions.

XIII. Charts and Records 180

The Chart: Cover Sheet; Temperature Sheet; Record Sheet; Medicine and Treatment Sheet.

Part IV * The Patient

XIV. Observation 189

The Nurse as an Observer. The Meaning of Observation. Method in Observation. The Significance of Symptoms. Conditions Which Require That the Surgeon Should be Called. Objective Symptoms and Signs. Subjective Symptoms: Those Connected with the Special Senses; Pain; Organic Sensations; Feelings. Measurements and Quantitative Estimations: Measurement, Quantitative Estimation, the Scale of Seven; the Record.

XV. Measures for the Comfort and Well-being of the Patient 201 The Work Done by the Nurse Without General or Special Orders. Position in Bed. Application of Heat and Cold. Measures for Relief of Pain. Water and Food. Attention to Bandages and Dressings. Precautions in Acutely Infected Cases : For the Patient; for the Household or Other Patients; for the Nurse.

x CONTENTS

XVI. Routine Nursing in Operative Cases 213

Preparation of the Patient for Operation: Bowel Function; Diet ; Field of Operation. Routine Treatment after Operation : Minor Steps for Comfort of the Patient; Administration of Water; Nourishment; Bladder Function; Bowel Function; Opiates; Dressings; Sitting Up; Going Home; Belts, Binders and Supports.

XVII. Post-operative Complications 222

Shock. Hemorrhage. Acute Dilatation of the Stomach. Intestinal Obstruction. Infections: Local Infections; Sapraemia; Peritonitis; Septicaemia; Pyaemia; Pulmonary Complications: Lobar Pneumonia; Bronchopneumonia. Urinary System: Retention of Urine; Retention with Overflow; Incontinence of Urine; Suppression of Urine.

XVIII. Anoci-association 229

Shock and Fear. The Technic of Anoci-association. The Nurse's Part in the Anoci-association Technic.

Part V The Operation

XIX. The Operating Room, its Outfit and Supplies 243

Organization. The Operating Suite. Fixtures: Sterilizers — Hot-air Sterilizer, Autoclave, Instrument Sterilizer, Utensil Sterilizer, Water Sterilizers. Operating-room Furniture. Supplies.

XX. Operating Material 261

Classification. Materials Which Come into Temporary Contact with the Wound. Materials Which are to Remain in the Wound for a Time or Permanently: Method of Preparing Catgut Sutures and Ligatures. Materials for Fixation of Wound Dressings. Methods of Assembling and Sterilizing Operating Material.

XXI. Surgical Instruments 278

Cutting Instruments; Clamping Instruments; Holding Instruments; Exposing Instruments; Sewing Instruments; Auxiliary Instruments; Care of Instruments.

XXII. The Aseptic Technic 296

Definitions. First Principles of Asepsis. Sterilization by Heat. Outlines of the Aseptic Technic: Methods of Sterilization; Assembling and Handling the Sterilized Outfit; Preparation of Members of the Clean Group; Conduct During the Operation; Conduct Between Operations. The Super-technic. Breaks in the Aseptic Technic.

CONTENTS xi

XXIII. Preparation for an Operation and the Operating-room Personnel 311

Necessary Preparations — For the Patient, for the Anaesthetist, for the Operator and Assistants, for the Scrubbed Nurses, for the Unscrubbed Nurse. Preparation of the Nurse: Cap, Scrub, Gown and Gloves. The Operating-room Personnel: Anaesthetist; the Operator; the First Assistant; the Second Assistant; the Nurse in Charge of the Instruments; the Nurse in Charge of the Sponges; the Unscrubbed Nurse; the Orderly. Duties of Operating-room Nurses: The Unscrubbed Nurse; Instrument and Suture Nurse; Sponge Nurse. Care of the Anaesthetized Patient. Application of the First Dressing. Care of the Patient after Operation.

XXIV. Selection of Instruments 323

The Dissecting Set; General Abdominal Set; Appendix Set; Gall-bladder Set; Stomach and Intestine Set; Kidney Set; Pelvic Set; Hernia Set; Extensive Dissecting Set; Rectal Set — For Hemorrhoids, for Fissure or Fistula in Ano, for Resection; Female Perineal Set; Uterine Curettage Set; Trachelorrhaphy Set; Perineal Prostatectomy Set; Cranial Set; Amputation Set. Wiring or Plating Set; Resection Set; Osteomyelitis Set.

XXV. Operative Steps 336

Operations upon the Head: Trephining; Craniotomy. Operations upon the Trunk: Resection of Rib; Gall-bladder Operations; Appendectomy; Radical Cure of Inguinal Hernia; Shortening of Round Ligaments; Hysterectomy; Dilatation and Curettage of Uterus; Trachelorrhaphy; Perineorrhaphy. Operations upon the Extremities : Amputation Through the Thigh; Disarticulation at the Shoulder.

XXVI. Operations in Private Houses 345

The Room; the Table; Utensils and Supplementary Supplies; Artificial Light; Substitutes for Lithotomy Posts; Kelly Pad; Anaesthetic; Sterilization of Instruments, Water, etc.

Part VI

XXVII. Gynaecological Dispensary 351

Records; Examining and Treatment Room; Instruments; Preparation for Examination; Drugs, Solutions, etc.; Draping of Patient for Examination.

xii CONTENTS

XXVIII. Emergencies 356

Accidents. Wounds. Burns. Fractures: Compound; Simple; Fractures at the Wrist; of the Forearm; at the Elbow- joint; of the Upper Arm and of the Clavicle; of the Leg, Ankle and Foot; of the Thigh; of the Jaw; of the Ribs; Dislocation; Injuries of the Knee; of the Ankle; of the Hip. Diagnosis of Injuries. Transportation of Patients. Hemorrhage: Methods of Controlling Hemorrhage — Elevation, Digital Compression, Flexion, the Tourniquet, Pressure by a Bandage, Packing the Wound, Direct Pressure, Heat and Cold, Styptic or Astringent Drugs; Indications for the Control of Hemorrhage According to Character and Location. Artificial Respiration. Shock in Accident Cases.

XXIX. The Personal Attitude of the Nurse 372

Attitude to the Patient. Attitude to the Surgeon. Attitude to the Hospital. Attitude to the Public. Attitude to Self.

XXX. An Epitome of Some Common Surgical and Gynaecological Conditions 377

Congenital Deformities and Defects : Cleft Palate and Hare-lip; Spina Bifida; Other Congenital Defects. Acquired Deformities. Foreign Bodies. Trauma: Definition; Lesions; Symptoms and Signs; Wounds of Special Structures; Treatment. Surgical Infections: Sepsis. Septic Diseases: Erysipelas; Phlegmon; Abscess; Sepsis in Bone, in Joints, in Serous Cavities. Treatment and Nursing. Surgical Tuberculosis. Tetanus. New-growths: Classification; Benign Tumors; Malignant Tumors; Tumors in Special Tissues. Other Organic Diseases: Goitre; Aneurism; Gangrene. Diseases of the Abdomen; Ulcer of the Stomach and Duodenum; Cancer of the Stomach and Intestines; Appendicitis; Intestinal Obstruction; Tuberculous Peritonitis; Hernia; Gall-stone Disease. Gynaecological Diseases: Malformations and Displacements; Atresia of the Vagina; Anteflexion of the Uterus; Retroversion of Uterus; Prolapse of Uterus. Injuries : Laceration of Cervix; Laceration of Perineum. Inflammations: Vulvitis; Endometritis; Salpingitis. New-growths: Ovarian Cysts; Fibroid Tumors of the Uterus; Cancer of the Uterus.

ILLUSTRATIONS

PAGE

1. Diagram of a Cell 9

2. Multiplication of a Cell (Craig) 10

3. Showing Relative Size of Bacteria 19

4. Diphtheria Bacilli (Carr) 20

6. Bacillus Subtilis, Showing Flagellar (Gray) 21

7. Diplococcus Pneumoniae (Carr) 21

8. Streptococci (Gray) 21

9. Staphylococci (Carr) 21

10. Bacilli Showing Spores (Parker) 21

11. Chart Showing Normal Temperature After Operation 38

12. Chart Showing Traumatic Temperature (Miss Kathleen Carroll) . . 39

13. Chart Showing Septic Infection (Local Abscess) After Operation. . . 40

14. Chart Showing Septic Infection, Continued Type (Miss Emily

Warren) 43

15. Staphylococcus Pyogenes (Carr) 47

16. Streptococcus Pyogenes (Parker) 47

17. Bacillus Coli Communis, Showing Flagellar (Gray) 48

18. Bacillus Pyocyaneus, Showing Flagellar (Gray) 48

19. Bacillus Tetani, Showing Flagellse (Gray) 49

20. Bacillus Tetani, Showing Spores (Carr) 49

21. The Gas Bacillus (Parker) 50

22. Tubercle Bacilli (Carr) 50

23. Treponema Pallidum (Gray) 51

24. Micrococcus Gonorrhoeae (Wood) 52

25. Frog's Mesentery, Normal (Agnew) 68

26. Frog's Mesentery, Inflamed (Agnew) 68

27. Emigration of Leucocytes (Wood) 69

28. Section Through Skin of Guinea-pig Eight Hours After a Wound

(Shakespeare) 70

29. Same at Later Stage (Shakespeare) 71

30. The Same Later (Shakespeare) 72

31. Cicatrix Formed in the Wound (Shakespeare) 73

32. Healing of a Wound by Granulation (Wood) 74

33. Varieties of Blood-cells 75

34. Amoeba Coli (Entamoeba Dysenteriae), Common Form 75

35. Phagocytosis (Wood) 77

36. Horizontal Recumbent Position 102

37. Trendelenburg Position 102

38. Dorsal Position 103

39. Dorsosacral (Lithotomy) Position 104

40. Right Lateral-prone Position 105

41. Genu-pectoral (Knee-chest) Position 106

42. Triangular Bandage (Eliason's Practical Bandaging) Ill

xiii xiv ILLUSTRATIONS

43. Single T-Bandage Ill

44. Four-tailed Bandage Ill

45. Modified Bandage of Scultetus 112

46. Rolling Bandage by Hand 113

47. Bandage Roller 114

48. Circular Turns of a Bandage (Eliason's Practical Bandaging) 118

49. Spiral and Oblique Turns (Eliason's Practical Bandaging) 119

50. Making Reverses 120

51. Figure-of-Eight Turns (Eliason's Practical Bandaging 121

52. Spica of the Hip 122

53. Recurrent of the Scalp (Eliason's Practical Bandaging) 122

54. Recurrent Bandage of the Stump 122

55. Recurrent Turns (Eliason's Practical Bandaging) 123

56. Figure-of-Eight of the Head and Neck (Eliason's Practical Ban-

daging) 123

57. Double Oblique of the Jaw (Eliason's Practical Bandaging) 123

58. Four-tailed Bandage of the Chin (Eliason's Practical Bandaging) . . 123

59. Barton's Bandage 124

60. Gibson Bandage (Eliason's Practical Bandaging) 124

61. Spiral Reverse of Lower Extremity (Eliason's Practical Bandaging) 126

62. Velpeau Modified (Dulles) (Eliason's Practical Bandaging) 127

63. Desault Bandage (Eliason's Practical Bandaging) 128

64. Finger Bandage 129

65. Spica of the Foot (Eliason's Practical Bandaging) 129

66. Method of Squeezing Water from Bandage (Eliason's Practical

67. Making Plaster Bandages (Eliason's Practical Bandaging) 131

68. Instruments for Removing Plaster Casts (Eliason's Practical Ban-

daging) 132

69. Buck's Extension . (Eliason's Practical Bandaging) 139

70. Dressing for Fracture of Shaft of Femur. 139

71. Median Section of Female Pelvis 143

72. Apparatus for Proctoclysis 147

73. Showing Notch Filed in Stop-cock 148

74. Taped Adhesive Strips 158

75. Chart Showing Morning and Evening Temperature (Septic Perito-

nitis) 181

76. Four-hour Chart (Septicopyemia) 182

77. Type of Record Sheet 183

78. Medicine and Treatment Sheet 185

79. Operating Room 245

80. Sterilizing Room 246

81. Hot-Air Sterilizer 247

82. Autoclave 248

83. Autoclave with Drums for Dressings 249

84. Instrument Sterilizer 250

85. Utensil Sterilizer 251

86. Water Sterilizers 252

ILLUSTRATIONS xv

87. Operating Table 253

88. Drums on Stand 254

89. Irrigator Stand 255

90. Needle and Thread for Arterial Suture (Bernheim) 276

91. Flask for Arterial Sutures 276

92. Cutting Instruments: Knives and Scissors 279

93. Cutting Instruments : Bone Drills and Trephines . . .' 280

94. Cutting Instruments: Curettes 280

95. Cutting Instruments: Bone Cutters 281

96. Cutting Instruments: Chisels and Gouges 281

97. Cutting Instruments: Bone Saws 282

98. Clamping Instruments: Haemostatic 284

99. Clamping Instruments 284

100. Clamping Instruments 284

101. Clamping Instruments: Intestinal Clamps 284

102. Holding Instruments 285

103. Holding Instruments 285

104. Exposing Instruments: Retractors 286

105. Exposing Instruments: Retractors 287

106. Exposing Instruments: Retractors 287

107. Exposing Instruments: Specula 288

108. Exposing Instruments: Specula (Vaginal) 288

109. Surgical Needles 289

110. Needle Holders 291

111. Sewing Instruments: Ligature and Suture Carriers 291

112. Auxiliary Instruments: Probes, Directors, Dissectors 292

113. Auxiliary Instruments: Dilators 292

114. Auxiliary Instruments: Dilators 294

115. Auxiliary Instruments: Evacuators (Catheters) 294

116. Auxiliary Instruments: Evacuators (Trocars and Cannula?) 294

117. Diagram of Arrangement of Operating Room 316

118. Showing Improper Position of Arm 320

119. Pillow Support Under Back 321

120. Instruments: the Dissecting Set 324

121. Additions for General Abdominal Set 324

122. Additions for Gall-Bladder Set * 326

123. Additions for Pelvic Set 326

124. Additions for Hemorrhoid Set 328

125. Additions for Female Perineal Set 328

126. Uterine Curettage Set 330

127. Cranial Set 330

128. Bone and Cranial Set 332

129. Amputation Set 332

130. Joint Resection Set 333

131. Rib Resection Set 334

132. Osteomyelitis Set 334

133. Shafer Method of Artificial Respiration, First Position 370

134. Shafer Method of Artificial Respiration, Second Position 370

Chapter I The Cells Of The Body And The Invading Cells

Modern surgery may be said to owe the whole of its wonderful advancement to the invention of a single instrument, the purpose and uses of which were so far removed from the obvious needs of the surgeon that not the wildest dreamer could have guessed its epoch-making importance in relation to surgical practice. The immensely widened field of vision which the microscope opened up to the students of living matter resulted finally, among many other benefits, in freeing surgery from the terrible handicap of wound infection under which it had labored for more than a score of centuries. Under this handicap surgical operations which are now considered trivial and practically devoid of risk, were attended with a huge mortality, and almost every form of operative interference involving the deeper parts of the body was absolutely prohibited by death in practically all the cases. All the great serous cavities of the body were thus placed beyond the possibility of surgical exploration. Abdominal surgery was an almost untouched field, surgical manipulation within the thoracic or cranial cavities undreamed of. Trephining the skull was a very ancient operation, it is true, but only the boldest surgeon ever ventured to cut through the lining membrane of the cranium which encloses the brain, and none dared repeat the venture often. John Hunter, greatest English surgeon of his time, declared that he never saw a case recover where the dura mater had been either wounded or incised at an operation. Even in the more external parts of the body wounds, whether operative or accidental, except the most trivial, resulted in a dreadful proportion of fatalities. The amputation of limbs, even in the most skilful hands, had a mortality of forty per cent, or more. Of compound fractures of the thigh treated during the Napoleonic wars over eighty per cent, were fatal. The menace of septic disease in wounds naturally increased in proportion as patients were brought together in large hospitals, so that the very circumstance which would otherwise have favored progress, by giving to the surgeon the advantage of an enlarged experience, became the means of retarding every effort at improvement in operative work by the almost prohibitive death rate which it imposed.

The emancipation of surgery from the bonds which had so long confined it began with the work of Joseph Lister, following the lead of the great Frenchman. Louis Pasteur. The time was peculiarly ripe for the triumph which Lister was destined to achieve. Anaesthesia by means of ether and chloroform had been discovered and had now been an established procedure in surgical practice for more than a decade. To make clear the full meaning of this innovation it is necessary to point out that its benefits were of two kinds. The ' 'Death of Pain," inestimable boon though it was for the patient, was of far less importance from the larger outlook than the opportunity now given to the surgeon of doing his work with deliberate care. In pre-anaesthetic days surgical operations had to be done at the highest attainable speed. Two or three minutes, for example, was the record for an amputation which every surgeon strove to equal or surpass. With the introduction of anaesthesia all this was changed. Hours instead of minutes were now available if necessary. The dexterity of the juggler ceased to be the ideal for the work of an operating surgeon, and the painstaking skill of an expert handicraftsman took its place. As a consequence the temptation to try out improved methods and new operationwas almost irresistible, and surgeons everywhere were pressing restlessly against the limitations which the huge mortalities from sepsis still imposed upon them. A quarter of a century earlier a great German anatomist had been the first to formulate clearly the theory of a living contagion: our own Dr. Oliver Wendell Holmes had pointed out the contagious nature of puerperal fever, and had suggested the employment of chemical disinfectants as a safeguard against it: in the obstetric wards of a great hospital in Vienna such measures had been put to the test of practical use with marked success; but because the time was unpropitious the voices of these pioneers had fallen on deaf ears, and to Joseph Lister was to belong the honor of leading the way in the greatest forward step that had been made since surgery began.

The early investigations of Pasteur had shown that the familiar phenomena of fermentation and putrefaction were in reality due to the action of minute living organisms which the microscope had made visible, and the character of the foul discharges from inflamed wounds, so like the putrefactive process, suggested to Lister the possibility of a similar causation. The case as regards fractures was particularly suggestive of this. It was a commonplace that simple fractures, i.e., where the skin was unbroken, healed without inflammation, fever or any foul discharge, and practically all these cases recovered. In compound fractures, on the other hand, i.e., where an open wound communicated with the broken bones, the putrefaction-like process of suppuration accompanied with inflammation and fever invariably occurred, and the majority of these patients died. In Lister's mind it was a clear inference that the difference in these two cases was due to the entrance into the wound of living germs from the air, and he acted on this idea. Carbolic acid was already known as an efficient preventive of putrefaction, and in August, 1865, Lister first applied a carbolic dressing to the wound of a compound fracture. The result was all that he had hoped. No suppuration occurred. A scab formed over the wound and the case progressed to recovery like a simple fracture. Other similar results followed, and he was encouraged to extend the application of what he called "the antiseptic principle in surgery" to other accidental wounds and also to operative wounds with equal success. Still possessed by the natural but mistaken idea that the air was the source from which the dangerous organisms came, he began to perform his operations under a cloud of spray impregnated with carbolic vapor formed by a steam nebulizer. Instruments were smeared with carbolic oil, hands, sponges, ligatures and dressings dipped into carbolic solution. These methods were crude in the light of later developments, but they sufficed.

The new principle in surgery thus inaugurated was naturally not accepted all at once or without controversy, but Lister's mind was of too fine a temper to be discouraged by opposition or embittered by hostile criticism. He pressed on, constantly improving his methods, and his results soon accumulated a weight of evidence that compelled recognition from his doubting colleagues. Even the most determined opponents of his theory unconsciously modified their own technic in accordance with the new idea, and in proportion as they did this were rewarded with improved results. Lister's investigations, however, were confined almost entirely to the practical side of the problem. He spoke vaguely of putrefaction in wounds resulting from the presence of living organisms, and the question as to the exact nature and life history of these organisms remained unanswered. His work, therefore, convincing as it was, lacked the completeness and precision of a scientific demonstration and it was reserved, as perhaps might have been expected, for the patient and exact methods so characteristic of German science to attain this goal.

A year after Lister's first experiment there was graduated from a Prussian university a young student in medicine who was destined to play a leading part in investigating the relation of microorganisms to infectious disease. Robert Koch began his studies of these organisms during the leisure moments that could be spared from a laborious country practice. The work which he did under these circumstances, judged in the light of its results, may be regarded as one of the most brilliant achievements of any scientific worker of modern times. The methods which he devised for manipulating, staining and cultivating bacteria, with the results of his investigations by means of these methods, brought him almost from the moment of their announcement a leading position among German scientists and made him virtually the founder of the science of bacteriology. The new science, attracting a host of eager workers, at once entered upon an amazingly rapid development, and in a few years the vague general ideas previously held had given place to a large fund of exact knowledge concerning the life history of many individual species of bacteria and their relation to communicable diseases, including the surgical infections. Koch himself, ten years after the publication of Lister's first paper, was able to give to the world a full account of some half-dozen species concerned in the traumatic infections in animals and man.

The methods of wound treatment and the technic at operations designed to prevent infection, which Lister's earlier experiments introduced, were crude indeed compared with those in use at the present time, but while nature holds us to strict account for disobedience to her laws she often rewards us generously, even lavishly, for only a partial understanding of her secrets. It was so now. As Lister's methods began to come into general use suppuration in wounds became less and less frequent. Large mortalities dropped to small and in some cases even to negligible figures. Healing "by first intention," so-called from the time of Hippocrates, i.e., healing without inflammation or suppuration, ceased to be a surgical curiosity and began to be called normal healing. The awful scourge of hospital gangrene, so common up to Lister's time, vanished utterly.

The result of Lister's work for surgery may be likened to the setting free of a lifelong captive from a dark and narrow prison. The strong doors, barred and guarded for so many ages, were now, almost suddenly, thrown wide open. Surgeons, groping forward in an unaccustomed freedom, many of them hardly realizing what had happened, began to find that they could now do many things safely that had always been prohibited. Constant improvements in technic opened the way for new successes. The gradual recognition of the fact that the entrance of bacteria into wounds occurs practically always by contact with material things to which these organisms adhere (hands, instruments, ligatures, dressings), while infection through the air is negligible; the introduction, first in Koch's laboratory, of sterilization by high -pressure steam; and the use of rubber gloves for the hands of the surgeon and his assistants, first practised by Halsted at the Johns Hopkins Hospital, revolutionized the earlier methods of preventing infection in operative wounds, inaugurating the present or what is known as the " aseptic" era, in contradistinction to the " antiseptic" era of early Listerian practice, and enabled surgeons to perform the most extensive operations in all the formerly forbidden regions of the body with an almost mathematical certainty that no infection would follow and that normal healing would be secured. The way was thus opened for the immense development of operative surgery which in the past fifty years has been many times greater than in all the preceding centuries. There were many new difficulties to be overcome and dangers to be encountered, but the difference was that under the old conditions these problems could not be approached at all; now the path was clear.

Among the many changes which the new era, resulting from these discoveries, has brought about, not the least in importance is concerned with surgical nursing. The time has long passed when a surgical operation was the work of one man with the assistance of one or two unskilled helpers. Success under modern conditions requires the coordinated efforts of a highly trained and perfectly organized team of workers. The aseptic surgical technic, that elaborate system which has been gradually worked out, whose object is to prevent the occurrence of infection in wounds, demands not only the strict observance of proper methods at the operation itself, but also expert knowledge and conscientious exactness in all the details of preparation. This work of preparation calls for its own separate organization, with an elaborate equipment of technical apparatus requiring special skill in its use, and the responsibility for this rests almost wholly upon the shoulders of the surgical nurse. It is highly important that the carrying out of this part of the work should depend, not upon the blind observance of a set of rules, vaguely understood and often imperfectly remembered, but rather upon an intelligent application of clearly comprehended principles, based upon a correct knowledge of the conditions under which wound infection takes place. Before entering, therefore, upon the practical side of our presentation of the technical duties involved in surgical and gynaecological nursing, it is necessary to devote some space to a consideration of the infection problem, the life history and distribution of the living organisms concerned, and the relation of these organisms to infectious disease.