The operating room, a primer for pupil nurses

Front matter

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IRMl II ill

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Foreword

This little book has been slowly and anxiously pieced together not by one continuous task, but by culling an idea here, a formula there, a test somewhere else, from the conversations of numerous good friends in the medical and nursing professions, and from happy memories of days in training under the kindly, thorough instruction of Miss A. M. Rykert and Miss J. MacCallum (now Mrs. Schenck, of Detroit), for the opportunity to be under whom those who were so fortunate have been increasingly proud and grateful as time goes by/ Yet, withal, this book will seem rather crude in comparison with the finished work of experienced authors. Generously excuse its faults on the ground that it is only a pioneer, from a nurse to nurses, and not from a physician to nurses! These data have been garnered from journals on nursing, from physicians' libraries, and from the practical experiences of friends. If its humble appearance proves to be an inspiration to others more skilled, to take up the labor and go farther, it will have accomplished much. If, again, any nurse chances to learn that she too can constantly acquire information that may be at any time, no matter how remote, tremendously useful to her, it will not have been written in vain.

My sincere thanks are due to Dr. T. Mitchell Prudden and Dr. W. M. Brickner for permission to quote from their valuable works, to Dr. C. A. Smith and Dr. C. H. Fulton for their constant personal assistance, to Dr. E. M. Smith and Dr. A. Beck for contributions on their special lines of work, to Mr. F. H. Kollman for useful pharmaceutic data, and to the firms Kny-Scheerer Corporation,

10 FOREWORD

Foregger Co., Inc., Lentz & Sons, for the loan of numerous electrotypes, and to J. F. Newman, manufacturing jeweller, for the design on the title-page.

Most especially, however, this work has been forwarded and is largely due to the encouragement and careful revision given by Miss B. I. Brazeau, R. N., and Miss I. M. Hall, R. N., two operating-room nurses, whose absolute conscientiousness, skill, and willing spirit, enhanced by many tenderer graces that make the perfect woman, deserve a far higher tribute than can here be given.

" The Trained Nurse and Hospital Review " kindly gave permission to use the original articles which were expanded for some of these chapters.

Amy Armour Smith.

New Rochelle, N. Y.

September, 1916.

Contents

CHAPTER I page

Rotation of Service, 17— The First Day, 18— The Little Hospital, 18— The Surgeon's Duty to the New Pupil, 20— Good vs. Bad Judgment, 21 — The Telephone, 22 — Some Ways of Arranging Work, 22 — Importance of Dusting, 23— Honesty in Running the Sterilizers, 24 — Some Difficulties which the Supervisor Has to Solve, 24 — Sequence of Instruction, 25 — Routine Cleaning, 26 — Utensils and Linen, 27 — Classes in Anatomy Daily, 29 — Impartiality, 29 — Relation Between the Operating Room and the Ward, 30 — Best Time to Give a Pupil this Service, 31 — Deportment, 31 —Eight-hour Day, 32— Scholarships, 32— Visitors, 33— Presence Not Demanded in Genito-urinary Work, 33 — Moving Pictures as Educational Feature, 34.

Chapter II

Her Numerous Duties, 36 — Sharpening the Instincts to Judge Time, Distance, etc., 39 — Visitors, 42 — How to Get Ready for a Second Case, 43 — Messages To or For the Doctor, 45 — Engineer's Instructions, 46 — Perspiration, 48 — Orders to the Wards, 48 — Special Beds, 48.

Chapter III

Positions for Operation, 50 — Setting Up the Anesthetic Room, 53 — Greeley Units for the Stimulation Tray, 54 — Duties to the Patient, 56 — Duties to the Anesthetist, 57 — Problem of Nurses' Giving Anesthetics, 58 — How to Follow One Case by Another, 59 — Oxygen, 59 — After the Operation, 61 — Special Anesthetics, 63 — Spinal Anesthesia, 63 — Rectal Anesthesia, 63 — The Pulmotor, 64.

Chapter IV

Procedure During a Case, 66 — Sutures, 67 — Needles, 67 — Ligatures, 68 — Scissors, 68 — Forceps, 68 — Instruments in General, 68 — Height of Table, 69 — Instruction in Conducting an Operating Room, 69 — General Hints, 71.

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CHAPTER V page

Preparedness, 77 — Discipline, 78 — Teaching Method, 79

— Nursing, 80 — Common Faults in Operating Rooms, 81 —

Legal Phases in Her Duties, 81 — Routine Work, 82 —

t Ethical Relations with the Rest of the House, 87 — To the

' Community, 88 — Economy of the Right Kind, 89.

Chapter VI

Position Relative to the Main Building, 90 — Lighting, 90 — Ventilation, 90 — Temperature, 92 — Clothing Required to Work Comfortably, 92 — Corners, 93 — Fumigation, 93 — Instrument Cases, 94 — Dark Room, 95 — Plumbing, 96 — The Table, 97 — Terms Used in Electric Appliances, 97 — Silent Clock, 98— Special Table Pads, 99— Tonsil Table, 99 — Cautery, 99 — A Cleanly Way to Evacuate a Cyst, 99 — Radium Outfit, 101— Doors, 101— Waste Receptacles, 101 — Other Rooms of the Suite, 101 — Elevators, 102 — Fire DriU, 102.

Chapter VII

Open-air Shaft to Reduce Humiditv, 104 — Cold Coil on Both Water Tanks, 104— Filters, 105— Fixtures, 105— Height Not Desirable for Tanks, etc., 105 — Engineer's Instructions, 106 — Perfected Autoclave, 106 — Packing Drums, 106— Duty of Night Nurses, 107— Tests for Complete Sterilization, 107 — Distillation of Water, 107 — Making Saline, 108— Clock, 108— Other Sterilizers, Gloves, Utensils, Instruments, etc., 108 — Special Precautions with Apparatus, 109 — Infections Due to this Department, 109 — Safety Devices, 109— Blanket Warmer, 110— Electricity, 110— Flooring, 110.

CHAPTER VIII The Workrooms Ill

Size, Ventilation, 111 — Cupboards, 111 — Desk, Counter, Seats, and Foot-rests, 111 — Rules for Work, 112 — Hopper Room, 113.

Chapter IX

Definition, 114 — Methods of Carrying Out Asepsis, 114 — Damp Dressings, 115 — Mechanical Cleanliness, 116 — Covers, 116— Caps, Masks, Glasses, 116 — How to Stand, 117 — Tests by Cultures, 118 — Tracing the Aseptic Chain, 119 — Some Errors in Technic, 122 — How to Handle Goods from a Jar, 124 — Dusting, 127 — Orderlies, 127 — Where the Anesthetist May Work, 127 — Contaminated Instruments, 128 — Breaks in Asepsis, 128 — How to Reduce the Activity

CONTENTS 13

PAGE

of Bacteria Liberated by Any Wound, 128— Table, 129— Floors, 129— Walls, 129— Shoes, 130— Health of Attendants, 130 — Emergency Cases, 131 — Contagious Cases, 131 — Clean Cases, 132 — Some Problems Confronting the Supervisor, 133— Nurses Who Are 111, 133.

Chapter X

Thiersch's Solution, 136 — Carrel-Dakin Antiseptic, 136 — Iodoform Packing, 136 — Catgut, 137 — Kangaroo Tendon, 138— Horsehair, 138— Silkworm-gut, 138— Silk, 138— Bone-wax, 138 — Aluminum Acetate Solution, 138 — Boric Acid, 139 — -Normal Saline, 139 — Solutions of Bichlorid of Mercury, 140 — Formaldehyd, 141 — Nitrate of Silver, 141 — Narcotics and Local Anesthetics, 142 — One Per Cent. Solutions, 142 — Rubber Tissue, 143 — Care of Rubber Gloves, 144 — Rubber Tubing, 146 — Catheters, Filiforms, and Bougies, 146 — Preservation of Specimens, 148 — Hard Black Rubber Goods, 148— Silver Leaf, 149— Care of Instruments, 149 — Care of Soft-rubber Articles, 150 — How to Sterilize Adhesive, 150 — Eye Knives, 151 — Glass Syringes, 151 — Tracheotomy Tubes, 151 — Hospital Cold Cream, 152 — Hospital Hand Lotion. 152 — To Sterilize Vaselin, 152.

Chapter XI

The Metric System. Some Brief Notes 153

Length, 153 — Volume, 154 — Weight, 155.

CHAPTER XII Special Dressings 157

Mastoid Tips, 157 — Mastoid Dressing, 157 — Gant Pad, 158 — Tampon Canula, 158 — Canule a Chemise, 158 — . Leg Rolls, 159— Tampons, 159— Small Sponges, 159— Cloth Retractors, 160 — Bandaging, 160 — Making Packing, 160 — Eye Pads, 160— Aristol Pledgets, 160— Applicators, 161— Tape Stickers, 161.

Chapter XIII

A List of Terms Describing the Pathologic Conditions that Require Operation and Their Definitions, 165.

Chapter XIV

Lists of Instruments for Certain Operations, with Accessory Articles, and Details of Actual Operating-

toom Nursing Care 185

Head, 185 — Mastoid, 186 — Cataract, 188 — Submucous Resection of the Nasal Septum, 188 — Frontal Sinus (Radical), 189 — Radical Operation on the Ear, 190 — Jugu-

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PAGB

lar Operation, 190 — Strabismus Operation, 190 — Enucleation of the Eye, 191— Adenoids, 191— Tonsils, 191— Pharyngeal Abscess, 192 — Tracheotomy, 192 — Brain Abscess, 192 — Skin-grafting, 193 — Breast Amputation, 193 — Resection of Rib for Empyema, 194 — Appendectomy, 196 . — Cholecystotomy, etc., 198 — Gastrostomy, etc., 200 — Hysterectomy, 200 — Cesarean Section, 202 — Herniotomy, 203— Nephrectomy, etc., 203— Curettage, 205— Trachelorrhaphy, 206 — Perineorrhaphy, 206 — Hemorrhoidectomy (Ligation Method), 206 — Operation on Fistula in Ano, 207 — Hemorrhoidectomy (Clamp and Cautery Method), 207.

CHAPTER XV Nomenclature 209

A List of the Terms Used in Naming What is Done in the Operating Room, with Definitions, 211.

Chapter XVI

How to Estimate the Amount Needed, 217 — Patterns, 217— White Linen, 218— Method of Laundering, 218— Open Net Bags, 219— Men's T-Binders, 219— Suspensories, 219— Scultetus Binders, 220 — Laparotomy Gowns and Stockings, 220— Breast Binder, 221— Caps, 221— Masks, 222— Vaginal Sheets, 223— Covers for Tubes of Packing, 225— Special Gown Covers, 225 — Special Glove Covers, 225 — Folding Linen, 225— Folding Gowns, 226— Blankets, 228— Stains, 228 — Linen for Isolated Cases, 229 — Measures for Suits and Gowns to Fit All Figures, 229.

Chapter XVII

Things N.)t to Buy, 230— A Buyer's Duty, 230— American Hospital Bureau of Standards and Supplies, 231 — Trade Names, 232— Buying a Good Quality of Stimulants, 232— Process of Obtaining Alcohol and Safeguarding It, 232 — How to Act When an Important Article is Needed in an Unforseen Contingency, 233 — Expense, 233.

CHAPTER XVIII Minor Work in the Operating Room or Based on Its

Technic 234

Intravenous Infusion, 234 — Hypodermoclysis, 242 — Injection of Blood-serum, 243 — Transfusion, 244 — Phlebotomy, Venesection, Blood-letting, 246 — Lumbar Puncture, 247— Injection of Antimeningitic Serum, 247 — Spinal Anesthesia, 248 — Artificial Respiration, 248.

CONTENTS 15

Chapter XIX Page

Preparations by the Nurse in Orthopedic Surgery 250

Definition of Terms of Pathologic Conditions, 250 — Description of Apparatus to Be Made in Any Operating Room, 252 — Bradford Frame, 252 — Buck's Extension for Fracture, 253 — Articles for the Lorenz Operation, 256 — Ordinary Plaster Cast, 257 — Putting on a Cast, 258 — Special Instructions, 260 — Orthopedic Tables, 262 — Strapping for Flat-foot, 262 — Limitations of General Hospitals, 262 — Explanation of Terms Relating to Unusual or Special Apparatus, 263.

Chapter XX

Some Hints, 266 — First Preparations, 266 — Linen, 266 : — How to Sterilize, 266— Saline, 266— Operating Table, 267 — Trendelenburg Position, 267 — Improvised Kelly Pad, 269— Stretcher, 270— Gown, 272— Cap and Mask for the Nurse, 272— Cleaning the Room, 272.

CHAPTER XXI A Plea to the Superintendent in Behalf of the Operating Room 274

Its Value to the Superintendent in His Administration, 274— Needs, 274— Sale of Sterile Goods, 274— Library, 275 — Buying Quickly, 275 — Observation Trips of Supervisor and Pupils to Other Institutions, 275 — Notifying the Operating Room of Every Case Coming In, 276 — Reinforcement in a Rush, 276 — Large Reserve Stock, 276 — The Laundry, 277 — The Superintendent's Attitude to the Nurses During a Case, 277 — Supporting the Supervisor by Providing Good Servants, 278.

CHAPTER XXII The Choice and Appointment of an Operating Room Supervisor 280

Importance, 280— Relation to Other Officials, 281— Desirable Qualities, 280 — Testimonials, Degrees, and Demonstrating Abilitv, 282 — Method of Conducting Interview, 282— Ratification by Board of Governors, 283— The Supervisor's Side, 284 — Registries as Bureaus of Information, 284 — "Pull," 285 — Duties of the American Hospital Association, 286.

Index 289

Chapter I

"A task! — To be honest, to be kind; ... to renounce when that shall be necessary and not be embittered; to keep a few friends, and these without capitulation; above all, on the same grim condition, to keep friends with himself; here is a task for all that man has of fortitude and delicacy." — Robert Louis Stevenson.

Rotation of Service. — The superintendent or directress of nurses must keep the operating-room supervisor thoroughly posted about the pupils' rotation of service, so that a new pupil's arrival in that department does not interfere with the smoothness of its workings. Then, too, illness and vacations being taken into consideration, there must always be available one nurse at least in small hospitals, more in the larger, who is free to go back to that service when needed. There is a tension and importance about this "core of the house" that enforces a sort of militarism, or establishment of a standing army of nurses who "have had operating room." There is a very pleasurable excitement in the arrival of one nurse and the departure of another, a large amount of speculation about where the latter will go, and how the former will fit in, that varies the monotony of the daily round '. It has often been demonstrated that out of very unpromising material a good operating-room nurse can be made, because of her sudden flaming-up of enthusiasm for a new kind of work in this tense atmosphere. We call it the "core" of the house because it contains all the

2 17 seeds of the future success of the institutions which undertake work that cannot be with equal facility and success conducted at home, and which are to be supervised by some of these same pupils in the future.

The First Day. — By a careful planning, calculating on the help in any emergency of the pupils who have finished the service, so as to be perfectly free to teach, in a period void of excitement or demands on her attention, the supervisor greets her novice in the early morning of the first day and begins at once to devote a certain number of hours to instructing her in the primary duties she will have to perform. It is impossible to devise arrangements to suit the operating-room personnel of all hospitals that undertake surgery, whether general, special, private, charitable only, or emergency, and besides, in a very large city where all these kinds exist side by side, conditions are so dominant as to force their work into certain grooves. It is rather toward the small hospitals in the suburban counties that these chapters are directed, since they toss hither and thither on the reefs of crystallized whims of a few men who by their early pugnacity, doubtful politics, or genuine philanthropy became the pillars of the staff and brought to its beds patients of such substantial means that the Board of Directors brings a pressure to bear on all resident officials to humor their notions somewhat. A generous, openhanded community, an upright body of governors, and an ethical Medical Board are the things to be desired for the hospital's backing, and it is in the hope that these are the goal of each man's ambition that the suggestions herein contained have been evolved.

The Little Hospital. — Many little operating rooms have been successfully conducted by one graduate nurse who at times performed other duties in the hospital as w T ell, simply calling one pupil from the wards during the period when the patient is under the anesthetic. Some have one steady pupil and one on call, others two steady pupils, and so on, up to the large institutions which conduct several operating rooms en suite at once, with the large staff of pupils working interchangeably to their mutual advantage. Let not the little hospital force be discouraged, however, because its gains are "writ large" in accuracy, thoroughness, and personal interest in surgeon and patient, besides a breadth sometimes that is derived from acquaintance with the methods of maybe as many as twenty-five of the picked surgeons from a near-by metropolis, who are pleased to come out to operate on the wealthy residents and find faithful, unerring service.

The little operating room was the first to subscribe to the wish now almost universally voiced, to standardize operating-room technic. The operating-room supervisor, as well as all officials above her, should be a member of the American Hospital Association, and become identified with the sessions of the surgical department. The Board of Directors should pay her or their expenses to these conferences, and demand a good report, and progress in the service of the hospital later. It is also incumbent upon us to promote more frequent conferences among these supervisors within our own counties. They are very important people. The occupations of the inhabitants, inclement climate, facilities for transportation all determine largely not only the hours at which operations are held, but the nature of the cases to be done. When they meet they should not brag about how they do things, but should ventilate all their difficulties and say, "How do you do this thing? How do you manage when that event happens? What percentage of skin infections do you get?" This requires the hearty cooperation of the senior officers in the hospital to arrange for substitutes and traveling expenses.

The large institutions of the nearby cities should be visited to see modern equipment, new methods, and often to derive, maybe, a great deal of consolation for feeling that in some respects they are not so up to date as the visitor's. But this moving about keeps one alert and vigilant, and many good hints are picked up.

Few of the professional journals accord to the operating room a special section, and yet, to the man on the street, to the nurse, .and to the majority of the general practitioners who send cases in to a hospital, the operating room is "the whole thing. "

On the first day of a pupil's term here the head nurse takes her through what has been hitherto forbidden ground, all the rooms belonging to the department, so that she may understand the "lay of the land," to find other persons quickly. She is introduced to all her fellowworkers in their respective capacities, scrubbed nurse, anesthetic nurse, so that the former, who is very much preoccupied, need not be disturbed for what the latter could just as well tell her. The successful supervisor gives her instructions in a clear, low, emphatic tone that reaches only the one it is intended for, and not too fast, at that. Frowns, signs, beckoning, or whispers are all very puzzling to novices, especially because they come up filled with terror, and are quite stage-struck and selfconscious at first.

The Surgeon's Duty to the New Pupil.- To this novice every surgeon or anesthetist has an obligation, for she may some day be the brightest star in his firmament. Instead of ignoring and snubbing her, he should help her in every way within his power. The surgeon is so dependent on others for help that he ought to be sensible about building for the future. There will be times that a new pupil has to appear in the main room, that is, the most important of all the suite, but a clever supervisor will plan, as far as any human being can, to grade her work so that the novice is never confronted with any condition that she cannot completely master. To arrange so that the first thing a new pupil is seen doing she does well gives not only her but the surgeon confidence. But he should be big enough of soul to accept his share of the burden of training the pupils of the school, and to forget whether they are bright eyed or young, but to teach them, impersonally, calmly, and definitely. They will remember every word he says, and it is much more profitable to say, "I always use ten-day chromic for the perineum," than to throw on the floor what she tremblingly hands him. Nothing depleted the ranks of the nursing force (i. e., in proportion to the increase in the number of hospitals and beds everywhere) like the oaths and throwing instruments about in the old-fashioned operating rooms.

A new pupil should never be sent to look for an instrument in a moment of panic if she has never heard of it and has no mental image of it. When you lose your thimble, you will never find it if you think about pears. You must think "thimble." In these panics the instrument is not described graphically, the pupil fails to find it, and time is lost. Be ahead of the game. All those things must be laid out beforehand, in even the remotest possibility of being used, though they need not be boiled. They can then be easily pointed out. One of the most meritorious qualities developed in a careful operating-room training is forethought. It is far better to lay out too many dressings, or to open and thus unsterilize some special form of dressing, than to rush frantically for some in the middle of a critical operation. The surgeon has to bear all the responsibility of the case and its results, whether fatal or happy, before the visiting physician who sent it in, the relatives, the hospital authorities, and public opinion. It is criminal to leave him without good, reliable support in caring for the patient. The fact that some surgeon may be persona non grata is no excuse for sending him an incompetent pupil as assistant. If all questions are answered on the basis, "What is best for the patient?" or "How can we do the greatest possible good to the greatest possible number?" there will be absolutely no unfairness to any person connected with the institution, whether it be a surgeon whose ways are not modern, or a pupil nurse who uses too many ward dressings.

Do not forget what the hospital is conducted to accomplish — to cure the sick and to rid the community of disease, unjust expense, and unhappiness. It does not exist for the purpose of training good operating-room nurses. That occurs if it does the other duty well.

The Telephone. — There will doubtless be free telephone communication with the operating-room department on account of the interns' relation to the wards, the presence of visiting doctors, and the calls of the surgeon's private practice. These calls must be very clearly taken; since it means money to the surgeon, and allaying the anxiety of the family at the other end of the wire, anxiously waiting. The supervisor, therefore, should keep a printed list of the names of the men who operate or view cases, and teach the new pupil the pronunciation of any difficult foreign names, so that she, being the superfluous nurse, may master them and take care of the telephone. There is one salient feature in all the training of pupil nurses, whether in a big metropolitan institution or some tiny suburban cottage hospital. They must roam about and learn the names of all highways and byways, so as to be familiar with the vicinity in which they work, on account of calls for doctors, the addresses of patients, and speed in sending out the ambulance — in brief, the development of a strong business acumen. It should be the duty of this same nurse to keep pad and pointed pencil for instant use at the telephone, this extension being so important that it should be of the desk variety, fixed on a table or desk, and not on a wall.

Some Ways of Arranging Work. — The most modern hospital methods include in the first few months' tuition of probationers, before they ever set foot on the wards, the making of all hospital dressings, for clinic, ward, or operating room, in which case they become very familiar with the names of all forms of gauze and cotton, i. e., wipes, compresses, fluffs, sponges, tampons, etc. This relieves the much busier, advanced pupil who is getting her operating-room training of a great deal of monotonous mechanical work, requiring no real professional skill and acting only as a sedative for a probationer's excited nerves. "Let George do it" is a good motto in many respects for hospitals to apply to their internal economy. There must be developed accuracy, skill, honesty, unselfishness along every line, but it is the rankest extravagance to make a second-year pupil sit folding gauze all morning and work then until midnight in the operating room, when dressings can be made by a probationer, a clean patient, or an orderly. It is quite usual for private patients, their special nurses, and their relatives to ask for some such thing to do. To ask a nurse to do what anyone less skilled can do just as well, after she knows how to do it well and quickly, wastes efficiency. The supply room should be separate from the rest of the hospital, though governed by the operating room, so as to regulate the amount of supplies as estimated from the operating-room records, where clean wounds, discharging wounds, and goods sold to physicians are all entered.

Importance of Dusting. — But the principle of using unskilled labor where possible does not apply to dusting, or several other things that some nurses would like to evade. Dusting in a hospital is a scientific process that must be performed by one on whom the hospital can place responsibility for the success of its work. Orderlies or maids have no connection whatever with the results in a wound further than their own healthy condition, but nurses are to be held accountable for all those features, such as air, light, heat, and dust, that rank as accessories to the main act. For the simple reason that orderlies and maids receive no diploma, may leave at a second's notice, and have no comprehension of the meaning of bacteria, dusting must not be left to them, but be performed by a responsible person. Nurses are members of a class in society who, presumably, take pride in their work, who work because they know that labor is necessary to keep well and sane, who do things well because they are proud to excel, and who want to satisfy a growing desire within themselves to attain more knowledge, more deftness, and more approval. The pupil who covers a great deal of ground and takes long strides and strokes, occasionally letting things fall and break, is a menace, though her pyrotechnic displays may impress an onlooker whose judgment is shallow. But a pupil whose work behind the scenes is honest and enduring, who knows that the water in the sterilizers has boiled long enough, or that she positively has scrubbed every inch of the marble pit with Sapolio and Labarraque's solution, who remembers and attends to every detail of pin, pledget, or packing with meticulous care, is the foundation of success in surgery. It is peculiar and unfortunate that the opinions of doctors and supervisors seldom coincide about who is a good nurse. There is a sort of superficial smartness and precocity which take very well with surgeons during their hour of tense strain, existing probably because the pupil is rested physically, and has not fatigued herself by doing her whole share behind the scenes, or because she has naturally more self-possession, or more readily places herself in an impressionable attitude of mind to receive a telepathic intimation of the surgeon's wish. It is very rare, but does occur, that a nurse does her share of the rough work honestly and at the same time shows great skill and coolness with instruments. But passing instruments for a surgeon has nothing to do with teaching other nurses, or humoring the relatives of a private patient, or paying one's dressmaker and yet saving money for one's old age. The ethical supervisor cannot decry the showy, dishonest pupil to the approving surgeons, but she must insist on thoroughness and completion of all that pupil's share — no putting off until tomorrow what should be done today. The operating room must be completely ready in every respect at the end of each day.

Some Difficulties which the Supervisor Has to Solve. — It makes a just supervisor's life very difficult to be at close range with a pupil whose tricky deceits make her feel uneasy about results, such as opening the autoclave too soon, or making up a hypodermic dose inaccurately, knowing all the while that this pupil is getting credit for cleverness from people who are easily fooled by show. Frank talk and constant checking up, combined with a nice judgment of human nature, a generous allowance for youthful vanity, and quick approbation for attempts to improve may help correct these obnoxious conditions. Otherwise they become a festering sore in the heart of the remaining pupils. s

There is a special gift in handing a surgeon what he wants without having to be told, but it is governed by certain important factors. One must first know every inch of the operating-room suite. This is gained by daily dusting, putting supplies away, and taking inventory. Second, one must have in mind an accurate, anatomic picture of the operation to be performed. This must be taught before each kind of case to the pupils who will take part. Then, third, one must have all the goods required generously supplied in a systematic way on the sterile tables. Fourth, the workings of every screw, lever, and button on instruments, cautery, or lights must be thoroughly known beforehand, learned in quiet lesson hours and practised to get speed, without an audience. To control the welfare of pupils or patients by these methods gives the shy nurse an equal chance, and elevates the operating-room supervisor's position to a lofty degree.

Sequence of Instruction. — After the pupil has been introduced to every hole and corner in her new scene of labor, she should be quizzed to find whether she took in what she saw, so as to form the habit of observation:

(1) What rooms adjoin the operating room?

(2) Where is the oxygen kept?

(3) Where is the normal saline?