SEVENTH STEP.-The operator grasps the two ends of the bowel in such a manner as to control the two halves of the button between the thumbs and fingers of each hand, and at the same time the assistant removes the forceps from the stems. The male stem is then slowly inserted into the female until the two halves of the button come together and firmly compress the intervening intestinal walls-thus completing the approximation (Fig. 911).

FIG. 913.-LATERAL ANASTOMOSIS BY MEANS OF THE MURPHY BUTTON-Eighth Step.

EIGHTH STEP.-A continuous Lembert suture is passed around the margin of the approximation (Fig. 912) and the edges of the mesentery whipped together by a continuous overhand suture (Fig. 913).

CHAPTER XLII.

Selection of the Operating Room. The room should be selected by the surgeon or the attending physician. It should be close to the room to be occupied by the patient after the operation; well lighted, when possible, by a northern exposure; and so constructed as to be readily cleaned.

Arrival of the Nurse.-For minor operations the nurse should be sent to the house on the morning preceding the day of operation and given detailed instructions in writing as to the preparation of the patient (see Minor Operations, p. 849) and the necessary arrangements to be made. For abdominal operations she should be sent to the patient's house six days before operation, which is the length of time usually devoted to the preparatory treatment (see Abdominal Operations, p. 854).

As in hospital practice the preparatory treatment of the patient may be shortened or lengthened according to circumstances, and in cases of emergency it may be necessary to operate at once.

Preparation of the Operating Room.-On the day before the opera

tion the furniture, curtains, pictures, carpets, and rugs should be removed from the room; the floor scrubbed with soap and water; and the woodwork, the ceil ing, and the walls wiped with a wet cloth. The operating and supply table and the washstand and chairs are then scrubbed with soap and water and wiped with a damp cloth.

On the morning of the operation the woodwork and all the articles in the room should be wiped with a wet cloth and everything properly arranged before the surgeon arrives.

ABDOMINAL OPERATIONS.

The nurse must personally attend to the following preparations for the operation:

Articles Required.-1. An ordinary wooden kitchen table to be used for operating upon.

2. Two tables, each about four feet long and twenty inches wide (one to be used for the instruments, etc., and the other for supplies).

3. A washstand or table to hold two basins for sterilization of the hands. 4. A wooden kitchen chair for the anesthetizer.

5. Two china or wooden buckets.

6. Five china or enameled pitchers (for cold, hot, and mixed sterile water and for cold and hot normal salt solution).

7. Four china or enameled basins (two for the sterilization of the hands of the operator and the assistant and two for use during the operation).

8. Three clean sheets (for the operating, instrument, and supply tables). 9. Six clean soft towels.

10. Two woolen blankets (one for the operating table and the other to throw over the patient).

11. Two large tin wash-boilers.

12. A tin pint ladle with a long handle to use for dipping out and measur ing the sterile water.

13. Six gallons each of hot and cold sterile water.

14. Three quarts each of hot and cold normal salt solution.

15. Hypodermic syringe.

16. A china dish for formalin solution.

Sterilization of the Water. The evening preceding the day of operation six gallons of water are boiled for half an hour in one of the washboilers (after it has been thoroughly scrubbed and rinsed) and set aside in the operating room to cool overnight. The cover should be kept on the boiler, otherwise the water will be unprotected and may become contaminated. On the morning of the operation six additional gallons of water are boiled for half an hour in the other wash-boiler and placed in the operating room; the tin ladle is sterilized by placing it in the wash-boiler while the water is boiling.

Sterilization of the Pitchers, Basins, Fountain Syringe, and China Dish.-On the day of the operation the pitchers, basins, and china dish are thoroughly scrubbed and rinsed and then boiled for five minutes in the wash-boiler which is used later for sterilizing the hot-water supply. The water is then carefully poured out of the boiler, which is taken to the operating room, and the pitchers and basins removed and placed on the supply table without touching the inside of any of the vessels.

The fountain syringe is wrapped in a towel which is secured with safety-pins and boiled with the pitchers and basins. It is taken out of the wash-boiler and placed on the supply table still wrapped in the towel.

Preparation of the Normal Salt Solution.-Shortly before the

operation the normal salt solution should be prepared as follows: Take twelve teaspoonfuls of chemically pure sodium chlorid and place them in a small agate cup holding a pint of water. Boil the solution for ten minutes and pour half into one of the china pitchers and the other half into another pitcher. Then pour with the ladle three quarts of hot sterile water from the wash-boiler into one of the pitchers and three quarts of cold sterile water into the other. The pitchers are then set aside on the supply table and the solutions mixed at the proper temperature when required.

Articles Sent by the Surgeon from the Druggist.-These articles should be delivered at the house of the patient the day before the operation:

1. Four ounces (124.4) of chemically pure sodium chlorid.

2. A cylinder of oxygen gas and the inhaling apparatus.

3. Twelve hypodermic tablets each of sulphate of strychnin (gr. 0.002), sulphate of atropin (gr. 10.0004), nitroglycerin (gr. 10.0006), and sulphate of morphin (gr.

0.008).

4. Eight ounces (236.00) of tincture of green soap.

5. Fountain syringe (three quarts).

6. Two hot-water bags.

7. One roll of Z.O. adhesive plaster 2 inches wide.

8. Twenty-four corrosive sublimate tablets (1 to a pint

9. One pint (473.11) of alcohol.

10. Three half-pound cans of ether and four ounces of chloroform.

II. Two hand-brushes made of vegetable fiber.

12. Bed-pan. Small alcohol lamp.

13. One pint (473.11) of a 10 per cent. aqueous solution of formalin. 14. One yard of rubber sheeting.

FIG. 914.-DIAGRAM SHOWING THE ARRANGEMENT OF A ROOM PREPARED FOR AN ABDOMINAL Operation.

Arrangement of the Operating Room.-Before the arrival of the surgeon the nurse must have everything ready and properly arranged as follows: 1. The operating table is placed in front of a window with a chair for the anesthetizer at its head and a bucket on the floor alongside of the position of the

966

ANTISEPSIS IN PRIVATE HOUSES.

operator. Two blankets and a sheet are folded separately and laid on the table ready to place in position when the adjustable operating frame is attached and the patient is under the anesthetic.

2. The instrument table is covered with a sheet and placed on the right side of the operating table within a convenient distance of where the operator stands. The two basins which contain the sterile water used by the surgeon for his hands during the operation are placed on the end of the table.

3. The supply table is covered with a sheet and placed out of the way on the opposite side of the room. The following articles should be placed on it: (a) Two pitchers containing hot and cold normal salt solution, two filled with hot and cold sterile water, and one empty pitcher for mixing; (b) the fountain syringe wrapped in the towel in which it was sterilized; (c) a hypodermic syringe and the cardiac and respiratory stimulants: strychnin, atropin, nitroglycerin, and morphin; (d) zinc oxid adhesive plaster and the alcohol lamp; (e) ether and chloroform; (f) a china dish filled with formalin solution.

4. The two wash-boilers containing hot and cold sterile water, the cylinder of oxygen gas, and the second bucket are placed on the floor at the side of the supply table.

5. The washstand or table used for hand sterilization is placed on the opposite side of the room from the supply table, and tincture of soap, two basins, and six soft towels are arranged on it.

Articles Carried by the Surgeon or His Assistants.-The following articles are brought to the patient's house by the surgeon or his assistant

at the time of the operation:

Operating paraphernalia. A portable Trendelenburg frame.

Thermometer, rubber drainage syringe, and catgut.

Operating Paraphernalia. -The method of sterilizing the articles and the manner in which they are conveyed to the house of the patient depend upon whether the surgeon has access to a high-pressure steam sterilizer or not. If he has, the articles are sterilized by high-pressure steam on the day of the operation, otherwise they are packed in a portable sterilizer which is heated on the range or by an alcohol lamp at the patient's house. High-pressure Steam Sterilizer. For operations at pri vate houses I have devised a large conveyance box which is made of heavy copper or tin and divided into two compartments. The box is 20 inches long, 10 inches wide, and 7 inches deep, and the lid is made with an outer and inner rim. The former is 3 inches and the latter of an inch deep, and they are separated from each other by a space of of an inch. This space, which forms a narrow slot into which the upper edges of the box fit, is loosely packed with cotton batting in order to protect the contents of the box after they have been sterilized (Fig. 915). With the upper edges of the box thus imbedded in cotton batting

FIG. 915-ASHTON'S LARGE CONVEYANCE BOX. Note the flange or inner rim of the lid of the box.

the contents are absolutely protected from contamination and can be kept in an aseptic condition indefinitely. I have a canvas cover for the box which straps tightly over it and keeps the lid firmly pressed down.

I keep two of these boxes at the hospital, each packed for an abdominal section, and when a call comes for an outside operation a list of the necessary instruments, ligatures, sutures, and needles is sent to the clinic nurse, who places them in one of the boxes, which is then sterilized and sent to my office. The box is returned to the hospital after the operation and at once repacked.

The following illustrations show how the box is placed in the sterilizer and the method of putting on the lid after sterilization without infecting its inner surfaces (Figs. 916 and 917).

The contents of the box are packed in a special order so that those articles which are used first will be on top and can be taken out without disturbing the

rest.

The following articles are placed in the box in the order in which they are given:

1. The abdominal dressings (see p. 847).

2. Two gauze tampons (see p. 846).

3. Glass and rubber drainage-tubes of different sizes; a long metallic nozzle for the fountain syringe; a needle for hypodermoclysis; a cannula for intravenous saline injections; and a rectal tube for enteroclysis.

These articles are wrapped in gauze and care should be taken to prevent the glass drainage-tubes from being broken. The needle, cannula, and irrigating nozzle are wrapped separately in a small towel with a teaspoonful of carbonate of soda (to prevent rusting) and secured with safety-pins.

4. Eight small and four large gauze pads.

5. Four dozen gauze sponges.

6. Eight safety-pins wrapped in gauze.

METHOD OF STERILIZING WITH ASHTON'S LARGE CONVEYANCE Box.

Fig. 916 shows the box in the sterilizer and the relative position of its lid; Fig. 917 shows the method of sliding the lid over the box before it is removed from the sterilizer.

7. Eight towels. 8. One sheet.

9. Instruments; needles; silk ligatures and sutures; and silkworm-gut. The instruments and needles are wrapped in a towel with an ounce of carbonate of soda (to prevent rusting) and secured with safety-pins. During the sterilization the soda is deposited as a fine powder on the instruments and needles and rusting is prevented, which invariably occurs unless this precaution is taken. The cutting instruments are protected by wrapping absorbent cotton around their blades and the needles kept together by passing them through a small gauze pad, which is then folded over upon itself and secured with a safety-pin.